Connor Morton

Survival After Pancreaticoduodenectomy is not Improved by Extending Resections to Achieve Negative Margins

Objective:This study was undertaken to determine the survival benefit of extending resections to obtain microscopically negative margins after positive intraoperative frozen sections. Summary Background Data:The impact of residual microscopic disease after pancreaticoduodenectomy is currently a point of controversy. It is, however, generally believed that microscopically positive margins negatively impact survival and this may be improved by ultimately achieving negative margins. Methods:Since 1995, patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma have been prospectively followed. Margin status has been codified as macro/microscopically negative (R0) or macroscopically negative/microscopically positive (R1). The impact of margin status on survival was evaluated utilizing survival curve analysis. Data are presented as median, mean ± SD where appropriate. Results:For pancreatic adenocarcinoma, 202 patients underwent pancreaticoduodenectomy. R0 resections were achieved in 158 patients, 17 of whom required extended resections to achieve complete tumor extirpation after an initially positive intraoperative frozen section (R1 → R0). R1 resections were undertaken in 44 patients. Median survival for patients undergoing R0 resections was 21 months, 26 ± 23.4 months versus 13 months, 17 ± 21.0 months for patients undergoing R1 resections (P = 0.02). Median survival for patients undergoing R1 → R0 resections was 11 months, 16 ± 17.3, (P = 0.001). Margin status had a significant correlation with “N” stage and AJCC stage but not “T” stage. Conclusion:Survival after pancreaticoduodenectomy is not improved by extending pancreatic resections to achieve negative margins after initially positive intraoperative frozen sections. Tumor-specific factors beyond the presence of disease at a surgical margin are responsible for the abbreviated survival seen in patients undergoing R1 resections.

The Learning Curve of Laparoendoscopic Single-Site (LESS) Cholecystectomy: Definable, Short, and Safe

BACKGROUND The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety. STUDY DESIGN We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications. RESULTS One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts. CONCLUSIONS For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia.

BACKGROUND Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. STUDY DESIGN Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. RESULTS Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. CONCLUSIONS Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.

Surgery residency training programmes have greater impact on outcomes after pancreaticoduodenectomy than hospital volume or surgeon frequency

BACKGROUND Hospital volume of pancreaticoduodenectomy (PD) and surgeon frequency of PD have been shown to impact outcomes. The impact of surgery residency training programmes after PD is unknown. This study was undertaken to determine the impact of surgery training programmes on outcomes after PD, as well as their importance relative to hospital volume and surgeon frequency of PD. METHODS The State of Florida Agency for Healthcare Administration Database was queried for patients undergoing PD during 2002-2007. Measures of outcome were compared for patients undergoing PD at centres with vs. without surgery residency training programmes. RESULTS A total of 2345 PDs were identified, of which 1478 (63%) were undertaken at training centres and 867 (37%) were performed at non-training centres. Patients undergoing PD at training centres had shorter lengths of stay, lower hospital charges and lower in-hospital mortality. Relative to surgeon frequency of PD, training centres had a greater favourable impact on hospital length of stay, hospital charges and in-hospital mortality (P < 0.001 for each, ancova). Relative to hospital volume of PDs undertaken, training centres had a greater impact on hospital charges (P < 0.001, ancova). CONCLUSIONS Surgery residency training programmes have a favourable effect on outcomes following PD and their impact on outcome is greater than the impact of hospital volume or surgeon frequency of PD.

Access for Laparoendoscopic Single Site Surgery

Laparoscopic surgery is the standard of care for many abdominal and pelvic operations and is widely applied today. LESS (Laparo-Endoscopic Single Site) surgery, originally attempted in the 1990s, is an advanced minimally invasive approach that allows laparoscopic operations to be undertaken through a small (<15 mm) incision in the umbilicus, a preexisting scar. The presence of a preexisting scar allows LESS surgery to be essentially scarless, which is the key benefit to LESS operations. Herein, we review our experience with over 500 LESS operations and discuss the key techniques to establishing access to the peritoneal cavity. We review the options for obtaining access, available instrumentation, common challenges and solutions for access. We conclude that LESS surgery is safe and provides outcomes with superior cosmesis relative to conventional laparoscopy. LESS surgery should be embraced, as patient demand is rapidly increasing.

TNFα gene delivery therapy for solid tumors

Importance of the field: Multimodality therapy, including adjuvant and neoadjuvant chemotherapy and radiotherapy, is now the mainstay of treatment for the majority of non-hematologic cancers. Host toxicity can, however, be significant, which may contribute to local and/or systemic failures. Novel adjunctive treatments that can limit systemic exposure while synergizing with standard therapy hold promise in the fight against an increasing number of cancers. Areas covered in this review: We discuss a TNFα gene delivery system used to generate high levels of intratumoral TNFα, while limiting systemic exposure. The delivery system utilizes a replication-deficient adenoviral vector. When injected intratumorally and activated by external beam radiation, infected cells synthesize and locally secrete large amounts of TNFα. What the reader will gain: This review will provide the reader with a thorough understanding of the gene-based TNFα delivery system with special emphasis on product characteristics, mechanisms of action, clinical efficacy, safety and tolerability. Take home message: The TNFα gene delivery system holds promise as an adjunctive agent for improved local control and increasing resectability rates for many solid tumors. The completion of several ongoing randomized trials will help to better define the role for TNFα gene delivery therapy in the treatment of solid tumors.

Medical comorbidities should not deter the application of laparoscopic fundoplication.

IntroductionLaparoscopic Nissen fundoplication offers significant improvement in gastroesophageal reflux disease (GERD) symptom severity and frequency. This study was undertaken to determine the impact of preoperative medical comorbidities on the outcome and satisfaction of patients undergoing fundoplication for GERD.MethodsPrior to fundoplication, patients underwent esophageal motility testing and 24-h pH monitoring. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Medical comorbidities were classified by organ systems, and patients were assigned points corresponding to the number of medical comorbidities they had. In addition, all patients were assigned Charlson comorbidity index (CCI) scores according to the medical comorbidities they had. A medical comorbidity was defined as a preexisting medical condition, not related to GERD, for which the patient was receiving treatment. Analyses were then conducted to determine the impact of medical comorbidities as well as CCI score on overall outcome, symptom improvement, and satisfaction.ResultsSix hundred and ninety-six patients underwent fundoplication: 538 patients had no medical comorbidities and 158 patients had one or more medical comorbidities. Preoperatively, there were no differences in symptom severity and frequency scores between patients with or without medical comorbidities. Postoperatively, all patients had improvement in their symptom severity and frequency scores. There were no differences in postoperative symptom scores between the patients with medical comorbidities and those without. The majority of patients were satisfied with their overall outcome; there was no relationship between the number of medical comorbidities and satisfaction scores. These findings were mirrored when patients’ CCI scores were compared with satisfaction, overall outcome, and symptom improvement.ConclusionThese results promote further application of laparoscopic Nissen fundoplication, even for patients with medical comorbidities.

Renal haemodynamics and function following partial portal decompression

BACKGROUND This study was undertaken to prospectively evaluate the impact of partial portal decompression on renal haemodynamics and renal function in patients with cirrhosis and portal hypertension. METHODS Fifteen consecutive patients (median age 49 years) with cirrhosis underwent partial portal decompression through portacaval shunting or transjugular intrahepatic portosystemic shunting (TIPS). Cirrhosis was caused by alcohol in 47%, hepatitis C in 13%, both in 33% and autoimmune factors in 7% of patients. Child class was A in 13%, B in 20% and C in 67% of patients. The median score on the Model for End-stage Liver Disease (MELD) was 14.0 (mean 15.0 +/- 7.7). Serum creatinine (SrCr) and creatinine clearance (CrCl) were determined pre-shunt, 5 days after shunting and 1 year after shunting. Colour-flow Doppler ultrasound of the renal arteries was also undertaken with calculation of the resistive index (RI) and pulsatility index (PI). Changes in the portal vein-inferior vena cava pressure gradient with shunting were determined. RESULTS With shunting, the portal vein-inferior vena cava gradients dropped significantly, with significant increases in PI in the early period after shunting. Creatinine clearance improved in the early post-shunt period. However, SrCr levels did not significantly improve. At 1 year after shunting, both CrCl and SrCr levels tended towards pre-shunt levels and the increase in PI did not persist. DISCUSSION Partial portal decompression improves mild to moderate renal dysfunction in patients with cirrhosis. Early improvements in renal function after shunting begin to disappear by 1 year after shunting.

W1645 Laparo-Endoscopic Single Site (LESS) Cholecystectomy With Epidural Anesthesia: A Safe, Cost Effective, and Appealing Approach

the 66 women choosing this approach and only 48% of the 42 men (P=0.02). Age >50 (P= 0.34), college or graduate level education (P=0.44), history of a prior cholecystectomy (P= 0.85) and an operation in the past 10 years (P=0.19) were not found to be significantly correlated with NOTES preference. The most commonly cited reason for choosing NOTES was less post-op pain (73%), followed closely by less family inconvenience (71%) and less risk of infection (71%). The lack of external scarring ranked fourth out of the six reasons, with 44% of patients selecting this as a factor in their decision. Other less commonly cited reasons were earlier return to work/income (59%) or sports (23%). For patients choosing laparoscopy over NOTES, more available data (86%) and surgical experience (83%) were both commonly selected factors. The oral orifice was most popular, with 64% of all participants preferring this approach. Conclusion: Female gender was significantly associated with a preference for NOTES. Other demographic factors did not correlate significantly with selection of either technique. Decreased pain, family inconvenience and risk of infection were found to be more important than scarring, earlier return to work/income or sports. The oral orifice was preferred by a majority of patients. Patients consider NOTES a reasonable alternative to laparoscopy.