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Waist Circumference Predicts Complications in Rectal Cancer SurgeryCourtney Balentine, Celia Robinson, Christy Marshall, Jonathan Wilks, KujtimHaderxhanaj, Shubhada Sansgiry, Nancy J. Petersen, Daniel Albo, David H. Berger

BACKGROUND The impact of obesity on development of postoperative complications aftergastrointestinal surgery remains controversial. This may be due to the fact that obesity istraditionally calculated by body mass index (BMI), an indirect measure that does not accountfor fat distribution. We hypothesized that a direct measure of obesity, waist circumference,would better predict complications after high-risk gastrointestinal procedures. METHODSRetrospective review of an institutional cancer database identified consecutive cases of menundergoing elective rectal resections. Waist circumference was calculated from preoperativeCT. Multivariate logistic regression was used to calculate independent predictors of complica-tions. RESULTS From 2002-2009, 152 patients with mean age 65.2±0.75 years and BMI28.0±0.43kg/m2 underwent elective resection of rectal adenoma or carcinoma. IncreasingBMI was not significantly associated with risk of postoperative complications includinginfection, dehiscence, and reoperation (Table 1). Greater waist circumference independentlypredicted increased risk of superficial infections (OR 1.98, 95% CI 1.19-3.30, p<0.008).Risk of wound disruption, dehiscence and reoperation were increased with expanding waistcircumference but the association did not achieve statistical significance. Overall, increasedwaist circumference predicted a significantly greater risk of having one or more postoperativecomplication (OR 1.56, 95% CI 1.04-2.34, p<0.034). CONCLUSIONS Although BMI iseasily calculated, it is an indirect measure of obesity that fails to account for differences infat quantity and distribution. Waist circumference, a direct measure of central adiposity, isa better predictor of short-term complications and can be used to identify patients who maybenefit from more aggressive infection control and prevention.

* indicates p<0.05 OR adjusted for age, ethnicity, smoking, DM, HTN, CAD, operative timeand laparoscopic vs open approach.

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Impact on Hospital Systems by Esophagectomy (EG) andPancreaticoduodenectomy (PD): Objective Comparison of SurgicalComplications Using the Accordion Severity Grading SystemDonald E. Low, MadhanKumar Kuppusamy, Yasushi Hashimoto, L. William Traverso

Introduction. EG and PD are complex GI operations that can impact a hospital system ifthe complication rate is high. The recently reported Accordion Severity Grading System ofSurgical Complications (ASGS) quantifies the amount of treatment (Tx) required to managesurgical complication by using readily available variables withminimal subjectivity (Ann Surg.2009 Aug;250(2):177-86). For the first time the ASGS will allow grading and comparison ofcomplications between individual case series to determine the impact of each operationon a hospital supportive systems. Methods. From prospective IRB-approved databases weretrospectively assigned ASGS categories 1-6 to all post-operative complications documentedin consecutive cases through December-2008 (EG=463 and PD=507) by a single esophagealor pancreatic surgeon respectively, in a tertiary-referral, resident-training hospital. Grade 1- mild, Grade 2 - moderate with pharmacologic Tx, Grade 3 - severe with invasive Tx notrequiring general anesthesia (GA), Grade 4 - severe invasive Tx with GA, Grade 5 - severewith organ failure, Grade 6 - postoperative death. Results. (Table. 1&2) Standard outcomemeasures were similar for EG and PD. As ASGS grade increased the number of cases decreasedand this decrease was similar (significant correlation) for EG vs. PD. As ASGS increased sodid LOS and the increase was similar for EG vs. PD. Conclusions. EG and PD have aremarkably similar incidence of standard outcome measures. As expected the new ASGScorrelates with LOS. For the first time severity grading of a complication, based on theamount of intervention required to treat, provides a clinically relevant tool for comparingcomplication rates between very different complex operations. Surprisingly their impact onthe hospital system was the same.Table.1

Table.2 Comparison of Complication Grades Between Procedures

S-853 SSAT Abstracts

Statistically significant correlation as % in Grade or LOS varied similarly for EG vs. PD,p<0.0001

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Predicting Post-Operative Mortality in Colorectal Cancer Surgery: ASystematic Review of the Accuracy of POSSUM, P-POSSUM and CR-POSSUMColin Richards, Fiona Leitch, Paul G. Horgan, Donald C. McMillan

Introduction The Physiological and Operative Severity Score for the enUmeration of Mortalityand morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CR-POSSUM) modifications are used extensively monitor post-operative outcome. This system-atic review assessed the predictive accuracy of each POSSUM model after colorectal cancerresection. Methods The review was undertaken according to a predefined protocol. Majorelectronic databases, including Medline, Embase, Cochrane Library and Pubmed weresearched using appropriate MeSH and free text terms. Abstracts were scanned and full textobtained for potentially relevant articles. The reference list of each article was then handsearched. Each study was entered into an electronic database using a data extraction tool.Two independent reviewers assessed each study against explicit inclusion criteria (colorectalcancer-specific data, actual and predicted mortality rates). Predictive accuracy for mortalitywas assessed by calculating weighted observed:expected (O:E) ratios with 95% confidenceintervals (CI) for each POSSUM model. Results 345 abstracts were scanned before 48 articleswere progressed to data extraction. After applying inclusion criteria, 18 studies, publishedbetween 1991 and 2009 were included in the final review. 10 studies (4799 patients)reported data on POSSUM, 17 studies (6576 patients) reported data on P-POSSUM and 13studies (4998 patients) reported data on CR-POSSUM. The majority of operations wereelective open colorectal cancer resections. Pooling of the data returned a weighted O:E ratioof 0.31 (CI 0.17-0.45, range 0.11-0.80) for POSSUM, 0.90 (CI 0.52-1.28, range 0.20-2.36)for P-POSSUM and 0.62 (CI 0.43-0.80, range 0.21-1.11) for CR-POSSUM. ConclusionThere was also significant heterogeneity in the reported O:E ratio for each POSSUM model,in particular P-POSSUM. Pooling of the data demonstrated P-POSSUM as the most accuratewith a weighted O:E ratio nearest to 1. POSSUM had a weighted O:E ratio furthest from1. CR-POSSUM, despite development specifically for use within colorectal surgery, was notas accurate as P-POSSUM and consistently over-predicted mortality.

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Flexible Endoscopic Cricopharyngeal Myotomy for Zenker's DiverticulumRichard A. Pierce, Danny V. Martinec, Trudie A. Goers, Erwin Rieder, Lee L. Swanstrom

Treatment of symptomatic Zenker's diverticuli has traditionally been via a transcervicalexcision of the diverticulum with a cricomyotomy, or endoluminal division of the septumbetween the esophagus and diverticulum using a rigid laparoscopic GIA stapler. When theseapproaches are not feasible or desirable, a cricopharyngeal myotomy may be performedthrough a flexible endoscopic approach. This video demonstrates the procedure using astandard endoscope and needle-knife, specialized dissecting tips, and endoscopic clips forwound edge approximation. The operation is quick and straightforward, and results in aone night patient stay with excellent emptying of the diverticulum and no leak.

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Laparoscopic PancreaticoduodenectomySujit Kulkarni, David Vivas, Tanuja Damani, Paresh C. Shah

Laparoscopic pancreaticoduodenectomy is technically challenging but gaining interest asinternational experience grows. We present a case of a 25 year old female who was diagnosedwith a psuedopapillary tumor in the head of the pancreas abutting the SMV. Our video willdemonstrate our technique for a totally laparoscopic pancreaticoduodenectomy with vascularisolation of the SMV via caudal-cranial approach. We have applied this technique to bothbenign and malignant lesions of the pancreas and ampulla with excellent results.

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A Standardized Approach to Minimally Invasive Transhiatal EsophagectomyJames Lopes, Steven N. Hochwald, Kfir Ben-David

We present a case of a 76 year old male patient who was diagnosed with an esophagealcancer in the distal third of his esophagus. This was biopsy proven to be adenocarcinoma andstaged by endoscopic ultrasound as a T2,N1 lesion. After receiving appropriate neoadjuvantchemoradiation, the patient was brought to the operating room for a transhiatal minimallyinvasive esophagectomy. Although there a variety of ways to perform the operation, wedemonstrate our technique in attempts to standardize the operation. The benefits of ouroperative methods have led to improved patient outcomes, when compared to the resultsof open esophagectomies, as well as optimal oncologic treatment.

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