Digestive Disease Week (DDW 2012)

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

CHICAGO – An 8-week course in mindfulness-based stress reduction reduced the severity of irritable bowel syndrome symptoms 6 and 12 months later, compared with 8 weeks of participation in a control group, follow-up on 68 women found.

Scores for overall irritable bowel syndrome (IBS) severity on the IBS Severity Scale (IBS-SS) were similar between groups at baseline (284 in the intervention group and 288 in the control group) but had improved significantly more in the mindfulness training group at 6 months (scores decreased 151 and 108 points, respectively) and at 12 months (scores decreased 115 vs. 26 points, respectively) compared with baseline.

The investigators originally reported significant benefits from the mindfulness course, compared with the control group immediately after the group sessions and at 3 months of follow-up in the prospective, randomized, controlled trial involving 75 patients (Am. J. Gastroenterol. 2011;106:1678-88). The current follow-up to 6 and 12 months shows lasting symptomatic improvements from mindfulness training, Olafur S. Palsson, Psy.D., and his associates reported at the annual Digestive Disease Week.

Among the 68 patients who completed 1 year of follow-up in the current analysis, the 33 who got mindfulness training also showed significantly greater improvements in secondary outcomes, compared with the 35 patients in the support group, said Dr. Palsson, a professor of medicine at the University of North Carolina, Chapel Hill.

Scores on the IBS Quality of Life Instrument were similar between groups at baseline (65 in the mindfulness group and 67 in the control group) but improved significantly more in the mindfulness group by 12 months (by 15 vs. 3, respectively).

Scores for gut-focused anxiety on the Visceral Sensitivity Index – which were not significantly different between groups at baseline or immediately after the group sessions – improved significantly more in the mindfulness group than in the control group by 3 months and the gains remained significantly greater at 6 months (by 12 vs. 2, respectively) and at 12 months (by 9 vs. –1, respectively).

"To our knowledge, these follow-up findings demonstrate some of the longest-duration therapeutic effects of mindfulness training ever reported in a clinical trial," he said.

Both interventions consisted of eight weekly sessions and a half-day retreat. The control group attended a conventional support group. The mindfulness course was based on the Mindfulness-Based Stress Reduction Program of Jon Kabat-Zinn, Ph.D., and Saki F. Santorelli, Ed.D., both of the University of Massachusetts, Worcester.

The longitudinal study controlled for the effects of race and income (less than or at least $40,000/year). The results suggest that the impact of mindfulness training on bowel symptom severity and gut-focused anxiety are well maintained and that improvements in health-related quality of life develop gradually over many months after the training, Dr. Palsson said. General psychological well-being did not change significantly based on the training, he added.

Scores for mindfulness on the Five-Facet Mindfulness Questionnaire were higher at every follow-up in the mindfulness group, compared with the control group, but the differences were not statistically significant. Mindfulness scores peaked in the mindfulness group at around 6 months and were attenuated at 12 months.

Patients ranged in age from 19 to 71 years, with a mean age of 43 years. Most patients were white, and women who were minorities or had lower incomes were more likely to drop out of the trial over time.

The National Center for Complementary and Alternative Medicine funded the study. Dr. Palsson and his coinvestigators reported financial associations with Takeda Pharmaceuticals, Ono Pharmaceuticals, Ironwood Pharmaceuticals, Entera Health, and/or the Rome Foundation.

[email protected]

On Twitter @sherryboschert

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital length of stay, compared with those who had open resection.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (mean of 3.3 days) than in the open group (mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.5), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-powered fields (OR, 4.7).

Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital length of stay, compared with those who had open resection.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (mean of 3.3 days) than in the open group (mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.5), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-powered fields (OR, 4.7).

Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital length of stay, compared with those who had open resection.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (mean of 3.3 days) than in the open group (mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.5), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-powered fields (OR, 4.7).

Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

An editorial in a recent issue of the Journal of the American Medical Association asked, Are medical conferences useful? The author concluded that we go to too many meetings, adding 10,000 tons of carbon to the environment for each moderate-sized meeting (JAMA 2012;307:1257-8).

I give the author credit for playing the environmental card – a card that a fellow from a green state like Oregon can’t dismiss – but the rest of the logic hardly stands.

It is argued that meetings preserve the status quo, serving as marketing platforms for pharma and device manufacturers while contributing little to science or practice, and that important findings can be released electronically without meeting presentation. The author misses the point that formal and informal discussion of the research findings is often more important than the presentation itself. Other reasons for attending meetings were completely opaque to the author. The editorial finishes with the question: "Are medical congresses dinosaurs doomed to become extinct?" This supposition feeds the common myth that meeting attendance is declining across the board.

I like to look at the data rather than accept dogma. I reviewed the attendance at three meetings I usually attend: the American College of Surgeons Clinical Congress, Digestive Disease Week, and the annual meeting of the American Surgical Association (ASA). Attendance at these meetings has remained constant over the past several years. There is little evidence that medical congresses are in danger of going extinct, unless we are overtaken by an Ice Age we cannot foresee. Even in countries where health care reform and reduced reimbursement have been the norm for decades, medical conferences are well attended.

The value of attending medical conferences is a blend of learning the science and practice of surgery, program and policy development (otherwise known as committee work), idea sharing, and relationship building. But how important is each of these? Here’s a little time-allocation exercise. When you attend a conference, how much time do you spend in the meeting rooms? How much time are you in the corridor, at the exhibits, or talking over a cup of coffee?

Rather than rely on my own experience to answer these questions, I conducted a straw poll at the recent ASA meeting. I found that most surgeons spend about 30% of their time in the meeting sessions, 20% of their time in committee and board meetings, and 50% of their time talking over coffee, over a drink, over dinner, or on the golf course. Eager for information, younger surgeons spend more time in the meeting rooms. Eager to learn through direct conversations and to re-establish friendships, older surgeons are more likely to converse outside the meeting rooms.

Why is this important? Your colleagues who don’t go to national meetings say that they can get all the new information they need from the Internet, journals, and local lectures and conferences. They are correct. What they can’t get is the face-to-face communication with a peer from across the country who may have some insights on problems that both are wrestling with close to home. The science of relationships is very similar to the science of societies. By living and working closely with each other, we all get smarter, and better solutions are developed in this manner than by individuals sitting behind their computers designing the next video game or mining the Internet for insight.

When the work product of a group is calculated, adding the IQs of the participants together underestimates the intellectual power of the group. This phenomenon has been termed "collective intelligence." The power of "groupthink" has been recognized in the science and technology sector for some time. For example, the Massachusetts Institute of Technology has a Center for Collective Intelligence, and new science is rarely funded by the National Institutes of Health these days without evidence that the aims of the project will be addressed through team science, which brings together diversity of training and intellect to focus on the problem at hand.

So what does collective intelligence have to do with a medical conference? The collective experience and wisdom of meeting attendees is amazingly helpful at deciphering which new findings are truly innovative and field changing and which are less likely to change our world. Upon returning from meetings and visits to other departments of surgery, I usually catalog one or two changes to my practice, or new thoughts for questions that need answering, that have been inspired by a meeting conversation or a scientific discussion. Most of our good papers have come from such inspiration.

All presidential addresses at professional meetings could be titled "Relationships Matter." It is through our relationships with others – mentors and peers – that we find our way successfully through our professional careers.

Relationships managed well bring success and happiness. Relationships managed poorly, usually by inattention or poor decision making, can bring failure and sadness, if not clinical depression. Unsupportive and imperious bosses and lazy or ill-informed subordinates are galling, but it is the failure of peer-to-peer relationships that brings the most angst.

Like any important relationship, professional peer relationships should not be taken for granted. A brief rule of thumb is that if you don’t feel that you are putting more into a relationship than you are receiving in return, you probably aren’t. Which means that your peers or partners are likely to believe that they are putting more into the relationship than they receive. So be generous with your time and energy, and be sensitive to the needs of others. When you receive an icy response from colleagues, it is probably because they feel you have taken something from them (patients, prestige, position). Listen to their desires and give back, if you can. A small investment can yield big rewards.

Dr. Hunter, chief of surgery at Oregon Health and Science University, Portland, is an ACS Fellow and president of the Society for Surgery of the Alimentary Tract. This is a condensed version of the SSAT Presidential Address presented by Dr. Hunter on May 20, 2012, at the annual Digestive Disease Week.

An editorial in a recent issue of the Journal of the American Medical Association asked, Are medical conferences useful? The author concluded that we go to too many meetings, adding 10,000 tons of carbon to the environment for each moderate-sized meeting (JAMA 2012;307:1257-8).

I give the author credit for playing the environmental card – a card that a fellow from a green state like Oregon can’t dismiss – but the rest of the logic hardly stands.

It is argued that meetings preserve the status quo, serving as marketing platforms for pharma and device manufacturers while contributing little to science or practice, and that important findings can be released electronically without meeting presentation. The author misses the point that formal and informal discussion of the research findings is often more important than the presentation itself. Other reasons for attending meetings were completely opaque to the author. The editorial finishes with the question: "Are medical congresses dinosaurs doomed to become extinct?" This supposition feeds the common myth that meeting attendance is declining across the board.

I like to look at the data rather than accept dogma. I reviewed the attendance at three meetings I usually attend: the American College of Surgeons Clinical Congress, Digestive Disease Week, and the annual meeting of the American Surgical Association (ASA). Attendance at these meetings has remained constant over the past several years. There is little evidence that medical congresses are in danger of going extinct, unless we are overtaken by an Ice Age we cannot foresee. Even in countries where health care reform and reduced reimbursement have been the norm for decades, medical conferences are well attended.

The value of attending medical conferences is a blend of learning the science and practice of surgery, program and policy development (otherwise known as committee work), idea sharing, and relationship building. But how important is each of these? Here’s a little time-allocation exercise. When you attend a conference, how much time do you spend in the meeting rooms? How much time are you in the corridor, at the exhibits, or talking over a cup of coffee?

Rather than rely on my own experience to answer these questions, I conducted a straw poll at the recent ASA meeting. I found that most surgeons spend about 30% of their time in the meeting sessions, 20% of their time in committee and board meetings, and 50% of their time talking over coffee, over a drink, over dinner, or on the golf course. Eager for information, younger surgeons spend more time in the meeting rooms. Eager to learn through direct conversations and to re-establish friendships, older surgeons are more likely to converse outside the meeting rooms.

Why is this important? Your colleagues who don’t go to national meetings say that they can get all the new information they need from the Internet, journals, and local lectures and conferences. They are correct. What they can’t get is the face-to-face communication with a peer from across the country who may have some insights on problems that both are wrestling with close to home. The science of relationships is very similar to the science of societies. By living and working closely with each other, we all get smarter, and better solutions are developed in this manner than by individuals sitting behind their computers designing the next video game or mining the Internet for insight.

When the work product of a group is calculated, adding the IQs of the participants together underestimates the intellectual power of the group. This phenomenon has been termed "collective intelligence." The power of "groupthink" has been recognized in the science and technology sector for some time. For example, the Massachusetts Institute of Technology has a Center for Collective Intelligence, and new science is rarely funded by the National Institutes of Health these days without evidence that the aims of the project will be addressed through team science, which brings together diversity of training and intellect to focus on the problem at hand.

So what does collective intelligence have to do with a medical conference? The collective experience and wisdom of meeting attendees is amazingly helpful at deciphering which new findings are truly innovative and field changing and which are less likely to change our world. Upon returning from meetings and visits to other departments of surgery, I usually catalog one or two changes to my practice, or new thoughts for questions that need answering, that have been inspired by a meeting conversation or a scientific discussion. Most of our good papers have come from such inspiration.

All presidential addresses at professional meetings could be titled "Relationships Matter." It is through our relationships with others – mentors and peers – that we find our way successfully through our professional careers.

Relationships managed well bring success and happiness. Relationships managed poorly, usually by inattention or poor decision making, can bring failure and sadness, if not clinical depression. Unsupportive and imperious bosses and lazy or ill-informed subordinates are galling, but it is the failure of peer-to-peer relationships that brings the most angst.

Like any important relationship, professional peer relationships should not be taken for granted. A brief rule of thumb is that if you don’t feel that you are putting more into a relationship than you are receiving in return, you probably aren’t. Which means that your peers or partners are likely to believe that they are putting more into the relationship than they receive. So be generous with your time and energy, and be sensitive to the needs of others. When you receive an icy response from colleagues, it is probably because they feel you have taken something from them (patients, prestige, position). Listen to their desires and give back, if you can. A small investment can yield big rewards.

Dr. Hunter, chief of surgery at Oregon Health and Science University, Portland, is an ACS Fellow and president of the Society for Surgery of the Alimentary Tract. This is a condensed version of the SSAT Presidential Address presented by Dr. Hunter on May 20, 2012, at the annual Digestive Disease Week.

An editorial in a recent issue of the Journal of the American Medical Association asked, Are medical conferences useful? The author concluded that we go to too many meetings, adding 10,000 tons of carbon to the environment for each moderate-sized meeting (JAMA 2012;307:1257-8).

I give the author credit for playing the environmental card – a card that a fellow from a green state like Oregon can’t dismiss – but the rest of the logic hardly stands.

It is argued that meetings preserve the status quo, serving as marketing platforms for pharma and device manufacturers while contributing little to science or practice, and that important findings can be released electronically without meeting presentation. The author misses the point that formal and informal discussion of the research findings is often more important than the presentation itself. Other reasons for attending meetings were completely opaque to the author. The editorial finishes with the question: "Are medical congresses dinosaurs doomed to become extinct?" This supposition feeds the common myth that meeting attendance is declining across the board.

I like to look at the data rather than accept dogma. I reviewed the attendance at three meetings I usually attend: the American College of Surgeons Clinical Congress, Digestive Disease Week, and the annual meeting of the American Surgical Association (ASA). Attendance at these meetings has remained constant over the past several years. There is little evidence that medical congresses are in danger of going extinct, unless we are overtaken by an Ice Age we cannot foresee. Even in countries where health care reform and reduced reimbursement have been the norm for decades, medical conferences are well attended.

The value of attending medical conferences is a blend of learning the science and practice of surgery, program and policy development (otherwise known as committee work), idea sharing, and relationship building. But how important is each of these? Here’s a little time-allocation exercise. When you attend a conference, how much time do you spend in the meeting rooms? How much time are you in the corridor, at the exhibits, or talking over a cup of coffee?

Rather than rely on my own experience to answer these questions, I conducted a straw poll at the recent ASA meeting. I found that most surgeons spend about 30% of their time in the meeting sessions, 20% of their time in committee and board meetings, and 50% of their time talking over coffee, over a drink, over dinner, or on the golf course. Eager for information, younger surgeons spend more time in the meeting rooms. Eager to learn through direct conversations and to re-establish friendships, older surgeons are more likely to converse outside the meeting rooms.

Why is this important? Your colleagues who don’t go to national meetings say that they can get all the new information they need from the Internet, journals, and local lectures and conferences. They are correct. What they can’t get is the face-to-face communication with a peer from across the country who may have some insights on problems that both are wrestling with close to home. The science of relationships is very similar to the science of societies. By living and working closely with each other, we all get smarter, and better solutions are developed in this manner than by individuals sitting behind their computers designing the next video game or mining the Internet for insight.

When the work product of a group is calculated, adding the IQs of the participants together underestimates the intellectual power of the group. This phenomenon has been termed "collective intelligence." The power of "groupthink" has been recognized in the science and technology sector for some time. For example, the Massachusetts Institute of Technology has a Center for Collective Intelligence, and new science is rarely funded by the National Institutes of Health these days without evidence that the aims of the project will be addressed through team science, which brings together diversity of training and intellect to focus on the problem at hand.

So what does collective intelligence have to do with a medical conference? The collective experience and wisdom of meeting attendees is amazingly helpful at deciphering which new findings are truly innovative and field changing and which are less likely to change our world. Upon returning from meetings and visits to other departments of surgery, I usually catalog one or two changes to my practice, or new thoughts for questions that need answering, that have been inspired by a meeting conversation or a scientific discussion. Most of our good papers have come from such inspiration.

All presidential addresses at professional meetings could be titled "Relationships Matter." It is through our relationships with others – mentors and peers – that we find our way successfully through our professional careers.

Relationships managed well bring success and happiness. Relationships managed poorly, usually by inattention or poor decision making, can bring failure and sadness, if not clinical depression. Unsupportive and imperious bosses and lazy or ill-informed subordinates are galling, but it is the failure of peer-to-peer relationships that brings the most angst.

Like any important relationship, professional peer relationships should not be taken for granted. A brief rule of thumb is that if you don’t feel that you are putting more into a relationship than you are receiving in return, you probably aren’t. Which means that your peers or partners are likely to believe that they are putting more into the relationship than they receive. So be generous with your time and energy, and be sensitive to the needs of others. When you receive an icy response from colleagues, it is probably because they feel you have taken something from them (patients, prestige, position). Listen to their desires and give back, if you can. A small investment can yield big rewards.

Dr. Hunter, chief of surgery at Oregon Health and Science University, Portland, is an ACS Fellow and president of the Society for Surgery of the Alimentary Tract. This is a condensed version of the SSAT Presidential Address presented by Dr. Hunter on May 20, 2012, at the annual Digestive Disease Week.

SAN DIEGO – African Americans and Asian Americans with hepatocellular carcinoma had significantly worse inpatient mortality than did white patients, and the data suggest that socioeconomic disparities in availability of health services may at least partially explain the difference.

In a multivariate analysis that also applied propensity-score matching, African American inpatients with hepatocellular carcinoma (HCC) were 30% more likely to die, compared with their white counterparts, and Asian Americans had a 60% higher inpatient mortality, compared with white Americans who had HCC.

The findings were based on data collected from 27,741 patients during 2002-2011 by the University Health Consortium, Dr. Sabeen F. Medvedev said at the the annual Digestive Disease Week.

The data analyzed by Dr. Medvedev and her associates showed a broad range of disparities by racial and ethnic groups for type of medical coverage, disease severity at the time of hospitalization, presence of metastatic disease, and whether patients received invasive treatment or liver transplantation.

"Despite increased survival due to advances in surveillance and surgical interventions for HCC, we found racial disparities exist in prognosis and disease presentation," said Dr. Medvedev of the division of gastroenterology and liver diseases at the George Washington University in Washington.

After propensity scores to mimic randomization of treatment options were used, a 60% excess mortality in African Americans, compared with whites, was reduced to a 30% excess, "indicating that the observed disparity in deaths might extend beyond disproportionate treatment allocation. The take home message is, due to their insurance and economic status and lack of access to care, African Americans did not have as many treatment options," Dr. Medvedev said. "We think that this is a delivery-of-care issue," she added in an interview.

The University Health Consortium includes 116 U.S. academic medical centers and 272 of their affiliated hospitals – about 90% of America’s nonprofit academic medical centers. HCC patients who were treated during the 9 years studied had a median age of 61 years; 54% of them were white, 16% were African American, 11% Asian, 9% Hispanic, and 10% were from other ethnic groups.

The white subgroup had the highest percentage of patients with private medical insurance (41%) and the lowest rate of Medicaid or uninsured status (15%). In contrast, among African Americans, 30% had private insurance, and 37% received Medicaid or were uninsured. Among Asian Americans, 38% had private insurance, and 30% had Medicaid or were uninsured.

An analysis of disease presentation and treatments applied showed that the African American and Asian American subgroups each had a 20% higher rate of HCC metastasis at the time of hospitalization, compared with the white subgroup.

African Americans also received significantly fewer liver transplants, resections, ablations, and transarterial chemoembolizations, compared with the white subgroup. Asian Americans received significantly fewer transarterial chemoembolizations, compared with whites, but their rates for other types of treatments were similar to the rates seen in the white subgroup. The only treatment received significantly less often by Hispanic patients, compared with whites, was resection.

Dr. Medvedev said that she had no disclosures.

SAN DIEGO – African Americans and Asian Americans with hepatocellular carcinoma had significantly worse inpatient mortality than did white patients, and the data suggest that socioeconomic disparities in availability of health services may at least partially explain the difference.

In a multivariate analysis that also applied propensity-score matching, African American inpatients with hepatocellular carcinoma (HCC) were 30% more likely to die, compared with their white counterparts, and Asian Americans had a 60% higher inpatient mortality, compared with white Americans who had HCC.

The findings were based on data collected from 27,741 patients during 2002-2011 by the University Health Consortium, Dr. Sabeen F. Medvedev said at the the annual Digestive Disease Week.

The data analyzed by Dr. Medvedev and her associates showed a broad range of disparities by racial and ethnic groups for type of medical coverage, disease severity at the time of hospitalization, presence of metastatic disease, and whether patients received invasive treatment or liver transplantation.

"Despite increased survival due to advances in surveillance and surgical interventions for HCC, we found racial disparities exist in prognosis and disease presentation," said Dr. Medvedev of the division of gastroenterology and liver diseases at the George Washington University in Washington.

After propensity scores to mimic randomization of treatment options were used, a 60% excess mortality in African Americans, compared with whites, was reduced to a 30% excess, "indicating that the observed disparity in deaths might extend beyond disproportionate treatment allocation. The take home message is, due to their insurance and economic status and lack of access to care, African Americans did not have as many treatment options," Dr. Medvedev said. "We think that this is a delivery-of-care issue," she added in an interview.

The University Health Consortium includes 116 U.S. academic medical centers and 272 of their affiliated hospitals – about 90% of America’s nonprofit academic medical centers. HCC patients who were treated during the 9 years studied had a median age of 61 years; 54% of them were white, 16% were African American, 11% Asian, 9% Hispanic, and 10% were from other ethnic groups.

The white subgroup had the highest percentage of patients with private medical insurance (41%) and the lowest rate of Medicaid or uninsured status (15%). In contrast, among African Americans, 30% had private insurance, and 37% received Medicaid or were uninsured. Among Asian Americans, 38% had private insurance, and 30% had Medicaid or were uninsured.

An analysis of disease presentation and treatments applied showed that the African American and Asian American subgroups each had a 20% higher rate of HCC metastasis at the time of hospitalization, compared with the white subgroup.

African Americans also received significantly fewer liver transplants, resections, ablations, and transarterial chemoembolizations, compared with the white subgroup. Asian Americans received significantly fewer transarterial chemoembolizations, compared with whites, but their rates for other types of treatments were similar to the rates seen in the white subgroup. The only treatment received significantly less often by Hispanic patients, compared with whites, was resection.

Dr. Medvedev said that she had no disclosures.

SAN DIEGO – African Americans and Asian Americans with hepatocellular carcinoma had significantly worse inpatient mortality than did white patients, and the data suggest that socioeconomic disparities in availability of health services may at least partially explain the difference.

In a multivariate analysis that also applied propensity-score matching, African American inpatients with hepatocellular carcinoma (HCC) were 30% more likely to die, compared with their white counterparts, and Asian Americans had a 60% higher inpatient mortality, compared with white Americans who had HCC.

The findings were based on data collected from 27,741 patients during 2002-2011 by the University Health Consortium, Dr. Sabeen F. Medvedev said at the the annual Digestive Disease Week.

The data analyzed by Dr. Medvedev and her associates showed a broad range of disparities by racial and ethnic groups for type of medical coverage, disease severity at the time of hospitalization, presence of metastatic disease, and whether patients received invasive treatment or liver transplantation.

"Despite increased survival due to advances in surveillance and surgical interventions for HCC, we found racial disparities exist in prognosis and disease presentation," said Dr. Medvedev of the division of gastroenterology and liver diseases at the George Washington University in Washington.

After propensity scores to mimic randomization of treatment options were used, a 60% excess mortality in African Americans, compared with whites, was reduced to a 30% excess, "indicating that the observed disparity in deaths might extend beyond disproportionate treatment allocation. The take home message is, due to their insurance and economic status and lack of access to care, African Americans did not have as many treatment options," Dr. Medvedev said. "We think that this is a delivery-of-care issue," she added in an interview.

The University Health Consortium includes 116 U.S. academic medical centers and 272 of their affiliated hospitals – about 90% of America’s nonprofit academic medical centers. HCC patients who were treated during the 9 years studied had a median age of 61 years; 54% of them were white, 16% were African American, 11% Asian, 9% Hispanic, and 10% were from other ethnic groups.

The white subgroup had the highest percentage of patients with private medical insurance (41%) and the lowest rate of Medicaid or uninsured status (15%). In contrast, among African Americans, 30% had private insurance, and 37% received Medicaid or were uninsured. Among Asian Americans, 38% had private insurance, and 30% had Medicaid or were uninsured.

An analysis of disease presentation and treatments applied showed that the African American and Asian American subgroups each had a 20% higher rate of HCC metastasis at the time of hospitalization, compared with the white subgroup.

African Americans also received significantly fewer liver transplants, resections, ablations, and transarterial chemoembolizations, compared with the white subgroup. Asian Americans received significantly fewer transarterial chemoembolizations, compared with whites, but their rates for other types of treatments were similar to the rates seen in the white subgroup. The only treatment received significantly less often by Hispanic patients, compared with whites, was resection.

Dr. Medvedev said that she had no disclosures.

SAN DIEGO – Measuring the number of oxygen desaturations a patient has that are coincident with episodes of esophageal acidity may be an effective new way to identify patients who primarily have respiratory symptoms secondary to gastroesophageal reflux, based on results from a controlled study involving 103 people.

"These data provide further proof of principle that reflux-associated oxygen desaturations are more common in GERD [gastroesophageal reflux disease] patients with respiratory complaints, and may be a useful discriminatory test in GERD patients with primarily respiratory symptoms," Dr. Candice L. Wilshire said at the annual Digestive Disease Week.

"We believe that the desaturations are due to reflux, and we think that if you stop the reflux with surgery you should cure it," said Dr. Wilshire, a thoracic surgeon at the University of Rochester (N.Y.). "We believe that looking at the reflux-associated desaturations could identify patients who have pulmonary symptoms due to reflux, as opposed to primarily pulmonary pathology."

But Dr. Wilshire cautioned that counting a patient’s reflux-associated oxygen desaturations is not ready for routine diagnostic use. "Currently, our indications for [antireflux] surgery have not changed," she said. "At the moment, we use a separate esophageal pH catheter and pulse oximeter, and there are some artifacts," which means that this assessment method is still in development, Dr. Wilshire said in an interview. Further research is needed to "discern what are true desaturations" caused by reflux and "what are artifacts. It would be nice to get some software that can do this for us. I think there are things we could do to make [these assessments] easier and to eliminate some of the artifacts."

Having a reliable way to identify patients who experience frequent oxygen desaturation episodes that are secondary to reflux should refine diagnoses and streamline delivery of appropriate treatment to patients, Dr. Wilshire said. "A subgroup of GERD patients have no gastrointestinal symptoms and just complain of a chronic cough. They get sent to us when they’re far down the road, after seeing pulmonologists." Her new approach for identifying the pulmonary consequences of GERD – by counting episodes of oxygen desaturation – may provide a way to more quickly identify these types of patients, she said.

Her study enrolled 37 GERD patients who primarily had respiratory symptoms (cough, hoarseness, or throat clearing), 26 GERD patients who primarily had gastrointestinal symptoms (such as heartburn or epigastric pain), and 40 controls who were asymptomatic.

All participants underwent 24-hour, ambulatory assessment with a pair of measurement devices: a finger-clip device for measuring oxygen saturation, and a multichannel, intraluminal pH impedance monitor to measure esophageal pH. The researchers tallied an oxygen desaturation episode whenever the subject’s blood oxygen level dropped below 90% or at least 6 percentage points below the person’s baseline level. They tallied acid-reflux episodes as times when esophageal pH registered less than 4, in both proximal and distal sites of the esophagus. They considered reflux-associated oxygen desaturations (RADs) to be desaturations that occurred within 5 minutes of a reflux episode.

The results showed that the controls had a median of 3.0 distal RADs during 24 hours, and the 95th percentile number was 11.0 RADs. In comparison, the patients with GERD and gastrointestinal symptoms had a median of 6.5 RADs, significantly more than the controls; the patients with GERD and pulmonary symptoms had a median of 17.0 RADs, significantly more than both the control group and those with gastrointestinal GERD.

The researchers found a similar pattern for proximal acid-episode RADs. The control group had a median of 1.0 episode during 24 hours, with a 95th percentile level of 7.0 episodes. Patients with gastrointestinal GERD symptoms had a median of 3.0 RADs, significantly more than the controls, whereas those with primarily pulmonary symptoms of GERD had a median of 8.0 RADs, significantly more than the controls and the patients with primarily gastrointestinal symptoms.

The percentage of patients with 11 or more distal RADs – the "elevated" threshold, based on the benchmark established by the controls – was 27% in patients with primarily gastrointestinal symptoms of GERD and 70% in those with primarily pulmonary symptoms of GERD. The percentage with an elevated number of proximal RADs (more than 7) was 19% in the gastrointestinal group and 62% in the pulmonary group, Dr. Wilshire reported.

In addition, RAD numbers substantially declined in the small number of patients in the study who had their symptoms improve by undergoing antireflux surgery and who had their RADs measured before and after surgery.

Dr. Wilshire said that she had no disclosures.

SAN DIEGO – Measuring the number of oxygen desaturations a patient has that are coincident with episodes of esophageal acidity may be an effective new way to identify patients who primarily have respiratory symptoms secondary to gastroesophageal reflux, based on results from a controlled study involving 103 people.

"These data provide further proof of principle that reflux-associated oxygen desaturations are more common in GERD [gastroesophageal reflux disease] patients with respiratory complaints, and may be a useful discriminatory test in GERD patients with primarily respiratory symptoms," Dr. Candice L. Wilshire said at the annual Digestive Disease Week.

"We believe that the desaturations are due to reflux, and we think that if you stop the reflux with surgery you should cure it," said Dr. Wilshire, a thoracic surgeon at the University of Rochester (N.Y.). "We believe that looking at the reflux-associated desaturations could identify patients who have pulmonary symptoms due to reflux, as opposed to primarily pulmonary pathology."

But Dr. Wilshire cautioned that counting a patient’s reflux-associated oxygen desaturations is not ready for routine diagnostic use. "Currently, our indications for [antireflux] surgery have not changed," she said. "At the moment, we use a separate esophageal pH catheter and pulse oximeter, and there are some artifacts," which means that this assessment method is still in development, Dr. Wilshire said in an interview. Further research is needed to "discern what are true desaturations" caused by reflux and "what are artifacts. It would be nice to get some software that can do this for us. I think there are things we could do to make [these assessments] easier and to eliminate some of the artifacts."

Having a reliable way to identify patients who experience frequent oxygen desaturation episodes that are secondary to reflux should refine diagnoses and streamline delivery of appropriate treatment to patients, Dr. Wilshire said. "A subgroup of GERD patients have no gastrointestinal symptoms and just complain of a chronic cough. They get sent to us when they’re far down the road, after seeing pulmonologists." Her new approach for identifying the pulmonary consequences of GERD – by counting episodes of oxygen desaturation – may provide a way to more quickly identify these types of patients, she said.

Her study enrolled 37 GERD patients who primarily had respiratory symptoms (cough, hoarseness, or throat clearing), 26 GERD patients who primarily had gastrointestinal symptoms (such as heartburn or epigastric pain), and 40 controls who were asymptomatic.

All participants underwent 24-hour, ambulatory assessment with a pair of measurement devices: a finger-clip device for measuring oxygen saturation, and a multichannel, intraluminal pH impedance monitor to measure esophageal pH. The researchers tallied an oxygen desaturation episode whenever the subject’s blood oxygen level dropped below 90% or at least 6 percentage points below the person’s baseline level. They tallied acid-reflux episodes as times when esophageal pH registered less than 4, in both proximal and distal sites of the esophagus. They considered reflux-associated oxygen desaturations (RADs) to be desaturations that occurred within 5 minutes of a reflux episode.

The results showed that the controls had a median of 3.0 distal RADs during 24 hours, and the 95th percentile number was 11.0 RADs. In comparison, the patients with GERD and gastrointestinal symptoms had a median of 6.5 RADs, significantly more than the controls; the patients with GERD and pulmonary symptoms had a median of 17.0 RADs, significantly more than both the control group and those with gastrointestinal GERD.

The researchers found a similar pattern for proximal acid-episode RADs. The control group had a median of 1.0 episode during 24 hours, with a 95th percentile level of 7.0 episodes. Patients with gastrointestinal GERD symptoms had a median of 3.0 RADs, significantly more than the controls, whereas those with primarily pulmonary symptoms of GERD had a median of 8.0 RADs, significantly more than the controls and the patients with primarily gastrointestinal symptoms.

The percentage of patients with 11 or more distal RADs – the "elevated" threshold, based on the benchmark established by the controls – was 27% in patients with primarily gastrointestinal symptoms of GERD and 70% in those with primarily pulmonary symptoms of GERD. The percentage with an elevated number of proximal RADs (more than 7) was 19% in the gastrointestinal group and 62% in the pulmonary group, Dr. Wilshire reported.

In addition, RAD numbers substantially declined in the small number of patients in the study who had their symptoms improve by undergoing antireflux surgery and who had their RADs measured before and after surgery.

Dr. Wilshire said that she had no disclosures.

SAN DIEGO – Measuring the number of oxygen desaturations a patient has that are coincident with episodes of esophageal acidity may be an effective new way to identify patients who primarily have respiratory symptoms secondary to gastroesophageal reflux, based on results from a controlled study involving 103 people.

"These data provide further proof of principle that reflux-associated oxygen desaturations are more common in GERD [gastroesophageal reflux disease] patients with respiratory complaints, and may be a useful discriminatory test in GERD patients with primarily respiratory symptoms," Dr. Candice L. Wilshire said at the annual Digestive Disease Week.

"We believe that the desaturations are due to reflux, and we think that if you stop the reflux with surgery you should cure it," said Dr. Wilshire, a thoracic surgeon at the University of Rochester (N.Y.). "We believe that looking at the reflux-associated desaturations could identify patients who have pulmonary symptoms due to reflux, as opposed to primarily pulmonary pathology."

But Dr. Wilshire cautioned that counting a patient’s reflux-associated oxygen desaturations is not ready for routine diagnostic use. "Currently, our indications for [antireflux] surgery have not changed," she said. "At the moment, we use a separate esophageal pH catheter and pulse oximeter, and there are some artifacts," which means that this assessment method is still in development, Dr. Wilshire said in an interview. Further research is needed to "discern what are true desaturations" caused by reflux and "what are artifacts. It would be nice to get some software that can do this for us. I think there are things we could do to make [these assessments] easier and to eliminate some of the artifacts."

Having a reliable way to identify patients who experience frequent oxygen desaturation episodes that are secondary to reflux should refine diagnoses and streamline delivery of appropriate treatment to patients, Dr. Wilshire said. "A subgroup of GERD patients have no gastrointestinal symptoms and just complain of a chronic cough. They get sent to us when they’re far down the road, after seeing pulmonologists." Her new approach for identifying the pulmonary consequences of GERD – by counting episodes of oxygen desaturation – may provide a way to more quickly identify these types of patients, she said.

Her study enrolled 37 GERD patients who primarily had respiratory symptoms (cough, hoarseness, or throat clearing), 26 GERD patients who primarily had gastrointestinal symptoms (such as heartburn or epigastric pain), and 40 controls who were asymptomatic.

All participants underwent 24-hour, ambulatory assessment with a pair of measurement devices: a finger-clip device for measuring oxygen saturation, and a multichannel, intraluminal pH impedance monitor to measure esophageal pH. The researchers tallied an oxygen desaturation episode whenever the subject’s blood oxygen level dropped below 90% or at least 6 percentage points below the person’s baseline level. They tallied acid-reflux episodes as times when esophageal pH registered less than 4, in both proximal and distal sites of the esophagus. They considered reflux-associated oxygen desaturations (RADs) to be desaturations that occurred within 5 minutes of a reflux episode.

The results showed that the controls had a median of 3.0 distal RADs during 24 hours, and the 95th percentile number was 11.0 RADs. In comparison, the patients with GERD and gastrointestinal symptoms had a median of 6.5 RADs, significantly more than the controls; the patients with GERD and pulmonary symptoms had a median of 17.0 RADs, significantly more than both the control group and those with gastrointestinal GERD.

The researchers found a similar pattern for proximal acid-episode RADs. The control group had a median of 1.0 episode during 24 hours, with a 95th percentile level of 7.0 episodes. Patients with gastrointestinal GERD symptoms had a median of 3.0 RADs, significantly more than the controls, whereas those with primarily pulmonary symptoms of GERD had a median of 8.0 RADs, significantly more than the controls and the patients with primarily gastrointestinal symptoms.

The percentage of patients with 11 or more distal RADs – the "elevated" threshold, based on the benchmark established by the controls – was 27% in patients with primarily gastrointestinal symptoms of GERD and 70% in those with primarily pulmonary symptoms of GERD. The percentage with an elevated number of proximal RADs (more than 7) was 19% in the gastrointestinal group and 62% in the pulmonary group, Dr. Wilshire reported.

In addition, RAD numbers substantially declined in the small number of patients in the study who had their symptoms improve by undergoing antireflux surgery and who had their RADs measured before and after surgery.

Dr. Wilshire said that she had no disclosures.

SAN DIEGO – Removing 12-20 lymph nodes for node-negative patients and 8-25 lymph nodes for node-positive patients confers a survival advantage in esophageal cancer, according to a data analysis of more than 2,100 patients.

"The maximum survival advantage was seen when a minimum of 15 lymph nodes were removed in node-negative patients and 20 in the node-positive patients," Dr. Kenneth L. Meredith said.

The Surveillance Epidemiology and End Results (SEER) analysis also revealed that the benefit of adjuvant radiation therapy on survival in esophageal cancer is limited to those with node-positive disease, suggesting that the management of esophageal cancer remains a work in progress, Dr. Meredith said at the annual Digestive Disease Week.

"Currently the treatment for these patients includes esophagectomy with or without neoadjuvant therapy," Dr. Meredith said. "There are many approaches to esophagectomy, and there are a multitude of recommendations for nodal clearance of these patients. If you look at single and multi-institutional database reviews, their recommendation for nodal harvest is anywhere from 6 to 40. We decided to perform a more recent analysis of the SEER database."

Dr. Meredith, chief of esophagogastric oncology and director of esophageal research at Moffitt Cancer Center, Tampa, Fla., and his associates queried the database for patients who underwent esophagectomy for cancer between 2004 and 2008. They identified 2,109 patients and categorized them by nodal harvest: greater than or less than 5, 8, 10, 12, 15, 20, 25, and 30.

Of the 2,109 patients, 467 were treated with adjuvant radiation and 1,642 were not. Patients treated with neoadjuvant radiation were excluded from the analysis, as were those who had histologic subtypes of cancer that were not adenocarcinoma or squamous cell carcinoma.

Dr. Meredith reported that use of adjuvant radiation was associated with decreased survival in patients with stage I disease (hazard ratio, 2.73; P less than .0001), no benefit in stage II (P = .075), increased survival in stage III (HR, 0.71; P = .005), and no benefit in stage IV (P = .913).

The median number of lymph nodes retracted from all patients was nine, "which is a little low by most standards," said Dr. Meredith.

Multivariate analysis revealed that among node-positive patients, the median survival with and without adjuvant radiation was 23 months and 20 months, respectively, and the 3-year survival rates were 34% and 26.7%, respectively (P = .023). Among node-negative patients, the 3-year survival with and without adjuvant radiation was 48.8% and 68.8%, respectively.

"The only lymph node cutoff we found was significant for all patients was that if you had more than five lymph nodes resected," Dr. Meredith said. "As you [removed more], lymph node harvesting did not translate into a survival benefit. However, when you subclassified whether they were node negative or node positive, a cutoff of 12 and 15, respectively, did translate into a survival benefit. In node-positive patients, those who had more than 8, 10, 12, 15, and 20 lymph nodes did translate into a survival benefit." He added that with regard to extended lymphadenectomy, or more than 20 lymph nodes resected in either cohort, no additional survival benefit was seen.

Dr. Meredith acknowledged certain limitations of the study, including its retrospective design and the fact that SEER lacks information on the nutritional status and performance status of patients. "There is also no information on margin status, chemotherapy, radiation dose, field design, and treatment technique," he said.

Dr. Meredith said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Removing 12-20 lymph nodes for node-negative patients and 8-25 lymph nodes for node-positive patients confers a survival advantage in esophageal cancer, according to a data analysis of more than 2,100 patients.

"The maximum survival advantage was seen when a minimum of 15 lymph nodes were removed in node-negative patients and 20 in the node-positive patients," Dr. Kenneth L. Meredith said.

The Surveillance Epidemiology and End Results (SEER) analysis also revealed that the benefit of adjuvant radiation therapy on survival in esophageal cancer is limited to those with node-positive disease, suggesting that the management of esophageal cancer remains a work in progress, Dr. Meredith said at the annual Digestive Disease Week.

"Currently the treatment for these patients includes esophagectomy with or without neoadjuvant therapy," Dr. Meredith said. "There are many approaches to esophagectomy, and there are a multitude of recommendations for nodal clearance of these patients. If you look at single and multi-institutional database reviews, their recommendation for nodal harvest is anywhere from 6 to 40. We decided to perform a more recent analysis of the SEER database."

Dr. Meredith, chief of esophagogastric oncology and director of esophageal research at Moffitt Cancer Center, Tampa, Fla., and his associates queried the database for patients who underwent esophagectomy for cancer between 2004 and 2008. They identified 2,109 patients and categorized them by nodal harvest: greater than or less than 5, 8, 10, 12, 15, 20, 25, and 30.

Of the 2,109 patients, 467 were treated with adjuvant radiation and 1,642 were not. Patients treated with neoadjuvant radiation were excluded from the analysis, as were those who had histologic subtypes of cancer that were not adenocarcinoma or squamous cell carcinoma.

Dr. Meredith reported that use of adjuvant radiation was associated with decreased survival in patients with stage I disease (hazard ratio, 2.73; P less than .0001), no benefit in stage II (P = .075), increased survival in stage III (HR, 0.71; P = .005), and no benefit in stage IV (P = .913).

The median number of lymph nodes retracted from all patients was nine, "which is a little low by most standards," said Dr. Meredith.

Multivariate analysis revealed that among node-positive patients, the median survival with and without adjuvant radiation was 23 months and 20 months, respectively, and the 3-year survival rates were 34% and 26.7%, respectively (P = .023). Among node-negative patients, the 3-year survival with and without adjuvant radiation was 48.8% and 68.8%, respectively.

"The only lymph node cutoff we found was significant for all patients was that if you had more than five lymph nodes resected," Dr. Meredith said. "As you [removed more], lymph node harvesting did not translate into a survival benefit. However, when you subclassified whether they were node negative or node positive, a cutoff of 12 and 15, respectively, did translate into a survival benefit. In node-positive patients, those who had more than 8, 10, 12, 15, and 20 lymph nodes did translate into a survival benefit." He added that with regard to extended lymphadenectomy, or more than 20 lymph nodes resected in either cohort, no additional survival benefit was seen.

Dr. Meredith acknowledged certain limitations of the study, including its retrospective design and the fact that SEER lacks information on the nutritional status and performance status of patients. "There is also no information on margin status, chemotherapy, radiation dose, field design, and treatment technique," he said.

Dr. Meredith said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Removing 12-20 lymph nodes for node-negative patients and 8-25 lymph nodes for node-positive patients confers a survival advantage in esophageal cancer, according to a data analysis of more than 2,100 patients.

"The maximum survival advantage was seen when a minimum of 15 lymph nodes were removed in node-negative patients and 20 in the node-positive patients," Dr. Kenneth L. Meredith said.

The Surveillance Epidemiology and End Results (SEER) analysis also revealed that the benefit of adjuvant radiation therapy on survival in esophageal cancer is limited to those with node-positive disease, suggesting that the management of esophageal cancer remains a work in progress, Dr. Meredith said at the annual Digestive Disease Week.

"Currently the treatment for these patients includes esophagectomy with or without neoadjuvant therapy," Dr. Meredith said. "There are many approaches to esophagectomy, and there are a multitude of recommendations for nodal clearance of these patients. If you look at single and multi-institutional database reviews, their recommendation for nodal harvest is anywhere from 6 to 40. We decided to perform a more recent analysis of the SEER database."

Dr. Meredith, chief of esophagogastric oncology and director of esophageal research at Moffitt Cancer Center, Tampa, Fla., and his associates queried the database for patients who underwent esophagectomy for cancer between 2004 and 2008. They identified 2,109 patients and categorized them by nodal harvest: greater than or less than 5, 8, 10, 12, 15, 20, 25, and 30.

Of the 2,109 patients, 467 were treated with adjuvant radiation and 1,642 were not. Patients treated with neoadjuvant radiation were excluded from the analysis, as were those who had histologic subtypes of cancer that were not adenocarcinoma or squamous cell carcinoma.

Dr. Meredith reported that use of adjuvant radiation was associated with decreased survival in patients with stage I disease (hazard ratio, 2.73; P less than .0001), no benefit in stage II (P = .075), increased survival in stage III (HR, 0.71; P = .005), and no benefit in stage IV (P = .913).

The median number of lymph nodes retracted from all patients was nine, "which is a little low by most standards," said Dr. Meredith.

Multivariate analysis revealed that among node-positive patients, the median survival with and without adjuvant radiation was 23 months and 20 months, respectively, and the 3-year survival rates were 34% and 26.7%, respectively (P = .023). Among node-negative patients, the 3-year survival with and without adjuvant radiation was 48.8% and 68.8%, respectively.

"The only lymph node cutoff we found was significant for all patients was that if you had more than five lymph nodes resected," Dr. Meredith said. "As you [removed more], lymph node harvesting did not translate into a survival benefit. However, when you subclassified whether they were node negative or node positive, a cutoff of 12 and 15, respectively, did translate into a survival benefit. In node-positive patients, those who had more than 8, 10, 12, 15, and 20 lymph nodes did translate into a survival benefit." He added that with regard to extended lymphadenectomy, or more than 20 lymph nodes resected in either cohort, no additional survival benefit was seen.

Dr. Meredith acknowledged certain limitations of the study, including its retrospective design and the fact that SEER lacks information on the nutritional status and performance status of patients. "There is also no information on margin status, chemotherapy, radiation dose, field design, and treatment technique," he said.

Dr. Meredith said that he had no relevant financial conflicts to disclose.

SAN DIEGO – A proposed quality measure for pancreatic surgery has the potential to assess performance more thoroughly than current volume and mortality measures, judging by surgeons’ responses to a recent survey.

The 12-item "Quality Scorecard," developed by Dr. Brian T. Kalish of Beth Israel Deaconess Medical Center, Boston, and a team of pancreatic surgeons from multiple academic medical centers, consists of actionable and meaningful measures. The scorecard is aligned with the Institute of Medicine’s health care quality domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability.

"Traditional quality metrics in high-acuity surgery on their own cannot measure or satisfy the [IOM] domains," Dr. Kalish explained in a plenary presentation at the annual Digestive Disease Week. "Our goal was to evaluate the need for broader quality metrics and whether such broader metrics would align to contemporary IOM domains."

"We expect the scorecard to reveal quality to an extent that volume and mortality alone cannot."

Toward this end, the development team worked with a professional market research firm to create a web-based survey and distribute it to expert pancreatic surgeons identified through specialty societies and verified by survey demographics, Dr. Kalish explained. "The survey asked respondents to rank [62] proposed quality metrics on level of importance, from essential to not important, and to align the metric to one or more of the [IOM] quality domains." Points were awarded for level of importance and multidomain alignment, and the two scores for a given quality metric were averaged to render a total quality score that was then normalized to a 100-point scale, he said.

The 21% survey response rate represented 106 surgeons primarily from academic medical centers in North America who perform an average of 43 pancreatic operations per year, said Dr. Kalish. The need for improved quality metrics was indicated by 90% of the respondents, while 81% believed that a "quality scorecard" in pancreatic surgery would probably or definitely be of value, he reported. More than one-third of the proposed metrics aligned to more than one IOM domain, and at least half of the respondents rated these as essential or very important, he said.

Of the 62 metrics, 12 emerged with the highest total quality score. In rank order, they are: multidisciplinary services for pancreatic diseases, major complication rate, perioperative mortality, overall complication rate, incidence of postoperative hemorrhage, venous thromboembolism prophylaxis, patients with malignancy who undergo adjuvant therapy, readmission rates (30 day, 90 day, total), incidence of postoperative pancreatic fistula, timely and appropriate perioperative antibiotics, survival rates (1 year and 5 year), and timing from diagnosis to surgical consultation.

"The metrics related to mortality, the rate and severity of complications, and access to multidisciplinary services for pancreatic disease had the highest total quality scores; technical and perioperative metrics had intermediate scores; and metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest total quality scores," Dr. Kalish observed. With respect to the IOM domains, "the least represented domains were equitability, efficiency, and patient-centeredness," he said.

Although the actual performance thresholds for each of the metrics require further definition and validation, "we expect the scorecard to reveal quality to an extent that volume and mortality alone cannot," Dr. Kalish stated, noting that the development process is ongoing.

Future efforts include the organization of patient focus groups and a formal survey of patients and family members to attain insight into which quality metrics are important to those receiving care, as well as a multicenter prospective validation.

Dr. Kalish reported having no relevant financial conflicts of interest.

SAN DIEGO – A proposed quality measure for pancreatic surgery has the potential to assess performance more thoroughly than current volume and mortality measures, judging by surgeons’ responses to a recent survey.

The 12-item "Quality Scorecard," developed by Dr. Brian T. Kalish of Beth Israel Deaconess Medical Center, Boston, and a team of pancreatic surgeons from multiple academic medical centers, consists of actionable and meaningful measures. The scorecard is aligned with the Institute of Medicine’s health care quality domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability.

"Traditional quality metrics in high-acuity surgery on their own cannot measure or satisfy the [IOM] domains," Dr. Kalish explained in a plenary presentation at the annual Digestive Disease Week. "Our goal was to evaluate the need for broader quality metrics and whether such broader metrics would align to contemporary IOM domains."

"We expect the scorecard to reveal quality to an extent that volume and mortality alone cannot."

Toward this end, the development team worked with a professional market research firm to create a web-based survey and distribute it to expert pancreatic surgeons identified through specialty societies and verified by survey demographics, Dr. Kalish explained. "The survey asked respondents to rank [62] proposed quality metrics on level of importance, from essential to not important, and to align the metric to one or more of the [IOM] quality domains." Points were awarded for level of importance and multidomain alignment, and the two scores for a given quality metric were averaged to render a total quality score that was then normalized to a 100-point scale, he said.

The 21% survey response rate represented 106 surgeons primarily from academic medical centers in North America who perform an average of 43 pancreatic operations per year, said Dr. Kalish. The need for improved quality metrics was indicated by 90% of the respondents, while 81% believed that a "quality scorecard" in pancreatic surgery would probably or definitely be of value, he reported. More than one-third of the proposed metrics aligned to more than one IOM domain, and at least half of the respondents rated these as essential or very important, he said.

Of the 62 metrics, 12 emerged with the highest total quality score. In rank order, they are: multidisciplinary services for pancreatic diseases, major complication rate, perioperative mortality, overall complication rate, incidence of postoperative hemorrhage, venous thromboembolism prophylaxis, patients with malignancy who undergo adjuvant therapy, readmission rates (30 day, 90 day, total), incidence of postoperative pancreatic fistula, timely and appropriate perioperative antibiotics, survival rates (1 year and 5 year), and timing from diagnosis to surgical consultation.

"The metrics related to mortality, the rate and severity of complications, and access to multidisciplinary services for pancreatic disease had the highest total quality scores; technical and perioperative metrics had intermediate scores; and metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest total quality scores," Dr. Kalish observed. With respect to the IOM domains, "the least represented domains were equitability, efficiency, and patient-centeredness," he said.

Although the actual performance thresholds for each of the metrics require further definition and validation, "we expect the scorecard to reveal quality to an extent that volume and mortality alone cannot," Dr. Kalish stated, noting that the development process is ongoing.

Future efforts include the organization of patient focus groups and a formal survey of patients and family members to attain insight into which quality metrics are important to those receiving care, as well as a multicenter prospective validation.

Dr. Kalish reported having no relevant financial conflicts of interest.

SAN DIEGO – A proposed quality measure for pancreatic surgery has the potential to assess performance more thoroughly than current volume and mortality measures, judging by surgeons’ responses to a recent survey.

The 12-item "Quality Scorecard," developed by Dr. Brian T. Kalish of Beth Israel Deaconess Medical Center, Boston, and a team of pancreatic surgeons from multiple academic medical centers, consists of actionable and meaningful measures. The scorecard is aligned with the Institute of Medicine’s health care quality domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability.

"Traditional quality metrics in high-acuity surgery on their own cannot measure or satisfy the [IOM] domains," Dr. Kalish explained in a plenary presentation at the annual Digestive Disease Week. "Our goal was to evaluate the need for broader quality metrics and whether such broader metrics would align to contemporary IOM domains."

"We expect the scorecard to reveal quality to an extent that volume and mortality alone cannot."

Toward this end, the development team worked with a professional market research firm to create a web-based survey and distribute it to expert pancreatic surgeons identified through specialty societies and verified by survey demographics, Dr. Kalish explained. "The survey asked respondents to rank [62] proposed quality metrics on level of importance, from essential to not important, and to align the metric to one or more of the [IOM] quality domains." Points were awarded for level of importance and multidomain alignment, and the two scores for a given quality metric were averaged to render a total quality score that was then normalized to a 100-point scale, he said.

The 21% survey response rate represented 106 surgeons primarily from academic medical centers in North America who perform an average of 43 pancreatic operations per year, said Dr. Kalish. The need for improved quality metrics was indicated by 90% of the respondents, while 81% believed that a "quality scorecard" in pancreatic surgery would probably or definitely be of value, he reported. More than one-third of the proposed metrics aligned to more than one IOM domain, and at least half of the respondents rated these as essential or very important, he said.

Of the 62 metrics, 12 emerged with the highest total quality score. In rank order, they are: multidisciplinary services for pancreatic diseases, major complication rate, perioperative mortality, overall complication rate, incidence of postoperative hemorrhage, venous thromboembolism prophylaxis, patients with malignancy who undergo adjuvant therapy, readmission rates (30 day, 90 day, total), incidence of postoperative pancreatic fistula, timely and appropriate perioperative antibiotics, survival rates (1 year and 5 year), and timing from diagnosis to surgical consultation.

"The metrics related to mortality, the rate and severity of complications, and access to multidisciplinary services for pancreatic disease had the highest total quality scores; technical and perioperative metrics had intermediate scores; and metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest total quality scores," Dr. Kalish observed. With respect to the IOM domains, "the least represented domains were equitability, efficiency, and patient-centeredness," he said.

Although the actual performance thresholds for each of the metrics require further definition and validation, "we expect the scorecard to reveal quality to an extent that volume and mortality alone cannot," Dr. Kalish stated, noting that the development process is ongoing.

Future efforts include the organization of patient focus groups and a formal survey of patients and family members to attain insight into which quality metrics are important to those receiving care, as well as a multicenter prospective validation.

Dr. Kalish reported having no relevant financial conflicts of interest.

SAN DIEGO – Ventral hernia repair is associated with overall financial losses reaching the thousands of dollars in some cases, a single-center study demonstrated.

"These financial losses are just simply not sustainable," Dr. Drew Reynolds said in an interview prior to the annual Digestive Disease Week, where the study was presented.

In what is believed to be the first study of its kind, he and his associates set out to systematically evaluate hospital finances with respect to open ventral incisional hernia repair in the tertiary care environment.

"There is limited cost data currently available in the literature," he said. "These patients are complex and often require management in tertiary referral centers. Biologic meshes have a legitimate role in certain clinical scenarios, especially in those encountered in the tertiary care environment. Reimbursement strategies need to be reevaluated with more appropriate adjustment for preoperative risk factors and operative complexity."

Hospital costs associated with complex hernia repairs include direct costs (mesh materials, supplies, and non–surgeon labor), and indirect costs (facility fees, equipment depreciation, and unallocated labor), said Dr. Reynolds, a fellow in minimally invasive surgery at the University of Kentucky, Lexington. "Operative supplies including mesh represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts," the researchers wrote in their abstract.

Dr. Reynolds and his associates evaluated cost data on 415 consecutive open ventral hernia repairs performed at the university’s hospital between July 1, 2008, and May 31, 2011, using CPT codes 49560, 49561, 49565, and 49566. They analyzed data based on hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. The primary end points were hospital revenue and costs. Revenue calculations were adjusted for comorbid conditions/diagnosis-related groups, and readmission costs were not included.

Of the 415 patients, 353 were inpatients and 62 were outpatients. Among the 353 inpatients, ventral hernia repair was the primary procedure performed on 173 patients and was the secondary procedure for 180 patients. The median net revenue was significantly greater for those who underwent hernia repair as a secondary procedure compared with those who had hernia repair as a primary procedure ($17,310 vs. $10,360, P less than .01), as were net losses ($3,340 vs. $1,700, P less than .01).

Among the inpatient primary ventral hernia repairs, 46 were repaired without mesh, 79 were repaired with synthetic mesh, and 48 were repaired with biologic mesh, for median direct costs of $5,432, $7,590, and $16,970, respectively (P less than .01).

Dr. Reynolds also reported that among all inpatient ventral hernia repairs, the median net losses for repairs without mesh were $500, while synthetic mesh–based repairs yielded a median net profit of $60. The median contribution margin for cases involving biologic mesh was –$4,560, and the median net financial loss was $8,370.

Among patients who underwent outpatient ventral hernia repairs, median net losses among those performed with and without synthetic mesh reached $1,560 and $230, respectively.

"It was surprising to note that the vast majority of open ventral incisional hernia repairs are performed at an overall financial loss for the hospital," Dr. Reynolds said. "Further, it was surprising to note that inpatient biologic mesh–based ventral hernia repairs resulted in such a sizable negative median contribution margin ($4,560), and the striking median net financial loss of $8,370."

He acknowledged certain limitations of the study, including the fact that data used in the analysis were retrieved by CPT code search. "Hospital readmission costs were not included, which leads to underestimation of the costs," he added.

Dr. Reynolds said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Ventral hernia repair is associated with overall financial losses reaching the thousands of dollars in some cases, a single-center study demonstrated.

"These financial losses are just simply not sustainable," Dr. Drew Reynolds said in an interview prior to the annual Digestive Disease Week, where the study was presented.

In what is believed to be the first study of its kind, he and his associates set out to systematically evaluate hospital finances with respect to open ventral incisional hernia repair in the tertiary care environment.

"There is limited cost data currently available in the literature," he said. "These patients are complex and often require management in tertiary referral centers. Biologic meshes have a legitimate role in certain clinical scenarios, especially in those encountered in the tertiary care environment. Reimbursement strategies need to be reevaluated with more appropriate adjustment for preoperative risk factors and operative complexity."

Hospital costs associated with complex hernia repairs include direct costs (mesh materials, supplies, and non–surgeon labor), and indirect costs (facility fees, equipment depreciation, and unallocated labor), said Dr. Reynolds, a fellow in minimally invasive surgery at the University of Kentucky, Lexington. "Operative supplies including mesh represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts," the researchers wrote in their abstract.

Dr. Reynolds and his associates evaluated cost data on 415 consecutive open ventral hernia repairs performed at the university’s hospital between July 1, 2008, and May 31, 2011, using CPT codes 49560, 49561, 49565, and 49566. They analyzed data based on hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. The primary end points were hospital revenue and costs. Revenue calculations were adjusted for comorbid conditions/diagnosis-related groups, and readmission costs were not included.

Of the 415 patients, 353 were inpatients and 62 were outpatients. Among the 353 inpatients, ventral hernia repair was the primary procedure performed on 173 patients and was the secondary procedure for 180 patients. The median net revenue was significantly greater for those who underwent hernia repair as a secondary procedure compared with those who had hernia repair as a primary procedure ($17,310 vs. $10,360, P less than .01), as were net losses ($3,340 vs. $1,700, P less than .01).

Among the inpatient primary ventral hernia repairs, 46 were repaired without mesh, 79 were repaired with synthetic mesh, and 48 were repaired with biologic mesh, for median direct costs of $5,432, $7,590, and $16,970, respectively (P less than .01).

Dr. Reynolds also reported that among all inpatient ventral hernia repairs, the median net losses for repairs without mesh were $500, while synthetic mesh–based repairs yielded a median net profit of $60. The median contribution margin for cases involving biologic mesh was –$4,560, and the median net financial loss was $8,370.

Among patients who underwent outpatient ventral hernia repairs, median net losses among those performed with and without synthetic mesh reached $1,560 and $230, respectively.

"It was surprising to note that the vast majority of open ventral incisional hernia repairs are performed at an overall financial loss for the hospital," Dr. Reynolds said. "Further, it was surprising to note that inpatient biologic mesh–based ventral hernia repairs resulted in such a sizable negative median contribution margin ($4,560), and the striking median net financial loss of $8,370."

He acknowledged certain limitations of the study, including the fact that data used in the analysis were retrieved by CPT code search. "Hospital readmission costs were not included, which leads to underestimation of the costs," he added.

Dr. Reynolds said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Ventral hernia repair is associated with overall financial losses reaching the thousands of dollars in some cases, a single-center study demonstrated.

"These financial losses are just simply not sustainable," Dr. Drew Reynolds said in an interview prior to the annual Digestive Disease Week, where the study was presented.

In what is believed to be the first study of its kind, he and his associates set out to systematically evaluate hospital finances with respect to open ventral incisional hernia repair in the tertiary care environment.

"There is limited cost data currently available in the literature," he said. "These patients are complex and often require management in tertiary referral centers. Biologic meshes have a legitimate role in certain clinical scenarios, especially in those encountered in the tertiary care environment. Reimbursement strategies need to be reevaluated with more appropriate adjustment for preoperative risk factors and operative complexity."

Hospital costs associated with complex hernia repairs include direct costs (mesh materials, supplies, and non–surgeon labor), and indirect costs (facility fees, equipment depreciation, and unallocated labor), said Dr. Reynolds, a fellow in minimally invasive surgery at the University of Kentucky, Lexington. "Operative supplies including mesh represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts," the researchers wrote in their abstract.

Dr. Reynolds and his associates evaluated cost data on 415 consecutive open ventral hernia repairs performed at the university’s hospital between July 1, 2008, and May 31, 2011, using CPT codes 49560, 49561, 49565, and 49566. They analyzed data based on hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. The primary end points were hospital revenue and costs. Revenue calculations were adjusted for comorbid conditions/diagnosis-related groups, and readmission costs were not included.

Of the 415 patients, 353 were inpatients and 62 were outpatients. Among the 353 inpatients, ventral hernia repair was the primary procedure performed on 173 patients and was the secondary procedure for 180 patients. The median net revenue was significantly greater for those who underwent hernia repair as a secondary procedure compared with those who had hernia repair as a primary procedure ($17,310 vs. $10,360, P less than .01), as were net losses ($3,340 vs. $1,700, P less than .01).

Among the inpatient primary ventral hernia repairs, 46 were repaired without mesh, 79 were repaired with synthetic mesh, and 48 were repaired with biologic mesh, for median direct costs of $5,432, $7,590, and $16,970, respectively (P less than .01).

Dr. Reynolds also reported that among all inpatient ventral hernia repairs, the median net losses for repairs without mesh were $500, while synthetic mesh–based repairs yielded a median net profit of $60. The median contribution margin for cases involving biologic mesh was –$4,560, and the median net financial loss was $8,370.

Among patients who underwent outpatient ventral hernia repairs, median net losses among those performed with and without synthetic mesh reached $1,560 and $230, respectively.

"It was surprising to note that the vast majority of open ventral incisional hernia repairs are performed at an overall financial loss for the hospital," Dr. Reynolds said. "Further, it was surprising to note that inpatient biologic mesh–based ventral hernia repairs resulted in such a sizable negative median contribution margin ($4,560), and the striking median net financial loss of $8,370."

He acknowledged certain limitations of the study, including the fact that data used in the analysis were retrieved by CPT code search. "Hospital readmission costs were not included, which leads to underestimation of the costs," he added.

Dr. Reynolds said that he had no relevant financial conflicts to disclose.