Desiree Villadolid

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.

Laparoscopic Heller Myotomy Provides Durable Relief From Achalasia and Salvages Failures After Botox or Dilation

Objective:To report outcome after laparoscopic Heller myotomy in a large number of patients. Summary Background Data:Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. Methods:Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). Results:Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. Conclusions:Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up. Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.

Obesity is not a contraindication to laparoscopic Nissen fundoplication.

Obesity has been shown to be a significant predisposing factor for gastroesophageal reflux disease (GERD). However, obesity is also thought to be a contraindication to antireflux surgery. This study was undertaken to determine if clinical outcomes after laparoscopic Nissen fundoplications are influenced by preoperative body mass index (BMI). From a prospective database of patients undergoing treatment for GERD, 257 consecutive patients undergoing laparoscopic Nissen fundoplication were studied. Patients were stratified by preoperative BMI: normal (<25), overweight (25-30), and obese (>30). Clinical outcomes were scored by patients with a Likert scale. Overweight and obese patients had more severe preoperative reflux, although symptom scores for reflux and dysphagia were similar among all weight categories. There was a trend toward longer operative times for obese patients. Mean follow-up was 26 ± 23.9 months. Mean heartburn and dysphagia symptom scores improved for patients of all BMI categories (P < 0.001). Postoperative symptom scores and clinical success rates did not differ among BMI categories. Most patients undergoing laparoscopic Nissen fundoplication are overweight or obese with moderate dysphagia and severe acid reflux. Clinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplication.

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome.

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/ after myotomy were scored by patients on a Likert scale (0-5). The median (mean _ SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 ± 21.9 months) versus 46.3 months (51.0 ± 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 ± 5.4 vs. 7.4 ± 6.0), and mean preoperative dysphagia score (4.9 ± 0.4 vs. 4.8 ± 0.4). Esophagotomy led to longer hospitalizations (5.2 days ± 2.5 days vs. 1.5 days ± 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 ± 1.7 vs. 2.1 ± 1.4), reflux scores (1.4 ± 1.7 vs. 2.3 ± 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy.

Surgeons Can Favorably Influence Career Choices and Goals for Students Interested in Careers in Medicine

BACKGROUND This study was undertaken to determine the impact of an academic summer research, shadowing, and mentorship program on students interested in medicine and surgery. STUDY DESIGN Forty-four (92%) of 48 participants of a summer research, shadowing, and mentorship program returned blinded questionnaires that focused on the programs impact on their scholarly skills, career choices, and goals. The program interfaced academic surgeons with students interested in careers in medicine and enabled students to participate in research projects, attend daily lectures, and shadow physicians in the operating room, clinic, and hospital. Proficiency in scholarly skills, before and after the program, was scored by the participants using a Likert scale (0 = none to 10 = proficient). RESULTS Ninety-three percent of participants were in or had completed college; only 7% had advanced degrees. With the program, proficiency in all categories assessed improved considerably, including medical terminology, abstract writing, statistical analysis, graph and table construction, article writing, and video production. During the last 5 years, participants coauthored 112 national presentations (29 video presentations), 46 published abstracts, and 57 peer-reviewed published articles. Ninety-two percent developed more favorable opinions of a career in medicine; 8% believed the experience deterred them from a career in medicine because of lifestyle and studious demands. Seventy-seven percent believed the program promoted a career in surgery; 82% believed it elevated their goals to become leaders in American medicine. CONCLUSIONS Shadowing opportunities, mentoring, and didactic teaching of scholarly skills for college and graduate students foster academic productivity and elevation of career goals. Academic surgeons can favorably influence career choices and goals for students interested in careers in medicine and surgery.

Upright, supine, or bipositional reflux : Patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication

IntroductionThis study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication—i.e., pattern of reflux—affects symptoms before or after laparoscopic Nissen fundoplication.MethodsA total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test.ResultsBefore fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved.ConclusionsPreoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.

Survival after pancreatectomy for pancreatic adenocarcinoma is not impacted by performance status

BACKGROUND Patients with the best performance status have the best prognosis after resection for pancreatic adenocarcinoma. This study was undertaken to determine the impact of performance status on survival after pancreatectomy for adenocarcinoma. METHODS Patients with a Karnofsky Performance Score (KPS) status (KPS) ≥60 after pancreatectomy for adenocarcinoma were evaluated, and the impact of the KPS at 6 weeks after pancreatectomy on survival was determined using survival curve analysis. RESULTS Recurrence was experienced by 84% of patients and negatively impacted patient survival. The median overall survival was 12 months, and the 2-year overall survival was 35%. The KPS after pancreatectomy did not impact survival when using survival curve analysis (P = .5740). CONCLUSIONS Performance status for patients with a KPS ≥60 after pancreatectomy does not impact survival. Patients with pancreatic adenocarcinoma without adjuvant therapy have poor overall survival, and KPS after pancreatectomy for adenocarcinoma should not be used to withhold therapy for these patients.

Laparoscopic resection of extraadrenal pheochromocytoma.

Laparoscopic resection is now considered standard of care for most pheochromocytomas arising from the adrenal glands. Extraadrenal pheochromocytoma presents unique challenges for laparoscopic resection. Considerations include preoperative preparation, port placement, exposure, anesthetic management, hemostasis and protection of surrounding normal anatomic structures. This multimedia article describes and illustrates the diagnosis, surgical approach and follow up of a 25 year old patient with extraadrenal pheochromocytoma and no family history. The presentation addresses all aspects of the management of this unique clinical entity and provides an excellent review for the surgeon considering laparoscopic approach to any retroperitoneal tumor occurring in this location.

Transduodenal Excision of Ampullary Polyp with Biliopancreatic Sphincteroplasty

In the past, surgeons developed experience with transduodenal excisions of duodenal and ampullary tumors, and sphincteroplasties for a variety of benign nonneoplastic disorders, including choledocholithiasis, benign stricture, and functional ampullary disorders. The advent of effective endoscopic therapies for these disorders, including endoscopic polypectomy and endoscopic sphincterotomy, as well as endobiliary and percutaneous biliary interventions has severely limited the experience of today s surgeons with transduodenal aproaches to the ampulla. Furthermore, benign neoplastic ampullary polyps are best treated by ampullectomy, which is likely curative; they are generally not amenable to endoscopic therapies. This presentation outlines important caveats in accomplishing a successful transduodenal ampullary excision. These include oblique duodenotomy overlying the ampullary orifice, control of the ampulla with traction sutures, and dissection in the submucosal plane, which leads to division of the biliary and pancreatic ducts. Equally important is the technique of reconstruction by biliopancreatic sphincteroplasty. The key element in reconstruction is the identification of the biliary and of the pancreatic duct, which is located at the 5 o clock position to the biliary orifice. Once these ducts are identified, careful reconstruction with a meticulous duct to mucosa technique is essential. As the numbers of operative biliary interventions undertaken continue to diminish, today s generation of surgeons will rely more on educational videos such as this to maintain their skills and knowledge in dealing with these complex and technically challenging operations.