49Th Annual Meeting

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 49th Annual Meeting

May 17 – 21, 2008 San Diego Convention Center San Diego, California

PROGRAM BOOK SSAT_inside_cov.fm Page 1 Tuesday, April 22, 2008 1:25 PM

Table of Contents

Continuing Medical Education Accreditation Statement...... 2 Current Ofﬁcers and Board of Trustees ...... 3 Standing Committees ...... 4 History of the SSAT...... 6

SSAT Foundation ...... 13Available in Print Version Only Founders Medal ...... 31 Guest Oration ...... 32 State-of-the-Art Lecture ...... 33 Program Schedule ...... 34 Poster Session Detail ...... 66 Plenary, Video, and Quick Shot Session Abstracts ...... 98 Poster Session Abstracts ...... 184 Author Index ...... 461 Disclosure Index ...... 477

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PROGRAM

FORTY-NINTH ANNUAL MEETING San Diego Convention Center San Diego, California May 17–21, 2008

PLEASE BRING THIS PROGRAM BOOK WITH YOU TO THE ANNUAL MEETING.

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CME STATEMENT

ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the Society for American Surgery of the Alimentary Tract. The American College of College Surgeons is accredited by the ACCME to Surgeons provide continuing medical education for physicians. Division of Education AMA PRA CATEGORY 1 CREDITS™ The American College of Surgeons designates this educational activity for a maximum of 23.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

DISCLOSURES Turn to page 477 for a complete index of program committee, moderator, and speaker disclosures.

AMERICANS WITH DISABILITIES ACT If you require special accommodations to attend or participate in the CME activity, please provide information about your requirements to SSAT, 900 Cummings Center, Suite 221-U, Beverly, MA 01915; phone: (978) 927-8330; fax: (978) 524-8890; e-mail: [email protected]

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA INFORMATION

THE SOCIETY FOR SURGERY GENERAL OF THE ALIMENTARY TRACT

OFFICERS: 2007–2008

President John C. Bowen, New Orleans, LA President-Elect David W. McFadden, Burlington, VT Vice President Richard A. Prinz, Chicago, IL Secretary John G. Hunter, Portland, OR Treasurer Robin S. McLeod, Toronto, ON Recorder Bruce D. Schirmer, Charlottesville, VA

BOARD OF TRUSTEES

L. William Traverso, Chair Seattle, WA Barbara L. Bass Houston, TX Kevin E. Behrns Gainesville, FL Mark P. Callery Boston, MA Merril T. Dayton Buffalo, NY James W. Fleshman St. Louis, MO Yuman Fong New York, NY Keith D. Lillemoe Indianapolis, IN Fabrizio Michelassi New York, NY Nathaniel J. Soper Chicago, IL Selwyn M. Vickers Minneapolis, MN

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STANDING COMMITTEES 2007–2008

EDUCATION COMMITTEE PATIENT CARE COMMITTEE Daniel B. Jones, Chair John W. Kilkenny, III, Chair John S. Bolton Elijah Dixon Thomas A. Broughan Douglas B. Evans Michael A. Choti Howard S. Kaufman O. Joe Hines Peter Muscarella, II Darryl T. Hiyama Seth I. Wolpert Michael J. Stamos Michael J. Zinner Debra L. Sudan Randall S. Zuckerman

FINANCE COMMITTEE PROGRAM COMMITTEE Robin S. McLeod, Chair Mark P. Callery, Chair John C. Bowen John C. Bowen John G. Hunter Craig P. Fischer A. James Moser Donald E. Low Sean J. Mulvihill David W. McFadden William H. Nealon Attila Nakeeb Richard A. Prinz Bruce D. Schirmer L. William Traverso David Shibata L. William Traverso LOCAL ARRANGEMENTS Sharon M. Weber COMMITTEE Edward E. Whang Mark A. Talamini, Chair PUBLIC POLICY COMMITTEE MEMBERSHIP COMMITTEE Steven C. Stain, Chair Thomas J. Howard Stanley W. Ashley, Chair Kimberly S. Kirkwood Joseph J. Cullen Stuart G. Marcus Karen E. Deveney Margo Shoup Gerald M. Fried Lygia Stewart Lynt B. Johnson Ernst J.M. Klar Ronald F. Martin PUBLICATIONS COMMITTEE Rodrigo O. Perez Bruce D. Schirmer, Chair Marek Rudnicki Kevin E. Behrns Richard T. Schlinkert Zane Cohen David Shibata Jeffrey A. Drebin Jennifer F. Tseng Daniel J. Scott Selwyn M. Vickers Brad W. Warner Sharon M. Weber John A. Windsor RESEARCH COMMITTEE Michael S. Woods Herbert Chen, Chair Gerard V. Aranha NOMINATING COMMITTEE Richard A. Hodin Keith D. Lillemoe, Chair Elin R. Sigurdson Barbara L. Bass Diane M. Simeone Steven M. Strasberg Scott A. Strong Mark A. Talamini L. William Traverso

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

STANDING COMMITTEES 2007–2008 INFORMATION GENERAL

REPRESENTATIVES Board of Governors of the American College of Surgeons Merril T. Dayton American Board of Surgery David M. Mahvi ABS GI Surgery Advisory Council John G. Hunter Fellowship Council Board Michael S. Nussbaum Fellowship Council Accreditation Committee Keith D. Lillemoe Theodore N. Pappas Nathaniel J. Soper Gastroenterology Women’s Coalition Natalie E. Joseph Jennifer F. Tseng Journal of Gastrointestinal Surgery John L. Cameron, Editor Jeffrey B. Matthews, Associate Editor Charles J. Yeo, Associate Editor

PROGRAM SUBCOMMITTEES

Biliary/Hepatic Pancreas Craig P. Fischer, Chair Sharon M. Weber, Chair Eddie K. Abdalla Gerard V. Aranha Elijah Dixon John D. Christein D. Rohan Jeyarajah Jason B. Fleming Julie A. Stein O. Joe Hines Magesh Sundaram Taylor S. Riall

Colon-Rectal/Combined Science Small Bowel/Stomach David Shibata, Chair Edward E. Whang, Chair Alessandro Fichera Thomas H. Magnuson Tracy L. Hull John Morton Neil H. Hyman John T. Mullen Deborah A. Nagle Ninh T. Nguyen Richard C. Thirlby Robert W. O’Rourke

Esophageal Video Donald E. Low, Chair Attila Nakeeb, Chair Steven P. Bowers Robert E. Glasgow Jonathan F. Critchlow Ellen J. Hagopian Blair A. Jobe Rebecca M. Minter Vic Velanovich Timothy M. Pawlik Tracey L. Weigel Randall S. Zuckerman

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HISTORY OF THE SSAT

The history of the SSAT begins in 1957 when Dr. Robert Turell dreamed “of launching a new surgical organization oriented to the problems of the alimentary tract and of creating a research or educational foundation.”1 He discussed the possibility of a new society with many prominent surgeons and many discouraged him, but he found substantial support from Dr. Warren Cole, who Dr. Warren Cole agreed to help under the condition that Dr. John Waugh would assist in the formation of the society. The three met in Rochester, Minnesota, at which time Dr. Waugh confessed that he had been entertaining similar thoughts for a society devoted to the advancement of alimentary surgery. The Society was incorporated on March 30, 1960, and was initially named the Association for Colon Surgery. The founding membership consisted of authors who had contributed papers to six issues of the Surgical Clinics of North America edited by Dr. Turell and the authors of the chapters in his textbook Diseases of the Colon and Anorectum. In Dr. Robert Turell the beginning it was thought advisable to limit the Society’s interest to surgery of the colon, but Dr. Cole proposed that the name be changed to The Society for Surgery of the Alimentary Tract to reﬂect wide interest in abdominal surgery. Dr. Robert Zollinger, the Society’s third president, gave a convincing address entitled “Justifying our Existence.”2 He noted that papers related to the alimentary tract made up less than half of the programs of other societies including the American College of Surgeons Clinical Congress, and that SSAT was the only North American organization focused on surgical problems of the entire alimentary tract, a situation which still Dr. John Waugh exists today.

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The requirements for membership in the Society have been a matter INFORMATION

of frequent debate since its inception. In 1965, ﬁve years after the GENERAL founding of the society, the Board of Trustees directed that the membership should be enlarged rather than restricted to a small group. The ﬁrst constitution of the Society was approved that same year. The requirements for membership were:

1. Fellowship in the American College of Surgeons or its equivalent; and

2. Demonstrated interest in the function and disease of the alimentary tract as evidenced by fundamental research or by publication of signiﬁcant papers.

Initially, the number of published papers was flexible, but by 1981, sixteen years later, the requirement for at least 10 publications became the law of the membership committee. As a result, the society’s growth flattened. In 1984, the Board of Trustees became concerned over the lack of growth and again decided that the publication requirement should be liberalized. Dr. James Thompson, Chairman of the Board, noted that “the ascendancy of our collegial organization, the American Gastroen- terological Association (AGA), to a position of great importance, many believe, dates from its adoption of the recommendation of Dr. Mort Grossman that it be an egalitarian and not an elitist organization.” Dr. Thompson urged the membership to identify surgeons practicing alimentary surgery in their community and propose them for membership. At this time, the only membership criteria were certification by the American Board of Surgery or its equivalent, membership in the American College of Surgeons or its equivalent, and an interest in gastrointestinal surgery. In 1993, President-Elect Dr. Bernard Langer set an agenda that focused on three important issues facing the Society: first, the creation of advanced training programs in gastrointestinal surgery; second, the need to increase substantially the membership of the Society to include the vast majority of surgeons practicing alimentary tract surgery in North America; and third, an assessment of starting the Society’s own journal of gastrointestinal surgery. During his presidency, Dr. Langer convened a task force that recommended to the Board a campaign to aggressively recruit members, a change in the membership process to one of direct application, and the creation of a trainee membership. The proposed criteria for membership were:

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1. A degree from a medical school acceptable to the Board of Trustees;

2. A license to practice medicine in the applicant’s state, providence or country;

3. Certiﬁcation by a board that is a member of the Board of the American Board of Medical Specialties, the Royal College of Physicians and Surgeons in Canada or an equivalent body; and

4. An interest in surgical aspects of digestive disease. The most important part of the proposal was that applications for membership could be initiated by the applicant. The result of these changes has been a substantial increase in the membership of the Society in recent years.

The development of the Society’s own journal took many years. The founders of the organization wished to live in harmony with the already established surgical organizations, which precluded consideration of an independent journal. After the first annual meeting, several existing journals expressed interest in publishing the Society’s papers the publication of the papers presented at the first annual meeting. Ultimately, a decision was made to publish in the American Journal of Surgery, edited by Dr. Zollinger; that journal subsequently published the papers presented at the Society for the next ten years. Only once during that period, in 1965, the Society reviewed the possibility of publishing its own journal, but thought it not to be desirable at the time. In 1970, the American Journal of Surgery became the official journal of the Society, with all members subscribing to the journal as part of their membership.

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The issue resurfaced again in 1993 as one of Dr. Langer’s three important INFORMATION

decisions facing the Society. The issue became part of the agenda of GENERAL the special task force convened during his presidency. In response to the report of the task force, the Board appointed a Publication Committee, chaired by Dr. Keith Kelly, to study the issue. At its October, 1995 meeting, the Board accepted the recommendation of the Publication Committee to proceed with establishing an SSAT journal. The name selected was the Journal of Gastrointestinal Surgery. Most importantly, the journal was to be owned and copyrighted by the Society. The Board made the decision to have dual editors and appointed Drs. Keith Kelly and John Cameron to the position. From the beginning, SSAT has shown an interest in integrating with other professional organizations. It all started in 1964, when Dr. Helger Jenkins urged that a committee be appointed to work out a joint membership with gastroenterologists. Apparently in response to his request, a Liaison Committee to the AGA was appointed by the Board around 1966. Dr. Lloyd Nyhus chaired the committee. Their charge was to explore possible ways of bringing the two societies interested in gastrointestinal diseases into closer relationship. The committee found it impossible to schedule a joint meeting with the AGA and the whole issue would have been dropped if it was not for the death of a prominent individual in Minneapolis from ulcerative colitis. The family of the deceased individual established the Digestive Disease Foundation of Minneapolis for the purpose of funding research in the broad scope of digestive diseases. In February, 1967 Dr. Nyhus, still attempting to make contact with the AGA, attended a conference on Digestive Disease as a National Problem. This conference was sponsored by the Digestive Disease Foundation of Minneapolis, the National Institute of Arthritis and Metabolic Diseases and the AGA. The purpose of the conference was to stress to the federal government the overall importance of digestive disease on the American public. Details regarding the promi- nence of the problem, the need for continued research, the needs for manpower and a plan to provide for these needs in the future were presented. As a direct result of the conference, the National Institute of Arthritis and Metabolic Disease identiﬁed the problem of gastrointestinal disease for in-depth study. The following year, Dr. Nyhus reported to the Society that the AGA had taken an interest in our Society because of the desire to have surgeons involved in discussions about digestive disease with governmental agencies. This provided an opportunity for the two societies to discuss a variety of issues, including the possibility of a joint annual meeting.

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At that time, the SSAT’s annual meeting was held in conjunction with the AMA meeting, and it was suggested that SSAT change its meeting dates to coincide with the AGA. The AGA, in moving towards its goal of obtaining research dollars, formed both a Federation of Digestive Disease Societies and a Digestive Disease Foundation. Dr. Morton Grossman addressed the SSAT’s Board of Trustees at its 1970 meeting, explaining that the goal of the Federation and Foundation was to develop a National Digestive Disease Institute similar to the National Cancer Institute. The purpose of the Institute would be to support research, education of the lay public, unify public relations and initiate legislation regarding digestive diseases. He expressed the hope that our Society would join both organizations. There was considerable discussion of Dr. Grossman’s presentation, and the decision was made to join both the Federation and Foundation. When the action of the Board was reported at the Society’s annual business meeting, Dr. Ward Griffen took the issue of integration with the AGA one step further and recommended that the membership be polled regarding moving the meeting of our Society to coincide with the AGA meeting. At the 1972 meeting, Dr. Nyhus reported that the poll of the membership showed that eighty percent were strongly in favor of changing the date and location of the meeting to coincide with the AGA in a so- called Digestive Disease Week; accordingly, arrangements for a combined meeting in New York were set for May, 1973. The combined meeting went exceedingly well and most members enthusiastically supported the motion to continue the arrangement. In October, 1974, six months after the annual meeting, Dr. Robert Zeppa and Dr. Frank Moody were authorized to attend the newly formed Digestive Disease Week Council as representatives of our Society. So it was that Digestive Disease Week came into being. Four years later, in his presidential address entitled “Cooperation to Meet the Challenges,”3 Dr. Zeppa reviewed the Society’s decision to join Digestive Disease Week Council. He noted that financial benefit and stability came to each of the four societies, namely the AGA, the American Association for the Study of Liver Diseases (AASLD), the American Society for Gastrointestinal Endoscopy (ASGE) and the SSAT; second, attendance at our meeting increased; third, the quality of our program improved; fourth, the educational benefits for our members expanded by the diversity of programs available; and fifth, there was increased accessibility for dialogue, formal and informal,

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with our medical colleagues. He concluded that the membership was INFORMATION

to be congratulated for its wise decision. GENERAL More recently we have furthered our relationship with the component societies of DDW by contributing to combined clinical symposiums, organizing a yearly consensus conference, and integrating appropriate oral and poster presentations of our papers into AGA focused research sections and the president’s plenary poster session. The Society’s founder, Dr. Robert Turell, in his presidential address, spoke of his dream of creating a research and educational foundation for alimentary surgery. In practical terms, creating a research and educational foundation required the development of an enduring source of funding. The first move in realizing this dream occurred at the Board of Trustees meeting in October, 1985. Dr. Bernard Jaffe, Chairman of the Ad Hoc Committee on Research and Education, recommended that the Board issue a policy statement supporting the development of a two year program for post-residency experience in research and clinical surgery of the digestive tract for the purpose of providing leadership for the discipline in the future. The committee further recommended that the Society sponsor a Career Development Award to support individuals involved in this advanced experience. The next year, the Society used its share of DDW profits to fund the fellowship. Drs. David Nahrwold and Jaffe worked out the process of application and selection with the understanding that the first award would be given in 1987. The annual award was subsequently increased step wise to its current level of $50,000 per year. The majority of its recipients currently have University appointments and many have ongoing NIH funding. The program has been a tremendous success. Five decades after Dr. Turell’s initial imaginings, the SSAT is a strong organization with a growing membership, strong ties to other disciplines in medicine involved in the study and treatment of digestive diseases, and a commitment to support the next generation of alimentary tract surgeons.

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References

1. Turell R. Quo Vadis. Am J Surg. 1968;115:2–5.

2. Zollinger RM. Justifying our existence. Am J Surg. 1964;107:233–38.

3. Zeppa R. Cooperation to meet the challenges. Am J Surg. 1979;137:3–6.

* This history of the SSAT was excerpted from the Presidential Address of Tom DeMeester at the 38th Annual Meeting in Washington DC by Richard Bell. The full text can be found in— DeMeester TR. Change, Relationships, and Accountability: Marks of a Vibrant Society. J Gastrointest Surg. 1998;2:2–10.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

FOUNDERS MEDAL INFORMATION GENERAL

Monday, May 19, 2008 8:00 AM – 8:15 AM San Diego Convention Center 25ABC

RONALD K. TOMPKINS, MD Professor Emeritus of Surgery General Surgery Division David Geffen School of Medicine at UCLA Los Angeles, CA

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DORIS AND JOHN L. CAMERON GUEST ORATION “The Coming American Revolution: How China Will Cause the Greatest Changes in the U.S. Since the Birth of the Nation”

Monday, May 19, 2008 11:15 AM – 12:00 PM San Diego Convention Center 25ABC

LOUIS McDANIEL BOWEN Chairman, Asia Capital Management Ltd. & China Advisors Ltd. Hong Kong, SAR, China

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

MAJA & FRANK G. MOODY INFORMATION STATE-OF-THE-ART LECTURE GENERAL “The Early Detection of Pancreatic Cancer: Lessons from Surveillance of 100 High-Risk Patients”

Tuesday, May 20, 2008 11:15 AM – 12:00 PM San Diego Convention Center 25ABC

TERESA BRENTNALL, MD Associate Professor of Medicine Division of Gastroenterology University of Washington Seattle, WA

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SCIENTIFIC PROGRAM Forty-Ninth Annual Meeting May 17–21, 2008

All rooms at the San Diego Convention Center unless otherwise indicated.

Indicates a ticketed session requiring a separate registration and fee. Indicates a session offering Simultaneous Oral Translation in Spanish and Japanese.

Saturday, May 17, 2008

8:30 AM – 2:30 PM RESIDENTS & FELLOWS Omni Hotel Gallery 2 RESEARCH CONFERENCE Participation in and attendance at this conference by invitation only. The 21 papers being presented are indicated throughout this program schedule by the icon to the left.

Monday, May 19, 2008 8:00 AM – 8:15 AM OPENING SESSION 25ABC Moderator: John C. Bowen New Orleans, LA Welcome and introduction of new members, announcements of SSAT scholarship awards, reports from the SSAT Foundation, recognition of the Foundation donors, and conferment of the Founders Medal.

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8:15 AM – 9:15 AM PRESIDENTIAL PLENARY A 25ABC (PLENARY SESSION I) Moderator: Richard A. Prinz Chicago, IL 215 Stepwise Circumferential and Focal Radiofrequency Ablation of Barrett’s Esophagus with High-Grade

Dysplasia or Intramucosal Cancer SCHEDULE Roos E. Pouw1, Joep J. Gondrie1, Frederike G. Van Vilsteren1, DAILY Carine Sondermeijer1, Wilda Rosmolen1, Wouter L. Curvers1, Lorenza Alvarez Herrero4, Fiebo J. Ten Kate2, Kausilia K. Krishnadath1, Thomas M. Van Gulik3, Paul Fockens1, Bas L. Weusten4, Jacques J. Bergman*1 1Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Pathology, Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Academic Medical Center, Amsterdam, Netherlands; 4Gastroenterology, St. Antonius Hospital, Nieuwegein, Netherlands 216 Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum Rajesh Nair*1, Erin M. Siegel1, Timothy J. Yeatman1, Mokenge P. Malafa1, Jorge Marcet2, David Shibata1 1Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; 2Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 217 High Volume Surgery and Outcome After Liver Resection: Surgeon or Center? Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah* Surgery, University of Massachusetts, Worcester, MA 218 Laparoscopic Vertical Sleeve Gastrectomy for Morbid Obesity: A Report of a Five-Year Experience with 750 Patients Crystine M. Lee, Paul T. Cirangle*, Gregg H. Jossart Surgery, California Pacific Medical Center, San Francisco, CA

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9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS 25ABC SP339 Introduction Richard A. Prinz, Chicago, IL SP340 Evolution of a Surgeon: A 40-Year Perspective John C. Bowen, New Orleans, LA 10:30 AM – 11:15 AM PRESIDENTIAL PLENARY B 25ABC (PLENARY SESSION II) Moderator: John C. Bowen, New Orleans, LA 249 Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis Abhishek Choudhary*, Matthew L. Bechtold, Craig Karpman, Srinivas R. Puli, Mohamed O. Othman, Praveen K. Roy Department of Internal Medicine, University of Missouri, Columbia, MO 250 Comparison of Surgically Resected Polypoid Lesions of the Gallbladder to Their Pre-Operative Ultrasound Characteristics Martin D. Zielinski*1, Peyton W. Davis1, Florencia G. Que1, Michael L. Kendrick1, Thomas D. Atwell2 1Gastrointestinal and General Surgery, Mayo Clinic, Rochester, MN; 2Radiology, Mayo Clinic, Rochester, MN 251 The Incidental Asymptomatic Pancreatic Lesion: Nuisance or Threat? Teviah E. Sachs*, Wande B. Pratt, Mark P. Callery, Charles M. Vollmer General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 11:15 AM – 12:00 PM DORIS AND JOHN L. CAMERON 25ABC GUEST ORATION SP359 The Coming American Revolution: How China Will Cause the Greatest Changes in the U.S. Since the Birth of the Nation Louis McDaniel Bowen, Hong Kong, SAR, China

12:00 PM – 2:00 PM POSTER SESSION I Sails Pavilion Authors available at their posters to answer questions 12 PM – 2 PM; posters on display 8 AM – 5 PM.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS SP386 Local Therapy for Rectal Cancer Carlsbad, South Anthony J. Senagore, Grand Rapids, MI Tower, Marriott Hotel & Marina SP391 Surgical Management of Achalasia 26B Donald E. Low, Seattle, WA SCHEDULE SP394 What’s New in Liver Tumor Ablation 26A DAILY David M. Mahvi, Madison, WI 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIA ESOPHAGEAL CANCER Ballroom 20A Sponsored by: SSAT, AGA Moderators: John G. Hunter, Portland, OR Stuart Jon Spechler, Dallas, TX SP401 The Intriguing Epidemiology of Esophageal Cancer: What Factors Underlie the Trends? Stuart Jon Spechler, Dallas, TX SP402 The Biology of Esophageal Cancer: What Factors Inﬂuence the Choice of Therapy? Jeffrey H. Peters, Rochester, NY SP403 Endoscopic Treatment of Esophageal Cancer Jacques J. Bergman, Amsterdam, Netherlands SP404 Surgical Treatment of Esophageal Cancer John G. Hunter, Portland, OR SP405 A Balanced Approach to the Treatment of Esophageal Cancer Charles R. Thomas, Jr., Portland, OR Discussion THE OPTIMAL MANAGEMENT OF Ballroom 20BCD LGI BLEEEDING Sponsored by: ASGE, AGA, SSAT Moderators: Kenneth R. McQuaid, San Francisco, CA Lisa L. Strate, Seattle, WA SP406 Why Is There So Much Controversy? Lisa L. Strate, Seattle, WA

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SP407 Should Urgent Colonoscopy Be Performed in Most Patients with Acute LGIB? YES! Dennis M. Jansen, Los Angeles, CA SP408 Should Urgent Colonoscopy Be Performed in Most Patients with Acute LGIB? NO! Don C. Rockey, Dallas, TX

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University Hospital Magdeburg, Magdeburg, Germany; 3Surgery, DAILY Carl Thiem Hospital Cottbus, Cottbus, Germany 343 Probiotics Improve Weight Loss, GI-Related Quality of Life and H2 Breath Tests After Gastric Bypass Surgery: A Prospective Randomized Trial Gavitt A. Woodard*, Joseph Peraza, John Downey, Betsy Encarnacion, John M. Morton Surgery, Stanford School of Medicine, Stanford, CA 344 Factors Related to Anastomotic Dehiscence and Mortality After Terminal Stomal Closure in the Management of Patients with Severe Secondary Peritonitis Jose L. Martinez*, Pablo Andrade, Enrique Luque-De-Leon Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI, Mexico DF, Mexico 345 Predictors of Survival in 865 Patients with Acinar Cell Carcinoma of the Pancreas: Survival After Surgery Compared to Ductal Adenocarcinoma C. Max Schmidt*1,4, Jesus M. Matos1, David J. Bentrem3, Mark S. Talamonti2, Keith D. Lillemoe1, Karl Y. Bilimoria3 1Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; 3Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 4Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 346 Preoperative Liver Function Tests and Hemoglobin Will Predict Complications Following Pancreaticoduodenectomy Christopher D. Hughes*1, Karen Rychlik2, Margo Shoup1, Gerard V. Aranha1 1Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center, Maywood, IL; 2The Cardinal Bernardin Cancer Center, Loyola University Medical Center, Maywood, IL

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347 Surgical Management of Early Hepatocellular Carcinoma: Resection or Transplantation? Emily C. Bellavance*2, Steven Cunningham2, Kimberly M. Lumpkins2, Warren R. Maley1, Cinthia Drachenberg3, Richard D. Schulick1, Andrew M. Cameron1, Michael Choti1, Nader Hanna2, Benjamin Philosophe2, Timothy M. Pawlik1 1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, University of Maryland, Baltimore, MD; 3Pathology, University of Maryland, Baltimore, MD 348 Increasing Regionalization of Hepatic Resection in Canada: 1995–2004 Ryan McColl*, Xiaoqing You, William A. Ghali, Elijah Dixon Department of Surgery, Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada 2:15 PM – 5:00 PM SSAT/AGA/ASGE 25ABC STATE-OF-THE-ART CONFERENCE OPTIMAL TIMING OF SURGERY FOR IBD Moderator: Richard A. Hodin, Boston, MA SP449 Introduction Richard A. Hodin, Boston, MA SP450 Pregnancy: Before, During, and After Robin S. McLeod, Toronto, ON SP452 An Updated Approach to Dysplasia in IBD David Rubin, Chicago, IL SP453 Fulminant Colitis Bruce Sands, Boston , MA SP454 Pyogenic Complications of Crohns James W. Fleshman, St. Louis, MO Case Presentations Q&A

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, SCHEDULE New York, NY; 2Medical and Surgical Department of Digestive Diseases, DAILY Institut Mutualiste Montsouris, Paris, France 350 Small Diameter Prosthetic H-Graft Portacaval Shunt for Portal Decompression Alexander S. Rosemurgy*, Harold Paul, Mark Shapiro, Desiree Villadolid, Sam Al-Saadi, Sharona B. Ross, Sarah Cowgill Surgery, University of South Florida and Tampa General Hospital, Tampa, FL 351 Functional Magnetic Resonance Imaging of Pancreatic Disease Tara S. Kent*1, Ivan Pedrosa3, Sunil Sheth2, Alphonso Brown2, Mark P. Callery1, Charles M. Vollmer1 1Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 3Radiology, Beth Israel Deaconess Medical Center, Boston, MA 352 Laparoscopic Extended Distal Pancreatectomy for Tumors of the Pancreatic Neck Christos A. Galanopoulos*, D. Rohan Jeyarajah HPB/Foregut Surgery, Methodist Dallas Medical Center, Dallas, TX 353 Laparoscopic Approach in Patients with Gastrinoma Which Are the Limits? Laureano Fernández-Cruz* Surgery, Hospital Clínic, Barcelona, Spain

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4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIA MEDICAL AND SURGICAL Ballroom 20BCD MANAGEMENT OF NAFLD Sponsored by: AASLD, SSAT Moderators: Nathan M. Bass, San Francisco, CA John M. Morton, Stanford, CA SP457 The Pathogenesis of NAFLD: The Rational Basis for Treatment Strategies Stephen H. Caldwell, Charlottesville, VA SP458 The Medical Management of NAFLD Paul Angulo, Rochester, MN SP459 The Surgical Management of NAFLD John M. Morton, Stanford, CA PANCREATIC CANCER Ballroom 20A Sponsored by: SSAT, ASGE, AGA Moderators: William R. Brugge, Boston, MA Douglas B. Evans, Houston, TX SP460 The Importance of Pretreatment Radiographic Staging: Deﬁnitions of Resectable, Borderline Resectable and Locally Advanced Pancreatic Cancer Chuslip Charnsangavej, Houston, TX SP461 Preoperative Biliary Stenting for Resectable Disease: Current Controversy and the Role for Metal Versus Plastic Peter B. Kelsey, Boston, MA SP462 Endoscopic Ultrasound-Guided FNA: Should It Be Routine in Patients with Localized Pancreatic Cancer? Michael J. Levy, Rochester, MN SP463 Patient Selection for Surgery: Diagnostic and Treatment Sequencing Mark P. Callery, Boston, MA Case Presentations

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Tuesday, May 20, 2008

7:30 AM – 10:00 AM VIDEO SESSION II: BREAKFAST 25ABC AT THE MOVIES Moderators: Craig P. Fischer, Houston, TX Attila Nakeeb, Indianapolis, IN SCHEDULE DAILY 449 Combined Treatment of Esophageal Perforation: A New Approach Bryan J. Sandler*, Michelle K. Savu, Garth R. Jacobsen, John Cullen, Thomas J. Savides, Mark A. Talamini, Santiago Horgan Department of Surgery, University of California, San Diego, San Diego, CA 450 Dual Incision Adjustable Gastric Band Placement Garth R. Jacobsen*, Bryan J. Sandler, John Cullen, Mark A. Talamini, Adam Spivack, Santiago Horgan Department of Surgery, University of California, San Diego, San Diego, CA 451 A Simpliﬁed Technique for Placement of Biologic Mesh in Paraesophageal Hernia Repair (PEH) Tayyab S. Diwan*, Danny V. Martinec, Michael Ujiki, Christy M. Dunst, Lee L. Swanstrom Minimally Invasive Surgery, Legacy Health System, Portland, OR 452 Human NOTES Hybrid Transgastric Cholecystectomy Edward Auyang*1, Khashayar Vaziri1, John A. Martin2, Eric S. Hungness1, Nathaniel J. Soper1 1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology, Northwestern University, Chicago, IL 453 Totally Laparoscopic Extended Right Hepatectomy Andrew A. Gumbs*1,2, Brice Gayet2 1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France 454 Standardization of Laparoscopic Distal Pancreatic Resection (LapDPR) with Regional Lymphadenectomy in Malignant Pancreatic Neoplasms (MPN) Laureano Fernández-Cruz* Surgery, Hospital Clínic, Barcelona, Spain 455 Laparoscopic Sigmoid Resection for Complicated Diverticulitis (Colovaginal Fistula) Barry Salky* Surgery, Mount Sinai Hospital, New York, NY

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456 Laparoscopic Celiac Artery Decompression Khashayar Vaziri*, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 457 Pneumatosis Coli: Resection of the Splenic Flexure with Intracorporeal Anastomosis Melina C. Vassiliou*1, Douglas S. Smink2, Gina L. Adrales1 1General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2General Surgery, Brigham and Women’s Hospital, Boston, MA

8:30 AM – 10:00 AM PUBLIC POLICY COMMITTEE PANEL 28ABC THE EFFECTS OF QUALITY INITIATIVES AND REPORTING ON PATIENT CARE AND REIMBURSEMENTS TO PHYSICIANS AND HOSPITALS Moderator: Lygia Stewart, San Francisco, CA SP538 Measuring Quality, and the Effects on the Quality of Care Clifford Ko, Los Angeles, CA SP539 Payment Reform: The Impact of CMS Value Based Payment Policies on Your Practice and Your Patients Susan Nedza, Chicago, IL SP560 How Are Quality Initiatives and Public Reporting Affecting Hospitals? Andrea Snyder, San Diego, CA SP561 Improving the Quality of Surgical Care Throughout a Region: The SCOAP Initiative of Washington State Carlos A. Pellegrini, Seattle, WA Panel and Audience Discussion

9:30 AM – 11:00 AM SSAT/AHPBA JOINT SYMPOSIUM 24ABC CURRENT APPROACH TO CARCINOMA OF THE GALLBLADDER Moderator: Bruce D. Schirmer, Charlottesville, VA SP550 Preoperative Detection and Approach to the Suspicious Gallbladder Reid B. Adams, Charlottesville, VA

44 6303_SSAT.book Page 45 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

SP551 Intraoperative Approach to an Unexpectedly Detected Lesion During Lap Cholecystectomy Charles M. Vollmer, Jr, Boston, MA SP552 Treatment Plan When Last Week’s Routine Lap Cholecystectomy Returns Cancer Brett C. Sheppard, Portland, OR SCHEDULE

SP553 Current Best Options for Stage III Disease DAILY Andrew M. Lowy, La Jolla, CA Panel and Audience Discussion

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46 6303_SSAT.book Page 47 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

47 6303_SSAT.book Page 48 Tuesday, April 22, 2008 1:26 PM

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569 Downregulation of AdiponectinAdipor2 Is Associated with Hepatic Inﬂammation and Steatosis in Obese Mice Yanhua Peng2,3, Drew A. Rideout*1,2, Steven S. Rakita1,2, Mini Sajan2,3, Robert Farese2,3, Min You3, Michel M. Murr1,2 1Department of Surgery, University of South Florida, Tampa, FL; 2Department of Surgery and Research, James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department of Molecular Medicine, University of South Florida, Tampa, FL 570 Ischemic Colitis Following Endovascular Aortoiliac Aneurysm Repair: A 10-Year Retrospective Review Aaron Miller*, Michael S. Marotta, Irini A. Scordi-Bello, Yolanda Tammaro, Celia M. Divino The Mount Sinai Hospital, New York, NY 571 Perianal Fistula Occurring After Ileal Pouch for Non-Crohn’s Colitis: A Word of Caution Isabella Mor*, Bo Shen, Susan Shedda, Margaret O’Malley, Jeffery Hammel, Feza H. Remzi Colorectal Surgery A-30, Cleveland Clinic Foundation, Cleveland, OH 572 Resection Versus Laparoscopic Radiofrequency Thermal Ablation of Solitary Colorectal Liver Metastasis Eren Berber*, Michael Tsinberg, Conrad H. Simpfendorfer, Allan Siperstein Cleveland Clinic, Cleveland, OH

48 6303_SSAT.book Page 49 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

10:30 AM – 12:00 PM DDW COMBINED Ballroom 20BCD CLINICAL SYMPOSIUM MANAGING COMPLICATIONS OF GI PROCEDURES Sponsored by: AGA, SSAT, ASGE Moderators: Kevin E. Behrns, Gainesville, FL Martin Freeman, Minneapolis, MN SCHEDULE SP556 Complications of Esophagogastroduodenoscopy (EGD) DAILY and Endoscopic Muscosal Resection (EMR) Jonathan Cohen, New York, NY SP557 Complications of Colonoscopy Douglas Brooks Nelson, Minneapolis, MN SP558 Complications of Endoscopic Retrograde Cholangiopancreatiography Martin Freeman, Minneapolis, MN SP559 Role of Surgery in Management of Endoscopic Complications George A. Sarosi, Jr, Gainesville, FL

11:15 AM – 12:00 PM MAJA AND FRANK G. MOODY 25ABC STATE-OF-THE-ART LECTURE SP601 The Early Detection of Pancreatic Cancer: Lessons from Surveillance of 100 High-Risk Patients Teresa Brentnall, Seattle, WA

12:00 PM – 2:00 PM POSTER SESSION II Sails Pavilion Authors available at their posters to answer questions 12 PM – 2 PM; posters on display 8 AM – 5 PM.

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS SP616 Laparoscopic Hepatectomy 26A Alan Koffron, Chicago, IL SP624 NOTES Update 30A Lee L. Swanstrom, Portland, OR SP626 Re-Classifying Acute Pancreatitis 26B Michael G. Sarr, Rochester, MN

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2:15 PM – 3:30 PM PLENARY SESSION V 28ABC Moderators: Susan Galandiuk, Louisville, KY Thomas H. Magnuson, Baltimore, MD 678 NOTES Rectosigmoid Resection Using Transanal Endosocopic Microsurgery (TEM) with Transgastric Flexible Endoscopic Assistance: A Pilot Study in Swine Patricia Sylla*1, Field F. Willingham2, Denise W. Gee1, William R. Brugge2, David W. Rattner1 1Surgery, Massachusetts General Hospital, Boston, MA; 2Medicine, GI unit, Massachusetts General Hospital, Boston, MA 679 Who Should Do NOTES: Initial Endoscopic Performance and Early Learning Curve of Laparoscopic Surgeons in Comparison to Endoscopists and Untrained Individuals Oliver J. Wagner*1, Monika E. Hagen2, Francois Pugin2, Philippe Morel2, Daniel Candinas1 1Department of Visceral and Transplantation Surgery, University Bern, Bern, Switzerland; 2Digestive Surgery, University Hospital Geneva, Geneva, Switzerland 680 To Prepare or Not the Colon for Elective Surgery with Primary Intraperitoneal Anastomosis. There Is No Question María Jesús Peña-Soria, Julio M. Mayol*, Rocio Anula, Ana M. Arbeo-Escolar, Jesus A. Fernandez-Represa Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain 681 Routine Liver Biopsy to Detect Non-Alcoholic Fatty Liver Disease (NAFLD) During Laparoscopic Cholecystectomy for Symptomatic Gallstone Disease (GD)—Is It Justified? Antonio Ramos-De La Medina*1, Federico B. Roesch2, Alfonso Perez Morales3, Silvia Cid-Juarez2, Jose M. Remes-Troche2 1Gastroenterology and Gastrointestinal Surgery Department, Veracruz Regional Hospital, Boca del Rio, Mexico; 2Digestive Physiology and Motility Laboratory, Medical-Biological Research Institute University of Veracruz, Veracruz, Mexico; 3University of Veracruz Medical School, Veracruz, Mexico 682 Reinterventions for Specific Technique-Related Complications of Stapled Haemorrhoidopexy (SH): A Critical Appraisal Pierpaolo Sileri*, Vito M. Stolfi, Antonio Chiaravalloti, Achille Lucio Gaspari Surgery, University of Rome Tor Vergata, Rome, Italy

50 6303_SSAT.book Page 51 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

2:15 PM – 3:45 PM DDW COMBINED Ballroom 20A CLINICAL SYMPOSIUM FECAL INCONTINENCE: NEW PERSPECTIVES ON EARLY DETECTION, CURRENT AND FUTURE THERAPIES Sponsored by: AGA, SSAT SCHEDULE

Moderators: Tracy L. Hull, Cleveland, OH DAILY William E. Whitehead, Chapel Hill, NC SP636 Epidemiology, GI Disease Risk Factors, and Recommendations of the NIH State of the Science Conference on the Prevention of Fecal and Urinary Incontinence Frank A. Hamilton, Bethesda, MD SP637 Quality of Life Impact Nancy Jean Norton, Milwaukee, WI SP638 Pathophysiology and New Diagnostic Tests Adil E. Bharucha, Rochester, MN SP639 Medical Management and Biofeedback Steve Heymen, Chapel Hill, NC SP640 Surgical Management Ann C. Lowry, St. Paul, MN

2:15 PM – 4:15 PM CONTROVERSIES IN GI SURGERY 24ABC DEBATE 1: INTRAMUCOSAL ESOPHAGEAL CANCER AND HIGH GRADE DYSPLASIA: WHICH TREATMENT? Moderator: Donald E. Low, Seattle, WA SP693 Frame the Issue Brant K. Oelschlager, Seattle, WA SP694 Endoscopic Therapy: Effective and Patient Friendly Drew Schembre, Seattle, WA SP695 Surgical Therapy: Improved Outcomes and Piece of Mind Jeffrey H. Peters, Rochester, NY Panel and Audience Discussion

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DEBATE 2: HEPATOCELLULAR CARCINOMA IN THE MILD CIRRHOTIC: TRANSPLANT OR RESECT? Moderator: Michael A. Choti, Baltimore, MD SP696 Frame the Issue Michael A. Choti, Baltimore, MD SP697 Transplant if Eligible Alan W. Hemming, Gainesville, FL SP698 Resection Is Best if Possible Timothy M. Pawlik, Baltimore, MD Panel and Audience Discussion DEBATE 3: BEST PRACTICES/CENTERS OF EXCELLENCE: EFFECTIVE TOOLS OR GOOD ADVERTISING? Moderator: John C. Bowen, New Orleans, LA SP699 Frame the Issue Daniel B. Jones, Boston, MA SP700 ACS and ASMBS Accreditation: Metrics Drive Quality James K. Champion, Marietta, GA SP701 Just Another Form of Consumer Marketing Edward L. Felix, Fresno, CA Panel and Audience Discussion

52 6303_SSAT.book Page 53 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

775 Excellent Results from Limited Resection of Duodenal SCHEDULE Carcinoid Tumors DAILY Kenzo Hirose*, Brown Nancy, Kristina Potanos, Bipan Chand, R. Matthew Walsh General Surgery, Cleveland Clinic, Cleveland, OH 776 Five-Year Outcome of a Randomized Trial Comparing Pylorus- and Duodenum-Preserving Pancreatic Head Resection for Chronic Pancreatitis Ulrich Adam*, Frank Makowiec, Eva Fischer, Tobias Keck, Hartwig Riediger, Ulrich T. Hopt Department of Surgery, University of Freiburg, Freiburg, Germany 777 Tailored Transoral Incisionless Fundoplication (TIF) in the Treatment of GERD: The Anatomic and Physiologic Basis for Reconstruction of the Esophagogastric Junction Using a Novel Approach Blair A. Jobe1, Ger H. Koek2, Stefan J. Kraemer3, Barry P. Mcmahon4, Bart Witteman2, Flemming H. Gravesen5, Cedric S. Lorenzo*1, Robert W. O’Rourke1, Douglas A. Shumaker6, Michael M. Owens6, John G. Hunter1, Nicole Bouvy2 1Surgery, Oregon Health & Science University, Portland, OR; 2Surgery, Maastricht University Hospital, Maastricht, Netherlands; 3Endogastric Solutions, Inc., Redmond, WA; 4Medical Physics & Clinical Engineering, Adelaide & Meath Hospital and Trinity College, Dublin, Ireland; 5Visceral Biomechanics and Pain, Aalborg Hospital, Hobrovej, Denmark; 6West Hills Gastroenterology, Portland, OR 779 Signal Detection: A New Statistical Method to Predict NASH in Gastric Bypass Patients John M. Morton*, Gavitt A. Woodard, Tina Hernandez-Boussard Surgery, Stanford School of Medicine, Stanford, CA

53 6303_SSAT.book Page 54 Tuesday, April 22, 2008 1:26 PM

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3:30 PM – 5:00 PM SSAT/ASCRS JOINT SYMPOSIUM 25ABC LAPAROSCOPIC RECTAL CANCER SURGERY: IS IT READY FOR PRIME TIME? Moderators: David Shibata, Tampa, FL Michael J. Stamos, Orange, CA SP702 Current State-of-the-Art Conor P. Delaney, Cleveland, OH SP703 Pro: The Time Is Now Jeffrey W. Milsom, New York, NY SP704 Con: Let’s Wait for the Data Peter W. Marcello, Burlington, MA Panel and Audience Discussion

54 6303_SSAT.book Page 55 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

4:00 PM – 5:30 PM DDW COMBINED Ballroom 20BCD CLINICAL SYMPOSIUM OBESITY SURGERY: ENDOSCOPIC AND SURGICAL MANAGEMENT OF COMPLICATIONS Sponsored by: SSAT, ASGE, AGA Moderators: Ram Chuttani, Boston, MA SCHEDULE

Ninh T. Nguyen, Orange, CA DAILY SP710 Overview of Bariatric Operations Raul J. Rosenthal, Weston, FL SP711 Endoscopic Clips, Sutures and Stents for Leaks, Fistule and Stomal Dilation Christopher Thompson, Boston, MA SP712 Laparoscopic and Endoscopic Management of Band Erosion Santiago Horgan, Chicago, IL SP713 Endoscopic Balloon Dilation for Gastrojejunal Stenosis Kenneth Chang, Orange, CA SP714 Laproscopic and Endoscopic Management of Postoperative GI Bleeding Ninh T. Nguyen, Orange, CA SP715 Emerging Endoscopic Bariatric Technologies Ram Chuttani, Boston, MA

5:00 PM – 6:00 PM ANNUAL BUSINESS MEETING 25ABC Members Only

7:00 PM – 9:00 PM MEMBERS RECEPTION The Don Room at El Cortez

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Wednesday, May 23, 2008

7:00 AM – 8:30 AM SSAT/ISDS JOINT BREAKFAST 25ABC SYMPOSIUM HOW I DO IT: AROUND THE WORLD IN 90 MINUTES Moderators: Mark P. Callery, Boston, MA Fabrizio Michelassi, New York, NY SP757 Laparoscopic Proctocolectomy with J-Pouch Ileo-Anal Anastomosis Tonia M. Young-Fadok, Scottsdale, AZ SP758 Advanced Liver Resections Chung-Mau Lo, Hong Kong, China SP759 Laparoscopic Sleeve Gastrectomy Herbert Freund, Jerusalem, Israel SP760 Debridment for Infected Pancreatic Necrosis Claudio Bassi, Verona, Italy SP761 Laparoscopic Paraesophageal Hernia Repair: Facts and Myths Marco G. Patti, San Francisco, CA Audience Discussion

8:30 AM – 10:00 AM EDUCATION COMMITTEE PANEL 24ABC TEACHING SAFETY IN THE OR Moderator: Michael J. Zinner, Boston, MA SP792 Learning from Errors and Near Misses Caprice Christian Greenberg, Boston, MA SP793 Aviation Richard C. Karl, Tampa, FL SP794 Who Belongs in the OR? (Who’s In and Who’s Out?) Debra L. Sudan, Omaha, NE SP795 Building More Effective Teams in Surgery Donald W. Moorman, Boston, MA Q&A

56 6303_SSAT.book Page 57 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Radio-Chemotherapy in Patients with Locally SCHEDULE Advanced Cancer of the Esophagus DAILY Jan Brabender*1, Daniel Vallböhmer1, Frederike C. Ling1, Andreas C. Hoffmann1, Georg Lurje1, Elfriede Bollschweiler1, Arnulf H. Hölscher1, Paul M. Schneider2, Ralf Metzger1 1Department of Surgery, University of Cologne, Cologne, Germany; 2Department of Surgery, University of zuerich, Zuerich, Switzerland 949 Strong Prognostic Value of Nodal Microinvolvement in Patients with Carcinoma of the Papilla of Vater Receiving No Adjuvant Chemotherapy Dean Bogoevski*, Paulus G. Schurr, Jussuf T. Kaiﬁ, Guell Cataldegirmen, Oliver Mann, Yogesh K. Vashist, Emre F. Yekebas, Jakob R. Izbicki General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany 950 The Prognostic Superiority of Log Odds of Lymph Nodes in Stage III Colon Cancer Jiping Wang*1,2, James M. Hassett1, Merril T. Dayton1, Mahmoud N. Kulaylat1 1Department of Surgery, State University of New York at Buffalo, Buffalo, NY; 2Department of Biostatistics, State University of New York at Buffalo, Buffalo, NY

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58 6303_SSAT.book Page 59 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

SP800 Transendoscopic Mucosal Resection for Rectal Polyps Theodore J. Saclarides, Chicago, IL SP801 Endoscopic Submucosal Dissection for Colorectal Polyps: How I Do It Mainor R. Antillon, Columbia, MO SCHEDULE

10:30 AM – 12:00 PM PLENARY SESSION VII 25ABC DAILY Moderators: O. Joe Hines, Los Angeles, CA Blair A. Jobe, Portland, OR 1018 Long-Term Results After Minimally Invasive Repair of Giant Paraesophageal Hernia in 105 Patients Katie S. Nason*, James D. Luketich, Rodney J. Landreneau, Irfan Qureshi, Samuel B. Keeley, Shannon E. Trainor, Manisha Shende, Arjun Pennathur Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 1019 Perioperative Treatment with Infliximab (IFX) in Patients with Crohn’s (CD) and Ulcerative Colitis (UC) Is Not Associated with Increased Rate of Postoperative Complications Hiroko Kunitake*1, Richard Hodin1, Paul C. Shellito1, Bruce E. Sands2, Joshua R. Korzenik2, Liliana Bordeianou1 1Surgery, Massachusetts General Hospital, Boston, MA; 2Gastroenterology, Massachusetts General Hospital, Boston, MA 1020 Use of Infliximab Within Three Months Prior to Ileocolonic Resection Is Associated with Significant Adverse Postoperative Outcomes in Crohn’s Patients Kweku A. Appau*, Victor W. Fazio, James M. Church, Bo Shen, Feza H. Remzi, Scott A. Strong, Bret Lashner, Takayuki Yamamoto, Paris P. Tekkis, Jeffery Hammel, Ravi P. Kiran Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH 1021 Selective Management of Iatrogenic Colonoscopic Perforations Dimitrios V. Avgerinos*, Omar H. Llaguna, Andrew Y. Lo, I. Michael Leitman Surgery, Beth Israel Medical Center, New York, NY

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10:30 AM – 12:00 PM VIDEO SESSION III: NOTES: WHERE ARE 27B WE TODAY? Moderators: Brian J. Dunkin, Houston, TX Nathaniel J. Soper, Chicago, IL 1024 NOTES: Dissection of the Critical View of Safety During Transcolonic Cholecystectomy Edward Auyang*1, Khashayar Vaziri1, Eric S. Hungness1, John A. Martin2, Nathaniel J. Soper1 1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology, Northwestern University, Chicago, IL 1025 Single Port Access (SPA) Cholecystectomy Paul G. Curcillo, Erica R. Podolsky*, Steven J. Rottman Surgery, Drexel University College of Medicine, Philadelphia, PA 1026 Single Incision Laparoscopic Cholecystectomy Using Flexible Endosocopy Glenn Forrester*, John N. Afthinos, Eugenius J. Harvey, Steven Binenbaum, Grace J. Kim, Julio Teixeira Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY

60 6303_SSAT.book Page 61 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Surgery, McMaster University, Hamilton, ON, Canada; 5Section of Digestive DAILY Diseases, Yale University, New Haven, CT; 6Division of Anatomy, University Geneva, Geneva, Switzerland 1028 Reverse NOTES: Transgastric ERCP Yoav Mintz, Santiago Horgan, Thomas J. Savides, John Cullen*, Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini Department of Surgery, University of California, San Diego, San Diego, CA

12:00 PM – 2:00 PM POSTER SESSION III Sails Pavilion Authors available at their posters to answer questions 12 PM – 2 PM; posters on display 8 AM – 5 PM.

12:00 PM – 3:00 PM SSAT/SAGES JOINT LUNCHEON 25ABC SYMPOSIUM: THE GASTROINTESTINAL ANASTOMOSIS: EVIDENCE VERSUS TRADITION Moderators: David W. McFadden, Burlington, VT Mark A. Talamini, San Diego, CA THE ESOPHAGEAL ANASTOMOSIS SP825 Traditional Methods to Prevent Leak Daniel Raymond, Rochester, NY SP826 Improving Blood Supply Decreases Leak Rate Kevin M. Reavis, Orange, CA Question & Answer THE PANCREATIC ANASTOMOSIS: THE DANGER OF A LEAK SP827 Which Anastomotic Technique Is Better? David B. Adams, Charleston, SC

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SP828 Stents, Glue, Etc.: Is Anything Proven to Help Prevent Leaks/Fistulae? Richard D. Schulick, Baltimore, MD SP829 Deﬁning, Controlling, and Treating a Fistula David M. Mahvi, Madison, WI Question & Answer Break THE COLON ANASTOMOSIS: DIVERSION OR PRIMARY ANASTOMOSIS SP830 Diverting Ostomy with Pouch Procedure: Should Be Done to Prevent Severe Morbidity Charles M. Friel, Charlottesville, VA SP831 Diverting Ostomy with Pouch Procedure: Causes More Morbidity Than It Prevents Mark J. Koruda, Chapel Hill, NC SP832 Colonic Trauma: Indications for Diversion vs. Repair Joseph DuBose, Los Angeles, CA Question & Answer THE BARIATRIC GASTROJEJUNOSTOMY: WHEN THINGS GO WRONG SP833 Dilating the Stenotic Gastrojejunostomy After Gastric Bypass Raul J. Rosenthal, Weston, FL SP834 Leak: Reoperate, Drain, and Feed Distally Eric J. DeMaria, Durham, NC SP835 Leak: Treat with Endoscopic Stent Klaus Thaler, Columbia, MO Question & Answer

62 6303_SSAT.book Page 63 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Ninh T. Nguyen SCHEDULE Department of Surgery, UC Irvine Medical Center, Orange, CA DAILY 1030 Optimizing Outcome Measurement in Pancreatic Surgery: Can NSQIP Measure Up? Craig P. Fischer*1,2, Thomas A. Aloia1,2, Bridget N. Fahy1,2, Stephen L. Jones1,2, Barbara L. Bass1,2 1Surgery, The Methodist Hospital, Houston, TX; 2Weill Medical College of Cornell University, New York, NY 1031 The Learning Curve of Laparoscopic Rectal Resection for Cancer: A Single-Center Experience Marco Montorsi*, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi, Riccardo Rosati General Surgery, University of Milan, Istituto Clinico Humanitas IRCCS, Milan, Italy 1032 Short-Term Outcomes After Laparoscopic-Assisted Compared to Open Colectomy for Cancer Karl Y. Bilimoria*1, David J. Bentrem1, Heidi Nelson2, Steven J. Stryker1, Clifford Y. Ko3, Nathaniel J. Soper1 1Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 2Department of Surgery, Mayo Clinic, Rochester, MN; 3Department of Surgery, UCLA and Greater Los Angeles VA, Los Angeles, CA 1033 Patient Demographics and Surgeon Volume in Pancreatic Resection Mortality Robert W. Eppsteiner*, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah Surgery, University of Massachusetts, Worcester, MA 1034 Are Seasoned Surgeons Still Safe in a Laparoscopic Surgical Crisis? Kinga A. Powers*1,2, Scott Rehrig1, Noel Irias1, Mark P. Callery1, Steven D. Schwaitzberg2, Daniel B. Jones1 1Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Surgery, Cambridge Health Alliance, Harvard Medical School, Boston, MA

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1035 Meta-Analysis of Mechanical Bowel Preparation for Elective Colon and Rectal Resection Carlos E. Pineda*, Andrew A. Shelton, Tina Hernandez-Boussard, John M. Morton, Mark L. Welton Department of Surgery, Stanford University, Stanford, CA 1036 Sequential Resections of Liver and Pulmonary Metastases of Colorectal Cancers: Results of 45 Patients Hannes Neeff*1, Frank Makowiec1, Eva Fischer1, Ulrich T. Hopt1, Bernward Passlick2 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Department of Thoracic Surgery, University of Freiburg, Freiburg, Germany 1037 Prognostic Factors Associated with Survival Following Hepatic Resection of Early-Stage Hepatocellular Carcinoma Hari Nathan*, Michael Choti, Richard D. Schulick, Timothy M. Pawlik Surgery, Johns Hopkins Hospital, Baltimore, MD 1038 Staging Error Does Not Explain the Relationship Between the Number of Nodes in a Colon Cancer Specimen and Survival Jesse Moore*1, Neil H. Hyman1, Peter Callas2, Benjamin Littenberg3 1Surgery, University of Vermont College of Medicine, Burlington, VT; 2Mathematics & Biostatistics, University of Vermont College of Medicine, Burlington, VT; 3Med-Gen Internal Medicine, University of Vermont College of Medicine, Burlington, VT

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS SP860 The Difﬁcult Cholecystectomy 26B Lygia Stewart, San Francisco, CA SP861 Total Mesorectal Excision 26A James W. Fleshman, St Louis, MO

64 6303_SSAT.book Page 65 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

2:15 PM – 3:45 PM DDW COMBINED Ballroom 20A CLINCIAL SYMPOSIUM BALANCING THE USE OF BIOLOGICS AND SURGERY IN MANAGEMENT OF ULCERATIVE COLITIS Sponsored by: AGA, SSAT SCHEDULE

Moderators: Stephen B. Hanauer, Chicago, IL DAILY Scott A. Strong, Cleveland, OH SP94 Beneﬁts of Biological Therapy in Severe Ulcerative Colitis Russell D. Cohen, Chicago, IL SP95 Beneﬁts of Surgery in Severe Ulcerative Colitis David W. Larson, Rochester, MN SP96 Risks of Biological Therapy in Severe Ulcerative Colitis Walter Koltun, Hershey, PA SP97 Risks of Surgery in Severe Ulcerative Colitis Asher Kornbluth, New York, NY

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POSTER SESSION DETAIL

Designated presenting authors listed. For complete author strings, turn to the Poster Session Abstracts starting on page 184.

Monday, May 19, 2008

12:00 PM – 2:00 PM SSAT POSTER SESSION SAILS PAVILION Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM. In addition, Posters of Distinction () will be available for further viewing in Room 25ABC on Tuesday, May 20, 2008.

CLINICAL SCIENCE POSTERS

Clinical: Biliary

M1500 Acute Calculous Cholecystitis: Indications for Early Percutaneous Cholecystostomy Gidon Almogy, Hadassah University Hospital, Jerusalem, Israel M1501 Polypoid Lesions of Gallbladder: Diagnosis and Follow-Up Hiromichi Ito, Memorial Sloan-Kettering Cancer Center, New York, NY M1502 Single Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope Glenn Forrester, St. Luke’s-Roosevelt Hospital Center, New York, NY M1503 Laparoscopic Cholecystectomy as a Standardized Teaching Operation: A Comparison of Operative Complications and Short-Term Outcome Between Surgical Residents and Attending Surgeons in 1220 Patients Rene Fahrner, Limmattal Hospital, Schlieren, Switzerland M1504 Malignant Melanoma of Lung and Gallbladder, Presenting with Hemoptysis: A Case Report and Review of Literature Ming-Chin Yu, Chang Gung Memorial Hospital, Taoyuan, Taiwan

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1505 Choledochal Cysts: Risk of Malignancy and Outcome in 68 Patients Undergoing Surgical Management at a Single Institution John P. Bois, Mayo Clinic, Rochester, MN M1506 Single Incision Laparoscopic Cholecystectomy Michael Albrink, University of South Florida and Tampa General Hospital, Tampa, FL M1508 Plugging Away at the Anal Fistula: An Exercise in Futility? Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH M1509 Clinical Feature and Management of Postoperative SESSIONS Pouch Bleeding After Ileal Pouch-Anal Anastomosis POSTER (IPAA) Lei Lian, Cleveland Clinic, Cleveland, OH M1510 Dosimetric Evaluation of Endoscopic Radiofrequency Ablation in the Human Colonic Epithelium in a Treat and Resect Trial Joseph A. Trunzo, University Hospitals Case Medical Center, Cleveland, OH M1511 A Population-Based Study of Surgical Treatment of Colon Cancer in Ontario, Canada Rahima Nenshi, University of Toronto, University Health Network, Toronto, ON, Canada M1512 Health Related Quality of Life and Clinical Outcome After Colonic Resection for Diverticular Disease: Long-Term Results Imerio Angriman, Clinica Chirurgica I°, University of Padova, Padova, Italy M1513 Prognostic Factors for Survival in 61 Patients with Carcinoma of the Splenic Flexure Simon S. Ng, The Chinese University of Hong Kong, Hong Kong, China M1514 Risk of Infection and Recurrence over Prolonged Follow Up in Patients Undergoing Ventral Hernia Repair During Colorectal Resection: Can the Use of Mesh Be Justiﬁed? Levilester B. Salcedo, Cleveland Clinic, Cleveland, OH M1515 The Prognostic Signiﬁcance of Circumferential Resection Margin Involvement in Colon Cancer Selman Sokmen, Dokuz Eylul University School of Medicine, Izmir, Turkey

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M1516 Results of Surgical Treatment of Local Recurrence in Rectal Cancer Patients Jörn Gröne, Charité Universitätsmedizin Berlin, Berlin, Germany M1517 Preoperative Plasma Levels of Fractalkine (CX3CL1) Are Signiﬁcantly Lower in Patients with Adenocarcinoma of the Colon When Compared to Benign Disease Patients Aviad Hoffman, Columbia University, New York, NY M1518 Hemorrhoidectomy in Day Surgery: A Comparison Between Four Techniques Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy M1519 Comparison of Quality of Life (QOL) Between Ileal J Pouch-Anal Anastomosis and Permanent Ileostomy After Proctocolectomy for Ulcerative Colitis in Elderly Patients Munenori Nagao, Tohoku university, Sendai, Japan M1520 CT Scan in the Diagnosis of Acute Appendicitis: Help or Hindrance? Akpofure Peter Ekeh, Wright State University Boonshoft School of Medicine, Dayton, OH M1521 The Likely Cause of Postoperative “Feeding Intolerance” and Its Prevention Gerald Moss, Rensselaer Polytechnic Institute, White Plains, NY M1522 The Clinical Signiﬁcance of Adult Intussusception Found by Computed Tomography Parissa Tabrizian, The Mount Sinai Medical Center NY, New York, NY

Clinical: Esophageal

M1523 Gastroesophageal Reﬂux Disease and Connective Tissue Disorders. Pathophysiology and Implications for Treatment Warren J. Gasper, University of California San Francisco, San Francisco, CA

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1525 Acid Reflux to the Proximal Esophagus Predicts Postoperative Success in Patients with Laryngopharyngeal Reflux Disease Carlos Godinez, University of Maryland Medical Center, Baltimore, MD M1526 Outcomes Following Esophagogastrectomy in Octogenarians Sebastian Defranchi, Mayo Clinic, Rochester, MN M1527 Analyzing Treatment Costs for Esophageal Cancer Patients at Different Stages Chih-Cheng Hsieh, Taipei Veterans General Hospital, Taipei, Taiwan M1528 Incorporation of Biologic Mesh Into Crural Closure SESSIONS Decreases Complications and Recurrence of POSTER Paraesophageal Hernias Tayyab S. Diwan, Legacy Health System, Portland, OR M1529 New Techniques for Endoscopic (Laparoscopic and Thoracoscopic) Esophagectomy of Esophageal Cancer, Ropeway Technique for Dissection Along with the Nerve and Double-Gloving Method of HALS for Reconstruction Hitoshi Satodate, Showa University Northern Yokohama Hospital, Yokohama, Japan M1530 Accidental Mucosal Perforation During Laparoscopic Heller-Dor Myotomy Does Not Affect the Final Outcome of the Operation Mario Costantini, University of Padua, Padova, Italy M1531 Prevalence of Kyphoscoliosis Among Patients with Giant Paraesophageal Hernia: Proposed Pathophysiology and Clinical Significance Matthew J. Schuchert, University of Pittsburgh Medical Center, Pittsburgh, PA M1532 Preoperative Chemoradiation with Intensify- Modulated Radiation Therapy (IMRT) Increases Pathological Complete Response Rate in Locally Advanced Squamous Cell Carcinoma of the Esophagus Chadin Tharavej, Chulalongkorn University, Bangkok, Bangkok, Thailand

Poster of Distinction

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Clinical: Hepatic

M1533 Hepatobiliary Resection with Inferior Vena Cava Resection and Reconstruction Using an Autologous Patch Graft for Intrahepatic Cholangiocarcinoma Tsuyoshi Sano, Aichi Cancer Center Hospital, National Cancer Center Hospital, Nagoya, Japan M1534 Postoperative Complications After Liver Resections for Colorectal Metastases: Analysis of Risk Factors and Inﬂuence of Preoperative Chemotherapy Frank Makowiec, University of Freiburg, Freiburg, Germany M1535 Second Liver Resection for Recurrent Metastases of Colorectal Cancer: Perioperative Complications and Oncological Results Hannes Neeff, University of Freiburg, Freiburg, Germany M1536 A Decision Analysis Model of Hepatectomy Versus Radiofrequency Ablation for Hepatocellular Carcinoma Amanda Cooper, Indiana University, Indianapolis, IN M1537 Image-Guided Laparoscopic Radiofrequency Ablation of Giant Liver Hemangiomas Rocio Anula, Hospital Clinico San Carlos, Hospital Clinico San Carlos, Madrid, Spain M1538 Monopolar Floating Ball Versus Bipolar Forceps for Hepatic Resection: A Prospective Randomized Clinical Trial Guido Torzilli, University of Milan, Istituto Clinico Humanitas – IRCCS, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy

Clinical: Pancreas

M1539 Long Term Follow-Up (7–34 Years) After Surgical Treatment of Chronic Pancreatitis Sergio Pedrazzoli, IV Surgical Clinic, PADOVA, Italy

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1540 High Complication Rate After Pancreas Preserving Surgical Procedures for Benign or Borderline Pancreatic Lesions. Careful Selection of Patients Is Needed Sergio Pedrazzoli, IV Surgical Clinic, PADOVA, Italy M1541 Predictable Factors for Poor Outcome After Severe Acute Pancreatitis Takeo Yasuda, Kinki University School of Medicine, Osaka-sayama, Japan M1542 Serum Immunosuppressive Acidic Protein Levels in Patients with Severe Acute Pancreatitis Makoto Shinzeki, Kobe University Graduate School of Medical Sciences, Kobe, Hyogo, Japan SESSIONS M1543 Risk Factors for Postoperative Complications After POSTER Pancreatic Head Resection: Multivariate Analysis of 608 Consecutive Operations Tobias Keck, University of Freiburg, Freiburg, Germany M1544 Quality of Life After Total Pancreatectomy: Requiem for a Surgical Dogma? Roberto Salvia, Università di Verona, Verona, Italy M1545 The Assessment of the Malignant Potential of IPMN: How Reliable Is the New Score from Fujino? Dominique Suelberg, University Hospital of Bochum, Bochum, Germany M1546 Volume in Pancreatic Surgery: The German Situation Guido Alsfasser, University of Rostock, Rostock, Germany M1547 The Lymph Node-Ratio Is the Strongest Factor Predicting Survival After Resection of Pancreatic Cancer Frank Makowiec, University of Freiburg, University of Freiburg, Freiburg, Germany M1548 Dynamic Magnetic Resonance Imaging (DMRI) of the Pancreas as a Predictor of Anastomotic Leakage After Pancreatic Resections Marco Niedergethmann, University Hospital Mannheim, Mannheim, Germany M1549 Combination of Bioabsorbable Polyglicolic Acid (PGA) Felt and Fibrin Glue for Prevention of Pancreatic Fistula Following Pancreaticoduodenectomy Kenichiro Uemura, Hiroshima University, Hiroshima, Japan

Poster of Distinction

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M1550 Radiofrequency Ablation of Locally Advanced Pancreatic Cancer Jennifer Logue, Glasgow Royal Inﬁrmary, Glasgow, United Kingdom M1551 Antibacterial Prophylaxis Does Not Prevent Infection of Pancreatic Necrosis in Acute Pancreatitis Eduardo A. Villatoro, University of Nottingham Medical School, Derby, Derby, United Kingdom M1552 Development of a Dedicated Team Decreases ICU Admission After Pancreaticoduodenectomy (PD) Julio Sokolich, Methodist Dallas Medical Center, Dallas , TX M1553 Predictive and Prognostic Value of CA 19-9 in Resected Pancreatic Adenocarcinoma Joshua G. Barton, Mayo Clinic, Rochester, MN

Clinical: Small Bowel

M1554 Long-Term Outcome After Distal Gastric Bypass Combined with Swedish Adjustable Gastric Banding (SAGB) Bruno M. Balsiger, Spitalnetzbern, Bern, Switzerland M1555 Gastro Intestinal Intramural Hematomas Versus Mesenteric Ischaemia- Clinico-Radiological Proﬁle Sudhindran Surendran, Amrita institute of medical Sciences, Kochi, India

Clinical: Stomach

M1556 Laparoscopic Lymphatic-Basin Dissection as an Additional Treatment to Endoscopic Submucosal Dissection in Early Gastric Cancer Toshiyuki Mori, Kyorin University, Tokyo, Japan M1557 Long Term Improvement of Comorbidities in Older and Medicare Patients with Gastric Bypass Peter T. Hallowell, University Hospitals Case Medical Center, Cleveland, OH M1558 Indications and Results of Reversal of Vertical Banded Gastroplasty (VBG) Rebecca Thoreson, University of Iowa, Coralville, IA M1559 Gastrectomy and Lymphadenectomy for Gastric Cancer: Is the Pancreas Safe? Fernando A. Herbella, Federal University of São Paulo, São Paulo, Brazil

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1560 Long Term Results of Completion Gastrectomies in Patients with Post-Surgical Gastroparesis James E. Speicher, Virginia Mason Medical Center, Seattle, WA M1561 Is Neoadjuvant Chemoradiation for Locally Advanced Gastric Cancer Feasible? Brian R. Untch, Duke University Medical Center, Durham, NC M1562 Inpatient Mortality Analysis of Paraesophageal Hernia Repair in Octogenarians Benjamin K. Poulose, University Hospitals Case Medical Center, Cleveland, OH M1563 Surgeon Performed Endoscopic Balloon Dilation for Gastrojejunostomy Stenosis SESSIONS Atul K. Madan, University of Tennessee Health Science Center, Miami, FL POSTER M1564 Qualifying the Relationship: Interaction Effects in the Correlation Between Bmi and Abdominal Wall Thickness Mark Ranzinger, University of Maryland, Baltimore, MD

BASIC SCIENCE POSTERS

Basic: Biliary

M1842 CD44-Hyaluronan Interaction Plays a Critical Role in Biliary Proliferation During the Development of Hepatic Cholestasis Gordon D. Wu, Cedars-Sinai Medical Center, Los Angeles, CA

Basic: Colon-Rectal

M1843 Decreased PLD2 Expression Correlates with NM404 Retention in Human Colorectal Cancer Xenografts Joseph Nwankwo, University of Wisconsin, Madison, WI M1844 The Effects of Dai-Kenchu-to (TU-100) on Propulsive Motility in the Colon Michael Wood, University of Vermont College of Medicine, Burlington, VT M1845 Effect of NOD2/CARD15 Mutations on Ileal Gene Expression Proﬁles in Crohn’s Disease Steven R. Hunt, Washington University, Saint Louis, MO

Poster of Distinction

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M1847 The Effect of Toll Like Receptor (TLR) 9 Agonist, CpG Oligodeoxynucleotides (ODN), on Abdominal and Gastrotomy Wound Healing in a Murine Model Ik-Yong Kim, Columbia University, Yonsei University, Wonju College of Medicine, New York, NY

Basic: Esophageal

M1848 Evaluation of the Cell Proliferation Expansion in the Columnar Mucosa of the Distal Esophagus in Patients with GERD: Immunohistochemical Analysis of KI67 (MIB1) Antigen in Columnar Mucosa With and Without Intestinal Metaplasia Richard R. Gurski, UFRGS, Porto Alegre, RS, Brazil M1849 The Pathogenesis of Barrett’s Esophagus: The Combination of Acid and Bile Is Synergistic in the Induction of CDX2 and EGFR Activation in Esophageal Cells Nelly E. Avissar, University of Rocehster, School of Medicine and Dentistry, Rcohester, NY M1850 Bile Reﬂux Induces Higher COX-2 Expression Than Mixed Acid and Bile Reﬂux in a Rat Model of Esophagitis Reginald V. N. Lord, University of Southern California Keck School of Medicine, St. Vincent’s Hospital, Sydney, NSW, Australia

Basic: Hepatic

M1851 Cellular Liver Regeneration After Extended Hepatic Resection in Pigs Ruth Ladurner, University of Tuebingen, Tuebingen, Germany M1852 Basics of Mouse Liver Anatomy from a Microsurgical Point of View Peter Studer, Inselspital, Bern, Switzerland M1853 Simultaneous Splenectomy Enhance Liver Regeneration After Major Hepatectomy via Decreasing Activin-A Expression Yan-Shen Shan, National Cheng Kung Univ Hosp, Tainan, Taiwan

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Pancreas

M1854 Cannabinoid Receptor Blockade Attenuates Acute Pancreatitis by an Adiponectin Mediated Mechanism Nicholas J. Zyromski, Indiana University, Indianapolis, IN M1855 Over-Expression of Focal Adhesion Kinase Inhibits Cell Proliferation in Gastrointestinal Neuroendocrine Tumor Cells Li Ning, University of Wisconsin, Madison, WI M1856 Potential Therapeutic Targets in Invasive Pancreatic Cancer Identiﬁed by Gene Expression Proﬁling SESSIONS

Annamarie Rogers, University of Dublin, Trinity College, Dublin , Ireland POSTER M1857 A Xenograft Model and Cell Line Deriving from Invasive Intraductal Papillary Mucinous Neoplasm of the Pancreas Stefan Fritz, Massachusetts General Hospital, Harvard Medical School, Cambridge, MA M1858 pp32 Is a Key Regulator of Cellular Differentiation: Implications for Anti-Cancer Therapy Timothy K. Williams, Thomas Jefferson University, Philadelphia, PA M1859 The Effect of ras/raf-1 Pathway Activation on Somatostatin Receptors in Gastrointestinal Carcinoid Tumor Cells Scott N. Pinchot, University of Wisconsin Hospital and Clinics, Madison, WI M1860 Pterostilbene Inhibits Pancreatic Cancer in Vitro Julie A. Alosi, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT

Basic: Small Bowel

M1861 Practical Considerations and Survival Techniques for a Rat Model of Roux-en-Y Gastric Bypass Drew A. Rideout, University of South Florida, James A. Haley Veterans Affairs Medical Center, Wesley Chapel, FL

Poster of Distinction

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M1862 Activation of Wnt Signaling Protects Intestinal Epithelial Cells from Apoptosis by Increasing Cytoplasmic Levels of RNA-Binding Protein HuR Emily C. Bellavance, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD M1863 The Immunonutrient Fish Oil Increases Blood Flow in the Ileum During Chronic Feeding in Rats Ryan T. Hurt, University of Louisville, University of Louisville, Louisville, KY

Basic: Stomach

M1864 Survivin Expression in Gastric Cancer: Association with Histomorphological Response to Neoadjuvant Therapy and Prognosis Daniel Vallbohmer, University of Cologne, Cologne, Germany

COMBINED SCIENCE POSTERS

Combined Science

M2091 The Effect of Major Abdominal Procedure Type on the Incidence and Economic Burden of Deep Vein Thrombosis or Pulmonary Embolism Debraj Mukherjee, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD M2092 Removal of Visceral Fat Improves Metabolic Syndrome and Hepatic Steatosis in Diet-Induced Obese Mice Xavier Dray, Johns Hopkins School of Medicine, Baltimore, MD M2093 Novel Therapeutic Targets in Esophageal Cancer: Impact of Coexpression of Receptor-Tyrosine-Kinases (RTK) and Chemokine Receptor CXCR4 Ines Gockel, Johannes Gutenberg-University, Mainz, Germany

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Tuesday, May 20, 2008

CLINICAL SCIENCE POSTERS SESSIONS Clinical: Biliary POSTER

T1695 Comparison Hilar Bile Duct Cancer with Intrahepatic Cholangiocarcinoma Involving the Hepatic Hilus Tsuyoshi Sano, Aichi Cancer Center Hospital, National Cancer Center Hospital, Nagoya, Japan T1696 Progress in Laparoscopic Surgery for Adult Choledochal Cysts-Kyushu University Experience Hiroki Toma, Kyushu university, Fukuoka city, Japan T1697 Outcomes of Endoscopic and Surgical Management of Sphincter of Oddi Dyskinesia in Patients Not Responding to Cholecystectomy for Chronic Acalculous Cholecystitis James O. Johnson, St Vincent Hosp & Hlth Care Ctr, Indianapolis, IN T1698 The Signiﬁcance of CD44 Expression in Ampullary Cancer Hui-Ping Hsu, National Cheng Kung Univ Hosp, Tainan, Taiwan T1699 Asymptomatic Cholelithiasis Occurrence in Patients of Kidney Transplantation List José Jukemura, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil T1700 Signiﬁcance of Tissue Expression of MUC5AC in Hilar and Intrahepatic Cholangiocarcinoma Andrea Ruzzenente, University of Verona Medical School, Verona, Italy T1701 Preoperative Assessment of Intrahepatic Cholangiocarcinoma: CT Features with Pathological Correlation Riccardo Manfredi, University of Verona Medical School, Verona, Italy

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Clinical: Colon-Rectal

T1702 Anastomotic Leaks After Bowel Resection: What Do We Learn from Peer Review? Neil H. Hyman, University of Vermont College of Medicine, Burlington, VT T1703 Preoperative Assessment of Nutritional Status in the Patients with Ulcerative Colitis: Evaluation of Nutritional Markers Which Predict Septic Complications Ken-ichi Takahashi, Tohoku Rosai Hospital, Sendai, Japan T1704 Cytokine Network in Rectal Mucosa in Perianal Crohn’s Disease: Relations with Inﬂammatory Parameters and Need for Surgery Imerio Angriman, Clinica Chirurgica 1°, University of Padova, Padova, Italy T1705 Abdominal Surgery Impact Scale (ASIS) Is Responsive in Assessing Outcome Following IPAA Indraneel Datta, Dr. Zane Cohen Digestive Diseases Clinical Research Center, Calgary, AB, Canada T1706 Morbidity and Mortality Associated with Emergency Abdominal Surgery in the Elderly Jill M. Zalieckas, Lahey Clinic Medical Center, Burlington, MA T1707 Is There a Critical Number of Recovered Nodes in ypT3-4 Rectal Cancer After Neoadjuvant CRT in Order to Provide Proper Final Disease Staging? Igor Proscurshim, University of São Paulo School of Medicine, São Paulo, Brazil T1708 Is Initial Pre-Treatment Staging for Distal Rectal Cancer Undergoing Neoadjuvant CRT Useful? Rodrigo O. Perez, University of São Paulo School of Medicine, São Paulo, SP, Brazil T1709 Are There Any “High Risk” Features in Stage II Rectal Cancer After Neoadjuvant CRT and Radical Surgery? Rodrigo O. Perez, University of São Paulo School of Medicine, São Paulo, SP, Brazil T1710 Does Laparoscopic Approach Affect the Number of Lymph Nodes Harvest in Colorectal Cancer? Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH

78 6303_SSAT.book Page 79 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1711 Risk of Leak After Laparoscopic Versus Open Bowel Anastomosis Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH T1712 Postoperative Bowel Function After Lumber Colonic Nerve Preserving Low Anterior Resection for Rectal Cancer Yoshitaka Tanabe, Kitakyushu Municipal Medical Center, Graduate School of Medical Sciences, Kyushu University, Kitakyushu, Japan T1713 Prospective Study on the Management of Acute Diverticulitis Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy SESSIONS T1714 Incidence of Adhesional Small Bowel Obstruction POSTER (SBO) After Colorectal Surgery Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy T1715 Laparoscopic Appendectomy for Complicated Appendicitis Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy T1716 Small Intestinal Bacterial Overgrowth Is Common in Patients with Lower Gastrointestinal Symptoms and a History of Previous Abdominal Surgery Grant G. Sarkisyan, University of Southern California, Los Angeles, CA T1717 Contemporary Surgical Management for Ileosigmoid Fistulas in Crohn’s Disease Genevieve B. Melton, Cleveland Clinic Foundation, Cleveland, OH T1718 The Usage of Botulinum Toxin in the Treatment of Chronic Anal Fissures Alex J. Ky, Mt Sinai Hospital, New York, NY

Clinical: Esophageal

T1719 Esophageal Adenocarcinoma Associated with Barrett’s Esophagus: Survival Beneﬁt? Valerie A. Williams, University of Rochester Medical Center, Rochester, NY T1720 Changing Prognosis of Spontaneous Esophageal Perforation (Boerhaave Syndrome): A Personal Experience of 64 Cases in a Single Center Jarmo A. Salo, Helsinki University Central Hospital, Helsinki, Finland

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T1721 The Value of Endoscopic Ultrasound to Distinguish the Number of Lymph Node Metastases in Patients with Esophageal Adenocarcinoma Jessica M. Leers, Keck School of Medicine, University of Southern California, Los Angeles, CA T1722 Significant Pressure Differences Between Solid-State and Water Perfused Systems in Lower Esophageal Sphincter Measurement Heinz Wykypiel, Medical University Innsbruck, Innsbruck, Austria T1723 Understanding Laryngopharyngeal Reflux (LPR): The Prevalence of Anatomic Esophagogastric Junction Degradation in LPR Patients Kyle A. Perry, Oregon Health & Science University, Portland, OR T1724 The Effect of Body Position on Hiatal Anatomy in Patients with GERD Kyle A. Perry, Oregon Health & Science University, Portland, OR T1725 Better Reflux Control with a Nissen Fundoplication: 10-Year Results After Laparoscopic Antireflux Surgery Martin Fein, University of Wuerzburg, Wuerzburg, Germany T1726 Association of Pregnane X Receptor (PXR) with Esophageal Disease in an Irish Population Mahwash Babar, St. James’s Hospital, Dublin, Trinity College, Dublin, Dublin, Ireland T1727 The Influence of FDG-PET on the Decision to Operate for Esophageal Carcinoma Jason W. Smith, Loyola University Medical Center, Maywood, IL T1728 Surgical Outcomes Following Laparoscopic Re-Do Heller Myotomy in the Treatment of Achalasia Matthew J. Schuchert, University of Pittsburgh Medical Center, Pittsburgh, PA

Clinical: Hepatic

T1729 Validation of the E-PASS Scoring System for Prediction of Mortality and Morbidity in Hepatic Resections Vanessa Banz, University Hospital Bern, Bern, Switzerland T1730 Prolonged Survival in Selected Patients Following Metastasectomy from Hepatocellular Carcinoma Chen Fang Lee, Chang-Gung Memorial Hospital, Taoyuan, Taiwan Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1731 Prognostic Factors After Liver Resection for Colorectal Metastases: Multivariate Analysis and Comparison with the FONG-Score Ulrich Adam, University of Freiburg, Freiburg, Germany T1732 Ultrasound Guided Liver Resection: Does This Approach Limit the Need for Portal Vein Embolization? Guido Torzilli, University of Milan, Istituto Clinico Humanitas – IRCCS, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy T1733 Surgical Management of Leiomyosarcoma of the Inferior Vena Cava in Eight Patients

T. Clark Gamblin, University of Pittsburgh Medical Center, Liver Cancer SESSIONS POSTER Center, Pittsburgh, PA

Clinical: Pancreas

T1734 EUS-Guided Drainage of Peripancreatic Fluid Collections Following Distal Pancreatectomy Shyam Varadarajulu, University of Alabama at Birmingham, Birmingham, AL T1735 Management of Intraductal Papillary-Mucinous Neoplasms of the Pancreas (IPMN): A 10-Year Experience in Two Pancreatic Centers in Germany Robert Grützmann, University Hospital Dresden, Dresden, Germany T1736 Indication for Special Therapies in Acute Pancreatitis: Optimum Severity Score for Continuous Regional Arterial Infusion and Enteral Nutrition Takashi Ueda, Kinki University School of Medicine, Osaka-sayama, Japan T1737 Usefulness of 13C-Labeled Mixed Triglyceride Breath Test for Evaluating Exocrine Pancreatic Function After Pancreatic Surgery Hiroyuki Nakamura, Hiroshima University, Hiroshima, Japan T1738 Surgical Resection of Renal Cell Carcinoma Metastatic to the Pancreas Joshua G. Barton, Mayo Clinic, Rochester, MN T1739 Pancreatic Acinar Cell Carcinoma: A Multi- Institutional Study Jesus M. Matos, Indiana University School of Medicine, Indianapolis, IN

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T1740 Pancreatic Exocrine Function in Patients Undergoing Distal Pancreatectomy as Assessed by Human Stool Elastase-1 James E. Speicher, Virginia Mason Medical Center, Seattle, WA T1741 Risk Factors for Pancreatic Leak Following Distal Pancreatectomy Hari Nathan, Johns Hopkins University, Baltimore, MD T1742 Analysis of Organ Failure, Mortality and Pancreatic Necrosis in Patients with Severe Acute Pancreatitis Tercio De Campos, Santa Casa School of Medical Sciences, University of São Paulo, São Paulo, SP, Brazil T1743 Quality of Life in Long-Term Survivors After Pancreaticoduodenectomy Stefano Crippa, Università di Verona, Verona , Italy T1744 Intraoperative Assessment of Margin Status at the Time of Pancreaticoduodenectomy Ensures R0 Resection in Patients with Pancreatic Cancer Robert Yates, Ohio State University, Columbus, OH T1745 Surgical Drainage of Symptomatic Peripancreatic Fluid Collections in the Era of Endoscopic Management Luis A. Benavente-Chenhalls, Mayo Clinic, Rochester, MN T1746 Estimation of Physiologic Ability and Surgical Stress (E-PASS) as a Predictor of Immediate Outcome After Pancreatic Surgery: The Score Needs to Be Adapted! Beat Gloor, Inselspital, University Bern, Bern, Switzerland T1747 Is Adjuvant Therapy Indicated After Pancreatectomy for Adenocarcinoma? Jonathan M. Hernandez, University of South Florida and Tampa General Hospital, Tampa, FL

Clinical: Small Bowel

T1748 Can Plain Abdominal X-Ray Predict the Need for Operation in Patients with Adhesive Small Bowel Obstruction? Nathan M. Novotny, Indiana University, Indianapolis, IN

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1749 A Proposed Algorithm for Ventral Hernia Repair Optimizes Patient Outcome Judy Jin, University Hospitals Case Medical Center, Cleveland, OH T1750 Laparoscopic Roux-en-Y Gastric Bypass in 400 Consecutive Patients Without Internal Hernia Richard S. Flint, Brigham & Women’s Hospital, Boston, MA

Clinical: Stomach

T1751 Surgical Therapy for Adenocarcinoma of the True Gastric Cardia

Marcus Feith, Technische Universitaet Muenchen, Munich, Germany SESSIONS POSTER T1752 Surgical Technique Affects the Incidence of Marginal Ulceration After Roux-en-Y Gastric Bypass Yong-Kwon Lee, University Nebraska Medical Center, Omaha, NE T1753 Results of Uncut Roux-En Y Reconstruction After Distal Gastrectomy for Gastric Cancer Chikashi Shibata, Tohoku University School of Medicine, Sendai, Japan T1754 Changes in Inflammatory Biomarkers Across Weight Classes in a Representative US Population: A Link Between Obesity and Inflammation Xuan-Mai T. Nguyen, Univ of CA, Irvine Medical Center, Ithaca, NY T1755 Order of Placement Does Not Change Complication Rates for Patients with Concomitant Ventriculoperitoneal Shunt and Percutaneous Endoscopic Gastrostomy Nora C. Meenaghan, University of Maryland, Baltimore, MD T1757 The Influence of Anastomotic Line Tumor Invasion and Mesenterial Lymph Node Metastases in Survival of Patients with Gastric Stump Cancer Claudio Bresciani, University of São Paulo School of Medicine, São Paulo, Brazil T1758 Duodenal Bypass in Lean Individuals Do Not Decrease Glucose Levels Ana C. Tineli, Federal University of São Paulo, São Paulo, Brazil

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T1759 Use of Polypropylene Mesh for Laparoscopic Adjustable Gastric Banding (LAGB) Allows for Minimum Post-Op Pain with No Narcotic Usage and Less Pain for Adjustments Leonierose Dacuycuy, Boston University, Boston, MA, SkyLex Advanced Surgical Inc., Los Angeles, CA

BASIC SCIENCE POSTERS

Basic: Biliary

T1901 Systemic Inﬂammatory Response After Natural Oriﬁce Translumenal Surgery: Transvaginal Cholecystectomy in Porcine Model Daniel K. Tong, University of Hong Kong, Queen Mary Hosp, Hong Kong, China

Basic: Colon-Rectal

T1902 Curcumin Inhibits the Mammalian Target of Rapamycin Subunits Rictor and Raptor in Colon Cancer Cells Sara M. Johnson, UTMB, Galveston, TX T1903 Increased Expression of Pontin in Human Colorectal Cancer Tissue Johannes C. Lauscher, Charite, Berlin, Germany T1904 Human Acute Immune Response to Colon and Rectal Surgery: Comparison Between Open, Laparoscopic and Hand Assisted Resection Laurie S. Norcross, Colon and Rectal Clinic of Orlando, Orlando Regional Hospital System, Orlando, FL T1905 Src Kinase Inhibition May Inhibit Experimental Cancer Metastasis Njwen Anyangwe, Wayne State University School of Medicine and John D. Dingell VAMC, Detroit, MI T1906 CD8+ T Cell Inﬁltration and Cancer Recrurrence in Squamous Cell Cancer of the Anus Sonia Ramamoorthy, UCSD, San Diego, CA

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Esophageal

T1907 Inhibition of YB-1 as a Novel Approach to Decrease the Expression of EGFR, HER-2 and IGF-1R in Esophageal Cancer Sabrina Thieltges, University Hospital Hamburg-Eppendorf, Hamburg, Germany T1908 Gene Polymorphisms of ERCC1 Predict Response to Neoadjuvant Radiochemotherapy in Esophageal Cancer Ralf Metzger, University of Cologne, Cologne, Germany SESSIONS T1909 Successful Evaluation of a New Animal Model Using POSTER Mice for Esophageal Adenocarcinoma Joerg Theisen, TU Munich, Munich, Germany

Basic: Hepatic

T1910 Postconditioning in Liver Ischemia-Reperfusion Injury Roberto Teixeira, University of São Paulo, São Paulo, Brazil T1911 Reversibility of Liver Fibrogenesis in Mice: STI571 Inhibit the Activation of Hepatic Stellate Cells Ming-Chin Yu, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Basic: Pancreas

T1912 Calcineurine Inhibitors Accelerate Microvascular Thrombus Formation in Vivo Anja Pueschel, University of Rostock, Rostock, Germany T1913 OSU-03012, a Celecoxib Derivative, Has Increased Cytotoxicity and Does Not Stimulate Vascular Endothelial Growth Factor Production Regardless of Cyclooxygenase-2 Expression in Pancreatic Cancer Cell Lines Desmond P. Toomey, University of Dublin, Trinity College, Tallaght, Ireland T1914 Inhibition of VEGF and Not COX-2 Is Effective in a Model of Pancreatic Cancer Angiogenesis Desmond P. Toomey, University of Dublin, Trinity College, Tallaght, Ireland

Poster of Distinction

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T1915 Anti-Lewis Y Antibody as a Novel Target for Pancreatic Adenocarcinoma Vivian E. Strong, Memorial Sloan-Kettering Cancer Center, New York, NY T1916 Differentiation, Origin and Mesothelial Adhesive Potential Affect Growth and Metastasis of Ductal Adenocarcinoma of the Pancreas Soeren Torge Mees, University Hospital Muenster, Muenster, Germany T1917 Pancreatic RegI and PAP2 Proteins Have Different Potencies on Macrophage TNF Expression Ehab Hassanain, SUNY Downstate, Brooklyn NY, NY

Basic: Small Bowel

T1918 Cold Ischemia of the Small Bowel Could Be Prolonged by Intestinal Lipid Absorption Before Gut Procurement Judith Junginger, University of Tuebingen, Tuebingen, Germany T1919 Diurnal Rhythmicity in the p53-Mediated Apoptotic Pathway in Rodent Small Intestine Anita Balakrishnan, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA

Basic: Stomach

T1920 Pre-Op Antibiotic Gastric Lavage Reduces Post- Operative Peritoneal Infection in a Murine Natural Oriﬁce Surgery Model John Cullen, University of California, San Diego, San Diego, CA T1921 Roux-en-Y Gastric Bypass Improves Obesity-Related Steatosis and Is Associated with Reduction in Serum Adiponectin Drew A. Rideout, University of South Florida, James A. Haley Veterans Affairs Medical Center, Wesley Chapel, FL

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

COMBINED SCIENCE POSTERS

Combined Science

T2095 Assessment of “Gene-Environment” Interaction in Cases of Familial and Sporadic Pancreatic Cancer Theresa P. Yeo, Thomas Jefferson University, Philadelphia, RI T2096 Natural Oriﬁce Translumenal Endoscopic Surgery for Roux-en-Y Gastric Bypass: An Experimental Surgical Study in a Human Cadaver Model Monika E. Hagen, University Hospital Geneva, Geneva, Switzerland SESSIONS T2097 A Novel System for Classifying Paraesophageal Hernias POSTER Tommy H. Lee, University of Maryland, Baltimore, MD

Poster of Distinction

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Wednesday, May 21, 2008

12:00 PM – 2:00 PM SSAT POSTER SESSION SAILS PAVILION Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.

CLINICAL SCIENCE POSTERS

Clinical: Biliary

W1635 Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis Bilal Kharbutli, Henry Ford Hospital, Detroit, MI W1636 A Novel Hepatico-Jejunostomy Technique Featuring a Purse-String Anastomosis and a Biodegradable Stent: A Preclinical Study in Minipigs Johanna Laukkarinen, Tampere University Hospital, Boston, MA W1637 Primary Gallbladder Cancer: A 22 Year Experience in a Tertiary Care Center Rubayat Rahman, West Virginia University, Morgantown, WV W1639 Only Pain from Acute Inﬂammation Is Relieved One Year Following Laparoscopic Cholecystectomy in Dyspeptic Patients with Cholelithiasis Samaad Malik, University of Saskatchewan, Saskatoon, SK, Canada W1640 Surgery for Symptomatic Portal Biliopathy Puneet Dhar, Amrita Institute of Medical Sciences, Cochin, Kerala, India W1641 Study of a Reverse Phase Polymer in Cholecystectomy: Prevention of Stone Migration and Enhancment of Dissection Marvin Ryou, Brigham & Women’s Hospital, Boston, MA

Clinical: Colon-Rectal

W1642 Laparoscopic and Open Anterior Resection and Low Colorectal Anastomosis for Adult Megacolon: Surgical Outcomes Sergio E. Araujo, University of São Paulo Medical School, São Paulo, São Paulo, Brazil

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1643 To Control Intraoperative Bacterial Contamination and SSI During Anterior Resection or Hartmann’s- Mile’s Operation: What Can We Do? Katsunori Nishikawa, Machida Municipal Hospital, Machida-shi, Japan W1644 Preoperative Versus Postoperative Radiotherapy for Rectal Cancer: Decision Analysis and Outcome Prediction Using a Modiﬁed Markov Model Andreas M. Kaiser, University of Southern California, Los Angeles, CA W1645 Effect of Metastatic to Examined Lymph Nodes Ratio on Colon Cancer Survival Sukhyung Lee, William Beaumont Army Medical Center, El Paso, TX SESSIONS W1646 A Prospective Single Center Experience of “Fast-Track” POSTER in Colorectal Surgery: Toward Zero Anastomotic Complications Pierluigi Di Sebastiano, IRCCS casa Sollievo Sofferenza, San Giovanni Rotondo, Italy W1647 Laparoscopic Versus Conventional Colostomy Closure of Hartmann’s Procedure: A Case-Matched Study Jung C. Kang, Buddhist Tzu Chi General Hospital, Hualien, Taiwan W1648 A New Method to Analyze the Quality and Progression of Colonoscopy Lars Enochsson, Karolinska Institutet, Stockholm, Sweden W1649 Image-Guided Sentinel Lymph Node Navigation in Colon Cancer: A Pilot Study Julio M. Mayol, Hospital Clinico San Carlos, Hospital Clinico San Carlos, Madrid, Spain W1650 Low Preoperative Serum Albumin Levels Do Not Affect Early Outcomes After Ileoanal Pouch Surgery but May Be Associated with Long-Term Mortality Kweku A. Appau, The Cleveland Clinic Foundation, Cleveland, OH W1651 TGF-Beta1 and IGF-1 and Anastomotic Recurrence of Crohn’s Disease After Ileo-Colonic Resection Imerio Angriman, Clinica Chirurgica 1°, University of Padova, Padova, Italy W1652 Pre- Versus Postoperative Pelvic Radiotherapy in Patients Undergoing Abdominoperineal Resections for Rectal Cancer: Does Timing Make a Difference on Long-Term Patient Quality of Life? Michael S. Kasparek, Mayo Clinic Rochester, Ludwig-Maximilians-University Munich, Munich, Germany

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W1653 Sacral Neuromodulation for the Treatment of Fecal Incontinence and Voiding Dysfunction in Female Patients: A Longterm Follow Up Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH W1654 Long Term Out Come and Quality of Life After Restorative Proctocolectomy in a Cohort of 955 Canadian Patients Marco Scarpa, University of Padova, Padova, Italy W1655 Colorectal Surgical Specimen Lymph Node Harvest: Improvement of Lymph Node Yield with a Physicians Assistant Robert C. Moesinger, McKay-Dee Hospital Center, University of Utah School of Medicine, Ogden, UT W1656 Relevance of Comorbidity for Postoperative Lethality and Morbidity After Surgery for Perforated Diverticulitis of the Sigmoid Colon Mario H. Mueller, Maximilians-University, Munich, Germany W1657 Management and Treatment of Iliopsoas Abscess Parissa Tabrizian, The Mount Sinai Medical Center NY, New York, NY W1658 Comparison of GFAP Expression and Mucosal Mast Cell Numbers in Pediatric Intestinal Diseases Eumenia Castro, Children’s Hospital of Pittsburgh, Pittsburgh, PA

Clinical: Esophageal

W1659 Outcomes of Laparoscopic Assisted Transhiatal Esophagectomy for Adenocarcinoma of Esophagus Martin I. Montenovo, University of Washington, Seattle, WA W1660 The Challenge of Diagnostic Assesment of a Failed Fundoplication: Beneﬁts of High-Resolution Manometry of the GE-Junction Attila Dubecz, University of Rochester, Rochester, NY W1661 Looking Beyond Age and Comorbidities as Predictors of Outcomes in Paraesophageal Hernia Repair Anirban Gupta, Johns Hopkins University School of Medicine, Baltimore, MD W1662 No Additional Value of Bronchoscopy After EUS in the Preoperative Assessment of Patients with Esophageal Cancer at or Above the Carina Mark Van Heijl, Academic Medical Centre, Amsterdam, Netherlands

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W1663 Analysis of First-Time Antireﬂux Redo-Surgery Versus Multiple Redo-Surgery Karl H. Fuchs, Markus-Krankenhaus, Frankfurt, Germany W1664 A Meta-Analysis of Trials Comparing the Effectiveness of Use of Mesh in Laparoscopic Repair of Paraesophageal Hernias Anne O. Lidor, Johns Hopkins University School of Medicine, Baltimore, MD W1665 Prediction of Response to Neoadjuvant Therapy in Esophageal Carcinoma by PET-CT Kirsten Thurau, University of Münster, Münster, Germany W1666 Endolumenal Fundoplication with EsophyX™: The SESSIONS Initial North American Experience POSTER Simon Bergman, The Ohio State University Medical Center, Columbus, OH W1667 Analysis of Utilization and Outcome of Laparoscopic and Open Paraesophageal Hiatal Hernia Repair Marcelo W. Hinojosa, University of California, Irvine Medical Center, Orange, CA W1668 High Prevalence of Lymph Node Metastases in pT1 Esophageal Cancer: Is Local Therapy Justiﬁed? Ines Gockel, Johannes Gutenberg-University, Mainz, Germany W1669 The Use of Alveolus Stents in the Treatment of Esophageal Leaks, Perforation or Fistulae Irfan Qureshi, University of Pittsburgh Medical center, Pittsburgh, PA

Clinical: Hepatic

W1670 Treatment Strategy for Synchronous Metastases of Colorectal Cancer: Is Hepatic Resection After an Observation Interval Appropriate? Yasuhiro Shimizu, Aichi Cacer Center Hospital, Nagoya, Aichi, Japan W1671 Non-Operative Management of High Grade Liver Injuries Beat Schnüriger, Bern University Hospital, Switzerland, Bern, Switzerland W1672 Yttrium-90 Microsphere Induced Gastrointestinal Tract Ulceration Christopher D. South, The Ohio State University Medical Center, Columbus, OH W1673 Hepatic Neuroendocrine Metastases: Bland or Chemoembolization? Susan C. Pitt, University of Wisconsin, Indiana University, Madison, WI W1674 Laparoscopic Treatment of Nonparasitic Hepatic Cysts Orlando J. Torres, Federal University of Maranhão, São Luis, Maranhão, Brazil

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Clinical: Pancreas

W1675 Human Telomerase Reverse Transcriptase (hTERT) Expression in Carcinogenesis of Serous Cystic Neoplasm of the Pancreas Akira Nakashima, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan W1676 Pulmonary Dysfunction Associated with Severe Acute Pancreatitis Hidehiro Sawa, Kobe University Graduate School of Medical Sciences, Nishi-Kobe Medical center, Kobe, Japan W1677 Incidence and Management of Chylous Leaks Following Pancreatic Resection: A High Volume Single-Center Institutional Experience Timothy M. Pawlik, Johns Hopkins Hospital, Baltimore, MD W1678 Clinical Signiﬁcance and Natural History of Microinvasive Pancreatic Adenocarcinomas Associated with Resected Intraductal Papillary Mucinous Neoplasms: A Multi-Institutional Experience Eugeen P. Kennedy, Thomas Jefferson University, Philadelphia, PA W1680 Surgical Management of Failed Endoscopic Treatment of Pancreatic Disease Kimberly A. Evans, University of Florida, Gainesville, FL W1681 Is Distal Pancreatectomy (DP) Useful for Treatment of Cancer of the Body or Tail of the Pancreas? Jane S. Wey, University of Pittsburgh Medical Center, Pittsburgh, CA W1682 In-Hospital Mortality for Distal Pancreatectomy: A National Study Melissa M. Murphy, UMass Memorial, Worcester, MA W1683 Pancreatic Adenocarcinoma with Isolated Local Venous Invasion: Does Surgical Resection Confer a Survival Beneﬁt? Michael Abramson, Brigham and Women’s Hospital, Brookline, MA W1684 Gemcitabine-Based Adjuvant Chemotherapy Following R1 Resection Still Improves Survival for Patients with Locally-Advanced Pancreatic Cancer Keita Wada, Teikyo University School of Medicine, Tokyo, Japan

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1685 Intra-Operative Application of the Hand-Held Confocal Microscope: A Pilot Study Nam Q. Nguyen, Bankstown Hospital, Adelaide, SA, Australia W1686 Complications Following Pancreaticoduodenectomy Are Common but Do Not Impact Long-Term Survival Mary E. Dillhoff, Ohio State University, Columbus, OH W1687 A National Survey Regarding the Management of Acute Pancreatitis in Brazil Tercio De Campos, University of São Paulo, Santa Casa School of Medical Sciences, São Paulo, SP, Brazil W1688 The Striking Incidence of Venous Thromboembolism SESSIONS in Hospitalized Patients with Necrotizing Pancreatitis POSTER James Lopes, Indiana University, Indianapolis, IN W1689 Feasibility of Laparoscopic Partial Pancreatic Head Resection with Lateral Pancreaticojejunostomy (Frey Procedure) for Chronic Pancreatitis Jayleen M. Grams, Mayo Clinic, Rochester, MN W1690 Surgeon’s Contribution to Long Term Survival of Pancreatic Cancer Calogero Iacono, University of Verona Medical School, Verona, Italy

Clinical: Small Bowel

W1691 Enteral Stenting: Management of Complications and Malfunctions in a Single Center Series of 46 Patients Melissa S. Phillips, University of Virginia, University of Virginia, Charlottesville, VA W1692 Primary Ileostomy Adenocarcinoma: Rare Condition After Proctocolectomy Rachel Forbes, Vanderbilt University, Nashville, TN W1693 Surgical Management of Acute Appendicitis: 50 Years of Progress William Scott Melvin, The Ohio State University, Columbus, OH

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Clinical: Stomach

W1694 Distal Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity Jean-Marc Heinicke, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland W1695 Utilization of Pre-Operative Patient Factors to Predict Post-Operative Vitamin D Deﬁciency for Patients Undergoing Gastric Bypass Judy Jin, University Hospitals Case Medical Center, Cleveland, OH W1696 Primary Stenting for Malignant Gastric Outlet Obstruction with Self-Expanding Metal Stents (SEMS) in Cape Town, South Africa John M. Shaw, University of Cape Town and Groote Schuur Hospital, Cape Town, Western Cape, South Africa W1699 The Molecular and Clinical Signiﬁcance of CD44 Proteolytic Cleavage in Gastrointestinal Stromal Tumors Kai-Hsi Hsu, Tainan Hospital, Department of Health, Executive Yuan, ROC, Institute of Clinical Medicine, College of Medicine, National Cheng Kung University Medical Center, Tainan, Taiwan, Tainan, Taiwan W1700 Laparoscopic Ajustable Gastric Banding: 4-Year Follow Up Philipp Busch, University Medical Center Hamburg-Eppendorf, Hamburg, Germany W1701 Gastrojejunal (GJ) Leak After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Carries Minimal Risk with an Aggressive Detection/Management Approach, Whereas Greater Morbidity/Mortality Occurs with Leak at the Jejunojejunostomy (JJ) Alexander Perez, Duke University Medical Center, Durham , NC W1702 Quantitative Analysis of Free Ubiquitin and Multi- Ubiquitin Chain in Precancerous and Cancerous Gastric Tissues Yoshio Ishibashi, Jikei University Shool of Medicine, Tokyo, Japan W1703 Surgical Outcomes of Patient with Gastrointestinal Stromal Tumors in the Era of Selective Drug Therapy Mehrdad Nikfarjam, Penn State, Milton S. Hershey Medical Center, Hershey, PA

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Colon-Rectal

W1827 Fluorophore-Conjugated Anti-CEA Antibody for Intraoperative Imaging of Pancreatic and Colorectal Cancer Michele McElroy, UCSD Medical Center, San Diego, CA W1828 Murine Colitis Is Inhibited in MMP-9 Knockout Mice: The Addition of IGFBP-3 Overexpression Does Not Further Decrease Disease Severity Raymond Baxter, Columbia University Medical Center, New York, NY W1829 Everolimus Impairs the Healing of Intestinal SESSIONS Anastomoses POSTER Markus A. Kueper, University of Tuebingen, Tübingen, Germany W1830 Polyphenon E, an EGCG Containing Green Tea Extract That Inhibits Tumor Growth, Has No Impact on Wound Collagen Content or Clinical Rate of Wound Infection or Dehiscence Yet Has a Mild Inhibitory Effect on Healing as Judged by Tensometry Aviad Hoffman, Columbia University, New York, NY

Basic: Esophageal

W1831 Polymorphism Arg290Arg in Esophageal Cancer Related Gene 1 (ECRG1) Is a Prognostic Factor for Survival in Esophageal Cancer Kai Bachmann, University Medical Center Hamburg Eppendorf, Hamburg, Germany W1832 Barrett’s Intestinal Metaplasia mRNA Expression Proﬁle in Formalin-Fixed, Parafﬁn-Embedded Endoscopic Biopsy Specimens Reginald V. N. Lord, UNSW, St. Vincents’ Hospital, Sydney, NSW, Australia W1833 KI-67 Antigen Is Overexpressed in Barrett’s Carcinogenesis Richard R. Gurski, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil

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Basic: Hepatic

W1834 Enteral Immunonutrition with Long Chain Triglycerides Signiﬁcantly Reduces the Recruitment of Immune Cells Into the Liver During Experimental Sepsis Maximilian Feilitzsch, University of Tuebingen, Tuebingen, Germany W1835 Association of Non-Alcoholic Steatohepatitis (NASH) and Inﬂammatory Mediators from Adipose Tissue Atul K. Madan, University of Miami, Miami, FL

Basic: Pancreas

W1836 Reduction of Local Inﬂammatory Response on Acute Pancreatitis in Rats: Effects of a Hypertonic Saline Solution Ana Maria M. Coelho, University of São Paulo, São Paulo, Brazil W1837 Effects of Late Administration of Pentoxifylline in Experimental Severe Acute Pancreatitis José Jukemura, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil W1838 Development of Monoclonal Antibodies to Aid in the Diagnosis of Pancreatic Cancer Karin M. Hardiman, Oregon Health and Science University, Portland, OR W1839 Combination Therapy with Suberoyl Bis-Hydroxamic Acid (SBHA) and Lithium Chloride for Gastrointestinal Carcinoid Tumors Joel T. Adler, University of Wisconsin, Madison, WI W1840 Epithelial to Mesenchymal Transition in Pancreatic Cancer: Expression and Role of the Transcription Factors Snail, Slug, and Twist Hubert G. Hotz, Charite Medical School, Berlin, Germany W1841 A Model for Deﬁning Molecular Aspects of Pancreatic Ductal Adenocarcinoma Patients for Targeted Adjuvant Therapy Shayna L. Showalter, Thomas Jefferson University, Philadelphia, PA

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Small Bowel

W1842 Small Bowel Engineering Using Small Intestinal Submucosa (SIS) Syde A. Taheri, University at Buffalo, Williamsville, NY W1843 Diurnal Regulation of Drug Transporters in the Small Bowel Adam T. Stearns, Brigham & Women’s Hospital and Harvard Mediacl School, Oxford University, Boston, MA W1844 Electrosurgical and Ultrasonic Devices: An Evaluation of Thermal Spread and Other Device Characteristics SESSIONS

Charles J. Dolce, Carolinas Medical Center, Charlotte, NC POSTER

Basic: Stomach

W1845 Epithelial Cell Turnover Is Increased in the Excluded Stomach Mucosa After Vertical Banded Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro, University of São Paulo, São Paulo, SP, Brazil

COMBINED SCIENCE POSTERS

Combined Science

W1993 Single Incision Laparoscopic Cholecystectomy Using Flexible Endoscopy: Saline Inﬁltration Gallbladder Fossa Dissection Technique John N. Afthinos, St. Luke’s-Roosevelt Hospital Center, New York, NY W1994 The Effect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease Mankanwal S. Sachdev, University of Tennessee, Memphis, TN W1995 Impact of Gastric Irrigation on NOTES Mesh Placement Lauren Buck, UTHSCSA, San Antonio, TX

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SSAT PLENARY, VIDEO, AND QUICK SHOT ABSTRACTS

Printed as submitted by the authors.

Monday, May 19, 2008 8:15 AM – 9:15 AM PRESIDENTIAL PLENARY A 25ABC (PLENARY SESSION I) Moderator: Richard A. Prinz Chicago, IL 215 Stepwise Circumferential and Focal Radiofrequency Ablation of Barrett’s Esophagus with High-Grade Dysplasia or Intramucosal Cancer Roos E. Pouw1, Joep J. Gondrie1, Frederike G. Van Vilsteren1, Carine Sondermeijer1, Wilda Rosmolen1, Wouter L. Curvers1, Lorenza Alvarez Herrero4, Fiebo J. Ten Kate2, Kausilia K. Krishnadath1, Thomas M. Van Gulik3, Paul Fockens1, Bas L. Weusten4, Jacques J. Bergman*1 1Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Pathology, Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Academic Medical Center, Amsterdam, Netherlands; 4Gastroenterology, St. Antonius Hospital, Nieuwegein, Netherlands BACKGROUND: Stepwise endoscopic circumferential and focal radiofrequency ablation (RFA) has been proven safe and effective for complete eradication of non-dysplastic Barrett’s esophagus (BE) in several trials. There is, however, little information regarding RFA for treatment of BE with high- grade dysplasia (HGD) or intramucosal carcinoma (IMC), and regarding the role, timing, and extent of endoscopic resection (ER) as adjuvant to RFA. AIM: Assess efﬁcacy and safety of RFA for BE-HGD/IMC in pts ± prior ER. METHODS: Enrolled pts had BE10 cm with HGD ± IMC. Any visible lesions were endoscopically resected using the cap– or multiband mucosectomy (MBM) technique. Exclusions: cancer >T1m3, N+ disease on EUS. Circumfer- ential ablation (CA) was performed with a balloon-based catheter and focal ablation (FA) with an endoscope-based catheter (HALO Systems). CA was performed 6 wks after last ER (if applicable), followed by CA/FA every 2 mos until BE was no longer evident on EGD. Thereafter, EGD with narrow band imaging and biopsies were performed at 2, 6, 12 mos, then annually.

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RESULTS: 44 pts were included (35 M, median age 68 yrs, median Prague C5M7). 35 ER sessions were performed in 31 pts (70%) prior to RFA. ER complications: 4 bleeds, 1 perforation. Worst ER histology per pt: 16 IMC, 12 HGD, 3 LGD. Post-ER/pre-RFA worst histology: 32 HGD, 10 LGD, 2 IM. Com- plete histological eradication of dysplasia and intestinal metaplasia (IM) was achieved in 43 pts (98%) after 1 (1–2) CA and 2 (1–2) FA, and 1 additional MBM in 3 pts. In one pt (2%) a 5-mm island with dysplasia persisted (protocol failure). In 3 pts a a non-transmural laceration (all asymptomatic) was observed at the level of the prior ER after CA using an ablation catheter with a relatively large diameter in relation to the esophageal diameter. Four pts developed dysphagia that resolved with dilations; all of them had widespread ER and/or a narrow esophagus at baseline. No stenoses or lacerations were observed in patients whithout prior ER.After a median of 12 mos (IQR 5–17) after last RFA, no dysplasia has recurred. In one patient, an endoscopically evident 1-mm BE island was identiﬁed at 18 mos after RFA, located where a 12 mo biopsy revealed 1 focus of subsquamous IM (SSIM). Five pts had focal IM detected immediately distal to the neo-squamocolumnar junction at a single FU. In 1475 biopsies obtained from neosquamous epithelium only one (0.07%) showed SSIM. CONCLUSION: Stepwise CA and FA of BE-HGD/IMC with and without prior ABSTRACTS ER is highly effective in achieving complete eradication of dysplasia and IM MONDAY (98%) and compares favorably to alternatives such as esophagectomy, radical ER or photodynamic therapy.

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216 Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum Rajesh Nair*1, Erin M. Siegel1, Timothy J. Yeatman1, Mokenge P. Malafa1, Jorge Marcet2, David Shibata1 1Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; 2Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL INTRODUCTION: Traditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NC) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NC. METHODS: Between July 1994 and August 2006, 44 patients were identified as having undergone full thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NC. Patients with a clinical complete response (CR) to preoperative treatment (n = 31) were offered TAE as an alternative to standard radical resection. The remaining patients did not have a clinical CR and were either deemed medically unfit for (n = 3) or refused (n = 10) radical resection. RESULTS: Our patient population consisted of 26 men and 18 women, with a median age of 69 (range 43–89) and a median follow up of 64 months (6–153). Of patients who had a clinical CR, 61% had a pathologic CR. Seven (16%) patients sustained disease recurrence of which 2 were local only, 2 local and systemic and 4 systemic only. Only 4 (9%) patients had died of disease at current follow up. Overall 5-year survival by stage was as follows (Table 1): 100% (8/8) for T2N0 patients; 72% (13/18) for T3N0 patients; and 71% (5/7) for T3N1 patients. Five patients underwent radical excision immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE. CONCLUSIONS: TAE of T2 and T3 rectal cancers following NC is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multicenter trials. Table 1. Patient Characteristics

Number of Patients 44 Pretreatment Tumor Diameter Mean (cm) 3.3 ± 0.98 cm Distance from Anal Verge Mean (cm) 5.2 ± 2.1 cm Differentiation Well Moderate Poor Not specified 4 (9%) 35 (80%) 2 (4%) 3 (7%) Pretreatment Stage T2N0 T3N0 T2/3N1 Unknown 10 (23%) 22 (50%) 11 (25%) 1 (2%) Clinical Response Complete Partial None 31 (70%) 11 (25%) 2 (5%) Pathologic Response Complete Partial None 25 (57%) 17 (39%) 2 (5%) Overall Survival 3 year 5 year 32/39 (82%) 26/34 (76%) 5 year Overall Survival by Stage T2N0 T3N0 T2/3N1 8/8 (100%) 13/18 (72%) 5/7 (71%) Disease-Specific Survival 3 year 5 year 94% 91%

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

217 High Volume Surgery and Outcome After Liver Resection: Surgeon or Center? Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah* Surgery, University of Massachusetts, Worcester, MA INTRODUCTION: Although center volume has been shown to be important in improved outcomes after liver resection (LR), the relationship of surgeon to center volume remains unclear. In a case controlled analysis, we attempted to determine if volume (surgeon or center) truly affects survival in LR after eliminating differences in background characteristics. METHODS: We used the Nationwide Inpatient Sample (NIS) to identify all LRs with available surgeon/hospital identifiers performed from 1998–2005. High volume (HV) hospitals were defined as ≥20 LR/yr and HV surgeons performed ≥10 LR/yr. Preoperative comorbidities were assessed with the Elix- hauser index. Incorporating patient and hospital factors, we used propensity scoring to adjust for background characteristics and create matched controls of low volume (LV) and HV hospitals. A logistic regression for mortality was then performed with these matched groups. To assess the relationship of surgeon and hospital volume, different combinations of HV and low volume ABSTRACTS (LV) surgeons and hospitals were grouped and assessed separately. MONDAY RESULTS: 3032 LRs were performed in the 8-year period. Compared to LV centers (n = 1504), patients treated at HV hospitals (n = 1528) were more often white (75% vs. 70%) than black (7% vs. 12%), private insurance holders (56% vs. 48%), elective admissions (93% vs. 78%) and high income residents (42% vs. 34%) (p < 0.005). Unadjusted in-hospital mortality was significantly lower in the HV group (6% vs. 3%, p <0.001). Propensity matching successfully eliminated differences in background characteristics between HV and LV hospitals. Logistic regression found that factors that significantly decreased risk of in-hospital mortality after LR were private insurance (OR 0.4, 95% CI 0.2–0.8) and elective admission type (OR 0.3, 95% CI 0.1–0.7); preoperative comorbidity increased risk of death. Patients treated by HV surgeons or centers alone did not achieve a survival benefit after adjustment of patient and hospital factors. Only LR performed by HV surgeons at HV centers was independently associated with improved in-hospital mortality (OR 0.5, 95% CI 0.3–0.8). CONCLUSIONS: Our results confirm that a socioeconomic bias (race, insurance, income) may exist at HV centers. When these factors are accounted for and adjusted, center volume does not appear to influence in-hospital mortality unless LR are performed by HV surgeons at HV centers.

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218 Laparoscopic Vertical Sleeve Gastrectomy for Morbid Obesity: A Report of a Five-Year Experience with 750 Patients Crystine M. Lee, Paul T. Cirangle*, Gregg H. Jossart Surgery, California Pacific Medical Center, San Francisco, CA INTRODUCTION: The vertical sleeve gastrectomy (VSG) is a purely restrictive procedure that was first published in 2002 as the first stage of a two-stage duodenal switch with the idea that it would reduce mortality due to a shorter operative time and no anastomoses. It has also been performed as a single stage alternative to gastric bypass and banding in lower BMI patients. This abstract reports our 5 year experience with 750 patients. METHODS: Laparoscopic VSG was performed in obese patients and compared retrospectively to patients who underwent the Roux-en-Y gastric bypass (RGB). A greater curvature gastrectomy was perfomed using linear GI staplers along a 32 Fr bougie to create a 40–80 ml gastric tube. Staple-line reinforcement with buttress material was used selectively. RESULTS: Between Nov 2002 and Sep 2007, 750 patients underwent VSG and 487 underwent RGB. The mean age in the VSG group was 43.1 years (range 16–68) and 595 (79%) were female. The mean VSG preop weight was 286 ± 69 lbs (range 201–620) vs. 280 ± 47 lbs (range 190–477) in the RGB. The mean VSG BMI was and 46 ± 9 kg/m2 (range 35–89) vs. 46 ± 6 kg/m2 (range 35–82) in the RGB. Of the 750 patients, 18 (2.4%) had a BMI of 70 + kg/m2, 50 (6.7%) had a BMI of 60–70 kg/m2, and 139 (18.5%) had a BMI of 50–60 kg/m2. The mean OR time for VSG was 79 ± 26 mins (range 34–297) vs. 137 ± 37 mins (range 90–300) in the RGB. The mean VSG length of stay was 1.7 ± 1.1 days vs. 2.7 ± 1.4 days after RGB. Staple-line dehiscence (only in high risk patients) occurred in 8 (1.0%) of VSG patients vs. 1 (0.2%) in RGB, strictures in 1 (0.1%) VSG vs. 19 (3.9%) in RGB, and bowel obstruction in 1 (0.1%) VSG vs. 12 (2.5%) in RGB. Ulcers occurred in 13 (2.7%) RGB and 0 VSG patients. No conversions to open or deaths occurred in the VSG group. No complications in the VSG group occurred beyond one month after surgery. CONCLUSIONS: Laparoscopic VSG demonstrates comparable weight loss to the RGB after three years with 0% mortality. Long term morbidity is almost nonexistent compared to the RGB.

VSG Weight Loss (lbs) VSG %EWL RGB Weight Loss (lbs) RGB %EWL 1 year 108 ± 39 69 ± 17% 113 ± 29 78 ± 14% 2 years 124 ± 58 67 ± 17% 110 ± 40 78 ± 28% 3 years 132 ± 64 59 ± 19% 103 ± 33 72 ± 19%

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

10:30 AM – 11:15 AM PRESIDENTIAL PLENARY B 25ABC (PLENARY SESSION II) Moderator: John C. Bowen, New Orleans, LA 249 Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis Abhishek Choudhary*, Matthew L. Bechtold, Craig Karpman, Srinivas R. Puli, Mohamed O. Othman, Praveen K. Roy Department of Internal Medicine, University of Missouri, Columbia, MO BACKGROUND AND PURPOSE: The role of prophylactic antibiotics in laparoscopic cholecystectomy in low risk patients is controversial. Several randomized controlled trials (RCTs) have reported conflicting results. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low risk patients undergoing laparoscopic cholecystectomy. METHODS: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (through 10/07). RCTs comparing prophylactic antibiotics to placebo or no treatment in the setting of low-risk lap- ABSTRACTS aroscopic cholecystectomy were included. Standard forms were used to MONDAY extract data by two independent reviewers. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of all infections (superficial wound infections, sub-hepatic fluid collections, and distant infections) and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD). Both random and fixed effect models were used. Publication bias was accessed by funnel plot. All studies were graded by Jadad scores. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. RESULTS: Eight RCTs (N = 1,361) met the inclusion criteria. The antibiotics used in the trials were: cefazolin (3 trials), cefotaxim (2 trials), cefotetan (1 trial), cefuroxime (1 trial), & cefotetan/cefazolin (1 trial). Antibiotics were administered preoperatively in all studies. 3 trials used multiple doses; first dose pre-operatively and other doses post-operatively. There was no significant heterogeneity among the studies (I2 = 0%). Quality score ranged from 2–5. Prophylactic antibiotics did not decrease the odds of post-operative infective complications (including superficial, deep and distant infections) (OR 0.64, 95% CI: 0.31–1.30, p = 0.22), superficial wound infections (OR 0.74, 95% CI 0.30–1.82, p = 0.52), sub-hepatic fluid collections (OR 1.03, 95% CI: 0.21–5.13, p = 0.98), or distant infections (OR 0.50, 95% CI: 0.13–1.97, p = 0.32). Prophylactic antibiotics also did not alter the length of hospital stay (WMD 0.02, 95% CI –0.10–0.14, p = 0.77). Funnel plot did not reveal the presence of publication bias. Pooling of data from high quality studies (Jadad score > 3) also did not reveal a reduction in the odds for total infection (OR 0.75, 95% CI 0.35–1.63, p = 0.72). CONCLUSIONS: Prophylactic antibiotics do not prevent infections in low risk patients undergoing laparoscopic cholecystectomy.

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250 Comparison of Surgically Resected Polypoid Lesions of the Gallbladder to Their Pre-Operative Ultrasound Characteristics Martin D. Zielinski*1, Peyton W. Davis1, Florencia G. Que1, Michael L. Kendrick1, Thomas D. Atwell2 1Gastrointestinal and General Surgery, Mayo Clinic, Rochester, MN; 2Radiology, Mayo Clinic, Rochester, MN BACKGROUND: Polypoid lesions of the gallbladder have been a common finding on ultrasound examinations of the abdomen and are more prevalent since our use of equipment incorporating pulse shaping, increased band- width and better phase use for image reconstruction began in 1996. Our study correlates the pre-operative ultrasonographic findings of these lesions to the surgically resected specimen with specific regard to identifying neoplastic polyps. METHODS: A retrospective review was performed of 137 patients who had a pre-operative ultrasonographic diagnosis of a polypoid lesion of the gallbladder and subsequently underwent cholecystectomy between August 1996 and July 2007 at the Mayo Clinic Rochester. RESULTS: 114 pseudopolyps (cholesterol polyps, inflammatory polyps and adenomyomas) and 23 true polyps (83.2% and 16.8% respectively) were identified on histopathologic analysis. 30 polyps had suspicious ultrasonographic characteristics for neoplastic changes. 26 were ≥10 mm, 3 had vascularity and 1 demonstrated invasion. Of these, there were 21 pseudopolyps, 2 benign adenomas and 7 with neoplastic changes on final pathology (2 low grade dysplasia, 2 high grade dysplasia and 3 adenocarcinomas). 2 asymptomatic polyps, sized 6 mm and 7 mm by ultrasound, were identified pre-operatively and not regarded as suspicious but had neoplastic changes at pathology (one low grade and one high grade dysplasia). 25 patients were followed with at least two serial ultrasound examinations. Of these, 6 demonstrated polyp growth of at least 3 mm. None of these specimens demonstrated neoplastic changes. The positive predictive value and negative predictive value for ultrasound diagnosing neoplasia based on current criteria was 23% and 98% respectively with a false negative rate of 7%. CONCLUSION: Histopathologic analysis of polypoid lesions of the gallbladder continues to be the gold standard to identify neoplasia. Ultrasound has been used extensively in the pre-operative management of these lesions but modern ultrasound techniques are unable to differentiate between pseudopolyps and true polyps with any certainty. We identified 2 polyps with neoplastic changes that were less than 10 mm. Therefore, we recommend decreasing the current threshold for surgical resection to 5 mm while continuing to offer cholecystectomy for lesions that demonstrate vascularity, show invasion or are symptomatic.

104 6303_SSAT.book Page 105 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

251 The Incidental Asymptomatic Pancreatic Lesion: Nuisance or Threat? Teviah E. Sachs*, Wande B. Pratt, Mark P. Callery, Charles M. Vollmer General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA INTRODUCTION: Although asymptomatic pancreatic lesions (APLs) are being discovered incidentally with increasing frequency, their true significance remains obscure. Treatment decisions pivot off concerns for malignancy, but at times might be excessive. To better understand the role of surgery, we scrutinized a spectrum of APLs as they presented to our surgical practice over defined periods. METHODS: All incidentally identified APLs that were operated upon during the past 5 years were clinically and pathologically annotated. Among features evaluated were method/reason for detection, location, morphology, interventions and pathology. For the past 2 years, since our adoption of the Sendai guidelines for cystic lesions, we scrutinized our approach to all patients presenting with APLs, operated upon or not. RESULTS: Over 5 yrs, APLs were identified during evaluation of: GU/Renal

(14%), Asymptomatic rise in LFTs (13%), Screening/Surveillance (7%) and ABSTRACTS Chest Pain (6%). APLs occurred throughout the pancreas (body/tail—63%; MONDAY head/UP—37%) with 51% being solid. 110 operations were performed with no operative mortality including 89 resections (Distal—57; Whipple—32) and 21 other procedures. During these 5 years, APLs accounted for 27% of all pancreatic resections we performed. In all, 21 different diagnoses emerged including IPMN (19%), serous cystadenoma (13%), and neuroendocrine tumors (13%), while 8% of pts had >1 distinct pathology and 12% had no actual pancreatic lesion at all. Invasive malignancy was present 17% of the time and these pts were older (67.3 to 60.9 yrs; p < .05). Adenocarcinoma predomi- nated (16%). An asymptomatic rise in LFTs correlated significantly (p < .01) with malignancy. Seven pts ultimately opted for operation over continued observation (mean 2.7 yrs), but none had cancer. In the last 2 years, we have evaluated 132 new patients with APLs, representing 47% of total referrals for pancreatic conditions. Nearly half were operated upon, with a 3:2 ratio of solid to cystic lesions. This differs significantly (p < .05) from the previous 3 years (2:3 ratio), reflecting tolerance for cysts <3 cm and side-branch IPMN. Surgery was undertaken more often for solid APLs (74%) than cysts (32%). Some solid APLs were actually unresectable cancers. Due to anxiety, 2 pts requested operation over continued observation, and neither had cancer. CONCLUSIONS: APLs occur commonly, are often solid and reflect a spectrum of diagnoses. Sendai guidelines are not transferable to solid masses, but have safely refined management of cysts. An asymptomatic rise in LFTs cannot be overlooked, nor should a patient or doctor’s anxiety, given the prevalence of cancer in APLs.

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2:15 PM – 5:00 PM PLENARY SESSION III 24ABC Moderators: Gerard V. Aranha, Maywood, IL Donald E. Low, Seattle, WA 338 Cervical Nodal Metastasis from Intrathoracic Esophageal Squamous Cell Carcinoma Is Not Necessarily an Incurable Disease Daniel K. Tong*, Simon Law, Kam Ho Wong, John Wong Department of Surgery, The University of Hong Kong, Hong Kong, China BACKGROUND: It remains controversial whether metastatic cervical lymph nodes in patients with intrathoracic esophageal cancer signify distant metastases, and therefore incurable; or they should be regarded as regional spread with still a potential for cure. The aim of this study is to review the treatment results in this group of patients. PATIENTS AND METHODS: Patients with intrathoracic esophageal squamous cell carcinoma from 1995–2007 were included. Only those who had cervical lymph node spread confirmed by fine needle aspiration cytology were studied. Patients with cancers in the cervical esophagus or gastric cardia, or histology other than that of squamous cell were excluded. RESULTS: There were 115 patients who satisfied the inclusion criteria, of whom 98 (89.9%) were men. The median age was 62 years (range: 34–88). Treatment methods included: chemoradiation plus salvage surgery (n = 22 [20.2%]); chemoradiation (n = 51 [46.8%]); primary surgical resection (n = 4 [3.7%]); chemotherapy (n = 2 [1.8%]); radiotherapy (n = 7 [6.4%]); chemoradiation with bypass surgery (n = 2 [1.8%]); prosthetic intubation (n = 12 [11%]); and no intervention (n = 9 [8.2%]). The median survival of patients with chemoradiation plus salvage surgery was significantly longer than those with surgery alone (34.8 months vs 5.9 months; p = 0.029) or patients with chemoradiation (34.8 months vs 8.9 months; p = 0.0003). There was no hospital mortality in patients who had chemoradiation plus salvage surgery. Twelve out of the 22 patients who had chemoradiation and resection were downstaged from stage IV to stage 0–II. CONCLUSIONS: Despite staged as stage IV disease; prognosis of patients with metastatic cervical nodes was not uniformly poor. Up to 20% could derive good survival after chemoradiation and surgical resection.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

339 The 3-Year Outcome of Optimal Medical or Surgical Management of GERD Patients with Barrett’s Esophagus: The Lotus Trial Experience Stephen E. Attwood*1, Lars R. Lundell2, Jan G. Hatlebakk3, Stefan Eklund4, Ola Junghard4, Jean Paul Galmiche5, Christian Ell6, Roberto Fiocca7, Tore Lind4 1North Tyneside Hospital, North Shields, United Kingdom; 2Karolinska University Hospital Huddinge, Stockholm, Sweden; 3Haukeland Hospital, Bergen, Norway; 4AstraZeneca R&D, Mölndal, Sweden; 5Hotel Dieu-CHU de Nantes, Nantes, France; 6Dr.-Horst-Schmidt- Kliniken Wiesbaden, Wiesbaden, Germany; 7University of Genova, Genova, Italy INTRODUCTION: The long-term management of gastroesophageal reflux disease (GERD) in patients with Barrett’s esophagus (BE) is not well supported by an evidence-based consensus. In patients with BE, standard doses of acid- suppression therapy often result in incomplete reflux control, both symptom- atically and as measured by pH monitoring. Similarly, the outcomes of antireflux surgery reported in the literature have been poor. This analysis aimed to compare the long-term outcome of optimal medical vs surgical anti-reflux treatment in patients with BE (biopsy-proven intestinal metaplasia). A secondary aim was to identify if there were any differences in treatment out- ABSTRACTS come comparing patients with and without BE. MONDAY METHODS: In the LOTUS trial (a European multicenter randomized study; ClinicalTrials.gov identifier: NCT00251927), standardized laparoscopic antireflux surgery (LARS) was compared with dose-adjusted medical therapy, starting with esomeprazole 20 mg od (ESO), and increasing if needed to 20 mg bd. Operative difficulty, complications, pre- and post-treatment symptoms (GSRS), time to treatment failure (i.e., need for alternative therapy), pre- and post-treatment measurements of esophageal acid exposure (after 6 months) and endoscopic findings (at 3 years) are reported. RESULTS: Out of 554 patients with chronic GERD, 60 patients had BE of whom 28 were randomized to medical treatment and 32 to LARS. The median acid exposure times before treatment were not significantly different in patients with or without BE. Before surgical treatment, patients with BE had acid with pH < 4 in their esophagus for 13.2% of the time, which reduced to 0.4% 6 months after surgery. The corresponding figures for medically treated patients were 7.4% and 4.9%. Operative difficulty was greater in patients with BE (23% vs 13% in patients with no BE). This was based on a longer operating time (30% >2 hrs vs 23% in non-BE), and larger hiatus hernias (37% >5 cm vs 15% in non-BE) requiring >3 crural sutures in 40% BE vs 28% non-BE. There was no apparent difference between the groups in postoperative complications. The GSRS scores of patients were similar for the medically and surgically treated groups, regardless of the presence or absence of BE, both at baseline and at 3 years. Three BE patients in the medically treated group and one in the surgically treated group were judged to be treatment failures at 3 years. CONCLUSION: There is a high degree of success at 3 years with optimal medical or surgical anti-reflux therapy. In a well-controlled surgical environment, the success of LARS in patients with BE is greater than expected and similar to that in patients without BE.

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340 Zenker’s Diverticula: Is a Tailored Approach Feasible? Christian Rizzetto1, Mario Costantini*1, Raffaele Bottin2, Elena Finotti1, Lisa Zanatta1, Martina Ceolin1, Loredana Nicoletti1, Giovanni Zaninotto1, Ermanno Ancona1 1Clinica Chirurgica 3, University of Padua, Padova, Italy; 2Medical and Surgical Specialities, University of Padua, Padua, Italy BACKGROUND: Zenker’s diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of minimally invasive (Group A) versus traditional open surgical approach (Group B) in the treatment of ZD. METHODS: Between 1993 and September 2007, 128 patients underwent transoral stapling (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms with a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations and intrabolus pharyngeal pressure. The dimension of the pouch was based on the barium swallow. The choice of the treatment was based on the operative risk, the size of the diverticulum and the patients’ preference. Long-term follow-up data were available for 120/128 (94%) patients with a median follow-up of 40 months (IQR: 17–83). RESULTS: Mortality was nil. Three patients (5.8%) in the group A and 10 in the group B (13%) had postoperative complications (p = n.s.). Hospital stay were markedly reduced in patients after diverticulostomy (p < 0.01). Postoper- ative manometry showed a UES pressure reduction, improved UES relaxation, and decreased intrabolus pressure in both groups (p < 0.05). Four patients in the open surgical group (5.2%) complained of severe dysphagia after surgery (3 of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for the persistence of symptoms (p < 0.01). All these 11 patients had a ZD smaller than 3 cm in dimension. After primary treatment and complementary treatment, 93.5% and 96% of patients, respectively for group A and group B, were symptom-free or signiﬁcantly improved at long term follow-up. CONCLUSION: Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as primary treatment and should be recommended for younger, healthy patients, especially with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because too short a septum does not allow a complete division of the sphincter ﬁbers.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

341 Quality of Life and Symptomatic Response to Gastric Neurostimulation for Gastroparesis Vic Velanovich* Surgery, Henry Ford Hospital, Detroit, MI BACKGROUND: Gastroparesis can be a difficult problem with patients suffering from symptoms intractable to medical management. Gastric neurostimulation has been developed as a treatment for diabetic and idiopathic gastroparesis for patients unresponsive to standard treatment. The purpose of this study is to report symptomatic and quality of life response to gastric neurostimulation. METHODS: This study was IRB-approved. Candidates for placement were patients with either idiopathic or diabetic gastroparesis who had symptomatic failure to standard dietary, prokinetic and antiemetic treatment. Prior to placement, the patients’ symptoms were recorded, and patients completed the Gastrointestinal Symptom Rating Scale (GSRS, three domains: dyspeptic syndrome, indigestion syndrome, and bowel dysfunction syndrome) and the SF-36 (eight domains: physical functioning, role-physical, role-emotional, bodily pain, vitality, mental health, social functioning, general health, plus a ABSTRACTS health transition item). The device (Enterra Therapy, Medtronic, Inc., Minne- MONDAY apolis, MN)was surgical placed using a hybrid laparoscopic/open technique. Patients were followed and adjustments made on the device until satisfactory symptom control was achieved or no response determined. At that time, patients completed both the GSRS and SF-36 and comparisons were made to preoperative values. RESULTS: 32 patients had the device placed, 23 females, mean age 42 + 14 yrs., with 20 diabetic patients and 12 idiopathic patients. 24 patients (75%) responded to variable degrees. 8 patients had no response. Of the responders, there were statistically significant improvements in all three domains of the GSRS—median scores (with interquartile ranges): Dyspeptic syndrome, 9 (7–12) to 4 (2–6), p = 0.02; indigestion syndrome 5 (3–9) to 4 (0–4), p = 0.02; bowel dysfunction syndrome 6 (3–8) to 3 (0–6), p = 0.05. In the SF-36, there were statistically significant improvement in the health transition item, 4 (4–5) to 1.5 (1–3), p = 0.01; and social functioning domain, 25 (12.5–62.5) to 75 (50–87.5), p = 0.03. Of non-responders, there was no difference between preoperative and postoperative scores. CONCLUSIONS: Three-quarters of gastroparesis patients respond to gastric neurostimulation to variable degrees. Gastrointestinal specific symptoms, health transition and social functiong are improved in responders. These results are encouraging considering that these patients had intractable symptoms with no other effective treatments available.

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342 Results of the Surgical Treatment of Cardia Carcinoma (Ca) Characterized by Outcome and Perioperative Factors in a Prospective Observational Multicentre Study for Quality Control Lutz Meyer*1, Olof Jannasch2, Frank Meyer2, Hans Lippert2, Ingo Gastinger3 1Surgery, HELIOS Vogtland Hospital Plauen, Plauen, Germany; 2Surgery, University Hospital Magdeburg, Magdeburg, Germany; 3Surgery, Carl Thiem Hospital Cottbus, Cottbus, Germany INTRODUCTION: Cardia Ca is characterized by different features compared with the remaining gastric Ca; its incidence in Western countries is increasing. The aim of the study was to investigate diagnostic, therapeutic and outcome measures of cardia Ca in daily surgical practice. PATIENTS AND METHODS: All consecutive patients with cardia Ca out of a pool of patients with histologically confirmed diagnosis of gastric Ca who were treated in surgical departments were enrolled in this prospective observational multicenter study through a period of 12 months. Detailed patient, diagnostic and treatment characteristics were recorded in a computer-based format for analysis. Short-term outcome was characterized by hospital stay, complication rate, morbidity and hospital mortality. RESULTS: From 01/01–12/31/2002, 1,139 patients with gastric Ca from 80 surgical departments of each level of care were registered, out of them 198 subjects (17.4%) with cardia Ca. Tumor localization was classified in 186 patients according to Siewert: Type I, n = 44 (22.2%); Type II, n = 80 (40.4%); Type III, n = 62 (31.3%). 172 patients underwent surgical intervention (operation rate, 86.9%) of whom 145 individuals underwent resection (rate, 84.3%). A potentially curative resection could be offered to 111 patients (R0 resection rate, 56.1% versus 82,3% in all gastric Ca). Fresh frozen section was only used in 72 resections (rate, 49.7%). Of 142 standard resections (distal esophagectomy with proximal or total gastrectomy), systematic D1, D2 and D3 lymphadenectomy was performed in 81.0%, 67.6% and 7.7%, resp. Histologic investigation revealed UICC stage I/II in 39.5% of all operated patients; III/IV, 54%; not classified, 6.5%. Distant metastases occurred most frequently at the peritoneal site (15.2%), liver (10.6%) and non-regional lymph nodes (7.1%). Postoperative morbidity was 33.7%. Anastomotic leakage occured in 13 patients (9.1% versus 5.8% in total of all gastrectomies in gastric Ca) from whom 8 subjects (5.6%) underwent surgical reintervention. Hospital mortality was 8.6% (n = 17) compared to 8.0% in all patients with gastric Ca. CONCLUSION: More than 50% of patients diagnosed with cardia Ca show an advanced tumor stage at the time of surgical intervention. Not all resections estimated as potentially curative were accompanied by D2 lymphadenectomy. In particular, to further improve R0 resection rate, to consequently use intraoperative fresh frozen section for the detection of an adequate tumor-free resection margin and to lower the rate of anastomotic insufficiency, it is suggested to treat patients with cardia Ca at surgical centres for optimal outcome (5-year survival rate is being under investigation).

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

343 Probiotics Improve Weight Loss, GI-Related Quality of Life and H2 Breath Tests After Gastric Bypass Surgery: A Prospective Randomized Trial Gavitt A. Woodard*, Joseph Peraza, John Downey, Betsy Encarnacion, John M. Morton Surgery, Stanford School of Medicine, Stanford, CA INTRODUCTION: Roux-en-Y Gastric Bypass (RNYGB) surgery provides sig- niﬁcant improvement in weight loss, comorbidity resolution, and life span. One potential complication after gastric bypass surgery is bacterial overgrowth which may affect the outcomes of gastro-intestinal motility, serology, quality of life, and weight loss. Our study aim was to determine if probiotic administration after surgery inﬂuenced these outcomes. METHODS: 42 patients successfully underwent laparoscopic RNYGB and were randomized into two groups. One group (PS) received 2.4 Billion Lacto- bacillus daily post-operatively while the other group served as control subjects (CS). The Gastro-Intestinal Related Quality of Life (GIRQoL) survey, Hydrogen (H2) breath test (H2 Sleuth®) and weight were obtained pre- and

post-operatively at 3 months and 6 months. At baseline, patient demograph- ABSTRACTS ics for the two groups were similar including GIRQoL, H2 breath test, H.Pylori MONDAY status, age 43, 82% female, and average pre-op BMI 49 for both groups. Con- tinuous and categorical variables were analyzed via T-test and Chi Square test respectively with a p value of 0.05 set as signiﬁcant. RESULTS: At six months, the probiotic group had a smaller H2 peak (3.6 vs 6.8), lower fasting insulin (6.7 vs 7.5), Lipoprotein A (28 vs 41), Triglycerides (99 vs 146), and higher HDL (46 vs 40) versus the control group. In addition, the probiotic group had a statistically signiﬁcant improvement in GIRQoL versus the control group (115 vs 109, P < .05). Furthermore, a difference in excess weight loss was noted, with the probiotic group losing 70 vs 66% for controls. CONCLUSION: In this novel prospective randomized trial, the use of probiotics after gastric bypass clearly reduces H2 breath test values, improves GI quality of life and leads to increased weight loss.

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344 Factors Related to Anastomotic Dehiscence and Mortality After Terminal Stomal Closure in the Management of Patients with Severe Secondary Peritonitis Jose L. Martinez*, Pablo Andrade, Enrique Luque-De-Leon Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI, Mexico DF, Mexico BACKGROUND: Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. AIM: To determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. MATERIAL AND METHODS: We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30 month period. Several patient, disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student’s T Test for continuous variables and chi-square or Fischer’s exact test when categorical variables were compared. Multivariate analyses were also performed. RESULTS: A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) were 2.5 (range, 1–15). A total of 76 (70%) had had generalized peritonitis and 33 (30%) required management with an open abdomen (20 of them with a skin only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14–2192). Stapled and hand sewn anastomosis were done in 23 and 85 patients, respectively. AD occurred in 11 patients (10%).Univariate analyses disclosed management with an open abdomen (p < 0.03) and lower preoperative hemoglobin values (p < .05) as risk factors for AD. None prevailed after multivariate analyses. A total of 7 patients died (6%). Factors associated with mortality were preoperative use of TPN (p < 0.03), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure < 3 months (p < 0.01), AD (p < 0.01) and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, AD and need for reoperation almost achieved statistical signiﬁcance (p < 0.06); time interval between stomal creation and closure < 3 months was the only factor that prevailed as a risk for mortality. CONCLUSIONS: Although several variables were related to AD and mortality, waiting longer than 3 months before attempting restoration of intestinal continuity seems to be the best approach in this group of challenging patients.

112 6303_SSAT.book Page 113 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

345 Predictors of Survival in 865 Patients with Acinar Cell Carcinoma of the Pancreas: Survival After Surgery Compared to Ductal Adenocarcinoma C. Max Schmidt*1,4, Jesus M. Matos1, David J. Bentrem3, Mark S. Talamonti2, Keith D. Lillemoe1, Karl Y. Bilimoria3 1Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; 3Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 4Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN BACKGROUND: Pancreatic acinar cell carcinoma (ACC) is a rare tumor with poorly deﬁned risk and prognostic factors. Our objective was to compare a large population of ACC to pancreatic adenocarcinoma in order to assess factors predicting ACC, assess differences in survival, and identify prognostic factors. METHODS: From the National Cancer Data Base (NCDB), patients with pancreatic ACC and adenocarcinoma were identiﬁed. Multiple logistic regression was used to assess differences between ACC and adenocarcinoma. Median follow-up in resected patients was 22 months. 5-year overall survival was estimated by ABSTRACTS

Kaplan-Meier method and compared using log-rank tests. Cox proportional haz- MONDAY ards modeling was used to identify predictors of survival in resected patients. RESULTS: 865 patients with ACC were identified (Stage I: 14.1%, II: 20.5%, III: 11.6%, IV: 33.5%, unknown 20.2%). Median age at diagnosis was 67 yrs. Tumors were located in the head of the pancreas 42.3%, body 7.6%, tail 19.8%, and diffuse/NOS 30.3%. Of the 333 who underwent resection, 62% underwent surgery alone, 17% received chemotherapy, 7% received radiation, and 26.8% underwent chemoradiation. Median tumor size was 6.9 cm (vs. 4.6 cm for adenocarcinoma). 32.1% had nodal metastases (vs. 48.0% for adenocarcinoma). 47% had high-grade tumors (vs.37.3% for adenocarcinoma). Resection margins were R0 in 77.3%, R1 in 13.7%, and R2 in 9.0%. Patients underwent resection at NCI centers 12.3%, other academic hospitals 34.2%, VA facilities 1.2%, and community hospitals 52.2%. Patients were more likely to have ACC if male, white, larger tumor size, no nodal involvement, or pancreatic tail tumors. Five-year survival in resected patients was significantly better than in patients who did not undergo resection: 36.2% vs. 10.4%. Stage-specific survival was significantly better for resected ACC vs. adenocarcinoma: I: 52.4% vs. 28.4%, II: 40.2% vs. 9.8%, III: 22.8% vs. 6.8%, and IV: 17.2% vs. 2.8%. On univariate analysis, age <65 yrs, well-differentiated tumors, R0 status, and adjuvant chemoradiation were associated with better long-term survival. On multivariate analysis, age <65, well-differentiated tumors, and negative margins (R0 vs. R1/R2) were the only independent prognostic factors. CONCLUSIONS: ACC accounts for ~1% of resected pancreatic cancers; however, it carries a considerably better prognosis than pancreatic adenocarcinoma. Tumors are typically larger, but size is not associated with survival and should not preclude resection. Thus, surgical resection with negative margins and consideration of adjuvant therapy is the best chance for long-term survival in these favorable pancreatic cancers.

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346 Preoperative Liver Function Tests and Hemoglobin Will Predict Complications Following Pancreaticoduodenectomy Christopher D. Hughes*1, Karen Rychlik2, Margo Shoup1, Gerard V. Aranha1 1Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center, Maywood, IL; 2The Cardinal Bernardin Cancer Center, Loyola University Medical Center, Maywood, IL BACKGROUND: Previous studies have identified an association between dilated pancreatic and biliary ducts and lower rates of pancreatic leak after pancreaticoduodenectomy (PD), but it remains unclear whether elevated liver function tests (LFTs) are also associated with lower rates of complications. The purpose of this study was to determine the predictive ability of preoperative LFTs on morbidity following PD. MATERIALS AND METHODS: We identified 452 patients who received PD at Loyola University Medical Center from 1990–2007. Each patient received standard PD with one of two anastomotic variants: pancreaticogastrostomy (PG) or pancreaticojejeunostomy (PJ). A panel of preoperative serum lab values and postoperative complication data was collected for each patient, and regression analyses were performed to identify predictors of postoperative complications. Normal values were determined according to our institution’s laboratory guidelines. RESULTS: 452 patients were analyzed. Mean age at surgery was 65 years, and 56% of the patients were male. 64% of patients experienced no significant postoperative complications. Among those patients who experienced complications, pancreatic leak was most commonly observed, with an incidence of 16%. There were no significant differences between PG and PJ with respect to postoperative complications. Mortality within 30 days of PD was 2% for the study population and was not significantly different between PG and PJ groups. In a univariate analysis, patients with a low or normal preoperative AST had a higher incidence of complications when compared to those patients with an elevated AST (p = 0.03). Additionally, a higher proportion of postoperative complications was demonstrated in those patients with a low or normal alkaline phosphatase when compared to patients with elevated preoperative levels (p = 0.03). Interestingly, preoperative hypoalbuminemia was not significantly associated with increased rates of complications. Multivariate analysis confirmed that an elevated alkaline phosphatase was associated with a lower incidence of postoperative complications (OR = 0.56, p = 0.02). Preoperative anemia (hemoglobin <14.0) was found to be an independent predictor of postoperative complications following PD as well (OR = 2.01, p = 0.02). CONCLUSIONS: Patients who were anemic and those with normal LFTs were significantly more likely to experience a complication after PD. This may represent extent of disease and tumors not causing biliary or pancreatic dilatation, respectively. Precautions, such as intraoperative ductal stents, should be considered when operating on this group of patients in order to minimize complications.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

347 Surgical Management of Early Hepatocellular Carcinoma: Resection or Transplantation? Emily C. Bellavance*2, Steven Cunningham2, Kimberly M. Lumpkins2, Warren R. Maley1, Cinthia Drachenberg3, Richard D. Schulick1, Andrew M. Cameron1, Michael Choti1, Nader Hanna2, Benjamin Philosophe2, Timothy M. Pawlik1 1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, University of Maryland, Baltimore, MD; 3Pathology, University of Maryland, Baltimore, MD INTRODUCTION: Although liver transplantation (LT) is the treatment of choice for patients (pts) with hepatocellular carcinoma (HCC) and advanced cirrhosis, the management of pts with early HCC within the Milan criteria and well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of pts with early HCC and compensated cirrhosis who were treated with initial resection (RSX) vs LT. METHODS: Between 1985 and 2007, 42 pts underwent hepatic RSX and 61 pts underwent LT for HCC within the Milan criteria. All pts had well-compensated Childs A or B cirrhosis. Data on morbidity, recurrence, and long-term

survival were collected. Prognostic factors were evaluated using univariate ABSTRACTS MONDAY and multivariate analyses; survival was calculated using the Kaplan-Meier method. RESULTS: RSX pts were younger than LT pts (mean age: 42 y vs. 61 y, respectively; P = 0.01) but had the same gender distribution (male: 83% vs. 82%, respectively; P = 0.54). There was no difference in the incidence of hepatitis (RSX 64% vs. LT 82%; P = 0.07). The median number of hepatic lesions was 1 (range: 1 to 3) in both treatment groups (P = 0.10). However, tumors in the resected group tended to be larger (mean size: RSX 3.2 cm vs. LT 2.7 cm; P = 0.03). No pt in either group had preoperative evidence of major vascular invasion. For pts who underwent RSX, surgery consisted of wedge resection (n = 34, 80%), hemihepatectomy (n = 5, 12%) or extended hepatectomy (n = 3, 7%). 6 (14%) pts had a positive margin. Of the LT patients, 5 (8%) underwent living donor LT and 56 (92%) had orthotopic LT. On pathologic analysis, there was no difference in the incidence of microscopic vascular invasion (RSX 26% vs. LT 15%; P = 0.12) or tumor grade (P = 0.08). 30-day operative mortality was similar (RSX 4.7% vs. LT, 6.5%; P = 0.83). Overall morbidity was also the same (RSX 52% vs. LT 67%; P = 0.15), with most complications being minor (Clavien grade 1–2) (RSX 31% vs. LT 39%; P = 0.83). The recurrence rate was 38% following RSX and 20% following LT (P = 0.05). Pts who underwent RSX had a similar 5-year survival rate (34%) compared with pts treated with LT (47%) (P = 0.19). Survival remained comparable when stratiﬁed by pre-MELD vs post-MELD era (both P > 0.05). Presence of microscopic vascular invasion predicted worse long-term prognosis (HR = 5.35, P = 0.005). CONCLUSION: In well-compensated pts with early-stage HCC, RSX and LT have comparable morbidity, mortality, and long-term survival. Given current limitations in organ availability, RSX should be considered as initial treatment in select pts with HCC.

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348 Increasing Regionalization of Hepatic Resection in Canada: 1995–2004 Ryan McColl*, Xiaoqing You, William A. Ghali, Elijah Dixon Department of Surgery, Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada PURPOSE: Liver resection is the only curative therapy for hepatic malignancy, both primary and secondary. Despite this, recent trends in the use and outcomes of hepatic resection in Canada are unknown. This study sought to describe patient characteristics and crude outcomes along with patterns of regionalization for hepatic resection in Canada from 1995–2004. METHODS: Discharge data from all hospitals across Canada except Quebec were obtained from the Canadian Institute for Health Information for 1995–2004. All patients undergoing a hepatic resection were identified using ICD 9 and 10 codes. Calculated mortality rates are based on in-hospital deaths according to year and surgical indication. High-volume hospitals were defined as those performing 10 or more procedures per year. RESULTS: Over the study period, 9912 patients (mean age 59.10) underwent hepatic resection at 247 hospitals. The national age- and sex-adjusted hepatic resection rate per 100 000 people aged ≥18 years increased from 3.22 in 1995 to 5.86 in 2004. Patients who underwent resection in the years 1995–1999 had a significantly increased chance of mortality compared to those operated on from 2000–2004 (odds ratio 1.43, 95% confidence interval 1.18–1.73). Rates of hepatic resection for metastases increased by 29% and had outcomes superior to that observed for primary malignancy (mortality rate 2.65% compared to 6.01%, p < 0.0001). The proportion of procedures performed at high- volume hospitals increased from 41.52% in 1995 to 83.53% in 2004. CONCLUSIONS: The rate of hepatic resection in Canada has increased dramatically, especially for metastatic disease. Over the same time period, mortality rates have significantly improved. Our study also demonstrates increasing regionalization likely due to growing evidence that high-volume centers have superior outcomes for complex procedures.

116 6303_SSAT.book Page 117 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

2:30 PM – 4:00 PM VIDEO SESSION I: HPB SURGERY 27B Moderators: Rebecca M. Minter, Ann Arbor, MI Randall S. Zuckerman, Cooperstown, NY 349 The Lateral Laparoscopic Approach to Lesions in the Posterior Segments Andrew A. Gumbs*1,2, Brice Gayet2 1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France Although some authors believe that laparoscopy is contraindicated for the posterior hepatic segments, we use a lateral approach for resections in these segments. The hepatic inflow is approached with patients in a modified partial left lateral with the surgeon between the legs. The hepatic outflow is then controlled laterally if not done so retrohepatically. We have safely performed this procedure in >25 patients with a 5% rate of major morbidity and 0% mortality. Average margin is >10 mm for malignant lesions. Long-term results are similar to our open patients. The Lateral Laparoscopic Approach to ABSTRACTS

hepatic lesions in the posterior segements of the liver are feasible and safe. MONDAY

350 Small Diameter Prosthetic H-Graft Portacaval Shunt for Portal Decompression Alexander S. Rosemurgy*, Harold Paul, Mark Shapiro, Desiree Villadolid, Sam Al-Saadi, Sharona B. Ross, Sarah Cowgill Surgery, University of South Florida and Tampa General Hospital, Tampa, FL H-graft portacaval shunts reduce portal pressures and, thereby, discourage variceal rehemorrhage and promote long-term survival. This video presents our technique of small diameter prosthetic H-graft portacaval shunt.Only a limited Kocher maneuver is necessary. The IVC and portal vein are exposed. Ringed PTFE graft, 3 cm from toe-to-toe and 1.5 cm from heel-to-heel, is utilized. Portal and caval pressures are measured before and after shunting. The cava-graft anastomosis is completed ﬁrst, followed by the portal vein-graft anastomosis. Shunting should decrease the portal pressures >10 mmHg and result in a gradient of <10 mmHg between the portal vein and IVC.

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351 Functional Magnetic Resonance Imaging of Pancreatic Disease Tara S. Kent*1, Ivan Pedrosa3, Sunil Sheth2, Alphonso Brown2, Mark P. Callery1, Charles M. Vollmer1 1Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 3Radiology, Beth Israel Deaconess Medical Center, Boston, MA MRCP serves as a useful diagnostic tool for many pancreatic diseases. Exogenous secretin administration augments traditional MRCP, converting it to a functional study (sMRCP) that better delineates ductal anatomy and pathology. This video depicts the successful application of sMRCP in a pancreatic surgical practice. The principles of sMRCP are explained and examples are provided of its utility in diagnosing and managing difﬁcult pancreatic conditions such as chronic pancreatitis, the disconnected pancreatic segment, pancreatic duct stenosis, pancreas divisum, and anomalous pancreaticobiliary junction. This modality provides added value in managing these challenging disease processes.

352 Laparoscopic Extended Distal Pancreatectomy for Tumors of the Pancreatic Neck Christos A. Galanopoulos*, D. Rohan Jeyarajah HPB/Foregut Surgery, Methodist Dallas Medical Center, Dallas, TX BACKGROUND: Laparoscopic distal pancreatectomy has been used for tumors of the pancreatic body/tail. Tumors overlying or adjacent to the SMV/ PV junction have been traditionally resected using open surgery. METHOD: 5 patients with tumors between 1–5 cm overlying/adjacent to the SMV/PV conﬂuence were laparoscopically resected by extending resection to the right of the vessels. RESULT: All had R0 resection and margins were to the right of the SMV/PV conﬂuence. Splenic vessels were ligated at their origin. Oncologic vascular control was completed prior to pancreatic transection. CONCLUSION: Tumors of the pancreatic neck can be laparoscopically resected with no change in morbidity or mortality.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

353 Laparoscopic Approach in Patients with Gastrinoma Which Are the Limits? Laureano Fernández-Cruz* Surgery, Hospital Clínic, Barcelona, Spain To present the limits of the laparoscopic approach in patients with gastrinoma in 4 consecutive patients. The Laparoscopic Approach (Lap A) was successful in one patient after tumor excision (1 cm) localized between the duodenum and vena cava (primary lymph node gastrinoma) and in another MEN-1 patient after spleen-preserving distal pancreatectomy. Conversion in 2 patients, one localized in the posterior duodenal wall, and in another with lymph node metastasis. The Lap A was feasible and achieved cured in 50% of gastrinomas. The association of lymph node metastasis or the localization in difﬁcult surgical areas, may limit its success. ABSTRACTS MONDAY

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Tuesday, May 20, 2008 7:30 AM – 10:00 AM VIDEO SESSION II: BREAKFAST 25ABC AT THE MOVIES Moderators: Craig P. Fischer, Houston, TX Attila Nakeeb, Indianapolis, IN 449 Combined Treatment of Esophageal Perforation: A New Approach Bryan J. Sandler*, Michelle K. Savu, Garth R. Jacobsen, John Cullen, Thomas J. Savides, Mark A. Talamini, Santiago Horgan Department of Surgery, University of California, San Diego, San Diego, CA Esophageal perforation can be difﬁcult to manage. This demonstrates a novel approach to this problem, using a combination of laparoscopic and endoscopic techniques to close and stent the perforation. The patient presented following dilatation of an esophageal stricture. His post-operative recovery was uneventful and he was discharged home without further intervention. This result is an example of the close collaboration between surgery and gastroenterology as both ﬁelds move forward, developing minimally invasive and endolumenal therapeutics.

450 Dual Incision Adjustable Gastric Band Placement Garth R. Jacobsen*, Bryan J. Sandler, John Cullen, Mark A. Talamini, Adam Spivack, Santiago Horgan Department of Surgery, University of California, San Diego, San Diego, CA Laparoscopic operations require multiple incisions to achieve the angles necessary to perform the operation. Wristed instruments allow for completion from fewer access points. Two patients underwent AGB placement using a two incision technique, under an IRB approved protocol. All ports were placed through a 3 cm incision in the patient’s abdomen. A liver retractor was placed in the epigastrium. Either a laparoscope or endoscope was used for visualization. The operation was successfully completed in both patients in under one hour. Flexible laparoscopic instruments can reduce the number of incisions needed to perform AGB placement.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

451 A Simpliﬁed Technique for Placement of Biologic Mesh in Paraesophageal Hernia Repair (PEH) Tayyab S. Diwan*, Danny V. Martinec, Michael Ujiki, Christy M. Dunst, Lee L. Swanstrom Minimally Invasive Surgery, Legacy Health System, Portland, OR The placement of mesh in the crural closure of PEH repairs has been shown to decrease hernia recurrence rates. Synthetic mesh is easy to use but has a high rate of esophageal erosion and therefore has been largely abandoned. Use of biologic mesh decreases the risk of erosion and recurrence rates, but there is currently no well described method for placement. We present a method which requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure. Our method incorporates biological mesh into the standard closure using pledgeted polyester sutures placed in a horizontal mattress fashion. This technique has worked well in over 150 PEH operations.

452 Human NOTES Hybrid Transgastric Cholecystectomy Edward Auyang*1, Khashayar Vaziri1, John A. Martin2, Eric S. Hungness1, Nathaniel J. Soper1 1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology, Northwestern University, Chicago, IL Natural Oriﬁce Translumenal Endoscopic Surgery (NOTES) is a rapidly devel-

oping area of minimally invasive surgery that has the potential to improve ABSTRACTS post-operative outcomes by eliminating abdominal incisions. Hybrid tech- TUESDAY niques using mostly endoscopic and minimal laparoscopic instruments are being performed in human patients. At Northwestern, we have successfully performed two human NOTES hybrid transgastric cholecystectomies and this video demonstrates the technique we have used to perform this procedure.

453 Totally Laparoscopic Extended Right Hepatectomy Andrew A. Gumbs*1,2, Brice Gayet2 1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France This video will demonstrate the relevant technical maneuvers necessary to perform a totally laparoscopic extended right hepatectomy. The five principal steps of this procedure include: mobilization of the liver, control of hepatic inflow, division of the hepatic parenchyma, control of the hepatic outflow and removal of the specimen. A total of 4 totally laparoscopic extended right hepatectomies have been successfully performed at our institution. Our short and long-term results have been similar to our open historical controls. No mortalities have been observed. The minimally invasive approach to hepatic resections is limited by the comfort level of the operator and not the technique.

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454 Standardization of Laparoscopic Distal Pancreatic Resection (LapDPR) with Regional Lymphadenectomy in Malignant Pancreatic Neoplasms (MPN) Laureano Fernández-Cruz* Surgery, Hospital Clínic, Barcelona, Spain Some surgeons have suggested that MPN are contraindicated to LapDPR because of concerns for the radicality of resection and oncological outcomes. Herein, described the LapDPR with and without splenectomy in patients with suspected pancreatic malignancy. The LapDPR includes radical lymph node dissection of the peripancreatic, portal, hepatic and superior mesenteric areas; the Gerota fascia and fatty tissue on the adrenal gland are also removed.The LapDPR achieved 90%. Ro resection in 15 patients with ductal adenocarcinoma and 100% in 10 patients with neuroendocrine MPN.

455 Laparoscopic Sigmoid Resection for Complicated Diverticulitis (Colovaginal Fistula) Barry Salky* Surgery, Mount Sinai Hospital, New York, NY This video demonstrates the technical challanges that can occur in complicated diverticulitis. This case has the small intestine walling off an abscess from the sigmoid in conjunction with the sigmoid’s attachment to the back wall of the bladder and the vagina. It demostrates a safe way to approach these structures, and it demostrates a good way to avoid ureteral injury. A tension free anastomosis to the upper rectum is shown, along with sigmoidos- copy to check the anastomosis.

456 Laparoscopic Celiac Artery Decompression Khashayar Vaziri*, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL Compression of the celiac artery by the diaphragmatic crura, the median arc- uate ligament or fibrous periaortic ganglionic tissue results in a rare constella- tion of symptoms known as celiac artery compression syndrome (CACS). First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. External compression of the celiac artery leads to a wide variety of symptoms frequently resulting in multiple diagnostic tests. A firm diagnosis is difficult to establish, and treatment is equally challenging. We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.

122 6303_SSAT.book Page 123 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

457 Pneumatosis Coli: Resection of the Splenic Flexure with Intracorporeal Anastomosis Melina C. Vassiliou*1, Douglas S. Smink2, Gina L. Adrales1 1General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2General Surgery, Brigham and Women’s Hospital, Boston, MA Pneumatosis coli is a clinical problem that infrequently requires surgical treatment. This video describes laparoscopic resection of the splenic flexure in a patient with symptomatic pneumatosis coli limited to this area. The decision to perform an intracorporeal anastomosis was based on body habitus and location of the diseased segment. Intracorporeal anastomosis requires less mobilization, limits the size of the extraction incision, and provides more flexibility when selecting the incision site. This video presentation briefly demonstrates mobilization of the left colon and splenic flexure and the creation of a side to side anastomosis entirely intracorporeally. ABSTRACTS TUESDAY

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10:00 AM – 11:15 AM BASIC SCIENCE PLENARY 25ABC (PLENARY SESSION IV) Moderators: David Shibata, Tampa, FL Sharon M. Weber, Madison, WI 557 Epigenetic Regulation of WnT Signaling Pathway Genes in Inflammatory Bowel Disease (IBD) Neoplasia Mashaal Dhir*1, Elizabeth A. Montgomery2, Kornel Schuebel3, Susan L. Gearhart1, Nita Ahuja1,3 1Surgery, Johns Hopkins University, Baltimore, MD; 2Pathology, Johns Hopkins University, Baltimore, MD; 3Oncology, Johns Hopkins University, Baltimore, MD BACKGROUND: DNA methylation of promoter CpG islands in the Wnt signaling pathway is an important event in the pathogenesis of Colorectal Can- cer (CRC). We hypothesized that chronic inflammatory states, like IBD, may lead to increased aberrant methylation and inactivation of Wnt genes which in turn accelerate the development of cancer. This study examined the role of epigenetic silencing of Wnt genes in the pathogenesis of IBD Neoplasia (Dysplasia and Cancer). METHODS: Paraffin embedded tissue samples were obtained from The Johns Hopkins Hospital Pathology archive with IRB approval. We analyzed 11 Wnt genes using methylation specific PCR including APC1A, APC2, dickkopf family genes (DKK1, DKK2), soluble frizzled related proteins (sFRP1, sFRP2, sFRP4, sFRP5), Wnt inhibitory factor-1 (WIF-1), Delta like3 (DLL3) and a serine threonine kinase, LKB1. Methylation analysis was performed in 41 IBD samples (6 IBD cancers, 2 High grade dysplasia [HGD], 8 Low grade dysplasias [LGD] and 25 IBD colitis) from 20 IBD patients (Median disease duration = 12 years), 27 normal colons (NCs) and 24 sporadic CRCs (Stage 1–3). RESULTS: There was no significant difference in the overall frequency of methylation of Wnt signaling pathway genes in sporadic CRC and IBD cancers (52% vs. 61%; p = 0.42). However, a progressive increase in the percentage of methylated genes from NCs (3.7%) to IBD Colitis (39.7%) to IBD Neoplasia (63.39%) was seen (NC vs. IBD Colitis p < 0.001, IBD Colitis vs. IBD associated Neoplasia p = 0.016). More importantly, a distinct increase in methylation of APC1A and APC2 was seen during progression to IBD Neoplasia (Figure 1). Multivariate logistic regression analysis showed that methylation of APC1a and APC2 were predictive of IBD Neoplasia as compared to IBD colitis (OR APC1a:6.2, 95% CI: 1.1–36.3; OR APC2:8.5, 95% CI: 1.2–59.0).

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Figure 1. Progressive increase in methylation frequency of APC1A & APC2 during IBD Neoplasia

CONCLUSIONS: The frequency of methylation of the Wnt signaling pathway genes increases progressively during development of IBD Neoplasia. Moreover, the ﬁndings of early methylation of APC1A and APC2 in IBD associated dysplasia may provide a method for early detection of IBD associated carcinoma. ABSTRACTS TUESDAY

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558 Sodium-Coupled Transport of Butyrate by SLC5A8 Mediates Tumor Suppression in the Colon Gail Cresci*1,2, Muthusamy Thangaraju2, Darren Browning2, Vadivel Ganapathy2 1Surgery, Medical College of Georgia, Augusta, GA; 2Biochemistry and Molecular Biology, Medical College of Georgia, Augusta, GA INTRODUCTION: Short-chain fatty acids (SCFA), generated in the colon by bacterial fermentation of dietary fiber, protect against colorectal cancer. Among the SCFAs, butyrate is believed to be most relevant to colonic health. Butyrate induces differentiation of colonocytes and promotes apoptosis in colonic tumor cells. The ability of butyrate to induce apoptosis in tumor cells is related to its function as an inhibitor of histone deacetylases (HDACs). To do this, butyrate must enter the colonocyte. SLC5A8 is a Na+-coupled transporter for SCFA expressed predominantly in the colon. SLC5A8 has been shown to be silenced in colon cancer and re-expression of the transporter in colon cancer cell lines leads to apoptosis. However the underlying mechanism of tumor suppression is unknown. HYPOTHESIS: SLC5A8-mediated concentrative entry of butyrate into colon cancer cells is responsible for tumor cell-specific induction of apoptosis. METHODS: Expression of SLC5A8 was compared in paired samples of human tumor and normal colon tissue, colon tissue from ApcMin/+ mice, a model for intestinal/colon cancer, and wild type mice, and several colon cancer and normal colon cell lines. Mature oocytes from X.laevis, injected with human SLC5A8 cRNA, were used for electrophysiological studies to characterize SLC5A8-mediated butyrate transport. The Na+-activation kinetics of butyrate-induced currents was analyzed by measuring the butyrate-specific currents with increasing amounts of Na+. Normal and colon cancer cell lines transfected with pcDNA or SLC5A8 cDNA and treated with or without butyrate were used to evaluate apoptosis, HDAC activity, and expression of pro- and anti-apoptotic genes. RESULTS: SLC5A8 transports butyrate via a Na+-dependent electrogenic process. Na+-activation of the transport process exhibits sigmoidal kinetics, indicating involvement of more than 1 Na+ in the activation process. SLC5A8 is silenced in colon cancer in humans, in a mouse model of colon cancer, and in colon cancer cell lines. The tumor-associated silencing of SLC5A8 involves DNA methylation by DNA methyltransferase 1. Re-expression of SLC5A8 in colon cancer cells leads to apoptosis, but only in the presence of butyrate. SLC5A8-mediated entry of butyrate into cancer cells is associated with inhibition of histone deacetylation. Changes in gene expression in SLC5A8/butyrate- induced apoptosis include upregulation of pro-apoptotic genes and downregulation of anti-apoptotic genes. Also, expression of phosphatidylinositol-3- kinase subunits is affected differentially. CONCLUSION: These studies show that SLC5A8 mediates the tumor-sup- pressive effects of the SCFA butyrate in the colon.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

559 Applying Proteomics Based Biomarker Tools for the Accurate Diagnosis of Pancreatic Cancer John D. Christein*1, Kyoko Kojima2, Senait G. Asmellash3, Christopher A. Klug2, James A. Mobley1 1Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Microbiology, University of Alabama at Birmingham, Birmingham, AL; 3Biochemistry and Molecular Genetics, University of Alabama at Birmingham, Birmingham, AL BACKGROUND: Clinical proteomics is the study of proteins and the physiologic state of an individual. The human proteome or biologic signature contains biomarkers associated with varying diseases. There is no biomarker set specific to pancreatic cancer and only a few proteomic studies have attempted to differentiate patients with pancreatic cancer from those without disease. AIMS: To evaluate the biologic fluid proteome of patients with and without pancreatic disease. For the first time, to accurately differentiate patients with pancreatic cancer based on proteome analysis by mass spectrometry. METHODS: From 2003–2007, 245 patients underwent prospective serum, plasma, and urine collection. Endoscopic ultrasound and/or surgical pathology were used to distinguish normal (N) patients from cancer (CA) or chronic pancreatitis (CP). A reproducible high throughput (HTP) method using a high affinity solid core lipophilic extraction resin enriched the low molecular weight protein fraction of a sample. Proteome analysis coupled the extraction with a high speed 200 Hz matrix-assisted laser desorption/ionization-time of

flight (MALDI-ToF/ToF) mass spectrometer (Bruker Ultraflex III). Poor quality ABSTRACTS samples and outliers were excluded from the sample set. Samples from N, CA, TUESDAY and CP groups underwent software processing with FlexAnalysis, Clinprot, MatLab, and Statistica to align and normalize spectra. Statistical nonparametric pairwise analysis, multidimensional scaling (MDS), hiearcical analysis, and leave one out cross validation (LOOCV) using a k-means based approach completed the comparison. RESULTS: Fifty usable serum samples (15 N 24 CA, 11 CP) underwent proteomic based analysis. Sensitivity (sn) and specificity (sp) of group comparisons were determined. Using 6 serum features, we accurately differentiated CA from N (sn 88.9%, sp 93.8%), CA from CP (sn 88.9%, sp 61.1%), and N from both CA and CP when combined (sn 88.9%, sp 76.4%). When combined with 14 features from urine spectra, CA was differentiated from N and CP with a sensitivity approaching 94%. Interestingly, the plasma samples (considered by the Human Proteome Organization to be the preferred biological fluid) did not show significant differences between patient groups. CONCLUSION: Human biologic fluids can successfully be used to differentiate patients with pancreatic cancer from those without disease or chronic pancreatitis. Proteomic analysis of human serum and urine can provide a high level of predictability for diagnosing pancreatic cancer. The proteomic analysis of biologic fluids may be able to be used to screen individuals for pancreatic cancer or differentiate benign from malignant disease.

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560 A Neurokinin-1 Receptor Antagonist (NK1RA) That Reduces Intraabdominal Adhesions Augments the Anti-Adhesive Effects of a Hyaluronic Acid/ Carboxymethylcellulose (HA/CMC) Adhesion Barrier in Rats Rizal Lim*1, Jonathan M. Morrill1,2, Karen L. Reed1,2, Adam C. Gower1, Bilaal McCloud1, Susan E. Leeman2,1, Arthur F. Stucchi1,2, James M. Becker1 1Surgery, Boston University Medical Center, Boston, MA; 2Pharmacology, Boston University Medical Center, Boston, MA INTRODUCTION: Intraabdominal adhesions can be a significant cause of postoperative morbidity. Previous work from this laboratory has shown that an NK1RA significantly reduces adhesion formation in a rat model. HA/CMC (Seprafilm Adhesion Barrier® Genzyme), proven to reduce the incidence of adhesions in patients undergoing laparotomy, may have its efficacy limited to the location of the film, typically under the midline incision. The purpose of this study was to evaluate the anti-adhesion efficacy of the NK1RA (CJ- 12,255; Pfizer) when administered in combination with HA/CMC in a rat model of adhesion formation. METHODS: Adhesions were created via a midline laparotomy by placing 3 ischemic buttons, 1 cm apart on each side of the peritoneum. Rats received no treatment (n = 6), NK1RA (25 mg/kg) (n = 5), HA/CMC and saline (n = 12), or HA/CMC and NK1RA (25 mg/kg) (n = 12) administered intraperitoneally at the time of surgery. HA/CMC was applied unilaterally over half the ischemic buttons and the NK1RA was administered in a 1ml saline lavage. The rats were sacrificed at 7 days and adhesions scored as percent of buttons with formed adhesions. To evaluate peritoneal fibrinolytic activity, ischemic buttons were created as above and randomized to receive NK1RA alone (n = 6), bilateral HA/CMC and saline lavage (n = 6), or bilateral HA/CMC and NK1RA lavage (n = 6). Animals were sacrificed at 24 hours, and peritoneal tissue and fluid collected for tissue plasminogen activator (tPA) activity assay, a measure of fibrinolytic activity. RESULTS: Rats treated with NK1RA had significantly fewer adhesions compared with controls (80 ± 8% vs. 20 ± 4%; p < 0.05). HA/CMC also significantly decreased adhesions from 75 ± 8.3% to 44 ± 10.3% (p < 0.05); however, adhesion reduction was limited to buttons over which HA/CMC was placed. The combination of the NK1RA and HA/CMC increased the efficacy of HA/ CMC, further reducing adhesions to 11 ± 4.7%, a 75% reduction compared to HA/CMC alone (p < 0.05). In these same animals the adhesions were reduced by 45% on the non- HA/CMC side (p < 0.05). Administration of the NK1RA alone increased peritoneal tPA activity more than 137% compared with HA/ CMC alone (26.7 ± 3.5 vs. 11.2 ± 2.2 U/ml, p < 0.05); however, this increase was attenuated when NK1RA was administered in the presence of HA/CMC (14.6 ± 3.5 U/ml, p < 0.05 compared with NK1RA alone). CONCLUSIONS: The efficacy of HA/CMC was significantly augmented by the addition of an NK1RA suggesting that further research is warranted to develop a biodegradable, barrier-based delivery system for more effective prevention of adhesions.

128 6303_SSAT.book Page 129 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

561 Differential Ileal Adaptation After Massive Proximal- Based Small Bowel Resection: Importance of the GLUT2 Hexose Transporter Michael G. Sarr, Corey W. Iqbal*, Javairiah Fatima, Molly E. Gross Department of Surgery, Mayo Clinic, Rochester, MN INTRODUCTION: SGLT1 and GLUT2 are the predominant glucose transporters in rat intestine but are present in low quantities in the ileum where very little glucose absorption occurs normally; however, glucose uptake in the ileum is highly adaptable after small bowel resection. HYPOTHESIS: Ileal adaptability for glucose absorption after jejunal resection is mediated predominately by an increase in GLUT2. METHODS: Lewis rats (250–300 g) underwent massive (70%) proximal-based jejunoileal resection (starting at the duodenojejunal junction). Transporter- mediated glucose uptake was measured in the proximal and distal aspects of the remnant ileum at 1 and 4 wk postoperatively (n = 6 each) in 20 mM D-glucose using the everted sleeve technique. Corresponding segments of ileum in naïve control and 1-wk sham laparotomy rats (n = 6 each) were also studied. Selective inhibitors of hexose transporters were then evaluated. Phlo- rizin (0.2 M) was used to inhibit SGLT1-mediated glucose uptake and indi- rectly any uptake by GLUT2 by inhibiting GLUT2 trafﬁcking to the apical membrane (Iqbal et al., Gastroenterology 2007; 132(4): A-891); phloretin (1 M) was used to inhibit GLUT2-mediated glucose uptake. Villous height of the proximal ileum was measured to assess for ileal adaptation. ABSTRACTS

RESULTS: There was essentially no transporter-mediated glucose uptake in TUESDAY control or sham rat ileum. After massive 70% proximal intestinal resection, the proximal aspect of the remnant ileum had markedly greater glucose uptake at 4 wk compared to controls and shams (80 vs 0 nmol/cm/min, p < 0.0001). In the terminal ileum, there was little increase in uptake (9 vs 0 nmol/cm/min, p = 0.17). Treatment with phlorizin (SGLT1 inhibition and indirect GLUT2 inhibition) led to complete inhibition of transporter- mediated glucose uptake in resected rats in both proximal and terminal ileum. Phloretin (GLUT2 inhibition) also inhibited completely transporter- mediated glucose uptake 4 wk after resection in both proximal (0 vs 80 nmol/ cm/min, p < 0.0001) and terminal ileum (0 vs 9 nmol/cm/min, p = 0.17); there was partial inhibition in the proximal ileum for the 1-wk resection group (1.4 vs 11 nmol/cm/min, p = 0.05). Histology of proximal ileum at 4 wk demonstrated markedly greater villous height compared to controls (500 vs 200 µm, p = 0.0001). CONCLUSIONS: Terminal ileum is not as adaptable as proximal ileum after proximal small intestinal resection. Complete inhibition of glucose uptake at 4 wk with either phlorizin or phloretin suggests that GLUT2 is the primary glucose transporter in the adapted ileum. (Support: NIH DK39337 [MGS]).

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10:00 AM – 11:15 AM QUICK SHOTS I 27B Moderators: Jonathan F. Critchlow, Boston, MA Julie A. Stein, Royal Oak, MI 562 Perioperative Allogenic Blood Transfusions Significantly Affect Survival Following Transthoracic En Bloc Resection for Esophageal Cancer Daniel Vallbohmer*1, Frederike C. Ling1, Daniel Schmidt1, Roland Grunenberg2, Birgit S. Gathof2, Elfriede Bollschweiler1, Arnulf H. Hoelscher1, Paul M. Schneider1,3 1Department of Surgery, University of Cologne, Cologne, Germany; 2Institute of Transfusion Medicine, University of Cologne, Cologne, Germany; 3Department of Visceral and Transplantation Surgery, University of Zurich, Zurich, Switzerland BACKGROUND: Recent studies suggest that the number of transfused allogenic blood in the surgical therapy of gastrointestinal tumors significantly correlates with survival. The aim of this study was to evaluate the prognostic influence of allogenic blood transfusions following resection for esophageal cancer. METHODS: A retrospective analysis (1997–2006) was performed including 305 patients (median age 59.8 years) with esophageal cancers who underwent transthoracic en bloc esophagectomy and 2-field lymphadenectomy. Squa- mous cell cancer was found in 46.9% and adenocarcinoma in 50.5% (2.6% rare histologies). Neoadjuvant chemoradiation was performed in 159 (52%) patients. Number of perioperative blood transfusions were determined and the potential prognostic cut-off for transfused units was calculated according to LeBlanc. RESULTS: The median number of perioperative blood transfusions was 2 (range 0–53). 107 patients (35.2%) received no transfusions. One hundred- eighteen patients were treated before and 187 patients after the legally mandatory introduction of leukocyte-depleted blood. Patients with ≤1 blood transfusion showed a significant survival benefit compared to patients receiving >1 unit (p < 0.02). Multivariate analysis in R0 resected tumors demonstrated that in addition to the pTNM categories (pT: p < 0.002, pN: p < 0001, pM: p < 0.02), perioperative blood transfusions (≤1 versus >1) were an independent prognostic factor (p < 0.05). There was no difference in survival for patients getting none versus one unit or more and there was no detectable influence of leucocyte-depleted versus non-depleted units (p = 0.28). CONCLUSIONS: The number of perioperative allogenic blood transfusions appear to be an independent factor for survival after R0 resections by transthoracic en bloc esophagectomy for esophageal cancer. The prognostic influence of leucocyte-depleted blood deserves further evaluation due to a shorter observation time and the observation that there was no difference between patients getting none or one unit of blood in our retrospective analysis.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

563 A New Biomechanical Device to Augment Lower Esophageal Sphincter (LES) Continence in Patients with Gastroesophageal Reﬂux Disease (GERD)—Initial Results of a Pilot Clinical Trial Luigi Bonavina*1, Greta Saino1, Davide Bona1, Tom R. Demeester2, John C. Lipham2, Robert A. Ganz3, Daniel H. Dunn3 1Department of Surgery, University of Milano, IRCCS Policlinico San Donato, Milano, Italy; 2University of Southern California, Los Angeles, CA; 3Abbott Northwestern Hospital, Minneapolis, MN BACKGROUND: The high prevalence of GERD and the growing public awareness of the related malignant complications continue to generate new, minimally invasive treatments for this disease. Recently, a biomechanical device (Torax Medical, Inc. Minneapolis, MN) designed to augment LES strength has been developed and tested in animal models. The Magnetic Esophageal Sphincter (MES) deploys magnetic attraction forces, in a circular fashion, to precisely augment the LES. The forces can attenuate to accommo- date swallow and belch functions. A multi-center pilot clinical study was designed to develop a minimal dissection technique for laparoscopic implantation of the device and to assess the clinical and functional outcome of the procedure. METHODS: The study was approved by the Ministry of Health and the local Ethical Committee. Patients with typical reﬂux symptoms responding to PPI, abnormal esophageal acid exposure, <3 cm sliding hiatal hernia, and normal

esophageal peristalsis were enrolled in the study. All patients had the MES ABSTRACTS device placed laparoscopically around the esophagus at the GE junction. A TUESDAY sizing tool was used to determine the outer circumference of the esophagus and the size of device to be used. The surgical approach involved partial dissection of the phreno-esophageal ligament and exclusion of the posterior vagus nerve. The fundus and short gastric arteries were left intact in all patients. After the procedure, position and function of the device were evaluated with barium esophagram. Upper endoscopy and 24-hour esophageal pH monitoring were planned at 3 months postoperatively. RESULTS: In our center, since March 13, 2007, 19 patients underwent laparoscopic MES device implantation. Operative time ranged from 24 to 84 minutes. No operative complications were recorded. A free diet was allowed after radiological assessment of esophageal transit on post-operative day 1, and patients were discharged within 48 hours. No migrations nor erosions of the device occurred. All patients stopped using proton pump inhibitors and other antireﬂux medications. 6/6 patients were found to have complete normalization of 24-hour pH at 3 months after operation. CONCLUSIONS: Laparoscopic implantation of the MES is safe and requires a minimal surgical dissection compared to the conventional Nissen fundoplication. Control of reﬂux symptoms and complete normalization of pH occurred in all tested patients. Further follow-up of these patients is eagerly awaited.

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564 Long-Term Outcome After 92 Duodenum-Preserving Pancreatic Head Resections for Chronic Pancreatitis: Comparison of FREY- and BEGER-Procedures Tobias Keck*1, Ulrich Adam2,1, Hartwig Riediger1,2, Ulrich T. Hopt1, Frank Makowiec1 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany INTRODUCTION: Duodenum-preserving pancreatic head resections (DPPHR) in the techniques described by FREY or BEGER may be an alternative to pancreaticoduodenectomy (PD) or drainage procedures for chronic pancreatitis (CP) predominantly of the pancreatic head. Data comparing the outcomes after both operations are rare. We, therefore, analyzed our long- term results after DPPHR in 92 patients. METHODS: Since 1995 113 patients underwent DPPHR for CP predominantly of the pancreatic head. The decision to perform either a FREY- or a BEGER procedure was always made individually depending upon the complications and morphological classification of CP. Up to now prospective outcome results including standardized questionnaires could be obtained in 92 patients with a median postoperative follow-up of 43 months. Of those 92 patients (82% male, median age 44 years) 77% had alcoholic CP. The leading indications for surgery were pain (87%), recurrent attacks of CP (90%), jaundice (22%) or symptomatic duodenal stenosis (10%). RESULTS: Any/surgery related postoperative complications occurred in 31%/20% after FREY-procedures and in 41%/30% after BEGER-procedures (n.s.). In median 43 months after surgery 62% (FREY) and 50% (BEGER) of the patients were completely free of pain, respectively. In the collection of patients still or again suffering from pain (FREY vs. BEGER) 6%/19% had pain at least once per week or daily and the remaining 32%/31% experienced pain attacks at least once per year (difference for pain frequency p = 0.55). Diabetes was documented in 57% (BEGER) and 60% (FREY; n.s.). During postoperative follow-up a de-novo diabetes occured in 17% after BEGER- and in 34% after FREY-procedures (p = 0.06). The frequencies of an exocrine insufficiency (74% vs. 76%, p = 0.8) and a postoperative de-novo exocrine insufficiency (33% vs. 34%; p = 0.9) were identical. The median gain in body weight until the last follow-up was not significantly different (three kg after BEGER vs. two kg after FREY). Two patients in each group had relevant biliary complications (stenosis or symptomatic duct stones) during follow-up requiring re-intervention. Actuarial five-year survival after DPPHR was 96% and clearly higher than survival in the 110 patients who underwent PD for CP at our institution (five- year survival 82%). CONCLUSIONS: Comparison of the outcomes after either a FREY- or a BEGER-procedure for CP reveals a tendency for better pain control after the FREY-operation. The functional outcomes (organ function, biliary) were almost identical. Surprisingly, late mortality after DPPHR was clearly lower than reported in other series and in the patients undergoing PD for CP at our institution.

132 6303_SSAT.book Page 133 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

565 Is Liver Resection Justiﬁed in Advanced Hepatocellular Carcinoma? Results of an Observational Study in 464 Patients Andrea Ruzzenente*1, Franco Capra2, Calogero Iacono1, Gianluca Piccirillo1, Marta Lunardi2, Stefano Pistoso3, Alessandro Valdegamberi1, Alfredo Guglielmi1 1Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy; 2Department of Internal Medicine, University of Verona Medical School, Verona, Italy; 3Department of Internal Medicine, Desenzano Hospital, Desenzano, Italy BACKGROUND AND OBJECTIVE: The role of liver resection of multinodular hepatocellular carcinoma (HCC) or with major vascular involvement is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced HCC. METHODS: 464 patients with HCC observed from 1991 to 2007 were included into the study. All the patients were evaluated for treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included into the study had no evidence of distant metastases. RESULTS: Median follow up time for surviving patients was 25 months (range 1–155). 260 patients were in Child-Pugh class A, 148 in class B and 18 in class C. 260 patients had sigle HCC, 79 patients had two HCCs, 37 three HCCs and 69 more than three HCCs. 136 (29.2%) patients were submitted to liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), 8 (1.7%) to liver ABSTRACTS

transplantation (LT) and 88 (19.0%) to supportive therapy (ST) Median sur- TUESDAY vival time for all patients was 30.4 months (95% CI 24–36). Median survival time was 57 months for LR, 30 for LAT and 8 for ST, with a 5 year survival of 47%, 20%, and 2.5% respectively (p = 0.001). 5-year survival for patients submitted to LT was 75%. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC with a median survival time of 39, 36, 18 and 11 months for patients with single HCC, with 2 HCCs, with 3 HCCs and with more than 3 HCCs respectively (p = 0.001). Survival for patients with single HCC was significatly longer in patients submitted to LR compare to LAT and ST with a median survival time of 57, 37, and 14 months respectively (p = 0.001). Also in patients with multinodular HCCs (2–3 HCCs) LR showed the best results with a a median survival time of 59 months compared to 22 and 8 months for LAT and ST (p = 0.001). In patients with more than 3 HCCs LR did not showed different results compared to LAT and ST. 66 patients had evidence of major vascular involvement, median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 19 and 52 months respectively. Survival for patients with major vascular involvement submitted to LR or LAT was significant longer compared to ST with a mean survival of 27, 30 and 12 respectively (p = 0.001). CONCLUSIONS: The present study shows that multinodular HCCs (2–3 nodules) can benefit from LR compared to LAT or ST. In patients with more than 3 HCCs or with major vascular involvement LR have similar results of LAT.

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566 An Improved Method of Assessing Esophageal Emptying Using the Timed Barium Study Following Surgical Myotomy for Achalasia Arzu Oezcelik*1, Jeffrey A. Hagen1, James M. Halls2, Jessica M. Leers1, Emmanuele Abate1, Shahin Ayazi1, John C. Lipham1, Farzaneh Banki1, Steven R. Demeester1, Tom R. Demeester1 1Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA; 2Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA INTRODUCTION: The timed barium study is a test used to quantitatively assess esophageal emptying in patients with achalasia by measuring the percent difference in area of the barium column on films obtained 1 and 5 minutes after ingesting 150 ml of barium. Improvement in emptying on the timed barium study has been documented after endoscopic therapy. After surgical myotomy, the improvement in esophageal emptying reported has been variable. Many patients following myotomy who have little change in emptying as traditionally measured have improved clearance of the barium before the 1 minute film is taken. The aim of this study was to evaluate a new method for assessing improvement in esophageal emptying after therapy in patients with achalasia. METHODS: A standard timed barium study was performed before and 3–6 months after a myotomy for achalasia in 30 patients. Esophageal emptying was assessed by comparing the area of the residual barium column on digital images obtained 1 and 5 minutes after ingestion of 150 ml of barium. Improvement in emptying was determined by comparing the results before and after therapy. We also assessed improvement after therapy by comparing the area of the barium column on the 1 minute images obtained before and after therapy, which we defined as initial esophageal clearance. Both measures of improvement were compared to clinical outcome. RESULTS: On clinical follow up, 21 (70%) patients had no symptoms, 4 (13%) had minimal symptoms, and 5 (17%) had moderate/severe symptoms. When calculated using the traditional method, esophageal emptying before and after surgery were not significantly different (25% vs. 37%; p > 0.05) and did not correlate with clinical outcome. However, when improvement in emptying was assessed by comparing clearance, the median improvement comparing the 1 minute films before and after therapy was 81%. Improvement in clearance correlated significantly with clinical outcome (Table). All patients with esophageal clearance less than 40% had moderate or severe symptoms. CONCLUSION: Esophageal emptying measured by the timed barium study calculated by the traditional method is not useful to assess outcome after surgical myotomy. We have described a new method for calculating esophageal clearance that correlates well with clinical outcome after surgical therapy.

Minimal Moderate/Severe Kruskal-Wallis No Symptoms Symptoms Symptoms p-value Traditional Method (Ratio of 0.7 (0.2–1.6) 0.4 (0.2–2.7) 0.9 (0.6–1.8) p = 0.78 pre- vs. post-therapy) Initial Esophageal Clearance 89 (77–98) 89 (77–98) 44 (28–48) p < 0.0002 (Percent improvement)

Value are shown as median (IQR) 134 6303_SSAT.book Page 135 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

567 Manometric Proﬁle After Laparoscopic Nissen Fundoplication and Endoluminal Fundoplication: A Comparative Study in Animals Silvana Perretta*, Bernard Dallemagne, Jacques Marescaux Digestive and Endocrine Surgery, IRCAD-EITS University of Strasbourg France, Strasbourg, France INTRODUCTION: Laparoscopic Nissen Fundoplication (LNF) is considered the gold standard of surgical treatment of GERD. An emerging endoscopic technology, the EsophyX (EsophyX™, EndoGastric Solutions Inc.) Endo Luminal Fundoplication (ELF), aims at reproducing the effect of the fundoplication by creating an intragastric valve with fasteners applied at the Gastro- Esophageal Junction (GEJ). Both techniques increase resting pressure and length of the Lower Esophageal Sphincter (LES). This study aims to compare the short term manometric proﬁle of ELF with 8 fasteners to LNF. MATERIALS AND METHODS: Twelve 40-kg pigs were randomized to either ELF or LNF. Under general aesthesia, the LES resting pressure (mm Hg) and length (cm), were manometrically assessed before (T0), immediately after (T2) and 1 and 4 weeks after each procedure (ELF and LNF). In the ELF group manometry was carried out midway through as well, after the placement of 4 corner fasteners (T1). Solid state manometric catheters with 4 sensors were used. Endoscopies were performed to assess the anatomy and location of the GEJ before and after fundoplication. RESULTS: The 2 groups were comparable according to preoperative manom-

etry and endoscopy. Median operative time was 45 minutes (range, 40–50) for ABSTRACTS ELF and 30 min (range, 25–35) for LNF. LES mean increase in resting pressure TUESDAY (9.22 for ELF vs 10.6 mmHg for LNF) and length (2 cm for both ELF and LNF; range, 1–3 cm) improved similarly and significantly (p < 0.05) in both groups with no significant difference in the measured parameters between the two techniques at any of the given time points. In the ELF group the main increase in LES resting pressure was achieved at T1 (p 0.02) with no significant raise between T1 and T2. The postoperative manometric profile in both groups was unchanged and similar 1 and 4 weeks postoperatively. Notably, the significant increase in LES resting pressure was preserved (p < 0.05). The endoscopic aspect of ELF and LNF was comparable 1 and 4 weeks postoperatively. CONCLUSIONS: This study demonstrated an immediate and short term physiological effect of ELF comparable to that achieved with the gold standard LNF, providing a similar increase in LES resting pressure and length. The position of the fasteners is an important factor of efficacy of the ELF.

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568 Immunologic Ignorance and Tolerance Both Play a Role in Hepatic Tumorigenesis Diego Avella*, Luis J. Garcia, Serene Shereef, Hephzibah Tagaram, Yixing Jiang, Mehrdad Nikfarjam, Niraj J. Gusani, Eric Kimchi, Kevin Staveley-O’Carroll Surgery, Penn State, Hershey, PA INTRODUCTION: Current literature suggests that immunologic tolerance plays a major role in allowing hepatic tumor growth. However, the immune system is dynamic and its response to tumor antigens may very well be different at various stages of tumor growth. We have developed a reliable model of spontaneous HCC in which tumor progression can be accurately followed with MRI even at very small sizes. Using this model, we evaluated tumor specific immune responses at different stages of tumor growth. METHODS: C57BL/6 mice were inoculated with syngeneic HCC cells expressing Tag of the SV40 virus via splenic injections (ISPL). Tumor growth was evaluated with contrast enhanced magnetic resonance imaging (MRI) after ISPL. Basal immune responses were evaluated at 9, 14, 21, 28, 42, and 56 days after ISPL. Animals were vaccinated with WT-19 (cell line expressing Tag) at three time points 14, 28, and 56 days after ISPL. Tetramer analysis was used to quantify Tag-specific CD8+ T cell proliferation and T-cell function was assessed through Tag-specific γ-interferon production. Autopsies were performed for macroscopic evaluation of tumor. Immunohistochemistry (IHC) was used to confirm Tag expression in the tumor foci. RESULTS: All animals injected ISPL developed HCC. These tumors were first detectable by 28 days after injection with MRI. MRI performed at 14 days did not reveal evidence of tumor foci. At 28 days, MRI demonstrated small tumor foci, <1 mm. At 56 days, MRI demonstrated tumor foci, 7–10 mm in size. At all time points there was no basal tumor specific CD8+ T cell proliferation or activation. At 14 and 28 days after injection there was a robust tumor specific CD8+ T cell proliferation and activation after vaccination. At 56 days after injection there was no tumor specific CD8+ T cell proliferation or activation after vaccination. Necropsies confirmed findings of MRI examinations. IHC showed T ag expression in tumor foci. CONCLUSION: Otherwise immunogenic tumor cells when delivered to the liver will grow. When this occurs, T cells are present and remain capable of producing a robust immune response when presented with the same tumor antigen. This response however, is not evident in animals with larger tumors. These results suggest that immunological ignorance is responsible for allowing tumor growth during early stages of tumorigenesis. Immunological tolerance appears to be important when tumors grow to a certain size. The exact size of tumor and mechanism responsible for this phenomenon is yet to be fully characterized.

136 6303_SSAT.book Page 137 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

569 Downregulation of AdiponectinAdipor2 Is Associated with Hepatic Inflammation and Steatosis in Obese Mice Yanhua Peng2,3, Drew A. Rideout*1,2, Steven S. Rakita1,2, Mini Sajan2,3, Robert Farese2,3, Min You3, Michel M. Murr1,2 1Department of Surgery, University of South Florida, Tampa, FL; 2Department of Surgery and Research, James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department of Molecular Medicine, University of South Florida, Tampa, FL BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a common manifestation of obesity and is linked to the metabolic syndrome through a complex interplay of hepatic glucose and lipid metabolism. Adiponectin reg- ulates fat storage, lipid oxidation, energy expenditure and inflammation. We propose that high fat diet reduces adiponectin and induces steatosis and hepatic inflammation. METHODS: 4 week-old C57BL mice were fed high fat diet (n = 8) or regular chow (control; n = 6) for 7 weeks to induce obesity. Body weight, liver weight and serum adiponectin were measured. Liver sections were stained with H&E and Oil Red for fat content. Liver homogenates were used to measure protein (immunoblotting) and mRNA (RT-PCR) of TLR4, TNF–α, SREBP-1, Adiponec- tin receptors (AdipoR1 and AdipoR2) in addition to nuclear phorsphorylated p65NF-κB. Gels were quantified using densitometry; t-test was used, p < 0.05 was significant. RESULTS: High fat diet increased body and liver weight by 50% and 33%, ABSTRACTS

respectively. Serum adiponectin decreased in mice fed a high fat diet (2,500 ± 20 TUESDAY vs. 6,500 ± 30; p < 0.001 vs. control). In liver sections, high fat diet increased fat content in hepatocytes (10,280 ± 120 vs. 1,542 ± 12 fat droplets; p < 0.001, vs. control) and hepatocyte ballooning (8,900 ± 50 vs. 1,523 ± 23 cells; p < 0.001 vs. control). Liver AdipoR2 decreased with high fat diet (protein: 1,308 ± 10 vs. 3,045 ± 18; mRNA: 1,981 ± 15 vs. 4,738 ± 20; all p < 0.001 vs. control); however, AdipoR1 was not changed. High fat diet increased hepatic levels of TLR4, TNF–α and SREBP-1 protein (TLR4: 4,678 ± 35 vs. 2,675 ± 15; TNF–α: 4,429 ± 35 vs. 2,390 ± 25, SREBP1: 4,543 ± 37 vs. 2,574 ± 26, all p < 0.001 vs. control) and mRNA (TLR4: 6,789 ± 35 vs. 3,458 ± 29; TNF–α: 3,200 ± 24 vs. 1,301 ± 25; SREBP1: 3,456 ± 23 vs. 1,528 ± 10; all p < 0.001 vs. control). Additionally, high fat diet increased activation of phorsphorylated p65NF-κB (5,438 ± 30 vs. 2,560 ± 21; p < 0.01 vs. control). CONCLUSIONS: High fat diet induces obesity, increases body and liver weight as well as hepatocyte fat content. Liver steatosis induced by high fat diet is associated with upregulation of hepatic SREBP-1 that promotes lipogenesis and fat storage. In addition, high fat diet is associated with upregulation of pro-inflammatory transcription factors and cytokines and downregulation of AdipoR2 that has anti-inflammatory properties. Moreover, obesity-induced reduction in serum adiponectin suggests that adiponectin signaling may be the crosslink between high fat diet, inflammation and NAFLD.

137 6303_SSAT.book Page 138 Tuesday, April 22, 2008 1:26 PM

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570 Ischemic Colitis Following Endovascular Aortoiliac Aneurysm Repair: A 10-Year Retrospective Review Aaron Miller*, Michael S. Marotta, Irini A. Scordi-Bello, Yolanda Tammaro, Celia M. Divino The Mount Sinai Hospital, New York, NY INTRODUCTION: The use of endovascular stent grafts for repair of abdominal aortic aneurysms (AAA) has become increasingly popular since its initial introduction in the early 1990’s. Endovascular stents are less invasive and can be done under spinal anesthesia, thus, generally providing less risk to the patient and quicker recovery times when compared with the traditional open repair. A major complication after traditional open repair is ischemic colitis, reported to be approximately 2–3 percent in the literature. The goal of this study is to examine the incidence, cause and outcomes of ischemic colitis after endovascular stent graft repair of aortoiliac aneurysms (EVAR). METHODS: 809 total patients from 1996 to April 2007 who underwent EVAR at the Mt. Sinai Hospital were included in the study. Preoperative data regarding the size of the AAA, hypogastric coil embolization and inferior mesenteric artery (IMA) patency were evaluated using CT scans and aorto- grams. Patients with suspicion of colonic ischemia underwent a lower endoscopy and/or surgical exploration. The diagnosis of ischemic colitis was made via lower endoscopy reports or pathological examination of specimens. RESULTS: Eleven patients total were found to have ischemic colitis (1.4%). Seven patients’ episode occurred less than 30 days from repair (early) while the other 4 occurred 30 days or later from repair (late). Three of the 4 patients with late ischemic colitis had factors other then the EVAR to explain the ischemia while this was not true for any of the 7 patients with early ischemic colitis. Microembolization was seen histologically in 2 patients with both of these patients undergoing bowel resections and ultimately expiring. The IMA was occluded in 10 of 11 patients preoperatively and the one patient it was patent had evidence of extensive microembolization. Six patients (3 early and 3 late) underwent preoperative unilateral hypogastric coil embolization and there was a signiﬁcant increase in ischemic colitis in these patients (p = 0.02). CONCLUSION: The incidence of ischemic colitis is decreased in patients undergoing EVAR versus traditional open repair. Ischemic colitis occurring early is directly related to the surgery and is often multifactorial. When microembolization is involved, the patients tend to have more extensive ischemia with a higher incidence of bowel resection and mortality. Patients with late ischemic colitis often have another co-morbidity to explain the ischemia. The incidence of ischemic colitis is increased in patients with preoperative hypogastric coil embolization, and it seems to affect patients with both early and late ischemia.

138 6303_SSAT.book Page 139 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

571 Perianal Fistula Occurring After Ileal Pouch for Non-Crohn’s Colitis: A Word of Caution Isabella Mor*, Bo Shen, Susan Shedda, Margaret O’Malley, Jeffery Hammel, Feza H. Remzi Colorectal Surgery A-30, Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: A perianal fistula occurring after proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative (UC) or indeterminate colitis (IC) may herald a change in diagnosis to Crohn’s disease (CD). However evidence for this association is limited. The aim of this study is to assess how often a perianal fistula following IPAA indicates the presence of CD. METHODS: Patients developing a perianal fistula after IPAA for UC or IC were identified from a prospective database and their medical record reviewed. Demographics, date of pouch surgery, colectomy histopathology, date of fistula diagnosis, clinical or pathological evidence of CD and follow- up were abstracted. Patients with anastomotic leak or fistula only to the abdominal wall or vagina were excluded. RESULTS: 105 patients were identified, 32 were female. 68 had an initial diagnosis of UC and 37 IC. Mean follow up was 118 ± 70 months. 43 (41%) patients with perianal fistulas were subsequently diagnosed with CD. This diagnosis was based on complex perianal disease in 18 patients, characteristic inflammation of the pouch and/or anal canal in 16, small bowel disease in 4, additional fistulas in 2 and Prometheus testing in 2. 11/43 (25%) had histological evidence of CD in the pouch, perianal area or small bowel. The median age of these patients was 28 ± 8 years compared with 34 ± 12 in those ABSTRACTS without CD (p = 0.007). Of those with an initial diagnosis of UC, 38% (26/68) TUESDAY were subsequently diagnosed with CD compared with 51% (19/37) who had an initial diagnosis of IC (p = 0.2). Smoking was not a significant risk factor for change of diagnosis with 4/12 smokers (33%) diagnosed with CD compared with 8/12 (66%) who were not (p = 0.51) Management of the fistula is presented in Table 1. Four patients with CD were treated with infliximab and 3 of these 4 were able to retain their pouches. CONCLUSION: Perianal fistula complicating IPAA for UC or IC is associated with a change in diagnosis to CD, with all the therapeutic and prognostic implications inherent in such a change. This is especially so in younger patients and those without pouchitis. While medical management continues to improve, this complication results in a significant incidence of pouch loss.

Table 1. Management of Fistula

Outcome CD (n = 43) Non-CD (n = 62) p-value Seton 15 2 <0.001 Fistulotomy 7 23 0.02 Flap repair or Pouch advancement 1 9 0.04 Plug 1 0 0.41 Diversion 2 2 0.7 Abscess drainage alone 0 3 0.27 Pouch Excision 9 1 0.001

139 6303_SSAT.book Page 140 Tuesday, April 22, 2008 1:26 PM

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572 Resection Versus Laparoscopic Radiofrequency Thermal Ablation of Solitary Colorectal Liver Metastasis Eren Berber*, Michael Tsinberg, Conrad H. Simpfendorfer, Allan Siperstein Cleveland Clinic, Cleveland, OH PURPOSE: There is scant data in the literature regarding radiofrequency thermal ablation (RFA) versus resection of colorectal liver metastases. Non- comparative studies have suggested a survival beneﬁt of RFA for unresectable colorectal liver metastases. The aim of this study is to compare the overall survival for patients with solitary colorectal liver metastasis treated with resection versus RFA from a single institution. METHODS: Between 1996 and 2007, 153 patients underwent RFA (n = 63) and open liver resection (n = 90) of solitary liver metastasis from colorectal cancer. Patients were evaluated in a multidisciplinary fashion and allocated to a treatment type. Data was collected prospectively for the RFA patients and retrospectively for the resection patients. RESULTS: There were 97 men and 56 women with an average age of 65 years (68 for RFA and 63 for Resection, p = 0.98). Mean tumor size was 3.9 cm ± 0.4 for RFA and 3.8 cm ± 0.4 for Resection (p = 0.81). 70% of the RFA patients had an ASA score ≥3 vs 48% of the Resection patients (p = 0.007). The main indication for RFA included technically challenging tumor location (n = 23), patient comorbidities (n = 20), extrahepatic disease (n = 10), patient preference (n = 7) and suspected bilobar disease (n = 3). Overall 19 RFA patients (30%) had extrahepatic disease at the time of treatment. 81% of the RFA patients received chemotherapy preoperatively versus 68% of the Resection patients. Mean operative time was 116 ± 7 min for RFA and 198 ± 8 min for Resection. There were no peri-operative mortalities in either group. The complication rate was 3.1% (n = 2) for RFA and 33.7% (n = 30) for Resection. Mean length of hospitalization was 1.2 ± 0.1 days for RFA and 6.8 ± 0.4 days for Resection. The overall Kaplan Meier median survival from the date of surgery was 29.5 months for RFA and 64.3 months for Resection (p < 0.0001). The 3- and 5-year survival rates were 35% and 19%, respectively for RFA, and 70% and 53%, respectively for Resection. The overall median survival after diagnosis of liver metastasis was 38.8 months for RFA and 72.1 months for Resection (p = 0.0005). CONCLUSIONS: This study shows that, although patients in both groups had a solitary liver metastasis, other factors including medical comorbidities, technically challenging tumor locations and extrahepatic disease were different, prompting selection of therapy. With a simultaneous ablation program, higher risk patients have been channeled to RFA, leaving a highly selected group of patients for resection with a very favorable survival.This study shows that RFA still achieved long term survival in patients who were otherwise not candidates for resection.

140 6303_SSAT.book Page 141 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

573 Frequency of Extrapancreatic Neoplasms in Intraductal Papillary Mucinous Neoplasm of the Pancreas Compared to Pancreatic Adenocarcinoma and Referral Patients Kellie L. Mathis*, Kaye M. Reid Lombardo, Christina M. Wood, William S. Harmsen, Michael G. Sarr Surgery, Mayo Clinic, Rochester, MN AIM: To estimate the frequency of extra-pancreatic benign and malignant neoplasms in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas and compare the derived frequency to two, matched, control groups. METHODS: We identiﬁed all cases of IPMN diagnosed from 1994–2006 using 4 institutional registries. For matched groups, we used control Group 1 consisting of patients diagnosed with pancreatic adenocarcinoma during the same time period matched for sex and age at diagnosis (±2 years). Control Group 2 was a random selection of referral patients seen at our institution during the time period matched 3:1 for sex, birth date (±5 years), year of registration at our clinic (±5 years), and geographic location of primary address. We compared the proportions of patients with any extra-pancreatic benign or malignant neoplasm diagnosed before and/or coincident with the diagnosis of IPMN or pancreatic adenocarcinoma between the IPMN cases and each control group separately using the Chi-square test. We calculated the risk of new benign or malignant neoplasms diagnosed after the diagnosis of IPMN or adenocarcinoma between groups using Cox proportional hazards regression. ABSTRACTS RESULTS: The IPMN group consisted of 477 patients, pancreatic adenocarci- TUESDAY noma group 471, and general referral group 1431. The proportion of patients in the IPMN group having any extra-pancreatic neoplasm (benign or malignant) diagnosed before or coincident to the index date was 52% (95% CI 47–56%), compared with 36% (95% CI 32–41%) in Group 1 (p < 0.001), and 43% (95% CI 41–46%) in Group 2 (p = 0.002). The most common benign neoplasms in the IPMN group were adenomatous colon polyps (n = 116), Bar- rett’s neoplasia (n = 18), and carcinoid neoplasms (n = 6). The most common malignant neoplasms were non-melanoma skin (n = 36), breast (n = 24), prostate (n = 24), and colorectal cancers (n = 19). The hazard ratio of diagnosis of any neoplasm after the index date was 3.8 (95% CI 2.0–7.3, p < 0.001) for the IPMN group compared to Group 1, and 1.4 (95% CI 0.9–2.1, p = 0.09) for the IPMN group compared to the Group 2. In the IPMN group, 47 patients had a new neoplasm diagnosed after the index date. CONCLUSIONS: Patients with IPMN are at greater risk of benign or malignant extra-pancreatic neoplasms compared to both control groups. The majority of neoplasms were diagnosed prior to or coincident with the IPMN diagnosis; however, the risk of developing neoplasms after the diagnosis of IPMN remains increased. Based on the frequency of colonic polyps, screening colonoscopy should be considered in all patients with IPMN.

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2:15 PM – 3:30 PM PLENARY SESSION V 28ABC Moderators: Susan Galandiuk, Louisville, KY Thomas H. Magnuson, Baltimore, MD 678 NOTES Rectosigmoid Resection Using Transanal Endosocopic Microsurgery (TEM) with Transgastric Flexible Endoscopic Assistance: A Pilot Study in Swine Patricia Sylla*1, Field F. Willingham2, Denise W. Gee1, William R. Brugge2, David W. Rattner1 1Surgery, Massachusetts General Hospital, Boston, MA; 2Medicine, GI unit, Massachusetts General Hospital, Boston, MA BACKGROUND: Transcolonic access has been used as an alternative to transgastric and transvaginal access for NOTES. Direct access to the rectosigmoid and specialized equipment makes TEM an ideal platform for transanal colorectal resection. PURPOSE: To determine the feasibility of transanal segmental colectomy in a porcine model. METHODS: Procedures were performed in 7 swine cadavers ranging 30–40 kg. After occluding the lumen of the proximal rectum with a pursestring suture, a full thickness incision was created through the posterior rectal wall to enter the presacral space. Circumferential dissection of the rectum and mesorectum was extended cephalad to the mid-sigmoid. A ﬂexible therapeutic colonoscope inserted through a gastrotomy was used to assist with retraction and achieve more proximal colon dissection. Once mobilized, the rectosigmoid was extracted transanally, transected, and a stapled anastomosis was completed. RESULTS: Transanal rectosigmoid resection was successfully completed in all animals with an average procedure time of 157 mins (range, 120–240). The average length of resected colon was 20.3 cm (range 10–27). Both procedure time and length of specimen improved with time and experience. The anastomoses were complete in 6 of 7 animals. In one animal, a posterior anastomotic defect was noted. The peritoneal cavity was entered in all animals. On post-procedure laparotomy, no leak or adjacent organ injury was observed.

CONCLUSIONS: Transanal colorectal resection with TEM is feasible in swine and allows resection of up to 27 cm of rectosigmoid. The combination of TEM and transgastric endoscopic assistance is a promising technique for NOTES segmental colectomy. 142 6303_SSAT.book Page 143 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

679 Who Should Do NOTES: Initial Endoscopic Performance and Early Learning Curve of Laparoscopic Surgeons in Comparison to Endoscopists and Untrained Individuals Oliver J. Wagner*1, Monika E. Hagen2, Francois Pugin2, Philippe Morel2, Daniel Candinas1 1Department of Visceral and Transplantation Surgery, University Bern, Bern, Switzerland; 2Digestive Surgery, University Hospital Geneva, Geneva, Switzerland BACKGROUND: A concern in the ﬁeld of NOTES is the question if surgeons with their lack of endoscopic experience or endoscopists without intrabdominal routine should perform that type of new treatment. Still, due to well trained manual dexterity, spatial orientation and hand-eye alignment, laparoscopically experienced surgeons—even without endoscopic experience—should master very quickly the handling of endoscopic equipment. Initial performance should be superior when compared to individuals without surgical training and learning curve rapid. Endoscopically inexperienced laparoscopic surgeons may even quickly reach the endoscopic dexterity of endoscopists. METHODS AND DESIGN: 25 individuals were tested for endoscopic dexterity. Group1 included 5 endoscopists. Group 2 included 10 laparoscopic surgeons without endoscopic experience. Group 3 contained 10 medical students without endoscopic and surgical experience. Each individual performed 10 times an easy, a medium and a difﬁcult task with endoscopic equipment on a NOTES skills-box. Time and errors were meassured, an overall score allocated and evaluated statistically.

RESULTS: Group 3 performed all 3 of their allocated tasks significantly ABSTRACTS worse when compared to group 1 and 2 (p < 0.05). No differences were TUESDAY detected between the performances of group 1 and 2 for the easy and the medium task (p > 0.05). Group 1 performed the difficult tasks significantly better than group 2 (p < 0.05). Group 2 demonstrated a very rapid learning curve between the first and tenth performance with a significantly better result for the tenth time of performance when compared to the first (p < 0.05). CONCLUSION: The data support the conclusion that endoscopically inexperienced laparoscopic surgeons learn very quickly the handling of endoscopic equipment. Their initial performance is superior when compared to individuals without any surgical training. Furthermore, intitial performance is similar when compared to trained endoscopists for easy and tasks of moderate difficulty. However, endoscopists are still superior in handling endoscopic material for complex tasks when compared to endoscopically untrained surgeons. The data therefore suggest that laparoscopic surgeons are not severely disad- vantaged by their lack of endoscopic experience and—due to their surgical experience—should perform NOTES.

143 6303_SSAT.book Page 144 Tuesday, April 22, 2008 1:26 PM

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680 To Prepare or Not the Colon for Elective Surgery with Primary Intraperitoneal Anastomosis. There Is No Question María Jesús Peña-Soria, Julio M. Mayol*, Rocio Anula, Ana M. Arbeo-Escolar, Jesus A. Fernandez-Represa Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain INTRODUCTION: The definitive analysis of a prospective single-blinded randomized trial to investigate whether preoperative mechanical bowel preparation decreases the incidence of surgical site infection and anastomotic failure after elective colorectal surgery by a single surgeon is presented. PATIENTS AND METHODS: All patients scheduled to undergo an elective colorectal procedure with a primary anastomosis by the same surgeon from October 2001 until January 2007 were enrolled and randomized to receive either oral polyethylene glycol (PEG) lavage solution (Group A) or no mechanical bowel preparation whatsoever (MBP) (Group B). Dietary restrictions were limited to 12 hours prior to surgery. A standard intravenous antibiotic prophylaxis scheme was used. Exclusion criteria included immunosupression, preoperative chemoradiotherapy, diverting stoma and perforated and/or obstructing tumor. Patients were followed by an independent observer for wound infection, intrabdominal sepsis and anastomotic failure within 30 days after surgery. Student’s T and Chi square tests were used for statistical analysis. Statistical significance was defined as p < 0.05. The number of patients needed to treat (NNT) was calculated as the inverse of the absolute risk reduction. The study was approved by Hospital Clinico San Carlos ethics committee. RESULTS: One hundred and forty five patients were enrolled. Three patients (2.06%) were preoperatively excluded because of active immunosupression. One hundred and forty two patients were randomized but 13 of them (8.9%) were excluded from analysis (diverting stoma in 10 cases, contained perforation in 1 patient and unresectable tumor in 2 patients). Of the remaining 129 patients, 64 were assigned to Group A and 65 to Group B. The mean age was 67.39 ± 15.9 years in Group A and 67.2 ± 12.6 years in Group B (NS). There was no difference in sex distribution between groups. Overall, 27 patients (20.9%) developed postoperative wound infection, 16 (24.6%) patients in Group A vs. 11 (17.2%) in Group B (NS). There were 3 cases of intrabdominal sepsis and all of them occurred in Group A (6.3%). The SSI rate was 29.7% (19/64) for Group A vs. 17.2% (11/65) for group B (NS). The overall rate of anastomotic failure was 5.4% (n = 7), 4 patients in Group A (6.2%) vs. 3 patients in Group B (4.6%) (NS). The overall complication rate (SSI+ anastomotic failure) in Group A was 35.9% vs., 21.5% in Group B (NS). The NNT was 7. CONCLUSION: the NNT in our definitive analysis suggests that better outcomes in terms of SSI and anastomotic failure rates would be achieved by a single surgeon if preoperative MBP with PEG is routinely omitted.

144 6303_SSAT.book Page 145 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

681 Routine Liver Biopsy to Detect Non-Alcoholic Fatty Liver Disease (NAFLD) During Laparoscopic Cholecystectomy for Symptomatic Gallstone Disease (GD)—Is It Justiﬁed? Antonio Ramos-De La Medina*1, Federico B. Roesch2, Alfonso Perez Morales3, Silvia Cid-Juarez2, Jose M. Remes-Troche2 1Gastroenterology and Gastrointestinal Surgery Department, Veracruz Regional Hospital, Boca del Rio, Mexico; 2Digestive Physiology and Motility Laboratory, Medical-Biological Research Institute University of Veracruz, Veracruz, Mexico; 3University of Veracruz Medical School, Veracruz, Mexico BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and its inﬂam- matory and progressive subtype non-alcoholic steatohepatitis (NASH) have emerged as a major health burden. NAFLD and Gallstone disease (GD) share common pathophysiologic and risk factors. Currently there are no recommendations regarding screening of NAFLD in patients at increased risk. More- over, non invasive methods to diagnose NAFLD are unreliable and liver biopsy is the only method for assessing the presence and extension of this condition. Firm recommendations of when to perform a liver biopsy in the routine clinical evaluations have not been developed. In this study our aim was to assess the prevalence of and factors associated with NAFLD in a cohort of patients operated for symptomatic GD and to evaluate the usefulness of routine liver biopsy as a screening method. METHODS: We prospectively evaluated 95 consecutive patients referred for cholecystectomy due to symptomatic GD between January 1st 2005 and June

th ABSTRACTS 30 2006. All patients had a liver biopsy performed at the end of a standard TUESDAY laparoscopic cholecystectomy. Demographics, anthropometric measurements, family history, risk factors, laboratory tests and abdominal ultrasound were registered and analyzed. Patients with a positive serology for hepatitis B or C virus, those with a history of alcohol ingestion greater than 150 gr/day, autoimmune hepatitis or other liver disease where excluded. RESULTS: Twenty-nine patients (30.5%) were male and 66 (69.4%) were female. Mean age was 52.15 ± 16.82 years (range 2–84 years) Forty-three patients (45%) had normal biopsies (Group A) while 52 patients (55%) had histological findings compatible with NAFLD (Group B). The patients in the later group where further classified according to the system proposed by Brunt as follows: stage I 51.93%, stage II 28.84%, stage III 19.23% and cirrhosis 3.15%. Patients in group B were older, had a higher body mass index, higher prevalence of diabetes, higher glicosilated hemoglobin levels, serum cholesterol and serum triglycerides than those in group A although they were not statistically significant. There were no complications secondary to the liver biopsies. DISCUSSION: In our series, our findings show that more than 50% of patients with GD have associated NAFLD. Awareness of this association may result in an earlier diagnosis of NAFLD in patients with GD. Moreover, the fact that NAFLD is highly prevalent in patients with GD may justify routine liver biopsy in all patients undergoing laparoscopic cholecistectomy. Laparo- scopic liver biopsy is a safe and effective method to establish the diagnosis and stage of NAFLD in patients with GD.

145 6303_SSAT.book Page 146 Tuesday, April 22, 2008 1:26 PM

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682 Reinterventions for Specific Technique-Related Complications of Stapled Haemorrhoidopexy (SH): A Critical Appraisal Pierpaolo Sileri*, Vito M. Stolfi, Antonio Chiaravalloti, Achille Lucio Gaspari Surgery, University of Rome Tor Vergata, Rome, Italy INTRODUCTION: Stapled haemorrhoidopexy (SH) is an attractive alternative to conventional haemorrhoidectomy (CH) because of reduced pain and earlier return to normal activities. However complications rates are as high as 31%. Although some complications are similar to CH, most are specifically technique-related. In this prospective audit we report our experience with the management of some of these complications. METHODS: Data on patients undergoing haemorrhoidectomy at our unit or referred to us are prospectively entered in a database. The onset/duration of specific SH-related complications as well as reinterventions for failed/complicated SH were recorded. RESULTS: From 1/03 to 10/07, 110 patients underwent SH, while 17 patients were referred after complicated/failed SH. Among SH performed in our group, we observed 21 specific complications in 17 patients (15.5%): urgency (12), tenesmus (5), severe persistent anal pain (2), haemorrhoidal thrombosis (2). Urgency resolved within 4 months in all patients but one in which lasted 8 months.Three patients (2.7%) had tenesmus up to 3 months. One patient with anal pain underwent exploration under anaesthesia (EUA) and retained stapled removal with complete symptoms resolution. The haemorrhoidal thrombosis occurred 4 and 12 days after SH and were treated medically. Six patients developed haemorrhoidal recurrence after 16 ± 5 months after SH (range 9–26 months). Four symptomatic patients underwent further CH. Two patients (1,8%) developed symptomatic anorectal stenosis with urgency and frequency and responded to anal dilatation with dilators. Overall reinterventions rate for this group was 5.5%. Among the referred SH-group, 1 patient underwent Hartmann’s procedure because of rectal perforation. The remaining 16 patients experienced at least one of the following: recurrence (6), urgency (6), severe anal pain (4), tenesmus (4), colicky abdominal pain (1), anal fissure (1) and stenosis (1). Recurrences where observed after 16 ± 6 months from surgery (range 9–36 months). Four patients underwent CH with regular postoperative recovery. Two patients underwent EUA because of persisting pain after SH (7 ± 6 months). Anorectal manometry and ultrasound were performed in both and pelvic MRI in one. In one patients the US showed a small submucosal abscess at the stapled line. The abscess was not seen at the MRI and it was not found at EUA. In both patients, surgical removal of retained staples resolved the pain. One patient underwent anoplasty. CONCLUSIONS: SH presents unusual and challenging complications. Abuses should be minimized and longer-term studies are needed to further clarify its role.

146 6303_SSAT.book Page 147 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

3:30 PM – 4:30 PM QUICK SHOTS II 28ABC Moderators: Robert E. Glasgow, Salt Lake City, UT Taylor S. Riall, Galveston, TX 772 Two-Hundred Consecutive Laparoscopic Liver Resections Andrew A. Gumbs*1,2, Brice Gayet2 1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France INTRODUCTION: Since the first report of a laparoscopic liver resection in 1992, laparoscopic resection of peripheral hepatic segments has become increasingly more common in the surgical treatment of both benign and malignant tumors. The minimally invasive approach to resections of the entire liver, however, is still only being performed in highly specialized centers do to lingering concerns about feasibility and efficacy. METHODS: Patients who underwent minimally invasive techniques were compared to results in the literature of patients treated at other European referral centers who were approached with open techniques. Our data was collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan-Meier curves of patients with hepatocellular carcinoma (HCC) and non-neuroendocrine metastatic disease were calculated to ascertain disease free and overall survival.

RESULTS: Over a 12-year period from January 1995 until June 2007, a total ABSTRACTS of 357 liver procedures were performed. Of these a total of 200 laparoscopic TUESDAY liver resections were performed. The average OR time, estimated blood loss and length of stay was 192 minutes (±106), 324 mL (±365) and 10 days (±9). Conversions occurred in 13 patients (7%). Complications occurred after laparoscopic resection for primary liver cancer in 23% and in 24.2% after resections of non-neuroendocrine hepatic metastases compared to 31% and 25% as reported in the open European literature, respectively. Overall 5-year survival in patients with primary liver cancer is 66% and 55% in patients with non-neuroendocrine secondary hepatic tumors in the laparoscopic group compared to 36% and 32%, respectively, in the open group. Thirty day mortality occurred in 1% in the laparoscopic group compared to 2% in the open group. CONCLUSIONS: Minimally invasive techniques for hepatic resections of the entire liver are feasible and safe, and high volume centers that specialize in these procedures can have results similar to historical open series. Five year overall survival may be superior when minimally invasive techniques are used, however, larger randomized-controlled trials are necessary to ascertain this.

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773 Long-Term Quality of Life Is Similar After Hepatic Resection for Malignant and Benign Diseases Vanessa Banz*, Regula Fankhauser, Peter Studer, Beat Gloor, Daniel Inderbitzin, Daniel Candinas University Hospital Bern, Bern, Switzerland BACKGROUND: Morbidity and mortality are continuously decreasing after major hepatic surgery due to more advanced operative methods and perioperative care. The extent and indications of liver resections (LR) are being pushed to the limits. As survival increases post-hepatectomy, quality of life (QOL) becomes a leading issue. Up until now, no studies address potential differences in long-term QOL in patients necessitating LR for benign or malignant conditions. Our aim was to see how postoperative diagnosis affected long-term self estimated QOL and health. METHODS: Patients eligible for QOL analysis were selected from our prospectively collected database. Long-term QOL was evaluated based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30, Version 3.0) questionnaire and the liver-specific QLQ-LMC21 module with 51 questions addressing 5 functional and 3 symptom scales. EORTC scores and clinical variables such as malignant versus benign diseases, age or extent of LR were analyzed to identify factors influencing overall QOL. Statistical analysis included the Wilcoxon rank-sum test and a cumulative logistic regression model. RESULTS: Between 2002–2006, 249 patients had hepatic surgery in our institution. Interventions were carried out in 76% for malignant and 24% for benign conditions and ranged from segmental resections to extended hemi- hepatectomies. 134 patients were contacted for further QOL analysis after a mean of 26.5 months (±16.2). There was no statistical difference in the global QOL and health scores between patients with malignant and benign diseases (p = 0.367) with an estimated odds ratio of 0.745 (95% CI 0.396–1.399). Note that the 95% confidence interval covers the value 1. Neither the extent of the resection (>2 segments versus <2 segments) (p = 0.975, OR 0.988, 95% CI 0.461–2.119) nor age significantly influenced over QOL and health and (p = 0.092). CONCLUSIONS: Contrary to general expectations, overall long-term QOL is surprisingly high in patients requiring LR for malignant diseases. Although patients with malignant conditions tended to fare worse within certain subgroup analyses, it is reasonable to conclude that patients with malignant and benign diseases have a similar QOL, although no p-value can be associated with this statement.A worse clinical prognosis does not correlate with a low QOL as judged in the eyes of the patient. For selected patients, “palliative liver resections” may be warranted. However, we are currently monitoring extended hepatic surgery and its associated QOL in a prospective trial with preoperative, short and long-term QOL assessment.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

774 Does Staging Laparoscopy Detect a Higher Rate of Occult Metastases in Patients with Resectable Pancreatic Adenocarcinoma? Carlo M. Contreras*, Robert J. Rettammel, David M. Mahvi, Layton F. Rikkers, Clifford S. Cho, Sharon M. Weber General Surgery, University of Wisconsin, Madison, WI BACKGROUND: Preoperative computed tomography understages pancreatic adenocarcinoma, with occult metastatic disease identified in up to 25% of patients at the time of operation. Because the role of staging laparoscopy continues to be debated, we sought to compare the incidence of occult unresectable disease for patients with radiographically resectable pancreatic adenocarcinoma explored with laparotomy versus laparoscopy, all of whom were evaluated with contemporary imaging over a recent time span. METHODS: Patients with radiographically resectable pancreatic adenocarcinoma were identified from a prospective hepatobiliary database and divided into two groups: those explored initially with laparoscopy versus laparotomy. Preoperatively, all patients were determined to be resectable based on imaging review at a multidisciplinary tumor conference with evaluation by specialists in surgical and medical oncology, gastroenterology, and radiology. Endpoints of resectability, survival, cost, and hospital stay were evaluated. RESULTS: Between April 2002 and November 2006, 78 patients with pancreatic adenocarcinoma underwent exploration. Twenty-five underwent initial laparoscopic exploration, and 53 underwent immediate laparotomy. There

was no difference in the type or number of preoperative imaging tests. Occult ABSTRACTS metastases were identified in 7/25 (28%) patients undergoing laparoscopy. In TUESDAY addition, 3/25 laparoscopy patients had unresectable disease identified at subsequent laparotomy. Thus, 40% (10/25) of the laparoscopy group had unresectable tumors. In the laparotomy group, only 6/53 (11%) patients were found to have intraoperative evidence of unresectable disease (p = 0.003 vs. laparoscopy). Occult peritoneal disease was identified more frequently in laparoscopy patients (32% vs. 11%, p = 0.03). Median survival for resected patients was 16 months versus 4 months for patients with unresectable tumors (p < 0.0001). Survival for resected patients was not significantly different between the laparoscopy and laparotomy groups. In patients with unresectable disease, there were no differences in length of stay, direct hospital costs, or interval to initiating postoperative chemotherapy between laparoscopy and laparotomy groups. CONCLUSIONS: In patients with apparently resectable pancreatic adenocarcinoma, occult metastatic disease is identified more frequently at the time of staging laparoscopy than at laparotomy. For the first time, this study demonstrates that improved visualization of the abdominal cavity with pneumoperitoneum results in an enhanced ability to detect peritoneal disease in patients evaluated with contemporary imaging.

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775 Excellent Results from Limited Resection of Duodenal Carcinoid Tumors Kenzo Hirose*, Brown Nancy, Kristina Potanos, Bipan Chand, R. Matthew Walsh General Surgery, Cleveland Clinic, Cleveland, OH AIM: To describe a single center’s experience with treatment of duodenal and periampullary carcinoid tumors. METHODS: This is a descriptive, retrospective review of 40 patients treated for duodenal and periampullary carcinoid. Clinical ﬁndings, operative treatment, pathologic staging, and recurrence rates were assessed. RESULTS: 40 patients underwent 45 interventions for duodenal or periampullary carcinoid tumors between 1990 and 2007. Mean follow-up was 44 months. Results are summarized in Table 1. Interventions included endoscopic resection (either forceps biopsy or endoscopic mucosal resection), transduodenal local excision (either laparoscopic or open), segmental duodenal resection (with or without antrectomy), pancreaticoduodenectomy, and double bypass for unresectable disease. Recurrence was most common in the endoscopic resection patients (n = 5), all treated successfully with either repeat endoscopic or surgical therapy. Two patients in the other groups experienced recurrent disease, both metastatic disease to the liver. 5 patients died; two died due to metastatic carcinoid tumor; the other three died of causes unrelated to carcinoid. Neither recurrence nor survival correlated with size of the original lesion or presence of positive lymph nodes. CONCLUSION: Excellent recurrence free and overall survival is enjoyed by patients with duodenal and periampullary carcinoid tumors. Selection of the appropriate resection strategy is largely based on location and technical considerations. More extensive resection is associated with higher detection of positive lymph nodes, but does not conclusively provide oncologic beneﬁt.

Therapy n Duodenal Peri-Ampullary Mean Size Node Positive Recurr. Death Endoscopic resection 18 17 1 1.1 cm 0 5 2 Transduod. local excision 15 12 3 0.9 cm 2 1 0 Segmental resection 5 5 0 4.0 cm 1 0 1 Whipple 6 0 6 1.5 cm3 1 1 Palliative procedure 1 1 0 4.0 cm 1 0 1 TOTAL 45 35 10 1.5 cm7 7 5

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

776 Five-Year Outcome of a Randomized Trial Comparing Pylorus- and Duodenum-Preserving Pancreatic Head Resection for Chronic Pancreatitis Ulrich Adam*, Frank Makowiec, Eva Fischer, Tobias Keck, Hartwig Riediger, Ulrich T. Hopt Department of Surgery, University of Freiburg, Freiburg, Germany INTRODUCTION: The “ideal” technique of pancreatic head resection (PHR) for chronic pancreatitis (CP) is still discussed controversially. Although few trials have shown advantages for duodenum-preserving (DPPHR) techniques many centres continue to perform pancreaticoduodenectomies either as Whipple or pylorus-preserving (PPPD) procedures. After presentation of our initial results to the Society in 2004 we have performed further follow-up evaluations and can now report the ﬁve-year outcomes after randomization of patients to either DPPHR or PPPD. Our initial evaluations (perioperative course and three-year outcome) showed comparable results between the groups including quality of life. METHODS: We re-evaluated the outcome in 85 patients who were randomly assigned to DPPHR (n = 42) or PPPD (n = 43) between 1997 and 2001. After randomization for DPPHR the surgeon could decide, depending upon the morphology of CP, to perform either a FREY- (n = 22) or a BEGER-procedure (n = 20). Follow-up evaluations were performed by standardized questionnaires, supplemented by phone contacts with the home physicians. Median postoperative follow-up was now 61 months.

RESULTS: Preoperatively, demographic and CP-related data showed no dif- ABSTRACTS ference between the groups. After a median of 61 months following surgery TUESDAY 63% (PPPD) and 57% (DPPHR) of the patients were completely free of pain, respectively (n.s.). Among the patients still suffering from pain (PPPD vs. DPPHR) 2%/4% had pain every day, 7%/7% had pain at least once per week, 7%/14% at least once per month and 20%/17% complained of pain less frequently (no difference between the groups). The pain scores as well showed no differences. Diabetes was documented in 44% (PPPD) and 45% (DPPHR), respectively, postoperative de novo-diabetes in 19% (PPPD) and 26% (DPPHR; n.s.). The frequencies of exocrine insufficiency (61% vs. 76%, p = 0.12) and postoperative de-novo exocrine insufficiency (21% vs. 26%; p = 0.57) were also comparable. Median gain in body weight was three kg after PPPD and two kg after DPPHR; n.s.). Further subgroup comparisons in the patients undergoing DPPHR (FREY vs. BEGER) did not reveal any differences in outcome. Up to now 15 of the 85 patients died a median of 3.5 years after surgery, in most cases as a consequence of alcohol and/or tobacco use. Actuarial survival was 82% after five and 70% after ten years, without differences between the two randomized groups. CONCLUSIONS: The late results of our randomized study demonstrate a comparable outcome after PPPD or DPPHR even five years after surgery. The type of PHR for CP might, therefore, be adapted to the morphology of CP and its local complications.

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777 Tailored Transoral Incisionless Fundoplication (TIF) in the Treatment of GERD: The Anatomic and Physiologic Basis for Reconstruction of the Esophagogastric Junction Using a Novel Approach Blair A. Jobe1, Ger H. Koek2, Stefan J. Kraemer3, Barry P. Mcmahon4, Bart Witteman2, Flemming H. Gravesen5, Cedric S. Lorenzo*1, Robert W. O’Rourke1, Douglas A. Shumaker6, Michael M. Owens6, John G. Hunter1, Nicole Bouvy2 1Surgery, Oregon Health & Science University, Portland, OR; 2Surgery, Maastricht University Hospital, Maastricht, Netherlands; 3Endogastric Solutions, Inc., Redmond, WA; 4Medical Physics & Clinical Engineering, Adelaide & Meath Hospital and Trinity College, Dublin, Ireland; 5Visceral Biomechanics and Pain, Aalborg Hospital, Hobrovej, Denmark; 6West Hills Gastroenterology, Portland, OR OBJECTIVE: To determine the anatomic and physiologic basis and short- term efﬁcacy of Transoral Incisionless Fundoplication (TIF) in GERD patients. METHODS: Nine patients with PPI-dependent GERD underwent TIF using the EsophyX™ device. TIF was performed endoscopically by enveloping the distal esophagus for 3 cm within the proximal stomach and securing this with transmural polypropylene fasteners. Pre- and post-TIF testing with pH, manometry, LES vector volume analysis, impedance planimetry, and upper endoscopy was performed. Mean time to follow-up was 3 months. RESULTS: Mean operative time was 60 minutes (range, 40–90). One patient developed pneumoperitoneum requiring needle aspiration. 8/9 patients were discharged within 24-hours post-TIF. All patients had complete symptomatic resolution of GERD and were off PPI at follow-up. LES cross-sectional area decreased in all patients post-TIF on impedance planimetry. CONCLUSIONS: TIF results in the elimination of symptoms and normalization of distal esophageal pH exposure in patients with GERD. Evaluation of the post-procedure EGJ indicates restoration to normal anatomy and physiology.

Endpoint Pre-TIF Post-TIF p-value Resting LES Pressure (mmHg) 10.57 25.15 0.124 LES Total/Abdominal Length (cm) 2.8/1.5 3.6/2.6 0.075/0.13 LES Vector Volume (mmHg2 × mm) 354 2904 0.015 Mean Hill Classification, Range II (I–IV) I (all I) 0.005 Nipple Valve (%) 0 89 0.02 Hiatal Hernia (% and mean size) 89/2 (1–3) 0/0 0.004 Esophagitis (%) 57 0 0.025 % time pH < 4 in 24 hours 8.5% (1.2–26.6) 0.7% (0–1.6) 0.019

152 6303_SSAT.book Page 153 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

779 Signal Detection: A New Statistical Method to Predict NASH in Gastric Bypass Patients John M. Morton*, Gavitt A. Woodard, Tina Hernandez-Boussard Surgery, Stanford School of Medicine, Stanford, CA BACKGROUND: Non-alcoholic steatohepatitis (NASH) is associated with morbid obesity, cardiac risk factor abnormalities, and metabolic syndrome. Currently, there are no adequate pre-operative predictive models for NASH identification. We present a new statistical method to address this need. METHODS: Signal detection affords the ability to identify patients at risk with both homogeneous outcomes and risk predictors and has been used in cardiac risk assessment. Potential risk factors for NASH were entered into the Signal Detection model by Kraemer et al. All patients underwent laparoscopic gastric bypass surgery with intra-operative liver biopsy at a single academic institution by a single surgeon. Preoperatively, liver function tests, cardiac risk factors, and comorbidities were assessed. We dichotomized liver pathology into NASH vs Steatosis (SS) per Brunt criteria for analysis by T-test or Chi- Square analysis as appropriate. RESULTS: 141 patients successfully underwent laparoscopic Roux-en-Y gastric bypass surgery. Patient demographics were mean age, 45; female, 88%; mean BMI, 49; diabetic, 38%; hypertensive, 62%; and hepatitis or alcohol abuse, 0%. Liver biopsy results were Normal (2%), Steatosis (60%) and NASH (38%). The model identified the following variables in order as most discrimi- nating in identifying patients with NASH: ALT >31, excess weight >109 kg, Lipoprotein A >21 and Hemoglobin A1C >6.9. This model identified this sub- ABSTRACTS group as having an 81% chance of having a pathologic NASH diagnosis. TUESDAY CONCLUSION: In this study, ALT, excess weight and hemoglobin A1C were correlated with NASH. This innovative new statistical technique affords a new ability to successfully identify gastric bypass patients with biopsy proven NASH.

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780 Visceral Sensitivity Is Increased During the Initial Development of Postoperative Ileus in Mice Mario H. Mueller*1, Mia Karpitschka3, Andrej Sibaev3, Jörg Glatzle2, Bing Xue1, Michael S. Kasparek1, Martin E. Kreis1 1Department of Surgery, Ludwig-Maximilians University, Munich, Germany; 2Department of Surgery, Eberhard-Karls University, Tuebingen, Germany; 3Institute of Surgical Research, Ludwig-Maximilians University, Munich, Germany INTRODUCTION: Neurogenic, inflammatory and pharmacological alterations during surgery contribute to the pathophysiology of postoperative ileus (POI). We hypothesized that during the initial hours after surgery, afferent nerve fibers supplying the intestine are sensitized for the pain mediator bradykinin and mechanical stimuli which may contribute to efferent reflex inhibition of intestinal motility. We, therefore, aimed to explore intestinal afferent nerve sensitivity and motility during the early development of POI in mice. METHODS: Under enflurane anesthesia, C57BL/6 mice underwent laparotomy followed by sham treatment or standardized small bowel manipulation to induce ileus. Then, after 1 h, 3 h or 9 h, extracellular multi-unit mesenteric afferent nerve recordings were established in vitro from 2 cm segments of jejunum (each subgroup n = 6) continuously superfused with Krebs buffer (32˚C, gassed with an O2/CO2 mixture). The segment was cannulated from both ends to monitor luminal pressure and intestinal motility simultaneously. Afferent discharge to luminal distension (0–80 cm H2O) and bradykinin (1 µM) was recorded. Peak discharge frequency and intestinal motor events were analyzed by two-way ANOVA. RESULTS: The mean amplitude of intestinal contractions was 0.8 ± 0.2 cm H2O 1 h after induction of POI and 5 ± 0.8 cm H2O in segments taken after 1 h from sham controls (p < 0.05). A similar difference was observed for segments harvested at the 3 h and 9 h time point (both p < 0.05). Serosal bradykinin was followed by an increase in afferent discharge to 61 ± 6 impsec-1 after 1 h, 217 ± 25 impsec-1 after 3 h and 217 ± 6 impsec-1 after 9h in ileus segments increased compared to 46 ± 3 impsec-1 after 1 h, 57 ± 10 impsec-1 after 3 h and 140 ± 13 impsec-1 after 9 h in sham controls (*P < 0.05). The afferent response during ileus was augmented at high threshold luminal distension at 80 cm H2O (912 ± 79 impsec-1 after 1 h, 933 ± 30 impsec-1 after 3 h and 1131 ± 63 impsec-1 after 9 h) when compared to sham controls (639 ± 39 impsec-1 after 1 h, 714 ± 40 impsec-1 after 3 h and 1,165 ± 30 impsec-1 after 9 h), (P < 0.05). CONCLUSIONS: Afferent discharge to bradykinin and high pressure luminal distension is augmented in the early stage of postoperative ileus. As high- threshold mechanosensitivity and the algesic mediator bradykinin activate predominantly spinal afferents, spinal sensitization seems to occur at the initial stage of postoperative ileus which may trigger a reflex inhibition of intestinal motility perpetuating postoperative ileus.

154 6303_SSAT.book Page 155 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

781 Tissue and Serum Levels of Substance P Correlate in Patients with Chronic Pancreatitis Giuseppe Mascetta1, Fabio Francesco Di Mola1, Federico Selvaggi1,2, Massimo Falconi4, Claudio Bassi4, Nathalia Giese2, Markus W. Buechler2, Helmut M. Friess3, Pierluigi Di Sebastiano*1 1Department of Surgery, IRCCS Casa Sollievo Sofferenza, San Giovanni Rotondo, Italy; 2Department of General Surgery, University of Heidelberg, Heidelberg, Germany; 3Department of Surgery, Technical University of Munich, Munich, Germany; 4Department of Surgery, University of Verona, Verona, Italy INTRODUCTION: The pathophysiology of pain in chronic pancreatitis (CP) is still unclear. Recent data suggest a role for neuropeptides such as substance P (SP) and the neuroimmune interaction in the inﬂammatory process of the pancreas. SP degradation is mediated by the endogenous extracellular metal- loenzyme called neutral endopeptidase (NEP). Actually, no data are available regarding the relationship between tissue and serum levels of SP in CP. In this study we aimed to investigate a possible correlation between SP mRNA expression in pancreatic tissue and serum levels of SP in patients undergoing surgical resection for CP and to test the hypothesis that neuroimmune inﬂammation is a pathogenetic factor in CP. MATERIALS AND METHODS: SP and NEP mRNA levels were analyzed by quantitative RT-PCR in pancreatic tissue specimens from 30 patients undergoing pancreatic resection for CP and 8 healthy organ donors. In addition, SP serum levels were determined before and after surgery and in 8 healthy indi-

viduals (control group) using an ELISA test. ABSTRACTS TUESDAY RESULTS: Quantitative RT-PCR demonstrated increased SP mRNA expression in CP tissues (P < 0.05) compared to controls, while NEP mRNA expression showed no significant changes between CP and healthy controls. The SP preoperative serum levels correlated with SP tissue levels in CP patients. After pancreatic resection, the majority of CP patients exhibited a significantly reduced expression of SP serum levels compared with preoperative levels. CONCLUSIONS: The present data show that expression of SP is increased during chronic inflammation whereas NEP tissue levels are unaltered. In the SP pathway, it would appear that NEP is unable to sufficiently degrade the increased amount of SP, which may in part explain the perpetuation of pancreatic inflammation. Removal of pancreatic inflamed tissue, the “pace- maker” of neuroimmune inflammation, resulted in the reduction of the circulating level of SP, supporting the hypothesis of neuroimmune crosstalk in CP. Furthermore the correlation between serum and tissue levels of SP suggest that this neuropeptide might also represent a reliable marker of neurogenic inflammation in CP.

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Wednesday, May 23, 2008

8:30 AM – 10:00 AM TRANSLATIONAL SCIENCE 25ABC PLENARY (PLENARY SESSION VI) Moderators: Deborah A. Nagle, Boston, MA Edward E Whang, Boston, MA 948 The Role of ERCC1 RNA Expression in Blood as a Non-Invasive Predictor of Response to Neadjuvant Radio-Chemotherapy in Patients with Locally Advanced Cancer of the Esophagus Jan Brabender*1, Daniel Vallböhmer1, Frederike C. Ling1, Andreas C. Hoffmann1, Georg Lurje1, Elfriede Bollschweiler1, Arnulf H. Hölscher1, Paul M. Schneider2, Ralf Metzger1 1Department of Surgery, University of Cologne, Cologne, Germany; 2Department of Surgery, University of zuerich, Zuerich, Switzerland BACKGROUND: Only patients with locally advanced cancer of the esophagus with a major response to neadjuvant radio-chemotherapy do benefit from this treatment. Unfortunately, no non-invasive molecular marker exists that can reliably predict response to neadjuvant therapy in this disease. To improve the treatment of patients with cancer of the esophagus, molecular predictors of response are desperately needed. Aim of this study was to determine the value of ERCC1 RNA-Expression in peripheral blood of patients with cancer of the esophagus as a non-invasive molecular predictor of response to neoadjuvant therapy. MATERIAL AND METHODS: A total of 29 patients with locally advanced cancer of the esophagus were included in this study. Blood samples were drawn from each patient prior to neoadjuvant therapy (cis-Platin, 5-FU, 36Gy). Transthoracic en-bloc esophagectomy was performed in all patients following completion of neadjuvant therapy. After extraction of cellular tumor-RNA from blood samples, quantitative expression analysis of ERCC1 and the internal reference gene beta-Actin was done by real-time RT-PCR. His- tomorphological regression was defined as major response when resected specimen contained <10% of residual vital tumor cells, and minor response with >10% of vital residual tumor cells. RESULTS: Nineteen of 29 (65.5%) patients showed a minor histopathological response and 10 (34.5%) showed a major-response to neadjuvant therapy. ERCC1 RNA expression in blood of patients was detectable for ERCC1 in 82.8% and 100% for beta-Actin. The median ERCC1 expression was 0.62 (min.: 0.00, max.: 2.48) in minor-responders and 0.24 (min.: 0.00, max.: 0.45) in major-responders (p = 0.004). No significant associations were detected between ERCC1 expression levels and patients clinical variables (histology, tumor stage, gender etc.). Relative ERCC1 expression levels above 0.452 were not associated with major histopathological response (sensitivity: 68.4; specificity: 100%) and 13 of 19 patients with minor response to the delivered neadjuvant therapy could be unequivocally identified.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

CONCLUSION: The applied method is technically feasable for the analysis of cellular ERCC1 RNA expression in blood of patients with cancer of the esophagus. Minor-responders to the applied therapy show a signiﬁcant higher ERCC1 expression level in their blood compared to major-resonders prior to therapy. ERCC1 expression levels in blood appear to be highly speciﬁc to predict minor-response to neoadjuvant radiochemotherapy in patients with esophageal cancer and could be applied to prevent expensive, noneffective, and potentially harmful therapies in a substantial number (45%) of patients. WEDNESDAY ABSTRACTS

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949 Strong Prognostic Value of Nodal Microinvolvement in Patients with Carcinoma of the Papilla of Vater Receiving No Adjuvant Chemotherapy Dean Bogoevski*, Paulus G. Schurr, Jussuf T. Kaifi, Guell Cataldegirmen, Oliver Mann, Yogesh K. Vashist, Emre F. Yekebas, Jakob R. Izbicki General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: To assess the prognostic significance of nodal microinvolvement in patients with carcinoma of the Papilla of Vater. METHODS: From 1993 to 2003 at the University Clinic Hamburg, 777 patients were operated upon pancreatic and periampullary carcinomas. The vast majority of patients were operated upon pancreatic ductal adenocarcinoma (n = 566, 73%), followed by carcinoma of the papilla of Vater (n = 112, 14%), neuroendocrine carcinoma (n = 39, 5%), IPMN (n = 33, 4%) and distal bile duct carcinoma (n = 27, 3%). Fresh-frozen tissue sections from 169 LN’s classified as tumor free by routine histopathology from 57 patients with R0 resected carcinoma of the papilla of Vater who had been spared from adjuvant chemotherapy were immunohistochemically (IHC) examined, using a sensitive IHC assay with the anti-epithelial monoclonal antibody Ber-EP4 for tumor cell detection. With regard to histopathology, 39 (63%) of the patients were staged as pT1/pT2, 21 (37%) as pT3/pT4, 30 (53%) as pN0, while 38 (67%) as G1/G2. RESULTS: Of the 169 “tumor free” LN’s, 91 LN’S (53.8%) contained Ber-EP4- positive tumor cells. These 91 LN’s were from 40 (70%) patients. The mean overall survival in patients without nodal microinvolvement of 35.8 months (median-not yet reached) was significantly longer than that in patients with nodal microinvolvement (mean 16.6; median 13) (p = 0.019). Multivariate Cox regression analysis for overall survival revealed that grading was the most significant independent prognostic factor (p = 0.001), followed by nodal microinvolvement (p = 0.013). CONCLUSIONS: The influence of occult tumor cell dissemination inLN’s of patients with histologically proven carcinoma of the papilla of Vater supports the need for further tumor staging through immunohistochemistry.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

950 The Prognostic Superiority of Log Odds of Lymph Nodes in Stage III Colon Cancer Jiping Wang*1,2, James M. Hassett1, Merril T. Dayton1, Mahmoud N. Kulaylat1 1Department of Surgery, State University of New York at Buffalo, Buffalo, NY; 2Department of Biostatistics, State University of New York at Buffalo, Buffalo, NY BACKGROUND: Recent literature has shown that lymph node ratio (LNR) and log of odds (LODDS) of positive lymph nodes (LN) can equally predict prognosis in patients with breast cancer. We hypothesize that in patients with stage III colon cancer, LODDS is even superior to LNR. METHODS: 24,477 stage III colon cancer cases from SEER are included. Based on LNR, patients are categorized into four groups, LNR1 to 4, according to cutoff points 1/14, 0.25 and 0.50 and on LODDS, patient are divided into five groups, LODDS 1 to 5, according to cutoff points –2.2, –1.1, 0 and 1.1. Kaplan-Meier and Cox proportional hazard model were used to evaluate the prognostic effect and estimate the relative risk (RR) and 95% confidence interval (CI). WEDNESDAY ABSTRACTS RESULTS: In stage III colon cancer, both LNR and LODDS are in agreement in staging patients except LNR4. When stratify LNR4 into LODDS4 and LODDS5, patients have significant different 5-year survival (33.5% vs. 23.3%, p < 0.0001). The observed 5-year survival for stage IIIB patients classified as LODDS1 to LODDS5 is 63.7%, 54.4%, 44.4%, 35.8% and 30.6% respectively (p < 0.0001). On the other hand, the observed 5-year survival for patients with stage IIIC diseases who are classified as LODDS2 to LODDS5 is 49.7%, 41.7%, 29.8% and 18.8% respectively (p < 0.0001). Univariate analysis shows that LODDS, LNR, age, race, number of negative LN (NNLN) or total number of LN examined (TNLN), tumor grade, size, and number of positive LN are significantly associated with survival. Whereas, in the multivariate Cox model, NNLN or TNLN, and LNR are not independently associated with survival after adjusting for LODDS.

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CONCLUSION: Patients with stage IIIB and IIIC colon cancer represent a heterogeneous group of patients with the majority either over-staged or under- staged. Patients with LNR4 also represent a heterogeneous group. In patients with stage III colon cancer, LODDS is a more accurate prognostic method than AJCC N staging, NNLN, and TNLN.

Table 1. Multivariate Cox model

Tumor Tumor Variables Age Race TNLN NPLN LNR LODDS Grade Size P-value <0.0001 <0.0001 <0.0001 <0.0001 0.54 <0.0001 0.52 <0.0001 Risk Ratio1.04 1.24 1.16 1.003 1.001 1.04 0.90 1.28 95% CI 1.037–1.040 1.19–1.30 1.12–1.21 1.002–1.003 0.997–1.005 1.03–1.05 0.65–1.24 1.19–1.39

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

951 High Expression of Heparanase Is Significantly Associated with Dedifferentiation and Lymph Node Metastasis in Patients with Pancreatic Ductal Adenocarcinomas and Correlated to PDGF-A and via HIF1a to HB-EGF and bFGF Andreas C. Hoffmann*1,2, Ryutaro Mori1, Daniel Vallbohmer2, Jan Brabender2, Uta Drebber3, Stephan E. Baldus5, Mizutomo Azuma1, Ralf Metzger2, Christina Hoffmann4, Arnulf H. Hölscher2, Kathleen D. Danenberg6, Klaus L. Prenzel2, Peter V. Danenberg1 1Department of Biochemistry and Molecular Biology and Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA; 2Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany; 3Department of Pathology, University of Cologne, Cologne, Germany; 4Department of Cardiology, Nuclear Medicine and Molecular Imaging, Heart Center North Rhine-Westphalia, Bad Oeynhausen, Germany; 5Department of Pathology, University of Düsseldorf, Düsseldorf, Germany; 6Response Genetics Inc, Los Angeles, CA BACKGROUND: Pancreatic cancer still has the worst prognosis of all cancers with a 5-year survival rate of 5%. Due to late symptoms of pancreatic cancer and therefore often late diagnosis, only 10%–20% of the patients are eligible for complete resection with curative intention, making it necessary to find markers or gene-sets which would further classify patients into different risk categories and thus allow more individually adapted multimodality treatment regimens. Some of the most promising genes described also in other entities are linked to angiogenesis. Especially HPSE has recently been discussed as a key factor in pancreatic cancer. MATERIALS AND METHODS: Paraffin-embedded tissue samples were obtained from 41 patients with pancreatic adenocarcinoma with a median age of 65 years (range 34–85 years) at time of operation who were scheduled for primary surgical resection. After laser capture microdissection direct quantitative real-time reverse transcriptase PCR (RT-PCR, TaqMan™) assays were performed WEDNESDAY in triplicates to determine HPSE, HIF1a, PDGF-A, HB-EGF and bFGF gene ABSTRACTS expression levels. Gene expression was normalized with beta-Actin. Decision tree analysis and the maximal chi-square method were adapted to determine which gene expression value best segregated patients into lymph node negative and positive, and high and low dedifferentiation subgroups. RESULTS: HPSE was significantly correlated to PDGF-A (p = 0.04) and to HIF1a (p = 0.04). The correlation of HIF1a to bFGF and HB-EGF expression was significant (p = 0.04, p = 0.02). We put all clinical, histopathological parameters and the used genes as independent variables in a stepwise multiple linear regression model with lymph node metastasis as the dependent variable. The overall model fit had a significance level of p = 0.029 (<0.05) with HPSE as the only significant predictor of lymph node metastasis, though pT was almost included. Using a stepwise multiple regression analysis to evaluate the most influential of the accessible factors on the dedifferentiation of the tumor the overall model fit was significant at a level of p = 0.003 (<0.05). The most significant independent factor was HPSE for predicting the grade of dedifferentiation.

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CONCLUSIONS: Considering the fact that Heparanase seems to be a highly signiﬁcant independent variable for lymph-node metastasis (p = 0.029; <0.05) as well as for dedifferentiation (p = 0.003; <0.05) we assume that HPSE plays a crucial role for the aggressiveness of pancreatic cancer. Though these results were obtained on a relatively small number of patients, larger studies including patients treated with actual chemotherapeutics seem to be warranted.

162 6303_SSAT.book Page 163 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

952 VEGF Gene Therapy Improves Anastomotic Healing in the Gastrointestinal Tract: Applications in Esophageal Surgery Kristian Enestvedt*1, Shelley R. Winn1, Brian S. Diggs1, Luke Hosack1, Barry Uchida2, Robert W. O’Rourke1, Blair A. Jobe1 1Department of Surgery, Oregon Health and Science University, Portland, OR; 2Dotter Institue, Department of Interventional Radiology, Oregon Health and Science University, Portland, OR BACKGROUND: Anastomotic leak related to ischemia is a source of significant morbidity and mortality. The aim of this study was to utilize VEGF gene therapy for the purpose of up-regulating angiogenesis, increasing anastomotic strength, and ultimately preventing dehiscence. METHODS: An opossum esophagogastrostomy model was employed. The vascular endothelial growth factor (VEGF165) gene was incorporated into a circular recombinant plasmid. The plasmid was complexed with a non-viral synthetic vector, Jet-PEI. Control animals received plasmid devoid of VEGF165 (n = 6). The experimental group received VEGF165 plasmid (n = 5). After esophagogastrectomy and gastric tubularization, plasmid was injected into the submucosa of the neoesophagus at the anastomotic site. Conduit arteriography was performed before and 10 days after injection. Euthanasia occurred on post-injection day 10 and the anastomosis was removed en bloc. Blood flow was measured with laser-Doppler prior to euthanasia. Ex vivo anastomotic bursting pressure was performed. Tissue samples were procured for RNA extraction and Factor VIII staining. Microvessel counts were obtained by 2 blinded observers. VEGF mRNA transcript levels were measured with quantitative RT-PCR using custom primers. RESULTS: There were no deaths in either group. There was one leak in the control group. Experimental animals demonstrated significantly increased bursting pressure and neovascularization compared to controls (Table). In WEDNESDAY

addition, there was a strongly positive correlation between the number of ABSTRACTS microvessels and bursting pressure (r = 0.808, p = 0.015, Pearson’s). On angiographic examination, treated animals demonstrated more neovascularization compared to controls. RT-PCR demonstrated a 2.1 fold increase in VEGF mRNA tissue transcript levels in treated animals compared to controls (p = 0.05, t-test). DISCUSSION: This ﬁrst description of successful gene therapy in the gastrointestinal tract using VEGF165 transfection demonstrates improved anastomotic healing in a clinically relevant model which may directly translate to human application.

Blood Flow at Harvest Microvessels (#/hpf) Bursting Pressure (mm Hg) Groups (ml/min/100gm) (p = 0.032, t-test) (p = 0.021, t-test) (p = 0.191, t-test) Control 20.33 4.18 86.73 Experimental 33.87 6.68 104.25

*all numbers are mean values

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953 Loss of Heterozygosity Portends Poor Survival of Patients with Resected Periampullary Cancer Jan Franko*1, Alyssa M. Krasinskas2, Marina N. Nikiforova2, Yuri E. Nikiforov2, Steven J. Hughes1, Kenneth K. Lee1, David L. Bartlett1, Herbert Zeh1, Arthur J. Moser1 1Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA BACKGROUND: Traditional AJCC staging system for periampullary adenocarcinoma has been well validated but improvements in prognostic accuracy are still needed. We hypothesized that molecular and genetic methods may predict biological behavior and postoperative survival independently of stage. METHODS: Pancreatic ductal and ampullary carcinomas treated by pancreaticoduodenectomy in 2006 (n = 50) were subjected to laser capture microdissection followed by loss of heterozygosity (LOH) analysis at 14 different chromosomal loci including 5q (APC), 6q (thrombospondin), 9p (p16), 10q (Pten), 12q (MDM2), 17p (p53), and 18q (DDC/DPC4). Mutations at k-ras exon 1 (codons 12 and 13) were assessed by PCR. The relationship between genetic alterations and clinical outcome was studied. RESULTS: Negative resection margins were achieved in 43 (86%) cases. AJCC stage distribution was: Ia/b (3), IIa (16), IIb (29), and III (2). K-ras mutations were observed in 31 cases (62%). Allelic losses were identified in 26 (52%) with a median fractional allelic loss score of 18% (range 7–64%). There was no concordance between LOH and k-ras mutations (McNemar p = 0.405). Sur- vival was significantly shorter in patients with allelic losses (17.5 versus 21.2 months; p = 0.039). Both higher AJCC stage (HR = 1.29, p = 0.018) and presence of LOH (HR = 6.60, p = 0.027) were identified as independent predictors of shorter survival in a Cox regression model. Increased fractional allelic loss portended worsened survival (HR = 1.043 per percent loss, p = 0.034), whereas age and k-ras mutations did not.

Figure 1. Survival of patients with resected periampullary cancer stratified by LOH status.

CONCLUSION: Loss of heterozygosity predicts survival independently from stage in resected periampullary cancer. Allelic losses indicate more aggressive tumor biology and may improve risk stratiﬁcation in future clinical trials.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

10:30 AM – 12:00 PM PLENARY SESSION VII 25ABC Moderators: O. Joe Hines, Los Angeles, CA Blair A. Jobe, Portland, OR 1018 Long-Term Results After Minimally Invasive Repair of Giant Paraesophageal Hernia in 105 Patients Katie S. Nason*, James D. Luketich, Rodney J. Landreneau, Irfan Qureshi, Samuel B. Keeley, Shannon E. Trainor, Manisha Shende, Arjun Pennathur Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA BACKGROUND: Laparoscopic repair of giant paraesophageal hernias (LRG- PEH) is increasingly utilized with excellent short-term results. Long-term (>60 months) clinical and radiographic results, however, are poorly described. Our objective was to evaluate the long term results after minimally invasive repair of GPEH. METHODS: We performed a review of patients undergoing elective LRGPEH (1995 to 2002) who had a minimum of 60-month clinical or radiographic follow-up. Clinical outcomes, barium swallow and quality-of-life measures were reviewed. RESULTS: There were 256 patients who underwent LRGPEH in this time- period. A minimum of 60-month clinical or radiographic follow-up was available on 105 patients. Hernia reduction, sac excision, crural repair (13.7% mesh-reinforcement) and fundoplication were performed in 98%. A Collis- gastroplasty was performed in 89 patients (85%). Median time for clinical follow-up was 82 months (60–124). GERD-Health-Related-Quality-of-Life (GERD-HRQL) scores were available for 98 patients, with a mean 3.9 ± 6 (median 1, range 0–23; 0 = no symptoms–45 = worst). Occasional heartburn and dysphagia to solids were the most common persistent symptoms in 30%

of patients. According to the GERD-HRQL scale (excellent = 0–5; good = 6–10; WEDNESDAY fair = 11–15; poor = 16–45), the results were excellent to good in 86.8% of ABSTRACTS patients, confirming the mild nature of the symptoms. Barium-swallow was obtained in 79/105 (75%) at a median time of 80 months (60–126). Radio- graphic recurrence of a hiatal hernia was identified in 9 (11%). GERD-HRQL scores were excellent in 77% of patients with radiographic recurrence compared to 72% in patients without radiographic recurrence. When patients were queried regarding satisfaction with surgery, over 90% (83/90) were satisfied or very satisfied. Re-operation was required in 5 (4.7%) patients for symptomatic recurrence at a median 44 months post-operative (range 8–80). CONCLUSIONS: This report summarizes the long-term results (7 years) of LRGPEH in 105 patients. Reoperation was required for symptomatic recurrence in only 4.7%. The GERD-related quality of life was well preserved and 90% of patients were satisfied with their surgery.

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1019 Perioperative Treatment with Infliximab (IFX) in Patients with Crohn’s (CD) and Ulcerative Colitis (UC) Is Not Associated with Increased Rate of Postoperative Complications Hiroko Kunitake*1, Richard Hodin1, Paul C. Shellito1, Bruce E. Sands2, Joshua R. Korzenik2, Liliana Bordeianou1 1Surgery, Massachusetts General Hospital, Boston, MA; 2Gastroenterology, Massachusetts General Hospital, Boston, MA PURPOSE: Small studies looking at the impact of IFX on postoperative complications after abdominal surgery in patients with CD or UC have had con- tradictory findings. Our aim was to clarify the relationship between IFX use and postoperative complications in a large cohort of patients. METHODS: 413 consecutive patients—45.5% with CD, 30.5% with UC, 23.8% with indeterminate colitis—underwent abdominal surgery at Massa- chusetts General Hospital between January 1993 and December 2006. Of these patients, 101 (24.5%) received IFX 8 weeks pre-surgery. They were compared to the other 312 with respect to demographics, Charlson Comorbidity Index (CCI), presence of preoperative infections, rate of steroid use, and nutritional status by using Chi Square, Fisher’s Exact or Student’s T-test. The two groups’ rates of surgical complications, including death rates, anastomotic leaks, infections, thrombotic complications, prolonged ileus/small bowel obstructions, cardiac and hepatic/renal complications were compared with chi square analysis. Statistically significant differences were further evaluated with logistic regression analysis, controlling for rates of preoperative infections and steroid exposure. RESULTS: Patients in both groups were similar with respect to gender (59.4 vs. 48.1, p = 0.06), age (36.1 vs.37.8, p = 0.32), Charlson Comorbidity Index (5.7 vs. 5.3, p = 0.83), concomitant steroids (75.3 vs. 76.9%, p = 0.89), preoperative albumin level (3.3 vs. 3.2, p = 0.36), rate of emergent surgery (3.0 vs. 3.5%, p = 0.79). IFX patients had higher rates of CD (56.4 vs. 41.9%, p < 0.05), concomitant azathioprine use (34.6 vs. 16.6%, p < 0.0001), and lower rates of intraabdominal abscess (3.9 vs. 11%, p < 0.05). Following surgery, the two groups had similar rates of death (0.3 vs. 2%, p = 0.09), anastomotic leak (2.98 vs. 2.9%, p = 0.97), thrombotic complications (0.6 vs. 2.9%, p = 0.06), prolonged ileus/small bowel obstructions (2.8 vs. 3.9%, p = 0.59), cardiac (0.6 vs. 0%, p = 0.42), hepatic or renal complications (0.6 vs. 0.9%, p = 0.72). On initial chi square analysis, rates of postoperative infections appeared higher in patients who did not receive IFX (1.0 vs. 5.7%, p < 0.05). However, the difference was not statistically significant on logistic regression analysis (OR 2.5, p = 0.14) after controlling for steroid use (OR = 1.2, p = 0.74) and preoperative infection (OR = 1.2, p = 0.76). CONCLUSIONS: In a surgical referral center where decisions to treat with IFX are frequently made in collaboration between gastroenterologists and surgeons, preoperative IFX was not found to be associated with an increase in postoperative surgical complications.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1020 Use of Infliximab Within Three Months Prior to Ileocolonic Resection Is Associated with Significant Adverse Postoperative Outcomes in Crohn’s Patients Kweku A. Appau*, Victor W. Fazio, James M. Church, Bo Shen, Feza H. Remzi, Scott A. Strong, Bret Lashner, Takayuki Yamamoto, Paris P. Tekkis, Jeffery Hammel, Ravi P. Kiran Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Few studies have evaluated postoperative outcomes of Crohn’s disease (CD) patients treated with infliximab prior to surgery. The aim of this study is to determine 30-day postoperative outcomes for CD patients treated with infliximab within three months before ileocolonic resection. METHODS: Retrospective review of prospectively accrued Crohn’s database of patients undergoing ileocolonic resection after 1998. Patient, disease, operative characteristics, 30-day complications and mortality for patients treated with infliximab (INF) within three months preoperatively were compared with those never treated with infliximab (NINF). Since adverse outcomes detected in the infliximab group could potentially reflect its use in sicker patients rather than ill-effects of the medication,outcomes for INF were compared with non infliximab patients undergoing surgery before 1998 (pre INF). RESULTS: 60 of 389 CD patients undergoing ileocolonic resection received infliximab. INF and NINF had similar gender (p = 0.73), cormorbidity (p = 0.99), severity of CD (p = 0.35), smoking history (p = 0.80), indication for surgery (p = 0.30), surgical technique (p = 0.91), ASA score (p = 0.35), and abscess at/before surgery (p = 0.43). Intraoperative complications,intra or post-operative transfusions, steroid and immunosuppressive use were similar between groups. Postoperative ileus, cardiopulmonary, neurological, and renal complications were similar. Significant findings on univariate analysis are shown in table. On Cox multivariate analysis, INF had significantly higher

Table 1. WEDNESDAY ABSTRACTS 30-day Odd’s Ratio NINF (n = 329) INF (n = 60) Pre-INF (n = 69) P-value complications (95%CI) Urinary 0% 1.7% 0.0% 0.15* 0.47† complications Wound 0.30% 0.0% 1.4% 1.0* 1.0† dehiscence 30-day 0% 1.7% 0.0% 1.0* 1.0† mortality Readmission 9.4% 20.0% 2.9% 2.40 (1.15,5)* 0.019* 0.007† rate 8.37 (1.79,39.15)† Sepsis 9.7% 20.0% 5.8% 2.32 (1.12, 4.82)* 0.024* 0.021† 4.06 (1.23,13.37)† Intraabdominal 4.3% 10.0% 4.3% 2.50 (0.92, 6.79)* 0.10* 0.30† abscess 2.44 (0.58,10.23)† Anastomotic 4.3% 10.0% 1.4% 0.09* 0.049† Leak Re-operation 3.0% 8.3% 0.0% 2.9 (0.95,8.81)* 0.06* 0.02†

*p: NINF VS. INF. †p: Pre-INF VS. INF

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risk of 30-day postoperative readmission (p = 0.045), sepsis (p = 0.027), and intra-abdominal abscess (p = 0.005). For INF patients, stoma use (n = 17) was associated with a significantly lower risk of sepsis (0% vs 27.9%, p = 0.013). Despite similar pre and perioperative factors, INF had significantly higher postoperative sepsis (20 vs. 5.8%, p = 0.021), anastomotic leak (p = 0.04) and readmissions (20% vs. 2.9%, p = 0.007) when compared with pre-INF. CONCLUSION: Use of infliximab within three months prior to surgery is associated with increased postoperative sepsis, abscess and re-admissions in CD patients. Presence of stoma above anastomosis appears to protect patients treated with infliximab.

168 6303_SSAT.book Page 169 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1021 Selective Management of Iatrogenic Colonoscopic Perforations Dimitrios V. Avgerinos*, Omar H. Llaguna, Andrew Y. Lo, I. Michael Leitman Surgery, Beth Israel Medical Center, New York, NY INTRODUCTION: Colonoscopy is a safe procedure in the hands of experienced physicians. However, perforations are unavoidable and occur in rare occasions, with a reported incidence rate of 0.03%–0.19% in the literature. The management of those perforations remains controversial. The present study evaluates the treatment options for patients with colonoscopic perforations based on their clinical presentation and indications for colonoscopy. METHODS: After Institutional Review Board approval, a retrospective analysis of all the patients that were treated for colonic perforation after diagnostic or therapeutic colonoscopy at a tertiary care teaching hospital over a twenty one-year period (from January 1986 to October 2007). Patient demographics, past medical and surgical history, type and indications for colonoscopy, colonoscopic findings, clinical presentation after suspected perforation, type of operation and intra-operative findings when operative management was undertaken, and method of non-operative approach were analyzed. Injury was verified by ability to visualize the intra-peritoneal space or diagnostic imaging. The decision to perform surgery was based upon the physical findings of peritonitis, signs of infection or hemodynamic changes. RESULTS: A total of 105,786 colonoscopies during the study period. Thirty- five perforations occurred (0.033% perforation rate). Twenty (57%) of these perforations followed routine diagnostic colonoscopy, whereas the rest 15 (43%) occurred following some type of therapeutic colonoscopy. Nineteen (95%) of the patients that previously underwent diagnostic colonoscopy required operative treatment, whereas only three patients (20%) of the patients that had perforation following therapeutic colonoscopy required operation and were managed conservatively with antibiotics and bowel rest. Both groups had comparable outcomes, with minimal morbidity and zero WEDNESDAY mortality. ABSTRACTS CONCLUSIONS: Although many surgeons recommend operation for all colonoscopic perforations, the present study shows that careful selection of patients who suffer bowel perforations during colonoscopy may be managed without surgery. Perforations resulting from therapeutic colonoscopies usually result in small injuries to the bowel wall, which often heal without the need for surgical intervention. On the other hand, perforations from diagnostic colonoscopies are usually large linear lacerations that require surgical repair or resection.

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1022 Pancreatic Fistula Rates After 442 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates Cristina R. Ferrone*, Andrew L. Warshaw, J. Ruben Rodriguez, Sarah P. Thayer, Carlos Fernandez-Del Castillo Surgery, Massachusetts General Hospital, Boston, MA INTRODUCTION: Pancreatic fistula is a common complication and a major source of morbidity after distal pancreatectomy (DP). We evaluated consecutive patients undergoing DP to determine if the type of stump closure could decrease fistula rates. METHODS: Retrospective review of a prospectively collected database between 2/1994 and 10/2007 identified 442 patients who underwent distal pancreatectomy. Clinicopathologic variables were reviewed. Pancreatic fistula was defined as a JP amylase >300U/L and an output >30 cc on POD#5 or development of a postoperative collection up to POD 30. RESULTS: Distal pnacreatectomy was performed in 442 patients with a mortality of <1% and a pancreatic fistula rate of 29% (130/442). Distal pancreatectomy with splenectomy was performed in 311 (70%) patients. Additional organs were resected in 99 (22%) patients and a laparoscopic procedure was performed in 12 (3%) patients. The pancreatic stump was closed with a fish- mouth suture closure in 228, of whom 69 (30%) developed a fistula. If a separate ductal ligation was performed the fistula rate was 27.6% (44/158) vs. 36% (25/70) if the duct was not ligated. A peritoneal falciform patch was used in 106, with a fistula rate of 30% (33/106). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (10/30). The pancreatic fistula rate was lowest (15%; 3/20) in patients who had a fish mouth suture closure with an omental patch. There is no significant difference in the rate of fistula formation between the groups (p = 0.33). CONCLUSIONS: In a series of 442 distal pancreatectomies the pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after distal pancreatectomy. Reduction of pancreatic fistulas after DP remains an unsolved challenge.

170 6303_SSAT.book Page 171 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1023 Reoperation for Recurrent Pain Following Failed Primary Operation in Chronic Pancreatitis Jeffrey S. Browne1, Nicholas J. Zyromski1, Harish Lavu1, Marshall S. Baker2, James A. Madura1, Thomas J. Howard*1 1Surgery, Indiana University, Indianapolis, IN; 2Surgery, Northwestern University, Chicago, IL INTRODUCTION: Resection and drainage procedures achieve long-term pain relief in approximately 80% of patients with chronic pancreatitis. In the 20% of patients who develop recurrent pain following failed primary operation, little data exists on effective treatment options. This study reports our experience with reoperation for recurrent pain following failed primary operation in patients with chronic pancreatitis. METHODS: Over 18 years (1988–2006), 316 pts. with histopathologically veriﬁed chronic pancreatitis underwent primary operation to achieve pain relief. Etiologies of chronic pancreatitis included: ETOH (38%), pancreas divisum (30%), idiopathic (25%), and miscellaneous (7%). Primary operations included: pancreaticoduodenectomy [PD] (N = 100), duodenum preserving pancreatic head resection [DPPHR] (N = 53), Peustow pancreaticojejunostomy [PPJ] (N = 51), and distal pancreatectomy [DP] (N = 112). Forty patients (13%) who failed primary operation had reoperations for pancreatic duct strictures (N = 25), biliary strictures (N = 6) or parenchymal disease progression (N = 9) identiﬁed by radiographic imaging (CT, MRCP, EUS, ERCP) and were retrospectively reviewed. RESULTS: Table.

Table 1.

Reoperation N Morbidity‡ > IIIa New Endocrine Insuff. Pain Relief TP 7 2 (29%) 5 (71%) 83% Revision 14 1 (7%) 2 (14%) 50% WEDNESDAY DP 3 2 (67%) 1 (33%) 50% ABSTRACTS DPPHR 8 2 (25%) 2 (25%) 25% PD 8 3 (38%) 3 (38%) 13%

‡Grading system of DeOliveira (Ann Surg 2006:244:931–9.) TP = total pancreatectomy

CONCLUSIONS: In reoperations, TP achieves the best pain relief (83%) at a high cost of new endocrine insufﬁciency. Revision operations have a low morbidity, less endocrine insufﬁciency, and a 50% incidence of pain relief. Pancreatic head resections (DPPHR, PD) are less effective (25%, 13% pain relief) than when used as the primary operation.

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10:30 AM – 12:00 PM VIDEO SESSION III: NOTES: WHERE ARE 27B WE TODAY? Moderators: Brian J. Dunkin, Houston, TX Nathaniel J. Soper, Chicago, IL 1024 NOTES: Dissection of the Critical View of Safety During Transcolonic Cholecystectomy Edward Auyang*1, Khashayar Vaziri1, Eric S. Hungness1, John A. Martin2, Nathaniel J. Soper1 1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology, Northwestern University, Chicago, IL Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging field that is driving the development of new surgical technology and techniques. Before NOTES gains widespread popularity, it must be proven to be a safe and efficacious technique. In this porcine model, we demonstrate the NOTES dissection of the critical view of safety during cholecystectomy which allows for safe identification and division of the cystic duct and artery. Demonstration of this view has been shown to reduce bile duct injuries in human patients.

1025 Single Port Access (SPA) Cholecystectomy Paul G. Curcillo, Erica R. Podolsky*, Steven J. Rottman Surgery, Drexel University College of Medicine, Philadelphia, PA The desire to minimize incisions has moved us to explore novel methods for standard laparoscopic procedures. We have developed a Single Port Access (SPA) surgical technique that allows us to perform a variety of standard laparoscopic procedures through a single umbilical incision (<18 mm). We have successfully applied this technique to cholecystectomy. A new approach of trocar placement and positioning within a single umbilical incision allows for standard laparoscopic dissection to be performed in SPA Cholecystectomy. We believe this technique can be easily taught and made available to our colleagues and ultimately to the large number of patients requiring cholecystectomy.

1026 Single Incision Laparoscopic Cholecystectomy Using Flexible Endosocopy Glenn Forrester*, John N. Afthinos, Eugenius J. Harvey, Steven Binenbaum, Grace J. Kim, Julio Teixeira Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY We describe a technique for performing laparoscopic cholecystectomy through a single periumbilical incision using ﬂexible endoscopic technology. Both a dual-channel ﬂexible endoscope and a 5 mm laparoscopic trocar are inserted into the peritoneal cavity through the same skin incision. The dissection of the gallbladder and the hilum is performed mostly using endoscopic tools, while ligation of hilar structures is done using standard clips. Though the procedure is technically challenging, the skills developed may serve as a bridge to performing NOTES.

172 6303_SSAT.book Page 173 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1027 NOTES-Assisted Roux-en-Y Gastric Bypass Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3, Nicolas C. Buchs1, Priya A. Jamidar5, Margherita Cadeddu4, Jean Fasel6, Philippe Morel1 1Digestive Surgery, University Hospital Geneva, Geneva, Switzerland; 2Department of Visceral and Transplantation Surgery, University Bern, Bern, Switzerland; 3Imperial College, London, United Kingdom; 4Department of Surgery, McMaster University, Hamilton, ON, Canada; 5Section of Digestive Diseases, Yale University, New Haven, CT; 6Division of Anatomy, University Geneva, Geneva, Switzerland BACKGROUND: NOTES-assisted Roux-en-Y gastric bypass (RYGB) might offer certain advantages, but the technical feasibility is unknown. METHODS AND DESIGN: We have performed NOTES-assisted RYGB in 4 human cadavers. VIDEO: The video shows pouch creation using a flexible gastroscope introduced transvaginally. Articulated linear staplers placed transumbilically transect the stomach. Measurement of small bowel is done with flexible and rigid graspers. A flexible transesophageal stapler is used for the gastrojejunostomy, a linear stapler for the jejuno-jejunal anastomosis. CONCLUSION: The video demonstrates the technical feasibility of RYGB in human cadavers using a NOTES-assisted approach.

1028 Reverse NOTES: Transgastric ERCP Yoav Mintz, Santiago Horgan, Thomas J. Savides, John Cullen*, Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini Department of Surgery, University of California, San Diego, San Diego, CA Choledocholithiasis following Roux-en-Y gastric bypass is a challenging problem to manage due to the anatomic changes. This case represents a novel approach with collaboration between surgeons and gastroenterologists when WEDNESDAY dealing with this problem. The patient was taken to the operating room and a ABSTRACTS laparoscopic gastrotomy was performed, through which ERCP was then accomplished via the excluded gastric remnant. These cases will undoubtedly become more and more common as gastric bypass is done more often and the patients live longer with their altered anatomy.

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12:30 PM – 1:30 PM QUICK SHOTS III 24ABC Timothy M. Pawlik, Baltimore, MD Magesh Sundaram, Morgantown, WV 1029 Outcome of Esophagectomy Based on Surgical Subspecialty Training Brian R. Smith*, Marcelo W. Hinojosa, Kevin M. Reavis, Ninh T. Nguyen Department of Surgery, UC Irvine Medical Center, Orange, CA BACKGROUND: Esophagectomy is commonly performed by general or thoracic surgeons and the type of operation is often dictated by the surgeons’ training. OBJECTIVE: The objective of the current study was to investigate the volume of operations and outcomes of esophagectomies performed by subspecialty vs. non-subspecialty surgeons. DATA SOURCES AND STUDY SELECTION: Clinical data of patients who underwent partial or total esophagectomy for esophageal cancer from 2003 through 2007 were obtained from the University Health System Consortium database. This database contains data from all major teaching hospitals in the US. The data were categorized between general vs. thoracic surgeon and were reviewed for the type and number of operations performed by each surgical specialty, demographics, length of stay, and postoperative morbidity and mortality. DATA SYNTHESIS: During the 60-month period, a total of 2,657 esophagectomies were performed; 1,079 (41%) were performed by general surgeons, while 1,578 (59%) were performed by cardiothoracic surgeons. CONCLUSIONS: The majority of esophagectomies for carcinoma of the esophagus are being performed by subspecialty trained surgeons. Thoracic specialists perform more Ivor-Lewis esophagectomies, while general surgeons favor the blunt transhiatal approach. Despite these differences, specialty training does not appear to be an important factor in determining the outcome for this complex operation.

General Surgeons Cardiothoracic Surgeons p-value Total no. of esophagectomies 1,079 1,578 N/A Procedure, blunt transhiatal (%) 56 37 <0.01* Procedure, Ivor-Lewis (%) 44 63 <0.01* Gender: male 4.3 4.2 N/A Mean ICU stay (days) 8.4 9.7 0.287† Mean length of hospital stay (days) 16.6 16.9 0.800† Overall complications (%) 55 52 0.11* Observed mortality (%) 3.6 2.9 0.31* Mortality index (obs/exp) 0.79 0.65 N/A

*Chi square test; †2-sample t-test.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1030 Optimizing Outcome Measurement in Pancreatic Surgery: Can NSQIP Measure Up? Craig P. Fischer*1,2, Thomas A. Aloia1,2, Bridget N. Fahy1,2, Stephen L. Jones1,2, Barbara L. Bass1,2 1Surgery, The Methodist Hospital, Houston, TX; 2Weill Medical College of Cornell University, New York, NY INTRODUCTION: A validated system to measure and compare outcomes in complex GI and HPB surgery has not been established. The ACS NSQIP has been criticized as inadequate, citing lack of procedure-specific outcomes and limitations inherent to sampling methodology. Institutional registries have been an alternative, but do not allow site to site comparison. To assess the accuracy of NSQIP data collection, we investigated the utility of our institutional NSQIP data to capture procedure specific outcomes after a complex abdominal procedure – pancreatectomy. METHODS: From July 2006–July 2007 31,332 surgical procedures were performed at our medical center. 1,638 (5.2%) were captured by the sampling method of NSQIP, including 32 pancreatic resections. Our institutional pancreatic database captured 75 patients having pancreatic resection during the same time period and included NSQIP occurrence categories and pancreatic fistula (PF) rates (ISGPF grade A, B, C). NSQIP nurses were instructed in ISGPF definitions and asked to retrospectively categorize patients with PF. Postoper- ative occurrences were compared. RESULTS: NSQIP captured equivalent outcomes to the pancreatic surgery database including rates of pancreatic fistula (Table 1). However, grading of pancreatic fistula by NSQIP increased the ISGPF grade in 3 cases. Two cases were upgraded from A to B, due to the discovery of a drain in-situ in the outpatient setting. NSQIP discovered readmission of one patient, upgrading this patient from grade A to B. All three upgrades were not detected by the pancreatic registry, which only focused on in-hospital morbidities. CONCLUSIONS: The data collected within the NSQIP at our institution com- WEDNESDAY

pares favorably to a procedure specific clinical database. The sampling meth- ABSTRACTS odology inherent to NSQIP did not compromise the validity of outcome observations. The quality of data collection by NSQIP nurse reviewers may lead to more accurate appraisal and interpretation of outcomes due to lack of self reporting bias. The collected PF data were sufficient to allow accurate grading according the ISGPF system. These findings suggest that NSQIP may be further improved by consensus development of procedure specific outcome variables. Table 1. NSQIP Pancreatic Surgery Outcomes

Category Pancreatic Registry NSQIP p-value N 75 32 NA Death 2.66% 3.13% NS Wound Infection 9.33% 12.5% NS Organ/Space SSI 13.33% 9.38% NS Respiratory 8.0% 6.25% NS Urinary 5.33% 9.36%NS Pancreatic Fistula (total) 21.3% 15.63% NS

SSI – surgical site infection.

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1031 The Learning Curve of Laparoscopic Rectal Resection for Cancer: A Single-Center Experience Marco Montorsi*, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi, Riccardo Rosati General Surgery, University of Milan, Istituto Clinico Humanitas IRCCS, Milan, Italy INTRODUCTION: Laparoscopic rectal resection (LRR) has been shown to be feasible but challenging. The role of the learning curve in this surgery is not fully elucidated. To evaluate its impact, we prospectively collected, in two consecutive periods, operative and outcome data of pts submitted to LRR for cancer at a single institute performed by four surgeons equally experienced in laparoscopic surgery. METHODS: From November 1999 to May 2007, 141 patients with rectal cancer were treated by laparoscopy. Learning curve was evaluated in two consecutive periods, 1999 to 2003 (first period) and 2004 to 2007 (second period). The evaluated variables were: operative data (operative time, conversion rate, intraoperative complications), short-term outcomes (postoperative complications, mortality, lenght of hospital stay, readmission rate), and oncological outcomes (site of the tumor, number of lymphnodes, resection margins, port recurrence). RESULTS: Number of patients (71 and 70), demographic data and oncological stage were similar in the two periods. No differences were found in operative time (274 and 294 minutes, p = 0.12), intraoperative (7% and 12.9%, p = 0.25) and postoperative complications rate (19.7% vs 17.1%, p = 0.69). Anastomotic leakages occured in 8 patients, equally in the first (11.3%) and in the second period (11.4%, p = 0.97). Lenght of hospital stay decreased in the second period (9 vs 8 days, p = 0.18). There were no readmission in hospital after discharge in both groups. No differences were observed among the four surgeons in operative data and outcomes. The number of resected lymphnodes per patient (18) was the same in the two periods. There were statistically significant differences in the distribution of tumor site (percentage of the tumors located in the mid and lower rectum was 45.1% in the first period and 72.9% in the second period, p = 0.01) and in conversion rate (23.9% vs 11.4%, p = 0.05). There were 2 microscopical infiltrations of the distal margin (2.8%) and 1 port site metastasis (1.4%), all in the second period. Five yrs overall and disease free survival rates were 82.1% and 75.6%. Disease free survival rate was significantly lower when conversion to open surgery was required (78.7% vs 61.8%, p = 0.04). CONCLUSIONS: When performed by experienced surgeons, LRR for cancer is feasible, safe and oncologically effective since the beginning of the experience. The parameters which significantly changed during the learning curve were conversion rate and the anatomic site of the rectal tumors. Operative time and morbidity did not show an improvement, probably due to a different case-mix in the second period (more distal tumours).

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1032 Short-Term Outcomes After Laparoscopic-Assisted Compared to Open Colectomy for Cancer Karl Y. Bilimoria*1, David J. Bentrem1, Heidi Nelson2, Steven J. Stryker1, Clifford Y. Ko3, Nathaniel J. Soper1 1Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 2Department of Surgery, Mayo Clinic, Rochester, MN; 3Department of Surgery, UCLA and Greater Los Angeles VA, Los Angeles, CA BACKGROUND: Randomized clinical trials have demonstrated that laparoscopic-assisted colectomy (LAC) outcomes are comparable to open colectomy (OC) when performed by experts; however, LAC has not been examined in a multi-institutional setting outside of trials. The objectives of this study were to assess differences in perioperative outcomes for LAC compared to OC. METHODS: Using the American College of Surgeons-National Surgical Qual- ity Improvement Project’s (NSQIP) participant-use dataset, patients were identified who underwent colectomy for cancer at 120 participating hospitals in 2005–2006. Multiple logistic regression was used to assess the risk-adjusted association between surgical approach (LAC vs. OC) and 30-day outcomes. Propensity scores were used to adjust for group differences. Patients were excluded if they underwent emergent procedures, were ASA class 5, or had metastatic disease. RESULTS: Of the 3,059 patients who underwent colectomy for cancer, 837 (27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no significant differences in age, comorbidities, ASA class, or BMI between patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likelihood of developing any adverse event (includes wound, cardiac, pulmonary, renal, neurologic, or hematologic complications) compared to OC (14.6% vs. 21.7%; OR 0.64, 95% CI 0.51–0.81, P < 0.0001). Mean length of stay was significantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P < 0.0001). There was no difference between LAC and OC in the rate of returns to the operating room

(5.5% vs. 5.8%, P = 0.79) or 30-day mortality (1.4% vs. 1.8%, P = 0.53). WEDNESDAY ABSTRACTS CONCLUSIONS: LAC was utilized in one-quarter of patients with colon cancer. LAC was associated with lower morbidity and length of stay in select patients.

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1033 Patient Demographics and Surgeon Volume in Pancreatic Resection Mortality Robert W. Eppsteiner*, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah Surgery, University of Massachusetts, Worcester, MA INTRODUCTION: Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level. METHODS: Using the Nationwide Inpatient Sample (NIS), discharge records for all non-trauma PR (n = 3,705) were examined from 1998–2005. Surgeons were divided into two groups: high volume (HV; ≥5 operations/year) or low volume (LV; <5/year). The Elixhauser index adjusted for patient comorbidity. We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient/hospital factors. To eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores. RESULTS: 128 HV and 1,329 LV surgeons performed 3,705 PR in 449 hospitals across 11 states that report surgeon identifier information over the 8-year period. Patients who underwent PR by HV surgeons were more likely to be male, white race, and a resident of a high-income zip code (p < 0.05). HV surgeons had a lower unadjusted mortality compared to LV surgeons (2.5% vs. 6.8% p < 0.0001). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance and surgery by HV surgeon (Table). Propensity scoring was used to create matched HV and LV groups; when HV surgeons performed PR an in-hospital mortality benefit was found across all groups. CONCLUSIONS: PR by a HV surgeon in this cohort was independently associated with a 60% reduction in in-hospital mortality. Removal of potential selection bias still resulted in improved outcomes after PR by HV surgeons. To our knowledge, this is the first population-based case-controlled evidence that demonstrates improved in-hospital mortality after PR is directly related to surgeon volume. Table 1. Logistic Regression of Operative Mortality

Factor OR (95% CI) Age 1.1 (1.0–1.1) Female gender 0.6 (0.4–0.9) Black race 1.6 (0.9–2.7) Hispanic race 1.5 (0.9–2.7) Medicaid insurance 2.4 (1.1–5.5) Highest income bracket 1.5 (1.0–2.1) Urgent admission 0.9 (0.6–1.3) Elixhauser comorbidity 1.1 (0.9–1.2) Malignant diagnosis 1.4 (0.9–2.2) High volume surgeon 0.4 (0.3–0.6)

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1034 Are Seasoned Surgeons Still Safe in a Laparoscopic Surgical Crisis? Kinga A. Powers*1,2, Scott Rehrig1, Noel Irias1, Mark P. Callery1, Steven D. Schwaitzberg2, Daniel B. Jones1 1Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Surgery, Cambridge Health Alliance, Harvard Medical School, Boston, MA INTRODUCTION: Seasoned surgeons are confronted with emerging technologies which were not part of their formal residency training. Our aim was to compare technical and team performances of surgeons of different ages and expertise. We hypothesize that seasoned surgeons are less prepared to deal with a laparoscopic surgical crisis than younger, expert laparoscopic surgeons. METHODS: Six seasoned surgeons (age 55–83) were compared to six control, expert laparoscopic surgeons (age 34–53). In a simulation mock operating room, surgeons established pneumoperitoneum, trocar access, and managed an intraabdominal hemorrhage in a previously described and validated model of an abdomen. Blood loss and time to control hemorrhage were measured. Videos were evaluated as part of an approved IRB. Surgeons’ performance in the simulated operating endosuite was assessed using described and validated technical and team performance scales. Statistics were by SAS/STAT software with p < 0.05 significance. RESULTS: All seasoned surgeons when confronted with the use of unfamil- iar technologies (Veress needle and optical trocar) used junior assistants appropriately. All control surgeons achieved intraabdominal pneumoperitoneum and trocar entry themselves. Mean blood loss for seasoned surgeons and control surgeons was 2.7 versus 2.8 liters, respectively (p = NS). Bleeding was successfully managed laparoscopically by two senior teams and one control team. On hemorrhage recognition, senior surgeons converted after 2:40 min vs. 3:30 min for the control surgeons (p = NS). Overall technical and team abilities of both groups were comparable. On debriefing, 85% of all sur- WEDNESDAY geons recommended simulation for recertification. ABSTRACTS CONCLUSIONS: Seasoned surgeons use their assistant surgeons well and are safe even when confronted with emerging technologies. Conversion to laparotomy addresses hemmorrhage during laparoscopic crisis. Simulation may prove a valuable tool for self assessment and recredentialing.

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1035 Meta-Analysis of Mechanical Bowel Preparation for Elective Colon and Rectal Resection Carlos E. Pineda*, Andrew A. Shelton, Tina Hernandez-Boussard, John M. Morton, Mark L. Welton Department of Surgery, Stanford University, Stanford, CA INTRODUCTION: Despite prior publications, including several meta-analyses and randomized controlled trials, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery. The aim of this paper is to review all the published prospective randomized controlled trials and perform a meta-analysis to evaluate the impact of MBP on anastomotic leak and wound infection rates. MATERIALS AND METHODS: We performed a systematic review of the literature of all trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal surgical resection. We performed a search in MEDLINE, LILACS, and SCISEARCH, followed by a manual search of reference lists for each article found, as well as abstracts of pertinent scientiﬁc meetings. Experts in the ﬁeld were queried as to knowledge of additional reported trials. The outcomes we abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto-Odds ratio. RESULTS: Of 3,247 patients (12 trials), 1,634 were allocated to MBP (Group 1) and 1,613 were allocated to no MBP (Group 2). Anastomotic leaks (Figure 1) occurred in 65 (4%) patients in Group 1, and in 44 (2.7%) patients in Group 2 (Peto OR = 1.488, CI 95%: 1.014–2.183, P = 0.04). Wound infections occurred in 137 (8.4%) patients in Group 1, and in 105 (6.5%) patients in Group 2 (Peto OR = 1.332, CI 95%: 1.024–1.733, P = 0.033). Subgroup analysis for low anterior resection favored no preparation.

DISCUSSION: This meta-analysis, that includes trials published in 2007, demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery and in fact, appears to be harmful, because the MBP group experienced higher anastomotic leak rates and wound infection rates. This data supports elimination of routine MBP in elective colorectal surgery and yet the persistence of the practice suggests that a multicenter randomized controlled trial may be necessary to provide sufficient evidence to change clinical practice. CONCLUSION: Mechanical bowel preparation is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet “standard of care.” 180 6303_SSAT.book Page 181 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1036 Sequential Resections of Liver and Pulmonary Metastases of Colorectal Cancers: Results of 45 Patients Hannes Neeff*1, Frank Makowiec1, Eva Fischer1, Ulrich T. Hopt1, Bernward Passlick2 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Department of Thoracic Surgery, University of Freiburg, Freiburg, Germany INTRODUCTION: Multimodal therapies (especially surgery of metastases and aggressive chemotherapy) in patients with metastases of colorectal cancers (CRC) are increasingly performed and may even provide healing in selected patients with more than one site of metastases. In the current literature there are only few studies with relatively low patient numbers reporting the outcome after resection of both, hepatic and pulmonary metastases of CRC. We, therefore, evaluated survival of patients who underwent sequential resections of hepatic and pulmonary metastases under potentially curative intention. METHODS: From 1989 until 2006 45 patients (31% female, median age 58 years) with (during the course of the disease) hepatic and pulmonary CRC- metastases underwent sequential resections at both metastatic sites. In all patients further tumor locations were excluded preoperatively. Metastases occurred synchronously (regarding primary CRC) in 29%. In 82% liver resection was performed prior to pulmonary resection. First resection of metastases was performed a median of 16 months after resection of the primary CRC, the median interval to the second resection of metastases was seven months. The primary CRCs were in 53% rectal and in 47% colon carcinomas (62% nodal positive, all with free resection margins). Survival analysis was performed using the Kaplan-Meier-method. RESULTS: In both, the first and the second resection of metastases, free margins were achieved in 94%. Actuarial five-year survival (5-y SV) was 63% after initial diagnosis of CRC, forty-three percent after the first resection of metastases and 29% after the last resection. Patients with synchronous metastases had a significant poorer survival compared to patients with WEDNESDAY metachronous metastases (37% 5-y SV after first metastasectomy vs. 72% in ABSTRACTS patients with metachronous disease; p < 0.01). The nodal status and the location of the primary CRC did not influence survival so far. CONCLUSIONS: Within a multimodal management of patients with metas- tasized CRC a resection of both, hepatic and pulmonary metastases may achieve acceptable survival rates or even healing in selected patients, especially in the presence of biologically less aggressive (=metachronous) disease. Survival rates in these selected patients are comparable to those of patients after isolated hepatic resection reported during the last decade.

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1037 Prognostic Factors Associated with Survival Following Hepatic Resection of Early-Stage Hepatocellular Carcinoma Hari Nathan*, Michael Choti, Richard D. Schulick, Timothy M. Pawlik Surgery, Johns Hopkins Hospital, Baltimore, MD INTRODUCTION: Factors associated with prognosis following resection of early-stage (5 cm) hepatocellular carcinoma (HCC) remain ill-defined. We sought to identify clinicopathologic factors that predict long-term survival in patients (pts) with early-stage HCC following hepatectomy. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 921 pts with histologically confirmed early-stage HCC who underwent surgical resection (not ablation or transplantation) between 1988–2004. Prognostic factors were evaluated and survival was stratified according to a novel clinical scoring system. RESULTS: Median tumor size was 3.3 cm; 19% of pts had tumors 2 cm. Most HCC lesions were solitary (74%), low histologic grade (84%), and had no evidence of vascular invasion (78%). Hepatic resection consisted mostly of wedge resection (59%) or hemi-hepatectomy (35%). Overall median and 5-yr survival were 39 mos and 37%, respectively. After adjusting for socio- demographic factors and histologic grade, tumor size >2 cm (HR = 1.9) and vascular invasion (HR = 1.4) remained independent predictors of poor survival (both P < 0.05). In contrast, tumor number (multiple vs single) had no effect on prognosis (HR = 1.3, P = 0.06). Based on these findings, a prognostic scoring system was developed that allotted 1 point each for tumor size >2 cm and vascular invasion. Using this system, pts with early-stage HCC could be stratified into 3 distinct prognostic groups (median and 5-yr survival, respectively: 0 points–60 mos, 49%; 1 point–38 mos, 37%; 2 points–23 mos, 24%; P < 0.001) (Figure).

CONCLUSIONS: Although early-stage HCC is generally associated with a good prognosis, a subset of high-risk pts can be identiﬁed. Pts with early-stage HCC who have tumors >2 cm ± vascular invasion have a signiﬁcantly increased risk of death. These data emphasize the importance of pathologic staging even in small HCC. 182 6303_SSAT.book Page 183 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

1038 Staging Error Does Not Explain the Relationship Between the Number of Nodes in a Colon Cancer Specimen and Survival Jesse Moore*1, Neil H. Hyman1, Peter Callas2, Benjamin Littenberg3 1Surgery, University of Vermont College of Medicine, Burlington, VT; 2Mathematics & Biostatistics, University of Vermont College of Medicine, Burlington, VT; 3Med-Gen Internal Medicine, University of Vermont College of Medicine, Burlington, VT PURPOSE: Survival in colon cancer is greater in those patients who have more lymph nodes identified at the time of resection. It is not clear if this is due to under-staging, confounding by treatment, social or clinical characteristics, or factors intrinsic to the tumor or host response. We studied whether the number of nodes analyzed per specimen remains predictive of survival while controlling for patient factors, surgeon, and hospital. METHODS: A retrospective cohort study of 11,399 patients in the SEER- Medicare database who were diagnosed with Stage I, II, or III colon cancer between 1994 and 1998 was performed. The primary predictor was the number of lymph nodes identified. Cox proportional hazards models were constructed to analyze overall and cancer-specific survival. Analyses were adjusted for age, sex, race, income, use of chemotherapy, surgeon’s specialty, and the usual tendency of the surgeon and hospital to identify lymph nodes. RESULTS: Overall and cancer specific survival was significantly higher as the number of nodes examined increased. Patients with more than 12 nodes examined had a 20% lower hazard (HR 0.80; 95% confidence interval 0.75–0.85) than those with fewer than 7 nodes examined. Controlling for patient factors did not change the hazard ratio associated with an increasing number of nodes. Further controlling for surgeon type, the surgeon’s and the hospital’s mean number of nodes examined per case in the models did not change the hazard ratios associated with an increasing number of nodes. This indicates that something other than patient demographics, treatment, oper-

ating surgeon or the hospital’s process for retrieving lymph nodes accounts WEDNESDAY for the observed effect. ABSTRACTS CONCLUSIONS: The number of analyzed nodes in a colon cancer specimen is predictive of survival, but is independent of patient demographics, surgeon and hospital. This argues strongly against under-staging or confounding as the mechanism for the improved survival with higher node counts. Other factors, such as those intrinsic to the tumor or the host immune response may be responsible for the differences in prognosis.

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POSTER SESSION DETAIL

Printed as submitted by the authors.

Monday, May 19, 2008

CLINICAL SCIENCE POSTERS

Clinical: Biliary

M1500 Acute Calculous Cholecystitis: Indications for Early Percutaneous Cholecystostomy Orly Barak1, Ram Elazay1, Liat Appelbaum2, Avraham Rivkind1, Gidon Almogy*1 1Department of General Surgery, Hadassah University Hospital, Jerusalem, Israel; 2Department of Radiology, Hadassah University Hospital, Jerusalem, Israel OBJECTIVE: To identify risk factors for failure of conservative treatment for acute cholecystitis and to identify earlier patients who will require percutaneous drainage. SUMMARY BACKGROUND: Current treatment options for acute calculus cholecystitis include either early cholecystectomy, or conservative treatment consisting of intra-venous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage of the gallbladder is reserved for patients who have failed conservative therapy or as a salvage procedure for high-risk patients. METHODS: Data on consecutive patients admitted with the diagnosis of acute cholecystitis was prospectively collected from January 01, 2005, through Jun, 31, 2006. Demographic, clinical, laboratory and imaging results were collected. Admission parameters, and parameters at 24 and 48 hours, were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy (PC). Logistic regression analysis was performed to identify predictors for failure of conservative treatment.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

RESULTS: The study population consisted of 103 patients (59 females, 57.3%) with a median age of 60 (range 18–97) who were treated for acute calculus cholecystitis during the study period. Twenty-seven patients (26.2%) required percutaneous drainage. Gender, length of symptoms, and the degree of abdominal tenderness were not different between the groups. On univariate analysis, age >70 years, diabetes mellitus, elevated white blood cell count (WBC) and tachycardia at admission, and sonographic findings of a distended gallbladder were found to be significantly more common in the PC group then in the conservative group (p < 0.001). Tachycardia and elevated WBC were significantly higher in the PC group throughout the initial 48 hours. On multivariate analysis age >70 (odds ratio [OR] 3.6), diabetes mellitus (OR 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were found to be predictors for the need for early cholecystostomy (p < 0.001). Age >70 (OR 5.2) and WBC >15000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (p < 0.001). CONCLUSIONS: The majority of patients suffering from acute cholecystitis can be successfully treated conservatively. Diabetes, age above 70, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (>15000) is a marker of refractory disease and should play a more crucial role in the clinical follow-up and decision-making process of patients with acute cholecystitis. POSTER ABSTRACTS MONDAY

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M1501 Polypoid Lesions of Gallbladder: Diagnosis and Follow-Up Hiromichi Ito*1, Lucy E. Hann2, Michael D’Angelica1, Yuman Fong1, Ronald P. Dematteo1, David S. Klimstra3, Leslie H. Blumgart1, William R. Jarnagin1 1Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; 2Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY; 3Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY BACKGROUND: Polypoid lesions of the gallbladder (PLG) are commonly seen on ultrasonography (US) but optimal management of them is ill- defined. The aims of this study were to assess the natural history and the histological characteristics of US-detected PLG. METHODS: Patients with PLG detected by US from were identified retrospectively. Patients with suspected gallbladder cancer were excluded. Histo- logic findings were analyzed in patients who underwent cholecystectomy and change in polyp size was determined in patients who underwent serial US imaging. RESULTS: From 1996 through 2007, 418 patients with PLG detected on abdominal US were identified. Two hundred and thirty patients (55%) were women and the median age was 59 years (range 20–94). Two hundred and sixty-five patients (64%) were found to have PLG on US during the work-up of unrelated disease while 94 patients (23%) had abdominal symptoms. Three hundred and ninety patients (93%) had PLGs 1cm while 28 patients (7%) had PLGs > 1 cm; 59% of patients had a single polyp and 12% had associated gallstones. Among 141 patients who had repeat US followup, growth was observed in 9 patients (7%), no change in 120 patients (85%) and regression in 12 patients (9%). Eighty patients underwent cholecystectomy and the histological diagnoses are shown in the Table. Most patients had no polyps (32%) or pseudopolyps (57%) (including cholesterol, inflammatory or hyperplastic polyps). Adenomas were seen in 9% of patients while invasive or in situ cancer was only seen in 2 patients, both with lesions ≥11 mm. CONCLUSION: Small PLG (less than 10 mm in diameter) detected by US are infrequently associated with symptoms and can be safely observed. The risk of cancer is size dependent, and cholecystectomy is warranted for lesions greater than 10 mm. Table 1. Pathological Diagnosis of PLG and the Size on US

Largest Diameter of PLG on US Histology <1–5 mm 6–10 mm 11 mm Total (%) Normal gallbladder 8 1 0 9 (11) Cholecystitis (no polyp) 3 3 2 8 (10) Cholelithiasis 6 1 2 9 (11) Cholesterol polyp, cholesterolosis 22 8 3 33 (41) Inflammatory polyp 0 0 3 3 (4) Hyperplastic polyp 5 2 3 10 (13) Adenoma 0 4 3* 7 (9) Adenocarcinoma 0 0 1 1 (1) Total 44 19 17 80 (100)

*including one adenoma with carcinoma in situ

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1502 Single Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope Glenn Forrester*, Eugenius J. Harvey, Steven Binenbaum, John N. Afthinos, Grace J. Kim, Julio Teixeira Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY BACKGROUND: The development of a purely NOTES cholecystectomy will be limited by the safety profile of access techniques and the sophistication of flexible instrumentation. Although NOTES cholecystectomy in humans has been reported, in all cases some form of percutaneous transperitoneal assistance has been required. We report our experience with 8 cases performing a laparoscopic cholecystectomy through a single periumbilical incision using flexible endoscopy. METHOD: From August to October 2007, a total of 8 patients (7 women, 1 man) underwent elective single incision laparoscopic cholecystectomy (SILC) using flexible endoscopic instruments. The patients’ ages ranged from 19 to 67 years old. Access was obtained through a 1.5 cm periumbilical incision. A dual-channel flexible endoscope (Olympus) was inserted into the peritoneal cavity. A 5 mm trocar was inserted through the same incision. In all but one case, dissection of the gallbladder and hilum was performed in a retrograde fashion using flexible endoscopic instruments, while ligation of the cystic duct and artery was accomplished with a standard laparoscopic clip applier. RESULTS: All procedures were completed through the single incision. There were no conversions to either traditional laparoscopic or open technique. Operative time ranged from 1 hour 50 minutes to 4 hours. Six of eight patients were discharged home on the same day of surgery; the other two were kept for observation overnight and were discharged the next morning. There were no complications. CONCLUSION: SILC is a technically challenging though feasible option in select patients requiring laparoscopic cholecystectomy. With fewer incisions, improved cosmetic outcome is an obvious advantage over traditional laparoscopic cholecystectomy. However, further studies are needed to establish its overall safety as well as to evaluate other potential benefits. Additionally, this approach avoids the potential risks of transgastric and transvaginal access while affording surgeons the opportunity to develop advanced endoscopic skills. POSTER ABSTRACTS MONDAY

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M1503 Laparoscopic Cholecystectomy as a Standardized Teaching Operation: A Comparison of Operative Complications and Short-Term Outcome Between Surgical Residents and Attending Surgeons in 1220 Patients Rene Fahrner*, Matthias Turina, Valentin Neuhaus, Thomas Kostler, Othmar Schöb Department of Surgery, Limmattal Hospital, Schlieren, Switzerland INTRODUCTION: Standardized, efficient surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare perioperative morbidity and mortality of laparoscopic cholecystectomy (LC) as a highly standardized teaching operation when being performed by junior and senior surgical residents (SR) as opposed to those performed by attending surgeons (AS), in a hospital with high percentage of laparoscopic operations. MATERIALS AND METHODS: 1220 LC were performed in a university- affiliated Swiss community hospital between 1999 and 2006. There were 788 (65%) female and 432 (35%) male patients, with an average age of 55 years (range 16–93 years); 874 operations were performed electively, 346 cases were urgent operations. All LC performed by resident surgeons were assisted by attending surgeons or chief residents. Intraoperative cholangiography was routinely performed. Observed parameters were the duration of operation and of hospital stay, 30-day perioperative morbidity, mortality, and readmission rate. Results are stated as mean ± SEM, with p < 0.05 defined as statistically significant. RESULTS: Overall length of operation was 92 ± 2 minutes for SR vs. 80 ± 2 minutes by AS (p < 0.001). Elective operations were shorter (91 ± 2 [SR] vs. 76 ± 2 [AS] minutes, p < 0.001) than urgent operations (96 ± 3 [SR] vs. 90 ± 3 [AS] minutes, p = 0.3). Length of hospital stay was shorter in patients treated by SR as compared to those treated by AS (elective LC: 5.2 ± 0.3 days [SR] vs. 6.7 ± 0.2 days [AS], p < 0.001; urgent LC: 6.8 ± 0.6 days [SR] vs. 8.2 ± 0.5 days [AS], p = 0.1). Intraoperative complications occured in 4.2%, and were independent of surgeon’s experience. Bile duct lesions occurred in 0.2% of all patients. Conversion to an open cholecystectomy for technical difficulties was performed in 24 patients (1.9%). Thirty day morbidity was 8.7% in urgent LC versus 3.3% in elective LC (p < 0.001). Overall mortality was 0.4% in elective LC and 1.9% in urgent LC (p > 0.001), again independent of surgical expertise. Discussion: Surgical residents are able to perform LC under appropriate supervision with results comparable to those of experienced surgeons. No differences could be detected with respect to perioperative morbidity or mortality; in particular, serious surgical complications such as bile duct injury are rare and are again independent of surgeon’s’ experience. A struc- tured residency quality control program can improve the quality of surgical care and pinpoint weaknesses of surgical training at individual institutions.

188 6303_SSAT.book Page 189 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1504 Malignant Melanoma of Lung and Gallbladder, Presenting with Hemoptysis: A Case Report and Review of Literature Ming-Chin Yu*, Miin-Fu Chen, Yi-Yin Jan Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan BACKGROUND: Malignant melanoma (MM) has the potential to spread to virtually any organ. We reported a case of MM presenting as hemoptysis, with two suspicious primary foci, lung and gallbladder, confirmed by histology. CASE PRESENTATION: A 56 year-old female smoker presented with pro- ductive cough and hemoptysis for half a year. She denied any dyspnea, fever, malaise, abdominal discomfort, and any personal history of lung or gastrointestinal disease. Chest film disclosed patchy opacity over right lower lung. Thorough physical examination of all skin surfaces, including her oral mucosa, was negative. The patient underwent the right lower lung lobectomy without complication, and a black, firm MM measured 4.7 × 4.5 × 4 cm was found. For searching other possible primary or metastatic site, PET-CT was performed and showed F-18 FDG avid lesions in the gallbladder. Partial hepatectomy and cholecystectomy were done and revealed one black, fragile and polypoid tumor measuring 9.0 × 4.0 × 3.4 cm. Both specimens were proved of MM. DISCUSSION: The pathologic diagnosis of MM in tumors from lung and gallbladder is confirmed by immunochemical study of S-100 and HMB-45. The imaging study of endoscopic ultrasound, computed tomography, and MRI was reported. Surgical therapy should be performed aggressively for complete removal. PET-CT plays a crucial role in detecting asymptomatic MM in gallbladder for this patient, and certainly help for more accurate patient selection for surgical excision. A series of image studies, including CT, MRI, endoscopic ultrasound, and abdominal ultrasound will be presented. After review of the literature, surgical resection is mandatory for improve survival in limited metastatic melanoma. POSTER ABSTRACTS MONDAY

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M1505 Choledochal Cysts: Risk of Malignancy and Outcome in 68 Patients Undergoing Surgical Management at a Single Institution John P. Bois*, Michael L. Kendrick, Michael B. Farnell, Florencia G. Que, John H. Donohue, Christopher Moir, David Nagorney Surgery, Mayo Clinic, Rochester, MN BACKGROUND: Choledochal cysts are an uncommon entity. Surgical management is considered standard of care to prevent morbidity and to avoid the potential risks of malignant transformation. Our aim is to describe the clinical presentation, evaluation, management, and outcome of these patients. METHODS: A retrospective review of clinical, imaging, surgical, and outcome data of patients undergoing surgical management of choledochal cysts from 1982 to 2006 at a single institution. RESULTS: A total of 68 patients (57 female, 11 male) with a mean age of 30 years (range: 2 mo–79 y) were identified. Symptoms prompted evaluation in 96% of patients with abdominal pain (81%), jaundice (21%), and cholangitis (18%) being the most frequent. Cysts were classified as Type I (79%), II (6%), III (4%), or IV (12%). Operative management was based on cyst type and included complete excision (n = 56, 82%), incomplete excision (n = 9, 13%), or biliary diversion (n = 3, 4%). Reconstruction after excision included Roux- en-Y hepaticojejunostomy (n = 42, 62%), hepaticoduodenostomy (n = 15, 22%). Decision to avoid complete cyst resection was based on cyst type, operative findings, and patient comorbidities. Median cyst size was 4.5 cm (range: 1–14). Neoplastic changes of cyst epithelium were identified in 4 (6%) patients, including cholangiocarcinoma in 2. Perioperative major morbidity or mortality occurred in 19% and 0% patients respectively. Follow-up was available in 78% of patients for a mean of 5 years (range: 1–242 months). Recurrent symptoms of cholangitis (n = 3), pancreatitis (n = 1), or chronic liver disease (n = 1) were observed in 9% of patients having undergone complete cyst excision. Of two patients with cholangiocarcinoma at cyst excision, both underwent an R0 resection. An additional patient developed intrahepatic cholangiocarcinoma 7 years after complete cyst excision of a benign type I choledochal cyst. When comparing children (<18 years) (n = 19) with adults (n = 49), no major differences were notable in presentation, surgical management, or outcome, although associated neoplasia was not observed in children. CONCLUSION: Choledochal cysts are an uncommon biliary tract abnormal- ity which my cause significant morbidity and risk of malignancy. While an uncommon harbinger of malignancy, cholangiocarcinoma was identified in 4% of patients at initial cyst resection or on subsequent follow-up. Compared to earlier series, this incidence appears to be decreasing in an era where early complete cyst excision is more widely accepted. Thorough preoperative evaluation, surgical treatment, and follow-up are recommended in patients with choledochal cysts.

190 6303_SSAT.book Page 191 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1506 Single Incision Laparoscopic Cholecystectomy Michael Albrink*, Connor Morton, Desiree Villadolid, Sharona B. Ross, Sarah Cowgill, Donovan Tapper, Alexander S. Rosemurgy Surgery, University of South Florida and Tampa General Hospital, Tampa, FL INTRODUCTION: The application of laparoscopy advanced General Sur- gery. Single Incision Laparoscopic Surgery may prove to be a further advancement, though currently an evolving concept. This study was undertaken to report our early experience with single incision laparoscopic cholecystectomy. PROCEDURE: Cholecystectomies were carried out utilizing two 5 mm ports placed through a single 1 cm incision at the umbilicus. 5 mm 0-degree or 30- degree laparoscopes were used. Sutures were placed into the gallbladder to facilitate extirpation. Gallbladders were removed through the umbilicus. Data are presented as median, mean + SD, where appropriate. RESULTS: Nine patients, six males and three females, of median age 45 years, 43 + 16 and median BMI of 27 kg/m2, 27 + 3.7, underwent single incision laparoscopic cholecystectomy. No patients undergoing attempted single incision cholecystectomies had conversions to “open” operations. Duration of operations was 73 minutes, 71 + 14.1. No intraoperative inadvertent events or complications occurred. Intraoperative blood loss was minimal. All patients had documented cholelithiasis and chronic cholecystitis. One patient experienced signiﬁcant nausea and pain postoperatively, leading to a 3-day hospital stay. Eight patients were discharged within 23 hours. CONCLUSIONS: Single incision laparoscopic cholecystectomy is feasible and safe, though it may require more time than conventional laparoscopic cholecystectomy. While many parameters of laparoscopic cholecystectomy are not notably impacted by single incision laparoscopic cholecystectomy, cosmesis and patient satisfaction is subjectively improved. Realistically, randomized trials comparing laparoscopic cholecystectomy to single incision laparoscopic cholecystectomy will doubtfully be undertaken. Nonetheless, single incision laparoscopic cholecystectomy will be embraced by consumers. Laparoscopic surgeons need to become proﬁcient in Single Incision Laparoscopic Surgery to meet consumer demand. POSTER ABSTRACTS MONDAY

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M1508 Plugging Away at the Anal Fistula: An Exercise in Futility? Galal S. El-Gazzaz*, Massarat Zutshi, Tracy L. Hull Colorectal surgery, Cleveland Clinic, Cleveland, OH PURPOSE: The many options for treatment of anal fistulas indicate that no one option has consistent results. The aim of this study was to analyze the efficacy of the Cook Surgisis® AFP™ anal fistula plug for the management of complex anal fistulas in our institution. METHODS: A retrospective review of all patients who underwent treatment for complex anal fistulas using Cook Surgisis® AFP™ anal fistula plug between October 2005–2007 was undertaken. Patient’s demographics, fistula etiology and success rates were recorded. The plug was placed in accordance with the company’s guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of any inflammation process. RESULTS: Thirty three patients underwent 49 plug insertions. The median age of the patients was 44.35 (±13.18) years; 18 females and 15 males. The fistula etiology was cryptoglandular in 20 (61%) patients and Crohn’s disease- associated in the 13 (39%) patients (23 high transphincteric; 8 low anal and 2 rectovaginal). Two patients had concomitant treatments; one underwent concomitant anal advancement flap at the time of plug placement and failed, the other underwent concomitant fibrin glue in multiple fistulas and healed. There were 11 smokers, 4 patients with diabetes and 7 patients on steroids. The mean follow up was 251.12 days (±163.06). One patient was lost to follow up. Twenty one patients had previously undergone failed surgical therapy to cure their fistula (anal advancement flap in 8, fistulotomy 10 and fibrin glue in 3). Twenty nine patients had draining setons in-situ at the time of plug placement. The mean time the seton was in place before insertion of plug was 55 days (range 31–143 days). The overall success rate was 11/48 (41%). The success rate after first attempt was 8/33 (24%), 2/14 (14%) after second attempt and 1/2 (50%) after third attempt. Two of the 22 (15%) Crohn’s disease-associated fistulas healed and 9 out of 26 (12.5%) procedures resulted in healing of cryptoglandular fistulas. The reasons for failure were sepsis in 31 procedures (87.0%), plug dislodgement in 6 (13.0%) procedures. Other predictor factors were race (African-American patient’s healing rates were higher p = 0.009), low fistula (internal os below dentate line) did better than high fistula, also presence of seton had a better outcome (p = 0.05). CONCLUSIONS: Anal fistula plug is associated with a low success rate than previously reported. African-Americans and presence of seton at time of plug placement were predictors of good outcome.

192 6303_SSAT.book Page 193 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1509 Clinical Feature and Management of Postoperative Pouch Bleeding After Ileal Pouch-Anal Anastomosis (IPAA) Lei Lian*, Victor W. Fazio, Feza H. Remzi, Pokala R. Kiran, Christine Hannaway, Bo Shen Digestive Disease Center, Cleveland Clinic, Cleveland, OH AIM: The clinical features of postoperative pouch bleeding vary and the management can be difficult. There is no published literature regarding pouch bleeding and its treatment. METHODS: Pouch bleeding was defined as significant bleeding or passing of clots transanally or into loop ileostomy bag with/without hypotension or drop in hemoglobin within 30 days after surgery. Patients were identified from a prospectively maintained Pouch Database. RESULTS: Pouch bleeding developed in 47 (1.5%) patients out of 3194 patients undergoing IPAA since 1983. 42 had inflammatory bowel disease, 4 had familial adenomatous polyposis, and 1 had colonic inertia. Staple line reinforcement was used in 17 (44.7%) patients with J pouch. 66% bleeding occurred within 7 days, of who 41.9% had postoperative anticoagulant use for thrombosis prophylaxis. 34 (72.3%) bled from neo-rectum, 9 from ileostomy, 2 from both. 2 patients had concurrent abdominal bleeding and 2 had anemic symptoms who were later found bleed from pouch by endoscopy. After initial fluid resuscitation, 28 patients had pouch endoscopy and clot evacuation followed by cauterization or iced saline and saline with epinephrine (1:100000) enemas. 27 of 28 had cessation of bleeding within 24 hours. 1 patient required 3 days of enema treatment before complete cessation. Epi- nephrine enema was used as initial treatment in 12 patients. 1 patient failed and had endoscopy with cauterization of bleeding point. 5 patients were observed. 28 patients were transfused. No surgery was required for pouch bleeding. 1 patient had reoperation and 1 patient died after transferred to intensive care unit due to concurrent intra-abdominal bleeding.

Table 1. Comparison: Patients with and without Pouch Bleeding

Pouch Bleeding No Pouch Bleeding p-value (N = 47) (N = 3147)

Age 33.3 ± 10.5 47.3 ± 13.8 0.011 POSTER ABSTRACTS Gender = male 34 (72.3%) 1752 (55.5%) 0.106 MONDAY Pouch type = J (vs. S) 38 (80.9%) 2764 (87.8%) 0.148 Anastomotic type = Stapled 35 (74.5%) 2618 (83.2%) 0.114 (vs. Hand-sewn)

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Table 2. Management of Pouch Bleeding and Outcomes

Initial Treatment: Endoscopy and Clot Evacuation (No. = 28,59.6%) Followed by Cauterization (Active Bleeding) 15 (53.6%) Followed by Epinephrine Enema (No Distinct Bleeding) 13 (46.4%) Initial Treatment: Epinephrine Enema (No. = 12,25.5%) Success 11 (91.7%) Need Endoscopy and Cauterization 1 (8.3%) Observation with/without Transfusion 5

CONCLUSION: Postoperative pouch bleeding after IPAA usually required intervention and can be managed nonoperatively. Pouch endoscopy with clot evacuation and cauterization of visible bleeding point followed by iced saline and saline with epinephrine enema is successful in managing this complication.

194 6303_SSAT.book Page 195 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1510 Dosimetric Evaluation of Endoscopic Radiofrequency Ablation in the Human Colonic Epithelium in a Treat and Resect Trial Joseph A. Trunzo*1, Michael F. Mcgee1, Benjamin K. Poulose1, Joseph Willis2, Bridget Ermlich1, Michelle Laughinghouse1, Bradley J. Champagne1, Conor P. Delaney1, Jeffrey M. Marks1 1Surgery, University Hospitals Case Medical Center, Cleveland, OH; 2Pathology, University Hospitals Case Medical Center, Cleveland, OH BACKGROUND: Radiofrequency ablation (RFA) has been used effectively for the treatment of Barrett’s esophagus. This technology may additionally have a role in the treatment of bleeding or neoplasia in the lower GI tract. The goal of this study was to determine the optimal treatment parameters to create ablative effect to the colonic mucosa/submucosa, without deeper transmural colonic injury. METHODS: In this IRB approved protocol, patients undergoing elective left colon or rectal resection were enrolled. Once margins of resection were determined intra-operatively, a colonoscope mounted with a planar RFA device (HALO90, BÂRRX Medical) with a 13 mm by 20 mm bipolar array was advanced to the resection segment. Areas of normal mucosa were ablated in situ with 2 or 4 applications (APP) while varying energy density (12, 15, or 20 J/cm2). After removal with the surgical specimen, ablation zones and untreated normal adjacent tissue were multiply sectioned and stained with H&E. An expert GI pathologist, blinded to the treatment parameters, assessed the deepest histological layer with any histopathological change (inﬂamma- tion, ablation, abnormal pattern, necrosis.) RESULTS: We created 51 ablations zones in 16 patients. When comparing max depth of histological change in 2 vs. 4 APP, regardless of energy density, evidence of serosal change occurred in 0% (0/24) vs. 15% (4/27) of zones (p = 0.11), whereas changes to the muscularis propria (MP) occurred in 25% (6/24) vs. 63% (17/27) of zones (p < 0.05).Comparing energy density settings of 12, 15, and 20 J/cm2, regardless of APP, we observed an unexpected inverse relationship of energy vs depth, in that changes were present in MP in 74% (17/ 23), 35% (6/17), and 0% (0/11), respectively (P < 0.05); and in serosa in 9% (2/23), 12% (2/17), and 0% (0/11) (P = 0.517). No changes in serosa were seen in any 2 APP ablation zone at any energy density. POSTER ABSTRACTS CONCLUSIONS: We observed a direct correlation between APP and ablation effect depth for this device in the colon. All ablation zones at 2 APP demon- MONDAY strated no changes to the serosa and only a 25% incidence of MP changes. We observed an unexpected inverse relationship between energy and ablation depth, counter to reports in similar trials involving the esophagus. This observed variability may be due to inconsistent electrode approximation to mucosa, variable colonic wall thickness, and possible coagulum formation on the electrode preventing conduction of energy. This evaluation has identiﬁed a safe treatment parameter (12 J/cm2, 2 APP) that penetrates no deeper than MP, and will guide follow-up trials for disorders of the lower GI tract, including hemorrhagic radiation proctitis.

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M1511 A Population-Based Study of Surgical Treatment of Colon Cancer in Ontario, Canada Rahima Nenshi*1,2, Marko Simunovic5,3, Nancy N. Baxter4,3, Nadia Gunraj3, Erin Kennedy2, Sue Schultz3, Drew Wilton3, David R. Urbach2,3 1University of Toronto, Toronto, ON, Canada; 2University Health Network, Toronto, ON, Canada; 3Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; 4St. Michael’s Hospital, Toronto, ON, Canada; 5Hamilton Regional Cancer Centre, Hamilton, ON, Canada BACKGROUND: Colorectal cancer is the third most common cause of cancer and the second most common cause of cancer death among Canadian men and women. In 2007, an estimated 8,129 persons in Ontario, Canada will be diagnosed with colorectal cancer and 2,793 will die from this disease. Surgical treatment is the cornerstone of the management of colorectal cancer; however there are few population-based reports of patterns of treatment. Lap- aroscopic colorectal surgery is also changing the surgical approach to the treatment of colorectal cancer. We used a population-based cancer registry and administrative health data to describe patterns of the surgical treatment of colon cancer in Ontario in the period 2003–2004. METHODS: We linked data from administrative health databases (Canadian Institute for Health Information [CIHI] and the Ontario Health Insurance Plan [OHIP]) to a population-based cancer registry (the Ontario Cancer Regis- try [OCR]) to measure hospitalizations and surgical treatment received by all patients with a new diagnosis of colon cancer in Ontario from March 1, 2003 to April 30, 2004. RESULTS: During this 1 year period, 5265 residents of Ontario were newly diagnosed with primary colon cancer. Of these, 50.9% were men and 20.3% were aged less than 60 years. 91.2% of all patients had a surgical procedure. Among persons aged less than 60 years, 1.3% (95% conﬁdence interval [95% CI] 0.5–1.9) had a resection with a permanent stoma, 11.9% (95% CI 9.9–14) had a resection with creation of a reversible stoma, 69.1% (95% CI 66.2–71.9) had a resection with primary anastomosis and 17.8% (95% CI 15.4–20.1) had an “other” surgical procedure (intestinal bypass, local excision or other abdominal procedure). Among persons older than 60 years, 1.1% (95% CI 0.8–1.4) had a resection with a permanent stoma, 11.5% (95% CI 10.5–12.6) had a resection with creation of a reversible stoma, 70.7% (95% CI 69.3–72.1) had a resection with primary anastomosis and 16.7% (95% CI 15.5–17) had an “other” surgical procedure. 354 (7.4%) of all cases were done laparoscopically. Among persons aged < 60 years, 8.8% (95% CI 7.1–10.6) had laparoscopic surgery compared to 7% (95% CI 6.2–7.8) in the older group (p for difference = 0.047). There was no difference in the rate of laparoscopic procedures between men and women. CONCLUSIONS: The majority of patients newly diagnosed with colon cancer in Ontario undergo resection without creation of a stoma. There was no signiﬁcant difference in rates of the different types of surgery received according to age. Less than 10% of operations were done laparoscopically and younger patients were more likely to undergo laparoscopic procedures.

196 6303_SSAT.book Page 197 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1512 Health Related Quality of Life and Clinical Outcome After Colonic Resection for Diverticular Disease: Long-Term Results Marco Scarpa, Duilio Pagano, Cesare Ruffolo, Anna Pozza, Francesa Erroi, Lino Polese, Davide F. D’Amico, Imerio Angriman* Clinica Chirurgica I°, University of Padova, Padova, Italy BACKGROUND AND AIMS: Colonic resection is mandatory in complicated colonic diverticular disease (DD). The most appropriate treatment in case of recurrent diverticulitis episodes, is less clear. The aim of the present study was to evaluate the long term clinical outcome and quality of life in patients affected by DD submitted to colonic resection compared to those who had only medical treatment. PATIENTS AND METHODS: Seventy-one consecutive patients admitted in our department for left iliac pain and endoscopical or radiological diagnosis of diverticular disease were enrolled. During the hospital stay 25 of them underwent colonic resection while 46 were treated with medical therapy. Dis- eased severity was assessed with Hinchey scale. After a median follow up of 47 (3–102) months after colonic resection, they were interviewed and they answered to Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire. Admittance and surgical procedures for DD were also investigated and surgery- and symptoms-free were calculated. Non parametric tests and survival analysis was used. RESULTS: After the follow up, CGQL total score obtained by the two patients were similar as well as the symptoms frequency. Only current quality of health item was signiﬁcantly worse in patients who had undergone colonic resection (p = 0.05). No difference was evidenced in the rate and in the timing of surgical procedures and hospital admitting for DD in the two groups. In particular the 9 patients who had been operated on for an Hinchey 1 class diverticulitis reported the same quality of life, symptoms frequency, operation and hospital admitting rate than those who had been admitted for an Hinchey 1 class diverticulitis and treated conservatively. CONCLUSIONS: Our study did not show any long term advantage in sub- mitting patients to colonic resection for DD. Thus, in our opinion, surgical resection should be reserved to patients who present with a complicated DD

and not to patients who present a mere abdominal discomfort attributed POSTER ABSTRACTS to DD. MONDAY

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M1513 Prognostic Factors for Survival in 61 Patients with Carcinoma of the Splenic Flexure Simon S. Ng*, Janet F. Lee, Wing Wa Leung, Raymond Y. Yiu, Jimmy C. Li, Sophie S. Hon, K. L. Leung Surgery, The Chinese University of Hong Kong, Hong Kong, China BACKGROUND: While carcinoma of the splenic flexure is uncommon, it is associated with a high risk of obstruction and a poor prognosis. The aim of this study was to evaluate the prognostic factors for recurrence and survival after surgery for carcinoma of the splenic flexure. METHODS: Between March 1986 and September 2007, a total of 2987 patients with colorectal carcinoma underwent surgery at our institution, of whom 61 (2%) had carcinoma of the splenic flexure. The clinicopathological factors possibly predicting survival among these 61 patients were retrospectively reviewed. Survival was calculated using Kaplan-Meier method and compared by log-rank test. Multivariate analysis was performed using Cox’s regression model. RESULTS: Forty-five patients (73.8%) underwent curative surgery (leaving no residual or metastatic disease). Thirty-five patients (57.4%) presented with intestinal obstruction and underwent emergency surgery. Multivisceral resections were needed in 14 patients (23%). Postoperative morbidity and mortality developed in 26 (42.6%) and 6 (9.8%) patients, respectively. Among patients surviving surgery, the cancer-specific survival at 5 years was 47.1%. Postoperative morbidity (P = 0.016), T4 tumour (P < 0.001), and non-curative surgery (P < 0.001) were found to be independent prognostic factors for poor cancer-specific survival. Thirteen patients developed recurrence after curative surgery, and the probability of being disease free at 5 years was 62%. Postop- erative morbidity (P = 0.020) and T4 tumour (P < 0.001) were found to be independent predictors for recurrence. Intestinal obstruction and surgical approach were not predictors for poor survival. CONCLUSION: In addition to curative surgery, T stage of tumour and postoperative morbidity are found to be independent prognostic factors for survival after surgery for carcinoma of the splenic flexure.

198 6303_SSAT.book Page 199 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1514 Risk of Infection and Recurrence over Prolonged Follow Up in Patients Undergoing Ventral Hernia Repair During Colorectal Resection: Can the Use of Mesh Be Justified? Levilester B. Salcedo*, Ravi P. Kiran, Ian Lavery, James M. Church, Victor W. Fazio Colorectal surgery, Cleveland Clinic, Cleveland, OH PURPOSE: Concerns pertaining to the risk of wound infection and subsequent need for mesh excision or recurrence deters the use of mesh to repair ventral hernia during colorectal resection. We evaluate the risk of infection and hernia recurrence after mesh repair in these patients over a prolonged follow up period. METHODS: A retrospective review of 274 patients with mesh repair for ventral hernia during colorectal surgery from 1991–2007 was done. Patients who did not have a bowel resection and those with only parastomal hernia were excluded. Patients demographics, diagnosis, comorbidity, size of defect, mesh type, surgical technique and early complications were evaluated from medical records. Long term follow up was determined by telephone interviews. Patients who had recurrence were compared with those without recurrence using Fishers exact, Chi-squared and Wilcoxon tests as appropriate statistical tools. RESULTS: 110 patients (56% male,mean age 59,median BMI 29) met the inclusion criteria. Diagnoses included colorectal cancer (n = 34), Crohn’s (n = 25), Diverticulosis (n = 18), ulcerative colitis (n = 16) and others (n = 17). Goretex (n = 39), Prolene (n = 38), Permacol (n = 23), Alloderm (n = 4), Bard composite (n = 3), Surgisis (n = 1) and others (n = 2) were used intraperitoneally with mean fascial defect of 10 × 11 cm. Mean follow up was 4 years. Rate of wound infection was 13.6% and recurrence 40%. Patients who had recurrence (n = 44) and non-recurrence (n = 66) had similar age (p = 0.4), gender (p = 0.2), BMI (p = 0.4), smoking history (p = 0.8), pulmonary comorbidity (p = 0.9), type of mesh (p = 0.7) and drain use (p = 0.5). A significantly greater proportion of recurrent group had hypertension (p < 0.05), diabetes (p < 0.01), larger fascial defect (p < 0.05), steroid use (p < 0.05), emergency surgery (76 vs 24%, p < 0.001) and wound infection (7 vs 4%, p < 0.05). On long term follow up, additional 6 patients (4 from recurrent group and 2 non- recurrent group) developed wound infection requiring readmission. 78% of patients were satisfied with their surgery. Quality of life for recurrent and POSTER ABSTRACTS

non-recurrent group was comparable (p = 0.5). MONDAY CONCLUSIONS: Recurrence following mesh repair of ventral hernia during colorectal resection is associated with emergency surgery, large fascial defects, presence of comorbidities, perioperative steroids and wound infection. In these situations use of synthetic mesh may be best avoided until conditions are more favorable.

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M1515 The Prognostic Significance of Circumferential Resection Margin Involvement in Colon Cancer Selman Sokmen*1, Mucahit Ozbilgin1, Aras Emre Canda1, Sulen Sarioglu2, Ozgul Sagol2, Mehmet Fuzun1 1Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey; 2Pathology, Dokuz Eylul University School of Medicine, Izmir, Turkey PURPOSE: Failure pattern after colon cancer surgery demonstrated that tumors localized at non-peritonealized part of the colon and sited adjacent to anatomically narrow mesentery were responsible for locoregional recurrent disease and reduced survival. The aim of this study was to assess the prognostic significance of circumferential resection margin (CRM) involvement in patients who underwent potentially curative resection for colonic cancer. METHODS: Prospectively collected clinicopathological data of 107 patients (T3–T4 tumors) who underwent curative radical resection were analyzed. The CRM represents the retroperitoneal or peritoneal adventitial soft tissue margin closest to the deepest penetration of tumor. RESULTS: CRM was not involved in 96 patients and involved in 11 patients. There was a significant association between CRM involvement and lymphatic vessel invasion, lymph node positivity, number of involved lymph nodes, and overall TNM stage (p < 0.01). Number of involved lymph nodes and overall TNM stage were independent predictors of clinical outcome. CRM positive tumors were associated with increased local recurrence and distant metastasis (p < 0.01). The median survival for patients with CRM involvement was only 13 months compared to 20 months without CRM involvement. CRM status had a significant prognostic value in T4 tumors (Figure 1).

CONCLUSION: The CRM involvement in the colon can be considered to be representative of advanced tumor spread. The CRM status is an important predictor of local and distant recurrence as well as survival. Patients with CRM involvement may beneﬁt from adjuvant treatment. It should be routine to comment on this prognostic factor in histopathology reports of resected colonic specimens.

200 6303_SSAT.book Page 201 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1516 Results of Surgical Treatment of Local Recurrence in Rectal Cancer Patients Jörn Gröne*, Martin Kruschewski, Joerg P. Ritz, Uwe Pohlen, Hubert G. Hotz, Monika Ciurea, Anton J. Kroesen, Heinz J. Buhr Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany BACKGROUND AND AIM: The implementation of total mesorectal excision (TME) in surgical treatment of rectal cancer has resulted in a reduced local recurrence rate. In spite of these technical improvements and multimodal therapy concepts local recurrence still occurs in 8%–16%. Tumor recurrence in the small pelvis continues to be a major challange für surgery. The only chance for cure in these patients is a new R0 resection. The aim of the study was to evaluate the rate of successfull R0 resection in patients with local recurrence of rectal cancer and the morbidity and mortality rates associated with extended surgical treatment. METHODS: Prospective observational study of all consecutive surgically treated patients with local reccurrence of rectal cancer in our department from 01st january 1995 to 30th june 2007. RESULTS: In that period 1314 patients with colorectal cancer underwent surgical treatment. Local recurrence of rectal cancer was diagnosed in 90 patients (7%), 52 men und 38 women, with median age of 65 years. Intralu- minal recurrence was diagnosed in 18%, extraluminal tumor in 77% and both, inta- and extraluminal tumor recurrence was found in 56% of the patients. 67% of the patients (n = 60) have been treated by tumor resection. In 37 patients (62%) surgery resulted in local R0 resection. R1 situation was histologically proven in 13 patients (22%) and a local R2 situation was diagnosed in 10 patients (16%). The rate of surigical major complications was 19%: 3 lesions of the ureter, 1 lesion of the bladder, 1 leakage of colon anastomosis, 5 abscesses (intraabdominal, sacral cavity), 1 ﬁstula of the small intestine, 2 intraabdominal bleeding, 1 prolonged intestinal paralysis and 3 disruptions of bladder function. Surgical revision rate was 4%, 30 days mortality was 5%. SUMMARY: (1) Most of the local recurrent tumor manifestions were located extraluminally. (2) More than 60% of the patients were treated by resection whereof in another two-thirds R0 resection succeeded. (3) Surgical treatment of local recurrence of rectal cancer is associated with a notable complication POSTER ABSTRACTS rate whereas mortality rate seem to be acceptable in comparison with morbidity.

(4) Surgical treatment of local recurrence of rectal cancer should be performed MONDAY primarily in specialized centers.

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M1517 Preoperative Plasma Levels of Fractalkine (CX3CL1) Are Significantly Lower in Patients with Adenocarcinoma of the Colon When Compared to Benign Disease Patients Aviad Hoffman*, Raymond Baxter, Ik-Yong Kim, Kumara H. Shantha, Abu Nasar, Vesna Cekic, Vincent Dimaggio, Daniel L. Feingold, Richard L. Whelan Surgery, Columbia University, New York, NY INTRODUCTION: Chemokines are a group of small proteins that play a part in angiogenesis, inflammation, tumor cell migration as well as lymphocyte and leukocyte recruitment, activation and chemotaxis. Fractalkine (CX3CL1) is a chemokine found on the surface of normal and malignant intestinal epithelial cells and also in the plasma in a soluble form. Its receptor, CX3CR1, is found on monocytes/macrophages, natural killer cells, and T cells. High tissue expression levels of fractalkine in colon cancers has been linked to better prognosis, presumably via recruitment of lymphocytes (tumor infiltrating lymphocytes) and immune cells to the tumor. Soluble fractalkine increases monocyte, NK cell, and T-cell chemotaxis and has also been shown to independently inhibit liver and lung metastases in the murine setting. Blood fractalkine levels have not been well studied thus far. It is possible that soluble fractalkine levels in the plasma may be altered in the cancer population and predictive of disease stage or prognosis. As the first step in evaluating soluble fractalkine as a cancer marker, plasma levels of this chemokine were determined in patients with cancer or benign colonic diseases. METHODS: Blood samples were taken preoperatively from 50 colorectal cancer patients and from 50 patients with benign colonic diseases. Plasma levels of soluble human Fractalkine were measured using a homemade ELISA kit in duplicate. Results are presented as mean ± SD. The Mann Whitney U-test and the students t-test were used (p-value < 0.05 was considered significant). RESULTS: The mean age of the patients was similar (Cancer 66.9, Benign 63.8). The majority of the benign disease patients had adenomas. The cancer stage breakdown was: Stage 1, 12; Stage 2, 17; Stage 3, 18, and Stage 4, 3 patients. Preoperative fractalkine values in cancer patients were significantly lower than those in benign patients (256.7 ± 116.9 pg/ml vs 438.5 ± 400.3 pg/ ml respectively, p = 0.005). No differences in fractalkine levels was noted between cancer stages. CONCLUSION: Cancer patients were found to have significantly lower plasma fractalkine levels than benign disease patients, however, no correlation was found between cancer stage and blood levels. Additional study is needed to determine whether plasma levels return to normal after surgery and to further investigate the potential role of fractalkine as a tumor marker.

202 6303_SSAT.book Page 203 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1518 Hemorrhoidectomy in Day Surgery: A Comparison Between Four Techniques Vito Maria Stolfi, Pierpaolo Sileri*, Chiara Micossi, Alessandro Falchetti, Achille Lucio Gaspari Surgery, University of Rome Tor Vergata, Rome, Italy INTRODUCTION: We report the results of a prospective randomized study comparing 4 techniques of surgical treatment of haemorrhoids in the Day Surgery department of our teaching Hospital. The hypothesis of the study was that hemorrhoidectomy in day care is feasible and safe, the aim of the study was to compare 4 techniques: Ferguson closed Hemorrhoidectomy (FH), Milligan Morgan hemorrhoidectomy (MMH), Longo Hemorrhoidopexy (LH), Hemorrhoidectomy with Ligasure (radiofrequency) (RFH). PATIENTS AND METHODS: Between January 2004 and June 2007, 413 patients, 231 male and 182 female, mean age 48.28 ± 12.97 were prospectively enrolled in this study and enclosed in a data base. Only ASA I and ASA II patients were included. Visual analogic scale (VAS) was recorded daily for 8 days. Postoperative duration of pain, soiling and bleeding, complications and recurrence were recorded. Statistical evaluation included chi square test for qualitative variables, parametric test for quantitative variables. Statistical testing was carried out on the basis of the following hypothesis: bilateral test and a first degree α-error risk of 0.05 (α = 5%). RESULTS: pain in the first 8 days was less (p = 0.05) in LH compared the other techniques which were not significantly different among them. Patients had prescription for Ketorolac 20 mg up to t.i.d. The rest of the data observed are gathered in table I. Postoperative pain duration showed LH vs MMH (p = 0.05). Soiling and bleeding were significantly less in LH vs MMH, RDH, FH (p < 0.02). Anal fissure was significantly higher in LH vs MMH and FH, p = 0.05, while anal stricture was significantly higher in RFH vs LH p = 0.05. recurrence and urgency at defecation had significantly higher rates in LH compared to MMH, FH, RFH. CONCLUSION: LH had some advantages in postoperative symptoms pain, pain duration, soiling and bleeding compared to the other techniques, although showed higher rate of anal fissure, urgency and recurrence, and a higher cost. Longo Ligasure MMH Ferguson Number of cases 108 137 81 87 Pain durat. (days) 14 ± 10.9 15.5 ± 9.9 19.4 ± 14.6 16.3 ± 10.4 POSTER ABSTRACTS Soiling duration 5.6 ± 8.5 17.8 ± 17.4 17.5 ± 13.2 19 ± 18.9 Bleeding duration 6.5 ± 8.5 11.3 ± 13.8 18 ± 15.2 15.2 ± 13.6 MONDAY Hitching duration 6.1 ± 13.3 9.8 ± 15.8 7.0 ± 14.8 7.6 ± 15.9 Complications Anal fissure 6 (5.5%) 4 (2.9%) 0 1 (1.1%) Anal stricture 2 (1.8%) 6 (4.3%) 2 (2.4%) 2 (2.3%) Hemorrhage 5 (4,6%) 7 (5.1%) 2 (2.4%) 2 (2.3%) Recurrence 6 (5.5%) 2 (1.4%) 2 (2.4%) 1 (1.1%) Urgency 6 (5.5%) 2 (1.4%) 0 1 (1.1%) Fecal incont. 1 (0.9%) 0 0 0

Poster of Distinction 203 6303_SSAT.book Page 204 Tuesday, April 22, 2008 1:26 PM

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M1519 Comparison of Quality of Life (QOL) Between Ileal J Pouch-Anal Anastomosis and Permanent Ileostomy After Proctocolectomy for Ulcerative Colitis in Elderly Patients Munenori Nagao*1, Kouhei Fukushima1, Chikashi Shibata1, Koh Miura1, Hitoshi Ogawa1, Yuji Funayama2, Michiaki Unno1, Iwao Sasaki1 1surgery, Tohoku university, Sendai, Japan; 2surgery, Tohoku-Rosai hospital, Sendai, Japan AIM: The aim was to study if different operative procedures affect postoperative QOL in elderly patients (≥50 years) with ulcerative colitis (UC). METHODS: Questionnaire to score QOL was mailed to each patient, and IBD-Q of Japanese edition was used for questionnaire. IBD-Q consists of questions asking bowel symptoms, systemic symptoms, emotional functions, and social functions. Patients were classiﬁed into 2 groups; young group (N = 18, 20–29 years old) as control and old group (N = 41, 50 years or older). Old group was further classiﬁed into 2 groups by operative procedures; 19 patients undergoing proctocolectomy with ileal J pouch-anal (canal) anastomosis (IPA(C)A group) and 22 patients undergoing proctocolectomy with permanent ileostomy (stoma group). All patients in young group underwent proctocolectomy with IPAA. RESULTS: There was no difference in the median age between IPA(C)A (56.5 years: range 50–75) and stoma (64.2 years: range 52–75) groups. Median total QOL scores did not differ between IPA(C)A (160) and stoma (166) group. The same was true for bowel function scores (55 in IPA(C)A group, 52 in stoma group), systemic function scores (24 in IPA(C)A group, 21.5 in stoma group), emotional function scores (66 in IPA(C)A group, 68 in stoma group), and social function scores (23 in IPA(C)A group, 21.5 in stoma group). Median total QOL scores in old group (166) were lower than those in young group (180, p < 0.05). Bowel symptom scores and social function scores in old group (54 for bowel symptom scores and 23 for social function scores) were also low compared to young group (61 for bowel symptom scores and 27 for social function scores, p < 0.05). Systemic function scores and emotional function scores were not different between old and young groups. CONCLUSIONS: Proctocolectomy with permanent ileosotomy was considered an acceptable procedure for elderly patients with UC, because not only total QOL scores but also each functional score did not differ between old patients undergoing IPA(C)A and permanent ileostomy. Total QOL scores as well as bowel symptoms and social functions were impaired in old patients compared to young patients.

204 6303_SSAT.book Page 205 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1520 CT Scan in the Diagnosis of Acute Appendicitis: Help or Hindrance? Akpofure Peter Ekeh*, Benjamin Monson, Curtis Wozniak, Jennell Smith, Mary C. Mccarthy, Alex Little Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH OBJECTIVE: The use of preoperative abdominal Computerized Tomography (CT) in the evaluation of presumed appendicitis has improved diagnostic accuracy and reduced negative appendectomy rates. We sought to identify the effect of the increased use of CT on the time to operative intervention and perforation rates at a single institution. METHOD: Patients who had appendectomies for presumed appendicitis between January 2000 and May 2006 were identified. Patients who had preoperative CT were recognized as was the type of CT technology used at the time of presentation (single slice, 4-slice or 16-slice). The length of time between presentation to the emergency department and the operative procedure, and histopathology reports were reviewed. RESULTS: In the studied period, 1416 appendectomies were performed for presumed appendicitis. Preoperative CT was performed in 56% of patients (30.2% in the single-slice period, 55.8% in 4-slice period and 78.6% in16-slice period.) The average time between presentation and commencement of surgery was increased in patients who had preoperative CT—12.2 ± 9.8 hours vs. 7.7 ± 6.3 hours in patients without preoperative CT. This was statistically significant (p < .001) The results were similar in the single slice, 4-Slice and 16-slice periods. There was also a statistically significant increase in the perforation rate in patients with preoperative CT (16.4% vs. 6.0%; p < 0.01). Preoperative CT was noted to be an independent risk factor for perforation by multivariate analysis—odds ratio of 3.16 (95% CI 2.09–4.77). CONCLUSION: Preoperative CT improves preoperative diagnostic accuracy for acute appendicitis but is associated with a delayed time to surgery and an increase in the perforation rate. Its use should be more selectively applied for these reasons. POSTER ABSTRACTS MONDAY

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M1521 The Likely Cause of Postoperative “Feeding Intolerance” and Its Prevention Gerald Moss* Biomedical Engineering Department, Rensselaer Polytechnic Institute, Troy, NY HYPOTHESIS: “Feeding intolerance” results from localized proximal G-I distention caused by total inflow to the feeding site (feedings + secretions) exceeding peristaltic outflow. Vagal reflexes initiate a “downhill spiral” that paralyzes the already sluggish gut, leading to generalized distention, poor respiratory mechanics, etc. METHODS: We studied consecutive surgical patients (160 cholecystectomy, 17 colectomy, and 3 esophagectomy). All were immediately fed elemental diet @ ≥100 kcal/hour into the distal duodenum. Efficient aspiration 7 cm proximal to the feeding site removed all air and any excess liquid (confirmed by X-ray). Colectomy patients had contrast X-ray motility study. Serial analyses were conducted for serum amino acids and glucose; aspirate was assayed for removed foodstuff; hourly nitrogen balances were determined. Cholecys- tectomy aspirate was replaced by IV fluids. Colectomy patients had degassed aspirate “refed” manually. Esophagectomy patients were “refed” automati- cally, in effect performing a “check for residual” every 30 seconds. RESULTS: No adverse events were attributable to the feeding-decompression regimens. Aspirate was free of feeding solution within two hours; serum levels of amino acids had risen above basal; glucose was >150 mg/dl. Most (even non-diabetics) required supplemental insulin to maintain euglycemia. Requirement for insulin dependent diabetics rose markedly during those initial 24 hours. All except esophagectomy patients (still on respiratory support) tolerated their usual diets by 24 hours after surgery without supplemental insulin.Every cholecystectomy patient (160:160) had a cathartic induced bowel movement, and was discharged within 24 hours of surgery. One patient (1:160) died of a pulmonary embolus 29 days later. One patient (1:160) developed an abdominal infection. One patients (1:160) was re- admitted for percutaneous aspiration of a sterile biloma. One patient (1:160) was re-admitted for a transient ischemic attack. Normal motility was noted within hours of colectomy. Net absorption was >2,300 kcal the initial 24 hours. Contrast traversed secure anastomoses to exit in a bowel movement within 48 hours, and all achieved positive protein balance within 2–24 hours. Four patients were discharged uneventfully 24 hours after colectomy. “Refed” patients had only 100–200 ml/day of aspirate discarded, containing <100 ml of elemental diet. CONCLUSIONS: “Feeding intolerance” appears to be triggered by G-I distention at the intestinal feeding site. A regimen that titrates inflow to match peristaltic outflow prevents this complication, while permitting more rapid achievement of nutritional goals.

206 6303_SSAT.book Page 207 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1522 The Clinical Significance of Adult Intussusception Found by Computed Tomography Parissa Tabrizian*1, Scott Q. Nguyen1, Alexander Greenstein1, Uma Rajhbeharrysingh1, Pamela A. Argiriadi2, Meade Barlow1, Tiffany E. Chao1, Celia M. Divino1 1General Surgery, The Mount Sinai Medical Center NY, New York, NY; 2Radiology, The Mount Sinai Medical Center NY, New York, NY OBJECTIVE: The finding of intestinal intussusception on radiographic imaging in adults remains a challenging clinical dilemma. The clinical significance of this finding is unknown and determining cases requiring operative therapy is difficult. We present a series of cases of adult intussusception (AI) found on computed tomography (CT) and examine the significant parameters that would guide the management of this condition. METHODS: A retrospective review of records of adult patients found to have intussusception on CT at the Mount Sinai Medical Center from 2001–2007 was performed. Chi-Square and multivariable logistic regression analyses were used to identify factors associated with a true intussusception. RESULTS: AI was found on CT scan in 80 patients (M = 34, F = 46) during the study period. The mean age was 45 years. Patients presented with obstructive symptoms in 41% and abdominal pain in 56%. On CT, the intussusceptions were enteroenteric in 87% enterocolic in 4%, and colocolic in 9%. Imaging demonstrated multiple intussusceptions in 6% and obstructive findings in 11% of patients. 53 patients were observed and all of these had no further associated clinical sequelae. 9 patients, found to have an incidental finding of intussusception on CT scan underwent surgery with no intraoperative finding of true intussusception. 18 patients were explored based on CT findings, out of which 12 were found to have a true intussusception. The operative specificity was 67%. A pathologic leadpoint was identified in 9 cases (Crohns enteritis [2], appendiceal mucinous cystadenoma [1], cecal fibroid tumor [1], carcinoid [2], and adenocarcinoma [3], idiopathic [3]). All patients with negative explorations recovered without complication. Factors associated with a true intussusception on univariate analysis were gastrointestinal symptoms, obstruction on imaging studies, and involvement of the colon (p < 0.05). Factors independently associated with a true intussusception on multivariate analysis were obstruction on imaging studies and colonic involvement (p < 0.05). POSTER ABSTRACTS CONCLUSION: The radiographic finding of AI remains a clinical dilemma. The majority of cases are incidental findings on CT and have no significant MONDAY clinical sequelae. Factors such as gastrointestinal symptoms, obstruction on imaging studies, colonic involvement are clinically significant and mandate prompt surgical intervention.

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Clinical: Esophageal

M1523 Gastroesophageal Reflux Disease and Connective Tissue Disorders. Pathophysiology and Implications for Treatment Warren J. Gasper*, Piero Fisichella, Francesco Palazzo, Marco G. Patti Department of Surgery, University of California San Francisco, San Francisco, CA BACKGROUND: It has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is routinely deteriorated, often with absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating dysphagia. HYPOTHESIS: a) in most patients with CTD and GERD, esophageal function is preserved; b) only in patients with end-stage lung disease (ESLD) peristalsis is frequently absent; c) a tailored approach (total vs. partial fundoplication) allows control of reflux without a high incidence of postoperative dysphagia. DESIGN: Retrospective review of a prospectively acquired database. SETTING: University tertiary care center. PATIENTS: Forty-eight patients with CTD were evaluated by esophageal manometry and 24 hour pH monitoring (EFT). Twenty patients (Group A) had EFT because of foregut symptoms and 28 patients with ESLD (Group B) had EFT as part of the lung transplant evaluation. Two hundred eighty-eight consecutive patients with GERD (Group C) served as a control group. Eight patients in Group B underwent a laparoscopic fundoplication (3 patients, 360˚; 5 patients, 240˚). RESULTS: Fundoplication resulted in control of reflux for 8 patients in Group B. One patient developed post-operative dysphagia, which resolved with Savary dilatation. CONCLUSIONS: These data show that: a) peristalsis was preserved in most patients with CTD, similar to patients who had GERD without CTD; b) peristalsis was absent in a third of patients with CTD and ESLD; and c) a surgical approach tailored to the esophageal peristalsis achieved control of reflux without a high incidence of dysphagia.

Group A Group B Group C LES pressure (mean ± SD) 14 ± 9 11 ± 7 11 ± 6 % patients with abnormal peristalsis 30%* 79%*‡ 36%‡ % patients without peristalsis (median, mmHg) 0 39% 0 Peristaltic amplitude (median, mmHg) 76 (26–186)* 19 (0–140)*‡ 79 (11–292)‡ Median reflux score (nl < 14.7) 83 (15–191)‡ 49 (15–280)‡

*p < 0.05, A vs. B; †p < 0.05, A vs. C; ‡p < 0.05, B vs. C

208 6303_SSAT.book Page 209 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1524 Association of Gastroesophageal Reflux and O2 Desaturation in Patients with GERD: A Novel Study of Simultaneous 24-Hour Impedance-pH and Continuous Pulse-Oximetry Renato Salvador*, Fernando A. Herbella, Attila Dubecz, Marek Polomsky, Thadeus Trus, Carolyn E. Jones, Daniel Raymond, Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester, Rochester, NY BACKGROUND: Respiratory symptoms are present in up to 50% of GERD patients and are the primary or sole symptoms in 20%–25%. The well described role of both reflex and reflux mechanisms, coupled with the lack of optimal diagnostic tests, make assessment of the role of GERD in symptom causation a challenge. The aim of this study was to assess the association of gastroesophageal reflux with O2 saturation in patients with and without respiratory symptoms using combined simultaneous ambulatory monitoring systems. METHODS: The study population consisted of 11 patients with symptoms of GERD in which 443 reflux episodes were detected by MII-pH study. Eight patients had primary respiratory symptoms (cough, wheezing, hoarseness), and 3 typical symptoms (heartburn and regurgitation). All patients underwent simultaneously timed 24 hr MII-pH and continuous O2 saturation monitoring via ambulatory reflux and pulse-oximetry monitoring. Reflux events were defined by 24 hr esophageal pH and/or impedance and O2 desaturation by one of 3 possible observations; 1) O2 saturation < 90%, 2) O2 saturation drop of 7%, and 3) any event 7% below the mean saturation over 24 hours. Proximal reflux was defined by pH < 4 20 cm above the LES or reflux in proximal 2 impedance channels. A reflux-desaturation association was considered present if O2 desaturation occurred within 30 seconds prior to or 10 minutes after a reflux event. RESULTS: Three hundred thirty eight reflux events occurred in patients with primary respiratory symptoms and 105 in those with typical GERD symptoms. Nearly 60% of these 443 reflux events were associated with O2 desaturation. Markedly more events were associated with O2 desaturation in patients with respiratory symptoms (68%, 229/338) than in patients with typical reflux symptoms (25%, 26/105, p < 0.01). The difference in reflux- desaturation association was even more profound when proximal reflux events were compared, occurring in 76% (130/171) of patients with respira- POSTER ABSTRACTS

tory symptoms vs 14% (8/56) of those with typical GERD symptoms (p < 0.01). MONDAY CONCLUSION: There is a remarkably high prevalence of oxygen desaturation associated with esophageal acidiﬁcation in patients with primary respiratory symptoms. This novel observation adds to our understanding of the pathogenesis of GERD related respiratory symptoms and, given further study, may prove to be a useful diagnostic test in this difﬁcult group of patients.

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M1525 Acid Reflux to the Proximal Esophagus Predicts Postoperative Success in Patients with Laryngopharyngeal Reflux Disease Carlos Godinez*1, Stephen M. Kavic1, George T. Fantry3, Paul F. Castellanos2, J. Scott Roth1, F Jacob Seagull1, Adrian E. Park1 1Surgery, University of Maryland Medical Center, Baltimore, MD; 2Otolaryngology, UAB, Birmingham, AL; 3Gastroenterology, University of Maryland Medical Center, Baltimore, MD BACKGROUND: Acid reflux to the proximal esophagus and oropharynx is reasonably assumed to play a role in the etiology of atypical symptoms of reflux disease. To date, little published data exists to confirm this relationship. Similarly, the role of laparoscopic Nissen fundoplication (LNF) as therapy for this condition remains unproven over the long term. We theorized that symptoms of laryngopharyngeal reflux disease (LPR) could be correlated to documented episodes of proximal acid reflux, and that LNF would improve or relieve these symptoms. METHODS: One hundred and forty-three patients were diagnosed with LPR based upon clinical evaluation, 24 hour esophageal pH probe monitor, and Reflux Symptom Index (RSI) score. pH probe data was analyzed for total number of proximal reflux episodes (defined as pH < 4.0 in the proximal esophagus), and correlation of symptom occurrence with proximal reflux episodes. Patients who underwent operation then completed validated symptom assessment instruments at multiple time points postoperatively. RESULTS: Since July 2002, 114 patients have undergone LNF for laryngopharyngeal reflux at our institution. Patients were followed for up to 3 years (mean follow-up 11.5 months). pH probe data was available for analysis on 45 patients. Eighteen patients (40%) reported symptoms in association with proximal reflux. Following LNF, Reflux Symptom Index score improved most significantly in patients experiencing five or more symptomatic proximal reflux episodes, compared to those experiencing four or fewer (p = 0.045). Further, patients whose absolute number of proximal reflux episodes exceeded thirty in a 24 hour period, regardless of symptom correlation, also had greater improvement in postoperative RSI scores (p = 0.032). CONCLUSIONS: Full-height acid reflux episodes do not uniformly correspond to symptom occurrence in patients with LPR. However, patients experiencing five or more symptomatic proximal reflux episodes in a 24 hour period report greater improvement in atypical symptoms following LNF. LNF is an effective therapy for LPR in carefully selected patients.

210 6303_SSAT.book Page 211 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1526 Outcomes Following Esophagogastrectomy in Octogenarians Sebastian Defranchi*, Francis C. Nichols, Claude Deschamps, Mark S. Allen, Stephen D. Cassivi, Dennis A. Wigle, K. Robert Shen General Thoracic Surgery, Mayo Clinic, Rochester, MN BACKGROUND: Conflicting information with regards to morbidity and mortality has been reported for esophagogastrectomy in octogenarians. METHODS: From our prospectively maintained database, all patients 80- years of age and older who underwent esophagogastrectomy at our institution between January 1999 and December 2005 were identified and their records reviewed. RESULTS: There were 34 patients (30 men and 4 women). Median age was 81.8 years (range: 80 to 86 years). Twenty-eight patients (82%) were symptomatic at presentation. Most common were dysphagia in 17 patients (50%) and bleeding in 8 (23%). Comorbdities included hypertension in 22 patients (64%), coronary artery disease in 14 (41%), cardiac arrhythmias in 6 (17%), and diabetes and renal failure in 4 each (11%). Histopathology was adenocarcinoma in 30 patients (88%) and squamous cell in 3 (8%). One patient (2%) had end-stage achalasia without malignancy. Four patients (11%) received neoadjuvant chemoradiation therapy. The type of esophagogastrectomy included Ivor Lewis in 19 patients (56%), transhiatal in 11 (32%), and McKeown in 4 (12%). Pathologic stage was 0 or I in 12 patients (35%), II in 12 (35%), and stage III in 10 (29%). Operative mortality occurred in 2 patients (5.9%). Complications occurred in 24 patients (70%)and included: pulmonary in 11 (32%), atrial fibrillation in 10 (29%), aspiration in 6 (21%), and anastomotic leak in 5 (15%). Only 1 patient with anastomotic leak required reoperation. Median hospitalization was 11.5 days (range: 6 to 83 days). Overall morbidity was more common in patients with a prior cardiac history, patients whose BMI was >30, or patients who had a McKeown procedure. In particular, pulmonary complications were more common in patients who had a history of major cardiac disease, or underwent a McKeown procedure. One-, two-, three- , and five-year survivals were 63%, 38%, and 30%, and 15% respectively. CONCLUSION: Esophagogastrectomy in octogenarians can be performed with low mortality but has high morbidity. Increasing morbidity is associated with a history of major cardiac disease, BMI > 30, and performance of the POSTER ABSTRACTS McKeown esophagogastrectomy procedure. MONDAY

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M1527 Analyzing Treatment Costs for Esophageal Cancer Patients at Different Stages Chih-Cheng Hsieh*1, Ching-Wen Chien2 1Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 2Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan BACKGROUND: Esophageal cancer (EC) is a complex disease. Poor treatment results and high medical expense make it unpopular in cost-effectiveness analyses. At present, the main treatment for EC is surgical or non-surgical treatment. The aim of this study is to compare relative performance in terms of survival time and medical expenses of the 2 treatments for EC patients at different stages. This Result can be used to assist clinical decision making. MATERIALS AND METHODS: Charge and clinical data of 356 EC patients treated between 2000/1 to 2003/6 were collected. Patients were divided into 2 groups—surgical and non-surgical groups. Survival time, total expense, expense per month and relative expense performance index (REPI) for 2 treatments were calculated and compared between patients at different stages. RESULTS: The survival time and total expense in surgical group were longer and higher than in non-surgical treatment at all stages. Expense per month of EC patients at stage I, II, and III were not signiﬁcantly different between 2 groups. The expense per month in surgical group is signiﬁcantly more than non-surgical group only for patients at stage IV. The REPI for patients at stage III was the highest and for patients at stage IV was lowest among four stages. CONCLUSIONS: From the perspective of survival time and REPI, patients at early stage of EC, even stage III, surgical treatment was a better treatment than non-surgical treatment. But, for EC patients at stage IV, surgical treatment has a low REPI which suggests that surgical treatment may need further evaluation if medical expenses were included in clinical consideration. Stage Variable Surgical group Non-surgical group p-value I Survival time (mo) 47.4 14.7 0.002 Total expense* 23216 9564 0.021 Expense per month* 919 822 0.773 REPI** 2.882 II Survival time (mo) 37.0 23.0 0.035 Total expense 25200 11420 < 0.001 Expense per month 2266 1332 0.243 REPI 0.946 III Survival time (mo) 23.0 12.9 < 0.001 Total expense 24694 11676 < 0.001 Expense per month 2373 1965 0.408 REPI 1.476 IV Survival time (mo) 13.8 8.6 < 0.001 Total expense 22873 12352 < 0.001 Expense per month 5000 2414 0.004 REPI 0.775

*Total expense and expense per month were calculated within 3 years after diagnosis in USD **REPI was calculated by the ratio of survival time benefit divided by the ratio of expense per month

212 6303_SSAT.book Page 213 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1528 Incorporation of Biologic Mesh Into Crural Closure Decreases Complications and Recurrence of Paraesophageal Hernias Tayyab S. Diwan*, Michael Ujiki, Yashodhan S. Khajanchee, Christy M. Dunst, Lee L. Swanstrom Minimally Invasive Surgery, Legacy Health System, Portland, OR INTRODUCTION: In 1973, Allison reported a 49% recurrence rate in 421 paraesophageal hernia (PEH) cases followed over 22 years. A more recent study shows a recurrence rate of 30% following a laparoscopic repair without mesh. The placement of mesh has been shown to decrease the PEH recurrence to less than 7% in some studies. Typical synthetic mesh are easy to use but have an unacceptable rate of erosion into the esophagus. Biologic mesh have recently gained favor as an alternative for crural reconstruction of PEH. In a recent randomized, prospective study by Oelschlager, recurrence rates decreased from 25% to 9% with the use of biologic mesh. However, a simple method for placing and securing the mesh to the diaphram has never been described. Methods that have been suggested include sutures, tacks, and staples, but risk complications of mesh migration, diaphragmatic injury, and pericar- dial injury as well as increased cost. We have employed a technique of crural incorporation (CI) of the biologic mesh into the closure of the diaphragmatic hiatus. We hypothesize that this method of crural repair will decrease the rate of hernia recurrence and avoid the cost and complications of other mesh placement techniques. METHODS: The pre-operative and post-operative data from 35 patients operated on from December 2005 to May 2007 was analyzed, including pre- and post-op EGD, manometry, and UGI. All patients were pre-operatively diagnosed with PEH using one or all of the tests formerly mentioned. A struc- tured systems assessment tool was also administered to all patients pre- and post-operatively. All pts underwent PEH repair with CI. Biologic mesh was incorporated into the crural closure using pledgeted zero polyester suture in a horizontal mattress stitch. Mean follow-up was 6.1 months (range 1–16 months). RESULTS: Pre-operatively, 60% of pts had GERD symptoms, 42% pulmonary symptoms (SOB, cough), and 25% had chest pain. Post-operatively 100% of pts had resolution of their pre-op symptoms. 5/35 (14%) of pts were found to have post-operative dysphagia. Twenty-one pts had post-op studies (egd, POSTER ABSTRACTS

manometry, or UGI). No patients were found to have recurrence of their PEH. MONDAY No intra-operative complications were noted. DISCUSSION: The use of biologic mesh has been demonstrated to decrease recurrence rates following PEH repair. The safest and most efﬁcient method of mesh placement has not been deﬁned. Our method of PEH repair with CI decreases the rate of mesh complications and the rate of recurrence while utilizing no extra suture or staples, while providing excellent apposition of mesh to the underlying crura and securely closing the hiatus.

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M1529 New Techniques for Endoscopic (Laparoscopic and Thoracoscopic) Esophagectomy of Esophageal Cancer, Ropeway Technique for Dissection Along with the Nerve and Double-Gloving Method of HALS for Reconstruction Hitoshi Satodate*, Haruhiro Inoue, Shin-Ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan INTRODUCTION: The concept of three-field lymph node dissection for esophageal cancer was developed by Japanese surgeons and now the three- field esophagectomy is in the mainstream of the esophageal cancer surgery in Japan, and also in the various countries. With advent of minimal access surgery, a myriad of different approaches have been devised and studied in recent years. Thoracoscopic esophageal mobilization is becoming popular approaches. METHODS: Hand-assisted laparoscopic surgery (HALS) for gastric conduit preparation, modified radical cervical node dissection and cervical esophagogastrostomy followed by thoracoscopic esophagectomy through the right chest is the authors practice. Recently we added two new methods toward complete and safe lymph node dissection. One is for excision of the nodes along both recurrent laryngeal nerves as they course through the mediastinum to the neck. Both recurrent nerves are taped after the neck dissection, and the tapes are extracted thoracic cavity during the thoracoscopic procedure. Then the tapes are retracted by the forceps and nodes along to the recurrent nerves are thoroughly excised. This procedure is also contributed to the protection of the nerves. We named this method as ropeway technique, because the nerves can be seen as ropeways after the completion of the dissection. Another one is new HALS method, named as double gloving method for HALS. With this method, thorough lymph node dissection of the lower mediastinum can be securely performed. RESULTS: Between April 2004 and October 2007, we had performed this procedure for 76 cases of esophageal cancer patient. After introduction of this method, the operation time has become shorter and the complication rate, especially hoarseness has decreased. CONCLUSIONS: These new two techniques, ropeway technique and double gloving method of HALS are feasible for endoscopic esophagectomy with the three-field lymph node dissection and also contribute to safer procedures.

214 6303_SSAT.book Page 215 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1530 Accidental Mucosal Perforation During Laparoscopic Heller-Dor Myotomy Does Not Affect the Final Outcome of the Operation Mario Costantini*, Christian Rizzetto, Lisa Zanatta, Elena Finotti, Alessandra Amico, Loredana Nicoletti, Emanuela Guirroli, Giovanni Zaninotto, Ermanno Ancona Clinica Chirurgica 3, University of Padua, Padua, Italy It is commonly believed that inadverted mucosal lesions during myotomy may affect the ﬁnal result of the operation. This study was therefore undertaken to determine if esophagotomy during myotomy jeopardized the outcome of the surgical treatment for achalasia. From 1992 to date, 400 laparoscopic Heller-Dor procedures were performed by 4 staff surgeons at the same institution. All patients were evaluated preoperatively by a detailed symptom questionnaire, esophageal manometry, endoscopy and barium swallow. Accidental perforation during the operation occurred in 14 patients (3.5%), that represent the object of this study (Group A). The population of the remaining 386 patients who underwent the operation uneventfully was used for comparison. Further, two different groups of patients, operated by the same surgeon immediately before (Group B) and immediately after the patients who experienced the perforation (Group C), were considered. All but 2 perforations were recognized and repaired during operation. Two perforation were detected by the routine gastrograﬁn swallow and treated conservatively. Perforations were not related to the severity of the disease, age, duration of symptoms, LES characteristics, vigourous achalasia or surgeon’s experience. A previous endoscopic treatment (87 patients) did not increase the perforation rate (2/87 vs 12/313 in the primarily treated patients, p = ns). The duration of the operation tended to be longer in Group A patients (185 min vs 135 min, p = ns); these also required a longer hospitalization (14 vs 5.5 days, p < 0.05). At a median follow up of 32 months, symptoms recurred in 2/14 (14.3%) patients who experienced a mucosal lesion, requiring complementary pneumatic dilation. That applied to 34 of the remaining 386 patients (8.8%, p = ns). Symptoms recurred in 1 patient of Group B and in none of the Group C. Further, post operative median symptom score was similar in all the 3 groups of patients.In conclusion, accidental perforation during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or other factors such as the surgeon’s personal experience. In spite of a more complicated operation and a more prolonged recovery, the outcome of surgical treatment in these patients is similar to those POSTER ABSTRACTS

undergoing uneventful myotomy. Moreover, patients undergoing the opera- MONDAY tion immediately after the same surgeon scored a mucosal perforation in a previous case, receive the same carefully performed operation and achieve the same excellent results as the patients operated before.

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M1531 Prevalence of Kyphoscoliosis Among Patients with Giant Paraesophageal Hernia: Proposed Pathophysiology and Clinical Signiﬁcance Matthew J. Schuchert*1, Prasad Adusumilli2, Chris C. Cook1, Brian L. Pettiford1, Joshua P. Landreneau1, Ricardo S. Santos1, James D. Luketich1, Rodney J. Landreneau1 1Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY BACKGROUND: Kyphoscoliosis, more common among women, is seen in approximately 4% of the octogenarian population of the United States. We hypothesized that patients with kyphoscoliosis are affected with a reduced intra-abdominal volume and progressive laxity of the musculature of the diaphragmatic hiatal sling mechanism leading to an increased risk of hiatal hernia formation and progression over time. METHODS: We retrospectively reviewed the clinical history and roentgeno- graphic data of 341 paraesophageal hernia patients over the last 4 years. The prevalence of kyphoscoliosis among this patient cohort, and the outcomes of surgical management were compared to paraesophageal hernia patients without kyphoscoliosis. RESULTS: Ninty-three of the 341 patients (27%) were found to have signiﬁ- cant kyphoscoliosis (mean age 74; 85% female). Laparoscopic repair of paraesophageal hernia with fundoplication was performed in 91% of these patients. There was one mortality (aspiration pneumonia) and 15% major postoperative morbidity. Mean length of hospital stay was 8 days (range 2–71). Prolonged stays were related mainly to marginal pulmonary status. Surgical outcomes among patients with or without kyphoscoliosis are compared in the Table. The presence of kyphoscoliosis was associated with increased major perioperative morbidity and length of stay following paraesophageal hernia repair. CONCLUSION: The prevalence of kyphoscoliosis was nearly 30% among patients with paraesophageal herniation. This frequently under-appreciated condition may contribute to the development and progression of type I “sliding” hiatal hernias into type III “mixed” paraesophageal hernias. Surgeons approaching paraesophageal hernia repair in this setting should be aware of the increased morbidity and postoperative care required in managing these patients.

Table 1. Clinical Significance of Kyphoscoliosis in Paraesophageal Hernia Patients

Paraesophageal Paraesophageal Hernia Patients Hernia Patients With Kyphoscoliosis Without Kyphoscoliosis Number of Patients (n) 93 248 Age (mean) 74 67 Length of Stay (mean days) 8 3 Major Complications (%) 15 6

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1532 Preoperative Chemoradiation with Intensify- Modulated Radiation Therapy (IMRT) Increases Pathological Complete Response Rate in Locally Advanced Squamous Cell Carcinoma of the Esophagus Chadin Tharavej*, Patpong Navicharern Surgery, Chulalongkorn University, Bangkok, Thailand INTRODUCTION: Pathological complete response (pCR) has been defined as a favorable indicator in esophageal cancer patients undergoing preoperative chemoradiation treatment. About 20%–30% of pCR has been reported in prospective randomized trials. Increased rate of pCR may translate into long term survival benefit for esophageal cancer patients. METHODS: Twenty-two patients with locally advanced squamous cell esophageal cancer (T3, N0-1, M0) underwent preoperative chemoradiation during 2006–2007. Concurrent chemoradiation with 2 cycles of cisplatin and 5-FU and 50Gy irradiation using IMRT were given to all patients. Esophagec- tomy was performed in all patients with resectable cancer within 6–8 weeks after complete neoadjuvant treatment. RESULTS: One out of 22 patients (4.5%) died during preoperative chemoradiation treatment from sepsis. Three out of 22 patients (13.6%) developed distant metastasis during preoperative therapy. Three patients refused surgery because of much clinical improvement which were able to have solid food. They underwent upper GI endoscopy and PET scan with no residual tumor demonstration in all 3 patients. Fifteen patients underwent esophagectomy with no operative mortality. Resectability rate was 83%. R0 resection was achieved in all 15 patients. Ten out of 15 patients (67%) had pathological complete response. Two patients had T0 N1, 1 patient had T1N0 and 2 patients had T1N1 lesion. All patients were still alive at the median follow up of 10 months. CONCLUSIONS: Two-third of locally advanced squamous cell esophageal cancer who had preoperative chemoradiation with high dose IMRT had pathological complete response. No operative mortality has been found with this treatment. This may translate into long term survival benefit over surgery alone for locally advanced esophageal cancer. Prospective randomized trial is ongoing in our institute. POSTER ABSTRACTS MONDAY

Poster of Distinction

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Clinical: Hepatic

M1533 Hepatobiliary Resection with Inferior Vena Cava Resection and Reconstruction Using an Autologous Patch Graft for Intrahepatic Cholangiocarcinoma Tsuyoshi Sano*1,2, Kazuaki Shimada2, Minoru Esaki2, Yoshihiro Sakamoto2, Tomoo Kosuge2, Yasuhiro Shimizu1, Yuji Nimura1 1gastroenterological surgery, Aichi Cancer Center Hospital, Nagoya, Japan; 2Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan BACKGROUND: In patients with advanced cholangiocarcinoma involving the inferior vena cava (IVC), an extended hepatobiliary resection with combined resection and reconstruction of the IVC is often prerequisite to obtain a clear resection margin. PATIENTS AND METHODS: We present our approach to repair of approximately half of a cross-sectional wall defect of the IVC using an autologous external iliac venous patch graft during extended hepatobiliary resection with a total hepatic vascular exclusion technique. The harvested external iliac vein graft was incised longitudinally and trimmed to ﬁt the IVC defect. After multiple stay sutures, a continuous running suture using 4-0 prolene was made. RESULTS: A 72-year-old woman underwent the complex surgery (left trisectionectomy with total caudate lobe resection) survives 28 months without recurrence sign of the tumor after surgery. Total operation time was 863 minutes and intraoperative blood loss was 2775 g. The patient was discharged on the 26th postoperative day. A 64-year-old man underwent the complex surgery (right trisectionectomy with total caudate lobe resection, portal vein sleeve resection and reconstruction) survives 21 months with lung metastasis after surgery. Total operation time was 780 minutes andintraoperative blood loss was 2110 g. Morbidity of transient edema of the ipsilateral lower leg potentially related to graft harvesting was noted in the latter patient after surgery, and thereafter no anticoagulant therapy was required. The patient was discharged on the 62nd postoperative day. CONCLUSIONS: The external iliac vein patch graft for IVC resection and reconstruction during hepatobiliary resection is technically simple, produces no stenosis or caliber change in the reconstructed IVC, and is applicable for at least half or less of a cross-sectional defect of the IVC wall to be reconstructed.

218 6303_SSAT.book Page 219 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1534 Postoperative Complications After Liver Resections for Colorectal Metastases: Analysis of Risk Factors and Influence of Preoperative Chemotherapy Frank Makowiec*1, Ulrich Adam1,2, Hannes Neeff1, Ulrich T. Hopt1 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany INTRODUCTION: In the context of multimodal therapy liver resections (LR) for metastases of colorectal cancer (CRC) are frequently performed after chemotherapy (CTx). Several CTx-medications may result in liver damage up to fibrosis or cirrhosis. Recent studies reported conflicting results regarding complications after LR in correlation to prior CTx. We, therefore, analyzed our experience with postoperative complications after LR for CRC metastases. METHODS: Since 1998 199 primary LR were performed for CRC metastases (wedge resections 14%, segmental 32% and hemi- or extended hemihepatectomy 54%). Following neoadjuvant CTx LR was performed not earlier than four weeks after CTx. CTx was performed in 62% before LR either as adjuvant CTx of the primary CRC or as neoadjuvant therapy for liver metastases. Dur- ing our analyses we also differentiated between the first and second part of the study period (P1/P2) and between limited (wedge/segmental) and extended (at least hemihepatectomy) LR. In P2, under new direction of the hepatobiliary surgery team, refined surgical techniques and perioperative management strategies were applied. In P2 the frequency of LR increased 3-fold compared to P1. Seven clinical, multiple laboratory parameters and preoperative CTx were evaluated on their prognostic influence on the occurrence of complications. Multivariate risk factors were analyzed by binary logistic regression. RESULTS: Any complication occurred in 48%, surgical complications in 32% and hepatic insufficiency in 6.5%. Mortality was 2.5%. In P1 four patients died perioperatively, in P2 only one (mortality < 1% in P2). Four of those five patients were diabetic. Multivariate risk factors for any complication were a diabetes (p < 0.05; relative risk RR 3.1) and extended resections (p < 0.05; RR 2.5). Risk factors for surgical complications were again extended resections (p < 0.001; RR 3.3) and male gender (p < 0.01; RR 3.2). Independent risk factors for hepatic insufficiency were a diabetes (p < 0.02; RR 2.0) and extended resections (p < 0.02; RR 2.3). A diabetes (p < 0.01; RR 3) and resections performed during P1 (p < 0.01; RR 2.6) were independent risk factors for mortal- POSTER ABSTRACTS

ity. Age, BMI, laboratory values and blood transfusions did not inﬂuence any MONDAY of the various complication rates. Preoperative CTx did not correlate with complications (even tendency of fewer complications after CTx) CONCLUSIONS: The extent of resections and diabetes are relevant risk factors for complications following hepatic resection for CRC metastases. An increasing centre experience clearly decreases perioperative mortality. In our experience a preoperative chemotherapy did not increase postoperative morbidity.

219 6303_SSAT.book Page 220 Tuesday, April 22, 2008 1:26 PM

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M1535 Second Liver Resection for Recurrent Metastases of Colorectal Cancer: Perioperative Complications and Oncological Results Hannes Neeff*1, Frank Makowiec1,2, Eva Fischer1, Oliver G. Opitz2, Ulrich Adam1,2, Ulrich T. Hopt1,2 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer Cancer Center Freiburg, University of Freiburg, Freiburg, Germany INTRODUCTION: Resections of liver metastases of colorectal cancer (CRC) are performed with increasing frequency, due to advances in multimodal therapy, low mortality and relatively good outcomes. However, only few data have been reported regarding the results of repeat liver resections for recurrent metastases. We, therefore, analyzed our experience of those selected patients in whom a second liver resection could be performed. METHODS: From 2002 until 2006 thirty-six patients had a second liver resection for recurrent hepatic metastases of CRC in our department (28% female, median age 64 years) a median of 16 months after first liver resection. In all patients other (extrahepatic) tumor manifestations were excluded during preoperative staging (CT/MRI, PET). Eighty-four percent of the patients had received chemotherapy prior to re-resection. A segmental or atypical resection was performed in 23 patients whereas the other 13 patients underwent hemihepatectomy. During five of the 36 re-resections an additional radiofrequency thermoablation was done. Survival analysis was performed using the Kaplan-Meier-method. The median follow-up after hepatic re-resection was two years (n = 34). RESULTS: Two of the 36 patients died postoperatively (hospital mortality 5.6%). Perioperative complications (any) occurred in 50%, surgical complications in 25% and hepatic insufficiency in two patients (5.6%). Blood transfusions were necessary in 37% of the re-resections. Free hepatic resection margins could be achieved in 78%. During follow-up eight of 34 patients died of recurrent CRC. The cumulative two- and four-year survival rates in our series are currently 75% und 64%. The status of the resection margin showed a clear tendency to influence prognosis after hepatic re-resection: After a margin-negative resection four-year survival was 75% whereas it was only 36% in patients with positive margins (p = 0.12). No further potential prognostic factors could be identified up to now, also because of the limited follow-up time. CONCLUSIONS: Repeat liver resections for recurrent metastases of CRC can be performed with acceptable morbidity and mortality in selected patients. Hepatic re-resections with free margins achieved (surprisingly) high survival rates in our series. In the context of modern multimodal treatment (especially chemotherapy) hepatic re-resection should always be considered in the absence of other tumor manifestations in patients fit for major surgery.

220 6303_SSAT.book Page 221 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1536 A Decision Analysis Model of Hepatectomy Versus Radiofrequency Ablation for Hepatocellular Carcinoma Amanda Cooper*, Mary A. Maluccio General Surgery, Indiana University, Indianapolis, IN BACKGROUND: With the introduction of less invasive modalities to treat hepatocellular carcinoma (HCC), the debate regarding whether hepatectomy is required has emerged. Recent studies suggest that radiofrequency ablation (RFA) is equivalent to resection for small solitary tumors. Decision analysis modeling is a unique method of evaluating medical decisions and highlight- ing features that might persuade us that one method is, in fact, superior. The objective of this study was to use decision analysis to predict which of these two treatments would result in the longest average survival for patients with early hepatocellular carcinoma. METHODS: An English language literature review was performed in PubMed and Medline to locate articles reporting outcomes for patients with hepatocellular carcinoma after hepatectomy and/or RFA. A decision tree was constructed in TreeAge Pro (Williamstown, MA). Weighted averages of values from the literature were used to determine the probabilities entered in the decision tree. Sensitivity analyses vary individual variables over a range of values and were performed to determine if varying individual probabilities impacted the outcome of the model. RESULTS: The following weighted averages were used in the mathematical model: 3.5% peri-operative mortality after hepatectomy, 69.2% 5-year tumor recurrence rate, 22-month median disease free interval, and 80.5% of recurrences amenable to salvage therapies. For RFA, we used a 0.2% peri-procedural mortality, 72.4% 5-year tumor recurrence rate, 16-month median recurrence free interval, and 77.4% of post RFA recurrences amenable to additional treatment. A 46-month median survival for patients who recur and are amenable to additional treatment was used for both groups, as was a 7.5- month median survival for patients unable to received additional therapy. The decision model predicted a 68.9-month survival after hepatectomy and a 64.7-month survival after RFA for a 4.2-month survival beneﬁt to for hepatectomy over RFA. This preferred treatment strategy was insensitive to changes within the published range for peri-procedural/operative mortality, 5-yr.

tumor recurrence rate after RFA, median time to recurrence, percentage ame- POSTER ABSTRACTS nable to additional therapy, or the median survival of patients ineligible to MONDAY additional treatment. CONCLUSION: The baseline analysis predicts that hepatectomy results in a 4.2 month longer life expectancy compared to the less invasive RFA treatment. However, RFA does result in an equivalent or potentially superior survival beneﬁt over hepatectomy for certain variables within the range reported in the literature.

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M1537 Image-Guided Laparoscopic Radiofrequency Ablation of Giant Liver Hemangiomas Rocio Anula*1,2, Ernesto Santos Martin3,2, Julio M. Mayol1,2, Iris Sanchez-Egido1, Jesus A. Fernandez-Represa1 1Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; 2Unidad de Cirugía Guiada por Imagen, Hospital Clinico San Carlos, Madrid, Spain; 3Servicio de Radiodiagnóstico, Hospital Clinico San Carlos, Madrid, Spain INTRODUCTION: The management of giant liver hemangiomas remains controversial because of their benign nature, the unclear risk of developing complications and the relatively high morbidity and mortality associated with surgical resection. New therapeutic modalities for liver malignancies, such as radiofrequency ablation, may be useful to treat these tumors in a minimally invasive fashion. We present a patient with a giant hepatic hemangioma successfully treated with laparoscopic ultrasound-guided multipolar radiofrequency ablation. CASE REPORT: A 38 year-old male patient who had been complaining of constant pain in his right upper quadrant for over 1 year and diagnosed with a cavernous hemangioma on an abdominal ultrasound, was referred for evaluation. A 7.5 cm hypervascular tumor in segments V–VI of the liver, near the gallbladder, was conﬁrmed on abdominal CT scanning. The patient was informed of the different alternatives and chose to undergo a minimally invasive treatment. Under general anesthesia, the patient was placed in the French position for laparoscopic cholecystectomy. Laparoscopic ultrasound scanning conﬁrmed the presence of a giant hemangioma occupying part of segments V and VI and adjacent to the gallbladder, After performing a laparoscopic cholycystectomy, six T40 needles of the bipolar Celon Power System (Celon AG medical instruments Olympus, Germany) were percutaneously inserted into the abdomen under direct laparoscopic control and into the tumor under ultrasound guidance. Radiofrequency energy was delivered with an initial power setting of 40 watts and subsequently increased until reaching a power of 250 watts at 470 Hz. Tissue impedance was continuously moni- tored by the generator. The effect of radiofrequency on the hemangioma was imaged on real time. After completing tumor ablation, the needles were slowly withdrawn while ablating the tract in the liver. No intraoperative complications occurred. The patient remained asymptomatic in the immediate postoperative period and was discharged on postoperative day 2. A follow-up CT scan obtained 3 months after the procedure showed complete ablation of the lesion without residual enhancement. The lesion was completely replaced by hypodense material. SUMMARY: Radiofrequency ablation is a safe and effective treatment for giant liver hemangiomas. The laparoscopic approach combined with intraoperative ultrasonographic imaging may become a sound minimally invasive option for symptomatic patients.

222 6303_SSAT.book Page 223 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1538 Monopolar Floating Ball Versus Bipolar Forceps for Hepatic Resection: A Prospective Randomized Clinical Trial Guido Torzilli*1,2, Matteo Donadon1,2, Matteo Marconi1,2, Fabio Procopio1,2, Angela Palmisano1,2, Daniele Del Fabbro1,2, Florin Botea1,2, Marco Montorsi2 1Liver Surgery Unit, 3rd Department of Surgery, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy; 23rd Department of Surgery, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy BACKGROUND: Intraoperative blood loss and blood transfusions are important predictors of outcome in hepatic surgery. Controversies exist about methods for coagulation, while the dissection technique by Pean-clasia is still effective. Monopolar ﬂoating ball (Tissuelink-TM) (MFB), used for blunt liver dissection, seems effective but leads to tissue necrosis, which may represent a source of morbidity. The aim of this study was to compare in a prospective randomized trial, the vessel coagulation after Pean-clasia dissection obtained with bipolar forceps (BF) versus the MFB coagulation. METHODS: Seventy-six patients (58 men, 18 women; mean age: 64.7 yrs) scheduled for liver resection were randomized in two groups: Group A (MFB, n = 38) and Group B (BF, n = 38). The two groups were homogeneous in terms of tumors presentation, and background liver features. Blood loss (ml/cm2), blood transfusions, transection time (min/cm2), ligatures (number/cm2), drains amount, drains bilirubin levels at 3rd, 5th, and 7th postoperative day, postoperative morbidity and mortality were analysed. RESULTS: Mean resection area was 93.9 cm2 in group A and 79.8 cm2 in group B (p = 0.956). Mean Pringle time was 112 min in group A and 94 min in group B (p = 0.847). There were no signiﬁcant differences in blood loss (mean 7.6 versus 7.2 ml/cm2; p = 0.162), blood transfusions (11.5% versus 16.5%; p = 0.450), transection time (mean 1.3 versus 1.3 min/cm2; p = 0.289), number of ligatures (mean 0.7 versus 0.7/cm2; p = 0.200), drains amount (median 55 versus 66.7 ml; p = 0.451), and drains bilirubin levels (mean 1.9 versus 2.1 mg/dL; p = 0.664). Both the transection devices were equally safe, and no mortality or major morbidity was recorded. CONCLUSION: Our preliminary data showed that the use of Pean-clasia with the MFB was safe, and minimized the blood loss during hepatic resection.

However, the use of MFB offered no signiﬁcant beneﬁt over the BF technique. POSTER ABSTRACTS MONDAY

223 6303_SSAT.book Page 224 Tuesday, April 22, 2008 1:26 PM

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Clinical: Pancreas

M1539 Long Term Follow-Up (7–34 Years) After Surgical Treatment of Chronic Pancreatitis Sergio Pedrazzoli*1, Claudio Pasquali1, Stefano Guzzinati2, Mattia Berselli1, Cosimo Sperti1 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Venetian Tumor Registry, Venetian Oncological Institute, PADOVA, Italy BACKGROUND: The natural history of chronic pancreatitis (CP) pts after surgery is rarely reported. (J Clin Gastroenterol 2003;36:159-65). METHODS: Between 1970 and 1999, 193 pts underwent surgery (S) for CP. After review 19 pts were excluded: 12 post SAP and 4 post-traumatic pseudocysts, 2 Vater’s papilla stenosis, 1 IPMN. 174 pts (mean age 45 ± 10.2; range 24–75 yrs) were followed with clinical examination, CT or MR, and/or telephone interview. They were divided in 4 Groups: 1) Resective S: 62 (Whip- ple [41], left pancreatectomy with [6] or without [13] pancreaticojejunostomy, Warren procedure [2]). 2) Derivative S: 82 (Puestow [20], Partington- Rochelle or Frey [44], cystojejunostomy [12] or cystoduodenostomy [1], ﬁstu- lojejunostomy [1], personal procedure [4]). 3) Non pancreas directed S: 23 (Cholecystectomy [1] and/or surgical sphincteroplasty or choledochoduode- nostomy [19], bilateral splanchnicectomy [1], embolization of a bleeding pseudoaneurysm [1], remake of a hepaticojejunostomy after a Whipple [1]). 4) Marsupialization: 7. A second S was required in 23 pts, a third in 4 of them: Group 1: 6 + 0, Group 2: 11 + 2, Group 3: 3 + 1, Group 4: 3 + 1. The actual status at December 31 2006 of all pts was retrieved. The cause of death was retrieved for 111/117 pts. Of the 6 remaining, 1 died abroad, and privacy prevented us to retrieve the cause for the other 5. RESULTS: Hospital mortality was 4/174 (2.3%). 57 pts (32.8%) are still alive. 49 pts (28.2%) developed cancer and 38 died of their cancer, 5 of another disease, 1 of unknown cause, and 5 are still alive. The more frequent was the lung cancer (22 pts) followed by oral, pharynx, larynx and esophageal cancers (10 pts). A small pancreatic cancer (PC) was found in the surgical specimen in 3 pts: 1 died of PC 18.3 years later, 1 died of unknown cause 30.5 years later, and 1 is alive and well 29 years later. A further patient died of PC 9 years after surgery. The other main causes of death were: liver cirrhosis (15 pts), vascular disease (11 pts), MI or failure (10 pts), acute pancreatitis, accidental trauma, complications of diabetes, bronchopneumonia (4 pts each). The overall 5, 10, 15, 20, 25 and 30 years survival rate was 82.8, 63.5, 49.7, 36.4, 27.5 and 23.1 and was the same for the 4 groups (P = 0.8447). CONCLUSIONS: The incidence of PC was 2.3%, but only 1 (0.6%) appeared during follow-up. The high incidence of lung, oral, pharynx, larynx and esophageal cancers (32/170; 18.8%) during follow-up is due to the smoking habits of almost 100% of our pts (Int J Cancer 2008;122:155–64). Eliminating smoking and increasing tests on organs at risk of cancer during follow-up may prolong survival in these pts.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1540 High Complication Rate After Pancreas Preserving Surgical Procedures for Benign or Borderline Pancreatic Lesions. Careful Selection of Patients Is Needed Cosimo Sperti, Claudio Pasquali, Mattia Berselli, Laura Frison, Tania Saibene, Sergio Pedrazzoli* Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy BACKGROUND: Since the first report in 1980, organ-function-preserving pancreatectomy has been increasingly performed in patients with benign or low-grade malignant lesions, in order to decrease the loss of normal pancreatic tissue. The aim of this study was to evaluate our experience with limited pancreatic resections with attention to perioperative and long-term outcome. METHODS: From November 1985 to December 2005, 54 patients underwent segmental pancreatectomy: 30 patients had central pancreatectomy (CP) and 24 had duodenum-preserving pancreatic head resection (DPPHR). Ten patients who underwent CP (Sperti C et al., J Am Coll Surg 2000;190:711–718) and 13 patients who underwent DPPHR (Pedrazzoli S et al., Pancreas 2001;23:309–315) were previously reported. There were 19 males and 35 females, with mean age of 50.2 years (range 13–74 years). The pathologic diagnosis was: serous cystadenoma (13), insulinoma (9), nonfunctioning endocrine tumor (9), Intraductal Papillary Mucinous Neoplasm (7), chronic pancreatitis (7), mucinous cystadenoma (4), metastasis from renal cell carcinoma (2), papillary-cystic tumor (1), biliary cyst (1), and solitary true cyst (1). RESULTS: There were no operative death. Postoperative course was uneventful in 27 patients (50%). Complications occurred in 15/30 CP and 12/24 DPPHR. In particular a pancreatic fistula was diagnosed in 13/30 CP (43.3%) and in 3/24 DPPHR (12.5%), a biliary fistula in 5/24 DPPHR (20.8%) (1 reoperation), an abdominal abscess in 2/24 DPPHR (1 reoperation), a peritoneal bleeding in 1 CP and 1 DPPHR (1 reoperation), a digestive bleeding in 1/24 DPPHR and a pneumonia in 1 CP. After a median follow-up of 48 months (range 23–264) only one patient recurred after a CP for renal cancer metastases: she underwent pancreaticoduodenectomy and partial resection of the residual body-tail. Four patients developed type two diabetes (2 after CP [6.9%] and 2 after DPPHR [8.7%]); one CP and one DPPHR patient were diabetics before surgery. Ten patients (18%) required pancreatic enzyme supplementation. POSTER ABSTRACTS

CONCLUSIONS: Segmental pancreatic resection preserves long term endo- MONDAY crine and exocrine function in a significant proportion of patients. While operative mortality is absent, this type of surgery is associated with a high complication rate, even in experienced hands. This is due to the presence of a normal pancreas, at high risk of pancreatic fistula, in almost all patients. The incidence of biliary fistula decreased with increasing experience. Therefore, caution is necessary when using these procedures, accurate selection of the patients being essential.

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M1541 Predictable Factors for Poor Outcome After Severe Acute Pancreatitis Takeo Yasuda*1, Yoshifumi Takeyama1, Takashi Ueda1, Makoto Shinzeki2, Hidehiro Sawa2, Yonson Ku2, Yoshikazu Kuroda2, Harumasa Ohyanagi1 1Department of Surgery, Kinki University School of Medicine, Osaka-sayama, Japan; 2Department of Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan BACKGROUND/PURPOSE: Long-term outcome of severe acute pancreatitis (SAP) is often complicated, because the etiology, severe inﬂammation and pancreatic necrosis can affect the endocrine/exocrine function and morphology of pancreas. It is favorable to predict the long-term outcome in the follow-up of patients after the recovery from SAP, but there have been no analyses about the predictable factors for poor outcome after SAP. This study was undertaken to evaluate the post discharge outcome of severe acute pancreatitis (SAP) and clarify the predictable factors for poor outcome. METHODS: Among 103 patients who had recovered from SAP according to the Japanese criteria, we analyzed 45 patients (36 men and 9 women) that we could follow-up more than 12 months after SAP. The mean follow-up period was 56 ± 6 months (range: 12–184). We analyzed the relationships of recurrence of acute pancreatitis (AP), transition to chronic pancreatitis (CP), and development into diabetes mellitus (DM) with the etiology and pancreatic necrosis at SAP, respectively. Moreover, we surveyed the predictable factors for poor outcome in laboratory data on admission of SAP by univariate and multivariate analyses. RESULTS: The recurrence rate of AP was 19%. The mean interval after SAP was 25 ± 6 months. The recurrence rate of AP in patients with pancreatic necrosis was higher than that in patients without pancreatic necrosis (32% vs. 5%, P < 0.05). Univariate analysis showed that the predictable factors for the recurrence of AP were CRP and white blood cell (WBC) count (P < 0.05). Multivariate analysis revealed that the independent predictable factor was CRP (P < 0.05). The transition rate to CP was 22%. The mean interval after SAP was 52 ± 10 months. The transition rate to CP was higher in alcoholic SAP than that in biliary SAP (32% vs. 0%, P < 0.05). Univariate analysis showed that the predictable factors for the transition to CP were WBC count, hematocrit, base excess (BE), Ranson score, and Japanese severity score (JSS) (P < 0.05). Multivariate analysis disclosed that the independent predictable factors were WBC count and JSS (P < 0.05). The development rate into DM was 39%. The mean interval after SAP was 26 ± 12 months. Univariate analysis showed that the predictable factors for the development into DM were blood glucose and BE (P < 0.05). Multivariate analysis revealed that the independent predictable factor was blood glucose (P < 0.05). CONCLUSIONS: Degree of inﬂammation and pancreatic necrosis may be related to the recurrence of AP. Alcoholic SAP with high severity may contribute to transition to CP. Impaired glucose tolerance is easy to develop into DM after SAP.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1542 Serum Immunosuppressive Acidic Protein Levels in Patients with Severe Acute Pancreatitis Makoto Shinzeki*1, Takashi Ueda2, Yoshifumi Takeyama2, Takeo Yasuda2, Kenro Hirata1, Hirochika Toyama1, Ippei Matsumoto1, Toshiaki Tsujimura1, Tsunenori Fujita1, Tetsuo Ajiki1, Yonson Ku1 1Division of Hepato-Billiary-Pancreatic Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan; 2Department of Surgery, Kinki University School of Medicine, Osaka, Japan OBJECTIVES: In severe acute pancreatitis (SAP), immunologic impairment in the early phase may be linked to subsequent infectious complications. Immunosuppressive acidic protein (IAP) is an immunosuppressive factor to be present in serum and ascites of cancer patients, and it is utilized as a tumor marker and an index of immune status of cancer hosts. METHODS: We measured serum IAP levels obtained on admission from 42 patients with SAP (Japanese severity score ≥ 2), and analyzed the relationships with disease severity, pancreatic necrosis, blood biochemical parameters on admission, and clinical outcome (infection and death). RESULTS: Serum IAP level increased (791 ± 285 µg/ml) on admission and recognized abnormal high level (normal range <500 µg/ml) in 37 patients (88.1%). Serum IAP level was significantly lower in patients of Stage 3 and 4 (Japanese severity score ≥ 9) (678 ± 187 µg/ml) than that in patients of Stage 2 (2 ≤ Japanese severity score ≤ 8) (848 ± 311 µg/ml). It was also significantly lower in patients whose Ranson score ≥ 5 (674 ± 287 µg/ml) than that in patients whose Ranson score ≤ 4 (910 ± 287 µg/ml). Moreover, it was significantly lower in patients with pancreatic necrosis (693 ± 194 µg/ml) than that in patients without pancreatic necrosis (922 ± 336 µg/ml). Among the blood biochemical parameters on admission, serum IAP was significantly negatively correlated with hematocrit, serum lipase, and serum interferon–, and was significantly positively correlated with serum total protein. Serum IAP levels in patients of Stage 2 reached higher peak 7 days after admission and decreased more rapidly than those in patients of Stage 3 and 4. CONCLUSIONS: Serum IAP levels were elevated in patients with SAP, but were significantly lower in patients with higher grade of severity or pancreatic necrosis. These results suggest that serum IAP levels may be related to sys-

temic inﬂammatory response and reﬂect the immunoresponsiveness in POSTER ABSTRACTS patients with SAP. MONDAY

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M1543 Risk Factors for Postoperative Complications After Pancreatic Head Resection: Multivariate Analysis of 608 Consecutive Operations Tobias Keck*1, Frank Makowiec1, Eva Fischer1, Ulrich Adam2,1, Ulrich T. Hopt1 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany INTRODUCTION: Mortality after pancreatic head resections (PHR) has been decreased clearly below five percent. However, complications are still frequent and influence the postoperative course and costs. The aim of our analyses was to evaluate morbidity after more than 600 PHR and to assess risk factors for various complications. METHODS: From 7/1994 to 2007 608 consecutive PHR were performed by five responsible surgeons in one team. The first 317 PHR were performed until 2001 in department A, the other 291 (after the team had moved end of 2001) since 2002 in department B. The documentation of the perioperative outcome was performed prospectively. Indications for surgery were periampullary or other malignancies (52%), chronic pancreatitis (43%) or others (5%). The techniques of PHR were: classical Whipple-procedure 14%, pylorus- preserving PHR 66%, duodenum-preserving PHR (DPPHR) 18% and total pancreatectomy 2%. Forty percent of the patients preoperatively had undergone biliary drainage (PBD). After examining 16 potential risk factors for complications univariately, multivariate analyses were performed using binary logistic regression. RESULTS: Any complication (AnyCompl) occurred in 49% of the patients, surgery-related complications (SurgCompl) in 33% and infectious complications (InfCompl) in 17%. Mortality was 2.4%. Multivariately significant risk factos (M-RF) for AnyCompl were the type of surgery (PD more complications than DPPHR), duration of surgery >7 Std., absence of PBD, extended resections (including adjacent organs), PHR performed in department B and a preoperatively increased creatinine (above upper normal value; 10% of the patients). M-RF forSurgCompl were the abscence of a PBD, a BMI >25, PHR performed in department B and again an increased creatinine-level. M-RF for InfCompl were again the type of PHR, the abscence of a PBD, a BMI >25, surgery performed in department B and an increased creatinine. None of the other laboratory values assessed (including bilirubine) showed any correlation with complication rates. Mortality decreased from 2.8% in department A to 1.8% in department B. The only risk factor for mortality was a preoperative diabetes (p < 0.05), although this parameter did not show any correlation with the different complication types. CONCLUSIONS: Obesity, impaired renal function and the absence of a PBD are relevant risk factors for complications which may be corrected preoperatively and/or considered in the perioperative management of patients undergoing PHR. Centre experience leads to decreased mortality even though complication rates increased. This phenomenon might reflect a more aggressive management of those complications.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1544 Quality of Life After Total Pancreatectomy: Requiem for a Surgical Dogma? Roberto Salvia*, Silvia Germenia, Stefano Partelli, Stefano Crippa, Claudio Bassi, William Mantovani, Massimo Falconi, Paolo Pederzoli Department of Surgery, Università di Verona, Verona, Italy Among pancreatic resections, total pancreatectomy (TP) is generally considered to lead to significant impairments in patients’ quality of life (QoL). Aim of this work was to evaluate QoL and long-term complications in patients undergoing TP at a tertiary referral center. Forty-eight patients undergoing TP between 1994 and 2006 were identified; the 32 survivors (median follow-up 30.5 months) were interviewed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ- C30), and with an Institutional questionnaire on pancreatic exocrine- endocrine function. Mortality after surgical resection was zero, and there were no deaths related to the long-term complications. Overall QoL after TP was acceptable (median: 5, scale from 1 to 7), despite a slightly decrease compared to the preoperative period (median: 6). A significant impairment in QoL was found only in patients with malignancies (P < 0.05). Twenty-nine patients (91%) complained of hypoglycemia, 72% of them at least once a week. Steatorrhea and abdominal pain were found in 66% and 44% of patients. Major impairments of leisure and work activities were reported in 56% and 31% of cases. In experienced centers TP is a viable and safe procedure. However, TP substantially affects health status, and the risk for long- term complications should be well evaluated; therefore careful patient-selection and long-term follow-up are of paramount importance in this setting. POSTER ABSTRACTS MONDAY

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M1545 The Assessment of the Malignant Potential of IPMN: How Reliable Is the New Score from Fujino? Dominique Suelberg*1, Ansgar M. Chromik1, Andrea Tannapfel3, Matthias H. Seelig1, Ulrich Mittelkötter2, Waldemar Uhl1 1Surgical Department, University Hospital of Bochum, Bochum, Germany; 2Surgical Department, Katharinen-Hospital, Unna, Germany; 3Institut of Pathology, University Hospital of Bochum, Bochum, Germany BACKGROUND: The intraductal papillary mucinous neoplasia of the pancreas (IPMN) was first reported 1982 in Japan. IPMNs are primary benign lesions but have an unknown malignant potential. In September 2007 a new score to assess the dignity preoperatively has been published by Fujino et. al. (Am.J.Surg.2007; 194; 304–307). The aim of this study was to evaluate this score using the prospective database of our institution. METHODS: All patients with a pancreatic operation were prospectively analyzed during a three year period (01.01.2004 to 31.12.2006). Patients with a diagnosed IPMN were analyzed by age, sex, surgical procedure, histological findings and preoperative findings of jaundice, diabetes mellitus, patulous papilla, tumor size ≥ 42 mm (scored 1 pt); main-duct-type (scored 2 pt); size of pancreatic duct ≥ 6.5 mm and Ca 19-9 ≥ 35 U/ml (scored 3 pt). These data were evaluated applying the score by Fujino. Predictive values were estimated by using a cross-tabulation. RESULTS: Among n = 402 patients receiving a pancreatic operation 17 patients (n = 10 men, n = 7 women) were diagnosed as IPMN. N = 12 had benign lesions and n = 5 carcinomas. Malignant lesions were significantly more frequent in male patients (80%) (p ≤ 0.05). The proportion of benign lesions was balanced. Histologically, the lesions were classified as n = 7 adenomas (41.2%), n = 5 tumors with unknown malignant potential (29.4%) and n = 5 carcinomas (29.4%). The values of the Fujino-Score were 8.4 for carcinomas, 4.0 for IPMN with unknown malignant potential and 4.14 for adenomas (p ≤ 0.05; T-Test). Only 2 lesions were scored from 0 to 1 pt and therefore predicted as benign lesions. Interestingly, the histological findings of these cases were tumors with unknown malignant potential. 10 lesions had score values ≥ 5 pt and so predicted as malign. All patients with carcinomas had a score ≥ 5 pt. N = 2 patients with adenomas were also scored as malign. The IPMN patients with unknown malignant potential were scored in all categories. All patients with carcinomas were scored true positive (sensitivity: 100%), whereas n = 5 benign tumors were scored false positive. 7 patients of 12 patients with benign tumors were scored true negative (specificity: 58%). Taken together the efficiency of the Fujino-Score was 71%. CONCLUSION: This analysis of the Fujino-Score showed a high sensitivity of 100% for the identification of carcinomas in IPMN lesions. One drawback might be the high proportion of false positive findings leading to a specificity of only 58%. The IPMN with unknown malignant potential were scored in all categories. Surgical exploration should be considered at a Fujino-Score ≥ 2 points.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1546 Volume in Pancreatic Surgery: The German Situation Guido Alsfasser*1, Julia M. Kittner1, Guenther Kundt2, Sven Eisold1, Ernst Klar1 1Dept of Surgery, University of Rostock, Rostock, Germany; 2Institute of Medical Informatics and Biometry, University of Rostock, Rostock, Germany INTRODUCTION: The relationship between operation volume and quality has been an ongoing debate for years. With an anonymous questionnaire amongst members of the German Society of Visceral Surgery (DGVC) we try to describe the situation in Germany. METHODS: A questionnaire was sent to Surgeons-in-chief with questions about frequency and results of pancreas resections in the year 2006. Opera- tions were divided in following volume categories: 1–5 operations (very low), 6–20 (low), 21–40 (medium) and more than 40 (high). Surgeon volume was defined as the total number of operations of each hospital divided by the number of participating surgeons. RESULTS: 262 of 520 hospitals returned the questionnaire (50.4%). 40 hospitals (15.3%) did not perform pancreatic surgery. In the remaining 222 hospitals 5253 pancreatic resections were performed. 20 hospitals were very low volume institutions (9%), 114 low volume (51%), 48 medium (22%) und 40 high volume (18%). Comparing very low/low/medium volume hospitals (LVH) with high volume hospitals (HVH) there are 26.1% with more than 5% mortality vs. 20% in HVH (n.s.). However, above 7.5% mortality there are significant more LVH than HVH (17.7% vs. 5%, p = 0.04). Considering surgeons volume, mortality is decreasing with higher volume (3.4% mortality with <5 operations per year, 3.2% with 6–10, 2.4% with >10 operations and 1.5% with >20). A single surgeon performs pancreatic surgery in 34.3% of all cases (mean mortality 2.2%). Two surgeons operate in 32.4% of hospitals with mean mortality of 2.8%. With four or more surgeons mean mortality rises to 4.4%. Overall, mortality in university hospitals, teaching hospitals and others was 2.5%, 2.9% and 2.6%. Summary: Pancreatic surgery is performed in many hospitals outside university institutions in Germany. Mortality in high volume centers is lower compared with all other hospitals. However, 20% of HVH have mortality rates >5%. Two Thirds of all operations are performed by one or two surgeons with a mean mortality of 2.5%. Hospitals with four of more surgeons showed a higher mortality (4.4%). CONCLUSION: Hospital volume does not seem to influence mortality in pancreatic surgery in Germany. Quality in pancreatic surgery highly depends POSTER ABSTRACTS

on specialized surgeons, whereas increase of mortality in centers with four or MONDAY more surgeons is an effect of the training process. Based upon this questionnaire of the year 2006 no general conclusion can be drawn. However, the implementation of a national pancreatic registry seems to be a suitable way to further analyze the volume-quality relationship in Germany.

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M1547 The Lymph Node-Ratio Is the Strongest Factor Predicting Survival After Resection of Pancreatic Cancer Frank Makowiec*1,2, Hartwig Riediger1, Eva Fischer1, Tobias Keck1, Oliver G. Opitz2, Ulrich Adam1, Ulrich T. Hopt1,2 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer Cancer Center, University of Freiburg, Freiburg, Germany INTRODUCTION: Survival after surgery of pancreatic cancer is still poor even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status or tumor grading were identified. However, only few data have been published regarding the prognostic influence of the LN-ratio (number of LN involved to number of examined LN), with sometimes conflicting results. We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer. METHODS: Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations (54% female). Of those 182 patients 88% had cancer of the pancreatic head, 5% of the body and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (86%), distal resection (11%) or pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier- and Cox-methods. RESULTS: In all 204 resected patients mortality was 3.9% (n = 8). In the 182 patients with follow-up 70% had free resection margins, 62% had G1 or G2- classified tumors and 70% positive LN. Median tumor size was 30 (7–80) mm. The median number of examined LN was 16, median number of involved LN one (range 0–22). Median LN-ratio was 0.1 (0–0.79). Cumulative five-year survival (5-y SV) in all patients was 16%. In univariate analysis a LN-ratio ≥ 0.2 (5-y SV 6% vs. 19% with LN-ratio <0.2; p = 0.003), LN-ratio ≥ 0.3 (5-y SV zero% vs. 18% with LN-ratio <0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analyses a LN-ratio ≥ 0.2 (p < 0.01; relative risk RR 1.7), LN-ratio ≥ 0.3 (p < 0.001; relative risk RR 2.4), positive margins (p < 0.03; RR 1.6) and poor differentiation (p < 0.05; RR 1.4) were independent factors predicting poorer outcome. The LN-ratio as a continuous variable also significantly correlated with survival whereas the conventional nodal status or the number of involved LN per se had no significant influence on survival. Patients with one LN involved had the same outcome than patients with negative nodes but prognosis worsened significantly in patients with two or more LN involved. CONCLUSIONS: Not the lymph node involvement per se but especially the LN-ratio is an independent prognostic factor after resection of pancreatic head cancers. In our series this LN-ratio was even the strongest predictor of survival (cutoff 0.2). The routine estimation of this LN-ratio may be helpful not only for the individual prediction of prognosis but also in the planning of adjuvant therapy and further outcome and therapy studies.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1548 Dynamic Magnetic Resonance Imaging (DMRI) of the Pancreas as a Predictor of Anastomotic Leakage After Pancreatic Resections Marco Niedergethmann*1, Dietmar J. Dinter2, Stefan Post1 1Department of Surgery, University Hospital Mannheim, Mannheim, Germany; 2Department of Radiology, University Hospital Mannheim, Mannheim, Germany BACKGROUND: The degree of pancreatic fibrosis is a main factor for leckage after pancreatico-jejunostomy. “Soft” and “firm” pancreatic tissue types are characterized by different perfusion behaviour in DMRI. In order to identify risk factors for postoperative pancreatic anastomotic leakage and in order to assess the role of pancreatic DMRI in detection of this complication and in prediction of pancreatic texture a cohort of patients was retrospectively reviewed. METHODS: Between 2000 and 2006 a total of 107 consecutive patients were examined by means of a standardized DMRI protocol (1.5 tesla MRI): 1) morphological T1 and T2 sequences, 2) transversal T1 with fat suppression (5 mm layer thickness) at 25 and 60 seconds after i.v. application of Gd-DTPA (Mag- nevist®, 0.1 mmol/kg body weight), 3) T1 sequences after Gd-DTPA application. The time intensity curve on DMRI was measured in the aorta, the pancreas, and the muscle tissue. For all patients with a standardized contrast medium curve in the aorta (n = 72) a muscle-normalized time intensity curve was calculated. The time intensity curves were classified in three groups: rapid increase (>1.1, early-arterial value > portal-venous value), intermediate (0.9–1.1), and slow increase (<0.9). All patients received a pancreatico-jejunostomy (duct-to-mucosa). The DMRI data was correlated with prospectively acquired clinical data. RESULTS: Leakage of the pancreatico-jejunostomy occurred more frequently (27%, p < 0.05) in patients with a time intensity curve >1.1 (“soft” pancreas, n = 37) compared to those with intermediate (0.9–1.1, n = 11) and slow curves (<0.9, n = 24, “firm” pancreas). Furthermore, patients with a rapid increase (>1.1) had significantly more abdominal complications such as abscess, delayed gastric emptying, as well as a pre-existing diabetes (p < 0.05). DISCUSSION: DMRI with time intensity curve calculation provides reliable information for prediction of the pancreatic texture. A rapid increase of the

time intensity curve correlates with anastomotic leakage and further abdomi- POSTER ABSTRACTS nal complications after pancreatic head resection. MONDAY

Poster of Distinction

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M1549 Combination of Bioabsorbable Polyglicolic Acid (PGA) Felt and Fibrin Glue for Prevention of Pancreatic Fistula Following Pancreaticoduodenectomy Kenichiro Uemura*, Yoshiaki Murakami, Yasuo Hayashidani, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Hiroyuki Nakamura, Taijiro Sueda Surgery, Hiroshima University, Hiroshima, Japan BACKGROUNDS AND AIMS: Mortality after pancreaticoduodenectomy (PD) in high volume centers had decreased to less than 2%. However, morbidity still remains considerably high, ranging 20%–50%. The most frequent cause of morbidity is pancreatic fistula (PF) in early postoperative period. Polyglicolic acid (PGA) felt is bioabsorbable recombinant membrane. It is easily shaped and it rapidly reacts with fibrin glue. PGA felt combined with fibrin glue as the topical agent have been reported to be successful in prevention of bile leakage after liver resection compared with fibrin glue alone. PGA felt combined with fibrin glue is also reported to be useful in preventing air leakage after lung surgery and cerebrospinal leakage after spinal surgery. The aim of this study was to assess the efficacy of PGA felt combined with fibrin glue as an adjunct of pancreaticoenterostomy for prevention of postoperative PF following PD. METHODS: PGA felt combined with fibrin glue as an adjunct of pancreaticoenterostomy were applied prospectively to 20 consecutive patients undergoing pancreaticoduodenectomy. The pancreatic anastomosis was reconstructed with a duct-to-mucosa pancreaticogastrostomy into the posterior wall of the stomach. Internal pancreatic duct stenting were used in all cases. No prophylactic octreotide was administered in this study. Drain amylase were measured daily after the surgery until drain was removed on the postoperative day 5. The incidence of postoperative pancreatic fistula and other postoperative complication were recorded. Pancreatic fistula was defined as drain output amylase levels greater than 3 times than the upper normal serum amylase value on or after postoperative day3 and graded according to the International Study Group Pancreatic Fistula definition. RESULTS: There were 11 males and 9 females (mean age 65 ± 15). The mean operative time was 351 ± 75 minutes. The pancreatic texture of the stump was “soft” in 16 cases. The median of the level of amylase in drain were 745 U/l on POD1, 427 U/l on POD2, 97 U/l on POD3, and 38 U/l on POD5. Only one patient (5%) developed grade A postoperative PF. The incidence of PF with clinically significant impact (grade B+C) was 0%. No patients required a change in management or adjustment in the clinical pathway. Other postoperative complications include one wound infection (5%) and one bile leakage (5%). Patient did not present any side effects related to the PGA and fibrin glue. There was no percutaneous drainage, readmission and reoperation. There was no mortality. CONCLUSIONS: Combination of bioabsorbable PGA felt and fibrin glue was extremely favorable for prevention of postoperative PF following PD.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1550 Radiofrequency Ablation of Locally Advanced Pancreatic Cancer Jennifer Logue*, Edward Leen, Susan J. Moug, Ross Carter, Colin Mckay Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom INTRODUCTION: Radiofrequency ablation has been demonstrated to be effective in the treatment of unresectable hepatic tumours and promising results have been obtained in other cancers. Small series and case reports suggest that this technique is feasible and safe in selected patients with pancreatic cancer. The aim of this study was to assess the safety of radiofrequency ablation in patients with non-metastatic, locally advanced pancreatic cancer. METHODS: Full ethical approval was obtained from the Local Research Eth- ics Committee. Pre-operative consent was obtained from 8 patients with non- metastatic pancreatic tumours staged as being of borderline resectability. Five patients (3 female, 2 male) with tumours deemed inoperable after full laparotomy were recruited. Radiofrequency ablation was performed using the Cool- tip ablation system with a single, cooled electrode. Accurate needle placement was confirmed by intra-operative ultrasound and the target temperature controlled by a thermosensor at the tip of the needle was 90°C. RESULTS: Three of the five patients developed life-threatening post-ablation complications. One patient died as a result of a post-operative biliary leak, severe sepsis and multi-organ failure. Significant gastrointestinal haemor- rhage occurred in two cases requiring angiographic embolisation. Given these initial complications, the study was terminated after discussion with the local ethics committee. Overall median survival was 6.6 months (range 0.4–4). CONCLUSION: The results of this pilot study suggest that radiofrequency ablation for locally advanced pancreatic cancer is associated with unacceptable, life-threatening post-ablation complications. POSTER ABSTRACTS MONDAY

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M1551 Antibacterial Prophylaxis Does Not Prevent Infection of Pancreatic Necrosis in Acute Pancreatitis Eduardo A. Villatoro*1, Mubashir G. Mulla2, Richard I. Hall2, Mike Larvin1 1Division of Surgery, University of Nottingham Medical School, Derby, Derby, United Kingdom; 2Surgical Directorate, Derby Hospitals, Derby, United Kingdom A series of randomised controlled trials (RCTs) has led to confusion as to the precise role of antibacterial prophylaxis against infection of pancreatic necrosis (PN) in acute pancreatitis. Published RCTs comparing antibacterial therapy versus placebo in patients with CT proven pancreatic necrosis were sought. Seven were found (Jan 1993–Sep 2007): five evaluated beta-lactams (n = 302) and two quinolone/imidazole (n = 102). None was adequately powered, end point reporting varied and overall study quality was variable. Three studies were double-blinded, but the latest only provided extractable data on PN infection rates. Meta-analysis was performed using “RevMan 4.2” software (Update, Oxon UK). Mortality was significantly lower after therapy (6.8%) versus control (15%), odds ratio (OR) 0.44 (95% CI 0.21–0.91), p 0.03, in 6 fully evaluable studies (n = 322). However infected PN rates did not differ significantly in all 7 studies. Non-pancreatic sepsis was significantly lower after therapy (20%) versus controls (30%), OR 0.54 (95% CI 0.30, 0.98), p 0.04, although only 4 studies (n = 236) provided these data. Four evaluable beta- lactam studies showed a trend to lower mortality (7.4%) versus controls (16%), but this was non-significant and no significant survival differences were found in two quinolone/imidazole studies. Beta-lactam therapy showed a trend towards less infected PN (16.8%) versus controls (24%), OR 0.61 (95% CI 0.34, 1.08), p 0.09, but there was a non-significant trend to higher infected PN rates with quinolone/imidazole therapy. Non-pancreatic infections were significantly lower after beta-lactams (15.4%) versus controls (28%) in 3 evaluable studies, OR 0.43 (95% CI 0.20, 0.92) p = 0.03. Only one quinolone/ imidazole study reported non-pancreatic infections which were not significantly different.This results suggest that antibacterial prophylaxis does reduce overall mortality, but not by reducing infection of PN. The mechanism is unclear, but contrary to the rationale for these RCTs, prophylaxis may be protective against fatal non-pancreatic infections, such as respiratory infection. More data are awaited from the most recent study, but we conclude that further, adequately powered, double-blinded studies, perhaps targeting beta- lactam agents, are required to elucidate the mechanism for reduced mortality. REFERENCES: Pederzoli et al. SGO 1993;176(5):480–483. Sainio et al., Lan- cet 1995;346:663–667. Nordback et al. J GI Surg 2001;5(2):113–118. Schwarz et al., Dtsch Med Wschr 1997;122:356–361. Isenmann et al., Gastroenterol- ogy 2004;126:997–1004. Rokke et al., Sc J Gastro 2007;42:771–776. Dellinger et al., Ann Surg 245:674–683.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1552 Development of a Dedicated Team Decreases ICU Admission After Pancreaticoduodenectomy (PD) Julio Sokolich*, Christos A. Galanopoulos, Allison Vo, Maggie White, Ernest Dunn, D. Rohan Jeyarajah General Surgery, Methodist Dallas Medical Center, Dallas, TX BACKGROUND: Outcome from PD is based not only in the natural history of the disease, but also on patient selection, operative technique, and postoperative care. Multiple studies have focused their attention on the former two factors. The purpose of this study is to evaluate if development of a dedicated multidisciplinary team can increase direct admission to the floor and reduce the ICU admission after PD. STUDY DESIGN: Between 2005 and 2007, 76 patients underwent a PD by a single surgeon at a non-university tertiary referral center (NUTRC). During the first year 45 PD were preformed and this data was compared with the 31 PD cases performed during the second year. The multidisciplinary team consists of gastroenterologist, surgeon, fellow, resident, ICU nursing staff, operating room team, and a surgery floor nursing staff. Standardized algorithms and a dedicated floor nursing staff were developed during this time period. RESULTS: Number of patients who suffered some type of complication dropped from 53% to 38% in the second year; Mortality rates remain similar (2.6% compared to 2.2% in year one); Pancreatic fistula rates dropped from 6.6% down to 5.3% at year two; Mean operative times (240 minutes) and mean blood loss (350 ml) were minimally impacted over the study period. Most importantly, ICU admission after PD dropped from 80% in the first year to 45% in the second year. CONCLUSION: This study demonstrates that a multidisciplinary team can be developed in a NUTRC for patients with pancreatic disease. This dedicated process can result in improved outcomes, as measured by complication rate. Importantly, this improved outcome can be achieved with decreased use of the ICU if a dedicated floor nursing team is developed. This decreased utilization of ICU care will translate to decreased hospital charges, earlier mobilization, and a more streamlined pathway for patients after PD. POSTER ABSTRACTS MONDAY

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M1553 Predictive and Prognostic Value of CA 19-9 in Resected Pancreatic Adenocarcinoma Joshua G. Barton*1, John P. Bois1, Christina M. Wood2, Rui Qin2, Michael L. Kendrick1, Michael B. Farnell1 1GI and General Surgery, Mayo Clinic, Rochester, MN; 2Biostatistics, Mayo Clinic, Rochester, MN BACKGROUND: Although CA 19-9 is most often used in pancreatic cancer as a diagnostic adjunct, or to follow response to treatment, its preoperative value has been reported to correlate with survival and recurrence. A corrected-CA 19-9 (c-CA19-9), obtained by dividing the CA 19-9 by total bilirubin, has been reported to improve this correlation. Our aim is to evaluate the predictive and prognostic value of CA 19-9 in a large single-institutional experience. METHODS: A retrospective review of all patients undergoing pancreatoduodenectomy from July 2001 through June 2007 at our institution was conducted. Preoperative serum CA 19-9 and total bilirubin levels were analyzed with histologic and survival data. RESULTS: Of 328 patients identified, 231 (58% male; 42% female) with a mean age of 66 (37–90) had both pre-operative serum CA 19-9 and total bilirubin levels and comprised our study group. Median follow-up was 2.1 years. All patients underwent pancreaticoduodenectomy for histologically confirmed pancreatic adenocarcinoma. Using receiver operator curves, neither CA 19-9 nor c-CA 19-9 demonstrated predictive value for lymph node status (c = 0.55/0.56) or margin status (c = 0.50/0.46). Tumor size and lymph node ratio very weakly correlated with CA 19-9 and c-CA 19-9 levels (Spear- man correlation coefficients for tumor size: 0.26 and 0.28; for lymph node ratio: 0.17 and 0.16, respectively). Survival was not different at 1 year (73% vs. 68%), 3-years (33% vs 22%), or 5-years (27% vs 16%) for patients with CA 19-9 ≤ 300 compared to those with values >300. Using corrected c-CA 19-9 with a cut-off of 50 also failed to demonstrate a significant difference in survival. Even at cutoffs of 500 and 100 for CA 19-9 and c-CA-19-9 respectively, there was no difference in survival compared to patients with lower levels (p > 0.2). Patients with a CA 19-9 > 300 or c-CA19-9 > 50 were at 1.30 and 1.29 times risk of death than those with CA 19-9 < 300 or c-CA 19-9 < 50 respectively. CONCLUSION: This large, single institution study demonstrates no histologic (lymph node or margin status) predictive value or prognostic value of CA 19-9 or c-CA19-9 in patients undergoing resection for pancreatic adenocarcinoma. These findings are in contrast to smaller previous studies that have suggested such a correlation. Our findings do not support broadening the use of CA 19-9 beyond aiding diagnosis and following therapeutic response.

238 6303_SSAT.book Page 239 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Small Bowel

M1554 Long-Term Outcome After Distal Gastric Bypass Combined with Swedish Adjustable Gastric Banding (SAGB) Bruno M. Balsiger*1, Folkert Maecker1, Andreas Glaettli2 1Internal Medicine, Spitalnetzbern, Bern, Switzerland; 2Visceral Surgery, Hirslanden Salem Spital, Bern, Switzerland BACKGROUND: Swedish adjustable gastric banding (SAGB) is currently one of the most performed laparoscopic procedures in bariatric surgery. This procedure was combined with an additional distal gastric bypass in patients with a BMI >50. AIM: To determine long-term outcome after SAGB and distal gastric bypass in a group of 37 consecutive patients studied prospectively. PATIENTS AND METHODS: Thirty seven patients, 11 men and 26 women, have been operated from 1996 to 2002. Age was 37 ± 1 (mean ± sem) years, BMI 54 ± 1 kg/m2. Follow-up was 65% at 60 months. RESULTS: Procedures: Most underwent a laparotomy (21) due to additional necessary surgery. Median hospital stay was 10 (4–26) days. One Patient died in hospital due to a pulmonary embolism, two patients needed antibiotic treatment for cystitis and pneumonia. 4 Patients suffered from local complications, such as wound infection, seroma, or healing problems. In one Patient the spleen was injured so splenectomie had to be performed in the same operation. Two patients required reoperation while still in hospital. Late complications were usually caused by problems with the SABG. Leakage of the adjustable ring in one patient, damage of the flexible tube in 6 patients. Mean time to occurance was 17.25 months (10 to 29). Three patients needed a second operation due to infections. In one patient a seroma needed to be removed 14 days after bariatric surgery. The same patient suffered from cholangitis due to choledocholithiasis 35 months later. In two patients the gastric banding was definitively removed after 95 months, there was significant dilatation of the oesophagus. Three patients required closure of hernias. Total cumulative reoperation rate was 62.9%. After 5 years BMI decreased from 54 ± 1 kg/m2 to 33 ± 1 kg/m2. Excess weight loss, EWL was 69 ± 1% after 5 (n = 24) and 70 ± 1% after 7 (n = 20) years. According to the Baros score the over all POSTER ABSTRACTS

results are good. 5 ± 3 points after 5 and 7 years. MONDAY SUMMARY: 5 Years after SAGB with additional gastric bypass 71% of the patients reached >65% EWL, 29% between 65 and 30% EWL. Weight reduction was a maintained between 5 to 7 years (EWL 71%). According to the Baros score the intervention was good, despite of a cumulative reoperation rate of 62.9%. CONCLUSION: A majority of the patients does well even after 7 years. Due to the high reoperation rate, the combined operation of SAGB with additional distal gastric bypass should be considered as a rescue when non- combined procedures have failed.

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M1555 Gastro Intestinal Intramural Hematomas Versus Mesenteric Ischaemia- Clinico-Radiological Profile Sudhindran Surendran*1, Unnikrishnan Gopalakrishnan1, Dayananda Lingegowda2, Sudheer Othiyil Vayoth1, Puneet Dhar1 1Gastro Intestinal Surgery, Amrita institute of medical Sciences, Kochi, India; 2radiology, Amrita institute of medical Sciences, Kochi, India AIM: Gastro intestinal (GI) Intramural bleeds, secondary to anticoagulation often mimic Mesenteric Ischemia. Whilst intramural bleeds can be conservatively managed, mesenteric ischaemia requires active intervention. Aim of the study was to analyze characteristics of patients presenting with GI intramural hematomas to help evolve guidelines based on clinical and imaging features to differentiate them from mesenteric ischemia. METHODS: Clinico-radiological features of all GI Intramural Hematomas diagnosed between 2000–2006 (Group 1 = 8) were compared with a group of surgically confirmed mesenteric ischemias in the same period (Group 2 = 27) by retrospective analysis of database. RESULTS: All patients in Group 1 were on anticoagulation for cardiac comorbidities. All underwent CT abdomen with plain and IV contrast aimed for venous phase. The first patient in Group I underwent an exploratory laparotomy and small bowel resection, due to suspicion of mesenteric ischaemia. The histopathology showed extensive hemorrhage with no evidence of ischaemia. The subsequent seven patients were suspected to have intramural bleeds and were managed conservatively with stabilization of INR.Clinical and imaging features of the two groups are given in Tables 1 and 2. Table 1. Imaging Features

Characteristics Group I (n = 8) Grup II (n = 27) p-value Proximal Site 6 3 0.002 Short segment 7 13 0.6 Thockness (mm) 17 ± 4 8 ± 3 0.001 Hounsefield Units 65 ± 14 34 ± 6 0.001 Fat stranding 4 15 0.8 Ascites 6 18 0.3 Mucosal enhancement 6 11 0.01 Dilatation 3 12 0.7

Table 2. Clinical Features

Characteristics Group I (n = 8) Group II (n = 27) p-value Age 54 ± 13 49 ± 14 0.3 Pain 8 23 0.2 Vomiting 7 17 0.2 Peripheral vascular disease 0 6 0.143 Rectal bleed 3 2 0.03 Anticoagulation 8 12 0.005 INR over 3 7 22 0.001

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

CONCLUSIONS: Anticoagulant therapy with rectal bleeding often suggest the possibility of GI Intramural hematoma. On CT scan-proximal location, increased wall thickness, hyper density on plain scan and contrast enhancement of mucosa were suggestive of mural hematoma. In such cases, a conservative approach maybe appropriate, albeit exercising a low threshold for laparotomy, given the differential diagnosis of mesenteric ischaemia. POSTER ABSTRACTS MONDAY

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Clinical: Stomach

M1556 Laparoscopic Lymphatic-Basin Dissection as an Additional Treatment to Endoscopic Submucosal Dissection in Early Gastric Cancer Toshiyuki Mori*, Nobutsugu Abe, Masanori Sugiyama, Yutaka Atomi Surgery, Kyorin University, Tokyo, Japan BACKGROUND: Endoscopic submucosal dissection (ESD) is widely accepted in Japan for early gastric cancer. Indication for this less invasive treatment is early cancer confined in the mucosa, 20 mm or less in diameter in differentiated carcinoma, and 10 mm or less for undifferentiated carcinoma, because the cancer can usually be completely removed and lymph node metastasis is extremely rare. When the tumor exceeds in size or in depth of invasion beyond the above-mentioned criteria, lymph node metastasis becomes more likely and standard gastrectomy may be indicated. As we previously reported, however, positive rate for lymphnode metastasis is as low as 10% in this group and parameters to predict lymphnode metastasis include tumor size and cancer invasion to lymphatic vessels. It is thus reasonable to remove the primary lesion by ESD for detailed pathologic examination and, if the risk factor(s) are identified, lymphatic basin potentially positive for metastasis is laparoscopically resected for further treatment. When the lymphnode positive for metastasis is identified, gastrectomy is indicated for potential residual cancer cells. When the negative result is obtained, the patients can be subjected for follow-up without further treatment. METHOD: Among the 158 cases with early gastric cancer in which primary lesion(s) were treated by ESD, 17 cases ware diagnosed for potentially positive for lymphnode metastasis. Mean prediction values for metastasis positive rate was 13%. Laparoscopic lymphatic basin dissection was performed in these cases. RESULTS: Responsible lymphnode basin was identified with ICG endoscopically injected around the ESD scar. Lymphatic vessels and nodes were identified with either laproscopic observation or infra-red laparoscopy. The upper lesser curvature lymphnodes were completely dissected in 13 cases, the upper lesser and greater curvature in 2 cases, and lower lesser and greater curvature in 2 cases, respectively. Mean duration of operation was 258 min, and postoperative course was uneventful except for one case who needed re-operation for ischemic perforation of the lesser curvature. There were two cases in which metastatic positive lymphnodes were identified, and both of them denied further treatment and were subjected to strict follow-up. The mean duration of follow up is 25 mo (2–62 mo), and no cancer recurrence is identified. Quality of life is fur much better in this group when compared to any type of series of gastrectomy. CONCLUSION: Although indication and steps in this treatment is somewhat complicated, ESD and lymphatic basin dissection serves as ultimate function preserving treatment for early gastric cancer.

242 6303_SSAT.book Page 243 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1557 Long Term Improvement of Comorbidities in Older and Medicare Patients with Gastric Bypass Peter T. Hallowell*, Thomas A. Stellato, John Jasper, Kristen Graf, Margaret M. Schuster Surgery, University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: A recently published review of bariatric surgery in a large Medicare database suggested a prohibitively high mortality rate. We have demonstrated that in carefully selected elderly and Medicare recipients’ gastric bypass can be safely performed with low morbidity and mortality. Evi- dence for beneﬁt in terms of improvement in co morbidities in these patients however, is lacking. Our hypothesis is that these patients should have improvement in their co morbidities with successful bypass surgery. METHODS: We reviewed our prospectively maintained bariatric database. Over 1000 patients have been accumulated. We identiﬁed 46 patients 60 years or older and 31 patients with Medicare as their primary insurer. RESULTS: In the older patients we had a 1, 3, 5 yr Follow up of 87%, 48%, and 75%. The average length of follow up was 30 months with a range of 1–84. The male female ratio for the elderly patients was 13%/87% and was 6%/94% in the Medicare group. The mean pre-op BMI for the elderly group was 50.4 and 56 in the Medicare group. Resolution or improvement of co morbidities is described in the table below. We know of one death 4.5 years from surgery in the Medicare group. CONCLUSIONS: Improvement in the major obesity related co morbidities is seen in elderly and Medicare recipients undergoing gastric bypass surgery. Resolution of GERD is seen in over 90% of both groups. Although hypertension is the least effected in the elderly, 50% still have improvement or resolution of this important co morbidity.

Elderly Patients Age 60–66 Medicare Recipients Age 31–66 Mean 61.6 (n = 45) Mean 47.7 (n = 31) Co Morbidities Resolved Improved Resolved Improved Hypertension 8/34 (24%) 9/34 (26%) 13/21 (62%) 2/21 (10%) p = 0.02 DM oral meds 15/20 (75%) 2/20 (10%) 9/11 (81%) 1/11 (9%) ns DM Insulin 1/3 (33%) 1/3 (33%) 2/6 (33%) 4/6 (67%) ns

OSA 10/32 (31%) 13/32 (41%) 8/22 (36%) 10/22 (46%) ns POSTER ABSTRACTS GERD 23/25 (92%) 0 16/17 (94%) 0 ns MONDAY

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M1558 Indications and Results of Reversal of Vertical Banded Gastroplasty (VBG) Rebecca Thoreson*, Joseph Cullen Surgery, University of Iowa, Iowa City, IA BACKGROUND: Vertical Banded Gastroplasty (VBG) was initiated in 1980 as a weight loss operation that restricted oral intake. A small volume pouch is created along the lesser curvature and the outlet is reinforced with a band of polypropylene mesh. Aims: To determine the results of patients who presented with complications of the VBG and wanted reversal of the VBG, not a conversion to another gastric weight loss operation. METHODS: From 1993 to 2007 26 patients had reversal of a VBG. 85% of the patients were female and presented on average 13 years (range 2–27 years) after the VBG. Presenting symptoms included nausea/vomiting in 88%, reflux in 65%, stricture requiring endoscopic dilatation in 38%, while 7% of patients had upper gastrointestinal bleeding or required total parental nutrition. All patients were offered conversion to another weight loss operation but decided on reversal of the VBG alone. All takedowns were performed in a similar manner by making a gastrotomy below the VBG pouch and placing a linear stapler through the gastrotomy with one of the limbs within the lumen of the gastroplasty and the other within the stomach pouch/fundus. The stapler is fired resulting in division of the polypropylene mesh band, resulting in continuity of the pouch with the rest of the stomach and reversal of the VBG pouch. RESULTS: No patients died from the procedure and morbidity included one wound infection and one wound seroma. Preoperative Visick score was 2.8 ± 0.1 and decreased to 1.3 ± 0.1 after the reversal (P < 0.001). Patients had significant weight loss after the VBG (P < 0.001) and prior to the VBG reversal (Table). With a mean followup of 32 months (range 2–144 months), there was not a significant weight gain after the VBG reversal (P = 0.3) (Table). After the reversal, reflux symptoms continued in two patients and nausea and vomiting continued in one patient. CONCLUSIONS: Reversal of a VBG results in symptomatic relief in the majority of patients. Patients should be instructed that some weight gain may occur after the reversal.

Table 1. Weight changes prior to VBG, prior to reversal, and most recent weight.

Pre-VBG Weight (Range) Weight at Reversal (Range) Weight After Reversal (Range) 139 kg (105–182)* 96 kg (56–151) 105 kg (63–157)

244 6303_SSAT.book Page 245 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1559 Gastrectomy and Lymphadenectomy for Gastric Cancer: Is the Pancreas Safe? Fernando A. Herbella*, Ana C. Tineli, Jorge L. Wilson, Jose C. Del Grande Department of Surgery, Federal University of São Paulo, São Paulo, Brazil BACKGROUND: Resection of the capsule of the pancreas is part of the radical operation for the treatment of gastric cancer proposed by the Japanese Gastric Cancer Association. It is unclear; however, if resection of the capsule is a safe procedure or even if it is necessary. This study aims to assess in patients treated for gastric cancer the occurrence of: (a) pancreatic fistula, and (b) metastasis to the pancreatic capsule. METHODS: We studied 80 patients (mean age 61 years, 42 males) submitted to gastrectomy and lymphadenectomy with resection of the pancreatic capsule by hydrodissection. Patients with anastomotic leakage, pancreatic disease, tumoral invasion of the pancreas, or submitted to concomitant splenectomy were excluded. The tumor was located in the distal third of the stomach in 61% of the patients, in the middle third in 27%, and proximally in 12%. Total gastrectomy was performed in 27% of the cases and partial gastrectomy in 73%. In all patients, amylase activity in the drainage fluid was measured on day 2. Subsequent measurements were performed in alternated days until normalization if initial measurement was abnormal. Pancreatic fistula was defined as amylase levels greater than 600. In 25 of these patients (mean age 53 years, 16 males) the pancreatic capsule was histologically analyzed for metastasis. RESULTS: Pancreatic fistula was diagnosed in 8 (10%) patients. The mean amylase level was 5863. Normalization of amylase levels was achieved within 7 days in all patients. No clinical complications of pancreatic fistula, such as intraabdominal abscesses, were noticed. In only one case, the surgeon suspected of pancreatic injury during removal of the capsule. Pancreatic fistula was associated to younger age (p = 0.03), but not to gender (p = 0.1), tumor location (p = 0.6) and type of gastrectomy (p = 0.8). Metastasis to the pancreatic capsule was not identified. CONCLUSION: Resection of the pancreatic capsule must be discouraged due to subclinical pancreatic fistula in a significant number of the cases and absence of metastasis to the capsule. POSTER ABSTRACTS MONDAY

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M1560 Long Term Results of Completion Gastrectomies in Patients with Post-Surgical Gastroparesis James E. Speicher*, Richard C. Thirlby, Joseph Burggraaf, Christopher P. Kelly, Sarah M. Levasseur Department of Surgery, Virginia Mason Medical Center, Seattle, WA INTRODUCTION: Post-surgical gastroparesis occurs in less than 5% of patients undergoing gastric surgery. The symptoms, however, are disabling and refractory to medical management. The only effective surgical procedure is completion gastrectomy. Few studies have examined in detail the long term results of this radical procedure. METHODS: From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or completion gastrectomies for refractory post-surgical gastroparesis by the same surgeon at a tertiary referral center. The average age was 52 (range 32–72). Gastroparesis was documented using a radionuclide solid food emptying study. Charts were reviewed retrospectively to identify preoperative symptoms and long term postoperative function, and the patients were contacted by phone to evaluate their current level of function. RESULTS: Of the original 44 patients, 57% (n = 24) were evaluated postoperatively at a mean of 6.0 years (range 0.5–14.2 years). Fourteen patients (32%) had expired, and nine (20%) were lost to follow up. Presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, ave = 19% of BW). Postopera- tive complications occurred in 33%, most commonly bowel obstruction (9%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death, from leak leading to sepsis. At last follow up, there were signiﬁcant improvements in abdominal pain (96% to 58%, p < 0.01), vomiting (96% to 38%, p < 0.01), nausea (83% to 46%, p < 0.01), and diet limited to liquids or nothing at all (52% to 9%, p < 0.01). Some symptoms were more common postoperatively: early satiety (25% to 93%, p < 0.01), postprandial fullness (13% to 71%, p < 0.01), bloating (25% to 43%, p = 0.3), and diarrhea (38% to 42%, p = 0.8). Average BMI was 23 prior to surgery and 21 at follow up. Osteoporosis was diagnosed pre- and postoperatively in 21% and 64% of patients, respectively (p < 0.01). Seventy-one percent of patients stated that they were in better health after surgery, while 21% were neutral; mean satisfaction with surgery was 4.8 (1–5 Likert scale). CONCLUSION: Completion gastrectomy in this patient population resulted in signiﬁcant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have ongoing gastrointestinal complaints and the incidence of osteoporosis is high. Regardless, patient satisfaction is very high and about 75% of patients believe their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe post-surgical gastroparesis.

246 6303_SSAT.book Page 247 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1561 Is Neoadjuvant Chemoradiation for Locally Advanced Gastric Cancer Feasible? Brian R. Untch*1, Michael E. Barfield1, Johanna C. Bendell2, Brian G. Czito3, Christopher G. Willett3, Theodore N. Pappas1, Rebekah White1, Douglas S. Tyler1 1Surgery, Duke University Medical Center, Durham, NC; 2Medical Oncology, Duke University Medical Center, Durham, NC; 3Radiation Oncology, Duke University Medical Center, Durham, NC BACKGROUND: Neoadjuvant chemoradiation is an effective strategy for the treatment of locally advanced esophageal carcinoma because it can down- stage tumors and improve resectability. Neoadjuvant chemotherapy has been shown to improve survival in patients with gastric cancer. The purpose of this study was to evaluate the feasibility of neoadjuvant chemoradiation for locally advanced gastric cancer. METHODS: A retrospective review identified 16 patients with biopsy- proven, locally advanced (T3/T4 or N1) gastric cancer that underwent neoadjuvant chemoradiation between 1997 and 2006 (41% with GE-junction involvement). Patients received external beam radiation with concurrent 5-FU or platinum-based chemotherapy. If restaging CT demonstrated no metastatic disease, surgical exploration was performed with the intent of performing gastrectomy. RESULTS: Five patients required hospitalization for treatment-related complications, but all patients were able to complete therapy. The median time from diagnosis to attempted gastrectomy was 104 days and the median time from completion of neoadjuvant therapy to attempted gastrectomy was 42 days. At the time of restaging, disease burden was evaluated: 3 patients showed evidence of local progression, 4 patients had decreased disease, and 9 patients had stable disease. All 16 patients underwent attempted gastrectomy. Gastrectomy was performed in 13 patients; in the remaining 3 metastatic disease was identified. In the gastrectomy patients, a complete histologic response was identified in 3 patients (19% of those treated neoadjuvantly), 8 patients had a partial response and 2 patients had no response. Two patients had positive margins and 8 patients had lymph node involvement. There was no perioperative mortality. Two gastrectomy patients developed anastomotic leaks that were treated conservatively. The median length of stay for patients undergoing gastrectomy was 10 days. The median survival for patients undergoing gastrectomy was 22 months. POSTER ABSTRACTS

CONCLUSIONS: Locally advanced gastric cancer carries a poor prognosis. MONDAY Neoadjuvant chemoradiation was well tolerated and was associated with acceptable perioperative morbidity. Patients with complete or partial histologic responses may translate to improved rates of R0 resection.

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M1562 Inpatient Mortality Analysis of Paraesophageal Hernia Repair in Octogenarians Benjamin K. Poulose*, Jeffrey M. Marks, Christine Gosen, Leena Khaitan, Michael J. Rosen, Joseph A. Trunzo, Jeffrey L. Ponsky Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: Paraesophageal hernia (PEH) repair is often performed in an elderly population. Few studies have evaluated perioperative mortality in this high risk group. We examined outcomes of patients who underwent PEH repair and identified predictors of inpatient mortality using a national dataset. METHODS: Patients 80 years of age or older undergoing PEH repair from an abdominal approach were identified in the 2005 Nationwide Inpatient Sam- ple (NIS). A coding algorithm was developed to include patients with type II, III, and IV hiatal hernias while excluding those with congenital diaphragmatic defects or traumatic injuries. Statistical methodology appropriate for NIS analysis was used accounting for its weighted and stratified database structure. RESULTS: 1005 patients with mean age of 84.7 years met inclusion criteria for analysis including 738 women (73%) and 267 men (27%). Overall inpatient mortality was 8.2% with mean length of stay 10.1 days. Emergent or urgent repair was performed in 43% of patients. In this group, length of stay (14.3 days) and mortality (16%) were increased compared to patients undergoing elective repair (7.0 days and 2.5% mortality; p < 0.05). A 7.1 increase in odds of death was observed for non-elective patients in univariate analysis (95% CI of 2.1–24.9, p < 0.05). Chronically symptomatic patients admitted electively were not associated with increased odds for death. When controlling for gender, hospital characteristics and comorbidities, emergent or urgent repair remained the sole predictor of inpatient mortality (odds ratio 6.2, 95% CI 1.8–21.3, p < 0.05). CONCLUSION: This study defines demographics, length of stay, and inpatient mortality risk in elderly patients undergoing PEH. Emergent or urgent repair was associated with an increased inpatient length of stay and mortality, including a 6 to 7 fold increase in the odds of death. However, chronically symptomatic patients who underwent elective repair were not at increased odds for inpatient death. Based on these data, earlier elective repair of PEH may reduce mortality.

248 6303_SSAT.book Page 249 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1563 Surgeon Performed Endoscopic Balloon Dilation for Gastrojejunostomy Stenosis Atul K. Madan*2, Khurram Khan1, David S. Tichansky1 1University of Miami, Miami, FL; 2University of Tennessee Health Science Center, Memphis, TN INTRODUCTION: Gastrojejunostomy stenosis after Roux-en-Y gastric bypass (RYGB) can usually be treated with endoscopic methods. This study tested the hypotheses that surgeon performed endoscopic balloon dilation for gastrojejuntostomy stenosis is effective and safe. METHODS: All patients who underwent endoscopic balloon dilation for a gastrojejunstomy stenosis by two surgeons were included in this study. All patients underwent similar techniques of endoscopic balloon dilation. Wire guided balloon dilation was performed in each case where the endoscope could not be passed into the jejunum. Charts were reviewed for success and complications. RESULTS: There were 32 endoscopic balloon dilations in 20 patients. Steno- sis occurred an average of 2.4 years (Range: 1 month to 20.5 years) after the original RYGB. Patients required an average of 1.7 dilations (Range: 1 to 10 dilations) for success; although 75% of patients only required 1 dilation. There was 1 (3%) microperforation (pneumoperitenum with no evidence of radiographic dye leak) after one of the dilations in the patient who received 10 total dilations. The patient was observed with no further sequelae from her dilation. No other complications were noted. After the last dilation, all patients had resolution/improvement of their symptoms. CONCLUSIONS: Surgeon performed endoscopic balloon dilation is effective and safe. Multiple dilations can be performed in patients who have recurrent stenosis. Patients who have multiple dilations may be at a higher risk of complications. POSTER ABSTRACTS MONDAY

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M1564 Qualifying the Relationship: Interaction Effects in the Correlation Between Bmi and Abdominal Wall Thickness Mark Ranzinger*, F Jacob Seagull, Adrian E. Park Surgery, University of Maryland, Baltimore, MD BACKGROUND: While NOTES promises incisionless access to the abdomen, for the foreseeable future laparoscopic entry will be via trocars. Understand- ing abdominal wall morphology is a key to optimal trocar placement, operative planning, and port design. METHODS: In a non-selected consecutive series of patients undergoing laparoscopic surgery of the foregut, colon, and solid organs, trocar location and abdominal wall thickness (AWT) under 12–15 mmHg of insufflation was measured. (Correlations are noted as * = p < .05) RESULTS: Data from 50 patients (mean age = 51.3, range = 18–77) with BMI average 29 (SD = 6.0, range = 17–46) are reported below. Averaged across all abdominal locations, BMI was predictive of AWT. However, the quality of this prediction varied across patient morphology, age, port location, and positioning. Morphology: In the non-obese population, BMI correlated well to AWT averaged across all abdominal locations (r = .53*), and at the epigastrum (r = .50), but less so in the obese population (r = .32, and r = .22). Age: Age also interacted with the strength of correlation, with BMI correlating more highly with AWT in those under age 55 overall and at the epigastrum (r = .73* and r = .63* respectively), compared to those aged over 55 (r = .56* and r = .37). Location: Umbilicus had the thinnest AWT, the lowest variability of all measured abdominal locations, and no significant correlation to BMI (r = –.37).Positioning: BMI is highly correlated with AWT when the patient is positioned laterally (r = .81*), compared to supine positions (r = .58*). Proce- dure: No interaction was found between the type of surgery and AWT. CONCLUSIONS: In previous research we have shown that BMI correlates to AWT and that there are regional differences in the abdominal wall. This study, based on a larger sample, shows that there is a better correlation between BMI and AWT in the young and non-obese populations, and for patients positioned laterally. Data suggest that, because of decreased AWT and AWT-variability, coupled with AWT’s low correlation to BMI, placing a port at the umbilicus may be a useful strategy to minimize at-the-trocar wall thickness and AWT variability between patients.The data presented here may be useful in providing further refinement for the understanding of differences in AWT.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

BASIC SCIENCE POSTERS

Basic: Biliary

M1842 CD44-Hyaluronan Interaction Plays a Critical Role in Biliary Proliferation During the Development of Hepatic Cholestasis Gordon D. Wu*1, Yao He1, Haimei Wang1, Hong Wang1, John M. Vierling2, Andrew S. Klein1 1Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA; 2Department of Hepatology, Baylor College of Medicine, Houston, TX BACKGROUND: High levels of CD44 and its ligand hyaluronic acid (HA) are present in cholestatic livers. The role of CD44-hyaluronic acid (HA) interaction in biliary pathology, however, is poorly undrstood. METHODS: A rat model of cholestatic liver induced by bile duct ligation (BDL) was employed for the studies. Histological distribution of CD44- expressing cells and disposition of extracellular hyaluronic acid (HA) were examined in cryostat sections of the livers with immunoﬂuorescence or his- tochemistry. Biliary epithelial cells (BEC), hepatic stellate cells (HSC), CD31+ hepatic endothelial cells (HEC) and ED2+ Kupffer cells (KC) were isolated and examined for expression of CD44 standard (s) and variant (v) isoforms with quantitative real time PCR. The regulatory role of CD44-HA interaction in biliary proliferation was investigated in biliary epithelial cell (BEC) cultures. RESULTS: BDL livers developed intensive intrahepatic bile duct proliferation. Epithelia lining the proliferative bile ducts were strongly positive for CD44. CD44 expression by the proliferative BEC was associated with markedly increased interstitial HA accumulation. Quantitative PCR revealed that CD44 expressed by the cholestatic livers increased 26-fold over the control (p < 0.01). BEC isolated from the cholestatic livers expressed high levels of CD44 mRNA, which was 3-fold, 17-fold, and 19-fold as that expressed by sinusoidal endothelia, Kupffer cells and hepatic stellar cells (p < 0.01, respectively). BEC signiﬁcantly increased expression of CD44 (p < 0.01) and cell proliferation marker ki-67 (p < 0.05) in responses to hyaluronan stimulation

in cultures. Cellular proliferation assay demonstrated that cholangiocyte POSTER ABSTRACTS propagation accelerated upon HA stimulation, and was antagonized by anti- CD44 treatment (p < 0.05). MONDAY CONCLUSION: The study provides compelling evidence to suggest that proliferative BEC lining the intrahepatic bile ducts are the major source of hepatic CD44. CD44-HA interaction, by enhancing biliary proliferation, plays a pathogenic role in the development of cholestatic liver diseases.

251 6303_SSAT.book Page 252 Tuesday, April 22, 2008 1:26 PM

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Basic: Colon-Rectal

M1843 Decreased PLD2 Expression Correlates with NM404 Retention in Human Colorectal Cancer Xenografts Joseph Nwankwo*1, Jaime H. Mccord1, Mary Wentworth1, Jamey Weichert2, Sharon M. Weber1 1Surgery, University of Wisconsin, Madison, WI; 2Radiology, University of Wisconsin, Madison, WI INTRODUCTION: Radioiodinated NM404 (12-(4-iodophenyl)-octade- cylphosphocholine), a second-generation phospholipid ether analog, has displayed remarkable tumor selectivity in rodent tumor models. This novel agent is retained within tumor cells for a prolonged time, thus allowing for clinical imaging applications that may enhance preoperative staging. Phos- pholipid ether analogs appear to be a substrate for phospholipase D (PLD) but not phospholipase A or C based on preliminary data. We hypothesized that the mechanism of prolonged retention of NM404 is likely due to a decrease in its breakdown secondary to either decreased PLD1 or PLD2 expression. METHODS: Three human colorectal cancer cell lines, DLD-1, HT-29 and LS- 180, were simultaneously implanted subcutaneously (1 × 106 cells) into SCID mice. When tumor size reached 0.5 cm, animals were injected i.v. with 124I- NM404 (80–100 µCi in 0.1 ml). MicroPET and microCT images were obtained at 24 and 72 hrs. post injection, while quantification of NM404 retention was determined by ROI analysis of the PET scans. Cell lines were analyzed for PLD1 and PLD2 mRNA using quantitative PCR. qPCR for the PLD gene transcripts involved 50 cycles of amplification by real-time PCR to give PCR products of 560 bp for PLD1 and 557 bp for PLD2. RESULTS: On microPET imaging, tumor conspicuity was excellent in all 3 tumor types at both 24 and 72 hours post injection. For NM404 retention, tumor-to-muscle ratios of 11.1, 6.0, and 4.0 were obtained for LS180, DLD-1, and HT-29, respectively. qPCR results from three separate experiments for PLD1 and PLD2 in the colorectal cancer cell lines were determined and expressed as a ratio to the level of gene expression in the normal CCD-18co colorectal cells after normalizing to the S26 house-keeping gene. There was no difference in PLD1 expression in the colorectal cell lines compared to CCD-18co. However, expression of PLD2 was markedly decreased in all three cell lines, with PLD2 values of 0.05 ± 0.02 (p = 0.006): 0.47 ± 0.19 (p = 0.083); and 0.14 ± 0.06 (p = 0.021) for LS-180, DLD-1, and HT-29, respectively. Thus a decreased PLD2 expression level correlated with increased retention levels of NM404. CONCLUSION: Human colorectal tumors showed excellent tumor conspicuity when utilizing 124I-NM404 microPET. This appears to be associated with a decrease in expression of PLD2. Further evaluation of the mechanism of selective retention of NM404 is needed in order to define a molecular profile that may classify tumors as more sensitive to NM404, enabling the selection of a subset of patients that would benefit from preoperative staging with NM404.

252 6303_SSAT.book Page 253 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1844 The Effects of Dai-Kenchu-to (TU-100) on Propulsive Motility in the Colon Michael Wood*1, Neil H. Hyman1, Gary M. Mawe2 1Surgery, University of Vermont College of Medicine, Burlington, VT; 2Anatomy & Neurobiology, University of Vermont College of Medicine, Burlington, VT PURPOSE: Opioid analgesics have long been the primary treatment of postoperative pain. The use of these agents, however, is often associated with adverse effects on gastrointestinal motility including postoperative ileus. Recent efforts have focused on selective antagonists of the opioid-mu receptor. The purpose of this study is to examine the use of the herbal medicine Dai-Kenchu-to (DKT) as a potential treatment for opiate-induced slowing of intestinal transit in an isolated guinea-pig colon model of motility. We then investigated whether DKT could act synergistically with the non-selective opiate receptor antagonist, naloxone to promote propulsive motility. METHODS: Isolated segments of distal guinea-pig colon were mounted in a perfusion chamber and imaged with a digital video camera interfaced with a computer. Fecal pellets were placed into the lumen at the oral end of the colonic segment and the rates of motility over a 3–4 cm segment of colon were determined. In addition, intracellular recording were obtained from intact circular muscle. Inhibitory and excitatory junction potentials, evoked by stimulation above or below the recording site, respectively were analyzed. RESULTS: The addition of DAMGO (D-Ala2, N-Me-Phe4, Gly-ol5), a selective mu-receptor agonist, caused a concentration-dependent decrease in colon motility. Naloxone did not affect basal activity, but partially restored motility in the DAMGO treated preparations. DKT (1 × 10–4–3 × 10–4 g/ml) also reversed the inhibitory effect of DAMGO treated colon in a concentration dependent manner. At higher concentrations (1 × 10–3–3 × 10–3 g/ml), however, this effect was lost. Motility slowed even further when naloxone and DKT were combined, with noticeable disruptions in spatiotemporal patterns. Interestingly, when added alone, DKT caused a reversal of the peristaltic reﬂex resulting in propulsion of the pellet in an anal to oral direction. In electrophysiological studies, DKT inhibited both excitatory and inhibitory junction potentials. CONCLUSIONS: DKT appears to be as effective as naloxone in restoring motility in DAMGO treated colon. These two agents, however, do not appear POSTER ABSTRACTS to have an addictive effect. When used on untreated colon segments, DKT

appears to cause disruptions in the intrinsic reﬂex circuit of the gut by inter- MONDAY fering with neuromuscular communication.

253 6303_SSAT.book Page 254 Tuesday, April 22, 2008 1:26 PM

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M1845 Effect of NOD2/CARD15 Mutations on Ileal Gene Expression Profiles in Crohn’s Disease Casey K. Mccullough2, Christina M. Hamm2, Elizabeth Gorbe2, Jonathan T. Unkart2, Ellen Li2, Qing Qing Gong2, Candace R. Miller1, Thaddeus S. Stappenbeck3, Christian Stone2, David W. Dietz4, Steven R. Hunt*1 1Department of Surgery, Washington University, Saint Louis, MO; 2Division of Gastroenterology, Washington University, Saint Louis, MO; 3Department of Pathology and Immunology, Washington University, Saint Louis, MO; 4Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Three mutations (Leu1007InsC, R702W, G908R) in the nucleotide-binding oligomerization domain (NOD)2/caspase recruitment domain (CARD)15 have been associated with an increased risk of Crohn’s disease (CD) and ileal disease location. Analysis of the effect of NOD2/CARD15 mutations on ileal gene expression could provide further insight on the pathogenesis of ileal CD. METHODS: We performed microarray analysis on normal ileal mucosa from three NOD2– (none of the three mutations) normal control subjects, and on inflamed and uninflamed ileal mucosa from three NOD2– CD patients, and three NOD2+ (at least one of three mutations) CD patients. All patients were nonsmokers. In the six CD patients, both inflamed and macroscopically uninflamed tissue biopsies were obtained from fresh pathologic specimens at the time of their initial ileocolic resection. The probes prepared from the ileal RNA and the common reference ileal RNA (from a fourth NOD2– control subject) were hybridized with the Agilent Whole Human Genome array using the two-color protocol. The data was analyzed using Statistical Analysis of Microarrays (SAM) software. RESULTS: SAM analysis detected no significant difference between NOD2+ and NOD2– uninflamed mucosa. We identified a number of genes that were upregulated in the NOD2+ inflamed ileal mucosa relative to NOD2– inflamed ileal mucosa. One of the identified target genes, CYBB, encodes cytochrome b-245, beta polypeptide, which is a component of the microbicidal oxidase system in phagocytes (q = 0.04). In addition, we observed altered expression of genes (q < 0.05) in the uninflamed mucosa in CD patients compared to control subjects that was independent of NOD2 status. CONCLUSIONS: We have identified target genes that are upregulated in inflamed ileal mucosal biopsies from NOD2+ CD patients relative to inflamed mucosa from NOD2– CD patients. One of these genes, CYBB, plays an integral role in mucosal defense. These experiments have also detected altered expression of genes in macroscopically normal ileal mucosa from CD patients compared to control subjects, prior to upregulation of pro-inflammatory genes associated with CD activity.

Poster of Distinction

254 6303_SSAT.book Page 255 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1847 The Effect of Toll Like Receptor (TLR) 9 Agonist, CpG Oligodeoxynucleotides (ODN), on Abdominal and Gastrotomy Wound Healing in a Murine Model Ik-Yong Kim*1,2, Xiaohong Yan1, Raymond Baxter1, Thomas R. Gardner3, Chandana Shantha Kumara Hm1, Aqeel Ahmed4, Carlos Cordon-Cardo4, Richard L. Whelan1 1Colorectal Surgery, Columbia University, New York, NY; 2Surgery, Yonsei University, Wonju College of Medicine, Wonju, South Korea; 3Orthopedic Surgery, Columbia University, New York, NY; 4Pathology, Columbia University, New York, NY INTRODUCTION: The synthetic TLR9 ligand, CpG ODN (CpG) has been used clinically as an anti-cancer immunotherapy. It has largely been used in the adjuvant or stage 4 setting. It has been shown experimentally that CpG, when given alone prior to surgery (preop), limits postoperative tumor growth. Perioperative (Periop) CpG might also limit post-surgical immuno- suppression. Prior to human periop studies CpG’s impact on wound healing must be determined. This study’s purpose was to assess abdominal wall wound and anastomotic healing after periop CpG. METHODS: Thirty Balb/C mice were randomized into 2 groups and given CpG 1826 (20 ug/dose) or PBS via i.p. both PreOP (7, 5, 3, and 1 day before surgery) and on PostOP day (POD) 1, 2, and 3. All mice underwent a laparotomy and gastrotomy that were carefully suture closed. The mice were sacri- ﬁced on POD7 and 21 and their abdominal pelts and stomachs excised. Tensometry was used to determine the peak force and total energy required to disrupt the abdominal wall wounds while the bursting pressure of the gastric wounds was measured via saline infusion. The Sircol assay was used to determine soluble collagen content and a blinded pathologist used a wound healing scoring system histologically to assess the pelts. RESULTS: There were no signiﬁcant differences in the bursting pressures of the gastrotomy wounds or in the peak force or total energy needed to disrupt the abdominal wounds when comparing the results of treated group to those of the control group on POD7 or 21. In regard to abdominal wound collagen content, no differences were noted between the control and treated groups at either time point. Importantly, there were no abdominal wall dehiscence or clinical gastrotomy leaks in CpG treated group. The histologic healing assess-

ment scores were similar between groups. POSTER ABSTRACTS

CONCLUSIONS: Perioperative administration of CpG doesn’t appear to have MONDAY a negative impact on abdominal wall or gastric wound healing in mice. Although it is not possible to extrapolate these results directly to the human setting, these ﬁndings lend support to the concept of a human Phase I perioperative CpG study.

255 6303_SSAT.book Page 256 Tuesday, April 22, 2008 1:26 PM

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Basic: Esophageal

M1848 Evaluation of the Cell Proliferation Expansion in the Columnar Mucosa of the Distal Esophagus in Patients with GERD: Immunohistochemical Analysis of KI67 (MIB1) Antigen in Columnar Mucosa With and Without Intestinal Metaplasia Marcelo Binato1,2, Renato B. Fagundes4, Luise Meurer3, Maria Isabel A. Edelweiss3, Richard R. Gurski*2 1General Surgery, UFSM, Santa Maria, Brazil; 2General Surgery, UFRGS, Porto Alegre, Brazil; 3Pathology, UFRGS, Porto Alegre, Brazil; 4Gastroenterology, UFSM, Porto Alegre, Brazil INTRODUCTION: Columnar mucosa without intestinal metaplasia in distal esophagus is considered to be the stage that precedes the metaplasia—dysplasia—adenocarcinoma sequence. In 20% of these cases, upper endoscopy and biopsy shall confirm diagnosis of intestinal metaplasia in subsequent tests. Histology alone cannot establish the percentage of patients that will develop intestinalization of columnar mucosa. Therefore, it is necessary to seek molecular markers capable of predicting progression to more severe stages of the disease. OBJECTIVES: Determine the proliferative activity of columnar mucosa in patients with gastroesophageal reflux subjected to digestive endoscopy and biopsy in the Unit of Digestive Endoscopy of Hospital Universitário de Santa Maria, between 2003 and 2006. METHODS: The Ki67 antigen was assessed by immunohistochemical technique with use of monoclonal antibody Ki67 (MIB1) in the 1:400 dilution. Proliferative activity was determined by the Ki67 index in every proliferative compartment of the intestinal crypt (lower layer, middle layer and epithelial surface). The 62 patients who had columnar mucosa in the distal esophagus were divided into two groups: G1: 30 patients with columnar epithelium without intestinal metaplasia and G2: 32 patients with columnar epithelium with intestinal metaplasia. RESULTS: In G1, proliferative activity of the Ki67 was limited to the lower layer of the gland in 83% of the patients, 3% showed positive reactivity up to the middle layer and 13% showed immunoreactivity up to the epithelial surface of the esophageal crypt. In G2, proliferative activity of the Ki67 was limited to the lower layer of the gland in 46.9% of the patients, 21.9% showed positive reactivity up to the middle layer and 31.2% showed immunoreactivity up to the epithelial surface. A significant increase in the prevalence of proliferative activity in the compartments above the lower layer of the gland in patients with metaplastic columnar mucosa was found (p < 0.001). CONCLUSION: The expansion of cell proliferation was significantly associated to the process of intestinalization of the columnar mucosa in the distal esophagus. Therefore, the presence of proliferative activity above the lower layer of the intestinal crypt in patients with columnar mucosa may assist in the identification of patients more prone to malignant transformation of the gastric mucosa or intestinalization and, consequently, at a greater risk of disease progression (metaplasia—dysplasia—adenocarcinoma sequence). Keywords: Ki67 (MIB1). Barrett’s esophagus. Columnar mucosa. Intestinal metaplasia.

256 6303_SSAT.book Page 257 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1849 The Pathogenesis of Barrett’s Esophagus: The Combination of Acid and Bile Is Synergistic in the Induction of CDX2 and EGFR Activation in Esophageal Cells Nelly E. Avissar*, Liana Toia, Yingchuan Hu, Alexi Matousek, Daniel Raymond, Carolyn E. Jones, Thomas J. Watson, Jeffrey H. Peters Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, NY INTRODUCTION: Clinical evidence strongly suggests that mixed reflux of duodenal and gastric content is associated with esophageal mucosal injury, particularly the development of Barrett’s esophagus. Caudal homeobox 2 (CDX2), a transcription factor involved in normal intestinal development is thought to be the key factor responsible for the intestinal phenotype. We have previously shown that deoxycholic acid (DCA), at neutral pH induces CDX2 through transactivation of the epidermal growth factor receptor (EGFR). The aim of this study was to test the hypothesis that a combination of bile and acid pH is more potent in inducing CDX2 and activating the EGFR than either component alone. METHODS: SEG-1 human esophageal adenocarcinoma cells were incubated with acid alone (pH 5), deoxycholic acid alone (100 or 300 µM), or their combination for up to 24 hours. CDX2 mRNA was determined by real-time PCR and EGFR site-specific tyrosine phosphorylation and receptor degradation were determined by Western blot analysis. RESULTS: Neither acid (pH 5) nor the 100 µM DCA dose alone induced CDX2 mRNA. In contrast, there was a synergistic 55 fold increase in CDX2 mRNA expression with exposure to 100 µM DCA at pH5. Each treatment (pH 5, DCA or pH 5 plus DCA) activated the EGFR on all tyrosines tested, but in different time courses. Acid alone induced peak EGFR phosphorylation at 8 h, DCA alone at 30 min and 8 hours and acid plus DCA at 1 hour. Interest- ingly, degradation of the EGF receptor occurred with the combination treatment but not with either acid or DCA alone, indicating differential transactivation pathways. The combination of pH 5 and 300 µM DCA resulted in significant cell death at all time points. CONCLUSION: The addition of acid markedly enhances bile salt induced activation of the transcription factor CDX2 and occurs coincident with acti-

vation of the epidermal growth factor receptor. CDX2 gene induction occurs POSTER ABSTRACTS at signiﬁcantly lower concentrations of bile salt than in the absence of acid, and may be due to differential EGFR transactivation. This data provides fur- MONDAY ther insight into the molecular pathogenesis of Barrett’s columnar metaplasia and identiﬁes molecular targets useful for diagnosis, risk assessment and therapeutic intervention.

Poster of Distinction 257 6303_SSAT.book Page 258 Tuesday, April 22, 2008 1:26 PM

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M1850 Bile Reflux Induces Higher COX-2 Expression Than Mixed Acid and Bile Reflux in a Rat Model of Esophagitis Reginald V. N. Lord*1,2, Stefan Oberg1,3, Jeffrey H. Peters1,4, Steven R. Demeester1, Jeffrey A. Hagen1, Tom R. Demeester1 1Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA; 2UNSW Department of Surgery, St. Vincent’s Hospital, Sydney, NSW, Australia; 3Department of Surgery, Lund University, Lund, Sweden; 4Department of Surgery, University of Rochester, Rochester, NY BACKGROUND AND AIMS: A rat model of severe esophagitis is induced by performing either an esophagoduodenostomy (ED, acid and non-acid/bile reflux) or esophagoduodenostomy with total gastrectomy (ED + TG, non-acid reflux only). Esophagitis is not found in control animals in which total gastrectomy with Roux-en-Y reconstruction is performed (TG + RY, no reflux). All three operations result in formation of well-differentiated tumors at the esophageal anastomosis. Consequently, the nature of these tumors is controversial. COX-2 is overexpressed in a stepwise manner in esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma. The aim of this study was to (1) compare esophageal cyclo-oxygenase 2 (COX-2) expression in the three operation models, and (2) characterize the tumors. METHODS: COX-2 enzyme expression was measured in the distal esophageal mucosa of 60 rats, 20 in each operation group, using a polyclonal rabbit antibody. Tumor and normal tissues were examined for DNA content and apoptotic index using flow cytometry with immunofluorescent propidium iodide and annexin V labeling, and for protein expression using immunohistochemistry. RESULTS: COX-2 expression was higher than controls in severe esophagitis in both ED and ED+TG arms but was significantly higher in the non-acid bile reflux ED+TG arm. The tumors were diploid in 5 of the 6 examined and the remaining animal had aneuploidy in both tumor and normal tissues. None of 12 tumors examined showed immunoreactivity with p53, DAS-1, c-erbB-2, CEA, chromogranin A, or synaptophysin antibodies. CONCLUSIONS: Injury severity, as measured by COX-2 overexpression, was significantly higher in a non-acid reflux environment in this animal model of esophagitis. The esophageal tumors that developed in this surgical model without exogenous carcinogen exposure were dissimilar to human esophageal adenocarcinomas.

258 6303_SSAT.book Page 259 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Hepatic

M1851 Cellular Liver Regeneration After Extended Hepatic Resection in Pigs Ruth Ladurner*, Martin Schenk, Frank Traub, Alfred Koenigsrainer, Jorg Glatzle General and Transplant Surgery, University of Tuebingen, Tuebingen, Germany BACKGROUND: The liver has an extremely effective regenerative capacity. There is some evidence, that a portosystemic shunt is beneficial for liver regeneration after extended resection. The aim of the study was to estimate, whether the regeneration is due to hypertrophy or hyperplasia of the remnant liver tissue and whether a portosystemic shunt is beneficial for liver regeneration. MATERIAL AND METHODS: An extended left hemihepatectomy (approximately 75% of liver volume) was performed in 6–8 weeks old domestic pigs (n = 25, body weight 25–35 kg). In n = 14 pigs a portosystemic H-shunt was inserted between the portal vein and the infrahepatic cava vein after extended resection. After surgery, animals were weaned from anesthesia and resumed oral feeding. Liver biopsies were histological examined before extended liver resection and weekly until the 3rd postoperative week. Liver regeneration was estimated by the liver volume, the size of the portal fields (mm2), the amount of hepatocytes per portal field and the amount of hepatocytes per mm2. RESULTS: Extended left resection was technically feasible in all animals with and without portosystemic shunt. Volume of the remnant right lateral segment reached 250% at the end of the first week after resection. The size of the portal fields increased significantly after resection (portal field [mm2]; animals with shunt before resection: 1.0 ± 0.4, 1 week after resection: 1.8 ± 0.9*; 3 weeks: 2.9 ± 1.3*, *p < 0.05; animals without shunt before resection: 1.1 ± 0.3, 1 week after resection 1.8 ± 0.7*; 3 weeks: 2.9 ± 1.7*, *p < 0.05). The number of hepatocytes in the portal fields increased significantly (hepatocytes/portal field, animals with shunt before resection: 3438 ± 1281; 1 week after resection: 5831 ± 3419*; 3 weeks: 8793 ± 3690*; *p < 0.05; animals without shunt before resection: 3053 ± 1096, 1 week after resection: 4580 ± 2007*; 3 weeks: 8014 ± 4809*, *p < 0.05). Interestingly there was no increase in hepatocytes/ mm2 and there was no difference between animals with or without portosystemic shunt. POSTER ABSTRACTS CONCLUSION: After extended liver resection the restoration of the liver vol- MONDAY ume is accomplished by an extensive and significant hyperplasia of hepatocytes within the preexisting portal fields, indicated by increased portal fields and hepatocytes per portal field, but constant hepatocytes per mm2. How- ever, there was no beneficial effect of a portosystemic shunt, regarding liver regeneration after extended liver resection.

259 6303_SSAT.book Page 260 Tuesday, April 22, 2008 1:26 PM

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M1852 Basics of Mouse Liver Anatomy from a Microsurgical Point of View Peter Studer*, Daniel Sidler, Beat Gloor, Andre E. Dutly, Daniel Candinas, Daniel Inderbitzin Inselspital, Bern, Switzerland BACKGROUND: During the development of different mouse liver resection models for the study of hepatic regeneration and basic liver pathology a significant lack of relevant anatomical data of the mouse liver became obvious. It has been shown, however, that different mouse liver lobes exhibit different regenerative capacities (less for the caudate lobe). In order to create a mouse model with standardized resections allowing a meaningful study of adaptive and regenerative responses the following basic anatomical studies of the mouse liver were undertaken. METHODS: In Balb/c mice (n = 32, 18–26 g) and Black 6 transgenic blue mice (n = 69, 19–27 g) liver mass and individual liver lobe weights were determined. The detailed three-dimensional anatomy of the hepatic vascular system was studied with corrosion casts (n = 8). For scanning electron microscopy (EM) the mouse liver was perfused with a Mercox solution. Casts were sputtered with gold (10 nm) and examined in a Philips XL 30 FEG scanning electron microscope. RESULTS: When comparing liver weight (LW)/ bodyweight (BW) ratio significant strain specific differences were detected. In Balb/c mice liver weight (LW) was increasing up to a mouse body weight (BW) of 23.6 g ± 1.6 gr and decreasing thereafter (LW [g] = –0.0022 * BW [g] 2 + 0.1025 * BW [g]). In contrast the LW in the Black 6 transgenic mice showed a linear increase with increasing BW. In Balb/c mice vascular corrosion casts demonstrated a single vascular pedicle in the right superior, right inferior and caudate lobes. In contrast, a common pedicle was seen for medial and left lobes in 26%, explaining the necrosis of the left lobe after medial lobe resection in around 30% of cases. In Balb/c mice histological sections vascular density, total vascular luminal area and calculated volumes of liver lobules were not different between liver lobes. EM showed significantly smaller hepatic lobules in the cudate lobe (when compared with the right superior lobe) with significantly increased vascular density. CONCLUSIONS: Relative mouse liver mass varies considerably with bodyweight and strain. A common vascular pedicle of the medial and left lobe in Balb/c mice explains the inhomogeneous perfusion of the liver remnant after some isolated medial lobe resections. This resection is therefore not recommended. A higher vascular density in the caudate lobe with smaller hepatic lobules as seen in EM might explain the impaired hepatic regenerative capacity. Our anatomical data underline the importance of careful selection of the appropriate microsurgical model when studying mechanisms of liver regeneration and basic liver pathologies.

260 6303_SSAT.book Page 261 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1853 Simultaneous Splenectomy Enhance Liver Regeneration After Major Hepatectomy via Decreasing Activin-A Expression Yan-Shen Shan*, Pin-Wen Lin National Cheng Kung Univ Hosp, Tainan, Taiwan BACKGROUND AND PURPOSE: Splenectomy can enhance liver regeneration after major hepatectomy probably due to removal of inhibitory factors released from the spleen. Activin-A, a superfamily of TGF-, can negatively regulate liver regeneration. Aim of our study was to investigate whether activin-a may play a role in enhancing liver regeneration in hepatectomized rats with splenectomy. MATERIAL AND METHODS: Male wistar rats, weighing 250 gw, received 70% hepatectomy without (PH) or with splenectomy (PHSL). These rats were sacrificed at different time schedule. The increasing liver/body weight ratio, regeneration of hepatocytes, mRNA and protein expression of activin-A were compared. RESULTS: The liver/body weight ratio was significantly higher in the PHSL group than that in PH group since 1 day later. The mRNA and protein expression of activin-A are significantly lower in the PHSL group than those in PH group in the first 12 hours. In the PHSL group, PCNA staining showed the regeneration of hepatocytes was increased and the expression of activin-A in the hepatocytes and kupper cells was decreased when compared with the PH group in the first 48 hours after operation. After the early mitogenic stimulation by HGF, the protein expression of activin-A is persistent decreased and negative correlated with liver weight ratio in PHSL group. CONCLUSION: After major hepatectomy, simultaneous splenectomy can accelerate early liver regeneration via decreasing expression of activin-A. POSTER ABSTRACTS MONDAY

Poster of Distinction

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Pancreas

M1854 Cannabinoid Receptor Blockade Attenuates Acute Pancreatitis by an Adiponectin Mediated Mechanism Nicholas J. Zyromski*, Abhishek Mathur, Terence Wade, Sue Wang, Deborah A. Swartz-Basile, Andrew Prather, Keith D. Lillemoe, Henry A. Pitt Surgery, Indiana University, Indianapolis, IN BACKGROUND: Obesity is an independent risk factor for developing severe acute pancreatitis. Adipose tissue produces hormones (adipokines) that regulate metabolism and inflammation. We recently showed that the potent anti- inflammatory adipokine adiponectin inversely mirrors the severity of acute pancreatitis in lean and congenitally obese mice. The endocannabinoid system is also important in regulating appetite and metabolism. Increases in circulating levels of adiponectin are observed after central blockade of the cannabinoid-1 (CB-1) receptor. We therefore hypothesized that CB-1 blockade would attenuate the severity of acute pancreatitis by elevating adiponectin. METHODS: 32 congenitally obese (Lepdb/db) mice were studied at 16 weeks of age. Half were subjected to acute pancreatitis by cerulein injection (50 µg/kg IP hourly × 6); the others received saline. For 7 days prior to study, half of the animals in each group (pancreatitis/control) received the CB-1 receptor antagonist rimonabant (10 mg/kg IP); the other half received vehicle. Mice were sacrificed 9 hours after pancreatitis induction. Histologic pancreatitis severity was determined by a validated method. Serum levels of adiponectin and tissue levels of the pro-inflammatory cytokine interleukin-6 (IL-6), and the chemoattractant molecule MCP-1 were measured by ELISA. ANOVA and Tukey’s test were applied where appropriate; p < 0.05 was considered statistically significant. RESULTS: CB-1 blockade with rimonabant significantly increased circulating adiponectin levels (p < 0.05, Table). In the control group, treatment with rimonabant did not change pancreatic levels of IL-6 or MCP-1. In the pancreatitis group, CB-1 blockade with rimonabant significantly decreased the histologic pancreatitis score (p < 0.001) as well as pancreatic IL-6 and MCP-1 expression (p < 0.001) compared to vehicle treated animals. CONCLUSION: These data demonstrate that CB-1 receptor blockade 1) increases circulating adiponectin and 2) significantly attenuates the severity of acute pancreatitis in congenitally obese mice. We conclude that the adipokine milieu is important in the pathogenesis of severe acute pancreatitis in obesity, and that CB-1 blockade attenuates acute pancreatitis by an adiponectin mediated mechanism. CONTROL PANCREATITIS Vehicle Rimonabant Vehicle Rimonabant Adiponectin (µg/mL) 2.2 ± 0.3 4.1 ± 0.6* 2.9 ± 0.4 4.8 ± 0.8* Pancreatitis Score 0.2 ± 0.5 0 ± 0 7.6 ± 1.0 2.9 ± 0.9† IL-6 (pg/mL) 231 ± 58 237 ± 148 3445 ± 1432 373 ± 52† MCP-1 (pg/mL) 380 ± 51 293 ± 66 7740 ± 1386 2096 ± 239†

*p < 0.05 vs vehicle in each group (control/pancreatitis); †p < 0.001 vs vehicle within pancreatitis group

262 6303_SSAT.book Page 263 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1855 Over-Expression of Focal Adhesion Kinase Inhibits Cell Proliferation in Gastrointestinal Neuroendocrine Tumor Cells Li Ning*, Muthusamy Kunnimalaiyaan, Herbert Chen Surgery, University of Wisconsin, Madison, WI BACKGROUND: Gastrointestinal neuroendocrine (NE) tumors frequently metastasize and have limited treatments. We have recently found that overexpression of focal adhesion kinase (FAK), a non-receptor tyrosine kinase that plays an important role in cancer biology, led to a signiﬁcant reduction in NE tumor markers in gastrointestinal NE tumor cells. However, the role of FAK on gastrointestinal NE tumor growth is not known. We hypothesize that over-expression of FAK might inhibit gastrointestinal NE tumor cell growth. METHODS: Human pancreatic carcinoid BON cells were transiently transfected with recombinant pKH3-FAK constructs encoding the full-length of wild-type FAK protein or vector alone and analyzed by Western blot for evidence of FAK over-expression in transfected cells. MTT (3-(4,5-Dimethylthia- zol-2-yl)-2,5-diphenyltetrazolium bromide) rapid colorimetric assay was used to measure cell viability in FAK transfected BON cells. Finally mechanism of growth inhibition was analyzed by Western blotting. RESULTS: At baseline, no FAK protein was present in BON cells. Transfection with recombinant pKH3-FAK constructs resulted in FAK over-expression and a concomitant decrease in cell viability (percentage) compared to vector alone in BON cells. Moreover, Western blotting identiﬁed an increase in phosphorylation of FAK Tyr407 only, and no change in FAK Tyr397 or FAK Tyr576/577 in BON cells transfected with pKH3-FAK plasmid. FAK overexpression in BON cells led to an increase in p21 and a decrease in CyclinD1 protein, indicating that the growth inhibition was mediated by cell cycle arrest. CONCLUSIONS: FAK expression leads to a reduction in cellular proliferation in gastrointestinal NE tumor cells. The mechanism of growth suppression is mediated by cell cycle arrest. FAK Tyr407 phosphorylation may contribute to negative regulation of kinase activity. Therefore, FAK is a potential target for the development of new treatments for advanced gastrointestinal NE tumors. POSTER ABSTRACTS MONDAY

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M1856 Potential Therapeutic Targets in Invasive Pancreatic Cancer Identified by Gene Expression Profiling Annamarie Rogers*, Joseph Murphy, Ellen Manahan, Desmond P. Toomey, Kevin C. Conlon Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland INTRODUCTION: Current management of pancreatic cancer is mired by late presentation and lack of effective adjuvant therapy. We investigated the genome-wide expression profiles of pancreatic cancer cell lines, AsPC-1 and BxPC-3, to identify diagnostic markers and therapeutic targets for this disease. METHODS: Cells were treated with Camptothecin (pro-apoptotic) or phorbol 12-myristate 13-acetate (PMA—pro-inflammatory). Non-treated cells were used as control. RNA was extracted and hybridised to Affymetrix arrays. Dif- ferentially expressed genes were identified using ArrayAssist®. Significantly interacting genes were linked and pathways mapped using Pathway Studio®. Genes were selected for validation by qRT-PCR based on pathway significance and fold change. RESULTS: Genesets for each condition displayed a 1.5 fold differential expression with p-values < 0.02. Pathway analysis revealed that camptothecin was primarily involved in signal transduction via MAP kinase pathways. PMA induced apoptotic signalling through a family of receptors known collec- tively as “death receptors” including Fas, DR3 and DR4-5. Quantitative RT- PCR confirmed microarray expression profiles. Genes selected included those already implicated in pancreatic cancer (SMAD3, BRCA2, MMP-1, IL1-R1) and also several not previously reported. Although camptothecin and PMA had distinct expression profiles, 3 genes (ATF3, PLAU and SOD2) were ≥ 10 fold up- and down-regulated in AsPC-1 and BxPC-3, respectively. CONCLUSION: novel genes have been identified in pancreatic cancer for evaluation as screening and therapeutic targets. Three genes (ATF3, PLAU and SOD2) are involved in early stage invasion and cell dissociation, thus demonstrating potential as specific tumour markers or molecular targets in pancreatic cancer.

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1857 A Xenograft Model and Cell Line Deriving from Invasive Intraductal Papillary Mucinous Neoplasm of the Pancreas Stefan Fritz*1, Carlos Fernandez-Del Castillo1, A. John Iafrate2, Mari Mino-Kenudson2, Nancy L. Neyhard1, Jennifer Lafemina1, Amy Stirman1, Andrew L. Warshaw1, Sarah P. Thayer1 1Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; 2Department of Molecular Diagnostics Laboratory, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA OBJECTIVES: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are characterized by a prominent intraductal component, which has malignant potential. Adenocarcinoma arising in IPMN has a less aggressive biological behavior, and survival after surgery has been shown to be better than for pancreatic ductal adenocarcinoma (PDAC). Many authors suggest that IPMNs are distinct neoplasms with a unique genetic signature. In addition to chromosomal instability, PDAC carries characteristic mutation types such as K-ras and p53 mutations. For PDAC, cell culture and xenograft models have become a powerful tool to study tumor behavior and genetics. Our lab recently reported that the Sonic Hedgehog (Shh) pathway is overexpressed in >95% of PDAC. In this study we describe a novel xenograft model and cell culture deriving from malignant IPMN, created to biologically and genetically characterize IPMNs and compare them to PDAC. METHODS: From a fresh surgical specimen of invasive main duct IPMN a xenograft tumor line and cell culture were created and its histology, K-ras and P53 status determined. Members of Shh pathway signalling (Shh, Ptch1, Ptch2, Smo, and Gli2) were assessed by quantitative RT-PCR, and global genomic changes were evaluated by array Comparative Genomic Hybridiza- tion (CGH). RESULTS: IPMN tumors were successfully implanted and enriched in a xenograft model, and a cell line was established. Histology of the xenograft tumors revealed characteristics identical to those of the parent tumor. Cyto- genetic analysis showed a tetraploid karyotype with multiple chromosomal aberrations reﬂecting genomic instability, K-ras mutation at codon 12 (GGT > GTT) and p53 mutation at codon 273 in exon 8 (CGT > TGT) as well as over

expression of the Shh pathway. Thus, IPMNs do share certain genetic features POSTER ABSTRACTS that characterize PDAC. Array CGH reveals chromosomal gains at 3q, 5p, 9p, 12p, 18p, and 19q, and losses which involve chromosomes 4, 5q, 6q, distal MONDAY 6p, 8p, 8q, 9q, 13q, 14q, 15q, 17p, 18q, 19p, and 21. These data are comparable to previously published chromosomal aberrations in IPMNs and show overlapping and distinct characteristics compared to PDAC. CONCLUSION: This study describes a novel xenograft model and cell line deriving from adenocarcinoma arising in IPMN. Characterization of the model shows similarities to the parent tumor in accord with previously published data on IPMNs. Compared to PDAC, this model shows shared aberrations as well as evidence for distinct genomic changes. More importantly, the xenograft model may be useful for future preclinical chemotherapy studies in vivo.

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M1858 pp32 Is a Key Regulator of Cellular Differentiation: Implications for Anti-Cancer Therapy Jonathan R. Brody1, Timothy K. Williams*1, Agnes Witkiewicz2, Joseph Cozzitorto1, Gary Pasternack3, Shrihari Kadkol3, Charles J. Yeo1 1Surgery, Thomas Jefferson University, Philadelphia, PA; 2Pathology, Thomas Jefferson University, Philadelphia, PA; 3Pathology, Johns Hopkins University, Baltimore, MD OBJECTIVE: To evaluate pp32 expression as a signal for the complex process of differentiation in normal and malignant cells. BACKGROUND: pp32 is a highly-conserved multi-functional nuclear protein whose biologic activities include inhibition of oncogene-mediated transformation, inhibition of histone acetyl transferase activity (INHAT), a role in the caspase-independent apoptotic pathway, and message stability of specific cytokine and oncogene messages. It has been previously shown that reduction of pp32 in a neoplastic cell line induced differentiation that accompanied inhibition of proliferation. Further, we recently reported that pp32 expression is nearly absent in poorly differentiated pancreatic ductal adenocarcinoma cells (Modern Pathology 2007 (20), 1238–1244). In adult tissues, pp32 is found in self-renewing (often basal) cells as well as in neoplastic cells, but not in most terminally differentiated cells. These findings suggest that in normal or cancer cells, pp32 expression is either involved in the control of differentiation, or is regulated by mechanisms that control differentiation. METHODS: We evaluated whether pp32 expression correlated with differentiation both in in vitro models and in vivo during murine embryogenesis. Undifferentiated HL-60 promyelocytic leukemia cells as well as ML-1 and K562 myeloid leukemia cell lines were assayed for levels of pp32 mRNA and protein. To determine the pattern of pp32 expression at different gestational ages, we examined transverse sections of embryos from Days 8, 10, 12 and 15 and sagittal sections from embryos from days 8–15. RESULTS: In all three cell line models, mRNA and protein levels decreased dramatically following phorbol ester-stimulated differentiation into different lineages. In the K562 system, reduction of pp32 expression induces morphology that is consistent with megakaryocytic differentiation. In murine embryos, pp32 mRNA levels are generally high in most tissues on Day 10, but are decreased after Day 12. As tissues differentiate, only a small fraction of cells continue to express pp32 at high levels. CONCLUSIONS: Based upon these results and our previous findings, we conclude that pp32 is differentiation-regulated in normal tissues, neoplastic cells, and during embryogenesis and is most likely a critical signal and marker for this process. These findings provide evidence that manipulation of pp32 expression may provide a novel ‘differentiation-induced’ therapy against different types of cancers that have the plasticity to differentiate. This strategy, in theory, would be more specific and safer than recent, similar approaches using HDAC inhibitors against cancers.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1859 The Effect of ras/raf-1 Pathway Activation on Somatostatin Receptors in Gastrointestinal Carcinoid Tumor Cells Scott N. Pinchot*, Herbert Chen Surgery, University of Wisconsin Hospital and Clinics, Madison, WI BACKGROUND: Gastrointestinal (GI) carcinoid tumors often cause debilitating symptoms due to excessive hormonal secretion. We have previously shown that activation of the ras/raf-1 signal transduction pathway in GI car- cinoids markedly suppresses chromogranin A (CgA) and serotonin production. Since somatostatin agonists have been shown to have similar effects, we hypothesized that raf-1 activation modulates neuroendocrine (NE) hormone production through alterations in somatostatin receptor (SSTR) expression. METHODS: Gastrointestinal carcinoid (BON) cells and an estrogen-inducible raf-1 cell line (BON-raf) were used to study the effects of raf-1 activation on somatostatin receptors (SSTR1-5). Cells were treated with either control (ethanol) or β-estradiol for two days. Protein isolates were analyzed by Western blot to confirm raf-1 activation and determine the level of somatostatin receptor activity utilizing subtype-specific antibodies for SSTR1-5. RESULTS: Estrogen treatment of BON-raf cells resulted in raf-1 pathway activation. Western blot analysis identified the presence of SSTR 1 and SSTR3-5 subtypes in BON cells; the SSTR2 subtype was not expressed. Raf-1 activation resulted in no significant alterations in SSTR subtype expression. CONCLUSIONS: Raf-1 mediated suppression of CgA and serotonin is not due to alterations in SSTR expression. NE hormonal suppression is therefore effected via an alternative mechanism. However, understanding the regulation of these receptors in response to raf-1 activation is an important first step in studying a potential synergistic effect between raf-1 activating compounds and somatostatin agonists. POSTER ABSTRACTS MONDAY

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M1860 Pterostilbene Inhibits Pancreatic Cancer in Vitro Julie A. Alosi*1,2, Debbie E. Mcdonald1, David W. Mcfadden1,2 1Department of Surgery, University of Vermont College of Medicine, Burlington, VT; 2Department of Surgery, Fletcher Allen Health Care, Burlington, VT BACKGROUND: Stilbenes are phenolic compounds present in grapes and blueberries. Resveratrol, a naturally occurring compound present in grapes, has been shown to have potent antioxidant properties as well as an ability to induce apoptosis. Resveratrol has also been reported to have significant inhibitory effects against a variety of primary tumors including breast, colon, and prostate. Pterostilbene, a naturally occurring analogue of resveratrol found in blueberries, also has antioxidant and antiproliferative properties. These effects have not been studied in pancreatic cancer. We hypothesized that pterostilbene would inhibit pancreatic cancer cell growth in vitro. METHODS: Two pancreatic cancer cell lines (MIAPACA and PANC1) were cultured using standard techniques. Cells were treated with graduated doses of pterostilbene ranging from 10 to 100 µM. Cell viability was measured by MTT at 24, 48, and 72 hours. RESULTS: Pterostilbene decreases cell viability in both cancer cell lines in a concentration- and time-dependent manner. Higher doses (75–100 µM) caused a significant reduction in cell viability at 24 and 48 hours. However, by 72 hours all tested concentrations of pterostilbene (10 to 100 µM) resulted in significantly reduced cell viability in both pancreatic cancer cell lines in a dose dependent fashion. Inhibition was slightly greater in PANC1 cells. Pterostilbene caused a dose-dependent 10%–63% inhibition in MIAPACA cells and 10–75% inhibition in PANC1 cells. CONCLUSIONS: Pterostilbene inhibits the growth of pancreatic cancer in vitro. Further in vitro mechanistic studies and in vivo experiments are warranted to determine its potential for the treatment of pancreatic cancer.

268 6303_SSAT.book Page 269 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Small Bowel

M1861 Practical Considerations and Survival Techniques for a Rat Model of Roux-en-Y Gastric Bypass Drew A. Rideout*1,2, Steven S. Rakita2,1, Yanhua Peng2,3, William R. Gower2,3, Michel M. Murr1,2 1Department of Surgery, University of South Florida, Tampa, FL; 2Department of Surgery, James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department of Molecular Medicine, University of South Florida, Tampa, FL BACKGROUND: A rat model for Roux-en-Y gastric bypass (RYGB) is associated with high operative mortality. We herein describe techniques to improve survival of obese rats that undergo RYGB. METHODS: Sprague-Dawley male rats were fed high fat diet for 14 weeks to induce obesity; subsequently obese rats underwent RYGB or sham operation. Despite following protocols published by others we continued to observe high rates of mortality in the immediate post-operative period. We, therefore, introduced a group of interventions aimed at improving survival after RYGB: 1) changed to inhalational anesthetic with streamlined operations to minimize anesthesia exposure (71 ± 4 min); 2) used metabolic cages perioperatively to prevent rats from eating their bedding and feces; 3) modiﬁed the peri-operative diet with a 12 hour pre-operative fast and a gradual advance to full-strength Ensure post-operatively, followed by solid chow at 1 week; 4) created smaller gastric pouch and larger gastrojejunostomy to facilitate gastric emptying; 5) minimized handling and manipulation of the tissues. Weight and survival in the pre and post-intervention groups were compared. RESULTS: The ﬁrst 8 rats were excluded to eliminate the confounding nature of the “technical” learning curve. RYGB was undertaken in 18 rats done according to published protocols and in 21 rats after introducing our set of interventions. All deaths in the pre-intervention group were in the immediate 36 hours post-operatively (Table). Overall survival at 6 weeks postoperatively increased dramatically from 11% to 86% immediately after introducing our interventions. Obese rats who underwent sham operations (n = 8) had similar overall survival (88%) as post-intervention RYGB rats. Survival

was the same in all groups at the time of earliest tissue harvest for molecular POSTER ABSTRACTS studies (6 weeks). Body weight at 9 weeks was lower in RYGB rats compared to sham controls (364 ± 45 gm vs. 496 ± 32 gm; p < 0.01). MONDAY CONCLUSION: RYGB is a technically challenging procedure in rodents; simple modiﬁcations in the operative conduct and peri-operative care of rats undergoing RYGB improve mortality in a predictable manner. Lessons learned from our experience will likely shorten the learning curve for researchers trying to establish animal models of obesity and RYGB. Operation Survival 36 Hours Survival 6 Weeks Pre-intervention (n = 18) RYGB 11% 11% Post-intervention (n = 21) RYGB 91% 86% Post-intervention (n = 8) Sham 100% 88%

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M1862 Activation of Wnt Signaling Protects Intestinal Epithelial Cells from Apoptosis by Increasing Cytoplasmic Levels of RNA-Binding Protein HuR Emily C. Bellavance*1, Lan Liu1, Rao N. Jaladanki1, Tongtong Zou1, Douglas J. Turner1, Jian-Ying Wang1,2 1Department of Surgery, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD; 2Department of Pathology, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD INTRODUCTION: Apoptosis plays a critical role in maintenance of gut mucosal homeostasis, but the mechanism underlying this process remains unclear. Wnts are cysteine-rich glycoproteins that act as short-range ligands to locally activate receptor-mediated signaling pathways. Central to this signaling pathway is the stabilization of β-catenin and its interaction with DNA- binding factors of the T-cell factor family in the nucleus. Recently, genetic studies have shown an essential role for canonical Wnt signaling in gut development and intestinal epithelial cell (IEC) proliferation. Activation of Wnt signaling is implicated in controlling cell fate and carcinogenesis by modulat- ing its target gene expression. HuR is the RNA-binding protein and plays a critical role in regulating apoptosis. Predominantly nuclear in unstimulated cells, HuR rapidly translocates to the cytoplasm where it induces expression of anti-apoptotic genes posttranscriptionally. We hypothesized that Wnt signaling activation protects IECs against apoptosis by altering HuR functions. METHODS: Studies were conducted in IEC-6 cells derived from rat small intestinal crypts. Wnt activation was induced by stable transfection with the expression vector containing Wnt-3 cDNA. Apoptosis was induced by exposure to tumor necrosis factor-α (TNF–α) in combination with cyclohexamide (CHX). Apoptosis was assessed by immunohistochemical staining for Annexin-V and by caspase-3 activity. Levels of cytoplasmic and nuclear HuR were determined by Western blot analysis. RESULTS: Stable Wnt3-transfected IEC-6 cells (Wnt-IECs) highly expressed Wnt3 protein. Levels of Wnt3 protein in Wnt-IECs were ~5-fold the value of parental IEC-6 cells (C-IECs) transfected with the vector containing no Wnt3 cDNA. After exposure to TNFα/CHX, Wnt-IECs had a signiﬁcantly lower percentage of apoptotic cells and exhibited decreased levels of caspase-3 activity compared with C-IECs (p < 0.001). C-IECs showed higher levels of caspase-3 activity and stronger Annexin-V staining, while Wnt-IECs displayed lower apoptotic indicators. Wnt-IECs also demonstrated 2-fold higher levels of cytoplasmic HuR, although there were no differences in total levels of HuR between C-IECs and Wnt-IECs. CONCLUSION: These ﬁndings indicate that 1) activation of Wnt signaling pathway protects IECs against TNF–α/CHX-induced apoptosis and 2) increased resistant to apoptosis by Wnt3 overexpression is associated with an increase in levels of cytoplasmic HuR.

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M1863 The Immunonutrient Fish Oil Increases Blood Flow in the Ileum During Chronic Feeding in Rats Ryan T. Hurt*3,4, Paul J. Matheson1,2, Brian M. Derhake5, El Rasheid Zakaria4, Richard N. Garrison1,2 1Surgery, University of Louisville, Louisville, KY; 2Research, Louisville VAMC, Louisville, KY; 3Medicine, University of Louisville, Louisville, KY; 4Physiology & Biophysics, University of Louisville, Louisville, KY; 5Anesthesiology, University of Louisville, Louisville, KY BACKGROUND: Benefits (decreased septic complications and length of stay) of enteral feeding with immune-enhancing diets (IED) depend on route (enteral vs. parenteral), timing (early vs. delayed) and composition (i.e., omega-3 fatty acids, arginine or RNA nucleotides). A central question is, why does enteral IED delivery provide benefits while parenteral delivery does not. We hypothesized that chronic feeding with certain individual immunonutrients would enhance gastrointestinal blood flow. METHODS: Male Sprague-Dawley rats (200–225 g) were fed a standard enteral diet supplemented with immunonutrients for 5 days prior to study. Study groups (n = 8) were: 1) standard rat chow; 2) liquid control diet alone (CD); 3) CD + Fish Oil; 4) CD + L-arginine; and 5) CD + RNA nucleotide frag- ments. Whole organ blood flow distribution was measured by colorimetric microsphere technique in antrum, small intestine (in thirds), colon, liver, spleen, pancreas and kidneys. POSTER ABSTRACTS MONDAY RESULTS: Chronic feeding with CD + Fish Oil increased blood flow in the distal third of the small intestine compared to CD alone. CD + L-arginine decreased blood flow in the small intestine (all segments) compared to CD alone. CD + RNA did not alter blood flow distribution. CONCLUSIONS: These findings agree with prior studies of acute gavage with CD, CD + individual immunonutrients or IED. Our current data suggest that blood flow benefits associated with fish oil persist during chronic feeding in rats. Enhanced GI perfusion might partially explain the benefits of early enteral feeding with immune-enhancing diets not seen with parenteral immunonutrient delivery.

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Basic: Stomach

M1864 Survivin Expression in Gastric Cancer: Association with Histomorphological Response to Neoadjuvant Therapy and Prognosis Daniel Vallbohmer*1, Uta Drebber2, Paul M. Schneider1,3, Stephan E. Baldus4, Elfriede Bollschweiler1, Jan Brabender1, Stefan Monig1, Arnulf H. Hoelscher1, Ralf Metzger1 1Department of Surgery, University of Cologne, Cologne, Germany; 2Department of Pathology, University of Cologne, Cologne, Germany; 3Department of Visceral and Transplantation Surgery, University of Zurich, Zurich, Switzerland; 4Department of Pathology, University of Dusseldorf, Dusseldorf, Germany BACKGROUND: Neoadjuvant multimodality treatment is frequently applied to improve the poor prognosis associated with locally advanced gastric cancer. However, only patients with a major histopathologic response to neoadjuvant therapy seem to have a significant survival benefit. Predictive markers to allow individualization of multimodality treatment could be very helpful. We aimed to examine the association of survivin protein expression, an inhibitor of apoptosis, with histopathologic response to neoadjuvant chemotherapy and prognosis in patients with gastric cancer. PATIENTS AND METHODS: Forty patients (30 men, 10 women; median age 54.1 years) with gastric cancer (cT2-4, Nx, M0) received neoadjuvant chemotherapy (PLF-protocol: cisplatin, leucovorin, 5-FU; 2 cycles over 6 weeks). Afterwards, 38 patients underwent total gastrectomy, while 2 patients received definitive chemotherapy because of tumor progression. Histomor- phologic regression was defined as major response when resected specimens contained less than 10% vital tumor cells. Intratumoral survivin expression was determined by immunohistochemistry in pretherapeutic biopsies and posttherapeutic resection specimens and correlated with clinicopathologic parameters. RESULTS: The pre- and posttherapeutic intratumoral survivin protein expression was not associated with the histomorphologic regression. In addition, posttherapeutic survivin expression did not have any prognostic impact. However, a significant association was detected between pretherapeutic survivin levels and prognosis: patients with a higher survivin protein expression showed a significant survival benefit compared with patients having low intratumoral protein levels (5-year survival rate: 50% vs. 21%; p = 0.038). In multivariate analysis pretherapeutic survivin expression was characterized as an independent prognostic marker, besides pN-status and histopathologic regression (p = 0.008). CONCLUSION: The pretherapeutic survivin protein expression seems to be an independent prognostic marker in the multimodality treatment of locally advanced gastric cancer. If intratumoral survivin levels can be used as a surrogate marker in the neoadjuvant therapy of gastric cancer, has to be validated in prospective trials.

272 6303_SSAT.book Page 273 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

COMBINED SCIENCE POSTERS

Combined Science

M2091 The Effect of Major Abdominal Procedure Type on the Incidence and Economic Burden of Deep Vein Thrombosis or Pulmonary Embolism Debraj Mukherjee*2,1, Susan L. Gearhart1, Anne O. Lidor1, David C. Chang1,2 1Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD; 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD BACKGROUND: Deep vein thrombosis/pulmonary embolus (DVT/PE) is a signiﬁcant cause of morbidity for surgical patients. The comparative risk across major abdominal procedures is unknown. METHODS: Retrospective analysis of a representative 20% sample of data from 37 states (Nationwide Inpatient Sample) over 5 years (2001–2005). Eight surgeries were identiﬁed: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age <18, patients with multiple major surgeries, or non-elective surgery were excluded. Primary outcome was occurrence of DVT/PE per AHRQ Patient Safety Indicator methodology. Independent variables included age, gender, race, Charlson Comorbidity Index, hospital teaching status, and calendar year. POSTER ABSTRACTS MONDAY

RESULTS: 244,387 patients were identiﬁed, with 2286 DVT/PE (0.94%) (DVT 0.63%, PE 0.39%). Overall death rate was 1.42%, and death rate among DVT/ PE was 8.86%. The unadjusted rate (0.35%) and adjusted risk for DVT/PE were lowest among bariatric patients. On multivariate analysis, the highest risk for DVT/PE, relative to bariatric surgery, was esophagectomy (odds ratio 4.45, 95% CI 2.80–7.07), (Figure) and is associated with $118,407 excess charges in those patients. The odds ratio of in-hospital mortality for DVT/PE was 4.84 (95% CI 3.98–5.89), and is associated with excess LOS of 9.86 days. This trans- lates into approximately $145 million per year in the US.

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CONCLUSION: The highest risk for DVT/PE following major abdominal surgery was seen in esophagectomy patients while the lowest risk was seen in bariatric patients. Since bariatric patients are known to have greater risk for this complication, these ﬁndings may be the result of better awareness and prophyalaxis in this population. Further studies are necessary to quantify the effect of best-practice guidelines, such as in bariatric surgery, on prevention of this costly complication.

274 6303_SSAT.book Page 275 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M2092 Removal of Visceral Fat Improves Metabolic Syndrome and Hepatic Steatosis in Diet-Induced Obese Mice Xavier Dray*1, Zhiping Li1, Jing Hua1, Samuel A. Giday1, Susan K. Redding2, Eun Ji Shin1, Ron J. Wroblewski1, Jonathan M. Buscaglia1, Priscilla Magno1, Dawn Ruben2, Michael A. Schweitzer4, Jeanne Clark3, Anthony N. Kalloo1 1Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, MD; 2Radiology Research Service Centre, Johns Hopkins School of Medicine, Baltimore, MD; 3Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 4Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD BACKGROUND: Increased visceral adiposity is a common feature of obesity and metabolic syndrome. The amount of visceral fat (VF) correlates with the insulin sensitivity, the key component of metabolic syndrome. We evaluated the effect of VF removal by laparotomy in a mouse model of diet-induced obesity and metabolic syndrome. METHODS: Wild type C57BL6 male mice were fed either a high fat diet (HFD, n = 14) or a normal diet (ND, n = 6) for 8 weeks. HFD mice were assigned to surgical removal of VF (HFD+VF–) or to sham surgery (HFD+VF+). The mice were fed additional 4 weeks on the same diet. Body weight, glucose tolerance,serum adipokines (ELISA), hepatic cytokine expressions (quantitative PCR) and liver histology were evaluated at the end of the 12 week study period. RESULTS: HFD induced obesity, insulin resistance and hepatic steatosis. A mean of 2.1 ± 0.4 g (4.9 ± 0.5% of body weight) VF was removed in HFD+VF– mice. Both HFD+VF– and HFD+VF+ mice recovered equally well from surgery and consumed similar amount of diet post operation. However, HFD+VF– mice lost more weight and had signiﬁcant improvement in insulin sensitivity and hepatic steatosis. HFD+VF– mice also had signiﬁcant lower serum leptin level, but a similar adiponectin level compared to controls, and had lower expression of hepatic TNFα. POSTER ABSTRACTS MONDAY

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CONCLUSION: Surgical VF removal improves insulin resistance and hepatic steatosis in mice with diet-induced metabolic syndrome and improves adipokine and cytokine proﬁles. VF removal may be a useful tool to treat metabolic syndrome in obesity.

Week 12 ND HFD+VF+ HFD+VF– Weight (g) 24.0 ± 1.8 47.6 ± 0.1* 37.0 ± 3.8** Steatosis grade 0.0 ± 0.0 2.8 ± 0.4 * 0.3 ± 0.5** Leptin (ng/mL) 8.3 ± 4.5 56.3 ± 2.5* 40.5 ± 6.1* TNF/GAPDH 0.2 ± 0.1 2.2 ± 0.8 1.1 ± 0.4**

*p < 0.05 compared to ND; **p < 0.05 compared to HFD

276 6303_SSAT.book Page 277 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

M2093 Novel Therapeutic Targets in Esophageal Cancer: Impact of Coexpression of Receptor-Tyrosine-Kinases (RTK) and Chemokine Receptor CXCR4 Ines Gockel*1, Carl C. Schimanski2, Daniel Drescher1, Kirsten Frerichs1, Markus Moehler2, Stefan Biesterfeld3, Peter R. Galle2, Theodor Junginger1 1Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany; 2First Medical Clinic, Johannes Gutenberg-University, Mainz, Germany; 3Institute of Pathology, Johannes Gutenberg-University, Mainz, Germany BACKGROUND: Despite curative surgery, prognosis of esophageal cancer is still poor. The aim of our study was to define the (co-) expression pattern of target receptor-tyrosine-kinases (RTK) and to evaluate the role of chemokine receptor CXCR4 in esophageal adenocarcinoma and squamous cell cancer. METHODS: The (co-) expression pattern of VEGFR1-3, PDGFR alpha/beta and EGFR1 was analyzed by RT-PCR in 50 human esophageal cancers (35 adenocarcinomas and 15 squamous cell cancers). In addition, IHC staining was applied for confirmation of expression and analysis of RTK localisation. In 102 consecutive patients undergoing esophageal resection for cancer, the LSAB+ system was used to detect the protein CXCR4. Tumor samples were classified into two groups based on the homogeneous staining intensity (weak and strong CXCR4 expression). RESULTS: Adenocarcinoma samples revealed a VEGFR1 (97%), VEGFR2 (94%), VEGFR3 (77%), PDGFR alpha (91%), PDGFR beta (86%) and EGFR1 (97%) expression at different intensities. 94% of esophageal adenocarcinomas expressed at least four out of six RTKs. Similarly, squamous cell cancers revealed a VEGFR1 (100%), VEGFR2 (100%), VEGFR3 (53%), PDGFR alpha (100%), PDGFR beta (87%) and EGFR1 (100%) expression at different intensities. All esophageal squamous cell carcinomas expressed at least four out of six RTKs. With regard to CXCR4 expression, in adenocarcinoma, a rate of 89.1% was detected with a weak intensity in 71.7% compared to strong staining in 29.3%. The overall expression rate for CXCR4 in esophageal squamous cell carcinoma was 94.1%, subdivided into 54.9% with weak and 45.1% with strong staining. CONCLUSION: Our results reveal a high rate of receptor-tyrosine-kinases (co-) expression and expression of chemokine receptor CXCR4 in esophageal

adenocarcinoma and squamous cell cancer and might therefore encourage an POSTER ABSTRACTS application of multiple-target RTK-inhibitors as well as of CXCR4-antagonists within a multimodal concept as a promising novel approach for innovative MONDAY treatment strategies.

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Tuesday, May 20, 2008

CLINICAL SCIENCE POSTERS

Clinical: Biliary

T1695 Comparison Hilar Bile Duct Cancer with Intrahepatic Cholangiocarcinoma Involving the Hepatic Hilus Tsuyoshi Sano*1,2, Kazuaki Shimada2, Minoru Esaki2, Yoshihiro Sakamoto2, Tomoo Kosuge2, Yasuhiro Shimizu1, Yuji Nimura1 1gastroenterological surgery, Aichi Cancer Center Hospital, Nagoya, Japan; 2Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan BACKGROUND: Clinically hepatobiliary resection is indicated for both hilar bile duct cancer (BDC) and intrahepatic cholangiocarcinoma involving the hepatic hilus (CCC). The aim of this study was to compare the long-term outcome of BDC and CCC. METHODS: Between 1990 and 2004, we surgically treated 158 consecutive patients with perihilar cholangiocarcinoma. The clinicopathological data on all of the patients were analyzed retrospectively. RESULTS: The overall 3-year survival rate, 5-year survival rate, and median survival time for BDC patients were 48.4%, 38.4%, and 33.7 months, respectively, and 35.8%, 24.5%, and 22.7 months, respectively, in CCC patients (p = 0.033). Significant differences were noted between stages I and II (p = 0.002), stages I and III (p = 0.045), and stages I and IV (p < 0.001) in BDC patients. Significant differences were also noted between stages I and IV (p = 0.004), stages II and IV (p = 0.011), and stages III and IV (p = 0.029) in CCC patients.According to subgroup analyses, there were no significant differences in pathological grading (p = 0.193 in wel, pap, p = 0.193 in others), lymph node status (p = 0.222 in patients with negative lymph node, p = 0.315 in those with positive), resected portal vein invasion (p = 0.513 in negative, p = 0.062 in positive invasion). There was a significant difference according to the resectional status in pathology, longer survival was achieved in BDC not R0 (p = 0.131) but R1, 2 resection (p = 0.014). Also, there was significant difference according to T-factor, longer survival was achieved in BDC with not T1, 2 (p = 0.915) but T3 and 4 tumor (p < 0.001).On multivariate analysis, three independent factors were related to longer survival in BDC patients:

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

achieved in curative resection with cancer free margin (R0) (p = 0.024), well differentiated or papillary adenocarcinoma (p = 0.011), and absence of lymph node metastasis (p < 0.001). Five factors were related to longer survival in CCC patients: absence of intrahepatic daughter nodules (p < 0.001), CEA level ≤ 2.9 ng/mL (p = 0.005), no red blood cell transfusion requirement (p = 0.016), and absence or slight degree of lymphatic system invasion (p < 0.001), and negative margin of the proximal bile duct (p = 0.003). CONCLUSIONS: BDC and CCC appear to have different prognosis after hepatobiliary resection. Therefore, differentiating between these two categories must impact on predicting postoperative survival in patients with perihilar cholangiocarcinoma. POSTER ABSTRACTS TUESDAY

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T1696 Progress in Laparoscopic Surgery for Adult Choledochal Cysts-Kyushu University Experience Hiroki Toma*, Shuji Shimizu, Shunichi Takahata, Masafumi Nakamura, Eishi Nagai, Koji Yamaguchi, Masao Tanaka Kyushu University, Fukuoka City, Japan AIM: Congenital choledochal cysts are considered an indication of surgery for recurrent cholangitis and/or pancreatitis and the potential development of bile duct cancer. Since our first report in the world of a successful adult case in 1996, we have accumulated clinical experience with a total of 20 patients with laparoscopic surgery for choledochal cysts. We attempted to elucidate our clinical outcomes of the procedure. METHODS: Surgical parameters including operation time, blood loss, complications, postoperative hospital stay, rate of open conversion were compared between the former period (group A: 1996 to 2000) and the latter period (group B: 2001 to 2007). RESULTS: Of 20 patients (6 men, 14 women, average age 33 years), 10 cases were allocated to group A and B, respectively. There was a statistically significant decrease in operation time (587 vs 464 min, p = 0.049) from group A to group B. Blood loss (485 vs 241 ml, p = 0.133) and postoperative hospital stay (48 vs 14 days, p = 0.053) tended to decrease, but the difference was not significant. The procedure was converted to open in 3 patients in group A (40%) and 1 patient in group B (10%) due to severe adhesion, bleeding, anatomical disorientation and pancreatic duct injury. The major postoperative complications occurred in 2 patients in group A (1 bile leakage and 1 pancreatic duct injury) and in 2 patients in group B (1 postoperative bleeding and 1 postoperative pancreatic fistula). There was no mortality in this study. CONCLUSIONS: Laparoscopic surgery for choledochal cysts still remains a challenge mainly due to technical difficulties, but we have shown promising results in this study. Both advances in surgical devices and our learning curve will contribute to future progress in this minimally invasive procedure.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1697 Outcomes of Endoscopic and Surgical Management of Sphincter of Oddi Dyskinesia in Patients Not Responding to Cholecystectomy for Chronic Acalculous Cholecystitis James O. Johnson*, Kirpal Singh, Maurice E. Arregui St Vincent Hosp & Hlth Care Ctr, Indianapolis, IN OBJECTIVE: Sphincter of Oddi dyskinesia (SOD) remains a challenge todiag- nose and treat with patients having variable results. Manometry is the gold standard for this diagnosis. The treatment is controversial, but centers on endoscopic retrograde cholangio-pancreatography with sphincterotomy (ERCP/ES). Transduodenal sphincteroplasty (TS) and pancreaticoduodenectomy are also utilized. We present our experience with longitudinal follow-up of a group of patients with mainly Type III SOD who did not resolve following cholecystectomy for chronic acalculous cholecystitis (CAC). METHODS: Patient charts, including manometry reading, operative reports and imaging were retrospectively reviewed. RESULTS: 69 patients, predominately female (89%),with a mean age of 52.3 that who did not respond to cholecystectomy were diagnosed with SOD using sphincter of Oddi manometry and clinical criteria. 63 of these patients had manometry studies that were available for interpretation. Normal manometry was found in 23 patients and of those 12 (52%) were improved after ERCP/ES. Abnormal manometry was found in 39 patients and of these 25 (64%) had a signiﬁcant improvement with ERCP/ES alone. 52 (75%) patients had ERCP/ES as their only intervention with 40 (77%) of them having a signiﬁcant improvement in symptoms and 11 (21%) with complete resolution of symptoms. 12 (23%) patients had initial success with a relapse or no success with ERCP/ES. 43 (83%) of these patients required 3 or fewer interventions. 13 (18%) of the initial patient population required TS. This was done after either initial or long term failure of ERCP/ES. Improvement of symptoms was seen in 10 (77%) patients and resolution in 1. Four (5%) of the initial cohort, that failed both ERCP/ES and TS, underwent pancreaticoduodenectomy. One of these patients had improvement in symptoms. Mean follow-up for this cohort was 21.9 months. Range of follow-up was 1 to 137 months.

CONCLUSION: Overall, the patients in this study did well. ERCP/ES and TS POSTER ABSTRACTS did decrease or eliminate symptoms in over 73% of patients. Early, aggressive intervention with ERCP/ES and if this fails, then TS may provide more relief TUESDAY to patients with Type III SOD after cholecystectomy for CAC.

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T1698 The Significance of CD44 Expression in Ampullary Cancer Hui-Ping Hsu*1, Kai-Hsi Hsu2, Yan-Shen Shan1, Pin-Wen Lin1 1National Cheng Kung Univ Hosp, Tainan, Taiwan; 2Department of Surgery, Tainan Municipal Hospital, Tainan, Taiwan PURPOSE: CD44 is a transmembrane protein involving cell proliferation, cell differentiation, cell migration, cell-cell adhesion or cell-matrix interaction. Cleavage of extracellular domain is prominent in human tumors and CD44 standard (CD44st) is the conservative portion. In present study, we evaluated the expression of CD44st in ampullary cancer in order to identify the potential predictor. MATERIAL AND METHODS: The paraffin blocks of ampullary neoplasms surgically resected specimens from patients at National Cheng Kung Univer- sity Hospital between March 1989 and June 2007 was collected. The collected specimens included dysplasia, adenoma, early or advanced adenocarcinoma. Immunohistochemistry (IHC) staining was performed over deparaffinized sections with using anti-human CD44st monoclonal antibody. The expression of CD44st was defined as loss, low or high. RESULTS: Total 81 patients (41 female and 40 male) were enrolled with average age 63 years, ranged from 32 to 90 years. IHC staining revealed membrane-type staining of CD44st in normal pancreatic duct, but not in normal duodenum. In ampullary neoplasms, diffuse dense membraneous positivity for CD44st was noted in 40 patients (49%), week staining in 24 patients (30%) and complete loss of CD44st in 17 patients (21%). The grading of CD44st staining was not related with age, sex, preoperative tumor markers, tumor size or lymph node involvement. But trends of CD44st loss were detected in tumors with pancreatic invasion or advanced TNM stage. The 5- year disease-specific survival rate was lower in patients with low or negative CD44st expression than those with dense CD44st expression. But in patients without pancreatic invasion, the expression of CD44st represented poor long- term survival, opposite to those with pancreatic invasion. CONCLUSION: CD44st expression in patients of early ampullary cancer is a poor predictor, but not in advanced cancer. Dual role of CD44 in ampullary cancer and other malignancies represent the complexities of adhesion mole- cules in carcinogenesis.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1699 Asymptomatic Cholelithiasis Occurrence in Patients of Kidney Transplantation List André T. De Brito1, André M. Siqueira1, Luiz S. Azevedo2, José Eduardo M. Cunha1, José Jukemura*1 1Gastroenterology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; 2Urology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil INTRODUCTION: There is no agreement in literature about the most correct treatment for patients with asymptomatic gallstones in kidney transplantation list. Some authors suggested routine screening to gallstones for patients who are awaiting a kidney graft and cholecystectomy is indicated to all the candidates with cholelithiasis. Meanwhile, the occurrence of asymptomatic cholelithiasis in the Brazilian kidney transplantation population is not well known. OBJECTIVE: This study aims to determine asymptomatic cholelithiasis occurrence in patients who are in the kidney transplantation list of the Hos- pital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. METHODS: We evaluated the 342 patients who were in kidney transplantation list of Hospital das Clínicas de São Paulo in the moment of the study. The candidates to a transplant were screened to gallstones and asked about previous cholecystectomy and symptoms related to cholelithiasis. All patients were submitted to total abdomen ultrasound. Data about symptoms, sex, age, body mass index, number of pregnancies, previous digestive system surgeries, hepatic diseases, hemodialysis time and laboratory exams were collected. RESULTS: The occurrence of biliary disease was 11.9% (41/342), which of these 29 (8.4%) patients had cholelithiasis and 12 (3.5%) had been cholecystectomized before being included in transplant list. All cholecystectomized patients were symptomatic (biliar colic pain, acute cholecystitis, jaundice or pancreatitis) at the time of the surgery. Among the evaluated, 41.5% (17/41) were or remained symptomatic. CONCLUSION: The occurrence of cholelithiasis in kidney transplantation list patients is similar to the general population, however an important part is symptomatic. POSTER ABSTRACTS TUESDAY

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T1700 Significance of Tissue Expression of MUC5AC in Hilar and Intrahepatic Cholangiocarcinoma Andrea Ruzzenente*1, Calogero Iacono1, Tommaso Campagnaro1, Paola Capelli2, Sara Mazzoldi1, Alessandro Valdegamberi1, Paola Nicoli1, Alfredo Guglielmi1 1Department of Surgery and Gastroenetrology, University of Verona Medical School, Verona, Italy; 2Department of Pathology, University of Verona Medical School, Verona, Italy BACKGROUND AND AIMS: Cholangiocarcinoma is a rare tumor with an increasing incidence wordwide. The surgical resection with curative intent is the only treatment for long term survival. Different prognostic factors have been identified in surgical series but the biological behaviour of this disease has not been clarified yet. The aim of this study is to evaluate the significance of tissue expression of mucins (MUC1, MUC2, MUC5AC, MUC6) in a group of patients with hilar and intrahepatic cholangiocacinoma (ICC) submitted to surgical resection with curative intent. PATIENTS AND METHODS: Between 1990 and 2007 224 patients with cholangiocarcinoma was evaluated at a single division of surgery of the Department of Surgery and Gastroenterology of University of Verona. 120 patients underwent surgical treatment. In the 38 consecutive recently observed patients (13 with hilar cholangiocarcinoma and 25 with ICC) tissue mucin expression was evaluated in surgical specimens. All the patients with ICC were classified according to Liver Cancer Study Group of Japan macroscopic criteria (2003): Mass Forming type (MF), periductal infiltrating type (PI) and intraductal grow type (IG). RESULTS: Macroscopic analysis showed MF type in 11 patients (44%), PI type in 12 (48%) and mixed MF + PI in 2 cases (8%). Pathology showed lymph-nodes involvement in 11 patients (29%), perineural invasion in 24 (63%), microscopic vascular invasion in 25 (65%) and macroscopic vascular invasion in 14 (37%). Tumors were well differentiated in 4 cases, moderate in 14 and poor in 8 cases. Mucin analysis showed that MUC2 and MUC6 were not present in all specimens. MUC1 was present in 38.5% of hilar tumors, in 41.7% of MF ICC, in 100% of PI ICC and in 45.5% of MF+PI ICC. MUC5AC was present in 84.6% of hilar cholangiocarcinoma, in 0% of MF ICC, in 100% of PI ICC anf in 63.6% of MF+PI type (p = 0.001). Further analyses in patients with hilar cholangiocarcinoma did not showed relationship between mucins expression and the following pathology findings: tumor diameter, lymph nodes involvement, vascular invasion and perineural invasion. Also in ICC MUC1, MUC2 and MUC6 were not related with pathology findings. Whereas expression of MUC5AC was significantly related with tumor diameter inferior to 3 cm (P = 0.01); poor differentiation degree (p = 0.05) and perineural invasion (p = 0.05). CONCLUSIONS: This study identify a significant relationship between MUC5AC expression and gross type of ICC (all the MF type tumors were negative) and with pathology findings related to aggressive biological tumor behavour. Further studies are necessary to clarify the prognostic significance of MUC5AC.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1701 Preoperative Assessment of Intrahepatic Cholangiocarcinoma: CT Features with Pathological Correlation Riccardo Manfredi*2, Sara Mehrabi2, Marco Motton2, Roberto Pozzi Mucelli2, Andrea Ruzzenente1, Paola Capelli3, Calogero Iacono1, Alfredo Guglielmi1 1Department of Surgery and Gastroenetrology, University of Verona Medical School, Verona, Italy; 2Department of Radiology, University of Verona Medical School, Verona, Italy; 3Department of Pathology, University of Verona Medical School, Verona, Italy AIM: The aim of this study is to determine the accuracy of computed tomography (CT) in assessing local spread of Intrahepatic Cholangiocarcinoma (ICC), and to compare radiological and pathological findings after surgical resection with curative intent. MATERIAL AND METHODS: A retrospective study over a period of 36 months was performed involving 28 patients (pts) with diagnosis of ICC.Inclusion criteria: Pts with CT exam before surgery; Pts with radiological diagnosis of ICC that underwent surgical resection with pathological confirmation of malignancy. EXCLUSION CRITERIA: Pts without CT exam before surgery (4 pts); surgical exploration with evidence of peritoneal metastases (5 pts). A final group of 19 pts was included in this Institutional Review Board (IRB) approved retrospective study. Two independent radiologists retrospectively reviewed CT imaging features with final consensus; imaging analysis included evaluation of: localization; size; presence of satellites nodules; macroscopic type according to Liver Cancer Study Group of Japan criteria (mass-forming (MF) type, periductal infiltrating type (PI), intraductal growth type (IG); hepatic atrophy; vascular invasion (arterial, portal vein or hepatic veins); bile ducts dilatation and infiltration; lymph-nodes involvement. RESULTS: Localization of ICC was correctly detected in 19/19 (100%) pts. Size of the tumor was correctly defined in 18/19 (95%) pts. Satellites nodules were correctly detected at CT exam in 6/8 (75%) pts and 2 pts with nodules smaller than 2 mm weren’t detected. CT showed 14/19 (73%) MF type and 4/ 19 (21%) PI type and 1/19 (5%) IG type. Whereas at pathological examination of the specimen tunors were classified as MF type in 11/19 (57%), as PI type in 5/19 (26%) and as IG type in 2/19 (10%). Presence or absence of atro-

phy of hepatic lobe of ICC was correctly detected in 19/19 (100%) Pts. Arte- POSTER ABSTRACTS rial infiltration was correctly detected by CT in 6/7 (85%) pts, in 1/7 (15%) pts CT didn’t detect the infiltration. Portal vein invasion was correctly detected TUESDAY at TC in 4/4 (100%) pts. Hepatic veins invasion was correctly detected at TC in 7/7 (100%). Presence or absence of intra-hepatic bile ducts dilation was correctly detected in 19/19 (100%) At pathology bile duct infiltration was present in 9/19 (47%) pts, CT correctly detected this features in 8/9 (88%). CT detected lymph-nodes suspect for metastases (size > 10 mm) in 15/19 (79%), whereas pathological examination confirmed positive lymph-node metastases only in 11/19 (58%). CONCLUSIONS: CT is a good technique for evaluation of ICC and preoperative fidings are well correlated with surgical and pathological patterns.

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Clinical: Colon-Rectal

T1702 Anastomotic Leaks After Bowel Resection: What Do We Learn from Peer Review? Neil H. Hyman*, Turner Osler, Peter Cataldo, Betsy Burns, Steven R. Shackford Surgery, University of Vermont College of Medicine, Burlington, VT PURPOSE: Anastomotic leaks are a dreaded complication of intestinal resection and have been associated with a high mortality rate. However, it is uncertain whether the leaks are typically the actual cause of death. We sought to assess the impact of surgeon on leak rates and determine the relationship of a leak to postoperative mortality. METHODS: All adult pts having a small or large bowel resection with anastomosis at a university hospital from 7/03–6/06 were entered into a prospectively maintained quality database; data was entered by a specially trained nurse practitioner who rounded daily with housestaff. Pts with a postop leak based on standardized criteria were identiﬁed. Pt characteristics, surgical procedure and operating surgeon were noted. Overall complication and leak rate by surgeon were compared using Fisher’s exact test. Individual case review by a group of peers was performed for all pts with a leak who died to determine the relationship to mortality.

RESULTS: 556 pts underwent resection with anastomosis during the study period. There were 27 leaks (4.9%), 6 of whom died. Leak rate for the highest volume surgeons ranged from 2.1 to 9.9% (p < .01; Figure 1) and overall complication rate varied from 30.5 to 44% (p = .04). In 4/6 deaths, leaks occurred in very ill pts undergoing emergency procedures and appeared to be premor- bid events. In only one case did the leak appear to be the primary cause of death. CONCLUSIONS: The variability in leak rate by surgeons doing similar cases suggests that many may be preventable. However, death after a leak is most often a surrogate for a critically ill patient and infrequently is the actual cause of death.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1703 Preoperative Assessment of Nutritional Status in the Patients with Ulcerative Colitis: Evaluation of Nutritional Markers Which Predict Septic Complications Ken-Ichi Takahashi*1, Tohru Asakura2, Yuji Funayama1, Kouhei Fukushima3, Chikashi Shibata3, Hitoshi Ogawa3, Hiromi Tokumura4, Iwao Sasaki3 1Department of Colorectal Surgery, Tohoku Rosai Hospital, Sendai, Japan; 2Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan; 3Department of Surgery, Division of Gastrointestinal and Colorectal Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan; 4Department of Surgery, Tohoku Rosai Hospital, Sendai, Japan BACKGROUND: Patients with refractory ulcerative colitis (UC) need to undergo total colectomy (TC) and ileal pouch anal anastomosis (IPAA). These patients are often malnourished prior to surgery, especially the patients with severe inflammation of entire colon are severely malnourished. And the incidence of early postoperative septic complications such as surgical site infection (SSI) is relatively high compared to other colorectal diseases. As malnutrition has been reported to be the risk factor of postoperative complication in abdominal surgery, the preoperative nutritional status is also thought to have an influence on these complications after TC for UC. How- ever, it has not been fully evaluated yet which nutritional markers are useful in predicting these postoperative septic complications. METHODS: Forty-four patients with UC who underwent TC in our hospital from 2003 to 2006 were included in this study. Eleven patients underwent TC and IPAA with loop ileostomy, three patients underwent TC with permanent end ileostomy and 30 patients underwent subtotal colectomy with end ileostomy. And nutritional markers such as anthropometry and laboratory data were compared between the patients with and without postoperative septic complications retrospectively. RESULTS: Septic complications occurred in 14 patients. Thirteen patients were affected by SSI, and one patient was affected by MRSA enteritis. In complication group, serum prealbumin level was significantly lower than in non- complication group (21.8 vs 28.6 mg/dl, p < 0.05). Retinol binding protein level was also significantly lower in complication group (2.7 vs 3.7 mg/dl,

p < 0.01). However, there was no signiﬁcant difference in serum albumin, POSTER ABSTRACTS choline esterase, total cholesterol and total lymphocyte count between two groups. There was also no signiﬁcant difference in anthropometry such as TUESDAY BMI, triceps skin fold thickness and arm muscle circumference. Although the preoperative daily dosage of prednisolone just before surgery was compared, no difference was observed between two groups. And no relationship was observed between the route of preoperative nutritional support (oral intake or total parenteral nutrition) and septic complications. CONCLUSIONS: It is suggested that preoperative mesurement of rapid turnover protein level such as prealbumin and retinol binding protein is useful in predicting the risk of postoperative septic complications.

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T1704 Cytokine Network in Rectal Mucosa in Perianal Crohn’s Disease: Relations with Inflammatory Parameters and Need for Surgery Cesare Ruffolo1, Marco Scarpa1, Diego Faggian2, Anna Pozza1, Filippo Navaglia2, Renata D’Incà4, Pravera Hoxha2, Giovanna Romanato3, Lino Polese1, Giacomo C. Sturniolo4, Mario Plebani2, Davide F. D’Amico1, Imerio Angriman*1 1Clinica Chirurgica 1°, University of Padova, Padova, Italy; 2Medicina di Laboratorio, University of Padua, Padua, Italy; 3CNR-Institute of Neurosciences—Aging Section, Padua, Italy; 4Gastroenterologia, University of Padua, Padua, Italy BACKGROUND: Nowadays anti-TNF-alpha antibodies are often used for the therapy of perianal Crohn’s disease. Nevertheless this treatment is effective only in a part of these patients and recent studies suggested an important role for other cytokines, such as IL-6, IL-1beta, IL-12 and TGF-beta1 in chronic bowel inflammation AIM: The aim of this study was to assess the cytokine profile in the rectal mucosa of patients affected by perianal Crohn’s diseases and to understand its relations with the systemic cytokine profile, the systemic inflammatory parameters and the need for surgery. PATIENTS AND METHODS: Seventeen patients affected by perianal Crohn’s disease, 7 affected by Crohn’s disease without perianal involvement and 17 healthy controls were enrolled in this study and underwent blood sampling and endoscopy. During endoscopy two rectal mucosal samples were taken and expression of TNF-alpha, IL-6, IL-1beta, IL-12 e TGF-beta1 was quantified with ELISA. Local cytokine levels were then compared and correlated to diagnosis, therapy, phenotype (fistulizing and stenosing) and disease activity parameters. RESULTS: In the group with perianal Crohn’s disease rectal mucosal IL- 1beta, IL-6 and serum IL-6 and TNF-alpha were higher than in patients with small bowel Crohn’s disease and healthy controls. IL-12 and TGF-beta1 mucosal levels did not show any differences among the three groups. Mucosal IL-6 significantly correlated with PDAI and mucosal TNF-alpha and IL-1beta. Mucosal TNF-alpha and IL-1beta showed a direct correlation with the histological grade of disease activity. CONCLUSIONS: The cytokines network analysis in perianal CD shows the important involvement of IL-1beta, IL-6 and TNF-alpha produced by macrophage and dendritic cells. These results seem to suggest that IL-6 and IL- 1beta might be alternative targets of an immunomodulatory therapy in case of anti-TNF-alpha failure.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1705 Abdominal Surgery Impact Scale (ASIS) Is Responsive in Assessing Outcome Following IPAA Indraneel Datta*1, Brenda I. O’Connor1, J Charles Victor3, Robin S. Mcleod2,4 1Dr. Zane Cohen Digestive Diseases Clinical Research Center, Toronto, ON, Canada; 2Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; 3Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; 4Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, AB, Canada PURPOSE: Various generic and disease specific quality of life instruments are available to assess outcome following surgery. However, they are not sensitive to assess outcome in the early postoperative period, which is important when assessing changes in postoperative care. Thus the aim of this study was to evaluate the responsiveness of the Abdominal Surgery Impact Scale (ASIS) in assessing quality of life in a cohort of patients undergoing ileal pouch-anal anastomosis (IPAA). METHODS: All patients over the age of 18 undergoing IPAA between March 2005 and October 2007 completed the ASIS on postoperative day 2 or 3 and at time of discharge. The ASIS consists of 6 domains and 18 items with scores ranging from 18 to 126. In addition, demographic, clinical and surgical data was collected including gender, age, steroids, laparoscopic assisted versus conventional surgery, ileostomy diversion, anastomotic leaks and small bowel obstructions. Length of stay data was also analyzed. Internal reliability of the ASIS was measured using Cronbach’s alpha coefficients. RESULTS: 92 patients (36 female, 56 male, mean age = 36.83 ± 10.79) completed the ASIS at the 2 time intervals (mean 3 days and mean 7 days postoperatively). 47 patients had an IPAA performed with an ileostomy; 11 patients had he IPAA performed laparoscopically. The mean hospital stay was 10.78 days. The overall mean ASIS score significantly increased over time (mean 56.93 ± 18.3 vs. 81.83 ± 17.27, p < 0.001). Patients who had an ileostomy had a significantly lower mean score at discharge (77.32 vs. 86.82), secondary to lower scores on the physical limitations, functional impairment and visceral function domains. Seven patients (7.6%) had ileo-anal anastomotic leaks and seven patients (7.6%) had small bowel obstructions. Both leaks and bowel obstructions resulted in increased length of stay. Laparoscopic patients had a significantly lower length of stay (8.8 days vs. 11.1 days). Cronbach’s alpha coefficient was 0.94 overall and ranged from 0.69 to 0.91 for subscales indi- POSTER ABSTRACTS

cating internal reliability. TUESDAY CONCLUSIONS: ASIS is a reliable instrument for measure quality of life in the postoperative period and is responsive to changes over time. Although quality of life increases postoperatively during hospital stay, at discharge, patients with IPAA still have decreased quality of life. Patients with ileostomies have further decreased scores.

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T1706 Morbidity and Mortality Associated with Emergency Abdominal Surgery in the Elderly Jill M. Zalieckas*, Patricia L. Roberts Lahey Clinic Medical Center, Burlington, MA BACKGROUND: Over 35 million Americans are at least 65 years old. This population is projected to double in the coming decades and as a result, the number of elderly (age ≥70) who present to the hospital requiring emergency surgery is rising. Emergency surgery is associated with increased morbidity and mortality, and is further magnified among the elderly. The aim of this study was to determine the mortality rates of elderly patients who underwent emergency laparotomy, and to define the variables associated with increased risk of morbidity and mortality, which can be used for quality improvement and informed surgical decision making in the preoperative setting. METHODS: A retrospective cohort study of patients age ≥70 that required emergency abdominal surgery by the Colorectal Surgery Department at a tertiary care center from 1994 to 2004 was conducted. Outcome variables included age, ASA classification, albumin level, diagnosis, co-morbid conditions and APACHE II score. The endpoints of in hospital mortality, length of hospitalization and one-year mortality were examined. RESULTS: Eighty-eight patients met inclusion criteria for analysis (55 F, 33 M). The average patient age was 79 years. Initial diagnoses included bowel obstruction, perforated diverticulitis, perforated cancer, ischemic colon and appendicitis. The primary procedures performed included resection with primary anastomosis, Hartman resection, diverting colostomy/ileostomy, appendectomy or lysis of adhesions. There was a 20% in hospital mortality. The 1-year mortality rate was 38%. Univariate analyses were performed on outcome variables. Increased ASA class (p < 0.001), length of stay in the SICU (p < 0.001), advanced age (p < 0.011) and decreased albumin level (p < 0.007) were associated with statistically significant increased mortality. There was no statistical difference in mortality based on etiology of abdominal emergency, APACHE II score or co-morbid conditions. However, patients presenting with perforated diverticulitis had an increased hospitalization compared with all other patients (21 vs. 14 days, p < 0.03). CONCLUSIONS: Emergency abdominal surgery in the elderly is associated with high 30-day morbidity and mortality. This cohort found an appreciable 1-year mortality (38%). Additionally, this study demonstrated that increased mortality was associated with increased ASA class, advanced age and decreased albumin level. The results of this study illustrate the factors which can augment the preoperative evaluation of elderly patients who present with abdominal emergencies, as well as provide data which can be used to enhance informed decision making between the surgeon and patient.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1707 Is There a Critical Number of Recovered Nodes in ypT3-4 Rectal Cancer After Neoadjuvant CRT in Order to Provide Proper Final Disease Staging? Igor Proscurshim*1, Rodrigo O. Perez1, Angelita Habr-Gama3, Guilherme São Julião1, Joaquim Gama-Rodrigues3, Fabio Campos1, Viviane Rawet2, Desiderio Kiss1, Ivan Cecconello1 1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil; 2Pathology, University of São Paulo School of Medicine, São Paulo, Brazil; 3Habr-Gama Research Institute, São Paulo, Brazil BACKGROUND: Decreased number of recovered nodes is a poor prognostic factor in rectal cancer and may reflect quality of surgery and inadequate sampling of nodes leading to significant understaging of patients. Neoadjuvant CRT seems to contribute to a decrease in the number of recovered nodes after radical surgery and therefore, the least number of nodes required to minimize underestimation of disease staging is undetermined. The purpose of this study was to determine the influence of the total number of nodes recovered on the risk of finding node metastases for advanced rectal cancer following neoadjuvant CRT. METHODS: Patients with non-metastatic distal rectal cancer who underwent neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery (TME) were eligible for the study. All patients with ypT3-4 rectal cancer managed by neoadjuvant CRT and radical surgery were retrospectively reviewed in order to determine a correlation between the number of recovered nodes and the risk of lymph node metastases and the critical number nodes associated with significant underestimation of nodal spread and disease staging. RESULTS: 435 patients with distal rectal cancer managed by neoadjuvant CRT were included in the study. Overall, 165 patients had ypT3-4 rectal cancer after radical surgery and TME. The median number of recovered nodes was 9 nodes/patient. Patients with >9 nodes/specimen were at increased risk for N+ disease (47% vs 27%; p = 0.01). Less than 6 nodes/specimen was associated with significant decreased risk of finding node metastases (p = 0.006: Sensitivity 82% and Specificity 39%). CONCLUSIONS: A minimum of 6 nodes/specimen is required to provide proper nodal staging in ypT3-4 rectal cancer after neoadjuvant CRT and radical surgery. Less than 6 lymph nodes/specimen in patients with ypT3-4 rectal POSTER ABSTRACTS cancer managed by neoadjuvant CRT and TME should be considered at TUESDAY increased risk for disease stage underestimation.

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T1708 Is Initial Pre-Treatment Staging for Distal Rectal Cancer Undergoing Neoadjuvant CRT Useful? Angelita Habr-Gama2, Rodrigo O. Perez*1, Igor Proscurshim1, Joaquim Gama-Rodrigues2, Guilherme São Julião1, Antonio R. Imperiale1, Desiderio Kiss1, Ivan Cecconello1 1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil BACKGROUND: One of the benefits from neoadjuvant CRT for distal rectal cancer is tumor downstaging determined by radiation necrosis. It is still controversial if final disease stage, recurrence or survival is dependent on initial (radiological) staging. METHODS: Patients with non-metastatic distal rectal cancer who underwent neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery (TME) and available initial disease staging were eligible for the study. all patients with distal rectal cancer managed by neoadjuvant CRT were staged according to estimation of TNM parameters based on spiral CT scans or endorectal ultrasound. RESULTS: Overall, 331 patients had available information on initial radiological staging and were included in the study. There were 39 patients with stage I (12%), 198 with stage II (60%) and 94 patients with stage III disease (28%). There was no correlation between initial disease stage and final pathological ypT status (p = 0.5), final tumor size (p = 0.06), ypN status (p = 0.7), overall recurrences (p = 0.8) or final disease stage (p = 0.2). 5-year overall and disease-free survival were similar for radiological stage I, stage II, and stage III disease (p = 0.4 and p = 0.9 respectively). Post-CRT staging was significantly associated with development of recurrent disease (p < 0.001) and with overall and disease-free survival (p < 0.001). CONCLUSIONS: Even though Initial radiological staging is crucial for patient selection there is no influence in final disease staging, recurrence or survival.

292 6303_SSAT.book Page 293 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1709 Are There Any “High Risk” Features in Stage II Rectal Cancer After Neoadjuvant CRT and Radical Surgery? Rodrigo O. Perez*1, Igor Proscurshim1, Guilherme São Julião1, Angelita Habr-Gama2, Joaquim Gama-Rodrigues2, Antonio R. Imperiale1, Fabio Campos1, Desiderio Kiss1, Ivan Cecconello1 1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil BACKGROUND: Stage II rectal cancer (pT3-4N0) comprises a considerably heterogenous group of patients in terms of disease recurrence and long-term survival. Therefore, several pathological and molecular features have been associated with poor prognosis among these patients and may ultimately be used for adjuvant therapy recommendations. However, neoadjuvant CRT has been considered the preferred initial treatment strategy for distal rectal. This neoadjuvant approach leads to significant tumor downstaging and may ultimately influence pathological features in this subgroup of patients and difficult identification of “high risk” patients. The purpose of this study was to determine clinico-patholgical features associated with increased risk of recurrence development in stage rectal cancer after neoadjuvant CRT and radical surgery. METHODS: Patients with non-metastatic distal rectal cancer who underwent neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery (TME) were eligible for the study. All patients with ypT3-4N0 rectal cancer managed by neoadjuvant CRT and radical surgery were retrospectively reviewed in order to determine risk factors for recurrent disease by univariate and multivariate analysis. RESULTS: 435 patients with distal rectal cancer managed by neoadjuvant CRT were included in the study. Overall, 108 patients had ypT3-4N0 rectal cancer after radical surgery and TME. None of the clinical (age, gender, initial disease staging, distance from anal verge or initial tumor size) or pathological findings (ypT, tumor grade, final tumor size, mucinous component, number of recovered nodes, perineural invasion and vascular invasion) were associated with increased risk for recurrent disease (p > 0.05). CONCLUSIONS: Current recommended high risk features for stage II rectal cancer should not be considered in management decision of these patients in

regards to additional therapy after neoadjuvant CRT and radical surgery. POSTER ABSTRACTS TUESDAY

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T1710 Does Laparoscopic Approach Affect the Number of Lymph Nodes Harvest in Colorectal Cancer? Galal S. El-Gazzaz*, Geisler P. Daniel, Tracy L. Hull Colorectal surgery, Cleveland Clinic, Cleveland, OH PURPOSE: Adequate lymph node (LN) retrieval (>12 LN) is increasingly being considered a surgical quality indicator for colorectal cancer. The purpose of this study is to assess LN yield after laparoscopic colorectal cancer resection compared to the open approach and to analyze changes in harvesting over time in our practice. METHODS: From 1996–2007, 431 colorectal cancer patients underwent curative laparoscopic resection. During the study periods of 1996–1997, 2002–2003, and 2006–2007, 243 patients undergoing laparoscopic resection for colorectal cancer were studied. They were matched to 260 control patients undergoing conventional surgery identified from our cancer database and matched by age, operation, gender, date of operation and body mass index. Numbers of examined and involved LNs were compared between the two techniques according to location of tumor and year of surgery. RESULTS: A total of 503 patients (303 male) with a mean age of 66.2 ± 12.3 years, and a mean body mass index of 26.7 ± 7.3 kg/m2 underwent colorectal cancer resection (243 laparoscopically, 260 open resection) during the study period. The overall average number of LNs retrieved per case was 23.9 ± 18.3. There was no statistically significant difference in number of LNs retrieved by laparoscopic versus conventional open surgery (24.1 ± 19.3 laparoscopic vs 23.79 ± 17.50 for open p = 0.4) There were significant difference between involved LNs retrieved laparoscopically and by open technique (2.04 ± 3.6 vs 1.88 ± 4.69 P = 0.032). Also, There were significant differences between number of LNs retrieved from right colon, left colon and rectum (28.03 ± 14.62, 24.48 ± 17.59 and 19.13 ± 15.11) respectively (P < 0.001).The year of surgery show significant difference in number of involved LNs in laparoscopic cases only between 1996/1997 and 2006/2007 (P = 0.003). CONCLUSION: Laparoscopic resection of colorectal cancer can achieve similar LN retrieval to the open approach. In this era of new technology and refinement of laparoscopic techniques, LN harvest becomes more optimized.

Laparoscopic Open p-value Overall No Examined Involved Examined Involved p-value p-value Variable (lap/open) LN LN LN LN Examined LN Involved LN Laparoscopic 243 (48.3%) Open 260 (51.7%) Examined LN 24.1 ± 19.3 23.8 ± 17.5 0.97 Involved LN 2.0 ± 3.6 1.8 ± 4.7 0.032 Rt Colon 194 (101/93) 26.2+/12.4 2.1 ± 4.6 28.4 ± 15.6 1.5 ± 2.7 0.2 0.04 Lt Colon 161 (82/79) 25.19 ± 11.9 2.2 ± 4 23.8 ± 19.7 2.3 ± 6.0 0.3 0.4 Rectum 148 (60/88) 19.0 ± 11.2 1.7 ± 4.3 19.8 ± 16.1 2.1 ± 5.3 0.4 0.3 1996–1997 125 (61/64) 25.0 ± 16.0 2.2 ± 3.2 23.4 ± 16.2 1.9 ± 3.6 0.23 0.29 2002–2003 127 (54/73) 20.5 ± 16.5 2.6 ± 5.5 23.8 ± 18.7 1.9 ± 4.8 0.052 0.04 2006–2007 251(128/123) 26.4 ± 17.4 1.7 ± 4.8 23.5 ± 19.8 1.9 ± 1.5 0.13 0.3

294 6303_SSAT.book Page 295 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1711 Risk of Leak After Laparoscopic Versus Open Bowel Anastomosis Galal S. El-Gazzaz*, Daniel P. Geisler, Tracy L. Hull Colorectal surgery, Cleveland Clinic, Cleveland, OH PURPOSE: Anastomotic leak after colorectal surgery is a major complication that is associated with sepsis, prolonged hospitalization, and increased morbidity and mortality. The aim of this study was to investigate the safety of laparoscopic surgery (LS) as reflected by the anastomotic leak rate compared to open surgery (OS) for colorectal resective procedures. METHODS: From 2000 through 2007, all data relative to 4774 patients undergoing colorectal resective procedures with anastomosis (1516 laparoscopic and 3258 open) were prospectively recorded and retrospectively reviewed from IRB approved databases. Patients were equally matched with regards to site of anastomosis, pathology, date of surgery, age, gender, and BMI. The incidence of anastomotic leak was compared between the two groups according to location of bowel anastomosis, primary diagnosis, and year of surgery. RESULTS: There was no significant difference in anastomotic leak rate between the two groups: 2.3% of the LS group (N = 35) versus 2.1% of the OS group (N = 67) (p = 0.57). With regards to the site of anastomosis, there was no significant difference in anastomotic leak rate between the two groups: right colectomy (p = 0.32) and left colectomy (p = 0.79). There was no significant difference in leak rate between the two groups when the operation was performed for cancer (p = 0.6) or diverticulitis (p = 1). There was a significant difference in anastomotic leak rate when the primary diagnosis was Crohn’s disease: 5.3% of the LS group versus 1.8% of the OS group (p = 0.002). CONCLUSIONS: Laparoscopic colorectal surgery is not associated with a higher risk of anastomotic leaks. The incidence of anastomotic leaks in Crohn’s patients may be higher when the procedure is done laparoscopically and needs to be studied further.

Colorectal Resection with Anastomotic Bowel P Value Anastomosis Leak Variables Overall lap open lap open Total number 4774 1516 3258 35 (2.3%) 67 (2.1%) P = 0.57 POSTER ABSTRACTS Age (Mean ± SD) 55.8 ± 17.4 51.97 ± 16.07 55.14 ± 16.62 P = 0.89

BMI (Mean ± SD) 27.8 ± 6.2 27.39 ± 6.03 28.43 ± 6.54 P = 0.25 TUESDAY Diagnosis Cancer 2162 (45.3%) 282 (18.6%) 1880 (57.7%) 2.8% 2.3% P = 0.6 Crohn’s 1412 (29.6%) 247 (16.3%) 1165 (35.8%) 5.3% 1.8% P = 0.002 Diverticulitis 588 (12.3%) 375 (24.7%) 213 (6.5%) 1.3% 0.94% P = 1 Others 612 (12.8%) 612 (40.4%) 0 (0%) 1.5% 0% Years 2000–2003 2822 (59.1%) 681 (44.9%) 2141 (65.7%) 3.9% 2.9% P = 0.51 2004–2004 1952 (40.9%) 835 (55.1%) 1117 (34.3%) 3.6% 2.0% P = 0.55 Site Right 987 (20.7%) 343 (22.6%) 644 (19.8%) 3.8% 2.6% P = 0.32 Left 1951 (40.9%) 743 (49.0%) 1208 (37.1%) 2.4% 2.2% P = 0.79 Other 1836 (38.5%) 430 (28.4%) 1406 (43.2%) 1.7% 1.2% P = 0.23

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T1712 Postoperative Bowel Function After Lumber Colonic Nerve Preserving Low Anterior Resection for Rectal Cancer Yoshitaka Tanabe*1,2, Hiroaki Matsunaga1, Takashi Ueki2, Shosaku Nakahara1, Masao Tanaka2 1Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan; 2Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan AIM: We previously investigated the control mechanism of lumber colonic nerve (LCN) on colonic motility in the animal experiments, and have prospectively introduced LCN preserving low anterior resection (LAR) for rectal cancer on clinical setting. We have demonstrated that LCN preserving LAR has the better bowel function even though autonomic nerve preserving lateral pelvic lymphadenectomy (LPA) was combined. As the LPA is uncommon in the western countries, the aim of this study was to re-evaluate the functional effects of LCN preserving LAR for rectal cancer added the cases without LPA. PATIENTS AND METHODS: Since 1994, prospective functional questionnaire have been cumulated consecutively after LAR. Between January 1994 and August 2003, inferior mesenteric artery (IMA) was ligated at the origin of the abdominal aorta (LCN-divided group). Since September 2003, IMA has been ligated at the level of superior rectal artery just beyond the bifurcation of the left colonic artery (LCA), and IMA and LCA were preserved with neural sheath of LCN while dissecting the adipose tissue around the IMA (LCN-preserved group). Total mesorectal excision (TME) with autonomic nerve preservation was performed principally. The LPA was performed for T3 or more advanced cancers in the lower rectum. The end to end anastomosis with double stapling technique was performed in all patients, and the patients whose anastomotic line was within 4 cm from the anal verge were enrolled. Func- tional questionnaire was obtained at postoperative month 1, 3, 6, and 12, and data were analyzed comparing LCN-divided group (n = 33) and LCN- preserved group (n = 14). Functions were assessed in four aspects: bowel frequency, degree of soiling, ability to distinguish flatus from stool, prolonged defecation and persistent anismus. Subjective questions were expressed as quantitative values utilizing time interval until recognition of symptomatic improvement or satisfaction. RESULTS: There were no significant differences in the mean age and the level of anastomotic line between two groups. Bowel frequency in LCN- preserved group was significantly less than in LCN-divided group at postoperative month 1 (6.1 ± 0.8 versus 9.7 ± 1.0, p < 0.05). Bowel frequency was not significantly different at the other time points, but LCN-preserved group tended to have better functions at any observing time points assessed. CONCLUSIONS: We have revealed the LCN preserving LAR expressed better bowel function at the early postoperative period compared with the conventional procedure irrespective of LPA. LCN preservation may be one of the feasible procedures for improving the postoperative bowel function after LAR.

296 6303_SSAT.book Page 297 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1713 Prospective Study on the Management of Acute Diverticulitis Pierpaolo Sileri*1, Vito M. Stolfi1, Paolo Gentileschi1, Giuseppe S. Sica1, Girolamo De Andreis2, Alessandra Di Giorgio2, Alberto Galante2, Achille Lucio Gaspari1 1Surgery, University of Rome Tor Vergata, Rome, Italy; 2Internal Medicine, University of Rome Tor Vergata, Rome, Italy INTRODUCTION: Acute diverticulitis (AD) is the most common presentation of diverticular disease with high morbidity and mortality. We report our experience with the management of AD and we examined several clinical parameters in order to evaluate their predictive role for early discharge or prolonged hospitalization/surgery. PATIENTS AND METHODS: We prospectively evaluated all patients with AD admitted to our teaching Institution between January 2005 and October 2007. AD requiring admission was defined by the presence of lower abdominal pain and tenderness and/or guarding in left iliac fossa associated with systemic inflammatory response as shown by the presence of one or more of the following: fever (>38˚C), WBC count >12.000 or CRP elevation (>20 mg/dl). Patient’s related data including age, gender, co-morbidities, onset and duration of symptoms before admission as well as clinical data were prospectively entered in a database and analyzed to assess their predictive role for prolonged hospitalization/surgery. RESULTS: According to our criteria, 146 patients were identified (68 M, 78 F; mean age 64 years, range 27–91). Duration of symptoms before admission averaged 5 days (1–30 days). At admission, fever was present in 58.2% of patients, increased WBC count in 61% and raised CRP in 78.1%. Nine-two patients (63%) had a previous diagnosis of diverticular disease, 31 (21.2%) had one or more previous admission for AD. Ten patients (6.8%) required immediate surgery, while the remaining were initially treated conservatively (analgesia, bowel rest and appropriate antibiotics). Medical treatment alone was effective in 94.1% of patients and 84.6% were discharged within 4 days. Twenty-one patients required prolonged hospitalization (average 11 days, range 5–112). Two patient required abscess percutaneos drainage. Medical treatment failed in 6 patients (4.4%) after 5.5 days ± 3.5 days. Overall, 16 patients (11%) underwent surgery: 9 Hartmann’s procedure, 5 bowel resections with primary anastomosis, 1 subtotal colectomy and 1 laparoscopy with POSTER ABSTRACTS

abscess drainage. Overall mortality and morbidity rates were 2.1% and 12.3%. TUESDAY Surgical mortality and morbidity were 12.5% and 56.2% including intraoperative bleeding managed with Mikulicz packing (1), surgical site infections (5), pneumonia (2) and cardiac arrhythmia (1). Previous AD, duration of symptoms before admission (>3 days), obesity, and steady elevation of CRP predicted prolonged hospitalization or surgery. CONCLUSIONS: After admission for AD the risk of hospitalization or surgery is signiﬁcantly higher if patient is obese, experienced previous similar admissions or if CRP mantains steady elevation.

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T1714 Incidence of Adhesional Small Bowel Obstruction (SBO) After Colorectal Surgery Pierpaolo Sileri*, Alessandra Mele, Vito Maria Stolfi, Nicola Di Lorenzo, Paolo Gentileschi, Giuseppe S. Sica, Achille Lucio Gaspari Surgery, University of Rome Tor Vergata, Rome, Italy BACKGROUND: Colorectal surgery (CRS) leads to high rates of access- related complications. Adhesive small bowel obstruction (SBO) is reported as high as 35% with large clinical impact and financial burden. In this study we evaluated the cumulative incidence of adhesive SBO in a cohort of patients after CRS. We also assessed the role of laparoscopy as adhesion prevention strategy. METHODS: Data on patients undergoing elective or emergency CRS (either open or laparoscopic) were prospectively entered in a database. Adhesive SBO episodes requiring admission or reintervention were recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analysed using Mann-Whitney U test and chi-square test. The Kaplan Meier method was used to calculate the cumulative probability of developing SBO. RESULTS: From 1/03 to 10/07, 426 patients satisfied our criteria and underwent elective (48.6%) or emergency (51.4%) colorectal surgery (73.7% open and 26.3% laparoscopic). Mean follow-up was 28 months. Eleven (2.6%) patients experienced 14 SBO episodes and 8 (1.9%) required surgery. There was a large variation in the first readmission interval, 54% occurred within 3 months, 38.5% between 3 and 12 months and 14.3% after 1 year. At first admission 54.5% of patients underwent surgery. Seven patients required adhesiolysis and 1 patient needed resection for small bowel ischaemia. The risk of readmission for SBO was higher during the first postoperative year and the cumulative risk steadily increased every year thereafter. The risk of reoperation was related to the number of readmissions for SBO, doubling at the second readmission and reaching 100% after the third. Mean length of stay was 8 and 15 days respectively for non-operative and operative treatment. SBO risk was significantly higher after pelvic surgery/extensive resections compared to minor procedures (5.2% vs 2.6%; p < 0.03), after open compared to laparoscopic (3.2% vs 0.9%; p < 0.001) but similar after emergency surgery compared to elective (NS). CONCLUSIONS: Colorectal surgery results in significant ongoing risk of SBO depending from the colorectal procedure. The number of readmissions for SBO predicts the need of surgery. Laparoscopy seems to minimize the risk of adhesive SBO.

298 6303_SSAT.book Page 299 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1715 Laparoscopic Appendectomy for Complicated Appendicitis Pierpaolo Sileri*, Paolo Gentileschi, Giuseppe S. Sica, Piero Rossi, Luana Franceschilli, Federico Perrone, Achille Lucio Gaspari Surgery, University of Rome Tor Vergata, Rome, Italy BACKGROUND: Laparoscopic appendectomy (LA) is associated with less postoperative pain and earlier return to normal activity. However its role in the management of complicated appendicitis remains undefined and the choice of the operative approach is mostly at surgeon’s discretion. In this prospective study we compared the laparoscopic and the open approaches in terms of safety and efficacy for complicated appendicitis. PATIENTS AND METHODS: Consecutive patients who underwent appendectomy for acute appendicitis from January 2003 to November 2007 at our teaching Institution were studied. Patient’s data including demographics, operative time, short term complications (including surgical site infections- SSI), length of stay and access-related longer-term complications (small bowel obstruction, incisional hernia) were prospectively recorded and entered in a database. Data from patients who underwent OA or LA for complicated appendicitis were compared. These data were also matched with OA or LA for uncomplicated appendicitis (controls). Complicated appendicitis was defined as gangrenous or perforated appendicitis with or without the presence of abscess. Exclusion criteria were: age <14 years, patients presenting with generalized peritonitis or patients requiring additional surgery to appendectomy. Student’s t-test, Mann-Whitney U test and the Fisher exact test were used for statistical analysis. RESULTS: A total of 260 patients (124 M, 136 F, mean age 29 ± 12 years) underwent appendectomy during the study period. Eighty-two (31.5%) were complicated appendicititis: 38 patients underwent open appendectomy (OA) while 44 underwent LA. Conversion rate to OA complicated appendicitis rate was significantly increased compared to uncomplicated (15.4% vs 2.2%; p < 0.003). No significant differences were observed in terms of mean operative time or length of stay between OA and LA for complicated appendicitis and results were similar to OA and LA performed for uncomplicated controls. Overall complication rate was higher (but not significant) after OA compared to LA for complicated appendicitis (7.9% vs 4.5%). Both rates were also

similar to uncomplicated controls. Overall incidence of SSI was 3.1% and POSTER ABSTRACTS infections were equally distributed between groups (complicated vs uncom- TUESDAY plicated: 2.4% vs 3.4%; OA vs LA: 4.5% vs 2.2%). One patient of OA group experienced incisional hernia. CONCLUSIONS: Complicated appendicitis is associated with an increased need of conversion to open technique. However this study failed to show signiﬁcant differences between LA and OA performed for complicated appendicitis.

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T1716 Small Intestinal Bacterial Overgrowth Is Common in Patients with Lower Gastrointestinal Symptoms and a History of Previous Abdominal Surgery Grant G. Sarkisyan*1, Maura Fernandez1, Eileen A. Coloma1, Patrizio Petrone1, Gabriel Akopian1, Adrian E. Ortega1,2, Howard S. Kaufman1,2 1Surgery, University of Southern California, Los Angeles, CA; 2Keck School of Medicine, Los Angeles, CA PURPOSE: Small intestinal bacterial overgrowth (SIBO) is a condition associated with irritable bowel syndrome (IBS) and a variety of autonomic symptoms. The SIBO breath test has been found to be positive in 84% of patients with IBS vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with IBS-like symptoms who have undergone previous abdominal surgery due to adhesions and potential for stasis. METHODS: A retrospective review of patients from a tertiary colorectal surgery clinic was performed to identify patients with SIBO considered in the differential diagnosis. Demographics, past medical and surgical history, presenting symptoms, and diagnostic evaluations were recorded. SIBO-positive patients were compared SIBO-negative patients in case-control fashion. Mul- tiple regression analysis was performed to identify etiologic factors for SIBO. RESULTS: Seventy subjects were identified during a 36-month period (2004–2007). 18 patients were excluded due to noncompliance with testing, and 2 were excluded due to a decision to treat for SIBO without formal testing. Common presenting symptoms included chronic abdominal pain (52%), bloating (46%), constipation (66%), and diarrhea (12%). Mean symptom duration was 45 months (range 2–216). Mean age was 52 years (range 17–91), weight 152 lb (range 93–264), and 86% were female. The majority of patients were Caucasian (81%) and Hispanic (17%). 80% of patients had previous abdominal surgery, mean 2 procedures (range 0–6), 18% of which involved foregut, 12% midgut, 27% hindgut, and 43% female reproductive organs. Prior surgery was performed laparoscopically in 20% of patients vs open in 80%. 8% of patients had a history of small intestinal obstruction. 76% of patients tested positive for SIBO, 78% with previous surgery vs 70% without previous surgery. SIBO-positive patients were older than SIBO-negative patients: mean age 56 vs 44 yrs, (p < 0.01). Logistic regression analysis did not reveal any clinically significant independent factors associated with SIBO. Symptoms resolved in 50% of patients treated with GI tract antibiotics. CONCLUSIONS: SIBO is very common in a colorectal surgery population presenting with lower GI complaints. Although a past history of abdominal and pelvic surgery was not associated with a statistically higher incidence of SIBO, the high prevalence of SIBO-positive breath tests was greater than historical control rates. While further study is needed to assess the risk of SIBO after abdominal surgery, SIBO should be considered in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.

300 6303_SSAT.book Page 301 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1717 Contemporary Surgical Management for Ileosigmoid Fistulas in Crohn’s Disease Genevieve B. Melton*, Luca Stocchi, Elizabeth Wick, Kweku A. Appau, Victor W. Fazio Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Ileosigmoid fistula (ISF) in Crohn’s disease (CD) is a challenging clinical condition. The current role of diagnostic modalities and specific surgical management options for ISF in CD are not well characterized. METHODS: Patients from a prospectively collected CD database who underwent surgery for ISF during 2002–2007 were included. Demographics, disease extent, diagnostic modalities, operative approach, perioperative outcomes, concurrent medication use, and smoking status were retrospectively reviewed. Overall length of hospital stay included any postoperative readmission and stoma reversal. Converted cases were considered as laparoscopic procedures in an intent-to-treat analysis. RESULTS: A total of 61 patients underwent operative management for ISF (37 females, median age 37 [range 18–78] years, 19 [31%] laparoscopic). All patients had ileocolic resection. Management of the sigmoid colon included primary repair 14 (23%), segmental resection 45 (74%), or subtotal colectomy 2 (3%). Additional CD findings were identified in 25 (41%) patients, including ileovesical fistula 8 (13%), enterocutaneous fistula 8 (13%), and small bowel disease requiring resection 8 (13%), strictureplasty 5 (8%), or both 2 (3%). Sensitivities of colonoscopy, CT scan and fluoroscopic contrast studies for ISF were 40% (21/53), 47% (21/45) and 54% (14/26), respectively. The combination of all diagnostic studies resulted in a preoperative diagnosis of ISF in 35 (57%) patients. Protective stoma was used in 33 (54%) patients and was more frequent if additional small bowel disease required surgery (77% vs. 44%, p = 0.03), for open vs. laparoscopic surgery (64% vs. 32%, p = 0.02), when a phlegmon or abscess were present (85% vs. 46%, p = 0.007), and was associated with the use of intraoperative ureteral stents (33% vs. 4%, p = 0.003). Sigmoid resection was more common in laparoscopic vs. open approach (95% vs. 69%, p = 0.02). There were no deaths. Overall morbidity was 35% and leak rate 8%. Neither was affected by stoma diversion, use of laparoscopic technique, or treatment of the sigmoid colon with resection vs. primary closure. Overall length of hospital stay was non-significantly shorter

with laparoscopic compared to open surgery (median 6 vs. 9 days, p = 0.25). POSTER ABSTRACTS

CONCLUSIONS: ISF in CD remains an often incidental surgical ﬁnding. Sig- TUESDAY moid resection and primary sigmoid repair have comparable morbidity if appropriately individualized. Laparoscopic treatment is acceptable in select cases and may allow reduction in diverting stoma rates and overall length of hospital stay with similar morbidity.

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T1718 The Usage of Botulinum Toxin in the Treatment of Chronic Anal Fissures Alex J. Ky*, Randolph M. Steinhagen, Erin K. Ly, Emily Steinhagen Surgery, Mt Sinai Hospital, New York, NY INTRODUCTION: To assess the role of botulinum toxin in the treatment of chronic anal fissure compared to conservative non-surgical treatment. METHOD: A retrospective chart review was performed on all patients who presented with anal fissure for more than 4 weeks. These patients were given the option of continuing conservative management of topical analgesic, fiber and hot sitzs bath or the option of having a fissurectomy with botulinum toxin (BTX) injection. Most of our patients did not want a sphincterotomy as a first line treatment so those were excluded from the study. RESULTS: A total of 722 patients were diagnosed with chronic fissure from January 2000 to December 2005. 490 were female and 232 male. The average duration of the CAF was 9 weeks. 115 patients underwent fissurectomy with botulinum toxin injection while 607 patients had conservative treatment. An average of 50 units of BTX were injected in those who had surgery. 697 (96 percent) were in the posterior midline while the rest of the fissures were located in the anterior midline. Overall fissure healing in those who underwent BTX injections and fissurectomy was 93 percent at 4 weeks. Thirteen of those still have a visible deep fissure but was asymptomatic since the surgery. For those who failed, 5 percent went on to have lateral internal sphincterotomy which cured their fissure. None of the patients reported problems with incontinence. The average follow up was 8 months. Twenty three of the 107 patients who were healed needed repeat treatment of either LIS or BTX injection an average of 13 months after the fissure was declared healed. CONCLUSION: BTX injection along with fissurectomy is a good first line surgical intervention for patient who does not want a sphincterotomy. The risk of incontinence is low and the potential benefit of a healed fissure is high. However, those patients who have extremely hypertrophied internal sphinc- ters, they should be prepared for possible repeat treatment.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Esophageal

T1719 Esophageal Adenocarcinoma Associated with Barrett’s Esophagus: Survival Benefit? Valerie A. Williams*, Thomas J. Watson, Katherine A. Dudley, Svetlana Zhovtis, Carolyn E. Jones, Daniel Raymond, Jeffrey H. Peters Surgery, University of Rochester Medical Center, Rochester, NY OBJECTIVE: Prior studies have suggested that adenocarcinoma associated with Barrett’s epithelium may represent a unique tumor biology. This has arisen from observations that patients with adenocarcinoma and residual Bar- rett’s in the surgical specimen may have better survival than those without residual Barrett’s. The aim of our study was to determine the influence of Bar- rett’s epithelium on survival of patients with esophageal adenocarcinoma as well as to identify factors predicting survival. METHODS: The study population consisted of 194 patients who underwent esophagectomy for adenocarcinoma. Eighty-four (43.3%) patients had Bar- rett’s epithelium identified in the surgical specimen. Mean age, M:F ratio, location of tumor, type of operation and mean follow-up were not significantly different between those with or without Barrett’s. Outcome measures included overall survival, morbidity and mortality and factors associated with prolonged survival. The effect of age, gender, operative approach, Barrett’s, stage, T and N-classification, and endoscopic surveillance on survival was assessed via logistic regression. RESULTS: Patients with adenocarcinoma associated with Barrett’s had significantly better 5-year survival as compared to those without Barrett’s, (37.2% v. 23.1%; p = 0.020). Patients with Barrett’s also had earlier stage cancers (I–IIb) (57/82, 69.5% v. 35/110, 31.8%; p < 0.05) and a higher prevalence of endoscopic surveillance (20/64, 31.3% v. 1/79, 1.3%; p < 0.05) than those without Barrett’s. There was no difference in perioperative morbidity or mortality between the two groups. On multivariate analysis, tumor depth, nodal status and enrollment in a surveillance program were significant predictors of long-term survival. The presence of Barrett’s epithelium was not. Survival was also similar when those with and without Barrett’s epithelium were examined via matched pair analysis.

CONCLUSIONS: Long-term survival of patients with adenocarcinoma and POSTER ABSTRACTS Barrett’s epithelium in the surgical specimen is superior to those without evi- TUESDAY dent Barrett’s epithelium. This survival advantage is due to earlier detection and to surveillance endoscopy and not the underlying tumor biology. Screen- ing endoscopy and subsequent surveillance of patients with Barrett’s esophagus should be strongly encouraged to allow for the detection of esophageal adenocarcinoma at an earlier stage.

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T1720 Changing Prognosis of Spontaneous Esophageal Perforation (Boerhaave Syndrome): A Personal Experience of 64 Cases in a Single Center Jarmo A. Salo*, Jari V. Räsänen, Eero I. Sihvo Division of General Thoracic and Esophageal Surger, Dept of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland BACKGROUND: Spontaneous esophageal perforation (SEP) or Boerhaaven Syndrome is a rare and life-threatening disease. Published series usually contain less than 10–15 patients treated variously during a long period of time. Therefore, the management of SEP is often based on personal experience and not on evidence-based results. PATIENT AND METHODS: We scrutinized retrospectively the possible changes in the prognosis of 64 SEP patients (mean age 62 years) treated in a single institute between 1979–2007 by a team having special interest in esophageal surgery. RESULTS: There was no significant difference between decades in diagnostic delay. This delay was >24 h in 43% and >48 h in 34% of patients. The primary treatment strategy included aggressive conservative treatment of infection and homeostasis with the best possible available medical resuscitation in all 64 patients. Surgical strategy was primary repair through thoracotomy in 30 patients having vital esophagus (47%), and esophagectomy in 24 cases (38%) with severe wall necrosis or large esophageal damage making primary repair impossible. 10 patients (16%) with a small perforation and no/or very small pleural fistula or no empyema were treated non-operatively or with endoscopically installed esophageal prosthesis. Of treated patients, 29 (45%) had 1–4 reoperations. Mortality of SEP (30-d) decreased significantly from 28% (8/29) in 1980s–1990s to 3% (1/35) in the 21st century (p = 0.029). Similarly, leak-rate after primary repair decreased significantly from 53% (8/15) to 7% (1/15). Median survival after discharge was 120 months, similar to general population. CONCLUSIONS: The treatment of SEP has improved despite of similar strategies during 3 different decades. One reason is a decrease in leak-rate after primary repair. In this retrospective study, other factors are difficult to point out. These are probably multi-factorial including improved intensive care and team experience. Evidence-based results are needed in the treatment of SEP. Until then, the results of more conservative strategies including covered stents have to be compared to presented results.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1721 The Value of Endoscopic Ultrasound to Distinguish the Number of Lymph Node Metastases in Patients with Esophageal Adenocarcinoma Jessica M. Leers*, Jeffrey A. Hagen, Shahin Ayazi, Arzu Oezcelik, Emmanuele Abate, Farzaneh Banki, John C. Lipham, Steven R. Demeester, Tom R. Demeester Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA BACKGROUND: The presence and the number of lymph node metastasis have been identified as significant prognostic factor in patients with esophageal adenocarcinoma. Therefore, assessment of lymph node status is important to separate patients with advanced lymph node disease who may benefit from neoadjuvant therapy from those with limited lymph node disease who can be cured by surgical resection alone. Endoscopic ultrasound (EUS) is a reliable staging tool to determine tumor depth and identify abnormal lymph nodes. The aim of this study was to assess the accuracy of EUS in determining the number of lymph nodes involved. METHODS: We reviewed the records of all patients who underwent esophagectomy with a systematic thoracic and abdominal lymphadenectomy at our institution between 1991 and 2007 as primary therapy for esophageal adenocarcinoma. EUS was performed by the operating surgeon and limited disease was defined by involvement of ≤4 lymph nodes and advanced disease by involvement of 5 or more lymph nodes. The results of EUS were compared with pathological findings of the esophagectomy specimen. RESULTS: A total of 139 patients were included. In 103 patients (74%), EUS correctly identified limited versus advanced lymph node involvement. The positive predictive value for identifying limited node disease was 79%. EUS was more accurate in assessing lymph node involvement in patients with T1 and T2 tumors than in T3/T4 disease (98%, 79%, and 56%, p < 0.0001). In patient with T1/T2 tumors, EUS had a positive predictive value of 100%. There were 23 patients (17%) with advanced lymph node disease and the predictive value for EUS was only 48%. Patients with advanced node disease on EUS had a significantly worse disease free survival compared to patients with limited node disease (p = 0.0035). CONCLUSIONS: Endoscopic ultrasound can accurately identify patients

with limited node disease with a positive predictive value of nearly 80%. This POSTER ABSTRACTS allows identiﬁcation of patients unlikely to beneﬁt from neoadjuvant therapy. Advanced node disease on EUS is associated with less survival. TUESDAY

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T1722 Signiﬁcant Pressure Differences Between Solid-State and Water Perfused Systems in Lower Esophageal Sphincter Measurement Heinz Wykypiel*1, Ronald A. Hinder2, Kenneth R. Devault3, Gerold J. Wetscher4, Alexander Klaus1, Paul J. Klingler1 1Department of General and Transplant Surgery, Medical University Innsbruck, Innsbruck, Austria; 2Department of Surgery, Mayo Clinic Jacksonville, Jacksonville, FL; 3Department of Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, FL; 4Department of Surgery, General Hospital Schwaz, Schwaz, Austria OBJECTIVE: To compare lower esophageal sphincter (LES) measurements obtained with water-perfused manometry with a new solid-state technique. Normal values for LES resting pressure in suspected GERD (gastroesophageal reﬂux disease)-patients have been established using water-perfused manometry. These standard-values are also applied using new solid-state techniques, although they have never been compared before. METHODS: Thirty healthy subjects were studied twice on the same day: Technique 1: Station pull through using a water perfused catheter with ports arranged at 0, 90, 180, and 270 degrees which were averaged to give a mean LES pressure. Technique 2: Solid-state circumferential probe with a single station pull through. Data were collected using the same computer system and program. The LES pressures were randomly and blindly analyzed. RESULTS: 28 subjects of 30 were analyzed. Using the solid state system, the mean LES pressure was higher (26.6 vs. 21.7 mm Hg, p < 0.02) and 24 of 28 (85%) individual measurements were higher. The correlation between the two sets of measurements was also poor (r = 0.54). Two subjects had a hypertensive LES by solid state (53.4 and 41.9 mm Hg) while their pressures were normal with water perfused manometry (19.4 and 23.4 mm Hg). The distal esophageal pressures (mean of pressure at 3 and 8 cm above LES) were the same with the two techniques. CONCLUSIONS: In normal control subjects LES measurement using circumferential solid-state transducers yields higher pressures than standard water perfused manometric measurement. Which system yields the more accurate measurement of the physiologic LES remains to be determined.

306 6303_SSAT.book Page 307 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1723 Understanding Laryngopharyngeal Reflux (LPR): The Prevalence of Anatomic Esophagogastric Junction Degradation in LPR Patients Kyle A. Perry*1, Cedric S. Lorenzo1, Paul H. Schipper1, Joshua S. Schindler2, Cynthia Morris3, Blair A. Jobe1 1Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department of Otolaryngology, Oregon Health & Science University, Portland, OR; 3Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR INTRODUCTION: Distortion of esophagogastric junction (EGJ) architecture, caused by repeated proximal gastric distention, creates susceptibility to GERD; the end result is permanent dilation of the gastric cardia which is directly proportional to disease severity, with the largest circumference present in those with Barrett’s esophagus (BE). Because of their propensity to reflux in the upright position, it is unclear whether cardia dilation with resultant anatomic valve deformation is also present in patients with laryngopharyngeal reflux (LPR) symptoms. METHODS: In a prospective study, 113 patients recruited from ENT (N = 87) and Gastroenterology Clinics (N = 26) underwent unsedated upper endoscopy in the upright position after completing validated questionnaires for GERD and LPR symptoms. Exclusions were made for a poor endoscopic view of the gastric cardia. Three populations were stratified based on symptom complex: 1) LPR symptoms only (Pure LPR), 2) Typical GERD symptoms only (GERD), and 3) Both LPR and typical GERD symptoms (Mixed). The primary outcome was cardia circumference (mm) as measured by an observer blinded to symptom complex using previously validated software. The secondary outcome was the prevalence of biopsy proven BE within each group as a proxy for disease severity and cancer risk. RESULTS: The Pure LPR group (N = 32) had a mean gastric cardia circumference of 33.6 ± 7.3 mm. Similarly, the values in GERD (N = 41) and Mixed (N = 40) groups were 36.5 ± 9.6 mm and 35.1 ± 8.0 mm, respectively (p = 0.347, One Way ANOVA). Hiatal hernia size positively correlated with cardia circumference (r = 0.219, p = 0.02, Pearson’s). The overall prevalence of BE was 20.4%. BE was present in 15.6%, 34.2%, and 10.0% of Pure LPR,

GERD, and Mixed patients, respectively (p < 0.02, Chi square test). BE POSTER ABSTRACTS patients had a larger cardia circumference of 39.1 mm compared to 34.2 mm in those without BE (p < 0.02, t-test). TUESDAY CONCLUSION: Patients with LPR display the same degree of EGJ anatomic degradation as those with typical GERD symptoms which suggests a similar pathophysiology. This finding indicates that although LPR patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of BE, accompanied by increased gastric cardia diameter in the complete absence of typical GERD symptoms, suggests the potential for occult disease progression and late discovery of cancer.

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T1724 The Effect of Body Position on Hiatal Anatomy in Patients with GERD Kyle A. Perry*1, Cedric S. Lorenzo1, Paul H. Schipper1, Joshua S. Schindler2, Cynthia Morris3, Blair A. Jobe1 1Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department of Otolaryngology, Oregon Health & Science University, Portland, OR; 3Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR INTRODUCTION: Permanent disruption of the clasp and collar sling muscle fibers that comprise the distal aspect of the lower esophageal sphincter is believed to predispose patients to GERD. However, little is known about the effect of body position on hiatal anatomy in patients with GERD. We propose that body position has a significant impact on esophagogastric junction anatomy, and that investigations of these differences may enhance our understanding of the pathophysiology underlying GERD. METHODS: Fifty-three patients with PPI responsive heartburn and/or regurgitation underwent upper endoscopy in the upright and supine positions. All patients having undergone prior hiatal surgery were excluded. Digital images of the cardia were obtained in both positions under a set insufflation volume. Gastric cardia circumference measurements were performed by an observer blinded to position using validated software. Measurements were compared using paired t-test with results presented as mean cardia circumference ± SEM. RESULTS: The gastric cardia circumference for patients in the supine position was 53.1 ± 2.3 mm. These values decreased to 32.9 ± 1.4 in the upright position (p < 0.01). A subgroup of patients with biopsy proven BE (N = 18) had increased cardia circumferences of 58.2 ± 4.2 mm for CSE and 37.1 ± 2.4 mm for SCE with a mean difference of 21.1 ± 4.4 mm (p < 0.01). CONCLUSION: Body position has a significant impact on the anatomic con- figuration of the esophagogastric junction as indicated by changes in the gastric cardia circumference. Whether this effect is directly related to positional changes in the crural diaphragm diameter or the cardia itself is unknown and requires further study.

308 6303_SSAT.book Page 309 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1725 Better Reflux Control with a Nissen Fundoplication: 10-Year Results After Laparoscopic Antireflux Surgery Martin Fein*1, Marco Bueter1, Andreas Thalheimer1, Karl-Hermann Fuchs2 1Department of Surgery, University of Wuerzburg, Wuerzburg, Germany; 2Department of Surgery, Markus-Hospital, Frankfurt, Germany BACKGROUND: Reflux recurrence is the most common long-term complication following fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after ten years. METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a “tailored approach” (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen-, 22 an anterior, and 10 a Toupet- fundoplication. Follow-up of 87% of the patients included disease related questions and the gastrointestinal quality of life index (GIQLI). RESULTS: 89% of patients would select surgery again. Heartburn was reported by 30% of the patients independent of the type of fundoplication. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). 28% were on acid suppression therapy again. Proton pump inhibitors were less frequently used following Nissen-fundoplication (p = 0.01). The GIQLI was 110 ± 24 without significant differences for the type of fundoplication. DISCUSSION: Ten years after laparoscopic fundoplication, overall results are satisfactory. A quarter of the patients are on acid suppression therapy. Nissen fundoplication appears to control reflux better than a partial fundoplication. POSTER ABSTRACTS TUESDAY

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T1726 Association of Pregnane X Receptor (PXR) with Esophageal Disease in an Irish Population Mahwash Babar*1,2, John V. Reynolds1, Ross Mcmanus2 1Surgery, St. James’s Hospital, Dublin, Dublin, Ireland; 2Clinical Medicine, Trinity College, Dublin, Ireland It has been shown that acid and bile reflux play a role in oesophageal inflammation and carcinogenesis and enhanced expression of bile acid/xenobiotic receptors (Farnesoid X receptor, FXR and Retinoid X receptor, RXR) has been shown in Barrett’s esophagus. These receptors act as transcriptional regulators of Cytochrome P450 3A4 (CYP3A4) which is an important xenobiotic/drug metabolizing enzyme (DME). Genome Wide Association studies have shown genetic polymorphisms in DME to be linked with susceptibility to oesophageal carcinoma in the Chinese population. Here we examined the associaton of variants in the Pregnane X Receptor (PXR) gene, a member of the xenobiotic receptor family, and oesophageal disease in the Irish population. We gen- otyped the SNP –25385 (C/T) (rs3814055) which is a promoter polymorphism in the PXR gene in 1614 individuals (EAC, n = 186, Barrett’s, n = 186, Reflux oesophagitis, n = 180, Controls, n = 876). The data from all loci conformed to Hardy-Weinberg Equilibrium in all the populations. When the allele frequencies between the patients and the healthy controls were compared, the reflux population showed an increased frequency of the C allele which reached significance when compared to the random irish control population (59 vs 65, p = 0.008, OR = 1.53). No significant association was observed between the other groups and the control population for this locus. These preliminary data show a suggestive association of the PXR gene polymorphism with reflux in the Irish population.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1727 The Influence of FDG-PET on the Decision to Operate for Esophageal Carcinoma Jason W. Smith*, Jonathan Moreira, Gerard Abood, Margo Shoup Surgery, Loyola University Medical Center, Maywood, IL BACKGROUND: The use of [18F] flourodeoxyglucose positron emission tomography (FDG-PET) as an adjunct to computerized tomography (CT) and endoscopic ultrasound (EUS) in the staging of esophageal carcinoma has increased. FDG-PET has been shown to have an increased sensitivity for identifying distant metastases over CT and EUS, however it is not known how often this additional information alters the clinical decision avoiding major surgical resections and its associated morbidity for patients who are unlikely to benefit. The purpose of this study is to evaluate the influence of FDG-PET on the decision to operate in patients undergoing a staging work up for distal esophageal carcinoma. METHODS: A review of patients with distal esophageal carcinomas who were staged preoperatively with FDG-PET in addition to standard screening with CT or CT and EUS to determine if the use of FDG-PET significantly changed the decision to perform a curative operation. Patients who were restaged after the administration of neoadjuvant or primary chemoradiotherapy were reviewed to determine if the change in the intensity of FDG uptake in primary lesions, using the standardized uptake value (SUV), correlated with response to therapy and survival for its potential use in estimating prognosis. RESULTS: Of the 53 patients who had were considered for surgery based on traditional staging methods including CT and EUS, 10 (19%) had findings on FDG-PET that precluded surgical intervention. 36 patients who had PET scans before and after CRT were evaluated based on the effect of therapy on SUV. A reduction in SUV by greater than 50% resulted in recurrence in 9 of 23 (39%) patients whereas a less than 50% reduction in SUV resulted in 10 of 13 (77%) patients (p < 0.05, RR = 2.6, 95% CI 0.92 to 7.53) recurring over an average follow-up period of 23 months. Interestingly, of the patients that did develop recurrent disease, the patients with larger reductions in SUV tended to suc- cumb to their disease more rapidly than patients that recurred who had smaller reductions in SUV. CONCLUSION: The use of FDG-PET in the staging of patients with esophageal carcinoma saves nearly 20% of patients from undergoing a morbid sur- POSTER ABSTRACTS

gical procedure unnecessarily. Additionally, A large reduction in SUV after TUESDAY CRT selects a group of patients that have a signiﬁcantly better prognosis. PET scan should become a routine elemet in the preoperative evaluation of esophageal carcimoma and repeat PET after CRT may become an important prognostic indicator.

Poster of Distinction

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T1728 Surgical Outcomes Following Laparoscopic Re-Do Heller Myotomy in the Treatment of Achalasia Matthew J. Schuchert*, James D. Luketich, Arman Kilic, Neil Christie, Miguel Alvelo-Rivera, Manisha Shende, Rodney J. Landreneau, Arjun Pennathur Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA INTRODUCTION: Approximately 10%–15% of patients undergoing minimally invasive esophagomyotomy for achalasia will require further surgical intervention for ongoing control of symptoms. The objective of this study is to review the outcomes of patients undergoing laparoscopic re-do Heller myotomy for recurrent or refractory symptoms in the setting of achalasia. METHODS: All patients undergoing laparoscopic re-do Heller myotomy were identiﬁed from 1992–2007. Outcome variables included perioperative morbidity and mortality, symptomatic improvement, and need for subsequent esophagectomy. Dysphagia was scored 1 (no dysphagia) to 5 (unable to swallow saliva). RESULTS: A total of 19 patients (10 men, 9 women) underwent laparoscopic re-do Heller myotomy for achalasia. The mean age was 49.3 years (range 23–80). Mean follow-up was 39.8 months. Median hospital stay was 3 days (range: 2–10), with no operative mortality or conversions to open. There were 3 complications (15.8%): 1 esophageal mucosal perforation that was repaired intraoperatively, 1 pneumothorax, and 1 case of chronic intraluminal mesh erosion subsequent to re-do Heller with cruroplasty. Immediate symptomatic improvement occurred in 89.5% of patients with the mean dysphagia scores improving from 3.4 to 1.8 (p = 0.003). However during longer term follow-up, esophagectomy was ultimately required in 6/19 (31.6%) patients due to recurrent dysphagia. CONCLUSIONS: Laparoscopic re-do Heller myotomy is safe and effective in the immediate improvement of dysphagia in nearly 90% of patients. On longer term follow-up, approximately two-thirds of patients remain free of subsequent surgical intervention. Further prospective studies with longer follow-up are required to identify the factors affecting the outcome in these patients.

Poster of Distinction

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Hepatic

T1729 Validation of the E-PASS Scoring System for Prediction of Mortality and Morbidity in Hepatic Resections Vanessa Banz*, Peter Studer, Regula Fankhauser, Beat Gloor, Daniel Inderbitzin, Daniel Candinas University Hospital Bern, Bern, Switzerland BACKGROUND: In-hospital mortality and morbidity are—if well defined— readily measurable and objective parameters for monitoring standard of care within a single institution and for comparisons between centres. The Estima- tion of Physiologic Ability and Surgical Stress (E-PASS) score was initially developed to predict adverse postoperative effects for patients requiring elective gastrointestinal surgery ranging from laparoscopic cholecystectomy through to transthoracic esophagectomy. Our aim was to review whether the E-PASS scoring system could be used without restrictions in hepatic surgery as a means of correctly predicting morbidity and mortality. METHODS: E-PASS predictor equations were prospectively collected and analyzed retrospectively for 243 patients requiring hepatic resections between 2002–2006. The Comprehensive Risk Score (CRS) was calculated using the E-PASS equations as previously stated, which includes calculation of the Pre- Operative Risk Score (PRS) and the Surgical Stress Score (SSS). Patients were divided into 5 severity groups, also as previously stated, for whom expected adverse outcomes increase with increasing CRS. Observed morbidity and mortality rates were compared with rates predicted by E-PASS using either the Fisher’s Exact Test, or for larger sample sizes the chi2 Test. The Wilcoxon rank-sum Test and the t-Test were applied for comparison of PRS and SSS between patients with and without morbidity or mortality. RESULTS: The observed and predicted overall mortality rates were 3.3 and 3.7 per cent respectively, morbidity rates were 31 and 28 per cent. The E-PASS model showed no significant difference between expected and observed in- hospital mortality (p = 0.641), indicating that it predicted outcome effectively. E-PASS under-predicted morbidity and showed significant lack of fit (chi2 = 11.1, 3d.f. p = 0.011). Although comparison of PRS and SSS between patients with and without complications revealed no overall significant

difference (t = –0.37, 241d.f. p = 0.714 and t = –1.69, 241d.f. p = 0.093), group POSTER ABSTRACTS specific comparisons showed lack of fit for groups 1, 2 and 4. Equally, patients who died postoperatively did not have a significantly higher PRS or SSS TUESDAY (p = 0.157 and p = 0.305). CONCLUSIONS: These data suggest that E-PASS does up to a certain extent accurately predict outcome in patients undergoing hepatic resections. This was especially true for predicting mortality. Morbidity was however under- predicted in the E-PASS model. A modified, new logistic equation might be required for liver-specific resections in order to correctly foresee postoperative complications and mortality after hepatic surgery.

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T1730 Prolonged Survival in Selected Patients Following Metastasectomy from Hepatocellular Carcinoma Chen Fang Lee*, Miin-Fu Chen Chang-Gung Memorial Hospital, Taoyuan, Taiwan OBJECTIVES: Hepatocellular carcinoma (HCC) is the most common cancer causing death in Taiwan. With the recent advances in diagnostic and surgical techniques, more patients are suitable for hepatectomy. However, the long- term outcome of patients remains poor due to high recurrence rate. Few articles have discussed the beneﬁt of metastasectomy. The aim of this study was to evaluate the role of surgery for pulmonary and other resectable metastases from HCC. METHODS: Eight patients underwent metastasectomy at Chang Gung Memorial Hospital between April 2000 and June 2007 were enrolled in this study. All of them had received the hepatectomy for primary HCC. The demographic information, the site of extrahepatic recurrence, the method of surgical intervention and the outcome were retrospectively reviewed. RESULTS: There were 6 men and 2 women with the mean age of 48.5 years. Five of them accepted multiple metastasectomy. Six patients had pulmonary metastases removed by wedge resection or lobectomy. One patients accepted craniotomy for metastatic HCC. One patient had the excision of right second rib and right femoral metastasis. One patient had removal of the metastasis from scalp, right atrium and inferior vena cava. The mean survival was 50.7 months (18 to 96 months). Four patients are still alive with or without the disease. CONCLUSIONS: Resection for metastases from HCC resulted in long-term survival in these highly selected patients. Although the number of patients suitable for resection of extrahepatic metastasis after curative hepatectomy for HCC is small, some long-term survivors will beneﬁt. Especially for patients with lung metastases, aggressive surgical resection is recommended if complete resection can be achieved.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1731 Prognostic Factors After Liver Resection for Colorectal Metastases: Multivariate Analysis and Comparison with the FONG-Score Ulrich Adam*1, Frank Makowiec1,2, Hannes Neeff1, Oliver G. Opitz2, Eva Fischer1, Ulrich T. Hopt1,2 1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer Cancer Center, University of Freiburg, Freiburg, Germany INTRODUCTION: Because of low mortality and morbidity and increasing survival rates the resection of liver metastases of colorectal cancer (CRC) plays an important role in the multimodal management of patients with metasta- sized CRC. The knowledge of prognostic factors (as for example the FONG- criteria) is crucial in the planning of different treatment options. We here evaluated the outcome after liver resection for CRC metastases and analyzed potential prognostic factors. METHODS: Long-term follow-up was available in 186 patients (32% female, median age 63 years) who underwent primary liver resection for CRC metastases between 1996 and 2006. Initially 57% had colon and 43% rectal cancer. 66% of the primary tumors were lymph node positive. The median time interval between resection of the primary and of liver metastases was 12 (range 0–140) months. For further analyses this interval was classified as <12 months or ≥12 months. Survival analysis was performed by the Kaplan-Meier- and Cox-methods. The FONG-criteria as well as age, gender, blood transfusions and extent of resection were evaluated for potential prognostic influence. RESULTS: An atypical or segmental resection was performed in 47%, whereas 53% had at least a hemihepatectomy. Free resection margins were achieved in 88%. Five year survival (5-y SV) of all patients after liver resection was 45% (median survival 4.1 years). Univariate risk factors for poorer survival were a positive margin (5-y SV 36% vs 47% with R-0; p = 0.001) and size of metastases ≥5 cm (5-y SV 33% vs 50% <5 cm; p = 0.009). A trend to poorer survival was found for patients with node-positive primaries, female gender, more than one metastasis and elevated CEA-levels. In multivariate analysis the resection margin (p = 0.003), size of metastases (p = 0.002) and gender (p < 0.05) were factors independently influencing survival. After classifying patients according to the FONG-criteria (0 to 5 positive) univariate survival analysis showed a clear correlation of survival with this FONG-score (p < POSTER ABSTRACTS

0.01): patients with a score of 0 or 1 had a 5-y SV of almost 60%, whereas the TUESDAY five-year survival of patients with a score of four of five was below 35%/20%. CONCLUSIONS: Prognosis after resection of CRC liver metastases is relatively good especially in the case of small metastases and free resection margins. Identified prognostic factors (e.g., FONG-criteria) should be considered in the planning of multimodal therapy in order to achieve optimal treatment results in the individual patient, possibly even without (primary) resectional therapy in high-risk patients.

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T1732 Ultrasound Guided Liver Resection: Does This Approach Limit the Need for Portal Vein Embolization? Guido Torzilli*1,2, Matteo Donadon1,2, Angela Palmisano1,2, Matteo Marconi1,2, Fabio Procopio1,2, Florin Botea1,2, Daniele Del Fabbro1,2, Marco Montorsi2 1Liver Surgery Unit, 3rd Department of Surgery, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy; 23rd Department of Surgery, University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy BACKGROUND: Since major removal of liver parenchyma is undoubtedly associated with higher risk of morbidity and mortality, portal vein embolization (PVE) has been advocated to minimize that risk. However, PVE itself has associated morbidity. Ultrasound-guided resection minimizing the need for major resections, could make PVE mostly unnecessary. The aim of this study was to validate this hypothesis. MATERIAL AND METHODS: Two hundred and ﬁfty-three consecutive patients who underwent liver surgery were reviewed. Sixty-eight of these patients with tumors corresponding to right 1st/2nd order portal branches (Zone P) and right hepatic vein (Zone H) were selected as potential candidates for major hepatectomy and as consequence to PVE. Indications to PVE were deﬁned according to the most recent reported criteria based on liver background, and expected remnant liver volume. Surgical strategy was based on the relationship between the tumor and the intrahepatic vascular structures at intraoperative ultrasonography (IOUS). Postoperative outcome, rate of local recurrence, rate of major hepatectomy and PVE were analyzed. RESULTS: Thirty-seven (54%) patients with tumors located in Zones H and P were potential candidates to PVE, but none underwent this procedure. Major hepatecomies were performed in 5 (7%) patients. No hospital mortality was seen. Morbidity rate was 15% and major morbidity occurred in 2 patients. Blood transfusion rate was 11%. Mean tumor-free margin was 0.13 cm (median 0.1; range 0–0.6). None had local recurrence after a mean follow-up of 27.3 months (median 25; range 6–61). CONCLUSIONS: In conclusion, these results show that IOUS guidance allows an alternative, safe, and effective surgical approach for patients generally submitted to major hepatectomy and most of them to preoperative PVE. In this perspective, further studies are required to reassess indications to PVE.

316 6303_SSAT.book Page 317 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1733 Surgical Management of Leiomyosarcoma of the Inferior Vena Cava in Eight Patients Sung W. Cho, James W. Marsh, David A. Geller, Jason Heckman, Shane Holloway, Matthew Holtzman, Herbert Zeh, David L. Bartlett, T. Clark Gamblin* University of Pittsburgh Medical Center, Liver Cancer Center, Pittsburgh, PA INTRODUCTION: Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor for which en bloc resection offers the only chance of cure. Due to its rarity, however, optimal surgical and adjuvant treatment strategies are not well deﬁned. METHODS: We performed a retrospective review of eight patients with IVC leiomyosarcoma. We evaluated clinical presentations, operative techniques, patterns of recurrence and survival. RESULTS: From 1990 to 2007, 8 patients (4 females) underwent curative resection. Median age was 58 years (40–76). Presentations included abdominal pain (5), back pain (2), leg swelling (3) and abdominal mass (2). Preopera- tive CT or MRI scans showed location of the tumor to be from the right atrium to renal veins (1), retrohepatic (4), and from hepatic veins to the iliac bifurcations (3). En bloc resection included right nephrectomy (3), right adrenalectomy (4), pancreaticoduodenectomy (1), right hepatic trisegmentec- tomy (1) and right hemicolectomy (1). The IVC was ligated in 5 patients, and a prosthetic graft was used for IVC reconstruction in 3 patients. Median size of the tumor was 10 cm in diameter (6–30). Resection margins were negative in 6 cases and microscopically positive in 2 cases. Median length of stay was 13 days (6–22). Morbidity included two cases of atrial ﬁbrillation, one retroperitoneal hematoma, and one transient hepatic encephalopathy. There was one postoperative death from multi-system organ failure. Three patients received adjuvant chemotherapy and/or radiation. Median follow-up was 43 months (2–111). 7 patients were alive at last follow-up. 4 patients had recurrence; liver (3), retroperitoneum (2) and lungs (1). The median time interval to recurrence was 14 months (3–28). 2 patients underwent successful resection of recurrence (ex-vivo right hepatic lobectomy and resection of a retroperitoneal mass respectively), and one received TACE for intrahepatic recurrence. CONCLUSIONS: Curative resection of IVC leiomyosarcoma can lead to long- term survival. However, recurrence is common, and effective adjuvant treat- POSTER ABSTRACTS ments are needed. In selected cases, aggressive surgical treatment of local

recurrence should be considered. TUESDAY

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Clinical: Pancreas

T1734 EUS-Guided Drainage of Peripancreatic Fluid Collections Following Distal Pancreatectomy Shyam Varadarajulu*1, John D. Christein2, Charles M. Wilcox1 1Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2Surgery, University of Alabama at Birmingham, Birmingham, AL BACKGROUND: Peripancreatic fluid collections (PFC) are a frequent complication following distal pancreatectomy (DP). Trans-papillary pancreatic stenting and percutaneous drainage are non-surgical management options with variable outcomes. Endoscopic trans-mural drainage by means of cyst- gastrostomy is feasible only when the PFC is large enough to causes luminal compression. However, endoscopic ultrasound (EUS) offers the potential to access PFC under direct sonographic visualization in patients without luminal compression. AIM: Evaluate the role of EUS in management of PFC following DP. METHODS: We prospectively collected data on all symptomatic patients referred for EUS-guided drainage of PFC following DP over a 3-yr period. Prior to EUS, all patients underwent contrast enhanced CT of the abdomen and ERCP. PFC was classified per Atlanta criteria. EUS-guided drainage was undertaken when trans-papillary pancreatic stenting failed or was ineffective. At EUS, the PFC were accessed trans-gastrically using a 19-gauge FNA needle and after passage of a 0.035 inch guidewire, sequential dilation of the trans-gastric tract was performed up to 8 mm and 7 Fr/10 Fr double pigtail stents/drainage catheters were deployed. Technical success was defined as successful placement of stent/drain within the PFC. Treatment success was defined as resolution of clinical symptoms and fluid collection on follow-up CT at 6-weeks. RESULTS: Ten patients (6 Male, mean age 54.1yrs [range, 29–79]) underwent EUS-guided drainage of PFC (5 pseudocyst, 5 abscess) following DP. These were inclusive of referred patients from outside facilities and different subspe- cialties. Indications for DP were neuroendocrine tumor in 4, cyst neoplasm (3), splenectomy (2), and trauma (1). Eight of 10 patients had undergone prior trans-papillary pancreatic stenting; ERCP was unsuccessful in 2 patients. Mean size of the PFC (largest dimension) was 68 mm (range, 40–110 mm) and did not cause luminal compression in any patient. EUS-guided drainage was technically successful in 9 of 10 (90%) patients. Trans-gastric site for PFC drainage was gastric cardia in 5 patients, fundus (3) and lesser curvature (1). Mean procedural duration was 46 minutes (range, 18–95). Treatment was successful in 7 of 9 patients (78%): two patients with pancreatic abscess had persistent symptoms requiring surgical drainage. No procedural complications were encountered. One patient had recurrence of PFC after 8 months and was managed successfully by repeat EUS-guided drainage. CONCLUSIONS: EUS-guided drainage is a safe, minimally invasive, and highly effective technique for management of PFC that develop following distal pancreatectomy.

318 6303_SSAT.book Page 319 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1735 Management of Intraductal Papillary-Mucinous Neoplasms of the Pancreas (IPMN): A 10-Year Experience in Two Pancreatic Centers in Germany Robert Grützmann*1, Dag Dittert3, Ralf Hildenbrand4, Stefan Post2, Hans Detlev Saeger1, Marco Niedergethmann2 1Surgery, University Hospital Dresden, Dresden, Germany; 2Surgery, University Hospital Mannheim, Mannheim, Germany; 3Pathology, University Hospital Dresden, Dresden, Germany; 4Pathology, University Hospital Mannheim, Mannheim, Germany BACKGROUND: The intraductal papillary-mucinous neoplasms (IPMN) were officially introduced into the TNM Classification in 1996. Based on a two-centre database we set out to reevaluate histopathological findings, clinicopathological clusters, predictive markers for malignancy and outcome. METHODS: Between 1996 and 2006 a total of 1,424 pancreatic resections were performed in the University Hospitals Dresden and Mannheim. Patholo- gists of both institutions reviewed the IPMN-cases and other with cystic or solid tumor diagnoses. All possible markers such as diabetes, jaundice, etc. were analyzed for prediction of malignancy. We performed a survival analysis based upon the morphologic classification to determine the prognosis of IPMN.

RESULTS: There were 43 cases of primarily diagnosed IPMN along with 1174 cases with diagnoses such as ductal adenocarcinoma. In 207 cases the diagnoses revealed other cystic or small solid tumors. A histopathological review of these cases revealed 54 IPMNs, resulting in a total of 97 IPMN-cases (29 non- POSTER ABSTRACTS

invasive, 68 invasive). All IPMN-cases had a median survival of 36 months. TUESDAY Recurrence occurred more frequently in invasive IPMN. Predictive markers of malignancy were pain, preoperative weight loss, jaundice and elevated CA 19.9. The strongest independent prognostic factor was invasive growth. The survival analysis revealed excellent prognosis for non-invasive IPMN. CONCLUSIONS: Since the introduction of IPMN in 1996 even specialized centers have had to deal with a learning curve. By re-evaluating all cystic or small solid tumors centres can improve and their patients treatment can be optimized. Since the preoperative diagnostic methods are not sensitive enough to differentiate between benign and malignant lesions surgery is advocated for all IPMN lesions.

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T1736 Indication for Special Therapies in Acute Pancreatitis: Optimum Severity Score for Continuous Regional Arterial Infusion and Enteral Nutrition Takashi Ueda*1, Yoshifumi Takeyama1, Takeo Yasuda1, Makoto Shinzeki2, Hidehiro Sawa2, Yonson Ku2, Yoshikazu Kuroda2, Harumasa Ohyanagi1 1Surgery, Kinki University School of Medicine, Osaka-sayama, Japan; 2Surgery, Kobe University School of Medical Sciences, Kobe, Japan BACKGROUND/AIM: Despite advances in intensive care, the mortality rate in severe acute pancreatitis (SAP) is still high. As special therapies, continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI), and enteral nutrition (EN) are now utilized in Japan. Since 1999, we have performed CRAI in patients with pancreatic necrosis and EN in patients with SAP according to the Japanese criteria. We recently reported that the mortality rate was lower in CRAI (+) group (37%) than that in CRAI (–) group (54%) and that the mortality rate was lower in EN (+) group (19%) than that in EN (–) group (35%). However, there have been no analyses about the indications for CRAI and EN. This study aimed to clarify the optimum severity score for CRAI and EN. METHODS: We evaluated 125 patients with SAP according to the Japanese criteria between 1990 and 2006. Severity scores (Ranson and APACHE II) were estimated on admission. CRAI administered a protease inhibitor (nafamostat mesilate: 250 mg/day) and an antibiotic (imipenem: 1.0 g/day) via the celiac artery and SMA for 5–7 days after admission. EN was started through the N-J tube within 3–7 days after admission and was continued until day 21. We analyzed the relationships between severity scores and the mortality rates in patients with and without CRAI and EN, respectively. RESULTS: In patients with Ranson ≤4, there was no significant difference between the mortality rates in CRAI (+) and CRAI (–) group. In patients with Ranson ≥5, the mortality rate was lower in CRAI (+) group (12/25 = 48%) than that in CRAI (–) group (15/19 = 79%) (P < 0.05). In patients with APACHE II 0–7, 8–14, and ≥22, there were no significant differences between the mortality rates in CRAI (+) and CRAI (–) group, respectively. In patients with APACHE II 15–21, the mortality rate was lower in CRAI (+) group (5/13 = 38%) than that in CRAI (–) group (9/12 = 75%) (P = 0.07). In patients with Ranson ≤2, there was no significant difference between the mortality rates in EN (+) and EN (–) group. In patients with Ranson ≥3, the mortality rate was lower in EN (+) group (9/38 = 24%) than that in EN (–) group (27/57 = 47%) (P < 0.05). In patients with APACHE II 0–7, 8–14, and ≥22, there were no significant differences between the mortality rates in EN (+) and EN (–) group, respectively. In patients with APACHE II 15–21, the mortality rate was lower in EN (+) group (3/10 = 30%) than that in EN (–) group (11/15 = 73%) (P < 0.05). CONCLUSIONS: In patients with Ranson ≥5 or APACHE II 15–21, CRAI was effective in reducing the mortality rate. In patients with Ranson ≥3 or APACHE II 15–21, EN was effective in reducing the mortality rate.

320 6303_SSAT.book Page 321 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1737 Usefulness of 13C-Labeled Mixed Triglyceride Breath Test for Evaluating Exocrine Pancreatic Function After Pancreatic Surgery Hiroyuki Nakamura*, Yoshiaki Murakami, Kenichiro Uemura, Yasuo Hayashidani, Takeshi Sudo, Taijiro Sueda Department of surgery, Graduate school of biomedical sciences, Hiroshima University, Hiroshima, Japan BACKGROUND: Among the previous described noninvasive markers for screening of exocrine pancreatic insufficiency, fecal elastase-1 test has been reported to be the most satisfactory exocrine pancreatic function test. Recently, indirect tests such as breath tests have developed in which stable isotopes (13C) are incorporated into test meals. The aim of this study was to evaluate the diagnostic efficacy of 13C-labeled mixed triglyceride breath test as an exocrine pancreatic test for patients undergoing pancreatic resection. METHODS: The 13C-labeled mixed triglyceride breath test and fecal elastase-1 test were performed in 7 healthy subjects, 10 patients with chronic pancreatitis and 95 patients undergoing pancreatic surgery. The 95 pancreatic resections consisted of 42 pylorus-preserving pancreatoduodenectomies (PPPD), 9 pancreatic head resections with segmental duodenectomy, 14 local resections of head of the pancreas combined with longitudinal pancreaticojejunostomy for chronic pancreatitis (Frey procedure), 8 necrosectomies for necrotizing acute pancreatitis, 6 segmental resections of the pancreas (SR), 13 distal pancreatectomies (DP) and 3 total pancreatectomies (TP). All patients undergoing surgery were examined when about one year had passed since operation. After a 12-hour fast, 200 mg of 13C-labeled mixed triglyceride was orally administered with a test meal, and breath samples were taken before and at 1-hour intervals for 7 hours. Thereafter, the increase in 13C/12C isoto- pic ratio in breath was analyzed by mass spectrometry. The concentration of fecal elastase-1 was determined using an enzyme-linked immunosorbent assay (Schebo-Tech, Wettenberg, Germany). RESULTS: The 13CO2 cumulative recovery at 7 hours was found to be significantly correlated with the concentration of fecal elastase-1 (n = 112, R2 = 0.14, P < 0.0001). Not only the 13CO2 cumulative recoveries at 7 hours, but also fecal elastase-1 concentrations of patients undergoing PPPD, patients undergoing Frey procedure and patients undergoing TP were significantly lower than those of healthy volunteers (P < 0.05). On the fourth day after with- POSTER ABSTRACTS

drawal of oral pancreatic enzyme supplement, 20/25 (80%) patients with low TUESDAY 13CO2 cumulative recoveries (less than 5%) showed symptoms of exocrine pancreatic insufﬁciency such as excessive volumes of stool or loose stool. CONCLUSIONS: These results suggested that 13C-labeled mixed triglyceride breath test was an useful test for evaluating exocrine pancreatic function in patients undergoing pancreatic resection.

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T1738 Surgical Resection of Renal Cell Carcinoma Metastatic to the Pancreas Joshua G. Barton*1, Jarrod R. Daniel1, Andrew C. Mccoy1, Michael J. Levy2, David Nagorney1, Florencia G. Que1, Michael B. Farnell1, Michael L. Kendrick1 1Surgery, Mayo Clinic, Rochester, MN; 2Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN BACKGROUND: Metastatic lesions to the pancreas account for less than 2% of pancreatic neoplasms. Outcomes of pancreatic resection for disease-specific metastases are poorly defined due to their low incidence and grouping of multiple tumor types in current series. Renal cell carcinoma appears to be the most common source of pancreatic metastases. Overall 5-year survival rates for unresectable metastatic renal cell carcinoma are typically less than 10%. Our aim is to define the surgical management and outcome of patients with metastatic renal cell carcinoma to the pancreas. METHODS: Retrospective review of all patients who underwent pancreatic resection for metastatic renal cell carcinoma at our institution from January 1990 to November 2007. Analysis included clinical evaluation, operative management, histology, and outcomes. RESULTS: A total of 32 patients (18 male, 14 female) with a mean age of 68 years (44–82) were identified. Presentation of the pancreatic metastases was metachronous in 31 patients and synchronous in 1. Solitary pancreatic metastases were identified in 21, while 11 patients had multiple pancreatic metastases (range: 1–6). Resection was limited to the pancreas (n = 19), involved additional metastatic sites (n = 9), or included renal-bed recurrence (n = 3). The median interval from nephrectomy to pancreatic resection was 9 years (1–42). Pancreatic resection included distal pancreatectomy (n = 26), total pancreatectomy (n = 3), and pancreaticoduodenectomy (n = 2). R0 resection was accomplished in 31 patients (97%). One patient underwent a palliative (R2) resection. One patient underwent completion pancreatectomy for recurrent pancreatic metastases 55 months after distal pancreatectomy. Perio- perative mortality was not observed. Follow-up data was available in 31 patients (97%) for a mean of 53 months. Tumor recurrence was observed in 15 patients (48%), a mean of 29 months (4–96) after pancreatic resection. Dis- ease-free and overall survival following pancreatic resection was 35 and 53 months respectively, with an actual 5-year survival of 42%. CONCLUSION: Metastatic renal cell carcinoma is typically associated with poor survival. Pancreatic resection for metastases may offer a survival advantage; however, potential patient selection bias and lack of comparative trials limit validation. Pancreatic resection does appear warranted in selected patients where an R0 resection is possible.

322 6303_SSAT.book Page 323 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1739 Pancreatic Acinar Cell Carcinoma: A Multi- Institutional Study Jesus M. Matos*1, C. Max Schmidt1,5, Marco Niedergethmann3, Hans Detlev Saeger2, Nipun Merchant4, Keith D. Lillemoe1, Robert Grützmann2 1Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Department of Surgery, University Hospital Dresden, Dresden, Germany; 3Department of Surgery, University Hospital Mannheim, Mannheim, Germany; 4Department of Surgery, Vanderbilt University Medical Center, Nashville, TN; 5Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN BACKGROUND: Acinar cell carcinoma of the pancreas (ACC) accounts for approximately 1% of exocrine pancreatic tumors. Prognosis is poor, but recent studies suggest a better prognosis than ductal adenocarcinoma (DA). This study represents pooled data from multiple academic institutions to better understand the natural history and outcomes of patients with this rare form of pancreatic cancer. METHODS: Multi-institutional retrospective review of patients with ACC was conducted to evaluate the clinical presentation and outcomes of patients with ACC. RESULTS: Between the years 1988 and 2007, 16 patients were identiﬁed with acinar cell carcinoma (ACC) of the pancreas. Median age at presentation was 65 years. Patients commonly presented with abdominal (56%), back pain (44%) and weight loss (40%). Jaundice was not a typical presenting symptom. Fourteen patients underwent 15 operations: pancreaticoduodenectomy (8), distal pancreatectomy (4), and exploratory laparotomy (3). Three patients were found to be unresectable at initial operation, two with regionally advanced tumors and one with occult liver metastases. One patient with a regionally advanced tumor received neoadjuvant chemotherapy and was subsequently resected, and the other underwent chemoradiation but developed distant disease (supraclavicular node). Two patients were referred for surgery, but were managed non-operatively due to metastases. Mean tumor size was 5.5 ± 0.7 cm. AJCC tumor stages were stage I (1); stage II (9); stage III (3); and stage IV (3). In resected cases, 1 year survival was 100% and 5 year survival was 50%. Seven of 12 resected patients remain alive. One, the longest survivor to date (stage II), has survived 83 months. Two experienced hepatic

metastases as a ﬁrst sign of recurrence. One succumbed 13 months after distal POSTER ABSTRACTS pancreatectomy, and the other remains alive 76 months after pancreaticoduodenectomy. Patients with pre-operative metastases managed non-oper- TUESDAY atively were found to have a broad range of survival (1–63 months). CONCLUSION: ACC of the pancreas is rare and has a presentation and outcome distinct from pancreatic ductal adenocarcinoma. Tumor size is larger at presentation, and prognosis in resected patients reﬂects other recent series demonstrating better survival. Patients with advanced disease managed non- operatively experience variable survival. A larger study is needed to examine treatment related outcomes and other predictors of survival in patients with ACC of the pancreas.

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T1740 Pancreatic Exocrine Function in Patients Undergoing Distal Pancreatectomy as Assessed by Human Stool Elastase-1 James E. Speicher*, L. William Traverso Department of Surgery, Virginia Mason Medical Center, Seattle, WA INTRODUCTION: What impact does distal pancreatectomy have on pancreatic exocrine function? With the recent ability to measure human stool elastase-1 (HSE-1), the evaluation of exocrine insufficiency has become less complex and has a negative predictive value of almost 100%. Our studies have suggested that pancreatic insufficiency after pancreaticoduodenectomy is caused by exocrine atrophy from pancreatic cancer and/or parenchymal loss from resection. Our objective was to use HSE-1 to determine exocrine function after distal pancreatectomy (DP)—this has not previously been studied. METHODS: During a 65 month period (July 2002–November 2007), 100 patients underwent DP by the same surgeon. The pathologic tissue diagnosis and the amount of pancreas resected were recorded. Extent of resection was divided into two categories, those limited to the left of the portal vein (PV) and those extending to the PV or further. HSE-1 values were measured preoperatively in 68 patients and repeated at 3 ± 2 months, 12 ± 3 months, and 24 ± 6 months in 39, 19, and 9 patients, respectively. HSE-1 was expressed as abnormal at ≤200 µg/g stool. RESULTS: Preoperative HSE-1 values were abnormal in 19% of patients prior to undergoing DP (67% if chronic pancreatitis, 38% if pancreatic adenocarcinoma, and 11% in all other diseases; p < 0.001). Postoperative HSE-1 levels were then compared by the amount of pancreas resected. At three months after resection, HSE-1 was normal or became normal in all patients if resection was limited to the left of the PV, but in just 79% if resection extended to the PV (p = 0.03). At 12 months, normal HSE-1 was observed in 100% of patients if the resection was to the left of the PV and 88% if resection extended to the PV (p = 0.2). At 24 months, our limited results showed normal function in 100% of patients if the resection was to the left of the PV and 75% if resection extended to the PV (p = 0.2). In the subgroup with normal preoperative HSE-1 (81% of patients) whose resection was limited to the left of the PV, 100% had normal exocrine function at all timepoints. If the resection extended to the PV, 82% had normal exocrine function at three months (p = 0.09), while 100% had normal exocrine function at 12 and 24 months. CONCLUSION: Of patients undergoing DP, one-fifth will have pancreatic insufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis. Postoperative pancreatic insufficiency was seen only in those with resection that extended to the PV or beyond, and was transient. Exocrine insufficiency before and after DP is related to both the disease and the extent of resection, and can improve with time.

Poster of Distinction

324 6303_SSAT.book Page 325 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1741 Risk Factors for Pancreatic Leak Following Distal Pancreatectomy Hari Nathan*, Michael Choti, Christopher L. Wolfgang, C. Rory Goodwin, Akhil K. Seth, Jordan M. Winter, Edil H. Barish, Richard D. Schulick, Timothy M. Pawlik, John L. Cameron Surgery, Johns Hopkins University, Baltimore, MD BACKGROUND: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. We sought to evaluate the incidence of and identify risk factors for the development of PL in patients undergoing distal pancreatectomy (DP). METHODS: All patients who underwent primary DP (excluding completion pancreatectomy and debridement) between 1/1/1984 and 7/1/2006 were identiﬁed. Data on demographics, clinicopathologic features, operative details, complications, and mortality were analyzed. Chi-squared and multivariate logistic regression analyses were performed to identify risk factors for PL. RESULTS: In a cohort of 704 patients undergoing primary DP, the median age was 58 years, 45% were male, and 80% were white. The indications for DP were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). Splenectomy was performed in 89%. The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and both stapled and sutured in 9%. Duct ligation was performed in 22%. Perioperative mortality was <1%, but overall morbidity was 33%. PL requiring a change in clinical management was seen in 12% of cases. Development of PL was associated with an increase in perioperative mortality from 1% to 4% (P = 0.04) and an increase in median length of stay from 7 to 10 days (P < 0.001). Of those with PL, 35% required additional percutaneous drainage, but only 2% required reoperative intervention. Multivariate analysis revealed that malignant neoplasm (odds ratio (OR) 1.3, P = 0.29) and chronic pancreatitis (OR 1.6, P = 0.12) as indications for DP did not change PL risk as compared to benign neoplasm. However, increased risk of PL was seen when DP was performed for trauma (OR 6.2, P = 0.001) or pseudocyst (OR 3.3, P = 0.02). Tobacco use (OR 2.0, P < 0.001) was associated with increased PL risk, while preoperative diabetes was associated with decreased risk (OR 0.33, P = 0.003). Neither staple vs. suture closure of the pancreatic remnant (OR 1.4, P = 0.65) nor ligation of the pancreatic duct (OR 2.0, P = 0.05) affected PL risk. POSTER ABSTRACTS

CONCLUSIONS: This largest reported series of DP demonstrates that this TUESDAY procedure can be performed with low mortality but still carries a substantial risk of morbidity, particularly PL. DP in the trauma setting signiﬁcantly increases the risk of PL. In contrast to previous studies, PL risk was not associated with surgical management of the pancreatic remnant. These results emphasize the need for prospective randomized trials to evaluate strategies to reduce PL occurrence.

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T1742 Analysis of Organ Failure, Mortality and Pancreatic Necrosis in Patients with Severe Acute Pancreatitis Tercio De Campos*1,2, Cinara Cerqueira1, Laise Kuryura1, Silvia Solda1, Jacqueline Perlingeiro1, Jose C. Assef1, Samir Rasslan2,1 1Emergency Unit, Santa Casa School of Medical Sciences, São Paulo, Brazil; 2General Surgery, University of São Paulo, São Paulo, Brazil BACKGROUND: Mortality in severe acute pancreatitis varies from 10% to 20%. The early identification of patients with higher risk of complications is crucial to treat them properly. APACHE II is the most used scoring system to determine the severity of acute pancreatitis. However, some problems have been related, as the overestimation of severity, and other scores have been proposed, such as SOFA and Marshall. The aim of this study is to determine variables related to the development of organ failure, mortality and necrotizing pancreatitis in patients with severe acute pancreatitis. METHODS: Evaluation of all patients with acute pancreatitis admitted in this hospital, including in the analysis only patients with APACHE II > 8 at admission. SOFA score and Marshall score were also obtained. The variables analyzed were age, sex, aetiology, hematocrit, leukocytes, C-reactive protein, computerized tomography and length of stay. These variables were related with the development of organ failure, mortality and necrotizing pancreatitis. RESULTS: One hundred and seventy-five patients were admitted with acute pancreatitis, and 39 (22.3%) were classified as severe acute pancreatitis due to APACHE II >8. The mean APACHE II value was 11.6 ± 3.1, SOFA score 3.2 ± 2 and Marshall 1.5 ± 1.9. Respiratory failure was present in six (15.4%) patients with severe acute pancreatitis. Eleven patients developed necrotizing pancreatitis. Mortality of patients with APACHE II >8 was 7.7%. The variables related with organ failure were APACHE II, SOFA >3 and Marshall >3, and variables related with mortality were SOFA >3 and leukocytosis >19,000. C-reactive protein >19.5 mg/dl and length of stay were related to necrotizing pancreatitis. CONCLUSION: The scoring systems, particularly the SOFA score, are related to the development of organ failure and mortality. C-reactive protein demonstrates relationship with necrotizing pancreatitis. There is no relationship between scoring systems and necrotizing pancreatitis in severe acute pancreatitis.

326 6303_SSAT.book Page 327 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1743 Quality of Life in Long-Term Survivors After Pancreaticoduodenectomy Roberto Salvia, Stefano Crippa*, Francesca Mazzarella, Claudio Bassi, Stefano Partelli, Massimo Falconi, Giovanni Butturini, Paolo Pederzoli Department of Surgery, Università di Verona, Verona, Italy Few data are available with respect to quality of life (QoL) in long-term survivors after pancreaticoduodenectomy (PD). Aim of this study is to evaluate QoL and long-term outcomes in patients who underwent PD between 1990 and 2003 with a minimum follow-up of 48 months. Among 268 patients identified, 168 were still alive and were surveyed with the European Organi- zation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), and with an Institutional questionnaire on long- term complications. Of the 168 surviving patients, 109 (65%) agreed to parte- cipate at a median of 7.5 years postoperatively. Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 75% of cases; 56 patients (51.5%) had malignant neoplasms, 23 (21%) borderline tumors, and 30 (27.5%) benign neoplasms. Intraductal papillary mucinous neoplasms (IPMNs) was the most common indication for surgical resection (27.5%) followed by ductal adenocarcinoma (12%). Postoperative complications were recorded in 63 patients (58%). Overall, 75% of patients reported good scores in their perception of QoL. A significant decrease in QoL was found in patients with malignancy, with IPMNs, in survivors > 10 years, and in those with postoperative complications (P < 0.05). Despite no significant differences in overall QoL perception, Whipple resection was more frequetly associated with alterations of functional and symptomatic domains than PPPD. 55% of patients complained of steatorrhea, 40% of dumping syndrome, 54% of weight loss. Dumping syndrome is not associated with Whipple procedure, while weight loss was more frequently observed after pancreo-gastrostomy than pancreo- jejunostomy. New endocrine insufficiency was found in 17% of cases. Recur- rent abdominal pain was found in 41% of patients, who had also a significant impairment of QoL. PD is associated with acceptable QoL over time. However a careful long-term follow-up is necessary given the significant rate of exocrine insufficiency rate and impairments in digestive function. Patients who had complicated postoperative course, malignancies and who undewent PD with pancreogastric anastomosis are at higher risk of long-term complications and QoL impairments. POSTER ABSTRACTS TUESDAY

327 6303_SSAT.book Page 328 Tuesday, April 22, 2008 1:26 PM

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T1744 Intraoperative Assessment of Margin Status at the Time of Pancreaticoduodenectomy Ensures R0 Resection in Patients with Pancreatic Cancer Robert Yates*1, Kristian Wall1, Peter Muscarella2, E. Christopher Ellison2, Mark Bloomston1 1Surgical Oncology, Ohio State University, Columbus, OH; 2General Surgery, Ohio State University, Columbus, OH BACKGROUND: The utility of intraoperative assessment of surgical margins is often brought into question by experienced pancreatic surgeons. We sought to review our experience with pancreaticoduodenectomy for pancreatic cancer to determine the impact of frozen section (FS) on margin negative resection and long-term outcome. METHODS: Between 1992 and 2007, 310 patients underwent PD at our institution, 223 of these were for pancreatic cancer. Charts were reviewed to determine demographics, final pathology, perioperative course, and long- term outcome. Data were compared by Fisher’s Exact and Student’s T tests. Survival curves were created using the Kaplan-Meier method and compared by Log-rank analysis. Predictors of R0 resection were determined by logistic regression analysis and predictors of survival determined by Cox Proportional Hazards analysis. RESULTS: FS analysis of resection margins were obtained in 75 while no intraoperative assessment was done in 148. Although patients who underwent FS were younger (median 62 yrs vs. 67, p = 0.01), the two groups were similar in terms of gender, comorbidities, preoperative stenting, pylorus preservation, tumor differentiation, nodal status, T stage, tumor size, length of stay, and complication rate. Margin-negative resection was more common when FS was undertaken (99% vs. 70%, p < 0.0001). However, intraoperative FS did not significantly increase disease-free (median 17.3 months vs. 12.5, p = 0.12) or overall survival (median 21.7 vs. 14.6, p = 0.20). Nodal status and tumor grade were predictive of survival only in patients not undergoing FS. CONCLUSIONS: Intraoperative assessment of margin status at the time of pancreaticoduodenectomy for pancreatic cancer increases the likelihood of obtaining an R0 resection. Noteworthy is that final margin status was not predictive of survival, however. While nodal metastasis was predictive of poorer survival for the entire cohort, this effect was lost when frozen section was undertaken.

328 6303_SSAT.book Page 329 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1745 Surgical Drainage of Symptomatic Peripancreatic Fluid Collections in the Era of Endoscopic Management Luis A. Benavente-Chenhalls*1, Eduardo E. Montalvo-Jave3, Michael B. Farnell1, Michael G. Sarr1, Todd H. Baron2, Michael L. Kendrick1 1General Surgery, Mayo Clinic, Rochester, MN; 2Gastroenterology, Mayo Clinic, Rochester, MN; 3Gastroenterology Research Unit, Mayo Clinic, Rochester, MN BACKGROUND: With the advent of endoscopic drainage of symptomatic peripancreatic fluid collections (PPFC), the role of surgical intervention has decreased. Patients with complex, inaccessible collections or with prior unsuccessful drainage attempts account for an increasing proportion of those managed surgically. Our aim was to evaluate the morbidity, mortality and outcomes of the surgical management of symptomatic PPFC in this new era. METHODS: Retrospective review of all patients undergoing surgical management of benign, symptomatic PPFC from 1990 to 2006. RESULTS: Of 449 patients having undergone drainage procedures for PPFC, 105 (23%) had surgical drainage, comprising our study group. The mean age was 50 years (21–86), with 58% male. The mean interval from the first episode of pancreatitis to surgical intervention was 18 months. Surgical intervention was the primary treatment in 57%, or secondary after previous endoscopic (38%) or percutaneous (5%) attempts. The mean number of endoscopic procedures was 2.6 (1–14) and included transgastric (63%), transpapil- lary (27%), and transduodenal (7%) approaches. Operative intervention included cyst-enterostomy (47%), cyst-gastrostomy (31%), distal pancreatectomy (10%), external drainage (9%), lateral pancreaticojejunostomy (1%), and total pancreatectomy (1%). Evidence of peripancreatic necrosis at operation was evident in 8%. Major postoperative morbidity or perioperative mortality occurred in 41% and 0% respectively. Perioperative complications included infection-related complications (23%), anemia requiring transfusion (17%), pulmonary embolism (6%), pancreatic fistula (3%), and small bowel obstruction (3%). Perioperative ICU admission was necessary in 15%, with a mean ICU stay of 8 days (1–33). Perioperative reoperation for abdominal sepsis or hemorrhage was required in 4 patients. The mean hospital stay was 31 days (2–242). Recurrent pancreatitis or pseudocyst occurred in 17% and 9% respectively. POSTER ABSTRACTS CONCLUSION: Surgical drainage of PPFC is less commonly performed in the era of endoscopic drainage. Operative intervention in these select patients is TUESDAY associated with a high morbidity and may be attributed to increased disease complexity preventing endoscopic drainage attempts, or to complicating factors after attempted drainage.

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T1746 Estimation of Physiologic Ability and Surgical Stress (E-PASS) as a Predictor of Immediate Outcome After Pancreatic Surgery: The Score Needs to Be Adapted! Simone Deyle, Markus Wagner, Katrin Becker, Daniel Inderbitzin, Beat Gloor*, Daniel Candinas Visceral and Transplantation Surgery, Inselspital, University Bern, Bern, Switzerland OBJECTIVE: In-hospital mortality and major morbidity following pancreatic resections has dropped significantly over the past decade. Single factors such as preoperative jaundice or renal or hepatic co-morbidity have been found to be associated with a worse outcome in various studies. The Estima- tion of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient’s physiologic reserve capacity and the surgical stress may determine postoperative morbidity and mortality. The initial calculation of the E-PASS included among 1281 patients only 32 (2.4%) patients undergoing pancreaticoduodenectomy. Our aim was to review whether the E-PASS scoring system could be used without restrictions in elective pancreatic surgery as a means of correctly predicting morbidity and mortality. METHODS: Relevant data of all patients undergoing pancreatic surgery at our institution are entered in a prospectively recorded statistical database. E-PASS data items were computed retrospectively and operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The relationship of the CRS to the incidence of morbidity and mortality was retrospectively examined and Receiver operating characteristics (ROC curve) were calculated. RESULTS: Between January 2002 and October 2007 a total of 305 consecutive patients were operated on pancreatic lesions. Median age was 63 (range 18–86), median BMI was 24 kg/m2 (range 15–38). 198 patients underwent pancreatic head resections (65%), 58 distal resections (19%), 17 total pancreatectomies (5%) and 30 other types of resection (11%). There were 9 deaths (2.9%) and 105 patients (34.5%) had complications postoperatively. Mean CRS in the groups of patients who survived and died were 0.47 (±0.28) and 0.75 (±0.43), respectively (p < 0.01). PRS, SSS, and CRS all failed to predict mortality and morbidity as demonstrated by low areas under the ROC curve (range 0.500 to 0.595). Neither did CRS show a linear association with length of hospital stay. CONCLUSION: The E-PASS scoring system appears to be ineffective in predicting postoperative morbidity and mortality in patients undergoing elective pancreatic surgery. Thus, further refinements focusing on problems specific for patients undergoing pancreatic resections may be warranted in order to delineate differences in immediate surgical outcome.

330 6303_SSAT.book Page 331 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1747 Is Adjuvant Therapy Indicated After Pancreatectomy for Adenocarcinoma? Jonathan M. Hernandez*, Daniel Molloy, Jennifer C. Cooper, Carl B. Bowers, Sarah Cowgill, Steven B. Goldin, Alexander S. Rosemurgy Surgery, University of South Florida and Tampa General Hospital, Tampa, FL INTRODUCTION: Resection is the only hope of cure for patients with pancreatic cancer, though 5-year survival after resection remains dismal. With hope of improving survival, application of adjuvant therapy is intuitively rational. However, adjuvant therapy is applied to a minority of patients after pancreatectomy. The rationale of adjuvant therapy is disconnected from its application. This study was undertaken to assess the data supporting adjuvant therapy following pancreatectomy for adenocarcinoma. METHODS: The National Library of Medicine and the National Institutes of Health were searched for trials of adjuvant therapy after pancreatectomy for adenocarcinoma published since 1980. This search identified 191 trials; 10 were observation-controlled prospective randomized trials. Each trial was graded on its level of data utilizing a National Cancer Institute scale (best score of 1iA to worst score of 3iiiDiii). Methodological deficiencies, including inclusion of other cancers, excluded 7 trials from further review. Meta- analysis was applied to 3 observation-controlled prospective randomized trials of adjuvant therapy. Data collected from the trials included therapies utilized, median survival, 1-year, 2-year, and 5-year survival, and differences in survival by survival curve analysis (Table). Meta-analysis attests that there was not a significant advantage to adjuvant therapy during the first two years after resection, but that a survival advantage did become apparent by five years after resection (odds ratio = 2.291, 1.002–5.246, 95% CI). RESULTS: See Table CONCLUSIONS: There are few observation-controlled prospective randomized trials of adjuvant therapy following pancreatectomy for adenocarcinoma and very few withstand scrutiny. Though very few in numbers, together these trials assert that adjuvant therapy after pancreatectomy for adenocarcinoma improves long-term survival and should be applied. All patients undergoing pancreatectomy for adenocarcinoma should be considered for adjuvant therapy. POSTER ABSTRACTS Median Survival

No. 1-Year 2-Year 5-Year TUESDAY Author Therapy Grade Survival Curve Patients Survival Survival Survival (Months) Difference GITSG 5FU/XBRT5FU 1iiA 21 20 63% 42% 19% p = .03 GITSG Observation 22 11 49% 15% 8% Klinkenbijl 5 FU/XBRT 1iiA 60 17.1 68% 37% 20% p = .10 Klinkenbijl Observation 54 12.6 54% 23% 10% Oettle Gemcitabine 1iiD 179 22.1 72.5% 48% 23% p = .06 Oettle Observation 175 20.2 72.5% 42% 12%

Meta-analysis attests that there was not a significant advantage to adjuvant therapy during the first two years after resection, but that a survival advantage did become apparent by five years after resection (odds ratio = 2.291, 1.002–5.246, 95% CI).

331 6303_SSAT.book Page 332 Tuesday, April 22, 2008 1:26 PM

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Clinical: Small Bowel

T1748 Can Plain Abdominal X-Ray Predict the Need for Operation in Patients with Adhesive Small Bowel Obstruction? Nathan M. Novotny*1, Daniel A. Liesen2, Anthony Senagore3, Thomas Z. Hayward1, Don J. Selzer1, Robert E. Pennington1, Imtiaz A. Munshi1, Nicholas J. Zyromski1 1General Surgery, Indiana University, Indianapolis, IN; 2General Surgery, Medical University of Ohio, Toledo, OH; 3General Surgery, Michigan State University, Grand Rapids, MI BACKGROUND: The decision to operate on a patient with adhesive small bowel obstruction (SBO) is multifactorial. However, in an age of ubiquitous computed tomography scans, our hypothesis was that plain abdominal x-ray (AXR) alone can predict whether or not patients would eventually need laparotomy for definitive management of SBO. METHODS: Thirty patients’ acute abdominal series were selected for inclusion. All patients had adhesive SBO; patients with SBO due to cancer or hernia were excluded. Half of these patients underwent laparotomy, with intraoperative findings or pathology confirming the need for operative intervention. The others half were successfully managed conservatively. Long- term (>1 year) follow-up confirmed no subsequent readmission or operation for SBO. Sixteen general surgeons of varying experience were asked to predict need for laparotomy based solely on AXR findings. RESULTS: Surgeons’ overall accuracy in predicting the need for operation was 50%. (Table) Surgeons with 0–10, 11–20, and 21+ years post-residency had an accuracy of 37%, 50%, and 56% respectively. Compared to surgeons with 0–5 years experience, surgeons with 11–20 and 21+ years of experience were significantly more accurate (p = 0.029 and p = 0.003 respectively). Three patients needing laparotomy had high agreement among all surgeons with 88–94% accuracy. In each of these patients, surgeons identified degree of small bowel distention as the primary reason for predicting need for laparotomy. CONCLUSION: These data show that plain abdominal x-ray alone is still important in deciding which patient with adhesive SBO will require operative intervention. Experienced gastrointestinal surgeons (>11 years) are significantly more likely than junior surgeons (0–5 years) to predict the need for surgery based on AXR alone.

Table 1. Summary of Surgeons Responses with Breakdown by Experience (Years Post Training)

N Percent Correct (Mean, Range in Parentheses) Specificity Sensitivity All Surgeons 16 50% (30%–63%) 51% 49% Experience 0–5 years 3 37% (30%–43%) 36% 37% 11–20 years 7 50%* (43%–63%) 62% 43% 21+ years 6 56%* (47%–63%) 46% 63%

*p < 0.05 when compared to experience of 0–5 years

332 6303_SSAT.book Page 333 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1749 A Proposed Algorithm for Ventral Hernia Repair Optimizes Patient Outcome Judy Jin*, Christina P. Williams, Michael J. Rosen Surgery, University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: In ventral hernia repairs, no single approach can adequately treat the full spectrum of this disease. This study reports our initial experience using a management algorithm incorporating both laparoscopic and open techniques for the repair of all ventral hernias. METHODS: Patients undergoing ventral hernia repair by a single surgeon from August 2005 to August 2007 were reviewed. Complex non-infected cases underwent open retro-rectus prosthetic repair (OP). Infected or contaminated cases were repaired with biologic mesh after fascial reapproximation (OB). Massive ventral hernias with loss of abdominal domain underwent staged ePTFE serial excision (SE). All other cases were initially approached laparoscopically (LP). RESULTS: 123 patients (LP = 85, OP = 17, OB = 13, SE = 8) were identified during the period. Patient demographic information was similar in these groups in terms of age (p = 0.38), body mass index (p = 0.34), American Society of Anesthesiology score (p = 0.09), however, the number of prior laparotomies or failed hernia repairs was significantly less in the LP group (p < 0.0001). The LP group also had the smallest defect (145 cm2, range 6–720 cm2) when compared with OB (252 cm2, range 48–600 cm2), OP (450 cm2, range 32–1305 cm2) and SE group (584 cm2, range 264–1258 cm2) (p < 0.001). The conversion rate to open repair in the LP group was 11%, and was most commonly due to dense adhesions. Five enterotomies occurred intra-operatively (LP 2, OB 1, SE 2). The SE group had the longest hospital stay at 27 days (LP 4 day, OP 5 day, OB 9 day, p < 0.001). There was no perioperative mortality noted. The LP group had the lowest overall post operative complication rate (LP 12%, OP 35%, OB 46%, SE 63%, p = 0.0002) and a significantly lower wound infection rate (LP 5%, OP = 53%, OB 46%, SE 50%, p < 0.0001). One patient developed an infected seroma 10 months after a LP repair eventually requiring mesh resection. There were no recurrences in the LP and OP group while one recurrence each was identified in OB and SE group. CONCLUSION: This study demonstrates that a standardized approach to the management of ventral hernias can result in minimal post operative complications and low recurrence rate. In addition, the routine use of laparoscopic POSTER ABSTRACTS

ventral hernia repairs resulted in signiﬁcantly lower post operative wound TUESDAY complications without recurrences.

333 6303_SSAT.book Page 334 Tuesday, April 22, 2008 1:26 PM

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T1750 Laparoscopic Roux-en-Y Gastric Bypass in 400 Consecutive Patients Without Internal Hernia Richard S. Flint*, Thien K. Nguyen, David B. Lautz Surgery, Brigham & Women’s Hospital, Boston, MA BACKGROUND: Elevated rates of small bowel obstruction (SBO)and internal herniation have been reported following laparoscopic Roux-en-Y gastric bypass (LRYG). METHODS: We reviewed our series of LRYGB for the incidence of SBO or internal hernia. The medical records of 409 consecutive patients who underwent LYRGB from April 2004, through November 2007 were reviewed. All procedures were antegastric and antecolic LRYGB, with complete running closure of both mesenteric defects, including closure of the Petersen defect to the margin of the transverse colon. The main outcomes measure was readmission with the diagnosis of small bowel obstruction. RESULTS: 409 patients underwent LRYGB during the time period examined. 8 admissions for SBO in 7 patients (1.7%) were identified. Mean preoperative BMI was 48.9 ± 7.8 kg/m2. Median time to development of SBO was 5.5 (2–442, IQR = 53) days with 5 patients presenting within the first postoperative week. All SBO episodes required re-operation with small bowel resection necessary in 3 episodes (all port site hernias). The causes of SBO at exploration were umbilical port site hernia (n = 5), incarcerated ventral hernia from previous laparotomy (n = 2), adhesions (n = 1). No admissions for SBO with subsequent findings of internal hernia were identified. The mean excess body weight loss in this group was 55.0 ± 17.4% at 1 year. CONCLUSION: This study suggests that the incidence of small bowel obstruction secondary to internal herniation following antecolic LRYGB can be minimized by running closure of all mesenteric defects. Most small bowel obstructions in this series were secondary to fascial defects.

334 6303_SSAT.book Page 335 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Stomach

T1751 Surgical Therapy for Adenocarcinoma of the True Gastric Cardia Marcus Feith*1, Hubert J. Stein2 1Department of Surgery, Technische Universitaet Muenchen, Munich, Germany; 2Department of Surgery, University Salzburg, Salzburg, Austria BACKGROUND: The classification and the surgical management of patients with true cardia carcinoma of the esophago-gastric junction (AEG Type II according to Siewert’s classification) are still controversial. In the classification of these tumour entity the UICC guidelines for gastric or esophagus carcinoma is contrary used and a standard surgical approach is missing. A clear outline for the surgical technique is requested. METHODS: We investigated 532 consecutive resected patients with an AEG Type II, the classification according the UICC guidelines for gastric and esophageal carcinoma were used and the optimal surgical approach was reported.The tumour infiltration, lymph node and distant metastases, residual tumour and the long time outcome were evaluated. Statistical analysis with Kaplan-Meier-Survival and Cox regression analysis were performed. RESULTS: Of the 532 consecutive resected patients, in 379 (71.2%) a transhiatal extended gastrectomy, in 91 (17.1%) an esophagectomy, in 32 (6.0%) an esophago-gastrectomy, and in 30 (5.7%) a limited resection of the cardia were performed. The strictly indication for an esophagectomy or esophagogastrectomy in up to 23% of the patients were the preoperatively (endoscopy) or intraoperatively (biopsy) detected tumour infiltration of the distal esophagus or lymph node metastases in the mediastinum. The R0-resection rate was with all approaches greater than 74%. In early carcinoma, limited to the mucosa or submucosa, the limited resection of the cardia with oncological lymphadenectomy and reconstruction with pedicled jejunal graft showed optimal results in the long-time follow-up (R0-resection rate 100%, 5-year survival 96%).The operative complications, the radicalism of the procedures and the long time survival between gastrectomy and esophagectomy are not significant different (p > 0.05). For the evaluation of the prognostic outcome showed the UICC classification for gastric carcinoma in true cardia carcinoma

the better differentiation. POSTER ABSTRACTS CONCLUSION: The classiﬁcation and operative approach in true carcinoma TUESDAY of the cardia request an own regulation. With the inﬁltration of the distal esophagus an esophagectomy is oncologically required and results not in elevated complications or reduction of the long time prognosis.

335 6303_SSAT.book Page 336 Tuesday, April 22, 2008 1:26 PM

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T1752 Surgical Technique Affects the Incidence of Marginal Ulceration After Roux-en-Y Gastric Bypass Yong-Kwon Lee*, Jon S. Thompson, Valerie Shostrom, Corrigan L. Mcbride University Nebraska Medical Center, Omaha, NE BACKGROUND: Marginal ulceration (MU) is an increasingly recognized complication of Roux-en-Y gastric bypass (RYGBP) surgery. Several possible risk factors have been reported. However, the mechanism of this is poorly understood. The aim of this study is to compare the effect of surgical technique on the incidence of marginal ulceration. METHODS AND MATERIAL: This is a retrospective study of 752 patient undergoing RYGBP over a ten year period with at least 1 year of follow up. The diagnosis of MU was made based on clinical symptoms and conﬁrmed by endoscopy. We assessed four different RYGBP techniques (T1: Open, non- divided stomach, TA 90-B transverse, circular stapler, non-vagotomy; T2: Open, divided, GIA vertical, circular stapler, vagotomy; T3: Laparoscopic, divided, GIA, circular staple, vagotomy; T4: Laparoscopic, divided, GIA, linear stapler, vagotomy). Parameters evaluated included demographics, risk factors, number of post operative endoscopy (POE) and number MU. Incidence of MU was compared among groups using the log-rank test. RESULTS:

Table 1. Clinical Characteristics

Techniques T1 T2 T3 T4 Number of cases 334 91 152 175 Mean BMI (range) 51.8 (36–88) 52.2 (36–76) 52.1 (32–78) 50.8 (36–79) Mean age (range) years 47 (25–72) 44 (25–71) 44 (22–74) 46 (26–71) Gender (% of Female) 88.3 78 91.4 88.6 POE number (%) 54 (16.2) 23 (25.3) 43 (28.3) 48 (27.4) Number of Marginal Ulcer (%) 7 (2.1) 5 (5.5)* 23 (15.1)* 22 (12.6)

*p-value < 0.05 compared to T1.

CONCLUSION: The incidence of MU after RYGBP surgery is inﬂuenced by surgical technique. The overall 7.5% incidence of MU is consistent with other studies. The lowest incidence of MU was with a non-divided stomach, no vagotomy and transverse staple line. There was no difference in MU using linear or circular stapler for the gastrojejunostomy and no difference in laparoscopic versus open bypass if a similar technique was employed.

336 6303_SSAT.book Page 337 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1753 Results of Uncut Roux-En Y Reconstruction After Distal Gastrectomy for Gastric Cancer Chikashi Shibata*, Terutada Kobayashi, Tatsuya Ueno, Masayuki Kakyou, Makoto Kinouchi, Kouhei Fukushima, Iwao Sasaki Tohoku University School of Medicine, Sendai, Japan INTRODUCTION: Roux stasis syndrome occurs in 10–25% of patients after distal gastrectomy with Roux-en-Y (RY) reconstruction. Aim of the present study was to study clinical results of uncut RY reconstruction, proposed to eliminate Roux stasis, after distal gastrectomy for gastric cancer. PATIENTS AND METHODS: Thirteen patients with gastric cancer underwent distal gastrectomy with uncut RY reconstruction. Briefly, after distal stomach was removed, a side-to-side gastrojejunostomy was performed by anastomosing greater curvature of the remnant stomach and the jejunum 35 cm distal to the ligament of Treitz in an isoperistaltic direction. A side-to-side jejunojejunostomy was performed between the jejunum 20 cm distal to the ligament of Treitz and the jejunum 40 cm distal to the gastrojejunostomy. Finally, the jejunum 3 cm proximal to the gastrojejunostomy was enterically closed using “knifeless” linear stapler. Transmural silk stitches were added around the staples to prevent the dislocation of the staples. RESULTS: There were 9 male and 5 female patients, and their mean age was 65 (range: 47–88) years. Clinical stages according to Japanese classification of gastric carcinoma were IA for 4, IB for 7, and II for 2 patients. Degree of lymph node dissection according to Japanese classification of gastric carcinoma was D1+α for 2, D1+β for 4, and D2 for 7 patients. As additional procedures, cholecystectomy was carried out in 3 patients, and resection of the rectum for rectal cancer was done in 1 patient. Mean operative time and intraoperative blood loss were 246 (range: 157–452) minutes and 381 (range: 185–895) ml, respectively. Mean time until start of normal diet was 8.7 (range: 6–22) days, and mean time of postoperative hospital stay was 16.2 (range: 9–42) days. Morbidity was observed in three patients (aspiration pneumonia, delayed gastric emptying with nausea and vomiting, and leakage of the duodenal stump). Re-canalization of the jejunum at enterically closed site was investigated endoscopically or fluoroscopically; 2 patients had re- canalization, 6 patients were free from re-canalization, and remaining 5 patients are scheduled to undergo endoscopic examination. Two patients

having re-canalization did not complain of symptoms associated with POSTER ABSTRACTS re-canalization. TUESDAY CONCLUSIONS: These results indicate that uncut RY after distal gastrectomy was a safe procedure. Re-canalization of enterically closed portion did not cause speciﬁc symptoms associated with re-canalization.

337 6303_SSAT.book Page 338 Tuesday, April 22, 2008 1:26 PM

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T1754 Changes in Inflammatory Biomarkers Across Weight Classes in a Representative US Population: A Link Between Obesity and Inflammation Xuan-Mai T. Nguyen*, Marcelo W. Hinojosa, Brian R. Smith, Ninh T. Nguyen Univ of CA, Irvine Medical Center, Orange, CA BACKGROUND: Obesity has been linked with inflammation which may be involved in the early onset of metabolic syndrome, cardiovascular disease, nonalcoholic steatohepatitis, and even cancer. The objective of this study was to examine the association between body mass index (BMI) and levels of inflammatory biomarkers from men and women participating in the latest National Health and Nutrition Examination Survey (NHANES). METHODS: Serum concentrations of C-reactive protein (CRP) and fibrinogen were reviewed from US participants in the NHANES between 1999 and 2004. Biomarker levels were calculated across the different weight classes where normal weight, overweight, and obesity classes 1, 2 and 3 were defined as BMI of <25.0, 25.0–29.9, 30.0–34.9, 35.0–39.9, and >40.0, respectively. RESULTS: With increasing overweight and obesity class, there are direct linear increases in both the mean CRP and fibrinogen concentrations. With CRP levels of normal weight individuals as a reference, CRP levels nearly doubled with each increase in overweight and obesity class: +0.11 mg/dL (95% CI, 0.06–0.16) for overweight, +0.21 mg/dL (95% CI, 0.16–0.27) for obesity class 1, +0.43 mg/dL (95% CI, 0.26–0.61) for obesity class 2, and +0.73 mg/dL (95% CI, 0.55–0.90) for obesity class 3. In contrast to individuals with BMI <25.0, fibrinogen levels were highest among obesity class 3 with an increase by +93.5 mg/dL (95% CI, 72.9–114.1). CONCLUSIONS: Obesity is associated with a chronic inflammatory state which may contribute to the development of many obesity-related comorbidities. Our findings suggest that the optimal weight class to minimize inflammation should be within the normal range with a BMI <25.0. Further research is needed to determine whether weight reduction in obese individuals is associated with a reduction in inflammation.

338 6303_SSAT.book Page 339 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1755 Order of Placement Does Not Change Complication Rates for Patients with Concomitant Ventriculoperitoneal Shunt and Percutaneous Endoscopic Gastrostomy Nora C. Meenaghan*, Elizabeth Franco, Adrian E. Park, J. Scott Roth Department of Surgery, University of Maryland, Baltimore, MD Ventriculoperitoneal shunt (VPS) placement is a common neurosurgical procedure performed for the treatment of hydrocephalus. Patients requiring VPS due to acute stroke, intracerebral hemorrhage, or trauma often require enteral access as a result of their neurologic injury. Percutaneous endoscopic gastrostomy (PEG) placement is the most commonly utilized method of enteral access in these patients. VPS and PEG are often performed in a staged manner to minimize the risk of VPS infections. This study investigates what effect the order of VPS and PEG procedures has on the outcomes of patients requiring both. From a retrospective review of 749 patients who underwent PEG placement at a single institution between January 2002 and June 2007, patients who underwent both PEG and VPS were identiﬁed. Information regarding the order and timing of the two procedures, VPS complications, PEG complications, and demographic information were recorded. Results were analyzed using chi square test. Fifty-six (7.5%) patients underwent PEG and VPS. Nine- teen (34%) patients underwent VPS prior to PEG (VP-PEG). Thrity-seven (66%) underwent PEG prior to VPS (PEG-VP). Number of days between procedures ranged from 5 to 414 (mean = 41 days) for the VP-PEG group and from 5 to 1080 (mean = 75 days) for the PEG-VP group. VPS complications occurred in 2/19 (10.5%) of patients undergoing VP-PEG and 6/37 (16.2%) of PEG-VP patients (p = 0.56). CSF infection rates were 1/19 (5.3%) in the VP- PEG group and 2/37 (2.7%) in the PEG-VP (p = 0.62). The CSF infections in both groups were treated with antibiotics alone without shunt revision.In the VP-PEG group one patient required proximal shunt revision for clogged shunt. In the PEG-VP group, 5 patients developed obstruction, 4 required proximal shunt revision and one patient required revision of the abdominal portion of the shunt. PEG-related complications occurred in 0/19 of the VPS- PG group and 2/37 (5.4%) of the PEG-VP group (p = 0.30). Both of these patients had intolerance to gastric feeds.VPS and PEG may be safely performed in the same patient. When this is the case, the incidence of PEG complications and VP-shunt complications is similar to the reported incidence of these complications when either procedure is performed alone. Additionally, POSTER ABSTRACTS

the order of the procedures does not appear to impact outcomes and compli- TUESDAY cations for either the shunt or the PEG.

339 6303_SSAT.book Page 340 Tuesday, April 22, 2008 1:26 PM

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T1757 The Influence of Anastomotic Line Tumor Invasion and Mesenterial Lymph Node Metastases in Survival of Patients with Gastric Stump Cancer Claudio Bresciani*1, Ana L. Carrasco1, Rodrigo O. Perez1, Carlos E. Jacob1, Joaquim Gama-Rodrigues2, Bruno Zilberstein1, Ivan Cecconello1 1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil BACKGROUND: Gastric stump cancer may represent a malignancy with distinct clinical and pathological features due to the anatomical differences in lymphatic drainage determined by previous gastric resection. The presence of mesenteric lymph nodes metastases may not only difficult radical excision but also significantly affect survival of these patients. The purpose of this study was to determine the influence of anastomotic line invasion of the primary tumor and the risk of mesenteric lymph node metastases and survival. METHODS: Seventy-two patients with gastric stump cancer managed by radical surgery were retrospectively reviewed. Resected specimens were reas- sessed to correlate the presence of anastomotic line (AL) tumor invasion with the presence of perigastric or mesenteric lymph node metastases and with survival. RESULTS: Overall, 54 patients had AL+ tumors. Of these, 66% had any lymph node metastases and 9% had mesenteric lymph node metastases. There was no correlation between the presence of AL+ and the risk of any or mesenteric lymph node metastases (p = 0.5). Survival was significantly worse for patients with any lymph node metastases and for patients with mesenteric lymph node metastases (p < 0.001 and p = 0.003 respectively). Anasto- motic line invasion had no significant impact on survival (p > 0.05). CONCLUSIONS: Anastomotic line tumor invasion is not a risk factor for mesenterial lymph node metastases and is not prognostic factor after radical surgery for gastric stump cancer. Lymph node metastases remains an independent and significant poor prognostic factor in gastric stump cancer.

340 6303_SSAT.book Page 341 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1758 Duodenal Bypass in Lean Individuals Do Not Decrease Glucose Levels Ana C. Tineli*, Fernando A. Herbella, Jorge L. Wilson, Jose C. Del Grande Department of Surgery, Federal University of São Paulo, São Paulo, Brazil BACKGROUND: It has been suggested that bariatric operations can control diabetes irrespective of weight loss. Change in glucose metabolism is credited to duodenal bypass and consequent variation in digestive hormones levels. This study aims to evaluate the effect of duodenal bypass on glucose levels in lean individuals submitted to gastrectomy for gastric cancer. METHODS: We reviewed 56 patients (36 males, mean age 61 years) submitted to gastrectomy and Roux-en-Y reconstruction for gastric cancer between January, 2000 to July, 2006. Partial gastrectomy was the operative approach in 37 (66%) patients and total gastrectomy in 19 (34%). Patients were excluded if obese (BMI > 30), diabetic, submitted to palliative surgery, or with a follow- up lower than 1 month. Six patients with the diagnosis of diabetes mellitus were studied separately (2 treated with insulin, 4 with oral medication). Glu- cose levels were measured the day before operation in all patients but did not follow specific clinical protocols after the operation. RESULTS: Glucose levels were not significantly altered after operation, p = 0.5 (table 1). There was no correlations between glucose level and time of follow-up for the whole population (r = 0.0002), partial gastrectomy (r = 0.0001) or total gastrectomy (r = 0.0042) (figure 1). Diabetes control was improved in 1 patient with oral medication (decrease in dosage). CONCLUSION: Duodenal bypass in lean individuals treated for gastric cancer do not decrease glucose levels.

Time (months) 0 1–6 7–12 13–18 19–24 24–36 37–48 >48 Glucose Level mg/dL (median) 99 94 94 90 93 96 91 102 POSTER ABSTRACTS TUESDAY

341 6303_SSAT.book Page 342 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

T1759 Use of Polypropylene Mesh for Laparoscopic Adjustable Gastric Banding (LAGB) Allows for Minimum Post-Op Pain with No Narcotic Usage and Less Pain for Adjustments Carson D. Liu1, Leonierose Dacuycuy*2,1 1Surgery, SkyLex Advanced Surgical Inc., Los Angeles, CA; 2Medicine, Boston University, Boston, MA INTRODUCTION: Outpatient bariatric surgery is a viable option for patients thinking about weight loss surgery. We describe our technique of 960 patients who have undergone Laparoscopic Adjustable Gastric Banding (LAGB) without using fixating sutures at the port. The implantation of polypropylene mesh allows for very little post-op pain and the lack of narcotics use postoperatively. Patients who had LAGB and mesh implantation experienced minimal pain without the need for admission to a hospital inpatient setting. METHODS: All patients undergoing LAGB underwent implantation of mesh sewn to the posterior aspect of the port device. Polypropylene mesh was placed over the 15 mm trocar site with coverage of the fascial defect. Prolene sutures were used to sew the hernia mesh to the port device. The port was placed in a superficial subcutaneous pocket to allow for easier access of port. RESULTS: Two patients out of 960 had a peri-port infection requiring resiting of port. All other patients did not require narcotic pain medications to control post-op pain. Patients tolerated liquid acetaminophen for pain control in the post-op pain. CONCLUSION: Implantation of mesh at the port site allows for removal of all post-op pain and the ability to remove all post-op narcotics. The use of non-narcotic pain medication decreases nausea and dysphoria after surgery. Patients also had all lap band adjustments under local anesthesia in a clinic setting as the port was easier to palpate in the more superficial position. The mesh prevents rotation of the port which has been reported as a common problem with LAGB.

342 6303_SSAT.book Page 343 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

BASIC SCIENCE POSTERS

Basic: Biliary

T1901 Systemic Inflammatory Response After Natural Orifice Translumenal Surgery: Transvaginal Cholecystectomy in Porcine Model Daniel K. Tong*, Joe Fan, Simon Law, Wai-Lun Law Univ of Hong Kong, Queen Mary Hosp, Hong Kong, China BACKGROUND: In the development of laparoscopic surgery, tremendous research was performed to address the immunological and inflammatory response following laparoscopy. Theoretically, with the lesser degree of trauma induced by NOTES, less perioperative proinflammatory response would be expected. In the current study, we aimed to study the systemic inflammatory responses associated with transvaginal cholecystectomy in porcine model. OBJECTIVE: To study circulating TNF-α and IL-6 after transvaginal Chole- cystectomy in porcine model. METHODS: Six female pigs were used for survival study after transvaginal cholecystectomy using endoscopic submucosal dissection (ESD) instruments and single channel endoscope. Blood was drawn pre-operatively and within 24 to 48 hours post-operatively. Another four pigs were used as control without intervention. Circulating serum TNF-α and IL-6 were measured 24–48 hours after the operation. RESULTS: In all six pigs in the treatment group, no major intra-operative complication occurred. The median post-operative TNF–α level for control group was 65.97 pg/ml (range 52.75–80.78 pg/ml) whereas transvaginal cholecystectomy group was 66.35 pg/ml (range 40.23–71.65 pg/ml). With Mann-Whitney test, there was no significant difference between 2 groups (p = 0.67). In addition, there was no significant difference between IL-6 level in operated group and control group with the mean of 57.04 pg/ml to 51.22 pg/ml (p = 0.45; Mann-Whitney test) with range of 49.47–93.78 pg/ml and 49.5–102.01 pg/ml respectively. CONCLUSIONS: NOTES is safe in animal models in terms of anatomical and POSTER ABSTRACTS

cellular level with minimal systemic inﬂammatory host responses elicited. TUESDAY Further study need to be carried out in human before generalization as daily routines.

343 6303_SSAT.book Page 344 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Colon-Rectal

T1902 Curcumin Inhibits the Mammalian Target of Rapamycin Subunits Rictor and Raptor in Colon Cancer Cells Sara M. Johnson*1, B. M. Evers1,2 1Department of Surgery, UTMB, Galveston, TX; 2Sealy Center for Cancer Cell Biology, UTMB, Galveston, TX INTRODUCTION: Curcumin, a plant polyphenol derived from the spice tur- meric, possesses anti-cancer and anti-inflammatory properties, and can be safely ingested with a low toxicity profile. Curcumin decreases cellular proliferation by inhibiting a variety of molecular targets, including Akt, a downstream effector of phosphatidylinositol 3-kinase (PI3K). However, the effects of curcumin on the related growth and survival signal, mammalian target of rapamycin (mTOR), have not been investigated in colon cancer cells. The purpose of this study was to: (i) determine the sensitivity of certain colon cancer cells to the antiproliferative effects of curcumin, and (ii) examine the effects of curcumin on the PI3K-mTOR pathway. METHODS: (i) Human colon cancer cells HT29 and KM20 were treated with varying doses of curcumin (10–200 µM) for 24, 48, or 72 h and cell proliferation was measured. (ii) Cytotoxicity was assessed using a colorimetric assay for lactate dehydrogenase (LDH), which is released from cells when their plasma membrane is damaged. (iii) Western blotting was used to detect changes in protein expression of the epidermal growth factor receptor (EGFR), PI3K catalytic and regulatory subunits (p110α and p85α, respectively), phosphorylated Akt, phosphorylated mTOR, raptor and rictor (subunits required for assembly of mTOR complexes 1 and 2, respectively), p70S6K, and 4EBP1. RESULTS: (i) Cell viability after 48 h of treatment with a moderate dose of curcumin (25 µM) was 32% and 75% in KM20 and HT29 cells, respectively. (ii) Cytotoxicity after 16 h treatment with curcumin (50 µM), was 120% for KM20 and 5% for HT29 cells. (iii) Expression of mTOR, rictor and raptor subunits was decreased after 2 h treatment with low doses of curcumin (5–20 µM). Protein expression of EGFR and the PI3K subunits was decreased after overnight treatment with high-dose curcumin (100 µM). Expression of pAkt, p70S6K and 4EBP1 was also decreased in most cells after curcumin treatment. CONCLUSIONS: We show, for the first time, that curcumin decreases protein expression of raptor and rictor, proteins required for the assembly of mTOR complexes 1 and 2. The inhibition of mTOR and PI3K subunits by curcumin, in addition to its established effects on Akt activation, is likely to contribute to the anticancer activity in colorectal cancer.

Poster of Distinction

344 6303_SSAT.book Page 345 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1903 Increased Expression of Pontin in Human Colorectal Cancer Tissue Johannes C. Lauscher*1, Jörn Gröne1, Christoph Loddenkemper2, Heinz J. Buhr1, Hubert G. Hotz1, Otmar Huber3 1Department of General Surgery, Charite, Berlin, Germany; 2Department of Pathology, Charite Universitaetsmedizin, Berlin, Germany; 3Department of Laboratory Medicine and Pathobiochemistry, Charite Universitaetsmedizin, Berlin, Germany INTRODUCTION: Development of colorectal carcinomas is often caused by dysregulation of the wnt pathway, which plays a fundamental role in cell growth and differentiation. By interacting with beta-catenin, pontin (also known as TIP49a) enhances the transcriptional activity of the LEF-1/TCF/ beta-catenin-complex in wnt pathway. The aim of our study was the evaluation of a possible involvement of pontin in the pathogenesis of colorectal carcinoma (CRC). PATIENTS AND METHODS: Immunhistochemical staining of pontin and beta-catenin on parafﬁn slides from colorectal cancer tissue and corresponding normal mucosa of 52 patients with CRC was followed by semiquantita- tive evaluation by two examiners and western blot analysis of pontin in cancer and normal tissue. Correlation with clinical and pathological data (age, sex, tumor localization, UICC-stage, grading, histological subtype) was done. RESULTS: Pontin staining was stronger in tumor tissue than in normal tissue in 86.8% of cases and equal in 13.2% of cases. In every case more than 76% of tumor cells showed cytoplasmatic pontin expression. In 29/52 (55.8%), nuclear staining in tumor tissue was observed (10–80% of nuclei were stained); whereas there was no nuclear staining in normal tissue. In 32.7% of cases we found a stronger and in 67.4% an equal staining of the invasive margin vs. tumor center; in dissociating tumor cells (tumor buds) in 32.6% a stronger and in 67.4% of cases an equal staining vs. tumor center was detected. In the subgroup of undifferentiated carcinomas (G4) (n = 18), we detected a higher percentage of nuclear expression (66.7%) vs. 50% in well to badly differentiated adeno carcinomas. Intensity of staining in undifferentiated carcinomas was at least moderate in 66.7% of cases vs. 47.1% in the rest of colon carcinomas. Pontin showed a co-expression with beta-catenin in nuclear staining, in the invasive margin and in tumor buds. In 8 patients a 4- 8-fold increase of pontin-expression in tumor tissue vs. normal tissue was POSTER ABSTRACTS

detected by western blot. TUESDAY CONCLUSION: This is the ﬁrst study revealing an enhanced pontin expression in human colorectal cancer tissue and the co-expression of pontin with beta-catenin as a key player in wnt signaling. By enhancing the transcriptional activity of the LEF-1/TCF/beta-catenin-transcriptional complex pontin may inﬂuence the control of proliferation in colorectal carcinoma and may have oncogenic potential by enhanced expression in colorectal cancer tissue. Pontin is a possible diagnostic marker and therapeutic target for colorectal cancer.

345 6303_SSAT.book Page 346 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

T1904 Human Acute Immune Response to Colon and Rectal Surgery: Comparison Between Open, Laparoscopic and Hand Assisted Resection Laurie S. Norcross*1,3, Melissa Donigan2,4, John Aversa1,3, Paul Williamson1,3, Samuel Dejesus1,3, Renee Mueller1,2, Andrea Ferrara1,3, Cheryl H. Baker2,4, Joseph T. Gallagher1,3 1Colon and Rectal Cancer, Colon and Rectal Clinic of Orlando, Orlando, FL; 2Cancer Research Institute, MD Anderson Orlando, Orlando, FL; 3Sugery, Orlando Regional Hospital System, Orlando, FL; 4Burnum School of Medical Sciences, Univ of Central Florida, Orlando, FL BACKGROUND: Cytokine levels in the serum, blood and tissue may be predictive of the degree of stress perceived by patients undergoing major abdominal surgery and may impact cancer related outcomes. Inflammatory response to trauma includes IL-1b, IL-6, and TNFa in varying levels. Furthermore, alterations in circulating proteins VEGF and PDGF could directly stimulate tumor growth in cancer patients. We hypothesize the surgery-related differences in IL-6, and TNF-α will correlate with the degree of surgical trauma. Therefore, this study will compare the differences in cytokine/protein levels between patients undergoing hand-assisted laparoscopy, laparoscopy, and laparotomy. METHODS: Patients presenting to a private practice for colon resection were included as possible participants. Because the majority of immunologic alterations that occur following major surgery are not diagnosis related, this study includes patients with both benign and malignant conditions. Specific exclusion diagnoses included active acute diverticulitis, inflammatory bowel disease and hematologic disorders. Blood draws were performed in pre-operative holding and post-operative times of 4 hours, 24 hours, and 48 hours. Serum was evaluated for levels of IL-6, IL-1β, TNF-α, VEGF and PDGF-A using standard ELISA procedures and analyzed by ANOVA 2-way statistical analysis. RESULTS: Data evaluates ten open, nine hand assist and seven laparoscopic cases. In all three surgical techniques, serum levels of IL-6 are significantly different between the pre-operative time point and 4 hours post surgery (p = 0.07). At 4 hours post surgery the TNF–α levels are lower in the laparoscopic patients as compared to those who received hand-assisted or open surgery. There is no change in the post-operative trend of IL-1β in all three surgical techniques. The VEGF serum levels significantly decreased 48 hours post surgery only in laparoscopic patients (p = 0.007). Interestingly, serum levels of PDGF-A are increased at 4 hours post surgery in patients undergoing open surgery when compared to both minimally invasive techniques. CONCLUSION: The data suggest an immunological benefit to patients undergoing laparoscopic large bowel resection as compared to laparotomy. There is a trend toward similar benefits in hand-assisted laparoscopy. Clearly, these results warrant more investigation as we continue to accrue patients for all three surgical techniques.

346 6303_SSAT.book Page 347 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1905 Src Kinase Inhibition May Inhibit Experimental Cancer Metastasis Njwen Anyangwe*, David H. Craig, Jochem Van Der Voort Van Zyp, Marc D. Basson Department of Surgery, Wayne State University School of Medicine and John D. Dingell VAMC, Detroit, MI Acutely increased extracellular pressure stimulates cancer cell adhesion to matrix proteins or endothelial cells via Src. We hypothesized that extracellular pressure might be chronically increased in rapidly growing tumors, and that such chronic pressure might similarly activate the metastatic potential of shed cancer cells via Src. We first measured interstitial pressure adjacent to and within human cancers undergoing percutaneous image-guided biopsy using a coaxial needle. Interstitial pressure in human cancers was on average 17 mmHg higher than interstitial pressure outside the tumors (n = 11, p < 0.05). Co26 murine colon cancer cells (105 cells/mL) were then exposed to ambient or 15 mmHg increased pressure for 30 minutes without or with the Src antagonist PP2 (20 µM), and seeded into murine surgical wounds for 30 minutes before non-adherent cells were washed away and the wounds were closed. We measured time to palpable tumor and time to 100 mg tumor in 2 independent studies over 160 and 90 days. In the first study, pressure pretreatment of the cancer cells caused palpable tumors in 80.6% of mice vs. 47.2% for controls. (n = 67, p < 0.001) Time to 100 mg tumor paralleled time to palpable tumor. We then blocked Src in some cells with 20 uM PP2. Pres- sure again promoted tumor formation by vehicle control cells (67% vs 49% at ambient pressure, n = 47, p < 0.04). However, PP2 not only blocked the pro- motion of tumor formation by pressure, but reduced tumor formation by pressure-treated cells even below untreated ambient pressure controls (34% in the PP2 and pressure group vs. 54% in the untreated ambient pressure control, n = 47, p < 0.05). Because PP2 inhibits 9 Src-related kinases, we reduced Src by specific siRNA in human SW620 colon cancer cells to prove Src was the key target. Increased pressure for 48 hrs stimulated subsequent SW620 adhesion under ambient pressure (511 + 21 cells/HPF) compared to cells maintained for 48 hrs at ambient pressure (392 + 16 cells/HPF, n = 42, P < 0.0001). Maintaining the increased pressure during the adhesion assay further increased adhesion (595 + 30 cells/HPF, n = 42, P < 0.001). siRNA-reduction of Src by 67 + 8% (p < 0.003) not only prevented stimulation of adhesion by 48 hrs of increased pressure but actually inhibited adhesion 46 + 7% vs. pressure- treated cells transfected with non-targeting control siRNA (n = 60, p < 0.01). POSTER ABSTRACTS Pressure-activated Src signaling may stimulate metastatic tumor formation in TUESDAY vivo, and mask a second counterregulatory pathway which inhibits adhesion. Src blockade may unmask this counterregulatory pathway and inhibit the stimulation of cancer cell metastatic potential by increased pressure within rapidly growing tumors.

Poster of Distinction

347 6303_SSAT.book Page 348 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

T1906 CD8+ T Cell Infiltration and Cancer Recrurrence in Squamous Cell Cancer of the Anus Sonia Ramamoorthy*1, Katsumi N. Miyai1,2, Linda Luo1, John M. Carethers1,2 1UCSD, San Diego, CA; 2VA San Diego, San Diego, CA BACKGROUND: The prognosis of patients with squamous cell cancer of the anus is most dependent on tumor staging and histopathology. Recent evidence suggests that the adaptive immune response, represented by T cells, is important in predicting clinical outcome in colon and other cancers. CD8+ T cells are a subpopulation of cytotoxic immune cells that have the potential to respond to and kill cancer cells. In this study, we correlated CD8+ T cell tumor infiltration with histopathology, HIV and HPV status, and anal cancer recurrence. METHODS: Archived, formalin-fixed tissues from 16 cases of squamous cell cancer of the anus were analyzed for CD8+ T cell infiltration using an anti- CD8 antibody. High-power microscope images were taken of the tumor with CD8+ cells counted by two observers. Tumors were called high infiltration if >150 CD8+ cells/HPF, low infiltration if <10 CD8+cells/HPF, and medium infiltration if >10 and <150 CD8+ cells/HPF. Each case was reviewed for histopathologic grade of tumor (well, moderate or poorly differentiated). This data was then correlated with retrospective clinical data on HIV status, and cancer recurrence after IRB approval was obtained. RESULTS: Of the sixteen cases of anal cancer included in the study, the histopathology showed: well-differentiated 4/16 (25%), moderately-differentiated 7/16 (44%) and poorly-differentiated 5/16 (31%). HIV was documented in 7/16 (44%) of cases. The overall recurrence rate in this population was 6/16 (37%). High CD8+ T cell infiltration was seen in 6/16 (37%) of cases, medium 4/16 (31%), and low infiltration in 6/16 (38%) of cases. There was a significant correlation between high CD8+ T cell infiltration and well to moderately differentiated tumors and between low CD8+ T cell infiltration and poorly differentiated tumors (p < 0.05). Of the patients with cancer recurrence two- thirds had low CD8+ T cell infiltration (p < 0.05). Of the seven patients in our cohort that were HIV positive, 70% of these patients had low CD8+ T cell infiltration (p < 0.05). CONCLUSIONS: There is a strong correlation of infiltrating CD8+ T cells with anal cancer tumors and histopathologic diagnosis, HIV status and cancer recurrence. The CD8+ T cell infiltration may confer part of the improved survival observed in HIV negative patients and in those patients with tumors that are well to moderately differentiated.

348 6303_SSAT.book Page 349 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Esophageal

T1907 Inhibition of YB-1 as a Novel Approach to Decrease the Expression of EGFR, HER-2 and IGF-1R in Esophageal Cancer Sabrina Thieltges*1, Tanya Kalinina1, Uta Reichelt2, Jussuf T. Kaifi1, Yogesh K. Vashist1, Paulus G. Schurr1, Peter R. Mertens3, Ronald Simon2, Jakob R. Izbicki1, Emre F. Yekebas1 1Department of General-, Visceral- and Thoracic Surgery, University Hospital Hamburg- Eppendorf, Hamburg, Germany; 2Department of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; 3Department of Nephrology and Immunology, University Hospital Aachen, Aachen, Germany The Y-box binding protein-1 (YB-1) is an oncogenic transcription factor that is highly expressed in many malignant tissues, including cancers of the breast, non-small cell lung cancer, ovarian adenocarcinoma and prostata cancer. Although these findings suggest an involvement of YB-1 in the progression of malignancies, so far no data as to its role in esophageal cancer (EC) are available. Different molecular profiling studies have identified HER-2, Epider- mal Growth Factor Receptor (EGFR) and Insulin-like-Growth-Factor I Recep- tor (IGF-IR) as important co-factors in tumor progression. Inhibition of YB-1 leads to suppression of EGFR and HER-2 in breast cancer. Also, EGFR, IGF-IR and HER-2 are highly expressed in EC and associated with tumor growth and poor survival. The aim of this study was to evaluate the impact of YB-1 in EC and its influence on different protein tyrosine kinase receptor expression. For this reason, a tumor tissue microarray (TMA) was constructed from 293 primary ECs (130 adenocarcinomas and 163 squamous cell carcinomas), 146 corresponding lymph nodes and 47 distant metastases. The TMA slides were analysed by immunhistochemistry for YB-1 expression. YB-1 was not detected in control tissues, including normal esophageal tissue. Overexpres- sion of YB-1 was seen in 141/276 cases (51.1%) without difference between adeno- and squamous cell carcinoma. There was a 67% concordance of YB-1 positivity in primary tumors and corresponding lymph node (p = 0.34) and metastasis (p = 0.07). Nevertheless, no significant relationship between YB-1 expression and survival was seen. YB-1 was simultaneously expressed with IGF-1R, EGFR and proliferation marker Ki67. The Fishers exact test showed that coexpression was significant. In 51% of patients YB-1 and HER-2 were coexpressed. A synergistic growth inhibition was shown by IGF-IR and HER-2

co-targeting in EC cell lines. These results suggest that YB-1 can transcription- POSTER ABSTRACTS ally induce EGFR, IGF-1R and HER-2. Using three different EC cell lines including one lymph node metastasis cell line, downregulation of endoge- TUESDAY nous YB-1 led to a reduction of proliferation of EC cell growth of more than 50%. Ongoing experiments knocking down YB-1 will clarify its interference with protein tyrosine kinase receptor expression. EGFR, HER-2 and IGF-1R are essential for EC tumor growth and progression. Targeting YB-1 is an attractive approach to inhibit simultaneously the expression of most important growth factor receptors. Therefore, YB-1 could be a novel therapeutic target for esophageal tumor suppression.

Poster of Distinction

349 6303_SSAT.book Page 350 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

T1908 Gene Polymorphisms of ERCC1 Predict Response to Neoadjuvant Radiochemotherapy in Esophageal Cancer Ralf Metzger*, Ute Warnecke-Eberz, Elfriede Bollschweiler, Daniel Vallbohmer, Jan Brabender, Arnulf H. Hoelscher Department of Surgery, University of Cologne, Cologne, Germany PURPOSE: Neoadjuvant treatment strategies have been developed to improve survival of patients with locally advanced esophageal cancer. Since only patients with major histopathological response benefit from this treatment, predictive markers indicating response or non-response would be needed. We examined the gene polymorphisms of ERCC1 to predict response to neoadjuvant radiochemotherapy (cis-platin, 5-FU,36 Gy) of patients with advanced esophageal cancer. PATIENTS AND METHODS: For analysis of single nucleotide polymorphisms (SNPs) genomic DNA was extracted from paraffin-embedded tissues of 52 patients. Allelic discrimination was performed by quantitative real-time PCR. Two allele-specific TaqMan probes in competition were used for amplification of ERCC1. Allelic genotyping was correlated with therapy response. RESULTS: ERCC1 SNP A/G (rs11615) was predictive for therapy response (p < 0.003). Within the AA genotype group of 25 patients 20 (80%) did not respond to chemoradiation, whereas 14 patients (70%) of 20 patients with the heterogenous A/G genotype were major responders. The GG genotype comprising 7 patients was not of predictive importance. The ERCC1 polymorphism was significantly (p < 0.02) associated with formation of lymph node metastases. CONCLUSION: Our data strongly support the role of ERCC1 as a predictive marker for therapy response. Single nucleotide polymorphisms of ERCC1 could be applied to further individualize treatment of patients with locally advanced esophageal cancer.

Poster of Distinction

350 6303_SSAT.book Page 351 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1909 Successful Evaluation of a New Animal Model Using Mice for Esophageal Adenocarcinoma Joerg Theisen*, Matthias C. Raggi, Helmut Friess Department of Surgery, TU Munich, Munich, Germany INTRODUCTION: For the better understanding of the pathophysiological events occurring in the sequence inflamation-metaplasia-carcinoma in esophageal adenocarcinoma established rat model have been used in the past. In order to study theses events on a molecular level mouse models would be desirable. This has not been successful in the past due to the high mortality involved. METHODS: Thirty BALB-C mice weighing between 22–25g underwent a esophago-jejunostomy as previously described in the rat model. After euthanisation between weeks 24 and 30 the esophgogastric junction and the esophagus were harvested and analysed histopathologically. RESULTS: Overall mortality was high with 33%, but these fatal outcomes happened during the first 10 animals. After that only 2 animals died due to the procedure. In 18 out of the 20 analysed animals a carcinoma was found just above the anastomosis, histologically an adenocarcinoma. All animals showed a severe esophagitis indicating a profound reflux. One animal demonstrated diffuse lung metastasis. CONCLUSION: These results demonstrate for the first time the feasibility of a mouse model for esophageal adenocarcinoma. However, a significant learning curve has to be expected when attempting these procedures. POSTER ABSTRACTS TUESDAY

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Hepatic

T1910 Postconditioning in Liver Ischemia-Reperfusion Injury Roberto Teixeira*, Nilza Molan, Marcia S. Kubrusly, Marta Privato, Ana Maria M. Coelho, Telesforo Bacchella, Marcel C. Machado University of São Paulo, São Paulo, Brazil INTRODUCTION: Liver ischemia-reperfusion injury (LIRI) is a process present in several events like liver resections, transplantation, shock and sepsis. Ischemia-reperfusion injury is a complex cascade of interactions that results in alteration of many different organs. The restoration of blood ﬂow may lead to local and sistemic injury. Several techniques have been developed in order to avoid or ameliorate LIRI in clinical situations. Precondition- ing, intermittent vascular occlusion, anti TNF-alpha and antioxidants have been tested with limited clinical results. Postconditioning is the application of a gradual, staged or stutter reperfusion after the ischemic lesion. Postcondi- tioning alters the hydrodynamics of early reperfusion and stimulates endogenous mechanisms that attenuate the reperfusion injury. OBJECTIVE: To evaluate the local and systemic potential protective effect of postconditioning in liver ischemia-reperfusion injury in rats. METHODS: Hepatic anterior pedicle of median and left anterolateral segments were exposed and clamped with an atraumatic vascular bulldog clamp for one hour. Two hours later, clamp was released in two different ways: Con- trol Group (n = 7): clamp was release straightforward; Postconditioning Group (n = 6): clamp was released intermittently, in 5 periods of 5 seconds open, followed of 5 seconds of closure. Hepatic liver enzymes, serum TNF-α and interleukins, pulmonary myeloperoxidase, malondialdehyde (MDA) and GST-α3 gene expression were studied. RESULTS: There was no signiﬁcant difference for all analysis between control and postconditioning groups except for MDA analysis. Lipidic peroxida- tion was reduced in the ischemic and non-ischemic liver by postconditioning. CONCLUSION: Postconditioning reduces LIRI in the ischemic and non- ischemic liver in this model. This protective action is independent of cytokines and TNF production. Further studies will be addressed to clarify this issue.

352 6303_SSAT.book Page 353 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1911 Reversibility of Liver Fibrogenesis in Mice: STI571 Inhibit the Activation of Hepatic Stellate Cells Ming-Chin Yu*, Miin-Fu Chen, Tsung-Han Wu, Chi-Neu Tsai, Wei-Chen Lee, Yi-Yin Jan Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan PURPOSE: Hepatic stellate cells (HSC), known as Ito cells, are important cells in the hepatic fibrogenesis. Through activation, HSCs transdifferentiate to myofibroblasts and produce extracellular matrix and induce tissue remodel- ing. The aim of this study is to inhibit the activation of HSC by STI571 to treat liver cirrhosis in mice. MATERIALS AND METHODS: C3H mice were treated with CCl4 2.0 gm/kg two times per week for 6 weeks. STI571 was used to treat mice by intra-peritoneal injection for one week. Four groups were designed: (1) no treatment, (2) with STI571, (3) CCl4 treatment, and (4) both CCl4 and STI-571). The mice were euthanized to check the histology and liver proliferation. POSTER ABSTRACTS TUESDAY RESULTS: STI571 has good antifibrotic effect in HE and Trichrome staining. This is also demonstrated in SMA immunohistochemistry. The apoptosis staining showed more positive in CCl4 group (3). In primary cell culture, HSCs showed lower proliferation activity with STI571 treatment and the cytoskeleton production in confocal microscopy. The extracellular matrix (procollagen (I)) production was also decreased in STI571 treated group. CONCLUSION: STI571 is effective to reverse the fibrogenesis in vivo and in vitro. This mechanism through tyrosine kinase inhibitors induce lower proliferation and higher apoptosis of HSC.

353 6303_SSAT.book Page 354 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Pancreas

T1912 Calcineurine Inhibitors Accelerate Microvascular Thrombus Formation in Vivo Anja Pueschel*1, Nicole Lindenblatt3, Juliane Katzfuss1, Brigitte Vollmar2, Ernst Klar1 1Department of Surgery, University of Rostock, Rostock, Germany; 2Institute for Experimental Surgery, University of Rostock, Rostock, Germany; 3Department of Reconstructive Surgery, University of Zürich, Zürich, Switzerland BACKGROUND: Thrombotic microangiopathy (TMA) is a fatal complication that occurs after pancreas-kidney transplantation leading to allograft dysfunction and graft loss. Immunosuppressants, e.g., calcineurine inhibitors, have been implicated in the development of nonimmune TMA. Tacrolimus has been shown to be associated with decreased NO-production, thus contributing to thromosis. ADMA acts as an endogenous NO-synthase inhibitor and is considered to be a marker of endothelial dysfunction. Aim of this study was to analyse the influence of different immunosuppressants on microvascular thrombus formation in vivo and to further examine the underlying endothelial function. METHODS: Using the skin fold chamber in C57BL/6J mice, microvascular thrombus formation was induced photochemically and quantitatively analyzed by intravital fluorescence microscopy. Mice were treated with Tacroli- mus (TAC: 10 mg/kg/d; n = 7), Cyclosporine (CYA: 5 mg/kg/d) or Sirolimus (RAPA: 1.5 mg/kg/d ip) on 3 consecutive days. Control-mice received NaCl 0.9% (10 ml/kg/d ip; n = 5). Drug plasma levels were examined to ensure therapeutic doses. Additionally, sP-, sE-Selectin and ADMA-plasma levels were measured by ELISA. RESULTS: Application of immunosuppressants produced clinically relevant plasma levels (TAC: 8 ± 2 ng/ml, CYA: 214 ± 16 ng/ml; RAPA: 9 ± 1 ng/ml). Microvascular thrombus formation was significantly accelerated in mice receiving TAC compared to control-mice (arteriolar and venular occlusion: 251 ± 101 s and 179 ± 27 s vs. control 818 ± 221 s and 749 ± 231 s; p < 0.05). Application of CYA significantly increased thrombus formation only in venules (276 ± 49 s; p < 0.05 vs. control), whereas RAPA had no significant effect on thrombosis induction. Plasma concentrations of sP- and sE-Selectin were slightly reduced after TAC and CYA application. ADMA-levels however were significantly increased in mice receiving TAC (1.28 ± 0.16 µmol/l vs. control: 0.74 ± 0.13 µmol/l; p < 0.05). CONCLUSIONS: The impact of immunosuppressants on TMA as well as the underlying mechanisms have not been clearly delineated. Our results show that clinically relevant plasma levels of Cyclosporine enhanced thrombus formation only in venules whereas Tacrolimus significantly accelerated thrombus formation in arterioles and venules. This effect could be explained by increased ADMA-levels in plasma resulting in impaired NO-bioavailability and increased thrombogenicity, thus presenting a new molecular mechanism in the development of transplant-thrombosis. Preliminary results in post-ischaemic tissue confirm the effect of Tacrolimus on microvascular thrombus formation, further underlining the significant role of calcineurine inhibitors in TMA.

Poster of Distinction 354 6303_SSAT.book Page 355 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1913 OSU-03012, a Celecoxib Derivative, Has Increased Cytotoxicity and Does Not Stimulate Vascular Endothelial Growth Factor Production Regardless of Cyclooxygenase-2 Expression in Pancreatic Cancer Cell Lines Desmond P. Toomey*, Ellen Manahan, Ciara K. Mckeown, Annamarie Rogers, Kevin C. Conlon, Joseph Murphy Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland INTRODUCTION: There is increasing evidence that Non Steroidal Anti- inflammatory Drugs (NSAIDs) have Cyclooxygenase-2 (COX-2) independent actions in cancer. These effects occur regardless of COX-2 expression and may be beneficial or detrimental. This study compared the actions of specific COX-2 inhibitors (Celecoxib, NS398) with that of OSU-03012, a celecoxib derivative, in pancreatic cancer. METHODS: A previous study confirmed that pancreatic cancer cell lines BxPC-3 and AsPC-1 have consistently high and negligible COX-2 expression, respectively. Proliferating cells were treated with NS398, celecoxib or OSU- 03012 and LC50’s determined using MTT assay. Prostaglandin E2 (PGE2) and Vascular Endothelial Growth Factor (VEGF) production were measured by ELISA. Significance was calculated using unpaired t test. RESULTS: Each of the reagents had a concentration dependant effect on cell viability regardless of cellular COX-2. The LC50 for NS398 was > 100 µM and for Celecoxib >50 µM. OSU-03012 was cytotoxic at 10 µM in AsPC-1 cells and had a LC50 of 15–20 µM in both cell lines. Of note, proliferating cells more susceptible than confluent (p < 0.01). COX-2 was inhibited by 1 µM Cele- coxib or NS398 (p < 0.001). PGE2 was moderately reduced by 10 µM OSU- 03012 (p < 0.001). NS398 and OSU-03012 did not effect VEGF levels however it was increased 1.8 (AsPC-1) and 2.1 (BxPC-3) fold by 50 µM Celecoxib (p < 0.01). CONCLUSION: Although high dose Celecoxib is cytotoxic to pancreatic cancer cells, it stimulates production of VEGF, a growth factor associated with worse prognosis. OSU-03012, a celecoxib derivative, has similar cytotoxicity but at lower, physiologically achievable concentrations without affecting VEGF. Thus OSU-03012 has exciting potential for pancreatic cancer therapy. POSTER ABSTRACTS TUESDAY

355 6303_SSAT.book Page 356 Tuesday, April 22, 2008 1:26 PM

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T1914 Inhibition of VEGF and Not COX-2 Is Effective in a Model of Pancreatic Cancer Angiogenesis Desmond P. Toomey*1, Ellen Manahan1, Ciara K. Mckeown1, Annamarie Rogers1, Helen Mcmillan2, Stephen Thow2, Michael Geary2, Kevin C. Conlon1, Joseph Murphy1 1Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland; 2The Department of Obstetrics, The Rotunda Hospital, Dublin, Ireland INTRODUCTION: In pancreatic cancer, angiogenesis is an exciting therapeutic target that has been linked to Cyclooxygenase-2 (COX-2) and Vascular Endothelial Growth Factor (VEGF) expression. The relationship of COX-2 and VEGF to endothelial cell (EC) survival and proliferation within the neoplastic environment was investigated in this study. METHODS: BxPC-3 or AsPC-1 pancreatic cancer cell lines (COX-2 positive and negative, respectively) were co-cultured with EC for 3–5 days. A 4µm porous membrane, insert system was used to facilitate passage of growth factors but not cells. SC-560 (COX-1 inhibitor), NS398 (COX-2 inhibitor) or VEGF neutralising antibody were added to the lower chamber. EC viability was measured by Giemsa staining and WST assays. PGE2 and VEGF were quantiﬁed by ELISA. Signiﬁcance was calculated using unpaired t test. RESULTS: BxPC-3 co-cultures produced 2.7 fold more PGE2 and 1.5 fold more VEGF than AsPC-1 wells (P < 0.01). This was associated with a 2 times greater EC viability in BxPC-3 wells relative to AsPC-1 (P < 0.01). PGE2 was reduced to minimal levels in BxPC-3 wells by NS398 but this had no effect on either VEGF production or EC viability. AsPC-1 showed similar patterns but at a proportionally lower level (P < 0.01). EC viability was reduced to that of negative control in both cell lines by VEGF neutralising antibody. CONCLUSION: COX-2 inhibition did not reduce VEGF production or EC viability. However, neutralisation of VEGF did markedly inhibit EC proliferation and survival. Therefore VEGF is not downstream of COX-2 and VEGF inhibitors have an important role in therapies targetting pancreatic cancer angiogenesis.

356 6303_SSAT.book Page 357 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1915 Anti-Lewis Y Antibody as a Novel Target for Pancreatic Adenocarcinoma Vivian E. Strong*1, Achim A. Jungbluth3, Peter J. Allen1, Laura H. Tang4, Lloyd Old3, Steven Larson2, Jorge Carrasquillo2, Yuman Fong1 1Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; 2Nuclear Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY; 3Ludwig Institute for Cancer Research, Memorial Sloan-Kettering Cancer Center, New York, NY; 4Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY Lewis Y antigen is a blood group antigen homogeneously expressed at high density on the surface of various tumor cells. Hu3S193 is a specific antibody against Lewis Y antigen and this antibody has shown exceptionally high specificity for Lewis Y antigen with no cross-reactivity and potent immune effector function. This study evaluated Lewis Y expression in pancreatic adenocarcinoma. Human tissue samples (n = 43) from paraffin embedded blocks were evaluated via immunohistochemical (IHC) staining with 3S193 antibody. An antigen retrieval technique was performed by immersing slides in preheated DAKO-TRS solution and ultimate detection with avidin biotin system. Binding was graded by review of two dedicated pathologists who were blinded as to the clinical history of each specimen. Grading was categorized as negative, focally positive or graded % binding. IHC staining of human pancreas tissue shows intense uptake of 3S193 antibody in regions consistent with pancreas adenocarcinoma (panel A). In contrast, panel B demonstrates minimal IHC staining of normal pancreatic tissue. Table 1 shows results of IHC staining for 55 human pancreas adenocarcinoma specimens with 80% showing strong staining. The results of this study demonstrate the up-regulation of Lewis Y antigen in pancreatic adenocarcinoma, and the targeting capability of Hu3S193. These results may allow the development of better imaging and novel therapies to specifically target pancreatic adenocarcinoma.

Table 1. Immunohistochemical (IHC) Staining From Human Pancreas Cancer Specimens

Amt of Staining via Number of Pancreas Percentage of Total Specimens Immunohistochemistry for Adenocarcinoma Specimens (n = 55) Hu3S193 Antibody Negative 11 20% Focally Positive 3 5% 5–25% 13 24% POSTER ABSTRACTS

25–50% 9 16% TUESDAY 50–75% 8 15% 75–100% 11 20% Total 55 100% Total Positive 44 80%

In 80% of all specimens examined (44/55) there was detectable staining of cancer cells with the anti-lewis Y antibody.

357 6303_SSAT.book Page 358 Tuesday, April 22, 2008 1:26 PM

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Figure 1. 3S193 immunostaining of pancreas adenocarcinoma (panel A) versus normal pancreas tissue (panel B). Brown regions represent positive staining for Lewis Y antigen.

358 6303_SSAT.book Page 359 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T1916 Differentiation, Origin and Mesothelial Adhesive Potential Affect Growth and Metastasis of Ductal Adenocarcinoma of the Pancreas Soeren Torge Mees*, Christina Schleicher, Mario Colombo-Benkmann, Norbert Senninger, Joerg Haier General Surgery, University Hospital Muenster, Muenster, Germany BACKGROUND: Adenocarcinomas of the exocrine pancreas belong to the most aggressive malignancies with an overall 5-year survival rate of still less than 5%. The early development of distant metastases, such as peritoneal carcinomatosis, is a specific characteristic of this particular tumor entity, but their mechanisms are poorly understood. In a series of newly established orthotopic models for pancreatic carcinomas tumor growth, metastasis and their potential for mesothelial adhesion as one of the first steps of metastasis formation were investigated. METHODS: 16 cell lines of well- to undifferentiated pancreatic cancers from different tumor sites (primary or metastatic lesions) were used to implant subcutaneous donor tumors and subsequent orthotopic transplantation in nude mice. After 12 weeks primary tumor volume, local infiltration, and patterns of systemic metastases were assessed using a standardized dissemination score. This in vivo behaviour was compared with in vitro tumor cell adhesion to mesothelial cells. The data was tested for significant differences using Scheffé- and t-test (SPSS 13.0). RESULTS: In vivo experiments resulted in a tumor take rate of 100%. Differ- ences regarding tumor size, infiltration and metastatic spread were found depending on differentiation and origin of the cell lines. Less differentiated cells of primary tumors and metastasis caused higher dissemination scores than better-differentiated cells (p < 0.05). A significant increase (p < 0.05) of tumor growth, infiltration and metastasis was also seen for cells originating from metastases compared to those from primary tumors. Adhesion assays revealed an adhesive potential at mesothelium of all cell lines (21%–95%). Primary tumors with well-moderate differentiation presented significantly increased adhesion rates (mean 74%–95%) compared to poorly-undifferentiated primary tumors (mean 31%–55%) and well-moderately differentiated (mean 21%–44%) or poorly-undifferentiated (mean 25%–45%) metastases (p < 0.05). The maximum adhesion rates were found in average 76 min after addition of pancreatic cells to mesothelial monolayers (observation period 90 min). POSTER ABSTRACTS

CONCLUSION: These experimental systems are an interesting tool for the TUESDAY investigation of mechanisms or pancreatic cancer progression and demonstrate that grade of differentiation and origins are relevant factors for tumor growth and metastatic spread. The correlation of pancreatic cells adhesion at the mesothelium with their origin and differentiation suggests that this adhesive potential is a required, but not rate-limiting step for the formation of peritoneal carcinomatosis in this tumor entity.

359 6303_SSAT.book Page 360 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

T1917 Pancreatic RegI and PAP2 Proteins Have Different Potencies on Macrophage TNF Expression Ehab Hassanain*, Domenico Viterbo, Cathy M. Mueller, Martin Bluth, Michael E. Zenilman Dept Surgery, SUNY Downstate, Brooklyn, NY BACKGROUND: Reg and PAP are homologous, endogenous proteins differentially expressed in the pancreas. We recently showed that PAP2 is protective in pancreatitis, and it may exert its effect by activating macrophages. Since RegI is constituitively expressed and PAP2 is induced only during pancreatitis, we postulated that they would have differential effects on macrophages. We also postulated that the highly conserved C-terminus, previously identified as critical for this activity, would be a bioactive fragment. METHODS: Rat macrophages (NR8383 alveolar cell line) were cultured with recombinant rat RegI or PAP2 proteins created in our lab, and isolated by affinity chromatography, a commercial PAP2 protein isolated by NH4 precipitation, or a synthetic 30 amino acid C-terminus peptide (20–10000 ng/ml) for 24 hr. Media was evaluated for TNF expression via ELISA. Controls consisted of cells cultured with vehicle alone. Significance was set at p < 0.05 (Student’s t-test). RESULTS: See Figure. Macrophages cultured in the presence of our laboratory’s recombinant rat RegI and PAP2 resulted in increased expression of TNFa when compared with controls (p < 0.05). But, PAP2 was 2 log-orders more potent. The highly conserved C-terminal peptide showed no activity. Importantly, commercially purchased PAP2 isolated by ammonium sulfate precipitation was inactive; its activity returned only after chemical refolding using serial dialysis in urea.

CONCLUSIONS: Despite their structural similarities, PAP2 is a much more potent macrophage stimulant than RegI. Since PAP2 is induced during acute pancreatitis, it is likely to be the more important signal for macrophage activation in the disease. A conserved peptide sequence is inactive, intact confor- mational structure is critical for its activity, and standard isolation techniques can render the protein non-functional.

360 6303_SSAT.book Page 361 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Small Bowel

T1918 Cold Ischemia of the Small Bowel Could Be Prolonged by Intestinal Lipid Absorption Before Gut Procurement Judith Junginger*, Theo Maier, Tobias Meile, Markus A. Kueper, Ruth Ladurner, Alfred Koenigsrainer, Jorg Glatzle General and Transplant Surgery, University of Tuebingen, Tuebingen, Germany INTRODUCTION: Small bowel transplantation is an established treatment option for patients with intestinal failure. However, the short cold ischemic tolerance of the small bowel is still an imminent problem. Recently, we have shown, that the inflammatory response of the gut during abdominal sepsis was significantly reduced during oral lipid administration (Glatzle; J. Gas- trointest. Sug 2007). HYPOTHESIS: An enteral treatment with long chain fatty acids before procurement will reduce the damage of the gut during cold ischemia. METHODS: Rats were continuously intestinally infused for 12 h either with NaCl, 1% olive oil or 4% olive oil (ClinOleic, Baxter, Germany, 3 ml/h; n = 4 each group). Thereafter rats were anesthetized, systemically infused with an organ preservation solution (Histidine-Tryptophan Ketoglutarate), the small bowel was immediately removed and stored in the HTK solution on ice. At the time periods t = 0, t = 2 h, t = 4 h, t = 8 h, t = 12 h a tissue sample of the gut was fixed and stained with H&E. The tissue was analyzed by three independent observers and scored for tissue damage (0 = no damage, 1 = minor damage, 2 = major damage, 3 = loss of structure) of the basal membrane of the mucosa, the integrity of the mucosa and integrity of villi. Data are represented as median. RESULTS: Both lipid pretreated groups reached after 4 h of cold ischemia a median damage score of 2 for the integrity of the basal membrane, whereas the control group reached a damage score of 3. The 1% olive oil treated rats showed either no damage or minor damage to the mucosa after 4 h of cold ischemia, whereas in the control group 75% of the animals had at least minor damage scores up to loss of structures. The most impressing results were seen in the lipid pretreated groups regarding the integrity of the villi. None of the 1% lipid treated animals showed a damage for the integrity of villi within 4h of cold ischemia, whereas 50% of the control animals showed al least minor POSTER ABSTRACTS damage scores. (median damage score for the integrity of villi, control: 0h: 0; TUESDAY 2 h: 0; 4 h: 0.5; 8 h:1.5; 12 h: 2; 1% lipid: 0 h: 0; 2 h: 0; 4 h: 0; 8 h:1; 12 h: 1.5; 4% lipid: 0h: 0; 2 h: 0; 4 h: 0; 8 h:2; 12 h: 3). CONCLUSIONS: Intestinal lipid absorption before gut procurement clearly decreases the histological damage of the small bowel during cold ischemia and 1% olive oil seems to be more efficient than 4%. Lipids or their metabo- lites stored in the enterocytes may have some anti-inflammatory character. Intestinal lipid administration in organ donors might also be a useful tool to increase cold ischemia of the small bowel in humans.

361 6303_SSAT.book Page 362 Tuesday, April 22, 2008 1:26 PM

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T1919 Diurnal Rhythmicity in the p53-Mediated Apoptotic Pathway in Rodent Small Intestine Anita Balakrishnan*1, Adam T. Stearns1, David B. Rhoads2, John S. Young1, Stanley W. Ashley1, Ali Tavakkolizadeh1 1Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; 2Pediatric Endocrinology, MassGeneral Hospital for Children and Harvard Medical School, Boston, MA INTRODUCTION: The intestine exhibits a diurnal rhythm in apoptosis, cued by feeding and peaking during fasting. The pathways regulating this rhythm have not been elucidated. p53 upregulates pro-apoptotic Bax and Bak, and downregulates anti-apoptotic Bcl-w and Bcl-XL, culminating in caspase-3 activation, in other models of apoptosis and proliferation. We hypothesized that diurnal rhythmicity in apoptosis was similarly regulated. METHODS: Rats were acclimatized to a 12:12 hour light/dark cycle and jejunal mucosal scrapings harvested at 6 hourly intervals, beginning at ZT0 (Zeit- geber Time 0, corresponding to 7 am and “lights-on,” n = 6 to 7 rats per time). mRNA expression of p53, Bcl-XL, Bcl-w, Bax, Bak and caspase-3 was determined using real-time PCR and statistical significance using ANOVA. RESULTS: p53 mRNA expression peaked at ZT0, the termination of the normal nocturnal feeding period (p < 0.05 vs. ZT18). Bak similarly peaked at ZT0 (p < 0.0001 vs. ZT6, ZT12 and ZT18), however, no significant difference in expression was noted for Bax. In contrast, Bcl-w and Bcl-XL expressions were significantly higher during the feeding period with a peak at ZT18 (p < 0.005 vs. ZT0 and ZT12). Bax and Bak expression were more than 3-fold higher than Bcl-XL and Bcl-w at ZT0 (p < 0.0005 vs. ZT12 and ZT18). Caspase-3 expression was significantly higher during the lights-on period at ZT0 and ZT6 (p < 0.05 vs. ZT12).

CONCLUSION: Our results identify a diurnal rhythm in the expression of components of the p53-mediated apoptotic pathway. Pro-apoptotic genes exhibited peak expression in the light period, when rats consume little food. Our ﬁndings suggest that diurnal rhythmicity in apoptosis may occur via a p53- mediated caspase-3 dependent pathway. Further understanding of the regulation of these apoptotic rhythms may allow the development of improved che- motherapeutic regimens with reduced gastrointestinal side-effects.

362 6303_SSAT.book Page 363 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Stomach

T1920 Pre-Op Antibiotic Gastric Lavage Reduces Post- Operative Peritoneal Infection in a Murine Natural Orifice Surgery Model Yoav Mintz, John Cullen*, Santiago Horgan, Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini Department of Surgery, University of California, San Diego, San Diego, CA INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique through which operations are performed by entering the abdominal cavity through a natural orifice such as the stomach. Infection is a potential risk of the procedure and the potential pathogens are different than with skin incisions. Currently, there is little data regarding prophylactic antibiotic treatment for NOTES. METHODS: 30 Sprague-Dawley rats underwent mini-laparotomy under general anesthesia in accordance with the UCSD Institutional Animal Care and Use Committee regulations. The control group (n = 10) underwent a sham procedure where a single stitch was placed in the anterior stomach. The saline treated group (n = 10) underwent mini-laparotomy followed by needle gastrotomy and gastric irrigation with normal saline. Following irrigation, the fluid was expressed from the stomach into the abdominal cavity. The gastrotomy and then the abdomen were closed. The antibiotic treated group (n = 10) underwent gastric irrigation with diluted antibiotic containing enrofloxacin solution followed by spillage and closure. All rats survived the operation. One rat from the Saline group was euthanized on post-operative day 2 for wound complications due to a technical error. All other rats survived and were euthanized at 4 weeks. RESULTS: Weight gain was similar amongst groups. In the saline treated only group, 3 out of 9 rats (33%) developed intra-abdominal abscess found at necropsy. In the control and antibiotic treated groups, no abscess was found at necropsy. Adhesions to the abdominal wall formation were found in four rats out of ten in the saline group. No adhesions were noted in the control or antibiotic treated groups. CONCLUSIONS: In a pilot study of a murine model designed to simulate NOTES gastric spillage, pre-op gastric antibiotic lavage decreased the adhe- POSTER ABSTRACTS

sion and infection rate when compared to saline only lavage. TUESDAY

363 6303_SSAT.book Page 364 Tuesday, April 22, 2008 1:26 PM

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T1921 Roux-en-Y Gastric Bypass Improves Obesity-Related Steatosis and Is Associated with Reduction in Serum Adiponectin Drew A. Rideout*1,2, Yanhua Peng2,3, Steven S. Rakita2,1, William R. Gower2,3, Min You3, Michel M. Murr1,2 1Department of Surgery, University of South Florida, Wesley Chapel, FL; 2Department of Surgery and Research, James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department of Molecular Medicine, University of South Florida, Tampa, FL BACKGROUND: Non-Alcoholic Fatty Liver Disease (NAFLD) is a manifestation of obesity and leads to cirrhosis. Adiponectin, an adipocyte hormone, has direct effects on inflammation and lipid metabolism. We tested the hypothesis that Roux-en-Y gastric bypass (RYGB) improves liver steatosis in a rat model of obesity and induces changes in serum adiponectin. METHODS: Five-week-old Sprague-Dawley male rats were randomized to regular chow or high fat diet (HFD) for 14 weeks to induce obesity prior to undergoing RYGB (n = 4) or sham (n = 3). Subsequently, rats were sacrificed at 9 weeks post-operatively. Body weight (weekly) and serum adiponectin were measured. Liver sections were stained with H&E and Oil Red. All tests were repeated in triplicate; gels were quantified using densitometry; data are mean ± SD; t-test, p < 0.05 was significant. RESULTS: HFD induces obesity and increases body weight in rats (452 ± 24 gm vs. 406 ± 22 gm; p < 0.01 vs. regular chow). RYGB induces progressive and significant weight loss in obese rats (364 ± 45 gm vs. 496 ± 32 gm; p < 0.01 vs. sham). Prior to RYGB, rats fed HFD had an increased serum adiponectin compared to regular chow (16,185 ± 2,459 vs. 7,309 ± 434; p < 0.01 vs. regular chow); RYGB reduced serum adiponectin in obese rats compared to obese sham controls (914 ± 564 vs. 3,441 ± 933; p < 0.05 vs. sham); similarly; serum adiponectin was reduced after RYGB as compared to levels from the same obese rats pre-operatively (5,099 ± 878 vs. 6,916 ± 415; p < 0.01). HFD increased the number and size of fat droplets in the liver compared to regular chow. RYGB decreased liver weight by 30% and significantly reduced the number and size of fat droplets in the liver compared to obese sham rats. More importantly, the degree of steatosis improved in rats after RYGB as compared to the same rats pre-operatively. CONCLUSION: HFD induces obesity and steatosis in obese rats. Surgically- induced weight loss in a rat model of RYGB exhibits an anti-lipogenic profile by improving liver steatosis. The novel observation that RYGB reduces serum adiponectin warrants further investigation into the complex signaling between peripheral adipose tissue and the liver in obese rats with NAFLD.

364 6303_SSAT.book Page 365 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

COMBINED SCIENCE POSTERS

Combined Science

T2095 Assessment of “Gene-Environment” Interaction in Cases of Familial and Sporadic Pancreatic Cancer Theresa P. Yeo*1, Ralph H. Hruban2, Alison P. Klein2, Kieran Brune2, Charles J. Yeo3 1School of Nursing, Thomas Jefferson University, Philadelphia, PA; 2Department of Pathology, Johns Hopkins University, Baltimore, MD; 3Department of Surgery, Thomas Jefferson University, Philadelphia, PA INTRODUCTION: Pancreatic cancer (PC) is the fourth leading cause of cancer death in the United States. This study characterizes one of the largest national registries of familial PC (FPC) and sporadic PC (SPC), focusing on demographics, clinical factors, self-reported environmental and occupational lifetime exposures and survival status. BACKGROUND: Reported risk factors for PC include: advancing age, a family history of PC, high-risk inherited syndromes, cigarette smoking, exposure to occupational and environmental carcinogens, African-American race, high fat/high cholesterol diet, obesity, chronic pancreatitis, and diabetes mellitus. METHODS: This retrospective cross-sectional, case-only analysis includes cases of FPC (n = 569) and SPC (n = 689) from the Johns Hopkins National Familial Pancreas Tumor Registry (NFPTR) enrolled between 1994 and 2005. RESULTS: Significant findings include: 1) Mild, multiplicative interaction between family history of PC and exposure to asbestos, environmental radon, and environmental tobacco smoke (ETS) (Odds Ratios >1.0). 2) Non-smoker ETS exposed cases were diagnosed at a significantly younger mean age (64.0 years) than non-smoker non-ETS exposed cases (66.5 years) (p < 0.0004). 3) FPC smokers with ETS exposure were diagnosed at a significantly (p = 0.05) younger mean age (63.7 years) compared to FPC non-smokers without ETS exposure (66.6.years). 4) Mean age at diagnosis for Ashkenazi Jewish SPC subjects was significantly younger (by 2.1 years) than Ashkenazi Jewish FPC cases (p = 0.05). 5) Ashkenazi Jewish FPC subjects who smoked were diagnosed 5.9 years earlier than Ashkenazi Jewish FPC non-smokers (p = 0.05). 6) Median survival for POSTER ABSTRACTS

unresected FPC cases was significantly shorter (168 days) compared to unre- TUESDAY sected SPC cases (200 days) (p = 0.04), survival significantly improved to 713 days for FPC cases and 727 days for SPC cases after surgical resection. CONCLUSIONS: These are the first data to show that occupational and environmental exposures may act synergistically with inherited or acquired genetic polymorphisms, resulting in earlier occurrence of PC. Exposure to cigarette smoking and ETS is associated with a younger mean age of diagnosis in FPC and SPC cases and those with an Ashkenazi Jewish heritage, compared to non-exposed cases. These results imply that unaffected individuals from fam- ilies with a history of PC who smoke, have had early life ETS exposure, or have certain occupational and environmental exposures may benefit from screening and early identification of pre-malignant lesions. 365 6303_SSAT.book Page 366 Tuesday, April 22, 2008 1:26 PM

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T2096 Natural Orifice Translumenal Endoscopic Surgery for Roux-en-Y Gastric Bypass: An Experimental Surgical Study in a Human Cadaver Model Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3, Nicolas C. Buchs1, Margherita Cadeddu4, Priya A. Jamidar5, Jean Fasel6, Philippe Morel1 1Division of Digestive Surgery, University Hospital Geneva, Geneva, Switzerland; 2Department of Visceral and Transplantation Surgery, University of Bern, Bern, Switzerland; 3Imperial College, London, United Kingdom; 4McMaster University, Hamilton, ON, Canada; 5Section of Digestive Diseases, Yale University, New Haven, CT; 6Division of Anatomy, University Geneva, Geneva, Switzerland BACKGROUND: Advantages of a NOTES or NOTES hybrid approach to Roux-en-Y gastric bypass (RYGB) might include: easier access to the peritoneal cavity, subtantial reduction in number of ports and port related complications, improved cosmesis and others. NOTES was initially concieved as a procedure for relatively minor intraperitoneal operations. The most common NOTES procedure currently is cholecystectomy which is of moderate complexity. RYGB is a complex surgical procedure of advanced level. The technical feasibility of a NOTES-RYGB and limitations of available flexible and rigid instrumentation for such a procedure is unknown. METHODS: NOTES hybrid RYGB was performed in 4 human cadavers (frozen or preserved) using a combination of flexible and rigid instruments. Pouch creation was achieved by needle knife dissection of a retrogastric win- dow using a flexible gastroscope introduced transvaginally. Articulated linear staplers were placed through a transumbilical port to transect the stomach. Measurements of the bilary and alimenary limbs were accomplished with flexible and rigid graspers. A 21 mm anvil was introduced through a needle- knife incision into the small intestine and connected to the flexible shaft of a flexible transesophageal stapler to form a gastrojejunostomy. A linear stapler was used for the jejuno-jejunal anastomosis. RESULTS: It was feasible to perform bypass surgery in all cadavers. Dissec- tion and pouch creation was easier than expected using flexible instruments to form the pouch. Ordinary rigid instruments (graspers and staplers) were too short for some transvaginal or transrectal manipulations. Anvil manipulation and docking was difficult using flexible instruments. Combinations of flexible and rigid visualization and manipulation were especially helpful for pouch creation and stapler manipulation. Transabdominal port access number was reduced from 5–7 to 1–3 with 1–2 translumenal access ports. CONCLUSIONS: Roux-en-Y bypass surgery is technically feasible in human cadavers using a NOTES hybrid approach. Port numbers can be reduced. A combination of flexible with rigid endoscopic techniques devices offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve complex hybrid endosurgical procedures.

366 6303_SSAT.book Page 367 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

T2097 A Novel System for Classifying Paraesophageal Hernias Tommy H. Lee*, Carlos Godinez, Stephen M. Kavic, Ivan M. George, George T. Fantry, Adrian E. Park University of Maryland, Baltimore, MD INTRODUCTION: The current system for classifying paraesophageal hernias is based on the herniated contents and the location of the gastroesophageal (GE) junction in relation to the diaphragmatic hiatus. While this system represents a basic anatomic description of the hernia, there is little clinical relevance to aid in pre-operative or intra-operative management. New imaging technology permits the study of these hernias in 3-dimensions, providing an understanding of their anatomy at a greater level of detail and relevance to the clinician. METHODS: 24 patients who underwent laparoscopic paraesophageal hernia repair were reviewed. Pre-operative CT scans were reconstructed using a unique protocol with semi-automatic segmentation. Reconstructions permit- ted analysis of the geometry of hiatal defects and herniated contents. Patients were categorized by hiatal shape, angulation of herniated contents, and the location of the herniated stomach. These groupings were then compared to patient outcomes, specifically, need for Collis gastroplasty, need for buttress of hiatus repair, gastrostomy, and intra-operative complications. RESULTS: Analysis revealed four distinct defect morphologies. The geometry of the herniated contents was described according to the amount of stomach situated in the chest, and by the angle formed by three anatomic structures: the GE junction, the base of the diaphragmatic crura, and the antrum (the “PEH angle”). Symmetric defects less often required gastric fixation, but were more likely to need a Collis gastroplasty. The mean PEH angle was 87˚. Patients requiring an esophageal lengthening had a mean angle of 82˚, compared to 100˚ in those who did not. Stomach location also influenced operative events, as evidenced by a 57% incidence of intra-operative complications such as enterotomies and liver injuries in patients with a stomach equally above and below the diaphragm, compared to 15% in those with the stomach mostly above, and 0% in those with the stomach mostly below (p = .106, Fisher Exact Test). CONCLUSION: Paraesophageal hernias remain a significant management challenge. Patients and surgeons alike stand to benefit from highly detailed pre-operative information on hernia anatomy and visceral relationships. POSTER ABSTRACTS

Combining advances in imaging and computing power, we propose a novel TUESDAY classification system based on advanced reconstruction techniques, which allows us to view these challenging surgical problems in ways not previously possible with fluoroscopy or even CT alone. Key anatomic features and relationships identified by these means can aid in pre-operative decision making and patient counseling, and predict operative difficulty.

Poster of Distinction

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Wednesday, May 21, 2008

12:00 PM – 2:00 PM SSAT POSTER SESSION SAILS PAVILION Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.

CLINICAL SCIENCE POSTERS

Clinical: Biliary

W1635 Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis Bilal Kharbutli*, Vic Velanovich Surgery, Henry Ford Hospital, Detroit, MI BACKGROUND: The management of symptomatic or incidentally-discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5%–15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even with higher incidence. Options for treatment include preoperative ERCP with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. METHODS: A Decision Analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE or Common Duct Double Lumen Catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/LS. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. RESULTS: One stage management of symptomatic CBD stones with LC/ LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two stage management even with a 100% positive IOC (9.4%, 0.5%). If a double lumen catheter is to be used for positive IOC, the morbidity would be higher than the two stage management only if the positive IOC incidence is more than 65% but still with no mortality.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

CONCLUSION: LCBDE has a lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a Common Duct Double Lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%. POSTER POSTER WEDNESDAY ABSTRACTS

369 6303_SSAT.book Page 370 Tuesday, April 22, 2008 1:26 PM

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W1636 A Novel Hepatico-Jejunostomy Technique Featuring a Purse-String Anastomosis and a Biodegradable Stent: A Preclinical Study in Minipigs Johanna Laukkarinen*1, Juhani Sand1, Jenni Leppiniemi2, Minna Kellomaki2, Isto Nordback1 1Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; 2Institute of Biomaterials, Tampere University of Technology, Tampere, Finland INTRODUCTION: In small-caliber bile ducts (BD), performing a well- functioning hepatico-jejunal (HJ) anastomosis can be challenging: bile leakage and stricture formation are well-known anastomotic complications. We have developed a biodegradable stent (BDS) and showed that it can be safely and effectively used in conventional HJ anastomosis, as well as in the treatment of cystic duct leakage and benign biliary strictures (GIE 2007). In addition, we have reported good results in patients with novel-technique pancreato-duodenectomy, where the anastomosis was created using purse- string technique and a BDS. We hypothesized that, instead of interrupted sutures, in small caliber BDs it might be easier and safer to create a purse- string anastomosis, and to use a BDS to ensure its patency. The aim of this study was to investigate the use of this novel technique for HJ, featuring a purse-string anastomosis and a BDS, and to compare the results to a conventional anastomosis without any stent in the minipigs.

MATERIALS AND METHODS: In this study the self-expanding PLA-BaSO4 BDSs (length 25 mm, wall 0.25 mm, diam 4/5 mm) and 23-kg minipigs were used. Cholecystectomy was performed and BD inner diameter measured. HJ was performed randomly either conventionally with interrupted sutures without any stent (n = 5) or by the novel purse-string technique (n = 4), where a BDS was ﬁrst introduced into the BD, after which the BD with the stent was slide with the aid of 3 stay-sutures well inside the jejunal purse- string, which was then tightened. The animals were followed by repeated x- rays and liver chemistry. RESULTS: The preoperative BD diameter was similar in the groups (aver 4.2 mm). 10 interrupted sutures in average were used in the conventional anastomosis. The time needed for creating the anastomosis was similar in the two groups (28.2 min in the conventional and 25 min in the purse-string + stent group). In the conventional group, one animal was sacriﬁced due to uncontrolled anastomotic bile leak on the 2nd postoperative day, and another animal developed a mild liver function failure with increased liver values at 1 month, and almost normal values at 3 months. All other animals (3/5 in conventional group and 4/4 in purse-string + stent group) had no signs of anastomotic leakage or liver function failure. In the abdominal radiograph the biodegradable stent had disappeared from all animals by 3 months. CONCLUSIONS: The described novel HJ technique featuring a purse-string anastomosis and a BDS is easy and safe to perform, and seems to ensure a well-functioning anastomosis in small-calibre BDs. These encouraging initial results point to further trials in the near future.

370 6303_SSAT.book Page 371 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1637 Primary Gallbladder Cancer: A 22 Year Experience in a Tertiary Care Center Rubayat Rahman*2, Yevgeniy Ostrinsky3,2, Magesh Sundaram1 1Department of Surgery/Surgical Oncology, West Virginia University, Morgantown, WV; 2Department of Medicine, West Virginia University, Morgantown, WV; 3Division of Digestive Diseases, West Virginia University, Morgantown, WV BACKGROUND: Gallbladder cancer (GBC) is an aggressive and an uncommon malignancy with overall dismal outcome. There have been only few studies examining the epidemiology, surgical outcomes and survival of GBC. AIM: To examine the demographic characteristics, pathology, surgical outcomes and survival of patients with GBC in a tertiary care center. METHODS: Patients diagnosed with primary GBC were identified from the WVU cancer registry. Cases were arbitrarily divided into pre-laparoscopic (1985–1995) and laparoscopic era (1996–2006). Information on demographics, symptoms, clinical staging, treatment modality, surgical procedures with outcomes and survival were obtained. RESULTS: A total of 47 cases were identified with 40 (85%) female and 7 (15%) male (p < 0.001). Average age was 66 years (37–85, median 68). 42 (90%) were white in the patient cohort. 39 (83%) patients had cholelithiasis and 32 (68%) had cholecystitis. Abdominal pain (85%) and nausea (81%) were the most common symptoms at presentation. 24 (51%) patients had jaundice at initial presentation and of these 15 (63%) had ERCP. US and CT were the most common initial modalities for evaluation. Of the cases where the type of cancer was reported, 39 (83%) patients had adenocarcinoma with 17 (36%) moderately differentiated and 30% (14) poorly differentiated cancer, 2 (4%) had squamous cell carcinoma, one small cell and one histiocytoma. Although the complication rate with attempted laparoscopic surgery was high, it did not affect the median survival when compared with open cholecystectomy. 30% (14) of patients had curative surgery and 45% (21) had palliative surgery. 51% (24) of patients were treated with chemotherapy, 32% (15) with radiation and 30% (14) with combination chemotherapy and radiation therapy. In the two eras we see a trend in improved survival (28 wks vs. 41 wks) that is statistically significant (Table). CONCLUSIONS: Our 22 year experience showed that significantly more patients were diagnosed with GBC in the laparoscopic era. Even though the

outcomes are dismal, there is a trend of signiﬁcant increase in stage speciﬁc POSTER

and overall survival over the last two decades. WEDNESDAY Table 1. GBC in Pre-Laparoscopic (1985–1995) and Laparoscopic (1996–2006) Era ABSTRACTS

Pre-Lap Era Lap Era p-value No of patients, n (%) 14 (30) 33 (70) <0.001 Incidental open cholecystectomy, n (%) 10 (71) 6 (18) <0.01 Incidental laparoscopic cholecystectomy, n (%) 0 (0) 20 (82) <0.0001 Stage I/II/III, n (%) 4 (29) 10 (30) NS Stage IV, n (%) 10 (71) 23 (70) NS Stage I/II/III survival (wk) 379/—/42 450/67/58 <0.001 Stage IV survival (wk) 23 37 <0.001 Overall survival (wk) 28 41 <0.001

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W1639 Only Pain from Acute Inflammation Is Relieved One Year Following Laparoscopic Cholecystectomy in Dyspeptic Patients with Cholelithiasis Roger G. Keith, Samaad Malik*, Bruce Reeder, Rajni Chibbar Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, SK, Canada INTRODUCTION: The purpose of this study was to determine if laparoscopic cholecystectomy (LC) in patients with cholelithiasis and dyspepsia will produce complete symptomatic relief one year after surgery. In this study dyspepsia was defined by a validated scoring system which measured epigastric pain, heartburn, belching and bloating. METHODS: Patients undergoing LC for uncomplicated gallstone disease in three university affiliated hospitals, from January 1, 2004 to June 30, 2005 received a validated questionnaire one year after surgery. This population based study used the questionnaire to identify patients with cholelithiasis and dyspepsia (Group I). For each symptom, the severity, frequency and duration were quantified using a Likert scale to produce a preoperative and postoperative total score per patient. Preoperative scores greater than 16 identified Group I patients. Postoperative scores less than 6 defined complete cessation of symptoms. Each gallbladder specimen was examined by a single pathologist blinded to patient clinical information. RESULTS: The survey response rate from 942 patients was 43%. Group I (N = 264) were dyspeptic (77%); Group II (N = 79) who had scores less than 16, had no dyspepsia (23%). Although Group I patients were improved overall one year after surgery (median postoperative total score: 12); only 40 patients (18.6%) achieved complete cessation of symptoms (scores <6). Ninety six patients (36.4%) had persisting dyspepsia (scores >16). One hundred and nineteen patients (45.1%) had reduced scores (7–15) one year after operation. Analysis of this subset identifed only pain was significantly reduced (p < 0.001). Pathological examination of these 119 gallbladders revealed histological evidence of acute cholecystitis in 57%, which accounts for the pain reduction in this subset. One hundred and forty four of all Group I patients (54.5%) had acute cholecystitis. Only 99 (37.5%) had chronic cholecystitis; 21 (8.0%) had normal gallbladders with cholelithiasis. CONCLUSIONS: This is the largest study to report outcomes for patients with gallstones and dyspepsia one year after LC. The majority of patients do not achieve complete cessation of symptoms. Pain was relieved more than other dyspeptic symptoms in this population. Half of the study group had acute inflammation of the gallbadder on histopathological examination.

372 6303_SSAT.book Page 373 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1640 Surgery for Symptomatic Portal Biliopathy Puneet Dhar*, Sudhindran Surendran, Sudheer Othiyil Vayoth, Shaji Ponnambathayil Gastrointestinal and HPB Surgery, Amrita Institute of Medical Sciences, Cochin, India BACKGROUND: Portal biliopathy is the presence of functional or structural biliary changes due to porto-systemic collaterals in portal hypertension (especially in extra hepatic portal vein obstruction—EHPVO). A preliminary portosystemic shunt is usually recommended before attempts at biliary decompression or bypass in symptomatic patients. AIM: To review our experience in the surgical management of symptomatic portal biliopathy. METHODS: From a prospectively maintained computerised database, 93 patients presenting with EHPVO were evaluated over the last 8 years. Surgery was required in 23 patients. Seven of these patients had features of portal biliopathy, and form the basis of this review. RESULTS: Presenting features were jaundice in 5 (cholangitis in 4); Gas- trointestinal bleeding in 3 and symptomatic hypersplenism in one. One of the jaundiced patients had been referred as hilar cholangiocarcinoma. Com- monest structural change observed was combined involvement of extrahepatic and bilateral intrahepatic biliary system (Type III b, n = 5). Five patients had Common bile duct calculi and 2 had gallstones. Three patients underwent portosystemic shunting (splenorenal in 2 and mesocaval in 1). Four patients had hepaticojejunostomy—one with bile duct resection (for presumed malignancy) and 3 without manifest GI bleed and operative appear- ance of mild portal hypertension, although they were kept prepared for a shunt (should it have been required). One patient each after shunt and bypass respectively, developed recurrent cholangitis but resolved on conservative management. The patient with bile duct resection had subsequent ectopic variceal bleed and required a splenorenal shunt. Follow-up serum bilirubin reduced faster (Range 4–57 weeks) than alkaline phosphatase levels (Range 4–208 weeks). CONCLUSIONS: Portal biliopathy must be considered in evaluation of biliary complications in EHPVO. Jaundice is the commonest presentation, and Type III b is the most frequently encountered anatomical anomaly. Surgery

can relieve most symptomatic patients. Shunt surgery (usually splenorenal) POSTER

may be adequate in some patients to decompress the biliary obstruction. WEDNESDAY Direct hepaticojejunostomy is possible in selected patients without severe ABSTRACTS portal Hypertension.

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W1641 Study of a Reverse Phase Polymer in Cholecystectomy: Prevention of Stone Migration and Enhancment of Dissection Marvin Ryou*1, Gloria Fernandez-Esparrach1, Sohail N. Shaikh1, David B. Lautz2, Christopher C. Thompson1 1Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Surgery, Brigham and Women’s Hopital, Boston, MA INTRODUCTION: Migration of stones from the gallbladder to the cystic duct has been reported in up to 15% of cases during laparoscopic cholecystectomy, with significant risk of residual choledocholithiasis. Additionally, gallbladder dissection is occasionally difficult due to adherence to the liver, with increased risk of bleeding and perforation. Poloxamer 407 is a non-ionic surfactant with rapid reversible sol-gel transition (solid at body temperature, liquid at cold temperatures), behavior that has been used to prevent ureteral stone migration in animal studies. AIM: To investigate a reverse phase polymer as a method of stabilizing stones in the gallbladder during cholecystectomy and as a means of tissue dissection in NOTES. METHODS: A partial NOTES cholecystectomy was performed in 2 non- survival using a double-channel endoscope via a transcolonic approach. The procedural steps were as follows: identification and exposure of the gallbladder; filling of the gallbladder with the polymer; injection of the polymer between the gallbladder and the liver, and dissection of the gallbladder from its bed. For the polymer injection we used a 22-G endoscopic needle. Polox- amer 407 was kept on ice during the intervention. Saline containing syringes were also kept on ice to cool the catheter immediately before poloxamer injections. Animals were sacrificed immediately after the surgery and necropsy performed. RESULTS: The gallbladder was able to be filled until distention was observed. No leakage of bile following needle withdrawal was noted, confirming gel occlusion. Injection between the gallbladder and liver was feasible and appeared to aid in gallbladder resection. At necropsy, 25 minutes after the polymer was injected, the gallbladder was filled by a yellow gel that confirmed the polymer had mixed with bile and remained in the solid phase. No polymer was identified in the cystic duct. The surgical bed did not show bleeding and there was a gel interface between the remaining gallbladder and the fossa allowing an easy manual separation of both structures. CONCLUSIONS: The use of a reverse phase polymer for cholecystectomy may prevent the leakage of bile in the case of a gallbladder perforation and the migration of stones through the cystic duct. Additionally, this may facilitate the dissection of the gallbladder from the fossa.

374 6303_SSAT.book Page 375 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Colon-Rectal

W1642 Laparoscopic and Open Anterior Resection and Low Colorectal Anastomosis for Adult Megacolon: Surgical Outcomes Sergio E. Araujo*, Afonso H. Sousa, Fabio G. Campos, Sergio C. Nahas, Caio S. Nahas, Desiderio R. Kiss, Ivan Cecconello Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil Chagas disease (American trypanosomiasis) is the most common cause of megacolon in adults in Brazil. Surgical treatment is indicated when complications occur or when quality of life remains severely compromised. Adequate surgical treatment requires resection of a largely dilated left colon and construction of a low colorectal anastomosis. Improvements in laparoscopic techniques enabled most colorectal procedures, even the most challenging one, to be performed using a video approach. This study was designed to compare the outcomes of laparoscopic anterior resection with low colorectal anastomosis with the open approach for treatment of acquired (chagasic) megacolon. A total of 22 patients who underwent laparoscopic (LAP) anterior resection for chagasic megacolon were compared to 22 patients submitted to open (OPEN) operation at the same time interval and at one institution. There were no differences between the groups regarding age, sex and previous abdominal operation. Operation time was longer in the LAP group (278 vs. 231 min; P = 0.031) but the blood loss was less (210 vs. 260 ml; P = 0.027). There was no difference regarding specimen length (29.8 vs. 30.9 cm; P = 0.775). There was no mortality. There were no intraoperative complications neither need for conversion. Length of stay was reduced for LAP group (10.5 vs. 12.7 days) but not signiﬁcantly (P = 0.173). There was no difference in postoperative morbidity between the groups. Anastomotic leakage occurred in two patients after LAP and in 3 patients after OPEN. Only one patient at the LAP group needed a reoperation. Four patients in the OPEN group were reoperated due to infectious complications. A laparoscopic approach for the treatment of acquired megacolon through colon resection and low colorectal anastomosis is feasible and represents a

safe option with short-term advantages when compared to the open POSTER

approach. WEDNESDAY ABSTRACTS

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W1643 To Control Intraoperative Bacterial Contamination and SSI During Anterior Resection or Hartmann’s- Mile’s Operation: What Can We Do? Katsunori Nishikawa*, Nobuyoshi Hanyuu, Masami Yuda, Hideharu Yasue, Takenori Hayashi, Susumu Kawano, Teruyuki Usuba, Isao Miyoshi, Ryouji Mizuno, Shuuichi Iwabuchi Surgery, Machida Municipal Hospital, Machida-shi, Japan BACKGROUND: The prevalence of surveillance of surgical site infection (SSI)have been playing important role in the prevention for the postoperative infection. However, intraoperative bacterial contamination (IBC) which can be a major cause for SSI has not been well investigated. AIM: The aim of study is to investigate whether ingenuity of surgical procedure could have an effect on decrement to IBC/SSI rate. METHODS: The subjects were 50 patients who underwent elective colorectal surgery (anterior resection (AR)/34, Hartmann’s-Mile’s operation (HM)/16) from November 2004 to June 2007. Of these, adoral colonic transection in early period during surgery (early transection: E-Tx) was performed in 30 patients (AR: 21, HM: 9) and late colonic transection, which colonic continuity was not cut off until anastomosis or stomal construction (late transection: L-Tx) was in 20 patients (AR: 13/HM: 7). Three samples as of 1) lrrigation fluid before abdominal closure (CLOS), 2) remained cutting suture ligated for peritoneal closure (SUTURE), and 3) subcutaneous swab of surgical wound (SUBCUT) were obtained intraoperatively and examined for the bacterial identification. RESULTS: The overall SSI rate was 26% (AR: 4/HM: 9) and all SSI occurred superficially. Eleven out of 13 SSI patients had extremely high IBC rate of 85%, as well as IBC patients had high SSI rate at 72%. Bacterial detection was highest in the CLOS (26%), and SUBCUT (26%), and followed by SUTURE (12%). SSI rate of L-Tx group was significantly lower than that of E-Tx group (10% vs. 36.7%, p < 0.05). Comparison of IBC rate between those 2 groups was also significant (E-Tx: 47%/ L-Tx: 20%, p < 0.05). CONCLUSION: Intraoperative contamination was considered as the one of important factor for SSI. Both IBC and SSI rate can be reduced by the shorten- ing of transected colonic time from which might contaminated by bacteria. Therefore thorough control of IBC should reconsider as the priority for SSI prevention than other remedy.

376 6303_SSAT.book Page 377 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1644 Preoperative Versus Postoperative Radiotherapy for Rectal Cancer: Decision Analysis and Outcome Prediction Using a Modified Markov Model Andreas M. Kaiser*, Daniel Klaristenfeld, Robert W. Beart USC Department of Colorectal Surgery, University of Southern California, Los Angeles, CA BACKGROUND DATA: Treatment for resectable rectal cancer has evolved into a multi-modality approach. Reduction of local recurrences has been achieved by radiotherapy, but also by improved surgical technique (total mesorectal excision). Radiotherapy has been associated with significant adverse effects and cannot exceed local dose limits. We hypothesized that reserving radiotherapy as treatment tool for high risk tumors and local recurrences improves the overall outcome of the group. OBJECTIVE: To simulate the benefit of preoperative versus selective postoperative radiotherapy in a theoretical Markov state-transition model with local recurrence and overall survival being the primary endpoints. Probabilities of life-time events were calculated based on a systematic literature review. DATA SOURCES: Computerized literature search of MEDLINE for publications in English between 1996–2006, supplemented by manual review of the retrieved reference lists. Medical subject headings used were rectal cancer, radiotherapy, surgery, RCT, randomized, clinical trial, mortality, adverse effects.

RESULTS: With baseline assumptions entered into the model, selective post-

operative radiotherapy evolved as preferred strategy with cure rates of 65.6% POSTER vs. 63.7% for selective and neoadjuvant radiotherapy, respectively, and a WEDNESDAY decrease of radiation exposure to 42.9% of the cohort. The system was sensitive to (1) the fraction of stage I cancers included in the cohort, (2) the differ- ABSTRACTS ence between local recurrence rates for neoadjuvant, adjuvant radiotherapy, or surgery-only approach, and (3) the compliance with the postoperative radiotherapy. After adjuvant radiotherapy, the local recurrrence threshold values to reverse the impact of compliance were 6.3%, 8.5%, and 18.3% if the surgery-only recurrence was set to 10%, 13%, and 27%, respectively. CONCLUSION: In patients with resectable rectal cancer, routine preoperative radiotherapy does not improve cancer-speciﬁc survival of the cohort compared with modern surgery alone or with selective postoperative radiation of high-risk individuals and local recurrences.

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W1645 Effect of Metastatic to Examined Lymph Nodes Ratio on Colon Cancer Survival Sukhyung Lee*, Brad Waddell Department of Surgery, William Beaumont Army Medical Center, El Paso, TX INTRODUCTION: Effect of Metastatic to Examined Lymph Nodes Ratio on Colon Cancer SurvivalIntroduction The number of lymph nodes examined in colon cancer surgery varies widely. The current staging system is based on the number of metastatic lymph nodes (N1: metastatic lymph nodes ≤3, N2: metastatic lymph nodes ≥4) and does not consider any variations of the number of lymph nodes examined. Therefore, a ratio-based staging system has been proposed. The aim of this study is to evaluate the metastatic to examined lymph node ratio (LNR) as a prognostic factor in stage III colon cancer. METHODS: Retrospective review of the Automated Central Tumor Registry of the Department of Defense was performed. There were 1,286 stage III colon cancer patients who underwent curative surgical resections. Cases were divided into quartiles by LNR (0.01–0.11 vs. 0.12–0.22 vs. 0.23–0.45 vs. 0.46–1.00). Effects of the LNR on colon cancer survival were analyzed using a Kaplan Meier survival curve and Cox proportional hazard model. RESULTS: Decreasing LNR was found to be associated with improved survival in colon cancer patients. Five year-overall survival was 68%, 65%, 56%, and 39% for the lowest to the highest quartiles (p < 0.001). Multivariate analysis identiﬁed age, sex, tumor grade, tumor T stage, tumor N stage, and LNR as prognostic factors. Cox proportional hazard analysis identiﬁed LNR as a better prognostic factor compared with conventional lymph node staging for stage III colon cancer. CONCLUSION: The metastatic to examined lymph node ratio is an excellent prognostic indicator in stage III colon cancer patients. This ratio-based staging system may provide more comparable prognostic information for colon cancer patient outcome.

378 6303_SSAT.book Page 379 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1646 A Prospective Single Center Experience of “Fast-Track” in Colorectal Surgery: Toward Zero Anastomotic Complications Pierluigi Di Sebastiano*, Nicola Mastrodonato, Giovanni Bisceglia, Beniamino Rucci, Antonio Cafaro, Antonio De Bonis, Angelo Ambrosio, Matteo Scaramuzzi, Vincenzo Crucinio, Fabio Francesco Di Mola, Giuseppe Mascetta, Matteo Tardio Department of Surgery, IRCCS casa Sollievo Sofferenza, San Giovanni Rotondo, Italy INTRODUCTION: The present study report a prospective observational single center experience of a multimodal perioperative management protocol (fast-track) in patients undergoing elective colorectal resection for cancer. We aimed to explore whether fast-track surgery can be safely applied and improve the outcomes of patients undergoing elective colorectal resection for cancer. METHODS: In December 2006 we started a fast-track protocol for patients with colorectal cancer. Since dec. 2006 to nov. 2007 we performed 252 colorectal procedures. Perioperative data from 90 consecutive patients (Group 1) who underwent elective R0 colorectal resection by means of fast-track surgery in a high-volume medical center were analysed and compared with 109 previously performed consecutive elective R0 resections out of 369 colorectal operations (group 2, nov 2005–nov 2006) and treated before the beginning with our fast-track management protocol. Fast-track patients received intravenous fluid restriction, early oral intake and prokinetic agents, early mobilisation and fixed pain treatment by mean of continuous elastomeric pump. Patients belonging to group 2 received conventional fluid administration to prevent oliguria, restricted oral intake until return of bowel motility and conventional analgesia. Endpoints were postoperative complications, postoperative stay and mortality. RESULTS: Of the 90 patients of group 1, 73 received a colon resection, 17 a total mesorectal excision for rectal cancer. Of the 109 patients of group 2, 83 received a colon resection, 26 a total mesorectal excision for rectal cancer. Patients in the group 2 required a longer median postoperative stay of 2 days (10 vs. 8). Patients of group 1 had significantly lesser medical and surgical complications, first of all in terms of respiratory distress (1.2% vs. 2%). In addition, we observed zero anastomotic leakage vs. 5% in group 2. There were 2 deaths in patients belonging to group 2 vs. 1 death in group 1. POSTER POSTER

CONCLUSIONS: Our data conﬁrm that fast-track surgery is feasible in col- WEDNESDAY orectal surgery and demonstrate that a multimodal management protocol is safe and able to signiﬁcantly reduce postoperative stay and morbidity. ABSTRACTS

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W1647 Laparoscopic Versus Conventional Colostomy Closure of Hartmann’s Procedure: A Case-Matched Study Jung C. Kang* Colon and Rectum Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan BACKGROUND: Reversal of Hartmann’s procedure is a major surgical procedure associated with substantial morbidity and mortality. The aim of this study was to compare the outcomes of patient who underwent laparoscopic or conventional colostomy closure of Hartmann’s procedure. METHODS: We reviewed all patients undergoing laparoscopic colostomy closure of Hartmann’s procedure at our institution between 2003 and 2007. Laparoscopic procedure was matched to conventional procedure by patient age, gender, American Society of Anesthesiologists score type and years of surgery. All of the patients had a left side colostomy. RESULT: Seventeen laparoscopic cases were matched with 17 conventional cases. There were three conversions (18%): two of dense adhesion and one of small bowel injury. There was no mortality. The hospital stay, length of incision wound, use of analgesics, estimated blood loss and bowel function return were signiﬁcantly less for the patients in the laparoscopic group. There was no difference in the postoperative complications and operative times in either group. CONCLUSION: Laparoscopic colostomy closure of Hartmann’s procedure is a feasible and safe procedure and has a similar complication rate to that of conventional procedure.

380 6303_SSAT.book Page 381 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1648 A New Method to Analyze the Quality and Progression of Colonoscopy Hans Törnblom2, Sanian Akbar3, René Tour4, Michael Wedén2, Urban Sjöqvist2, Lena B. Flodqvist2, Monica Boman-Galiamoutsa2, Leif Torkvist1, Lars Enochsson*1 1Department of Surgery, Karolinska Institutet, Stockholm, Sweden; 2Department of Gastroenterology and Hepatology, Karolinska Institutet, Stockholm, Sweden; 3Karolinska Institutet, Stockholm, Sweden; 4Department of Medicine Gastroenterology Unit, Capio St Görans Hospital, Stockholm, Sweden INTRODUCTION: Methods to objectively determine the performance of laparoscopic cholecystectomy have been established. We describe a new method to evaluate the quality of colonoscopy in patients where anatomical landmarks and instrument position can be identified. METHODS: Fourteen colonoscopies were evaluated (6 by specialists and 8 by residents). The colonoscopy image was mixed together with the digital image from ScopeGuide® (Olympus, Japan) and recorded on a laptop computer. The result was then stored on digital media. Endoscopists and patients graded their experience of the colonoscopy on a VAS-scale immediately after the examination. A new experimental evaluation protocol (Enochsson-Ritter) was used to objectively evaluate the progression and outcome of the colonoscopy. Two independent observers who were blinded with regard to identity of the endoscopist made the formal evaluation. RESULTS: The specialists reached the splenic flexure faster than the residents (3.8 ± 1.0 vs. 22.8 ± 7.9 min, P < 0.05). Residents found the colonoscopies to be technically more difficult and generally “worse than expected” compared with the specialists. The time for both specialists and residents to reach each segment of the left colon correlated with the parameter “worse than expected” as scored by the patient. The estimated technical difficulties for the specialist correlated better than that of the residents with the objectively measured time for the passage of the endoscope. Prolonged passage in the right colon during endoscopy by specialists increased the pain in patients. CONCLUSION: A new method to estimate the quality and progression of colonoscopy in patients is described. The method can distinguish between residents and experts and also demonstrates differences in examination qual-

ity that correlates with patient satisfaction. The method might be a valuable POSTER

future tool to monitor the quality and technical skills of endoscopists. WEDNESDAY ABSTRACTS

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W1649 Image-Guided Sentinel Lymph Node Navigation in Colon Cancer: A Pilot Study Julio M. Mayol*1,3, Rocio Anula1,3, Roberto Delgado-Bolton2,3, Iris Sanchez-Egido1, Jose Luis Carreras-Delgado2,3, Jesus A. Fernandez-Represa1,3 1Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; 2Servicio de Medicina Nuclear, Hospital Clinico San Carlos, Madrid, Spain; 3Unidad de Cirugia Guiada por Imagen, Hospital Clinico San Carlos, Madrid, Spain INTRODUCTION: Over the last two decades, the concept of sentinel lymph node (SLN) biopssy has emerged as a minimally invasive staging tool for melanoma and breast cancer. There is no consensus on its indication for colon cancer because technical issues limit its validity for staging and prognosis. We present our initial experience with intraoperative lymphascintigraphic scanning/mapping for SLN navigation using a portable gamma camera in patients with non-metastasic colon cancer. PATIENTS AND METHODS: Between March and October 2007, patients over 18 years of age with histologically proven colorectal adenocarcinoma and non-metastasic disease, scheduled to undergo curative resection by the same group of surgical oncologists were included in this pilot study. Although the group of surgeons had extensive experience with SLN biopsy in melanoma patients, they had not done any colon cancer SLN biopsies previously. The in vivo technique required open exploration of the abdomen to exclude metastasic disease, after location of the primary tumor, a peritumoral subsero- sal injection of 4 doses (0.5 mCi in 2 ml each) of 99mTc- nanocolloid (diameter <80 nm) was performed. The intraoperative portable miniature gamma camera (Sentinella 102TM, GEM Imaging SA Valencia, Spain) was intraoperatively used to monitor radiocolloid migration via lymphatic vessels. Once the SLN had been located as a “hot spot” in situ, the specimen was removed as the standard resection, and the node isolated ex vivo for histophatological examination. H&E and immunohistochemical staining were used. RESULTS: Five women and 4 men with a mean age of 71 years (39–87), all of them had resectable adenocarcinomas without metastasic disease, were included. In three cases the primary tumor was in the right colon, two in the transverse colon and 4 in the left colon. Migration of the radiocolloid to the first lymph node took between 5 and 15 minutes. One SLN was identified and isolated in 8 of 9 patients. The only failure occurred in a patient with a bulky tumor located in the cecum (failure rate: 12%). TNM pathologic staging showed 7 tumours were T3 and 3 were T4. Seven tumours were N0, one were N1 and two N2. In those 3 N-positive patients, the sentinel lymph node was also positive with H&E staining. CONCLUSIONS: Our pilot study suggests that intraoperative image-guided SLN mapping with a portable gammacamera is technically feasible and may be useful for SLN identification in colon cancer patients. Further research will be necessary to determine if image-guided SLN detection and biopsy provides additional prognostic information, improves staging and modifies patient management.

382 6303_SSAT.book Page 383 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1650 Low Preoperative Serum Albumin Levels Do Not Affect Early Outcomes After Ileoanal Pouch Surgery but May Be Associated with Long-Term Mortality Kweku A. Appau*, Ravi P. Kiran, Feza H. Remzi, Ian Lavery, Victor W. Fazio Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Despite reports of adverse outcomes for patients with low serum albumin levels undergoing general surgical operations, this association has not been investigated in ileoanal pouch surgery (IPAA). We investigated the effect of preoperative albumin on early and late outcomes after IPAA in ulcerative colitis (UC). METHODS: Data of patients prospectively accrued into a pouch database were evaluated to determine the association between preoperative albumin and outcomes after IPAA. Preoperative and perioperative factors and 30-day complications for patients with albumin of ≤3.0, 3.1–3.5 and >3.5 g/dl were compared. Chi-squared, Fisher’s exact tests, Kaplan-Meier method and Cox multivariable statistical analyses were performed. RESULTS: 1185 UC patients (44% female) had documented preoperative serum albumin. Comparing patients with albumin <3.5 (n = 139) and >3.5 (n = 1046), there was no difference in gender (p = 0.98), ASA score (p = 0.13), comorbidity (p = 0.92) and use of defunctioning ileostomy (p = 0.09). The group with albumin <3.5 was older (p = 0.004), and received greater intraoperative transfusion (p = 0.01). A greater proportion of patients in the <3.5 group had predominant surgical indication as failed medical therapy and steroid dependence (p = 0.001), perioperative steroid use (p = 0.001) and underwent proctocolectomy at IPAA (p = 0.001). Despite this, 30-day complications including wound infection (p = 0.2), sepsis (p = 0.4), anastomotic separation (p = 1) and long-term pouch-failure (p = 0.9) and pouchitis (p = 0.73) were similar. Estimated 5-year mortality risk was signiﬁcantly greater for the <3.5 albumin group (6.2% vs. 1.4%, p = 0.02). Age (p = 0.001), steroid use (p = 0.012), and albumin of <3.5 were associated with long-term mortality on multivariate analysis. Comparison of the <3.0 and >3.1 group did not show any difference in 30-day postoperative complications or long-term outcomes. CONCLUSION: Serum albumin levels <3.5 g/dl are seen in patients who are ill and are associated with long term mortality. Proctocolectomy in these

patients may be inevitable. When performing IPAA, due care directed to sur- POSTER gical technique and decision-making prevents adverse early outcomes. WEDNESDAY ABSTRACTS

383 6303_SSAT.book Page 384 Tuesday, April 22, 2008 1:26 PM

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W1651 TGF-Beta1 and IGF-1 and Anastomotic Recurrence of Crohn’s Disease After Ileo-Colonic Resection Marco Scarpa1, Marina Bortolami2, Susan L. Morgan3, Andromachi Kotsafti2, Cesare Ruffolo1, Renata D’Incà2, Eugenia Bertin1, Lino Polese1, Davide F. D’Amico1, Giacomo C. Sturniolo2, Imerio Angriman*1 1Clinica Chirurgica 1°, University of Padova, Padova, Italy; 2Gastroenterologia, University of Padua, Padua, Italy; 3Department of Pathology, Institute for Cancer Studies, Birmingham Medical School, University of Birmingham, Birmingham, United Kingdom BACKGROUND: After bowel resection, Crohn’s disease (CD) recurs frequently in the site of anastomosis and “end-to-end” anastomoses are associated with a higher rate of recurrence compared to “side-to-side” ones. Alteration of normal healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) are involved in wound healing mechanisms with pro-fibrogenic properties. The aim of this study is to understand if a differential expression of reparative factors in the different zones of the bowel wall can explain why side-to-side anastomoses are associated to a lower rate of recurrence. PATIENTS AND METHODS: Sixteen patients affected by CD who underwent ileo-colonic resection in our department, over the period 2004 to 2005, were enrolled in this study and their follow up investigated. Full-thickness tissue samples were obtained from the mesenteric side, the lateral side and the anti-mesenteric side of the ileum wall. Two samples series were collected from macroscopically diseased and healthy ileum for each patient. TGF-beta1 and IGF-1 mRNAs were quantified by absolute Real Time PCR using GAPDH as the housekeeping gene. Myeloperoxidase (MPO) activity and histological disease activity were assessed to quantify the ileal inflammation. Comparisons and correlations were carried out with nonparametric tests. RESULTS: Although no significant difference was observed between the three groups, a significant correlation between TGF-beta1 relative levels in diseased bowel and the sampling site was observed (tau = 0.43, p = 0.03); the closer the sampling site was to the mesenteric side the higher were TGF-beta1 relative levels. In comparison, neither IGF-1 mRNA transcripts nor MPO activity showed any relation with the sampling site. CONCLUSION: Our study seems to suggest that TGF-beta1 mRNA expression is lower in the anti-mesenteric side of the ileum. Since we have previously demonstrated that high expression of TGF-beta1 is associated with early recurrence it seems rational to construct the anastomosis on the anti-mesenteric side of the bowel. Therefore a side-to-side anastomosis seems to be the most suitable to minimize the recurrence risk of CD.

384 6303_SSAT.book Page 385 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1652 Pre- Versus Postoperative Pelvic Radiotherapy in Patients Undergoing Abdominoperineal Resections for Rectal Cancer: Does Timing Make a Difference on Long-Term Patient Quality of Life? Michael S. Kasparek*1,2, Imran Hassan3, Robert R. Cima1, David W. Larson1, Eric J. Dozois1, Rachel E. Gullerud4, Dirk R. Larson4, John H. Pemberton1, Bruce G. Wolff1 1Department of Colorectal Surgery, Mayo Clinic Rochester, Rochester, MN; 2Department of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany; 3Department of General Surgery, Southern Illinois University School of Medicine, Springﬁeld, IL; 4Division of Biostatistics, Mayo Clinic Rochester, Rochester, MN INTRODUCTION: Pelvic radiotherapy (XRT) whether given pre- or postoperatively is associated with improved oncologic outcomes in patients (pts) undergoing abdominoperineal resection (APR) for locally advanced rectal cancer. However, few reports have compared quality of life (QOL) of pts after preoperative (preop) or postoperative (postop) XRT and APR.

Postoperative XRT Preoperative XRT p (n = 35) mean (SD) (n = 53) mean (SD) EORTC QLQ-C30 Global health status 74 (17) 68 (21) .16 FS: Physical functioning 88 (17) 84 (19) .38 FS: Role functioning 87 (21) 77 (31) .21 SS: Nausea and vomiting 4 (9) 6 (12) .61 SS:Appetite loss 7 (14) 12 (21) .35 SS: Constipation 11 (20) 14 (24) .86 SS: Diarrhoea 15 (22) 19 (26) .56 EORTC QLQ-CR38 FS: Sexual functioning: Males 76 (22) 72 (24) 52 FS: Sexual functioning: Females 92 (16) 85 (17) .17 FS: Sexual enjoyment: Males 57 (16) 44 (28) .33 FS: Sexual enjoyment: Females 56 (38) 100 (0) .18 SS: Micturition problems: Males 24 (15) 26 (21) 0.90 SS: Micturition problems: Females 16 (14) 17 (14) .96

SS: Symptoms of GI-tract 12 (22) 20 (16) .01 POSTER

SS: Stoma-related problems 27 (21) 32 (23) .34 WEDNESDAY

FS: functionalscale; SS: symptomscale ABSTRACTS

METHODS: At a single institution between 1994–2004, 204 pts underwent APR for rectal cancer and received XRT (112 preop and 92 postop). One hundred and twenty nine (63%) pts were alive at last follow-up and mailed the EORTC QLQ-C30 and EORTC QLQ-CR38. Response rate was 68% (53 preop and 35 postop XRT) and not different between the two groups (69% vs. 67% p = 0.86). Median follow-up was 77 months (mo) (range 25–148 mo). Responders had a higher proportion of males (70% vs. 54%, p = 0.06) but

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were similar in age (59 vs. 62 years, p = 0.16) compared to non responders. Data are on a 0–100 point scale (100 = best [functional scales] or worst [symptom scales]; mean [SD]). RESULTS: Pts receiving preop XRT had a higher proportion of males (77% vs. 60%, p = 0.08 ) and a shorter median follow-up (62 vs. 103 mo, p < 0.001) compared to pts receiving postop XRT; however, the mean age (58 vs. 60 years, p = 0.73) was similar. There were no signiﬁcant clinical differences between the two groups in any of the symptom and functional subscales of the EORTC QLQ-C30 and EORTC QLQ-CR38 except GI tract symptoms which was worse in pts receiving preop XRT (20(16) vs. 12(12), p = 0.01). CONCLUSION: Among APR pts receiving XRT for locally advanced rectal cancer, timing of XRT (preop or postop) does not affect long-term patient QOL. These ﬁndings are important for counselling pts with locally advanced rectal cancer requiring an APR and XRT.

386 6303_SSAT.book Page 387 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1653 Sacral Neuromodulation for the Treatment of Fecal Incontinence and Voiding Dysfunction in Female Patients: A Longterm Follow Up Galal S. El-Gazzaz*, Levilester B. Salcedo, Massarat Zutshi, Tracy L. Hull Colorectal surgery, Cleveland Clinic, Cleveland, OH PURPOSE: Sacral nerve modulation (SNM) for fecal incontinence (FI) is not yet approved by the FDA. The aim of this study is to evaluate the efficacy of SNM in treatment of fecal incontinence with voiding dysfunction (VD) in female patients. METHODS: Twenty four female patients with FI and VD underwent two stage SNM implantation after successful peripheral nerve stimulation between October 2003–2007 by the Urologists. Patients demographics and morbidity were reviewed. The patients were evaluated by preoperative and postoperative questionnaires which included Wexner incontinence scores, Fecal Incontinence Quality of Life Scale (FIQL) and Bristol stool scale. This was done via review of their medical records and telephone interviews. RESULTS: Twenty four female patients underwent successful implantation of the stimulator. 16 patients could be contacted. The median follow up was 28 months (range 3–49 months). Seven (43.8%) experienced no symptom improvement after SNM, five (31%) patients had the stimulator removed; three (19%) because of poor clinical response and two due to infection at the site of the stimulator. Two (12%) received a colostomy for symptom control although the stimulator remains in place for urinary symptoms. Nine (56%) patients in whom SNM is currently functioning show significant improvement in their symptoms. Incontinence scores (Wexner 0–20,) was reduced from mean 15 ± 2.8 before sacral nerve stimulation to mean 10 ± 7.2 (p = 0.006). FIQL scores improved significantly with improvement in all areas: life style from 1.9 to 2.5 (p = 0.01), coping-behavior from 1.8 to 2.3 (p = 0.03), depression and self-perception from 2.5 to 3.2 (p = 0.003), and embarrassment from 2.39 to 3.03 (p = 0.03). This was also accompanied by a change stool form on the Bristol scale. CONCLUSIONS: SNM in patients with FI and VD helps control of symptoms and improves quality of life. The lack of FDA approval limits the use of SNM for FI as an exclusive diagnosis. POSTER POSTER

Table 1. Showing Preoperative and Postoperative Scores WEDNESDAY

Pre-Sacral Post-Sacral ABSTRACTS Parameter p-value Nerve Stimulation Nerve Stimulation Wexner Score for FI Mean ± SD 15.6 ± 2.8 10.13 ± 7.12 0.006 Life style 1.91 2.55 0.01 Fecal Incontinence Coping 1.18 2.30 0.03 Quality Of Life Scale (FIQL) Depression 2.52 3.23 0.003 Mean values Embarrassment 2.39 3.03 0.03

Wexner Score = 0–20 . 0 = Total continence

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W1654 Long Term Out Come and Quality of Life After Restorative Proctocolectomy in a Cohort of 955 Canadian Patients Marco Scarpa*1, Brenda I. O’Connor2, J Charles Victor2, Robin S. Mcleod2 1Clinica Chirurgica I, University of Padova, Padova, Italy; 2Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada BACKGROUND AND AIMS: Restorative proctocolectomy (RPC) is the procedure of choice for ulcerative colitis (UC) and familial adenomatous polyposis (FAP) but it has an important impact on quality of life (HRQL). The aims of this cross sectional study were to validate an English version of the Padova Inflammatory Bowel Disease Quality of Life questionnaire (PIBDQL) in patients undergoing RPC to investigate the possible predictors of long term HRQL. Functional outcome was also investigated. PATIENTS AND METHODS: In 2005, the English PIBDQL, the Short Inflammatory Bowel Disease Questionnaire, Short Form-36 and the Pelvic Pouch Follow-up questionnaires were mailed to 1379 patients who underwent RPC at the Mount Sinai Hospital between 1982 and 2004. Nine hundred sixty-nine (69%) returned the questionnaires. The translation and validation of PIBDQL into English language implied the assessment of test-retest reliability, internal consistency, construct validity and discriminative ability. RESULTS: The test-retest reliability, internal consistency, construct validity and discriminative ability of the English version of PIBDQL were adequate. Multivariate analysis showed that although female patients experienced the same rate of complications and stool frequency as males, they obtained worse PIBDQL scores (p < 0.01); patients with Crohn’s disease (CD) experience worse long term HRQL compared to UC or FAP patients (p < 0.01); patient who had pouch reconstruction obtained significantly worse scores than patients who had not.In our study group the 67% of patients reported a full continence during the day time after a follow up of about 9 years. Only very few patients (<1%) reported a complete day time incontinence. The bowel movement frequency in the 24 hours was 7.7 ± 3.2 and mean frequency during the night was 1.7 ± 1.3. Female patients reported more frequent sexual restrictions due to pelvic pouch. CONCLUSIONS: As far as we know, this is the largest series of RPC patients to be investigated with a disease specific tool for the measurement of HRQL and in this series female gender, CD and pouch redoing were significant risk factors for a worse HRQL long term outcome.

388 6303_SSAT.book Page 389 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1655 Colorectal Surgical Specimen Lymph Node Harvest: Improvement of Lymph Node Yield with a Physicians Assistant Robert C. Moesinger*1,2, Christopher L. Hall3, Jeffery A. Reese4 1Department of Surgery, McKay-Dee Hospital Center, Ogden, UT; 2Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT; 3Department of Pathology, McKay-Dee Hospital Center, Ogden, UT; 4Department of Radiology, McKay-Dee Hospital Center, Ogden, UT INTRODUCTION: Adequate lymph node harvest (at least 12) from colorectal cancer resection specimens has become a standard of care, inﬂuencing both staging and survival. To improve lymph node harvests in our hospital, a physicians assistant in the Department of Pathology was trained to harvest as many lymph nodes as possible from colorectal cancer specimens. An analysis of trends in lymph node harvest over time in our community hospital is presented. METHODS: Pathology reports were retrospectively reviewed of the number of lymph nodes harvested from 391 consecutive colorectal adenocarcinoma specimens in a single community hospital over an 8 year period (1999–2006). This spanned 4 years prior to the training of the physicians assistant and 4 years after. RESULTS: In the following table, results are given for each year in terms of average lymph node harvest and percent of specimens greater than 12 lymph nodes. Comparing 1999–2002 with 2003–2006, the difference in the average lymph node harvest reaches a p-value of <0.00001 (T-test). Comparing the number of specimens with at least 12 lymph nodes between 1999–2002 and 2003–2006, the difference reaches a p-value of <0.00001 (Chi-square).

Year # of Specimens Mean # of Lymph Nodes % Specimens with >11 Lymph Nodes 1999 18 13.3 67% 2000 48 12.2 50% 2001 53 14.3 55% 2002 49 14.4 67% Training of PA 2003 40 20.7 83%

2004 50 20.6 84% POSTER

2005 75 18.4 87% WEDNESDAY 2006 58 20.0 86% ABSTRACTS

CONCLUSIONS: As the awareness of the importance of adequate lymph node harvests in colorectal cancer specimens increased, lymph node harvests at our hospital steadily increased. The training of a physicians assistant to meticulously harvest as many lymph nodes as possible from colorectal cancer specimens dramatically affected lymph node harvests and can be a crucial component of pathologic analysis of these specimens.

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W1656 Relevance of Comorbidity for Postoperative Lethality and Morbidity After Surgery for Perforated Diverticulitis of the Sigmoid Colon Mario H. Mueller*, Mia Karpitschka, Michael S. Kasparek, Martin E. Kreis Department of Surgery, Maximilians-University, Munich, Germany INTRODUCTION: Perforated diverticulitis of the sigmoid colon is a common cause for emergency laparotomy. Several non-randomized studies reported in recent years that a sigmoid colectomy with primary anastomosis in Hinchey I–III patients yields similar results when compared to the Hart- mann procedure, while avoiding the frequently difficult operation for take- down and reanastomosis of the colostomy. The aim of this study was to review the results of this practise in our hospital and to identify patients at risk for morbidity and lethal outcome. METHODS: All patients who were admitted to our hospital with the diagnosis diverticulitis of the sigmoid colon from 1996 to 2006 were identified by the institutional data base and the patient charts reviewed. While 787 patients were admitted, 73 were operated on an emergency basis i.e., within 24 h after hospitalization (f:m ratio 1.3:1; median age 66 years, range 42–91). The primary end points were lethality, anastomotic leakage in patients with primary anastomosis and leakage of the rectal stump following Hartmann’s procedure. Statistical analysis was performed by Chi-Square Test. RESULTS: 36 (49%) of 73 patients who were operated on an emergency basis had a primary anastomosis without any stoma. 11 (15%) patients received a primary anastomosis and a loop ileostomy. A Hartmann procedure was performed in 26 (36%) patients. Complications were observed in 27 (37%) of all patients. Anastomotic leakage occurred in 9 of 36 patients (25%) following primary anastomosis without protective loop ileostomy and in 1 of 11 patients (10%) who had an additional loop ileostomy. Seven patients died. Six of them had undergone a Hartmann operation and two primary anastomosis; one with and one without loop ileostomy (total mortality 10%). The incidence of anastomotic leakage was independent of the Hinchey classification (Hinchey I. 3 pts, Hinchey II: 4 pts., Hinchey III 2 pts; n.s.), but associated with the comorbidity of the patients (ASA II: 1 pts; Asa III: 5 pts; ASA IV: III pts.; p < 0.05). CONCLUSIONS: Lethality and morbidity following operations for perforated sigmoid diverticulitis are high. Anastomotic leakage was primarily associated with severe comorbidity and was not dependent on the extent of the abdominal infection according to the Hinchey classification. The indication for a primary anastomosis following emergency surgery for sigmoid colectomy in perforated diverticulitis should not be based on the local intraabdominal findings but rather on the extent of the patients comorbidity.

390 6303_SSAT.book Page 391 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1657 Management and Treatment of Iliopsoas Abscess Parissa Tabrizian*, Scott Q. Nguyen, Alexander Greenstein, Uma Rajhbeharrysingh, Celia M. Divino General Surgery, The Mount Sinai Medical Center NY, New York, NY BACKGROUND: Iliopsoas abscess (IPA) is an uncommon condition presenting with vague clinical symptoms often resulting in delayed diagnosis and signiﬁcant morbidity. Treatment strategies remain nonstandardized. METHOD: A retrospective review was performed of patients diagnosed with IPA at the Mount Sinai Medical Center from 2000–2007. Records were reviewed with respect to patient demographics, medical history, predisposing and presenting features, diagnostic workup, laboratory results, microbiologi- cal investigation, treatment options and hospital course. RESULTS: IPA was diagnosed in 61 patients (M = 32, F = 29). The average age was 53 years. The majority of patients presented with pain (95%), gastrointestinal complaints (43%) and lower extremity pain (29%). Mean duration of symptoms was 13 days and mean hospital stay was 25 days. Primary abscess occurred in 11% and secondary in 89%. Underlying causes of secondary abscesses were gastrointestinal in 29%, bacteremia in 13%, immunosupressed state in 8%, and post-procedural in 8%. Broad spectrum antibiotics were pre- scribed in 100% of cases. Computed tomography (CT) was the most common diagnostic modality used and was successful in 88% of cases. Abscesses were larger than 6 cm in 39%, bilateral in 13% and multiple in 25%. 15% of patients were initially treated with antibiotics alone (Group1) with a success rate of 78%. 89% of these were less than 3.5 cm and the most common cause was bacteremia. 85% of patients initially underwent drainage (open 6% [Group2] and percutaneous 79% [Group3]) with a success rate of 100% and 40%, respectively. Among those cases which did not resolve, 71% ultimately required operative therapy. The majority of these cases had an underlying gastrointestinal etiology. Overall mortality was 5%. CONCLUSION: IPA remains a therapeutic challenge. Gastrointestinal disease is the most common underlying etiology. CT scan is the diagnostic modality of choice. Antibiotic treatment alone for abscesses less than 3.5 cm and without gastrointestinal cause is typically successful. Percutaneous drainage remains the primary initial treatment modality but rarely is the sole therapy required. Cases with a gastrointestinal etiology are likely to require ultimate operative management. POSTER WEDNESDAY ABSTRACTS

391 6303_SSAT.book Page 392 Tuesday, April 22, 2008 1:26 PM

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W1658 Comparison of GFAP Expression and Mucosal Mast Cell Numbers in Pediatric Intestinal Diseases Eumenia Castro*1, John Ozolek1, Kelly A. Miller2 1Pathology, Children’s Hospital of Pittsburgh, Pittsburgh, PA; 2Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA BACKGROUND: Enteric glia likely play major roles in gut barrier function and vascular integrity. Glial fibrillary acidic protein (GFAP) expression is decreased in Crohn’s, Hirschsprung Disease (HD), and necrotizing enterocoli- tis (NEC). Inflammatory cells including mast cells are present in normal bowel and evidence suggests a functional interaction between mast cells and enteric glia in diseased bowel. The aims are to enumerate and delineate the relationship between enteric glia and mucosal mast cell number in pediatric diseased bowel. DESIGN: Paraffin-embedded colon from 47 cases of ulcerative colitis (UC), resolved NEC (R-NEC), acute NEC (A-NEC), ischemic bowel (ISC), HD associated with inflammation (HDI), HD, and normal (NL) were stained for GFAP and mast cell tryptase. All stain controls were appropriate. Glial cells with a visible process and cytoplasmic staining for GFAP were counted in myenteric (M) and submucosal (S) plexi. In HD, cells were counted in ganglionic (G), transitional zone (TZ), and aganglionic segments (AG). Non-parametric analysis was done with p-values <0.05 significant. Results are shown as density (median number of cells per centimeter; minimum and maximum values in parentheses). RESULTS: Glial cells (M) were greater than glial cells (S) except in UC where UC demonstrated the highest median number of glial (S). Glial (M) in ISC and A-NEC were significantly higher than glial (S). While glial cells within the ganglionic segment of HDI were greater than in the TZ, this was not statistically significant. UC and NL had significantly higher number of mast cells compared to other groups (p < 0.05). The number of mast cells did not differ between the G, TZ, and AG segments in either HDI or HD. A-NEC had the highest ratio of glial (M) to mast cell number (1.18) while A-NEC, HDI, and HD had the highest ratio of glial (S) to mast cell number (0.10, 0.17, and 0.095 respectively). CONCLUSION: Mast cell numbers appear increased in UC. HD shows decreased myenteric glial cells compared to other groups except NL. Other conditions including HD show decreased numbers of mast cells compared to NL and UC. We speculate that mucosal mast cells may exert an effect on expression of GFAP within submucosal glial cells under chronic inflammatory conditions.

MAST MAST MAST N GFAP#-G-M GFAP#-G-S GFAP#-TZ-M GFAP#-TZ-S CELL#-G CELL#-AG CELL#-TZ NL 80 (0,53) 0 (0,2) — — 110 (45,72) — — UC 7 12 (0,30) 12 (0,50) — — 180 (57,222) — — HDI 7 30 (2,55) 10 (0,41) 7.5 (0,49) 9 (0,35) 51 (39,110) 40 (22,45) 51.5 (20,68) HD 6 3.5 (0,49) 3 (0,8) 5 (0,23) 6 (1,15) 43 (18,66) 44.5 (21,63) 40 (26,56) ISC 7 36 (0,72) 0 (0,3) — — 64 (28,180) — — A-NEC 7 30 (0,80) 1 (0,15) — — 29 (9,72) — — R-NEC 5 22 (0,75) 0 (0,10) — — 62 (46,90) — —

392 6303_SSAT.book Page 393 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Esophageal

W1659 Outcomes of Laparoscopic Assisted Transhiatal Esophagectomy for Adenocarcinoma of Esophagus Martin I. Montenovo*, Kyle J. Chambers, Carlos A. Pellegrini, Brant K. Oelschlager Surgery, University of Washington, Seattle, WA HYPOTHESIS: Laparoscopic-assisted transhiatal esophagectomy (LA-THE) decreases the morbidity and mortality associated with esophagectomy, at the same time enabling a more oncologic operation. DESIGN: Retrospective cohort study. SETTING: University tertiary care medical center METHODS: Seventy-two consecutive patients that underwent LA-THE for adenocarcinoma between 9/1995 and 12/2006. Follow-up was complete to July 2007, 6 to 140 (mean 34) months after LA-THE. RESULTS: Patient characteristics and treatment: Mean patient age: 63.9 ± 9.6 years; mean body mass index: 27.5 ± 3.8. Thirty-nine patients (54%) underwent neoadjuvant chemoradiotherapy. LA-THE was used in all patients. The mean operative time: 321 ± 73 minutes; blood loss 318 ± 239 ml. All margins were free of cancer and a mean of 11 ± 7 lymph nodes were retrieved. The median ICU stay was 1 day (1–35) and hospital-stay 9 days (7–58). One patient (1.4%) died within 30-days postoperatively. Complications: Minor: atrial ﬁbrillation 8 (11.1%) patients; pleural effusion 9 (12.5%); wound infection 7 (9.7%); transient recurrent nerve palsy 6 (8.3%); pneumothorax requiring no intervention 12 (16.7%). Major complications: anastomotic leak requiring intervention 7 (9.7%) patients; anastomotic leak requiring no intervention in 7 (9.7%); pneumonia in 7 (9.7%); pneumothorax requiring intervention 6 (8.3%); deep vein thrombosis 4 (5.5%); pulmonary embolism 3 (4.1%); myocardial infarction 2 (2.7%). Late complications included anastomotic stricture in 13 (18.0%) patients. (See Survival Table) CONCLUSION: Our study suggests that LA-THE may reduce morbidity and mortality of esophagectomy and with good survival rates, thus should be considered an alternative to open esophagectomy in the treatment of esophageal adenocarcinoma. POSTER POSTER

Table 1. Kaplan-Meier Survival by stage WEDNESDAY

1-Year 3-Year 5-Year ABSTRACTS Stage I (n = 22) 100% 100% 80% Stage IIa (n = 21) 86% 57% 57% Stage IIb (n = 5) 100% 80% 80% Stage III (n = 24) 68% 41% 41% Overall 85% 68% 63%

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W1660 The Challenge of Diagnostic Assesment of a Failed Fundoplication: Benefits of High-Resolution Manometry of the GE-Junction Attila Dubecz*, Renato Salvador, Marek Polomsky, Oliver Gellersen, Thomas J. Watson, Jeffrey H. Peters University of Rochester, Rochester, NY BACKGROUND: Assessing symptomatic patients following failed fundoplication can be challenging. Although upper endoscopy, and barium esopha- gography often reveal anatomic abnormalities, functional information allowing insight into the cause of recurrent symptoms can be key to clinical decision making. Previous studies have shown that LES residual pressures or percent LES relaxation measured by postoperative conventional manometry correlates with dysphagia, but it is highly susceptible to interobserver variability. High resolution manometry (HRM) is a novel, imaged based technology which may yield superior, more easily interpreted results in the evaluation of esophageal function particularly given difficult postoperative anatomy. AIM: To study the high resolution manometric characteristics of postfundoplication patients with dysphagia. PATIENTS AND METHODS: The study population consisted of 17 patients with foregut symptoms following fundoplication referred between 2005–2007. The most common symptom was dysphagia in 12/17 (71%), regurgitation in 9 (53%), heartburn in 4 (24%), cough in 3 (18%), vomiting in 2 (12%), chest- pain in 5 (29%) and bloating in 1 (6%). HRM studies were analyzed systemat- ically with particular attention to characteristics of the neo-high pressure zone including resting/residual pressure, total and abdominal length and esophageal body function. Values of 50 normal subjects studied in the same laboratory were used as reference. Endoscopy revealed a failed fundoplication in 13/17 patients, 4 patients had no apparent anatomic changes. RESULTS: Percent LES relaxation was significantly lower (31.4 vs. 76.1), and LES residual pressure was significantly higher (12.1 vs. 6.1) in postfundoplication patients. Eighty eight percent of the patients had lower than normal intra-abdominal LES lengths. There was no significant difference between esophageal body amplitudes. A majority (59%) of post-fundoplication patients had abnormal double-peaked waves suggesting outflow obstruction. The percent LES relaxation in postfundoplication patients with dysphagia was significantly lower than in patients with other symptoms. CONCLUSION: HRM revealed high residual pressures and low percent LES relaxations of the neo-high pressure zone in virtually all patients with postfundoplication dysphagia. Further this measure correlated with the presence of dysphagia. The image based analysis and high density of recording sides coupled with software interpolation available in HRM, allows novel and clinically useful observations in the evaluation of complex esophageal pathology.

394 6303_SSAT.book Page 395 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1661 Looking Beyond Age and Comorbidities as Predictors of Outcomes in Paraesophageal Hernia Repair Anirban Gupta*1, David C. Chang1,2, Michael A. Schweitzer1, Kimberley E. Steele1, Anne O. Lidor1 1Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 2Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD INTRODUCTION: Patients undergoing paraesophageal hernia (PEH) repair are typically older with more comorbidities than patients undergoing antireflux operations for gastroesophageal reflux disease (GERD) and these factors are thought to contribute to worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes. METHODS: We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001–2005). Patients undergoing any abdominal anti-reflux operation with or without PEH repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with GERD or PEH, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed, one adjusting for pre-treatment variables (age, gender, race, comorbidities, hospital teaching status and volume of antireflux surgery, calendar year), and the second adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax [PTX], hemorrhage, cardiac, pulmonary, and thromboembolic events [VTE]). RESULTS: Of the 23,458 patients, 6706 patients had PEH. Of 88 total deaths, 50 were in the PEH group (0.75%). PEH patients are older (60.4 vs 49.1, p < 0.001) and have significantly more comorbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. (Table) Further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients. Adjustment for cardiac complications or PTX does not eliminate the difference. CONCLUSIONS: Although PEH patients have worse post-operative outcomes than GERD patients, age and comorbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of VTE. Additionally, the POSTER impact of hemorrhagic complications underscores the importance of experi- WEDNESDAY

enced surgeons. ABSTRACTS Complications OR: PEH vs GER (95% CI) p-value Mortality 1.81 (1.06–3.09) 0.030 Esophageal laceration 2.00 (1.29–3.10) 0.002 Splenectomy 1.44 (1.03–2.01) 0.033 Technical Pneumothorax 2.45 (1.64–3.65) 0.000 Hemorrhage 1.53 (1.22–1.92) 0.000 Pulmonary 1.48 (1.26–1.75) 0.000 Peri-op Cardiac 2.11 (1.43–3.11) 0.000 Thromboembolic 2.34 (1.29–4.23) 0.005

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W1662 No Additional Value of Bronchoscopy After EUS in the Preoperative Assessment of Patients with Esophageal Cancer at or Above the Carina Mark Van Heijl*1, Jikke M. Omloo1, Jacques J. Bergman2, Mia G. Koolen4, Mark I. Van Berge Henegouwen1, Jan J. Van Lanschot1,3 1Surgery, Academic Medical Centre, Amsterdam, Netherlands; 2Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Erasmus Medical Center, Rotterdam, Netherlands; 4Pulmonary Diseases, Academic Medical Center, Amsterdam, Netherlands INTRODUCTION: Esophageal cancer is an aggressive disease with a strong tendency to infiltrate into surrounding structures. Especially tumors at or above the carina are associated with early invasion of the tracheobronchial tree, precluding radical surgical resection. Endoscopic ultrasonography (EUS) is considered the most accurate diagnostic modality to determine the T-stage of the tumor. In the preoperative work-up for patients with tumors at or above the carina, it is recommended to perform a bronchoscopy (with biopsy on indication) to exclude airway invasion. Aim of the present study is to determine the additional value of bronchoscopy (with biopsy on indication) for detecting invasion of the tracheobronchial tree after having performed EUS in the preoperative assessment of patients with esophageal cancer at or above the carina. METHODS: Between January 2003 and December 2006, 45 patients were analyzed in our department for histologically proven esophageal cancer at or above the carina. All patients underwent both EUS and bronchoscopy (with biopsy on indication) in the preoperative assessment of local resectability. RESULTS: After extensive diagnostic work-up 19 of 45 patients (42%) were eligible for potentially curative oesophagectomy. Distant metastases were found in 13 of 26 patients (50%) not suitable for curative surgery. In the 13 other patients (50%) local irresectability (T-stage 4) due to invasion of vital structures was described on EUS: invasion of the aorta in three patients, invasion of the pleura in six patients and invasion of the lung in two patients; in two patients invasion of the tracheobronchial tree was described, which was confirmed by bronchoscopy with positive biopsy results. Therefore, no additional value of bronchoscopy after EUS was seen in this cohort of patients. CONCLUSION: For patients with newly diagnosed esophageal tumors at or above the carina, no additional value of bronchoscopy (with biopsy on indication) to exclude invasion of the tracheobronchial tree is seen after performing EUS in a specialized centre. Even though based on small numbers, we conclude that bronchoscopy is not indicated if no invasion of the airways is identified on EUS.

396 6303_SSAT.book Page 397 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1663 Analysis of First-Time Antireflux Redo-Surgery Versus Multiple Redo-Surgery Karl H. Fuchs*, Wolfram Breithaupt, Martin Fein Surgery, Markus-Krankenhaus, Frankfurt, Germany INTRODUCTION: Laparoscopic antireflux surgery is well established since more than 15 years. Redo-antireflux surgery with laparoscopic and open access is following this development, since 4%–5% of failures need operative revision. The purpose of this study is the analysis of a possible difference between a first time failure and redo-surgery versus multiple failures and multiple Redo-surgery. METHODS: In a center with experience of approximately 80 primary laparoscopic antireflux cases per year in a time period of 10 years 104 consecutive redo operations were performed and all involved perioperative details were prospectively documented. There were 61 males and 43 females with a mean age of 48 years (17–85). Diagnostic work up consisted of history and physical examination, endoscopy, video barium sandwich study, esophageal manometry, 24 pH monitoring and in selectve cases bilirubine monitoring and scintg- raphy. Operative techniques in Redo surgery consisted of laparoscopic adhesiolysis, esophageal mobilisation, hiatoplasty, fundoplication full or partial, in case of short esophagus a lengthening by Collis plasty and in cases of massive shortage and/or destruction, strictures and scaring of the gastroesophageal junction a resection and jejunal interposition or gastrectomy and Roux-en-Y pouch reconstruction.All details were prospectively documented. Follow up was performed within the first year. Quality of Life was assessed by the Gastrointestinal Quality of Life Inedx GIQLI. RESULTS: Redo-surgery was performed in 59 first failure cases (group FR) and in 45 multiple failure cases (group MR). Recurrent reflux was the major problem in the first failure cases (81%) compared to 53% in the multiple failure cases. Dysphagia was similar frequent in both groups. However pain and vomiting was significant different (FR: 6%; MR: 36%). Major reason for failures were in both groups migration (FR: 53%; MR: 40%). In the MR group paraesophageal herniation and scaring (“frozen Hiatus”) was an important reason for pain and vomiting. Standard Nissen and Toupet fundoplication in the laparoscopic technique was performed in 93% in the FR group and only in 53% in the MR group. Collis-plasty and resections were performed in 46%

of the MR group. Outcame in Quality of life showed preop/postop 1year: FR POSTER

in 14% <100 (normal 120) MR in 29% <100. WEDNESDAY

CONCLUSION: Multiple failures of laparoscopic antireflux procedures are ABSTRACTS difficult to manage. Outcome can be worse than first time redo-surgery. Pain and vomiting are major symptoms, which require revision. Therefore revision in cases with multiple failure should be performed in specialized centers.

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W1664 A Meta-Analysis of Trials Comparing the Effectiveness of Use of Mesh in Laparoscopic Repair of Paraesophageal Hernias Anne O. Lidor*1, Debraj Mukherjee1, Dorry Segev1, David C. Chang1,2, Kimberley E. Steele1, Michael A. Schweitzer1 1Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 2Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD OBJECTIVE: Paraesophageal hernias (PEH) are commonly and safely repaired via a laparoscopic approach, usually with a posterior cruroplasty followed by an anti-reﬂux operation. Unfortunately, there is a relatively high rate of recurrent hiatal herniation reported postoperatively. We sought to determine the effectiveness of the routine use of mesh in laparoscopic repair of PEH. METHODS: A systematic literature search (Medline, Embase, Cochrane Library, and Pub of Med) was performed to identify all eligible articles. Ran- domized controlled trials (RCT) and prospective cohort studies (PCS) comparing use of mesh (biologic and prosthetic) versus primary suture repair were reviewed and the methodologic quality of included studies was evaluated independently by 2 authors. Pooled estimates of relative risk of recurrences were calculated using a random effects model to account for heterogeneity in study designs.

RESULTS: In total, 216 abstracts were reviewed and assessed for eligibility, with 3 RCT and 3 PCS identified. A total of 455 patients were analyzed. Mesh closure was associated with 60% lower risk of recurrence than primary suture repair (Relative risk (RR) = 0.40, 95% CI 0.22 to 0.73, p = 0.003). Similar trends were seen when stratified by study design type (for RCT, RR = 0.30, 95% CI 0.15 to 0.62, p = .001) but were not statistically significant for cohort studies (RR = 0.77, 95% CI 0.26 to 2.34, p = 0.60), possibly due to sample size (only 47 patients with mesh closure in PCS) or selection biases inherent in PCS. There were no reports of mesh erosion in any study. CONCLUSION: In pooled analysis, the use of mesh seems to offer an advantage over primary suture closure in laparoscopic repair of paraesophageal hernia. Future well designed studies evaluating the clinical implications of use of biologic versus prosthetic mesh are warranted.

398 6303_SSAT.book Page 399 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1665 Prediction of Response to Neoadjuvant Therapy in Esophageal Carcinoma by PET-CT Kirsten Thurau*1, Matthias Bruewer1, Joerg Haier1, Christine Franzius2, Kai U. Juergens3, Norbert Senninger1 1Surgery, University of Münster, Münster, Germany; 2Nuclear Medicine, University of Muenster, Muenster, Germany; 3Radiology, University of Muenster, Muenster, Germany OBJECTIVES: To evaluate the use of hybrid positron emission tomography using [(18)F]-fluorodeoxyglucose (FDG-PET)/CT scan in the assessment of primary staging and evaluation of treatment response during neoadjuvant radio-chemotherapy (RTX) in esophageal carcinoma (EC). BACKGROUND DATA: In EC accurate pre-therapeutic tumour evaluation should be provided for a multi-disciplinary and individually tailored patient management programme. Therefore, the ability to predict early treatment response in an individual EC patient would greatly aid therapeutic planning. METHODS: 84 patients with histologically proven EC underwent PET/CT. 28 patients underwent primary esophagectomy, 9 palliative treatment and 47 neoadjuvant RTX (cisplatin, 5-FU, radiation: 50.4 Gy). In the latter PET/CT was repeated 6 weeks after induction chemotherapy. Quantitative measurements of tumour FDG uptake (SUV) were correlated with histopathologic response. Degree of histomorphologic regression was classified into major (<10% vital residual tumor cells [VRCT]) and minor histomorphologic response (≥10% VRCT). Statistics: Wilcoxon U-test RESULTS: At primary staging SUV was increased in 81 of 84 EC (negative in 3 T1 tumours) and was more intense towards locally advanced tumours. Additional findings by PET/CT were found in 15 patients leading to a therapy change in 6. In patients with primary esophagectomy pathologic lymph nodes were found in 14 and 8 by endoscopic ultrasound and PET/CT (histology n = 10), respectively. Until now 36 patients underwent surgery after RTX. Overall SUV decreased in median by 52%. 4 patients did not show any decrease in SUV after induction therapy. In patients with major histomorphologic response decrease of SUV was significantly higher than in patients with minor histomorphologic response (67% vs 45%, p < 0.001). CONCLUSIONS: PET/CT is a valuable tool for the noninvasive assessment of initial staging and histopathologic tumour response during neoadjuvant RTX and may differentiate responding and nonresponding tumours early. By POSTER avoiding ineffective and potentially harmful treatment, this may markedly WEDNESDAY

facilitate the use of preoperative therapy, especially in patients with poten- ABSTRACTS tially resectable tumors.

399 6303_SSAT.book Page 400 Tuesday, April 22, 2008 1:26 PM

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W1666 Endolumenal Fundoplication with EsophyX™: The Initial North American Experience Simon Bergman*1, Cedric S. Lorenzo2, Blair A. Jobe2, Dean J. Mikami1, John G. Hunter2, W. S. Melvin1 1Department of Surgery, The Ohio State University Medical Center, Columbus, OH; 2Department of Surgery, Oregon Health and Science University, Portland, OR BACKGROUND: EsophyX™ is a novel endolumenal therapeutic option for treatment of gastroesophageal reflux disease (GERD). The device is passed over an endoscope into the stomach where it deploys a series of fasteners to create a neo-gastroesophageal valve. Phase I European data has demonstrated proton pump inhibitor (PPI) discontinuation in 80% of patients at six months. The objective of this study was to demonstrate the safety and characterize the effectiveness of this approach by measuring postprocedural subjective outcomes, such as quality of life and symptom severity. METHODS: This is a retrospective multicenter study of consecutive patients with GERD having undergone endolumenal fundoplication with the EsophyX™ device, at two institutions. Demographic and periprocedural data were collected. At follow-up, PPI usage was elicited and two validated questionnaires were administered measuring GERD health related quality of life (HRQL) (range 0–50) and symptom severity (range 0–72). Data is reported as mean ± standard deviation. RESULTS: Seven patients (3 males, 4 females) underwent endolumenal fundoplication between September and November 2007. Mean age was 50 ± 14 years and body mass index was 32 ± 4 kg/m2. All patients had abnormal pre- procedural ph studies. All cases were done under general anesthesia with nasotracheal intubation. Mean procedural time was 63 ± 28 minutes and there were no complications. At a mean follow-up of 39 ± 22 days, 4/7 patients were not taking PPIs. These patients reported being satisfied with their present condition, whereas those still on PPIs were either neutral or dis- satisfied. Mean GERD-HRQL score was 8 ± 8 and mean symptom severity score was 18 ± 16. CONCLUSION: The initial North American experience with EsophyX™ endolumenal fundoplication suggests that this procedure is associated with low morbidity and is both safe and effective in treating GERD. Further studies comparing this technique to conventional medical and surgical therapies are necessary.

400 6303_SSAT.book Page 401 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1667 Analysis of Utilization and Outcome of Laparoscopic and Open Paraesophageal Hiatal Hernia Repair Marcelo W. Hinojosa*, Kevin M. Reavis, Dhavan Parikh, Esteban Varela, Ninh T. Nguyen University of California, Irvine Medical Center, Orange, CA BACKGROUND: Paraesophageal hiatal hernia operations are complex and the most appropriate operative approach (lap vs. open) remains controversial. The aim of this study was to compare the utilization and outcome of laparoscopic versus open paraesophageal hiatal hernia repair performed at academic medical centers. METHODS: Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium clinical database of 1,824 patients who underwent laparoscopic or open paraesophageal hiatal hernia repair between 2004 and 2007. The data were reviewed for demographics, length of hospital stay, 30-day readmission, morbidity, observed-to-expected (risk-adjusted) mortality, and costs. RESULTS: A total of 1,281 patients underwent laparoscopic repair and 543 patients underwent open repair. Patient who underwent laparoscopic repair had a signiﬁcantly shorter length of stay (3.1 vs. 7.3 days, p < 0.001); lower 30-day readmission rate (1.8% vs. 4.3%, p < 0.01); lower overall complications (16.1% vs. 31.1%, p < 0.001); lower rates of wound infections and hemorrhagic complications, and lower costs ($11,459 vs. $18,392, p < 0.001). Observed-to-expected mortality ratio was 1.2 for the laparoscopic group and 0.8 for the open group, with no difference in the observed in-hospital mortality (0.6% vs. 0.6%). CONCLUSION: Within the context of this analysis of academic centers, the current practice of paraesophageal hiatal hernia repair is primarily the laparoscopic approach. Laparoscopic paraesophageal hiatal hernia repair is as safe as open repair but was associated with a signiﬁcantly shorter length of stay, lower morbidity, and cost. POSTER POSTER WEDNESDAY ABSTRACTS

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W1668 High Prevalence of Lymph Node Metastases in pT1 Esophageal Cancer: Is Local Therapy Justified? Ines Gockel*1, Torsten Hansen2, Faszillo S. Sultanov1, Tran T. Trinh1, Mario Domeyer1, Ursula Goenner1, Theodor Junginger1 1Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany; 2Institute of Pathology, Johannes Gutenberg-University, Mainz, Germany BACKGROUND: Treatment of pT1 esophageal cancer is increasingly performed by endoscopic local therapy. The aim of our study was to analyze the distribution of lymph node metastases in esophageal resectates of mucosal- (pT1a) and submucosal esophageal cancer (pT1b, sm level I–III) with a differentiated view of the two predominant histologic tumor types. METHODS: Out of 507 patients who underwent esophageal resection due to malignancy between 9/1985 and 8/2007 in our department, in 62 patients a pT1-squamous cell carcinoma or adenocarcinoma was found. In 45 of these, paraffine-embedded blocks were worked up by a single pathologist (T.H.) with respect to the differentiation between mucosal and submucosal (sm) carcinomas and—in the latter—the tumor depth according to the level sm I–III classification. All patients had a complete follow-up. RESULTS: Lymph node metastases were found in 14.3% of pT1a squamous cell cancers and in 10% of pT1a adenocarcinomas. pT1b sm level I–II tumors revealed a positive lymph node rate in 16.7% (squamous cell cancer) and in 28.6% (adenocarcinoma) respectively. Sm level III-squamous cell carcinomas had in 20% and adenocarcinomas in 25% a pN1-category. Long-term survival was not statistically significant different between pT1a, sm I–II und sm III- esophageal cancers with respect to both histologic tumor types (log rank-test: p = 0.6578 (squamous cell carcinoma) and p = 2.162 (adenocarcinoma) respectively). CONCLUSION: pT1 esophageal cancer reveals a high prevalence of lymph node metastases. Curative treatment in these patients can only be achieved by surgical resection and radical lymph node dissection. Local-therapeutic procedures in esophageal cancer requisite a perfect pretherapeutic staging with detection of all potential lymph node metastases.

402 6303_SSAT.book Page 403 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1669 The Use of Alveolus Stents in the Treatment of Esophageal Leaks, Perforation or Fistulae Irfan Qureshi*, James D. Luketich, Miguel Alvelo-Rivera, Rodney J. Landreneau, Sebastien Gilbert, Matthew J. Schuchert, Arjun Pennathur Heart,Lung and Esophageal Surgery Institute, University of Pittsburgh Medical center, Pittsburgh, PA BACKGROUND: The new generation of a hybrid esophageal stent (Alveo- lus), combines the features of plastic and self-expanding metallic stents. These stents are utilized for various esophageal benign and malignant diseases. The main objective of this study is to evaluate our initial experience with Alveolus expandable stents in the treatment of esophageal leaks, perforations, or fistulae. METHODS: A total of 19 Alveolus stents were placed in 7 patients for an esophageal perforation, leak from an esophagogastric anastomosis after esophagectomy, and a tracheoesophageal fistula. All 7 patients were men, with a median age of 66 years (range 25–83). The most common indication for placement in this study was for an anastomotic leak in 5 patients (72%). They were placed for perforation in 1 patients (14%); and for a tracheoesophageal fistula in 1 patient (14%). The primary location for stent placement was in the distal esophagus in 5 patients (72%) while the remaining 2 patients had placement of the stent in the proximal esophagus. We evaluated the hospital course, complications, and outcomes. RESULTS: The median stay was 26 days (range of 0–100). Complications included migration in 3 patients (42%), recurrent fistula in 1 patient , and a disruption in the esophagogastric anastomosis in 1. Reintervention was required predominantly due to migration of the stent at a mean interval of 37 days days (range 0–150). The stent successfully occluded leak or fistula in a majority of patients (4/7 = 57%). A total of 6 patients (85%) also had drainage established as an adjunct to stent placement. In patients with an esophageal leak, two of the five patients (40%) also underwent a thoracoscopic drainage procedure for the leak. CONCLUSIONS: Alveolus Stent is a newly designed stent with potential applications in various esophageal diseases. They are not commonly used for the treatment of esophageal perforations or leaks, however had a reasonable

success in this selected group. Their primary disadvantage is a high migration POSTER

rate and further improvements in design are required to decrease this high WEDNESDAY incidence of migration. ABSTRACTS

403 6303_SSAT.book Page 404 Tuesday, April 22, 2008 1:26 PM

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Clinical: Hepatic

W1670 Treatment Strategy for Synchronous Metastases of Colorectal Cancer: Is Hepatic Resection After an Observation Interval Appropriate? Yasuhiro Shimizu*, Tsuyoshi Sano, Kenji Yamao, Yuji Nimura Aichi Cacer Center Hospital, Nagoya, Aichi, Japan BACKGROUND: In cases of synchronous colorectal hepatic metastases the primary colorectal cancer maintains a strong inﬂuence on the metastases, so the possibility of occult hepatic and extrahepatic metastases must be kept in mind. Our treatment policy has been to reevaluate the metastases at an interval of 3 months after colorectal resection and determine treatment strategy. We examined the appropriateness of interval hepatic resection for synchronous hepatic metastasis. METHODS: Study1. The subjects were 164 patients who underwent resection of hepatic metastasis of colorectal cancer (synchronous, 70 patients; metachronous, 94 patients) between January 1983 and December 2003. Back- ground factors for hepatic metastasis and postoperative results were compared for synchronous and metachronous cases. Study2. Of the patients who underwent colon resection at our hospital between 1995 and 2005, the treatment course was investigated for 28 interval patients with no extrahepatic lesion remnants at colorectal surgery and a simultaneously resectable liver (H1 group). RESULTS: Study1. The cumulative survival rate for 164 patients at 3, 5, and 10 years postoperatively was 71.9%, 51.8%, and 36.6%, and the post-resection recurrence rate in remnant livers was 26.8%. Interval resection for synchronous hepatic metastases was conducted in 49 cases after a mean interval of 131 days. No difference was seen in postoperative outcome between synchronous and metachronous cases. Study2. The treatment course in the H1 group was decided after an observation interval. Hepatic resection was not indicated in 9 of the 28 patients during the interval. New lesions appeared during the interval in 7 of 19 interval hepatic resection patients. In 16 of 28 (57%) interval patients there was a change in the hepatic resection procedure or surgical indications. CONCLUSION: Delaying resection allows accurate understanding of the number and location of hepatic metastases, and is beneﬁcial in determining candidates for surgery and in selecting surgical procedure.

404 6303_SSAT.book Page 405 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1671 Non-Operative Management of High Grade Liver Injuries Beat Schnüriger*, Miranda Schafer, Daniel Inderbitzin, Jean-Marc Heinicke, Daniel Candinas Visceral and Transplantation Surgery, Bern University Hospital, Switzerland, Bern, Switzerland OBJECTIVE: Modern approach to complex abdominal trauma favours conservative treatment including endovascular intervention for solid organ lesions. The aim of this study was to review the safety of non-operative management of high-grade (III–IV) liver injuries (NOMLI) beyond established criteria as defined by algorithms of Advanced Trauma Live Supportâ (ATLSâ). METHODS: All patients with liver injuries (LI) admitted our hospital between 2000–2006 were included. LI were identified by contrast enhanced abdominal computed tomography scan or laparotomy and graded according to Moore et al. NOMLI was attempted in all hemodynamically stable patients. RESULTS: A total of 186 (125 male, 61 female) patients with LI were identified. There were 180 blunt and 6 penetrating abdominal traumas. Mean injury severity score (ISS) of the operatively and non-operatively treated patients was 29.8 ± 12.1, and 26.6 ± 12.5 respectively (p = 0.1438, students t-test). 42 patients required immediate surgical or endovascular abdominal interventions. Of these, 19 (45.2%) procedures were purely liver related. All of these liver lesions were grade III, IV and V. Endovascular coiling was carried out in 3 out of 19 patients. One patient needed surgical evacuation of a hematoma on day 3 after selective coiling of a right segmental hepatic artery. In total, 169 out of 186 (90.9%) patients profited from a NOMLI. Alternative indications for a primarily surgical approach were splenic injuries grade IV–V in hemodynamically unstable patients (n = 10), penetrating abdominal injury (n = 6), major intra-abominal vascular lesion (n = 4), and visceral perforation (n = 3). The overall cohort mortality was 16.7% but only 6 patients died due to the LI (3.2%). A total of 59 (73.8%) out of 80 patients with LI grade III–V were primarily managed by NOMLI. Of these patients, 8 (13.6%) suffered from liver related complications (5 biliary leakages, 1 abscess formation and 2 delayed bleedings) and 14 (23.7%) from extra-abdominal complications.

CONCLUSIONS: Even in high grade LI (grade III–IV) NOMLI represents a POSTER

safe treatment option with a low probability of liver related (13.6%) but a rel- WEDNESDAY atively high rate of extra-abdominal complications (23.7%). The successful management of LI implements in the majority of cases the treatment of col- ABSTRACTS lateral injuries and general complications. The option of endovascular coiling seems to lower the risk of emergency laparotomies and the rate of NOMLI failure. The beneﬁt and safety of endovascular interventions and the timely and correct implementation into the trauma algorithms requires further investigation.

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W1672 Yttrium-90 Microsphere Induced Gastrointestinal Tract Ulceration Christopher D. South*1, Marty M. Meyer1, Gregory Meis1, Edward Y. Kim2, Fred B. Thomas1, Mark Bloomston3 1Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Medical Center, Columbus, OH; 2Radiation Oncology, The Ohio State University Medical Center, Columbus, OH; 3Division of Surgical Oncology, The Ohio State University Medical Center, Columbus, OH BACKGROUND: Selective internal radiotherapy (SIRT) utilizing yttrium-90 microspheres has been shown to be as effective as regional treatment for primary and secondary hepatic malignancies. Although there has been an increase in the utilization of SIRT, little has been reported about the extent or frequency of gastrointestinal complications. We sought to determine the frequency of symptomatic GI tract ulceration as a complication of the procedure. METHODS: Between 2004 and 2007, 27 patients underwent SIRT for hepatic malignancies. All patients underwent a pre-procedural arteriogram to evaluate vascular anatomy and a macroaggregated albumin study to quantify extra-hepatic shunting. Charts were subsequently reviewed to determine the incidence and severity of GI ulceration. No patients were lost to follow-up. RESULTS: SIRT was completed in 27 patients for colorectal metastases (N = 15), hepatocellular carcinoma (4), cholangiocarcinoma metastases (2), neuroendocrine metastases (2), unknown primary metastases (2), prostate metastases (1), and melanoma metastases (1). Three patients presented with gastrointestinal bleeding (two with concomitant abdominal pain) and underwent upper endoscopy 2, 3.5, and 5 months after SIRT. Angiograms prior to SIRT showed normal vascular anatomy in two while one patient who had undergone prior chemoembolization had evidence of sclerosed hepatic vasculature. None had undergone prophylactic gastroduodenal artery (GDA) embolization. Endoscopic findings included diffuse inflammation, small gastric ulcerations, and large gastric ulcers (>15 mm) with surrounding inflammation. Microspheres were visible on endoscopic biopsy. In two patients, gastric ulcers were persistent at the time of repeat endoscopy 1–4 months later despite proton pump inhibitor therapy. One elderly patient who refused surgical intervention died from recurrent hemorrhage. CONCLUSION: Gastrointestinal ulceration is a known yet rarely reported complication of Y90 microsphere embolization with potentially life-threatening consequences. Since vague upper abdominal discomfort is common after SIRT and often not thoroughly evaluated, the true incidence of occult ulceration is not known. Once diagnosed, refractory ulcers should be considered for aggressive surgical management.

406 6303_SSAT.book Page 407 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1673 Hepatic Neuroendocrine Metastases: Bland or Chemoembolization? Susan C. Pitt*2,6, Jamie Knuth6, James M. Kiely4, John C. Mcdermott1, Sharon M. Weber2, William S. Rilling3, Edward J. Quebbeman4, David M. Agarwal5, Henry A. Pitt6 1Department of Radiology, University of Wisconsin, Madison, WI; 2Department of Surgery, University of Wisconsin, Madison, WI; 3Department of Radiology, Medical College of Wisconsin, Milwaukee, WI; 4Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; 5Department of Radiology, Indiana University, Indianapolis, IN; 6Department of Surgery, Indiana University, Indianapolis, IN INTRODUCTION: Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Treatment options include hepatic resection, tumor ablation, and hepatic artery embolization. However, most of these patients have multiple, bilobar metastases. As a result, in recent years hepatic artery approaches have become more popular. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. Therefore, we designed a study to test the hypothesis that hepatic artery chemoembolization (HACE) would result in better survival than bland embolization (HAE) in patients with hepatic NE metastases. METHODS: Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through June 2007. Overall survival from both the date of diagnosis of metastases and the date of first treatment was calculated using the Kaplan- Meier method. RESULTS: The study identified 98 patients managed by HACE (n = 47) and HAE (n = 51). Patients were similar with respect to age (57.7 vs. 54.4 yrs), gender (49 vs. 37% female), and primary tumor type (gastrointestinal carcinoid 60 vs. 51% or pancreatic islet cell 30 vs. 29%). However, the HACE patients underwent a greater number of hepatic artery procedures (2.98 vs. 2.08, p = 0.01). Median and 5-year survival results are presented in the table below from the time of metastatic disease diagnosis and the time of first embolization procedure. CONCLUSIONS: These data suggest that survival is similar in patients with hepatic NE metastases managed by hepatic artery chemoembolization or POSTER bland embolization. We conclude that hepatic artery embolization with or WEDNESDAY

without chemotherapy may be employed in patients not amenable to resec- ABSTRACTS tion and/or ablative techniques.

Metastases Diagnosis First Embolization Treatment Median (mo) 5-year (%) Median (mo) 5-year (%) HAE 39.1 33.4 26.2 13.0 HACE 50.1 47.9 25.5 20.4 p = 0.51 p = 0.73

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W1674 Laparoscopic Treatment of Nonparasitic Hepatic Cysts Orlando J. Torres*, Maria Helena D. Costa, Aline M. Farias, Mauricio M. Matias, Felipe L. Barbosa, Higor C. Aranha, Soraya M. Froes Department of Digestive Surgery, Federal University of Maranhão, São Luis, Brazil BACKGROUND: Hepatic cysts are quite common, with a prevalence of up to 4%–7% and a sharp rise with age. Although different classiﬁcation schemes have been established, the simple distinction between true congenital and acquired cysts is more practicable. Most of liver cysts are asymptomatic and need no therapy. Only large and symptomatic require surgical intervention. Since when the laparoscopic treatment was performed, the fenestration has been widely used. AIM: The aim of this study is to present the outcome of laparoscopic fenestration of solitary cysts and polycystic liver disease. METHODS: Between May 2003 and August 2006, 13 patients with a nonparasitic cyst of the liver were selected for laparoscopic liver surgery. There were nine female (69.2%) and four male (30.8%). The average age of patients was 46.3 years (range, 35–59 years). All patients were symptomatic. Presenting complaints included right upper quadrant pain and symptoms related to compression to adjacent organs. All patients underwent preoperative ultrasonography or computed tomography. Simple cyst were observed in ten patients (76.9%) and polycystic liver disease in three patients (23.1%). The average size of the simple cysts was 11.3 cm (range, 9.5–17 cm), while the cysts of the patients with polycystic liver disease had an average diameter of 7.3 cm. The liver function tests were performed in all patients. The Lin technique was performed in all cases. Giant liver cyst was approached by the dome that was opened using scissors, and the ﬂuid was aspirated and sent for pathology. The cyst cavity was examined for the presence of neoplastic changes. Careful hemostasis of the cyst edge was performed with electro- cautery. A drain was placed in the residual cavity at the completion of the procedure. RESULTS: Laparoscopic fenestration was successfully completdd in all patients. The average operative time was 85 min (range, 53–110 min). There were no intraoperaive complications and no need for blood transfusion. The length of hospital stay was 3.5 days (range, 2–9 days). Recurrence was observed by computed tomography in one patient with polycystic liver disease after two years of laparoscopic surgery. At histopatological examination teh cystic wall show no malignant changes. There was no death in the entire series. CONCLUSION: Laparoscopic fenestration is a procedure wit low morbidity and is recommended for the treatment of nonparasitic liver cysts.

408 6303_SSAT.book Page 409 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Clinical: Pancreas

W1675 Human Telomerase Reverse Transcriptase (hTERT) Expression in Carcinogenesis of Serous Cystic Neoplasm of the Pancreas Akira Nakashima*1, Yoshiaki Murakami1, Kenichiro Uemura1, Yasuo Hayashidani1, Takeshi Sudo1, Yasushi Hashimoto1, Hiroki Ohge1, Taijiro Sueda1, Eiso Hiyama2 1Department of Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan; 2Department of Biomedicine, Graduate School of Biomedical Sciences and Natural Science Center of Basic Research and Development, Hiroshima University, Hiroshima, Japan BACKGROUNDS: Serous cystic neoplasms of the pancreas (SCNs) have a low malignancy rate. The histopathological features in the primary tumor of serous cystadenocarcinoma (SCAC) are remarkably similar to those of serous cystic adenoma (SCA), it is therefore difﬁcult to separate SCAC from SCA when the SCAC doesn’t have distant metastases or distinct direct invasion. Expression of human telomerase reverse transcriptase (hTERT), a catalytic subunit of telomerase, is a useful marker for cancer diagnosis, because expression of hTERT is upregulated in almost all human malignant tumors but not in benign or normal tissues with the exception of germline cells, proliferative stem cells, activated lymphocytes, and certain benign tumors. OBJECTIVES: To evaluate hTERT expression in SCNs, which have potential to be a biomarker of the SCAC. METHODS: hTERT expression was examined by immunohistochemistry in eight patients who underwent pancreatic resection for SCNs which included serous microcystic adenoma (SMA; n = 3), serous oligocystic adenoma (SOA; n = 3), and SCAC (n = 2). Table 1. Background of the Patients

Serous Microcystic Serous Oligocystic Serous Subtype Adenoma Adenoma Cystadenocarcinoma Number of the subtype 3 3 2 Average age 65 (58–69) 46 (45–58) 73.5 (71–76) Sex (Male/Female) 0/3 0/3 1/1 Average of the tumor 60 mm (40–92) 24.7 mm (19–30) 93.5 mm (40–147) POSTER Part of the tumor head: 3 body to tail: 3 body to tail: 2 WEDNESDAY

Have sympton 3/3 0/3 1/2 ABSTRACTS hTERT expression 0/3 0/3 2/2

RESULTS: The histopathological findings of the two SCACs were similar to those of the other SCNs, and difficult to give a diagnosis without findings of invasions or metastasis. hTERT expression was detectable in two of two SCACs. One case had four lesions of liver metastases and direct invasion to transverse colon. The other case had invasions to lymph nodes and adipose around the pancreas. Cancer cells of the primary tumors, and all of the metastatic lesions were immunoreactive for hTERT, and the intensity of staining

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were stronger in presenting parts than the central portions of the tumors. The expression of hTERT was not detected in the three of three SMAs and three of three SOAs. The cells in the papillary structures, which were found on the cyst walls of two of SMAs, were not also stained. CONCLUSIONS: Our results suggested that hTERT expression indicates malignant transformation in SCNs. hTERT may be a useful biomarker for diagnosis of serous cystadenocarcinoma of the pancreas.

410 6303_SSAT.book Page 411 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1676 Pulmonary Dysfunction Associated with Severe Acute Pancreatitis Hidehiro Sawa*1,2, Yoshifumi Takeyama3, Takashi Ueda3, Takeo Yasuda3, Makoto Shinzeki1, Masazou Hayashi2, Yonson Ku1, Yoshikazu Kuroda1 1Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan; 2Surgery, Nishi-Kobe Medical center, Kobe, Japan; 3Surgery, Kinki University School of Medicine, Osaka-sayama, Japan BACKGROUND AND AIM: Organ dysfunction is a serious complication in severe acute pancreatitis (SAP), and pulmonary dysfunction (PD) is most frequently experienced. Incidence of PD complicating AP varies from 15% to 55%, and the severity of PD varies from mild hypoxemia without clinical abnor- mality to severe ARDS. It is conceivable that the presence of PD is correlated with the mortality rate in SAP, but there have been few clinical studies. This study aimed to clarify the clinical characteristics of PD associated with SAP. METHODS: We analyzed the data of 105 patients with SAP according to the Japanese criteria. Pulmonary dysfunction was defined as PaO2 <60 mmHg (room air) or hypoxia requiring respirator-assisted ventilation during hospitalization. 1) We compare the clinical features between PD (–) group (n = 53) and PD (+) group (n = 52). 2) In PD (+) group, we surveyed the prognostic factors between survivor (n = 22) and non-survivor (n = 30). 3) Clinical outcome was investigated in 3 subgroups according to the timing of PD: on admission PD (within 24 h after admission, n = 30); early PD (1–7 days after admission, n = 10); and late PD (more than 7 days after admission, n = 12). RESULTS: 1) The incidence of PD during hospitalization was 50%. Ranson score (5.1 vs. 2.7) and APACHE II score (13.7 vs. 6.4) on admission and frequency of necrotizing pancreatitis (79% vs. 36%) were significantly higher in PD (+) group. Among blood biochemical parameters on admission, base excess, urea nitrogen, creatinine (Cr), glucose, LDH, CRP, Ca, total protein, and PMN-elastase were significantly different between PD (–) group and PD (+) group. The incidence of infection during hospitalization (48% vs. 4%) and the mortality rate (58% vs. 2%) were significantly higher in PD (+) group. Moreover, the incidence of infection (56% vs. 18%) and the mortality rate (68% vs. 18%) were significantly higher in patients with PD together with multiple organ dysfunction syndrome (MODS) compared with PD alone. 2) In PD (+) group, prognostic factors on admission were AST, ALT, total bilirubin, Cr, Ca, and LDH (P < 0.05). 3) In patients with on admission PD, early POSTER PD, and late PD, the incidences of infection were 47%, 0%, 75%, and the WEDNESDAY

mortality rates were 63%, 10%, 83%, respectively. In PD of every phase, the ABSTRACTS mortality rates were higher in patients with PD together with MODS compared with PD alone. CONCLUSIONS: The incidence of PD associated with SAP was high, and the incidence of infection and the mortality rate were higher in patients with PD (especially together with MODS). Systemic intensive care including a strategy against infection is needed in patients with PD together with MODS.

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W1677 Incidence and Management of Chylous Leaks Following Pancreatic Resection: A High Volume Single-Center Institutional Experience Lia R. Assumpcao, John L. Cameron, Christopher L. Wolfgang, Edil H. Barish, Kurt Campbell, Michael Choti, Richard D. Schulick, Timothy M. Pawlik* Surgery, Johns Hopkins Hospital, Baltimore, MD BACKGROUND: Chyle leaks are a rare, but potentially morbid, postoperative complication. No data on incidence, management, or natural history of chyle leaks following pancreatic resection (PR) have been published. We sought to identify possible risk factors associated with chyle leaks following PR, as well as determine the natural history of this rare complication. METHODS: Between 1993–2007, 2835 patients (pts) underwent PR at a single institution. Data on demographics, operative details, primary tumor status, and—when indicated—chyle leak were collected. To identify risk factors associated with chyle leak a matched 3:1 paired analysis was used to compare pts with chyle leaks vs pts without chyle leaks. RESULTS: Of 2835 pts undergoing PR, 41 (1.4%) developed a chyle leak (n = 31, contained chyle leak vs n = 10, diffuse chylous ascites). Primary disease was adenocarcinoma (53.7%), intraductal papillary mucinous neoplasm (12.2%), neuroendocrine (12.2%), pancreatitis (7.3%), or other (14.6%). PR included pylorus preserving pancreaticoduodenectomy (PD) (70.7%), classic PD (19.5%), total pancreatectomy (7.3%), and distal pancreatectomy (2.5%). Chyle leak was identiﬁed at median 8 days following surgery (leak, 5 days vs ascites, 13 days; P < 0.001). Median drain triglyceride and amylase levels were 442 ng/dL and 17.5 ng/dL, respectively. After matching on tumor size, disease etiology, and resection type, history of concomitant vascular resection predicted higher risk of chyle leak (OR = 4.9; P = 0.03). Increasing number of harvested lymph nodes was not associated with risk of chyle leak (P = 0.18). The majority of pts (53.7%) were managed with total parenteral nutrition (TPN) (leak, 14 days vs ascites, 23 days; P = 0.03). Although lymphoscintigraphy (n = 4) and lymphangiogram (n = 2) were utilized, site of chyle leak was iden- tiﬁed in only 2 cases. Attempts at sclerotic therapy (n = 1) and re-operation (n = 1) were unsuccessful. Overall, the median time to resolution of the chyle leak was 13 days (leak, 10 days vs ascites, 38 days; P < 0.001). On matched analysis, the median survival of patients with chylous leak was 32.1 months compared with 29.7 monthss for patients without a leak (P = 0.79). Pts with chyle ascites (median, 21.9 months) tended to have a worse overall survival vs chyle leak (median, 38.2 months) (P = 0.11). CONCLUSION: Chyle leak was a rare (1.4%) complication following pancreatic resection that was associated with concomitant vascular resection. In general, chyle leaks were successfully managed with TPN with no adverse impact on outcome. Pts with chylous ascites, however, had a more protracted clinical course and tended to have a worse long-term survival.

412 6303_SSAT.book Page 413 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1678 Clinical Significance and Natural History of Microinvasive Pancreatic Adenocarcinomas Associated with Resected Intraductal Papillary Mucinous Neoplasms: A Multi-Institutional Experience Eugeen P. Kennedy*1, Charles J. Yeo1, Patrick B. White2, Thomas J. Howard2, Patricia K. Sauter1, Agnes Witkiewicz3, Keith D. Lillemoe2, C. Max Schmidt2 1Surgery, Thomas Jefferson University, Philadelphia, PA; 2Surgery, Indiana University, Indianapolis, IN; 3Pathology, Thomas Jefferson University, Philadelphia, PA OBJECTIVE: This study was designed to determine the rate of recurrence and long-term survival of patients found to have a microinvasive (less than 1cm diameter) pancreatic adenocarcinoma contained within a fully resected intraductal papillary mucinous neoplasm (IPMN). BACKGROUND: IPMNs are intraductal mucin-producing neoplasms of the pancreas with clear malignant potential. Published series report an incidence of invasive cancer associated with IPMN in up to 40% of patients with five year survival of 40% to 60%. These data combined with the ever growing utilization of high quality cross sectional imaging as part of routine medical evaluations and a wider knowledge of the entity has led to increased detection and surgical resection of IPMNs. An increasingly common clinical sce- nario is the resection of IPMNs that are thought to be benign on gross pathologic examination at the time of surgery but on microscopic examination are found to contain a small focus of invasive cancer. The rate of recurrence and associated rate of long term survival of such microinvasive cancers associated with IPMNs are not well understood. METHODS: This is a retrospective review of prospectively collected data from two academic institutions with particular expertise in pancreatic diseases. In this study, microinvasive pancreatic adenocarcinoma was defined as a focus of invasive cancer less than 1 cm in diameter contained within a fully resected IPMN. RESULTS: Ten patients were identified meeting the inclusion criteria who underwent pancreatic resection between July 1996 and August 2007. The mean age at time of operation was 61 years and 70% were male. Pancreati- coduodenectomy was performed in 50% of patients, distal pancreatectomy in 40%, and total pancreatectomy in 10%. All had R0 resections with negative

lymph nodes. At a median follow-up of 36 months, 80% of patients are alive POSTER

and disease free. One patient had local recurrence of adenocarcinoma in the WEDNESDAY

remnant gland 96 months following resection and is currently alive with dis- ABSTRACTS ease at 120 months. One patient died of metastatic adenocarcinoma 23 months post-operatively. DISCUSSION: Some reports suggest that cancers associated with IPMNs have a better prognosis than typical pancreatic ductal adenocarcinoma. This study indicates that microinvasive cancer associated with IPMNs have an even better prognosis. These data suggest that patients with resected IPMNs (with or without associated microinvasive cancer) should undergo surveillance scans of the pancreatic remnant but that routine adjuvant chemoradiation therapy may not be indicated in this population due to the overall favorable prognosis.

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W1680 Surgical Management of Failed Endoscopic Treatment of Pancreatic Disease Kimberly A. Evans*, Colby W. Clark, Stephen B. Vogel, Kevin E. Behrns Surgery, University of Florida, Gainesville, FL INTRODUCTION: Endoscopic therapy has alleviated symptoms and decreased the need for operative intervention in patients with acute and chronic pancreatitis. However, recurrent or persistent symptoms occur in a significant proportion of endoscopically-treated patients and definitive surgical management is required. Our aim was to determine which patients are likely to fail endoscopic therapy and to assess the clinical outcome of surgical management following initial endoscopic therapy. METHODS: Patients were identified by comparing institutional databases searching for ICD-9 pancreatic disease codes and CPT codes for endoscopic therapy followed by surgical procedures. Patients with neoplastic disease were excluded. Nine-hundred twenty-five patients with pancreatic disease and interventional management were identified over a ten-year period. Patients that had well-documented acute or chronic pancreatitis treated by endoscopic therapy prior to surgical therapy were included for analysis of demographic data, etiology of pancreatitis, endoscopic management, and surgical therapy. RESULTS: Eighty-nine (10%) patients of the 925 screened were included in the study. Sixty-four percent of patients had chronic pancreatitis with alcohol-induced disease in 40 of 89 patients. The common indications for surgery were: persistent symptoms (28%), anatomy not amenable to further endoscopic treatment (26%), common bile duct or pancreatic duct stricture (18%), infection or clinical deterioration (16%), and persistence or recurrence of a pseudocyst (16%). Definitive surgical procedures included internal drainage of a pseudocyst or an obstructed pancreatic duct in 41 (46%) patients, debridement or pancreatic abscess drainage in 22 (25%) patients and pancreatic resection in 27 (30%) patients. Eight (7%) patients had duodenal-sparing pancreatic head resection. Death occurred in 3% of patients and reoperation was necessary in 4%. The most common complications were hemorrhage (16%), ARDS/pneumonia (11%) and wound infection 12%. CONCLUSION: Chronic pancreatitis with persistent or newly-developed symptoms is the most common reason for pancreatic surgery following endoscopic therapy. Surgical therapy can largely be accomplished by drainage procedures but pancreatic resection is common. These complex procedures can be performed with acceptable mortality but significant risk for morbidity.

414 6303_SSAT.book Page 415 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1681 Is Distal Pancreatectomy (DP) Useful for Treatment of Cancer of the Body or Tail of the Pancreas? Jane S. Wey*, Steven J. Hughes, A. J. Moser, Herbert Zeh, Kenneth K. Lee Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA BACKGROUND/METHODS: Although the majority of patients with cancer of the body or tail of the pancreas present with advanced disease, in selected patients a DP with curative intent can be performed. We reviewed records of 41 consecutive patients undergoing open or laparoscopic DP with curative intent for pancreatic adenocarcinoma between 2000 and 2007 to determine if surgical resection is useful treatment for such cancers. RESULTS: Thirty-four open DP, four laparoscopic DP, and three laparoscopic DP converted to open procedures were identified. Extended resection was required in nine patients to achieve adequate surgical margins (22%), including four portal vein resections (10%) and en-bloc resection of additional organs in six (15%). Negative microscopic resection margins were achieved in 33 (80%) patients, and 26 patients (63%) received adjuvant therapy. The overall postoperative complication rate was 54%, with pancreatic fistulas developing in 32%. No deaths occurred during the same hospitalization or within 30 days. Median followup was 8.7 months. Recurrence was documented radiographically in 23 patients (6 local, 17 distant; 56%) with a median disease free interval of 5.6 months (range 0.7–60.3 months). Among the eight patients with positive margins, radiographic evidence of recurrence was found in five (63%) with a median time to progression of 5.1 months. No recurrences were identified in patients resected laparoscopically. Recurrence rates and time to progression were similar between patients receiving standard and extended resections. Local recurrence was identified in six patients (15%) overall, two of whom had positive surgical margins. Median survival was 6.7 months (Kaplan-Meier), and 32% survived greater than one year. Two patients (5%) are 5-year survivors. Survival did not differ significantly between those receiving open and laparoscopic DP. Median survival was improved by adjuvant therapy (8.1 vs. 5.1 months). CONCLUSIONS: These data demonstrate that DP can be performed for pancreatic cancer with low morbidity and may be an effective means of treating or preventing local complications such as obstruction or pain. Moreover, in our limited series, laparoscopic DP does not appear to compromise locore-

gional control. However, in many patients undetectable micrometastatic dis- POSTER

ease is present at the time of surgery, leading to early distant recurrence. WEDNESDAY Improved survival after curative resection is likely to depend upon develop- ABSTRACTS ment of more effective adjuvant chemotherapy and better staging of patients. Use of preoperative neoadjuvant therapy may also help to identify patients likely to develop early distant recurrence.

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W1682 In-Hospital Mortality for Distal Pancreatectomy: A National Study Melissa M. Murphy*, James T. Mcphee, Theodore P. Mcdade, Shimul A. Shah, Giles F. Whalen, Jennifer F. Tseng General Surgery, UMass Memorial, Worcester, MA BACKGROUND: Distal Pancreatectomy (DP) is performed for various indications including malignant and non-malignant pancreatic disease. The objective of this study was to evaluate mortality for DP, predictors of mortality, and review national trends. METHODS: The Nationwide Inpatient Sample (NIS) was queried to identify all DPs performed during 1998–2005. Univariate analyses and multivariable logistic regression were performed to evaluate in-hospital mortality (SASv9.1,Cary, N.C.). RESULTS: By weighted national estimate 22,097 patient discharges occurred for DP during 1998–2005. 57.6% of patients were women; mean age was 57.4 years (SEM = 0.28). 53.8% of DPs were for malignant pancreatic disease (defined as ICD-9 codes for primary and secondary malignancies, including carcinoma in-situ and neoplasms of uncertain behavior). 46.2% of DPs were for non-malignant disease (defined as pancreatic cysts, pseudocysts, benign neoplasms, and pancreatitis), P < .0001. The number of DPs increased over time with 1593 performed in 1998 and 3951 performed in 2005, P < .0001. Overall, in-hospital mortality was 3.7%, which declined from 1998 (4.7%) to 2005 (3.1%), P < .0001. Mortality was higher for men vs. women (2.0% vs. 1.7%, P = .001), older age vs. younger age (>70 6.5%, 50–69 3.5%, <50 1.6%, P < .0001) and malignant vs. non-malignant (4.46% vs. 2.99%, P < .0001). DP associated with laparoscopy comprised 2.9% of all DPs. Mean length of stay (LOS) for non-laparoscopy associated DP was 10.4 d and 6.7 d for laparoscopy associated DP. There were no significant differences in the rate of laparoscopy in patients with malignant vs. non-malignant disease or over the time course included in the study. Independently significant factors for mortality included age >70 yrs vs. <50 (OR 3.46; 95% CI 2.07–5.80) and >70 vs. 50–69 (OR 1.66; 95% CI 1.15–2.40), men vs. women (OR 1.58; 95% CI 1.15–2.17). The presence of medical co-morbidities including chronic lung disease, renal failure, congestive heart failure, and diabetes were significant predictors of increased mortality. CONCLUSION: DP is being performed with higher frequency in the US with a concomitant decrease in mortality. Male sex, increasing age, and the presence of medical comorbidities were significantly associated with increased mortality. DPs performed in conjunction with laparoscopy demonstrated a decreased LOS in comparison to non-laparoscopic DP. Additional studies including patient-level data, overall survival, and with more specific coding for laparoscopic DP are warranted to provide a better understanding of the specific predictors of outcome after DP.

416 6303_SSAT.book Page 417 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1683 Pancreatic Adenocarcinoma with Isolated Local Venous Invasion: Does Surgical Resection Confer a Survival Benefit? Michael Abramson*, Edward W. Swanson, Ioannis Konstantinidis, Edward E. Whang Surgery, Brigham and Women’s Hospital, Boston, MA BACKGROUND: Benefit from pancreaticoduodenectomy (PD) combined with superior mesenteric-portal vein (SMV-PV) resection for pancreatic adenocarcinoma with local venous invasion is controversial. METHODS: Using formal decision analysis, we compared outcomes for PD plus SMV-PV resection (group I) versus those for palliative chemoradiotherapy (no resection, group II) in patients with pancreatic adenocarcinoma with local venous invasion. Studies were identified using MEDLINE. 2,144 group I and 709 group II patients were evaluated. Patients with arterial invasion or distant metastases were excluded. RESULTS: Group I patients had a 40% higher 1-yr survival rate (p < 0.0001) than group II patients. 1-way sensitivity analyses indicated the robustness of this finding is contingent on perioperative mortality rate and the percentage of cases in which true venous invasion by cancer is documented histologically. In the studies evaluated, median perioperative mortality was 3.6% (range, 0–29%), and the median percentage of cases with true venous invasion was 63.6% (range, 2.9–100%)We conducted a 2-way sensitivity analysis to evaluate the impact of varying these two parameters (Figure 1). The shaded portion of the figure (lower perioperative mortality rate and lower percentage of cases with true venous invasion) represents the area for which resection confers a higher 1-year survival than palliative treatment. POSTER POSTER WEDNESDAY ABSTRACTS

CONCLUSIONS: Our analysis suggests that pancreaticoduodenectomy with SMV-PV resection may confer a survival advantage over non-resectional palli- ation in select patients believed to have pancreatic adenocarcinoma with local venous invasion. Given the difﬁculty of identifying true vascular invasion preoperatively, these procedures should be done only if low perioperative mortality rates can be achieved.

417 6303_SSAT.book Page 418 Tuesday, April 22, 2008 1:26 PM

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W1684 Gemcitabine-Based Adjuvant Chemotherapy Following R1 Resection Still Improves Survival for Patients with Locally-Advanced Pancreatic Cancer Keita Wada*, Hodaka Amano, Fumihiko Miura, Naoyuki Toyota, Kenichiro Kato, Makoto Shibuya, Susumu Kadowaki, Masahiro Yoshida, Ikuo Nagashima, Tadahiro Takada, Takehide Asano Surgery, Teikyo University School of Medicine, Tokyo, Japan BACKGROUND: Radical resection (R0) is the surgical goal in pancreatic cancer surgery, but it often results in R1 resection. Sub-analysis of recent RCT (CONKO-001) for adjuvant chemotherapy with gemcitabine (GEM) showed significant advantage in patients with R1 resection, e.g., median disease free survival (DFS) was 15.8 months in patients with gemcitabine compared with 5.5 months in observation arm. In this study we evaluated the role of adjuvant chemotherapy with gemcitabine in locally-advanced pancreatic cancer treatment. METHODS: We reviewed the data of 277 patients who underwent pancreatic resection for pancreatic cancer at Teikyo university hospital, Tokyo, Japan during 1981–2007. Of 277 patients 37 patients have had liver metastasis at the time of operation and these cases were excluded in this study. Pancreati- coduodenectomy was performed in 68%, distal pancreatectomy in 19% and total pancreatectomy in 13%. Vascular resection was performed in 124 patients (52%). R0 resection was achieved in 62%, R1 was in 21%, and R2 was in 12%. Adjuvant chemotherapy with gemcitabine was used in 56%. Kaplan-Meier survival curve was calculated, and survival was compared by logrank test. RESULTS: Mortality was 2.9%. Morbidity was 37%. Median survival time (MST) for entire cohort was 18 months and 5-year survival was 15.9%. Sur- vival comparing patients with GEM versus without GEM significantly different (MST: 22 vs. 13 months, P = 0.003). Survival for patients having had R1 and R2 resection was significantly improved by the use of GEM-based adjuvant chemotherapy (Table and Figure).

MST w/GEM (M) MST w/o GEM (M) P R0 25 (N = 86) 28 (N = 61) n.s. R1 22 (N = 30) 8 (N = 21) <0.001 R2 9 (N = 13) 3 (N = 16) 0.006

418 6303_SSAT.book Page 419 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

CONCLUSION: Gemcitabine-based adjuvant chemotherapy signiﬁcantly improves survival in patients with R1 resection approaching to the survival of patients with R0 resection. This result would support more radical surgical approach, such as vascular resection, in the management of locally-advanced pancreatic cancer, as long as surgical mortality, morbidity and patient’s quality of life is acceptable. POSTER POSTER WEDNESDAY ABSTRACTS

419 6303_SSAT.book Page 420 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1685 Intra-Operative Application of the Hand-Held Confocal Microscope: A Pilot Study Nam Q. Nguyen*1, Rupert W. Leong1, Andrew V. Biankin2, Elise R. Murr3, Peter M. Delaney3, Neil Merrett2 1Gastroenterology, Bankstown Hospital, Bankstown, NSW, Australia; 2Upper Gastrointestinal Surgery, Bankstown Hospital, Bankstown, NSW, Australia; 3Optiscan Ltd, Melbourne, VIC, Australia INTRODUCTION: The Optiscan confocal laser microscope (CLM) is a hand- held probe that enables real-time in vivo histological surface and sub-surface imaging at laparoscopy or laparotomy. It may provide immediate intraoperative assessment of histology, tumor margins and microvasculature. To date, there is no data on the intra-operative application of this technique. AIMS: This study aimed to evaluate the clinical feasibility and utility of CLM during intra-abdominal surgery and to determine the quality of images acquired. METHODS: Intravenous ﬂuorescein contrast was used. Ten procedures were performed and obtained confocal images of normal pancreas, bile duct, liver, omentum, lymph nodes and spleen, both from the serosal and cut surfaces. Chronic pancreatitis and pancreatic cancers were also assessed. Surgeons’ feedback was obtained.

RESULTS: Confocal cellular and architectural features of intra-abdominal organs were described and found to be reproducible. Quality of the images improved with experience. Liver capsule prevented deep hepatic imaging. Normal pancreatic acini were obvious and differentiated from chronic pancreatitis and pancreatic cancer (ﬁgure). Bleeding impaired some surface imaging, especially from dysplastic tissues. The duration of confocal examination varied from 7 to 15 minutes and no adverse effect was observed. Intra- operative real time histology was possible without signiﬁcant disruption of the operation and only minor equipment re-design was suggested. The dis- posable outer sheaths successfully maintained sterility. CONCLUSIONS: Real-time “virtual histology” during intra-abdominal surgery is safe, feasible and reproducible. CLM has the potential to assist surgeons in diagnosing tissue pathology and guiding resection margins.

420 6303_SSAT.book Page 421 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1686 Complications Following Pancreaticoduodenectomy Are Common but Do Not Impact Long-Term Survival Mary E. Dillhoff*1, Kristian Wall1, Peter Muscarella2, E. Christopher Ellison2, Mark Bloomston1 1Surgical Oncology, Ohio State University, Columbus, OH; 2General Surgery, Ohio State University, Columbus, OH BACKGROUND: Pancreaticoduodenectomy in the modern era is generally a safe operation for lesions of the pancreatic head. Still, complications are common but not often thoroughly reported. We sought to review our experience with pancreaticoduodenectomy (PD) to focus on predictors of postoperative complications and mortality. METHODS: After approval by the institutional review board, the clinicopathologic records of 309 consecutive patients undergoing PD between 1992 and 2006 were reviewed. Patients with significant postoperative complications were identified and compared by Student’s T-test or Fisher’s Exact test, where appropriate. Kaplan-Meier survival curves were constructed and compared by Log-rank analysis. RESULTS: PD was undertaken for periampullary cancers in 226 (73%), neuroendocrine carcinoma (NEC) in 26 (8%), chronic pancreatitis in 49 (16%), and other benign tumors in 8 (3%). Pylorus preservation was undertaken in 33% and pancreatic reconstruction was completed in a duct-to-mucosa fashion in 88%. Median length of stay was 12 days (range 5–49). Complications occurred in 44% including infectious complications 17%, pulmonary 7%, pancreatic fistula 8%, delayed gastric emptying 9%, and hemorrhage 7%. Postoperative mortality was 4.5%. Compared to patients with uneventful postoperative courses, patients with complications were similar in terms of age, gender, comorbidities, preoperative biliary stenting, pylorus preservation, tumor size, and type. Surprisingly, length of hospitalization was not significantly impacted by the presence of complications (median 15 days vs. 12). Median survival for periampullary malignancies was 21.7 months, 139.7 months for NEC, and was not reached in patients with benign diseases. Over- all survival was not different in patients with and without perioperative complications regardless of the final pathology. CONCLUSIONS: Perioperative complications following pancreaticoduodenec-

tomy are common but rarely life-threatening. After recovery, patients suffering POSTER

complications can expect long-term survival similar to those in which no com- WEDNESDAY plications occurred. ABSTRACTS

421 6303_SSAT.book Page 422 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1687 A National Survey Regarding the Management of Acute Pancreatitis in Brazil Tercio De Campos*1,2, Jose G. Parreira1, Edivaldo M. Utiyama1, Samir Rasslan1 1General Surgery, University of São Paulo, São Paulo, Brazil; 2Emergency Unit, Santa Casa School of Medical Sciences, São Paulo, Brazil BACKGROUND AND AIM: Acute pancreatitis (AP) is a frequent illness, with incidence of 50–80 cases per year for each 100,000 inhabitants in the United States. In Brazil the incidence is of 15.9 cases per year for each 100,000 inhabitants. The treatment of AP remains controversial in some topics, due mainly to difficulties to the accomplishment of clinical studies. Some Con- sensuses exist in the literature that direct the management of AP. Based on these difficulties, this research was idealized to evaluate as AP is managed by the Brazilian surgeon. METHODS: A questionnaire has been sent to 2,000 members of the Brazilian College of Surgeons, with 618 (30.9%) answers obtained. The questionnaire consisted of questions related to the experience of the surgeon and in particular to the treatment of AP, such as definition of severity, role of CT scan and ERCP, options of nutritional support, characterization of operative treatment and the use of antibiotics. RESULTS: With regard to the number of cases treated by the interviewed surgeons, 182 (33.6%) answered to treat up to five cases per year and 147 (27.2%) treat six to ten cases per year. The most cited criteria used for the definition of severe AP was clinical evaluation for 306 (57.4%) interviewed, followed by the Ranson criteria for 294 (55.2%), CT scan for 262 (49.2%), APACHE II for 167 (31.3%) and C-reactive protein for 68 (12.8%). Regarding the use of CT, 275 (51.5%) interviewed answered that make use of CT scan for all patients with AP. The parenteral nutritional support was the method of choice indicated for 248 (46.6%) interviewed, exclusive enteral support for 142 (26.7%), and the association of enteral and parenteral support for others 142 (26.7%). The infection of fluid collection and/or pancreatic necrosis was the main reason for surgical treatment with 447 (83.6%) answers. The optimum period to operate a patient with severe AP was considered up to seven days for 116 (22.6%) interviewed, eight to 14 days for 162 (31.6%), 15 to 21 days for 119 (23.2%) and after 21 days for 116 (22.6%). With relation to antibiotics, 371 (68.6%) use antibiotics in the treatment of severe AP, against 170 (31.4%) that answered not to use them. CONCLUSION: These findings demonstrate a wide variation in the treatment of AP in Brazil, despite the number of guidelines in the literature. Little experience of the surgeons and controversial issues are probably the main factors responsible for this lack of standardization. A national Consensus based on new concepts and worldwide experience is crucial to adjust these thoughts.

422 6303_SSAT.book Page 423 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1688 The Striking Incidence of Venous Thromboembolism in Hospitalized Patients with Necrotizing Pancreatitis James Lopes*, Nicholas J. Zyromski, Yuriy Zhukov, Attila Nakeeb, Henry A. Pitt, Keith D. Lillemoe, C. Max Schmidt, Thomas J. Howard Surgery, Indiana University, Indianapolis, IN BACKGROUND: Acute pancreatitis is a substantial medical problem, accounting for more than 220,000 hospital admissions yearly in the US. Twenty percent of these patients will develop necrotizing pancreatitis (NP), which is characterized by pancreatic and peripancreatic necrosis. Venous thromboembolism (VTE) is also a major national health concern, with an incidence in all hospitalized patients approaching 10%. Surprisingly few data are available regarding VTE in NP. The aim of this study was to determine the incidence of VTE in patients with NP. METHODS: Retrospective review (1992–2007) of patients with NP treated at a University Hospital. The diagnosis of VTE was confirmed using standard radiographic criteria for duplex ultrasonography (U/S) or helical Computed Tomography (CT). Chi square was used to compare discrete variables, accept- ing p < 0.05 as statistically significant. RESULTS: 171 patients with NP were identified. Of these, 96 patients (56%) had radiographic evidence of VTE. Fifty-one (53%) of patients with VTE had thrombi identified in multiple locations for a total of 152 DVT identified in this series. Four patients (2%) had documented pulmonary emboli. DVT was found more frequently in abdominal vasculature (n = 121/78%) as compared to the extremities (n = 31/20%) (p < 0.001). Fourteen out of sixteen (88%) patients with an upper extremity DVT had an associated intravenous catheter. The following table details DVT location. CONCLUSION: These data demonstrate that: 1) 56% of patients with NP have associated DVT and that 53% of these patients had more than one thrombus, 2) Patients with NP are more likely to develop abdominal DVT (78%) compared to extremity DVT (20%), and 3) 88% of UE DVT are associated with catheter placement. From these data, we conclude that VTE is a significant problem in patients with NP and that aggressive VTE prophylaxis should be implemented.

LOCATION Splenic SMV/PV UE LE Catheter Associated PE POSTER

# (%) 63 (40) 58 (37) 16 (10) 15 (10) 14 (88*) 4 (2) WEDNESDAY

SMV/PV – superior mesenteric/portal vein, UE – upper extremity, LE- lower extremity, PE – pulmonary embolus ABSTRACTS *88% of UE DVT were associated with an intravenous catheter.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1689 Feasibility of Laparoscopic Partial Pancreatic Head Resection with Lateral Pancreaticojejunostomy (Frey Procedure) for Chronic Pancreatitis Jayleen M. Grams*1, Santhi S. Vege2, Michael L. Kendrick1 1Surgery, Mayo Clinic, Rochester, MN; 2Medicine, Mayo Clinic, Rochester, MN BACKGROUND: Partial pancreatic head resection with lateral pancreaticojejunostomy (Frey procedure) is a well-described successful treatment for symptomatic patients with chronic pancreatitis. To our knowledge, completion of this procedure laparoscopically has not previously been reported. While laparoscopic lateral pancreaticojejunostomy alone has been reported, the Frey procedure has several advantages and is increasingly performed (via laparotomy) over other drainage procedures. Our aim is to describe the technical aspects and feasibility of the laparoscopic Frey procedure. METHODS: Retrospective review of patient records, operative and perioperative data. RESULTS: Two female patients (age 57 and 72 years) underwent a laparoscopic Frey procedure at our institution during the year of 2007. Clinical and radiographic evaluation confirmed chronic calcific pancreatitis with medically refractory abdominal pain. Both patients had parenchymal calcification, ductal stones, and a diffusely dilated pancreatic duct on CT imaging. The operative procedure was completed laparoscopically in both patients. Steps of the procedure included: 1) Exposure of the lesser sac through the gastrocolic ligament; 2) Laparoscopic ultrasound to assess the pancreatic ductal anatomy and surrounding vasculature; 3) Opening of the pancreatic duct in the body with extension to the termination of the duct in the tail; 4) Placement of hemostasis sutures and the duodenopancreatic interface; 5) V-shaped wedge resection of pancreatic parenchyma anterior to the duct in the neck, widen- ing to a core resection of parenchyma from the pancreatic head; 6) Stone retrieval from the pancreatic duct and exposed branch ducts; 7) Roux-en-Y pancreaticojejunostomy with a single layer of running suture. The mean operative time and estimated blood loss were 246 minutes (155–337) and 138 ml (100–175) respectively. In both patients, histologic confirmation of chronic pancreatitis in the resected pancreatic specimen was obtained, with a mean specimen weight of 660 milligrams (650–664). Mean length of hospital stay was 6.5 days (5–8). Both patients reported near resolution of preoperative pain symptoms at time of discharge. No perioperative morbidity or mortality was observed. CONCLUSION: This is the first report describing completion of the laparoscopic Frey procedure and demonstrates the technical feasibility of this approach. Appropriate assessment of outcomes will require additional patients and longer follow-up to substantiate expected benefits and equivalent long-term results of the laparoscopic versus conventional laparotomy approach.

424 6303_SSAT.book Page 425 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1690 Surgeon’s Contribution to Long Term Survival of Pancreatic Cancer Calogero Iacono*1, Andrea Ruzzenente1, Tommaso Campagnaro1, Alessandro Valdegamberi1, Chiara Zugni1, Maurizio Cantore2, Alfredo Guglielmi1 1Department of Surgery and Gastroenetrology, University of Verona Medical School, Verona, Italy; 2Departement of Oncology, Massa Carrara Hospital, Massa Carrara, Italy BACKGROUND AND OBJECTIVE: Several surgical series have clearly demonstrated the prognostic signficance of curative (R0) resection. The aim of this study is to evaluate the role of R0 resection and of the extent of lymphnodes (LN) involvement. PATIENTS AND METHODS: Fifty four patients were submitted to modified extended pancreaticoduodenectomy (MEPD) for pancreatic cancer from 1994 to 2005. After MEPD 20 pts received adjuvant chemotherapy: 15 with intra- arterial chemotherapy employng FLEC regimen (in 7 pts followed by systemic gemcitabine) and 5 with other adjuvant regimens. RESULTS: Median follow up time for surviving pts was 46 months (range 26–157). In 44 pts (82%) MEPD had negative margin resection; all pts with R1 resection showed positive retroperitoneal margin. All the patinets had more than 10 LN dissected, 11 patients had 10 to 20 LN examinated, 27 had 20 to 40 LN examinated and 16 patients had more than 40 LN examinated. Nega- tive LN were found in 10 pts, positive N1 in 33 pts, positive N1+N2 in 9 pts and positive N2 in 2 pts. 12 patients had 1–2 positive LN, 28 patients had 3–9 positive LN and 4 patients had more than 10 positive LN. The overall median survival was 18 months with actuarial 3 and 5-year survival rates of 29% and 19%. At univariate analysis we identified that factors related with survival were: histological grading (p = 0.01), LN status (p = 0.04), radical resection (p = 0.01), UICC TNM stage (p = 0.005). We did not identify statistical differences between survival in pts with positive N1 and N2 LN, however all 11 pts with N2 LN metastases died within 46 months. A statistical significant relationship between the number of positive LN and survival was observed with a median survival time of 16, 17 and 7 months for patients with 1–2 positive LN, 3–9 positive LN and more than 10 positve LN, respectively (p = 0.03). These data were confirmed also with linear regression model.Multivariate analysis in pts with R0 resection showed that factors related with survival were adjuvant chemotherapy (HR 0.39, p = 0.04), histological grading (HR = 2.5, p = 0.02) and LN status (HR = 1.95, p = 0.04). POSTER WEDNESDAY CONCLUSIONS: Our study confirm the prognostic significance of R0 resection that can be achieved with a accurate clearance of lymphatic, neural and ABSTRACTS connective tissue at the right side of superior mesenteric artery and of retroperitoneum. Our results emphasize the prognostic significance of the number of positve LN; in our opinion an accurate lymph node dissection (more than 10 LN) can improve the evaluation of LN status. Adjuvant chemotherapy improved significantly long term survival after R0 resection while in R1 it did not show benefit.

425 6303_SSAT.book Page 426 Tuesday, April 22, 2008 1:26 PM

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Clinical: Small Bowel

W1691 Enteral Stenting: Management of Complications and Malfunctions in a Single Center Series of 46 Patients Melissa S. Phillips*2,1, Sonia Gosain1, Charles M. Friel2,1, Hugo Bonatti2, Patrick G. Northup1, Michel Kahaleh1 1Digestive Health, University of Virginia, Charlottesville, VA; 2Surgery, University of Virginia, Charlottesville, VA BACKGROUND: The current management of malignant gastric outlet obstruction (GOO) in unresectable patients include surgical diversion or placement of an enteral stent. AIMS: We analyzed the long term results including predictive factors of outcomes, and complications associated with enteral stents with focus on their management. METHODS: Between 1997 and 2007, 46 patients with malignant GOO underwent palliative placement of a uncoverered self expandable metal stent (SEMS). Patients were captured in a database and followed until complication or death. Patency, management of complications and long term survival were analyzed.

RESULTS: 46 patients had a mean survival of 146 days ± 225 days and a mean SEMS patency rate of 110 days ± 211 days. Life table analysis demonstrates SEMS patency rates of 80%, 33%, 18%, and 8% at 1, 3, 6 and 12 months respectively. 13 (28%) patients presented with recurrent obstructive symptoms and included 2 SEMS migration, 2 early occlusion (within 1 week), 1 fracture, 4 malignant recurrence of obstruction (>2 weeks) and 4 failed to have symptomatic improvement despite conﬁrmed endoscopic patency. Interventions included endoscopic balloon dilation (3), argon plasma coagulation (1), and/or SEMS replacement (3) while 6 had PEG-J placed. Two patients underwent surgical bypass for continued symptoms. One patient with duodenal perforation underwent successful surgical repair and one developed an aortoenteric ﬁstula managed with a combination of endovascular stenting and surgery.

426 6303_SSAT.book Page 427 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

CONCLUSIONS: SEMS effectively palliate gastric outlet obstructions that result from upper GI malignancies, especially in the short term. Their beneﬁt has to be weighted against potential complications or malfunctions. With gastroenterologists placing those devices more frequently, it is crucial for the surgeons to be aware of their potential complications and the best management options. POSTER POSTER WEDNESDAY ABSTRACTS

427 6303_SSAT.book Page 428 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1692 Primary Ileostomy Adenocarcinoma: Rare Condition After Proctocolectomy Rachel Forbes*, Robert Riviello, Alan J. Herline, Roberta L. Muldoon, Paul E. Wise Department of Surgery; Division of Colorectal Surgery, Vanderbilt University, Nashville, TN PURPOSE: Total proctocolectomy (TPC) and end ileostomy has been considered the gold standard for surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) since the early 1950s. Adenocarcinoma arising in an ileostomy is a late, rare complication. We report four cases of primary ileostomy adenocarcinoma (ICa) and review the literature. METHODS: A medical records search was conducted at an academic medical center to identify patients with ileostomy adenocarcinoma. Clinical details (demographics, operative details, pathology, and outcomes) were obtained via chart review. Histopathology was reviewed. A Medline search of the English literature from 1969–2005 was then conducted for keywords: ileostomy, adenocarcinoma, UC, and FAP. RESULTS: Cases: 1) A 78 yo woman with UC s/p TPC in 1959 presented in 1998 with ICa; 2) A 76 yo woman with UC s/p TPC in 1982 presented in 1994 with ICa in a polyp. She re-presented in 2005 with a new Stage II ICa arising from a tubulovillous adenoma; 3) A 62 yo woman with FAP s/p TPC in 1971 presented in 2005 with Stage I ICa in a villous adenoma; 4) A 58 yo male with UC s/p TPC in 1971 presented in 2006 with ICa arising from a polyp. Each patient underwent wide ileostomy excision with abdominal wall margin and adjacent/ileum mesentery followed by stomal resiting. Each is without evidence of recurrent disease at most recent follow-up (79 months, 10 months, 9 months, and 1 month, respectively). Average time from stoma creation to ICa was 27 ± 15 years. Review of the literature identiﬁed 50 cases of ICa with an average interval of 26 years from stoma creation to ICa. CONCLUSIONS: Our four cases were similar to those found in the literature in terms of average interval to ICa formation, ratio of occurrence in UC and FAP, and formation as a polypoid mass in the majority. One of our patients represents the ﬁrst reported case of a metachronous primary ICa. Ileostomy excision with abdominal wall margin and stomal resiting is the treatment of choice with low recurrence rates for early ICa and low morbidity/mortality. Ileostomy polyps should be excised, and ileostomies should be surveilled for ICa yearly starting at 10 years after TPC/ileostomy formation.

428 6303_SSAT.book Page 429 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1693 Surgical Management of Acute Appendicitis: 50 Years of Progress William Scott Melvin*1, Austin Lehr2, Joshua Hill2, Peter Muscarella1, E. Christopher Ellison1, Columbus Surgical Society1 1Surgery, The Ohio State University, Columbus, OH; 2Surgery, Ohio Health, Columbus, OH Acute appendicitis is a common malady, affecting more than six hundred eighty thousand Americans each year. Despite advances in diagnostic technology, establishing the correct diagnosis of appendicitis remains problem- atic, resulting in a significant rate of negative surgical interventions. In an effort to gain insight into changes in management over the last half century, we compared data gathered in a single metropolitan region in 1955 to recent time. Data from hospitals in a single metropolitan area were collected by the local Surgical Society in 1955, recorded and preserved. Recently, we collected data from hospitals in the same region, excluding the pediatric hospital, on all patients undergoing appendectomies. Patient demographics, diagnostic tests, type of surgery, and pathological and clinical outcomes were recorded. Statistical signifigance was analyzed using a Students T test. A total of 2096 appendectomies were studied. In 1955, 1123 appendectomies were recorded and in 2004, 973. The negative exploration rate decreased from 16.9%. to 5.9% (p < .05). Percentage female (60%), and age at diagnosis were similar. Mortality improved significantly (0.0 vs. 0.35%, p < 0.5). In 1955, more patients had other pathology at the time of exploration compared to now. (6.0% vs. 0.5%). Recent data showed 90% of patients underwent a CT Scan, 55% underwent surgery by laparoscopy, however the rate of laparoscopy varied widely among the institutions. The current average hospital stay was 1.6 days. The positive predictive value of a CT Scan was 86%, with a false negative rate of 1.0%. The diagnosis of acute appendicitis remains a common surgical dilemma. Currently, most patients undergo a CT Scan as a predictive tool and many patients undergo a laparoscopic procedure. The modern error rate of 5.9% is significantly improved compared to the rate of 50 years ago of 16.9%, and now, other pathology is rarely discovered. Mortality from acute appendicitis is uncommon. POSTER POSTER WEDNESDAY ABSTRACTS

429 6303_SSAT.book Page 430 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Stomach

W1694 Distal Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity Jean-Marc Heinicke*, Daniel Inderbitzin, Beat Schnüriger, Daniel Candinas, Bernhard Egger Department of Visceral and Transplantation Surgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland BACKGROUND: We present mid-term results of a pilot study using a distal, only moderately restrictive Roux-en-Y gastric bypass in 50 consecutive patients suffering from morbid obesity (BMI > 40 kg/m2). METHODS: The almost purely restrictive mechanism of classical gastric bypass was avoided by forming a proximal gastric pouch of approximately 60 ml on the lesser curvature and by using a 25 mm circular stapler for the gastrojejunostomy. Malabsorption was achieved by constructing a common channel of 110 to 150 cm. The biliopancreatic limb length was 100 cm. RESULTS: 25 open and later on 25 laparoscopic interventions have been performed in 32 females and 18 males with a median age of 41 years and a median BMI of 50.2 kg/m2. 6 patients had removal of a gastric banding at the same operation. Median postoperative hospitalisation time was 11 days. No severe intraoperative complications have been observed and no anastomotic leakage was noted in the postoperative period. 4 patients needed balloon dilation of an anastomotic stricture. Besides these 4 patients no others have been reporting vomiting or marked restriction in food intake so far. 15 patients were having intermittent diarrhea or steatorrhea, treated by pancretic enzyme supplementation. Two marginal ulcers occurred at the gastrojejunostomy. The actual median follow-up time is 18 months. All patients showed a remarkable good weight loss with an overall median BMI-reduction of 17 to an actual median BMI of 31.9 kg/m2, corresponding to a EBL of 73%. Obesity- related comorbid conditions were signiﬁcantly reduced or cured. CONCLUSION: dRYGB shows excellent results with marked reduction of weight and comorbid conditions. This new technique has proved to be feasible and safe. Avoiding massive restrictive measures allows a more physiological food intake and a continuous increase in quality of life in comparison to patients after a mainly restrictive intervention. Furthermore the risk of protein malabsorption is greatly reduced compared to biliopancreatic diversion.

430 6303_SSAT.book Page 431 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1695 Utilization of Pre-Operative Patient Factors to Predict Post-Operative Vitamin D Deficiency for Patients Undergoing Gastric Bypass Judy Jin*, Thomas A. Stellato, Peter T. Hallowell, John Jasper, Scott M. Wilhelm Surgery, University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: Vitamin D deficiency occurring after gastric bypass procedures can predispose patients to calcium and parathyroid hormone (PTH) level abnormalities. The aim of the study is to identify pre-operative patient risk factors for post operative vitamin D deficiency. METHODS: We retrospectively reviewed patients who underwent Roux-en-Y gastric bypass (short limb = 75 cm, long limb = 165 cm) procedures at our institution from January 2005–October 2006. Patient demographics, laboratory values of calcium, vitamin D and PTH were followed at quarterly intervals for one year. Statistical analysis included paired t-test for continuous variables and Fisher’s exact test (FET) for categorical variables. A backward stepwise logistic regression model was used to predict probability of post operative vitamin D deficiency. RESULTS: 145 patients were included in the study after 50 patients were eliminated for incomplete follow up. The mean age for the group was 44 ± 10 years with an average body mass index (BMI) of 49.5 kg/m2. 86% of patients were female and 23% of the population was African American. Forty two percent of the patients had vitamin D deficiency (<20 ng/mL) either pre-operatively or at year one, with minimal change in mean values over the one year (25.7 → 25.0 ng/mL, p = 0.54). However, the mean calcium levels decreased significantly from 9.39 to 9.16 mg/dL (p < 0.001) while the mean PTH levels increased significantly from 25.7 to 43.9 ng/mL (p < 0.001) over the same period. On univariate analysis, post operative vitamin D deficiency was associated with higher pre-operative BMI (51.1 vs 48.4 kg/m2, p = 0.037), African American race (FET, p = 0.0002), long limb bypass (FET, p = 0.017), lower preoperative calcium levels (9.27 vs 9.47 mg/dL, p = 0.018) and lower pre-operative vitamin D levels (19.9 vs 30.0 ng/mL, p < 0.0001). Age, sex, reduction in BMI and pre-operative PTH levels did not appear to affect post operative vitamin D values. A logistic regression model used to predict post operative vitamin D levels recognized pre-operative vitamin D levels, race and bypass limb length to be the only significant factors (p < 0.05). POSTER POSTER CONCLUSION: Our study identified several characteristics that predispose patients for vitamin D deficiency after the bypass procedures. However, only WEDNESDAY pre-operative vitamin D values, race and limb length were significant for pre- ABSTRACTS dicting post operative vitamin D values. It is important to recognize these patients who are at risk before surgery so that early intervention could be in place to minimize further post operative deficiency.

431 6303_SSAT.book Page 432 Tuesday, April 22, 2008 1:26 PM

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W1696 Primary Stenting for Malignant Gastric Outlet Obstruction with Self-Expanding Metal Stents (SEMS) in Cape Town, South Africa John M. Shaw*, Eugenio Panieri Gastrointestinal Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa AIM: To prospectively evaluate the use of SEMS as a primary intervention for relieving malignant gastric outlet obstruction in a resource limited environment in South Africa. BACKGROUND: Gastro-duodenal obstruction secondary to advanced malignancy is often a difficult symptom to palliate. Surgical bypass can be inappro- priate or contra-indicated due to advanced disease or co-morbidity. Primary stenting aims to rapidly restore enteral intake with minimal morbidity. SEMS enables patients with limited life expectancy to be independent of parenteral fluid administration and facilitates early discharge. SEMS are now interna- tionally accepted as an alternative to surgery and can be a useful adjunct to management where expertise, operating time, limited hospital beds and other resource limitations exist. This is the first reported series using SEMS (performed by surgeons) for palliating malignant gastro-duodenal obstruction in Africa. METHOD: Patients with clinical and endoscopically proven malignant gastro-duodenal obstruction and relative contra-indication to surgical bypass were eligible. A duodenoscope combined with fluoroscopic screening was used to place the SEMS under direct vision. Data was collected prospectively until death from November 2004 to November 2007. RESULTS: 42 patients, median age 64 years (range 39–84) had attempted SEMS placement. The obstruction was due to antral gastric carcinoma (n = 17), pancreatic carcinoma (n = 17), duodenal carcinoma (n = 1), cholangiocarcinoma (n = 3), gallbladder carcinoma (n = 1) and other (n = 3). Relative contraindications to surgery were locally advanced tumour (n = 23), metastatic disease (n = 12) and co-morbidity (n = 7). The site of obstruction was gastric antrum (n = 17), bulb (n = 11), second/third part (n = 13) and third/ fourth part (n = 1) of the duodenum. There were four technical failures (9.5%). In the 38 (90.5%) technically successful placements, 36 (94%) patients resumed oral intake (n = 4 liquid, n = 15 soft diet, n = 17 full diet) and two failed (second obstruction distal to gastro-duodenal obstruction). 14 patients required additional biliary stenting. The median time from stent to discharge was two days (range 1–8). Median survival following SEMS was 41 days (range 4–194) with 10 patients still alive at a median of 26 days (range 14–321). One patient (gastric carcinoma) required a three unit blood transfusion following stent placement. There were no other immediate complications. CONCLUSION: SEMS has a high technical success rate (90.5%) and is able to rapidly restore enteral intake in 94% of patients with malignant gastro- duodenal obstruction who are unsuitable for surgery in a resource-limited environment.

432 6303_SSAT.book Page 433 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1699 The Molecular and Clinical Signiﬁcance of CD44 Proteolytic Cleavage in Gastrointestinal Stromal Tumors Kai-Hsi Hsu*1,2, Yan-Shen Shan3, Hung-Wen Tsai4, Pin-Wen Lin3 1Department of Surgery, Tainan Hospital, Department of Health, Executive Yuan, ROC, Tainan, Taiwan; 2Institute of Clinical Medicine, College of Medicine, National Cheng Kung University Medical Center, Tainan, Taiwan, Tainan, Taiwan; 3Department of Surgery, National Cheng Kung University Medical Center, Tainan, Taiwan, Tainan, Taiwan; 4Department of Pathology, National Cheng Kung University Medical Center, Tainan, Taiwan, Tainan, Taiwan PURPOSE: CD44 is a type I transmembrane protein that has been implicated in a lot of cellular activities, including cell migration, invasion and metastasis. It has been found that CD44 loss can be a poor prognostic factor in gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumor of the gastrointestinal tract. The purpose of this study is to investigate the activities of CD44 ectodomain cleavage and the putative mechanisms of CD44 protein loss in GIST. MATERIALS AND METHODS: From January 1999 to August 2007, 31 patients undergoing surgical resection for GIST in National Cheng Kung Uni- versity Hospital (NCKUH) were included in this study. Clinicopathologic data of these patients were collected. Immunohistochemistry for CD44 protein, reverse transcription -polymerase chain reaction (RT-PCR) for CD44 mRNA, and Western blot for CD44 cleavage products were conducted in the tumor and normal tissues from these patients available at the NCKUH tissuebank. RESULTS: We previously identiﬁed loss of CD44 protein expression in GIST as a poor prognostic factor in GIST. In this study, CD44 cleavage products could be detected in the majority of GIST tumor tissues but not in most of their normal counterparts, suggesting the high prevalence of CD44 cleavage in GIST. Enhanced CD44 cleavage activities were found to be related to CD44 protein loss without concurrent CD44 mRNA loss, indicating that CD44 cleavage might play a role in the mechanism of CD44 protein loss in GIST. CONCLUSION: The expression of CD44 and its cleavage have been noted to be involved in tumor invasion and metastasis. We have found that loss of CD44 expression and the associated poor clinical outcomes in GIST may be related to the increased cleavage activities of CD44, which may be the puta- POSTER tive mechanism responsible for CD44 protein loss in GIST. WEDNESDAY ABSTRACTS

433 6303_SSAT.book Page 434 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1700 Laparoscopic Ajustable Gastric Banding: 4-Year Follow Up Philipp Busch*, Jens Aberle, Helen M. Ameis, Anna Freier, Stephanie Gros, Nina Mommsen, Jakob R. Izbicki, Oliver Mann University Medical Center Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: We evaluated the long term impact of ajustable gastric banding (LAGB) on obesity associated comorbidities, namely hypertension and diabetes mellitus type 2, as well as the quality of life in morbidly obese patients. METHODS: 94 patients (77 female and 17 male; BMI von 49.5 ± 9.2 kg/m2) who underwent LAGB between 12/1997 and 11/2003 were recruited in this study. In all cases preoperative assessment included upper GI endoscopy, 24-h-pH-monitoring, esophageal manometry, barium swallow. Evaluation of the quality of life was done by using the BAROS and SF-36 questionaire. Follow-up period was at least 48 months. RESULTS: Excessive Weight Loss (EWL) was 47.67% after 5 years. In patients suffering of GERD prior to LAGB no significant impact on acid refux could be detected. Preoperative evaluation identified 18/94 patients (19%) to have diabetes mellitus Typ II. 60 months postoperativly only 3/94 patients (3%) were not able to discontinue their diabetic medication (p < 0.01). Furthermore in 32/94 of the patients (34%) hypertension was diagnozed compared to only 12/94 patients (13%) 60 months after LAGB (p < 0.01). Quality of life was also significantelly improved and corresponded to the weight loss progress (BAROS good to bis excellent 71/94 [75%] [p < 0.01]). CONCLUSION: Long term weight loss after LAGB has a positve impact not only on the weight associated comorbidities, but also improves the quality of life significantelly.

434 6303_SSAT.book Page 435 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1701 Gastrojejunal (GJ) Leak After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Carries Minimal Risk with an Aggressive Detection/Management Approach, Whereas Greater Morbidity/Mortality Occurs with Leak at the Jejunojejunostomy (JJ) Alexander Perez*, Eric J. Demaria, Dana D. Portenier, John P. Grant, Aurora D. Pryor Surgery, Duke University Medical Center, Durham, NC BACKGROUND: Anastomotic leaks after LRYGB are uncommon and an independent risk factor for mortality. METHODS: Retrospective analysis of prospectively collected database from 1/1/01–11/1/07. All patients underwent linear-stapled GJ and JJ anastomosis. RESULTS: 1792 patients underwent LRYGB. 23 (1.3%) developed leaks. Demographics included age 44 ± 9, female (75%), and BMI 51 ± 8. There were 16 GJ leaks (0.9%). The incidence was evenly distributed over time. Air leak on intra-op testing was a risk factor for postoperative leak, occurring in 3/16 (23%). Routine postoperative UGI was negative in 7/16 (44%) patients with GJ leak. 11/16 (69%) were symptomatic. 9/16 (56%) were managed operatively on average post-op day 2 ± 2. 7/16 (44%) were managed with drainage alone. There were no deaths. Average hospital stay was 8 ± 7 days.There were 5 JJ leaks; all during the ﬁrst half of our series. None were diagnosed by UGI. All patients were symptomatic and were managed operatively on post-op day 3 ± 3. There were 2 deaths (40%), and hospital stay was 16 ± 9 days.Sensitivity of UGI is higher for GJ than JJ leaks (56% vs 0%, p = 0.04). Both are similarly symptomatic. Operative management was employed similarly. JJ leaks have a longer LOS (16 ± 9 vs 8 ± 7 days, p = 0.02) and a higher mortality (40% vs 0%, p = 0.04). CONCLUSIONS: Leak is an uncommon complication of LRYGB (1.3%). The GJ leak presents minimal morbidity/mortality with early detection/treatment in the modern era of LRYGB. Routine UGI is questioned due to its poor sensitivity for leak detection. JJ leaks cause greater morbidity and mortality than GJ leaks. Quality improvement efforts should not overlook the importance of detection and prevention of JJ leaks. POSTER POSTER WEDNESDAY ABSTRACTS

435 6303_SSAT.book Page 436 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1702 Quantitative Analysis of Free Ubiquitin and Multi- Ubiquitin Chain in Precancerous and Cancerous Gastric Tissues Yoshio Ishibashi*, Hideyuki Kashiwagi, Norio Mitsumori, Hiroshi Nimura, Yutaka Suzuki, Nobuo Omura, Katsutoshi Kobayashi, Akira Matsumoto, Koji Takada, Katsuhiko Yanaga Surgery, Jikei University Shool of Medicine, Tokyo, Japan BACKGROUND: Free ubiquitin (FUb) conjugates various proteins selectively intracellularly and forms multi-Ub chain (MUC) to activate degradation of these proteins by proteasome. Accordingly, ubiquitin (Ub) exists in vivo as FUb prior to ubiquitination and as MUC after functional modiﬁcation or degradation. As degradation of nuclear proteins such as cyclins and p53 protein are dependent on Ub, Ub mediated proteolitic systems are regarded to play an important role in cartinogenesis. We have previously reported by immunohistochemical analysis that Ub immunoreactivity is higher in various maling- nant tumors than normal tissues. The purpose of this study was to examine the levels of FUb and MUC in precancerous and cancerous gastric tissues. METHOD: Nine pairs of gastric cancers and adjacent normal tissues were obtained by surgery. Another 9 samples of atrophic gastritis mucosa were obtained at the time of endoscopic examination. As reported by Takada et al. (Eur J Biochem 1995), we used speciﬁc immunoassay systems to measure levels of the two forms of Ub in each tissue specimen. Ub-immunoreactive proteins were analyzed by Western blotting. Serum Ub was also measured. RESULT: As compared with normal gastric tissue, the concentration of MUC was higher in gastric cancer (p < 0.05). The concentration of FUb was much higher in atrophic gastritis mucosa(p < 0.05). Various bands of MUC were present in both cancerous and normal tissues. In gastric cancer, some peculiar bands which were absent in the normal tissue were recognized. CONCLUSION: The levels of FUb and MUC were upregulated in precancerous and cancerous gastric tissues. Ub seems important in tumorigenesis.

436 6303_SSAT.book Page 437 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1703 Surgical Outcomes of Patient with Gastrointestinal Stromal Tumors in the Era of Selective Drug Therapy Mehrdad Nikfarjam*1, Serene Shereef1, Yixing Jiang3, John Liang2, Niraj J. Gusani1, Eric Kimchi1, Mandeep S. Sehmbey1, Kevin Staveley-O’Carroll1 1Surgery, Penn State, Milton S. Hershey Medical Center, Hershey, PA; 2Pathology, Penn State, Milton S. Hershey Medical Center, Hershey, PA; 3Medicine, Penn State, Milton S. Hershey Medical Center, Hershey, PA BACKGROUND: The discovery of c-Kit mutations and targeted drug therapy with imatinib mesylate, has revolutionized the management of Gastrointesti- nal Stromal Tumors (GISTs). The outcome of patients with GISTs treated surgically in the era of selective drug therapy was assessed to determine factors associated with adverse outcomes. METHODS: Patients with GISTs requiring surgery at a tertiary care center between 2002 and 2007 were reviewed. Patients were followed-up 3 monthly after tumor resection with abdominal imaging. The effect of various prognostic factors on disease recurrence and survival were determined by univariate and multivariate analysis. RESULTS: Forty patients were surgically treated for GISTs. The median age at presentation was 59 years. The stomach (55%), colon (15%), small intestine (10%), duodenum (10%), mesentery (7.5%) and esophagus (2.5%) were the sites of primary disease. The median primary tumor size was 7 cm (0.7–24 cm). Eleven (28%) patients had metastatic disease at the time of surgery. Surgical treatment was undertaken in all patients with curative intent. Multi-organ resection was required in 10 (25%) patients. Imitinab mesylate was administered preoperatively and post-operatively in 13% and 68% of patients respectively. Median follow-up was 24 (1–74) months, with 16 (40%) recurrences during this period. Repeat surgical resection was performed in 10 of 16 (63%) cases. The peritoneum and liver were the main sites of recurrent disease. The 5 year disease free survival (DFS) and disease specific survival (DSS) was 35% and 65% respectively. High mitotic rate (P < 0.001), tumor size greater than 5 cm (P = 0.0246), tumor size greater than 10 cm (P < 0.001), post-operative imitinab mesylate (P = 0.01) were prognostically significant adverse factors in DFS. Patient gender, symptom type, location of primary tumor, surgical extent, peri-operative blood transfusion, mucosal involvement, tumor rupture and tumor necrosis were not prognostically adverse factors. High mitotic rate (P = 0.026) and tumor size greater than 10 cm (P = 0.008) were the only POSTER significant factors on multivariate analysis. WEDNESDAY CONCLUSION: Aggressive surgical treatment and follow-up of GISTs, com- ABSTRACTS bined with selective drug therapy, improves long-term patient survival when compared to historical reports. Tumor recurrence is independently associated with a high tumor mitotic rate and size greater than 10 cm.

437 6303_SSAT.book Page 438 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Colon-Rectal

W1827 Fluorophore-Conjugated Anti-CEA Antibody for Intraoperative Imaging of Pancreatic and Colorectal Cancer Michele Mcelroy*1, Sharmeela Kaushal1, George A. Luiken2, Robert M. Hoffman3,1, Michael Bouvet1 1UCSD Medical Center, San Diego, CA; 2OncoFluor, Inc, San Diego, CA; 3AntiCancer, San Diego, CA Colorectal and pancreatic cancers together comprise the third and fourth most common causes of cancer-related death in the United States. In either type of cancer detection of both primary and metastatic disease is critical to patient survival. We have investigated the use of a fluorophore-labeled anti- CEA monoclonal antibody to aid in cancer visualization in nude mouse models of human colorectal and pancreatic cancer. Monoclonal anti-CEA was conjugated with AlexaFluor 488. In vitro staining demonstrated positive CEA expression in five human pancreatic cancer cell lines (ASPC-1, BxPC-3, Panc-1, CFPAC and CAPAN-1) and four human colon cancer cell lines (HCT-116, LS174T, SW948 and LOVO). Ten days after subcutaneous injection of either ASPC-1, BxPC-3 or LS174T cells into athymic mice, 100 µg conjugated antibody was delivered via tail vein injection. Small (1–2 mm diameter) subcutaneous tumors were clearly visible with bright green fluorescence after skin- flap elevation 24 hours after administration of the labeled antibody. Figure upper panels show representative in vitro staining, lower panels show subcutaneous tumor staining (scale bar 10 mm). The signal remained present for at least eight days. In addition, a primary human colon cancer specimen origi- nally harvested from a liver metastasis was passaged several times in nude mice. This tumor tissue was also analyzed for in vivo staining with the fluoro- hopre-conjugated anti CEA and stained strongly positive in a subcutaneous model. These results indicate that fluorophore-labeled anti-CEA offers a novel intra-operative imaging technique for the enhanced visualization of tumor in both colorectal and pancreatic cancer when CEA expression is present.

438 6303_SSAT.book Page 439 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1828 Murine Colitis Is Inhibited in MMP-9 Knockout Mice: The Addition of IGFBP-3 Overexpression Does Not Further Decrease Disease Severity Raymond Baxter*1, Aviad Hoffman1, Ik-Yong Kim1, Abu Nasar1, Kumara H. Shantha1, Mark Foster1, Keith Hoffman1, Richard L. Whelan1 1Surgery, Columbia University Medical Center, New York, NY; 2Pathology, Columbia University Medical Center, New York, NY INTRODUCTION: Matrix Metalloproteinase 9 (MMP-9) has been found to be upregulated in the setting of inflammatory bowel disease (IBD). In the absence of MMP-9 production the disease has been found to be significantly less severe. Levels of Insulin like Growth Factor Binding Protein 3 (IGFBP-3), a cell growth inhibitor that is cleaved by MMP-9, are significantly decreased during active episodes of IBD and return to normal during remission. Although unproven, IGFBP-3 may inhibit colitis. The goals of this study were to determine the severity of chemically induced colitis in wild type (WT), MMP-9 null (KO), and MMP9 null/IGFBP-3 transgenic(KO/TG) mice. METHODS: All mice used were CD1 background: 10 WT, 10 KO, and 8 TG/KO. Colitis was induced with dextran sodium sulfate (DSS) supplemented drinking water given for 14 days after which the animals were sacrificed. On day of sacrifice body weight and occult blood in stool were assessed. The colons were resected and evaluated and paraffin blocks prepared after which slides were made and stained with H&E and scored by a pathologist according to an established method. Results are reported as mean ± sd. Statistical analyses were done using Fischer’s exact test, student’s t-test, and student’s paired t-test. Significance is p < 0.05. RESULTS: Fecal occult blood and colitis was noted in all mice. Histologic analysis by a blinded observer confirmed that severe colitis was found more frequently in WT mice than in either the TG/KO or KO groups (p = 0.007 and 0.01 respectively). Specifically, 63% of the TG/KO and 60% of the KO mice had mild colitis based on the scoring system vs 0% of the WT animals. Although all animals lost weight, the least severe losses were noted in the TG/ KO mice (13 ± 7%) than in the KO mice (15 ± 7%) or WT mice (21 ± 10%, vs TG/KO, p = 0.058). There were no significant differences between the TG/KO and the KO groups for any of the parameters.

CONCLUSIONS: Less severe colitis and less weight loss were noted in both POSTER

the TG/KO and the KO groups when compared to the WT mice. However, WEDNESDAY overexpression of IGFBP-3, in the absence of MMP-9, in this model, did not further attenuate the colitis. Although IGFBP-3 levels are inﬂuenced by IBD ABSTRACTS disease activity, IGFBP-3, in and of itself, may not inhibit colitis.

439 6303_SSAT.book Page 440 Tuesday, April 22, 2008 1:26 PM

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W1829 Everolimus Impairs the Healing of Intestinal Anastomoses Markus A. Kueper*, Stefan Beckert, Petra Mayer, Jorg Glatzle, Juergen Weinreich, Alfred Königsrainer, Stephan Coerper Department for General, Visceral and Transplant Surgery, University of Tuebingen, Tuebingen, Germany INTRODUCTION: The mTOR-inhibitor everolimus is a derivate of sirolimus. It is known, that immunosuppressive drugs impair the healing of the skin both clinical and in an animal model.1,2 The most distinctive wound complications were noticed under medication with sirolimus.2 Aim of this experimental research is to investigate the effects of everolimus on the healing of experimental colonic anastomoses. MATERIAL AND METHOD: Three groups (n = 10/group) of male Sprague- Dawley-rats received a distal colonic anastomosis and afterwards daily treatment with either vehicle [P] or everolimus in two different dosages (1.0mg/kg BW [E1]; 3.0 mg/kg BW [E2]). After 7 days the rats were killed, the anastomosis was resected in toto and the “bursting pressure” (mmHg) was measured. A basic histological staining followed (HE and Azan), as well as the quantitative measurement of hydroxyprolin as a parameter for the collagen content of the tissue (µg/mg dry-weight [DW]) and PCNA as a marker for the cell proliferation (Quantimet: positive cells/mm2). RESULTS: The anastomotic “bursting pressure” was significantly decreased by the everolimus treatment in both dosages (117 ± 25 vs. 142 ± 17 mmHg; p = 0.02 E1 vs. P and 108 ± 30 vs. 142 ± 17 mmHg; p = 0.006 E2 vs. P). The anastomotic hydroxyprolin-content was reduced only by the high everolimus dosage (6.20 vs. 9.77 µg/mg DW; p = 0.007 E2 vs. P). The number of PCNA- positive cell nuclei also was significantly reduced by everolimus (P: 11091 ± 1976/mm2, E1: 8067 ± 1127/mm2, E2: 6352 ± 1271/mm2). The Azan-staining revealed more unordered collagen fibres under everolimus treatment. CONCLUSION: Everolimus impairs the intestinal wound healing by inhibition of the cell proliferation, which increases with rising dosages. On the other hand, the anastomotic hydroxyprolin content was reduced only by the high dosage of everolimus. Corrensponding to these data, the anastomotic “bursting pressure” is significantly reduced under treatment with everolimus. REFERENCES: 1. Schaffer et al., 2005, J Invest Surg. 18: 71–79. 2. Dean et al., 2004, Transplantation 77:1555–1561;

440 6303_SSAT.book Page 441 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1830 Polyphenon E, an EGCG Containing Green Tea Extract That Inhibits Tumor Growth, Has No Impact on Wound Collagen Content or Clinical Rate of Wound Infection or Dehiscence Yet Has a Mild Inhibitory Effect on Healing as Judged by Tensometry Aviad Hoffman*1, Raymond Baxter1, Abu Nasar1, Thomas R. Gardner3, Kumara H. Shantha1, Keith Hoffman1, Richard L. Whelan1 1Surgery, Columbia University, New York, NY; 2Pathology, Columbia University, NY, NY; 3Orhtopedics, Columbia University, NY, NY INTRODUCTION: Catechins in green tea, in particular EGCG (epigallocat- echin-3-gallate), inhibit tumor growth in many murine models. Polyphenon E (PolyE) is a concentrated mixture of catechins (65% EGCG) with minimal side affects in humans that has stronger anti-cancer effects than tea alone. Surgery is associated with increased rates of tumor growth and metastases postoperatively(postop) in the murine setting. Perioperative (periop) administration of Poly E may limit surgery’s tumor stimulatory effects. Prior to a Phase 1 study, PolyE’s effects on wound healing must be studied. This study’s purpose was to assess PolyE’s impact on laparotomy wound strength and collagen content. METHODS: Balb/C mice were randomized to plain water (Control, n = 20) or a 1% PolyE solution (n = 25) for drinking; 10 days later all mice underwent sham laparotomy that was suture closed. Mice were sacrificed on postop days (PODs) 7 or 21 and the abdominal wall pelts were harvested. The peak force and total energy required to rupture each wound was determined via tensometry; wound collagen content was determined via a Sircol Collagen assay. Serum EGCG levels were determined in 3 PolyE mice on POD1, 7, and 21 to verify drug ingestion. Results are presented as mean ± SD; data was assessed using the student’s t-test and Mann-Whitney U-test (significance, p < 0.05). RESULTS: No wound infections or dehiscences were noted in either group. The mean peak rupture force for each group was statistically similar on POD 7 and 21. There was no statistical difference in the total energy required for rupture on POD 7, however, on POD 21 the total energy required in the PolyE group (4.1 ± 0.78 N-mm) was significantly lower than for the control mice (5.6 ± 1.7 N-mm; p = 0.026). When the 2 groups wound collagen results on

POD 7 were compared there was no difference noted, the same was true for POSTER

the POD 21 results. EGCG was detected in the PolyE mice serum on POD 1 WEDNESDAY and POD 7; on POD21 very low levels were detected. ABSTRACTS CONCLUSIONS: Perioperative PolyE administration was not associated with wound complications. The peak force for rupture and the collagen content was similar at both time points for the 2 groups as was total energy for rupture on POD 7; total energy on POD 21 was less for the PolyE group. PolyE warrants further study as a perioperative anti-cancer agent in the cancer setting.

441 6303_SSAT.book Page 442 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Esophageal

W1831 Polymorphism Arg290Arg in Esophageal Cancer Related Gene 1 (ECRG1) Is a Prognostic Factor for Survival in Esophageal Cancer Kai Bachmann*, Jussuf T. Kaifi, Paulus G. Schurr, Jakob R. Izbicki, Tim Strate General Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Hamburg, Germany PURPOSE: Esophageal cancer is one of the most frequent cancers worldwide and is associated with poor outcome. Besides clinicopathological data, few prognostic molecular markers exist. Esophageal Cancer Related Gene1 (ECRG1) short tandem repeats are associated with higher risk for developing esophageal squamous cell carcinoma. The aim of the present study was to evaluate the impact of DNA polymorphisms in the coding region of ECRG1 in esophageal carcinoma. METHODS: Genomic DNA of 107 patients with esophageal cancer that underwent complete surgical resection between 1997 and 2005 and of 100 healthy controls was extracted. DNA was analyzed for ECRG1 polymorphisms Arg290Arg, Arg290Gln, and Gln290Gln by PCR and gel electrophoresis. Poly- morphisms were correlated with survival data by the Kaplan-Meier method, multivariate Cox regression analysis, and odds ratio were determined. RESULTS: Follow-up data of 102 patients with esophageal cancer were available after complete surgical resection for a mean follow-up time of 24.3 months. Polymorphism Arg290Arg was found in 47 patients (46.1%), Arg290Gln in 48 patients (47.0%) and Gln290Gln in 7 cases (6.9%). Arg290Arg polymorphism was significantly associated with reduced survival by the log-rank test (p = 0.011). Multivariate regression analysis by Cox revealed polymorphism Arg290Arg to be a significant independent prognostic factor for survival (p = 0.012). CONCLUSIONS: Polymorphism Arg290Arg in ECRG1 is associated with poor clinical outcome after complete surgical resection in patients with esophageal cancer. This genetic polymorphism might be used to predict the response to neoadjuvant treatment. The role of ECRG1 in esophageal cancer development has to be determined in future studies.

442 6303_SSAT.book Page 443 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1832 Barrett’s Intestinal Metaplasia mRNA Expression Profile in Formalin-Fixed, Paraffin-Embedded Endoscopic Biopsy Specimens Fiona I. Schneiders1, Natalia K. Botelho1, Reginald V. N. Lord*1,2 1Oesophageal Cancer Research Laboratory, Centre for Immunology, UNSW, Sydney, NSW, Australia; 2UNSW Department of Surgery, St. Vincents’ Hospital, Sydney, NSW, Australia BACKGROUND AND AIM: Widespread applicability of genetic testing for Barrett’s esophagus depends on developing accurate methods for assaying archival formalin-fixed, paraffin-embedded (FFPE) histopathology specimens taken at endoscopy. We sought to develop an accurate mRNA comparative quantification method for FFPE tissues that would detect disease even in patients with Barrett’s intestinal metaplasia, who have small alterations in gene expression compared to patients with dysplasia or cancer. METHODS: mRNA was isolated from formalin-fixed, paraffin-embedded (FFPE) small endoscopic biopsies from 10 patients with IM and 11 control patients with a normal squamous-lined esophagus. IM tissues included only small numbers of glands in a single endoscopic biopsy in some cases. Multi- plex tandem PCR (MT-PCR) was used to quantitate genes of interest for Bar- rett’s esophagus and control genes in duplicate using the Rotor-Gene 6000 system (Corbett Life Sciences). RESULTS: Significantly increased expression of hTERT, ODC1, MYB, SPARC, RAR-A, and significantly decreased expression of GSTP1 and RAR-G were found in IM compared to normal tissues. The direction and magnitude of the differences were very similar to those found using fresh frozen tissues. Two novel genes identified from a microarray study, CD151 (which encodes a protein that enhances cell motility, invasion and metastasis of cancer cells) and TCIRG1 (T-cell, immune regulator 1, ATPase, H+ transporting, lysosomal V0 subunit A3) were overexpressed in IM. CONCLUSIONS: Accurate mRNA comparative quantification, matching fresh frozen tissue results, can be obtained from even single small formalin- fixed, paraffin-embedded Barrett’s esophagus endoscopic biopsy tissues using a multiplex tandem PCR method. POSTER POSTER WEDNESDAY ABSTRACTS

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1833 KI-67 Antigen Is Overexpressed in Barrett’s Carcinogenesis Bernardo Volkweis, Richard R. Gurski*, Luise Meurer, Maria Isabel A. Edelweiss, Gustavo Morellato, Marcelo K. Schmidt Digestive Surgery, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil OBJECTIVES: To evaluate the Ki-67 antigen expression in patients with Bar- rett’s esophagus and esophageal adenocarcinoma and to analyse its correlation with the metaplasia-esophageal adenocarcinoma progression. METHODS: Through imunohistochemical analysis we evaluated Ki-67 index in patients with Barrett’s esophagus, esophageal adenocarcinoma and controls, assisted at Hospital de Clinicas de Porto Alegre between 2002 and 2005. We included patients with endoscopically visible columnar mucosa of the distal esophagus, whose biopsy proved specialized intestinal type metaplasia, patients with esophageal and esophagogastric tumors type I and II and patients with histologically normal gastric mucosa (control).

RESULTS: We studied 57 pacients. There was no statistically signiﬁcant differences between the groups regarding age or race. Patients with cancer were predominantly men. Ki-67 index averaged 10 ± 4% in patients with normal gastric mucosa (n = 17), 21 ± 15% in patients with Barrett’s esophagus (n = 21) and 38 ± 16% in patients with cancer (n = 19). Ki-67 expression was signiﬁcantly different between all groups (P < 0.05). There was strong linear correlation between Ki-67 expression and metaplasia-adenocarcinoma sequence (P < 0.01). In patients with cancer, Ki-67 was not associated with clinical or surgical staging. CONCLUSIONS: Ki-67 antigen has increased expression along the metaplasia- adenocarcinoma sequence. There is strong linear correlation between Ki-67 proliferative activity and Barrett’s carcinogenesis.

444 6303_SSAT.book Page 445 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Hepatic

W1834 Enteral Immunonutrition with Long Chain Triglycerides Significantly Reduces the Recruitment of Immune Cells Into the Liver During Experimental Sepsis Maximilian Feilitzsch*, Theo Maier, Judith Junginger, Tobias Meile, Markus A. Kueper, Alfred Koenigsrainer, Jorg Glatzle General and Transplant Surgery, University of Tuebingen, Tuebingen, Germany BACKGROUND: There is strong evidence that hepatocellular injury during sepsis is initiated by inflammatory processes originated by both activated Kupffer cells and circulating blood cells which become adherent within the endotoxemic liver. Recently, we have shown, that an enteral immunonutrition with long chain triglycerides significantly reduced lung injury during sepsis (Glatzle et al., J. Gastrointest. Surg. 2007). AIM: To investigate, whether an enteral immunonutrition with long chain triglycerides reduces inflammatory response in the liver during sepsis. METHODS: Mesenteric lymph was obtained from lymph fistula donor rats under control conditions (n = 6, control lymph, CL) or during sepsis (n = 6, LPS, 5 mg/kg i.p., sepsis lymph, SL). Sepsis lymph was also collected during enteral immunonutrition with 1% olive oil (n = 6, SL-OO) or 1% of fish oil (n = 6, SL-FO). CL, SL, SL-OO, SL-FO were re-infused into the jugular vein of separate healthy recipient rats (n = 4 each group). Thereafter, liver tissue was collected and the number of Kupffer cells (ED2) or recruited macrophages (ED1) were analyzed at t = 90 and t = 180 min (n = 30 optical sections per rat). RESULTS: The release of TNFa from the gastrointestinal tract into mesenteric lymph was up to 200-fold increased during sepsis. Infusion of sepsis lymph into separate recipient rats increased the number of ED1 positive cells by more than twice at t = 180 min, whereas no changes were observed after 90 min. Infusion of sepsis lymph did not change the number of ED2 positive cells in the liver of recipient rats. Interestingly, infusion of sepsis lymph collected during an enteral immunonutrition with either olive oil or fish oil, significantly reduced the number of recruited ED1 positive macrophages into the liver by more than 30% and 40% respectively (ED1 positive cells/optical field, t = 180 min: CL: 0.89 ± 0.09, SL: 1.8 ± 0.1*, SL-OO: 1.2 ± 0.1#, SL-FO: 1.0 ± 0.07#, *p < 0.001 vs. CL, #p < 0.001 vs. SL). POSTER WEDNESDAY CONCLUSION: An enteral immunonutrition with long chain triglycerides during sepsis reduces inflammatory mediator release from the gastrointestinal ABSTRACTS tract and has a protective effect regarding inflammatory response of the liver during sepsis.

445 6303_SSAT.book Page 446 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1835 Association of Non-Alcoholic Steatohepatitis (NASH) and Inflammatory Mediators from Adipose Tissue Atul K. Madan*1, David S. Tichansky2, John Fain2 1University of Miami, Miami, FL; 2University of Tennessee Health Science Center, Memphis, TN INTRODUCTION: The epidemics of nonalcoholic steatohepatitis (NASH) and obesity continue to increase. Since many of the deleterious effects of obesity are thought to be due to the release of inflammatory mediators by adipose tissue, NASH may be related to the release of such cytokines. Elucidation of the pathways associated with NASH may help with novel treatment options. The study investigated the hypothesis that morbidly obese patients with NASH would have increased mRNA content of obesity-related inflammatory mediators from omental adipose tissue compared to morbidly obese patients without NASH. METHODS: Patients who were undergoing laparoscopic bariatric surgery and liver biopsy were included in this study. During each procedure, omental adipose tissue was harvested from the abdomen and mRNA content of select obesity-related inflammatory mediators (IL-6, Vaspin, MAP4k4, 11β HSD-1, visfatin, PPARγ, CIDEA, leptin, GPX-3, adiponectin, and CIDEC) was measured. Patients with NASH were matched for ethnicity, gender, body mass index, and waist to patients with no NASH. Values are presented as change from cyclophillin Cp values. RESULTS: There were 16 patients in this study. As the table demonstrates, there were no statistically significant changes between obesity-related inflammatory mediators from omental adipose tissue between patients who had NASH and those that did not have NASH. CONCLUSIONS: Of the obesity-related inflammatory mediators we tested, none were related to NASH. Either other obesity-related mediators or mechanisms are involved with the pathogenesis of NASH.

NASH No NASH IL-6 –6.2 ± 0.9 –7.7 ± 1.3 Vaspin –1.7 ± 0.7 –1.8 ± 1.3 MAP4k4 –2.0 ± 2.8 –2.3 ± 0.3 11β HSD-1 0.4 ± 0.3 0.3 ± 0.3 Visfatin 2.3 ± 0.5 2.4 ± 1.3 PPARγ 1.5 ± 0.2 1.4 ± 0.1 CIDEA 1.0 ± 0.1 1.0 ± 0.3 Leptin 2.9 ± 0.2 2.0 ± 0.5 GPX-3 3.9 ± 0.3 4.0 ± 0.3 Adiponectin 4.2 ± 0.2 3.8 ± 0.7 CIDEC 3.5 ± 0.1 3.3 ± 0.2

p = NS for all comparisons between NASH and no NASH

446 6303_SSAT.book Page 447 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Pancreas

W1836 Reduction of Local Inflammatory Response on Acute Pancreatitis in Rats: Effects of a Hypertonic Saline Solution Ana Maria M. Coelho*, Jose Jukemura, Sandra N. Sampietre, Nilza T. Molan, Lourenilson J. Souza, Rosely A. Patzina, José Eduardo M. Cunha, Marcel C. C. Machado Gastroenterology, University of São Paulo, São Paulo, Brazil INTRODUCTION: In acute pancreatitis (AP) local proinflammatory cytokine production within the pancreas may lead to a systemic inflammatory response with potentially fatal multiorgan failure. Previous studies have demonstrated that hypertonic saline solutions present significant potential as an immunomodulator agent. AIM: To evaluate the effect of a hypertonic saline solution on local inflammatory response on acute pancreatitis in rats. METHODS: AP was induced in male Wistar rats by intraductal 2.5% tauro- cholate injection. The animals were divided in 3 groups: NT (n = 15): no treated AP, NS (n = 15): animals received 34 ml/kg of normal saline solution (NaCl 0.9%) IV, 1 hour after AP, and HTS (n = 15): animals received 4 ml/Kg of hypertonic saline solution (NaCl 7.5%) IV., 1 hour after AP. After 2 and 24 hours of induction of AP volume of ascitic fluid and TNF-alfa, IL-6 and IL-10 levels in the ascitic fluid and pancreatic tissue were determined by enzyme- linked immunosorbent assay (ELISA). Pancreatic myeloperoxidase (MPO) and malondialdehyde (MDA) were analyzed 2 and 24 hours after AP. Pancreatic histology was also analyzed. RESULTS: A significant decrease on volume of ascitic fluid and levels of peritoneal TNF-alfa, IL-6 and IL-10 was observed two hours after AP in animals of HTS group (p < 0.05). Also, 2 and 24 h after AP a significant reduction on pancreatic levels of TNF-alfa, IL-6 and IL-10 was observed in group HTS when compared to NT and NS groups (p < 0.05). However, there were no significant differences in pancreatic MPO, MDA and histological findings (edema, acinar necrosis, hemorrhage, fat necrosis, and inflammation) in animals of the three groups. POSTER POSTER

CONCLUSION: These ﬁndings suggest that administration of hypertonic WEDNESDAY saline solution decreases local inﬂammatory response in acute pancreatitis ABSTRACTS without changing the intensity of the pancreatic lesions. Supported by FAPESP n0 2007/03980-5.

447 6303_SSAT.book Page 448 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1837 Effects of Late Administration of Pentoxifylline in Experimental Severe Acute Pancreatitis Tiago A. Kunitake, José Jukemura*, Ana Maria M. Coelho, Marcel C. Machado, José Eduardo M. Cunha Gastroenterology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil INTRODUCTION: Acute pancreatitis (AP) is a typical cause of systemic inflammatory response (SIRS), which can lead to multiple organ dysfunction syndrome (MODS), whose the first sign is often the adult respiratory distress syndrome. The systemic effects of AP have many similarities to those of other conditions such as septicaemia, severe burns and trauma. Cytokines play a critical role in the pathogenesis of AP and more so of the subsquent inflammatory response. Levels of these cytokines appear to be correlated with the severity of pancreatic inflammation. Tumor necrosis factor alpha (TNF–α) has a central role in the inflammatory cascade of AP and its related systemic complications. Pentoxifylline is a drug with rheologic and anti-inflammatory properties and inhibits the production of TNF–α. Some authors have shown amelioration of experimental AP using pentoxifylline; however, drug administration started on the time of the induction of pancreatitis, that is not possible in clinical practice. Our aim is determine the effects of pentoxifylline in experimental severe AP, starting drug administration one hour after the induction of disease (after the inflammatory cascade activation). METHODS: Severe AP was induced by injection of 0.5 mL of 2.5% sodium taurochoate into the pancreatic duct. Sixty male Wistar rats were utilized and divided into two groups: Control (AP plus saline) and Pentoxifylline (AP plus 25 mg/kg pentoxifylline, starting administration one hour after induction). Systemic inflammatory response was analyzed measuring inflammatory cytokines levels in blood (IL-6 and IL-10) and peritoneal fluid samples (TNF–α). Lung samples were collected to evaluate sequestration of neutrophils within this organ by assessment of tissue myeloperoxidase enzyme activity (MPO). Twenty rats of each group were kept alive for study of mortality rate in 72 hours. RESULTS: The Pentoxifylline group had a statiscally significant reduction of plasma IL-6 levels (278.9 ± 87.2 vs. 63.9 ± 20.4, p < 0.05), plasma IL-10 levels (37.6 ± 5.3 vs. 17.1 ± 7.3, p < 0.05) and peritoneal levels of TNF–α (87.6 ± 14.8 vs. 49.6 ± 9.4, p = 0.05). Pentoxifylline also reduced 72-hour mortality rate (30% vs. 10%), but the difference was not significant (p = 0.10). There was no difference in MPO activity between two groups (0.175 ± 0.030 vs. 0.128 ± 0.016). CONCLUSION: Late administration of pentoxifylline decreased the systemic inflammatory response, but it did not improve mortality rate. The drug failure to ameliorate pulmonary damage by neutrophilic infiltration. Supported by FAPESP 2007/1758-3.

448 6303_SSAT.book Page 449 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1838 Development of Monoclonal Antibodies to Aid in the Diagnosis of Pancreatic Cancer Karin M. Hardiman*1, Craig S. Dorrell2, Christopher Corless3, Brett C. Sheppard1, Markus Grompe2, Philip R. Streeter2 1Department of Surgery, Oregon Health and Science University, Portland, OR; 2Oregon Stem Cell Center, Oregon Health and Science University, Portland, OR; 3Department of Pathology, Oregon Health and Science University, Portland, OR Pancreatic ductal adenocarcinoma is the fourth leading cause of cancer mortality in the United States and the five year survival is only 1%–5%. The best available treatment for pancreatic cancer patients is surgery which is only effective at early stages of disease. However, only about 15% of patients diagnosed with pancreatic cancer have early stage disease. Failure to diagnose pancreatic cancer at early stages and lack of effective systemic treatments has led to the high mortality seen in patients with this disease. Thus, better tools are needed for diagnosis and treatment of pancreatic cancer. As monoclonal antibodies have been effective in the treatment of other cancers we sought to develop antibodies with high specificity for pancreatic cancer. BALB/c mice were immunized with fresh pancreatic ductal adenocarcinoma samples or normal pancreatic tissue. Splenocytes from immunized mice were fused with SP2/0 Ag14 myeloma cells and hybridized cells were selected and cultured. The supernatants from the hybridized cell cultures were screened for cancer- reactive monoclonal antibodies on fixed frozen sections of pancreatic cancer, pancreatitis and normal pancreas. Cy-3 conjugated secondary antibody was used to detect section-bound monoclonal antibodies. Monoclonal antibodies, DHIC2 4-A10 and DHIC3 5-H10, were found to selectively detect antigens in specimens of pancreatic adenocarcinoma, liver cholangiocarcinoma, stomach adenocarcinoma, and lung adenocarcinoma. Flow cytometry using dispersed cells from the pancreatic cancer cell line, Panc1, revealed that these antibodies recognize cell surface antigens on these cells. The antibodies were also tested on normal tissues and were found to react with ductal cells in pancreas and liver. This technique for making tumor reactive monoclonal antibodies has the potential to identify reagents that may be useful in the diagnosis and treatment of this lethal disease. POSTER POSTER WEDNESDAY ABSTRACTS

449 6303_SSAT.book Page 450 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1839 Combination Therapy with Suberoyl Bis-Hydroxamic Acid (SBHA) and Lithium Chloride for Gastrointestinal Carcinoid Tumors Joel T. Adler*, Daniel G. Hottinger, Muthusamy Kunnimalaiyaan, Herbert Chen Surgery, University of Wisconsin, Madison, WI BACKGROUND: Carcinoid tumors of the gastrointestinal tract often metastasize to the liver and are associated with debilitating symptoms and a poor quality of life. In the human gastrointestinal carcinoid cell line BON, the histone deacetylase inhibitor suberoyl bis-hydroxamic acid (SBHA) has been shown to inhibit growth and decrease the secretion of hormones. Lithium is an inhibitor of the glycogen synthase kinase 3β (GSK-3β) pathway. The combination of distinct mechanisms of action could be an effective treatment modality with lower toxicity. We hypothesized that more signiﬁcant growth inhibition could be achieved with combination therapy of both drugs. METHODS: BON cells were treated with varying combinations of 0–20 µM SBHA and 0–20 mM lithium chloride for up to 96 hours. Western analysis was used to measure neuroendocrine tumor markers achaete-scute complex-like 1 (ASCL1) and chromogranin A (CgA). Growth was measured by a methylthiaz- olyldiphenyl-tetrazolium bromide cellular proliferation assay, and Western analysis was used to determine the mechanism of growth regulation and the effects on the Notch-1 and GSK-3β pathways. RESULTS: A dose-dependent decrease in ASCL1 and CgA with the combination of 20 mM lithium and 5–20 µM SBHA was observed after 48 hours; this was more pronounced at 96 hours. SBHA increased the amount of active Notch-1 protein. Lithium was associated with phosphorylation of GSK-3β, demonstrating inhibition of the pathway. Growth was inhibited equally by 20 µM SBHA and the combination of 10 µM SBHA with 20 mM lithium after 96 hours. The levels of both p21 and p27 increased, suggesting that growth inhibition occurs through cell cycle arrest. CONCLUSIONS: Treatment of BON cells with SBHA and lithium chloride suppresses neuroendocrine markers ASCL1 and CgA while upregulating Notch-1 and inhibiting GSK-3β. This combination reduces growth through cell cycle arrest, and these outcomes were attained with lower doses in combination than treatment with either compound alone. With equal efﬁcacy and theoretically decreased toxicity, combination therapy may be a viable therapeutic approach for gastrointestinal carcinoid tumors.

450 6303_SSAT.book Page 451 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1840 Epithelial to Mesenchymal Transition in Pancreatic Cancer: Expression and Role of the Transcription Factors Snail, Slug, and Twist Hubert G. Hotz*, Birgit Hotz, Heinz J. Buhr Surgery I, Charite Medical School, Berlin, Germany BACKGROUND: Epithelial to mesenchymal transitions (EMT) are vital for tumor progression and metastasis. Several inducers of EMT are transcription factors that repress E-Cadherin expression such as Snail, Slug and Twist. In this study we aimed to examine the expression and role of these transcription factors in pancreatic cancer. METHODS: The expression of Snail, Slug, Twist, and E-Cadherin was detected by immunohistochemistry in tissue samples from 36 patients with pancreatic ductal adenocarcinoma. Four human pancreatic cancer cell lines (Capan-1, HPAF-2, MIAPaCa-2, and Panc-1) and human endothelial cells (HUVEC; control) were analyzed by RT-PCR, real-time PCR and western blotting. An orthotopic nude mouse model was applied for in vivo experiments: tumors were derived from the four human pancreatic cancer cell lines and animals (12 per group) observed for 14 weeks. Expression of the transcription factors and E-Cadherin was correlated with tumor spread and metastasis (dissemination score) in the mice. RESULTS: 78% of human pancreatic cancer tissues showed an expression of Snail, and 50% of the patients displayed positive expression of Slug. Twist showed no or only weak expression. A strong Snail expression in undifferentiated cancer cell lines (MIAPaCa-2 and Panc-1) was associated with low E-Cadherin and extensive metastasis in the mouse model. In contrast, low Snail and strong E-Cadherin expression in more differentiated cells lines (Capan-1, HPAF-2) corresponded with a signiﬁcantly reduced tumor spread in the animals (table). Snail mRNA expression correlated positively with metastatic potential of the cancer cells (r = 0.8), whereas a negative correlation was found between E-Cadherin and metastasis (r = –0.9). CONCLUSIONS: The transcription factors and EMT-regulators Snail and Slug are expressed in pancreatic cancer but not in normal tissue. The upregulation of Snail is associated with low expression of the adhesion molecule E-Cadherin, suggesting a role for Snail in the progression and metastasis of human pancre-

atic carcinomas. POSTER WEDNESDAY Relative mRNA Concentration Cell Line Snail E-Cadherin Metastasis (Dissemination Score) ABSTRACTS Capan-1 0.39 7.64 5.9 ± 0.6* HPAF-2 1.03 5.58 6.9 ± 0.5* MIAPaCa-2 7.17 0.10 14.3 ± 0.9 Panc-1 11.42 0.69 10.8 ± 0.7 HUVEC (Control) 1 1

p < 0.05: * vs. MIAPaCa-2 / Panc-1

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1841 A Model for Defining Molecular Aspects of Pancreatic Ductal Adenocarcinoma Patients for Targeted Adjuvant Therapy Shayna L. Showalter*1, Agnes Witkiewicz2, Joseph A. Cozzitorto1, Patricia K. Sauter1, Eugeen P. Kennedy1, Charles J. Yeo1, Jonathan R. Brody1 1Surgery, Thomas Jefferson University, Philadelphia, PA; 2Pathology, Thomas Jefferson University, Philadelphia, PA OBJECTIVE: To evaluate resected human pancreatic ductal adenocarcinoma (PDA) for selection of targeted adjuvant therapy. BACKGROUND: Standard adjuvant therapy for PDA generates a small but significant improvement in post-resection survival. Recent data have shown that PDAs with defects in a DNA repair pathway, such as BRCA2, are hyper- sensitive to interstrand cross-linking agents including cis-platinum. The challenge is to efficiently select patients that will optimally benefit from targeted therapy. METHODS: Patients were chosen for this study by evaluating personal history, family history and ethnic background. Molecular assays were performed to determine a deficiency in the DNA repair pathway. Patients’ tumor samples were obtained immediately in the operating room, placed into media for cell culture and extracted for DNA, mRNA, and protein. DNA was also isolated from laser capture microdissected material of patient A’s tongue and endometrial cancers.

RESULTS: Patient A had a strong family history of breast cancer and a personal history of tongue, endometrial, and breast cancers before presenting with pancreatic cancer. She was positive for a mutation in BRCA2 that causes a premature stop codon, and thus she was placed on cis-platinum therapy. Patient B presented with a medical and family history suggestive of a mutation in the BRCA2/FANC pathway. A cell line from patient B was generated and genetic analysis on several critical DNA repair genes including BLOOM, FANCC, BRCA2, and FANCA revealed no obvious alterations. However, the FANCD2 gene, showed markedly reduced protein and mRNA expression. Hence, this patient is also a candidate for targeted adjuvant therapy. CONCLUSIONS: We present a model that provides promising and novel methods to appropriately select patients to receive targeted adjuvant therapy. Larger cohort studies involving patients with similar criteria will reveal whether patients who receive such optimized, targeted adjuvant therapies will have a survival advantage.

452 6303_SSAT.book Page 453 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Small Bowel

W1842 Small Bowel Engineering Using Small Intestinal Submucosa (SIS) Syde A. Taheri*1, Umesh Patel3, William Van Alstine2, Merril T. Dayton1 1Surgery, University at Buffalo, Williamsville, NY; 2Purdue University, West Lafayette, IN; 3Cook Inc., West Lafayette, IN OBJECTIVE: 1. To induce tissue regeneration of small intestine using small intestinal submucosa (SIS) extracellular matrix. 2. To increase absorptive capacity of the bowel. METHODS: Five pigs given general anesthesia underwent a laparotomy. A segment of the small bowel approximately 15–30 cm. distal to the ligament of Treitz was isolated. An antimesentric enterotomy incision 3 to 10 cm was made. A lyophilized, multi-laminate construct of small intestinal submucosa (SIS) was sutured to the enterotomy incision and reinforced by the greater omentum with marker stitches. The size on construct ranged from 1.5 × 3 cm to 2 × 9 cm in the five animals. The abdomen was closed. RESULT: All animals survived, gained weight and were euthanized after six weeks. There was no sign of leak or peritonitis. A fibrous cord connected remodeled intestine to the greater omentum. Histological results showed the SIS material to be replaced with connective tissue, thinned mucosa and relatively mature epithelium. Re-epethelization with normal crypts, regenerated smooth muscle fibers and angiogenesis were seen. CONCLUSION: The results provided evidence of functioning tissue regeneration with SIS meterial. This regeneration is due to cells recruitment and tissue specific differentiation and was facilitated by the vascular supply provided by the greater momentum. POSTER POSTER WEDNESDAY ABSTRACTS

453 6303_SSAT.book Page 454 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1843 Diurnal Regulation of Drug Transporters in the Small Bowel Adam T. Stearns*1,2, Anita Balakrishnan1, David B. Rhoads3, Stanley W. Ashley1, Ali Tavakkolizadeh1 1Surgery, Brigham & Women’s Hospital and Harvard Mediacl School, Boston, MA; 2Physiology, Anatomy & Genetics, Oxford University, Oxford, United Kingdom; 3Pediatric Endocrinology, MassGeneral Hospital for Children and Harvard Medical School, Boston, MA INTRODUCTION: Drug metabolism varies with a diurnal rhythmicity. Intestinal drug transporters located on the small bowel enterocyte apical and basal membranes are very important in drug pharmacokinetics, controlling influx and efflux of many drugs. Extrusion of drugs into the intestinal lumen contributes significantly to clearance of many drugs, including chemothera- peutic agents. AIM: We hypothesized that drug transporters, in common with other enterocyte nutrient transporters, vary with a diurnal rhythmicity. Timing of drug and chemotherapy administration with these rhythms would allow better bioavailability, with delayed clearing of the drug. METHODS: 50 Male Sprague-Dawley rats were acquired and acclimatized to a 12-hour light dark cycle. Jejunal mucosa was harvested by killing animals at 3-hour intervals (n = 6–7) over 24 hours, starting at Zeitgeiber time ZT0 (lights-on, 7 am). mRNA was extracted, reverse transcribed and subjected to qPCR. The following transporters were studied: multidrug resistance protein MDR1, 3; multidrug resistance-associated protein MRP1-3; organic anion transporter 2B1 (OATP-B); organic cation/carnitine transporter 2 (OCTN2); Breast cancer resistance protein (BCRP); monocarboxylate transporter 1 (MCT1); and peptide transporter 1 (PepT1). qPCR products were expressed relative to Actin.

Relative Peak Fold Transporter Gene Name Substrate Examples p-value Expression Time Change MCT1 SLC16A1 Monocarboxylates, aspirin ++ ZT0 5.1 0.0009 MDR1 ABCB1 Small hydrophobic drugs, digoxin +++ ZT6 4.4 0.00006 OCTN2 SLC22A5 Verapamil +++ ZT0 4.3 0.00002 PepT1 SLC15A1 Small peptides, beta-lactams +++ ZT6 4.3 0.0001 MRP2 ABCC2 Ceftriaxone, doxorubicin +++ ZT6-12 2.4 0.0006 BCRP ABCG2 Purine analogs, methotrexate ++++ ZT0 1.9 0.02 OATP-B SLCO2B1 Organic anions, pravastatin +++ None N/A N/A MRP1 ABCC1 Hydrophobic peptides, vincristine + None N/A N/A MRP3 ABCC3 Glucuronides, vincristine ++ None N/A N/A MDR3 ABCB4 Phospholipids, vinblastin + None N/A N/A

RESULTS: All transporters were expressed in the small intestine, across a very wide range of expression levels (approximately 4 log difference). Pro- found diurnal rhythms were observed for MCT1, MDR1, OCTN2, PepT1, MRP2, and BCRP signal (see Table). All peaked during fasting. The remaining

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

transporters showed no clear diurnal rhythmicity, although notably these transporters were expressed at a much lower levels. CONCLUSIONS: We describe for the ﬁrst time diurnal rhythmicity in transcriptional expression of major drug transporters, which helps establish diurnal rhythms as a novel in vivo model for studying physiological drug transporter regulation. Their diurnal expression rhythm suggests that timing of drug administration is likely to impact drug bioavailability, including chemotherapy agents. POSTER POSTER WEDNESDAY ABSTRACTS

455 6303_SSAT.book Page 456 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1844 Electrosurgical and Ultrasonic Devices: An Evaluation of Thermal Spread and Other Device Characteristics Charles J. Dolce*, Jennifer E. Keller, Kenneth C. Walters, Jessica Heath, Amy E. Lincourt, James Norton, B. Todd Heniford, David A. Iannitti Surgery, Carolinas Medical Center, Charlotte, NC BACKGROUND: Bipolar electrosurgical and ultrasonic devices are routinely used in laparoscopic and open surgeries for hemostasis. Thermal spread and other device characteristics were evaluated for the Ligasure V (LV), Ligasure Advance (LA) (Valleylab, Boulder, Colorado), and Harmonic ACE (HS) (Ethicon). METHODS: Five millimeter laparoscopic instruments were tested within an in-vivo porcine model. Splenic, renal, uterine, and small bowel mesenteric vessels were tested. Each device was used to seal vessels less than 6-mm in diameter. Time to seal, device peak temperatures, time to peak temperatures, average jaw temperatures, and thermal spread were determined. Thermal imaging data was collected using the FLIR SC6000. SAS® software was used for statistical analysis. P-values < 0.05 were considered statistically significant. RESULTS: The mean times to seal for the LV, LA, and HS were 3.29 (0.50 standard deviation), 3.26 (0.27), and 7.24 seconds (1.76). There was a difference in time to seal between the LV vs. HS (p < 0.0001) and LA vs. HS (p < 0.0003) but not between LV vs. LA (p = 0.68). The mean peak temperatures for the LV (96.9˚C, 6.64 SD), LA (83.0˚C, 7.05 SD) and HS (297.7˚C, 9.66) were significantly different (p < 0.0001). When comparing LV vs. LA, significance was also achieved (p < 0.0001). The time to peak temperature for each device (LV 2.63 seconds, 0.46 SD, LA 3.82, 0.93 SD, HS 6.83, 0.89 SD) was also significantly different (p < 0.0001) as well as the average jaw temperatures of LV vs. LA (63.2˚C, 5.14 SD vs. 68.3˚C, 5.94 SD, p < 0.02) when compared to HS (237.9˚C, 9.37, p < 0.001 and p < 0.004). There was less thermal spread with the LV vs. LA (1.14 mm, 0.53 SD vs. 1.25 mm, 0.34 SD, p < 0.0495) and significantly less thermal spread when both the LV and LA were compared to the HS (1.73 mm, 0.50 SD, p < 0.0001 and p < 0.0001). CONCLUSIONS: The LV and LA had significantly less thermal spread and peak temperatures when compared to HS, thus minimizing the risk of thermal damage to adjacent tissues. The LV had less thermal spread, lower average jaw temperatures, and quicker time to peak temperatures than the LA. Further investigations including burst pressure testing and histological analysis of sealed vessels will help elucidate differences between these electrosurgical devices.

456 6303_SSAT.book Page 457 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Basic: Stomach

W1845 Epithelial Cell Turnover Is Increased in the Excluded Stomach Mucosa After Vertical Banded Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro*1, Pedro A. Petersen1,2, Ulysses Ribeiro1, Bruna S. Quevedo1,2, Thaise Y. Tomokane2, RogéRio Kuga1, Joel Faintuch1, Paulo Sakai1, Arthur B. Garrido1, Carlos E. Corbett2, Ivan Cecconello1 1Gastroenterology, University of São Paulo, São Paulo, SP, Brazil; 2Pathology, University of São Paulo, São Paulo, Brazil INTRODUCTION: Mucosal alterations after vertical banded Roux-en-Y gastric bypass for morbid obesity have not been clearly evaluated, since the excluded stomach is not easily reached by conventional endoscopy. AIM: to analyze the mucosal alterations (proliferative rate, Ki-67; apoptosis, caspase-3; hormonal function, gastrin; and inflammatory infiltrate (CD3 and CD4) in the excluded stomach and in the gastric stump (functional pouch) after gastric bypass. METHODS: Double balloon endoscopy was performed in 35 patients who underwent vertical banded Roux-en-Y gastric bypass longer than 36 months. They underwent endoscopic examination with multiple biopsies of the gastric stump mucosa (four), of the excluded stomach mucosa (four at the body and four at the antrum) and duodenal biopsies (four). Gastric biopsies from 31 non-operated obese patients were utilized as controls. Endoscopic biopsies were cut from tissue blocks fixed in formalin and embedded in paraffin. Sec- tions 4 µm thick were examined for expression of gastrin, Caspase-3, Ki-67, CD3 and CD4 using the streptavidin-biotin-peroxidase method. The grade of inflammation, atrophy and/or intestinal metaplasia, and the presence of Heli- cobacter pylori were recorded. RESULTS: Thirty patients (85.7%) were female and the mean age was 43.4 years-old (22–61 years-old). The mean post-operative time was 77.6 months (range 36–110 months). All patients had chronic gastritis in the bypassed stomach, with pangastritis in 33/35 (94.3%). Five cases (5/35, 14.3%) presented atrophy and four of them also had intestinal metaplasia. H. pylori was detected in 7/35 (20%) of the excluded stomach, and was positive in the antrum in all of them, and also positive in the body in four patients. The mean number of positive gastrin cells was 51.2 (13.6%) in the control group POSTER and 32.5 (9.2%) in the cases, p = 0.02. Ki-67 proliferative index in cases (body WEDNESDAY

= 25.4%, antrum = 25.6%), was significantly higher than that in controls ABSTRACTS (body = 14.8% and antrum = 20.2%), p = 0.02 and 0.03. Caspase-3 immu- noexpression was higher in the excluded stomach compared to the controls (45% vs. 18%), p = 0.02. The CD3+ T cell population contained 54% CD4+ (range 10–70%). There was no difference in studied immunoexpressions between the functional pouch and the controls for Caspase-3, Ki-67 and inflammatory infiltrate. There was no association between the immunoexpressions and the presence of Helicobacter pylori or histological alterations. CONCLUSIONS: Cell proliferation and apoptosis are increased in the excluded stomach mucosa compared to the non-operated obese controls. Alterations in cell turnover in these conditions may be of relevance in long term follow up.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

COMBINED SCIENCE POSTERS

Combined Science

W1993 Single Incision Laparoscopic Cholecystectomy Using Flexible Endoscopy: Saline Infiltration Gallbladder Fossa Dissection Technique John N. Afthinos*, Glenn Forrester, Steven Binenbaum, Eugenius J. Harvey, M. J. Latif, Scott J. Belsley, Ninan Koshy, James J. Mcginty, Domingo C. Nunez, George J. Todd, Grace J. Kim, Julio Teixeira Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY BACKGROUND: The introduction of natural orifice translumenal endoscopic surgery (NOTES) has demanded the creation of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. We evaluated a technique similar to that employed in endoscopic mucosal resection and applied it to the dissection of the gallbladder from the liver bed. METHODS: Eight patients underwent an elective, transumbilical single incision cholecystectomy using a flexible endoscope in our institution from August to October of 2007. Approximately 15 mL of saline were strategically injected into the gallbladder fossa with an endoscopic injection needle. After infiltration of this potential space, dissection of the gallbladder and hilum was carried out with endoscopic instruments and the cystic duct and artery were clipped with standard instruments. RESULTS: One of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between the gallbladder and the liver bed. CONCLUSIONS: The technique of saline injection to develop surgical planes is an invaluable tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of the potential space between the gallbladder and the liver bed improved visualization in all of our patients. This technique can prove valuable in dissections and requires further experi- mentation to evaluate its effectiveness in other applications.

458 6303_SSAT.book Page 459 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

W1994 The Effect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease Mankanwal S. Sachdev*1, David S. Tichansky2, Atul K. Madan3 1Gastroenterology & Hepatology, University of Tennessee, Memphis, TN; 2Surgery, University of Tennessee, Memphis, TN; 3Surgery, University of Miami, Miami, FL BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is becoming an epidemic in the United States. NAFLD is a spectrum of disease that includes steatosis and non-alcoholic steatohepatitis (NASH). This mirrors the obesity epidemic, which is thought to be an integral part of the pathogenesis of NAFLD. As a result of the rise of the prevalence of obesity, the number of bariatric surgery procedures performed across the United States has been increasing. This study investigates the hypothesis that steatosis and NASH improve after bariatric surgery. METHODS: All patients who underwent bariatric surgery from 1997 to 2002 were retrospectively reviewed. Any patients who underwent another surgical procedure with a concomitant liver biopsy were included in this study. Fisher’s exact test were utilized for statistical analysis. RESULTS: There were 37 patients (34 females) with an average age of 39.3 years (range 23 to 57), average age was with paired biopsies identiﬁed. All liver biopsies were performed from an average of 21 months (range 8–58) after the procedure. All patients had evidence of NAFLD at the ﬁrst operation, and of those, 31 showed improvement at the time of second surgery (p < 0.001) Preoperatively 34 had steatosis, of these, 28 (82%) had improvement, 5 demonstrated no change and 1 showed progression to NASH. There were 3 patients who had NASH at the original surgery. All three improved post operatively. CONCLUSIONS: Bariatric surgery is an effective tool to help improve histology in those patients with NAFLD. Patients who are morbidly obese and have NAFLD should be considered for bariatric surgery. POSTER POSTER WEDNESDAY ABSTRACTS

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

W1995 Impact of Gastric Irrigation on NOTES Mesh Placement Lauren Buck*, Joel E. Michalek, Samer Sbayi, Kent Van Sickle, Wayne H. Schwesinger, Juliane Bingener Dept of Surgery, UTHSCSA, San Antonio, TX INTRODUCTION: To avoid intestinal contamination of the peritoneal cavity is a long held surgical principle that is not fully compatible with Natural Orifice Surgery. We investigated the impact of gastric saline irrigation on bacterial content in animals pretreated with Proton pump inhibitors and in animals undergoing transgastric intraperitoneal mesh placement. METHODS: 24 Yorkshire swine were randomized to NOTES transgastric mesh placement or proton pump inhibitor pretreatment for 14 days, upper endoscopy + laparoscopic mesh placement. A 12 swine control group received NOTES with diagnostic peritoneoscopy. All groups received prophylactic parenteral antibiotics and gastric lavage with 500 cc saline. Gastric aspi- rates were cultured on blood agar for 48 hrs. The laparoscopy group utilized a 3 trocar procedure with polypropylene mesh. In the NOTES mesh group a transport balloon was used to transfer the mesh into the peritoneal cavity under minimal contamination. In both groups the mesh was clipped to the periumbilical peritoneum. Total procedure time for all groups was preset at 90 minutes. The animals were survived for 14 days. At necropsy peritoneal and mesh infection was assessed. RESULTS: Gastric irrigation reduced bacterial content in the gastric aspirate significantly in all groups (p < 0.001). There was no statistically significant difference in the mean bacterial count after irrigation at 24 or 48 hrs between the group that had undergone PPI treatment and the untreated groups. In the endoscopy + laparoscopic mesh placement group no clinically apparent mesh infection was encountered. In the transgastric mesh placement group 4 of 12 animals were found to have a grossly apparent mesh infection (p = 0.03). In the infected group mean count of colony forming units at 24 hrs was 6.3 + 7.2; the bacterial count in the uninfected group was 6.9 + 9.1 (p = 0.81). No peritoneal infection was seen in the NOTES control group. CONCLUSION: Gastric irrigation with 500 cc saline significantly decreased the gastric bacterial count independently of pretreatment with proton pump inhibitors. Mesh infection was significantly more frequent in the transgastric route despite prophylactic antibiotics, gastric irrigation and a protective transport balloon. NOTES mesh infection appeared independent of the gastric bacterial count after irrigation in this study. Additional measures will have to be taken to enable translumenal mesh placement.

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

AUTHOR INDEX

A Asakura, Tohru ...... T1703 Asano, Takehide ...... W1684 Abate, Emmanuele...... 566, T1721 Ashley, Stanley W...... T1919, W1843 Abe, Nobutsugu ...... M1556 Asmellash, Senait G...... 559 Aberle, Jens ...... W1700 Assef, Jose C...... T1742 Abood, Gerard ...... T1727 Assumpcao, Lia R...... W1677 Abramson, Michael ...... W1683 Atomi, Yutaka ...... M1556 Adam, Ulrich ..... 564, 776, M1534, M1535, Attwood, Stephen E...... 339 ...... M1543, M1547, T1731 Atwell, Thomas D...... 250 Adams, David B...... Sp827, W1679 Auyang, Edward...... 452, 456, 1024 Adams, Reid B...... Sp550 Avella, Diego ...... 568 Adler, Joel T...... W1839 Aversa, John ...... T1904 Adrales, Gina L...... 457 Avgerinos, Dimitrios V...... 1021 Adusumilli, Prasad...... M1531 Avissar, Nelly E...... M1849 Afthinos, John N...... 1026, M1502, W1993 Ayazi, Shahin ...... 566, T1721 Agarwal, David M...... W1673 Azevedo, Luiz S...... T1699 Ahmed, Aqeel ...... M1847 Azuma, Mizutomo ...... 951 Ahuja, Nita ...... 557 Ajiki, Tetsuo...... M1542 B Akbar, Sanian...... W1648 Akopian, Gabriel...... T1716 Babar, Mahwash...... T1726 Al-Saadi, Sam ...... 350 Bacchella, Telesforo...... T1910 Albrink, Michael...... M1506 Bachmann, Kai...... W1831 Allen, Mark S...... M1526 Baker, Cheryl H...... T1904 Allen, Peter J...... T1915 Baker, Marshall S...... 1023 Almogy, Gidon ...... M1500 Balakrishnan, Anita ...... T1919, W1843 Aloia, Thomas A...... 1030 Baldus, Stephan E...... 951, M1864 Alosi, Julie A...... M1860 Balsiger, Bruno M...... M1554 Alsfasser, Guido ...... M1546 Banki, Farzaneh...... 566, T1721 Alvarez Herrero, Lorenza ...... 215 Banz, Vanessa...... 773, T1729 Alvelo-Rivera, Miguel ...... T1728, W1669 Barak, Orly ...... M1500 Amano, Hodaka...... W1684 Barbosa, Felipe L...... W1674 Ambrosio, Angelo...... W1646 Barﬁeld, Michael E...... M1561 Ameis, Helen M...... W1700 Barish, Edil H...... T1741, W1677 Amico, Alessandra ...... M1530 Barlow, Meade...... M1522 Ancona, Ermanno ...... 340, M1530 Baron, Todd H...... T1745 Andrade, Pablo ...... 344 Bartlett, David L...... 953, T1733 Angriman, Imerio ...M1512, T1704, W1651 Barton, Joshua G...... M1553, T1738 Angulo, Paul ...... Sp458 Bass, Barbara L...... 1030 Antillon, Mainor R...... Sp801 Bassi, Claudio... 781, Sp760, M1544, T1743 Anula, Rocio ...... 680, M1537, W1649 Basson, Marc D...... T1905 Anyangwe, Njwen ...... T1905 Baxter, Nancy N...... M1511 Appau, Kweku A...... 1020, T1717, W1650 Baxter, Raymond...... M1517, M1847, Appelbaum, Liat ...... M1500 ...... W1828, W1830 Aranha, Gerard V...... 346 Beart, Robert W...... W1644 Aranha, Higor C...... W1674 Bechtold, Matthew L...... 249 Araujo, Sergio E...... W1642 Becker, James M...... 560 INDICES Arbeo-Escolar, Ana M...... 680 Becker, Katrin ...... T1746 Argiriadi, Pamela A...... M1522 Beckert, Stefan...... W1829 Arregui, Maurice E...... T1697 Behrns, Kevin E...... W1680

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Bellavance, Emily C...... 347, M1862 Buchs, Nicolas C...... 1027, T2096 Belsley, Scott J...... W1993 Buck, Lauren ...... W1995 Benavente-Chenhalls, Luis A...... T1745 Buechler, Markus W...... 781 Bendell, Johanna C...... M1561 Bueter, Marco ...... T1725 Bentrem, David J...... 345, 1032 Buhr, Heinz J...... M1516, T1903, W1840 Berber, Eren...... 572 Burggraaf, Joseph ...... M1560 Bergman, Jacques J...... 215, Sp403, W1662 Burns, Betsy...... T1702 Bergman, Simon ...... W1666 Buscaglia, Jonathan M...... M2092 Berselli, Mattia...... M1539, M1540 Busch, Philipp ...... W1700 Bertin, Eugenia ...... W1651 Butturini, Giovanni ...... T1743 Bharucha, Adil E...... Sp638 Bianchi, Paolo P...... 1031 C Biankin, Andrew V...... W1685 Biesterfeld, Stefan ...... M2093 Cadeddu, Margherita ...... 1027, T2096 Bilimoria, Karl Y...... 345, 1032 Cafaro, Antonio ...... W1646 Binato, Marcelo...... M1848 Caldwell, Stephen H...... Sp457 Binenbaum, Steven...1026, M1502, W1993 Callas, Peter...... 1038 Bingener, Juliane...... W1995 Callery, Mark P...... Sp463, 251, Bisceglia, Giovanni...... W1646 ...... 351, 1034 Bloomston, Mark ... T1744, W1672, W1686 Cameron, Andrew M...... 347 Blumgart, Leslie H...... M1501 Cameron, John L...... T1741, W1677 Bluth, Martin ...... T1917 Campagnaro, Tommaso...... T1700, W1690 Bogoevski, Dean ...... 949 Campbell, Kurt...... W1677 Bois, John P...... M1505, M1553 Campos, Fabio...... T1707, T1709 Bollschweiler, Elfriede...... 562, 948, Campos, Fabio G...... W1642 ...... M1864, T1908 Canda, Aras Emre...... M1515 Boman-Galiamoutsa, Monica...... W1648 Candinas, Daniel...... 679, 773, M1852, Bona, Davide ...... 563 ...... T1729, T1746, W1671, W1694 Bona, Stefano...... 1031 Cantore, Maurizio ...... W1690 Bonatti, Hugo ...... W1691 Capelli, Paola ...... T1700, T1701 Bonavina, Luigi...... 563 Capra, Franco...... 565 Bordeianou, Liliana ...... 1019 Carethers, John M...... T1906 Bortolami, Marina ...... W1651 Carrasco, Ana L...... T1757 Botea, Florin ...... M1538, T1732 Carrasquillo, Jorge...... T1915 Botelho, Natalia K...... W1832 Carreras-Delgado, Jose Luis...... W1649 Bottin, Raffaele ...... 340 Carter, Ross...... M1550 Bouvet, Michael...... W1827 Cassivi, Stephen D...... M1526 Bouvy, Nicole...... 777 Castellanos, Paul F...... M1525 Bowen, John C...... Sp340 Castro, Eumenia...... W1658 Bowen, Louis M...... Sp359 Cataldegirmen, Guell...... 949 Bowers, Carl B...... T1747 Cataldo, Peter...... T1702 Brabender, Jan...... 948, 951, M1864, T1908 Cecconello, Ivan ...... T1707, T1708, T1709, Breithaupt, Wolfram...... W1663 ...... T1757, W1642, W1845 Brentnall, Teresa ...... Sp601 Cekic, Vesna ...... M1517 Bresciani, Claudio...... T1757 Ceolin, Martina...... 340 Brody, Jonathan R...... M1858, W1841 Cerqueira, Cinara...... T1742 Brown, Alphonso...... 351 Chambers, Kyle J...... W1659 Browne, Jeffrey S...... 1023 Champagne, Bradley J...... M1510 Browning, Darren ...... 558 Champion, James K...... Sp700 Bruewer, Matthias...... W1665 Chand, Bipan ...... 775 Brugge, William R...... 678 Chang, David C. ...M2091, W1661, W1664 Brune, Kieran...... T2095 Chang, Kenneth...... Sp713

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Chao, Tiffany E...... M1522 Cunningham, Steven...... 347 Charnsangavej, Chuslip ...... Sp460 Curcillo, Paul G...... 1025 Chen, Herbert...... M1855, M1859, W1839 Curvers, Wouter L...... 215 Chen, Miin-Fu ...... M1504, T1730, T1911 Czito, Brian G...... M1561 Chiaravalloti, Antonio ...... 682 Chibbar, Rajni...... W1639 D Chien, Ching-Wen ...... M1527 Cho, Clifford S...... 774 D’Amico, Davide F...... M1512, T1704, Cho, Sung W...... T1733 ...... W1651 Choti, Michael...... 347, Sp696, 1037, D’Angelica, Michael...... M1501 ...... T1741, W1677 D’Incà, Renata...... T1704, W1651 Choudhary, Abhishek...... 249 Dacuycuy, Leonierose ...... T1759 Christein, John D...... 559, T1734 Dallemagne, Bernard ...... 567 Christie, Neil...... T1728 Danenberg, Kathleen D...... 951 Chromik, Ansgar M...... M1545 Danenberg, Peter V...... 951 Church, James M...... 1020, M1514 Daniel, Geisler P...... T1710 Chuttani, Ram ...... Sp715 Daniel, Jarrod R...... T1738 Cid-Juarez, Silvia...... 681 Datta, Indraneel ...... T1705 Cima, Robert R...... W1652 Davis, Peyton W...... 250 Cirangle, Paul T...... 218 Dayton, Merril T...... 950, W1842 Ciurea, Monika...... M1516 De Andreis, Girolamo ...... T1713 Clark, Colby W...... W1680 De Bonis, Antonio...... W1646 Clark, Jeanne ...... M2092 de Brito, André T...... T1699 Coelho, Ana Maria M...... T1910, W1836, De Campos, Tercio ...... T1742, W1687 ...... W1837 Defranchi, Sebastian A...... M1526 Coerper, Stephan ...... W1829 DeJesus, Samuel ...... T1904 Cohen, Jonathan ...... Sp556 Del Fabbro, Daniele ...... M1538, T1732 Cohen, Russell D...... Sp866 Del Grande, Jose C...... M1559, T1758 Coloma, Eileen A...... T1716 Delaney, Conor P...... Sp702, M1510 Colombo-Benkmann, Mario ...... T1916 Delaney, Peter M...... W1685 Conlon, Kevin C...... M1856, T1913, T1914 Delgado-Bolton, Roberto ...... W1649 Contreras, Carlo M...... 774 DeMaria, Eric J...... Sp834, W1701 Cook, Chris C...... M1531 DeMatteo, Ronald P...... M1501 Cooper, Amanda...... M1536 DeMeester, Steven R.....566, M1850, T1721 Cooper, Jennifer C...... T1747 DeMeester, Tom R...... 563, 566, M1850, Corbett, Carlos E...... W1845 ...... T1721 Cordon-Cardo, Carlos ...... M1847 Derhake, Brian M...... M1863 Corless, Christopher...... W1838 Deschamps, Claude...... M1526 Costa, Maria Helena D...... W1674 DeVault, Kenneth R...... T1722 Costantini, Mario ...... 340, M1530 Deyle, Simone ...... T1746 Cowgill, Sarah ...... 350, M1506, T1747 Dhar, Puneet ...... M1555, W1640 Cozzitorto, Joseph ...... M1858 Dhir, Mashaal...... 557 Cozzitorto, Joseph A...... W1841 Di Giorgio, Alessandra ...... T1713 Craig, David H...... T1905 Di Lorenzo, Nicola ...... T1714 Cresci, Gail...... 558 di Mola, Fabio Francesco ...... 781, W1646 Crippa, Stefano...... M1544, T1743 Di Sebastiano, Pierluigi ...... 781, W1646 Crucinio, Vincenzo...... W1646 Dietz, David W...... M1845 Csikesz, Nicholas ...... 217, 1033 Diggs, Brian S...... 952 Dillhoff, Mary E...... W1686

Cullen, John ...... 449, 450, 1028, T1920 INDICES Cullen, Joseph ...... M1558 DiMaggio, Vincent...... M1517 Cunha, José Eduardo M...... T1699, W1836, Dinter, Dietmar J...... M1548 ...... W1837 Dittert, Dag ...... T1735

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Divino, Celia M...... 570, M1522, W1657 Faintuch, Joel ...... W1845 Diwan, Tayyab S...... 451, M1528 Falchetti, Alessandro...... M1518 Dixon, Elijah...... 348 Falconi, Massimo ...... 781, M1544, T1743 Dolce, Charles J...... T1756, W1844 Fan, Joe...... T1901 Domeyer, Mario...... W1668 Fankhauser, Regula ...... 773, T1729 Donadon, Matteo ...... M1538, T1732 Fantry, George T...... M1525, T2097 Donigan, Melissa ...... T1904 Farese, Robert ...... 569 Donohue, John H...... M1505 Farias, Aline M...... W1674 Dorrell, Craig S...... W1838 Farnell, Michael B...... M1505, M1553, Downey, John...... 343 ...... T1738, T1745 Dozois, Eric J...... W1652 Fasel, Jean...... 1027, T2096 Drachenberg, Cinthia...... 347 Fatima, Javairiah ...... 561 Dray, Xavier ...... M2092 Fazio, Victor W...... 1020, M1509, Drebber, Uta...... 951, M1864 ...... M1514, T1717, W1650 Drescher, Daniel ...... M2093 Feilitzsch, Maximilian...... W1834 Dubecz, Attila ...... M1524, W1660 Fein, Martin ...... T1725, W1663 DuBose, Joseph ...... Sp832 Feingold, Daniel L...... M1517 Dudley, Katherine A...... T1719 Feith, Marcus...... T1751 Dunn, Daniel H...... 563 Felix, Edward L...... Sp701 Dunn, Ernest...... M1552 Fernandez, Maura ...... T1716 Dunst, Christy M...... 451, M1528 Fernandez-del Castillo, Carlos ...... 1022, Dutly, Andre E...... M1852 ...... M1857 Fernandez-Esparrach, Gloria...... W1641 E Fernandez-Represa, Jesus A. ....680, M1537, ...... W1649 Edelweiss, Maria Isabel A....M1848, W1833 Fernández-Cruz, Laureano...... 353, 454 Egger, Bernhard ...... W1694 Ferrara, Andrea...... T1904 Eisold, Sven...... M1546 Ferrone, Cristina R...... 1022 Ekeh, Akpofure Peter ...... M1520 Finotti, Elena...... 340, M1530 Eklund, Stefan...... 339 Fiocca, Roberto...... 339 El-Gazzaz, Galal S...... M1508, T1710, Fischer, Craig P...... 1030 ...... T1711, W1653 Fischer, Eva...... 776, 1036, M1535, M1543, Elazay, Ram...... M1500 ...... M1547, T1731 Ell, Christian...... 339 Fisichella, Piero ...... M1523 Ellison, E. Christopher...... T1744, W1686, Fleshman, James W...... Sp454, Sp861 ...... W1693 Flint, Richard S...... T1750 Encarnacion, Betsy ...... 343 Flodqvist, Lena B...... W1648 Enestvedt, Kristian...... 952 Fockens, Paul...... 215 Enochsson, Lars ...... W1648 Fong, Yuman...... M1501, T1915 Eppsteiner, Robert W...... 217, 1033 Forbes, Rachel ...... W1692 Ermlich, Bridget...... M1510 Forrester, Glenn ...... 1026, M1502, W1993 Erroi, Francesa ...... M1512 Foster, Mark...... W1828 Esaki, Minoru...... M1533, T1695 Franceschilli, Luana ...... T1715 Evans, Kimberly A...... W1680 Franco, Elizabeth...... T1755 Evers, B. M...... T1902 Franko, Jan ...... 953 Franzius, Christine...... W1665 F Freeman, Martin ...... Sp558 Freier, Anna...... W1700 Faggian, Diego ...... T1704 Frerichs, Kirsten ...... M2093 Fagundes, Renato B...... M1848 Freund, Herbert...... Sp759 Fahrner, Rene...... M1503 Friel, Charles M...... Sp830, W1691 Fahy, Bridget N...... 1030 Friess, Helmut ...... T1909 Fain, John ...... W1835 Friess, Helmut M...... 781

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Frison, Laura ...... M1540 Godinez, Carlos...... M1525, T2097 Fritz, Stefan...... M1857 Goenner, Ursula...... W1668 Froes, Soraya M...... W1674 Goldin, Steven B...... T1747 Fuchs, Karl H...... W1663 Gondrie, Joep J...... 215 Fuchs, Karl-Hermann...... T1725 Gong, Qing qing ...... M1845 Fujita, Tsunenori...... M1542 Goodwin, C. Rory ...... T1741 Fukushima, Kouhei...... M1519, T1703, Gopalakrishnan, Unnikrishnan...... M1555 ...... T1753 Gorbe, Elizabeth...... M1845 Funayama, Yuji...... M1519, T1703 Gosain, Sonia ...... W1691 Fuzun, Mehmet ...... M1515 Gosen, Christine ...... M1562 Gower, Adam C...... 560 G Gower, William R...... M1861, T1921 Graf, Kristen...... M1557 Galanopoulos, Christos A...... 352, M1552 Grams, Jayleen M...... W1689 Galante, Alberto ...... T1713 Grant, John P...... W1701 Gallagher, Joseph T...... T1904 Gravesen, Flemming H...... 777 Galle, Peter R...... M2093 Greenberg, Caprice Christian ...... Sp792 Galmiche, Jean Paul ...... 339 Greenstein, Alexander ...... M1522, W1657 Gama-Rodrigues, Joaquim....T1707, T1708, Grompe, Markus ...... W1838 ...... T1709, T1757 Gros, Stephanie...... W1700 Gamblin, T Clark...... T1733 Gross, Molly E...... 561 Ganapathy, Vadivel ...... 558 Grunenberg, Roland ...... 562 Ganz, Robert A...... 563 Gröne, Jörn ...... M1516, T1903 Garcia, Luis J...... 568 Grützmann, Robert...... T1735, T1739 Gardner, Thomas R...... M1847, W1830 Guglielmi, Alfredo ...... 565, T1700, Garrido, Arthur B...... W1845 ...... T1701, W1690 Garrison, Richard N...... M1863 Guirroli, Emanuela ...... M1530 Gaspari, Achille Lucio ...... 682, M1518, Gullerud, Rachel E...... W1652 ...... T1713, T1714, T1715 Gumbs, Andrew A...... 349, 453, 772 Gasper, Warren J...... M1523 Gunraj, Nadia...... M1511 Gastinger, Ingo ...... 342 Gupta, Anirban ...... W1661 Gathof, Birgit S...... 562 Gurski, Richard R...... M1848, W1833 Gayet, Brice...... 349, 453, 772 Gusani, Niraj J...... 568, W1703 Gearhart, Susan L...... 557, M2091 Guzzinati, Stefano...... M1539 Geary, Michael...... T1914 Gee, Denise W...... 678 H Geisler, Daniel P...... T1711 Geller, David A...... T1733 Habr-Gama, Angelita ...... T1707, T1708, Gellersen, Oliver...... W1660 ...... T1709 Gentileschi, Paolo..... T1713, T1714, T1715 Hagen, Jeffrey A...... 566, M1850, T1721 George, Ivan M...... T2097 Hagen, Monika E...... 679, 1027, T2096 Germenia, Silvia ...... M1544 Haier, Joerg...... T1916, W1665 Gersin, Keith S...... T1756 Hall, Christopher L...... W1655 Ghali, William A...... 348 Hall, Richard I...... M1551 Giday, Samuel A...... M2092 Hallowell, Peter T...... M1557, W1695 Giese, Nathalia...... 781 Halls, James M...... 566 Gilbert, Sebastien...... W1669 Hamilton, Frank A...... Sp636 Glaettli, Andreas...... M1554 Hamm, Christina M...... M1845 Glatzle, Jorg ...... M1851, T1918, Hammel, Jeffery ...... 571, 1020 ...... W1829, W1834 Hann, Lucy E...... M1501 INDICES Glatzle, Jörg ...... 780 Hanna, Nader...... 347 Gloor, Beat ...... 773, M1852, T1729, T1746 Hannaway, Christine ...... M1509 Gockel, Ines ...... M2093, W1668 Hansen, Torsten ...... W1668

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Hanyuu, Nobuyoshi ...... W1643 Howard, Thomas J...... 1023, W1678, Hardiman, Karin M...... W1838 ...... W1688 Harmsen, William S...... 573 Hoxha, Pravera...... T1704 Harvey, Eugenius J....1026, M1502, W1993 Hruban, Ralph H...... T2095 Hashimoto, Yasushi...... M1549, W1675 Hsieh, Chih-Cheng ...... M1527 Hassan, Imran...... W1652 Hsu, Hui-Ping...... T1698 Hassanain, Ehab ...... T1917 Hsu, Kai-Hsi...... T1698, W1699 Hassett, James M...... 950 Hu, Yingchuan ...... M1849 Hatlebakk, Jan G...... 339 Hua, Jing ...... M2092 Hayashi, Masazou...... W1676 Huber, Otmar ...... T1903 Hayashi, Takenori...... W1643 Hughes, Christopher D...... 346 Hayashidani, Yasuo...... M1549, T1737, Hughes, Steven J...... 953, W1681 ...... W1675 Hull, Tracy L...... M1508, T1710, T1711, Hayward, Thomas Z...... T1748 ...... W1653 He, Yao...... M1842 Hungness, Eric S...... 452, 456, 1024 Heath, Jessica...... W1844 Hunt, Steven R...... M1845 Heckman, Jason...... T1733 Hunter, John G...... Sp404, 777, W1666 Heinicke, Jean-Marc...... W1671, W1694 Hurt, Ryan T...... M1863 Hemming, Alan W...... Sp697 Hyman, Neil H...... 1038, M1844, T1702 Heniford, B. Todd ...... T1756, W1844 Hölscher, Arnulf H...... 948, 951 Herbella, Fernando A...... M1524, M1559, ...... T1758 I Herline, Alan J...... W1692 Hernandez, Jonathan M...... T1747 Iacono, Calogero...... 565, T1700, T1701, Hernandez-Boussard, Tina...... 779, 1035 ...... W1690 Heymen, Steve...... Sp639 Iafrate, A. John...... M1857 Hildenbrand, Ralf ...... T1735 Iannitti, David A...... W1844 Hill, Joshua ...... W1693 Imperiale, Antonio R...... T1708, T1709 Hinder, Ronald A...... T1722 Inderbitzin, Daniel...... 773, M1852, T1729, Hinojosa, Marcelo W...... 1029, T1754, ...... T1746, W1671, W1694 ...... W1667 Inoue, Haruhiro ...... M1529 Hirata, Kenro ...... M1542 Iqbal, Corey W...... 561 Hirose, Kenzo...... 775 Irias, Noel ...... 1034 Hiyama, Eiso...... W1675 Ishibashi, Yoshio...... W1702 Hodin, Richard ...... Sp449, 1019 Ito, Hiromichi ...... M1501 Hoelscher, Arnulf H..... 562, M1864, T1908 Iwabuchi, Shuuichi ...... W1643 Hoffman, Aviad .... M1517, W1828, W1830 Izbicki, Jakob R...... 949, T1907, W1700, Hoffman, Keith...... W1828, W1830 ...... W1831 Hoffman, Robert M...... W1827 Hoffmann, Andreas C...... 948, 951 J Hoffmann, Christina ...... 951 Holloway, Shane...... T1733 Jacob, Carlos E...... T1757 Holtzman, Matthew ...... T1733 Jacobsen, Garth R.... 449, 450, 1028, T1920 Hon, Sophie S...... M1513 Jaladanki, Rao N...... M1862 Hopt, Ulrich T...... 564, 776, 1036, M1534, Jamidar, Priya A...... 1027, T2096 ...... M1535, M1543, M1547, T1731 Jan, Yi-Yin ...... M1504, T1911 Horgan, Santiago ...... Sp712, Jannasch, Olof...... 342 ...... 449, 450, 1028, T1920 Jansen, Dennis M...... Sp407 Hosack, Luke...... 952 Jarnagin, William R...... M1501 Hottinger, Daniel G...... W1839 Jasper, John ...... M1557, W1695 Hotz, Birgit...... W1840 Jeyarajah, D. Rohan ...... 352, M1552 Hotz, Hubert G...... M1516, T1903, W1840 Jiang, Yixing...... 568, W1703 Jin, Judy...... T1749, W1695

466 6303_SSAT.book Page 467 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Jobe, Blair A...... 777, 952, T1723, Kharbutli, Bilal...... W1635 ...... T1724, W1666 Kiely, James M...... W1673 Johnson, James O...... T1697 Kilic, Arman ...... T1728 Johnson, Sara M...... T1902 Kim, Edward Y...... W1672 Jones, Carolyn E. ....M1524, M1849, T1719 Kim, Grace J...... 1026, M1502, W1993 Jones, Daniel B...... Sp699, 1034 Kim, Ik-Yong ...... M1517, M1847, W1828 Jones, Stephen L...... 1030 Kimchi, Eric...... 568, W1703 Jossart, Gregg H...... 218 Kinouchi, Makoto ...... T1753 Juergens, Kai U...... W1665 Kiran, Pokala R...... M1509 Jukemura, Jose ...... W1836 Kiran, Ravi P...... 1020, M1514, W1650 Jukemura, José ...... T1699, W1837 Kiss, Desiderio...... T1707, T1708, T1709 Jungbluth, Achim A...... T1915 Kiss, Desiderio R...... W1642 Junghard, Ola ...... 339 Kittner, Julia M...... M1546 Junginger, Judith ...... T1918, W1834 Klar, Ernst...... M1546, T1912 Junginger, Theodor...... M2093, W1668 Klaristenfeld, Daniel ...... W1644 Klaus, Alexander ...... T1722 K Klein, Alison P...... T2095 Klein, Andrew S...... M1842 Kadkol, Shrihari...... M1858 Klimstra, David S...... M1501 Kadowaki, Susumu ...... W1684 Klingler, Paul J...... T1722 Kahaleh, Michel...... W1691 Klug, Christopher A...... 559 Kaiﬁ, Jussuf T...... 949, T1907, W1831 Knuth, Jamie ...... W1673 Kaiser, Andreas M...... W1644 Ko, Clifford Y...... Sp538, 1032 Kakyou, Masayuki...... T1753 Kobayashi, Katsutoshi...... W1702 Kalinina, Tanya...... T1907 Kobayashi, Terutada...... T1753 Kalloo, Anthony N...... M2092 Koek, Ger H...... 777 Kang, Jung C...... W1647 Koenigsrainer, Alfred ...... M1851, T1918, Karl, Richard C...... Sp793 ...... W1834 Karpitschka, Mia...... 780, W1656 Koffron, Alan ...... Sp616 Karpman, Craig ...... 249 Kojima, Kyoko...... 559 Kashiwagi, Hideyuki...... W1702 Koltun, Walter...... Sp868 Kasparek, Michael S... 780, W1656, W1652 Konstantinidis, Ioannis...... W1683 Kato, Kenichiro...... W1684 Koolen, Mia G...... W1662 Katzfuss, Juliane...... T1912 Kornbluth, Asher ...... Sp869 Kaufman, Howard S...... T1716 Koruda, Mark J...... Sp831 Kaushal, Sharmeela...... W1827 Korzenik, Joshua R...... 1019 Kavic, Stephen M...... M1525, T2097 Koshy, Ninan ...... W1993 Kawano, Susumu ...... W1643 Kostler, Thomas ...... M1503 Keck, Tobias ...... 564, 776, M1543, M1547 Kosuge, Tomoo...... M1533, T1695 Keeley, Samuel B...... 1018 Kotsafti, Andromachi...... W1651 Keith, Roger G...... W1639 Kraemer, Stefan J...... 777 Keller, Jennifer E...... T1756, W1844 Krasinskas, Alyssa M...... 953 Kellomaki, Minna...... W1636 Kreis, Martin E...... 780, W1656 Kelly, Christopher P...... M1560 Krishnadath, Kausilia K...... 215 Kelsey, Peter B...... Sp461 Kroesen, Anton J...... M1516 Kendrick, Michael L... 250, M1505, M1553, Kruschewski, Martin ...... M1516 ...... T1738, T1745, W1689 Ku, Yonson...... M1541, M1542, Kennedy, Erin ...... M1511 ...... T1736, W1676 Kennedy, Eugeen P...... W1678, W1841

Kubrusly, Marcia S...... T1910 INDICES Kent, Tara S...... 351 Kudo, Shin-ei ...... M1529 Khaitan, Leena...... M1562 Kueper, Markus A...... T1918, W1829, Khajanchee, Yashodhan S...... M1528 ...... W1834 Khan, Khurram...... M1563 Kuga, Rogério ...... W1845

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Kulaylat, Mahmoud N...... 950 Li, Ellen ...... M1845 Kundt, Guenther ...... M1546 Li, Jimmy C...... M1513 Kunitake, Hiroko ...... 1019 Li, Zhiping...... M2092 Kunitake, Tiago A...... W1837 Lian, Lei...... M1509 Kunnimalaiyaan, Muthusamy...... M1855, Liang, John...... W1703 ...... W1839 Lidor, Anne O...... M2091, W1661, W1664 Kuroda, Yoshikazu ...... M1541, T1736, Liesen, Daniel A...... T1748 ...... W1676 Lillemoe, Keith D...... 345, M1854, T1739, Kuryura, Laise ...... T1742 ...... W1678, W1688 Kuwada, Timothy ...... T1756 Lim, Rizal ...... 560 Ky, Alex J...... T1718 Lin, Pin-Wen ...... M1853, T1698, W1699 Königsrainer, Alfred...... W1829 Lincourt, Amy E...... W1844 Lind, Tore ...... 339 L Lindenblatt, Nicole ...... T1912 Ling, Frederike C...... 562, 948 Ladurner, Ruth...... M1851, T1918 Lingegowda, Dayananda...... M1555 LaFemina, Jennifer ...... M1857 Lipham, John C...... 563, 566, T1721 Landreneau, Joshua P...... M1531 Lippert, Hans...... 342 Landreneau, Rodney J...... 1018, M1531, Littenberg, Benjamin ...... 1038 ...... T1728, W1669 Little, Alex...... M1520 Larson, David W...... Sp867, W1652 Liu, Carson D...... T1759 Larson, Dirk R...... W1652 Liu, Lan ...... M1862 Larson, Steven...... T1915 Llaguna, Omar H...... 1021 Larvin, Mike...... M1551 Lo, Andrew Y...... 1021 Lashner, Bret...... 1020 Lo, Chung-Mau...... Sp758 Latif, M. J...... W1993 Loddenkemper, Christoph...... T1903 Laughinghouse, Michelle ...... M1510 Logue, Jennifer...... M1550 Laukkarinen, Johanna ...... W1636 Lopes, James...... W1688 Lauscher, Johannes C...... T1903 Lord, Reginald V. N...... M1850, W1832 Lautz, David B...... T1750, W1641 Lorenzo, Cedric S...... 777, T1723, T1724, Lavery, Ian ...... M1514, W1650 ...... W1666 Lavu, Harish...... 1023 Low, Donald E...... Sp391 Law, Simon ...... 338, T1901 Lowry, Ann C...... Sp640 Law, Wai-Lun...... T1901 Lowy, Andrew M...... Sp553 Lee, Chen Fang ...... T1730 Luiken, George A...... W1827 Lee, Crystine M...... 218 Luketich, James D. ....1018, M1531, T1728, Lee, Janet F...... M1513 ...... W1669 Lee, Kenneth K...... 953, W1681 Lumpkins, Kimberly M...... 347 Lee, Sukhyung ...... W1645 Lunardi, Marta ...... 565 Lee, Tommy H...... T2097 Lundell, Lars R...... 339 Lee, Wei-Chen ...... T1911 Luo, Linda ...... T1906 Lee, Yong-Kwon...... T1752 Luque-de-Leon, Enrique...... 344 Leeman, Susan E...... 560 Lurje, Georg ...... 948 Leen, Edward ...... M1550 Ly, Erin K...... T1718 Leers, Jessica M...... 566, T1721 Lehr, Austin ...... W1693 M Leitman, I. Michael ...... 1021 Leong, Rupert W...... W1685 Machado, Marcel C...... W1837, T1910 Leppiniemi, Jenni ...... W1636 Machado, Marcel C. C...... W1836 Leung, K. L...... M1513 Madan, Atul K...... M1563, W1835, W1994 Leung, Wing Wa ...... M1513 Madura, James A...... 1023 Levasseur, Sarah M...... M1560 Maecker, Folkert...... M1554 Levy, Michael J...... Sp462, T1738 Magno, Priscilla...... M2092

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Mahvi, David M...... Sp394, 774, McGinty, James J...... W1993 ...... Sp829 McKay, Colin...... M1550 Maier, Theo...... T1918, W1834 McKeown, Ciara K...... T1913, T1914 Makowiec, Frank... 564, 776, 1036, M1534, McLeod, Robin S...... Sp450, T1705, W1654 ...... M1535, M1543, M1547, T1731 McMahon, Barry P...... 777 Malafa, Mokenge P...... 216 McManus, Ross ...... T1726 Maley, Warren R...... 347 McMillan, Helen ...... T1914 Malik, Samaad ...... W1639 McPhee, James T...... W1682 Maluccio, Mary A...... M1536 Meenaghan, Nora C...... T1755 Manahan, Ellen ...... M1856, T1913, T1914 Mees, Soeren Torge ...... T1916 Manfredi, Riccardo ...... T1701 Mehrabi, Sara ...... T1701 Mann, Oliver ...... 949, W1700 Meile, Tobias ...... T1918, W1834 Mansker, Deanna R...... W1679 Meis, Gregory...... W1672 Mantovani, William ...... M1544 Mele, Alessandra ...... T1714 Marcello, Peter...... Sp704 Melton, Genevieve B...... T1717 Marcet, Jorge...... 216 Melvin, W. S...... W1666 Marconi, Matteo ...... M1538, T1732 Melvin, William Scott...... W1693 Marescaux, Jacques...... 567 Merchant, Nipun ...... T1739 Marks, Jeffrey M...... M1510, M1562 Merrett, Neil...... W1685 Marotta, Michael S...... 570 Mertens, Peter R...... T1907 Marsh, James W...... T1733 Metzger, Ralf ...... 948, 951, M1864, T1908 Martin, John A...... 452, 1024 Meurer, Luise...... M1848, W1833 Martinec, Danny V...... 451 Meyer, Frank ...... 342 Martinez, Jose L...... 344 Meyer, Lutz ...... 342 Mascetta, Giuseppe...... 781, W1646 Meyer, Marty M...... W1672 Mastrodonato, Nicola...... W1646 Michalek, Joel E...... W1995 Matheson, Paul J...... M1863 Micossi, Chiara...... M1518 Mathis, Kellie L...... 573 Mikami, Dean J...... W1666 Mathur, Abhishek...... M1854 Miller, Aaron ...... 570 Matias, Mauricio M...... W1674 Miller, Candace R...... M1845 Matos, Jesus M...... 345, T1739 Miller, Kelly A...... W1658 Matousek, Alexi ...... M1849 Milsom, Jeffrey W...... Sp703 Matsumoto, Akira...... W1702 Mino-Kenudson, Mari...... M1857 Matsumoto, Ippei ...... M1542 Mintz, Yoav ...... 1028, T1920 Matsunaga, Hiroaki ...... T1712 Mitsumori, Norio ...... W1702 Mawe, Gary M...... M1844 Mittelkötter, Ulrich ...... M1545 Mayer, Petra ...... W1829 Miura, Fumihiko ...... W1684 Mayol, Julio M...... 680, M1537, W1649 Miura, Koh ...... M1519 Mazzarella, Francesca ...... T1743 Miyai, Katsumi N...... T1906 Mazzoldi, Sara...... T1700 Miyoshi, Isao...... W1643 McBride, Corrigan L...... T1752 Mizuno, Ryouji ...... W1643 McCarthy, Mary C...... M1520 Mobley, James A...... 559 McCloud, Bilaal ...... 560 Moehler, Markus ...... M2093 McColl, Ryan ...... 348 Moesinger, Robert C...... W1655 McCord, Jaime H...... M1843 Moir, Christopher ...... M1505 McCoy, Andrew C...... T1738 Molan, Nilza...... T1910 McCullough, Casey K...... M1845 Molan, Nilza T...... W1836 McDade, Theodore P...... W1682 Molloy, Daniel ...... T1747

McDermott, John C...... W1673 Mommsen, Nina ...... W1700 INDICES McDonald, Debbie E...... M1860 Monig, Stefan...... M1864 McElroy, Michele...... W1827 Monson, Benjamin ...... M1520 McFadden, David W...... M1860 Montalvo-Jave, Eduardo E...... T1745 McGee, Michael F...... M1510 Montenovo, Martin I...... W1659

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Montgomery, Elizabeth A...... 557 Nathan, Hari ...... 1037, T1741 Montorsi, Marco ...... 1031, M1538, T1732 Navaglia, Filippo ...... T1704 Moore, Jesse ...... 1038 Navicharern, Patpong ...... M1532 Moorman, Donald W...... Sp795 Nedza, Susan ...... Sp539 Mor, Isabella ...... 571 Neeff, Hannes...... 1036, M1534, M1535, Moreira, Jonathan ...... T1727 ...... T1731 Morel, Philippe ...... 679, 1027, T2096 Nelson, Douglas Brooks ...... Sp557 Morellato, Gustavo...... W1833 Nelson, Heidi ...... 1032 Morgan, Katherine A...... W1679 Nenshi, Rahima...... M1511 Morgan, Susan L...... W1651 Neuhaus, Valentin ...... M1503 Mori, Ryutaro...... 951 Neyhard, Nancy L...... M1857 Mori, Toshiyuki ...... M1556 Ng, Simon S...... M1513 Morrill, Jonathan M...... 560 Nguyen, Nam Q...... W1685 Morris, Cynthia ...... T1723, T1724 Nguyen, Ninh T...... Sp714, 1029, Morton, Connor ...... M1506 ...... T1754, W1667 Morton, John M...... 343, Sp459, 779, 1035 Nguyen, Scott Q...... M1522, W1657 Moser, A. J...... W1681 Nguyen, Thien K...... T1750 Moser, Arthur J...... 953 Nguyen, Xuan-Mai T...... T1754 Moss, Gerald ...... M1521 Nichols, Francis C...... M1526 Motton, Marco...... T1701 Nicoletti, Loredana ...... 340, M1530 Moug, Susan J...... M1550 Nicoli, Paola ...... T1700 Mueller, Cathy M...... T1917 Niedergethmann, Marco...... M1548, Mueller, Mario H...... 780, W1656 ...... T1735, T1739 Mueller, Renee ...... T1904 Nikfarjam, Mehrdad...... 568, W1703 Mukherjee, Debraj ...... M2091, W1664 Nikiforov, Yuri E...... 953 Muldoon, Roberta L...... W1692 Nikiforova, Marina N...... 953 Mulla, Mubashir G...... M1551 Nimura, Hiroshi ...... W1702 Munshi, Imtiaz A...... T1748 Nimura, Yuji...... M1533, T1695, W1670 Murakami, Yoshiaki...... M1549, T1737, Ning, Li ...... M1855 ...... W1675 Nishikawa, Katsunori...... W1643 Murphy, Joseph ...... M1856, T1913, T1914 Norcross, Laurie S...... T1904 Murphy, Melissa M...... W1682 Nordback, Isto...... W1636 Murr, Elise R...... W1685 Northup, Patrick G...... W1691 Murr, Michel M...... 569, M1861, T1921 Norton, James ...... T1756, W1844 Muscarella, Peter.... T1744, W1686, W1693 Norton, Nancy Jean ...... Sp637 Novotny, Nathan M...... T1748 N Nunez, Domingo C...... W1993 Nwankwo, Joseph ...... M1843 Nagai, Eishi ...... T1696 Nagao, Munenori...... M1519 O Nagashima, Ikuo...... W1684 Nagorney, David...... M1505, T1738 O’Connor, Brenda I...... T1705, W1654 Nahas, Caio S...... W1642 O’Malley, Margaret...... 571 Nahas, Sergio C...... W1642 O’Rourke, Robert W...... 777, 952 Nair, Rajesh...... 216 Oberg, Stefan...... M1850 Nakahara, Shosaku ...... T1712 Oelschlager, Brant K...... Sp693, W1659 Nakamura, Hiroyuki ...... M1549, T1737 Oezcelik, Arzu ...... 566, T1721 Nakamura, Masafumi ...... T1696 Ogawa, Hitoshi...... M1519, T1703 Nakashima, Akira...... M1549, W1675 Ohge, Hiroki...... W1675 Nakeeb, Attila ...... W1688 Ohyanagi, Harumasa ...... M1541, T1736 Nancy, Brown ...... 775 Old, Lloyd ...... T1915 Nasar, Abu...... M1517, W1828, W1830 Omloo, Jikke M...... W1662 Nason, Katie S...... 1018 Omura, Nobuo ...... W1702

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Opitz, Oliver G...... M1535, M1547, T1731 Peña-Soria, María Jesús ...... 680 Ortega, Adrian E...... T1716 Phillips, Melissa S...... W1691 Osler, Turner ...... T1702 Philosophe, Benjamin...... 347 Ostrinsky, Yevgeniy ...... W1637 Piccirillo, Gianluca...... 565 Othiyil Vayoth, Sudheer.....M1555, W1640 Pinchot, Scott N...... M1859 Othman, Mohamed O...... 249 Pineda, Carlos E...... 1035 Owens, Michael M...... 777 Pistoso, Stefano ...... 565 Ozbilgin, Mucahit...... M1515 Pitt, Henry A...... M1854, W1673, W1688 Ozolek, John...... W1658 Pitt, Susan C...... W1673 Plebani, Mario...... T1704 P Podolsky, Erica R...... 1025 Pohlen, Uwe...... M1516 Pagano, Duilio ...... M1512 Polese, Lino ...... M1512, T1704, W1651 Palazzo, Francesco ...... M1523 Polomsky, Marek...... M1524, W1660 Palmisano, Angela ...... M1538, T1732 Ponnambathayil, Shaji ...... W1640 Panieri, Eugenio...... W1696 Ponsky, Jeffrey L...... M1562 Pappas, Theodore N...... M1561 Portenier, Dana D...... W1701 Parikh, Dhavan...... W1667 Post, Stefan...... M1548, T1735 Park, Adrian E...... M1525, M1564, Potanos, Kristina...... 775 ...... T1755, T2097 Poulose, Benjamin K...... M1510, M1562 Parreira, Jose G...... W1687 Pouw, Roos E...... 215 Partelli, Stefano...... M1544, T1743 Powers, Kinga A...... 1034 Pasquali, Claudio...... M1539, M1540 Pozza, Anna...... M1512, T1704 Passlick, Bernward ...... 1036 Pozzi Mucelli, Roberto ...... T1701 Pasternack, Gary ...... M1858 Prather, Andrew ...... M1854 Patel, Umesh...... W1842 Pratt, Wande B...... 251 Patti, Marco G...... Sp761, M1523 Prenzel, Klaus L...... 951 Patzina, Rosely A...... W1836 Prinz, Richard A...... Sp339 Paul, Harold...... 350 Privato, Marta ...... T1910 Pawlik, Timothy M...... 347, Sp698, 1037, Procopio, Fabio ...... M1538, T1732 ...... T1741, W1677 Proscurshim, Igor...... T1707, T1708, T1709 Pederzoli, Paolo ...... M1544, T1743 Pryor, Aurora D...... W1701 Pedrazzoli, Sergio...... M1539, M1540 Pueschel, Anja...... T1912 Pedrosa, Ivan ...... 351 Pugin, Francois...... 679, 1027, T2096 Pellegrini, Carlos A...... Sp541, W1659 Puli, Srinivas R...... 249 Pemberton, John H...... W1652 Peng, Yanhua...... 569, M1861, T1921 Q Pennathur, Arjun...... 1018, T1728, W1669 Pennington, Robert E...... T1748 Qin, Rui...... M1553 Peraza, Joseph...... 343 Que, Florencia G...... 250, M1505, T1738 Perez, Alexander ...... W1701 Quebbeman, Edward J...... W1673 Perez, Rodrigo O...... T1707, T1708, Quevedo, Bruna S...... W1845 ...... T1709, T1757 Qureshi, Irfan...... 1018, W1669 Perez Morales, Alfonso ...... 681 Perlingeiro, Jacqueline...... T1742 R Perretta, Silvana...... 567 Perrone, Federico ...... T1715 Raggi, Matthias C...... T1909 Perry, Kyle A...... T1723, T1724 Rahman, Rubayat...... W1637 Peters, Jeffrey H...... Sp402, Sp695, Rajhbeharrysingh, Uma..... M1522, W1657 .....M1524, M1849, M1850, T1719, W1660 Rakita, Steven S...... 569, M1861, T1921 INDICES Petersen, Pedro A...... W1845 Ramamoorthy, Sonia ...... T1906 Petrone, Patrizio ...... T1716 Ramos-De la Medina, Antonio ...... 681 Pettiford, Brian L...... M1531 Ranzinger, Mark ...... M1564

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Rasslan, Samir...... T1742, W1687 Rychlik, Karen...... 346 Rattner, David W...... 678 Ryou, Marvin ...... W1641 Rawet, Viviane ...... T1707 Räsänen, Jari V...... T1720 Raymond, Daniel...... Sp825, M1524, ...... M1849, T1719 S Reavis, Kevin M...... Sp826, 1029, W1667 Redding, Susan K...... M2092 Sachdev, Mankanwal S...... W1994 Reed, Karen L...... 560 Sachs, Teviah E...... 251 Reeder, Bruce ...... W1639 Saclarides, Theodore J...... Sp800 Reese, Jeffery A...... W1655 Saeger, Hans Detlev...... T1735, T1739 Rehrig, Scott...... 1034 Safatle-Ribeiro, Adriana V...... W1845 Reichelt, Uta ...... T1907 Sagol, Ozgul ...... M1515 Reid Lombardo, Kaye M...... 573 Saibene, Tania ...... M1540 Remes-Troche, Jose M...... 681 Saino, Greta...... 563 Remzi, Feza H...... 571, 1020, M1509, Sajan, Mini ...... 569 ...... W1650 Sakai, Paulo ...... W1845 Rettammel, Robert J...... 774 Sakamoto, Yoshihiro...... M1533, T1695 Reynolds, John V...... T1726 Salcedo, Levilester B...... M1514, W1653 Rhoads, David B...... T1919, W1843 Salky, Barry...... 455 Ribeiro, Ulysses...... W1845 Salo, Jarmo A...... T1720 Rideout, Drew A...... 569, M1861, T1921 Salvador, Renato...... M1524, W1660 Riediger, Hartwig ...... 564, 776, M1547 Salvia, Roberto ...... M1544, T1743 Rikkers, Layton F...... 774 Sampietre, Sandra N...... W1836 Rilling, William S...... W1673 Sanchez-Egido, Iris ...... M1537, W1649 Ritz, Joerg P...... M1516 Sand, Juhani...... W1636 Riviello, Robert ...... W1692 Sandler, Bryan J...... 449, 450, 1028, T1920 Rivkind, Avraham...... M1500 Sands, Bruce E...... Sp453, 1019 Rizzetto, Christian ...... 340, M1530 Sano, Tsuyoshi ...... M1533, T1695, W1670 Roberts, Patricia L...... T1706 Santos, Ricardo S...... M1531 Rockey, Don C...... Sp408 Santos Martin, Ernesto...... M1537 Rodriguez, J. Ruben ...... 1022 Sarioglu, Sulen ...... M1515 Roesch, Federico B...... 681 Sarkisyan, Grant G...... T1716 Rogers, Annamarie...... M1856, T1913, Sarosi, George A...... Sp559 ...... T1914 Sarr, Michael G...... 561, 573, Sp626, T1745 Romanato, Giovanna ...... T1704 Sasaki, Iwao ...... M1519, T1703, T1753 Rosati, Riccardo ...... 1031 Satodate, Hitoshi...... M1529 Rosemurgy, Alexander S...... 350, M1506, Sauter, Patricia K...... W1678, W1841 ...... T1747 Savides, Thomas J...... 449, 1028 Rosen, Michael J...... M1562, T1749 Savu, Michelle K...... 449 Rosenthal, Raul J...... Sp710, Sp833 Sawa, Hidehiro ...... M1541, T1736, W1676 Rosmolen, Wilda ...... 215 Sbayi, Samer ...... W1995 Ross, Sharona B...... 350, M1506 Scaramuzzi, Matteo...... W1646 Rossi, Piero...... T1715 Scarpa, Marco...... M1512, T1704, Roth, J. Scott ...... M1525, T1755 ...... W1651, W1654 Rottman, Steven J...... 1025 Schafer, Miranda ...... W1671 Rottoli, Matteo...... 1031 Schembre, Drew ...... Sp694 Roy, Praveen K...... 249 Schenk, Martin...... M1851 Ruben, Dawn ...... M2092 Schimanski, Carl C...... M2093 Rubin, David T...... Sp452 Schindler, Joshua S...... T1723, T1724 Rucci, Beniamino...... W1646 Schipper, Paul H...... T1723, T1724 Ruffolo, Cesare...... M1512, T1704, W1651 Schleicher, Christina...... T1916 Ruzzenente, Andrea...... 565, T1700, Schmidt, C. Max ...... 345, T1739, ...... T1701, W1690 ...... W1678, W1688

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Schmidt, Daniel...... 562 Shin, Eun Ji ...... M2092 Schmidt, Marcelo K...... W1833 Shinzeki, Makoto ...... M1541, M1542, Schneider, Paul M...... 562, 948, M1864 ...... T1736, W1676 Schneiders, Fiona I...... W1832 Shostrom, Valerie...... T1752 Schnelldorfer, Thomas...... W1679 Shoup, Margo...... 346, T1727 Schnüriger, Beat...... W1671, W1694 Showalter, Shayna L...... W1841 Schuchert, Matthew J...... M1531, T1728, Shumaker, Douglas A...... 777 ...... W1669 Sibaev, Andrej ...... 780 Schuebel, Kornel...... 557 Sica, Giuseppe S...... T1713, T1714, T1715 Schulick, Richard D...... 347, Sp828, 1037, Sidler, Daniel...... M1852 ...... T1741, W1677 Siegel, Erin M...... 216 Schultz, Sue...... M1511 Sihvo, Eero I...... T1720 Schurr, Paulus G...... 949, T1907, W1831 Sileri, Pierpaolo ...... 682, M1518, T1713, Schuster, Margaret M...... M1557 ...... T1714, T1715 Schwaitzberg, Steven D...... 1034 Simon, Ronald ...... T1907 Schweitzer, Michael A...... M2092, W1661, Simpfendorfer, Conrad H...... 572 ...... W1664 Simunovic, Marko...... M1511 Schwesinger, Wayne H...... W1995 Singh, Kirpal ...... T1697 Schöb, Othmar ...... M1503 Siperstein, Allan ...... 572 Scordi-Bello, Irini A...... 570 Siqueira, André M...... T1699 Seagull, F Jacob ...... M1525, M1564 Sjöqvist, Urban...... W1648 Seelig, Matthias H...... M1545 Smink, Douglas S...... 457 Segev, Dorry...... W1664 Smith, Brian R...... 1029, T1754 Sehmbey, Mandeep S...... W1703 Smith, Jason W...... T1727 Selvaggi, Federico ...... 781 Smith, Jennell ...... M1520 Selzer, Don J...... T1748 Snyder, Andrea...... Sp540 Senagore, Anthony...... Sp386, T1748 Sokmen, Selman...... M1515 Senninger, Norbert ...... T1916, W1665 Sokolich, Julio...... M1552 Seth, Akhil K...... T1741 Solda, Silvia ...... T1742 Shackford, Steven R...... T1702 Sondermeijer, Carine ...... 215 Shah, Shimul A...... 217, 1033, W1682 Soper, Nathaniel J...... 452, 456, Shaikh, Sohail N...... W1641 ...... 1024, 1032 Shan, Yan-Shen...... M1853, T1698, W1699 Sousa, Afonso H...... W1642 Shantha, Kumara H...... M1517, W1828, South, Christopher D...... W1672 ...... W1830 Souza, Lourenilson J...... W1836 Shantha Kumara HM, Chandana.... M1847 Spechler, Stuart Jon...... Sp401 Shapiro, Mark ...... 350 Speicher, James E...... M1560, T1740 Shaw, John M...... W1696 Sperti, Cosimo...... M1539, M1540 Shedda, Susan...... 571 Spivack, Adam...... 450 Shellito, Paul C...... 1019 Stappenbeck, Thaddeus S...... M1845 Shelton, Andrew A...... 1035 Staveley-O’Carroll, Kevin...... 568, W1703 Shen, Bo...... 571, 1020, M1509 Stearns, Adam T...... T1919, W1843 Shen, K. Robert ...... M1526 Steele, Kimberley E...... W1661, W1664 Shende, Manisha ...... 1018, T1728 Stein, Hubert J...... T1751 Sheppard, Brett C...... Sp552, W1838 Steinhagen, Emily...... T1718 Shereef, Serene...... 568, W1703 Steinhagen, Randolph M...... T1718 Sheth, Sunil ...... 351 Stellato, Thomas A...... M1557, W1695 Shibata, Chikashi..... M1519, T1703, T1753 Stewart, Lygia...... Sp860

Shibata, David ...... 216 Stirman, Amy ...... M1857 INDICES Shibuya, Makoto...... W1684 Stocchi, Luca ...... T1717 Shimada, Kazuaki ...... M1533, T1695 Stolﬁ, Vito M...... 682, T1713 Shimizu, Shuji ...... T1696 Stolﬁ, Vito Maria...... M1518, T1714 Shimizu, Yasuhiro...M1533, T1695, W1670 Stone, Christian ...... M1845

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Strate, Lisa L...... Sp406 Thalheimer, Andreas...... T1725 Strate, Tim...... W1831 Thangaraju, Muthusamy ...... 558 Streeter, Philip R...... W1838 Tharavej, Chadin ...... M1532 Strong, Scott A...... 1020 Thayer, Sarah P...... 1022, M1857 Strong, Vivian E...... T1915 Theisen, Joerg...... T1909 Stryker, Steven J...... 1032 Thieltges, Sabrina...... T1907 Stucchi, Arthur F...... 560 Thirlby, Richard C...... M1560 Studer, Peter...... 773, M1852, T1729 Thomas, Charles R...... Sp405 Sturniolo, Giacomo C...... T1704, W1651 Thomas, Fred B...... W1672 Sudan, Debra L...... Sp794 Thompson, Christopher ...... Sp711 Sudo, Takeshi...... M1549, T1737, W1675 Thompson, Christopher C...... W1641 Sueda, Taijiro ...... M1549, T1737, W1675 Thompson, Jon S...... T1752 Suelberg, Dominique...... M1545 Thoreson, Rebecca ...... M1558 Sugiyama, Masanori ...... M1556 Thow, Stephen ...... T1914 Sultanov, Faszillo S...... W1668 Thurau, Kirsten ...... W1665 Sundaram, Magesh ...... W1637 Tichansky, David S...... M1563, W1835, Surendran, Sudhindran ...... M1555, W1640 ...... W1994 Surgical Society, Columbus ...... W1693 Tineli, Ana C...... M1559, T1758 Suzuki, Yutaka...... W1702 Todd, George J...... W1993 Swain, Paul ...... 1027, T2096 Toia, Liana...... M1849 Swanson, Edward W...... W1683 Tokumura, Hiromi ...... T1703 Swanstrom, Lee L...... 451, Sp624, M1528 Toma, Hiroki ...... T1696 Swartz-Basile, Deborah A...... M1854 Tomokane, Thaise Y...... W1845 Sylla, Patricia ...... 678 Tong, Daniel K...... 338, T1901 São Julião, Guilherme...... T1707, T1708, Toomey, Desmond P...... M1856, T1913, ...... T1709 ...... T1914 Torkvist, Leif...... W1648 T Torres, Orlando J...... W1674 Torzilli, Guido ...... M1538, T1732 Tabrizian, Parissa ...... M1522, W1657 Tour, René ...... W1648 Tagaram, Hephzibah...... 568 Toyama, Hirochika...... M1542 Taheri, Syde A...... W1842 Toyota, Naoyuki...... W1684 Takada, Koji ...... W1702 Trainor, Shannon E...... 1018 Takada, Tadahiro...... W1684 Traub, Frank ...... M1851 Takahashi, Ken-ichi ...... T1703 Traverso, L. William ...... T1740 Takahata, Shunichi ...... T1696 Trinh, Tran T...... W1668 Takeyama, Yoshifumi...... M1541, M1542, Trunzo, Joseph A...... M1510, M1562 ...... T1736, W1676 Trus, Thadeus ...... M1524 Talamini, Mark A. ....449, 450, 1028, T1920 Tsai, Chi-Neu...... T1911 Talamonti, Mark S...... 345 Tsai, Hung-Wen...... W1699 Tammaro, Yolanda...... 570 Tseng, Jennifer F...... 217, 1033, W1682 Tanabe, Yoshitaka ...... T1712 Tsinberg, Michael...... 572 Tanaka, Masao ...... T1696, T1712 Tsujimura, Toshiaki...... M1542 Tang, Laura H...... T1915 Turina, Matthias...... M1503 Tannapfel, Andrea ...... M1545 Turner, Douglas J...... M1862 Tapper, Donovan ...... M1506 Tyler, Douglas S...... M1561 Tardio, Matteo ...... W1646 Törnblom, Hans...... W1648 Tavakkolizadeh, Ali...... T1919, W1843 Teixeira, Julio...... 1026, M1502, W1993 U Teixeira, Roberto...... T1910 Tekkis, Paris P...... 1020 Uchida, Barry ...... 952 ten Kate, Fiebo J...... 215 Ueda, Takashi ...... M1541, M1542, T1736, Thaler, Klaus ...... Sp835 ...... W1676

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49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Ueki, Takashi ...... T1712 Wallace, Michael B...... Sp799 Uemura, Kenichiro .M1549, T1737, W1675 Walsh, R. Matthew...... 775 Ueno, Tatsuya ...... T1753 Walters, Kenneth C...... T1756, W1844 Uhl, Waldemar ...... M1545 Wang, Haimei ...... M1842 Ujiki, Michael ...... 451, M1528 Wang, Hong ...... M1842 Unkart, Jonathan T...... M1845 Wang, Jian-Ying ...... M1862 Unno, Michiaki ...... M1519 Wang, Jiping ...... 950 Untch, Brian R...... M1561 Wang, Sue...... M1854 Urbach, David R...... M1511 Warnecke-Eberz, Ute...... T1908 Usuba, Teruyuki...... W1643 Warshaw, Andrew L...... 1022, M1857 Utiyama, Edivaldo M...... W1687 Watson, Thomas J...... M1524, M1849, ...... T1719, W1660 V Weber, Sharon M...... 774, ...... M1843, W1673 Valdegamberi, Alessandro ...... 565, T1700, Wedén, Michael ...... W1648 ...... W1690 Weichert, Jamey...... M1843 Vallbohmer, Daniel...... 562, 951, M1864, Weinreich, Juergen...... W1829 ...... T1908 Welton, Mark L...... 1035 Vallböhmer, Daniel...... 948 Wentworth, Mary...... M1843 Van Alstine, William ...... W1842 Wetscher, Gerold J...... T1722 van Berge Henegouwen, Mark I...... W1662 Weusten, Bas L...... 215 Van der Voort Van Zyp, Jochem...... T1905 Wey, Jane S...... W1681 Van Gulik, Thomas M...... 215 Whalen, Giles F...... W1682 van Heijl, Mark...... W1662 Whang, Edward E...... W1683 van Lanschot, Jan J...... W1662 Whelan, Richard L...... M1517, M1847, Van Sickle, Kent...... W1995 ...... W1828, W1830 Van Vilsteren, Frederike G...... 215 White, Maggie...... M1552 Varadarajulu, Shyam ...... T1734 White, Patrick B...... W1678 Varela, Esteban ...... W1667 White, Rebekah...... M1561 Vashist, Yogesh K...... 949, T1907 Wick, Elizabeth ...... T1717 Vassiliou, Melina C...... 457 Wigle, Dennis A...... M1526 Vaziri, Khashayar...... 452, 456, 1024 Wilcox, Charles M...... T1734 Vege, Santhi S...... W1689 Wilhelm, Scott M...... W1695 Velanovich, Vic...... 341, W1635 Willett, Christopher G...... M1561 Victor, J Charles...... T1705, W1654 Williams, Christina P...... T1749 Vierling, John M...... M1842 Williams, Timothy K...... M1858 Villadolid, Desiree ...... 350, M1506 Williams, Valerie A...... T1719 Villatoro, Eduardo A...... M1551 Williamson, Paul...... T1904 Viterbo, Domenico ...... T1917 Willingham, Field F...... 678 Vo, Allison ...... M1552 Willis, Joseph ...... M1510 Vogel, Stephen B...... W1680 Wilson, Jorge L...... M1559, T1758 Volkweis, Bernardo...... W1833 Wilton, Drew...... M1511 Vollmar, Brigitte ...... T1912 Winn, Shelley R...... 952 Vollmer, Charles M...... 251, 351, Sp551 Winter, Jordan M...... T1741 Wise, Paul E...... W1692 W Witkiewicz, Agnes...... M1858, W1678, ...... W1841 Wada, Keita...... W1684 Witteman, Bart...... 777 Waddell, Brad ...... W1645

Wolff, Bruce G...... W1652 INDICES Wade, Terence...... M1854 Wolfgang, Christopher L. ....T1741, W1677 Wagner, Markus...... T1746 Wong, John...... 338 Wagner, Oliver J...... 679, 1027, T2096 Wong, Kam Ho...... 338 Wall, Kristian ...... T1744, W1686 Wood, Christina M...... 573, M1553

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Wood, Michael ...... M1844 Yiu, Raymond Y...... M1513 Woodard, Gavitt A...... 343, 779 Yoshida, Masahiro...... W1684 Wozniak, Curtis ...... M1520 You, Min...... 569, T1921 Wroblewski, Ron J...... M2092 You, Xiaoqing ...... 348 Wu, Gordon D...... M1842 Young, John S...... T1919 Wu, Tsung-Han...... T1911 Young-Fadok, Tonia M...... Sp757 Wykypiel, Heinz ...... T1722 Yu, Ming-Chin ...... M1504, T1911 Yuda, Masami...... W1643 X Z Xue, Bing ...... 780 Zakaria, El Rasheid ...... M1863 Y Zalieckas, Jill M...... T1706 Zanatta, Lisa ...... 340, M1530 Yamaguchi, Koji...... T1696 Zaninotto, Giovanni ...... 340, M1530 Yamamoto, Takayuki ...... 1020 Zeh, Herbert ...... 953, T1733, W1681 Yamao, Kenji...... W1670 Zenilman, Michael E...... T1917 Yan, Xiaohong ...... M1847 Zhovtis, Svetlana...... T1719 Yanaga, Katsuhiko ...... W1702 Zhukov, Yuriy...... W1688 Yasuda, Takeo...... M1541, M1542, Zielinski, Martin D...... 250 ...... T1736, W1676 Zilberstein, Bruno ...... T1757 Yasue, Hideharu...... W1643 Zinner, Michael J...... Sp791 Yates, Robert ...... T1744 Zou, Tongtong...... M1862 Yeatman, Timothy J...... 216 Zugni, Chiara ...... W1690 Yekebas, Emre F...... 949, T1907 Zutshi, Massarat ...... M1508, W1653 Yeo, Charles J...... M1858, T2095, Zyromski, Nicholas J...... 1023, M1854, ...... W1678, W1841 ...... T1748, W1688 Yeo, Theresa P...... T2095

476 6303_SSAT.book Page 477 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

DISCLOSURE INDEX In order to comply with the ACCME’s Updated Standards for Commercial Support, The American College of Surgeons, as the accredited provider of this activity, has implemented a new disclosure process to ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. Per these updated standards, it is mandatory that both the program committee and speakers complete disclosures. Members of the program committee were required to disclose all financial relationships and speakers were required to disclose any financial relationship as it pertains to the content of the presentations. ACS defines a “commercial interest” as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies. The ACS considers “relevant” financial relationships as financial transactions (in any amount) occurring within the past 12 months that may create a conflict of interest.

The updated standards also require that ACS, through our joint sponsorship partners, manage any reported conﬂict and eliminate the potential for bias during the session. The program committee members (if applicable) and speakers were contacted and the conﬂicts listed below have been managed to our satisfaction. However, if you perceive a bias during a session, please advise us of the circumstances on the session evaluation form.

Please note we have advised the speakers that it is their responsibility to disclose at the start of their presentation if they will be describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage.

The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships through full disclosure, and to allow the audience to form its own judgments regarding the presentation.

Abdalla, Eddie (Program Subcommittee) Berber, Eren Honorarium: RITA Speakers Bureau: Medical Systems, Inc. (now AngioDynamics) Sanoﬁ Aventis Bergman, Jacques Commericial Interest: Adams, David B. Nothing to Disclose Olympus Japan, BARRX Medical, Inc., Adams, Reid B. Grant/Research AstraZeneca Pharmaceuticals, Cook Support: Karl Storz Endoscopy Medical Appau, Kweku Nothing to Disclose Bilimoria, Karl Nothing to Disclose Aranha, Gerard (Program Subcommittee, Moderator) Blackstone, Jon (Staff) Nothing to Disclose Nothing to Disclose Bogoevski, Dean Nothing to Disclose Attwood, Stephen Consultant: AstraZeneca Bonavina, Luigi Nothing to Disclose Pharmaceuticals, Ethicon, & JanssenCilag Bowen, John C. (Program Committee, Moderator) Auyang, Edward Nothing to Disclose Nothing to Disclose

Avella, Diego Nothing to Disclose Bowen, Louis M. Nothing to Disclose INDICES Avgerinos, Dimitrios Nothing to Disclose Bowers, Steven (Program Subcommittee) Banz, Vanessa Nothing to Disclose Nothing to Disclose Bassi, Claudio Nothing to Disclose Brabender, Jan Nothing to Disclose Bellavance, Emily Nothing to Disclose Brentnall, Teresa Nothing to Disclose

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Brugge, William R. (Moderator) Fleshman, James W. Nothing to Disclose Grant/Research Forrester, Glenn Nothing to Disclose Support: PENTAX, Boston Scientific Franko, Jan Nothing to Disclose Callery, Mark P. (Program Committee Chair, Moderator) Freund, Herbert Nothing to Disclose Grant/Research Friel, Charles M. Nothing to Disclose Support: Covidien (formally US Surgical/ Galandiuk, Susan (Moderator)Nothing to Disclose Tyco/Valleylab), Advisory Committees or Galanopoulos, Christos Nothing to Disclose Review Panels: Stryker Endoscopy, Glasgow, Robert (Program Subcommittee, Moderator) Management Position: TissueLink Nothing to Disclose Champion, James K. Nothing to Disclose Greenberg, Caprice Christian Nothing to Disclose Chang, Kenneth Nothing to Disclose Gumbs, Andrew Nothing to Disclose Charnsangavej, Chuslip Nothing to Disclose Hagen, Monika Nothing to Disclose Choti, Michael (Moderator) Consultant: Sanofi- Hagopian, Ellen (Program Subcommittee) Synthelabo; Speakers Bureau: Genentech Nothing to Disclose Choudhary, Abhishek Nothing to Disclose Hemming, Alan W. Nothing to Disclose Christein, John (Program Subcommittee) Hines, O. Joe (Program Subcommittee, Moderator) Nothing to Disclose Nothing to Disclose Chuttani, Ram (Moderator) Advisory Committee: Hirose, Kenzo Nothing to Disclose NDO Surgical; Consulting: Olympus Hodin, Richard (Moderator) Nothing to Disclose America; Speakers Bureau: Boston Scientific Hoffmann, Andreas Nothing to Disclose Cirangle, Paul Consultant: Ethicon; Horgan, Santiago Nothing to Disclose Advisory Committee: Allergan Medical, Howard, Thomas J.(Moderator) NDO Surgical Nothing to Disclose Contreras, Carlo Nothing to Disclose Hughes, Christopher Nothing to Disclose Costantini, Mario Nothing to Disclose Hull, Tracy (Program Subcommittee) Cresci, Gail Nothing to Disclose Grant/Research Critchlow, Johnathan (Program Subcommittee, Support: Cook, Medtronic, Carbon Moderator) Nothing to Disclose Medical Technology, INC, Q-Med Cullen, John Nothing to Disclose Hunter, John G. (Moderator) Nothing to Disclose Delaney, Conor P. Nothing to Disclose Hyman, Neil (Program Subcommittee) DeMaria, Eric J. Nothing to Disclose Nothing to Disclose Dhir, Mashaal Nothing to Disclose Iqbal, Corey Nothing to Disclose Di Sebastiano, Pierluigi Nothing to Disclose Jacobsen, Garth Nothing to Disclose Diwan, Tayyab Nothing to Disclose Jeyarajah, D. Rohan (Program Subcommittee) Dixon, Elijah (Program Subcommittee) Consultant: Johnson Nothing to Disclose & Johnson (Janssen) DuBose, Joseph Nothing to Disclose Jobe, Blair (Program Subcommittee, Moderator) Dunkin, Brian J. (Moderator) Advisory Committee: Grant/Research Covidien (formerly US Surgical/Tyco/ Support: Olympus America, Sandhill Valleylab); Consulting: Ethicon Endo- Scientific, Boston Scientific, EndoGastric Surgery; Speakers Bureau: Boston Solutions, Covidien (formally US Scientific, BARRX Medical Surgical/Tyco/Valleylab) Enestvedt, Kristian Nothing to Disclose Jones, Robert P. (Staff) Nothing to Disclose Eppsteiner, Robert Nothing to Disclose Jones, Daniel B. Nothing to Disclose Evans, Douglas B. Nothing to Disclose Karl, Richard C. Nothing to Disclose Felix, Edward L. Fellowship Grant: Keck, Tobias Nothing to Disclose Covidien; Grant Research Support: N.L. Kelsey, Peter B. Nothing to Disclose Gore & Associates Kent, Tara Nothing to Disclose Fernendez-Cruz, Laureano Nothing to Disclose Ko, Clifford Y. Nothing to Disclose Ferrone, Cristina Nothing to Disclose Koffron, Alan Nothing to Disclose Fichera, Alessandro (Program Subcommittee) Koruda, Mark J. Nothing to Disclose Nothing to Disclose Kunitake, Hiroko Nothing to Disclose Fischer, Craig (Program Committee, Moderator) Levy, Michael J. Nothing to Disclose Nothing to Disclose Lim, Rizal Nothing to Disclose Fleming, Jason (Program Subcommittee) Lo, Chung-Mau Nothing to Disclose Nothing to Disclose Lorenzo, Cedric Nothing to Disclose

478 6303_SSAT.book Page 479 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

Low, Donald (Program Committee, Moderator) Pellegrini, Carlos A. Nothing to Disclose Nothing to Disclose Perretta, Silvana Nothing to Disclose Lowy, Andrew M. Nothing to Disclose Peters, Jeffrey H. Nothing to Disclose Magnuson, Thomas (Program Subcommittee, Pineda, Carlos Nothing to Disclose Moderator) Nothing to Disclose Podolsky, Erica Nothing to Disclose Mahvi, David M. (Moderator) Nothing to Disclose Powers, Kinga Nothing to Disclose Marcello, Peter Advisory Committee: Prinz, Richard A. (Moderator) Covidien (formally US Surgical/Tyco/ Nothing to Disclose Valleylab); Consulting: Endo-Surgery, Ramos-De la Medina, Antonio Olympus America Nothing to Disclose Martinez, Jose Nothing to Disclose Raymond, Daniel Nothing to Disclose Mathis, Kellie Nothing to Disclose Reavis, Kevin M. Nothing to Disclose Mayol, Julio Nothing to Disclose Riall, Taylor S. (Program Subcommittee, Moderator) McColl, Ryan Nothing to Disclose Nothing to Disclose McCord, Jaime Nothing to Disclose Rideout, Drew Nothing to Disclose McFadden, David W. (Program Committee, Moderator) Rosemurgy, Alexander Nothing to Disclose Nothing to Disclose Rosenthal, Raul J. Nothing to Disclose McLeod, Robin S. Nothing to Disclose Rubin, David T. Nothing to Disclose Meyer, Lutz Nothing to Disclose Ruzzenente, Andrea Nothing to Disclose Michelassi, Fabrizio (Moderator) Sachs, Teviah Nothing to Disclose Nothing to Disclose Salky, Barry Nothing to Disclose Miller, Aaron Nothing to Disclose Sandler, Bryan Nothing to Disclose Milsom, Jeffrey W. Grant/Research Sands, Bruce E. Consultant: Axcan Support: Olympus America, Covidien Pharma; Grant/Research Support & Minter, Rebecca (Program Subcommittee, Moderator) Speakers Bureau: Centocor; Advisory Nothing to Disclose Committee: Procter & Gamble Montorsi, Marco Nothing to Disclose Pharmaceuticals Moore, Jesse Nothing to Disclose Sarr, Michael G. Nothing to Disclose Moorman, Donald W. Nothing to Disclose Schembre, Drew Nothing to Disclose Mor, Isabella Nothing to Disclose Schirmer, Bruce (Program Committee, Moderator) Morton, John (Program Subcommittee) Nothing to Disclose Nothing to Disclose Schmidt, C. Max Nothing to Disclose Mueller, Mario Nothing to Disclose Schulick, Richard D. Nothing to Disclose Mullen, John (Program Subcommittee) Senagore, Anthony J. Nothing to Disclose Nothing to Disclose Shah, Shimul Nothing to Disclose Nagle, Deborah (Program Subcommittee, Moderator) Sheppard, Brett C. Nothing to Disclose Nothing to Disclose Shibata, David (Program Committee, Moderator) Nair, Rajesh Nothing to Disclose Nothing to Disclose Nakeeb, Attila (Program Committee, Moderator) Sileri, Pierpaolo Nothing to Disclose Nothing to Disclose Smith, Brian Nothing to Disclose Nason, Katie Nothing to Disclose Snyder, Andrea Nothing to Disclose Nathan, Hari Nothing to Disclose Soper, Nathaniel J. (Moderator) Nedza, Susan Nothing to Disclose Speakers Bureau: Neeff, Hannes Nothing to Disclose Covidien, Ethicon Endo-Surgery; Grant/ Nguyen, Ninh (Program Subcommittee, Moderator) Research Support: Karl Storz Endoscopy, Grant/Research Boston Scientiﬁc, USGI Medical Support: Covidien; Consultant: Ethicon, Spechler, Stuart Jon (Moderator) W.L.Gore & Associates Grant/Research Nutter, Heather (Staff) Nothing to Disclose Support: AstraZeneca Pharmaceuticals, Oelschlager, Brant K. Nothing to Disclose Tap Pharmaceutical, BARRX Medical Oezcelik, Arzu Nothing to Disclose Stamos, Michael J. (Moderator)

O’Rourke, Robert (Program Subcommittee) Grant/Research INDICES Nothing to Disclose Support: Ethicon Endo-Surgery; Advisory Patti, Marco G. Nothing to Disclose Committee: Covidien (formally US Pawlik, Timothy M. (Program Subcommittee, Moderator) Surgical/Tyco/Valleylab) Nothing to Disclose

479 6303_SSAT.book Page 480 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Stein, Julie (Program Subcommittee, Moderator) Tong, Daniel Nothing to Disclose Nothing to Disclose Traverso, L. William (Program Committee) Stweart, Lygia (Moderator) Nothing to Disclose Nothing to Disclose Sudan, Debra L. Nothing to Disclose Vallbohmer, Daniel Nothing to Disclose Sundaram, Magesh (Program Subcommittee, Moderator) Vassiliou, Melina Nothing to Disclose Nothing to Disclose Vaziri, Khashayar Nothing to Disclose Swanstrom, Lee L. Grant/Research Velanovich, Vic (Program Subcommittee) Support: Boston Scientific, Olympus Commericial Interest: Japan; Consultant: USGI Medical Medtronic Gastroenterology & Urology Sylla, Patricia Nothing to Disclose Vollmer, Charles M. Nothing to Disclose Talamini, Mark A. (Moderator) Wagner, Oliver Nothing to Disclose Speakers Bureau: Wang, Jiping Nothing to Disclose Olympus America, Stryker Endoscopy; Weber, Sharon M. (Program Committee, Moderator) Consultant: Ethicon Endo-Surgery Nothing to Disclose Thaler, Klaus Advisory Committee, Weigel, Tracey (Program Subcommittee) Consultant & Grant/Research Support: Nothing to Disclose Ethicon Endo-Surgery; Grant/Research Whang, Edward E. (Program Committee, Moderator) Support: Olympus America, PENTAX, Nothing to Disclose Cook, Boston Scientific, Alveolus Woodard, Gavitt Nothing to Disclose Thirlby, Richard (Program Subcommittee) Young-Fadok, Tonia M. Nothing to Disclose Nothing to Disclose Zielinski, Martin Nothing to Disclose Thomas, Charles R., Jr. Nothing to Disclose Zinner, Michael J.(Moderator) Thompson, Christopher Consultant: USGI Nothing to Disclose Medical, Valentx, Hansen, Boston Zuckerman, Randall (Program Subcommittee, Moderator) Scientific; Grant/Research Support: Nothing to Disclose Olympus America; Speakers Bureau: ConMed Endoscopic Technologies; Advisory Committee: Covidien (Formarlly US Surgical/Tyco/Valleylab), Power Medical; Royalties & Consultant: Davol;

480 6303_SSAT.book Page 481 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

NOTES

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

NOTES

482 6303_SSAT.book Page 483 Tuesday, April 22, 2008 1:26 PM

49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA

NOTES

483 6303_SSAT.book Page 484 Tuesday, April 22, 2008 1:26 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

San Diego Convention Center Upper Level Partial View

SSAT Scientific Session Room (28ABC)

SSAT Scientific Session Room (27B) SSAT Office (27A)

SSAT Scientific Session Room (25ABC)

SSAT Scientific Session Room (24ABC)

Speaker Ready

Room (23ABC) HVc9^Z\d7Vn

Combined Clinical Symposia Ballrooms 20A & 20BCD

SSAT Poster Sessions (Sails Pavilion)

484

SSAT_inside_bak_cov.fm Page 1 Tuesday, April 22, 2008 1:25 PM

FUTURE SSAT MEETINGS

2009 May 30 – June 3, Chicago, IL

2010 May 1 – 5, New Orleans, LA

2011 May 7 – 11, Chicago, IL

NATIONAL OFFICE 900 Cummings Center, Suite 221-U Beverly, MA 01915 Telephone: (978) 927-8330 Facsimile: (978) 524-8890 E-Mail: [email protected] Web Site: www.ssat.com Schedule-at-a-Glance Saturday, May 17, 2008 8:30 AM – 2:30 PM Residents & Fellows Research Conference Omni Hotel Gallery 2

Sunday, May 18, 2008 8:00 AM – 5:15 PM Postgraduate Course 28ABCD Unresolved Problems and Evolving Solutions in Surgical Gastroenterology

Monday, May 19, 2008 8:00 AM – 8:15 AM Opening Session 25ABC 8:15 AM – 9:15 AM Presidential Plenary A (Plenary Session I) 25ABC 9:15 AM – 10:00 AM Presidential Address 25ABC Evolution of a Surgeon: A 40-Year Perspective 10:30 AM – 11:15 AM Presidential Plenary B (Plenary Session II) 25ABC 11:15 AM – 12:00 PM Doris and John L. Cameron Guest Oration 25ABC The Coming American Revolution: How China Will Cause the Greatest Changes in the U.S. Since the Birth of the Nation 12:00 PM – 2:00 PM Poster Session I Sails Pavilion 12:30 PM – 1:45 PM Meet-the-Professor Luncheons Local Therapy for Rectal Cancer Carlsbad, South Tower, Marriott Hotel & Marina Surgical Management of Achalasia 26B What’s New in Liver Tumor Ablation 26A 2:15 PM – 3:45 PM DDW Combined Clinical Symposia Esophageal Cancer (SSAT, AGA) Ballroom 20A The Optimal Management of LGI Bleeeding (ASGE, AGA, SSAT) Ballroom 20BCD 2:15 PM – 5:00 PM Plenary Session III 24ABC 2:15 PM – 5:00 PM SSAT/AGA/ASGE State-of-the-Art Conference 25ABC Optimal Timing of Surgery for IBD 2:30 PM – 4:00 PM vIDEO Session I: HPB Surgery 27B 4:00 PM – 5:30 PM DDW Combined Clinical Symposia Medical and Surgical Management of NAFLD (AASLD, SSAT) Ballroom 20BCD Pancreatic Cancer (SSAT, ASGE, AGA) Ballroom 20A

Tuesday, May 20, 2008 7:30 AM – 10:00 AM vIDEO Session II: Breakfast at the Movies 25ABC 8:30 AM – 10:00 AM Public Policy Committee Panel 28ABC The Effects of Quality Initiatives and Reporting on Patient Care and Reimbursements to Physicians and Hospitals 9:30 AM – 11:00 AM SSAT/AHPBA Joint Symposium 24ABC Current Approach to Carcinoma of the Gallbladder 10:00 AM – 11:15 AM Basic Science Plenary (Plenary Session IV) 25ABC 10:00 AM – 11:15 AM Quick Shots I 27B 10:30 AM – 12:00 PM DDW Combined Clinical Symposium Ballroom 20BCD Managing Complications of GI Procedures (AGA, SSAT, ASGE) 11:15 AM – 12:00 PM Maja and Frank G. Moody State-of-the-Art Lecture 25ABC The Early Detection of Pancreatic Cancer: Lessons from Surveillance of 100 High-Risk Patients 12:00 PM – 2:00 PM Poster Session II Sails Pavilion 12:30 PM – 1:45 PM Meet-the-Professor Luncheons Laparoscopic Hepatectomy 26A NOTES Update 30A Re-Classifying Acute Pancreatitis 26B 2:15 PM – 3:30 PM Plenary Session V 28ABC 2:15 PM – 3:45 PM DDW Combined Clinical Symposium Ballroom 20A Fecal Incontinence: New Perspectives on Early Detection, Current and Future Therapies (AGA, SSAT) 2:15 PM – 4:15 PM Controversies in GI Surgery 24ABC Debate 1: Intramucosal Esophageal Cancer and High Grade Dysplasia: Which Treatment? Debate 2: Hepatocellular Carcinoma in the Mild Cirrhotic: Transplant or Resect? Debate 3: Best Practices/Centers of Excellence: Effective Tools or Good Advertising? 3:30 PM – 4:30 PM Quick Shots II 28ABC 3:30 PM – 5:00 PM SSAT/ASCRS Joint Symposium 25ABC Laparoscopic Rectal Cancer Surgery: Is It Ready for Prime Time? 4:00 PM – 5:30 PM DDW Combined Clinical Symposium Ballroom 20BCD Obesity Surgery: Endoscopic and Surgical Management of Complications (SSAT, ASGE, AGA) 5:00 PM – 6:00 PM Annual Business Meeting (members only) 25ABC 7:00 PM – 9:00 PM Members Reception The Don Room at El Cortez

Wednesday, May 21, 2008 7:00 AM – 8:30 AM SSAT/ISDS Joint Breakfast Symposium 25ABC How I Do It: Around the World in 90 Minutes 8:30 AM – 10:00 AM Education Committee Panel 24ABC All rooms at Teaching Safety in the OR the San Diego 8:30 AM – 10:00 AM Translational Science Plenary (Plenary Session VI) 25ABC Convention Center 10:30 AM – 12:00 PM DDW Combined Clincial Symposium Ballroom 20A unless otherwise The Big Polyp: Who Owns It? (ASGE, SSAT, AGA) indicated. 10:30 AM – 12:00 PM Plenary Session VII 25ABC indicates a 10:30 AM – 12:00 PM vIDEO Session III: NOTES: Where Are We Today? 27B ticketed session 12:00 PM – 2:00 PM Poster Session III Sails Pavilion requiring a separate 12:00 PM – 3:00 PM SSAT/SAGES Joint Luncheon Symposium 25ABC registration and fee. The Gastrointestinal Anastomosis: Evidence vs. Tradition 12:30 PM – 1:30 PM Quick Shots III 24ABC indicates a 12:30 PM – 1:45 PM Meet-the-Professor Luncheons session offering The Difficult Cholecystectomy 26B Simultaneous Total Mesorectal Excision 26A Oral Translation 2:15 PM – 3:45 PM DDW Combined Clincial Symposium Ballroom 20A in Spanish and Balancing the Use of Biologics and Surgery in Management of Ulcerative Colitis (AGA, SSAT) Japanese.