Michael J. Pucci

Laparoscopic approaches to gastric gastrointestinal stromal tumors: an institutional review of 57 cases

IntroductionGastrointestinal stromal tumors (GIST) are uncommon gastric neoplasms, which are typically treated by surgical excision. During the past 10xa0years, our institution has gained experience in resecting these tumors by minimally invasive methods. The purpose of this study is to review our experience with laparoscopic resection, report our short-term outcomes, and offer our perspective on the technical nuances involved in handling these neoplasms.MethodsWe retrospectively queried our prospectively maintained, institutional review board-approved database for all gastric GISTs resected from 2002 to 2012. We analyzed all cases that were resected via laparoscopy. Operative notes were reviewed for the technique employed. Data on tumor location, size, margin status, operative time, and blood loss were collected and analyzed.ResultsDuring the 10-year study period, 104 gastric GISTs were resected. Laparoscopy was attempted in 58 cases with only one conversion to an open procedure. Tumors were separated based on anatomic zones. Forty-seven tumors (82xa0xa0%) were located on the body or fundus of the stomach (18 on the posterior wall and 29 on the anterior wall). Five GISTs (9xa0%) were located at the gastroesophageal junction (GEJ). Five tumors (9xa0%) were located at the antrum. The mean tumor size was 3.8xa0cm with a mean estimated blood loss of 40xa0ml. We achieved R0 resection in 100xa0% of the cases. Most tumors (96xa0%) were amenable to wedge resection. Tumors at the extremes of the stomach required variations of technique to achieve resection. Intraoperative endoscopy was selectively utilized.ConclusionsAs our experience with gastric GISTs has increased, laparoscopic resection has become our first-line treatment for most small- and moderate-sized tumors. By employing a structured approach to tumors along the entire stomach, laparoscopic resection of these tumors can be performed safely with adequate short-term results.

Does Resident Experience Affect Outcomes in Complex Abdominal Surgery? Pancreaticoduodenectomy as an Example

ObjectivesUnderstanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.MethodsWe reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed.ResultsForty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44xa0%; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28xa0% of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0xa0%; pu2009>u20090.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27xa0%, respectively; pu2009=u20090.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (ORu2009=u20090.97; pu2009<u20090.01). For a residents first PD case, the predicted probability of a PD-specific complication is 27xa0%; this rate decreases to 19xa0% by resident case number 15.ConclusionsComplex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume–outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee.

Safety of perioperative aspirin therapy in pancreatic operations.

BACKGROUNDnAntiplatelet therapy with aspirin is prevalent among patients presenting for operative treatment of pancreatic disorders. Operative practice has called for the cessation of aspirin 7-10 days before elective procedures because of the perceived increased risk of procedure-related bleeding. Our practice at Thomas Jefferson University has been to continue aspirin therapy throughout the perioperative period in patients undergoing elective pancreatic surgery.nnnSTUDY DESIGNnRecords for patients undergoing pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy between October 2005 and February 2012 were queried for perioperative aspirin use in this institutional research board-approved retrospective study. Statistical analyses were performed with Stata software.nnnRESULTSnDuring the study period, 1,017 patients underwent pancreatic resection, of whom 289 patients (28.4%) were maintained on aspirin through the morning of the operation. Patients in the aspirin group were older than those not taking aspirin (median 69 years vs 62 years, P < .0001). The estimated intraoperative blood loss was similar between the two groups, aspirin versus no aspirin (median 400 mL vs 400 mL, P = .661), as was the rate of blood transfusion anytime during the index admission (29% vs 26%, P = 0.37) and the postoperative duration of hospital stay (median 7 days vs 6 days, P = .103). The aspirin group had a slightly increased rate of cardiovascular complications (10.1% vs 7.0%, Pxa0=xa0.107), likely reflecting their increased cardiovascular comorbidities that led to their physicians recommending aspirin therapy. Rates of pancreatic fistula (15.1% vs 13.5%, Pxa0=xa0.490) and hospital readmissions were similar (16.9% vs 14.9%, Pxa0=xa0.451).nnnCONCLUSIONnThis is the first study to report that aspirin therapy is not associated with increased rates of perioperative bleeding, transfusion requirement, or major procedure related complications after elective pancreatic surgery. These data suggest that continuation of aspirin is safe and that the continuation of aspirin should be considered acceptable and preferable, particularly in patients with perceived substantial medical need for treatment with antiplatelet therapy.

The influence of transection site on the development of pancreatic fistula in patients undergoing distal pancreatectomy: A review of 294 consecutive cases

BACKGROUNDnPancreatic fistula (PF) is a significant cause of morbidity in patients undergoing distal pancreatectomy (DP), with an incidence of 15-40%. It remains unclear if the location of pancreatic transection affects the rate of PF occurrence. This study examines the correlation between the transection site of the pancreas during DP and the incidence of PF.nnnMETHODSnAll cases of DP from October 2005 to January 2012 were reviewed retrospectively from an institutional review board-approved database at the Thomas Jefferson University Hospital. Patient demographics and perioperative outcomes were analyzed. The pancreatic transection location was determined by review of operative reports, and then dichotomized into 2 groups: neck/body or tail. PF were graded following the International Study Group on Pancreatic Fistula guidelines.nnnRESULTSnDuring the study period, 294 DP were performed with 244 pancreas transections at the neck/body and 50 at the tail. Of the 294 patients, 52 (17.7%) developed a postoperative PF. The incidence of PF after transection at the tail of the pancreas was higher (28%) when compared with transection at the neck/body (15.6%; P = .04). When stratified by PF grade, grade A PF occurred more commonly when transection of the gland was at the tail (22% tail vs 8.2% neck/body; P = .007); however, no difference was found for grade B/C PF (6% tail vs 7.4% neck/body; P = 1).nnnCONCLUSIONnOur data suggest that PF occurs more often when the tail is transected during DP, although the majority are low grade and of minimal clinical significance. More severe PF occurred equally between the transection sites.

Use of Robotics in Colon and Rectal Surgery

The pace of innovation in the field of surgery continues to accelerate. As new technologies are developed in combination with industry and clinicians, specialized patient care improves. In the field of colon and rectal surgery, robotic systems offer clinicians many alternative ways to care for patients. From having the ability to round remotely to improved visualization and dissection in the operating room, robotic assistance can greatly benefit clinical outcomes. Although the field of robotics in surgery is still in its infancy, many groups are actively investigating technologies that will assist clinicians in caring for their patients. As these technologies evolve, surgeons will continue to find new and innovative ways to utilize the systems for improved patient care and comfort.

Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases.

BackgroundPancreatic body and tail ductal adenocarcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its various branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to “supercharge” the inflow. Herein, we review all reported cases of AR with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with arterial reconstruction including two cases with arterial bypasses not requiring interposition grafting.MethodsPerioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with celiac axis resection and concurrent AR was performed.ResultsFrom the literature, 12 reports involving 28 patients were identified of distal and total pancreatectomy with AR after CA resection. The most common AR in the literature, performed in 12 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our institutional experience, patient #1 had a primary side-to-end aorto-CHA bypass, patient #2 had a primary end-to-end bypass of the transected distal CHA to the left gastric artery in the setting a replaced left hepatic artery, and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All patients recovered from their operations without ischemic complications, and they are currently 16, 15, and 13xa0months post-op, respectively.ConclusionsThe criteria for resectability in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary arterial re-anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the CA. The modified Appleby procedure with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced pancreatic body and tail tumors.

Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center

BackgroundLaparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC.MethodsForty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to “time-out” and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale.ResultsIn the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (pxa0<xa00.001). The number of videos with CVS score >4 increased from 15.7 to 52xa0% (pxa0<xa00.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7xa0%, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41–93xa0%, pxa0<xa00.001) and offered appropriate bailout techniques (77–94xa0%, pxa0<xa00.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert scorexa0=xa04.71, SDxa0=xa00.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σxa0=xa00.83).ConclusionThe combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

Emergent pancreaticoduodenectomy: a dual institution experience and review of the literature

BACKGROUNDnEmergent pancreaticoduodenectomy (EPD) is an uncommon surgical procedure performed to treat patients with acute pancreaticoduodenal trauma, bleeding, or perforation. This study presents the experience of two university hospitals with EPD.nnnMETHODSnClinical data on EPD in trauma and nontrauma patients from 2002-2012 were extracted from the hepatopancreatobiliary surgery databases at Thomas Jefferson University and Kaunas Medical University Hospitals. Data on indications, perioperative variables, morbidity, and mortality rates were evaluated.nnnRESULTSnTen single-stage EPD patients were identified. Five underwent a classic Whipple resection, whereas five had pylorus preservation. Seven patients had traumatic indications for pancreaticoduodenectomy: three from gunshot wounds to the abdomen and four from blunt high-energy injuries (two sustained injuries by falling from height and two by direct assaults on the abdomen). Three cases of nontrauma patients had EPD surgery for massive gastrointestinal hemorrhage. The median age of the EPD cohort was 46 y (range, 19-67 y). All 10 patients were recovered and were discharged from the hospital with a median postoperative length of stay of 24 d (range, 8-69 d). There were no perioperative mortalities.nnnCONCLUSIONSnDespite a high morbidity rate and prolonged recovery, this dual institutional review suggests that EPD can serve as a lifesaving procedure in both the trauma and the urgent nontrauma settings.

Long-term functional outcomes of laparoscopic resection for gastric gastrointestinal stromal tumors.

IntroductionLaparoscopic resection is rapidly becoming the treatment of choice for small- to medium-sized gastric gastrointestinal stromal tumors (GIST). While long-term oncologic data are available, quality of life outcomes are less known.MethodsOur IRB-approved prospectively maintained database was retrospectively queried (2003–2013) for patients who underwent laparoscopic gastric GIST resection. Demographics along withxa0perioperative and oncologic outcomes were collected and analyzed. Patients were contacted and asked to complete a quality of life survey consisting of Likert scales scored from 1 to 5. Patients also completed the Gastrointestinal Quality of Life Index (GIQLI).ResultsA total of 69 patients were identified and 36 patients (59.0xa0% of eligible patients) responded to the survey. Median follow-up was 39xa0months. Patients most commonly reported no change in weight, appetite, early satiety, heartburn, persistent cough, dysphagia, and reflux medication dosing postoperatively. The median scores for chest pain and regurgitation were 4, falling in the “worsened” range. 8.33xa0% of patients reported worsened chest pain and 11.11xa0% of patients reported worsened regurgitation postoperatively. The GIQLI scores had a mean of 126.9 (range 77–141).ConclusionWhile some patients reported a worsening in early satiety, most patients reported no change in symptoms postoperatively, and the GIQLI scores remained within the normal range. Laparoscopic resection of gastric GIST provides durable results with minimal effect on longer-term quality of life.

A Modern Approach to the Surgical Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disorder that can cause a variety of typical and atypical symptoms. Although most patients can be rendered asymptomatic with medical treatment, some experience persistent breakthrough symptoms. A long history of GERD is associated with the risk for the development of Barretts esophagus and ultimately esophageal carcinoma. Although often underutilized, minimally invasive antireflux surgery can help manage these patients. However, thorough evaluation and accurate diagnosis of GERD and its underlying pathophysiology are critical in ensuring successful surgical treatment. This review offers a stepwise approach to the diagnostic workup of GERD and how to appropriately tailor available surgical treatments to specific patient subgroups.