Kenneth Luberice

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.

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.

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

The learning curve for laparoendoscopic single-site (LESS) surgery was found to be definable, short, and safe.

Sulfonylureas (not metformin) improve survival of patients with diabetes and resectable pancreatic adenocarcinoma

Introduction: Patients with pancreatic adenocarcinoma have an increased propensity for diabetes. Recent studies suggest patients with diabetes and pancreatic adenocarcinoma treated with metformin have increased survival. This study was undertaken to determine whether metformin use is associated with increased survival in patients with pancreatic adenocarcinoma. Methods: Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 1991 to 2013 were included in this study. Survival was evaluated by Kaplan-Meier analysis. Median data are reported. Significance was accepted with 95% probability. Results: Of 414 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, 132 (32%) were diabetic. Of patients with diabetes, 35 (27%) were diet-controlled, 34 (26%) were treated with insulin alone, 18 (14%) were treated with metformin alone, 14 (10%) were treated with sulfonylureas alone, 7 (5%) were taking sulfonylureas with insulin, and 24 (18%) patients were taking metformin with sulfonylureas and/or insulin. Patients with/without diabetes not taking sulfonylureas had survival of 16.4 months compared with patients taking sulfonylureas who achieved survival of 27.5 months after undergoing pancreaticoduodenectomy (P<0.05). Conclusions: Patients taking sulfonylureas with or without other therapy had improved survival compared with patients not taking sulfonylureas after pancreaticoduodenectomy. Metformin does not seem to be beneficial for patients with resectable disease, but may be beneficial for patients with unresectable and/or metastatic disease as shown in prior studies. The use of sulfonylureas is associated with a survival benefit for patients undergoing resection for pancreatic adenocarcinoma. Tumor staging and margin status continue to be the overriding predictors of survival in patients with resectable pancreatic adenocarcinoma, not metformin therapy.

Sulfonylureas (Not Metformin) Improve Survival for Patients with Diabetes andResectable Pancreatic Adenocarcinoma

Objective: Patients with pancreatic adenocarcinoma have an increased propensity for diabetes. Recent studies suggest patients with diabetes and pancreatic adenocarcinoma treated with metformin have increased survival. This study was undertaken to determine if metformin use is associated with increased survival for patients with pancreatic adenocarcinoma. Methods: Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 1991-2013 were included in this study. Survival was evaluated by Kaplan-Meier analysis. Median data are reported. Significance was accepted with 95% probability. Results: Out of 414 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, 132 (32%) was diabetic. Of diabetic patients, 35 (27%) were diet-controlled, 34 (26%) were treated with insulin alone, 18 (14%) were treated with metformin alone, 14 (10%) were treated with sulfonylureas alone, 7 (5%) were taking sulfonylureas with insulin, and 24 (18%) patients were taking metformin with sulfonylureas and/or insulin. Patients with or without diabetes not taking sulfonylureas had survival of 16.4 months compared to patients taking sulfonylureas who achieved survival of 27.5 months after undergoing pancreaticoduodenectomy (p<0.05). Conclusion: Patients taking sulfonylureas with or without other therapy had improved survival compared to patients not taking sulfonylureas after pancreaticoduodenectomy. Metformin does not appear to be beneficial for patients with resectable disease, but may have a benefit for patients with unresectable and/or metastatic disease as shown in prior studies. The use of sulfonylureas is associated with a survival benefit for patients undergoing resection for pancreatic adenocarcinoma. Tumor staging and margin status continue to be the overriding predictors of survival for patients with resectable pancreatic adenocarcinoma, not metformin therapy.

Portal Hypertension Over the Last 25 Years: Where Did It Go?

BACKGROUND Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. STUDY DESIGN Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed. RESULTS Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001). CONCLUSIONS In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.

Tu1576 Surgical Apgar Score Does Not Predict Morbidity and Mortality for Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

S A T A b st ra ct s 51.9%, electrocautery 34.6%, ultrasonic scalpel 8.4%, saline coupled radio frequency ablation (RFA) 3.17% and scalpel 1.8%. The visible pancreatic duct and/or parenchymawere oversewn in 73%. In 21.6%, pancreatic stump was treated with the RFA device. Clinically significant leak was seen in 3.4% of patients whose pancreas was transected with a stapler and oversewn versus 15.3% of patients in whose pancreas was stapled. Patients whose pancreas was transected using the scalpel or an energy device and treated with RFA had a 13.3% CSL rate. Pancreas transected using a stapler and the stump treated with RFA had a 19.2% CSL rate, whereas oversewing a pancreatic margin that had been treated with the RFA device had a 28.6% clinically significant leak rate. A patient with transected margin treated with oversewn relative to a patient whose pancreas transected with stapler and oversewn was at highest risk for CSL [p = ,0.001, OR 11.5 (CI 3.1 42.4)]. In univariate models, the use of the RFA device and oversewing of the pancreatic duct were predictors of a CSL (p ,0.05). On evaluating various modes of transection, there was interaction of RFA with oversewing and stapling with oversewing of the pancreatic stump (p ,0.001)]. Conclusion: Among various methods available for pancreatic transection during DP, many of them recent technologies, none have a clinical superiority. Using the stapler to transect the pancreas has a higher rate of clinically significant leak as compared to treating the transected stump with RFA. Using the RFA device in addition to a stapler or oversewing the transected margin has a higher rate of clinically significant leak and should not be attempted. Randomized trials of newer technologies to help solve this age old dilemma are necessary.