Smith, C. Daniel

125 Background: Treatment for locally advanced esophageal carcinoma is radiation and chemotherapy, with or without surgery. Radiation has traditionally been delivered with 3D conformal radiation therapy (3D CRT). This study evaluates late toxicity in patients treated with IMRT as well as early outcomes and acute toxicity. Methods: This is a retrospective review of 32 patients with esophageal carcinoma treated with IMRT at Mayo Clinic Florida from 2008 -2012. Pathology includes squamous cell and adenocarcinomas. Tumor sites include middle and lower thoracic and GE junction. Clinical stages are TX-T3, N0-3, M0-1. All patients received at least one cycle of concurrent chemotherapy. IMRT dose was 50.4 Gy in 28 fractions prescribed to a target volume including the tumor and regional lymphatics. IMRT plans utilized coplaner beams in a 7-9 beam arrangement or volumetric modulated arc therapy. Results: Median follow-up is 8.9 months (range 2.4-23.0) for all patients and 13.1 months (range 2.8-23.0 months) in surviving patients. Median patient age is 69 (range 46-87). Trimodality treatment was completed in 20 patients (62.5%). Surgery was either an open or minimally invasive esophagogastrectomy. The incidence of grade 3 or greater late toxicity at 1 year was 48% in surgery patients and 26% in non-surgery patients. The most common grade 3 or higher toxicity was esophageal strictures in 25%. The incidence of any grade 3 or greater acute toxicity was 65% in the surgery patients and 75% in the non-surgery patients. Overall survival (OS) for all patients at 18 months is 57% (CI 37-86%) and progression-free survival (PFS) is 60% (36-99%). OS and PFS for trimodality therapy at 12 months is 83% (66-100%) and 81% (63-100%) respectively and for bimodality therapy is 34% (12-93%) and 70% (33-100%) respectively. Conclusions: Increased late toxicity occurs in surgery patients, and increased acute toxicity in non-surgery patients. Lower survival in non-surgery patients may be due to early progression, morbidities which preclude surgery or improved survival with surgery. Overall, IMRT is a feasible treatment modality, which may be equally efficacious to 3D CRT for the treatment of esophageal carcinoma.

Abstract Introduction: With an expanding population of patients requiring ventricular assist devices, it is inevitable that these patients will require noncardiac surgery. Ventricular assist devices provide mechanical support for a failing heart either as a bridge to transplant or now as a long-term support if transplant is not available, so-called destination therapy. These devices can add significant technical challenges to abdominal surgery, in that the power supply and drivelines crossing the abdomen can potentially be damaged. The use of preoperative or intraoperative imaging may aid in locating these devices and increase patient safety. Materials and Methods: We describe a laparoscopic cholecystectomy in two patients supported with HeartMate ® II (Thoratec Corp., Pleasanton, CA) left ventricular assist devices. Our use of fluoroscopic guidance in port placement is also described. A literature review was performed to assess the frequency of laparoscopic procedures performed on patients with similar ventricular assist devices and of complications associated with the device and other comorbidities. Results: Laparoscopic cholecystectomy was performed without significant intraoperative hemodynamic changes. The use of imaging, such as fluoroscopy, can identify the location of the ventricular assist device and its associated drive wires to assure they are not damaged intraoperatively. Conclusions: Laparoscopic cholecystectomy can be performed safely on patients with ventricular assist devices. Complications due to damage to the device can be avoided with the assistance of fluoroscopy to identify the implanted abdominal portions of the ventricular assist device. Each laparoscopic procedure performed on these patients presents the surgeon with unique obstacles in which careful operative planning and intraoperative monitoring are essential.

Hands-on training courses with local mentoring are excellent educational tools in laparoscopic surgery; however, the need for the physical presence of specialized instructors represents a limitation because of costs, time, and geographic constraints. Remote robotic telementoring using a wireless videoconferencing mobile robot could represent an alternative to local instruction. The authors compare local active and passive mentoring with remote robotic telementoring using the wireless RP-6 Robot that worked through a WiFi 802.11b connection during a hands-on laparoscopic training session. Surgeons were mentored once in France from the United States. Robot mentoring was well received and appreciated (assessment score of 2.65; scale, 0 to 4). There was no statistical difference in the different mentoring sessions (active, passive, and remote). Mobile wireless robot is a valuable tool in laparoscopic telementoring. Robotic-assisted telementoring may not replace onsite mentoring, but it may enhance educational opportunities and the quality of hands-on training courses by implementing tutoring with expert assistance from remote locations.

Abstract Occasionally pancreatoduodenectomy is performed for clinically suspected pancreatic malignancy only for the surgeon to find that a benign aetiology accounts for the pancreatic mass. The aim of this study was twofold: to determine the incidence of pancreatoduodenectomy performed for a misdiagnosis of pancreatoduodenal malignancy and to identify potentially avoidable errors in preoperative and intraoperative judgement. Between 1956 and 1990, radical pancreatoduodenectomy was performed in 603 patients at the Mayo Clinic; 29 (5 per cent) underwent pancreatoduodenectomy for a diagnosis made before and during surgery of primary pancreatic or periampullary malignancy that was later proven histopathologically to be either unsuspected subacute or chronic pancreatitis (22 patients), benign fibrous common bile duct stricture (two), and penetrating duodenal ulcer, metastatic melanoma, ampullary adenoma, intrahepatic drug-induced cholestasis and pseudocyst (one each). No patient had a preoperative diagnosis of chronic pancreatitis. Weight loss, pain and/or jaundice were present in 27 of the 29 patients. Objective imaging tests, such as computed tomography, ultrasonography and/or endoscopic retrograde cholangio-pancreatography, were performed in 25 patients. Potential errors in judgement may be avoided by a more aggressive attempt at biopsy in selected patients; in others, resection for presumed malignancy may be unavoidable.

AbstractWhile pancreaticoduodenectomy is today performed with an operative mortality of <5%, the incidence of significant operative morbidity remains at least 25%. Albeit rarely, completion pancreatectomy during the early postoperative period may be required to manage uncontrolled pancreatic anastomotic leaks. From 1964 to 1988, pancreaticoduodenectomy was performed on 479 patients at our institution, 178 (37%) of whom required re‐operation in the early postoperative period. Of these, 11 (6%) patients underwent completion pancreatectomy at a mean interval of 18 days following Whipple resection. The indications prompting re‐operation included a suspected pancreatic leak (n=8), intra‐abdominal hemorrhage (n=2), and pancreaticocutaneous fistula (n=1). Operative findings necessitating completion pancreatectomy included pancreatic anastomotic dehiscence with severe surrounding inflammation/necrosis prohibiting reanastomosis or repair (n=10) and necrotizing pancreatitis with uncontrolled hemorrhage (1). Seven (64%) of these 11 patients died postoperatively of sepsis and multiple organ failure. The mean hospital stay in the 4 surviving patients was 46 days (range, 26 to 53 days). These 4 patients survived for a mean period of 24 months following hospital dismissal.