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Innovations in Foregut Surgery

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Surgery Grand rounds Presentation at Rush University Medical Center on March 20, 2013. Presentation highlights clinical use of Prone Thoracoscopy, Fluorescence Angiography, Transcervical Videoscopic ...

Surgery Grand rounds Presentation at Rush University Medical Center on March 20, 2013. Presentation highlights clinical use of Prone Thoracoscopy, Fluorescence Angiography, Transcervical Videoscopic Esophageal Dissection (TVED) and Linx.

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  • Retrospecive review of 97 charts: Jan 2007- August 2010
  • Retrospecive review of 97 charts: Jan 2007- August 2010
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.

Innovations in Foregut Surgery Innovations in Foregut Surgery Presentation Transcript

  • Conflict of Interest / Disclosure • Paid Consultant to Torax - LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 1
  • Innovations in Foregut Surgery Surgery Grand Rounds Rush University Medical Center March 20, 2013 Chicago, Illinois C. Daniel Smith, MD, FACS 2
  • My Cases for The Past Two Weeks? Surgery Grand Rounds Rush University Medical Center March 20, 2013 Chicago, Illinois C. Daniel Smith, MD, FACS 3 View slide
  • March 4 - March 15 - Personal Case ListWeek of March 4 Monday Tuesday Wednesday Thursday Friday • O Umbilical Hernia • L Hiatal Hernia/Nissen • L Nissen • L Hiatal • L Redo Hiatal Hernia/Nissen/PEG Hernia/Nissen/PEG • L Nissen • 2-Field MIE • L Hiatal Hernia/NissenWeek of March 11 Monday Tuesday Wednesday Thursday Friday • LES Augmentation • LES Augmentation • L Esophageal • L Hiatal Hernia/Nissen Diverticulectomy • Stage II 3-Field MIE • L Heller/Toupet • L Ventral Hernia Rush University Medical Center Surgery Grand Rounds: Innovations in Foregut Surgery, March 20, 2013 3 View slide
  • March 4 - March 15 - Personal Case ListWeek of March 4 Monday Tuesday Wednesday Thursday Friday • O Umbilical Hernia Esophageal • L Hiatal Hernia/Nissen Diverticulectomy • L Nissen • L Hiatal • L Redo Hiatal Hernia/Nissen/PEG Hernia/Nissen/PEG • L Nissen • 2-Field MIE • L Hiatal Hernia/Nissen Stage II 3-Field MIEWeek of March 11 2-Field MIE Monday Tuesday Wednesday Thursday Friday • LES Augmentation • LES Augmentation • L Esophageal • L Hiatal Hernia/Nissen LES Augmentation • Stage II 3-Field MIE Diverticulectomy • L Heller/Toupet • L Ventral Hernia Rush University Medical Center Surgery Grand Rounds: Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery That I Use Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Prone ThoracoscopyRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Prone ThoracoscopyRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Prone Thoracoscopy - Advantages • Gravity facilitated dissection & exposure Blood and lung fall away from operative field • Ergonomically better angles for surgeon Stand only on one side of patient • Fewer trocars / retractor sites Three trocar technique • No need for a skilled assistant Camera driver only role for assistant • Dissecting too deep less concernRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Case 1 • 53 yo female • History of Barrett’s • Recently developed dysphagia and was found to have esophageal adenocarcinoma (T3N0Mo) • Underwent neoadjuvant therapy, restaged as T1NoMo • Now undergoing esophagectomyRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • • Go to next slide for Prone MIE Video 12
  • Prone ThoracoscopyRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • MIE Open Difference [Open-MIE]Outcome P-value (N=56) (N=41) (95% CI)Cardiac complications 18 (32%) 17 (41%) 9% (-10%, 29%) 0.40Pulmonary complications 19 (34%) 18 (44%) 10% (-10%, 30%) 0.40Pulmonary intervention 17 (30%) 14 (34%) 4% (-15%, 23%) 0.83Pulmonary embolism or deep vein thrombosis 4 (7%) 1 (2%) -5% (-13%, 4%) 0.39Leak 6 (11%) 4 (10%) -1% (-13%, 11%) 1.00Leak intervention 3 (5%) 0 (0%) -5% (-11%, 1%) 0.26Renal complications 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Wound infection 3 (5%) 4 (10%) 4% (-6%, 15%) 0.45Pharmacologic interventions* 22 (39%) 21 (51%) 12% (-8%, 32%) 0.30Delayed gastric emptying 1 (2%) 1 (2%) 1% (-5%, 7%) 1.00Voice hoarseness/laryngeal injury 5 (9%) 3 (7%) -2% (-13%, 9%) 1.00In-hospital mortality 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Discharged on total parental nutrition 2 (4%) 1 (2%) -1% (-8%, 6%) 1.00Discharged on tube feeding 2 (4%) 10 (24%) 21% (7%, 35%) 0.004Clavien classification (Grade III or higher) 19 (34%) 17 (41%) 8% (-12%, 27%) 0.5330-day mortality** 2 (4%) 3 (7%) 4% (-6%, 13%) 0.6590-day follow-upDilatations for stricture 5 (9%) 5 (12%) 3% (-9%, 16%) 0.74- P-values result from Fisher’s exact test. *Pharmacologic intervention includes total parental nutrition, tube feeding, and blood transfusion.**30-day mortality includes those patients who died in the hospital.
  • MIE Open Difference [Open-MIE]Outcome P-value (N=56) (N=41) (95% CI)Cardiac complications 18 (32%) 17 (41%) 9% (-10%, 29%) 0.40Pulmonary complications 19 (34%) 18 (44%) 10% (-10%, 30%) 0.40Pulmonary intervention 17 (30%) 14 (34%) 4% (-15%, 23%) 0.83Pulmonary embolism or deep vein thrombosis 4 (7%) 1 (2%) -5% (-13%, 4%) 0.39Leak 6 (11%) 4 (10%) -1% (-13%, 11%) 1.00Leak intervention 3 (5%) 0 (0%) -5% (-11%, 1%) 0.26Renal complications 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Wound infection 3 (5%) 4 (10%) 4% (-6%, 15%) 0.45Pharmacologic interventions* 22 (39%) 21 (51%) 12% (-8%, 32%) 0.30Delayed gastric emptying 1 (2%) 1 (2%) 1% (-5%, 7%) 1.00Voice hoarseness/laryngeal injury 5 (9%) 3 (7%) -2% (-13%, 9%) 1.00In-hospital mortality 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Discharged on total parental nutrition 2 (4%) 1 (2%) -1% (-8%, 6%) 1.00Discharged on tube feeding 2 (4%) 10 (24%) 21% (7%, 35%) 0.004Clavien classification (Grade III or higher) 19 (34%) 17 (41%) 8% (-12%, 27%) 0.5330-day mortality** 2 (4%) 3 (7%) 4% (-6%, 13%) 0.6590-day follow-upDilatations for stricture 5 (9%) 5 (12%) 3% (-9%, 16%) 0.74- P-values result from Fisher’s exact test. *Pharmacologic intervention includes total parental nutrition, tube feeding, and blood transfusion.**30-day mortality includes those patients who died in the hospital.
  • Case 2 • 72 yo male • Known about problem for 10 years • Worsening coughRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • • Go to next slide for Prone Diverticulectomy Video 17
  • Case 2 - Postop • Barium swallow POD 1 • Tolerated liquids • Discharged POD 2Rush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fluorescence Angiography • Indocyanine Green (ICG) Fluorescence • Assess quality of tissue perfusions and blood flow • Capture images of fluorescence • Real time quantitative analysis of perfusionRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fluorescence Angiography - Spy Elite• 2 cc if ICG intravenous followed by 10 cc NaCl flush• Fluorescence video of tissue capturedRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fluorescence Angiography • Use in breast reconstruction and tissue flap surgery • Preliminary use in GI surgery to assess anastomoses and bowel perfusion • Described in esophagectomy to assess gastric conduitRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Two Stage 3-Field MIE • Complications related to gastric conduit ischemia remain significant morbidity/mortality • In small studies, ischemic preconditioning may improve conduit perfusion • Clinical effectiveness difficult to prove - large sample size to show lower leak rate • Fluorescence angiography may provide real- time quantitative assessment of perfusionRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Two Stage 3-Field MIE Stage I • Diagnostic laparoscopy, ligation left gastric and short gastric artery, J-tube placement 2-3 weeks tube feeds - Impact Stage II • 3-field MIERush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Case 1 (again) • 53 yo female • History of Barrett’s • Recently developed dysphagia and was found to have esophageal adenocarcinoma (T3N0Mo) • Underwent neoadjuvant therapy, Stage II restaged as T1NoMo • Now undergoing esophagectomy • Next slide for video or SPY SetupRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fluorescence AngiographyRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fluorescence Angiography - ACS Forum 2013Rush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • 2-Field MIE (TVED)Rush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Case 3 • 74 yo male • 15 year history of Barrett’s • Sep 2012 EGD with biopsy - HGD and single flat area of adenoCa • Oct 2012 underwent EMR with RFA • Focus of adeno with deep margin positive T1bN0Mo • Next slide for 2-Field MIE VideoRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Case 3 - Pathology (T1bN1M0)A: EsophagusTUMOR SIZE: Greatest dimension: at least 0.6 cm HISTOLOGIC TYPE:Adenocarcinoma HISTOLOGIC GRADE: G2: Moderately differentiated G3: Poorly differentiatedMICROSCOPIC TUMOR EXTENSION: Tumor invades submucosa PROXIMAL MARGIN: Uninvolvedby invasive carcinoma DISTAL MARGIN: Uninvolved by invasive carcinoma or dysplasiaTREATMENT EFFECT: Marked response Moderate response PERINEURAL INVASION: Notidentified PRIMARY TUMOR (pT): pT1b: Tumor invades submucosa REGIONAL LYMPH NODES(pN): pN1: Regional lymph node metastasis involving 1 to 2 nodes NUMBER OF LYMPH NODE(S)INVOLVED: 1 NUMBER OF LYMPH NODE(S) EXAMINED: 26 ADDITIONAL PATHOLOGICFINDINGS: Intestinal metaplasia (Barretts esophagus)Rush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Fundoplication• Use of fundoplication for GERD has peaked, use slowly declining• GIs have largely stopped referring patients except for desperate or complicated cases• Most cases are done for complicated conditions (redo, large hiatal hernia, Barretts, severe refractory GERD• PPIs remain treatment of choice for all but the most severe cases of GERD 5
  • Fundoplication – Why Not?• Technical failures – inconsistent and questionable outcomes• Lack of standardized approach/technique• Inconsistent use – patients still have fundoplication performed without objective confirmation of GERD• Patients are afraid of the operation – troubling side- effects of gas bloat and excess flatus or perception that failure rate is 50%• Competing treatments – primarily PPIs, some endolumenal approaches 6
  • Case 4 • 33 yo male, attorney • Heartburn for past 18 years controlled with daily PPI • Recently with breakthrough symptoms and now on twice-daily PPI - HB symptoms better • Sleeps with HOB elevated and frequently wakes up regurgitatingRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Case 4 (cont.) • EGD - no esophagitis, irregular SCJ (no Barrett’s), no hiatal hernia • Bravo pH - pH in distal esophagus < 4 5% of time day one, 11% day 2 • BaSw - normal • Motility study - LESP 12mmHg, mild disordered peristalsis (80%), body pressure 45mmHg • Concerned about long-term effects of PPIs and side effects of fundoplicationRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • LinxFDA Approved March 2012 - PMA 8
  • Linx - Animations• Go to next 2 slides for Linx Animations 10
  • Linx – Barium Swallow Next slide for Video Esophagram 11
  • Linx - Postop Capsule LINX Bead Fibrous Capsule In-tact Muscular Layer MucosaNext slide for Explant Video 13
  • Linx – Procedure 12
  • Linx - Clinical Studies 14
  • Linx - Pivotal Study Results n engl j med 368;8 nejm.org february 21, 2013 14
  • Linx - Patient Satisfactionn engl j med 368;8 nejm.org february 21, 2013 14
  • Linx - Symptom Responsen engl j med 368;8 nejm.org february 21, 2013 14
  • Linx - Symptom Responsen engl j med 368;8 nejm.org february 21, 2013 14
  • Linx - Esophageal Acid Exposure n=100 P<0.001 n=96n engl j med 368;8 nejm.org february 21, 2013 15
  • Linx - Gas Bloat P<0.001 n=100 n=90 n=84 n=95n engl j med 368;8 nejm.org february 21, 2013 22
  • Linx - Clinical SummaryBaseline Post-LINX% of Pts Characteristic % of Pts 3 Years 100% Daily PPI dependence 8% 70% Reflux affecting their sleep on a daily basis 2% Reflux affecting their food tolerances on a daily 76% basis 2% Moderate or severe regurgitation including 57% aspirations 1% 55% Severe heartburn affecting their daily life 1% Experiencing extra esophageal symptoms in 51% addition to heartburn and/or regurgitation 12% 40% Esophagitis 11%
  • Innovations in Foregut Surgery - My Practice Esophageal Prone Thoracoscopy Diverticulectomy Fluorescence Stage II 3-Field MIE Angiography 2-Field MIE 2-Field MIE (TVED) LES Augmentation LinxRush University Medical Center Surgery Grand Rounds:Innovations in Foregut Surgery, March 20, 2013 3
  • Innovations in My Foregut Practice Surgery Grand Rounds Rush University Medical Center March 20, 2013 Chicago, Illinois C. Daniel Smith, MD, FACS 54