Increasing body mass index portends abbreviated survival following pancreatoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: Body mass index (BMI), a common surrogate marker for grading obesity, does not differentiate between metabolically active visceral fat and the relatively inert subcutaneous fat. We aim to determine the utility of BMI as a prognostic marker for the impact of obesity on outcomes and survival following pancreatoduodenectomy for pancreatic adenocarcinoma. METHODS: From a database of over 1,000 patients who had undergone pancreatoduodenectomy, 228 patients with a diagnosis of pancreatic adenocarcinoma were identified. Demographic data including BMI and perioperative parameters-operative time, estimated blood loss, length of stay, survival, nodal status, and American Joint Committee on Cancer stage-were obtained. Data are presented as median. RESULTS: One hundred ninety-two patients had a BMI less than or equal to 29 and 36 patients had a BMI greater than or equal to 30 (24 vs. 34, P < .001). Median age was 70 and the majority of the patients (52%) were male and the 2 groups of patients did not differ in this regard. A significantly greater number of obese patients had positive nodes (69% vs. 62%, P < .05) and this was associated with a worse survival (14 vs. 18 months, P < .05). CONCLUSIONS: For patients with pancreatic adenocarcinoma undergoing pancreatoduodenectomy, obesity does not impact operative complexity or length of stay but results in a shortened survival. Therefore, we conclude that BMI is an important prognostic marker that portends an abbreviated survival following pancreatoduodenectomy for pancreatic adenocarcinoma.

A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer.

OBJECTIVE: To assess the ability of preoperative computed tomography (CT) scan of the abdomen/pelvis and serum CA-125 to predict suboptimal (>1cm residual disease) primary cytoreduction in advanced ovarian, fallopian tube, and peritoneal cancer. METHODS: This was a prospective, non-randomized, multicenter trial of patients who underwent primary cytoreduction for stage III-IV ovarian, fallopian tube, and peritoneal cancer. A CT scan of the abdomen/pelvis and serum CA-125 were obtained within 35 and 14 days before surgery, respectively. Four clinical and 20 radiologic criteria were assessed. RESULTS: From 7/2001 to 12/2012, 669 patients were enrolled; 350 met eligibility criteria. The optimal debulking rate was 75%. On multivariate analysis, three clinical and six radiologic criteria were significantly associated with suboptimal debulking: age ≥ 60 years (p=0.01); CA-125 ≥ 500 U/mL (p<0.001); ASA 3-4 (p<0.001); suprarenal retroperitoneal lymph nodes >1cm (p<0.001); diffuse small bowel adhesions/thickening (p<0.001); and lesions >1cm in the small bowel mesentery (p=0.03), root of the superior mesenteric artery (p=0.003), perisplenic area (p<0.001), and lesser sac (p<0.001). A 'predictive value score' was assigned for each criterion, and the suboptimal debulking rates of patients who had a total score of 0, 1-2, 3-4, 5-6, 7-8, and ≥ 9 were 5%, 10%, 17%, 34%, 52%, and 74%, respectively. A prognostic model combining these nine factors had a predictive accuracy of 0.758. CONCLUSIONS: We identified nine criteria associated with suboptimal cytoreduction, and developed a predictive model in which the suboptimal rate was directly proportional to a predictive value score. These results may be helpful in pretreatment patient assessment.

Transduodenal ampullectomy for ampullary adenomas: a safe and effective procedure with long-term salutary outcomes.

With widespread use of endoscopy, ampullary adenomas are more frequently identified, many of which are not amenable to endoscopic resection. Pancreatoduodenctomy is curative for these lesions but carries high morbidity. The purpose of this study was to determine the safety and efficacy of transduodenal ampullectomy for these lesions. Data were collected on 32 patients who underwent transduodenal ampullectomy from 2002 to 2010. The median age of patients was 64 years. Adenomas were found because of abdominal pain in 34 per cent, jaundice in 22 per cent, and incidentally on endoscopic screening in 16 per cent and on computed tomography scan of the abdomen in 9 per cent. All patients had a preoperative diagnosis of premalignant disease; 6 per cent required intraoperative conversion to pancreaticoduodenectomy after frozen section evaluation documented carcinoma. Of ampullectomies, 97 per cent had clear margins. Follow-up was 28 months. Four (13%) patients developed recurrent disease at 4 years, 2 years, 1.5 years, and 4 months; all had clear margins at ampullectomy and underwent subsequent pancreaticoduodenectomy with invasive malignancy in a single patient. After preoperative biopsy documenting premalignant disease, malignancy at ampullectomy is unusual. Recurrence is uncommon but occurs even with clear margins necessitating diligent follow-up; even with diligent follow-up, recurrence can be malignant.

The learning curve of laparoendoscopic single-Site (LESS) fundoplication: definable, short, and safe.

BACKGROUND AND OBJECTIVES: This study of laparoendoscopic single-site (LESS) fundoplication for gastroesophageal reflux disease was undertaken to determine the "learning curve" for implementing LESS fundoplication. METHODS: One hundred patients, 38% men, with a median age of 61 years and median body mass index of 26 kg/m(2) , underwent LESS fundoplications. The operative times, placement of additional trocars, conversions to "open" operations, and complications were compared among patient quartiles to establish a learning curve. Median data are reported. RESULTS: The median operative times and complications did not differ among 25-patient cohorts. Additional trocars were placed in 27% of patients, 67% of whom were in the first 25-patient cohort. Patients undergoing LESS fundoplication had a dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P < .05), particularly for heartburn and regurgitation, without causing dysphagia. CONCLUSION: LESS fundoplication ameliorates symptoms of gastroesophageal reflux disease without apparent scarring. Notably, few operations required additional trocars after the first 25-patient cohort. Patient selection became more inclusive (eg, more "redo" fundoplications) with increasing experience, whereas operative times and complications remained relatively unchanged. The learning curve of LESS fundoplication is definable, short, and safe. We believe that patients will seek LESS fundoplication because of the efficacy and superior cosmetic outcomes; surgeons will need to meet this demand.

Defining the learning curve of laparoendoscopic single-site Heller myotomy.

Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to "open" operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy (P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.

Laparoendoscopic single site (LESS) vs. conventional laparoscopic fundoplication for GERD: is there a difference?

BACKGROUND: This report details our experience with laparoendoscopic single site (LESS) fundoplication for GERD and provides a comparison to earlier contiguous patients undergoing conventional laparoscopic fundoplication. METHODS: With institutional review board approval, symptoms before and after LESS fundoplications and conventional laparoscopic fundoplications were scored by patients. Outcomes after 130 consecutive LESS fundoplications were compared to 130 contiguous consecutive outcomes after conventional laparoscopic fundoplications. RESULTS: Patients undergoing conventional laparoscopic vs. LESS fundoplication were very similar. There were no conversions to "open" operations and no notable complications with LESS fundoplication. Symptom reduction was broad and dramatic for patients undergoing LESS or conventional laparoscopic fundoplication; 96 % of patients who underwent LESS fundoplication scored their incision as ≥8 (1 = revolting to 10 = beautiful). CONCLUSIONS: Relative to conventional laparoscopy, LESS surgery provides excellent resolution of symptoms without an apparent scar. In comparison to conventional laparoscopy, LESS fundoplication is as safe with similar symptom improvement and superior cosmesis.

A single institution's experience and journey with over 1000 laparoscopic fundoplications for gastroesophageal reflux disease.

There have been great advances in laparoscopic surgery for gastroesophageal reflux disease (GERD), including laparoendoscopic single-site (LESS) surgery. This study details our experience with over 1000 patients undergoing fundoplication for GERD and the journey therein. A total of 1078 patients have been prospectively followed after fundoplication. Patients scored the frequency/severity of symptoms using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). We compared the outcomes of the first and last 100 patients. Median data are reported. Of 1078 patients, 943 underwent conventional laparoscopic fundoplication and 135, most recently, underwent LESS fundoplication. Before fundoplication, patients noted frequent/severe symptoms (e.g., heartburn: frequency = 8, severity = 8). Fundoplication ameliorated frequency/severity of symptoms (e.g., heartburn: frequency = 2, severity = 0; less than preoperatively, P < 0.05). Relative to our first 100 patients, patients after LESS surgery had similar symptom control (e.g., heartburn: frequency = eight to two vs eight to zero, severity = eight to one vs six to one) but had shorter hospital stays (2 vs 1 day, P < 0.05) and had no apparent scars. Laparoscopic fundoplication provides durable and efficacious treatment for GERD; long-term symptom resolution and patient satisfaction support its continued application. The advent of LESS surgery advances surgeons' abilities to provide safe and salutary care while promoting cosmesis.

Readmissions after pancreaticoduodenectomy: efforts need to focus on patient expectations and nonhospital medical care.

Readmissions after operations are a burden. This study was undertaken to determine factors predicting readmissions after pancreaticoduodenectomy. Since 1991, patients undergoing pancreaticoduodenectomy have been prospectively followed. Nineteen per cent of 913 patients were readmitted within 30 days after discharge from pancreaticoduodenectomy. The causes for readmissions were reviewed. Median data are presented. All patients had preoperative comorbidities; most common were cardiovascular (26%), gastrointestinal (23%), or endocrine (15%). Twenty-nine per cent had extended pancreaticoduodenectomy, including major vascular resections. The most common reasons for readmission were: nausea/vomiting (26%), wound infection (15%), and abdominal pain (18%). Gender, body mass index, duration of operation, blood loss, length of stay, pathology, American Joint Committee on Cancer™ stage, and margin status did not predict readmission. Patients being readmitted were younger (65 vs 69 years, P < 0.001) and had more comorbidities (P < 0.001). Readmission did not curtail long-term survival. Pancreaticoduodenectomy is a complex operation undertaken in patients with notable comorbidities. Readmissions occur frequently after pancreaticoduodenectomy and patients with more comorbidities are at particular risk. Readmissions are not generally the result of complications specific to pancreaticoduodenectomy, but seem more related to ill health, inaccessible nonhospital medical care, and poor expectations. Efforts must focus on patient expectations, intermediate care, home health care, and improving medical care after discharge.

Targeting early deaths following pancreaticoduodenectomy to improve survival.

INTRODUCTION: There is increasing focus on disease-specific outcomes. This study was undertaken to analyze early mortality after pancreaticoduodenectomy as part of a strategy to improve long-term outcome. METHODS: One thousand thirty-one patients who underwent pancreaticoduodenectomy from 1992 to 2010 were studied. Median data are reported. RESULTS: Fifty-eight (5.6%) patients died within 90 days after pancreaticoduodenectomy. All patients had at least one significant comorbidity, commonly cardiorespiratory in nature (76%). Sixty percent of patients had depressed serum albumin levels, and 43% were jaundiced. The American Society of Anesthesiologists class was: 17% class II, 72% class III, and 10% class IV. Seventy-four percent had malignant disease. Twenty-two percent of patients underwent a major vascular resection at the time of pancreaticoduodenectomy. Causes of death were vascular/bleeding related (26%), cardiorespiratory causes (17%), multiorgan failure (12%), leak/perforation (10%), cancer progression (9%), infection (7%), or indeterminate (19%). CONCLUSIONS: Death within 90 days after pancreaticoduodenectomy is uncommon, occurs in relatively older deconditioned patients, and is generally not causally related to underlying malignancy. Early death is generally associated with vascular or bleeding complications. Strategies to minimize early death should focus on careful patient selection and prompt recognition and management of herald bleeding or vascular thrombosis, as it can often result in perioperative death following pancreaticoduodenectomy.

Gastroesophageal reflux disease.

Millions of Americans are affected by gastroesophageal reflux disease (GERD) in many different ways. The magnitude of the problem of GERD was brought to light by the ambulatory pH test, the introduction of minimally invasive surgery, and the advent of the many medications that are effective in acid suppression. Patients with GERD suffer from various consequences associated with the disease. However, interventions beyond medical therapy, such as laparoscopic fundoplication, provide satisfactory outcomes and definitive relief of acid reflux.

Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?

INTRODUCTION: Polytetrafluoroethylene (PTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stents purportedly provide superior patency. This study was undertaken to determine whether covered stents provide better long-term patency and outcomes after TIPSs. METHODS: Patients with portal hypertension undergoing TIPS at a large teaching hospital from 2001 to 2010 were studied. Median data are presented. RESULTS: Two hundred forty-six patients underwent TIPS; 70 received uncovered stents, and 176 received covered stents. Patients who received uncovered stents had more severely impaired liver function (41% were Child class C cirrhotics). The follow-up was longer with uncovered stents (48 vs 24 months, P < .01). Reinterventions for stenosis were undertaken in 33% with uncovered stents versus 19% with covered stents (P = .01). Shunt dysfunction occurred in 57% with uncovered stents versus 21% covered (P = .05). A deterioration of hepatic function occurred in 31% with uncovered stents versus 30% with covered (P = .32). Survival with uncovered stents was 31 months versus 33 months with covered stents (P = .55, Kaplan-Meier). CONCLUSIONS: Covered stents may improve patency but do not mitigate postshunt hepatic dysfunction and do not improve survival.

Intestinal endometriosis--a rare cause of colonic perforation.

Endometriosis is the ectopic growth of viable endometrium outside the uterus, affecting approximately 7% of females. It commonly affects pelvic structures including the bowel. Perforation of the colon by endometriosis is very rare and the patients generally present with an asymptomatic or painful pelvic mass, often in the left iliac fossa. Our patient presented acutely unwell and her symptoms were more suggestive of pyelonephritis or diverticulitis. We therefore report an unusual cause of acute abdomen. The purpose of the following case report is to elucidate certain diagnostic and therapeutic problems of the disease, concerning both surgeons and gynaecologists. In summary, intestinal endometriosis should be considered in the differential diagnosis of all post-menarche women with episodic gastrointestinal symptoms. A past history of endometriosis or co-existent gynaecological symptoms should increase the index of suspicion, and laparoscopy prior to formal laparotomy should be considered. Our patient, in retrospect, had a history of mild endometriosis, but we feel that this case serves as a reminder of a rare, but important, differential diagnosis of acute abdomen in females.

Laparoscopic Nissen fundoplication ameliorates symptoms of reflux, especially for patients with very abnormal DeMeester scores.

Intuitively, more severe acid reflux causes more severe symptoms. This study was undertaken to correlate preoperative DeMeester scores with symptoms before and after laparoscopic Nissen fundoplication. Before fundoplication, all patients with gastroesophageal reflux disease underwent 24 to 48 hour pH testing. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Four hundred and eighty-one patients underwent fundoplication and were followed for a mean of 32 months. The preoperative median DeMeester score was 41 (range 14.8 to 361.5). Before fundoplication, DeMeester scores correlated with severity of gastroesophageal reflux disease symptoms (Spearman regression analysis, P < 0.05 for all). Postoperatively, all symptom scores improved (Wilcoxon matched pairs test, P < 0.05 for all). After fundoplication, preoperative DeMeester scores did not correlate with the frequency or severity of symptoms. For patients with excessive acid reflux, reflux severity impacts the frequency and severity of symptoms before fundoplication. Laparoscopic Nissen fundoplication improves the frequency and severity of all reflux symptoms. The severity of preoperative reflux does not impact the frequency or severity of symptoms after fundoplication. Relief of excessive acid reflux, regardless of severity or degree (i.e., DeMeester scores), ameliorates symptoms of acid reflux thereby encouraging fundoplication, especially for patients with very abnormal DeMeester scores.