47Th Annual Meeting

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

47th Annual Meeting

May 20 - 24, 2006 Los Angeles Convention Center Los Angeles, California

program BOOK

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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 ...... 13 Founders Medal ...... 14 Guest Oration ...... 15 State-of-the-Art Lecture ...... 16 Program Schedule ...... 17 Poster Session Detail ...... 38 Oral, Video, and Posters of Distinction Session Abstracts ...... 79 Poster Session Abstracts ...... 134 Author Index ...... 364 Subject Index ...... 378 Disclosure Index ...... 387

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PROGRAM

FORTY-SEVENTH ANNUAL MEETING Los Angeles Convention Center Los Angeles, California May 20–24, 2006

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

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ACCME ACCREDITATION STATEMENT

ACCREDITATION 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 Division of Surgery of the Alimentary Tract. The American Education College Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME CREDIT The American College of Surgeons designates this educational activity for a maximum of 22.75 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA INFORMATION

THE SOCIETY FOR SURGERY GENERAL OF THE ALIMENTARY TRACT

OFFICERS: 2005-2006

President Barbara L. Bass, Houston, TX President-Elect L. William Traverso, Seattle, WA Vice President Robert V. Stephens, Phoenix, AZ Secretary David W. McFadden, Morgantown, WV Secretary-Elect John G. Hunter, Portland, OR Treasurer Jeffrey B. Matthews, Cincinnati, OH Recorder Bruce D. Schirmer, Charlottesville, VA

BOARD OF TRUSTEES

Keith D. Lillemoe, Chair Indianapolis, IN Robert W. Beart, Jr. Los Angeles, CA Kevin E. Behrns Gainesville, FL Mark P. Callery Boston, MA Merril T. Dayton Buffalo, NY Josef E. Fischer Boston, MA James W. Fleshman St. Louis, MO Yuman Fong New York, NY Fabrizio Michelassi New York, NY David W. Rattner Boston, MA Nathaniel J. Soper Chicago, IL

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STANDING COMMITTEES 2005-2006

EDUCATION COMMITTEE PATIENT CARE COMMITTEE Gordon L. Telford, Chair Michael S. Nussbaum, Chair Darryl T. Hiyama Douglas B. Evans Daniel B. Jones Ronald A. Hinder Amanda M. Metcalf Howard S. Kaufman David I. Soybel John W. Kilkenny, III Michael J. Stamos Peter Muscarella, II J. Nicolas Vauthey FINANCE COMMITTEE Charles M. Vollmer, Jr. Jeffrey B. Matthews, Chair Michael J. Zinner Barbara L. Bass John G. Hunter PROGRAM COMMITTEE Keith D. Lillemoe David M. Mahvi, Chair David W. McFadden Barbara L. Bass A. James Moser Mark P. Callery Jeffrey H. Peters Steven A. Curley Anthony J. Senagore Susan Galandiuk Robert V. Stephens Natalie E. Joseph Keith D. Lillemoe LOCAL ARRANGEMENTS Attila Nakeeb Howard S. Kaufman Bruce D. Schirmer L. William Traverso Edward E. Whang MEMBERSHIP COMMITTEE Stanley W. Ashley, Chair PUBLIC POLICY COMMITTEE Herbert Freund David A. Iannitti Richard A. Prinz, Chair Lynt B. Johnson James M. Becker Roger G. Keith Thomas J. Howard Ronald F. Martin Kimberly S. Kirkwood Don M. Morris C. Daniel Smith Dmitry Oleynikov Steven C. Stain Rodrigo O. Perez Lygia Stewart Janice F. Rafferty Marek Rudnicki PUBLICATIONS COMMITTEE Richard T. Schlinkert Bruce D. Schirmer, Chair David Shibata Richard H. Bell, Jr Bruce E. Stabile Zane Cohen Selwyn M. Vickers Helmut M. Friess Sharon M. Weber Kirk A. Ludwig John A. Windsor Daniel J. Scott Brad W. Warner NOMINATING COMMITTEE Josef E. Fischer, Chair RESEARCH COMMITTEE Robert W. Beart, Jr. Herbert Chen, Chair Raymond J. Joehl Walter Koltun Keith D. Lillemoe Ming Pan Charles J. Yeo Scott A. Strong Elin R. Sigurdson Diane M. Simeone

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

STANDING COMMITTEES 2005-2006 INFORMATION GENERAL

REPRESENTATIVES Board of Governors of the American College of Surgeons Richard H. Bell, Jr. American Board of Surgery Theodore N. Pappas ABS GI Surgery Advisory Council John G. Hunter Fellowship Council Board John G. Hunter Fellowship Council Accreditation Committee Keith D. Lillemoe Michael G. Sarr Journal of Gastrointestinal Surgery John L. Cameron, Co-Editor Keith A. Kelly, Co-Editor

PROGRAM SUBCOMMITTEES

Biliary/Hepatic Pancreas Ravi S. Chari Helmut M. Friess Bryan M. Clary Thomas J. Howard Kenneth K. Tanabe Max Schmidt Charles M. Vollmer, Jr. Douglas S. Tyler Sharon M. Weber Selwyn M. Vickers

Colon-Rectal/Combined Science Small Bowel/Stomach Joerg Haier Juliane Bingener-Casey Charles P. Heise Joseph J. Cullen Howard S. Kaufman Samer G. Mattar Janice F. Rafferty C. Daniel Smith Steven D. Wexner Video Esophageal Jon C. Gould Timothy M. Farrell Jeffrey B. Matthews Steven J. Hughes Aurora D. Pryor Marco G. Patti Nathaniel J. Soper Jeffrey H. Peters

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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 exists Dr. John Waugh today.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

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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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

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 Insti- tute 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 prominence 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 govern- mental agencies. This provided an opportunity for the two societies to discuss a variety of issues, including the possibility of a joint annual

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meeting. 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, with our medical col- leagues. He concluded that the membership was to be congratulated for its wise decision.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

More recently we have furthered our relationship with the component INFORMATION

societies of DDW by contributing to combined clinical symposiums, GENERAL 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 award was subsequently increased step wise to its current level of $40,000 per year. To date ten awards have been given, and eight of the ten who received the award currently have University appointments and six 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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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

SSAT FOUNDATION INFORMATION GENERAL

The SSAT Foundation is the philanthropic and marketing arm of the Society for Surgery of the Alimentary Tract. The Foundation was established in 2000 to help the Society achieve its mission. Founded over forty years ago, the SSAT now has a membership of over 2500 physicians and is in the forefront of its medical specialty. The SSAT’s mission is to stimulate, foster, and provide surgical leadership in the art and science of patient care; to promote and support the education and research of the diseases and functions of the alimentary tract; to provide a forum for the presentation of such research and educational endeavors; and to foster training and funding opportunities and scientiﬁc publications in support of these activities. Research and education remain the cornerstone of fulﬁlling the Society’s mission, and the Foundation seeks to support the SSAT’s current initiatives including the Career Development Award for young faculty members, the Residents and Fellows Research Conference held at the time of Digestive Disease Week, the Traveling Fellowships for Surgeons in Private or Hospital-Based Community Practice, and the International Traveling Fellowship for Surgeons in Academic Practice. The SSAT Foundation receives support from a variety of sources including private foundations, industry, and individual friends of the Society, most notably SSAT members. The Foundation offers a variety of giving opportunities including charitable lead trusts, charitable remainder trusts, bequests, and other planned giving instruments. The Foundation is proud of its supporters and pays special tribute to its donors through recognition of them in the following list.

SSAT FOUNDATION OFFICERS AND TRUSTEES Michael G. Sarr, Chair Josef E. Fischer, Vice Chair David W. McFadden, Secretary John G. Hunter, Secretary-Elect Jeffrey B. Matthews, Treasurer Barbara L. Bass Robert W. Beart, Jr. Daniel B. Jones Keith D. Lillemoe Bruce D. Schirmer Nathaniel J. Soper

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FOUNDERS MEDAL

Monday, May 22, 2006 8:00 AM – 8:15 AM Los Angeles Convention Center 403A

TOM R. DEMEESTER, MD Chair, Department of Surgery, USC School of Medicine Los Angeles, CA

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

GUEST ORATION INFORMATION “Present and Future Advances in GENERAL Surgical Technologies and Surgical Education”

Monday, May 22, 2006 11:15 AM – 12:00 PM Los Angeles Convention Center 403A

JACQUES MARESCAUX, MD, FRCS, FACS University Hospital of Strasbourg, Strasbourg, France President, IRCAD-EITS Institute, Strasbourg, France

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STATE-OF-THE-ART LECTURE “Back to the Future: New Directions in Surgical Education”

Tuesday, May 23, 2006 11:15 AM – 12:00 PM Los Angeles Convention Center 403A

JEFFREY L. PONSKY, MD Oliver H. Payne Professor and Chairman, Department of Surgery Case Western Reserve University School of Medicine and University Hospitals of Cleveland Cleveland, OH

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

SCIENTIFIC PROGRAM Forty-Seventh Annual Meeting May 20–24, 2006 All rooms at the Los Angeles Convention Center unless otherwise indicated. SCHEDULE DAILY

MONDAY, MAY 22, 2006

8:00 AM – 8:15 AM SSAT OPENING SESSION 403 A Chair: President Barbara L. Bass. MD, Houston, TX 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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9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS 403 A Sp237 Introduction Robert V. Stephens, Phoenix, AZ Sp238 Who’s Going to Do My Operation? Expectations for the Next Generation of Surgeons SSAT President Barbara L. Bass, MD, The Methodist Hospital, Houston, TX

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

11:15 AM – 12:00 PM GUEST ORATION 403 A Sp239 Present and Future Advances in Surgical Technologies and Surgical Education Jacques Marescaux, University Hospital of Strasbourg, Strasbourg, France SCHEDULE

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

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Sp347 Obesity Surgery: Which Procedure Is Best? Wilshire Grand L.A. Balboa Room Ninh T. Nguyen, Orange, CA Sp351 The Role of HAI vs. Systemic Chemotherapy 309 After Liver Resection for CRC William Jarnagin, New York, NY, & Nancy Kemeny, New York, NY Sp349 Surgical Management of Non-Colorectal Liver Mets Wilshire Grand L.A. Glenwood Room Sharon Weber, Madison, WI

2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIA CYSTIC TUMORS OF THE PANCREAS Concourse Hall 151 Sponsored by: AGA, ASGE, & SSAT Co-Chairs: Michael L. Kochman, Philadelphia, PA James Scheiman, Ann Arbor, MI Sp354 Clinical Evaluation: Cross-Sectional Imaging and EUS Marcia Canto, Baltimore, MD Sp355 Surgical Evaluation of the Patient with a Pancreatic Cyst Jeffrey A. Drebin, Philadelphia, PA Sp356 Developing a Rational Patient Care Approach to the Patient with a Pancreatic Cyst James M. Scheiman, Ann Arbor, MI

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TREATMENT OF HEMORRHOIDS AND FISSURES Concourse Hall 152 Sponsored by: ASGE, SSAT, & AGA Co-Chairs: Rome Jutabha, Los Angeles, CA Ann C. Lowry, St. Paul, MN Sp357 Management of Fistulas Michael J. Stamos, Orange, CA Sp358 Management of Fissures Mika Varma, San Francisco, CA Sp359 Management of Hemorrhoids Dean Jensen, Los Angeles, CA

2:15 PM – 5:00 PM SSAT PLENARY SESSION 402 A Co-Moderators: Natalie E. Joseph, Philadelphia, PA Howard S. Kaufman, Los Angeles, CA 370 Liver Metastasis Echogenicity on Intraoperative Ultrasound Is a Prognostic Factor After Curative Hepatic Resection Michelle DeOliveira, Timothy M. Pawlik, Ana Gleisner, Lia Assumpto, Michael A. Choti; Surgery, Johns Hopkins Hospital, Baltimore, MD 371 Neoadjuvant Chemoradiation Changes the Relationship Between pT And pN Status, and Their Prognostic Signiﬁcance in Esophageal Cancer Simon Law1, Dora Kwong2, Kam-Ho Wong1, Ka-Fai Kwok1, Jonathan Sham2, John Wong1; 1Department of Surgery, The University of Hong Kong, Hong Kong, China; 2Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China 372 Hepatic Artery Chemoembolization in 122 Patients with Metastatic Carcinoid Tumor: Lessons Learned Mark Bloomston1, Osama Al-Saif1, Bryan Palmer1, Manisha Shah2, E. Christopher Ellison1, Gregory Guy3, Edward W. Martin1; 1Surgery, Ohio State University, Columbus, OH; 2Medicine, Ohio State University, Columbus, OH; 3Radiology, Ohio State University, Columbus, OH

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

373 Does Pancreatic Duct Stenting Decrease the Rate of Pancreatic Fistula Following Pancreaticoduodenectomy? Results of a Prospective Randomized Trial Jordan M. Winter1, John L. Cameron1, Kurtis A. Campbell1, David Chang1, JoAnn Coleman1, Patricia K. Sauter2, Taylor S. Riall3, Chris L. Wolfgang1, Chris J. Sonnenday1, Michael R. Marohn1, Richard D. Schulick1, Michael A. Choti1, Charles J. Yeo2; 1Surgery, Johns Hopkins Hospital, 2 SCHEDULE Baltimore, MD; Surgery, Thomas Jefferson University, Philadelphia, DAILY PA; 3Surgery, University of Texas Medical Branch, Galveston, TX 374 Pancreatic Cancer in the General Population: Improvements in Survival over the Last Decade Taylor S. Riall, Jean L. Freeman, Courtney M. Townsend, James S. Goodwin, Yong-fang Kuo, Zhang Dong, William H. Nealon; Surgery, University of Texas Medical Branch, Galveston, TX 375 Postoperative Pancreatic Fistulas Are Not Equivalent After Proximal, Distal, and Central Pancreatectomy Wande Pratt, Shishir Maithel, Tsafrir Vanounou, Mark P. Callery, Charles M. Vollmer; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 376 The Durability of Laparoscopic Nissen Fundoplication: Ten Year Outcomes Craig B. Morgenthal1, A. Stival1, M.D. Shane1, N.A. Gletsu1, G. Milam1, V. Swafford1, J.G. Hunter2, C.D. Smith1; 1Endosurgery Unit, Emory University School of Medicine, Atlanta, GA; 2Surgery, Oregon Health and Science University, Portland, OR 377 Gastrectomy as a Remedial Operation for Failed Fundoplication Valerie A. Williams, Thomas J. Watson, Oliver Gellersen, Sebastian Feuerlein, Daniela Molena, Carolyn Jones, Lelan Sillin, Jeffrey H. Peters; Department of Surgery, Division of Thoracic/Foregut Surgery, University of Rochester Medical Center, Rochester, NY 378 Long-Term Outcome After Resection for Chronic Pancreatitis: Results of 203 Patients Frank Makowiec, Hartwig Riediger, Eva Fischer, Ulrich Adam, Ulrich T. Hopt; Department of Surgery, University of Freiburg, Freiburg, Germany

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2:15 PM – 5:30 PM SSAT/AGA/ASGE STATE-OF-THE-ART 403 A CONFERENCE MANAGEMENT OF DIVERTICULAR DISEASE Moderator: Scott A. Strong, Cleveland, OH Sp391 Epidemiology and Pathogenesis of Diverticulosis and Diverticulitis Charles P. Heise, Madison, WI Sp392 Natural History of Diverticulitis Clifford Y. Ko, Los Angeles, CA Sp393 Imaging and Interventional Techniques in Diverticulitis Mark E. Baker, Cleveland, OH Sp394 Acute Diverticulitis of the Left Colon: Value of the Initial CT and Timing of Elective Colectomy Patrick Ambrosetti, Geneva, Switzerland Sp395 Operative Treatment of Recurrent or Complicated Diverticulitis Eric J. Dozois, Rochester, MN

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 CONTROVERSIES IN THE TREATMENT OF RECTAL CANCER Sponsored by: SSAT, ASGE, & AGA Co-Chairs: Frank Gress, Durham, NC

Robin S. McLeod, Toronto, ON SCHEDULE DAILY Sp403 Laparoscopic Surgery and Rectal Cancer Matt Mutch, St. Louis, MO Sp404 The Role of Local Excision in Rectal Cancer Julio Garcia-Aguilar, San Francisco, CA Sp405 Role of Neoadjuvant and Adjuvant Therapy in Rectal Cancer Edith Miller, Philadelphia, PA

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

TUESDAY, MAY 23, 2006

7:30 AM – 9:00 AM SSAT VIDEO BREAKFAST SESSION 403 A Co-Moderators: David M. Mahvi, Madison, WI Attila Nakeeb, Indianapolis, IN 470 Minimally Invasive Esophagectomy: Thoracoscopic Mobilization of Esophagus in Prone Position Chinnuswamy Palaninvelu, Palanisamy Senthilnathan, Ramakrishnan Parthsarathi, Rangaswamy Senthilkumar; Department of Surgical Gastroenterology & Minimal Access Surgery, GEM Hospital India Pvt Limited, Coimbatore, TamilNadu, India 471 Laparoscopic Redo Nissen Fundoplication with Reduction of Paraesophageal Hernia and Sliding Hiatal Hernia with Reconstruction of Esophageal Hiatus Alexander S. Rosemurgy, Kerry Thomas, Desiree Villadolid, Donald Thometz, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL 472 Laparoscopic Resection of Gastric Cardia Gastrointestinal Stromal Tumor Don J. Selzer; Surgery, Indiana University, Indianapolis, IN; Surgery, Clarian Health Partners, Indianapolis, IN 473 Transgastric Repair of a Gastrogastric Fistula Following Laparoscopic Roux-Y Gastric Bypass Kurt E. Roberts1, Andrew J. Duffy1, Walter E. Longo1, Priya Jamidar2, Robert L. Bell1; 1Surgery, Yale School of Medicine, New Haven, CT; 2Medicine, Yale School of Medicine, New Haven, CT 474 Pancreas Preserving Duodenectomy for Duodenal Familial Adenomatous Polyposis R.M. Walsh, Andrew Smith; General Surgery, Cleveland Clinic Foundation, Cleveland, OH 475 Resection and Reconstruction of the Superior Mesenteric Vein for Locally Advanced Pancreatic Adenocarcinoma Craig P. Fischer, Barbara L. Bass; Department of Surgery, The Methodist Hospital/Weill Medical College of Cornell University, Houston, TX 476 Laparoscopic Ileocolic Resection for Crohn’s Disease— Ileosigmoid Fistula Barry Salky, David Hazzan; Surgery, Mount Sinai Hospital, New York, NY

24 SSAT.book Page 25 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

8:30 AM – 10:00 AM SSAT PUBLIC POLICY COMMITTEE PANEL 402 A A MEDICAL MALPRACTICE PRIMER: ADVERSE EVENTS—WHAT YOU NEED TO KNOW AND DO Moderator: James M. Becker, Boston, MA Sp445 Deﬁnitions, Dos, and Don’ts Steven M. Strasberg, St. Louis, MO SCHEDULE Sp446 Advice from a Plaintiff’s Attorney DAILY Bruce Fagel, Los Angeles, CA Sp447 Risk Management in This Litigious Milieu John C. Metcalfe, Long Beach, CA

8:30 AM – 10:00 AM SSAT/AHPBA JOINT SYMPOSIUM 402 B ADVANCED SURGICAL THERAPY FOR PANCREATIC CANCER Moderator: Theodore N. Pappas, Durham, NC Sp485 Overview and Current Update on Dr. Whipple’s Operation J. Michael Henderson, Cleveland, OH Sp486 Extended Surgical Resection for Pancreatic Adenocarcinoma Bryan M. Clary, Durham, NC Sp487 Combined Modality Treatment for Localized Pancreatic Adenocarcinoma Peter W.T. Pisters, Houston, TX Sp488 Laparoscopic Pancreatic Resection Attila Nakeeb, Indianapolis, IN

10:00 AM – 10:30 AM ISDS LECTURE 403 A Sp448 Liver Transplantation in Asia—Beyond the Titanic ISDS President Chung-Mau Lo, University of Hong Kong Medical Center, Hong Kong, China

25 SSAT.book Page 26 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

11:15 AM – 12:00 PM STATE-OF-THE-ART LECTURE 403 A Sp449 Back to the Future: New Directions in Surgical Education Jeffrey L. Ponsky, University Hospitals of Cleveland, Cleveland, OH

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Sp567 Medical vs. Surgical Management of 410 Ulcerative Colitis Fabrizio Michelassi, New York NY, & Ellen J. Scherl, New York, NY

26 SSAT.book Page 27 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Sp569 Minimally Invasive Pancreatic Surgery Wilshire Grand L.A. Verdugo Room Atilla Nakeeb, Indianapolis, IN Sp570 Multidisciplinary Management of Biliary Leaks/ Injuries Wilshire Grand L.A. Chandler Room Keith D. Lillemoe, Indianapolis, IN SCHEDULE

Sp577 Preoperative Decision Making in the Difﬁcult 405 DAILY Patient with Pancreatic Cancer Mark P. Callery, Boston, MA Sp579 Surgical Management of GI Neuroendocrine Tumors Wilshire Grand L.A. Sawtelle Room Herbert Chen, Madison, WI Sp583 Treatment of Villous Adenocarcinoma Endoscopy vs. Local Resect vs. Whipple Wilshire Grand L.A. Balboa Room Carlos Fernandez-del-Castillo, Boston, MA

27 SSAT.book Page 28 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 EVIDENCE-BASED MANAGEMENT OF OBESITY SURGERY AND ITS COMPLICATIONS Sponsored by: SSAT, ASGE, & AGA Co-Chairs: Bruce D. Schirmer, Charlottesville, VA Richard Rothstein, Lebanon, NH Sp593 Effectiveness and Common Complications of Bariatric Surgery: Roux-en-Y Gastric Bypass Ninh T. Nguyen, Orange, CA Sp594 Effectiveness and Common Complications of Bariatric Surgery: Lap Adjustable Gastric Band Jeff W. Allen, Louisville, KY Sp595 Effectiveness and Common Complications of Bariatric Surgery: Biliopancreatic Diversion and Duodenal Switch Peter F. Crookes, Los Angeles, CA Sp596 Medical Management of Complications After Bariatric Surgery Lee M. Kaplan, Boston, MA Sp597 Emerging Endoscopic Treatments for the Treatment of Obesity Lee L. Swanstrom, Portland, OR

28 SSAT.book Page 29 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

James T. McPhee, Maksim Zayaruzny, Giles F. Whalen, Demetrius E. SCHEDULE Litwin, Mary E. Sullivan, Frederick A. Anderson, Jennifer F. Tseng; Surgery, DAILY University of Massachusetts Memorial Medical Center, Worcester, MA 699 Targeting MEK with PD325901 Inhibits Hepatocellular Carcinoma Growth in TGF-α Transgenic Mice Matthew Hennig1, Patrick Klein1,2, Navin Bansal3, Nedumangalam Hekmatyar3, Sabrina Wentz1, Amanda Norris1, Stephen Noble1, Courtney Doyle1, Huangbing Wu1, Yufang Wang1, Jean Campbell4, Nelson Fausto4, Glenn Merlino6, Judith Sebolt-Leopold7, C.M. Schmidt1,8; 1Surgery, Indiana University, Indianapolis, IN; 2Pharmacology and Toxicology, Indiana University, Indianapolis, IN; 3Radiology, Indiana University, Indianapolis, IN; 4Pathology, University of Washington, Seattle, WA; 5Biology, University of North Carolina-Charlotte, Charlotte, NC; 6Molecular Genetics, National Institutes of Health, Bethesda, MD; 7Pfizer Global R&D, Inc., Ann Arbor, MI; 8Richard L. Roudebush VAMC, Indianapolis, IN 700 Does Reflux Height Matter? A Study of 1680 Patients Guilherme M. Campos1, Fernando Herbella1, Ian Nipomnick1, Marco Patti1, Eric Vittinghoff2; 1Surgery, University of California, San Francisco, San Francisco, CA; 2Epidemiology, University of California, San Francisco, San Francisco, CA 701 Short Tandem Repeat Polymorphism in EXON 4 of Esophageal Cancer Related Gene—2 As a Prognostic Marker for Esophageal Carcinoma Tamina Rawnaq1, Jussuf T. Kaifi1, Paulus G. Schurr1, Michael Bubenheim2, Oliver Mann1, Emre F. Yekebas1, Petra Merkert1, Viacheslav Kalinin1, Bjoern-Christian Link1, Tim Strate1, Guido Sauter3, Klaus Pantel4, Jakob R. Izbicki1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg- Eppendorf, Hamburg, Germany; 2Institute for Biometry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Institute for Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 4Institute for Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

29 SSAT.book Page 30 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

702 A Prospective Evaluation of an Algorithm Incorporating Routine Pre-Operative Endoscopic Ultrasound-Guided Fine Needle Aspiration in Suspected Pancreatic Cancer Patients Mohamad Eloubeidi1, Shyam Varadarajulu1, Shilpa Desai1, Rhett Shirley1, Martin Heslin2, Mohit Mehra1, Juan P. Arnoletti2, Isam Eltoum3, C. Mel Wilcox1, Selwyn Vickers2; 1Gastroenterology and Hepatology, University of Alabama at Birmigham, Birmingham, AL; 2Surgery, University of Alabama, Birmingham, AL; 3Pathology, University of Alabama, Birmingham, AL 703 Detection of Microsatellite Alteration in Serum DNA As a Tool for Differentiation Between Benign and Malignant Diseases of the Pancreas Robin Wachowiak1, Jussuf T. Kaifi1, Bjoern C. Link1, Dean Bogoevski1, Guellue Cataldegirmen1, Uta Reichelt2, Lars Wolfram1, Jakob R. Izbicki1, Emre F. Yekebas1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany 704 Microsatellite DNA Alterations of Gastro-Intestinal Stromal Tumors Are Predictive for Outcome Paulus G. Schurr1, Stefan Wolter1, Jussuf Kaifi1, Uta Reichelt2, Helge Kleinhans1, Robin Wachowiak1, Emre Yekebas1, Tim Strate1, Viacheslav Kalinin1, Hansjoerg Schaefer1, Izbicki Jakob1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg, Hamburg, Germany; 2Department of Pathology, University Medical Center Hamburg, Hamburg, Germany 705 Robotic Assisted Versus Laparoscopic Cholecystectomy: Outcome and Cost Analysis in a Case-Matched Control Study Stefan Breitenstein, Antonio Nocito, Carmen Oggier, Markus Weber, Perre-Alain Clavien; Universitiy Hospital Zurich, Zurich, Switzerland 706 Radiofrequency Ablation for HCCn Cirrhotic Patients: Prognostic Factors for Survival Andrea Ruzzenente, Marco Sandri, Calogero Iacono, Silvia Pachera, Corrado Pedrazzani, Sebastiano Tasselli, Alfredo Guglielmi; Surgery and Gastroenterology, University of Verona, Verona, Italy 707 Hyperbilirubinemia in Appendicits: A New Predictor of Perforation Joaquin Estrada, Rodney J. Mason, Mikael Petrosyan, Jordan Barnhart, Matthew Tao, Shirin Towfigh; Surgery, University of Southern California, Los Angeles, CA

30 SSAT.book Page 31 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

3:30 PM – 5:00 PM SSAT/ASCRS JOINT SYMPOSIUM 403 A MINIMALLY INVASIVE APPROACHES TO RECTAL DISEASE Moderator: Mark H. Whiteford, Portland, OR Sp645 Transanal Endoscopic Microsurgery Resection of Rectal Tumors SCHEDULE

Mark H. Whiteford, Portland, OR DAILY Sp646 The STARR Procedure for Rectocele C. Neal Ellis, Mobile, AL Sp647 Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis David W. Larson, Rochester, MN Sp648 Laparoscopic Management of Rectal Prolapse Conor P. Delaney, Cleveland, OH

4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIA SURGERY IN THE CIRRHOTIC PATIENT Concourse Hall 151 Sponsored by: AASLD & SSAT Co-Chairs: Patrick Kamath, Rochester, MN David M. Mahvi, Madison, WI Sp653 The Hepotologist’s Viewpoint Lawrence Friedman, Newton, MA Sp654 The Anesthesiologist’s Viewpoint David Plevak, Rochester, MN Sp655 The Surgeon’s Viewpoint W. Scott Helton, Chicago, IL

31 SSAT.book Page 32 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

2:00 AM CALL: MANAGEMENT OF Concourse Hall 152 GI EMERGENCIES Sponsored by: ASGE, AGA, & SSAT Co-Chairs: John G. Lee, Orange, CA Ken McQuaid, San Francisco, CA Sp649 GI Bleeding, When to Scope, When to Sleep? Ian Mark Gralnek, Los Angeles, CA Sp650 Cholangitis: What’s a Real Emergency? John G. Lee, Orange, CA Sp651 Foreign Bodies: What Gets Into People Anyway? Greg Ginsberg, Philadelphia, PA Sp652 Emergency Potpourri: Caustic Ingestions, Trauma, and Acute Intestinal Pseudo-Obstruction John Patrick Cello, San Francisco, CA

5:00 PM – 6:00 PM SSAT BUSINESS MEETING 403 A

7:00 PM – 9:00 PM SSAT MEMBERS RECEPTION Natural History Museum of Los Angeles County

32 SSAT.book Page 33 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

WEDNESDAY, MAY 24, 2006

8:30 AM – 10:00 AM SSAT PLENARY SESSION 403 A Co-Moderators: L. William Traverso, Seattle, WA Edward E. Whang, Boston, MA

800 Effect of Location and Speed of Diagnosis on Anastomotic SCHEDULE DAILY Leak Outcomes in 3838 Gastric Bypass Patients Sukhyung Lee1,2, Brennan Carmody1, Luke Wolfe1, Eric DeMaria1, John M. Kellum1, Harvey Sugerman1, James W. Maher1; 1Surgery, Va. Commonwealth U., Richmond, VA; 2Surgery, William Beaumont Army Medical Center, El Paso, TX 801 Treatment of Gastric Adenocarcinoma Based on Institution Type/Approvals Category in the United States Kaye M. Reid1, Lina Patel3, Jaffer Ajani2,3, John H. Donohue1,3, Members of the Gastric PCE Project The3; 1General Surgery, Mayo Clinic – Rochester, Rochester, MN; 2GI Medical Oncology, M.D. Anderson, Houston, TX; 3American College of Surgeons, Commission on Cancer, Chicago, IL 802 Exocrine Function After the Whipple Procedure as Assessed by Stool Elastase Joe Matsumoto, William Traverso; General Surgery, Virginia Mason Clinic, Seattle, WA 803 A R0 Resection Accomplished with Minimal Blood Loss Is the Surgeons Contribution to Long-Term Survival in Pancreatic Cancer Thomas J. Howard, Joseph E. Krug, Jian Yu, Christian M. Schmidt, Lewis E. Jacobson, James A. Madura, Eric A. Wiebke, Keith A. Lillemoe; Surgery, Indiana University, Indianapolis, IN 804 Efﬁcacy of Preoperative Combined 18-Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography for Assessing Primary Rectal Cancer Response to Neoadjuvant Therapy Genevieve B. Melton1, William C. Lavely2, Heather A. Jacene2, Richard D. Schulick1, Michael A. Choti1, Richard L. Wahl2, Susan L. Gearhart1; 1Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; 2Department of Nuclear Medicine, Johns Hopkins Medical Institutions, Baltimore, MD

33 SSAT.book Page 34 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

8:30 AM – 10:00 AM SSAT EDUCATION COMMITTEE PANEL 402 A BARIATRIC SURGERY TRAINING: GETTING YOUR TICKET PUNCHED Moderator: Daniel B. Jones, Boston, MA Sp705 Mini-Fellowships Philip R. Schauer, Cleveland, OH Sp706 Fellowship Model (One-Year) C. Daniel Smith, Atlanta, GA Sp707 Epidemiology: The Whole Truth David R. Flum, Seattle, WA Sp708 Zero Tolerance for Bad Outcomes: An Achievable Goal? Bruce D. Schirmer, Charlottesville, VA

10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 CARE OF THE LIVER TRANSPLANT PATIENT IN A NON-TRANSPLANT CENTER Sponsored by: AGA, AASLD, & SSAT Co-Chairs: Emmet B. Keeffe, Palo Alto, CA John Moore Vierling, Los Angeles, CA Sp739 When to Refer for Liver Transplantation J. Eileen Hay, Rochester, MN Sp740 Immunosuppression and Its Long-Term Consequences Kelly Burak, Rochester, MN Sp741 Management of Recurrent Disease Norah Terrault, San Francisco, CA

34 SSAT.book Page 35 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Samir Mehta, John Bennett, David Mahon, Michael Rhodes; SCHEDULE Department of Upper Gastrointestinal Surgery, Norfolk and Norwich DAILY University Hospital, Norwich, United Kingdom 883 Gastroesophageal Reflux Disease and Obesity: Pathophysiology and Implications for Treatment Fernando A. Herbella, Ian Nipomnick, Pietro Tedesco, Marco G. Patti; Department of Surgery, University of California, San Francisco, San Francisco, CA 884 Quality of Life Convergence of Laparoscopic and Open Antireflux Surgery for Gastroesophageal Reflux Disease Aisha Violette, Vic Velanovich; Surgery, Henry Ford Hospital, Detroit, MI 885 Ileorectal Anastomosis for Slow Transit Constipation: Long-Term Functional and Quality of Life Results. Imran Hassan1, John H. Pemberton1, Yi-Qian N. You1, Ernesto R. Drelichman1, Doris M. Rath-Harvey1, Cathy D. Schleck2, Drik R. Larson2, Tonia M. Young-Fadok1; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Section of Biostatistics, Mayo Clinic, Rochester, MN 886 Autologous Versus Allogeneic Transfusions: No Difference in Peri-Operative Outcome After Partial Hepatectomy James O. Park, Mithat Gonen, Michael D’Angelica, Ronald Dematteo, Fong Yuman, Leslie H. Blumgart, William R. Jarnagin; Surgery, MSKCC, New York, NY 887 Enteral Immunonutrition During Sepsis Prevents Pulmonary Dysfunction in a Rat Model Jorg Glatzle1, Michael S. Kasparek1, Tobias Meile1, Jutta Hahn1, Mario H. Mueller2, Martin E. Kreis2, Alfred Konigsrainer1, Wolfgang Steurer1; 1General Surgery, University, Tuebingen, Germany; 2General Surgery, University of Munich, Munich, Germany

35 SSAT.book Page 36 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

12:00 PM – 3:00 PM SSAT/SAGES JOINT SYMPOSIUM 403 A CONTROVERSIES IN MINIMALLY INVASIVE COLORECTAL SURGERY Co-Moderators: Bruce D. Schirmer, Charlottesville, VA Tonia M. Young-Fadok, Scottsdale, AZ Controversy #1: Is Severe Obesity a Contraindication to Performing a Laparoscopic Colectomy? Sp757 Yes Anthony J. Senagore, Cleveland, OH Sp758 No Peter W. Marcello, Burlington, MA Controversy #2: Is the Hand Device a Good Bridge to Overcome the Learning Curve and in Selected Cases? Sp759 Yes Garth Hadden Ballantyne, Hackensack, NJ Sp760 No Thomas Read, Pittsburgh, PA Controversy #3: Should Proctocolectomy and IPAA Be Done Totally Laparoscopically? Sp761 Yes Tonia Young-Fadok, Scottsdale, AZ Sp762 No, but Laparoscopic-Assisted Charles Friel, Charlottesville, VA Controversy #4: Should Pelvic Dissection for Rectal Cancer Be Performed Laparoscopically? Sp763 Yes Matthew Mutch, St. Louis, MO Sp764 No Richard L. Whelan, New York, NY Controversy #5: Should Both Laparoscopic and Open Approaches Be Offered to All Patients with Colon Cancer? Sp765 Yes Barry A. Salky, New York, NY Sp766 No Richard P. Billingham, Seattle, WA

36 SSAT.book Page 37 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Sp787 Management of Necrotizing Pancreatitis Wilshire Grand L.A. Fernwood Room Stanley W. Ashley, Boston, MA Sp791 Management of GI Stromal Tumors 407 Todd W. Bauer, Charlottesville, VA SCHEDULE DAILY 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 THE RIGHT THERAPY AT THE RIGHT TIME: EVIDENCE-BASED MANAGEMENT OPTIONS FOR CROHN’S DISEASE Sponsored by: SSAT & AGA Co-Chairs: Barbara L. Bass, Houston, TX Steve Hanauer, Chicago, IL Sp806 What Are Appropriate End Points for Medical and Surgical Trials in Inﬂammatory Bowel Disease? Brian Feagan, London, ON Sp807 Management of Complex Perineal Disease Zane Cohen, Toronto, ON Sp808 Stricturing Disease: Determining Factors in Surgical Management of Jejunoileal and Colonic Disease Fabrizio Michelassi, New York, NY Sp809 Step Up or Top Down: Therapeutic Choices to Optimize Disease Control William J. Sandborn, Rochester, MN

37 SSAT.book Page 38 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

POSTER SESSION DETAIL

Monday, May 22, 2006

12:00 PM – 2:00 PM SSAT POSTER SESSION West Hall A 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 authors will deliver abbreviated oral presentations of their work during the “Posters of Distinction Quick Shots” session, 3:30 PM – 4:30 PM, Tuesday, May 23, 2006, in Room 402 A.

BASIC SCIENCE POSTERS

Basic: Biliary

Basic: Colon-Rectal

38 SSAT.book Page 39 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1866 Fenofibrate, a PPAR α Agonist, Inhibits the Growth of a Murine Colon Adenocarcinoma In Vivo Avraham Belizon, Patrick K. Horst, Irena Kirman, Emre Balik, H.M. Shantha Kumara, Suvinit Jain, Richard L. Whelan; Surgery, Columbia University Medical Center, New Hyde Park, NY M1868 Atropine Increases Survival in an LPS Model of Sepsis: A Kinetic Study Joseph Fuentes, Mark Talamini, Eric Hanly, Antonio Demaio; Surgery, Johns Hopkins, Baltimore, MD M1869 Identification of Chromosomal Domains of Differential Gene Expression in Colorectal Cancer by Comparative Chromosomal Gene Expression Analysis (CCGEA) SESSION Joern Groene1, Stefan Roepke2, Maya Heinze1, Heinz J. Buhr1, Eike POSTER Staub2; 1Department of Surgery, Charite Universitaetsmedizin Berlin, Berlin, Germany; 2Max Planck Institute for Molecular Genetics, Berlin, Germany M1870 Slit/Robo Signalling in Colorectal Cancer — Differential Expression of Angiogenic Markers Joern Groene1, Oliver Doebler1, Christoph Loddenkemper2, Heinz J. Buhr1, Sarah Bhargava1; 1Department of Surgery, Charite – Universitaetsmedizin Berlin, Berlin, Germany; 2Institute of Pathology, Charite – Universitaetsmedizin Berlin, Berlin, Germany M1871 5-FU and PT-11 Significantly Reduce Intraperitoneal Tumor Growth in Experimental Investigations of Peritoneal Carcinomatosis Arndt Hribaschek1, Frank Meyer1, Matthias Pross1, Karsten Ridwelski2, Regine Schneider-Stock3, Hans Lippert1; 1Department of Surgery, University Hospital, Magdeburg, Germany; 2Department of Surgery, Municipal Hospital, Magdeburg, Germany; 3Institute of Pathology, University Hospital, Magdeburg, Germany M1872 The Prevalence of Colorectal Neoplasia in End Stage Renal Disease: A Case Control Study Sharon Lee, Nir Wasserberg, Patrizio Petrone, Jason Rosca, Rick Selby, Adrian Ortega, Howard Kaufman; Surgery, University of Southern California, Los Angeles, CA M1873 Evaluation of the Physical Properties of a New Fully Degradable Suture Material with a Shape Memory Effect for Visceral Surgery Christoph Reissfelder1, Joerg-Peter Ritz1, Steffen Kelch2, Andreas Lendlein2, Heinz Buhr1; 1Department of General Surgery, Charite, Campus Benjamin Franklin, Berlin, Germany; 2Institute of Chemistry, GKSS Research Center Geesthacht GmbH, Teltow, Germany

39 SSAT.book Page 40 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Esophageal

40 SSAT.book Page 41 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

1,2 1 1 SESSION Tomoharu Miyashita , Jiaai Wang , C.M.Shahbaz Sarwar , Katsunobu POSTER Oyama2, Takashi Fujimura2, Yiping Huang3, Alexey Fomenkov3, Guy Marti1, Elizabeth Montgomery4, Mark Duncan1, Koichi Miwa2, Edward Ratovitski3, John W. Harmon1; 1Department of Surgery, Johns Hopkins University, Baltimore, MD; 2Department of Surgery, Kanazawa University, Kanazawa, Japan; 3Department of Dermatology, Johns Hopkins University, Baltimore, MD; 4Department of Pathology, Johns Hopkins University, Baltimore, MD M1881 Cox-2 Gene Expression in Long Segment Barrett’s Esophagus Is Inﬂammatory in Origin Daniel S. Oh1, Steven R. Demeester1, Jeffrey A. Hagen1, Hidekazu Kuramochi2, Koji Tanaka2, Kathleen D. Danenberg3, Peter V. Danenberg2, Christian G. Peyre1, Cedric G. Bremner1, John Lipham1, Tom R. Demeester1; 1Surgery, University of Southern California, Los Angeles, CA; 2Biochemistry & Molecular Biology, University of Southern California, Los Angeles, CA; 3Response Genetics Inc., Los Angeles, CA +M1882 Short Tandem Repeat Polymorphism in EXON 4 of Esophageal Cancer Related Gene – 2 as a Prognostic Marker for Esophageal Carcinoma Tamina Rawnaq1, Jussuf T. Kaiﬁ1, Paulus G. Schurr1, Michael Bubenheim2, Oliver Mann1, Emre F. Yekebas1, Petra Merkert1, Viacheslav Kalinin1, Bjoern-Christian Link1, Tim Strate1, Guido Sauter3, Klaus Pantel4, Jakob R. Izbicki1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg- Eppendorf, Hamburg, Germany; 2Institute for Biometry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Institute for Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 4Institute for Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

+ Poster of Distinction

41 SSAT.book Page 42 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

+ Poster of Distinction

42 SSAT.book Page 43 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

43 SSAT.book Page 44 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1891 Apigenin Inhibits Pancreatic Cancer Cell Proliferation via Down-Regulation of the GLUT-1 Glucose Transporter Laleh Golkar1, Mohammad R. Salabat1, Xian-Xhong Ding1, Michael B. Ujiki1, Sambasiva M. Rao2, Thomas E. Adrian1, Mark S. Talamonti1, Richard H. Bell1, Jill Pelling2, David J. Bentrem1; 1Surgery, Northwestern, Chicago, IL; 2Pathology, Northwestern University, Chicago, IL M1892 Thioredoxin-Interacting Protein Expression Is Reduced in Metastatic Gastrointestinal Neuroendocrine Tumors David Y. Greenblatt1, Abram Vaccaro1, Muthusamy Kunnimalaiyaan1, Anath Shalev2, Herbert Chen1; 1Department of Surgery, University of Wisconsin, Madison, WI; 2Department of Medicine, University of Wisconsin, Madison, WI M1893 Diagnostic Relevance of Human Telomerase Reverse Transcriptase (hTERT) Expression Detected by Immunohistochemistry in Pancreatic Tumors Yasushi Hashimoto1, Eiso Hiyama2,1, Yoshiaki Murakami1, Kenichiro Uemura1, Yasuo Hayashidani1, Takeshi Sudo1, Yoichi Sugiyama1, Taijiro Sueda1; 1Department of Surgery, Graduate School of Biomedical Science, Hiroshima University, Hiroshima, Japan; 2Department of Biomedicine, Graduate School of Biomedical Science and Natural Science Center of Basic Research and Development, Hiroshima University, Hiroshima, Japan M1894 NF-κB Targeting in Pancreatic Cancer Promotes the Antiproliferative Effects of Gemcitabine Bryan Holcomb1, Michele Yip-Schneider1, Matthew Ralstin1, Jennifer Dixon1, Julie Mahomed1, Christopher Sweeney2, Harikrishna Nakshatri1, Peter Crooks3, Christian M. Schmidt1,4; 1Surgery, Indiana University, Indianapolis, IN; 2Hematology/Oncology, Indiana University, Indianapolis, IN; 3Toxicology, University of Kentucky, Lexington, KY; 4Richard L. Roudebush VAMC, Indianapolis, IN M1895 A Nude Mouse Resection Model of Ductal Pancreatic Cancer to Evaluate Novel Adjuvant Treatment Strategies Hubert G. Hotz, Birgit Hotz, Sarah Bhargava, Heinz J. Buhr; Department of Surgery, Charite – Medical School, Campus Benjamin Franklin, Berlin, Germany

44 SSAT.book Page 45 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1896 Adhesion Molecules Under Volume Therapy in a Pig Model of Acute Severe Pancreatitis Helge Kleinhans1, Oliver Mann1, Jussuf T. Kaifi1, Felix Reinknecht1, Bente Hansen1, Marc Freitag2, Emre Yekebas1, Jakob R. Izbicki1, Tim G. Strate1; 1General Surgery, University Medical Center Hamburg Eppendorf, Hamburg, Germany; 2Anesthesiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany M1897 Expression of Netrin-1 but Not of Its Receptors Has Significant Influence on Time to Tumor Recurrence in Patients with Adenocarcinoma of the Pancreas Bjoern-Christian Link1, Uta Reichelt2, Matthias Schreiber1, Robin Wachowiak1, Dean Bogoevski1, Jussuf T. Kaifi1, Susanne Petri2, Emre F. SESSION Yekebas1, Jakob R. Izbicki1; 1Department of General, Visceral and POSTER Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany; 2Department of Pathology, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany M1899 N-Acetyl Cysteine Attenuates Pancreatic Injury and Increases Expression Level of GST-α Gene After Pancreatic Ischemia-Reperfusion Induction Model in Rats Roberto F. Meirelles1,2, Marcia S. Kubrusly1, Sandra V. Sa3, Nilza A. Molan1, Maria L. Correa-Gianella3, Daniel Gianella3, Telesforo Bacchella1, Marcel C. Machado1; 1Clinica Cirurgica I, Disciplina de Transplante e Cirurgia do Figado, LIM 37, FMUSP, Sao Paulo, Brazil; 2Cirurgia- Disciplina de Cirurgia Geral, FAMERP, Sao Jose do Rio Preto, Brazil; 3Clinica Medica, Disciplina de Endocrinologia, LIM 25, FMUSP, Sao Paulo, Brazil M1900 Methylene Blue Improves Hemodynamic Shock but Increases Lipoperoxidation in Severe Acute Pancreatitis Model Roberto F. Meirelles1, Fernanda V. Borges2, Paulo R. Evora2, Reginaldo Ceneviva3; 1Cirurgia, Disciplina de Cirurgia, FAMERP, Sao Jose do Rio Preto, Brazil; 2Cirurgia e Anatomia, Laboratorio de Funcao Endotelial, FMRP-USP, Ribeirao Preto, Brazil; 3Cirurgia e Anatomia, FMRP-USP, Ribeirao Preto, Brazil M1901 Protein Kinase C-Zeta Is Critical in Acute Pancreatitis- Induced Kupffer Cell Apoptosis Yanhua Peng, Celia Sigua, Scott F. Gallagher, Michel M. Murr; Surgery, University of South Florida, College of Medicine, Tampa, FL

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1902 Up-Regulation of MICA/B Expression in Panc-1 Pancreatic Cancer Cells by Radiation, Gemcitabine, and 5-Fluorouracil (5-Fu) Geetha Rao, Carmen Solorzano, Xiulong Xu, Richard Prinz; General Surgery, Rush University Medical Center, Chicago, IL M1903 Overexpression of Geminin in Pancreatic Cancer Tissue and Its Down-Regulation by Apigenin Mohammad R. Salabat1, Xian Z. Ding1, Laleh Golkar1, Michael B. Ujiki1, Sambasiva M. Rao2, Richard H. Bell1, Thomas E. Adrian1, Jill C. Pelling2, Mark S. Talamonti1, David J. Bentrem1; 1Surgery, Northwestern University, Chicago, IL; 2Pathology, Northwestern Surgery, Chicago, IL M1904 In Vitro Evidence for Acinar Cell Cytokine Production Via Stress Kinase Activation Isaac Samuel, Asgar Zaheer, Rory A. Fisher; University of Iowa CCOM & VAMC, Iowa City, IA M1905 Acute Pancreatitis Afeccts Kuppfer Cells Function by Mechanism Dependent on Paf Lourenilson J. Souza, Marina T. Shio, Nilza A. Molan, Ana Maria M. Coelho, Jose Eduardo M. Cunha, Jancar Sonia, Marcel Cerqueira C. Machado; Gastrointestinal Surgery, University of Sao Paulo, Sao Paulo, Brazil +M1906 Detection of Microsatellite Alteration in Serum DNA as a Tool for Differentiation Between Benign and Malignant Diseases of the Pancreas Robin Wachowiak1, Jussuf T. Kaiﬁ1, Bjoern C. Link1, Dean Bogoevski1, Guellue Cataldegirmen1, Uta Reichelt2, Lars Wolfram1, Jakob R. Izbicki1, Emre F. Yekebas1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany M1907 Changes in the Systemic Innate Immune Response in Two Experimental Models of Severe Acute Pancreatitis Vincent S. Yip1, James J. Powell1, Christopher O. Bellamy2, Ian F. Ansell1, James A. Ross1, Stephen J. Wigmore3, O.J. Garden1; 1Department of Surgery, University of Edinburgh, Edinburgh, United Kingdom; 2Department of Pathology, University of Edinburgh, Edinburgh, United Kingdom; 3Liver Unit, Department of Surgery, University of Birmingham, Birmingham, United Kingdom

+ Poster of Distinction

46 SSAT.book Page 47 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Basic: Small Bowel

M1908 Functional and Molecular Evidence for the Expression of Autocrine Serotonin Receptors on an Enterochromafﬁn Cell Line Jarrod D. Day, Roberto C. Iglesias, Jessie G. Howell, Dorne R. Yager, John M. Kellum; General Surgery, Medical College of Virginia, Richmond, VA M1909 Hexose Transporter Expression in the Mouse Jejunum: Role of Diurnal Rhythms Javairiah Fatima, Scott G. Houghton, Judith A. Duenes, Michael G. Sarr; Department of Surgery and Gastroenterology Research Unit, Mayo SESSION Clinic College of Medicine, Rochester, MN POSTER M1910 Molecular Analysis of Colonic Transformation in the Ileum After Total Colectomy in Rats Kouhei Fukushima, Sho Haneda, Yuji Funayama, Chikashi Shibata, Ken-Ichi Takahashi, Hitoshi Ogawa, Iwao Sasaki; Surgery, Tohoku University, Graduate School of Medicine, Sendai, Japan

47 SSAT.book Page 48 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Stomach

M1918 Functional Polymorphism in Nf-κB1 Promoter Is Related to the Risk of Gastric Cancer Su-Shun Lo1,2, Chew-Wun Wu1,2; 1Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 2National Yang Ming University, Taipei, Taiwan M1919 Mechanisms of Body Weight Loss After Gastric Bypass Surgery in Rats Bjorn Stenstrom1, Marianne Furnes1, Chun-Mei Zhao1, Karin Tommeras1, Carl-Jorgen Arum1, Unni Syvenssen1, Suzanne Dickson2, Duan Chen1; 1Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 2Department of Physiology, University of Cambridge, Cambridge, United Kingdom

48 SSAT.book Page 49 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

CLINICAL SCIENCE POSTERS

Clinical: Biliary

M1388 Surgery for Acute Cholecystitis in Denmark Alan P. Ainsworth1, Sven Adamsen2, Jacob Rosenberg3, Flemming Burcharth2; 1Department of Surgery, Odense University Hospital, Odense C, Denmark; 2Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark; 3Department of Gastrointestinal Surgery, Copenhagen University Hospital Gentofte, Copenhagen, Denmark + SESSION M1389 Robotic Assisted Versus Laparoscopic Cholecystectomy: POSTER Outcome and Cost Analysis in a Case-Matched Control Study Stefan Breitenstein, Antonio Nocito, Carmen Oggier, Markus Weber, Perre-Alain Clavien; Universitiy Hospital Zurich, Zurich, Switzerland M1390 Surgical Treatment of Hepatolithiasis on Particular Reference to Long-Term Results Miin-Fu Chen; Department of General Surgery, Chang Gung Memorial Hospital, Kweishan, Taiwan; Surgery, Chang Gung University, Kweishan, Taiwan M1391 Visuospatial Tests Predict the Performance of Simulated ERCP Among Endoscopists Irrespective of Previous ERCP Experience Lars Enochsson1,3, Fredrik Swahn1, Bo Westman3,4, Urban Arnelo1, Ann Kjellin1,3, Li Fellander-Tsai2,3; 1Department for Clinical Science Intervention and Technology (CLINTEC), division of surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden; 2Department for Clinical Science Intervention and Technology (CLINTEC), Division of Orthopaedics, Karolinska University Hospital Huddinge, Stockholm, Sweden; 3Center for Advanced Medical Simulation, Karolinska University Hospital Huddinge, Stockholm, Sweden; 4Department of Surgery, Sodertalje Hospital, Stockholm, Sweden

+ Poster of Distinction

49 SSAT.book Page 50 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1392 Does Endoscopic Ultrasound Have Anything to Offer in the Diagnosis of Suspected Common Duct Stones? Gareth J. Morris-Stiff1, Ben Frost3, Wyn Lewis1,3, Phillip Webster1, Malcolm C. Puntis1, Ashley Roberts2; 1Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom; 2Department of Radiology, University Hospital of Wales, Cardiff, United Kingdom; 3Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom M1393 Inﬂammatory Myoﬁbroblastic Biliary Strictures Masquerading as Cholangiocarcinoma Thomas C. Gamblin1, Alyssa Krasinskas3, Adam Slivka4, Susan Caro1, Mitch E. Tublin2, Anthony J. Demetris3, Wallis Marsh1, A.J. Moser1; 1Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA; 3Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA; 4Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA M1394 Emerging Role of ERCP in Blunt Extrahepatic Hepatic Duct Injuries Nikhil P. Jaik1, Stanislaw P. Stawicki1, Brian A. Hoey2; 1Department of Surgery, St. Luke’s Hospital and Health Network, Bethlehem, PA; 2University of Pennsylvania Trauma Network, Philadelphia, PA M1395 Sphincter of Oddi: A Structural & Functional Study Kewal K. Maudar; Surgery, Armed Forces Medical College, Pune, Pune, India +M1396 Cancer of the Gallbladder: National Patterns of Surgical Intervention James T. Mcphee, Maksim Zayaruzny, Giles F. Whalen, Demetrius E. Litwin, Mary E. Sullivan, Frederick A. Anderson, Jennifer F. Tseng; Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA M1397 Prevalence and Outcome of Cholangiocarcinoma in Patients with Primary Sclerosing Cholangitis Referred to a Regional Liver Transplant Unit Gareth J. Morris-Stiff, Chandra Bhatti, Bridget Gunson, David Mayer, John Buckels, Darius Mirza, Simon Bramhall; Department of Hepato- Pancreatico-Biliary Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom

+ Poster of Distinction

50 SSAT.book Page 51 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Urban Medical Center SESSION POSTER Choichi Sugawa, Lester Young, Hiromi Ono, Toshiki Matsubara, Gen Tohda, Charles E. Lucas; Department of Surgery, Wayne State University, Detroit, MI

Clinical: Colon-Rectal

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1405 Invasive Squamous Cell Carcinoma of the Anus in HIV: Is There a Role for the Surgeon? Gregory Chipman2, Harry L. Reynolds1, Colin Mooney2, Joseph Skitzki1, James Merlino4, Conor Delaney1, Timothy Kinsella3, Scott Remick2; 1Case Surgery, University Hospitals of Cleveland, Cleveland, OH; 2Medical Oncology, University Hospitals of Cleveland, Cleveland, OH; 3Radiation Oncology, University Hospitals of Cleveland, Cleveland, OH; 4Case Surgery, Metro Health Medical Center, Cleveland, OH M1406 Prospective Randomized Trial: Preemptive Antibiotic Treatment Versus Standard Treatment in Patients with Elevated Serum Procalcitonin Levels After Elective Colorectal Surgery Ansgar M. Chromik1, Frank Endter2, Waldemar Uhl1, Arnulf Thiede2, Hans B. Reith2, Ulrich Mittelkoetter1; 1Surgical Department, University Hospital of Bochum, Bochum, Germany; 2Surgical Department, University Hospital of Wurzburg, Wurzburg, Germany +M1407 Hyperbilirubinemia in Appendicits: A New Predictor of Perforation Joaquin Estrada, Rodney J. Mason, Mikael Petrosyan, Jordan Barnhart, Matthew Tao, Shirin Towﬁgh; Surgery, University of Southern California, Los Angeles, CA M1408 Laparoscopic Versus Open Surgery in Patients with Ileocolonic Crohn’s Disease: A Prospective Comparative Study Alessandro Fichera1, Stephanie L. Peng2, Alan S. Rosman3, Michele A. Rubin1, Roger D. Hurst1; 1Surgery, University of Chicago, Chicago, IL; 2Pritzker School of Medicine, University of Chicago, Chicago, IL; 3Medicine, Bronx VAMC and Mount Sinai School of Medicine, New York, NY M1409 Single Institution Comparison of Open, Hand-Assist Laparoscopic, and Laparoscopic Colon and Rectal Surgical Technique Ariel Forstner-Barthell1, Andrea Ferrara1, Joseph Gallagher1, Samuel Dejesus1, Paul Williamson1, Sergio Larach2, Paul Charron1, Eduardo Krajewski1; 1CRC of Orlando, Orlando, FL; 2Colon and Rectal Surgery, Florida Hospital, Orlando, FL

+ Poster of Distinction

52 SSAT.book Page 53 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1410 Early Postoperative Results of Novel Procedure of Side-to- Side Isoperistaltic Ileocolonic Anastomosis for Crohn’s Disease – Randomized Controlled Trial Yuji Funayama, Kouhei Fukushima, Chikashi Shibata, Ken-Ichi Takahashi, Hitoshi Ogawa, Sho Haneda, Kazuhiro Watanabe, Katsumasa Kudo, Atsushi Kohyama, Ken-Ichi Hayashi, Iwao Sasaki; GI & Colorectal Surgery, Tohoku University Hospital, Sendai, Japan M1411 Predictive Factors in Clostridium Difﬁcile Colitis for Failure of Medical and Need for Surgical Treatment Claudia Gonzalez-Ruiz, Shlomo Israelit, Paul Selvindoss, Robert W. Beart, Petar Vukasin, Glenn Ault, Andreas M. Kaiser; USC Department of Colorectal Surgery, University of Southern California, Los Angeles, CA SESSION POSTER M1413 Optimal Follow-Up of Stage I Colorectal Cancer Patients Tetsuro Higuchi, Masayuki Enomoto, Kenichi Sugihara; Surgical Oncology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan M1414 Outcomes in Bloodless Care Patients Having Colonic Resection James Izanec1, Deborah A. Nagle2; 1Gastroenterology, Graduate Hospital, Philadelphia, PA; 2Surgery, Cooper University Hospital, Camden, NJ M1416 Long-Term Quality of Life Is Not Different After Laparoscopic or Open Sigmoid Colectomy – A Matched-Pairs Analysis Michael S. Kasparek1, Elke Schiele1, Joerg Glatzle1, Guido Seitz3, Alfred Koenigsrainer1, Martin E. Kreis2; 1Department of General Surgery, Eberhard-Karls-University Tuebingen, Tuebingen, Germany; 2Department of Surgery, Ludwig-Maximilian’s-University Munich, Munich, Germany; 3Department of Paediatric Surgery, Eberhard-Karls- University Tuebingen, Tuebingen, Germany M1417 Synchronous Cancer in Obstructive Colo-Rectal Cancer Jaehwang Kim1, Byung-Ik Jang2, Min-Chul Shim1; 1General Surgery, Yeungnam university Medical center, Daegu, South Korea; 2Internal Medicine, Yeungnam university Medical center, Daegu, South Korea M1418 Gore Tex Perineal Sacral Suspension Reduces Symptoms of Obstructed Defecation Christopher J. Lahr1,2, Elizabeth T. Clerico2, Brooke H. Gurland3, Thomas Schnelldorfer1, John C. Pezzullo4, Vicki M. Limehouse2; 1Medical University of South Carolina, Charleston, SC; 2Roper St. Francis Hospitals, Charleston, SC; 3Maimonides Medical Center, Brooklyn, NY; 4Georgetown Medical University, Washington, DC

53 SSAT.book Page 54 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1419 Clinicopathological Factors Predictive of Systemic Recurrence After Curative Resection of Stage II Colon Cancer Yee Man Lee, Wai Lun Law, Hok Kok Choi, Chi Leung Seto, Siu Hung Lo, Wai Chu Ho; Surgery, Queen Mary Hospital, Hong Kong SAR, Hong Kong M1420 Fecal Urgency After Circular Stapled Mucosectomy in Hemorrhoidal Disease – Manometric and Clinical Features Rafal Pankala1, Jaroslaw Leszczyszyn2, Igor Lebski1; 1Department of GI Surgery, EuroMediCare Hospital, Wroclaw, Poland; 2Faculty of Physiotherapy, Physical Education University, Wroclaw, Poland M1421 Recurrent Distal Rectal Cancer Following Neoadjuvant Chemoradiation Therapy – Risk Factors and Outcomes Marcelo B. Linhares, Angelita Habr-Gama, Rodrigo O. Perez, Afonso H. Sousa, Fabio G. Campos, Igor G. Proscurshim, Desiderio R. Kiss, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil M1422 Intraoperative Radiotherapy for Oncological and Function Preserving Surgery in Patients with Advanced Lower Rectal Cancer – Preliminary Report of Prospective Randomized Trial Tadahiko Masaki1, Makoto Takayama2, Hiroyoshi Matsuoka1, Nobutsugu Abe1, Hisayo Ueki1, Masanori Sugiyama1, Ayako Tonari2, Junko Kusuda2, Shinsaku Mizumoto3, Yutaka Atomi1; 1Surgery, Kyorin University, Mitaka, Japan; 2Radiation Oncology, Kyorin University, Mitaka, Japan; 3Karasuyama Clinic for Anorectal and Urological Diseases, Setagaya, Japan M1423 Mechanical Bowel Preparation Inﬂuences the Outcomes of Elective Colorectal Resection with Primary Anastomosis by a Single Surgeon: Intermediate Analysis of a Prospective Single-Blinded Randomized Trial Maria Jesus Pena-Soria, Julio M. Mayol, Rocio Anula, ANA Arbeo- Escolar, Jesus A. Fernandez-Represa; Servicio de Cirugia I, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Madrid, Spain M1425 Laparoscopic Resection for Rectal Cancer: A Prospective Evaluation in 107 Consecutive Patients Marco Montorsi1, Paolo P. Bianchi1, Riccardo Rosati2, Chiara Ceriani1, Stefano Bona2, Matteo Rottoli1, Ugo Elmore2; 1General Surgery. University of Milano, Istituto Clinico Humanitas IRCCS, Rozzano (Milano), Italy; 2Minimally Invasive Surgery, Istituto Clinico Humanitas IRCCS, Rozzano (Milano), Italy

54 SSAT.book Page 55 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1426 Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis (IPAA): Is There a Volume-Outcomes Effect? John Morton, Andrew Shelton, Mark Welton; Surgery, Stanford University, Stanford, CA M1427 Emergency Laparoscopic Versus Open Right Hemicolectomy for Obstructing Right-Sided Colonic Carcinoma: A Comparative Study Simon S. Ng, Janet Lee, Raymond Yiu, Jimmy Li, Ka Lau Leung, Enders Ng; Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong M1428 Laparoscopic Colorectal Surgery in Patients with Major

Pulmonary Co-Morbidities SESSION POSTER Ikenna C. Okereke, Daniel P. Geisler, Thomas E. Garofalo, Feza H. Remzi, Luca Stocchi, Jon D. Vogel, Elena Manilich, Victor W. Fazio; Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Heights, OH M1429 Lymph Node Retrieval After Surgery for N0 Distal Rectal Cancer: Is There a Critical Number of Lymph Nodes to Be Recovered After Neoadjuvant Chemoradiation Therapy? Rodrigo O. Perez, Angelita Habr-Gama, Igor Proscurshim, Afonso H. Sousa, Fabio G. Campos, Jose M. Jorge, Desiderio R. Kiss, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil M1430 Laparoscopic Colorectal Resections: A Single Center Experience Silvana Perretta2, Roberto Campagnacci1, Mario Guerrieri1, Angelo De Sanctis1, Maddalena Baldarelli1, Giovanni Lezoche2, Emanuele Lezoche2; 1Clinica di Chirurgia Generale e Metodologia Chirurgica, University of Ancona, Ancona, Italy; 2Department of Surgery, Paride Stefanini, Universita La Sapienza, Roma, Italy M1431 Local Immunosuppression After Neoadjuvant Chemoradiation Therapy May Result in Loss of the Protective Role of Peritumoral Inﬂammatory Response Igor Proscurshim1, Rodrigo O. Perez1, Rafael M. Santos1, Kleiton R. Yamacake1, Viviane Rawet2, Fabio G. Campos1, Desiderio R. Kiss1, Angelita Habr-Gama1; 1Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Esophageal

56 SSAT.book Page 57 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1440 Generation of a Mathematical Model to Predict the SESSION POSTER Probability of Achalasia from Non-Manometric Findings Lorenzo E. Ferri1,3, Gail Darling2, Linda Miller2, Gerald M. Fried3; 1Thoracic Surgery, McGill University, Montreal, QC, Canada; 2Thoracic Surgery, University of Toronto, Toronto, ON, Canada; 3General Surgery, McGill University, Montreal, QC, Canada M1441 Results of Conventional Heller Myotomy in Patients with Achalasia: A Prospective 20-Year Analysis Ines Gockel1, Theodor Junginger1, Volker F. Eckardt2; 1Department of General and Abdominal Surgery, Johannes Gutenberg University of Mainz, Mainz, Germany; 2Department of Gastroenterology, German Diagnostic Clinic, Wiesbaden, Germany M1442 Skip Metastasis in Oesophageal Carcinoma: Incidence and Prognostic Value Stephanie J. Gros1, Dean Bogoevski1, Florian Onken1, Bjoern C. Link1, Michale Bubenheim2, Lars Wolfram1, Uta Reichelt3, Oliver Mann1, Philipp Busch1, Emre F. Yekebas1, Jakob R. Izbicki1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute for Medical Biometry and Epidemiology, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 3Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany M1443 Overexpression in KI67 Proliferative Activity Could Be Associated with P53 Molecular Changes in GERD – Metaplasia – Adenocarcinoma Sequence Marcelo Binato1, Renato Fagundes1, Maria I. Edelweiss2, Luise Meurer2, Richard R. Gurski2; 1Cirurgia, UFSM, Santa Maria, Brazil; 2Cirurgia, UFRGS, Porto Alegre, Brazil

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1444 Esophagectomy After Cardiac Surgery Karen Harrison-Phipps, Stephen D. Cassivi, Mark S. Allen, Frank C. Nichols, Peter C. Pairolero, Claude Deschamps; General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN +M1445 Does Reflux Height Matter? A Study of 1680 Patients Guilherme M. Campos1, Fernando Herbella1, Ian Nipomnick1, Marco Patti1, Eric Vittinghoff2; 1Surgery, University of California, San Francisco, San Francisco, CA; 2Epidemiology, University of California, San Francisco, San Francisco, CA M1446 Primary Versus Secondary Esophageal Motility Disorders: Diagnosis and Implications for Treatment Fernando A. Herbella, Ian Nipomnick, Pietro Tedesco, Marco G. Patti; Department of Surgery, University of California, San Francisco, San Francisco, CA M1447 Combined Transabdominal Gastroplasty and Fundoplication for Short Esophagus: Impact on Reflux-Related and Overall Quality of Life Scott G. Houghton1, Claude Deschamps1, Stephen D. Cassivi1, Mark S. Allen1, Francis C. Nichols1, Sunni A. Barnes2, Peter C. Pairolero1; 1Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN; 2Department of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN M1448 A Four-Point Multidisciplinary Hospital-Wide Strategy of Preemptive Aspiration Precautions to Prevent Pneumonia and Mortality After Esophagectomy Tracey Weigel1,2, Anna R. Ibele1,2, Joanna Hwang4, Joanne Robbins3; 1Thoracic Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI; 2General Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI; 3Geriatric Research Education and Clinical Center, William S. Middleton Vetrans Hospital, Madison, WI; 4Otolaryngology, University of Wisconsin Hospitals and Clinics, Madison, WI M1449 Clinical Significance of SUMO-1 in Esophageal Squamous Cell Carcinoma Yoshio Ishibashi1, Yutaka Suzuki1, Hideyuki Kashiwagi1, Nobuyoshi Hanyu1, Koji Nakada1, Nobuo Omura1, Naruo Kawasaki1, Koji Takada2, Mitsuyoshi Urashima3, Katsuhiko Yanaga1; 1Surgery, Jikei University Shool of Medicine, Tokyo, Japan; 2Biochemistry, Jikei University School of Medicine, Tokyo, Japan; 3Division of Clinical Research and Development, Jikei University School of Medicine, Tokyo, Japan

+ Poster of Distinction

58 SSAT.book Page 59 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1450 Incidence and Determinants of Surgery for Gastroesophageal Reﬂux Disease in Ontario, Canada Steven R. Lopushinsky, David R. Urbach; University of Toronto, Toronto, ON, Canada M1451 Patterns of Reﬂux After Successful Nissen Fundoplication Renee C. Minjarez, Eugene Y. Chang, Charles Y. Kim, John G. Hunter, Blair A. Jobe; Department of Surgery, Oregon Health and Science University, Portland, OR M1453 Preliminary Experience by a Thoracic Service with Endoscopic Trans-Oral Stapling of Cervical (Zenker’s)

Diverticulum SESSION POSTER Christopher R. Morse1, Hiran C. Fernando2, Peter F. Ferson3, Rodney J. Landreneau3, Miguel F. Alvelo-Rivera3, James D. Luketich3; 1Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA; 2Division of Cardiothoracic Surgery, Boston Medical Center, Boston, MA; 3Division of Thoracic & Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA M1454 Outcome of Survival Following Surgery for Oesophago- Gastric Cancer Does Not Depend on Pre-Operative Chemotherapy Alone Dhiren Nehra, Sarah Wemyss; Upper GI Surgery, Epsom & St. Helier University Hospital, Carshalton, United Kingdom M1456 Evaluation of the Gastric Tube Viability After Esophagectomy by Its Diameter Using Thermal Imaging Katsunori Nishikawa, Yuujirou Tanaka, Tetsuya Yamagata, Hideki Matsudaira, Hideyuki Suzuki, Ryouji Mizuno, Nobuyoshi Hanyuu, Shuuichi Iwabuchi; Surgery, Machida Municipal Hospital, Machida-shi, Japan M1457 Clinical Failure of Laparoscopic Nissen Fundoplication: Relationship to Anatomic and Functional Findings Marco Aurelio, Cedric G. Bremner, Daniel S. Oh, Christy M. Dunst, Jeffrey A. Hagen, Steven R. Demeester, John C. Lipham, Tom R. Demeester; Surgery, University of Southern California, Los Angeles, CA M1458 Predictors of Anatomic Recurrence After Paraesophageal Hernia Repair: The Importance of the Learning Curve Allan Okrainec, Lorenzo S. Ferri, Liane S. Feldman, Gerald F. Fried; Steinberg-Bernstein Centre for Minimally Invasive Surgery, Mcgill University, Montreal, QC, Canada

59 SSAT.book Page 60 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1459 48-Hour pH Monitoring Increases Risk of False Positive Studies When the Capsule Is Passed Victor Bochkarev, Chad D. Ringley, Michelle Vitamvas, Dmitry Oleynikov; Surgery, UNMC, Omaha, NE M1460 Thoraco-Laparoscopic Esophagectomy for Carcinoma Esophagus Middle Third (Thoracoscopic Mobilization in Prone Position) Chinnuswamy Palaninvelu, Palanisamy Senthilnathan, Ramakrishnan Parthasarathi, Rangswamy Senthilkumar; Department of Surgical gastroenterology & Minimal Access Surgery, GEM Hospital India Pvt Limited, Coimbatore, India M1461 Should Laparoscopic Heller Myotomy Be Used as Primary Therapy for Achalasia Regardless of Age? Christian G. Peyre, Colleen B. Gaughan, Jeffrey A. Hagen, Brendan J. Boland, Christian Rizzetto, Steven R. Demeester, Cedric G. Bremner, John C. Lipham, Tom R. Demeester; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA M1462 Impedance/pH Monitoring: the Importance of Nonacid Pharyngeal Reﬂux in Reﬂux Laryngitis Elina Quiroga1, Nicole Maronian2, Jim Sillery1, Brant Oelschlager1; 1The Swallowing Center Department of Surgery, University of Washington, Seattle, WA; 2Otolaryngology, University of Washington, Seattle, WA M1463 Age Does Not Affect the Long-Term Outcome of Heller-Dor Operation Christian Rizzetto, Mario Costantini, Giuseppe Portale, Emanuela Guirroli, Martina Ceolin, Loredana Nicoletti, Renato Salvador, Sabrina Rampado, Giovanni Zaninotto; Clinica Chirurgica III, University of Padua, Padova, Italy M1464 Esophagectomy for Adenocarcinoma in the Elderly Christian Rizzetto, Cedric Bremner, Jeffrey A. Hagen, Steve R. Demeester, John C. Lipham, Colleen Gaughan, Christian Peyre, Brendan Boland, Daniel Oh, Tom R. Demeester; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA M1466 Normal Lower Esophageal Sphincter Function Does Not Impact Outcome After Laparoscopic Nissen Fundoplication Alexander S. Rosemurgy, Sam Al-Saadi, Desiree Villadolid, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL

60 SSAT.book Page 61 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1467 Clinicopathological and Molecular Characterization of Gastroesophageal Junction (GEJ) Adenocarcinoma Before Age of 40 Years Alberto Ruffato1, Laura H. Tang2, Manjit S. Bains1, Robert J. Downey1, Raja Flores1, Bernard J. Park1, Nabil Rizk1, Valerie W. Rusch1, Murray Brennan1, Daniel Coit1, Yuman Fong1, David Jaques1, David Klimstra2; 1Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 2Pathology, Memorial Sloan Kettering Cancer Center, New York, NY; 3Medicine Solid Tumors, Memorial Sloan Kettering Cancer Center, New York, NY M1468 Increased Formation of Oxidative DNA Damage, 8-Hydroxydeoxyguanosine, in Barrett’s Esophagus, SESSION and in Adenocarcinoma of the Esophagus and POSTER Esophagogastric Junction Jari V. Rasanen1, Eero I. Sihvo1, Markku O. Ahotupa2, Martti A. Farkkila3, Jarmo A. Salo1; 1Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2Research Laboratory Department of Physiology, University of Turku, Turku, Finland; 3Department of Medicine, Division of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland M1469 Role of Diagnostic Video-Laparoscopy Prior to Neoadjuvant Treatment in Esophageal Adenocarcinomas Compared to Gastric Cancers Paul M. Schneider1, Ralf Metzger1, Stephan E. Baldus2, Stefan P. Moenig1, Daniel Vallboehmer1, Jan Brabender1, Hans P. Dienes2, Arnulf H. Hoelscher1; 1Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany; 2Institute of Pathology, University of Cologne, Cologne, Germany M1470 Long-Term (6 Year) Outcome of Laparoscopic Nissen and Toupet Fundoplication John M. Shaw1, P C. Bornman1, M D. Callanan1, D.C. Metz2; 1Surgical Gastroenterology, University of Cape Town, Cape Town, South Africa; 2Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA M1471 Clavicle Lifting Strategy in Radical Three Field Lymphadenectomy Improved Survival of Patients with Esophageal Cancer Yutaka Suzuki, Hiroaki Aoki, Naruo Kawasaki, Nobuo Omura, Yoshio Ishibashi, Kouzi Nakata, Hideyuki Kashiwagi, Nobuyoshi Hanyu, Katuhiko Yanaga; Surgery, The Jikei University School of Medicine, Tokyo, Japan

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Clinical: Hepatic

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Prognostic Factors for Survival SESSION POSTER Andrea Ruzzenente, Marco Sandri, Calogero Iacono, Silvia Pachera, Corrado Pedrazzani, Sebastiano Tasselli, Alfredo Guglielmi; Surgery and Gastroenterology, University of Verona, Verona, Italy M1486 Telomerase Activity in Tumor and Remnant Liver as Predictor for Recurrence and Survival in Hepatocellular Carcinoma After Resection Yan-Shen Shan1, Yu-Hsiang Hsieh2, Pin-Wen Lin1; 1Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan; 2Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD

Clinical: Pancreas

+ Poster of Distinction

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M1489 The Current Role of Surgical Resection and Cytoreduction in the Treatment of Pancreatic Neuroendocrine (NE) Tumors Mark Bloomston1, Osama Al-Saif1, Peter Muscarella1, W. Scott Melvin1, Edward W. Martin1, Manisha Shah3, Wendy L. Frankel2, E. Christopher Ellison1; 1Surgery, Ohio State University, Columbus, OH; 2Pathology, Ohio State University, Columbus, OH; 3Medicine, Ohio State University, Columbus, OH M1490 Increased Serum Levels of IgE and Soluble CD23 in Patients with Pancreatic Cancer Martin H. Bluth1, Joelle Pierre1, Michael Hagler1, Cathy M. Mueller1, Tamar A. Smith-Norowitz2, Michael E. Zenilman1; 1Surgery, SUNY Downstate Medical Center, Brooklyn, NY; 2Pediatrics, SUNY Downstate Medical Center, Brooklyn, NY M1491 PKC 412 – A Pan-Antiangiogenic Compound from Bench to Bedside Peter Buechler, Jamael El-Fitori, Yun Su, Klaus Felix, Markus W. Buechler, Helmut Friess; General Surgery, University of Heidelberg, Heidelberg, Germany M1492 Comparison of Clinical Aspects Between Biliary and Alcoholic Acute Pancreatitis: Lipase and Fluid Replacement Can Make a Difference in the Initial Approach of Alcoholic Patients Tercio De Campos, Laise Kuryura, Paulo Furbetta, Jose Cesar Assef, Samir Rasslan; Surgery, Santa Casa School of Medical Sciences, Sao Paulo, Brazil M1493 Complications Management Due to Catastrophic Endoluminal Bleeding After Major Pancreatic Surgery Guellue Cataldegirmen1, Emre F. Yekebas1, Lars Wolfram1, Dean Bogoevski1, Yogesh Vashist1, Bjoern C. Link1, Oliver Mann1, Lena Liebl1, Gerhard Adam2, Gerrit Krupski2, Jakob R. Izbicki1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Diagnostic and interventional Radiology, University Clinic Hamburg-Eppendorf, Hamburg, Germany M1494 Do p16, p53, or MUC4 Mutations Affect Outcomes After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma? John D. Christein1, Ruth R. Leeth1, Rashmi K. Murthy1, Martin Heslin1, Nirag C. Jhala2, Juan P. Arnoletti1, Selwyn M. Vickers1; 1Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Pathology, University of Alabama at Birmingham, Birmingham, AL

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1495 Is Total Pancreatectomy (TP) Safe and Reasonable? Olivier Corcos1, Alain Sauvanet2, Anne Couvelard3, Olivier Farges2, Vinciane Rebours1, Pascal Hammel1, Philippe Levy1, Jacques Belghiti2, Philippe Ruszniewski1; 1Service de Gastroenterologie, Hopital Beaujon, Clichy, France; 2Service de Chirurgie Digestive, Hopital Beaujon, Clichy, France; 3Service D’anatomopathologie, Hopital Beaujon, Clichy, France M1496 When Is Resectable Pancreas Cancer Really Resectable? Matthew J. D’Alessio1, Ivan Parra1, Douglas M. Potter2, Kevin M. Mcgrath3, Herbert J. Zeh1, David L. Bartlett1, Kenneth K. Lee1, Arthur J. Moser1; 1Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Biostatistics, Univerisity of Pittsburgh Cancer Institute, Pittsburgh, PA; 3Gastroenterology, University of SESSION Pittsburgh Medical Center, Pittsburgh, PA POSTER +M1497 A Prospective Evaluation of an Algorithm Incorporating Routine Pre-Operative Endoscopic Ultrasound-Guided Fine Needle Aspiration in Suspected Pancreatic Cancer Patients Mohamad Eloubeidi1, Shyam Varadarajulu1, Shilpa Desai1, Rhett Shirley1, Martin Heslin2, Mohit Mehra1, Juan P. Arnoletti2, Isam Eltoum3, C. Mel Wilcox1, Selwyn Vickers2; 1Gastroenterology and Hepatology, University of Alabama at Birmigham, Birmingham, AL; 2Surgery, University of Alabama, Birmingham, AL; 3Pathology, University of Alabama, Birmingham, AL M1498 The Inﬂuence of Positive Peritoneal Cytology on Survival in Patients with Pancreatic Adenocarcinoma Cristina R. Ferrone1, Peter J. Allen1, David P. Jaques1, Daniel G. Coit1, Barbara Haas2, Yuman Fong1, Murray F. Brennan1; 1Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; 2Surgery, McGill University, Montreal, QC, Canada M1499 Ischemic Preconditioning Improves Postoperative Liver Function, Following Resection of the Superior Mesenteric-Portal Vein for Pancreatic Adenocarcinoma Craig P. Fischer; Surgery, The Methodist Hospital/Cornell Weill School of Medicine, Houston, TX

+ Poster of Distinction

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

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M1512 Long Term Follow-Up of Patients Who Survive an Episode of Acute Necrotizing Pancreatitis (ANP) William H. Nealon, Taylor S. Riall; Surgery, University of Texas medical Branch, Galveston, TX M1513 Laparoscopic Pancreaticoduodenectomy – A Single Centre Experience of 35 Cases Chinnuswamy Palaninvelu, Palanisamy Senthilnathan, S. Rajapandian, P.S. Rajan; Department of Surgical Gastroenterology & Minimal Access Surgery, GEM Hospital India Pvt Limited, Coimbatore, India M1514 Endoscopic and Surgical Management of Pancreatitis in Pancreas Divisum Anand C. Patel, Maurice E. Arregui; Surgery, St. Vincent Hospital, Indianapolis, IN M1515 Enucleation of Endocrine Pancreatic Tumors: 25-Year Experience Sergio Pedrazzoli1, Claudio Pasquali1, Cosimo Sperti1, Sabrina Scappin1, Paola Baratella1, Guido Liessi2; 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Department of Radiology, Castelfranco Veneto Hospital, Castelfranco Veneto (TV), Italy M1516 Conservative Treatment of Postoperative Pancreatic Fistulas Sergio Pedrazzoli1, Claudio Pasquali1, Cosimo Sperti1, Sabrina Scappin1, Guido Liessi2; 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Department of Radiology, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy M1517 Establishing Standards of Quality for Elderly Patients Undergoing Pancreaticoduodenectomy Wande Pratt, Tsafrir Vanounou, Shishir Maithel, Charles M. Vollmer, Mark P. Callery; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA M1518 Drain Amylase Levels Following Pancreatico- duodenectomy for Cancer: Correlation with Outcomes and Proposal for a Uniform Grading System H. Ramesh, Sadiq S. Sikora; Lakeshore Hospital & Research Center, Cochin, India

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1519 Reduction in Pancreatic Leak Following Distal Pancreatectomy – A Novel Technique Utilizing an Autologous Falciform Patch Jose Ruben Rodriguez, Andres Oswaldo Razo, Jennifer A. Wargo, Sarah P. Thayer, Andrew L. Warshaw, Carlos Fernandez Del-Castillo; General Surgery, Massachusetts General Hospital, Boston, MA M1520 Long-Term Outcome After Distal Pancreatectomy for Chronic Pancreatitis Thomas Schnelldorfer1, Joshua M. Hubbard1, David N. Lewin2, David B. Adams1; 1Department of Surgery, Medical University of South Carolina, Charleston, SC; 2Department of Pathology, Medical University of South Carolina, Charleston, SC SESSION POSTER M1521 Durability of Portal Venous Reconstruction Following Resection During Pancreaticoduodenectomy Rory Smoot1, John Christein2, Michael Farnell1; 1Surgery, Mayo Clinic, Rochester, MN; 2Surgery, Univerisity of Alabama Birmingham, Birmingham, AL M1522 Aggressive Pancreatic Resection for Benign and Malignant Pancreatic Neuroendocrine Tumors: Is It Justiﬁable? Swee H. Teh, John G. Hunter, Brett C. Sheppard; Department of Surgery, Oregon Health & Science University, Portland, OR M1523 Tissuelink™ Decreases Pancreatic Complications After Distal Pancreatectomy in a Porcine Model Mark J. Truty1, Florencia G. Que1, Sunni A. Barnes2, Lawrence J. Burgart3; 1Surgery, Mayo Clinic, Rochester, MN; 2Biostatistics, Mayo Clinic, Rochester, MN; 3Pathology, Mayo Clinic, Rochester, MN M1524 Predictive Factor for Malignant Branch Duct Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas: Can Clinical Symptoms and Morphological Features Predict the Malignancy? Kenichiro Uemura1, Yoshiaki Murakami1, Yasuo Hayashidani1, Takeshi Sudo1, Yasushi Hashimoto1, Tamito Sasaki2, Taijiro Sueda1; 1Surgery, Hiroshima University, Hiroshima, Japan; 2Gastroenterology, Hiroshima University, Hiroshima, Japan

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Clinical: Small Bowel

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1531 Internal Hernias: Clinical Findings, Management, and Outcomes in 49 Nonbariatric Cases Saber Ghiassi, Scott Nguyen, Avraham Schlager, Celia Divino, John Byrn; Department of Surgery, Mt. Sinai Medical Center, New York, NY M1532 Gastrointestinal Stromal Tumors (GIST) of the Small Bowel: High-Risk Pathologic Features Predict the Need for Adjuvant Therapy Imran Hassan1, Yi-Qian N. You1, Roman Shyyan2, Eric J. Dozois1, Scott H. Okuno3, Thomas C. Smyrk4, John H. Donohue2; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 3Department of Medical Oncology, Mayo Clinic, Rochester, MN; SESSION 4Division of Anatomic and Surgical Pathology, Mayo Clinic, Rochester, MN POSTER M1533 Influence of Postoperative Complications on Long-Term Quality of Life in Patients Undergoing Abdominal Surgery for Crohn’s Disease Michael S. Kasparek1, Joerg Glatzle1, Andreas Schneider1, Mario H. Mueller2, Alfred Koenigsrainer1, Martin E. Kreis2; 1Department of General Surgery, Eberhard-Karls-University Tuebingen, Tuebingen, Germany; 2Department of Surgery, Ludwig-Maximilian’s-University Munich, Munich, Germany M1534 Effectiveness of Diagnostic Paracentesis for Suspected Strangulation Obstruction Shin Kobayashi1, Kenji Matsuura2, Kazuhide Matsushima2; 1Surgery, Okinawa Yaeyama Hospital, Ishigaki, Japan; 2Surgery, Okinawa Chubu Hospital, Okinawa, Japan M1535 Clostridium Difficile Enteritis: An Early Post-Operative Complication in IBD Patients Following Colectomy Sarah J. Lundeen1, Mary F. Otterson1, Gordon L. Telford1, David G. Binion2, William J. Peppard3; 1Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; 2Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; 3Froedtert Memorial Lutheran Hospital, Milwaukee, WI M1536 Long-Term Outcomes of the Modified Rives-Stoppa Repair in 254 Complex Incisional Hernias Tuan H. Pham, Corey W. Iqbal, Antony Joseph, Jane L. Mai, Geoffrey B. Thompson, Michael G. Sarr; Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN

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M1537 Trends and Predictors for Vagotomy When Performing Oversew of Acute Bleeding Duodenal Ulcer in the United States Brian Reuben, Greg Stoddard, Robert Glasgow, Leigh Neumayer; General Surgery, University of Utah, Salt Lake City, UT M1538 Effect of Alvimopan on Gastrointestinal (GI) Recovery Following Small Bowel Resection (SBR) in Patients With and Without Crohn’s Disease (CD): Results of a Pooled Analysis of 3 Randomized, Placebo-Controlled Trials Bruce Wolff1, Eugene Viscusi2, Conor Delaney3, Wei Du4, John G. Fort4, Lee Techner4; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Department of Anesthesiology, Jefferson Medical College, Philadelphia, PA; 3Division of Colorectal Surgery, University Hospitals of Cleveland, Cleveland, OH; 4Adolor Corporation, Exton, PA M1539 Crohn’s Disease: A Patient’s Perspective Massarat Zutshi1, Tracy Hull1, Jeffery Hammel2; 1Colorectal Surgery A-30, Cleveland Clinic, Cleveland, OH; 2Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, OH

Clinical: Stomach

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1545 Laparoscopic and Endogastric Resection for Gastric SESSION POSTER Stromal Tumors – A Group’s Initial Experience Claudio Bresciani, Rodrigo O. Perez, Carlos E. Jacob, Roger Coser, Igor Proscurshim, Bruno Zilberstein, Ivam Cecconello, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil M1546 Effect of Splenectomy on the Survival of Patients Undergoing Curative Total Gastrectomy for Proximal Gastric Cancer Yeon Soo Chang, Se Keon Oh, Kil Yeon Lee, Suk-Hwan Lee, Choong Yoon; Department of Surgery, Kyung Hee University Hospital, Seoul, South Korea M1547 Prevalence of Metabolic Bone Disorders After Radical Gastrectomy for Carcinoma of Stomach Frances K. Cheung, Sheung-Wai Law, Nelson Tang, Wt Siu, Philip Chiu, Lm Mui, Sf Hon, Candice Lam, Bonnie Tsung, Enders Ng; The Chinese University of Hong Kong, Hong Kong, Hong Kong M1548 Secondary Esophageal Peristalsis in Gastric Banding Patients Ruxandra Ciovica, Michael Gadenstatter, Gerhard P. Schwab, Wolfgang Lechner; Department of Surgery, General Hospital of Krems, Krems, Austria M1549 Bariatric Surgery at the Extremes of Age Javairiah Fatima, Scott G. Houghton, Jane L. Mai, Corey W. Iqbal, Geoffrey B. Thompson, Florencia G. Que, Michael L. Kendrick, Michael G. Sarr; Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN

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M1550 Tsunami Medical Relief in Rural Aceh: Role of the General Surgery Resident Eric J. Hanly, Hannah Bell, Tena Bell, Andrew Bell, Lee Jacobs; Surgery, Johns Hopkins, Baltimore, MD M1551 Laparoscopic Sleeve Gastrectomy Is an Effective Primary Procedure for Morbid Obesity Thomas Hirai1, Hazem A. Elariny1, Howard D. Reines1, Michael Sheridan2, Oscar Chan1; 1Surgery, Inova Fairfax Hospital, Falls Church, VA; 2Medicine, Inova Fairfax Hospital, Falls Church, VA M1552 Incidence, Risk Factors, and Outcomes for Incisional Hernias After Open Gastric Bypass Surgery Michael G. House, Michael A. Schweitzer, Thomas H. Magnuson; Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD M1553 Irinotecan Combined with S-1 for Advanced Gastric Cancer – Results of Phase II Study and Gene Expressions Mikito Inokuchi, Kazuyuki Kojima, Hiroyuki Yamada, Mikiko Hayashi, Kenichi Sugihara; Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan M1555 Gastric Adenocarcinoma: Clinico-Pathological Characteristics in Young Patients Carlos E. Jacob, Claudio J. Bresciani, Bruno Zilberstein, Rodrigo Perez, Rafael Santos, Igor Proscurshim, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil M1556 Clinicopathologic and Immunohistochemistry Characterization of Multiple Primary Gastric Adenocarcinoma Uana M. Jorge1, Ulysses Ribeiro Junior1, Adriana V. Safatle-Ribeiro1, Donato Mucerino1, Osmar K. Yagi1, Natalia M. Felicio1, Cristovam Scapulatempo2, Edwin R. Parra1, Carlos E. Corbett2, Venancio A. Alves2, Bruno Zilberstein1, Joaquim J. Gama-Rodrigues1; 1Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo, Sao Paulo, Brazil M1557 Endoscopic Management of Anastomotic Stricture Following Roux-en-Y Gastric Bypass for Morbid Obesity George B. Kazantsev, Ajay K. Upadhyay, Rakhee N. Shah, Steven A. Stanten, Arthur Stanten, Roupert Horupian; Surgery, Alta Bates Summit Medical Center, Oakland, CA M1558 Predicting Stricture in Post-Gastric Bypass Patients Jennefer A. Kieran, Amy J. Koler, Melissa M. Davis, Robin P. Blackstone; Surgery, Scottsdale Bariatric Center, Scottsdale, AZ

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

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M1566 Laparoscopic Surgical Treatment of Type II Diabetes Mellitus for Patients with BMI Between 22–35 Aureo L. De Paula1, Antonio L. Macedo2, Alfredo Halpern2, Nelson Hassi1, Vladimir Schraibman2; 1Surgery, Hospital de Especialidades de Goiania, Goiania, Brazil; 2General Surgery, Albert Einstein Hospital, Sao Paulo, Brazil M1567 “Redo” Fundoplications Are Effective Treatment for Dysphagia and Recurrent Gastroesophageal Reﬂux Alexander S. Rosemurgy, Kerry Thomas, Dean Arnaoutakis, Desiree Villadolid, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL M1568 What to Expect in the Excluded Stomach Mucosa After Vertical Banded Gastroplasty – Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro1, Rogerio Kuga1, Robson K. Ishida1, Ulysses Ribeiro1, Faintuch Joel1, Kyoshi Iriya2, Carlos E. Corbett2, Thaise Y. Tomokani2, Bruno Zilberstein1, Joaquim J. Gama-Rodrigues1, Shinichi Ishioka1, Paulo Sakai1; 1Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo, Sao Paulo, Brazil M1569 Gastric Electrical Stimulation for Gastroparesis: Experience with Higher Settings Thomas Schnelldorfer1, Thomas L. Abell2, Vicki M. Limehouse3, Christopher J. Lahr1; 1Department of Surgery, Medical University of South Carolina, Charleston, SC; 2Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; 3Bon Secours St. Francis Hospital, Charleston, SC +M1570 Microsatellite DNA Alterations of Gastro-Intestinal Stromal Tumors Are Predictive for Outcome Paulus G. Schurr1, Stefan Wolter1, Jussuf Kaiﬁ1, Uta Reichelt2, Helge Kleinhans1, Robin Wachowiak1, Emre Yekebas1, Tim Strate1, Viacheslav Kalinin1, Hansjoerg Schaefer1, Izbicki Jakob1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg, Hamburg, Germany; 2Department of Pathology, University Medical Center Hamburg, Hamburg, Germany M1571 Laparoscopic Wedge Resection of Gastric Stromal Tumors Wing Tai Siu1,2, Kwok Kay Yau2, Chung Ngai Tang2, Philip Wai Yan Chiu1, Lik Man Mui1, Frances Ka Yin Cheung1, Michael Ka Wah Li2, Enders Kwok Wai Ng1; 1Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong

+ Poster of Distinction

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1572 Laparoscopic Repair for Perforated Peptic Ulcer Wing Tai Siu1,2, Kwok Kay Yau2, Chung Ngai Tang2, Ping Yiu HA2, Philip Wai Yan Chiu1, Enders Kwok Wai Ng1, Michael Ka Wah Li2; 1Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong M1573 Gastric Adenocarcinoma: Reduction of Perioperative Mortality by Avoidance of Nontherapeutic Laparotomy Brian R. Smith, Bruce E. Stabile; Surgery, Harbor-UCLA Med Ctr, Torrance, CA M1574 Does the Position of the Alimentary Limb in Roux-en-Y Gastric Bypass Surgery Make a Difference? I. Michael Leitman, Jerome D. Taylor, James (Butch) Rosser, Brian R. Davis, SESSION POSTER Elliot Goodman; Surgery, Beth Israel Medical Center, New York, NY M1575 Gastric Bypass Does Not Influence Olfactory Function Jon S. Thompson, Brynn Richardson, Eric Vander Woude, Ranjan Sudan, Donald Leopold; Surgery, University of Nebraska Medical Center, Omaha, NE M1576 Current Strategy for Treatment of Perforated Gastric Ulcer (PGU) and Duodenal Ulcer (PDU): Can Computed Tomography (CT) Really Diagnose Perforating Site? Tatsuya Ueno, Hiroo Naito, Michinaga Takahashi, Akihiro Kanno, Shinji Goto, Munenori Nagao; Surgery, South Miyagi Medical Center, Miyagi-Pref, Japan M1577 Results of a Randomized, Prospective Trial Comparing Residual Stomach, Duodenum and Uncut Jejunal Interposition (Gastrojejunoduodenostomy) to Standard Billroth-II Reconstruction After Subtotal Gastrectomy for Distal Gastric Cancer Qin Zhang1,2, Mark S. Talamonti2, Zaiyuan Ye3, Hongqi Shi4, Jianfa Yu1; 1Gastrointestinal Surgery, Affilliated Hospital of Zhejiang College of Traditional Chinese Medicine, Hangzhou, China; 2Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Department of Surgery, Zhejiang Provincial People Hospital, Hangzhou, China; 4Department of Surgery, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

SSAT ORAL, VIDEO, AND POSTERS OF DISTINCTION ABSTRACTS

Printed as submitted by the authors.

MONDAY, MAY 22, 2006

8:15 AM – 9:15 AM PRESIDENTIAL PLENARY SESSION 403 A Moderator: Robert V. Stephens, Phoenix, AZ 256 A Randomized Controlled Trial of Laparoscopic Nissen Fundoplication (LNF) Versus Proton Pump Inhibitors ABSTRACTS for Treatment of Patients with Chronic Gastro- MONDAY Esophageal Reflux Disease (GERD) Mehran Anvari1, Christopher J. Allen2, ELVIS Research Group3; 1Surgery, McMaster University, Hamilton, ON, Canada; 2Medicine, McMaster University, Hamilton, ON, Canada; 3McMaster University, Hamilton, ON, Canada BACKGROUND: In patients with GERD who were stable and symptomati- cally controlled on long-term medical therapy we performed an RCT to compare ongoing optimized medical therapy with laparoscopic Nissen fundoplication (LNF). METHODS: The entry criteria were; (1) Males or females 18–70 years with chronic symptoms of GERD requiring long-term therapy, (2) Prior long-term treatment with PPI with minimum duration of one year with expected future duration of at least two more years (3) Symptoms controlled prior to study, defined as GERD Symptom score < 18 (without cough) and score of 70 or more on 1–100 Global Rating Scale (GRS) at screening (on medication), (4) Percent acid reflux in 24 hr > 4% at baseline (off medication). 201 patients were eligible for randomization, 104 gave informed consent (mean age 42.4 ± 1.07 male 56 female 48). Patients randomized to medical therapy received optimized treatment with PPI using a standardized management protocol based on best evidence and published guidelines. Surgical patients underwent LNF by four surgeons using previously published technique. Patients underwent symptom evaluation every 3 months using a published and validated instrument and 24 hour pH testing after 1 year. RESULTS: 98 patients were available for follow up, and both medical and surgical patients improved significantly with regard to both 24 hour pH (medical p = 0.0204, surgical p < 0.0001), GERD symptoms (both groups p < 0.0001). The overall symptom control score (GRS) at one year was unchanged

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compared to baseline in the medical patients (p = 0.084) but improved in the surgical patients (p < 0.0001). When the changes in the medical and the surgical patients were compared using repeated measures ANOVA there was no signiﬁcant difference between the groups in improvement in pH (p = 0.2723) but the surgical patients had a signiﬁcantly greater improvement in symptom scores (p < 0.0001). CONCLUSIONS: Patients controlled on long term PPI therapy for chronic GERD are excellent surgical candidates and should experience improved symptom control after surgery.

Improvement: Medical Surgical Surg vs Med Initial (off PPI) 1 Year (on PPI) Initial (off PPI) 1 Year (off PPI) p % pH < 4 9.30 ± 0.78 5.44 ± 1.57 10.26 ± 1.63 1.50 ± 0.57 0.2723 GERD Score 29.48 ± 1.97 12.82 ± 1.60 30.82 ± 1.52 8.46 ± 1.23 < 0.0001 GRS 82.5 ± 1.55 (on PPI) 73.3 ± 3.43 81.5 ± 1.84 90.2 ± 2.04 < 0.0001

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

257 Hospital Readmission Following Pancreaticoduodenectomy Dawn M. Emick1, Taylor S. Riall2, John L. Cameron1, Jordan M. Winter1, Keith D. Lillemoe3, JoAnn Coleman1, Patricia K. Sauter1, Charles J. Yeo4; 1Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD; 2Surgery, University of Texas Medical Branch, Galveston, TX; 3Surgery, Indiana University, Indianapolis, IN; 4Surgery, Jefferson University, Philadelphia, PA BACKGROUND: Extensive data exist on the morbidity and mortality of patients undergoing pancreaticoduodenectomy (PD), but there are few reports about hospital readmissions following this procedure. OBJECTIVE: This study was designed to evaluate the number of/reasons for readmission after initial discharge following PD and the factors influencing readmission, including the influence of initial length of stay (LOS). METHODS: We reviewed the initial hospitalization and subsequent readmissions for 1643 patients undergoing PD between 01/1996 and 12/2003. Patients readmitted for reasons unrelated to their PD or underlying disease process were excluded. Patients were grouped by readmission status and com- ABSTRACTS pared using chi-square and Wilcoxon rank sum-tests. Logistical regression MONDAY was used to determine the odds ratios of the variables found to increase the likelihood of hospital readmission following PD. RESULTS: 431 of 1643 patients (26%) were readmitted to our institution a total of 678 times after PD. Patients readmitted were younger (mean = 61.8 vs 64.6 yrs, p < 0.0001), but had no significant differences in gender, comorbidities, presenting symptoms, or final pathology. 72% of patients were readmitted within 1 yr following PD, while 28% were readmitted after 1 yr. Within the first year, patients were more likely to be readmitted for postop complications such as delayed gastric emptying (DGE, 12% vs. 4%, p = 0.01), intraabdominal abscess (17% vs. 4% p < 0.0001), and wound infections (6% vs. 1%, p = 0.02). Patients readmitted after a year were more likely to have incisional hernias (12% vs. 3%, p < 0.0001), obstructive jaundice (17% vs. 4%, p < 0.0001), and/or metastatic disease (12% vs. 5%, p < 0.0001). Factors from the initial hospitalization most strongly associated with readmission were vessel resection at surgery (OR = 3.2, 95% CI = 1.25–8.23), intraabdominal abscess (OR = 2.7, 95% CI = 1.6–4.8), wound infection (OR = 1.8, 95% CI = 1.1–2.8), and DGE (OR = 1.5, 95% CI = 1.03–2.22). The LOS did decrease over time, with a median LOS of 10.5 days in 1996 vs 7 days in 2003. The percentage of patients being readmitted after PD decreased as well with 33.1% being readmitted in 1996 compared to 20.1% (p = 0.004) in 2003. CONCLUSIONS: Readmission following PD is a common occurrence, observed in 26% of patients. For patients readmitted in the first year, the readmission is more commonly related to postop complications while those readmitted after a year more often have metastatic disease or recurrent jaundice. Postop complications and vessel resection are independent risk factors for readmission. Finally, early hospital readmission rate has not increased in association with a decreased LOS after PD.

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258 Rates and Patterns of Recurrence for Percutaneous Radiofrequency Ablation (RFA) and Open Wedge Resection for Solitary Colorectal Liver Metastasis Rebekah White, I. Avital, C. Sofocleous, K. Brown, L. Brody, A. Covey, G. Getrajdman, W. Jarnagin, R. Dematteo, Y. Fong, L. Blumgart, M. D’Angelica; Memorial Sloan-Kettering Cancer Center, New York, NY INTRODUCTION: Percutaneous RFA is a minimally invasive technique that is gaining popularity in the management of colorectal liver metastases. The purpose of this study was to examine rates and patterns of recurrence following percutaneous RFA and open wedge resection for solitary liver metastasis. METHODS: Retrospective review of a prospectively maintained database identified 30 patients between 1992 and 2002 who underwent non-anatomic wedge resection for a solitary liver metastasis. Since 1998, 21 patients were identified who underwent percutaneous RFA rather than resection. Serial imaging studies were retrospectively reviewed for evidence of recurrence. RESULTS: Indications for RFA were prior liver resection (52%), medical comorbidity (38%), and unresectability (10%). Patients in the RFA group were more likely to have undergone prior liver resection, to have a disease-free interval (DFI) greater than one year, and to be female (Table). RFA was associated with a lower incidence of major complications (4 vs. 14%, P < 0.01) and shorter hospital stays (1.3 vs. 8.1 days, P < 0.01). After a median follow-up 62 and 13 months, respectively, true local liver disease-free survival (DFS) at the ablation/resection site at one year was 100% in the Wedge group and 52% in the RFA group (P < 0.01), and overall liver DFS rates at one year were 86% and 49% (P < 0.01). Long-term true local DFS was 85% in the Wedge group. Two patients in the RFA group were re-ablated and two patients were resected to improve “assisted” local DFS at one year to 74%. Median overall survival was 80 months in the Wedge group and 31 months in the RFA group. One-third of patients in each group presented with distant metastasis as a component of their first recurrence. CONCLUSIONS: Local and overall liver recurrences are common after percutaneous RFA but are potentially salvageable with close followup and reablation or resection for recurrence.

Wedge (N = 30) RFA (N = 21) P Value Prior liver resection 7 (23%) 11 (52%) 0.03 DFI from primary resection > 1 year 12 (40%) 15 (71%) 0.03 DFI from last resection > 1 year 12 (40%) 14 (67%) 0.06 Female 10 (33%) 14 (67%) 0.02 Extrahepatic disease 10 (33%) 3 (14%) NS Mean age (± SD) 63 (± 9.6) years 61 (+7.6) years NS Mean diameter (± SD) 2.7 (± 1.1) cm 2.4 (±1.0) cm NS Node positive primary 19 (63%) 14 (67%) NS

SD = standard deviation; NS = not significant

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

259 Management of T2 N0 Rectal Tumors: Long-Term Randomized Study Comparing Transanal Endoscopic Microsurgery Versus Laparoscopic Resections Emanuele Lezoche1, Mario Guerrieri2, Angelo De Sanctis2, Roberto Campagnacci2, Maddalena Baldarelli2, Giovanni Lezoche1, Silvana Perretta1; 1Department of Surgery Paride Stefanini, University La Sapienza, Roma, Italy; 2Department of Surgery, Polytechnical University of Marche, Ancona, Italy AIM: To assess the oncological results with a 5 years minimum follow-up of Transanal Endoscopic Microsurgery (TEM) and Laparoscopic Low Anterior Resection (LLAR) with total mesorectal excision after preoperative chemo radiation in the treatment of T2 N0 rectal cancer. METHODS: Seventy patients (pts) staged at the admission as T2 N0, G1-2 rectal cancer with a tumour diameter lower than 3 cm and located within 6 cm from the anal verge were enrolled: 35 were randomized to TEM and 35 to LLAR. The pts of both groups were previously underwent high dose radiotherapy (overall administration of 5,040 cGy in 28 fractions over 5 weeks) combined with continuous infusion of 5-Flurouracil (200 mg/m2/day). ABSTRACTS RESULTS: The advantages of TEM over the LLAR, consist in less surgical MONDAY trauma and a more comfortable post operator period with minimum uneasi- ness for the patient, thanks to the negligible post-operator pain (sometimes totally absent in the medium-high localizations), minimum breathing dys- functions, early mobility, fast regain of the gastrointestinal peristalsis, low morbidity rate (usually minor complications), 24–48 hours hospitalization and absence of surgical scars. At median follow-up of 68.3 months (60–108) in both arms 2 local recurrence (5.7%) were observed after TEM and 1 (2.9%) after LLAR (p = 0.981). One distant metastasis (2.9%) occurred after TEM and 1 (2.9%) after LLAR. The cumulative survival probability was 0.971 for TEM and 0.943 for LLAR. CONCLUSION: Local control and survival rates in pts underwent TEM are comparable to those underwent LLAR. TEM appears to be an effective treatment of selected T2 carcinomas of the rectum.

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10:30 AM – 11:15 AM SSAT PLENARY SESSION 403 A Moderator: Barbara L. Bass, MD, Houston, TX 296 Anastomotic Leakage Is Associated with Poor Long Term Outcome in Patients Following Curative Colorectal Resection for Malignancy Wai Lun Law, Hok Kwok Choi, Yee Man Lee, Judy W. Ho, Chi Leung Seto; Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong, Hong Kong BACKGROUND: The impact of anastomotic leakage on long term survival and cancer recurrence in following curative surgery for colorectal cancer has not been well documented. This study aimed to investigate impact of anastomotic leakage on the long term survival and recurrence of patients who underwent curative resection for colorectal cancer. METHODS: Prospectively collected data of the 1580 patients (904 men) with the median age of 70 years (range: 24–94) who underwent curative resection for colorectal cancer between 1996 and 2004 were included. Patients without an anastmosis were excluded. In the analysis of long term outcome, patients died postoperatively (30 days) were excluded. Survival and recurrence were analyzed using Kaplan Meier method and variables were compared with log rank test. Cox regression model was used in multivariate analysis. PATIENTS WITH RESULTS: The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3% vs. 2.0%, p < 0.001). The 5-year cancer specific survivals were 56.9% in those with leakage and 75.9% in those without complications (p = 0.012). The 5-year systemic recurrence rates were 48.4% and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001) while the 5 year local recurrence rates were 10.5% and 5.7%, respectively (p = 0.009). The presence of postoperative leak remained an independent factor associated with a worse cancer specific survival (p = 0.043, hazard ratio: 1.62, 95% CI: 1.02–2.61) and a higher systemic recurrence rate (hazard ratio: 2.00, 95% CI: 1.26–3.17) when the gender, urgency of the operation, the site and stage of the tumor were adjusted in multivariate analysis. CONCLUSION: The presence of anastomotic leakage is associated with a worse cancer specific survival and a higher systemic recurrence rate in patients following curative colorectal resection.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

297 Pancreatic Regeneration in Chronic Pancreatitis Requires Activation of the Notch Signalling Pathway Peter Buechler, Yun Su, Amiq Gazdhar, Markus W. Buechler, Helmut Friess; General Surgery, University of Heidelberg, Heidelberg, Germany INTRODUCTION: Chronic pancreatitis is a continuous inflammatory and fibrosing process of the pancreas characterized by irreversible morphological changes, permanent endocrine and exocrine dysfunction and pain for unknown reasons. Pancreatic regeneration, inflammation and likely cancer development are closely related processes. During pancreatic regeneration an embryonic genetic program is reinstated including re-activation of Notch signalling pathway (Notch-1/4, Jagged-1/2, Delta-1/2). This pathway governs development of exocrine, endocrine and neuronal tissue as well as early neoplastic transformation in the pancreas. The current study analyzed this pathway in chronic pancreatitis, and characterized its influence on pain, fibrogenesis and neoplastic transformation. MATERIAL AND METHODS: Real time quantitative PCR was used to quantify mRNA expression in human CP specimens. Immunohistochemistry was used to localize protein expression within tissue specimens. Recombinant activation of the Notch signalling was done by transfection of NIH 3T3 cells ABSTRACTS and one pancreatic cell line with a constitutive active Notch-1 mutant MONDAY (Notch-IC). Over expression of Jagged and Delta was achieved by retroviral transfection of full length cDNA. Notch activation was determined by a specific Luciferase-HES-1-reporter constructs after cell transfection and stimulation insulin, glucagon, somatostatin, steroids, glucose and bile acids. RESULTS: Notch-2, Notch-3 and Notch-4 mRNA were significantly overexpressed in human chronic pancreatitis specimens. Among the ligands Jagged-1, Jagged -2 and Delta were highly overexpressed. Immunopositivity of Jagged-1, Delta, Notch-1 and Notch-4 were seen in nerves and regenerating exocrine cells as well as in the endocrine compartment. The correlation between pain and reactivation of Notch gene members was conducted for all six factors. Cell transfection studies revealed a strong activation of Notch activation upon cell stimulation with glucose, steroids and bile acids. High glucose levels were further associated with increased collagen I production which was revertible upon addition a Notch inhibitor. CONCLUSION: The embryological active Notch pathway is reactivated in chronic pancreatitis in exocrine cells, neuronal structures and islet regeneration. These findings indicate that the Notch pathway mediates the regenerative potential in the inflamed pancreas. Among the stimuli activating the Notch pathway are steroids, high glucose levels and bile acids. This study provides insides in mechanisms of pancreatic tissue regeneration.

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298 A 30 Year Analysis of Colorectal Adenocarcinoma in Transplant Recipients and Proposal for Altered Screening Erik E. Johnson, Glen E. Leverson, John D. Pirsch, Charles P. Heise; Surgery, University of Wisconsin, Madison, WI PURPOSE: The risk of malignancy after solid-organ transplantation is well- documented. However, the incidence and specific risk for colorectal adenocarcinoma, though previously proposed, has been difficult to calculate. We reviewed the University of Wisconsin transplant database for all cases of colorectal adenocarcinoma to assess the risk of this malignancy, as well as the need for improved screening in this population. METHODS: The transplant database was queried using diagnosis codes for colorectal adenocarcinoma to configure a list of eligible patients. Exclusion criteria included: age less than 18 years at the time of transplant, diagnosis of colorectal cancer or patient death less than 12 months post-transplant, and pre-transplant history of colorectal cancer or proctocolectomy. Statistical analysis determined the incidence, survival and age-specific considerations for this population. RESULTS: A total of 5603 kidney, liver, pancreas, or combination trans- plants were eligible for analysis from 1966 through 2004. We identified 40 cases of colorectal adenocarcinoma. Twenty-five of these cases (62%) occurred in kidney transplant recipients, 13 after liver transplant, and 2 after combination kidney-pancreas. Twenty-seven patients (68%) diagnosed with cancer have died, 12 of metastatic disease. The mean survival post-cancer diagnosis was 1.72 years. These results were compared to the National Cancer Institute SEER database for colon and rectal cancer. The current age-adjusted incidence based on year 2000 census data is 0.053% (52.9/100,000). The incidence in the transplanted cohort is 0.71% (40/5603). Five year survival post cancer diagnosis is 64.1% in the general population (SEER) vs. 30.7% in the transplanted population. The SEER median age at diagnosis of colorectal adenocarcinoma is 72.0 years. The average age at cancer diagnosis after transplant was 57.5 years (32.4–78.2), and 11 patients (27%) were diagnosed at or before age 50. In the U.S. population, the incidence of colorectal adenocarcinoma below the age of 50 is 0.0055% (5.52/100,000) compared to 0.20% (11/5603) in the transplant population. In this under 50 cohort, average time from transplant to cancer diagnosis was 9.8 years. CONCLUSION: The incidence of and five year survival after diagnosis of colorectal adenocarcinoma in transplant recipients is markedly different from the general population. Patients often present with advanced disease and are diagnosed at a younger age. With current screening guidelines, over 25% of at-risk patients would not be screened. We propose modifying these guidelines to allow earlier detection of colorectal cancer in this population.

SSAT_abstract.fm Page 87 Wednesday, April 26, 2006 12:03 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

2:15 PM – 5:00 PM SSAT PLENARY SESSION 402 A Co-Moderators: Natalie E. Joseph, Philadelphia, PA Howard S. Kaufman, Los Angeles, CA 370 Liver Metastasis Echogenicity on Intraoperative Ultrasound Is a Prognostic Factor After Curative Hepatic Resection Michelle DeOliveira, Timothy M. Pawlik, Ana Gleisner, Lia Assumpto, Michael A. Choti; Surgery, Johns Hopkins Hospital, Baltimore, MD INTRODUCTION: Survival after resection of colorectal liver metastases (CRLM) has traditionally been associated with clinicopathologic factors. We sought to examine the appearance of CRLM on intraoperative ultrasound to determine if echogenicity is a prognostic factor of outcome after curative resection of CRLM. METHODS: Between 1998–2004, prospective data on IOUS appearance of CRLM was collected in 84 patients who underwent hepatic resection for CRLM. At the time of surgery, IOUS images were digitally recorded, blindly reviewed and scored for echogenicity (hypo-, iso-, or hyperechoic). Clinicopathologic factors and long-term survival were analyzed using chi-square and log-rank tests.

RESULTS: The primary tumor was located in the colon in 59 (70%) patients ABSTRACTS and the rectum in 25 (30%) patients. The median tumor number was 1 MONDAY (range, 1 to 6) and the median tumor size was 5.0 cm (range, 1.5 to 9.0 cm). At the time of surgery, the ultrasound appearance of the colorectal liver metastases were hypoechoic in 35 (42%) patients, isoechoic in 37 (44%) patients, and hyperechoic in 12 (14%) patients. In patients with multiple metastases, there was a strong concordance in echogenicity among tumors in the same patient (P < .05). Patient clinicopathologic characteristics were similar among the different echogenicity types (all P > .05). At a median follow-up of 26 months, 56 patients (67%) were alive and 28 (33%) had died. The overall median actuarial survival was 43 months and 5-year survival was 30%. Patients with hypoechoic CRLM had a shorter median survival (31 months) compared with patients who had isoechoic (54 months) or hyperechoic (43 months) lesions (P = .01) (Figure).

CONCLUSION: Patients with hypoechoic CRLM have a worse overall survival following curative hepatic resection. Echogenicity should be included as a prognostic factor when considering long-term outcome following surgery for CRLM.

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371 Neoadjuvant Chemoradiation Changes the Relationship Between pT And pN Status, and Their Prognostic Significance in Esophageal Cancer Simon Law1, Dora Kwong2, Kam-Ho Wong1, Ka-Fai Kwok1, Jonathan Sham2, John Wong1; 1Department of Surgery, The University of Hong Kong, Hong Kong, China; 2Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China BACKGROUND: Chemoradiation therapy is widely used in the treatment of esophageal cancer. After chemoradiation, it is not clear if pathologic TNM stage after resection will have the same prognostic significance compared to patients without neoadjuvant treatment. Two hypotheses were tested: (1) pT stage has different relationship to pN stage compared to patients without prior treatment, (2) pT and pN stage has different prognostic significance compared to patients without chemoradiation therapy. METHOD: From 1995 to 2004, 279 patients were selected from a prospectively collected database for analysis. All patients had squamous cell cancers of the thoracic esophagus. Neoadjuvant chemoradiation comprised of 2 courses of Cisplatin and 5-FU concurrent with 40Gy of external beam irradia- tion. Patients were given chemoradiation either as part of a randomized controlled trial comparing neoadjuvant chemoradiation with surgical resection alone, or because of advanced disease at presentation. Pathologic staging data were analyzed in relation to long-term survival. RESULTS: 170 patients had surgical resection only without prior treatment, while 109 had neoadjuvant therapy. Transthoracic resection with two-field lymphadenectomy was the preferred approach, which was carried out in 93% of patients. In the surgery alone group, pT1, 2, 3, 4 disease were found in 15, 17, 104, and 34 patients, their respective N1 rates were 13.3%, 29.4%, 57.7% and 64.7%, p = 0.001. In the chemoradiation group, pT0, T1, 2, 3, 4 were found in 48, 12, 23, 21, and 5 patients, their respective N1 rates were 31.3%, 16.7%, 21.7%, 52.4% and 20%, p = 0.15. Logistic regression analysis of factors predictive of N1 status showed that for the surgery alone group, pT stage correlated with N1 status: OR 5.230 (95% CI = 2.12–12.9), while for the chemoradiation group, pT status lost its predictive value. Cox regression analysis of factors predictive of survival showed that in the surgery alone group, pT and pN status were independent prognostic factors. HR for pT = 1.901 (95% CI = 1.42–2.55), and HR for pN = 1.758 (95% CI = 1.17-2.64). In contrast, for the chemoradiation group, while pN status remains prognostic: HR = 2.257 (95% CI = 1.34–3.8), pT status has lost its significance. Instead, female gender (HR = 0.252 (95% CI = 0.08–0.81), and R-category (HR = 8.984 (95% CI = 3.78–21.4) became important. CONCLUSIONS: After chemoradiation, the clear relationship between advancing pT stage and more frequent N1 status was diminished. While nodal status remains of prognostic significance for survival, pT status lost its independent prognostic value.

88 SSAT.book Page 89 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

372 Hepatic Artery Chemoembolization in 122 Patients with Metastatic Carcinoid Tumor: Lessons Learned Mark Bloomston1, Osama Al-Saif1, Bryan Palmer1, Manisha Shah2, E. Christopher Ellison1, Gregory Guy3, Edward W. Martin1; 1Surgery, Ohio State University, Columbus, OH; 2Medicine, Ohio State University, Columbus, OH; 3Radiology, Ohio State University, Columbus, OH BACKGROUND: HACE is the procedure of choice in the management of metastatic carcinoid. We reviewed our experience to identify potential factors that inﬂuence response to therapy and survival. METHODS: The records of 122 consecutive patients with metastatic carcinoid tumor undergoing HACE between 1992 and 2005 were reviewed. Kaplan-Meier Survival curves were constructed and compared by log-rank analysis. Cox Proportional Hazards Analysis was applied to pre-HACE variables of age, gender, comorbidity, location of primary tumor, resection of primary, tumor differentiation, presence of carcinoid syndrome, presence of extrahepatic disease, and serum pancreastatin ≥5,000 pg/ml to identify factors predictive of decreased survival. RESULTS: Median follow-up for all living patients was 22 months. HACE ABSTRACTS

was undertaken for symptom palliation in 83% or to reduce tumor burden in MONDAY 17%. Complications occurred in 23% with periprocedural mortality of 5%. Reduction in the size and/or number of lesions by CT was seen in 82% with stabilization of disease in 11% and progression in 6%. Median duration of CT response was 13 months. Signiﬁcant improvement in symptoms was documented in 80% for a median duration of 11 months. HACE resulted in complete normalization of serum pancreastatin in 14% with a greater than 20% reduction in another 66%. Median overall survival was 33.3 months after HACE with median progression-free survival of 10 months. Post-procedure complication and the lack of symptom improvement, pancreastatin reduction, or CT response were associated with decreased overall survival (p < 0.05). Of all pre-HACE variables analyzed, only pancreastatin level ≥5,000 was associated with decreased survival by multivariate analysis. These patients had greater periprocedural mortality and were less likely to experience signiﬁ- cant reduction in pancreastatin following HACE (table).

Pre-HACE Pancreastatin (pg/mL) <5,000 ≥5,000 Periprocedural mortality 1.6% 10.3%* >20% pancreastatin reduction after HACE 94% 71%† Median survival (months) 40.7 22.9†

*p = 0.07 vs. pre-HACE pancreastatin < 5,000 †p < 0.05 vs. pre-HACE pancreastatin < 5,000

CONCLUSION: This report represents the largest experience with HACE in the management of unresectable carcinoid metastases. Though safe, it should be approached cautiously in patients with signiﬁcant tumor burden as evidenced by pancreastatin levels ≥5,000. We do not recommend whole-liver embolization in these patients but prefer a staged approach to each side of the liver. HACE offers good control of tumor burden, hormone levels, and symptoms related to carcinoid metastases resulting in long-term survival.

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373 Does Pancreatic Duct Stenting Decrease the Rate of Pancreatic Fistula Following Pancreaticoduodenectomy? Results of a Prospective Randomized Trial Jordan M. Winter1, John L. Cameron1, Kurtis A. Campbell1, David Chang1, JoAnn Coleman1, Patricia K. Sauter2, Taylor S. Riall3, Chris L. Wolfgang1, Chris J. Sonnenday1, Michael R. Marohn1, Richard D. Schulick1, Michael A. Choti1, Charles J. Yeo2; 1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, Thomas Jefferson University, Philadelphia, PA; 3Surgery, University of Texas Medical Branch, Galveston, TX BACKGROUND: Pancreatic fistula (PF) is one of the most common complications following pancreaticoduodenectomy (PD). OBJECTIVE: This study was designed to evaluate pancreatic duct stenting in patients undergoing PD. METHODS: Between March 2004 and October 2005, nine surgeons performed PDs on 224 patients. Patients were randomized to either pancreatic stent (PS) or no stent (NS) placement. Patients who randomized to the PS group had a 6 cm stent placed. All pancreaticojejunal (PJ) anastomoses were hand sewn in two layers. Recorded variables included pancreas texture (soft vs. hard), diameter of the pancreatic duct, diameter of the pancreatic stent, PJ technique (invagination vs. duct-to-mucosa), PJ orientation (end-to-side vs. end-to-end) and the number of drains placed. The primary endpoint was the PF rate, as defined by an International Study Group (Surgery 138; 8, 2005) as drain fluid amylase greater than three times the normal serum level, on or after the third postoperative day. The study conclusions were similar when the definition for PF used in prior studies from our institution was applied (over 50 ml of drain output containing amylase rich fluid, on or after the tenth postoperative day). Secondary endpoints included postoperative length of stay and mortality.

Parameter Odds Ratio P value Stent 1.1 0.8 Soft pancreas 4.5 0.001 Anastomosis (duct-to-mucosa) 2.2 0.1 P-J (end-to-end) 11.9 0.2 Size of duct (≥5 mm) 0.2 0.02

RESULTS: There were 220 patients included in the ﬁnal analysis (four patients were withdrawn from the study because their ducts could not be stented). The PF rate for the total cohort was 22.7% (11.4% when applying the abovementioned institutional deﬁnition of PF). There were 113 patients in the NS group and 107 patients in the PS group. Age and gender distribution were statistically similar between the two groups. The two groups were also similar for each of the evaluated endpoints, including PF rate (20% NS vs. 25% PS, p = 0.4), postoperative length of stay (median, 7 days NS vs. 8 days PS, p = 0.7), and perioperative death (3% NS vs. 2% PS, p = 0.7). The results of

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

a multivariate logistic regression analysis are presented in the table. A soft pancreas and a small pancreatic duct were associated with an increased risk for developing a PF, independent of the use of a stent. CONCLUSION: Inclusion of a pancreatic duct stent in the PJ anastomosis does not reduce the incidence of PF following PD. Two factors independently associated with PF are a soft pancreas and a small pancreatic duct. ABSTRACTS MONDAY

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374 Pancreatic Cancer in the General Population: Improvements in Survival over the Last Decade Taylor S. Riall, Jean L. Freeman, Courtney M. Townsend, James S. Goodwin, Yong-fang Kuo, Zhang Dong, William H. Nealon; Surgery, University of Texas Medical Branch, Galveston, TX BACKGROUND: Pancreatic cancer (PCa) is the 4th leading cause of cancer deaths in men and women in the US. High-volume pancreatic surgery centers (>50 cases/yr) have shown improvements in survival following surgical resection over the last 3 decades. It is unknown whether this improvement has been translated to all patients with PCa, many of whom are not treated at high-volume centers. OBJECTIVE: The goal of this study was to examine population-based data in patients with PCa to evaluate trends in surgical resection and survival over the last decade. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, all patients diagnosed with PCa from 1988–1999 were identified. The database was divided into 3 equal time intervals from 1988–1991, 1992– 1995, and 1996–1999. The survival and proportion of patients undergoing surgical resection were compared for each time period. RESULTS: There were 24,016 patients with PCa identified. Of the 19,533 patients with stage data available, 7.3% had localized disease, 23.9% had regional disease, and 50.1% had distant disease. For all patients with localized PCa there was no difference in 2-yr survival when comparing the 3 time periods. The percentage of patients resected increased from 18.8% to 20.2% to 25.5% over the 3 time periods (p = 0.003). For those with localized disease undergoing surgical resection, 2-year survival ranged from 43.0% to 46.5% over the three time periods (p = 0.93). Patients with regional PCa showed an improvement in survival from 9.5% to 13.5% over the three time periods (p < 0.0001). Significantly, the rate of surgical resection increased from 23.0% to 28.6% to 32.5% (p < 0.0001) in those with regional disease. Following surgical resection for regional PCa, 2-yr survival increased from 21.5% to 28.9% (p = 0.002) over the three time periods. In a Cox model of all patients with resected local/regional PCa, the year of diagnosis was significant with a 3% improvement in survival per year studied (CI = 2.5%–4.5%, p = 0.0001) after adjusting for other prognostic factors. For all patients with distant disease, the 2-yr survival increased from 1.4% in 1988–1991 to 2.3% in 1996–1999 (p < 0.0001). CONCLUSIONS: Patients with PCa in the general population are shown to have improved survival over the past decade in both unadjusted and adjusted models. This improvement is most striking for patients with local/regional disease and is consistent with trends seen at high-volume centers The improved survival likely reflects increased resection rates and improvements in resection techniques over time. Improvements seen for distant disease may be explained by advances in chemotherapeutic regimens.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

375 Postoperative Pancreatic Fistulas Are Not Equivalent After Proximal, Distal, and Central Pancreatectomy Wande Pratt, Shishir Maithel, Tsafrir Vanounou, Mark P. Callery, Charles M. Vollmer; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA BACKGROUND: Some still believe that postoperative pancreatic fistulas (POPF) following distal (DP) and central pancreatectomy (CP) behave similarly to those following pancreaticoduodenectomy (PD). To date, this has not been validated either clinically or economically. METHODS: 227 consecutive pancreatic resections from 10/01 to 10/05 (166 PD; 56 DP; 5 CP) were evaluated according to the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. POPF was defined as any measurable drainage on or after POD 3 with an amylase content > 3x serum value. Outcomes were divided into 4 grades: no fistula (NF), biochemical fistula without clinical sequelae (A), fistula requiring any therapeutic intervention (B), or fistula with severe clinical sequelae (C). Grades B and C are considered clinically relevant (CR-POPF) based on worsening morbidity, increased LOS, readmission, and increased costs/resource utilization. Clinical and economic

outcomes were compared—grade for grade—across the 3 resection types. ABSTRACTS MONDAY RESULTS: Fistulas of any extent (Grades A to C) occurred in one-third of all patients. Two-thirds had NF. Overall, there were 15 readmissions (7%), 8 reoperations (4%), and no deaths attributable to POPF. Outcomes for NF and A patients were identical, though Grade A POPF was more common in DP. For each resection type, LOS and costs progressively increased with Grades B and C. However, the negative impact of a CR-POPF (Table) varied between resection types. Rates for ICU admission and rehab placement were higher among PD patients. TPN and antibiotic use were similar, but percutaneous drainage was utilized more often for DP. Grade B POPF was more severe after DP, as indicated by increased LOS, readmissions, and total cost. Although reoperation rates for Grade C POPF were equivalent, intervals to reoperation were substantially longer following DP and CP.

Table 1. Clinically-Relevant POPF After Pancreatic Resection

Proximal Resections Distal Resections Central Resections Outcome n = 166 n = 56 n = 5 # POPF/LOS/costs 21 / 12d /\$24,283 6 / 35d / 6/16d/ \$25,313 2 / 22d / 3 / 11d / \$34,644 1 / 20d / (median) Grade \$119,083 \$43,313 \$57,737 B Grade C ICU admission 5 (19%) 0 (0%) 1 (25%) (% CR-POPF) Rehab 13 (48%) 0 (0%) 0 (0%) (% CR-POPF) Percutaneous drainage 4 (15%) 4 (50%) 1 (25%) (% CR-POPF) Readmission for 5 (24%) 6 (100%) 1 (33%) Grade B POPF (%) Intervals to reoperation 7d 92d 260d (median)

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CONCLUSION: When classiﬁed according to ISGPF criteria, clinically- relevant pancreatic ﬁstulas behave differently depending on type of pancreatectomy. This translates into variable severity that guides management decisions, which ultimately dictate clinical outcomes and economic impact.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

376 The Durability of Laparoscopic Nissen Fundoplication: Ten Year Outcomes Craig B. Morgenthal1, A. Stival1, M.D. Shane1, N.A. Gletsu1, G. Milam1, V. Swafford1, J.G. Hunter2, C.D. Smith1; 1Endosurgery Unit, Emory University School of Medicine, Atlanta, GA; 2Surgery, Oregon Health and Science University, Portland, OR BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireﬂux procedure since its introduction in 1991. There are few studies with greater than 5 year outcomes. Herein we report a series of patients with a mean follow-up of 10 years. METHODS: From a prospectively maintained database, 45 patients were identiﬁed with an average follow-up after LNF of 10 years. Patient demographics and symptom scores for typical symptoms, such as heartburn (HB) and regurgitation (REG), and atypical symptoms were recorded preoperatively and at recent follow-up (0 = none, 1 = mild, 2 = moderate, 3 = severe). HB and REG were evaluated at baseline, 6 weeks, and recent follow-up to assess for durability of symptom response. Total symptom score (TSS) for each patient was summed from the 7 symptoms assessed for a maximum value of

21. Patient satisfaction and use of antireflux medication was also assessed. ABSTRACTS MONDAY RESULTS: The mean follow-up was 10.2 ± 1.5 years (median 10.4 years, range 6.7 to 12.9 years). There were 28 men (62%) and 17 women (38%) with a mean age of 46.8 ± 15.1 years (range 14–75 years) at the time of operation. The table shows symptom scores for HB and REG, the two most improved symptoms, with values expressed as percent of patients. All symptoms were significantly improved over baseline following LNF (p < 0.02) except cough and asthma. The TSS at follow-up was 3.2 ± 2.8 down from 7.3 ± 2.4 at baseline, with a mean difference of –4.4 (N = 26, median –5.0, range –10.8 to 0.75) per patient. The percentage of patients stating they would have the procedure again was 93.2%, while 97.3% were either satisfied or very satisfied, and 75% were off all PPI and H-2 blockers. CONCLUSION: In patients undergoing LNF, outcomes at a mean of 10 years are excellent, and the symptom response is durable. The overwhelming majority of patients are satisfied with their results and off antireflux medica- tions. HB and REG are the symptoms most responsive to LNF, while the atypical symptoms were less so.

Table 1. Symptom Scores: Heartburn and Regurgitation

Pre 6 wk 10 yr HB none 11 89 64 HB mild 3622 HB mod 42 0 13 HB sev 45 6 0 REG none 23 91 78 REG mild 8918 REG mod 38 0 4 REG sev 31 0 0

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377 Gastrectomy as a Remedial Operation for Failed Fundoplication Valerie A. Williams, Thomas J. Watson, Oliver Gellersen, Sebastian Feuerlein, Daniela Molena, Carolyn Jones, Lelan Sillin, Jeffrey H. Peters; Department of Surgery, Division of Thoracic/Foregut Surgery, University of Rochester Medical Center, Rochester, NY The decision for, and choice of, a remedial antireflux procedure following a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes following re-operative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. METHODS: The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or redo fundoplication (n = 25) between 1997–2005. Average age, M:F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients’ overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and redo fundoplication groups, respectively (p = 0.43). RESULTS: Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% v 4%, p = 0.006) and of multiple prior fundoplications than those having redo fundoplication (75% v 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and redo fundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% v 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after redo fundoplication (67% v 16%, p = 0.003) and new onset dumping developed in two gastrectomy patients. CONCLUSION: In select patients with severe GERD and multiple previous fundoplications, symptomatic outcome following gastrectomy is as good as or better than redo fundoplication. This occurs in association with higher morbidity and postoperative dumping. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

378 Long-Term Outcome After Resection for Chronic Pancreatitis: Results of 203 Patients Frank Makowiec, Hartwig Riediger, Eva Fischer, Ulrich Adam, Ulrich T. Hopt; Department of Surgery, University of Freiburg, Freiburg, Germany Organ complications like biliary or duodenal stenosis as well as intractable pain are current indications for surgery in patients with chronic pancreatitis (CP). We here present our experience with pancreatic resection for CP and focus on the long-term outcome following surgery regarding pain and exocrine/ endocrine pancreatic function. METHODS: During the last 11 years 272 pancreatic resections were performed in our institution for CP. Perioperative mortality was 1%. Follow-up data using standardized questionnaires were available in 203 patients with a postoperative follow-up of > 12 months. The types of resection in these 203 patients were Whipple (9%), pylorus-preserving PD (PPPD; 42%), duodenum- preserving pancreatic head resection (DPPHR; 42%, 47 FREY, 38 BEGER), distal (6%) and one central resection. Eighty-six of the patients were part of a randomized study comparing PPPD and DPPHR, as reported earlier to the Society. All other patients were operated as indicated individually. The perioperative and follow-up (f/up) data were prospectively documented. Exocrine ABSTRACTS insufficiency was regarded as the presence of steatorrhea and/or the need for MONDAY oral enzyme supplementation. Median postoperative f/up was 37 months. RESULTS: Perioperative surgical morbidity was 25% and did not differ between the different types of resection. At last f/up 75% of the patients were pain-free (62%) or had pain less frequently than once per month (13%). Twenty-five percent had pain at least once per month (no difference between operative procedures). Patients with postoperative surgical complications more frequently reported pain during f/up (54%) compared to patients without surgical complications (32%; p < 0.01). At last f/up 67% had exocrine insufficiency, half of them developed it during the postoperative course. Eigh- teen percent of the patients postoperatively developed de novo diabetes. Both, exocrine and endocrine insufficiency were independent of the type of surgery. After PPPD 10% of the patients had peptic jejunal ulcers whereas five percent presented with biliary complications after DPPHR. Late mortality is still not completely evaluated but at least 22 of the 272 patients (8%) died within six years after surgery, in most cases unrelated to CP. CONCLUSIONS: Pancreatic resection leads to adequate pain control in the majority of patients with CP. Long-term outcome does not depend on the type of surgical procedure but is influenced by postoperative surgical complications (regarding pain). Some patients develop procedure-related late complications. Late mortality is relatively high, probably due to the high co-morbidity (alcohol, smoking) in many of these patients.

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379 Lentivirus-Mediated RNA Interference of HMGA1 Gene Promotes Chemosensitivity to Gemcitabine in Pancreatic Adenocarcinoma Siong-Seng Liau, Stanley W. Ashley, Edward E. Whang; Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA BACKGROUND: The high mobility group A1 (HMG A1) proteins are overexpressed in pancreatic cancers. They are architectural nuclear proteins, which regulate gene expression. We have previously shown that carcinoembryonic antigen-related cell adhesion molecule 6 (CEACAM6) is a molecular determinant of chemosensitivity in pancreatic adenocarcinoma. In this study, we hypothesize that HMG A1 is a nuclear regulator of CEACAM6 and hence, its silencing will promote chemosensitivity in pancreatic adenocarcinoma. METHODS: We studied highly malignant pancreatic adenocarcinoma cell lines (BxPC3, MiaPaCa2 and PANC1). Four short-hairpin RNA (shHMGA1) expression vectors targeting different regions of HMG A1 were assessed for the degree of silencing of HMGA1 expression. Construct with greatest degree of silencing of HMGA1 was selected for generation of lentiviral particles. Stable transfectants were developed after lentiviral transduction. Full-length cDNA of HMGA1 was cloned into pIRES-puro vector and stably transfected into MiaPaCa2 cells with inherent underexpression of HMGA1 (pIRES-HMGA1.1 and 1.2). Nuclear expression of HMGA1 and cellular expression of CEACAM6 were confirmed using Western analysis. Chemosensitivity to gemcitabine was determined by IC50 analysis. Apoptosis was measured by caspase 3 activation using cleaved-caspase 3 ELISA assay. Akt kinase assay was performed based on GSK-3 phosphorylation. RESULTS: Lentivirally-transduced RNA interference resulted in 90% silencing of HMG A1 expression in all cell lines. Silencing of HMGA1 resulted in a significant reduction in the CEACAM6 expression, and forced overexpression of HMGA1 elevated the expression of CEACAM6 (p < 0.05 based on densito- metry). Silencing of HMGA1 resulted in significant reduction in Akt kinase activity. Silencing of HMGA1 enhanced chemosensitivity to gemcitabine with two- to four-fold reduction in IC50 (all cell lines, p < 0.05 vs. controls i.e., lentivirus carrying scrambled RNAi sequence). Lentivirus-mediated silencing of HMGA1 promoted the activation of caspase 3, a central mediator of apoptosis, on exposure to gemcitabine (p < 0.05 versus controls). On the contrary, pIRES-HMGA1.1 and 1.2 MiaPaCa2 clones with forced overexpression of HMGA1 showed a decrease in chemosensitivity to gemcitabine, with significant two-fold increase in IC50 (p < 0.05 vs. empty pIRES vector). CONCLUSIONS: HMG A1 is a molecular determinant of gemcitabine chemosensitivity in pancreatic adenocarcinoma, and this may in part be mediated by its regulatory role on the cellular expression of CEACAM6. Lentivirus-mediated RNA interference of HMGA1 may represent a feasible therapeutic option for pancreatic cancer.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

380 Metabolic Characterization of Non-Diabetic Severely Obese Patients Undergoing Gastric Bypass; Preoperative Classiﬁcation Predicts the Effects of Surgery on Insulin-Glucose Homeostasis Richard A. Perugini, Stephen Quarfordt, Donald Czerniach, MItchell Cahan, John J. Kelly, Demetrius E. Litwin; Surgery, UMass Medical School, Worcester, MA INTRODUCTION: Obesity is associated with insulin resistance (IR) and diabetes (DM). Some obese individuals, however, have normal insulin-glucose metabolism. While gastric bypass (GB) cures IR and DM, its effects on normal physiology have not been described; in addition, there are reports of postoperative pathological hypoglycemia. We studied IR and beta-cell sensitivity for patients undergoing gastric bypass. METHODS: 123 patients undergoing GB had fasting insulin and glucose levels drawn on days 0, 12, 40, 180, and 365. Twenty nine (24%) patients with DM were excluded from this analysis. Homeostasis model of assessment was used to estimate IR (HOMA-IR) and beta-cell sensitivity (HOMA-B). Patients were categorized with IR if HOMA-IR > 3.6. HOMA-B of 100 signiﬁed normal

beta-cell sensitivity. Student’s t-test was used to determine whether differ- ABSTRACTS MONDAY ences were signiﬁcant. RESULTS: Adipose mass, as estimated by BMI, did not correlate with IR. Forty three (35%) patients had IR. Correction of IR for this group occurred by 12 days postoperatively. Fifty one (41%) patients did not have IR, with normal HOMA-IR and HOMA-B preoperatively. They demonstrated an increase of beta-cell sensitivity by 12 days postoperatively, which corrected by six-months. Major alterations in HOMA-IR or HOMA-B occurred by 12 days, after which the IR and non-IR groups mirrored each other. CONCLUSIONS: Adipose mass, in and of itself, does not lead to IR. Severely obese individuals can be categorized as insulin resistant or non-insulin resistant, and the effect of GB depends upon this preoperative physiology; IR decreases in the former and beta-cell sensitivity increases in the latter. Meta- bolic characterization of patients is imperative in order to determine preoperative risk of obesity and assess outcomes following GB.

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TUESDAY, MAY 23, 2006

471 Laparoscopic Redo Nissen Fundoplication with Reduction of Paraesophageal Hernia and Sliding Hiatal Hernia with Reconstruction of Esophageal Hiatus Alexander S. Rosemurgy, Kerry Thomas, Desiree Villadolid, Donald Thometz, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL A ﬁve-trocar technique is used. The gastrohepatic omentum is opened and the dissection is carried up the right crus and into the mediastinum. The dissection includes division of the short gastric vessels. 8 cms of intraabdominal esophagus is ideal, so that the reconstructed valve mechanism lies well within the abdominal cavity. Bringing the left and right crura together behind the esophagus, the hiatus is reconstructed. The failed fundoplication should be augmented well above the GE junction. The existing fundoplication is not taken apart. The posterior fundus is attached to the esophagus and the right crus. Trocar sites are closed and dressings placed.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

472 Laparoscopic Resection of Gastric Cardia Gastrointestinal Stromal Tumor Don J. Selzer; Surgery, Indiana University, Indianapolis, IN; Surgery, Clarian Health Partners, Indianapolis, IN BACKGROUND: Gastrointestinal stromal tumors (GISTs) occur throughout the gastrointestinal tract. Resection is a principal component of treatment. Arguments support anatomical resection over wedge resection. This is a case study of a GIST resection. METHODS: A 70 year old male with multiple medical co-morbidities presents with melena. A video was created from operative footage and pre-operative and post-operative studies. RESULTS: Wedge resection of a large gastric cardia GIST was performed. The patient’s course was unremarkable. CONCLUSION: In the gastric cardia, a non-anatomical resection is safe and potentially favored to a proximal gastrectomy in a high risk patient.

473 Transgastric Repair of a Gastrogastric Fistula Following Laparoscopic Roux-Y Gastric Bypass Kurt E. Roberts1, Andrew J. Duffy1, Walter E. Longo1, Priya Jamidar2, Robert L. Bell1; 1Surgery, Yale School of Medicine, New Haven, CT; 2Medicine, Yale School of Medicine, New Haven, CT The successful repair of a Gastrogastric ﬁstula following laparoscopic Roux-Y

Gastric Bypass via the transgastric approach is presented.Laparoscopically the ABSTRACTS TUESDAY stomach was pulled up to the abdominal wall and a gastrotomy was performed. The endoscope was inserted. Transorally a wire was passed thru the fistula into the gastric remnant. Clips to close the fistula were unsuccessful. A second Trocar was placed into the abdomen/gastric remnant. The gastrogastic fistula was successfully closed using an endostitch device. A stapler was used to close the two gastrotomies.The transgastric repair of a gastrogastric fistula is safe and can be recommended as a treatment for gastrogastric fistulae.

474 Pancreas Preserving Duodenectomy for Duodenal Familial Adenomatous Polyposis R.M. Walsh, Andrew Smith; General Surgery, Cleveland Clinic Foundation, Cleveland, OH Advanced familial adenomatous polyposis of the duodenum can be difﬁcult to manage. Local treatment performed by endoscopy or surgery typically leads to recurrence, and thus no improvement in disease status or cancer prevention. While virtually all patients with familial polyposis develop duodenal polyps, only 5% will develop carcinoma. It is our approach to perform pancreas-preserving duodenectomy for patients with Spigelman IV disease to prevent carcinoma. This video demonstrates our current technique.

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475 Resection and Reconstruction of the Superior Mesenteric Vein for Locally Advanced Pancreatic Adenocarcinoma Craig P. Fischer, Barbara L. Bass; Department of Surgery, The Methodist Hospital/Weill Medical College of Cornell University, Houston, TX Resection of the superior mesenteric vein for locally advanced pancreatic adenocarcinoma is described. Focus is upon the technical details of obtaining and cancer-free surgical margin, and reconstruction of the superior mesenteric -portal venous system, using autologous internal jugular vein.

476 Laparoscopic Ileocolic Resection for Crohn’s Disease— Ileosigmoid Fistula Barry Salky, David Hazzan; Surgery, Mount Sinai Hospital, New York, NY Complex Crohn’s Disease is often sited as a reason for open surgery. This case demonstrates advanced laparoscopic techniques required to accomplish these difﬁcult cases. Familiarity with the proper anatomical surgical planes, angled telescopes and surgical stapling instruments are necessary. Proper atraumatic instrumentation for usage on the bowel wall is required. Identiﬁcation of the ureter is mandatory in these complex cases. A short, general review of the author’s experience with 265 patients undergoing laparoscopic surgery for Crohn’s Disease is included.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

10:30 AM – 11:15 AM SSAT PLENARY SESSION 403 A Co-Moderators: Susan Galandiuk, Louisville, KY Kenneth K. Tanabe, Boston, MA 620 Is a Peroperative End to End Anastomosis for a Bile Duct Injury Justiﬁed? Philip R. de Reuver1, Otto M. van Delden2, Erik A. Rauws3, Olivier R. Busch1, Thomas M. van Gulik1, Dirk J. Gouma1; 1Surgery, Amsterdam Medical Center, Amsterdam, Netherlands; 2Radiology, Amsterdam Medical Center, Amsterdam, Netherlands;3Gastroenterology, Amsterdam Medical Center, Amsterdam, Netherlands INTRODUCTION: The management of a bile duct injury (BDI) detected during laparoscopic cholecystectomy is still under discussion. An end to end anastomosis (EEA) (with or without T-tube drainage) in patients without extensive tissue loss has been used frequently in the past, but is reported to be associated with a high incidence of recurrent jaundice due to stricture formation of the anastomosis area. A more complicated procedure as a primary hepaticojejunostomy is therefore recommended. Patients referred to a tertiary center after previous EEA will represent the worst selection of the population treated with EEA. The aim of this study was to evaluate the long term outcome in this selected group of patients after a complicated primary EEA. RESULTS: Of a total of 485 BDI patients referred between 1991 and 2005, 56 patients (11.5%) were referred after a primary EEA. In 42 patients (75%) a complete transsection was diagnosed during the initial operation. In 49 patients (87%) the anastomosis was performed over a T-tube, and a peropera- ABSTRACTS tive cholangiography was performed in 24 patients (43%). Median duration TUESDAY of T-tube drainage was 42 days, range 2–145. Patients were referred after a median of 16 weeks (range 0–141) after the initial operation. The indication for referral was leakage in 10 patients (18%) and biliary obstruction in 46 patients (82%). After referral 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n = 3, 5%). After a mean follow up of 7 ± 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents, median duration 364 days range 36–1355, median stent replacements 6, range 2–15. A total of 18 patients (32%) underwent a hepaticojejunostomy, in 5 patients (9%) because initial treatment failed and in 13 patients (23%) primary reconstructive surgery was performed. Post operative complications occurred in 3 patients (5%). Leakage of the anastomosis (n = 1) was treated by percutaneous transhepatic stent and in two patients a stenosis of the secondary anastomosis was successfully treated with a percutaneous transhepatic dilatation. CONCLUSION: An end to end anastomosis might be considered as a primary treatment for BDI because even complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage in 66% and reconstructive surgery after EEA is a procedure with acceptable morbidity and no mortality.

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621 Combination Therapy with TRA-8 Anti-Death Receptor-5 Antibody Significantly Reduces Pancreatic Adenocarcinoma Cell Viability In Vitro and Growth In Vivo Leo C. DeRosier1, Zhi Huang1, Jeffrey Sellers2, Kurt Zinn3, Donald Buchsbaum2, Selwyn Vickers1; 1Department of Surgery, University of Alabama, Birmingham, AL; 2Department of Radiation Oncology, University of Alabama School of Medicine, Birmingham, AL; 3Department of Medicine, University of Alabama School of Medicine, Birmingham, AL Gemcitabine (Gem) is a first line agent for pancreatic cancer, but yields minimal survival benefit. This study evaluated in vitro and in vivo effects of a monoclonal antibody (TRA-8) to human death receptor 5 (TRAIL R2), combined with gem, using two human pancreatic cancer cell lines, S2VP10 (S2) and MIA PaCa-2 (M2). A subcutaneous and intrapancreatic model of pancreatic cancer with ultrasound monitoring was developed to test in vivo efficacy.S2 and M2 cells were treated with varying doses of gem and TRA-8. Cell viability was determined using an ATP assay and apoptosis was verified with Annexin V staining. Mitochondrial membrane destabilization was evaluated with FACS analysis of JC-1 stained cells. Signal transduction was evaluated by Western blot analysis. M2 subcutaneous xenografts in athymic nude mice were evaluated for response to treatment: 200 µg of TRA-8 (days 9, 13, 16, 20, 23, 27 post-implant) and 120 mg/kg gem (days 10, 17, 24). Tumors were measured with calipers. Intrapancreatic tumors were established by injecting 2.5 × 106 M2 cells into the pancreas of SCID mice. Tumor growth was measured by ultrasound imaging on post-implant days 21 and 41.M2 cells demonstrated sensitivity to TRA-8 (IC50 = 15.9 ng/ml) and additive reduction in cell viability in combination with gem. Combination treatment produced synergistic reduction in cell viability in S2 cells (TRA-8 resistant, IC50 > 1000 ng/ml). M2 and S2 cells receiving combination treatment demonstrated enhanced Annexin V staining and mitochondrial destabilization compared to either agent alone. X-linked inhibitor of apoptosis (XIAP) decreased more in S2VP10 cells receiving combination treatment, than with either agent alone. Enhanced caspase-3 activation was observed in both cell lines receiving combination treatment. In vivo studies demonstrated mean subcutaneous tumor doubling times of 38d-untreated, 32d-gem, 49d-TRA-8, and 64d-combination. Using ultrasound measurements, the mean intrapancreatic tumor size (n = 10) at 21d post implant was 42 ± 9 mm2 and 106 ± 15 mm2 at 41d. TRA-8 is an apoptosis inducing monoclonal antibody with synergistic effects with gem, possibly through enhanced caspase activation and downregulation of XIAP. These findings, with substantial inhibition of tumor growth in a mouse xenograft model receiving combination therapy, are encouraging for anti-death receptor therapy in the treatment of pancreatic cancer. An intrapancreatic model of pancreatic cancer can be followed using ultrasound measurement without sacrifice of study animals, providing a relevant model for evaluating novel therapies for pancreatic cancer.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

622 Gallstones Containing Bacteria Are Biofilms: Bacterial Slime Production and Ability To Form Pigment Solids Determines Infection Severity and Bacteremia Lygia Stewart1, J. MacLeod Griffiss2, Gary A. Jarvia2, Lawrence W. Way3; 1Surgery, UCSF/SF VAMC, San Francisco, CA; 2Microbiology and Labarotory Scinece, UCSF/SFVAMC, San Francisco, CA; 3Surgery, UCSF, San Francisco, CA OBJECTIVE: Bacterial microcolonies in gallstones provide a reservoir for biliary infections. Bacterial slime production facilitates adherence, while β-glucuronidase (bG) and phospholipase (PhL) generate colonization surface. These factors are known to facilitate infectious gallstone formation. But, to cause severe infections (and bacteremia) these bacteria need to detach from the biofilm and reflux into the systemic circulation (cholangiovenous reflux). We previously reported that abundant slime inhibited cholangiovenous reflux in rats. The influence of these bacterial factors (slime, bG/PhLprod) on the development of severe infections and bacteremia in a clinical setting has not been studied. In this study we examined the influence these factors on infection severity and bacteremia. METHODS: 260 patients with gallstone disease were studied. Gallstones, bile, and blood (as applicable) were cultured. Bacteria were tested for bG/PhLprod and quantitative slime production. Severe infections (bacteremia, cholangitis, abscess, hypotension, organ failure) were correlated with the bacterial factors (slime, bG/PhLprod). RESULTS: Biliary bacteria were present in 45% of patients, 17% with bacter- ABSTRACTS

emia. Severe infections varied directly with bG/PhLprod (50% with vs 17% TUESDAY without, P = 0.004) and inversely with magnitude of slime production (52% vs 8%, slime <75 or >75, P = 0.004). Low (<75) slime production and bG/PhLprod were additive: severe infections were present in 60% with both, but 11%–16% with either/none (P < 0.03). bG/PhLprod facilitated bactibilia (84% with vs 50% without, P = 0.003), while slime production trended lower with bactibilia (31 vs 68, P = 0.07). Average slime production was 21 (+9.8) vs 45 (+6.7) for bacteria that did or did not cause bacteremia (P < 0.0001), and no bacteria with slime production >75 demonstrated bacteremia. Bacteremia was more common if bG/PhLprod bacteria were present in the gallstone (18% vs 3%, with vs without bG/PhLprod, P = 0.038). CONCLUSIONS: Bacteria-laden gallstones are biofilms whose characteristics influence bacterial colonization, detachment, and cholangiovenous reflux. Factors creating colonization surface (bG/PhL) facilitated bacteremia and severe infections; but abundant slime production, while facilitating colonization, inhibited detachment and cholangiovenous reflux. High slime-producing isolates were recovered from bile, but not blood. This underscores the liver’s filtering effect, which inhibited cholangiovenous reflux of high slime-producing bacteria. This data shows how the properties of the gallstone biofilm determine the severity of the associated clinical illness.

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2:15 PM – 3:30 PM SSAT PLENARY SESSION 402 A Co-Moderators: Jeffrey B. Matthews, Cincinnati, OH C. Max Schmidt, Indianapolis, IN 693 Steatocholecystitis: An Explanation for Increased Cholecystectomy Rates Hayder Al-Azzawi1, Attila Nakeeb1, Romil Saxena2, Henry A. Pitt1; 1Department of Surgery, Indiana University, Indianapolis, IN; 2Department of Pathology, Indiana University, Indianapolis, IN INTRODUCTION: Gallbladder disease represents a major health care problem in the United States. Over the past decade, the number of cholecystectomies and the percentage with chronic acalculous cholecystitis have increased. However, a good explanation for these trends has not been established. Dur- ing the same period, obesity has become epidemic among Americans, and obesity is a known risk factor for gallbladder disease. We have recently reported that congenitally obese mice and lean mice fed a high fat diet have increased gallbladder wall lipids and poor gallbladder emptying. Therefore, we tested the hypothesis that compared to patients with a normal gallbladder, patients with both acalculous and calculous cholecystitis would have increased gallbladder wall fat and inflamation (steatocholecystitis). METHODS: Eleven patients with impaired gallbladder emptying who underwent cholecystectomy for symptomatic chronic acalculous cholecystitis were identified. Twelve nondiseased controls without biliary symptoms who underwent incidental cholecystectomy during surgery for liver or pancreatic disease and 13 diseased controls who underwent cholecystectomy for symptomatic chronic calculous cholecystitis were chosen from a database of over 500 patients and were matched for gender, Body Mass Index (BMI) and surgeon to the acalculous cholecystitis patients. Acalculous cholecystitis and control demographics were recorded. Surgical pathology specimens from cases and controls were reviewed in a blinded fashion for gallbladder wall fat and inflammation (04+). Data were analyzed by Student’s t test. RESULTS: Acalculous cholecystitis patients were younger (p < 0.05) than nondiseased or diseased controls (41 vs 57 vs 57 years). Gallbladder (GB) wall thickness (mm), fat thickness (mm), % fat and inflammatory scores (IS) are presented in the table.

GB Wall GB Fat % Fat IS Nondiseased Controls 2.1 ± 0.2 0.1 ± 0.1 6.8 ± 3.7 1.3 ± 0.4 Acalculous Cholecystitis 1.6 ± 0.2 0.6 ± 0.2† 33.6 ± 8.9† 1.5 ± 0.3 Calculous Cholecystitis 3.2 ± 0.5* 1.1 ± 0.3† 34.9 ± 6.9† 2.9 ± 0.3§

*p < 0.03 vs Acalculous; †p < 0.03 vs Controls; §p < 0.001 vs Controls and Acalculous CONCLUSIONS: These data suggest that compared to nondiseased controls 1) patients with acalculous cholecystitis are younger and have increased gallbladder fat and 2) patients with calculous cholecystitis have increased gallbladder fat and inﬂammation. We conclude that increased gallbladder fat may lead to poor gallbladder emptying and biliary symptoms. Thus, steatocholecystitis may explain, in part, the increased need for cholecystectomy and the higher percentage of these patients with acalculous cholecystitis.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

694 Rapid Re-Operation for Crohn’s Disease Mary Otterson, KR Theriot, David Binion, D. Thameem, S. Shidham, O.A. Hatoum, Sarah Lundeen, Gordon Telford; Medical College of Wisconsin, Milwaukee, WI BACKGROUND: A subpopulation of Crohn’s Disease (CD) patients requires rapid re-operation. We analyzed multiply resected pts to characterize the factors contributing to rapid re-operation. METHODS: Consecutive CD pts requiring multiple surgeries (resection & anastomosis and/or strictureplasty) at a tertiary IBD center over 7 y were reviewed. Rapid re-operation was defined as repeat abdominal surgery within 2 y. Operations at outside institutions & our facility were analyzed. Demo- graphic data & medical therapy were recorded. Factors contributing to rapid re-operation were defined as technical, adhesions, inadequate immunomodu- lator therapy (IMT) & severe disease despite IMT. Technical was defined as retained strictures & stenotic anastomoses. IMT included azathioprine/6MP, methotrexate & or infliximab. Pts with insufficient 6MP metabolites were included as inadequate therapy. RESULTS: 432 CD patients were reviewed; 65 pts required > 2 surgeries (200 abdominal operations). 32 of these pts required re-operation within 2 y (50 surgeries). There was no significant difference in gender, smoking status, disease location & age of onset between groups. Time between diagnosis & 1st surgery did not predict rapid re-operation. There were 27 rapid re-operations in the 1st post-op y (technical—30%, adhesions—4%, inadequate IMT—47%, severe disease despite IMT—19%). Between y 1–2, there were 23 rapid re-operations. In this group, the technical error contributed to 13% and severe ABSTRACTS disease despite IMT—9%; inadequate IMT was linked to the majority of these TUESDAY rapid re-operations (78%). Pts who underwent rapid re-operation were more likely to undergo additional surgical procedures < 2 years. The operative interval for all surgical procedures for pts who had undergone rapid re-operation was 2.9 + 4.5 y (mean + SD) compared to those pts who had never had rapid re- operation (7.6 + 4.9 y). Rapid re-operation pts had a similar number of surgical procedures to those with longer time intervals between procedures (rapid 3.0 + 1.2 surgeries; longer interval 2.9 + 1.3 surgeries). The interval between procedures 1 through 4 is significantly shorter in pts who have ever been categorized as rapid re-operative (p < 0.05; Mann Whitney). CONCLUSIONS: Crohn’s disease pts requiring rapid re-operation exhibit a distinct clinical pattern. Technical problems caused re-operation in 1/3 of pts in y 1 following laparotomy but only accounted for 13% of rapid re-operation by y 2. Lack of effective IMT became the dominant factor associated with rapid re-operation during post-op y 2. Pts who require rapid re-operation for CD continued to require more frequent surgeries & represent a more ill subset of pts.

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695 A New Drug Delivery System Targeting Ileal Epithelial Cells Induced Electrogenic Sodium Absorption: Possible Promotion of Intestinal Adaptation Following Total Colectomy Sho Haneda1, Kouhei Fukushima1, Yuji Funayama1, Chikashi Shibata1, Ken-ichi Takahashi1, Hitoshi Ogawa1, Yasuhiko Tabata2, Iwao Sasaki1; 1Surgery, Tohoku University, Graduate School of Medicine, Sendai, Japan; 2Institute for Frontier Medical Science, Kyoto University, Kyoto, Japan BACKGROUND: Patients undergoing total proctocolectomy (TPC) suffer from persistent postoperative diarrhea and frequent bowel movement. We investigated mechanisms of intestinal adaptation and demonstrated induction of the epithelial sodium channel (ENaC), prostasin, and 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) and activation of sodium transport mediated by those molecules in the remnant ileum (AJP276:G975, Surgery137:75). Aldosterone infusion also induced the expression of these molecules (J GI Surg9:236), suggesting locally enhanced mineralocorticoid action in the absence of systemic effects may be therapeutically beneficial in patients with persistent diarrhea after TPC. OBJECTIVE: The aims of the present study were to develop a new drug delivery system that targets ileal epithelial cells, to induce the molecules for sodium absorption and to investigate whether this system has therapeutic roles for postoperative diarrhea following TPC. METHODS: We established D-aldosterone-containing D, L-lactide/glycolide copolymer (PLGA) microspheres (Ald-PLGA). Ald-PLGA are absorbed in the terminal ileum and gradually release aldosterone in rats. Blood and terminal ileal tissues were collected two weeks after the administration of Ald-PLGA, D-aldosterone or PLGA alone. We measured the aldosterone concentrations in plasma and ileal tissues. We evaluated mRNA expressions of three subunits of ENaC, prostasin, 11β-HSD2, sodium/glucose co-transporter 1 (SGLT-1), and α1-, and β1-subunit of Na/K ATPase in epithelial cells of the ileum. Protein expression of ENaCα-subunit and ENaC-mediated sodium transport were evaluated by immunohistochemical and electrophysiological techniques, respectively. RESULTS: Significantly high levels (200 pg/g) of tissue aldosterone in the absence of elevated plasma levels were detected only in the Ald-PLGA-treated rats. Epithelial expression of ENaC subunits, prostasin and 11β-HSD2 but not of SGLT-1 and Na/K ATPase subunits mRNAs increased significantly only in the Ald-PLGA-treated animals. ENaC protein expression was enhanced in the brush border of the ileal epithelia only in the Ald-PLGA-treated rats. That was the case in amiloride-sensitive electrogenic sodium transport. CONCLUSION: Ald-PLGA successfully induced the expression of several molecules participating in aldosterone-mediated sodium absorption and activated sodium transport in the ileal mucosa, both of which are essential for intestinal adaptation. Pre- and/or post-operative treatment with this drug may compensate for the excessive loss of sodium and water following TPC.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

696 1382 Pancreaticoduodenectomies for Pancreatic Cancer: A Single Institution Experience Jordan M. Winter1, John L. Cameron1, Kurtis A. Campbell1, David Chang1, JoAnn Coleman1, Patricia K. Sauter2, Ralph H. Hruban5, Taylor S. Riall3, Richard D. Schulick1, Michael A. Choti1, Keith D. Lillemoe4, Charles J. Yeo2; 1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, Thomas Jefferson University, Philadelphia, PA; 3Surgery, University of Texas Medical Branch, Galveston, TX; 4Surgery, Indiana University, Indianapolis, IN; 5Pathology, Johns Hopkins Hospital, Baltimore, MD OBJECTIVE: This study reviewed pancreaticoduodenectomy (PD) for pancreatic cancer. METHODS: We reviewed 1382 patients who underwent a PD for pancreatic cancer between April 1970 and November 2005. RESULTS: A total of 1382 PDs were performed for pancreatic cancer, with 600 PDs performed in the last ﬁve years. Pathologic diagnoses included 1168 ductal adenocarcinomas, 93 malignant neuroendocrine tumors, 90 IPMNs with invasive cancer, and 31 other neoplasms. Patients with ductal adenocarcinoma were analyzed in detail: the most common preoperative symptoms included jaundice (75%), weight loss (51%), and abdominal pain (38%). Seventy-two percent of the PDs were pylorus preserving and 6% were total pancreatectomies. The median tumor diameter was 3 cm, 43% of the resections had positive margins, 78% had positive nodes, 52% had small vessel invasion, and 91% had perineural invasion. The perioperative morbidity was 38%, with the most common complications being delayed gastric emptying ABSTRACTS

(14.2%), wound infection (8.6%), and pancreatic ﬁstula (4.7%). Median post- TUESDAY operative stay was 9 days. The perioperative mortality, by decade, was 30.4% in the 1970s (p < 0.001 compared to the 2000s), 4.5% in the 1980s (p = 0.03), 1.9% in the 1990s, and 1.1% in the 2000s. The median survival for all patients with ductal adenocarcinoma was 17 months (1-year survival = 65%, 5-year survival = 17%). The median survival with no positive lymph nodes, negative margins, and tumor diameter less than 3 cm was 32 months (1-year survival = 78%, 5-year survival = 38%). In a cox proportional hazards model,

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pathologic factors that had a signiﬁcant negative impact on survival included margin status (hazard ratio, HR = 1.6), lymph node status (HR = 1.4), and tumor diameter (HR = 1.4). CONCLUSION: This is the largest single institution experience with resected pancreatic cancer. Patients who have cancers with favorable pathological features have a signiﬁcantly improved long-term survival.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

697 Successful Diaphragm Pacing in a Porcine Model with Natural Orifice Transvisceral Endoscopic Surgery (NOTES): Increasing the Options for Intensive Care Unit (ICU) Patients Raymond Onders1,2, Michael McGee1,2, Jeffrey Marks1,2, Anthony Ignagni1,2, Michael Rosen1,2, Amitabh Chak1,2, Ashley Faulx1,2, Robert Schilz1,2, Steve Schomisch1,2, MaryJo Elmo1,2, Jeffrey Ponsky1,2; 1University Hospitals of Cleveland, Cleveland, OH; 2Case Western Reserve University, Cleveland, OH BACKGROUND: Patients requiring prolonged mechanical ventilation in ICUs spend up to 40% of the time weaning from the ventilator. Failure to wean from mechanical ventilation is attributed to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics; all of which may benefit from a physiologically negative chest pressure with diaphragm pacing. We have shown that laparoscopic implantation of a diaphragm pacing stimulation (DPS) system provides adequate ventilation in spinal cord injured patients and decreases respiratory decline in patients with amyotrophic lateral sclerosis (ALS. We propose that acute ventilator assistance with interventional diaphragmatic neurostimulation is feasible and could facilitate weaning from mechanical ventilation. Bedside placement, like a gastrostomy tube, of the DPS system will expand the benefits of DPS to a new population of critically ill patients. This study expands our previous feasibility evaluations in a porcine model. METHODS: Pigs were anesthetized and peritoneal access with the flexible

endoscope was obtained using a guidewire, needle knife cautery and balloon ABSTRACTS dilatation. The diaphragm was mapped to locate the motor point (where TUESDAY stimulation yields maximal muscle contraction) with a novel endoscopic electrostimulation catheter. Intramuscular electrodes were placed at the motor point with a percutaneous needle into each hemidiaphragm. The electrodes were attached to the DPS system for pacing. The gastrotomy was sealed with a gastrostomy tube. RESULTS: Three pigs were studied; the motor point was located in all animals with the endoscopic mapping instrument. Under trans-gastric endoscopic visualization bilateral percutaneous pacing electrodes were placed in all animals in less than 15 minutes. With the DPS system, ventilation was performed and tidal volumes recorded with Wright Spirometer. The animals were sacriﬁced and examined. There were no trans-diaphragmatic injuries from percutaneous needle placement, the gastrostomy tube adequately closed the gastric opening and the pacing wires could be completely removed with less tensile force than standard temporary cardiac pacing wires. CONCLUSIONS: These animal studies conﬁrm that trans-gastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation is feasible. This NOTES method of implanting temporary pacing wires will be assessed as a continuation of an IRB approved trial of laparoscopic implantation of temporary pacing wires for patients on prolonged mechanical ventilation requiring feeding tube placement.

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3:30 PM – 4:30 PM SSAT POSTERS OF DISTINCTION 402 A QUICK SHOTS Co-Moderators: Mark P. Callery, Boston, MA Nathaniel J. Soper, Chicago, IL 698 Cancer of the Gallbladder: National Patterns of M1396 Surgical Intervention James T. McPhee, Maksim Zayaruzny, Giles F. Whalen, Demetrius E. Litwin, Mary E. Sullivan, Frederick A. Anderson, Jennifer F. Tseng; Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA PURPOSE: Gallbladder cancer (GBC) is the 5th most common gastrointestinal malignancy. GBC carries a poor prognosis due to its often advanced stage at presentation. We sought to evaluate disease demographics as well as national patterns of surgical intervention. METHODS: Using the National Inpatient Sample (NIS) 1998-2003 we identified 3345 patients (16,460 nationally by weighted average) discharged from U.S. hospitals with a primary diagnosis of GBC (ICD-9 diagnostic code [156.0]). Patients were categorized based on primary as well as secondary (up to 15) surgical interventions during the same hospitalization based on ICD-9 procedure codes for cholecystectomy (CCY), bile duct resection, hepatectomy or pancreaticoduodenectomy. Primary outcomes measured were procedure type and in-hospital mortality. RESULTS: Of 3345 patients with GBC, 71% were female. 70% were white, 12% were Hispanic, and 10% were Black. Mean age was 70. Overall in-hospital mortality for the entire cohort was 11.6%. Of the initial cohort, 44.3% underwent CCY as the primary surgical intervention (28.9% open, 15.6% laparoscopic). Other primary procedures included pancreaticoduodenectomy (0.2%), hepatic resection (5.3%), or bile duct resection (1.1%) in conjunction with CCY. For the simple CCY group, 2.5% of patients underwent further resection (hepatic resection or bile duct resection) during the same hospitalization. Patients admitted to non-teaching hospitals had higher mortality than patients admitted to teaching hospitals on univariate analysis; after adjustment for comorbidities using multivariate logistic regression, this difference remained significant (adjusted OR 2.03, 95% CI 1.36–3.03). Females had a decreased risk of in-hospital mortality compared to males after multivariate analysis (adjusted OR 0.79, 95% CI 0.63–0.99). Of note, on univariate analysis, open CCY had a significantly higher mortality rate than laparoscopy (5.3% vs. 4.1%, p < .05, chi square), however after multivariate analysis, this difference became insignificant (adjusted OR 0.69, 95% CI 0.41–1.18). CONCLUSIONS: The surgical management of GBC is critical, as 1) GBC is generally only diagnosed in early stages as an incidental finding at routine cholecystectomy, and 2) at present, treatment of GBC with curative intent must include complete surgical resection. Based on this large population study, > 50% of patients discharged with a diagnosis of GBC underwent resection, with the vast majority of patients undergoing cholecystectomy alone. More detailed studies that include follow-up care are warranted to ascertain that patients with GBC receive adequate surgical treatment for this aggressive malignancy.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

699 Targeting MEK with PD325901 Inhibits Hepatocellular M1885 Carcinoma Growth in TGF-α Transgenic Mice Matthew Hennig1, Patrick Klein1,2, Navin Bansal3, Nedumangalam Hekmatyar3, Sabrina Wentz1, Amanda Norris1, Stephen Noble1, Courtney Doyle1, Huangbing Wu1, Yufang Wang1, Jean Campbell4, Nelson Fausto4, Glenn Merlino6, Judith Sebolt-Leopold7, C.M. Schmidt1,8; 1Surgery, Indiana University, Indianapolis, IN; 2Pharmacology and Toxicology, Indiana University, Indianapolis, IN; 3Radiology, Indiana University, Indianapolis, IN; 4Pathology, University of Washington, Seattle, WA; 5Biology, University of North Carolina-Charlotte, Charlotte, NC; 6Molecular Genetics, National Institutes of Health, Bethesda, MD; 7Pfizer Global R&D, Inc., Ann Arbor, MI; 8Richard L. Roudebush VAMC, Indianapolis, IN BACKGROUND: Hepatocellular carcinoma (HCC) is a common cause of death from solid organ malignancy worldwide. Systemic chemotherapy has been largely unsuccessful; thus, novel treatments are needed. Extracellular- regulated kinase kinase (MEK) signaling is a critical growth regulatory pathway in HCC. Targeting MEK with a novel small molecule inhibitor, PD325901, may inhibit HCC tumorigenesis. METHODS: MT-42 (CD-1) TGF- transgenic mice spontaneously form HCC, a process accelerated with diethylnitrosamine (5 mg/kg i.p.) at 2 weeks of age. Hepatocytes (TAMH) isolated from the livers of TGF-α transgenic mice grow aggressively in culture and form flank HCC tumors in athymic nude mice. ERK expression was determined by Western blot. MEK activity was determined by phospho-specific ERK immunoblot. Cell growth was determined by trypan-blue excluded cell counts. Tumor growth was determined by caliper ABSTRACTS measurement or volumetric averaging by magnetic resonance imaging (MRI). TUESDAY RESULTS: PD325901 (0.01–100 nM) inhibited MEK activity in TAMH cells in a concentration-dependent fashion at 1 hr and 24 hr time points. PD325901 treatment also resulted in a concentration-dependent inhibition in cell growth (48 hr IC50 = 0.1 nM). Athymic mice bearing TAMH flank tumors >100 mm3 were treated with vehicle or PD325901 (20 mg/kg; once daily; gavage) for 24 hrs or 16 days. Ex vivo analysis revealed a significant reduction of MEK activity (average 54%, n = 10, p < 0.01) in TAMH tumors at 24 hours after a single dose of PD325901. Growth rate of flank tumors over the 16 days was reduced 3 fold in the treatment arm (1113 ± 269% v 3077 ± 483%, P < 0.01). To confirm this in our developmental model, 37 MT-42 (CD- 1) TGF-α mice (DEN) at 9 months of age were treated with either vehicle or PD325901 (20 mg/kg; gavage) for 5 weeks. Forty-seven percent of mice sacrificed on vehicle had gross HCC whereas only 14% had HCC in the treatment arm. Separately, MT-42 (CD-1) TGF- mice (DEN) underwent screening magnetic resonance imaging (MRI) to detect HCC at >6 months of life. Two mice with index lesions (HCC) underwent determination of baseline tumor growth with volumetric averaging by bi-weekly MRI, followed by treatment with PD325901. Volumetric determinations demonstrated an average 43% decrease in tumor growth with PD325901 relative to vehicle. CONCLUSIONS: These studies demonstrate that targeting MEK with PD325901 decreases experimental HCC growth in vitro and in vivo. This provides com- pelling preclinical evidence that targeting MEK in human clinical trials may be promising in the treatment of HCC.

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700 Does Reflux Height Matter? A Study of 1680 Patients M1445 Guilherme M. Campos1, Fernando Herbella1, Ian Nipomnick1, Marco Patti1, Eric Vittinghoff2; 1Surgery, University of California, San Francisco, San Francisco, CA; 2Epidemiology, University of California, San Francisco, San Francisco, CA BACKGROUND: Dual-channel pH monitoring, which measures if gastric reflux reaches the proximal esophagus, is used mostly in patients with atypical symptoms of gastroesophageal reflux disease (GERD), but its value in clinical practice is undetermined. AIMS: To study the clinical characteristics of proximal reflux in a large institutional sample of patients with GERD and evaluate the usefulness of dual- channel pH monitoring. PATIENTS AND METHODS: We reviewed the records of all patients who underwent dual-channel esophageal pH monitoring between January 1990 and July 2005. Patients with named esophageal motility disorders and previous foregut surgery were excluded. Patients were grouped according to primary symptom [typical symptoms (heartburn, regurgitation or dysphagia) versus atypical symptoms [respiratory, chest pain, or ear, nose and throat (ENT)], and pH profile findings [combined reflux (CR)—abnormal distal reflux (composite score >14.7) and abnormal proximal reflux (number of single reflux episodes >18) or abnormal distal reflux only (ADRO)]. Group differences were analyzed with Chi-square or Mann-Whitney U Tests. RESULTS: Of the 1,680 patients who underwent dual-channel pH monitoring, over 60% had CR; and abnormal proximal reflux prevalence was similar in the groups (Table 1). Patients with ENT symptoms had greater proximal esophageal exposure to acid than other groups. Proximal esophageal exposure to acid in all other groups was similar (Table 2). Table 1. Prevalence of ADRO and CR

Group All (n = 1680) ADRO (n = 596) CR (n = 1084) p value Typical Symptoms 1342 (79.9%) 475 (35.4%) 867 (65.6%) Atypical Symptoms 338 (20.1%) 121 (35.8%) 217 (64.2%) 0.9 Respiratory 174 (10.4%) 61 (35.1%) 113 (64.9%) 1.0 Chest pain 128 (7.6%) 50 (39.1%) 78 (60.9%) 0.4 ENT 36 (2.1%) 10 (27.8%) 26 (72.2%) 0.4

Values are expressed as number and percentages. Table 2. Reflux Profile in Patients Groups Divided by Primary Symptom

Group Typical Sx. Respiratory Chest Pain ENT p value # RE Distal 149 (100–225) 137 (100–208) 138 (89–215) 125 (100–187) 0.3 # RE Proximal 28 (13–55) 27 (11–55) 29 (9–59) 44 (14–76) 0.04 %TpH < 4 Distal 10.5 (5–25.7) 8.6 (5–20) 8 (3.6–18.5) 12.7 (8–50) 0.08 %TpH < 4 Proximal 1 (0–4) 1 (0.2–3) 1 (0–4) 3.1 (1.1–7.8) 0.01

Values are expressed as median (Interquartile range) and number (percentages); # RE = number of reflux episodes, %TpH < 4 = percent time pH < 4 CONCLUSIONS: Greater proximal esophageal exposure to acid may cause ENT symptoms. Abnormal proximal reﬂux is not a distinctive feature of reﬂux induced respiratory and chest pain symptoms. Additional clinical information is needed to support the use of Dual-channel pH monitoring in clinical practice.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

701 Short Tandem Repeat Polymorphism in EXON 4 of M1882 Esophageal Cancer Related Gene—2 As a Prognostic Marker for Esophageal Carcinoma Tamina Rawnaq1, Jussuf T. Kaiﬁ1, Paulus G. Schurr1, Michael Bubenheim2, Oliver Mann1, Emre F. Yekebas1, Petra Merkert1, Viacheslav Kalinin1, Bjoern-Christian Link1, Tim Strate1, Guido Sauter3, Klaus Pantel4, Jakob R. Izbicki1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg- Eppendorf, Hamburg, Germany; 2Institute for Biometry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Institute for Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 4Institute for Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Short tandem repeat (STR) polymorphisms in exon 4 of esophageal cancer related gene (ECRG2) have been described to be a risk marker for esophageal carcinoma. The aim of the present study was to examine whether ECRG2 STR polymorphisms are a genetic prognostic marker for esophageal carcinoma. 86 esophageal carcinoma patients that underwent complete surgical resection were included. We retrospectively analyzed peripheral blood samples for STR TCA3/TCA3, TCA3/TCA4 and TCA4/TCA4 in the noncoding region of exon 4 of ECRG2 by using PCR, capillary electrophoresis and DNA sequencing analysis. Associations between STRs and survival were investigated with log-rank test and Cox multivariable analysis. All statistical tests were two-sided. ECRG2 STR TCA3/TCA3 and TCA3/TCA4 genotype were found in 40 (47%)

patients respectively, and TCA4/TCA4 was found in 6 (7%) cases. TCA3/TCA3 ABSTRACTS TUESDAY was statistically significantly associated with reduced tumor-specific, relapse- free and overall survival, compared with grouped TCA3/TCA4 and TCA4/ TCA4 genotypes (P < 0.05; log-rank test). The median tumor-specific survival of patients with TCA3/TCA3 genotype was 19 months (95% confidence interval [CI] 5–33 months) and TCA3/TCA4 and TCA4/TCA4 genotype was 34 months (95% CI: 12–55 months). TCA3/TCA3 STR in ECRG2 was statistically the strongest prognostic factor for tumor-specific (relative risk [RR] 2.34 (95% CI 1.31–4.16); p = 0.004) and relapse-free survival (RR 2.89, 95% CI 1.63–5.11; p < 0.001) determined by multivariable Cox regression analysis. STR polymorphism TCA3/TCA3 in exon 4 of ECRG2 is associated with poor clinical outcome in esophageal cancer patients. ECRG2 might play a role in carcinogenesis of esophageal carcinoma and the mechanism has to be explored in future studies.

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702 A Prospective Evaluation of an Algorithm Incorporating M1497 Routine Pre-Operative Endoscopic Ultrasound-Guided Fine Needle Aspiration in Suspected Pancreatic Cancer Patients Mohamad Eloubeidi1, Shyam Varadarajulu1, Shilpa Desai1, Rhett Shirley1, Martin Heslin2, Mohit Mehra1, Juan P. Arnoletti2, Isam Eltoum3, C. Mel Wilcox1, Selwyn Vickers2; 1Gastroenterology and Hepatology, University of Alabama at Birmigham, Birmingham, AL; 2Surgery, University of Alabama, Birmingham, AL; 3Pathology, University of Alabama, Birmingham, AL BACKGROUND: Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) has emrged as safe, accurate and cost effective method for tisse diagnosis in suspected pancreatic cancer. It is also used as a research tool for obtaining tissue for pharmcagenomics analysis to assess response to induction chemotherapy and radiotherapy. In addition, we have shown that cytologic grade predicts survival in patients with pancreatic cancer.Whether tissue diagnosis is required in the pre-operative evaluation of patients with suspected pancreatic cancer (PanCA) remains controversial. We prospectively evaluated the accuracy, safety and potential impact on surgical intervention of an algorithm that incorporated (EUS-FNA) in the pre-operative evaluation in patients suspected to have PanCA. METHODS: All patients referred to our institution (n = 547) over a 4.5 year period were enrolled. Patient underwent EUS-FNA on outpatient basis by one of two experienced endosonographers in the presence of a cytopathologist. Patient underwent surgical exploration and resection based on their comorbidity status, evidence of resectability based on spiral CT and EUS imaging reviewed in a multidisciplinary approach. RESULTS: Of 547 enrolled, (median age was 64 years, 60% male) 49% presented with obstructive jaundice. Diagnostic accuracy of EUS-FNA was 94%, sensitivity 95.0%, speciﬁcity 89%, PPV of 97% and NPV 81%. Of the 414 true positive patients by EUS-FNA, 138 (33%) were explored. Of patients deemed operable by combined imaging, 74% had surgical resection. Eighty four percent of true positive patients were not resected and received palliative therapy or chemotherapy. Of the 94 patients with true negative cytology based on extended follow up, only 7 (7%) underwent surgical resection. Of those with false negative diagnoses (n = 24), 5 patients underwent exploration/resection based on detection of mass lesions by EUS. The remaining patients had unresectable disease. Mild self-limiting pancreatitis occurred in (0.91%). CONCLUSIONS: EUS-FNA is a safe and highly accurate method for tissue diagnosis in patients with PanCA. This approach allows for pre-operative counseling of patients, minimizing surgeon’s operative time in cases of unresectable disease, and avoids surgical biopsies in the majority of patients with inoperable PanCA. It allows also conservative management of patients with benign biopsies. We still, however, recommend exploration for patients with clinical scenario suspicious for PanCA, a mass found on EUS or CT but incon- clusive or negative cytology.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

703 Detection of Microsatellite Alteration in Serum DNA M1906 As a Tool for Differentiation Between Benign and Malignant Diseases of the Pancreas Robin Wachowiak1, Jussuf T. Kaifi1, Bjoern C. Link1, Dean Bogoevski1, Guellue Cataldegirmen1, Uta Reichelt2, Lars Wolfram1, Jakob R. Izbicki1, Emre F. Yekebas1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: The diagnosis of pancreatic masses to distinguish pancreatic carcinoma from chronic pancreatitis may be difficult. In patients with pancreatic masses of dubious dignity, the detection of tumor specific DNA alterations like “Loss of heterozygosity” could be a helpful tool in an easily accessible anatomical compartment. METHODS: DNA was analysed from serum and peripheral blood from 24 patients with ductal adenocarcinoma of the pancreas, 12 patients with chronic pancreatitis and 12 healthy individuals. In total, 12 microsatellite markers were investigated. RESULTS: Twenty-two (92%) of 24 carcinoma patients had one or more alterations in the serum DNA. In contrast, only four (33%) of 12 patients with chronic pancreatitis had one LOH in the serum. In the serum DNA of the 12 healthy individuals, no LOH was detected. Specificity of the 12 markers examined ranged from 50% to 100%, whereas sensitivity was 3% to 78%. LOH was identified most frequently with a sensitivity of 56% and a specificity of 91% at the microsatellite marker region D17S787 localized on ABSTRACTS

chromosome 17. TUESDAY CONCLUSION: In comparison to patients with chronic pancreatitis, a high incidence of LOH appeared in the serum DNA of pancreatic carcinoma patients. Microsatellite detection in easily accessible serum of pancreatic carcinoma patients could be an important tool for early and differential diagnosis of unclear pancreatic masses.

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704 Microsatellite DNA Alterations of Gastro-Intestinal M1570 Stromal Tumors Are Predictive for Outcome Paulus G. Schurr1, Stefan Wolter1, Jussuf Kaiﬁ1, Uta Reichelt2, Helge Kleinhans1, Robin Wachowiak1, Emre Yekebas1, Tim Strate1, Viacheslav Kalinin1, Hansjoerg Schaefer1, Izbicki Jakob1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg, Hamburg, Germany; 2Department of Pathology, University Medical Center Hamburg, Hamburg, Germany PURPOSE: In gastro-intestinal stromal tumors (GIST), loss of heterozygosity (LOH) on chromosome 22 has been described. The prognostic value of these and other DNA regions for patient survival remain unclear. EXPERIMENTAL DESIGN: 60 patients who underwent surgery at our institution between 1992 and 2003 were histopathologically re-classiﬁed by immunohistochemistry and the GIST consensus group criteria 2001. 23 microsatellite loci on chromosomes 3, 9, 13, 17, 18 and 22 were screened for alterations in tumor and healthy DNA. Survival was calculated by Kaplan- Meier plots.

RESULTS: 11/60 patients showed metastases at presentation (18.3%). 13/60 (21.7%) were high-risk GIST. LOH were found in all tumors. 28/60 (46.7%) showed more than 2 LOH in 23 microsatellite marker sites. The frequency of single marker LOH varied from 1.7% to 28.3% among tumors. Frequent LOH were found on chromosome 22 and 17. The correlation of LOH positivity and the consensus scoring was significant (p < 0.001, chi-square test). After a median observation time of 33.3 months (95% confidence interval: 23.9– 42.6), overall survival was best for very low, low and intermediate risk tumors with only 6/36 death events, whereas 14/24 high risk and metastasized patients had died (p < 0.001, log-rank test). Likewise, LOH significantly predicted survival (p = 0.014) and the effect was particularly detrimental for LOH on chromosome 17 (p < 0.001). CONCLUSIONS: LOH are useful phenomena for the prognosis of GIST. Rather than chromosome 22 markers, chromosome 17 markers independently predict survival. From its linkage to chromosome 17, a fundamental role of p53 in the late stages of GIST can be derived.

118 SSAT.book Page 119 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

705 Robotic Assisted Versus Laparoscopic Cholecystectomy: M1389 Outcome and Cost Analysis in a Case-Matched Control Study Stefan Breitenstein, Antonio Nocito, Carmen Oggier, Markus Weber, Perre-Alain Clavien; Universitiy Hospital Zurich, Zurich, Switzerland BACKGROUND: The advantages of robotic assisted surgical procedures, specifically 3D view, magnification and flexibility of the instruments, are well documented. However, pressure is universally applied to decrease costs, leading to restriction of development and implementation of new technologies. So far, neither outcome nor costs of computer assisted versus laparoscopic cholecystectomies have been analyzed. METHODS: From September 2004 to August 2005, data from 50 consecutive patients who underwent robotic assisted cholecystectomy (Da Vinci Robot, Intuitive Surgical) was collected. These patients were matched 1:1 to 50 patients with laparoscopic cholecystectomy (operated from 2001 to 2005) according to age, gender, ASA (American Society of Anesthesiology) histology and the experience of the surgeon. Endpoints constituted morbidity, graded according to a new severity classification, operation time, hospital stay and related costs. RESULTS: Both groups were comparable regarding patient characteristics, co-morbidities and histology. One severe complication occurred in each group (2%). In the robotic group a postoperative bile leak of the cystic duct was treated by endoscopic stenting (severity score 3a). In the laparoscopic group a re-operation due to jejunal perforation (severity score 3b) had to be

performed. Operation time (skin-to-skin) for robotic assisted cholecystectomy ABSTRACTS was significantly shorter than for the laparoscopic approach (75’ vs 98’, p < TUESDAY 0.001). In contrast, hospital stay was comparable in both groups (2.6d vs 2.8d, p = 0.49).Overall hospitalization costs for robotic assisted cholecystectomy were significantly higher compared to the laparoscopic group ( 5881 vs. 5181, p < 0.001), basically due to amortisation and consumables for the robotic system ( 1451 vs. 387). Variable costs generated in the operating theatre, such as medical and nursing time, were significantly lower in the robotic group ( 1522 vs. 1745, p = 0.01). Fixed and variable costs generated on the ward were comparable in both groups ( 2908 vs. 3060, p = 0.67). Excluding amortisation and maintenance costs for the robotic system, the overall hospitalisation costs were similar in both groups ( 5285 vs. 5181, p = 0.45). CONCLUSIONS: Robotic assisted cholecystectomy is a safe and therefore valuable approach. Despite the shorter operation time compared to laparoscopic cholecystectomy, purchase costs and maintenance fees clearly and unequivocally render robotic assisted cholecystectomy the more expensive procedure. Therefore a reduction of these acquisition and maintenance costs is a pre-requisite for a large-scale adoption and implementation of this technology in surgery.

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706 Radiofrequency Ablation for HCCn Cirrhotic Patients: M1485 Prognostic Factors for Survival Andrea Ruzzenente, Marco Sandri, Calogero Iacono, Silvia Pachera, Corrado Pedrazzani, Sebastiano Tasselli, Alfredo Guglielmi; Surgery and Gastroenterology, University of Verona, Verona, Italy BACKGROUND: Radiofrequency ablation of hepatocellular carcinoma has proved to be useful in local control of tumor, few data on survival after treatment are available in literature. The aim of the study was to evaluate factors related to survival and to identify different classes of risk after radiofrequency ablation. METHODS: ninety-eight cirrhotic patients with 145 hepatocellular carcinomas were treated with radiofrequency ablation from January 1998 to May 2004. In 55 patients cirrhosis was in Child-Pugh class A and in 43 in class B. Tumor was single in 60 and multiple in 38, mean tumor number was 1.5 (range 1–3). Tumor size ranged from 1.5 to 6.0 cm, mean 3.8 cm. Mean follow up period was 24.9 months. Radiofrequency ablation was performed with expandable type needle with percutaneous approach under real-time ultrasound guidance. For statistical analysis univariate and multivariate analysis were performed. RESULTS: Complete ablation of the tumor was achieved in 85.5% of lesions. 1- and 3- years survival was 76.7% and 36.6%, respectively. Univariate analysis showed that CLIP (Cancer of The Liver Italian Program) score, tumor growth pattern, alpha-fetoprotein level and complete tumor necrosis, were factors signiﬁcantly related to poor survival. Multivariate analysis identiﬁed that factors related to poor survival were alpha-fetoprotein level >100 ng/ml, Child-Pugh class B and incomplete tumor necrosis with an hazard ratio of 4.0, 2.7 and 3.8, respectively. After complete ablation median survival was 38 months in patients with Child-Pugh class A cirrhosis and alpha-fetoprotein level ≤100 ng/ml, 22 months for patient with Child-Pugh class B cirrhosis and alpha-fetoprotein ≤100 ng/ml and 9 months for patient with Child-Pugh class A cirrhosis and alpha-fetoprotein >100 ng/ml (p < 0.01). CONCLUSIONS: Complete necrosis and absence of residual tumor positively affect survival after treatment. In patients with Child-Pugh A cirrhosis and alpha-fetoprotein level ≤100 radiofrequency ablation have results that are comparable to those of surgical resection, 55% after 3 years. In patients with Child-Pugh B cirrhosis and/or alpha-fetoprotein >100 ng/ml showed less satisfactory results.

120 SSAT.book Page 121 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

707 Hyperbilirubinemia in Appendicits: A New Predictor of M1407 Perforation Joaquin Estrada, Rodney J. Mason, Mikael Petrosyan, Jordan Barnhart, Matthew Tao, Shirin Towfigh; Surgery, University of Southern California, Los Angeles, CA HYPOTHESIS: Elevated serum bilirubin is associated with perforated appendicitis. DESIGN: Retrospective observational descriptive study using multiple logistic regression expressed as odds ratios. SETTING: Large public teaching hospital. PATIENTS: One hundred and seventy consecutive patients with a diagnosis of appendicitis. Patients were included in the study if they had liver function tests on admission and underwent appendectomy. MAIN OUTCOME MEASURES: 1) Incidence of hyperbilirubinemia. 2) Dependent variable: Presence of pathologically defined gangrenous/ perforated appendicitis (vs. acute appendicitis). 3) Independent variables: Age (≤ and >18 years), duration of symptoms (≤ and >24 hours), admission temperature (≤ and >38°C), white blood cell count (WBC ≤ and >10.3 K/cumm), and systematic inflammatory response score (SIR score ≤ and >2). RESULTS: Appendicitis was found and confirmed pathologically in 157 (92%) of 170 patients. Elevated total bilirubin levels (>1 mg/dL) were found in 59 (38%) of 157 patients. Patients with pathologically defined gangrene or perforation were significantly (p = .004) more likely to have hyperbilirubine- ABSTRACTS

mia than those with acute appendicitis (see table). No statistical differences TUESDAY were observed for any of the other variables (see table). On logistic regression the only significant relationship between the presence or absence of appendiceal gangrene and perforation was the presence of hyperbilirubinemia (p = 0.031, 95% confidence interval 1.11–7.6). None of the other variables showed any significant relationship. The odds of appendiceal perforation are 3 times higher (Odds ratio of 2.96) for patients with hyperbilirubinemia compared to those with normal bilirubin levels.

Gangrenous/ Acute Appendicitis Perforated Appendix p value n = 116* n = 41* Total Bilirubin ( >1mg/dL) 36 (31%) 23 (56%) .004 Duration of symptoms ( >24hrs) 69 (59%) 31 (76%) .065 WBC ( >10.3 K/cumm) 89 (77%) 30 (73%) .429 Temp > 38oC 26 (22%) 13 (31%) .236 SIR Score (>2) 17 (15%) 9 (22%) .280 Age (≤18 years) 12 (10%) 4 (10%) .915

*A pathological normal appendix was found in 13 patients.

CONCLUSIONS: Hyperbilirubinemia is frequently associated with appendicitis. Elevated bilirubin levels have a predictive potential for the diagnosis of appendiceal perforation.

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WEDNESDAY, MAY 24, 2006

8:30 AM – 10:00 AM SSAT PLENARY SESSION 403 A Co-Moderators: L. William Traverso, Seattle, WA Edward E. Whang, Boston, MA 800 Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3838 Gastric Bypass Patients Sukhyung Lee1,2, Brennan Carmody1, Luke Wolfe1, Eric DeMaria1, John M. Kellum1, Harvey Sugerman1, James W. Maher1; 1Surgery, Va. Commonwealth U., Richmond, VA; 2Surgery, William Beaumont Army Medical Center, El Paso, TX Leaks after Roux-en-Y gastric bypass (GB) are a major cause of mortality. This study attempts to define the relationship between the leak site, detection time, method of diagnosis, and mortality rate. METHODS: Analysis of 3838 patients in the GB database identified 150 patients with leaks. Statistical tests included chi square, Fisher’s and Wilcoxon score. RESULTS: Of the leaks (3.9% overall), 60/2276 (2.57%) occurred after open gastric bypass (OGB), 57/1024 (5.27%) after laparoscopic gastric bypass (LGB), and 33/378 (8.03%) after revisions (RGB). Leaks were more common in older patients (45.3 ± 10.4 vs. 40.6 ± 10.3 years, p < 0.0001) and males (28.7% vs. 18.2%, p = 0.003). Overall mortality rate due to leaks in OGB and LGB was similar [0.64% (15/2336) vs. 0.46% (5/1081), p = 0.5345], and accounted for half (20 deaths) of all mortality. In OGB, there were 39 leaks (1.7%) at the gastrojejunostomy (GJ), and 11 (0.47%) at the jejunojejunostomy (JJ). In the LGB group, there were 44 leaks (4.1%) at the GJ and 5 (0.46%) at the JJ. Eight LGB leaks occurred elsewhere with 3 from the excluded stomach. Mortality from a GJ leak was higher in OGB than LGB (17.9 vs. 0%, p = 0.003)although there was one death at an outside hospital in an LGB patient from a leak of undetermined site. Sixty-eight percent of GJ leaks required reoperation (27/37 OGB, 28/43 LGB). There were no deaths in the nonoperative group. Detec- tion time for a GJ leak in the OGB group was longer than in the LGB group (3 vs 1 days, Wilcoxon score p < 0.0001, mean 5.0 ± 6.7 days vs. 2.2 ± 2.6 days, p = 0.02). Mortality and detection time after JJ leak was similar in both OGB and LGB. JJ leak was associated with a 40% mortality rate (vs. 8.1% GJ, p = 0.003). Initial upper G.I. (UGI) missed 9/10 JJ leaks compared to 16/88 GJ leaks (90.0% vs. 18.2%, p = 0.00001). Median detection time was longer in the JJ leak group than the GJ leak group (4 vs 2 days, p = 0.033 Wilcoxon). Tachycardia (p > 120) was seen in 65% of GJ leaks and 83% of JJ leaks (p = NS). Patients with JJ leaks had a higher BMI than those with GJ leaks (BMI 55.25 ± 10 vs. 48.81 ± 10 p = 0.022). DISCUSSION: Leak mortality and time of detection was higher in OGB than LGB. JJ leaks are more lethal than GJ leaks and take longer to detect. GBP patients with persistent tachycardia may harbor leaks, especially at the JJ or excluded stomach, even with normal UGI studies. Normal UGI findings should not delay therapy if clinical signs suggest leak.

122 SSAT.book Page 123 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

801 Treatment of Gastric Adenocarcinoma Based on Institution Type/Approvals Category in the United States Kaye M. Reid1, Lina Patel3, Jaffer Ajani2,3, John H. Donohue1,3, Members of the Gastric PCE Project The3; 1General Surgery, Mayo Clinic – Rochester, Rochester, MN; 2GI Medical Oncology, M.D. Anderson, Houston, TX; 3American College of Surgeons, Commission on Cancer, Chicago, IL INTRODUCTION: The concept that high risk surgical procedures should be performed in high volume centers in order to improve both surgical morbidity and mortality is becoming widely accepted. Our aim was to determine if there is a difference in treatment of gastric cancer among hospitals categorized as community cancer centers, comprehensive community cancer centers, teaching/research centers as deﬁned by the American College of Surgeons, Commission on Cancer (CoC). METHODS: Data from the National Cancer Data Base (NCDB) 2001 Gastric Cancer Patient Care Evaluation (PCE) Study were analyzed. The data for patients diagnosed with gastric adenocarcinomas in 2001 were voluntarily submitted by 711 CoC-approved cancer programs. Proportional differences were based on two- sided chi-square test with a signiﬁcant level of 0.05. Tests were adjusted for all pairwise comparisons using the Bonferroni correction at a 0.05 level. RESULTS: Of the 6042 with adenocarcinoma, 3151 (52%)were treated surgically. The mean number of patients treated at teaching hospitals was higher than community centers (Table). The utilization of laparoscopy and endoscopic ultrasound (EUS) were highest at research centers (p < 0.001 for both). More than 15 nodes were pathologically evaluated in 21.5% of the resection specimen at community centers and 30% at research centers (p = < 0.001). A D1 lymphadenectomy was most frequently preformed (mean of 59% at all centers). Post-operative wound infections and bleeding occurred at all institutions with similar frequency. Adjusted to cancer stage, chemotherapy and radiation therapy were utilized with equal frequency at all types of treatment WEDNESDAY

centers (p = 0.62, p = 0.82 respectively). The 30-day post-operative mortality ABSTRACTS was lowest at research centers compared to community cancer centers (p = ≤ 0.001) and comprehensive cancer centers (p = ≤ 0.01). There were no differences between both types of community treatment centers (p = ≤ 0.20).

Community Comprehensive Teaching/ Cancer Center Cancer Center Research Mean Cases/year 5 9 14 >15 Lymph nodes, % 21 22 31 30 Day Mortality, % (long term data not available) 9 7 5 CONCLUSION: Thirty day mortality for gastric cancer operations is signiﬁ- cantly less at research centers which supports established data that rare diseases treated at higher volume centers have more favorable outcomes. There is no difference by the category of institution in the frequency of post operative hemorrhage, wound infection, or use of either chemotherapy or radiation therapy. Because only a third of patients have > 15 nodes assessed, the staging and subsequent adjuvant therapy are likely compromised in the United States.

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802 Exocrine Function After the Whipple Procedure as Assessed by Stool Elastase Joe Matsumoto, William Traverso; General Surgery, Virginia Mason Clinic, Seattle, WA INTRODUCTION: What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001 we began preoperative assessment and then increasingly employed postoperative measurements. PATIENTS: From 11/2001 until 11/2005, 171 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 122 (71%) and was repeated postoperatively at 3 ± 1 mo, 12 ± 2 mo, and 24 ± 3 mo. At the same time periods an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by lack of pancreatic duct dilation in the remnant (“dilation” = duct > 3 mm or, if duct dilated preop, then duct that failed to decrease in size). Indications for PD in the 122 cases were pancreatic cancer (20%), other periampullary tumors (19%), cystic tumors (39%), chronic pancreatitis (19%), and other (2%). PD was pylorus-preserving in 93%. All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 µg/gram stool), moderately reduced (100–200 µg/g), or severely reduced (<100 µg/g). RESULTS: Preoperative stool elastase values were “normal” in 69% (pancreatic cancer 40% normal vs. all other groups > 76% normal, p ≤ 0.001). Preopera- tive values were then compared to post-PD levels to assess if the patient maintained their pre-PD level (table). The CT scans at the time of the 64 stool elastase measurements after PD were examined for pancreatic duct dilation in the pancreatic remnant. Duct dilation was observed in 13% (4/30) where elastase levels had been “reduced” after PD versus 4% (1/27, not signiﬁcant) in the group with stool elastase “increased” or “maintained.”

Months after PD Increased Maintained Reduced 3 mo (N = 37) 5% 43% 52% 1 year (N = 14) 21% 7% 72% 2 years (N = 13) 0% 54% 46% Total (N = 64) 8% 37% 55%

CONCLUSIONS: Based on stool elastase one-third of patients about to have PD will have exocrine insufﬁciency; an observation most common among the patients with pancreatic cancer (60%). After PD, levels of stool elastase are further depressed in the majority of cases probably from parenchymal loss since we could not implicate an occluded pancreatic anastomosis. After PD exocrine supplementation should be given to at least all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD each surgeon should assess the effect of their own type of pancreatico-enteric technique on exocrine function.

124 SSAT.book Page 125 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

803 A R0 Resection Accomplished with Minimal Blood Loss Is the Surgeons Contribution to Long-Term Survival in Pancreatic Cancer Thomas J. Howard, Joseph E. Krug, Jian Yu, Christian M. Schmidt, Lewis E. Jacobson, James A. Madura, Eric A. Wiebke, Keith A. Lillemoe; Surgery, Indiana University, Indianapolis, IN INTRODUCTION: Pancreatic cancer has a poor prognosis. Complete surgical resection is the only therapy to offer a chance for long-term survival. While the morbidity and mortality of pancreatic resection has fallen dramatically over the last 20 years, long-term survival rates in most series have remained stagnant. The aim of this study is to identify the actual 3- and 5-year survival rate after resection of pancreatic cancer and identify clinicopathologic or operative variables that influence survival. METHODS: Between 1981 and 2002, 227 consecutive patients had resection with curative intent for pancreatic adenocarcinoma. There were 188 (83%) pancreaticoduodenectomies, 27 (12%) distal resections, and 12 (5%) total pancreatectomies. Operative morbidity was 42% and 30-day mortality was 6%. Actual 3-year survival rate was 19% (N = 43), and actual 5-year survival rate was 5% (N = 11). We compared 21 patients (9%) (15 m, 6 f, mean age 62 + 9) who died from early tumor recurrence (<12 mos.) with 34 patients (15%) (16 m, 18 f, mean age 61 + 11 years) who survived at least 3 years postoperatively for clinicopathologic and operative variables. RESULTS: There were no differences in tumor size, stage, vascular invasion, operative time, or blood transfusions between groups. Multivariate analysis using logistic regression identified poor tumor differentiation (O.R. 9.4, 95% C.I. = 1.2–73.0, P = 0.03), extent of resection (O.R. 35.5, 95% C.I. = 2.8–449.0, P = 0.006) and blood loss (O.R. 1.002, 95% C.I. = 1.000–1.003, P = 0.04) as significant predictors of early recurrence. CONCLUSION: Survival after resection with curative intent in patients with pancreatic carcinoma has an actual 19% 3-year and 5% 5-year survival in this series. Of the variables identified as independent predictors of early tumor WEDNESDAY

recurrence, a positive surgical margin (R1 resection) and operative blood loss ABSTRACTS are factors which can be impacted on by surgeons. Early Tumor Long-Term Survival p value Recurrence (N = 21) (N = 34) Tumor differentiation 0.03 Poor 9 (43%) 3 (10%) Moderate 10 (48%) 20 (67%) Well 2 (9%) 7 (23%) Lymph node positive 14 (67%) 11 (38%) 0.03 Extent of Resection 0.004 R0 4 (19%) 18 (62%) R1 17 (81%) 11 (38%) Median operative blood loss (ml) 1400 950 0.009 Postoperative treatment* 0.05 Chemotherapy 4 (21%) 1 (5%) Chemoradiotherapy 6 (32%) 15 (68%) No adjuvant treatment 9 (47%) 6 (27%)

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804 Efficacy of Preoperative Combined 18-Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography for Assessing Primary Rectal Cancer Response to Neoadjuvant Therapy Genevieve B. Melton1, William C. Lavely2, Heather A. Jacene2, Richard D. Schulick1, Michael A. Choti1, Richard L. Wahl2, Susan L. Gearhart1; 1Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; 2Department of Nuclear Medicine, Johns Hopkins Medical Institutions, Baltimore, MD PURPOSE: Although F-18 fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) holds great potential for determining tumor response to neoadjuvant therapy, its efficacy in primary rectal cancer is not well-established. The goal of this study was to determine the ability of serial FDG-PET/CT to predict tumor down-staging and the percentage of residual tumor in resected specimens of primary rectal cancer. METHODS: Primary rectal cancer patients undergoing neoadjuvant therapy and definitive surgical resection at a single institution were included. All tumors were ≤12 cm from the anal verge and assessed for size and stage with endoscopic ultrasound (EUS) (n = 16) or MRI (n = 1). FDG-PET/CT was obtained prior to and 4 weeks following completion of neoadjuvant therapy. FDG-PET/CT parameters used to determine tumor response included visual response score (VRS), standardized uptake value (SUV), PET-derived tumor volume (PETvol), CT-derived tumor volume (CTvol), and total lesion glyocol- ysis (TLG). Primary outcome measures included percentage residual tumor using pathological response score (PRS) (0: no response/progression, 1: < 33%, 2: 34–66%, 3: 67–95%, 4: 96–10%), tumor down-staging, and lymph node status based upon pretreatment staging and final pathology. RESULTS: From May 2003 to October 2005, 17 patients with primary rectal cancer (10 male, median age 63) underwent neoadjuvant treatment (2 CT, 2 RT, 13 CT/RT) and serial FDG-PET/CT. Preoperative staging demonstrated uT2N1 (3, 18%), uT3N0 (3, 18%), uT3N1 (7, 41%), cT3N2 (1, 6%), uT4N1 (2, 12%), and uT4N2 (1, 6%). All parameters studied on serial FDG-PET/CT were significantly greater (p < 0.001) in patients demonstrating a pathological response to treatment (n = 14). The percentage of residual tumor in resected specimens (PRS 0–4) correlated best with VRS (r = 0.60, p = 0.011) and CTvol (r = 0.59, p = 0.012). VRS (p = 0.044) and SUV (p = 0.029) were able to predict patients with tumor down-staging (n = 11). Although FDG-PET/CT was unable to predict the presence of positive lymph nodes on EUS, the presence of positive lymph node disease on final pathology (n = 5) was associated with lower VRS (p = 0.018), CTvol (p = 0.045), and PETvol (p = 0.043). CONCLUSION: Serial FDG-PET/CT parameters are effective for predicting tumor down-staging, the percentage of residual tumor, and final lymph node status following preoperative treatment of primary rectal cancer. Accurate assessment of tumor response to neoadjuvant therapy can assist in surgical treatment planning for rectal cancer.

126 SSAT.book Page 127 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

805 Patterns of Local Failure and Survival for Non- Operative Treatment of Stage c0 Distal Rectal Cancer Following Neoadjuvant Chemoradiation Therapy Angelita Habr-Gama1, Rodrigo O. Perez1, Afonso H. Sousa1, Fabio G. Campos1, Igor E. Proscurshim1, Wladimir Nadalin2, Desiderio R. Kiss1, Joaquim Gama-Rodrigues1; 1Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Radiology, Univeristy of Sao Paulo School of Medicine, Sao Paulo, Brazil BACKGROUND: Neoadjuvant chemoradiation therapy (CRT) is considered the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal for the non-operative as an alternative treatment for highly selected patients with complete clinical response. However, the risk of tumor recurrence and local failure following this strategy remains undetermined. PATIENTS AND METHODS: 361 patients with distal rectal cancer were managed by neoadjuvant CRT including 5FU, Leucovorin and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. Patients with sustained complete clinical response at 12 months of follow-up were considered clinical stage 0. Patients with incomplete clinical response detected before 12 months of follow-up were managed by immediate radical surgery. RESULTS: 99 patients were considered stage c0 (27.4%) and were managed by non-operative close follow-up. 262 patients (72.6%) were considered to have incomplete clinical response and were managed by radical surgery. Mean follow-up interval for patients with stage c0 was 60 months (12–172). Overall, there were 12 recurrences (12.1%) being 5 exclusively endorectal recurrences (5.1%), 6 systemic recurrences (6%) and 1 combined endorectal and systemic recurrence (1%). All 5 isolated endorectal recurrences were amenable to salvage treatment. There were 5 deaths associated with disease WEDNESDAY

progression. Overall and Disease Free 5-year cancer-related survival was 94% ABSTRACTS and 86%. CONCLUSIONS: Non-operative treatment for sustained complete clinical response following neoadjuvant CRT is safe and associated with high overall and disease-free survival rates. Moreover, local failure is associated with high rates of possibility of salvage therapy and local disease control.

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10:30 AM – 12:00 PM SSAT PLENARY SESSION 403 A Co-Moderators: Janice F. Rafferty, Cincinnati, OH Joerg Haier, Muenster, Germany 882 Prospective Trial of Laparoscopic Nissen Fundoplication Versus Proton Pump Inhibitor Therapy for Gastro- Oesophageal Reflux Disease: Seven Year Follow-Up Samir Mehta, John Bennett, David Mahon, Michael Rhodes; Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich, United Kingdom INTRODUCTION: Laparoscopic Nissen fundoplication and proton pump inhibitor (PPI) therapy are both established treatments for gastro-oesophageal reflux disease (GORD). We have performed a prospective randomised study comparing these two treatments (Br J Surg 2005;92:695–9) and now have long-term follow-up data. METHODS: Between July 1997 and August 2001, 217 patients took part in a randomised controlled trial comparing laparoscopic Nissen fundoplication and PPI therapy for the treatment of GORD. After a median of 6.9 years (range = 4.3–8.3) patients from Norwich (84% of the cohort) were followed up and asked to complete a reflux symptom questionnaire. RESULTS: There were 91 patients in the surgery arm (Group 1) and 92 patients in the PPI arm. 54 patients randomised to PPI went on to have antireflux surgery after 12 months (Group 2a); the remaining 38 did not (Group 2b). 75% of patients responded to the postal questionnaire. Mean Demeester symptom scores (range 0–9) are shown in the table below: In all 3 groups there was a significant improvement in symptom score by 12 months (p < 0.01 Mann-Whitney). However, patients in Group 2a experienced a further improvement following subsequent surgery (p < 0.01) despite having had optimal PPI treatment beforehand.

Description n Start 12 months Median of 6.9 years Group 1 Surgery 91 3.5 0.9 1.1 Group 2a PPI then Surgery 54 3.3 2.3* 0.7* Group 2b PPI alone 38 2.4 1.1 0.9

* denotes difference in score is significant (Mann-Whitney test p < 0.01)

CONCLUSION: Both optimal PPI therapy and laparoscopic Nissen fundoplication are effective and durable treatments for GORD. However, surgery offers additional beneﬁt for those who have only partial symptomatic relief whilst on PPIs.

128 SSAT.book Page 129 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

883 Gastroesophageal Reflux Disease and Obesity: Pathophysiology and Implications for Treatment Fernando A. Herbella, Ian Nipomnick, Pietro Tedesco, Marco G. Patti; Department of Surgery, University of California, San Francisco, San Francisco, CA BACKGROUND: One third of morbidly obese patients have gastroesophageal reflux disease (GERD). Even though it is accepted that GERD is multifactorial in origin, the pathophysiology of the disease in this group of patients has never been fully investigated. The findings can have important therapeutic implications, both in terms of medical or surgical therapy. AIMS: The aims of this study were to compare in patients with GERD and different body mass indexes (BMI): (a) lower esophageal sphincter (LES) profile; (b) esophageal body function; and (c) esophageal acid exposure. PATIENTS AND METHODS: We reviewed the esophageal manometry and ambulatory pH monitoring studies of 599 consecutive patients with GERD (reflux score > 14.7). Patients were divided in 5 groups based on their BMI: group A, BMI < 25, 192 patients (32%); group B, BMI 25-29, 227 patients (41%); group C, BMI 30–34, 101 patients (17%); group D, BMI 35–39, 35 patients (6%); and group E, BMI > 40, 44 patients (7%). Patients with previous foregut surgery or named esophageal motility disorders were excluded. RESULTS: Results are shown in the table.

ABCDE Age 52 ± 14 51 ± 13 51 ± 11 47 ± 2* 45 ± 9* % males 42 55 37 23* 20* LESP (mmHg) 14 ± 7 13 ± 7 16 ± 9 14 ± 9 19 ± 9* LESL (cm) 2.4 ± 0.8 2.3 ± 0.8 2.4 ± 0.8 2.3 ± 1.0 2.3 ± 0.9 89 ± 52 99 ± 53 103 ± 57 106 ± 65 124 ± 5* 99 ± 53 DEA (mmHg) 103 ± 57* WEDNESDAY

106 ± 65 ABSTRACTS 124 ± 55* PEA (mmHg) 67 ± 36 66 ± 31 69 ± 35 74 ± 37 73 ± 30

LESP: LES pressure. LESL: LES length. DEA: distal esophageal body amplitude. PEA: proximal esophageal body amplitude. *Statistically significant compared to group A (p < 0.005)

CONCLUSIONS: The results of this study show that: (a) about 1/3 of patients with GERD are obese; (b) in most obese patients with GERD, reﬂux occurs despite the presence of a normal or hypertensive LES, and normal or hypertensive esophageal peristalsis. These ﬁndings raise concern about the wisdom of performing a Nissen fundoplication in obese patients with GERD, and suggest that surgical therapy should be directed toward normalization of the patient’s weight.

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884 Quality of Life Convergence of Laparoscopic and Open Antireflux Surgery for Gastroesophageal Reflux Disease Aisha Violette, Vic Velanovich; Surgery, Henry Ford Hospital, Detroit, MI BACKGROUND: Although laparoscopic antireflux surgery (LARS) has become the surgical treatment of choice for gastroesophageal reflux disease (GERD), it is unclear whether the quality of life (QoL) advantage of LARS over open antireflux surgery (OARS) persists in the long term. The purpose of this study was to compare long-term QoL between LARS and OARS patients. METHODS: A prospectively gathered database of all patients who underwent either LARS or OARS for symptomatic GERD was reviewed. Preopera- tively, patients completed the GERD-HRQL symptom severity questionnaire (best score 0, worst score 50), and the SF-36 generic QoL instrument (8 domains, physical functioning, PF; role-physical, RP; role-emotional, RE; bodily pain, BP; vitality, VT; mental health, MH; social functioning, SF; general health, GH. Best score 100, worst score 0). Postoperatively, patients completed both questionnaires at 6 weeks and at least 1 year. Data are presented as medians and statistically analyzed using the Mann-Whitney U-test. A beta-error was determined to assess adequacy of sample size. RESULTS: 289 patients underwent either LARS and 124 OARS. The table presents the median scores. At 6 weeks, there were statistically significantly better scores for LARS in the domains of PF, RP, RE, BP and SF. However, after 1 year, there were no statistically significant differences. The beta-error for non- statistically significant differences were all < 0.2, which is considered an adequate sample size.

Total GERD-HRQL PF RE RP BP VT MH SF GH Preop 27 85 100 100 61 50 72 75 62 LARS 6 weeks 495100 100 74 55 84 100 72 OARS 6 weeks 37506762 50 72 75 72 LARS > 1 year 390100 100 79 55 84 100 75 OARS > 1 year 185100 100 92 63 92 100 72

All data are median scores

CONCLUSION: Although LARS does produce better QoL scores in the early postoperative period, after 1 year, these scores converge.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

885 Ileorectal Anastomosis for Slow Transit Constipation: Long-Term Functional and Quality of Life Results. Imran Hassan1, John H. Pemberton1, Yi-Qian N. You1, Ernesto R. Drelichman1, Doris M. Rath-Harvey1, Cathy D. Schleck2, Drik R. Larson2, Tonia M. Young-Fadok1; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Section of Biostatistics, Mayo Clinic, Rochester, MN INTRODUCTION: The results of colectomy ileorectal anastomosis (IRA) in patients diagnosed by physiologic testing as having slow transit constipation (STC) have been reported (Nyam DCNK, et al. Dis Colon Rectum 1997; 40:273–279). The durability of functional results and long-term quality of life (QoL) in these patients, however, has not been established. METHODS: Between 1987 and 2002, 3670 patients were evaluated for constipation at our institution of which 112 (3%) patients fulﬁlled the criteria for STC and underwent an IRA. Patients were followed through a prospective database and functional outcomes were assessed annually by standardized questionnaires. After a median follow-up of eleven years, 104 eligible patients were mailed validated questionnaire to assess QoL and functional outcomes (Knowles-Eccersley-Scott Symptom (KESS) score, the Irritable Bowel Syndrome Quality of Life (IBS-QOL) and the SF-12 health survey questionnaires. RESULTS: Prospectively assessed functional data was available on 85 of 104 (82%) eligible patients. At last follow-up, improvement of constipation and satisfaction with bowel function was reported by 98% and 85% of patients respectively. Social activity, household work, sexual life, and family relationships were reported to have improved or were not affected as a result of surgery by 73%, 86%, 82% and 86% of the patients respectively. At 11 years (median) 59, of the 104 eligible (57%) patients responded to the validated QoL and functional outcome questionnaires. Functional outcomes measured by annual standardized questionnaire did not differ signiﬁcantly between responders and non-responders. All 59 patients reported their constipation to WEDNESDAY

be better since IRA, 83% did not require any constipating or anti-diarrheal ABSTRACTS medication and 85% reported being satisﬁed with their bowel function. The KESS score of patients undergoing IRA for STC (median 6, range 0–35) was less than reported scores of patients with STC not operated upon (median 21, range 11–35, P < 0.001) (Knowles CH, et al. Dis. Colon Rectum 2000; 43:1419–1426) suggesting symptomatic improvement after operation. Mean IBS-QOL scores were similar to reported scores of patients undergoing IRA for other benign conditions (80 vs. 84, SD20, P = 0.7) (You YN, et al. Colorectal Dis. 2005; 7:S1). Mean SF-12 physical and mental summary scores were similar to reported SF-12 scores of the normal population (49.5 vs. 50, P = 0.70, 48.7 vs. 50, P = 0.42). CONCLUSION: Ileorectal anastomosis in highly selected patients with slow transit constipation results in durable symptomatic relief and a long-term quality of life indistinguishable from the general population.

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886 Autologous Versus Allogeneic Transfusions: No Difference in Peri-Operative Outcome After Partial Hepatectomy James O. Park, Mithat Gonen, Michael D’Angelica, Ronald Dematteo, Fong Yuman, Leslie H. Blumgart, William R. Jarnagin; Surgery, MSKCC, New York, NY INTRODUCTION: Blood transfusion is often necessary in patients undergoing liver resection. Because of the risks associated with allogeneic blood products, pre-operative autologous blood donation has been advocated, but its beneﬁt is unclear. This study compares peri-operative outcome in patients transfused only with autologous blood to a matched cohort transfused with allogeneic blood. METHODS: All patients subjected to hepatic resection and given peri-operative autologous red cell transfusions (Auto) were identiﬁed from a database of 2123 patients and reviewed retrospectively. This group was matched to patients transfused with a comparable number of allogeneic red cell units (Allo) and to a control group that received no blood products. All patients in the Auto or Allo group received either 1 or 2 units. Matching was based on age, comorbidity, extent of hepatic resection, and estimated blood loss. Matched pair analysis was performed using the t-test and McNemar’s test. RESULTS: From 12/91 to 5/03, 124 patients undergoing hepatic resection received peri-operative autologous blood only, for which optimal matching was possible in 104. The groups were similar with respect to age, co-morbidities, and blood loss; the proportions receiving pre-operative chemotherapy, requiring a major resection (3 segments) or a complex procedure (concomitant major procedure in addition to the principal hepatic resection) were also similar. There were no differences between the Allo and Auto groups in length of hospitalization, complications, and operative mortality. CONCLUSIONS: In patients undergoing hepatic resection, autologous blood transfusion does not demonstrably improve peri-operative outcome when compared to a matched cohort of patients receiving a similar number of allogeneic units.

Variables Control (N = 104) Auto (N = 104) Allo (N = 104) P (Auto vs. Allo) Age (yr) 56.4 ± 12.5 55.7 ± 12.5 56.2 ± 14.8 0.6 Co-morbidity (%) 32.7 32.7 32.6 0.4 Pre-operative chemo (%) 32.7 34.6 35.6 0.1 Resection 3 segments (%) 65.4 65.4 65.4 0.9 Complex procedure (%) 34.6 37.5 35.6 0.8 Normal liver parenchyma (%) 72.7 61.5 58.5 0.1 EBL (ml) 805.6 ± 495 898.7 ± 707 893.8 ± 570 0.9 Length of stay (days) 9.2 ± 4.4 9.6 ± 4.2 10.2 ± 4.8 0.3 Complications (%) 40.4 48.1 45.2 0.7 Major complications (%) 11.5 20.2 24 0.7 Operative Mortality (%) 1 0 0 1.0

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

887 Enteral Immunonutrition During Sepsis Prevents Pulmonary Dysfunction in a Rat Model Jorg Glatzle1, Michael S. Kasparek1, Tobias Meile1, Jutta Hahn1, Mario H. Mueller2, Martin E. Kreis2, Alfred Konigsrainer1, Wolfgang Steurer1; 1General Surgery, University, Tuebingen, Germany; 2General Surgery, University of Munich, Munich, Germany Sepsis often results in severe pulmonary dysfunction. Via the thoracic duct, the lung is the first organ exposed to gut derived mediators released into the mesenteric lymph. It has been shown that an acute insult to the gastrointestinal (GI) tract, results in inflammatory mediator release into mesenteric lymph inducing pulmonary dysfunction (Deitch EA, Shock 2004). AIM: To investigate whether enteral immunonutrition during sepsis results in a reduced inflammatory response of the GI tract and therefore improving pulmonary function. METHODS: Mesenteric lymph was obtained from lymph fistula donor rats. Saline or LPS (5 mg/kg, sepsis model) were injected ip, thereafter control lymph (CL) or sepsis lymph (SL) were collected. Additionally SL was collected during enteral immunonutrition with long chain fatty acids (SL-OO, olive oil, or SL-SFO, soybean/fish oil). CL, SL, SL-OO, or SL-SFO were reinfused into the jugular vein of separate recipient rats for 2 h (3 ml/h). Thereafter the lung tissue was harvested, stained with hematoxylin-eosin and analyzed for 1. perpendicular parenchyma thickness of the alveolar wall (oxygen diffusion), 2. myelo-peroxidase (MPO) positive cells (inflammatory response) 3. TUNEL positive cells (apoptosis, n = 6 rats per group, n = 30 optical sections per rat). RESULTS: Sepsis increased TNF release into mesenteric lymph about 99 fold within the first two hours (TNF pg/ml, CL vs SL, 0-2h: 120 ± 21 vs 11877 ± 1130*, 2–4h: 158 ± 36 vs 3501 ± 2089*, 4–6h: 172 ± 66 vs 132 ± 27, *p < 0.005). Enteral immunonutrition during sepsis reduced the TNFα output into the mesenteric lymph significantly (TNFα pg/ml, 0-2h: SL 11877 ± 1130, SL-OO 2330 ± 1279*, SL-SFO 2605 ± 1802*; 2–4h: SL: 3501 ± 2089, SL-OO 896 WEDNESDAY ± 661*, SL-SFO 981 ± 412*, *p < 0.05 vs SL). SL infusion induced a significant ABSTRACTS increase in alveolar wall thickness, whereas infusion of SL-SFO had on effect ([µm] NaCl 9 ± 0.2, SL 15 ± 0.4*, SL-SFO 9 ± 0.3; *p < 0.001 vs NaCl or SL- SFO). The number of MPO or TUNEL positive cells were significantly increased after infusion of SL and markedly reduced after infusion of SL-SFO (cells/optical section MPO: NaCl 6 ± 1; SL 53 ± 2*, SL-SFO 19 ± 1; TUNEL: NaCl 4 ± 1; SL 13 ± 2*; SL-SFO 1 ± 0.05; *p < 0.01 vs NaCl or SL-SFO). CONCLUSIONS: Mediators in sepsis lymph induce pulmonary dysfunction, such as an increased distance for oxygen transport, inflammatory reaction and apoptosis. The lung may be protected by an enteral immunonutrition containing long chain fatty acids. Products of chylomicron formation like apolipoprotein (apo) A-IV might be involved, since it was shown that apo A-IV potently reduces acute inflammation (Vowinkel, J Clin Invest 2004). Sup- ported by DFG GL 311, 3/1.

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POSTER SESSION ABSTRACTS

Printed as submitted by the authors.

Monday, May 22, 2006

12:00 PM – 2:00 PM SSAT POSTER SESSION West Hall A Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM. Posters of Distinction abstracts may be found in the “Oral, Video, and Posters of Distinction Session Abstracts” on pages 112-121. Posters of Distinction authors will deliver abbreviated oral presentations of their work during the “Posters of Distinction Quick Shots” session, 3:30 PM – 4:30 PM, Tuesday, May 23, 2006, in Room 402 A.

BASIC SCIENCE POSTERS

Basic: Biliary

M1863 Capnoperitoneum Mediated Anti-Inflammatory Effect Is Peritoneal Macrophage Dependent Alexander Aurora1, Eric Hanly1, Joseph Fuentes1, Samuel Shih1, Antonio Demaio1, Mark Talamini2; 1Surgery, Johns Hopkins, Baltimore, MD; 2Surgery, UCSD, San Diego, CA INTRODUCTION: The key to the accelerated recovery of laparoscopic versus open surgery has remained unidentified until now. The anti-inflammatory effects of CO2 have been touted by many including ourselves without clarifi- cation of the cellular or molecular mechanisms. Using a model of macrophage depletion we have exposed the cellular target of CO2. METHODS: Male Sprague-Dawley rats were depleted of their peritoneal macrophages using clodronate liposomes. Control rats received empty liposomes leaving their peritoneal macrophages intact and functional. The macrophage deplete rats and control rats were subdivided into 4 experimental groups: LPS; anesthesia; CO2 or Helium pneumoperitoneum. All experimental groups received bacterial endotoxin immediately following their 30 min experimental procedure. Blood was harvested for determination of cytokine levels of IL-10 and TNF-alpha.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

RESULTS: The CO2-pneumoperitoneum significantly increased plasma levels of IL-10 in control rats compared to LPS controls (1993 vs 723 pg/ml; p < 0.05 n = 6). In rats deplete of their peritoneal macrophages the CO2-mediated increase in IL-10 was abrogated to control levels. This effect was specific to CO2. Alternatively, plasma TNF-alpha was attenuated by all experimental conditions compared to LPS control (p < 0.005 n = 6). However, the attenuat- ing effect of CO2 was significantly greater than that of anesthesia alone (p < 0.05). Furthermore, peritoneal macrophage depletion itself significantly decreased TNF-alpha in LPS controls by more than 60% (18630 vs 7189 pg/ ml; p < 0.005 n = 6). CONCLUSION: These results strongly suggest that the anti-inflammatory effects conveyed by CO2-pneumoperitoneum act via modulation of the peritoneal macrophage response to an inflammatory insult. It is likely that elevated levels of IL-10 provoked by CO2-induced modulation of peritoneal macrophage function contribute to the improved clinical outcome of patients benefiting from minimally invasive procedures such as cholecystectomy. ABSTRACTS POSTER

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M1864 Effect of Bile in the Pathogenesis of Acute Simple Mechanical Intestinal Obstruction Tzu-Ming Chang1,2, Lih-Min Tsai3, Ruey-Hwa Lu4; 1Surgery, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan; 2Surgery, National Defense Medical Center, Taipei, Taiwan; 3Physiology, National Defense Medical Center, Taipei, Taiwan; 4Surgery, Taipei City Hospital-Zhong Xing Branch, Taipei, Taiwan BACKGROUND: Mechanical intestinal obstruction, characterized by bowel distension, hypersecretion and altered motility, is one of the most common admissions for acute abdominal conditions. Although the underlying mechanisms leading to these physiologic derangements have been proposed to be associated with the interactions between intestinal microflora and mucosal cells, the role of another potential mediator, bile, has not been well identified. This study was aimed to delineate the role of bile in the pathogenesis of acute simple mechanical bowel obstruction. MATERIALS AND METHODS: Forty-two Sprague-Dawley rats were randomized into 6 groups and subjected to different treatments: Group 1, sham operation; Group 2, complete ileal ligation (IL) at 20 cm to the cecum; Group 3, IL followed by common bile duct ligation (CBDL); Group 4, IL + CBDL followed by external drainage (ED); Group 5, IL + CBDL followed by CBD-urinary bladder diversion (UBD); Group 6, IL + CBDL followed by bile diversion to the ileum distal to the obstruction. All rats were sacrificed 2 days after operations. The bowel distension, fluid accumulation, superoxide anion production and the histopathological alterations in the obstructed intestines were measured. RESULTS: Ileal ligation resulted in marked bowel distension, copious fluid secretion and free radical production as compared to the sham group. These effects were significantly attenuated by CBD ligation or CBD ligation with bile diversion to either outside the body or urinary bladder. In contrast, no such beneficial effects were observed in the group of IL + CBDL with bile diversion to the ileum. Histopathological examinations revealed that bile deprivation from the obstructed intestinal segment did not affect the obstruction-induced mucosal damage. Also, there was no significant correlation between the extent of mucosal injury and the magnitude of fluid secretion or superoxide anion production. CONCLUSION: Bile is partially responsible for the observed manifestations of acute simple mechanical intestinal obstruction, probably through both direct and indirect mechanisms.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Basic: Colon-Rectal

M1865 Statins (HMG-CoA Reductase Inhibitors) Reduce Intraabdominal Adhesions by Increasing Peritoneal Fibrinolytic Activity via Mechanisms That May Involve the Rho Signaling Pathway Cary Aarons, Philip Cohen, Adam Gower, Karen L. Reed, Arthur F. Stucchi, James M. Becker; Surgery, Boston University Medical Center, Boston, MA BACKGROUND: Intraperitoneal adhesions develop in up to 95% of patients following laparotomy, often accounting for significant long-term morbidity. Studies suggest that adhesions are reduced by mechanisms that upregulate fibrinolysis within the peritoneum. Statins promote fibrinolysis in the cardiovascular system and consequently may play a role in the prevention of adhesions. The aims of this study were to determine if statins reduce adhesion formation in vivo and to identify the mechanism of action in vitro. METHODS: Adhesions were surgically induced in male Wistar rats (N = 102) using a previously described ischemic button model. Rats received either vehicle (controls), lovastatin (30 mg/kg), or atorvastatin (30mg/kg) as a single intraperitoneal dose at the time of laparotomy. Animals were sacrificed and adhesions were quantified at day 7. Peritoneal fluid and tissue were collected at day 1 to measure tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) by real-time PCR and ELISA. To assess the effects of statins on tissue healing, burst pressures were measured in anastomoses of the colon. The effects of lovastatin on tPA and PAI-1 production were measured in vitro in human mesothelial cells (HMC) in the presence or absence of mevalonate (MVA), geranylgeranyl-pyrophosphate (GGPP) and farnesyl- pyrophosphate (FPP), all intermediates in the cholesterol biosynthetic pathway downstream of HMG-CoA. The effect of a Rho protein inhibitor, exoenzyme C3 transferase, on tPA production was also determined. RESULTS: The administration of both lovastatin and atorvastatin reduced adhesion formation by 26% and 58%, respectively (p < 0.05) without affecting anastomotic burst pressure. tPA mRNA levels in peritoneal tissue and tPA activity in peritoneal fluid from lovastatin-treated animals were increased by 57% and 380%, respectively (p < 0.05), while PAI-1 levels were unchanged. HMC incubated with either lovastatin or atorvastatin showed concentration-

dependent increases in tPA production and decreases in PAI-1 production (p < ABSTRACTS 0.05). These lovastatin-induced changes in tPA and PAI-1 production were POSTER signiﬁcantly reversed by the addition of MVA, GGPP and FPP. The Rho protein inhibitor increased tPA production and rescued tPA production from the inhibitory effect of GGPP. CONCLUSION: These data suggest that statins administered within the peritoneum can upregulate local ﬁbrinolysis, while the in vitro studies show that this effect may be mediated, in part, by intermediates of the cholesterol biosynthetic pathway that regulate Rho protein signaling. Therefore, statins may provide a viable strategy to prevent adhesion formation.

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M1866 Fenofibrate, a PPAR α Agonist, Inhibits the Growth of a Murine Colon Adenocarcinoma In Vivo Avraham Belizon, Patrick K. Horst, Irena Kirman, Emre Balik, H.M. Shantha Kumara, Suvinit Jain, Richard L. Whelan; Surgery, Columbia University Medical Center, New Hyde Park, NY PURPOSE: Recent literature has suggested that peroxisome proliferator activated receptor (PPAR) agonists may have a role in preventing tumor growth and spread. There are a number of PPAR subtypes; including α, β, γ, and δ. Although some studies have shown that PPAR agonists inhibit angiogenesis and induce apoptosis in multiple tumor cell lines, there is little data about PPAR α agonists. PPAR α agonists are of interest because they may inhbit angiogenesis and also inhibit the release of MMP-9, which has been implicated in tumor spread. Our goal was to examine the effects of fenofibrate (FF), a PPAR alpha agonist, on tumor cell growth in a colon cancer murine model. METHODS: 37 8 weeks old C57BL/6 mice were included in this study. 19 mice received daily gavage of FF (100 mg/kg) dissolved in 100% vegetable oil. 18 mice received daily gavage of placebo (100% vegetable oil). Mice were gav- aged for a total of 24 days. On day number 13, all mice underwent subcutaneous implantation of 20,000 MC-38 tumor cells under the dorsal skin. Tumor size was assessed by measuring the furthest distance from end to end and multiplying it by its perpendicular distance. On day 25 the mice were sacrificed and tumors were excised, measured, and weighed. RESULTS: 10 mice in the FF group and 3 mice in the placebo group died between days 13–15. Of the mice that survived, the FF group had a significantly lower incidence of tumor implantation when compared to the placebo group (44% vs. 80%; p < 0.05). In addition the tumors that did implant were significantly smaller than the corresponding tumor size in the placebo group(6.84 mm2 vs. 25.5 mm2; p < 0.05). The tumor weights were also significantly lower in the FF group when compared to the placebo group (8.89 mg vs. 52 mg; p < 0.05). CONCLUSIONS: Despite a high mortality rate, fenofibrate a PPAR alpha agonist, inhibited murine colonic tumor growth and implantation in this model. Further studies are necessary to evaluate its mechanism of action. In addition, our high mortality rate may be due to the duration of treatment as well as the mode of delivery. Future experiments are needed to evaluate the mortality following a shorter duration treatment, as well as different routes of administration.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1868 Atropine Increases Survival in an LPS Model of Sepsis: A Kinetic Study Joseph Fuentes, Mark Talamini, Eric Hanly, Antonio Demaio; Surgery, Johns Hopkins, Baltimore, MD Atropine is a naturally occurring alkaloid extracted from the plant Belladona atropina, atropine and related compounds compete with acetylcholine for a common binding site on the muscarinic receptor. In previous studies we have found that atropine attenuates TNF-alpha production and upregulates IL-10 and also increases survival when given 10 minutes before lipopolysaccharide (LPS) administration. In this study we determine if other time points would also effect cytokine production and survival.To determine atropine’s therapeutic window in our model of LPS, C57BL/6J (B6) mice were injected with atropine (1 mg/kg) at –10 min, 0 min, +10 min or + 30 min with respect to LPS (15 mg/kg) administration. Blood was harvested 1.5 hours after LPS administration and TNF and IL-10 levels were analyzed by ELISA. In a separate experiment a mortality experiment was conducted with the same protocol mentioned above except that the final endpoint was mortality. Atropine treated animals at –10, 0, and +10 min had suppressed TNF levels while IL-10 correlated again with increased levels within these groups (P < 0.05). The group that received atropine thirty minutes after LPS administration failed to suppressed TNF levels or upregulate IL-10 levels. Atropine treated animals at –10 min, 0 min, +10 and at even +30 min had an increase in survival (75%, 67%, 58%, and 58% respectively vs 0% in the LPS control, (P = <0.001). Our cytokine data correlated with increase in survival for all groups, except for the +30 minutes groups in which the cytokine data failed to reach statistical significance compared to the LPS control group. These findings suggest that atropine attenuates the inflammatory response and increases survival from endotoxic shock in rodents. Further studies should investigate the mechanism and determine if atropine might be useful in the treatment of critically ill patients. ABSTRACTS POSTER

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M1869 Identification of Chromosomal Domains of Differential Gene Expression in Colorectal Cancer by Comparative Chromosomal Gene Expression Analysis (CCGEA) Joern Groene1, Stefan Roepke2, Maya Heinze1, Heinz J. Buhr1, Eike Staub2; 1Department of Surgery, Charite Universitaetsmedizin Berlin, Berlin, Germany; 2Max Planck Institute for Molecular Genetics, Berlin, Germany Cancer development is accompanied by genetic phenomena that influence gene expression in large chromosomal regions like deletion and amplification of chromosome parts or alterations of chromatin structure. However, little is known about effects of such regional phenomena on mRNA expression levels of genes. In this study we present a visualisation method for gene expression imbalanced chromosomal regions at much higher resolution than conventional technologies, called CCGEA (comparative chromosomal gene expression analysis). We investigated genome-wide gene expression in a panel of 50 microdissected samples of paired colorectal carcinoma (CRC) and normal epithelial tissue from 25 patients using large scale oligonucleotide arrays (~33.000 genes). CCGEA allowed the identification of several chromosomal domains with differential expression patterns at high resolution. We observed that regions that are frequently deleted in colon cancer tend to show reduced expression. Regions that are known to be amplified in colorectal tumors tend to show predominantly an increase, but occasionally a decrease of mRNA levels. The majority of chromosomal regions that are linked to hereditary colorectal cancer in the literature show deregulated expression. Many known genes implicated in other tumors localize to chromosomal domains of deregulated expression in CRC. We conclude that DNA copy number are likely to influence mRNA expression levels in CRC, although especially for amplifications the direction of influence is yet unpredictable. The knowledge of such integration of mRNA expression profiles along the chromosomes may provide alternative markers for cancer detection, prognosis and/or strategic therapeutic applications.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1870 Slit/Robo Signalling in Colorectal Cancer — Differential Expression of Angiogenic Markers Joern Groene1, Oliver Doebler1, Christoph Loddenkemper2, Heinz J. Buhr1, Sarah Bhargava1; 1Department of Surgery, Charite – Universitaetsmedizin Berlin, Berlin, Germany; 2Institute of Pathology, Charite – Universitaetsmedizin Berlin, Berlin, Germany The family of the roundabout (Robo) proteins is related to the transmem- brane receptors and plays a major role in the process of axonal guidance in neurogenesis. It has recently been shown that Robo proteins are also associated with tumor angiogenesis with Slit2 acting as the corresponding ligand. The aim of this study was to validate the differential expression by means of microarray analysis and Real-time PCR in colorectal cancer and to analyze the in situ expression of Robo1 and Robo4 in tissue sections. Quantitative analyses of Robo1, Robo4 and Slit2 mRNA expression measured by large scale gene expression studies (Affymetrix U133A) showed a signiﬁcant up-regulation of Robo1 in tumor vs. normal tissue, whereas Robo4 and Slit2 showed no significant deregulation. For subsequent Real-time PCR experiments, paired colorectal tissue samples from cancerous and corresponding noncancerous tissues were obtained from 50 colorectal cancer patients who underwent surgical resection. Robo1 mRNA overexpression in cancerous tissues compared with normal counterparts was observed in 80% of the patients with a 4-fold expression in 45% and a 12-fold expression in 15%. For Robo4, an up-regulation was detected in more than 70% (36/50). For Slit2, no differential expression could be observed. The overexpression of Robo1 and Robo4 in tumor vs. normal tissue was veriﬁed using Real-time PCR. The histological analysis revealed an expression of Robo1 mainly in tumor cells, whereas Robo4 is located primarily in endothelial cells of tumor vessels. Therefore, the Robo proteins provide potential target structures for the anti-tumorigenic and antiangiogenic therapy of colorectal carcinoma. ABSTRACTS POSTER

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M1871 5-FU and PT-11 Significantly Reduce Intraperitoneal Tumor Growth in Experimental Investigations of Peritoneal Carcinomatosis Arndt Hribaschek1, Frank Meyer1, Matthias Pross1, Karsten Ridwelski2, Regine Schneider-Stock3, Hans Lippert1; 1Department of Surgery, University Hospital, Magdeburg, Germany; 2Department of Surgery, Municipal Hospital, Magdeburg, Germany; 3Institute of Pathology, University Hospital, Magdeburg, Germany After surgical resection of gastrointestinal cancer, recurrent tumor growth at the peritoneum remains an unsolved problem. Currently, there are no established or standardized protocols for the treatment or prevention of peritoneal carcinomatosis.The aim of the study was to investigate whether CPT-11 or 5-FU can decrease i.p. tumor growth and if there is a difference between both drugs. METHODS: I.p. tumor growth was induced using a colon carcinoma cell line. The tumor cells were transferred into the abdominal cavity of WAG rats (weight 250–260 g). CPT-11 (group 1, 2) and 5-FU (gr. 3, 4) were administered i.p. (gr.1) and i.v. (gr.2) 10 min after tumor cell transfer (gr.A). In gr.B, an early postoperative chemotherapy was performed applying the drugs on d 5,10,15 after tumor cell transfer. After 30 days, rats were sacrificed and tumor weight of the greater omentum and the mesenteric tissue was determined. In addition, characteristics of tumor growth such as frequency of histologically detectable tumor growth was assessed. RESULTS: Table 1. In summary, both cytostatic dugs were able to significantly decrease the i.p. tumor weight after i.p. application. The greatest effect was achieved with direct intraoperative chemotherapy with slight differences between both drugs. In gr.B, the effect of both agents was also comparable. However, using the i.v. application route, neither CPT-11 nor 5-FU were capable to achieve a significant effect onto the i.p. tumor growth. In conclusion, 5-Fu and CPT-11 appear to be potential chemotherapeutic drugs providing a significant effect in the therapeutic management of peritoneal carcinomatosis under experimental conditions.

Table 1. Characteristics of Experimental Tumor Growth & the Effects of i.p. Versus i.v. Chemotherapy

Greater Mesenteric Histological omentum [g] tissue [g] tumor detection [n] Control I (NaCL, 0.9% only) 0.70 ± 0.82 1.94 ± 0.11 0 Control II (Tumor cell transfer only) 4.50 ± 0.49 5.18 ± 0.51 8 A1 (i.p.) Ox 300 mg/sqm 0.91 ± 0.11 2.68 ± 0.25 6 A2 (i.v.) Ox 300 mg/sqm 4.00 ± 0.41 4.98 ± 0.63 8 A3 (i.p.) 5-FU 425 mg/sqm 1.65 ± 1.06 2.47 ± 0.63 8 A4 (i.v.) 5-FU 425 mg/sqm 3.61 ± 0.38 5.25 ± 0.70 8 B1 (i.p.) Ox 300 mg/sqm 1.60 ± 0.29 2.74 ± 0.11 8 B2 (i.v.) Ox 300 mg/sqm 4.06 ± 0.92 4.97 ± 0.29 8 B3 (i.p.) 5-FU 425 mg/sqm 1.00 ± 0.20 2.45 ± 0.25 8 B4 (i.v.) 5-FU 425 mg/sqm 3.94 ± 0.57 4.88 ± 1.36 8

Ox, Oxaliplatin 5-FU, 5-Fluorouracil sqm, square meter

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1872 The Prevalence of Colorectal Neoplasia in End Stage Renal Disease: A Case Control Study Sharon Lee, Nir Wasserberg, Patrizio Petrone, Jason Rosca, Rick Selby, Adrian Ortega, Howard Kaufman; Surgery, University of Southern California, Los Angeles, CA PURPOSE: The scarcity of organs for transplantation has led to aggressive pretransplant evaluations. Many younger kidney transplant patients with end stage renal disease (ESRD), who would ordinarily be at average risk for colorectal cancer, undergo screening colonoscopy as part of this evaluation. The purpose of this study was to determine the prevalence of colorectal neoplasia in patients with ESRD who are potential transplant candidates. METHODS: A retrospective chart review was performed of kidney transplant candidates who underwent pre-transplant screening colonoscopy at our institution from August 1999 to December 2004. Charts were assessed for clinicopathologic data including, age, gender, ethnicity, obesity, personal history of diabetes mellitus or colorectal polyps, family history of colon cancer, colonoscopic ﬁndings, and pathology results. The control group was comprised of 60 age- and gender-matched subjects without ESRD who underwent routine screening colonoscopy. RESULTS: The study group included 58 patients (16/42 F/M), median age of 55 years (33–74), 16 of which were younger then 50 years old. The prevalence of polyps in ESRD patients was 36% vs 21.6% in the control group. Of patients with ESRD50 years old, 17 (40%) had polyps vs 21.9% in the control group. The prevalence of polyps in ESRD patients < 50 years old was 31% vs 21% in controls. None of these differences reached statistical signiﬁcance. There were no cancers detected, and none of the polyps excised and examined had high grade dysplasia. None of the risk factors studied were found to predict the presence of polyps in the study group. Diabetes (OR 13.8, 95% CI 1.73–104.9, P = 0.007), and a family history of colorectal cancer (OR 4.291, 95% CI 1.105–16.784, P = 0.034) were associated with the presence of polyps in the control group. CONCLUSION: The prevalence of colorectal polyps in patients with ESRD who are candidates for kidney transplantation is not statistically different than age- and gender- matched controls of otherwise similar risk. These results suggest that screening guidelines for colorectal cancer for the general population should be adequate for potential kidney transplant recipients. ABSTRACTS POSTER

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M1873 Evaluation of the Physical Properties of a New Fully Degradable Suture Material with a Shape Memory Effect for Visceral Surgery Christoph Reissfelder1, Joerg-Peter Ritz1, Steffen Kelch2, Andreas Lendlein2, Heinz Buhr1; 1Department of General Surgery, Charite, Campus Benjamin Franklin, Berlin, Germany; 2Institute of Chemistry, GKSS Research Center Geesthacht GmbH, Teltow, Germany INTRODUCTION: The insufficiency rate of colorectal anastomoses deci- sively influences the results and prognosis of colonic operations. The suturing and knotting technique is a major risk factor due to the possible induction of microcirculatory disturbances and/or inadequate adaptation. Novel suture materials with a shape memory effect are potentially able to offset such risk factors by readaptation (self-knotting). Suitable new polymer-based suture materials were evaluated for their biocompatibility, anastomotic bursting pressure, mechanical and shape memory properties and compared with conventional suture materials. MATERIALS AND METHODS: Linear multiblock copolymers were chosen for the shape memory material (SMM). Apart from the crystallizing oligo (p-dioxanone) diol for the hard segment, oligo (ζ-caprolactone) diol was used as the precursor for the switch segments. The SMM was programmed for 25% shortening. The physical properties (shape memory effect with temperature elevation) of the SMM were examined in various solutions (0.9% NaCl, blood, air) at 38˚ and 45˚C and compared with conventional suture material. 3T3 fibroblasts, human fibroblasts and umbilical endothelial cells (HUVEC) are used for biocompatibility testing with respect to cytotoxicity, adhesion, proliferation, morphology, and functional activity. Hemocompatibility is assessed by evaluating coagulation and complement activation of normal pooled human plasma after material contact. To measure the bursting strength, a descendorectostomy was created with 4-0 Vicryl and SMM 25% sutures in rats. Between day 1–28 anastomotic bursting pressure was measured on narcotised rats. RESULTS: Compared with room temperature, rising temperatures led to shortening of the SMM up to 25% (p < 0.05) in all solutions. There was no reduction in the length of conventional suture material (Vicryl®, PDS®). The materials tested according ISO 10993-5 caused no cytotoxic effects. By using SMM the anastomotic bursting pressure was 33% higher compared to Vicryl® (p < 0.007) within the first 4 days. DISCUSSION: 1.) The newly developed SMM shows a significant length reduction under physiological conditions. 2.) The materials tested according ISO 10993-5 caused no cytotoxic effects. 3.) The anastomotic bursting pressure was higher under the use of SMM during the first 4 days. 4.) This novel suture material is potentially able to ensure temporarily juxtapositioned self- knotting in the interval (tightening effect) and to thus possibly improve the suture insufficiency rate.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1874 Superoxide Enhancement of L-Type Ca2+ Channels in Colonic Smooth Muscle Is Dependent on Gβγ and PI3-Kinase Mandeep S. Saund1,2, Mahmood Zare3, Madhu Prasad1,2; 1Surgery, Harvard Medical School, Boston, MA; 2Surgery, Brigham and Women’s Hospital, Boston, MA; 3Surgery, Boston University School of Medicine, Boston, MA 2+ 2+ 2+ L-type Ca (Ca L) channels govern action potential upstroke and Ca influx, which underlie phasic contraction of colonic smooth muscle. In colitis, activated neutrophils generate large amounts of the highly toxic superoxide – – radical (O2 ). This study tested the hypothesis that O2 produced by inflammatory cells contributes to markedly irregular motility patterns present in colitis by modulating Ca2+ channels in colonic smooth muscle cells (SMC). METHODS: Single SMCs prepared from intact tissues were placed in a recording chamber, superfused with HEPES-buffered physiological solution and studied using patch clamp techniques to record whole cell Ca2+ currents (ICa,L). – RESULTS: The O2 donor pyrogallol (PYR, 100 µM) increased whole cell 2+ 2+ Ca current ICa,L by 64 + 7% (n = 8). PYR-induced enhancement of Ca channels was prevented by superoxide dismutase (100 U/ml), demonstrating – mediation via O2 . The highly selective PI3-kinase (PI3K) inhibitors LY – – 294002 (20 µM) and wortmannin (WM) blocked O2 activation of ICa,L. O2 - induced ICa,L was restored in WM-treated cells dialyzed with exogenous PI3K-γ, confirming the central role of PI3K in this pathway. Neither calphos- tin c (50 nM) which inhibits classical and novel protein kinase C (PKC) iso- – forms, nor the classical PKC antagonist Gö6976 (200 nM) prevented O2 βγ 2+ activation of ICa,L. Anti-G antibodies also prevented activation of Ca L – channels by O2 , suggesting a locus of action upstream to PI3K. The c-src – antagonist PP-2 (10 µM) prevented O2 activation of ICa,L. Similar inhibition – of OO2 -induced ICa,L was found in cells dialyzed with anti-c-src antibodies. PYR depolarized smooth muscle cells by 11 + 2 mV (n = 4) in intact strips of colon and induced spontaneous action potential spikes, effects that were 2+ abolished by the Ca L channel blocker nifedipine. CONCLUSIONS: Superoxide radical, a strongly reactive oxidant ubiquitous to sites of inflammation, markedly enhances the activity of Ca2+ channels in – βγ colonic smooth muscle. O2 activates G , leading to downstream enhance- 2+ ment of PI3K, c-Src kinase activation, and opening of Ca L channels. ABSTRACTS

2+ POSTER Though novel PKC is partly responsible for acetylcholine-induced Ca L – – channel opening, it plays no role in activation of this channel by O2 . O2 - 2+ enhancement of Ca L channels increases electrical excitability of intact 2+ strips of colonic smooth muscle. Increased activity of Ca L channels in the – 2+ presence of O2 would promote Ca entry thereby altering the electrical and mechanical properties of colonic smooth muscle, actions that may in part explain the dysfunctional motility widely present in colitis.

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Basic: Esophageal

M1875 Aberrant DNA-Hypermethylation of Adenomatous Polyposis Coli (APC) and Death-Associated Protein Kinase (DAPK) in Esophageal Cancer: Association with Response to Neaodjuvant Treatment and Prognosis Jan Brabender1, Daniel Vallbohmer1, Daniela Desombre1, Ralf Metzger1, Stephan E. Baldus2, Arnulf H. Holscher1, Paul M. Schneider1; 1Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany; 2Department of Pathology, University of Cologne, Cologne, Germany INTRODUCTION: Transcriptional silencing by DNA-Hypermethylation is one fundamental process involved in the development of many cancers and has been linked to worse prognose in esopahgeal cancer. However, the association of this epigenetic event with response to neoadjuvant radio-/chemotherapy in cancer of the esophagus has not been investigated. Aim of our study was to determine the association of APC and DAPK Hypermethylation with histomorphologic response to neoadjuvant radiochemotherapy in esophageal cancer. MATERIAL AND METHODS: 50 patients with resectable esophageal cancers (cT2-4, Nx, M0) received neoadjuvant radiochemotherapy (cisplatin, 5-FU, 36 Gy) followed by transthoracic en bloc esophagectomy. Histomor- phologic regression was defined as major response when resected specimens contained less than 10% of residual vital tumor cells. DNA was isolated from endoscopic biopsies (paired tumor and normal tissue) prior to neoadjuvant treatment. Quantitative methylation-specific real-time PCR (TaqMan™) assays were performed to determine methylation levels for DAPK and APC standardized for umethylated b-actin. RESULTS: Median APC (p = 0.003) and DAPK Methylation (p < 0.001) levels were significantly higher in tumor tissues compared to paired normal tissues. APC and DAPK Methylation levels in tumor tissues showed no associations with response to neadjuvant radiochemotherapy, prognosis or patients clinical parameters. Histopathologic response to neadjuvant therapy was significantly associated with patients prognosis. The 5-year survival probabilities were 21.8% ± 8.2 months for minor responders and 62.6% ± 12.9 months for major responders (p = 0.009). CONCLUSION: These data show that hypermethylation of APC and DAPK is a common event in esophageal cancer and suggest a role for this epigenetic event in the development of this disease. However, hypermethylation of these genes is not associated with response to neadjuvant therapy and not useful as a clinical response marker. Response to neoadjuvant therapy is associated with patients prognosis in this disease.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1876 The Pathogenesis of Barrett’s Esophagus: Secondary Bile Acids Upregulate Intestinal Differentiation Factor CDX2 Expression Yingchuan Hu, Valerie A. Williams, Oliver Gellersen, Carolyn Jones, Thomas J. Watson, Jeffrey H. Peters; Department of Surgery, University of Rochester, Rochester, NY Clinical evidence strongly suggests that bile acids are important in the development of Barrett’s esophagus, although the mechanism remains unknown. Caudal- related homeobox 2 (CDX2) is a transcription factor recently implicated in early differentiation and maintenance of normal intestinal epithelium and is suggested to play a key role in the pathogenesis of intestinal metaplasia in Barrett’s esophagus. The aim of this study was to investigate the effect of primary and secondary bile acids on CDX2 mRNA expression in human esophageal cells. METHODS: Human esophageal cells: 1) squamous, immortalized by SV40 (Het-1A), 2) adenocarcinoma (SEG-1), and 3) squamous cell carcinoma (HKESC-1 & HKESC-2), were exposed in tissue culture for 1–24 hours to 100– 1000 µM deoxycholic, chenodeoxycholic and glycocholic acid. Total RNA was extracted before and after bile acid treatment and reverse transcribed to cDNA. CDX2 mRNA expression was determined by both quantitative real time and reverse transcription PCR. RESULTS: CDX2 mRNA expression was absent before bile acid exposure in all cell lines. CDX2 expression increased in a dose and time dependent fashion with deoxycholic and chenodeoxycholic but not glycocholic acid in all four cell lines. The maximal induction of CDX2 expression was seen in SEG-1 adenocarcinoma cells (Figure, up to 1973-fold increases). Expression in Het-1A cells also increased signiﬁcantly as did expression in HKESC-1,2 cells although to a lesser extent than in adenocarcinoma. ABSTRACTS POSTER

CONCLUSIONS: These ﬁndings show that secondary bile acid stimulation upregulates CDX2 gene expression in both normal and cancer cell lines. They further support the role of bile acids in the pathogenesis of Barrett’s esophagus and link the clinical evidence of a high prevalence of luminal bile acids in Barrett’s to expression of the gene thought to be responsible for the pheno- typic expression of intestinal metaplasia.

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M1877 Loss of Manganese SuperOxide Dismutase Expression Leads to Barrett’s Esophagus Robert C. Martin, Yan Li, Ruby Su, John Wo; Surgery, Divison of Surgical Oncology, Univeristy of Louisville, Louisville, KY Manganese superoxide dismutase (MnSOD) is known to protect oxygen- utilizing cells from the toxicity of the reactive oxygen species and evidence has shown that decreased MnSOD expression has been observed in both reflux esophagitis and Barrett’s Esophagus (BE). Thus, the aim of this study is to investigate the role of MnSOD expression and activity in the development of BE. METHODS: Our established novel external esophageal perfusion animal model perfused 0.5% bovine bile, pH 7.4 in rats along with saline perfusion for 1, 2, and 4 weeks. The esophageal mucosal was isolated for MnSOD expression by Western blot and activity of SOD was evaluated by Xanthine Oxidase-Cytochrome C Assay. RESULTS: Severe esophagitis was observed at both 1 and 2 week perfusion, with BE being identified at 4 weeks with glandular structures consistent with columnar cells appearing in the submucosa by HE staining. A significant deceased of MnSOD expression with bile perfusion was demonstrated by computer imaged analyzed staining of both Western blot (p = 0.01) and immunohistochical evaluation (Figure). Similarly, MnSOD enzyme activity but not copper/zinc SOD enzyme activity was significantly decreased in bile perfused esophageal mucosal tissues when related to the saline controls and the standard.

Figure 1. MnSOD expression by Western Blot (above) and enzyme activity for standard (St), normal (NE) compared to bile perfusion (PAR2).

CONCLUSIONS: MnSOD expression and activity is signiﬁcantly decreased in bile induced esophagitis. This loss of MnSOD expression leads to the decreased total SOD activity, which might contributes to the metaplastic changes of BE.

148 SSAT.book Page 149 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1878 On the Road to a Vaccine for Barrett’s Esophagus Tomoharu Miyashita1, Todd D. Armstrong2, Jiaai Wang1, Kiyoshi Yoshimura2, Furhawn Shah1, C.M. Shahbaz Sarwar1, Pramod Bonde1, Parsa Mohebi1, Guy Marti1, Elizabeth Montgomery3, Mark Duncan1, Elizabeth M. Jaffee2, John W. Harmon1; 1Department of Surgery, Johns Hopkins University, Baltimore, MD; 2Department of Hematology/ Oncology, Johns Hopkins University, Baltimore, MD; 3Department of Pathology, Johns Hopkins University, Baltimore, MD INTRODUCTION: Individuals with Barrett’s metaplasia of the esophagus are at increased risk for developing adenocarcinoma of the esophagus. We propose to utilize a whole cell Granulocyte Macrophage Colony Stimulating Factor (GM-CSF)-secreting vaccine to protect against the development of cancer in a rat reflux model of esophageal carcinogenesis. METHODS AND RESULTS: Three cancer-cell lines, JA, JB and AMY, were established from rat esophageal cancer, that had the capacity to produce carcinoma both orthotopically and heterotopically in nude mice. These cell lines shared molecular characteristics of human esophageal cancer cells including the over-expression of EGF receptors. MHC class I expression in the JA and JB cell lines was observed by flow cytometric analysis utilizing the mouse monoclonal (OX-18) antibody against MHC class I (Abcam®, Cambrige, MA) (Fig. 1). To develop vaccines from these tumor cell lines, each cell line was transfected with GM-CSF. JA cells produced GM-CSF (JA-GM-CSF) at the rate of 55 ng/24 hours/1 × 106 cells, as measured by ELISA. Vaccine cells were tested for immu- nogenicity by irradiating them with 5000 Gy to prevent their propagation, and injection of 1 × 107 cells/0.5ml in phosphate buffer solution subcutaneously into rats. GM-CSF transfected JA cells, promoted an inflammatory response at the vaccination site as seen by the infiltration of T-cells, Eosinophils, Macroph- ages, and the granuloma size that was greater than that seen in rats injected/ vaccinated with GM-CSF negative cells. (Table). ABSTRACTS POSTER

JA-GM-CSF JA Size of granuloma (µ) 190 ± 71 38 ± 68 Number of Eosinophils / hpf 26 ± 18 1 ± 1 CONCLUSION: JA-GM-CSF cells act in a similar manner as previously reported GM-CSF-secreting whole cell vaccines. We have designed experiments to test the ability of JA-GM-CSF cells to prevent or delay recurrence of esophageal carcinogenesis in rats.

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M1879 Cisplatinum Induced Apoptosis Is Associated with Down-Regulation of DeltaNp63alpha in Cell Lines from Rat Model of Reflux Induced Esophageal Cancer Tomoharu Miyashita1, Jiaai Wang1, Engrid Wu1, Yiping Huang2, Alexey Fomenkov2, C.M. Shahbaz Sarwar1, Guy Marti1, Elizabeth Montgomery3, Mark Duncan1, Edward Ratovitski2, John W. Harmon1; 1Department of Surgery, Johns Hopkins University, Baltimore, MD; 2Department of Dermatology, Johns Hopkins University, Baltimore, MD; 3Department of Pathology, Johns Hopkins University, Baltimore, MD INTRODUCTION: The p53 gene is well-known to impede carcinogenesis by inducing apoptosis. p63 is a recently discovered relative of the p53 gene family. The biological function of p63 is still under investigation. DeltaNp63alpha is an isoform of DeltaNp63 that lacks the transactivation domain. Its function may be to act as an “anti-p53”. We evaluated the effect of Cisplatinum on apoptosis and the expression of DeltaNp63alpha in three rat-cell lines: JA, JB and AMY. These cell lines were derived from our reflux model of esophageal carcinoma. METHODS: A mouse monoclonal antibody against all p63 isotypes (4A4) (Santa Cruz Biotechnology, Santa Cruz, CA) and a rabbit polyclonal antibody against the N-terminus of DeltaNp63 isotypes (p40Ab-1) (Oncogene Science Inc., Cambridge, MA) were used in this study. Cell proliferation was evaluated using the MTT cell proliferation assay kit (ATCC reg.). Apoptotic cells were identified with anti-active caspase-3 pAb (Promega) staining. Apoptosis was initiated by Cisplatinum (Sigma) treatment. RESULTS: First, we found a direct correlation between p63 expression and the rate of cell growth with the JA and JB cell lines growing faster and with more p63 expression than the AMY cell line (Fig. 1). Secondly, we found that Cisplatinum induced apoptosis, while reducing levels of DeltaNp63alpha in the JB cell line (Fig. 2, 3).

CONCLUSION: We conclude that Cisplatinum may induce apoptosis by diminishing DeltaNp63alpha levels and thereby allowing p53 to be more active in inducing apoptosis in this cellular model of esophageal cancer.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1880 Expression of p63 as a Marker for Squamous Esophageal Carcinogenesis Induced by Duodeno-Esophageal Reflux in Sequential Rat Model Tomoharu Miyashita1,2, Jiaai Wang1, C.M.Shahbaz Sarwar1, Katsunobu Oyama2, Takashi Fujimura2, Yiping Huang3, Alexey Fomenkov3, Guy Marti1, Elizabeth Montgomery4, Mark Duncan1, Koichi Miwa2, Edward Ratovitski3, John W. Harmon1; 1Department of Surgery, Johns Hopkins University, Baltimore, MD; 2Department of Surgery, Kanazawa University, Kanazawa, Japan; 3Department of Dermatology, Johns Hopkins University, Baltimore, MD; 4Department of Pathology, Johns Hopkins University, Baltimore, MD BACKGROUND: In the embryo, p63 seems to control development of stratified squamous epithelium. p63 is frequently over-expressed in human squamous cell carcinomas of head and neck. We hypothesized that altered expression of p63 may be involved in the sequential development of esophageal carcinomas induced by duodenal content reflux without carcinogens. METHODS: In our study we performed total gastrectomy for rats, followed by esophago-jejunostomy, in order to induce chronic duodenal content reflux esophagitis. The animals were sacrificed sequentially, at the 10th, 20th, 30th and 40th week after surgery and their esophagi were examined. A mouse monoclonal antibody against all p63 isotypes (4A4) (Santa Cruz Biotechnol- ogy, Santa Cruz, CA) was used in this study. Expression and localization of 4A4 was carried out and examined by immuno-histochemical analysis. RESULTS: At 20 weeks post-surgery, squamous hyperplasia, dysplasia and columnar lined epithelium were observed. At 30–40 weeks after surgery, 10/29 rats had developed esophageal cancer ( 2 squamous, 10 adeno and 1 adeno- squamous). The p63 immunohistochemistry staining with 4A4 antibody showed nuclear expression of p63 in all the stages of squamous carcinogenesis including normal squamous basal cells (Fig 1), hyperplasia, dysplasia and carcinoma (Fig 2). In contrast, the cells undergoing adeno carcinogenesis including Barrett’s metaplasia, Barrett’s dysplasia and adenocarcinoma did not stain positively for p63 with 4A4 antibody (Fig 3). ABSTRACTS POSTER

CONCLUSIONS: As reported in human esophageal cancer, p63 expression may be required to promote the development of neoplastic transformation in cancer cells with squamous differentiation, but not adenocarcinoma.

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M1881 Cox-2 Gene Expression in Long Segment Barrett’s Esophagus Is Inflammatory in Origin Daniel S. Oh1, Steven R. Demeester1, Jeffrey A. Hagen1, Hidekazu Kuramochi2, Koji Tanaka2, Kathleen D. Danenberg3, Peter V. Danenberg2, Christian G. Peyre1, Cedric G. Bremner1, John Lipham1, Tom R. Demeester1; 1Surgery, University of Southern California, Los Angeles, CA; 2Biochemistry & Molecular Biology, University of Southern California, Los Angeles, CA; 3Response Genetics Inc., Los Angeles, CA BACKGROUND: Cox-2 is an inducible enzyme that is known to be involved in both inflammation and gastrointestinal carcinogenesis. Clinical studies on Barrett’s esophagus (BE) have shown that inflammation is greatest at the proximal end of the segment, while cancers occur more commonly in the distal end. To determine if upregulation of Cox-2 in BE is secondary to inflammation or tumorigenesis, we compared gene expression of Cox-2 and IL-8, a more specific marker of inflammation, throughout the length of long segment BE. METHODS: Endoscopic biopsies were taken at 2 cm increments in 4 quad- rants from 15 patients with long segment, non-dysplastic BE. The paraffin embedded tissue blocks were sectioned and microdissected. RNA was isolated, reverse transcribed to cDNA, and gene expression was measured using quantitative real-time PCR relative to the reference gene -actin. Patients were off acid suppression therapy and none had previous foregut surgery. RESULTS: Median BE length was 8 cm (range 4–17). Both Cox-2 and IL-8 gene expression were highest at the top of the BE segment, with significantly lower expression at the bottom (Figure). Biopsies from the distal 3 cm of the Barrett’s segment showed intestinal metaplasia in 37 and cardiac mucosa in 7, and Cox-2 and IL-8 expression were similar in both types of mucosa (p = 0.19).

CONCLUSION: Cox-2 expression parallels IL-8 expression in long segment BE. An expression gradient exists for both genes along the Barrett’s segment, with highest expression at the top. This suggests that upregulation of Cox-2 is initiated by inﬂammation and occurs prior to neoplastic changes.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1883 Towards the Molecular Characterization of Disease: Comparison of Molecular and Histological Analysis of Esophageal Epithelia Daniel Vallbohmer1, Paul Marjoram2, Hidekazu Kuramochi3, Daisuke Shimizu3, Hsuan Jung2, Steve R. Demeester1, Daniel Oh1, Parakrama T. Chandrasoma4, Kathleen D. Danenberg5, Tom R. Demeester1, Peter V. Danenberg3, Jeffrey H. Peters6; 1Department of Surgery, University of Southern California, Los Angeles, CA; 2Department of Preventive Medicine, University of Southern California, Los Angeles, CA; 3Department of Biochemistry and Molecular Biology, University of Southern California, Los Angeles, CA; 4Department of Pathology, University of Southern California, Los Angeles, CA; 5Response Genetics, Inc., Los Angeles, CA; 6Department of Surgery, University of Rochester, Rochester, NY BACKGROUND: Reliable quantification of gene expression offers the possibility of more accurate and prognostically relevant characterization of tissues than potentially subjective interpretations of histopathologists. The aim of this study was to evaluate the feasibility of molecular characterization of normal and pathologic esophageal epithelia. Therefore we measured the expression of 18 selected genes and compared them to histological features in a spectrum of esophageal disease. METHODS: Esophageal tissue biopsies from patients with foregut symptoms were laser-capture microdissected and the expression levels of 18 selected genes were measured by QRT-PCR (Taqman®). Linear discriminant analysis, which uses combinations of genes to distinguish between histological groups, was performed to compare gene expression and the following 5 histological groups: 1) normal squamous epithelium, (n = 32); 2) reflux-esophagitis, (n = 13); 3) non-dysplastic Barrett’s, (n = 17); 4) dysplastic Barrett’s, (n = 10); 5) adenocarcinoma, (n = 22). RESULTS: A panel of 7 genes had 90–94% predictive power to distinguish non-dysplastic and dysplastic Barrett’s esophagus. Clustering analysis revealed structure in gene expression values even in the absence of histology. Expression levels in 17 genes differed significantly across histological groups. Classification based on gene expression agreed with histopathological assessment in the following percentage of cases: normal squamous epithelium = 53%, reflux-esophagitis = 31%, non-dysplastic Barrett’s = 76%, dysplastic Bar- ABSTRACTS

rett’s = 40% and adenocarcinoma = 59%. Interestingly, predictive power POSTER improved markedly when inﬂammatory and dysplastic tissues were removed (77%–94%) [Table]. CONCLUSION: Gene expression classiﬁcation agrees well with histopathological examination. When differences occur, it is unclear whether this effect is due to intra-observer variability in pathological diagnosis or to a genuine difference between gene expression and histopathology.

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Linear discriminant analysis for the three histological groups normal squamous epithelium, non-dysplastic Barrett’s and esophageal adenocarcinoma using the full panel of genes.

Genetic Prediction Group Non- Squamous Predictive dysplastic Adenocarcinoma Epithelium Power [%] Barrett’s Squamous 30 1 1 94 Epithelium Actual histologic Non-dysplastic 0 15 2 88 group Barrett’s Adenocarcinoma 2 3 17 77

154 SSAT.book Page 155 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Basic: Hepatic

M1884 Impact of Left Portal Branch Ligation on Hepatic Microcirculation and Regeneration Michael C. Gock1, Christian Eipel2, Brigitte Vollmar2, Ernst Klar1; 1Department of Surgery, University of Rostock, Rostock, Germany; 2Department of Experimental Surgery, University of Rostock, Rostock, Germany INTRODUCTION: Partial ligation of portal branches leads to atrophy of the deprived lobes and hypertrophy of the intact lobes. The trigger of the liver regeneration cascade is currently not completely known. It is hypothesized that an increased shear stress in the hepatic circulation due to higher portal blood flow velocity causes release of NO and thus triggers liver regeneration. For the first time this in vivo study examines the effects of portal branch ligation on liver microcirculation. METHODS: Under isoflurane gas anaesthesia the left portal branch was ligated (PBL) in male Sprague-Dawley rats. At day 1 and 3 after PBL (n = 5 per group) fluorescence microscopic analysis of the hepatic microcirculation of the ligated and non-ligated lobes was performed. One group without PBL served as control (C, n = 4). Sinusoidal flow velocity was assessed by fluorescence tagged latex beads. Additional measurements included sinusoidal perfusion rate and diameter as well as leukocyte-endothelium interaction. Sinusoidal blood flow and shear stress were calculated. Mean ± SEM, unpaired t-test; *p < 0.05 vs. C. RESULTS: At day 1 in PBL areas sinusoidal flow velocity was reduced compared with controls (µm/s;1d-PBL267 ± 8* vs. C313 ± 16), whereas flow velocity in non-ligated lobes (NLL) was markedly elevated (µm/s;1d-NLL554 ± 70*). At day 3 flow velocity remained elevated in NLL and reduced in PBL (µm/s; 3d-PBL242 ± 14*, 3d-NLL523 ± 75*). Sinusoidal diameters were significantly reduced in the NLL group versus both the control and the PBL group at day 1 and 3 (µm; 1d-NLL 6, 5 ± 0,3*, 3d-NLL6, 5 ± 0, 2* vs. C7, 9 ± 0, 4; 1d-PBL 9, 3 ± 0,5, 3d-PBL 9, 1 ± 0,3), whereas sinusoidal diameters in the PBL group were only slightly increased. In NLL groups, shear stress was markedly higher at day 1 and 3 compared to controls and the PBL group (dynes*cm-2;1d-NLL 13, 4 ± 1,8*, 3d-NLL 12, 8 ± 2* vs. C 6, 4 ± 0,3), whereas shear stress in the PBL group was reduced (dynes*cm-2;1d-PBL4, 5 ± 0, 4*, 3d-PBL4, 3 ± 0, 3* vs. C6,

4 ± 0, 3). Sinusoidal blood flow showed no significant difference and ABSTRACTS remained stable at day 1 and 3, but sinusoidal perfusion rate after PBL was POSTER reduced at day 1 and 3 (%;1d-PBL 93 ± 4*, 3d-PBL 88 ± 6* vs. C100 ± 0). DISCUSSION: This in vivo study demonstrates an elevation of shear stress in NLL together with a reduction in PBL lobes at different time points after left portal branch ligation, whereas sinusoidal flow was kept constant in all areas. This underlines the hypothesis that shear stress plays a pivotal role to trigger liver hypertrophy in the NLL. In addition, the study clearly shows that the organ liver aims at a constant tissue mass and sinusoidal blood flow, most probably in favour of maintenance of clearance function.

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M1886 Granulocyte Colony Stimulating Factor Supports Liver Regeneration in a Surgical Small for Size Liver Remnant Mouse Model Daniel Inderbitzin1, Guido Beldi1, Daniel Sidler1, Rosy Weimann2, Peter Studer1, Beat Gloor1, Daniel Candinas1; 1Department of Visceral and Transplantation Surgery, University Hospital Bern, Bern, Switzerland; 2Department of Pathology, University Hospital Bern, Bern, Switzerland Intense liver regeneration and almost 100% survival follows partial hepatectomy of up to 70% of liver mass in rodents. More extensive resections of 70 to 80% have an increased mortality and partial hepatectomies of > 80% con- stantly lead to acute hepatic failure and death in mice. The aim of the study was to determine the effect of systemically administered granulocyte colony stimulating factor (G-CSF) on animal survival and liver regeneration in a small for size liver remnant mouse model after 83% partial hepatectomy (liver weight < 0.8% of mouse body weight). METHODS: Male Balb C mice (n = 80, 20–24g) were preconditioned daily for ﬁve days with 5µg G-CSF subcutaneously or sham injected (aqua ad inj). Sub- sequently 83% hepatic resection was performed and daily sham or G-CSF injection continued. Survival was determined in both groups (G-CSF n = 35; Sham: n = 33). In a second series BrdU was injected (50 mg/kg Body weight) two hours prior to tissue harvest and animals euthanized 36 and 48 hours after 83% liver resection (n = 3 each group). To measure hepatic regeneration the BrdU labeling index and Ki67 expression were determined by immunohistochemistry by two independent observers. Harvested liver tissue was dried to constant weight at 65 deg C for 48 hours. RESULTS: Survival was 0% in the sham group on day 3 postoperatively and signiﬁcantly better (26.2% on day 7 and thereafter) in the G-CSF group (Log rank test: p < 0.0001). Dry liver weight was increased in the G-CSF group (T-test: p < 0.05) 36 hours after 83% partial hepatectomy. Ki67 expression was elevated in the G-CSF group at 36 hours (2.8 ± 2.6% (Standard deviation) vs 0.03 ± 0.2%; Rank sum test: p < 0.0001) and at 48 hours (45.1 ± 34.6% vs 0.7 ± 1.0%; Rank sum test: p < 0.0001) after 83% liver resection. BrdU labeling at 48 hours was 0.1 ± 0.3% in the sham and 35.2 ± 34.2% in the G-CSF group (Rank sum test: p < 0.0001) CONCLUSIONS: The surgical 83% resection mouse model is suitable to test hepatic supportive regimens in the setting of small for size liver remnants. Administration of G-CSF supports hepatic regeneration after microsurgical 83% partial hepatectomy and leads to improved long-term survival in the mouse. G-CSF might prove to be a clinically valuable supportive substance in small for size liver remnants in humans after major hepatic resections due to primary or secondary liver tumors or in the setting of living related liver donation.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1887 Effects of Pentoxifylline in Liver Regeneration After Partial Hepatectomy in Rats Rodrigo B. Martino, Ana Maria M. Coelho, Sandra N. Sampietre, Nilza A. Molan, Alcione S. Alexandre, Regina Leitao, Telesforo Bacchella, Marcel C.C. Machado; Surgery, University of Sao Paulo, Sao Paulo, Brazil Liver regeneration after partial hepatectomy is regulated by several factors that activate or inhibit hepatocyte proliferation. After hepatectomy, cytokines play an important role in injury to the remnant liver and subsequent impairment of liver regeneration. Tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) are thought to be the initial cytokines associated with liver injury as well with regeneration. Pentoxifylline is a derivative of methyl xan- tine, inhibitor of TNF-α production, and has showed good benefits in sepsis, shock and acute pancreatitis. AIM: To evaluate if the blockade of the initial cytokine response by pentoxifylline could modulate the cytokine cascade, resulting in improved hepatocyte protection and proliferation. METHODS: Thirty-two Wistar rats were submitted to partial hepatectomy (70%) and divided in 2 groups: Group P (n = 16): rats received pentoxifylline (25 mg/Kg intraperitoneally), and Group C (n = 16): control rats that received saline solution intraperitoneally. Ten rats of each group were sacrificed after 2 hours for determination of serum levels of TNF-α, IL-6 and aminotransferases (AST, ALT). Liver tissues were obtained 48 hours after surgery and regenerative activity assessed by proliferating cell nuclear antigen (PCNA) expression and mitotic index. RESULTS: Comparing the groups, two hours after surgery it was observed a significant decrease of serum TNF-α (8 ± 3 vs. 42 ± 15 pg/ml) and serum IL-6 (10 ± 5 vs. 59 ± 10 pg/ml) in the group treated with pentoxifylline (p < 0.05). The levels of aminotransferase didn’t show difference between the groups. The PCNA labeling and mitotic index of the pentoxifylline group were significantly higher compared to the control group (p < 0.05). CONCLUSION: The results suggest that pentoxifylline inhibits TNF-α production, ameliorates liver injury and accelerates hepatic regeneration after hepatectomy in rats. ABSTRACTS POSTER

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M1888 Effects of a High-Fat Diet with PUFAs-W-3 in the Hepatic and Pulmonary Disturbances Secondary to Ischemia and Reperfusion Injury of Rat’s Liver Ana Maria M. Coelho, Wellington Andraus, Sandra N. Sampietre, Nilza A. Molan, Alcione S. Alexandre, Regina Leitao, Telesforo Bacchella, Marcel C.C. Machado; Surgery, University of Sao Paulo, Sao Paulo, Brazil Hepatic ischemia-reperfusion (I/R) is associated with hepatocellular injury and distant organ dysfunction. Previous studies have demonstrated that a high-fat diet enriched with polyunsaturated fatty acids (PUFAs-w-3) has a protective effect on the liver, causing only mild liver steatosis. AIM: To evaluate the effect of a high-fat diet enriched with PUFAs (fish oil) on hepatic and pulmonary disturbances associated with hepatic ischemia- reperfusion injury. METHODS: Thirty-one Wistar rats were divided in 2 groups: Group I (n = 17): rats with fatty liver induced by high-fat diet enriched with PUFAs-w-3 for 4 weeks and Group II (n = 14): received standard diet. Ten rats of group I and seven of group II were submitted to I/R. Hepatic mitochondrial oxidation and phosphorylation were measured polarographically by determining oxygen consumption without ADP (basal respiration, S4), and in the presence of ADP (activated respiration, S3). Serum aminotransferases (AST, ALT) were determined, and the study of hepatic tissue histology was carried out. The evaluation of the pulmonary lesions was done using the Evans blue test and the tissular determination of mieloperoxidade. RESULTS: In the animals with fatty diet it was observed mild liver steatosis in the periportal zone, compared to group with a standard diet. Comparing the groups submitted to I/R, there was an increase in state 3 respiration (88.38 ± 15.01 vs. 26.33 ± 7.50), in the respiration control rate (2.86 ± 0.59 vs. 1.55 ± 0., 36), and the ADP/O ratio (1.72 ± 0.18 vs. 1.21 ± 0.16) in the group with a high-fat enriched with PUFAs-w-3 diet in relation of group II, with a standard diet (p < 0.05). The PUFAs-w-3 enriched diet group had also lower levels of aminotransferases (AST:1087 ± 775 vs. 6607 ± 806; ALT: 1333 ± 892 vs. 7132 ± 1102) and the histological findings were significantly less intense (p < 0.05). The pulmonary lesion didn’t show difference between the groups. CONCLUSION: The results suggest that a high-fat diet enriched with polyunsaturated fat (w-3) may have a protective effect in hepatic ischemia-reperfusion injury, probably due to PUFAs-w-3 capacity to reduce inflammatory response and the production of reactive oxygen species in the liver.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1889 COX-1 and COX-2 Inhibitors Ameriolates Hepatic Oxidative Stress During Ischemia Reperfusion Injury in Rat Eduardo Montalvo-Jave1, Arturo Ortega-Salgado2, Montalvo-Arenas Cesar1, Enrique Pina1, Carrasco Daniel2, David Jay3, Andres Castel1, Roberto Gleason4; 1Surgery, Cell Biology and Biochemistry, Faculty of Medicine, UNAM, Mexico City, Mexico; 2Department of Pediatric Surgery and Pathology, National Institute of Pediatrics, Coyoacan, Mexico City, Mexico; 3Cardiovascular Molecular Biomedicine, National Institute of Cardiology, Tlalpan, Mexico City, Mexico; 4Department of Solid State, Institute of Physic, UNAM, Coyoacan, Mexico City, Mexico BACKGROUND AND AIMS: The hepatic ischemia-reperfusion injury (HIRI). is associated with liver transplantation, hepatic surgical procedures or trauma and the oxidative damage induced after HIRI is considered to be the ﬁrst event leading to graft dysfunction and to a rise in reactive oxygen species (ROS). The aims of the present study was to characterize some changes due to the increased presence of ROS, such as lipid peroxidation (LP), protein carbo- nylation (PC), and release of serum enzymes (SE) during HIRI. And evaluate the effect of the COX-1 (Piroxicam) and COX-2 (Meloxicam) inhibitors during the (HIRI). METHODS: 90 male Wistar rats, allocated randomly to 9 study groups (n = 10), were subjected to 30 m of total warm liver ischemia and the determinations were made at 0, 0.5, 1.0, 1.5, 2.0, 4.0, 12, and 24 h after reperfusion. The following indicators were quantiﬁed in liver biopsies: LP levels measured as thiobarbituric acid-reactive substances (TBARS), PC measured immunohis- tochemically (IHCh) by bound 2,4-dinitrophenylhydrazine to proteins, and SE activities of LDH, AST, ALT, and OTC released from the liver. The ROS activity was evaluate in bile samples using electron paramagnetic resonance (EPR). RESULTS: Increased TBARS levels and PC were found at 1.0, 1.5, and 2.0 h. Serum levels of OTC, AST, ALT, and LDH were increased during the reperfusion phase, especially during the period between 1.0 and 4.0 h. In the group of COX-1 and 2 the TBARS, SE, PC and EPR activity was ameliorates compared with sham group. CONCLUSIONS: The protective effects of the COX-1 and 2 was investigated in the prevention of free radical mediated tissue damage in liver ischemia- ABSTRACTS

reperfusion injury. The temporal course of the oxidative stress and its correla- POSTER tion with SE in 24 hours after our experiments suggest that generation of ROS during total HIRI are responsible, at least partially for the transient rise in TBARS, PC and catalytic activity of serum enzymes with a maximum effects at around 2 h after reperfusion.

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Basic: Pancreas

M1890 Influence of Clinically Relevant Chemotherapeutics on the Expression of Multidrug-Resistance Family Members in Human Pancreatic Carcinoma Cell Lines Sven Eisold1, Dirk Nauheimer2, Jan Schmidt2, Thomas Giese3, Ernst Klar1, Michael Linnebacher1; 1Surgery, University of Rostock, Rostock, Germany; 2Surgery, University of Heidelberg, Heidelberg, Germany; 3Immunology, University of Heidelberg, Heidelberg, Germany Treatment of pancreatic carcinomas by chemotherapy in an adjuvant, neoadjuvant or palliative setting is often impeded by an intrinsic multidrug resistance (MDR) of these tumor cells. An important mechanism causing the MDR phenotype is the ATP-dependent export of drugs across the plasma membrane mediated by transporters of the P-glycoprotein family (ABCB) or of the multidrug resistance related protein (MRP) family (ABCC). To elucidate the contribution of ABCB and ABCC family members for the MDR phenotype of pancreatic carcinomas, we analyzed the mRNA expression of MDR-1, MDR-3, MRP1, MRP3 and MRP5, which have been shown before to confer resistance to chemotherapeutic drugs in several tumor entities. Quantitative RT-PCR expression analyses of 10 human pancreatic carcinoma cell lines were performed with and without in vitro chemotherapy (14 to 28 days) including gemcitabine, 5-fluorouracil, cisplatin or a combination of 5-fluorouracil with cisplatin. MDR1 and MDR3 mRNA expression was detectable in all cell lines but not significantly influenced by chemotherapeutic treatment. In the untreated pancreatic cell lines Pan-1, KCI-MOH-1, Mia-PaCa-2, PK-1, PK-8, PK-9 and ASPC-1, these analyses demonstrated high base line levels of MRP5 > MRP3 > MRP1, whereas Patu 8902, HupT4 und Fampac expressed only marginal amounts of these mRNA transkripts. Under chemotherapeutic treatment, all tested cell lines showed a significant upregulation of MRP3 > MRP1 > MRP5. Expression levels were influenced (in falling order of upregulating potency) by 5-fluorouracil and cisplatin in combination, 5-fluorouracil, cisplatin and gemcitabine. These data suggest that MRP1, MRP3 and MRP5 are likely to be involved in the multidrug resistance phenotype often seen in pancreatic carcinomas. The majority of pancreatic carcinoma cells expresses high levels of MRPs even without prior chemotherapeutic treatment. Quantification of MRP expression levels may be helpful to guide therapy decisions and to predict individual tumors responses towards chemotherapeutic treatment. Our finding of a minor MRP upregulating capacity of gemcitabine may be an explanation for the significantly better outcome of pancreatic carcinoma patients treated with gemcitabine. Eventually, the treated cell lines may be a valuable tool for future analyses of the pancreatic carcinoma MDR phenotype and its therapeutic reversal.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1891 Apigenin Inhibits Pancreatic Cancer Cell Proliferation via Down-Regulation of the GLUT-1 Glucose Transporter Laleh Golkar1, Mohammad R. Salabat1, Xian-Xhong Ding1, Michael B. Ujiki1, Sambasiva M. Rao2, Thomas E. Adrian1, Mark S. Talamonti1, Richard H. Bell1, Jill Pelling2, David J. Bentrem1; 1Surgery, Northwestern, Chicago, IL; 2Pathology, Northwestern University, Chicago, IL INTRODUCTION: Pancreatic cancer continues to have a poor prognosis despite resection and adjuvant therapy. As tumor cells outgrow their blood supply, hypoxia induces an increase in anaerobic metabolism, glucose uptake and the expression of the facilitative glucose transporter, GLUT-1. GLUT-1 is up-regulated in many cancers and is induced by the transcription factor hypoxia-inducible factor-1 (HIF-1). Apigenin is a plant ﬂavonoid with antiproliferative effects in pancreatic cancer cells and has been shown to inhibit HIF-1 expression. We hypothesized that apigenin inhibits pancreatic cancer cell proliferation via down-regulation of the GLUT-1 glucose transporter and thus decreases glucose uptake. MATERIALS AND METHODS: Immunohistochemistry with anti-GLUT-1 antibody was used to quantify expression in 15 human pancreatic tumor and respective control tissue samples using a grading system of: 0 none, 1+ weak and 2+ strong staining. DNA synthesis was measured in CD18 human pancreatic cancer cells after treament with a non-metabolized glucose analogue (D-Mannoheptulose) to demonstrate glucose dependent-growth. Viable cell counts were performed on two pancreatic cancer cell lines (CD18 and S2-103) that were treated with apigenin (6.25–100 µM) to evaluate cell proliferation. Real time RT- PCR was performed on CD18 and S2-013 pancreatic cancer cells treated with apigenin (0–50 µM) to evaluate concentration dependent GLUT- 1 expression. C14-2-deoxyglucose uptake was measured in CD18 and S2-013 pancreatic cancer cells treated with apigenin (0–100 µM) versus control. RESULTS: GLUT-1 expression was signiﬁcantly increased in human pancreatic tumor samples versus controls (2+ strong staining in 15/15 of the tumor samples versus 0/15 with 2+ strong staining and 2/15 with 1+ weak staining in controls (P < 0.001). D-Mannoheptulose inhibited both basal and insulin- stimulated DNA synthesis in CD18 pancreatic cancer cells (P < 0.01, control vs D-Mannoheptalose; P < 0.01, insulin vs insulin+D-Mannoheptulose) in parallel with inhibition of basal and insulin-stimulated glucose uptake. In ABSTRACTS

CD18 and S2-013 human pancreatic cancer cells, apigenin signiﬁcanlty inhib- POSTER ited cell growth (48 and 72 hours; P < 0.001) and down-regulated GLUT-1 expression (6.25–100 µM, P < 0.05). Apigenin (50 µM) decreased C14-2- deoxyglucose uptake in CD18 and S2-013 pancreatic cancer cells compared to control. CONCLUSIONS: Apigenin induces growth inhibition in human pancreatic cancer cells, which are dependent on glucose for proliferation. One of the mechanisms of apigenin-mediated anti-proliferative activity may be via down-regulation of GLUT-1 expression and in turn decreased glucose uptake and metabolism.

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M1892 Thioredoxin-Interacting Protein Expression Is Reduced in Metastatic Gastrointestinal Neuroendocrine Tumors David Y. Greenblatt1, Abram Vaccaro1, Muthusamy Kunnimalaiyaan1, Anath Shalev2, Herbert Chen1; 1Department of Surgery, University of Wisconsin, Madison, WI; 2Department of Medicine, University of Wisconsin, Madison, WI BACKGROUND: Gastrointestinal (GI) neuroendocrine tumors are highly metastatic. Thioredoxin-Interacting Protein (TXNIP) is a metastasis suppressor gene that has been reported to be downregulated in metastatic neuroendocrine tumors such as pheochromocytomas. We hypothesized that TXNIP expression may also be reduced in metastatic GI neuroendocrine tumors. METHODS: Nine patients with GI neuroendocrine tumors were treated with surgical resection, and tumor tissue samples were collected for analysis. Clini- cal, operative, and pathology findings were reviewed. Tumor lysates were prepared and Western blot analysis using anti-TXNIP antibody was performed. TXNIP protein expression was quantified and correlated with clinical characteristics for each patient. RESULTS: For the patients with GI neuroendocrine tumors, the average age was 52 ± 5 years, and 67% were female. The primary site of the neuroendocrine tumors included pancreas (5), small bowel (1), ampulla (1), appendix (1), and colon (1). Six patients (67%) had stage IV disease with distant metastases, two (22%) had stage III disease with nodal metastases, and one patient (11%) hade localized stage I disease. Of the patients with stage IV disease, four had liver metastases and two had carcinomatosis. Western analysis demonstrated TXNIP protein expression to be significantly reduced in GI neuroendocrine tumors with distant metastases (average TXNIP intensity 16 ± 3.9) compared to non-metastatic tumors (average TXNIP intensity 35 ± 7.1, p = 0.01, Wilcoxon signed rank test). CONCLUSIONS: TXNIP expression is reduced in metastatic GI neuroendocrine tumors. Downregulation of this metastasis suppressor may be an important step in neuroendocrine tumor progression to a metastatic phenotype. Restoration or induction of TXNIP represents a potential therapeutic strategy for the prevention of metastases in patients with GI neuroendocrine malignancies.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1893 Diagnostic Relevance of Human Telomerase Reverse Transcriptase (hTERT) Expression Detected by Immunohistochemistry in Pancreatic Tumors Yasushi Hashimoto1, Eiso Hiyama2,1, Yoshiaki Murakami1, Kenichiro Uemura1, Yasuo Hayashidani1, Takeshi Sudo1, Yoichi Sugiyama1, Taijiro Sueda1; 1Department of Surgery, Graduate School of Biomedical Science, Hiroshima University, Hiroshima, Japan; 2Department of Biomedicine, Graduate School of Biomedical Science and Natural Science Center of Basic Research and Development, Hiroshima University, Hiroshima, Japan Human telomerase reverse transcriptase (hTERT), a catalytic subunit of telomerase, is considered as a useful diagnostic marker for cancers. But there were few studies to be attempted immunohistochemical detection of hTERT in pancreatic tumors. OBJECTIVES: To evaluate the feasibility of immunohistochemistry (IHC) of hTERT as diagnostic marker, we analyzed hTERT expression by IHC and compared with telomerase activity. MATERIALS AND METHODS: Forty invasive ductal adenocarcinomas (IDCs), 69 intraductal papillary-mucinous neoplasms (IPMNs: 31 adenomas, 10 borderline lesions, 14 non-invasive carcinomas, and 14 invasive carcinomas), 5 endocrine cell tumors, 5 mucinous cystic neoplasms, 5 solid pseudo-papillary tumors, 7 chronic pancreatitis, 5 normal pancreatic tissues, and 10 ex vivo brushing samples of the pancreatic duct were examined. These specimens were analyzed for hTERT expression by IHC and telomerase activity by TRAP assay. RESULTS: There were signiﬁcant correlations between hTERT expression and telomerase activity, indicating that accumulation of hTERT is a limiting step for the activity of telomerase. IHC could assess hTERT expression at the cellular level without complicated procedure than by TRAP assay. hTERT expression showed gradual stepwise increase with increasing degree of cellular atypia in IPMNs. One of 7 pancreatitis sample was positive for telomerase activity, derived from inﬁltrated lymphocytes, without detectable hTERT expression. In 10 ex vivo brushing samples, 5 of 5 with IDCs expressed hTERT with detectable

Table 1. Positive Rates of hTERT Expression and Telomerase Activity in Pancreatic Tissues

Pancreatic Diseases n hTERT Expression Telomerase Activity

Invasive ductal carcinoma 40 87.5% 90.0% ABSTRACTS POSTER IPMN adenoma 31 3.2% 10.0% IPMN borderline lesion 10 10.0% 10.0% IPMN non-invasive carcinoma 14 35.7% 75.0% IPMN invasive carcinoma 14 85.7% 100.0% Endocrine cell tumor 5 20.0% 20.0% Mucinous cystic neoplasms 5 0% 0% Solid pseudo-papillary tumor 5 0% 0% Chronic pancreatitis 7 0% 14.3% Normal pancreatic epithelium 5 0% 0% ex vivo brushing sample 10 50.0% 50.0%

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telomerase activity, whereas 0 of 5 benign lesions did. In 4 IDCs and one adenoma of IPMN, hTERT was detected in some parts of tumor cells without detectable telomerase activity, however, these discordant results might be caused by the inherent heterogeneity of hTERT expression in these tumors. CONCLUSIONS: Immunohistochemical detection of the hTERT may be useful diagnostic value in carcinogenesis of pancreas and clinical applicability for preoperative diagnosis.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1894 NF-κB Targeting in Pancreatic Cancer Promotes the Antiproliferative Effects of Gemcitabine Bryan Holcomb1, Michele Yip-Schneider1, Matthew Ralstin1, Jennifer Dixon1, Julie Mahomed1, Christopher Sweeney2, Harikrishna Nakshatri1, Peter Crooks3, Christian M. Schmidt1,4; 1Surgery, Indiana University, Indianapolis, IN; 2Hematology/Oncology, Indiana University, Indianapolis, IN; 3Toxicology, University of Kentucky, Lexington, KY; 4Richard L. Roudebush VAMC, Indianapolis, IN BACKGROUND: Pancreatic cancer is the fourth most common cause of cancer death in the U.S. Gemcitabine is the most active single agent for pancreatic cancer, but chemoresistance to gemcitabine is common. Nuclear factor kappa-B (NF-κB) has been implicated in the chemoresistance of solid organ malignancies. We hypothesized that gemcitabine induces NF-κB activity, and inhibition of NF-κB promotes the antiproliferative effects of gemcitabine on pancreatic cancer. METHODS: Panc-1, PaCa-2, and BxPC-3 human pancreatic cancer cell lines were treated with gemcitabine in the presence/absence of curcumin or LC-1 (novel NF-κB inhibitor). NF-κB DNA binding activity was measured using an electromobility shift assay (EMSA). The expression of IκB-α (endogenous NF- κB inhibitor) was measured using Western blot. Proliferation was determined using trypan blue-excluded cell counts. RESULTS: NF-κB was constitutively active in all pancreatic cancer lines. Gemcitabine treatment induced an increase in NF-κB activity in all lines. In BxPC-3, gemcitabine (0.2 µM) increased NF-κB activity at 24 hours by 21%. In Panc-1 and PaCa-2, gemcitabine (0.2–10 µM) did not change NF-κB activity at 24 hours; however, at 48 hours it increased NF-κB activity by 67% and 20%, respectively. Individually, gemcitabine (0.005–20 µM) and NF-κB targeted agents, curcumin (0.05–10 µM) and LC-1 (1–10 µM), dose-dependently inhibited proliferation in all lines. The antiproliferative effects of gemcitabine in combination with curcumin on average were slightly greater than additive. Panc-1 and PaCa-2 were the most sensitive to the combination. LC-1 was synergistic in promoting the antiproliferative effect of gemcitabine in Panc-1 cells. Conversely, BxPC-3 and PaCa-2 failed to show any beneﬁt of the combination with LC-1. In the resistant PaCa-2 cells, LC-1 in combination with gemcitabine decreased NF-κB activity 16% compared to baseline (total 36%). Conversely, in the sensitive Panc-1 cells, LC-1 in combination with gemcitabine decreased NF-κB activity 65% (total 132%). In the sensitive Panc-1 cells, ABSTRACTS

gemcitabine decreased the (30%) level of inhibitory IκB-α (0.2–20 µM) at 24 POSTER hours. Conversely, gemcitabine failed to decrease IκB-α in the resistant PaCa-2 (0.2–20 µM, 24–72 hr). CONCLUSION: Gemcitabine induced a variable increase in NF-κB activity in pancreatic cancer cells. Greater gemcitabine-induced increases in NF-κB activity correlated with decreases in IκB-α and a greater antiproliferative effect of the gemcitabine-NF-κB targeted agent combination. NF-κB targeting may improve the effectiveness of gemcitabine in the treatment of patients with pancreatic cancer.

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M1895 A Nude Mouse Resection Model of Ductal Pancreatic Cancer to Evaluate Novel Adjuvant Treatment Strategies Hubert G. Hotz, Birgit Hotz, Sarah Bhargava, Heinz J. Buhr; Department of Surgery, Charite – Medical School, Campus Benjamin Franklin, Berlin, Germany BACKGROUND: Aggressive local and systemic spread is characteristic for ductal pancreatic cancer. Even after curative resection, most patients will suc- cumb to local and systemic tumor recurrence. This study aimed to create a nude mouse resection model of pancreatic cancer that reflects the situation after curative surgical treatment and allows the evaluation of novel adjuvant treatment strategies. METHODS: Two fragments (1 cmm) of subcutaneous donor tumors (derived from the human pancreatic cancer cell line AsPC-1) were orthotopically implanted into the pancreatic tail of 30 nude mice. Animals were randomly allocated into 5 groups and sacrificed after 2, 4, 6, 8, and 10 weeks. Primary tumor growth was determined at autopsy, as well as local infiltration and systemic metastasis (dissemination score). In a second set of experiments, orthotopic tumors were induced in 21 other mice. Either the primary tumor with the spleen (resection group), or the spleen alone (splenectomy group) was resected after two weeks. A third group of mice served as control and was only observed after tumor induction. The mice were autopsied after 14 weeks or after death, and local and systemic tumor spread was quantified. H&E stained sections were analyzed from all resected specimens to confirm complete tumor resection. RESULTS: Donor tumor implants were grown to small primary tumors (28 ± 18 cmm) two weeks after implantation, without local or systemic spread. In contrast, animals developed already large tumors and metastasis after 4 weeks. Tumors and metastasis grew continuously until 10 weeks of observation. Sec- ond set of experiments: table. CONCLUSIONS: 1) A histologically confirmed curative resection is feasible two weeks after tumor induction in this model. Later on, local and distant spread is already present. 2) Despite a seemingly curative tumor resection, there were no significant differences with regard to metastasis and survival in comparison to untreated controls or splenectomized animals (table). 3) As in human beings, early tumor recurrence and aggressive spread develops in this model after resection of the primary. This nude mouse model may be suitable to evaluate novel adjuvant therapies for pancreatic cancer. Second set of experiments:

Parameter Control group Resection group Splenectomy group Dissemination score (points) 31.0 ± 2.0 24.8 ± 5.3 22.0 ± 2.1 Liver metastasis (n/n; %) 3/9; 33.3 2/9; 22.2 1/3; 33.3 Lung metastasis (n/n; %) 9/9; 100 8/9; 88.9 3/3; 100 Lymph node metastasis (n/n; %) 6/9; 66.6 4/9; 44.4 2/3; 66.6 Survival (days) 56.5 ± 23.0 48.3 ± 10.0 38.0 ± 17.0

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1896 Adhesion Molecules Under Volume Therapy in a Pig Model of Acute Severe Pancreatitis Helge Kleinhans1, Oliver Mann1, Jussuf T. Kaifi1, Felix Reinknecht1, Bente Hansen1, Marc Freitag2, Emre Yekebas1, Jakob R. Izbicki1, Tim G. Strate1; 1General Surgery, University Medical Center Hamburg Eppendorf, Hamburg, Germany; 2Anesthesiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany BACKGROUND: The severity of acute pancreatitis results from the transmigration and activation of leukocytes within the pancreas and release of proinflammatory mediators that transform a local injury into a systemic inflammatory response like lung injury. Adhesion molecules play an important role in this transmigration process. Expression of PCAM-1 (CD 31), VCAM-1 (CD 106), P and E-SELECTIN on vascular endothelial is essential for regulating leucocyte trafficking from blood vessels into tissue during inflammatory deseases.The aim of this study was to evaluate the therapeutic approach of volume therapy with HBOC-301 with and without isovolemic hemodilution (IHD) with regard to the survival rate and expression of adhesion molecules in pancreatic tissue in pigs suffering from acute necrotizing pancreatitis. METHODS: After approval of the local ethics committee 39 pigs were anesthetized, endotracheally intubated and normoventilated. After laparotomy the pancreatic duct was canulated. After 30 min. equilibration (M0) AP was induced by a combination of intravenous cerulein and intraductal glycodeox- ycholic acid. Fifteen min. and 75 min. after induction of AP animals were randomized to isovolemic (PAOP-constant) hemodilution with 10% HES 200,000/0.5 plus HBOC-301 (+ 0.6 g dl-1 plasmatic Hb; Oxyglobin®, Biopure, USA) (IHD+HBOC) or to HBOC-301 (+ 0.6 g dl-1 plasmatic Hb) (HBOC), or to hemodilution with Ringer`s solution (IHD RINGER) to a hematocrit (Hct) of 15%. After six hours abdomen was closed and animals were extubated. After six days (144 hours) surviving animals were sacrified. For immunostaining of vascular adhesion molecules on lung vessels, slides were stained with monoclonal pig antibodies (Ab) against PECAM-1, VCAM-1 E- and P-SELECTIN. Fluorescein isothiocyanate (FITC)—conjugated anti-pig IgG was used as a secondary Ab. Evaluation of expression FITC-stained adhesion molecules was based on the method described by Tang and Hendricks for detection of PECAM. Statistical analyses were performed using the Kruskal-Wallis and Hohns test (significance p < 0.05). ABSTRACTS

RESULTS: The survival rate at the end of the observation period was higher POSTER in the IHD+HBOC group (10/13) (p < 0.001) and in the HBOC-group (9/13) (p < 0.001) compared to the Ringer group (2/13) (p = 0,001 Kruskal-Wallis Test). The expression of adhesion molecules did not differ among the groups. CONCLUSION: The therapeutic application of HBOC-301 was able to improve survival after induction of severe AP. The endothelial cell surface expression of PCAM-1, VCAM-1, P and E-SELECTIN in the lung tissue is detectable but did not show signiﬁcant differences in this model.

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M1897 Expression of Netrin-1 but Not of Its Receptors Has Significant Influence on Time to Tumor Recurrence in Patients with Adenocarcinoma of the Pancreas Bjoern-Christian Link1, Uta Reichelt2, Matthias Schreiber1, Robin Wachowiak1, Dean Bogoevski1, Jussuf T. Kaifi1, Susanne Petri2, Emre F. Yekebas1, Jakob R. Izbicki1; 1Department of General, Visceral and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany; 2Department of Pathology, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: Netrin-1 and its receptors, DCC, UNC5H and Neogenin have been shown to play a major role during nervous system development. However, they have also been described recently as putative tumor suppres- sors and survival factors in various tumor entities. This study was performed to assess if expression of Netrin-1 and its receptors in pancreatic adenocarcinoma is correlated to survival or time to tumor recurrence. METHODS: Patients with resectable pancreatic adenocarcinoma, who had undergone radical operation (pancreaticoduodenectomy) between April 1992 and November 2002 in the Department of General, Visceral and Thoracic Sur- gery of the University Medical Center of Hamburg-Eppendorf, Germany, were included. Patients receiving adjuvant chemoradiation or chemotherapy, as well as patients with R2-resection or patients who died within 90 days after surgery were excluded. Informed consent was obtained from all the patients before their inclusion in the study.Paraffin-embedded sections of the primary tumor were examined regarding their expression patterns of Netrin-1, DCC, UNC5H3 and Neogenin using immunohistochemical staining. Kaplan-Meier analyses were performed to assess the prognostic relevance of the examined expression patterns. RESULTS: A total of 82 patients met the study’s criteria. Median age was 62 ± 10.9 years (range, 33–83). Median follow-up was 15 ± 19.9 months (range, 4–108). Patients suffering from tumors with no or little expression of Netrin-1 (n = 67) had a median recurrence-free survival of 10 months (95% CI, 7–13), while a middle or strong expression (n = 15) was associated with a significantly lower median recurrence-free survival of only 4 months (95% CI, 3–5) (p = 0.0165). Median overall survival in the two groups was 16 months (95% CI, 13–19) and 9 months (95%, 3–15), respectively (p = 0.314). Overall and recurrence-free survival showed no significant differences between the different expression patterns of DCC, UNC5H3 or Neogenin. CONCLUSIONS: Expression of Netrin-1 has significant impact on time to tumor relapse in adenocarcinoma of the pancreas. Three of its six known receptors, namely DCC, UNC5H3 and Neogenin, have no influence on survival. To elucidate the underlying pathophysiology and the role of the additional receptors in this context further studies have to be performed.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1899 N-Acetyl Cysteine Attenuates Pancreatic Injury and Increases Expression Level of GST-α Gene After Pancreatic Ischemia-Reperfusion Induction Model in Rats Roberto F. Meirelles1,2, Marcia S. Kubrusly1, Sandra V. Sa3, Nilza A. Molan1, Maria L. Correa-Gianella3, Daniel Gianella3, Telesforo Bacchella1, Marcel C. Machado1; 1Clinica Cirurgica I, Disciplina de Transplante e Cirurgia do Figado, LIM 37, FMUSP, Sao Paulo, Brazil; 2Cirurgia- Disciplina de Cirurgia Geral, FAMERP, Sao Jose do Rio Preto, Brazil; 3Clinica Medica, Disciplina de Endocrinologia, LIM 25, FMUSP, Sao Paulo, Brazil INTRODUCTION: Simultaneous pancreas-kidney transplantation became the ﬁrst treatment option for type I diabetes patients with end stage renal failure. However, graft acute pancreatitis remains a frequent complication (35%) on immediate pos-operative period and it may contribute to graft loss. Ischemia- reperfusion injury may be involved in the pathogenesis of graft acute pancreatitis. Gene expression is strongly modiﬁed after cellular injury. Glutathione-S- transferases (GST) enzymes provide protection against electrophiles and products of oxidative stress, by catalyzing the formation of glutathione conjugates and by eliminating peroxides during ischemia-reperfusion injury. N-acetyl cysteine (NAC) has been shown to improve pancreatic microcirculation alterations in experimental pancreas transplantation. AIM: Evaluate pancreatic injury and expression level of isoform GST-α after pancreatic ischemia-reperfusion induction on rat model. METHODS: Twenty-four Wistar rats weighting 300–350g were divided into four groups: Group 1—sham; Group 2—ischemia-reperfusion; Group 3— ischemia-reperfusion plus NAC iv; Group 4—ischemia-reperfusion plus NAC po. Splenic pancreatic portion underwent to 1 hour ischemia followed by 4 hours of reperfusion. Group 3 received intravenously150mg/kg body weight 15 minutes before reperfusion followed by 50mg/kg body weight during the remaining time. Group 4 received NAC (4800 mg/L) ad libitum 48 hours before the experiment. Blood and splenic pancreatic tissue samples were collected after 4hour of reperfusion. Serum amylase was determined and expression level of isoform GST-α was evaluated by quantitative real-time polymerase chain reaction (qRT-PCR). Total pancreatic RNA (20ng) from all animals was subjected to qRT-PCR. Normalized qRT-PCR data were determined from the ratio of GST-α/β-actin values for each sample.

RESULTS: Serum amylase levels were 6.11 (sd = 0.55) mg/mL/min, 10.30 (sd = ABSTRACTS 0.50) mg/mL/min, 9.77 (sd = 1.24) mg/mL/min and 7.82 (sd = 0.38) in POSTER Groups 1, 2, 3 and 4, respectively. There was an increase in serum amylase when compared group 1 with group 2 (p = 0.0002) and a decrease when compared group 2 with group 4 (p = 0.003). An increase in GST-α expression was observed in groups 3 and 4 when compared to group 2 (p = 0.016). CONCLUSION: N-acetyl cysteine given 48 hours before experimental ischemia- reperfusion injury induction normalizes hyperamilasemia. This protective effect in pancreatic tissue under ischemia-reperfusion injury may be due to an increase in expression level of GST-α gene. Finally, NAC may have a potential beneﬁt in graft acute pancreatitis related to ischemia-reperfusion injury.

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M1900 Methylene Blue Improves Hemodynamic Shock but Increases Lipoperoxidation in Severe Acute Pancreatitis Model Roberto F. Meirelles1, Fernanda V. Borges2, Paulo R. Evora2, Reginaldo Ceneviva3; 1Cirurgia, Disciplina de Cirurgia, FAMERP, Sao Jose do Rio Preto, Brazil; 2Cirurgia e Anatomia, Laboratorio de Funcao Endotelial, FMRP-USP, Ribeirao Preto, Brazil; 3Cirurgia e Anatomia, FMRP-USP, Ribeirao Preto, Brazil OBJETIVES: This study was conceived to study the hemodynamic pattern during methylene blue (MB) treatment on taurocholate—enterokinase induced acute pancreatitis (AP) in pigs and whether MB oxide nitric blockage influence on lipoperoxidation and histopathological findings. METHODS: Thirty anesthetized Dalland pigs were divided in five groups: 1) control group (n = 6); 2) MB group (n = 6); 3) AP group (n = 6); 4) MB previous AP (n = 6) and; 5) MB after 90 minutes of induced AP group (n = 6). MB was given in a bolus dose of 2mg.kg-1 iv followed by a maintenance dose of 2 mg.kg-1.h-1 iv. Hemodynamic parameters including mixed venous oxygen saturation were recorded continuously during 180 min by a Swan-Ganz catheter and a cardiac monitor. Blood samples were taken every 60 min to determine arterial and venous nitrate, malondialdehyde (MDA), amilase and blood gases. At the end of the experiment the pancreas was removed for histopathological study. RESULTS: Mean arterial blood pressure and cardiac output decreased over time in AP group. In the MB previous induced-AP group, there was a 70 minutes delay in the beginning of the mean decrease of the mean arterial blood pressure and cardiac output. In MB group arterial and venous nitrite decreased over time. MB infusion increased serum MDA when associated to AP. After induced AP, MB blue did not reversed the mean blood pressure and cardiac output decrease. There was no change in the serum hyperamilasemia and necrohemorragic findings with MB treatment. CONCLUSION: MB given prior but not after induced AP improves hemodynamic shock although it increases lipoperoxidation. Neither hyperamilasemia or hystopathological findings changed with MB treatment in taurocholate-enterokinase induced AP in pigs.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1901 Protein Kinase C-Zeta Is Critical in Acute Pancreatitis- Induced Kupffer Cell Apoptosis Yanhua Peng, Celia Sigua, Scott F. Gallagher, Michel M. Murr; Surgery, University of South Florida, College of Medicine, Tampa, FL BACKGROUND: Acute pancreatitis-activated Kupffer cells undergo accelerated apoptosis via NF-κB transcriptional regulation of Fas/FasL. We tested the hypothesis that Protein kinase C-zeta (PKC-ζ), which regulates cell death via NF-κB, plays a critical role in Kupffer cell apoptosis during acute pancreatitis. METHODS: Acute pancreatitis was induced by cerulein injection in adult male Sprague-Dawley rats; 24 hrs later, liver homogenates were assayed for key cell signaling systems [PKC-ζ protein (immunoblots) and kinase activity, NF-κB nuclear translocation (ELISA), Fas/FasL (immunoblot)], and apoptosis [(Caspase-3 activation (immunoblot), DNA fragmentation (ELISA]. In an in- vitro model of acute pancreatitis, fresh rat Kupffer cells were infected with a PKC-ζ domain-negative adenovirus (AdPKCζ-DN) to inhibit PKC-ζ and then were treated with pancreatic elastase (1 U/ml). Cellular extracts were assayed for PKC-ζ, NF-κB, Fas/FasL, Caspase-3, and DNA fragmentation. n ≥ 3; data: mean ± SD; ANOVA and t-test with Bonferroni’s correction were used. RESULTS: Cerulein-induced pancreatitis upregulated PKC-ζ protein (3,305 ± 18 vs. 1,555 ± 38), PKC-ζ activity (2.4 ± 0.1 vs. 1 ± 0.1), NF-κB nuclear translocation (16 ± 0.3 vs. 4 ± 0.1), Fas (3,551 ± 26 vs.1540 ± 26), FasL (3,343 ± 27 vs. 1,444 ± 26), Caspase-3 activation (2,553 ± 33 vs. 1,053 ± 32) and DNA fragmentation (30 ± 1 vs. 8 ± 1%) in rat livers (all p < 0.001 vs. control). In vitro, infection of fresh Kupffer cells with AdPKCζ-DN abolished the elastase-induced upregulation of PKCζ protein and activity, NF-κB nuclear translocation, Fas, FasL, Caspase-3 activation and DNA fragmentation (Table: all p < 0.001; * vs. control untreated cells; ¶ vs. infection control).

NF-κB PKCζ PKCζ Nuclear Cas-3 DNA Protein Activity Translocation Fas FasL Activation Fragmentation Control 707 ± 8 1 ± 0.1 3.2 ± 0.1 1,120 ± 22 1,326 ± 19 896 ± 19 6.1 ± 0.1 Elastase (E) 1,334 ± 28* 3.1 ± 0.2* 6.1 ± 0.1* 2,131 ± 9* 2,505 ± 32 1,554 ± 13* 16 ± 0.2* AdPKCζ-DN + E 751 ± 17¶ 1.5 ± 0.1¶ 3.2 ± 0.1¶ 1,137 ± 19¶ 1,137 ± 19¶ 900 ± 24¶ 6.5 ± 0.1¶

CONCLUSION: Pancreatitis induces upregulation of PKC-ζ and Kupffer cell apoptosis. Inhibiting PKC-ζ signiﬁcantly attenuated the elastase-induced upregulation of key pro-apoptotic signaling within Kupffer cells and reduces ABSTRACTS POSTER apoptosis. Regulation of Kupffer cell apoptosis by PKC-ζ and NF-κB warrants further investigation. The ability of Kupffer cells to autoregulate their stress response by apoptosis may have therapeutic implications.

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M1902 Up-Regulation of MICA/B Expression in Panc-1 Pancreatic Cancer Cells by Radiation, Gemcitabine, and 5-Fluorouracil (5-Fu) Geetha Rao, Carmen Solorzano, Xiulong Xu, Richard Prinz; General Surgery, Rush University Medical Center, Chicago, IL BACKGROUND: MICA/B (major histocompatibility antigen related chain A and B) are two stress inducible cell surface molecules that act as ligands for the immune receptor NKG2D expressed on activated NK and T cells. MICA/B are broadly expressed in a variety of malignancies including pancreatic cancer. MICA/B expression in pancreatic cancer cell lines correlates with their sensitivity to the cytotoxic activity of NK-92 cells, a natural killer cell line which is now being tested in clinical trials for cancer. HYPOTHESIS: Recent studies showed that uric acid can function as a novel “Danger” signal in injured cells to alert the immune system. We hypothesize that radiation or DNA damaging drugs gemcitabine or 5-FU, that induce uric acid accumulation in DNA-damaged pancreatic cancer cells, can induce MICA/B expression. METHODS: Panc-1 cells were treated with uric acid (250 µg/ml), 5-FU (10 µM), gemcitabine (2 µM), and radiation (40 Gy) in the absence or presence of allopurinol (AP) (500 µg/ml) and analyzed for MICA/B expression by ﬂuores- cein-activated cell sorting (FACS) with an anti-MICA/B mAb.

RESULTS: Uric acid, 5-FU, gemcitabine, and radiation increased MICA/B expression on Panc-1 cells, as demonstrated by a right shift of MICA/B peak (green line), compared to the untreated control. AP (a purine metabolism pathway antagonist) alone had no effect on MICA/B expression. AP blocked MICA/B expression in 5-FU and gemcitabine-treated and radiated Panc-1 cells, as shown by a shift of the MICA/B peak to the left (pink line). CONCLUSION: Radiation and DNA damaging drugs induce MICA/B expression in Panc-1 cells. Since this is blocked by allopurinol, it seems that induction of MICA/B expression is due to uric acid accumulation in DNA-damaged cells. Since MICA/B enhances NK-92 cell-mediated cytotoxicity, this study suggests that the effects of radiation and chemotherapy on pancreatic cancer can be augmented by immunotherapy.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1903 Overexpression of Geminin in Pancreatic Cancer Tissue and Its Down-Regulation by Apigenin Mohammad R. Salabat1, Xian Z. Ding1, Laleh Golkar1, Michael B. Ujiki1, Sambasiva M. Rao2, Richard H. Bell1, Thomas E. Adrian1, Jill C. Pelling2, Mark S. Talamonti1, David J. Bentrem1; 1Surgery, Northwestern University, Chicago, IL; 2Pathology, Northwestern Surgery, Chicago, IL BACKGROUND AND AIM: Geminin is a novel cell cycle regulatory protein. Complex formation of several genes on chromatin during the G1 phase of the cell cycle followed by replication firing at the beginning of the S phase lead to DNA replication initiation and any disruption in this process can result in genomic instability, promoting cancer or cell death. Geminin blocks loading of the MCM complex on chromatin, hence inhibiting yet another replication. In human cancer cell lines, (HCT116 colorectal and H1299 lung carcinoma cells) depletion of geminin by siRNA results in G2/M phase arrest. Geminin has been shown to be overexpressed in 60% of breast and colon cancer tissues. Overexpression of geminin has been shown to increase cell proliferation. Apigenin is a dietary flavonoids that has been shown to have antiproliferative effects in several cancer cell lines. It has been shown that apigenin induces G2/M arrest in mutant p53 HT-29 colorectal adenocarcinoma cells and CD18 human pancreatic cancer cells. We sought to identify the expression of geminin in pancreatic cancer tissue and to investigate the effect of apigenin on geminin expression in pancreatic cancer cells. METHODS: We investigated the expression of geminin in pancreatic tissues by immunohistochemistry (IHC). Expression of geminin was also evaluated by western blotting and real time RT-PCR. Immunofluorescence staining was used to localize geminin by confocal microscopy. RESULTS: Our results show that there is a significant increase in staining of geminin in the nucleus of ductal cancer cells in pancreatic tumor tissue compared to normal pancreatic tissue. In the fifteen samples of cancer tissues and their corresponding adjacent normal tissue that were stained with a geminin antibody, geminin stained positive in more than 20% of the ductal cancer cells in 10 of 15 (75%) samples, between 10 and 20% positive in 3 of 15 (20%) samples and less than 10% in only 2 of 15 (5%) samples. None of the normal tissue samples stained for geminin. Geminin mRNA and protein expression levels were significantly reduced by 50 µM apigenin in pancreatic cancer cell lines, S2013 and CD18 cells, by real time RT-PCR (p < 0.05 and p < 0.01, respectively) and western blotting. Immunofluorescence staining in the S2013 pancreatic cancer cell line, localized geminin to the nucleus and cells ABSTRACTS POSTER treated with 50 µM apigenin demonstrated decreased levels of geminin after 4 and 24 hours compared to the control levels. CONCLUSION: Geminin is upregulated in human pancreatic cancer tissue. Geminin is downregulated by apigenin which may contribute to its antiproliferative effect in human pancreatic cancer cells.

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M1904 In Vitro Evidence for Acinar Cell Cytokine Production Via Stress Kinase Activation Isaac Samuel, Asgar Zaheer, Rory A. Fisher; University of Iowa CCOM & VAMC, Iowa City, IA INTRODUCTION: Pancreatic acinar cells overproduce cytokines following cell surface receptor hyperstimulation. Elucidation of mechanisms of acinar cell cytokine production is crucial for a better understanding of acute pancreatitis pathogenesis. Tumor necrosis factor-alpha (TNF) and interleukin-1-beta (IL-1) are key cytokines that initiate, maintain and propagate acute pancreatic inflammation. The role of stress kinases in acinar cell cytokine production is not completely understood. We hypothesize that the stress kinases p38 and ERK play an important role in acinar cell TNF and IL-1 production. METHODS: Pancreatic fragments prepared from normal rats were equili- brated for 3 h in an incubator in tissue culture medium (5% CO2, 95%N, RT) and then treated with saline, or 100 nM of the CCK-A receptor agonist caerulein, or 100 nM caerulein and specific p38 inhibitor (10 µM SB203580) or ERK inhibitor (100 µM PD98059), or the inhibitor alone. After 3 h pancreatic fragments were homogenized and assayed for total and phosphorylated p38 and ERK, and for TNF and IL-1 concentrations (ELISA). RESULTS: (*ANOVA, p < 0.05): Pancreatic fragments stimulated with caerulein showed several-fold increases* in TNF and IL-1 concentrations that were accompanied by significantly* increased phosphorylation of p38 and ERK. Specific p38 and ERK inhibitors significantly* inhibited caerulein-induced activation of the corresponding stress kinase and significantly* attenuated caerulein-induced IL-1 and TNF production by an impressive 50% margin. The increased activation of p38 and ERK in pancreatic fragments was not associated with significant increases in total-p38 and total-ERK concentrations, indicating that increases in p38 and ERK activation following caerulein- hyperstimulation are not a side-effect of stress kinase induction but are rather the consequence of phosphorylation of pre-existing p38 and ERK. The ERK inhibitor did not significantly inhibit p38 activation, and the p38 inhibitor did not significantly inhibit ERK activation, corroborating the specificity of the respective inhibitor. Furthermore, the inability of the p38 inhibitor SB203580 to inhibit activation of ERK following caerulein hyperstimulation does not support the recent view (J Biol Chem, June 3, 2005) that SB203580 may cross-react and antagonize the CCK-A receptor. In control groups, the individual stress kinase inhibitors used alone (without caerulein) showed no significant* effect. CONCLUSION: ERK and p38 play an important role in caerulein-stimulated acinar cell overproduction of IL-1 and TNF. (Support: American College of Surgeons Faculty Research Fellowship 2003-2005; NIH Career Development Award #K08-DK062805)

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1905 Acute Pancreatitis Afeccts Kuppfer Cells Function by Mechanism Dependent on Paf Lourenilson J. Souza, Marina T. Shio, Nilza A. Molan, Ana Maria M. Coelho, Jose Eduardo M. Cunha, Jancar Sonia, Marcel Cerqueira C. Machado; Gastrointestinal Surgery, University of Sao Paulo, Sao Paulo, Brazil INTRODUCTION/AIMS: The major complication of acute pancreatitis (AP) is secondary infection. We have previously observed in experimental AP, that the translocation of intestinal bacteria to several organs is reduced by administration of PAF antagonists and that this phenomenon is accompanied by Kupffer cells (KC) hyperplasia. In the present study we compared some functions of hepatic cells and isolated KC from rats with AP to those from healthy animals, treated or not with a PAF antagonist. MATERIALS AND METHODS: AP was induced in Wistar rats by sodium taurocholate (0.5 ml of 2.5% solution) injection into the main pancreatic duct. The animals were killed 24h later, the liver perfused with Krebs solution, non-parenchymal hepatic cells were obtained by Percoll separation and KC by removal of the non-adherent cells. The cells were stimulated or not with LPS (1 mg/mL). Nitrite levels were measured in the supernantants 48h later by Griess reaction and TNF after 6h by bioassay in L929 cells. Microbicidal activity was evaluated by the capacity to kill Candida albicans. The PAF- antagonist WEB2170 (10 mg/kg) was administered iv 30 min before induction of AP. RESULTS: We observed that the non-parenchymal hepatic cells from rats with AP produced higher levels of NO and TNF than those from healthy rats. Stimulation of these cells with LPS increased NO and TNF levels in cells from both, healthy and AP rats. Treatment of the animals with the PAF-antagonist WEB 2170 before induction of pancreatitis, signiﬁcantly reduced NO but had no effect on TNF production by KC and total hepatic cells. This treatment increased the capacity of KC to kill Candida albicans. CONCLUSIONS: These results suggest that PAF released during AP inhibits KC microbicidal activity and this could explain the increased bacterial circu- latory dissemination that occurs in AP and the reduction of bacterial translocation observed by using PAF antagonists. ABSTRACTS POSTER

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M1907 Changes in the Systemic Innate Immune Response in Two Experimental Models of Severe Acute Pancreatitis Vincent S. Yip1, James J. Powell1, Christopher O. Bellamy2, Ian F. Ansell1, James A. Ross1, Stephen J. Wigmore3, O.J. Garden1; 1Department of Surgery, University of Edinburgh, Edinburgh, United Kingdom; 2Department of Pathology, University of Edinburgh, Edinburgh, United Kingdom; 3Liver Unit, Department of Surgery, University of Birmingham, Birmingham, United Kingdom OBJECTIVE: Bacterial and fungal associated infections are common complications of severe acute pancreatitis (AP), suggesting that the innate immune response is impaired during the disease process. This study aims to characterize aspects of the systemic innate immune response within two experimental models of AP. AIMS: To determine the rates of apoptosis and necrosis of peripheral blood leukocytes during an episode of severe AP; andTo determine the phagocytic capacity of peripheral blood leukocytes during an episode of severe AP. METHODS: Severe AP was induced in rats using either intraperitoneal arginine or caerulein injections. 90 Fischer/Lewis rats were randomized to 3 groups (arginine, caerulein, control). AP was confirmed on the basis of biochemistry and histology. At fixed time points between day 1 and day 14 post induction, peripheral blood leukocyte function was determined. Leukocyte apoptosis and necrosis was quantified using YOPRO/7AAD and AnnexinV/PI. The ability of leukocytes to phagocytose Escherichia coli was quantified using flow cytometric technique. Appropriate ANOVA techniques were performed for statistical analysis. RESULTS: Following induction of AP with caerulein, the rates of both apoptosis and necrosis of peripheral blood granulocytes demonstrated a triphasic pattern with a significant increase on day 1 (vs. control p = 0.011), followed by a fall on day 3 (p < 0.05) with a further increase in rates on day 10 (vs. other time-points p < 0.05). This triphasic pattern was not observed following induction with arginine, although a trend of increased necrosis of granulocytes was observed after day 7. Following induction of AP with caerulein, the rate of lymphocyte apoptosis initially fell but became elevated by day 10, which was statistically significant as compared to other time-points (p < 0.02). In comparison, induction with arginine led to an early increase in the rate of necrotic cell death of lymphocytes but had no effect on late lymphocyte loss.In both models of AP the rates of granulocyte phagocytosis were significantly reduced at day 7 (H(2) = 8.29, p = 0.016) but not at other time points. CONCLUSION: Experimental acute pancreatitis is associated with significant changes in systemic innate immune function. These changes may, in part, depend on the agent used to induce acute pancreatitis. The present observation of an increase in late leukocyte apoptosis and necrosis, coupled with reduced leukocyte phagocytic ability, suggests a reason why patients with acute pancreatitis are at increased risk of septic complications.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Basic: Small Bowel

INTRODUCTION: Recent studies suggest that the exclusively neuronal 5-HT3 receptor, important in the serotonin secretory pathway, is expressed at the mucosal level in the enterochromaffin (EC) cell. There is also evidence that the 5-HT4 receptor may be an autocrine inhibitory receptor for 5-HT release from these cells. These studies have all been done in vascularly-perfused organ or intact tissue models. The BON cell is a unique human pancreatic tumor cell line with many EC cell characteristics. The aim of this study is to demonstrate the existence of autocrine receptors on BON cells. METHODS: BON cells were subcloned by serial dilution, and a clone was chosen based on having the largest amount of 5-HT released by a calcium ionophore. Cells were propagated and maintained as a monolayer culture using standard tissue culture techniques. Cells were treated with a 5-HT3 receptor agonist, 2-methyl-5-HT (2Me5HT), in the absence and presence of either a 5-HT4 receptor agonist (GR113808) or antagonist (HTF919). 5-HT was measured by HPLC an hour after the addition of ligands. Secondly, BON cell protein extracts were prepared and used for immunoprecipitation for 5-HT3 and 5-HT4 receptors using rabbit polyclonal antibodies. Finally, RNA was isolated from BON cells and served as a template for real-time RT-PCR to generate and clone a partial cDNA which corresponds to the 5-HT3 receptor transcript. RESULTS: 2Me5HT was associated with a 200% increase (p < 0.05, one-way RM ANOVA, paired data, n = 10, table) in 5-HT release from baseline. Neither GR113808 nor HTF919 caused a significant change in 5-HT release compared to control. The combination of 2Me5HT with GR113808 did not increase release compared to 2Me5HT alone. Immunoprecipitation of the BON cell lysate revealed an immunogenic band at the expected 55 kilodaltons for the 5-HT3 receptor but no identifiable band for the 5-HT4 receptor. The RT-PCR product for the 5-HT3 receptor was of the expected size of 250 base pairs and verified by DNA sequencing. Real-time RT-PCR revealed detection thresholds

of 25 and 35 cycles for 5-HT3 and 5-HT4 transcripts, respectively. ABSTRACTS POSTER Serotonin Release P Value LIGAND (Mean ± SEM) (difference from Control) Control (No Drug) 5.7 ± 1.7 ng/ml --- 2Me5HT (50 µM) 15.2 ± 3.7 ng/ml p < 0.05 2Me5HT (50 µM) + GR113808 (10 nM) 15.9 ± 3.5 ng/ml p < 0.05 GR113808 (10 nM) 5.9 ± 2.1 ng/ml Not significant HTF919 (10 nM) 7.3 ± 2.2 ng/ml Not significant

CONCLUSIONS: There exists autocrine 5-HT3 receptors on BON cells which mediate release of 5-HT. However, even though 5-HT4 receptors are expressed, they appear to have no functional role in the regulation of serotonin release.

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M1909 Hexose Transporter Expression in the Mouse Jejunum: Role of Diurnal Rhythms Javairiah Fatima, Scott G. Houghton, Judith A. Duenes, Michael G. Sarr; Department of Surgery and Gastroenterology Research Unit, Mayo Clinic College of Medicine, Rochester, MN BACKGROUND: Expression of hexose transporters (mRNA and proteins) is known to have a diurnal variation in rat jejunum, however, the subject remains unexplored in the mouse. Establishing the presence of such diurnal variation in murine small intestine will facilitate study of molecular mechanisms controlling this process. AIM: To investigate the diurnal variation in the expression of SGLT1, GLUT2, and GLUT5 mRNA and protein levels in mouse small bowel. HYPOTHESIS: Hexose transporter mRNA and protein levels exhibit a diurnal rhythm in the mouse jejunum. METHODS AND MATERIALS: 24 c57bl6 mice (weight 20-25g) were maintained in a strict 12 hour light/dark room (lights on 6AM to 6PM) with free access to food and water. 6 mice were sacriﬁced at 3AM, 9AM, 3PM and 9PM (n = 6 at each time-point). Jejunal mucosa was harvested into appropriate buffers, and snap frozen immediately in liquid nitrogen. mRNA levels were determined by reverse transcription real-time PCR. Protein was isolated and quantiﬁed by Western blot technique (semi-quantitative). Transporter mRNA and protein levels were expressed relative to the housekeeping gene glyceral- dehyde-6-phosphate dehydrogenase (GAPDH). RESULTS: mRNA levels of GLUT2 and GLUT5 exhibited a diurnal rhythm with a peak at 3PM (p < 0.01). SGLT1 mRNA levels exhibited a diurnal rhythm and peaked at 9PM (p = 0.02). Protein levels of SGLT1 and GLUT2 exhibited a diurnal rhythm and peaked 6–12 hours later at 3AM (p ≤ 0.04 each; Fig.). Protein expression of GLUT5 is pending.

Figure 1. SGLT1 expression in the mouse jejunum (similar findings occurred with GLUT2 expression).

SUMMARY: mRNA levels of all three hexose transporters showed a daily diurnal variation (anticipatory to darkness). SGLT1 and GLUT2 protein levels peaked 6–12 hours later during the dark cycle when 70% of feeding occurred. CONCLUSION: Hexose transporter mRNA and protein (SGLT1 and GLUT2) levels exhibit a diurnal rhythm in temporal association with the nocturnal eating pattern of mice; protein expression peaks after message expression. These observations will allow study of genetic control of hexose transporter expression.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1910 Molecular Analysis of Colonic Transformation in the Ileum After Total Colectomy in Rats Kouhei Fukushima, Sho Haneda, Yuji Funayama, Chikashi Shibata, Ken-Ichi Takahashi, Hitoshi Ogawa, Iwao Sasaki; Surgery, Tohoku University, Graduate School of Medicine, Sendai, Japan BACKGROUND: Colonic transformation is thought to be an altered phenotype in the ileum following total colectomy (TC) but has not been well addressed at molecular level. We previously demonstrated increased plasma aldosterone levels concomitant with the induction of molecules essential for sodium and water absorption in the rat model of TC. However, TC may result in a variety of alterations in intestinal function except for electrolyte transport. METHODS: Ileal and/or colonic epithelial cells were isolated from control, TC (four weeks after surgery) and aldosterone-infused rats. Epithelial gene expression was compared between the ileum and distal colon in control rats by CodeLink Bioarrays (UniSet Rat 1 containing 10,060 elements, Motorola Inc., Schaumberg, IL). Genes were categorized into “colonic”, “common”, and “ileal” genes according to signal intensity with more than 3-fold difference. Then, ileal gene expressions in (a) the control and TC rats and (b) the control and aldosterone-infused rats were compared to detect altered genes or assess the role of aldosterone in intestinal adaptation. We assessed the mRNA expression of MUC 3, an induced “colonic” gene, and lysozyme, an induced “ileal” gene following TC, by quantitative RT-PCR. RESULTS: A total of 6,109 genes were categorized into “colonic” (627), “common” (5103) or “ileal” (379) gene pools. A comparison of the control and TC rats yielded 82 and 91 genes that were induced and suppressed in the ileum following TC, respectively. Thirty-ﬁve % of them were associated with “colon-like” transformation, i.e., the induction of “colonic” genes or the suppression of “ileal” genes. The expressions of MUC3 and lysozyme mRNAs were signiﬁcantly enhanced in the ileum following. In comparison, aldosterone infusion modulated a total of only 21 genes in the ileum. CONCLUSION: The present data clearly demonstrate that intestinal adaptation four weeks following TC is characterized, at least in part, by a “colon-like” transformation, i.e., ileal epithelial cells assuming a partial colonic phenotype, as well as losing a portion of the ileal phenotype. However, epithelial cells in the remnant ileum adapt to the TC-altered environment by inducing effective molecules regardless of their initial “colonic”, “common”, or “ileal” ABSTRACTS

nature. Circulating aldosterone appears to play a part of roles in altering and/ POSTER or adapting gene expression in intestinal epithelium.

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M1911 The 5-HT3 Receptor Agonist 2-Methyl-5-HT Mediates Nonneural Stimulation of Chloride Secretion in Human Small Bowel Roberto C. Iglesias, Jarrod D. Day, Jessica G. Howell, John M. Kellum; Surgery, Virginia Commonwealth University, Richmond, VA BACKGROUND: Serotonin (5-HT) is a known mediator of intestinal chloride secretion; its importance is elucidated by the several pathologic conditions to which it contributes, including carcinoid syndrome, irritable bowel syndrome, and cholera. Studies have shown that electrogenic chloride secretion can be measured through a change in short-circuit current ()Isc. Through such studies, our lab has previously demonstrated that intestinal chloride secretion occurs at the mucosal level via a non-neural [tetrodotoxin (TTX)— insensitive] 5-HT3 receptor mediated pathway in rats. The aim of this study was to evaluate the effects of 2-methyl-5-HT, a 5-HT3 agonist, on TTX-pre- treated human intestinal mucosa. Our hypothesis is that selective 2-methyl- 5-HT induces intestinal chloride secretion in human small bowel through a non-neural pathway. METHODS: Human jejunum, obtained during obesity surgery, was stripped of its seromuscular layer, mounted into Ussing chambers and placed under short-circuit conditions. Tetrodotoxin (TTX) at (1 × 10–6 M) alone or TTX plus 2-methyl-5-HT (5 × 10–5 M) were added to the chambers. ()Isc was then measured continuously over a 30 minute period with recording of ()Isc maximum value.

RESULTS: The data were expressed as ()Isc over time. The 5-HT3 receptor agonist, 2-methyl-5-HT, signiﬁcantly increased Isc from 4.8 µA/cm2 to 17.95 µA/cm2 (p < 0.01. N = 4, repeated measure ANOVA). The stimulatory effect of 2-methyl- 5-HT plus TTX was statistically signiﬁcant when compared to TTX alone. CONCLUSION: 2-Methyl-5-HT induces chloride secretion by a non-neural, tetrodotoxin-insensitive pathway in human small intestines.

180 SSAT.book Page 181 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1912 Molecular Mechanisms Contributing to Glutamine- Mediated Intestinal Cell Survival Shawn D. Larson, Jing Li, Dai H. Chung, B. Mark Evers; Department of Surgery, The University of Texas Medical Branch, Galveston, TX Glutamine (Gln), the most abundant amino acid in the bloodstream, is essential for maintenance of gut homeostasis and proliferation. Deprivation of Gln induces intestinal cell apoptosis and mucosal atrophy; however, the molecular mechanisms regulating the effects of Gln are poorly understood. Protein kinase D (PKD), a novel protein kinase which is structurally distinct from PKC proteins, has been implicated in numerous cellular functions including cell proliferation and anti-apoptotic signals. The purpose of our study was to determine whether Gln activates PKD which ultimately enhances intestinal cell survival. METHODS: (i) Rat intestinal epithelial (RIE-1) cells were maintained in the presence or absence of Gln for 24 h; cell survival and apoptosis were determined by MTT assay and Cell Death ELISA, respectively. (ii) RIE cells were serum and Gln deprived for 24 h. Cells were then treated with Gln (1 mmol/L) or vehicle (control); cells were lysed and protein extracted over a time course (0, 1, 2, 4, 18, and 24 h). Expression of phosphorylated and total PKD was assessed by Western blot. RESULTS: Gln deprivation significantly reduced cell survival when compared to cells maintained in the presence of Gln (p < 0.05). DNA fragmentation, an indicator of apoptosis, was increased in cells deprived of Gln although this did not achieve statistical significance. Interestingly, phosphorylated (i.e. activated) PKD levels were increased at 1, 2, 4, 18, and 24 h after addition of Gln; total PKD expression was not affected. CONCLUSIONS: Gln is an essential amino acid for intestinal cell growth and survival. We demonstrate, for the first time, that addition of Gln increases expression of phosphorylated PKD in intestinal cells; this induction of activated PKD likely contributes to the cell survival effects of Gln. Moreover, our results identify a critical role for the PKD protein in gut homeostasis. ABSTRACTS POSTER

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M1913 Regulation of Gut Gene Expression by Thyroid Hormone Receptor Variants Gitonga Munene, Madhu S. Malo, Moushumi Mozumder, Wenying Zhang, Premraj Pushpakaran, Richard A. Hodin; Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA INTRODUCTION: Thyroid hormone (T3) plays a critical role in gut development and homeostasis. T3 action is mostly mediated through its nuclear receptors, TRα1 and TRβ1, the bona-fide TR isoforms that contain both DNA and hormone binding domains. However, it has recently become clear that several TR variants also exist, notably TR ∆ α1 and TRα2, which lack the DNA and/or hormone binding domains. The present studies were undertaken to define the role of these TR variants in the context of a T3-regulated gut-specific gene, intestinal alkaline phosphate (IAP), an enterocyte differentiation marker that limits fat absorption. METHODS: Transient transfections were performed in Caco-2 cells with an IAP-Luciferase reporter plasmid and the bona-fide TRα1 ± the TR variants. RNA was extracted and subjected to RT-PCR to assess effects on endogenous gene expression. EMSA were performed with radiolabeled DNA corresponding to the IAP T3 response element (IAP-TRE) and in vitro synthesized proteins. RESULTS: IAP-Luc reporter assays showed that TRα1 activated the IAP gene approximately 8-fold, confirming our previously published data. RT-PCR (standard and real time) also confirmed the endogenous IAP gene induction by TRα1. The TR variants, TR ∆ α1 and TRα2, had no effects alone on IAP activation, but in co-transfections each was able to inhibit the TR1-mediated activation of IAP. These effects of the TR inhibitors were directly related to the dosage of plasmid transfected. In addition, real-time PCR demonstrated that the TR variants caused dramatic inhibition of TRα1-mediated endogenous IAP gene activation (approximately 80% and 60%, respectively). This inhibition of IAP gene activation was specific to the T3 pathway, since there was no inhibition of the Cdx1 transcription factor-mediated IAP activation. As expected, EMSA confirmed that TRα2, but not TR ∆ α1, binds to the IAP-TRE. CONCLUSION: The two naturally occurring TR variant isoforms (TRα1 and TR ∆ α2) repress TRα1-mediated activation of the IAP gene through distinct mechanisms, indicating that there is a complex interplay among the various TR proteins in modulating the physiological effects of T3 in the gut.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1914 Heparanase-1 Expression in Carcinoid Tumors Naris Nilubol1, Todd Beyer1, Carmen C. Solorzano1, Paolo Gattuso2, Xiulong Xu1, Richard Prinz1; 1General Surgery, Rush University, Chicago, IL; 2Pathology, Rush University Medical Center, Chicago, IL INTRODUCTION: Heparanase-1 (HPR) is an endoglycosidase that specifically degrades heparan sulfate proteoglycans, a major component of the extracellular matrix (ECM) and basement membrane. Expression of HPR is associated with tumor invasion and metastasis. HPR expression has been demonstrated in a number of tumors including neuroendocrine tumors such as pheochromocytoma. This study evaluates whether HPR is expressed in carcinoid tumors and assesses whether HPR expression correlates with carciniod tumor invasiveness. METHODS: The paraffin-embedded blocks from 59 patients who had carcinoid tumors biopsied or removed from 1993 to 2004 were analyzed. Patient charts and pathology reports were reviewed. HPR expression was determined by immunohistochemistry (IHC) using a rabbit anti-HPR antibody. All slides were reviewed and the intensity of the staining was graded by a single pathologist. Fisher’s Exact Test was used to compare invasive and metastatic tumors to non-invasive tumors. RESULTS: There were 26 males and 33 females with a mean age of 56 years (range 19–89 years). There were 20 bronchial carcinoids, 16 small bowel carcinoids, 13 rectal, 6 colonic and 4 carcinoid tumors from other sites. Thirty six patients had localized tumors, 10 had lymph node metastasis and 13 had distant metastasis. Forty seven of 59 tumors (80%) had HPR expression on IHC. Sixteen of 18 (88.2%) localized carcinoid tumors that invaded muscularis pro- pria and/or mucosa expressed HPR. Nineteen of 23 tumors (82.6%) with lymph node and/or distant metastasis had HPR expression. Seven of 13 (53.8%) with localized tumors without invasion expressed HPR. Five patients had an endoscopic biopsy and depth of invasion could not be assessed. Inva- sive and metastatic carcinoid tumors had significant higher HPR expression than non-invasive tumors (35 of 41 versus 7 of 13, p = 0.03). CONCLUSION: Most carcinoid tumors express HPR. Invasive and metastatic carcinoid tumors have significantly greater HPR expression than non-invasive tumors. HPR expression may be useful in predicting aggressive tumor behavior. ABSTRACTS POSTER

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M1915 The Effect of L-Arginine and Aprotinin on Intestinal Ischemia-Reperfusion Injury Constantine P. Spanos, Christos Papakonstandinou, Panagiota Papakonstandinou, Panagiotis Spanos; Surgery, Aristotelian University, Thessaloniki, Greece BACKGROUND: Intestinal ischemia-reperfusion (I/R) results in local mucosal injury, systemic injury and organ dysfunction. These injuries are characterized by altered microvascular and epithelial permeability and villous damage. Activation of neutrophils, platelets and endothelial factors are known to be involved in this process. Cytokines and oxygen-derived free radicals are believed to be important pathogenic mediators. Capillary no-reflow is also known to play a role in I/R.The aim of our study was to examine the role of L-arginine and aprotinin on intestinal I/R. METHODS: Pigs weighing 20–25 kg were used. Ischemia was established by clamping the superior mesenteric artery (SMA) at its origin and was sustained for 2 hours. Duration of reperfusion was 2 hours. Animals were divided into four groups: A, the control group, which was submitted to I/R injury only, B, in which L-arginine was administered at a rate of 5 mg/kg/min during ischemia and continuing throughout reperfusion, C, in which aprotinin was administered with an initial bolus dose of 20000U/kg during ischemia followed by a continuous dose at 50 U/h throughout reperfusion and D in which both substances were administered. In all groups TNF-α, IL-1 and IL-6 levels were measured using ELISA at baseline, 1 hour and 2 hours of ischemia, and 30 min 1 hour and 2 hours of reperfusion. SMA blood flow was measured with an electromagnetic probe at baseline, 10 min, and 2 hours of reperfusion. Histologic changes of the intestinal mucosa were examined and graded on a 5-point scale. RESULTS: In the control group, levels of TNF-α, IL-1, and IL-6 were significantly increased during reperfusion (p < 0.05) as compared to baseline. Administration of L-arginine and aprotinin led to suppression of the release of TNF-α, IL-1 and IL-6 during reperfusion in a statistically significant manner (all p < 0.05). A synergistic or additive effect of L-arginine and aprotinin was not observed. SMA blood flow in the control group was decreased (p > 0.05) during reperfusion as compared to baseline. In animals treated with L-arginine and aprotinin, SMA blood flow during reperfusion was significantly increased (p < 0.05) as compared to the control group. Histologic examination of the intestinal mucosa was characterized by villous flattening and necrosis in the control group. In the treated animals, less severe histological changes were noted. CONCLUSIONS: Administration of L-arginine and aprotinin may lead to amelioration of intestinal I/R injury. We did not note a synergistic or additive effect of these two substances. These findings warrant further studies in clinical settings for future treatment efforts.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1916 Enhancement of Neointestinal Cyst Formation Using Abdominal Wall Musculature in a Rat Model Panagiotis Tryphonopoulos1, Werviston Defaria1, Maria B. Torres1, Phillip Ruiz2,1, Andreas Tzakis1; 1Surgery, University of Miami, Miami, FL; 2Pathology, University Of Miami, Miami, FL INTRODUCTION: The implantation of a suspension of rat enterocytes into the abdominal cavity of syngeneic animals results in the formation of a cyst containing neo-intestine. In this study we attempted to enhance the cyst formation by wrapping up the enterocyte suspension in a pouch made of abdominal wall muscle. MATERIALS AND METHODS: The intestine of neonate (6 to 8 days old) DA rats was removed and underwent enzymatic digestion with collagenase and dispase. The resulting organoid units were seeded on a polyglactin polymer absorbable mesh (100.000 units per mesh). The surface of the mesh was covered with the abdominal wall (muscle layer and fascia) that was harvested too from the donor rats, forming a muscular pouch around the mesh and enterocyte suspension. The pouch was then implanted at the peritoneal cavity of an adult syngeneic animal. The omentum of the recipient was sutured loosely around the pouch to assure its vascularization. Animals were sacri- ﬁced 4 weeks later and implants were harvested for histologic studies. Parafﬁn sections of the formed cysts were stained with hematoxylin and eosin for microscopy observation. RESULTS: Our previous experience, consisting of the implantation of the mesh containing the cell suspension, showed that many of the cells dispersed through the mesh in the peritoneal cavity. This would lead sometimes to the formation of multiple small cysts or a multilobulated larger cyst, that were not adequate to work with to study the neo-intestinal function. Using this new method, enterocyte dispersion was minimized and as a result we obtained single cysts, larger than those of our previous experience. On histological examination, that cyst consisted of a muscular wall and its lumen contained intestinal epithelium with villi. The cyst was vascularized by the omentum. CONCLUSION: The implantation of rat enterocyte suspension in the abdominal cavity of syngeneic animals in a pouch made from abdominal wall musculature, minimizes cell dispersion and leads to the development of a single large cyst. The wall of this cyst is made of muscle tissue and its lumen is lined by intestinal neo-epithelium. Its large size allows us to better study in vivo ABSTRACTS

the properties of the neo-formed intestinal epithelium. POSTER

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Basic: Stomach

M1918 Functional Polymorphism in Nf-κB1 Promoter Is Related to the Risk of Gastric Cancer Su-Shun Lo1,2, Chew-Wun Wu1,2; 1Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 2National Yang Ming University, Taipei, Taiwan BACKGROUND: Nuclear factor-kB (NF-kB), a transcription factor, is a critical element regulating cell physiology and excessive NF-kB activation has been linked to cancer formation. NFKB1encodes NF-kB/p50 subunit. A common insertion (ins)/deletion (del) polymorphism (-94ins/delATTG) in NFKB1 promoter was recently found. It is reported that the ins allele may drive two-fold increase in NFKB1 transcription relative to del allele. Polymorphism of NFKB1 promoter was analyzed in patients with gastric cancer. PATIENTS AND METHODS: To determine the -94ins/delATTG polymorphism in the NFKB1 promoter, DNAs from blood samples obtained from 182 gastric cancer patients and 263 controls were subjected to PCR-based geno- typing. The primers generating amplicons of 305 (for del allele) or 309 bps (for ins allele) were sense: 5’-CCGCACCAAAAACCAGTAGAG-3’ and anti- sense: 5’-AGGGAGCCCCCAGGAAG-3’. The 5’ site of the sense primer was labeled with FAM fluorescence dye. The PCR products were subjected to DNA sequencer and the fluorescence were analyzed by Genescan. RESULTS: The alleotypic frequencies of NFKB1 ins is significantly higher in gastric cancer patients than controls (46.8% vs. 58.5%, p = 0.0006), even adjusted with age and sex (p = 0.024, OR: 1.64; 95% CI: 1.07–2.52). The frequency of genotype ins/ins is also significantly higher in patients with gastric cancer (p = 0.029, OR: 2.57, 95% CI: 1.10–5.95). CONCLUSION: The frequencies of alleotype NFKB1 ins and genotype ins/ins are significantly higher in gastric cancer patients and that suggest polymorphism of NFKB1 promoter is related to the risk of gastric cancer.

186 SSAT.book Page 187 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1919 Mechanisms of Body Weight Loss After Gastric Bypass Surgery in Rats Bjorn Stenstrom1, Marianne Furnes1, Chun-Mei Zhao1, Karin Tommeras1, Carl-Jorgen Arum1, Unni Syvenssen1, Suzanne Dickson2, Duan Chen1; 1Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 2Department of Physiology, University of Cambridge, Cambridge, United Kingdom BACKGROUND/AIM: Bariatric surgery Roux-en-Y gastric bypass (RYGB) has been designed to limit food intake by creating small gastric pouch and to reduce nutrient absorption by bypassing long-limb intestine. In fact, the stomach is also bypassed after RYGB. The aim of the present study was to elucidate the contribution of stomach bypass on body weight (BW) loss in rats. METHODS: Male rats (Sprague-Dawley and Long-Evans) were used in a series of experiments including i) total gastrectomy (GX), ii) gastric bypass (GB), and iii) gastric + duodenal bypass (GDB). BW, body composition, bone mineral density (BMD), and bone mineral content (BMC) were followed up by dual energy X-ray absorptiometry (DXA). Eating activity, food and water consumptions, oxygen (VO2) and carbon dioxide (VCO2) consumptions, and locomotor activity were measured simultaneously by a computerized monitoring system. Serum gastrin and ghrelin levels were determined by radioim- munoassay. The stomachs were examined immunohistologically and the brains examined by Affymetrix GeneChip or in situ hybridisation analysis. RESULTS: Rats (250 g BW) subjected to GX, GB or GDB gained 50–70% less than sham-operated rats during the postoperative course of 2 months. It was no difference between GB and GDB. One year follow-up by DXA showed that BW, BMD, BMC, lean and fat tissues were signiﬁcantly lower in GX or GDB than sham-operated controls already after 1 month, and that GDB rats stopped growing after 6 months in contrast to the controls that gained continuously as a result of expansion of fat compartment. Long-Evans rats (600 g) subjected to GDB loss BW by 28% after 5 months, whereas sham-operated rats gained little. Food intake was not reduced rather than increased by 150% in GDB rats, which was resulted from frequently eating during both light and dark phases. VO2, VCO2 and spontaneous locomoter activity were slight higher in GDB rats than sham-operated controls. The serum concentration of ghrelin was reduced in GX rats but unchanged in GB or GDB rats, while hypogastrinemia developed in GX, GB or GDB rats. Gene expression proﬁle ABSTRACTS

in the whole brain and the gene expressions of neuropeptide Y, agouti-related POSTER peptide, anorexigenic pro-opiomelanocortin and melanin-concentrating hormone in the hypothalamus appeared to be unchanged after GX or GDB. CONCLUSIONS: The present study of rats suggests that 1) the body weight reduction after the gastric bypass surgeries is most likely due to the stomach exclusion; 2) the loss of body weight after gastric bypass surgery is not due to the reduced food intake; and 3) like gastrectomy, the gastric bypass may lead to the development of osteoporosis.

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CLINICAL SCIENCE POSTERS

Clinical: Biliary

M1388 Surgery for Acute Cholecystitis in Denmark Alan P. Ainsworth1, Sven Adamsen2, Jacob Rosenberg3, Flemming Burcharth2; 1Department of Surgery, Odense University Hospital, Odense C, Denmark; 2Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark; 3Department of Gastrointestinal Surgery, Copenhagen University Hospital Gentofte, Copenhagen, Denmark BACKGROUND: The aim of the study was to investigate how acute cholecystitis has been treated in Denmark after implementation of laparoscopic cholecystectomy. METHOD: An analysis of data from the mandatory Danish National Patient Registry, which covers all public hospitals in Denmark, was performed. The annual number of cholecystectomies and the annual number of cholecystectomies performed for acute cholecystitis from 1996 to 2003 were registered. Separate data for open and laparoscopic operations were obtained and compared. RESULTS: An increase in the number of cholecystectomies for acute cholecystitis from 13.6 in 1996 to 17.1/100,000 in 2003 was observed (P < 0.05). The proportion of patients treated for acute cholecystitis in relation to all cholecystectomies performed declined from 0.14 in 1996 to 0.12 (P < 0.05), and 41% of cholecystectomies performed for acute cholecystitis were completed laparoscopically in 1996 compared with 61% in 2003 (P < 0.05). For laparoscopic cholecystectomies performed for other reasons than acute cholecystitis, the corresponding rates were 78% and 83%, respectively (P < 0.05). CONCLUSION: The number of patients having cholecystectomy for acute cholecystectomy has increased signiﬁcantly, as has the rate of laparoscopically completed cholecystectomies for acute cholecystitis, but 39% still have an open procedure. There is therefore room for further reduction in open cholecystectomy in order to provide more patients the beneﬁts of minimal invasive surgery.

188 SSAT.book Page 189 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1390 Surgical Treatment of Hepatolithiasis on Particular Reference to Long-Term Results Miin-Fu Chen; Department of General Surgery, Chang Gung Memorial Hospital, Kweishan, Taiwan; Surgery, Chang Gung University, Kweishan, Taiwan Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported. We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen between January 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to 10 years and constituted the basis of this study. Long-term results of 427 patients hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105/355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8% (12 of 427), and mortality rate 10.3% (44 of 427). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5%), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0%) than did the nonhepatectomy group (p < 0.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < 0.01). Long- term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) than required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received hepatectomy or without residual stones after choledochoscopy had a good prognosis and quality of life. ABSTRACTS POSTER

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M1391 Visuospatial Tests Predict the Performance of Simulated ERCP Among Endoscopists Irrespective of Previous ERCP Experience Lars Enochsson1,3, Fredrik Swahn1, Bo Westman3,4, Urban Arnelo1, Ann Kjellin1,3, Li Fellander-Tsai2,3; 1Department for Clinical Science Intervention and Technology (CLINTEC), division of surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden; 2Department for Clinical Science Intervention and Technology (CLINTEC), Division of Orthopaedics, Karolinska University Hospital Huddinge, Stockholm, Sweden; 3Center for Advanced Medical Simulation, Karolinska University Hospital Huddinge, Stockholm, Sweden; 4Department of Surgery, Sodertalje Hospital, Stockholm, Sweden BACKGROUND: Endoscopic Retrograde Cholangio Pancreaticography (ERCP) is a technically demanding endoscopic intervention associated with increased risk of complications (bleeding and pancreatitis) and discomfort to the patient if not properly performed. Advanced medical simulators have introduced the possibility to train endoscopic surgeons in visuospatially difficult interventional procedures to proficiency levels without harming the patient. Visuospatial skills have been demonstrated to predict the performance of medical students and residents in virtual gastroscopy. Little has, however, been reported to what extent visuospatial ability play a role in the technically more advanced virtual ERCP. METHODS: Ten endoscopists with varying ERCP experience were included. Prior to the virtual ERCPs in GI-mentor II, Simbionix® (ERCP: Cases 1 and 5, module 2) they performed two visuospatial tests: 1/ Card Rotation Test (CRT) and 2/ Picsor which both monitor the ability of the tested person to create a 3-D image from a 2-D presentation. The results of the visuospatial tests were correlated to the objective assessment parameters of the endoscopic simulator. RESULTS: Total time to view the papilla correctly and Papilla contacts before first cannulation both correlated well with CRT (r2 = 0.56 P = 0.05 and r2 = 0.78 P = 0.01, respectively). There was also a strong correlation between Total time to view the papilla correctly and Papilla contacts before first cannulation and the picsor test (r2 = 0.75 P = 0.01 and r2 = 0.64 P = 0.03, respectively). The simulator could also discriminate between experts and residents regarding the parameters Total time to view the papilla correctly and Total time of the examination. CONCLUSION: Good visuospatial ability has a great impact on the performance of ERCP in an endoscopic simulator and seems to be irrespective of previous clinical ERCP experience.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1392 Does Endoscopic Ultrasound Have Anything to Offer in the Diagnosis of Suspected Common Duct Stones? Gareth J. Morris-Stiff1, Ben Frost3, Wyn Lewis1,3, Phillip Webster1, Malcolm C. Puntis1, Ashley Roberts2; 1Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom; 2Department of Radiology, University Hospital of Wales, Cardiff, United Kingdom; 3Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom OBJECTIVES: The advent of endoscopic ultrasound (EUS) in the 1990s provided an alternative to endoscopic retrograde and magnetic resonance cholangiopancreatography (ERCP/MRCP) in the evaluation of the biliary tree. The aim of this study was to assess the value of selective EUS in the diagnosis of gallbladder and common bile duct (CBD) stone disease in patients with negative conventional imaging. METHODS: All patients undergoing biliary EUS between January 2000 and December 2004 were identified from the radiology computerised database. Forty-two patients (25 male, mean age 53 ± 3.2 years) with negative prior USS, CT and MRCP underwent EUS to evaluate for the presence of gallstones or microlithiasis. Prior and later radiological investigations, hospital readmission, and the need for further surgical intervention were also analysed. RESULTS: EUS was normal in 17 patients and demonstrated signs of recent acute pancreatitis in 8 patients. Cholelithiasis or microlithiasis was identified in 14 patients, and choledochal stones in 6 patients. In 1 patient, calculi were seen in the CBD but not the gallbladder. In a further case with recurrent acute pancreatitis, chronic pancreatitis was diagnosed on EUS. All patients with CBD stones underwent ERCP and sphincterotomy, and stones were universally confirmed. One patient with gallbladder calculi alone underwent cholecystectomy and the latter developed jaundice whilst awaiting cholecystectomy and underwent ERCP which demonstrated CBD microlithiasis. No patients with a normal EUS have subsequently been diagnosed with cholelithiasis. CONCLUSIONS: EUS provided additional diagnostic information in 16 of the 41 (39%) patients. Moreover, exclusion of gallstones/microlithiais is also important as it facilitates a search for other causes of pancreatitis. In conclusion, most cases of cholelithiasis can be diagnosed with standard imaging modalities but when these fail to identify a cause, EUS has an important role. ABSTRACTS POSTER

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M1393 Inflammatory Myofibroblastic Biliary Strictures Masquerading as Cholangiocarcinoma Thomas C. Gamblin1, Alyssa Krasinskas3, Adam Slivka4, Susan Caro1, Mitch E. Tublin2, Anthony J. Demetris3, Wallis Marsh1, A.J. Moser1; 1Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA; 3Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA; 4Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA Inflammatory myofibroblastic biliary strictures (IMBS) are a rare cause of jaundice in patients with dominant strictures by ERCP and no prior biliary surgery. Because the clinical presentation of IMBS masquerades as bile duct cancer, these benign lesions are usually identified following extended hepato- biliary resection. We describe the clinical management as well as the pathologic and molecular features of IMBS in an effort to characterize this rare cause of benign biliary strictures. METHODS: A consecutive series of inflammatory myofibroblastic biliary strictures (IMBS) treated between 1998–2005 was analyzed. We characterized the clinical presentation, radiographic findings, preoperative cytology, surgical management, pathologic features, and postoperative outcome of patients with IMBS. All pathologic specimens were reviewed, and additional immunohistochemistry (IHC) and loss of heterozygosity (LOH) analysis was performed. RESULTS: Ten patients with suspected bile duct cancer were found to have IMBS on final pathology. All presented with jaundice, were evaluated by CT and ERCP, had negative cytologic brushings, and underwent surgical exploration for a dominant biliary stricture. Five patients had a preexisting autoimmune disease and a sixth developed it during follow-up. Eight patients underwent extrahepatic bile duct resection with five concomitant liver resections. Two patients underwent incisional biopsy for unresectable strictures. Light microscopy showed fibrous lesions admixed with chronic inflammation. By IHC, the lesions were negative for cytokeratin, ALK1, CD21, S100, Ki67 and p53, and focally positive for CD34. Smooth muscle actin (indicating myofibroblasts) was positive in all lesions except one (this patient died from metastatic adenocarcinoma of unknown primary). Adjunctive LOH in 2 cases revealed no K-ras mutations and one allelic loss. 6 patients received postoperative steroids. After 31 month median follow-up (4–85 months), 6 patients are alive without evidence of disease. Two patients died without recurrence, and one is lost to follow-up. CONCLUSIONS: IMBS is a rare cause of benign biliary stricture that masquerades as cholangiocarcinoma but responds to resection and steroid management. IMBS is more common in the setting of autoimmune disease and cannot be identified preoperatively with cytologic brushings. IHC indicates a myofibroblastic lesion with normal p53 expression and absent markers for cellular proliferation (Ki67) and carcinoma (cytokeratin). Evaluation by LOH analysis is an area of future interest. To our knowledge this series is the most definitive characterization of IMBS to date.

192 SSAT.book Page 193 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1394 Emerging Role of ERCP in Blunt Extrahepatic Hepatic Duct Injuries Nikhil P. Jaik1, Stanislaw P. Stawicki1, Brian A. Hoey2; 1Department of Surgery, St. Luke’s Hospital and Health Network, Bethlehem, PA; 2University of Pennsylvania Trauma Network, Philadelphia, PA INTRODUCTION: Blunt traumatic injuries to the extrahepatic biliary system are rare. Debate continues regarding the best way to diagnose and treat extrahepatic hepatic ductal injury (EHDI). The purpose of this study is to review and characterize the EHDI, and to evaluate the impact of endoscopic retrograde cholangiopancreatography (ERCP) on the treatment of EHDI. METHODS: A literature review was performed. A case from our institution was also added (total, 52 cases). Cases were then analysed (patient demographics, mechanism of injury, associated injuries, treatment modalities). RESULTS: Of 52 EHDI cases, 83% were men and 17% were women. Mean patient age was 22 years old (y/o) (men 23 y/o, women 16.2 y/o). Twenty patients were <18 y/o (38.5% cases, 13 male, 7 female). Fifty percent of injuries were automobile related—36% motor vehicle crashes (MVC) and 14% automobile vs pedestrians. The remaining 50% of EHDI were due to crush injuries, motorcycle crashes, sports/recreational injuries, and falls. Mortality was 2/52 (3.8%). Isolated left hepatic duct (LHD) injury occurred in 24/52 (46.1%) cases. The right hepatic duct (RHD) was injured in 8 (15.4%) cases. Both LHD and RHD were injured in 7 (13.5%) cases. Bifurcation of hepatic ducts was involved in 13 (25.0%) cases. Delay from time of injury to correct diagnosis was common (mean 14 days, median 10 days). Fifteen injuries (33%) were missed at initial laparotomy or investigation. Reported mean length of hospital stay was 42 days.Associated injuries included liver (29/52 cases), lower extremity fractures (10), pelvic fracture(s) (9). Splenic injury and gallbladder injury were each reported in 5 cases. Concomminant non-EHDI biliary ductal injury was reported in 3 cases. Formal surgical exploration was carried out in 47 (90.4%) patients; 34 patients (65.4%) had deﬁnitive surgical repair by either biliary-enteric anastomosis or primary ductal repair. Recently, ERCP was utilized either diagnostically or therapeutically (17 of 52, 32.7%). Other treatment options included simple drainage, ductal ligation and stenting. Reported mean follow-up was 25.6 months. Follow-up ERCP results were reported in 7/17 patients. Six of 7 showed resolution of biliary leak and no evidence of biliary stricture and 1/7 showed non-visualization of the previously injured LHD. ABSTRACTS

CONCLUSION: The management of EHDI continues to evolve. The availabil- POSTER ity of ERCP presents physicians with a new diagnostic and therapeutic option. Although deﬁnitive surgical treatment remains the gold standard, ERCP may assume increasingly important role in management of EHDI as its long-term results and safety record become better established.

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M1395 Sphincter of Oddi: A Structural & Functional Study Kewal K. Maudar; Surgery, Armed Forces Medical College, Pune, Pune, India INTRODUCTION: Mesenteric ganglia & abundant nerve bundles in the sphincter musculature generate evoked potential by the activity of galanin containing neurones & catecholamine containing neurones. NANC, CGRP, VIP, Peptide YY, NO & Somatostatin regulate sphincter mechanism. METHODS: Histopathology of 30 specimens of Sphincter of Oddi (SO) from cadavers of both sexes & of different ages with no history of pancreaticobiliary diseases were studied. SOD Manometery, ERCP & scintigraphy on 125 patients with biliopancreatic disease—cholelithiasis (70), acute pancreatitis (30) post cholecystectomy syndrome (25) were analysed. RESULTS: There were two functional segments of the Sphincter of Oddi arranged into C1 to C5 groups of fibres. Alteration of the mucous glands in the form of Adenomatosis (75%), Centrifugal proliferation of glands (75%), club like valvulae (50%), obstruction in neck of glands (50%), increased gob- let cells (75%), adeno connective dysplasia (50%), inflammatory infiltration (100%), muscular hypertrophy (±), sclerosis ( ± ). SO Dysfunction: Abnormal- ity on SOD manometery (45%), scintigraphy (17%), ERCP (38%); in the form of rhythmic contractions 4–5/min, antegrade, duodenum, retrograde, gallbladder; integrated with MMC of duod, with 5–15 mm Hg of CBD, & 15–30 mm Hg pressure of duod. Gradient—CBD/Duodenum: 15 mm Hg, PD/ Duodenum: 17 mm Hg; Basal SO—15 ± 10 mm Hg; Phasic SO—Amplitute 130 ± 16 mm Hg, Frequency 4 ± 0.5 p/min, Duration 4.3 ± 1.5 sec. Abnormal biliary motility includes: Basal sphincter pressure > 15 mm Hg, Basal PHD/ CBD pressure > 13 mm Hg, Phasic amplitudes > 220 mm Hg, Duration of phasic contractions > 8 sec &, Propagation > 50% retrograde & increased amplitude of phasic contraction, increased frequency of contraction & paradoxical response to CCK. Sphincter dyskinesia was rapid phasic contractions, intermittent increased basal pressure, increased retrograde contractions & paradoxical response to CCK by sphincter contractions instead of relaxation. SOD dysfunction was classified on Milwaukee criteria & treated by endoscopic sphinctertomy, pharmacotherapy & Botulinum toxin inadditon to the treatment of biliopancreatic disease. CONCLUSION: The histological alterations in SO indicate reactive changes to repeated physical, chemical & inflammatory insult. SOD manometery, scintigraphy & ERCP reveal SO dysfunction in bilio-pancreatic diseases with specificity of 78%, positive predictive value of 83%. Endoscopic or open sphinctertomy were effective in treating SOD.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1397 Prevalence and Outcome of Cholangiocarcinoma in Patients with Primary Sclerosing Cholangitis Referred to a Regional Liver Transplant Unit Gareth J. Morris-Stiff, Chandra Bhatti, Bridget Gunson, David Mayer, John Buckels, Darius Mirza, Simon Bramhall; Department of Hepato- Pancreatico-Biliary Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom BACKGROUND: Cholangiocarcinoma (CCa) is a recognised complication of primary sclerosing cholangitis (PSC) with prevalence rates of 8–18% reported from tertiary referral centres where screening protocols have lead to early identification of tumours. The aims of this study were to report the prevalence and outcome of CCa in PSC for a United Kingdom centre with a defined referral population. METHODS: All patients referred to the unit over a 20 year period from 1985– 2004 with a diagnosis of PSC were prospectively entered into a departmental database. The database was interrogated to determine all patients who had in addition a diagnosis of CCa either at presentation or subsequently. For this cohort, the mode of presentation, management and outcome were determined. RESULTS: 370 patients (265 M and 105 F) with a median age of 50.5 years were referred with confirmed or suspected PSC of which 207 were subsequently transplanted. 48 patients (13%) developed a CCa with a mean interval from referral to tumour diagnosis of 4 months. The mode of presentation included: inoperable tumours at presentation (n = 14); incidental findings in transplant hepatectomy specimens (n = 13); PSC follow-up (n = 9), transplant work-up (n = 5), whilst on transplant waiting list (n = 5), suspected tumour confirmed at transplant (n = 1); and incidental finding at cholecystectomy. (n = 1). The diagnosis was confirmed by: radiology-guided biopsy (n = 27); MRI (n = 2); CT (n = 2); at laparoscopy/laparotomy (n = 2); and by frozen section at transplant in 1 case. Management consisted of: transplantation (n = 13, incidental on post transplant histology); hepatic resection (n = 8); palliation through stenting (n = 26); no treatment (n = 1). The overall median survival was 5.3 months increasing to 7.6 months for transplant recipients and 52.8 months for patients undergoing resection. Survival for the palliation group was 2.8 months. CONCLUSIONS: CCa is a common finding in PSC. Unfortunately, many patients with CCa/PSC will have inoperable tumours by the time they are

referred and regular screening of PSC patients at referring centres is advocated ABSTRACTS to detect early tumours as resection offers signiﬁcantly better outcomes for POSTER this cohort of patients.

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M1398 Outcomes and Utilization of Laparoscopic Partial and Complete Cholecystectomy in Academic Centers Esteban Varela1, Ninh Nguyen1, Scott Helton2; 1Surgery, University of California Irvine, Orange, CA; 2Surgery, University of Illinois at Chicago, Chicago, IL BACKGROUND: Laparoscopic complete cholecystectomy (LCC) is the preferred and most common method for gallbladder removal. Laparoscopic partial cholecystectomy (LPC) is an alternative approach to LCC when exposure of critical anatomical structures is obscured by inflammation. This study analyzes the outcomes and utilization of laparoscopic partial cholecystectomy compared to complete in academic centers in the US. METHODS: By using ICD-9 diagnosis from the University Health System Consortium database, 46,198 laparoscopic cholecystectomies were identified from 2002 to 2005. Of these, 46,094 were complete (99.7%) and 104 partial (0.3%). Demographic and outcome data included: length of stay (LOS), 30-day readmission, mortality, costs and complications. RESULTS: Subgroup analysis revealed that high risk patients who underwent an emergent/urgent cholecystectomy by either approach had similar morbidity (LCC: 14.0 vs. LPC: 19.4%) and mortality (LCC: 0.7 vs. LPC: 0%). There was one leak and one bleeding case (0.05%) in the high risk LPC group while these were increased more than 30-fold after high risk LCC. CONCLUSION: In academic centers, laparoscopic partial cholecystectomy is rarely used except in the face of major illness and in the urgent/emergent setting. Laparoscopic partial cholecystectomy has comparable incidence of complications with longer length of stay and higher costs. There was a non- significant lower leak, bleeding rate and mortality among the high risk group who underwent urgent/emergent partial cholecystectomy. This data suggests that high risk patients in need of urgent/emergent laparoscopic cholecystectomy may benefit from the partial approach. RESULTS:

Variables LCC (n = 46,094) LPC (n = 104) Female (%) 71.8 60.1* Caucasian (%) 52.3 58.7 Elderly (% > 60 years) 26.0 28.9 Severity: major (%) 12.3 21.2* ICU cases (%) 5.2 15.1* Urgent/emergent (% 70.4 83.7* Mean LOS (days) 4.1 ± .08 6.1 ± .7** 30-day readmission (%) 7.7 11.5 Mortality (%) 0.3 0 Mean Costs (K\$) 9.4 ± .3 15.0 ± 2** Overall complications (%) 8.8 12.5 Bile leaks or injury (%) 1.3 1.0 Postoperative Bleeding (%) 1.0 1.0

Means ± SE; * = p < 0.05 by Z-test; ** = p < 0.05 by t-test.

196 SSAT.book Page 197 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1399 Hepaticojejunostomy – Definition of Risk Factors for Postoperative Bile Leaks Jurgen Weitz, Dalibor Antolovic, Moritz Koch, Peter Kienle, Jan Schmidt, Helmut Friess, Markus Buechler; Department of Surgery, University of Heidelberg, Heidelberg, Germany Anastomoses between the jejunum and the bile duct are frequently performed; however, the incidence of clinically relevant bile leaks after this procedure has not yet been adequately defined. The objective of this study was to describe the incidence of bile leaks after hepaticojejunostomy and to define factors associated with this risk. MATERIALS AND METHODS: Between 10/2001 and 05/2004, a hepaticojejunostomy was performed in 519 patients (318 male, 201 female, median age: 61 years) at our institution in a standardised way. Patient and treatment related data of these patients were analysed as risk factors for a bile leak defined as bilirubin concentration in the drain fluid exceeding serum bilirubin resulting in a change of clinical management or occurrence of a bilioma necessitating drainage. Statistical computations were done using the software package JMP. Continuous variables were expressed as medians and compared using the Wilcoxon Test while categorical variables were compared using the Fisher’s Exact or chi-square test. Multivariate logistic regression was performed by incorporating factors with a p-value ≤ 0.05 on univariate analysis. Statistical significance was defined as p ≤ 0.05. RESULTS: In addition to hepaticojejunostomy 321 patients underwent a pancreatic resection, 26 patients a liver transplantation and 10 patients a liver resection. The underlying diagnoses were pancreatic cancer (n = 317), benign pancreatic tumours (n = 28), tumours of the biliary system (n = 34), liver cirrhosis (n = 24), chronic pancreatitis (n = 68), cholangitis (n = 33), redo after liver transplantation (n = 6), and others (n = 9). The overall complication rate was 33% with bile leaks occurring in 5.6% of patients. The overall mortality rate was 1.3%. The table demonstrates the results of the multivariate logistic regression of factors predicting a bile leak. CONCLUSION: Hepaticojejunostomy can be performed with a low postoperative complication rate if performed in a standardised way. Simultaneous liver resection, preoperative radio/chemotherapy, reoperation after liver transplantation and low preoperative ChE levels are risk factors for postoperative bile leaks. The results of this study might help in developing strategies for further improving outcome of hepaticojejunostomy. ABSTRACTS POSTER 95%-Confidence Factor Odds Ratio Interval p-value Liver resection 19.2 4.6–83 < 0.001 Preop. Cholinesterase Level 0.87 0.75–1.0 0.05 Neoadj. Radio/Chemotherapy 3.8 1.4–10.9 0.01 Redo after Liver Transplantation 12.8 2.2–77 0.005

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M1400 Congenital Pancreaticobiliary Anomalies in an Urban Medical Center Choichi Sugawa, Lester Young, Hiromi Ono, Toshiki Matsubara, Gen Tohda, Charles E. Lucas; Department of Surgery, Wayne State University, Detroit, MI INTRODUCTION: Congenital pancreaticobiliary anomalies (PBA) are rare and may be classified into various subtypes. This study defines their incidence, associations with biliary and pancreatic diseases, and treatment options. METHODS: Retrospective examination of records and films of 5081 patients (pts) who underwent endoscopic retrograde cholangiopancreatography (ERCP) by a single endoscopist in an urban medical center from 1972–2005. PBA was grouped as 1) pancreatic divisum (PD), 2) congenital biliary dilatation (CBD), 3) anomalous pancreaticobiliary ductal union (APBDU) and 4) other congenital pancreaticobiliary anomalies (OPBA). RESULTS: Congenital PBA was seen in 209 pts including 157 pts with PD, 22 pts with CBD, 14 pts with APBDU and 16 pts with OPBA. 1. Associated findings in the 157 PD pts included pancreatitis (54 pts), biliary lithiasis (20 pts). There were associations with other pancreaticobiliary maljunction (2 pts), CBD (1 pt), gall bladder cancer (4 pts), ampullary cancer (3 pts) and pancreatic cancer (2 pts). Treatment included major sphincterotomy (5 pts), minor sphincterotomy (1 pt), and Whipple’s procedure (2 pts). 2. The 22 CBD were subgrouped into columnar types (4 pts), cystic type (5 pts), and spindle type (13 pts). Treatment included cholecystectomy with cholangioduodenostomy (3 pts), sphincterotomy (3 pts), cholecystectomy alone (1 pt) and choledoch- oectomy with hepatocholangiojejunostomy (1 pt). 3. There were 14 pts with APBDU. 5 pts had associated dilation, whereas, 9 pts had normal sized duct. Associated conditions included cholelithiasis (2 pts), sickle cell disease (2 pts), pancreatitis (3 pts), choledocholithiasis (1 pt) and gallbladder cancer (1 pt). Two pts also had PD. Treatment included sphincterotomy (2 pts), cholecystectomy (2 pts), cholecystectomy and lymphadenectomy (1 pt), and choledo- chectomy with hepatocholangiojejunostomy (1 pt). 4. The 16 OPBA were choledochocoele (8 pts), Caroli’s disease (4 pts), double main pancreatic duct (2 pts), double gallbladder (1 pt), and cystic duct diverticulum (1 pt). CONCLUSION: Congenital pancreaticobiliary anomalies are rare and often overlooked. PD, the most common congenital PBA, is often associated with pancreatitis, cholelithiasis, and choledocholithiasis. There is also a correlation with pancreaticobiliary cancer, APBDU, and CBD. Both CBD and APBDU are associated with PD and with gallbladder cancer. Surgical treatment is indicated for cancer and symptomatic pts. Appreciation of PBA is important for proper diagnosis and treatment strategies.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Clinical: Colon-Rectal

M1401 Topical GTN for Anal Fissure: A Single Centre Experience From Pakistan Jawad Ahmad1,2,, Alexander P. Boddy2, Yawar Saeed2, Javaid Gardezi2; 1Upper GI Surgery, Norfolk & Norwich University Hospital, Norwich, UK, Norwich, United Kingdom; 2General Surgery, Jinnah Hospital, Lahore, Pakistan INTRODUCTION: Topical Glyceryl Trinitrate (GTN) has gained popularity as first line treatment for anal fissure. This study was done to investigate the role of GTN as a treatment option for both acute and chronic anal fissure in a South Asian setting. METHODS: A prospective, double blinded, randomised controlled trial was conducted at a teaching hospital in Pakistan on 50 consecutive patients with either acute or chronic anal fissure. Group A (25 patients) was given 0.2% GTN ointment and Group B (25 patients) lignocaine ointment twice daily for 8 weeks. Healing was then assessed clinically and adverse effects of the treatment were sought. Patients were reviewed at 6 months for recurrence. RESULTS: Symptomatic relief was earlier in Group A compared to Group B (average 8 vs 13 days). Pain relief (assessed with Visual Analogue Scale for Pain) was maintained in those treated with GTN but returned to pre-treatment scores within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 77% of patients with acute and 81% with chronic anal fissure in Group A showed clinical signs of healing compared to 44% and 25% in Group B (p value 0.015 and > 0.001). Significantly more patients in Group A complained of headache (68% vs 28%, p = 0.01), but this was always mild and no patient had to stop the treatment. At 6 months follow-up, recurrence was seen in 24% patients in Group A and 38% in Group B. All were subjected to another course of GTN and 60% of the patients responded. CONCLUSION: Topical GTN is an effective treatment for both acute and chronic anal fissure. Mild headache is the most common side effect but is tolerated well. The results of this study are comparable with the published international data. ABSTRACTS POSTER

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M1402 Cytokine Network in Chronic Perianal Crohn’s Disease and Indeterminate Colitis After Proctocolectomy Cesare Ruffolo1, Marco Scarpa1, Diego Faggian3, Annamaria De Pellegrini2, Giovanna Romanato2, Fabio Pilon1, Teresa Filosa1, Daniela Prando1, Lino Polese1, Michele Scopelliti1, Elena Ossi2, Davide F. D’Amico1, Imerio Angriman1; 1Dipartimento di Scienze Chirurgiche e Gastroenterologiche, University of Padova, Padova, Italy; 2Dipartimento di Scienze Mediche e Chirurgiche, University of Padova, Padova, Italy; 3Medicina di Laboratorio, University of Padova, Padova, Italy BACKGROUND: The incidence of perianal involvement in Crohn’s disease (CD) ranges from 30–40%. Cytokines play a central role in the modulation of the intestinal immune system and can be the target of neutralizing antibodies. Clinical use of anti-TNF is widely established but recent studies suggest that the underlying fistula tract may persist, in spite of a clinical response. IL-12 is a key cytokine that drives the inflammation mediated by T helper 1 cells. Treatment with antibodies against IL-12 was reported to induce clinical responses and remissions in patients with active CD. The aim of our study was to analyze the systemic cytokine network (TNF-α, IL-12, IL-1β, IL-6) in chronic perianal CD, in indeterminate colitis (IC) after restorative proctoclec- tomy (RPC), in intestinal CD and in healthy controls. MATERIALS AND METHODS: We enrolled 12 patients with chronic perianal CD, 7 with IC submitted to RPC with perianal complications, 7 with intestinal CD and 19 healthy controls. Disease activity was assessed with Crohn and Perianal Disease Activity Indexes (CDAI and PDAI) scores. Cytokines serum levels were quantified in fasting patients with ELISA and immunometric assay. The inflammatory and immunological status was assessed by quantify- ing erythrocyte sedimentation rate, white blood cell count, platelets blood count (PLT), albuminhaemia and C-reactive protein and pANCA serum levels, respectively. Data were presented as mean ± standard error. Mann-Whitney U two-tailed test and Spearman’s rank correlation test were used. Statistical significance was set at p < 0.05. RESULTS: Serum TNF-α levels were significantly higher in patients with IC with perianal complications after RPC than perianal CD patients and healthy controls (25, 7 ± 15, 2 vs 21, 9 ± 13, 3 and vs 7, 1 ± 0,5, p < 0.05). Serum TNF- levels significantly correlated with PDAI and CDAI (R = 0.32, p = 0.03; R = 0.40, p < 0.01). Serum IL-12 levels as well as IL-1B ones were similar in all groups and there was no correlation with any of the parameters considered. Serum IL-6 levels did not differ among the four groups and they significantly correlated with PLT and albuminhaemia (R = 0.53, p = 0.02; R = –0.57, p = 0.01). No correlation was found between serum cytokine levels and pANCA. DISCUSSION: Our study confirmed that TNF-α plays a major role in the perianal and intestinal CD as demonstrated by the correlation with both activity indexes. Furthermore the significantly higher TNF-α serum levels in patients with IC with perianal complications after RPC suggest the use of anti-TNF in such patients. Moreover, there were no correlations between the serum levels of IL12 and disease activity in chronic perianal CD or IC.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1404 Gender Disparities in Colorectal Cancer Screening: True or False? Rachael A. Callcut1,2, Stephanie Kaufman2, Robert Stone-Newsom2, David Mahvi1, Patrick Remington2; 1Department of Surgery, University of Wisconsin Hospital, Madison, WI; 2Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI INTRODUCTION: To date, nearly all studies examining gender disparities in colorectal cancer screening report a lower endoscopic screening rate in women. Using a statewide claims database with full capture of patient encounters, gender differences in screening rates were analyzed in an attempt to validate gender disparities reported in prior survey based studies. METHODS: Procedural-level dataset containing all patient encounters for 2003 in which a colonoscopy or flexible sigmoidoscopy were performed was created for patients residing in Wisconsin from the Physician Outpatient Visit Database and the Ambulatory Surgery Discharge Database. Procedures were selected using CPT codes and surveillance or screening designation was determined using ICD- 9-CM codes. Univariate analysis was performed using SAS v 8.0. RESULTS: Statewide for average-risk individuals 50 years or older, 65,232 endoscopic procedures were performed in 2003. The majority (83%) of endoscopic screening procedures were colonoscopies. Overall, the rate of screening in average-risk women 50 years old or older (38 procedures/1000 people) was slightly lower than men (42/1000), but not statistically significant. The rates of screening were higher in women before the age of 60 years old compared with men and lower after the age of 60 years old [Figure 1]. No clinically significant difference was found in the type of screening procedure performed. Colonoscopy was done in 81% of men and 84% of women. ABSTRACTS POSTER

CONCLUSIONS: Gender disparities in rates and types of colorectal cancer screening reported in prior survey studies are not validated in this patient encounter data study. There is no overall statistically signiﬁcant difference in rates of screening or type of screening. However, screening rates of men and women do vary across age groups with more women being screened at younger ages compared with men.

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M1405 Invasive Squamous Cell Carcinoma of the Anus in HIV: Is There a Role for the Surgeon? Gregory Chipman2, Harry L. Reynolds1, Colin Mooney2, Joseph Skitzki1, James Merlino4, Conor Delaney1, Timothy Kinsella3, Scott Remick2; 1Case Surgery, University Hospitals of Cleveland, Cleveland, OH; 2Medical Oncology, University Hospitals of Cleveland, Cleveland, OH; 3Radiation Oncology, University Hospitals of Cleveland, Cleveland, OH; 4Case Surgery, Metro Health Medical Center, Cleveland, OH PURPOSE: Squamous cell carcinoma of the anus (SCCA) has been routinely treated with chemotherapy and radiation (CR). Prior to the era of highly active anti-retroviral therapy (HAART) for treatment of human immunodefi- ciency virus infection (HIV), HIV patients faired poorly with CR. There is a paucity of data on the outcome of HIV patients treated with CR in the HAART era. We outline our experience. METHODS: Retrospective review of prospective database of all HIV patients with SCCA treated at a tertiary care center from 1999 to 2005. Age, sex, CD4 count, viral load, treatment toxicity, survival and surgical intervention were recorded. Survival was calculated with Kaplan-Meier method, and Students-t was utilized as appropriate. RESULTS: 15 patients were identified, 12 males. Mean age 43 (34–51). 13/15 were compliant with HAART. All patients received CR with mitomycin-C and 5-fluorouracil. Radiation dose ranged from 54Gy to 68Gy. 14/15 completed CR with 1 death at induction from neutropenic sepsis. Initial complete response was seen in 12/15 (80%). 1 recurred and underwent abdominal perineal resection, 1 had recurrent in situ carcinoma, 1 had a partial response with unresectable disease, 1 declined follow-up exam. At mean follow-up of 26 months (1–48), 4 deaths occurred. Overall survival at 1, 2, and 3 years was 93.3%, 75.4%, and 56.6%. No difference in mean CD4 or viral loads was identified between survivors and non-survivors. Need for surgical intervention was significant, with 6/15 (40%) requiring laparotomy and 4/15 (27%) requiring permanent stoma either for recurrent/persistent disease or radiation stenosis. CONCLUSIONS: CR for SCCA in the HAART era is initially well tolerated with 75% survival at 2 years. However, laparotomy (40%) and permanent diversion (27%) are frequently necessary, emphasizing the need for active involvement of the surgeon in a multidisciplinary team. Future studies with longer follow-up comparing outcomes to a matched non-HIV population are warranted.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1406 Prospective Randomized Trial: Preemptive Antibiotic Treatment Versus Standard Treatment in Patients with Elevated Serum Procalcitonin Levels After Elective Colorectal Surgery Ansgar M. Chromik1, Frank Endter2, Waldemar Uhl1, Arnulf Thiede2, Hans B. Reith2, Ulrich Mittelkoetter1; 1Surgical Department, University Hospital of Bochum, Bochum, Germany; 2Surgical Department, University Hospital of Wurzburg, Wurzburg, Germany BACKGROUND: Procalcitonin (PCT) is regarded as a specific indicator of bacterial infection. Infectious complications in patients after colorectal surgery are a common cause of morbidity and mortality. The aim of this study was to investigate a) whether PCT could serve as a negative predictive marker for postoperative complications and b) whether in patients with elevated PCT levels a preemptive treatment with the third-generation cephalosporin ceftriaxone is superior to an antibiotic treatment starting later on the appearance of clinical signs and symptoms of infection. PATIENTS AND METHODS: By screening 250 patients with colorectal surgery we identified 20 patients with PCT serum levels > 1.5 ng/ml on at least 2 of the first 3 postoperative days. The remaining 230 patients were followed up for the occurrence of infectious complications. The 20 patients with elevated PCT were included in a prospective randomised pilot study comparing preemptive antibiotic treatment with ceftriaxone versus standard treatment. RESULTS: The negative predictive value of PCT for systemic infectious complications was 98.3%. In patients receiving preemptive antibiotic treatment (ceftriaxone) both the incidence and the severity of postoperative systemic infections were significantly lower compared to those in a control group (Pearson’s c2 test p = 0.001 and p = 0.007, respectively). Major differences were also observed with respect to duration of antibiotic treatment and length of hospital stay. CONCLUSIONS: PCT is an early marker for systemic infectious complications after colorectal surgery with a high negative predictive value. A significant reduction in the rate of postoperative infections in patients with elevated PCT serum concentrations was achieved by means of preemptive antibiotic treatment. ABSTRACTS POSTER

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M1408 Laparoscopic Versus Open Surgery in Patients with Ileocolonic Crohn’s Disease: A Prospective Comparative Study Alessandro Fichera1, Stephanie L. Peng2, Alan S. Rosman3, Michele A. Rubin1, Roger D. Hurst1; 1Surgery, University of Chicago, Chicago, IL; 2Pritzker School of Medicine, University of Chicago, Chicago, IL; 3Medicine, Bronx VAMC and Mount Sinai School of Medicine, New York, NY INTRODUCTION: Patients with Crohn’s disease have been considered particularly challenging laparoscopic candidates due to the nature of the disease and the morbidity of aggressive medical treatment. Hence large definitive prospective studies are lacking. The aim of this study was to compare short and long term outcomes of laparoscopic and open surgery in consecutive patients with ileocolonic Crohn’s disease. METHODS: Patients were referred to either a laparoscopic or an open surgeon in our group between August 2002 and July 2005 and were prospectively enrolled. Patients and disease-specific characteristics, intraoperative variables, and short and long term postoperative outcome were analyzed. RESULTS: 83 consecutive patients were operated upon and included in the study. 40 laparoscopic assisted and 43 open ileocolonic resections with hand sewn anastomosis were performed. There were six conversions (15%). Eigh- teen patients in the laparoscopic group (45%) and 17 in the open (40%) underwent additional surgical procedures. There were no differences in age, gender, body mass index, steroid use, parameters of nutrition and inflammation, previous abdominal surgeries and in the Vienna classification for location or behavior of disease between the two groups. Although the estimated operative blood loss was not statistically different, postoperative blood transfusions were administered only to patients in the open group. The operative time was significantly longer in the laparoscopic group, 216 (100–478) vs. 178 minutes (110–380) (p = 0.016). However this difference was due to longer duration of the converted cases (273 minutes) included in the laparoscopic group for intent to treat analysis. The length of stay was shorter, 5.3 + 0.4 vs. 6.7 + 0.4 days in the laparoscopic group (p < 0.05). Using stepwise multiple regression analysis, the use of laparoscopic surgery was significantly associated with a reduction in the length of hospital stay (p < 0.05) even after correcting for other variables such as the anatomical site, behavior of disease, age and prior surgeries. Postoperative mortality was nil. Complication rates were similar including one anastomotic leak requiring reoperation in each group. One patient in each group presented during follow-up with small bowel obstruction, treated conservatively. At a median follow-up of 17 months there have been no surgical Crohn’s disease recurrences. CONCLUSIONS: Our study shows that minimally invasive surgery leads to a faster recovery without compromising surgical remission. Laparoscopic surgery should be offered to patients with ileocolonic Crohn’s disease as a safe and effective alternative to open surgery.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1409 Single Institution Comparison of Open, Hand-Assist Laparoscopic, and Laparoscopic Colon and Rectal Surgical Technique Ariel Forstner-Barthell1, Andrea Ferrara1, Joseph Gallagher1, Samuel Dejesus1, Paul Williamson1, Sergio Larach2, Paul Charron1, Eduardo Krajewski1; 1CRC of Orlando, Orlando, FL; 2Colon and Rectal Surgery, Florida Hospital, Orlando, FL INTRODUCTION: Few centers have the extensive experience with open, hand-assist laparoscopic and laparoscopic surgical approaches to colon and rectal surgery. A retrospective review was undertaken at a single center with a colon and rectal fellowship program comparing operative time, morbidity and mortality, and time to discharge for hand-assist, laparoscopic, and open approaches to abdominal colectomy. METHODS: Retrospective review of database of all consecutive hand-assisted laparoscopic (hal) cases performed between May 2002 and September 2005 for benign and malignant disease by single surgeon. All converted cases were excluded. 68 cases were case-matched to laparoscopic and to open cases, using a database spanning 1990 to 2005. Cases were stratified according to the following procedures: APR, LAR, Left/Sigmoid, Right, Total. Cases were matched according to gender, co-morbidities, and stage (if malignant disease). RESULTS: Co-morbidities were similar in all three groups, as was average BMI (28.5 k/m2). The overwhelming majority of hand-assist cases were done for malignant disease or unresectable polyp (96%), and > 85% were done for stage 0-II disease. Length of surgery for all procedures trended longer from lap to hal to open (177, 195, 204 mins). Hal technique did not decrease surgical length for either sigmoid/left colectomies or for LAR, compared to lap technique, but it did shorten the time compared to open technique. Time to hospital discharge was significantly longer for the open group (8d) as opposed to the lap group (5d) or the hal group (6d). Significantly, the hal group for LAR left the hospital 1 day earlier than the lap group for LAR. Ninety-day post-op mortality in the hal group was zero, however two deaths occurred in the lap group—both from cardiac events. Morbidity from 30–90d was similar for all groups (7%). However, the hal group had a significantly greater immediate post-op complication rate (30% v 15%), primarily related to the incidence of wound infection (13%). CONCLUSIONS: Length of surgery was similar for all techniques, however,

the hand-assist technique did not shorten operative time as compared to the ABSTRACTS laparoscopic technique. Hand-assist technique did result in shorter operative POSTER times than the open approach to abdominal colon and rectal surgery, and resulted in post-operative hospital stays as short or shorter than the laparoscopic technique. While the post-operative morbidity and mortality overall was low, there was a signiﬁcantly high number of wound infections within the hand-assist group. However, this technique remains an important part of a surgeon’s armamentarium.

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M1410 Early Postoperative Results of Novel Procedure of Side-to- Side Isoperistaltic Ileocolonic Anastomosis for Crohn’s Disease – Randomized Controlled Trial Yuji Funayama, Kouhei Fukushima, Chikashi Shibata, Ken-Ichi Takahashi, Hitoshi Ogawa, Sho Haneda, Kazuhiro Watanabe, Katsumasa Kudo, Atsushi Kohyama, Ken-Ichi Hayashi, Iwao Sasaki; GI & Colorectal Surgery, Tohoku University Hospital, Sendai, Japan AIM: In Crohn’s disease, the pathogenesis of anastomotic recurrence has been attributed to impaired blood flow, ileocolonic reflux, narrowed caliber of anastomosis, or stasis of intestinal contents. To reduce the risk of anastomotic recurrence, we designed a new ileocolonic anastomosis, and evaluated by the prospective randomized study. PATIENTS AND METHODS: Since October 1999, 72 patients underwent intestinal resection and ileocolonic anastomosis for Crohn’s disease. The patients were divided at random into two groups, that is, side-to-side isoperistaltic anastomosis (SSIA) and functional end-to-end anastomosis (FEEA). In SSIA group (N = 33), their median age at operation was 28.6 (range 16–54), and postoperative period was 35.3 (2–72) months. Five patients had ileitis, 24 had ileocolitis, and 4 had colitis. Fifteen patients had stricturing disease, 15 had penetrating disease, and 3 had inflammatory disease. In FEEA group (N = 39), their median age at operation was 31.7 (15–72), median postoperative follow- up was 21.7 (1–67) months. Thirteen patients had ileitis, 24 had ileocolitis, and 2 had colitis. Twenty patients had stricturing disease, 18 had penetrating disease, and one had inflammatory disease. Gender, age at operation, affected sites, disease behavior, postoperative follow-up period were not significantly different between two groups. PROCEDURES: In SSIA, both ends were placed in isoperistaltic manner and full thickness of bowel wall was sutured with continuous running suture using 4-0 PDS. Mesenteric side of cut ends were approximated to antimesenteric side of each other intestine. In anastomosis, diseased segment was avoided and the size of anastomosis was designed as long as 8 cm. In FEEA, both ends were placed parallel in antiperistaltic manner, and anastomosed at antimesenteric sides using linear stapler (GIA80 or PLC75). RESULTS: In SSIA group, early postoperative surgical complication (anastomotic leakage) was noted in only one of these patients. Four patients underwent reoperation for recurrence and in three of them anastomosis was removed. But in none of them anastomotic complication was noted. In FEEA group, there were no early surgical complications. Four patients underwent reoperation, and in three of them anastomotic site was removed. In one of these three patients, fistula formation was identified from FEEA. CONCLUSION: In short term results, side-to-side isoperistaltic ileocolonic anastomosis was safe procedure and is expected to provide good long-term results.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1411 Predictive Factors in Clostridium Difficile Colitis for Failure of Medical and Need for Surgical Treatment Claudia Gonzalez-Ruiz, Shlomo Israelit, Paul Selvindoss, Robert W. Beart, Petar Vukasin, Glenn Ault, Andreas M. Kaiser; USC Department of Colorectal Surgery, University of Southern California, Los Angeles, CA PURPOSE: Clostridium difficile colitis (CDC) includes a wide spectrum of presentations and outcomes ranging from mild and self-limited diarrhea, to colitis with abdominal tenderness, to eventually fulminant colitis with potentially fatal outcome. Even though treatment for CDC is theoretically defined and consists of antibiotics for milder forms and surgery for toxic colitis, there is insufficient data regarding appropriate criteria to identify patients who fail conservative treatment and will need a surgical intervention before it is too late. in patients. Our current study aimed at establishing possible predictive indicators favoring surgical over medical treatment for CDC. METHODS: Medical records of patients with the diagnosis of CDC were retrospectively reviewed between 01/1999 and 01/2005. Included were patients diagnosed with CDC by ELISA and/or Stool culture. We excluded symptomatic patients with negative C. difficile toxin and patients with incomplete charts. Data collected included general demographics, BMI, APACHE-II score, clinical and laboratory data. End points were (1) the timing and success of conservative treatment, and (2) the eventual need for total or subtotal colectomy, and (3) overall outcome. Statistical analysis was based on the 2-sample Student test and Mann-Whitney Rank-Sum test. For proportions, the p-value is based on the 2-sided Fisher’s Exact test. RESULTS: 86 patients with CDC (M/F 44:42, mean age 53 years, range 68–48) were available for analysis. Pneumonia and UTI were the most frequent cause for the antibiotics that triggered CDC. 76 patients were treated medically only, 10 required surgery. The mortality rate was 3.1% in the conservative and 40% in the operated group, suggesting that the indication for surgery often came too late.The following factors showed statistical significance (P value < 0.05) when the surgical vs the non-surgical group were compared: Temperature, heart rate, respiratory rate, WBC, APACHE II score, abdominal tenderness. Treatment with a combination of metronidazole + Vancomycin was more effective than mono-therapy. Factors which did not show a statistically significant impact inclued length of hospital stay, interval after trigger- ing antibiotics, mean blood pressure, and immunossupresion. CONCLUSION: Based on our data, we identified 7 factors which correlated ABSTRACTS

with the need for an operation in patients with CDC. However, further inves- POSTER tigation will need to establish criteria to optimze the timing for intervention.

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M1413 Optimal Follow-Up of Stage I Colorectal Cancer Patients Tetsuro Higuchi, Masayuki Enomoto, Kenichi Sugihara; Surgical Oncology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan AIMS: The purpose of follow-up of patients after curative surgery for colorectal cancer is to improve survival and quality of life. However, there has been no standard system of follow-up. The aim of this study is to investigate an optimal follow-up system of stage I colorectal patients. PATIENTS AND METHODS: Consecutive 1599 stage I patients, who underwent curative resection at 16 institutions in Japan of the Study Group on Postoperative Follow-Up of Colorectal Cancer Patients from January 1991 to December 1996, were enrolled in this study. Patients with T1 cancer, who underwent only endoscopic resection, were excluded. A common follow-up system consisted of carcinoembryonic antigen measurement every 3 months, ultrasonic imaging for liver every 3–6 months, chest X-ray every 6 months and colonoscopy every 1–2 years. Where recurrences were suspected, CT or/ and MRI were applied. The median follow-up period was 89 months. The 5- year overall survivals of T1N0 and T2N0 cancer were 94.3% and 90.5%, respectively. Recurrence rates and sites, treatments for relapse and outcome of re-resection were investigated. RESULTS: The recurrences were observed in 20/814 (2.5%) patients with colon cancer and 57/785 (7.3%) with rectal cancer. The median periods of the recurrences were 26 months. Cumulative appearance rates of recurrence were 22%, 68%, and 92% within 1, 3, and 5 years after surgery, respectively. 4 patients of 488 (0.8%) with T1N0 colon cancer had recurrences. The median periods were 18 months. The recurrence sites were liver in 1 and multiple hematogenous metastases in 3. All patients were passed away by a speciﬁed cancer. 16 of 326 (4.9%) with T2N0 colon cancer had recurrences. The median periods were 23 months. The recurrence sites were liver in 10, lung in 1, multiple hematogenous metastases in 3, and unknown in 2. Only 3 patients with liver metastasis survived more than 3 years after re-resection. 14 of 338 (4.1%) in T1N0 rectal cancer had recurrences. The median periods were 39 months. The sites were liver in 2, local recurrence in 6, lung in 4, and unknown in 4. 43 of 447 (9.6%) with T2N0 rectal cancer had recurrences. The median periods were 23 months. The sites were liver in 13, lung in 5, local in 15, multiple hematogenous metastases in 6, and unknown in 4. CONCLUSIONS: There were small numbers of recurrences in T1N0 colon cancer, and if once recurrence, these prognoses were very poor. Follow-up may not beneﬁt for T1N0 colon cancer. In T2N0 colon cancer, it may be reasonable that the follow-up system is target for liver recurrence. T1N0 and T2N0 rectal cancer may be recommended to be followed up for liver, lung, and local recurrences.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1414 Outcomes in Bloodless Care Patients Having Colonic Resection James Izanec1, Deborah A. Nagle2; 1Gastroenterology, Graduate Hospital, Philadelphia, PA; 2Surgery, Cooper University Hospital, Camden, NJ BACKGROUND: Patients who require abdominal surgery but cannot receive blood products for religious reasons pose unique challenges. Our institution specializes in the medical and surgical care of these patients, specifically the judicious use of erythropoietin and intravenous iron, as well as limiting blood draws. Hemodilution is not used at our institution. We investigated to see how the outcomes in patients undergoing colectomy with bloodless care compared with those receiving traditional care. METHODS: A total of 27 bloodless care patients underwent colectomy between 1998 and 2005. We reviewed the charts of these 27 patients along with 43 age matched, procedure-matched controls. Operations preformed included total abdominal colectomy, subtotal colectomy, open hemicolectomy, laparscopic assisted hemicolectomy and proctectomy. Demographics, comorbidities, laboratory tests and outcomes were then recorded and then examined with either a paired t-test or with chi-squared analysis. RESULTS: There was no statistically significant difference in rates of coronary artery disease, hypertension, COPD, CVA, DM, end-stage renal disease, need for emergent surgery, or type of procedures between the two groups. The study group had a lower pre-op hemoglobin, 9.7 ± 2.8 g/dL vs. 11.8 ± 1.8 g/dL (p < .005 compared to control group), and nadir hemoglobin of 8.7 ± 2.4 g/dL vs 9.2 ± 1.8 g/dL (p < .01). The study group was more likely to have received erythropoeitin (85% vs. 9%, p < .0001). There were no significant differences in age, prothombin time, blood loss during surgery, length of stay, or complication rates between the two groups (Table 1). There were no deaths (0/27)in the perioperative period (21 days from surgery) in the study group; there was one in the control group (1/43, 2%; p = NS).

Table 1. Outcomes in Study Population and Control Population

Control Group p value (x-Squared Study Group (n = 27) (n = 43) Test or Paired t-test) pre-op Hb (g/dL) 9.7 ± 2.8 11.8 ± 1.8 <.005 nadir hemoglobin (g/dL) 8.7 ± 2.4 9.2 ± 1.8 .05

estimated operative blood loss (mL) 249 ± 249 263 ± 241 NS ABSTRACTS use of erythropoietin 23/27 4/43 p < .0001 POSTER peri-op mortality 0/26 1/43 NS MI or CVA 0/26 0/43 NS LOS (days) 10 ± 11 13 ± 15 NS units of PRBC transfused/patient 0 2.0±3.5 <.005

CONCLUSIONS: Bloodless care patients who have colorectal surgery have outcomes similar to patients who can accept blood products, despite lower hemoglobin levels and without the use of hemodilution. Our center found no differences in peri-operative mortality or morbidity.

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M1416 Long-Term Quality of Life Is Not Different After Laparoscopic or Open Sigmoid Colectomy – A Matched-Pairs Analysis Michael S. Kasparek1, Elke Schiele1, Joerg Glatzle1, Guido Seitz3, Alfred Koenigsrainer1, Martin E. Kreis2; 1Department of General Surgery, Eberhard-Karls-University Tuebingen, Tuebingen, Germany; 2Department of Surgery, Ludwig-Maximilian’s-University Munich, Munich, Germany; 3Department of Paediatric Surgery, Eberhard-Karls- University Tuebingen, Tuebingen, Germany AIM: To compare hospital outcomes and long-term quality of life (QOL) in patients after open vs. laparoscopic sigmoid colectomy. METHODS: Patients who underwent laparoscopic sigmoid colectomy from 1996 through 2002 at our institution were matched to the same number of control patients after open sigmoid colectomy according to age, sex, indication for operation, and follow-up time. Each group consisted of 38 patients with an median age (range) of 59 years (38–89y) and an overall follow-up of 55 months (8–74 mo). Indications for operation were recurrent diverticulitis in 26 and cancer in 12 patients in each group. Hospital stay, first bowel movement, duration of operation, and complications were quantitated. A telephone interview followed a standardized questionnaire to determine patients’ general gastrointestinal and overall well-being. Thereafter, the gastrointestinal quality of life index (GIQLI) was sent to patients and controls. 23 of the 38 patients (61%) in each group returned the questionnaire. RESULTS: Long-term QOL, determined by the overall GIQLI, was similar after open and laparoscopic sigmoid colectomy when performed either for recurrent diverticulitis (mean ± SEM; 95 ± 9 vs. 95 ± 8; n.s.) or for colonic cancer (106 ± 11 vs. 114 ± 10; n.s.). Overall satisfaction with the operation did not differ between groups and was 100% in the cancer group for both operations. In the diverticulitis group one patient (4%) after the laparoscopic and three patients (12%) after the open operation complained of persistent abdominal pain. Therefore, overall satisfaction was 96% and 88%, respectively. Less patients complained of aesthetically displeasing scars in the laparoscopic group when the operation was performed for diverticulitis (0% vs. 64%; p < 0.05), whereas no differences occurred in the colon cancer groups (0% vs. 12%; ns). Postoperative bowel habits at time of follow-up did not differ between groups. Operating time (mean ± SEM) was longer in the laparoscopic group (171 ± 8 vs. 128 ± 5 min; p < 0.05), while postoperative stay was shorter (7 ± 1 vs.11 ± 1 days; p < 0.05). The first postoperative bowel movement (median [range]) occurred earlier after laparoscopic sigmoid colectomy (3 days [2–4d] vs. 3.5 days [2–5d]; p < 0.05). No major complications occurred in either group, but minor complications occurred more frequently in the open group (53% vs. 11%; p < 0.05). CONCLUSION: The operative approach (laparoscopic vs. open) for recurrent diverticulitis or sigmoid colon cancer has no apparent influence on long-term gastrointestinal QOL. However, the laparoscopic approach offers a better cos- metic result and a lesser incidence of minor postoperative complications.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1417 Synchronous Cancer in Obstructive Colo-Rectal Cancer Jaehwang Kim1, Byung-Ik Jang2, Min-Chul Shim1; 1General Surgery, Yeungnam university Medical center, Daegu, South Korea; 2Internal Medicine, Yeungnam university Medical center, Daegu, South Korea The theory of the adenoma-carcinoma sequence suggests an adenoma progresses a full carcinoma. AIM: To determine if the rate of synchronous cancer increases in advanced cancers such as obstructive distal colon cancer. METHOD: The medical records (1999–2002) of the 386 consecutive patients with distal colon cancer who underwent an intraoperative (obstruction; n = 80) or preoperative(non-obstruction; n = 306) colonoscopy at our hospital were retrospectively reviewed. An intraoperative colonoscopy was performed after an on-table lavage for cases in which colon cancer prevented the proximal bowel from being examined preoperatively. A new device, which enables an easy on-table lavage and a subsequent colonoscopy before resecting the tumor, was used for this study. RESULTS: The obstruction and non-obstruction groups had similar demographics. The TNM stage of the obstruction and non-obstruction group was I 0 (0%), II 27 (34.2%), III 33 (41.3%), IV 20 (25.3%) and I 56 (18.3%), II 127 (41.5%), III 102 (33.3%), IV 21 (6.9%). No signiﬁcant difference was observed between the groups (obstruction vs non-obstruction) in rates with synchronous polyps(57.5 vs 60.8%; p = 0.87) or synchronous cancer (12.5 vs 7.8%; P = 0.24). CONCLUSIONS: These results do not suggest that an increased synchronous cancer appears in an obstructing distal colon cancer. However, because of the frequently associated neoplasm, all patients with a colorectal cancer obstruction are advised to undergo a full colonoscopy intraoperatively. ABSTRACTS POSTER

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M1418 Gore Tex Perineal Sacral Suspension Reduces Symptoms of Obstructed Defecation Christopher J. Lahr1,2, Elizabeth T. Clerico2, Brooke H. Gurland3, Thomas Schnelldorfer1, John C. Pezzullo4, Vicki M. Limehouse2; 1Medical University of South Carolina, Charleston, SC; 2Roper St. Francis Hospitals, Charleston, SC; 3Maimonides Medical Center, Brooklyn, NY; 4Georgetown Medical University, Washington, DC INTRODUCTION: This study prospectively evaluates a unique surgical procedure, Gore-Tex Perineal Sacral Suspension (GPSS), to relieve symptoms of obstructed defecation (OD). METHODS: One surgeon evaluated and treated women with symptomatic OD. Women with complaints of hard, painful BM’s, difficult evacuation, pelvic pain, and straining were evaluated with anal manometry, EMG, pudendal nerve latency, defecography, cystography, enterography and transit time. Women selected for operation had: significant symptoms, strong desire for relief, failed other therapies and anatomic defect on x-ray (anterior rectocele, enterocele or sigmoidocele). The operation included bilateral sacral rectopexy with Gore-Tex sutures to which a Gore-Tex strip was attached on each side. Perineal sacral suspension was performed using two #2 Prolene sutures passed through the pelvic floor from the pelvic cavity to the perineal skin and back with a single prong Cobb-Ragde needle. The sutures were placed via shallow transverse perineal skin incisions. Each suture passed on both sides of the midline. Tying the Prolene recreated a narrow pelvic inlet. Each Prolene suture was suspended to one Gore-Tex strip. A detailed symptom questionnaire was completed before and after GPSS at each visit and prospectively entered into a database. Statistical analysis with McNemar’s test and Fisher’s exact test were used and P < .05 were considered significant. RESULTS: Between January 10, 2001 and September 1, 2005, 56 women underwent GPSS for OD in the absence of colonic inertia. There were no pelvic infections and no deaths. OD symptoms were significantly reduced post operatively (see table). After surgery 84% were satisfied, 16% neutral and none were unsatisfied. Mean follow-up was 8.8 months.

Table 1. Symptomatic Improvement Following GPSS

Symptom Preop Postop P-value >25% BMs Difficult 76% 16% p < 0.0001 Incomplete Emptying 76% 8% p < 0.0001 Intense Pain 63% 16% p < 0.0001 Straining 63% 3% p < 0.0001

DISCUSSION: GPSS can be performed safely with signiﬁcant reduction of OD symptoms and high patient satisfaction. It seems to narrow the muscular pelvic outlet, recreate a thicker rectovaginal septum and lift the perineum correcting perineal descent. It seems to be an effective surgical therapy for women suffering from perineal descent and associated symptoms of obstructed defecation.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1419 Clinicopathological Factors Predictive of Systemic Recurrence After Curative Resection of Stage II Colon Cancer Yee Man Lee, Wai Lun Law, Hok Kok Choi, Chi Leung Seto, Siu Hung Lo, Wai Chu Ho; Surgery, Queen Mary Hospital, Hong Kong SAR, Hong Kong BACKGROUND: The use of adjuvant chemotherapy in stage II colon cancer remains controversial. Identification of risk factors associated with poor outcome can help to select patients for chemotherapy. OBJECTIVE: To identify clinicopathological factors predictive of systemic recurrence in patients having curative resection for stage II colon cancer. METHOD: A prospective review on clinical data of all patients having curative resection for stage II colon cancer in a single tertiary centre from 1996 to 2003. The primary outcome measure was systemic recurrence. Secondary outcome measures included overall survival and disease free survival. Patients were assigned to group I (no recurrence) or group II (recurrence). Analysis on survival data was performed with Kaplan Meier test.Univariate analysis was performed using log-rank test and multivariate analysis was performed using Cox proportional hazards regression model. RESULTS: The study comprised of 315 and 61 patients in group I and II, respectively. The median age was 72 years in both groups, there was no difference in distribution of gender.The median overall survival were 39.8 months in group I and 26.5 months in group II (p < 0.001). Median disease free survival were 39.8 months and 18.5 months, respectively (p < 0.001). The median number of lymph nodes harvested were 11 and 10 in group I and II, respectively (p = 0.725). Three clinicopathological factors were found significant for systemic recurrence in both univariate and multivariate analyses: emergency operation (hazard ratio 2.22, 95% CI 1.27–3.86), anastomotic leakage (hazard ratio 3.34, 95% CI 1.27–8.77) and perineural permeation (hazard ratio 3.01, 95% CI 1.23–7.25). Other factors included in analysis but not significant were resection margin <5 cm, T stage, differentiation of tumour, lymphovascular permeation, presence of mucin and signet ring cells. CONCLUSION: Adjuvant chemotherapy may be offered to patients operated in emergency setting, complicated by anastomotic leakage or whose tumour showed perineural permeation after curative resection for stage II colon cancer. ABSTRACTS POSTER

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M1420 Fecal Urgency After Circular Stapled Mucosectomy in Hemorrhoidal Disease – Manometric and Clinical Features Rafal Pankala1, Jaroslaw Leszczyszyn2, Igor Lebski1; 1Department of GI Surgery, EuroMediCare Hospital, Wroclaw, Poland; 2Faculty of Physiotherapy, Physical Education University, Wroclaw, Poland Circular stapled mucosectomy (CSM) (Longo procedure), offers a new approach in the surgical treatment of hemorrhoids. Circumferential resection of rectal mucosa causes hemorrhoids blood supply cut off as well as lifting nodes up in the anal canal. Long term observations show good clinical outcome, some publications however reported incidents of persistent, postoperative fecal urgency.The aim of the study was to assess manometric and clinical findings in patients complaining of fecal urgency after CSM. MATERIAL AND METHODS: Study was approved by local Bioethics Commis- sion. 24 patients with symptomatic hemorrhoids, who were qualified for CSM, were enrolled into the study. 5 (20, 8%) patients had II° hemorrhoids, 13 (54, 2%)—III° and 6 (25%)—IV°. Apart from standard proctologic and endoscopic examinations, all patients underwent anorectal manometry before surgery and 3 months after CSM. Parameters measured during manometry were: maximum resting anal pressure (MRAP)—maximum squeeze anal pressure (MSAP)—high pressure zone length (HPZL)—volume of first rectal sensation (VIRS)—volume of constant rectal sensation (VCRS)—maximum tolerable volume (MTV) None of the patients reported any incidents of fecal urgency before surgery. RESULTS: 3 months after surgery 7 (29, 1%) patients (group B) reported symptoms of fecal urgency. No differences were found between patients without fecal urgency (group A) in proctologic and endoscopic exams. Stapling line distance from verge of dentate line was: in group A—31 mm (24–41mm, SD 4, 82), in group B—30 mm (23–39 mm, SD 4, 91) Results of anal manometry in both groups are shown in the table. All patients completed a follow-up visit 6 months after surgery. In all cases fecal urgency receded completely.

Group A Group B Statistical Statistical Parameter Before Surgery After Surgery Significance Before Surgery After Surgery Significance MRAP 77,85 ± 15,61 73,22 ± 12,2 NS 91,91 ±1 7,5 79,91 ±1 9,32 NS (mmHg) MSAP 178,4 ± 80,47 169,44 ± 67,3 NS 167,24 ± 39,17 161,12 ± 48,52 NS (mmHg) VIRS (ml) 48,82 ± 16,91 40,58 ± 14,77 NS 51,42 ± 27,34 39,28 ± 13,04 NS VCRS (ml) 85,88 ± 24,5 78,23 ± 21,0 NS 95,71 ± 25,72 72,85 ± 22,88 NS MTV (ml) 133,52 ± 29,77 130,0 ± 32,97 NS 150,0 ± 41,63 117,14 ± 49,9 p < 0.001 Presence 17/17 17/17 NS 6/7 6/7 NS of RAIR HPZL (mm) 29,4 ± 6,1 32,3 ± 6,15 NS 33,5 ± 3,7 29,2 ± 6,0 NS

CONCLUSIONS: Fecal urgency after CSM may be caused by decrease of rectal ampulla volume. However reasons for the urgency can be multifactorial, thus requiring further investigations.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1421 Recurrent Distal Rectal Cancer Following Neoadjuvant Chemoradiation Therapy – Risk Factors and Outcomes Marcelo B. Linhares, Angelita Habr-Gama, Rodrigo O. Perez, Afonso H. Sousa, Fabio G. Campos, Igor G. Proscurshim, Desiderio R. Kiss, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil BACKGROUND: Neoadjuvant chemoradiation therapy (CRT) is considered the preferred treatment option for distal rectal cancer due to increased local control, tumor downstaging and increased survival. However, due to this downstaging, the impact of final pathological features on recurrence has been questioned. PATIENTS AND METHODS: 361 patients with distal rectal cancer were managed by neoadjuvant CRT including 5FU, Leucovorin and 5040 cGy. Patients with complete tumor response were not immediately operated on and were closely followed. Patients with incomplete tumor regression were managed by radical surgery. Recurrent disease was also categorized as curable and incurable when radical salvage treatment was feasible. RESULTS: Overall, 97 patients experienced any recurrence during follow-up. There was a significant association between any recurrent disease and pT status (0.04), pN status (< 0.001), perineural and lymphovascular invasion (< 0.001). Recurrent disease not amenable to radical salvage therapy was significantly associated with pN status and perineural/lymphovascular invasion (p < 0.001). Incurable recurrence was significantly more frequent than curable recurrent disease (70% vs. 30%). Patients with recurrent disease amenable to radical salvage therapy had significantly improved 5-yr overall survival rates when compared to patients without possibility of radical salvage treatment (78% vs 49%; p = 0.001). CONCLUSIONS: Pathologic T, N, and patterns of invasion are features that remain significantly associated with the risk of disease recurrence even after neoadjuvant chemoradiation therapy. Radical salvage therapy is possible only in one third of these patients and may significantly improve survival. ABSTRACTS POSTER

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M1422 Intraoperative Radiotherapy for Oncological and Function Preserving Surgery in Patients with Advanced Lower Rectal Cancer – Preliminary Report of Prospective Randomized Trial Tadahiko Masaki1, Makoto Takayama2, Hiroyoshi Matsuoka1, Nobutsugu Abe1, Hisayo Ueki1, Masanori Sugiyama1, Ayako Tonari2, Junko Kusuda2, Shinsaku Mizumoto3, Yutaka Atomi1; 1Surgery, Kyorin University, Mitaka, Japan; 2Radiation Oncology, Kyorin University, Mitaka, Japan; 3Karasuyama Clinic for Anorectal and Urological Diseases, Setagaya, Japan BACKGROUNDS: Pelvic autonomic nerve preservation (PANP) with lateral lymph node dissection (LLND) has been introduced in rectal cancer surgery in Japan, however, its indication has not been standardized yet. PATIENTS AND METHODS: Thirty-seven patients with advanced lower rectal cancer were randomized to either the standard treatment group or the intraoperative radiotherapy (IORT) group. All patients underwent potentially curative resection of the rectum with total mesorectal excision. The standard treatment group underwent bilateral LLND and limited PANP. The IORT group underwent bilateral LLND, complete PANP, and IORT. Patients allocated to the IORT group received IORT to the bilateral preserved pelvic nerve plexuses separately. Patients’ clinicopathologic parameters, postoperative complications, voiding function, and prognosis were compared between the two groups. RESULTS: Among 37 patients enrolled, 3 patients were excluded from the analysis, resulting in 17 patients in each group. Patients’ demographic and pathological parameters and postoperative complications were well balanced between the two groups. Oncological outcomes including overall and disease- free survival were also similar. Local recurrence was observed in one patient (6%) in each group. Among the 27 patients not complicated with intrapelvic abscess, the mean duration of urinary catheter indwelling was 8 days in the IORT group, and 15 days in the standard treatment group (p = 0.09). In the long- term, medication for urination was necessitated in 4 patients in the standard treatment group, whereas in none in the IORT group (p = 0.04). DISCUSSIONS: Oncological outcomes in the IORT group are equal to those in the standard treatment group, and voiding functions in the IORT group are superior to those in the standard treatment group. These results suggest that IORT may be useful to expand the indication of complete PANP with LLND for advanced lower rectal cancer. Table 1. Quality of Surgery

Standard Tx IORT Tx p-value Autonomic Nerve Preservation Complete 0 15 Unilateral 11 2 p < 0.001 Partial 6 0 Operation SPO 9 11 APR 8 6 0.486 Adjuvant Chemotherapy Yes 6 5 No 11 12 0.714

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1423 Mechanical Bowel Preparation Influences the Outcomes of Elective Colorectal Resection with Primary Anastomosis by a Single Surgeon: Intermediate Analysis of a Prospective Single-Blinded Randomized Trial Maria Jesus Pena-Soria, Julio M. Mayol, Rocio Anula, ANA Arbeo- Escolar, Jesus A. Fernandez-Represa; Servicio de Cirugia I, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Madrid, Spain INTRODUCTION: The benefits of mechanical bowel preparation for elective colorectal surgery have been challenged by multi-center, multi-surgeon randomized trials. However, the procedure is an established practice. Heteroge- neity in study design may have prevented surgeons from translating “scientific evidence” to their individual clinical practice. We designed a prospective single-blinded randomized trial to investigate whether preoperative mechanical bowel preparation influences the incidence of surgical site infection and anastomotic failure after elective colorectal surgery by a single surgeon. PATIENTS AND METHODS: All patients scheduled to undergo an elective colon or proximal rectal resection with a primary anastomosis by the same surgeon from October 2001 were enrolled and randomized to receive either oral polyethylene glycol lavage solution (Group A) or no mechanical bowel preparation whatsoever (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. RESULTS: Until July 2005, one hundred and ten patients had been enrolled. Two patients (2%) were preoperatively excluded because of active immunosupression. One hundred and eight patients were randomized but 11 of them (10%) were excluded from analysis (diverting stoma in 9 cases, contained perforation in 1 patient and unresectable tumor in 1 patient). Of the remaining 97 patients, 48 were assigned to Group A and 49 to Group B. The mean age was 66.5 ± 12 years in Group A and 67.9 ± 15 years in Group B (NS). There was no difference in sex distribution between groups. The most frequent indication for surgery was colorectal adenocarcinoma (71%). Overall, twelve patients (12.4%) developed postoperative wound infection, six in each group ABSTRACTS

(Group A = 12.2% and Group B = 12.5%; NS). There were 3 cases of intrab- POSTER dominal sepsis and all of them occurred in Group A (6.3%). The overall rate of anastomotic failure was 6.3% (n = 6), 4 patients in Group A (8.3%) vs. 2 patients in Group B (4.1%) (NS). The overall complication rate in Group A was 27.1% vs, 16.3% in Group B. The NNH was 9.3 CONCLUSION: Although underpowered, our intermediate analysis suggests that a surgeon may have worse outcomes in terms of surgical site infection and anastomotic failure rates if preoperative mechanical bowel preparation with poliethylenglycol is routinely used.

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M1425 Laparoscopic Resection for Rectal Cancer: A Prospective Evaluation in 107 Consecutive Patients Marco Montorsi1, Paolo P. Bianchi1, Riccardo Rosati2, Chiara Ceriani1, Stefano Bona2, Matteo Rottoli1, Ugo Elmore2; 1General Surgery. University of Milano, Istituto Clinico Humanitas IRCCS, Rozzano (Milano), Italy; 2Minimally Invasive Surgery, Istituto Clinico Humanitas IRCCS, Rozzano (Milano), Italy BACKGROUND: The role of laparoscopic resection in the management of rectal cancer is still controversial. There are few reports demonstrating feasibility and efficacy of laparoscopic rectal resection for rectal cancer. Aim of this study is a prospective evaluation of the perioperative outcome and long-term results of laparoscopic rectal resection for rectal cancer in a single institution. METHODS: From November 1999 to November 2005 one-hundred and seven consecutive patients with rectal cancer were treated by laparoscopy. Patients with locally advanced disease and no evidence of distant metastases were candidates for neoadjuvant chemo-radiotherapy. All patients were followed up prospectively to evaluate complications and late outcomes. The survival rates were calculated with the Kaplan-Meier method. RESULTS: A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation and one a laparoscopic Hartmann procedure. The tumor location was: upper third 43.9%, middle third 43.0% and lower third of the rectum 13.1%. Mean operative time was 278 min (range 135/430). Conversion rate was 18.7% (20/107). A protective ileostomy was performed in 21/104 patients (20.2%). The overall morbidity rate was 29%, with an overall anastomotic leak rate of 13.4% (14/104). There was no postoperative mortality. UICC tumor stages were as follow: stage I: 48.7%, stage II: 19.6%, stage III: 26.2%, stage IV: 7.5%. Average number of lymph nodes removed was 18 (range 1/49). The mean distance of the distal margin from the tumor was 2.6 cm (range 0–10), in two cases (1.9%) a microscopically invasion of the distal margin was registered (2T3 stage, one converted for technical reasons). Mean hospital stay was 9 days (range 4–43). The mean follow-up period was 35.8 months and 88patients (82.2%) have a follow-up superior to 12 months. The local recurrence rate was 0.95% (1/105), there was no port site metastases. The cumulative survival rate at 5 years was 75.3%. CONCLUSIONS: This prospective study demonstrates that laparoscopic rectal surgery is feasible but technical demanding (conversion rate 18.7%) and time consuming (mean operative time 278 min.). Laparoscopic rectal surgery is not associated with higher morbidity and mortality than open surgery. Oncological and surgical principles are respected and long-term outcomes are at least comparable to the open published series. Further randomized studies will be necessary to confirm long-term clinical outcome in cancer patients and to evaluate the true benefits of this technique.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1426 Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis (IPAA): Is There a Volume-Outcomes Effect? John Morton, Andrew Shelton, Mark Welton; Surgery, Stanford University, Stanford, CA BACKGROUND: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is a procedure requiring significant commitment and expertise. Little is known about the relationship between IPAA hospital volume and outcomes. To determine if a volume effect exists between the number of IPAA procedures and outcomes, national outcomes for IPAA surgery were examined from 1997–2003. METHODS: The National Inpatient Sample, a 20% sample of all non-federal hospital discharges, was queried for all patients who had IPAA surgery denoted by ICD9 procedure code 45.95. Hospital transfers and pediatric patients were excluded. Two hospital volume cohorts of less or greater than 15 annual IPAA procedures were established: Low Volume Hospitals (LVHs) or High Volume Hospitals (HVHs). Both demographic and outcome variables were compared by either T-test or Chi-Square analysis with a P value of < 0.05 as significant. Confounding variables were controlled for with linear and logistic regression models for LOS and mortality respectively. RESULTS: No clinically significant differences existed between the two volume groups for age or gender. Significant differences between LVHs and HVHs did exist for the general (Charlson) comorbidity index > 0 respectively: %, 41 vs. 30, p < 0.0001. Significant differences in LOS and mortality between LVHs and HVHs also existed respectively: LOS > 14 Days (%, 11 vs. 7.5, p < 0.0001), and in-patient mortality (%, 0.74 vs. 0.27, p < 0.0001). In addition, logistic regression analysis indicated potential predictors for mortality in all IPAA procedures. HVHs were associated with a protective effect upon mortality with an Odds Ratio (OR) of 0.45. The following factors were associated with increased risk of in-patient mortality (OR): age > 65 (1.94), male gender (1.14), Charlson Index > 0 (1.09). CONCLUSIONS: This population-based study indicates a hospital volume- outcomes effect for IPAA procedures. Higher volume hospitals may have better outcomes due to patient selection, surgeon experience, and hospital resources. Further investigation may reveal the effect factors other than volume exert on IPAA surgery outcomes. ABSTRACTS POSTER

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M1427 Emergency Laparoscopic Versus Open Right Hemicolectomy for Obstructing Right-Sided Colonic Carcinoma: A Comparative Study Simon S. Ng, Janet Lee, Raymond Yiu, Jimmy Li, Ka Lau Leung, Enders Ng; Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong BACKGROUND: With advancements in skills and technology, colorectal emergencies like malignant obstruction can now be successfully treated with the laparoscopic approach. The aim of this study was to compare the clinical outcomes of emergency laparoscopic versus open right hemicolectomy for obstructing right-sided colonic carcinoma. METHODS: Between July 2003 and August 2005, 29 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 10 with the laparoscopic approach and 19 with the open approach. The demographic data, operative details, and clinical outcomes were prospectively recorded and compared between the two groups. RESULTS: There were no significant differences between the two groups with respect to age, genders, comorbidities, tumour length, and tumour staging. The operative time was also not significantly different between the two groups, but the median blood loss was significantly lower in the laparoscopic group (20 ml vs. 100 ml, P = 0.026). The laparoscopic group required significantly shorter median duration of parenteral analgesia (1.5 days vs. 4 days, P = 0.016) and the median time to full ambulation was significantly shorter (4 days vs. 7 days, P = 0.013). However, the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (42.1% vs. 10%), but the difference was not statistically significant. The two groups were also not different in postoperative mortality. Oncological results, in terms of number of lymph nodes removed, recurrence rates, and survival rates were similar in the two groups. CONCLUSION: Emergency laparoscopic right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. Comparing with the open approach, the laparoscopic approach is associated with less blood loss, less analgesic requirement, earlier ambulation, and possibly lower morbidity, without jeopardizing the oncological results.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1428 Laparoscopic Colorectal Surgery in Patients with Major Pulmonary Co-Morbidities Ikenna C. Okereke, Daniel P. Geisler, Thomas E. Garofalo, Feza H. Remzi, Luca Stocchi, Jon D. Vogel, Elena Manilich, Victor W. Fazio; Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Heights, OH PURPOSE: Pulmonary co-morbidities are recognized risk factors in conventional colorectal surgery. The avoidance of an upper abdominal incision in patients with major pulmonary co-morbidities is appealing, but the effect of a carbon dioxide pneumoperitoneum on such patients has not been well documented. We examine here the feasibility and safety of laparoscopic colorectal surgery in this high-risk patient population, deﬁned by need for home oxygen, history of severe obstructive pulmonary disease, or extensive smoking history. METHODS: Between January 1995 and June 2005, data from 1,602 consecutive patients undergoing laparoscopic colorectal surgery were prospectively recorded and serve as the basis for this retrospective case-matched analysis. 492 patients presented with a major pulmonary co-morbidity and were compared to a group of patients without pulmonary co-morbidities undergoing laparoscopic colorectal surgery and later to a case-matched group of patients undergoing open surgery during a similar time period. RESULTS: While patients with pulmonary co-morbidities were more likely to have diabetes and be on steroids, the overall morbidity was similar in the two laparoscopic groups (9.8% vs. 9.5%, p = 0.90). This group was also more likely to have cardiac and renal co-morbidities. The effects of a carbon dioxide pneumoperitoneum on patients with pulmonary co-morbidities did not translate into an increased conversion rate in this high-risk patient subset (p = 0.18). The rates of segmental atelectasis (6% vs. 7%) and pneumonia (6% vs. 2%) did not signiﬁcantly differ between the two groups and compared quite favorably to the open group. Furthermore, length of stay was slightly decreased in the group with pulmonary co-morbidities (4.3 vs. 5.1 days, p = 0.12). CONCLUSIONS: Patients presenting with underlying pulmonary disease frequently have other co-morbidities as well. With proper patient selection and laparoscopic experience, advanced laparoscopic procedures can be performed in this complicated patient population without undue morbidity or mortality. A minimally invasive approach and avoidance of an upper abdominal incision is associated with improved postoperative recovery compared with conventional surgery. ABSTRACTS POSTER

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M1429 Lymph Node Retrieval After Surgery for N0 Distal Rectal Cancer: Is There a Critical Number of Lymph Nodes to Be Recovered After Neoadjuvant Chemoradiation Therapy? Rodrigo O. Perez, Angelita Habr-Gama, Igor Proscurshim, Afonso H. Sousa, Fabio G. Campos, Jose M. Jorge, Desiderio R. Kiss, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil BACKGROUND: Resection of a minimum number of lymph nodes (LN) has been considered crucial during radical surgery for the treatment and staging of colorectal cancer. However, distal rectal tumor downstaging as consequence of neoadjuvant chemoradiation therapy (CRT) may lead to primary tumor as well as lymph node sterilization. Therefore, the optimal number of retrieved lymph nodes in this situation and its role in survival has not yet been determined. PATIENTS AND METHODS: 237 patients with distal rectal cancer, managed by neoadjuvant CRT were retrospectively reviewed. Patients with incomplete tumor response after at least 8 weeks from CRT completion were referred to radical surgery. Patient outcomes were compared according to the total number of lymph nodes retrieved from the resected specimen in patients with N0 tumors. RESULTS: 68 patients had at least one metastatic lymph node after pathological examination. The remaining 169 patients had a mean of 8.8 lymph node/specimen. 76 patients (55%) had ≥9 LN/specimen recovered while 93 patients (45%) had <9 LN/specimen. There were no significant differences in terms of OS (91% vs 93%) and DFS (66% vs 66%) between patients with <9 LN/specimen and ≥9 LN/specimen (p = 0.6 and 0.8) for all N0 patients, as well as stage-adjusted (Stage p0-II). These results were also not significant when dividing patients with <3LN/patient and 1LN/patient. Both groups (≥9LN/ patient and <9LN/patient) had better OS and DFS rates when compared to patients with stage III disease (p < 0.001). CONCLUSIONS: Decreased number of lymph node retriveal after radical surgery for N0 distal rectal cancer following neoadjuvant CRT is not a prognostic factor. The presence of at least one LN metastases remains as a significant prognostic factor in these patients. These results support the hypothesis that CRT may lead to sterilization of perirectal lymph nodes and not to understag- ing due to inadequate sampling.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1430 Laparoscopic Colorectal Resections: A Single Center Experience Silvana Perretta2, Roberto Campagnacci1, Mario Guerrieri1, Angelo De Sanctis1, Maddalena Baldarelli1, Giovanni Lezoche2, Emanuele Lezoche2; 1Clinica di Chirurgia Generale e Metodologia Chirurgica, University of Ancona, Ancona, Italy; 2Department of Surgery, Paride Stefanini, Universita La Sapienza, Roma, Italy BACKGROUND: Since our first minimally invasive colon resection 13 years ago, laparoscopic colorectal resection has been implemented as techniques have evolved. This study aims to evaluate the surgical outcomes, and the present role of laparoscopic surgery for benign and malignant colorectal diseases. METHODS: From 1992 to 2005, 758 patients (pts) underwent laparoscopic colorectal resection by the same surgical team; 572 (75.4%) pts (mean age 65,6 years) underwent laparoscopic colon resections (359 left and 213 right hemicolectomies)and 186 (24.6%) pts (mean age 63.8) rectal resections. Data collection included preoperative, operative, postoperative and oncologic results with long-term follow-up. RESULTS: Overall mean operative time was 180.5 min for the right, 289 for the left hemicolectomies and 255 min for rectal resection. In the last five years the op. time shortened to 135 min for the right (R), 240 for the left (L) hemicolectomies and 217 min for rectal resections. Fourteen conversions (2.4%) occurred, 1 in the R and 13 in the L-hemicolectomies. Ten out of 14 conversions occurred in the first 134 cases. In the rectal group there were 12 conversions (6.5%), 9 in the first 94 and 3 in the last 92 pts. Mortality was 1.4% in the R-hemicolectomy group and zero for left colon and rectal resections. There were 16 (5.6%) major complications in the colon group: 5 in the R and 11 in the L-hemicolectomies. In the rectal group 14 major complications occurred (8.4%). The mean number of lymph nodes removed was 15, 10, and 11 in the R and L-hemicolectomies and rectal resections respectively. Mean overall p.o. stay for hemicolectomies was 7.9 days range 5–76). In the rectal resections, mean p.o. stay was 8.6 days (6–52). At a minimum follow-up of 5 years there were 3 (3.5%) local recurrences, 1 carcinomatosis (1.1%) and 9 (10.5%) metachronous metastases in pts who underwent colectomies whereas in those who underwent rectal resection 10 (19.2%) local recurrences, 1 (1.8%) carcinomatosis and 8 (15.3%) metachronous metastases occurred.The cumulative survival probability according to TNM stage was ABSTRACTS

0.88 and 0.71 for Stage I to III, 0.76 and 0.58 for Stage III in the colon and rec- POSTER tal pts respectively. CONCLUSIONS: Laparoscopic colorectal resection is a safe and feasible procedure for benign and malignant colorectal diseases although it requires a long and steep learning curve. While survival after laparoscopic colorectal resection for cancer appears to be at least equal to survival after open resection, in our experience a higher complication rate occured when operating for malignancy.

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M1431 Local Immunosuppression After Neoadjuvant Chemoradiation Therapy May Result in Loss of the Protective Role of Peritumoral Inflammatory Response Igor Proscurshim1, Rodrigo O. Perez1, Rafael M. Santos1, Kleiton R. Yamacake1, Viviane Rawet2, Fabio G. Campos1, Desiderio R. Kiss1, Angelita Habr-Gama1; 1Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil OBJECTIVES: Peritumoral inflammatory response has been considered a good prognostic factor for colorectal cancer. However, patients with distal rectal cancer managed by preoperative chemoradiation therapy may represent a subset of patients where this inflammatory infiltrate is present but inactive due to the immunosuppressive action of the neoadjuvant treatment. For this reason we decided to study the effect of the presence of this pathological finding on disease recurrence and survival. METHODS: 180 patients with distal rectal cancer managed by preoperative chemoradiation therapy followed by radical surgery were retrospectively reviewed. Patients with peritumoral inflammatory response were compared to patients without this finding. RESULTS: Overall, 37% patients had peritumoral inflammatory response at pathology. The lack of peritumoral inflammatory response was significantly associated with increased patient’s age (60 vs. 56 years; p = 0.04) and the presence of mucinous component (13% vs 3%; p = 0.02). 5-year overall survival (91% vs 81%) and disease-free survival (57% vs 48%) were not statistically different between patients with and without peritumoral inflammatory response (p = 0.5 and 0.3 respectively). CONCLUSIONS: Peritumoral inflammatory response is not a favorable prognostic factor in patients with distal rectal cancer following neoadjuvant chemoradiation therapy. Possibly, the immunosuppressive action of chemoradiation therapy may lead to a loss function of the immunological response. The loss of this immunological action may represent a disadvantage of the neoadjuvant approach for the management of distal rectal cancer.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1432 Fecal Incontinence: Are Patients with Sphincter Defects Different? Jennifer Y. Wang1, Silvana Perretta1, Taryn Patterson1,2, Stacey Hart2, Madhulika G. Varma1; 1Surgery, University of California, San Francisco, San Francisco, CA; 2Psychiatry, University of California, San Francisco, San Francisco, CA OBJECTIVE: Sphincter defects are a common cause of fecal incontinence (FI). We examined FI severity and medical factors to determine their association with sphincter defects on anal ultrasound (US). METHODS: We examined data from a cohort of patients with FI who had US performed in our institution from 2001 to 2005. Data were obtained from self-report questionnaires, anorectal physiology testing, and US. Univariate (Chi square and t-tests) and multivariate (logistic regression) analyses were performed to determine which factors were associated with sphincter defects. RESULTS: Of 613 patients with FI, 491 (57 men) had US performed. We divided our cohort into two groups; 59% had intact sphincters and 41% had a defect in the external, internal, or both sphincters. The mean age was 61 ± 14 years in those with no defect and 52 ± 14 years in those with a defect (p < .001). Women were more likely to have a sphincter defect than men (43% vs. 23%, p < .003). Sphincter defects were also associated with less constipation (11% vs. 23%, p = .001) and higher prevalence of anal surgery (37% vs. 21% p < .001). No signiﬁcant differences between groups were noted for loss of mucus, liquid, or solid stool, urine leakage, sense of urgency, pad use, and incomplete evacuation. Among patients with defects, men reported more anal surgery than women (85% vs. 34%, p < .001). Those with no defects were more likely to be diabetic (p = .016) and have a unilateral pudendal neuropathy (left nerve: p = .013; right nerve: p = .038). In women, episiotomy, forceps or vacuum delivery, prolonged labor, and tear at delivery were related to presence of a defect (p’s < .001–.02). Multivariate analysis showed that younger age (p < .001), being female (p < .004), anal surgery (p < .001), less constipation (p < .001), and tear at delivery (p < .001), and were independently associated with a sphincter defect. CONCLUSIONS: Our data show patients with a sphincter defect are more likely to be younger, women with a tear at the time of delivery, or men with a history of anal surgery. Patients with no sphincter defects are likely to have other causes of FI, such as diabetes or pudendal neuropathy. Interestingly, the

presence of a sphincter defect did not predict FI severity. Despite the different ABSTRACTS

etiologies for FI in these two groups, their clinical characteristics are quite POSTER similar, indicating that complete evaluation including US should be performed in all patients regardless of FI severity or associated symptoms.

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M1433 The Effect of Surgically Induced Weight Loss on Pelvic Floor Disorders in Morbidly Obese Women Nir Wasserberg, Patrizio Petrone, Mark Haney, Salman Khan, Peter F. Crookes, Maria Harrison, Howard S. Kaufman; Surgery, University of Southern California, Los Angeles, CA PURPOSE: Urinary incontinence is a common symptom in morbidly obese women. The prevalence of other pelvic floor disorders (PFD’s) is less well documented. While many metabolic comorbidities resolve following bariatric surgery, resolution of global pelvic floor dysfunction has not been well described. The purpose of this study is to evaluate the effect of surgically induced weight loss on pelvic floor disorders (PFD) in morbidly obese women. METHODS: 400 women investigating surgical weight loss completed 2 validated questionnaires of pelvic floor dysfunction (Pelvic Floor Distress Inven- tory—PFDI-20 and Pelvic Floor Quality of Life Impact Questionnaire—PFIQ-7). Both instruments are sensitive tools designed to detect initial prevalence as well as post treatment outcomes by evaluating 3 main domains of PFD: pelvic organ prolapse distress /impact, colorectal-anal distress/impact, and urogeni- tal distress/urinary incontinence impact. To date, 30 women who have achieved ≥50% excess body weight (EBW) loss have completed postoperative questionnaires. Pre- and postoperative scores were compared by Wilcoxon signed rank tests. RESULTS: Of these 30 patients, 25 (83%), median age 39 (23–67), mean BMI: 44.4 ± 3.6 kg/m2, reported various degrees of preoperative PFD’s with corresponding negative impact on QOL (r = 0.3, P = 0.02). At a median follow-up of 17 months (10–21), mean %EBW loss was 77 ± 36%, and mean BMI was 25.2 ± 2.4 kg/m2 (P < 0.001 vs preop). A statistically significant decrease was demonstrated in total mean post surgery distress scores (47 ± 7.8 to 21.4 ± 6.3, P = 0.04), mainly contributed by a decrease in urinary symptoms (20.2 ± 4.2 to 4.4 ± 1.6, P < 0.01). Other PFD domains showed a reduction in symptom scores without achieving statistical significance. There was a trend towards improvement in QOL scores (P = 0.08). CONCLUSION: Surgically induced weight loss significantly reduces symptoms of pelvic floor disorders in morbidly obese women.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1434 The Impact of Obesity on Technical Feasibility and Postoperative Outcomes of Laparoscopic Colectomy Marc Zerey, Kent W. Kercher, Amy E. Lincourt, Dimitrios Stefanidis, Timothy S. Kuwada, Keith S. Gersin, B. Todd Heniford; Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC BACKGROUND: The influence of obesity on laparoscopic surgical outcomes is not clearly defined. We present the effects of obesity on patient outcomes following laparoscopic colectomy. METHODS: We retrospectively surveyed all laparoscopic colectomies performed at our institution from 1998 to 2005. Patients were categorized as obese (body mass index (BMI) > 30 kg/m2) or non-obese (BMI ≤ 30 kg/m2). Data obtained included demographics, perioperative data, length of stay (LOS), complications, and charges. Standard statistical methods were used to determine significance (P < 0.05). RESULTS: A total of 224 patients were included for analysis, 63 (28.1%) of which were obese. Gender distribution was similar in both groups but obese patients were younger than non-obese (male gender: 51.5% vs 48.5%; P = 0.61; age 53.7 ± 16.1 years vs 59.5 ± 12.8 years; P = 0.01) and more likely to have comorbidities (58.7% vs 39.1%; P = 0.01). Mean OR time and conversion rates were not significantly different (OR time: obese 195.5 ± 54.6 min, non-obese 184.0 ± 53.3 min; P = 0.19; conversions: obese: 14.3%, non-obese: 12.4%; P = 0.71). In patients undergoing colectomy for cancer, proximal margin, distal margin, length of bowel resected and lymph nodes resected did not differ significantly between obese and non-obese groups (proximal margin: 8.3 ± 7.6 vs 11.4 ± 12.8 cm; P = 0.20; distal margin: 7.5 ± 4.7 vs 11.1 ± 11.5 cm; P = 0.33; length of bowel resected: 18.9 ± 8.3 cm vs 21.6 ± 13.3 cm; P = 0.36; lymph nodes resected: 14.7 ± 8.0 vs 17.5 ± 12.1 nodes; P = 0.55). Complica- tion rates, LOS, and total charges were not statistically different between obese and non-obese groups (Overall complications: 15.9% vs 9.9%; P = 0.21; pneumonia: 1.59% vs 1.86%; P = 1.0; wound infection: 11.1% vs 5.6% P = 0.15; LOS: 5.9 days vs 6.1 days; P = 0.57; total charges: $23,494.87 vs $21,857.39; P = 0.81). CONCLUSIONS: Despite higher comorbidity rates and operating times in obese patients, short-term outcomes following laparoscopic colectomy are similar to the non-obese. Obesity should not be a contraindication to laparo-

scopic colectomy. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Esophageal

M1435 The Impact of Lymph Node Yield and Ratio of Positive Lymph Nodes on Overall Survival in Patients with Oesophageal Carcinoma Dean Bogoevski1, Stephanie J. Gros1, Florian Onken1, Bjoern C. Link1, Michael Bubenheim2, Lars Wolfram1, Jussuf Kaifi1, Oliver Mann1, Philipp Busch1, Emre F. Yekebas1, Jakob R. Izbicki1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute for Medical Biometry and Epidemiology, University Clinic Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: The extent of lymph node dissection can affect tumor node metastasis staging. The resulting “stage migration” might hamper stage-by-stage comparison between different forms of oesophageal resection. METHODS: Between 1992 and 2004, 368 patients with resectable carcinomas of the oesophagus underwent esophagectomy. Subtotal esophagectomy was performed either by thoracoabdominal (150 patients, 40.8%) or by transhiatal approach (218 patients, 59.2%). RESULTS: According to the regional lymph node (LN) yield the patients were divided in three groups (6 or lower, 7 to 18 and 19 and more). No significant overall survival differences were identified between the groups when comparing patients with nodal involvement (pN1). Focusing only on pN0- patients, the median overall survival (MOS) of those operated on transhi- atally was 33 (≤6 LN), 43 (7–18 LN, n.s. vs. group 1), and 84 months (≥19 LN, p = 0.0190 vs. 0–6; p = 0.0203 vs. 7-18 LN). MOS of patients operated on through a thoracoabdominal approach was 8 (≤6 LN), 15 (7–18 LN, n.s. vs. group 1), and 63 months (≥19 LN, p = 0.0005 vs. 0–6; p = 0.0131 vs. 7–18 LN). The median ratio of positive lymph nodes during thoracoabdominal resection was 6% versus 10% for the transhiatal procedure (chi square = 0.001). According the ratio of positive lymph nodes, the patients were divided in four groups (without positive, 0–11%, 11–33%, and 33% and more). Consid- ering only the transhiatal approach, the patients could be, in fact, divided into 2 groups, below and above 11%, since there were no statistical differences between other groups (below vs. above 11% log rank < 0.0001). On contrary, in patients operated on by a thoracoabdominal approach, patients with 33% and more positive lymph nodes had a significantly worse 5-year overall survival probability than those of the other 3 groups (w/o positive log rank = 0.0001; 0–11% log rank = 0.001; and 11–33% log rank = 0.005). CONCLUSIONS: Recommended regional LN yield from the UICC for oesophageal carcinoma (6 LN) is neither reliable for correct staging of the disease nor provides curative benefits for the patients. Evidence of lymph node metastases indicates that a generalized disease is present which can no longer be influenced by local, surgical measures.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1436 To Divide or Not to Divide the Short Gastric Vessels? A Question with an Answer After 10 Years of Follow Up Engstrom Cecilia1, Jalal Mardani1, Hans Lonroth1, Lars Lundell2; 1Dept of Surgery, Sahlgrenska University Hostpital/SS, Goteborg, Sweden; 2Department of Surgery, Karolinska Insitutet, Stockholm, Sweden BACKGROUND AND AIM: Laparoscopic Nissen fundoplication is the most common antireflux operation. Problems with side effects remain such as dysphagia and gas bloat. In order to minimise those division of the short gastric vessels has been proposed. We and others have offered no evidence to support the routine use of this when evaluated during the first postoperative year. Hereby the long-term (10 years) consequences have been determined. PATIENTS AND METHODS: Originally 99 patients were enrolled in a randomised clinical trial (RCT) evaluating the part of short gastric vessel division on the functional outcome after a laparoscopic Nissen. Forty-seven had their vessels intact (group I) and 52 had them all divided (group II). These patients were now re-evaluated by use of validated questionnaires and the patients Quality of Life (QoL) was assessed by use of psychological general well-being index (PGWB) and gastrointestinal symptom rate scale (GSRS) instruments. RESULTS: Thirteen patients were lost to follow up of whom 7 had died, 3 had moved abroad and 3 were lost to follow up. We were unable to reveal any difference in GERD control based on symptoms. Moreover postfundoplica- tion complaints were reported in similar frequencies in both groups. Accord- ingly QoL was quite comparable as well except for a total PGWB score, which favoured those having the short gastric vessels intact. CONCLUSION: The impact of dividing the short gastric vessels at the time of constructing a floppy laparoscopic Nissen has been debated. Short-term and now also long-term grade A evidence shows that this is not an essential part of the procedure. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1437 Spastic Motility Disorders and Absence of Objective GERD Features Are More Prevalent in Female Patients Presenting for Physiological Testing Before Antireflux Surgery Walter W. Chan1, L. Michael Brunt2, Brent D. Matthews2, Ray E. Clouse1; 1Department of Medicine, Washington University School of Medicine, St. Louis, MO; 2Department of Surgery, Washington University School of Medicine, St. Louis, MO Esophageal manometry (EM) and ambulatory pH monitoring (APM) have been used in preoperative physiological evaluation of patients with refractory GERD who are being considered for laparoscopic antireflux surgery. Spastic disorders on EM, particularly nonspecific spastic disorders, and absence of GERD on APM each predict more postoperative symptoms and poorer surgical outcome. 1092 patients (613 female and 469 male) referred for pre-operative EM (720 for both EM and APM) were examined to determine the rates of these poor outcome predictors and their gender distribution within the patient population. METHODS: High-resolution EM was performed on each subject using a 21- lumen water-perfused system and categorical pattern classification scheme with 4 principal categories: normal, hypomotility (body and/or lower esophageal sphincter), hypermotility (achalasia, spastic disorders [diffuse esophageal spasm, nonspecific spastic disorders]), and mixed disorders. APM was performed for at least 20 hours with either standard catheter or wireless systems. GERD was evident from APM if thresholds for acid exposure time and/or positive symptom association probability (SAP) were passed. RESULTS: Hypomotility was found in 188 (36.7%) females vs 205 (43.7%) males, while hypermotility was found in 192 (31.3%) females vs 93 (19.8%) males (p < 0.001 for each comparison). Within the latter group, 172 (28.1%) females had nonspecific spastic disorders vs 68 (14.5%) males (p < 0.001); other hypermotility disorders were equally distributed. Distribution of EM patterns was nearly identical to the entire group in the subset of 720 patients who also underwent APM (p = 0.5). Among these patients, 115 (27.0%) females and 55 (18.7%) males showed no objective evidence of GERD (p = 0.01). Of the 550 subjects with abnormal APM, 43 (7.8%) demonstrated only positive SAP with normal acid exposure time, including 36 (11.6%) females and 7 (2.9%) males (p < 0.001). Overall, 197 (46.2%) females presented with at least one poor outcome predictor compared with 102 (34.7%) males (p = 0.002). CONCLUSIONS: Female patients being considered for laparoscopic antireflux surgery are at greater risk of having EM and APM findings associated with persistent symptoms and poorer surgical outcome, although these findings are present in many patients of either sex at preoperative evaluation. Both nonspecific spastic disorders and absence of GERD indicators on APM are more common in females. The explanation may rest in part on greater esophageal sensitivity to physiological events in this sex.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1438 Laparoscopic Epiphrenic Diverticulectomy, Heller Myotomy, and Anterior Fundoplication Safely Relieve the Symptoms of Advanced Achalasia Sarah Cowgill, Desiree Villadolid, Mallika Tarkas, Alexander S. Rosemurgy; Surgery, University of South Florida, Tampa, FL INTRODUCTION: This study was undertaken to determine long-term outcome after diverticulectomy, laparoscopic Heller myotomy, and anterior fundoplication for achalasia complicated by epiphrenic diverticulum. METHODS: 15 of 300 patients undergoing laparoscopic Heller myotomy concomitantly underwent epiphrenic diverticulectomy and anterior fundoplication and 39 months later, using a Likert scale (0 = never/severe to 10 = always/very severe), they scored the frequency and severity of dysphagia, choking, chest pain, vomiting, regurgitation, and heartburn. Outcomes for 60 concurrent patients without diverticulectomy are compared. RESULTS: Premyotomy, patients with epiphrenic diverticula had less frequent dysphagia and regurgitation, and less severe dysphagia, choking, and vomiting compared to patients with achalasia alone (p < 0.05, Mann-Whitney U test). There were no conversions to celiotomy and only one late minor uncomplicated leak. Pneumonia (N = 3) was the most notable complication. After diverticulectomy, frequency and severity of all symptoms improved (p < 0.05, Wilcoxon matched pairs test) and were similar to symptoms after myotomy without diverticulectomy (Mann-Whitney U test). After myotomy with diverticulectomy vs. myotomy alone, 70% vs. 90% reported their symptoms were greatly improved/resolved, 70% vs. 90% felt their outcome was satisfy- ing or better, and 70% vs. 86% felt that they would undergo laparoscopic Heller myotomy (± diverticulectomy and fundoplication), if necessary. CONCLUSION: Preoperatively, patients with epiphrenic diverticula had relatively less frequent and severe symptoms of achalasia, possibly because of chronicity of the underlying achalasia. Epiphrenic diverticulectomy adds little morbidity or complications to and does not alter efﬁcacy of laparoscopic Heller myotomy and anterior fundoplication, though it carries relatively lower patient satisfaction for reasons that are unclear. Laparoscopic epiphrenic diverticulectomy, Heller myotomy, and anterior fundoplication relieve the symptoms of advanced achalasia safely and their application is encouraged. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1439 Repair of Esophageal Perforation: A Diversiﬁed Approach Chance D. Felisky1, Elizabeth M. Kline2, Donald E. Low1; 1Department of General, Thoracic, & Vascular Surgery, Virginia Mason Medical Center, Seattle, WA; 2Department of Thoracic Surgery, Charleston Thoracic, Charleston, SC OBJECTIVE: Esophageal perforation has a diverse presentation and high mortality rate. Outcomes have been linked to timing of diagnosis, location and extent of injury, and physiologic status. We believe the experience of the managing team, particularly with respect to the accurate assessment and appropriate application of the initial approach to repair, has become increasingly important due to the evolution of treatment alternatives. METHODS: Records were reviewed for all patients treated at our institution with a diagnosis of esophageal perforation between June 1989 & June 2005. RESULTS: 60 patients with esophageal perforation were treated in the study period. Mean age was 65.2 years (range 22–96), with 38 males and 22 females. Mean ASA was 3.0. Perforations were categorized as iatrogenic (n = 37), baro- genic (n = 21), spontaneous (n = 1) and abnormal esophagus (n = 1). Loca- tions included cervical (n = 12), middle (n = 5), and distal (n = 44). Mean time to diagnosis was 33.2 hrs (range 1–360). 75% were diagnosed early (≤24 hours), and 25% late (>24 hours). Whenever feasible, UGI studies were done or repeated with the surgical team present. 50% of all patients presenting in the last 5 years were managed non-operatively, 18 over the entire study period. 42 patients were managed operatively. Mean time to operation was 29.9 hours (range 2–240). 31 underwent primary repair, 6 underwent resection (including revision of two defunctioning procedures that were performed prior to transfer to VMMC), and 7 underwent operative drainage alone. 7 Celestin tubes and 2 T-tubes were used. Intra-operative endoscopy was utilized in 17 patients. Mean LOS was 19.6 days (range 3–86). 33 complications occurred in 25 patients; 38% in the early group, 53% in the late. There were 2 deaths in the non-operative group and 1 death in the operative group, for an overall mortality rate of 5%. CONCLUSIONS: The use of an UGI contrast study viewed in real time by the managing surgeon for accurate assessment and planning, and the use of intra-operative endoscopy to precisely locate the perforation, assess mucosal integrity, and evaluate the quality of repair, have increased the opportunity for primary repair. This factor, along with selective utilization of intra-operative stents, T-tubes, and resection will avoid the necessity for defunctioning procedures. The incidence of non-operative management is increasing. In our operative experience, delay in diagnosis leads to an increase in complication rate but not mortality. Selection of the appropriate initial procedure is key to the best long term outcome and will decrease the overall mortality and morbidity in these complex patients.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1440 Generation of a Mathematical Model to Predict the Probability of Achalasia from Non-Manometric Findings Lorenzo E. Ferri1,3, Gail Darling2, Linda Miller2, Gerald M. Fried3; 1Thoracic Surgery, McGill University, Montreal, QC, Canada; 2Thoracic Surgery, University of Toronto, Toronto, ON, Canada; 3General Surgery, McGill University, Montreal, QC, Canada INTRODUCTION: Limited access to esophageal motility (EM) may delay achalasia patient identification and treatment. In order to assess predictors to fast-track patients for manometric confirmation of achalasia, we compared the clinical, radiographic and endoscopic characteristics of achalasia patients (AP) to non-achalasia dysphagic controls (C). METHODS: Patients referred for EM to assess functional dysphagia from 2/04 to 2/05 were asked to participate in this prospective study. The Achalasia Symptom Questionnaire (ASQ), a structured 11-question survey (score: 0-best, 67-worst), was completed by all consenting patients. ASQ scores, esophago- gastro-duodenoscopy (EGD), upper GI contrast study (UGI) were compared between patents with subsequently confirmed achalasia (AP) and those in whom achalasia was excluded by EM (C). Data presented as mean ± SD; Univariate analysis (t-test and Chi-square) identified predictors that were tested in multivariate logistic regression to generate the model. (*p < 0.05). RESULTS: Of 803 EM performed from 2/04–2/05, 95 patients were referred specifically to rule out achalasia. 50 APs and 45 Cs were identified. ASQ scores were higher in AP (37 ± 13 vs 23 ± 10)*. EGD and/or UGI reports were available in 92% APs and 80% Cs. Significant predictors for achalasia with odds ratios are presented in the table. Probability of achalasia is predicted by P where P = ey/(1+e y) and y = –5.6 + (0.089 × ASQ) + (2.088 × EGD) + (3.083 × UGI), e = exponential constant 2.7182, EGD and UGI = 0 if normal and 1 if abnormal. For a given patient with ASQ > 40, abnormal UGI and EGD the probability of achalasia is > 96%, if ASQ < 30 with normal UGI and EGD probability is less than 5% for achalasia.

PREDICTOR OR 95% CI ASQ > 40* 11.3 3.1–41.3 EGD-dilated esoph* 17.1 4.3–67.2 EGD-retained food* 12.6 3.2–49.1 EGD-tight GEJ* 7.3 2.4–22.3 ABSTRACTS

EGD-any abnorm.* 8.3 2.8–24.5 POSTER UGI-contrast hold-up* 10.8 2.8–40.2 UGI-dilated esoph.* 17.2 3.9–74.5 UGI-any abnorm.* 27.1 5.0–144.5

CONCLUSIONS: Achalasia can be accurately predicted in patients with functional dysphagia based on clinical, endoscopic, and radiographic ﬁndings allowing for a prioritization of esophageal motility.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1441 Results of Conventional Heller Myotomy in Patients with Achalasia: A Prospective 20-Year Analysis Ines Gockel1, Theodor Junginger1, Volker F. Eckardt2; 1Department of General and Abdominal Surgery, Johannes Gutenberg University of Mainz, Mainz, Germany; 2Department of Gastroenterology, German Diagnostic Clinic, Wiesbaden, Germany BACKGROUND: Heller myotomy has recently proved to be an efficient primary therapy in patients with achalasia, especially in younger patients (<40 years of age). The results of laparoscopic myotomy cannot be finally assessed—on account of the shorter postoperative follow-up. The aim of our study was a 20-year analysis of the conventional cardiomyotomy as a standard for minimal-invasive surgery. PATIENTS AND METHODS: Within 20 years (Sept. 1985–Sept. 2005), 161 operations for achalasia were performed in our clinic. Enrolled in this study were 108 patients with a conventional, transabdominal Heller myotomy in combination with an anterior semifundoplication (Dor procedure) and a median follow-up of 6 months. All patients were prospectively followed and besides radiological and manometrical examinations of the esophagus, the patients were asked for their clinical symptoms by structured interviews in two-year intervals. RESULTS: The median age at the time of surgery was 44.5 (14–78) years, 72.2% of the patients were males. The median length of the preoperative symptoms was 3 years (3 months–50 years), the postoperative follow-up was 55 (6–206) months. In 70 (64.8%) patients, a pneumatic dilation had been performed. The preoperative Eckardt score of 6 (2–12) could be reduced to 1 (0–4) after Heller myotomy (p < 0.0001). Consequently, with 97.2% of all patients a good to excellent result was achieved in the long-term follow-up, corresponding to a clinical stage I-II. Postoperatively, 69 patients (63.9%) gained weight. The radiologically measured maximum diameter of the esophagus decreased from preoperatively 45 (20–75) to postoperatively 30 (20–60) mm, while the minimum diameter of the cardia increased from 3.4 (1–10) mm to 10 (5–15) mm. The resting pressure of the lower esophageal sphincter could be reduced from 28.4 (9.4–56.0) mmHg to 8.6 (3.0–22.5) mmHg. CONCLUSION: Conventional Heller myotomy leads in the long-run with high efficiency to an improvement of the symptoms evident in achalasia. These results are to be regarded as standard for the assessment of the minimal-invasive procedure.

234 SSAT.book Page 235 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1442 Skip Metastasis in Oesophageal Carcinoma: Incidence and Prognostic Value Stephanie J. Gros1, Dean Bogoevski1, Florian Onken1, Bjoern C. Link1, Michale Bubenheim2, Lars Wolfram1, Uta Reichelt3, Oliver Mann1, Philipp Busch1, Emre F. Yekebas1, Jakob R. Izbicki1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute for Medical Biometry and Epidemiology, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 3Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany OBJECTIVE: Although studies on lymphatic spread of oesophageal carcinoma have been previously conducted, the impact of skip metastases on prognosis still remains to be defined. BACKGROUND: Skip metastases which have been well described in non- small cell lung carcinoma are reported to be associated with a more favour- able postoperative prognosis in this tumor entity. METHODS: Between 1992 and 2004, 368 patients were operated on due to adenocarcinoma or squamous cell carcinoma (SCC) of the oesophagus. Lymph nodes were mapped and grouped according to their location. The influence of continuous or discontinuous (“skipping”) lymph node spread on overall survival in pN1 disease (n = 150) was evaluated. Histological type and operative approach were included in the analysis. RESULTS: Positive continuous lymph nodes were identified in 76.7% (n = 115) of patients. Skip metastases were found in 23.3% (n = 35). In SCC, 34.2% (n = 25) of patients had discontinuous lymph node spreading, whereas the incidence of skipping in adenocarcinoma was 12.5% (n = 10). Overall, significant differences regarding survival were not identified between continuous and discontinuous lymphatic spread in adenocarcinoma and SCC. Neither a significant influence of surgical approach (transhiatal vs. thoracoabdominal) was found. Further sub-analysis showed that skip metastases in early T stages (pT1 and pT2) were associated with significantly better survival compared to patients with non-skip metastases (p = 0.0399). CONCLUSION: The results overall showed an unpredictable lymphatic metastatic spreading pattern that is inconsistent with the sentinel node concept. However, better survival was recorded in patients with skip metastases in early pT1/2 oesophageal carcinoma as compared to continuous lymph node spread. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1443 Overexpression in KI67 Proliferative Activity Could Be Associated with P53 Molecular Changes in GERD – Metaplasia – Adenocarcinoma Sequence Marcelo Binato1, Renato Fagundes1, Maria I. Edelweiss2, Luise Meurer2, Richard R. Gurski2; 1Cirurgia, UFSM, Santa Maria, Brazil; 2Cirurgia, UFRGS, Porto Alegre, Brazil BACKGROUND AND AIMS: Gastroesophageal reﬂux disease (GERD) is a common disorder and could be a risk factor for esophageal cancer. Many molecular changes occur in esophageal carcinogenesis; however, the exact molecular pathway in development of adenocarcinoma is unknown. Our aim is to evaluate prevalence of two potential biomarkers (p53 and ki67) in the multistep carcinogenesis process in patients with GERD. METHODS: We investigated 203 patients with GERD analyzing the immunoexpression of p53 and ki67 (MIB-1) in biopsy specimens obtained by endoscopy, from patients with normal esophageal mucosa, esophagitis, columnar epithelium in distal esophagus and adenocarcinoma. The patients were distributed into four groups according to the histological diagnosis: Group 1: normal squamous epithelium (60), Group 2: chronic oesophagitis (83), Group 3: columnar epithelium in distal esophagus (with or without intestinal metaplasia) (45), Group 4: adenocarcinoma (15). RESULTS: p53 immunoexpression was present in 11.6% in G1, 38.5% in G2, 51% in G3 and 53.3% in G4 (p < 0.01%). The rate of Ki67 immunoexpression also increased according with the severity of the histological diagnosis, G1 = 21.1%, G2 = 39.4%, G3 47.8%, G4 = 63.7% (p < 0.001). We observed an association between the severity of histological alterations and the likelihood of ki67 and p53 expression. We observed a linear progressive correlation from normal squamous epithelium to adenocarcinoma of both biomarkers (p < 0.05–ANOVA and Chi-square for trend). CONCLUSIONS: p53 and ki67 expression may be one of the useful biomarkers for assessing the risk of progression to esophageal cancer in patients with GERD. Proliferative alterations measured by Ki67 (MIB-1) could be associated with molecular changes assessed by p53.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1444 Esophagectomy After Cardiac Surgery Karen Harrison-Phipps, Stephen D. Cassivi, Mark S. Allen, Frank C. Nichols, Peter C. Pairolero, Claude Deschamps; General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN BACKGROUND: Since esophagectomy can incur significant mortality and morbidity, past medical and surgical history should be factored into the risk/ benefit analysis. However, no data exists to quantify risk due to cardiac surgery prior to esophagectomy. METHODS: We retrospectively reviewed all patients at our institution (1984–2004) who underwent esophagectomy after cardiac surgery. RESULTS: There were 27 patients (26 men). Median age was 68 years (range, 50–81). Median follow-up was 41 months (range, 2–123). The median interval from sternotomy to esophagectomy was 54 months (range, 1 week–8.9 years). Prior cardiac surgical procedures included 22 coronary revasculariza- tions (3 with concomitant valve procedure) and 5 valve procedures. Signifi- cant peripheral vascular disease was present in 7 patients (26%). Indications for esophagectomy included carcinoma in 26 and benign perforation in 1. Esophagectomy approach included 20 Ivor Lewis, 5 transhiatal and 2 thoraco-abdominal resections. Operative mortality was nil and no perioperative coronary events occurred. Complications included anastomotic leak in 3 patients (11%) including gastric conduit necrosis in 1 (4%), atrial fibrillation in 5 (19%), wound dehiscence in 2 (7%), pneumonia in 2 (7%), and temporary vocal cord paralysis in 1 (4%). Clinically significant strictures requiring dilatation occurred in 11 patients (41%). Overall 5-year survival was 61% (95% confidence interval (CI): 45–84%). Five-year survival in patients who had a CABG was 58% (95% CI: 40-83%) and 80% (95% CI: 52–100%) in patients who had only a valve procedure (p = 0.53). Two-year survival in patients with early stage esophageal cancer (high grade dysplasia or stages 1 or 2) was 90% (95% CI: 77–100%) and significantly higher than the 50% (95% CI: 25–100%) in patients with advanced stage (stage 3 or 4; p = 0.0001). CONCLUSIONS: Esophagectomy after cardiac surgery is not associated with either increased operative mortality or postoperative coronary events. Although previous cardiac surgery may indicate increased risk for peripheral vascular disease, few postoperative complications attributable to peripheral vasculopathy were encountered. Patients should not be denied esophagectomy based solely on prior cardiac surgery. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1446 Primary Versus Secondary Esophageal Motility Disorders: Diagnosis and Implications for Treatment Fernando A. Herbella, Ian Nipomnick, Pietro Tedesco, Marco G. Patti; Department of Surgery, University of California, San Francisco, San Francisco, CA BACKGROUND: In untreated patients with a manometric pattern of either diffuse esophageal spasm (DES) or nutcracker esophagus (NE), the findings of a pH monitoring study are essential as the disease is considered a primary motility disorder (PEMD) only in the absence of reflux (GERD). If reflux is present, the motility abnormality is considered secondary and treatment is directed towards reflux. AIMS: To determine in patient with a manometric picture of DES and NE: (a) if symptoms alone distinguish PEMD from GERD; and (b) the value of ambulatory pH monitoring. PATIENTS AND METHODS: Ambulatory pH monitoring identified GERD in: (1) 124/180 patients (69%) with a manometric picture of NE: 31/56 patients (55%) with a primary disorder were thought to have GERD, and were taking proton pump inhibitors; (2) 73/121 patients (60%) patients with a manometric picture of DES: 39/48 patients (81%) with a primary disorder were thought to have GERD, and were taking proton pump inhibitors. RESULTS: See table for results.

NE DES PEMD (n = 56) GERD (n = 124) PEMD (n = 48) GERD (n = 73) Age (years) 52 ± 14 56 ± 12 51 ± 12 50 ± 14 Dysphagia (% patients) 21 11 34* 8* Dysphagia score (1–4) 3.4 3.3 3.6 3.5 Chest pain (% patients) 911126 Chest pain score (1–4) 3.8* 3.2* 3.0 3.4 Heartburn (% patients) 23* 39* 21 26 Heartburn score (1–4) 3.5* 3.6* 3.0 3.8

*statistical significant (p < 0.05)

CONCLUSIONS: These data show that: (a) 2/3 of patients with a manometric picture of NE or DES have GERD; and (b) symptoms did not allow to distinguish PEMD from GERD; and (c) 68% of patients with PEMD had been treated for GERD. Esophageal manometry and pH monitoring are essential to distinguish PEMD from GERD and to guide appropriate therapy.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1447 Combined Transabdominal Gastroplasty and Fundoplication for Short Esophagus: Impact on Reflux-Related and Overall Quality of Life Scott G. Houghton1, Claude Deschamps1, Stephen D. Cassivi1, Mark S. Allen1, Francis C. Nichols1, Sunni A. Barnes2, Peter C. Pairolero1; 1Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN; 2Department of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN BACKGROUND: Transabdominal gastroplasty is used to lengthen the esophagus during hiatal hernia repair and establishes an acid-secreting neoesopha- gus above the fundoplication resulting potentially in less effective control of reflux symptoms and impaired quality of life (QOL). Little is known about its effect on QOL. AIM: To determine the effect of transabdominal gastroplasty on overall and reflux-related QOL. HYPOTHESIS: Transabdominal gastroplasty impairs QOL as compared to matched controls. METHODS: Retrospective matched cohort study comparing 116 consecutive patients who had transabdominal gastroplasty and fundoplication for a short esophagus to 116 matched control patients who had transabdominal fundoplication alone between January 1997 and June 2005. Overall and reflux- related QOL were evaluated with Short Form-36 (SF-36) and Quality Of Life in Reflux and Dyspepsia (QOLRAD) instruments. Overall survey response rates were 72% in the gastroplasty group and 70% in the control group. Altogether 58 matched pairs returned both the gastroplasty and control surveys. Long- term follow-up and QOL were compared for the 58 matched pairs. RESULTS: The groups did not differ by age, sex, operative approach, hospital stay, or complications (p > 0.05). Gastroplasty patients had larger hiatal hernias (6 vs. 3 cm) and higher body mass index (BMI) (29 vs. 28 kg/m2), and were more likely to have had a previous fundoplication (14% vs. 4%) (p < 0.05). There were no perioperative deaths in either group. Major morbidity occurred in 18% of both groups. Survey respondents were older than non-respondents (p < 0.05). Complications did not impact response rates (p > 0.05). Median follow-up in the gastroplasty group was 18 months (range, 2 to 72) and 26 months (range, 3 to 79) (p = 0.02) in controls. No difference was observed in the 58 matched pairs regarding the 8 domain and 2 composite scores of the ABSTRACTS

SF-36 and the 5 domain scores of the QOLRAD (p > 0.05). The overall fre- POSTER quency of patient satisfaction, perceived health status, and self reported symptoms of reﬂux, dysphagia, bloating, diarrhea, and belching also did not differ between the groups (p > 0.05 for all). Control patients, however, were more likely to require additional hospitalizations/interventions (p < 0.05). CONCLUSION: Transabdominal gastroplasty and fundoplication for shortened esophagus results in similar long term QOL compared to patients undergoing fundoplication alone.

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M1448 A Four-Point Multidisciplinary Hospital-Wide Strategy of Preemptive Aspiration Precautions to Prevent Pneumonia and Mortality After Esophagectomy Tracey Weigel1,2, Anna R. Ibele1,2, Joanna Hwang4, Joanne Robbins3; 1Thoracic Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI; 2General Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI; 3Geriatric Research Education and Clinical Center, William S. Middleton Vetrans Hospital, Madison, WI; 4Otolaryngology, University of Wisconsin Hospitals and Clinics, Madison, WI INTRODUCTION: Surgical resection offers the highest survival rate for patients with esophageal cancer. However, esophagectomy is associated with high morbidity and mortality rates. The risk of aspiration and subsequent pneumonia is as high as 30% in recent large esophagectomy series and is associated with up to 20% mortality. METHODS: A four-point, multidisciplinary, hospital-wide strategy of preemptive aspiration precautions is practiced at our institution which includes: preoperative instructions to the patient and family that the patient is not to lie flat post-operatively for any reason (including radiology studies such as CT scans), a “HOB up 90 degrees at all times” sign over patients hospital ICU and floor bed, timely removal of the NG tube on POD #2, and fluorocoscopic swallow evaluation with esophogram performed by otolaryngology speech/ swallow service in conjunction with radiology on POD #5–7. A retrospective review of prospectively collected data was conducted on all esophagectomies performed 7/15/02–11/15/04. RESULTS: Sixty-two esophagectomies were performed with 0% perioperative mortality and a medium length of stay of 9 days. The incidence of major complications was 33.9% including anastomotic leak 14.5%, reintubation 4.8%, chylothorax 4.8% PE 3.2% and pneumonia 3.2%. CONCLUSIONS: A hospital wide, multidisciplinary strategy directed at implementing preemptive aspiration precautions and careful post-operative swallowing assessment by specialized swallowing service results in a low incidence of pneumonia and mortality among patients after esophagectomy.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1449 Clinical Significance of SUMO-1 in Esophageal Squamous Cell Carcinoma Yoshio Ishibashi1, Yutaka Suzuki1, Hideyuki Kashiwagi1, Nobuyoshi Hanyu1, Koji Nakada1, Nobuo Omura1, Naruo Kawasaki1, Koji Takada2, Mitsuyoshi Urashima3, Katsuhiko Yanaga1; 1Surgery, Jikei University Shool of Medicine, Tokyo, Japan; 2Biochemistry, Jikei University School of Medicine, Tokyo, Japan; 3Division of Clinical Research and Development, Jikei University School of Medicine, Tokyo, Japan PURPOSE: SUMO-1 (small ubiquitin-related modifier-1) is a novel ubiquitin- like protein that is conjugated like ubiquitin, by a set of enzymes to cellular regulatory proteins including oncogenes and tumor suppressor genes. In this study, we aimed to investigate the significance of SUMO-1 expressions in cancerous esophageal lesions as a prognostic factor. METHOD: Tissue samples from 101 patients with esophageal squamous cell carcinoma were stained with anti-SUMO-1 antibody for immunohistochemical analysis. Using oligonucleotide microarrays, we analysed total RNA expression levels of ubiquitin-related genes in paired cancerous and normal tissue operative specimens in 12 patients. Immunoblot analysis of the paired cancerous and normal tissue samples were examined using an anti-SUMO-1 antibody. RESULT: SUMO-1 overexpression in cancerous tissues was related to lymphatic vessel invasion (p < 0.001). Hierarchical clustering analysis using gene expression ratios (cancer/normal) divided the 12 patients into two groups. The expression of SUMO-1 was up-regulated in the poor prognostic cluster. Various bands of proteins conjugated with SUMO-1 were present in both cancerous and normal tissues. In esophageal squamous cell carcinoma, some peculiar bands which were absent in the normal tissue were recognized. CONCLUSION: In esophageal squamous cell carcinoma, overexpression of SUMO-1 correlated with lymphatic vessel invasion and a poor prognosis. SUMO-1 conjugation may important in the course of tumorigenesis. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1450 Incidence and Determinants of Surgery for Gastroesophageal Reflux Disease in Ontario, Canada Steven R. Lopushinsky, David R. Urbach; University of Toronto, Toronto, ON, Canada INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common disorder that is associated with significant patient morbidity and health care utilization. There is a paucity of population-based data on the determinants of surgical therapy in patients with GERD. The role of surgery in the treatment of reflux disease remains controversial. Our objectives were to determine the incidence of surgery in a cohort of patients with GERD and to identify factors associated with its use. METHODS: A retrospective inception cohort of patients with GERD was created using administrative data in Ontario, Canada. An index event was defined by the first combination of an upper gastrointestinal endoscopy and an associated GERD-related diagnosis code between the fiscal years 1991 and 1994. Exclusion criteria included age less than 18 years, regions without physician-billing data, and a history of cancer. Follow-up data were collected to the fiscal-year ending 2004. The incidence rate of surgery was defined as the number of overall procedures in the numerator and patient years of follow up in the denominator. Comorbidity was measured using the Charlson score. Univariate and multiple logistic regression models were developed to examine the determinants of surgery. Odds ratios and 95% confidence intervals are presented. RESULTS: We identified a cohort of 43,992 patients who underwent an upper GI endoscopy and were assigned a diagnosis of GERD during the fiscal years 1991–1994, of whom 1,878 (4.3%) subsequently underwent an antireflux procedure. The incidence of surgery was 43 procedures per 10,000 patient years of follow up. Patient age (p < 0.0001), Charlson co-morbidity score (p < 0.0001), esophageal ulcer (p = 0.05), esophageal stricture (p = 0.04), and income quintile in neighborhood of residence (p = 0.003) were found to be univariate predictors of surgery. In multivariable models, patient age (OR 0.97, 0.97–0.98), Charlson scores of 0 (OR 3.19, 1.80–5.66) or 1 (OR 2.26, 1.24–4.11), and the presence of an esophageal ulcer (OR 1.91, 1.17–3.12) were significantly associated with the use of surgery. Patient gender and income quintile were not associated with surgical intervention. CONCLUSIONS: We estimated the population-based incidence of antireflux surgery for a cohort of patients with GERD in Ontario, Canada. Patient age, co-morbidity and complicated esophageal disease appear to be important factors in the decision to proceed with surgery. Further investigation of healthcare delivery factors, such as the availability of specialist care, in determining the use of surgery for GERD may further explain variation in the use of antireflux surgery.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1451 Patterns of Reflux After Successful Nissen Fundoplication Renee C. Minjarez, Eugene Y. Chang, Charles Y. Kim, John G. Hunter, Blair A. Jobe; Department of Surgery, Oregon Health and Science University, Portland, OR BACKGROUND: Nissen fundoplication (NF) is thought to provide a mechanical barrier to all forms of reflux, irrespective of pH content. It is this anatomic barrier which is hypothesized to prevent ongoing esophageal injury and progression along the metaplasia-dysplasia-carcinoma sequence. Com- bined 24-hour pH-impedance is the most sensitive means by which to detect the proximity, content, duration, and pH of reflux events; while reflux patterns have been well-characterized in normal, non-GERD subjects, they have never been examined in patients who have undergone successful NF. We hypothesize that NF creates a barrier to reflux which is more effective than the native barrier in normal subjects. METHODS: Satisfied patients who have undergone NF for documented GERD were evaluated with manometry, upper endoscopy, and validated symptom-based questionnaires. Those who had a normal LESP and were completely free of esophagitis, GERD-related symptoms, and fundoplication- related side-effects underwent 24-hour pH-impedance. A normal DeMeester score was required for inclusion in the final analysis. Impedance patterns of reflux were then characterized. RESULTS: Ten patients (mean age 57 yrs) were studied at a mean follow-up of 33 months postoperatively. A total of 299 reflux events were detected, of which 41.8% were acid, 38.8% non-acid, 16% weakly acid, and 3.3% acid re- reflux. Two-thirds of all events were liquid, and the remainder were mixed liquid and gas. Of all reflux events, 48.2% occurred within one hour after meals; of these, 51% were acidic events. Twenty-five percent of reflux events reached 15 cm above the LES. Mean bolus clearance time was 17 seconds (range, 13.6–23.15). Most reflux events (81%) occurred in the upright position. The table shows the median number of reflux events per patient and interquartile range (IQR).

Table 1. Median Number of Reflux Events per 24 Hours per Patient

All Reflux Acid Reflux Non-Acid Reflux Weakly Acid Reflux Acid Re-Reflux All positions 13.5 (6.25, 41.5) 1 (0, 11) 9.5 (6.25, 14) 0.5 (0, 4.5) 0 (0, 1.5)

Upright 8.5 (5.25, 33.75) 0.5 (0, 9.5) 6 (4.25, 11.75) 0 (0, 1.75) 0 (0, 1.5) ABSTRACTS Supine 3.5 (1.25, 8) 0 (0, 1) 2 (0.25,5.5) 0.5 (0, 1.75) 0 (0,0) POSTER

CONCLUSION: Compared with previously published data in healthy subjects which showed a median of 44 reflux events per patient, asymptomatic post-NF patients have fewer reflux events. A substantial proportion of reflux events after NF are non-acidic and would not be detected with pH monitoring alone. A properly performed NF allows physiologic postprandial reflux and, as suggested by the lack of acid re-reflux, does not hinder esophageal clearance. These findings establish the normal reflux profile of a properly performed NF.

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M1453 Preliminary Experience by a Thoracic Service with Endoscopic Trans-Oral Stapling of Cervical (Zenker’s) Diverticulum Christopher R. Morse1, Hiran C. Fernando2, Peter F. Ferson3, Rodney J. Landreneau3, Miguel F. Alvelo-Rivera3, James D. Luketich3; 1Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA; 2Division of Cardiothoracic Surgery, Boston Medical Center, Boston, MA; 3Division of Thoracic & Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA OBJECTIVES: Recently endoscopic transoral stapling (ES) of cervical (Zenker’s) diverticulum (ZD) has been reported. This abstract describes our experience with ES and compares results to our open surgical(OS) repairs for ZD. METHODS: A retrospective 10 year review identified 47 patients undergoing ES or OS for ZD. ES was attempted in 28 patients and OS in 19. The only absolute requirement for ES was a ZD of at least 3cm. ES was performed transorally using a Weerdascope (extended laryngoscopy) to identify the septum between the esophagus and diverticulum. An Endostitch placed in the septum provided cephalad traction during division by a transorally placed Endo-GIA stapler. OS included myotomy alone (n = 1), myotomy with diverticulopexy (n = 14), or myotomy with diverticulectomy (n = 4). Outcomes examined included operative time, length of stay and dysphagia severity using a scale from 1 (no dysphagia) to 5 (severe dysphagia). RESULTS: There were 28 (59.6%) males and 19 (40%) females. ES was completed in 24/28. There were 4 conversions to OS. These 4 patients were excluded from further analysis and comparison made between the 24 successful ES and the 19 OS patients. The mean age was 76 years for the ES group and 70 years for the OS group (p = 0.027). There were no deaths and only one complication in each group. Mean operative time (1.2 versus 2.4 hours.) was less (p < 0.01) in the ES group. Length of stay (1.8 versus 2.4 days) was shorter for ES but not significant (P = 0.13). Mean follow up was 17 (1–103) months for both groups. Dysphagia scores were comparable between the two groups preoperatively (2.71 ES versus 2.79 OS; p = 0.78) and improved significantly (p = 0.001) to 1.1 after ES and 1.0 after OS. The time to oral intake was 1.09 days in the ES group and 1.29 days in the OS group (p = 0.36). CONCLUSION: ES is feasible and can be performed with shorter operative times and comparable results to OS.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1454 Outcome of Survival Following Surgery for Oesophago- Gastric Cancer Does Not Depend on Pre-Operative Chemotherapy Alone Dhiren Nehra, Sarah Wemyss; Upper GI Surgery, Epsom & St. Helier University Hospital, Carshalton, United Kingdom AIM: Recent Medical Research Council trials in UK have shown significantly improved disease free survival for patients receiving preoperative chemotherapy for oesophageal and gastric cancer, albeit only by a few months. The aim of the study was to study in isolation other factors affecting survival in consecutive patients undergoing surgery irrespective whether they were recruited to participate in the trial. METHODS: Between April 1999 and Dec 2003 a total of 56 patients diagnosed to have operable gastric (n = 33) and oesophageal adenocarcinoma (n = 23) after staging (endoscopy, thin slice spiral CT, endoluminal ultrasonography, staging laparoscopy) underwent radical resection with extended lymphadenectomy. 29 patients were randomised to receive neoadjuvant chemotherapy (3 cycles of epirubicin, cisplatin, 5FU pre- and post-operative for gastric cancer and 2 cycles of cisplatin, 5FU preoperative for oesophageal cancers. Fol- low-up was based on clinical progress and investigations only in suspected recurrence or patients with progressive weight loss. RESULTS: There was 0% 30 day post-operative mortality. One patient died on day 48 from cachexia due to advanced disease. The mean survival for chemotherapy + surgery (CS) group was significantly longer 27 months versus 17 months for surgery (S) alone group(p = 0.005). There was no difference in the overall survival. The most important prognostic factor in the survival outcome was the T staging. 14/21 patients with early stage (T1/2 N0) cancer were long term survivors and disease free at median follow-up of 3 years. 28 patients presented with more advanced stage (T3N0/1) with only nine surviving and there was no difference between the 2 groups. 7 patients were under- staged and had pathological T4 lesions resulting in poor outcome (Median survival 6 months). 9/29 patients tumour were deemed downsized by the chemotherapy but this did not translate into improved survival. CONCLUSION: Neoadjuvant chemotherapy improves progressive disease free survival but this benefit is offset by the prolonged duration of chemotherapy administration and slower recovery from surgery. Accrual of patients for trials has been based on preoperative staging which has its inherent problems with accuracy. The authors believe that pre-operative chemotherapy ABSTRACTS

may improve survival outcome in patients with low volume tumours. POSTER

Alive (3 years) Died T1/2N0 T3N0/1 T1/2N0 T3N0/1 T4N1/2 Chemo+Surgery n = 29 7 4 5 10 3 Surgery alone n = 27 7 5 2 9 4 Total n = 56 14 9 7 19 7

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M1456 Evaluation of the Gastric Tube Viability After Esophagectomy by Its Diameter Using Thermal Imaging Katsunori Nishikawa, Yuujirou Tanaka, Tetsuya Yamagata, Hideki Matsudaira, Hideyuki Suzuki, Ryouji Mizuno, Nobuyoshi Hanyuu, Shuuichi Iwabuchi; Surgery, Machida Municipal Hospital, Machida-shi, Japan PURPOSE: The stomach is used as a substitute for the esophagus after esophagectomy because of its abundant blood supply and its favorable elasticity. However poor vascularization of proximal region of the gastric tube can be impaired, leading to anastomotic leakage or gastric tube ischemia. It is still controversial whether difference of the gastric tube vascularization depends on its diameter. The purpose of this study is to compare the gastric tube viability between a narrow and a wide gastric tube by using thermal image. METHODS: Twelve patients who underwent esophagectomy and esophagogastric anastomosis between January 2004 and October 2005 were randomly allocated to either reconstruction using a narrow gastric tube (n = 6, diameter: 3.0–3.5 cm) or using a wide gastric tube (n = 6, diameter: 4.5–5.5 cm). Surface temperature of the gastric tube and the devascularized stomach were measured as its viability by thermal imaging system from the proximal end to the pylorus. Correlations between the type of gastric tube and postoperative complications such as leakage and anastomotic stricture were examined. RESULTS: Mean surface temperature at the proximal region of the narrow gastric tube and wide gastric tube were 26.6 degrees C and 28.8 degrees C, respectively (p < 0.05). Mean decline rate of surface temperature at the proximal region of a narrow gastric tube and a wide gastric tube compared to the devascularized stomach were 14.2% and 7.9%, respectively (p < 0.01). On the contrary, there was no signiﬁcant difference in the mean surface temperature and decline rate between the types of gastric tubes. None of patients developed anastomotic leakage, however, 4 of 6 patients with a narrow gastric tube had an anastomotic stricture as compared to 0 of 6 patients with a wide gastric tube. CONCLUSION: Our preliminary results suggest that thermal camera is non- invasive with high reproducibility in detecting gastric viability after devascu- larization or gastric tube construction. Although there was no difference in anastomotic leakage, a wide gastric tube seems to have higher viability than a narrow gastric tube, which may lead to a better anastomotic healing. Practical application of thermal imaging systems for routine intraoperative determination of the gastric tube viability may be anticipated.

246 SSAT.book Page 247 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1457 Clinical Failure of Laparoscopic Nissen Fundoplication: Relationship to Anatomic and Functional Findings Marco Aurelio, Cedric G. Bremner, Daniel S. Oh, Christy M. Dunst, Jeffrey A. Hagen, Steven R. Demeester, John C. Lipham, Tom R. Demeester; Surgery, University of Southern California, Los Angeles, CA BACKGROUND: Failure of antireflux surgery has been difficult to define and usually consists of reports on reoperations. An alternative approach is to con- sider any dissatisfied patient as a failure as opposed to only those with a cor- rectable functional or anatomic abnormality. This is a more realistic evaluation of the success of antireflux surgery. We hypothesize that failure of laparoscopic Nissen (LN) is more common if patient dissatisfaction, rather than need for reoperation, is used as a marker. METHODS: 667 patients had primary LN between 1995-2003. Preop evaluation included video esophagram, endoscopy, manometry and pH testing. Clinical failure was a dissatisfied patient for any reason. Patients who failed were evaluated for functional and/or anatomic abnormalities. Known preop predictors for failure (atypical symptoms, poor response to PPIs, normal pH score, non-reducible hernia, long segment Barrett’s, stricture) were recorded. RESULTS: 42 patients (6%) were dissatisfied with the results of LN and were classified as clinical failures. This occurred between 6–76 months postoperatively. 11 patients (26%) were anatomically and functionally normal, including normal acid exposure. A predictive factor for failure was present in 5/11 (45%), the most common being atypical symptoms and poor response to PPIs (4/5). None had re-operation. 12 patients (29%) were anatomically normal but functionally abnormal. All had normal acid exposure. A predictive factor for failure was present in 10/12 (83%): 7 had atypical symptoms and 3 had typical symptoms but normal acid exposure. Re-operation was performed in 1 patient. 19 patients (45%) had anatomic abnormalities (18 recurrent hernia and/or 7 altered Nissen). Patients with anatomic abnormalities presented later than those without (22 vs. 13 months, p = 0.01). A predictive factor for failure was present in 17/19 (89%), the most common was a preop non-reducible hiatal hernia (12/17). Thirteen had postop pH monitoring and abnormal acid exposure was present in 7 (54%). Fifteen had postop manometry and it was abnormal in 8 (53%). Three patients with anatomic abnormalities were functionally normal. Re-operation was performed in 13 patients (12 for recurrent hernia and 1 for a slipped Nissen). CONCLUSION: Overall failure of LN is 6% and no anatomical or functional ABSTRACTS

abnormality was observed in 26%. These patients commonly have atypical POSTER preoperative symptoms questioning the correct diagnosis. Patients with an anatomic abnormality commonly have a functional abnormality and most require reoperation. The majority of these patients have a non-reducible hernia prior to the initial operation suggesting esophageal shortening.

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M1458 Predictors of Anatomic Recurrence After Paraesophageal Hernia Repair: The Importance of the Learning Curve Allan Okrainec, Lorenzo S. Ferri, Liane S. Feldman, Gerald F. Fried; Steinberg-Bernstein Centre for Minimally Invasive Surgery, Mcgill University, Montreal, QC, Canada INTRODUCTION: There are numerous reports in the literature document- ing high recurrence rates after laparoscopic paraesophageal hernia repair (LPEHR). The purpose of this study was to identify factors predictive of recurrence in patients undergoing LPEHR. METHODS: 44 consecutive patients (14M:30F) with paraesophageal hernia were evaluated prospectively before and after LPEHR performed by a single sugeon between 1997 and 2005. (All repairs were done without prosthetic mesh or esophageal lengthening). UGI was performed 3 mo post-op to look for recurrence, defined as any fundus above the diaphragm. Clinical, operative, and post-operative data were analyzed for predictors of recurrence. T-test or chi-square determined significance (p < 0.05). RESULTS: Post-op UGI was available in 42 patients (93%). Anatomic recurrence occurred in 8 patients (19%). Age, gender, symptoms, BMI, ASA, type of PEH, operative time, blood loss, or length of stay were not predictive of recurrence. When patients were stratified based on early (first 20 cases) vs late experience, there was a significantly higher recurrence rate during the first 20 cases (33% vs 8%, p = .04). The cumulutive sum (CUSUM) method was used to analyze the learning curve (Fig). CUSUM analysis showed that the learning curve was 26 cases before we were achieving an acceptable recurrence rate, (<20%) with 95% probability.

CONCLUSIONS: Surgeon experience is the most signiﬁcant predictor of recurrence after LPEHR. CUSUM analysis revealed that the recurrence rate diminishes after 20 cases (point A) and reaches an acceptable rate after 26 cases (point B).

248 SSAT.book Page 249 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1459 48-Hour pH Monitoring Increases Risk of False Positive Studies When the Capsule Is Passed Victor Bochkarev, Chad D. Ringley, Michelle Vitamvas, Dmitry Oleynikov; Surgery, UNMC, Omaha, NE Ambulatory wireless 48-hour esophageal pH monitoring (Bravo Medtronic, Shoreview, MN) has been shown to be more sensitive in detecting abnormal esophageal acid exposure compared with trans-nasal 24-hour pH probes. However, accurate interpretation of the wireless monitoring data is para- mount when contemplating surgical intervention for those with gastroesophageal reflux disease. The aim of this study is to evaluate the incidence of false positive interpretations of this wireless data secondary to premature transit of the Bravo probe into the stomach and subsequently into the duodenum prior to the completion of the 48-hour study period. We reviewed 100 consecutive Bravo pH studies at our University Esophageal Motility. There were 58 women and 42 men included in our evaluation. Premature transit of the Bravo probe into the stomach and subsequently into the small bowel was defined by a prolonged gastric pH phase with either evidence of alkaliniza- tion and no further reflux episodes or loss of communication with the Bravo capsule prior to the end of the 48 hour data collection period. Of the 100 patients reviewed, 11% manifested evidence of early passage of the Bravo probe resulting in misinterpreting the data as abnormal esophageal acid exposure. The mean time of inaccurate data recording after transit of the Bravo capsule was 18 hours and 42 minutes. The mean length of time that the probe was retained in the stomach prior to duodenal passage was 4 hours. If the aforementioned false data was included in the final interpretation of the study it yielded a mean DeMeester score of 44.25 with a mean total time of pH < 4 of 14.7% per case. Exclusion of the prolonged gastric phase from the final interpretation of each case resulted in a statistically significant reduction in the mean total time the pH < 4 (4.33% vs. 14.7%, p < 0.05) and the mean DeMeester score (12.81 vs. 44.25 p < 0.05). The mean time from the initiation of esophageal pH data collection to passage of the Bravo probe into the stomach was 15 hours and 22 minutes. Falsely elevated esophageal acid exposure can be recorded by the computer as a result of early passage of the Bravo probe into the stomach. This observation mandates meticulous inspec- tion of the pH tracing by the interpreting physician throughout the entirety of a 48-hour study in order to identify premature transit of the capsule. Trac- ings that show prolonged acid exposure or loss of communication with the Bravo probe should be screened for its possible early dislodgement and pre-

mature advancement into the stomach. ABSTRACTS POSTER

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M1460 Thoraco-Laparoscopic Esophagectomy for Carcinoma Esophagus Middle Third (Thoracoscopic Mobilization in Prone Position) Chinnuswamy Palaninvelu, Palanisamy Senthilnathan, Ramakrishnan Parthasarathi, Rangswamy Senthilkumar; Department of Surgical gastroenterology & Minimal Access Surgery, GEM Hospital India Pvt Limited, Coimbatore, India OBJECTIVE: To evaluate our outcomes after minimally invasive or thoraco- laparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. METHODS: From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proven squamous cell carcinoma of middle third of the esophagus. Only 1 (0.77%) patient received neo-adjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. RESULTS: There were 102 males and 28 females. Median age was 67.5 years (range, 38–78). There was no conversion to open method. The median intensive care unit stay was 1 day (range, 1–32); hospital stay was 8 days (range, 4–68). The perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury; and no evidence of postoperative pneumonia. At the mean follow-up of 20 months (range, 2–70), stage speciﬁc survival was similar to open as well as other minimally invasive series. CONCLUSIONS: TLE with thoracoscopic part in prone position is technically feasible with low incidence of respiratory complications and requires less operative time. In our experience, we observed a lower mortality rate (1.54%), shorter hospital stay (8 days) and no incidence of postoperative pneumonia.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1461 Should Laparoscopic Heller Myotomy Be Used as Primary Therapy for Achalasia Regardless of Age? Christian G. Peyre, Colleen B. Gaughan, Jeffrey A. Hagen, Brendan J. Boland, Christian Rizzetto, Steven R. Demeester, Cedric G. Bremner, John C. Lipham, Tom R. Demeester; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA INTRODUCTION: Clinical guidelines for the treatment of achalasia encourage surgical myotomy for patients under age 45, based on poor outcome of balloon dilatation of patients in this age group and a perceived higher operative risk in older patients. Despite these guidelines many patients are referred for surgery after a previous balloon dilatation and the comparison of risk from laparoscopic myotomy in the younger and older age groups has not been well documented. The purpose of this study was to evaluate the impact of previous therapy and age on the outcome of laparoscopic myotomy. METHODS: Retrospective chart review of patients who had laparoscopic myotomy with partial fundoplication from 1996 to 2005. Data including symptom evaluation, previous medical therapy, operative data and results of esophageal manometry were recorded. In a subgroup of patients, a timed barium swallow was obtained postoperatively. Success was deﬁned as near or complete resolution of dysphagia and regurgitation. Patients younger than and older than 45 years were compared. RESULTS: Myotomy was performed in 106 patients. There were 62 patients in the ≥45 years group (58 [IQR 51–67]) and 44 in the <45 years group (36 [IQR 29–42]). Duration of symptoms, use of antisecretory medication, and frequency of dysphagia, regurgitation, and heartburn were similar in both groups. 35 patients had previous balloon dilatation, and there was no difference between older and younger patients (35% v 30%, p = 0.54) Findings on manometry (sphincter length, resting pressure, sphincter relaxation, esophageal pressurization, vigorous body contractions) were similar in both groups. The frequency of perioperative complications was similar, but the mean length of hospital stay was longer in older patients (2.9 v 2.2 days, p = 0.005). Relief of regurgitation and dysphagia were similar in both groups (TABLE). The rate of development of heartburn was also similar. A timed barium swallow was performed in 40 patients and there was no difference in emptying between groups. A previous balloon dilatation did not affect outcome of myotomy. Overall phycisian assessment of success was similar in both groups (98% v 91%) and more than half were asymptomatic at followup. ABSTRACTS POSTER <45 years ≥45 years P Value Complete Relief of Dysphagia 33 (77%) 50 (86%) 0.22 Complete Relief of Regurgitation 36 (92%) 51 (94%) 0.68 Development of Heartburn 1 (5%) 4 (12%) 0.36 % Emptying (SD) (Timed Barium Swallow) 74% (38) 73% (36) 0.93

CONCLUSION: Laparoscopic myotomy with partial fundoplication is an effective therapy for achalasia in all patients regardless of age and outcome is not affected by previous pneumatic balloon dilatation.

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M1462 Impedance/pH Monitoring: the Importance of Nonacid Pharyngeal Reflux in Reflux Laryngitis Elina Quiroga1, Nicole Maronian2, Jim Sillery1, Brant Oelschlager1; 1The Swallowing Center Department of Surgery, University of Washington, Seattle, WA; 2Otolaryngology, University of Washington, Seattle, WA HYPOTHESIS: The character (nonacid vs. acid) and proximal extension (esophagus and pharynx) of gastroesophageal reflux episodes is different in patients with reflux-induced laryngitis compared to controls. DESIGN: Prospective study using a new tool, (esophageal Multichannel Intraluminal Impedance (MII)) which detects acid and non-acid reflux episodes, simultaneously with traditional 24-hour pH monitoring. SETTING: University Referral CenterStudy population: 30 consecutive patients with suspected reflux-induced laryngitis. Control Group: 10 asymptomatic volunteers without GERD symptoms. INTERVENTIONS: Simultaneous 24-hour analysis of reflux episodes with a specially designed system which determines impedance and pH measurements in both the esophagus and pharynx of acid and non-acid reflux. Esophageal motility was evaluated with manometry and impedance (esophageal clearance of a swallowed bolus). MAIN OUTCOME MEASUREMENT: Acid and nonacid reflux in the esophagus and pharynx. RESULTS: Table I depicts the % of time pH was below 4 in the distal esophagus as well as the number and character of reflux episodes in the esophagus and pharynx. Table II shows the manometric and % of swallows that had a normal transit (EBT). CONCLUSIONS: Patients with reflux related laryngitis have the same number of episodes of gastroesophageal reflux as controls, but more are non-acid and more reach the pharynx. Impaired esophageal motility may facilitate upward extension of reflux episodes by delaying esophageal clearance.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1463 Age Does Not Affect the Long-Term Outcome of Heller-Dor Operation Christian Rizzetto, Mario Costantini, Giuseppe Portale, Emanuela Guirroli, Martina Ceolin, Loredana Nicoletti, Renato Salvador, Sabrina Rampado, Giovanni Zaninotto; Clinica Chirurgica III, University of Padua, Padova, Italy INTRODUCTION: In recent years, laparoscopic Heller-Dor operation (LapHD) has emerged as the treatment of choice for patients with esophageal achalasia. However, elderly patients are generally switched to less invasive treatments (pneumatic dilations or botulinum toxin injections). Aims & METHODS: The aim of this study was to evaluate the surgical outcome in patients older than 65 years who underwent LapHD as primary treatment for esophageal achalasia. From 1992 to October 2005, we operated 29 patients older than 65 years [18 male/11 female, median age 69 years (range 65–80), Group A]. In the same period, 207 patients younger than 65 years underwent the operation [Group B]. Fifty-one additional patients who underwent surgery after failed endoscopic treatment were excluded from the analysis. All patients underwent a detailed symptom-score questionnaire, barium swallow, endoscopy and esophageal manometry. Surgery was performed by 4 staff surgeons. RESULTS: The median symptoms score and median duration of symptoms was similar in the two groups. Also similar were the functional and radiological findings. A similar frequency of intraoperative complication (i.e. mucosal lesions) was observed in the two groups (1/29 and 6/207), whereas the median operative time was longer in the Group A (172 min [118–280]) compared to group B (150 min [70–280], p < 0.05). Mortality was nil and morbidity was similar in both groups. The median follow-up was 30 months (1–133) in Group A and 49 months (1–131) in Group B; p = n.s. The symptoms score significantly decreased in both groups (from 21 [0–33] to 0 [0–14], p < 0.05, and from 20 [0–33] to 3 [0–26], p < 0.05, in group A and B respectively) even if post-operative symptoms score was lower in Group A patients than in Group B (p < 0.05), together with a lower post-operative LES resting pressure (6 mmHg [2–16] vs 10 mmHg [4–50]; [p < 0.05]). However, the percentage of patients classified as failure and requiring further treatment was similar in both groups (2/29 vs 22/207, p = n.s.). The same applied for patients showing post-operative GERD at pH-monitoring (1/11 in the Group A vs 6/113 in the Group B, p = n.s.). ABSTRACTS

CONCLUSIONS: Ageing does not affect the feasibility and ﬁnal outcome of POSTER LapHD. Surgical myotomy is a safe and effective procedure that signiﬁcantly improves symptoms in all patients, irrespective of age. Older patients seems also to take advantage from the operation better than younger patients. Therefore age should no longer represent contraindication for surgical therapy of achalasia.

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M1464 Esophagectomy for Adenocarcinoma in the Elderly Christian Rizzetto, Cedric Bremner, Jeffrey A. Hagen, Steve R. Demeester, John C. Lipham, Colleen Gaughan, Christian Peyre, Brendan Boland, Daniel Oh, Tom R. Demeester; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA INTRODUCTION: An aging population and a rising incidence of esophageal adenocarcinoma have resulted in more elderly patients being evaluated for esophagectomy. This procedure is associated with signiﬁcant morbidity and mortality and advanced age is often considered a relative contraindication. Our purpose was to compare clinicopathologic characteristics and outcome of esophagectomy in patients 75 years and older with younger patients. METHODS: Records of 420 consecutive patients who had esophagectomy from 1992 to 2005 were reviewed. The extent of operation (en-bloc, transhiatal, staged reconstruction) performed was selected based on age and comorbid conditions. Clinical characteristics, demographic information and outcome were recorded. These were compared between patients <75 years (n = 344) and those ≥ 75 years (n = 76). RESULTS: Demographic information and symptoms at presentation were similar in the 2 groups. Comorbid conditions of hypertension and cardiac disease were more common in the older group. Neoadjuvant therapy was given more common in younger patients. Cardiac complications and deep vein thrombosis were more common in the older group. Length of ICU stay was longer in the older group, however the length of hospital stay was similar in both groups. (Table).

< 75 years (344 patients) ≥ 75 years (76 patients) p Pre-operative comorbid conditions Hypertension 94 (27.3%) 37 (48.7%) 0.0005 Cardiac disease 61 (17.7%) 31 (40.8%) 0.0001 Neoadjuvant therapy 76 (23%) 6 (8%) 0.002 Post-operative complications Surgical complication 122 (35.5%) 26 (34.2%) n.s. Cardiac complication 46 (13.4%) 17 (22.3%) 0.052 Deep venous thrombosis 8 (2.3%) 7 (9.2%) 0.009 Hospital mortality 21 (6.1%) 4 (5.2%) n.s. Length of ICU stay 4 days (IQR 3–7) 4 days (IQR 4–9) n.s. Length of hospital stay 16 days (IQR 12–23) 16 days (IQR 12–25) 0.02

CONCLUSION: Esophagectomy can be performed safely in elderly patients if the extent of operation is modiﬁed based on comorbid conditions. Elderly patients are more likely to have cardiac and vascular complications and require intensive perioperative support, but mortality and hospital stay are not different.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1466 Normal Lower Esophageal Sphincter Function Does Not Impact Outcome After Laparoscopic Nissen Fundoplication Alexander S. Rosemurgy, Sam Al-Saadi, Desiree Villadolid, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL INTRODUCTION: Intuitively, a manometrically normal lower esophageal sphincter (LES) will promote dysphagia after laparoscopic Nissen Fundoplica- tion, without improving reflux. This study was undertaken to compare outcomes after laparoscopic Nissen fundoplication for patients with GERD and normal vs. manometrically inadequate LES. METHODS: Before fundoplication, the length and resting pressure of LES was determined manometrically in 66 patients with GERD. 32 patients had a manometrically normal LES, with resting pressure >10 mmHg and length >2 cm. 34 other patients had resting pressures of ≤10 mmHg and length of ≤2 cm. Patients also underwent a 24-hr ambulatory pH study. Before and after fundoplication, patients graded the frequency and severity of symptoms of GERD utilizing a Likert scale (0 = never/not bothersome to 10 = always/ very bothersome). For each patient, symptom scores before vs. after fundoplication were compared using Wilcoxon matched pairs test. DeMeester scores and symptoms before and after fundoplication were compared between patients using Mann-Whitney U-test. RESULTS: Before fundoplication, the LES function impacted neither the elevation of the DeMeester scores nor the frequency or severity of reflux symptoms (Table). All symptoms improved significantly with fundoplication independent of LES function (Table). Prefundoplication LES function did not impact the frequency or severity of reflux symptoms after fundoplication (Table).

Table 1. Symptoms of Patients Before and After Laparoscopic Nissen Fundoplication

Normal LES (n = 32) Inadequate LES (n = 34) DeMeester Score 38.0 (43.2 ± 30.2) 65.0 (77.6 ± 69.8) Preop 8.0 (5.4 ± 4.0) 4.0 (4.6 ± 3.0) Chest Pain Frequency Postop 2.0 (3.8 ± 3.6) 2.0 (2.2 ± 2.2) Preop 6.0 (6.4 ± 3.2) 6.0 (5.6 ± 3.2) Regurgitation Frequency Postop 0.0 (2.4 ± 3.4) 0.0 (2.0 ± 3.0) Preop 2.0 (3.6 ± 3.6) 4.0 (4.2 ± 4.2) Choking Frequency Postop 0.0 (1.8 ± 3.0) 0.0 (1.4 ± 2.4)

Preop 8.0 (6.8 ± 3.0) 8.0 (8.0 ± 2.8) ABSTRACTS Heartburn Frequency POSTER Postop 2.0 (2.6 ± 3.4) 2.0 (2.4 ± 3.2) Preop 8.0 (6.7 ± 3.4) 9.5 (7.9 ± 3.0) Heartburn Severity Postop 1.0 (2.0 ± 3.0) 1.0 (1.9 ± 2.6) Preop 7.0 (6.2 ± 3.3) 7.0 (6.2 ± 3.3) Regurgitation Severity Postop 1.0 (1.9 ± 2.7) 0.0 (1.2 ± 2.6) Preop 6.0 (5.5 ± 4.0) 5.0 (4.8 ± 3.6) Choking Severity Postop 1.0 (2.4 ± 3.5) 2.0 (2.1 ± 2.1) Preop 3.5 (4.0 ± 4.0) 1.0 (3.0 ± 3.5) Chest Pain Severity Postop 0.0 (1.6 ± 2.6) 1.0 (1.2 ± 1.5)

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CONCLUSIONS: Patients suffering from GERD, normal LES function does not impact the presentation of GERD or the outcome after laparoscopic Nis- sen fundoplication. Symptoms globally and significantly improve after laparoscopic Nissen fundoplication independent of LES function. Normal LES function does not impact outcome after laparoscopic Nissen fundoplication. Laparoscopic Nissen fundoplication should be recommended for patients with GERD independent of LES function. All preop vs postop were significantly different from Wilcoxon matched-pairs test. All preop vs preop and postop vs postop were not significantly different using Mann-Whitney U-test. Data Format Median(Mean ± SD)

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1467 Clinicopathological and Molecular Characterization of Gastroesophageal Junction (GEJ) Adenocarcinoma Before Age of 40 Years Alberto Ruffato1, Laura H. Tang2, Manjit S. Bains1, Robert J. Downey1, Raja Flores1, Bernard J. Park1, Nabil Rizk1, Valerie W. Rusch1, Murray Brennan1, Daniel Coit1, Yuman Fong1, David Jaques1, David Klimstra2; 1Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 2Pathology, Memorial Sloan Kettering Cancer Center, New York, NY; 3Medicine Solid Tumors, Memorial Sloan Kettering Cancer Center, New York, NY GEJ adenocarcinoma occurs most commonly in patients in their 6th–7th decade and is uncommon before age of 40 years. While certain clinical, pathological, and molecular features of GEJ adenocarcinoma in older patients have been extensively studied, they remain to be determined in the younger population. We evaluated 608 patients admitted to surgery for GEJ adenocarcinoma and stratified them into 2 age-groups of <40 and >50 years, respectively. We compared their demographics, tobacco exposure, clinicopathological features, treatment strategies, and prognosis. Fluorescence in situ hybridization (FISH) with selected DNA probes of Y chromosome was investigated in selected male patients with the focus on uninvolved squamous mucosa, intestinal metaplasia, glandular dysplasia, and adenocarcinoma. Probes for centromeres of Y chromosome were hybridized to formalin fixed and paraffin embedded tissue sections and a minimum of 100 cells were enumerated for each histopathologic pattern. The clinical and pathologic characteristics are summarized in Table 1. There was no difference in the surgical techniques applied in the two age groups and most patients underwent Ivor Lewis esophagectomy. The only statistically significant finding was the higher frequency of tobacco smoking in the older patients. Table 2 demonstrates a progressive loss of Y chromosome from benign squamous epithelium to Barrett’s mucosa and dysplasia, and, ultimately, to a nearly complete loss in adenocarcinoma. While there was a trend of more losses of Y chromosome during this pathologic progression in older patients, they did not a reach statistical significance. In conclusion, when compared with the older age-group, young patients with GEJ adenocarcinoma possess similar known clinical and pathologic characteristics. The commonly detected genetic aberration of progressive Y chromosomal loss is also present in the younger patients. Possible additional molecular alterations responsible for the accelerated neoplastic

process in young patients are being investigated. ABSTRACTS POSTER

Table 1.

Neoadjuvant Mean Tobacco Stage Chemo- 3 yr Case # Age M:F Exposure GERD Barrett’s 0&I&IIa radiotherapy DFS 3 yr OS Young 24 33.4 3:1 52.20% 29.10% 37.50% 59.10% 58.30% 58.60% 59.00% Old 584 65.7 4:1 72.10% 34.20% 45.40% 56.30% 48.00% 49.50% 53.00% p value <.001 0.49 0.049 0.61 0.44 0.79 0.32 NS NS

GERD—Gastroesophageal Reflux Disease DFS—Disease Free Survival OS—Overall Survival NS—not significant

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Table 2. Results of FISH for the Detection of Y chromosome Loss

Patient Percentage of Y chromosome loss Case # Group Squamous Mucosa Barrett’s Mucosa Dysplasia Adenocarcinoma Young 12 13.9 ± 7.6 35.2 ± 12.4 70 ± 18.3 90.1 ± 2.19 Old 79 ± 2.62 48.7 ± 15.4 86.6 ± 10.1 92.2 ± 5.74 p Value 0.273 0.249 0.179 0.360

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1468 Increased Formation of Oxidative DNA Damage, 8-Hydroxydeoxyguanosine, in Barrett’s Esophagus, and in Adenocarcinoma of the Esophagus and Esophagogastric Junction Jari V. Rasanen1, Eero I. Sihvo1, Markku O. Ahotupa2, Martti A. Farkkila3, Jarmo A. Salo1; 1Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2Research Laboratory Department of Physiology, University of Turku, Turku, Finland; 3Department of Medicine, Division of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland BACKGROUND AND AIM: The incidence of adenocarcinoma of the esophagus and esophagogastric junction has increased dramatically in many Western countries. An important risk factor, gastroesophageal reflux disease, causes inflammation and increased production of oxygen free radicals in the esophageal mucosa. These radicals can produce a promutagenic DNA lesion, 8-hydroxydeoxyguanosine (8-OH-dG), linked to carcinogenesis in several malignancies. We examined alterations in the oxidative DNA damage (8-OH-dG) in Barrett’s mucosa with and without associated adenocarcinoma or high- grade dysplasia compared to normal control’s squamous mucosa. PATIENTS AND METHODS: We measured oxidative DNA damage (8-OH-dG) in 46 patients: 13 Barrett’s metaplasia, 24 adenocarcinoma or high-grade dysplasia of distal esophagus/esophagogastric junction, and 9 normal controls. The formation of 8-hydroxydeoxyguanosine was determined using routine liquid chromatography. All samples were taken either at endoscopy, or, during surgery, from resected specimen. The average 8-OH-dG concentration was expressed as the ration of 8-OH-dG per 105 deoxyguanosine ± standard error of mean. RESULTS: Analysis revealed significantly increased oxidative DNA damage (8-OH-dG) in the distal esophagus in both Barrett’s epithelium (3.19 ± 1.75) and adenocarcinoma/high-grade dysplasia (1.23 ± 0.07) compared to controls (0.77 ± 0.47), p = 0.02 for both. In patients with Barrett’s mucosa, no significant difference existed in 8-OH-dG levels between samples from distal and proximal esophagus. CONCLUSIONS: Oxidative DNA damage (8-OH-dG) is increased significantly in malignant transformation of Barrett’s esophagus and seems to play ABSTRACTS

an important role in the carcinogenesis of esophageal mucosa. POSTER

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M1469 Role of Diagnostic Video-Laparoscopy Prior to Neoadjuvant Treatment in Esophageal Adenocarcinomas Compared to Gastric Cancers Paul M. Schneider1, Ralf Metzger1, Stephan E. Baldus2, Stefan P. Moenig1, Daniel Vallboehmer1, Jan Brabender1, Hans P. Dienes2, Arnulf H. Hoelscher1; 1Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany; 2Institute of Pathology, University of Cologne, Cologne, Germany Neoadjuvant multimodality treatment followed by radical surgical resection is a treatment option still under discussion for locally advanced gastric and esophageal cancers. To exclude patients with occult peritoneal carcinomatosis, video-laparoscopy is generally suggested prior to induction of neoadjuvant treatment. We compared the results of standardized diagnostic video-laparoscopy for consecutively treated patients with gastric and esophageal adenocarcinomas.34 patients with locally advanced adenocarcinomas (cT3/4, Nx, M0) of the stomach (n = 17) and gastroesophageal junction type II und III according to Siewert’s classification (n = 17) were scheduled for neoadjuvant chemotherapy (cisplatin, leucovorin, 5-FU). 34 patients with adenocarcinomas of the esophagus (cT2-4, Nx, M0) received simultaneous neoadjuvant chemoradiation (36 Gy, cisplatin, 5-FU). Clinical staging in both groups consisted of endoscopy with biopsy, endoscopic ultrasound, and CT chest and abdomen. To exclude occult unsuspected peritoneal carcinomatosis, standardized diagnostic video-laparoscopy with biopsy, peritoneal lavage and conventional cytology was performed prior to neoadjuvant treatment induction. In 5/34 (14, 7%) patients with gastric or gastroesophageal junction tumors (Siewert type II and III), peritoneal carcinomatosis was discovered by diagnostic video- laparoscopy and proven by biopsy. These patients were excluded from the neoadjuvant protocol and received definitive chemotherapy. In all patients with biopsy-proven peritoneal carcinomatosis, conventional cytology in peritoneal washings also detected tumor cells. In contrast, none of the 34 patients with adenocarcinomas of the esophagus showed macroscopic peritoneal carcinomatosis and peritoneal washings were all negative by conventional cytology. Diagnostic video-laparoscopy with biopsy and lavage identified peritoneal carcinomatosis in 14.7% of patients with gastric cancers with a consecutive change in the therapeutic concept. In patients with esophageal adenocarcinoms none of them showed occult peritoneal carcinomatosis and therefore no change in the planned treatment was necessary. We therefore stopped using video-laparoscopy in the diagnostic work-up in patients with locally advanced esophageal adenocarcinomas with unsuspected peritoneal carcinomatosis prior to neoadjuvant treatment.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1470 Long-Term (6 Year) Outcome of Laparoscopic Nissen and Toupet Fundoplication John M. Shaw1, P C. Bornman1, M D. Callanan1, D.C. Metz2; 1Surgical Gastroenterology, University of Cape Town, Cape Town, South Africa; 2Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA INTRODUCTION: Laparoscopic Toupet (270˚ partial) fundoplication (LT) may have fewer post-operative side effects when compared with Nissen (360˚) fundoplication (LN). AIM: To evaluate long-term outcome after LT and LN fundoplication in patients with gastro-oesophageal reflux disease (GORD). METHODS: We previously reported results for 100 patients with PPI dependent GORD who were randomized to either LT or LN fundoplication1. Oesophageal manometry, 24-hour pH studies and a detailed symptom questionnaire were completed pre- and 3 months post procedure in all patients. Visual analogue symptom (VAS) scores were assessed annually thereafter. In February to March 2005 we telephonically contacted patients for an outcome questionnaire a mean of 6 years (range 2.5–8 yrs) after initial intervention. Patients were asked whether they would recommend surgery to others, whether they would undergo the procedure again and whether they felt they were better than before the surgery. Student T, Wilcoxin and Fisher exact tests were performed as appropriate. RESULTS: We reached 73 of the initial cohort (3 had died and 24 were lost to follow-up). In the LN group 33/37 would recommend surgery, 32/37 would have repeat surgery and 34/37 felt they were better despite 8 patients still requiring PPI’s and 3 undergoing redo-surgery. The corresponding numbers for the LT group were 35/36, 30/36, and 33/36 with 2 on PPI’s and 3 requiring redo-surgery. None of these parameters were statistically different between the two groups (p = 0.9, 1.0, 1.0, 0.07, 1.0 respectively). At 3 months, there were no differences for symptoms and physiological variables except lower oesophageal pressure (LOSP) was higher in the LN group (16.1 vs. 12.8 mmHg, p = 0.04) increasing by a mean of 12 vs. 4.8 mmHg (p = 0.03). There was significant improvement post procedure within each group with respect to LOSP, lower oesophageal sphincter length (LOSL), % time pH < 4.0, De Meester score and VAS scores of heartburn, regurgitation and flatulence. The gasbloat VAS score decreased post-procedure in the LT group (p = 0.009), but

was no different in the LN group. When we restricted the deﬁnition of GORD ABSTRACTS

to a distal pH exposure of <4 for >4.2% of time and/or erosive oesophagitis POSTER grade B-D (n = 69), there were no signiﬁcant differences between the groups. CONCLUSION: Patients undergoing both LN and LT are generally happy with their surgery despite 13.6% still requiring PPI’s and 8.2% requiring redo surgery. There do not appear to be any long-term differences in outcome between LN and LT despite LN achieving a higher LOSP at 3 months. REFERENCE: 1. SAMJ 2004, 94(8); 675

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M1471 Clavicle Lifting Strategy in Radical Three Field Lymphadenectomy Improved Survival of Patients with Esophageal Cancer Yutaka Suzuki, Hiroaki Aoki, Naruo Kawasaki, Nobuo Omura, Yoshio Ishibashi, Kouzi Nakata, Hideyuki Kashiwagi, Nobuyoshi Hanyu, Katuhiko Yanaga; Surgery, The Jikei University School of Medicine, Tokyo, Japan OBJECTIVE: To determine the effects of clavicle-lifting strategy as a part of radical 3 field lymphadenectomy for patients with esophageal cancer on survival. SUMMARY BACKGROUND DATA: Removal of bilateral recurrent nerve nodes in upper mediastinallesion and cervical lesion as 3-field lymphadenectomy was reported to improve prognosis in esophageal cancer, which is still in debate. METHODS: To dissect cervical and upper thoracic lymph nodes thoroughly and safely,we created a clavicle-lifting technique, which can extend the operative field around the subclavicular space by lifting the clavicle upward with a pediatric extension retractor. The endpoint was defined as death due to progression of esophageal cancer. RESULTS: Without increasing morbidity/mortality, patients treated with clavicle lifting (n = 35) survived significantly longer than those treated with 2-field lymphadenectomy (n = 163) (P = 0.0116), even after multivariate adjustment for cancer stage, calendar year of surgery, and the use of chemoradiotherapy (Hazard Ratio: 0.11 95% CI 0.01–0.84 P = 0.033). Moreover, patients treated with clavicle lifting (n = 30) were survived longer than stage and surgery-matched patients treated with 2-field lymphadenectomy (n = 30) (P = 0.0073), even after multivariate adjustment (Hazard Ratio: 0.06; 95% CI:0.01–0.50; P = 0.009). In addition,clavicle lifting significantly decreased the risk of cervical and thoraciclymph node metastasis (P = 0.024), but not abdominal lymph node and vascular metastasis. CONCLUSIONS: These results suggest that the clavicle-lifting strategy may allow a more thorough dissection of cervical and upper thoracic lymph nodes, without increasing morbidity/mortality, and may improve prognosis of patients with esophageal cancer by reducing lymphatic metastasis.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1472 Neoadjuvant Therapy in Esophageal Cancer Patients Is Associated with Significant Down Staging (40%) and Enhanced Survival Compared to Surgical Resection Alone Harold J. Wanebo; Surgery, Roger Williams Medical Center, Providence, RI; Surgery, Boston University, Boston, MA INTRODUCTION: The overall survival of esophageal cancer continues to be poor. In spite of numerous adjuvant studies in esophageal cancer, there is still limited data to support a survival benefit. We have reviewed our experience with resectable esophageal cancer to assess possible benefit of cisplatin-based neoadjuvant therapy. METHODS: We reviewed data from 170 patients diagnosed with esophagus cancer (including gastro-esophageal junction cancers) treated between 1989–99. Complete data was available for 136 patients. Fifty-four (40%) patients were treated with an esophago-gastrectomy with negative margins. During the last 5 years, most patients with Stage II lesions were treated with preoperative chemo-RT (Cisplatin + 5-FU or paclitaxel, with 45 Gy). RESULTS: The site of the lesion was distal esophagus and GE junction in 94 patients (70%), mid -esophagus in 28 (20.5%), and proximal esophagus in 14 (10%). Adenocarcinoma was the prevalent histologic type in 61% patients, with squamous cell Ca accounting for almost all the other cases. The mean overall survival was 8 months compared to 22 months in the curative resection group. The 3 and 5 yr. survival was 30%/21% (Neoadjuvant) vs. 26%/ 13% (Surgery alone) P < 0.05. Of the 23 patients receiving neo-adjuvant therapy, nine patients (40%) were down-staged based on pathological findings, with a complete response in 7 patients (30%). The peri-operative mortality in all patients having surgery was 2% and the morbidity was 40.7%. CONCLUSIONS: Although esophageal cancer has an overall poor prognosis, and only 40% are amenable to curative surgery, neoadjuvant therapy appears to increase long term survival in resectable high stage patients.

Clinical Stage Survival No. Age 0-I II III IV Unknown 1-yr 3-yr 5-yr All patients 136 69 12 50 16 36 22 32% 10% 7% All curative resections 54 66 8 36 1 0 9 54% 22% 13% Surgery alone 31 67 7 18 1 0 5 51% 26% 13%

Surgery+ neoad-juvantRX 23 66 1 18 0 0 4 65% 30% 21% ABSTRACTS POSTER Palliative treatment 82 71 4 14 15 36 13 18% 2% 1%

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M1473 Long Term Quality of Life After Heller Myotomy: Patient’s Perspective Yassar K. Youssef, Alfonso Torquati, Kenneth W. Sharp, Nikhilesh Sekhar, William O. Richards; General Surgery, Vanderbilt University Medical Center, Nashville, TN BACKGROUND AND OBJECTIVE: Quality of life (QOL) is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on the QOL along with their direct effect on diseases they are targeting. The aim of the study was to assess the impact of residual dysphagia on QOL after Heller myotomy. METHODS: QOL was evaluated using the short-form-36 (SF-36) and postoperative dysphagia was assessed using a dysphagia score. The score (range 0–10) was calculated by combining the frequency of dysphagia (0 = never, 1 = <1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5 = daily) with the severity (0 = none, 1 = very mild, 2 = mild, 3 = moderate, 4 = moderately severe, 5 = severe). Long term follow up (range 12–96 months; average 36 months) was achieved in 60 patients (31 female; mean age 51 years). Myot- omy was considered ineffective when the patient’s dysphagia score exceeded the 75th percentile. RESULTS: The overall long-term success in relieving dysphagia (responder group) was 78.3%. However, only 5 (8%) were not satisfied with surgery results. Significant differences between the responder and non responder groups were found for most all SF-36 components (Table). Thirty patients reported reflux symptoms. These patients had a significant lower Mental Component Score (MCS) than patients without reflux symptoms (66 ± 22 vs. 80 ± 15, P = 0.01). However, patients who underwent Heller plus Dor fundoplication (n = 18) did not have higher SF-36 and dysphagia scores than patients who underwent Heller alone.

Table 1. SF-36 Subscale Score in the Two Groups

Components Responders (n = 47) Non-Responders (n = 13) P Physical Functioning 85 ± 18 67 ± 37 0.03 Role—Physical 76 ± 37 67 ± 44 NS Bodily Pain 70 ± 23 58 ± 29 NS General health 68 ± 21 56 ± 20 0.04 Vitality 61 ± 24 47 ± 19 0.04 Social Functioning 86 ± 20 71 ± 31 0.04 Role—Emotional 85 ± 31 64 ± 48 0.04 Mental health 79 ± 16 65 ± 21 0.01 PCS 72 ± 21 59 ± 26 0.04 MCS 76 ± 17 60 ± 25 0.01 Total SF-36 76 ± 16 62 ± 26 0.01

CONCLUSION: Heller myotomy is a long term effective procedure that improves symptoms and quality of life.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1474 Laparoscopic Repair of Large Type II-II Hiatal Hernia: The Use of Mesh Allows a Lower Recurrence Rate Giovanni Zaninotto, Mario Costantini, Giuseppe Portale, Emanuela Guirroli, Sabrina Rampado, Loredana Nicoletti, Ermanno Ancona; Clinica Chirurgica III, Department Medical Surgical Sciences, Padova, Italy Laparoscopic repair of large paraesophageal (type II) or mixed (type III) hiatal hernias (HH) with prosthetic hiatal closure is now considered feasible and effective with similar results to open surgery. However, in most studies, the outcome analyses are based on symptomatic assessment and relatively short- term follow-up (F-up); concerns remain on possible high recurrence rates in the long-term F-up with objective tests. We retrospectively evaluated the outcomes of laparoscopic repair of large type II-III HH, with or without prosthetic hiatal closure, in the long-term F-up, by means of both symptomatic and radiologic/ endoscopic evaluation. From January 1992 to June 2005, 54 pts (10M:4F, median age 64.5 yrs) with a diagnosis of large type II-III HH (>1/3 radiographic/intraoperative stomach in the chest) underwent laparoscopic repair. Principles of surgical technique included reduction of the hernia, complete excision of the sac, primary closure of the crura (with/without mesh reinforcement) and antireflux procedure (Nissen or Toupet). Simple sutured crural closure was performed in 19 pts (group A), a double mesh was added in 35 pts (group B). Median operative time was 180 min. The operation was completed laparoscopically in 89% of the cases: all but one conversions occurred in the first 13 pts. Intraoperative complications occurred in 2 (3.7%) pts, including 1 spleen lesion and 1 gastric lesion. Postop complication rate was 9%, including 1 cardiorespiratory arrest with apallic status. The median lenght of radiographic/endoscopic F-up was 64 mos (IQR: 10–98) group A and 27 mos (IQR: 7–47) group B (p = 0.05). Recurrences occurred in 11/54 (20%) pts: 8/19 (42.1%) group A pts and 3/35 (8.6%) group B pts (p = 0.01). The 3 recurrences in group B (mesh) pts occurred all within the first 12 mos post-op; 5/8 recurrences in group A pts occurred ≥3 yrs after surgery. 5 pts with recurrence underwent reoperation. 4/54 (7%) pts presented a small sliding hernia (≤2 cm ‘telescoping’) on post-op barium swallow and did not require reoperation (they are all asymptomatic at median F-up of 93 mos). On multivariate logistic regression analysis, only the absence of mesh significantly predicted hernia recurrence or wrap migration in the chest. Laparoscopic repair of large type II-III hiatal hernias is a safe and effective treatment. Short-term symptomatic results are excellent, but long-term objective radiologic and/or endo- ABSTRACTS

scopic evaluation reveals a signiﬁcant percentage of recurrence: the main POSTER reason for failure of hiatal repair is tension. The use of prosthetic mesh effectively reduce the incidence of postoperative hernia recurrence or wrap migration in the chest.

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M1475 Long-Term Outcome of Operated and Unoperated Esophageal Epiphrenic Diverticula Giovanni Zaninotto, Mario Costantini, Giuseppe Portale, Emanuela Guirroli, Sabrina Rampado, Loredana Nicoletti, Ermanno Ancona; Clinica Chirurgica III, Department Medical Surgical Sciences, Padova, Italy Esophageal epiphrenic diverticula (ED) are uncommon; they tend to be associated with motility disorders. The natural history of ED is not entirely clear and the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated ED patients. Clinical, radiological and motility ﬁndings, operative morbidity and long-term outcome of 37 ED pts referred from 1993 to June 2005 were analyzed. All pts were reviewed at the outpatients clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessments. 20 pts (10M:10F, median age 60 years) were operated. One pt underwent surgery for spontaneous rupture of a large ED. Operative mortality was nil; postoperative morbidity was 26%, the most severe complication being suture leakage (4 pts, managed conservatively). The median follow-up was 53 mos. 18 pts (7M:11F, median age 70 years) were not operated. 2 pts received pneumatic dilations. The median follow-up was 37 mos. No patients in either group died for reasons related to their ED. Recurrent ED was observed in 1 pt. Four pts in the operated group had GERD symptoms and/or esophagitis. Surgery is an effective treatment for ED, but carries a signiﬁcant morbidity, mainly related to suture leakage. Even in the long term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted for cases of small, mildly symptomatic ED.

Table 1. Clinical Findings

Subjective Outcome* Operated (N = 20) Non Operated (N = 18) Better 17 (85%) 4 (22%) Worse 3 (15%) 1 (5%) Unchanged — 14 (73%)

*Better compared to worse or unchanged (operated vs. non operated, p = 0.0002)

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Clinical: Hepatic

M1476 The Impact of Age on Hepatic Resection for Colorectal Metastasis Chandrakanth Are, Mithat Gonen, Michael D’Angelica, Ronald P. Dematteo, Yuman Fong, Leslie H. Blumgart, William R. Jarnagin; Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, NY INTRODUCTION: Hepatic resection for colorectal metastasis (CRM) is increasingly performed in older patients. This study analyzes the impact of age on the results of hepatic resection for CRM in a large single centre series. MATERIALS AND METHODS: All patients undergoing hepatic resection for CRM from 1991 to 2003 were identified. Patients were divided into two age groups (Group I: ≤70 yrs and Group II: >70 yrs of age) and complications were graded from 0 (none) to 5 (death). Five year survival and morbidity were compared between both the groups. Morbidity was correlated to other potential predictors such as, transfusion, major hepatic resection (≥3 segments), body mass index (BMI) and pre operative co-morbidities. RESULTS: A total of 1119 patients underwent hepatic resection for CRM during this period. The majority of patients were ≤70 yrs (Group I = 842 patients, 75%) compared to 277 patients who were >70 yrs of age (Group II = 25%). There was no difference in overall morbidity (44 and 42%, p = 0.5) or major morbidity (55 and 57%, p = 0.7) between both the groups. The need for transfusion and the rate of major hepatic resection were similar in both groups (56 and 58%, 50 and 48% respectively) and did not affect the morbidity. In patients with BMI > 30, there was a statistically insignificant increase in complications in Group II when compared to Group I (65% vs 50%, p = 0.15). The presence of pre-op co-morbidity did not affect the outcome between the two groups. The five year survival for the two groups was 37.5 and 36.8% (p = 0.5) respectively. CONCLUSION: This study provides evidence that hepatic resection for colorectal metastasis is safe and effective in older patients. Age alone should therefore not factor into the decision regarding hepatic resection for colorectal metastasis Morbidity Age ≤70 Yrs (% ) Age > 70 Yrs (% ) p Overall morbidity 44 42 0.5 ABSTRACTS

Major morbidity 55 57 0.7 POSTER Without transfusion 36 29 0.17 With transfusion 56 58 0.68 Minor hepatic resection 35 32 0.54 Major hepatic resection 50 48 0.80 BMI 30 44 39 0.26 BMI >30 50 65 0.15 Without pre op co morbidity 41 38 0.82 With pre op co morbidity 51 44 0.14 5 year survival 37.5% 36.8% 0.5

Total number of patients = 1119.

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M1481 MELD as a Predictor of Morbidity and Mortality in Child’s a Patients and Its Association with Histology Alicia Holt, Rebecca Nelson, Eric Feliberti, Layla Rouse, Lawrence Wagman; Surgery, City of Hope, Duarte, CA BACKGROUND: The Model for End Stage Liver Disease (MELD) score has been used to predict operative morbidity and mortality of the cirrhotic patient. We sought to determine if the MELD score could be used in risk strat- iﬁcation of Child’s A patients having liver surgery. Further, we looked at the association of the MELD score with lesion histology. METHODS: A retrospective chart review was conducted of 136 consecutive patients having hepatic surgery for primary, metastatic, or benign liver disease from 1998–2005. Surgery consisted of ablation and/or resection of liver lesions. Outcomes measured were length of stay, perioperative mortality, and complications. RESULTS: Of the 136 Child’s A patients, there were 98, 28 and 10 patients operated on with metastatic cancer, hepatocellular cancer (HCC), or benign liver lesions, respectively. The mean age was 58.6 years old, range 19–90. For the entire cohort, the mean and median MELD scores were 3.9 and 4.0, respectively, and ranged from –4 to 12. The median length of hospital stay was 7.0 days, ranging from 2–68 days. The average MELD score for patients with a complication was 3.6 versus 4.7 for patients without a complication (p = 0.07. Length of stay and perioperative mortality was not associated with MELD scores. The mean MELD scores for patients with metastatic cancer, HCC, and benign liver disease were 3.7, 5.0, and 2.7, respectively (p = 0.07). Patients with HCC had a higher rate of 30-day complications (42.9% vs. 23.7%, p = 0.05) and a higher 30-day mortality rate (14.3% vs. 1.0%, p = 0.0005) than those patients with metastatic disease. Patients with HCC who had a complication had an average MELD score of 6.5 versus 3.9 for those without a complication (p = 0.03). CONCLUSION: MELD score can be used to predict perioperative complications in Child’s A patients with HCC. The MELD score is not helpful in predicting length of stay or perioperative mortality in Child’s A patients having liver surgery.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1482 Modern Surgical and Perioperative Techniques Together with a High Case Load Decrease Mortality and Major Morbidity After Liver Resection Frank Makowiec, Eva Fischer, Ulrich Adam, Ulrich T. Hopt; Department of Surgery, University of Freiburg, Freiburg, Germany Low mortality and encouraging survival rates led to increasing numbers of liver resections, especially for colorectal cancer metastases, during the last two decades. It has been shown that mortality after liver surgery correlates with hospital volume. We present our recent experience with liver resection. Subgroup analyses were performed comparing the periods before and after the establishment of a new liver surgery programm with a different surgical staff. METHODS: From 1998 until 2005 358 liver resections were performed. Peri- operative and survival data are documented prospectively since 2002. In 2001 a new liver surgery programm was established with refinements in operative techniques (e.g. parenchyma dissection with CUSA) and perioperative care. The 358 resections were undertaken for colorectal cancer (CRC) metastasis (n = 178), hepatocellular carcinoma (n = 60), other metastasis (n = 39) and various others (n = 81). Analyses of the perioperative outcome were compared between the periods before (P1; n = 100) and after 9/2001 (P2; n = 258). Fur- ther analyses were performed in patients with metastases of CRC including data on long-term survival. RESULTS: The mean annual number of liver resection increased from 24 (P1) to 59 (P2). The relative frequency of major resections (classical hemihepatectomy or extended hemihepatectomy) increased from 40% (P1) to 54% (P2). Mortality decreased from 9.1% (P1) to 3.9% (P2; p = 0.06), overall complication rates were 56% and 50%, respectively (n.s.). The frequency of patients requiring perioperative blood transfusions decreased from 64% to 26% (p < 0.001). In the subgroup of patients with primary liver resection for CRC-metastases (n = 156) the frequency of major resections increased from 38% in P1 to 56% in P2. Mortality decreased from 10% in P1 to zero in P2 (p < 0.01) whereas morbidity showed only a slight reduction (56% vs. 43%; p = 0.1). Since 2001 117 consecutive primary liver resections for CRC-metastases were performed without mortality, and none of these patients required relaparotomy for bleeding. Survival data after primary resection for CRC- metastases were available in 138 patients. Three and five year survival were 65% and 52%, respectively (patients at risk: 38 after three and 11 after five

years). ABSTRACTS POSTER CONCLUSIONS: Modern surgical and perioperative techniques together with a high case load reduce mortality and major complications in liver surgery, despite more extended resections. In the view of a multidisciplinary approach the very low operative mortality and relative good oncological outcome in CRC liver metastases should encourage medical oncologists to present all eligible patients to the hepatic surgeon.

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M1483 The Role of Hepatectomy for the Patients with Liver Metastases of Gastric Cancer Zenichi Morise, Atsushi Sugioka, Sojun Hoshimoto, Takazumi Kato, Akihiko Horiguchi, Shuichi Miyakawa; Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan BACKGROUNDS AND AIM: Although hepatic resection for colorectal liver metastases had become a gold standard of the therapy, the role of hepatic resection for those from gastric cancer has yet to been well defined. There are only a few reported series (10–30 patients, each) of hepatic resection for metastatic gastric cancer. We reviewed our cases of hepatic resection for metastatic gastric cancer and compared them to the cases of colorectal liver metastases. PATIENTS: Between 1989 and 2004, 18 patients underwent hepatic resection for liver metastases from gastric cancer in our department. They were 16 men and 2 women and their ages were in the range of 51–76 (mean 64.1) years old. Hepatic resection was indicated for patients with synchronous metastases who did not have peritoneal dissemination or any other distant metastases (11 patients), and patients with metachronous metastases who did not have any other recurrent lesions (7 patients). 14 patients had solitary and 4 had multiple liver metastases. Median follow up period was 64 (mean 91.6) months. RESULTS: Overall survival rate for 1, 2, 3, and 5 years are 56.3, 36.5, 27.3, and 27.3%, respectively. Although the 5-year survival rate was considerable, they had early and rapid decrease of survival rate in the first 1-2 years (compared with the patients of colorectal liver metastases (153 cases between 1989 and 2004) who had 88.3, 66.9, 54.9, and 42.2% of survival rate for 1, 2, 3, and 5 years, respectively). All patients with multiple metastases died within 1 year, and the survival rates of the patients with solitary and multiple metastases were significantly different (p < 0.05). There was no significant difference observed between the outcomes of the patients with synchronous and metachronous metastases. CONCLUSION: Surgical resection for liver metastases of gastric cancer is thought to be beneficial for part of the patients (around 30%) with solitary metastasis. However, for the other patients, the survival curve after the resection dropped rapidly during the first 1–2 years. The procedure may provide only limited beneficial effects on the survivals of those patients. Further investigations for the favorable prognostic factors to select the patients and adjuvant therapy for those patients with poor prognosis should be needed.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1484 Recurrent Hepatic Colorectal Metastases: Does the Extent of Surgical Resection Effect Outcome? Ann P. O’Rourke, Andrew Kastenmeier, John E. Niederhuber, David M. Mahvi, Layton F. Rikkers, Sharon M. Weber; Surgery, University of Wisconsin, Madison, WI INTRODUCTION: Complete resection of recurrent hepatic colorectal metastases results in a median survival of 30–40 months. However, the impact of the extent of surgical resection on outcome has not been well deﬁned. METHODS: Patients with recurrent hepatic colorectal metastases undergoing surgical resection were identiﬁed from a prospective database. Patient outcome was analyzed according to the type of surgical treatment: anatomic resection (segmental or larger excision) vs. nonanatomic resection (wedge resection or tumor ablation). Demographic data, tumor characteristics, and survival were analyzed. RESULTS: From 1993 to 2005, 48 procedures were performed in 40 patients with recurrent hepatic colorectal metastases, including 15 anatomic and 33 nonanatomic resections. There was no difference in clinicopathologic risk factors between the two groups, including size of largest tumor, number of tumors, preoperative CEA, disease-free interval, node positive primary tumor, or use of adjuvant therapy. Patients who underwent hepatic ablation did so because of tumor location, poor hepatic reserve, or medical comorbidities. In patients treated curatively, there was an improvement in overall and disease- free survival in patients undergoing anatomic resection (Table, median FU 16 months). No other clinicopathologic feature was predictive of overall or disease-free survival. CONCLUSIONS: In patients with recurrent hepatic colorectal metastases, anatomic surgical resection is associated with an improvement in overall and disease-free survival compared to nonanatomic resection. Anatomic resection is the preferred option in patients with recurrent hepatic colorectal metastases who are candidates for surgery.

Type of Surgery Median Survival* Median Disease-Free Survival* Anatomic 50 mo. 39 mo. Nonanatomic 20 mo. 21 mo.

*p = 0.03 ABSTRACTS POSTER

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M1486 Telomerase Activity in Tumor and Remnant Liver as Predictor for Recurrence and Survival in Hepatocellular Carcinoma After Resection Yan-Shen Shan1, Yu-Hsiang Hsieh2, Pin-Wen Lin1; 1Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan; 2Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD BACKGROUND AND AIM: Hepatocellular carcinoma from HBV and HCV is increasing. Results after curative liver resection are unsatisfactory due to high postoperative intrahepatic recurrence and liver failure, the latter often merely the result of postoperative therapies. Specific predictors to facilitate decision for use and choice of postoperative adjuvant therapy may improve patient survival. This study evaluates telomerase activity in tumor and non- tumor liver, and an array of clinicopathological factors as predictors for recurrence, survival and optimal postoperative therapeutic regimens. MATERIAL AND METHODS: Liver tissue from 53 hepatocellular carcinoma patients receiving curative resection during the period of 1998 to 2000 was analyzed for telomerase activity within tumor and non-tumor liver. Clin- ical and pathological data were collected during regular follow-up including recurrence rates, types of recurrence, mortality rates and adjuvant therapy types. The collected data were analyzed to identify risk factors for recurrence and survival. RESULTS: Telomerase activity was detected in 98% of tumor and 70% of non-tumor liver tissue. Telomerase activity in cancerous liver correlated significantly with HCV infection and cirrhotic change of liver parenchyma, and correlated marginally with HBV infection. Telomerase activity in non-cancerous liver correlated with high serum AFP level. During 60 months (median) follow-up, the 1-, 3- and 5-year survival rates were respectively 88%, 64% and 57% in all patients, 100%, 94% and 88% in non-recurrence patients and 76%, 51% and 44% in recurrence patients. Recurrence could be predicted by abnor- mally high tumor telomerase activity or by advanced TMN stage. TMN stage or high serum ALT level could predict multi-nodular intrahepatic recurrence, and TMN stage also could predict single nodular intrahepatic recurrence. High serum AFP (>400ng/ml) combined with high telomerase activity in non- tumor liver had significant predictive ability for poor survival. CONCLUSION: Tumor telomerase is a useful independent predictor of recurrence. Simultaneous high remnant liver telomerase and high serum AFP is a strong negative predictor for survival. Because adjuvant therapies have severe side effects, patient survival can be optimized by using indicators such as tumor telomerase to limit adjuvant treatment only to patients with high risk of recurrence.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Clinical: Pancreas

M1487 Cachexia Worsens the Prognosis in Patients with Resectable Pancreatic Cancer Jeannine Bachmann, Boris E. Frohlich, Corneliu Dimitriu, Markus W. Buchler, Helmut Friess, Marc E. Martignoni; Department of Surgery, University of Heidelberg, Heidelberg, Germany BACKGROUND: Progressive weight loss has been determined to be an important prognostic factor in various malignancies. In particular, in pancreatic cancer many patients develop a dramatic cachexia syndrome during the progression of their disease. Therefore, the aim of the study was to examine the influence of cachexia on perioperative morbidity and mortality and its impact on the outcome of patients with resectable pancreatic cancer. MATERIAL AND METHODS: From June 2004 to November 2005, 220 patients with ductal adenocarcinoma of the pancreas were admitted to our department for surgical therapy. We defined cachexia as an unintended loss of body weight of more than 10% of the original weight within 6 months. The data of all patients were collected in a prospective database. Each patient gave his informed consent for data collection and collection of blood samples for research. RESULTS: Of the included 220 patients with histologically proven ductal adenocarcinoma of the pancreas, 38.5% presented with cachexia (median weight loss 12 kg), 61.5% had no or less than 10% weight loss (median weight loss 0 kg). There was no significant difference between the two groups regarding age (P = .606), gender (P = .413), ASA-classification (P = .455), tumor size (P = .458), lymph node metastasis (P = .87), and grading (P = .308). Tumor stage at time of operation in cachectic and non-cachectic patients was UICC II in 50.0% versus 66.7% and UICC IV (metastatic disease) in 46.1% versus 29.8%, respectively (P = .03). A significant difference regarding resection rate was determined, with 50% in the cachectic versus 72.6% in the non-cachectic group (P = .001). The perioperative morbidity rate revealed no significant differences in both groups (P = .653). However, there was a significant difference in perioperative mortality, with a worse rate for cachectic patients (P = .034). In palliative, non-resected patients, the overall survival was shorter in the cachectic group than in the non-cachectic group with a median survival of 91 days versus 181 days, respectively; in resected patients, both groups showed

statistically non-significant differences. ABSTRACTS CONCLUSION: In patients with pancreatic cancer, cachexia is a considerable POSTER prognostic factor which is still underestimated. Cachexia significantly worsens the prognosis of patients with pancreatic cancer regarding resection rate, perioperative mortality and survival. Surprisingly, occurrence of cachexia is independent of tumor size or lymph node status, but significantly correlated to aggressivness of the tumor and the potential to metastasize.

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M1488 Fast-Track Concept in Pancreatic Surgery Is Safe and Decreases Hospital Stay Pascal O. Berberat, Heike Ingold, Antanas Gulbinas, Joerg Kleeff, Michael W. Mueller, Carsten Gutt, Markus W. Buechler, Helmut Friess; Department of General Surgery, University of Heidelberg, Heidelberg, Germany BACKGROUND: In colorectal surgery, so-called ‘fast-track’ concepts, which focus on optimal perioperative care, have shown to significantly reduce complication rates and hospital stay (Basse et al Ann Surg 2000). This study evaluates whether fast-track concepts are also safely applicable to major abdominal surgeries such as pancreatic resection. METHODS AND PATIENTS: As in colorectal surgery, a fast track concept was introduced in pancreatic surgery through the application of optimized anesthetic and analgesic methods, supporting early normal gastrointestinal function and encouraging early mobilization. The perioperative data from 255 consecutive patients undergoing pancreatic resection between January and December 2004 in a high-volume center, were analyzed using univariate and multivariate models. RESULTS: Of the 255 patients, 71% were operated for pancreatic tumors and the remaining 29% for chronic pancreatitis. Of these patients, 180 received a pancreatic head resection, 51 a distal, 15 a total and 9 a segmental pancreatectomy. A total of 228 patients (89%) were extubated within four hours after the operation. In 80% of the cases, the nasogastric tube was removed with the extubation and clear liquids were started the first postoperative day. Patients were transferred back to the normal ward on median day 2 and showed to be fully mobile on day 3. After the first stool on median day 4, the patients were eating normal food by day 5. Finally the patients were discharged on median day 10 with a 30-day readmission rate of 4%. The mortality was 2% and medical and surgical morbidity were observed in 17% and 26%, respectively. The fast track parameters such as first stools, normal food, complete mobilization and back to normal ward correlated significantly with early discharge (p < 0.05). Several factors such as younger age, low ASA score, short operation time, low intraoperative blood loss, absence of blood transfusion, type of resection, and early extubation were predictive of early discharge in the univariate analysis (p < 0.05), whereas the use of epidural anesthesia and routine prokinetic medication did not influence postoperative recovery and discharge time. Age, operation time and early extubation proved in multivariate analysis to be independent factors of early discharge (Odds ratio: 4.2 and 2.8, respectively; p < 0.05). CONCLUSION: Fast-track concepts work also in major abdominal surgery such as pancreatic resections, leading to earlier discharge without compromising the outcome. Furthermore, the fast-track approach is feasible and safe with low re-admission, mortality and morbidity rates.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1489 The Current Role of Surgical Resection and Cytoreduction in the Treatment of Pancreatic Neuroendocrine (NE) Tumors Mark Bloomston1, Osama Al-Saif1, Peter Muscarella1, W. Scott Melvin1, Edward W. Martin1, Manisha Shah3, Wendy L. Frankel2, E. Christopher Ellison1; 1Surgery, Ohio State University, Columbus, OH; 2Pathology, Ohio State University, Columbus, OH; 3Medicine, Ohio State University, Columbus, OH BACKGROUND: We reviewed our experience with pancreatectomy for NE tumors to determine outcomes after complete (R0/R1) or incomplete (R2) resection and compare them to patients in whom resection was not attempted (NR). METHODS: Data were reviewed for all patients presenting with NE tumors of the pancreas between 1990 and 2005. Survival curves were created using the Kaplan-Meier method and compared by log-rank analysis. Multivariate regression analysis was completed using Cox Proportional Hazards Analysis to identify risk factors for poor survival in patients undergoing resection. Data are reported as median overall survival. RESULTS: Of 120 patients presenting with NE tumors of the pancreas, 65 (54%) had functional tumors, 13 of which had MEN1. Resection was undertaken in 83: distal pancreatectomy in 41, pancreaticoduodenectomy in 27, enucleation in 14, and central pancreatectomy in one. Survival was significantly longer if resection was undertaken (91 months vs. 24, p < 0.001). R0/R1 resection was accomplished in 64 (77%) and resulted in lower perioperative mortality (1.5% vs. 21%, p = 0.01) and longer survival (112 months vs. 24, p < 0.001) compared to R2 resection. Sur- vival was the same between patients undergoing R2 resection and those in which resection was not attempted (figure). Factors predictive of decreased survival by multivariate analysis were age, moderate/poor differentiation, R2 resection, and malignant histology. CONCLUSION: Long-term survival is possible following complete resection for NE tumors of the pancreas. However, cytoreductive operations resulting in incomplete tumor removal carry significant perioperative mortality without long-term survival benefit and should be discouraged. ABSTRACTS POSTER

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M1490 Increased Serum Levels of IgE and Soluble CD23 in Patients with Pancreatic Cancer Martin H. Bluth1, Joelle Pierre1, Michael Hagler1, Cathy M. Mueller1, Tamar A. Smith-Norowitz2, Michael E. Zenilman1; 1Surgery, SUNY Downstate Medical Center, Brooklyn, NY; 2Pediatrics, SUNY Downstate Medical Center, Brooklyn, NY BACKGROUND: Although IgE is well known for its role in atopic disease and parasitic infections, new evidence suggests that IgE is a pleotropic immu- noglobulin molecule with many functions. We and others have recently shown that IgE possesses anti-viral activity, and can elicit anti-cancer effects. Others have recently proposed that patients with allergy/atopy have decreased incidence of pancreatic cancer. We therefore investigated serum levels of IgE and its low affinity receptor, soluble CD23 (sCD23), in patients with pancreatic carcinoma. METHODS: Twelve patients were evaluated for pancreatic cancer by imaging (CT, MRI, EUS) with subsequent biopsy or surgery. Serum samples were collected prior to any intervention. Serum IgE and sCD23 levels were measured by enzyme linked immunosorbant assay (ELISA) in a blinded manner. Serum obtained from fifteen healthy volunteers served as controls. Patients and controls did not have any history of atopy or parasitic infections. IgE and sCD23 levels are expressed as IU/mL and U/mL, respectively (mean + SE) with significance between groups set at p < 0.05 (Student’s t-test). RESULTS: Serum levels of IgE were significantly elevated in patients with pancreatic cancer (148 + 45 IU/ml), compared with controls (30 + 6.3 IU/ml) (p = 0.022). Serum levels of sCD23 were also significantly elevated in patients with pancreatic cancer (2.82 + 0.91 U/ml), compared with controls (1.42 + 0.22 U/ml) (p = 0.006). CONCLUSIONS: Serum levels of IgE and sCD23 were significantly increased (5-fold and 2-fold, respectively) in patients with pancreatic cancer, compared with controls. These data suggest that IgE and sCD23 may serve as useful biomarkers for patients with pancreatic cancer, and may be important in the immune response to this disease.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1491 PKC 412 – A Pan-Antiangiogenic Compound from Bench to Bedside Peter Buechler, Jamael El-Fitori, Yun Su, Klaus Felix, Markus W. Buechler, Helmut Friess; General Surgery, University of Heidelberg, Heidelberg, Germany INTRODUCTION: Pancreatic cancer is an aggressive malignancy with a poor prognosis. Currently there is no effective therapy. The increasing awareness of the role of tumor neoangiogenesis in growth of solid tumors resulted in a consensual opinion that abrogated neoangiogenesis may cause tumor growth arrest. Angiogenesis is also necessary for local and systemic tumor progression both hallmarks of pancreatic cancer. PKC412 is a novel pan-inhibitor of mutated FLT3, PKC, KDR, c-KIT, PDGFRα, and PDGFRβ. The aims of this study were to analyse the therapeutic efficiency of this novel multi target compound in vitro and in vivo using a novel orthotopic model for experimental pancreatic cancer. METHODS: Five human pancreatic cancer cell lines AsPc-1 (A1), Capan-1 (C1), HPAF-2 (HP2), PANC-1 (P1) and MIA PaCa-2 (MP2) were analyzed. RT-PCR was used for FLT3 mutation in pancreatic cancer cells. Anchorage dependent cell growth was quantified with the MTT assay. Soft agar assays were used to study anchorage independent growth. Cell cycle progression was analyzed by flow cytometry. In vivo HP2 and AsPC-1 cells were used to induce orthotopic tumors in a novel murine model for pancreatic cancer (each n = 12). Animals received every day 10 mg/kg PKC412 i.p. for 8 weeks. Immunohistochemistry (anti CD31) was used to quantify microvessel density. RESULTS: No FLT3 mutation could be detected in any of the pancreatic cancer cell lines. Cell growth was inhibited in all cell lines tested; PKC412 resulted in a dose and time dependent growth suppression. In flow cytometric analysis a strong G2/M-phase arrest was detectable. Anchorage independent growth was also significantly reduced in a dose dependent and time dependent manner. The in vivo correlate was a significant growth reduction of orthotopic tumors growth in both cell lines tested. Growth suppression in vivo was mediated not only by antimitogenic activity but also by suppression of tumor neoangiogenesis since the number of blood vessels in treated animals was significantly lower. CONCLUSION: PKC412 is a highly promising new compound with strong anti-mitogenic and in vivo antiangiogenic activity. This dual efficiency will likely be of therapeutic value for patients with pancreatic cancer. ABSTRACTS POSTER

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M1492 Comparison of Clinical Aspects Between Biliary and Alcoholic Acute Pancreatitis: Lipase and Fluid Replacement Can Make a Difference in the Initial Approach of Alcoholic Patients Tercio De Campos, Laise Kuryura, Paulo Furbetta, Jose Cesar Assef, Samir Rasslan; Surgery, Santa Casa School of Medical Sciences, Sao Paulo, Brazil AIM: To compare clinical aspects between biliary and alcoholic acute pancreatitis (AP). METHODS: All patients with AP from August 2003 to October 2005 were included in this prospective protocol, which was approved by the Ethical committee from the Hospital. We compared clinical features between the patients with biliary and alcoholic etiology. The patients with gallstones that had a regular intake of alcohol were excluded of this study. Chi square and Student’s t test were used for statistical analysis, considering p < 0.05 as signiﬁcant. RESULTS: We obtained 162 patients with AP in this period, with the following etiologies: gallstones in 90 (55.6%) patients, alcohol in 49 (30.2%), idiopathic in 12 (7.4%), hyperlipidemia in 3 (1.9%), and 8 (4.9%) patients had gallstones and regular alcohol intake history. We observed differences between the biliary and alcoholic groups regarding to gender and previous episodes of pancreatitis (Table 1). Furthermore, amylase was not able to conﬁrm the diagnosis of AP in 10% of patients with biliary etiology and in 59.2% of patients with alcoholic etiology, while 17 (18.9%) patients with gallstones and 5 (10.2%) with alcoholic etiology had lipase increased less than

Variables Biliary (%) n = 90 Alcohol (%) n = 49 p Gender male 29 (32.2%) 47 (95.9%) <0.001 Previous pancreatitis 8 (8.9%) 20 (40.8%) <0.001 Mean age 50.1 ± 17.4 45.6 ± 13.6 0.119 Amylase 1045.3 ± 703.7 485.4 ± 570.8 <0.001 Amylase (<3x) 9 (10%) 29 (59.2%) <0.001 Lípase 1568.8 ± 2480.8 1020.5 ± 961.8 0.140 Lípase (<3x) 17 (18.9%) 5 (10.2%) 0.273 TGO 203.2 ± 233.2 88.2 ± 114.9 0.001 TGP 289.5 ± 245.0 55.9 ± 64.8 <0.001 FA increased 59 (65.6%) 6 (12.2%) <0.001 GGT increased 84 (93.3%) 27 (55.1%) <0.001 Hb 13.0 ± 1.8 13.9 ± 2.3 0.012 Leucocytes 12016.1 ± 8420.6 12241.4 ± 5445.1 0.866 HCO3 20.7 ± 3.3 19.4 ± 3.7 0.035 Creatinin 1.0 ± 0.4 1.6 ± 1.8 0.003 Balthazar D/E 8 (8.9%) 6 (12.2%) 0.739 Necrosis 9 (10%) 9 (18.4%) 0.255 CT index 2.7 ± 2.6 3.7 ± 3.0 0.042 Severe AP 22 (24.4%) 15 (30.6%) 0.558 APACHE II 4.7 ± 4.3 5 ± 4.5 0.7 Pancreatic operation 0 (0%) 2 (4.1%) 0.236 Deaths 1 (1.1%) 2 (4.1%) 0.589

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

3 times (p = n.s.). AST, ALT, AP and GGT were significantly higher in the biliary group. We have also found an increase in the levels of hemoglobin and creatinin, and a decrease in the bicarbonate levels in the alcoholic patients when compared with the biliary group. There were no differences in severity, morbidity and mortality between the groups. CONCLUSION: We conclude that lipase plays a role in the diagnosis of AP in patients with alcoholic etiology. Although we did not find differences in morbidity and mortality, the patients with alcoholic etiology appear to be more dehydrated on admission, requiring a more vigorous fluid replacement. ABSTRACTS POSTER

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M1493 Complications Management Due to Catastrophic Endoluminal Bleeding After Major Pancreatic Surgery Guellue Cataldegirmen1, Emre F. Yekebas1, Lars Wolfram1, Dean Bogoevski1, Yogesh Vashist1, Bjoern C. Link1, Oliver Mann1, Lena Liebl1, Gerhard Adam2, Gerrit Krupski2, Jakob R. Izbicki1; 1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Diagnostic and interventional Radiology, University Clinic Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: Here, we report a single institutional experience as to the management of endoluminal bleeding complications originating from the enteropancreatic anastomosis following major pancreatic surgery. METHODS: Between 1992 and 2004, 1445 patients were operated on for treatment of pancreatic diseases. Out of these, 1136 patients underwent major pancreatic surgery (492 duodenal preserving pancreas head resections, 311 classic Whipple resections, 146 pylorus preserving pancreato-duodenectomies, 71 distal pancreatectomies, 116 other interventions on pancreas). RESULTS: A severe postoperative endoluminal bleeding (median number of transfused blood units was 9) occurred in 46 patients among whom 24 (52%) had malignant and 22 (48%) had benign diseases. 15 patients (33%) died due to hemorrhage, mostly (n = 13) originating from devastating pseudoaneu- rysms. Out of these patients, 12 patients had malignant diseases and proven pancreatic fistula had developed in 10 cases preceding hemorrhage. Due to the severity of hemorrhage, 9 patients had to be primarily operated. The rest of 37 patients were initially subjected to interventional angiography. From these 37 patients, angiography succeeded in definite treatment in 25 (68%) cases, whereas 12 (32%) patients underwent repeated angiography or had to be secondarily operated under emergency conditions. In 30 patients (81%), in whom angiography succeeded in localizing hemorrhage bleeding sources originated from branches of the common hepatic, splenic, and superior mesenteric arteries. CONCLUSIONS: Patients with malignant diseases have a higher risk to develop significant bleeding and have an increased mortality following major pancreatic surgery. Interventional angiography showed good results using the coiling method and therefore should be the method of first choice in severe visceral bleeding.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1494 Do p16, p53, or MUC4 Mutations Affect Outcomes After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma? John D. Christein1, Ruth R. Leeth1, Rashmi K. Murthy1, Martin Heslin1, Nirag C. Jhala2, Juan P. Arnoletti1, Selwyn M. Vickers1; 1Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Pathology, University of Alabama at Birmingham, Birmingham, AL BACKGROUND: The implications of biological markers as they relate to outcomes after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma is unclear in the literature. PURPOSE: To determine associations between MUC4, p16, and p53 mutations with outcomes in patients after PD for pancreatic adenocarcinoma. METHODS: All patients undergoing R0 or R1 PD for pancreatic adenocarcinoma from 1997–2005 were included in this review. All pathology reports were updated according to the AJCC 6th edition. Specimens were immuno- histochemically stained using antibodies for MUC4, p53, and p16. Appropriate positive and negative controls were stained to determine validity. For both p53 and p16, tumor specimens with a percentage of positive cells greater than the mean plus 2 standard deviations were considered positive. Tumor specimens stained for MUC4 were categorized into a low expression group (<20% positive cells) or a high expression group (<20% positive cells). Student’s t-tests and Chi-square were used to describe differences between expression groups. The Kaplan-Meier method was used to determine survival; univariate and multivariate analyses using the Cox proportional hazards regression model were performed to ascertain impact on survival. RESULTS: 126 patients underwent PD for adenocarcinoma with follow-up available on all but 5 patients (96%). Sixty-seven percent were male and the mean age was 65 years. 9.5% of patients were under 50 years of age. Mean tumor size was 3 cm. Fifteen patients underwent R1 resections (12%). Median survival was 22 months. 108 cases (86%) had tissue available for staining. High MUC4 expression was present in 91 cases (84%). Survival between low and high MUC4 expression groups was signiﬁcantly different, 12 vs. 18 months, respectively (p < 0.03). There was an inverse relationship between p53 and p16 positivity. Patients with a p16 mutation were more likely to be African-American (p = 0.02), undergo an R1 resection (p < 0.01), and have smaller tumors (p < 0.05). Overall, p53 and p16 results did not affect survival.

Of the variables analyzed, surgical margin was the only independent predic- ABSTRACTS tor of survival, with a 2.5 times greater rate of death for patients with positive POSTER margins (p < 0.01). CONCLUSION: Survival for pancreatic adenocarcinoma patients after PD with MUC4 expression < 20% positive cells was signiﬁcantly worse than that for patients with high MUC4 expression. African-Americans were more likely to be p16 positive. Multivariate analysis determined surgical margin to be predictive of survival after PD for pancreatic adenocarcinoma.

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M1495 Is Total Pancreatectomy (TP) Safe and Reasonable? Olivier Corcos1, Alain Sauvanet2, Anne Couvelard3, Olivier Farges2, Vinciane Rebours1, Pascal Hammel1, Philippe Levy1, Jacques Belghiti2, Philippe Ruszniewski1; 1Service de Gastroenterologie, Hopital Beaujon, Clichy, France; 2Service de Chirurgie Digestive, Hopital Beaujon, Clichy, France; 3Service D’anatomopathologie, Hopital Beaujon, Clichy, France AIM OF THE STUDY: TP may be proposed for patients (pts) with diffuse intraductal papillary mucinous tumors of the pancreas (IPMT) or multiples endocrine tumors (mostly associated with MEN-1). Decisions pertaining to TP can be elective when abnormalities are diffuse (e.g., diffuse IPMT) or during surgery where resection margins are involved requiring further resection. Dis- ease-relapse following partial pancreatectomy may also require surgical totalisation. Little data related to survival and morbidity is available. PATIENTS AND METHODS: From 1995 to 2005, 23 patients undergoing TP were retrospectively evaluated. Mean age at TP was 56 (27–76) Years. Indi- cations for TP were: a) non-invasive diffuse IPMT (n = 9) or invasive cancer (n = 7), multiples endocrine tumors (n = 5, 4 with MEN-1), ductal adenocarcinoma (n = 1), and relapse of endocrine tumor (n = 1); b) totalisation of pancreatectomy was performed in 6 pts for either relapse or incomplete resection performed a median of 2 (0–7) years before. The diagnosis was made preoperatively prior to TP in all patients except 2 (the latter included a case of SLE- related pancreatitis and multicystic chronic ﬁbrosing pancreatitis mimicking IMPT, respectively). Morbidity related to TP and survivals were estimated. RESULTS: Post-operative death was nil. After a median follow-up of 1.4 (0.2– 12) years, 16 patients are still alive (5-year actuarial survival = 70%). Seven deaths occured form relapse of adenocarcinoma (n = 5), late anastomotic ulcer bleeding (n = 1) and hypoglycemia (n = 1). A reversible hypoglycemic coma and a gastrojejunal anastomotic ulcer were observed in 3 (15%) and 5 (20%) patients, respectively. Among the 8 patients with invasive adenocarcinoma, 5 relapsed at a median of 9 (3–19) months. Among the 8 patients not suspected of having malignant IPMT prior to surgery, 3 were found to have invasive cancer after TP. No patient with endocrine tumors died. CONCLUSIONS: After TP: 1) post operative mortality is minimal; 2) mortality due to endocrine insufﬁsency is 4%; 3) anastomotic ulcers are more frequent than after pancreaticoduodenectomy; 4) when an invasive adenocarcinoma is suspected in cases of IMPT, partial pancreatectomy appears to be a more acceptable treatment option in view of the high recurrence rates; and 5) in light of the possibility of diagnostic errors, TP should not be performed without preoperative histology.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1496 When Is Resectable Pancreas Cancer Really Resectable? Matthew J. D’Alessio1, Ivan Parra1, Douglas M. Potter2, Kevin M. Mcgrath3, Herbert J. Zeh1, David L. Bartlett1, Kenneth K. Lee1, Arthur J. Moser1; 1Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Biostatistics, Univerisity of Pittsburgh Cancer Institute, Pittsburgh, PA; 3Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA Despite high-resolution preoperative imaging, many patients with apparently resectable pancreas cancer still undergo non-curative surgical procedures. We quantified factors potentially influencing surgical decision-making in order to generate an algorithm for optimizing the treatment of patients with pancreas cancer. We hypothesize that modern helical computed tomography (CT) and endoscopic ultrasound (EUS) can be used to predict the probability of a complete surgical resection (R0) as well as the likelihood of unsuspected metastases. METHODS: 180 patients underwent surgical exploration for pancreatic neoplasms between 2002 and 2005. All patients underwent modern helical CT using a pancreas mass protocol. EUS was obtained at the discretion of the treating physicians. In addition to preoperative clinical data and tumor markers, CT and EUS findings were compared with the operative results and pathology reports to quantify variables which may predict resectability and analyzed by a biostatistician using both univariate (chi-square & Wilcoxon rank-sum) and multivariate analyses. RESULTS: Of the 98 patients with pancreatic adenocarcinoma, 65 had margin-negative (R0) pancreatic resections, 12 had unsuspected metastases, 11 had positive margins, and 9 were locally unresectable. Resections included pancreaticoduodenectomy (64), distal pancreatectomy (10), and total pancreatectomy (3). 11 patients (14%) required portal vein (PV) resection. The addition of PV resection had no effect on the positive margin rate (p = 0.52). By univariate analysis, predictors of an R0 resection included the absence of vascular involvement (p = 0.02) and tumor size (p = 0.04) by CT, and the EUS stage by AJCC criteria (p = 0.02). Patients with suspected nodal disease by EUS were more likely to have metastases (36% vs. 13%, p = 0.06). Excluding patients with metastases, vascular involvement by CT reduced the R0 resection rate from 80% to 45% (p = 0.01). Moreover, each increase in the EUS stage portended a 2.7 fold increased probability of a non-curative procedure by multivariate logistic regression (p = 0.004). The decrease in the R0 resec- ABSTRACTS

tion rate was particularly evident between EUS stages IIA and IIB, in which POSTER the rate of resectability dropped form 70% to 45% and the R0 rate fell from 55% to 36% (p = 0.01). CONCLUSIONS: The assessment of vascular involvement by CT and preoperative stage by EUS were both highly predictive of resectability as well as R0 status. Using modern imaging, these data provide a probability algorithm for predicting which patients with pancreas cancer are likely to undergo a curative operation and form a basis for optimizing future treatment for this lethal disease.

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M1498 The Influence of Positive Peritoneal Cytology on Survival in Patients with Pancreatic Adenocarcinoma Cristina R. Ferrone1, Peter J. Allen1, David P. Jaques1, Daniel G. Coit1, Barbara Haas2, Yuman Fong1, Murray F. Brennan1; 1Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; 2Surgery, McGill University, Montreal, QC, Canada INTRODUCTION: The current AJCC staging system for pancreatic adenocarcinoma classifies positive peritoneal cytology as stage IV disease. Data are limited, however, with respect to the prevalence of positive peritoneal cytology, and its influence on survival in patients with radiographically resectable, locally advanced, and metastatic disease. METHODS: Peritoneal cytology was obtained in 463 patients undergoing staging laparoscopy for pancreatic adenocarcinoma between Jan 1995 and Dec 2005. Cytology results were not available intraoperatively, and patients without ascites found to have resectable disease at laparoscopy underwent laparotomy and attempted resection. Kaplan-Meier survival comparisons were performed to evaluate the significance of positive peritoneal cytology on overall survival (OS) in resected patients, and in patients with locally advanced and metastatic disease. RESULTS: Pancreatic resection was performed in 218 of the 463 patients (47%) in the study. Locally advanced disease was identified in 104 patients (22%), and 139 (31%) patients had metastatic disease. Peritoneal cytology was positive in 17% of patients (77/463), and was associated with stage of disease (table 1). Cytology was more likely to be positive in the setting of peritoneal, rather than liver, metastases (peritoneal: 29/45, 64% vs. liver: 24/94, 26%; p < 0.001; table 1). Positive cytology was not significantly associated with OS in patients with metastatic disease or locally advanced disease, but was associated with OS in resected patients (Table 1). Node positive disease was present in eight of the ten patients resected with positive cytology. Within the sub-group of resected node positive patients cytologic results were also associated with survival (2yr OS 12% cytology positive vs. 26% negative, p = 0.003).

Table 1. Peritoneal Cytology in Patients with Pancreatic Adenocarcinoma

Locally Resected (n = 218) Advanced (n = 104) Metastatic (n = 139) Positive Cytology 10 (5%) 14 (14%) 53 (38%) 2yr OS positive cytology 10% 36% (p < 0.001) 2% 5% (p = 0.36) 7% 8% (p = 0.96) negative cytology

CONCLUSIONS: Cytology is positive in 5% of resectable cases. These patients have a similar survival to other patients with stage IV disease.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1499 Ischemic Preconditioning Improves Postoperative Liver Function, Following Resection of the Superior Mesenteric-Portal Vein for Pancreatic Adenocarcinoma Craig P. Fischer; Surgery, The Methodist Hospital/Cornell Weill School of Medicine, Houston, TX INTRODUCTION: Resection of the superior mesenteric-portal vein (SMPV)performed at the time of pancreaticoduodenectomy (PD) induces a period of warm hepatic ischemia (WHI). The effects upon hepatic function post operatively have not been well studied, and have implications for postoperative recovery. We analyze the impact of WHI on post-operative liver function, and the impact of the use ischemic preconditioning (IPC) in patients undergoing revascularization of the SMPV axis for locally advanced pancreatic adenocarcinoma. METHODS: Between January 2001 and October 2005, 178 patients underwent PD for periamampullary disease, 42 of whom required resection of the SMPV axis. 18 patients were selected to undergo ischemic preconditioning (IPC), depending upon technical complexity of vascular reconstruction. Peri- operative data were prospectively recorded, including warm ischemia time and post-operative liver function, as well as length of stay in the intensive care unit. Data were compared with students pared t-test. P < 0.05 were considered statistically significant. RESULTS: The age, operative time, hepatic warm ischemia time, blood loss, and length of stay (LOS) in the intensive care unit were statistically similar between patients undergoing IPC and those with no IPC. IPC induced a statistically significant reduction in prothrombin time (and international normalized ratio INR -data not shown) and ALT values, when compared to patients who did not undergo IPC, on the first postoperative day. This effect was abrogated by postoperative day 5. CONCLUSIONS: IPC appears to protect the liver from ischemia-reperfusion injury during resection of the SMPV axis, for pancreatic adenocarcinoma. This is the first report of warm ischemia-mediated hepatic dysfunction following resection of the SMPV performed at the time of P.D. and the protective effects of I.P.C. Methods of hepatic protection may prevent ischemia- reperfusion mediated liver injury during operations, which require hepatic inflow occlusion.

Table 1. Ischemic Preconditioning and Liver Function, Following Resection of the Superior ABSTRACTS

Mesenteric-Portal Vein for Pancreatic Adenocarcinoma POSTER

Number of patients – IPC + IPC P value ALT preop 117 ± 9* 129 ± 11 ns ALT on post operative day 1 317 ± 12 204 ± 13 P < 0.0001 ALT on post operative day 5 166 ± 8 144 ± 12 ns PT preoperative 11 ± 0.5 11 ± .05 ns PT on post operative day 1 19 ± .04 13 ± 0.5 P < 0.0001 PT on post operative day 5 12 ± 0.3 12 ± 0.4 ns

ALT (alanine aminotransferase), PT (prothrombin time [seconds]) * ± standard error (S.E.)

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M1500 Resected Serous Cystic Neoplasms of the Pancreas – 158 Patients: Results and Outcomes Charles Galanis, John L. Cameron, Kurtis A. Campbell, Keith D. Lillemoe, Amir Zamani, David Caparrelli, David Chang, Ralph H. Rhuban, Charles J. Yeo; The Johns Hopkins Hospital, Baltimore, MD BACKGROUND: Serous cystic neoplasms of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. Objective: To perform the largest single institution review of patients who underwent surgical resection for serous cystic neoplasms of the pancreas. METHODS: Between June 1988 and January 2005, 158 patients with serous cystic neoplasms of the pancreas underwent surgical resection. A retrospective analysis of a prospectively collected database was performed. Univariate and multivariate models were used to determine factors influencing perioperative morbidity and mortality. Major complications were defined as pancreatic fistula or anastamotic leak, postoperative bleed, retained operative material, or death. Minor complications were defined as wound infection, postoperative obstruction/ileus requiring TPN, delayed gastric emptying, arrhythmia, or other infection. RESULTS: The mean age of the patients was 62.1 years, with 75% being female. The majority of patients were asymptomatic at presentation (63%). Of the 158 patients, 75 underwent distal pancreatectomy, 65 underwent pancreaticoduodenectomy, 9 underwent central pancreatectomy, 5 underwent local resection or enucleation, and 4 underwent total pancreatectomy. Mean tumor diameter was 5.1 cm. Mean operative time was 277.5 minutes. Mean postoperative length of stay was 11 days. One patient was diagnosed with serous cystadenocarcinoma. The remaining 157 patients were diagnosed with benign serous cystadenoma. Two of three patients with locally aggressive benign disease later presented with metastatic disease. Resection margins for all 158 patients were negative for tumor and only 1 (0.6%) showed lymph node involvement. There was one intraoperative death. Major perioperative complications incidence was 18% while minor complications incidence was 33%. Men were significantly more likely to experience minor perioperative complications (OR = 3.74, P = .008) while patients greater than 65 years showed a trend toward fewer major complications (OR = .36, P = .09). CONCLUSIONS: Serous cystic neoplasms of the pancreas which are surgically resected are typically seen in asymptomatic women with 5 cm neoplasms and are predominantly benign. Most are resected via either a left or right sided pancreatectomy with low mortality risk, but with notable major or minor morbidity. Cystadenocarcinoma is a rare finding on initial resection of serous cystic neoplasms. However, initial pathology specimens exhibiting benign but locally aggressive neoplasia may indicate an increased likelihood of recurrence or metachronous metastasis.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1502 Routine Drainage of the Pancreatic Stump into a Roux-en-Y Loop of Jejunum Decreases the Incidence of Postoperative Pancreatic Fistulas: A Single Centre Study of 42 Consecutive Patients Treated Between January 2002 and September 2005 Markus Wagner, Beat Gloor, Markus Ambuehl, Mathias Worni, Jon-Andri Lutz, Markus Trochsler, Eliane Angst, Daniel Candinas; Department of Visceral and Transplant Surgery, University Hospital, Berne, Switzerland BACKGROUND: Closure of the pancreatic stump after pancreatic left resection (plr) is still a controversial issue. Postoperative pancreatic fistula (ppf) rates of up to 20% after plr have been reported even from high volume centers. While modern imaging guided percutaneous drainage techniques combined with antisecretory regimen circumvent the need for surgical re-intervention in most patients, ppf may prolong recovery and therefore rise in-hospital stay and costs considerably. Therefore, we tested the feasibility of routine drainage of the pancreatic stump into a Roux-en-Y loop following plr in order to decrease the incidence of ppf. METHODS: Group1: Since June 2003, all 23 patients undergoing plr were enrolled into a prospective study. Following plr, the main pancreatic duct and the pancreatic stump were oversewn with PDS and additionally anastomosed into a jejunal Roux-en-Y loop by a single layer PDS suture. A drainage was placed near the anastomosis and patients received octreotide for 5–7 days postoperatively (3 × 0.2 mg sc daily). Drainage volume was registered daily and amylase concentration of drained fluid was recorded every 2nd day. Patient’s demographics, length of hospital stay, incidence of pancreatic fistulas, peri-operative morbidity and follow-up after discharge was recorded and compared with our initial series of patients in whom the pancreatic remnant was oversewn only (Group 2, 19 cases). A pancreatic fistula was defined as secretion of at least 30ml of amylase-rich fluid (more than 5000 units/l) per day for at least 10 days. RESULTS: Indications for plr were: chronic pancreatitis in 7 cases, pancreatic tumors in 28 cases, other tumors in 5 cases and other reasons in 2 cases. Indi- cations for resection and patient demographics were comparable between the two groups. Median Op-time did not differ between groups and was 326 (range 195–480) vs 298 min (range 180–450) in group 1 and 2, respectively.

Median blood loss was 813ml (range 200–4000) in group 1 vs 940 ml (range ABSTRACTS

100–3000) in group 2(n.s.). There was no difference considering the ability to POSTER tolerate an oral diet between the two operative procedure. There were 4 (21%) pancreatic ﬁstulas in group 2 whereas none in group 1 (p = 0.035). Total surgical- related morbidity was 37% in the oversewn group versus 22% in the anastomotic group (n.s.). Median hosp. stay and long-term morbidity was not inﬂuenced by the surgical procedure. CONCLUSIONS: The Roux-en-Y pancreaticojejunostomy prevented the occurrence of ppf and showed a trend towards a lower number of surgery related morbidity following plr. Therefore, we feel at ease to continue our current surgical approach.

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M1503 Has the Dagradi-Serio-Iacono Operation or Central Pancreatectomy Been Correctly Applied in Surgical Practice? Calogero Iacono, Luca Bortolasi, Enrico Facci, Marco Frisini, Andrea Ruzzenente, Alfredo Guglielmi; Surgery and Gastroenterology, University of Verona, Verona, Italy Since the Eighties the panorama of pancreatic surgery has been enlarged with the acquisition of a new operation: central pancreatectomy (CP). This operation was first performed by Dagradi and Serio in 1982 to resect an insulinoma of the pancreatic neck and described by them in 1984. In the last two decades Iacono and Serio have spent their effort to spread CP with correct indications that must be benign or low grade malignant tumours located in the pancreatic neck. In 1997 at 38th SSAT Meeting we put forward a question: “Is there a place for Central Pancreatectomy in Pancreatic Surgery?” (J Gastrointest Surg 1998; 2: 509–517) Now, eight years later, we believe to have the answer supported by our experience and the literature. The aim of the present work is to review our and literature experience in order to verify indications and results of this operation. At the Department of Surgery of the University of Verona 20 patients underwent CP. In the English literature (1988 to October 2005), 353 patients (350 laparotomic and 3 laparoscopic) have been reported. We have taken in consideration number of cases, sex, age, pathological diagnosis, size of tumour, operative time, estimated blood loss, blood transfusion, type of treatment of proximal and distal stumps, local and systemic complications, re-operation rate, mortality rate, length of hospital stay, endocrine and exocrine insufficiency, recurrence rate. Tumour pathology is available in 333 out of 373: the main indication for CP is serous and mucinous cystadenoma (124 pts) followed by endocrine tumours (96 pts) and Intraductal Mucinous Pro- ducing Neoplasms (IMPN) in 44 cases. The most performed reconstruction has been pancreatico-jejunostomy followed by pancreatico-gastrostomy. Considering all the cases (373) morbidity and mortality rate is 35% and 0.2%, respectively, while re-operation rate is 6%. Recurrence rate is 2.3% due to incorrect indication (cancer and IMPN). Endocrine and exocrine insufficiency is 4% and 4.3%. CP is a conservative procedure that is indicated for benign lesion or low grade malignant tumours; in IMPN CP should be applied with caution due to recurrences. Data of literature confirm our hypothesis regarding low mortality and acceptable morbidity, with very low incidence of pancreatic insufficiency. On the other hand it must be noticed that a incorrect indication entails a risk of recurrence and late complications. Eventually the Dagradi-Serio-Iacono operation is correctly applied in almost all the cases reported. However seen the limited number of cases for a single Institution we suggest for the future to collect all the new cases in a database to value more precisely the data.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1504 Distal Pancreatectomy: A Ten-Year Single-Institution Experience Jennifer L. Irani, Stanley W. Ashley, Monica M. Bertagnolli, David C. Brooks, Robert T. Osteen, Richard S. Swanson, Whang E. Edward, Michael J. Zinner, Thomas E. Clancy; Surgery, Brigham and Women’s Hospital, Boston, MA PURPOSE: To evaluate the indications for and the outcomes from distal pancreatectomy at a single institution. METHODS: A retrospective chart review and analysis of all patients who underwent distal pancreatectomy at our hospital between January 1996 and August 2005. RESULTS: Over a 10-year period, 171 patients underwent distal pancreatectomy; mean age was 54 years (range 17–83 years old). The most common indications included cystic (23%) or solid (27%) mass and chronic pancreatitis (7.6%). Nearly one-third of distal pancreatectomies were performed as part of an en bloc resection for a contiguous or metastatic tumor. Fifty-six percent of the patients underwent a standard distal pancreatectomy (± splenectomy), whereas 44% of distal pancreatic resections included additional organs or contiguous intraperitoneal or retroperitoneal tumor. Four cases were resected laparoscopically. The overall postoperative complication rate was 39%; the most common complications were pancreatic duct leak, defined as amylase- or lipase-rich drain fluid (26%), intraabdominal abscess (7.6%), and new onset IDDM (3.5%). There were 5 (3%) post-operative deaths. Ten patients (6%) required re-operation, with the most common indication being small bowel obstruction. The median post-operative length of stay was 9 days. Final pathology demonstrated contiguous/metastatic tumor from another organ (29%), mucinous cystadenoma (12%), pancreatic adenocarcinoma (11%), chronic pancreatitis (11%), neuroendocrine tumor (9.9%), and other (11%). Chi-squared analysis and Fisher’s Exact test revealed that when compared to patients undergoing standard distal pancreatectomy, those with a more extensive resection including multiple viscera and/or metastatic or contiguous tumor resection had no significant difference in overall complication rate (38% v. 41%, p = 0.610), leak rate (27% v. 24%, p = 0.647), new-onset IDDM (3% v. 4%, p = 1.0), and mortality (2% v. 4%, p = 0.656). CONCLUSION: Distal pancreatectomy is performed with relative safety for a wide variety of indications. This series includes a large number of patients in

whom distal pancreatectomy was performed as part of a multivisceral resec- ABSTRACTS

tion or with en bloc resection of contiguous tumor. Complications were no POSTER different in these patients when compared to patients undergoing straightfor- ward distal pancreatectomy. When broadly deﬁned, pancreatic duct leaks were fairly common but usually clinically indolent and easily managed with drains.

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M1505 The Impact of a Microscopic Positive Margin in the Era of Chemoradiation in Patients Undergoing Pancreaticoduodenectomy for Adenocarcinoma Jocelyn M. Logan-Collins, Andrew M. Lowy, Raji Nair, Jefferson Lyons, Laura E. James, Curtis J. Wray, Jeffrey B. Matthews, Syed A. Ahmad; Department of Surgery, University of Cincinnati, Cincinnati, OH INTRODUCTION: Patients with adenocarcinoma of the pancreas have long- term survival of less than 15%. Previous studies have documented worse overall survival in patients undergoing resection with positive margins. Most of these studies have included both R1 and R2 resections. The impact of a R1 (microscopic) resection margin in patients receiving chemoradiation is not clear. METHODS: Our pancreas database was queried for patients undergoing pancreaticoduodenectomy for adenocarcinoma between January 2002 and August 2006. All operative specimens were analyzed to determine the status of their pancreas, bile duct and retroperitoneal margins. Standard demographic, clinicopathologic, and outcome variables were recorded. All patients were divided into either margin negative (R0) or microscopically positive (R1) resections. Standard statistical calculations were performed. RESULTS: Over the study period 80 patients underwent pancreaticoduodenectomy for adenocarcinoma. Of these only 42 patients (12 males, 30 females), completed adjuvant chemoradiation. 29 patients underwent a R0 resection and 13 patients were found to have microscopic positive margin (R1). Patients with grossly positive margins (R2) were excluded from analysis. Positive margins included the retroperitoneal margin (n = 8), and pancreas margin (n = 5). There were no differences between the two groups with respect to age, sex, race, tumor grade, T-stage or angiolymphatic invasion. Patients undergoing a R1 resection had an increased local recurrence rate (42% vs 4%, p = 0.01). A single patient who underwent a R0 resection had a local recurrence 23 months following surgery, while the median time to local recurrence for the R1 group was 8 months. There were no differences in overall survival between R1 and R0 resections. CONCLUSION: Margin positivity can be due to either surgical technique or tumor biology. Despite chemoradiation, an increased recurrence rate was seen in patients with microscopic positive margins, although this did not impact overall survival. Future clinical trials need stratiﬁcation for margin status when analyzing novel adjuvant therapies.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1506 Cystic Lesions of the Pancreas and F-18 Fluorodeoxyglucose Whole Body Positron Emission Tomography: A Review of 68 Cases John C. Mansour, Neeta Pandit-Taskar, Steven M. Larson, Yuman Fong, Peter Allen; Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY BACKGROUND: Previous studies have suggested that malignant cystic lesions of the pancreas can be reliably distinguished from benign cysts with whole body positron-emission tomography (PET). METHODS: We reviewed the Department of Surgery pancreatic cyst database to identify patients who had undergone whole body PET imaging for a cystic lesion of the pancreas between January 1997 and May 2005. A total of 68 patients were identified who had undergone F18 fluorodeoxyglucose (FDG) whole body PET. Patient, cyst, operative, radiographic, and PET imaging characteristics were reviewed. RESULTS: Operative resection was performed in 21 patients (31%), and 47 patients were managed with radiographic follow-up. The average diameter of the cystic lesions was 2.7 cm (0.6 to 15.0 cm), and 66% were discovered incidentally. FDG-avid lesions were identified in eight of the 68 patients (12%), and the average SUV of positive studies was 4.6 (range, 1.9–8.0). Within the resected group of patients, four of seven patients (57%) with either in situ or invasive malignancy (adenocarcinoma: 3/5; papillary mucinous carcinoma: 1/2) had a positive PET scan (mean SUV: 5.9; range 2.5–8.0). Positive PET scans were obtained in two of 14 patients (14%) who underwent resection for a benign lesion (serous cystadenoma 1/5, benign or borderline IPMN 0/3, mucinous cystadenoma 0/2, or pseudocyst 1/4). Within the group of 47 patients being followed radiographically, two patients (4.3%) had FDG-avid lesions. These two patients had lesions with maximum SUV’s of 1.9 and 5.0, and have been followed radiographically without significant change for 15 and 11 months respectively. Within the group of 21 resected patients, the sensitivity of whole body PET imaging for identifying malignant pathology was 57%, and the specificity was 86%. CONCLUSIONS: In this study, whole body FDG PET imaging had a sensitivity of 57% and a specificity of 86% for identifying in situ or invasive histolo- gies. Regional pancreatic PET imaging, or the use of targeted agents, may improve the sensitivity and specificity of PET. ABSTRACTS POSTER

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M1507 Risk Factors for Pancreatic Fistula. Does It Have a Clinical Application for Early Identification of Patients with High Risk to Develop Pancreatic Fistula After Pancreaticoduodenectomy? Andre S. Matheus, Andre L. Montagnini, Jose Jukemura, Ricardo Jurendini, Sonia Penteado, Emilo E. Abdo, Jose Eduardo M. Cunha; Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil Operative mortality rates after pancreaticoduodenectomy (PD) have decreased over the past 3 decades and recent series have reported very low mortality. Nevertheless pancreatic fistula remains the major cause of morbidity. A significant fraction of patients undergoing PD develop a postoperative pancreaticocutaneous leak. To analyze the clinical application of risk factors for pancreatic leakage after PD, we conducted a retrospective review of patients undergoing PD. METHODS: Thirty-seven patients who underwent PD at our hospital between January 2004 and July 2005 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, gastric cancer, and pancreatic metastases. Standard PD was performed for 3 cases and pylorus-preserving PD for 34 cases. A duct-to-mucosa pancreaticojejunostomy was performed in all patients and a transanasto- motic stent was placed in patients with soft pancreas and non-dilated duct. Octreotide was not used after surgery. Four preoperative, two intraoperative, and five postoperative risk factors with potential to affect the incidence of pancreatic fistula were analyzed. The recent established definition of pancreatic fistula was used to make the fistula diagnostic—a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase. RESULTS: Of the 37 patients, 11 (29.7%) were identified as having pancreatic leakage after operation. The hospital mortality in this series was 5.4% (2/37), and the mortality associated with pancreatic fistula was 0% (0/37). General risk factors including patient age, gender, history of jaundice, preoperative nutrition, and pathological diagnosis didn’t have any relation with pancreatic fistula occurrence. Intraoperative risk factor, texture of the remnant pancreas, was not found to be significantly associated with pancreatic leakage. Blood loss, type of resection, and serum amylase level on postoperative day 1 did not have significantly relation with pancreatic fistula. The incidence of pancreatic leakage was 81.9% (9/11) in those patients with abdominal drain amylase level >1000UI/dL on postoperative day 1, it was the only risk factor with significantly relation with pancreatic fistula (p < 0.05). CONCLUSION: Amylase level >1000UI/dL in the abdominal drain on postoperative day 1 shows a significant relation with the occurrence of pancreatic fistula and seems to be an important factor for early identification of development of pancreatic fistula after PD.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1508 Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT Scanning and Endoscopic Ultrasound Susannah Yovino1, Peter Darwin2, Barry Daly4, Michael Garofalo1, Robert Moesinger3; 1Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD; 2Division of Gastroenterology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD; 3Division of Surgical Oncology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; 4Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD BACKGROUND: Accurate preoperative staging optimizes treatment of pancreatic cancer. Predicting unresectability in many cases is very difficult, despite advances in diagnostic imaging technology. We propose a scoring system using computed tomography (CT) scan and endoscopic ultrasound (EUS) that more accurately predicts unresectability in patients with pancreatic cancer than either modality alone. METHODS: Reports of preoperative EUS and CT scans from 79 patients who underwent exploration for pancreatic cancer were reviewed, as were operative notes and surgical pathology reports. Chi-squares were used to identify radiologic factors significantly correlated with unresectability. A total of five factors were identified as predictors of unresectability and incorporated into a scoring system. Each patient received a score of 0–5 by counting the number of criteria fulfilled. RESULTS: Five criteria were identified that predicted unresectability: 1) suspicious liver lesions too small to biopsy or characterize (p < 0.001); 2) adenopathy (>1 cm) identified by EUS (p = 0.05); 3) adenopathy (>1 cm, long axis) identified by CT (p < 0.001; 4) suspicion of vascular involvement on EUS (p < 0.001); and 5) suspicion of vascular involvement on CT (p 0.53; specificity 91%). Patients with scores of 0, 1, 2, and 3 had resectability rates of 83.0%, 36.7%, 15.4%, and 0%, respectively. The most accurate results were achieved in the group of 49 patients who were evaluated with CT and EUS. In this group of patients, all unresectable patients had a score ≥1. 24/30 resectable patients who underwent both CT and EUS had a score of “0,” for an overall accuracy of 88.2%. CONCLUSION: We propose a scoring system combining EUS and CT to ABSTRACTS

assess risk for unresectability in pancreatic cancer. This scoring system is an POSTER effective method of stratifying pancreatic cancer patients into three groups: 1) patients with a score of zero: high probability (83.0%) of successful resection; 2) patients with a score of one: mediocre probability (36.7%) of successful resection; and 3) patients with a score of two or higher: low probability (11.1%) of successful resection. This stratiﬁcation of resection probabilities can be used to guide surgical management.

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M1509 Laparoscopic Distal Pancreatectomy Is a Safe and Effective Treatment for Incidental Pancreatic Lesions Daniela Molena, John A. Primomo, Ammit Khanna, Luke O. Schoeniger; University of Rochester, Rochester, NY BACKGROUND: The role of diagnostic laparoscopy is well accepted in the staging of pancreatic body and tail lesions. Similarly, the feasibility of laparoscopic distal pancreatectomy (LDP) has been demonstrated. To evaluate the indications, safety, and efficacy of LDP we retrospectively review our initial experience with this procedure. PATIENTS AND METHODS: This study reports a single institution experience with 13 consecutive patients (6 F, 7 M, average age 51 ± 16), from 2002 to 2005 whose planned operation was a LDP. Charts were retrospectively reviewed for procedure indication, complications and post-operative outcome. Data are expressed as median value (range 5th–95th percentile). RESULTS: 8 (62%) pancreatic lesions were incidentally found on CT scan. Indication for surgery in asymptomatic patients was the need for diagnosis and a concern for neoplasm. Average lesion size was 2.9 × 2.6 cm. Pathology showed 4 endocrine tumor (3 islet cell and 1 VIPoma), 2 mucinous cystadenoma, 1 adenocarcinoma, 1 plasmacytoma and 5 benign lesions (3 serous cystadenoma, 1 accessory spleen, 1 dermoid cyst). Only 1 procedure was converted to open secondary to high suspicion for malignancy. 11 patients (85%) had a distal pancreatectomy and splenectomy, while 2 (15%) had a splenic preservation. Median operative time was 4.5 hours (range 3–6), median intraoperative blood loss was 75 cc (28–670). There were no deaths. Complications included 1 pneumothorax, 2 self-limited pancreatic leaks, 1 symptomatic pseudocyst presenting two months post operatively and requiring surgical treatment. The median length of hospital stay was 6 days (range 4–10), median diet resumption was 3 days (1–8) and patient controlled anesthesia was discontinued after a median of 3 days (range 0–9). All patients with benign disease had an excellent outcome at a median of 7 months follow up (range 2–24). A single patient who was converted for malignant disease survived for 30 months. CONCLUSIONS: Laparoscopic surgery for resection of pancreatic lesions remains a technically challenging operation. At centers where expertise exists in both laparoscopic and pancreatic surgery, the technique is being increasingly used and offers a valuable tool for the diagnosis and treatment of incidentally discovered pancreatic lesions. This retrospective audit establishes the safety and confirms the effectiveness of LDP even early in the learning curve. LDP affords carefully selected patients the benefits of laparoscopic surgery.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1510 Haemorrhage Following Pancreaticoduodenectomy: A Predictable and Preventable Complication? Gareth J. Morris-Stiff2, Susrutha Wickremseekera2, David Mayer2, John Buckels2, Darius Mirza2, Simon Bramhall2; 1Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom; 2Department of Hepato-Pancreatico-Biliary, Queen Elizabeth Hospital, Birmingham, United Kingdom BACKGROUND: The risk of haemorrhage following pancreaticoduodenectomy (PD) is reported as varying between 1.7–20.2%. Embolisation of bleeding vessels is beneficial in the management of HPB trauma although its role in postoperative haemorrhage is unclear. The aim of this study is to document the prevalence of haemorrhagic complications following PD and to evaluate management strategies. METHODS: All patients undergoing PD between 01/03–06/05 were identified from a prospective database. Patients with a post-operative haemorrhage were analysed to determine the presence of risk factors, management and outcome. RESULTS: 107 patients underwent PD and haemorrhagic complications were noted in 15 patients (14%) (6 primary and 9 secondary bleeds). Primary haemorrhages (fall in haemoglobin/blood in drains, no evidence of leaks or sepsis) were noted on days 1–14 and no preoperative risk factors were present. Primary therapy was; 2 patients embolisation (1 proceeding to laparotomy), 3 laparotomy, and 1 conservative. Mortality was 4/6 (1 embolisation and 3 laparotomy including failed embolisation). Patients with secondary haemorrhage presented at a median of 16 days (range: 2–27). All patients had 1 or more risk factors; prior biliary stenting (n = 6), bactibilia (n = 5), preoperative hyperbilirubinaemia (n = 3), postoperative pancreatic (n = 4) or biliary leak (n = 3), and postoperative sepsis (n = 8). All risk factors were more frequent in patients with secondary haemorrhage than in the others undergoing PD. Pri- mary therapy was; 6 embolisation (successful in only 1 case), 5 laparotomy (4 following failed embolisation, 1 failed embolisation was unfit for laparotomy), 2 managed conservatively. Mortality was 4/9 including 3 patients undergoing laparotomy after failed embolisation and 1 patient where embolisation failed but laparotomy was not performed. CONCLUSIONS: Haemorrhage is common following PD and has a high mortality. Embolisation does not appear effective in controlling haemorrhage and

might delay deﬁnitive management. ABSTRACTS POSTER

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M1511 Endoscopic Ultrasound Reliably Identifies Chronic Pancreatitis When Other Imaging Modalities Have Been Non-Diagnostic Gareth J. Morris-Stiff1, Phillip Webster1, Ben Frost3, Wyn Lewis3, Malcolm C. Puntis1, Ashley Roberts2; 1Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom; 2Department of Radiology, University Hospital of Wales, Cardiff, United Kingdom; 3Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom OBJECTIVES: There are classical radiological features for the diagnosis of chronic pancreatitis (CP) on endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT), however, not all patients exhibit these features despite convincing clinical histories, which may result in diagnostic delay. The aim of this study was to assess the use of endoscopic ultrasound (EUS) in the diagnosis of CP when other imaging modalities had not yielded a diagnosis. METHODS: All patients undergoing pancreatic EUS between January 1996 and December 2004 were identified from the radiology computerised database. Sixteen patients with a clinical diagnosis of CP (10 male, mean age 53 ± 4 years) underwent EUS after normal conventional imaging. RESULTS: Thirteen patients exhibited features of CP unidentified by other modalities, which included duct dilatation (n = 8), calcification (n = 7); parenchymal change (n = 6), irregular undilated ducts (n = 2), and pancreatic ductal calculi (n = 1) and fine calcification. Of the remaining 3 patients, a diagnosis of sclerosing pancreatitis was made in one, in another, there was a pancreatic duct stricture of uncertain origin which was stented, and in only 1 case was no diagnosis established. CONCLUSIONS: EUS provided additional diagnostic information in 94% of patients in the above series, in particular early CP, when cross-sectional imaging or ERCP had failed to support a diagnosis of CP. EUS should be used as a second line investigation in the face of patients with negative CT and MRCP with convincing clinical diagnoses of CP.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1512 Long Term Follow-Up of Patients Who Survive an Episode of Acute Necrotizing Pancreatitis (ANP) William H. Nealon, Taylor S. Riall; Surgery, University of Texas medical Branch, Galveston, TX BACKGROUND: Considerable attention has been paid to the issuessur- rounding an episode of ANP. There have been few reports examining the long term outcomes in these patients. OBJECTIVE: We aim to provide data regarding the natural course in patients who have survived an episode of ANP. METHODS: Since 1985, patients who survived ANP and were followed for more than one year were included in our study. ANP was defined as more than 5 Ranson prognostic indicators,as stay of at least 5 days in the ICU and radiographic evidence of necrosis.Note was made of the measures required during the acute event. Patients were monitored for re-hospitalization,repeat episodesof acute pancreatitis (AP), need for operation, percutaneous or endoscopic procedures, persistent drainage after operation or nonoperative measures, pseudocyst, main pancreatic duct (MPD) injuries and need for insulin or enzymes. RESULTS: We have followed 134 patients for a mean follow-up of 61 months.44 patients were transferred after their episode of ANP. Necrosec- tomy/debridement was performed in 64 patients. Percutaneous treatment was used in 56 patients including 24 of the necrosectomy patients. 71 patients had gallstone AP. 53 patients had an uncomplicated long term course. MPD in 42 of these 53 was normal in 38 and mild stricture in 4.81 patients had a complicated course. 77 required operation for pseudocyst (35/77) inflammatory mass or persistently draining fistula (37/77) and for recurrent AP with or without these other findings (57/77) Among the 134 survivors 79 became insulin dependent (24 after late surgery). There was one death in a late operated patient. MPD disruption,stricture or leak was seen in all 81 complicated patients. No repeat episodes of ANP was seen. No patient with gallstone AP had a repeat episode of AP in spite of a mean interval to cholecystectomy of 39.2 days. CONCLUSION: Survivors of ANP are at risk for subsequent complications primarily predicated upon MPD injuries. Operative management is often required and can be performed safely. ABSTRACTS POSTER

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M1513 Laparoscopic Pancreaticoduodenectomy – A Single Centre Experience of 35 Cases Chinnuswamy Palaninvelu, Palanisamy Senthilnathan, S. Rajapandian, P.S. Rajan; Department of Surgical Gastroenterology & Minimal Access Surgery, GEM Hospital India Pvt Limited, Coimbatore, India BACKGROUND: In this fast growing laparoscopic era more and more complex challenging surgeries have been performed by laparoscopic method. Pancreaticoduodenectomy is one of the most important among all. So far very few literature have been published describing this procedure. The aim of this article is to emphasis the technically feasibility of laparoscopic pancreaticoduodenectomy (Whipple’s procedure) and their added advantages over the conventional open method. METHODS: All patients (35) who had undergone laparoscopic Whipple’s procedure during April 1998 to June 2005 at Coimbatore Institute of Gas- trointestinal Endo Surgery (CIGES), GEM hospital were included. Among them 19 were males and 16 were females. Age varies from 28 to 63. Mean age was 48.7. The indications include ampullary growth, early carcinoma head of pancreas, small distal CBD growth and duodenal carcinoma. RESULTS: Mean duration of surgery is 6.4 hours (400 minutes). The average blood loss was 395 ml. The mean post operative high dependency unit (HDU) stay was 3.2 days and the average hospital stay was 10.2 days. The post operative complications were drastically reduced when compared to open method. Most of them passed flatus after 48 hours. Nasogastric aspiration was <50 ml in 48 hours and thus removed. Oral fluids started on the 3rd or 4th post operative day. None of them had post operative pulmonary complications like atelectasis or pneumonia. There were two pancreatic leaks in my series so far. One of the patients developed features of cholangitis which was subsided with change of antibiotics. Most of them passed flatus after 48 hours. Oral fluids started on the 3rd or 4th post operative day. Wound infection was virtually absent. None of them had post operative pulmonary complications like atelectasis or pneumonia. There were two pancreatic leaks in my series so far. One of the patients developed features of cholangitis which was treated with antibiotics. One of the patients had prolonged gastric stasis for which we did laparotomy on the 12th post operative day. Morbidity has been well reduced to 10–20% when compared to 40–60% of open method. CONCLUSION: The outcome to date, including ours are encouraging, and we conclude that with advanced instrumentation and improved skills, laparoscopic pancreaticoduodenectomy is feasible and requires further training and education.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1514 Endoscopic and Surgical Management of Pancreatitis in Pancreas Divisum Anand C. Patel, Maurice E. Arregui; Surgery, St. Vincent Hospital, Indianapolis, IN INTRODUCTION: Current management of pancreatitis associated with pancreas divisum involves therapeutic ERCP as the initial treatment modality. In those who do not respond to endoscopic therapy, surgery remains an important intervention. We present our experience of 21 patients with pancreatitis and pancreas divisum. METHODS AND PROCEDURES: A retrospective review of 21 charts from one surgical service was performed with the inclusion criteria being only the diagnosis of pancreatitis and pancreas divisum from 1997 to the present. Data collected consisted of demographics; number, frequency, and types of endoscopic intervention; surgical intervention; and response to therapy. RESULTS: There were 6 males and 15 females. Ages ranged from 16–89 years (mean 47.8 years). 16 Patients (76.2%) were primarily referred to our service and 5 patients (23.8%) were referred for surgery by gastroenterologists. 17 patients (81.0%) were successfully treated with various techniques. 3 patients (14.3%) have failed multiple treatment strategies. 1 patient (4.8%) who had a pancreaticoduodenectomy was lost to follow up. All 21 patients were initially managed by ERCP. 11 patients (53.4%) were managed solely by therapeutic ERCP. These patients underwent a mean of 3.4 (range 1–7) ERCP with sphincterotomy and stenting. This cohort remains asymptomatic for a mean of 40.0 months (range 2–98). Surgical management was used for 10 patients (47.6%) in whom ERCP was not possible (3), had little or no resolution of symptoms from ERCP (4) or no longer desired further endoscopic treatments (4). 6 patients (28.6%) underwent open transduodenal sphincteroplasty. 3 patients are asymptomatic at a followup of 9.3 months (range 5–13). 1 patient has had recurrent symptoms. 2 patients were further managed by pancreaticoduodenectomy; both with dramatic improvement. 4 patients (19.0%) had pancreaticoduodenectomy as a second intervention; 2 patients have reduced symptoms. CONCLUSION: Endoscopic intervention in pancreas divisum is the appropriate initial tool as both diagnostic and therapeutic measures. Operative management may be used for those patients who have multiple recurrent stenoses, patients in whom endoscopy is not technically feasible or no longer desire endoscopy. Open sphincteroplasty is the most suitable initial surgical ABSTRACTS

intervention. Pancreaticoduodenectomy may be applicable in select refrac- POSTER tory cases.

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M1515 Enucleation of Endocrine Pancreatic Tumors: 25-Year Experience Sergio Pedrazzoli1, Claudio Pasquali1, Cosimo Sperti1, Sabrina Scappin1, Paola Baratella1, Guido Liessi2; 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Department of Radiology, Castelfranco Veneto Hospital, Castelfranco Veneto (TV), Italy BACKGROUND: Enucleation of pancreatic endocrine tumors (PETs) is considered a simple operation from the technical point of view, but with a pancreatic fistula rate ranging from 25 to 50%. A pancreatic related local complication rate of 29% is reported also after laparoscopic enucleation (1). AIM: Retrospective evaluation of our series of PETs that underwent surgical treatment. METHODS: From 1980 to 2004, 109 patients underwent surgery for PET. Enucleation was performed in 33 patients, while 76 underwent several different procedures; 24 (73% of cases) were insulinoma. Age, sex, site and size of the tumor, associated diseases, hospital stay and complications were retrospectively reviewed by the clinical records. Since 1986 intraoperative ultrasonography (IOUS) allowed us to choose among different surgical procedures in relation to the distance of PET from the Wirsung duct. Furthermore, after enucleation IOUS allowed to verify that the Wirsung duct was intact. RESULTS: Patients (12 males and 21 females) averaged 56.8 years, range 20– 86 years. Mean size of the tumor was 1.7 cm and 54.5% were in the pancreatic head; 78.8% of cases had medical associated diseases. Overall hospital stay averaged 12 days (range 6–81 days) and it was reduced to 8.9 days in the last 5 years. Mean period of gastric suction was 4 days. Sixty percent had an uneventful postoperative course. Complications were divided in early (related to pancreatic surgery, to general open surgery and medical) and late events. Complication related to pancreatic surgery were 6/33 (18.2%); 5 pancreatic fistulas (4 low output) and 1 acute pancreatitis, while 5/33 had a general surgery complication (2 leaking due to gastric and duodenal associated operations). Medical complications were recorded in 7 cases. Late complications occurred in 4 cases (2 laparocele, 1 pseudocyst, and 1 keloid). No patient underwent surgery for pancreatic complication; 1 underwent treatment for evisceration and a somatostatinoma patient underwent urgent parathyroidectomy for postoperative hyperparathyroidism. No mortality occurred. Of notice, the fistula rate of the 24 insulinoma was 8% (2/24), and no fistula was registered since 1986 among 17 insulinoma patients in whom IOUS was applied. CONCLUSION: In our experience enucleation of PETs can be performed with a very low pancreatic fistula rate provided that IOUS is performed.1) Mabrut JY, et al. Laparoscopic pancreatic resection: results of a multicenter European study of 127 patients. Surgery. 2005 Jun;137(6):597–605.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1516 Conservative Treatment of Postoperative Pancreatic Fistulas Sergio Pedrazzoli1, Claudio Pasquali1, Cosimo Sperti1, Sabrina Scappin1, Guido Liessi2; 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Department of Radiology, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy BACKGROUND: Pancreatic fistula is a feared complication after pancreatic surgery. Surgical treatment and mortality rate decreased during recent years, but the mortality risk from a major pancreatic fistula is up to 28% due to retroperitoneal sepsis and hemorrhage (1). AIM: Retrospective evaluation of the incidence of pancreatic fistula, and of the results of treatment, of patients who underwent pancreatic surgery. Methods. From January 1994 and August 2005, 307 patients underwent pancreatic surgery for benign, borderline or malignant diseases. Nine total pancreatectomies were excluded living a total of 298 patients. The output and amylase concentration of abdominal drains were determined during the postoperative period. Drains were removed within 8 days whenever possible. A pancreatic fistula was diagnosed on the basis of drainage of more than 50 ml of amylase- rich fluid (>5000 IU)/day. Once diagnosed, the drain was exchanged under fluoroscopic control; a pig-tail catheter was also inserted trough the fistula in the intestinal lumen whenever possible. A control contrast injection under fluoroscopy was performed once or twice a week, and the drains exchanged whenever needed. Aim of the treatment was to create a straight external fistula that then closed immediately after removing the drain. RESULTS: Out of 298 patients: 119 underwent surgery for pancreatic or periampullary cancers, 66 for endocrine pancreatic tumors, 45 for cystic tumor of the pancreas, 14 for IPMN; 42 for chronic pancreatitis, 11 for pseudocyst post SAP, one for thesaurismosis. A pancreatic fistula was diagnosed in 45 patients (15.1%). The fistula rate was 8.8% (10/114) after pancreatoduodenectomy, 9.6% (8/83) after left pancreatectomy, 46.1% (12/26) after central pancreatectomy, 47% (8/17) after DPPHR, 17.2% (5/29) after enucleation, 6.6% (1/15) after pancreatico-jejunostomy, 20% (1/5) after subtotal pancreatectomy, 0% after cystojejunostomy (0/9). All but one underwent conservative treatment. A patient in dialysis for renal insufficiency developed abrupt generalized peri- tonitis 8 days after PD. She underwent surgical treatment aimed to recreate the condition of a guided external fistula as for the other patients. All fistulas closed spontaneously after a mean of 25 days (range 4–60). No patient died of pancreatic fistula. ABSTRACTS POSTER CONCLUSION: An early and intensive interventional radiology treatment of external pancreatic fistulas can avoid severe complications that usually need surgical treatment and, in some cases, a high risk completion pancreatectomy. 1) Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Review. Dig Surg 2004;21:262–74.

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M1517 Establishing Standards of Quality for Elderly Patients Undergoing Pancreaticoduodenectomy Wande Pratt, Tsafrir Vanounou, Shishir Maithel, Charles M. Vollmer, Mark P. Callery; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA BACKGROUND: Pancreaticoduodenectomy (PD) in the elderly is plausible and safe. To date, current standards of quality for the elderly, and how they compare to those for younger patients, remain unclear. We examined our clinical outcomes and complication rates for elderly patients using a cost- analysis model designed to identify elements for quality improvement. METHODS: 166 consecutive patients underwent PD from 10/01 to 11/05. Two patient cohorts deﬁned as elderly (≥75 years) and non-elderly (<75 years) were compared in terms of clinical outcomes. A complication-based cost analysis was developed by merging 4 degrees of clinical impact (none, minor, moderate, and severe) with length of stay (LOS) data, and assigning related costs to reveal the quality impact of complications. RESULTS: Elderly patients comprised one-fourth of all patients. Benchmark standards of quality were achieved in the elderly, and included median EBL 375 ml, LOS 9d, mortality 2.6%, and readmission 8%. Despite higher patient acuity (ASA class III/IV 82% vs. 59%), these clinical outcomes were comparable to those of non-elderly patients at a total cost increase of only $1,913 per case. However, complication-based cost analysis revealed unique features of PD in the elderly (Table). Minor complications were no more debilitating for elderly patients than for younger patients. Moderate complications required more interventions (blood transfusion, supplemental parenteral nutrition, percutaneous drainage), although costs for the elderly remained comparable to those for younger patients. However, Severe complications were far more threatening to older patients. LOS doubled, ICU duration was >4× longer; and elderly patients more commonly required invasive interventions. These outcomes drove higher costs and increased resource utilization but helped to identify new care-delivery strategies that could improve quality going forward. Table 1. Impact of Complications: Non-Elderly vs. Elderly

Complication Outcome Non-Elderly n = 128 Elderly n = 38 Minor Complications LOS (median days)\Total Cost (median) 10 \$27,336 9 \$21,646 LOS (median days)\Total Cost (median) 15 \$35,671 16 \$37,092 Moderate Complications Hospital transfusion (%) 3 (21%) 3 (38%) TPN (%) 6 (43%) 5 (63%) Percutaneous drainage (%) 1 (7%) 2 (25%) LOS (median days)\Total Cost (median) 15 \$46,610 33 \$120,082 ICU duration (median days) 4 18 Severe Complications Percutaneous drainage (%) 2 (29%) 3 (60%) Reoperation (%) 5 (71%) 5 (100%)

CONCLUSION: Quality standards for PD in the elderly can and should equal those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and planned early rehab placement, can be designed to mitigate the impact of complications in the elderly, and guarantee quality.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1518 Drain Amylase Levels Following Pancreatico- duodenectomy for Cancer: Correlation with Outcomes and Proposal for a Uniform Grading System H. Ramesh, Sadiq S. Sikora; Lakeshore Hospital & Research Center, Cochin, India BACKGROUND: There are no clear cut, widely applied identified criteria for diagnosing pancreato-enteric anastomotic leak in practice. AIM: Analyse the drain fluid amylase levels on Days 1, 3, 5,7 after surgery and correlate with clinical outcomes. METHODS: The data of 100 patients who underwent pancreaticoduodenectomy for malignancy were analysed. Drain fluid amylase levels were recorded, and correlated with other clinical parameters such as fever, tachypnoea, raised leucocyte counts, intra abdominal collection, delayed restoration of intestinal function as evidenced by intolerance to enteral feeding. RESULTS: Three patterns of drain fluid amylase levels were identified: a) persistently low <500 Units or <3 times serum amylase: group A; n = 56b) High drain amylase levels >500 units or >3 times serum amylase on Day1, 3 which reduced to low levels by Day 5; group B; n = 29c) Peristently high drain amylase levels which did not decrease below three times serum amylase by Day 5; Group C. n = 15A correlation with patient parameters is described in the table. Accordingly, a proposal is made for a uniform grading system for pancreato-enteric anastomotic leak following pancreaticoduodenectomy: Type 1: Drainage of clear fluid with amylase levels over 1000 Units/mla. Drain output less than 50 mlb. Drain output 50 ml or greater Type 2: Type 1 plus turbid/ ‘coca cola’ fluid drainage or two of the following: a.) fever, b.) raised counts, c.) intra-abdominal collection, d.) delayed intestinal function as evidenced by failure of enteral feeding, ileus, etc. Type 3: Type 1+2+bleed a. intraperitoneal manifesting as drain output or intra-abdominal hemorrhagic collection

Table 1. Patient Parameters and Amylase Levels

Parameter Group A: n = 47 Group B: n = 38 Group C: n = 15 P Value Turbid drain fluid 3 3 13 < 0.01 Fever 7 9 10 < 0.01 Raised leucocyte count 14 17 11 < 0.01 Tachypnea 4 4 8 < 0.01 Intra abdominal collection 6 4 8 0.01 ABSTRACTS

Intolerance to enteral feeding 7 5 7 0.01 POSTER Late bleeding 0 0 4 < 0.01

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M1519 Reduction in Pancreatic Leak Following Distal Pancreatectomy – A Novel Technique Utilizing an Autologous Falciform Patch Jose Ruben Rodriguez, Andres Oswaldo Razo, Jennifer A. Wargo, Sarah P. Thayer, Andrew L. Warshaw, Carlos Fernandez Del-Castillo; General Surgery, Massachusetts General Hospital, Boston, MA RATIONALE AND OBJECTIVE: Leakage from the pancreatic stump (PL) is the most common complication following distal pancreatectomy, and its incidence has remained unchanged. The purpose of this study was to assess the effectiveness of a novel pancreatic stump closure technique utilizing an autologous patch taken from the falciform ligament. PATIENTS AND METHODS: The hospital and clinic records of 316 patients who underwent distal pancreatic resections at Massachusetts General Hospital from 1994 to 2005 were reviewed. Pancreatic leak was carefully defined a priori as a pancreatic fistula, abscess or amylase rich sterile collection. 256 cases were performed over the first 10 year period and served as a historical control group. The experimental group consisted of 60 patients who underwent elective distal pancreatectomy from 08/04 to 11/05. In these patients, the pancreatic stump was closed with interlocking mattress silk stitches and sealed with a peritoneal patch taken from the translucent portion of the falciform ligament adhered by a layer of fibrin glue. Data regarding their clinical course was recorded prospectively and compared with the control group. RESULTS: Overall, there were 60% women and the test and control groups were comparable with regard to their clinical characteristics. The most frequent diagnosis was neuroendocrine tumor (19%) followed by ductal adenocarcinoma (16%). The overall leak rate in the control group was 35% and did not change over time. The patch group leak rate was 22% (p = 0.05). The added cost of this intervention was $160, and did not prolong median operative time. Mortality was 0.8% in the control group and there were no deaths in the test group. The postoperative length of stay was lower in the patch group (mean 5.7 ± 1.6 vs. 7.5 ± 5.0, median 5 vs. 6, range 3–56, p < 0.001). CONCLUSIONS: Complications derived from PL following distal pancreatectomy continue to present a challenge. The technique of stump closure described herein decreased the pancreatic leak rate by 37% and shortened length of stay. The minimal added cost is readily justified. A randomized trial should be undertaken to confirm the utility of this technique.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1520 Long-Term Outcome After Distal Pancreatectomy for Chronic Pancreatitis Thomas Schnelldorfer1, Joshua M. Hubbard1, David N. Lewin2, David B. Adams1; 1Department of Surgery, Medical University of South Carolina, Charleston, SC; 2Department of Pathology, Medical University of South Carolina, Charleston, SC INTRODUCTION: Distal pancreatectomy has an important role in the treatment of selected patients with severe chronic pancreatitis. This single-institution experience reviews the outcome after distal pancreatectomy for chronic pancreatitis. METHODS: The records of 91 consecutive patients who underwent distal pancreatectomy for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Long-term outcome was assessed by patient survey with a mean follow-up of 5.1 years. RESULTS: Indication for distal pancreatectomy was pancreatic duct disruption in 57 patients, intractable pain in 26 patients, and inflammatory mass within the tail in 8 patients. Peri-operative morbidity was 29% with intraabdominal abscess (16%) and pancreatic fistula (5%) being the most common complications. Risk factors for increased morbidity were malnutrition, duration of symptoms, POSSUM physiologic score, and degree of parenchymal fibrosis. ICU stay was necessary in 13% of patients. Bowel function was regained 4 ± 0.2 days after procedure and patients’ average length of stay was 8 ± 1.4 days. There were two peri-operative deaths. Thirty-four patients were lost to follow-up and 7 patients died in the follow-up period. Thirty-eight percent of the remaining 50 patients were pain free and 22% had good pain control after the procedure. Seventy-two percent returned to work. Quality of life assessed by SF-36v2 questionnaire showed a mean physical component score on the 42 ± 1.6 percentile and a mean mental component score on the 47 ± 1.3 percentile using norm-based scoring. New onset of endocrine and exocrine insufficiency was present in 46% and 20% of patients respectively. Patients’ weight at follow-up was practically unchanged (mean weight loss 1 ± 1.2 kg). CONCLUSION: In patients with disease localized to the tail and body of pancreas causing pancreatic duct disruption, inflammatory masses, or intractable pain, distal pancreatectomy for chronic pancreatitis can be performed with a low mortality and acceptable morbidity. The procedure can provide good

pain control, return to work, and satisfactory quality of life in the majority of ABSTRACTS

patients. POSTER

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M1521 Durability of Portal Venous Reconstruction Following Resection During Pancreaticoduodenectomy Rory Smoot1, John Christein2, Michael Farnell1; 1Surgery, Mayo Clinic, Rochester, MN; 2Surgery, Univerisity of Alabama Birmingham, Birmingham, AL BACKGROUND: Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). There are multiple options for reconstruction of the mesenteric venous system ranging from primary repair to grafting with autologous or synthetic material. Few studies report on the patency rates and long-term morbidity of these repairs. We sought to describe our experience with venous reconstruction during PD with speciﬁc attention to patency and long-term morbidity and mortality. HYPOTHESIS: Thrombosis rates of mesenteric venous reconstruction during PD are low, with low associated morbidity. DESIGN: Retrospective Cohort. PATIENT AND METHODS: Clinical, operative, and pathologic data were collected from consecutive patients 1988–2003. Graft patency on follow-up imaging studies was determined and short as well as long-term morbidity and mortality were recorded. RESULTS: Sixty-four patients underwent PD with venous resection/ reconstruction from 1988–2003. Mean age was 63 years with pancreatic ductal adenocarcinoma as the pathology in 88%. Reconstruction consisted of primary lateral venorrhapy in 29 (45%), PTFE graft in 18 (28%), primary end- to-end repair in 13 (20%), and autologous vein graft in 4 (6%). There was one peri-operative death (2%). Follow-up imaging to assess patency was available for a mean of 12.2 months postoperatively. Eleven thromboses were diagnosed at a mean of 11.9 months. Three thromboses (5%) were noted within 30 days requiring full anticoagulation. Fifty-three percent of patients received anticoagulation with aspirin, warfarin, or clopidogrel. There was no difference in thrombosis rates in those receiving anticoagulation and those that did not (p = 1.0). In those patients with thrombosis outside the acute time period morbidity was limited to ascites in three patients and splenic vein thrombosis with uncomplicated esophageal varices in another patient. CONCLUSIONS: Mesenteric venous resection and reconstruction during PD has a high patency rate, and those reconstructions that do thrombose are associated with a low morbidity. The majority of reconstruction thromboses are associated with recurrence.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1522 Aggressive Pancreatic Resection for Benign and Malignant Pancreatic Neuroendocrine Tumors: Is It Justiﬁable? Swee H. Teh, John G. Hunter, Brett C. Sheppard; Department of Surgery, Oregon Health & Science University, Portland, OR INTRODUCTION: Benign and malignant pancreatic neuroendocrine tumors (PNET) are rare and long term outcomes are generally poor without surgical intervention. The aim of the study is to determine whether aggressive pancreatic resection is justiﬁable for patients with PNET. METHODS: All consecutive patients that had undergone major pancreatic resection for PNET from Jan 1997 to Jan 2005 were retrospectively reviewed and analyzed. RESULTS: There were 33 patients (16 M, 17 F) with mean age of 53 year old. Five patients had MEN I and 1 patient had von Hippel-Lindau syndrome. There were 20 benign (9 functional) and 13 malignant (6 functional) neoplasms. The mean tumor size was 4.2 cm with multiple tumors noted in 10 patients (33%). 8 patients (25%) had a pancreticoduodenectomy, 4 patients (12%) had extended distal pancreatectomy and 21 patients (63%) had a standard distal pancreatectomy. Regional lymph node involvement was present in 10 patients (30%) and 6 patients (18%) had liver metastases. 4 patients (12%) had resection of an adjacent organ due to disease extension. The median intra-operative blood loss was 500 ml. Perioperative morbidity was 36% (12 patients) and mortality was 3% (1 patient). Symptomatic palliation was complete in 93% (14/15 patients) and partial in 1 patient due to unresectable hepatic disease. The median hospital stay was 11.5 days. The median disease free survival was 20 months for patients undergoing complete resection. After a median follow up of 36 months, disease progression and the survival rate in patients with malignancy was 75% (9/12 patients) and 58% (7/12 patients), respectively. There were no local recurrences. 4 patients had progression of their unresectable hepatic metastases. They were treated with chemoembolisation/infusion therapy and 2 patients subsequently developed bony metastases. Disease progression resulted in mortality in 5 patients (42%). 1 patient with metastatic insulinoma developed recurrent endocrine symptoms. New hepatic lesions developed in 4 patients, 2 were treated with partial hepatic resections, 1 with TACE and 1 with observation. The sole long term survivor after hepatic recurrence is disease free at 36 months following hepatic resection. ABSTRACTS

CONCLUSIONS: Aggressive pancreatic resection for PNET can be performed POSTER with low perioperative mortality and morbidity. Unlike available non-operative therapy this approach offers an excellent means of symptomatic palliation and local disease control. In malignant PNET metastatic recurrence is not uncommon and will usually require additional multimodality therapy. When possible an aggressive approach to PNET is justiﬁed to optimize palliation and survival.

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M1523 Tissuelink™ Decreases Pancreatic Complications After Distal Pancreatectomy in a Porcine Model Mark J. Truty1, Florencia G. Que1, Sunni A. Barnes2, Lawrence J. Burgart3; 1Surgery, Mayo Clinic, Rochester, MN; 2Biostatistics, Mayo Clinic, Rochester, MN; 3Pathology, Mayo Clinic, Rochester, MN BACKGROUND: Fistula from the remnant pancreatic stump after distal pancreatectomy has an incidence of 20% or higher. Many techniques have failed to decrease the rate of this complication. A device used for renal and hepatic soft tissue coagulation and hemostasis, Tissuelink™, offers the possibility of sealing the parenchyma of the pancreatic stump using saline-cooled radiofrequency energy without the need to oversew. HYPOTHESIS: Tissuelink™ treatment of the pancreatic stump leads to fewer leaks and subsequent complications after distal pancreatectomy compared to traditional stump closure. METHODS: 40 large domestic swine underwent distal pancreatectomy/ splenectomy and were randomized to traditional oversewing of the stump (n = 20) or Tissuelink™ treatment of the stump alone (n = 20) after transec- tion. Post-operatively, animals were inspected by blinded observers for complications. Drain fluid was collected daily for the first 10 post-operative days and sent for amylase determination. Half the animals in each group underwent necropsy at 3 or 5 weeks post-operatively. At necropsy the operative site was inspected for undrained fluid collections or abscesses and fluid sent for amylase determination. The proximal pancreatic duct was injected retrograde with methylene blue dye to assess for extravasation. The distal pancreatic resection margin was fixed in formalin for histologic analysis by a blinded pathologist. Primary endpoints were: dye extravasation, undrained amylase- rich fluid collections or abscesses, and greater than 3-fold drain-to-serum amylase activity after the 3rd post-operative day. Secondary endpoints included prolonged post-operative narcotics, lethargy, anorexia, emesis, and bowel or wound complications. RESULTS: The total rate of pancreatic complications in the Tissuelink™ group was 5% vs. 40% in the control group (p = 0.01). These complications included dye extravasation (n = 0 Tissuelink™ and n = 3 Control) and undrained amylase-rich fluid collections/abscess (n = 1 Tissuelink™ and n = 5 Control). There was a greater than 3-fold mean drain-serum amylase activity in the control group versus Tissuelink™ on post-operative days 3–8. There were no differences in other clinical measures between groups. Histologic analysis supported necropsy findings. SUMMARY: Tissuelink™ treatment of the pancreatic remnant leads to fewer pancreatic complications compared to traditional methods of stump closure after distal pancreatectomy in a porcine model. CONCLUSION: Tissuelink™ treatment appears to be a feasible alternative to traditional methods of stump closure and may have benefit in minimizing pancreatic leaks after resection in the clinical setting.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1524 Predictive Factor for Malignant Branch Duct Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas: Can Clinical Symptoms and Morphological Features Predict the Malignancy? Kenichiro Uemura1, Yoshiaki Murakami1, Yasuo Hayashidani1, Takeshi Sudo1, Yasushi Hashimoto1, Tamito Sasaki2, Taijiro Sueda1; 1Surgery, Hiroshima University, Hiroshima, Japan; 2Gastroenterology, Hiroshima University, Hiroshima, Japan BACKGROUNDS: In branch duct intraductal papillary mucinous neoplasms (IPMNs), the previous reports suggest the predictive factors for malignancy or invasive carcinoma by morphological features and symptoms (e.g., size of the cystic lesion, mural nodule, jaundice). OBJECTIVES: The purpose of the present study was to identify useful predictive factors for malignant branch duct IPMNs of the pancreas. METHOD: Among 77 IPMNs of the pancreas, 37 patients with branch duct IPMNs without main pancreatic duct dilatation (<6 mm) treated surgically at Hiroshima University Hospital from 1990 to 2005 were reviewed. These patients consisted of 27 patients with adenoma, 5 patients with borderline lesion, 4 patients with non-invasive carcinoma, and 1 patient with invasive carcinoma (According to WHO classiﬁcation of tumours). Preoperative predictive factors of malignant IPMNs were analyzed among 13 factors including age, gender, pain, jaundice, diabetes, extrapancreatic malignancy, serum CEA, serum CA19-9, tumor location, diameter of cystic lesion, mural nodule, patulous papilla, and pancreatic juice examination (cytology, telomerase activity) by statistical analysis. RESULTS: Table 1.: Predictive factor for malignancy in Branch duct IPMN of the pancreas Pancreatic juice examination was the only signiﬁcant factor associated with malignant IPMNs. Table 1.

Benign (n = 32) Malignant (n = 5) P value Age 65 ±11 64 ± 8 0.369 Gender (Male%) 78% 40% 0.127 Pain 36% 20% 1.00 Jaundice 0% 0% 1.00 Diabetes 15% 0% 1.00 Other malignancy 22% 0% 0.559 Raised serum CEA 14% 0% 1.00

Raised serum CA19-9 23% 0% 0.558 ABSTRACTS Tumor location (head%) 60% 100% 0.139 POSTER Cyst size >30 mm 41% 40% 1.00 Mural nodule 50% 40% 1.00 Patulous papilla 25% 0% 0.555 Pancreatic juice exam positive 12% 100% <0.01 CONCLUSIONS: Carried out single institution analysis showed predictive factor for malignant branch duct IPMNs of the pancreas. It is of note that asymptomatic branch duct IPMNs without typical morphological features can harbor malignant components. This study suggests that pancreatic juice examination may be indispensable for proper management of branch duct IPMNs.

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M1526 Endoscopic Ultrasound Is Remains Important in the Staging of Pancreatic Carcinoma Gareth J. Morris-Stiff1, Phillip Webster1, Ben Frost3, Wyn Lewis1,3, Malcolm C. Puntis1, Ashley Roberts2; 1Department of Surgery, University Hospital of Wales, Cardiff, United Kingdom; 2Department of Radiology, University Hospital of Wales, Cardiff, United Kingdom; 3Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom OBJECTIVES: The traditional radiological staging of pancreatic carcinoma by pancreatography allied to cross-sectional imaging may not always be accurate or confirm the diagnosis. The aim of this study was to assess the role of endoscopic ultrasound (EUS) in the preoperative staging of suspicious or confirmed pancreatic carcinoma. METHODS: All patients undergoing staging pancreatic EUS between January 1996 and December 2004 were identified from the radiology computerised database. Fifty-eight patients (36 male, mean age of 61 ± 1.6 years) were identified all of whom had undergone prior US and CT and 35 prior ERCP, and 28 of whom underwent EUS guided biopsy. Thirty-seven patients had a mass believed to be a carcinoma and 21 had a suspicious lesion in the pancreatic head. RESULTS: Thirty-two of the 37 patients with a mass on prior imaging had a diagnosis of carcinoma confirmed (mean diameter 3.1 ± 0.3 cm). Fifteen tumours were deemed irresectable on EUS criteria: portal vein (n = 4) or superior mesenteric vein invasion (n = 8); unrecognised liver metastases (n = 4), ascites (n = 1); lymph nodes metastases outside the resection limits (n = 1). Only 1 patients underwent an open and close laparotomy due to a discrep- ancy between operative and EUS findings (small right liver lobar metastasis). The EUS diagnosis of the remaining 5 masses were: pancreatitis (n = 2); peri- pancreatic lymph node (n = 1); pancreatic cystic tumour (n = 1) and IPMT (n = 1). Eleven of the 21 patients with suspicious pancreatic lesions were confirmed as carcinomas (3 irresectable), 3 patients had chronic pancreatitis, 1 patient IPMT, 1 patient gallbladder carcinoma, and in 5 patients no mass was evident on EUS. CONCLUSIONS: EUS was effective in assessing resectability of pancreatic adenocarcinomas in cases in which there was CT suspicion of mesenteric or portal vessel invasion and also facilitatedtargeted biopsies in order to confirm a diagnosis of carcinoma.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1527 The Use of Somatostatin and Its Analogues in the Prevention of Complications Following Pancreatic Surgery – A Systematic Review Moritz N. Wente1, Eva Morris2, Markus K. Diener1, Hanns-Peter Knaebel1, Christoph M. Seiler1, Derek Alderson3, Helmut Friess1, Markus W. Buchler1; 1Department of Surgery, University of Heidelberg, Heidelberg, Germany; 2Unit of Epidemiology and Health Services Research, University of Leeds, Leeds, United Kingdom; 3Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, United Kingdom BACKGROUND: The use of somatostatin and its analogues in pancreatic surgery to reduce the incidence of complications is still under debate. The objective of this systematic review and meta-analysis is to quantitatively assess the efficacy of the perioperative use of somatostatin in pancreatic surgery. METHODS: A systematic literature search according to Cochrane collabora- tion standards (Medline, Embase, Cochrane library, conference reports) was performed. Randomized controlled trials (RCTs) comparing the perioperative treatment with or without use of somatostatin were eligible. A critical appraisal of included studies was performed using a standardized form to extract and evaluate pre-specified parameters and methodological quality. Two reviewers independently extracted quantitative data on peri- and postoperative morbidity and mortality. Main outcome measures were overall postoperative complications, pancreatic associated complications, pancreatic fistula, mortality, and hospital stay. Further analyses were performed for pre- specified subgroups of pancreatic cancer, chronic pancreatitis, pancreaticoduodenectomy, distal pancreatectomy, somatostatin s.c., and somatostatin i.v. Summarized treatment effect was computed in a meta-analysis (Review- Manager software 4.2.8) using the random effects model. Thus, pooled effect estimates were presented as odds ratios (OR) and the corresponding 95% confidence intervals (CI). RESULTS: A total of 16 RCTs including overall 2153 patients, referring to the use of somatostatin or its analogues in pancreatic surgery, met the inclusion criteria. Meta-analysis of somatostatin versus control revealed a significant reduction of overall postoperative complications in the somatostatin group (OR .57, CI .39–.81; P = .002). Accordingly, pancreatic associated complications (OR .49, 95% CI .33–.73, P = .0004) and the rate of pancreatic fistula

(OR .56, 95% CI .39–.80, P = .001) were reduced significantly in the treatment ABSTRACTS group. There were no differences in mortality (OR 1.07, 95% CI .66–1.74; P = .77) POSTER and hospital stay (Weighted Mean Difference –1.85, CI –6.03–2.33; P = .39). Similar results were determined in subgroup analyses of patients with pancreatic cancer or chronic pancreatitis, pancreaticoduodenectomy or distal pancreatectomy, and application of somatostatin s.c. or i.v. CONCLUSION: According to the results, a beneficial effect of the use of somatostatin in pancreatic surgery in terms of lower mortality rate or shortened hospital stay could not be demonstrated. However, somatostatin significantly reduced the rate of overall and pancreas specific postoperative complications, in particular also the occurrence of pancreatic fistula.

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Clinical: Small Bowel

M1528 Short Residual Intestine of Postsurgical CD Patients Is a Risk for Earlier Relapse of Infliximab Administration Toshifumi Ashida1, Kohtaro Okamoto1, Toru Kono2, Yoshiaki Ebisawa2, Yohei Konno1, Chisato Ishikawa1, Ryu Sato1, Jiro Watari1, Shinichi Kasai2, Yutaka Kohgo1; 1The Third Internal Medicine, Asahikawa Medical College, Asahikawa, Japan; 2The Second Department of Surgery, Asahikawa Medical College, Asahikawa Medical College, Japan BACKGROUNDS/AIMS: It has been clarified the difference of genetic background of Crohn’s disease (CD) between the patients in US and Japanese patients, such as the incidence of NOD2 mutation. Moreover, diversities of therapeutic regimens that have been applied to Japanese patients with CD are present, such as a long-term application of elemental diet, or less frequent use of 6MP/AZA. In this study, we purposed to verify the efficacy of Infliximab administration on Japanese CD patients by assessing the sequential changes of symptomatic and luminal disease activities. PATIENTS/METHODS: Forty-eight CD patients were administrated with 5 mg/kg of Infliximab by one or three-dose regimen in Asahikawa Medical College Hospital, from June/2002 to Dec/2004. CDAI was calculated at every two weeks before and after the administration for a year. Serum CRP levels were also measured as a marker of inflammation. Luminal activities were determined by colonoscopic examination before and at 4 week after the first administration. Thirty-four out of 48 patients received maintenance doses of 5 mg/kg Infliximab at every 8 weeks. Re-admission rate after remission- induction by Infliximab was calculated as a marker of long-term efficacy. RESULTS: Initial CDAI of the patients was 230.4 ± 76.0. Response rate (25% or 75 points reduction of pretreatment CDAI) at 2 week after the first infusion was 56.3%, whereas total remission rate (CDAI below 150) until 8 week was 84.3%. Luminal disease activity was improved at 4 week after the first injection in 82.3% of patients tested, and especially the decrease of density of aphthous ulcers in left side colon was noted in 85.7% of patients. Re-admission within 2 years after initial injection occurred 41.7% of the patients. Logistic regression analysis performed to elucidate the risk factor of earlier re-admission revealed that the postsurgical residual intestine less than 200 mm was a significant risk factor, whereas the scheduled administration of Infliximab detected as a preventing factor. (Table). Factor p value 95% C.I. history of bowel resection (+) 0.232 0.027–2.34 residual intestine less than 200 mm 0.026 1.51–535.1 Infliximab every 8 week 0.038 0.017–0.89 6MP/AZA 0.214 0.51–1.95 CONCLUSIONS: Despite the difference of genetic background and therapeutic environment, Japanese CD patients in our institute showed remarkable response to Infliximab in both symptomatic and luminal disease activities. Postsurgical patients with short residual intestine should have the significant risk of earlier relapse through Infliximab treatment.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1529 Determinants of the Epidemiology, Development, Management & Outcome in 9,991 Patients with Acute Appendicitis Through a Time Period of 27 Years Hagen Boenigk1, Frank Meyer2, Hans Lippert2, Ingo Gastinger3; 1Department of Internal Medicine, University Hospital, Magdeburg, Germany; 2Department of Surgery, University Hospital, Magdeburg, Germany; 3Department of Surgery, Municipal Hospital, Cottbus, Germany AIM: The aim of the study was to investigate: i) management and outcome of a representative patient cohort (n = 9,991) with acute appendicitis enrolled in a prospective unicenter study through a time period of 27 years (middle Europe) & ii) the frequency & impact of specific categories (e.g., characteristics of the medical history, clinical & intraoperative findings, complications, relative risk factors of the disease) & iii) prognosis. METHODS: By the mean of a prospective unicenter observational study, numerous characteristics (see “Aims”) were documented & influencing variables with significant impact on the outcome were statistically determined through 3 subsequent time periods. RESULTS: 1) The wound abscess rate was 10.9%. Perforation, surgical intervention on time, acute, gangrenous & chronic appendicitis, age, adverse diseases such as obesity, arterial hypertonus, diabetes mellitus, sex & missing intraoperative pathological finding showed a significant impact on the postoperative development of a wound abscess. 2) The longer the specific appendicitis- related medical history lasted, i) the more frequently a perforated appendicitis occurred (this rate significantly increased up to 13.1% through the time periods), ii) the greater the false-positive appendectomy rate was (P < 0.001) & iii) the higher the rate of required subsequent interventions was (4.3%; P < 0.001), which occurred significantly more often in obesity (6.5%) & wound abscess (5.8%). 3) The mean hospital stay was 11 days. 4) There was a significant decrease of the percentage of patients with no pathological finding of the “Appendix vermiformis“ intraoperatively, in particular through the last investigation period from 1997–2000 to only 6.8% (1974–1985, 15.5%; 1986– 1996, 10.3%). 5) The mortality was 0.6% showing no significant difference between i) male & female patients (P = 1.0), ii) the 3 investigation periods (P = 0.077) & iii) the patients with false-positive appendectomy (0.4%) & those with acute appendicitis (0.6%; P = 0.515).In summary, this prospective study demonstrated a substantial progress of the quality of surgical care with regard ABSTRACTS

to the rates of false-positive appendectomies, of postoperative wound POSTER abscesses &, in particular, to mortality. Despite this, there was an increasing rate of perforated appendicitis in the investigated cohort. CONCLUSION: Quality control remains an indispensable tool for the assessment of surgical care even in the most frequent diseases of daily practice, which can be further increased by i) a multicenter study setting in the future & ii) selected aspects investigated in randomized studies.

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M1530 Management of Open Abdominal Wounds with Vacuum Assisted Closure Therapy (VAC @ Kinetic Concepts Inc., UK) Shwetal S. Dighe, Kyaw Toe, Dhiren Nehra; General Surgery, Epsom and St Helier Hospital, London, United Kingdom AIMS: Introduction of the new VAC dressing has greatly facilitated the management of open abdominal wounds. This study looks at the use of VAC dressings in patients who have undergone multiple major abdominal surgeries. METHODS: Nine patients admitted to an Intensive unit of a District General Hospital, between the year 2004/5, had a VAC dressing applied after surgery for following indications: multiple stab wounds (n = 1), abdominal compartment syndrome (n = 2), necrotising pancreatitis (n = 3), abdominal dehiscence (n = 2) and anastomotic leak after low anterior resection (n = 1). Three patients had an enterocutaneous fistula. Initial management involved cover- ing the exposed bowel with a Bogota bag. VAC dressing with open pore foam dressing interface was used to avoid injuring the bowel and a continuous negative pressure of 125 mm of Hg was applied (Topical Negative Pressure TNP). The suction applied helped exert a centripetal force on the wound edges drawing them closer (Reverse Tissue Expansion). It reduced the bacterial load in the wound by continuous suction of the effluent fluid, which could be accurately measured and sent for microbiological or biochemical assessment if required and made the wound easy to manage. Dressings were changed under strict aseptic precautions whenever the suction effect was lost. VAC therapy was discontinued after the wound granulation tissue reached the skin edges. Wound healing was monitored with serial photographs. RESULTS: The average duration of VAC dressing application was 27 days (range 14 to 52 days). Two patients died due to sepsis, however both the wounds were healthy. In the remaining cases wound improvement and closure was achieved effectively without need for further complex procedures. The 2 patients with enterocutaneous fistulae arising from the jejunum and ileum were controlled well as low output fistulae. The patient with fistula due to anastomotic leak after anterior resection closed spontaneously. One patient needed a skin grafting and 1 patient developed an incisional hernia. VAC dressing facilitated nursing of patients and in addition removed much of the odour associated with conventional methods of open dressing. CONCLUSION: VAC dressing has revolutionised the management of difficult abdominal wound closure and control of sepsis, avoiding the need for relook laparotomies and repetitive change of open dressing. The presence of an enterocutaneous fistula was not a contraindication for its use.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1531 Internal Hernias: Clinical Findings, Management, and Outcomes in 49 Nonbariatric Cases Saber Ghiassi, Scott Nguyen, Avraham Schlager, Celia Divino, John Byrn; Department of Surgery, Mt. Sinai Medical Center, New York, NY INTRODUCTION: Internal hernia (IH), the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. Except for ones complicating bariatric surgery, IHs are sparsely described in the literature. We report one of the largest series of IHs, excluding ones formed as a consequence of operations for morbid obesity. This study dis- cusses the clinical presentation, surgical management, and outcomes of IHs at our institution. METHODS: Retrospective review of patients at our institution yielded 49 cases of surgically confirmed IH between 1994 and 2004. RESULTS: Majority of patients presented with abdominal pain (85.7%), nausea (77.6%) and vomiting (71.4%) for median 3 days (Range: hours to 5 months). Small bowel obstruction was a common radiographic finding in 31% of obstructive series, 44% of CT scans, and 75% of small bowel series. While 16% of CT scans and 25% of small bowel series were suspicious for IH, in no cases the preoperative diagnosis of IH was made. The average number of days from admission to surgery was 1.7 days. All IHs consisted of small bowel except for one patient with herniation of terminal ileum and proximal ascending colon. The most frequent IH were transmesenteric (58.0%) and 34 hernias (69%) were caused by defects secondary to previous surgery (see table). All IHs were reduced and the mesenteric and peritoneal defects were repaired. Twenty-two patients had compromised bowel at exploration and 11 (22.5%) had irreversible changes requiring small bowel resection. Two patients required re-exploration for postoperative abscesses. The mean postoperative hospital length of stay was 10.9 days (Range: 3–65 days). The overall mortality rate from our series is 2%, and the morbidity rate is 8.2%. CONCLUSION: We have found that transmesenteric hernias, as complications of previous surgeries, are the most prevalent IH. Preoperative diagnosis of IH is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, IHs can be repaired with acceptable morbidity and mortality.

Internal Hernia Type n (%) Transmesenteric 28 (58) ABSTRACTS

Paraduodenal 6 (12) POSTER Transomental 5 (10) Intersigmoid 3 (6) Pericecal 3 (6) Paravesical 3 (6) Foramen of Winslow 1 (2)

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M1532 Gastrointestinal Stromal Tumors (GIST) of the Small Bowel: High-Risk Pathologic Features Predict the Need for Adjuvant Therapy Imran Hassan1, Yi-Qian N. You1, Roman Shyyan2, Eric J. Dozois1, Scott H. Okuno3, Thomas C. Smyrk4, John H. Donohue2; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 3Department of Medical Oncology, Mayo Clinic, Rochester, MN; 4Division of Anatomic and Surgical Pathology, Mayo Clinic, Rochester, MN INTRODUCTION: Understanding the natural history and prognostic factors associated with disease recurrence and survival of resected small bowel GIST is necessary to appropriately select patients for adjuvant therapy. METHODS: Oncologic outcomes of 69 patients with primary small bowel GIST surgically treated between 1976 and 2004 at a single institution were reviewed. Prognostic factors analyzed included age, gender, tumor site (duodenum, jejunum, ileum), extent of disease at presentation (local, locally advanced, metastatic), type of resection (R0, R1, R2) and pathologic characteristics. Tumors were assigned risk levels (high, intermediate, low, very-low) on the basis of size and mitotic rate according to current NIH (National Insti- tutes of Health) recommendations. RESULTS: Mean patient age was 59 years with 46 men. Median follow-up for survivors was 61 months. Tumors were most frequently found in the jejunum 52% (36) followed by the ileum 25% (17) and the duodenum 23% (16). Ninety-nine percent of patients had a R0 resection of their primary tumor. Sixty-seven tumors (99%) were c-KIT positive. There were 59% high-, 19% intermediate-, 16% low-, and 6% very low-risk GIST. Local and distant recurrences occurred in 3 and 30 patients, with median time to event of 31 months and 16 months, respectively. In patients with very-low or low-risk GIST no local or distant recurrences or disease-specific mortality was observed. Among patients with high- and intermediate-risk GIST, 5-year distant disease- free survivals were 27% and 61%, respectively. The 5-year disease-specific survivals for these two groups were 26% and 71%, respectively. In a Cox analysis, NIH pathological classification was the only independent prognostic factor associated with disease-free and disease-specific survival. CONCLUSION: High-risk small bowel GIST have a significantly higher risk of disease recurrence and poorer survival despite complete surgical resection. These patients should be routinely considered for adjuvant therapy with a tyrosine kinase inhibitor.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1533 Influence of Postoperative Complications on Long-Term Quality of Life in Patients Undergoing Abdominal Surgery for Crohn’s Disease Michael S. Kasparek1, Joerg Glatzle1, Andreas Schneider1, Mario H. Mueller2, Alfred Koenigsrainer1, Martin E. Kreis2; 1Department of General Surgery, Eberhard-Karls-University Tuebingen, Tuebingen, Germany; 2Department of Surgery, Ludwig-Maximilian’s-University Munich, Munich, Germany Quality of life (QOL) improves rapidly in patients undergoing uncomplicated abdominal surgery for Crohn’s disease (JACS 2003). AIM: To determine influence of postoperative complications on long-term QOL in patients undergoing abdominal surgery for Crohn’s disease. METHODS: From 1996 through 2002, 347 abdominal operations were performed for Crohn’s disease in 305 patients at our institution. Patients with postoperative complications (n = 66) were categorized into minor and major complications. A standardized questionnaire determining general well-being and four well-established, validated QOL instruments (SF-36, Gastrointestinal QOL Index, Cleveland Global QOL score, Short Inflammatory Bowel Disease Questionnaire) were sent to the 66 patients who had a postoperative complication and to 66 randomly chosen controls who underwent abdominal surgery for Crohn’s disease with uneventful postoperative recovery. RESULTS: Questionnaires were returned from 46 patients with complications (73%) at a postoperative follow-up (mean [range]) of 43 months [12–96 mo] and from 43 controls (65%) at a follow-up of 49 months [19–101 mo]. Age, sex, duration of disease, number of patients with previous surgery, and follow-up did not differ between groups. 31 minor complications (urinary tract infection 17, postoperative ileus 9, wound infection 4, and pneumonia 1) and 17 major complications (7 anastomotic leaks, 7 intraabdominal abscesses, and 1 each with postoperative intraabdominal hemorrhage, mechanical bowel obstruction, and pulmonary embolism) occurred in the 46 patients with complications. All major complications required re-operation, except the patient with pulmonary embolism and 5 with intraabdominal abscess, treated with a CT-guided drainage and antibiotics. Hospital stay was prolonged after minor and major complication (21 days [4–52 d] and 44 days [10–252 d] vs. 13 days [6–25 d] in controls; p < 0.05). No differences were observed at time of follow-up between groups for all four applied QOL instru-

ments except for the domain “physical functioning” in the SF-36, where ABSTRACTS scores (mean ± SEM) for patients with major, minor, and no complications POSTER were 70 ± 4%, 69 ± 5%, and 83 ± 3%, respectively (p < 0.05). Postoperative complications did not affect the presence of symptoms due to Crohn’s disease at the time of follow-up (minor 65%, major 56% vs. controls 70%; ns.). CONCLUSION: Postoperative complications after abdominal surgery for Crohn’s disease prolong hospital stay, although long-term QOL seems not to be affected in large part. The aspect of “physical functioning” may, however, deteriorate.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1534 Effectiveness of Diagnostic Paracentesis for Suspected Strangulation Obstruction Shin Kobayashi1, Kenji Matsuura2, Kazuhide Matsushima2; 1Surgery, Okinawa Yaeyama Hospital, Ishigaki, Japan; 2Surgery, Okinawa Chubu Hospital, Okinawa, Japan SUMMARY BACKGROUND DATA: Strangulation obstruction is surgical emergency, but its accurate diagnosis and timely surgical treatment are still a matter of debate. We have prospectively analyzed our cases with suspected strangulation obstruction to see whether our diagnostic paracentesis under ultrasound is effective for the timely diagnosis. METHOD: We have prospectively examined the case collection with suspected strangulation obstruction. Diagnostic paracentesis under ultrasound was performed preoperatively if possible and ascites at the time of incision was obtained if paracentesis was impossible. Then, it was examined whether ascites color and laboratory parameters could be reliable indicators of strangulation. RESULTS: During 18 months of study period, 32 patients were suspected of strangulation preoperatively by history, physical exams, and radiographic imaging, and had their ascites obtained either by paracentesis or at laparotomy. Among those 32 patients, strangulation obstruction was confirmed at laparotomy for 21 patients, 2 patients had simple obstruction, 1 patient had non-therapeutic laparotomy for pseudoobstruction, and 7 patients were treated conservatively. Asites hematocrit, red blood cell, and lactate are identified as indicators to predict strangulation obstruction by univariate study (TABLE), and hematocrit and RBC sufficiently predicted strangulation by multivariate study. Ascites hematocrit above 0.3% predicted strangulation at 93.3%, and if it was over 0.4%, bowel resection was highly necessary. Table 1. Correlation between laboratory parameters and strangulation.

Strangulation Non-Strangulation Parameters Mean S.D.** Mean S.D.** P value* RBC (x 104/mm3) 12.35 16.30 2.75 5.82 < 0.05 Ht (%) 0.89 1.01 0.25 0.59 < 0.05 WBC (x 103/mm3) 1.84 3.63 2.90 7.56 0.30 Lactate (mmol/L) 4.26 3.88 1.73 0.91 < 0.05 pH 7.39 0.32 7.420.12 0.43 B.E. (mEq/L) 1.02 8.24 3.60 3.15 0.28 ALP (IU/L) 264.6 284.7 168.7 184.7 0.17 LDH (IU/L) 772.7 1061.3 439.2 633.3 0.18 Amy (IU/L) 83.0 182.3 48.7 32.1 0.28 D-Bil (IU/L) 0.19 0.14 0.14 0.05 0.14

*P value was calculated by unpaired t-test **S.D.; standard deviation CONCLUSIONS: Paracentesis under ultrasound guidance is an easy and useful technique for diagnosis of strangulation obstruction, which is highly predicted with ascites hematocrit above 0.3%. All false negative cases were diagnosed to be strangulation by unequivocal clinical ﬁndings. Careful physical exams and paracentesis for equivocal physical ﬁndings enable early diagnosis of strangulation obstruction.

318 SSAT.book Page 319 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1535 Clostridium Difficile Enteritis: An Early Post-Operative Complication in IBD Patients Following Colectomy Sarah J. Lundeen1, Mary F. Otterson1, Gordon L. Telford1, David G. Binion2, William J. Peppard3; 1Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; 2Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; 3Froedtert Memorial Lutheran Hospital, Milwaukee, WI INTRODUCTION: Clostridium difficile (C diff) is known to cause severe colitis, and is the leading cause of hospital-acquired diarrhea in the United States. However, C diff associated small bowel enteritis is a rare complication, with only 19 case reports in the literature (1979–2000), but is associated with mortality rates as high as 73%. C diff has increased in incidence with a marked increase among patients with inflammatory bowel disease (IBD). We report a series of 5 patients (2004–2005), all treated at our tertiary IBD referral center that experienced severe enteritis. C diff toxins were detected in the ileostomy effluent of all patients in the early post-operative time frame (<90 days). We report the demographics, presentation, management and disposition in this cohort of patients. RESULTS: Five patients were identified that developed C diff enteritis following total abdominal colectomy and ileostomy. All received a dose of preoperative antibiotics. 2 patients underwent ileal pouch and loop ileostomy. All 5 patients had a final pathology of ulcerative colitis (4 female, 1 male). Four/5 patients had C diff colitis prior to colectomy. Presenting symptoms were high volume watery ileostomy output followed by ileus in 5/5 patients; 4/5 presented with fever and elevated WBC. 4/5 developed complications which resulted in further surgery or prolonged hospitalization. These included 2 readmissions with fever and dehydration, 1 reoperation to bypass strictured small bowel, 1 patient was transferred to the ICU for the management of hemodynamic instability. Patients diagnosed with C. diff enteritis were treated with intravenous hydration and metronidazole until able to take oral vancomycin. One patient was treated with vancomycin alone due to intolerance and one patient was treated with mentronidazole alone. None of the 5 patients died, and all have resumed education or employment. DISCUSSION: Despite the historical rarity of C diff enteritis, incidence is rising. Clinicians should have a high suspicion of C diff enteritis, especially in patients with a history of IBD and C diff colitis prior to colectomy. Although published rates of mortality approached 2/3, there were no deaths in our ABSTRACTS

series of 5 patients. Our favorable outcomes may be attributed in part to rapid POSTER diagnosis and aggressive treatment of the C diff enteritis.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1536 Long-Term Outcomes of the Modified Rives-Stoppa Repair in 254 Complex Incisional Hernias Tuan H. Pham, Corey W. Iqbal, Antony Joseph, Jane L. Mai, Geoffrey B. Thompson, Michael G. Sarr; Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN Repair of complex incisional hernias characterized by large and/or multiple defects, multiple recurrences, obesity, and extensive intra-abdominal adhesions pose major challenges. AIMS: To review outcomes of the modified Rives-Stoppa repair of complex incisional hernias. METHODS: We maintained an IRB-approved, prospective database of patients undergoing modified Rives-Stoppa, mesh-based repair of complex incisional hernias from 1990–2003. Prostheses were placed, whenever possible, intramurally, i.e. posterior to rectus muscle but anterior to posterior rectus fascia; some were fully intraperitoneal. Patients were followed prospectively through clinic visits and mailed questionnaires. Follow-up data obtained via chart review was complete in all patients, and 87% of patients completed and returned the questionnaire. Mean follow-up was 70 months (range 24–177 months). Primary outcome measures were 30-day perioperative mortality, morbidity, and hernia recurrence. Secondary outcome measures were duration of stay, peri-incisional pain at follow-up, and patient self-reported satisfaction. RESULTS: 254 patients underwent Rives-Stoppa mesh repair. The most frequent comorbidities were morbid obesity (33%), diabetes (16%), and chronic obstructive pulmonary diseases (8%). 30% of the patients had one or more prior failed hernia repairs. Prostheses included polypropylene (75%), polypropylene/ePTFE (14%), and ePTFE (9%) depending on presence/absence of intraperitoneal exposure. Mean mesh area was 744 ± 26 cm2. Mean hospital stay was 6 days. Mortality was zero and overall morbidity was 13% (wound infection—4%, acute mesh infection—3%, and seroma-hematoma—4%). Overall hernia recurrence rate was 5% (includes mesh infections requiring mesh explanation). Risk factors for hernia recurrence were postoperative wound/mesh infection (31% vs 4%, p = 0.003) and respiratory comorbidities (25% vs 4%, p = 0.007). Risk factors for mesh infection included bowel resec- tive procedures or enterotomies at time of mesh implantation and history of prior mesh infection. 27% of respondents reported intermittent pain (average worse-episode score of 4.7 on standard 0–10 pain scale), yet 89% reported overall satisfaction with their repair. CONCLUSIONS: The modified Rives-Stoppa repair of complex incisional hernia is safe with low recurrence rate (5%) and high patient satisfaction. Risk factors for hernia recurrence were postoperative infection and respiratory comorbidities. Permanent mesh should not be used in patients at high-risk for infection or even in a clean-contaminated field.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1537 Trends and Predictors for Vagotomy When Performing Oversew of Acute Bleeding Duodenal Ulcer in the United States Brian Reuben, Greg Stoddard, Robert Glasgow, Leigh Neumayer; General Surgery, University of Utah, Salt Lake City, UT BACKGROUND: Surgical treatment of acute bleeding duodenal ulcers involves pyloroplasty and oversew of the bleeding vessel. In the era of H. pylori treatment, the role of vagotomy in this setting is debatable. To determine the current surgical treatment of acute bleeding duodenal ulcers and evaluate the use of vagotomy in this setting, national outcomes for acute bleeding duodenal ulcers were examined from 1999 to 2003. METHODS: Data were analyzed from the Nationwide Inpatient Sample (NIS) from the year 1999 to 2003. International Classification of Disease (ICD-9) codes were used for diagnostic and procedure codes to identify patients with an acute duodenal ulcer bleed and patients undergoing simple oversew of the bleeding ulcer. Appropriate sampling weights are applied for national estimates. Multiple linear and logistic regression analyses are used to examine predictive variables for the addition of a vagotomy with oversew of a bleeding ulcer. RESULTS: The total number of bleeding duodenal ulcers did not change between the years 1999 to 2003 (table). 8.1% of vagotomies performed during oversew of an acute bleeding ulcer are highly selective while 91.9% are trun- cal or not otherwise specified. Using logistic regression analysis for predictors of vagotomy in acute bleeding duodenal ulcers, a high co-morbidity index (odds ratio (OR), 0.60, p 0.017), operation performed in the South (OR 0.50, p 0.00) and operation performed in the West (OR 0.68, p 0.034) were predictive of not undergoing vagotomy as part of surgery for a bleeding duodenal ulcer. Patients with higher household income were less likely to undergo vagotomy by univariate analysis (OR 0.85, p 0.03). Age, race, acuity of admission, gender, hospital teaching status, rural or urban location of the hospital and type of insurance were not significant predictors for vagotomy in either univariate or multivariate models.

1999 2000 2001 2002 2003 Total number of bleeding ulcers 85,070 85,118 85,953 82,389 80,602 Number of acute bleeding ulcers 24,719 23,325 20,939 16,353 15,595 % to surgery 4.8% 4.8% 5.2% 4.6% 4.5% ABSTRACTS

% undergoing vagotomy 53.0% 49.1% 35.5% 45.2% 45.3% POSTER

CONCLUSIONS: The current incidence of surgical vagotomy when performing oversew of an acute bleeding duodenal ulcer is approximately 46% and remained relatively constant over the ﬁve year study period. Patients with greater numbers of co-morbidities and higher household income are less likely to undergo vagotomy. Surgeons in the South and West perform fewer vagotomies than their counterparts in the Midwest and the Northeast.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1538 Effect of Alvimopan on Gastrointestinal (GI) Recovery Following Small Bowel Resection (SBR) in Patients With and Without Crohn’s Disease (CD): Results of a Pooled Analysis of 3 Randomized, Placebo-Controlled Trials Bruce Wolff1, Eugene Viscusi2, Conor Delaney3, Wei Du4, John G. Fort4, Lee Techner4; 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; 2Department of Anesthesiology, Jefferson Medical College, Philadelphia, PA; 3Division of Colorectal Surgery, University Hospitals of Cleveland, Cleveland, OH; 4Adolor Corporation, Exton, PA Crohn’s disease is a common indication for bowel resection (BR), and the prevalence of surgery (strictureplasty or BR) in this setting ranges from 38% to 96%. Postoperative ileus (POI), a temporary impairment of GI function, occurs after abdominal surgery. Alvimopan, a novel, peripherally acting, mu- opioid receptor antagonist under investigation for the management of POI, accelerated GI recovery in patients undergoing laparotomy for BR or total abdominal hysterectomy in 3 multicenter phase III trials. Pooled data from these trials were analyzed for patients with and without CD who received SBR.Trials enrolled patients ≥18 years old who were scheduled for postoperative opioid IV patient-controlled analgesia. Alvimopan (6 or 12 mg) or placebo was administered 0.5 to 5 hours before surgery and twice daily starting postoperative day (POD) 1 until hospital discharge for ≤7 PODs. Cox proportional hazard ratios were used to analyze treatment effects on time to events and to provide an estimate (in hours) of treatment effect. The primary endpoint was GI-3 recovery (time to first flatus or bowel movement [BM] and toleration of solid food). Secondary endpoints included time to first BM and time to hospital discharge order written. Of the patients who participated in the phase III alvimopan trials, 47 patients with CD and 54 patients without CD underwent SBR. Results are reported in Table 1. Although the number of patients in this analysis was small, patients who received alvimopan (regardless of their CD diagnosis) had reduced time to GI recovery and discharge compared with placebo. Moreover, efficacy was comparable for patients with and without CD. Table 1. Time to Recovery in Patients Undergoing SBR With and Without CD, MITT Population

Patients With CD Patients Without CD Placebo Alvimopan Alvimopan Placebo Alvimopan Alvimopan n = 11 6 mg n = 19 12 mg n = 17 n = 17 6 mg n = 20 12 mg n = 17 GI-3 HR (CI) –115 1.37 2.88 –98 2.33 2.79 Time to event, (0.6, 3.1) 100 (1.2, 6.8) 71 (1.2, 4.7) 73 (1.3, 6.0) 69 median hours BM HR (CI) – 88 1.35 1.84 –89 3.19 3.12 Time to event, (0.6, 3.0) 77 (0.8, 4.2) 69 (1.5, 6.9) 51 (1.4, 7.0) 51 median hours DCO written HR (CI) –134 1.49 2.43 –118 1.97 2.62 Time to event, (0.7, 3.4) 108 (1.1, 5.6) 91 (1.0, 3.9) 96 (1.2, 5.5) 89 median hours

SBR = Small bowel resection; CD = Crohn’s disease; MITT = Modified intent to treat; GI-3 = Time to first flatus or BM and toleration of solid food; HR = Hazard ratio; CI = Confidence interval; BM = Bowel movement; DCO = Discharge order.

322 SSAT.book Page 323 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1539 Crohn’s Disease: A Patient’s Perspective Massarat Zutshi1, Tracy Hull1, Jeffery Hammel2; 1Colorectal Surgery A-30, Cleveland Clinic, Cleveland, OH; 2Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, OH AIM: As healthcare providers for Crohn’s disease we assume that we have a good understanding of the disease progression and its symptoms. The aim of this study was to gather information about what patients with Crohn’s disease think are relevant to their symptoms and what helps them cope with this lifelong benign disease. METHODS: A questionnaire was sent to all patients with a diagnosis of Crohn’s disease seen in the Digestive Disease Center in the last 5 years. An analysis of the first 307 questionnaires recived is given below. RESULTS: (See table for 3 main factors in each variable) 63% respondents were female. 1/3 were between the ages of 35–50 years. 64% were married. 1/3 had a graduate degree, 22% were unemployed. 48% patients still smoked, a majority less than one pack a day. 67% said that their symptoms affected work and 1/4 changed jobs due to this. Foods worsened symptoms in 60% with a decrease in symptoms while on a low fibre foods and white meats. Life style changes worsened symptoms in 66%. More than half used Remicade with 1/3 stating that it was helpful. 9% had never used steroids. Alcohol increased symptoms in 1/3. Factors that did not cause a significant change were children at any age, pregnancy, menopause and HRT. A change in the caregiver was not a significant stressor. Surgery caused half the patients to improve for many years although 1/3 felt a lowered self-esteem postoperatively. CONCLUSION: Patients with Crohn’s disease should be managed in a more comprehensive manner to provide optimal care. Thus a team approach that includes a dietician and counselor should be considered as an integral part of this team. This will allow patients to have enhanced skills to cope with changes in their symptoms whether they are due to the disease itself or changes in their routine.

Table 1. Results of Top 3 Factors that Affect Symptoms in Each Variable

Variable (Improve/Worsen) No. 1 Factor No. 2 Factor No. 3 Factor Work stress (worsen) Deadlines Boss Environment Foods (worsen) Oily/Spicy Nuts Citrus fruits Lifestyle change (worsen) Home Work Partner Medicines (improve) Antidiarrheals Pain medication Vitamins ABSTRACTS POSTER Weather (worsen) Heat and humidity Cold Humidity Surgery (concerns) Fear of surgery Surgical stress Being off medication Stoma (concerns) Clothes Physical activity Appearance

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Stomach

M1540 Is the Very Long Limb Roux-en-Y Gastric Bypass Effective for Patients with BMI > 60 Kg/M2? An Analysis of Long-Term Follow-Up in a Cohort of 118 Patients Taghreed Almahmeed, Tracy Torrella, Ali Kandil, Rodrigo Gonzalez, Malene Ingram, Scott F. Gallagher, Michel M. Murr; Surgery, University of South Florida, College of Medicine, Tampa, FL INTRODUCTION: We have utilized the Very-Long limb Roux-en-Y Gastric Bypass (VLRYGB) which involves anastomosing the biliopancreatic limb to the ileum 100 cm proximal to the ileocecal valve, in the treatment of superobese patients. The aim of this study is to evaluate the outcomes of VLRYGB in the treatment of patients whose BMI >60 kg/m2. METHODS: Prospectively collected data in all 118 consecutive patients with BMI ≥60 Kg/m2 who underwent VLRYGB for the treatment of clinically sig- niﬁcant obesity from 1998–2005 were analyzed. Patients’ clinical characteristics, comorbidities, weight loss and complications were reviewed. Follow-up was from clinic visits and phone interviews. Data are mean ± SEM. RESULTS: 83 women and 35 men who underwent VLRYGB (age: 43 ± 1 year; pre-operative BMI: 69 ± 1 kg/m2) had the following major comorbidities: obstructive sleep apnea (64%), hypertension (61%), diabetes (32%) and venous thrombotic events (3%). Mean length of hospital stay was 6 ± 1 days. Compli- cations included: anastomotic leak (4%), gastrointestinal bleeding (3%), venous thrombotic events (3%), myocardial infarction (3%), sepsis (2%), anastomotic ulcer (1%), primary respiratory failure (1%), and renal failure (1%). In-hospital mortality was 3% and was mainly from anastomotic leaks and primary respiratory failure; 30 day mortality was 4%. Within one year post-operatively, 5 patients (4%) developed protein-calorie malnutrition which was reversed with enteral and parenteral protein supplements in 3 patients and by lengthening of the common channel in one patient; one patient who refused intervention died from subsequent liver failure. Overall follow-up was 30 ± 2 months and is complete in 80% of patients. % Excess body weight loss (%EBWL) peaked at 2 years (66 ± 2%, 95% conﬁdence interval (CI): 63–70%) and was sustained at 5 years (66 ± 4%, 95% CI: 58–74%) with 80% of patients achieving >50% EBWL. 95% of patients reported improvement in quality of life, diabetes, hypertension and/or obstructive sleep apnea. CONCLUSION: VLRYGB is effective in inducing durable and sustainable weight loss in super-obese patients that is associated with resolution of obesity-related comorbidities and improvement in quality of life. Close postoperative monitoring may reduce in-hospital mortality. Strict monitoring of nutritional indices is imperative to avoid long-term consequences of protein calorie malnutrition.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1541 Is an Elevated Body Mass Index Associated with Worse Outcomes in Trauma Patients Bolanle Asiyanbola, John Bonadies, Donald Kim; Saint Raphael Hospital, New Haven, CT INTRODUCTION: Obesity and morbid obesity as defined by a body mass index(BMI) of greater than 30kg/m2 and 40 kg/m2 respectively are increasing in prevalence and have been associated with increased mortality and morbidity compared with a normal weight cohort. Within the trauma population it is unclear whether the presence of an elevated body mass index is associated with a poorer outcome. HYPOTHESIS: An elevated body mass index is associated with worse outcomes in trauma patients. METHODS: A retrospective study of all patients admitted to a single level 2 trauma center over a 2 year period was conducted. Data was collected as to age, sex, BMI, Injury severity score (ISS), length of hospital stay and mortality. Patients were stratified by BMI into 2 cohorts: normal weight BMI 18–24 kg/ m2 and elevated BMI (BMI >30kg/m2). The primary outcome measures were length of hospital stay and In-hospital mortality. RESULTS: 513 patients were admitted over the study period. 180 patients were excluded due to incomplete BMI data, age less than 18 or BMI less than 18. There was no statistically significant difference in the age, sex or ISS range between both groups. There was no difference in the pattern of injury encountered in both groups. Length of hospital stay was 5d in the normal weight cohort compared to 8d in the cohort with an elevated BMI, p = 0.04. In patients with severe injury (ISS > 15), the length of stay was noted to be longer in the cohort with an elevated BMI (7.5d) compared to 12.8d in the normal weight cohort (p = 0.03). There was no statistical difference in mortality rates. CONCLUSIONS: An elevated body mass index is associated with a longer length of stay in trauma patients particularly in the more severly injured patient. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1542 Objective and Quantitative Demonstration of Improvement in Voice Quality After Anti-Reflux Surgery Shahin Ayazi1, Rana Madani1, Judith Pearson1, James Malone-Lee2, Majid Hashemi1; 1Surgery, University College of London(UCL), London, United Kingdom; 2Medicine, University College of London(UCL), London, United Kingdom AIM: We have applied a new method for the quantitative assessment of voice to investigate the effect of anti-reflux surgery (ARS) on voice quality. METHODS: 59 asymptomatic volunteers were examined with the laryngograph, providing normal values for percentage irregularity of voice frequency (%CFx) and amplitude (%CAx). The values were distributed normally; values greater than the 95th percentile were regarded as abnormal. 16 patients due to undergo ARS underwent laryngograph studies pre-operatively and four weeks post-operatively. All subjects completed a standardised symptom questionnaire and read a standardised phonetically balanced text whilst laryngograph measurements of impedance across the larynx and vocal cord contact were obtained by means of electrodes applied to the neck. All ARS patients also underwent 24-hours pH and motility studies pre-operatively and underwent laparoscopic 360 or 180 fundoplication. Abnormal preoperative CFx & CAx values were found in 6/16 patients which comprised the study population. RESULTS: There was a significant reduction in irregularity of both frequency (P = 0.002) and amplitude (P = 0.004) post-surgery (Table 1). 24 pH studies were abnormal (Demeester score >14.7) in the distal oesophagus in 4/6 and proximally in 1/6 (16%). Pre-operative voice/laryngeal symptoms were absent in 5/6 (83.4%), and present in 1/6 patient which resolved after ARS.

Table 1. Comparision of Pre and Post Operative Changes

Normal Mean (n = 59) Preoperative Mean Postoperative Mean P-Value (% CFx) 27.9 (S.D = 18.0) 70.7 (S.D = 3.18) 40.8 (S.D = 9.6) P = 0.002 (%CAx) 11.4 (S.D = 5.7) 23.9 (S.D = 11.6) 9.3 (S.D = 4.7) P = 0.004

CONCLUSION: We have demonstrated that after ARS there is signiﬁcant reduction in irregularity of voice frequency and amplitude. This objective improvement in voice quality may represent correction of laryngeal sequel of GORD that are rarely identiﬁed by symptoms, and which may occur in the presence of normal proximal pH studies in the majority of patients.

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1543 2001 Gastric PCE: Overview of the Treatment of Gastric Lymphoma in the United States Ijeoma A. Azodo1, Kaye M. Reid1, Lina Patel2, John H. Donohue1,2, Members of the Gastric PCE Project2; 1General Surgery, Mayo Clinic – Rochester, Rochester, MN; 2American College of Surgeons, Commission on Cancer, Chicago, IL BACKGROUND: The management of gastric lymphoma has changed from surgical to medical over the last several decades. Our aim was to evaluate the current management of gastric lymphoma in the United States (U.S.). METHODS: Data from 711 U.S. hospitals in the Gastric Cancer Patient Care Eval- uation (PCE) Study sponsored by the National Cancer Data Base (NCDB) were reviewed. Participating institutions submitted patient data from hospital admissions and/or clinic visits for the period of January 1, 2001 to December 31, 2001. RESULTS: Lymphomas accounted for 10% (688/7084) of the gastric malignancies submitted in this study. The lymphoma population was predominat- ingly white (74%) and men outnumbered women (57% to 42%). The mean age at diagnosis was 68.5 with the peak age prevalence in the seventh decade (31%). The frequencies of presenting symptoms are tabulated in Table 1. A history of Helicobacter pylori infection was present in 24% of patients, 29% had negative testing. The most common gastric lymphoma sites were unspeciﬁed/ diffuse (38%) and cardia (15%). Large cell diffuse lymphoma, NOS was present in 47% of patients and marginal zone B cell lymphoma in 36%. The majority of patients (87%) were treated without an operation. In the 88 patients that had an operation, 23% underwent a distal gastrectomy. Radiation therapy was used in 21% and chemotherapy was administered in 51% of patients. Single drug chemotherapy was the most common regimen. The 30-day surgical mortality was 13% and an additional 6% of deaths in the hospital >30 days postoperatively. The total surgical mortality was 19%. Long term follow-up data are unavailable at this time. Table 1. Pre-diagnostic Symptoms of Table 2. Postoperative Morbidity Gastric Lymphoma and Mortality

Symptom (%) Complication (%) Pain 74 30-day mortality* 13 Weight loss 61 Hospital Death > 30 days 6 Melena 47 Wound Infection 5 Early satiety 40 Sepsis 4 ABSTRACTS

Hemorrhage 3 POSTER Doudenal Stump leak 3

*In hospital (6%) & Post-discharge (7%)

CONCLUSIONS: Gastric lymphoma is a rare disease occurring more often in older Caucasian men. Operative therapy is currently used infrequently (10%), a ﬁnding that agrees with recent studies of this malignancy. Signiﬁcant mortality is associated with surgical intervention for gastric lymphoma.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1544 30-Day Morbidity After Curative Resections for Gastric Cancer in Elderly Patients Ralph Bahde, Esra Kultas, Matthias Bruewer, Norbert Senninger, Joerg Haier; Department of General Surgery, University Hospital Muenster, Müenster, Germany BACKGROUND: In the western countries the population is rapidly aging resulting in an increasing number of elderly patients. In parallel, the incidence of gastric cancer in people over 65 years of age has increased remark- ably. The optimal treatment for these patients remains a challenge to the surgeon. The aim of this retrospective analysis was to compare the results of curative resections for gastric cancer in patients with different age. METHODS: We performed a retrospective analysis of 182 patients who underwent total or partial gastrectomy with extended D2-lymphadenectomy for gastric carcinoma between 2000 and 2004. Postoperative complication rates (30-day morbidity) were compared between patients in three age groups (<45y.: n = 24, 45–65y.: n = 74, >65y.: n = 84). Chi-square tests were performed for statistical analyses. RESULTS: Advanced tumor growth (T-stage) was signiﬁcant more frequent in younger patients (p < 0.001), where nodal involvement (N-stage) was not statistical different. Major surgical complications occurred in 12% of all patients and minor complications were documented in additional 9%. The 30-day morbidity was signiﬁcantly higher in young patients (p < 0.05). The most important course for major complications were anastomotic leckages. DISCUSSION: The operative outcome of gastric cancer patients over 65 years of age was comparable to that of younger patients after curative resections with extensive lymphadenectomy. The increased 30-day morbidity in patients with an age <45 years can be explained by more advanced local tumors in this group.

Table 1. Morbidity After Curative Resections

Age n Major Compl. Minor Compl. 30-Day Morbidity <45 y. 24 21% 13% 33% 45–65 y. 74 12% 11% 23% >65 y. 84 8% 7% 15% total 182 12% 9% 21%

328 SSAT.book Page 329 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1545 Laparoscopic and Endogastric Resection for Gastric Stromal Tumors – A Group’s Initial Experience Claudio Bresciani, Rodrigo O. Perez, Carlos E. Jacob, Roger Coser, Igor Proscurshim, Bruno Zilberstein, Ivam Cecconello, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil BACKGROUND: Radical surgery for gastric stromal tumors (GIST) entails a free-margin gastric resection without the requirement for associated lymph- node resection. For this reason, minimally invasive surgery represents an excellent option for the management of many of these tumors. Conventional laparoscopy with wedge resection is an option for anterior wall tumors, however, endoluminal growing lesions, especially when located at the posterior gastric wall close to the cardia or at the gastric fundus are troublesome for a standard laparoscopic approach due to technical difficulties. In this setting, endogastric laparoscopic resection may offer an excellent surgical field for resection of these tumors. PATIENTS AND METHODS: Between January 2004 and June 2005, eight patients with GIST were managed by laparoscopic resection and were retrospectively reviewed. RESULTS: Five patients were managed by laparoscopic endogastric resection and three by laparoscopic wedge resection. The mean operative time for these procedures was 182.1 ± 10.2 min. In all three patients managed by wedge resection a linear stapler was used to remove the tumor, for the remaining 5 managed by endogastric resection, the tumor was removed with a har- monic scalple. There was no conversion to open surgery. All 8 resected specimens had free margins. None of the patients presented any significant perioperative morbidity and there was no mortality. CONCLUSIONS: Laparoscopic surgery for both wedge and endogastric resections are safe and adequate radical treatment options for GIST with low morbidity and mortality rates. Further study is needed to evaluate these results. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1546 Effect of Splenectomy on the Survival of Patients Undergoing Curative Total Gastrectomy for Proximal Gastric Cancer Yeon Soo Chang, Se Keon Oh, Kil Yeon Lee, Suk-Hwan Lee, Choong Yoon; Department of Surgery, Kyung Hee University Hospital, Seoul, South Korea AIMS: Standard treatment of proximal gastric cancer is total gastrectomy with D2 lymph node dissection. But, role of splenectomy in the surgical management of proximal gastric cancer is still controversial. Aim of this study is to evaluate the effect of simultaneous splenectomy on the survival of patients who underwent curative total gastrectomy for proximal gastric cancer. METHODS: Ninety-two patients who underwent curative total gastrectomy for gastric cancer were included. Patient’s characteristics, pathologic features, TNM stages and prognosis were compared between splenectomy (n = 63) and preserving group (n = 29). RESULTS: There was no difference in age, sex ratio, tumor location between two groups. In terms of gross tumor morphology, splenectomy group had more advanced diseases significantly (p < 0.05). There was no difference in tumor differentiation and diameter (6.7 Vs. 5.4 cm) between two groups. Proximal (3.3 Vs. 3.6 cm) and distal (9.3 Vs. 9.3 cm) resection margin, number of retrieved lymph nodes (35.5 Vs. 33.9), number of metastatic lymph node (9.5 Vs. 7.8) also showed no differences. Regarding TNM stages, there were more advanced stage significantly in splenectomy group. Disease-free survival showed no significant difference in TNM stage I&II (82.4% Vs. 85.7%) and in TNM stage III & IV (42.3% Vs. 49.1%) between splenectomy and preserving group. Multivariate-analysis with Cox-hazard regression model showed that only TNM stage was independent prognostic factor (p < 0.05). Splenectomy itself had no influence on patient’s survival. CONCLUSIONS: Splenectomy was performed more frequently in advanced gastric cancer and simultaneous splenectomy had no effect on the survival of patnents who underwent curative gastrectomy for proximal gastric cancer. Randomized prospective clinical trial using more precise criteria to indicate the need for splenectomy are need.

330 SSAT.book Page 331 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1547 Prevalence of Metabolic Bone Disorders After Radical Gastrectomy for Carcinoma of Stomach Frances K. Cheung, Sheung-Wai Law, Nelson Tang, Wt Siu, Philip Chiu, Lm Mui, Sf Hon, Candice Lam, Bonnie Tsung, Enders Ng; The Chinese University of Hong Kong, Hong Kong, Hong Kong BACKGROUND: Radical gastrectomy is the main modality of treatment for gastric cancer in Hong Kong. Metabolic bone disorder is a complication of gastrectomy, with reported prevalence varies from 10 to 40%. We aim to measure the prevalence of metabolic bone disease after radical gastrectomy in our locality. METHODS: Patients who had radical gastrectomy performed for gastric tumor more than 3 years ago and now on remission of the disease were invited for the study. Serum and urine markers of bone metabolism were measured. Bone density of lumbar spine (from L2 to L4) and hip were measured with dual-energy x-ray absorptiometry. The prevalence of biochemical abnormalities and bone mineral loss in terms of osteropenia and osteoporosis were determined. RESULTS: 68 patients entered into the study, with mean age of 60 (SD = 10.9) years. There were 27 female. Twenty-four patients underwent radical total gastrectomy while the rest had subtotal gastrectomy. All had gastrointestinal continuity restored by Roux-en-Y reconstruction. They were 6.9 ± 3.5 years after the operation. Altered serum markers of bone metabolism were observed in 35 (51%) of them, with decreased 25-hydroxy-vitamin D in 5 patients (7%), increased serum phosphate in 6 (9%), elevated bone alkaline phosphate in 16 (24%) and parathyroid hormone raised in 14 patients (21%), Signiﬁcant loss of bone mineral density occurred in 48 patients (71%), with osteoporosis (T score less than –2.5) in 13 patients and osteopenia (T score between –1 to –2.5) in 35. Prevalence of signiﬁcant bone loss was higher in those with biochemical abnormalities than those without (80% vs. 56%, p = 0.032). CONCLUSION: There is a high prevalence of metabolic bone disease in patients after gastrectomy for carcinoma of stomach, especially those with abnormal biochemical markers of bone mineral metabolism. ABSTRACTS POSTER

331 SSAT.book Page 332 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1548 Secondary Esophageal Peristalsis in Gastric Banding Patients Ruxandra Ciovica, Michael Gadenstatter, Gerhard P. Schwab, Wolfgang Lechner; Department of Surgery, General Hospital of Krems, Krems, Austria PURPOSE: Laparoscopic gastric banding has become a routine procedure in the treatment of morbid obesity. At present there is no accepted method to standardize the quantity of postoperative band filling. Gastric banding causes an outflow obstruction regulated by band adjustment. In this study the dependence of secondary peristaltic waves on outflow obstruction was investigated with a new method of in vivo intraband manometry. PATIENTS AND METHODS: 30 patients (mean age 37.7 years; mean BMI 44.2) were included in the study. In all patients a Swedish adjustable gastric band (SAGB) was implanted in pars flaccida technique in a standardized way. According to international standards the first band filling was performed six weeks postoperatively by 0.5 ml steps. The technical equipment for intrasys- temic band manometry consists of a Hoover needle which is placed in the port. Using a transducer (Edwards, Truwave PX-600red) manometric waves at the site of the band can be visualized and recorded (Datex-Ohmeda, S/5-Collect, Vers.4.0). Patients were asked to perform 15 ml wet swallows. The manometric profile is dependent on the outflow obstruction caused by intraband filling. The number of secondary waves and the pressure rises inside the band at each adjustment were investigated. Obstruction of the band was defined when secondary waves after a wet swallow occured for more than two minutes. RESULTS: Depending on the fill volume of the band, different increases of pressure and the appearance of secondary peristaltic waves triggered by wet swallows were recorded. Obstruction of the band occured at a mean volume of 7.3 ml, in each patient an occlusion in barium x-ray control was then observed. At a mean fill volume of 6.3 ml a mean number of secondary waves of 1.4 occured. The SAGB has a range of 1.5 ml between no secondary peristalsis and total occlusion of the band. CONCLUSION: Secondary esophageal peristalsis has a strict dependence on the amount of outflow obstruction. Intraband pressure measurement is an encouraging new access to gastric banding. It appears to be a feasible method to control band adjustment without need for x-ray studies in low pressure bands.

332 SSAT.book Page 333 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1549 Bariatric Surgery at the Extremes of Age Javairiah Fatima, Scott G. Houghton, Jane L. Mai, Corey W. Iqbal, Geoffrey B. Thompson, Florencia G. Que, Michael L. Kendrick, Michael G. Sarr; Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN The safety and efﬁcacy of bariatric surgery in adolescents and especially in Medicare population has been challenged (JAMA 2005) and remains controversial. AIM: To determine short-term (30-day) and long-term outcomes of bariatric surgery in patients ≥60 years and ≤18 years old. METHODS: Query of our 20-year Mayo Clinic bariatric surgery database (n = 1786 patients) identiﬁed 155 patients ≥60 years (range 60–76) and 12 patients ≤18 years (range 12–18) who underwent bariatric surgery. 98% had a Roux- en-Y gastric bypass, 40 of which were re-operative revisions of prior bariatric procedures. We obtained morbidity and mortality rates from medical records and sent a questionnaire to all surviving patients; 127 of 139 survivors ≥60 years and all 12 adolescents returned the questionnaire (92%) at a mean of 5 years (range 1–19 years). Time and cause of death was determined in all non-surviving patients. Current follow-up was available in all 167 patients. RESULTS: For patients ≥60 years, indications for bariatric surgery included serious co-morbidities (diabetes, severe hypertension, sleep apnea and/or joint arthropathy). 30-day mortality was 0.7% (1 of 155 patients), serious morbidity delaying discharge was 14% (6 wound infections and 1 seroma, 5 bowel obstructions, 3 anastomotic leaks, 4 cardiovascular or respiratory events, and 1 each with renal failure, gastric stasis and gastro-intestinal bleed). 5-year mortality was 6%. Mean follow-up was 5 years (range 1–19 years). Body mass index (BMI in kg/m2) decreased from a mean (± SEM) of 46 ± 1 to 33 ± 1 with a 51% resolution of weight-related co-morbidities and an 89% subjective overall satisfaction rate. For patients ≤18 years, indications for operation included insulin-resistant diabetes mellitus (n = 3), sleep apnea (n = 3), obesity-induced asthma (n = 3), and prevention of impending weight-related morbidity or psychosocial retardation (n = 12). There were no deaths and no serious co-morbidities. BMI decreased from a mean of 55 (range 39–74) to 36 (range 27–53) at a follow-up of 3 years (range 1–8 years). Resolution of weight-related co-morbidities was 82%, and satisfaction with outcome was 83%.

SUMMARY: 30-day hospital mortality (<1%) and 5 year mortality (6%) were ABSTRACTS much lower than reported previously in the senior population (JAMA 2005), POSTER with acceptable morbidity and importantly, with good outcomes. CONCLUSIONS: Bariatric surgery is both safe and effective at high volume centers for patients with morbid obesity at both extremes of age.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1550 Tsunami Medical Relief in Rural Aceh: Role of the General Surgery Resident Eric J. Hanly, Hannah Bell, Tena Bell, Andrew Bell, Lee Jacobs; Surgery, Johns Hopkins, Baltimore, MD INTRODUCTION: On December 26, 2004, a 9.0 magnitude earthquake cen- tered 155 miles off the coast of northern Sumatra, Indonesia, generated a tsunami wave that killed more than 283,100 people in Indonesia, Sri Lanka, India, Thailand, and other Indian Ocean costal nations. Though perhaps not intuitively obvious, the general surgery resident possesses a specific blend of medical knowledge and procedural skills uniquely suited to provide medical relief under such circumstances. METHODS: A 12-person team of volunteers provided medical care to a rural Aceh population of an estimated 6,000 people for a period of 6 days 3 weeks following the disaster. The team was comprised of 4 nurses, 4 translators, 1 public health worker, 1 security/communications officer, 1 infectious disease physician, and 1 general surgery resident. The team conducted well-child, maternity health, and acute care clinics, in addition to serving the emergency medicine needs of the population whose own healthcare infrastructure had been destroyed. RESULTS: The team treated 311 patients from four primary villages. 163 patients (52%) were female, and 137 patients (44%) were age five & under. 144 patients (47%) had lost their homes and 54 patients (17%) had lost one or more 1st-degree relatives as a result of the tsunami. 55% of children seen were under the 30th percentile in weight for age, and 20% were under the 5th percentile. The 10 most common diagnoses among the patients treated were Well Child (69), URI (56), Viral Syndrome (18), Impetigo (14), Musculoskeletal Pain (13), Headache (12), Helminthic Infection (12), Pregnancy (11), Dyspep- sia (9), and Fever of Unknown Origin (9). An additional 7 patients required minor surgical interventions for incision & drainage of abscesses, wound debridement, or repair of skin lacerations. CONCLUSIONS: Medical relief work following a natural disaster is challenging because numerous factors affect the health of the surviving population. In this case, the remnant of the physical trauma inflicted by the tsunami itself was superimposed on a background of endemic tropical infectious disease, poor nutrition, poor hygiene, and poor health education. The result is a displaced population of people with limited physiologic reserve who require a combination of care for old infected wounds, new wounds, new infections, post-traumatic mental illness, and ongoing health maintenance. General surgery residents are chronologically close to their primary medical education, possess the procedural ability to manage infected wounds and skin lacerations, and are generally resourceful individuals who can manage such issues under austere conditions.

334 SSAT.book Page 335 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1551 Laparoscopic Sleeve Gastrectomy Is an Effective Primary Procedure for Morbid Obesity Thomas Hirai1, Hazem A. Elariny1, Howard D. Reines1, Michael Sheridan2, Oscar Chan1; 1Surgery, Inova Fairfax Hospital, Falls Church, VA; 2Medicine, Inova Fairfax Hospital, Falls Church, VA BACKGROUND: Sleeve Gastrectomy (SG) has gained acceptance as the first part of a 2-stage procedure in individuals with super morbid obesity (BMI > 55), and has increasingly been suggested as a primary operation for morbid obesity. METHODS: 84 patients underwent SG from Feb. 2001 to May 2002. Forty six patients had a follow up >1 year (average of 34 months). 32 patients had a BMI ≤ 55 and 14 patients had a BMI > 55. All patients were followed until a 2nd-stage procedure occurred or for the length of their follow up. Success was defined as an EBWL of >45%. Patients with BMI > 55 were not subjected to the success/fail demark as 2nd stage intervention usually precluded this analysis. The SG procedure was performed using the lesser curve gastric tube fash- ioned over a 60F bougie. RESULTS: Of the 46 patients, 70% were females, average age was 40.5 years and average BMI was 51.9. There were no deaths, no leaks, and no re-operations for complications. Patients with BMI ≤ 55, achieved success 66% of the time (21/32) and these patients achieved an average EBWL of 71% (95% CI = 65% to 78%). As compared to 11 failures (34%) in this group with an average EBWL of 23% (95% CI = 14% to 32%). This remarkable difference reached statistical significance (p < .0001). CONCLUSION: These data show that over a 3 year follow up, SG performed as a primary procedure in MO patients with a BMI ≤ 55, is successful in fully two-thirds of patients and achieves an EBWL of 71%. These results are comparable to gastric bypass historical data. Although, longer follow-up and a larger cohort is required to validate these results and to assess the validity and efficacy of SG for patients with a BMI > 55, our data suggest that sleeve gastrectomy is a viable and reasonable alternative to gastric bypass. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1552 Incidence, Risk Factors, and Outcomes for Incisional Hernias After Open Gastric Bypass Surgery Michael G. House, Michael A. Schweitzer, Thomas H. Magnuson; Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD BACKGROUND: Compared to laparoscopic bariatric surgery, open Roux-en-Y gastric bypass surgery (RYGBP) carries an increased risk for postoperative incisional hernia formation. Recently, there has been increasing interest in applying adjunctive techniques for abdominal wall closure in order to reduce the incidence of incisional hernias after open bariatric surgery. The purpose of this study was to determine the incidence and risk factors for incisional hernia after open RYGBP. METHODS: A retrospective analysis of a prospectively collected outcomes database was performed on all patients undergoing open RYGBP at a single institution by a single surgeon using a standardized surgical technique between 1999 and 2004. Both univariate and multivariate models were used to determine the factors influencing the development of a postoperative incisional hernia within one year after open RYGBP. RESULTS: During this 5-year period, 588 patients underwent open RYGBP for morbid obesity. All patients were followed postoperatively by the primary surgeon at 3-month intervals. The mean age of all patients was 42 years, and the mean BMI was 55 kg/m2. Within one year of the time of surgery, incisional hernias were detected clinically or radiographically in 133 patients (22.6%). Age, BMI, and preoperative diabetes mellitus did not predict postoperative hernia formation. Superobese patients (BMI ≥60 kg/m2) were not at increased risk for an incisional hernia. Among patients who developed incisional hernias, 49% had preoperative sleep apnea; whereas, sleep apnea was present in only 30% of patients who did not develop a postoperative hernia, p = < 0.0001. Other significant univariate risk factors for incisional hernia included male gender (risk ratio (RR) = 2.28, p = 0.0001) and the development of a postoperative surgical site infection (RR = 3.19, p = 0.0007). African- American patients were protected against incisional hernia formation (RR = 0.56, p = 0.02). No patient developed an acute wound dehiscence or hernia- related bowel incarceration after open RYGBP. CONCLUSIONS: Incisional hernias occur in nearly a quarter of patients who undergo open RYGBP. Preoperative independent predictors of incisional hernia formation include sleep apnea and male gender. Patients at high risk for postoperative incisional hernia after open RYGBP may benefit from techniques aimed at supporting abdominal fascial closure at the time of surgery.

336 SSAT.book Page 337 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1553 Irinotecan Combined with S-1 for Advanced Gastric Cancer – Results of Phase II Study and Gene Expressions Mikito Inokuchi, Kazuyuki Kojima, Hiroyuki Yamada, Mikiko Hayashi, Kenichi Sugihara; Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan We conducted a phase I/II study of irinotecan (CPT-11) combined with S-1, an oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine, in advanced gastric cancer (AGC). S-1 was administered orally at 80 mg/m2/day from day 1 to 14 of a 28-day cycle and CPT-11 was given intravenously on day 1 and 8 at initial dose of 70 mg/m2/day, stepping up to 100 mg/m2. The treatment was repeated every 4 weeks, unless disease progression was observed. In the phase I portion, the recommended dose of CPT-11 was determined as 80 mg/m2. In the phase II portion, 42 patients were evaluated. The median treatment course was five (range: 1–13). The incidences of severe (grade 3–4) hematological and nonhematological toxicities were 19% and 10%, respectively, but all were manageable. The response rate was 62% (26/ 42, 95% confidence interval: 47.2–76.6%), and the median survival time was 444days. Our phase I/II trial showed S-1 combined with CPT-11 is effective for AGC and well tolerated with acceptable toxicity. We also evaluated gene expressions of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyl transferase (OPRT), thymidine phosphorylase (TP), topoisomerase-I (Topo-I) in patients with gastric cancer treated by this chemotherapy retrospectively. TS mRNA of responding tumors was lower than that of non-responding ones. However, there was no statistically significant difference in overall survival time and time to progression, compared high TS group with low one. ABSTRACTS POSTER

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1555 Gastric Adenocarcinoma: Clinico-Pathological Characteristics in Young Patients Carlos E. Jacob, Claudio J. Bresciani, Bruno Zilberstein, Rodrigo Perez, Rafael Santos, Igor Proscurshim, Joaquim Gama-Rodrigues; Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil Gastric cancer is a leading cause of death in the world. In Brazil, this disease is the most frequent gastrointestinal cancer and occurs mainly in elderly people. Prognosis of gastric cancer in young patient is a subject of of debate The aim of this study was to analyze clinicopathologic characteristics of young patients with gastric adenocarcinoma. We analysed the gastric cancer database of University of São Paulo School of Medicine (Hospital das Clinicas). The period of the study is from January 1, 1971 to December 31, 2004. A retrospective review of charts from patients 45 years or younger with a diagnosis of gastric adenocarcinoma was done. We found 2217 patients with gastric adenocarcinoma. Of these population, 263 (11.9%) were 45 years of age or younger (range 14 to 45). The mean age of diagnosis was 39 yeras. There were 154 male (58.6%) and 109 female (ratio 1.4:1). The mean time of symptoms was 8 months (range 0 to 45) and the main complaint was epigastric pain. Family history of gastric cancer was observed in only 8 patients (3%). Resec- tion was possible in 180 patients (68.4%), but radical intention (D2 lymphadenectomy) was performed in 125 cases (47.5% of all patients). Twenty- three patients had resection of others organs due to radical lymphadenectomy or direct invasion. Subtotal gastrectomy was performed in the majority of patients (63%). Complications were observed in 21 patients submitted to D2 lymphadenectomy (16.8%). The mortality rate of this group was 2.4%. Half of the patients had a tumor located at distal third. The majority od the cases were Diffuse Lauren’s type. Early gastric cancer were observed in 15% of this population. Lymph node metastasis were found in 50% of patients submitted to radical operation. Advanced stage (III and IV AJCC staging) were observed in half of this population. Follow-up ranges from 12 to 288 months. Recurrence ocurred in 31% (39 patients), mainly in advanced cases. In spite some diferences in clinico-pathological characteristics when compared to general population, young patients with gastric adenocarcinoma could be treated with D2 lymphadenectomy with similar survival rates.

338 SSAT.book Page 339 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1556 Clinicopathologic and Immunohistochemistry Characterization of Multiple Primary Gastric Adenocarcinoma Uana M. Jorge1, Ulysses Ribeiro Junior1, Adriana V. Safatle-Ribeiro1, Donato Mucerino1, Osmar K. Yagi1, Natalia M. Felicio1, Cristovam Scapulatempo2, Edwin R. Parra1, Carlos E. Corbett2, Venancio A. Alves2, Bruno Zilberstein1, Joaquim J. Gama-Rodrigues1; 1Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo, Sao Paulo, Brazil Multiple primary gastric adenocarcinomas (MPGA) have been reported from 3.5% to 10% of the patients. The presence of MPGA in the same stomach at the time of resection may alter the extension of surgical treatment. Moreover, the route of carcinogenesis has not been clearly clariﬁed in these tumors (mutator pathway or suppressor pathway). AIM: To evaluate clinicopathologic and immunohistochemical characteristics of MPGA. METHODS: Hospital records from 1995 to 2003 of the gastric cancer patients regarding the presence of MPGA were retrospective reviewed, and compared to the patients who had solitary adenocarcinomas in the same period. Immu- nohistochemistry for p53 (suppressor pathway) and for hMLH1, hMSH2 and hMSH6 (mutator pathway) was performed using streptavidin-biotin complex method. RESULTS: 553 patients underwent gastric resection during the studied period. MPGA was detected in 19 (3.43%) of the patients. Thirteen (68.4%) were men and the mean age was 64.8 (range = 15–81 years-old). Sixteen patients had two separated tumors and three patients had three tumors. The tumors were localized in distal stomach in 22; body in 14 and proximal in 5. In fourteen patients the lesions were close to each other (less than 3 cm), while in ﬁve patients the neoplasias were distant, in another portion of the stomach. There was no statistical difference between age, gender and tumor location when a comparison with the solitary lesions was performed. There was a predominance of intestinal type tumors in the group of synchronic tumors compared to the solitary lesions, 73.2% vs. 38.5%, p = 0.016. More- over, synchronic neoplasias were diagnosed in earlier stage than solitary neoplasias, T1–T2 = 47.4% vs. T1–T2 = 25.9%, p = 0.01; and N0–N1 = 73.7%, vs. N0–N1 = 55.2%, p = 0.001. Immunohistochemistry for p53 was detected in 58.5% of the MPGA. Altered hMLH1 immunoexpression occurred in 19%

patients and hMSH6 in 4.8%. Immunostaining for hMSH2 was positive in all ABSTRACTS MPGA, indicating absence of alterations of this repair gene marker. There was POSTER an inverse association between immunoexpression of hMLH1 and p53 in MPGA. Thus, p53 was solely detected in 17 tumors, while hMLH1 was altered in 14/24 negative p53 tumors, p = 0.01. CONCLUSIONS: 1. MPGA presented higher frequency of intestinal type and early gastric cancer in comparison to solitary gastric cancer; 2. Two routes of carcinogenesis, mutator and suppressor, appears to be involved independently in the development of MPGA; 3. Carefull endoscopic examination of the entire stomach should be performed in patients with gastric cancer to avoid missed lesions.

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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

M1557 Endoscopic Management of Anastomotic Stricture Following Roux-en-Y Gastric Bypass for Morbid Obesity George B. Kazantsev, Ajay K. Upadhyay, Rakhee N. Shah, Steven A. Stanten, Arthur Stanten, Roupert Horupian; Surgery, Alta Bates Summit Medical Center, Oakland, CA BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the US. Depending on the technique used (hand-sewn, linear stapler, circular stapler), the incidence of gastrojejunal anastomotic stricture varies between 5 and 20%. Endoscopic dilation is the treatment of choice for anastomotic stricture, however the recommendations regarding the timing and optimal method vary among surgeons and gastroenterologists. We have reviewed our experience with endoscopic dilation of anastomotic strictures following RYGBP. METHODS: Between October 2003 and October 2005, 182 patents (pts) underwent RYGBP for morbid obesity. The procedures were done laparoscopically in 158 (86%) cases. Gastrojejunostomy was made with a 21 mm EEA stapler in 112 and in a hand-sewn fashion (2 layers over 34 FR tube) in 70 pts. Endo- scopic evaluation was performed using GIF 160 Olympus endoscope (external diameter of 8.6 mm). The stricture was diagnosed if anastomosis could not be intubated with the scope. All dilations were performed with controlled radial expansion (CRE) balloon dilators of increasing size (10-12-13.5 mm, one minute each). Recurrent strictures were dilated to 15 mm in a similar fashion. RESULTS: A total of 25 patients (13.7%) developed anastomotic strictures and underwent dilation at the mean time of 47 days after surgery (range 21 to 150 days). The presenting symptoms were postprandial nausea and vomiting for solids; in addition, 3 patients experienced severe retrosternal pain after eating. All pts tolerated dilation under IV sedation. No complications occurred. Most pts (n = 21) required only one dilation; three had to have a repeat dilation, and one required three dilations. No surgical revisions were necessary. The rate of stricture was slightly lower in the hand-sewn group: 11.4% vs. 15% (NS); there was a clear trend towards decrease in the stricture rate with experience in the hand-sewn group: out of ﬁrst 35 anastomoses performed in this fashion 6 strictured (17%), while only 2 (5.7%) strictured in the second group of 35 pts. CONCLUSION: Anastomotic stricture after RYGBP (deﬁned as inability to intubate the anastomosis with a 8.6 mm scope) occurred at a rate 13.7% in our series. Presenting symptoms are intolerance of solid food and postprandial vomiting. Endoscopic dilation with CRE balloon dilators performed as early as 21 days after surgery is safe and effective. Although samples are small, there is a strong trend towards decreased stricture rate if anastomosis is performed in a hand-sewn fashion, especially after the learning curve is passed.

340 SSAT.book Page 341 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1558 Predicting Stricture in Post-Gastric Bypass Patients Jennefer A. Kieran, Amy J. Koler, Melissa M. Davis, Robin P. Blackstone; Surgery, Scottsdale Bariatric Center, Scottsdale, AZ BACKGROUND: Gastrojejunostomy stricture after gastric bypass occurs 3–27% of the time. Technique can influence this rate, but we questioned whether there were patient factors that contribute to stricture rates. METHODS: Retrospective review of prospective database was performed. From 11/01 to 11/05, 1352 patients underwent laparoscopic gastric bypass at a single institution. The technique of transoral EEA 21 mm stapler was utilized in all patients. Linear regression was performed on all data points to identify risk factors for postoperative stricture. RESULTS: 76 patients developed postoperative stricture (5.6%), all of which were treated by endoscopic dilation. Of all the preoperative comorbidities, only Gastroesophageal Reflux Disease was statistically significant. (p < 0.05) Postoperative complications including intraabdominal hematoma and abscess were significant. (p < 0.05) Excess weight loss was similar in both groups at one year. (83.1% stricture vs. 82.6% non-stricture). CONCLUSIONS: Neither BMI, male gender, nor major preoperative comorbidities are indicators of postoperative stricture rate in gastric bypass patients. ABSTRACTS POSTER

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M1559 Surgical Resection for Gastric Cancer in the United States: A Dying Art? Anne T. Le1,4, Melvin K. Lau3, David H. Berger1,4, Hashem B. El-Serag2,4; 1Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; 2Divisions of Gastroenterology and Health Services Research, Baylor College of Medicine, Houston, TX; 3Department of Internal Medicine, Baylor College of Medicine, Houston, TX; 4Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX BACKGROUND: Although the overall incidence of non-cardia gastric cancer has declined, the incidence of localized disease (conﬁned to the stomach) has remained unchanged (1 per 100,000). The overall survival with gastric cancer remains poor and unchanged over the past 2 decades. This brings into question the quantity and quality of gastrectomy and lymphadenectomy, the main treatment for non-metastatic gastric cancer. To ensure accurate staging and hence proper treatment, lymph node (LN) sampling of at least 15 nodes is recommended (American Joint Committee on Cancer, 1997). We examined the determinants of gastric resection and adequate LN sampling for gastric cancer. METHODS: Data from Surveillance, Epidemiology, and End Results (SEER) registries was used to identify patients with non-cardia gastric cancer diagnosed during 1983–2002. Logistic multivariable regression was used to examine determinants of gastric resection and adequacy of lymphadenectomy. Cox proportional hazard (PH) models were used to examine trends in mortality risk. All models adjusted for age, race, gender, geographic region, and cancer stage (localized, regional, metastatic); Cox PH models also adjusted for treatment (gastrectomy, gastrectomy and radiation). RESULTS: Resection for non-cardia gastric cancer has steadily declined between 1983 and 2002 from 66% to 60% of all cases. In multivariable models, gastrectomies were less likely to be performed in 2002 (–48% compared to 1983), patients +70 (–39% compared to patients younger than 40), White race (–54% compared to Asian), and localized disease (–78% compared to regional disease). In localized disease, only 75% underwent resection. Wide geographic variability was found also (lowest in New Mexico [–45%] as compared to highest in Hawaii). Adequate LN sampling (15+ LN) was recorded in only 25% overall and 19% of localized disease. Improvement in LN collection since 1997 has been modest, with only a 7% increase. Again, the greatest dis- parity was related to geographic region; for example, adequate sampling occurred less in Utah (–83%) compared to Hawaii. Cox PH models showed a 66% (95% CI, 65%–68%) and 71% (95% CI, 68%–73%) increased chance of survival with gastrectomy and with both gastrectomy and radiotherapy compared to those who received no treatment. CONCLUSION: There is apparent underutilization of gastrectomy for gastric cancer, even for early stage disease. Furthermore, in up to 65% cases where gastrectomies are performed, LN collection is inadequate. Geographic varia- tions in performing gastric resection and adequate LN sampling were almost as signiﬁcant as stage of the cancer.

342 SSAT.book Page 343 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1560 Gastrointestinal Stromal Tumours (GIST) of the Stomach – Surgical Therapy & Early Postoperative Outcome Frank Meyer1,2, Lutz Meyer1,3, Hans Lippert1,2, Ingo Gastinger1,3; 1Institute of Quality Control, University Hospital, Magdeburg, Germany; 2Department of Surgery, University Hospital, Magdeburg, Germany; 3Department of Surgery, Municipal Hospital, Cottbus, Germany AIM: The aim of the study was, by the mean of a representative patient group, to investigate frequency, profile of tumor sites, extension & characteristics of tumor growth of gastric GIST related to patient characteristics, diagnostic/therapeutic spectrum & outcome in daily surgical practice. PATIENTS & METHODS: Out of a prospective, multicenter observational study on quality control in surgery with 1,199 consecutive patients with gastric carcinoma(Ca) or GIST from 01/01/2002–12/31/2002, a case series of patients with GIST was studied with regard to the diagnostic criteria, the treatment results such as operation & resection rate, spectrum of surgical interventions, perioperative morbidity, hospital mortality & results of the 3-year follow up. RESULTS: In total, 55 cases with GIST (55/1,199; 4.6%) were treated (mean age, 62 years; sex ratio, m/w = 33/22), out of which 29% (n = 16) were malignant. In the diagnostic profile, gastroscopy (87.3%), abdominal ultrasound (81.8%) & CT scan (67.3%) were predominant (EUS, 35.5%). Tumor sites were distributed as follows: Corpus (n = 19; 41,3%); antrum/pylorus (n = 16; 34.8%). Histologic diagnosis was preoperatively clarified in only 47.3% (n = 26; no histologic diagnosis, n = 18; 32.7%). All patients underwent surgical intervention; 94.5% (n = 52) were curative (R0) (lymph node metastases, n = 5; 5.5%/non-local metastases, n = 2; 3,6%). A limited tumor resection predomi- nated with 61.8% (n = 34) versus 36.4% (n = 20) with radical resection (gastric Ca, 6.6% & 78.9%, respectively) combined with no or with lymphadenectomy: 65.5% (n = 36) & 34.5% (n = 19), respectively. The perioperative morbidity was 23.6% (n = 13; gastric Ca, 42.0%); the mortality was 0% (gastric Ca, 8.6%). The 3-year follow up (range, 2.5–3.5 years) showed a tumor-free survival of 88.7% (n = 47/53); one patient could not be followed, & one patient declined follow-up investigation (1.8% each). In 4 cases (7.5%), metastases were found: Liver (n = 2); liver/spleen & lung (n = 1 each). There was no local recurrent tumor growth; the overall survival was 98.1% (n = 52/53).

CONCLUSION: Gastric GIST represent approximately 5% of primary gastric ABSTRACTS tumor lesions. A lymphogenic metastatic tumor growth occurs rarely (5.5%), POSTER however, it can not be totally excluded, in particular, in advanced tumor stages. The predominantly limited surgical interventions can provide a healing rate of more than 90% associated with a low perioperative morbidity & mortality.

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M1561 Function-Preserving Gastrectomy Procedures (Preservation of Hepatic and Celiac Branches of Vagal Nerve, and Pylorus) Improve Long-Term Quality of Life in Gastrectomized Patients for Early Gastric Cancer Koji Nakada, Hiroshi Nimura, Yutaka Suzuki, Nobuo Omura, Yoshio Ishibashi, Naruo Kawasaki, Norio Mitsumori, Sumio Takayama, Nobuyoshi Hanyu, Hideyuki Kashiwagi, Katsuhiko Yanaga; Surgery, The Jikei University School of Medicine, Chiba, Japan In Japan, the preservation of hepatic and celiac branch of vagal nerve (DGpv), and also pylorus (PPGpv) are often performed with distal gastrectomy (DG) for early gastric cancer located in the mid-to-lower stomach, and these function-preserving gastrectomy procedures is thought to attenuate postgastrectomy syndrome. AIM: To evaluate the efﬁcacy of function-preserving gastrectomy procedures on long-term quality of life (QOL) in gastrectomized patients. METHODS: The questionnaire was sent to 129 gastrectomized patients for early gastric cancer in our institute at least more than two years after the operation. They consisted of 86 patients with DG, 22 patients with DGpv and 21 patients with PPGpv. The degree of weight loss and the incidence of diarrhea as well as dumping symptoms were compared among the groups. RESULTS: In DG, DGpv and PPGpv patients, mean weight loss was 12.5:9.3*:7.2*%. The incidence of weight loss more than 20% was 17:14:0*%. The incidence of diarrhea was 60:19*:16*%. The incidence of dumping symptoms (systemic) was 36:27:19%. (* p < 0.05 vs. DG patients). CONCLUSIONS: Both function-preserving gastrectomy procedures for early gastric cancer was associated with improved long-term QOL in terms of body weight, diarrhea and dumping symptoms, which therefore could confer clinical beneﬁt.

344 SSAT.book Page 345 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1563 Clinical Management of Gastrointestinal Stromal Tumor (GIST) of the Stomach: Feasibility of Laparoscopic Surgery for Small GIST Yoshihide Otani1, Masaki Kitajima2; 1Surgery, Saitama Medical School, Saitama, Japan; 2Surgery, Keio University School of Medicine, Tokyo, Japan BACKGROUND: Most gastrointestinal stromal tumors (GISTs) are located in the stomach as submucosal tumors. They are defined as spindle cell or epithe- lioid mesenchymal tumors of the gastrointestinal (GI) tract. Recently developed immunohistochemical staining methods allow the differentiation of GISTs from myogenic, neurogenic and other mesenchymal tumors. Routine GI screening is well established in Japan and relatively small, asymptomatic GISTs are frequently detected. Although a tyrosin kinase receptor antagonist, imatinib mesylate, has shown excellent results in patients with unresectable or metastatic GIST, surgical resection of the primary tumor is the treatment of first choice when cure is sought. METHODS: In our institution (Keio University Hospital) laparoscopic wedge resection (LWR) has been performed for the treatment of gastric submucosal tumors (SMTs) since 1993. LWR is the primary procedure for tumors between 2 to 5 cm, while those larger than 5 cm are resected by open methods or laparoscopy-assisted surgery. To investigate the feasibility and efficacy of these methods, the clinicopathological findings and treatment outcome in 60 patients with GIST were analyzed. RESULTS: Among the 60 patients, thirty-five lesions (58.3%) were treated by LWR, 3 by laparoscopic surgery with a small skin incision and 22 by conventional open procedures. The mean size of the tumors was 42.5 mm with a range of 18 to 150 mm. All surgical margins were clear but one case had liver metastases at the time of primary surgery. In the 35 cases of LWR, most patients were discharged uneventfully between 5 to 7 days postoperatively. All patients of the laparoscopically treated group have survived without recurrence on up to 11 years’ follow-up. No port-site recurrence has been encountered. DISCUSSION & CONCLUSION: Laparoscopic surgery for gastric GIST can be regarded as a minimally invasive, curative and safe method. The literature reported that even incidentally found GIST smaller than 1 cm has mutation in the c-kit gene, especially at exon 11, the most common site in malignant

GIST. These ﬁndings support the idea that GIST is potentially malignant even ABSTRACTS

when small and emphasize the importance of resection of gastric SMT larger POSTER than 2 cm diagnosed as GIST.

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M1564 The Impact of Clinicopathological Factors on Survival of Patients with Gastric Cancer Jateen Patel, Sayon Dutta, Margo Shoup, Jack Pickleman, Gerard Aranha; Department of Surgery, Loyola University Medical Center, Maywood, IL OBJECTIVES: To determine whether or not the survival of patients undergoing surgical resection for gastric cancer was influenced by clinical presentation and/or pathological staging. MATERIALS AND METHODS: The Loyola Cancer Registry was accessed for information regarding 93 consecutive patients who had undergone gastric resection for gastric adenocarcinoma between July 1994 and January 2004. Survival data was obtained for all patients through September 2004. Patient charts were reviewed for clinicopathologic variables leading to further diagnostic testing, perioperative events and complications and postoperative adjuvant therapy. Pathology reports from resected specimens were reviewed for tumor staging and histological markers. The SPSS program was utilized to perform multivariate and univariate analyses relating survival to symptoms, nodal status, tumor stage, tumor size and margin status. RESULTS: There were 62 men (median age = 71) and 31 women (median age = 75). The median follow-up time for patients still alive was 20 months. Of the presenting clinical symptoms of weight loss, nausea/vomiting, abdominal pain, and early satiety, only weight loss (n = 27) was associated with a significantly worse prognosis with a median survival of 13 months versus 44 months in patients with no weight loss (p = 0.0155). Lymph node status was associated with a worse median survival only in those patients (n = 43) in whom at least 15 nodes were identified (14 months for node positive disease vs. median survival not reached for node negative disease). Median survival of patients with positive margins (n = 38) was significantly less than patients with negative margins (n = 55), (22 months vs. not yet reached for patients with negative margins, p = 0.0206). Lymphovascular invasion on histological analysis was associated with shorter median survival time than without invasion (14 months vs. 58 months, p = 0.0068). Comparison of survival among patients from each tumor stage (T1 through T4) showed significant differences (T1, n = 16, 63 months; T2, n = 39, 33 months; T3, n = 35, 15 months; T4, n = 3, 5 months, p = 0.0007). On multivariate analysis only tumor stage significantly influenced survival in our patients (p = 0.03; CI: 1.04–2.3). CONCLUSIONS: Weight loss at presentation implies a significantly worse prognosis in patients with gastric adenocarcinoma. Lymphovascular invasion and positive margins conferred a shorter median survival time when considered as independent factors. Our data confirms previously reported observations that gastric adenocarcinoma of advanced tumor stage adversely affects survival in patients undergoing resection.

346 SSAT.book Page 347 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1565 Multiple Failed Fundoplications Are Likely Not Amenable to Laparoscopic Repair B.L. Paton, Yuri W. Novitsky, Kent W. Kercher, B. Todd Heniford; Department of Surgery, Carolinas Medical Center, Charlotte, NC The laparoscopic approach to reoperative nissen fundoplication has proven to be feasible with excellent overall results. The minimally invasive approach to redo fundoplication however will not be possible for all patients. The aim of this study is to determine predictors of which patients will require an open redo fundoplication. METHODS: From May 1997 to July 2005, at a tertiary referral center for complex laparoscopic procedures, the records of patients who underwent redo fundoplication were retrospectively reviewed. RESULTS: Ninety patients (43 male: 47 female) with a mean age of 49 years (range 28–82) presented with recurrent symptoms after undergoing an antireflux procedure. Forty-eight patients had a previous open repair and forty-two patients had a previous laparoscopic repair. Seventeen patients included in the open group and eight patients in the laparoscopic group were undergoing their third or fourth fundoplication. Laparoscopic repair was attempted in seventy-four patients (82%); with twelve patients requiring conversion (13%). Sixteen patients (18%) underwent planned open repair. Of the patients who required conversion, eight had a previous open repair (with two patients having undergone three prior fundoplications) and four had previously undergone a laparoscopic repair (with two patients having undergone two previous fundoplications). Of the planned open group fifteen patients (93.8%) had previously had an open repair with two undergoing their third fundoplication attempt. Three patients had concurrent procedures including cholecystectomy and ventral hernia repair. Thirteen patients (27%) however who had a previous open repair were successfully treated with the laparoscopic approach. Of the twenty-five patients who were requiring their third or fourth fundoplication, only two patients were successfully repaired laparoscopically. Complications were higher for the open group and included an intraabdominal abscess, pneumonia, four wound infections, and one deep vein thrombosis. One patient in the laparoscopic group developed pneumonia. The mortality rate was 0%. CONCLUSION: Complex patients who have had multiple failed fundoplications are likely not candidates for laparoscopic repair. The laparoscopic repair is possible however for those who have had one previous open repair and ABSTRACTS

though the procedure is technically challenging it does have a lower rate of POSTER complications.

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M1566 Laparoscopic Surgical Treatment of Type II Diabetes Mellitus for Patients with BMI Between 22–35 Aureo L. De Paula1, Antonio L. Macedo2, Alfredo Halpern2, Nelson Hassi1, Vladimir Schraibman2; 1Surgery, Hospital de Especialidades de Goiania, Goiania, Brazil; 2General Surgery, Albert Einstein Hospital, Sao Paulo, Brazil INTRODUCTION: Type 2 diabetes mellitus is a disease with high prevalence that is related to innumerous complications and is also associated to a diminished life expectancy. Most of the patients are obese and weight reduction is one of the best ways to have a metabolic control of the disease. Bariatric surgery is an efﬁcient procedure for the control of DM2 in morbidly obese patients. Incretins hormones, GLP-1 and GIP, are related to glycemic homeostasis. The objective of this study is to evaluate the possibility of the Laparo- scopic transposition of a segment of ileum to the jejunum in order to treat DM2 patients. METHOD: The Laparoscopic procedure was done in 42 patients between Nov 2003 and Nov 2005. 24 were female and 18 male. Mean age was 51.8 years (29–62). Mean BMI was 26.6 (22–34.1). All patients were DM2 with inappropriate control of their glycemia, despite dietetic, oral hypoglycemic therapy and or insulin for at least 3 years. Mean duration of DM2 was 6.8 years (3–14). Three techniques were performed, consisting in different combinations of Ileal interposition in the proximal jejunum and vertical gastrectomy. RESULTS: Mean operative time was 192 min. Mean hospital stay was 3.2 days. There were no complications in the short-term (30-days). Mean postoperative follow-up was 9.2 months. 39 (92.9%) patients achieved adequate glycemic control and 3 had improvement. Mean percentage of body weight loss was 22% (11–34). Mean BMI was 23.8 (19–26.8). After 30 days, all patients normalized their cholesterol levels. Triglycerides were also normalized, however later on in the follow-up. The patients that did not normalize their glycemia were using oral hypoglycemic agents (2) and insulin (1) at lower doses. CONCLUSIONS: The Laparoscopic Ileal interposition seems to be a promising procedure to be used for the control of DM2, independently of the initial BMI. A longer follow-up period is needed.

348 SSAT.book Page 349 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1567 “Redo” Fundoplications Are Effective Treatment for Dysphagia and Recurrent Gastroesophageal Reflux Alexander S. Rosemurgy, Kerry Thomas, Dean Arnaoutakis, Desiree Villadolid, Sarah Cowgill; Surgery, University of South Florida, Tampa, FL BACKGROUND: With ever greater numbers of fundoplications being undertaken, increasing numbers of fundoplications will fail and increasing numbers of patients will be considered for “redo” fundoplications. This study was undertaken to determine long-term outcomes after “redo” fundoplications. METHODS: From 1992 to 2005, 92 patients underwent “redo” fundoplications and were prospectively followed. The failed fundoplications had been undertaken laparoscopically in 59% and by celiotomy in 42%. Reflux and dysphagia before and after “redo” fundoplication were scored utilizing a Likert scale (0 = none/never, 10 = severe/always). RESULTS: Patients were primarily troubled by dysphagia in 17%, recurrent reflux in 52%, or both in 26% before “redo fundoplication; median DeMeester score was 43. Causes of failure prior to “redo” fundoplication included hiatal failure in 30%, wrap failure in 15%, both in 38%, and slipped Nissen fundoplication in 20%. “Redo” fundoplication was not attempted laparoscopically in 17% because of extensive previous abdominal operations. Laparoscopic “redo” fundoplication was successfully completed in 91% for whom it was attempted; most frequent inadvertent events included gastrotomy in 19%, CO2 pneumothorax in 12%, and esophagotomy in 3%, without notable consequences. After reoperation, dysphagia scores improved from 4.6 ± 4.5 to 2.5 ± 3.1 (p = 0.0005) and reflux scores improved from 7.7 ± 3.3 to 1.4 ± 2.5 (p < 0.0001) (paired Student t-test). Excellent or good outcomes after “redo” fundoplications were reported by 80% of patients with reflux, 100% of the patients with dysphagia, and 71% with both. CONCLUSIONS: “Redo” fundoplications are technically challenging, especially laparoscopically, with relatively frequent, though inconsequential, inadvertent intraoperative events. “Redo” fundoplications, if undertaken laparoscopically, are likely to be completed laparoscopically. “Redo” fundoplications relieve symptoms of reflux and dysphagia with high rates of patient satisfaction and their application is supported. ABSTRACTS POSTER

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M1568 What to Expect in the Excluded Stomach Mucosa After Vertical Banded Gastroplasty – Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro1, Rogerio Kuga1, Robson K. Ishida1, Ulysses Ribeiro1, Faintuch Joel1, Kyoshi Iriya2, Carlos E. Corbett2, Thaise Y. Tomokani2, Bruno Zilberstein1, Joaquim J. Gama-Rodrigues1, Shinichi Ishioka1, Paulo Sakai1; 1Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil; 2Pathology, University of Sao Paulo, Sao Paulo, Brazil Mucosal alterations after vertical banded gastroplasty-Roux-en-Y gastric bypass has not been clearly evaluated, since the excluded stomach is not easily reached by conventional endoscopy. The new technique of enteroscopy, a double-balloon method, enables endoscopic evaluation of the excluded stomach. AIM: To analyze the histological findings and the presence of Helicobacter pylori (H. pylori) in the excluded stomach. METHODS: Forty consecutive patients who underwent Roux-en-Y gastric bypass longer than 36 months were selected for double-balloon enteroscopy. The excluded stomach was reached in 35/40 patients (87.5%). All H. pylori positive patients were treated before surgery. Morphological alterations were analyzed through hematoxilin and eosin and the presence of H. pylori was confirmed with Giemsa staining. RESULTS: Thirty patients (85.7%) were female and the mean age was 43.4 years-old. The mean post-operative time was 77.6 months (range 36–110 months). Eight cases (8/35, 22.8%) presented endoscopically normal bypassed stomach. According to Sydney classification, 4/35 (11.4%) patients had body or antrum gastritis, including three atrophic and one erythematous. Twenty-three patients (23/35, 65.7%) had pangastritis, including nine erythematous, nine flat erosive and five atrophic. Two patients 2/35 (5.7%) also had suspicious areas of intestinal metaplasia. Histologically, 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. Mild gastritis were detected in 23/35 (65.7%) and moderate gastritis in 12 out 35 (34.3%). No severe gastritis was found. 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. Severity of gastritis of the excluded stomach was associated to the presence of H. pylori, p = 0.02. Moreover, H. pylori was positive in the gastric stump (functional pouch) in 12/35 (34.3%). All positive H. pylori patients in the excluded stomach were also positive in the gastric stump, p = 0.0005. CONCLUSIONS: 1.) H. pylori is still present in the excluded stomach after Roux-en-Y gastric bypass and might be considered for treatment; 2.) Histolog- ical findings indicated high prevalence of atrophy and intestinal metaplasia in this selected population; 3.) Long-term endoscopic follow-up with biopsies is advised.

350 SSAT.book Page 351 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1569 Gastric Electrical Stimulation for Gastroparesis: Experience with Higher Settings Thomas Schnelldorfer1, Thomas L. Abell2, Vicki M. Limehouse3, Christopher J. Lahr1; 1Department of Surgery, Medical University of South Carolina, Charleston, SC; 2Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; 3Bon Secours St. Francis Hospital, Charleston, SC INTRODUCTION: Gastric electrical stimulation is a safe and efﬁcient treatment option in medically refractory gastroparesis. Several controlled and open label trials have shown the effectiveness of gastric electrical stimulation in symptom palliation for patients with gastroparesis. Initial settings were established based on experiences in the animal model. We reviewed our experience using higher stimulator settings on symptom reduction after implantation of gastric electrical stimulators. METHODS: 42 consecutive patients (38 females and 4 males, mean age 43 ± 1.8 years) with medically refractory gastroparesis were followed after implantation of gastric electrical stimulator between 1999 and 2005. The 42 patients included 29 patients with idiopathic gastroparesis and 13 patients with diabetic gastroparesis Baseline stimulation settings were 14 Hz, 5 mAmps, 330 micro-sec pulse width, 0.1 sec on, and 5 sec off. At each follow-up gastrointestinal symptom scores were assessed. If symptoms were unsatisfactory, stimulator settings were increased according to a standardized protocol. Dose response relationships were evaluated. RESULTS: After a mean follow-up of 19 ± 2.6 months, 83% of patients had higher settings (p < 0.001, Fisher’s exact test). Solid gastric emptying time during this period decreased from 195 ± 45 to 106 ± 38 minutes (T1/2 value, p < 0.05, paired t-test) along with an average weight change from 64 ± 5.3 to 62 ± 5.6 kg (p > 0.05, paired t-test). There were 258 stimulator interrogations with a stepwise improvement in total symptom score (R2 = 0.08, p < 0.001). Multivariate regression analysis showed that frequency of electric stimulation was independently associated with improvement of total symptom score (R2 = 0.06, p < 0.02). A prolonged cycle on time correlated with worsening of nausea score (R2 = 0.09, p < 0.02) and vomiting score (R2 = 0.13, p < 0.001). A measurement of high impedance independently correlated with a low vomiting score (R2 = 0.19, p < 0.0001). Though not statistically signiﬁcant, most patients’ symptoms were optimized at mean current of 10 mAmps, frequency of 55 Hz, pulse width of 330 micro-sec, cycle on time of 0.1 sec, and cycle off ABSTRACTS

time of 1 sec. POSTER CONCLUSION: The majority of patients seem to beneﬁt from higher than baseline settings. Optimal settings of the implanted device must be determined on an individual basis, but based upon experience in humans seem to be 10 mAmps, 55 Hz, 0.1 sec on, 0.4 to 1 sec off.

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M1571 Laparoscopic Wedge Resection of Gastric Stromal Tumors Wing Tai Siu1,2, Kwok Kay Yau2, Chung Ngai Tang2, Philip Wai Yan Chiu1, Lik Man Mui1, Frances Ka Yin Cheung1, Michael Ka Wah Li2, Enders Kwok Wai Ng1; 1Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong Traditionally gastric stromal tumors necessitated open wedge resection. We reported a series of laparoscopic wedge resection for gastric stromal tumors. PATIENTS & METHODS: Sixty-seven patients with submucosal gastric tumours diagnosed by upper endoscopy or incidentally diagnosed by laparoscopy were recruited. Pre-operative imaging with CT scan and endoscopic ultrasound were performed for clinically stable patients. Patients with actively bleeding lesions underwent emergency operations. Patients with lesions located at cardia and pylorus, exceptionally large lesions, and those lesions with imaging revealed adjacent viscera invasions or metastasis were excluded. Diagnostic laparoscopy and laparoscopic ultrasound were performed prior to tumors resections. Extragastric closed technique was employed for mobile tumors with adequate surrounding normal gastric wall. Transgastric approach via gastrototomy was employed whenever extragastric technique was not feasible and precise lesion localization and resection was required. Operative time, time to resumption of full diet, analgesic requirement, post-operative stay, morbidity and mortality were analysed prospectively. RESULTS: From June 1995 to October 2005, perioperative data of 67 patients, aged 28–84 (mean 64.5) with gastric stromal tumors underwent laparoscopic wedge resection was prospectively collected for analysis. There were 35 men and 32 women; twenty of them had signiﬁcant co-morbidities and belonged to ASA classes III or IV. The lesions were located at gastric body (18), fundus (24), lesser curve (15), greater curve (7), and closed to esophageal- gastric junction (3). Extragastric closed techniques were employed for 16 tumors, and 51 lesions were extirpated via gastrotomy. Average operative time was 82.3 (35–180) minutes. Twelve patients necessitated conversions to open for esophago-gastric junction lesions (3), broad-based and retroperitoneal adhesions at the fundus (3), high lesser curve lesions (4), and technical difﬁculty (2). Patients required 2 doses (mean) of post-operative pethidine injection and 5 days (median) to resume full diet. The median post-operative stay was 6 days. Two ASA IV patients developed post-operative stroke. One patient with posterior fundal lesion removed was complicated by reactionary hemorrhage and radiological evidence of leakage, which was managed conservatively. Another patient had diffuse peritoneal metastasis 30 months after the procedure. CONCLUSION: Laparoscopic wedge resection of gastric stromal tumors is safe and feasible and associated with satisfactory post-operative outcomes.

352

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1572 Laparoscopic Repair for Perforated Peptic Ulcer Wing Tai Siu1,2, Kwok Kay Yau2, Chung Ngai Tang2, Ping Yiu HA2, Philip Wai Yan Chiu1, Enders Kwok Wai Ng1, Michael Ka Wah Li2; 1Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong AIM: This study prospectively evaluates the results of laparoscopic repair for perforated peptic ulcers (PPU) in an institution. PATIENTS & METHOD: From Jan 1994 to Jan 2005, 291 patients diagnosed clinically with PPU were treated by laparoscopic suture repair. The initial 63 patients were recruited for a randomised controlled trial comparing open versus laparoscopic omental patch repair. After the trial, all patients with PPU were treated via laparoscopy. We excluded patients with history of upper abdominal surgery, concomitant evidence of ulcer bleeding or gastric outlet obstruction. Patients with clinically sealed off perforation were treated conservatively. Laparoscopic procedure would be converted for non-juxtapyloric gastric ulcers or for perforations larger than 10 mm. RESULTS: There were 233 male and 58 female patients treated, aged 16 to 88 year (mean = 55). 177 patients had perforated duodenal ulcers, 39 prepyloric and 17 gastric ulcers. There were 53 conversions (18.2%) for large duodenal perforations (27), perforated non-juxtapyloric gastric ulcers (13), un-identifiable perforations (5), and technical difficulties (8). Ten patients underwent definitive ulcer procedures. Average operating time was 50 minutes (10–196). Post-operatively, the average analgesic requirement (by intramuscular pethidine) was 1 dose. MORBIDITY & MORTALITY: There were 11 leakages from repaired site, 5 of them required re-operations. One patient developed duodenal ulcer bleeding after operation. Sixteen ASA III and IV patients died in the post-operative period. Another patient with conversion was complicated by port site herniation. CONCLUSION: Laparoscopic repair of perforated peptic ulcer is a safe emergency procedure in routine clinical practice for patients with perforated pyloroduodenal ulcer. ABSTRACTS POSTER

Figure 1. Laparoscopic “single-stitch” suture repair of duodenal perforation with omental patch augmentation

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M1573 Gastric Adenocarcinoma: Reduction of Perioperative Mortality by Avoidance of Nontherapeutic Laparotomy Brian R. Smith, Bruce E. Stabile; Surgery, Harbor-UCLA Med Ctr, Torrance, CA BACKGROUND: National trends indicate an ongoing decline in gastric adenocarcinoma due presumably to a decreasing prevalence of H. pylori infection. Nonetheless, surgical outcomes continue to include high morbidity and mortality rates related to the advanced stage of disease encountered. HYPOTHESIS: Recent immigration patterns are responsible for a leveling off of the declining incidence of gastric cancer caused by H. pylori infection. Fur- thermore, advances in preoperative tumor staging and nonoperative palliation now allow better patient selection for operation and lower perioperative morbidity and mortality rates. DESIGN AND SETTING: Retrospective review of a consecutive case series at a public teaching hospital located in an area of high immigration. PATIENTS AND METHODS: All patients presenting from 1995 through 2004 with gastric adenocarcinoma. For time comparison purposes patients were divided into Early (1995–1999) and Recent (2000–2004) Periods. RESULTS: A total of 260 patients were treated over 10 years of whom 137 (53%) underwent operation (Table). The operation rate decreased from the Early Period to the Recent Period as fewer advanced stage (M1) patients underwent exploratory laparotomy and were palliated by nonoperative means such as endoscopic stenting for obstruction and argon beam photoco- agulation for bleeding. Of the 4 total perioperative deaths, 2 followed 11 nontherapeutic laparotomies (18% mortality), while the only 2 additional deaths followed 120 curative or palliative laparotomies (2% mortality) (p = 0.046). Relative Early Period 1995–1999 Recent Period 2000–2004 Change Patients 128 132 3% Male:Female Ratio 1.6:1 1.1:1 –31% H. pylori Infection Rate 82% 79% –4% Endoscopic Palliation Rate 21% 35% 67% Staging Laparoscopy Rate 20% 25% 25% Overall Operation Rate 59% 46% –22% Stage M1 Operation Rate 34% 20% –41% Operative Resection Rate 81% 93% 15% Nontherapeutic Laparotomy Rate 11% 5% –55% Perioperative Morbidity Rate 29% 23% –21% Perioperative Mortality Rate 5% 0% –100% CONCLUSIONS: 1) In an area of high immigration there has been no decline in gastric adenocarcinoma over the past decade; 2) The H. pylori infection rate remains very high; 3) The historic male predominance has virtually disap- peared; 4) Improvements in preoperative staging and nonoperative palliation have allowed a substantial reduction in the nontherapeutic laparotomy rate; 5) The marked decrease in overall perioperative mortality is primarily due to obvi- ation of the excessive mortality attending nontherapeutic laparotomy.

354 SSAT.book Page 355 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1574 Does the Position of the Alimentary Limb in Roux-en-Y Gastric Bypass Surgery Make a Difference? I. Michael Leitman, Jerome D. Taylor, James (Butch) Rosser, Brian R. Davis, Elliot Goodman; Surgery, Beth Israel Medical Center, New York, NY BACKGROUND: Intestinal obstruction occurs in 2-3% of patients following Roux-en-Y gastric bypass (RYGB) surgery; many of these are due to Petersen’s internal hernia. There is controversy as to whether the alimentary limb should be placed in the retro-colic or ante-colic position to reduce this incidence. METHODS: A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75 cm alimentary limb based upon technical consideration. Group A (216) patients had placement of the Roux limb anterior to the transverse colon and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19–64) and the body mass index BMI ranged from 40–75 kg/m2. Patients were followed for 14–80 months (mean 30 months). Any patient lost to follow-up was excluded. RESULTS: Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, p > 0.05). 13 patients required re-operation for intestinal obstruction (7 patients in group A and 6 patients in group B (p > 0.05). None of the intestinal obstructions in group A were due to Petersen’s hernia whereas this was the etiology in four of the six patients in group B. The development of anastomotic stricture was 1 patient (0.5%) in group A and 3 patients (1%, p > 0.05) in group B. No other complications during the follow-up period were attributed to the position of the alimentary limb. CONCLUSION: Placement of the Roux limb in the antecolic position is technically easier in some patients and does not appear to be associated with more complications than a retrocolic alimentary limb. It avoids the risk of an internal hernia through the transverse mesocolon but does not appear to reduce the incidence of intestinal obstruction or feeding difﬁculties either in the early or late post-operative period. ABSTRACTS POSTER

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M1575 Gastric Bypass Does Not Influence Olfactory Function Jon S. Thompson, Brynn Richardson, Eric Vander Woude, Ranjan Sudan, Donald Leopold; Surgery, University of Nebraska Medical Center, Omaha, NE BACKGROUND: Morbidly obese individuals have been shown to have altered taste and smell. Gastric bypass surgery has previously been shown to alter taste. Gastric bypass surgery may also alter smell and the combination of these changes may account for changes in food tolerance and appetite in morbidly obese persons. The aim of this study was to evaluate the effect of abdominal operation, specifically gastric bypass, on olfactory function. METHODS: 55 persons undergoing Roux-en-Y gastric bypass (GBP) and cholecystectomy and 40 persons undergoing cholecystectomy (CC) alone were administered the Cross Cultural Smell Identification Test (CC-SIT) preoperatively and at 2 and 6 weeks postoperatively. Patients undergoing GBP underwent further tests at 3, 9, and 12 months. Body mass index (BMI), age, and gender were also assessed pre-operatively and BMI was followed at the time of post-operative testing. RESULTS: Mean BMI was noted to be significantly greater in the GBP group (50.6 v. 30.6, p < 0.05). Age and gender distribution were similar between groups. 12.7% of GBP patients and 5% of CC patients had abnormal CC-SIT results pre-operatively. Post-operatively, there were no significant differences in percentage of abnormal tests at 2 and 6 weeks (2 weeks: GBP 7.5% v CC 5.8%, p > 0.05; 6 weeks: GBP 10.8% v CC 3.2%, p > 0.05). BMI was noted to decrease in the GBP group from 50.6 pre-operatively to 34.2 at 12 months post-operative with 10.8% olfactory dysfunction. CONCLUSION: Olfactory dysfunction in morbidly obese persons does not appear to be affected by weight loss. Additionally abdominal operation does not appear to influence olfactory function.

356 SSAT.book Page 357 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M1576 Current Strategy for Treatment of Perforated Gastric Ulcer (PGU) and Duodenal Ulcer (PDU): Can Computed Tomography (CT) Really Diagnose Perforating Site? Tatsuya Ueno, Hiroo Naito, Michinaga Takahashi, Akihiro Kanno, Shinji Goto, Munenori Nagao; Surgery, South Miyagi Medical Center, Miyagi-Pref, Japan CT is very useful to ﬁnd small amount of free air in abdominal cavity. To determine the most appropriate treatment, it’s very important to detect the perforating site, which has been pointed out by emergent endoscopy and/or upper GI radiological examination so far. However, these examinations are so invasive for this kind of patients. AIM: to clarify characteristics of PGU and PDU, and possibility whether CT can differ PGU from PDU. METHOD: medical records and CT of 37 patients (Pts) who were treated in our hospital in recent three years, were retrospectively reviewed. RESULT: mean age of the Pts are 61 in PGU (14 Pts), and 48 in PDU (23 Pts). 26 Pts (70%) did not have past history of peptic ulcer. Abdominal pain sud- denly occurred in 17 Pts (46%), though 20 Pts (54%) noticed worsening symptom of peptic ulcer at least 24 hours before admission. Only 3 cases were under the medical treatment of peptic ulcer at the time of admission. HP positive rate were 25% in PGU and 91% in PDU. Non-surgical, conservative therapy was adopted according to following criteria, 1.) Less than 65 years old, 2.) Hospital arrival in less than 6 hours after severe symptoms occurred, 3.) Do not have serious general complications, 4.) Accumulating small amount of ascites localized in the subphrenic cavity. Conservative therapy consists of 1.) fasting 2.) proton pump inhibitor i.v. 3.) antibiotics i.v. 4.) insertion of nasogastric tube and drained by 10 cmH2O. PDU were cured by conservative therapy in 15 Pts (65%), while PGU were in only one Pts (0.7%). Surgical management include omental plombage+drainage (12 Pts), drainage only (4 Pts), gastrectomy (1 Pts), and selective proximal vagotomy+pyloplasty (2 Pts). 2 Pts (PDU) were converted from conservative to surgical management. Duration of nasogastric tube, fasting, and hospital stay were 4.7, 7.8, 15.1 days respectively in non-surgical group vs 9.3, 12.2, 28.3 days in surgical group. In all cases, perforating sites were diagnosed with initial CT reviewed by radiologist, which had been conﬁrmed by operation and/or endoscopy. CONCLUSION: PGU usually need surgical management, while PDU do not. We can differ PDU from PGU by CT reviewing without endoscopy. Careful ABSTRACTS POSTER reviewing CT will promise us with early and non-invasive decision making of treatment method and good clinical outcome in patients with PGU and PDU.

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M1577 Results of a Randomized, Prospective Trial Comparing Residual Stomach, Duodenum and Uncut Jejunal Interposition (Gastrojejunoduodenostomy) to Standard Billroth-II Reconstruction After Subtotal Gastrectomy for Distal Gastric Cancer Qin Zhang1,2, Mark S. Talamonti2, Zaiyuan Ye3, Hongqi Shi4, Jianfa Yu1; 1Gastrointestinal Surgery, Affilliated Hospital of Zhejiang College of Traditional Chinese Medicine, Hangzhou, China; 2Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Department of Surgery, Zhejiang Provincial People Hospital, Hangzhou, China; 4Department of Surgery, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China This randomized, prospective study compares a new type of digestive reconstruction, gastrojejunoduodenostomy with uncut jejunal interposition, to standard Billroth-II gastrojejunostomy after subtotal gastrectomy. The new procedure consists of: an end-to-side gastrojejunostomy 25 cm distal to the Treitz ligament, a side-to-end jejunoduodenostomy at the efferent jejunum 30 cm distal to the gastrojejunostomy, and side-to-side jejunojejunostomy, two jejunal occlusions one proximal to the gastrojejunostomy and a second distal to the jejunoduodenostomy. 86 cases with distal gastric cancer were randomized: 41 cases with the new procedure (Group A) and 45 cases with standard Billroth-II procedure (Group B). Body weight (BW), Prognosis nutritional indexes (PNI) and Visick scoring (VS) at three & six months after surgery were compared. BW and PNI in Group A at 6 months were back to the level before surgery unlike those in Group B. VS in Group A at six months was superior to that in Group B (u = 2.85, P < 0.01). This new procedure may offer a better option for digestive reconstruction after subtotal gastrectomy by restoring digestive physiological passage through the duodenum, avoiding bile reflux, and improving quality of life.

Figure 1. Gastrojejunoduodenostomy A,B: mark the ligation location

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Table 1. Results of Pre- and Post Operative Conditions

Body Weight (Kilogram) Prognosis Nutritional Indexes Group n Before 3 Months 6 Months Before 3 Months 6 Months A4159.29 ± 6.13 56.34 ± 5.33 59.71 ± 5.11 45.89 ± 4.88 39.93 ± 5.2 45.54 ± 4.37 B4558.27 ± 5.12 53.44 ± 3.79 55.53 ± 4.00* 44.83 ± 5.51 36.3 ± 4.05 40.05 ± 4.41*

∆: compared to “before” of the same group, there was a significant difference (P < 0.05) *: compared to “3 month” of the same group, there was a significant difference (P < 0.05) ABSTRACTS POSTER

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COMBINED SCIENCE POSTERS M2286 A Novel System for Performing Endoluminal Antireflux Surgery and Other Endosurgical Procedures Aureo L. Depaula1, Richard A. Kozarek2, Desmond H. Birkett3, Nathaniel J. Soper4, Bruce V. Macfadyen5, John D. Mellinger5, Lee L. Swanstrom6; 1Department of Surgery, Hospital de Especialidades, Goiania, Brazil; 2Section of Gastroenterology, Virginia Mason Medical Center, Seattle, WA; 3Department of Surgery, Lahey Clinic, Burlington, MA; 4Department of Surgery, Northwestern University, Chicago, IL; 5Department of Surgery, Medical College of Georgia, Augusta, GA; 6Dept. of Surgery, Legacy Health System, Portland, OR INTRODUCTION: Endoluminal antireflux surgery has, to date, had disap- pointing results due to failure to create an aggressive and durable antireflux barrier. New technologies for natural orifice surgery include endoluminal tools that provide advanced maneuverability and access, high degrees of force transmission and tissue manipulation, and creation of durable tissue approxi- mations. Such a new endoluminal system (USGI, San Clemente, CA) was tested in two animal models to assess the ability to reconfigure the esophageal flap valve with multiple full-thickness “sutures” to create an antireflux barrier that corresponds to valves created by fundoplications. MATERIALS AND PROCEDURES: The endoluminal system is comprised of a flexible multilumen, steerable guide constructed using ShapeLock® technology and a combination grasper/approximation device used to create deep tissue plications secured via tissue anchor pairs. Tissue anchors deploy in a low profile then expand when cinched against tissue. Anchors maintain tissue approximation until tissue fibrosis and remodeling occurs. The system was used in a retroflexed position to maintain continuous access and visualization of the gastroesophageal junction (GEJ). Multiple, deep tissue folds were grasped and secured to create an arc of tissue around the GEJ. Variable numbers and placement of plications at the GEJ in both swine and canines were studied to assess the capabilities of the system for endoluminal reconfiguration of the valve. Acute assessments included endoscopic examination and gastric yield pressure. Chronic assessments included both endoscopic and histological evaluation. RESULTS: Multiple full thickness plications were successfully placed in an arc around the GEJ. Eleven animals had the procedure done with an average of 5 anchor pairs placed. Measured gastric yield pressure doubled following valve reconfiguration. Examination at 4 weeks showed intact plications and a benign tissue response to the tissue anchors. Endoscopic Hill valve grades were either 1 or 2. Microscopic examination showed a localized, inflammatory response with fibrosis and remodeling of the serosa and muscularis layers. CONCLUSIONS: The feasibility of endoluminal surgery using a novel system was demonstrated. The system enabled successful endoluminal reconfiguration of the esophageal flap valve. Good long term durability of created full thickness plications is predicted based upon evidence of transmural fibrosis and tissue remodeling. Study of this new system in GERD patients is warranted to evaluate the effectiveness of this reconfigured valve as an antireflux barrier.

360 SSAT.book Page 361 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M2287 Gastric pH and Nutritional Course After Gastroplasty for Morbid Obesity Joel Faintuch1, Rogerio Kuga1, Rejane Mattar1, Paulo Sakai1, Robson K. Ishida1, Ivan Cecconello1, Ulisses Ribeiro1, Adriana S. Ribeiro1, Shinichi Ishioka1, Bruno Zilberstein1, Miyoko Mijakabi2, Denise F. Barbeiro3, Francisco F. Soriano3, Hermes V. Barbeiro3; 1Gastroenterology, Hospital das Clinicas, Sao Paulo, Brazil; 2Microbiology, Adolpho Lutz Institute, Sao Paulo, Brazil; 3LIM 51, University of Sao Paulo Medical School, Sao Paulo, Brazil AIMS: Gastric acidity may be influenced by gastroplasty, but actual changes have not been reported. In a prospective study, gastric pH was compared to clinical course in a bariatric population. MATERIAL AND METHODS: All patients ( n = 26, 47.1 ± 10.0 years, preoperative and current BMI respectively 52.7 ± 8.7 and 33.6 ± 6.4 kg/m2) underwent gastroplasty with Roux-en-Y bypass (RYGB). Samples for gastric pH were obtained by the Fujinon EM-450P5 enteroscope from both the micro-pouch and the excluded stomach. Findings were correlated with body mass index (BMI), serum albumin, plasma lipids, hemoglobin concentration and general clinical findings. No patient had ongoing gastric complaints or received antacid medication. RESULTS: All subjects displayed neutral pH (7.0) in the active pouch, whereas in the excluded stomach pH was 2.3 ± 0.7, in association with various degrees of gastritis. Moderate anemia along with normal albumin and lipids was the biochemical pattern of this population, and recurrent obesity (BMI > 40 kg/m2) was detected in 12.3%. Nevertheless, none of these findings could be correlated to gastric pH in either chamber. CONCLUSION: 1) Gastric acid suppression occurred in the functional pouch, in contrast to maintained secretion in the excluded viscus; 2) Nutritional profile was mostly adequate with some events of recurrent obesity; 4) Relevance of gastric pH changes to digestive and nutritional status could not be shown, but there was association with both gastritis and bacterial overgrowth. ABSTRACTS POSTER

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M2288 Joint Kinematics Vary with Performance Skills During Laparoscopic Exercise (Fundamentals of Laparoscopic Surgery [FLS] Task 1) Gyusung Lee, Matthew J. Weiner, Stephen M. Kavic, Ivan M. George, Adrian E. Park; Surgery, University of Maryland, Baltimore, MD INTRODUCTION: Surgeons who perform minimally invasive surgery (MIS) may achieve better surgical performance by optimizing joint kinematics. The development of standard joint kinematics matrices could be beneficial in guiding surgical training. In this study, we investigated how joint kinematics are correlated to skill levels during performance of pegboard transfer task as put forth in FLS. METHODS: Six, right-handed subjects with different levels of MIS experience were recruited to perform the FLS pegboard transfer task. A motion capture system using twelve high-speed, digital, infrared, high-resolution cameras recorded upper body movements of participants. For each subject, left- and right-side data was captured in three rotations—flexion/extension, abduction/ adduction and internal/external—at three joints—shoulder, elbow, and wrist. To determine how joint kinematics and skill level are related, performance time was correlated with three variables: two established, range of motion (ROM) and mean joint angle (MJA), and one novel, mean joint movement amplitude (MJMA). MJMA was defined as averaged absolute angular deviation from MJA. RESULTS: MJA revealed skill differences. Participants requiring the most time to perform showed more mean flexion angles (r = .684, P < .05) at the left elbow while maintaining approximately 90 degrees at the right elbow. Regarding the left wrist, more skilled participants, requiring the least time, showed more external rotations (r = .680, p < .05) while less skilled subjects maintained the neutral position. Less skilled subjects showed more external rotation at the right wrist (r = –.751, p < .05). No significant correlations were discovered in regard to the shoulders and the right elbow. Performance skill levels during pegboard transfer task were not predictable by ROM or MJMA. CONCLUSIONS: This study showed MJA was correlated with skill level repre- sented by performance time. In developing a standardized joint kinematic matrix for FLS task 1, MJA must be included. Since ROM and MJMA showed no significant correlation among different skill levels, further investigations should be undertaken on joint movement patterns to better formulate joint control strategies that can be standardized for optimal laparoscopic surgery training.

362 SSAT.book Page 363 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

M2289 Knowledge and Opinions Regarding Medicare Reimbursement for Laparoscopic Cholecystectomy Atul K. Madan, David S. Tichansky, Ginny Barton, Raymond J. Taddeucci; Surgery, University of Tennessee Health Science Center, Memphis, TN INTRODUCTION: Medicare, via its fee schedule, determines amount of payment to physicians for services on its beneﬁciaries. Since many private insurance companies base their payment schedule on Medicare rates, it is important for physicians to know the rates of commonly performed procedures. In addition, it seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient, student, resident, and surgeon knowledge and opinion of Medicare reimbursements for laparoscopic cholecystectomy (LC). METHODS: Patients, students, residents, and surgeons ﬁlled out an IRB exempted survey. The survey included a written description of a LC. All participants were asked to give their thoughts of what Medicare currently reim- burses for a LC ($622) as well as what they thought Medicare should reimburse for a LC for our geographic area. Nonparametric ANOVA (Kruskal- Wallis Test) and the nonparametric Wilcoxon matched pairs test were utilized for statistical analysis as appropriate. RESULTS: There were 105 participants (47 patients, 17 medical students, 33 surgical residents, and 8 attending surgeons) in the investigation. Table below demonstrates what the mean ± standard deviation reimbursements by each group. The mean reimbursements were statistically different between all groups in both the amount Medicare currently pays and the amount Medi- care should pay (p < 0.05). In addition, there were statistical differences between the mean amount Medicare currently pays and the amount Medi- care should pay for both the surgical resident and the attending surgeon groups (p < 0.05).

Medicare currently pays Medicare should pay Patients \$9,396 ± \$19,443 \$8,067 ± \$17,988 Medical Students \$3,077 ± \$3,315 \$3,971 ± \$3,356 Surgical Residents \$800 ± \$665 \$1,444 ± \$896 Attending Surgeons \$711 ± \$100 \$1,600 ± \$341

CONCLUSION: Most of our participants overestimated what Medicare cur- ABSTRACTS

rently pays for LC. Even the mean amount reported in the attending surgeon POSTER group was greater than the actual payment. All groups felt Medicare should pay more than the current rate; however, only patients thought Medicare should pay less than they currently pay (probably due to the incorrect perception of the current Medicare fee schedule). The surgical community needs to do a better job in educating the public, the medical profession, and the legis- lature on the amount of payment from Medicare.

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AUTHOR INDEX

A Ashida, Toshifumi ...... M1528 Ashley, Stanley W...... 379, M1504, Sp787 Aarons, Cary ...... M1865 Asiyanbola, Bolanle ...... M1541 Abdo, Emilo E...... M1507 Assef, Jose Cesar ...... M1492 Abe, Nobutsugu ...... M1422 Assumpto, Lia ...... 370 Abell, Thomas L...... M1569 Atomi, Yutaka ...... M1422 Adam, Gerhard ...... M1493 Ault, Glenn ...... M1411 Adam, Ulrich ...... 378, M1482 Aurelio, Marco ...... M1457 Adams, David B...... M1520 Aurora, Alexander ...... M1863 Adamsen, Sven ...... M1388 Avital, I ...... 258 Adrian, Thomas E...... M1891, M1903 Ayazi, Shahin ...... M1542 Ahmad, Jawad ...... M1401 Azodo, Ijeoma A...... M1543 Ahmad, Syed A...... M1505 Ahotupa, Markku O...... M1468 B Ainsworth, Alan P...... M1388 Ajani, Jaffer ...... 801 Bacchella, Telesforo ...... M1887, M1888, Al-Azzawi, Hayder ...... 693 ...... M1899 Al-Saadi, Sam ...... M1466 Bachmann, Jeannine ...... M1487 Al-Saif, Osama ...... 372, M1489 Bahde, Ralph ...... M1544 Alderson, Derek ...... M1527 Bains, Manjit S...... M1467 Alexandre, Alcione S...... M1887, M1888 Baker, Mark ...... Sp393 Allen, Christopher J...... 256 Baldarelli, Maddalena ...... 259, M1430 Allen, Jeff W...... Sp594 Baldus, Stephan E...... M1469, M1875 Allen, Mark S...... M1444, M1447 Balik, Emre ...... M1866 Allen, Peter J...... M1498, M1506 Ballantyne, Garth H...... Sp759 Almahmeed, Taghreed ...... M1540 Bansal, Navin ...... 699, M1885 Alvelo-Rivera, Miguel F...... M1453 Baratella, Paola ...... M1515 Alves, Venancio A...... M1556 Barbeiro, Denise F...... M2287 Ambrosetti, Patrick ...... Sp394 Barbeiro, Hermes V...... M2287 Ambuehl, Markus ...... M1502 Barnes, Sunni A...... M1447, M1523 Ancona, Ermanno ...... M1474, M1475 Barnhart, Jordan ...... 707, M1407 And, Elvis Research Group ...... 256 Bartlett, David L...... M1496 Anderson, Frederick A...... 698, M1396 Barton, Ginny ...... M2289 Andraus, Wellington ...... M1888 Bass, Barbara L...... Sp238, 475 Angriman, Imerio ...... M1402 Bauer, Todd W...... Sp791 Angst, Eliane ...... M1502 Beart, Robert W...... M1411 Ansell, Ian F...... M1907 Becker, James M...... M1865 Antolovic, Dalibor ...... M1399 Beldi, Guido ...... M1886 Anula, Rocio ...... M1423 Belghiti, Jacques ...... M1495 Anvari, Mehran ...... 256 Belizon, Avraham ...... M1866 Aoki, Hiroaki ...... M1471 Bell, Andrew ...... M1550 Aranha, Gerard ...... M1564 Bell, Hannah ...... M1550 Arbeo-Escolar, Ana ...... M1423 Bell, Richard H...... M1891, M1903 Are, Chandrakanth ...... M1476 Bell, Robert L...... 473 Armstrong, Todd D...... M1878 Bell, Tena ...... M1550 Arnaoutakis, Dean ...... M1567 Bellamy, Christopher O...... M1907 Arnelo, Urban ...... M1391 Bennett, John ...... 882 Arnoletti, Juan P...... 702, M1494, M1497 Bentrem, David J...... M1891, M1903 Arregui, Maurice E...... M1514 Berberat, Pascal O...... M1488 Arum, Carl-Jorgen ...... M1919 Berger, David H...... M1559

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Bertagnolli, Monica M...... M1504 C Beyer, Todd ...... M1914 Bhargava, Sarah ...... M1870, M1895 Cahan, Mitchell ...... 380 Bhatti, Chandra ...... M1397 Callanan, M.D...... M1470 Bianchi, Paolo P...... M1425 Callcut, Rachael A...... M1404 Billingham, Richard P...... Sp766 Callery, Mark P...... 375, M1517, Sp577 Binato, Marcelo ...... M1443 Cameron, John L. .... 257, 373, 696, M1500 Binion, David G...... 694, M1535 Campagnacci, Roberto ...... 259, M1430 Birkett, Desmond H...... M2286 Campbell, Jean ...... 699, M1885 Blackstone, Robin P...... M1558 Campbell, Kurtis A...... 373, 696, M1500 Bloomston, Mark ...... 372, M1489 Campos, Fabio G...... 805, M1421, M1429, Blumgart, Leslie H...... 258, 886, M1476 ...... M1431 Bluth, Martin H...... M1490 Campos, Guilherme M...... 700, M1445 Bochkarev, Victor ...... M1459 Candinas, Daniel ...... M1502, M1886 Boddy, Alexander P...... M1401 Canto, Marcia ...... Sp354 Boenigk, Hagen ...... M1529 Caparrelli, David ...... M1500 Bogoevski, Dean ...... 703, M1435, M1442, Carmody, Brennan ...... 800 ...... M1493, M1897, M1906 Caro, Susan ...... M1393 Boland, Brendan J...... M1461, M1464 Cassivi, Stephen D...... M1447, M1444 Bona, Stefano ...... M1425 Castel, Andres ...... M1889 Bonadies, John ...... M1541 Cataldegirmen, Guellue ...... 703, M1493, Bonde, Pramod ...... M1878 ...... M1906 Borges, Fernanda V...... M1900 Cecconello, Ivan ...... M1545, M2287 Bornman, P.C...... M1470 Cecilia, Engstrom ...... M1436 Bortolasi, Luca ...... M1503 Cello, John Patrick ...... Sp652 Brabender, Jan ...... M1469, M1875 Ceneviva, Reginaldo ...... M1900 Bramhall, Simon ...... M1397, M1510 Ceolin, Martina ...... M1463 Breitenstein, Stefan ...... 705, M1389 Ceriani, Chiara ...... M1425 Bremner, Cedric G...... M1457, M1461, Cesar, Montalvo-Arenas ...... M1889 ...... M1464, M1881 Chak, Amitabh ...... 697 Brennan, Murray F...... M1467, M1498 Chan, Oscar ...... M1551 Bresciani, Claudio J...... M1545, M1555 Chan, Walter W...... M1437 Brody, L...... 258 Chandrasoma, Parakrama T...... M1883 Brooks, David C...... M1504 Chang, David ...... 373, 696, M1500 Brown, K...... 258 Chang, Eugene Y...... M1451 Bruewer, Matthias ...... M1544 Chang, Tzu-Ming ...... M1864 Brunt, L. Michael ...... M1437 Chang, Yeon Soo ...... M1546 Bubenheim, Michael ...... 701, M1435, Charron, Paul ...... M1409 ...... M1442, M1882 Chen, Duan ...... M1919 Buchler, Markus W...... M1487, M1527 Chen, Herbert ...... M1892, Sp579 Buchsbaum, Donald ...... 621 Chen, Miin-Fu ...... M1390 Buckels, John ...... M1397, M1510 Cheung, Frances Ka Yin .....M1547, M1571 Buechler, Markus W...... 297, M1399, Chipman, Gregory ...... M1405 ...... M1488, M1491 Chiu, Philip Wai Yan ...... M1547, M1571, Buechler, Peter ...... 297, M1491 ...... M1572 Buhr, Heinz J...... M1869, M1870, Choi, Hok Kok ...... M1419 ...... M1873, M1895 Choi, Hok Kwok ...... 296 Burak, Kelly ...... Sp740 Choti, Michael A...... 370, 373, 696, 804 Christein, John D...... M1494, M1521

Burcharth, Flemming ...... M1388 INDICES Burgart, Lawrence J...... M1523 Chromik, Ansgar M...... M1406 Busch, Olivier R...... 620 Chung, Dai H...... M1912 Busch, Philipp ...... M1435, M1442 Ciovica, Ruxandra ...... M1548 Byrn, John ...... M1531 Clancy, Thomas E...... M1504

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Clary, Bryan M...... Sp486 Demeester, Tom R...... M1457, M1461, Clavien, Perre-Alain ...... 705, M1389 ...... M1464, M1881, M1883 Clerico, Elizabeth T...... M1418 Demetris, Anthony J...... M1393 Clouse, Ray E...... M1437 Deoliveira, Michelle ...... 370 Coelho, Ana Maria M...... M1887, M1888, Depaula, Aureo L...... M2286 ...... M1905 Derosier, Leo C...... 621 Cohen, Philip ...... M1865 Desai, Shilpa ...... 702, M1497 Cohen, Zane ...... Sp807 Deschamps, Claude ...... M1444, M1447 Coit, Daniel G...... M1467, M1498 Desombre, Daniela ...... M1875 Coleman, Joann ...... 257, 373, 696 Dickson, Suzanne ...... M1919 Corbett, Carlos E...... M1556, M1568 Diener, Markus K...... M1527 Corcos, Olivier ...... M1495 Dienes, Hans P...... M1469 Correa-Gianella, Maria L...... M1899 Dighe, Shwetal S...... M1530 Coser, Roger ...... M1545 Dimitriu, Corneliu ...... M1487 Costantini, Mario ...... M1463, M1474, Ding, Xian Z...... M1903 ...... M1475 Ding, Xian-Xhong ...... M1891 Couvelard, Anne ...... M1495 Divino, Celia ...... M1531 Covey, A...... 258 Dixon, Jennifer ...... M1894 Cowgill, Sarah ...... 471, M1438, M1466, Doebler, Oliver ...... M1870 ...... M1567 Dong, Zhang ...... 374 Crookes, Peter F...... M1433, Sp595 Donohue, John H...... 801, M1532, M1543 Crooks, Peter ...... M1894 Downey, Robert J...... M1467 Cunha, Jose Eduardo M. .... M1507, M1905 Doyle, Courtney ...... 699, M1885 Czerniach, Donald ...... 380 Dozois, Eric J...... M1532, Sp395 Drebin, Jeffrey A...... Sp355 D Drelichman, Ernesto R...... 885 Du, Wei ...... M1538 D’alessio, Matthew J...... M1496 Duenes, Judith A...... M1909 D’amico, Davide F...... M1402 Duffy, Andrew J...... 473 D’angelica, Michael ...... 258, 886, M1476 Duncan, Mark ...... M1878, M1879, M1880 Daly, Barry ...... M1508 Dunst, Christy M...... M1457 Danenberg, Kathleen D. .... M1881, M1883 Dutta, Sayon ...... M1564 Danenberg, Peter V...... M1881, M1883 Daniel, Carrasco ...... M1889 E Darling, Gail ...... M1440 Darwin, Peter ...... M1508 Ebisawa, Yoshiaki ...... M1528 Davis, Brian R...... M1574 Eckardt, Volker F...... M1441 Davis, Melissa M...... M1558 Edelweiss, Maria I...... M1443 Day, Jarrod D...... M1911, M1908 Edward, Whang E...... M1504 De Campos, Tercio ...... M1492 Eipel, Christian ...... M1884 De Paula, Aureo L...... M1566 Eisold, Sven ...... M1890 De Pellegrini, Annamaria ...... M1402 El-Fitori, Jamael ...... M1491 De Reuver, Philip R...... 620 El-Serag, Hashem B...... M1559 De Sanctis, Angelo ...... 259, M1430 Elariny, Hazem A...... M1551 Defaria, Werviston ...... M1916 Ellis, Clyde N...... Sp646 Dejesus, Samuel ...... M1409 Ellison, E. Christopher ...... 372, M1489 Delaney, Conor P...... M1405, M1538, Elmo, Maryjo ...... 697 ...... Sp648 Elmore, Ugo ...... M1425 Demaio, Antonio ...... M1863, M1868 Eloubeidi, Mohamad ...... 702, M1497 Demaria, Eric ...... 800 Eltoum, Isam ...... 702, M1497 Dematteo, Ronald P...... 258, 886, M1476 Emick, Dawn M...... 257 Demeester, Steven R...... M1457, M1461, Endter, Frank ...... M1406 ...... M1464, M1881, M1883 Enochsson, Lars ...... M1391

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Enomoto, Masayuki ...... M1413 Friedman, Lawrence ...... Sp653 Estrada, Joaquin ...... 707, M1407 Friel, Charles ...... Sp762 Evers, B. Mark ...... M1912 Friess, Helmut ...... 297, M1399, M1487, Evora, Paulo R...... M1900 ...... M1488, M1491, M1527 Frisini, Marco ...... M1503 F Frohlich, Boris E...... M1487 Frost, Ben ...... M1392, M1511, M1526 Facci, Enrico ...... M1503 Fuentes, Joseph ...... M1863, M1868 Fagel, Bruce ...... Sp446 Fujimura, Takashi ...... M1880 Faggian, Diego ...... M1402 Fukushima, Kouhei ....695, M1410, M1910 Fagundes, Renato ...... M1443 Funayama, Yuji ...... 695, M1410, M1910 Faintuch, Joel ...... M2287 Furbetta, Paulo ...... M1492 Farges, Olivier ...... M1495 Furnes, Marianne ...... M1919 Farkkila, Martti A...... M1468 Farnell, Michael ...... M1521 G Fatima, Javairiah ...... M1549, M1909 Faulx, Ashley ...... 697 Gadenstatter, Michael ...... M1548 Fausto, Nelson ...... 699, M1885 Galanis, Charles ...... M1500 Fazio, Victor W...... M1428 Gallagher, Joseph ...... M1409 Feagan, Brian ...... Sp806 Gallagher, Scott F...... M1540, M1901 Feldman, Liane S...... M1458 Gama-Rodrigues, Joaquim J...... 805, Feliberti, Eric ...... M1481 ...... M1421, M1429, M1545, Felicio, Natalia M...... M1556 ...... M1555, M1556, M1568 Felisky, Chance D...... M1439 Gamblin, Thomas C...... M1393 Felix, Klaus ...... M1491 Garcia-Aguilar, Julio ...... Sp404 Fellander-Tsai, Li ...... M1391 Garden, O.J...... M1907 Fernandez Del-Castillo, Carlos ...... M1519, Gardezi, Javaid ...... M1401 ...... Sp583 Garofalo, Michael ...... M1508 Fernandez-Represa, Jesus A...... M1423 Garofalo, Thomas E...... M1428 Fernando, Hiran C...... M1453 Gastinger, Ingo ...... M1529, M1560 Ferrara, Andrea ...... M1409 Gattuso, Paolo ...... M1914 Ferri, Lorenzo E...... M1440 Gaughan, Colleen B...... M1461, M1464 Ferri, Lorenzo S...... M1458 Gazdhar, Amiq ...... 297 Ferrone, Cristina R...... M1498 Gearhart, Susan L...... 804 Ferson, Peter F...... M1453 Geisler, Daniel P...... M1428 Feuerlein, Sebastian ...... 377 Gellersen, Oliver ...... 377, M1876 Fichera, Alessandro ...... M1408 George, Ivan M...... M2288 Filosa, Teresa ...... M1402 Gersin, Keith S...... M1434 Fischer, Craig P...... 475, M1499 Getrajdman, G...... 258 Fischer, Eva ...... 378, M1482 Ghiassi, Saber ...... M1531 Fisher, Rory A...... M1904 Gianella, Daniel ...... M1899 Flores, Raja ...... M1467 Giese, Thomas ...... M1890 Flum, David ...... Sp707 Ginsberg, Greg ...... Sp651 Fomenkov, Alexey ...... M1879, M1880 Glasgow, Robert ...... M1537 Fong, Yuman ...... 258, M1467, M1476, Glatzle, Joerg ...... M1416, M1533 ...... M1498, M1506 Glatzle, Jorg ...... 887 Forstner-Barthell, Ariel ...... M1409 Gleason, Roberto ...... M1889 Fort, John G...... M1538 Gleisner, Ana ...... 370 Frankel, Wendy L...... M1489 Gletsu, N.A...... 376 Freeman, Jean L...... 374 Gloor, Beat ...... M1502, M1886 INDICES Freitag, Marc ...... M1896 Gock, Michael C...... M1884 Fried, Gerald F...... M1458 Gockel, Ines ...... M1441 Fried, Gerald M...... M1440 Golkar, Laleh ...... M1891, M1903

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Gonen, Mithat ...... 886, M1476 Hassi, Nelson ...... M1566 Gonzalez, Rodrigo ...... M1540 Hatoum, Oa ...... 694 Gonzalez-Ruiz, Claudia ...... M1411 Hay, J. Eileen ...... Sp739 Goodman, Elliot ...... M1574 Hayashi, Ken-Ichi ...... M1410 Goodwin, James S...... 374 Hayashi, Mikiko ...... M1553 Goto, Shinji ...... M1576 Hayashidani, Yasuo ...... M1524, M1893 Gouma, Dirk J...... 620 Hazzan, David ...... 476 Gower, Adam ...... M1865 Heinze, Maya ...... M1869 Gralnek, Ian Mark ...... Sp649 Heise, Charles P...... 298, Sp391 Greenblatt, David Y...... M1892 Hekmatyar, Nedumangalam ...699, M1885 Grifﬁss, J. Macleod ...... 622 Helton, Scott ...... M1398, Sp655 Groene, Joern ...... M1869, M1870 Henderson, J. Michael ...... Sp485 Gros, Stephanie J...... M1435, M1442 Heniford, B. Todd ...... M1434, M1565 Guerrieri, Mario ...... 259, M1430 Hennig, Matthew ...... 699, M1885 Guglielmi, Alfredo ..... 706, M1485, M1503 Herbella, Fernando A...... 700, 883, Guirroli, Emanuela ...... M1463, M1474, ...... M1445, M1446 ...... M1475 Heslin, Martin ...... 702, M1494, M1497 Gulbinas, Antanas ...... M1488 Higuchi, Tetsuro ...... M1413 Gunson, Bridget ...... M1397 Hirai, Thomas ...... M1551 Gurland, Brooke H...... M1418 Hiyama, Eiso ...... M1893 Gurski, Richard R...... M1443 Ho, Judy W...... 296 Gutt, Carsten ...... M1488 Ho, Wai Chu ...... M1419 Guy, Gregory ...... 372 Hodin, Richard A...... M1913 Hoelscher, Arnulf H...... M1469 H Hoey, Brian A...... M1394 Holcomb, Bryan ...... M1894 Ha, Ping Yiu ...... M1572 Holscher, Arnulf H...... M1875 Haas, Barbara ...... M1498 Holt, Alicia ...... M1481 Habr-Gama, Angelita ...... 805, M1421, Hon, Sf ...... M1547 ...... M1429, M1431 Hopt, Ulrich T...... 378, M1482 Hagen, Jeffrey A...... M1457, M1461, Horiguchi, Akihiko ...... M1483 ...... M1464, M1881 Horst, Patrick K...... M1866 Hagler, Michael ...... M1490 Horupian, Roupert ...... M1557 Hahn, Jutta ...... 887 Hoshimoto, Sojun ...... M1483 Haier, Joerg ...... M1544 Hotz, Birgit ...... M1895 Halpern, Alfredo ...... M1566 Hotz, Hubert G...... M1895 Hammel, Jeffery ...... M1539 Houghton, Scott G...... M1447, M1549, Hammel, Pascal ...... M1495 ...... M1909 Haneda, Sho ...... 695, M1410, M1910 House, Michael G...... M1552 Haney, Mark ...... M1433 Howard, Thomas J...... 803 Hanly, Eric J...... M1550, M1863, M1868 Howell, Jessica G...... M1911 Hansen, Bente ...... M1896 Howell, Jessie G...... M1908 Hanyu, Nobuyoshi ...... M1449, M1471, Hribaschek, Arndt ...... M1871 ...... M1561 Hruban, Ralph H...... 696 Hanyuu, Nobuyoshi ...... M1456 Hsieh, Yu-Hsiang ...... M1486 Harmon, John W...... M1878, M1879, Hu, Yingchuan ...... M1876 ...... M1880 Huang, Yiping ...... M1879, M1880 Harrison, Maria ...... M1433 Huang, Zhi ...... 621 Harrison-Phipps, Karen ...... M1444 Hubbard, Joshua M...... M1520 Hart, Stacey ...... M1432 Hull, Tracy ...... M1539 Hashemi, Majid ...... M1542 Hunter, John G...... 376, M1451, M1522 Hashimoto, Yasushi ...... M1524, M1893 Hurst, Roger D...... M1408 Hassan, Imran ...... 885, M1532 Hwang, Joanna ...... M1448

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I Junginger, Theodor ...... M1441 Jurendini, Ricardo ...... M1507 Iacono, Calogero ...... 706, M1485, M1503 Ibele, Anna R...... M1448 K Iglesias, Roberto C...... M1908, M1911 Ignagni, Anthony ...... 697 Kaiﬁ, Jussuf T...... 703, 704, M1435, Inderbitzin, Daniel ...... M1886 ...... M1570, M1896, M1897, Ingold, Heike ...... M1488 ...... M1906, 701, M1882 Ingram, Malene ...... M1540 Kaiser, Andreas M...... M1411 Inokuchi, Mikito ...... M1553 Kalinin, Viacheslav ...... 701, 704, Iqbal, Corey W...... M1536, M1549 ...... M1570, M1882 Irani, Jennifer L...... M1504 Kandil, Ali ...... M1540 Iriya, Kyoshi ...... M1568 Kanno, Akihiro ...... M1576 Ishibashi, Yoshio ...M1449, M1471, M1561 Kaplan, Lee M...... Sp596 Ishida, Robson K...... M1568, M2287 Kasai, Shinichi ...... M1528 Ishikawa, Chisato ...... M1528 Kashiwagi, Hideyuki ...... M1449, M1471, Ishioka, Shinichi ...... M1568, M2287 ...... M1561 Israelit, Shlomo ...... M1411 Kasparek, Michael S. ..887, M1416, M1533 Iwabuchi, Shuuichi ...... M1456 Kastenmeier, Andrew ...... M1484 Izanec, James ...... M1414 Kato, Takazumi ...... M1483 Izbicki, Jakob R...... 701, 703, M1435, Kaufman, Howard S...... M1433, M1872 ...... M1442, M1493, M1882, Kaufman, Stephanie ...... M1404 ...... M1896, M1897, M1906 Kavic, Stephen M...... M2288 Kawasaki, Naruo ... M1449, M1471, M1561 J Kazantsev, George B...... M1557 Kelch, Steffen ...... M1873 Jacene, Heather A...... 804 Kellum, John M...... 800, M1908, M1911 Jacob, Carlos E...... M1545, M1555 Kelly, John J...... 380 Jacobs, Lee ...... M1550 Kemeny, Nancy ...... Sp351 Jacobson, Lewis E...... 803 Kendrick, Michael L...... M1549 Jaffee, Elizabeth M...... M1878 Kercher, Kent W...... M1434, M1565 Jaik, Nikhil P...... M1394 Khan, Salman ...... M1433 Jain, Suvinit ...... M1866 Khanna, Ammit ...... M1509 Jakob, Izbicki ...... 704, M1570 Kienle, Peter ...... M1399 James, Laura E...... M1505 Kieran, Jennefer A...... M1558 Jamidar, Priya ...... 473 Kim, Charles Y...... M1451 Jang, Byung-Ik ...... M1417 Kim, Donald ...... M1541 Jaques, David P...... M1467, M1498 Kim, Jaehwang ...... M1417 Jarnagin, William R...... 258, 886, Kinsella, Timothy ...... M1405 ...... M1476, Sp351 Kirman, Irena ...... M1866 Jarvia, Gary A...... 622 Kiss, Desiderio R...... 805, M1421, M1429, Jay, David ...... M1889 ...... M1431 Jensen, Dean ...... Sp359 Kitajima, Masaki ...... M1563 Jhala, Nirag C...... M1494 Kjellin, Ann ...... M1391 Jobe, Blair A...... M1451 Klar, Ernst ...... M1884, M1890 Joel, Faintuch ...... M1568 Kleeff, Joerg ...... M1488 Johnson, Erik E...... 298 Klein, Patrick ...... 699, M1885 Jones, Carolyn ...... 377, M1876 Kleinhans, Helge ...... 704, M1570, M1896 Jorge, Jose M...... M1429 Klimstra, David ...... M1467 Jorge, Uana M...... M1556 Kline, Elizabeth M...... M1439 INDICES Joseph, Antony ...... M1536 Knaebel, Hanns-Peter ...... M1527 Jukemura, Jose ...... M1507 Ko, Clifford ...... Sp392 Jung, Hsuan ...... M1883 Kobayashi, Shin ...... M1534

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Koch, Moritz ...... M1399 Lee, Suk-Hwan ...... M1546 Koenigsrainer, Alfred ...... M1416, M1533 Lee, Sukhyung ...... 800 Kohgo, Yutaka ...... M1528 Lee, Yee Man ...... 296, M1419 Kohyama, Atsushi ...... M1410 Leeth, Ruth R...... M1494 Kojima, Kazuyuki ...... M1553 Leitao, Regina ...... M1887, M1888 Koler, Amy J...... M1558 Leitman, I. Michael ...... M1574 Konigsrainer, Alfred ...... 887 Lendlein, Andreas ...... M1873 Konno, Yohei ...... M1528 Leopold, Donald ...... M1575 Kono, Toru ...... M1528 Leszczyszyn, Jaroslaw ...... M1420 Kozarek, Richard A...... M2286 Leung, Ka Lau ...... M1427 Krajewski, Eduardo ...... M1409 Leverson, Glen E...... 298 Krasinskas, Alyssa ...... M1393 Levy, Philippe ...... M1495 Kreis, Martin E...... 887, M1416, M1533 Lewin, David N...... M1520 Krug, Joseph E...... 803 Lewis, Wyn ...... M1392, M1511, M1526 Krupski, Gerrit ...... M1493 Lezoche, Emanuele ...... 259, M1430 Kubrusly, Marcia S...... M1899 Lezoche, Giovanni ...... 259, M1430 Kudo, Katsumasa ...... M1410 Li, Jimmy ...... M1427 Kuga, Rogerio ...... M1568, M2287 Li, Jing ...... M1912 Kultas, Esra ...... M1544 Li, Michael Ka Wah ...... M1571, M1572 Kunnimalaiyaan, Muthusamy ...... M1892 Li, Yan ...... M1877 Kuo, Yong-Fang ...... 374 Liau, Siong-Seng ...... 379 Kuramochi, Hidekazu ...... M1881, M1883 Liebl, Lena ...... M1493 Kuryura, Laise ...... M1492 Liessi, Guido ...... M1515, M1516 Kusuda, Junko ...... M1422 Lillemoe, Keith D...... 257, 696, Kuwada, Timothy S...... M1434 ...... 803, M1500, Sp570 Kwok, Ka-Fai ...... 371 Limehouse, Vicki M...... M1418, M1569 Kwong, Dora ...... 371 Lin, Pin-Wen ...... M1486 Lincourt, Amy E...... M1434 L Linhares, Marcelo B...... M1421 Link, Bjoern-Christian ...... 701, 703, Lahr, Christopher J...... M1418, M1569 ...... M1435, M1442, M1882, Lam, Candice ...... M1547 ...... M1493, M1906, M1897 Landreneau, Rodney J...... M1453 Linnebacher, Michael ...... M1890 Larach, Sergio ...... M1409 Lipham, John C...... M1457, M1461, Larson, David W...... Sp647 ...... M1464, M1881 Larson, Drik R...... 885 Lippert, Hans ...... M1529, M1560, M1871 Larson, Shawn D...... M1912 Litwin, Demetrius E...... 380, 698, M1396 Larson, Steven M...... M1506 Lo, Chung-Mao ...... Sp448 Lau, Melvin K...... M1559 Lo, Siu Hung ...... M1419 Lavely, William C...... 804 Lo, Su-Shun ...... M1918 Law, Sheung-Wai ...... M1547 Loddenkemper, Christoph ...... M1870 Law, Simon ...... 371 Logan-Collins, Jocelyn M...... M1505 Law, Wai Lun ...... 296, M1419 Longo, Walter E...... 473 Le, Anne T...... M1559 Lonroth, Hans ...... M1436 Lebski, Igor ...... M1420 Lopushinsky, Steven R...... M1450 Lechner, Wolfgang ...... M1548 Low, Donald E...... M1439 Lee, Gyusung ...... M2288 Lowy, Andrew M...... M1505 Lee, Janet ...... M1427 Lu, Ruey-Hwa ...... M1864 Lee, John G...... Sp650 Lucas, Charles E...... M1400 Lee, Kenneth K...... M1496 Luketich, James D...... M1453 Lee, Kil Yeon ...... M1546 Lundeen, Sarah J...... 694, M1535 Lee, Sharon ...... M1872 Lundell, Lars ...... M1436

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Lutz, Jon-Andri ...... M1502 Mayol, Julio M...... M1423 Lyons, Jefferson ...... M1505 Mcgee, Michael ...... 697 Mcgrath, Kevin M...... M1496 M Mcphee, James T...... 698, M1396 Mehra, Mohit ...... 702, M1497 Macedo, Antonio L...... M1566 Mehta, Samir ...... 882 Macfadyen, Bruce V...... M2286 Meile, Tobias ...... 887 Machado, Marcel Cerqueira C...... M1887, Meirelles, Roberto F...... M1899, M1900 ...... M1888, M1899, M1905 Mellinger, John D...... M2286 Madan, Atul K...... M2289 Melton, Genevieve B...... 804 Madani, Rana ...... M1542 Melvin, W. Scott ...... M1489 Madura, James A...... 803 Merkert, Petra ...... 701, M1882 Magnuson, Thomas H...... M1552 Merlino, Glenn ...... 699, M1885 Maher, James W...... 800 Merlino, James ...... M1405 Mahomed, Julie ...... M1894 Metcalfe, John C...... Sp447 Mahon, David ...... 882 Metz, D.C...... M1470 Mahvi, David M...... M1404, M1484 Metzger, Ralf ...... M1469, M1875 Mai, Jane L...... M1536, M1549 Meurer, Luise ...... M1443 Maithel, Shishir ...... 375, M1517 Meyer, Frank ...... M1529, M1560, M1871 Makowiec, Frank ...... 378, M1482 Meyer, Lutz ...... M1560 Malo, Madhu S...... M1913 Michelassi, Fabrizio ...... Sp567, Sp808 Malone-Lee, James ...... M1542 Mijakabi, Miyoko ...... M2287 Manilich, Elena ...... M1428 Milam, G...... 376 Mann, Oliver ...... 701, M1435, M1442, Miller, Edith ...... Sp405 ...... M1493, M1882, M1896 Miller, Linda ...... M1440 Mansour, John C...... M1506 Minjarez, Renee C...... M1451 Marcello, Peter W...... Sp758 Mirza, Darius ...... M1397, M1510 Mardani, Jalal ...... M1436 Mitsumori, Norio ...... M1561 Marescaux, Jacques ...... Sp239 Mittelkoetter, Ulrich ...... M1406 Marjoram, Paul ...... M1883 Miwa, Koichi ...... M1880 Marks, Jeffrey ...... 697 Miyakawa, Shuichi ...... M1483 Marohn, Michael R...... 373 Miyashita, Tomoharu ...... M1878, M1879, Maronian, Nicole ...... M1462 ...... M1880 Marsh, Wallis ...... M1393 Mizumoto, Shinsaku ...... M1422 Marti, Guy ...... M1878, M1879, M1880 Mizuno, Ryouji ...... M1456 Martignoni, Marc E...... M1487 Moenig, Stefan P...... M1469 Martin, Edward W...... 372, M1489 Moesinger, Robert ...... M1508 Martin, Robert C...... M1877 Mohebi, Parsa ...... M1878 Martino, Rodrigo B...... M1887 Molan, Nilza A. ... M1887, M1888, M1899, Masaki, Tadahiko ...... M1422 ...... M1905 Mason, Rodney J...... 707, M1407 Molena, Daniela ...... 377, M1509 Matheus, Andre S...... M1507 Montagnini, Andre L...... M1507 Matsubara, Toshiki ...... M1400 Montalvo-Jave, Eduardo ...... M1889 Matsudaira, Hideki ...... M1456 Montgomery, Elizabeth .....M1878, M1879, Matsumoto, Joe ...... 802 ...... M1880 Matsuoka, Hiroyoshi ...... M1422 Montorsi, Marco ...... M1425 Matsushima, Kazuhide ...... M1534 Mooney, Colin ...... M1405 Matsuura, Kenji ...... M1534 Morgenthal, Craig B...... 376 Mattar, Rejane ...... M2287

Morise, Zenichi ...... M1483 INDICES Matthews, Brent D...... M1437 Morris, Eva ...... M1527 Matthews, Jeffrey B...... M1505 Morris-Stiff, Gareth J...... M1392, M1397, Maudar, Kewal K...... M1395 ...... M1510, M1511, M1526 Mayer, David ...... M1397, M1510 Morse, Christopher R...... M1453

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Morton, John ...... M1426 Oelschlager, Brant ...... M1462 Moser, Arthur J...... M1393, M1496 Ogawa, Hitoshi ...... 695, M1410, M1910 Mozumder, Moushumi ...... M1913 Oggier, Carmen ...... 705, M1389 Mucerino, Donato ...... M1556 Oh, Daniel S...... M1457, M1464, Mueller, Cathy M...... M1490 ...... M1881, M1883 Mueller, Mario H...... 887, M1533 Oh, Se Keon ...... M1546 Mueller, Michael W...... M1488 Okamoto, Kohtaro ...... M1528 Mui, Lik Man ...... M1571 Okereke, Ikenna C...... M1428 Mui, Lm ...... M1547 Okrainec, Allan ...... M1458 Munene, Gitonga ...... M1913 Okuno, Scott H...... M1532 Murakami, Yoshiaki ...... M1524, M1893 Oleynikov, Dmitry ...... M1459 Murr, Michel M...... M1540, M1901 Omura, Nobuo ..... M1449, M1471, M1561 Murthy, Rashmi K...... M1494 Onders, Raymond ...... 697 Muscarella, Peter ...... M1489 Onken, Florian ...... M1435, M1442 Mutch, Matt ...... Sp403, Sp763 Ono, Hiromi ...... M1400 Ortega, Adrian ...... M1872 N Ortega-Salgado, Arturo ...... M1889 Ossi, Elena ...... M1402 Nadalin, Wladimir ...... 805 Osteen, Robert T...... M1504 Nagao, Munenori ...... M1576 Otani, Yoshihide ...... M1563 Nagle, Deborah A...... M1414 Otterson, Mary F...... 694, M1535 Nair, Raji ...... M1505 Oyama, Katsunobu ...... M1880 Naito, Hiroo ...... M1576 Nakada, Koji ...... M1449, M1561 P Nakata, Kouzi ...... M1471 Nakeeb, Attila ...... Sp488, Sp569, 693 Pachera, Silvia ...... 706, M1485 Nakshatri, Harikrishna ...... M1894 Pairolero, Peter C...... M1444, M1447 Nauheimer, Dirk ...... M1890 Palaninvelu, Chinnuswamy ...... 470, Nealon, William H...... 374, M1512 ...... M1460, M1513 Nehra, Dhiren ...... M1454, M1530 Palmer, Bryan ...... 372 Nelson, Rebecca ...... M1481 Pandit-Taskar, Neeta ...... M1506 Neumayer, Leigh ...... M1537 Pankala, Rafal ...... M1420 Ng, Enders ...... M1427, M1547 Pantel, Klaus ...... 701, M1882 Ng, Enders Kwok Wai ...... M1571, M1572 Papakonstandinou, Christos ...... M1915 Ng, Simon S...... M1427 Papakonstandinou, Panagiota ...... M1915 Nguyen, Ninh ...... M1398, Sp347, Sp593 Park, Adrian E...... M2288 Nguyen, Scott ...... M1531 Park, Bernard J...... M1467 Nichols, Francis C...... M1444, M1447 Park, James O...... 886 Nicoletti, Loredana ...... M1463, M1474, Parra, Edwin R...... M1556 ...... M1475 Parra, Ivan ...... M1496 Niederhuber, John E...... M1484 Parthasarathi, Ramakrishnan ...... M1460 Nilubol, Naris ...... M1914 Parthsarathi, Ramakrishnan ...... 470 Nimura, Hiroshi ...... M1561 Pasquali, Claudio ...... M1515, M1516 Nipomnick, Ian .. 700, 883, M1445, M1446 Patel, Anand C...... M1514 Nishikawa, Katsunori ...... M1456 Patel, Jateen ...... M1564 Noble, Stephen ...... 699, M1885 Patel, Lina ...... 801, M1543 Nocito, Antonio ...... 705, M1389 Paton, B.L...... M1565 Norris, Amanda ...... 699, M1885 Patterson, Taryn ...... M1432 Novitsky, Yuri W...... M1565 Patti, Marco G...... 700, 883, ...... M1445, M1446 O Pawlik, Timothy M...... 370 Pearson, Judith ...... M1542 O’rourke, Ann P...... M1484 Pedrazzani, Corrado ...... 706, M1485

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Pedrazzoli, Sergio ...... M1515, M1516 R Pelling, Jill C...... M1891, M1903 Pemberton, John H...... 885 Rajan, P.S ...... M1513 Pena-Soria, Maria Jesus ...... M1423 Rajapandian, S...... M1513 Peng, Stephanie L...... M1408 Ralstin, Matthew ...... M1894 Peng, Yanhua ...... M1901 Ramesh, H...... M1518 Penteado, Sonia ...... M1507 Rampado, Sabrina ...... M1463, M1474, Peppard, William J...... M1535 ...... M1475 Perez, Rodrigo O...... 805, M1421, M1429, Rao, Geetha ...... M1902 ...... M1431, M1545, M1555 Rao, Sambasiva M...... M1891, M1903 Perretta, Silvana ...... 259, M1430, M1432 Rasanen, Jari V...... M1468 Perugini, Richard A...... 380 Rasslan, Samir ...... M1492 Peters, Jeffrey H...... 377, M1876, M1883 Rath-Harvey, Doris M...... 885 Petri, Susanne ...... M1897 Ratovitski, Edward ...... M1879, M1880 Petrone, Patrizio ...... M1433, M1872 Rauws, Erik A...... 620 Petrosyan, Mikael ...... 707, M1407 Rawet, Viviane ...... M1431 Peyre, Christian G...... M1881, M1461, Rawnaq, Tamina ...... 701, M1882 ...... M1464 Razo, Andres Oswaldo ...... M1519 Pezzullo, John C...... M1418 Read, Thomas ...... Sp760 Pham, Tuan H...... M1536 Rebours, Vinciane ...... M1495 Pickleman, Jack ...... M1564 Reed, Karen L...... M1865 Pierre, Joelle ...... M1490 Reichelt, Uta ...... 703, 704, M1442, M1570, Pilon, Fabio ...... M1402 ...... M1897, M1906 Pina, Enrique ...... M1889 Reid, Kaye M...... 801, M1543 Pirsch, John D...... 298 Reines, Howard D...... M1551 Pisters, Peter W...... Sp487 Reinknecht, Felix ...... M1896 Pitt, Henry A...... 693 Reissfelder, Christoph ...... M1873 Plevak, David ...... Sp654 Reith, Hans B...... M1406 Polese, Lino ...... M1402 Remick, Scott ...... M1405 Ponsky, Jeffrey L...... 697, Sp449 Remington, Patrick ...... M1404 Portale, Giuseppe ...... M1463, M1474, Remzi, Feza H...... M1428 ...... M1475 Reuben, Brian ...... M1537 Potter, Douglas M...... M1496 Reynolds, Harry L...... M1405 Powell, James J...... M1907 Rhodes, Michael ...... 882 Prando, Daniela ...... M1402 Rhuban, Ralph H...... M1500 Prasad, Madhu ...... M1874 Riall, Taylor S...... 373, 696, M1512, Pratt, Wande ...... 375, M1517 ...... 257, 374 Primomo, John A...... M1509 Ribeiro, Adriana S...... M2287 Prinz, Richard ...... M1902, M1914 Ribeiro, Ulisses ...... M2287 Proscurshim, Igor ..... 805, M1421, M1429, Ribeiro, Ulysses ...... M1568 ...... M1431, M1545, M1555 Ribeiro Junior, Ulysses ...... M1556 Pross, Matthias ...... M1871 Richards, William O...... M1473 Puntis, Malcolm C...... M1392, M1511, Richardson, Brynn ...... M1575 ...... M1526 Ridwelski, Karsten ...... M1871 Pushpakaran, Premraj ...... M1913 Riediger, Hartwig ...... 378 Rikkers, Layton F...... M1484 Q Ringley, Chad D...... M1459 Ritz, Joerg-Peter ...... M1873 Quarfordt, Stephen ...... 380 Rizk, Nabil ...... M1467 Que, Florencia G...... M1523, M1549 Rizzetto, Christian ...... M1461, M1463, INDICES Quiroga, Elina ...... M1462 ...... M1464

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Robbins, Joanne ...... M1448 Scapulatempo, Cristovam ...... M1556 Roberts, Ashley .....M1392, M1511, M1526 Scarpa, Marco ...... M1402 Roberts, Kurt E...... 473 Schaefer, Hansjoerg ...... 704, M1570 Rodriguez, Jose Ruben ...... M1519 Schauer, Philip ...... Sp705 Roepke, Stefan ...... M1869 Scheiman, James M...... Sp356 Romanato, Giovanna ...... M1402 Schiele, Elke ...... M1416 Rosati, Riccardo ...... M1425 Schilz, Robert ...... 697 Rosca, Jason ...... M1872 Schirmer, Bruce ...... Sp708 Rosemurgy, Alexander S...... 471, M1438, Schlager, Avraham ...... M1531 ...... M1466, M1567 Schleck, Cathy D...... 885 Rosen, Michael ...... 697 Schmidt, Christian M...... 699, 803, Rosenberg, Jacob ...... M1388 ...... M1885, M1894 Rosman, Alan S...... M1408 Schmidt, Jan ...... M1399, M1890 Ross, James A...... M1907 Schneider, Andreas ...... M1533 Rosser, James (Butch) ...... M1574 Schneider, Paul M...... M1875, M1469 Rottoli, Matteo ...... M1425 Schneider-Stock, Regine ...... M1871 Rouse, Layla ...... M1481 Schnelldorfer, Thomas ...... M1418, M1520, Rubin, Michele A...... M1408 ...... M1569 Ruffato, Alberto ...... M1467 Schoeniger, Luke O...... M1509 Ruffolo, Cesare ...... M1402 Schomisch, Steve ...... 697 Ruiz, Phillip ...... M1916 Schraibman, Vladimir ...... M1566 Rusch, Valerie W...... M1467 Schreiber, Matthias ...... M1897 Ruszniewski, Philippe ...... M1495 Schulick, Richard D...... 373, 696, 804 Ruzzenente, Andrea ... 706, M1485, M1503 Schurr, Paulus G...... 701, 704, M1570, ...... M1882 S Schwab, Gerhard P...... M1548 Schweitzer, Michael A...... M1552 Sa, Sandra V...... M1899 Scopelliti, Michele ...... M1402 Saeed, Yawar ...... M1401 Sebolt-Leopold, Judith ...... 699, M1885 Safatle-Ribeiro, Adriana V...... M1556, Seiler, Christoph M...... M1527 ...... M1568 Seitz, Guido ...... M1416 Sakai, Paulo ...... M1568, M2287 Sekhar, Nikhilesh ...... M1473 Salabat, Mohammad R...... M1891, M1903 Selby, Rick ...... M1872 Salky, Barry A...... 476, Sp765 Sellers, Jeffrey ...... 621 Salo, Jarmo A...... M1468 Selvindoss, Paul ...... M1411 Salvador, Renato ...... M1463 Selzer, Don J...... 472 Sampietre, Sandra N...... M1887, M1888 Senagore, Anthony J...... Sp757 Samuel, Isaac ...... M1904 Senninger, Norbert ...... M1544 Sandborn, William J...... Sp809 Senthilkumar, Rangaswamy ....470, M1460 Sandri, Marco ...... 706, M1485 Senthilnathan, Palanisamy ...... 470, Santos, Rafael M...... M1431, M1555 ...... M1460, M1513 Sarr, Michael G. ....M1536, M1549, M1909 Seto, Chi Leung ...... 296, M1419 Sarwar, C.M.Shahbaz ...... M1878, M1879, Shah, Furhawn ...... M1878 ...... M1880 Shah, Manisha ...... 372, M1489 Sasaki, Iwao ...... 695, M1410, M1910 Shah, Rakhee N...... M1557 Sasaki, Tamito ...... M1524 Shalev, Anath ...... M1892 Sato, Ryu ...... M1528 Sham, Jonathan ...... 371 Saund, Mandeep S...... M1874 Shan, Yan-Shen ...... M1486 Sauter, Guido ...... 701, M1882 Shane, M.D...... 376 Sauter, Patricia K...... 257, 373, 696 Shantha Kumara, H.M...... M1866 Sauvanet, Alain ...... M1495 Sharp, Kenneth W...... M1473 Saxena, Romil ...... 693 Shaw, John M...... M1470 Scappin, Sabrina ...... M1515, M1516 Shelton, Andrew ...... M1426

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Sheppard, Brett C...... M1522 Stone-Newsom, Robert ...... M1404 Sheridan, Michael ...... M1551 Strasberg, Steven M...... Sp445 Shi, Hongqi ...... M1577 Strate, Tim G...... 701, 704, M1570, Shibata, Chikashi ...... 695, M1410, M1910 ...... M1882, M1896 Shidham, S...... 694 Stucchi, Arthur F...... M1865 Shih, Samuel ...... M1863 Studer, Peter ...... M1886 Shim, Min-Chul ...... M1417 Su, Ruby ...... M1877 Shimizu, Daisuke ...... M1883 Su, Yun ...... 297, M1491 Shio, Marina T...... M1905 Sudan, Ranjan ...... M1575 Shirley, Rhett ...... 702, M1497 Sudo, Takeshi ...... M1524, M1893 Shoup, Margo ...... M1564 Sueda, Taijiro ...... M1524, M1893 Shyyan, Roman ...... M1532 Sugawa, Choichi ...... M1400 Sidler, Daniel ...... M1886 Sugerman, Harvey ...... 800 Sigua, Celia ...... M1901 Sugihara, Kenichi ...... M1413, M1553 Sihvo, Eero I...... M1468 Sugioka, Atsushi ...... M1483 Sikora, Sadiq S...... M1518 Sugiyama, Masanori ...... M1422 Sillery, Jim ...... M1462 Sugiyama, Yoichi ...... M1893 Sillin, Lelan ...... 377 Sullivan, Mary E...... 698, M1396 Siu, Wing Tai ...... M1571, M1572 Suzuki, Hideyuki ...... M1456 Siu, Wt ...... M1547 Suzuki, Yutaka ...... M1449, M1471, M1561 Skitzki, Joseph ...... M1405 Swafford, V...... 376 Slivka, Adam ...... M1393 Swahn, Fredrik ...... M1391 Smith, Andrew ...... 474 Swanson, Richard S...... M1504 Smith, Brian R...... M1573 Swanstrom, Lee L...... M2286, Sp597 Smith, C. Daniel ...... 376, Sp706 Sweeney, Christopher ...... M1894 Smith-Norowitz, Tamar A...... M1490 Syvenssen, Unni ...... M1919 Smoot, Rory ...... M1521 Smyrk, Thomas C...... M1532 T Sofocleous, C...... 258 Solorzano, Carmen C...... M1902, M1914 Tabata, Yasuhiko ...... 695 Sonia, Jancar ...... M1905 Taddeucci, Raymond J...... M2289 Sonnenday, Chris J...... 373 Takada, Koji ...... M1449 Soper, Nathaniel J...... M2286 Takahashi, Ken-Ichi ...... 695, M1410, Soriano, Francisco F...... M2287 ...... M1910 Sousa, Afonso H...... 805, M1421, M1429 Takahashi, Michinaga ...... M1576 Souza, Lourenilson J...... M1905 Takayama, Makoto ...... M1422 Spanos, Constantine P...... M1915 Takayama, Sumio ...... M1561 Spanos, Panagiotis ...... M1915 Talamini, Mark ...... M1863, M1868 Sperti, Cosimo ...... M1515, M1516 Talamonti, Mark S...... M1577, M1891, Stabile, Bruce E...... M1573 ...... M1903 Stamos, Michael J...... Sp357 Tanaka, Koji ...... M1881 Stanten, Arthur ...... M1557 Tanaka, Yuujirou ...... M1456 Stanten, Steven A...... M1557 Tang, Chung Ngai ...... M1571, M1572 Staub, Eike ...... M1869 Tang, Laura H...... M1467 Stawicki, Stanislaw P...... M1394 Tang, Nelson ...... M1547 Stefanidis, Dimitrios ...... M1434 Tao, Matthew ...... 707, M1407 Stenstrom, Bjorn ...... M1919 Tarkas, Mallika ...... M1438 Stephens, Robert V...... Sp237 Tasselli, Sebastiano ...... 706, M1485 Taylor, Jerome D...... M1574

Steurer, Wolfgang ...... 887 INDICES Stewart, Lygia ...... 622 Techner, Lee ...... M1538 Stival, A...... 376 Tedesco, Pietro ...... 883, M1446 Stocchi, Luca ...... M1428 Teh, Swee H...... M1522 Stoddard, Greg ...... M1537 Telford, Gordon L...... 694, M1535

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Terrault, Norah ...... Sp741 Varma, Madhulika G...... M1432 Thameem, D...... 694 Varma, Mika ...... Sp358 Thayer, Sarah P...... M1519 Vashist, Yogesh ...... M1493 The, Members Of The Gastric Velanovich, Vic ...... 884 Pce Project ...... 801, M1543 Vickers, Selwyn M...... 621, 702, Theriot, Kr ...... 694 ...... M1494, M1497 Thiede, Arnulf ...... M1406 Villadolid, Desiree .....471, M1438, M1466, Thomas, Kerry ...... 471, M1567 ...... M1567 Thometz, Donald ...... 471 Violette, Aisha ...... 884 Thompson, Geoffrey B...... M1536, M1549 Viscusi, Eugene ...... M1538 Thompson, Jon S...... M1575 Vitamvas, Michelle ...... M1459 Tichansky, David S...... M2289 Vittinghoff, Eric ...... 700, M1445 Toe, Kyaw ...... M1530 Vogel, Jon D...... M1428 Tohda, Gen ...... M1400 Vollmar, Brigitte ...... M1884 Tommeras, Karin ...... M1919 Vollmer, Charles M...... 375, M1517 Tomokani, Thaise Y...... M1568 Vukasin, Petar ...... M1411 Tonari, Ayako ...... M1422 Torquati, Alfonso ...... M1473 W Torrella, Tracy ...... M1540 Torres, Maria B...... M1916 Wachowiak, Robin ...... 703, 704, M1570, Towﬁgh, Shirin ...... 707, M1407 ...... M1897, M1906 Townsend, Courtney M...... 374 Wagman, Lawrence ...... M1481 Traverso, William ...... 802 Wagner, Markus ...... M1502 Trochsler, Markus ...... M1502 Wahl, Richard L...... 804 Truty, Mark J...... M1523 Walsh, R.M...... 474 Tryphonopoulos, Panagiotis ...... M1916 Wanebo, Harold J...... M1472 Tsai, Lih-Min ...... M1864 Wang, Jennifer Y...... M1432 Tseng, Jennifer F...... 698, M1396 Wang, Jiaai ...... M1878, M1879, M1880 Tsung, Bonnie ...... M1547 Wang, Yufang ...... 699, M1885 Tublin, Mitch E...... M1393 Wargo, Jennifer A...... M1519 Tzakis, Andreas ...... M1916 Warshaw, Andrew L...... M1519 Wasserberg, Nir ...... M1433, M1872 U Watanabe, Kazuhiro ...... M1410 Watari, Jiro ...... M1528 Ueki, Hisayo ...... M1422 Watson, Thomas J...... 377, M1876 Uemura, Kenichiro ...... M1524, M1893 Way, Lawrence W...... 622 Ueno, Tatsuya ...... M1576 Weber, Markus ...... 705, M1389 Uhl, Waldemar ...... M1406 Weber, Sharon M...... M1484, Sp349 Ujiki, Michael B...... M1891, M1903 Webster, Phillip .... M1392, M1511, M1526 Upadhyay, Ajay K...... M1557 Weigel, Tracey ...... M1448 Urashima, Mitsuyoshi ...... M1449 Weimann, Rosy ...... M1886 Urbach, David R...... M1450 Weiner, Matthew J...... M2288 Weitz, Jurgen ...... M1399 V Welton, Mark ...... M1426 Wemyss, Sarah ...... M1454 Vaccaro, Abram ...... M1892 Wente, Moritz N...... M1527 Vallboehmer, Daniel ...... M1469 Wentz, Sabrina ...... 699, M1885 Vallbohmer, Daniel ...... M1875, M1883 Westman, Bo ...... M1391 Van Delden, Otto M...... 620 Whalen, Giles F...... 698, M1396 Van Gulik, Thomas M...... 620 Whang, Edward E...... 379 Vander Woude, Eric ...... M1575 Whelan, Richard L...... Sp764, M1866 Vanounou, Tsafrir ...... 375, M1517 White, Rebekah ...... 258 Varadarajulu, Shyam ...... 702, M1497 Whiteford, Mark H...... Sp645 Varela, Esteban ...... M1398

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Wickremseekera, Susrutha ...... M1510 Yeo, Charles J...... 257, 373, 696, M1500 Wiebke, Eric A...... 803 Yip, Vincent S...... M1907 Wigmore, Stephen J...... M1907 Yip-Schneider, Michele ...... M1894 Wilcox, C. Mel ...... 702, M1497 Yiu, Raymond ...... M1427 Williams, Valerie A...... 377, M1876 Yoon, Choong ...... M1546 Williamson, Paul ...... M1409 Yoshimura, Kiyoshi ...... M1878 Winter, Jordan M...... 257, 373, 696 You, Yi-Qian N...... 885, M1532 Wo, John ...... M1877 Young, Lester ...... M1400 Wolfe, Luke ...... 800 Young-Fadok, Tonia M...... 885, Sp761 Wolff, Bruce ...... M1538 Youssef, Yassar K...... M1473 Wolfgang, Chris L...... 373 Yovino, Susannah ...... M1508 Wolfram, Lars ...... 703, M1435, M1442, Yu, Jian ...... 803 ...... M1493, M1906 Yu, Jianfa ...... M1577 Wolter, Stefan ...... 704, M1570 Yuman, Fong ...... 886 Wong, John ...... 371 Wong, Kam-Ho ...... 371 Z Worni, Mathias ...... M1502 Wray, Curtis J...... M1505 Zaheer, Asgar ...... M1904 Wu, Chew-Wun ...... M1918 Zamani, Amir ...... M1500 Wu, Engrid ...... M1879 Zaninotto, Giovanni ...... M1463, M1474, Wu, Huangbing ...... 699, M1885 ...... M1475 Zare, Mahmood ...... M1874 X Zayaruzny, Maksim ...... 698, M1396 Zeh, Herbert J...... M1496 Xu, Xiulong ...... M1902, M1914 Zenilman, Michael E...... M1490 Zerey, Marc ...... M1434 Y Zhang, Qin ...... M1577 Zhang, Wenying ...... M1913 Yager, Dorne R...... M1908 Zhao, Chun-Mei ...... M1919 Yagi, Osmar K...... M1556 Zilberstein, Bruno ...... M1545, M1555, Yamacake, Kleiton R...... M1431 ...... M1556, M1568, M2287 Yamada, Hiroyuki ...... M1553 Zinn, Kurt ...... 621 Yamagata, Tetsuya ...... M1456 Zinner, Michael J...... M1504 Yanaga, Katsuhiko ...... M1449, M1471, Zutshi, Massarat ...... M1539 ...... M1561 Yau, Kwok Kay ...... M1571, M1572 Ye, Zaiyuan ...... M1577 Yekebas, Emre ...... Yekebas, Emre F...... 701, 703, 704, ...... M1435, M1442, M1493, M1570, ...... M1882, M1896, M1897, M1906 INDICES

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SUBJECT INDEX Absorption; Intestinal Apoptosis/Cell Death Hexose Transporter Expression in ...... M1909 Combination Therapy with Tra-8 An...... 621 The 5-HT3 Receptor Ago ...... M1911 Lentivirus-Mediated RNA Interfere ...... 379 Absorption; Nutrient Molecular Mechanisms Contributing ...... M1912 Enteral Immunonutrition During Se...... 887 Barrett’s Hexose Transporter Expression in ...... M1909 Role of Diagnostic Video-Laparosc...... M1469 Achalasia Barrett’s Esophagus Age Does Not Affect the Long-Term...... M1463 Clinicopathological and Molecular...... M1467 Generation of a Mathematical Mode ...... M1440 COX-2 Gene Expression in Long Seg...... M1881 Laparoscopic Epiphrenic Diverticu...... M1438 Esophagectomy for Adenocarcinoma ..... M1464 Long Term Quality of Life After H...... M1473 Increased Formation of Oxidative ...... M1468 Results of Conventional Heller My ...... M1441 Loss of Manganese Superoxide Dism ...... M1877 Should Laparoscopic Heller Myotom ...... M1461 On the Road to a Vaccine for Barr...... M1878 Anal Diseases Overexpression in Ki67 Proliferat ...... M1443 The Pathogenesis of Barrett’...... M1876 Cytokine Network in Chronic Peria...... M1402 Fecal Urgency After Circular Stap...... M1420 Benign Tumors Invasive Squamous Cell Carcinoma ...... M1405 Has the Dagradi-Serio-Iacono Oper...... M1503 Topical Gtn for Anal Fissure: a S...... M1401 Bile Flow Angiogenesis Effect of Bile in the Pathogenesi...... M1864 Fenofibrate, a Ppar Agonis ...... M1866 Biliary Cancer Pkc 412 – a Pan-Antiangiogenic Co...... M1491 Cancer of the Gallbladder: Nation...... 698 Slit/Robo Signalling in Colorecta ...... M1870 Cancer of the Gallbladder: Nation...... M1396 Animal Models Inflammatory Myofibroblastic Bili...... M1393 A Nude Mouse Resection Model of D...... M1895 Prevalence and Outcome of Cholang ...... M1397 Combination Therapy with Tra-8 An...... 621 Biliary Strictures Enhancement of Neointestinal Cyst ...... M1916 Inflammatory Myofibroblastic Bili...... M1393 Enteral Immunonutrition During Se...... 887 Loss of Manganese Superoxide Dism ...... M1877 Biliary Surgery Emerging Role of ERCP in Blunt Ex ...... M1394 Animal Study Hepaticojejunostomy – Definition ...... M1399 Effects of a High-Fat Diet with P...... M1888 Inflammatory Myofibroblastic Bili...... M1393 Enhancement of Neointestinal Cyst ...... M1916 Surgical Treatment of Hepatolithi...... M1390 Impact of Left Portal Branch Liga...... M1884 Mechanisms of Body Weight Loss Af ...... M1919 Biliary Tract Congenital Pancreaticobiliary Ano ...... M1400 Antireflux Surgery Does Endoscopic Ultrasound Have A...... M1392 A Novel System for Performing End...... M2286 Emerging Role of ERCP in Blunt Ex ...... M1394 A Randomized Controlled Trial of ...... 256 Gallstones Containing Bacteria Ar...... 622 Clinical Failure of Laparoscopic ...... M1457 Hepaticojejunostomy – Definition ...... M1399 Combined Transabdominal Gastropla .....M1447 Sphincter of Oddi : a Structural ...... M1395 Gastrectomy As a Remedial Operati ...... 377 Visuospatial Tests Predict the Pe ...... M1391 Long Term Quality of Life After H...... M1473 Long-Term (6 year) Outcome of Lap ...... M1470 Cancer Chemotherapy Objective and Quantitative Demons...... M1542 5-FU and Cpt-11 Significantly Red...... M1871 Patterns of Reflux After Successf...... M1451 Cisplatinum Induced Apoptosis Is ...... M1879 Prospective Trial of Laparoscopic ...... 882 Gastrointestinal Stromal Tumors ( ...... M1532 Spastic Motility Disorders and Ab ...... M1437 Influence of Clinically Relevant ...... M1890 The Durability of Laparoscopic Ni...... 376 Invasive Squamous Cell Carcinoma ...... M1405 To Divide Or Not to Divide the sh...... M1436 Irinotecan Combined with S-1 for ...... M1553

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Lentivirus-Mediated RNA Interfere...... 379 Superoxide Enhancement of L-Type ...... M1874 Neoadjuvant Chemoradiation Change...... 371 The Impact of Obesity On Technica...... M1434 Nf-B Targeting in Pancreati ...... M1894 Colon Cancer Outcome of Survival Following Sur ...... M1454 5-FU and Cpt-11 Significantly Red ...... M1871 Role of Diagnostic Video-Laparosc ...... M1469 A 30 Year Analysis of Colorectal ...... 298 Targeting Mek with Pd325901 Inhib ...... 699 Anastomotic Leakage Is Associated...... 296 Targeting Mek with Pd325901 Inhib ...... M1885 Clinicopathological Factors Predi...... M1419 Up-Regulation of Mica/B Expressio...... M1902 Emergency Laparoscopic Versus Ope...... M1427 Cancer Genetics Fenofibrate, a Ppar Agonis ...... M1866 Diagnostic Relevance of Human Tel ...... M1893 Identification of Chromosomal Dom...... M1869 Microsatellite DNA Alterations of...... 704 Laparoscopic Colorectal Resection ...... M1430 Microsatellite DNA Alterations of...... M1570 Optimal Follow-Up of Stage I Colo...... M1413 Overexpression in Ki67 Proliferat ...... M1443 Prospective Randomized Trial: Pre...... M1406 Overexpression of Geminin in Panc...... M1903 Rates and Patterns of Recurrence ...... 258 Short Tandem Repeat Polymorphism ...... 701 Recurrent Hepatic Colorectal Meta...... M1484 Short Tandem Repeat Polymorphism ..... M1882 Slit/Robo Signalling in Colorecta...... M1870 Carcinoid Tumors Synchronous Cancer in Obstructive...... M1417 Heparanase-1 Expression in Carcin ...... M1914 Colonoscopy Hepatic Artery Chemoembolization ...... 372 Synchronous Cancer in Obstructive...... M1417 The Current Role of Surgical Rese...... M1489 Constipation Cell Adhesion Ileorectal Anastomosis for Slow T...... 885 Adhesion Molecules Under Volume T ..... M1896 Cost-Effectiveness Cell Culture Establishing Standards of Quality...... M1517 Acute Pancreatitis Afeccts Kuppfe...... M1905 Reduction in Pancreatic Leak Foll...... M1519 The Pathogenesis of Barrett’...... M1876 Crohn’s Disease Cell lines; Intestinal Crohn’S Disease : a Patient ...... M1539 Functional and Molecular Evidence ...... M1908 Cytokine Network in Chronic Peria ...... M1402 Molecular Mechanisms Contributing...... M1912 Early Postoperative Results of No ...... M1410 Cell lines; Pancreatic Effect of Alvimopan On Gastrointe...... M1538 Influence of Postoperative Compli...... M1533 Apigenin Inhibits Pancreatic Canc ...... M1891 Laparoscopic Vs. Open Surgery in ...... M1408 Overexpression of Geminin in Panc...... M1903 Rapid RE-Operation for Crohn’s Di ...... 694 Up-Regulation of Mica/B Expressio...... M1902 Short Residual Intestine of Posts...... M1528 Chromosomal Abnormalities Identification of Chromosomal Dom ...... M1869 Cyclooxygenase Inhibitors COX-1 and COX-2 Inhibitors Amerio...... M1889 Colitis Predictive Factors in Clostridium...... M1411 Cytokines Superoxide Enhancement of L-Type ...... M1874 Acute Pancreatitis Afeccts Kuppfe...... M1905 Atropine Increases Survival in An...... M1868 Colon Cytokine Network in Chronic Peria ...... M1402 Evaluation of the Physical Proper...... M1873 Effects of Pentoxifylline in Live...... M1887 Hyperbilirubinemia in Appendicits ...... 707 Enteral Immunonutrition During Se...... 887 Hyperbilirubinemia in Appendicits ...... M1407 In Vitro Evidence for Acinar Cell...... M1904 Ileorectal Anastomosis for Slow T...... 885 Laparoscopic Colorectal Surgery i...... M1428 Databases Long-Term Quality of Life Is Not ...... M1416 2001 Gastric Pce: Overview of the...... M1543 Mechanical Bowel Preparation Infl...... M1423 Determinants of the Epidemiology,...... M1529 Outcomes in Bloodless Care Patien ...... M1414 Treatment of Gastric Adenocarcino...... 801 INDICES Prospective Randomized Trial: Pre...... M1406 Trends and Predictors for Vagotom ...... M1537 Single Institution Comparison of ...... M1409 Tsunami Medical Relief in Rural A...... M1550

379 SSAT.book Page 380 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Decision Analysis Short Tandem Repeat Polymorphism ...... M1882 Laparoscopic Colorectal Surgery i ...... M1428 Skip Metastasis in Oesophageal Ca ...... M1442 Long Term Follow-Up of Patients W ...... M1512 The Impact of Lymph Node Yield an...... M1435 Diabetes Mellitus Thoraco-Laparoscopic Esophagectom...... M1460 Laparoscopic Surgical Treatment o...... M1566 Esophageal pH Duodenal Ulcers 48-Hour pH Monitoring Increases R ...... M1459 Current Strategy for Treatment of ...... M1576 Spastic Motility Disorders and Ab...... M1437 Trends and Predictors for Vagotom ...... M1537 Esophageal Sphincter; Lower Education Gastroesophageal Reflux Disease a...... 883 Joint Kinematics Vary with Perfor ...... M2288 Normal Lower Esophageal Sphincter ...... M1466 Visuospatial Tests Predict the Pe...... M1391 Esophageal Surgery Endoscopic Surgery Aberrant DNA-Hypermethylation of ...... M1875 A Novel System for Performing End...... M2286 Age Does Not Affect the Long-Term...... M1463 Clinical Management of Gastrointe...... M1563 Combined Transabdominal Gastropla..... M1447 Joint Kinematics Vary with Perfor ...... M2288 Esophagectomy After Cardiac Surge...... M1444 Successful Diaphragm Pacing in a ...... 697 Esophagectomy for Adenocarcinoma ..... M1464 Visuospatial Tests Predict the Pe...... M1391 Laparoscopic Repair of Large Type ...... M1474 Long-Term Outcome of Operated and ..... M1475 Endoscopy Normal Lower Esophageal Sphincter ...... M1466 Congenital Pancreaticobiliary Ano...... M1400 Preliminary Experience By a Thora...... M1453 Endoscopic Management of Anastomo....M1557 Quality of Life Convergence of La ...... 884 Gender Disparities in Colorectal ...... M1404 Repair of Esophageal Perforation: ...... M1439 Preliminary Experience By a Thora ...... M1453 Should Laparoscopic Heller Myotom...... M1461 What to Expect in the Excluded St...... M1568 Skip Metastasis in Oesophageal Ca ...... M1442 Endotoxins The Impact of Lymph Node Yield an...... M1435 Atropine Increases Survival in An ...... M1868 Esophagitis; Reflux Epidemiology Expression of p63 As a Marker for...... M1880 Clavicle Lifting Strategy in Radi ...... M1471 Overexpression in Ki67 Proliferat ...... M1443 Determinants of the Epidemiology, ...... M1529 Esophagus Prevalence of Metabolic Bone Diso ...... M1547 Generation of a Mathematical Mode...... M1440 Surgery for Acute Cholecystitis i ...... M1388 Incidence and Determinants of Sur ...... M1450 ERCP; Therapeutic Laparoscopic Epiphrenic Diverticu ...... M1438 Emerging Role of ERCP in Blunt Ex...... M1394 Laparoscopic Repair of Large Type ...... M1474 Long-Term Outcome of Operated and ..... M1475 Esophageal Cancer Repair of Esophageal Perforation: ...... M1439 A Four-Point Multidisciplinary Ho ...... M1448 Towards the Molecular Characteriz...... M1883 Aberrant DNA-Hypermethylation of ...... M1875 Cisplatinum Induced Apoptosis Is ...... M1879 Gallbladder Clavicle Lifting Strategy in Radi ...... M1471 Cancer of the Gallbladder: Nation...... 698 Clinical Significance of Sumo-1 i...... M1449 Cancer of the Gallbladder: Nation...... M1396 Clinicopathological and Molecular...... M1467 Robotic Assisted Vs. Laparoscopic...... 705 Esophagectomy After Cardiac Surge...... M1444 Robotic Assisted Vs. Laparoscopic...... M1389 Esophagectomy for Adenocarcinoma ...... M1464 Steatocholecystitis: An Explanati ...... 693 Evaluation of the Gastric Tube Vi...... M1456 Gallbladder Surgery Expression of p63 As a Marker for...... M1880 Cancer of the Gallbladder: Nation...... 698 Neoadjuvant Chemoradiation Change ...... 371 Cancer of the Gallbladder: Nation...... M1396 Neoadjuvant Therapy in Esophageal...... M1472 Knowledge and Opinions Regarding ...... M2289 On the Road to a Vaccine for Barr...... M1878 Outcomes and Utilization of Lapar...... M1398 Outcome of Survival Following Sur...... M1454 Robotic Assisted Vs. Laparoscopic...... 705 Short Tandem Repeat Polymorphism ...... 701 Robotic Assisted Vs. Laparoscopic...... M1389

380 SSAT.book Page 381 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Gallstone Formation Gastric Ulcers Gallstones Containing Bacteria Ar...... 622 Current Strategy for Treatment of ...... M1576 Gallstones Gastroesophageal Reflux (GERD) Does Endoscopic Ultrasound Have A...... M1392 A Randomized Controlled Trial of ...... 256 Gallstones Containing Bacteria Ar...... 622 Clinical Failure of Laparoscopic ...... M1457 Robotic Assisted Vs. Laparoscopic...... 705 COX-2 Gene Expression in Long Seg ...... M1881 Robotic Assisted Vs. Laparoscopic...... M1389 Does Reflux Height Matter? a Stud...... 700 Surgery for Acute Cholecystitis i...... M1388 Does Reflux Height Matter? a Stud...... M1445 Surgical Treatment of Hepatolithi...... M1390 Gastrectomy As a Remedial Operati ...... 377 Gastric Cancer Gastroesophageal Reflux Disease a ...... 883 Incidence and Determinants of Sur...... M1450 2001 Gastric Pce: Overview of the ...... M1543 Long-Term (6 year) Outcome of Lap...... M1470 30-Day Morbidity After Curative R...... M1544 Multiple Failed Fundoplications A ...... M1565 Clinicopathologic and Immunohisto...... M1556 Normal Lower Esophageal Sphincter...... M1466 Effect of Splenectomy On the Surv...... M1546 Objective and Quantitative Demons...... M1542 Functional Polymorphism in Nfkb1 ...... M1918 Patterns of Reflux After Successf...... M1451 Function-Preserving Gastrectomy P...... M1561 Primary Versus Secondary Esophage ...... M1446 Gastric Adenocarcinoma: Clinico-P...... M1555 Prospective Trial of Laparoscopic...... 882 Gastric Adenocarcinoma: Reduction ...... M1573 Quality of Life Convergence of La...... 884 Gastrointestinal Stromal Tumours ...... M1560 The Durability of Laparoscopic Ni...... 376 Irinotecan Combined with S-1 for ...... M1553 To Divide Or Not to Divide the sh...... M1436 Laparoscopic and Endogastric Rese...... M1545 Outcome of Survival Following Sur ...... M1454 Gene Expression Role of Diagnostic Video-Laparosc ...... M1469 Clinical Significance of Sumo-1 i...... M1449 Surgical Resection for Gastric Ca ...... M1559 COX-2 Gene Expression in Long Seg ...... M1881 The Impact of Clinicopathological...... M1564 Expression of p63 As a Marker for ...... M1880 The Role of Hepatectomy for the P...... M1483 Hexose Transporter Expression in ...... M1909 Treatment of Gastric Adenocarcino ...... 801 Identification of Chromosomal Dom...... M1869 Gastric Secretion N-Acetyl Cysteine Attenuates Panc ...... M1899 Slit/Robo Signalling in Colorecta...... M1870 Gastric pH and Nutritional Course...... M2287 The Pathogenesis of Barrett’ ...... M1876 Gastric Surgery Towards the Molecular Characteriz ...... M1883 2001 Gastric Pce: Overview of the ...... M1543 Clinical Management of Gastrointe...... M1563 Gene Regulation Does the Position of the Alimenta...... M1574 Apigenin Inhibits Pancreatic Canc...... M1891 Effect of Splenectomy On the Surv...... M1546 Cisplatinum Induced Apoptosis Is ...... M1879 Endoscopic Management of Anastomo ... M1557 Regulation of Gut Gene Expression...... M1913 Function-Preserving Gastrectomy P...... M1561 Health Care Delivery Gastric Bypass Does Not Influence ...... M1575 Bariatric Surgery At the Extremes ...... M1549 Gastrointestinal Stromal Tumours ...... M1560 Crohn’S Disease : a Patient ...... M1539 Incidence, Risk Factors, and Outc...... M1552 Gender Disparities in Colorectal ...... M1404 Laparoscopic Repair for Perforate ...... M1572 Incidence and Determinants of Sur...... M1450 Laparoscopic Sleeve Gastrectomy I...... M1551 Health Care Economics Laparoscopic Surgical Treatment o ...... M1566 Knowledge and Opinions Regarding ...... M2289 Laparoscopic Wedge Resection of G ...... M1571 Postoperative Pancreatic Fistulas ...... 375 Mechanisms of Body Weight Loss Af...... M1919 Prevalence of Metabolic Bone Diso...... M1547 Hepatic Resection Results of a Randomized, Prospect...... M1577 Autologous Versus Allogeneic Tran ...... 886 Secondary Esophageal Peristalsis ...... M1548 Liver Metastasis Echogenicity On ...... 370 Surgical Resection for Gastric Ca ...... M1559 Modern Surgical and Perioperative...... M1482 INDICES The Impact of Clinicopathological...... M1564 Rates and Patterns of Recurrence ...... 258 Treatment of Gastric Adenocarcino ...... 801 Recurrent Hepatic Colorectal Meta...... M1484 The Role of Hepatectomy for the P ...... M1483

381 SSAT.book Page 382 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Hepatic Surgery Intestinal Surgery Effects of a High-Fat Diet with P...... M1888 Bariatric Surgery At the Extremes...... M1549 Effects of Pentoxifylline in Live...... M1887 Early Postoperative Results of No...... M1410 Hepatic Artery Chemoembolization ...... 372 Effect of Alvimopan On Gastrointe...... M1538 Surgical Treatment of Hepatolithi ...... M1390 Emergency Laparoscopic Versus Ope ...... M1427 Telomerase Activity in Tumor and ...... M1486 Evaluation of the Physical Proper ...... M1873 The Impact of Age On Hepatic Rese...... M1476 Intraoperative Radiotherapy for O...... M1422 Hepatitis; Viral Short Residual Intestine of Posts ...... M1528 Telomerase Activity in Tumor and ...... M1486 Laparoscopy Hepatocellular Cancer Age Does Not Affect the Long-Term...... M1463 Radiofrequency Ablation for HCC i ...... 706 Capnoperitoneum Mediated Anti-Inf ...... M1863 Radiofrequency Ablation for HCC i ...... M1485 Clinical Management of Gastrointe...... M1563 Targeting Mek with Pd325901 Inhib...... 699 Emergency Laparoscopic Versus Ope ...... M1427 Targeting Mek with Pd325901 Inhib...... M1885 Joint Kinematics Vary with Perfor...... M2288 Telomerase Activity in Tumor and ...... M1486 Laparoscopic and Endogastric Rese...... M1545 Laparoscopic Colorectal Resection...... M1430 Hypoxia Laparoscopic Colorectal Surgery i ...... M1428 Pancreatic Regeneration in Chroni ...... 297 Laparoscopic Distal Pancreatectom...... M1509 IBD Surgery Laparoscopic Epiphrenic Diverticu ...... M1438 A New Drug Delivery System Target...... 695 Laparoscopic Pancreaticoduodenect ...... M1513 Clostridium Difficile Enteritis: ...... M1535 Laparoscopic Repair for Perforate...... M1572 Early Postoperative Results of No ...... M1410 Laparoscopic Resection for Rectal ...... M1425 Influence of Postoperative Compli...... M1533 Laparoscopic Vs. Open Surgery in ...... M1408 Molecular Analysis of Colonic Tra...... M1910 Laparoscopic Wedge Resection of G...... M1571 Long Term Quality of Life After H...... M1473 IBD; Therapy Long-Term Quality of Life Is Not ...... M1416 Short Residual Intestine of Posts ...... M1528 Outcomes and Utilization of Lapar...... M1398 Image Analysis Single Institution Comparison of ...... M1409 Liver Metastasis Echogenicity On ...... 370 Surgery for Acute Cholecystitis i ...... M1388 Immunology The Influence of Positive Periton ...... M1498 Thoraco-Laparoscopic Esophagectom...... M1460 Changes in the Systemic Innate Im...... M1907 Increased Serum Levels of Ige and...... M1490 Liver On the Road to a Vaccine for Barr...... M1878 COX-1 and COX-2 Inhibitors Amerio...... M1889 Up-Regulation of Mica/B Expressio ...... M1902 Granulocyte Colony Stimulating Fa...... M1886 Incontinence; Fecal Impact of Left Portal Branch Liga ...... M1884 Ischemic Preconditioning Improves ...... M1499 Fecal Incontinence: Are Patients ...... M1432 MELD As a Predictor of Morbidity ...... M1481 Inflammation Modern Surgical and Perioperative ...... M1482 Adhesion Molecules Under Volume T...... M1896 Prevalence and Outcome of Cholang ...... M1397 Atropine Increases Survival in An ...... M1868 Radiofrequency Ablation for HCC i ...... 706 Capnoperitoneum Mediated Anti-Inf ...... M1863 Radiofrequency Ablation for HCC i ...... M1485 Determinants of the Epidemiology, ...... M1529 The Impact of Age On Hepatic Rese...... M1476 Effects of a High-Fat Diet with P...... M1888 Hyperbilirubinemia in Appendicits...... 707 Liver Regeneration Hyperbilirubinemia in Appendicits...... M1407 Effects of Pentoxifylline in Live ...... M1887 Local Immunosuppression After Neo...... M1431 Granulocyte Colony Stimulating Fa...... M1886 Predictive Factors in Clostridium ...... M1411 Impact of Left Portal Branch Liga ...... M1884 Interleukins Macrophages/Dendritic Cells The Effect of L-Arginine and Apro...... M1915 Capnoperitoneum Mediated Anti-Inf ...... M1863 Protein Kinase C-Zeta Is Critical...... M1901 Intestinal Adaptation A New Drug Delivery System Target...... 695 Molecular Analysis of Colonic Tra...... M1910

382 SSAT.book Page 383 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

MAP Kinases Nutrition Targeting Mek with Pd325901 Inhib ...... 699 Enhancement of Neointestinal Cyst...... M1916 Targeting Mek with Pd325901 Inhib ...... M1885 Gastric Bypass Does Not Influence ...... M1575 Mesenteric Ischemia Gastric pH and Nutritional Course...... M2287 Molecular Mechanisms Contributing...... M1912 The Effect of L-Arginine and Apro...... M1915 Metastasis Obesity 5-FU and Cpt-11 Significantly Red...... M1871 Bariatric Surgery At the Extremes ...... M1549 Gastrointestinal Stromal Tumors (...... M1532 Does the Position of the Alimenta...... M1574 Heparanase-1 Expression in Carcin ...... M1914 Effect of Location and Speed of D ...... 800 Thioredoxin-Interacting Protein E...... M1892 Endoscopic Management of Anastomo....M1557 Gastric Bypass Does Not Influence ...... M1575 Metastasis; Liver Gastroesophageal Reflux Disease a ...... 883 Hepatic Artery Chemoembolization ...... 372 Incidence, Risk Factors, and Outc...... M1552 Liver Metastasis Echogenicity On ...... 370 Is An Elevated Body Mass Index As ...... M1541 Modern Surgical and Perioperative...... M1482 Is the Very Long Limb Roux-en-Y G...... M1540 Rates and Patterns of Recurrence ...... 258 Laparoscopic Sleeve Gastrectomy I...... M1551 Recurrent Hepatic Colorectal Meta...... M1484 Long-Term Outcomes of the Modifie ...... M1536 The Impact of Age On Hepatic Rese ...... M1476 Mechanisms of Body Weight Loss Af...... M1919 The Role of Hepatectomy for the P...... M1483 Metabolic Characterization of Non...... 380 Minimally Invasive Surgery Secondary Esophageal Peristalsis ...... M1548 A Novel System for Performing End ...... M2286 The Impact of Obesity On Technica...... M1434 Effect of Location and Speed of D...... 800 What to Expect in the Excluded St...... M1568 Laparoscopic Colorectal Resection...... M1430 Other Laparoscopic Repair for Perforate ...... M1572 Gore Tex Perineal Sacral Suspensi...... M1418 Laparoscopic Repair of Large Type...... M1474 Impedance/pH Monitoring: the Impo...... M1462 Management of t2 N0 Rectal Tumors ...... 259 Internal Hernias: Clinical Findin...... M1531 Should Laparoscopic Heller Myotom...... M1461 Is a Peroperative END to END Anas...... 620 The Impact of Obesity On Technica ...... M1434 Laparoscopic Ileocolic Resection ...... 476 Motility; Intestinal Laparoscopic Redo Nissen Fundopli...... 471 Gastric Electrical Stimulation fo ...... M1569 Laparoscopic Resection of Gastric ...... 472 Knowledge and Opinions Regarding ...... M2289 Management of Open Abdominal Superoxide Enhancement of L-Type ...... M1874 Woun...... M1530 Minimally Invasive Esophagectomy:...... 470 Motility; Oro-Pharyngeal/Esophageal Pancreas Preserving Duodenectomy ...... 474 Does Reflux Height Matter? a Stud ...... 700 Predictors of Anatomic Recurrence...... M1458 Does Reflux Height Matter? a Stud ...... M1445 Redo" Fundoplications Are Effecti ...... M1567 Generation of a Mathematical Mode...... M1440 Resection and Reconstruction of t...... 475 Primary Versus Secondary Esophage...... M1446 Statins (HMG-CoA Reductase Inhibi ...... M1865 Results of Conventional Heller My...... M1441 The Effect of Surgically Induced ...... M1433 Spastic Motility Disorders and Ab...... M1437 The Prevalence of Colorectal Neop ...... M1872 Mouse Transgastric Repair of a Gastroga...... 473 A Nude Mouse Resection Model of D ...... M1895 Outcomes Fenofibrate, a Ppar Agonis...... M1866 A Four-Point Multidisciplinary Ho ...... M1448 Granulocyte Colony Stimulating Fa ...... M1886 A R0 Resection Accomplished with ...... 803 Neuroendocrine Tumors Aberrant DNA-Hypermethylation of ...... M1875 Aggressive Pancreatic Resection f...... M1522 Anastomotic Leakage Is Associated...... 296 Heparanase-1 Expression in Carcin ...... M1914 Cachexia Worsens the Prognosis in...... M1487

The Current Role of Surgical Rese...... M1489 Clinical Failure of Laparoscopic ...... M1457 INDICES Thioredoxin-Interacting Protein E...... M1892 Crohn’S Disease : a Patient ...... M1539 Nitric Oxide Do p16, P53, Or Muc4 Mutations Af...... M1494 Does the Position of the Alimenta...... M1574 Methylene Blue Improves Hemodynam.. M1900

383 SSAT.book Page 384 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Esophagectomy After Cardiac Surge...... M1444 Pancreatic Regeneration in Chroni ...... 297 Establishing Standards of Quality...... M1517 Predictive Factor for Malignant B...... M1524 Fast-Track Concept in Pancreatic ...... M1488 Reduction in Pancreatic Leak Foll ...... M1519 Fecal Urgency After Circular Stap...... M1420 Resected Serous Cystic Neoplasms ...... M1500 Incidence, Risk Factors, and Outc...... M1552 The Current Role of Surgical Rese ...... M1489 Is the Very Long Limb Roux-en-Y G...... M1540 The Impact of a Microscopic Posit ...... M1505 Laparoscopic Sleeve Gastrectomy I...... M1551 Tissuelink™ Decreases Pancr...... M1523 Laparoscopic Vs. Open Surgery in ...... M1408 Pancreatic Enzymes Outcomes and Utilization of Lapar ...... M1398 Exocrine Function After the Whipp...... 802 Outcomes in Bloodless Care Patien...... M1414 Risk Factors for Pancreatic Fistu ...... M1507 Pancreatic Cancer in the General ...... 374 Patterns of Local Failure and Sur ...... 805 Pancreatic Exocrine Cancer Postoperative Pancreatic Fistulas...... 375 1382 Pancreaticoduodenectomies fo ...... 696 Predictive Factors in Clostridium ...... M1411 A Nude Mouse Resection Model of D...... M1895 Quality of Life Convergence of La...... 884 A R0 Resection Accomplished with ...... 803 Recurrent Distal Rectal Cancer Fo ...... M1421 Cachexia Worsens the Prognosis in ...... M1487 Reduction in Pancreatic Leak Foll ...... M1519 Complications Management Due to C .... M1493 Restorative Proctocolectomy with ...... M1426 Detection of Microsatellite Alter ...... 703 Routine Drainage of the Pancreati...... M1502 Detection of Microsatellite Alter ...... M1906 Surgical Resection for Gastric Ca...... M1559 Durability of Portal Venous Recon...... M1521 The Durability of Laparoscopic Ni...... 376 Endoscopic Ultrasound Is Remains ...... M1526 Trends and Predictors for Vagotom ...... M1537 Exocrine Function After the Whipp...... 802 Expression of Netrin-1 But Not of...... M1897 Oxidative Injury Haemorrhage Following Pancreatico ...... M1510 COX-1 and COX-2 Inhibitors Amerio...... M1889 Ischemic Preconditioning Improves ...... M1499 Increased Formation of Oxidative ...... M1468 Lentivirus-Mediated RNA Interfere ...... 379 Loss of Manganese Superoxide Dism ...... M1877 Nf-B Targeting in Pancreati ...... M1894 Methylene Blue Improves Hemodynam...M1900 Pancreatic Cancer in the General ...... 374 Thioredoxin-Interacting Protein E ...... M1892 Pkc 412 – a Pan-Antiangiogenic Co ...... M1491 Pancreas Predicting Unresectability in Pan...... M1508 1382 Pancreaticoduodenectomies fo...... 696 Predictive Factor for Malignant B...... M1524 A Prospective Evaluation of An Al...... 702 The Impact of a Microscopic Posit ...... M1505 A Prospective Evaluation of An Al...... M1497 The Inﬂuence of Positive Periton ...... M1498 Apigenin Inhibits Pancreatic Canc...... M1891 When Is “Resectable” ...... M1496 Combination Therapy with Tra-8 An...... 621 Pancreatic Secretion Comparison of Clinical Aspects Be...... M1492 Conservative Treatment of Postope ...... M1516 Congenital Pancreaticobiliary Ano...... M1400 Risk Factors for Pancreatic Fistu ...... M1507 Conservative Treatment of Postope...... M1516 Diagnostic Relevance of Human Tel...... M1893 Pancreatic Surgery Distal Pancreatectomy: a Ten-Year...... M1504 1382 Pancreaticoduodenectomies fo ...... 696 Does Pancreatic Duct Stenting Dec ...... 373 A R0 Resection Accomplished with ...... 803 Drain Amylase Levels Following Pa...... M1518 Aggressive Pancreatic Resection f...... M1522 Durability of Portal Venous Recon ...... M1521 Cachexia Worsens the Prognosis in ...... M1487 Endoscopic and Surgical Managemen...... M1514 Complications Management Due to C .... M1493 Endoscopic Ultrasound Reliably Id ...... M1511 Conservative Treatment of Postope ...... M1516 Enucleation of Endocrine Pancreat ...... M1515 Cystic Lesions of the Pancreas an ...... M1506 Fast-Track Concept in Pancreatic ...... M1488 Distal Pancreatectomy: a Ten-Year ...... M1504 Haemorrhage Following Pancreatico...... M1510 Do p16, P53, Or Muc4 Mutations Af...... M1494 Increased Serum Levels of Ige and...... M1490 Does Pancreatic Duct Stenting Dec...... 373 Inﬂuence of Clinically Relevant ...... M1890 Drain Amylase Levels Following Pa...... M1518 Is Total Pancreatectomy (TP) Safe...... M1495 Durability of Portal Venous Recon...... M1521 N-Acetyl Cysteine Attenuates Panc ...... M1899 Endoscopic Ultrasound Is Remains ...... M1526 Overexpression of Geminin in Panc ...... M1903 Enucleation of Endocrine Pancreat...... M1515

384 SSAT.book Page 385 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Establishing Standards of Quality...... M1517 Patient Satisfaction Exocrine Function After the Whipp ...... 802 Long-Term Outcomes of the Modifie ...... M1536 Fast-Track Concept in Pancreatic ...... M1488 PH Monitoring Haemorrhage Following Pancreatico...... M1510 48-Hour pH Monitoring Increases R...... M1459 Has the Dagradi-Serio-Iacono Oper...... M1503 A Randomized Controlled Trial of ...... 256 Hospital Readmission Following Pa...... 257 Does Reflux Height Matter? a Stud...... 700 Is Total Pancreatectomy (TP) Safe ...... M1495 Does Reflux Height Matter? a Stud...... M1445 Ischemic Preconditioning Improves...... M1499 Gastric pH and Nutritional Course...... M2287 Laparoscopic Distal Pancreatectom ...... M1509 Primary Versus Secondary Esophage ...... M1446 Laparoscopic Pancreaticoduodenect...... M1513 Long Term Follow-Up of Patients W...... M1512 Polyps; Colorectal Long-Term Outcome After Resection...... 378 Synchronous Cancer in Obstructive...... M1417 Pancreatic Cancer in the General ...... 374 Protein Expression Postoperative Pancreatic Fistulas ...... 375 Clinical Significance of Sumo-1 i...... M1449 Predicting Unresectability in Pan ...... M1508 Predictive Factor for Malignant B ...... M1524 Protein Kinase C Resected Serous Cystic Neoplasms ...... M1500 Protein Kinase C-Zeta Is Critical...... M1901 Risk Factors for Pancreatic Fistu...... M1507 Proton Pump Inhibitors Routine Drainage of the Pancreati...... M1502 Prospective Trial of Laparoscopic...... 882 The Use of Somatostatin and Its A...... M1527 Quality Assurance Tissuelink™ Decreases Pancr...... M1523 30-Day Morbidity After Curative R...... M1544 When Is “Resectable” ...... M1496 Gastrointestinal Stromal Tumours ...... M1560 Pancreatitis; Acute Quality of Life Comparison of Clinical Aspects Be...... M1492 Combined Transabdominal Gastropla...... M1447 Endoscopic and Surgical Managemen ..... M1514 Function-Preserving Gastrectomy P ...... M1561 In Vitro Evidence for Acinar Cell...... M1904 Ileorectal Anastomosis for Slow T...... 885 Long Term Follow-Up of Patients W...... M1512 Influence of Postoperative Compli...... M1533 Methylene Blue Improves Hemodynam.. M1900 Is the Very Long Limb Roux-en-Y G...... M1540 N-Acetyl Cysteine Attenuates Panc...... M1899 Long-Term Quality of Life Is Not ...... M1416 Pancreatitis; Chronic Results of a Randomized, Prospect ...... M1577 Complications Management Due to C .... M1493 To Divide Or Not to Divide the sh...... M1436 Detection of Microsatellite Alter...... 703 Radiation Therapy Detection of Microsatellite Alter...... M1906 Intraoperative Radiotherapy for O ...... M1422 Drain Amylase Levels Following Pa ...... M1518 Invasive Squamous Cell Carcinoma ...... M1405 Endoscopic and Surgical Managemen ..... M1514 Local Immunosuppression After Neo...... M1431 Endoscopic Ultrasound Reliably Id...... M1511 Neoadjuvant Chemoradiation Change ...... 371 Long-Term Outcome After Distal Pa...... M1520 Neoadjuvant Therapy in Esophageal...... M1472 Long-Term Outcome After Resection...... 378 Pancreatic Regeneration in Chroni...... 297 Radiographic Studies Prevalence of Metabolic Bone Diso ...... M1547 Pancreatitis; Experimental Acute Acute Pancreatitis Afeccts Kuppfe...... M1905 Rat Adhesion Molecules Under Volume T ..... M1896 Changes in the Systemic Innate Im...... M1907 Changes in the Systemic Innate Im...... M1907 Effect of Bile in the Pathogenesi...... M1864 Protein Kinase C-Zeta Is Critical ...... M1901 Evaluation of the Physical Proper...... M1873 Pathology Receptors Expression of Netrin-1 But Not of...... M1897 Functional and Molecular Evidence ...... M1908 Microsatellite DNA Alterations of...... 704 Rectal Cancer Microsatellite DNA Alterations of...... M1570 Anastomotic Leakage Is Associated...... 296 INDICES Resected Serous Cystic Neoplasms ...... M1500 Efficacy of Preoperative Combined...... 804 The Effect of L-Arginine and Apro...... M1915 Intraoperative Radiotherapy for O ...... M1422 Towards the Molecular Characteriz ...... M1883

385 SSAT.book Page 386 Friday, April 21, 2006 12:58 PM

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Laparoscopic Resection for Rectal ...... M1425 Has the Dagradi-Serio-Iacono Oper...... M1503 Local Immunosuppression After Neo...... M1431 Is Total Pancreatectomy (TP) Safe...... M1495 Lymph Node Retrieval After Surger...... M1429 Laparoscopic Pancreaticoduodenect ...... M1513 Management of t2 N0 Rectal Tumors...... 259 Long-Term Outcomes of the Modifie ...... M1536 Optimal Follow-Up of Stage I Colo ...... M1413 Mechanical Bowel Preparation Infl ...... M1423 Patterns of Local Failure and Sur ...... 805 Neoadjuvant Therapy in Esophageal ...... M1472 Recurrent Distal Rectal Cancer Fo ...... M1421 Outcomes in Bloodless Care Patien...... M1414 Rectum Predicting Stricture in Post- Gas...... M1558 Preliminary Experience By a Thora...... M1453 Prospective Randomized Trial: Pre...... M1406 Rapid RE-Operation for Crohn’s Di...... 694 Screening; Cancer Repair of Esophageal Perforation: ...... M1439 Prevalence and Outcome of Cholang...... M1397 Routine Drainage of the Pancreati ...... M1502 The Influence of Positive Periton ...... M1498 Single Institution Comparison of ...... M1409 Screening; Colorectal The Impact of a Microscopic Posit ...... M1505 A 30 Year Analysis of Colorectal ...... 298 Thoraco-Laparoscopic Esophagectom...... M1460 Efficacy of Preoperative Combined ...... 804 Tissuelink™ Decreases Pancr...... M1523 Gender Disparities in Colorectal ...... M1404 Swallowing Signal Transduction A Four-Point Multidisciplinary Ho...... M1448 In Vitro Evidence for Acinar Cell...... M1904 Transcription Factors Small Intestine Nf-B Targeting in Pancreati ...... M1894 A New Drug Delivery System Target...... 695 Regulation of Gut Gene Expression ...... M1913 Clostridium Difficile Enteritis: ...... M1535 Tumor Markers Effect of Bile in the Pathogenesi...... M1864 Clinicopathologic and Immunohisto ...... M1556 Effectiveness of Diagnostic Parac...... M1534 Diagnostic Relevance of Human Tel ...... M1893 Gastrointestinal Stromal Tumors (...... M1532 Do p16, P53, Or Muc4 Mutations Af...... M1494 Laparoscopic Surgical Treatment o...... M1566 Increased Serum Levels of Ige and ...... M1490 Molecular Analysis of Colonic Tra...... M1910 Rapid RE-Operation for Crohn’s Di ...... 694 Tumorigenesis Regulation of Gut Gene Expression...... M1913 Expression of Netrin-1 But Not of...... M1897 The 5-HT Receptor Ago ...... M1911 Increased Formation of Oxidative ...... M1468 3 Pkc 412 – a Pan-Antiangiogenic Co ...... M1491 Somatostatin The Use of Somatostatin and Its A ...... M1527 Ultrasonography; Endoscopic (EUS) A Prospective Evaluation of An Al...... 702 Staging A Prospective Evaluation of An Al...... M1497 The Impact of Clinicopathological...... M1564 Does Endoscopic Ultrasound Have A...... M1392 Stomach Endoscopic Ultrasound Is Remains ...... M1526 48-Hour pH Monitoring Increases R...... M1459 Endoscopic Ultrasound Reliably Id ...... M1511 Clinicopathologic and Immunohisto...... M1556 Predicting Unresectability in Pan...... M1508 Laparoscopic Wedge Resection of G...... M1571 When Is “Resectable” ...... M1496 Microsatellite DNA Alterations of...... 704 Vitamins Microsatellite DNA Alterations of...... M1570 The Use of Somatostatin and Its A...... M1527 Predicting Stricture in Post- Gas ...... M1558 What to Expect in the Excluded St...... M1568 Surgical Technique 30-Day Morbidity After Curative R...... M1544 Enucleation of Endocrine Pancreat ...... M1515 Evaluation of the Gastric Tube Vi...... M1456

386 SSAT.book Page 387 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, 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.

Al-Azzawi, Hayder Nothing to Disclose Bass, Barbara L. (Program Committee, Allen, Jeff W. Inaned Health: Moderator); Adolor: Consulting Fee Proctor; Storz: Speaker/Teacher; Ethicon: Bauer, Todd W. Nothing to Disclose Speaker/Teacher; U.S. Surgical: Speaker/ Becker, James M. (Moderator); Nothing Teacher; Gore: Speaker/Teacher to Disclose Ambrosetti, Patrick Nothing to Disclose Billingham, Richard P. Nothing to Disclose Anvari, Mehran Nothing to Disclose Bingener-Casey, Juliane (Program Ashley, Stanley W. Nothing to Disclose Subcommittee); Tyco International: Baker, Mark E. Nothing to Disclose Honorarium, Consultant; Ethicon: Ballantyne, Garth Hadden Ethicon: Educational Educational Grant; Gore: Educational Grant, Fellowship Director; Ethicon: Grant Honorarium, Speaker; Tyco Autosuture: Blackstone, Jon (Staff); Nothing to

Educational Grant, Fellowship Director; Disclose INDICES Tyco Autosuture: Honorarium, Speaker; Bloomston, Mark Nothing to Disclose Applied Surgical: Honorarium, Speaker Breitenstein, Stefan Nothing to Disclose

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Buechler, Peter Nothing to Disclose Habr-Gama, Angelita Nothing to Disclose Callery, Mark P. (Program Committee, Haier, Joerg (Program Moderator); Stryker Endoscopy: Subcommittee); Nothing to Disclose Honorarium, Advisory Board; Tissue Haneda, Sho Nothing to Disclose Link Medical: Honorarium, Advisory Hassan, Imran Nothing to Disclose Board; U.S. Surgical: Honorarium, Heise, Charles P. (Program Research Support, Advisory Board Subcommittee); Nothing to Disclose Chari, Ravi S. (Program Henderson, J. Michael Nothing to Disclose Subcommittee); Genzyme: Investigator; Hennig, Matthew Nothing to Disclose Novartis: Investigator; CellzDirect: Herbella, Fernando A. Nothing to Disclose Investigator; Zymogenetics: Investigator; Howard, Thomas J. (Program Thermogenesis: Investigator; Medigene: Subcommittee); Nothing to Disclose Investigator Hughes, Steven J. (Program Chen, Herbert Nothing to Disclose Subcommittee); Cephcid: Constultant, Clary, Bryan M. (Program Advisory Board Subcommittee); Nothing to Disclose Jarnagin, William Nothing to Disclose Cohen, Zane Nothing to Disclose Johnson, Erik E. Nothing to Disclose Cowgill, Sarah Nothing to Disclose Jones, Bob (Staff); Nothing to Crookes, Peter F. Nothing to Disclose Disclose Cullen, Joseph J. (Program Jones, Daniel B. (Moderator); Tyco Subcommittee); Nothing to Disclose Autosuture: Instrument Consultant; Curley, Steven A. (Program Committee); Tyco Autosuture: Honorarium, Speaker; Nothing to Disclose USSC: Honorarium, Speaker; Inamed: Delaney, Conor P. Ethicon: Honorarium, Honorarium, Advisory Committee Speaker/Consultant; U.S. Surgical: Joseph, Natalie E. (Program Committee, Honorarium, Speaker/Consultant; Moderator); Nothing to Disclose Adolor: Research Grant, Consultant; Kaplan, Lee M. Nothing to Disclose W.L. Gore: Research Grant, Consultant Kaufman, Howard S. (Program DeOliveira, Michelle Nothing to Disclose Subcommittee, Moderator); U.S. Surgical: DeReuver, Philip Rogier Nothing to Disclose Educational Grant, Consultant; DeRosier, Leo Christopher Nothing to Disclose Medtronic: Research Grant; Genzyme Dozois, Eric J. Nothing to Disclose Biosurgery: Honorarium, Consultant Ellis, Clyde N. Ethicon: Research Kemeny, Nancy Nothing to Disclose Grant, Investigator; Cook Surgical: Larson, David W. Nothing to Disclose Research Grant, Consultant Law, Simon Nothing to Disclose Eloubeidi, Mohamad Nothing to Disclose Law, Wai Lun Nothing to Disclose Emick, Dawn M. Nothing to Disclose Lee, Sukhyung Nothing to Disclose Estrada, Joaquin Nothing to Disclose Lezoche, Emanuele Nothing to Disclose Fagel, Bruce Nothing to Disclose Liau, Siong-Seng Nothing to Disclose Farrell, Timothy M. (Program Lillemoe, Keith D. (Program Committee); Subcommittee); Nothing to Disclose Nothing to Disclose Feagan, Brian Elan: Consultant/ Lo, Chung-Mau Nothing to Disclose Advisory Committee Mahvi, David M. (Program Committee, FernandezDelCastillo, Carlos Nothing to Disclose Moderator); Nothing to Disclose Fischer, Craig Peter Nothing to Disclose Makowiec, Frank Nothing to Disclose Flum, David R. Nothing to Disclose Marcello, Peter W. Applied Medical: Friel, Charles Nothing to Disclose Honorarium, Consultant; Ethicon: Friess, Helmut M. (Program Honorarium, Consultant; Olympus: Subcommittee); Nothing to Disclose Honorarium, Consultant; Valley Labs: Galandiuk, Susan (Program Committee, Honorarium, Consultant Moderator); Convatec: Advisory Board; Marescaux, Jacques Nothing to Disclose Baxter: Investigator Mattar, Samer G. (Program Garcia-Aguilar, Julio Nothing to Disclose Subcommittee); U.S. Surgical: Glatzle, Jorg Nothing to Disclose Honorarium Gould, Jon C. (Program Subcommittee); Nothing to Disclose

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47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

Matthews, Jeffrey B. (Program Schauer, Philip R. Ethicon: Grant Subcommittee, Moderator); Nothing to Support, Investigator; Stryker Disclose Endoscopy: Grant Support, Investigator; McPhee, James T. Nothing to Disclose Invacare: Grant Support, Investigator; Mehta, Samir Nothing to Disclose W.L. Gore: Honorarium, Speaker; Bard: Melton, Genevieve B. Nothing to Disclose Grant Support, Investigator Metcalfe, John C. Nothing to Disclose Scherl, Ellen Nothing to Disclose Michelassi, Fabrizio Nothing to Disclose Schirmer, Bruce D. (Program Committee, Miller, Edith Nothing to Disclose Moderator); Ethicon Endo Surgery: Morgenthal, Craig B. Nothing to Disclose Fellowship, Grant Support, Consultant, Mutch, Matt Applied Medical: Board Honorarium, Lap Course; U.S. Surgical: Schmidt, C. Max (Program Honorarium, Lap Course Subcommittee, Moderator); Pﬁzer: Nakeeb, Attila (Program Committee, Honorarium, Speaker Moderator); Nothing to Disclose Schurr, Paulus G. Nothing to Disclose Nguyen, Ninh T. Nothing to Disclose Selzer, Don Jay Nothing to Disclose Onders, Raymond Synapse Biomedical: Senagore, Anthony J. Ethicon: Advisory Board Board Palaninvelu, Chinnuswamy Nothing to Disclose Smith, C. Daniel (Program Pappas, Theodore N. (Moderator); Nothing Subcommittee); Nothing to Disclose to Disclose Soper, Nathaniel J. (Program Park, James O. Nothing to Disclose Subcommittee, Moderator); Karl Storz Patti, Marco G. (Program Endoscopy: Research Support, Director Subcommittee); Nothing to Disclose of Lab; U.S. Surgical: Research Support, Perugini, Richard Anthony Nothing to Disclose Director of Lab; Power Medical Peters, Jeffrey H. (Program Inc.: Research Support, Director of Lab Subcommittee); Endovx: Consultant Stephens, Robert V. (Moderator); Nothing Pisters, Peter W.T. Novartis Oncology: to Disclose Honorarium, Speaker Stewart, Lygia Nothing to Disclose Ponsky, Jeffrey L. Nothing to Disclose Strasberg, Steven M. Nothing to Disclose Pratt, Wande Nothing to Disclose Strong, Scott A. (Moderator); Nothing Pryor, Aurora D. (Program to Disclose Subcommittee); Barosense: Consultant; Swanstrom, Lee L. Ethicon: Education Autosuture: Honorarium Grant, Researcher; USGI: Research Rafferty, Janice F. (Program Funding, Advisor/Researcher Subcommittee, Moderator); Ethicon: Tanabe, Kenneth K. (Program Honorarium, Consultant Subcommittee, Moderator); Schering Rawnaq, Tamina Nothing to Disclose Speaker’s Bureau: Honorarium, Speaker Read, Thomas Applied Medical: Theriot, K.R. Nothing to Disclose Research Support, Site Private Traverso, L. William (Program Committee, Investigator; Applied Medical: Moderator); Nothing to Disclose Honorarium, Course Faculty/Director; Traverso, William Nothing to Disclose U.S. Surgical: Fellowship Support, Tyler, Douglas S. (Program Program Director, Honorarium, Course Subcommittee, Moderator); Nothing to Faculty Disclose Reid, Kaye Marie Nothing to Disclose Vickers, Selwyn M. (Program Riall, Taylor Sohn Nothing to Disclose Subcommittee); Nothing to Disclose Roberts, Kurt Eric Nothing to Disclose Violette, Aisha Nothing to Disclose Ruzzenente, Andrea Nothing to Disclose Vollmer, Charles M. (Program Salky, Barry A. Nothing to Disclose Subcommittee); Nothing to Disclose Sandborn, William J. Elan: Grant/Research Wachowiak, Robin Nothing to Disclose

Support, Consultant/Advisory Walsh, R. Matthew Nothing to Disclose INDICES Committee Weber, Sharon M. (Program Subcommittee); Nothing to Disclose

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Wexner, Steven D. (Program White, Rebekah Nothing to Disclose Subcommittee); Baxter: Advisory Board; Whiteford, Mark H. (Moderator); Nothing Ethicon Endo Surgery: Consultant; to Disclose Curon Medical: Grants, Research Williams, Valerie A Nothing to Disclose Support; Intuitive Surgical: Stock Winter, Jordan Michael Nothing to Disclose Options Wood, Heather (Staff); Nothing to Whang, Edward E. (Program Committee, Disclose Moderator); Nothing to Disclose Yeo, Charles J. Nothing to Disclose Whelan, Richard L. Lexion: Research Young-Fadok, Tonia M. (Moderator); US Grant; Applied Medical: Research Grant; Surgical: Grant, Fellow; Ethicon: Olympus: Research Grant; NiTi Honorarium, CRFA CD-ROM; Gore: Corporate: Research Grant; Berlex: Honorarium, Speaker Research Grant,

390 SSAT.book Page 391 Friday, April 21, 2006 12:58 PM

47TH ANNUAL MEETING • MAY 20-24, 2006 • LOS ANGELES, CA

NOTES

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Los Angeles Convention Center Overview

392

SSAT_inside_bak_cov.fm Page 1 Thursday, April 20, 2006 5:06 PM

FUTURE SSAT MEETINGS

2007 May 19 – 23, Washington, DC

2008 May 17 – 21, San Diego, CA

2009 May 30 – June 3, 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 Saturday, May 20, 2006 8:00 AM - 2:45 PM Residents & Fellows Research Conference Schedule-at-a-Glance Sheraton Los Angeles Downtown Santa Monica Room Sunday, May 21, 2006 8:00 AM - 5:45 PM Postgraduate Course 403 AB Surgical Disorders of the Gastrointestinal Tract: Optimizing Outcomes with Multidisciplinary Management Monday, May 22, 2006 8:00 AM - 8:15 AM SSAT Opening Session 403 A 8:15 AM - 9:15 AM Presidential Plenary Session 403 A 9:15 AM - 10:00 AM Presidential Address 403 A Who’s Going to Do My Operation? Expectations for the Next Generation of Surgeons 10:30 AM - 11:15 AM SSAT PLENARY SESSION 403 A 11:15 AM - 12:00 PM GUEST ORATION 403 A Present and Future Advances in Surgical Technologies and Surgical Education 12:00 PM - 2:00 PM SSAT POSTER SESSION West Hall A 12:30 PM - 1:45 PM Meet-the-Professor LUNCHEONS Obesity Surgery: Which Procedure Is Best? Wilshire Grand L.A. Balboa Room The Role of HAI vs. Systemic Chemotherapy After Liver Resection for CRC 309 Surgical Management of Non-Colorectal Liver Mets Wilshire Grand L.A. Glenwood Room 2:15 PM - 3:45 PM DDW Combined Clinical Symposia Cystic Tumors of the Pancreas (AGA, ASGE, SSAT) Concourse Hall 151 Treatment of Hemorrhoids and Fissures (ASGE, SSAT, AGA) Concourse Hall 152 2:15 PM - 5:00 PM SSAT PLENARY SESSION 402 A 2:15 PM - 5:30 PM SSAT/AGA/ASGE State-of-the-Art Conference 403 A Management of Diverticular Disease 4:00 PM - 5:30 PM ddw COMBINED CLINICAL SYMPOSIUM Controversies in the Treatment of Rectal Cancer (SSAT, ASGE, AGA) Concourse Hall 151 Tuesday, May 23, 2006 7:30 AM - 9:00 AM SSAT VIDEO BREAKFAST SESSION 403 A 8:30 AM - 10:00 AM SSAT PUBLIC POLICY COMMITTEE PANEL 402 A A Medical Malpractice Primer: Adverse Events — What You Need to Know and Do 8:30 AM - 10:00 AM SSAT/AHPBA Joint Symposium 402 B Advanced Surgical Therapy for Pancreatic Cancer 10:00 AM - 10:30 AM ISDS Lecture 403 A Liver Transplantation in Asia—Beyond the Titanic 10:30 AM - 11:15 AM SSAT PLENARY SESSION 403 A 11:15 AM - 12:00 PM STATE-OF-THE-ART LECTURE 403 A Back to the Future: New Directions in Surgical Education 12:30 PM - 1:45 PM Meet-the-Professor LUNCHEONS Medical vs. Surgical Management of Ulcerative Colitis 410 Minimally Invasive Pancreatic Surgery Wilshire Grand L.A. Verdugo Room Multidisciplinary Management of Biliary Leaks/Injuries Wilshire Grand L.A. Chandler Room Preoperative Decision Making in the Difficult Patient with Pancreatic Cancer 405 Surgical Management of GI Neuroendocrine Tumors Wilshire Grand L.A. Sawtelle Room Treatment of Villous Adenocarcinoma Endoscopy vs. Local Resect vs. Whipple wilshire Grand L.A. Balboa Room 2:15 PM - 3:30 PM SSAT PLENARY SESSION 402 A 2:15 PM - 3:45 PM ddw COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 Evidence-Based Management of Obesity Surgery and Its Complications (SSAT, ASGE, AGA) 3:30 PM - 4:30 PM SSAT Posters of Distinction Quick Shots 402 A 3:30 PM - 5:00 PM SSAT/ASCRS Joint Symposium 403 A Minimally Invasive Approaches to Rectal Disease 4:00 PM - 5:30 PM DDW Combined Clinical Symposia Surgery in the Cirrhotic Patient (AASLD, SSAT) Concourse Hall 151 2:00 AM Call: Management of GI Emergencies (ASGE, AGA, SSAT) Concourse Hall 152 5:00 PM - 6:00 PM SSAT Business Meeting 403 A 7:00 PM - 9:00 PM SSAT Members Reception Natural History Museum of Los Angeles County Wednesday, May 24, 2006 8:30 AM - 10:00 AM SSAT PLENARY SESSION 403 A 8:30 AM - 10:00 AM SSAT Education Committee Panel 402 A Bariatric Surgery Training: Getting Your Ticket Punched 10:30 AM - 12:00 PM ddw COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 Care of the Liver Transplant Patient in a Non-Transplant Center (AGA, AASLD, SSAT) 10:30 AM - 12:00 PM SSAT PLENARY SESSION 403 A 12:00 PM - 3:00 PM SSAT/SAGES JOINT SYMPOSIUM 403 A Controversies in Minimally Invasive Colorectal Surgery 12:30 PM - 1:45 PM Meet-the-Professor LUNCHEONS Management of GI Stromal Tumors 407 Management of Necrotizing Pancreatitis Wilshire Grand L.A. Fernwood Room 2:15 PM - 3:45 PM ddw COMBINED CLINICAL SYMPOSIUM Concourse Hall 151 The Right Therapy at the Right Time: Evidence-Based Management Options for Crohn’s Disease (SSAT, AGA) All rooms at the Los Angeles Convention Center unless otherwise indicated.