The effect of endograft relining on sac expansion after endovascular aneurysm repair with the original-permeability Gore Excluder abdominal aortic aneurysm endoprosthesis

OBJECTIVE

Endovascular abdominal aortic aneurysm repair (EVAR) with the original-permeability Excluder (W.L. Gore & Associates, Flagstaff, Ariz) has been associated with postoperative sac expansion in the absence of endoleak. In these cases, we have performed an endovascular revision, relining the original endograft with another Excluder, in an effort to arrest sac expansion by reducing permeability. We have studied these cases to determine the effect of relining on aneurysm expansion.

METHODS

Patients who demonstrated sac expansion (>or=5 mm diameter, >or=5% three-dimensional volume) after EVAR with the original Excluder were evaluated. Between 1999 and 2004, the original-permeability endoprosthesis was used in 97 patients who underwent EVAR for asymptomatic abdominal aortic aneurysm (AAA). Sac expansion occurred in 24 patients, of which multiple imaging modalities showed 12 had expansion without demonstrable endoleak. Nine of the 12 have had endovascular relining, and five of these nine have >6 months follow-up to form the primary basis for this report.

RESULTS

AAA size was stable or smaller in the first 6 months after the original EVAR for all patients. Once expansion began (typically in the time frame of 6 to 12 months), multimodality imaging showed no aneurysm spontaneously decreased in size without intervention, despite the absence of endoleak (n = 12). Expansion exceeded clinically significant thresholds at 30 months (mean) by diameter criteria and 22 months (mean) by three-dimensional volume criteria for the five patients with >6 months follow-up after relining. Endovascular relining was performed at a mean of 36 months, with a mean hospital stay of 1 day, and no morbidity or mortality. Over the entire duration of expansion (mean, 26 months), aneurysms expanded by 6.0 +/- 1 mm/year diameter and by 12% +/- 2%/year by three-dimensional volume. At a mean of 16 months follow-up after relining with another Excluder, the mean diameter decrease was 2.0 mm/year (P < .03) and the mean volume decrease was 2.6%/year (P < .01). After relining, all AAAs were smaller by diameter or volume, or both, exceeding thresholds defining shrinkage in two of the five with >6 months follow-up after relining. There was no rupture, migration, endoleak, conversion to open repair, or aneurysm-related death in any patient.

CONCLUSIONS

It appears from the initial follow-up that AAA expansion owing to permeability issues after EVAR with the original Excluder can be arrested by endovascular relining with a low-permeability Excluder endoprosthesis.

Current status of carotid artery stenting

This Clinical Update summarizes the results of larger case series, industry-sponsored registries, and randomized trials of carotid artery stenting (CAS). In >20 case series that studied >24,000 patients undergoing CAS, 51% of patients were symptomatic, most procedures (97%) resulted in successful stent deployment, and 30-day stroke rates varied from 1% to 8%, with a trend toward lower rates as experience and embolic protection device (EPD) use increased. In 12 industry-sponsored registries (none were published in peer-reviewed journals), 30-day stroke rates varied from 2% to 7%, and 30-day combined adverse events, including stroke, death, and myocardial infarction, were 3% to 9%. More than 12 randomized trials comparing CAS and carotid endarterectomy (CEA) have been initiated since 1998. Results have varied over time, depending on the population studied and the technology used. However, the largest and most recent results of the completed SAPPHIRE trial in high-risk patients undergoing CAS with the use of EPDs demonstrated that CAS is at least not inferior to CEA, with a 1-year combined adverse event rate of 12% for CAS and 20% for CEA (P = .05). Other ongoing trials will address not only whether CAS could be superior to CEA in high-risk patients but also, more importantly, whether CAS is beneficial in other subgroups, such as low-risk and asymptomatic patients.

Specialty Training and Mortality After Esophageal Cancer Resection

BACKGROUND

Surgeons with advanced training have lower mortality rates with some surgical procedures. The objective of the current study was to investigate the impact of thoracic surgery training on mortality rates of esophageal cancer resection.

METHODS

We studied esophageal cancer resection in the national Medicare population during 1998 and 1999. Operative mortality rates (in-hospital or 30-day) were compared for thoracic surgeons and other surgeons, adjusting for patient characteristics, hospital volume, and surgeon volume. Surgeons with specialty training in thoracic surgery were those certified by the American Board of Thoracic Surgery.

RESULTS

Of the 1,946 patients, 625 (32%) had their operation performed by a thoracic surgeon. After adjustment for patient characteristics, mortality rates were 37% (odds ratio, 1.37; 95% confidence interval, 1.02 to 1.82) higher for surgeons without specialty training compared with thoracic surgeons (adjusted mortality 16.5% versus 12.4%; p = 0.01). However, differences in mortality between high-volume and low-volume hospitals (24.3% versus 11.4%; p < 0.001) and surgeons (20.7% versus 10.7%; p < 0.001) were larger than those between thoracic and general surgeons. Although thoracic surgeons had lower mortality rates after adjusting for hospital volume, the effect of thoracic surgery training was no longer significant after accounting for surgeon volume (odds ratio, 1.23; 95% confidence interval, 0.92 to 1.63).

CONCLUSIONS

Specialty training in thoracic surgery has an independent association with lower mortality after esophageal resection. But specialty training appears to be less important than hospital and surgeon volume.

Neoadjuvant chemoradiotherapy for esophageal carcinoma: a meta-analysis

BACKGROUND

The effectiveness in improving survival of neoadjuvant chemoradiotherapy (NCRT) in patients undergoing surgery for esophageal carcinoma remains unclear.

METHODS

MEDLINE, the Cochrane Database of Systematic Reviews, BIOSIS Previews, and other resources were searched from January 1966 through January 2003. Randomized trials were selected on the basis of study design (NCRT followed by surgery vs surgery alone). Of 21 potential studies identified by abstract review, 6 (29%) met the inclusion criteria.

RESULTS

Across 6 studies, a total of 374 patients underwent NCRT followed by surgery and 364 underwent surgery alone. In 5 of the 6 studies in our meta-analysis, there was a small, non-statistically significant trend toward improved survival with NCRT. Only 1 study demonstrated a statistically significant benefit to NCRT. In our summary measure for all 6 studies, we found a small, non-statistically significant trend toward improved long-term survival in the NCRT followed by surgery group (relative risk of death in the NCRT group [RR], 0.86; 95% confidence interval [CI], 0.74 to 1.01; P = .07).

CONCLUSIONS

NCRT followed by surgery is associated with a small, non-statistically significant improvement in overall survival. Whether this benefit is sufficient to warrant the considerable expense and risks associated with NCRT should be the subject of future larger randomized trials.

Surgeon specialty and operative mortality with lung resection

OBJECTIVE

We sought to examine the effect of subspecialty training on operative mortality following lung resection.

SUMMARY BACKGROUND DATA

While several different surgical subspecialists perform lung resection for cancer, many believe that this procedure is best performed by board-certified thoracic surgeons.

METHODS

Using the national Medicare database 1998 to 1999, we identified patients undergoing lung resection (lobectomy or pneumonectomy) for lung cancer. Operating surgeons were identified by unique physician identifier codes contained in the discharge abstract. We used the American Board of Thoracic Surgery database, as well as physician practice patterns, to designate surgeons as general surgeons, cardiothoracic surgeons, or noncardiac thoracic surgeons. Using logistic regression models, we compared operative mortality across surgeon subspecialties, adjusting for patient, surgeon, and hospital characteristics.

RESULTS

Overall, 25,545 Medicare patients underwent lung resection, 36% by general surgeons, 39% by cardiothoracic surgeons, and 25% by noncardiac thoracic surgeons. Patient characteristics did not differ substantially by surgeon specialty. Adjusted operative mortality rates were lowest for cardiothoracic and noncardiac thoracic surgeons (7.6% general surgeons, 5.6% cardiothoracic surgeons, 5.8% noncardiac thoracic surgeons, P = 0.001). In analyses restricted to high-volume surgeons (>20 lung resections/y), mortality rates were lowest for noncardiac thoracic surgeons (5.1% noncardiac thoracic, 5.2% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for difference between general surgeons and thoracic surgeons). In analyses restricted to high-volume hospitals (>45 lung resections/y), mortality rates were again lowest for noncardiac thoracic surgeons (5.0% noncardiac thoracic, 5.3% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for differences between all 3 groups).

CONCLUSIONS

Operative mortality with lung resection varies by surgeon specialty. Some, but not all, of this variation in operative mortality is attributable to hospital and surgeon volume.

Do cancer centers designated by the National Cancer Institute have better surgical outcomes?

BACKGROUND

The National Cancer Institute (NCI) designates cancer centers as regional centers of excellence in research and patient care. Although these centers often advertise their superior outcomes, their relative performance has not been examined empirically. In the current study, the authors assessed whether patients at NCI cancer centers compared with patients at control hospitals had lower mortality rates after major cancer surgery.

METHODS

Using the national Medicare database (1994-1999), the authors assessed surgical mortality and late survival rates for 63,860 elderly patients undergoing resection for lung, esophageal, gastric, pancreatic, bladder, or colon carcinoma. For assessing performance, patients treated at the 51 NCI cancer centers were compared with patients from 51 control hospitals with the highest volumes for each procedure. Mortality rates (surgical and 5-year rates) were adjusted for patient characteristics and residual differences in procedure volume.

RESULTS

NCI cancer centers had lower adjusted surgical mortality rates than control hospitals for 4 of the 6 procedures, including colectomy (5.4% vs. 6.7%; P = 0.026), pulmonary resection (6.3% vs. 7.9%; P = 0.010), gastrectomy (8.0% vs. 12.2%; P < 0.001), and esophagectomy (7.9% vs. 10.9%; P = 0.027). Nonsignificant trends toward lower adjusted operative mortality rates at NCI cancer centers were also observed for cystectomy and pancreatic resection. Among patients surviving surgery, however, there were no important differences in subsequent 5-year mortality rates between NCI cancer centers and control hospitals for any of the procedures.

CONCLUSIONS

For many cancer procedures, patients undergoing surgery at NCI-designated cancer centers had lower surgical mortality rates than those treated at comparably high-volume hospitals, but similar long-term survival rates.

Paraduodenal hernia and jejunal diverticulosis

A case of left-sided paraduodenal hernia and jejunal diverticulosis is described in 75-year-old man who presented with chronic intermittent abdominal pain, weight loss, and anemia. A brief review of the epidemiology, pathogenesis, and clinical presentation displays the variety of symptoms associated with these rare conditions.

Surgeon volume and operative mortality in the United States

BACKGROUND

Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.

METHODS

Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers.

RESULTS

Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced.

CONCLUSIONS

For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.

A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs

BACKGROUND

Although ventral hernia repair is increasingly performed laparoscopically, complication rates with this procedure are not well characterized. For this reason, we performed a prospective study comparing early outcomes after laparoscopic and open ventral hernia repairs.

METHODS

We identified all the patients undergoing ventral (including incisional) hernia repair at a single tertiary care center between September 1, 1999 and July 1, 2001 (overall n = 257). To increase the homogeneity of the sample, we excluded umbilical hernia repairs, parastomal hernia repairs, nonelective procedures, procedures not involving mesh, and repairs performed concurrently with another surgical procedure. Postoperative complications (in-hospital or within 30-days) were assessed prospectively according to standardized definitions by trained nurse clinicians.

RESULTS

Of the 136 ventral hernia repairs that met the study criteria, 65 (48%) were laparoscopic repairs (including 3 conversions to open surgery) and 71 (52%) were open repairs. The patients in the laparoscopic group were more likely to have undergone a prior (failed) ventral hernia repair (40% vs 27%; p = 0.14), but other patient characteristics were similar between the two groups. Overall, fewer complications were experienced by patients undergoing laparoscopic repair (8% vs 21%; p = 0.03). The higher complication rate in the open ventral hernia repair group came from wound infections (8%) and postoperative ileus (4%), neither of which was observed in the patients who underwent laparoscopic repair. The laparoscopic group had longer operating room times (2.2 vs 1.7 h; p = 0.001), and there was a nonsignificant trend toward shorter hospital stays with laparoscopic repair (1.1 vs 1.5 days; p = 0.10).

CONCLUSIONS

The patients undergoing laparoscopic repair had fewer postoperative complications than those receiving open repair. Wound infections and postoperative ileus accounted for the higher complication rates in the open ventral hernia repair group. Otherwise, these groups were very similar. Long-term studies assessing hernia recurrence rates will be required to help determine the optimal approach to ventral hernia repair.

Do hospitals with low mortality rates in coronary artery bypass also perform well in valve replacement?

BACKGROUND

While hospital performance in coronary artery bypass graft (CABG) surgery is reported widely, patients may find it difficult to learn about their hospital's performance in heart valve replacement. We sought to determine if a hospital's performance in CABG is correlated to its performance in heart valve replacement.

METHODS

We studied operative mortality after CABG, aortic valve replacement (AVR), and mitral valve replacement (MVR) using the 1994 to 1999 national Medicare database. After excluding any hospital that did not perform at least 50 CABGs and 20 valve replacements per year we examined the correlation between hospital mortality in CABG and hospital mortality in AVR and MVR using least-squares simple linear regression models. Operative mortality was adjusted for patient characteristics using logistic regression models.

RESULTS

A total of 684 hospitals performed 817,606 isolated CABGs, 142,488 AVRs (54% with concomitant CABG), and 61,252 MVRs (45% with concomitant CABG). Hospital mortality rates with AVR ranged from 6.0% to 13.0% between hospitals in the lowest and highest, respectively, 10th percentile of CABG performance. Similarly hospital mortality rates with MVR ranged from 10.1% to 20.5% in the lowest and highest respectively, 10th percentile of CABG performance. Adjusted mortality rates for both AVR and MVR were closely correlated with isolated CABG mortality rates (correlation coefficients 0.592 and 0.538, respectively; p = 0.001 for both correlations). In stratified analyses these correlations persisted regardless of whether valve replacement was performed with or without concomitant CABG or whether valve replacement was performed in a high- or low-volume hospital.

CONCLUSIONS

Hospital mortality rates with CABG are closely correlated with mortality rates with valve replacement. These findings suggest that shared processes and systems of care are important determinants of performance in cardiac surgery.

Hospital volume, length of stay, and readmission rates in high-risk surgery

OBJECTIVE

Aimed at reducing surgical deaths, several recent initiatives have attempted to establish volume-based referral strategies in high-risk surgery. Although payers are leading the most visible of these efforts, it is unknown whether volume standards will also reduce resource use.

METHODS

We studied postoperative length of stay and 30-day readmission rate after 14 cardiovascular and cancer procedures using the 1994-1999 national Medicare database (total n = 2.5 million). We used regression techniques to examine the relationship between length of stay, 30-day readmission, and hospital volume, adjusting for age, gender, race, comorbidity score, admission acuity, and mean social security income.

RESULTS

Mean postoperative length of stay ranged from 3.4 days (carotid endarterectomy) to 19.6 days (esophagectomy). There was no consistent relationship between volume and mean length of stay; it significantly increased across volume strata for 7 of the 14 procedures and significantly decreased across volume strata for the other 7. Mean length of stay at very-low-volume and very-high-volume hospitals differed by more than 1 day for 6 procedures. Of these, the mean length of stay was shorter in high-volume hospitals for 3 procedures (pancreatic resection, esophagectomy, cystectomy), but longer for other procedures (aortic and mitral valve replacement, gastrectomy). The 30-day readmission rate also varied widely by procedure, ranging from 9.9% (nephrectomy) to 22.2% (mitral valve replacement). However, volume was not related to 30-day readmission rate with any procedure.

CONCLUSION

Although hospital volume may be an important predictor of operative mortality, it is not associated with resource use as reflected by length of stay or readmission rates.

Hospital volume and operative mortality in cancer surgery: a national study

BACKGROUND

Although initiatives to regionalize cancer surgery are already under way, the relative importance of volume in cancer surgery is disputed.

HYPOTHESIS

We examined surgical mortality with 8 cancer resections in the US population to better quantify the influence of hospital volume.

METHODS

Using information from the all-payer Nationwide Inpatient Sample (1995-1997), we examined mortality with 8 cancer resections (N = 195 152). After dividing patients into 3 evenly sized volume groups based on hospital procedure volume (low, medium, and high), we used regression techniques to describe relationships between hospital volume and in-hospital mortality, adjusting for patient characteristics.

RESULTS

Trends toward lower operative risks at high-volume hospitals were observed for 7 of the 8 procedures. However, differences between low- and high high-volume hospitals were statistically significant for only 3 operations (esophagectomy, 15.0% vs 6.5%; pancreatic resection, 13.1% vs 2.5%; and pulmonary lobectomy, 10.1% vs 8.9%, respectively). Although they did not reach statistical significance, absolute differences in mortality between low- and high-volume hospitals were greater than 1% for the following 3 procedures: gastrectomy, 8.7% vs 6.9%; cystectomy, 3.6% vs 2.5%; and pneumonectomy, 10.6% vs 8.9%, respectively. Mortality reductions for nephrectomy and colectomy were small. In general, in terms of absolute differences in mortality, the effect of volume was greatest in elderly patients.

CONCLUSIONS

Operative mortality decreases with increasing hospital volume for several cancer resections. However, volume may be most important in patients who are older and at higher risk.

Should volume standards for cardiovascular surgery focus only on high-risk patients?

BACKGROUND

Payers and policy makers are attempting to concentrate selected cardiovascular procedures in high-volume centers. A recent analysis of coronary artery bypass grafting (CABG), however, suggests that volume-based referral initiatives should focus only on high-risk patients.

METHODS AND RESULTS

Using the national Medicare database (1994 to 1999), we studied the operative mortality in patients undergoing 4 cardiovascular procedures (CABG, aortic valve replacement, mitral valve replacement, and elective abdominal aortic aneurysm repair). We defined 2 categories of patient risk: high-risk (patients in the highest 25th percentile of predicted risk on the basis of a logistic regression model) and low-risk (patients in the lowest 75th percentile). We then compared operative mortality in patients undergoing surgery at very-high volume hospitals (VHVH, highest 20th percentile of procedure volume) and very-low volume hospitals (VLVH, lowest 20th percentile of procedure volume). Absolute differences in operative mortality between VLVH and VHVH were somewhat larger in high-risk patients. However, volume-related differences in mortality were also significant for low-risk patients undergoing one of the 4 procedures. In relative terms, the effect of hospital volume was similar in both high- and low-risk patients. For high- and low-risk patients, the relative risk (RR) of mortality between VHVH and VLVH were nearly equal for CABG (RR=0.78 for low-risk patients, RR=0.77 for high risk patients), aortic valve replacement (0.73 versus 0.76), mitral valve replacement (0.73 versus 0.74), and abdominal aortic aneurysm repair (0.51 versus 0.54).

CONCLUSIONS

Although the merits of volume-based referral initiatives can be debated on many grounds, there seems to be little rationale for restricting these initiatives to high-risk patients.

Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis

BACKGROUND

Although laparoscopic repair of ventral hernia has become increasingly popular, its outcomes relative to open repair have not been well characterized. For this reason, we performed a meta-analysis of studies comparing open and laparoscopic ventral (including incisional) hernia repair.

HYPOTHESIS

Laparoscopic ventral hernia repair results in better short-term outcomes than open ventral hernia repair.

DATA SOURCES

Structured MEDLINE search for published studies. One unpublished study was also identified.

STUDY SELECTION

Studies were selected on the basis of study design (comparison of laparoscopic and open ventral hernia repair). The 3 main outcome measures were perioperative complications, operative time, and length of hospital stay. Of 83 potential studies identified by abstract review, 8 (10%) met the inclusion criteria.

DATA EXTRACTION

Two reviewers assessed each article to determine eligibility for inclusion and, where appropriate, abstracted information on patient characteristics and main outcome measures.

DATA SYNTHESIS

Across 8 studies, 390 patients underwent open repair and 322 underwent laparoscopic repair. Perioperative complications were less than half as likely to occur in patients undergoing laparoscopic repair (14% vs 27%; P =.03; odds ratio, 0.42; 95% confidence interval, 0.29-0.68). Average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P =.02). No statistically significant difference in operative times was noted between laparoscopic and open repair (99 vs 96 minutes; P =.38).

CONCLUSIONS

Laparoscopic ventral hernia repair offers lower complication rates and shorter length of stay than open repair. However, randomized controlled trials and studies with long-term follow-up are needed to confirm these findings and to assess long-term rates of hernia recurrence.

Is surgery getting safer? National trends in operative mortality

BACKGROUND

Although mortality rates for some cardiovascular procedures seem to have declined, it is unclear whether other high-risk procedures are becoming safer over time.

STUDY DESIGN

We examined national trends between 1994 and 1999 in operative mortality for 14 high-risk cardiovascular and cancer procedures in the national population of Medicare beneficiaries over age 65. Secular trends were examined using logistic regression adjusting for age, gender, race, socioeconomic status, admission acuity, comorbidities, and hospital volume.

RESULTS

Observed mortality rates varied widely across the 14 procedures, from 2% (carotid endarterectomy) to 16% (esophagectomy). Over the 6-year study period, average patient age increased for all procedures, and patients were more likely to undergo operation at high-volume hospitals for some procedures (pancreatic resection, esophagectomy, cystectomy, and pneumonectomy). After accounting for these changes, operative mortality declined significantly for three cardiovascular procedures, as evidenced by adjusted odds ratios (OR) for the 6-year effect on operative mortality (coronary artery bypass graft OR = 0.85, 95% confidence interval [CI] 0.81 to 0.88; carotid endarterectomy OR = 0.86,95% CI 0.80 to 0.93; mitral valve replacement OR = 0.89, 95% CI 0.81 to 0.97). In contrast, operative mortality did not decline for any of the cancer procedures. In fact, adjusted mortality increased for colectomy for colon cancer (OR= 1.13, 95% CI 1.07 to 1.19).

CONCLUSIONS

Although risks of some cardiovascular procedures are declining over time, there is no evidence that other types of high-risk surgery are becoming safer. These findings suggest the need for systematic efforts to monitor and improve surgical performance.

Peptic ulcer/stricture after gastric bypass: a comparison of technique and acid suppression variables

BACKGROUND

Mason's original animal experiments on the gastric bypass (GBP) showed little acid production in the gastric pouch, a finding confirmed in humans. Despite this, GBP in humans is associated with an incidence of ulcer/stricture (U/S) at the gastrojejunostomy of 3 to 20%, with both acid secretion and staple-line dehiscence considered important risk factors or etiologies. Our series of GBP patients was reviewed to determine what technical or management factors, if any, were associated with U/S.

METHODS

All patients undergoing first time GBP at Dartmouth-Hitchcock Medical Center by one surgeon from June 1991 until June 2000 were reviewed. The incidence of U/S as confirmed on upper endoscopy was determined by retrospective chart review. The technique of surgery, frequency of acid suppressive therapy at discharge, postoperative day of U/S diagnosis by endoscopy, length of follow-up with a member of the multidisciplinary bariatric team, and incidence of staple-line dehiscence were tabulated.

RESULTS

158 patients (72% female, mean BMI 53, mean age 42) underwent GBP. Two gastric stapling methods were used to create the gastric pouch: 4-rows (136 patients) and 8-rows (22 patients). No other technical feature was adjusted in the series. The two patient groups were similar in gender, age, and BMI. Acid suppressive therapy at the time of discharge was similar in each group with U/S (4-rows 64% and 8-rows 50%, p = 0.5). U/S developed in 12 (55%) of the 8-row group and in 14 (10%) of the 4-row group (p < 0.001). U/S typically occurred within the first 2 months postoperatively (mean 48 days, SD 40). No patients in our series developed a staple-line dehiscence.

CONCLUSION

U/S occur in the first few months following GBP. Twice the number of gastric staple-lines is associated with over five times the incidence of U/S, whereas post-discharge acid suppressive therapy is not predictive of U/S. Thus, a technique performed to decrease the risk of staple-line breakdown was associated with a much higher incidence of U/S. Staple-line dehiscence is not the etiology of this condition. Therefore, U/S after GBP does not appear to be explained by acid injury. We speculate that local, tissue injury related factors may be more responsible, a speculation that invokes a novel pathophysiologic mechanism for U/S formation following gastrojejunostomy.