53Rd Annual Meeting

THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 53rd Annual Meeting

May 18-22, 2012 San Diego Convention Center San Diego, California

Program Book Abstract Supplement Table of Contents

Schedule-at-a-Glance ...... 2

Sunday Plenary and Video Session Abstracts ...... 4

Monday Plenary and Video Session Abstracts ...... 17

Tuesday Plenary, Video, and Quick Shot Session Abstracts ...... 51

Sunday Poster Session Abstracts ...... 61

Monday Poster Session Abstracts ...... 110

Tuesday Poster Session Abstracts ...... 158 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

PROGRAM BOOK ABSTRACT SUPPLEMENT

FIFTY-THIRD ANNUAL MEETING San Diego Convention Center San Diego, California May 18–22, 2012 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Schedule-at-a-Glance

FRI, MAY 18, 2012 SATURDAY, MAY 19, 2012 SUNDAY, MAY 20, 2012 Exhibit 28ab 28abcdOther 26ab 27b 28ab 28cd Other Hall 7:00 AM 7:15 AM 7:30 AM 7:45 AM OPENING SESSION 8:00 AM 8:15 AM PRESIDENTIAL 8:30 AM PLENARY A 8:45 AM (PLENARY SESSION I) 9:00 AM 9:15 AM PRESIDENTIAL

9:30 AM DDW CCS: ADDRESS Mgt of Pt @ High @ of Pt Mgt

9:45 AM Colon CA Risk for 10:00 AM 10:15 AM 10:30 AM PRESIDENTIAL 10:45 AM PLENARY B 11:00 AM (PLENARY SESSION II)

11:15 AM CA (by invitation only) STATE-OF-THE-ART w/Obesity DDW CTS: DDW CTS: DDW CCS: DDW CCS: DDW CCS: DDW CCS: GI Mgt of Pt

11:30 AM in Probiotics

Tx of Early GI LECTURE

11:45 AM Disease & Health 12:00 PM 12:15 PM 12:30 PM 12:45 PM

1:00 PM RESIDENTS & FELLOWS RESEARCH CONFERENCE 1:15 PM MEET-THE- PROFESSOR 1:30 PM LUNCHEONS 1:45 PM 2:00 PM 2:15 PM MAINTENANCE OF CERTIFICATION COURSE: 2:30 PM 2:45 PM

3:00 PM Evidence Based Treatment of Hepatopancreatobiliary Diseases GI SURGERY 3:15 PM DDW CCS: Mgt of Fecal Incontinence Colitis; Pancreatic Cystic Neoplasms DEBATES A: C Diff POSTER SESSION I (authors available @ posters 12:00 PM - 2:00 PM)

3:30 PM CONTROVERSIES IN 3:45 PM CONFERENCE: 4:00 PM VIDEO SESSION I: Robotic, Endoscopic, & & Endoscopic, Robotic, Adv. Laparoscopic GI Sx Laparoscopic GI Adv.

4:15 PM STATE-OF-THE-ART Colon and Rectal Cancer the Surgical Treatment of PLENARY SESSION III 4:30 PM Technological Advances in WARD WARD Duct Stone CLINICAL Difficult Bile Bile Difficult 4:45 PM I: ROUNDS 5:00 PM 5:15 PM 5:30 PM 5:45 PM

2 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Schedule-at-a-Glance

MONDAY, MAY 21, 2012 TUESDAY, MAY 22, 2012 Exhibit Exhibit 26ab 27b 28ab 28cd Other 27b 28ab 28cd Other Hall Hall 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM Outcomes 8:30 AM g B'FAST

8:45 AM THE MOVIES BREAKFAST AT PLENARY SYMPOSIUM: VIDEO SESSION II:

9:00 AM SESSION VI WARD WARD SSAT/ISDS JOINT CLINICAL ROUNDS I: I: ROUNDS Diverticulitis 9:15 AM Optimizin PANEL DDW CCS: DDW CCS: 9:30 AM Mgt of HCC & ADVOCACY

9:45 AM PUBLIC POLICY 10:00 AM

10:15 AM JOINT Neoplasms 10:30 AM Benign Liver SSAT/AHPBA SYMPOSIUM: HPB & VIDEO Foregut QUICK

10:45 AM SHOTS PLENARY SESSION I SESSION IV 11:00 AM SESSION III:

11:15 AM Curve QUALITY GUEST Can You Eliminate Barrett's? Esophagus DDW CCS: DDW CCS: OUTCOMES 11:30 AM DDW CCS:

ORATION PLENARY SESSION VII HEALTH CARE & Disorders of the the Disorders of

11:45 AM PANEL: GI Sx Cost 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM MEET-THE- MEET-THE- PROFESSOR PROFESSOR 1:30 PM LUNCHEONS LUNCHEONS 1:45 PM

2:00 PM Foregut Motility

2:15 PM SSAT/SAGES JOINT

2:30 PM LUNCHEON SYMPOSIUM: 2:45 PM II QUICK SHOTS SESSION 3:00 PM GERD Biliary Crohn's GI SURGERY DDW CCS: DDW CCS: 3:15 PM Endoscopic Complications PLENARY of Complicated Complicated of DDW CCS: Mgt Mgt DDW CCS: DEBATES B: Band / POSTER SESSION II (authors available @ posters 12:00 PM - 2:00 PM) SESSION V Morbid Obesity; 360 v POSTER SESSION III (authors available @ posters 12:00 PM - 2:00 PM) BEST OF DDW CONTROVERSIES IN 3:30 PM Partial Fundoplication / 3:45 PM 4:00 PM JOINT JOINT 4:15 PM SSAT/ASCRS SYMPOSIUM: III

4:30 PM Ulcerative Colitis GI Sx & WARD WARD QUICK SHOTS Endoscopy CLINICAL SESSION

4:45 PM ROUNDS III:

5:00 PM CCS: DDW Pancreatic Cystic 5:15 PM Neoplasms & IPMN 5:30 PM ANNUAL ANNUAL MEETING

5:45 PM BUSINESS

3 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

SSAT PLENARY, VIDEO, AND QUICK SHOT ABSTRACTS Printed as submitted by the authors. indicates a paper that is also being presented at the Residents & Fellows Research Conference. Participation in and attendance at this conference is by invitation only. indicates a video presentation scheduled during a Plenary Session. Sunday, May 20, 2012

8:15 AM – 9:15 AM 28ab PRESIDENTIAL PLENARY A (PLENARY SESSION I)

287 provided an additional six million patient visits. Texas hospitals have saved $100 million /year which has allowed Texas Tort Reform Increased Access to Health Care them to deliver more charity care ($500 million/year), Ronald M. Stewart1, Lisa Rocheleau2, Kenneth Sirinek1 expand patient safety programs (58%), subsidize short- 1. Surgery, UTHSCSA, San Antonio, TX; 2. Boone & Rocheleau, falls in government programs such as Medicaid (46%), San Antonio, TX raise salaries for nurses and increase nurse staffi ng (46%), Prior reports have confi rmed that comprehensive tort and maintain, improve or add new equipment (39%). In reform in Texas (2003) has resulted in fewer malpractice conclusion, medical liability reform enacted by the Texas claims and lawsuits against physicians and a reduction in Legislature in 2003, has afforded Texans an increased abil- the cost of both insurance premiums and the associated ity to access health care and would appear to be an ideal litigation fees. We hypothesize that Texas medical liability tort reform template for adoption by the other 49 states. reforms have achieved the Legislature’s intent of improving 288 statewide access to critical health care services. The positive impact on physician manpower has been monumental Enhancement of the Small Bowel Obstruction Model with 21,000+ new medical licenses issued since tort reform with the Use of the Gastrografi n Challenge Test (62% for past 3 years compared to the 3 years pre-tort Naeem Goussous, Patrick W. Eiken, Micheal P.P.Bannon, reform). The number of new licenses issued by the Texas Martin D. Zielinski Medical Board in 2008 was 3,600 (a record high) compared Mayo Clinic, Rochester, MN to 2000 for the year 2001 (lowest for the preceding 10 BACKGROUND: years). Eight in ten Texas hospitals have reported that it Based on previous published data on is now easier to recruit medical specialists in the wake of small bowel obstruction (SBO) management, a three fea- tort reform. Since 2003, 218 new obstetricians have come ture model has been adopted in our institution predict- to Texas with 27% practicing in medically underserved ing the need for exploration. Obstipation combined with areas and all 254 counties now have at least one obste- mesenteric edema and lack of the small bowel feces sign trician. Similar increases have occurred in neurosurgery, on computed tomography (CT) were associated with the emergency medicine, cardiology, cardiovascular surgery, need for exploration. Patients with 2 or less features were orthopedic surgery, pediatrics, and geriatrics. Eleven coun- managed non-operatively and administered a Gastrografi n ties have their fi rst general surgeon and 24 counties have (GG) challenge. added at least one general surgeon. The Rio Grande Valley, HYPOTHESIS: We hypothesize that the (GG) challenge a former hotbed of medical malpractice claims, has seen an test, when used in combination with the predictive model, infl ux of 220 physicians. Although impossible to document will decrease the rate of explorations in patients not meet- except from medical society hearsay, there has been a posi- ing the criteria for immediate operation. tive manpower impact from the physicians who reversed METHODS: IRB approval was obtained to review patients their decision to retire as a result of tort reform implemen- admitted with SBO from November 2010 to September tation. The Texas Medical Association has estimated that 2011. Presenting with signs of strangulation or all three fea- this additional physician manpower since tort reform has

4 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

tures, and those who had an abdominal operation within 6 weeks of admission were excluded. All patients had an 290 abdominal/pelvic CT scan and GG challenge upon diagno- Abstracts Time-Trends and Disparities in Lymphadenectomy Sunday sis. GG patients were compared to historic controls man- for Gastrointestinal Cancer in the United States: A aged without the GG (July to December 2009). Successful GG challenge was considered as the presence of contrast in Population-Based Analysis of 342,792 Patients 1 1 1 the colon after an 8 hour plain abdominal fi lm or a bowel Attila Dubecz , Michael Schweigert , Rudolf J. Stadlhuber , motion. Data is presented as medians or percentages. Sig- Norbert Solymosi2, Jeffrey H. Peters3, Hubert J. Stein1 nifi cance was considered at p < 0.05. 1. Surgery, Klinikum Nurnberg, Nurnberg, Germany; RESULTS: One hundred and thirty three patients with a 2. Veterinary Medicine, Szent István University, Budapest, diagnosis of SBO were identifi ed (47% male) with 54 receiv- Hungary; 3. Division of Thoracic and Foregut Surgery, Department ing GG (study) and 79 historic control patients. There was of Surgery, University of Rochester School of Medicine and no difference in age (71 vs 65 years), prior SBO (52% vs Dentistry, Rochester, NY 47%), diabetes mellitus (20% vs 18%), history of malignancy BACKGROUND: The value of lymphadenectomy in most (35% vs 41%) or cardiac disease (29% vs 37%). Both groups localized gastrointestinal (GI) malignancies is well estab- had similar number of previous abdominal operations (2 lished. Our objective was to evaluate the time-trends of vs 2). The presence of mesenteric edema (67% vs 76%), the lymphadenectomy in GI cancer and identify factors associ- lack of small bowel feces sign (50% vs 48%) and obstipa- ated with inadequate lymphadenectomy in a large population (24% vs 22%) were similar in both groups. Patients in tion-based sample. the GG group had a lower rate of abdominal exploration METHODS: (26% vs 43% p = 0.044) and fewer complications (11% vs Using the National Cancer Institute’s Sur- 33% p = 0.004) compared to the control group. There was veillance Epidemiology and End Results-Database (1998– an equivalent number of strangulation obstructions (4% vs 2008), a total of 342,792 patients with surgically treated 10%), bowel perforation (4% vs 4%), length of hospital stay GI malignancy(esophagus: 13,471; stomach: 21,094; small (4 vs 7 days), days from admission to operation (5 vs 3) and bowel: 10,588; colon: 243,982; rectum: 41,683; pancreas: mortality (9% vs 6%). 46 patients had a successful GG chal- 11,974) were identifi ed. Adequate lymphadenectomy lenge with 8 failures. There was a higher rate of exploration was defi ned based on review of pusblished data and was in patients with a failed challenge compared to those who defi ned as: 23 esophagus, 15 stomach, 12 small bowel, 12 passed (88% vs 15%, p < 0.001). colon, 12 rectum and 12 pancreas. The median number of lymph nodes removed and prevalence of adequate and/or CONCLUSION: The use of the GG challenge enhanced the no lymphadenectomy for each cancer type were assessed SBO prediction model by decreasing the need for explo- and trended over the 10 study years. Multivariate logistic ration in patients not meeting the criteria for immediate regression was employed to identify factors predicting ade- operation. Patients who failed the GG challenge test were quate lymphadenectomy. much more likely to undergo exploration. RESULTS: The median number of excised nodes improved over the decade of study in all types of cancer; esophagus: 289 from 7–13, stomach 9–12, small bowel 3–6, colon 9–15, Laparoscopic Total Gastrectomy with Multi-Organ rectum 8–13 and pancreas 7–11. Further the percentage Resection for Large Gastric Cancer of patients with an adequate lymphadenectomy (median Amanda K. Arrington, Marjun Philip N. Duldulao, 42.3% for all types) steadily increased and those with zero nodes removed (median 7.1% for all types) steadily Alessio Pigazzi, Joseph Kim decreased in all types of cancer, although both remained Surgical Oncology, City of Hope National Medical Center, Duarte, CA far from ideal. By 2008, the percentage of patients with ade- Despite the wide acceptance of laparoscopic surgical tech- quate lymphadenectomy was 16.4% for esophagus, 37.4% niques, its use for higher staged gastric cancer has been lim- for stomach, 31.4% for small intestine, 72.7% for colon, ited. Laparoscopic total gastrectomy poses many complex 58.2% for rectum and 49.9% for pancreas. Men, non-white challenges, in particular the construction of the esophago- race, patients >65 yrs, or those undergoing surgical therapy jejunal anastomosis. This video shows the resection of a earlier in the study period and living in areas with high large gastric cancer in an otherwise healthy 53 yo male that poverty rates were signifi cantly less likely to receive ade- required total gastrectomy, distal pancreatectomy, splenec- quate lymphadenectomy (all p < .0001). tomy, and transverse colectomy. Thus multi-organ resec- CONCLUSIONS: Lymph node retrieval during surgery tion and total gastrectomy, including the construction of for GI cancer remains inadequate in a large proportion of an esophagojejunal anastomosis, can safely and effi ciently patients in the United States although the median number be performed laparoscopically. of resected nodes increased over the last ten years. Gender, socioeconomic and racial disparities in receiving adequate lymphadenectomy were observed.

5 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

10:30 AM – 11:15 AM 28ab PRESIDENTIAL PLENARY B (PLENARY SESSION II)

372 ment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed Hiatal Hernia, Barrett’s Esophagus and Long-Term by univariate analysis and by using Cox’s multiple hazards Symptom Control After Laparoscopic Fundoplication regression. for Gastresophageal Refl ux RESULTS: 1,2 2 3 According to Kaplan-Meier estimates the rate Joumanah Hafez , Johannes Lenglinger , Friedrich Wrba , of refl ux symptom recurrence was 15% after 108 months, 4 2 2 Marcus Hudec , Christiane Wischin , Johannes Miholic 11% in cases without intestinal metaplasia, but 43% in 1. Department of ENT, Martin Luther University Halle, Medical patients with long-segment (33 cm) Barrett’s esophagus Faculty, Halle/Saale, Germany; 2. Department of Surgery, Medical (BE; p < 0.0001). Refl ux symptoms recurred in 22% of cases University Vienna, Vienna, Austria; 3. Department of Pathology, with a hiatal hernia (HH) 33 cm before operation, but only Medical University Vienna, Vienna, Austria; 4. Department of in 7% with smaller or absent HH (p = 0.005). Multivari- Scientifi c Computing, University of Vienna, Vienna, Austria ate analysis revealed a relative risk of 6.6 (CI 3.0) for long- OBJECTIVE: segment BE and of 3.0 (CI 1.7) for HH 33 cm. A strong To determine the long-term symptom con- statistical interaction was found between HH 33 cm and trol after laparoscopic fundoplication for gastroesophageal long-segment BE: the small group (n = 18) of cases exhib- refl ux disease (GERD), and possible prognostic factors. iting both risk factors revealed an exaggerated recurrence DESIGN, SETTING AND PATIENTS: A cohort of 271 rate of 72% at 108 months. patients, operated at a university hospital from 1996 CONCLUSIONS: Laparoscopic fundoplication for symp- through 2002, was eligible for evaluation after a median tomatic GERD provided a long-lasting abolition of refl ux interval of 102 months (range, 12 to 158). symptoms in 231 of 271 (85%) patients. HH 33 cm and MAIN OUTCOME MEASURES: The time between opera- long-segment BE materialized as independent prognostic tion and recurrence of refl ux symptoms (i.e. time to treat- factors favoring recurrence.

Univariate Analysis of Putative Risk Factors for Symptom Recurrence

Variable n % Recurrence After 36 Months % Recurrence After 108 Months p-Value (Log-Rank Test) All patients 271 7% 15% Mode of fundoplication 0.49 Total (Nissen) n = 197 7% 16% Partial (Toupet) n = 74 7% 14% Intestinal metaplasia <0.001 Absent n = 199 3% 11% Short segment BE n = 43 12% 16% Long segment BE n = 29 28% 43% DeMeester’s score <50 n = 209 5% 10% 0.001 ≥50 n = 62 15% 28% Hiatal hernia <3 cm n = 93 5% 7% 0.005 >3 cm n = 153 10% 22% Contraction amplitudes <62 mmHg n = 131 10% 19% 0.07 >62 n = 138 6% 12% Gender, age, LES pressure and operation time period were not signiﬁ cant.

6 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Multivariate Analysis (Cox’s Multiple Hazards Model) of Prognostic loss was $8,370. Outpatient ventral hernia repairs with and Factors for Time to Symptom Recurrence without synthetic mesh resulted in median net losses of

$1,560 and $230, respectively. Abstracts Sunday Variable Risk Ratio Lower CL Upper CL p-Value CONCLUSIONS: Ventral hernia repair is associated with overall fi nancial losses. Inpatient synthetic mesh repairs are ≥ 3.8 1.7 10.2 <0.001 HH 3 cm essentially budget neutral. Outpatient repairs and inpatient BE ≥ 3 cm 6.6 3.1 13.5 <0.001 repairs without mesh result in net fi nancial losses. Inpa- tient biologic mesh repairs result in a negative contribu- Nissen vs. 1.0 0.7 1.5 0.91 tion margin and striking net fi nancial losses. Cost-effective Toupet strategies for managing ventral hernias in a tertiary care Propensity 0.97 0.6 1.2 0.85 environment need to be developed in light of the fi nancial score implications of this patient population.

373 374 Financial Implications of Ventral Hernia Repair at an Impact of MRSA Nasal Colonization on Surgical Site Academic Institution Infections Following Major Gastrointestinal Surgery Drew Reynolds, Daniel L. Davenport, Ryan L. Korosec, Harry T. Papaconstantinou, Marcela Ramirez, Michelle J. Scott Roth Marchessault, Cara Govednik-Horny, Daniel Jupiter Department of Surgery, University of Kentucky, Lexington, KY Surgery, Scott & White Memorial Hospital, Temple, TX INTRODUCTION: Complicated ventral hernias are often PURPOSE: The prevalence of methicillin-resistant Staphy- referred to tertiary care centers. Hospital costs associated lococcus aureus (MRSA) colonization is increasing, and with complex hernia repairs include direct costs (mesh is an important pathogen in surgical site infections (SSI). materials, supplies, non-surgeon labor costs), and indirect Nasal-swab testing is effective for identifying patients with costs (facility fees, equipment depreciation, and unallo- MRSA colonization, and has been shown to be predictive cated labor). Operative supplies including mesh represent of SSI in cardiac and orthopedic surgery cases. However, a signifi cant component of direct costs, especially in an era the role of MRSA colonization on SSI following major gas- of proprietary synthetic meshes and biologic grafts. We aim trointestinal (GI) surgery is not known. The purpose of this to evaluate the cost-effectiveness of complex abdominal study is to determine if MRSA colonization affects SSI after wall hernia repair at a tertiary care referral facility. major GI surgery. METHODS: Cost data on all consecutive open ventral her- METHODS: In 12/2007, we began universal nasal swab nia repairs (CPT Codes 49560, 49561, 49565, and 49566) testing for MRSA colonization within 24 hrs of admission. performed between July 1, 2008 and May 31, 2011 were MRSA-colonized patients were placed on contact precau- analyzed. Cases were analyzed based upon hospital status tions and isolated. We retrospectively reviewed the charts (inpatient vs. outpatient) and whether the hernia repair of all patients undergoing major GI surgery (esophagus, was a primary or secondary procedure. We examined stomach, hepatobiliary, pancreatic, duodenum, small median net revenue, direct costs, contribution margin, bowel, colon and rectum) from 12/2007 to 8/2009. Patients indirect costs, and net profi t/loss. Among primary hernia were grouped according to nasal swab test results as MRSA- repairs, cost data was further analyzed based upon mesh colonized (MRSA+), methicillin-sensitive Staphylococcus utilization (no mesh, synthetic, or biologic). aureus-colonized (MSSA+) or not colonized (Negative). RESULTS: 415 patients underwent ventral hernia repair Data analyzed included demographics, incidence of SSI, (353 inpatient, 62 outpatient). 173 patients underwent organisms cultured from the wound, length of hospital ventral hernia repair as the primary procedure. 180 stay (LOS) and mortality. patients underwent hernia repair as a secondary proce- RESULTS: A total of 1137 patients were identifi ed and dure. Median net revenue ($17,310 vs. $10,360, p < 0.01) grouped according to nasal swab results; 897 (78.9%) Nega- and net losses (3,430 vs. 1,700, p < 0.01) were signifi cantly tive, 167 (14.7%) MSSA+, and 73 (6.4%) MRSA+. The mean greater for those who underwent hernia repair as a second- age was 59.5 years, 44.5% were men, 47.9% had colon or ary procedure. Among primary ventral hernia repairs, 46 rectal operations, and 9% were emergent operations. There were repaired without mesh; 79 were repaired with syn- with no signifi cant difference between groups. There were thetic mesh and 48 with biologic mesh. Median direct costs 101 patients identifi ed with SSI (8.9%), and the MRSA+ for cases performed without mesh were $5,432; median group was associated with a higher rate of SSI when com- direct costs for those using synthetic and biologic mesh pared to Negative and MSSA+ groups (13.7% vs. 9.4% vs. were $7,590 and $16,970, respectively (p < .01). Median 4.2%; p < 0.05). Wound culture results were identifi ed in net losses for repairs without mesh were $500. Median 92 (91.1%) patients with SSI. When SSI was present the net profi t of $60 was observed for synthetic mesh based MRSA+ group had a signifi cantly higher rate of MRSA repairs. The median contribution margin for cases utilizing positive wound cultures when compared to non-MRSA biologic mesh was –$4,560 and the median net fi nancial colonized patients (70% [7/10] vs. 8.5% [7/82]; p < 0.0001).

7 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

The mean LOS was 12.5 days for MRSA+ group, and was 4 CONCLUSIONS: Our data suggest that MRSA nasal colo- days longer than Negative and MSSA+ groups (8.8 and 7.6 nization is associated with a longer LOS and an increase in days, respectively; p < 0.001). Although the presence of SSI incidence of SSI in patients undergoing major GI surgery. signifi cantly increased LOS from 6.2 days to 15.7 days (p Furthermore, when SSI occurred, MRSA nasal colonization <0.001), there was no difference in LOS for patients with was strongly predictive of MRSA-associated SSI. Preopera- SSI between nasal swab groups (p = 9.2). Overall mortal- tive nasal swab test with decolonization of MRSA+ patients ity was 4.0% (45/1137) and deaths were evenly distributed may decrease LOS and reduce the incidence of MRSA-asso- between nasal-swab groups. ciated SSI after major GI surgery. A cost benefi t analysis is required. 2:15 PM – 4:30 PM 26ab VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND ADVANCED LAPAROSCOPIC GI SURGERY

519 521 Robotic Assisted Excision of Pelvic Neurofi broma Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Celeste Y. Kang, Alessio Pigazzi Gastrectomy (SADI-S): A Simplifi ed Duodenal Switch Surgery, University of California Irvine School of Medicine, Irvine, CA with Metabolic Orientation A 55 year old male with a recent history of left renal cell Andrés Sánchez-Pernaute, Miguel Angel Rubio Herrera, carcinoma underwent laparoscopic partial nephrectomy. Elia Pérez-Aguirre, Pablo Talavera, Antonio J. Torres During the work up, a 3 cm pelvic mass was also found. A Surgery, Hospital Clínico San Carlos, Madrid, Madrid, Spain robotic assisted excision of the pelvic mass was performed. Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gas- The rectum was mobilized by entering the presacral plane trectomy (SADI-S is a simplifi ed duodenal switch in which between the mesorectum and the presacral fascia. The dis- a loop duodeno-ileostomy is performed instead of the clas- section was carried down distally to the level of the pelvic sical Roux-en-Y diversion. The preservation of the pylorus fl oor until a cystic mass was noted. The mass was care- makes unnecessary the bile diversion. The operation is fully dissected out using monopolar and bipolar cautery simpler, shorter and has the advantage of less number of until the mass was excised in its entirety. Final pathology anastomosis and no mesenteric opening. SADI-S has been revealed a benign neurofi broma. This video emphasizes the performed in our Department since May-2007 over more technique, feasibility and safety of this procedure. than 100 patients. The mean long-term excess weight is around 100%, with only 1% of failures and 3% cases of 520 recurrent hypoproteinemia. Long remission of diabetes is Single Incision Laparoscopic Right Hemicolectomy obtained in more than 90% of the cases. with Intracorporeal Anastomosis 522 Celeste Y. Kang, Steven Mills, Alessio Pigazzi Surgery, University of California Irvine, Orange, CA Robotic-Assisted Esophageal Epiphrenic Diverticulectomy, A 69 year old female with a tubular adenoma near the Myotomy and Dor Hemi-Fundoplication hepatic fl exure undergoes a single incision laparoscopic Daniel K. Tong, Simon Law, Fion S. Chan right hemicolectomy. Using a 3 cm periumbilical incision Surgery, The University of Hong Kong, Hong Kong, Hong Kong and a single access port is inserted. The colon is mobilized A 57-year-old woman presented with intermittent dyspha- in a medial to lateral fashion. The ileocolic pedicle and the gia and occasional regurgitation for 6 months. Pre-inter- right branch of the middle colic artery are divided. The vention investigations included contrast upper GI study, bowel is divided proximally and distally. The specimen is endoscopy and manometry that showed a 4 cm epiphrenic removed though the single port with no need to lengthen diverticulum located at the lower esophagus facing the the incision. A 60 mm linear stapler is used to create a side right side. Manometry revealed an increased lower esopha- to side anastomosis. The enterotomy is closed intracorpore- geal sphincter resting pressure. Diverticulectomy, myot- ally in two layers. This video emphasizes the feasibility of omy and Dor hemi-fundoplication was performed using intracorporeal anastomosis during single access colectomy. Robotic-assistance. The operative steps included isolation of the diverticulum with sparing of the vagi, diverticulectomy by using a linear stapler, anterior myotomy and a Dor 180 degree anterior hemi-fundoplication.

8 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

523 common bile duct. Follow up after endoscopic ampullectomy demonstrated recurrence of the lesion. The adenoma

Laparoscopic Reversal of Roux-en-Y Gastric Bypass to was then resected using a robotic-assisted transduodenal Abstracts Sunday Treat Recalcitrant Hyperinsulinemic Hypoglycemia approach with bile and pancreatic duct reconstruction. Jacob A. Greenberg1, Dawn B. Davis2, Haggi Mazeh1, This case demonstrates the ability to establish precise Guilherme M. Campos1 excisional margins and to remove lesions that cannot be 1. Surgery, University of Wisconsin School of Medicine and Public resected endoscopically via the use of robotic assistance. Health, Madison, WI; 2. Medicine, University of Wisconsin School This method demonstrates an alternative option to avoid of Medicine and Public Health, Madison, WI the morbidity associated with pancreaticoduodenectomy for benign lesions. The video presents technical steps for Laparoscopic Reversal of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy, and results of pre and post-op metabolic testing. The 526 patient underwent RYGB at another institution (BMI 46). Per-Oral Endoscopic Myotomy (POEM): Techniques for Two years after RYGB (BMI 25), presented with recalcitrant Successful Submucosal Dissection hyperinsulinemic hypoglycemia episodes and hypoglyce- Eric M. Pauli, Jeffrey M. Marks, Jeffrey L. Ponsky mia unawareness. A laparoscopic gastrostomy was placed Surgery, University Hospitals Case Medical Center, Cleveland, OH in the excluded stomach. A meal test (MT) administered orally and through the gastrostomy showed altered insulin Recently, a new endoscopic method for reducing lower and glycemic responses through the RYGB. Laparoscopic esophageal sphincter pressure in achalasia patients, per-oral reversal was performed. Patient symptoms subsided; and endoscopic myotomy (POEM), has been developed. The 6 months later (BMI 29), a MT showed normal insulin and most diffi cult part of POEM is the submucosal dissection, glycemic profi les. which spatially separates the mucosa and the musculature and provides an intact tissue plane for secure esophageal 524 closure. The purpose of this video is to review six technical pearls identifi ed over our series of POEM patients that Transanal NOTES Sigmoidectomy in a Cadaver Model permit successful, reproducible creation of the submucosal Ezra N. Teitelbaum, Fahd O. Arafat, Byron F. Santos, tunnel. Eric S. Hungness, Anne M. Boller Surgery, Northwestern, Chicago, IL 527 This video shows a transanal hybrid natural orifi ce trans- Thoracoscopic Esophageal Leiomyoma Enucleation luminal endoscopic surgery (NOTES) sigmoidectomy per- Jason Richardson, Ninh T. Nguyen formed in a cadaver model using a TEM proctoscope. We Surgery, University of California Irvine Medical Center, Orange, CA employ a combined laparoscopic and endoscopic technique to place a stapler anvil in the proximal colon prior to This is a video presentation of a patient who was inciden- initiation of colon dissection. This allows for a completely tally found to have an esophageal mass. EUS revealed a × intra-corporeal anastomosis to be performed without the 25 14 mm hypoechoic submucosal lesion at 28–30 cm need for colon exteriorization. Techniques for occluding arising from the muscularis propria with normal overly- the rectal lumen with a purse-string suture, performing a ing mucosa and no obvious nodal involvement. FNA dem- full thickness dissection at the rectosigmoid junction, and onstrated spindle cells. A thoracoscopic enucleation was creating a colorectal anastomosis through the TEM procto- performed and is featured in this video. Final path was scope are also shown. consistent with leiomyoma. Port positioning, endoscopy, esophageal mobilization, mass enucleation, and muscular 525 layer reapproximation are featured in this video. Robotic-Assisted Transduodenal Resection of Ampullary Tumor with Bile and Pancreatic Duct Reconstruction

John Prodromo1, Mehmet F. Can3, Jennifer R. Bonfi li3, Dev Patel1, Herbert Zeh1,2, A. James Moser1,2 1. University of Pittsburgh School of Medicine, Pittsburgh, PA; 2. Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 3. University of Pittsburgh Medical Center, Pittsburgh, PA A 75 year old woman presented with recurrent pancreatitis and endoscopic evidence of a duodenal papillary mass that did not show high grade dysplasia extending up the

9 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

2:15 PM – 5:00 PM 27b PLENARY SESSION III

CONCLUSION: IOC remains a frequently used procedure. 528 In a national study, most surgeons appear to be using IOC Is Routine Intraoperative Cholangiogram Necessary in selectively. A 10% minority of surgeons appear to approach the 21st Century? A National View IOC as mandatory. Intriguingly, a surgeon’s routine use of 1 1 1 IOC is correlated with increased rates of post-surgical pro- Elizaveta Ragulin-Coyne , Elan R. Witkowski , Zeling Chau , Sing cedures, and is associated with increased overall compli- 1 1 2 Chau Ng , Heena P. Santry , Mark P. Callery , cations, with no additional decrease in CBD injury rate. Shimul A. Shah1, Jennifer F. Tseng1,2 Further studies are warranted to determine if additional 1. Surgical Outcomes Analysis & Research, University of surgeon, patient, or perioperative factors contribute to the Massachusetts Medical School, Worcester, MA; 2. Department apparently unhelpful effect of compulsory IOC. of Surgery, Beth Israel Deaconess Medical Center, Boston, MA INTRODUCTION: Intraoperative cholangiogram (IOC) 528a can defi ne biliary ductal anatomy. Routine IOC has been Quality Assessment in Pancreatic Surgery: What Might proposed previously. However, as the “critical view of Tomorrow Require? safety” technique has become widespread, current practice Brian T. Kalish1, Charles M. Vollmer2, Tara S. Kent1, and outcomes of IOC are unclear. William H. Nealon3, Jennifer F. Tseng1, Mark P. Callery1 METHODS: Nationwide Inpatient Sample 2004–2009 was 1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA; queried for patients with acute/urgent biliary disease under- 2. Surgery, University of Pennsylvania, Philadelphia, PA; going laparoscopic and/or open cholecystectomy; IOC was 3. Surgery, Vanderbilt University, Nashville, TN quantifi ed. We limited analyses to states with consistent coding of provider and hospital ID data, and excluded sur- INTRODUCTION: The Institute of Medicine (IOM) geons performing <10 cholecystectomies/year. We dichot- defi nes healthcare quality across six domains: safety, time- omized surgeons into a high-IOC group (top 10%, using liness, effectiveness, patient centeredness, effi ciency, and yearly ratio of IOC/cholecystectomy frequency) vs. stan- equitability. Traditional quality metrics in high-acuity dard group (lower 90%). Our outcomes included bile duct surgery (volume and mortality) cannot alone measure or injury, overall complications, in-hospital mortality, length satisfy these domains. We asked experts in pancreatic sur- of stay (LOS), use of additional studies such as endoscopic gery (PS) whether broader quality metrics are needed, how retrograde cholangiopancreatography (ERCP), and hospi- important they might be, and whether they align to con- talization cost. Statistical analysis included weighted uni- temporary IOM healthcare quality domains. variable and multivariable analysis, and Cochran-Armitage METHODS: Together with a professional market research trend test. fi rm, we created and distributed a web-based survey to pan- RESULTS: 518488 nationally weighted patients under- creatic surgeons. These experts were identifi ed through PS went cholecystectomy; 33.9% had IOC. Over time, IOCs specialty societies, and verifi ed by survey demographics. utilization increased (31% to 34%, p < 0.0001), annual Respondents (Rpds) ranked 62 proposed PS quality met- number of cholecystectomies remained stable. 12,527 rics on level of importance (LoI). Next, Rpds aligned each non-weighted annual surgeon volumes were included in metric to one or more IOM quality domains (MDA, multi- analysis. On average, each surgeon performed 31.9 cho- domain alignment). Descriptive statistics were used to lecystectomies and 7.9 IOCs annually, with mean annual summarize responses. To calculate and rank relative qual- surgeon-specifi c IOC/CCY ratio of 0.23. The high-IOC (top ity scores, points were awarded for LoI (4-Essential, 3-Very 10%) group used IOC for 100% of cases. Of note, 25% of important, 2-Somewhat important, 1-A Little important, surgeons used IOC for at least half of cases. Comparing 0-Not important) and MDA (1 point/each aligned domain). high-IOC group to standard group, high-IOC had no dif- LoI Scores and MDA Scores for a given quality metric were ference in bile duct injury (0.25% vs. 0.27% for standard averaged together to render a Total Quality Score (TQS = group, p = 0.2; a higher rate of overall complications: 7.2% LoI + MDA/2) normalized to a 100-point scale. vs. 6.9%, p = 0.04; and no difference in mortality 0.4% vs. RESULTS: 106 surgeons (21%) completed the survey (82% 0.4% p = 0.8). Patients of high-IOC surgeons had shorter North America and 84% Academic). On average, Rpds and LOS, 3.9 vs. 4.2 days, p = 0.002, and were more likely to use their institutions perform 43 and 114 pancreatic operations additional procedures: ERCP 16.0% vs. 13.1%, p = <0.0001.

10 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

per year, respectively. By descriptive analysis, 90% of Rpds 530 indicated a defi nite or probable need for improved quality metrics in PS. 81% of Rpds indicated a defi nite or prob- High Grade Dysplasia and Adenocarcinoma Are Fre- Abstracts Sunday able value for a “Quality Scorecard” in PS. Of 13 PS quality quent in Side-Branch Intraductal Papillary Mucinous metrics rated as Essential by >25% Rpds, 10 aligned most Neoplasm Measuring Less Than 3 cm on Endoscopic strongly to the IOM Safety domain. 22/62 proposed metrics Ultrasound aligned to more than 1.75 IOM Domains, and were rated Joyce Wong1, Jill Weber1, Barbara A. Centeno3, Shivakumar by >50% Rpds as High LoI (Essential or Very Important; Vignesh2, Cynthia L. Harris2, Jason B. Klapman2, Pamela Hodul1 Figure). 12 proposed scorecard metrics (Table) emerged 1. Surgery, H. Lee Moffi tt Cancer Center, Tampa, FL; with the highest TQS. Those related to mortality, to the 2. Gastroenterology, H. Lee Moffi tt Cancer Center, Tampa, FL; rate and severity of complications, and to access to multi- 3. Pathology, H. Lee Moffi tt Cancer Center, Tampa, FL disciplinary services for pancreatic disease had the highest TQS. Technical and peri-operative metrics had intermedi- BACKGROUND: Surgical resection for intraductal pap- ate TQS. Metrics related to patient satisfaction with care, illary mucinous neoplasm (IPMN) of the pancreas has costs of care, and patient demographics had the lowest increased over the last decade. While IPMN with main duct TQS. The least represented IOM domains were equitability, communication are generally recommended for resection, effi ciency, and patient-centeredness. indications for resection of side-branch IPMN (SDIPMN) have been less clear. We reviewed our single-institutional experience with SDIPMN and indications for resection. METHODS: Patients who underwent resection for IPMN were identifi ed from a prospectively maintained IRB approved database. Patients with main pancreatic duct communication were excluded. Outcome, clinical and pathologic characteristics were correlated with endoscopic ultrasound (EUS) fi ndings. RESULTS: From 2000 to 2010, 105 patients who underwent pre-operative EUS evaluation and resection for CONCLUSIONS: We propose a 12-item “Quality Score- SDIPMN were identifi ed. The mean age was within the sixth card” for PS based on rank-scoring of quality metrics that decade of life, and there was a slight female predominance PS experts view as both highly important and aligned with (55% vs. 45%). The most common presenting symptom more than one IOM healthcare quality domain. While the was abdominal pain (N = 47, 45%), followed by jaundice (N actual performance thresholds for these metrics require fur- = 24, 23%) and weight loss (N = 24, 23%). Only 10 patients ther defi nition and validation, they may reveal quality to (10%) were asymptomatic at presentation; 8 (80%) had susan extent that volume and mortality alone cannot. picious features on EUS. Of the total cohort, few patients had intracystic septations (N = 27, 26%) or presence of Top Pancreatic Surgery “Quality Scorecard” Metrics by Total mural nodules (N = 2, 2%) on EUS. Of 39 patients who had invasive pancreatic ductal adenocarcinoma (PDAC) Quality Score (TQS) on fi nal pathology, EUS-fi ne needle aspiration (EUS-FNA) Metric TQS demonstrated malignancy in only 21 (54%). Multidisciplinary services for pancreatic diseases 63 EUS evaluation of cyst size was correlated with fi nal pathology. Of 70 patients with EUS cyst size <3 cm, 12 (17%) had Major complication rate 60 a pre-operative EUS diagnosis of malignancy. Final pathol- Peri-operative mortality (0–90 days) 59 ogy revealed 24 (34%) to have PDAC: 1 of 7 (14%) patients with cyst size <1 cm, 2 of 19 (11%) with cyst size 1–2 cm, Overall complication rate 57 and 21of 44 (48%) with cyst size 2–3 cm. 15 of 35 (43%) Incidence of post-operative hemorrhage 55 patients with cyst size >3 cm had PDAC on fi nal pathology. Of the patients with cyst size <3 cm, 16 (23%) had Venous thromboembolism (VTE) prophylaxis 54 high-grade dysplasia on fi nal pathology: 3 of 7 (43%) with Patients with malignancy who undergo adjuvant therapy 54 cyst size <1 cm, 3 of 19 (16%) with cyst size 1–2 cm, and Readmission rates (30 day, 90 day, total) 54 10 of 44 (23%) with cyst size 2–3 cm. Seven of 35 (20%) patients with cyst size >3 cm had high-grade dysplasia on Incidence of post-operative pancreatic ﬁ stula 54 fi nal pathology. Timely and appropriate peri-operative antibiotics 53 Although overall survival (OS) at 48 months stratifi ed by Survival rates (1 yr and 5 yr post-operative) 52 EUS cyst size did not signifi cantly differ between groups, Timing from diagnosis to surgical consultation 51 patients with PDAC on fi nal pathology had signifi cantly

11 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

worse OS compared to non-invasive pathology. A total of 8 and sporadic IBD. 4. Alteration of the ZO-1 protein by the patients (8%) developed recurrent disease, all of whom had SNP may lead to conformational changes or alterations in PDAC on fi nal pathology. binding sites that make it resistant to degradation in IBD. CONCLUSION: EUS is a helpful modality for the diagnos- Further study of the changes in the ZO-1 protein by a muta- tic evaluation of SDIPMN. Considering the high incidence tion at rs260526 may lead to a better understanding of the of malignancy as well as high-grade dysplasia in SDIPMN role of ZO-1 in IBD. greater than 2 cm, EUS features should be used in conjunction with other clinical criteria to guide management deci- 532 sions. Patients with SDIPMN greater than 2 cm that do not Ostomy Creation Signifi cantly Increases ER Visits and undergo surgical resection may benefi t from more inten- Hospital Readmission After Colorectal Resection sive surveillance. Lisa S. Poritz1, Arthur Berg2 531 1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA; 2. Biostatistics and Bioinformatics, The Milton S. Hershey Medical Mutation in ZO-1 Is Associated with Protection from Center, Hershey, PA Familial Infl ammatory Bowel Disease INTRODUCTION: Readmission after colorectal (CR) sur- Lisa S. Poritz, Leonard R. Harris, Arthur Berg, Tara M. Connelly, gery continues to be a signifi cant problem and quality of John P. Hegarty, Sue Deiling, Zhenwu Lin, Rishabh Sehgal care issue. The purpose of this study was to identify factors Surgery, The Milton S. Hershey Medical Center, Hershey, PA predictive of readmission after CR surgery. INTRODUCTION: Infl ammatory bowel disease (IBD) METHODS: 30% (computer generated list) of the records is thought to occur due to an environmental insult in a of all patients admitted to the CR service at our institu- genetically susceptible individual. Multiple genetic vari- tion from July 2008—June 2011 were reviewed for patients ants have been identifi ed to be associated with IBD. The undergoing colorectal resection. Patients who died within tight junction complex (TJ) is part of the intestinal epithe- 60 days of surgery or were discharged to hospice were lial barrier and has been shown to be altered in patients excluded. All others were then subdivided into 2 groups: with IBD. The purpose of this study was to identify genetic those patients that were either re-admitted or visited the variants in the TJ complex that may be associated with IBD. emergency room (ER) within 60 days after discharge and METHODS: DNA from members of our IBD registry was those patients that did not. Additional data abstracted previously collected and stored. Initially 284 members from the medical record included total length of stay (LOS), of our IBD registry and non-diseased controls underwent post-operative LOS (POD), diagnosis subcategorized into genotyping for 25 TJ single nucleotide polymorphisms malignant, diverticulitis, IBD, other benign disease; proce- (SNP) on an IlluminaTM platform. Genes studied coded dure subcategorized into colon resection, rectal resection, for both transmembrane and membrane associated pro- combined resection; presence of an ostomy, laparoscopic teins. Based on initial screening results, a total of 670 IBD or open (converted procedures were in the open category), patients and non-diseased controls were genotyped for the surgeon, admission type (urgent/emergent or elective), rs260526 SNP by polymerase chain reaction (PCR). IBD and patient age. Univariate and multivariate analysis was patients were subdivided into familial (at least one family performed. member with IBD besides the index patient) or sporadic RESULTS: 242 patients met criteria. Data is shown in the (no family members with IBD). Three genetic models (gen- table. 74 (30.6%) patients were readmitted or visited the eral, additive, and dominant) were used to quantify the ini- ER within 60 days of discharge. Diagnosis, type of resec- tial genotyping. For rs260526, groups were compared with tion, approach (lap vs open), age, and type of admission a two-sided Fisher’s exact test. were not different between patients readmitted and those RESULTS: Of the 25 initial SNPs only rs260526, a SNP in that were not. Presence of an ostomy (ileostomy or colos- the ZO-1 gene, was shown to be statistically signifi cant by tomy) was the most signifi cant factor associated with read- all three genetic models when comparing IBD patients to mission, with 77% of the readmitted patients having an non-diseased controls. ZO-1 is a key protein in the TJ com- ostomy (p = 0.0000014). Surgeon performing the proce- plex and has been shown to be altered in IBD. Therefore, dure, LOS, and POD, were also signifi cant factors determin- additional IBD patients and non-diseased controls were ing readmission on univariate analysis and all remained genotyped for rs260526 by PCR. When the IBD patients statistically signifi cant on multivariate analysis. The most were subdivided, this ZO-1 SNP was found to be statistically common reasons for readmission were nausea, vomiting, signifi cant when comparing patients with familial IBD to abdominal pain, and dehydration. 53/74 (72%) of the read- non-diseased controls, p = 0.0213, OR = 0.468, Cl = [0.225, mitted patients had at least one of these as their diagnosis. 0.911]). The mutation was more common in the non-dis- 129/242 (53%) of the patients in this series had an ostomy eased controls, and therefore protective against IBD. post-operatively, likely due to the large number of patients with IBD and rectal cancer. Emergent or urgent procedures CONCLUSIONS: 1. Of all the TJ SNPs studied, only a were not a signifi cant risk factor for ostomy creation. The mutation in the ZO-1 gene was associated with IBD. 2. image shows probability of readmission with increasing This SNP was found to be protective against the develop- LOS for patients with and ostomy (top curve) and without ment of familial IBD. Lack of signifi cance of this SNP in (bottom curve). Bands are 95% confi dence intervals. sporadic IBD supports a different pathogenesis for familial

12 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSIONS: The most signifi cant predictive factor for readmission in this study was an ostomy. Ostomies are

frequently used with elective and urgent CR and decreas- Abstracts Sunday ing their use may not be prudent. However, the creation of each ostomy should be evaluated for necessity by the surgeon. Quality improvement projects should be directed at assessing readiness of ostomy patients for discharge and adequacy of support at home.

533 Costs Associated with Colorectal Resection: Does Body Mass Index and Obesity Adversely Impact Resource Utilization? John P. Cullen, Pokala R. Kiran, Ryan Williams Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Obesity rates have soared drastically in Probability of Readmission: Top line: with ostomy, bottom line: without recent years and complications of obesity lead to increased ostomy Shaded areas are 95% conﬁ dence intervals health-care costs. Whether costs after colorectal surgery are specifi cally higher for obese patients has however not pre- No viously been assessed. The aim of this study was to compare Readmission Readmission p value direct costs for obese and non-obese patients undergoing Total patients 74 168 colon resection. Age (years, mean ± 55.12 ± 1.94 55.71 ± 1.20 0.562 METHODS: All patients undergoing elective open partial standard error) colectomy at a single high-volume colorectal unit over Diagnosis 0.138 the last 3 years were identifi ed. Patients with metastatic malignancy were excluded. Patients were stratifi ed based IBD 27 45 on increasing body mass index (BMI) and matched for age, Malignancy 30 77 gender and ASA class. Data relating to operation, length Diverticulitis 8 33 of stay (LOS) and complications and costs were compared. Subgroup analysis was performed on underweight and Other Benign 9 13 morbidly (BMI >40) obese patients. Type of resection 0.255 RESULTS: A total of 285 complete charts for patient under- Colon 44 117 going partial colon resection were reviewed. Groups were similar with regards to age, gender, ASA class and procedure. Rectal 27 44 Cancer and diverticulitis were the main diagnoses across all Multiple 3 7 groups, except for the underweight group, where Crohn’s Ostomy disease predominated and this group was excluded from further analysis. Mean LOS was similar between groups. Ileostomy/colostomy/no 43/14/17 56/16/95 0.0000034 Obese patients had greater mean hospital costs ($14803) ostomy than non-obese ($12992) but this difference was not sig- Any ostomy/no ostomy 57/17 72/95 0.0000014 nifi cant (p = 0.82). Wound infection rate approached 45% Open/Laparoscopic 50/24 117/50 0.762 in the morbidly obese group and was only 8% in patients who were not obese. The overall morbidity, wound infec- Surgeon 0.0395 tion and costs progressively increased with increasing BMI A 22 75 (table). Morbidly obese patients had signifi cantly increased overall morbidity and costs when compared to non obese B 14 28 patients (p = 0.04). C 9 26 CONCLUSION: For patients undergoing elective colon D 29 38 resection, obesity leads to increased direct costs, with the LOS (days, mean ± 11.22 ± 1.22 7.49 ± 0.30 0.00608 morbidly obese having the greatest costs. The increased standard error) costs are likely due both to operating room costs and to the increasing higher overall morbidity, especially wound POD (days, mean ± 9.81 ± 1.09 6.79 ± 0.24 0.0168 standard error) infection associated with increasing BMI. This risk should be accounted for in future health care policy including Admission type 0.363 reimbursement and resource allocation strategies. Emergent/urgent 16 28 elective 56 140

13 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Group Underweight (n = 18) Non Obese (n = 185) Obese (n = 64) Morbidly obese (n = 18) BMI (kg/m2) <20 20–30 31–39 40–64 Age (years) 53 58.7 60.3 56.7 ASA class 1.7 2.3 2.5 2.6 Gender (% female) 55% 50% 55% 60% Overall Morbidity 26% 35% 31% 72% Wound infection 4% 8% 11% 44% Total Direct Costs ($) 11450 12992 14803 (p = 0.82) 18980 (p = 0.04) Nursing Costs ($) 2320 2498 3061 (p = 0.02) 2903 (p = 0.17) OR costs ($) 678 1007 1127 (p = 0.78) 2340 (p < 0.01) Pharmacy Costs ($) 972 751 1274 (p = 0.09) 1307 (p = 0.03)

with complications following non-operative management 534 including bowel obstruction, fi stula, clostridium diffi cile Natural History of Acute Diverticulitis: Low Risk of infection and lower GI bleed. Recurrence Following Non-Operative Management in CONCLUSION: Conservative management of diverticuli- a Population-Based Study tis results in a low rate of recurrence, further supporting a Jennifer D. Stanger, George Roxin, Anthony R. MacLean, non-operative approach. The only predictor of recurrence William D. Buie was patient comorbidity. Non-operative management is associated with a low rate of complications. Department of Surgery, University of Calgary, Calgary, AB, Canada BACKGROUND: The natural history of acute diverticulitis 535 remains poorly understood, and the role of surgical intervention is controversial. The purpose of this study was to Visceral Fat Volume Better Than BMI at Risk Stratifying determine the rates of recurrence and associated complica- Colorectal Cancer Patients tions following non-operative management of acute diver- Aaron S. Rickles, James C. Iannuzzi, Andrew-Paul Deeb, ticulitis in a population-based setting. Fergal Fleming, John R. Monson METHODS: All patients admitted to an adult hospital in Surgery, University of Rochester, Rochester, NY a large urban area between January 2007 and March 2010 INTRODUCTION: The extent to which obesity effects were identifi ed using a health records search (ICD-10 codes colorectal cancer outcomes has been inconsistent in the lit- K 572, 573, 578 and 579). Patients who underwent emer- erature, which may be a result of BMI being a poor descrip- gency surgery were excluded. Demographic, clinical, radio- tor of fat distribution. Compared to subcutaneous adipose logic, treatment, complication and recurrence data were tissue, visceral adipose tissue is more metabolically active, collected. Data was analysed with logistic regression; a two- leading to a chronic infl ammatory state and increasing the sided p-value of 0.05 was considered signifi cant. risk for diabetes, cardiovascular disease, and tumorigenesis. RESULTS: A total of 645 patients presented with acute In addition, men and women distribute fat differently, thus diverticulitis. 502 patients were managed non-operatively leading to differences in outcomes based on BMI. The aim (49 percutaneous drains, 456 antibiotics). Median age of this study is to describe the effect of visceral obesity on of patients was 55 (range 24–103), 51% of patients were colorectal cancer outcomes between gender groups. female, median follow-up was 34 months (range 14–50). METHODS: We conducted a retrospective chart review of Seventy eight patients (15.5%) required acute readmission colorectal cancer patients who underwent surgery at our to hospital, of which 67 (85.9%) were related to recur- institution between 2003 and 2010. Patient selection was rent diverticulitis. 14 (20.9%) patients required urgent restricted to those who had a pre-operative CT scan of the surgical intervention. Of the remaining 53 patients man- abdomen and pelvis. Exclusion criteria included emer- aged non-operatively, 8 (15.1%) required a second acute gency surgery, metastatic cancer, and patients with IBD or readmission (6 due to recurrent diverticulitis, 2 requiring HNPCC. CT scans were used to measure visceral fat volume surgery). On univariate analysis only a Charlson Comor- (VFV) using Carestream PACS 10.2 (Carestream Health, bidity score of 1 or greater was a predictor of recurrence inc.). Patients with a BMI ≥30 were considered obese and (p = 0.02). Of the 559 total admissions for diverticulitis viscerally obese patients were defi ned as those with a VFV managed non-operatively, there were 51 (9.1%) in hospital greater than the mean. Linear regression was used to ana- complications (Dindo-Clavien grade 1 = 20, grade 2 = 25, grade 3 = 6). 10 (1.9%) patients were readmitted to hospital

14 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

lyze the correlation between BMI and VFV, and indepen- role these factors play in the development of CDC recur- dent sample t-test and Kaplan-Meier survival curves were rence is unknown. This study tested the hypothesis that used for outcome analysis. bacterial virulence factors predict CDC recurrence and the Abstracts Sunday RESULTS: A total of 233 patients met inclusion criteria, need for admission to the hospital. 75 Stage I (32%), 77 Stage II (33%), and 81 Stage III (35%). METHODS: Patients ≥18 years of age treated at our institu- The mean age was 67, mean BMI 28.5, and mean VFV 1637 tion for CDC of any severity were consecutively enrolled. cm3. There was no signifi cant difference in BMI between CDC was defi ned as symptoms of colitis with a positive PCR males and females (28.1 vs. 28.9, p = 0.294), however males stool test. Each bacterial isolate was studied for virulence had signifi cantly more visceral fat than females (1867 cm3 factors: tcdC mutation, binary toxin and ribotype 027 by vs. 1371 cm3, p = 0.0001). In addition, BMI proved to be a PCR, and the presence of toxins A and B using restriction poor descriptor of visceral obesity on linear regression (r2 = fragment length polymorphism. Chi Square tests, t-tests 0.314, see Figure1). When analyzing disease free survival at and logistic and linear regression were used to determine three years (DFS3yr) there was no difference between obese which virulence factors predicted the number of recurrent and non-obese patients based on BMI. When analyzing episodes and the need for admission to the hospital for outcomes based on VFV, non-obese females with Stage II treatment. cancer had signifi cantly better DFS3 yr compared to viscer- RESULTS: Sixty-nine patients (male: 57%) were stud- ally obese females (86.3% vs. 60.0%, p = 0.034) although ied, with a mean age of 64 ± 13 years. Twenty-one (30%) there was no signifi cant difference in DFS3 yr amongst patients were initially diagnosed as outpatients, while the males. remainder developed CDC during hospitalization. A majority of patients harbored at least one virulence factor (Table 1). There was no difference (p > 0.05) between virulence factors among inpatients and outpatients. Binary toxin was the single virulence factor independently associated with CDC recurrence (p = 0.02). A higher number of CDC recurrences was also observed with toxin A (p = 0.01) and tcdC mutation (p = 0.001) when either was present with binary toxin, with the combination of binary toxin and tcdC mutation being the strongest predictor, increasing the number of recurrences by an average of two episodes. The need for hospital admission for CDC recurrence was strongly associated with tcdC mutation (p = 0.04), binary toxin (p = 0.02) and ribotype 027 (p = 0.02). The combination of toxins A, B and binary toxin exerted an additive effect by increasing risk of readmission three-fold when all three toxins were present (p = 0.02). No resistance to met- ronidazole or vancomycin was encountered based on measurement of minimum inhibitory concentrations. Figure 1: Linear regression of Visceral fat Volume and BMI. CONCLUSION: This novel method for risk stratifi cation Association of Virulence Factors with Recurrence And Admission demonstrates that visceral obesity decreases three year dis- for C. Difﬁ cile Colitis ease free survival for women with stage II colorectal cancer and should be considered in the discussion of chemo- Incidence Association Association therapy use in these patients. Further study is necessary to (n = 69) with Recurrence with Admission delineate the effect of visceral obesity in men at various Virulence Factor (p Value) (p Value) stages of colorectal cancer. Toxin A 61 (88%) 0.56 0.78 536 Toxin B 66 (96%) 0.73 0.60 Binary toxin 42 (61%) 0.02 0.02 Predicting Recurrence of C. diffi cile Colitis Using Bacterial Virulence Factors: Binary Toxin Is the Key tcdC mutation 39 (56%) 0.18 0.04 David B. Stewart, Arthur Berg, John P. Hegarty Ribotype 027 26 (38%) 0.32 0.02 Surgery/Division of Colon and Rectal Surgery, Penn State Hershey CONCLUSIONS: 1) Binary toxin is an independent pre- Medical Center, Hershey, PA dictor of CDC recurrence, which has not previously been BACKGROUND: Recurrence of C. diffi cile colitis (CDC) reported. 2) The combination of binary toxin and tcdC is common, yet the ability to predict CDC recurrences is mutation is associated with the highest number of CDC virtually non-existent. Certain C. diffi cile virulence factors recurrences, such that their combined presence is associ- have been implicated in the development of severe forms ated with a 70% recurrence rate. 3) C. diffi cile which proof CDC, including toxins A and B, binary toxin, tcdC duces binary toxin may require longer antibiotic regimens mutation (leading to higher toxin production) and certain to prevent disease recurrence. strains of the bacteria such as ribotype 027. However, the

15 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

537 Table 1: Comparison of Mean Serosal EGG Values of Primary vs. Replacement GES in Gastroparesis Patients Long-Term Effects of Gastric Stimulation on Gastric Electrical Physiology Frequency Amplitude Freq/Amp 1 1 1 Patrick A. Williams , Yana Nikitina , Thomas L. Abell , Primary Serosal EGG 5.27 0.33 40 Christopher J. Lahr2, Thomas S. Helling2 1. Digestive Diseases, University of Mississippi Medical Center, Replacement Serosal EGG 3.75 0.3 24.3 Jackson, MS; 2. Surgery, University of Mississippi Medical Center, p-value 0.000002 0.66 0.002 Jackson, MS Normal EGG values 2.7–3.3 0.50 <10 INTRODUCTION: This study evaluates the modeling of gastric electrophysiology (GEP) tracings during long term gastric electrical stimulation (GES) for gastroparesis (GP). Electrogastrography (EGG) via serosal recordings was performed on gastroparesis patients through stimulator leads prior to stimulation and again with stimulator off at time of stimulator replacement for battery depletion. We hypothesized that serosal EGG may change over time representing gastric remodeling from GES. PATIENTS: 66 patients with gastroparesis underwent placement of gastric stimulator for refractory symptoms. EGG was performed after the gastric leads were placed but before stimulation was begun. Patients underwent continuous stimulation until pacer batteries depleted and the stimulator was then replaced. At the time of stimulator replacement, after the stimulator was removed, but before the new pacemaker was attached, serosal EGG was again performed using the gastric leads. Mean age at initial GES Figure 1 placement was 44 years (range: 8–76); current mean age is CONCLUSION: Long-term gastric stimulation causes 49; the majority of the subjects were female (n = 52, 79%). Only a minority had diabetes-induced gastroparesis (n = 16, improvement in basal unstimulated gastric frequency 24%); the remainder were either idiopathic, post-surgical, towards normal. or sarcoidosis-induced. METHODS: At the time of GES placement, mucosal EGG 538 is performed through the GES leads. Once the GES battery Multivisceral Transplantation: Expanding Indications expires, it is replaced. At the time of replacement, EGG is performed again, and GEP tracings are repeated. and Improving Outcomes Richard S. Mangus, A. Joseph Tector, Rodrigo M. Vianna RESULTS: After a mean of 3.9 years (46 months) of GES Indiana University School of Medicine, Indianapolis, IN therapy, the mean unstimulated baseline frequency for INTRODUCTION: gastroparesis patients before initial GES therapy was 5.27 Multivisceral transplantation (MVT) cycles/min (SD = 1.89) and declined to 3.75 (1.58) after includes the simultaneous transplantation of multiple replacement (p = 0.000001), with a mean baseline fre- abdominal viscera including the stomach, duodenum, pan- quency decrease of 0.03/month (Table 1, Figure 1). The creas and small intestine, with (MVT) or without the liver mean amplitude was 0.33 mV (0.39) before initial GES (Modifi ed MVT or MMVT). This study reviews the chang- therapy and decreased to 0.30 (0.34) afterward (p = 0.66). ing indications and outcomes for this procedure over a The frequency/amplitude ratio was 40.0 (40.7) before ini- 7-year period at a university medical center. tial GES therapy and decreased favorably to 24.3 (25) after- METHODS: This study is a retrospective case review of mul- ward (p = 0.002). tivisceral transplants performed between 2004 and 2010 at a single center. All cases were either MVT or MMVT, and included a simultaneous kidney transplant, if indicated. Graft failure was defi ned as loss of the graft or complete loss of function. Graft function was monitored by laboratory values and serial endoscopy with biopsy.

16 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: During the study period, 92 patients received 50% patient survival during the period from 2004 to 2007, 100 transplants including 85 MVT and 15 MMVT. There followed by a 75% patient survival during the period from were 19 patients who received a simultaneous kidney graft. 2008 to 2010. Primary complications included rejection There were 24 pediatric and 76 adult recipients (range 4 (45% MMVT and 15% MVT), infection (>90% in the fi rst months to 66 years). Indications included short gut with year), graft versus host disease and post-transplant lympho- liver failure, cirrhosis with complete portal mesenteric proliferative disorder. thrombosis, slow growing central abdominal tumors, intes- CONCLUSION: Indications for MVT and MMVT have tinal pseudoobstruction and frozen abdomen. All patients broadened to include patients with slow growing tumors, received antibody-based induction immunosuppression complete portomesenteric thrombosis and abdominal catas- with calcineurin inhibitor-based maintenance immuno- trophes not amenable to other surgical therapy. Outcomes suppression. At a median follow-up of 36 months, 1-, 3- continue to improve with many patients returning to full and 5-year graft survival is 75%, 64% and 64%. There was functional status and enjoying long-term survival.

a learning curve with this complex procedure resulting in a Abstracts Monday

Monday, May 21, 2012

7:30 AM – 9:15 AM 28ab VIDEO SESSION II: BREAKFAST AT THE MOVIES

582 583 Right Hepatectomy with Caval Thrombectomy After Hybrid Laparoscopic Total Colectomy/Robotic Neoadjiuvant Therapy-TACE and Sorafenib-for HCC Extralevator Abdominoperineal Resection with Caval Thrombosis Celeste Y. Kang, Alessio Pigazzi Alfredo Guglielmi, Andrea Ruzzenente, Elisabeth Baldiotti, Surgery, University of California Irvine, Orange, CA Tommaso Campagnaro, Calogero Iacono A 26 year old female with a large cecal polyp and rectal Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy adenocarcinoma involving the spincter in the setting of A patient affected by HCV-related cirrhosis and multiple newly discovered familial adenomatous polyposis under- HCC in the right hepatic lobe with caval vein thrombosis is goes a hybrid laparoscopic/robotic total colectomy with described. Considered the good response to treatment with extralevator abdominoperineal resection. An oncologic TACE and sorafenib, the patient underwent to right hepa- colon resection with high vessel ligation is performed lapa- tectomy and caval thrombectomy with anterior approach roscopically followed by robotic e-APR. Total mesorectal and total vascular exclusion. The specimen revealed com- excision is performed and the levator fi bers are divided at plete necrosis of hepatic nodules and caval thrombus. After their origin laterally on the pelvic side wall. The dissection one year, recurrence appeared near the surgical margin, is carried out in the ischiorectal space as far distally as pos- successfully treated with RFA. Six months later, CT scan sible utilizing the robotic arms. This video emphasizes the revealed three HCC nodules in the left lobe. A TACE was technique, feasibility and safety of this procedure. performed with complete response. Two years after surgery, the patient is alive and without recurrence.

17 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

584 587 Per-Oral Esophageal Myotomy (POEM) and Subsequent Laparo-Endoscopic Transgastric Resection of a Salvage Laparoscopic Heller Myotomy Submucosal Mass at the Gastro-Esophageal Junction Ezra N. Teitelbaum, Nathaniel J. Soper, Eric S. Hungness Neil Ghushe, Parambir S. Dulai, Thadeus Trus Surgery, Northwestern University, Chicago, IL Dartmouth-Hitchcock Medical Center, Lebanon, NH This video shows two procedures performed on the same The management of gastric submucosal masses adjacent patient: a per-oral esophageal myotomy (POEM) and sub- to the gastro-esophageal junction presents an interesting sequent salvage laparoscopic Heller myotomy after recur- therapeutic challenge. Wedge resection is not possible in rence of dysphagia. The POEM portion illustrates the key this location without compromising the lower esophageal steps of this novel procedure and shows intra-operative sphincter or esophagus. Endoscopic submucosal dissection bleeding that may have led to the patient’s eventual clini- provides an inadequate deep tissue margin. We present a cal failure. The patient underwent a laparoscopic Heller combined laparo-endoscopic approach for transgastric myotomy four months later which is shown in the second resection of this type of lesion. part. We see that the prior POEM had not created signifi - cant mediastinal or submucosal adhesions. This is the fi rst 581 evidence that patients who fail POEM can then undergo laparoscopic Heller myotomy without signifi cant added The Standardization of Laparo-Endoscopic Single Site operative diffi culty. (LESS) Cholecystectomy Sharona B. Ross1,2, Alexander S. Rosemurgy2, Michael H. Albrink1,2, 585 Edward Choung2, Scott F. Gallagher10, Jonathan M. Hernandez1, Santiago Horgan 14,18, Michael Kia20, Jeffrey M. Marks6, Hiatal Mesh: When the Crura Cannot Be Closed Jose Martinez17, Yoav Mintz12, Harold Paul2, Aurora D. Pryor3, Tatyan M. Clarke, Ross F. Goldberg, Armando Rosales-Velderrain, David W. Rattner7,8, Homero Rivas9, Kurt E. Roberts5, Steven P. Bowers Eugene Rubach15, Steven D. Schwaitzberg8,19, Lee L. Swanstrom16, Surgery, Mayo Clinc – Florida, Jacksonville, FL John F. Sweeney11, Erik Wilson13, Harry Zemon4, Natan Zundel21 The value of mesh-buttress over approximated crural mus- 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa culature in hiatal hernia repair remains a topic of contin- General Hospital, Tampa, FL; 3. Surgery, Stony Brook University, ued research and debate. However, there are situations in New York, NY; 4. Surgery, North Shore Lij Hospital, New Hyde which mesh use is essential. When the crura are fi brotic, Park, NY; 5. Surgery, Yale Medical Group, New Haven, CT; immobile, or damaged, and in the case of unusually large defects, crural re-approximation is not feasible and a mesh- 6. Surgery, University Hospitals Case Medical Center, Cleveland, bridge repair is indicated. OH; 7. Surgery, Massachusetts General Hospital, Boston, MA; 8. Surgery, Harvard Medical Group, Boston, MA; 9. Surgery, Presented here are 3 cases where mesh is deemed necessary Stanford School of Medicine, Stanford, CA; 10. Surgery, Forsyth and appropriate. First, a case of fi brotic crura after hiatal hernia recurrence. The second case describes the technique Medical Center, Winston-Salem, NC; 11. Surgery, Emory University, of repair for a large para-hiatal hernia. The fi nal case dem- Atlanta, GA; 12. Surgery, Hadassah Hebrew University Medical onstrates repair of hiatal hernia occurring years after tran- Center, Jerusalem, Jerusalem, Israel; 13. Surgery, The University shiatal esophagectomy. of Texas Medical School at Houston, Houston, TX; 14. Surgery, University of California, San Diego, CA; 15. Surgery, New Jersey 586 Medical School, Newark, NJ; 16. The Oregon Clinic, Portland, OR; 17. Surgery, University of Miami Health Systems, Miami, Minimally-Invasive Robot-Assisted Modifi ed Appleby FL; 18. Surgery, UC San Diego Medical Center, San Diego, CA; Resection for Pancreatic Adenocarcinoma 19. Cambridge Health Alliance, Cambridge, MA; 20. Surgery, Joel Baumgartner, Mehmet F. Can, Herbert Zeh, A. James Moser McLaren Regional Medical Hospital, Flint, MI; 21. Florida University of Pittsburgh Medical Center, Pittsburgh, PA International University College of Medicine, Miami, FL Selected patients with pancreatic adenocarcinoma involving This video presents a standardized approach to LESS chole- the celiac trunk may derive prolonged survival benefi t from cystectomy. Bupivacaine was injected at the umbilicus. A 12 surgical resection. We report two patients who underwent mm vertical incision was made. A 4-trocar port was inserted. robot-assisted modifi ed Appleby resection after chemoradia- A 5 mm defl ectable tip laparoscope was utilized. With spe- tion. Median age was 82. Median duration of surgery was cifi c placement as denoted in the video, a bariatric length 374 minutes, median EBL 225 and 11 day length of stay. grasper and a bent grasper retracted the gallbladder. A win- Surgical margins were negative in both patients. The most dow was developed between the gallbladder and the liver severe morbidity was Clavien grade 3 gastric ischemia that bed, promoting the “critical view.” The cystic duct and artery resolved with bowel rest. The other patient had an ISGPF were divided and the gallbladder removed. The diaphragm grade C pancreatic leak requiring endoscopic drainage. was irrigated with bupivacaine solution. The umbilical defect Robot-assisted minimally invasive modifi ed Appleby resec- was closed in a fi gure-of-eight fashion. This video promotes tion can be completed safely with acceptable morbidity and a standardized approach to LESS cholecystectomy. mortality.

18 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

10:00 AM – 11:15 AM 27b PLENARY SESSION IV

was classifi ed as less or more than once a week. Patients 668 were also questioned about known risk factors for pouchi- Robotic-Assisted Rectal Dissection for Restorative tis including tobacco use, extraintestinal manifestations of Proctectomy for Ulcerative Colitis IBD, primary sclerosing cholangitis (PSC) and the use of NSAIDS. Data on the use of fi ber supplementation, antidi- Brian Bello, Marie C. Ziesat, Konstantin Umanskiy, Abstracts

arrheal medications, probiotics, and immunosuppressive Monday Alessandro Fichera medications was also obtained. Two-sided Fisher’s exact The University of Chicago Medical Center, Chicago, IL test was used to compare groups. Robotic-assisted rectal dissection for cancer has been well- RESULTS: 85 patients were identifi ed that had complete described, but experience in patients with infl ammatory PPI/H2 data available. The data is shown in the table. There bowel disease is lacking. The infl amed, friable tissue of the was a statistically signifi cant increase in the use of daily PPI/ ulcerative colitis patient adds an element of complexity H2 in patients without pouchitis. There was also a statisti- to the rectal dissection during a restorative proctectomy. cally signifi cant increase in the use of antacids more than Robotic assistance can aid in visualization and maneuver- one time per week in patients without pouchitis. There was ing within the limited space of a narrow pelvis. At our insti- no association between the use of PPI/H2 and the use of tution, we use the robot to safely perform the complete antacids. Occasional use of PPI/H2 did not alter the rate circumferential rectal dissection in patients with infl am- of pouchitis. None of the other variables were statistically matory bowel disease. We depict a robotic-assisted rectal signifi cantly different between groups (see Table). dissection during a restorative proctectomy in a thirty-one year old female patient with ulcerative colitis. No Pouchitis Pouchitis p Value 669 PPI/H2 antagoinist: Never (Y/N) 26/20 28/11 0.178 Chronic Use of PPI and H2 Antagonists Decreases the PPI/H2 antagoinist: Daily (Y/N) 15/31 5/34 0.041 Risk of Pouchitis After IPAA for Ulcerative Colitis PPI/H2 antagoinist: Occasional (Y/N) 5/41 6/32 0.534 Lisa S. Poritz1, Rishabh Sehgal1, Arthur Berg3, Lacee Laufenberg1, ≥ 22/12 24/3 0.0381 Christine Choi1, Emmanuelle Williams2 Antacid use (<1/week/ 1/week) 1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA; PSC (Y/N) 5/25 2/24 0.436 2. Gastroeneterology, The Milton S. Hershey Medical Center, Extraintestinal manifestations (Y/N) 14/21 14/13 0.443 Hershey, PA; 3. Biostatistics and Bioinformatics, The Milton S. Smoking 0.568 Hershey Medical Center, Hershey, PA Never 25 18 INTRODUCTION: Pouchitis is one of the most common long term complications after ileal pouch anal anastomosis Quit 7 8 (IPAA) for ulcerative colitis (UC). One common theory of Current 3 1 pathogenesis is bacterial overgrowth in the pouch. Proton Use of Probiotics (Y/N) 7/37 11/26 0.182 pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric Use of NSAIDS > 1/week (Y/N) 14/21 8/19 0.435 acid. The change in pH of the stomach effl uent caused by Use of ﬁ ber supplementation (Y/N) 7/28 8/19 0.257 anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known Use of anti-diarrheal medication (Y/N) 19/16 14/13 1 to be associated with small bowel bacterial overgrowth. We Use of immunosuppressive 5/30 4/23 1 hypothesize that chronic use of PPI or H2 antagonists will medications (Y/N) alter the incidence of pouchitis after IPAA for UC. CONCLUSIONS: METHODS: 1) Our data suggests that the daily use Patients who had undergone IPAA for UC at of PPI or H2 antagonists is associated with a decreased least 2 years ago were identifi ed from our familial infl am- risk of pouchitis and may be protective against pouchitis matory bowel disease registry. They were classifi ed as hav- in patients with IPAA for UC. 2) Occasional use of these ing no history of pouchitis (no attacks of pouchitis since agents did not seem to afford the same protection. 3. Regu- IPAA 2 or more years ago) or pouchitis (documented epi- lar antacid use provided similar protection as PPI and H2 sodes of pouchitis in the medical record by biopsy and/ antagonists. 4. This data suggests that altering the acid con- or endoscopy and response to antibiotic therapy). Patients tent/pH of the GI tract may infl uence the development of were then contacted and questioned about use of PPI, H2, pouchitis, possibly by altering the bacterial fl ora. Further and antacids. PPI and H2 were classifi ed as never used, work to identify the changes in fecal fl ora is warranted. daily use, or occasional use (1/month-2/week). Antacid use

19 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

670 RESULTS: Of the 308 BDI: 223 (72%) were active (ActBDI), 77 (25%) were passive (PassBDI), and 8 (3%) followed The Prevention of Laparoscopic Bile Duct Injuries: CBDE with T-tube. The level of biliary injury is shown in Delineation of the Principal Active and Passive the second table; injury to proximal bile ducts was more Mechanisms of Bile Duct Injury common with ActBDI. Fewer PassBDI (16%) than ActBDI Lygia Stewart1,2, John G. Hunter3, Lawrence Way2 (34%) were recognized intra-op (P = 0.006). Factors lim- 1. Surgery, UCSF / SF VAMC, San Francisco, CA; 2. Surgery, iting visibility (infl ammation, bleeding, etc) were more UCSF, San Francisco, CA; 3. Surgery, OHSU, Portland, OR common in PassBDI (Table); while what were thought to INTRODUCTION: be abnormal anatomic fi ndings (additional ductal/tubu- The most common mechanism of lar structures, arteries, vessels, abnormal biliary anatomy) major bile duct injury (BDI) involves misidentifi cation of were more common in ActBDI (Table). The surgeon’s intra- the CBD as the cystic duct, which is then deliberately tran- operative sense-making also differed: a deliberate search for sected. A common, but less frequent, mechanism occurs possible BDI was more common in ActBDI than in PassBDI when the hepatic duct is injured during dissection in the (Table); cases were more commonly opened for compro- triangle of Calot that is unknowingly too close to the com- mised visibility with PassBDI (Table); and ActBDI were mon hepatic duct. Both mechanisms involve mispercep- more commonly identifi ed intra-op among all BDI cases as tion, but one is active and the other passive. We analyzed well among those converted to a laparotomy. Certain cues the two to fi nd clues that would help improve prevention. inhibited BDI detection. Detection of all BDI was less com- METHODS: 433 lap cholecystectomies (125 uncompli- mon in cases with bleeding (9% vs 36%, bleeding vs none, cated, 308 BDI) were studied. BDI were categorized accord- P < 0.0001), and when multiple factors limited visibility ing to the type: active (deliberate transection of common (BDI detection: 35% no visibility issues, 28% one issue, but bile duct mistaken for the cystic duct) and passive (lateral only 11% with two or more factors limiting visibility, P < injuries during dissection too close to the common hepatic 0.0001). duct). Operative reports were examined for sensemaking cues and clinical factors.

Active and Passive BDI Characteristics

Active BDI N = 223 Passive BDI N = 77 No BDI N = 125 P Value Visibility Issues Bleeding 35 (17%)* 28 (36%)* 7 (6%)* <0.0001 Inﬂ ammation 75 (34%) 45 (58%)* 39 (31%) <0.0001 One or more 81 (36%) 63 (82%)* 43 (34%) <0.0001 Irregular Anatomic Extra/Abnormal Artery or Vessel 87 (39%)* 18 (23%)* 11 (9%)* <0.02 Cues Extra Bile Duct/Tubular Structure 59 (26%)* 3 (4%) 1 (1%) <0.0001 Abnormal Biliary Anatomy 76 (34%)* 13 (17%) 11 (9%) <0.008 Surgeon Sensemaking Search BDI 43 (19%)* 4 (5%) 0 0.006 Identify BDI 75 (34%)* 12 (16%) 0 0.004 Open visibility issues 15 (7%) 20 (26%)* 0 <0.0001 Open concern anatomy/BDI 17 (8%) 1 (1%) 0 0.085 BDI identify w/conv open 18/32 (56%)* 5/21 (23%) — 0.026 * Signiﬁ cant factors BDI = bile duct injury

Distribution of Injuries

Above Bifurcation Involvement Isolated Right CBD/CHD Bifurcation Lobar Ducts Ductal Injury Active BDI 139(62%) 30(13%) 26(12%) 11(5%) 17(8%) Passive BDI 57(74%) 6(8%) 1(1%) 0 13(17%) BDI after T-tube 8(100%) 0 0 0 0

20 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSIONS: This study highlights differences in BDI There was no difference in the incidence of symptoms mechanisms and possible means of prevention. Most sur- between the two groups (p = NS). Within the GERD+ group, geons are aware of the perceptual trap of misidentifying 37 patients (47%) had refl ux at the esophagogram and 41 the CBD for the cystic duct, but passive injury has been (53%) had no refl ux. Among the GERD- patients, 17 (30%) less completely elucidated. These data show that PassBDI had refl ux and 39 (70%) had no refl ux. Therefore, the were less often detected, and identifi cation of all BDI was sensitivity of esophagogram was 47% and the specifi city hindered when visibility was impaired (mainly by bleeding was 70%. A hiatal hernia was present in 40% and 32% of or infl ammation). Thus, when the surgeon’s attention was patients respectively. Esophagitis was found at endoscopy occupied by infl ammation or bleeding, consideration of an in 16% of GERD+ patients and in 20% of GERD- patients, injury to the bile duct was inhibited. Increased emphasis accounting for a sensitivity of 16% and a specifi city of on this risk factor should help prevent passive injury to the 80%. Esophageal manometry showed no difference in the common hepatic duct. pressure of the lower esophageal sphincter or the quality

of peristalsis. Ambulatory 24-hour pH monitoring clearly Abstracts 670a separated the 2 groups (Table). Monday Gastroesophageal Refl ux Disease (GERD) and Antirefl ux N = 134 GERD+ (78 pts) GERD– (56 pts) p Surgery (ARS): What Is the Proper Preoperative Refl ux score 48 ± 37 6 ± 4 <0.0001§ Work-Up? Heartburn (57) 73% (35) 62% 0.193* Brian L. Bello, Marco Zoccali, Roberto Gullo, Arunas E. Gasparaitis, Mustafa Hussain, Fernando A. Herbella, Marco G. Patti Regurgitation (48) 61% (26) 46% 0.083* University of Chicago, Chicago, IL Dysphagia (39) 50% (31) 55% 0.540* BACKGROUND: Many surgeons feel comfortable per- Refl ux on BE (37) 47% (17) 30% 0.047* forming ARS on the basis of symptomatic evaluation, Hiatal Hernia on BE (31) 40% (18) 32% 0.368* endoscopy and esophageal manometry, while a pH monitoring is seldom obtained. Esophagitis (6) 16% (5) 20% 0.477* AIMS: To analyze the sensitivity and specifi city of symp- LES pressure (mmHg) 18 ± 10 25 ± 26 0.37§ toms, barium esophagogram, endoscopy and manometry Normal peristalsis (53) 68% (45) 80% 0.110* as compared to pH monitoring in the preoperative evaluation of patients for ARS. §Wilcoxon-Mann Whitney test; *Chi-square test; BE = barium esophagram; LES = lower esophageal sphincter; refl ux score normal <14.7 Continuous PATIENTS AND METHODS: 134 patients referred for variables are expressed as mean ± standard deviation. ARS with a diagnosis of GERD based on symptoms, endoscopy, barium esophagogram and manometry. Ambulatory CONCLUSIONS: The results of this study showed that: 24 hour pH monitoring was performed preoperatively in (a) symptoms were unreliable in diagnosing GERD; (b) the all of them. presence of refl ux or hernia on esophagogram did not cor- RESULTS: relate with refl ux on pH monitoring; (c) endoscopy had Based on the presence or absence of GERD on low sensitivity and specifi city; and (d) manometry was pH monitoring, patients were divided into two groups: mostly useful for positioning the pH probe and rule out GERD+ (n = 78) and GERD– (n = 56). The groups were com- achalasia. We conclude that ambulatory pH monitoring pared with respect to the incidence of symptoms, presence should be routinely performed in the preoperative work- of refl ux and hiatal hernia on esophagogram, endoscopic up of patients suspected of having GERD in order to avoid fi ndings, and esophageal motility. useless ARS.

21 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

672 desaturation (RAD) was defi ned as the fi rst O2 desaturation event occurring within a 5-minute interval following A Novel Method for the Diagnosis of Refl ux-Related a refl ux episode. Values are expressed as median ±IQR. Respiratory Symptoms: Normalization of Refl ux- RESULTS: Associated Oxygen Desaturations Following Nissen Patients with typical symptoms had a median of 65, those with respiratory symptoms 64 and normal sub- Fundoplication and Establishment of Normal Values jects 26 distal refl ux events/24 hours. There was no signifi - Candice L. Wilshire, Renato Salvador, Boris Sepesi, Stefan Niebisch, cant difference in refl ux events extending proximally in the Thomas J. Watson, Virginia R. Litle, Christian G. Peyre, 3 groups; 47% (380/804) typical, 45% (1411/3166) respira- Carolyn E. Jones, Jeffrey H. Peters tory and 41% (114/276) in normal subjects. The number Thoracic and Foregut Surgery, University of Rochester Medical of distal refl ux events associated with O2 desaturation was Center, Rochester, NY signifi cantly greater in patients with respiratory symptoms 14 (9–20) than those with typical symptoms 5 (1–6; p < BACKGROUND: Current diagnostic techniques aimed at 0.001) or normal subjects 2 (1–5; p < 0.001). This was also establishing gastroesophageal refl ux disease (GERD) as the true for the number of proximal RADs: 7 (4–13) in patients underlying cause in patients presenting with respiratory with respiratory symptoms versus 2 (0–3; p < 0.001) with symptoms are poor. We previously reported preliminary typical symptoms and 1 (0–2; p < 0.001) in normals. Repeat data suggesting that quantifying the association between study in 8 post-Nissen patients showed marked improve- refl ux events and oxygen desaturation may be a useful ment with RADs approaching those of normal subjects in discriminatory test. The aim of this study was to further 6/8; 20 (9–20) distal pre-operative versus 3 (2–5; p = 0.05) refi ne the proof of principle by assessing whether antirefl ux post-operative; and 12 (2–15) proximal pre-operative ver- surgery normalizes refl ux-associated desaturations and to sus 2 (0–2) post-operative. Two post-operative patients were establish normal values. found to have recurrent GERD; minimal improvement METHODS: Forty seven patients with GERD-related respi- and/or worsening in the number of RADs were identifi ed ratory symptoms, 10 with typical symptoms, and 11 normal in each patient. Using a threshold of 95th %tile of normal subjects underwent simultaneous 24-hour multichan- subjects, the number of RADs equaled or exceeded normal nel intraluminal impedance (MII)-pH and pulse-oximetry in 81% (38/47) of patients with respiratory symptoms. monitoring. Eight patients returned for post-Nissen stud- CONCLUSIONS: These data provide further proof of prin- ies. Acid refl ux episodes were defi ned as pH <4 5 cm (distal) ciple that measurement of the association between refl ux or 20 cm (proximal) above LES and non-acid episodes as events and oxygen desaturation may be a useful discrimi- a drop ≥50% from baseline in impedance 3, 5, 7 or 9 cm natory test in GERD patients presenting with primary above LES (distal) and 15 or 17 cm above LES (proximal). respiratory symptoms, and may predict response to anti- Oxygen (O2) desaturation events were defi ned as a drop in refl ux surgery. O2 saturation <90%, or a decrease ≥6%. Refl ux-associated

10:00 AM – 11:15 AM 26ab QUICK SHOTS SESSION I

extent, including portal vein invasion and lobar atrophy, 673 has been proposed. The aim of this study was to evaluate Staging and Survival of Resected Hilar Cholangiocarci- current staging systems for hilar cholangiocarcinoma and noma: An Analysis of 80 Consecutive Patients identify clinical factors associated with improved survival. Victor M. Zaydfudim, Clancy J. Clark, Michael L. Kendrick, METHODS: In this retrospective cohort study, clinical and Florencia G. Que, Kaye M. Reid Lombardo, John H. Donohue, pathologic characteristics were obtained for all resected Michael B. Farnell, David M. Nagorney patients with Bismuth-Corlette Type IIIa and IIIb hilar cholangiocarcinoma from 1993 to 2011. Patients were Division of Gastroenterologic and General Surgery, Mayo Clinic, stratifi ed by the 7th edition AJCC TNM staging parame- Rochester, MN ters and by the modifi ed Blumgart staging system which INTRODUCTION: Predicting long-term survival in hilar includes portal vein invasion and presence of lobar atro- cholangiocarcinoma is diffi cult. The revised AJCC staging phy. Univariate and multivariate analyses were used to test system has not been extensively evaluated and may not effects of clinicopathologic factors and staging systems on correlate with clinical outcomes. An alternative staging overall survival. system which incorporates factors related to local tumor

22 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: Eighty consecutive patients (median age 64 674 years (range 36–82), 64% male) underwent an anatomic hepatectomy with a bile duct resection and reconstruction Value Analysis of Single Incision Laparoscopic for Bismuth-Corlette IIIa (51%) and Bismuth-Corlette IIIb Cholecystectomy (49%) cholangiocarcinoma. Margin negative resection was Michael Cameron, Vic Velanovich achieved in 94% of resections; 30-day mortality was 10%. Surgery, University of South Florida, Tampa, FL Median follow-up was 26 months (range 0–181 months) BACKGROUND: Single incision laparoscopic surgery with overall median survival of 34 months. Twenty-three (SILS), particularly laparoscopic cholecystectomy (SILS-C), percent of the patients had well-differentiated cholangio- has been advocated as both a means of improving stan- carcinoma. The AJCC staging system stratifi ed patients dard 4-port laparoscopic cholecystectomy (LC) and as a into following groups: T1–26%, T2–58%, T3–16%; N0–61%, stepping-stone to natural orifi ce trans-luminal endoscopic N1–39%; Stage I-20%, Stage II-30%, Stage III-50%. None of surgery (NOTES). Data has been confl icting as to whether

the patients had distant metastases at the time of resec- Abstracts

SILS-C accomplishes its main goals of improved cosmesis Monday tion. Kaplan-Meier estimates did not demonstrate an asso- and less pain, while meeting all other requirements of a ciation between survival and AJCC staging parameters (all cholecystectomy. We performed a value analysis of SILS-C p ≥ 0.121). Blumgart staging system stratifi ed patients into compared to standard LC using the generally accepted defi - following groups: Blumgart T1–58%, Blumgart T2–41%; nition of value = quality/costs. one patient had a Blumgart T3 cholangiocarcinoma with invasion into portal vein bifurcation. Univariate analyses METHODS: The direct supply costs for both SILS-C and LC demonstrated an association of survival with tumor grade from our institution were obtained. In addition, the extant (p = 0.033) and Blumgart T-stage (p = 0.010). One- and fi ve- literature on SILS-C was review for operating room costs, as year survival estimates for Blumgart T1 and Blumgart T2/ well as measures of quality pertaining to pain control and T3 were 86% and 47% vs. 74% and 17% (p = 0.010). After cosmesis were obtained. The incremental costs of each unit adjusting for tumor grade, Blumgart T2/T3 stage correlated of improvement in quality were calculated. with increased likelihood of mortality (HR = 1.93, 95%CI: RESULTS: The direct supply costs of SILS-C was $1,582.90 1.09–3.42, p = 0.024). compared to $753.30 for LC. Published operating room costs were $2,109 for SILS-C compared to $2,069 for LC. However, average reimbursement was $5,602 for SILS- C compared to $6,403 for LC. Assessment of pain varied among study, however, standardizing assessment of pain across studies was done, with SILS-C having a 0.1 unit improvement, for a cost of $400 per unit improvement using published operating room costs. Assessment of cosmesis yield a cost for unit improvement varied between $32-$40. These costs would be more is just the direct supply costs were the primary driver of value and reimbursement is less. CONCLUSIONS: It does not appear that SILS-C provides value for the patient and hospital. Improved pain control and cosmesis is not consistent among studies published, and the costs for each unit improvement variable depend- CONCLUSIONS: While the current AJCC TNM staging ing on which costs data are important, but consistently system did not predict survival in the current study, the higher. Couple this with less reimbursement, the value of Blumgart staging system which emphasizes portal vein SILS-C is questionable. invasion and lobar atrophy predicted overall survival independent of other clinical and pathologic factors. Inclusion of lobar atrophy into the T classifi cation might improve accuracy of the AJCC system, and help defi ne prognosis in patients with hilar cholangiocarcinoma.

23 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

675 676 A Randomised, Single Blind Study of Miniports (3 mm) Versus Conventional Ports in Laparoscopic A Tool for Risk Adjusting Colorectal Surgery Pay for Cholecystectomy Performance Models: Cr-POSSUM Scoring Mark Bignell, Edward Cheong, Michael P. Lewis, Michael Rhodes Jasna Coralic, Kirthi Kolli, Anjali S. Kumar General Surgery, Norfolk and Norwich University Hospital, Section of Colon and Rectal Surgery, Washington Hospital Center, Norwich, United Kingdom Washington, DC BACKGROUND: INTRODUCTION: Single incision laparoscopic cholecys- Pay for performance (P4P) models are an tectomy (SILC) is said to provide improved cosmesis with emerging way of holding physician payment accountable a reduction in postoperative pain, but involves a change for quality of care. Current reimbursement methods entail in operative technique. We have conducted a single-blind, standard payments based solely on procedure performed. randomised controlled trial study of cosmetic outcome and As P4P models are instituted, the current payment system post-operative pain comparing laparoscopic cholecystec- does not account for individual patient morbidity and tomy (LC) using either 3 mm or 5 mm ports. mortality risks. HYPOTHESIS METHODS: 80 patients with symptomatic gallstones were : A simplistic, validated, peri-operative risk recruited from a single centre and randomised to a LC using stratifi cation score (Cr-POSSUM) for lower intestinal sur- either a 10 mm and three 5 mm ports (control) or a 5 mm geries can be used as a risk adjustment tool for reimburse- port and three 3 mm ports. The 5 mm port was extended as ment integrating expected outcomes. necessary at the end of the operation to facilitate removal METHODS: We analyzed single institution retrospective of the gallbladder. Operative details, time and pain scores data for four colorectal and three surgical oncology sur- at 1h, 6h, and 1 week and analgesia required in the 1st geons over a systematic period spanning from 2006–2010 week were collected. for colorectal cases and captured data for 179 patients. Cr- Statistical analysis was undertaken using a paired t-test or POSSUM scores were calculated for each patient and t-test fi sher’s exact test as appropriate. analyses were performed using STATA10. RESULTS: RESULTS: 40 patients were recruited to each group. The Cr-POSSUM scores for each organ system had mean age of the 3 mm group was 53 (±14) compared to broad ranges for small bowel (0.38–25.98), colon (0.68– 52 (±12) in the control group (p = 0.89). There were 11 57.56), rectal (2.30–40.83), and cytoreduction (4.17–24.84) males in the 3 mm group vs. 4 in the control group. One surgeries which attest to the vast array of patient mortal- patient in the control group was converted to open whilst ity despite undergoing similar surgeries. As expected, there 2 patients in the 3 mm group had a 3 mm port converted was a signifi cant difference in scores among those who had to a 5 mm port and 4 patients required the insertion of post-operative complications and those who did not (p < a 10 mm and 5 mm ports. The mean operative time was 0.005). Cytoreductive and rectal surgery had a signifi cant 49 minutes (±12, range 24–120 mins) in the 3 mm group difference in Cr-POSSUM score (p < 0.001) when compared versus 46 minutes (±19, range 21–124 mins) in the control to other organ systems. Surgeons whose practice involved group (p = 0.40). There was no statistical difference in the a high percentage of cytoreductive and/or rectal surgeries day case rate between the 2 groups. The pain scores in the 3 had higher mean Cr-POSSUM scores (p < 0.005) and higher mm group at 1h, 6h, and 1 week were 2.5 ± 2.1, 3.2 ± 2.2, complication rates. and 0.8 ± 2.2 versus 4.2 ± 2.9, 3.3 ± 2.4, and 2.1 ± 2.4 in CONCLUSION: When evaluating a surgeon’s performance the control group (p Value = 0.003, 0.63, and 0.002). The based on outcomes, the Cr-POSSUM score should be used mean daily analgesia score, calculated using the WHO pain for risk adjustment in P4P models for lower intestinal sur- ladder to attribute each class of analgesia a value, was 3.47 geries. Current reimbursement systems to not account for (± 3.2) in the 3 mm group vs 5.21 (±4.8) in the control individual patient risk. group (p = 0.008). CONCLUSION: The use of 3 mm ports is technically feasible in patients undergoing LC for gallstones with comparable operating times to conventional LC with reduced pain scores and need for analgesia.

24 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CRPOSSUM n Mean Cr-POSSUM Score (Range) P-value % Post-Op Complications Organ System small bowel 29 4.1 (0.4–26.0) 0.09 34% colon 65 5.6 (0.7–57.6) 0.3 29% rectal 27 7.9 ( 2.3–40.8) 0.2 40% cytoreduction 35 9.8 (4.2–24.8) 0.002 37% Highest Volume Physicians (case volume %) CRS Doctor 1 (26% rectal) 27 6.6 (0.3–40.8) 0.8 56% Abstracts CRS Doctor 2 (20% rectal) 53 5.8 (0.3–57.6) 0.5 28% Monday Surg Onc Doctor 1 (8% rectal) 25 4.8 (0.5–19.6) 0.3 16% Surg Onc Doctor 2 (94% cytoreduction) 37 9.3 (0.7–24.8) 0.007 39%

RESULTS: For pts with local and regional CC, 181,035 had 677 confi rmed LN examinations. For Stages I-III, there has been A 21-Year Analysis of Lymph Node Trends in Colon a dramatic improvement in compliance for pts with >12 Cancer: Do Quality Measures Really Matter? LNs harvested over the recent two 5-yr periods (19, 21, 18% 1 2,3 1 respectively, p < 0.0001) whereas previously only a 5–7% Danielle M. Hari , Alexander Stojadinovic , Anna M. Leung , increase occurred over time (see Table). This rise in compli- 1 1 4,5 Connie Chiu , Myung-Shin Sim , Anton Bilchik ance had the greatest effect on the increased survival trend 1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica, for stage II CC with minimal change for those with Stage CA; 2. Surgery, Walter Reed National Military Medical Center, I and Stage III CC. Irrespective of LN examined there has Bethesda, MD; 3. Surgery, United States Military Cancer Institute, been a signifi cant increase in OS for all stages over time Bethesda, MD; 4. Surgery, California Oncology Research Institute, (p < .0001). Santa Monica, CA; 5. Surgery, David Geffen School of Medicine at CONCLUSIONS: In the largest time-dependent assessment University of California, Los Angeles, CA of LN examination in CC, signifi cant improvements in sur- BACKGROUND: Lymph node (LN) number has been gical quality measures have occurred over the past decade endorsed as a quality measure (QM) in colon cancer (CC) for Stage I, II and III. These measures have translated into because of the impact on survival. However, the current improvements in OS particularly for Stage II disease. LN mandate requiring >12 LNs has been questioned. We eval- yield alone is not an adequate QM for pts with stage I and uated whether compliance of this QM has improved and III CC. whether this has impacted overall survival (OS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Database was queried to identify patients (pts) with pathologically confi rmed, localized and regional CC (Stage I-III) diagnosed between 1988 and 2008. Interval trends in lymph node (LN) harvest and OS were evaluated over time (Year Strata (YS): 1988–1993, 1994–1998, 1999–2003 and 2004–2008).

1988–1993 1994–1998 1999–2003 2004–2008 > 12 LN > 12 LN > 12 LN > 12 LN (% Pts) 5-yr OS (% Pts) 5-yr OS (% Pts) 5-yr OS (% Pts) 5-yr OS Stage I 15.84% 76.45% 19.04% 78.22% 25.72% 80.54% 44.44% 83.27% Stage II 36.16% 68.69% 40.79% 70.24% 46.21% 71.67% 66.88% 74.26% Stage III 50.57% 45.54% 47.13% 48.57% 52.80% 52.80% 70.65% 56.96%

25 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

678 METHODS: After IRB approval, we conducted a retrospective review of all gracilis muscle transpositions performed Recognizing Risk: Colectomy in the Growing Chronic for complex fi stulas and perineal defects from 1/2001– Renal Failure Population 9/2011. Patients were divided into three groups: rectovagi- James C. Iannuzzi, Andrew-Paul Deeb, Abhiram Sharma, nal fi stulas, rectourethral fi stulas and perineal defects. Aaron S. Rickles, John R. Monson, Fergal Fleming RESULTS: 97 gracilis transpositions were performed in 86 University of Rochester Medical Center, Rochester, NY patients. 43 interpositions were performed in 33 females BACKGROUND: Projections indicate that the number of for rectovaginal fi stulas and 5 for pouch-vaginal fi stulas; people living with chronic end stage renal disease (ESRD) 52% had a mean of 1.5 (1–4) failed repairs prior to gracilis will double in the next 10 years. An increasing incidence interposition. The overall success rate was 89%; with an portends a growing surgical challenge given the high risk 18% post-operative complication rate. 4 patients required from immunosuppression, haemostatic abnormality, and a second gracilis interposition. All Crohn’s disease-asso- nutritional defi ciency secondary to renal failure. There ciated fi stulas (7) healed; however 42% required further exists a paucity of high quality data on the ESRD popula- procedures. 48 interpositions were performed in 42 males tion in abdominal surgery. The authors sought to defi ne for rectourethral fi stulas primarily due to prostate can- the risk of elective colectomy in ESRD using a large and cer treatment (95%); 29% had a mean of 1.2 (1–3) failed representative national clinical database. repairs prior to gracilis interposition. The overall success rate was 95%; with a 26% post-operative complication rate. METHODS: The American College of Surgeons National 6 patients required a second gracilis interposition. 6 trans- Surgical Quality Improvement Program database was que- positions were performed for reconstruction of perineal ried from years 2005 to 2010 for all colectomies. Patient defects in 2 females and 4 males; 33% had a mean of 1.5 demographics, preoperative risk factors and intraoperative (1–3) failed repairs prior to gracilis transposition. The over- variables were recorded. The primary end point was mor- all success rate was 100% with a 33% complication rate. tality at 30 days in dialysis dependent chronic renal failure patients. Chronic renal failure was defi ned by dialysis use CONCLUSION: Gracilis muscle transposition is a versatile prior to index admission excluding patients with acute kid- and effective technique for treatment of complex fi stulas ney injury within 48 hours of colectomy. Univariate (chi- and reconstruction of perineal defects. squared), and multivariate analysis (linear regression) were performed to determine predictors of mortality. 680 RESULTS: The study population included 1685 ESRD Hospital Readmission for Fluid and Electrolyte patients undergoing colectomy, 750 were elective and 935 Abnormalities Following Ileostomy Construction: emergent. Median age was 65, median ASA score was 4 and there were 850 men (50.4%). Overall mortality and mor- Preventable or Unpredictable? bidity was 27.5% and 54.9%. Emergent surgery was asso- Dana M. Hayden, Maria C. Mora P, Amanda B. Francescatti, ciated with an increased mortality {36.3% vs. 16.5% (p > Sarah C. Edquist, Matthew R. Malczewski, Jennifer M. Jolley, 0.0001)} and morbidity {66.5% vs. 40.4% (p > 0.0001)} Marc I. Brand, Theodore J. Saclarides when compared to elective surgery. Eight factors were inde- General Surgery, Rush University Medical Center, Chicago, IL pendent predictors of 30-day mortality: age greater then BACKGROUND: Ileostomy creation has perioperative and 75, functional status, pulmonary, cardiac, hepatic, neuro- postoperative complications, including re-hospitalization logic comorbidity, intraoperative time, and hypoalbumin- for fl uid and electrolyte abnormalities. Although several emia. Hypoalbuminemia doubled the mortality risk (odds studies have identifi ed predictors of this morbidity, read- ratio 2.0 95% CI [1.4, 3.2]). mission rates remain high. CONCLUSION: This study demonstrates that colorectal METHODS: Retrospective chart review was performed on surgery in ESRD confers a greater morbidity and mortal- patients who had an ileostomy created for any surgical dis- ity than previously described. Preoperative optimization of ease by two board-certifi ed colorectal surgeons at a single other organ systems and nutritional status will reduce the tertiary institution January 2008—June 2011. event rate in elective surgery in patients with ESRD. RESULTS: 154 patients were included in this study; 71 679 (46.1%) were female. The mean age and BMI were 49  (range 16–91 years) and 26.9 (13–52), respectively. The Gracilis Transposition Is a Good Option for the most common indications for ileostomy creation were Treatment of Complex Perianal Fistulas and cancer (39.6%) and infl ammatory bowel disease (48.1%). Unhealed Perineal Wounds 115 (74.7%) patients had loop ileostomies constructed; 80 Marylise Boutros, Karla Arancibia, Neha Hippalgaonkar, (51.9%) were performed laparoscopically and 7.8% were created emergently. The readmission rate for fl uid and Fabio Potenti, Giovanna DaSilva, Steven Wexner electrolyte abnormalities was 20.1%, which was 43.7% Colorectal Surgery, CCF, Weston, FL of total re-hospitalizations. Gender, older age, and BMI PURPOSE: We reviewed our experience with gracilis trans- were not associated with readmission. Laparoscopy, loop position for treatment of complex fi stulas and reconstruc- ileostomy and emergency surgery were also not predictive. tion of perineal defects.

26 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Infl ammatory bowel disease and specifi cally Crohn’s dis- of life—at 1 year after treatment. Secondary outcome mea- ease were not signifi cant, nor was previous intestinal resec- sures included retreatment, generic quality of life (SF-36), tion. Cancer was strongly associated with readmission achalasia symptoms, esophageal emptying quantifi ed by (X2 = 4.73, p = 0.03) as was neoadjuvant therapy (X2 = timed barium esophagram (TBE), and abnormal 24 hour 9.20, p = 0.01); after logistic regression, only neoadjuvant ambulatory esophageal pH monitoring (24h pH, as defi ned remained signifi cant. Examination of potential predictors by pH <4.0 for >4.0% of the total time). We enrolled suf- showed preoperative use of narcotics, fi ber, stool softeners, fi cient subjects to detect a clinically signifi cant difference laxatives and anti-diarrheals were not predictive. Preopera- between treatment groups (20 points in the 0–100 ASQ tive and discharge renal function, sodium and magnesium scale). Patients were analyzed according to their assigned levels were not signifi cantly associated; however, increased treatment group. mean potassium level upon discharge trended toward sig- Follow up data were available for 22 subjects who were nifi cance (4.21 versus 4.05, p = 0.089). Stoma and urine initially assigned to PD and 23 who were assigned to HM.

output on the day of discharge were not associated with Abstracts

There were no major differences between the groups at Monday readmission; number of days with ileostomy output >1500 baseline. Five subjects required re-treatment, all of whom ml/24 hours was also not signifi cant. Length of hospital- were initially assigned to PD (22.7%, 95% confi dence ization, postoperative ileus, obstruction or sepsis was not interval [CI] 7.8% to 45.4% as compared with 0%, 95% CI predictive. Postoperative chemotherapy and radiation were 0% to 14.8%, P = 0.02). The mean improvement in ASQ not statistically signifi cant. 52 (34%) patients were given at 1 year, analyzing the last pre-re-treatment observation anti-diarrheals and 22 (14.4%) were given fi ber supple- for re-treated subjects, was 20.9 (standard deviation [SD] ments; neither correlated with readmission. 103 (66.9%) 18.0) among PD patients as compared with 27.5 (SD 21.1) patients had stoma reversal; 4 had ileostomy closure early, among HM patients (mean difference 6.6, 95% CI–5.2 to but only 2 of these patients were readmitted for fl uid and 18.4). Six months after treatment, the mean improvement electrolyte abnormalities. in TBE percent emptying after 5 minutes was 30.4% among CONCLUSIONS: Our results show that only neoadjuvant PD patients as compared with 19.7% among HM patients therapy was signifi cantly associated with hospitalization (mean difference 10.7%, 95% CI–16.7% to 38.2%). Among for fl uid and electrolyte abnormalities. Therefore, this mor- patients who had 24h pH at 6 months, none treated by bidity does not appear to be preventable. Our study implies HM had abnormal acid exposure (95% CI 0% to 16.8%) as that home regimen and follow-up are the main determi- compared with 9.1% (95% CI 1.1% to 29.2%) among PD nants of readmission. Prospective studies focused on dili- patients (P = 0.17). None of the changes in measured symp- gent stoma monitoring by patients and physicians may be toms or quality of life scores were signifi cantly different the key to decreasing readmission rates. between treatment groups. The reduction in lower esophageal sphincter resting pressure was signifi cantly larger 680a among patients assigned to HM (25.5 mmHg [SD14.4] as compared with 14.2 mmHg [SD 17.6], mean difference 11.3 Randomized Controlled Trial of Disease-Specifi c mmHg, 95% CI 0.4 mmHg to 22.2 mmHg). Quality of Life After Laparoscopic Heller Myotomy and Among healthy patients newly diagnosed with achalasia, Pneumatic Dilatation for Newly Diagnosed Achalasia HM does not result in a clinically signifi cant improvement 1 1 2 David R. Urbach , Gail E. Darling , Nicholas E. Diamant , in quality of life as compared with PD. Patients treated ini- Paul P. Kortan1, George A. Tomlinson1, Wayne Deitel1, tially by PD are signifi cantly more likely to require re-treat- Audrey Laporte1 ment as compared with patients treated initially by HM. 1. University of Toronto, Toronto, ON, Canada; 2. Queen’s University, Kingston, ON, Canada Pneumatic dilatation and laparoscopic Heller myotomy with partial fundoplication are both commonly performed for the treatment of achalasia. It is not known whether one procedure is superior with respect to disease-specifi c quality of life. We randomly assigned 50 healthy persons aged 18 years or older who were newly diagnosed with achalasia to either laparoscopic Heller myotomy with partial fundoplication (HM) or to pneumatic dilatation (PD) with a 30 mm balloon at 4 Canadian cities (Kingston, Toronto, Edmonton and Calgary). The primary outcome measure was the Achalasia Severity Questionnaire (ASQ) score—a validated disease-specifi c measure of health related quality

27 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

683 682 Comparison of Perioperative Outcomes After Per-Oral Iron Defi ciency Anemia Is a Common Presenting Esophageal Myotomy (POEM) and Laparoscopic Heller Issue with Giant Paraesophageal Hernia and Resolves Myotomy Following Repair Eric S. Hungness1, Ezra N. Teitelbaum1, Byron F. Santos1, Philip W. Carrott, Sheraz Markar, Jean Hong, Donald Low Fahd O. Arafat1, John E. Pandolfi no2, Nathaniel J. Soper1 Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 1. Surgery, Northwestern University, Chicago, IL; BACKGROUND: Giant Paraesophageal hiatal hernias 2. Gastroenterology, Northwestern University, Chicago, IL (PEH) are most commonly associated with symptoms of INTRODUCTION: Per-oral esophageal myotomy (POEM) chest pain, early satiety and GERD. However, Iron-defi - is a novel procedure for the treatment of achalasia creating ciency anemia is an under-appreciated condition associated a myotomy across the esophagogastric junction (EGJ) with- with giant PEH. The aim of this study was to evaluate the out skin incisions. To date, no study has compared POEM incidence of iron-defi ciency anemia in a cohort of patients perioperative outcomes with the surgical standard-of-care, with giant PEH and assess the incidence of resolution asso- laparoscopic Heller myotomy (LHM). ciated with operative PEH repair. METHODS: A review was conducted of a single-institution METHODS: Between 2000 and 2010, 270 patients under- database to compare outcomes after POEM and LHM. 11 went operative repair of PEH and were prospectively patients underwent POEM from 8/2010—11/2011 under entered into an IRB-approved database. From this cohort, the following IRB-approved inclusion criteria: age 18–85, 123 (45.6%) patients demonstrated a pre-existing diagno prior treatment for achalasia, and non-sigmoid esopha- nosis of iron-defi ciency anemia. 77 patients had a docu- gus. 50 patients were identifi ed who had undergone LHM mented pre-operative hemoglobin level (Hb) consistent from 3/2004—7/2011 and fi t these same criteria. T-tests with iron-defi ciency anemia and a follow-up Hb level at and Fisher exact tests were used to compare results. least 3 months following surgery and constituted the study population. RESULTS: There were 7 (64%) and 26 (52%) male patients in the POEM and LHM groups respectively (p = ns). POEM RESULTS: From the cohort of 77 patients with docu- patients were younger (36 ± 11 vs. 50 ± 16 years; p < 0.01). mented pre-operative iron-defi ciency anemia, 72 (94%) BMI and ASA classifi cations were similar. There was no dif- underwent elective PEH repair, with a median age was 75 ference in duration of symptoms prior to surgery (2 ±5 vs. (range 39–91). Cameron erosions were endoscopically doc- 2 ± 3 years). POEM and LHM had similar procedure times umented preoperatively in 25 patients (32%). The average (121 ± 42 vs. 126 ± 29 min; p = ns). POEM had less EBL (≤10 preoperative Hb value was 11.8 (7.6–16). Postoperatively ml in all cases vs. 91 ± 55 ml; p < .001) but LHM had longer at 3–12 month follow-up, the average Hb level was 13.2 myotomy lengths (8.0 ± 1.1 vs. 8.5 ± 0.7 cm; p = .04). Pain (10.7–17), and at more than 1 year follow-up it was 13.6 scores were similar on the day of surgery (3.3 ± 3.1 vs. 2.1 ± (9.2–17.2) (P < 0.05). Furthermore 90% of patients had a 2.3; p = ns) and on POD#1 (2.5 ± 2.8 vs. 2.1 ± 2.3; p = ns). rise in post-operative hemoglobin level by at least 1g/dL. Patients used similar amounts of narcotics on the day of Anemia was fully resolved postoperatively (Hb ≥ 12.0 in surgery (4.8 ± 5.2 vs. 2.8 ± 4.3 mg morphine equivalents; p females, ≥14.0 in males) in 55 (71%) patients. This resolu- = ns) and POD#1 (6.9 ± 7.7 vs. 4.6 ± 5; p = ns) despite the tion was observed more commonly in women (40/50, 80%) fact that fewer POEM patients received ketorolac (18% vs. than men (15/27, 56%, P < 0.05). Also younger patients 78%; p < .001) due to concern for potential post-op bleed- (<70 years) were more likely to resolve their anemia (29/33 ing in the sub-mucosal tunnel. Length of stay was similar vs. 26/44; P < 0.05) and have a greater post-operative (2.3 ± 3.6 vs. 1.6 ± 2.9 days; p = ns) and all POEM patients Hb (14.0 vs. 13.0 g/dL; P < 0.05) than older patients. 40 except for one were discharged by POD#2. No mortalities patients required preoperative iron supplementation, 29 and 1 major complication occurred in each group: a POEM (73%) were able to discontinue iron following surgery. patient had a contained leak at the EGJ requiring laparo- There was no signifi cant difference in the resolution of ane- scopic drain placement and a LHM patient had a delayed mia in patients with or without Cameron erosions (19/25 esophageal leak requiring thoracotomy for drainage and vs. 36/52, p = 0.54). repair. 3 (27%) minor complications occurred in POEM CONCLUSION: This single institution study shows a high patients, compared with 7 (14%) in LHM patients (p = ns). incidence of iron-defi ciency anemia (45.6%) in patients Per-protocol post-op high-resolution manometry (HRM) with giant PEH. Elective repair results in resolution of and timed barium esophagram (TBE) at six weeks showed the anemia and discontinuation of iron supplementation that POEM patients had decreased basal expiratory EGJ therapy, in more than 70% of patients. This improvement pressures (12 ± 7 vs. 25 ± 10 mmHg, p = .04) and relaxation in Hb is independent of the presence of pre-operative pressures (15 ± 3 vs. 29 ± 17 mmHg, p < .05) and decreased Cameron erosions. This study demonstrates the clinical contrast column heights at 1, 2 and 5-minutes (4, 2 and 2 and potential economic benefi ts of elective PEH repair of vs. 17, 16 and 11 cm), although only signifi cantly at 1 and patients with Giant PEH and iron-defi ciency anemia. 2-minutes (p = .02 and .004). LHM patients did not routinely undergo repeat HRM or TBE.

28 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSIONS: POEM is a feasible procedure for creat- esophagus parameters were recorded by giving 10 swallows ing an endoscopic myotomy for the treatment of achala- of 5 mL of water at 30-second intervals. The analysis was sia. POEM and LHM appear to have similar perioperative performed with the commercial dedicated software. Four- outcomes. Further data are needed to defi ne and compare teen individuals also underwent a concomitant transnasal long-term functional outcomes after POEM. pharyngoscopy. RESULTS: Manometric parameters are depicted in Table 1. 684 The correlation between HRM plots and pharyngeal ana- Anatomo-Physiology of the Pharyngo-Upper tomic landmarks is shown in Figure 1. Esophageal Area in Volunteers at the Light of High Resolution Manometry: Defi ning Normal Values Luciana C. Silva1, Fernando A. Herbella1, Luciano R. Neves1, 1 1 2 Fernando P. Vicentine , Sebastião Pannocchia , Marco G. Patti Abstracts Monday 1. UNIFESP, Sao Paulo, São Paulo, Brazil; 2. Department of Surgery, University of Chicago, Chicago, IL INTRODUCTION: High resolution manometry (HRM) is a recent and valuable tool in the assessment of esophageal motility. The experience with this technology in the evaluation of pharyngeal and upper esophageal disorders is still incipient. This study aims to: (a) defi ne normal values for pharyngo-upper esophageal motility, and (b) correlate HRM plots with pharyngeal anatomic landmarks. METHODS: 29 healthy individuals (mean age 30 years, CONCLUSION: Normal values for pharyngeal, upper 62% males) underwent HRM with a solid-state catheter esophageal sphincter and proximal esophagus parameters with 36 circumferential sensors spaced 1 cm apart posi- have been determined. These results may be applied in tioned to record from the base of the tongue to the esopha- future studies. gus. Pharyngeal, upper esophageal sphincter and proximal

Manometric Values

Pharynx Upper Esophageal Sphincter Proximal Esophagus Peak pressure at 2 cm above 203,8 (160–225,6) Basal pressure 88,5 (65,72–119,55) Amplitude 2 cm below mid UES 64,3 (51,7–100,4) mid UES Contraction duration at 2 cm 471 (349–697) Residual pressure 4,1 (0,85–-7,77) Amplitude 4 cm below mid UES 65,7 (45,7–76,5) above mid UES Start at 2 cm above mid UES to –494 (–541 –419) Relaxation time to nadir 198 (169,7–264) Amplitude 6 cm below mid UES 35,05 (18,8–47,3) UES start Start at 2 cm above mid UES to -235 (-355– –181) Ralaxation duration 698,5 (629,7–773,2) UES nadir Start at 2 cm above mid UES to 212 (183–269) Recovery duration 475 (380,2–561,5) UES end

Data presented as median (interquartile range)

29 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

10:00 AM – 11:15 AM 28cd VIDEO SESSION III: HPB & FOREGUT VIDEOS

685 First, laparoscopic hepatoduodenal lymphadenectomy was performed. Lymphadenectomy started at proper hepatic Robotic Assisted Duval Procedure for Pancreas Divisum artery and continued towards celiac artery. Next, liver seg- and Cystic Neoplasm ment IVb and V were resected laparoscopically with a 2 cm John Rodriguez, Sricharan Chalikonda, Au Bui, Jessica Titus, margin. Matthew Walsh The patient was discharged home in 2 days. Pathology: no Surgery, Cleveland Clinic, Cleveland, OH evidence of tumor in liver or lymph nodes. We present the case of a 35 year old female that was referred for management of recurrent pancreatitis. On pre-operative 688 evaluation she was found to have pancreas divisum with a long narrowed segment of the main pancreatic duct. On Laparo-Endoscopic Single Site (LESS) Distal further review of MRCP images, a cystic lesion was found Pancreatectomy and Splenectomy with in the proximal duct. Our therapeutic goals consisted of Extraction Port resection of the cystic lesion and drainage of the proximal Alexander S. Rosemurgy2, Harold Paul2, Krishen Patel2, duct. She was taken to the operating room and a robotic Edward Choung2, Sharona B. Ross1,2 assisted Duval procedure was successfully completed. We 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa believe that this approach is safe and offers the benefi ts General Hospital, Tampa, FL of minimally invasive surgery for this complex pathology. This is a video of a single incision distal pancreatectomy 686 with splenectomy. A 12 mm vertical incision was made at the umbilicus. A 5 mm defl ectable tip laparoscope was A Year in the Life of a Tubulovillous Adenoma: utilized. The stomach was mobilized and the gastrocolic Combined Endoscopic and Laparoscopic Management omentum was divided. A retractor lifted the liver and the Niket Sonpal, Amit Jain, Patrick Saitta, Truptesh H. Kothari, dissection was carried along the inferior border of the pan- Gregory B. Haber, Paresh C. Shah creas toward the caudal tip of the spleen. The pancreas was divided utilizing a reinforced laparoscopic linear stapler. Lenox Hill Hospital, Hauppauge, NY The specimen was delivered via extraction bag using a 2.2 A 39-year-old male with a large symptomatic tubulovillous cm lateral incision. The diaphragm was irrigated with bupi- adenoma of the fi rst and second portion of the duodenum vacaine solution. The umbilicus was closed in a fi gure-of- was initially managed by endoscopic submucosal resection eight fashion. There was no notable scar. (EMR). The majority of the adenoma was excised by EMR in two stages. However, follow up endoscopy revealed per- 689 sistent adenoma with regrowth to about 30% circumferential involvement of the duodenum and proximity to the Transduodenal Resection of a Ampullary Adenoma ampulla. A laparoscopic trans-duodenal local resection was Robert Grützmann, Marius Distler then performed with primary repair of the medial and lat- Surgery, University Hospital Dresden, Dresden, Germany eral duodenum avoiding a pancreaticoduodenectomy with Ampullary tumors display a favorable prognosis com- excellent oncologic and clinical results. pared with other periampullary tumors. This prognostic difference can be attributed to the early presentation 687 and easy diagnosis by upper gastrointestinal endoscopy Laparoscopic Partial Hepatectomy with Hepatoduodenal and simultaneous histological verifi cation and to biologi- Lymphadenectomy for Early Gallbladder Cancer cal differences that may determine the prognostic superi- ority of these tumors. The therapy of choice is complete Ziad Awad, Keyur A. Chavda resection. In benign cases this can be achieved either by University of fl orida, Jacksonville, FL endoscopic resection or surgical transduodenal resection, Our case is 61year old female with T1b adenocarcinoma whereas malignant tumors should be treated with a pan- of gallbladder found incidentally after laparoscopic chole- creatic head resection and lymphadenectomy. Here we cystectomy for chronic cholecystitis. CT scan showed no describe the technique of transduodenal resection of a ade- evidence of liver lesion. noma of the papilla of Vater. Two 12 mm and four 5 mm ports were used.

30 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

2:15 PM – 3:15 PM 28ab QUICK SHOTS SESSION II

CONCLUSIONS: Hepatic duct diameter increases after Roux- 727 en Y gastric bypass. Patients with prior cholecystectomy Post Roux-en-Y Gastric Bypass Biliary Dilation: Natural have a trend toward increased hepatic duct diameter, though Process or Signifi cant Entity? this change was not statistically signifi cant. A better under- 1 1 2 standing of this phenomenon may limit the need for fur-

Kevin M. El-Hayek , Poochong Timratana , Joseph Meranda , Abstracts ther work-up in patients with incidentally detected biliary Monday 1 1 Hideharu Shimizu , Bipan Chand dilation and help to redefi ne what is considered normal 1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, and abnormal in this population. OH; 2. Imaging Institute, Cleveland Clinic, Cleveland, OH BACKGROUND: Changes in the biliary system after gas- 728 tric bypass are not well defi ned. Dilation may be normal First Time Colonoscopy in the Elderly Yields a High or due to biliary tract pathology, that latter of which is problematic to manage because access to the biliary tree Rate of Curable Colorectal Cancer 1 2 2 following gastric bypass often requires specialized care due Therese Kerwel , Theodor Asgeirsson , Donald G. Kim , to altered anatomy. The purpose of this study is to review Nadav Dujovny2, Rebecca Hoedema2, Heather Slay2, Ryan Figg2, patients who underwent imaging of their biliary system Martin Luchtefeld2 both before and after Roux-en Y gastric bypass in an effort 1. Department of Colorectal Surgery, Grand Rapids Medical to elucidate the effect this operation has on hepatic duct Education Partners/MSU, Grand Rapids, MI; 2. Department of diameter. Colorectal Surgery, Spectrum Health Medical Group/Ferguson METHODS: Using an IRB approved database, patients who Clinic, Grand Rapids, MI underwent laparoscopic Roux-en Y gastric bypass from PURPOSE: The use of screening colonoscopy in the elderly 6/1/2010 and 9/30/2011 were evaluated. Those with imag- has become controversial with the USPSTF recommenda- ing both before and at least 3 months after gastric bypass tion against routine screening in adults aged 76 to 85 years were analyzed. Patients who underwent remote cholecys- as well as lack of Medicare reimbursement. However, early tectomy prior to gastric bypass during this time period were detection of colorectal cancer in healthy elderly patients included in subgroup analysis. Data collected included may prevent morbidity and mortality from late presenta- patient demographics, operative details, post-operative tion. This study aims to determine cancer detection rates weight loss, and time interval between surgery and second in the elderly undergoing outpatient index colonoscopy imaging. Indications for post-operative imaging included and cancer detection for repeat colonoscopy in the same abdominal symptoms. For purposes of this study, all imag- population. ing was re-reviewed by a radiologist whereby the common METHODS: hepatic duct was measured at the level of the porta hepatis We identifi ed 903 outpatient exams in to determine interval changes. patients 76 to 85 years over a 2-year period (1/09–12/10). Patient demographics, exam indication and gross fi ndings RESULTS: A total of 551 patients underwent Roux-en Y were noted. Inpatient and outpatient charts were reviewed gastric bypass during the study period. Of these, 82 had for the pathology reports and previous history of colonos- biliary imaging both before and after surgery. Thirty-three copy in the subjects. patients had post-operative imaging at least 3 months fol- RESULTS: lowing gastric bypass. Mean age was 44 years (21–65) and Indications for all exams were as follows: 79% were female. There were 8 patients who had remote screening (19.7%), surveillance (34.0%), symptom clari- cholecystectomy prior to gastric bypass and 25 patients fi cation (25.6%), and multiple symptoms or indications with gallbladders. In all 33 patients, mean hepatic duct (12.0%). Carcinoma detection rate was 2.3%, adenoma diameter was 5.2 ± 2 mm and 7.1 ± 2.6 mm pre-operatively detection rate 23.8% and normal exam or insignifi cant and post-operatively respectively (p < 0.01). Patients with polyps 70.3%. Among patients documented to be undergo- prior cholecystectomy had hepatic duct diameters of 7.9 ± ing colonoscopy for the fi rst time, the carcinoma detection 1.3 mm and 9.5 ± 3.5 mm pre-operatively and post-opera- rate was 9.4% (5/53), this was statistically signifi cant when tively respectively (p = 0.3). Patients who had not previously compared to the rest of the group who had all previously undergone cholecystectomy had hepatic duct diameters of had a colonoscopy (P = 0.01). Carcinoma detection rate was 4.3 ± 1.1 mm and 6.4 ± 1.8 mm pre-operatively and post- 5.4% if the previous colonoscopy was 10+ years prior. 63% operatively respectively (p < 0.01). Overall excess weight of the carcinomas found in the index colonoscopy group loss was 26.8% at a mean follow-up of 8 months (3–14). and in patients undergoing repeat colonoscopy 10+ years

31 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

later were stage 1 or 2 and 38% were in stage 3. There were appendicitis (n = 22,50%), followed by nonspecifi c abdom- no cases with metastasis. Subjects who had a previous colo- inal pain (n = 10, 22.7%), increasing abdominal girth, noscopy within 3 years and 4–5 yrs ago had a 2.8% (6/213) and incidental diagnosis (n = 5, 11.4%). Nineteen patients and 0% carcinoma detection rate respectively. When colo- (43.2%) had a CT score of zero, 20 patients (45.5%) had noscopies are stratifi ed by indication, anemia had the high- a socre of one, and 5 patients (11.4%) a score of two. The est yield with 3.9% rate of carcinoma followed by GI blood mean PCI was 8.2 (range 0–27). A total of 22(50%) patients loss at 3.3%. Indications predicting a low yield were single were upstaged when surgically explored, mostly in patients symptoms such as altered bowel habits, abdominal pain or with a CT score of zero (n = 6, 27.3%) and one (n = 13, weight loss (rate 0%). Screening and surveillance had rates 59.1%). Preoperative variables including age, sex, tumor of 1.7% and 2.3%, respectively. marker levels, PCI score, or presentation with a perforated CONCLUSIONS: The majority of outpatient exams in the appendix did not predict upstaging of disease burden. Esti- elderly reveal insignifi cant fi ndings, demanding too much mated blood loss and PCI were associated with upstaging from limited resources. However, detection of carcinoma (OR = 1.007, 1.782 and p-value = 0.023, 0.0007 respec- according to timing of the most recent exam has a much tively). For the entire cohort, the median survival was 22 higher yield than indication. The highest rates of carci- months. Patients with CT score zero had a 25th percentile noma are among elderly patients undergoing outpatient survival of 34 months, compared to those with a score of colonoscopy for the fi rst time or after more than 10 years 1 (23 months), and a score of two (18 months). With a and results in acceptable rates of curative colorectal cancer median follow-up 23 months, twenty two patients (50%) resection. Early detection should reduce the morbidity of remain disease free, 11 patients (25%) are alive with disease late presentation and surgical emergencies often seen in and 8 patients have died due to disease recurrence. this population. Further guidelines designed to effi ciently CONCLUSION: Accurate assessment of disease burden for utilize resources should focus on minimizing redundant early stage PMP remains challenging. Our data indicates exams unlikely to yield signifi cant results while supporting that approximately 50% of patients with no evidence of screening exams with high yield. disease or minimal amount of disease can be upstaged at surgery. Based on this we recommend laparoscopic explora- 729 tion and possible cytoreductive surgery and hyperthermic chemoperfusion (HIPEC) for all patients with appendiceal Pre-Operative Imaging Does Not Accurately Stage cancer. Patients with Early Stage Appendiceal Cancer Mohammed A. Alzahrani, Hanseman Dennis, Jeffrey Sussman, 730 Syed A. Ahmad Surgical Oncology, University of Cincinnati, Cincinnati, OH Pelvic Radiation Increases the Risk of Ileal Pouch Failure in Patients with Colorectal Cancer Complicating INTRODUCTION: Pseudomyxoma perotenei(PMP)is a Infl ammatory Bowel Disease rare clinical entity that mainly originates from appendiceal Xianrui Wu1, Pokala R. Kiran1, Feza H. Remzi1, Saurabh Mukewar2, tumors. A subset of patients are referred after management 2 of their primary tumor (i.e.appendectomy) for evaluation of Bo Shen cytoreductive surgery (CRS)and hyperthermic intraperito- 1. Department of Colorectal Surgery, The Cleveland Clinic neal chemoperfusion(HIPEC).Some of these patients have Foundation, Cleveland, OH; 2. Department of Gastroenterology, no visible disease on radiographic imaging and the value of The Cleveland Clinic Foundation, Cleveland, OH further surgery in this subset remains controversial. BACKGROUND: The impact of preoperative radiation METHODS: Our single institution’s Peritoneal Cancer therapy on pouch function and survival has NOT been Database was reviewed over a ten year period.During this studied in ulcerative colitis (UC) patients with colorectal time over 200 patients were treated with appendiceal can- cancer (CRC) who undergo restorative proctocolectomy cer.We identifi ed 44 patients who meet the criteria for none with ileal pouch-anal anastomosis (IPAA). The aim of this or minimal residual disease at pre-operative imaging. A CT study was to evaluate pouch outcomes in UC-CRC-IPAA scoring system incorporating the peritoneal carcinomatosis patients with or without preoperative radiation therapy. index (PCI) was devised where a score of zero denoted a METHODS: Patients with UC-CRC who underwent restor- normal scan, a score of one signifi ed a possible minimal ative proctocolectomy with IPAA from 1984–2009 were disease, and a score of two denotes a more obvious local- evaluated. Patients who underwent IPAA for medically ized disease. This cohort of patients was reviewed for basic refractory IBD or familial adenomatous polyposis, and demographic,clinical,and pathological features. Operative patients whose initial pouch confi guration was other than treatment and postoperative course were also highlighted. J or S type were excluded. Pouch failure was defi ned as the RESULTS: Forty four patients, 15 males and 29 females, requirement of permanent diversion or pouch excision. with a mean age of 50.4 years met the inclusion criteria The effect of pelvic radiation on pouch related outcomes for none or minimal disease according to the proposed was evaluated. CT score. The commonest initial presentation was acute

32 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Demographic and Clinicopathological Characteristics RESULTS: A total of 63 pouch patients with confi rmed UC-CRC were included (37 male and 26 female). Mean age Without With at pouch surgery was 46.9 ± 10.6 years. Of the 63 patients, All Pelvic Pelvic loop ileostomy was not closed in 2 patients, and 5 were lost Characteristic Cases Radiation Radiation P Value to follow-up. Of the 56 patients eligible for fi nal analysis, 9 Number of patients 63 52 11 patients received pelvic radiation. Among them, 5 patients had neo-adjuvant radiation, 2 received adjuvant radiation Histologic type, n (%) 0.69 after colectomy but before IPAA, while 2 had prior radia- Adenocarcinoma 54 44 (84.6%) 10 (90.9%) tion for previous cervical cancer. Pouch failure occurred Mucinous adenocarcinoma 9 8 (15.4%) 1 (9.1%) in 13 patients after a median follow-up of 66.4 (range: 2.7–322.2) months, and 4 (30.8%) of them had radiation Synchronous dysplasia, 34 31 (59.6%) 3 (27.3%) 0.051 therapy. Causes of pouch failure included pouch/anal tran- n (%)

sition zone (ATZ) cancer (n = 4), chronic pouchitis (n = 3), Abstracts Histologic grade of tumor, 0.43 pouch stricture (n = 3), pelvic abscess (n = 2), and incon- Monday n (%), tinence (n = 1). Pelvic radiation correlated signifi cantly Poor 20 16 (32.7%) 4 (50.0%) with chronic pouchitis (p = 0.024). There was, however, no association between pelvic radiation and pouch/ATZ can- Well to moderate 37 33 (67.3%) 4 (50.0%) cer, pouch stricture, pelvic abscess, and pouch fi stula/sinus Tumor location, n (%) 0.005 (p > 0.05, Table). Kaplan-Meier analysis revealed that pelvic Rectum 26 17 (32.7%) 9 (81.8%) radiation was associated with poor pouch outcome (log- rank test, P < 0.001, Figure). The impact of pelvic radiation Colon 37 35 (67.3%) 2 (18.2%) on pouch outcome was further confi rmed in the subgroup TNM stage, n (%) 0.008 analysis of rectal cancer patients (log-rank test, P = 0.020, Figure). 0 + I + II 35 33 (63.5%) 2 (18.2%) III + IV 28 19 (36.5%) 9 (81.8%) Neo-adjuvant 6 0 (0.0%) 6 (54.5%) <0.001 chemotherapy, n (%) Adjuvant chemotherapy, 26 29 (36.5%) 7 (63.6%) 0.176 n (%) Conﬁ guration of pouch, 0.10 n (%) J pouch 50 39 (75.0%) 11 (100.0%) CONCLUSIONS: S pouch 13 13 (25.0%) 0 (0.0%) Pelvic radiation even before IPAA creation is signifi cantly associated with poor pouch outcomes Method of anastomosis, 0.73 in this small sample-sized, yet the largest study in the litera- n (%) ture. This information needs to be considered and discussed Stapled 31 25 (51.0%) 6 (60.0%) with patients with prior RT undergoing IPAA. Further, the potential oncological benefi ts of chemo-radiation should Hand-sewn 28 24 (49.0%) 4 (40.0%) be carefully balanced against any potential adverse effects Hospitalization, days 8.1±3.5 8.0±3.6 8.1±2.8 0.95 on functional results on a case by case basis when deciding Pelvic abscess, n (%) 9 7 (14.9%) 2 (22.2%) 0.63 management of UC patients with CRC. Pouch ﬁ stula/sinus, n (%) 8 7 (14.9%) 1 (11.1%) 0.77 Pouch stricture, n (%) 16 14 (29.8%) 2 (22.2%) 0.72 Chronic pouchitis, n (%) 18 12 (25.5%) 6 (66.7%) 0.024 Pouch/ATZ neoplasia, n (%) 7 6 (12.8%) 1 (11.1%) 0.89

33 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

731 cally sizes to the esophageal lumen. One to two ablations were performed in separate areas in each patient in mucosa Initial Human Experience with a Novel Through- proximal to the tumor. After resection, the ablation sites the-Scope Cryoballoon Device for Mucosal Ablation were removed as a full-thickness block and examined his- Steven R. DeMeester1, Omar Awais3, Jacques J. Bergman2, tologically by a central study pathologist. Symptoms were Kimberly S. Grant1, Blair A. Jobe3, Stefan Niebisch4, assessed prior to ablation, on the day of and 3 days after Jeffrey H. Peters4, Dirk Schölvinck2, Mark I. van Berge the procedure using a standardized questionnaire with a Henegouwen2, Bas L. Weusten2 10-point scale. 1. Surgery, Univ. of Southern California, Los Angeles, CA; RESULTS: Twenty-one ablations were performed in 13 2. Gastroenterology, Academic Medical Center, University of patients for 6, 10, 12 or 14 seconds, and the esophagus was Amsterdam, Amsterdam, Netherlands; 3. Surgery, University removed 0, 4 or 7 days after the procedure. The ablation of Pittsburgh, Pittsburgh, PA; 4. Surgery, University of Rochester, was in squamous mucosa in 12 patients and in dysplastic Rochester, NY Barrett’s in 1 patient. There were no adverse events and no perforations. No pain was present in 78% of patients the INTRODUCTION: Ablation of Barrett’s with high-grade day of the procedure and in 89% of patients 3 days after dysplasia has become standard. The most common abla- the procedure. The mean scores for pain on the day of and tion technique uses radiofrequency energy, but a drawback at 3 days after the procedure were 0.89 and 0.2 respectively. is the requirement that the devices be used either separate Swallowing diffi culty was present in 11% on the day of and from or attached to the outside of an endoscope. An alter- in 22% at 3 days after the procedure. The mean scores for native is cryoablation, but current cryotherapy devices are swallowing diffi culty on the day of and at 3 days after the cumbersome, require gastric venting, and ablation depth is procedure were 0.3 and 0.6 respectively. Details of the his- diffi cult to standardize. A device that goes down the work- tology are shown (Table). ing channel of an endoscope that delivers a uniform and CONCLUSIONS: reproducible ablation would potentially be safer and more Ablation with a novel cryoballoon device user-friendly. The aim of this study was to assess depth of for 10–14 seconds results in substantial mucosal injury with injury related to time of ablation using a novel through- minimal pain or impaired swallowing. Depth of necrosis the-scope balloon-based cryotherapy device. was maximal at day 4 and was typically into the superfi cial muscularis propria. By 7 days the injury was resolving, a METHODS: Patients with esophageal cancer were enrolled fi nding similar to previous work with this device in ani- in a multi-center prospective trial evaluating a novel cryo- mals. Major advantages of this device include the ability balloon ablation device prior to esophagectomy. The to standardize the ablation along with the ease of use and device is a through-the-scope, highly compliant balloon quickness of the procedure. Future studies will assess the catheter that is infl ated and cooled by an inert refrigerant risk of stricture and effi cacy for Barrett’s ablation with this delivered from a handheld unit. The balloon automati- device.

Day (Post-Esophagectomy) 0 0 0 0 4 4 4 7 7 7 Ablation time (sec) 6 10 12 14 10 12 14 10 12 14 n 1 1 1 4 4 2 5 1 1 1 Circumferential mucoscal ablation; Avg 30% 80% 50% 3.75% 64% 80% 68% 15% 0 100% and (range) when n>1 (0–10) (25–90) (65–95) (50–80) Depth of necrosis* Avg, (range) 1 1 1 1 (0–1) 3 (3–3) 3 (2–4) 3 (2–4) 1 1 2 Adjacent injury* Avg, (range) 0 0 0 1 (0–1) 2 (0–3) 3 (2–4) 2 (0–3) 0 0 2 *Key: 0 = no necrosis; 1 = necrosis only involving mucosa including or superﬁ cial to muscularis mucosa; 2 = necrosis into but not through submucosa; 3 = necrosis into superﬁ cial muscularis propria; 4 = necrosis involving full-thickness of muscularis propria, no perforation

34 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

732 733 A Multicenter Randomized Trial Comparing Two Indirect Costs of Mortality and Morbidity and Direct Ablation Regimens for Focal Radiofrequency Ablation Economic Costs in a Randomized Controlled Trial of of Barrett’s Mucosa Using the HALO90 System Emergency Therapy of Bleeding Esophageal Varices in Frederike G. van Vilsteren1, Lorenza Alvarez Herrero2, Cirrhosis Roos E. Pouw1, Kai Yi N. Phoa1, Carine Sondermeijer1, Marshall J. Orloff1, Jon I. Isenberg1, Florin Vaida2, Mike Visser3, Fiebo J. ten Kate3, Mark I. van Berge Henegouwen4, Henry O. Wheeler1, Kevin Haynes1, Horacio Jinich-Brook1, Bas L. Weusten2, Erik J. Schoon5, Jacques J. Bergman1 Roderick C. Rapier1, Robert J. Hye1, Wendy Max3 1. Gastroenterology, Academic Medical Center, Amsterdam, 1. Surgery, University of California, San Diego, San Diego, CA; Netherlands; 2. Gastroenterology, St Antonius Hospital, Nieuwegein, 2. Family and Preventive Medicine/Biostatistics and Bioinformatics, Netherlands; 3. Pathology, Academic Medical Center, Amsterdam, University of California, San Diego, San Diego, CA; 3. Institute for Abstracts Netherlands; 4. Surgery, Academic Medical Center, Amsterdam, Health and Aging, University of California, San Francisco, San Monday Netherlands; 5. Gastroenterology, Catharina Ziekenhuis, Francisco, CA Eindhoven, Netherlands OBJECTIVE(S): Economic cost is an important mea- BACKGROUND: The currently recommended regimen sure of effectiveness of treatment of cirrhosis and bleed- for endoscopic focal radiofrequency ablation (RFA) of Bar- ing esophageal varices (BEV). There have been no reports rett’s esophagus (BE) comprises two applications of energy, of costs of any form of emergency treatment of BEV. We cleaning of the device and ablation zone, and two addi- examined costs of care in a randomized controlled trial tional applications of energy. A simplifi ed regimen may be (RCT) that compared endoscopic sclerotherapy (EST) (n = of clinical utility, if it were faster, easier and equally safe 106) to emergency portacaval shunt (EPCS) (n = 105), in and effective. unselected, consecutive patients (“all comers”). AIM: To compare the effi cacy of two focal RFA regimens. METHODS: Diagnostic workup and treatment were undertaken within 8 hours. Crossover rescue treatment was METHODS: In 3 centers, consecutive patients scheduled applied when primary therapy failed according to clearly for endoscopic focal RFA of BE were enrolled having fl at defi ned criteria. 96% of patients underwent 10+ years fol- type BE with at least 2 BE islands or mosaic groups of islands low-up, or until death. (each less than the surface area of two HALO90 ablation catheters). Targeted BE areas were paired according to simi- Indirect costs measured by the economic value of prema- lar size: one of each area was randomized to the ’standard’ ture death (mortality) and by days lost from work (morbid- regimen (2 × 15J/cm2-clean-2 × 15J/cm2) or “simplifi ed” ity) were determined from tables of life expectancy, average regimen (3 × 15J/cm2-no clean), allocating the second area earnings at each age, labor force participation rates, and automatically to the other regimen. The % surface area of an integrating computer program. Direct costs were deter- each target was scored at 2 months by the endoscopist, mined from complete data on all inpatient and outpatient who was blinded to patient and regimen type. Patients charges by hospitals and physicians for 10 years. underwent RFA every 2 months until complete histological RESULTS: Indirect costs were signifi cantly lower follow- response of each targeted BE area was achieved for neopla- ing EPCS than after EST (p < 0.001) based on (1) costs of sia and intestinal metaplasia (CR-N; CR-IM). Primary out- mortality measured by shortened life expectancy; and (2) come: CR-IM for each target at 2 months (non-inferiority costs of morbidity incurred by days lost from productive defi ned as <20% difference in the paired proportions, sam- activities. When added to direct costs (hospitalization, out- ple size calculated at 46 pairs). Secondary outcome: surface patient care, physician services), total costs following EPCS regression (%) for each target at 2 months. were signifi cantly lower than after EST (p < 0.001). RESULTS: Forty-fi ve equivalent pairs of target BE areas CONCLUSIONS: In this RCT of emergency treatment of were randomized by Dec ’11, in 40 patients (29 male, age BEV in cirrhosis with regular follow-up for 9.6 to 10+ years, 64 ± 12 years, BE C4M7). The proportion of targets show- indirect costs (mortality and morbidity) were signifi cantly ing CR-IM at 2 months after focal-RFA was 30/45 (66.7%) lower following EPCS than after EST. Combining indirect for standard and 33/45 (73.3%) for simplifi ed: a difference and direct costs, overall costs of EPCS were signifi cantly of 6.7% (95%CI–12.2 to +25.6). The median surface regres- less than costs of EST. Results of this fi rst reported analysis sion for each target at 2 months was 100% in both groups, of economic costs of emergency treatment of BEV, when whereas for not completely eradicated areas this was 77.5% added to other benefi ts of EPCS observed in this RCT, pro- (IQR50–90)% for standard and 75% (IQR50–90) for sim- vide support for EPCS as a fi rst-line emergency treatment plifi ed (p = 1.0). No complications occurred. By Dec ’11, of BEV. CR-IM and CR-N was achieved in 91.1% (31/34) and 100% of patients, whereas 7 patients are under treatment. CONCLUSIONS: The results of this multicenter randomized trial suggest that a simplifi ed 3x15J/cm2 focal ablation regimen is not inferior to the standard regimen. Therefore, the simplifi ed regimen may be recommended for residual Barrett’s islands.

35 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

bined procedures were less common in 2009 compared to 734 2005 (OR; 95% CI, 0.7; 0.5, 0.8), and RYGB+C patients were Does Concomitant Cholecystectomy at Time of more likely to receive an open operation (4.9; 4.4, 5.5), to Roux-en-Y Gastric Bypass Impact Adverse Operative have a severe ASA score (1.2; 1.0, 1.3), and be functionally dependent (2.1; 1.4, 3.0). Post-operatively, the percentage Outcomes? of RYGB+C patients experiencing a major complication 1 2 1 Robert B. Dorman , Wei Zhong , Anasooya A. Abraham , was signifi cantly greater compared to RYGB alone patients Sayeed Ikramuddin1, Waddah B. Al-Refaie1, Daniel B. Leslie1, (6.6% vs 4.9%, P < 0.001). While risk was increased for Elizabeth Habermann1 RYGB+C patients for developing septic shock (P = 0.02), 1. Surgery, University of Minnesota, Minneapolis, MN; acute renal failure (P = 0.01), prolonged intubation (P = 2. Biostatistics, University of Minnesota, Minneapolis, MN 0.001), and return to the operating room (P < 0.001) on univariate analysis, only return to the operating room was BACKGROUND: Previous investigations of the short-term signifi cant in multivariate adjustment models (1.3; 1.0, operative outcomes associated with a concomitant cho- 1.7). Overall, RYGB+C was a risk factor for predicting major lecystectomy at time of Roux-en-Y gastric bypass (RYGB) adverse events following laparoscopic procedures but not for obesity are mixed and confi ned to the biases of single- open (Table). Prolonged LOS was more common among center experiences. Using a robust multi-hospital surgical RYGB+C patients who underwent either laparoscopic database, we sought to determine the infl uence of concom- (13.5% vs 9.5%, P < 0.001) or open (14.1% vs 9.6%, P < itant cholecystectomy (RYGB+C), hypothesizing that the 0.001) RYGB following adjustment (Table). Overall mortal- addition of cholecystectomy will adversely impact opera- ity at 30-days (0.2%) was low and did not vary with con- tive outcomes following RYGB. comitant cholecystectomy (0.35% RYGB+C vs 0.19% RYGB METHODS: Patients who underwent a RYGB were iden- alone, P = 0.16) following adjustment for confounding tifi ed in the 2005–2009 American College of Surgeons variables (Table). National Surgical Quality Improvement Program (ACS- CONCLUSION: The risk for major adverse events is signifi - NSQIP) database. Demographic and outcome variables cantly greater for RYGB+C patients following laparoscopic were compared between patients that underwent RYGB procedures, and the risk for PLOS is greater for RYGB+C alone versus RYGB+C using univariate analysis. Multi- patients following both open and laparoscopic procedures. variate logistic regression with adjustment for confound- While thirty-day mortality was greater, it was not signifi - ing variables was utilized to identify risk factors for major cantly associated with concomitant cholecystectomy. The adverse events, prolonged length of stay (PLOS), and mor- short-term risks identifi ed in this study can assist in deci- tality at 30 days. Prolonged LOS was defi ned as those who sion making when considering concomitant cholecystec- experienced a hospital stay beyond the 90th percentile. tomy at the time of RYGB. RESULTS: We identifi ed 32,946 patients who underwent RYGB; of these, 1,731 (5.2%) underwent RYGB+C. Com-

Predictors of Major Complications, PLOS, and Mortality After RYGB

Major Events+ N = 32880 Open OR (95% CI) Laparoscopic OR (95% CI) Prolonged Length of Stay+ 30-Day Mortality Predictors N = 4276 N = 28604 N = 32880 OR (95% CI) N = 32946 OR (95% CI) RYGB+C vs RYGB Alone 0.8 (0.6, 1.2) 1.3 (1.0, 1.7) 1.5 (1.3, 1.8) 1.2 (0.5, 2.9) Age (Years) 35–49 50–64 ≥65 Ref. 1.3 (1.0, 1.7) Ref. 1.2 (1.0, 1.4) Ref. 1.3 (1.2, 1.5) Ref. 1.4 (0.8, 2.4) 0.9 (0.5, 1.6) 1.2 (0.9, 1.7) 1.9 (1.5, 2.2) 2.3 (0.9, 5.9) BMI (kg/m2) 45–49 50–54 Ref. 1.4 (0.9, 1.9) Ref. 1.0 (0.8, 1.2) Ref. 1.1 (1.0, 1.2) Ref. 1.9 (0.8, 4.5) 55–59 ≥ 60 1.3 (0.9, 1.9) 1.8 (1.2, 2.5) 1.3 (1.0, 1.6) 1.3 (1.0, 1.6) 1.4 (1.2, 1.6) 1.6 (1.4, 1.8) 2.1 (0.8, 5.3) 3.8 (1.7, 8.6) Open Surgery — — 0.9 (0.8, 1.0) 2.2 (1.3, 3.8) Diabetes 1.3 (1.0, 1.7) 1.0 (0.9, 1.1) 1.1 (1.0, 1.2) 2.1 (1.2, 3.5) Cardiac Co-morb. 1.6 (1.0, 2.5) 1.2 (0.9, 1.6) 1.4 (1.2, 1.7) 3.3 (1.7, 6.6) Total Events N (%) 366 (8.5) 1224 (4.3) 3213 (9.8) 66 (0.2) C-Index of model 0.61 0.58 0.62 0.77

Abbreviations: OR, odds ratio; CI, confi dence interval; BMI, body mass index; Co-morb., co-morbidities. Signifi cant values are bolded and italicized. Variables also adjusted for include, but are not limited to, race, sex, pulmonary comorbidities as well as preoperative liver enzymes, white blood cell count, hemoglobin, albumin, and sodium. Prolonged LOS was defi ned as those who experienced a hospital stay beyond the 90th percentile. Note: +Only patients discharged alive were included.

36 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

735 hemoglobin values were respectively 5.3%, 5.2%, 5.4%, and 5.4%. 94% of diabetics with more than 1 year follow Weight Loss and Metabolic Profi les of Obese Patients up were under no treatment; glycemia was under 100 mg/dl in After Single-Anastomosis Duodeno-Ileal Bypass with 88% of them and glycated hemoglobin under 6% in 92% of Sleeve Gastrectomy (SADI-S) them. The rate of dyslipemia fell from 64 to 20%. No vom- Andrés Sánchez-Pernaute1, Miguel Angel Rubio-Herrera2, its or alkaline refl ux have been observed. Mean number of Pablo Talavera1, Elia Pérez-Aguirre1, Antonio J. Torres García1 daily bowel movements is 2.5. Five patients suffered at least 1. Surgery, Hospital Clínico San Carlos, Madrid, Spain, Madrid, one episode of clinical hypoproteinemia, and 3 of them Madrid, Spain; 2. Endocrinology, Hospital Clínico San Carlos, presented it recurrently. Two patients have been revised to Madrid, Madrid, Spain a Roux-en-Y duodenal switch with a 3 meter alimentary limb and a 2 meter common channel. Now no patient has INTRODUCTION: Single-anastomosis duodeno-ileal suffered any intestinal obstruction. bypass with sleeve gastrectomy (SADI-S) is a simplifi ed Abstracts duodenal switch in which the duodeno-ileal diversion is Monday performed in one loop at 200 to 250 cm from the ileo-cecal valve. Theoretical advantages of the technique are a shorter operative time, the reduction to only one anastomosis and the non-opening of the mesentery. AIM: To analyze the weight evolution and the improvement of the metabolic profi les of obese patients submitted to SADI-S. PATIENTS AND METHODS: 102 patients have been submitted to SADI-S as a primary bariatric operation consecutively since May–2007 (Clinical Trials NCT01463904). There were 64 women and 38 men. Mean age was 48 years (22–71), mean weight 119 kg (72–164) and mean excess weight 53 kg (27–99). There were 65 type-2 diabetics, 41% of them on insulin therapy. Mean preoperative glycemia was 153 mg/dl and mean glycated hemoglobin 9.5%. There were 64 patients with dyslipemia and 57 patients had criteria of metabolic syndrome. The operation was performed laparoscopically in 96% of the cases. The sleeve gastric resection was always performed over a 54 French bougie; the duodeno-ileal anastomosis was performed at 200 cm from the cecum in the fi rst 50 patients and at 250 cm in the next 52, to decrease the 6% rate of clinical hypoproteinemia. One self-limited anastomotic leak and 2 gastric CONCLUSIONS: SADI-S is a simplifi ed duodenal switch leaks were registered. There were no postoperative deaths. that offers a satisfactory weight loss and very good meta- RESULTS: Mean excess-weight loss was 78% at 6 months, bolic results. The preservation of the pylorus makes unnec- 94% at 1 year, 100% at 2 years, 93% at 3 years and 108% essary the performance of a Roux-en-Y diversion. The at 4 years. Only one patient failed to achieve a 50% excess- technique reduces operative time and postoperative com- weight loss. Mean glycemia fell to 94 mg/dl in the fi rst plications, in the short term by reducing the number of year, 93 mg/dl in the second one, 91 mg/dl in the third and intestinal anastomosis and in the long term by decreasing 95 mg/dl in the fourth postoperative year. Mean glycated the possibility of internal hernia.

37 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

736 patients was 2. In two patients there was complete resolution of the leak, one requiring a second clip placement. The Initial Experience with an Innovative Endoscopic third patient had a contained leak following clip placement Clipping System that was followed clinically, follow up swallow study at six Alisa M. Coker1, Marcos Michelotti1, Nikolai A. Bildzukewicz1, days showed improvement, and she was discharged home. Takayuki Dotai1, Luciano Antozzi1, Geylor A. Acosta1, Two patients had gastro-gastric fi stulas following roux-en-y Santiago Horgan1, Bryan J. Sandler1, Mark A. Talamini1, gastric bypass surgery. One of these patients had complete Thomas J. Savides2, Garth R. Jacobsen1 resolution of the fi stula. The other had initial success but 1. Surgery, UCSD, La Jolla, CA; 2. Gastroenterology, UCSD, the clip displaced and fi stula recurred. Two patients pre- La Jolla, CA sented with anastomotic leak following colon resection. In one case the patient had extensive adhesions resulting in a Introduction: There are few options available for treatment rigid colon and the Ovesco system on a pediatric scope was of fi stulas, leaks, and perforations endoscopically. Here we too large to reach the fi stula, so the procedure was aborted. describe our experience with a new endoscopic clipping In the second case, the leak was successfully treated with system. a single clip. Three patients were successfully treated for METHODS: A retrospective review of all cases using the esophageal perforation. One had a 9 mm mid-esophageal Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tue- perforation that required staged placement of two clips. bingen, Germany) between August 2011 and November One had two separate distal esophageal perforation sites, 2011. Resolution of leak was determined by a swallow each requiring one clip. The fi nal esophageal perfora- study or CT scan. tion was treated with a single clip. The average operative RESULTS: time for clip placement was 61 minutes. There were no The system was utilized in ten patients with complications. clinically signifi cant gastrointestinal surgical complications. Three patients were referred for treatment of gastric CONCLUSIONS: This over the scope endoscopic clip sys- leaks following a sleeve gastrectomy, two had post-opera- tem is simple to use, safe, and successful in approximating tive colonic leaks, two had gastro-gastric fi stulas following tissue to treat traditionally diffi cult surgical complications. roux-en-y gastric bypass, and three had esophageal perfo- There is a potential for broad applications of this new rations. All three gastric leaks occurred just distal to the technology. Further experience and longer follow up are GE junction and each had undergone previous attempts needed to assess its indications as related to defect size and at treatment with other endoscopic methods. The aver- location. age number of over the scope clips placed in these three

2:15 PM – 4:00 PM 27b PLENARY SESSION V

based on the surgeon’s assessment of resectability at lapa- 806 roscopic staging, (e.g. mobile tumors and low lymph node Propensity Matched Analysis of Surgeon-Driven burden). Our study aim was to determine whether sur- Treatment Allocation for Locoregionally Advanced vival is impacted by a selective approach to treatment that includes minimally invasive esophagectomy (MIE) alone. Esophageal and Gastroesophageal Junction Adenocarcinoma METHODS: Patients with stage II or higher EG adeno- Haris Zahoor2, James D. Luketich1, Thomas Murphy1, carcinoma treated with MIE (n = 375; 1997–2009) were reviewed. Demographics, comorbidities, tumor and treat- Michael Gibson2, Manisha Shende1, Dan Winger3, 1 1 1 ment variables were abstracted. To determine the probabil- Tyler J. Foxwell , Blair A. Jobe , Katie S. Nason ity of treatment assignment to either induction therapy 1. Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; followed by MIE (E-) or to MIE alone (E+), propensity 2. Medicine, University of Pittsburgh, Pittsburgh, PA; scores were calculated. Variables are listed in Table 1. Com- 3. Clinical and Translational Science Institute (CTSI), University plete data for the propensity variables were available in of Pittsburgh, Pittsburgh, PA 280 patients and 80 closely matched pairs (n = 160) were BACKGROUND: Attempts to defi ne the optimal treat- generated. Data missingness was random; survival relevant ment strategy for resectable but locoregionally advanced variables in excluded patients did not differ signifi cantly esophagogastric (EG) adenocarcinoma have yielded con- from the included patients. Hazard ratios for death were fl icting results. As a result of high local failure rates, most calculated by stratifi ed Cox proportional-hazards regres- thoracic oncologists favor induction therapy followed by sion model after controlling for age, gender, BMI, smoking surgery. In our center, a selective approach has been used history and age adjusted CCI.

38 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: MIE was the primary therapy in 47% (n = 178) of single-incision trocar system, a complete mediastinal dis- patients and induction therapy in 53% (n = 197; 51% che- section of the esophagus can be accomplished under direct motherapy alone and 49% chemoradiation). Chemother- vision. This can be performed simultaneously with the apy included cisplatin (61%), 5-FU (76%), and paclitaxel abdominal portion of the esophagectomy. This allows for a (42%). Complete response following induction therapy shorter operative time, eliminating the need for single-lung was confi rmed at MIE in 13%; 44% were node-negative at ventilation, and reducing the risk for postoperative pulmo- resection compared to 20% for MIE alone. Median num- nary complications by avoiding the pleural cavity. Thank ber of lymph nodes examined was 21 (IQR 15, 29). Median you for considering this video. time to follow-up was 23 months (IQR 11, 38). Adjuvant therapy was given to 53% of patients following MIE. In the 808 80 matched pairs, there were 117 deaths (73%; median 18 months, IQR 9, 29). Surgery as primary mode of treatment Prior Fundoplication Does Not Improve Subsequent Safety or Effi cacy Outcomes of Radiofrequency was not associated with signifi cantly different hazard for Abstracts death after adjusting for age, sex, BMI, smoking history Ablation (RFA): Results from the U.S. RFA Registry Monday and age-adjusted Charlson Comorbidity index (0.96; 95% Nicholas J. Shaheen1, William J. Bulsiewicz1, William D. Lyday2, CI 0.58–1.6). Complete response was not associated with a George Triadafi lopoulos3, Herbert C. Wolfsen4, signifi cant improvement in median survival (19 versus 17 Srinadh Komanduri5, Gary W. Chmielewski6, Atilla Ertan7, months; p = 0.24). F. Scott Corbett8, Daniel S. Camara9, Richard I. Rothstein10, Bergein F. Overholt11 Variables Included in Propensity Matching 1. Division of Digestive Diseases, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Age Body Mass Indes Smoking History Chapel Hill, NC; 2. Atlanta Gastroenterology Associates, Atlanta, Pack-years smoked Sex Surgeon GA; 3. Stanford University School of Medicine, Palo Alto, CA; 4. Alcohol use Gerd history Histologically conﬁ rmed Mayo Clinic Florida, Jacksonville, FL; 5. Northwestern Memorial Barrett’s Hospital, Chicago, IL; 6. Rush University Medical Center, Chicago, History of MI History of CHF History of CABG or IL; 7. University of Texas Health, Houston, TX; 8. Sarasota coronary stent Memorial Hospital, Sarasota, FL; 9. Sisters of Charity Hospital, History of vascular History of renal failure History of diabetes Buffalo, NY; 10. Dartmouth-Hitchcock Medical Center, Lebanon, disease requiring treatment NH; 11. Gastrointestinal Associates, Knoxville, TN History of pulmonary History of stroke or TIA History of malignancy BACKGROUND: Ongoing acid and bile refl ux are hypoth- disease other than current esized to impair healing and squamous re-epithelialization History of metastaatic History of liver disease Final pretreatment after treatment of Barrett’s esophagus (BE) with radiofre- cancer clinical stage quency ablation (RFA). It is unclear if prior fundoplication improves subsequent safety and/or effi cacy of ablation. We Operation status Prior esophageal Esophageal cancer used data from a nationwide registry of patients treated surgery location with RFA for BE to assess the relationship between prior fundoplication and these outcomes. CONCLUSION: We found that a selective approach to treat- METHODS: ment of EG adenocarcinoma does not negatively impact The U.S. RFA Registry is a prospective study patient survival. Complete response rates to induction of patients with BE treated with RFA at 148 institutions therapy in this series were not associated with improved (113 community-based, 35 academic-affi liated). Informa- survival. Our data suggest that surgeon-driven treatment tion collected in the registry includes demographic data, allocation for locoregionally advanced esophagogastric histology prior to treatment, endoscopic fi ndings, date adenocarcinoma, including aggressive lymph node dissec- and number of treatment sessions, ablation outcomes, and tion, is a reasonable alternative to treating all patients with complications. Medical therapy with proton pump inhibi- induction therapy. tors was used in subjects without fundoplication. Our safety cohort consisted of all patients treated with RFA, while our 807 effi cacy cohort was restricted to subjects who had biop-  sies ≥12 months after RFA treatment initiation. Complete Transcervical Videoscopic Esophageal Dissection in eradication of intestinal metaplasia (CEIM) was achieved a Two-Field Minimally Invasive Esophagectomy if last biopsies demonstrated no IM. We compared safety Ross F. Goldberg, Tatyan M. Clarke, Armando Rosales-Velderrain, and effi cacy outcomes between those with a history of fun- John Stauffer, Horacio J. Asbun, C. Daniel Smith, Steven P. Bowers doplication and those undergoing medical management, using parametric tests. Safety outcomes included rates of Surgery, Mayo Clinic – Florida, Jacksonville, FL stricture, bleeding, and hospitalization. Effi cacy outcomes This video report demonstrates a patient undergoing a included CEIM, complete eradication of dysplasia (CED), 2-fi eld minimally invasive esophagectomy using a transcer- and number of treatment sessions to CEIM. Effi cacy results vical videoscopic esophageal dissection. Using a modifi ed are reported for the full cohort and stratifi ed as non-dysplastic BE (NDBE) versus dysplastic BE.

39 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: Among 5,539 patients receiving RFA, 318 (p > 0.05 for both comparisons). Subjects with prior fun (5.7%) had a prior fundoplication. Of these subjects, 0.9% doplication had similar rates of CED, CEIM, and number developed stricture after RFA and 1.3% were hospitalized. of RFA sessions for eradication when compared to those There were no perforations or clinically signifi cant bleeding without prior fundoplication (see table). in the fundoplication group. Rates of stricture, bleeding, CONCLUSIONS: In the largest reported cohort of patients and hospitalization were not statistically different (p>0.05) treated with RFA for BE, RFA in subjects with a prior fundo- between patients with and without prior fundoplication plication was safe and effective. However, prior fundoplica- (see Table). In all, 2,135 of 5,539 (39%) had biopsy data tion was not associated with improved effi cacy or reduced available after 12 months. CEIM and CED were achieved in number of ablation sessions, when compared to medical 78% and 93% of subjects with a fundoplication, and 72% management using proton pump inhibitors. and 87% of subjects without a fundoplication, respectively

Safety and Efﬁ cacy Outcomes Among Patients with and without Fundoplication Prior to Treatment with RFA.

Fundoplication Medical Therapy p-value Complication Rates Per Patient N 318 5221 Stricture 0.9% 2.2% 0.14 Bleeding 0 0.4% 0.27 Hospitalization 1.3% 0.6% 0.18 Efﬁ cacy for all Subjects N 139 1996

CEIM 78% 72% 0.18 CED 93% 87% 0.13 RFA treatment sessions, mean (SD) 2.8 (1.6) 2.8 (1.6) 0.91 Efﬁ cacy for Nondysplastic BE N 79 875 CEIM 80% 81% 0.72 RFA treatment sessions, mean (SD) 2.7 (1.8) 2.6 (1.6) 0.68 Efﬁ cacy for Dysplastic BE and IMC N 60 1121 CEIM 75% 65% 0.13 CED 93% 87% 0.13 RFA treatment sessions, mean (SD) 3.0 (1.4) 3.0 (1.6) 0.90

Complications and outcomes were also compared. Socio- 809 demographic factors were examined as effectors of surgery Nationwide Inpatient Sample: Have Antirefl ux location. Procedures Undergone Regionalization? RESULTS: A total of 11804 cases were performed in T1 and Paul D. Colavita, Igor Belyansky, Amanda Walters, Sofi ane El 8856 in T2. In T1, 41.0% of procedures were performed in a Djouzi, Alla Zemlyak, Amy E. Lincourt, B. Todd Heniford HVC vs 35.4% in T2. LVC rates increased with time: 20.53% General Surgery, Carolinas Medical Center, Charlotte, NC vs. 26.87% (p < 0.0001). Rural hospitals had decreased surgical volume (19.10% vs. 10.33%, p < 0.0001), while all INTRODUCTION: With improved outcomes demon- urban hospitals increased volumes: teaching (48.23% vs. strated at high volume centers, many complex surgical pro- 51.03%, p < 0.0001) and non-teaching (32.67% vs. 38.64%, cedures have migrated to large, specialized hospitals. The p < 0.0001). Using multivariate regression, the following purpose of this study is to examine the extent of regional- were predictors of surgery at a LVC in T1: non-caucasian ization and outcomes in anti-refl ux surgery. race (OR 1.42, p < 0.0001), emergent admission (OR 2.24, METHODS: The Nationwide Inpatient Sample (NIS) data p < 0.0001), living in a zip code with low median income were analyzed from 1998–99 (T1) and 2008–09 (T2) for all (OR 1.52 lowest vs. highest, p = 0.0039), increasing age antirefl ux operations in patients with gastroesophageal (p = 0.0002), and increasing concurrent diagnosis num- refl ux symptoms using ICD-9-CM codes. Hospitals were ber (p = 0.0029). In T2, emergent admission (OR 1.34, p = stratifi ed into high-, mid-, and low-volume centers (HVC, 0.038), low median income (OR 1.69 highest vs lowest, p < MVC, LVC) based on annual antirefl ux surgery volume. 0.0001), and number of concurrent diagnoses (p = 0.034)

40 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

were independent predictors of antirefl ux surgery at a LVC. RESULTS: Major hepatectomy was performed in 539 In T2, mean LOS at a LVC was 4.0 days vs 3.3days at a patients. In the major hepatectomy group, median tumor HVC (p < 0.0001), but this was not signifi cant in multivari- size was 10 cm (range:1–27 cm) and 22% of the patients ate analysis. Total charges were lower at a LVC ($38000 vs had bilateral lesions. The TNM Stage distribution included $41000, p = 0.0032) in multivariate analysis. Complication 29% Stage I, 31% Stage II, 38% Stage III, and 2% Stage IV. rates increased at all centers with time, but were twice as The postoperative histologic examination indicated that common in LVCs (6.39% vs. 3.16% at HVCs, p < 0.0001) in chronic liver disease was present in 35% of the patients and T2. Controlling for confounding variables, complications microvascular tumor invasion was identifi ed in 60% of the remained more likely in LVCs (T1: OR 1.71, p < 0.0001, patients. The 90-day postoperative mortality rate was 4%. T2: OR 1.49, p < 0.0001). In hospital mortality decreased After a median follow-up time of 63 months, the 5-year in all centers with time and did not differ signifi cantly in overall survival rate was 40%. Patients treated with right either era. Patients at all centers have increased their mean hepatectomy (n = 332) and those requiring extended hepa-

number of concurrent diagnoses over time(3.92 vs 6.70, p tectomy (n = 207) had similar 90-day postoperative mor- Abstracts < 0.0001). tality rates (4% and 4%, respectively, P = .976) and 5-year Monday CONCLUSION: Despite improved results at HVCs, LVCs overall survival rates (42% and 36%, respectively, P = .523). have increased their percentage of antirefl ux operations Overall survival and postoperative mortality rates after over time. The urban non-teaching hospitals have expe- major hepatectomy were similar among the participating rienced the largest gains in caseload. Overall complica- countries (P > .1) and improved over time with 5-year sur- tion rates have increased with time, possibly due to noted vival rates of 30%, 40%, and 51% for the years 1981–1989, increased incidence of comorbidities in the patients seeking 1990–1999, and the most recent era of 2000–2008, respec- antirefl ux surgery. After controlling for confounding vari- tively (P = .004) (Figure). Factors that were associated with ables, complications remain more likely in LVCs. Region- worse survivals included AFP level >1000 ng/mL, tumor alization has not occurred over time, but may improve out- size >5 cm, presence of major vascular invasion, presence comes if supported. of extrahepatic metastases, positive surgical margins, and earlier time period in which the major hepatectomy was performed (all MV P < 0.05). 810 Improved Long-Term Survival After Major Resection for Hepatocellular Carcinoma: A Multicenter Analysis Based on a New Defi nition of Major Hepatectomy Andreas Andreou1, Jean-Nicolas Vauthey1, Daniel Cherqui2, Eddie Abdalla1, Steven Wei1, Steven Curley1, Alexis Laurent2, Ronnie Poon3, Jacques Belghiti4, David M. Nagorney5, Thomas Aloia1 1. Surgical Oncology, MD Anderson Cancer Center, Houston, TX; 2. Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Hôpital Henri Mondor, Créteil, France; 3. Department of Surgery, University of Hong Kong/Queen Mary Hospital, Hong Kong, China; 4. Department of Surgery, Hôpital Beaujon, Clichy, France; 5. Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN BACKGROUND: Advances in the surgical management of hepatocellular carcinoma (HCC) have expanded the indi- Improved Survivals After Major Resection of HCC Over Time cations for curative hepatectomy, including more extensive liver resections. The purpose of this study was to examine CONCLUSIONS: This multinational, long-term HCC sur- long-term survival trends for patients treated with major vival analysis indicates that expansion of surgical indi- hepatectomy for HCC. cations to include major hepatectomy is justifi ed by the PATIENTS AND METHODS: Clinicopathologic data signifi cant improvement in outcomes over the past 3 for 1115 patients with HCC who underwent hepatectomy decades observed in both the East and the West. between 1981 and 2008 at 5 hepatobiliary centers in France, China, and the USA were assessed. In addition to other performance metrics, outcomes were evaluated using resection of ≥4 liver segments as a novel defi nition of major hepatectomy.

41 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

811 812 Bariatric Surgery: Still Have an Appetite? Circadian Genes in Pancreatic Ductal Adenocarcinoma: Nayna A. Lodhia, Jaffer M. Kattan, Dylan Gwaltney, Alterations and Clinical Correlations Margaret M. Nkansah, Shushmita Ahmed, John M. Morton Daniel Relles, Galina Chipitsyna, Terry Hyslop, Charles J. Yeo, Stanford School of Medicine, Palo Alto, CA Hwyda A. Arafat INTRODUCTION: Understanding eating patterns in Surgery, Thomas Jefferson University, Philadelphia, PA patients following laparoscopic roux-en-Y-gastric bypass BACKGROUND: The circadian rhythm regulates various (LRYGB) is important to determine long term success. The metabolic processes, physiologic homeostasis and behavior. purpose of this study was to analyze changes eating habits Epidemiologic studies have demonstrated that disruption of patients following LRYGB using the three-factor eating of the circadian rhythm is associated with cancer develop- questionnaire (TFEQ-R18). ment and tumor progression. Several circadian clock genes METHODS: Demographic, preoperative, three, six and with tightly connected transcriptional feedback loops have twelve month postoperative data were prospectively been implicated in loss of cell cycle control, impaired DNA obtained for 204 consecutive laparoscopic RNYGB patients damage repair, and subsequent tumor formation in multi- at a single academic institution. All patients enrolled in ple cancer models. However, the direct links between aber- the study completed the three-factor eating question- rant circadian clock gene expression and human pancreatic naire (TFEQ-R18), an 18 question inventory that measures ductal adenocarcinoma (PDA) have not been elucidated. In 3 aspects of eating behavior: cognitive restraint, uncon- this study, we investigated the expression profi les of several trolled eating, and emotional eating at each clinic visit. circadian clock genes in PDA. Higher scores in each category indicate a higher degree of METHODS: We analyzed the expression of 10 circadian restraint or eating pattern. Patients were compared on the clock genes in matched invasive human PDA (n = 62) and basis of age, gender and body-mass index (BMI). Data at surrounding adjacent tissues and in benign lesions (n = 10). pre-operative and TFEQ-R18 scores were analyzed with a Quantitative real-time polymerase chain reaction (qPCR) one way ANOVA for continuous variables and chi-squared was used to examine the following core clock genes: analysis for dichotomous variables using Stata/IC 11.1 and (BMAL, Clock, Cry1, Cry2, CK1E, Per1, Per2, Per3, Timeless, R2.13.1 software. Timeless-interacting protein). Gene expression levels were RESULTS: Patient mean demographics included BMI 47, correlated with clinicopathological parameters. Receiver age 47, 65% white, income $62,100, 78% with private operator curve (ROC) analysis was completed using logistic insurance, and 4 total preoperative comorbidities. Comor- regression based on individual circadian genes measured in bidities included 43% with diabetes, 69% with hyperten- tumor and benign samples, and is reported as area under sion, 53% with hyperlipidemia, 46% with GERD, 48% with the ROC curve (AUC). Spearman correlation was used to sleep apnea, and 41% with depression. By 3 months post- assess the relationship between circadian genes within operative, patients saw a signifi cant reduction from their tumor samples. Univariable Cox models were completed preoperative BMI to 42.3 kg/m2 (p < 0.01). Patients saw a to assess survival of PDA patients, using the median gene signifi cant improvement in cognitive restraint from preop- expression level as stratifi cation factor. erative to 3, 6 and 12 months postoperative (54.1, 76.8, 73.5, RESULTS: In the tumor tissue of PDA patients, compared 74.4; p < 0.001); uncontrolled eating (39.3, 10.7, 13.0, 16.7; to their matched adjacent tissue, expression levels of all p < 0.001); and emotional eating (44.6, 14.0, 16.0, 22.5; p < circadian genes were signifi cantly lower (P < 0.05). Benign 0.001). Patients over the age of 50 years had a signifi cantly tissues also expressed signifi cantly (P < 0.05) higher levels higher emotional eating score at 3 months postoperative of all circadian genes when compared to malignant lesions. (10.0 versus 19.6, p = 0.01); however, these differences were Spearman correlations of all 10 genes in tumors showed no longer signifi cant at 6 months postoperative. signifi cant correlations of their expression levels rang- CONCLUSIONS: Patients undergoing LRYGB see signifi - ing from 0.57 to 0.93, p < 0.001 in all cases. Univariable cant improvements in their cognitive restraint, uncon- survival analysis indicated that Per2 (p = 0.004), Per3 (p trolled eating and emotional eating as early as 3 months = 0.007), Cry2 (p = 0.016), Tim (p = 0.016) and CK1E (p = postoperative, at which point their TFEQ-R18 scores are 0.024) are signifi cantly related to survival. within population norms for healthy weight individuals. CONCLUSIONS: Our results reveal for the fi rst time a Eating behaviors may portend future weight maintenance disturbed transcription of several circadian genes in PDA. success. Elevation of the gene levels in the benign and matched adjacent tissues may be indicative of their role during the process of tumorigenesis. Altered expression of Per2, Per3, Cry2, Tim and CK1E in PDA provides the basis for future studies to explore their validity as predictive markers of the outcomes and survival in PDA patients.

42 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

4:00 PM – 5:00 PM 27b QUICK SHOTS SESSION III

813 814 Repeat Hepatectomy for Recurrent Liver Metastasis from Gastric Carcinoma Is There a Role for Simultaneous Hepatic and Akio Saiura, Nobuyuki Takemura, Rintaro Koga, Junichi Arita, Colorectal Resections? A Contemporary View from Abstracts Yoshihiro Ono, Ryuji Yoshioka NSQIP Monday 1 1 2 Cancer Institute Hospital, Tokyo, Japan Mathias Worni , Christopher R. Mantyh , Igor Akushevich , Ricardo Pietrobon1, Bryan M. Clary1 BACKGROUND: The effi cacy of repeat hepatectomy 1. Surgery, Duke University Medical Center, Durham, NC; for recurrent colorectal liver metastases has been widely 2. Center for Population Health and Aging, Duke University accepted as a treatment of potential cure. However, indication for hepatectomy in cases of gastric cancer liver metasta- Medical Center, Durham, NC sis (GLM) remains unclear. Moreover, no benefi ts have been BACKGROUND: The optimal timing of primary and reported of repeat hepatectomy for intrahepatic recurrence metastatic tumor management in patients with synchro- of GLM. The aim of this study is to clarify the survival ben- nous hepatic colorectal metastases remains controversial. efi t of hepatectomy for primary and recurrent GLM. Although simultaneous colorectal/liver resection (SCLR) is AIM: The objective of this retrospective study is to clarify an attractive option, the safety of this strategy has not been the indications for and benefi t of primary and repeat hepa- explored outside of small single institutional experiences. tectomy for GLM. The goal of this investigation was to compare perioperative outcomes of SCLR with isolated resections utilizing a more METHODS: Seventy-three patients underwent hepatecto- inclusive national clinical database. mies for GLM with curative intent from January 1993 to Jan- METHODS: uary 2011. Curative surgery was performed in 64 patients National Surgical Quality Improvement Pro- and repeat hepatectomy was done in 14 of 35 patients with gram (NSQIP) data from 2005 to 2009 was examined to intrahepatic recurrence; in total, 78 liver resections were construct descriptive statistics and risk-adjusted general- performed. Clinicopathological factors were evaluated by ized linear models. These were used to compare 30-day univariate and multivariate analysis among patients who postoperative outcomes among patients undergoing SCLR received curative resection for those affecting survival. with colorectal resections (CR) and liver resections (LR) only in patients with metastatic colorectal cancer. RESULTS: The cancer-specifi c 1-, 3-, and 5-year survival RESULTS: rates after curative hepatectomy (n = 64) for GLM were 87, 3,983 patients with metastatic colorectal cancer 50, and 37%, respectively, with a median survival of 34 were identifi ed who underwent SCLR (192), LR (1,857) or months. By multivariate analysis, serosal invasion of the CR (1,934). Minor differences in patient demographics were primary gastric cancer and larger tumor (>5 cm in diam- noted. Patients undergoing SCLR were younger compared eter) were found to be independent indicators of poor to CR and LR with mean ages of 40.4 years (SD: 10.8), 45.5 prognosis. Forty-three patients developed postoperative (13.5), and 41.7 (11.7), respectively (p < 0.001). Mean num- recurrence (67%) after the curative resection for GLM. ber of comorbidities in the SCLR group was 0.63 (SD: 0.89), Intrahepatic recurrence occurred in 37 patients, corre- in the CR group 0.87 (1.01), and 0.74 (0.89) in the LR group sponding to 86% of all patients with recurrence. A repeat (p < 0.001). Rectal resection was performed in 45 (23.4%) hepatectomy for intrahepatic recurrence was performed in SCLR-patients and 269 (13.9%) CR-patients (p < 0.001). 14 patients (40%) based on the same indication as initial Major hepatectomy (≥ three segments) was performed in hepatectomy for GLM. The actuarial 1-, 3-, and 5-year can- 69 (35.9%) SCLR-patients and 774 (41.7%) of LR-patients cer-specifi c survival rates after second hepatectomy were (p = 0.12). Median operation time was signifi cantly longer 71, 47, and 47%, respectively, with a median survival of 30 for SCLR 273 minutes (95% CI: 253–295), in comparison months. Three patients have survived more than 5 years to CR (172 minutes, 95% CI: 167–176) and LR (223 min- after the repeat hepatectomy. utes, 95% CI:217–229). Median length of hospital stay was signifi cantly longer for SCLR (9.5 days, 95% CI: 8.7–10.4) CONCLUSIONS: GLM patients with tumors <5 cm in than CR (8.1 days, 95% CI: 7.8–8.3) and LR (6.5 days, 95% diameter and without serosal invasion of the primary gas- CI: 6.3–6.6). Patients in the SCLR group were more likely to tric cancer are the best candidate for hepatectomy. Repeat experience postoperative complications (risk-adjusted mean hepatectomy for recurrent GLM offers a chance of cure as that after the primary hepatectomy.

43 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

number of complications: 0.69, 95% CI: 0.47–0.90) com- signifi cantly higher than for CR and LR. In addition, the pared to CR (0.44, 95% CI: 0.39–0.49) and LR (0.34, 95% CI: median operation time and hospital stay is longer for 0.30–38) (p < 0.001 for CR and LR versus SCLR). Excess com- SCLR than for CR and LR only. However, higher short-term plications were dominated by infectious and cardiopulmo- adverse outcomes in patients undergoing SCLR might be nary issues (Table). Mortality in patients undergoing SCLR acceptable since anesthetic risk is decreased and adjuvant was not increased compared to patients undergoing LR. consolidating chemotherapy regimens can be conducted DISCUSSION: Among hospitals reporting outcomes to earlier. Additional population-based investigations are nec- NSQIP the risk of 30-day adverse outcomes for SCLR is essary to prove that SCLR is widely benefi cial.

CR LR SCLR Risk-adjusted OR (n = 1,934, 48.6%)* (n = 1,857, 46.6%)* (n = 192, 4.8%)* (95% CI) # p-Value Superfi cial surgical site infection 168 (8.7) 79 (4.3) 14 (7.3) 1.20 (0.62–2.32) 0.53 0.59 0.07 (0.27–1.04) Incisional surgical site infection 48 (2.5) 13 (0.7) 13 (6.8) 0.42 (0.18–0.98) 0.14 0.05 <0.001 (0.05–0.35) Organ space site infection 100 (5.2) 95 (5.1) 24 (12.5) 0.41 (0.24–0.69) 0.33 0.001 <0.001 (0.19–0.56) Any surgical site infection 291 (15.1) 181 (9.8) 45 (23.4) 0.64 (0.42–0.97) 0.35 0.04 <0.001 (0.23–0.53) Cardiopulmonary complication 120 (6.2) 108 (5.8) 19 (9.9) 0.37 (0.21–0.66) 0.43 0.001 0.004 (0.25–0.77) Renal/urinary complication 129 (6.7) 85 (4.6) 15 (7.8) 0.59 (0.31–1.10) 0.54 0.09 0.06 (0.28–1.02) DVT/pulmonary embolism 59 (3.1) 45 (2.4) 7 (3.7) N/A 0.38ç Septic complication 173 (9.0) 133 (7.2) 26 (13.5) 0.43 (0.26–0.71) 0.39 0.001 <0.001 (0.24–0.64) Mortality 89 (4.6) 23 (1.2) 2 (1.0) N/A <0.001ç Intraoperative use of red blood 305 (15.8) 452 (24.3) 53 (27.6) 0.41 (0.27–0.62) 1.12 <0.001 0.58 cell products (0.75–1.67) *Numbers are given as counts and %. # Reference category SCLR, fi rst estimate CR vs SCLR, second estimate LR vs SCLR. Adjustment for: sex, race, age, BMI, comorbidity, dyspnea, ASA score, preoperative weight loss, preoperative radio-/chemotherapy, wound classifi cation, hypoalbuminemia, hypercreatininemia, anemia, and hyponatremia. ç Chi-square test.

815 hepatectomy after preoperative chemotherapy and clarify which patients can take advantage from use of CE-IOUS. Usefulness of Contrast-Enhanced Intraoperative METHODS: From January 2011 to August 2011 25 patients Ultrasonography in Colorectal Liver Metastases After with CRLM, after preoperative chemotherapy, underwent Preoperative Chemotherapy IOUS and CE-IOUS during hepatectomy. These fi ndings were Andrea Ruzzenente, Tommaso Campagnaro, Simone Conci, compared with preoperative staging imaging, performed with Elisabeth Baldiotti, Marco Costa, Elisabeth Baldiotti, contrast-enhanced ultrasonography (CE-US), CT and/or MRI. Calogero Iacono, Alfredo Guglielmi RESULTS: Preoperative staging imaging detected a total Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy of 40 metastatic lesions in 25 patients. In 7 patients (28%), BACKGROUND AND AIM: Hepatic resection is the only IOUS detected 19 missed hepatic nodules for a total of 59 treatment offering a chance of long-term survival for lesions (detection rate higher of 47.5% than preoperative patients with colorectal liver metastases (CRLM). Preopera- imaging). In 9 patients (36%), CE-IOUS detected further 6 tive chemotherapy improves survival and resectability but nodules for a total of 65 hepatic lesions detected (detec- reduces accuracy of preoperative staging due to reduction of tion rate higher of 10.2% than preoperative imaging and size or disappearing of the metastases. Intraoperative Ultra- IOUS). All these new detected lesions were removed by an sonography (IOUS) is considered the standard method of additional resection and histopathologically diagnosed intraoperative staging. Contrast-enhanced intraoperative as metastases. Moreover, at univariate analysis we found ultrasonography (CE-IOUS), using second generation con- three factors signifi cantly correlated to dectection of new trast agents, seems to improve detection of liver metastases nodules with CE-IOUS: more than three metastasis before after preoperative chemotherapy. chemotherapy (p = 0.022), complete response to chemotherapy (p = 0.03) and size of nodules less than 20 mm after The aim of this study is to evaluate the ability of CE-IOUS chemotherapy (p = 0.008). in detecting metastases in patients with CRLM during

44 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSION: In patients who undergo surgery for soft glands. Patients randomized to the FF group had a leak CRLM, CE-IOUS improves the sensitivity of IOUS to detect rate of 20% as compared with 19.6% in the SS group (p = liver metastases enhancing the rate of treatment with cura- 1.000). Fistula grades in both groups were similar: 1A, 8B, tive intent. Patients with multiple nodules, patients who and 1C compared to 1A, 8B and 1C in the FF and SS groups achieve complete response or with nodule size less than respectively. Complication rates were comparable between 20 mm after chemotherapy can take advantage with use the two groups. The median length of postoperative hos- of CE-IOUS. pital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group 816 (28% vs. 17.6%, p = 0.243). Based on conditional probability calculations with 52.5% of enrollment, the probability A Dual-Institution Randomized Controlled Trial of of success of the trial given the current trend fell below Remnant Closure After Distal Pancreatectomy: Does 50%, and the trial was ended.

the Addition of Falciform Patch and Fibrin Glue Abstracts Improve Outcomes? Table 1. Demographics of Patients in the Study (FF) and Monday Timothy I. Carter1, Zhi Ven Fong1, Terry Hyslop2, Harish Lavu1, Control (SS) Group, Showing no Signiﬁ cant Differences Wei Phin Tan1, Jeffrey Hardacre3, Eugene P. Kennedy1, Charles J. Yeo1, Ernest L. Rosato1 FF (n = 50) SS (n = 51) p-Value 1. Surgery, Thomas Jefferson University, Philadelphia, PA; Gender 2. Department of Pharmacology and Experimental Therapeutics, Male 22 19 0.546 Division of Biostatistics, Thomas Jefferson University, Female 28 32 0.546 Philadelphia, PA; 3. Surgery, Case Western Reserve University, Cleveland, OH Race OBJECTIVE: The objective of the study was to assess the White 47 41 0.072 effi cacy of two pancreatic remnant closure techniques— Black 1 3 0.617 stapled/sutured closure versus stapled/sutured closure plus Asian 0 1 1.000 falciform patch and fi brin glue reinforcement—in the setting of a prospective randomized, controlled trial, with the Unknown 2 6 primary endpoint being pancreatic fi stula. Age SUMMARY AND BACKGROUND DATA: Pancreatic Median 62.5 65.0 stump leak following left sided resection remains common. Mean 62.0 62.3 0.969 Despite multiple and varied techniques for closure, the leak rate averages 30%. A retrospective review by Ferrone et al. Range 29–84 20–82 detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fi brin glue. Table 2. Clinical Outcomes of Patients in the Study (FF) and METHODS: Between April 2008 and October 2011, all Control (SS) Group, Showing no Signiﬁ cant Differences willing patients undergoing distal pancreatectomy at the authors’ institutions, were consented and enrolled at the FF (n = 50) SS (n = 51) p-Value preoperative offi ce visit. Patients were intraoperatively Pancreatic Fistulas stratifi ed as “hard” or “soft” glands and randomized to Grade A 1 1 1.000 one of two groups: (1) closure utilizing standard stapling, suturing, or both (SS) versus (2) stapled, sutured, or both Grade B 8 8 1.000 plus fi brin glue and falciform ligament patch (FF). The Grade C 1 1 1.000 trial design and power analysis (α = 0.05, β = 0.2, power Postoperative Hospital 5.0 5.0 — 80%, chi-square test) assumed the FF intervention would Stay (days, median) reduce the endpoint (pancreatic fi stula) from 30% to 15% and yielded an accrual goal of 190 patients. Secondary end- Mortality 1 00.495 points included length of stay, mortality, readmission, and Readmissions 14 9 0.243 ISGPF fi stula grade. RESULTS: The trial accrued 109 patients, 55 in the con- CONCLUSION: The addition of a falciform ligament patch trol group and 54 in the experimental group. Enrollment and fi brin glue to standard stapled or sutured remnant clo- was closed early, following an interim analysis and futility sure did not reduce the rate or severity of pancreatic fi stula calculation. Due to insuffi cient enrollment, patients strati- in patients undergoing distal pancreatectomy. (ClinicalTri- fi ed as having a “hard” gland were excluded (n = 8) from als.gov number NCT00889213) analysis, leaving 101 patients in the soft stratum. The pancreatic leak rate was 19.8% (20 patients) for patients with

45 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

817 The Prognostic Infl uence of Resection Margin Clearance Following Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma Nigel B. Jamieson, Nigel Chan, Euan J. Dickson, Colin McKay, Ross Carter West of Scotland Pancreatic Unit, Glasgow University Department of Surgery, Glasgow Royal Infi rmary, Glasgow, Lanarkshire, United Kingdom INTRODUCTION: The poor overall survival associated with pancreatic ductal adenocarcinoma (PDAC) despite complete resection suggests that occult metastatic disease is present in most at the time of surgery. Resection margin involvement (R1) following resection is an established poor prognostic factor. However the defi nition of an R1 resection varies and the impact of margin clearance on outcome Kaplan Meier survival curves illustrating that a cut-off of greater than has not been examined in detail. 1.5 mm identiﬁ es a subgroup of patents (15%) with pancreatic ductal adenocarcinoma with a good prognostic outcome following resection by METHODS: In a cohort of 215 consecutive patients who underwent pancreaticoduodenectomy for PDAC with cura- pancreaticoduodenectomy. tive intent at a single institution between 1996–2010, the prognostic signifi cance of the proximity of margin clear- 818 ance was investigated. Microscopic margin clearance was Incidence of Systemic Infl ammatory Response Syndrome stratifi ed by 0.5 mm increments from tumor present to greater that 2 mm. Groups were dichotomized into clear After Total Laparoscopic Pancreatoduodenectomy: A and involved groups according to the different R1 defi ni- Comparison with Open Pancreatoduodenectomy tions. Multivariate survival analysis was used to establish Naru Kondo, Clancy J. Clark, Florencia G. Que, Kaye M. Reid independent prognostic factors. Clearance of individual Lombardo, David M. Nagorney, John H. Donohue, margins was also considered. Michael B. Farnell, Michael L. Kendrick RESULTS: Stratifi cation of the minimal clearance distance Mayo Clinic, Rochester, MN revealed that there was no signifi cant difference in the BACKGROUND: Although feasibility of total laparoscopic outcome of patients with tumor ≤1 mm from the margin pancreatoduodenectomy (TLPD) has been established, a when compared to those with tumor ≤0.5 mm from the large scale study comparing the invasiveness of TLPD with margin (P = 0.67, Log-rank test). For the 32 patients (15%) open pancreatoduodenectomy (OPD) has never reported. where the tumor was >1.5 mm from the closest involved PURPOSE: The purpose of this study was to investigate if margin there was a signifi cantly prolonged overall survival TLPD can reduce the postoperative incidence of systemic (median 49.0 months 95% confi dence interval: 25.7–72.3, infl ammatory response syndrome (SIRS) compared with P < 0.0001, Log-rank test, Figure 1). This cut-off represented OPD. the optimum distance for predicting long-term survival. METHODS: CONCLUSION: A single-institutional retrospective cohort These results demonstrate that mar- study of all pancreaticoduodenectomy patients between gin clearance by at least 1.5 mm identifi es a subgroup of 2007 and 2010 was performed. The incidence of SIRS was patients with a particularly good outcome. Stratifi cation of measured three times a day (at the nearest point of 8, 16 patients into future clinical trials based upon the degree and 24 o’clock) from postoperative day (POD) 1 to POD 5. of margin clearance may identify those patients likely to The incidence of SIRS on each POD was defi ned by meeting benefi t from adjuvant therapy. the criteria of SIRS at two or more points out of the daily three measurement points. Perioperative outcomes including the incidence of SIRS were compared between TLPD and OPD group. The relationship between the clinicopathological factors and the incidence of postoperative SIRS was investigated using univariate and multivariate analyses.

46 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: Five hundred twenty-seven consecutive patients (TLPD n = 125, OPD n = 402) were included in study. Six patients (5%) with conversion to OPD were included in TLPD group based on intent-to-treat. The reasons for conversion were the possibility of major venous resection (n = 3), bleeding (n = 1), severe adhesion (n = 1) and expected diffi cult reconstruction (n = 1). Compared with patients in the OPD group, those in the TLPD group had signifi cantly less preoperative clinical jaundice (42% vs. 53%, P = 0.03), less adenocarcinoma (58% vs. 70%, P = 0.01), and smaller pancreatic duct size (3.7 mm vs. 4.2 mm, P = 0.002). Median estimated blood loss was less for the TLPD group than the

OPD group (200ml vs. 600ml, P < 0.001). However, there Abstracts were no differences in postoperative complication (62% vs. Monday 67%, P = 0.3) or clinically relevant pancreatic leak (21% vs. Recurrence-free survival among R0 resections for IPMN with at least 21%, P = 0.8). The incidence of SIRS in the TLPD group was three months follow up, stratiﬁ ed by invasive pathology. Non-invasive signifi cantly less than that of OPD group on POD 1 (9% vs. IPMN includes adenoma (76), borderline or moderate dysplasia (36), 24%, P < 0.001). Within a subset of 179 patients without and carcinoma in situ(30). Median follow up was 30.8 months (502 postoperative complication, the incidence of SIRS in the TLPD group was signifi cantly less than that of OPD group person-years). Invasive IPMN was more likely to recur than non-invasive on POD 1 (2% vs. 13%, P = 0.01) and POD 2 (4% vs. 15%, P tumors (HR 3.7, 95% CI 1.7–8.4), with a median time to recurrence of = 0.03). Multivariate analysis revealed that increased body 13.5 months. Of the 17 non-invasive IPMNs that recurred, four recurred mass index (> 27) (HR 1.7, 95% CI 1.1 - 2.6, P = 0.005), with invasive disease. OPD (HR 1.8, 95% CI 1.1 - 2.9, P = 0.01) and postoperative RESULTS: Two hundred and eight patients underwent complication (HR 2.3, 95% CI 1.4 - 3.7, P < 0.001) were resection for IPMN. At presentation, 57% were symptom- independently associated with SIRS on POD 1 and/or 2. atic, 20% had a mural nodule or an associated mass, and CONCLUSION: TLPD independently reduced the early median cyst size was 1.8 cm. Sixty-eight (32.7%) opera- incidence of SIRS after pancreatoduodenectomy. The lap- tions for high grade disease were performed, of which 33 aroscopic approach to pancreatoduodenectomy appears revealed invasive carcinoma. Among 165 R0 resections to provide an advantage of less invasiveness compared with greater than three months of follow-up we have with the open approach especially in patients that do not observed 26 cases of recurrent disease over 502 person- develop postoperative complications. years (median follow-up time 30.8 months). Nine (39%) patients originally diagnosed with invasive carcinoma and 819 17 (12%) patients originally diagnosed with non-invasive IPMN have recurred. Of the latter, four (23.5%) recurred as Predictors of Recurrence in Intraductal Papillary invasive carcinoma. Most disease recurred locally (25/26) Mucinous Neoplasm: Experience with 208 Pancreatic but three individuals had concurrent metastatic disease at Resections the fi rst observation of recurrence. Median time from ini- Megan Winner, Irene Epelboym, Joseph DiNorcia, Minna K. Lee, tial treatment to recurrence was 18.2 months, but ranged James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf from 3.7 to 126.8 months. Invasive tumors were more Department of Surgery, Columbia University College of Physicians likely to recur (HR 3.7, p = 0.002) with a median time to and Surgeons, New York, NY recurrence of 13.5 months. Among non-invasive tumors, no single histologic feature—including dysplastic changes BACKGROUND: Intraductal papillary mucinous neo- at the surgical margin or distant from the primary tumor— plasm (IPMN) is being diagnosed and resected with increas- meaningfully predicted recurrence. Seven patients had ing frequency, but little long-term data exist to guide a completion pancreatectomy on average 22.7 months postoperative management of surgically treated patients. after their initial surgery. Of these, three had low grade or METHODS: We examined all patients who underwent moderate dysplasia on fi nal pathology and have survived surgical resection for IPMN between January 1997 and greater than 34 months after the second operation, com- April 2011 at our institution. IPMN was categorized as non- pared with median survival of 14.4 months after diagnosis invasive low grade (adenoma and borderline dysplasia), of recurrent, invasive IPMN. non-invasive high grade (carcinoma in situ), or invasive. CONCLUSIONS: Invasive IPMN has a high risk of recur- Histologic features of primary and recurrent disease were rence, but even low grade tumors may recur with high grade examined and we evaluated predictors of recurrence using disease. IPMN can recur remote from the time of primary Kaplan Meier curves and Cox proportional hazards models. surgery and no histologic feature beyond invasion predicts recurrence risk. Most recurrence is local and completion pancreatectomy can be associated with excellent survival if recurrent disease is identifi ed early. We therefore recommend that surveillance of the remnant pancreas continue after primary resection for all tumor types.

47 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

820 821 Survival Following Resection of Well-Differentiated Mechanisms of GLUT2 Activation in Rats In Vivo: Pancreatic Neuroendocrine Tumors: Examining the Absence of Evidence for PKC Dependency New 2010 WHO Classifi cation Rizwan M. Chaudhry1,2, Mohamed M. Abdelfatah2, Alok Garg2, Toshiyuki Moriya1,2, Timothy R. Donahue2, Oscar J. Hines2, Judith A. Duenes2, Michael G. Sarr1,2 James J. Farrell3, Howard A. Reber2, David Dawson4 1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology 1. First Department of Surgery, Yamagata University, Yamagata, Research Unit, Mayo Clinic, Rochester, MN Japan; 2. Department of Surgery, University of California Los Absorption of glucose at concentrations exceeding the Angeles, Los Angeles, CA; 3. Department of Medicine, University capacity of sodium glucose co-transporter 1 (SGLT1) is of California Los Angeles, Los Angeles, CA; 4. Department of attributed to the recruitment of GLUT2 at the apical mem- Pathology and Laboratory Medicine, University of California Los brane of enterocytes in vivo. Protein kinase C (PKC) has Angeles, Los Angeles, CA been implicated in this process in cell culture and in vitro. Introduction: In 2010 the WHO adopted a new grading HYPOTHESIS: Activating and inhibiting protein kinase system for neuroendocrine neoplasms (NET) of foregut C (PKC) will increase and decrease, respectively, GLUT2- origin based on proliferation determined by mitotic count mediated glucose absorption via a mechanism dependent and Ki67 index. Using a large single-institution cohort of on the microtubular cytoskeleton. resected pancreatic NETs (PNETs), we have retrospectively AIM: To explore the role of PKC in activating GLUT2- examined the prognostic value of the WHO 2010 classifi ca- mediated glucose absorption. tion system, the prior WHO classifi cation system and AJCC METHODS: stage for well-differentiated neuroendocrine tumors of the Isosmolar glucose-containing solutions were pancreas. perfused through isolated, 30-cm segments of jejunum in anesthetized rats. Carrier-mediated glucose uptake was mea- METHODS: Search of pathology archives identifi ed 114 sured in 10 mM and 100 mM glucose solutions (n = 6 rats, patients who underwent pancreatic resection for PNETs each) with and without 10 μM chelerythrine (PKC inhibi- at UCLA Medical Center from 1991–2009. Retrospective tor), 200 nM PMA (PKC activator), and 10 μM nocodazole review of medical, surgical, and pathology databases was (microtubule disruptor). Carrier-mediated absorption of performed. Correlations between patient survival and vari- glucose was calculated by the difference in amount infused ous clinicopathologic factors were determined. minus the amount recovered after subtracting passive RESULTS: By univariate analysis, signifi cant predictors of absorption (3H-L-glucose) and expressed as mean±SEM; n = disease-specifi c survival (DSS) in PNETs included positive 6. After ending the experiment, the mucosa was harvested margin status (p = 0.019, HR 7.73, 95%CI [1.392–43.01]), rapidly in 4°C temperature; brush border membranes were and AJCC stage (Stage I, IIA versus IIB, IV, p = 0.043, HR isolated and subjected to Western blot analysis. 6.87, 95% CI [1.06–37.41]). Individually, tumor size, peri- RESULTS: Inhibition of PKC with chelerythrine chloride neural invasion, vascular invasion and functional tumor at the 10 and 100 mM glucose concentrations resulted in status were not signifi cant predictors of DSS in the patient a small decrease in carrier-mediated absorption from 2.3 ± cohort. In our cohort, the new WHO 2010 classifi cation 0.2 to 1.9 ± 0.3 μmol/min/30-cm intestine (p < 0.0001) and scheme did not signifi cantly predict DSS for well-differen- 10.8 ± 1.8 to 9.0 ± 1.7 μmol/min, respectively. PMA (PKC tiated PNETs (G1 PNETs versus G2 PNETs, p = 0.085, HR stimulant) also decreased absorption at the 10 and 100 mM 5.35, 95% CI [0.60–48.10]). In contrast, the prior WHO perfusates (1.9 ± 0.1 to 1.6 ± 0.2; p < 0.003 and 13.7 ± 1.2 to 2000 classifi cation scheme was a signifi cant predictor of 11.6 ± 1.5, respectively). Nocodazole (microtubular disrup- DSS (1.0 + 1.1 PNETs versus 2.0 PNETs, p = 0.048, HR 6.90, tion) decreased carrier-mediated uptake at 10 mM glucose 95% CI [1.12–39.62]). We also examined whether WHO from 2.1 ± 0.2 to 1.7 ± 0.2 (p < 0.0008) and from 13.5 ± 1.6 2010 classifi cation and AJCC staging parameters could be to 12.9 ± 1.5 at 100 mM glucose. No signifi cant changes used in combination to better stratify patients into groups were observed at the 100 mM glucose perfusate with all of variable prognostic signifi cance. In stratifi ed analysis of three pharmacologic agents. Western blots of isolated those patients with node-positive disease, G1 vs. G2 status brush border membranes showed no difference in GLUT2 showed a non-signifi cant trend towards predicting patient levels at the 10 and 100 mM glucose concentrations. survival after resection (p = 0.13, HR 5.2, 95%CI [0.6–43.9]). CONCLUSIONS: Activation and/or inhibition of protein CONCLUSIONS: Consideration of both AJCC staging kinase C and disruption of microtubular architecture had parameters and WHO 2010 G grade may be useful for the minimal effect at the concentration of luminal glucose accurate prediction of DSS in resected, well-differentiated when GLUT2 should be maximally translocated. Other PNET, particularly for those patients with node-positive intracellular pathways (such as activation of sweet taste disease. Our fi ndings in this retrospective analysis of a sin- receptors or voltage-gated Ca2+ channels) may be respon- gle institution cohort of PNET warrant further prospective sible for increasing GLUT2 activity at the apical membrane. analysis in a larger patient cohort. (Support: NIH Grant DK39337 [MGS]).

48 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

822 Hypoxic Recovery Following Massive Small Bowel Resection as Measured by Photoacoustic Microscopy Kathryn J. Rowland1, Junjie Yao2, Lidai Wang2, Christopher R. Erwin1, Lihong Wang2, Brad Warner1 1. Pediatric Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO; 2. Biomedical Engineering, Washington University in St. Louis, St. Louis, MO PURPOSE: Massive small bowel resection (SBR) results in an adaptive response within the remnant bowel and is associated with villus angiogenesis. Using optical-resolution Abstracts photoacoustic microscopy (OR-PAM), a non-invasive, label- Monday free, high-resolution hybrid in vivo imaging modality, we have recently demonstrated an immediate (within 10 minutes) reduction in both intestinal blood fl ow and arterial Figure 1. * p < 0.05 vs pre-values and venous oxygen saturation (sO2) after SBR. The present study sought to determine the duration of resection- induced intestinal hemodynamic alterations. METHODS: OR-PAM was used to record vessel diameter, blood fl ow, and sO2 of the terminal mesenteric arteri- ole and accompanying vein within the intestinal wall of C57B6 mice following a 50% proximal SBR. Measurements were taken on post-operative day (POD) 1 (n = 3), POD 3 (n = 3), and POD 7 (n = 6) and compared to pre-operative values (n = 7) and immediately following SBR (10 minutes; n = 7). All measurements were made 6 cm proximal to the ileocecal junction and are presented as mean ±SE. A p value ≤ 0.05 was considered signifi cant. RESULTS: Arterial and venous sO2 dropped immediately following SBR, as demonstrated in Figure 1. Compared with pre-operative values, signifi cantly lower arterial and venous sO2 measurements persisted on POD1. By POD3, Figure 2. * p < 0.05 vs pre-values the arterial sO2 recovered to pre-operative values, however venous sO2 remained signifi cantly lower than pre-operative values. This low venous sO2 persisted on POD7. Arterial and venous blood fl ow decreased signifi cantly immediately post-SBR, as demonstrated in Figure 2. This trend persisted on POD1. By POD3 arterial blood fl ow recovered to preoperative levels, however, venous blood fl ow signifi cantly exceeded pre-operative levels. This enhanced venous blood fl ow persisted on POD7. CONCLUSION: Massive SBR results in a relative hypoxic state within the remnant bowel characterized by a signifi cant reduction in both intestinal blood fl ow and sO2 . Although hemodynamic recovery is observed by POD3, a low venous sO2 consistent with increased tissue oxygen utilization persisted through POD7. These changes may contribute to villus angiogenesis via triggers for genes related to a hypoxic milieu.

49 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

822a METHODS: This retrospective cohort study comprised 79 MMR gene mutation carriers (18 MLH1, 55 MSH2, 4 MSH6 Metachronous Colorectal Cancer Risk Following and 2 PMS2) from the Colon Cancer Family Registry who Surgery for First Rectal Cancer in Mismatch Repair had a surgical resection for their fi rst primary rectal cancer. Gene Mutation Carriers Age-dependent cumulative risks of metachronous colon Aung Ko Win1, Susan Parry2,3, Bryan Parry4, Matthew F. Kalady5, cancer were calculated using the Kaplan-Meier method. Finlay A. Macrae6, Noralane M. Lindor7, Robert W. Haile8, Risk factors for metachronous colon cancer were assessed Polly A. Newcomb9, Loïc Le Marchand 10, Steven Gallinger11,12, using a Cox proportional hazards regression. John Hopper1, Mark A. Jenkins1 RESULTS: During 866 person-years of observation 1. Centre for Molecular, Environmental, Genetic and Analytic (median 9 years; range 1–32 years) since diagnosis of fi rst Epidemiology, The University of Melbourne, Carlton, VIC, rectal cancer, a total of 21 (27%) carriers were diagnosed Australia; 2. New Zealand Familial Gastrointestinal Cancer with metachronous colon cancer (incidence 24.2; 95% CI Registry, Auckland City Hospital, Auckland, New Zealand; 3. 15.8–37.2 per 1000 person-years). Incidence for carriers Department of Gastroenterology, Middlemore Hospital, Auckland, who had an anterior resection (26.8; 95% CI 15.5–46.1 per 1000 person-years) was not different from that for carri- New Zealand; 4. Colorectal Surgical Unit, Auckland City Hospital, ers who had an abdominoperineal resection (21.0; 95% CI Auckland, New Zealand; 5. Department of Colorectal Surgery, 10.5–42.1 per 1000 person-years) (P = 0.1). Cumulative risk Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 6. of metachronous colon cancer was 19% (95% CI 9–31%) at Colorectal Medicine and Genetics, The Royal Melbourne Hospital, 10 years, 47% (95% CI 31–68%) at 20 years and 69% (95% Parkville, VIC, Australia; 7. Department of Medical Genetics, CI 45–89%) at 30 years after surgical resection. There was Mayo Clinic, Rochester, MN; 8. Department of Preventive no difference in the frequency of surveillance colonoscopy Medicine, University of Southern California, Los Angeles, CA; 9. between the two types of surgery (one colonoscopy per 1.1 Cancer Prevention Program, Fred Hutchinson Cancer Research (95% CI 0.9–1.2) years after anterior resection vs. one colo- Center, Seattle, WA; 10. University of Hawaii Cancer Center, noscopy per 1.4 (95% CI 1.0–1.8) years after abdominoperi- University of Hawaii, Honolulu, HI; 11. Samuel Lunenfeld neal resection). Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; CONCLUSIONS: For carriers of MMR gene mutations diag- 12. Cancer Care Ontario, Toronto, ON, Canada nosed with rectal cancer, the metachronous colon cancer BACKGROUND: risk is substantial and mirrors that seen for carriers who Metachronous colorectal cancer risk for have undergone segmental resection for primary colon Lynch syndrome patients with primary colon cancer is high cancer, despite the majority continuing to receive frequent and total colectomy is the preferred option. However if the surveillance colonoscopy. Whereas total colectomy for pri- index primary cancer is in the rectum, management advice mary colon cancer in mutation carriers is appropriate, for is complicated by considerations of worsening bowel func- primary rectal cases this strategy has major implications tion or stoma formation. To aid surgical decision-making, for continence and need for stoma. Nevertheless, given the we estimated the risk of metachronous colon cancer for high metachronous risk, this procedure needs serious con- Lynch syndrome patients who underwent either anterior sideration especially for younger patients. resection or abdominoperineal resection for primary rectal cancer.

50 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tuesday, May 22, 2012

8:00 AM – 9:30 AM 27b PLENARY SESSION VI

920 86% and compares favorably to 69% in historical controls. Subgroup analysis showed that patients receiving 300 mil- Addition of Algenpantucel-L Immunotherapy to lion cells per dose tended toward a longer OS compared to Standard Adjuvant Therapy for Pancreatic Cancer: those receiving 100 million cells per dose, 96% vs. 80% (p A Phase 2 Study = 0.053). As of this analysis, median overall survival has Jeffrey M. Hardacre1, Mary Mulcahy2, William Small2, not been reached. Algenpantucel-L was well tolerated with Mark Talamonti3, Jennifer Obel3, Caio S. Rocha-Lima4, no grade 4 or 5 adverse events. There were nine grade 3 Howard Safran5, Heinz-Joseph Lenz6, Elena G. Chiorean7 adverse events directly or possibly due to the immunother- 1. University Hospitals Case Medical Center, Cleveland, OH; apy. The most common adverse events were injection site 2. Northwestern University, Chicago, IL; 3. Northshore University pain and induration. Helath System, Evanston, IL; 4. University of Miami, Miami, FL; CONCLUSION: Addition of algenpantucel-L to stan- 5. Brown University, Providence, RI; 6. University of Southern dard adjuvant therapy for resected pancreatic cancer may Abstracts California, Los Angeles, CA; 7. Indiana University, Indianapolis, IN improve survival. A multi-institutional, phase 3 study Tuesday began patient enrollment in May 2010. BACKGROUND: Pancreatic cancer portends a poor prognosis with ~4% long-term survival. Among the estimated 20% of patients who have resectable disease, the 1/3/5-year 921 survival rates approximate only 70%/30%/18%, even with Hereditary Pancreatitis: Endoscopic and Surgical adjuvant therapy. Better treatment options are needed, Management and addition of algenpantucel-L immunotherapy to stan- Eugene P. Ceppa1, Henry A. Pitt1, JoAnna Hunter1, dard adjuvant therapy is proposed to improve prospects for Charles Leys1, Nicholas J. Zyromski1, Frederick J. Rescorla1, survival. Algenpantucel-L is composed of irradiated, live, Kumar Sandrasegaran2, Evan L. Fogel3, Lee McHenry3, allogeneic human pancreatic cancer cells expressing the 3 3 3 enzyme α-1,3 galactosyl transferase (α-GT), which is the James L. Watkins , Stuart Sherman , Glen A. Lehman major barrier to xenotransplantation from lower mammals 1. Surgery, IN University School of Medicine, Indianapolis, IN; to humans (e.g., hyperacute rejection). Up to 2% of circu- 2. Radiology, IN University School of Medicine, Indianapolis, IN; lating human antibodies are directed against the α-GT epi- 3. Gastroenterology, IN University School of Medicine, Indianapolis, IN tope of algenpantucel-L and are the proposed mechanism INTRODUCTION: Hereditary pancreatitis is a very rare of initiating the anti-tumor immune response. cause of chronic pancreatic infl ammation. In recent years METHODS: Open-label, dose-fi nding, multi-institutional the genetic mutations leading to hereditary pancreatitis Phase 2 study evaluating algenpantucel-L (100 or 300 mil- have been characterized. Patients with hereditary pancre- lion cells per dose) + standard adjuvant therapy (RTOG- atitis present in childhood and, as adults, are reported to 9704, JAMA, 2008: gemcitabine + 5-FU-XRT) for pancreatic have an extremely high risk of pancreatic cancer. However, cancer patients undergoing R0/R1 resection. Disease-free the rarity of this disorder has resulted in a gap in clinical survival (DFS) was the primary endpoint with overall sur- knowledge. Therefore, the aims of this analysis are to char- vival (OS) and toxicity being secondary endpoints. acterize a large series of patients with hereditary pancreatitis and to establish clinical guidelines. RESULTS: 70 patients with a 21-month median follow-up received gemcitabine + 5-FU-XRT + algenpantucel-L (mean METHODS: Pediatric and adult endoscopic, surgical, 12 doses, range 1–14). Demographics and prognostic fac- radiologic and genetic databases were searched from tors: median age 62 years, 47% female, 81% lymph node 1994–2011. Patients with chronic pancreatitis and genetic positive, median tumor size 3.2 cm (range 2–15 cm; 25% > mutations for PRSS-1 or SPINK-1 as well as those with a 4 cm), and 17% post-operative CA 19–9 ≥180. The primary signifi cant family history of chronic pancreatitis were endpoints of median and 12-month DFS were 14.3 months included. Patients with chronic pancreatitis due to other and 63%, respectively, for the entire cohort. These com- causes, idiopathic pancreatitis without a positive family pare favorably to rates of 11.4 months and <50% in histori- history, and familial pancreatic cancer were excluded. Data cal controls treated with standard adjuvant therapy alone. were gathered on genetic testing, endoscopic and surgical Subgroup analysis showed that patients receiving 300 mil- management as well as the occurrence of pancreatic cancer. lion cells per dose had a longer 12-month DFS compared to RESULTS: Eighty-six patients were identifi ed, and the those receiving 100 million cells per dose, 81% vs. 52% (p = mean age at presentation was 17 years. Forty-four (51%) 0.02). Overall survival at one year in the entire cohort was

51 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

were female. Genetic testing confi rmed the diagnosis in 38 (CC3–4) occurred more commonly after TP (29%) than DP families (44%) while 48 patients (56%) had a signifi cant (28%), LPJ (10%), or PD (10%) (p < 0.01). Resections with family history. In recent years adult patients were coun- IAT did not have a higher overall (66% v. 53%) (p > 0.05) seled to avoid tobacco and alcohol. Eighty patients (93%) nor severe (20% v. 16%) complication rate than those with a median age of 15 years were managed endoscopi- without IAT (p > 0.05). Specifi cally looking at PD with cally with sphincterotomy (69%), stone removal (31%) and without IAT, length of stay (14 v. 10) and complica- and/or stenting of pancreatic duct strictures (85%). In tion rate (72% v. 46%) appeared to be higher, but neither recent years endoscopic ultrasound was performed in 13 reached statistical signifi cance (both p > 0.05). There was patients (15%) to screen for cancer. Twenty-nine patients no difference in complication rate between TP-IAT and PD- (34%) have undergone 35 operations at a mean age of 19 IAT (67% v. 72%) (p > 0.05). Overall (CC1–5) and severe years. Surgery included 15 drainage procedures (lateral (CC3–4) complication rate was similar when all pancreatic pancreaticojejunostomy-9, cystenterostomy-3, Duval-2, resections with IAT (65% and 20%) and those without IAT sphincteroplasty-1) and 20 resections (proximal-10, dis- (53% and 16%) were compared to those undergoing PD for tal-9, total-1). Islet transplantation was performed in the pancreatic cancer (n = 133, 65% and 20%) (all p > 0.05). one patient who underwent a total pancreatectomy. While Reoperation for bleeding after IAT was not different than 22 patients (26%) were older than 40 years, only one 67 after PD for pancreatic cancer (p > 0.05). Partial portal vein year old man developed pancreatic cancer and died. The thrombosis (4%)after IAT and had no long term sequelae. remaining 85 patients are all alive and cancer free. CONCLUSIONS: Operations for chronic pancreatitis are CONCLUSIONS: Many children and young adults with well established and pose no greater risk than resections, hereditary pancreatitis can be managed initially with endo- specifi cally PD, for malignancy. Complication rates remain scopic therapy. When surgery is undertaken, the procedure formidable and mortality rates are low. Improvements to should be tailored to the pancreatic anatomy and the can- quality of life after IAT have been documented; further- cer risk. With aggressive endoscopic and surgical manage- more, the addition of IAT to resections for chronic pancre- ment as well as avoidance of cocarcinogens the incidence atitis adds no risk when compared to those for malignancy. of pancreatic cancer is surprisingly low in patients with At institutions with capability, IAT should be offered to hereditary pancreatitis. patients during resection for chronic pancreatitis.

923 924 Islet Cell Autotransplantation and Morbidity After Venous Involvement During Pancreaticoduodenec- Operations for Chronic Pancreatitis tomy: Is There a Need for Redefi nition of “Borderline John C. McAuliffe, Sandre F. McNeal, Manasi S. Kakade, Resectable Disease”? Brandon A. Singletary, John D. Christein Kaitlyn J. Kelly1, David Kooby3, Alex Parikh4, Clifford S. Cho1, University of Alabama at Birmingham, Birmingham, AL Emily Winslow1, Charles R. Scoggins2, Syed A. Ahmad5, 2 3 6 BACKGROUND: Quality of life studies after pancreatic Robert C. Martin , Shishir K. Maithel , Hong Jin Kim , resection and islet cell autotransplantation have shown Nipun Merchant4, Sharon M. Weber1 improvement and already been published. Mortality rates 1. Surgery, University of Wisconsin, Madison, WI; 2. Surgery, have improved, but morbidity remains high after pancre- University of Louisville, Louisville, KY; 3. Surgery, Emory atic operations, in particular total pancreatectomy (TP) and University, Atlanta, GA; 4. Surgery, Vanderbilt University, pancreaticoduodenectomy (PD). Few studies have evalu- Nashville, TN; 5. Surgery, University of Cincinnati, Cincinnati, ated outcomes after pancreatic operations specifi cally for OH; 6. Surgery, University of North Carolina, Chapel Hill, NC chronic pancreatitis, with or without islet cell autotrans- INTRODUCTION plantation (IAT), and compared these to operations for : The consensus defi nition of border- pancreatic cancer. line resectable pancreas cancer includes patients with any venous (SMV-PV) or limited arterial (SMA or GDA/ METHODS: A retrospective review for patients undergo- CHA) involvement. Recent recommendations suggest that ing operation for chronic pancreatitis from 2005–2011 patients with borderline resectable pancreatic adenocarci- by a single surgeon at an academic center. Morbidity was noma should receive neoadjuvant therapy to increase the evaluated to 90 days according to the Clavien Classifi ca- likelihood of achieving R0 resection. It is established that tion (CC). Patients undergoing pancreatic resection with a subset of patients with limited venous involvement can IAT were evaluated as a subgroup. Both groups were com- achieve R0 resection by utilizing vein resection. This study pared to those undergoing similar operations for pancreatic compares outcome of patients who underwent pancreati- cancer. Statistical analysis was applied. coduodenectomy with (VR-PD) or without (PD) vein resec- RESULTS: Of the 200 patients (55% men, mean age 49 tion, and is unique because none received neoadjuvant years), ninety-eight underwent resection alone (65 PD, 27 therapy. distal (DP) and 6 TP), 67 underwent resection with IAT (47 METHODS: A large, multi-institutional database of patients TP, 18 PD, 2 DP), and 22 underwent drainage with lateral who underwent PD without neoadjuvant therapy was pancreaticojejunostomy (LPJ). There was no mortality; reviewed. Patients who required vein resection due to SMV- however, the overall morbidity rate was 55% (CC 1–5) PV involvement by tumor were compared to those who and 29% of these experienced a more severe complica- underwent PD without vein resection. tion requiring intervention (CC 3–4). Severe complications

52 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Multivariate Analysis of Demographic, Pathologic, and Operative Factors for Patients Undergoing PD for Adenocarcinoma that May Inﬂ uence Disease Free (DFS) and Overall Survival (OS)

DFS OS Factor HR 95% CI P HR 95% CI P Tumor Size (cm) 1.00 0.90–1.10 0.97 1.01 0.92–1.10 0.85 Tumor Grade <0.05 <0.01 Well 1.66 1.07–2.57 1.93 1.33–2.81 Moderate 1.93 0.77–4.85 1.74 0.80–3.81 Poor 2.06 1.24–3.42 3.03 1.97–4.64 Positive Lymph Nodes 1.57 1.18–2.09 <0.01 1.56 1.22–1.99 0.01 Vein Involvement 1.15 0.78–1.68 0.83 1.20 0.87–1.63 0.26 R1 Margin 1.26 0.94–1.70 0.09 1.80 1.39–2.30 <0.01 Blood Loss (mL) 1.00 — 0.01 1.00 — <0.01 Adjuvant Chemo 1.19 0.89–1.57 0.25 0.74 0.58–0.94 <0.01

RESULTS: Of 492 total patients, 70 (14%) underwent METHODS: We reviewed the medical records of all patients VR-PD and 422 (86%) underwent PD. There was no differ- with pancreatic ductal adenocarcinoma who underwent Abstracts ence in R0 resection (66% VR-PD vs. 75% PD, p = 0.11) or pancreaticoduodenectomy (PD) at our institution between Tuesday local recurrence rate (18% VR-PD vs. 14% PD, p = 0.33), at March 1992 and March 2011. We identifi ed patients who a median follow up of 16 months (range 3.0–129.7). There received neoadjuvant (NA) therapy or required major was no difference in median DFS (10.1 months VR-PD vs. vascular resection and evaluated demographics, opera- 15.2 months PD, p = NS, HR 1.24 (0.94–1.64)). Positive tive characteristics, morbidity, mortality, and survival. margin, increased EBL, advanced tumor grade, and lymph Student’s t- or Mann-Whitney U tests and Chi-squared or node involvement, but not vein involvement, were inde- Fisher’s exact tests were used to compare continuous and pendent predictors of DFS. These same factors, as well as categorical variables, respectively. Kaplan-Meier curves and use of adjuvant therapy, predicted OS (see Table above). Cox proportional hazards models were used to compare CONCLUSION: This is the largest modern series examin- survival. ing patients with borderline resectable pancreas cancer due to SMV-PV involvement, none of whom received neoadjuvant therapy. This cohort of patients with vein involvement selected for up-front surgical resection demonstrates that oncologic outcomes, including R0 rate, local recurrence rate, and DFS, were not compromised when vein resection was required. These data suggest that up-front surgical resection is an appropriate option for patients with isolated vein involvement and calls into question the inclusion of all SMV-PV involvement within the defi nition of “borderline resectable disease.”

925 Neoadjuvant Therapy and Vascular Resection During Neoadjuvant (NA) therapy and vascular resection can bring select Pancreaticoduodenectomy: Shifting the Survival Curve patients with initially locally unresectable pancreatic cancer to for Patients with Locally Advanced Pancreatic Cancer pancreaticoduodenectomy with a signiﬁ cant survival beneﬁ t. In this Joseph DiNorcia, Megan Winner, Minna K. Lee, Irene Epelboym, series, median survival of resected NA patients was similar to resected James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf non-NA patients (24.9 months vs. 19.3 months, p>0.05) and longer than Surgery, Columbia University College of Physicians and Surgeons, non-NA patients aborted for locally advanced disease (24.9 months vs. New York, NY 8.9 months, p < 0.05). Median survival of NA patients aborted for locally BACKGROUND: Neoadjuvant chemoradiation therapy advanced disease was 13.3 months. and more aggressive surgery with vascular resection are two strategies to bring patients with locally advanced pancreatic cancer to the operating room for potential cure.

53 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: A total of 600 patients were brought to the oper- morbidity (54.9% vs. 33.7%, p < 0.001) and mortality (1.8% ating room for attempted resection. One hundred fi fty-four vs. 6.3%, p = 0.008), but similar R0 resection rates (74% vs. (25.6%) had received NA therapy for initially unresectable 81%, p = 0.07) and lengths of stay (10 days vs. 9 days, p = disease whereas 446 (74.4%) were explored at presentation. 0.07) compared to standard PD. Median survival of resected One hundred twenty-four (80.5%) NA patients underwent NA patients was similar to resected non-NA patients (24.9 successful PD compared to 340 (76.5%) non-NA patients. months vs. 19.3 months, p>0.05) and signifi cantly longer The NA patients were younger (62.7 years vs. 67.5 years, p than non-NA patients aborted for locally advanced disease < 0.001), more often had prior resection attempts (26.6% (24.9 months vs. 8.9 months, p < 0.05). NA patients who vs. 0.9%, p < 0.001), had longer median operative times required vascular resection had longer survival than non- (390 min vs. 328 min, p < 0.001), and had higher median NA patients who required vascular resection (23.6 months estimated blood loss (1500mL vs. 1000mL, p < 0.001) than vs. 14.4 months, p < 0.05). non-NA patients. There were no statistically signifi cant dif- CONCLUSION: Many patients with locally advanced pan- ferences in R0 resection rate (82.3% vs. 78.2%, p = 0.34), creatic cancer can be brought to resection through NA median length of stay (9 days vs. 10 days, p = 0.16), mor- therapy and vascular resection with acceptable morbidity bidity (50% vs. 49.4%, p = 0.91), or mortality (6.5% vs. and mortality. These patients have signifi cantly improved 2.7%, p = 0.09) between the two groups. Sixty-one percent survival over patients deemed locally inoperable by tradi- of NA patients versus 18.8% non-NA patients required vas- tional criteria. cular resection (p < 0.001), therefore a subset analysis was performed. PD with vascular resection resulted in increased

9:30 AM – 12:00 PM 27b PLENARY SESSION VII

1004 age or reoperation. Hemorrhage was defi ned as bleeding requiring reoperation. Hepatic insuffi ciency was defi ned Greater Complexity of Liver Surgery Is Not Associated as a peak serum bilirubin level of >7mg/dL at any time with an Increased Incidence of Liver Related postoperatively. Complications Except for Bile Leak: An Experience RESULTS: 2628 hepatic resections were performed with 2628 Consecutive Resections between 1997 and 2011 with a 90 day morbidity of 37% Robert E. Roses, Giuseppe Zimmitti, Thomas Aloia, and mortality of 2%. Comparison of case type between Andreas Andreou, Steven Curley, Jean-Nicolas Vauthey the later and earlier cohorts revealed an increase in com- Surgical Oncology, University of Texas MD Anderson Cancer plexity over time as evidenced by the greater number of Center, Houston, TX re-resections (11.2% vs 4.3%; p < 0.001), second stage resec- BACKGROUND: Advances in technique, technology and tion(4.0% vs 0.9%; p < 0.001) and extended right hepa- perioperative care have allowed for the more frequent per- tectomies (18.4% vs 14.9%; p = .017) and increasing use formance of complex and extended hepatic resections. The of preoperative portal vein embolization (9.1% vs 5.9%; p purpose of this study was to determine if this increasing = 0.002) in the later group. Despite this, the incidence of complexity has been accompanied by a rise in liver related abdominal collection (2.1% vs 3.4%; p = .031) and hemor- complications. rhage (0.3% vs 0.9%; p = .045) decreased and the incidence of hepatic insuffi ciency (2.6% vs 3.1%; p = 0.41) remained METHODS: A large prospectively maintained single insti- stable. In contrast, the rate of bile leak increased (5.9% vs tution database of patients who underwent hepatic resec- 3.7%; p = 0.011). For the entire cohort, bile leak was associ- tion was utilized to identify the incidence of liver related ated with increased 90 day mortality (11.1% vs 1.8%; p < complications. Patients were divided into two groups of 0.001) and increased length of stay (mean 13 vs 8 days; p equal size: an earlier group and a later group (surgery per- < 0.001). Independent predictors of bile leak included bile formed before or after 5/18/2006). Patient characteristics duct resection (OR 3.9; p < 0.001), resection of >3 segments and perioperative factors were compared between the two (OR 3.1; p < 0.001), second stage resection (OR 2.5; p = groups. Abdominal collection was defi ned as a non-bilious 0.019) and intraoperative blood loss> 1 liter (OR 1.9; p = fl uid collection requiring drainage. Bile leak was defi ned as 0.019). bilious drainage from the postoperative drain or incision for 3 days or more, or a bilious collection requiring drain-

54 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

1005 Effect of the Artifi cial Sweetener, Acesulfame Potassium, a Sweet Taste Receptor Agonist, on Glucose Uptake in Small Intestinal Cell Lines Ye Zheng2, Michael G. Sarr1,2 1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology Research Unit, Mayo Clinic, Rochester, MN Activation of sweet taste receptors may enhance glucose uptake several fold in rat intestine. AIM: To explore mechanisms of sweet taste receptor activation in glucose uptake in 3 intestinal cell lines. HYPOTH- ESIS: The artifi cial sweetener, acesulfame potassium (AceK), increases glucose uptake via activating sweet taste receptors to induce translocation GLUT2 to the apical membrane through the PLC βII pathway. Complexity of Liver Surgery METHODS: Caco-2, RIE-1, and IEC-6 cells (human, rat, and rat intestinal cell lines) were seeded on a 24-well plate at a density of 4x104 cells/cm2 in growth culture media and left to differentiate for 15 days after confl uence. Caco-2 and RIE-1 cells express GLUT2, while IEC-6 cells do not.

Cells were starved from glucose for 1 h and pre-incubated Abstracts with and without 10 mM AceK for 30 min. Glucose uptake Tuesday was measured by incubating the cells for 1 to 10 min with 0.5–50 mM glucose with and without 10 mM AceK. 14C-D- glucose was used to measure stereospecifi c, transporter- mediated uptake and 3H-L-glucose to measure passive uptake with or without the inhibitors 10 μM U-73122, a PLC βII inhibitor, 10 μM chelerythrine, a PKC inhibitor, and 2 μM cytochalasin B, a microtubular system disrupter. Glucose uptake was stopped by adding ice-cold PBS; cells were washed with PBS 2 times and solubilized with 0.1 N NaOH. All experiments were done on at least 3 separate Liver Related Complications occasions in triplicate. RESULTS: In Caco-2 and RIE-1 cells, 10 mM AceK CONCLUSIONS: Despite an increasing complexity of increased carrier-mediated glucose uptake by 20–30% liver surgery, the rates of liver related complications have at apical glucose concentrations >25 mM (p < 0.05), but remained stable or decreased. An important exception to not in the lesser glucose concentrations (<10 mM) nor at this is bile leak which has increased in incidence and is 1-min or 10-min incubations. U-73122, a PLC βII inhibitor, now a major cause of surgical morbidity. Given the strong inhibited glucose uptake at the greater (>25 mM) glucose association between bile leak and other poor outcomes, the concentrations during the 5-min incubation; chelerythrine development of novel technical strategies to reduce bile and cytochalasin B had similar effects. No effect was seen leak is indicated. in IEC-6 cells. CONCLUSION: The artifi cial sweetener AceK, a known sweet taste receptor agonist, has no effect on glucose uptake in low (<25 mM) glucose concentrations, but increased glucose uptake at greater concentrations (> 25 mM) in our cell culture models when GLUT2 translocation occurs. The role of artifi cial sweeteners on glucose uptake appears to act in part by effects on the enterocyte itself. (Support: NIH DK39337-MGS)

55 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

1006 LIR + ERAS LIR + CC Combination of Laparoscopy and Enhanced Recovery (n = 20) (n = 70) p Program Improves Outcomes After Ileocecal Resection Time to fi rst fl atus 1.7 ± 0.7 2.8 ± 1.5 0.002* for Crohn’s Disease (days—mean ± SD) Antonino Spinelli1, Piero Bazzi1, Matteo Sacchi1, Silvio Danese3, Time to fi rst bowel movement 3.0 ± 0.9 3.6 ± 1.1 0.03* Gionata Fiorino3, Lorenzo Gentilini5, Alberto Malesci4, (days—mean ± SD) Gilberto Poggioli5, Marco Montorsi1,2 Postoperative length of stay 5.3 ± 1.6 6.8 ± 3.1 0.04* 1. Department of Surgery, Istituto Clinico Humanitas IRCCS, (days—mean ± SD) Rozzano Milano, Italy; 2. Department of Surgery, University Total length of stay 5.3 ± 1.6 7.9 ± 3.4 0.001* of Milan, Milano, Italy; 3. IBD Unit – Department of (days—mean ± SD) Gastroenterology, Istituto Clinico Humanitas IRCCS, Rozzano Postoperative pain: VAS 8; 40% 19; 27.1% n.s.° Milano, Italy; 4. Department of Gastroenterology, Istituto Clinico Score > 3 on p.o. day 1 Humanitas IRCCS, Rozzano Milano, Italy; 5. Department of (n; %) Surgery, Policlinico S. Orsola – Malpighi – University of Bologna, Postoperative pain: VAS 2; 10% 4; 5.7% n.s.° Bologna, Italy Score > 3 on p.o. day 2 BACKGROUND: Two major innovations have drastically Major complication rate 3; 15% 7; 10% n.s.° modifi ed colorectal surgery over the last 20 years: lapa- (bleeding, leakage, roscopy and the introduction of multimodal integrated abdominal abscess) perioperative programs (ERAS, Enhanced Recovery After Minor complication rate 2; 10% 10; 14.3% n.s.° Surgery, also known as Fast Track programs). ERAS applies (ileus, intraluminal bleeding, evidence-based concepts to perioperative care of surgical wound infection) patients: it aims to reduce surgical stress, allowing a faster Readmissions within 30 days 0; 0% 2; 2.8% n.s.° and smoother postoperative recovery. A recent RCT proved from discharge that the combination of laparoscopy with ERAS represents the best option for colorectal cancer patients. There are sur- * t-test; ° 2-test prisingly no data on Crohn’s disease (CD) patients treated 1007 by laparoscopy and ERAS program.  METHODS: Twenty consecutive patients planned for ileo- Predictors of Unsuccessful Laparoscopic Resection of cecal resection due to stricturing CD at two IBD referral Gastric Submucosal Neoplasms centers were prospectively enrolled. Patients underwent Sabha Ganai1, Vivek N. Prachand1, Mitchell C. Posner1, laparoscopic ileocecal resection (LIR) and were treated John C. Alverdy1, Eugene A. Choi1, Irving Waxman1, according to ERAS program (LIR+ERAS group): no preop- Marco G. Patti, Kevin K. Roggin erative bowel preparation nor fasting, no nasogastric tubes, Department of Surgery, The University of Chicago, Chicago, IL no abdominal drains, early removal of urinary catheters, INTRODUCTION: early feeding and mobilization, multimodal opioid-free While minimally-invasive techniques analgesia and restrictive perioperative fl uid management. have an integral role in foregut surgery, their optimal use Enrolled patients were compared with 70 patients treated in the resection of gastric neoplasms awaits validation in by LIR and conventional care (CC) (LIR+CC group), clinical practice. We hypothesized that conversion of oper- matched for age, sex, disease presentation, BMI, ASA score, ations to open could be predicted by specifi c anatomical preoperative therapy. and pathological factors. METHODS: RESULTS: See Table. A retrospective analysis was conducted on patients with attempted laparoscopic resection (n = 69) CONCLUSION: This is the fi rst experience combining and open resection (n = 25) of submucosal neoplasms of laparoscopic surgery with integrated multimodal ERAS the stomach from October 2002 through October 2011. protocols on CD patients. Our data showed a signifi cantly Nonparametric statistical tests were used for comparisons faster return of normal bowel function and shorter hospital between groups. stay for the LIR+ERAS group. This suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.

56 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Laparoscopic (n = 62) Conversion (n = 7) Open (n = 25) p Symptoms: 14 (24%) 23 (39%) 8 (14%) 1 (14%) 2 (29%) 1 (4%) 8 (32%) 0.01 – Asymptomatic 0 14 (24%) 1 (14%) 0 3 (43%) 2 (8%) 1 (4%) 13 (52%) – GI bleed – Reﬂ ux/Dyspepsia – Dysphagia – Abdominal Pain Neoadjuvant Imatinib 2 (3%) 2 (29%) 6 (24%) 0.005 Preoperative Size (cm) 3.5 ± 1.8 7.7 ± 5.4 9.5 ± 7.1 <0.0001 Pathological Size (cm) 4.0 ± 2.2 7.6 ± 5.0 8.5 ± 6.2 0.0004 Operative Time (min) 145 ± 60 246 ± 84 231 ± 96 <0.0001 Estimated blood loss (mL) 35 ± 70 376 ± 422 373 ± 280 <0.0001 Accordian Severity Score 0 – no 51 (82%) 3 (5%) 4 (7%) 3 (43%) 1 (14%) 9 (36%) 4 (16%) 7 (28%) 0.0003 complications 1 (2%) 2 (3%) 0 1 (2%) 3 (43%) 0 0 0 0 2 (8%) 1 (4%) 1 (4%) 1 (4%) 1 – minor (wound, foley) 2 – minor (PRBCs, Abx, TPN) 3 – Endoscopic / IR Intervention 4 – Operative Intervention 5 – MSOF 6 – Death Hospital length of stay (days) 3.5 ± 3.9 6.4 ± 1.1 8.7 ± 5.8 <0.0001 Abstracts Tuesday

RESULTS: Patients were 63 ± 14 years old, 52% male, and had a BMI of 29.5 ± 7.3 kg/m2. Diagnostic endoscopic ultra- 1008 sound use was greater in the laparoscopic group than the Minimally Invasive Approach GE Junction and open (86% vs. 64%, p < 0.05). Lesions in the laparoscopic Esophageal GIST and open cohorts included gastrointestinal stromal tumors 1 1 2 (71% vs. 88%), leiomyomas (9% vs. 12%), schwannomas Jon Gould , Andrew Kastenmeier , Mario Gasparri (9% vs. 0), and other (11% vs. 0). There were 7 (10%) conver- 1. Minimally Invasive General Surgery, Medical College of sions to open in the laparoscopic group. Posterior location Wisconsin, Milwaukee, WI; 2. Thoracic Surgery, Medical College was a predictor of conversion (71% vs. 32%, p < 0.01) and of Wisconsin, Milwaukee, WI selection for an open technique (67%, p < 0.01). There were Gastrointestinal stromal tumors are rare neoplasms of no other predictors of conversion by location of the mass uncertain malignant potential. The most common site of along the stomach. Conversions (29%) and open resections origin is the stomach. Approximately 5% of all GISTs origi- (40%) were more likely to have multivisceral involvement nate from the esophagus. Traditional management of gas- than the laparoscopically-treated patients (2%, p < 0.0001). tric GIST is wedge resection to grossly negative margins. Combined laparoendoscopic approaches were used in 10% Tumors located at the GE junction are diffi cult to resect of laparoscopic procedures (n = 62), which included wedge without impairing esophageal emptying. Tumors in the or sleeve resection in 47 (76%), transgastric wedge resec- esophagus cannot be resected with wedge resection tech- tion in 5 (8%), submucosal resection in 3 (5%), midbody niques. Rather than performing an esophagectomy, enucle- gastrectomy in 2 (4%), antrectomy in 1 (2%), and other ation of low-risk lesions may be appropriate. We present in 4 (6%). Patients selected for open resection were more a video demonstrating the laparoscopic resection of two likely to require a gastroenteric anastomosis in comparison GIST lesions in diffi cult anatomic locations: the GE junc- to patients initially selected for a laparoscopic approach tion and the distal esophagus. (40% vs. 4%, p < 0.0001). Signifi cant differences in tumor size, operative time, morbidity, and length of stay were noted between groups (refer to Table, p < 0.001). CONCLUSIONS: Selection for laparoscopic versus open resection appears to be infl uenced by factors including tumor size, multivisceral involvement, and the need for gastric reconstruction. Conversion to open is also more likely with tumors in a posterior location. Laparoscopic gastric resection has decreased morbidity, operative time, and hospital length of stay and is appropriate in well-selected patients with gastric submucosal neoplasms.

57 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

1009 1010 Epigenetic Modulation of Adhesion and Proliferation Adjuvant Radiation Therapy and Lymph Node Dissection Pathways by Methionine Defi ciency Attenuates in Esophageal Cancer: A SEER Database Analysis Potential for Dissemination of Gastric Cancer Cells Ravi Shridhar2, Jill Weber1, Sarah Hoffe2, Khaldoun Almhanna1, Luigina Graziosi2, Andrea Mencarelli1, Barbara Renga1, Richard Karl1, Ken L. Meredith1 Emanuel Cavazzoni2, Angela Bruno1, Chiara Santorelli2, 1. Gastrointestinal Oncology, Moffi tt Cancer Center, Tampa, FL; Emanuele Rosati2, Stefano Fiorucci1, Annibale Donini2 2. Radiation Oncology, H. Lee Moffi tt Cancer Center, Tampa, FL 1. Medicina Clinica e Sperimentale, University of Perugia, Objectives: The number of lymph nodes removed during Perugia, Italy; 2. Dipartimento di Scienze Chirurgiche, esophagectomy and the impact on survival remains unde- Radiologiche e Odontostomatologiche, University of Perugia, fi ned. We sought to determine the effects of post-operative Perugia, Italy radiation therapy and lymph node dissection on survival BACKGROUND: Methionine dependency is a feature in esophageal cancer. unique to cancer cells, as demonstrated by their inability METHODS: We performed an analysis of patients who to grow in a methionine depleted environment even if the underwent esophagectomy for cancer from the SEER database medium is supplemented with homocysteine, the imme- between 2004–2008 to determine association of adjuvant diate precursor of methionine. Treatment of disseminated radiation and lymph node dissection on survival. Patients gastric cancer is unsatisfactory and gastric tumors are fre- treated with neoadjuvant radiation were excluded. Survival quently chemoresistant. curves were calculated according to the Kaplan-Meier method AIM: To investigate the effect of methionine defi ciency in with log-rank analysis. Multivariate analysis (MVA) was per- rodent models of gastric cancer dissemination. formed by the Cox proportional hazard model. MATERIAL AND METHODS: Moderate (MKN74) and RESULTS: We identifi ed 2109 patients who met inclusion poorly differentiated (MKN45 and KatoIII) human gastric criteria. There were 467 and 1642 patients treated with and cancer cell lines were used for these studies. To generate without radiation. Radiation was associated with increased models of experimental peritoneal carcinomatosis (10 days) survival in stage III patients (HR 0.71; 95% CI: 0.56 - 0.90; and xenograft model (65 days), these cell lines were injected p = 0.005), no benefi t in stage II (p = 0.075) and IV (p = intraperitoneally or subcutaneously, respectively, in NOD- 0.913) patients, and decreased survival in stage I patients SCID mice. For in vitro studies cells were growth in a com- (HR 2.73: 95% CI: 1.76 - 4.22; p < 0.0001). Univariate anal- plete medium with 10% bovine dyalized serum in a ysis revealed that radiation therapy was associated with a methionine free medium containing homocysteine(Met- survival benefi t in node positive (N1) patients while it was Hcy+) or a medium containing methionine but depleted of associated with a detriment in survival for node negative homocytesine (Met+Hcy-). (N0) patients. The median and 3 year survival with and RESULTS: In the xenograft models induced by subcutane- without radiation is 23 months and 34%, and 20 months ous implantation of MNK45 and MNK74 cells, two cycles of and 26.7%, respectively (p = 0.0225) for N1 patients and methionine defi cient diet (from day 20 to 27 and from day the 3-year survival with and without radiation is 48.8% 34 to 41) reduced the tumor growth, measured on day 70, and 68.8%, respectively (p < 0.0001) for N0 patients. In by 50% (p < 0.05 versus control diet). In the model of peri- node negative patients, removing <12 versus >12 lymph toneal carcinomatosis, induced by MNK45 cells injection, nodes (HR 1.316; 95% CI 1.060 - 1.634; p = 0.013) and <15 a cycle of methionine defi cient diet for 10 days reduced versus >15 (HR 1.313; 95% CI: 1.032 - 1.670; p = 0.027) peritoneal nodules from 27.0 ± 3.68 to 6.7 ± 0.8 (p < 0.05). was associated with increased mortality. Similarly, in node The intraperitoneal injection of MNK74 cells precultured positive patients, removing <8 versus >8 (HR 1.325; 95% for 3 days in a Met-Hcy+ medium almost abrogated peri- CI 1.066– 1.646; p = 0.011), <10 versus >10 (HR 1.311; toneal dissemination (p < 0.05 versus Met+Hcy- medium 95% CI 1.069–1.608; p = 0.009), <12 versus >12 (HR 1.299; precultured group). 95% CI 1.066– 1.582; p = 0.009), <15 versus >15 (HR 1.258; 95% CI 1.031– 1.535; p = 0.024), and <20 versus >20 (HR Three-days in vitro culture In vitro of MKN45,MKN74 and 1.325; 95% CI 1.056–1.662; p = 0.015) was associated with KATOIII cells in a methionine defi cient medium inhib- increased mortality. In node negative patients, age and ited cell proliferation by 70-% and induced cell apoptosis. tumor stage, were prognostic for worse survival, while gen- In addition, culturing cells in a methionine free medium der and number of lymph nodes removed were prognostic reduced cell adhesion and migration signifi cantly in compar- for better survival. Adjuvant radiation, tumor location, and ison to Met+Hcy- medium (p < 0.05). Finally, by microarray histopathology were not prognostic for survival. In node designed to analyze the methylation of promoter CpG-islets, positive patients, age and tumor stage were associated with we found that methionine defi ciency reduced the promoter increased mortality while number of lymph nodes removed methilation of E-Cadherin and secreted frizzled-related pro- and adjuvant radiation were associated with decreased tein 2 (SFRP-2) by 50%, two genes involved in the gastric mortality. Gender, tumor location, and histopathology cancer cell adhesion and proliferation, respectively. were not prognostic for survival in node positive patients. CONCLUSIONS: Our experimental data suggest that a CONCLUSION: The number of lymph nodes removed in defi cient methionine diet might affect neoplastic tumor esophageal cancer is associated with increased survival. growth by regulation of cell cycle, inducing apoptosis and The benefi t of adjuvant radiation therapy on survival in decreasing cellular adhesion and migration. esophageal cancer is limited to N1 patients.

58 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

1012 1011 Health-Related Quality of Life in Patients Esophageal Extent of Lymphadenectomy Does Not Predict Survival Cancer: Predictors Analysis at the Different Steps of in Patients Treated with Primary Esophagectomy Treatment Joyce Wong, Jill Weber, Khaldoun Almhanna, Sarah Hoffe, Marco Scarpa1, Luca Saadeh1, Alessandra Fasolo1, Rita Alfi eri1, Ravi Shridhar, Ken L. Meredith Matteo Cagol1, Giovanni Zaninotto2, Ermanno Ancona2, Surgery, H. Lee Moffi tt Cancer Center, Tampa, FL Carlo Castoro1 BACKGROUND: The number of lymph nodes resected 1. Oncological Surgery Unit, Venetian Oncology Institute and its impact on survival for patients with esophageal (IOV-IRCCS), Padova, Italy; 2. Department of Surgical and cancer remains undefi ned. Current guidelines recommend Gastroenterological Sciences, University of Padova, Padova, Italy extended lymphadenectomy in patients not receiving neo- BACKGROUND: adjuvant therapy. We reviewed our single institutional The main outcome parameters in esoph- experience with nodal harvest for esophageal cancer in a ageal oncology have traditionally been morbidity and non-neoadjuvant therapy setting. mortality but recent improvements in the treatment of esophageal cancer suggest to take in consideration quality METHODS: Patients who underwent esophagectomy as of life. Esophagectomy is associated with signifi cant dete- primary therapy were indentifi ed from a prospectively rioration of the health related quality of life, which persists maintained database consisting of 704 patients who under- during the follow-up period. The aim of this study was to went esophagectomy. Patients were stratifi ed by number analyze quality of life before and after esophagectomy for of lymph nodes (LN) resected: >5, 10, 12, 15, or 20. Sur- esophageal cancer and to identify possible predictors of vival, clinical and pathologic parameters were analyzed quality of life at the different steps of the treatment. with Kaplan-Meier curves, chi-square or Fisher’s exact tests Patients and methods One hundred twenty six consecutive where appropriate. Abstracts patients presenting with esophageal cancer at the Oncolog- Tuesday RESULTS: We identifi ed 246 patients who underwent ical Surgery Unit of the Veneto Institute of Oncology have esophagectomy as initial treatment. The mean age was 65 been enrolled in this prospective study from 2009 to 2011. years ±10 years. The majority of patients were male (87%). The patients answered to three quality of life questionnaires Ivor-Lewis esophagectomy was performed for 71%, mini- at diagnosis of esophageal cancer, after the neoadjuvant mally-invasive esophagectomy for 15%, transhiatal esoph- therapy, after surgery and at 1, 3, 6 and 12 months after agectomy for 12%, and three-fi eld esophagectomy for 2%. surgery. The questionnaires were administered during the At 60 month follow-up, there was no statistically signifi - hospitalization and outpatient visits. The questionnaires cant difference in overall survival (OS) or disease free sur- were the Italian version of the QLQ-C30, QLQ-OES18 and vival (DFS) between patients with < vs. >5 LN resected (p = IN-PATSAT32 models, developed by the European Organi- 0.74 and p = 0.67, respectively) or in the < vs. >10 (p = 0.33, zation for Research and Treatment of Cancer (EORTC). Uni- p = 0.11), 12 (p = 0.82, p = 0.90), 15 (p = 0.45, p = 0.79), variate and multivariate analysis were performed. or 20 (p = 0.72, p = 0.86) resected LN groups. Patients were RESULTS: then sub-divided into node positive and node negative Global quality of life (QL2 item) improved after cohorts and stratifi ed by nodal harvest. In the subgroups neoadjuvant therapy compared to the baseline levels, it of patients with node-negative and node-positive disease, decreased immediately after surgery (p = 0.06) and then it OS and DFS also did not signifi cantly differ between groups improved after 1 year (p = 0.03). At diagnosis, QL2 item cor- with respect to number of nodes resected (p>0.05). A total related signifi cantly with tumor size, gender and dysphagia of 49 (20%) patients developed recurrent disease; however but none of these items was an independent predictor at recurrence was not statistically associated with number of multivariate analysis. After neoadjuvant therapy, only age LN resected (p > 0.05). revealed to be an independent predictor of good quality of life (b = 0.33, p = 0.02). After surgery, gastroenterologi- CONCLUSION: We found no impact of extent of lymph- cal complications of radiochemotherapy were independent adenectomy on overall or disease free survival in patients predictor of poor quality of life (b = – 0.33, p = 0.04). One treated with esophagectomy without neoadjuvant therapy. year after esophagectomy postoperative complications In addition, the number of nodes resected at esophagec- were independent predictor of poor quality of life at this tomy did not affect recurrence rates. Current recommenda- stage (b = – 0.63, p = 0.01). Dysphagia (DYS item) improved tions for increased nodal resection during esophagectomy dramatically after surgery (p < 0.01). After surgery DYS was in patients not receiving neoadjuvant therapy may not independently predicted by the presence of skin complica- improve patient outcomes, and this phenomenon warrants tion of chemo radiation, hospital stay duration and the use further investigation. of jejunostomy (b = 0.33, p = 0.04, b = 0.40, p = 0.04 and b = -0.45, p = 0.02, respectively).

59 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSIONS: Even if in the short-term quality of life chief component. Presently, there is no simple in vitro cul- seems to be negatively infl uenced by esophagectomy after ture system of human esophageal cells that can be used 12 months the scale returns to baseline levels. However, to observe the morphological and molecular effects of bile the minimally invasive techniques do not seem to confer acid and low pH on a stratifi ed epithelium. In this study, special benefi ts. On the contrary, dysphagia improve signif- we showed that h-TERT-transformed primary esophageal icantly after esophagectomy. Older patients seem to cope squamous cells (EPC1) form a 10–11 layered stratifi ed epi- more easily with neoadjuvant therapy while complications thelium when grown on polyester trans-well fi lters apically of chemo radiation and of surgery deeply affect quality of and basally supplemented with keratinocyte serum-free life at different stage of the natural history of the disease. media with 0.6 mM Ca+2. This stratifi ed epithelium shows epithelial barrier function and expresses squamous specifi c 1013 genes like GRHL-1, K10, KDAP, DSG1, and IVL. Moreover, when exposed to bile acids at pH5 in short pulses, EPC1 Bile Acid at Low pH Reduces the Squamous cells demonstrate reduction in the stratifi cation layers and Differentiation and Induces Columnar Differentiation in the expression of squamous specifi c genes. The epithe- of Primary Esophageal Cells, Possibly by Activating lium also exhibits loss of barrier function possibly due to EGFR Signaling disruption of desmosomal junctions and phosphorylation- Sayak Ghatak1,2 activation of epidermal growth factor receptor (EGFR) and 1. Biology, University of Rochester, Rochester, NY; 2. Surgery, down-stream pathways. In addition, the epithelium starts University of Rochester, Rochester, NY expressing columnar specifi c transcription factor CDX2 as early as day 3 of treatment. These results indicate that bile Esophageal Adenocarcinoma is the fastest growing cancer acid at low pH is responsible for skewing the differentia- in the United States and is the sixth leading cause of cancer- tion status of stratifi ed squamous esophageal epithelium related death. In its precancerous lesion, Barrett’s Esopha- in vitro to a more columnar type possibly by initiating a gus, the normal squamous epithelium of the esophagus mucosal restitution response through activation of EGFR undergoes columnar metaplasia due to long-term exposure signaling. to refl ux contents of which bile acid at acidic pH is the

60 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

POSTER SESSION DETAIL Printed as submitted by the authors. indicates a Poster of Distinction. Sunday, May 20, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.

12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME)

Basic: Colon-Rectal Total purifi ed RNA was isolated from tissue samples and cDNA synthesized. CDH3 expression was analyzed by quantitative PCR (QPCR) using the SYBR Green platform. Su2020 Tumor expressions levels were determined and compared to expression levels in normal colonic tissue and PLC. The Tumor Associated Antigen P-Cadherin (CDH3) CDH3 expression in other normal organs was also assessed. in Colorectal Cancer Holds Promise as a Prognostic Tumors with expression levels 0.1% or more than the PLC Marker Rather Than as Specifi c Immunotherapy Target result were considered positive. Plasma CDH3 levels were C.M. Shantha Kumara H*1, Otavia L. Caballero2, determined via ELISA in pts for whom PreOp blood sam- Sonali A. Herath1, Tao Su3, Aqeel Ahmed3, Linda Njoh1, ples were available. Plasma CDH3 levels and tumor QPCR Vesna Cekic1, Richard L. Whelan1 levels were correlated (P < 0.05). Colon and rectal tumor expression levels were also compared (p < 0.05). 1. Surgery, St. Luke Roosevelt Hospital, New York, NY; 2. Ludwig Poster Abstracts Collaborative Laboratory for Cancer Biology and Therapy Department RESULTS: A total of 77 paired CRC and normal colon of Neurosurgery, Johns Hopkins University School of Medicine, specimens (36 M/ 41 F, age 67.3 ± 14.5) were assessed Sunday Baltimore, MD; 3. Herbert Irving Comprehensive Cancer Center, (82% colon, 18% rectal; Cancer Stage 2, 44; Stage 3, 33). All tumors (100%) had CDH3 expression levels over 0.1% Columbia University, New York, NY of the PLC level and, also, a tumor to normal colon ratio INTRODUCTION: Placental-Cadherin, type 1 (CDH3) is a greater than 1.Expression ratios in 25 tumors were above cell adhesion molecule that plays a role in cellular localiza- 100 and in 19 tumors were in the 50–100 range. CDH3 tion and tissue integrity. Because CDH3 is highly expressed expression was noted in 8/20 normal organ tissues. There by the placenta (PLC) it holds promise as a cancer testis was a positive correlation between tumor CDH3 QPCR and antigen and, possibly, a vaccine target. Its expression pro- PreOp CDH3 blood levels (n = 57, P = 0.038). Expression fi le in normal tissues has not been well studied, to date. levels were signifi cantly higher in rectal vs. colon tumors Up-regulation of CDH3 expression has been reported in (p = 0.019). esophageal, pancreatic, bladder, prostate, melanoma, and CONCLUSION: All tumors over expressed CDH3 as judged breast cancer; expression levels in colorectal cancer (CRC) by RT-PCR when compared to normal colon tissue; tumor remain poorly characterized. This study’s aims were: 1) to expression was also greater than 0.1% of PLC expression evaluate CDH3 expression in CRC tumors and other tissues levels. Unfortunately, CDH3 was expressed by other nor- as well as to assess preoperative plasma CDH3 levels and mal organs, thus, it is not a promising vaccine target or a 2) to determine if CDH3 holds promise as a vaccine target. cancer testis antigen. Of note, appreciable plasma CDH3 METHODS: An IRB approved plasma and tumor bank was levels were noted and the correlation between plasma and utilized. CRC patients (pts) for whom tumor and normal tumor CDH3 levels suggests CDH3 may have value as a colon tissue samples were available were enrolled. Demo- prognostic marker. A larger study is needed to determine if graphic and pathologic data were collected prospectively. plasma and/or tumor expression levels correlate with T, N, Tumor samples were OCT embedded and stored at –80C°. or fi nal tumor stage.

61 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su2021 Basic: Esophageal The Tumor Suppressive Effects of HPP1 via STAT Signaling in Colon Cancer Are Abrogated by Su2023 Site-Directed Mutation of Its EGF-Like Domain Development of a Robust Stricture Model to Assess Abul Elahi*, Whalen Clark, Jonathan M. Hernandez, Jian Wang, Yaping Tu, Leigh Ann Humphries, David Shibata Therapeutic Interventions Following Circumferential H. Lee Moffi tt Cancer Center and Research Institute, Tampa, FL Endoscopic Esophageal Submucosal Dissection *1 1 2 INTRODUCTION: Eric M. Pauli , Steve J. Schomisch , Amitabh Chak , The novel tumor suppressor gene, HPP1 Jeffrey L. Ponsky1, Jeffrey M. Marks1 is downregulated in over 80% of colorectal cancers and 1. Surgery, University Hospitals Case Medical Center, Cleveland, OH; mediates its effects by alterations in STAT (Signal Trans- ducer and Activator of Transcription) signaling. HPP1 is 2. Gastroenterology, University Hospitals Case Medical Center, a secreted transmembrane protein that contains a single Cleveland, OH Epidermal Growth Factor (EGF)-like domain which dif- INTRODUCTION: Circumferential endoscopic esopha- fers from EGF by having a His instead of an Arg at what is geal submucosal dissection (EESD) for high grade dysplasia thought to be a critical amino acid (AA) site. We sought to or early cancer provides an intact specimen for histol- investigate the impact of targeted site-directed mutagenesis ogy, offers less-invasive therapy than esophagectomy and at this AA site on HPP1’s biologic behavior. potentially allows one-step en bloc eradication of Barrett’s METHODS: Site-directed mutagenesis technology was uti- esophagus. As such, the technique holds potential for stag- lized to create a mutated HPP1 construct substituting an ing, treating and preventing esophageal cancer. However, Arg moiety in the place of His at site 299 in its EGF-like aggressive stricture formation after EESD has limited its domain. Computed 3-D protein folding models demon- clinical use. We hypothesized that an in vivo esophageal strate no alterations in the overall confi guration of HPP1 stricture model could be developed to assess endoscopic as a result of this mutation. Full-length wild-type HPP1, interventions designed to prevent stricture formation fol- the mutated HPP1 (H299R) and empty vector control were lowing EESD. transfected into the HPP1 non-expressing HCT116 colon METHODS: Five swine were utilized in this study. Under cancer cell line. Biologic effects on STAT signaling were anesthesia, a fl exible endoscope with a band ligator and assessed by RT-PCR and Western Blot analyses. Effects on snare was used to circumferentially incise the mucosal proliferation and anchorage-independent growth were layer 20 cm proximal to the lower esophageal sphincter. evaluated by MTT and soft agar assays respectively. An approximately 10 cm circumferential segment of tissue RESULTS: We have previously demonstrated that HPP1 was dissected free from the underlying muscle and excised overexpression results in a substantial reduction in pro- using electrocautery and snare. Weekly barium esophago- liferation, growth in soft agar and tumorigenicity. These grams evaluated for reduction in esophageal diameter and effects are associated with activation of suppressive STAT1 assessed stricture length and proximal dilation. Animals were and –2 with down regulation of oncogenic STAT3, –5 and followed clinically and were euthanized when the stricture –6. Transfection of HPP1 H299R resulted in a reversal of exceeded 80% and they were unable to gain weight (despite this profi le with a reduction in activated STAT1 and –2 and high-calorie liquid diet). A blinded pathologist evaluated increased phosphorylation of STAT3, –4 and –5. Moreover, EESD and necropsy specimens. forced expression of mutated HPP1 abrogated tumor sup- RESULTS: Resected specimens ranged from 90–110 mm pressive behavior with increased cell proliferation (Optical in length. Histology confi rmed uniform en bloc mucosal Density-OD: 0.78 ± 0.18 vs.; 0.33 ± 0.13 p ≤ 0.001) and resection down to the superfi cial submucosa. All fi ve ani- colony formation in soft agar (543 ± 20 vs 2 ± 1 colonies; mals rapidly developed strictures following EESD. At one p ≤ 0.001) as compared to wild-type HPP1 transfectants. week, animals demonstrated a 62.2 ± 12.9% reduction in Cell growth parameters were similar between HPP1 H299R luminal diameter, longitudinal shortening to 77.6 ± 12.4% and EV control transfectants (OD 0.75 ± 0.07; 591 ± 176 of the original resected length with dilation in the proxi- colonies; P = NS). mal esophagus to 128 ± 6.2% baseline diameter. By two CONCLUSION: The EGF-like domain of HPP1 is essential weeks, animals demonstrated a 77.7 ± 12.1% reduction in for its tumor suppressive effects with the Histidine moiety luminal diameter, longitudinal shortening to 62.7 ± 12.3% at position 299 being critical for mediating its associated of the original resected length with dilation in the proxi- biologic and molecular signaling effects. Therapeutic tar- mal esophagus to 174.8 ± 27.3%. Based on criteria, no ani- geting of the erbB family of receptors is of great interest mal survived beyond the third week of study. There was and our fi ndings may lead to a greater understanding of no correlation between resected specimen length and the the complex and sometimes contradictory nature of their degree of luminal narrowing or survival. Stricture zone his- associated signaling pathways. tology showed unepitheliazed submucosa with abundant PMNs, fi brosis and neovascularization.

62 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSIONS: We describe the successful development Su2025 of an esophageal stricture model. EESD in the porcine esophagus removes specimens of uniform length and depth Positive Correlation Between Serum Phosphate Levels without damaging the underlying muscule. Circumferen- and Acute Pancreatitis Severity in a Rat Model of tial EESD results in clinically signifi cant stricture forma- Pancreatitis Induced by Sodium Taurocholate tion within weeks. Esophagograms demonstrated uniform Guilherme D. Mazzini*1,2, Daniel T. Jost1, Rafael Machoseki1, reduction in luminal diameter in the area of resection with Mateus A. Zeni1, Luiz V. Portela1, Maria I. Edelweiss2, concomitant proximal esophageal dilation. Histology con- Diogo O. Souza1, Alessandro B. Osvaldt2 fi rmed the presence of infl ammation and fi brosis. Future areas of investigation will focus on endoscopic methods to 1. Biochemistry, Universidade Federal do Rio Grande do Sul, Porto alleviate or prevent stricture formation following EESD. Alegre, Brazil; 2. Gastrointestinal Surgery, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil Basic: Pancreas INTRODUCTION: Severe acute pancreatitis (AP) may lead to serious complications, with high mortality rates. Although several clinical and radiological scores and bio- Su2024 chemical markers can determine if an episode of AP is severe, there is not available a precise predictor for the Aging Is Related to Increased Intestinal Damage and severity of the pancreatitis, which could allow an early Bacterial Translocation in Acute Pancreatitis in Rats intensive management of those patients. Our group has ANA Maria M. Coelho*1, Marcel C. Machado1, Sandra N. focused on the study of serum ecto-nucleotidase activity Sampietre1, Nilza A. Molan1, Inneke M. Van Der Heijden2, (NTPD-ases) and purine levels, and their possible role as José Eduardo M. Cunha1, Luiz C. D’Albuquerque1 predictor of severity in AP. Extracellular nucleotides play signifi cant role in infl ammation in peripheral circulation, 1. Gastroenterology, University of São Paulo, São Paulo, Brazil; and their serum levels are partially controlled by NTPD- 2. Infectious Diseases, University of São Paulo, São Paulo, Brazil ases. Consequently, those enzymes act as regulatory ele- BACKGROUND/AIM: Acute pancreatitis (AP) in elderly ments in infl ammation, hydrolyzing nucleotides. However, patients in spite of similar occurrence of local complica- results from our main experiments have shown an intrigu- tions is followed by a substantial increase in multiple organ ing data, which could point to a possible marker of severity failure possibly due to increased bacterial translocation. in AP, with a promising clinical use. Intestinal mucosal barrier may be damage with increased METHODS: The local ethics committee approved the permeability promoting bacterial translocation. Intestinal study. AP was induced in 20 Wistar male rats, age 90–120 fatty acid binding protein (I-FABP), a 15-kd protein located days, by retrograde infusion of sodium taurocholate in Poster Abstracts at the intestinal mucosa may leak out of damaged intesti- the pancreatic duct. Ten sham-operated animals were sub- nal mucosal cells to the peripheral circulation. Therefore, mitted to median laparotomy and closure. There were 5 Sunday plasma levels of I-FABP may be an indication of bacterial absolute control animals. Blood was collected from the tail translocation. The aim of the present study was to evaluate before surgery (time 0) and after 3h and from cardiac punc- the effect of aging on intestinal damage, bacterial translo- ture at 12h, when pancreas were excised and fi xed in for- cation, and organ failures in AP. malin for histopathology. AP diagnosis was made based on METHODS: AP was induced in male Wistar rats by intra- amylase serum levels, determined by a colorimetric assay, ductal 2.5% taurocholate injection and divided into 2 and severity was graded by histopathology, using a vali- experimental groups: GI (n = 20): Young (3 month old rats), dated scale (from 0 to 28 points). As a control for the colo- and GII (n = 20): Older (18 month old rats). Two and 24 rimetric assay to determine NTPD-ase activity (measured by hours after AP blood were collected for determinations of phosphate release), in each serum sample the basal phos- plasma ileal fatty acid binding protein (I-FABP), and bio- phate levels were measured. These values produced inter- chemical markers: amylase, AST, ALT, urea, creatinine, and esting data, and will be presented here. glucose. Pulmonar myeloperoxidade (MPO) activity was Results: Four animals from AP group died before 12h. Addi- also performed. Bacterial translocation was evaluated by tional 2 animals from AP group were excluded from the bacterial cultures of pancreas expressed in colony-forming analysis due to invalid results. Serum amylase was diagnos- units (CFU) per gram. tic of AP in pancreatitis group, at 3h and 12h. Severity score RESULTS: A signifi cant increase in serum amylase, AST, in AP group was 19.0 ± 4.9 (mean ± SD). Basal phosphate ALT, urea, creatinine, and I-FABP levels was observed in the levels at 12 h were signifi cantly higher than 0h and 3 h in older group compared to the young group (p < 0.05). Pul- AP group, and signifi cantly higher than 0h, 3 h and 12 h, in monar myeloperoxidade (MPO) activity was also increased sham and control groups, which did not present signifi cant in the older group compared to the young group (p < 0.05). alterations in phosphate levels along the experiment (Fig- Compared to young rats, rate of positive bacterial cultures ure 1). Additionally, in AP group, phosphate levels at 12 h obtained from pancreas cultures in the older rats was sig- showed a positive correlation with the severity of the pan- nifi cantly increased. creatitis, r = 0.74 (Pearson’s coeffi cient, p = 0.02) (Figure 2). CONCLUSION: This study demonstrated that aging is associated to an increased distant organ damaged and bacterial translocation, and that plasma level of I-FABP is an important marker of bacterial translocation.

63 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

extensively studied, whereas very little data exists regarding the role of IL-33 in anti-tumor immune responses. No study has been performed to address the direct effect of IL-33 on tumor cell proliferation or apoptosis. METHODS: In the present study, clonogenic survival assay, immunohistochemistry (IHC), TUNEL staining, proliferation and caspase-3 activity kits were used to evaluate the effects of IL-33 on cell survival, proliferation and apoptosis of a pancreatic cancer cell line, MiaPaCa-2. We further investigated the possible molecular mechanisms by using RT-PCR, IHC, and Western blot. RESULTS: We found that the percentage of colonies of MiaPaCa-2 cells, PCNA+ cells and the OD value of cancer cells were all decreased after incubation with IL-33. Figure 1: Serum phosphate levels in AP group at 12h is signiﬁ cantly TUNEL+ cells and the relative caspase-3 activity in cancer higher then other times and other groups. * p < 0,5 by ANOVA. cells were increased in the presence of IL-33. The anti- proliferative effect of IL-33 on cancer cells correlated with downregulation of pro-proliferative molecule cdk2 and cdk4 and upregulation of anti-proliferative molecule p15, p21 and p53. The pro-apoptotic effect of IL-33 correlated with downregulation of anti-apoptotic molecule FLIP and upregulation of pro-apoptotic molecule TRAIL. CONCLUSIONS: IL-33 inhibits proliferation and induces of apoptosis of pancreatic cancer cells in vivo. Manipula- tion of the IL-33/ST2 pathway might be a promising strategy to treat pancreatic cancer.

Basic: Small Bowel

Su2027

Figure 2: Correlation between AP severity and serum phosphate levels Histone Deacetylase Inhibitors Decrease Postoperative at 12h. (Pearson’s coefﬁ cient r = 0.74, p = 0.02) Adhesions with a Single Intraoperative Dose by Targeting Early Events in Adhesiogenesis Michael R. Cassidy*, Joseph J. Gallant, Alan C. Sherburne, DISCUSSION: Our group brings preliminary experimental results with a novel approach to the assessment of severe Holly K. Sheldon, Melanie L. Gainsbury, Arthur F. Stucchi, AP. Although the strong correlation between pancreatitis James M. Becker severity and serum phosphate levels was observed late in Surgery, Boston University Medical Center, Boston, MA the course of the experimental pancreatitis, it could be use- INTRODUCTION: Postoperative (postop) adhesions are fully evaluated in experimental and clinical studies. a formidable source of morbidity, and previous studies in our laboratory have shown that peritoneal infl ammation Su2026 and reduced peritoneal fi brinolysis contribute to adhesiogenesis. Histone deacetylase inhibitors (HDACIs) includ- IL-33 Inhibits Proliferation and Induces of Apoptosis of ing valproic acid (VPA), suberoylanilide hydroxamic acid Pancreatic Cancer Cells (SAHA), and MS-275 modulate protein acetylation and Michael Nicholl*1,2, Yujiang Fang1,2, Elizabeth J. Herrick1, gene transcription, and have anti-infl ammatory and anti- Kathryn M. Cook1 proliferative properties that we hypothesized could reduce 1. Surgery, University of Missouri, Columbia, MO; 2. Surgical postop adhesions. Oncology, Ellis Fischel Cancer Center, Columbia, MO METHODS: 42 male rats underwent laparotomy with cre- BACKGROUND: IL-33, a member of the IL-1 cytokine ation of 6 peritoneal ischemic buttons to induce adhesions. family, acts in both an autocrine and paracrine manner by A single intraperitoneal (IP) dose of 50mg/kg VPA, 50mg/kg binding its receptor, ST2. The role of IL-33 in host immune SAHA, or 10 mg/kg MS-275 was administered intraopera- responses to infectious pathogens and allergens has been tively (intraop). Control animals received vehicle alone. To

64 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

evaluate for a critical window of opportunity for interven- and increased oxidative stress are implicated in adhesio- tion, an additional 25 rats underwent ischemic button cre- genesis. Peritoneal fi brinolytic activity, determined by tis- ation with either an intraop or a delayed IP dose of VPA at sue plasminogen activator (tPA) activity, is modulated by 1, 3, or 6 hours postop. On postop day 7, adhesions were the mesothelial RAS. We hypothesized that losartan, by quantifi ed as percent of ischemic buttons with adhesions. blocking the angiotensin II receptor (AIIR) and modulating To investigate mechanism, ischemic buttons were created the peritoneal RAS, could reduce adhesions. in 24 rats and either VPA or saline was administered in one METHODS: Wistar rats (n = 50) were randomized to non- intraop dose. 8 untreated rats served as non-operated con- operative controls (NonOp), operative controls (Op + Saline) trols. 3 or 24 hours later, peritoneal fl uid was collected and or intraperitoneal (IP) administration of losartan (Op + fi brinolytic activity was measured in a kinetic assay for tis- Losartan). Operated rats were administered either 1-ml sue plasminogen activator, and peritoneal tissue was col- normal saline or losartan (100mg/kg) via IP injection 6-hrs lected for RNA extraction and real-time PCR. pre-operatively, intra-operatively, 6- and 12-hrs post-opera- RESULTS: A single intraop dose of VPA signifi cantly reduced tively. Adhesions were induced using our ischemic button adhesions by 45% relative to vehicle controls (39.4 ± 4.1% model and scored on POD7. Additional rats were sacrifi ced vs 71.3 ± 4.4%, p < 0.001). Similarly, single intraop doses on POD1 for peritoneal tissue analysis of 8-isoprostane (a of SAHA and MS-275 reduced postoperative adhesions by marker of oxidative stress) by ELISA and AIIR mRNA by 48% (44.4 ± 8.2% vs 86.1 ± 5.1%) and by 45% (47.2 ± 5.1% PCR. AIIR protein expression was studied by immunohis- vs 86.1 ± 5.1%), respectively (p < 0.001). Delayed doses of tochemical staining. Peritoneal fl uid was also collected on VPA at 1, 3, or 6 hours postop did not reduce adhesions POD1 to measure tPA activity by kinetic assay. Addition- (73.3 ± 4.1%, 66.7 ± 9.1%, 63.3 ± 6.2% vs 73.3 ± 4.1%). In ally, an in vitro study of AIIR MAP-Kinase signaling was operated animals, peritoneal fi brinolytic activity at 3 and performed using primary rat peritoneal mesothelial cells at 24 hours postop was not signifi cantly different between treated with angiotensin II (AII), losartan (Los), or angio- animals administered saline and VPA (6.99U/ml vs 6.75U/ tensin II + losartan (AII+Los) and downstream phospho- ml and 2.61U/ml vs 2.08U/ml). There was no differential ERK levels were measured via Western blot. regulation of gene transcription for IL-6, HIF-1a, tissue fac- RESULTS: Losartan signifi cantly decreased adhesion tor, or PAI-1 at 3 or at 24 hours postop with administration formation by 73.3% compared to Op+Saline (16.7 ± 4.6 of VPA versus saline. vs. 62.5 ± 4.2%, p < 0.001). While surgery increased tPA CONCLUSIONS: Three different HDACIs signifi cantly activity levels by 1.7-fold compared with NonOp, Op + reduce postop adhesions with very comparable effi cacy, Losartan further increased tPA 1.4-fold compared to Op + suggesting a similar mechanism of action. That the effi - Saline (0.56 ± 0.01 vs. 0.95 ± 0.18 vs. 2.24 ± 0.5 U/ml, p < cacy of VPA is limited to intraop administration only, with 0.05). AIIR mRNA levels were upregulated 5.1-fold in Op + delayed administration of even 1 hour postop having no Losartan compared to Op + Saline (31.9 ± 2.0 vs. 6.3 ± 0.5 Poster Abstracts effect, suggests that HDACIs target very early events in fold change of NonOp, p < 0.01). Immunohistochemical adhesiogenesis that are unrelated to previously described analysis also showed increased AIIR staining of peritoneal Sunday mechanisms such as fi brinolytic activity or transcription of mesothelial cells in Op + Losartan compared to Op + Saline. infl ammatory regulators. These data further indicate that While in vitro rat peritoneal mesothelial cells administered HDACIs reduce adhesions by a novel mechanism needing AII showed a 95-fold increase in phospho-ERK protein lev- further investigation. els compared to controls, the addition of losartan (AII + Los) attenuated this response by 70% (1 vs. 95.0 ± 19.2 vs. Su2028 28.5 ± 8.2 fold change of NonOp, p < 0.05). The oxidative stress biomarker 8-isoprostane was reduced by 45% in Op The Angiotensin II Receptor Blocker (ARB) Losartan + Losartan versus Op + Saline (8.4 ± 0.7 vs. 4.6 ± 0.6 ng/mg Decreases Post-Operative Intraabdominal Adhesions protein, p < 0.05). by Modulating Renin-Angiotensin System (RAS) and CONCLUSIONS: Losartan signifi cantly reduces intraab- Oxidative Stress Pathways dominal adhesions, suggesting a novel mode-of action for Melanie L. Gainsbury*, Holly K. Sheldon, Michael R. Cassidy, this ARB. Both regulation of peritoneal fi brinolytic activity Daniel I. Chu, Stanley Heydrick, Somdutta Mitra, by RAS and attenuation of postoperative peritoneal oxida- Arthur F. Stucchi, James M. Becker tive stress are implicated. Surgery, Boston University Medical Center, Boston, MA INTRODUCTION: Post-operative intraabdominal adhesions are a major source of morbidity and our understanding of their formation remains incomplete. Our laboratory has previously shown that reduced peritoneal fi brinolysis

65 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Biliary 9%, or when the probability that a retained CBD stone would eventually become symptomatic was less than 60%. Similarly, if the sensitivity, specifi city, or technical success Su1497 of an IOC fell below 78%, 54%, or 80%, LC alone was the preferred strategy. Universal MRCP and ERCP were both MRCP Is Not a Cost Effective Strategy in Management more costly and less effective than surgical strategies, even of Common Bile Duct Stones at high probability of asymptomatic choledocholithiasis. Irene Epelboym*, Megan Winner, John D. Allendorf Within the tested range for both procedural and hospital- Surgery, New York Presbyterian, Columbia University, New York, NY ization related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost effec- BACKGROUND: Few formal cost effectiveness analyses tive than universal MRCP or ERCP, irrespective of presence simultaneously evaluate radiographic, endoscopic, and sur- or absence of complications. Varying the cost, sensitivity, gical approaches in the management of choledocholithiasis. and specifi city of MRCP had no effect on this outcome. METHODS: Using the decision analytic software TreeAge, CONCLUSIONS: LC with routine IOC is the preferred we modeled the initial clinical management of a patient strategy in a cost effectiveness analysis of the management presenting with symptomatic cholelithiasis without overt of symptomatic cholelithiasis with asymptomatic choledo- signs of choledocholithiasis. In this base case we assumed a cholithiasis. MRCP was both more costly and less effective 10% probability of concurrent asymptomatic choledocho- under all tested scenarios. lithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal MRCP, universal ERCP, laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy Su1498 with universal intraoperative cholangiogram (LCIOC). The Role of Intraoperative Fluorocholangiography All probabilities were estimated from review of published literature. Procedure and intervention costs were equated During the Advance Laparoscopic Cholecystectomy Era * with Medicare reimbursements. Costs of hospitalizations Harsha Jayamanne , Jonathan Lloyd-Evans, Ashraf M. Rasheed were derived from median hospitalization reimbursement Department of Surgery, Royal Gwent Hospital, Newport, United for New York State using diagnosis-related groups (DRG). Kingdom Sensitivity analyses were performed on all cost and prob- INTRODUCTION: Intra-operative fl uorocholangiography ability variables. (IOF) allows real time demonstration of biliary anatomy and identifi cation of common bile duct stones irrespective of size or site of the stones. However, routine use of IOF for detection of unsuspected choledocholithiasis ignited a debate during the open era that continued into the current laparoscopic era. Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic retrograde cholangiography pancreatography (ERCP)/ endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and re-ignited the debate in the clinical utility of pre-operative magnetic resonance cholangiography (MRCP) and laparoscopic IOF. Aims: To assess indications and utilization of IOF during laparoscopic cholecystectomy at Aneurin Bevan Health Board and to compare its clinical utility to MRCP in order to evaluate -their impact on patients management. METHODS: All the laparoscopic cholecystectomy (LC) RESULTS: The most effective strategy in the diagnosis and procedures performed during the period of January 2008 management of symptomatic cholelithiasis with a 10% risk to 2010 were retrieved from computerized database. We of asymptomatic choledocholithiasis was LCIOC. This was examined the indications and fi ndings of IOF and MRCP followed closely by MRCP, LC alone, and ERCP; expected and their impact on the treatment strategy. values of success in each strategy did not differ in a clini- RESULTS: A total of 700 consecutive cases of LCs were cally meaningful way. Varying the prevalence of asymp- performed. Liver enzymes were elevated in 273 of 700 tomatic choledocholithaisis or the probability that retained (39%) patients. MRCP was carried out in 139 of 700 (20%) stones would eventually cause symptomatic biliary obstruc- patients. A hundred and eighteen patients (118) had pre tion did not affect the optimal strategy. When procedure operative MRCP, while 21 patients had postoperative and hospitalization costs were taken into consideration, MRCP. Forty two (42) patients (6%) underwent ERCP, half LCIOC was the most cost effective approach, followed by of these (21/42) were performed before surgery and other laparoscopic cholecystectomy. LC was preferred when the half was performed after it. A total of 182 (26%) underwent prevalence of asymptomatic choledocholithiasis fell below IOF during LC.

66 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Choledocholithiasis was noted in 46 patients (6.6%), 70% chemotherapy, 19 (60%) underwent only chemotherapy, of the 46 were detected by MRCP and 30% by IOC. MRCP while 8 (25%) received supportive care. In patients affected reported common bile duct stones (CBDS) in 32 (27%). IOC by ICC, Five patients (16%) received surgical treatment, 13 was performed in 21 patients who had a negative MRCP (41%) chemo- or radiotherapy and 14 (43%) only support- revealing a stone in a single case. ive care. Regarding the impact of treatment on survival, the A hundred and three ((18.4%) of 558 patients who did not median survivals in patients submitted to surgery, chemo- undergo MRCP had IOF and stones were seen in 13/103 therapy or supportive care were 45.5, 12.5, and 2.9 months patients (2.3%). Eleven patients out of the 13 went on to respectively (p < 0.05). have a successful single-stage laparoscopic clearance. CONCLUSIONS: Recurrence after liver resection with cura- CONCLUSIONS: MRCP is an accurate non-invasive diag- tive intent is correlated to a poor prognosis. When feasible, nostic and triaging modality while IOF remains to be the aggressive treatment with radical resection of recurrence gold standard when CBD stones are suspected. IOF docu- can improve the prognosis in these patients. ment site and size of known CBD stones and detect unsuspected ones in patients, who may benefi t from a single stage Su1500 laparoscopic common bile duct clearance. A leaner preoper- Experiences from the Use of Peroral Cholangio- ative choledocholithiasis predictability criterion is desirable to reduce the redundancy in MRCP and IOF utilization. Pancreaticoscopy as a Routine Diagnostic Work Up Tool in a Tertiary Referral Center Su1499 Lars Enochsson*1,2, Lars R. Lundell2,1, Fredrik Swahn1,2, Matthias Loehr1,2, Urban Arnelo1,2 Risk Factors, Pattern of Onset and Result of Treatment 1. Department of Surgery, Karolinska University Hospital, Stockholm, of Recurrence After Liver Resection of Peri-Hilar and Sweden; 2. Karolinska Institutet, CLINTEC, Stockholm, Sweden Intrahepatic Cholangiocarcinoma BACKGROUND: Although there are a variety of modalities * Andrea Ruzzenente , Alessandro Valdegamberi, to diagnose pathology within the pancreatobiliary ductal Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti, tract the introduction of the single-operator peroral cholan- Calogero Iacono, Alfredo Guglielmi gio-pancreaticoscopy (SOPOC), SpyGlass Direct Visualization Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy System has added a signifi cant contribution to the diagnos- AIM: The aim of this study was to clarify the risk factors, tic arsenal. At Karolinska University Hospital we have since the pattern of occurrence and the results of treatment of 2007 used the system as an integrated part of the diagnostic recurrence in patients affected by cholangiocarcinoma work up programme. The aim of this paper is to describe our submitted to surgical resection for peri-hilar (PCC) and experiences and defi ne its role in clinical practice. Poster Abstracts intrahepatic cholangiocarcinoma (ICC). METHODS: Between 2007 and 2010, 167 SOPOC exami- Sunday METHODS: We retrospectively analyzed the clinico- nations have been performed using the SpyGlass system. pathologic data of 132 patients submitted to liver resec- As we got more familair with the system there was a grad- tion with curative intent from January 1990 to July 2011, ual increase in the number of examinations over the years 71 of whom affected by PCC and 61 withICC. Thirty-two (19 (2007); 45 (2008); 50 (2009); 53 (2010)). In all 28% of patients for both groups developed recurrence during the the patients were referred to us from other centers. In 145 follow-up period (45% and 52.5%, respectively). We esti- (91.8%) of the examinations the complete system includ- mated the risk factors, the onset pattern of recurrence and ing the optical probe (SpyGlass) and the access and deliv- the impact of treatment on survival in these patients. ery catheter (SpyScope) was used. In the remaining 8.2% the SpyGlass was introduced through a sphincterotome RESULTS: The 3- and 5-year disease-free survival was 41% catheter. and 21% for both groups (p = 0.35). Among the patients RESULTS: affected by PCC, 11 (34%) developed intrahepatic recur- 167 examinations were completed in 161 rence, 5 (15%) developed peritoneal carcinomatosis, 4 (13%) patients. Among these were 56.3% males (mean age 58.4; anastomotic and 4 (13%) lymph-nodal recurrence. Percu- range 21–87) and 43.7% females (mean age 61.5; range taneous transhepatic biliary drainage catheter tract recur- 23–89). There were 104 (62.3%) examinations of the bili- rence occurred in 3 patients (9%). At univariate analysis, ary, 45 (26.9%) of the pancreatic duct system and in 18 the tumor size, the macroscopical portal involvement and cases (10.8%) the ampullary tract. The optical quality of elevated serum level of Ca 19.9 were signifi cantly associ- the examination was considered to be good in 90.8%, fair ated with recurrence. In the intrahepatic cholangiocarci- in 6.1% and inadequate in the remaining 3.1%. The overall noma group, 19 patients (59%) developed intrahepatic postoperative complication rate of the ERCP examinations recurrence. Five factors were signifi cantly associated with with SpyGlass was 13.3%. Postoperative complications, recurrence at univariate analysis in this group: tumor size, however, differed signifi cantly depending on which tract serum level of Ca 19.9 and CEA, multifocal disease at resec- that was investigated since postop complication rates were tion and grading. The overall 3-year survival after recur- 12.6% in the biliary, 20.0% in the pancreatic and 0% in the rence was 17%. The type of treatment was different between ampullary region. The diagnostic gain was in the biliary two groups. In patients with PCC, 5 (9%) patients were system 82.7%, in the pancreatic duct system 68.9% and submitted to surgical treatment of recurrence followed by 100% in the ampullary region.

67 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: The single-operator SpyGlass Direct Visu- signifi cantly greater OR prep, operative, emergence and alization System offers a valuable diagnostic aid with sig- PACU time was required for patients undergoing the TVC nifi cant gains in both the biliary as well as the pancreatic approach. This retrospective analysis of transvaginal chole- duct system. The large variation in postprocedural com- cystectomy patients suggests that there is indeed less post- plication rates suggests the room for preventive measures operative pain measured by the reduced opioid use after which requires further studies. transvaginal NOTES cholecystectomy.

Su1501 Su1502 Transvaginal NOTES Cholecystectomy: Retrospective Follow-Up of Ultrasound–Detected Gallbladder Analysis of Immediate Post-Operative Pain Polypoid Lesions Stephanie Wood*, Nalini Vadivelu, Mikhael Hosni, Amir Kambal*, Chris Brown, Ramesh Y. Kannan, Omer Jalil, Susan Dabu-Bondoc, Feng Dai, Lucian Panait, Robert Bell, Abu Feroz, Ashraf M. Rasheed Andrew Duffy, Walter Longo, Kurt E. Roberts Royal Gwent Hospital, Newport, United Kingdom Surgery, Yale School of Medicine, New Haven, CT OBJECTIVES: Gallbladder polyps are reported in 5% of INTRODUCTION: Transvaginal cholecystectomy (TVC) screening ultrasonography (US). The majority are benign, is the most common Natural Orifi ce Transluminal Surgery however some do have a malignant potential. The pre- (NOTES) performed in women to date yet there is a paucity operative confi rmation of the nature of these lesions is of data on intraoperative and immediate post operative “diffi cult” and the optimal management remains to be pain management. Previous studies have demonstrated ill-defi ned that NOTES procedures are associated with less post-opera- AIMS: To determine the nature and assess the current tive pain and faster recovery times. We analyzed the intra- clinical pathways for the ultrasound-detected gallbladder operative and postoperative opioid use for TVC compared polyps (GBP) and propose a follow -up and a therapeutic to traditional 4-port laparoscopic cholecystectomies (LC) strategy based on size and symptomatology during the last 2 years in our facility. METHODS: A retrospective search of the US database for METHODS: We performed a retrospective analysis of the “polyp” in gallbladder for the period between January 1st last 20 TVC to the last 20 LC patients at our facility. We com- 2009 and Dec 31st 2010 was conducted. A database was pared demographics, intraoperative and postoperative opioid then constructed including demographics, clinical presen- use and times in the operating room and in the Post Anes- tation, principal symptoms, management and pathology. thesia Care Unit (PACU). The opioid use is described in the Histologic fi ndings were analyzed in patients who under- morphine equivalent (mg). We obtained data from electroni- went cholecystectomy. The electronic medical records were cally recorded anesthesia records of the perioperative period. searched to check the clinical outcome, pathologic data RESULTS: There were no signifi cant differences between and follow-up arrangements the average age and BMI between the LC (41years, 30kg/ RESULTS: Ultrasound detected gallbladder polyps were m2) vs. TVC (40years, 30kg/m2) groups (p = 0.9; p = 0.88). reported in 347 patients, 214 female and 133 males with an The average time of patient in the operating room was sig- age range between 14–93 yrs, (Median 5, IQR = 41–58). Pol- nifi cantly greater for the TVC (115.3 ± 20.2 min) compared yps were found during the course of investigation for the to LC (88.4 ± 21.6 min, p = 0.002). The OR preparation possibility of gallbladder disease in 125 patients (36%). The time (TV: 36.2 ± 8.1min vs. LC: 22.5 ± 5.1; p < 0.001), oper- rest were incidental fi nding during investigation of other ative time (TV: 115.3 ± 21.6 min vs. LC: 82.4 ± 19.8 min; p illnesses. The majority of referrals for the US came from pri- < 0.001) and emergence time (TV: 17 min vs. LC: 10.5 min; mary care (60%), the rest came from hospital physicians in p = 0.04) were signifi cantly greater for the TVC compared (24%) and surgeons in (13%) of cases. Forty two percent of to LC. The OR opioid use was signifi cantly greater for the the reports made no mention of polyp actual size and 39% TV group (TV: 31.8 ± 10.7mg vs. LC: 25.6 ± 6.9mg; p = reported the polypoid lesion to be <10 mm without giving 0.04), however, after adjusting for OR time the difference the actual size. The actual size was reported in only 12% in OR opioid between two groups becomes non-signifi cant of cases. Eighteen patients (5%) underwent laparoscopic (p = 0.09). Interestingly, while the average (PACU) time cholecystectomy revealing neoplastic polyps (adenoma) in was signifi cantly greater for the TVC group (195.7 ± 88.9 2 cases and one case turned out to be invasive adenocar- min vs. 141.7 ± 61.6 min, p = 0.03), the average opioid use cinoma. Sixty six cases (19%) were under poorly defi ned with signifi cantly less for the TV group (0mg, range 0–2.5) surveillance and only 5 had follow up scans and more than compared to LC group (6.3mg, range 0–9.5), p = 0.01. The 70% of the patients had no plans for follow up overall opioid use (OR + PACU) was not signifi cantly dif- CONCLUSION: ferent between the groups (TV: 33.6 ± 10.1mg vs. LC: 31.6 Our preliminary data confi rm that the major- ± 7.3mg; p = 0.48). The average PACU pain Visual Ana- ity of the US detected “polypoid lesions” are incidental fi nd- logue Pain Score was not statistically signifi cantly different ings and are not true epithelial polyps. The majority of patients between the TVC and LC groups (p = 0.51). with symptomatic polyps who underwent cholecystectomy had cholelithiasis on histology. The current management CONCLUSION: There was signifi cantly less use of opioids strategy of asymptomatic polyps relies on its size and hence in the PACU period for the TVC group despite no differ- must be included in the US report which was poorly complied ence shown in Visual Analogue Pain scores. Additionally, with in this series. Small (<10 mm) asymptomatic polyps need

68 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

better characterisation by magnetic resonance imaging (MRI) Su1504 and/or endoluminal ultrasound (EUS), while those >10 mm should be offered cholecystectomy. A well defi ned long term Biliary Stone Disease (BSD) and Its Complications in follow up of patients is necessary to allow better understand- Patients Under 25 Years ing of this pathological entity and a nationwide registry or Anibal Rondan*, Rafael A. Redondo, Mauricio Ramirez, Mariano large longitudinal observational study is warranted as these Gimenez, Marcelo Fasano, Alberto R. Ferreres might represent a missed opportunity for early detection of Department of Surgery, University of Buenos Aires, Buenos Aires, cancer. Argentina INTRODUCTION: Su1503 BSD is one of the most frequent disorders affecting the gastrointestinal tract; its incidence in the Incidence of Cystic Duct Stones During Laparoscopic adult population is above 25% for females and around 10% Cholecystectomy for males. Race and ethnicity play a major role in its develop- Amir Kambal*, Tomos Richards, Harsha Jayamanne, ment, more frequent in hispanics and native descendents. In some latinamerican countries (Chile, Bolivia, Colombia) the Zeyad A. Sallami, Ashraf M. Rasheed, Taha R. Lazim incidence of gallbladder cancer is the highest in the world. A Royal Gwent Hospital, Newport, United Kingdom high incidence of these conditions and its complications has OBJECTIVE: With the advent of the Laparoscopic Cho- been found in the younger population. lecystectomy (LC) era, the loss of tactile element hindered OBJECTIVE: analyze the incidence, clinical presentation the detection of cystic duct stones (CDS) during surgery. and course and prognosis of BSD in patients under 25 years. These stones are implicated in the post cholecystectomy pain syndrome, failure of the insertion of intra-oprative METHODS AND MATERIALS: After approval of our cholangiogram (IOC) catheter and the subsequent devel- institutional IRB a retrospective analysis of medical records opment of common bile duct (CBD) stones. The preopera- of patients who underwent admission for BSD at our single tive imaging rarely detects their presence. The aim of this institution between January 2005 and January 2011 was analysis is to quantify the frequency of the incidental fi nd- performed. 5377 patients were admitted for BSD and/or ing of CDS during LC and to emphasise the importance of its complications, being 591 (10.99%) under 25 years with the awareness of it in our routine practise. a median age of 20 (range 12/24). 449 (76%) were female METHOD: and 9 patients were pregnant at the time of clinical onset A cohort of consecutive patients undergoing of symptoms. Our guidelines included a minimal invasive LC during the period from November 2006 to May 2010 approach for treatment of illness and complications. were included. Data was collected prospectively. Their RESULTS: 457 (77.33%) patients were admitted for elec-

liver function tests were documented in the preoperative Poster Abstracts period. The procedure entailed careful dissection of the cys- tive surgery (laparoscopic cholecystectomy with intraop- tic duct to the proximity of common bile duct. A clip was erative cholangiogram and/or CBD exploration) and the Sunday then placed at the gall bladder and cystic duct junction. previous medical history included: acute pancreatitis in If an IOC was required, the cystic duct was opened in the 56 (12.25%), pancreatic pseudocysts in 3 (0.65%), acute routine fashion. A partially closed endoclip was then used cholecystitis in 12 (2.62%), common bile duct stones in to milk the cystic duct towards the gallbladder; any CDS 32 (7.00%). Laparoscopic cholecystectomy was completed encountered were retrieved and documented. If IOC was in 433 (94.74%), intraoperative cholangiography was not indicated, the cystic duct was milked prior to the appli- achieved in 397 cases (86.66%). The remaining 24 patients cation of gallbladder/cystic clip. required conversión through a right subcostal incisión RESULTS: due to: Mirizzi’s síndrome (3), cholecystocolonic fi stula The study included 330 patients; 80 male and (2), cholecystoduodenal fi stula (2), CBD multiple stones, 250 females. Age ranged between 16 to 88 years (Median 50, intense adhesions, intraoperative complications (bleeding, IQR: 36,62). In 266 patients no CDS were detected. However, liver laceration). The other 134 (22.67%) were admitted in 64 (19%) patients CDS were identifi ed using the above as emergency cases. The initial diagnosis was: acute cho- technique; 28 (45%) having a single stone. The remaining lecystitis (75), acute colangitis (55), liver abscess (4). The 36 (55%) patients had more than one stone with a maxi- treatment was the following: laparoscopic cholecystectomy mum detected number of 7 stones in the cystic duct. Preop- 75, ERCP with papillotomy and stone removal, and per- erative imaging failed to detect CDS in the majority of cases. cutaneous drainage. Postoperative complications were the Of those 64 patients with CDS, 47 (75%) showed deranged following:surgical site infection (5%), intraabdominal col- liver function tests at some stage of their disease prior to lections (2%), retained CBD stones (1%). No bile duct inju- surgery. In comparison, of the 266 patients with no CDS, ries were registered. 152 (57%) also demonstrated abnormal liver function tests. CONCLUSIONS: DISCUSSION: the spectrum of BSD, its progress and The results demonstrate the fact pre-opera- complications in the young population imposes a prompt tive investigations are not helpful in diagnosing cystic duct diagnosis and surgical treatment in order to correct symp- stones. Their occurrence is common. In order to detect CDS, toms, prevent complications and avoid sequelae and dis- specifi c intra-operative vigilance is needed. Careful upward ability. Pregnant patients poises a clinical management and milking of the cystic duct before applying clips is a simple, challenge, mainly in the fi rst trimester pregnancies. safe and effective way of detecting and extracting these stones. This study changed our practice as this procedure is now included in all our Laparoscopic Cholecystectomies.

69 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Colon-Rectal Su1506 Quality of Life After Surgery for Colorectal Cancer: A Su1505 Multicentric Prospective Study Loretta Di Cristofaro1, Cesare Ruffolo2, Matteo Cortinovis2, The Prognostic Value of Plasma TIMP-1 in Resectable Alessandra Fasolo3, Maurizio Massa1, Rita Alfi eri3, Matteo Cagol3, Colorectal Cancer: A Prospective Validation Study Luca Saadeh3, Aurelio F. Costa1, Nicolò Bassi2, Carlo Castoro3, *1 2 3 Hans J. Nielsen , Nils BrüNner , IB J. Christensen Marco Scarpa*3 1. Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark; 1. Department of Surgery, Montepulciano Hospital, Montepulciano, 2. Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Italy; 2. II Department of Surgery (IV unit), Regional Hospital Cà Denmark; 3. Finsen Laboratory, University of Copenhagen, Foncello, Treviso, Treviso, Italy; 3. Department of Surgery, Veneto Copenhagen, Denmark Oncological Institute (IOV-IRCCS), Padova, Italy BACKGROUND: Results from retrospective studies show BACKGROUND: The aims of this multicentric prospec- that preoperative plasma TIMP-1 and CEA levels carry tive study were to assess the postoperative quality of life independent prognostic information of patients with pri- in patients who had colonic resection for colorectal cancer mary CRC. The purpose of the present, prospective study and to determine its positive and negative predictors. was to validate the prognostic value of preoperative plasma PATIENTS AND METHODS: TIMP-1 and CEA in patients with primary CRC. One hundred and four METHODS: patients were enrolled in this study: 68 consecutive Blood samples were collected before surgery patients who had undergone laparoscopic assisted colonic from 297 patients with stage I-IV disease. TIMP-1 and CEA resection, and 31 patients who had open colonic resection. levels were determined in ETDA plasma using an auto- The patients answered to three questionnaires about their mated platform (ArchitectÒ, Abbott Laboratories, Chicago, generic quality of life (EORTC QLQ-C30), their disease spe- USA). The Cox proportional hazards model was used with cifi c quality of life (EORTC CR29) and about their treat- TIMP-1 and CEA on a continous scale (log base 2) adjusted ment satisfaction (EORTC IN-PATSAT32) at admission and for clinical covariates. The endpoints were overall survival one month after surgery. Non-parametric tests and forward (OS) and disease-free survival—time from operation to any stepwise multiple regression analysis were used for statisti- event (DFS). cal analysis. RESULTS: Of the 297 patients 118 were females and 179 RESULTS: Generic quality of life in the fi rst post opera- males with a median age of 70 (32–79) years. Using the tive month as well as patients satisfaction were similar in TNM stage 50 had stage I, 91 stage II, 70 stage III and 86 patients who had minimally invasive colonic resection and stage IV distributed as 180 with colonic and 117 with rectal in those who had open surgery. Body image was better in cancer. The median observation period was 6.1 (5.2–7.3) patients who had minimally invasive colonic resection (p years and 162 deaths were recorded. In a multivariate = 0.03). In the postoperative period the role functioning analysis including age, gender, stage, localization, plasma decreased signifi cantly (p = 0.04) while the emotional func- TIMP-1 and CEA it was shown that plasma TIMP-1 had tioning improved (p < 0.01) compared to the preoperative independent, signifi cant prognostic value: HR = 2.9; 95% assessment. Anastomotic leakage and post operative psy- CI: 2.0–4.8; p < 0.0001, whereas the value of CEA was non- chiatric complication (i.e. depression) were the only inde- signifi cant. Restricting the analysis to stages II and III and pendent negative predictors of postoperative global quality patients not receiving adjuvant chemotherapy plasma of life (β = –0.44, p = 0.001 and ß = –30, p = 0.008, respec- TIMP-1 had independent, signifi cant prognostic value: HR tively). Doctors availability was the only positive predictor = 2.9; 95% CI: 1.3–6.8; p = 0.013, whereas the value of CEA of postoperative global quality of life (β = 0.33, p = 0.002) was non-signifi cant. Analysis including those patients, CONCLUSIONS: who received adjuvant chemotherapy, showed that neither Although patients who had minimally plasma TIMP-1 nor CEA had any prognostic value. This invasive surgery reported a better body image their global indicates that adjuvant chemotherapy may be effi cient to quality of life did not seem to be positively infl uenced by patients with high plasma TIMP-1 levels. Similar analysis this improved surgical technique. Postoperative quality of of patients with stages II and III and focus on DFS as the life is affected by postoperative complication but can be endpoint could not demonstrate signifi cant results. improved by positive relationship with the surgeons in CONCLUSION: charge. These effects seemed help patients to accept the The present results achieved in a pro- burden of surgery. spective study confi rm that preoperative plasma TIMP-1 has independent prognostic value. In addition, the results suggest that patients with stage II or III and high plasma TIMP-1 values have particular benefi t of adjuvant chemotherapy. The results must however be confi rmed in prospective studies with inclusion of suffi cient numbers of patients to confi rm the results.

70 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1507 Su1508 Single-Site Laparoscopic Colorectal Surgery Provides The Impact of a Dedicated Acute Care Surgery Clinical Similar Costs to Patients and Hospitals Compared to Care Pathway for Suspected Appendicitis on Diagnostic Standard Laparoscopic Surgery Imaging and Flow Through the Emergency Department Evangelos Messaris*, Arthur Berg, David B. Stewart Chad G. Ball*, Elijah Dixon, Anthony R. Maclean, Colon and Rectal Surgery, PennState University, Hershey, PA May Lynn Quan, Gilaad G. Kaplan, Francis R. Sutherland BACKGROUND: Single-site laparoscopy provides an Surgery, University of Calgary, Calgary, AB, Canada alternative minimally invasive approach to standard lapa- PURPOSE: The widespread implementation of Acute Care roscopy. There is currently no published data comparing Surgery (ACS) services dedicated to urgent surgical issues costs for patients and hospitals accrued by these two tech- has led to signifi cant improvements in both patient fl ow niques for colorectal surgery. We provide cost comparisons and care. Despite these advancements, the use of diagnos- between single-site and standard laparoscopic colorectal tic computed tomography (CT) continues to increase across surgeries performed at a single institution. all diagnoses. Given the high incidence of appendicitis, METHODS: An IRB approved, retrospective review of all the primary aim of this study was to evaluate the impact standard (SDL) and single-site laparoscopic (SSL) colon and of implementing an ACS clinical care pathway dedicated to rectal resections performed from 2008–2011 was under- suspected appendicitis on the timing and use of CT, as well taken. Two-sided Mann-Whitney U tests and two-sided as on patient fl ow through the emergency department (ED). Fisher’s exact tests were used to evaluate continuous and METHODS: All adults within a large urban health care sys- discrete variables, respectively, comparing total hospi- tem (Calgary, Alberta, Canada) who presented to any ED (3 tal charges to patients, costs to the hospital and hospital hospitals) with a diagnosis of suspected, or actual, appendi- payments received. Charges to patients were further sub- citis were analyzed. Three distinct time periods (3 months categorized by charges accrued from the operating room, duration each) were compared (pre-implementation, post from room and board, pharmacy, radiology and emer- implementation, and 12 months (follow-up) post imple- gency department visits. All monetary units were infl ation mentation). The pathway assessment included history and adjusted to represent 2011 US dollar value. physical examination, laboratory testing, and potentially RESULTS: A total of 167 SDL and 47 SSL cases were identi- CT or ultrasound). Standard statistical methodology was fi ed. Compared to SSL, SDL surgeries were associated with employed (p < 0.05 = signifi cance). longer median times in the operating room (SSL: 190 min RESULTS: Among 1168 ED consultations for “appendi- vs. SDL: 233 min; p = 0.01) as well as longer median times citis” at 3 large centers, 877 (75%) were admitted to the for completion of surgery (SSL: 128 min vs. SDL:183 min, Acute Care Surgery service. This included 349 (pre-imple- Poster Abstracts p = 0.009). Despite these differences, median operating mentation), 392 (post-implementation), and 427 (6 month room costs were similar (SSL: $6,110 vs. SDL: $6,460; p = follow-up) patients. Overall, 83% of all patients under- Sunday 0.36). Median postoperative length of hospital stay was went surgery in less than 6 hours (time between admission similar for SSL (3.5 days) and SDL (4 day; p = 0.87), with no request and procedure). There was a signifi cant decrease in signifi cant differences with respect to patient room charges the mean wait time from CT scan request to actual CT scan (SSL: $3,080 vs. SDL: $3,940; p = 0.59). There was no signif- with the implementation of the pathway at all sites (197 vs. icant difference between SSL and SDL with respect to total 143 minutes; p < 0.05). This improvement was sustained at patient charges (SSL: $33,700 vs. SDL: $32,100; p = 0.06), all sites at the 12-month follow-up period (131 minutes; costs to the hospital (SSL: $12,100 vs. SDL: $12,300; p = p < 0.05). The percentage of CT scans performed in less 0.48) and actual hospital payments received (SSL: $16,100 than 2 hours increased from 3% to 42% with the pathway vs. SDL: $17,200; p = 0.9). There were no signifi cant differ- implementation (p < 0.05). The pathway included a short ences between the two groups with respect to radiology, course oral contrast load of 1–2 hours. No decrease in the pharmacy or emergency department charges. Among lapa- total number of CT scans (p > 0.05) or in the pattern of roscopic cases requiring conversion to laparotomy, SSL and ultrasonography was noted (p > 0.05). The clinical pathway SDL had similar median operating room costs (SSL: $6,990 also resulted in a shorter wait time from ED triage to surgi- vs. SDL: $6,560; p = 0.32), though SSL was found to have cal procedure (697 vs. 642 minutes; p < 0.05). approximately two-fold higher median overall patient CONCLUSIONS: Implementation of a clinical care path- charges (SSL: $76,497 vs. SDL: $41,392; p = 0.006) and costs way dedicated to suspected appendicitis (based on Alvarado to the hospital (SSL: $29,837 vs. SDL: $16,111; p = 0.01) score and/or imaging) can decrease the time to both CT compared to SDL. scan and surgical intervention. CONCLUSION: Adopting a single-site laparoscopic approach for colon and rectal surgery provides for similar lengths of hospital stay and similar costs to patients and hospitals compared to standard laparoscopic surgery. Con- version from SSL to open surgery is more costly to hospitals and patients than are conversions from SDL to open surgery, which may suggest that patients at high risk for requiring conversion to laparotomy should not be offered SSL.

71 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1509 ference was statistically signifi cant (interaction p-value = 0.011). Body mass index (BMI) was an important risk factor Laparoscopic or Open Ileal Pouch-Anal Anastomosis for wound infection after both laparoscopic and open IPAA (IPAA): Which Approach to Use and When? (p = 0.035 and p < 0.001, respectively). Surgeon, number Usama Ahmed Ali*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran of surgery stages and pulmonary co-morbidities were all Cleveland Clinic Foundation, Cleveland, OH associated with wound infection in open but not in lapa- PURPOSE: roscopic surgery (table). Interaction analysis did not reveal To determine whether different factors deter- signifi cant differences for these factors. Diabetes mellitus mine poor pouch-related outcomes after IPAA by the lapa- was strongly associated with increased wound infection roscopic and open approaches. after open (p < 0.001) but not laparoscopic IPAA (p = 0.26). METHODS: Cohort study based on a prospectively col- Interaction analysis suggested the presence of a difference lected database of IPAA patients operated from 1998–2010. between laparoscopic and open IPAA for this risk factor, Primary study outcomes were pouch failure and pelvic although not statistically signifi cant (interaction p = 0.1). sepsis. Secondary outcomes were wound infection, small For functional outcomes, no differences were seen in risk bowel obstruction and functional outcomes (bowel fre- factors for pouch failure between laparoscopic and open quency and incontinence). Regression analysis evaluating IPAA for both bowel frequency and incontinence after 3 the interaction of potential risk factors with operative tech- years of follow-up. nique (open vs. laparoscopic) was performed to identify CONCLUSION: Although risk factors for poor outcome differences in risk factors between the 2 techniques. after laparoscopic and open IPAA are largely similar, some RESULTS: Of 1962 patients, 224 (11.4%) underwent differences do exist. In patients with a higher ASA grade, laparoscopic and 1738 (88.6%) open IPAA. Laparoscopic the laparoscopic approach is associated with a greater risk patients were younger (36 vs. 40 years, p = 0.014), had of pelvic sepsis after IPAA. However, patients with high risk lower BMI (25.3 vs. 26.3 kg/m2, p = 0.004) with fewer ASA of wound infection, e.g. diabetes, benefi t from the laparo- III patients (9.1% vs. 19.1%, p = 0.003). Pouch failure was scopic approach since this may decrease the infl uence of observed in 61 (3.1%) patients (laparoscopic: 2.7%, open: predisposing risk factors. This novel analysis elaborating 3.2%, p = 0.9). On multivariate analysis, no differences specifi c benefi ts of the two procedures will likely addition- were seen in risk factors for pouch failure between lapa- ally help guide clinicians and patients decide upon the best roscopic and open IPAA. Increased ASA-classifi cation was approach when discussing the operative strategy prior to associated with a higher rate of pelvic sepsis after laparo- IPAA. scopic (p = 0.017), but not open IPAA (p = 0.51), this dif-

Comparison of Risk Factors Between Laparoscopic and Open IPAA Pelvic Sepsis Wound Infection Association with Association with Interaction Association with Association with Interaction Lap (p-value) Open (p-value) P-Value* Lap (p-value) Open (p-Value) P-Value* Age at Surgery 0.103 0.294 0.25 0.630 0.0423 0.81 BMI 0.863 0.967 0.88 0.0350 0.00098 0.19 Diagnosis 0.765 0.0603 0.36 0.166 0.419 0.25 Duration of disease 0.838 0.500 0.65 0.178 0.498 0.29 ASA classiﬁ cation 0.0166 0.506 0.011 0.952 0.287 0.72 Surgeon 0.784 0.130 0.36 0.300 0.00285 0.9 Number of Surgery Stages 0.638 0.281 0.87 0.796 0.0110 0.86 Immunosuppressive drugs 0.566 0.174 0.31 0.283 0.793 0.35 Diabetes 0.227 0.583 0.28 0.264 0.00098 0.1 Cardiac co-morbidities 0.843 0.243 0.61 0.937 0.140 0.65 Pulmonary co-morbidites 0.749 0.0225 0.27 0.887 0.0102 0.33 ASA: American Society of Anesthesiologists. BMI: body mass index. IPAA: ileal pouch anal anastomosis. Lap: laparoscopic. * Due to the conservative nature of interaction analysis, the signiﬁ cance level used for identifying interactions was 0.10, which is warranted to achieve a prudent balance of probabilities between type I and type II errors.

72 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1510 Su1511 Pre-Operative Colonoscopic Localization of Tumour Right Sided Diverticulitis (RSD): Highly Successful with Tattoo: A Re-Audit of Current Practice at a Non-Operative Management and Low Recurrence Rate District General Hospital Juan E. Arminan*, George Roxin, Jennifer D. Stanger, Akshay Kansagra, Sofoklis Panteleimonitis*, Ugo Ihedioha, Anthony R. Maclean, William D. Buie Alison Luther, John Isherwood, John Evans, Peter Kang General Surgery, University of Calgary, Calgary, AB, Canada General Surgery, Northampton General Hospital, Northampton, BACKGROUND: RSD, defi ned as diverticulitis involving United Kingdom the colon proximal to the splenic fl exure, is uncommon in INTRODUCTION: Preoperative localisation of tumour is western countries. A low index of suspicion could affect the an essential requirement in Laparoscopic colorectal sur- diagnosis and management of these patients. The purpose of gery. Tattooing guidelines should be simple to follow and this study was to examine presentation, treatment and out- consistent for all lesions irrespective of the location of the come of patients admitted with RSD in a large urban area. tumour. METHODS: The health records of all patients admitted with OUR RECOMMENDATIONS WERE: To place at least diverticulitis between January 2007 and March 2010 were two spots of tattoo distal to each lesion, and clearly docu- reviewed and the subset of patients admitted with RSD was ment site of tattoo with respect to tumour in the endos- identifi ed. Records were reviewed looking at demographic, copy report. clinical, radiologic, treatment and outcome factors. RESULTS: METHOD: We conducted a prospective audit of endo- 715 patients presented with acute diverticulitis, scopic tattooing of colorectal tumours resected in our hos- 68 had RSD (9.5%). Median age was 45 years (range 19 to pital from February 2010 to January 2011. It was felt that 92 yrs), 58.8% were female, median follow up 29.5 months the current guidelines were too complicated, leading to (range 12 to 50). 60 patients (88.2%) presented with uncom- higher rates of inaccurate tattooing. Thereafter new guide- plicated and 8 (11.8%) with complicated diverticulitis. lines were developed and subsequent practice reaudited. 59 patients (86.7%) had a CT scan. 10 of these (14.7%) RESULTS: 2010: 37 patients in total were identifi ed. 14 were required surgery due to diagnostic uncertainty (2 inciden- not tattooed. 3 patients had a tattoo which was inaccurate. tal appendectomies, 8 segmental resections). 49 patients 13 had accurate and well documented tattoos. 7 patients (83.1%) had CT diagnosis of RSD and were successfully had tattoos of unknown accuracy. treated non-operatively. 2011: 24 patients in total were identifi ed. 6 patients were 9 patients (13.2%) had surgery without imaging for pre- not tattooed. 4 patients had no tattoos visible at operation. sumed appendicitis (4 incidental appendectomies, 5 seg- Poster Abstracts 1 patient had a tattoo which was inaccurate. 11 patients mental resections). Post-operative morbidity was only 2.8%. had accurate and well documented tattoos. 2 patients had Of the 55 patients whose RSD was treated without segmen- Sunday tattoos of unknown accuracy. tal resection, 1 was readmitted with recurrent diverticulitis Of those patients which were tattooed and seen at surgery, at 2 weeks and underwent elective resection. 78.6% were accurate and clearly documented in 2011 com- 33 patients (60%) underwent subsequent colonoscopy at a pared to 56.5% in 2010 (p = 0.2124). mean of 3.5 months from admission, no alternate diagnoses Of those patients which were tattooed and seen at surgery, found. 14.2% had unknown accuracy (not clearly documented) in CONCLUSIONS: CT scan is accurate at diagnosing RSD. 2011, compared to 30.4% in 2010 (p = 0.3032). Once diagnosed, it can be successfully treated non-opera- Of those patients which were tattooed and seen at surgery tively. Risk of recurrent RSD following non operative man- 7.14% were deemed inaccurate (tattoo in wrong place) in agement is very low. 2011, compared to 13.04% in 2010 (p = 0.6043). CONCLUSION: The simpler method of tattooing all tumours distally has improved the accuracy of tattooing.

73 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1512 CONCLUSION: At a high-volume specialized colorectal unit, proctectomy can be performed with similar longterm Impact of Obesity on Operation Performed, oncologic outcomes and ability to restore intestinal con- Complications and Long Term Outcomes in Terms tinuity in obese patients when compared with the non- of Restoration of Intestinal Continuity for Patients obese. The increased technical complexity expected in with Mid and Low Rectal Cancer obese patients likely explains the associated increased use of NCRT and occurrence of anastomotic leak in obese when Erman Aytac*, Ian C. Lavery, Matthew F. Kalady, Pokala R. Kiran compared with non-obese patients. Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease Institute, Cleveland, OH Characteristics of the Groups PURPOSE: The impact of obesity per se on the surgical strategy i.e. sphincter sacrifi ce (abdominoperineal resection, Non Obese Obese APR) vs. restorative rectal resection (RRR), perioperative (n = 314) (n = 157) P Value outcomes, and long-term maintenance of intestinal conti- Age 62.2 ± 10.2 61.6 ± 10.7 0.62 nuity has been poorly studied in patients with mid and low rectal cancer. We compare these outcomes for obese and Gender (male) 230 115 1 non-obese patients with mid and low rectal cancer under- ASA score‡ 3 (1–4) 3 (1–4) 1 going surgery. Body mass index (kg/m2) 24.9 ± 3.6 35.7 ± 4.6 <.0001 METHODS: All patients undergoing curative surgery for Tumor location (low/mid rectum) 120/194 60/97 1 mid or low rectal adenocarcinoma at a single institution from 1976–2011 were identifi ed from a prospective cancer Neoadjuvant chemoradiation 121 (38.5%) 76 (48.4%) 0.048 database. Obese and non-obese patients were matched 1:2 Restorative rectal resection 241 (76.8%) 121 (77.1%) 1 for age, gender, ASA class, location (low or mid rectum) and stage of tumor. Demographics, use of neoadjuvant chemo- Postoperative hospital stay 8.2 ± 5.7 8.6 ± 5.3 0.23 radiothrapy (NCRT) and adjuvant therapy, operative and Reoperation 16 (5.1%) 9 (5.7%) 0.83 perioperative outcomes, pathology, longterm outcomes Early period postoperative 3 (1%) 2 (1.3%) 1 including oncologic outcomes and whether or not restora- mortality tion of intestinal continuity was performed were compared. Readmission 13 (4.1%) 12 (7.6%) 0.13 RESULTS: 157 obese patients and 314 non-obese patients, mean age 62 years at proctectomy were included. The Follow up (years) 5.3 ± 4.5 5 ± 4.2 0.4 groups were similar for matched characteristics. NCRT rate Local recurrence 10 (3.2%) 3 (1.9%) 0.56 was higher in obese patients (p = 0.048). A similar propor- Cancer speciﬁ c mortality 40 (12.7%) 25 (15.9%) 0.55 tion of non-obese and obese patients underwent RRR (p = 1) while postoperative hospital stay (p = 0.23) and 30-day Complications postoperative reoperation (p = 0.83), mortality (p = 1) Bleeding 9 (2.9%) 7 (4.5%) 0.69 and readmissions (p = 0. 13) was similar. Non-obese and Ureteral injury 3 (1%) 1 (0.9%) 1 obese patients also had similar tumor differentiation (p = 0.92) and lymph nodes examined (p = 0.64). Anastomotic Wound infection 12 (3.8%) 12 (7.6%) 0.11 leak was greater in obese patients (p = 0.0003). End colos- Stoma complication 1 (0.3%) 1 (0.6%) 1 tomy could not been reversed in 8 cases (3 obese and 5 non-obese, p = 1) after a Hartmann’s procedure which was Anastomotic leak* 5 (2.1%) 14 (8.9%) 0.0003 performed as the initial curative intervention. During fol- ‡median (range) *The cases, which had no anastomosis, excluded from the low up, a loop ileostomy was created after an ileal pouch leak percentage calculation anal anastomosis, because of pouch failure and two cases (1 obese and 1 nonobese, p = 1) received a permanent stoma after secondary operations for recurrences. Cancer specifi c mortality (p = 0.55) and local recurrence (p = 0.56) were similar for non-obese and obese patients after similar mean follow up time of 5 years for both groups (p = 0.4).

74 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1513 Su1514 Stoma Reversal in Patients Who Underwent Low Robotic Low Anterior Resection with Trans-Anal Anterior Resection and Diversion Stoma for Rectal vs.Trans-Abdominal Extraction Cancer Christopher R. Oxner*, Julian Sanchez, Rebecca Nelson, Wong-Hoi She*, Jensen T. Poon, Wai-Lun Law, Joe K. Fan Joseph Kim, Julio Garcia-Aguilar Department of Surgery, The University of Hong Kong, Hong Kong, City of Hope, Duarte, CA Hong Kong BACKGROUND: Recently, there have been many stud- BACKGROUND: Defunctioning ileostomy or colostomy ies initiated to validate robotic TME. Also, there have been is usually used to protect a high-risk anastomosis after low a variety of minimally invasive extraction techniques for anterior resection for rectal cancer. Although the stoma protocolectomy ranging from trans-abdominal to trans- is usually considered temporary, many a time, closure of vaginal. However, there has been little comparison of the stoma is not performed because of various reasons. robotic techniques combined with completely minimally We aimed to review the incidence of reversal of stoma in invasive approach. The goal of this study was to describe patients after low anterior resection (LAR) with a diversion our experience with robotic TME for very low rectal ade- stoma. The factors associated with non stomal closure were nocarcinoma and compare trans-abdominal vs. trans-anal analyzed. extraction. METHODS: Five hundred and eighty-fi ve patients who Demographic and Operative Comparisons underwent LAR and diversion stoma from January 1999 to December 2010 were reviewed from our prospective col- Anal Abdominal lected database. LAR was performed with either laparo- Extraction Extraction p-Value scopic or open approach. Diversion stoma was performed when the anastomosis was within 5 cm from the anal verge. Age 56.9 ( ± 9.1) 59.6 ( ± 12.2) 0.4468 Contrast enema was performed to assess the integrity of AJCC Stage 0 3 (21.4%) 9 (22.5%) 0.9045 the anastomosis before closure. Patients’ characteristics, 1 5 (35.7%) 11 (27.5%) disease status, operative details and adjuvant treatment were reviewed. The reasons for not closing the stoma were 2 1 (7.1%) 4 (10%) also studied. 3 5 (35.7%) 14 (35%) RESULTS: Closure of stoma after initial LAR was per- 4 0 (0%) 2 (5%) formed in 469 patients. The median age was 67.3 months and duration between the two operations was 6.1 months. ASA 2 6 (42.9%) 21 (52.5%) 0.5346 Poster Abstracts The remaining patients (n = 111, 19.1%) did not undergo 3 8 (57.1%) 19 (47.5%) stoma closure. The reasons for unable underwent closure BMI 29.7 ( ± 4.6) 27.6 ( ± 4.6) 0.1499 Sunday were broadly divided into two categories, anastomotic- related (47.7%) and non-anastomotic-related (52.3%). Conversion to Open 0 (0%) 3 (7.5%) 0.2917 Of those anastomotic-related, persistent leakage, fi stula Days to Regular Diet 1.5 ( ± 0.5) 2.8 ( ± 3.3) 0.1413 and stricture composed 79.2% (n = 42/53); while disease EBL 241.1 ( ± 146) 235.1 ( ± 0.9117 progression (n = 39/58, 67.2%) predominated in non- 179.5) anastomotic related group. Pre-operative radiotherapy signifi cantly decreased the chance of subsequent closure of Nodes Harvested 14.3 ( ± 4.7) 13.8 ( ± 5.6) 0.7545 stoma (26/84, 31.0%, p = 0.001). Adjuvant chemotherapy Length of Stay 4.6 ( ± 2.9) 7.7 ( ± 8) 0.1678 did not have any adverse effect to the closure of stoma nor Distance from Anal 4.8 ( ± 2.2) 6.8 ( ± 2.7) 0.0196 post-operative complications. The result of closure of ileos- Verge tomy and colostomy were similar in terms of the types and incidences of post-operative. Operative Time 351.1 ( ± 71.6) 290.9 ( ± 0.0200 83.7) CONCLUSIONS: The temporary stoma after low anterior resection may become permanent in some patients. Over Positive Nodes 1.1 ( ± 3.7) 1.7 ( ± 3.1) 0.6046 half of the patients who did not undergo closure of stoma Complications 3 (21.4%) 15 (37.5%) 0.2723 were due to reasons other than anastomotic complica- Robotic Time 64.4 ( ± 26.6) tions. Preoperative radiation therapy is associated with a higher chance of not closing the stoma. Thus a careful Gender Male 12 (85.7%) 27 (67.5%) assessment of the disease status and general condition of Female 2 (14.3%) 13 (32.5%) the patient before deciding the use of a diversion stoma is recommended. Tumor Size 1.7 ( ± 2.3) 2.6 ( ± 1.4) 0.1089

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METHODS: This is a single institution, retrospective review METHODS: All patients seen in the academic practice of comparing patients from December 2005 till August 2011 two colorectal surgeons were administered the EORTC-C30 who underwent robotic TME for rectal adenocarcinoma with questionnaire between January 2009 and October 2011. coloanal anastomosis. The patients were stratifi ed into two The EORTC-C30 is a disease specifi c questionnaire that was groups, trans-abdominal extraction or trans-anal extraction. designed to measure QOL in cancer patients but has also Data were then collected on operative outcomes, complica- been used extensively to measure QOL of patients with tions, pathological specimen, etc. These groups were then benign colorectal diseases. Four hundred and ninety-four compared using chi-square and t-test. surveys were returned (response rate 78%). One hundred RESULTS: Fifty four patients underwent robotic TME with and twenty four patients were evaluated for complaints low anastomosis. 40 had a trans-abdominal extraction and related to HD and represented the study cohort while 61 14 a trans-anal extraction. Patient demographics, BMI, patients who were asymptomatic as measured by the symp- blood loss, ileus, anastomotic leak rate, hospital stay, and tom scales were used as the control group (majority of these days to regular diet were not signifi cantly different. How- patients had presented for screening colonoscopies). The ever, there was a signifi cant difference observed in opera- minimally important difference (MID) which is defi ned as tive time and distance from the anal verge (p-value < 0.05). the smallest difference in scores of a QOL instrument that Operative time for trans-anal was 350 ± 71 minutes com- is considered clinically signifi cant, was estimated by cal- pared to 290 ± 80 minutes for trans-abdominal. The trans- culating the Cohen’s D effect size of the mean differences. anal group average distance from the anal verge was 4.8 cm RESULTS: Gender, age and marital status were similar while the average distance for the trans-abdominal group between the 2 groups. Mean difference in functional scales 6.8 cm for the with a p-value of 0.0196. Hospital stay dif- between patients with HD and asymptomatic patients was fered from 4.6 ± 3 days vs. 7.7 ± 8 days for the trans-anal 16 points and corresponded to a mean Cohen’s D of 0.42 and trans-abdominal groups respectively but did not reach (moderate effect size) and was considered the MID. clinical signifi cance. Patients with HD had signifi cantly worse QOL on all mea- CONCLUSIONS: The feasibility of robotic TME has already sured functional scales compared to asymptomatic patients been proven while its validity although early is comparable (Table). Common presenting complaints for HD included to laparoscopic TME. Furthermore, very low tumors ame- rectal bleeding (67%), pain (38%), change in bowel hab- nable to sphincter preservation can lend themselves to a its (21%) and discharge (10%). Among the patients with trans-anal extraction without compromising on operative HD there were no clinically signifi cant differences in over- and short term outcomes. In light of these equivocal results, all QOL of patients with and without symptoms of rectal this technique may be a more favorable option in patients bleeding (70 vs. 70), rectal pain (65 vs. 73) and rectal dis- when it is more diffi cult to get an adequate distal margin charge (59 vs. 71). However patients with change in bowel such as patients with a narrow pelvis (men), patient subsets habits had clinically signifi cant worse overall QOL com- with larger body habitus, or very low tumors. While the pared to patients not reporting this symptom (57 vs. 73). feasibility of trans-anal extraction is clear, larger numbers, prospective data, and patient stratifi cation will be required Comparison of QOL of Patients with HD versus Asymptomatic to prove if there exists patient benefi t to this technique. Patients

Su1516 Patients with HD Asymptomatic Patients Quality of Life of Patients Presenting with Global Health Status/ QOL 67.9 (22.2) 87.0 (15.9) Hemmorhoidal Disease: The Importance of Using Physical Functioning 87.2 (17.4) 99.0 (4.2) the Right Tool for the Right Question to Get the Right Role Functioning 80.3 (28.4) 99.4 (4.3) Answer Emotional Functioning 75.5 (23.2) 93.5 (11.3) * Vriti Advani , Margaret Boehler, Jan Rakinic, Imran Hassan Cognitive Functioning 84.4 (20.6) 96.8 (9.5) Surgery, Southern Illinois University School of Medicine, Springfi eld, IL Social Functioning 78.8 (30.0) 94.1 (20.7) INTRODUCTION: Based on clinical experience hemmorhoidal disease (HD) is considered to have a signifi cant CONCLUSION: HD and its related symptoms have a nega- impact on patient quality of life (QOL). However there tive impact on patient QOL that is measurable with the use have been only two published studies that have measured of the appropriate QOL instruments. Monitoring resolu- QOL in patients with HD and both were unable to detect a tion of symptoms during treatment of hemmorhoidal dis- signifi cant impact of HD on QOL using generic QOL instru- ease is essential to offset their impact on QOL. ments. We hypothesized that HD and its related symptoms have a negative impact on patient QOL and that this could be detected if the appropriate QOL instrument was used.

76 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1517 resection by providing bowel rest. This mantra has been historically scrutinized for the potential risk of retaining Impact of Opioid-Related Adverse Events (ORAE) on a permanent stoma without reducing the need for bowel Length of Stay (LOS) and Hospital Costs in Patients resection. Recent data demonstrate the usefulness of anti- Undergoing a Laparoscopic Colectomy TNFα therapy in inducing and maintaining remission in Sonia Ramamoorthy* Crohn’s disease, but its effect on pediatric colonic Crohn’s patients is unclear. We hypothesized anti-TNFα therapy in UCSD, La Jolla, CA conjunction with temporary fecal diversion would induce PURPOSE: Laparoscopic colectomy results in decreased remission and reduce the need for bowel resection in medi- postoperative ileus, pain, and disability, and can therefore cally refractory pediatric colorectal Crohn’s disease, ulti- lead to a shorter length of hospital stay (LOS) and reduced mately, allowing successful restoration of bowel continuity. costs of care. As opioids are often used in the treatment METHODS: Following IRB approval, records of Crohn’s of postsurgical pain, this retrospective analysis, a subset of disease patients who underwent fecal diversion, between data from a large health economics and outcomes research July 2006 and April 2011, at our institution were reviewed. project, examined the impact of opioid-related adverse Analysis focused on the clinical course and medical ther- events (ORAEs) on LOS and hospital costs for patients who apy in the perioperative periods, and long term results. underwent laparoscopic colectomy procedures. Outcomes were analyzed using Fisher’s exact test. METHODS: Over a 2-year period, 9/1/2008 through 9/30/2010, RESULTS: Eleven patients with colorectal or perianal approximately 10 million annual hospital discharges were Crohn’s disease had undergone proximal fecal diver- reviewed from a large national database including over 450 sion with either ileostomy (81.8%) or colostomy (18.2%) hospitals. Data on opioid usage, ORAEs, LOS, and hospital between July 2006 and April 2011. Average follow-up was costs were reviewed for some of the most common surger- 27.4 months (4.0–61.4 months) and average age at diver- ies in the US: open colectomy, laparoscopic colectomy, lap- sion was 15.1 years (7–21 years). A diversion procedure aroscopic cholecystectomy, total abdominal hysterectomy reduced the number of patients requiring corticosteroids and hip replacement, and populations were matched at a from 10 (90.9%) to 7 (63.6%), but this was not statistically 3:1 ratio for age, gender, and APR severity of illness. Statis- signifi cant (p = 0.3). Seven patients (63.6%) required seg- tical analysis was performed on 181,283 matched hospital mental colon resections and 2 (18.2%) required procto- discharges after surgery, including 12,620 matched laparo- colectomy. Restoration of continuity was performed in 8 scopic colectomies. (72.7%) patients after an average of 9.7 months (3.0–15.1 RESULTS: Of the 12,620 matched laparoscopic colecto- months). Four of the 5 patients (80%) treated with an anti- mies reviewed, mean unadjusted LOS for patients who had TNFα (Tumor Necrosis Factor) agent after diversion and 4 an ORAE was 7.7 days compared to 6.2 days for patients of the 6 patients (66.7%) off anti-TNFα therapy underwent Poster Abstracts without an ORAE (P < 0.0001). Similarly, unadjusted mean restoration of continuity (p = 1.0). However, three patients total costs for patients with an ORAE were signifi cantly (37.5%) required re-diversion (2 in the anti-TNFα group Sunday higher than for patients who did not have an ORAE and 1 in the non-anti-TNFα-treated patients; p = 1.0). At ($18,322 vs $15,720, respectively; P < 0.0001). the conclusion of the follow-up period only 5 (45.5%) of CONCLUSION: Patients who had a laparoscopic colec- the patients retained intestinal continuity. Complications tomy and experienced an ORAE had a longer LOS and secondary to the original ostomy occurred in 9.1% of higher total cost than similar patients who did not expe- patients and in 66.7% of the re-diverted patients. rience an ORAE. As the benefi ts of laparoscopic surgery CONCLUSIONS: Despite therapeutic advances, particu- include reduced LOS and cost, reducing the use of opioids larly the advent of anti-TNFα agents, fecal diversion in and their consequent ORAEs would be expected to result in pediatric patients with colorectal or perianal Crohn’s dis- greater maintenance of those benefi ts. ease is ultimately associated with a low rate of restoration and maintenance of intestinal continuity. Proximal diver- Su1518 sion does not obviate the need for colonic resection in this patient population. Counseling families regarding tem- Role of Fecal Diversion in Pediatric Colorectal Crohn’s porary fecal diversion in pediatric patients with Crohn’s Disease in the Era of Anti-TNF-α Therapy colitis requires tempered optimism in ultimately regaining Artur Chernoguz*1, Richard Falcone1, Jaimie D. Nathan1, intestinal continuity. Shehzad A. Saeed2, Lee Denson2, Daniel Von Allmen1, Jason Frischer1 1. Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2. Gastroenterology, Hepatology, & Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH PURPOSE: Colonic Crohn’s disease is a therapeutic challenge in up to 80% of pediatric patients. Temporary fecal diversion aims to induce remission and avoid colonic

77 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1520 Clinical: Esophageal Surgical Approach to Perineal Dissection Does Not Infl uence Radial Margin After Abdominoperineal Su1521 Resection Neoadjuvant Therapy Infl uences Lymph Node Ratios Sekhar Dharmarajan*, Bashar Safar, James W. Fleshman, Matthew Mutch, ELISA H. Birnbaum, Steven R. Hunt and Overall Survival Without Decreasing Total Node Surgery, Washington Univ, St. Louis, MO Harvest * PURPOSE: Renato S. Luna , James P. Dolan, Brian S. Diggs, Nathan W. Bronson, Positive radial margins and intraoperative rec- Miriam Douthit, John G. Hunter tal perforation adversely affect outcome after abdomino- General Surgery, OHSU, Portland, OR perineal resection (APR) for low rectal cancer. Use of the prone jackknife position during the perineal dissection BACKGROUND: There has been considerable debate around may improve exposure and therefore oncologic outcome. the infl uence of neoadjuvant therapy on lymph node har- Our purpose was to determine whether performing the per- vest and the prognostic value of this information follow- ineal dissection of APR in prone jackknife versus lithotomy ing esophagectomy for esophageal adenocarcinoma. The position improves radial margin clearance and reduces purpose of this study was to evaluate the effects of neoad- intraoperative rectal perforations. juvant therapy in the number of lymph node harvested, lymph node ratio and survival after esophagectomy. METHODS: An IRB-approved retrospective review of 130 cases of APRs over 8 years was performed after exclud- METHODS: A single center retrospective analysis of 169 ing patients with no radial margin reported, non-adeno- patients who underwent esophagectomy for esophageal carcinoma pathology, and pelvic exenterations. Primary adenocarcinoma was performed. Patients were divided in endpoints of radial margin and intraoperative rectal per- two groups: one group underwent neoadjuvant treatment foration were obtained from pathology reports. Data on prior to surgery (NEO) and another group underwent sur- patient demographics, preoperative staging, preoperative gery only. (SURG). therapy, and intraoperative positioning was obtained. Sta- RESULTS: One hundred and three patients (61%) under- tistical analysis was performed using t test or Fisher’s exact went neoadjuvant therapy (NEO) prior to resection. The test with signifi cance set at p < 0.05. mean age was 66 years (39–89), and 83 (82%) were treated RESULTS: Perineal dissection was performed in prone with 2 or 3 fi eld esophagectomy. Sixty six patients were jackknife position in 65 patients and in lithotomy posi- treated with surgery alone (SURG). The mean age was 70 tion in 65 patients. There were no signifi cant differences years (39–89) in this group, and 28 (44%) were treated between these groups in terms of patient gender, age, per- with 2 or 3 fi eld esophagectomy (p < 0.001). The median cent receiving preoperative therapy, distance of tumor from number of nodes harvested in the NEO group and SURG dentate line, or preoperative stage. There was no signifi cant group was 14.0 and 11.5 respectively (p = 0.11). Looking difference in mean radial margin between patients whose soley at those undergoing 2 or 3 fi eld esophagectomy in perineal dissection was performed in the prone jackknife NEO to SURG groups, the median number of lymph nodes versus lithotomy position (0.54 cm vs. 0.56 cm, p = 0.76). harvested was 16 and 15.5 respectively. In the NEO group The percent of positive radial margins in each group was the median number of lymph nodes harvested was 14.5 for not signifi cantly different (17% vs. 13%, p = 0.62) and the complete responders, 16 for incomplete responders, 12 for percent of intraoperative rectal perforations in each group non-responders, and 13 in those who were pathologically also did not differ (13% vs. 24%, p = 0.35). There was a upstaged (p = 0.252). The in-hospital mortality was 5% in trend toward decreased operative time in lithotomy (196 the NEO group and 3% in the SURG group (p = 0.56). The min vs. 222 min, p = 0.12). median lymph node ratio was 0 for complete responders, 0 for incomplete responders, 0.055 for non-responders and CONCLUSIONS: APR with perineal dissection performed 0.125 for upstaged patients (p < 0.001). Survival was infl u- in prone jackknife position is associated with longer opera- enced by the number of positive lymph nodes harvested in tive times compared to lithotomy position and does not both groups (p < 0.001). Survival was signifi cantly improved appear to confer any oncologic advantage with respect to by neoadjuvant therapy in stage III patients and in patients radial margin clearance or intraoperative rectal perforation. with N1 disease (p < 0.001 and p = 0.03, respectively). CONCLUSION: At esophagectomy, the total number of lymph nodes harvested was not signifi cantly infl uenced by neoadjuvant treatment or by the pathologic response to treatment. The number of positive lymph nodes was similar in both groups, but the lymph nodes ratio are inversely related to the response to neoadjuvant therapy. The only negative prognostic marker identifi ed was presence of nodal disease. Neoadjuvant therapy improved survival in this group.

78 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1522 shock. A limitation is the inability to distinguish between traditional versus thoracoscopic approaches; the impact of Esophagectomies Employing Thoracic Incisions Carry a minimally invasive thoracic approach remains unclear. Increased Pulmonary Morbidity Neil H. Bhayani*1, Aditya Gupta2, Ashwin A. Kurian1, Su1523 Maria A. Cassera3, Kevin M. Reavis3, Christy M. Dunst3, Lee L. Swanstrom3 The Status of the Lower Esophageal Sphincter at 1. Providence Portland Cancer Center, Portland, OR; 2. Legacy Weight Rest and the Degree of Esophageal Acid Exposure Management Clinic, Portland, OR; 3. The Oregon Clinic, Portland, OR in Patients with Gastroesophageal Refl ux Disease *1 1 1 INTRODUCTION: Shahin Ayazi , Jeffrey A. Hagen , Joerg Zehetner , A thoracic approach is not required for 1 1 1 all esophagectomies. Some research suggests an increased Kimberly S. Grant , Michael Hermansson , Arzu Oezcelik , 1 1 1 risk of pulmonary morbidity when a thoracic incision Steven R. Demeester , John C. Lipham , Daniel S. OH , is used. We studied the impact of a thoracic incision on Michael M. Kline2, Tom R. Demeester1 complications after esophagectomy through a national 1. Surgery, University of Southern California, Los Angeles, CA; database. This represents the largest analysis of pulmonary 2. Medicine/Gastroenterology, University of Southern California, morbidity after esophagectomy. Los Angeles, CA METHODS: The National Surgical Quality Improvement INTRODUCTION: A manometrically normal lower esoph- Project (NSQIP) database was queried for non-emergent ageal sphincter (LES) is necessary to protect the esophagus esophagectomies with reconstruction from 2005–2010. from exposure to gastric juice. Manometric measurements Patients with metastatic disease were excluded. Patient related to the competency of the LES are resting pressure, who underwent trans-hiatal esophagectomy (THE) were overall length, and the length exposed to the environmen- compared to those who had a thoracic incision. The THO- tal pressure of the abdomen. We hypothesized that the RACIC group was patients with Ivor-Lewis (thoracic & magnitude of the esophageal acid exposure is related to the abdominal incisions) or McKeown (cervical, abdominal & degree of permanent deterioration of the LES. thoracic incisions) techniques. The primary outcome was METHODS: The records of 2,723 patients referred to our pulmonary morbidity; secondary outcomes were death, esophageal function laboratory for the assessment of refl ux overall morbidity, infection, and thrombo-embolic compli- symptoms between 1998–2008 were reviewed. Those with cations. Multivariable regression models controlled for age, a named motility disorder or previous foregut surgery were smoking, chronic obstructive pulmonary disease, hyper- excluded. The study population consisted of the remaining tension, diabetes, American Society of Anesthesiology class patients, who had a detailed assessment of their LES with

3 or higher, malignancy, and preoperative weight loss. Poster Abstracts slow motorized pull-through manometry and an abnormal RESULTS: Of 1568 patients, 717 (46%) underwent THE 24-hour pH monitoring study off acid suppression ther- and 851 (54%) were in the THORACIC group (487/31% apy. The LES was graded on a scale of 0–3, according to Sunday Ivor-Lewis & 364/23% McKeown). The overall population the number of abnormal LES components on manometry was 80% male, with a mean age of 63 years. Patients under- using previously defi ned normal values for resting pres- going THE were older (p = 0.02). Pre-operative co-morbidi- sure (<5.1 mmHg), overall length (<2.7 cm) and abdominal ties were similar except for more diabetes (16% v. 11%, p = length (<1.4 cm). Grade 0 indicated all components were 0.02) in the THORACIC group. Malignancy was more com- normal; 1, only one component abnormal; 2, two compo- mon in THORACIC patients, 91% v. 87% (p = 0.01). Over- nents abnormal; 3, all three components abnormal. all, morbidity was 46.5% and mortality was 3.1% without RESULTS: The fi nal study group consisted of 918 patients a difference between groups. Length of stay was 1.6 days (58% male, median age 53 and median BMI 28.3) who shorter (p = 0.009) for THE patients. On multivariable anal- met the inclusion criteria and had an abnormal 24-hour ysis, the use of a thoracic incision was associated with an composite pH score as objective evidence for GERD. Of increase in pneumonia (47%, p = 0.007), ventilator depen- these 406 (44%) had grade 0, 152 (17%) grade 1, 272 (30%) dence >48 hours (34%, p = 0.04), and septic shock (86%, p grade 2 and 88 (9%) grade 3 LES. Corresponding values = 0.001). Mortality, surgical site infections, and thrombo- for the median (IQR) composite pH score were 30.9 (20.6– embolic events were similar. On subgroup analysis of the 46.5), 39.5 (23.1–57.8), 42.0 (27.0–75.1) and 63.2 (31.8– THORACIC group, the McKeown approach increased the 90.2) respectively (p < 0.0001, Kruskal-Wallis test). Patients odds of superfi cial surgical site infection by 71% (p = 0.02) with a normal LES at rest had less esophageal acid expo- but showed similar odds of septic shock compared to the sure compared to those with one or more LES manometric Ivor-Lewis technique. abnormalities (30.9 vs. 42.2, p < 0.0001, Mann-Whitney CONCLUSION: Esophagectomies carry an acceptable mor- U-test). The values for all three LES components, irrespec- tality rate but have signifi cant morbidity. We show that the tive of the LES grade, were inversely correlated to the com- thoracic incision is associated with increased pneumonia, posite pH score: total length (r = –0.23), abdominal length ventilator dependence, and septic shock. This septic shock (r = –0.22) and resting pressure (r = –0.28), (p < 0.0001 for is unlikely due to anastamotic leaks, given the similar all 3 analyses). The most common abnormal manometric among of septic shock between McKeown and Ivor-Lewis fi nding was a short overall length and the least common patients. When appropriate, avoiding a thoracic incision was a hypotensive LES pressure. may decrease pulmonary morbidity and resulting septic

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CONCLUSION: Permanent manometric abnormalities of the margins (p < 0.001) and LNR >0.1 (p < 0.001) signifi cantly LES measured at rest are associated with increased esopha- worsened prognosis. In multivariate analysis a LNR >0.1 geal acid exposure. The degree of acid exposure is related (p < 0.001; RR 11), no response to neoT (p < 0.01; RR 1.6) to the extent of the manometric abnormalities. Forty four and SCC (p < 0.02; RR 1.5) were independent negative percent of the GERD patients have a normal LES measured prognostic factors. Compared to SCC patients with AC had at rest despite having increased esophageal acid exposure. higher rates of positive margins (10% vs 4%) and LNR >0.1 These patients have the lowest esophageal acid exposure (43% vs 16%). and are likely to have transient manometric abnormalities CONCLUSIONS: Tumorbiological parameters (histologi- of the LES during periods of activity. cal type, LN-ratio) infl uenced prognosis after resection of esophageal cancer. Response to neoadjuvant therapy inde- Su1524 pendently improved the outcome and contributed to the Response to Neoadjuvant Therapy and the Lymph clearly better outcome achieved in the later study period. Node Ratio (LNR) Are the Strongest Prognostic Factors Su1525 After Esophageal Resection for Cancer Frank Makowiec*1, Peter Baier1, Peter Bronsert2, Jens Hoeppner1, Surgical and Endoscopic Treatments for Achalasia: A Hannes P. Neeff1, Tobias Keck1, Michael Henke3, Ulrich T. Hopt1 Single Institution Comparison of 190 Patients 1. Department of Surgery, University of Freiburg, Freiburg, Germany; Amy K. Yetasook*1, John G. Linn1, Woody Denham1,2, 2. Pathological Institute, University of Freiburg, Freiburg, Germany; Joann Carbray1, Michael B. Ujiki1,2 3. Department of Radiation Oncology, University of Freiburg, Freiburg, 1. Surgery, NorthShore University HealthSystem, Evanston, IL; Germany 2. Surgery, University of Chicago, Chicago, IL INTRODUCTION: The exact role of neoadjuvant therapy BACKGROUND: Controversy still remains as to whether (neoT) including its prognostic infl uence in esophageal an endoscopic or surgical approach should be primary cancer is still under debate. Pooled data (metaanalysis) treatment for patients with achalasia. We report our experi- suggest a prognostic advantage of neoT but defi nitve data ence with endoscopic and surgical treatments in patients are lacking. We analyzed our institutional experience with with achalasia over a 10-year period. resected esophageal cancer including the effect of neodju- METHODS: Retrospective analysis of electronic medical vant therapy on long-term outcome. records was gathered from 190 patients with confi rmed METHODS: We evaluated overall survival in 304 patients achalasia between January 1, 2000 and August 9, 2011. undergoing esophageal resection between 1988 and 2010 Demographics, data from motility studies, peri-operative (patients with hospital mortality excluded). 53% had squa- intervention data, endoscopic intervention data, the use of mous cell (SCC) and 46% adenocarcinoma (AC). Indica- a proton pump inhibitor (PPI), and presence of symptoms tions for neoT were in general T-stage >2 and/or positively (dysphagia and GERD-related symptoms) throughout their staged lymph nodes. Tumors were in the lower third in course of treatment from clinical visits were collected. 64%. 66% of the patients underwent neoT (60% chemo- RESULTS: In our surgical cohort, 72 patients underwent radiation 36 Gy+FU+Cisplatin; 6% chemotherapy alone). various types of procedures (surgical myotomy with or The proportion of neoT increased from 16% in the fi rst without a full or partial fundoplication), with 8 (11%) third to 78% in the last third of the study period. In patho- patients having more than one surgical admission for a logical analysis the median number of examined nodes was total of 80 surgical interventions. Thirty-two percent of the 17; 43% were node positive. Survival was analyzed by the surgical patients underwent prior endoscopic treatment. Kaplan-Meier- and Cox-models. In our endoscopic cohort, 76 patients underwent only RESULTS: The proportion of patients with AC increased endoscopic treatments (balloon dilation, botulinum injec- from 22% (fi rst third) to 61% (last third of the study tion or both) with 53 (70%) patients undergoing multiple period). After neoT 81% of the patients showed partial or treatments for a total of 174 endoscopic interventions. The total response. Patients without neoT had more frequently remaining 42 patients did not have an endoscopic or surgi- positive margins (13% vs 4% after neoT; p < 0.01). Postop- cal intervention, or did not have adequate follow up. The erative nodal disease was independent on neoT (40% after endoscopic-only managed patients underwent a mean of 3 neoT vs 50% without neoT) although patients in the neoT ( ± 2) and a median of 2 (range 1–8) interventions. There group had more frequently positive nodes in pretherapeuti- was no statistically signifi cant difference between groups cal staging (71% vs 39% in patients without neoT; p < 0.01). when comparing BMI, smoking status, pre-intervention Overall 5-year survival (5y-Surv) was 36% and improved mean resting lower esophageal sphincter (LES) pressures, clearly during the study period (5y-Surv 14% until 1994; pre-intervention mean lower esophageal sphincter (LES) 35% 1994–2001; 49% since 2002; p < 0.001), parallel to an relaxation pressure, or use of a PPI. Patients in the surgical increased use of neoT. This signifi cant improvement in sur- cohort were signifi cantly younger at 56.3 years versus 72.7 vival over time was also seen in the subgroups of patients years (P < 0.001). Endoscopic-only managed patients had with SCC (p < 0.01) and AC (p < 0.001). 5y-Surv in patients both signifi cantly more dysphagia (42.1% versus 16.7%, with response (any/total) was 52%/60%, but only 19% in P < 0.005) and GERD-related symptoms (72.6% versus patients without response/without neoT (p < 0.001). In fur- 15.3%, P < 0.005) throughout and after their course of treat- ther univariate analysis positive nodes (p < 0.001), positive ment as compared to the surgical group. The mean period

80 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

between the fi rst and second endoscopic procedures was 14 (17.5%). Manometric evidence of functional outfl ow signifi cantly less at 2.5 ( ± 4.79) years as compared to 16.34 obstruction (elevated intra-bolus pressure and/or elevated (± 15.9) years in between a fi rst and second surgery for 4-second integrated relaxation pressure) was present in achalasia (P < 0.05). Patients in the endoscopic cohort had 29/80 (36.3%) of patients. One patient met the manometric comparable average follow-up course of 7.26 (± 6.72) versus criteria for Achalasia. Manometric evidence of the sliding 7.35 (± 8.47) years compared to the surgical cohort. Thirty- component of the PEH was present in 17/21 (81%) with a day morbidity in the surgical cohort was 6.9% (5 patients) mean length of 4.1 ± 2.1 cm. Overall LES length was short versus 1.3% (1 patient) and there were no mortalities. in 14/21 (67%) patients, 19/21 (91%) had a shortened CONCLUSION: Surgery may offer a more effi cacious option intra-abdominal segment and 2/21 (10%) were hyperten- for patients with achalasia than endoscopic treatment sive at rest. alone with less need for repeated interventions and signifi - CONCLUSION: Signifi cant abnormalities of esophageal body cant relief of symptoms. function are present in a large percentage (56%) of patients with paraesophageal hiatal hernia. Nineteen percent have Su1526 severely compromised circular muscle strength. These data suggest that HRM should be included in the preoperative High Resolution Motility Assessment of the Esophageal evaluation of patients with PEH whenever possible. Body in Patients with Paraesophagel Hiatal Hernia Stefan Niebisch*, Marek Polomsky, Candice L. Wilshire, Su1527 Carolyn E. Jones, Virginia R. Litle, Christian G. Peyre, Effi cacy and Safety of Self-Expanding Plastic Stent Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester Medical Center, (SEPS) in the Management of Esophageal Disorders * Rochester, NY Yuk Law , Daniel K. Tong, Simon Law Surgery, The University of Hong Kong, Queen Mary Hospital, Hong INTRODUCTION: The clinical management of patients Kong, Hong Kong with large type III paraesophageal hiatal hernia (PEH) in both elective and urgent circumstances has become quite INTRODUCTION: Self-expanding plastic stent (SEPS) was common. Repair of PEH now accounts for 30–50% of fun- introduced in recent years. Because it is easily removed doplications in high volume centers. Given the primary endoscopically, it can be used to treat both malignant and focus on hernia repair, and not gastro-esophageal refl ux benign disorders of the esophagus; including strictures, (GERD), the utility of esophageal motility in patients with fi stulae and perforations. The present study evaluates our PEH is unclear. Furthermore, the availability of esophageal experience in the use of SEPS, assessing its effi cacy and motility testing, emergent presentation of patients and safety. Poster Abstracts complex anatomy making catheter placement diffi cult, METHODS: A prospectively collected database of the use all limit the routine use of preoperative motility. The aim of SEPS from 2007 to 2011 was retrospectively reviewed. Sunday of this study was to characterize preoperative esophageal Treatment effi cacy was evaluated by comparing the pre- function in patients with PEH and to determine the preva- and post-stenting dysphagia score in patients who had lence of esophageal dysmotility which might impact surgi- esophageal strictures. Success of sealing of fi stulae and per- cal approach. forations was also assessed. Short-term and long-term com- METHODS: Eighty patients (mean age 64.5 ± 11.9 years; plications were analyzed. mean BMI 30.7 ± 5.8; 65% female), with endoscopic and/ RESULTS: A total of 30 stents were inserted for 23 patients or radiographic type III hiatal hernia, who underwent (20 men and 3 women). The median age was 69 yrs (range preoperative High Resolution Manometry (HRM) from 51–85). Indications included benign stricture (20%, n = 6), December 2006 to October 2011 formed the study popu- malignant stricture (20%, n = 6), tracheo-esophageal fi stula lation. All studies were analyzed using current esophageal (10%, n = 3), post esophagectomy anastomotic leak (16.7%, body motility classifi cations and current analysis software n = 5) and benign perforation (33.3%, n = 10). (ManoViewTM v2.0.1). Assessment of the lower esophageal sphincter (LES) was possible in 21 patients (26%) in which For patients with stricture (both benign and malignant, the catheter was passed through the diaphragmatic crura n = 10), the median dysphagia score improved from a pre- into the intra-abdominal cavity. All manometry parameters treatment score of 3 (liquid diet) to post-treatment score of were referenced to normal-values previously established in 2 (semisolid diet), p < 0.001. SEPS provided satisfactory seal- our institution. ing in all 3 patients who had tracheo-esophageal fi stulae; none required additional intervention. Of the 5 patients RESULTS: Esophageal body function including wave with anastomotic leak, 3 were successfully managed by propagation and circular muscle strength was normal in SEPS with sealing of leak after stenting. Closure was not 35/80 (44%) of patients. A simultaneous/spastic contrac- achieved in the other 2, who required subsequent surgical tion pattern (distal latency <4.5 sec and/or contractile management. In the 5 patients who had benign perfora- front velocity >9 cm/s) was present in 14/80 (17.5%) and tion, all had adequate sealing by SEPS and recovered. One abnormal contraction strength (overall distal contractile patient required 5 stents in total because of repeated stent integral <500 mmHg•cm•s, weak peristalsis with peristal- migration. tic defects and/or frequent failed peristalsis) in another

81 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tracheal compression occurred in one patient under benign pathological response (pCR) to NACRT in 18 (18.9%) and perforation group immediately upon SEPS deployment. 75 (64.1%) had partial response. No patient with adeno- The SEPS was removed and the lesion was successfully carcinoma had pCR. Overall survival in these patients who managed using another SEPS of shorter length. This was underwent Neoadjuvant chemoradiotherapy and subse- the only short-term complication identifi ed in present quently surgery was 65.4% at 1 yr, 28.7% at 3 yr, 19.1% in study. For delayed complications, migration was most fre- 5 yrs. 11 patients are still alive at the time of analysis of our quently observed (40%, n = 12). Other delayed complica- data. Out of 87 patients, 62 patients were on regular follow tions included food bolus obstruction (10%, n = 3), erosion up. Disease free survival (DFS) in these patients was 53.2% to surrounding structure (0%, n = 0) and tumor ingrowth at 1 yr, 19.4% at 3 yr, 12.9% at 5 yr (Mean 26.87months (3.3%, n = 1) were infrequently seen. and median was 13 months).On analyzing factors affecting CONCLUSION: SEPS is a worthy alternative to metal stent survival; only those patients who had complete pathologi- in malignant disease and has emerged as a new tool for cal response to NACRT had statistically signifi cant sur- managing anastomotic leaks and benign perforations with vival compared to patients who had no response or partial a high success rate. Migration remains a major concern. response to NACRT (DFS median 21 months vs. 12 months, p – 0.019). Out of 62 patients who were on regular follow up, 51 (43.6%) had documented recurrence before death Su1528 with most common site of recurrence being lung Impact of Neoadjuvant Chemoradiotherapy on CONCLSION: With NACRT we could achieve mean sur- Survival in Carcinoma Esophagus: A Decade’s vival of 33 ± 5.39 months in carcinoma esophagus. 12% of Experience patients developed complications of NACRT. Patient with Rajesh Gupta*1, Sunil D. Shenvi1, Rakesh Kapoor2, complete pathological response and smaller lesions were found to have better survival by multivariate analysis Surinder S. Rana3, Deepak K. Bhasin3 1. Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2. Radiation Su1529 Oncology, Postgraduate Institute of Medical Education and Research, Is Idiopathic Pulmonary Fibrosis Really Idiopathic?: Chandigarh, India; 3. Gastroenterology, Postgraduate Institute of Patterns of Refl ux Analyzed by Bi-Positional High- Medical Education and Research, Chandigarh, India Resolution Manometry and Hypopharyngeal BACKGROUND: Neoadjuvant chemoradiotherapy followed Multichannel Intraluminal Impedance by surgery has become standard of care at most of the centres. Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe OBJECTIVE: To assess the impact of Neoadjuvant chemo- Cardiothoracic Surgery, University of Pittsburgh Medical Center, radiotherapy on survival in patients with locally advanced Pittsburgh, PA carcinoma esophagus. BACKGROUND: Idiopathic pulmonary fi brosis (IPF) is a MATERIALS AND METHODS: From our prospectively diffuse fi brotic lung disease of unknown etiology. The asso- maintained database, we retrospectively reviewed all ciation between IPF and gastroesophageal refl ux disease patients who underwent Neoadjuvant chemoradiotherapy (GERD) has been suggested. The objective of this study was for resectable esophageal cancer between November 1999 to determine the prevalence of GERD and assess the proxim- and December 2010. ity of refl ux events in patients with histologically proven IPF. RESULTS: Out of total 188 patients with carcinoma esopha- METHODS: This is a retrospective review of prospectively gus, 117 patients underwent Neoadjuvant chemoradiotherapy collected data for patients with histologically confi rmed (NACRT).104 patients had squamous cell carcinoma (SCC) IPF (via lung biopsy) who underwent objective esophageal and 13 patients had adenocarcinoma (ADC). 15 (12.8%) physiology testing including bi-positional high-resolution patients developed complications on CRT and 4 (3.4%) manometry (HRM) and hypopharyngeal multichannel patients died as a consequence of complications. Out of all intraluminal impedance (HMII). In bi-positional HRM, 10 the patients who underwent NACRT, 22 patients did not swallows with 5ml water each were delivered in the supine undergo surgery (4 deaths on CRT, two had progression of position; this was followed by 5 additional swallows in disease, 7 patients were not willing for surgery, 9 patients the upright position. Defective LES was defi ned as either were lost to follow up). Mean interval between NACRT and LES pressure of <5.0 mmHg, total length of LES of <2.4 cm surgery was 44.36 days. 95 patients underwent surgery with or intra-abdominal length of LES of <0.9 cm. Abnormal curative intent [82 underwent Transhiatal esophagectomy, esophageal motility was considered present when failed 7 underwent Tran thoracic esophagectomy, 6 underwent swallows ≥30% and/or mean wave amplitude <30 mmHg open assessment and closure for intrabdominal metastatic was present. HMII used a specialized impedance catheter to disease. On assessing fi nal histopathology of all patients measure the proximal refl ux events such as laryngopharyn- who underwent curative resection, we found complete

82 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

geal refl ux (LPR) and full column refl ux (refl ux 2 cm distal METHODS: The records of all patients who were diagnosed to the upper esophageal sphincter). Based on the previous with esophageal perforation between 2004 and 2011 were study of healthy subjects, abnormal proximal exposure reviewed. Patients who underwent primary surgery were was considered present when laryngopharyngeal refl ux compared to patients who were treated endoscopically. (≥1/day) and/or proximal esophageal refl ux (≥5/day) were RESULTS: The study population consisted of 47 patients present. with a median age of 64 years. Cervical perforation was seen RESULTS: From October 2009 to June 2011, 37 patients in 9 patients (19%), thoracic in 25 (53%) and abdominal with IPF (male 22, female 15) including 8 patients who had in 13 (28%). The cause of perforation was iatrogenic in 29 undergone lung transplant prior to objective esophageal patients (62%) and spontaneous in 17 (38%). The median testing were examined. Mean age and BMI were 62 years time to diagnosis was 12 hours. The size of the perforation (range, 41–78) and 27.6 (range, 14.8–38.1), respectively. was >10 mm in all cases. Surgical therapy (primary repair or Two patients were excluded from this study due to lack of esophagectomy) was performed in 26 patients (55%); 6 cer- HMII. All patients except two were symptomatic; 26 had vical, 11 thoracic and 9 abdominal perforations. Defi nitive predominately pulmonary symptoms such as cough and endoscopic therapy (stent implantation or primary closure 9 had isolated typical GERD symptoms such as heartburn with clips) was performed in 21 patients (45%); 3 cervi- and regurgitation. Abnormal proximal exposure was pres- cal, 14 thoracic and 4 abdominal perforations. Of these 47 ent in 19/35 (54%) patients. Esophageal mucosal injury patients, 16 (36%) died after a median time of one month. such as esophagitis and Barrett’s esophagus and/or hiatal The mortality rate was signifi cantly higher in patients with hernia was found in 28/32 (88%) patients. However, 29/35 thoracic perforation who underwent endoscopic therapy (83%) patients had a negative DeMeester score. All patients (Table). There was no signifi cant difference between the with IPF had refl ux predominately in the upright posi- groups regarding time to diagnosis, perforation size and tion. Bi-positional HRM increased the diagnostic yield of cause of perforation. defective LES from 78% (supine) to 93% (upright). Sixteen patients (50%) had abnormal esophageal motility includ- Mortality of Patients who Underwent Surgical Therapy Compared to ing aperistaltic esophagus (n = 9). Patients Who Underwent Endoscopically Therapy CONCLUSION: A large number of patients with IPF have objective evidence of GERD without typical symptoms. Surgical Endoscopic Proximal refl ux was common despite a frequently negative Therapy Therapy p-Value* DeMeester score. Refl ux events occurred primarily in the Cervical Perforation 1/6 patients (16%) 0/3 patients (0%) 0.3 upright position and this was associated with a decrease in Thoracic Perforation 3/11 patients (27%) 10/14 patients (71%) 0.04 LES integrity when examined with bi-positional HRM. Abdominal Perforation 2/9 patients (22%) 0/4 patients (0%) 1.0 Poster Abstracts Su1530 CONCLUSION: The results of the study suggest that tho- Sunday The Multidisciplinary Management of Esophageal racic perforation of the esophagus can not be managed Perforations endoscopically and thus should be treated with early sur- Arzu Oezcelik*1, Andreas Paul1, Renate Reinhardt1, Mark gery, independently from the cause of perforation or time Sandfort1, Guido Gerken2, Alexander Dechene2 to diagnosis. Cervical or abdominal perforation can be 1. General, Visceral and Transplantation Surgery, University of treated endoscopically in a high proportion of patients. Essen, Essen, Germany; 2. Internal Medicine, Gastroenterology and Hepatology, University of Essen, Essen, Germany BACKGROUND: Perforation of the esophagus is a challenging problem and can induce devastating complications. Although there are endoscopic and surgical treatment options available, the optimal management strategy remains unclear. The aim of this study was to evaluate the treatment and outcome of patients with esophageal perforations in an academic referral centre with a multidisciplinary spe- cialist group for esophageal diseases.

83 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1531 Hybrid Ivor-Lewis Oesophagogastrectomy: Results of the First 100 Cases and a Novel Way of Analysing Performance Geoffrey Roberts*, Adriana Rotundo, Priyantha Siriwardana, Cheuk Bong Tang, Michael Harvey, Sritharan S. Kadirkamanathan Upper GI Surgery, MEHT, Chelmsford, United Kingdom INTRODUCTION: The surgical management of oesophago-gastric cancer in the UK has recently been centralised to high volume surgical cancer centres. Increasing attention has been paid to measuring surgical outcomes and monitoring performance. The authors demonstrate results from a UK surgical cancer centre and present a novel technique for monitoring outcomes in “real-time”. METHODS: A prospectively collected database was used to identify the fi rst consecutive 100 oesophagectomies performed using a “hybrid” technique (laparoscopic abdominal approach, open thoracic approach) in the Unit. The CONCLUSIONS: cumulative sum (CUSUM) technique was applied to exam- The early learning curve results from a ine the incidence of clinically relevant anastomotic leaks UK surgical cancer centre show acceptable 30 day mortality and 30-day post-operative deaths. and anastomotic leak rates. Cumulative sum (CUSUM) techniques, originally devel- The CUSUM technique is a viable method of observing oped as industrial control techniques, have the potential trends in anastomotic leak rates and mortality, highlight- to provide rigorous, “real-time” monitoring of surgical out- ing when the rates rise above an unacceptable level which comes. Already used in cleft surgery and burns intensive would then trigger internal audit. CUSUM analysis could care, CUSUM compares actual to predicted outcome rates be further refi ned with the use of a risk stratifi cation tool, on a case-by-case basis. The technique described plots case such as O-POSSUM. These tools could be implemented in number on the x-axis versus the actual minus predicted a prospective fashion, allowing “real-time” assessment of outcome rate on the y-axis. The graph is not allowed to periods of varying performance. pass below the y = 0 point, preventing periods of good performance maskng a period of poor performance. A period Su1532 of performance “as predicted” would be represented by a Outcomes After Transhiatal and Transthoracic horizontal line, a period of worsening performance as a rising line and vice versa. The setting of “alarm points”, i.e. Esophagectomy for Esophageal Cancer the y value at which performance warrants review, means Christopher S. Davis, Eileen Bock*, Kirstyn E. Brownson, the unit can perform that review at the time of the wors- Cynthia Weber, P. Marco Fisichella, Margo Shoup, ened outcomes and make immediate changes. Gerard V. Aranha RESULTS: Ninety-seven cases were completed laparoscop- Surgery, Loyola University Chicago, Health Sciences Campus, ically, with three converted to open procedures. Mean age Maywood, IL was 66.4 years (SD 9.2). Median length of inpatient stay BACKGROUND: Controversy persists as to the preferred was 15 days. The 30-day mortality was 5%. operative approach to esophageal cancer. Therefore, we The crude anastomotic leak rate was 6%. CUSUM analysis investigated the peri-operative, short-term, and mid-term of the incidence of leaks (Figure 1) demonstrated a peak at outcomes between transhiatal esophagectomy (THE) and case 65. This however did not breach the alarm line at two transthoracic esophagectomy (TTE) at our institution. leaks above the expected rate. CUSUM analysis of mortality revealed two peaks, neither of which breached the alarm line at two point fi ve deaths above predicted.

84 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

METHODS: We conducted a retrospective review of 114 Su1533 patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those Venous Thromboembolism in Patients Receiving patients who underwent THE or TTE we compared: a) clini- Neoadjuvant Chemotherapy for Esophagogastric cal characteristics; b) pathologic fi ndings; and c) outcomes. Carcinoma Parametric and non-parametric tests of signifi cance were David Bowrey1, Achal Khanna*1, Alex M. Reece-Smith2, performed, and survival was determined by Kaplan-Meier Anne Thomas3, Simon Parsons2 analysis. 1. Surgery, University Hospitals of Leicester NHS Trust, Leicester, RESULTS: We identifi ed 32 patients who underwent THE, United Kingdom; 2. Surgery, Nottingham University Hospitals and 82 patients who underwent TTE. Age, gender, race/eth- NHS Trust, Nottingham, United Kingdom; 3. Oncology, University nicity, alcohol and tobacco use, weight loss and body mass Hospitals of Leicester NHS Trust, Leicester, United Kingdom index at the time of surgery, operative risk, chemoradiation regimen, tumor stage, and pathologic fi ndings were similar BACKGROUND: The association between venous throm- between groups. Those who underwent THE had a greater boembolism and chemotherapy for esophagogastric cancer intra-operative blood loss (p = 0.003), required more intra- is well known in patients treated with palliative intent. operative blood transfusions (p < 0.0001), spent a longer Whether this risk extends to the neoadjuvant and periop- time on the ventilator (p < 0.0001) and in the intensive erative setting is unclear. care unit (p = 0.002), and had a higher 30-day mortality (p METHODS: Retrospective interrogation of databases of = 0.023). Likewise, those who underwent THE had a greater patients receiving perioperative chemotherapy for poten- prevalence of post-operative vocal cord dysfunction (17% tially curative intent at the Leicester (2006–2011) and Not- vs 3%, p = 0.027) and anastomotic leak (29% vs. 1%, p < tingham (2004–2011) esophagogastric cancer centres. 0.0001). Compared to THE, patients undergoing TTE had RESULTS: a greater number of lymph nodes sampled (mean 13.0 vs Thromboembolic events were diagnosed in 42 of 13.6, respectively) and frequency of lymph nodes positive 384 patients (11%), 16 (4%) at presentation, 14 (4%) during for carcinoma (29% vs 35%, respectively). Finally, survival neodjuvant chemotherapy and 12 (3%) in the postopera- at 3-years was signifi cantly less after THE than after TTE tive period. By site these comprised catheter-related axil- (26% vs. 53%, p = 0.035), as was overall 5-year survival (p lary vein thrombosis in 6 patients, deep venous thrombosis = 0.039) (Figure 1). in 16 patients and pulmonary embolism in 16 patients. All of the pulmonary emboli were incidental fi ndings on staging CT imaging. There was no correlation between the risk of thromboembolism and chemotherapy regimen. Seven of the 42 patients (17%) who developed thromboembolism did not proceed to surgery because of deterioration Poster Abstracts in performance status. Thromboembolic disease resulted in a non-signifi cant increase in the interval between chemo- Sunday therapy and surgery, but did not infl uence either length of hospital stay or survival. CONCLUSIONS: Eleven percent of patients treated with potentially curative intent will develop venous thromboembolism. This adverse event can occur at any time during the patient journey. In contrast to the commonly held view, this did not translate into a poorer prognosis.

CONCLUSIONS: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach.

85 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1535 Su1536 Methylene Blue (MB) Test Versus Contrast Study (CS) Defi ning the Learning Curve for Robotic-Assisted in the Detection of Anastomotic Leak Following Esophagogastrectomy Oesogephactomy: A Prospective Study of 58 Patients Jonathan M. Hernandez*, Jill Weber, Khaldoun Almhanna, Sarah Adriana Rotundo*, Geoffrey Roberts, Francesco Pata, Hoffe, Ravi Shridhar, Richard Karl, Ken L. Meredith Geoff Pratt, Michael Harvey, Cheuk Bong Tang, Surgery, H. Lee Moffi tt Cancer Center, Tampa, FL Sritharan S. Kadirkamanathan INTRODUCTION: The expansion of robotic-assisted sur- Upper GI Surgery, MEHT, Chelmsford, United Kingdom gery is occurring quickly, though little is generally known BACKGROUND: Anastomotic leak is a serious complication about the “learning curve” for the technology with utiliza- following oesophagectomy. It is associated with consider- tion for complex esophageal procedures. The purpose of able morbidity and mortality. The aim of our study was to this study is to defi ne the learning curve for robotic-assisted compare the accuracy of MB and CS (Gastrografi n) in detect- esophagogastrectomy with respect to operative time, con- ing anastomotic leaks after Ivor-Lewis oesophagectomy. version rates, and patient safety. METHODS: METHODS: The study included 58 patients who under- We have prospectively followed all patients went laparoscopic assisted Ivor-Lewis oesophagectomy undergoing robotic-assisted esophagogastrectomy and from September 2009 to November 2011. All patients had compared operations performed at our institutions by a intra-thoracic oesophago-gastric anastomosis, end to side single surgeon in successive cohorts of 10 patients. Our using an endoscopic circular stapler (CDH © Ethicon Endo- measures of profi ciency included: operative times, conver- Surgery, Inc.2010). The integrity of the anastomosis was sion rates, and complications. checked on day 5 using both MB and CS. 100ml of Gas- RESULTS: Fifty-two patients (41 (78.8%) male: 11 (22.2%) trografi n was used in the CS which was performed by an female) of mean age 66.2 ± 8.8 years underwent robotic- experienced oesophageal radiologist. 10 ml of MB diluted assisted esophagogastrectomies for malignant esophageal in 200ml of water was given orally to test the anastomosis. disease. Neoadjuvant chemoradiation was administered to The CS was performed before the MB test and was reviewed 35 (67.3%) patients. A signifi cant reduction in operative by the radiologist who was blinded to the results of MB. times (p < 0.005) following completion of 20 procedures MB test was considered positive when the dye was seen in was identifi ed (514 ± 106 vs. 397 ± 71.9). No signifi cant the chest drain in less than 30 minutes. The leak was con- reduction in the number of procedures requiring conver- sidered clinically signifi cant if there was evidence of sepsis. sions to open operations was observed. Complication Chi square test was used to assess the difference between rates were low, and not signifi cantly different between any the two investigations 10-patient cohort, although no complications occurred in RESULTS: There were 37 males and 21 females with median the fi nal 10-patient cohort. However the frequency of com- age of 65 (range 43–78). Anastomotic leaks was diagnosed in plications decreased signifi cantly after 28 cases: 9 (32.1%) 6 patients (10.3%). In 4 cases the leak was considered clini- vs 3 (12.5%) p = 0.04. There were no in hospital mortalities. cally signifi cant (7%). MB detected all 4 signifi cant leaks. CONCLUSIONS: For surgeons profi cient in performing CS detected 5 leaks, 3 clinical and 2 non-clinical, but was minimally invasive esophagogastrectomies, the learning reported as a normal study in 1 of the clinically signifi cant curve for a robotic-assisted procedure appears to begin near leak. All patients recovered with conservative management. profi ciency after 20 cases. However this may be increased There was no signifi cant difference between MB and CS in in surgeons transitioning from an open approach. Opera- diagnosing anastomotic leaks (p = ns). tive complications and conversions were infrequent and CONCLUSION: Our study shows no difference between CS unchanged across successive 10-patient cohorts and appear and MB in detecting anastomtic leaks. MB might be a more to be less then smaller previously published series. In addi- convenient investigation and could be used in a ward set- tion, there is a decrease in frequency of complications after ting without the need for radiology. It could well form part 28 cases. of the strategy of enhanced recovery after surgery (ERAS) programme following oesophageal surgery.

86 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Clinical: Hepatic Su1538 Single Hepatocellular Carcinoma Less Than 3 cm in Su1537 Cirrhotic Livers: Is Resection Better Than Ablation? Marco Massani1, Cesare Ruffolo1, Luca Bonariol1, Ezio Caratozzolo1, Risk Factors for Postoperative Mortality After General Marco Scarpa*2, Francesco Calia Di Pinto1, Francesco E. D’Amico1, Surgery in 231 Patients with Liver Cirrhosis Bruno Pauletti1, Giuseppe Battistella3, Nicolò Bassi1 Frank Makowiec*1, Hans-Christian Spangenberg2, Tobias Keck1, 1. II Department of Surgery (IV unit), Regional Hospital Cà Foncello, Ulrich T. Hopt1, Hannes P. Neeff1 Treviso, Treviso, Italy; 2. Department of Surgery, Veneto Oncological 1. Department of Surgery, University of Freiburg, Freiburg, Germany; Institute, Padova, Italy; 3. Statistics and Epidemiology Service, 2. Department of Gastroenterology and Hepatology, University of Regional Hospital “Cà Foncello”, Treviso, Italy Freiburg, Freiburg, Germany BACKGROUND: Hepatocellular carcinoma (HCC) is one INTRODUCTION: Postoperative mortality rates after sur- of the most frequent tumors and it is the predominant gery in patients with liver cirrhosis are high. Risk factors primitive liver cancer and in most cases associated with cir- for mortality may help planning therapy in those high risk rhosis, regardless of the etiology. patients. We, therefore, evaluated/updated potential risk AIM: factors (including Child- and MELD-scores) for periopera- The purpose of this study was to compare the over- tive mortality after more than 200 operations in patients all survival after percutaneous ablation and resection in with cirrhosis performed during the last decade. patients with a single HCC lesion measuring less than 3 cm in diameter originating on liver cirrhosis. Patients and METHODS: Since 2001 231 various general surgical pro- methods From January 1999 to December 2008 556 con- cedures (80% intraabdominal, 20% abdominal wall) were secutive patients were evaluated in our center for HCC. performed in patients with liver cirrhosis (38% emergent). Only patients with cirrhosis and a single nodule <3 cm Cirrhosis was classifi ed according to Child (41% A; 38% were taken into consideration: 48 underwent liver resec- B, 21% C) and MELD-score (median 11). Procedures were tion and 51 treated with percutaneous procedures. subclassifi ed as major (laparotomy with resection) or minor RESULTS: (abdominal wall, ‘minor’ laparotomy, laparoscopy). Uni- The minimum follow up was 20 months. The variate and multivariate (binary logistic regression) anal- survival rate of resected patients was signifi cantly higher ysis was undertaken to identify risk factors for mortality. compared to the ablated patients (p = 0.0006). Child A Multivariate analysis was performed in different models to was a protective factor for both groups (p = 0.0001) and exclude collinearity due to overlapping parameters (Child, HCV positive patients had worse outcomes (p = 0.005). Moreover, age and survival were signifi cantly associated to

MELD, laboratory values). Poster Abstracts resected patients (p = 0.0195). Early recurrence occurred in RESULTS: Overall postoperative mortality was 17%. In 3 patients after resection and in 7 after ablation. univariate analysis the CHILD classifi cation (mortality: 6% CONCLUSIONS: Sunday Child A; 11% Child B, 45% Child C; p < 0.001), higher/ This experience confi rmed that in case increasing MELD score (p < 0.001), higher/increasing ASA of single nodule <3 cm in cirrhosis resection must be con- score (p < 0.001), emergency procedures (35% vs 5% elec- sidered as the primary choice for all patients with adequate tive; p < 0.001), major procedures (p < 0.02), need for trans- functional reserve. Nevertheless the ablative treatment can fusions (36% vs 4% in patients without transfusions; p < be considered a good second line option since it ensure 0.001) and various preoperative laboratory values (anemia, good results in terms of survival. thrombocytopenia, hyponatremia; all p < 0.05) were associated with increased mortality. In multivariate risk factor analyses blood transfusions (p < 0.001; RR 7), ASA score (p < 0.01), Child class (p < 0.02) and a thrombocytopenia (p < 0.02) were independent predictors for mortality. The MELD score, emergent procedures and extent of surgery showed a trend but did not signifi cantly predict mortality in the multivariate model. CONCLUSIONS: Patients requiring blood transfusions have a very high risk for mortality. Preoperative liver function and co-morbidity also predict early mortality after surgery. In our series the CHILD score was a better predictor for postoperative mortality than the MELD-score.

87 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1539 Clinical: Pancreas Safety and Outcomes Following Resection of Colorectal Cancer Liver Metastases in the Era of FOLFOX Su1542 Ilia Gur*1, Jesse A. Wagner1, Brett C. Sheppard4, Susan L. Orloff2, Gina M. Vaccaro3, Charles D. Lopez3, Brian S. Diggs4, Underuse of Surgical Therapy of Gastrointestinal Kevin G. Billingsley1 Cancer in the United States *1 2 1 1. Surgical Oncology, OHSU, Portland, OR; 2. Abdominal Organ Attila Dubecz , Norbert Solymosi , Michael Schweigert , 1 3 1 Transplantation, OHSU, Portland, OR; 3. Hematology, Oncology, Rudolf J. Stadlhuber , Jeffrey H. Peters , Hubert J. Stein OHSU, Portland, OR; 4. General Surgery, OHSU, Portland, OR 1. Surgery, Klinikum Nürnberg, Nuremberg, Germany; 2. Veterinary OBJECTIVE: Medicine, Szent István University, Budapest, Hungary; 3. Division of Report the safety and outcomes following Thoracic and Foregut Surgery, Department of Surgery, University of the introduction of routine periopereative multiagent che- Rochester School of Medicine and Dentistry, Rochester, NY motherapy in the multidisciplinary treatment of patients with colorectal liver metastases (CRLM). BACKGROUND: Surgery is the mainstay of curative therapy for most localized gastrointestinal (GI) malignancies. BACKGROUND: Increasingly preoperative chemotherapy Our objective was to evaluate the utilization of surgery in is integrated into the management of patients with liver non-metastatic GI cancer and identify factors predicting metastases. This strategy has likely expanded the number failure to undergo surgery. of surgical candidates but postoperative safety and survival have not been clearly defi ned. METHODS: Using the National Cancer Institute’s Surveil- lance Epidemiology and End Results-Database (1998–2008), METHODS: We performed a retrospective review of all a total of 331,911 patients (esophagus: 20,475; stomach: patients undergoing liver resections for metastatic colorec- 18,585; small bowel: 2,647; colon: 184,675; rectum: 45,599; tal cancer between 2003 and 2011 in a single academic liver: 24,318; pancreas: 35,612) were identifi ed with non- oncology center. Demographic data, tumor characteristics, metastatic cancer. The rate of surgical therapy in each chemotherapy, details of surgical procedure, complications type was calculated. Multivariate logistic regression was and survival were analyzed. employed to identify factors predicting failure to undergo RESULTS: The study population consisted of 158 patients surgical therapy. Reason for no surgery and the impact of that underwent 169 liver operations. 11 (6.9%) patients surgery on survival were also assessed. had repeat resections. Median length of follow up from RESULTS: Surgical resection for locoregional cancer a fi rst liver resection was 22.3 months. 87 (55%) patients was surprisingly low for cancers of the liver (27%), pan- presented with synchronous lesions. 114 patients (72%) creas (32%), and esophagus (56%). Cancers of the colon underwent chemotherapy prior to the liver resection (of (91%) rectum (72%) stomach (78%) and small intestine them 68% FOLFOX, 12% FOLFIRI). Mean size of the lesions (74%) had higher rates although as many as one quarter 3.97 cm (0.2 -18 cm) .Preoperative Portal Vein Emboliza- of patients did not undergo surgical resection. The primary tion was utilized in 16 (10.1%) patients Overall survival was reason for not undergoing surgery was classifi ed as “not 89%, 57% and 17% at 1, 3 and 5 years respectively. Median recommended” in from 1–49% of the patients again high- survival was 42.8 months. Perioperative mortality (30, 60 est in pancreas (49%), liver (47%) and esophagus (26%). and 90 days respectively) was 1.26%, 1.89% and 2.53%. Men, non-white race, patients >80 yrs, or those undergo- Overall complication rate was 24% (5%–liver related) The ing surgical therapy later in the study period and living in complication rate was not signifi cantly different if patients areas with high poverty rates were signifi cantly less likely had preoperative chemotherapy (27% no chemotherapy, to receive surgical treatment (all p < .0001). Median sur- 24% with chemotherapy). Mean length of stay was 8.68 vival in patients who did not undergo surgical resection days. On univariate analysis negative predictors of sur- was signifi cantly better than those with metastatic disease vival included positive margins, >3 lesions, patient age >70 (9 vs 6, p < 0.0001) but far worse than patients who under- years. On a multivariate analysis only the presence of >3 went surgery for locoregional disease (96 vs 9, p < 0.0001). lesions predicted poor survival. CONCLUSIONS: When viewed from a national perspec- CONCLUSIONS: In recent years preoperative oxaliplatin- tive the rates of surgical resection for locoregional GI can- based chemotherapy has become commonplace in the cer vary considerably. These data suggest that operative management of patients with resectable CRLM. Our results therapy in esophageal, liver and pancreatic cancer is par- suggest that even with chemotherapy and resection only ticularly underutilized. a subset of patients remain disease free after 5 years. How- ever, even in high risk patient with multiple lesions, preoperative chemotherapy may be administered safely without increase in postoperative complications. These results support the use of perioperative chemotherapy particularly in patients with multifocal (>3 lesions) metastatic disease in the liver.

88 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1543 Su1544 Serum Lipid Levels Are Associated with the Severity Intra-Abdominal Pressure in Acute Pancreatitis: Canary of Acute Pancreatitis in Coal Mine? Result After a Rigorous Validation Jahangir Khan, Isto Nordback, Juhani Sand* Protocol Tampere University Hospital, Tampere, Finland Vimal Bhandar*, Sumit Budania, Jiten Jaipuria AIMS: Serum lipid concentrations are known to react Surgery, VMMC & Safdarjung Hospital, New Delhi, India during acute disease. In this study, we sought to measure INTRODUCTION: Intra-abdominal hypertension [I.A.H.] changes in the serum lipid profi le during acute pancreatitis is increasingly reported in patients with severe acute pan- and whether these changes were associated with the sever- creatitis [S.A.P.] and is associated with signifi cantly higher ity of the disease. mortality rates. Though a clear causal relationship could METHODS: We analyzed 233 patients hospitalized for not be demonstrated, some reports show excellent out- acute pancreatitis between 1995–1995. All etiologies of acute comes in pancreatitis patients undergoing abdominal pancreatitis were included, as were patients with their fi rst decompression suggesting that I.A.H. may be a target for acute pancreatitis or recurrencies. Serum samples were early intervention. Many studies however highlight the obtained during the fi rst days after admission and further issue of I.A.H. in patients with severe disease with absence follow-up samples were obtained later during the course of data in those with mild disease making it confusing to of the disease. In most cases (n = 203, 87%), samples were conclusively recommend whether Intra-abdominal Pres- available from the fi rst two days of hospitalization. The sure measurement should be a routine in all patients. serum total cholesterol, HDL-cholesterol and triglyceride AIMS AND OBJECTIVES: The present study was under- levels were measured enzymatically and the concentrations taken to evaluate Intra-abdominal Pressure as a marker of of serum LDL-cholesterol were calculated using the Friede- severity in acute pancreatitis and to ascertain the relation- wald formula. ship between I.A.H. and development of complications in RESULTS: The most common etiology for acute pancre- patients with S.A.P. atitis was alcohol use (n = 131, 56%), followed by biliary MATERIAL AND METHOD: A total of 40 patients [24 (n = 48, 21%) and idiopathic (n = 36, 16%) pancreatitis. male, 16 female] fulfi lling the inclusion criteria were 64 (28%) patients had a severe pancreatitis, with 13 (6%) selected in the study. Selected patients were further enrolled mortalities. Serum total cholesterol, HDL-cholesterol and into two groups [Group 1: Mild Pancreatitis, n = 24 and LDL-cholesterol measured within 2 days of admission were Group 2: Severe pancreatitis, n = 16] based on the defi ni- signifi cantly lower in patients with severe pancreatitis and tions given in the Atlanta Symposium. Group 2 patients associated with in-hospital mortalities and longer hos- were further categorized into two sub-groups depending Poster Abstracts pitalization (p < 0.05). In subgroup analysis, the fi ndings upon the presence and absence of raised intra-abdominal remained statistically signifi cant in patients with alcohol pressure [Group 2a: consistently raised I.A.P. >12 mmHg Sunday induced acute pancreatitis, though were similar with all and Group 2b: not satisfying above criteria, no elevations etiologies. Furthermore, these fi ndings were evident even in I.A.P.]. later during the course of the disease. OBSERVATIONS: Development of intra-abdominal CONCLUSIONS: Serum lipid concentrations react during hypertension was noted to be an early phenomenon in acute pancreatitis. The levels of serum total cholesterol, patients with S.A.P. The positive and negative predictive HDL-cholesterol and LDL-cholesterol are signifi cantly lower value of I.A.H. in developings S.A.P. were 100% and 75% in patients with severe acute pancreatitis and are associated respectively. Sensitivity of I.A.H. in identifying those with with in-hospital mortality and longer hospital stay. These severe pancreatitis was 50% while the specifi city was 100%. changes are already present during the early stages of the Patients with S.A.P. and I.A.H. also had signifi cantly higher disease and are similar in all etiologies of acute pancreatitis. APACHE-2 Scores, a higher CT severity index and increased Furthermore, the changes observed are present even later incidence of persistent SIRS, organ failure, occurrence of during the course of the disease. Further studies are needed pleural effusions, intra-abdominal collections and overall to study the mechanisms of this association. mortality.

89 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1

MEAN Mean CT Length of APACHE 2 Severity Maximum SIRS Organ Pleural Hospital Ascites/Fluid Population SCORE index I.A.P. >48 hr Failure Effusion Stay Collections Total Entire population 6.6 3.5 8.05 12 8 6 7.92 6 40 Patients with mild pancreatitis: 4.4 1.62 4.36 0 0 1 5.66 0 24 GROUP 1 Patients with severe 10 6.31 13.81 12 8 5 11.31 6 16 pancreatitis: GROUP 2 Patients with severe 13.6 8.37 19.37 8 8 5 15.12 5 8 pancreatitis and I.A.H. GROUP 2a Patients with severe 6.4 4.25 8.25 4 0 0 7.5 1 8 pancreatitis and no I.A.H. GROUP 2B Patients with A.C.S. 18 10 26.66 3 3 3 6.33 3 3

Table 2: Comparison of Presence of I.A.H., Presence of Pleural Effusion and A.P.A.C.H.E. 2 Score >8 [in the Initial 24 Hours] in Identifying Patients with Severe Pancreatitis

Patients with Severe Pancreatitis Sensitivity Speciﬁ city Positive Predictive Value Negative Predictive Value Presence of I.A.H. 50% 100% 100% 75% Presence of APACHE 2 SCORE >8 68.70% 83.30% 73.33% 80% Presence of pleural effusion 31.25% 95.8% 83.33% 67.64%

CONCLUSIONS: Presence of I.A.H. in the setting of S.A.P. is Su1545 associated with a higher incidence of complications including pancreatic necrosis, persistent SIRS, organ failure, pleu- Reconsideration of Safety and Effi cacy of ral effusions, intra-abdominal collections, longer duration Pancreaticoduodenectomy for Periampullary Cancers of hospital stay, mortality and thus intra-abdominal pres- in Elderly Patients Aged ≥80 Years sure measurement may have a defi nite place in being used Seiji Oguro*, Kazuaki Shimada, Yoji Kishi, Satoshi Nara, Minoru as a predictive marker for severe disease. Esaki, Tomoo Kosuge REFERENCES: Hepatobiliary and Pancreatic Surgery, National Cancer Center 1. De Waele JJ, Hoste E, Blot SI et al Intra-abdominal hyper- Hospital, Tokyo, Japan tension in patients with severe acute pancreatitis. Crit BACKGROUND: Given that the life expectancy is increas- Care 2005;9: R452–57. ingly becoming longer, safety and effi cacy of pancreaticodu- 2. Adish Basu. A low cost technique for measuring the intra- odenectomy for periampullary cancers in elderly patients is abdominal pressure in non-industrialized countries. Ann a great clinical concern. Over the last decade many reports R Coll Engl 2007;89:431–37. have described outcome of pancreaticoduodenectomy in elderly patients, but the results are still inconsistent. METHODS: From a database of all the patients with periampullary cancers undergoing pancreaticoduodenectomy between 2001 and 2009, the patients over 80 years were identifi ed. Perioperative characteristics, postoperative complications, mortality, and a long-term survival were retrospectively compared between the patients aged 80 and older, and the patients younger than 80 years.

90 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: Among a total of 561 patients undergoing pan- important role in adjuvant chemotherapy for not only unre- creaticoduodenectomy, 22 patients (3.9%) were over 80 sectable but also resected pancreatic carcinoma. However, years. The pathological diagnosis in the elderly patients the problem is that a substantial number of patients have a consisted of as follows; pancreatic cancer (n = 8), bile duct resistance to gemcitabine. The aim of this study was to clar- cancer (n = 5), ampullary neoplasm (n = 5), intraductal ify which is more useful as a predictive marker of adjuvant papillary mucinous neoplasm (n = 3), and gallbladder can- gemcitabine-based chemotherapy for pancreatic carcinoma cer (n = 1). The elderly patients had a higher ASA score (P after surgical resection, intratumoral human equilibrative = 0.02) than the younger patients, but there was no sig- nucleoside transporter 1 (hENT1) or ribonucleotide reduc- nifi cant difference in operative time (455 vs 520 minutes; tase regulatory subunit M1 (RRM1) expression. P = 0.08), and blood loss (654 vs 838 ml; P = 0.38). The METHODS: Intratumoral hENT1 and RRM1 expression mortality rate was 4.5% in the elderly patients and 0.9% were examined by immunohistochemistry in 109 pan- in the younger patients, though the difference was not sta- creatic carcinoma patients who received adjuvant gem- tistically signifi cant (p = 0.106). Although the incidence of citabine-based chemotherapy after surgical resection from postoperative pancreatic fi stula and delayed gastric empty- January 2002 to May 2011. Relationships between clinico- ing were similar between the two groups, that of intraab- pathological factors, including hENT1 and RRM1 expres- dominal abscess, intraabdominal hemorrhage, pneumonia sion, and disease free or overall survival (DFS or OS) were and ascites in the elderly patients (22.7%, 18.2%, 9.1% evaluated by univariate and multivariate analyses. This and 4.5%, respectively) were higher than in the younger study was a retrospective analysis on retrospectively col- patients (6.9%, 2.2%, 0.6% and 0.2%, respectively). The lected tissue and data. rate of grade IIIa or higher complication (Clavien-Dindo classifi cation) was 27.3% in the elderly patients and 6.3% RESULTS: High intratumoral hENT1 and RRM1 expres- in the younger patients (P = 0.008). There was no signifi - sion was observed in 78 (72%) and 44 (40%) cases, respec- cant difference in overall survival between the two groups. tively. DFS rates for all 109 patients were 59% at 1 year, Among the elderly patients, the median survival for those 42% at 2 years, and 26% at 5 years, and OS rates were 81% with pancreatic cancer was signifi cantly shorter than that at 1 year, 61% at 2 years, and 31% at 5 years, respectively. with non-pancreatic cancer. (P = 0.003) In univariate analysis, both hENT1 and RRM1 expression CONCLUSIONS: were signifi cantly associated with DFS (hENT1: P = 0.004, Pancreaticoduodenectomy in patients RRM1: P = 0.011) and OS (hENT1: P = 0.001, RRM1: P = aged 80 and older should be indicated carefully, because of 0.040). In multivariate analysis, the both were identifi ed the higher incidence of the severe postoperative complica- as independent factors for DFS (hENT1: P = 0.001, RRM1: tions. Pancreaticoduodenectomy for pancreatic cancer in P = 0.009) and OS (hENT1: P = 0.001, RRM1: P = 0.019). elderly patients could not provide a satisfactory outcome The evaluation of the combination of the both was also in terms of a long-term survival compared with that for identifi ed as a powerful independent predictor for DFS (P < Poster Abstracts non-pancreatic cancers. 0.001) and OS (P < 0.001). CONCLUSIONS: Sunday Su1546 Both hENT1 and RRM1 expression is useful as a predictive marker of adjuvant gemcitabine-based Which Is More Useful as a Predictive Marker of chemotherapy for pancreatic carcinoma after surgical Adjuvant Gemcitabine-Based Chemotherapy for resection. In addition, combined analysis of the two is even Pancreatic Carcinoma After Surgical Resection, more useful. Human Equilibrative Nucleoside Transporter 1 or Ribonucleotide Reductase Regulatory Subunit M1 Expression? Naoya Nakagawa*, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Naru Kondo, Hironori Kobayashi, Hiroki Ohge, Taijiro Sueda Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan BACKGROUND/OBJECTIVE: Although postoperative adjuvant chemotherapy for pancreatic carcinoma improves survival in some patients, the effi cacy varies by individuals, and the results remain unsatisfying. Gemcitabine plays an

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Su1547 advanced age, complications, lack of jaundice, and IPMN. Early tumor progression was identifi ed in seven of these Failure to Receive Adjuvant Therapy Following patients. Four principal reasons for unutilized therapy Resection for Pancreatic Cancer: Patterns and were identifi ed (Table). These segregated into two disparate Implications groups—Poor Clinical Outcomes (2/3rds) and Therapy Not Russell S. Lewis*1, Jeffrey A. Drebin1, Mark P. Callery2, Douglas L. Elected (1/3rd), which demonstrated a marked median sur- Fraker1, Tara S. Kent2, Jenna Gates1, Charles M. Vollmer1 vival difference (6.0 mo vs. 62.6 mo respectively; p < 0.001, Graph). The Therapy Not Elected group was characterized 1. Surgery, The University of Pennsylvania School of Medicine, by favorable tumor biology. The Poor Clinical Outcome Philadelphia, PA; 2. Surgery, Beth Israel Deaconess Medical Center, group contained two-thirds of all Major complications Harvard Medical School, Boston, MA (Clavien 3b-5) in this entire series. When scrutinized fur- INTRODUCTION: Although adjuvant therapy optimizes ther by multivariate analysis, the only preoperative factors the prognosis for resected pancreatic ductal adenocarci- associated with this group were older age and COPD, and noma (PDAC), literature indicates that this approach is this cohort could not be discriminated by preoperative risk not applied in up to half of patients. This has prompted scoring systems. some to advocate preoperative adjuvant therapy to ensure receipt of all elements of multidisciplinary oncologic care. We sought to identify the frequency, reasons, and predictors of unutilized post-operative adjuvant therapy in a multidisciplinary, specialty setting. METHODS: A database containing PDAC resections performed at two institutions over a decade (2001–2011) was studied. Eligible patients who did not undergo adjuvant therapy were identifi ed and categorized based on the rationale for not receiving treatment. Demographics, perioperative features, tumor characteristics, and surgical risk scores (ASA, POSSUM, Charlson, SOAR) were analyzed by univariate analysis and multivariate regression to assess factors associated with these untreated patients, focusing further on a subset that displayed poor clinical outcomes. RESULTS: Of 412 resected PDAC patients 336 (82%) CONCLUSIONS: This series demonstrates that the vast received some form of postoperative treatment, while only majority of PDAC patients can receive post-operative adju- 52 (including 90 d mortalities, N = 7) did not. Treated vant therapy following surgical resection. There are vari- patients had median, 1- & 5-year survivals of 23.5 mo, ous reasons for non-utilization, not all of which represent 80% & 25%, compared to 9.4 mo, 44% & 22% in the inadequate care. The ability to employ adjuvant therapy Untreated group (p < .001). 24 patients whose treatment is predicated on optimal surgical outcomes. Pre-operative status is unknown exhibited equivalent survival to the prediction of the minority of patients with poor outcomes treated cohort (19.3 mo, 78% & 17%; p = .296). Character- that prevent adjuvant treatment, using current risk assess- istics of the Untreated cohort by multivariate analysis were ment models, remains elusive.

Patients Who Did Not Receive Adjuvant Therapy after Pancreatic Resection—Categorized by Reasons

Frequency Survival n % Median (mo) 1 yr 3 yr 5 yr

Poor Clinical Outcome 34 65.4 6.0 24% 5% n/a

1. Early Death (90d) 7 13.5 1.8 0% 0% 0%

2. Diminished Functional Capacity (Complications/Early Recurrence) 27 51.9 6.9 31% 7% n/a

Therapy Not Elected 18 34.6 62.6 82% 66% 54%

3. Declined Against Medical Advice—Patient’s Choice 8 15.4 10.4 57% 0% 0%

4. Deemed Unnecessary—Physician’s Choice 10 19.2 Not Reached 100% 100% 82%

Total 52 100.0 9.4 44% 27% 22%

92 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1548 CONCLUSION: While the presence of infected necrosis or persistent organ failure in SAP (group III) is associated Retrospective Audit of Management of Patients with high mortality, the combination of “infected necro- Admitted to Intensive Care Unit (ITU) with Severe sis and persistent organ failure” (group IV) is uniformly Acute Pancreatitis (SAP) fatal. Further research is necessary to confi rm the fi ndings Omer Jalil*, Chirag Patel, Aamer F. Iqbal, Amir Kambal, in our study and to explore ways of optimising patients in Ashraf M. Rasheed group III to improve survival. Royal Gwent Hospital, Upper GI Surgery, Newport, United Kingdom INTRODUCTION: Atlanta classifi cation stratifi es acute Su1549 pancreatitis (AP) into mild and severe. Severe acute pan- Rare Benign Cystic Lesions of the Pancreas Mimicking creatitis (SAP) is best managed in HDU or ITU setting and associated with high mortality and morbidity despite best Premalignant Neoplastic Cysts efforts at attaining early diagnosis and timely intervention. Nidhi Agrawal, Nishi Dedania, Sean O’Donnell, Ross Mazo, Jordan M. Winter, Eugene P. Kennedy, Charles J. Yeo, AIM: To compare management strategies and mortality of Harish Lavu* patients admitted to ITU with SAP against national stan- dards and study the group who succumbed to their disease Department of Surgery, Thomas Jefferson University, Philadelphia, PA in detail in an attempt to defi ne the circumstances that INTRODUCTION: Given the increased use of cross- lead to this event and identify the most accurate prognostic sectional radiologic imaging in recent years, cystic lesions indicators in this group of patients. of the pancreas are now being diagnosed with greater fre- METHODS: Retrospective audit of management and quency. The majority of these lesions are premalignant outcome of consecutive patients admitted to ITU with cystic neoplasms of the pancreas, such as intraductal pap- SAP during the period of 2007–2010. The development of illary mucinous neoplasms (IPMNs) and mucinous cystic necrosis, infected necrosis (IN) or organ failure (OF) was neoplasms (MCNs). While pseudocysts account for most of recorded. Patients were classifi ed into group I (No necrosis the remainder, there are a number of rare, benign cystic or OF), group II (sterile necrosis or transient OF), group III lesions of the pancreas that can mimic neoplastic cysts. The (IN or persistent OF) and group IV (infected necrosis and objective of this study was to review a single institution’s persistent OF). The four groups were compared regard- experience with these benign cystic lesions of the pancreas. ing the clinical course, radiological/surgical intervention, METHODS: We conducted a retrospective analysis of all any post-intervention complications, use of antibiotics/ patients who underwent surgical resection for pancreatic antifungal and nutritional support. lesions from 2005–2011 at our institution. Out of a total Poster Abstracts RESULTS: Fifty one (51) patients were admitted to ITU with of 947 pancreatic resections, we isolated those cases per- SAP (APACHE II >8, modifi ed Glasgow score >3) during the formed for benign cystic disease and then examined the period of 2007–2010. All cases fulfi lled the Atlanta criteria clinicopathological data on these patients. Sunday of SAP. Median age: 66 ± 17.5. The pancreatitis was alcohol RESULTS: Thirteen patients (1.5%) out of a total of 170 induced in 12% and due to gallstones in 59% of patients; no pancreatic operations performed for cystic disease were cause was found in 25% of patients. Median ITU stay was found to have non-neoplastic cystic lesions of the pancreas 3.23 days. The overall mortality rate during the study period (9 distal pancreatectomies, 4 pylorus-preserving pancreati- (3 years) was 38% (n-19) above national standard of 30%. All coduodenectomies). Preoperative imaging revealed primary 7 patients in group IV died, 5 of them underwent necrosec- lesions in all patients, 6 of which were found incidentally. tomy and 1 had CT guided drainage of infected acute fl uid Preoperative clinical and imaging studies suggested that collection. The table shows the total number of patients 11 lesions were consistent with mucinous neoplasms and and respective mortality of SAP in all four groups. Forty one 2 with pancreatic adenocarcinoma. However, postopera- patients (80%) received antibiotics and 35 patients (69%) tive pathology revealed 5 patients with ductal retention had nutritional support but neither of them seems to have cysts, 4 squamoid cysts, 1 mucinous non-neoplastic cyst, a signifi cant impact on survival (p = 0.6 and 0.06 respec- 1 congenital ciliated foregut cyst, 1 endometrial cyst, and tively). Outcome (death) correlated with organ dysfunction 1 lymphoepithelial cyst. Two patients had complications criteria (Atlanta criteria and APACHE II score). postoperatively, 1 pancreatic fi stula and 1 superior mesenteric vein thrombosis, both of which resolved with conser- The Mortaltiy of SAP in the Different Groups vative management. All patients remain disease free with median follow up of 2 years post resection. Group Total Number Mortality % of Mortality I1200% II 2 0 0% III 30 12 40% IV 7 7 100%

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Table 1: Clinicopathological Data of 13 Patients with Non-neoplastic Cystic Lesions of the Pancreas Patient Age Sex Pre-op Symptoms Pre-Op Imaging EUS Results Procedure Pathology 1 78 F Abdominal Pain CT Not Performed PPPD Squamoid Cyst 2 66 M None CT, MRI Not Performed DPS w/ partial Left Squamoid Cyst, Hepatocellular Carcinoma Hepatectomy 3 80 F None CT, MRI Not Performed DPS w/ partial Right Ductal Retention Cyst, Cholangiocarcinoma Hepatectomy 4 49 F None CT Epithelial Cells DP Ductal Retention Cyst 5 56 F Pancreatitis CT No cells obtained DPS Ductal Retention Cyst 6 37 M Pancreatitis CT Epithelial Cells PPPD Squamoid Cyst 7 65 M None CT, MRI Mucin DPS Congenital Ciliated Foregut Cyst 8 32 F Abdominal Pain CT Amylase, Elevated DPS Endometrial Cyst CEA 9 72 F None CT Not Performed Laproscopic DP Squamoid Cyst 10 77 F Abdominal Pain MRI Atypical PPPD Ductal Retention Cyst 11 52 F Nausea CT Mucin PPPD Mucinous Non-neoplastic Cyst 12 46 F Pancreatitis CT Not Performed DPS Ductal Retention Cyst 13 69 M None CT, MRI Not Performed DPS Lymphoepithelial cyst PPPD, Pylorus- preserving Pancreaticoduodenectomy; DPS, Distal Pancreatectomy & Splenectomy; DP, Spleen-preserving Distal Pancreatectomy

CONCLUSIONS: While pseudocysts tend to refl ect infl am- METHODS: A retrospective chart review of 40 patients mation and necrosis of the pancreas, there exist rare non- undergoing robotic distal pancreatic resections between neoplastic cystic lesions that may not be associated with 2006 and 2010 was performed. Data was collected for any underlying disease process. In our institutional expe- demographics, clinical presentation, perioperative course, rience, these lesions are often indistinguishable from pre- histology, and survival. Comparisons were performed malignant cystic neoplasms of the pancreas preoperatively between two groups of patients undergoing robotic spleen despite advances in diagnostic imaging and endoscopic preserving distal pancreatectomy (SPDP) and distal pancre- ultrasound fl uid analysis. Although it is possible to safely atectomy with splenectomy (SDP). Survival analysis was perform pancreatic resection in these patients, it is unnec- performed using the Kaplan-Meier method. essary if the patient is asymptomatic. It is important to RESULTS: Twelve patients underwent SPDP compared recognize the existence of these entities to aid in avoiding to 28 SDP patients. The two groups were similar in the surgical resection when not clinically indicated. distribution of their clinical characteristics, including ASA class. There were no signifi cant differences between SPDP Su1550 and SDP groups in respect to the operative time (181 vs. Robotic Spleen Preserving Distal Pancreatectomy Is 210 min, p = 0.09), blood loss (151 vs. 174 ml, p = 0.95) and perioperative blood transfusions (n = 1, 8% vs. n = 0, Safe and Feasible p = 0.30). The incidence of postoperative Clavien grade I Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2 and II complications (n = 4, 33% vs. n = 10, 36% p = 0.99), 1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and Clavien grade III and IV complications (n = 2, 17% vs. n = 0, Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ p = 0.09) and clinically signifi cant pancreatic fi stulas (n = 0 BACKGROUND: Robotic assisted minimal invasive vs. n = 2, 7%, p = 0.99) also did not differ between the two approach has the potential to overcome the limitations of groups. There were no perioperative mortalities. There was conventional laparosopic pancreatic resections. We analyzed no signifi cant difference in the incidence of malignancy (n the outcomes of robotic distal pancreatectomies performed = 3, 25% vs. n = 10, 36% p = 0.71) and median length of at our institution to demonstrate the safety and feasibility of hospital stay (4.5 vs. 5 d, p = 0.49). One and two year sur- spleen preservation during distal pancreas resections. vival rates were also similar in both groups (1 y = 86% vs. 88%, 2 y = 86% vs. 68%, p = 0.34).

94 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSION: Robotic spleen preserving distal pancre- Su1551 atectomy is a safe and feasible surgery with similar perioperative and survival outcomes when compared to distal Quality Measures Have Improved Survival in pancreatectomy with splenic resection. Pancreatic Cancer: A 21-Year Population-Based Study Danielle M. Hari*1, Connie Chiu1, Anna M. Leung1, Stacey Stern1, Perioperative and Survival Outcomes Anton Bilchik2,3 Spleen Preserving Distal 1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica, Distal Pancreatectomy CA; 2. Surgery, David Geffen School of Medicine at University Pancreatectomy with Splenectomy of California, Los Angeles, CA; 3. Surgical Oncology, California (SPDP, n = 12) (SDP, n = 28) P-Value Oncology Research Institute, Santa Monica, CA Operative time 181 210 0.09 OBJECTIVE: To evaluate whether quality measures have (min) improved overall survival for pancreatic adenocarcinoma Estimated blood 151 174 0.95 after surgical resection over two decades. loss (ml) DESIGN, SETTING, PATIENTS: Data from the National Perioperative 1 0 0.30 Cancer Institute’s Surveillance, Epidemiology and End blood transfusion Results program (1988–2008) were used to identity 12,772 Clavien grade I or 4 (33%) 10 (36%) 0.99 patients who underwent surgical resection for adenocarci- II complications noma of the pancreas. Patients were stratifi ed according to number of lymph nodes (LNs) examined over time. Clavien 2 (17%) 0 0.09 grade III or IV MAIN OUTCOME MEASURES: Examination of LNs over complications time (year stratums (YS) 1988–1993, 1994–1998, 1999–2003 Clinically 0 2 (7%) 0.99 and 2003–2008) and correlation with overall survival (OS). signiﬁ cant RESULTS: Patients with at least 15 LNs (n = 2867) have pancreatic ﬁ stula increased over time (by YS: 10%, 14%, 17% & 33%, p < ISGPF§ grade B 0.0001). While the LN positivity rate has increased so has or C OS (Table 1, p < 0.0001). Median OS per LN stratum (1–9, Median length 4.5 5 0.49 10–14 or >15) for localized (Stage I), regional (Stage II & of hospital stay III) and distant (Stage IV) disease increased over time: local (days) (32, 33 and 54 months); regional (14, 16 & 18 months) and

1 year survival 86% 88% 0.34 distant (9, 11 and 12 months). Poster Abstracts 2 year survival 86% 68% 0.34 CONCLUSIONS: In the largest study evaluating pancreatic Sunday § resection for pancreas cancer, signifi cant improvements in ISGPF: International study group deﬁ nition of postoperative pancreatic ﬁ stula. surgical quality measures have occurred over the past two decades. This may be contributing to a dramatic improve- Histopathology ment in overall survival. Distal Spleen Preserving Pancreatectomy Distal Pancreatectomy with Splenectomy Node Positivity Rate and Overall Survival (*Only Includes Patients (SPDP, n = 12) (SDP, n = 28) P-Value with ≥1 LN Examined) Pancreatic 3 (25%) 10 (36%) 0.71 % with Carcinoma Year N = ≥15 LN % Node 1-yr Neuroendocrine 4 (33%) 4 (14%) Stratum (YS) 12,772 Examined Positive* OS 3-yr OS 5-yr OS tumor 1988–1993 1318 131 (10%) 55% 42.9% 16.4% 12.4% IPMN 1 (8%) 5 (18%) 1994–1998 1799 242 (14%) 56% 51.8% 19.9% 13.8% Other benign 3 (25%) 6 (21%) 1999 2003 4419 770 (17%) 58% 55.0% 22.0% 15.5% neoplasms – 5236 1724 (33%) 62% 68.7% 30.4% 22.0% Chronic Pancreatitis 0 0 2004–2008

95 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1552 Su1553 Indicator for Proper Management of Surgical Drains Autologous Islet Cell Transplantation After Extended/ Following Pancreaticoduodenectomy Total Pancreatectomy for Treatment of Chronic Kenichiro Uemura*, Yoshiaki Murakami, Takeshi Sudo, Pancreatitis: A Single Institution Experience Yasushi Hashimoto, Akira Nakashima, Hiroki Ohge, Taijiro Sueda Avinash Agarwal*, Linda Langman, Preeti Chhabra, Surgery, Hiroshima Univ, Hiroshima, Japan Bartholomew Kane, Harry Dorn-Arias, Kenneth L. Brayman BACKGROUND AND OBJECTIVES: Recent reports University of Virginia, Charlottesville, VA suggested that early removal of surgical drains following OBJECTIVE: To describe the safety and effi cacy of autolo- pancreaticoduodenectomy (PD) reduce the postoperative gous pancreatic islet transplants following an extended/ complications including postoperative pancreatic fi stulas total pancreatectomy as a treatment for chronic pancreatitis. (POPFs) with decreased hospital stay and costs. However, METHODS: the indicator for proper drain management still remains Between January 2007 and October 2011, fi f- unclear. The aim of this study was to identify the indicators teen patients underwent an extended pancreatectomy for for proper drain management after PD. defi nitive treatment of chronic pancreatitis. Pancreata were METHODS: surgically removed by the transplant division and sent to Prospectively collected data from 200 con- the islet processing facility. The islets were isolated using secutive patients who underwent PD were evaluated. (86 the Ricordi method, purifi ed using Biocoll gradient and females and 114 males, median age 66 years; range 19–88). loaded into a sterile infusion bag containing transplant The pancreatic anastomosis was reconstructed with a media for infusion. Three different enzymes were used for two-layered duct-to-mucosa pancreaticogastrostomy with transplants since 2007. internal stent. POPF was assessed using the criteria of International Study Group Pancreatic Fistula (ISGPF). The RESULTS: Nine patients underwent total pancreatectomy surgical complications were classifi ed according to the Cla- with six cases of near-total pancreatectomy. Mean age was vien-Dindo (C-D) classifi cation. Predictive clinical factors 38 years (range 15–62) with a male to female ratio of 6:9. for clinically relevant POPFs (Grade B and C) were analyzed Fourteen of fi fteen patients received and tolerated autolo- by logistic regression analysis. Management of surgical gous islet cell infusion. One patient did not receive islet drains was also analyzed. infusion secondary to infectious concerns. The mean islet RESULTS: Of 200 patients, 44 developed pancreatic fi s- equivalents were 202,903 ± 100,108 Islet equivalents (IEQs) tulas; grade A in 29 patients, grade B in 12, and grade C with mean IEQ/kg of 3,016 ± 1571 IEQ/kg. One year and in 3. Thus, clinically relevant POPFs were occurred in 15 three year actuarial patient survival was 100% and 91% (8%). Severe surgical complications (over C-D classifi cation (one case of bacteremia). There was low morbidity associ- Grade3) were occurred in 17 (9%). ated with pancreatectomy with autologous islet cell transplantation (no portal thrombosis, one pancreatic leak, one By univariate analysis, drain amylase on postoperative day SMA injury). No patients required insulin prior to sur- (POD) 2, 3, 4, 5, the color of surgical drain fl uid (dark red) gery. At mean follow up of 23 ± 18 months, six patients on POD1,3,4, WBC on POD3,4, serum C-reactive protein (43%) remain insulin independent (two patients require (CRP) on POD 3,4, and body temperature on POD3,4,5 oral hypoglycemics). Eight patients have a mean insulin were found to be signifi cantly associated with clinically relevant POPFs (p < 0.05). By multivariate analysis on POD4, requirement of only 6 ± 5 U/day. At one month follow-up, the color of surgical drain fl uid (dark red) [p = 0.01, Odds 13 patients (93%) had detectable c-peptide (mean 1.7 ± 1.4 ratio 9.8, 95%CI 1.7–58.3] and serum CRP [p = 0.03, Odds ng/mL). Overall, all patients reported a signifi cant decrease ratio 1.2, 95% CI 1.1–1.4] were found to be independent in pain and narcotic requirements. predictive factors for clinically relevant POPFs. CONCLUSIONS: Autologous islet transplantation after Based on the receiver operating characteristic curve analy- extensive pancreatic resection for chronic pancreatitis is a sis, serum CRP >15.6 mg/dl on POD 4 displayed the opti- safe and successful procedure. It offers defi nitive treatment mal sensitivity (80%) and specifi city (87%). of their diseased pancreas without the morbidity of brittle diabetes. The fi nancial burden of chronic pancreatitis and In the patients with serous fl uid in surgical drain, and poor health associated with diabetes can be successfully serum CRP levels <15.6 mg/dl on POD4 (n = 163, drains mitigated with pancreatectomy followed by isolation and to be removed on POD5), clinically relevant POPFs were autologous transplantation of insulin producing islet clus- occurred in 2 (1%). 5 patients (3%) required additional ters. Ideally, patients should be offered this therapy earlier percutaneous drainage. Severe surgical complications were to decrease chronic abdominal pain and preserve endog- occurred in 12 (7%). On the other hand, in the patients enous endocrine function. with the dark red fl uid in surgical drain, or serum CRP levels >15.6mg/dl on POD4 (n = 37, drains to be removed on POD6 or longer), clinically relevant POPFs were occurred in 13 (35%). 5 patients (14%) required additional percutaneous drainage. Severe surgical complications were occurred in 6 (16%) including one surgical mortality. CONCLUSIONS: A combination of serum CRP levels and the color of surgical drain fl uid on POD4 may be indicators for proper management of surgically placed drains following PD.

96 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1554 Su1555 National Trends in Resection of the Distal Pancreas The Association Between Survival and the Pathologic Armando Rosales-Velderrain*, Steven P. Bowers, Ross F. Goldberg, Features of Peri-Ampullary Tumors Varies Over Time Tatyan M. Clarke, Mauricia Buchanan, John Stauffer, Jennifer K. Plichta*1, Anjali S. Godambe2, Zachary C. Fridirici3, Horacio J. Asbun Sherri Yong2, Margo Shoup1, Gerard V. Aranha1 General Surgery, Mayo Clinic Florida, Jacksonville, FL 1. Surgery, Loyola University, Maywood, IL; 2. Pathology, Loyola BACKGROUND: The authors queried three national patient University, Maywood, IL; 3. Stritch School of Medicine, Loyola care databases evaluating what data is available to assess the University, Maywood, IL current status and trends for distal pancreatectomy (DP). INTRODUCTION: Several pathologic features of periam- METHODS: From the National Inpatient Sample (NIS, pullary tumors (of the pancreas, ampulla, distal common 2003–9), the National Surgical Quality Improvement Proj- bile duct, and duodenum) have been shown to be corre- ect (NSQIP, 2005–10), and the Surveillance Epidemiology lated with survival following resection. We aim to evalu- and End Results (SEER, 2003–9) DP were identifi ed using ate the association between survival and both perineural appropriate diagnostic and procedural ICD-9 (NIS) and CPT invasion and the lymph node ratio at multiple time-points. codes (NSQIP). Utilization of minimally invasive surgery METHODS: A retrospective chart review identifi ed 147 (MIS) was defi ned by ICD-9 procedure code (NIS) but it patients with periampullary adenocarcinoma tumors who could not be differentiated if done for resection or diagno- underwent attempted curative resection (pancreaticoduo- sis which was followed by an open resection. We assessed denectomy) between 1/1/2003 and 12/31/2008. The Social trends in patient demographics, surgical approach, out- Security Death Index was utilized to determine current liv- come metrics, hospital demographics and surgical volume, ing status. Clinical and pathologic features were assessed and oncologic outcomes. from the medical record, and the data were analyzed using RESULTS: NIS, NSQIP and SEER identifi ed 4242, 2681 and univariate and multivariate analyses. 1259 distal pancreatectomy resections, respectively. Mean RESULTS: Of the 141 patients identifi ed, there were 71 age was 60.8 years (NIS) and 61.9 years (NSQIP). There males and 70 females with an average age of 67 years. The was a female predominance, (NIS 62%, NSQIP 59%, SEER median follow-up was 1.7 years (vs. 5.4 years for survivors 55%). Mean BMI was 28.0 and 13% of patients had BMI alone), and the crude overall survival was 33% at the end >35 (NSQIP). There was no signifi cant change of BMI or of the follow-up period. Most tumors were pancreatic in frequency of BMI >35 over the course of study. MIS was uti- origin (57% vs. 26% ampullary, 8.5% distal common bile lized in 15% of operations and splenectomy was performed duct, and 8.5% duodenum). The average tumor size was 2.9 in 72% (NIS). The use of MIS did not change signifi cantly cm, and an R0 resection was achieved in 70% of patients. Poster Abstracts over the course of the study. Resection was performed for On average, 20 lymph nodes were identifi ed in a surgical malignancy in 59% (NIS) and 66% (NSQIP). The mean specimen, and at least one lymph node was positive in 66% Sunday length of stay (LOS) was signifi cantly longer in patients of patients. The median lymph node ratio was 18%, while with malignancy vs. benign disease (10.1 vs. 8.4 days, p 70% of tumors demonstrated perineural invasion. At 1 year < 0.001, NIS; and 8.6 vs. 7.4 days, p < 0.001, NSQIP) and follow-up, 25% of patients had expired, which increased LOS was reduced in resections for malignancy where MIS to 60% by 3 years. Using univariate analyses, 1 year mor- was used (NIS). Mean hospital charges were $137,723.27 tality was independently associated with age, tumor size, (NIS) and were not signifi cantly different between MIS and margin status, lymph node status, lymph node ratio, and open resection. The majority of resections were performed perineural invasion. Multivariate analysis also revealed a in teaching hospitals (77% NIS and 85% NSQIP), but MIS signifi cant association between 1 year mortality and the was not more likely to be used in teaching hospitals. Mean lymph node ratio (OR 1.4, p = 0.037), after adjusting for annual hospital volume for hospitals performing resection age, tumor size, and margin status. Perineural invasion and was less than one case per year (NIS). Hospitals in the top lymph node status were no longer signifi cant in similar decile for volume were more likely to be teaching hospi- analyses at 1 year. However, there was a signifi cant associa- tals than lower volume deciles (88% vs 43%), and were no tion between 3 year mortality and both lymph node ratio more likely to utilize MIS at resection. Complication rate in (OR 2.6, p < 0.001) and perineural invasion (OR 4.9, p < teaching and the top decile hospitals was not signifi cantly 0.001), after controlling for age, tumor size, and margin decreased.Over the time course of the study, there was sig- status. Notably, perineural invasion had a stronger associa- nifi cant increase in lymph node (LN) harvest at resection tion with overall mortality (HR 2.56, p = 0.001) than the for malignant disease but distribution of histologic type lymph node ratio (HR 1.35, p < 0.001), after adjusting for (ductal 30%, IMPN 21%, NET 15% and islet cell tumor 7%) age, tumor size, and margin status. Stepwise selection mod- was unchanged. One-year survival (mean 76.4%) was also eling of overall mortality again revealed a stronger associa- unchanged (SEER). tion with perineural invasion than the lymph node ratio CONCLUSIONS: Each database shows unique aspects of (HR 2.42 vs. 1.34), which also included age and tumor size. the trends in DP, demonstrating their individual advan- CONCLUSIONS: Survival appears to be more closely tages and weaknesses. There appears to be an overall unde- related to lymph node ratio within the fi rst year follow- rutilization of laparoscopy for distal pancreatectomy across ing surgery, while longer follow-up periods demonstrated a the United States despite the benefi ts demonstrated on stronger association between survival and perineural inva- multiple published series. sion at both 3 years follow-up and in overall survival.

97 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1556 Su1557 Epidural Use During Pancreaticoduodenectomy Major Complication and Open Approach Are Nicolas Zea*1, William C. Conway1, Garret Owen2, Predictors of Prolonged Hospital Stay After Darryl Schuitevoerder1, Adrianna C. Dornelles3, John S. Bolton1 Pancreaticoduodenectomy 1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA; Michael J. Ferrara*, Naru Kondo, Florencia G. Que, 2. Anesthesia, Ochsner Clinic Foundation, New Orleans, LA; 3. Center Michael B. Farnell, John H. Donohue, David M. Nagorney, for Health Research, Ochsner Clinic Foundation, New Orleans, LA Kaye M. Reid Lombardo, Michael L. Kendrick INTRODUCTION: While multiple studies report favorable Mayo Clinic, Rochester, MN outcomes with epidural anesthesia and analgesia (EAA) BACKGROUND: Length of hospital stay is frequently use during major abdominal surgery, there is limited data reported to be reduced with laparoscopic approaches. Few in regards to EAA use during pancreatic head resection. A studies have accounted for readmission hospital days which recent switch from EAA to narcotic PCA with OnQ pain may obviate any perceived benefi t. The aim of this study catheters, allowed us to critically evaluate outcomes in was to evaluate the impact of total laparoscopic approach patients undergoing a Whipple procedure with and with- and other clinicopathologic factors on length of index hos- out an epidural catheter. pital stay, readmission rates and total hospital days after METHODS: After obtaining IRB approval, a retrospec- pancreaticoduodenectomy. tive chart review of 100 pancreaticoduodenectomies (PD) METHODS: A retrospective review of clinical, pathologic was performed; this included our most recent 50 patients and outcomes data was performed for all patients undergo- without EAA use, and the last 50 patients with EAA just ing pancreaticoduodenectomy from January 2007 through before we discontinued using this device, with all cases December 2010 at a single institution. Initial hospital stay, spanning from March of 2008 to July of 2011. Peri-opera- readmission rates, and total hospital stay (initial hospital tive and immediate post-operative clinical outcomes were days plus readmission days) were compared between total compared. laparoscopic pancreaticoduodenectomy (TLPD) and open RESULTS: For obvious reasons, but not without impor- pancreaticoduodenectomy (OPD). The relationship between tance, EAA patients had longer time from anesthesia start the clinicopathological factors and total hospital stay was time to surgery start time (p = 0.004). The EAA group had investigated using univariate and multivariate analyses. signifi cantly higher rates of intra-operative hypotension (p RESULTS: A total of 527 patients were identifi ed having = 0.001), and revealed a trend towards a higher intra-opera- undergone TLPD (n = 125) or OPD (n = 402). There were tive blood transfusion rate (56% EAA vs. 38%, p = 0.071). No no differences in mean age, BMI or ASA Score. A malig- statistical signifi cance was found between groups in terms nant diagnosis was more common in patients undergo- of length of surgery, estimated blood loss, or intra-opera- ing OPD (80% vs. 68%, p = 0.004), however, there were tive fl uid administration. Post-operatively, EAA patients no differences in overall or pancreas specifi c postoperative had a signifi cant delay in diet initiation (8 days vs 5.6 days, complication rates. Median length of hospital stay was p = 0.015), and a higher requirement of post-operative fl uid less for the laparoscopic group (7 vs. 10 days, p < 0.001). administration on post-op day # 1 (3,983 ml VS. 3,088.1 Hospital readmission within 30 days was observed in 16% ml, p = 0.001). Although the overall morbidity rate was and was not different between the TLPD and OPD groups similar between the two groups, the EAA group had higher (14% vs. 17%, p = 0.4) Common diagnoses on readmission rates of urinary tract infections (5/50 VS. 1/50), and intra- included pancreatic fi stula (25%), delayed gastric empty- abdominal abscess (5/50 VS. 0/50). 10 of 50 (20%) patients ing (21%), and abdominal collection or abscess (20%). Of in the EAA group had premature discontinuation of epidu- patients requiring readmission, 62% had Clavien grade 3 or ral catheter secondary to hypotension or inadequate pain 4 complications diagnosed during initial hospitalization or control. Length of stay was similar between the two groups at subsequent readmission. Median length of readmission (EAA- 17 days VS. PCA- 15.1 days, p > 0.05). hospital stay was 5 days for both TLPD and OPD groups. CONCLUSIONS: In the current study, EAA during PD was When accounting for readmission days, total hospital days associated with a delay in surgery start time, increased were less for patients undergoing TLPD compared to OPD (8 episodes of intra-operative hypotension, a trend toward vs.11, p < 0.001). Multivariate analysis demonstrated that increased intra-operative blood transfusion and a 20% Clavien Grade ≥3) complication (HR 6.9, 95% CI 4.3–11.5, device failure rate. While pain relief may be excellent with P < 0.001) and open approach (HR 2.5, 95% CI 1.5–4.4, EAA, these issues must be considered when selecting a peri- P < 0.001) were independent predictors of prolonged total operative pain control strategy. hospital stay. CONCLUSIONS: Compared with open approaches, TLDP results in shorter hospital stay, similar readmission rates and less total hospital days. Major complication and open approach are independent predictors of prolonged total hospital stay. Limitations of this study include potential selection bias as noted by a higher incidence of malignancy in the open group. The impact of reduced hospital stay on cost and patient-specifi c advantages such as improvement in quality of life needs to be evaluated.

98 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1558 after R1 resection (Figure). Among patients treated with preoperative therapy, median overall survival was 26 and Defi ning Resection Margins in Pancreatic Cancer After 15 months with negative margin width of >1 mm and ≤1 Neoadjuvant Chemoradiotherapy mm, respectively (p = 0.002). Width of negative margin Alan A. Thomay*, John P. Hoffman, Yun Shin Chun did not signifi cantly affect survival among patients who did Fox Chase Cancer Center, Philadelphia, PA not receive preoperative therapy. BACKGROUND: Although surgical margin status is an CONCLUSIONS: Resection margin status is associated established prognostic factor after resection of pancreatic with overall survival but not local recurrence rates. Width adenocarcinoma, there is no consensus on what consti- of negative margin >1 mm is a signifi cant prognostic factor tutes R0 versus R1 resection. R1 resection is defi ned in among patients treated with neoadjuvant therapy but not North America as the presence of cancer cells at a resec- among patients undergoing upfront surgery. tion margin and in Europe, as tumor up to 1 mm from a resection margin. We sought to determine the association Clinical: Small Bowel between width of resection margin and recurrence rates and survival. METHODS: Retrospective analysis was performed of 301 Su1559 consecutive patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreatic head or unci- Somatostatin Analogues for the Treatment of nate process at a single institution over a 20 year period Enterocutaneous Fistulas: A Systematic Review and (1991–2011). Adenocarcinomas arising within IPMN or Meta-Analysis mucinous cystadenomas were excluded. Analyzed vari- Shaun Coughlin* ables included age, sex, margin status, use of neoadjuvant Surgery, University of Western Ontario, London, ON, Canada therapy, recurrence, and survival. A p value <0.05 was con- BACKGROUND: Enterocutaneous fi stulas are abnormal sidered signifi cant. connections between the skin and gastrointestinal tract that most commonly occur following surgery. Somatosta- tin analogues have been used in their treatment. Our objective was to determine if somatostatin analogues shorten the time to closure of post-operative enterocutaneous fi stuals compared to placebo. METHODS: We searched Medline, EMBase, The Cochrane Central Register of Controlled Trials, as well as reference Poster Abstracts lists of textbooks and relevant articles for randomized controlled trials comparing somatostatin analogues to control Sunday in the treatment of post-operative enterocutaneous fi stulas. We systematically assessed trials for eligibility and validity, and extracted data in duplicate. We pooled data across studies using a random effects model. RESULTS: Our initial search yielded 720 studies, of which 8 RCTs ultimately met eligibility criteria and were included in this review. Somatostatin analogues signifi cantly decreased the time to closure of fi stulas compared to placebo (Weighted mean difference (WMD) –6.37 days [95% CI –8.33, –4.42]). The duration of hospital stay was also signifi cantly decreased with somatostatin analogue treatment (WMD –4.53 days [95% CI –8.29, –0.77]). No difference in mortality was identifi ed with somatostatin treatment (Rela- tive risk 0.87 [95% CI 0.49 to 1.55]). RESULTS: Of the 301 patients, 102 (34%) received preoperative chemoradiation, and 199 did not. The resection CONCLUSION: Somatostatin analogues appear to decrease margin was grossly positive (R2) in 4 patients (1%), micro- the duration of enterocutaneous fi stuals and duration of scopically positive (R1) in 108 (36%), negative by ≤1 mm in hospital stay while no mortality benefi t was identifi ed. 54 (18%), and negative by >1 mm in 135 (45%). Resection The quality of evidence for outcomes in this review ranged margin status did not correlate with rates of local or distant from low to moderate. Future, large, blinded randomized recurrence (p > 0.05). Overall survival was similar among controlled trials would be useful in improving the confi - patients with negative margin width of ≤1 mm vs. >1 mm, dence in the treatment effects identifi ed in this systematic with median survival rates of 19 and 21 months, respec- review and meta-analysis. tively, contrasted with a median survival of 13 months

99 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1560 ondary outcome complication rates. The average length of post-operative stay was similar in all groups. Use of steroids Timing of Pre-Operative Anti-Tumor Necrosis Factor was not associated with a difference in EPC or length of Therapy Does Not Affect Early Post-Operative stay in any group, removing patients on budesonide alone had no effect. However, a greater proportion of ALLT pts Complication Rates in Infl ammatory Bowel Disease were on steroids 43.4% vs. 18.4%, p = 0.001 compared to Patients Undergoing Intestinal Resection the IM group at the time of surgery. Parin N. Desai, Anil Sharma, Amar S. Naik, Mary F. Otterson, CONCLUSION: * Despite an increased likelihood of being Yelena Zadvornova, Lilani P. Perera, Nanda Venu, Daniel J. Stein exposed to steroids and having more severe CD, patients Medical College of Wisconsin, Milwaukee, WI on pre-operative anti-TNF therapy had similar EPC rates INTRODUCTION: Patients with moderate to severe compared to IM only patients. Further investigation of infl ammatory bowel disease (IBD) have a high likelihood of anti TNF therapy timing in the pre-operative period is war- being exposed to anti-tumor necrosis factor (TNF) therapy ranted to recognize its contribution to EPC rates and to as well as undergoing an operative resection. Studies look- optimize treatment in the peri-operative period. ing at preoperative anti-TNF therapy effects on the early post-operative period have shown contradictory fi ndings. Su1561 Some physicians time operations with the nadir of the anti- TNF therapy to minimize their immunosuppressive effect; Endoscopic Ultrasound (EUS) Evaluation in the however it is unclear if this practice improves outcomes. Surgical Treatment of Duodenal and Peri-Ampullary AIMS: 1) Determine early post-operative complication (EPC) Adenomas rates in IBD patients on anti-TNF therapy compared to Lilian C. Azih*1, Brett L. Broussard1, Milind A. Phadnis2,4, Martin patients on immunomodulators (IM) alone and 2) assess J. Heslin1, Mohamad A. Eloubeidi3,2, Shyam Varadarajulu2, Juan the effect of remote versus immediate anti-TNF pre-operative Pablo Arnoletti1 therapy on EPC rates. 1. General Surgery, University of Alabama Birmingham, Birmingham, METHODS: A retrospective review of a prospectively col- AL; 2. Gastroenterology, University of Alabama Birmingham, lected database of pts with IBD who underwent resection Birmingham, AL; 3. Gastroenterology, American University of Beirut, of small or large intestine from July 1st, 2005 to July 1st, Beirut, Lebanon; 4. Biostatistics, University of Alabama, Birmingham, 2010 was performed. Main outcome of interest was the AL combined EPC rate, defi ned as any of the following second- INTRODUCTION: ary outcomes: infection, anastomotic leak, re-admission, Precise characterization of benign reoperation, thrombosis, acute kidney injury (AKI), ileus, duodenal and peri-ampullary tumors, offers a diagnostic or new drain within 30 days after surgery. All pts on anti- challenge to reliably distinguish adenomas from malig- TNF therapy (ALLT) were compared to pts on IM alone. The nant lesions and render the possibility of trans-duodenal ALLT group was divided into remote preoperative (RP) and resection. EUS has emerged as a useful technique in assess- immediate preoperative (IP) groups; pts receiving a TNF ing tumor depth of invasion and is often employed at dose greater than and less than ½ of their dosing interval our institution when planning therapeutic approach. We prior to the operation, respectively. performed a retrospective review of patients with benign duodenal and peri-ampullary adenomas who underwent RESULTS: A total of 114 pts (60% F; 86.8% Crohn’s Dis- preoperative EUS to determine the accuracy of this tech- ease) had resections, 76 ALLT pts (46 IP and 30 RP pts) and nique in predicting the absence of muscular invasion and 38 IM pts. All groups were similar in terms of age, gender, also to analyze outcomes associated with endoscopic and race, smoking, and disease duration; except ALLT had a trans-duodenal surgical resection. higher prevalence of penetrating CD than the IM group METHODS: (43% vs. 29.4%; p = 0.05). Comparison of the ALLT to the Records of 111 patients seen at our institu- IM alone group showed no difference (43.4% vs. 26.3%, p tion over the last 10 years with post-operative pathologi- = 0.08) in terms of the combined EPC rates, or in individ- cal diagnosis of benign ampullary and duodenal adenomas ual secondary outcome rates. Comparison of the IP and RP were identifi ed and reviewed. We analyzed information on groups showed no signifi cant difference (21.7% vs. 30.0% patient gender, age, tumor location and size, EUS results, p = 0.16) in the combined EPC rate, or in individual sec- type of resection performed, fi nal pathology fi ndings and incidence of local tumor recurrence.

100 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: Among 111 patients with benign ampullary adhesiolysis is most benefi cial and cost-effective. Our aim and duodenal adenomas, 47 underwent preoperative EUS was to compare the clinical and cost outcomes of early ver- for 29 periampullary lesions and 18 duodenal lesions. In sus late adhesiolysis for AIOs. 38 (81%) patients, EUS reliably identifi ed absence of sub DESIGN: Patients undergoing adhesiolysis for intestinal mucosal and muscularis invasion. In 4 cases, EUS underesti- obstruction were identifi ed from the 2007 Nationwide mated sub mucosal invasion that was proven by pathology. Inpatient Sample (n = 8,034,632) and stratifi ed to early In the other 5 patients, EUS predicted muscularis invasion (≤2 days from admission) vs. late (>2 days) adhesiolysis. which could not be demonstrated in the resected speci- The primary outcome comparison was in-hospital mortal- men. Type of resection performed included endoscopic ity and secondary outcomes were post-operative compli- resection in 25 cases, partial duodenectomy in 6 cases, cations (POCs), post-operative length of stay (PLOS) and transduodenal ampullectomy with sphincteroplasty in 10 in-hospital cost. Propensity score methods were used to cases and pancreaticoduodenectomy in 6 cases. There were balance patient characteristics before making outcome 6 local recurrences (13%; median follow-up = 20 months) comparisons. As a secondary analysis, different cut-off days 4 of which were in patients with Familial Adenomatous (from 1 and 3 to 10 days post-admission) of adhesiolysis Polyposis (FAP). The main post-operative fi nal pathologi- were used to redefi ne early versus late groups and reana- cal results included villous adenoma (n = 5), adenoma lyzed for the above outcomes. (n = 6), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2),. Among the 47 RESULTS: From 5,443 patients who underwent adhesioly- patients who underwent resection, 8 (17%, 5 of which cor- sis for AIOs in the United States in 2007, 53% and 47% responded to surgical resection) developed post-procedural underwent early and late adhesiolysis, respectively. Late complications which included retroperitoneal hematoma, adhesiolysis patients were older (65.0 vs. 60.1), differed in intraabdominal abscess, wound infection, delayed gastric insurance (55.4% vs. 44.4% Medicare-covered), and had emptying and prolonged ileus. 14 co-morbidities with increased frequency compared to CONCLUSION: the early group (p < 0.05). After adjustment by propen- EUS can accurately predict depth of muco- sity score methods, no difference in mortality (odds ratio sal invasion in 81% of benign ampullary and duodenal [OR] 0.95, 95% confi dence-intervals [CI] 0.67–1.36, p = adenomas. These patients can safely undergo endoscopic 0.79) or POCs (OR 1.01, 95%CI 0.89–1.14, p = 0.91) was or local resection with acceptable local control rates spar- observed between the two groups. Patients undergoing late ing the need for more extensive operations. adhesiolysis, however, had increased PLOS (9.8% increase in days, p < 0.001) and in-hospital cost (41.9% increase in Su1562 cost, p < 0.001) compared to the early group. Repeat analysis with redefi ned early and late adhesiolysis groups at dif-

Early Versus Late Adhesiolysis for Adhesive-Related Poster Abstracts ferent procedure days showed that mortality signifi cantly Intestinal Obstruction: A Nationwide Analysis of increased when adhesiolysis was performed 8 days after Inpatient Outcomes admission (OR 2.06, 95% CI 1.21–3.53, p < 0.01) while no Sunday Daniel I. Chu*, Melanie L. Gainsbury, Lauren A. Howard, differences in POCs were observed. Arthur F. Stucchi, James M. Becker CONCLUSIONS: These data suggest that the historically- Department of Surgery, Boston University Medical Center, Boston, MA based 2-day time limit of waiting is not associated with BACKGROUND: Adhesive-related intestinal obstructions increased mortality or POCs for those patients undergo- (AIOs) are a signifi cant cause of morbidity and mortality ing adhesiolysis for an AIO, but instead is associated with for the surgical patient. Classical surgical teaching advo- increased PLOS and in-hospital cost. Risk of mortality was cates a watchful waiting period of 2-days before operating found to increase after 8 days of admission, and future on an AIO, but it remains unclear whether an early or late studies will need to better understand this observation.

101 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Stomach Of 87 patients without recurrent symptoms after placement of GES who have not needed a replacement, 15 were selected as the control arm, matched by the three variables Su1563 of investigator-derived independent outcome score (IDI- OMS), baseline symptom scores before initial GES implan- Evaluation and Treatment of Gastric Stimulator Failure tation, and etiology of disease (i.e. diabetic or idiopathic). *1 1 1 Nancy Salloum , Micah R. Walker , Patrick A. Williams , METHODS: Each patient met specifi c indications to receive Yana Nikitina1, Thomas S. Helling2, Thomas L. Abell1, GES replacement surgery. All patients had a preoperative Christopher J. Lahr2, James Griffi th1 diagnosis of either diabetic or idiopathic, drug-refractory, 1. Digestive Diseases, University of Mississippi Medical Center, Jackson, or post-surgical gastroparesis, and disordered gastric emp- MS; 2. Surgery, University of Mississippi Medical Center, Jackson, MS tying with signifi cant weight change. Patients with failed GES were evaluated over a 1–2 week period with insertion INTRODUCTION: Some patients who undergo gastric of a temporary endoscopic gastric stimulator. Patients with electrical stimulation (GES) for gastroparesis (GP) develop a positive response to temporary stimulation undergo GES recurrent symptoms i.e.: vomiting, nausea, early satiety, replacement surgery. Common gastroparesis symptoms were bloating, and abdominal pain despite an initial good result, evaluated before and after gastric pacemaker replacement replete with a functioning stimulator and unbroken leads. using the Likert score system 0–4. These symptoms include This study evaluates treatment for these patients, which vomiting, nausea, epigastric pain, early satiety and bloating. includes temporary stimulation at a new gastric location RESULTS: and if symptoms are relieved this is followed by implan- See Tables 1 and 2. Total score of symptoms tation of new leads and stimulator. We expect symptom improved for 12 out of the 15 (80%) patients that under- scores to signifi cantly decrease in the control group; we went the GES replacement surgery. The frequency, ampli- hypothesize that the symptom scores will also show a sig- tude, freq/amplitude ratio (FAR), and gastric emptying nifi cant decrease in the replacement group. times (GET) are displayed to reinforce physiological similarity between the two groups. PATIENTS: 15 patients with recurrent symptoms after CONCLUSION: placement of GES have undergone surgical insertions of a Trial gastric mucosal electrical stimula- new gastric electrical stimulation (GES) system. Of the 15 tion followed by implantation of new leads and stimulator replacement surgeries, 10 (67%) were female, 5 were male successfully salvages the majority of patients whose gastric (33%) (mean age of all: 45), and 3 (20%) had diabetes- electrical stimulator is no longer relieving symptoms. induced gastroparesis; the remainder (80%) were either idiopathic, post-surgical, or sarcoidosis-induced.

Table 1: Comparison of Mean Pre-Op and Mean Post-Op Symptom Scores Replacement (n = 15) Mean of Pre-Op Scores Mean of Post-Op Scores Difference in Symptom Scores p-Value of Difference Vomiting ± SD 3.2 ± 1.3 2.1 ± 1.3 1.2 0.001 Nausea ± SD 3.9 ± 0.3 3.3 ± 1.1 0.6 0.088 Early satiety ± SD 3.3 ± 0.6 2.4 ± 1.5 0.9 0.041 Bloating ± SD 3.3 ± 0.6 2.5 ± 1.5 0.8 0.057 Epigastric pain ± SD 3.6 ± 0.6 3.3 ± 1.4 0.3 0.24 Total Score ± SD 17.3 ± 1.6 13.6 ± 3.7 3.6 0.017 No Replacement (n = 15) Mean of Pre-Op Scores Mean of Post-Op Scores Difference in Symptom Scores p-value of Difference Vomiting ± SD 3.0 ± 0.9 2.0 ± 1.5 1.0 0.019 Nausea ± SD 3.2 ± 1.2 3.0 ± 0.9 0.2 0.5 Early satiety ± SD 3.1 ± 1.0 2.4 ± 1.1 0.7 0.019 Bloating ± SD 2.8 ± 1.2 2.6 ± 1.1 0.2 0.7 Epigastric pain ± SD 3.1 ± 1.4 3.0 ± 1.2 0.1 0.88 Total Score ± SD 15.8 ± 3.6 12.3 ± 3.5 3.5 0.011

Table 2: Comparison of Mean EGG Values Replacement (n = 15) No Replacement (n = 15) p-value Normal EGG values Frequency ± SD 5.5 ± 3.0 5.8 ± 1.5 0.73 2.7–3.3 Amplitude ± SD 0.44 ± 0.6 0.6 ± 0.6 0.54 0.5 Freq/amp ratio ± SD 31.2 ± 31.5 32.4 ± 42.3 0.94 <10 Gastric emptying time (GET), 1;2;4 hr (%) 72, 49, 25 76, 48, 22 0.61, 0.96, 0.77 Total GET (%) ± SD 146 ± 59 146 ± 60 0.99 Table is displayed to reinforce physiological similarity between the two groups.

102 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Su1564 Su1565 Thromboembolic Events After Laparoscopic Adjustable Changes in Quality of Life Before Roux-en-Y Gastric Gastric Band: Identifi cation of High-Risk Factors Bypass for Morbidity Obesity and After a Short and Chad Gonczy*, Imran Hassan, Sajida Ahad, Stephen Markwell Long Term Follow-Up SIU School of Medicine, Springfi eld, IL Rafael M. Laurino Neto*, Fernando A. Herbella INTRODUCTION: In-hospital prophylaxis against throm- Federal University of São Paulo, São Paulo, Brazil boembolic events (TE) is considered routine for patients INTRODUCTION: Roux-en-Y gastric bypass is considered after laparoscopic adjustable gastric band (LAGB) for mor- an effective therapy for weight loss although weight regain bid obesity due to the increased risk of TE in this patient may be observed in a long-term follow-up. It is unclear if population. However, there are limited data regarding the quality of life is sustained in a long-term follow-up when benefi t of extending this prophylaxis beyond discharge. weight regain occurs. Utilizing the American College of Surgeons-National Sur- METHODS: gery Quality Improvement Project (ACS-NSQIP) database, Three groups were studied: Group A—50 we analyzed patients undergoing LAGB to determine the patients (88% females, age 51, BMI 37Kg/m2, time of fol- incidence of pre- and post-discharge TE and associated risk low-up 112 months) submitted to Roux-en-Y gastric bypass factors. more than 7 years, Group B—50 patients (82% females, age 44, BMI 31Kg/m2, time of follow-up 17 months) submit- METHODS: Patients undergoing LAGB between 2005–2009 ted to Roux-en-Y gastric bypass 1–2 years, Group C—50 were identifi ed from the public use fi le of the ACS-NSQIP patients (80% females, age 42, BMI 47Kg/m2) morbid obese database using the Current Procedural Terminology code in the pre-operative period. We use the MOS 36-Item Short- for LAGB. Univariate comparison and regression analysis Form Health Survey (SF-36) to analyze the quality of life of demographics and comorbidities of patients with and differences among the 3 groups. without TE were performed to determine independent risk RESULTS: factors for the development of TE. Groups were similar for gender. Group A was older than the other groups due to the time from opera- RESULTS: During the study period, 16,015 patients tion. BMI was signifi cantly lower for Group B compared to underwent LGB, of whom 19 (0.12%) developed a TE (10 Group C and higher for Group A compared to Group B. SF-36 (0.062%) developed a pulmonary embolus, 11 (0.069%) parameters are depicted in Table 1 on next page. Physical developed a deep-vein thrombosis, and 2 developed both) Functioning, Social Functioning, Emotional Problems and within 30 days of surgery. Eighty percent of the pulmo- Mental Health were not different when the 3 groups were nary embolisms and ninety-one percent of the deep venous compared (p = 1). Role Functioning, Pain, General Health thromboses were diagnosed after discharge. On regression Perceptions and Vitality showed an increase after the oper- Poster Abstracts analysis several patient characteristics, medical comorbidi- ation and a signifi cant decrease at the 7 year follow-up (p ties and postoperative complications were independently < 0.0001) (Figure). Sunday associated with increased risk of TE. (Table)

Signiﬁ cant Independent Risk Factors After LAGB

Risk Factor Odds Ratio P-value Transfusion in OR 101.24 <0.0001 Cardiac Complications Excluding PE 27.95 <0.0001 Reoperation 17.71 <0.0001 Non-caucasian 3.28 0.01 Age ≥40 years 6.27 0.02 OR Time 2.58 0.05

CONCLUSION: The 30-day incidence of thromboembolic events after LAGB in ACS-NSQIP hospitals is exceedingly low, although the majority of these events occur following CONCLUSIONS: Some Quality of Life parameters are discharge. Certain patients are at higher risk for TE, and not changed by Roux-en-Y gastric bypass while others may represent a cohort that could benefi t from extended are improved by the operation even though a signifi cant post-operative prophylaxis. decreased is noted at a long term follow-up.

103 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1: SF-36 Concepts for the 3 Groups Role Physical Pain General Health Vitality Social Emotional Mental Functioning Functioning Perceptions Functioning Problems Health Group A 77 (50–88) 75 (6–100) 51 72 (58–84) 55 (40–75) 68 (40–87) 66 (33–100) 66 (48–83) (22–70) Group B 95 (86–100) 100 (75–100) 84 92 (87–100) 85 (75–90) 100 (87–100) 100 (100–100) 90 (80–92) (61–100) Group C 50 (25–68) 37 (0–75) 41 54 (40–75) 40 (30–70) 56 (37–84) 33 (0–100) 58 (33–75) (31–74) Data presented as median (interquartile range 25–75).

Su1567 was similar for both the diabetic and idiopathic subgroups. Post-operatively, 15 of 23 patients were able to discon- Laparoscopic Gastric Pacer Therapy for Medical tinue supplemental nutrition. BMI increased in both the Refractory Diabetic and Idiopathic Gastroparesis idiopathic and diabetic cohorts (see Graph 1 and 2). Four Poochong Timratana*1, Kevin M. El-Hayek1,2, Hideharu Shimizu1, patients underwent conversion to laparoscopic Roux-en-Y Matthew Kroh1,2, Bipan Chand1 gastric bypass for persistent poorly controlled symptoms 1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH; and morbid obesity with associated comorbidities. Symp- 2. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH tom control was achieved in 2 of these patients with an overall mean excess weight loss of 22% (8–39) at 7 month BACKGROUND: Gastroparesis is a disorder of chronic follow-up (3–12). nausea and vomiting that may result in failure to thrive. CONCLUSION: Etiologies are multifactorial, but most often are classifi ed as Gastric pacer placement is feasible using a diabetic, idiopathic, post-surgical, or medication induced. laparoscopic approach. Medical refractory gastroparesis in Several large series have shown effi cacy of gastric pacer the diabetic and idiopathic groups had signifi cant symp- implantation in certain groups with gastric dysfunction. tom improvement with no difference between the two However, laparotomy is often employed for placement. groups. Gastric pacing may decrease the need for ongoing The aim of this study is to review outcomes of all patients supplemental nutrition. who underwent gastric pacer therapy regardless of etiology. Su1568 METHODS: Patients who underwent gastric pacer (Enterra Therapy System; Medtronic, Minneapolis, MN) implanta- Assessment of Muscular Loss After Bariatric Surgery tion with subsequent interrogation and programming Through Bioimpedancy between March 2001 and November 2011 were analyzed. Wilson R. Freitas*, Paulo Kassab, Roberto D. Cordts Filho, Elias J. Data reviewed included demographics, pre-operative Ilias, Osvaldo A. Castro, Fabio Thuler, Paulo G. Porto, Carlos A. symptoms, operative technique, and post-operative symptom and nutritional improvement. Malheiros Surgery, Santa Casa São Paulo Medical School, São Paulo, Brazil RESULTS: A total of 113 patients underwent gastric pacer BACKGROUND: placement during the study period. Mean age was 40 years The evident weight loss observed dur- (19–88) and 83% of patients were female. Operations were ing the fi rst six months after bariatric surgery is due to the completed laparoscopically in 110/111 cases, with one reduction in body fat and muscular mass. There is, how- conversion to laparotomy due to severe adhesions. Two ever, the need to keep track the body composition of obese cases involved pacer revision for battery replacement. Gas- patients during this period of time in order to monitor the troparesis symptoms were present for a mean duration of different body composition fractions such as water, fat-free 4.8 years prior to surgery (1–20). Surgical intervention was mass, and fat. Bioimpedancy is a useful tool to assess body only offered for patients with medical refractory diabetic composition and a portable and easy-to-use alternative to and idiopathic gastroparesis. Prior to implantation, thirty- determine variations of these fractions in obese patients three patients were on supplemental nutrition (23 on jeju- during their weight loss period. nal feeds and 10 on total parental nutrition). There were METHODS: Thirty-six morbid obese patients were sub- no operative or immediate peri-operative complications. jected to gastroplasty with silastic ring and Roux-en-Y dis- Battery depletion occurred in 6 patients at a mean interval tal gastric bypass, and their percentages of fat, water, and of 75 months. Pacer malfunction occurred in 4 cases. Two fat-free mass were measured the day before the surgery, as of these cases required removal secondary to lead erosion, well as 2, 4, and 6 months after the surgery. A four-channel 1 underwent conversion to Roux-en Y gastric bypass, and 1 Bioelectrical Body Composition Analyzer, which measures had no therapy. At a mean follow-up of 24 months, symp- the difference between upper right limb and lower right tom improvement was achieved in 91 patients (80%) and limb was used.

104 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: The results indicated a pattern in the mea- and improvement of co-morbid conditions are years after surements obtained in all cases. A linear reduction of the implantation of the adjustable gastric band. Lifestyle changes average fat content was observed, ranging from 50.9% at which include diet, exercise, and stress management in addi- the pre-operatory to 40.8% 6 months after the surgery. tion to follow up with the adjustable gastric band are key The results also showed a linear reduction of average BMI, components in resolution of medical co-morbidities. which varied from 55.1 kg/m2 to 37.7 kg/m2 in 6 months, and a linear increase of water content varying from 35.9% Su1570 to 43.4% during the same period. Although there was a decrease in the total fat-free mass (76.9 kg to 62.7 kg), Is Laproscopic Single Stage Bilio-Pancreatic Diversion an increase in its percentage relative to the total weight Safe in the Super-Morbidly Obese? (49.1% to 58.9%) was observed during the study. Sidhbh Gallagher*, Gintaras Antanavicius, Iswanto Sucandy, CONCLUSIONS: Bioimpedancy measurements carried out Amarita Klar, Fernando Bonanni up to 6 months after the surgery did not reveal signifi cant Department of Surgery, Abington Memorial Hospital, Abington, PA loss in muscular mass, indicating only a minor effect of BACKGROUND: It is hypothesized that the morbidity malnutrition associated to weight loss, and an increase in and mortality of laproscopic bilio-pancreatic diversion the percentage of fat-free mass relative to the total weight. with duodenal switch (LBPD/DS) are likely to increase with increasing body mass index (BMI), especially when Su1569 >50 kg/m(2). Some authors, therefore, advocate a two-stage Timing of Resolution of Comorbidities in Patients approach to this procedure in the super-morbidly obese. We hypothesize that a BMI ≥50 kg/m(2) does not signifi cantly with Laparoscopic Adjustable Gastric Banding (LAGB) infl uence peri-operative morbidity with this procedure. N = 698 METHODS: * A prospective database of all patients who David A. Nguyen , Grace J. Kim, Regina M. Ramos, Carson D. Liu underwent laproscopic/robotic bilio-pancreatic diversion Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA with duodenal switch between January 2009 and September INTRODUCTION: Bariatric surgery has been shown to be 2011 was analyzed. Two groups were identifi ed: those with an effective solution for sustainable weight loss in the mor- BMI <50 kg/m(2) (Group 1) and those with BMI ≥50 kg/m(2) bidly obese. This study aims to investigate the impact of (Group 2). Patient demographics, length of procedure (LOP), LAGB on weight loss and obesity comorbidities (diabetes, intra-operative complications, conversion to open rates and hypertension, sleep apnea, and hypercholesterolemia). postoperative outcomes, including 30-day complication rate, rate of re-operation at 30 days, rate of other interven- METHODS: 698 patients with average preoperative BMI of

tions, length of stay (LOS) and readmission were compared. Poster Abstracts 42.1 ± 6.5 were retrospectively analyzed through electronic T-test and Fischer’s exact test were used where appropriate. medical records from 2007–2011. Of those patients, 18.3% P-values <0.05 were considered signifi cant. were men and 81.7% were women, with a mean age of 43. Sunday Resolution of comorbidities and weight loss were analyzed RESULTS: 226 patients underwent (LBPD/DS). Mean at three different intervals after band implantation (after patient age was 44.9 years (range: 20–72). 170 (75%) of year one, year two, and year three). All adjustments were patients were female. Mean BMI was 50.2 kg/m(2) (range: performed in clinic setting without fl uoroscopy. Analysis 37.2–68.8). 127 had BMI <50 kg/m(2) (Group 1), and 99 was performed with ANOVA. *P < 0.05 considered statistical had a BMI ≥50 kg/m(2) (Group 2). The LOP in Group 1 was signifi cance. 296 minutes and 287 minutes in Group 2 (p = 0.25). The rate of conversion to open was 3% in Group 2 and 1.5% in RESULTS: Analysis reveals that the fi rst two years after Group 1 (p = 0.65). LAGB are most critical for excess weight loss. The average percentage excess weight loss achieved was 54.2% ± 3.6% There were no mortalities. Only one intra-operative compli- at year one, 67.9% ± 4.5% at year two, and 74.3% ± 7.5% at cation occurred in Group 1; none in Group 2. The rate of ste- year three after band implantation. Average change in body nosis requiring endoscopic intervention was 0.7% in Group mass index was 11.9 kg/m2 ± 1.6 kg/m2. Resolutions of 1 and 1% in Group 2 (p = 1.0). Two leaks occurred in Group comorbidities were analyzed each year after band implan- 1; no patient in Group 2 developed these complications. tation. Diabetes was resolved in 49% of the patients at year One patient in Group 2 developed pulmonary embolism. one, 58% at year two, and 61% at year three. Hypertension The rates of all other complications resulting in a longer LOS was resolved in 37% of the patients at year one, 45% at year were 11% in Group 1 and 8% in Group 2 (p = 0.50). two, and 53% at three. Obstructive sleep apnea was resolved The 30-day re-operation rate was 3% in Group 1 and 1% in in 63% of the patients at one, 76% at year two, and 91% Group 2 (p = 0.39). The rate of re-intervention (endoscopic at year three. Hypercholesterolemia was resolved in 45% of or percutaneous) was 1.57% in Group 1 and 1% in Group the patients at year one, 59% at year two, and 65% at year 2 (p = 1.0). The mean LOS was 3.97 days for Group 1 and three. Of note, many patients continued their cholesterol 3.67 for Group 2 (p = 0.34). The 30-day readmission rate medications with normal levels post-operatively. There was was 11% in Group 1 and 10% in Group 2 (p = 1.00). no mortality in the span of four years of the study. CONCLUSION: BMI ≥50 kg/m(2) does not increase intra- CONCLUSION: We are reporting a four year consecu- operative or postoperative complications at 30 days in ( tive data with no deaths and resolution of comorbidi- LBPD/DS ). No signifi cant differences were noted between ties were observed to be long lasting in correlation with the 2 groups in any of the outcomes. A single-stage proce- their weight loss. We are reporting continued weight loss dure can be safely offered to patients with BMI ≥50 kg/m(2).

105 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1571 Su1572 Laparoscopic Median Arcuate Ligament Release: Are Is Weight Loss Correlated with Race in Laparoscopic We Improving Symptoms? Adjustable Gastric Banding (LAGB) Patients? Yes * Kevin M. El-Hayek1, Jessica Titus*1, Au Bui1, Tara M. Mastracci2, Grace J. Kim , David A. Nguyen, Regina M. Ramos, Carson D. Liu Matthew Kroh1 Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA 1. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; INTRODUCTION: Variability of percentage excess weight 2. Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH loss (%EWL) in LAGB patients can be infl uenced by many BACKGROUND: preoperative factors, such as gender, race/ethnicity, and Median arcuate ligament syndrome is a age. We hypothesize that race/ethnicity plays an important rare disorder characterized by abdominal pain, weight loss, predictor in the post-operative weight loss. and isolated celiac stenosis. Though the diagnosis is often diffi cult to determine, it can be made with vascular ultra- METHODS: A retrospective analysis of 428 patients using sound, axial imaging with angiography, or formal angi- electronic medical record was performed to assess differ- ography. Several reports have shown that surgical release ential %EWL for patients across a period of three years of the median arcuate ligament is a durable and effective post-band implantation, with an average of 1.53 years for treatment option for symptomatic patients. We present our all groups and no signifi cant differences between ethnic experience using a laparoscopic approach for this particu- groups. Average initial BMI is 42 ± 5. ANOVA was used to larly uncommon problem. analyze data and P < 0.05 considered signifi cant. METHODS: This is a prospectively collected, retrospective RESULTS: Percent excess weight loss (EWL) are reported analysis of 14 patients at our institution. Between March for the following racial groups. Asians lost the most, fol- 2007 and June 2011, patients treated with laparoscopic lowed by Caucasians, the Hispanics and fi nally African median arcuate ligament release were analyzed. Data col- Americans. The Caucasian group lost 66.33% ± 2.4%%EWL lected included patient demographics, pre-operative symp- (N = 209); the Asian group lost 88.6% ± 7.7 %EWL (N = 23); toms, operative approach, and post-operative outcomes. the Hispanic group (50.2% ± 2.3%; P = 1.5E-05, N = 123), Pre-operative evaluation included vascular ultrasound or and African American group lost 44.4% ± 3.3%; P = 9.96E- axial imaging (CT or MR angiography) in all cases. Mini- 06, (N = 73). Furthermore, the average number of adjust- mally invasive surgical options included laparoscopy and ments was 6 for the Caucasian group, 5 for the Asian group, robotic assisted laparoscopy. Endovascular management and 4 for the Hispanic and African American groups. was used in select cases. Using an IRB approved database, CONCLUSION: Our fi ndings suggest that weight loss outpatients were then contacted to complete a post-operative come for LAGB may be related to a patient’s race/ethnicity. survey aimed at assessing resolution of symptoms and Patients in the Caucasian group have signifi cantly more overall satisfaction. adjustments than any other group. Excess weight loss is RESULTS: The mean age was 34 years (17–68) and 92% correlated with race and number of adjustments as well of patients were female. Mean pre-operative BMI was 24.1 as willingness to diet and exercise. Cultural differences in kg/m2 (19–32) and 64% of patients had prior abdominal types of food and exercise is also important in weight loss surgery. Mean celiac velocity was 374 cm/s (210–600). Pre- outcome. operative CT angiogram was performed on 10 patients with 7 patients demonstrating celiac stenosis. Thirteen patients Translational Science: Colon-Rectal had laparoscopic median arcuate ligament release while 1 patient had robotic assisted laparoscopic release. Mean operating time was 184 minutes (79–473) and average Su2094 estimated blood loss was 229 cc (5–2000). There were two intra-operative complications. One was an aortic injury Surgeon Leadership Enables Development of a and another was an ulnar artery occlusion from endovas- Colorectal Cancer Biorepository cular stenting. The aortic injury occurred with the robotic Miriam Douthit, Vassiliki L. Tsikitis, Kim C. Lu, Daniel O. Herzig* assisted approach and required a laparotomy for vascular Department of Surgery, Oregon Health and Science University, repair. All other cases were completed laparoscopically. Portland, OR Eleven patients had post-operative vascular ultrasounds with a mean velocity of 215 cm/s (135–306). Mean post- BACKGROUND: A cancer biorepository that links a operative BMI was 24.7 (18–32). Response rate for the patient’s demographic, clinico-pathologic and tissue molec- post-operative survey was 79% at a mean follow-up of 16.5 ular profi le data is critical for translational research to months (5–32.6). All but one patient experienced complete develop personalized cancer treatment. We hypothesize that resolution of symptoms with no persistent pain. a surgeon-directed biorepository optimizes the collection of CONCLUSION: all necessary elements needed to build a complete, robust Laparoscopic release of the median arcu- research resource. ate ligament is a safe, feasible and effective means of managing median arcuate ligament syndrome. Post-operative symptomatic relief is seen in the vast majority of patients undergoing this procedure.

106 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

METHODS: All colorectal cancer patients treated at a virulence factors exist. Molecular biology allows detec- university medical center and its affi liates were eligible tion of virulence-associated genes independent of species. for inclusion in the biorepository. All patients signed an Because of transmural infl ammation in CD, we hypothesize Institutional Review Board-approved genetic consent form that submucosal bacterial populations are more relevant to and medical release authorization. Data was collected chronic infl ammatory disease as opposed to mucosal or from: an 18-page personal and family health question- luminal populations. The purpose is to determine preva- naire completed by the patient; a prospectively maintained lence of virulent genes and/or infectious agents in subclinical database which included oncologic outcomes; and mucosal tissues from patients with disease and controls molecular testing. Specimen collection for the bioreposi- using genomic markers in a comparative assay. Submu- tory included: serum, plasma and peripheral blood mono- cosal tissues were obtained from fresh surgical specimens nuclear cells as well as tumor and normal tissue maintained by manual excision and digestion of mucosal layers. DNA as snap frozen samples, cryovials and paraffi n blocks. The was extracted by a modifi cation of the Human Microbi- patient cohort was divided into a surgeon-referred group ome Project protocol and assayed for 30 virulence genes and a clinician-referred group. The groups were analyzed and/or unique genomic sequences representing 16 distinct with the primary outcome variable as complete collection bacterial species using quantitative real-time PCR (qPCR). of data (clinical data, blood samples and tissue collection). All positive results were repeated, and all qPCR products Statistical analysis was performed using Student’s t-test. were verifi ed by gel electrophoresis and sequencing of the RESULTS: Since inception of the program in 2006, 452 PCR amplicon product. Non-Infl ammatory Bowel Disease patients were approached to join the registry and 430 (nIBD) controls represented negative margins of colon can- (95%) patients have been enrolled. Of these, 124 patients cer patients. A positive result was assigned only if results were referred by their surgeon and consented at the time were reproducible and the PCR product was at least 97% of surgery, and 306 patients were consented in a clinical homologous to the known sequence. Tissues from 11 setting or over the telephone. Of patients referred by their patients with Crohn’s disease and 7 controls have been surgeon, tumor tissue, blood samples and clinical data were examined. The intestinal intimin (eaeA) invasion gene of obtained in 119 patients; conversely, in patients referred by enteropathogenic E. coli and the InvA invasion gene of Sal- oncologists or other clinicians the combination of tumor monella were detected predominately in Crohn’s disease tissue, blood samples and clinical data were obtained in (6/11–55%). The absence of other sequences suggests these 133 patients (96% vs. 43.5%, p < 0.05). A total of 257 tissue plasmid-mediated invasion genes may not be associated samples were obtained from all patients. Additional testing with either E. coli or Salmonella. In the absence of eaeA has been performed on 228 specimens including immuno- and InvA invasion genes, M. paratuberculosis associated histochemistry, microsatellite testing, and genotype muta- sequences were detected in 4/11 (36%) of CD submucosal tissues. Virulence-associated genes were not identifi ed in tional analysis. Poster Abstracts one suspected Crohn’s patient (1/11, 9%). The eaeA inva- CONCLUSION: Surgeon-directed enrollment in a biore- sion gene was detected in only 1/7 nIBD controls (14%). pository improves the ability to collect blood and tissue Other virulence-associated genes and/or infectious agents Sunday samples in conjunction with demographic and clinic- sought in our assay system were randomly detected in both pathologic data. Surgeons should take a leadership role in study populations. This study examines and reports on the the development of tumor biorepositories. bacterial populations within submucosal tissues as opposed to the mucosal and/or luminal microbiome. Preliminary Su2095 data suggests the existence of a submucosal microbiome in both normal and diseased intestinal tissue. CD may be Bacterial Genomic Sequences Within Submucosal divided into 2 distinct populations based on presence/ Tissues Suggest Distinct Populations Within the absence of adhesion/invasion genes or the presence of M. Crohn’s Disease Spectrum paratuberculosis-associated sequences. Future efforts focus Brian R. Davis*1, Rod Chiodini2, William Chamberlin2, on confi rming these fi ndings in populations from various Jerzy Sarosiek2, Richard Mccallum2 geographical locations. Confi rmation of these fi ndings 1. Surgery, Texas Tech University Health Sciences Center, El Paso, TX; could have ramifi cations to the care of CD by the implementation of targeted therapy based on the submucosal 2. Internal Medicine, Texas Tech University Health Sciences Center, microbiome-type. El Paso, TX Bacteria have been suspected in the etiopathogenesis of Crohn’s disease (CD). Over 80% of intestinal microbial fl ora represent unidentifi ed species for which plasmid-mediated

107 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Esophageal Translational Science: Small Bowel

Su2096 Su2097 Evaluation of Clinical Predictors of Epcam Evidence for the Hindgut Hypothesis After Ileal Over-Expression in Patients with Esophageal Interposition Associated with Sleeve Gastrectomy: Adenocarcinoma Increased Number of GLP-1-Producing Cells in Erik M. Dunki-Jacobs*, Yan LI, Charles R. Scoggins, Interposed Ileum and Pancreatic Islets in Rats Kelly M. Mcmasters, Glenda Callender, Robert C. Martin Helene Johannessen*1, Yosuke Kodama1, Chun-Mei Zhao1, Department of Surgery, Division of Surgical Oncology, University of Gjermund Johnsen2, Ronald MåRvik2, Baard Kulseng2,1, Duan Louisville, Louisville, KY Chen1 INTRODUCTION: Epithelial Cell Adhesion Molecule 1. Department of Cancer Research and Molecular Medicine, Norwegian (EpCAM) is a transmembrane glycoprotein expressed by University of Science and Technology, Trondheim, Norway; human epithelial cells. EpCAM is known to be involved in 2. Department of Surgery, St. Olav’s Hospital, Trondheim University cell-cell adhesion, proliferation, differentiation and apop- Hospital, Trondheim, Norway tosis. The aim of this study was to evaluate the clinical pre- BACKGROUND/AIM: Based on the hindgut hypothesis, dictors of EpCAM over-expression in patients with resected ileal interposition with sleeve gastrectomy (II-SG) has been esophageal adenocarcinoma (EAC). proposed as a procedure in metabolic surgery. The aim of METHODS: EpCAM expression was assessed using immu- the present study was to study the underlying mechanism nohistochemical (IHC) staining in patients undergoing of II-SG in rats. esophagogastrectomy for EAC. EpCAM expression was METHODS: Male Sprague-Dawley rats were subjected classifi ed as low (<10%), intermediate (11–60%), or high to laparotomy, ileal interposition (II), sleeve gastrectomy (>60%). EpCAM expression in malignant tissue was com- (SG), or II-SG. Metabolic parameters were monitored by pared to expression in benign esophageal tissue harvested an open-circuit indirect calorimeter composed in compre- approximately 1–2 cm from the margin of the tumor. Age, hensive laboratory animal monitoring system. The num- gender, TNM stage at diagnosis, and presence of neoadju- ber of GLP-1-producing cells was examined by quantitative vant therapy were evaluated as possible clinical predictors immunohistochemistry of increased EpCAM expression. Disease-free survival (DFS) and overall survival (OS) were evaluated. RESULTS: After II alone, satiety ratio i.e., intermeal interval/meal size, was reduced while calorie intake was increased RESULTS: The median age of the patient population was at two weeks postoperatively. Respiratory exchange ratio, 61 years. Pre-operative TNM stage distribution was n = 3, i.e., VCO2/VO2, was increased to above 1.0 (i.e., carbo- n = 4, and n = 6, for stages 1, 2, and 3 respectively. 62% hydrate metabolism) during both daytime and nighttime of patients underwent neoadjuvant therapy. Low, inter- two and six weeks postoperatively. After SG alone, satiety mediate, and high EpCAM expression in malignant tissue ratio and respiratory exchange ratio were unchanged, and occurred in 61%, 31%, and 8% of patients respectively and the number of GLP-1-producing cells was not increased in in 77%, 23%, and 0% of benign adjacent tissue respec- the ileum (in terms of volume density), but increased in tively. EpCAM expression in malignant tissue was not the pancreatic islets (number of cells per islet). After II-SG, shown to be signifi cantly higher than EpCAM expression rate of eating was reduced, while meal duration (minutes/ in benign adjacent tissue (p = 0.3). Clinical variables of age, gram) was increased during both daytime and nighttime TNM stage at diagnosis, and neoadjuvant therapy did not at two and six weeks postoperatively. The number of GLP- predict level of EpCAM expression (p = 0.9, p = 0.4, and p 1-producing cells increased by about 2.5-fold in the inter- = 0.6 respectively). Median DFS and OS were 12 months posed ileum, and also increased to the same extent in the and 28 months respectively. DFS and OS did not correlate pancreatic islets as seen after SG alone. The increased GLP- with EpCAM expression (p = 0.6 and p = 0.6 respectively). 1-producing cells in the pancreas were distributed around Median survival after recurrence was 1 month and did the insulin-producing cells. not correlate with EpCAM expression (p = 0.6). Complete response to neoadjuvant therapy based on postoperative CONCLUSION: The present study provides evidence that pathologic stage was associated with an increased level of II-SG stimulates GLP-1 production not only in the inter- EpCAM expression (p = .02). posed ileum (to act by endocrine mechanism) but also in the pancreatic islets (to act on the cells by paracrine CONCLUSION: EpCAM expression is signifi cantly mechanism), leading to the metabolic benefi cial effects and increased in patients who have complete response to neo- the altered eating behavior as manifested by eating slowly. adjuvant therapy. Further evaluation is needed to better characterize the relationship between EpCAM over-expres- ACKNOWLEDGMENTS: The research leading to these sion and pathologic response to neoadjuvant therapy for results has received funding from the European Union Sev- EAC. enth Framework Programme (FP7/2007–2013) under grant agreement n°266408, the Faculty of Medicine, Norwegian University of Science and Technology, and the Central Nor- way Regional Health Authority.

108 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Translational Science: Stomach RESULTS: Expression of ARF1 mRNA was signifi cantly upregulated in 67.2% of gastric cancer patients by using Real-time quantitative RT-PCR test. Paired comparison of Su2098 IHC study for ARF1 revealed that the IHC scores of cancerous tissues were higher than those of the nontumorous Overexpression of ADP-Ribosylation Factor 1 (ARF1) counterparts in 76.5% of patients. Elevated ARF1 expres- in Human Gastric Cancer and Its Clinicopathological sion was strongly correlated with lymph node metastasis Signifi cance (p = 0.008), serosal invasion (p = 0.046), lymphatic inva- Chia-Siu Wang*1, Kwang-Huei Lin2 sion (p = 0.035) and pathological staging (p = 0.010). More- 1. Department of General Surgery, Chang Gung Memorial Hospital, over, the 5-year survival rate for the lower ARF1 expression Chiayi, Putz City, Taiwan; 2. Department of Biochemisty, Chang group (n = 50; IHC score <90) was higher than that of the higher expression group (n = 60; IHC score ≥90) (log rank Gung University, Taoyuen, Taiwan p = 0.0228). Our functional studies also demonstrate that BACKGROUND: Gastric cancer is the second most com- ARF1-overexpressing clones display enhanced cell prolif- mon cancer worldwide and the sixth leading cause of can- eration, migration and invasion. cer-related death in Taiwan. Biomarkers are investigated to DISCUSSION & CONCLUSION: ARF, a family of small improve early detection and patient survival. Previously, GTP-binding proteins, play important roles in intracellu- ARF1 was identifi ed as one of the strongest upregulated lar traffi cking in animal and yeast cells. Over-expression of proteins by using proteomic technique: two-dimensional ARF1 in cancer cells has been reported in human breast (2D) gel electrophoresis combined with matrix-assisted cancer cells. ARF1 regulates breast cancer cell growth and laser desorption/ionization time-of-fl ight mass spectrom- invasion during cancer progression. Our data demonstrated etry. ARF1 belongs to the Ras superfamily or GTP-bind- that expression of ARF1 is associated with tumor progres- ing protein family and has been shown to enhance cell sion and survival outcome. And, it might be a potential proliferation. prognostic marker for gastric cancer. These fi ndings collec- SUBJECTS & METHODS: A total of 110 patients (69 tively support the utility of ARF1 as a potential prognostic males, 41 females; median age: 66 years, range 28–86 marker for gastric cancer and its role in cell invasion. years) with gastric cancer undergoing gastrectomy were enrolled into this study. Real-time quantitative RT-PCR, western blot analysis and immunohistochemistry (IHC) on resected specimens were used to confi rm the ARF1 overexpression in surgical patients. The clinical signifi cance of

ARF1 expression was evaluated by clinicopathological cor- Poster Abstracts relations and patient’s suruvial outcome. To establish the

specifi c function of ARF1 in human gastric cancer, isogenic Sunday ARF1-overexpressing cell lines were prepared.

109 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Monday, May 21, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.

12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME)

Basic: Biliary CONCLUSION: A signifi cant number of patients continue to experience symptoms following laparoscopic cholecystectomy. In patients were pain was the most trouble- Mo1874 some symptom pre-operatively, signifi cant symptomatic improvement was noted. Similarly, those patients that Persistent Symptoms Following Cholecystectomy Is experienced symptoms more dyspeptic in nature pre-oper- Unacceptably High and in Need of Further Evaluation atively were less likely to be symptom free following LC. Rami Radwan*, Chris Brown, Jonathan Lloyd-Evans, A careful biliary history, a focused physical examination Chirag Patel, Omer Jalil, Ashraf M. Rasheed and a thorough pre-operative assessment must be carried Minimal Access Surgery, Royal Gwent Hospital, Newport, out prior to LC to rule out conditions that masquerade as United Kingdom gallbladder disease. INTRODUCTION: Up to 20% of patients undergoing cholecystectomy continue to experience symptoms. We con- Basic: Colon-Rectal sider such results unacceptably high and in need of further evaluation. Mo1875 Objectives: To identify the biliary symptoms for which the cholecystectomy was carried out and then determine the Human Growth Hormone (hGH) Abolishes the prevalence and the nature of persistent symptoms follow- Negative Effects of Everolimus on Intestinal ing cholecystectomy in a cohort of 500 consecutive cases. Anastomotic Healing METHODS: A validated pre-operative symptoms survey Markus A. KüPer*, JüRgen Weinreich, Frank Traub, was completed at the time of listing of 500 consecutive Alfred KöNigsrainer, Stefan Beckert laparoscopic cholecystectomies (LC) followed by a follow Department for General, Visceral and Transplant Surgery, University up phone survey 12 weeks after the procedure to record the of Tübingen, Tübingen, Germany nature, severity and frequency of symptoms experienced pre- and post-operatively. A detailed clinical profi ling was INTRODUCTION: The mTOR-inhibitor everolimus inhib- carried out on all patients with persistent biliary symptoms. its healing of intestinal anastomoses by interfering with RESULTS: the infl ammatory phase of healing and reducing collagen All patients had at least 2 symptoms pre-opera- deposition. Aim of this study was to investigate whether tively and 337 (67.4%) had 3 or more. The most common the simultaneous administration of everolimus and hGH symptoms pre-operatively were abdominal pain (93.8%), abolishes the negative effects of everolimus on anastomotic nausea (65.8%), pain related to food (54.4%) and bloating healing. (48.6%). METHODS: 48 male Sprague-Dawley-rats were random- A total of 90 patients were symptomatic post-operatively. ized to three groups of 16 animals each (I: vehicle; II: Eighty one patients (16.2%) complained of abdominal everolimus 3mg/kg p.o.; III: everolimus 3mg/kg p.o. + hGH pain, while 63 (12.6%) patients also experienced associated 2,5mg/kg s.c.). Animals were pre-treated with hGH and/or dyspeptic symptoms. Seventy three patients (14.6%) devel- everolimus daily for seven days. Then a standard anasto- oped 1 or more new symptoms post-operatively, the most mosis was created in the descending colon and treatment common being heartburn found in 34 (6.8%) and abdomi- was continued for another seven days. The anastomosis nal bloating in 29 (5.8%). was resected in toto and mechanical, biochemical and his- Sixty patients underwent further investigation follow- tological parameters of intestinal healing were assessed. ing LC; 36 patients went on to have a secondary diagno- RESULTS: Anastomotic bursting pressure was signifi cantly sis made, the most common (13/36) being hiatus hernia, reduced by everolimus and a simultaneous treatment with seven patients were found to have a retained common bile hGH resulted in considerably higher values (I: 134 ± 19, duct stone. Overall, there was no signifi cant difference in II: 85 ± 25, III: 114 ± 25 mmHg; p < 0,05 I vs. II; p = 0,09 histology among patients post-operatively.

110 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

I vs. III and II vs. III) Hydroxyproline concentration was Mo1877 signifi cantly increased by hGH compared to everolimus alone (I: 14,9 ± 2,5, II: 8,9 ± 3,6, III: 11,9 ± 2,8 μg/mg; p < Intra-Abdominal Adipose Tissue as a Major Source of 0,05 I vs. II/III and II vs. III). The number of MPO-positive IL-6 During Acute Experimental Colitis cells was reduced signifi cantly by hGH compared to evero- W.C. Mustain*1,2, Marlene E. Starr1,2, Daiki Okamura1,2, limus alone (I: 10 ± 1, II: 15 ± 3, III: 9 ± 2 n/sqmm; p < 0,05 B. Mark Evers1,2, Hiroshi Saito1,2 I vs II und II vs. III), while the number of PCNA-positive 1. Markey Cancer Center, University of Kentucky, Lexington, KY; cells were increased by hGH (I: 28 ± 3, II: 12 ± 3, III: 26 ± 2. Department of Surgery, University of Kentucky, Lexington, KY 12 /sqmm; p < 0,05 I vs. II und II vs. III). Corresponding INTRODUCTION: to these biochemical fi ndings, HE-histology revealed sig- Adipose tissue has been shown to pro- nifi cantly increased amount of granulation tissue in hGH- duce a number of infl ammatory cytokines and may play a treated animals. role in the development and progression of several infl ammatory diseases. Accumulation of intra-abdominal fat cor- CONCLUSION: The inhibitory effects of everolimus on relates more strongly with infl ammatory disease states than intestinal wound healing can be partially neutralized by does total body fat, suggesting depot-specifi c differences in simultaneous treatment with human growth hormone. the infl ammatory potential of adipose tissue. In infl amma- hGH-treatment addresses both the infl ammatory phase as tory bowel disease specifi cally, recent clinical studies sug- well as collagen deposition. gest that patients with increased intra-abdominal fat may suffer a more aggressive clinical course. Mo1876 OBJECTIVE: The purpose of the present study was to eval- Intestinal Permeability for Macromolecules Following uate the signifi cance of infl ammatory cytokine production by various adipose tissue depots during acute experimental Mechanical Ileus in Mice colitis. Xue Zhao, Till Macheroux, Michael S. Kasparek, Mario H. Mueller, METHODS: Colitis was induced in C57BL mice by addi- Martin E. Kreis* tion of 2% dextran sulfate sodium (DSS) to drinking water Surgery, University of Munich, Munich, Germany for 5 days. Mice were sacrifi ced at Day 3, 7, 14, and 21 INTRODUCTION: Acute mechanical ileus is a frequent following initiation of DSS treatment. Control mice were disorder seen in general surgery which—if untreated—ter- sacrifi ced prior to initiation of treatment. Plasma cytokine minates in peritonitis secondary bacterial translocation. levels at time of sacrifi ce were analyzed by multiplex assays. We aimed to investigate the time course of changes in gut Colonic tissue damage was evaluated histologically by H&E permeability during acute mechanical ileus for molecules staining. Tissue levels of cytokine mRNA were compared of different molecular weight. between the colon, 3 adipose tissue depots (mesenteric, epididymal, and subcutaneous), kidney, and liver by qRT-PCR. METHODS: C57Bl6 mice were anesthetized by isofl urane RESULTS: inhalation and gavaged with fl ourescein isothiocyanate Histologic evidence of colitis and signifi cantly conjugated dextrane (FITC-dextrane, 4.4 kDa) and horse- increased plasma IL-6 levels were evident by Day 7 and radish peroxidase (HRP, 40 kDa). After a minilaparotomy, peaked at Day 14. Changes in cytokine expression within the small intestine was ligated approximately 5 cm distal the colon occurred earlier, with signifi cant increases in to the ligament of Treitz, while controls received a mini- TNF-a, IL-1b, and IL-6 mRNA all evident by Day 3 (P = laparotomy only. Intestinal permeability was assessed in 0.016). Of the cytokines analyzed, IL-6 in the colon exhib- ileus animals or controls 3 and 9 hours later in different ited the most profound increase with colitis, with levels at subgroups (each n = 4). For this purpose blood was taken Day 7 increased 230-fold from baseline (P = 0.002). Anal- ysis of adipose tissues from this time point revealed that

by right ventricular puncture and serum concentrations of Poster Abstracts while IL-6 mRNA expression in mesenteric and epididy- FITC-dextrane and HRP determined by spectrophotometry. mal adipose tissue was signifi cantly increased compared

Data are mean ± SEM. Monday to controls, 8.6-fold (P = 0.016) and 3.8-fold (P = 0.004) RESULTS: At 3 hours after the beginning of mechanical respectively, no increase in subcutaneous adipose tissue ileus, the FITC-dextrane concentration was 187 ± 7.6 ng/ml IL-6 mRNA was observed. Multi-tissue analysis at this time in ileus animals and 147 ± 8.1 ng/ml in sham controls (p point revealed that mesenteric and epididymal adipose < 0.05), while it was 86 ± 8.9 and 62 ± 0.8 ng/ml at the tissue expressed signifi cantly more IL-6 mRNA than the 9 hour time point (p < 0.05). For the bigger molecule, HRP, kidney or the liver, whose levels of IL-6 did not increase concentrations at 3 hours were 5.6 ± 3.6 ng/ml in ileus ani- signifi cantly from baseline. mals and 4.1 ± 1.6 ng/ml in sham controls which was not CONCLUSIONS: This study demonstrates that intra- different. At 9 hours the serum concentrations were 23.0 ± abdominal adipose tissue is a major source of IL-6 during 4.3 ng/ml in ileus animals which was higher compared to acute experimental colitis. The time course analysis suggests 9.0 ± 3.1 ng/ml in sham controls (p < 0.05). that intra-abdominal fat may have a signifi cant impact on CONCLUSIONS: Intestinal permeability for macromol- plasma IL-6 levels. Unlike the mesentery, the epididymal ecules increases a few hours after acute mechanical ileus. fat pad is not contiguous with the infl amed bowel and It seems that soon after the beginning of mechanical does not contain the venous or lymphatic drainage of the ileus, intestinal permeability is increased for small-sized affected bowel. This suggests a tissue-specifi c response by molecules, while it takes a few hours more until it is also the intra-abdominal adipose tissue, rather than merely a increased for bigger sized molecules. local lymphoid reaction to tissue damage in the colon.

111 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Esophageal

Mo1879 EGFR in Gastroesophageal Refl ux Disease, Barrett’s Esophagus, and Esophageal Adenocarcinoma Guilherme Pretto*1,2, Richard R. Gurski1,2, Daniel Navarini1, Marcelo Binato1, Luise Meurer2, Laura Z. Costamilan2, Guilherme D. Mazzini2, Gabriela G. Costa1 1. Programa de Pós-Graduação em Cirurgia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; 2. Digestive Surgery, Hospital Figure 2: Immunohistochemical expression of EGFR in the three de Clínicas de Porto Alegre, Porto Alegre, Brazil groups assessed. INTRODUCTION: Gastroesophageal refl ux disease (GERD) CONCLUSIONS: GERD patients showed lower levels of is a common pathology with a wide range clinical and EGFR expression than patients with Barrett’s esophagus or endoscopic manifestations whose underlying mechanisms patients with adenocarcinoma of the esophagus, suggest- are not well understood. Epidermal growth factor receptor ing a direct relationship between EGFR expression and dis- (EGFR), found in the epithelium of the digestive tract, plays ease progression. an important role in epithelial repair and shows increased expression in a number of different neoplasms, including KEYWORDS: EGFR, GERD, adenocarcinoma, esophagus, esophageal tumors. Barrett’s esophagus. OBJECTIVES: To evaluate EGFR expression using immunohistochemistry in esophageal biopsies obtained from Basic: Pancreas patients with GERD, Barrett’s esophagus, and adenocarcinoma of the esophagus. Mo1880 METHODS: EGFR expression was immunohistochemically determined in biopsies from 194 patients with symptoms Effects of Intravenous Administration of Pentoxifylline suggestive of GERD or adenocarcinoma of the esophagus in Pancreatic Ischemia/Reperfusion Injury seen at two Brazilian university hospitals between Janu- Edmond R. Campion, ANA Maria M. Coelho*, Marcel C. ary 2003 and December 2008. Based on histopathological analysis, patients were divided into three groups: GERD, Machado, Sandra N. Sampietre, Nilza A. Molan, José Jukemura, Barrett’s esophagus and adenocarcinoma of the esophagus. Luiz C. D’Albuquerque EGFR expression was considered positive when staining Gastroenterology, University of São Paulo, São Paulo, Brazil was detected in the membrane. BACKGROUND/AIM: Therapeutics strategies to reduce pancreatic ischemic/reperfusion injury (I/R) might improve the outcome of human pancreatic-kidney transplantation. Pentoxifylline (PTX) beside its hemorrheologic effects has an anti-infl ammatory effect by inhibiting NF-kappaB activation. We have previously demonstrated that PTX had anti-infl ammatory response in acute pancreatitis and liver ischemia/reperfusion models. We have hypothesized that PTX could reduce pancreatic, renal lesions and the systemic infl ammatory response in pancreatic I/R injury. The aim of this study was to evaluate the effect of PTX administration in a rat model of pancreatic I/R injury METHODS: Pancreatic ischemia was performed in Wistar Figure 1: Esophageal biopsy from a patient with Barrett’s esophagus, rats during one hour by clamping the splenic vessels under positive for EGFR expression mechanical ventilation. The vascular clamp was removed RESULTS: Mean age was 55.25 years (30–90). Patients 1 hour after ischemia and pancreatic revascularization was with GERD (n = 127) accounted for 65.5% of the sample, achieved, followed by 4h or 24h of reperfusion. The ani- compared with 12.4% (n = 24) of patients with Barrett’s mals submitted to ischemic/reperfusion were randomly esophagus and 22.2% (n = 43) of patients with esophageal divided into 2 groups: Group C (n = 20): control, rats adenocarcinoma. Immunohistochemical analysis was posi- received saline solution IV, 45 minutes after ischemia, and tive for EGFR in 19.1% of the patients (37/194), divided Group P (n = 20): rats received PTX (25mg/Kg) IV, 45 min- as follows: 8.7% (11/127) in the GERD group, 25% (6/24) utes after ischemia. Four and twenty four hours after reper- in the Barrett’s esophagus group, and 46.5% (20/43) in fusion blood were collected for determinations of amylase, the esophageal adenocarcinoma group. Statistical analysis creatinine, TNF-α, IL-6, and IL-10. Pancreatic malondialde- revealed signifi cant differences between the three groups hyde (MDA) content was also performed. After 24 hours of (p = 0.0001). reperfusion pulmonary tissues were assembled for myeloperoxidade (MPO) analyses.

112 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: A signifi cant reduction in serum TNF-α, IL-6, that DCAMKL-1 mRNA levels in adjacent tissues are signifi - IL-10, and creatinine levels was observed in PTX group cantly higher than the respective tumor tissues. DCAMKL-1 compared to control group (p < 0.05). No differences in mRNA levels were higher in the adjacent tissues compared pancreatic MDA content and in serum amylase levels were to the respective tumor tissues of stage II (7-fold) and stage observed between two groups. Twenty-four hours after III (2.7-fold) patients. Furthermore, we observed increased ischemia it was not observed any signifi cant difference in DCAMKL-1 immunostaining in all stages of cancer com- the results of lung myeloperoxidase activity (MPO). pared to controls. Although there were no signifi cant differences between the stages, we observed increased stromal CONCLUSION: Pentoxifylline administration reduced the staining compared to the epithelium within the specimens. systemic infl ammatory response and renal dysfunction in CONCLUSION: pancreatic I/R injury and could be a useful tool in pancreas- These data suggest that DCAMKL-1 is increased in all stages of pancreatic cancer tissues. Addition- kidney transplantation ally, the higher DCAMKL-1 level in the tissue adjacent to the tumor may suggest a premalignant condition in this tissue. Mo1881 Furthermore, DCAMKL-1 is elevated in plasma of stage I and The Expression of Putative Pancreatic Stem Cell II patients, suggesting that it may potentially be used as a biomarker for the early detection of pancreatic cancer. Marker DCAMKL-1 Is Elevated in Early Stage Pancreatic Adenocarcinoma Patients Mo1882 Jeremy J. Johnson*1, Dongfeng Qu2, Sripathi M. Sureban2,3, Randal May2,3, Stanley Lightfoot5, Lewis A. Hassell5, DNA Methylation as a Biomarker System for Pancreatic Shubham Pant4, Russell G. Postier1,3, Courtney W. Houchen2,3 Adenocarcinoma 1. Surgery, The University of Oklahoma Health Sciences Center, Qi Huang*2, ADAM A. Golas2, Zhongmin Guo2, Kenneth P. Nephew2, Oklahoma City, OK; 2. Medicine/Gastroenterology, OUHSC, Oklahoma Michael G. House1,2 City, OK; 3. Veterans Affairs Medical Center, Oklahoma City, OK; 1. Surgery, Indiana University School of Medicine, Indianapolis, IN; 4. Medicine/Hematology and Oncology, The University of Oklahoma 2. Biology, Indiana University, Bloomington, IN Health Sciences Center, Oklahoma City, OK; 5. Pathology, The BACKGROUND: Reliable biomarkers to predict prognosis University of Oklahoma Health Sciences Center, Oklahoma City, OK are lacking for patients with pancreatic ductal adenocar- BACKGROUND: Pancreatic ductal adenocarcinoma carcinoma (PDAC) who are being considered for appropriate ries a grave prognosis with the majority of patients present- multimodality treatment. The aim of this study was to ing with locally advanced or metastatic disease. Patients investigate aberrant hypermethylation of a candidate set diagnosed with early stage pancreatic cancer are often of tumor suppressor genes as a potential cancer-specifi c candidates for surgical resection and have improved over- molecular marker system related to outcomes for patients all 5 year survival. Doublecortin and CaM kinase-like-1 with resected PDAC. (DCAMKL-1), a microtubule-associated kinase, is a putative METHODS: Isolated DNA samples from primary PDAC intestinal and pancreatic stem cell marker. We have previ- and individually matched adjacent normal tissue from 37 ously demonstrated that DCAMKL-1 is upregulated in mul- patients who underwent operative resection were analyzed. tiple cancers. The aims of this study are to determine the The methylation status of 6 gene promoters (RASSF1A, plasma expression level of DCAMKL-1 in pancreatic can- MGMT, GSTP1, APC, P16/CDKN2A, and NEFL) was deter- cer patients by stage, and to measure the tissue expression mined by quantitative methylation-specifi c PCR (QMSP). level of DCAMKL-1 in this patient population. Promoter site methylation levels were calculated and cor- METHODS: related with clinical, pathologic, and outcome factors.

Purifi ed plasma samples from controls (n = Poster Abstracts RESULTS: 10) and stage I (n = 9), II (n = 15), III (n = 14) and IV (n Hypermethylation of the neurofi lament light chain (NEFL) gene was signifi cantly higher in PDAC com- = 11) pancreatic cancer patients were subjected to West- Monday ern blot and ELISA analysis. Surgical cancer specimens and pared to matched adjacent normal tissue (p < 0.01). Pro- normal pancreas (commercial tissue array) were immunos- moter methylation levels of APC in PDAC correlated with tained for DCAMKL-1. An independent pathologist scored overall survival, HR = 1.004 (95% CI, 1.001–1.007), and the immunohistochemical staining based on intensity and APC gene hypermethylation in matched normal tissue was tissue involvement. Samples of tumor and adjacent normal associated with death within one year after resection (OR tissue from pancreatic surgical specimens were homoge- 0.073; 95% CI, 0.007–0.724). Promoter methylation of APC nized. Total RNA isolated from these samples was subjected in host normal tissue along with APC methylation levels of primary tumors and surgical resection margin status can to real-time PCR to measure mRNA expression levels. be used to evaluate the risk of death within one year after RESULTS: We observed greater than a 2.5-fold increase resection with a predictive accuracy of 87%. in plasma DCAMKL-1 in patients with stage I pancreatic CONCLUSION: Hypermethylation of the promoter region cancer compared to controls by Western blot analysis (p < of candidate tumor suppressor genes in patients with pan- 0.05). We also observed increased DCAMKL-1 expression creatic adenocarcinoma treated by operative resection is by ELISA: stage I (3.42-fold, p = 0.07); II (4.1-fold, p < 0.05); associated with early recurrence and death. Larger scale III (2.06-fold, p > 0.05) and IV (1.15-fold, p > 0.05). There studies will be necessary to validate patterns of gene meth- were similar DCAMKL-1 mRNA expression levels in both ylation as a potential cancer-specifi c molecular marker sys- stage II and III tumor tissues (n = 8). Interestingly, we found tem related to outcomes for pancreatic cancer.

113 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Basic: Small Bowel were observed, these changes appear not to be specifi c for POI, as they occurred also in SC, without delayed intestinal transit or infl ammation. However, these postoperative Mo1884 changes in α-adrenergic neurotransmission might still par- Changes in Neurotransmission via α1- and ticipate in disturbances of postoperative bowel function. DFG KA2329/5–1 α2-Receptors During Postoperative Ileus in Rat Bernhard Stoklas*, Brigitte Goetz, Petra Benhaqi, Martin E. Kreis, Michael S. Kasparek Basic: Stomach Department of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany Mo1885 BACKGROUND: The role of α-receptors in control of intestinal motility is poorly understood. We aimed to Intratumoral Epcam Expression in Gastric Cancer: A α α Potential Prognostic Marker and Therapeutic Target study the mechanism of action of 1- and 2-agonists and to investigate changes in α-adrenergic neurotransmission Daniel Vallbohmer*1, Agnieszka Dulian1, Feride KröPil1, potentially participating in pathophysiology of POI. Andreas Krieg1, Stephan E. Baldus2, Wolfram T. Knoefel1, 1 METHODS: Circular, jejunal muscle strips (n = 8/rat) were Nikolas H. Stoecklein obtained from male Sprague Dawley rats (n = 6/group). 1. Department of General, Visceral and Paediatric Surgery, University Groups: Naïve controls (NC), sham controls 12h and 3d of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology, after laparotomy to study combined effects of anesthesia University of Dusseldorf, Dusseldorf, Germany and laparotomy (SC12h, SC3d), and rats 12h and 3d after INTRODUCTION: Intratumoral expression of the epithe- laparotomy and small bowel manipulation (P12h, P3d) to lial cellular adhesion molecule (EpCAM) is of great prog- induce POI. Dose-dependent effects of α -agonist phenyl- 1 nostic impact in various malignant tumors. However, less –8 –5 α –8 ephrine (10 –10 M) and 2-agonist clonidine (3 × 10 –3 –5 data about its role in gastric cancer is available. Therefore, × 10 M) without and with TTX (blocking enteric nerves; we investigated the expression patterns of EpCAM in this 10–6M), L-NIL (blocking inducible nitric oxide-synthase; –5 malignancy and its prognostic impact on gastric cancer 3 × 10 M) and nimesulide (blocking cyclooxygenase-2; patients undergoing primary surgical therapy. 10–5M), or α-receptor antagonist phentolamine (10–5M) were studied. Intestinal transit was studied by charcoal PATIENTS AND METHODS: The intratumoral protein gavage ([%] small bowel passed by marker). Histology in expression of EpCAM was assessed in 163 gastric cancer whole mounts was performed for myeloperoxidase positive patients undergoing primary surgical therapy (61 diffuse-, cells (MPO), macrophages, and mastcells (cells/mm2). Data: 62 intestinal-, 32 mixed-type and 8 unclassifi ed tumors) by mean ± SEM. immunohistochemistry, using the monoclonal antibody RESULTS: Ber-EP4. Intensity of staining was classifi ed according the Phenylephrine and clonidine caused dose- HercepTest-Score as a standardized scoring system. After- dependent inhibition in all groups (p < 0.05). Phenyleph- wards intratumoral EpCAM expression patterns were cor- rine-induced inhibition was increased only in SC3d (p < related with clinicopathologic parameters including overall 0.05 vs NC). TTX reduced phenylephrine-induced inhibi- survival. tion in NC, P3d, and SC3d (all p < 0.05 vs without TTX), while L-NIL and nimesulide had no effect on phenyleph- RESULTS: EpCAM expression was observed in 77% of the rine-induced inhibition (p = NS vs without L-NIL and tumors. Of these, 58% (n = 74) presented a homogeneous nimesulide). Clonidine-induced inhibition was reduced in intratumoral EpCAM expression while 42% presented a dif- P3d and SC12h (p < 0.05 vs NC). TTX reduced clonidine- ference between the centre and invasion front of the tumor. induced inhibition in NC while it increased the clonidine- Interestingly, tumors with high EpCAM expression in the effect in P3d (both p < 0.05 vs without TTX). L-NIL and invasion front were associated with a signifi cantly higher nimesulide reduced clonidine-induced inhibition in P12h, proportion of lymph node metastases and lower median SC12h, and SC3d (all p < 0.05 vs without L-NIL and nime- overall survival (p = 0.03; p = 0.001). This observation was sulide). Phentolamine prevented phenylephrine- and signifi cantly (p = 0.04) higher in diffuse type of gastric can- clonidine-induced inhibition in all groups (all p < 0.05). cers compared to the intestinal type. Multivariate survival Intestinal transit was delayed only in P12h (P12h 28 ± 3; analysis identifi ed high EpCAM expression in the invasion NC 54 ± 2%; p < 0.05 vs NC). MPO positive cells and mast front as an independent prognostic factor (Cox-Regression cells were increased in P12h and P3d, but not in sham con- analysis). trols (MPO: NC 12 ± 2; P12h 908 ± 125; P3d 828 ± 84; mast- CONCLUSION: Intratumoral EpCAM expression in the cells: NC 19 ± 4; P12h 639 ± 174; P3d 1137 ± 225; all p < invasion front was associated with a signifi cant decrease in 0.05 vs NC). Macrophages were elevated in only P3d (NC overall survival of patients with gastric cancer. Considering 369 ± 30; P3d 1274 ± 237; p < 0.05 vs NC). the discontenting results of the current neoadjuvant/adju- CONCLUSION: We demonstrated that contractile activity vant concepts for gastric cancer patients, EpCAM might α α provide a promising target for a neoadjuvant/adjuvant can be inhibited via 1- and 2-receptors and that this effect is in parted mediated via enteric nerves. Although postop- immunotherapy. α α erative changes in 1- and 2-adrenergic neurotransmission

114 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Clinical: Biliary Blood loss in patients with LT was signifi cantly more than in those with LH (2100ml versus 1300ml; P = 0.017). The incidence of Grade IIIa complication in patients with LT was Mo1455 signifi cant higher than RH and LH (P = 0.044 and P = 0.014), but Grade IIIb and IV complication did not occur in patients Extended Left Hepatic Trisectionectomy as a with LT. Overall 5-year survival rate was 40% with median Feasible Surgical Procedure for Advanced Perihilar survival of 45.8 years. There was no signifi cant difference in Cholangiocarcinoma survival in patients between LT and other two procedures. Minoru Esaki*1, Kazuaki Shimada1, Seiji Oguro1, Yoji Kishi1, CONCLUSIONS: LT for perihilar cholangiocarcinoma Satoshi Nara1, Tomoo Kosuge1, Yoshihiro Sakamoto2, is feasible and can provide a comparable prognosis for 3 advanced perihilar cholangiocarcinoma originating from Tsuyoshi Sano left hepatic duct or segment 4 especially extending to the 1. Hepato-biliary pancreatic surgery, National Cancer Center Hospital, root of the right anterior portal pedicle or confl uence of the Tokyo, Japan; 2. Hepato-Biliary-Pancreatic Surgery Division, Graduate anterior and posterior branch of the bile duct. School of Medicine, University of Tokyo, Tokyo, Japan; 3. Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan Mo1456 OBJECTIVES: The aim of this study was to clarify the Audit of the Use of Critical View of Safety and short and long term outcome of extended left hepatic trisectionectomy (LT) for perihilar cholangiocarcinoma. Infundibular Cystic Technique in Cystic Duct Identifi cation in Laparoscopic Cholecystectomy METHODS: Patients with perihilar cholangiocarcinoma who Anokha Oomman*1,2, Ashraf M. Rasheed2, Karthic Rajaram2, underwent LT between January 2000 and October 2010 for 2 perihilar cholangiocarcinoma were analyzed retrospectively. Krithika Murugan Operative variables, mortality, morbidity, recurrence sites and 1. Withybush General Hospital, Haverfordwest, United Kingdom; survival of three groups were compared among LT, right hemi- 2. Gwent Institute of Minimal Access Surgery, Royal Gwent Hospital, hepatectomy (RH) and left hemihepatectomy (LH). Newport, United Kingdom RESULTS: A total 203 patients underwent surgical resec- INTRODUCTION: The commonest cause of bile duct tion for perihilar cholangiocarcinoma, 22 (11%) of whom injury (BDI) during laparoscopic cholecystectomy (LC) is underwent LT, 79 (39%) underwent RH, and 84 (41%) the confusion of bile duct with cystic duct. Operation notes underwent LH. No mortality occurred, but 17 patients had must include the anatomical rationale by which the cystic morbidity. Operative time and blood loss were 655 ± 142 duct was conclusively identifi ed. minutes and 2100 ± 1080 ml, respectively. AIM: To examine the quality of documentation and the terms used to describe the method/methods utilised to identify the cystic duct during laparoscopic cholecystectomy. METHOD: The documentation of the method/s used for cystic duct identifi cation was examined in 322 consecutive non-converted LCs that were carried out between the months of August 2010 and January 2011. Non-pro- tocolised operation notes were studied and stratifi ed into different groups according to the descriptive terms used. The strata included: 1). No documentation of the method used, 2). Calot’s triangle was dissected or demonstrated, 3)

Infundibular or infundibulo-cystic technique used, 4). Crit- Poster Abstracts ical view of safety (CVS) demonstrated, 5) Intra-operative

cholangiogram used, or 6) Other methods. Monday RESULTS: Demonstration of the critical view of safety was documented in (4/310) 1.3% of the cases. Infundibular or infundibulo-cystic technique was used to defi ne the cystic duct in (9/310) 3.4% of the notes. Calot’s triangle was mentioned in (255/310) 82.3% of the notes. In (43/310) 13.9% of cases, the cystic artery and duct were mentioned without any reference to critical view of safety, infundibular/ infundibulo-cystic technique or Calot’s triangle. CONCLUSION: Written documentation of the method of cystic duct identifi cation in the operation notes during LC is sub-optimal. We, hence recommend standardization of the cholecystectomy operative report, inclusion of a video clip and/or photo image using digital information and communication in medicine (DICOM) to complement the textual operation notes and move towards structured computerised input that links to the picture archiving and communication system (PACS).

115 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1457 CONCLUSION: Complications, particularly stent occlusion, occur frequently after PBD in patients scheduled to Self-Expandable Metallic Stents Do Not Impact undergo PD for malignancy. Compared to PS, SEMS do not on the Frequency of Complications Related to impact on the incidence of major postoperative compli- Preoperative Biliary Drainage or Subsequent cations and may be cost-effective as fi rst-line endobiliary Pancreatoduodenectomy drainage given the high incidence of early stent occlusion with PS. Wesley D. Leung*1, Gregory A. Cote1, Damien M. Tan1, Joshua A. Waters2, C. Max Schmidt2, Stuart Sherman1, Glen A. Lehman1, Evan L. Fogel1, James L. Watkins1, Lee Mchenry1, Mo1458 Michael G. House2 The Infl uence of Analgesia, Antiemetics and Operative 1. Gastroenterology, Indiana University, Indianapolis, IN; 2. Surgery, Factors on Admission Following Cholecystectomy: A Indiana University School of Medicine, Indianapolis, IN Retrospective Review BACKGROUND: Preoperative endobiliary drainage (PBD) Mark Bignell*, Anna Bayston, David Nunn, Michael P. Lewis is commonly performed in patients with malignant General Surgery, Norfolk and Norwich university Hospital, Norwich, obstruction for whom operative resection is eventually United Kingdom planned. The aim of this study was to compare the safety INTRODUCTION: of pancreatoduodenectomy (PD) following PBD with self- Laparoscopic cholecystectomy is the expandable metallic stents (SEMS) versus standard plastic most commonly performed elective abdominal operation stents (PS). and can be performed as a day case procedure. However day case rates in the UK vary widely between hospitals with METHODS: We conducted a single center, retrospective fi gures ranging from 6.4% to 50% with higher performing cohort study of patients undergoing PBD followed by PD for centres feeling rates up to 70% are achievable. The reasons periampullary cancer between January 1998 and December for such disparity between hospitals is multifactorial and 2009. Patients were excluded if PBD was solely performed therefore a retrospective review was undertaken to deter- at a different facility because details regarding PBD com- mine if any perioperative factors infl uenced length of stay. plications and stent type were unavailable. To determine METHODS: the potential impact of SEMS on PBD and postoperative 100 patients (50 day case and 50 overnight outcomes, we compare patient characteristics as well as stay) who underwent elective laparoscopic cholecystec- PBD and postoperative complications between groups. If tomy were subjected to a medical note review. Information patients had more than one PBD procedure, we present on operative time, duration, surgeon, anaesthetist, patient complications during 1) any PBD and 2) the last PBD pro- demographics and perioperative medication such as the cedure. SEMS were routine placed at least 1 cm from the use of opiates and antiemetics were collected. Statistical hepatic bifurcation. Variables are presented as simple pro- analysis was undertaken using a Fishers’ exact test. portions or medians, with two-way statistical comparisons RESULTS: The mean age in the day case group was 48 (Fisher’s exact or Mann-Whitney-U test). years compared to 55 years in the overnight group (NS). RESULTS: We identifi ed 147 patients who underwent PBD There were 12 males in the day case group compared to 13 and then PD at our center, 17 (12%) of who underwent in the overnight group. The mean ASA was 2 in both groups placement of a fully covered (10) or uncovered (7) SEMS. (range 1–2 in each group). 80% (n = 40) of day case patients Among PS patients, 74% had a 10Fr PS placed during their had an anaesthetic start time before 12pm compared to fi nal PBD. In all patients, 29% had previously undergone 48% (n = 24) in the overnight group (p = 0.0016). Intra- 1 (25%) or 2 (4%) PBDs with PS. Neoadjuvant therapy operative morphine was used in 40% (n = 20) of day case was used in 8.0% of PBD and 17.6% of SEMS patients (p patients compared to 68% (n = 34) of overnight patients (p = 0.20). Including previous PBD attempts, patients had at = 0.0088) whilst this use changed to 6% (n = 3) and 26% least one failed PBD (17%) or other complication (18%) (n = 13) respectively in recovery (p = 0.0122). The use of including early stent occlusion (n = 22), pancreatitis (n = 1) fentanyl was not statistically signifi cant between the two and perforation (n = 1). Complications specifi c to the last groups intraoperatively or in recovery (88% versus 86% PBD were similar (5.9% v. 7.1%, p = 0.85) in SEMS and PS intraoperatively and 52% versus 60% in recovery). Dexa- patients, with no cases of early stent occlusion in the SEMS methasone was used in 92% (n = 46) of day case patients group. The median number of PBD procedures was signifi - intraoperatively compared to 70% (n = 35) in the overnight cantly greater in SEMS v. PS, 2 v. 1, p < 0.001; no SEMS cases group (p = 0.0095). The use of ondansetron was not signifi - required repeat PBD. cantly different between the two groups. CONCLUSION: The median time from last PBD to surgery was longer in Anaesthetic start time and the use of fen- SEMS v. PS patients, 31 v. 18 days, p = 0.004. Postoperative tanyl and dexamethasone are associated with a shorter stay complications Clavien grade ≥3 occurred in 22% of SEMS in hospital whilst the use of morphine either intraopera- versus 11% of PS patients, p = 0.37. Infection-specifi c com- tively or in recovery leads to a longer length of stay follow- plications after PD were similar in the SEMS (11.1%) and PS ing elective laparoscopic cholecystectomy. groups, 26.8%, p = 0.31. Perioperative cholangitis occurred in one SEMS patient while one postoperative bile leak was recorded in the PS group. Median postoperative length of stay was similar in SEMS and PS patients, 8.5 v. 8.0 days; p = 0.87.

116 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1459 pulmonary embolism, ventilator dependence more than 48 hours, progressive or acute renal insuffi ciency, and sep- Perioperative Outcomes of Patients Undergoing sis or septic shock. Overall morbidity was defi ned as hav- Laparoscopic Cholecystectomy: The Critical Impact ing documentation of a serious morbidity or at least one of Age and Operative Status of the following complications: superfi cial SSI, deep SSI, Sajida Ahad, Ibrahim B. Cetindag, Stephen Markwell, pneumonia, unplanned intubation (without preoperative ventilator dependence), urinary tract infection, peripheral Imran Hassan* neurological defi cit and deep vein thrombosis. Preopera- SIU School of Medicine, Springfi eld, IL tive variables including patient characteristics and co-mor- INTRODUCTION: We evaluated the perioperative out- bidities and postoperative outcomes were compared by age comes of patients undergoing elective and emergency lapa- groups (<80 vs. >80 years) and operation status (elective vs. roscopic cholecystectomy (LC) who were <80 and >80 years emergency). Multiple logistic regression was used to assess of age. the infl uence of age and operation status on outcomes after PATIENTS AND METHODS: Patients undergoing LC accounting for available covariates. for benign disease between 2005 and 2010 were identifi ed RESULTS: During the study period 91,034 patients under- from the ACS-NSQIP participant use fi le (PUF) utilizing the went LC, which represented 90% of patients undergoing a current procedural terminology (CPT) codes for LC with LC in the database. Patients older than 80 years were likely and without intraoperative cholangiogram. Patients under- to have more preoperative comorbidities and worse periop- going any other procedure except a LC as identifi ed by the erative outcomes, however the outcomes were much worse CPT codes were excluded. A procedure was considered an when they underwent emergency surgery. These unad- emergency if so designated by the surgeon or anesthesiolo- justed comparisons persisted in the multivariable analysis. gist or if surgery was performed no later than 12 hours after Male gender and presence of medical comorbidities were the patient was admitted to the hospital or after the onset also independently associated with worse perioperative of related preoperative symptoms. Outcome measures ana- outcomes. (Table) lyzed included 30-day mortality, return to operating room, CONCLUSIONS: Patients older than 80 years of age have serious morbidity and overall morbidity. Serious morbidity more medical comorbidities and worse perioperative out- was defi ned as having documentation of one of the follow- comes, particularly if they undergo emergency LC. These ing complications: organ space surgical site infection (SSI), patients represent a high risk group and therefore in emer- wound dehiscence, neurologic event (cerebrovascular acci- gency situations, a non operative approach should be ini- dent or coma lasting more than 24 hours) cardiac arrest, tially considered if feasible. myocardial infarction, bleeding requiring transfusion of more than 4 units of packed red cells or whole blood,

Elective LC Emergency LC ≤80 Years (n = 79,641) >80 Years (n = 3,277) ≤80 Years (n = 7,679) >80 Years (n = 437) Bivariate Comparisions* 30-day mortality 0.1 1.7 0.4 5.3 Serious morbidity 0.9 4 2 10 Overall morbidity 2.5 7 4 14

Return to OR 1 1.6 1.2 2.8 Poster Abstracts Male Gender 25 40 31 45 Monday Diabetic 10 18 10 19 Pulmonary disease 7 20 5 19 Independent functional status 98 85 96 75 30-Day Mortality Serious Morbidity Overall Morbidity Return to OR Logistic regression** Emergency vs. elective 2.3 (1.6–3.2) 2 (1.6–2.2) 1.6 (1.4–1.7) 1.3 (1.0–1.6) >80 vs.≤80 2.7 (2.0–3.7) 1.3 (1.1–1.6) 1.3 (1.2–1.5) NS Male vs. female NS 1.5 (1.4–1.7) 1.1 (1.0–1.2) 1.3 (1.1–1.5) Diabetes vs. No diabetes NS 1.3 (1.2–1.5) 1.3 (1.2–1.5) 1.2 (1–1.5) Pulmonary disease vs. No pulmonary disease 2.3 (1.7–1.9) 1.6 (1.4–1.9) 1.5 (1.3–1.6) NS Cardiac disease vs. No cardiac disease 1.4 (1.0–1.9) NS NS 1.3 (1.1–1.6) * All values are expressed in percentage. ** Odds ratio (95% conﬁ dence interval) NS = Not Signiﬁ cant

117 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1460 results and the importance of early surgical intervention for improved outcomes in patients with cholecystitis, espe- Is HIDA Scan Necessary for Sonographically Suspicious cially when focusing on effi cient resource utilization, it Cholecystitis? would be advisable to proceed to cholecystectomy imme- Irina Bernescu*, Tomer Davidov diately following positive ultrasound fi ndings without the Surgery, Robert Wood Johnson UMDNJ, New Brunswick, NJ delay or expense of a confi rmatory HIDA scan. INTRODUCTION: Gallbladder disease is a common and escalating problem, particularly in the United States and Mo1461 other developed countries, where a variety of modifi able Costs Associated with Delayed Cholecystectomy After a factors (including diet, alcohol consumption, and activity Biliary Migration level) come into play. It is estimated that 20–25 million * Americans have gallstones, representing 10–15% of the Charles MéNard , René-Paul Beauchamp adult population. Of these, approximately 20% become Gastro-Enterology, Sherbrooke, Sherbrooke, QC, Canada symptomatic at some point, causing cholecystitis to account Biliary migration treated with ERCP alone carries an for 3–9% of hospital admissions for acute abdominal pain, increased risk ok recurrent biliary event compared to cho- with 1–3% requiring removal of the gallbladder. The pro- lecystectomy. It is our impression that delayed gallbladder gressively increasing prevalence of gallbladder disease rep- removal also imposes additionnal costs to healthcare. resents a major health burden, with direct plus indirect Charts from1600 patients with a primary diagnosis of costs of approximately $6.2 billion annually in the United biliary migration, cholangitis, biliary pancreatitis or gall- States. In this context, the timely and effi cient diagnosis stone-related obstructive jaundice event between 1994 and of cholecystitis is of paramount importance, as length of 2008 in a single community-based teaching hospital were hospital stay and multiple diagnostic tests for each patient reviewed. Minor aged patients, one-day elective surgery at are major contributors to the cost of treating gallbladder the fi rst diagnosis of a biliary event and excessive lenght of disease. Currently, abdominal ultrasound is the study of stay were excluded.The costs of hospital care was calculated choice for diagnosing cholelithiasis, while HIDA scan is the using consultation fees, procedure costs, hospital stay and study of choice for diagnosing cholecystitis. However, our clinical support related costs. Totals costs related to the bili- study had the goal of determining whether patients with ary event when the cholecystectomy was performed at the suspected cholecystitis on ultrasound benefi tted from sub- initial event were compared to the total health care costs of sequently having a HIDA scan to clarify diagnosis. postponed cholecystectomy. METHODS: We retrospectively reviewed patients evalu- Surprisingly, biliary event-related costs of initial chole- ated for presumed cholecystitis between 2007 and 2010, cystectomy ($CAN 15 531.53) was slightly higher (but through the Emergency Department of our 600-bed aca- non-signifi cantly) than later cholecystectomy ($CAN 14 demic medical center. We identifi ed 154 patients who 822,70), even when readmission and ERCP occured inbe- underwent abdominal ultrasound and HIDA scan, and pro- tween for recurrent biliary complication. This unsuspected ceeded to cholecystectomy on the same admission. Ultra- twist may be driven by the longer lenght of stay during sound results were compared to those of HIDA scan. The the initial event caused by delays related to imaging, ERCP pathology fi ndings of the cholecystectomy were used as and other tests done before the surgery. It is possible that the gold standard for the diagnosis of cholecystitis. in a different health care setting where procedural costs are RESULTS: Statistical analysis revealed that abdominal much higher, the economic weight of late cholecystectomy ultrasound had 47% sensitivity for cholecystitis, with a would have leaned if favor of faster access to surgery. positive predictive value of 96%. HIDA scan had a sensitiv- Readmission for new biliary complication occured signif- ity of 62% for cholecystitis, with a positive predictive value icantly more often during the lenght of the study when of 96%. cholecystectomy was delayed (17%) compared with initial CONCLUSIONS: Our study confi rmed previous fi ndings cholecystectomy (7.5%), imposing unnecessary incon- related to the superior sensitivity of HIDA scan in diag- venience to patients and increased technical and human nosing cholecystitis. However, we also showed that both burden to the health care system. Late cholecystectomy ultrasound and HIDA scan have a positive predictive value does not seem to impose additionnal costs over fi rst epi- of 96%, suggesting that a HIDA scan would not provide sode cholecystectomy in Quebec health care system but is additional diagnostic benefi t in a patient with sonographic associated with increased admission for relapsing biliary fi ndings consistent with cholecystitis. Based on these events.

118 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Clinical: Colon-Rectal Mo1464 Impact of Operative Duration on Postoperative Mo1462 Pulmonary Complications Among Patients Undergoing Complex Gastrointestinal Procedures Colostomy vs. Ileostomy: An ACS-NSQIP Evaluation Rachel M. Owen*, Sebastian D. Perez, John F. Sweeney of Complications from Diverting Stoma Reversal Surgery, Emory University, Atlanta, GA Dhruvil R. Shah*1, Yueju LI2, Laurel Beckett2, David Wisner1, BACKGROUND: Steve R. Martinez1, Vijay P. Khatri1 Postoperative pulmonary complications (PPC) are associated with higher healthcare costs, pro- 1. Surgery, University of California Davis, Sacramento, CA; longed hospital stays, and increased morbidity and mortal- 2. Public Health Sciences, University of California, Davis, CA ity than that of other postoperative complications. Many BACKGROUND: The optimal method of fecal diversion studies have demonstrated that prolonged operative dura- remains controversial as either colostomy or ileostomy may tion is associated with increased postoperative morbidity be suffi cient. Perioperative outcomes associated with sub- and mortality. To our knowledge, the direct impact of oper- sequent stoma reversal may inform the decision of which ative duration on PPCs has not been specifi cally analyzed. diversion method to use. Our aim was to evaluate periop- We hypothesize that longer operative times are indepen- erative morbidity and mortality associated with colostomy dently associated with an increased risk of PPCs in patients and ileostomy reversal. undergoing complex gastrointestinal procedures. METHODS: The American College of Surgeons National METHODS: We queried American College of Surgeons Surgical Quality Improvement Program database was que- National Surgical Quality Improvement Program 2009 Par- ried for all patients who underwent diverting stoma rever- ticipant User File for patients who underwent elective open sal between 2005 and 2008. Patients were excluded if the colectomy, hepatectomy, or pancreatectomy. For this study, type of stoma reversal could not be ascertained via CPT or PPC was defi ned as pneumonia, prolonged mechanical ICD-9 code. Outcomes evaluated included overall morbid- ventilation greater than 48 hours, and unplanned reintu- ity (≥1 serious complication), mortality, wound infections, bation. Patients both with and without PPCs were evalu- and total surgical length of stay. Multivariate analysis iden- ated for operative duration, length of hospital stay, and tifi ed patient- and procedure-related risk factors associated 30-day mortality. The impact of operative duration on the with each outcome. We reported adjusted odds ratios (aOR) risk of PPC was evaluated using logistic regression models and 95% confi dence intervals (95% CI). with PPC occurrence as an outcome and operative time (in RESULTS: A total of 5190 patients met inclusion criteria. hours) as the predictor. A model was also run controlling There were 2188 colostomy reversals and 3002 ileostomy for preoperative functional status and American Society of reversals. The colostomy reversal group had a signifi cantly Anesthesiologist (ASA) class to account for differences in higher median operative time (151 min vs. 75 min, p < preoperative patient acuity. 0.01). The number of contaminated and dirty wounds was RESULTS: 8620 cases (5523 colectomies, 915 hepatec- similar between both types of stoma reversal (49% vs. 49). tomies, and 2182 pancreatectomies) were reviewed. 456 There was no signifi cant difference in mortality, median patients (5.3%) experienced at least one PPC. For operations surgical length of stay, or re-operation rates. On multivari- less than 480 minutes, each 60-minute increase in opera- ate analysis, the following preoperative factors were signifi - tive time was associated with a 13% increased risk of PPC cant predictors of postoperative morbidity: Cr >2.0 (aOR (OR 1.133; 95% CI, 1.077–1.192). For operations exceed- 1.99, 95% CI :1.33–2.93), WBC between 10–20 (aOR 1.44, ing 480 minutes, each additional 60 minutes of operative

95% CI:1.13–1.81), moderate exertional dyspnea (aOR time beyond 8 hours was associated with a 30% increased Poster Abstracts 1.94, 95% CI: 1.47–2.53), and ASA status greater than 3 risk of PPC (OR 1.296; 95% CI, 1.143–1.470). Controlling

(aOR 1.79, 95% CI:1.53–2.10). Colostomy reversal was also for differences in operative procedures did not affect regres- Monday associated with higher odds of overall morbidity (aOR 1.28, sion modeling. Thirty-day mortality occurred in 54 (0.7%) 95% CI:1.08–1.50) and wound infections (aOR 1.70, 95% patients without PPC, whereas 72 patients (15.7%) with CI :1.39–2.07). one or more PPC died postoperatively. Overall, patients CONCLUSION: Colostomy reversal is associated with with one or more PPC were 28 times more likely to die than increased overall morbidity, wound infections, and nearly those who did not have a PPC (OR 28.3, p < 0.0001). The twice the operative time compared to ileostomy reversal. average length of stay for patients with at least one PPC was These factors should be considered when deciding which nearly three times as long as those without PPCs (20.08 vs. type of diverting stoma to perform. 7.43 days, respectively; p < 0.0001). CONCLUSIONS: Operative duration is independently associated with increased risk of PPC in patients undergoing complex gastrointestinal procedures, thus indirectly leading to increased postoperative mortality and longer hospital stays.

119 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1465 Mo1466 Microlaparoscopic Colectomy: Initial Experience Longer LOS Yet Similar Return of BM for Hand-Assisted Christopher Foglia*, Stuart L. Blackwood, Pierre F. Saldinger (vs. Laparoscopic) Colorectal Resection Patients Who Surgery, Danbury Hospital, Danbury, CT Had a Higher BMI and Risk Profi le INTRODUCTION: There has been a recent trend toward Samer Naffouje*1, Sonali A. Herath1, M.C. Shantha Kumara H1, decreasing surgical invasiveness by minimizing incision Xiaohong Yan1, Joon Ho Jang1, Linda Njoh1, Elizabeth Myers1, size using single incision laparoscopic surgery. The tech- Tromp Wouter1, Vesna Cekic1, Daniel L. Feingold2, nique and tools for performing this type of surgery are Richard L. Whelan1,2 completely different from conventional laparoscopic sur- 1. Department of Surgery, St. Luke’s Roosevelt Hospital Center, New gery thus generating a steep learning curve and increased York, NY; 2. Department of Surgery, Columbia University College of operative time. We have explored the use of microlaparos- Physicians and Surgeons, New York, NY copy in colon surgery to minimize the trauma of surgery without the need for learning an entirely new skill set. INTRODUCTION: Most minimally invasive surgery (MIS) surgeons utilize Laparoscopic Assisted (LA) or Hand- METHODS: A retrospective review of all microlaparo- Assisted (HA) colorectal resection methods; the majority do scopic segmental colectomies performed by a single sur- not use both methods. This review of the experience of a geon over a 28 month period at a teaching hospital was group of MIS surgeons who embrace both methods selec- conducted. Microlaparoscopic surgery was defi ned as the tively for sigmoid resection (SR) was begun in an attempt use of 3 mm trocars in addition to a 12 mm Hasson umbili- to identify factor(s) that infl uence the choice of surgical cal incision, which was later widened for specimen extrac- method. It was believed that the selective use of LA and tion. Cases were excluded if the decision to use either a HA methods would allow more cases to be done using MIS GelPort, or standard laparoscopic instruments was made at methods. the outset of the case. METHODS: A retrospective review of SR data from 2 insti- RESULTS: 38 patients underwent microlaparoscopic col- tutions over a 10 year period was carried out. Demographic ectomy for cancer (n = 14), polyps (n = 7), diverticulitis data as well as comorbidities, indications, operative data, (n = 14), Crohn’s disease (n = 2) and volvulus (n = 1). Six and short term results were reviewed. patients (16%) required conversion: 2 to limited laparotomy, 3 to a hand assisted approach through an 8 cm pfan- RESULTS: A total of 536 SR patients (pts) were identi- nenstiel incision, and 1 where a 3 mm port was upsized to fi ed, the methods used were: LA, 286 pts (53.4%); HA, 172 12 mm. Reasons for conversion included: diffi cult visual- (32.1%); and Open (OP), 78 (14.5%). SR indications were ization, inadvertent colotomy, excessive visceral fat, adhe- cancer in 206 pts (38.4%) and benign problems (diverticu- sions, inadequate reach of 3 mm instruments, need for litis, polyps, IBD, etc) in 330 pts (61.6%). The HA group’s use of a right lower quadrant GIA stapler, and one positive mean BMI (29.04 ± 6.18) was signifi cantly greater than the intra-op leak test. In patients who had resection for cancer, mean BMI of the LA (25.85 ± 5.35) and OP (25.88 ± 5.53) average lymph node harvest was 25 (range 14–70 nodes). groups (p < 0.0001 for both comparisons). In regards to Patients who were completed with microlaparoscopic tech- benign SR’s, the HA group had signifi cantly more high risk nique had an average extraction incision length of 3.8 cm patients (HRP) than the LA group but signifi cantly fewer (range 3.0–6.5 cm) and on average two additional 3 mm HRP’s than the OP group (Charlson Comorbidity Index). port sites. Right colon resections had on average a shorter In the cancer pts there was a trend toward more HRP’s in operative time (181 minutes) when compared to left colon the HA vs. the LA group (p = 0.074). Notably more OP pts resections (253 minutes). Median length of stay was 4 days required transfusions (34.6%) than LA (8.3%) or HA (7%) (range 3–13 days). 5 patients experienced a total of 10 post pts (p < 0.0001 for both). The mean incision lengths (IL) operative complications. These included CDiff, AFib, CHF, were: LA, 6.59 ± 4.18 cm; HA, 9.82 ± 3.57 cm; and OP, 19.35 pneumonia, acute renal insuffi ciency, respiratory failure, ± 5.94 cm (p < 0.05 for all). The mean time to fi rst fl atus (FL) DVT, wound infection, GI bleed, recurrence of colovesical and mean time to fi rst bowel movement (BM) were signifi - fi stula, and one anastomotic leak 2 weeks postoperatively cantly shorter for the LA (FL, 2.60 days; BM, 3.09 days) and that was managed non-operatively. Thirty day mortality HA groups (FL, 2.70 days; BM, 3.30 days) when compared rate was 0/38 to the OP group’s results (FL, 3.76 days; BM, 4.11 days). The HA mean length of stay (LOS) of 7.12 ± 5.0 days was longer CONCLUSION: Microlaparoscopic colectomy is safe and than for the LA pts (6.14 ± 3.8 days; p = 0.03) yet shorter feasible. It offers a minimally invasive technique that than the OP LOS (11.5 ± 10.6 days; p < 0.0001). The overall reduces incision length while using similar techniques as morbidity rate for the three methods was: LA, 24.5%; HA, standard laparoscopic colectomy. Future advances may 38.4%, and OP, 48.7% (LA vs. OP; p = 0.002, LA vs. HA; p continue the trend toward reducing instrument size, thus = 0.0021). The leak/abscess rates were: LA, 2.1%; HA, 2.9%; reducing trauma to the patient while preserving a tech- and OP, 3.8% (p = ns for all). There was no difference in the nique that has already taken years to infi ltrate common wound infection, bleeding, or cardiac complication rates. practice for colon surgery.

120 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSIONS: The majority of SR’s were done using LA Despite the complexity of pelvic colorectal reoperations, methods whereas HA methods were used for about 1/3 of in experienced hands, the overall complication rate is low. cases. HA methods were used for higher BMI and higher Whenever possible, patients should be counseled to taper risk pts (vs. LA patients). The HA LOS was 1 day longer than steroids and reach ideal BMI prior to undergoing pelvic the LA group yet the HA and LA return of bowel function reoperative surgery. was similar. Except for BMI, the OP pts were the most challenging. Utilization of both HA and LA methods allows the Mo1468 great majority of SR cases to be done using MIS methods. Ethnicity Defi nes the Risk of Crohn’s Disease of the Mo1467 Ileoanal Pouch Saurabh Mukewar*1, Xianrui Wu3, Rocio Lopez4, Pokala R. Kiran2, Predictors of Successful Pelvic Reoperations in Feza H. Remzi2, Bo Shen3 Colorectal Surgery: A Multivariate Analysis 1. Cleveland Clinic Foundation, Ohio, Cleveland, OH; 2. Colorectal * Emanuela Silva , Marylise Boutros, Ricardo Aliendre, Surgery, Cleveland Clinic Foundation, Ohio, Cleveland, OH; 3. Fabio Potenti, Giovanna Dasilva, Steven Wexner Gastroenterology and Hepatology, Cleveland Clinic Foundation, Ohio, Colorectal Surgery, Cleveland Clinic Florida, Weston, FL Cleveland, OH; 4. Quantitative Health Sciences, Cleveland Clinic Predictors of successful outcomes following reoperative Foundation, Ohio, Cleveland, OH pelvic surgery are poorly defi ned. We aim to identify pre- BACKGROUND: A few previous paired studies (including dictors of successful pelvic colorectal reoperations. ours) showed that African-American (AA) and Hispanic- After IRB approval, we identifi ed all patients from our pro- American (HA) had similar pouch related outcomes after spective database who underwent re-operative pelvic sur- ileal pouch-anal anastomosis (IPAA). There is no previous gery from 01/02–07/11. Patient demographics and clinical data on pouch outcomes for Indian-American (IA) patients. variables were confi rmed by chart review. Primary outcome Further, whether ethinicity differentially infl uences pouch was the overall complication rate; including early (≤30 related outcomes after IPAA has not been investigated. day) and late (>30 day) complications, and the secondary AIM: To compare differences in outcomes after IPAA for outcome was diverting stoma closure [SC]. Chi-square and ulcerative colitis (UC) for AA, HA, IA and Caucasian-Amer- student’s t test were performed. All variables with p < 0.1 ican patients. on univariate analysis were included in multivariate cox regression analysis. METHODS: From a prospectively maintained Pouchitis Database, this historical cohort study identifi ed and com- 254 pelvic reoperations (mean age 52 years, 47% male) were pared UC patients with different racial background (AA, HA, performed, including 104 with establishment of intestinal IA or Caucasian-american) who underwent IPAA. Pouch continuity. The most common diagnoses were: mucosal patients with familial adenomatous polyposis, and those ulcerative colitis (35%), rectal cancer (24%), diverticulitis with unknown or mixed racial background were excluded. (18%), Crohn’s disease (6%) and familial adenomatous CD of the pouch was diagnosed based on a combined polyposis (6%). The most common initial operations per- assessment of endoscopic, histologic, and radiographic fea- formed were: total proctocolectomy with ileoanal pouch tures. A total of 25 demographic and clinical variables were anastomosis [IPAA] (41%), resection with colorectal anas- evaluated with both univariate and multivariable analyses. tomosis (27%) and resection with coloanal anastomosis (17%). Indications for reoperation included: anastomotic RESULTS: There were 22 IA, 26 AA, 37 HA and 822 leak (53%), fi stula (14%), anastomotic stricture (10%), IPAA Caucasian-American patients. Results of unvariable and multivariable analyses associated with characteristics and dysfunction (11%) and recurrent cancer (8%). The overall Poster Abstracts complication rate after reoperation was 20%; 8% early and outcomes for the various groups are shown in the following Tables 1 and 2, respectively. 12% late. On multivariate regression, BMI ≥ 25 kg/m2 (p < Monday 0.03) and anastomotic complications (leak, fi stula or stric- CONCLUSION: Signifi cant differences in the disease ture) as the indication for reoperation (p < 0.0001) were course of UC before colectomy such as disease extent, use of independent predictors of complications. Intraoperative immunomodulator or biologics, and duration of UC exist complications during initial operation (p < 0.002) and ste- between the various ethnic groups. Racial background is roids at the time of reoperation (p < 0.01) were independent independently associated with the risk for developing CD predictors of early and late complications, respectively. 104 of pouch with AA patients having a 11-fold and Caucasian- patients underwent reoperation with re-establishment of Americans an 8-fold higher risk of developing CD of pouch intestinal continuity with an overall complication rate of compared to IA UC patients undergoing IPAA surgery. 19% (8% early and 11% late). 88% had an ileostomy at time of reoperation, of whom 71% underwent SC. Com- plications after reoperation delayed time to SC (380 vs. 196 days, p < 0.05). On multivariate regression, IPAA (p < 0.0001) and ASA class I (p < 0.03) were independent predictors of SC; while rectal cancer (p < 0.005) and diverticulitis (p < 0.02) as the initial indication for operation, and coloanal anastomosis at initial operation (p < 0.03) were independent negative predictors of SC.

121 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1: Risk Factors for Post-Op Development of CD of the Pouch: Multivariable Logistic Regression Analysis

Factor Odds Ratio (95% Conﬁ dence Interval) p-Value African-American vs. Indian-American 11.2 (1.1, 1507.3 0.012 Caucasian-American vs. Indian-American 8.1 (1.10, 1040.0) 0.008 Hispanic-American vs. Indian-American 4.2 (0.40, 572.0) 0.091 Age at time of pouch creation (5 yr. increase) 0.87 (0.81, 0.93) <0.0001 Pouch duration (5 yr. increase) 1.2 (1.08, 1.4) 0.002 Pre-operative diagnosis: CD vs. UC 6.6 (2.2, 21.5) 0.001 Family history of CD 2.0 (1.06, 3.6) 0.035

Table 2: Descriptive Characteristics of IPAA Patients Based on Racial Background Caucasian-American African-American Indian-American Hispanic-American Factor (N = 822) (N = 26) (N = 22) (N = 37) p-Value Male 458 (55.7) 13 (50.0) 10 (45.5) 23 (62.2) 0.59 Age at time of diagnosis (yrs.) 27.6 ± 12.4 28.0 ± 11.1 28.7 ± 10.3 24.4 ± 13.2 0.45 Age at time of IPAA surgery (yrs.) 36.2 ± 13.9 33.3 ± 11.6 36.7 ± 11.9 32.9 ± 13.5 0.39 Current age (yrs.) 46.2 ± 14.2 39.5 ± 9.3 43.7 ± 13.5 41.9 ± 15.0 0.027 Duration of UC from diagnosis to IPAA 6.0[2.0,12.0] 5.0[2.0,7.0] 5.5[4.0,12.0] 8.0[2.0,11.0] 0.56 surgery (yrs.) Smoking 0.026 . Never 630 (76.6) 24 (92.3) 22 (100.0) 27 (73.0) . Ex-smoker 122 (14.8) 2 (7.7) 0 9 (24.3) . Current smoker 70 (8.5) 0 0 1 (2.7) Chronic NSAID use 50 (6.1) 5 (19.2) 1 (4.5) 2 (5.4) 0.058 Family history IBD 179 (21.8) 1 (3.8) 1 (4.5) 10 (27.0) 0.026 CD 53 (6.4) 0 0 1 (2.7) 0.25 UC 132 (16.1) 1 (3.8) 1 (4.5) 9 (24.3) 0.073 Indication for colectomy 0.083 . Refractory to medical therapy 716 (87.1) 26 (100.0) 20 (90.9) 29 (78.4) . Dysplasia 106 (12.9) 0 2 (9.1) 8 (21.6) Pre-operative diagnosis 0.53 . UC 744 (90.5) 26 (100.0) 21 (95.5) 35 (94.6) . IC 66 (8.0) 0 1 (4.5) 1 (2.7) . CD 12 (1.5) 0 0 1 (2.7) Extent of ulcerative colitis <0.001 . Pancolitis 777 (94.5) 3 22 (84.6) 15 (71.4)1 35 (94.6) . Left-sided colitis/Proctitis 45 (5.5) 4 (15.4) 6 (28.6) 2 (5.4) Fulminant colitis 88 (10.7) 0 3 (13.6) 4 (10.8) 0.34

122 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Caucasian-American African-American Indian-American Hispanic-American Factor (N = 822) (N = 26) (N = 22) (N = 37) p-Value Pre-operative use of biologics 70 (8.5) 4 (15.4) 5 (22.7) 4 0 3 0.015 Number of visits to pouch clinic 2.0 [1.00,3.0] 3,4 1.00 [1.00,2.0] 1.00 [1.00,2.0] 1 1.00 [0.00,2.0] 1 <0.001 Pouch type 0.7 . J 767 (93.4) 26 (100.0) 21 (95.5) 36 (97.3) . S 25 (3.0) 0 0 0 . Other 29 (3.5) 0 1 (4.5) 1 (2.7) Stage of pouch surgery 0.85 . 1 28 (3.4) 0 0 0 . 2 626 (76.2) 22 (84.6) 16 (84.2) 30 (81.1) . 3 120 (14.6) 3 (11.5) 3 (15.8) 5 (13.5) . 4 or redo pouch 48 (5.8) 1 (3.8) 0 0 Post-operative use of immunomodulator 88 (10.7) 2 (7.7) 1 (4.5) 2 (5.4) 0.55 Post-operative use of biologics 75 (9.1) 2 (7.7) 1 (4.5) 1 (2.7) 0.5 Autoimmune disease 115 (14.0) 4 (15.4) 0 3 (8.1) 0.2 Primary sclerosing cholangitis 43 (5.2) 1 (3.8) 1 (4.5) 1 (2.7) 0.9 Liver transplantation 8 (0.97) 1 (3.8) 0 1 (2.7) 0.39 Signiﬁ cant comorbidities 65 (7.9) 3 (11.5) 0 2 (5.4) 0.44 Final diagnosis 0.003 . Normal pouch 82 (10.0)4 5 (19.2) 7 (31.8) 13 (35.1) 1 . Irritable pouch syndrome 142 (17.3) 4 (15.4) 1 (4.5) 5 (13.5) . Active pouchitis 164 (20.0) 5 (19.2) 7 (31.8) 6 (16.2) . Refractory pouchitis 107 (13.0) 1 (3.8) 3 (15.8) 5 (13.5) . Crohn’s pouch 164 (20.0) 5 (19.2) 0 4 (10.8) . Cufﬁ tis 83 (10.1) 2 (7.7) 1 (4.5) 2 (5.4) . Surgical complications 78 (9.5) 4 (15.4) 3 (15.8) 2 (5.4) . Anismus 2 (0.24) 0 0 0 Extra-intestinal manifestations 314 (38.2) 7 (26.9) 6 (27.3) 9 (24.3) 0.16 Post-op hospitalization 133 (16.2) 4 (15.4) 6 (27.3) 8 (21.6) 0.46 Pouch failure 62 (7.5) 3 (11.5) 4 (18.2) 2 (5.4) 0.24 Poster Abstracts Follow up of Pouch Failure (yrs.) 9.0 [5.0,14.0] 2,3 4.5 [2.0,10.0] 1 4.0 [2.0,10.0] 1 9.0 [4.0,13.0] <0.001

Values presented as Mean ± SD with ANOVA; Median [P25, P75] or Median (min, max) with Kruskal-Wallis test, or N (%) with Pearson’s chi-square test unless Monday otherwise stated. 1Signifi cantly different from Caucasian 2Signifi cantly different from African-Am 3Signifi cantly different from Indian 4Signifi cantly different from Hispanic

123 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1469 CONCLUSIONS: Severe CD require adequate and important medical therapy thus this is an almost unavoidable Intestinal Surgery for Crohn’s Disease: Role of variable affecting the surgical outcome of these patients. Preoperative Therapy in Postoperative Outcome Curiously enough, “topic” steroids seemed to be associated Marco Scarpa*1, Matteo Martinato2, Anna Pozza2, Cesare Ruffolo3, to poor outcome after intestinal surgery while oral steroid Giorgia Maran2, Renata D’Incà2, Romeo Bardini2, Imerio seemed to not affect it. Azathioprine association to postop- Angriman2 erative rectal bleeding may be due to a decreased platelets 1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS), count that sometimes occurs during the use of this immunomodulator . Padova, Italy; 2. Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy; 3. IV Unit of Surgery, Ospedale Regionale “Ca’ Foncello”, Treviso, Italy Mo1470 INTRODUCTION: During their life, 80% of patients Factors Associated with Long-Term Quality of Life (QL) affected by Crohn’s disease (CD) require at least one sur- After Ileocolic Resection (ICR) for Crohn’s Disease gical procedure. All CD patients assume lifelong medical Felipe Bellolio*1,4, Zane Cohen1,4, Helen M. Macrae1,4, J. Charles therapy and this therapy may have several severe side Victor2, Brenda I. O’Connor4, Harden Huang4, Robin S. Mcleod1,3 effects that can affect the outcome after surgery. The aim of 1. Surgery, University of Toronto, Toronto, ON, Canada; 2. Dalla this study was to evaluate the role of preoperative medical Lana School of Public Health, University of Toronto, Toronto, ON, therapy in the outcome of intestinal surgery for CD. Canada; 3. Health Policy, Managment and Evaluation, University of PATIENTS AND METHODS: In our department, 453 Toronto, Toronto, ON, Canada; 4. Zane Cohen Centre for Digestive surgical procedures for intestinal CD were performed from Diseases, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, 1982 to 2011. Adequate data about preoperative therapy Toronto, ON, Canada (6 months before the operation) were available for 100 patients that were thus enrolled in this retrospective study. INTRODUCTION: ICR is the most commonly performed They were 40 women and their median age was 35 (IQR: procedure in patients with Crohn’s disease yet there are few 18–44). The median CD duration was 92 (IQR: 33–160) reports regarding long term QL and factors associated with it. months and 26 patients presented a fi stulizing phenotype. PATIENTS AND METHODS: All patients who had ICR Medical therapy before the operation (use and dose of sul- between 1990 and 2010 were identifi ed from a prospec- phasalazine, mesalazine, azathioprine, prednisone, beclo- tively maintained IBD database. A12 item questionnaire metasone, budesonide, anti-TNFalpha) was used as possible which included questions regarding current status, use of predictor of postoperative outcome. Surgical predictors postoperative medications, tobacco history, need for fur- (video assisted intestinal surgery, strictureplasty, stoma ther surgery, fertility (in females) as well as the short version creation, ileal resection and colonic resection) as well as of the IBDQ [scores ranging from 1 (poorest) to 7 (best)] clinical predictors (age, gender, CD duration, activity and were mailed to all patients. Uni and multivariate analyses localization, recurrent CD) were also evaluated. Outcome were performed to determine factors associated with QL. measures were medical and surgical complication, reopera- RESULTS: tion, day of fi rst bowel movement, postoperative hospital Of 434 patients surveyed, 206 (47.5%) (mean stay. Univariate and multivariate analysis were performed. age 33.9 ± 12.3 years at the time of surgery; 122 women) responded. Eighty-six (41.7%) received postoperative RESULTS: Preoperative rectal administration of beclo- maintenance therapy and 25 (12.1%) are current smok- metasone was the only independent predictor of the anas- ers. Overall, 88 (42.7%) patients reported having recur- tomotic leak (beta = 0.36, p < 0.001) in a model that also rent disease of which 71 (80.6%) were clinical recurrences included minimally invasive surgery, colonic resection, and 17 (19.8%) required surgery, 15 of them resection of obstructing phenotype, type of suture and end-to-end the previous ileocolic anastomosis. Eighteen (15%) of the anastomosis (R2 = 0.29, p < 0.001). Preoperative therapy 119 females who responded stated they had fertility prob- with budesonide was the only independent predictor of the lems (at least one episode longer than 12 months trying delayed canalization after surgery (beta = 0.44, p < 0.001) to get pregnant) although 17 were ultimately successful in in a model that also included minimally invasive surgery, becoming pregnant. The mean SIBQ score was 5.2 ± 1.3 patients gender, disease activity, ileocolonic resection, stric- with scores ranging from 1.4 to 7.0 in the four domains. turoplasty, and therapy with mesalazine and beclometa- On multivariate analysis only recurrence of Crohn’s disease sone (R2 = 0.29, p = 0.003). Postoperative rectal bleeding (p < 0.001) and the absence of penetrating disease at the was independently predicted by azathioprine dose (beta = original surgery (p = 0.039) were associated with decreased 0.29, p = 0.012) while reoperation in the fi rst month was SIBD scores. independently predicted by the use of budesonide (beta CONCLUSIONS: = 0.25, p = 0.044). No adverse effect on surgical outcome Most patients have a good QL following were observed after the use of anti TNFalpha therapies. ICR. However non-penetrating disease at surgery and disease recurrence appear to negatively impact on QL.

124 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1471 Mo1472 Is Laparoscopic Resection for Recurrent Disease Nervosa Anorexia Leads to Defaecatory Disorders Benefi cial in Patients with Previous Intestinal Compared to General Population Resection for Crohn’s Disease Through Midline Pierpaolo Sileri1, Iacoangeli Fabrizio2, Federica Starr2, Laparotomy? A Case-Matched Study Luana Franceschilli*1, Elisabetta De Luca1, Alessandra Di Giorgio1, Erman Aytac*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran Marilena Raniolo1, Maria Irene Bellini1, Stefano D’ Ugo1, Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease Achille Gaspari1 Institute, Cleveland, OH 1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Internal Medicine, University of Rome, Tor Vergata, Rome, Italy BACKGROUND: Patients undergoing abdominal surgery for Crohn’s disease are predisposed to recurrence requir- BACKGROUND: We have previously shown that Defae- ing reoperation. The effectiveness of laparoscopic vs. open catory Disorders (DDs) can be as high as 60% in obese resection in patients with previous intestinal resection for patients and are reversed after bariatric surgery. Conversely, Crohn’s through a midline laparotomy is controversial. similar data on DDs in patients with nervosa anorexia have been overlooked. In this case-control study we evaluated METHODS: Patients with previous open resection for the prevalence and type of DDs in patients with nervosa intestinal Crohn’s disease undergoing elective laparoscopic anorexia. surgery for recurrent bowel disease from 1997–2011 were case-matched with open counterparts based on age (±5 PATIENTS AND METHODS: A questionnaire-based study years), gender, body mass index (±2 kg/m2), ASA score, sur- was proposed to patients with nervosa anorexia. Data gical procedure and year of surgery (±3 years).Groups were included mean body mass index (BMI), demographics, past compared using chi-square or Fisher exact tests for categor- medical, surgical and obstetrics histories, as well as eating ical and the Wilcoxon rank sum test for quantitative data. disorders duration. Wexner Constipation Score (WCS) and the Faecal Incontinence Severity Index (FISI) questionnaires RESULTS: 26 patients undergoing laparoscopic ileocolec- were used to evaluate constipation and incontinence. For tomy (n = 14), proctocolectomy (n = 5), small bowel resec- the purpose of this study, we considered clinically relevant tion (n = 4), abdominoperineal resection (1), extended a WCS ≥5 and a FISI score ≥10. Data were compared to a right colectomy (1) and stricturoplasty (n = 1) were well- matched control group with 18 < BMI >28. matched to 26 patients undergoing open surgery. The number of previous operations, steroid use, and incidence RESULTS: a total of 32 anorexia patients (group A) accepted of hypertension, diabetes, cardiopulmonary, neurological, the study and 30 patients fi lled the questionnaires as renal and hepatic comorbidities were comparable in the 2 matched control-group (group B). Overall, in group A groups. There were no deaths and 3 patients (12%) required mean BMI was 17 ± 3 Kg/mq(2)(range 12–23); mean illness conversion because of adhesions. Laparoscopic and open duration 5 ± 3 (range 1–13); mean WCS was 10 ± 5 (range groups had statistically similar operating times (169 ± 83 2–22), while mean FISI score was 6 ± 8 (range 0–38). Over- vs. 158 ± 42 minutes, p = 0.94), estimated blood loss (222 all, 90% of these patients reported DDs according to the ± 181 vs. 427 ± 589 ml, p = 0.32), overall morbidity (39% above-mentioned scores. Thirty patients (94%) had WCS vs. 69%, p = 0.051), reoperation rates (8% vs. 0, p = 0.5), ≥5. Eleven patients (34%) had FISI score ≥10. While eleven postoperative return to bowel function (3.5 ± 1.4 vs. 3.9 ± patients (34%) reported combined abnormal scores. In 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 Group B, mean BMI 21 ± 3 (range 18–28); mean WCS was vs. 6.9 ± 3.5 days, p = 0.12) and readmission rates (8% vs. 3.8 ± 3 (range 0–10), while FISI score was 0. Overall, 53% of 12%, p = 0.64). Wound infection rate was decreased after these patients reported DDs according to the above-men- laparoscopic surgery (0 vs. 27%, p = 0.01). tioned scores. Sixteen patients (53%) had WCS ≥5. None Poster Abstracts had FISI score ≥10. In group A, according to the illness CONCLUSIONS: Bowel resection for recurrent Crohn’s dis- duration (<5 years/>5 years) we found a statistical signifi - Monday ease in patients with previous primary resection through cance in terms of WCS ≥5 and FISI score ≥10 (p < 0.0001, laparotomy can be frequently and safely completed laparo- p < 0.02). According to the WCS ≥5, we found a statistical scopically. Wound infection rates are reduced but there are signifi cance between the two groups (p < 0.0001). no clear recovery advantages when compared with open surgery. The decision to operate laparoscopically should CONCLUSION: Defaecatory Disorders are common in therefore be carefully calibrated. anorexia nervosa patients compared to general population. The risk of DDs increases with anorexia nervosa duration.

125 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1473 Mo1475 Role of Metastatic Lymph Node Ratio as a Prognostic Does Laparoscopic Colectomy Have Reduced Post- Index in Colorectal Cancer Surgery Operative Morbidity and Mortality in Octogenarians Pierpaolo Sileri1, Stefano D’ Ugo*1, Giulio P. Angelucci1, Compared to Open? Luana Franceschilli1, Marco D’Eletto1, Mara Capperucci1, Roman Grinberg, Muhammad Asad Khan*, John Afthinos, Vincenzo Formica2, Giampiero Palmieri3, Nicola Di Lorenzo1, Karen E. Gibbs Achille Gaspari1 Surgery, Staten Island University Hospital, Staten Island, NY 1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Oncology, OBJECTIVES: The benefi ts of laparoscopic colectomy are University of Rome, Tor Vergata, Rome, Italy; 3. Pathology, University well described in the literature and its use has been contin- of Rome, Tor Vergata, Rome, Italy ually increasing. Given the sharp rise in the octogenarian BACKGROUND: The ratio of metastatic to total retrieved population from longer life expectancy, they will make up nodes, defi ned Lymph Node Ratio (LNR), has shown a bet- a larger proportion of patients which are cared for by sur- ter prognostic signifi cance in several gastrointestinal can- geons. We wished to compare the outcomes of laparoscopic cers compared to the absolute number of positive lymph and open colon resections in this distinct and challenging nodes. The aim of this study was to assess the value of LNR age group. on long-term outcome of patients submitted to colorectal METHODS: Using the ACS-NSQIP database, we identifi ed surgery for malignancies. all elective laparoscopic colectomies performed between METHODS: Clinical and pathologic data of patients 2007 and 2009 in patients ≥80 years of age. Preoperative underwent colorectal surgery for resectable cancer at our co-morbidities, operative time, length of hospitalization Department of Surgical Sciences were routinely and pro- and perioperative mortality and morbidity were compared spectively inserted in a database between January 2003 between the two groups using chi-square and independent and August 2011 . We reviewed the total number of lymph t-test as appropriate. nodes retrieved in the surgical specimen and the number of RESULTS: A total of 3,898 patients ≥80 years old were lymphatic metastasis. The value of the LNR was compared identifi ed who underwent a colectomy with primary with the long term outcome for each patients, and the anastomosis. Of these, 1,123 (28.8%) patients underwent prognostic signifi cance of LNR evaluated using the Kaplan- laparoscopic colectomy while 2775 (71.2%) patients under- Meier survival curve and the log-rank test. went open colectomy. There were no statistically signifi - RESULTS: From an overall database of 1004 patients we cant differences between the laparoscopic and open groups selected two hundred and thirty patients in terms of comorbidities. The only statistically signifi cant complications were cardiac arrest, superfi cial wound com- (51.3% male, 48.6% female) that fulfi lled the study criteria. plication and sepsis, all of which were higher in the open The mean age of the study group was 68.4 ± 10.5 years. group. The type of surgery performed were right colectomy in 72 patients (31.3%), left colectomy in 73 patients (31.7%), There was otherwise no statistically signifi cant difference anterior resection or miles procedure in 79 patients (34.3%) in surgical wound complications between open and lapa- and other procedures in 6 patients ( 2.6%). Ten patients roscopic group. There was no difference in operative times (4.3%) were T1 staged, 30 (13.1%) were T2, 167 (72.6%) between the two groups. Length of stay (7.9 ± 7 days vs. were T3 and 23 (10%) were T4. The mean number of lymph 10.8 ± 8.1 days, p < 0.001) and rate of major complications node retrieved were 13.6 ± 6.9 and 89 patients (38.7%) were was signifi cantly less in the laparoscopic group (12.9% vs. node positive with a mean metastatic lymph node number 17.9%, p < 0.001). The post-operative mortality rate was of 1,4 ± 2.7. Since LNR increase as a function of metastatic similar in both groups (3.2% vs. 3.3% for laparoscopic vs. lymph node number we found that a LNR between 0.1 open, respectively, p = 0.05). and 0.2 compared to LNR major than 0.2 has a signifi cant CONCLUSION: Minimally invasive colectomy in patients difference in predicting the long term outcome of these ≥80 years old reduces length of stay and major post- patients ( p = 0.04). operative complications when compared to the open CONCLUSION: After colorectal cancer surgery the LNR is approach. However, mortality is not different. This sug- an accurate prognostic factor in node-positive patients in gests that laparoscopic colectomy has potential benefi ts for long term overall survival and disease free survival. octogenarians and should be considered as the approach of choice when feasible.

126 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1476 Mo1477 Does the Laparoscopic Approach to Colectomy Lessen Endoscopic Resection of Rectal NETs: Establishing the Post-Operative Complications in Octogenarians? Guidelines for Oncologic Endpoints Muhammad Asad Khan*, Roman Grinberg, John Afthinos, Thomas Curran*1, Vitaliy Y. Poylin1, Robert M. Najarian2, Karen E. Gibbs Deborah Nagle1 Surgery, Staten Island University Hospital, Staten Island, NY 1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA; OBJECTIVES: The percentage of octogenarians in the 2. Pathology, Beth Israel Deaconess Medical Center, Boston, MA population is increasing and these patients are now more BACKGROUND: Neuroendocrine tumors (NETs) of the rec- commonly seen in surgical practice. Colonic pathology is tum are often indolent in nature with metastatic potential a major disease entity for which surgical therapy is sought related to grade and size of the primary tumor. Endoscopic by this age group. Octogenarians are more susceptible to management of small NETs may be appropriate though complications and mortality after colectomy given their uncertain oncologic adequacy of resection frequently leads high incidence of comorbid factors and decreased physi- to more invasive procedures. This study aims to delineate ologic reserve. There have been confl icting reports in the adequate oncologic endpoints for management of rectal literature regarding the outcomes of this population with NETs by endoscopic means alone. respect to laparoscopic colectomy. We sought to evaluate METHODS: All pathologically confi rmed, endoscopically this using a national database sample. diagnosed rectal NETs at a tertiary care center from 2000 METHODS: Using the ACS-NSQIP database, we identifi ed to 2010 were retrospectively reviewed. Clinical data from all elective laparoscopic colectomies performed between were evaluated. Pathologic criteria including tumor size, 2007 and 2009 in patients ≥80 years of age. Preoperative margin status, mitotic rate, depth of invasion, lymphovas- co-morbidities, operative time, length of hospitalization cular invasion and other factors were considered. and perioperative mortality and morbidity were compared RESULTS: 40 patients (21 male) with rectal NETs were between the two groups using chi-square and independent identifi ed. Mean age was 55 years (range: 31.8–73.9 years). t-test as appropriate. A multivariate logistic regression anal- Mean follow up was 44 months (range: 1–122 months). A ysis was used to analyze potential factors contributing to majority (68%) were asymptomatic, undergoing colonos- post-operative morbidity and mortality. copy for general screening. 27 (68%) underwent whole RESULTS: We identifi ed 16,536 patients, of which 2,155 endoscopic resection while the remainder underwent patients (13%) were ≥80 years and 14,381 patients (87%) piecemeal resection (N = 9) or biopsy (N = 4). Mitotic rate were <80 years old. Elective laparoscopic colectomy of was <2 mitoses per high-powered fi eld in 29 (97%). Mean any type with primary anastomosis was accomplished in tumor size was 0.9 cm (range 0.2–2.5 cm). Margin positive each case. Independent predictors associated with a signifi - patients (N = 18) showed no residual disease on re-resection cantly increased rate of mortality were male gender (AOR in 11 cases (2 TEM, 9 endoscopic); 3 had remaining disease 2.12), age above 80 years (AOR 2.92), dyspnea on exertion managed endoscopically and 3 went to OR for resection and rest (AOR 1.75 and 5.85 respectively), partially and of large or deeply invasive tumors. Indeterminate margin completely dependent functional status (AOR 3.4 and 3 patients (N = 11) showed no residual disease in 6 cases; 2 respectively), COPD (AOR 2.08), HTN (AOR 2.68), previous had remaining disease managed endoscopically, 3 went to cardiac surgery (AOR 2.07), >10% weight loss (AOR 2.3), OR for resection of large/deeply invasive tumors, 1 died of ASA III/IV (AOR 2.9), ascites (AOR 23.3). In the immediate other causes before follow up. Negative margin patients postoperative period the group of patients ≥80 years had (N = 7) had no further interventions or no residual disease a higher incidence of PE (1.1% vs. 0.3%), failure to wean

in 5 cases; 1 had residual disease managed endoscopically Poster Abstracts and subsequent reintubation (2.2% vs. 0.9% and 2.9% vs. and 1 went to the OR for resection for large size. Tumor size 1.1% respectively), cardiac arrest (0.6% vs. 0.2%) and septic was not signifi cantly different between groups. Overall, 31 Monday shock (2.4% vs. 0.8%). There was no difference in terms patients with mean tumor size 0.8 cm (max 2.0 cm) were of wound-related complications in both groups. Operative managed with endoscopy alone; 23 required 2 procedures time was found to be shorter for patients ≥80 years (141 vs. while 8 required single procedure. None of these had recur- 161 min), but reoperation rate within 30 days was higher rent disease. 9 patients required surgery (3 proctectomy, 3 (AOR 3). The rate of major complications and death were transanal excision, 3 TEM) with most common indication also higher (AOR 1.73 and 6 respectively). being size 2 cm or greater. 1 node positive patient devel- CONCLUSION: Despite the potential benefi ts derived from oped distant metastasis. a laparoscopic approach, octogenarians had a higher mor- CONCLUSIONS: This retrospective study suggests that bidity and mortality rate. Independent risk factors which patients with rectal NETs less than 2 cm and without evi- increased the probability of complications post-operatively dence of nodal disease on imaging may safely undergo were defi ned. These must be weighed carefully in the risk- endoscopic management alone if subsequent surveillance benefi t analysis of an octogenarian about to undergo an biopsy demonstrates no residual disease. Positive margin elective colectomy. Interestingly, the presence of ascites status in endoscopically resected rectal NETs may not refl ect was the strongest predictor of mortality in this analysis. residual disease and should not be used alone as an indication for surgery. Larger, prospective trials will be needed to further investigate these fi ndings.

127 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Esophageal CONCLUSION: This study demonstrates that delirium is a risk factor for complicated post-operative recovery and increased treatment costs following esophagectomy, and Mo1478 furthermore that age is independently predictive of its development. Focused screening will allow targeted pre- The Clinical and Economic Cost of Delirium Following ventative strategies to be employed in the peri-operative Surgical Resection for Esophageal Malignancy period to reduce complications and cost associated with Sheraz Markar*1, Alan Karthikesalingam2, Donald Low1 delirium. 1. Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA; 2. Department of Outcome Research, St George’s Hospital, London, Mo1479 United Kingdom The Incidence of Hiatal Hernia After Minimally BACKGROUND: Delirium is an under-estimated and seri- Invasive Esophagectomy ous complication following major surgery, particularly in Nathan W. Bronson*, James P. Dolan, Renato A. Luna, the elderly population. The aim of this study was to identify pre-operative risk factors for delirium following esoph- Brian S. Diggs, John G. Hunter agectomy for malignancy, and investigate its impact upon Department of General Surgery, Oregon Health and Science University, short and long-term outcome. Portland, OR METHODS: All patients undergoing esophagectomy for INTRODUCTION: Minimally invasive esophagectomy cancer between 1991 and 2011 had information prospec- (MIE) has evolved as a means to minimize the morbidity tively entered in an IRB-approved database. Patients were of an operation which is traditionally associated with sig- divided into two groups based upon the presence or absence nifi cant morbidity and mortality. Given recent reports of of clinically-signifi cant post-operative delirium, and were increased hiatal herniation after robot assisted esophagec- compared with respect to use of neoadjuvant therapy, tomy, we intended to describe the incidence and outcomes medical co-morbidities, operative outcomes, post-operative of hiatal hernia in a large cohort of post-MIE patients. complications, overall cost and survival. For the purposes METHODS: Clinical follow up data on one hundred and of this study delirium was defi ned as an acute fl uctuating fourteen patients who had undergone minimally invasive confusional state that required intervention. esophagectomy between 2000 and 2011 was retrospectively RESULTS: 500 patients were included in this analysis; reviewed. Imaging fi ndings derived from routine computed 46 (9.2%) patients with post-operative delirium and 454 tomography (CT) scans of the chest and abdomen were patients without. Age was signifi cantly increased (71 ± 8.12 used to establish the diagnosis of hiatal herniation after yrs vs. 63 ± 10.86 yrs) and BMI was reduced (25 ± 4.24 vs. minimally invasive esophagectomy. Age, gender, comorbid 27 ± 4.82 kg/m2) in the delirium group. There were no sig- conditions, clinical tumor stage, specimen size, length and nifi cant differences in cardiac, pulmonary or renal co-mor- cost of hospital admissions, presenting complaint for hiatal bidities, however ASA grade was signifi cantly increased in hernia, operation performed to correct hiatal herniation, the delirium group (2.83 ± 0.44 vs. 2.62 ± 0.54). There were and mortality were all recorded for analysis. no signifi cant differences between the groups in the use of RESULTS: Of the 114 patients identifi ed in the database neoadjuvant therapy. who underwent MIE, a total of 8 were identifi ed with post- Analysis demonstrated that delirium was associated with operative hiatal herniation (7% incidence). Five of these a signifi cantly longer hospital (13.98 ± 7.54 vs. 10.88 patients were asymptomatic. One of the three symptom- ± 5.67 days) and ICU stay (3.59 ± 3.82 vs. 2.68 ± 16.92 atic patients presented with a perforated colon in the chest. days). Furthermore post-operative delirium was associated One patient complained of abdominal pain, nausea and with a signifi cantly increased incidence of post-operative vomiting, and a fi nal patient complained of gastric out- pneumonia (21.74% vs. 7.93%), pneumothorax (10.87% let obstruction with chest and neck fullness. All patients vs. 2.64%), re-intubation (10.87% vs. 1.76%) and increased except the one who presented emergently were repaired overall treatment costs ($28223 ± 13018 vs. $22702 ± 9689; laparoscopically on an elective basis. The average length of P < 0.05). stay associated with hiatal hernia repair in this setting was 5 days at an average expense of $40,785 (range $25,264– Age was the only pre-operative predictor of post-operative $83,953). At follow-up only 1 patient complained of symp- delirium in multivariate modeling (Odds ratio = 1.08; 95% toms associated with refl ux. C.I. = 1.04–1.12, P < 0.05). Patients were followed up for an average of approximately 4 years. There was no signifi cant CONCLUSION: Hiatal herniation is not a rare event after difference between the groups in overall survival (1105 ± MIE. It is also associated with a large health care cost and 910 days vs. 1273 ± 1428; P = 0.28) and there was no dif- may be lethal. Most occurrences appear to be asymptom- ference in Kaplan Meier curve distribution between the atic and if detected, can be repaired with good resolution of groups. symptoms and minimal associated morbidity.

128 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1480 Mo1481 The Utility of Esophageal Stents as an Adjunct in the The Impact of Impedance (MII) Testing on Patient Perioperative Management of Cancer of the Esophagus Selection for Anti-Refl ux Surgery in the Setting of a Nicolas Zea*1, John Bolton1,2, Lisa L. Wang2, Abbas Abbas1,2 Normal 24-Hour pH Test 1. Department of Surgery, Ochsner Health Systems, New Orleans, LA; Ashwin A. Kurian*1, Ahmed Sharata2, Neil H. Bhayani1, 2. Department of Surgery, The University of Queensland, Australia Kevin M. Reavis2, Christy M. Dunst2, Lee L. Swanstrom2 School of Medicine, Brisbane, QLD, Australia 1. Providence Portland, Portland, OR; 2. GMIS, Oregon Clinic, INTRODUCTION: Esophageal stents (ES) may be used as Portland, OR an adjunct in the management of patients with resectable BACKGROUND: Gastroesophageal refl ux (GER) has been cancer of the esophagus (EC) to improve nutritional status defi ned as abnormal acid exposure in the distal esophagus as during neoadjuvant therapy, or to manage postoperative measured by 24 hr pH testing. However, there is a subset of anastomotic leaks or strictures. We describe our experience patients who present with classic refl ux symptoms but have a with the use of ES in a consecutive series of 97 patients normal pH test. These patients present a treatment dilemma undergoing resection of EC between September of 2007 for the esophageal surgeon as anti-refl ux surgery (ARS) based and March of 2011. on symptoms alone has often been associated with unpre- METHODS: This is a retrospective record review with IRB dictable outcomes. Non-acid refl ux has been suggested as approval. All patients receiving ES at our institution for a valid indication for ARS in certain subsets of patients as whom follow up is available are included. The indication identifi ed by multi-channel intraluminal impedance (MII) testing . However, there is a paucity of data regarding the for ES placement was noted and the clinical effectiveness incorporation of this modality in routine surgical decision was determined: did the ES successfully resolve the clinical making. The aim of this study is to evaluate the impact of problem for which it was placed? MII-pH testing in a high volume ARS practice. RESULTS: Among 97 consecutive patient undergoing METHODS: Routine pH-MII testing was incorporated in resection of EC, 46 patients received ES for the following our esophageal testing laboratory in 2010. Prospectively indications: to improve preoperative nutritional status (25 collected data for all patients who underwent standard patients), for postoperative anastomotic leak (13 patients), laparoscopic Nissen fundoplication from 2004–2010 was and for postoperative anastomotic stricture (14 patients). reviewed. Patients with partial fundoplication, gastroparesis, 9 patients had multiple ES placed at different time points paraesophageal hernia, redo ARS or Collis gastroplasty were for multiple indications. ES deployment was technically excluded. Patients were divided into 2 groups (pH-ONLY, successful in all patients. Preop ES: Swallowing symptoms pH-MII) based on the type of testing they had before surgery. improved in 52% of patients; however, nutritional sta- Standardized symptom assessment scores (pre and postop- tus deteriorated in 80%, with a median weight loss of 15 erative), indication for operation and pH and pH-MII results lbs and median decrease in serum albumin of .4gms/dl. were analyzed. Total number of referrals for ARS with nor- ES migration, which occurred in 64%, and upper gastro- mal preoperative pH testing was recorded for comparison. intestinal symptoms, which occurred in 72% of patients RESULTS: Three hundred fi ve ARS patients were analyzed receiving neoadjuvant therapy, limited the effectiveness (250 pH-ONLY, 55 pH-MII). In the pH ONLY group, 17/250 of preop ES. ES for postop leak: Postop leak occurred in (6.8%) underwent ARS despite a normal preoperative pH the neck in 10 patients and in the chest in 3 patients. ES test compared to 13/55 (23.6%) in the pH-MII group (p = effectively sealed the leak and allowed prompt (within 48 0.0004). The average number of referrals for ARS with nor- hrs) resolution of oral intake in only 4/13 patients (31%). mal preoperative pH testing was 50/yr and did not change

Early ES migration (7 patients) and the presence of limited with the introduction of pH-MII testing but annual rate of Poster Abstracts conduit necrosis (2 patients) was associated with ES failure. ARS in patients with a normal preoperative pH increased

ES for postop stricture: 12 of the 14 strictures for which from 4/50 (8%) to 12/50 (24%) (p = 0.03). Primary symp- Monday stents were deployed were in the neck and 2 were in the tho- toms for patients with normal pH were similar for both rax. 57% of patients had sustained relief of dysphagia and groups. The most common surgical indications were simi- required a median of only one subsequent intervention for lar between groups: esophagitis, large-volume regurgita- stricture. Stent failure occurred in 43%, due to early migration, and symptom correlation (pH-ONLY) or positive tion (4 patients), pharyngeal or mediastinal pain (1 patient symptom index (pH-MII). The MII testing infl uenced the each), or bilious vomiting (2 patients). ES migrated prema- decision to operate in seventy-seven percent of patients turely in 11/14 patients, including 6/8 successfully treated in the pH-MII group (6/13 abnormal refl ux events, 4 posi- patients and 5/6 unsuccessfully treated patients. tive symptom index) and the remainder (3/13) had biopsy CONCLUSIONS: The effectiveness of ES placement for proven esophagitis. The symptom scores for heartburn, preop nutritional stabilization (20%) and resolution of regurgitation, and chest pain were improved after surgery postop leak (31%) is low. ES for postop anastomotic stric- in both groups (p < 0.05). ture is moderately effective (57%). The high proportion of CONCLUSIONS: Conventional pH testing has been the patients with cervical anastomoses in our patient popula- gold standard for selecting patients for ARS. In patients tion predisposes to ES migration; in addition, the preva- with normal 24-hour pH testing, the addition of impedance lence of foregut symptoms with neoadjuvant therapy limits resulted in a 3-fold increase in patients identifi ed as appro- the effectiveness of preop ES. priate surgical candidates.

129 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1482 Table 1: The Prediction Accuracies of the Proposed Automatic Cancer Staging Model for Esophageal Cancer Based on Different Automatic Cancer Staging for Esophageal Pathological Editions of AJCC Cancer Staging Ssystem Reports by Text Mining and Data Mining: Comparison Between AJCC 6th and 7th Editions Based on Based on Yung-Han Sun*1,2, Chih-Cheng Hsieh1,3, Chun-Hsien Chen1,2, 7th Edition 6th Edition Shih-Wei Lin1,2 Cell type 97.5% 97.5% 1. Department of Surgery, Taipei-Veterans General Hospital, Taipei, Tumor Depth status (T) 88.5% 88.5% Taiwan; 2. Department of Information Management, Chang Gung Lymph node metastasis status (N) 91.9% 95.0% University, Taoyuan, Taiwan; 3. School of Medicine, National Yang-Ming University, Taipei, Taiwan Distant metastasis status (M) 95.3% 96.3% BACKGROUNDS: Cancer staging by manual interpretation of pathological report is very time-consuming. In our CONCLUSIONS: This study provides a computational previous research, text mining and data mining techniques model for automatic cancer staging of esophageal patho- were applied to automatic staging of esophageal cancer for logical reports according to the 7th edition American Joint pathological reports according to the 6th edition American Committee on Cancer (AJCC) cancer staging system. In Joint Committee on Cancer (AJCC) cancer staging system. the future, we hope to apply this automatic cancer staging Since the staging system is updated every several years, model to pathological reports of other cancers and collect how to quickly and accurately transform the old stages into clinical data for other text fi le reports. new stages becomes an important issue. The nodal status for esophageal cancer staging in the 6th edition was just Mo1483 grouped into positive (N1) and negative (N0), but it was different in the 7th edition. The aim of this study was to pH-Symptom Indices Do Not Predict Symptom compare the results of the automatic cancer staging model Improvement After Antirefl ux Surgery using new staging edition with those based on the old stag- Stefan Niebisch*, Candice L. Wilshire, Carolyn E. Jones, ing edition. Virginia R. Litle, Christian G. Peyre, Thomas J. Watson, METHODS: Pathological reports of 234 patients under- Jeffrey H. Peters gone esophagectomy were collected in this study. All the Department of Surgery, University of Rochester Medical Center, pathological reports were collected and entered into Access Rochester, NY database as text fi le. The reports were compuationally con- INTRODUCTION: Prospective randomized trials docu- verted into weighted frequency vectors of keywords by ment long term relief of gastro-esophageal refl ux (GERD) using text mining techniques to analyze cancer staging symptoms in 85% of patients following antirefl ux surgery. related keywords in the reports. Lymph node metastasis One of the key challenges, in the decision to pursue anti- status N of a pathology report were derived from the total refl ux surgery, is assuring that the patients symptoms are number of positive lymph nodes and the distal metasta- actually caused by GERD. Mathematical calculations of the sis status (M) were also modifi ed by analyzing the text relationship of refl ux events to the occurrence of symp- keywords of the pathology report computationally. J48 toms have been proposed as a mechanism to support GERD decision tree learning algorithm was used to train the clas- as the underlying cause of both typical and atypical refl ux sifi cation model for cancer staging. One third of the data symptoms. The symptom index (SI) and Symptom Associa- was used for training and two thirds of the data was used tion Probability (SAP) are the most commonly calculated for testing in evaluating the prediction performance of the measures in clinical use. The clinical utility of these mea- model. sures is unclear and unexplored with respect to antirefl ux RESULTS: The results were shown in Table 1. The predic- surgery. tion accuracies for cell type and T status nearly did not METHODS: The study population included 66 patients change, and the prediction accuracies for N and M status (mean age 52.6 years; 58% female) undergoing laparo- reached 91.9% and 95.3% respectively. Comparison with scopic fundoplication from November 2006 to October the accuracies for predicting N and M status based on the 2011. All were pH-positive (DeMeester Score >14.72) with 6th edition of AJCC cancer staging guideline, those based either cough, heartburn and/or regurgitation, in which SI on the new edition decreased just a little. (positive ≥50%) and SAP (positive ≥95%) were calculated pre-op. Symptom outcome after surgery was categorized as ‘improvement’, ‘no change’ and ‘worsening’ in their symptoms. All available data were logged into SPSS (version 18) for statistical analyses.

130 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: At the time of pH testing heartburn was duration was 302 min (150–465min). The operative proce- recorded in 51 (84%), regurgitation in 22 (33%) and cough dures and route of reconstruction of these 57 patients were in 21 (32%) patients. One or both symptom indices were listed in Table 1 and 2 respectively. The reasons of using positive in 85% (56/66) and both negative in 15% (10/66) colonic interposition included: stomach was involved of the patients. Cough was signifi cantly less associated by tumor (n = 18 (31.6%)), prior gastrectomy (n = 34 with positive SI and/or SAP when compared to heartburn (59.6%)), presence of peptic ulcer (n = 3 (5.3%)) and other and regurgitation (SI 19% vs. 72.5% and 81.8%; p < 0.0001; (n = 2 (3.5%)). There were 6 (10.5%) had conduit gangrene SAP 33.3% vs. 78.4% and 68.2%; p = 0.0007 and p = 0.0337 required re-exploration. Nine (15.8%) patients had either respectively). Overall, 93% (62/66) of patients reported clinical or subclinical anastomotic leakage. The median improvement in their symptoms which was independent survival was 34.8 months (17–52 months). The 30-day of a positive or negative SI or SAP. Eighty percent of patients mortality rate was 3.5% (n = 2) and the hospital mortality (8/10) with negative SI and SAP pre-op improved compared rate was 15.8% (n = 9). Presence of major post-operative to 87% (54/62) with positive SI and/or SAP (p = 0.6217). medical complications such as stroke or myocardial infarc- There was no signifi cant difference in symptom improve- tion (p = 0.026, HR 2.114, 95%CI 1.094–4.084) was identi- ment between atypical and typical symptoms; patients fi ed to be predictive factor for poor survival. with heartburn improved in 98%, regurgitation in 95.5% and cough in 85.7% (p = 0.072). Table 1. Operative Procedures of 57 Patients had Colonic CONCLUSION: These data show that symptom improve- Interposition in Esophagectomy for Esophageal Cancer with ment following antirefl ux surgery is independent of the Curative Intent commonly used 24hour pH symptom indices SI and SAP. Atypical symptoms such as cough are less likely associated Procedures N = 57 (100%) with a positive symptom index, particularly when compared Pharyngolaryngoesophagectomy 5 (8.8) to typical symptoms such as heartburn and regurgitation. Transhiatal 9 (15.8) Mo1484 Minimally invasive esophagectomy 2 (3.5) 3 phase esophagectomy 13 (22.8) Operative Outcomes of Colonic Interposition in the Treatment of Esophageal Cancer: A Three Decades Lewis Tanner esophagectomy 18 (31.6) Experience Staged 5 (8.8) Daniel K. Tong*, Simon Law, Fion S. Chan Other 5 (8.8) Surgery, The University of Hong Kong, Hong Kong, Hong Kong BACKGROUND: Colonic interposition is the treatment of choice when the stomach cannot be used as a substitute for Table 2. Route of Reconstruction of 57 Patients who had Colonic reconstruction after esophagectomy for esophageal cancer. Interposition in Esophagectomy for Esophageal Cancer with The aim of present study was to review our experience on Curative Intent colonic interposition. PATIENT AND METHODS: A prospectively collected Route of Reconstruction N = 57 (100%) database on patients with esophageal cancer from 1982– Subcutaneous 3 (5.3) 2010 was reviewed. Outcomes of these patients were ana- Retrosternal 19 (33.3) lyzed. The indications, morbidity, mortality, long-term Right chest 6 (10.5) survival and potential predictive factors were evaluated. Poster Abstracts RESULTS: A total of 119 patients were found to have colon Orthotopic 29 (50.9) harvested for management of esophageal cancer. Of whom, Monday 62 had palliative bypass surgery and 46 (74.2%) were performed in 80s, 16 (25.8%) in 90s, and none in 00s. The role CONCLUSIONS: The role of bypass surgery using colon for of bypass surgery become less popular was probably due to esophageal cancer management is fading. Colonic interpo- the availability of less invasive palliative modalities such sition remained an important treatment option in patients as stenting. For the remaining 57 patients, the median age with prior gastrectomy or when the stomach was invaded was 64 (28–82) and 49 (86%) were male. The median blood by the tumor. The operative procedure was complex and loss was 850ml (150–2500ml), and the median operative could associated with high morbidity rate.

131 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1485 Mo1486 Short-Term Outcome of Antirefl ux Surgery on Patients PET-CT for Response Assessment of Neoadjuvant with Chronic Cough and Abnormal Proximal Exposure Chemoradiation in Locally Advanced Squamous Cell as Measured by Hypopharyngeal Multichannel Carcinoma Esophagus: Initial Experience from Tertiary Intraluminal Impedance Referral Center in North India Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe Saurabh Kalia*, Prasanna Chandrasekaran, Rajesh Gupta, Cardiothoracic Surgery, University of Pittsburgh Medical Center, Ganga R. Verma, Rakesh Kapoor, Bhagwant Rai Mittal, Pittsburgh, PA Rakesh K. Vasishta, Rajinder Singh BACKGROUND: Chronic cough can be caused by direct PGIMER, Chandigarh, India, Chandigarh, India exposure of gastric refl uxates to the aerodigestive tract. The INTRODUCTION: Neoadjuvant chemoradiation is a part treatment outcome has been confl icting due to the lack of of multimodality management of locally advanced car- objective testing to directly measure the proximal extent of cinoma esophagus. 18F FDG PET-CT (PET-CT) has been gastric refl uxates. The objective of this study was to evalu- evaluated for assessing the response to neoadjuvant ther- ate the proximity of refl ux events in patients with chronic apy and correlated with the prognosis in various studies cough and to assess the outcome of antirefl ux surgery (ARS) with inconsistent results. We report our experience from on patients, who were selected based on the presence of prospectively collected data at tertiary referral center from abnormal proximal exposure as measured by hypopharyngeal multichannel intraluminal impedance (HMII). North India. METHODS: METHODS: This is a retrospective review of symptomatic We reviewed prospective data of 34 patients patients who were referred for the evaluation of gastro- of potentially resectable squamous cell carcinoma esopha- esophageal refl ux disease (GERD) and subsequently under- gus from Feb 2010 to Nov 2011 at our institute. All patients went HMII with a specialized catheter to measure proximal (M:F 1.6:1, mean age 51 years) had locally advanced squa- refl ux events such as laryngopharyngeal refl ux (LPR) and mous cell carcinoma of middle and lower 1/3rd esophagus full column refl ux (refl ux 2 cm distal to the upper esoph- (Stage T2–4NxM0) on initial staging with CECT thorax and ageal sphincter) at our institution. Chronic cough was abdomen ± PET-CT. Patients with good performance score defi ned as persistent cough with unknown etiology, which underwent Neoadjuvant chemoradiation (NACRT) proto- lasted for more than 6 months. Patients with positive Tb col including Cisplatin (30 mg/m2) + 5FU (500mg/m2)from test and a history of seasonal allergy or pulmonary diseases Day1 to Day4 and EBRT 30 Gy/10#/over 2 weeks. Restag- such as asthma and pulmonary fi brosis were excluded. ing was done with PET-CT after >4 weeks after completion Based on HMII, abnormal proximal exposure was defi ned of NACRT. All resectable patients underwent transhiatal/ as LPR ≥1/day and/or full column refl ux ≥5/day. Patients transthoracic esophagectomy without formal lymphad- with abnormal proximal exposure subsequently under- enectomy. Histomorphological regression was graded as went ARS. The outcomes were reviewed. per four tiered scheme described by CAP Cancer Protocol RESULTS: From October 2009 to June 2011, 314 symp- for Esophageal carcinoma (TRG 0 and 1 as complete and tomatic patients underwent HMII at our institution. Of moderate response respectively and TRG 2 and 3 as mini- 314, 55 patients were identifi ed as having chronic cough mal and poor response respectively)by single experienced with unknown etiology (male 16, female 39). Mean age pathologist blinded to clinical data. Post NACRT PET-CT and BMI were 57 years and 30.3, respectively. Six patients Standard uptake value (SUVmax) and percentage change were excluded because of inadequate information avail- of SUVmax was correlated with tumor regression (TRG 0 able. Of the remaining 49 patients, 36 patients were found and 1). to have LPR ≥1/day (n = 10, range 1–12/day) and/or full column refl ux ≥5/day (n = 35, range 5–32/day). Of these RESULTS: Transhiatal esophagectomy was done in 30 36 patients with abnormal proximal exposure, 33 (92%) patients and Transthoracic esophagectomy in 2 patients. patients were found to have either endoscopic evidence of Two patients had metastatic disease at surgery. Mean SUV- esophageal mucosal injury such as esophagitis or Barrett’s max was 13.6 and 6.45 for Pre NACRT and Post NACRT esophagus, radiographic evidence of hiatal hernia or PPI respectively suggesting metabolic response to therapy. dependence. However, 67% (24/36) of patients had a nega- Tumor regression (TRG 0 and 1) was seen in 12 (35.3%) tive DeMeester score. Of these 33 patients with abnormal patients. The percentage decrease in SUVmax >80% cor- proximal exposure and objective evidence of GERD, 14 related with tumor regression with sensitivity, specifi city, patients subsequently underwent ARS including Nissen (n PPV, NPV and accuracy of 71.4%, 92.8%, 83.3%, 80% and = 8), Dor (n = 2), Toupet (n = 1) and esophagojejunostomy 85.7% respectively. Post NACRT SUVmax <4.0 correlated (n = 3), and 12 patients (86%) had a complete resolution with tumor regression with sensitivity, specifi city, PPV, of cough and 2 (14%) had a signifi cant improvement at a NPV and accuracy of 83.3%, 86.3%, 76.9%, 90.4% and 85% mean follow-up of 4 months (range, 0.5–12 months). respectively CONCLUSIONS: Abnormal proximal exposure as measured by HMII is likely to be associated with objective evidence of GERD in patients with chronic cough regardless of whether there is a positive DeMeester score. Presence of abnormal proximal exposure could be an indicator of successful ARS for patients with chronic cough.

132 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

METHODS: All patients (pts) undergoing esophagectomy from 2005–11 for malignant disease at a North American university hospital were identifi ed from a prospectively collected database. All patients were subject to BE within the fi rst week postoperatively. Patients were dichotomized according to whether they had an AL or not and the sensitivity and specifi city of barium swallow was determined. In pts who had an AL, the relationship between barium swallow results and time to AL, hospital length of stay, and start of enteral feeding was determined. Furthermore, the effect of BE results on postoperative management, defi ned Figure 1: PET-CT images with complete metabolic response in a as cessation of enteral feeding, additional interventions, 72 year old male or delay in discharge was recorded. Data are expressed as median (range). Mann Whitney U and Fischer’s exact test determined signifi cance (*p < 0.05). RESULTS: Two-hundred and twenty-seven pts underwent esophagectomy over the study period. Twenty-nine pts (12.8%) developed an AL, of which 12 (41.4%) had a positive BE, 11 (37.9%)had a negative BE and the remaining 6 (20.7%) were not subject to BE and were diagnosed either clinically (1/6), by CT (4/6), or endoscopically (1/6). AL in pts with a negative BE was confi rmed either clinically Figure 2: Gross and Microscopic tumor regression (Complete (4/11 pts), by CT (5/11 pts), endoscopically (1/11 pts), or at reoperation (1/11 pts). In pts who had an AL, those with pathological response) CAP TRG 0 in the same patient. a positive BE leaked earlier than those with a negative BE (POD 7 (2–8) vs POD 10.5 (6–22)* respectively). The sensi- CONCLUSIONS: 18F FDG PET/CT is 85% accurate in tivity and specifi city of barium BE in this series was 36.3% response assessment of Neoadjuvant Chemoradiation for and 99.7% respectively. Result of BE in pts with an AL did squamous cell carcinoma esophagus. not correlate with hospital length of stay or date of com- mencement of enteral feeding. Overall, BE altered postop- Mo1487 erative management in 6/227 (2.6%) pts with 4/227 (1.7%) pts undergoing further testing which went on to confi rm a Routine Barium Esophagram Has Minimal Impact leak. Conversely 2/227 (0.9%) pts demonstrated clinically on the Post-Operative Management of Patients insignifi cant AL, having their discharge delayed without Undergoing Esophagectomy for Esophageal Cancer additional intervention. Maxime Noreau-Nguyen*, Jonathan Cools-Lartigue, David S. CONCLUSIONS: Barium esophagram has a poor sensi- Mulder, Lorenzo E. Ferri tivity in the detection of anstamotic leak and has mini- Surgery, McGill University, Montreal, QC, Canada mal impact in the postoperative management of patients INTRODUCTION: undergoing esophagectomy for malignant disease. The Esophagectomy is currently the treat- routine use of contrast esophagograms after esophageal ment modality of choice in patients with esophageal car- resection should be abandoned. cinoma. Post-operatively, routine fl uoroscopic imaging Poster Abstracts with barium sulfate is employed in order to detect occult anastamotic leaks (AL) prior to resumption of enteral feed- Monday ing. This modality is plagued by a low sensitivity, and its routine use has been called into question. Accordingly, we sought to demonstrate the clinical impact of routine barium esophagography (BE) in the post-operative management of patients undergoing esophagectomy for malignant disease.

133 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1488 CONCLUSIONS: This study shows for the fi rst time an effective endoscopic treatment for GERD patients. The new Effective Endoscopic Treatment of Gastroesophageal developed Medigus stapling device can endoscopically cre- Refl ux Disease Using a New Endoscopic Stapling ate an anterior fundoplication. The procedure under gen- System Results of a Prospective Controlled Multicenter eral anesthesia showed acceptable complications (6%), Tria high effi cacy rates (74%) and can be recommended for patients with small hernias. Aviel Roy-Shapira*1,2, Amol Bapaye1, Ralf Kiesslich1, Santiago Horgan1, Sebastian F. Schoppmann1, Johannes Zacherl1, Luigi Bonavina1, Glen A. Lehman1 Mo1489 1. Surgery A, Soroka Univesity Hospital, Beer Sheva, Israel; 2. Critical Resolution of Anemia Following Repair of Giant Care Medicine, Soroka University Hospital, Beer Sheva, Israel Paraesophageal Hernias INTRODUCTION: A new system which is designed for Michael Hermansson*, Steven R. Demeester, Joerg Zehetner, transoral endoscopic treatment of Gastro Esophageal Refl ux Kimberly S. Grant, Daniel S. OH, Tom R. Demeester, Jeffrey A. Disease (GERD) was tested in a multicenter study. The Hagen device is a fl exible video endoscope coupled with a surgi- Surgery, Keck medical center of USC, University of Southern cal stapler and an ultrasonic range fi nder. The device can California, Los Angeles, CA endoscopically create an anterior fundoplication. Aim of BACKGROUND AND AIM: the current prospective controlled multicenter trial was to The association between ane- evaluate safety and effi ciency of the newly developed endo- mia and paraesophageal hernia (PEH) was reported in 1931. scopic stapling device in GERD patients with small hernias. Nonetheless, extensive evaluation for a source of bleeding in patients with anemia and PEH is common. The aim of METHODS: Inclusion criteria moderate to severe GERD this study was to evaluate the prevalence of anemia in with response to PPI treatment, abnormal 24h esophageal patients with PEH and the impact of surgical PEH repair acid exposure and Hill gastro-esophageal valve grade ≥II. on anemia. Patients with signifi cant comorbidities, esophageal motil- METHODS: ity disorders and hiatal hernia >3 cm were excluded. Proce- A retrospective chart review was performed of dures were performed under general anesthesia at 5 centers all patients who underwent primary repair of a PEH with using positive end expiratory pressure (PEEP) to optimum 50% or more of the stomach in the chest between May reduction of the hernia. Anterior fundoplication was per- 1998 and January 2010. Patients with incomplete or miss- formed with two or three stapling sites between the esoph- ing records were excluded. Patients with a history of ane- agus and the stomach under control of the ultrasonic range mia were contacted postoperatively and the status of their fi nder. Patients were followed at 1, 2 and 4 weeks for safety anemia was determined. and at 6 months for effi cacy. The primary outcome of the RESULTS: There were 118 patients that met the inclusion study was safety and reduction of the off PPI GERD Health criteria. A history of anemia was present in 41 patients Related Quality of Life scores (GERD-HRQL) score by at (35%), and these patients formed the study group. There least 50%. Secondary outcome criteria were elimination or were 14 males (34%) and 27 females (66%). The mean age reduction of PPI use, improvement in 24h acid exposure was 64 years. The median duration of anemia prior to PEH and Hill valve grade. repair was 4 years. Treatment for anemia consisted of oral RESULTS: 67 patients were fi nally treated as per protocol. iron supplements (n = 17), intravenous iron infusions (n = Primary outcome—Safety: There were 2 occult perforations 2) and blood transfusions (n = 11). Evaluations for anemia (pneumomediastinum—asymptomatic and empyema— consisted of upper endoscopy (n = 41), colonoscopy (n = chest tube drainage) and one case of bleeding (treated 20), capsule enteroscopy (n = 3), push enteroscopy (n = 1), endoscopically). Hospital stay was prolonged in another and tagged red blood scan (n = 2). In the 41 patients with patient due to signs of infection. Additional adverse events preoperative anemia detailed postoperative follow-up was occurred in 12 patients, were mostly related to elevated available in 23 patients (56%). The median follow-up for infl ammatory markers in the fi rst 24–48h post procedure these 23 patients was 59 months (range 25–133). Resolu- and did not appear to carry any clinical signifi cance. They tion of anemia occurred in 18 patients (78%). In 5 patients were more common when only two rather than three sta- anemia has persisted and they remain on oral iron supple- plings had been placed. ments. The median follow-up in these patients did not differ from those with resolution of their anemia. No patient PRIMARY OUTCOME—EFFICACY: 74% patients (50/67) has required a blood transfusion or intravenous iron infu- met the primary success criterion—50% reduction in GERD- sion after PEH repair. A recurrent hernia was found in 2 of HRQL scores. The median scores drooped from baseline of those 5 patients 29 to 6 at six months post-procedure (p < 0.001). Acid expo- CONCLUSION: sure normalized in 49% (33/67) subjects and improved in Anemia is common in patients with a additional 18% (12/67). PPI usage reduced by ≥50% in 85% giant PEH, and surgical PEH repair resolved the anemia in (57/67) patients (p < 0.001,. 73% patients (46/63) demon- 78% of patients. Therefore, repair of a giant PEH is indi- strated an improved fl ap valve angle at 6 months. cated in patients with anemia. Extensive evaluations for an alternative explanation for the anemia in patients with a giant PEH are unlikely to be useful.

134 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1490 Mo1491 Annual CT Scans Do Not Improve Survival Following Infl uence of Postoperative Morbidity on Longterm Oesphagectomy for Cancer: A Follow Up Study of Cancer Survival After Esophagogastric Surgery 126 Patients David Bowrey, Steve Satheesan*, Sukhbir Ubhi, Amar Eltweri Stefan S. Antonowicz*, Bruno Lorenzi, Adriana Rotundo, Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Cheuk Bong Tang, Michael Harvey, Sritharan S. Kingdom Kadirkamanathan BACKGROUND: Previous studies have shown that post- Upper GI Surgery, MEHT, Chelmsford, United Kingdom operative adverse events after colorectal resection predict BACKGROUND: Evidence for the best approach to follow- a poor prognosis with early cancer relapse. The aim of this up after oesophagectomy for cancer is scant and confl ict- study was to report the outcome of patients undergoing ing. Routine computer tomography scanning (CT) remains esophagogastric resection to assess the infl uence of in-hos- an integral part of oesophageal cancer follow up, despite pital factors on longterm cancer survival. recurrences often being signposted by symptoms and other METHODS: Retrospective review of patients undergoing mechanisms fi rst. Additionally, there is wide variation in esophagogastric resection for carcinoma during the years the frequency of CT scanning schedule owing to resource 2006–2010 at our institution. Minimum follow-up of 12 pressures and anecdotally perceived benefi t. months was required. AIMS: We sought to determine how useful routine CT RESULTS: The study population was 164 patients (110 scanning was in detecting treatable stages of recurrence in male) of median age 64 years (range 32–84). 84 underwent an Upper Gastrointestinal cancer centre. esophagectomy, 80 gastrectomy. Ninety-nine received neo- METHODS: We performed a retrospective review of 126 adjuvant chemotherapy. The 90-day, 1-year and 3-year consecutive patients who have undergone oesophagec- survivals were 92%, 84% and 49% respectively. Sixty-nine tomy between 2001 and 2009. Annual CT-scan was part of patients (42%) developed postoperative complications the routine follow-up in all patients. Two patients were lost (commonest: pneumonia 19%, anastomotic leak 7%, to follow-up. Outcome data was focused on recurrence and wound infection 6%). None of tumor site (esophagus vs. mortality. Data was analysed using chi squared for bino- stomach, p = 0.73), length of ITU stay (<3 days vs. >3 days, mial comparisons, the method of Kaplan-Meier for survival p = 0.50) or development of postoperative complications estimates, and the log-rank statistic to compare survival (p = 0.70) infl uenced longterm prognosis. The only two between cohorts. factors that infl uenced longterm outcome were UICC stage (p < 0.001) and circumferential resection margin (positive vs. RESULTS: Recurrence was detected in 46 cases (37%). negative, p < 0.001). Median time to recurrence was 9 months (range 1–108 CONCLUSIONS: months). Median time to death from radiological confi r- Patients experiencing postoperative mor- mation of recurrence was 4 months (range 1–18 months), bidity can expect the same longterm oncologic outcome as increasing to 13 months (range 6–18 months) if the patient those not suffering these early setbacks. subsequently underwent an interventional therapy (2 = 25.63, log-rank p < 0.001). In nine cases, the recurrences were loco-regional; the remainder had a systemic component. In 12 cases CT detected recurrence in asymptomatic patients; in the remaining 34, suspicious symptoms or tumour marker rise prompted further investigation. Routine-detected recurrences were not more likely to have Poster Abstracts further interventional treatment for their cancer (Fisher, p = 0.519), nor did it confer survival benefi t (log-rank, p = Monday 0.532). Subgroup analysis by neo-adjuvant therapy, preoperative stage and resection status further confi rmed this. CONCLUSION: Routine CT appeared to detect preclinical recurrences only in a handful of patients who had undergone oesophagectomy. The majority of recurrences were diagnosed when patients presented with symptoms. Our data suggests that routine CT scanning in asymptomatic patients may not add any survival benefi t. A well-designed prospective study may give a defi nitive answer.

135 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1492 Clinical: Hepatic Symptomatic and Radiographic Evaluation of Hiatal Hernia Recurrence Following Laparoscopic Mo1493 Paraesophageal Hernia Repair with Polyester Safety of a Multimodal Enhanced Recovery Pathway in Composite Mesh Reinforcement Jeffrey Eakin, Mark Wendling*, Dean J. Mikami, Liver Resection Surgery Clancy J. Clark*1, Shahzad M. Ali1,3, ADAM K. Jacob2, David M. Bradley Needleman, W.S. Melvin, Kyle A. Perry 1 Division of General and Gastrointestinal Surgery, The Ohio State Nagorney 1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; University Medical Center, Columbus, OH 2. Anesthesiology, Mayo Clinic, Rochester, MN; 3. 2nd Department INTRODUCTION: Laparoscopic paraesophageal hernia of Medicine, University Hospital and Faculty of Medicine, Hradec repair (LPEHR) is the preferred treatment for symptomatic paraesophageal hiatal hernia in specialized centers. LPEHR Kralove, Czech Republic has yielded excellent perioperative outcomes and symptom BACKGROUND: Implementation of enhanced recovery control; however, it has been associated with high radio- and fast-tract care pathways in colorectal surgery have graphic recurrence rates. Hiatal reinforcement with PTFE demonstrated decreased overall cost and length of stay mesh prevents hernia recurrence, but is associated with (LOS) while resulting in no signifi cant increase in periop- unacceptable mesh related complications. Conversely, bio- erative morbidity and readmission rate. Similar pathways absorbable mesh placement has proven safe, but failed to are yet established for liver surgery due to concern for peri- produce long term reductions in hiatal hernia recurrence. operative coagulopathy, hepatic dysfunction, and periop- The primary objective of this study was to review a single erative volume management. The aim of this study was to institution experience to evaluate the initial safety and effi - evaluate the safety of an enhanced recovery pathway (ERP) cacy of LPEHR with crural reinforcement using a polyester for patients undergoing open liver resection. composite mesh. METHODS: METHODS: A retrospective review of patients undergoing A single-institution, observational cohort LPEHR from 2006–2011 was conducted under an institu- study was performed by comparing the clinical outcomes tional review board approved protocol. All patients who of patients treated before and after implementation of an underwent LPEHR with placement of polyester compos- ERP. The ERP included pre-operative oral celecoxib and ite mesh were contacted for study enrollment. Long-term gabapentin, standardized anesthetic including general follow-up evaluation was performed in person or by tele- anesthesia, intrathecal analgesia, and postoperative nau- phone questionnaire. Outcomes included barium esopha- sea prophylaxis, and a standardized post-operative care gram, GERD health related quality of life (GERD-HRQL) regimen. Clinical outcomes including morbidity, mortal- assessment, and patient satisfaction with their operation. ity, reoperation, LOS, and readmission rate were compared Signifi cant refl ux was defi ned as a GERD-HRQL score >12. between ERP and non-ERP cohorts on an intention-to-treat RESULTS: Between 2006 and 2011, 175 patients under- basis. went LPEHR, and polyester composite mesh was used for RESULTS: A total of 126 patients (ERP = 53, non-ERP = hiatal reinforcement in 29 cases. Twenty (70%) patients 73) were included in the study. Patient characteristics and completed the questionnaires, and 12 (41%) patients operative details including ASA (p = 0.71), diagnosis (p returned for a post-operative barium esophagram to assess = 0.32), type of liver resection (p = 0.86), and estimated for hernia recurrence. The median follow-up interval was blood loss (p = 0.81) were similar between groups. Over- 29.5 (6–66) months, and esophagrams were performed at a all complication rate was slightly lower in the ERP cohort, median of 34 (9–66) months following LPEHR. There were but not statistically signifi cant (28.3% vs. 37.0%, p = 0.86). no mesh related complications within the study group. Before and after pathway implementation, the median LOS Eight of the twelve patients (75%) who underwent a radiographic evaluation with barium had evidence of recur- remained identical (5 days vs. 5 days, p = 0.71). No differ- rence. The incidence of signifi cant refl ux was 15%. There ences were identifi ed for reoperation rate (2.7% vs 3.8%, was no signifi cant difference between the median GERD- p = 1.00), complication requiring ICU transfer (13.7% vs. HRQL scores between those with radiographic recurrence 7.6%, p = 0.40), or readmission (2.7% vs 3.8%, p = 1.00). and those without (p = 0.732). Fifteen percent (n = 3) of After adjusting for age, type of resection, and ASA, ERP and patients reported moderate to severe dysphasia, and esoph- non-ERP patients had no increased risk of major complica- agram demonstrated a recurrent hiatal hernia in each case. tion (OR 0.38, 95% CI 0.14–1.02, p = 0.06) or LOS greater Eighty-one percent of patients polled reported being satis- than 5 days (OR 1.21, 95% CI 0.18–2.62, p = 0.62). fi ed with their surgery, and 86% reported that they would, CONCLUSIONS: Routine use of a multimodal ERP is safe with the benefi t of hindsight, have their surgery again. and is not associated with increased the post-operative mor- CONCLUSIONS: LPEHR with polyester composite mesh bidity after major open liver resection. However, the current reinforcement provides durable symptomatic relief with study found that LOS was unchanged for patients treated high levels of patient satisfaction at intermediate follow- with an ERP compared to conventional management. up. No mesh related complications or side effects occurred in this series. While anatomic hiatal hernia recurrence detected by routine post-operative imaging is common, most of these are asymptomatic and do not correlate with patient symptoms or dissatisfaction with the operation.

136 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1494 Mo1495 Prediction of Survival After Surgery in Patients with Patterns and Prognostic Signifi cance of Lymph-Node Liver Cirrhosis Dissection for Surgical Treatment of Peri-Hilar and Hannes P. Neeff*1, Hans-Christian Spangenberg2, Tobias Keck1, Intrahepatic Cholangiocarcinoma * Ulrich T. Hopt1, Frank Makowiec1 Andrea Ruzzenente , Tommaso Campagnaro, 1. Department of Surgery, University of Freiburg, Freiburg, Germany; Alessandro Valdegamberi, Francesca Bertuzzo, 2. Department of Gastroenterology and Hepatology, University of Fabio Bagante, Calogero Iacono, Alfredo Guglielmi Freiburg, Freiburg, Germany Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy BACKGROUND: INTRODUCTION: Patients with cirrhosis have an Lymph node (LN) metastasis is a major increased risk of postoperative mortality. In addition, negative prognostic factor for intrahepatic (ICC) and peri- patients with cirrhosis per se have a reduced life expectancy. hilar (PCC) cholangiocarcinoma. Prognostic signifi cance Little is known about the combined effect of these reduced of LN dissection (LND), number of metastatic LN, LN sta- outcomes after surgery. We thus evaluated early and long- tions and lymph-node ratio (LNR) are still under debate for term survival after surgery in patients with cirrhosis. cholangiocarcinoma. AIMS: METHODS: For prediction of long-term outcome we eval- The aims of this study are to evaluate the prognostic uated survival after general surgical procedures performed value of LND, of the number of LNs harvested, of number during the last decade by two different approaches: I) Actu- of positive LNs, of LN stations and of LNR in ICC and PCC. arial survival was estimated in 180 patients after surgery METHODS: Extension of LND, according with Japanese (thus including postoperative deaths) and II) Survival was Society of Biliary Surgery (JSBS), number and status of analyzed separately in 143 patients who were discharged harvested LNs were retrospectively evaluated in patients after postoperative treatment (i.e. patients without in-hos- cholangiocarcinoma submitted to surgical resection with pital mortality) and with survival information available. curative intent between 1990 and December 2010. Survival was analyzed by actuarial methods, risk factors RESULTS: One hundrend and thirty patients were submit- were assessed univariately (log rank) and multivariately ted to surgical resection with curative intent; 61 were ICC (Cox regression, multiple models). and 69 PCC. Lymph-node dissection (LND) was performed RESULTS: I) Survival in all 180 operated patients was in 71% of patients with ICC and in 96% with PCC. Median 54% after one and 25% after 5 years (median survival 1.24 survival of patients with 0, 1 to 3 and more than 3 LNs years). In univariate analysis the CHILD-score (p < 0.001), retrieved was respectively 31, 37 and 36 months for ICC MELD-score (p < 0.001), ASA-score (p = 0.05), emergency (p = 0.53) and 3, 18 and 34 for PCC (p < 0.01), respectively. procedures (p < 0.001), viral hepatitis (p < 0.01 vs alcoholic/ Median survival of patients with negative LN (N0) and other origin), hyponatremia (p < 0.01) and major proce- with LN metastasis (N+) was 43 and 19 months in ICC (p = dures (p < 0.03 vs minor) were associated with decreased 0.03) and 42 and 20 months in PCC (p = 0.01), respectively. survival. In multivariate analysis CHILD- (p < 0.02) and Median survival of patients with up to 3 N+ and more than MELD-score (p < 0.001), ASA-class (p < 0.01), preopera- 3 N+ was 52 and 7 months in ICC (p < 0.01), and 26 and tive hyponatremia and thrombocytopenia were indepen- 11 months in PCC (p < 0.01). Median survival of patients dently associated with poor prognosis. II) Survival in 143 with LNR up to 0.25 and greater than 0.25 was 42 and 14 patients discharged after surgery was 68% after one and months in ICC (p = 0.01), and 37 and 11 months in PCC, 32% after 5 years (median survival 2.8 years). Long-term respectively (p < 0.01). At multivariate survival analysis survival (univariately) correlated with CHILD- and MELD- LNR and macroscopic vascular invasion were signifi cantly scores (p < 0.01/ < 0.001), (preoperative) hyponatremia (p related to survival with hazard ratios of 3.00 (95% CI 1.69– Poster Abstracts < 0.01) and ASA class (p < 0.05). In multivariate analysis 5.34; p < 0.001) and of 1.90 (95% CI 1.17–3.07; p = 0.009) the MELD-score (p < 0.001) and hyponatremia (p < 0.01) respectively. Monday but not signifi cantly the CHILD-score (p = 0.06) or ASA- CONCLUSIONS: LN metastasis is a major prognostic fac- class independently predicted the outcome after hospital tor for survival after surgical resection of ICC and PCC. discharge. Neither an underlying malignant disease nor age Lymphadenectomy should be performed because number nor emergency operations independently correlated with of LN retrieved and LNR showed high prognostic value. long-term survival. LNR can stratify patients with positive LNs and identify CONCLUSIONS: Long-term survival in patients with liver patients with not favourable prognosis that might be fea- cirrhosis requiring general surgery is poor. In the entire sible of adiuvant therapy. patient group poor liver function and, in part, factors infl uencing postoperative mortality like comorbidity (ASA) or thrombocytopenia are prognostic factors. In patients surviving the early postoperative period the long-term outcome is determined mainly by the natural course and severity of liver disease (MELD better than Child).

137 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1496 RESULTS: The primary endpoint occurred in 6.7% (n = 6) of operations and was signifi cantly associated with platelet Serum Markers for Predicting Surgical Outcomes count <80, hemoglobin (Hb) <10, total protein (TP) <6, in Patients with Cirrhosis lactate dehydrogenase >220, albumin <2.8, INR >1.4, and Edward Chu, Andrew N. Harrington, Malika Garg*, Cr >1.2, and total bilirubin (TB) >2. The secondary end- Celia M. Divino point occurred in 42.7% (n = 38) of operations and was Surgery, The Mount Sinai School of Medicine, New York, NY signifi cantly associated with Hg <10, TP <6, albumin <2.8, INR >1.4, and TB >2. Transaminases (AST and ALT), alka- INTRODUCTION: Predictors of post-operative outcomes line phosphatase, white blood count and gamma-glutam- for patients with liver disease who undergo general surgical yltransferase showed no signifi cant association with the procedures have not been adequately assessed. Coagulation primary or secondary endpoint. status consisting of a complete blood count (CBC), pro- CONCLUSION: thrombin time (PT), partial thromboplastin time (PTT) and The current classifi cation systems utilized international normalized ratio (INR) is the only routinely for risk stratifi cation in cirrhotic patients undergoing gen- measured preoperative screening tool. Child-Pugh and eral surgery are not optimal. Preliminary analysis shows Model for End-Stage Liver Disease (MELD) scores have also candidate serum markers for predicting 30 day complica- been used to estimate perioperative risk but with inconsis- tion and mortality rate. These additional indicators can be tent results. The aim of this study is to identify if certain used to supplement the Child-Pugh and MELD scores in serum assays of the liver function panel and hematologi- assessing surgical outcomes. cal parameters are associated with increased morbidity and mortality in cirrhotic patients who undergo abdominal Clinical: Pancreas surgery. METHODS: After receiving IRB approval, a retrospective chart review was performed which identifi ed 83 cirrhotic Mo1498 patients who underwent 89 abdominal surgical procedures Quality of Life in Patients After Total Pancreatectomy between 2001 and 2008 at Mount Sinai Medical Center. Pre-operative demographic information, comorbidities, Is Comparable to Quality of Life in Patients After a etiology of cirrhosis, and serum test results consisting of Partial Pancreatic Resection PT, PTT, INR, CBC, liver function panel, blood urea nitro- Irene Epelboym*, Megan Winner, Joseph Dinorcia, gen (BUN), and creatinine (Cr) were collected. The primary Minna K. Lee, James A. Lee, Beth Schrope, John A. Chabot, endpoint was 30-day post-operative mortality. The second- John D. Allendorf ary endpoint was development of post-operative compli- Surgery, New York Presbyterian, Columbia University, New York, NY cation prior to discharge, 30-day readmission or 30-day BACKGROUND: re-operation. Univariate analysis was performed using chi Quality of life after total pancreatectomy square test and Student’s t test. Associations with p values is perceived to be poor secondary to insulin-dependent less than 0.05 were considered signifi cant. diabetes and pancreatic insuffi ciency. As a result, surgeons may be reluctant to offer this treatment for benign and Table 1. Mortality and Complication Rate premalignant diseases. METHODS: We retrospectively reviewed a prospectively maintained database of pancreatic operations and identifi ed patients who underwent a total pancreatectomy between 1994 and 2011 at our institution. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Quality of life was assessed using institutional questionnaires and validated general, pancreatic disease-related, and diabetes-related instruments (EORTC QLQ-C30, EORTC-PAN26, ADD-QOL) in patients alive at the time of analysis, and compared with frequency-matched controls, patients after a pancreaticoduodenectomy. Continuous variables were compared using Student’s t-test or ANOVA. Categorical variables were compared using chi-square or Fisher’s exact test. RESULTS: Between 1994 and 2011, 77 total pancreatectomies were performed, 39 for benign or premalignant, and 38 for malignant disease. Overall morbidity after total pancreatectomy was 49%, but only 12 (16%) patients experienced a major complication. Perioperative mortality was 2.6%. At the time of this study, 33 (43%) patients were alive and 25 agreed to participate in the survey; fi nal

138 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

results represent aggregate responses of 15 (10 benign Mo1499 and premalignant, 5 malignant). Mean time between surgery and survey administration was 3.2 years. Scores were Defi ning Quality for Distal Pancreatectomy: Does the compared with 14 matched patients who underwent pan- Laparoscopic Approach Protect Patients from Poor creaticoduodenectomy (10 benign and premalignant, 4 Quality Outcomes? malignant; 8 with postoperative diabetes). There were no Marshall Baker*1,2, Karen L. Sherman3, Amanda V. Hayman3, statistically signifi cant differences in quality of life in the Richard Prinz1,2, David J. Bentrem3, Mark Talamonti1,2 global health, functional status, or symptom domains of 1. Surgery, NorthShore University Health System, Evanston, IL; the EORTC QLQ-C30 or in the pancreatic disease-specifi c EORTC-PAN26 between total and partial pancreatectomy 2. Surgery, University of Chicago, Pritzker School of Medicine, patients, regardless of fi nal pathology. Total pancreatec- Chicago, IL; 3Surgery, Northwestern University, Feinberg School of tomy patients had slightly but not signifi cantly higher Medicine, Chicago, IL incidence of hypoglycemic events as compared to partial OBJECTIVES: Established systems for grading postopera- pancreatectomy patients with postoperative diabetes. The tive complications do not change the assigned grade when negative impact of diabetes as assessed by the ADD-QOL multiple interventions or readmissions are required to man- did not differ between total and partial pancreatectomy age the complication. We seek to defi ne a quality outcome patients. Life domains most negatively impacted by diabe- for distal pancreatectomy (DP) and determine if laparo- tes involved travel and physical activity, while self-confi - scopic distal pancreatectomy (LDP) affords an improvement dence, friendships and personal relationships, motivation, in quality relative to open distal pancreatectomy (ODP). and feelings about the future remained unaffected. METHODS: Inpatient and offi ce charts for patients undergoing either ODP or LDP between January 2006 and Decem- ber 2009 were reviewed to capture all complications and 90-day readmission events. Clavien-Dindo grade IIIb, IV and V complications were classifi ed as severe adverse postoperative outcomes (SAPO). II and IIIa complications requiring either prolonged overall lengths of stay (>2 standard devia- tions beyond the mean for patients undergoing ODP without complication) including readmissions or more than one interventional procedure were also classifi ed as SAPOs. All others were considered minor adverse outcomes (MAPO). RESULTS: 127 patients underwent DP. 63 (49%) had a complication. 91% of DP patients had a complication of low/ moderate Clavien-Dindo grade (I, II, IIIa) or no complication. Using our re-classifi cation, however, 24.8% had what was considered to be a poor quality outcome (SAPO) while 75.2% had a high quality outcome (MAPO or no complication). Of the patients undergoing DP, 77 underwent ODP and 50 underwent LDP. Compared to patients undergoing ODP, patients undergoing LDP were statistically less likely to have ductal adenocarcinoma (4% vs. 26%, p < 0.01) and tended to have smaller tumors (3.1 + 0.36 cm vs. 3.9 + 0.26 cm, p = 0.05). Those undergoing LDP did also demonstrate, however, lower volumes of intraoperative blood loss (234+30.1 mLs vs 752 + 152.7 mLs, p < 0.01), lower rates of Poster Abstracts postoperative transfusion (2% vs 20%, p < 0.01), lower rates of postoperative morbidity (35% vs 58%, p < 0.01), shorter Monday initial postoperative lengths of stay (4.1 + 0.23 vs 8.3 + 0.7 days, p < 0.01), shorter overall lengths of stay including 90-day readmissions (6.1 + 0.9 days vs. 10.51 + 0.9 days, p < 0.01), and were less likely to have a poor quality (SAPO) outcome (15% vs 31%, p = 0.02)than those undergoing ODP. There were no statistical differences between the two groups in regard to age, presenting symptoms, incidence of diabetes, chronic pancreatitis or comorbid cardiopulmonary disease, preoperative albumin, operative time, the rate of readmission or of pancreatic fi stula. CONCLUSIONS: While total pancreatectomy-induced CONCLUSIONS: Generic grading systems underestimate diabetes negatively impacts select activities and functions, the severity of some complications following distal pancre- overall quality of life is comparable to that of patients after atectomy. Using a procedure specifi c metric for quality fol- a partial pancreatic resection. lowing distal pancreatectomy, LDP affords a higher quality postoperative outcome than ODP resulting in shorter initial and overall lengths of stay, a lower incidence of postoperative transfusion and a lower incidence of severe adverse postoperative outcomes.

139 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1500 Mo1501 Clinical Pathway for Pancreaticoduodenectomy Postoperative Systemic Infl ammatory Response Improves Short Term Outcomes at a Rural Tertiary Syndrome Is a Predictor of Major Complication Care Center After Pancreatoduodenectomy Halle Beitollahi*, Erica L. Case, Nicole L. Woll, Naru Kondo*, Clancy J. Clark, Florencia G. Que, Kaye M. Reid Mohsen M. Shabahang, Angela Huttenstine, Lombardo, David M. Nagorney, John H. Donohue, Kathy J. Gorton, Marie A. Hunsinger, Joseph A. Blansfi eld Michael B. Farnell, Michael L. Kendrick General Surgery, Geisinger Medical Center, Danville, PA Mayo Clinic, Rochester, MN INTRODUCTION: Pancreaticoduodenectomy (PD) is a BACKGROUND: Pancreatoduodenectomy (PD) has long complex procedure with historically high rates of morbid- been associated with high rates of morbidity and mortality. ity but can be performed effi ciently at high volume cen- Identifi cation of early predictors of postoperative compli- ters. Clinical pathways increase effi ciency for multiple cations is important to minimize the morbidity of PD. operations including PD and have been shown to decrease OBJECTIVE: To assess the usefulness of systemic infl am- length of stay and cost of PD at academic institutions. Our matory response syndrome (SIRS) as a predictor of major goal was to study implementation of a clinical pathway for complications after PD. PD at a rural tertiary care center to determine if length of stay decreased post implementation. HYPOTHESES: 1) Early SIRS (postoperative day [POD] METHODS: ≤3) can predict major complications after PD. 2) Late SIRS Patient outcomes prior to and following (POD 4–7) can predict late major complications (≥POD 8) implementation of a PD clinical pathway were studied after PD. between January 2006 and February 2011. Thirty fi ve patients underwent PD prior to implementation of the clin- METHODS: A retrospective cohort study of 527 consecu- ical pathway and twenty two underwent PD after imple- tive patients who underwent PD between 2007 and 2010 mentation. Primary outcomes included hospital length of was performed. Incidence of SIRS was investigated three stay and intensive care unit length of stay; operative time times a day (at the nearest point of 8, 16 and 24 o’clock) and estimated blood loss were analyzed as well. The path- from POD 1 to POD 7. SIRS was diagnosed based on the way consists of pre-established daily goals; implementation standard criteria including body temperature, heart rate, began at the pre-operative visit and goals were set for the respiratory rate and white blood cell count. A day of SIRS operative and the post-operative course. was defi ned by meeting the criteria of SIRS at two or more RESULTS: points during the same day. Postoperative incidence of SIRS The two groups were well matched in terms of was classifi ed into two groups: Early SIRS (at least one day age, gender, BMI, and histology. The primary outcome was of SIRS between POD 1 and 3), and Late SIRS (at least one length of stay, determined to be 14 days prior to pathway SIRS positive day between POD 4 and 7). The relationship implementation and 7 days following pathway implemen- between clinicopathological factors, Early and Late SIRS, tation (p < 0.0001). Operative time was also statistically and major complications was evaluated by univariate and shorter in the pathway group. There was no statistically multivariate analyses. signifi cant difference in length of intensive care unit stay between the two groups. RESULTS: Early and Late SIRS presented in 193 (37%) CONCLUSION: and 121 (23%) patients, respectively. Major complications Implementation of a clinical pathway for were observed in 149 patients (28%) with72 (13%) patients PD is possible at a rural tertiary care center. Following our developing late. Sixty-day mortality was 1.3%. Total num- pathway led to more reproducible post operative care. At ber of days with SIRS was associated with severity of com- our institution this pathway led to a decrease in length of plication (P < 0.001). Incidence of Early SIRS was associated stay and thereby improved short term patient outcomes. with postoperative major complication (P < 0.001) with a sensitivity and specifi city of 57% and 71%, respectively. Multivariate analysis demonstrated that the incidence of Early SIRS (HR 2.5, 95% CI, 1.6–3.9, P < 0.001), soft pancreatic texture (HR 2.4, 95% CI 1.4–3.8, P < 0.001), and prolonged operative time (>360 min) (HR1.6, 95% CI 1.1–2.5, P = 0.02) were independent risk factors for major complications after PD. For late complications, multivariate analysis demonstrated that Late SIRS (HR 3.6, 95% CI 1.8–7.1, P < 0.001), soft pancreatic texture (HR 2.1, 95% CI 1.1–4.1, P = 0.01), and male patients (HR, 1.9, 95% CI 1.1–3.6, P = 0.02) were identifi ed as independent risk factors. CONCLUSION: In a large cohort of pancreaticoduodenectomy patients, early postoperative SIRS (POD ≤ 3) was an independent predictor of major complications after PD; and, similarly, Late SIRS (POD 4–7) independently predicted late major complications (≥POD 8).

140 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1502 to REINF. Heterogeneity was calculated for prospective, retrospective and combined data. Prospective data had a Bioabsorbable Staple Line Reinforcement Reduces Risk Q-statistic of 0.44 with I2 of 0, consistent with low het- of Fistula Following Pancreatic Resection erogeneity. In contrast, retrospective data had Q-statistic of Eric H. Jensen*1, Ming Teng2, Jessica Chowaniec2 11.62 (p-value 0.02) with I2 of 66, indicative of moderate 1. Surgery, University of Minnesota Medical Center, Minneapolis, MN; to severe heterogeneity. This is consistent with our observa- 2. Covidien, New Haven, CT tion that prospective studies all identifi ed similar increased RR of leak with STPL technique, while there was confl icting BACKGROUND: Pancreatic fi stula remains a common data in the retrospective group. A forest plot summarizing post-surgical complication following stapled pancreatic the relative risk of pancreatic fi stula for the 5 prospective transection. Surgical staple line reinforcement with bio- studies is shown in Figure 1. absorbable materials has grown in popularity in recent years with hopes that they may reduce pancreatic leaks. We sought to determine whether staple line reinforcement reduces risk of pancreatic fi stula compared to bare metal staples. METHODS: We performed a meta-analysis of existing data regarding pancreatic fi stula following stapled pancreatic transection, comparing bare metal staples to reinforced staple loads. RESULTS: We identifi ed 10 manuscripts between 2007 and 2009 reporting outcomes following stapled division of the pancreas, comparing bare staples (STPL) to reinforced staples (REINF). Five retrospective reviews and 5 prospective case series were included (Table 1). A total of 483 stapled pancreatic resections are included in this meta-analysis. Of these, 234 (48%) were REINF and 249 (52%) were STPL. Out of 483 cases, there were a total of 100 documented pancreatic leaks (21%). Sixty-one leaks were reported out of 249 STPL divisions (24%), while 39 leaks were reported Figure 1: Forest Plot summarizing prospective studies to date. Meta- following REINF division (17%). The overall relative risk analysis indicates signiﬁ cantly increased risk of pancreatic leak with bare of developing a pancreatic fi stula following distal pancre- staples (STPL) compared to reinforced staple loads (REINF). atectomy was not signifi cantly different comparing STPL to REINF when all studies were combined (RR 1.00 95%CI CONCLUSION: 0.65–1.53). We further evaluated the data stratifying by We have identifi ed a signifi cant reduc- study design (prospective or retrospective). In doing this, tion in risk of pancreatic fi stula comparing reinforced to we found that prospective studies reported a signifi cantly bare staples. Ideally, a randomized clinical trial should be higher risk of pancreatic fi stula with STPL compared to performed to validate our observations. In the absence of REINF technique (RR 14.45, 95% CI 3.15–66.21). Both that, however, reinforced staples should be the preferred fi xed and random effects models for the retrospective data method of pancreatic stump closure following distal revealed similar RR for pancreatic fi stula comparing STPL pancreatectomy. Poster Abstracts

Table 1: Summary of Studies Included in this Meta-Analysis with Total Number of Pancreatic Surgeries and Pancreatic Leaks Identiﬁ ed Monday

Study Type Study (Year) STPL Total STPL Leaks REINF Total REINF Leaks Prospective Rotellar (2008) 2 2 (100%) 7 0 (0%) Pugliese (2008) 6 4 (67%) 7 0 (0%) Melotti (2007) 51 16 (31%) 7 0 (0%) Thaker (2007) 11 4 (36%) 29 1 (3%) Jiminez (2007) 18 7 (39%) 13 0 (0%) Retrospective Yamamoto (2009) 25 5 (20%) 47 2 (4%) Johnson (2009) 44 7 (16%) 70 7 (10%) Ferrone (2008) 41 10 (24%) 45 15 (33%) Guzman (2009) 15 3 (20%) 15 11 (73%) Laxa (2008) 21 3 (14%) 9 3 (33%)

141 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1503 The results are summarized in the following Table.

Indications for Total Pancreatectomy and Islet TP + IAI for Indications Other Than Intractable Pain in Chronic Auto-Infusion Beyond Chronic Pancreatitis with Pancreatitis Intractable Pain Luis F. Lara1, Marlon F. Levy*2,4, Morihito Takita4,5, Patient 1 Patient 2 Patient 3 Shinichi Matsumoto4,5, Daniel C. Demarco3,4 basal c-peptide 1.8 ng/ml 0.9 ng/ml 0.5 ng/ml 1. Department of Gastroenterology, Cleveland Clinic Florida, Weston, basal SUITO index 73 46.6 6.6 FL; 2. Division of Gastroenterology, Baylor All Saints Medical Center, Total islet yield (IE) 500,351 212,463 Impossible to remove Fort Worth, TX; 3. Division of Gastroenterology, Baylor University head of pancreas Medical Center at Dallas, Dallas, TX; 4. Baylor Regional Transplant Institute, Dallas, TX; 5Baylor Research Institute, Dallas, TX IE/kg 4313 3708 post IAI c-peptide 0.7 ng/ml 0.5 ng/ml BACKGROUND/AIMS: Total pancreatectomy with islet auto-infusion (TP + IAI) is effective in selected patients post IAI SUITO index 10.5 5.8 with chronic pancreatitis (CP) who have intractable pain Insulin need *Partial *Partial unresponsive to medical and interventional therapies. IAI can maintain adequate glycemic control, possibly insulin TP = total pancreatectomy; IAI = islet auto-infusion; *Partial = c-peptide independence, and has been used in selected cases fol- measurable but insulin needed for glycemic control lowing total pancreatectomy for IPMN, pancreas trauma CONCLUSIONS: The pt with IRAP had a higher c-peptide, or pancreas necrosis with persistent leak. We report our SUITO index and islet yield compared to the patient with experience with TP + IAI for indications beyond chronic HP, but post-procedure c-peptide and glycemic control pancreatitis. were similar. Despite purity of the pancreas extract ductal METHODS: TP + IAI has been performed since 2006 at cells could have been injected into the portal vein, which BUMC. Pancreata are preserved using chilled ET-Kyoto was explained to the patient with HP and who consented. solution and using the oxygen-charged static two layer As TP + IAI becomes more routine studies are needed to method. Digestion is by the modifi ed Ricordi method, and understand its application beyond treatment of intractable purifi ed when over 10 ml of tissue is obtained and then pain and glycemic control in CP. injected into the portal vein. A SUITO index of >10 and islet yield of 500,000 correlates with increased insulin inde- Mo1504 pendence. Patients who had the procedure for a diagnosis other than chronic pancreatitis and intractable pain were Does Pancreatic Stump Closure Method Infl uence selected from the IRB approved database. Fistula Rate After Distal Pancreatectomy RESULTS: Thirty seven patients had a TP + IAI since 2006; Eugene P. Ceppa*, Robert M. Mccurdy, Molly Kilbane, 34 patients had CP confi rmed by CT/MRI and/or EUS/ Attila Nakeeb, C. Max Schmidt, Nicholas J. Zyromski, ERCP, endoscopic secretin stimulated pancreas function Keith D. Lillemoe, Henry A. Pitt, Michael G. House testing (ePFT) and histology. Three patients had the proce- Surgery, Indiana University Medical Center, Indianapolis, IN dure for other indications and are reported. INTRODUCTION: Pancreatic fi stula (PF) remains the Patient 1: 32 y/o F with idiopathic recurrent acute pancre- primary morbidity following distal pancreatectomy (DP). atitis (IRAP)resulting in multiorgan failure (MOF), ARDS Previous studies have reported specifi c methods of paren- and ventilator dependency with each attack. EUS/ERCP chymal transection and sealing in an effort to decrease the were not diagnostic of CP, ePFT was normal. No evidence PF rate with highly variable results. The aim of this study of endocrine/exocrine failure. No genetic mutations found. was to determine the pancreatic fi stula rate following vari- Decision to perform TP + IAI after last admission with 2 ous sealing methods. month hospitalization with MOF. METHODS: All cases of DP were reviewed at a single high- Patient 2: 31 y/o M with hereditary chronic pancreatitis volume institution between January 2008 and June 2011. (HP) with PRSS1 (R122H) mutation, mother with CP and Sealing method of the pancreatic stump was used to create PRSS1, 2 family members with CP, 2 family members with operation groups (suture, staple, or saline linked radiofre- pancreas cancer (<55 y/o). Intermittent pain exacerbations quency (SLRF)). All cases were monitored with complete treated mostly at home. Decision to perform procedure due 30-day outcomes through the American College of Sur- to known mutation and family history of cancer. geons-National Surgical Quality Improvement Program Patient 3: 62 y/o F with ampullary adenoma, recurrent high (ACS-NSQIP). Two and three-way statistical analyses were grade dysplasia despite repeated ampullectomies compli- performed among the operation groups. cated by pancreas necrosis, and distal pancreatectomy with persistent leak. Decision to perform procedure as a completion pancreatectomy was expected.

142 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: Two hundred and three patients underwent DP Mo1505 over the 42-month period. The most common diagnoses included pancreatitis (32%), adenocarcinoma (19%), and Reduction in Delayed Gastric Emptying Following IPMN (13%) which did not differ signifi cantly among the Non-Pylorus Preserving Pancreaticoduodenectomy by 3 operation groups. The suture, staple, and SLRF groups Addition of Braun Enteroenterostomy included 90 (44%), 61 (30%), and 52 (26%) patients, Mehrdad Nikfarjam* respectively. Operative technique included open (68%) and Surgery, University of Melbourne, Melbourne, VIC, Australia minimally invasive (32%) approaches and did not differ among the stump sealing groups. Thirty-six patients (59%) BACKGROUND: Delayed gastric emptying (DGE) is a within the staple group received staple line reinforcement major cause of morbidity following pancreaticoduodenec- with bioabsorbable material. Postoperative outcomes for tomy (PD), with various factors implicated in its devel- the three groups of patients are summarized in the table. opment. The infl uence of operative technique on the Overall complications and PFs were similar in each group. occurrence of DGE is controversial. The impact of a Braun Operative technique was not associated with the need for enteroenterostomy (BE) in reconstruction following classic carryover outpatient drainage, postoperative interven- PD was assessed. tional drain placement, or hospital readmission. METHODS: Forty-four consecutive patients undergoing non-pylorus preserving PD from August 2009 to November SLRF, Staple, Suture, 2011 by a single surgeon were included in this study. The N = 52 N = 61 N = 90 p-Value* fi rst twenty patients had a standard antecolic gastrojejunal anastomosis. The subsequent twenty-four patients had an Overall complications 16 (31%) 23 (38%) 35 (39%) 0.61 antecolic gastrojejunal anastomosis with the addition of a Pancreatic ﬁ stula 13 (25%) 16 (26%) 23 (26%) 0.95 BE. The groups were compared and complications assessed according to criteria set by the International Study Group Panc ﬁ stula grade B/C 6 (11%) 11 (18%) 15 (17%) 0.60 of Pancreatic Surgery (ISGPS). Home drain 4 (8%) 10 (16%) 15 (17%) 0.29 RESULTS: Patient characteristics between the groups were IR drainage procedure 6 (11%) 6 (10%) 13 (14%) 0.71 similar as was the extent of surgery and tumour and pan- 30d hosp readmission 7 (14%) 14 (23%) 17 (19%) 0.44 creatic characteristics. The median estimated blood loss was greater in the standard reconstruction group (450 ml *Chi-square correlations among all three groups (100–1500) vs 325 (100–1500 ml) p = 0.04). All other operative factors, including intra-operative blood transfusions CONCLUSIONS: Postoperative outcomes after distal pan- were similar between the two groups. The DGE rate in the createctomy are unaffected by the use of SLRF sealing of the BE was signifi cantly lower than the standard reconstruc- pancreatic stump when compared to traditional suture or tion group (1 (4%)versus 7 (35%); p = 0.015). In the stan- reinforced stapling techniques. A randomized clinical trial dard group, 6 of 7 cases of DGE were Class C in nature. The comparing these three operative techniques may not dem- pancreatic fi stula rate in the BE group was similar to the onstrate a difference that is clinically signifi cant. standard reconstruction group (4 (21% versus 5 (29%); p = 0.706) as was the median length of hospital stay (10 days (7–38) vs 15 (7–45); p = 0.291). On assessing factors associated with DGE, the BE technique was the only signifi cant factor in this study. CONCLUSION: The use of BE following non-pylorus pre-

serving PD appears to results in a signifi cant reduction in Poster Abstracts DGE. Monday

143 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1506 Mo1507 Duct-to-Mucosa Pancreaticogastrostomy Reduces Risk Factors, Hospital Cost, and Complications Postoperative Pancreatic Stump Leak Rates After Associated with Transfusion in Elective Distal Pancreatectomy Pancreatectomy Yasushi Hashimoto*, Yoshiaki Murakami, Kenichiro Uemura, Raphael C. Sun*1, Anna M. Button2, Brian J. Smith2, Takeshi Sudo, Akira Nakashima, Taijiro Sueda Hisakazu Hoshi1, Richard F. Leblond3, Howe R. James1, Department of Surgery, Division of Clinical Medical Science, Graduate James J. Mezhir1 School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan 1. Surgery, University of Iowa, Iowa City, IA; 2. Biostatistics, BACKGROUND: Pancreatic stump leak is the major source University of Iowa, Iowa City, IA; 3. Internal Medicine, University of morbidity after distal pancreatectomy. We hypothesized of Iowa, Iowa City, IA that a duct-to-mucosa pancreaticogastrostomy after distal BACKGROUND: There is now increased awareness of the pancreatectomy (DP-PG) can decrease pancreatic fi stula detrimental effects of transfusion in elective general surgi- (PF) rates when compared to hand-sewn or staple closure. cal procedures. Our objectives are to determine 1) which Since 2008, we conducted the nonrandomized cohort study preoperative clinical variables can predict the need for with a prospective DP-PG group, forming our experimental intraoperative transfusion and 2) the impact of transfusion group, and a retrospective control group undergoing hand- sewn closure. The aim of this study is to analyze the safety on hospital costs and complications in pancreatectomy. and effi cacy of this method. METHODS: Using our prospective institutional and ACS- METHODS: DP-PG was intended to prevent PF after DP NSQIP database, we identifi ed 173 patients who had elec- in 30 patients between April 2008 and November 2011. A tive pancreatectomy from 9/2007 to 9/2011. Univariate historical control group was composed of 30 consecutive and multivariate analyses were performed using 24 preop- patients undergoing hand-sewn closure between January erative clinical variables to identify risk factors associated 2005 and March 2008. Main outcome measure was inci- with transfusion. Preoperative severity of illness (SOI) and dence of PF which was defi ned and graded according to the mortality risk were determined using the Agency for Health International Study Group on Pancreatic Surgery (ISGPS) Research and Quality (AHRQ) Risk Adjustment Score, a classifi cation. Secondary measures were complications standardized metric used by the University Health System which were assessed by the Clavien classifi cation and post- Consortium. Hospital costs and operative complications operative hospital length of stay. Two groups were com- were also evaluated. pared using Kruskal-Wallis test or chi-square tests. RESULTS: Patients had left pancreatectomy (n = 60) or RESULTS: Overall, a cohort of 60 patients underwent pancreaticoduodenectomy (n = 113) to treat malignant DP between 2005 and 2011. In the DP-PG group (n = 30), (n = 134) or benign (n = 39) disease. Median OR time was none PF was observed in 19 patients (63%), Grade A was 7.4 hours (2.4–12.3). Median LOS was 10 days (4–77) and 10 (33%), Grade B was 1 (3%), and Grade C was none. In 51 patients (29%) spent at least one night in the ICU. 98 the control group (n = 30), none PF was observed in 17 patients (56.6%) had a complication and 90-day mortality patients (57%), Grade A was 7 (23%), Grade B was 5 (17%), was 2.9% (n = 5). SOI at admission was minor in 21 patients and Grade C was 1 (3%). Therefore the clinically-relevant PF (ISGPS Grade B/C) rate was signifi cantly lower in the (12.1%), moderate in 59 (34.1%), and major/extreme in 43 DP-PG group (3%) comparing to the control group (20%; P (24.8%). Risk of mortality at admission was: minor (n = 91, = 0.01). Re-operation was required for one patient in both 53%), moderate (n = 58, 34%), and major (n = 24, 14%). groups, but no one was due to PF. The mortality was zero in There were 78 patients (45%) who received at least 1 unit both groups. The operative time was slightly longer in the of blood and the median number of intraoperative transfu- DP-PG group (median, 237 min) comparing to the control sions was 3.0 units (1–55); 11 of these patients (6.4%) also group (198min, P = 0.05). The Clavien III-V severe compli- received plasma. Mean total hospital costs observed was cations were observed in 2 patients (7%; none for PF) in the $39,434 ($13,285-$251,157). Compared to patients who DP-PG group, but in 4 patients (13%) in the control group. did not receive a transfusion, those who received at least Development of a pancreatic leak resulted in prolonged one blood product had a higher mean hospital cost and hospital stays: 20 days in the DP-PG group vs. 29 days in hospital charges (Table 1). Among transfused patients, 65% the control group (P = 0.03). The advantage of this technique is that pancreatic juice leaking from smaller branches (n = 51) experienced at least one complication vs. 49% (n = on the cut surface which cannot be drained through the 47) of patients not transfused (p = 0.036), including infec- remnant main duct directly passes into the stomach and tious complications and pancreatic fi stula/leak/abscess also allows decompress the intraductal pressure through (Table). In multivariate analysis, independent predictors the anastomosis. of increased transfusion likelihood included lower hema- CONCLUSIONS: tocrit, increased BMI, and worse AHRQ SOI and mortality Drainage through the pancreatic stump risk scores. Age, gender, comorbidities, diagnosis, ASA class, provided by duct-to-mucosa pancreaticogastrostomy after procedure, OR time, and ICU stay were not independent distal pancreatectomy (DP-PG) appears to have abruptly reduced clinically-relevant PF (ISPGS Grade B/C) rate and predictors of transfusion risk. hospital stay. The economic impact of lower leak rates is refl ected in lower morbidity rate and signifi cantly shorter hospital stays. The results of our study should be validated in a randomized controlled trial.

144 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Table 1: Cost and Complications Associated with Transfusion in Pancreatectomy Infectious Grade III Pancreatic Transfusion Hospital Cost p-Value (a) Hospital Charges p-value (a) Complication p-Value (b) Fistula/Leak/Abscess p-Value (b) Yes No $53,239 <0.0001 $123,978 $66,023 <0.0001 46% 18% <0.0001 22% 3% 0.001 $28,099 *p-values determined using (a) two-sample t-tests and (b) chi-square tests.

CONCLUSIONS: Blood transfusion is associated with pancreas. The groups were similar for gender, ethnicity, increased hospital cost and morbidity in pancreatectomy. and in-hospital mortality rates but cancer patients were on Factors associated with increased risk for transfusion such average 6.9 years older (P = 0.0001) and had higher Charl- as preoperative hematocrit, BMI and AHRQ scores can be son comorbidity indices (scores ≥2: 75.5% vs. 50.8%, P = utilized to stratify patients in clinical trials and inform 0.0001). On univariate analyses, patients undergoing LDPs patients of their risk for transfusion. Further research is for malignancies had longer lengths of stay (8.95 vs. 6.89 needed to determine the extent to which transfusion con- days, P = 0.02), higher overall complication rates (34.4% vs. tributes to morbidity and cost independently of SOI. 22.0%, P = 0.045), more inadvertent organ injuries (5.5% vs. 1.1%, P = 0.03), higher splenectomy rates (93.8% vs. Mo1508 71.4%, P < 0.0001) and increased requirements for blood transfusions (15.8 vs. 6.6%, P = 0.019). On multivariate Laparoscopic Distal Pancreatectomy for Benign and analyses, LDPs performed for cancer were associated with a Malignant Lesions: A Nationwide Analysis of Patient statistically signifi cant increase in the incidence of splenec- Outcomes tomy (OR 5.92, 95% CI 2.32–15.1). In contrast, there were Hop S. Tran Cao*, David Chang, Andrew M. Lowy, no differences in individual complication rates, including fi stulae, infections/abscesses, hemorrhage/hematomas, Michael Bouvet, Mark A. Talamini, Jason K. Sicklick inadvertent organ injuries, wound complications, organ Department of Surgery, University of California, San Diego, dysfunction, thromboembolic events, or in-hospital mor- La Jolla, CA tality based upon disease indication for LDP. BACKGROUND: Laparoscopic distal pancreatectomy CONCLUSIONS: The reported experiences of single or (LDP) was fi rst reported in 1996. Since then, all publica- multiple institutions with LDP for cancerous lesions of the tions evaluating LDP have consisted of single center or pancreas remain limited. We now report the nationwide multi-institutional case series. We hypothesized that a experience and outcomes of LDP for patients with benign national database inquiry could offer insight into the indi- and malignant pancreatic diseases utilizing a national data- cations and outcomes of LDP. base. We show that patients undergoing LDP for pancreatic METHODS: The Nationwide Inpatient Sample was que- cancer tend to be older, have more comorbities, and are ried for patients undergoing LDP for benign and malig- more likely to undergo concurrent splenectomy. However, nant pancreatic lesions from 1998 to 2009. Univariate on multivariate analyses, this does not result in increased and multivariate analyses were performed using logistic in-hospital morbidity or mortality rates. In summary, the regression models, adjusting for age, gender, ethnicity, and application of laparoscopic distal pancreatic resections for comorbidities. malignancies has emerged as a feasible and safe approach with comparable outcomes to resections performed for RESULTS: 1,908 LDPs were performed between 1998 and benign pancreatic lesions. However, long-term oncological

2009. 506 cases were excluded due to unclearly coded Poster Abstracts outcomes need to be better studied before this technique ICD-9 diagnoses. The remaining 1,402 LDPs were coded can be widely accepted as standard of care. for benign (57.8%) or malignant (42.2%) diseases of the Monday

145 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1509 Contemporary Treatment and Outcomes of Periampullary Adenocarcinomas at a Single Institution Vei Shaun Siow*, Zhi Ven Fong, Harish Lavu, Eugene P. Kennedy, Patricia K. Sauter, Leonidas Koniaris, Ernest L. Rosato, Charles J. Yeo, Jordan M. Winter Thomas Jefferson University Hospital, Philadelphia, PA INTRODUCTION: Periampullary adenocarcinoma (PA) is the most common indication for pancreaticoduodenectomy (PD). The four cancers that comprise the PAs include pancreatic ductal (PDA), ampullary (AA), distal common bile duct (CBDA), and duodenal adenocarcinoma (DA). While PDA has been studied extensively, it is unclear whether these data are applicable to the rarer PAs. Kaplan-Meier survival curves for patients with periampullary METHODS: We queried our institutional PD database for adenocarcinoma. patients treated for PA from November 2005 to October 2011. Out of 650 resections, 390 (60%) patients had PA. Clinicopathologic data were analyzed, and statistical com- CONCLUSIONS: These fi ndings support the notion that parisons between PA subtypes were made with respect to PAs are a heterogeneous group. As compared to AAs and PDA, unless otherwise indicated. We aimed to identify the DAs, PDAs had more aggressive pathologic features and differences in the biology, natural history, and treatment worse long-term survival. In addition, CA19–9 was a more patterns between PAs. sensitive test for PDAs than the non-pancreatic PAs. Our RESULTS: The 390 resected PAs included 293 (75%) PDAs, practice patterns approach pancreatobiliary cancers pri- 48 (12%) AAs, 28 (7%) distal CBDAs, and 21 (5%) DAs. Pre- marily with gemcitabine-based treatment, which differs operative CA 19–9 levels were elevated in 76% of patients from the approach with the other subtypes. with PDA, 56% with distal CBDs (p = 0.04), 62% with AA (p = 0.071), and 55% with DA (p = 0.06). In general, resected Mo1511 PDAs and CBDAs had the more aggressive pathologic features. Specifi cally, perineural invasion was identifi ed in Predictive Factors of Pancreatic Fistula and 92% of PDAs, 93% of distal CBDAs (p = 1.0), 51% of AAs (p Postoperative Complications After Pancreatic < 0.0001) and 34% of DAs (p < 0.0001). Lymph node metas- Resections in Two High Volume Centers: Comparison tases were identifi ed in 74% of PDAs, 50% of distal CBDAs Between Posterior Invagination and Duct-to-Mucosa (p = 0.013) 60% of AAs (p = 0.05) and 57% of DAs (p = 0.1). Pancreaticogastrostomy Documented recurrence patterns were available in a sub- Filippo Scopelliti*1, Giovanni Butturini1, Carlo Frola2, set of patients (22%) followed at our own institution. Due Mohammad Abu Hilal2, Claudio Bassi1 to the small number of patients, non-pancreatic PAs were analyzed together. The site of fi rst recurrence was the surgi- 1. Department of Surgery, Verona University, Verona, Italy; 2. Hepato cal bed in 24% of PDAs and 20% of non-pancreatic PAs. A Pancreatico Biliary Surgery Unit, Southampton General Hospital, distant metastasis was identifi ed in 76% of PDAs and 80% Southampton, United Kingdom of non-pancreatic PAs (p = 1.0). With regards to treatment INTRODUCTION: Pancreatic fi stula (PF) is a major com- patterns at our institution (N = 158 with treatment data), plication after pancreatic resections. Well known risk fac- patients with PDA and distal CBDAs are virtually always tors are soft pancreatic remnant and small duct. The most treated with adjuvant gemcitabine (91%), as compared to widely used techniques to reconstruct the pancreo-diges- the other two subtypes (55%, p < 0.0001) which are fre- tive continuity are pancreojejunostomy (PJ) and pancreo- quently treated with a 5-FU based regimen. The median gastrostomy (PG), either executable by invagination or and 2-year survivals associated with each PA were (Figure): duct-to-mucosa. Unlike PJ, there are no studies evaluating PDA, 19 months and 39%; CBDA, 18 months and 37% (p = short term outcome and PF rate comparing invagination 0.8); AA, 43 months and 65% (p = 0.002); and DA, median versus duct-to-mucosa PG. not reached and 67% (p = 0.04). After adjusting for lymph METHODS: node metastases, AA was still more favorable than PDA In this dual-institution retrospective study, (hazard ratio = 0.73, p = 0.01) while DA showed a trend 345 patients, reconstructed by invagination or duct-to- but was not signifi cantly more favorable (hazard ratio, 0.8, mucosa PG after pancreatic resections, were stratifi ed in p = 0.1). two groups by the type of PG performed. The invagination group consists of 173 patients from 2000 and 2010 at the same institution, selected for having soft pancreatic remnant. The duct-to-mucosa group consists of 172 consecutive patients from 2007 and 2010 at the other institution. Primary end point was to compare the two groups in terms of postoperative complications, including PF rate and grad-

146 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

ing, as defi ned by the International Study Group of Pan- CONCLUSIONS: The type of pancreogastrostomy does creatic Fistula. Secondary end point was the assessment of not signifi cantly infl uence the overall postoperative com- possible predictive risk factors of PF, unrelated to the type plication rate or incidence of PF. However, abdominal of anastomosis. collections and delayed gastric emptying are signifi cantly RESULTS: No differences in demographic data between reduced in patients treated by invagination PG. Further- the two groups were found except of the median age, sig- more invagination seems to be safer than duct-to-mucosa nifi cantly higher in duct-to-mucosa group (67 vs 62 years; in case of soft pancreatic remnant. In addition, soft pancre- P = 0,001). In invagination group 90,1% of patients had a atic remnant and small duct can be confi rmed as indepen- soft pancreatic remnant vs 48,2% in the duct-to-mucosa dent risk factors for PF. group (P = 0,0001). There were 47 PFs (27,2%) in the invagination group and 44 (25,6%) in the duct-to-mucosa group Mo1512 (P = NS). Furthermore no differences in PF grading were Pancreaticoduodenectomy at High Volume Centers: found. The patient in duct-to-mucosa group experienced abdominal collections in 42 cases (24,2%) respect of the Surgeon Volume Goes Beyond the Leapfrog Criteria 18 patients (10,4%) in the invagination group (P = 0,001). Abhishek Mathur*1, Kenneth Luberice2, Edward Choung2, Also delayed gastric emptying rate was signifi cantly higher Sharona B. Ross1, Alexander S. Rosemurgy2 in duct-to-mucosa group, 44 cases (25,6%) respect of the 1. Surgery, University of South Florida, Tampa, FL; 2. Surgery, 10 (5,8%) in the invagination group (P = 0,0001). Mortality Tampa General Medical Group Tampa General Hospital, Tampa, FL was 0% in invagination group and 4,1% (7 cases) in duct- INTRODUCTION: The Leapfrog Group has stated that out- to-mucosa group, but this difference may be due to the comes after high-risk procedures, like pancreaticoduodenec- higher median age of this population respect of the invagi- tomy, are superior at high-volume hospitals. High-volume nation group. In multivariate analysis for PF, independent hospitals are inexorably intertwined to high-volume sur- risk factors, unrelated to the type of anastomosis, included geons; however, high-volume hospitals also have low-volume sex male (P = 0,0001), soft pancreatic remnant (P = 0,0001) surgeons. This study was undertaken to determine if out- and small pancreatic duct (P = 0,005). comes after pancreaticoduodenectomy are different for high- volume vs. low-volume surgeons at high-volume hospitals. METHODS: High-volume hospitals for pancreaticoduodenectomy (defi ned by the Leapfrog Group as ≥12/year) were identifi ed from the State of Florida Agency for Health Care Administration database for a 33-month period ending in October 2010. In these centers, outcomes for high-volume surgeons (undertaking ≥12 pancraetoduodenectomies per year) were compared to those of low-volume surgeons (undertaking <12 pancraetoduodenectomies per year). Median data are presented. RESULTS: 55 surgeons undertook 928 pancreaticoduodenectomies at 6 high-volume hospitals; 10 surgeons were high-volume surgeons. High-volume surgeons in these high-volume hospitals had shorter lengths of stay (LOS), lower in-hospital mortality, and lower hospital costs (p <

0.001) than low-volume surgeons (Table). Poster Abstracts

Figure 1: Invagination PG # of # of LOS In-Hospital Hospital Monday Surgeons PD’s (days) Mortality Charge ($) High-Volume 55 928 11 (15 ± 14) 4.09% 99,409 Hospitals ( $142,578 ± 153,064) High-Volume 10 705 10 (15 ± 14) 2.83% 98,848 Surgeons ( $133,218 ± 136,379) Low-Volume 45 223 12 (17 ± 14)* 8.07%* 100,289 Surgeons ( $172,166 ± 194,142)* *p < 0.01 vs. High-Volume Surgeons

Figure 2: Duct-to-mucosa PG

147 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSIONS: Within high-volume hospitals, high-vol- complications were identifi ed after any DBE procedure in ume surgeons have superior outcomes (including decreased mean follow-up period of 6 months. Mean procedure time lengths of stay, in-hospital mortality, and cost of care) rela- was 89.6 (38–180) minutes and average fl uoroscopy time tive to low-volume surgeons. Outcomes after pancreatecti- was 173 (15–466) seconds. coduodenectomy at high-volume hospitals are dependent upon surgeon volume; any “hospital affect” is limited and Indications of DBE without ERCP (n = 53 pts) n (%) does not benefi t low-volume surgeons. Persistent abdominal pain Bleeding—Overt 17 (32) 10 (19) 8 (16) Bleeding—Obscure Other 18 (33) Clinical: Small Bowel Indications of DBE-ERCP (n = 11 pts) n (%) Acute cholangitis Recurrent pancreatitis Biliary 3 (27.3) 2 (18.2) 2 Mo1513 Stricture Other (18.2) 4 (36.3) Double Balloon Enteroscopy in Patients with CONCLUSION: Surgically Altered Bowel Anatomy: Analysis of Large The DBE is a safe procedure and carries Prospectively Collected Database very high diagnostic yield in the patients with surgically *1 1 1 2 altered bowel anatomy for various indications. The diag- Mihir K. Patel , Victoria Gomez , Ali Lankarani , John Stauffer , nostic yield remains high even if there are negative radiol- 1 1 Mark E. Stark , Frank Lukens ogy tests and/or capsule endoscopy prior to DBE procedure. 1. Gastroenterology, Mayo Clinic, Jacksonville, FL; 2. Surgery, The diagnostic yield of small bowel aspirate was very high Mayo Clinic, Jacksonville, FL while diagnostic yield of gastrointestinal biopsies were low. BACKGROUND: The referral of patients with surgically In our study, we found fair success rate of DBE with ERCP altered bowel anatomy such as Bariatric surgery, Billroth procedure in terms of adequate examination with required II surgery, and Roux en Y anastomosis during liver trans- therapeutic intervention. plants etc. for endoscopic evaluation is rising. The Double Balloon Enteroscopy (DBE) procedure has both diagnostic Mo1514 and therapeutic value in small bowel evaluation in these patients. Reported data on DBE in the patients with surgi- Fifteen Cases of Superior Mesenteric Artery Syndrome: cally altered bowel anatomy is limited. Diagnosis and Surgical Strategies 1,2 1,2 1,2 AIM: Romeo Bardini , Angelica Ganss , Marinella Menegazzo , To evaluate the success rate, diagnostic yield, and 1,2 *1,2 safety of DBE procedure in patients with surgically altered Marco Tonello , Imerio Angriman bowel anatomy. 1. University of Padova, Padova, Italy; 2. Surgical & Gastroenterologic Science, University of Padova, Padova, Italy METHODS: We reviewed our large prospectively collected DBE database from 2006 to 2011. The patients with history INTRODUCTION: Superior mesenteric artery syndrome of surgically altered bowel anatomy who underwent DBE (SMAS) is a condition caused by duodenal compression were included in our study analysis. Patients’ Demographics between aorta and superior mesenteric artery (SMA). along with DBE procedure indication, fi ndings and compli- SMAS’s symptoms are nausea, vomiting, post-prandial epi- cations were recorded. We used the frequency statistics to gastric pain and weight loss. Computed tomography (CT) calculate the diagnostic yield of the DBE in these patients. angiography and magnetic resonance (MR) angiography RESULTS: are at present the most informative diagnostic technique. A total of 1218 DBE procedures were performed Diagnostic criteria are a narrowing in the aorto-mesenteric from 2006 to 2011 at our tertiary referral center. Out of angle lesser than 22° (normal 28°–65°) and a reduction these, 64 DBEs (11 DBE-ERCP) performed in 62 patients of the aorto-mesenteric distance to 8 mm or less (normal (73% Female) with surgically altered bowel anatomy were 10–28 mm). Usually SMAS is not recognized and mis- included in our study analysis. Their mean age was 51 2 treated. Medical treatment includes pro-motility agents, (26–77) years and mean BMI was 28.2 (20.3–53.6) kg/m . but surgical approach is advocate in case of conservative Bariatric surgery was the most common 83% (n = 53) type treatment failure. of the surgery for altered bowel anatomy. The most common indication of DBE was abdominal pain and DBE-ERCP METHODS & AIM: Fifteen consecutive patients (11F, 4 M, was acute cholangitis (see table). The overall procedure mean age 45 ± 9 years) who underwent surgical correction success rate for adequate examination of roux limb was of SMAS between 2008 and 2010 have been enrolled in this 92.2% (59/64). The success rate of DBE–ERCP with ade- prospective study. Before operation all patients have been quate examination of pancreato-biliary tree and required investigated with CT and/or MR angiography with multi- therapeutic intervention was 63.3% (n = 7/11). The overall planar three-dimensional reconstructions, EGDS, barium diagnostic yield (pertinent positive fi ndings) of DBE proce- contrast radiography. In patients previously operated for dure was found to be 64% (n = 41). The diagnostic yield in GERD, also pH-metry and esophageal manometry were patients with prior negative imaging and/or capsule endos- performed. Postoperative outcome was evaluated consider- copy was found to be 47% (n = 30). The diagnostic yield ing the following clinical variables: weight, BMI, medical of small bowel biopsy (targeted or random) was 9.4% (n = therapy, serum albumine, amylase and lipase. Aim of the 3/32), while the diagnostic yield of small bowel aspirate for study is to evaluate safety, effi cacy and outcome of surgical bacterial overgrowth was found to be 100% (n = 5/5). No correction of SMAS.

148 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

RESULTS: All the patients enrolled were symptomatic DISCUSSION: ICP was signifi cantly elevated with the for abdominal pain, nausea and anorexia. In addition 11 insuffl ation associated with laparoscopy up to a maximum patients reported GERD, 3 had recurrent episodes of acute 12.5 cm H2O above the desuffl ated baseline. These data sug- pancreatitis and 7 cases presented symptoms of upper GI gest that laparoscopy should be used cautiously in patients obstruction. 5 patients had previously undergone fun- with a baseline elevated ICP or head trauma. doplication without symptoms relief. Mean aorto-mesenteric angle was 18° ± 1.8 and distance 4.6 ± 2.1 mm. A Mo1516 duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal Effects of Preoperative Enteral Glutamine and Arginine duodenum resection. There were no mortality, we observed in Patients Submitted to Surgical Treatment of 2 post operative complications: an abdominal bleeding and Enterocutaneous Fistulas a mild acute pancreatitis. At mean follow period of 10 ± Jose L. Martinez, Enrique Luque-De-LEóN*, Eduardo A. Ferat-Osorio 6.3 months, all patients are well and alive, 2 of them are Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional still complaining mild epigastric pain. There is a signifi cant improvement in patient weight (pre-operatory mean 50 ± 1 SXXI, Mexico DF, Mexico kg, post-operatory mean 55 ± 9 kg p = 0.003) and BMI (pre- INTRODUCTION: Sepsis remains the main cause of mor- operatory mean 18.1 ± 3.4 kg, post-operatory mean 20.0 bidity and mortality in patients with enterocutaneous fi s- ± 3.4 kg p = 0.004) and there is a signifi cant decreased in tulas (ECF). Although preoperative immunonutrition has need of PPI therapy (p = 0.004). We didn’t observed signifi - shown less infectious complications (IC) in patients with cant differences, in the outcome, between the two surgical gastrointestinal malignancies submitted to operative treat- procedures. ment, no studies have been done regarding use of these CONCLUSIONS: Duodenojejunostomy can be recom- agents in patients with ECF. Our aim was to assess the mended as a safe and appropriate option for SMAS. In our effects of preoperative enteral glutamine and arginine in series there is no signifi cant difference between distal duo- patients with ECF who require surgical attempts for its denal resection with duodenojejunostomy and duodenoje- closure. junostomy bypass. PATIENTS AND METHODS: During a 24 month study period, 38 patients with ECF were operated upon. All had Mo1515 at least 100 cm of proximal small bowel. They were divided in 2 groups: patients in group A (control, n = 20) were man- Impact of Abdominal Insuffl ation for Laparoscopy on aged with our standard preoperative protocol; patients in Intracranial Pressure group B (experimental, n = 18) received oral glutamine (4.5 Tovy H. Kamine*1, Efstathios Papavassiliou2, Benjamin E. Schneider1 g/day) and arginine (10 g/day) preoperatively for 7 days. 1. Surgery, BIDMC, Boston, MA; 2. Neurosurgery, BIDMC, Boston, MA Patient, disease, and operative variables were prospectively collected. Our primary endpoint was IC. Secondary end- INTRODUCTION: Diagnostic laparoscopy has recently points included ECF recurrence, defi nitive ECF healing and emerged as an alternative to laparotomy in trauma patients. mortality. Comparisons were made using Students T test However, the impact of abdominal insuffl ation on intracra- for continuous variables and chi-square or Fischers exact nial pressure is not well described outside animal models. test for categorical variables. We present a retrospective review of patients who under- RESULTS: went a laparoscopic assisted ventriculoperitoneal shunt All patient, disease and operative variables were placement (lap VPS) at our single institution with intraop- similar for both groups. IC developed in 8 and 2 patients erative intracranial pressure (ICP) measurements. (groups A and B respectively, p = 0.06). Some patients in

group A had more than one IC and thus this difference Poster Abstracts METHODS: Retrospective chart review was performed for became more evident when total number of complications sequential patients who underwent laparoscopic-assisted per group were calculated (15 vs 2 respectively, p < 0.05). Monday VPS placement since 2008. Abdominal insuffl ation was per- Comparing secondary endpoints for patients in group A formed using CO2 to 15 mmHg. ICP was measured through vs B, ECF recurred in 8 and 2, respectively (p = 0.06), and the ventricular catheter with insuffl ation and desuffl ation, defi nitive ECF closure was achieved in 12 and 16, respec- using a manometer. Baseline data were obtained as well tively (p = 0.06). Three patients died in group A, and 1 in including: age, sex, HTN, CHF, cancer, cirrhosis, renal fail- group B (from an unrelated non-septic cause), p = 0.60. ure, BMI, and prior abdominal or cranial surgery. Paired CONCLUSIONS: t-tests were performed to determine differences between Use of preoperative enteral glutamine ICP on insuffl ation and desuffl ation. Baseline data ana- and arginine seems to provide benefi cial effects for patients lyzed using linear regression to the ICP difference. with ECF submitted to operative treatment. There were less number of total IC and a clear tendency towards less RESULTS: Nine patients had ICP measurements noted. number of patients with IC, less ECF recurrence and more The mean increase in ICP with insuffl ation was 7.22 cm defi nitive ECF closures and healing. H2O (95%CI:5.38–9.07; p < 0.001). The maximum ICP difference was 12.5 cm H2O. The maximum ICP measured in this population with insuffl ation was 25 cm H2O. None of the baseline data measured had a signifi cant effect on increase in ICP with insuffl ation.

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Clinical: Stomach Mo1518 Correlation Between Gastric Emptying Time and Mo1517 Weight Loss After Silastic Ring Roux-en-y Gastric Bypass Revisional Bariatric Surgery for Weight Regain and Jorge M. Junior1, Fernando Herbella*2, Antonio C. Valezi1, Complications 3 * Silvia Brito Hideharu Shimizu , Matthew Kroh, Tomasz Rogula, 1. Surgery, Uel, Londrina, Brazil; 2. Digestive Surgery, Unifesp, Bipan Chand, Philip R. Schauer, Stacy A. Brethauer São Paulo, Brazil; 3. Nutrition, Uel, Londrina, Brazil Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH PURPOSE: INTRODUCTION: The real importance of gastric pouch emptying With the increase in the number of time to determine weight loss is still unclear. This study bariatric surgery performed every year, there are growing aims to evaluate the association between excess weight loss numbers of patients who require revisional surgery due to (EWL) and gastric pouch emptying time of obese subjects undesirable results from their primary procedures. Ana- who underwent silastic ring Roux-en-Y gastric bypass. tomic complications and weight regain are the two most METHODS: common reasons for pursuing revisional bariatric surgery. 159 morbid obesity patients (mean age 41 ± 11 METHODS: years, 112 females) underwent silastic ring Roux-en-Y gas- We conducted a retrospective analysis from tric bypass and were followed for two years. Gastric pouch a single institution to evaluate medium-term weight loss emptying time was studied by scintigraphy at 1 and 2 years and complication rates after revisional bariatric procedures. after the operation. Individuals with diabetes or inability to RESULTS: From 01/04 to 01/11, 2918 patients underwent ingest the test meal in 10 min were excluded. Pearson and bariatric surgery at our institution. 155 (5%) had revisional Spearman correlation test, analysis of variance, and Bonfer- surgery. 81% were female. The mean age at revision was roni tests were used in the statistical analysis. 49 and the mean BMI at time of revision was 44. The most RESULTS: Gastric pouch emptying time ranged from 58 common primary procedures were Roux-en-Y gastric bypass to 83 min (mean = 71 min) and 58 to 81 min (mean = (RYGB) (n = 55, 36%), vertical banded gastroplasty (n = 37, 70min) during fi rst and second year, respectively. A posi- 24%), sleeve gastrectomy (SG) (n = 26, 17%), and adjust- tive correlation between weight loss and gastric emptying able gastric banding (AGB) (n = 23, 15). Two groups were time at the fi rst year (r = 0.584, p < 0.001) and at the second defi ned according to the indication for revision. Group A year of follow-up (r = 0.660, p < 0.001) was found. included patients with unsatisfactory weight loss or regain CONCLUSION: of co-morbidities (n = 108) and Group B included compli- Gastric pouch emptying time was associ- cations from their primary procedures (n = 47). In group ated with weight loss after silastic ring Roux-en-Y gastric A, majority of the patients (69%) were revised to standard bypass, during the two years follow-up. or distal RYGB. Others underwent redo gastrojejunostomy, KEY WORDS: Gastric pouch emptying; weight loss; placement of AGB over a large gastric pouch or stoma, or gastric bypass. SG. Mean excess weight loss at 1 year follow up was 56% after revision of primary restrictive procedures and 40% Mo1519 after primary bypass procedures (p < 0.01). At mean follow up of 3 years, EWL was 48% and 37%, respectively (p Change in National Trends Adversely Impact Survival = 0.08). In group B, 77% of the patients were revised to in Stage IV Gastric Cancer RYGB. The complications prompting revision (recalcitrant Anna M. Leung*1, Danielle M. Hari1, Connie Chiu1, Anton gastrojejunal stricture, refractory marginal ulcer, severe Bilchik1,2 gastroesophageal refl ux disease, and malnutrition) were 1. Department of Surgery, John Wayne Cancer Institute, Santa effectively treated by revisional surgery. The mean BMI in Group B was 30 at the time of revision and was 32 at 3 Monica, CA; 2. Surgery, California Oncology Research Institute, Santa years. Revisional surgery was performed laparoscopically Monica, CA in 121 patients (78%). Major and minor complications BACKGROUND: With more effective systemic chemo- were observed in 13 and 17%, respectively, of those who therapy, the role for palliative gastrectomy in patients with had laparoscopic surgery and 29 and 35%, respectively, of Stage IV gastric cancer has been questioned. those who had open surgery (p < 0.05). Open revisions had METHODS: greater blood loss (p < 0.01), and longer length of hospi- Using the National Cancer Data Base we iden- tal stay (p < 0.01) compared with laparoscopic revisions. tifi ed 29,655 patients with Stage IV gastric cancer over a Mortality was seen in 1 patient (0.6%) 5 months after open 14 year period (1994–2008). Patient demographics, tumor surgery. related features, and treatments were analyzed. Overall survival rates were examined using log-rank test power CONCLUSION: Revisional bariatric surgery was performed analysis. effectively to manage undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed safely in the majority of these patients. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.

150 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Observed Survival for Stage IV Gastric CA OverTime (1994–1997) vs. (1998–2002)

Year of 1 Year 2 Year 3 Year 4 Year 5 Year 95% Conﬁ dence Diagnosis Total Patients (% Survival) (% Survival) (% Survival) (% Survival) (% Survival) Interval P-Value (1994–1997) 12,132 23.8 12.1 9.1 7.8 6.0 5.6–6.4 p < 0.05 (1998–2002) 17,523 22.6 8.4 5.0 3.6 2.9 2.7–3.2 p < 0.05

RESULTS: There was a decrease in surgical resection from CONCLUSIONS: RYGBP determined profound changes 31.2% in 2000 to 22% in 2008 (p < 0.0001), a decrease in in urinary composition which predisposed to a lithogenic radiation from 20% in 2000 to 18.5% in 2008 (p = 0.0009), profi le. The prevalence of urinary lithiasis increased almost and an increase in systemic therapy from 45.5% in 2000 70% in the postoperative period. A metabolic evaluation to 55.1% in 2008 (p < 0.001). There were no differences for nephrolithiasis is suggested for obese patients following in gender, age, or histology, but there was a decreasing RYGBP. trend of Caucasians diagnosed (p < 0.0001). Survival rates decreased signifi cantly over time p < 0.05 (see Table below). Mo1521 CONCLUSIONS: Over the past 14 years there has been an Gastric Electrical Stimulation for Symptom Control of increase in the use of systemic chemotherapy and a reduction in palliative gastrectomy for stage IV gastric cancer. Patients with Diabetic, Idiopathic, and Post Surgical The negative impact on survival suggests that treatment Gastroparesis pathways be reevaluated. Samira Hasan1, Chad J. Davis*1, Joel C. Hammond1, Thomas V. Nowak2, Lisa Ruehr2, Curtis Ramsey1 Mo1520 1. St. Vincent Hospital, Indianapolis, IN; 2. St. John’s Hospital, Anderson, IN Urinary Evaluation After RYGBP: A Lithogenic Profi le INTRODUCTION: with Early Postoperative Increase in the Incidence of Gastric electrical stimulation has been used for over a decade for symptom control of gastroparesis Urolithiasis refractory to medical treatment. Antonio C. Valezi1, Fernando Herbella*2,1, Jorge M. Junior1, Paulo OBJECTIVE: Fuganti1 To evaluate long-term symptom control with gastric pacemaker therapy and the relationship to improve- 1. Surgery, Universty of Londrina, Londrina, Brazil; 2. Paulista School ment in gastric emptying. of Medicine, São Paulo, Brazil METHODS: PURPOSE: A retrospective review of symptom scores Bariatric surgery is followed by multiple and gastric emptying nuclear scans of 117 patients at a changes of urinary composition with a propensity toward single center from 2000 to 2011. The patients included a lithogenic profi le. We prospectively studied patients who in the study were 55 with diabetic gastroparesis, 55 with underwent Roux-en-Y gastric bypass (RYGBP) to assess uri- idiopathic gastroparesis, and 7 with post-surgical gastro- nary composition and lithiasis incidence. paresis. Symptoms scores were compared for severity and MATERIALS AND METHODS: One hundred and fi fty frequency of nausea, vomiting, early satiety, and epigastric one obese patients underwent RYGBP and were followed pain at pre-op, 6 months, 1 year, 3 years, and 5 years. Gas- for one year. The analysis comprised two study time points: tric emptying scan results from pre-op, 6 months, and 1 preoperative (T0) and one year after surgery (T1). They were year were compared. Poster Abstracts analyzed for urinary stones, blood tests and 24h-urinary RESULTS: Symptom scores for all patients were signifi - evaluation. Nonparametric tests, logistic regression and cantly improved at all follow-up intervals compared to Monday multivariate analysis were conducted using SPSS 17. pre-op (P < 0.0001). Patients with idiopathic gastroparesis RESULTS: Median BMI decreased from 44.1kg/m2 to achieved the same degree of symptom control as diabetic 27.0kg/m2 (p = 0.0001) in the postoperative period. Uri- patients. There was no signifi cant change in gastric empty- nary oxalate (24mg versus 41mg; p = 0.000) and urinary ing from pre-op to 6 months or at 1 year post-op. uric acid (545mg versus 645mg; p = 0.000) increased sig- CONCLUSIONS: Symptoms for all patients signifi cantly nifi cantly postoperatively (preoperative versus postopera- improved after initiation of gastric electrical stimulator tive, respectively). Urinary volume (1310ml versus 930ml; therapy. The improvement continued for up to 5 years p = 0.000), pH (6.3 versus 6.2; p = 0.019), citrate (268mg postoperatively. Patients with idiopathic gastroparesis had versus 170mg; p = 0.000), calcium (195mg versus 105mg; p similar symptom improvement as those with diabetic gas- = 0.000) and magnesium (130mg versus 95mg; p = 0.004) troparesis. Despite symptom improvement, gastric empty- decreased signifi cantly postoperatively (preoperative versus ing, as measured by nuclear scanning, was not signifi cantly postoperative, respectively). Stone formers increased from changed with gastric electrical stimulation. This obser- 16 (10.6%) to 27 (17.8%) patients in the postoperative vation suggests that gastric stimulation improves symp- analysis (p = 0.001). Predictors for new stone formers after toms via a mechanism independent of the rate of gastric RYGBP were postoperative urinary oxalate (p = 0.015) and emptying. uric acid (p = 0.044).

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Mo1522 Mo1523 GLP-1 Analogues Do Not Improve Remission of Newly-Devised Method for Totally Laparoscopic Total Diabetes After Gastric Bypass Gastrectomy (TLTG), Application Easiness and Cost Andrew A. Taitano*1, Tejinder P. Singh2,1 Effectiveness: The Experience of Over 140 Cases in 1. General Surgery, Albany Medical Center, Albany, NY; 2. AMC Single-Institution Bariatric Surgery Group, Albany Medical Center, Albany, NY Hitoshi Satodate*, Haruhiro Inoue, Shin-Ei Kudo INTRODUCTION: Surgical treatment for morbid obesity Digestive Disease Center, Showa University Northern Yokohama via Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB) leads Hospital, Yokohama, Japan to weight loss and remission of diabetes in most patients INTRODUCTION: Although laparoscopy-assisted distal with type 2 diabetes mellitus (T2DM). The outcomes in gastrectomy for gastric cancer is becoming popular proce- patients taking GLP-1 analogues for glycemic control are dure especially in Japan and Korea, laparoscopy-assisted not well understood. We analyzed the rate of remission of total gastrectomy is less common operative procedure. One T2DM in patients after gastric bypass surgery with respect of the major problems is diffi culty of intracorporeal recon- to the diabetic medications taken preoperatively. struction, and another problem is cost. We developed TLTG METHODS: 157 patients with T2DM were studied. Base- procedures that requirement of disposable instruments is line demographics, hemoglobin A1C levels, and medica- minimal, within the coverage of Japanese insurance system. tion lists were evaluated for patients undergoing LRNYGBP METHOD: A 12-mm trocar is placed through umbilical between January 2005 and December 2009. incision, and four additional trocars are placed. Only two RESULTS: The mean age was 50 years, 73.9% were female, 12-mm trocar incisions and three 5-mm trocar incisions, mean BMI at surgery was 47.6. Mean follow-up was 2.34 including for the camera, are created for this procedure. years. 79.0% of patients were off medications for T2DM at After thorough mobilization of the abdominal esophagus, last follow-up. 19.1% of patients were on a GLP-1 analogue the esophagus is divided with stapler, and Orvil is inserted at the time of surgery. The average preoperative hemoglo- per orally, and the anvil is loaded into the esophageal stump. bin A1c level was higher in this group (6.92 vs 6.80), but no Then the handpiece of EEA stapler is introduced from the other signifi cant differences were found. The rate of remis- umbilical port incision, and the jejunojejunal anastomosis sion of diabetes was not signifi cantly different between is also created from the umbilical port incision. patients on a GLP-1 analogue and others (80.0% vs 78.7%). RESULTS: We have performed 142 cases of the TLTG with Remission rates did not vary according to the number of this procedure, and have experienced only one minor anas- anti-diabetic agents taken at the time of surgery (91.1% for tomotic leakage. No other major problems had occurred. 1, 89.6% for 2, 90.0% for 3 or 4). Multivariate regression Mean operation time is 231 min. And the mean time for analysis revealed preoperative insulin use to be the only the whole procedures for reconstruction including creation signifi cant predictor of postoperative T2DM status (RR of Roux-en-Y jejunojejunal anastomosis is 53 min. 5.48, 95% CI 2.91 to 10.30). CONCLUSION: CONCLUSIONS: Two clear advantages can be mentioned The use of GLP-1 analogues in patients with this method, compare with other techniques. First, who undergo LRNYGBP surgery is not associated with this technique can be relatively easily applied for the can- improved glycemic control, lower BMI at the time of sur- cer of the cardia. Second, minimize the use of disposable gery, or improved long term outcomes. Preoperative insulin instruments. Only three linear staplers and one circular sta- use is a risk-factor for non-remission of T2DM postopera- pler are needed, and these are completely covered by insur- tively. Surgical intervention prior to insulin dependence is ance. This technique could become the standard methods needed to maximize long term remission rates. Early surgi- for reconstruction after TLTG, and facilitate the acceptance cal intervention for morbidly obese patients with T2DM of TLTG. And also lead to the hospital benefi t. We will should be considered instead of escalation of medical show our clinical practice. management.

152 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Mo1524 of potentially curative cancer resections of the foregut, including esophagus, stomach, liver, and pancreas. Preoperative Chemotherapy in High Risk Gastric METHODS: The Nationwide Inpatient Sample was que- Cancer: No Guarantee of Downstaging But Remains ried to identify all esophageal, gastric, liver and pancreas Our Best Magic Bullet resections performed for cancer during 1998–2009. Annual Veeraiah Siripurapu*, Ashley Mekala, Elizabeth T. Liu, incidence, major in-hospital postoperative complications, Dhiresh R. Jeyarajah length of stay and in-hospital mortality were evaluated. Surgery, Methodist Dallas Medical Center, Dallas, TX Univariate and multivariate analysis performed by chi square and logistic regression. For all comparisons, p-values INTRODUCTION: With the advent of the MAGIC trial, <0.05 were considered statistically signifi cant. preoperative chemotherapy is utilized for high risk tumors in gastric cancer (T3 and higher/Node positive tumors). The regimen is often toxic and often necessitates nutritional support with the hope of downstaging these aggressive tumors. We aim to see if our population of high risk tumors receiving preoperative therapy experienced any downstaging in comparison to those who did not. AIM: All gastric cancer cases operated on by a single surgeon in the last fi ve years were queried. Of these, only those who had strict clinical staging with radiological imaging/ EUS and who were deemed high risk were included for analysis. Clinical stage was correlated to pathologic stage with a view to see if any tumors were upstaged, downstaged or had complete pathologic response. RESULTS: A total of 27 patients met all criteria. Twelve patients (44%) had tumors designated as Siewert 3 and 1 patient as Siewert 2. Of the 27 patients, 15 (55%) were node positive. Twenty patients (74%) were staged T3 or higher. Ten patients received no preoperative therapy. The major preoperative regimen used was Epirubicin, Cisplatin & 5FU (ECF) or a combination similar such as EOX (78%). Of those who received preoperative therapy, ten patients (58%) were downstaged. There were 4 complete pathologic responses (cPR). All these patients received either ECF or EOX. Tumor location was varied for those with cPR CONCLUSIONS: Complete pathologic response is obtain- able in high risk gastric cancer. Downstaging of these RESULTS: 298,871 patients (nationally-weighted) under- tumors happens in 58% of the high risk gastric popu- went cancer directed foregut surgery 1998–2009. Of those lace. For those who can tolerate the regimens, this should 19,002 (6%) were esophagectomies, 123,198 (41%) were remain the standard of care until further trials establish dif- gastrectomies, 62,313 (21%) were hepatectomies and 94,358 ferent treatment approaches.

(32%) were pancreatectomies. From early years (1998–2000) Poster Abstracts to late years (2007–2009) use of laparoscopy in foregut sur- Mo1525 gery increased from 3% to 5%. Laparoscopy in esophagec- Monday Foregut Surgery in the Modern Era: A National Survey tomy increased the most from 1% to 5%, while its use in *1 1 1 hepatectomy remained unchanged at 4%. Gastrectomy and Zeling Chau , Jillian K. Smith , Elan R. Witkowski , Elizaveta pancreatectomy involving minimally invasive techniques 1 1 3 1 Ragulin-Coyne , Sing Chau NG , Tara S. Kent , Shimul A. Shah , increased from 2% to 5% and 5% to 6%, respectively. For all Jennifer F. Tseng2,1 four foregut surgery types, patient comorbidities increased 1. Surgical Outcomes Analysis & Research, University of Massachusetts over time; patients with ≥2 major comorbidities increased Medical School, Worcester, MA; 2. Division of Surgical Oncology, Beth from 53% to 64%. Conversely, patient mortality and length Israel Deaconess Medical Center, Harvard Medical School, Boston, of stay (LOS) decreased over time. However, we observed an MA; 3. Department of General Surgery, Beth Israel Deaconess Medical increase in complications for all sites combined from 22.8% Center, Harvard Medical School, Boston, MA to 24.4%. Laparoscopy was not signifi cantly associated with decreased complications, but was associated with lower mor- BACKGROUND: Foregut surgery is technically complex. In tality when compared to open resection alone 3.1% vs. 5%. recent years, increasing attention has been paid to high-stakes Independent predictors of increased complications included surgery outcomes, including mortality and complications. In older age, gender, higher comorbidity, hospital volume. addition, the use of advanced technology including minimally Older age, male sex, higher comorbidity, low volume center invasive approaches has been introduced. The current study and non-use of laparoscopy were independent predictors of aims to determine national trends in utilization and outcomes in-hospital mortality.

153 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: Foregut surgery in the modern era is being Translational Science: Colon-Rectal increasingly deployed on sicker patients. While decreased in-hospital mortality and LOS are commendable, complication rates remain substantial and nondecreasing. Minimally Mo2071 invasive techniques have minor but increasing penetrance in foregut surgery. Our results suggest comparable advances Thromboelastography Delineates Hypercoagulation in and potential pitfalls among major types of foregut surgery an Immunocompentent Murine Model of Metastatic in the current era. Colon Cancer Karen K. Lo*1,2, Theresa Chin1, Marguerite Kelher3, Martin Mo1526 Mccarter1, Ernest E. Moore2, Christopher Silliman1,3, Carlton C. 2 What Motivates Weight Loss Surgery Patients? Barnett 1. Surgery, University of Colorado, Denver, Aurora, CO; 2. Surgery, Nayna A. Lodhia*, Jaffer M. Kattan, Dylan Gwaltney, Kate E. Denver Health, Denver, CO; 3. Bonfi ls Blood Center, Denver, CO Kiely, Shushmita Ahmed, Homero Rivas, John M. Morton Surgery, Stanford University, Stanford, CA INTRODUCTION: The association between malignancy BACKGROUND: and venous thrombosis (VTE) has been well documented By better understanding patient motiva- since the 1860s. Moreover, it has been demonstrated that tions, patient education can be individualized for the most perioperative blood transfusions increase the risk of VTE in effective healthcare possible. The purpose of this study was colon cancer patients. Despite efforts to prevent VTE, cur- to evaluate patient motivations for bariatric surgery. rent diagnostic tests (INR, PTT, PT, platelet count) are often METHODS: Preoperative, three, six and twelve month unreliable. Recently, our lab has demonstrated that Throm- postoperative data were prospectively obtained for 169 boelastography (TEG) is able to better assess coagulation consecutive laparoscopic Roux-en Y gastric bypass sur- kinetics and direct patient therapy than conventional gery patients at a single academic institution. All patients testing. We hypothesize TEG will delineate coagulation were given a standardized multiple choice questionnaire abnormalities in a murine model of transfusion mediated which asked them about their primary motivations for metastatic colon cancer. bariatric surgery preoperatively, then 6 and 12 months METHODS: C57/BL6 male mice, age 7–9 weeks, under- postoperatively. went splenic inoculation with 2.5 × 104 MC38 murine RESULTS: Better health was the primary motivator preop- colon adenocarcinoma cells. Control mice underwent the eratively and at 12 months postoperatively (87, 89%, respec- same surgery with splenic injection of normal saline. One tively). A better appearance was a primary motivation for week after inoculation, all mice were randomized to receive only 15% of patients preoperatively and 20% of patients 12 blood transfusion via tail vein injection in the amount of months postoperative. Within health-related motivations 1 mg/kg or the equivalent dose of normal saline. N ≥ 4 for bariatric surgery, 29% of patients expressed a primary in all groups. Three weeks after cancer inoculation, cardiac desire to live longer preoperative and, by 12 months postoper- puncture was performed and blood was collected with atively, this number increased to 38.7% of patients postop- citrate in a 1:10 ratio. TEG was performed on TEG® 5000 eratively. The primary motivation for bariatric surgery from Thrombelastograph® Hemostasis Analyzer. Necropsies a family perspective was to have more energy with chil- were then performed: tumors were harvested and metas- dren preoperatively and remained so at 12 months postop- tases were determined. TEG was compared between mice eratively (44 to 46%). The second most common familial with metastatic cancer with and without transfusion and motivation was to be a healthy role model which did not control mice, who received sham cancer surgery, with and change from pre- to post-operatively (29.8 to 29.5%). Pre- without transfusion. Data were analyzed using ANOVA operatively, 65% of patients thought that diet and exercise with p ≤ 0.05 used to determine signifi cance. would be the most important factor to maintain long-term RESULTS: Mice with cancer that received blood transfu- weight loss; however, by 12 months postoperatively, only sions were found by TEG to have signifi cantly lower R times 56% of patients thought that diet and exercise would be the (4.4 minutes versus 8.5 minutes p = 0.018), K times (1.6 most important factor. Patients gave an increasingly greater minutes versus 3.3 minutes p = 0.0004), and signifi cantly role to surgery as an important factor for weight loss raising higher angles (67° versus 52° p = 0.0005), MA (68 mm ver- its importance from 45% preop to 58% at one year postop- sus 62 mm p = 0.019), and G (10.7 versus 8.05 dynes/cm2 eratively. Observed to patient-expected (O:E) ratios of 12 p = 0.04) when compared to mice who received a sham month percent excess weight loss became more accurate as operation and blood transfusions. TEG value interpreta- patients progressed from preop to 6 and 12 months postop tion shown (Table 1); R times demonstrate that mice with (0.60, 0.70, 0.78). Pre-operative O:E Ratios of percent excess metastatic colon cancer form clot signifi cantly faster than weight loss were strongly correlated with 12 postoperative mice without cancer (Figure 1). Surprisingly, blood product excess weight loss (p < 0.001). transfusion did not affect hypercoagulabilty. CONCLUSIONS: Patients had increasingly, more realistic expectations for surgery’s role and ideal weight. Preopera- tively, accurate patient expectation of surgical weight loss resulted in better observed post-op weight loss. Patient motivation may be a prime factor for weight loss and should be harnessed for improved outcomes.

154 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Table 1: TEG Value Interpretation MATERIALS AND METHODS: After obtaining approval Decrease Increase from our Animal Ethics Committee, ten pigs were anes- Value Meaning Indicates Indicates thetized using a standard protocol. A midline laparotomy was performed and the terminal ileum identifi ed. Subse- R Clotting Time, i.e. time Hypercoagulable Hypocoagulable quently the intestine was completely sectioned 30 cm (minutes) until the fi rst Factor defi ciency, proximal to the ileocecal valve. All hand-sewn end-to-end detectable levels of fi brin anticoagulant, anastomoses were performed by the same surgeon, using clot formation. Generally hypofi brinoginemia refl ects coagulation factor interrupted absorbable (3-0 polyglactine 910) sutures and levels leaving an orifi ce of 18French in the suture line (as shown in Figure 1). Animal were randomized to the application of K Clot Kinetics. Measures the Hypercoagulable Hypocoagulable a synthetic sealant (polyethylene glycol, group I) or fi brin speed to reach clot strength sealant (group II) on the defect and the suture line. Animal of 20 mm amplitude. Looks at intrinsic clotting factors, were postoperatively followed for 7 days and prematurely fi brinogen, platelet function sacrifi ced if sepsis developed. Otherwise, they underwent a second surgery for revision and the anastomosis was iso- Angle Clot strengthening, rapidity Hypocoagulable Hypercoagulable lated and removed for subsequent histological examina- of fi brin-buildup and clot Hypofi brinogenemia formation, angle of tracing or thrombocytopenia tion. Fischer’s and Student’s t test was used for statistical from r to K value. analysis. P < 0.05 was considered signifi cant. MA, G Overall Clot strength, Hypocoagulable Hypercoagulable represents maximum dynamics of fi brin and platelet bonding

Figure 1 RESULTS: Preoperative data was comparable between groups, with no statistical difference. No septic complications developed in any of the study Figure 1: * p = 0.05% p = 0.003 # p = 0.02 subjects. Only one animal presented a contained wound CONCLUSION: TEG is able to delineate hypercoagulabilty dehiscence. On the second surgery, macroscopic fi ndings associated with metastatic colon cancer in an immuno- showed no difference between the 2 groups: There was no competent murine model. Receipt of packed red blood cell evidence of diffuse purulent peritonitis or bowel obstruc- product did not affect hypercoaguability in this model. As tion. One contained anastomotic leak was found in each Poster Abstracts thrombotic events are morbid and potentially mortal, addi- group (1/5 vs. 1/5, NS). Adhesions between intestinal loops tional investigation of this modality in perioperative man- were found 4 animals: 2 in group I and 2 in group II (2/5 Monday agement of cancer patients appears warranted. vs. 2/5, NS). An infl ammatory mass, containing the leak appeared in 1 case (0/5 vs. 1/5, NS). Microscopically, the Mo2072 local infl ammatory response, with granulation tissue and local peritonitis was similar in both groups. Continuity of Reinforcing the High Risk Intestinal Anastomosis: the mucosal layer was observed in 4 of 10 samples, similar Experimental Pilot Study in both groups (2/5 vs. 2/5, NS). Epithelial inclusions in the Jana Dziaková*1,2, Iris Sanchez Egido1,2, Diego Sierra Barbosa1,2, anastomotic line was found in 1 case in group I and in 3 Julio Mayol1,2 cases in group II (1/5 vs. 3/5, p = 0,26). 1. Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; DISCUSSION: We present a preliminary study describing a 2. Universidad Complutense, Madrid, Spain new model of incompetent anastomosis in a large animal, designed to study the effect of sealants and glues on intes- INTRODUCTION: Anastomotic leakage is one of the tinal healing. Our fi ndings show that this is a viable model causes of increased morbidity and mortality in gastrointes- and that both synthetic and fi brin sealant may be useful in tinal and colorectal surgery and it is also associated with reinforcing incompetent anastomoses. Further studies are elevated costs. The aim of this study was to investigate the needed to understand the role of these products in the pre- effect of synthetic hydrogel sealant and a fi brin sealant on vention of anastomotic leaks. incompetent anastomosis in animal experimental model.

155 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Esophageal adverse consequences, hence appropriate training is essential for the safe adoption of this procedure. The objective of this study was to compare swine and fresh human cadavers Mo2073 (FHC) as training models for POEM. METHODS: Impact of Blood Biomarker of Neoadjuvant Treated Healthy Yorkshire male pigs (40–46 kg) were Patients with Esophageal Carcinoma used for POEM training. Procedures were also performed in *1 1 1 male and female FHC during the same time period. A stan- Peter P. Grimminger , Juliane Bergenthal , Hakan Alakus , dardized procedure was used in both models. Following sub- 1 1 1 Martin K. Maus , Till Herbold , Elfriede Bollschweiler , mucosal injection of methylene blue dye to mark the distal Ralf Metzger1, Arnulf H. HöLscher1, Jan Brabender2 extent of the dissection, a mucosotomy was made in the 1. Department of General-, Visceral- and Tumor Surgery, University mid-esohagus. The endoscope was then inserted into the Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery, mucosotomy and a submucosal tunnel bluntly dissected. St. Antonius Hospital, Cologne, Germany Endoscopic myotomy of the circular muscle layer from the mid-esophagus to the gastroesophageal junction was The prognostic value of ERCC-1 (excision repair cross Com- performed using a triangular tip knife. The mucosotomy plementing genes), TS (thymidylate synthase) and DPD was subsequently closed with endoscopic clips. Follow- (dihydropyrimidine dehydrogenase) RNA expression in the ing POEM in swine, the animals were sacrifi ced and nec- blood of patients with esophageal cancer is not known. The ropsy performed to assess for organ injury and myotomy aim of this study was to evaluate the signifi cance of these adequacy. In FHC, thoracoscopic and laparoscopic evalu- molecular alterations in the blood as a prognostic marker ation was performed to assess for pleural violation,organ for patients with neoadjuvant treated esophageal cancer. injury and myotomy adequacy. Adequacy of myotomy was A total of 29 patients with locally advanced esophageal determined by endoscopic transillumination at distal most cancer (cT3-T4, Nx, M0) were enrolled in this prospective myotomy site. study. All patients received neoadjuvant radio-chemother- RESULTS: POEM was performed in 7 acute swine and 6 apy followed by a transthoracic resection (curative trans- FHC. In swine, POEM was successfully completed in 5 ani- thoracic en bloc esophagectomy, RO). Peripheral blood mals (72%). Two animals (29%) expired during the proce- samples were drawn before initiation of therapy. The anal- dure from cardiopulmonary collapse. In the remaining 5 ysis was performed using quantitative real-time RT-PCR animals, POEM was uncomplicated with no evidence of (TaqMan ©). The histomorphological regressionsgrading complication on necropsy. The average procedure time was after neoadjuvant therapy was defi ned as follows: major 90 minutes (range70–120 minutes). The primary limita- response (MaR) = less than 10% vital tumor tissue, minor tion of the swine model related to the attenuated circular response (MiR) = more than 10% vital tumor tissue. muscle of the porcine esophagus which made myotomy 19 out of 29 patients (65.5%) had a MiR and 10 (34.5%) technically diffi cult and pleural violation a frequent com- had a MaR. The median survival of patients was 2.08 years plication. No problems closing the myotomy were encoun- (0.15–4.53). Among the tested genes, the RNA expression of tered. In contrast, POEM was successfully performed in all TS was signifi cantly associated with prognosis of patients. FHC. The average procedure time was 85 minutes (70–120 Patients with TS expression above 0.78 had a median sur- minutes). Pleural violation was noted in one cadaver. In vival of 1.1 years (0.21 -3.16) compared to 3.36 years (0.15 4 cadavers, the mucosotomy was inadvertently extended to 4.53) in patients with TS expression lower than 0.78 (p = during creation of the submucosal tunnel. The technical 0.031, log rank test). There was no association between limitations of the cadaver model were diffi culties with the clinical variables (eg, tumor stage, gender, age, etc.) and the mucosotomy and submucosal tunnel dissection due to RNA expression of TS in the serum. decreased tissue pliability and poor tissue distension. The RNA expression of TS in the blood is a potential prog- CONCLUSION: Although cadavers are more anatomi- nostic marker in patients with neoadjuvant treated esopha- cally relevant as a training model for POEM, creation of geal cancer. The signifi cance of these molecular alterations the mucosotomy and submucosal tunnel is limited by poor as non-invasive prognostic marker for esophageal cancer tissue pliability. Conversely, mucosotomy and submucosal should be evaluated in prospective studies. tunnel dissection is more easily achieved in an acute swine model, but the myotomy limited by attenuated circular Mo2074 muscle. A hybrid teaching paradigm using both porcine and human cadaver model may be necessary for compre- Training for Per-Oral Endoscopic Myotomy (POEM): hensive POEM training. Cadavers or Swine? Dana A. Telem*1, Ozanan R. Meireles1, Denise W. Gee1, Patricia Sylla1, William R. Brugge2, David W. Rattner1 1. Surgery, Massachusetts General Hospital, Boston, MA; 2. Gastroenterology, Massachusetts General Hospital, Boston, MA BACKGROUND: POEM is a promising totally endoscopic method for treating achalasia. Esophageal perforation and incomplete myotomy are technical errors with severe

156 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Translational Science: Hepatic

Mo2075 Triptolide Demonstrates Novel Chemotherapeutic Potential as Single-Agent or Combination Therapy with Sorafenib for Treatment of Hepatocellular Carcinoma Tara C. Krosch*, Veena Sangwan, Sulagna Banerjee, Ashok Saluja, Eric H. Jensen, Selwyn M. Vickers Department of Surgery, University of Minnesota, Minneapolis, MN BACKGROUND: Hepatocellular carcinoma (HCC) is the most common malignant primary liver tumor worldwide. Systemic treatment in advanced disease has been limited to sorafenib, a broad spectrum tyrosine kinase inhibitor, with many adverse side effects and suboptimal outcomes. Our lab has investigated triptolide, a diterpene triepoxide, as a Figure 1: Hep3B and HuH-7 HCC cell viability to triptolide and sorafenib. potential chemotherapeutic option. This study evaluates Hep3B and HuH-7 HCC cells were treated in vitro with varying concentrations of the response of HuH-7 and Hep3B HCC cells to triptolide, triptolide or sorafenib and viability was assessed at various time points. A with or without combination therapy with sorafenib. concentration of 2.5 uM sorafenib has been equated to a therapeutic plasma METHODS: HuH-7 and Hep3B HCC cell lines were treated concentration in treated patients, with 5 uM used as a supra-therapeutic and in vitro with triptolide and/or sorafenib at varying con- likely toxic dose in this experiment. Hep3B HCC cells were susceptible to low centrations. Cell viability (MTT assay), caspase activation doses of triptolide or sorafenib, with signiﬁ cant cell death at 72 hours. HuH-7 (Promega), and Annexin V positivity (Guava Nexin) were cells were less susceptible to treatment. (N = 4, * = p<0.05, Bars = + SEM). then assessed. Real-time PCR was utilized to determine the changes in mRNA levels, and Western blots were used for evaluation of protein expression. RESULTS: Triptolide and sorafenib were equally effective at reducing cell viability in Hep3B cells, at low concentrations (FIGURE 1). Within 72 hours of 25 nM triptolide treatment, 80% cell death was noted, and similar a reduction in cell viability was seen with 2.5 uM sorafenib. Increased concentrations of either drug achieved minimal increases in cell death. In distinction to the Hep3B cell line, the HuH-7 cells were more resistant to single agent treatment. Sorafenib treatment (2.5 uM) resulted in 70% cell death at 72 hours, whereas triptolide (100 nM) resulted in 40% cell death (Figure 1). Combination therapy was attempted in this cell line. Notably, a signifi cant reduction in cell viabil- Figure 2: HuH-7 HCC cell viability to triptolide and sorafenib combination ity was found using lower concentrations of each drug, in therapy. HuH-7 HCC cells were treated with low doses of triptolide, Poster Abstracts comparison to either drug concentration alone, with less sorafenib or combined doses, and viabilty was assessed at 2h-hour than 20% cell viability at 72 hours (Figure 2). intervals. Notably, the combination of 100 nM triptolide and 0.625 uM Monday Cell death with both treatments resulted in increased caspase-3 sorafenib was found to have increased efﬁ cacy in comparison to either activation and Annexin V positivity in both cell lines, con- treatment alone. (N = 2-3, Bars = + SEM). fi rming apoptosis. Evaluation of mRNA and protein levels in response to triptolide showed signifi cant downregulation of the CONCLUSIONS: Treatment of advanced HCC is currently heat shock protein cascade, with levels of HSF-1 decreased in limited to sorafenib therapy, with many adverse side effects both cell lines. Downstream expression of HSP70 and HSP27, and suboptimal outcomes. We have shown that triptolide known upregulated proteins in metastatic HCC disease, were treatment in vitro induces HCC cell death by apoptosis, also signifi cantly decreased. with decreased expression of proteins found to be normally upregulated in metastatic disease. While triptolide therapy alone results in signifi cant cell death in Hep3B cells, combination therapy with sorafenib, both at low concentrations, results in notably superior cell death to either treatment alone in the more resistant HuH-7 cells. Our study suggests triptolide may serve as a therapeutic option for advanced HCC. Orthotopic mouse model studies are underway.

157 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Stomach gastric cancer pts with non-response to chemotherapy were performed. The Affymetrix assay was done by the guidelines provided by Affymetrix. For statistical evaluation a Mo2076 pathway analysis approach using the KEGG BIOCARTA REACTOM and AMBION database, including 1266 path- SNP Array 6.0 Analysis in Advanced Gastric Cancer ways, was performed. Patients Treated with 5-FU and Platinum or Irinotecan RESULTS: Several hundred SNP were identifi ed with a pos- Based Chemoradiation sible association with response to chemotherapy. However, Peter P. Grimminger*1, Martin K. Maus1, Frederick Schumacher2, focusing on biochemical pathways with possible involve- Ralf Metzger1, Jan Brabender3, Arnulf H. HöLscher1, Heinz-Joseph ment in the effi ciency of the chemotherapy treatment 6 Lenz2 pathways of the KEGG database were identifi ed with an 1. Department of General-, Visceral- and Tumor surgery, University association to response to adjuvant treatment. The six iden- Clinic Cologne, Cologne, Germany; 2. Division of Medical Oncology, tifi ed pathways were: KEGG Colorectal Cancer Pathway (p University of Southern California/Norris Comprehensive Cancer = 0.0001, FDR = 0.343), Ambion Epithelial Tight Junctions Center, Los Angeles, CA; 3. General- and Visceral Surgery, St. (p = 0.001, FDR = 0.357), Reactome Muscle Contraction (p = 0.001, FDR = 0.331), KEGG Chronic Myeloid Leukemia (p Antonius Hospital, Cologne, Germany = 0.001, FDR = 0.463), Ambion Transcritptional Regulatory BACKGROUND: Biochemical pathway SNP’s as possible Network in Embryonal Stem Cell (p = 0.006, FDR = 0.553 ) molecular markers for response prediction in adjuvant che- and Biocarta ALK Pathway (p = 0.004, FDR = 0.646). motherapy in gastric cancer have already been reported. CONCLUSION: The SNP’s of the six identifi ed pathways In our study we performed a systematic Single Nucleo- have a possible impact on response to 5-FU and platinum/ tide Polymorphism genotyping analysis by Affymetrix irinotecan based chemoradiation. Our future aim is to SNP 6.0 arrays that interrogates 906,600 single nucleotide identify the key SNP in the pathways which may play the polymorphisms. crucial role for treatment response. Future SNP array stud- MATERIALS/METHODS: Affymetrix SNP Array 6.0 anal- ies are in process to validate the identifi ed pathways and ysis of 16 gastric cancer pts with response to chemotherapy also the single involved SNPs. (5FU + platinum or irinotecan and/or Radiation) and 30

Tuesday, May 22, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.

12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME)

Basic: Colon-Rectal of action of these receptors remains unclear. We studied the role of 5-HT3 and 5-HT4 receptors in colonic transit and peristalsis in guinea pigs in vivo and in vitro. Tu2052 METHODS: For in vivo colonic transit study, 51Cr was 5-HT3 and 5-HT4 Receptors Promote Colonic Peristalsis infused into the proximal colon after saline, ondansetron via Different Mechanisms in Guinea Pigs (a 5-HT3 receptor antagonist; 1 mg/kg), or GR 125487 (a Irena Gribovskaja-Rupp*, Jung-Myun Kwak, Toku Takahashi, Kirk 5-HT4 receptor antagonist; 1 mg/kg) injection. Three hours later, geometric center (GC) of the 51Cr distribution in A. Ludwig the entire colon was calculated. For in vitro studies, distal Surgery, Medical College of Wisconsin, Milwaukee, WI colonic segments were laid fl at in an organ bath with Krebs- BACKGROUND: Pelvic surgery may damage extrinsic Henseleit buffer. Oral ends of segments were connected to nerves, resulting in colonic dysmotility and constipation. an infusion syringe, and anal ends to a pressure transducer. Adaptation restores motility after extrinsic denervation. Pressure changes in response to luminal infusion (0.2 ml) We showed that intrinsic 5-HT3 and 5-HT4 receptors are were recorded in the presence of ondansetron (3 × 10–6 M) upregulated to compensate for the loss of extrinsic 5-HT3 or GR 125487 (3 × 10–6 M). In another setting, oral and anal receptors after parasympathetic denervation in rats (J Surg ends were opened and the peristaltic refl ex in response to Res. 2011, 171:510–516). However, the specifi c mechanism pellet insertion or luminal balloon infl ation was studied.

158 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

reduced oral contractions and increased anal contractions. As a result, the ratio of anal/oral contractions was increased to 1.4 ± 0.2 by GR 125487, compared to controls (0.6 ± 0.1; n = 9, p < 0.01). Similarly, L-NAME (a nitric oxide inhibitor, 10–4 M) signifi cantly increased anal contractions (Figure 2). CONCLUSION: Ondansetron impairs colonic transit by lowering the magnitude of peristaltic contractions. GR 125487 impairs colonic transit by generating potent contractions on the anal side. Because L-NAME has a similar

effect with GR 125487, it is suggested that 5-HT4 receptors stimulate nitric oxide release distally. In contrast, 5-HT3 receptors stimulate excitatory neurotransmission proximally. Our study offers new insight into the function of

5-HT3 and 5-HT4 receptors in regulating colonic peristalsis.

Tu2054 Figure 1: Luminal infusion-induced pressure increase in the presence of Tumor Growth Is Stimulated After Sham Laparotomy ondansetron and GR 125487 of the guinea pig distal colon. Ondansetron and Is Associated with Enhanced Tumor Angiogenesis reduced, while GR 125487 increased motor responses to luminal infusion (**p < 0.01, n = 4–7). and Elevated Serum PDG-BB Levels in Mice Xiaohong Yan*, Joon Ho Jang, Daniel D. Kirchoff, Sonali A. Herath, Linda Njoh, C.M. Shantha Kumara H, Samer Naffouje, Richard L. Whelan St. Luke’s Roosevelt Hospital, New York, NY INTRODUCTION: Surgical trauma-related increased rates of metastasis formation and tumor growth have been noted in murine models. In humans, major abdominal surgery has been associated with persistent proangiogenic plasma protein changes and postoperative plasma been shown to promote Endothelial cell (EC) proliferation, migration, and invasion. The current murine study was done to determine: 1) if tumor angiogenesis and growth was increased after sham laparotomy (SL) vs. anesthesia alone (control, AC) and 2) to assess postoperative (postop) serum levels of four proangiogenic proteins. METHODS: Fifty BALB/cJ mice were subcutaneously inoc- ulated with syngeneic CT26 colon adenocarcinoma cells on Day 1. On Day-15 the mice were randomized into 2 groups (n = 25/group), one underwent SL and the other Figure 2: Magnitude of oral and anal contractions in response anesthesia alone (AC). Tumor Study: On Day-29 the mice to balloon distention of the guinea pig distal colon. Ondansetron were sacrifi ced and the tumors excised, measured, and signiﬁ cantly reduced both anal and oral contractions. In contrast, GR weighed. The tumor microvessel density was determined 125487 or L-NAME signiﬁ cantly decreased the magnitude of oral via IHC CD34 staining. Serum Study: Blood samples were contraction and increased anal contractions, compared to controls (*p < taken and serum harvested from a second group of mice 0.05, **p < 0.01, n = 4–7). that underwent SL or anesthesia alone (total n = 84). The RESULTS: Colonic transit was impaired by ondansetron sampling points were: preoperative (Preop), POD1, 3, 5, 7, (GC = 4.5 ± 0.3, n = 6, p < 0.01) and GR 125487 (GC = 5.3 ± 10, and 14. Serum levels of FGF, VEGF, sVCAM and PDGF- 0.3, n = 7, p < 0.01) compared to controls (GC = 6.8 ± 0.3, n BB were determined via ELISA. = 10). Ondansetron reduced intraluminal pressure increase RESULTS: The median tumor volume of the SL group by 40 ± 9% (n = 4, p < 0.01), whereas GR 125487 increased (625.9 mm3) was signifi cantly larger than the AC group it by 76 ± 28% (n = 7, p < 0.01) (Figure 1). Pellet transit result (510.2 mm3, p = 0.01). Also, the SL group’s median Poster Abstracts time was 46 ± 9 sec (n = 5) in controls, which was com- tumor mass (0.55g) was greater than that of the AC group pletely abolished by ondansetron (n = 4) and prolonged by (0.35g, p = 0.04). Lastly, a higher microvessel density was Tuesday GR 125487 to 137 ± 41 sec (n = 8, p < 0.05). In response to found in the SL group tumors (8.5/fi eld) than in the AC balloon distention, contractions observed at the anal side group (6.7/fi eld, p = 0.001). Elevated serum PDGF-BB levels were smaller than those at the oral side (n = 8). Ondanse- were observed in the SL group on POD5 (SL, median level tron reduced the magnitude of oral and anal contractions 15.40 ng/ml, vs AC, 8.90 ng/ml, p = 0.002) and POD7 (SL, in response to balloon distention. In contrast, GR 125487 median 10.85 ng/ml, vs AC, 7.59 ng/ml, p = 0.02).

159 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: Tumor growth was increased after SL as CONCLUSION: Chromosal aberration patterns in lymph was tumor angiogenesis and serum PDGF-BB levels. These node metastases and disseminated tumor cells of patients results support the hypothesis that increased tumor growth with esophageal cancer undergoing multimodality ther- after SL may, at least in part, be due to proangiogenic plasma apy are very similar while primary tumors show a differ- protein alterations that promote tumor angiogenesis. ent genomic aberration pattern. These individual genetic tumor characteristics might guide future multimodality Basic: Esophageal treatment options in esophageal cancer. Basic: Hepatic Tu2055 Evaluation of Chromosal Aberrations in the Primary Tu2056 Tumor, Lymph Node Metastases and Disseminated Tumor Cells of Patients with Esophageal Cancer: Sevofl uorane Reduces Liver Damage Secondary to Implications for Anti-Tumoral Therapy? Ischemic/Reperfusion Injury by a Mechanism Not Daniel Vallbohmer*1, Sarah Schumacher1, Stephan E. Baldus2, Related to a Preconditioning Effect * Christian Vay1, Andreas Krieg1, Jan Schulte Am Esch1, Fernanda P. Cavalcante, ANA Maria M. Coelho , Marcel C. Wolfram T. Knoefel1, Nikolas H. Stoecklein1 Machado, Sandra N. Sampietre, Nilza A. Molan, Eleazar Chaib, 1. Department of General, Visceral and Paediatric Surgery, University Luiz C. D’Albuquerque of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology, Gastroenterology, University of São Paulo, São Paulo, Brazil University of Dusseldorf, Dusseldorf, Germany BACKGROUND/AIM: Previous studies have demonstrated INTRODUCTION: Recent analyses uncovered genetic that sevofl urane protects liver from ischemia/reperfusion variations between paired samples from primary gastroin- (I/R) injury however it was not shown yet if this protec- testinal tumors, lymph node metastases and disseminated tion is by preconditioning or if it depends on a continu- tumor cells (DTCs). These fi ndings might help to explain ous administration of the anesthetic during the whole I/R individually variable responses to standard (neo-)adjuvant period. In the present study we evaluated the mechanism therapies and further suggest that multimodality treatment of the protective effect of sevofl urane in ischemia/reperfu- options in gastrointestinal cancer should be guided by sion injury these individual genetic tumor characteristics. Therefore, METHODS: Wistar male rats underwent partial liver isch- we assessed the genetic variations in the primary tumor, emia performed by clamping the pedicle from medium lymph node metastases and DTCs of patients with esopha- and left anterior lateral segments. Liver pedicle clamp was geal cancer. removed after 1 hour of partial ischemia. Anesthesia was PATIENTS AND METHODS: In this translational analy- induced with cetamine and xylazine and rats were intu- sis 86 patients with esophageal cancer undergoing multi- bated and mechanical ventilated. Rats were divided in 3 modality therapy were included. Initially, we established groups: Group1-Sevo Continued (n = 15): sevofl urane was a protocol for double immunofl uorescence labeling for administered during the whole I/R injury time and ani- simultaneous visualization of epithelial cell adhesion mol- mals remained intubated during the whole I/R time, Group ecule (EpCAM) expression on cytokeratin positive cells for 2-Sevo 30 minutes (n = 15): sevofl urane was administered the detection of DTCs in bone marrow and lymph nodes. during 30 minutes and discontinued before liver ischemia, After isolation of positively stained cells, their genomic and Group-3 Control (n = 15): animals was submitted to DNA was globally amplifi ed using the MSE-adapter PCR I/R and no sevofl urane was administrated. Just as group method. Finally, we applied comparative genomic hybrid- 2, rats were extubated after reperfusion. Four hours after ization (CGH) for the genome-wide screening of DNA- reperfusion blood was collected for determinations of AST, gains/-losses on paired samples from primary tumors, ALT. Liver tissues were assembled mitochondrial oxidation lymph node metastases and DTCs of the study patients. and phosphorylation and malondialdehyde (MDA) content. Pulmonary vascular permeability and myeloperoxi- RESULTS: DTCs were detected in 25% of the bone mar- dade (MPO) were also determined. row and 38% of the lymph node samples. Interestingly, RESULTS: CGH analysis revealed differences between the numbers of Four hours after reperfusion Sevo Continued chromosal aberrations in DTCs of the bone marrow com- group presented elevation of AST and ALT serum levels sig- pared to the lymph node samples with a higher frequency nifi cantly lower than Sevo 30 minutes and Control groups of aberrations in DTCs in the lymph node samples. In addi- (p < 0.05). A signifi cant reduction on liver mitochondrial tion, genomic analysis revealed differences in the nature dysfunction and pulmonary vascular permeability was of chromosomal aberrations between primary tumors and observed in Sevo Continued group compared to Sevo 30 corresponding lymph node metastases. Moreover, cluster minutes and Control groups (p < 0.05). No differences in analysis demonstrated similarities of the aberration spec- liver MDA and pulmonary MPO activity were observed trum between the DTCs and lymph node metastases while CONCLUSION: Sevofl urane attenuates liver ischemia/ primary tumors showed distinct profi les. reperfusion injury probably by a mechanism not related to a by preconditioning effect.

160 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Basic: Pancreas Tu2058 LRP6 Overexpression as a Potential Marker of Early Tu2057 Stage Tumor Progression in Pancreatic Ductal Adenocarcinoma Anti-Infl ammatory Effects of Hypertonic Saline Nicolas Zea1,3, William C. Conway1, John S. Bolton1, Solution in Pancreatic Ischemia/Reperfusion Injuries Nancy K. Davis6, Cruz Velasco5, Paul B. Fossier4, Renato S. Godoy*, ANA Maria M. Coelho, Sandra N. Sampietre, Jovanny Zabaleta*2,3 Nilza A. Molan, Oscar M. Takayanagi, Marcel C. Machado, José 1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA; Jukemura, Luiz C. D’Albuquerque 2. Pediatrics, LSU Health Sciences Center, New Orleans, LA; Gastroenterology, University of São Paulo, São Paulo, Brazil 3. Stanley S. Scott Cancer Center, LSU Health Sciences Center, New BACKGROUND/AIM: Injury caused by ischemia/reperfu- Orleans, LA; 4. School of Medicine, LSU Health Sciences Center, New sion (I/R) may result in pancreatic graft loss in pancreas Orleans, LA; 5. School of Public Health, LSU Health Sciences Center, transplants. Therapeutics strategies to reduce pancreatic I/R New Orleans, LA; 6. Anatomic Pathology, Ochsner Clinic Foundation, injury are extremely important to improve the outcomes New Orleans, LA of clinical transplantation. We have previously demonstrated that hypertonic saline 7.5% had anti-infl ammatory INTRODUCTION: The Wnt-β-Catenin signaling pathway, response in acute pancreatitis and liver ischemia/reper- in particular the canonical pathway, has been implicated in fusion models. The aim of this study was to evaluate the pancreatic ductal adenocarcinoma (PDAC) development. effects of hypertonic saline solution 7.5% in I/R pancreatic. Since mutations in the key intracellular components of this pathway are rare in PDAC, understanding the molecu- METHODS: Pancreatic ischemia was performed in Wistar lar mechanisms by which the signaling pathway is aber- rats during one hour by clamping the splenic vessels under rantly activated, and how it infl uences tumor behavior, is mechanical ventilation. The vascular clamp was removed of utmost importance. In this study, we hypothesized that 1 hour after ischemia and pancreatic revascularization was over-expression of components upstream of the signaling achieved, followed by 4h or 24h of reperfusion. The ani- pathway, in particular the Wnt signaling co-receptor LRP6, mals divided into 3 groups: Group NT (n = 20): subjected to are involved in PDAC tumorigenesis. pancreatic I/R without treatment; Group NS (n = 20): subjected to I/R and treated with normal saline solution (NaCl METHODS: Twelve lymph node negative (LN–) and twelve 0.9%), 15 minutes before reperfusion; Group HTS (n = 20): lymph node positive (LN+) paraffi n embedded tumor tis- subjected to I/R pancreatic and treated with hypertonic sues were randomly selected to perform screening gene saline solution (NaCl 7.5%), 15 minutes before reperfusion. identifi cation via gene chip microarray analysis. Once Four and twenty four hours after reperfusion blood were genes of interest were identifi ed by fold-change, 61 tumor collected for determinations of amylase, TNF-α, IL-6, and samples were obtained and then subcategorized in terms of IL-10, creatinine, urea. Pancreatic malondialdehyde (MDA) lymph node status, survival time, and grade of differentia- content was also performed. After 24hours of reperfusion tion and used to validate the results using real-time PCR pulmonary tissues were assembled for myeloperoxidade (RT-PCR). (MPO) analyses. RESULTS: 20,817 genes were investigated with the micro- RESULTS: There was a decrease of infl ammatory cyto- array analysis. Using gene chip microarray software, we kines in the Group HTS compared with control, NT and NS removed the background and used scatter graphs to select groups. It was observed a signifi cant decrease in serum urea those genes with at least 2-fold difference (up or down) and creatinine in the animals treated with normal (NS) and between LN– and LN+. Further selection by p value (p < hypertonic saline (HTS) compared to not treated animals 0.05) identifi ed 957 genes signifi cantly different between (NT). The serum amylase levels and the determination of the two groups. The LRP6 gene expression showed a 2.46- pancreatic MDA showed no signifi cant differences between fold increase in the LN– when compared to LN+ samples groups with I/R. (1192.9 vs 485). RT-PCR for LRP6 in LN– (n = 29) and LN+ (n = 32) confi rmed results of the microarray (p-value = CONCLUSIONS: Hypertonic saline solution decreases the 0.00044). In addition, LRP6 showed a trend of over-expres- systemic infl ammatory response by cytokines reduction sion towards tumors of lower grades of differentiation (TNF-α, IL-6, and IL-10)in pancreatic I/R injury. Further (Table). In terms of survival time, no statistical signifi cance studies will be necessary to prove the clinical benefi ts in was found between LN– and LN+. patients subject to pancreatic transplantation. Poster Abstracts Tuesday

161 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSIONS: The Wnt signaling co-receptor LRP6 is one by 55% (4.8 ± 0.16 vs 2.2 ± 0.19; p < 0.05) and 56% (5.0 ± of the most upstream genes involved in the Wnt-β-Catenin 0.0 vs 2.2 ± 0.2; p < 0.05), respectively compared to WT+S. signaling pathway. Our data shows that LRP6 is signifi cantly CONCLUSIONS: These data suggest that the NK-1R medi- over-expressed in patients with negative nodal status, as well ates leukocyte migration into the peritoneum indicating a as portraying a tendency of over-expression in lower differen- new role for the NK-1RA in adhesiogenesis. tiation grades of pancreatic tumor. Our results refl ect an overexpression of LRP6 early in the series of tumorigenesis events and depict the importance of further studies to understand its Tu2060 relationship to tumor behavior and prognosis. Sphingosine-1-Phosphate Prevents LPS-Induced Loss of Permeability in Intestinal Epithelial Cells Difference within Tumor Samples Regarding Grade of Differentiation Ruiyun LI*1,2, Alexis D. Smith1,2, Ping Jiang1,2, Lan Liu1,2, 1,2 1,2 1,2 Gene N Samples Grade Average Fold Induction Jiang-Yang Wang , Jaladanki N. Rao , Douglas J. Turner 1. University of Maryland, Baltimore, MD; 2. Baltimore VAMC, LRP6 6 na 2.24 Baltimore, MD 1 undifferentiated 2.28 Intestinal epithelial barrier dysfunction results from a wide 15 poor 2.08 variety of pathologic conditions; at the gastrointestinal 27 moderate 2.45 mucosal layer cells must be capable of maintaining barrier integrity, and do this through the interplay of multiple 12 well 3.41 active processes. Previous reports from our lab have shown that Sphingosine-1-phophate (S1P) promotes intestinal epithelial barrier function in part through regulation of Basic: Small Bowel barrier proteins, and S1P has also been found to be protective in various pathologic states. Lipopolysaccharide (LPS) has been shown to increase paracellular permeability, and Tu2059 recently, to also decrease intracellular S1P. In the current study we hypothesized that S1P would decrease paracellu- A Neurokinin-1 Receptor (NK1R) Antagonist (NK-1RA) lar permeability upon LPS exposure, and would act in part That Reduces Postoperative Adhesions Reduces the through regulation of caveolin-1 expression Adhesion Related Chemokines CXCL1(KC) and CXCL2 IEC-Cdx2L1 (Cdx) differentiated intestinal epithelial (MIP-2) and Their Receptor, CXCR2 cells were utilized. Western blot analysis, real-time PCR, Hisashi Kosaka*, Michael R. Cassidy, Arthur F. Stucchi, immunohistochemical staining, were utilized by standard James M. Becker techniques. Transwell permeability to C14-mannitol, FITC- surgery, Boston University School of Medicine, Boston, MA dextran, and measurement of transepithelial electrical resis- INTRODUCTION: tance (TEER) were utilized for permeability assessments. Postoperative adhesions occur in 90–100% Sphingosine Kinase 1 (SphK-1) overexpression stable cell of patients after abdominopelvic surgery. We previously lines were selected in rat intestinal epithelial cells (IECs). showed that adhesiogenesis is associated with leukocyte SphK-1 activity and S1P production were measured by migration into the peritoneum and that the NK1R plays an important role in adhesiogenesis. The aim of this study was radioactive isotope assay. to characterize the temporal changes and the effects of a LPS-treated (50 mcM) Cdx cells show dramatically increased NK-1RA on the gene expression of the leukocyte chemoat- permeability at 4h, but pretreatment with S1P (0.5 mcM tractants CXCL1 and CXCL2 during adhesiogenesis. for one hour) was protective of this LPS-induced increase METHODS: Adhesions were induced in mice using our in permeability, and returned permeability to normal lev- previously published cecal cauterization model. Wild-type els. S1P also prevented LPS-associated decreases in phos- (WT) mice (n = 7/group) were administered saline (WT+S) or phorylated occludin, and in immunofl uorescence studies a NK-1RA (WT+NK) (25 mg/kg) intraperitoneally at surgery. S1P preserved cortical accumulation of occludin that was At 0, 3, and 6-hrs post-operatively, cecal adhesion tissue was disrupted with LPS administration alone. S1P was found measured for CXCL1, CXCL2 and CXCR2 mRNA levels by to increase levels of toll-like receptor (TLR) 2 in Cdx cells, real-time-PCR. Adhesions were measured on POD 7 (n = with no change in levels of TLR4. Similarly, cells stably 7/group) in WT, WT+NK and CXCR2 knockout (KO) mice. overexpressing SphK1 demonstrated increased levels of S1P and also increased levels of TLR2 and not TLR4. Cells over- RESULTS: In WT+S mice, CXCL1 and CXCL2 mRNA levels expressing SphK1 and S1P showed dramatically increased increased at 3-hrs post-operatively compared to non-oper- plasma membrane levels of Stim1, TRPC1, and the scaf- ated controls (380.8 ± 143 vs 0.04 ± 0.08; p < 0.05; 198.3 ± folding protein caveolin-1. Phosphorylated caveolin-1 105 vs 0.07 ± 0.05; p < 0.05) while CXCR2 mRNA increased was signifi cantly decreased with exposure to LPS (5 mcM), at 6-hrs (16.5 ± 2.9 vs 0.17 ± 0.06; p < 0.05). Administration however co-treatment with S1P preserved basal caveolin-1 of the NK-1RA signifi cantly reduced mRNA levels of CXCL1 levels. Finally, inhibition of caveolin-1 with siRNA pre- and CXCL2 3hrs post-operatively compared to controls vented S1P rescue of LPS loss of permeability. (380.8 ± 143 vs 89.9 ± 23.7; p < 0.05; 198.3 ± 105 vs 22.7 ± 6.2; p < 0.05) while CXCR2 mRNA levels were reduced by Our fi ndings demonstrate that S1P prevents LPS-associated 64% (16.5 ± 2.8 vs 5.9 ± 1.6; p < 0.05) at 6hrs. Adhesion for- loss of permeability, and this is in part through its ability to mation was reduced in both WT+NK and CXCR2 KO mice prevent LPS-associated loss of caveolin-1.

162 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu2061 Clinical: Biliary Changes in Peptidergic Neurotransmission with VIP and Substance P During Postoperative Ileus in Rat Tu2044 Brigitte Goetz*, Petra Benhaqi, Martin E. Kreis, Michael S. Kasparek Department of Surgery, Ludwig-Maximilians-University Munich, Non Invasive Pathway to Reduce Negative ERCP Munich, Germany in Patients Presented by Obstructive Jaundice with BACKGROUND: Gallstones Changes in peptidergic neurotransmis- 2 2 *1,2 sion might participate in pathophysiology of postopera- Abdeen Elfateh , Tariq Chundrigar , Bilal O. AL-Jiffry tive ileus (POI), but have not been studied yet. We aimed 1. Surgery, Taif University, Taif, Saudi Arabia; 2. Surgery, AlHada to explore changes in neurotransmission with Vasoactive Military Hospital, Taif, Saudi Arabia Intestinal Polypeptide (VIP; inhibitory) and Substance P BACKGROUND: Common bile duct stones (CBDs) are the (Sub P; excitatory) during POI. most common cause of obstructive jaundice and cholangi- METHODS: Mucosa free, circular, jejunal muscle strips (n tis. This occurs in about 10% of patients with symptomatic = 8/rat) were studied in organ chambers. Six male Sprague gallstone. This study aimed to fi nd non-invasive preopera- Dawley rats were studied per group: Naïve controls (NC), tive tests for predicting CBDs to select patients for preop- rats 12h (P12h) and 3d (P3d) after laparotomy and stan- erative endoscopic retrograde cholangiopancreatography dardized small bowel manipulation to induce POI, and (ERCP) before laparoscopic cholecystectomy (LC). sham controls after 12h (SC12h) and 3d (SC3d) to study METHODS: combined effects of anesthesia and sham laparotomy. We conducted a prospective preoperative Dose-responses to exogenous VIP (10–10–10–7M) and Sub P study on 896 patients with symptomatic gall stones who (3 × 10–10–3 × 10–7M) were studied without and with L-NNA underwent LC at Al Hada military Hospital, Taif, Saudi Ara- (blocking nitric oxide (NO)-synthase; 10–4M) or L-NIL (selec- bia from April 2006 to April 2010. All patients were subjected tive blocker of inducible NO-synthase; 3 × 10–5M). Effects of to clinical, laboratory (LFT) and ultrasound (US) examina- endogenously released neurotransmitters were studied dur- tion. Patients with normal LFTs and US were referred to LC. ing electrical fi eld stimulation (EFS; 20V, 4ms, 3Hz) without Patients with jaundice and US proven CBD abnormality and with L-NNA, VIP antagonist ([D-p-Cl-Phe6,Leu17]-VIP; (stones, dilatation >7 mm or both) were referred for ERCP 10–6M), or Sub P antagonist ([D-Pro2,D-Trp7,9]-Sub P; 10–6M). for diagnosis confi rmation and stone removal, followed by Studies were performed under non-adrenergic, non-cho- LC. Patients with jaundice and normal US were referred to –7 linergic conditions (propranolol 5 × 10 M, phentolamine magnetic resonance cholangiopancreatography (MRCP). –5 –7 10 M, atropine 10 M). Intestinal transit was measured When MRCP detected CBDs, the patients were referred for by charcoal gavage ([%] small bowel passed by marker). ERCP for confi rmation and stone extraction followed by Histology for myeloperoxidase positive cells (MPO), mac- LC. MRCP and ERCP negative cases were subjected to LC rophages, and mast cells was performed in whole mounts with Intraoperative cholangiography (IOC). (cells/mm2). Data: mean ± SEM. RESULTS: There were 707/896 patients (78.5%) who had RESULTS: VIP caused dose-dependent inhibition in all groups (p < 0.05). Inhibition was more pronounced in LC without the need for preoperative ERCP or/and MRCP. P12h, P3d, and SC3d (p < 0.05 vs NC). L-NNA reduced VIP- 193/896 patients (21.5%) were diagnosed to have obstruc- induced inhibition in NC and P12h (p < 0.05), while L-NIL tive jaundice on clinical and laboratory bases. 102/193 had no effect on VIP responses (p = NS). Sub P caused dose- (52.8%) had normal bile ducts by US, the other 91 (47.2%) dependent excitation in all groups (p < 0.05), which was had CBD abnormalities on US. CBDs were found in 23/91 reduced in P12h and increased in P3d (both p < 0.05 vs. (25.3%), dilatated CBD in 28/91 (30.8%), and 40/91 NC), while it was unaffected in sham controls (p = NS). EFS (40.3%) had dilated CBD with stones. These 91 patients induced inhibition was more pronounce in P12h (-67 ± 8%) were referred to ERCP. Stones were extracted in 20/23 compared to NC (–33 ± 8; p < 0.05). VIP and Sub P antag- (87%) who had CBDs, 24/28 (85.7%) with dilated CBD and onists had no effect on EFS responses (all p = NS), while 38/40 (95%) who had both. The 102 patients with normal L-NNA prevented EFS-induced inhibition in all groups (all CBD on US were referred to MRCP, 70/102 (68.6%) were p < 0.05). Intestinal transit was delayed in POI groups and normal by MRCP and were subjected to LC with IOC. CBDs SC12h (P12h 27 ± 2; P3d 40 ± 3; SC12h 48 ± 2%; all p < were detected in 2/70 (2.9%). 32/102 (31.4%) had stones by 0.05 vs NC 60 ± 3%). MPO positive cells and mast cells were MRCP and referred to ERCP which detected CBDs in 25/32 increased in P12h and P3d, but not in sham controls (MPO: (78.2%). When CBD was abnormal, ERCP detected stones NC 9 ± 2; P12h 551 ± 86; P3d 579 ± 45; mast cells: NC 21 in 82/91 patients (90%) and when normal ERCP detected ± 3; P12h 694 ± 73; P3d 460 ± 10; all p < 0.05 vs NC) and stones in 27/102 (26.5%). MRCP helped avoid un-necessary macrophages were increased only in P3d (NC 347 ± 7; P3d ERCP in 68/102 (66.7%) with false negative results of 2/102 Poster Abstracts 1163 ± 31 p < 0.05 vs NC). (1.96%) and false positive results of 7/102 (6.7%). CONCLUSION: Induction of POI causes specifi c changes Tuesday in neurotransmission with VIP and Sub P that are accompanied by intramural infl ammatory response and delayed gastrointestinal transit. Therefore, changes in peptidergic neurotransmission with VIP and Sub P appear to participate in pathophysiology of POI in rat. DFG KA2329/5–1

163 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: We have documented a considerably vant gemcitabine-based chemotherapy and those who did higher incidence of obstructive jaundice in our area, one not was observed among patients with high hENT1 expres- that makes this simple disease a community health issue. sion (P = 0.002), but not among patients with low hENT1 Also, with the small number of MRCP machines most hos- expression (P = 0.525). Intratumoral hENT1 expression was pitals have a long waiting time facility. Our aim was to fi nd only an independent predictive factor for patients treated a simple pathway to get the cost-effective balance between with adjuvant gemcitabine-based chemotherapy by multi- MRCP and ERCP. Therefore, patients with obstructive jaun- variate analysis (P = 0.027). dice and abnormal CBD on US are considered of high risk CONCLUSION: High intratumoral hENT1 expression for CBDs and the use of MRCP is not justifi ed. However, if was associated with increased overall survival in patients any of the tests were normal MRCP is indicated to decrease with cholangiocarcinoma who received adjuvant gem- the incidence of negative ERCP. citabine-based chemotherapy. Intratumoral hENT1 expression may be a potent predictive marker for cholan- Tu2045 giocarcinoma patients treated with adjuvant gemcitabine- Prognostic Impact of Human Equilibrative Nucleoside based chemotherapy. Transporter 1 Expression in Adjuvant Gemcitabine- Tu2046 Based Chemotherapy After Surgical Resection for Cholangiocarcinoma Image Documentation and Textual Operative Hironori Kobayashi*, Yoshiaki Murakami, Kenichiro Uemura, Description of the Technique and the Findings of Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Naru Laparoscopic Intraoperative Cholangiography Are Kondo, Hiroki Ohge, Taijiro Sueda Sub-Optimal Hiroshima Univ, Hiroshima, Japan Alex Karran*, Ashleigh Majoe, Ashraf M. Rasheed OBJECTIVE: Although the prognosis in patients with Gwent Institute of Minimal Access surgery, Newport, United Kingdom biliary carcinoma remains poor, adjuvant gemcitabine- BACKGROUND: There is a wealth of data to dispute the based chemotherapy after surgical resection for biliary car- role of laparoscopic intra-operative cholangiography (IOC) cinoma has been shown to improve survival. There have but there little published literature to describe the optimal been no reports concerning a useful predictive biomarker technique or to recommend a standardised reporting sys- in patients with cholangiocarcinoma treated with adju- tem. The operative report is a legal document that must vant gemcitabine chemotherapy. To clarify the relation- contain details of all interventions. ship between expression of intratumoral enzymes related AIMS: to the metabolism of gemcitabine and its derivatives and This study aims to examine the details of the tech- response to adjuvant chemotherapy with gemcitabine for nique of IOC and to audit the quality of the captured cholangiocarcinoma, we evaluated human equilibrative images and the content of operative notes in relation to nucleoside transporter 1 (hENT1) expression immunohis- documentation of essential IOC anatomical landmarks tochemically in resected cholangiocarcinoma tissues. METHOD: A retrospective analysis of 100 consecutive METHODS: Polyclonal antibodies were used to immu- laparoscopic intra-operative cholangiograms that were nostain sections of 105 formalin-fi xed paraffi n-embedded attempted at the Aneurin Bevan Health Board (ABHB) specimens of cholangiocarcinoma resected between 1989 between February 2009 and March 2010 was undertaken. and 2010. The relationship between intratumoral hENT1 The visualisation of 7 essential anatomical landmarks on expression and prognosis was evaluated statistically. This captured IOC images and specifi c reference made to each in study was a retrospective analysis on retrospectively col- the operation notes were assessed. lected tissue and data. RESULTS: A signifi cant inter-operator variability was RESULTS: Out of 105 patients, 51 (49%) received adjuvant noted in the performance and the interpretation of IOC. gemcitabine-based chemotherapy. High and low intratu- Only 34% of captured images identifi ed all 7 recognised moral hENT1 expression was present in 74 (70%) and 31 essential IOC landmarks. The majority (63.8%) of opera- (30%) cases, respectively. There were no signifi cant differ- tion notes failed to make reference to all 7 landmarks, with ences in clinicopathological factors between patients with a mean number of landmarks referred to as 1. There was a high hENT1 expression and those with low hENT1 expres- signifi cant difference (p < 0.001) between landmarks iden- sion. Survival of patients with high hENT1 expression was tifi ed on the captured images and their documentation signifi cantly better than that of patients with low hENT1 within the operation notes. expression among patients who received adjuvant gem- CONCLUSIONS: This study confi rms that laparoscopic citabine-based chemotherapy (P = 0.008), but not among IOC is sub-optimally performed and poorly reported. It patients who did not (P = 0.894). Moreover, a signifi cant highlights the need for standardisation of the IOC tech- difference in survival between patients who received adju- nique and systematisation of its reporting.

164 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu2047 Is Cholecystostomy a Safe Procedure in Patients with Cirrhosis? Rajiv Jayadevan*1, Malika Garg1, Thomas Schiano2, Celia M. Divino1 1. Surgery, The Mount Sinai School of Medicine, New York, NY; 2. Division of Liver Disease, The Mount Sinai School of Medicine, New York, NY INTRODUCTION: Abdominal surgical intervention in cirrhotic patients is correlated with high mortality due to coagulopathy, bleeding, and sepsis from ascitic breach.1 Although percutaneous cholecystostomy has been advo- RESULTS: No signifi cant difference in gender, age, race, cated as a safer alternative to cholecystectomy in high-risk ASA score, LFTs, duration of tube placement, gallbladder critically ill patients with concurrent gallbladder disease, disease, ultrasound fi ndings or CT fi ndings was found no study has focused exclusively on the outcomes of cho- between cirrhotic and non-cirrhotic patients. Cirrhotic lecystostomy in patients with cirrhosis. As a result, it is patients were found to be more likely to have HCV (p = unknown whether the outcomes of cholecystostomy in 0.001), ascites (p = 0 .004), jaundice (p = 0.045), and cirrhotics are as encouraging as those of their non-cirrhotic encephalopathy (p = 0.012). While cirrhotic patients had counterparts. Physicians thus often face a predicament in a signifi cantly greater amount of post-operative complica- treating cirrhotic patients with gallbladder disease refrac- tions (p < 0.001), e.g. bleeding (p = 0 .041), no signifi cant tory to medical management. The purpose of this investi- difference was found in post-operative survival between gation was to determine whether cholecystostomy is a safe cirrhotic and non-cirrhotic patients. and viable option in the treatment of gallbladder disease in CONCLUSION: Although cirrhotic patients have a greater patients with cirrhosis. number of complications than their non-cirrhotic counter- METHODS: A retrospective chart review was performed parts after cholecystostomy, there is no signifi cant differ- which identifi ed 16 cirrhotic and 49 non-cirrhotic patients ence in survival between the two types of patient. Cirrhosis treated with cholecystostomy tubes between 2000 and does not appear to be a contraindication to performing 2011. Information investigated included demographics, cholecystostomy, which is an appropriate temporizing pro- common comorbidities, markers of disease severity (rel- cedure for cirrhotic patients with gallbladder disease. evant labs and ASA scores), type of gallbladder and liver REFERENCE: disease, post-operative complications, and post-operative survival time. Differences in survival time was assessed 1. Mansour A, Watson W, Shayani V, Pickleman J. Abdom- with Kaplan-Meier survival analysis. Qualitative and quan- inal operations in patients with cirrhosis: still a major titative variables were compared with Chi-square and two surgical challenge. Surgery. 1997;122 (4):730–735; dis- independent sample t-tests respectively. cussion 735–736. Poster Abstracts Tuesday

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Tu2048 clarify the anatomy in Calot’s triangle. Planned IOC was performed in 58 cases (8.1%): 34 for gallstone pancreatitis, Dome-Down Dissection Is a Safe and Practical Primary 10 for choledocolithiasis, 9 for biliary colic, 3 for cholangi- Approach to Laparoscopic Cholecystectomy: Results of tis, and 1 for primary biliary sclerosis. a Ten Year Experience CONCLUSIONS: This 10 year, single-operator experience Dylan Nieman*1, Neil Ghushe2, Jacob Moalem1, demonstrates that DDLC is a safe and practical approach Marabel D. Schneider1, Kendra Klein1, D. Owen Young1, to CCY in a diverse group of patients and can be used as Brandon Stein1, Luke O. Schoeniger1 a primary approach to laparoscopic cholecystectomy (LC) 1. Department of Surgery, University of Rochester, Rochester, NY; with a low complication rate. We hypothesize that because 2. Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH this approach requires circumferential visualization of the contents of Calot’s triangle, the CVS is readily identifi ed PURPOSE : To audit our experience with a dome down in all cases. Improved visualization enhances the safety of technique for laparoscopic cholecystectomy (DDLC) regard- this approach and has caused some to advocate DDLC as a ing clinical outcomes, safety, and demonstration of the criti- way to avoid conversion to open CCY in patients with “dif- cal view of safety (CVS). fi cult gallbladders”. We posit that the high rate of bile duct METHODS: We reviewed a prospectively collected data injuries associated with the dawn of laparoscopy, may have set of all patients who underwent cholecystectomy (CCY) been a byproduct of the shift from dome-down to bottom- from 2000 through 2010 by a single surgeon. All patients up infundibular dissection rather than the shift from open were planned for primary DDLC and transection of the cys- to laparoscopic techniques, per se. While we acknowledge tic artery with a Harmonic Scalpel. Electronic records were that experienced surgeons should continue to use tech- queried for additional data. niques with which they have experienced success, we propose a greater role for DDLC as an initial approach to LC in surgical training, to demonstrate the CVS and to allow a safe laparoscopic cholecystectomy in all circumstances.

Tu2049 Use the Duodenum, It’s Already There: A Retrospective Cohort Study Comparing Biliary Reconstruction to the Either the Jejunum or Duodenum John B. Rose*, John A. Ryan, Thomas R. Biehl General Surgery, Virginia Mason Medical Center, Seattle, WA BACKGROUND: Surgical reconstruction of the biliary system is required for a variety of reasons. Roux-en-Y jejunal anastomoses (RJA) are the current gold standard for repair. Direct duodenal anastomoses (DDA) are a less common approach, however it has the benefi t of operative simplic- ity and ease of endoscopic evaluation. We compared the outcomes of non-palliative DDA to RJA. The Critical View of Safety in Dome Down Laparoscopic Cholecystectomy: (A) cystic artery (B) cystic duct (C) common bile duct (D) infundibulum of METHODS: A retrospective cohort study was performed at gallbladder (E) gallbladder fossa. a single tertiary care center comparing DDA to RJA between the years 2000 and 2010. Standard patient demographics, RESULTS: 715 consecutive patients (72% female) under- complications rates, mortality rates, need for endoscopic went CCY; 581 (74%) elective, 134 (26%) acute. One or radiologic interventions, and long term outcomes were (0.14%) required conversion to open CCY; all others under- compared. went DDLC. Five (0.69%) had minor complications: ileus RESULTS: A total of 105 non palliative reconstructions in 2 cases, trocar site hernia in 1. Biloma was found in 2 were performed between 2000 and 2010. 67 DDA and 38 patients however there were no bile duct injuries or biliary RJA reconstructions were performed in an end-to-side fash- strictures on subsequent evaluation. A single enterotomy ion for either bile duct injury, cholangiocarcinoma, chole- occurred during Hasson canula placement in a patient dochal cysts, or benign strictures. The groups were similar with extensive adhesions; this led to the sole conversion with regard to demographics, preoperative diagnoses, post- to open CCY. Estimated blood loss was minimal in all operative length of stay (7 days vs. 7.5 days), postoperative cases. Most patients (84%) were discharged on the day of mortality rates (1.7% vs. 2.9%; P = 0.72), and overall (Grade surgery. Length of stay and complication rate did not vary III or greater) complication rates (47.1% vs. 47.1%; P = between patients who had acute or elective indications 0.83). However, anastomotic related complications (leaks, for surgery. The CVS was identifi ed in all (566) patients abscesses/bilomas, or strictures) were fewer in the DDA since 2001, when we began documenting identifi cation or cohort (11.7% vs. 35.3%; P = 0.01). Of those developing non-identifi cation of the CVS. In cases for which precise stricture, 5 of 6 in RJA cohort required percutaneous tran- operative times were available, DDLC averaged 37 minutes. shepatic access for management, as opposed to only 1 of 3 Intra-operative cholangiogram (IOC) was never needed to in the DDA cohort.

166 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSION: Direct duodenal anastomosis is a safe and CONCLUSIONS: the colposcopic NOTES access has proved often preferable method for biliary reconstruction. It may to be safe, with excellent outcomes, no complications and have decreased anastomotic complication rates, while ben- void of sequelae in the gynecologic and sexual aspects. The efi ting from easier postoperative endoscopic management. risks of rectal injury, infection and sexual or pregnancy dysfunctions are considered to be minimal. Tu2050 Tu2051 Gynecologic and Fertility Issues in NOTES Colposcopic Procedures Gallbladder Wall Changes in Patients with and Anibal Rondan*, Rafael A. Redondo, Marcelo Fasano, Mariano Without Metabolic Syndrome Gimenez, Mauricio Ramirez, Alberto R. Ferreres Maria Fernanda Gonzalez-Medina*, Antonio Ramos-De La Medina, Department of Surgery, University of Buenos Aires, Buenos Aires, Jose Remes-Troche, Gustavo M. Melgarejo Ortiz, Peter Grube Argentina Pagola, Isabel Ruiz JuáRez, Alfonso Perez-Morales, BACKGROUND: the clinical application of NOTES proce- Joaquin Valerio-Ureña, Federico B. Roesch dures have raised issues regarding the ways of access to the Gastrointestinal Surgery and Investigation Department, Hospital abdomen. The transvaginal access has been long and widely Regional de Alta Especialidad de Veracruz, Veracruz, Mexico used and eliminates the disadvantages and risks associated BACKGROUND: Recent research has described that obe- with other NOTES approaches. With the development of sity and high carbohydrates intake increases fat content of laparoscopic techniques, the vagina was used not only as a the gallbladder, decreases its motility and mucosal absorp- port of entry but also as an excellent channel for removal tion, leading to a condition known as steatocholecystitis. of surgical specimens. The easy closure of the incision and Gallstone disease (GD) and the metabolic syndrome (MS) the minimal risk of infection represent some of the benefi ts share common risk factors. of this access, outweighting the other NOTES alternatives. OBJECTIVE: To identify if MS contributes to the devel- OBJECTIVE: to present the followup of our fi rst 107 opment of functional disorders and wall changes of the patients who were operated on through a hybrid NOTES gallbladder. transvaginal access METHODS: A Prospective study was conducted from METHODS AND MATERIALS: after institutional IRB August 2010 to July 2011 on patients with symptomatic approval a program of NOTES surgery was started at our gallbladder disease undergoing laparoscopic cholecystec- single institution in august 2007. Between that date and tomy. Forty two patients were included and divided into august 2009 107 procedures were attempted (100 chole- two groups; 22 patients with MS and 20 patients without cystectomies and 7 appendectomies) with a colposcopic MS. Family history, risk factors, anthropometric, clinical NOTES approach with hybrid technique. The average age and laboratory variables were evaluated before surgery. Gall- was 33.5 years with ranges between 22 to 46. After dis- bladder specimens were analyzed, measured and graded by charge, refrain from sexual activity was prescribed for 15 two pathologists at 3 standardized areas (cystic duct, liver days (fi rst 30 patients) and for 30 days in the following bed, free margin and fundus). patients, due to inobservance. The postoperative follow up RESULTS: included gynecologic assessment at postoperative days 7, Thirty three patients who underwent chole- 30, 60, 180 and 360. The evaluation included: guided ques- cystectomy were female. A family history of GD and MS tionnaire, physical examination and colposcopy to assess were present in 90% of patients. Chronic cholecystitis was healing, presence of anatomical injuries, vaginal secretion the most frequent diagnostic (93%). Median weight was and other alterations. 75.5kg ± 14.3 and 67.1kg ± 9.2 for MS and No-MS groups respectively. Gallbladder wall thickness was signifi cantly RESULTS: the cholecystectomy with the NOTES col- increased (P = 0.012) in the MS group. This thickness poscopic hybrid technique could be completed in 99 of was secondary mainly observed in the cystic duct area of the 100 patients (95%). In the remaining case the opera- patient with MS. The percentage of fatty infi ltration of the tion had to be performed laparoscopically due to pelvic gallbladder wall, muscle degeneration and cholesterolosis adhesions (5 previous cesarean sections). One case ( # 6) did not show signifi cant differences between groups. required a minilaparotomy through a previous Pfannes- CONCLUSIONS: tiel incision for checking hemostasis of the vaginal cul de MS is associated with an increased gall- sac and 8 required the placement of an additional 2.5 mm bladder wall thickness. Muscle fi brosis in the cystic duct trocar. The appendectomy was completed in all 7 cases, in was the most important wall modifi cation in these patients. In our series, MS was not associated to fat infi ltration of the

2 with the placement of an additional 2.3 mm trocar. No Poster Abstracts major complications were attained. gallbladder wall or cholesterolosis.

The systematic assessment proved adequate healing of Tuesday the vaginal access with no local complications as well as absence of granulomas, hematomas, adhesions or retrac- tions. None of the patients refer dyspareunia. Thirteen patients (12%) got pregnant after the procedure, 10 with a normal birth delivery and 3 cesarean sections, without complications due to the previous access

167 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Colon-Rectal Tu1746 Predictive Factors of Acute Respiratory Failure in Colon Tu1745 and Rectal Surgery Hossein Masoomi*, Joseph C. Carmichael, Steven Mills, Emergent Restorative Surgery for Ulcerative Colitis: Matthew O. Dolich, Alessio Pigazzi, Michael J. Stamos Expertise May Matter Most When It’s Hard to Find Surgery (Colorectal Division), University of California, Irvine-Medical *1,2 1 1 Caitlin W. Hicks , Richard A. Hodin , Liliana Bordeianou Center, Orange, CA 1. Surgery, Massachusetts General Hospital, Boston, MA; INTRODUCTION: 2. Cleveland Clinic Lerner College of Medicine, Cleveland, OH Postoperative acute respiratory failure (ARF) is a major factor of morbidity and mortality in colon INTRODUCTION: The aim of our study was to compare and rectal surgery. outcomes of patients treated with elective vs. urgent sur- OBJECTIVES: gery for active Ulcerative Colitis (UC) in the hopes of defi n- To evaluate the prevalance of ARF following modifi able factors that could decrease complications. ing colorectal surgery and to evaluate the effect of patient characteristics, comorbidities, pathology, resection type, METHODS: We performed a retrospective review of 179 surgical technique and admission type on ARF in colorectal UC patients undergoing surgery for failure of medical man- surgery. agement. Patients treated urgently (while hospitalized) METHODS: were compared to those treated electively with univariate Using the National Inpatient Sample (NIS) (chi square, t test) and multivariable regression analyses. database, we examined the clinical data of patients who underwent colon and rectal resection from 2006–2008. RESULTS: Patients undergoing urgent (n = 99) vs. elective Multivariate regression analysis was performed to identify (n = 80) surgery were younger (28.3 ± 1.6 vs. 32.6 ± 1.6 years; factors predictive of ARF. p = 0.05) with lower mean BMI (22.3 ± 0.1 vs. 25.9 ± 0.6 kg/ m2; p = 0.0001). Signifi cantly more urgent patients were on RESULTS: A total of 975,825 patients underwent colorec- steroids at the time of surgery (93.5% vs. 66.7%; p < 0.0001). tal resection during this period. Overall, the rate of acute Use of anti-TNF drugs (21.3% vs. 26.3%; p = 0.44) and other respiratory failure was 10.42% (elective surgery: 4.51% vs. immunomodulators (42.5% vs. 43.4%; p = 0.91) were equiv- emergent surgery: 18.59%; p < 0.01). Patients who experi- alent between the two groups. Urgent patients reported enced ARF following colorectal surgery had a signifi cantly more daily bowel movements at the time of surgery (11.7 ± higher rate of in-hospital mortality (26.84% vs. 1.90%) and 0.7 vs. 9.0 ± 0.8; p = 0.01) and had an increased prevalence a longer mean length of hospital stay (22.31 days vs. 9.32 of severe disease on fi nal pathology (87.5% vs. 73.7%; p = days) compared with patients without ARF. Using multivar- 0.02) compared to patients treated electively. iate regression analysis, patient factors including emergent During surgery, urgent and elective patients had similar operation (odds ratio [OR]: 2.91), congestive heart failure degrees of hemodynamic stability (mean apgar scores 6.1 ± (OR, 2.51), alcohol abuse (OR, 2.13), pulmonary hyperten- 0.2 vs. 6.5 ± 0.1; p = 0.1). However, urgent cases had more sion (2.01), chronic renal failure (OR, 2.0), chronic lung than a 5-fold increase in the proportion of subtotal colec- disease (OR, 1.96), age over 65 (OR, 1.92), diverticulitis tomies (5.1% vs. 29%; p < 0.0001) and half as many laparo- (OR, 1.71), liver disease (OR, 1.66), peripheral vascular scopic procedures (8.8% vs. 18%; p = 0.07). Postoperatively, disease (OR, 1.58), malignant tumor (OR, 1.53), obesity patients treated urgently had more short-term complica- (OR, 1.41) and ulcerative colitis (OR, 1.25) signifi cantly tions (1.0 ± 0.3 vs. 0.6 ± 0.2; p = 0.05), but no increase in impacted the risk of ARF. Technical factors including total anastamotic leaks [OR 1.7 (0.5, 6.5); p = 0.26] or in-hospital colectomy (OR: 2.66), open procedure (OR, 1.71), left col- length-of-stay (7.3 ± 0.5 vs. 6.5 ± 0.4 days; p = 0.21) at their ectomy (OR, 1.50), and transverse colectomy (OR, 1.41), initial operation. Long-term complications, including pou- were also associated with higher risk of ARF. Although male chitis, fi stula/abscess, ileus/SBO, stricture, and pouch failure sex (OR: 1.09), teaching hospital (OR, 1.07), Black race (OR: were similar regardless of urgency status (p ≥ 0.08). Multi- 1.04), and Hispanic race (AOR, 1.03) also had statistically variate regression analysis controlling for disease severity, signifi cant impact on rates of ARF, these were less clinically steroid use, and infl iximab use suggested that short-term signifi cant than the other factors. There was no association complications were attributable to higher BMI in addition with hypertension, diabetes, smoking, Asian race, sigmoid- to urgent status (p ≤ 0.05). Surgeon inexperience and use of ectomy, proctectomy or Crohn’s disease and ARF. immunomodulators other than infl iximab were associated CONCLUSIONS: Respiratory failure is a relatively com- with increased odds of long-term fi stula/abscess [OR 5.56 mon complication following colorectal surgery. Emergent (1.1, 33); p = 0.05) and pouch failure [OR 13.3 (1.75, 318); surgery is the strongest predictor of acute respiratory fail- p = 0.01], respectively. ure in colorectal surgery. Surgical approaches such as total CONCLUSION: Although urgent surgery is associated with colectomy, left colectomy and transverse colectomy, that an increased number of short-term complications, it does classically involve upper abdominal incisions, are associ- not affect the risk of anastomotic leak, in-hospital length- ated with a higher rate of respiratory failure. of-stay, or long-term complications provided that the surgery is performed by an expert. Weaning from immunomodulators other than infl iximab and early transfer to an institution with IBD expertise would likely decrease complications overall for patients undergoing both elective and urgent interventions for severe UC.

168 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1747 RESULTS: (Table). Compared with healthy subjects, FIAS patients showed lesser rectal compliance (p = 0.0129) and Altered Rectal Tone and Compliance and rectal tone at lower volume (p = 0.0029). The thresholds Hyposensitivity for Non-Noxious Stimuli in Patients for non-noxious stimuli of gas sensation (p = 0.0272) and with Fecal Incontinence After Anorectal Surgery urge-to-defecate sensation (p = 0.0245) were reported by Richard A. Awad*1, Francisco Flores-Judez2, Santiago Camacho1, FIAS patients at higher pressure than healthy subjects. The Alfredo Serrano1, Evelyn Altamirano1 noxious stimulus of pain was reported by FIAS patients at similar pressure than healthy subjects (p = 0.9). Compared 1. Experimental Medicine and Motility Gastroenterology Service with healthy subjects FIAS patients showed greater anal U 107, Mexico City General Hospital, Mexico, Mexico; 2. Surgery squeeze pressure (p = 0.041). However, anal resting pres- Service, Mexico City General Hospital, Mexico, Mexico sure and rectoanal inhibitory refl ex parameters (RAIR) were INTRODUCTION/OBJECTIVES: It is reported that fecal similar. incontinence may present as a late complication of anal CONCLUSION: FIAS patients preserve internal anal fi ssure (1) or other anorectal procedures, that rectal dis- sphincter function but present with impaired rectal tone tensibility and volume thresholds for sensations decrease and compliance and hyposensitivity for non-noxious stim- after stapled hemorrhoidopexy (2), and that noxious and uli. The results also support the concept that noxious and non-noxious distensions stimulate different afferent nerve non-noxious distensions stimulate different afferent nerve pathways (3). This study aimed to search anal sphincter pathways and suggest that an impaired afferent nerve and rectal factors that determine fecal incontinence after pathway and abnormal rectal structure and function are anorectal surgery (FIAS). involved in the genesis of fecal incontinence after anorec- METHODS: Seventeen patients (50 ± 15 years, 11 females) tal surgery. with fecal incontinence (10 ± 15 CI: 3–17 incontinence epi- REFERENCES: sodes per week) after anorectal surgery (sphincterotomy = 5, fi stulotomy = 5, rectal prolapse = 4, hemorrhoidectomy 1. Levin A et al. Int J Colorectal Dis 2011. = 1, others = 2; 2 ± 1 CI:1.2–3.2 years after surgery) were 2. Corsetti M et al. J Gastrointest Surg 2009;13:2245–51. studied [clinical assessment, rectosigmoidoscopy, anorectal 3. Awad RA et al. Gastroenterology 2011;140:S744. manometry (MMS, Netherlands) and barostat (G&J, ON, CA)] and compared with healthy subjects (n = 11, 22 ± 2 years, 10 females for manometry and; n = 10, 25 ± 7 years, three females, for barostat studies). Rectal sensory thresholds, tone and compliance were evaluated with an electronic barostat using the ascending method of limits. Mean ± SD, binominal 95% confi dence interval, and nonpaired Student two-tailed t test with alpha = 0.05.

Table Variable Fecal Incontinence Healthy (Mean ± SD) After Surgery Subjects Tone (ml) 43 ± 42 CI: 23−63 103 ± 51 CI: 71–135* Compliance (v/p) 5 ± 5 CI: 2–7 11 ± 6 CI: 7–16* First sensation (mmHg) 16 ± 4 CI: 14–18 14 ± 5 CI: 10–17 Gas sensation (mmHg) 23 ± 5 CI: 20–25 17 ± 6 CI: 14–21* Urge to defecate (mmHg) 30 ± 8 CI: 25–35 22 ± 7 CI: 17–26* Pain sensation (mmHg) 36 ± 7 CI: 32–40 35 ± 8 CI: 30–41 Anal resting pressure (mmHg) 46 ± 25 CI: 34–58 34 ± 22 CI: 21–48 Anal squeeze pressure (mmHg) 87 ± 65 CI: 56–118 43 ± 24 CI: 28–57* RAIR duration (s) 20 ± 7 CI: 17–24 19 ± 5 CI: 16–23

RAIR relaxation (%) 59 ± 17 CI: 51–-67 74 ± 31 CI: 55–93 Poster Abstracts

* = p < 0.05 compared with healthy subjects Tuesday

169 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1748 Tu1749 Laparoscopic Right Hemicolectomy: A Comparison Colorectal Cancer in Patients Under 50 Years of Age: of Natural Orifi ce vs. Transabdominal Specimen Frequent and More Often Advanced? Extraction Elizabeth Myers*1, Joon Ho Jang1, Daniel L. Feingold2, Reginald L. Griffi n*1, Irfan Qureshi1, Eve Oganesyan1,2, Tracey D. Arnell2, Kenneth A. Forde2, Jon Kluft2, Samer Naffouje1, Ziad Awad1 Sonali A. Herath1, Richard L. Whelan1 1. University of fl orida, Jacksonville, FL; 2. LECOM, Bradenton, FL 1. Colorectal Surgery, St. Luke’s Roosevelt Hospital Center, New BACKGROUND: Conventional laparoscopic assisted right York, NY; 2. Surgery, College of Physicians and Surgeons, Columbia hemicolectomy (LARH) involves making an abdominal University, New York, NY incision to remove the specimen and perform the anasto- INTRODUCTION: The overall incidence of colorectal mosis. The skin incision extraction site continues to be a cancer (CRC) in Western countries is falling in part due major source of morbidity after both open and LARH, spe- to aggressive adenoma surveillance programs. It has been cifi cally with regard to postoperative pain, wound infection previously noted that more patients (pts) under age 50 are and hernia formation. Totally laparoscopic right hemico- developing CRC and are more likely to present with Stage 3 lectomy with intracorporeal anastomosis and transvaginal or 4 disease yet average risk pts under 50 are excluded from extraction ie. natural orifi ce specimen extraction (NOSE) CRC screening programs. This review was undertaken to eliminates the skin incision extraction site and may pos- investigate CRC in pts under 50 at 2 institutions to deter- sible leads to better outcome compared to LARH. mine if the above trends are observed in this population. METHODS: Our study reviewed two consecutive case METHODS: The records of pts under the age of 50 who matched cohorts: LARH and NOSE performed during 2007 underwent an operation for CRC between July 1996 and July and 2011. Forty consecutive female patients total were 2011 at 2 hospitals were reviewed. The main study variables reviewed: 20 LARH and 20 NOSE. The two groups were included: age, symptoms, family history, tumor location, matched for benign and malignant disease, sex, age, race, resection performed, and stage & differentiation of disease. American Society of Anesthesiologist (ASA) score, pathology, RESULTS: Over the 15 year period, a total of 174 CRC tumor stage, lymph node (LN) number, body mass index pts under age 50 were identifi ed that underwent surgery (BMI), previous abdominal surgeries, and comorbidities (90 males, 85 females; mean age 41.4, range 17–49). Pts including chronic obstructive pulmonary disease (COPD), under 50 accounted for 12% of all CRC cases (all ages) for coronary artery disease (CAD), hypertension, diabetes mel- the 5 year period (2006–2011) for which the full data set litus (DM), chronic kidney disease (CKD), and nicotine was available. Sixteen pts (9%) had a fi rst degree, 17 pts dependence. Our goal was to determine signifi cant differ- (10%) had a second degree, and 3% had both a fi rst and ences between the two groups with regard to postoperative second degree family history of CRC; 125 pts (71%) had a pain, wound infection, hernia formation, postoperative negative family history. The vast majority (93%) presented ileus, septic complications, length of hospital stay, read- with symptoms: the most common were bleeding (57%), mission rate, time interval for postoperative chemotherapy obstruction (9%), and abdominal/rectal pain (35%). Not if indicated, symptom distress score (SDS), Visick grade, uncommonly, work-up and diagnosis were delayed because Quality of life Index (QLI) and cosmetic score. of patient and/or doctor complacence. Bleeding was often RESULTS: The two groups were comparable for all cat- attributed to hemorrhoids; 2 pts had symptoms for 18–24 egories. Follow up was available on all patients (100%). months prior to colonoscopy. Advanced CRC (Stage 3 or 4) At a mean follow-up of 25.23 months (range 6–53, there was found in 95 pts (55%). The tumor locations were: right was no difference between postoperative pain between or transverse, 46 (26%); descending or sigmoid, 59 (34%); the two groups on postoperative day one, postoperative rectal, 69 (40%). The vast majority of pts had segmental day two or greater than 2 weeks (p = .571),(p = .861),(p = resections. Five pts had a subtotal/total abdominal colec- .688), respectively. The NOSE group had no postoperative tomy, of which 2 had a fi rst degree family history. Most hernia formation or wound infections compared to the pts (70%) had moderately or well differentiated cancers, LARH group which had 10% hernia formation rate and 5% whereas 21 pts (12%) had poorly differentiated lesions and wound infection rate, however the difference was not sig- 34 (19%) had mucin producing CRC’s, of which almost two nifi cant (p = .439)and (p = .267), respectively. There was thirds had Stage 3 or 4 disease. no difference between groups in postoperative ileus (p = CONCLUSIONS: Young patients with sporadic CRC con- .192), septic complications (p = 1.000), length of hospital tinue to present with advanced disease. In this series the stay (p = .243), readmission rate (p = .394), time interval tumors were predominantly located in the distal colon and for postoperative chemotherapy (p = .645), SDS (p = .446), rectum. The vast majority of these pts had no contribut- Visick grade (p = .176) or QLI (p = .175). The NOSE group, ing family history similar to the situation for the over 50 however, have statically signifi cant better cosmetic scores CRC population. An alarming number of young pts have (p = .018). symptoms that are often attributed to common benign CONCLUSION: NOSE is comparable LARH with regard to colorectal problems and that lead to a delay in diagnosis. short and long term postoperative outcomes. NOSE is asso- Clinicians must maintain a low threshold for evaluating ciated with better cosmetic outcome. young symptomatic patients to exclude an occult cancer as the outcome of CRC treatment strongly depends on the stage at diagnosis.

170 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1750 CONCLUSIONS: Clostridium diffi cile colitis is a serious problem that carries signifi cant morbidity and mortality. st Clostridium Diffi cile Colitis: 21 Century Pandemia The majority of the patients did not require surgery, but Haisar E. Dao*, Peter E. Miller, Justin Lee, Reza Kermani, those who did had a fourfold increase in mortality risk. Alan W. Hackford Patients over 65 years old and those who develop acute Surgery, St. Elizabeth’sMedical Center. Tufts University School of renal failure also had a higher risk of in-hospital mortality. Medicine, Boston, MA OBJECTIVE: Clostridium diffi cile colitis has become a Tu1751 signifi cant problem among healthcare facilities in the Never Too Old for Abdominal Surgical Repair of Rectal United States. Our objective is to analyze Clostridium dif- Prolapse fi cile colitis associated hospitalizations and contemporary * outcomes. Jaime Benarroch-Gampel , Aakash Gajjar, Casey A. Boyd, Kristin Sheffi eld, Taylor S. Riall METHODS: Analysis of the Nationwide Inpatient Sample Surgery, University of Texas Medical Branch, Galveston, TX (NIS) was performed for the years 2005–2007. This database incorporates 100% of all hospital discharges from a 20% BACKGROUND: The effect of age on short-term outcomes stratifi ed sample of US hospitals. Diagnosis and procedures in patients undergoing surgical repair for full-thickness rec- were identifi ed using ICD-9 codes. Primary outcomes were tal prolapse is unknown. in-hospital mortality and need for surgical intervention. METHODS: Using the National Surgical Quality Improve- Multivariable analysis was performed to determine the rela- ment Program (NSQIP) database (2005–2010) we selected tionship between independent variables and in-hospital a total of 1,876 patients with full-thickness rectal prolapse mortality. who underwent either perineal or abdominal repairs. Out- RESULTS: 859,350 discharges were identifi ed with a diag- come variables included any or major postoperative com- nosis of Clostridium diffi cile colitis. The mean age of the plications (unplanned intubation, pulmonary embolism, population was 68.5 ± 19.4 years (Female 58.8%), and the acute renal failure, stroke, coma, cardiac arrest, myocar- median length of stay was 8.0 days (0–360). Overall in- dial infarction, sepsis/septic shock, bleeding requiring hospital mortality was 8.1%. Total abdominal colectomy blood transfusion and death). Multivariate logistic regres- was performed in 6722 patients (0.8%). Multivariable anal- sion models were used to describe the impact of age on ysis revealed that patients who underwent total abdomi- outcomes. nal colectomy had a higher mortality rate than patients RESULTS: A total of 909 patients (48.5%) underwent an that did not require surgical intervention, 31.8% vs.7.8%, abdominal procedure. Comorbid illness increased with respectively (OR 4.0, 95% CI 3.7–4.3, p < 0.0001). In addi- age. Use of an abdominal approach decreased from 80.95% tion to total abdominal colectomy, acute renal failure was in the youngest patients (≤54 years) to 14.76% in the old- independently associated with an increase in in-hospital est patients (≥85 years, P < 0.0001). When compared to mortality (OR 2.8, 95% CI 2.7–2.8, p < 0.0001). patients younger than 54 years old, patients between 55–69 years were 51% less likely (OR = 0.49, 95% CI 0.36–0.66), Multivariable Analysis of Risk Factors Associated with In-hospital patients between 70–84 years were 87% less likely (OR = Mortality in Patients with Clostridium Difﬁ cile Colitis 0.13, 95% CI 0.09–0.17) and patients older than 85 years were 95% less likely (OR = 0.05, 95% CI 0.03–0.07) to n = 859,350 Odds Ratio 95% CI p have an abdominal procedure. Even in patients with no Total abdominal colectomy 4.0 3.71–4.30 <0.0001 comorbidities (N = 495) the use of an abdominal approach decreased with increasing age (83.78% to 10.42%, P < White 1.0 1.01–1.06 0.06 0.0001). When patients in the overall cohort were strati- Female 09 0.92–0.95 <0.0001 fi ed by age (≤54 y, 55–69 y, 70–84 y, and ≥85 y), there were no differences within each strata with regards to overall Age over 65 1.5 <0.0001 1.5–1.6 or major complication rates between the two approaches. CHF 1.2 1.2–1.3 <0.0001 After adjusting for patient comorbidities and surgical approach, no differences in overall complications or major HTN 0.8 0.8 0.9 <0.0001 – complications were observed across age groups. (Table 1) COPD 1.1 <0.0001 1.1–1.2 CONCLUSIONS: With older age, fewer people with full- CRF 1.0 0.9–1.0 0.2 thickness rectal prolapse undergo abdominal surgical repair,

even after controlling for baseline condition. Our data sug- Poster Abstracts DM 0.5 0.5–0.6 <0.0001 gest that in carefully selected older patients, an abdominal CHF: Congestive heart failure, HTN: Hypertension, COPD: Chronic obstructive approach to repair a rectal prolapse can be safely used. Tuesday pulmonary disease,CRF: Chronic renal failure, DM: Diabetes mellitus.

171 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1. Effect of Age on Postoperative Complications: Bivariate and Multivariate Analysis

Any Complication Major Complications Unadjusted Model Adjusted Model* Unadjusted Model Adjusted Model# Age Groups OR 95% CI OR 95% CI OR 95% CI OR 95% CI ≤54 years Reference group Reference group 55–69 years 1.04 0.69–1.57 0.91 0.60–1.39 1.87 0.86–4.06 1.33 0.62–3.07 70–84 years 1.13 0.77–1.67 0.95 0.61–1.48 3.11 1.52–6.35 2.05 0.94–4.48 ≥85 years 0.88 0.57–1.37 0.71 0.42–1.19 2.55 1.18–5.48 1.60 0.68–3.78 *Adjusted to surgical approach, ASA class and dyspnea. #Adjusted to surgical approach, ASA class, cardiac comorbidities and chronic obstructive pulmonary disease

Tu1752 Tu1753 Ventral Rectopexy with Biological Mesh: Surgical Complications of Hartmann Takedown in the Era of Option for Selected Patients with Obstructed Primary Anastomosis Defecation Syndrome Ari Garber*, Neil Hyman, Turner Osler Angelo Stuto*1, Francesca Da Pozzo2, Andrea Braini1, Surgery, University of Vermont College of Medicine, Burlington, VT Alessandro Favero1 INTRODUCTION: Primary anastomosis with or without 1. 1st Surgical Department, Az. Osp “SMA”, Pordenone, Italy; proximal diversion is increasingly applied to pts requiring 2. Department of Gen Surgery, Trieste University Hospital, urgent colectomy for complicated disease of the sigmoid Trieste, Italy colon. Conversely, the Hartmann procedure (HP) is now often restricted to patients who are unstable or otherwise OBJECTIVE: The aim of this study is a retrospective anal- ill suited to primary anastomosis. As such, pts who are ysis of our experience in Laparoscopic Ventral Rectopexy evaluated for Hartmann takedown often have formidable (LVR) with biological mesh to assess the safety and the effi - comorbities and considerable judgment is often required in cacy of this surgical treatment for Obstructed Defecation pt selection. We sought to defi ne the complication rate of Syndrome (ODS). Hartmann takedown in this setting. METHODS: Between July 2010 and November 2011, fi f- METHODS: A prospective complication database was teen patients had LVR with biological mesh for symptom- searched for consecutive adult patients undergoing colos- atic ODS with enterocele, recto-rectal prolapse and third tomy takedown with colorectal anastomosis (HP) at an degree rectocoele. All patients underwent preoperative academic teaching hospital from 1/1/02 to 12/31/10. anoscopy, colonoscopy and perineo-defecography. The Demographics, BMI, ASA classifi cation, interval between operative technique was standardized and in all cases a Hartmann procedure and subsequent takedown, surgical biological mesh was used. No colon resection or Stapled indication, surgeon volume and specialty, length of stay Transanal Rectal Resection (STARR) was performed in asso- and complications were recorded. Fisher’s exact test was ciation with LVR. ODS score and Symptom Severity Score used to identify risk factors for postoperative complications. (SSS) were both used in follow up to assess morbidity and effi cacy of this surgical procedure. RESULTS: 104 pts underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons did 4 or fewer pro- RESULTS: Perioperative morbidity was 6,6% (one patient cedures during the study period. 39 pts had their original required reintervention for ileal volvolus) with no mortal- Hartmann procedure done elsewhere; 38 of these reversals ity. No major and minor complication as sepsis, bleeding, were done by a colorectal surgeon. During the same time fecal urgency and urinary retention were recorded. The period, 334 patients underwent a Hartmann procedure at median hospital stay was . No recurrence after a mean fol- our institution. 77/104 pts (74%) had their HP for compli- low up period of 5,7 months was observed with good over- cated diverticulitis; anastomotic leak was the second most all patient satisfaction. The mean ODS score was 18 preop common indication. The median age was 61 years (31–84 vs 5 postop, SSS 16 vs 7. yrs) and the interval from Hartmann procedure to reversal CONCLUSION: In our experience LVR is a safe and effec- ranged from 87–1489 days. Only 8 pts (7.7%) had an ASA tive procedure for treatment of ODS in selected patient. of 1 and at least 30 patients required a concomitant ven- However for patient with internal rectal prolapse STARR tral hernia repair. 30 pts (29%) had complications and 12 procedure remains the gold standard. LVR is an innovative (11%) had two or more complications (Table 1). There were feasible technique for patients with ODS associated with two deaths, four anastomotic leaks, and seven patients complex pelvic disease. had inadvertent enterotomies. Only ASA status predicted postop complications (p = .01)

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Table 1: Complications (n = 30 pts) pre-operative comorbidities {cardiac (p = 0.009) and neu- SSI 7 rological (p = 0.005)}. Operative time was longer with a laparoscopic approach (mean 135 min vs. 87 min, p = 0.0001). Inadvertent enterotomy 7 Univariate analysis showed no difference in the complica- Blood transfusions 6 tion rate between laparoscopic and perineal approach (4% vs 6.9%, p = 0.09). After risk adjustment for age, ASA, pre- Anastomotic leak 4 operative comorbidities and operative time, the difference Arrhythmia 4 in major complications between laparoscopic and perineal Urinary 3 approach remained non signifi cant on multivariate analysis. Independent predictors of major complication included MI 2 presence of pulmonary disease (OR = 1.91, 95% CI = [1.03, Death 2 3.55], p = 0.04), bleeding disorder (OR = 3.42, 95% CI = [1.65, 7.10], p = 0.001), and anemia (OR = 2.09, 95% CI = Other 14 [1.06, 4.10], p = 0.033). CONCLUSION: CONCLUSIONS: This study shows that even after risk Hartmann takedown is a morbid opera- adjustment the complication rate for laparoscopic recto- tion with a substantial risk of inadvertent enterotomy and pexy is no higher than perineal approach. Laparoscopic serious complications. Excluding cases referred from else- approach for repair of rectal prolapse should therefore be where, there were more than fi vefold the number of Hart- the preferred approach in most patients in view of the mann procedures than takedowns performed during the lower recurrence rate. study period. This suggests that Hartmann procedures are largely restricted to patients who are poor candidates for takedown and that their colostomy is highly likely to be Tu1755 permanent. Effect of Iatrogenic Spleen Injuries During Colorectal Carcinoma Surgery on the Early Postoperative Result Tu1754 Meyer Frank*1,5, Rene Mettke2,5, A. Schmidt3,5, Stefanie Wolff1,5, Rectal Prolapse Repair: Laparoscopic or Perineal Andreas Koch4,5, Henry Ptok2,5, Hans Lippert1,5, Ingo Gastinger5 Approach? 1. Department of General, Abdominal & Vascular Surgery, University Aaron S. Rickles*, Abhiram Sharma, James C. Iannuzzi, Hospital, Magdeburg, Germany; 2. Department of Surgery, Municipal Andrew-Paul Deeb, Fergal Fleming, John R. Monson Hospital, Cottbus, Germany; 3. Oncological Practice, Municipal Surgery, University of Rochester, Rochester, NY Health Care, Cottbus, Germany; 4. Surgical Practice, Municipal Health Care, Cottbus, Germany; 5. Institute for Quality Assurance in INTRODUCTION: The perineal approach to rectal pro- Operative Medicine, University Hospital, Magdeburg, Germany lapse repair is commonly chosen over open abdominal rectopexy for high-risk patients. A higher risk of recurrence INTRODUCTION: Unlike in gastric carcinomas, the con- has been accepted as a tradeoff for reduced morbidity. sequences of a spleen injury during operative treatment Increasingly rectopexy is now performed laparoscopically of the colorectal carcinoma are hardly investigated, as a and this approach may reduce the incidence of complica- splenectomy is not performed on these tumour patients to tions while maintaining the durability of an abdominal extend the radicality. In this context, the only interest is procedure. The aim of this study was to compare the 30-day in the iatrogenic intraoperative spleen lesions, which make outcomes of laparoscopic versus perineal rectal prolapse a splenectomy necessary or require reconstructive spleen repair using outcomes from a national clinical database. preservation. METHODS: Laparoscopic and perineal rectal prolapse sur- METHODS: During the study period 01/01/2000–12/31/2004, geries were selected from the American College of Surgeons the perioperative data of a prospective multi-center obser- National Surgical Quality Improvement Program (NSQIP, vational study of 46,682 patients whose tumour had been 2005–2010) by cross referencing Current Procedural Termi- removed with a curative or palliative intention were anal- nology codes (CPT codes 45400, 45130, and 45541) and ysed with respect to the early postoperative consequences International Classifi cation of Disease, 9th edition codes of an iatrogenic spleen lesion. (ICD-9 codes) for rectal prolapse. Patient demograph- RESULTS: Of these 46,682 patients, 640 patients (1.4%) ics, preoperative risk factors and operative variables were suffered an iatrogenic spleen injury during the operative recorded. The primary outcome was occurrence of major therapy. The spleens of 127 patients (0.3%) were removed, complication (mortality, organ space infection, return to the spleens of 513 patients (1.1%) were able to be left in situ Poster Abstracts OR, renal failure, venous thromboembolism, cardiac, neu- following repair. In more than 80% of the cases with an iat- 2 rological or respiratory complications). Univariate ( ), and rogenic spleen injury, the tumour was localised in the left Tuesday multivariate (logistic regression) analysis was performed to colon and in the rectum. In the logistic regression, the deci- identify independent predictors of major complications. sive risk factor for this organ lesion was the mobilisation of RESULTS: During the study period 1385 patients under- the left colonic fl exure on tumour localisation in the left went rectal prolapse repair by perineal approach and 248 colon and rectum. Following a spleen lesion, compared to had laparoscopic rectopexy. Perineal cases were older (p = the patients without spleen injury (36.5%), a signifi cantly 0.0001) with a higher ASA class (p = 0.0001) and more higher morbidity rate was registered (47.2% following

173 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

splenectomy; 48.5% following spleen repair). Anastomotic CONCLUSIONS: Patients younger than 50 with rectal leaks requiring operation were most frequently observed cancer are more likely to have poorly or undifferenti- following a splenectomy (7.9%). This rate was signifi cantly ated tumors. They may also be more likely diagnosed at lower following spleen preservation with 3.3% (p = 0.003). an advanced stage. Interestingly, these young patients are The total hospital mortality was 3.1%. In patients with not more likely to have a family history or personal history splenectomy the hospital mortality was 11.8% and follow- of CRC or CRC-related cancer. These results suggest that ing repair with organ preservation was 4.7% (p < 0.0001). younger patients may have worse prognostic factors and CONCLUSION: Iatrogenic spleen lesion during colorectal we should be aggressive in evaluating symptoms in young carcinoma surgery represents a signifi cant risk factor for a patients regardless of their history. poorer early postoperative result. In particular, this concerns the high rate of anastomotic leaks and infectious—sep- Tu1758 tic complications. This also affects the rate of higher total Tumors Confi ned to the Presacral Space: A Diverse morbidity and hospital mortality. By comparison, a signifi - cantly worse postoperative result is found in the group of Group Requiring Individualized Evaulation and splenectomised patients compared to the group with organ Surgery preservation through repair of the injured spleen. Craig A. Messick*, Tracy L. Hull, Jorge M. Rosselli Londono, Pokala R. Kiran Tu1757 Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH Rectal Cancer in the Young: Is It a Different Disease? Purpose: Tumors occurring within the presacral space are Dana M. Hayden*, Neha Hippalgaonkar, Marylise Boutros, Eric a heterogeneous group and occur with very low incidence. Their low incidence has led to a paucity of published expe- G. Weiss, Steven Wexner rience regarding surgical approaches, recurrence rates, and CCF, Weston, FL survival. This study aims to update the current literature BACKGROUND: Patients under 50 years old are not on these tumors from a single-center with three decades of screened for colorectal cancer (CRC) unless they have experience. symptoms or family history. However, recent studies have METHODS: Patients were identifi ed using a combination shown a rising incidence of rectal cancer in young patients. of a natural language search and SNOWMED codes que- This study examines patient and tumor characteristics of ried from a prospectively maintained Pathology database rectal cancer patients younger than 50. from 1981–2011. A retrospective chart review was con- METHODS: Retrospective chart review was performed on ducted recording patient demographics, tumor character- patients who had radical resection for primary rectal can- istics, operative procedure, recurrence, and survival data. cer at two tertiary institutions by board-certifi ed colorectal Only patients ≥18 years old and with complete data were surgeons, 2002–2008. included. RESULTS: 57 of 294 patients (19.4%) were less than 50 RESULTS: Presacral tumors were identifi ed in 87 patients; years of age. 28 (49.1%) were male and the mean age was 77% (67/87) female, median age at diagnosis was 44 years 42 (24–49 years). One patient had IBD (1.8%), 12 (21.1%) (19–88), and median follow-up was 8 months (0.1–225). a family history of CRC and 13 (22.8%) a family history Fourteen patients developed recurrence. Of the 27 different of CRC-related cancer. No patients had personal history histologic tumors diagnosed, hamartomas were the most of CRC or CRC-related cancer. The most common indi- common (29%; n = 28) followed by both teratomas and cation for colonoscopy was rectal bleeding (48%). 77.3% epidermal cysts each at 10% (n = 9). 52% (14/27) of tumor of the patients with accurate preoperative stage recorded types were malignant totaling 43% (37/87) of all tumors. had locally advanced tumors (>T2) and 41 out of the 57 CT scans were obtained in 84% (73/87) of patients, MRI (71.9%) received neoadjuvant treatment. When compared in 59% (51/87), and TRUS in only 16% (14/87). While to patients over 50, young rectal cancer patients were 74% (64/87) of tumors were at or below the S4 level, more likely to be female (X2 = 4.63, p = 0.031), however, operative approach was strictly posterior in 73% (46/63) there were no differences in personal history of CRC or of those tumors (one tumor not resected). Cumulatively, CRC-related cancer, family history or smoking. 20 of 41 3/87 patients were treated non-operatively. 28% (24/87) of patients with complete preoperative data had low tumors patients had a diagnostic biopsy with no reported biopsy (<6 cm from anal verge; not different than patients over site recurrences. Malignant tumors recurred in 24% (8/34), 50). Younger patients were more likely to have poorly or while benign tumors recurred in 12% (6/50). Chordomas undifferentiated tumors (X2 = 9.276, p = 0.002); this dif- recurred in 5/7 patients. Overall survival was 93% (81/87), ference remained signifi cant in a logistic regression model 84% (31/37) for malignant tumors and 98% (49/50) for (Wald test 8.11, p = 0.004), controlling for gender and benign tumors. other factors. Lymphovascular or perineural invasion and the presence of mucin were not more commonly found in the younger group. Six (14.6%) young rectal cancer patients had complete response to neoadjuvant therapy; complete and any response to neoadjuvant was not different between the groups.

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Histologic Types of Presacral Tumors Tu1759 Hamartoma 28 Diabetic Patients Take Longer to Recover Than Teratomas* 9 Non-Diabetics Within an Enhanced Recovery Epidermal Cyst 9 Programme Alison Luther*, Sofoklis Panteleimonitis, Peter Kang, John Evans Schwannoma 7 Northampton General Hospital, Northampton, United Kingdom Chordoma 7 INTRODUCTION: The enhanced recovery after surgery Dermoid Cyst 4 (ERAS) protocol encompasses a number of evidence-based B-Cell Lymphoma 2 interventions designed to lessen the impact of surgery upon the patient. It has been shown to reduce the length of Myelolipoma 2 stay and improve outcomes in elective colorectal surgical Neuroendocrine Tumor 2 patients when compared to traditional post-operative management. NHS diabetes has recently released guidelines on Rectal Duplication Cyst 2 the management of adults with diabetes undergoing sur- Chondrosarcoma 1 gery. Despite this, no studies have assessed the impact of Ewing’s Sarcoma 1 diabetes on patients in an ERAS programme. Fibrosarcoma 1 METHODS: Two laparoscopic colorectal surgeons trained in the national Fellowship Programme were appointed in Fibrous Histiosarcoma 1 early 2010. Consecutive patients undergoing elective major Ganglioneuroma 1 colorectal procedures from March 2010 to September 2011 Gastrointestinal Stromal Tumor 1 had data regarding length of stay, comorbidities and major complications prospectively collected. Hemangiopericytoma 1 RESULTS: 143 patients were included in the study. Aver- Liposarcoma 1 age age was 64 (range 21–88). The median length of stay Mucinous Cystic Neoplasm 1 in the non-diabetic group was 5 days (Interquartile range 4–7.5, n = 125) whilst in the diabetic group the median Pecoma 1 length of stay was signifi cantly longer at 7 days (5–15.5, n = Neuroﬁ broma 1 18, P = .041, Mann-Whitney). Smooth Muscle Tumor 1 DISCUSSION: Diabetic patients who have elective colorec- Spindle Cell Tumor 1 tal procedures have a signifi cantly longer length of stay in hospital than non-diabetic patients despite being managed Squamous Cell Tumor (metastasis) 1 with an ERAS protocol. This has implications for periopera- Squamous Cell Cyst (Ovarian) 1 tive management of diabetic patients. It is unclear whether *Teratomas included those that were only teratomas (6) and those with both the increased length of stay is due to a higher rate of major adenocarcinoma (2) and carcinoid (1) components, totalling 27 different complications or a slower return of gut function. Further histologic types of presacral tumors. work needs to be undertaken to look at markers of gut function in the postoperative period. CONCLUSIONS: Presacral tumors remain a heterogeneous group and continue to be a diagnostic and treatment challenge. Even though these tumors are confi ned to one space, surgeons must individualize preoperative work-up and operative approach based on each individual patient. A selective biopsy, which would infl uence treatment deci- sions, appears to be safe for tumors not associated with cord lesions. Presacral tumors are rare and studies such as this add to our understanding and guide patient recommendations regarding treatment. Poster Abstracts Tuesday

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Tu1760 Clinical: Esophageal Radiation Therapy for Locally Advanced Colon Cancer Sekhar Dharmarajan*1, James W. Fleshman1, Robert J. Myerson2, Tu1761 Bashar Safar1 1. Surgery, Washington Univ, St. Louis, MO; 2. Radiation Oncology, Does Morbid Obesity Worsen Outcomes After Washington University School of Medicine, St. Louis, MO Esophagectomy? Neil H. Bhayani*1, Aditya Gupta2, Valerie J. Halpin2, PURPOSE: The surgical management of locally advanced Kevin M. Reavis1, Christy M. Dunst1, Lee L. Swanstrom1 colon cancer is associated with higher rates of positive surgical margins, which translates to higher local recurrence 1. Providence Portland Cancer Center, Portland, OR; rates and reduced overall and disease-free survival. While 2. Legacy Weight Management Institute, Portland, OR the use of radiation therapy in rectal cancer is well estab- INTRODUCTION: With national and worldwide increases lished to downstage tumors preoperatively and reduce local in both esophageal cancer and obesity, the number of recurrence, its application to patients with locally advanced esophagectomies in morbidly obese patients will increase. colon cancer has not been well studied. The purpose of this Proper surgical risk stratifi cation and patient counseling study was to examine the use of radiation therapy in the require a better understanding of the esophagectomy mor- pre- and post-operative management of locally advanced bidity associated with obesity. colon cancer. METHODS: We studied non-emergent, subtotal or total METHODS: This study was conducted as a retrospective esophagectomies with reconstruction in the National Sur- review of patients with locally advanced colon cancer gical Quality Improvement Project database from 2005– treated with radiation therapy at a single institution from 2009. After excluding patients with disseminated disease 1997 to 2008. Only patients with adenocarcinoma located and with body mass index (BMI) <18.5, the outcomes of at least 15 cm above the anal verge were included in the normal BMI patients, (BMI 18.5–25) were compared to study. The primary endpoints of the study were ability to morbidly obese patients (BMI ≥35). Outcomes were mortal- achieve margin-negative resection, local recurrence rates ity, aggregated morbidity, wound, pulmonary and cardiac and overall and disease-free survival. morbidity. Multivariable regression controlled for pre-oper- RESULTS: 32 patients with locally advanced colon can- ative comorbidities differing between groups (p < 0.2) and cer treated with RT were identifi ed, with an average age at established confounders of outcomes. presentation of 58. 6 of these patients had distant metastases at the time of presentation. 19 patients received neo- Table 1. Adjusted Odds of Morbidity with Morbid Obesity adjuvant RT and 13 were treated in the adjuvant setting. All patients received chemotherapy concurrent with RT. 1 Adjusted Odds Conﬁ dence patient developed hematologic toxicity and 6 developed GI Ratio Interval p-Value toxicity. 57% of cancers were located in the sigmoid colon, Death 1.1 0.7–1.7 0.8 36% in the right colon, and 7% in the transverse colon. Of Any Morbidity 1.1 0.9–1.3 0.2 the 19 patients treated with preoperative RT, 18 underwent defi nitive surgery and 17/18 (94%) achieved an R0 (margin Superﬁ cial SI 1.2 0.9–1.5 0.1 negative) resection. Of the 13 patients treated with post- Deep SI 1.7 1.04–2.8 0.04 operative chemoRT, 2 had positive surgical margins at the time of resection. Pathologic staging revealed, 18 patients Organ SI 0.9 0.7–1.3 0.7 had stage II disease, 8 patients had stage III disease. Average Pneumonia 1 0.8–1.2 0.7 followup was 4.33 years. The overall survival was 97%; 1 Reintubation 1 0.9–1.3 0.7 death that occurred prior to surgical intervention. The disease free survival was 69% (22/32); 2 with local recurrence Fail to Wean 1 0.8–1.2 0.9 only, 6 with distant recurrence only, and 2 with both local PE 1.4 1.0–2.1 0.09 and distant recurrence. DVT 1.3 0.9–1.8 0.2 CONCLUSIONS: The use of radiation therapy in locally Cardiac Arrest 0.6 0.3–1.3 0.2 advanced colon cancer is safe and potentially provides better local disease control, negative resection margins and Myocardial Infarction 1.4 0.5–3.5 0.5 improved survival. Further studies are warranted in order Bleeding 1.6 0.6–4.1 0.3 to delineate the role of radiation therapy in the treatment of locally advanced colon cancer. Sepsis 1 0.8–1.2 0.3 Shock 1.1 0.9–1.4 0.4 Return to OR 0.9 0.7–1.1 0.3 ** compared to normal-weight patients † Adjusted for age, smoking, diabetes, hypertension, red cell transfusion, American Society of Anesthesiologists class ≥3, and weight loss of >10%.

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RESULTS: Of the 483 patients, 373 (77%) had a normal RESULTS: A total of 5,851 patients underwent partial BMI and 315 (29%) were morbidly obese. The overall popu- (65.60%) and total (34.30%) esophagectomy during this lation was 77% male, with a mean age of 62 years with 43% period. The mean age was similar between groups (partial: of patients older than 65 years. Normal BMI patients were 63.3, total: 64.4 years; p = 0.07) and the majority of patients older (p = 0.02) and more likely to smoke (37% v. 15%, p were male (partial: 81.8%, total: 79.3%; p = 0.02) and Cau- < 0.001). Pre-operative co-morbidities were similar except casian (partial: 84.92%; total: 87.55%; p = 0.02). Most of for a signifi cantly higher incidence of hypertension (62% the comorbidities were similar between groups (hyperten- v. 48%) and diabetes (24% v. 13%) and a lower incidence of sion, congestive heart failure, chronic lung disease, liver preoperative weight loss of ≥10% (11% v. 23%) in the obese disease, renal failure, weight loss, anemia, smoking, periph- population (p < 0.001). Morbidly obese patients received eral vascular disorder and alcohol abuse). Outcome mea- fewer red cell transfusions intraoperatively (12% v. 22%, p sures between groups are shown below. = 0.02). Overall, the rate of major morbidity was 51% and mortality was 3.5%; there was no difference between the Perioperative Outocomes of Partial Esophagectomy vs. Total groups. On multivariable analysis, all outcomes were the Esophagectomy same between groups except deep space infections (DSI). Morbidly obese patients were at 70% higher risk (OR 1.7, Outcome Partial Total 95% CI 1.04–2.8, p = 0.04) of DSI. Measures Esophagectomy Esophagectomy P-Value CONCLUSIONS: In our study, there were no differences Number 3838 2013 in post-operative mortality or pulmonary, cardiac, and Acute respiratory failure 23.2 32.4 <0.01 thrombo-embolic morbidity between morbidly obese and (%) normal BMI patients. Morbidly obese patients had elevated Pneumonia (%) 10.3 11.3 0.25 odds of deep wound infections. Overall, a BMI >35 does not confer signifi cant morbidity after esophagectomy. Empyema (%) 3.5 1.8 <0.01 Obese patients with esophageal pathology should not be Fistula (%) 1.9 1.6 0.47 denied resection based on BMI alone. Overall complication 43.0 50.7 <0.01 rate* (%) Tu1762 In-hospital mortality (%) 5.8 8.4 <0.01 Outcomes of Partial Versus Total Esophagectomy for Mean length of hospital 16.9 18.1 0.20 Malignancy stay (days) Hossein Masoomi*, Brian R. Smith, Michael J. Stamos, Mean total hospital 146,542 161,962 0.12 Ninh T. Nguyen sharges ($) Surgery (Colorectal Division), University of California, Irvine-Medical *Patient who had at least one postoperative complication Center, Orange, CA INTRODUCTION: Despite improvement in surgical CONCLUSION: The most frequent procedure for esoph- technique, morbidity and mortality is still signifi cant ageal malignancy is partial esophagectomy. Compared after esophagectomy. Operative technique might be con- to the total esophagectomy, partial esophagectomy was sidered as an important factor in the outcomes of this associated with lower morbidity and lower mortality and operation. This study was intended to evaluate the periop- comparable hospital stay and hospital charges. Partial erative outcomes of partial versus total esophagectomy for esophagectomy may improve morbidity and mortality in malignancy. esophageal malignancy. METHODS: Using the Nationwide Inpatient Sample (NIS) database, clinical data of patients who underwent esophagectomy (partial or total) with the diagnosis of esophageal malignancy including carcinoma in situ from 2006–2008 were examined. Patient characteristics, comorbidities, perioperative complications, length of stay, hospital charges and in-hospital mortality were evaluated.

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Tu1763 Tu1764 Esophageal Perforation: Trend Towards Endoscopic Esophageal Stripping Creates a Clear Operative Field Treatment for Lymph-Node Dissection along the Left Recurrent Peter P. Grimminger*1, Till Herbold1, Hartmut SchäFer1, Laryngeal Nerve in Prone Video-Assisted Thoracoscopic Jan Brabender2, Wolfgang SchröDer1, Arnulf H. HöLscher1 Surgery of Esophagus (VATS-E) 1. Department of General-, Visceral- and Tumor surgery, University Hiroshi Makino*1,2, Hiroshi Yoshida1, Tsutomu Nomura2, Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery, Takeshi Matsutani2, Nobutoshi Hagiwara2, Tadashi Yokoyama1, St. Antonius Hospital, Cologne, Germany Atsushi Hirakata1, Masao Miyashita2, Eiji Uchida2 INTRODUCTION: Esophageal perforation is rare, but 1. Surgery, Nippon Medical School, Tama-Nagayama Hospital, despite improvements in detection, surgical techniques, Tokyo, Japan; 2. Gastro-Enterological Surgery, Nippon Medical and intensive care medicine, esophageal perforation School, Tokyo, Japan remains potentially fatal. For treatment of esophageal per- INTRODUCTION: Video assisted thoracoscopic surgery of foration, there are several treatment options. Depending the esophagus (VATS-E) in prone position is remarkable in on the cause and extent of the perforation the treatment Japan because the lung moves below by the gravity, and is primary surgical, endoscopic interventional or conserva- a good operative fi eld is obtained. A clear operative view tive. The intention for the presented retrospective study is of the middle and lower mediastinum has been obtained; to evaluate the causes and treatment in order to draw con- however, the working space in the upper mediastinum is clusions for appropriate therapy for this disease. limited. MATERIALS AND METHODS: Esophageal perforations PATIENTS: Twenty patients in left lateral position and treated between 1996 and 2011 were assessed. These 17 patients in prone position, with esophageal squamous were 71 patients (46 men and 25 women) with a median cell carcinomas underwent VATS-E since 2005 and 2009, age of 52 years. Clinical data was reviewed and analyzed respectively. retrospectively. METHODS: At fi rst the patients are fi xed at semi-prone RESULTS: Iatrogenic injury was the most frequent cause position because both prone and left lateral positions can of esophageal perforation (n = 43, 60%), followed by Boer- be set by rotating. Three 5 mm ports and two 10 mm ports haave syndrome (n = 19, 27%) and traumatic perforation are used at the 3rd, 7th, 9th and 5 th, 9th intercostal space caused by accidentally swallowed foreign bodies (n = 7, (ICS). The pneumothorax by maintaining CO2 insuffl ation 10%). In two patients, the reasons were not determinable pressure of 6 mmHg is made, and esophagectomy is per- (3%). The patients were operated in 50.7%, 25 patients formed in prone position. In the case of emergent thoracot- (35.2%) were treated endoscopically with stent (n = 23) omy the patient will be rotated to the left lateral position. or endo-VAC (n = 2), 9 patients (12.7%) were treated con- The lymph nodes around the trachea and bronchus, above servatively with antibiotics and nasogastric tube and one the diaphragm and along the bilateral recurrent laryngeal patient (1.4%) with a perforated aortic aneurism into the nerves are dissected. Working space at the left upper medi- esophagus died before treatment. Before 2008 operation astinal area for lymph nodes dissection around recurrent was performed in 57% (25/44) and after 2008 the propor- laryngeal nerve is limited in prone position. To obtain tion of patients who underwent surgery dropped to 41% the space the residual esophagus is stripped in the reverse (11/27), while 50.2% (14/27) received endoscopic manage- direction and retracted toward the neck after the stomach ment (stent, n = 12 and endo-VAC, n = 2). The hospital tube is removed through the nose. mortality was 7% (6.8% before 2008 and 7.4% after 2008). RESULTS: 1. Mean estimated blood loss was 166 ml of CONCLUSION: The evaluation of the individual manage- chest procedure in prone position. 2. The rate of recurrent ment of esophageal perforation in a 15 year period shows laryngeal nerve paralysis was 11.7% (2/17), and anasto- a trend towards endoscopic treatment, with low mortality. motic leak and postoperative pneumonia was 5.8% (1/17), respectively. 3. There was no incidence of conversion to open method. 4. Lymphadenectomy along the left recurrent laryngeal nerve after esophageal stripping is available in prone position of VATS-E. CONCLUSION: Our result indicates that esophageal stripping in prone VATS-E allows for safe and straight forward lymph node dissection along the left recurrent laryngeal nerve. Our technique overcame the diffi culty of the lymph node dissection along the left recurrent laryngeal nerve in prone position.

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Tu1765 METHODS: Patients with GERD confi rmed by pHmoni- toring and manometric pattern of DES (simultaneous con- Outcomes of Laparoscopic Nissen Fundoplication tractions 20–90% of wet swallows), NE (increased mean in Patients with Manometric Patterns of Esophageal distal amplitude greater than 180 mmHg), or HLES (lower Motility Disorders esophageal sphincter pressure greater than 45 mmHg) that Bruna D. Cassao1, Fernando A. Herbella*1, Jose F. Farah1, Adorisio underwent LNF were studied. A group of 50 consecutive Bonadiman1, Luciana C. Silva1, Alberto Goldenberg1, Marco G. patients with normal esophageal motility that underwent LNF were used as controls. Groups were comparable to con- Patti2 trols for age, gender, pre-operative symptoms, hiatal hernia 1. Surgery, Federal University of São Paulo, São Paulo, Brazil; 2. and barrett s esophagus, except for NE that had younger Department of Surgery, University of Chicago, Chicago, IL individuals (Table 1). INTRODUCTION: Manometric pattern of either diffuse RESULTS: Symptomatic outcome was similar when groups esophageal spasm (DES), nutcracker esophagus (NE), or were compared to controls (Table 2). hypertensive lower esophageal sphincter (HLES) can be CONCLUSION: considered a primary esophageal motility disorder only in LNF is an adequate treatment for patients the absence of gastroesophageal refl ux disease (GERD). If with GERD and manometric patterns of esophageal motil- GERD is present, the motility abnormality is considered ity disorders. secondary, and treatment is directed toward refl ux. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders.

Table 1. Preoperative Data

Age Esophageal Extra-Esophageal % Barrett’s % Hiatal N (Years) % Females Dysphagia Symptoms Symptoms Esophagus Hernia Hypertensive Les 3 57 66 66 100 0 0 66 Diffuse Spasm 14 52 50 15 86 29 29 86 Nutcracker 13 46 61 15 100 23 8 69 Controls 50 57 64 14 84 28 10 88

Table 2. Postoperative Data

Follow-Up (Months) Dysphagia Esophageal Symptoms Extra-Esophageal Symptoms Hypertensive Les 21 33 0 0 Diffuse Spasm 32 7 7 7 Nutcracker 25 0 8 8 Controls 36 20 18 2

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Tu1766 Prognostic Factors of Very Long-Term Survival and Causes of Death in Early Esophageal Adenocarcinoma Juha T. Kauppi1, Ines Gockel2, Tuomo Rantanen1, Torsten Hansen3, Ari RistimäKi4, Hauke Lang2, Theodor Junginger2, Jarmo A. Salo*1 1. Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2. Department of General and abdominal Surgery, University Medical Center, Mainz, Germany; 3. Institute of Pathology, University Medical Center, Mainz, Germany; 4. Department of Pathology, HUSLAB, Helsinki University Central Hospital and Haartman Institute and Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland PATIENTS AND METHODS: 85 patients (p) (36 women and 49 men, median age 72, range 40–94) without neoadjuvant treatment were operated on because of EEAC (pT1N0-1, M0) between 1984–2011. Autopsy records and death certifi cates were acquired. Medical and pathology reports were reviewed and 75 (88%) specimens could be CONCLUSION: Patients with intramucosal and superfi - reanalyzed for cancer penetration by two experienced cial submucosal (Sm1) cancer infi ltration die mostly not pathologists (HT and RA). Survival was calculated accord- of EEAC. Less invasive therapy may be suffi cient in this ing to Kaplan-Meier and the Cox regression proportional group. For patients with deeper cancer infi ltration (Sm2- hazards model. 39 p had transhiatal, 36 transthoracic en- Sm3) more radical treatment options should be considered. bloc, 5 vagal-sparing esophageal resection and, 5 solely endoscopic mucosal resection. Tu1767 RESULTS: Cancer penetration: pT1a in 33 p and pT1b in 42 p. Overall survival probability: 67.7% at 5, 49.2% at 10, Laparoscopic Ischemic Conditioning as a Modality 41% at 20 years. Disease specifi c survival: 78.3% at 5, 72.3% to Reduce Gastric Conduit Morbidity Following at 10 years. Lymph-node metastasis: (HR 7.9 [95%CI 2.53– Esophagectomy 24.78] p < 0.0001 and Sm2–3 infi ltration (HR 4.85 [95% CI 1.36–17.3] p = 0.015) showed worse prognosis. Cumulative Laparoscopic Ischemic Conditioning As a mortality: 33/85 (38.8%). Cause of death: esophageal ade- Modality to Reduce Gastric Conduit Morbidity nocarcinoma (EAC) 13 (39.4%), secondary malignancy 5 (15.2%), cardiovascular 3 (9.1%), miscellaneous 9 (27.2%). Following Esophagectomy Lowest number of EEAC-deaths in patients with infi ltra- Marco Zahedi*1, Sabha Ganai2, Amy K. Yetasook1, Mark Talamonti1,2, tion depth pT1a and pT1b (Sm1): 4 p (12.1%). Michael B. Ujiki1,2, Joann Carbray1, John Howington1,2 1. Surgery, NorthShore University HealthSystem, Evanston, IL; 2. Surgery, University of Chicago, Chicago, IL INTRODUCTION: Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. We aimed to assess conduit morbidity in a two stage operation involving laparoscopic ischemic preconditioning of the stomach prior to esophagectomy and gastric pull-up, compared to a single stage operation.

180 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

METHODS: We conducted a retrospective review com- PATIENTS AND METHODS: Data of 1127 patients with paring conduit morbidity of 63 consecutive patients who esophageal cancer presenting from 2000 to 2008 at the underwent an esophagectomy for Stage I-III esophageal Regional Center of the Esophageal Diseases were prospec- cancer. Twenty three patients received pre-conditioning, tively collected. Detailed anthropometric data about the which included laparoscopic ligation of the left and short BMI before the disease onset were available for 464 patients gastrics, celiac node dissection, and jejunostomy tube who were then included in this study. Sixty seven of them placement, followed by formal resection and reconstruc- were classifi ed as obese (BMI >30), 199 were classifi ed as tion between 3–9 days later. Forty patients underwent overweight (BMI 25–29.9) and 168 were classifi ed as nor- thoracotomy, esophagectomy and gastric pull-up without mal weight (BMI <24.9). Outcome and survival of the three pre-conditioning. groups were compared. Frequency and survival analysis RESULTS: The two groups were similar with respect were preformed. to gender and mean age. More patients in the precondi- RESULTS: Overweight and obese patients with esopha- tioned group received neoadjuvant therapy (88% vs 40%, geal cancer were more often male (p < 0.01), they tended p < 0.0001). There were no conversions to open in the to have more frequently multiple tumours (p = 0.06) and pre-conditioned group. Mean time interval between the they more often suffered high blood pressure (p < 0.01) conditioning procedure and esophagectomy was 6.6 ± 1.5 than normal weight patients. Adenocarcinoma was more days. Seventeen percent of the preconditioned group dem- frequent in overweight and obese patients (p < 0.01). No onstrated ischemic changes along the fundus leading to signifi cant difference was observed among the three groups modifi cation of the planned transection line. There were in term of preoperative neoadjuvant therapy, type of oper- signifi cantly less post-operative strictures in the precondi- ation, radicality of the esophagectomy and postoperative tioned group (8% vs 32%, P < 0.03), and a trend toward outcome. Nodal metastasis were more frequently localized less anastomotic leaks (13% vs 26%, P < 0.20), and delayed in paraesophageal nodes in overweight and obese patients gastric emptying (25% vs 45%, P < 0.12). There was no sta- (p = 0.01). No signifi cant difference was observed among tistical difference between groups in terms of morbidity or the three groups in term of disease free survival. At multi- mortality. Mean follow-up in months was 11.4 ± 8.9 in the variate survival analysis the only independent predictors preconditioned group, and 26.0 ± 27.6 (P < 0.02) in the of overall survival after radical esophagectomy were a BMI single-stage group. between 25 and 29.9 [HR = 0.63 (0.43–0.93), p = 0.02], pT CONCLUSIONS: Laparoscopic ischemic conditioning stage 3 or 4 [HR = 2.13 (1.34–3.26), p < 0.01] and pN 1 sta- results in less strictures and a trend toward less gastric con- tus [HR = 1.84 (1.20–2.82), p < 0.01]. duit morbidity (anastomotic leaks, delayed gastric empty- CONCLUSION: This data seem to suggest that in spite of ing) when compared to single-stage esophagectomy and several unfavorable features a moderate increase of weight gastric pull-up. may be associated to increased long-term survival after esophagectomy for cancer. Tu1768 Overweight Patients Operated on for Cancer of the Esophagus Survive Longer Than Normal Weight and Obese Patients Marco Scarpa*1, Matteo Cagol1, Silvia Bettini2, Rita Alfi eri1, Amedeo Carraro1, Francesco Cavallin1, Elisabetta Trevellin2, Alberto Ruol3, Roberto Vettor2, Ermanno Ancona3,1, Carlo Castoro1 1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS), Padova, Italy; 2. Department of Medical and Surgical Sciences, University of Padova, Padova, Italy; 3. Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy BACKGROUND: Esophageal adenocarcinoma is often associated to obesity and the relative risk to develop an esophageal adenocaricoma is 1.52 if the Body Mass Index (BMI) is increased of 5 Kgm-2. The aim of this study was to assess the surgical and oncological outcome and the survival of overweight and obese patients with esophageal cancer.

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Tu1769 Tu1770 Esophageal Failure and Refractory Dysphagia Esophageal Perforation: Review of Outcomes from a Following Roux-en Y Esophagojejunostomy Single-Institution Series Alfredo Amenabar*, Toshitaka Hoppo, Omar Awais, Blair A. Jobe Hugo Santos-Sousa*1, Tiago Bouca-Machado1, Attila Dubecz2, Cardiothoracic Surgery, University of Pittsburgh Medical Center, André GonçAlves1, John Preto1, José Barbosa1, José Costa-Maia1 Pittsburgh, PA 1. Esophageal and Gastric Surgery Unit, General Surgery Department, BACKGROUND: Roux-en-Y esophagojejunostomy (RYEJ) Centro Hospitalar de São João/Faculty of Medicine, University of is an effective treatment option in some patients with Porto, Porto, Portugal; 2. General, Visceral and Thoracic Surgery complicated gastroesophageal refl ux disease (GERD). Post- Department, Klinikum Nord Nuremberg, Nuremberg, Germany operative dysphagia is common, and is most often caused BACKGROUND: Esophageal perforation is an important by mechanical problems such as stricture or bowel obstruc- therapeutic challenge. The aim of this study was to review tion; however some patients develop refractory dyspha- the outcomes of esophageal perforations treated by a spe- gia in the absence of mechanical obstruction and do not cialized unit in esophageal surgery. respond to empiric dilation. The objective of this study was METHODS: to evaluate the patients who underwent RYEJ and subse- We performed a retrospective review of 52 quently developed dysphagia, and assess the etiology of consecutive patients with non-neoplasic esophageal per- dysphagia. foration, between January 1991 and December 2008. Demographics, cause and location of perforation, time of METHODS: This is a retrospective review of patients diagnosis, management results and outcomes were evalu- who had undergone RYEJ to treat GERD following prior ated. The management and outcomes trends over time upper gastrointestinal surgery. Prior to RYEJ, all patients were evaluated. For that, the cases were catalogued in three underwent esophageal physiology testing including upper groups of 6 consecutive years. endoscopy, high-resolution manometry (HRM) and pH RESULTS: testing. Patients who developed postoperative dysphagia Spontaneous perforation occurred in 9 (17,3%) underwent both radiographic and endoscopic assessment patients. Iatrogenic perforations were present in 15 (28,8%) to evaluate stricture formation and bowel obstruction, and patients and 28 (53,8%) patients had traumatic perfora- subsequently underwent dilation (empiric or therapeutic). tions. In half of the patients diagnosis was done in the Patients who were un-responsive to dilation in the absence fi rst 24 hours. The perforation’s location was cervical in 14 of mechanical obstruction, underwent HRM combined (26,9%) cases, thoracic in 31 (59,6%) and abdominal in 7 with antegrade impedance using both liquid and paste (13,5%). The traumatic perforations were diagnosed signifi - (pudding) to assess esophageal motility as a possible etiol- cantly later than the other causes (p = 0,02). In 9 patients ogy of dysphagia. (17,3%) the treatment was non-operatively. For the patients submitted to surgery (82,7%), a primary repair was done in RESULTS: From July 2009 to July 2011, 13 patients under- 23 cases (53,5%), a bipolar exclusion was performed in 18 went RYEJ, 10 of whom had prior surgery including Nis- (41,9%) and a conservative operative approach (drainage sen fundoplication (n = 2), vertical banded gastroplasty only) performed in 2 (3,8%). There were signifi cant dif- (n = 3), Heller myotomy with Dor fundoplication (n = 1), ferences in the type of operative treatment according to gastric bypass (n = 3) and Billroth II gastrectomy (n = 1). the location (p = 0,035) [thoracic perforations were more Mean age and BMI were 55.3 years (range, 44–66 years) and times treated with bipolar exclusion]. In the analysis of 34.3 (range, 26.3–48.1), respectively. Eight of 13 (61.5%) the trends over time, there were signifi cant differences in patients developed dysphagia after RYEJ. No patients had the location (p = 0,027) and the type of management (p = radiographic evidence of small bowel obstruction. Upper 0,012) [more patients treated surgically with primary repair endoscopy demonstrated anastomotic stricture (n = 8) or in the last periods]. The morbidity and mortality rates were roux limb narrowing within the transverse mesocolon (n 46,2% and 13,5%, respectively. There were signifi cant dif- = 2), which was successfully treated with dilation. Three ferences in morbidity according to the cause of perforation patients had incapacitating dysphagia with regurgitation (p = 0,047) [the iatrogenic perforations had less morbid- in the absence of mechanical obstruction. HRM demon- ity] and the type of management (p = 0,041) [the patients strated esophageal primary peristaltic failure as evidenced treated conservative either operatively or non-operatively by low mean wave amplitude ordered contractions and had lower morbidity rate], but only the type of manage- dropped peristaltic waves. All three patients had 100% ment was an independent risk factor in the logistic regres- incomplete bolus clearance with paste and this correlated sion analysis (OR 0,071, CI95% 0,007–0,696, p = 0,003). with symptom of dysphagia. Two of three patients under- There were signifi cant differences in mortality according went esophagectomy with neck anastomosis and had com- to the age (p = 0,022) [older patients with higher mortality plete symptom resolution. rate] and age was an independent risk factor in multivariate CONCLUSION: For patients with non-obstructive, dila- analysis (OR 1,095, CI95% 1,003–1,196, p = 0,005). There tion refractory dysphagia following RYEJ, HRM combined weren’t signifi cant differences in morbidity and mortality with antegrade impedance testing using a defi ned liquid rate over time. and paste protocol with symptom correlation is effective in determining etiology. Esophagectomy is an effective treatment option in this setting but long-term follow-up is required.

182 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

CONCLUSION: An approach to esophageal perforation fundoplication (NF), Hill repair (HR), or a combination of based on injury severity and the degree of mediastinal Nissen plus Hill hybrid repair (NH). Clinical and objective and pleural contamination is of paramount importance. testing and quality of life metrics were administered pre- Although operative management remains the standard in operatively and at 6–12 month follow-up. Ninety patients the majority of patients with esophageal perforation, non- underwent pre-and post-operative manometry (NF = 27; operative management may be successfully implemented HR = 37; NH = 26). in selected patients with a low morbidity rate. RESULTS: Manometric results are listed in the table. Post- operative lower esophageal sphincter pressure (LESP) was Tu1771 increased signifi cantly for NF and NH but not HR; residual Comparative Manometric Characteristics of 3 LESP was highest in NF. DeMeester scores were equivalent, NF = 6.58; HR = 10.89, NH = 7.3. Postoperative quality of Anti-Refl ux Operations life scores were equivalent, NF = 6.24; HR = 6.24; NH = 6.69; Alia Qureshi*1, Ralph W. Aye1, Brian E. Louie1, Postoperative dysphagia scores were better for NH, 43.0 vs Alexander S. Farivar1, Ariel Knight1, Lee L. Swanstrom2 NF = 37.2 and HR = 38.1 (p = 0.019). Postoperative medi- 1. Swedish Medical Center, Seattle, WA; 2. Legacy Health, Portland, OR cation use was less for NH, 2.4% vs NF = 19.5% and HR = BACKGROUND: The impact of antirefl ux operations on 17.0%. esophageal motility and lower esophageal sphincter char- CONCLUSIONS: Combining NF and HR in one opera- acteristics is incompletely understood. Comparing the tion results in manometric lower esophageal sphincter manometric features of various repairs may provide insight characteristics that are similar to the individual compo- through differences and similarities. nent repairs, with low medication use and reduced long- MATERIALS AND METHODS: 153 patients with gas- term dysphagia. This suggests that there may be benefi t to troesophageal refl ux and/or hiatal hernia underwent one intra-abdominal fi xation of the gastroesophageal junction of 3 laparoscopic operations at 2 institutions through 1 of Further study of the relative contributions of the fundopli- 2 IRB-approved prospective protocols evaluating Nissen cation and the diaphragmatic repair are warranted.

Trivariate Manometric Comparisons Preoperative Preoperative Preoperative NF (N = 46) HR (N = 55) NH (N = 43) P Value Postoperative NF Postoperative HR Postoperative NH p Value Average LESP 14.3 18.2 18.5 0.152 26.3 19.3 23.2 0.027 (mmHG) Average residual 4.6 9.48 4.6 0.059 14.7 8.5 11.1 0.042 LESP (mmHg) Average mean distal 75.6 85.4 72.3 0.238 81.6 99.0 76.1 0.074 amplitudes (mmHg) Peristalsis normal 92% 92% 84% 79% 87% 77% Peristalsis moderate 4% 4% 9% 7% 8% 23% dysfunction Peristalsis severe 4% 4% 7% 14% 5% 0% dysfunction

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Tu1772 Tu1773 The Infl uence of Postoperative Complications Fully Covered Self Expanding Removable Metal on Recurrence and Long-Term Survival After Stents Are Effective for Esophageal Fistulas, Leaks, Esophagectomy for Esophageal Cancer Perforations and Benign Strictures Arzu Oezcelik*1,2, Shahin Ayazi1, Steven R. Demeester1, Jennifer L. Kramer*, Alexander S. Farivar, Eric VallièRes, Joerg Zehetner1, Jeffrey A. Hagen1, Tom R. Demeester1 Ralph W. Aye, Brian E. Louie 1. Surgery, University of Southern California, Los Angeles, CA; Swedish Medical Center and Cancer Institute, Seattle, WA 2. General, Visceral and Transplantation Surgery, University of Essen, PURPOSE: Expandable plastic stents are the only stent Essen, Germany approved for benign esophageal disease. However these BACKGROUND: The aim of this study was to identify fac- stents are prone to migration and inadequate leak control. tors associated with postoperative complications and to The self-expanding design of fully covered metal stents evaluate whether the severity of postoperative complica- (CS), approved for malignancy only, is ideally suited for tions as classifi ed using the Clavien classifi cation was asso- benign esophageal disease. Not only are they removable, ciated with cancer recurrence and survival. but the continued radial force may reduce migration, result METHODS: in durable stricture resolution and effect control of fi stulas, The records of all patients who underwent an leaks and perforations. We reviewed our experience with esophagectomy for cancer between 2002 and 2007 were CS in 2 groups: benign strictures and fi stulas/leaks/perfora- reviewed. Postoperative complications were graded using tions to evaluate our outcomes and defi ne the role of CS in the Clavien Classifi cation, and scored from minor (Gra- the treatment algorithms these complex problems. deI) through the most serious (GradeIV). We defi ned major complications as those ≥ Grade IIIb. METHODS: Chart review of all stents inserted for fi stu- RESULTS: las, leaks, perforations, and benign strictures from 2005 to The study population consisted of 422 patients 2011. with a median age of 63 years. Neoadjuvant therapy was given in 94 patients (22%). En bloc, transhiatal and mini- RESULTS: A total of 56 CS were placed in 39 patients. Indi- mally invasive esophagectomies were performed. Post- cations were stricture (14), anastomotic leak (12), perfora- operative complications occurred in 191 patients (45%). tion (4), staple line leak (4), fi stulas (4) and other (1). There Complications were considered minor (Clavien Grade I-IIIa) was no procedural mortality. There were complications in in 116 (27%) and major (Grade IIIb or IV) in 75 (18%). On 32%: 10 stent migrations, 3 upper GI bleeds, 4 impactions multivariate analysis, increasing age, stage, blood transfu- and 1 erosion. sion and Clavien classifi cation ≥ Grade IIIb complications Benign Stricture Group: Strictures had been previously were independent negative predictors of survival. Factors dilated a median of 2.5 times prior to stenting in 13/14 associated with cancer recurrence included tumor stage, patients. Stents were removed at a mean of 25 days. At a blood transfusion and major postoperative complications. mean of 219 days of follow up, strictures remained pat- Factors associated with Clavien Grade IIIb or higher com- ent. Eleven patients were managed with a single stent but plications included increasing age and blood transfusion. 3 patients required sequentially larger stents to achieve Neoadjuvant therapy, tumor stage and type of resection patency. Adjunctive intralesional steroids were used in were not associated with postoperative complications. 11/14 patients. CONCLUSION: The study suggests that in addition to Fistula/Leak/Perforation Group: Control of the disruption known prognostic factors such as tumor stage, the occur- was achieved in 79% of patients with fi stulas (3/4), leaks rence of major complications are associated with a higher (12/16) and perforations (4/4), but needed to be combined frequency of recurrence and decreased survival after with drainage, VATS or laparoscopy in 12/24 leaks. All dis- esophagectomy for cancer. Esophagectomy should be done ruptions healed but 13/24 had to remain NPO during this in experienced centers where major complications are time. Stents were removed at a mean of 42 days in this minimized. group. CONCLUSIONS: CS are effective in the management of benign refractory strictures, fi stulas, leaks, and perforations. A CS with intralesional steroids is an alternative to serial dilations for stricture. Whereas fi stulas, leaks and perforations when combined with minimally invasive drainage, may avoid open repair or even salvage a prior open repair. CS are well tolerated and removable, with acceptable complication rates and have a low migration rate.

184 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1774 Tu1775 Predictors of Complicated Diaphragmatic Hernia Pathologic Response in Esophageal Cancer Does Roman Grinberg*, Muhammad Asad Khan, John Afthinos, Not Necessarily Correlate with Improved Survival Karen E. Gibbs Veeraiah Siripurapu*, Amit S. Khithani, John Jay, Surgery, Staten Island University Hospital, Staten Island, NY Dhiresh R. Jeyarajah OBJECTIVE: Due to their relatively infrequent occurrence, Surgery, Methodist Dallas Medical Center, Dallas, TX it has been historically diffi cult to predict which patient INTRODUCTION: Esophageal cancer presents with a with a diaphragmatic hernia (DH) will go on to either high mortality amongst the solid tumors with a threefold obstruct or strangulate and result in a surgical emergency. increase in the incidence of adenocarcinoma in recent Given that patients with DH tend to be older and have decades. Despite the use of better diagnostic and staging multiple comorbidities, avoiding such an emergent situa- modalities such as EUS and PET- CT, treatment of locally tion would be benefi cial. Our goal was to defi ne potential advanced tumors is associated with a poor survival. We comorbidities which could predict the likelihood of devel- aim to see if preoperative treatment with chemo-radiation oping a complicated diaphragmatic hernia. has improved survival in those patients who respond com- METHODS: Using the NSQIP database, we identifi ed all pared to those who do not. diaphragmatic hernias and grouped them by ICD9M code METHODS: All esophageal surgeries performed coopera- as either uncomplicated (553.3—without obstruction or tively by two surgeons between 2005 to 2010 were retro- gangrene) or complicated (551.3—with gangrene,552.3— spectively reviewed. Only those patients deemed locally with obstruction). Preoperative comorbidities, operative advanced (>T2, Node positive) who received preoperative time, length of hospitalization and perioperative mortal- chemoradiation were included for analysis. All patients ity and morbidity were compared between the two groups were staged by CT & endoscopic ultrasound. using chi-square and independent t-test as appropriate. A RESULTS: multivariate regression analysis was used to analyze poten- 52 patients were identifi ed, with 5 patients tial factors contributing to obstruction or strangulation. excluded due to outside institution referral. Of the 47 Logistic regression was used to select correlates of 30 day patients, 38 (81%) had adenocarcinoma versus 9 patients mortality that were subsequently weighted and integrated (19%) who had squamous cell carcinoma. Majority of the into a scoring system based on the number of comorbidities. patients received Paclitaxel, Carboplatin and 5FU with radiation. The operative surgery was either a minimally inva- RESULTS: We identifi ed 4778 patients, of which 4059 sive or open transhiatal esophagectomy with no difference (85%) had an uncomplicated DH and 719 (15%) who had a in survival (p = 0.09). There were 2 operative mortalities complicated DH. The mean age for uncomplicated DH was and no anastamotic leaks. Patient response to chemother- statistically less than for a complicated DH (62.2 ± 14.1 vs apy was designated either as No response, Partial response 66.9 ± 15.2, p < .001). Independent predictors associated or complete pathologic response (cPR). 21 patients (45%) with a complicated DH included dyspnea at rest (AOR 2.9), had no response, 9 ( 19%) had partial response, while 17 partially or totally dependent functional status (AOR 4.4 patients (36%) had a cPR. Median survival was respectively and 7.1), CHF (AOR 4.3), history of MI (AOR 7.97) and >10% 22 months, 23 months and 27 months (p = 0.53) (see Fig2). weight loss (AOR 1.82). Active smoking, alcohol consump- CONCLUSIONS: tion, dyspnea at exertion and use of steroids had no signifi - Preoperative treatment with esophageal cant association. Risk stratifi cation based on the number cancer can lend to a high complete pathologic response. of preoperative comorbid factors demonstrated a step-wise Despite the encouragement of a cPR, this data would sug- increase in the rate of complicated DH: 12.1% (0–2 comor- gest that this does not translate to an improvement in bidities), 21.5% (3–4 comorbidities), and 38.5% (≥5 comor- survival. bidities). Analysis of perioperative outcomes revealed that the mortality rate in the complicated DH group is much higher when compared to that of the uncomplicated DH group (5.1% vs 0.7%, P < .001). The same is true for the reoperation rate (6.3% vs 3.2%, p < .001) and length of stay (9.1+9.6 d, vs 4.1+6.7 d, p < .001). CONCLUSION: This tool provides a simple, accurate and easily applicable method for predicting a complicated DH. Of note, history of a prior MI and dependent functional status most strongly predicted a complicated diaphragmatic hernia. Our fi ndings suggest that if patients with uncomplicated DH are discovered and have a high score, elective repair should be sought expeditiously to avoid a life-threatening emergency. More studies are needed to further evaluate the timing of the progression from diagnosis of an uncomplicated DH to complication.

185 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1776 Clinical: Hepatic Does FDG-Uptake on PET-CT Provide Additional Prognostic Information for Patients with Esophageal Tu1777 Carcinoma? Preoperative Chemotherapy, Histological Tumor David Bowrey, Sukhbir Ubhi, Claire N. Brown* Surgery, University Hospitals of Leicester NHS Trust, Leicester, Regression and Long-Term Outcome After Resection United Kingdom of Colorectal Liver Metastasis *1 2 3 BACKGROUND: Frank Makowiec , Peter Bronsert , Gerald Illerhaus , Tobias Several previous studies have reported Keck1, Oliver Drognitz1, Hannes P. Neeff1, Ulrich T. Hopt1 that the FDG standardised uptake value (SUVmax) on PET- 1. Department of Surgery, University of Freiburg, Freiburg, Germany; CT imaging may be a useful prognostic marker. The majority of these studies have assessed selected populations. The 2. Pathological Institute, University of Freiburg, Freiburg, Germany; aim of this study was to report the infl uence of FDG SUV- 3Department of Oncology, University of Freiburg, Freiburg, Germany max on the outcome of an unselected cohort of patients INTRODUCTION: In patients with colorectal liver metas- undergoing PET-CT for esophageal carcinoma. tases (CRC-LM) preoperative chemotherapy (preCTx) is fre- METHODS: The SUVmax was determined for 105 patients quently used in a perioperative setting and/or to downsize undergoing PET-CT during the time period 2007–10. irresectable CRC-LM. Especially in the perioperative setting, Patients were subdivided into quartiles according to SUV- however, the exact role of preCTx is not well defi ned. To max and its infl uence on prognosis assessed by univariate improve patient selection for preCTx factors predicting and multi-variate analysis. response and/or prognosis should be identifi ed. In our study RESULTS: we analyzed the pathohistological response to preCTx in The study population was 105 patients (77 male) almost 150 patients who had had any form of CTx before of median age 65 years (range 41–83). Histology was ade- liver resection, and correlated this response with survival. nocarcinoma in 77 patients, squamous carcinoma in 28. METHODS: Treatment intent was curative for 64 patients (resection 31, We could evaluate the outcome of 147 patients radical chemoradation 31, endoscopic mucosal resection 2) who had hepatic resection for CRC-LM during the last and palliative for the remaining 41 patients. On univari- decade in our institution, with pathohistological assessment ate analysis, SUVmax was not infl uenced by sex (p = 0.08), of tumor regression grade (TRG) of metastatic disease and age (p = 0.19), histology (p = 0.81) or tumor site (p = 0.07), suffi cient follow-up. Preoperatively the patients had under- but was heavily linked to UICC stage (p < 0.001). Survival gone various regimens of CTx (42% FU-based, 40% Oxali- was signifi cantly associated with quartile of SUVmax score platin and/or Irinotecan, 18% CTx plus antibodies/targeted (p = 0.03). This effect disappeared on multivariate analy- therapy). 55% of the resections were at least a hemihepatec- sis because prognosis was so strongly linked to UICC stage tomy, 45% segmental or wedge resections. Free hepatic mar- (p = 0.01). However, subgroup analysis identifi ed that for gins were achieved in 90%, free overall margins (including patients treated by radical chemoradiation, UICC stage (p = extrahepatic disease) in 81%. For this study all pathological 0.002) and SUVmax (p = 0.01) were the only factors linked specimens were reanalysed to classify TRG (grade 1 = total to prognosis. regression to grade 5 = no regression/vital tumor). Survival was estimated by Kaplan-Meier- and Cox-methods. CONCLUSIONS: This study did not confi rm the FDG SUV- RESULTS: max on PET-CT to offer additional prognostic information Only 3% of the patients showed TRG grade 1 for most patients with esophageal carcinoma. It may be (total regression), 28% had good or moderate regression helpful in patients treated by primary chemoradiation. (TRG 2/3), and 69% had minor or no regression (TRG 4/5). TRG was better after CTx + targeted therapy (11% TRG1, 33% TRG 2/3; p < 0.01 vs CTx alone). TRG was also better in patients receiving more than 6 months of preCTx (p < 0.03 vs preCTx < 6 months). Overall 5 year survival (5y-Surv) was 42%. 5y-Surv was formally 100% in the few patients with total tumor regression (TRG 1), but comparable in the groups with TRG2/3 or TRG 4/5 (44%/38%; p = 0.1). In univariate and multivariate analysis in this subgroup of 147 patients with assessment of TRG only the hepatic margin (p < 0.01) or the overall margin (p < 0.001) signifi cantly infl uenced survival. Type and duration of pre- CTx, extent of hepatic resection, nodal disease of primary CRC, number and size of metastases, and gender did not infl uence survival. CONCLUSION: Only few patients with preoperative chemotherapy show total regression of the resected colorectal liver metastases. Addition of targeted therapy to CTx may enhance pathohistological tumor regression. Total response to preoperative chemotherapy may be associated with a clearly improved prognosis.

186 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1779 Clinical: Pancreas Impact of Non-Alcoholic Fatty Liver Disease on Long-Term Survival for Resected Intrahepatic Tu1780 Cholangiocarcinoma Role of Endoscopic Retrograde Pancreatography Clancy J. Clark*1, Shahzad M. Ali1,2, Victor M. Zaydfudim1, Michael L. Kendrick1, Kaye M. Reid Lombardo1, John H. to Detect Early Pancreatic Ductal Adenocarcinoma Donohue1, Michael B. Farnell1, David M. Nagorney1, Concomitant with Intraductal Papillary Mucinous Florencia G. Que1 Neoplasm of the Pancreas 1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; Takao Ohtsuka*, Noboru Ideno, Teppei Aso, Yousuke Nagayoshi, 2. 2nd Department of Internal Medicine, University Hospital and Hiroshi Kono, Yasuhisa Mori, Junji Ueda, Shunichi Takahata, Faculty of Medicine, Hradec Kralove, Czech Republic Kazuhiro Mizumoto, Masao Tanaka Surgery and Oncology, Kyushu University, Fukuoka, Japan BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) leads to a chronic infl ammatory state hypothesized as car- BACKGROUND: Intraductal papillary mucinous neoplasm cinogenic. The clinical signifi cance of NAFLD for patients (IPMN) of the pancreas often has distinct pancreatic duc- diagnosed with ICC is not known. The aim of this study tal adenocarcinoma (PDAC) in the same pancreas. Roles of was to evaluate the signifi cance of NAFLD on overall sur- endoscopic retrograde pancreatography (ERP) during the vival (OS) for patients with ICC. management of IPMN in terms of early diagnosis of con- METHODS: comitant PDAC have not been well documented. The aim In this single-institution, retrospective cohort of this study was to clarify whether ERP would be useful study, all patients who underwent curative resection for ICC for the early detection of concomitant PDCAs in patients from 1997 to 2011 were identifi ed. NAFLD was defi ned as with IPMNs. pathologic evidence of steatosis or steatohepatitis in unin- volved liver parenchyma at time of resection or preopera- METHODS: Medical records of 179 patients who were his- tive liver biopsy. Patients with clinical history or pathologic tologically confi rmed to have IPMNs by resected specimens evidence of underlying liver disease other than NAFLD (n at our department between 1987 and 2011 were retrospec- = 17) and patients who died of perioperative complications tively reviewed. The patients having concomitant PDACs (n = 2) were excluded from survival analyses. Kaplan-Meier were selected, and then the diagnostic abilities to detect estimates and Cox regression proportional hazards were concomitant PDACs of computed tomography (CT), mag- used to evaluate predictors of OS. netic resonance imaging/cholangiopancreatography (MRI/ RESULTS: MRCP), endoscopic ultrasonography (EUS), and ERP were One-hundred and thirty-eight patients (median compared between early-stage (stage 0 or I according to the age 60.5; 39.9% male) underwent curative resection for ICC Japanese general rules for pancreatic cancer) and advanced with pathologic evidence of NAFLD in 18 (13.0%) patients. PDACs (stage II, III, and IV). Abnormal fi ndings to suspect Median follow-up was 29 months (IQR 43) and median the presence of PDAC in CT, MRI/MRCP, and EUS included OS was 55 months. Age, sex, ASA, MELD score, CA 19–9, an irregular solid mass lesion and stenosis/dilation of pan- and BMI were similar between NAFLD and non-NAFLD creatic duct, distinct from IPMNs. Abnormalities suspicious patients. AJCC 7th Edition T-Stage was signifi cantly lower of the presence of PDAC in ERP were defi ned as irregularity in NAFLD patients compared with non-NAFLD patients: T1 of pancreatic duct such as stenosis and obstruction, and/or 50% vs 44%; T2a 22% vs 2.5%; T2b 6% vs 23%; T3 11% vs positive results (class IV or V) of pancreatic juice/brushing 13%, and T4 11% vs 18% (p = 0.02). However, AJCC 7th cytology. Edition TNM Stage was not signifi cantly different between NAFLD and non-NAFLD patients (p = 0.56). In univariate RESULTS: A total of 23 PDACs developed synchronously analysis, predictors of decreased OS were larger tumor size or metachronously in 20 patients, and the prevalence of (p < 0.01), node positive disease (p < 0.01), and presence of PDACs concomitant with IPMNs was 11.2% (20/179). multiple tumors (p = 0.02). Pathologic evidence of NAFLD Sensitivities to detect PDACs of CT, MRI, and EUS in early did not predict decreased OS (HR 1.5, 95% CI 0.8–3.0, group (16%, 29%, 29%, respectively) were signifi cantly p = 0.20). In subgroup analysis of node-negative patients lower than those in advanced group (87%, 93%, 92%, (n = 77), NAFLD was a predictor of decreased OS (HR 3.7, respectively) (p < 0.01). On the other hand, sensitivity of 95% CI 1.6–8.5, p < 0.01). Other predictors of worse OS in ERP in early group was as high as that in advanced group node-negative patients were tumor size, ASA, and positive (86% vs. 82%, p > 0.99). Among 7 early PDACs, 3 were resection margin (all p ≤ 0.04). After adjusting for other diagnosed only by ERP. signifi cant covariates in the node-negative cohort, NAFLD CONCLUSION: ERP has an important role in the early was an independent predictor of decreased OS (HR 2.7, diagnosis of distinct PDACs in patients with IPMNs. Fur- 95% CI 1.1–6.6, p = 0.03). ther investigation is necessary to clarify the indication and CONCLUSIONS: Although NAFLD is not a predictor of timing of ERP during the management of IPMNs in term of OS for all patients undergoing hepatic resection for ICC, early detection of concomitant PDACs. NAFLD is associated with decreased OS in patients with node-negative ICC. This adverse correlation of NAFLD and OS in patients with ICC suggests that treatment strategies should include management of NAFLD.

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Tu1781 vs. 27%, p = 0.56), Clavien grade I and II complications (46% vs. 43%, p = 0.84), Clavien grade III and IV complica- Major Pancreatic Resections in Octogenarians: A tions (21% vs. 21%, p = 0.99), clinically signifi cant fi stulas Community Hospital Experience (21% vs. 14%, p = 0.43), and perioperative mortalities (8% Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2 vs. 5%, p = 0.49). Malignancy had a higher incidence in the 1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and older group (87% vs. 62%, p = 0.02). The median length of Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ hospital stay was also signifi cantly higher in ≥80 y patients (14 vs. 9 days, p = 0.03). Although survival was signifi cantly BACKGROUND: Major pancreatectomies are increasingly less in the octogenarian group for all pathologies (p = 0.04), being performed in octogenarian (≥80 y) patients with notably, for pancreatic cancer patients, one and two year reported clinical outcomes from large-volume medical survival outcomes were similar (p = 0.25). centers. In this study we analyzed the outcomes of pancreatic resections in octogenarians at our community-based Perioperative and Survival Outcomes institution. METHODS: A retrospective chart review of 148 patients ≥80 years <80 years undergoing pancreatic resections by a single surgeon (A.Y.) (n = 24) (n = 124) P-value between 2006 and 2010 was performed. Data was collected Pancreaticoduodenectomy (PD) 16 (67%) 83 (67%) 0.98 for demographics, clinical presentation, perioperative course, histology, and survival. We compared patients who Distal Pancreatectomy (DP) 8 (33%) 41 (33%) were older and younger than 80 years with statistical sig- Operative time 228 245 (125–560) 0.09 nifi cance of p < 0.05. Survival analysis was performed using (160–290) the Kaplan-Meier method. Estimated blood loss (ml) 273 312 (20–3000) 0.60 (20–1400) Patient Characteristics and Histopathology Perioperative blood transfusion 8 (33%) 34 (27%) 0.56 ≥80 years <80 years Clavien grade I and/or II 11 (46%) 54 (43%) 0.84 (n = 24) (n = 124) P-Value complications Age (years) 83 (80–90 y) 67 (26–79) Clavien grade III and/or IV 5 (21%) 26 (21%) 0.99 Female 16 (67%) 47 (38%) 0.01 complications ASA class ≥3 10 (59%) 47 (46%) 0.35 Perioperative mortality 2 (8%) 6 (5%) 0.49 Cardiovascular comorbidity 17 (71% 78 (63%) 0.46 Postoperative pancreatic fi stula: 6 (25%) 24 (19%) 0.53 ISGPF (§) Diabetes Mellitus 5 (21%) 35 (28%) 0.46 Clinically signifi cant pancreatic 5 (21%) 14 (18%) 0.43 Preoperative ERCP 5 (21%) 18 (14%) 0.43 fi stula ISGPF (§) grade B or C Histopathology Median length of hospital stay 14 (4–41) 9 (3–108) 0.03 Pancreatic carcinoma 21 (87%) 77 (62%) 0.02 (days) Neuroendocrine tumor 2 (8.3%) 11 (8.8% Reoperation 1 (4%) 15 (12%) 0.25 IPMN 1 (4%) 14 (11%) 30-days postdischarge 4 (17%) 25 (20%) 0.69 readmission Other benign lesions 0 15 (12%) Delayed Gastric Emptying (DGE) 6 (25%) 17 (14%) 0.16 Chronic pancreatitis 0 5 (4%) Survival Peripancreatic invasion 11 (52%) 44 (57%) 0.80 1 year survival 45.7% 69.1% 0.04 Positive surgical margins 4 (19%) 17 (22%) 0.75 2 year survival 32.6% 51.8% Lymphovascular invasion 9 (43%) 42 (54%%) 0.46 Median survival (months) 8.7 33.2 Positive lymph node 11 (52%) 47 (61%) 0.62 spread Cancer only 1 year survival 40.7% 56.2% 0.25 Cancer only 2 year survival 27.1% 33.5% RESULTS: Twenty-four patients ≥80 y old underwent pan- §ISGPF: International study group defi nition of postoperative pancreatic fi stula. createctomies (n = 24, range 80–90 y) compared to 124 patients <80 y (n = 124, range 26–79 y). The two groups CONCLUSION: Major pancreatic resections can safely be were similar in the distribution of their clinical character- performed in octogenarians in a community-based hospital istics, including ASA class. Pancreaticoduodenectomy (PD) with similar perioperative outcomes to younger patients. was the most common procedure performed in the two Comparable survival outcomes can be achieved in octoge- groups (≥80 y n = 16, 67%; <80 y n = 83, 67%; p = 0.98). narians when surgery is limited to malignant indications. There were no signifi cant differences between the older and younger patients in respect to the operative time (228 vs. 245 min, p = 0.09), perioperative blood transfusions (33%

188 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1782 Tu1783 Neoadjuvant Chemoradiation Therapy Using S-1 Meta-Analysis of Trials Comparing Central and Distal for Patients with Pancreatic Cancer Pancreatectomies: Short and Long-Term Outcomes Sohei Satoi*, Hideyoshi Toyokawa, Hiroaki Yanagimoto, Mohammad Sarhan*1, Alan S. Rosman4, John D. Allendorf2, Tomohisa Yamamoto, Satoshi Hirooka, so Yamaki, Taku Leaque Ahmed1, Zahra Shafaee3 Michiura, Kentaro Inoue, Yoichi Matsui, a-Hon Kwon 1. Columbia University at Harlem Hospital Center, New York, NY; Department of Surgery, Kansai Medical University, Hirakata, Japan 2. Columbia University College of Physicians and Surgeons, New York, INTRODUCTION: The results of surgical therapy alone NY; 3. Lawrence Hospital, Bronxville, NY; 4. Mount Sinai School of for pancreatic cancer are disappointing. We have reported Medicine and Bronx VAMC, New York, NY that surgical resection following neo-adjuvant chemoradia- INTRODUCTION: Recent literature suggests superior pancre- tion therapy (NACRT) can be associated with the higher atic function after Central Pancreatectomy (CP) compared rate of R0, and with the lower rate of metastastic lymph to Distal Pancreatectomy (DP) in patients with benign or nodes, resulting in improved prognosis of patients with low grade malignant neoplasms of the neck or body of T3/4 pancreatic cancer (Pancreas 2009 and 2011 in press). pancreas. Available data is limited to single institutional However, there is no consensus on the regimen of NACRT studies with small sample size. In order to overcome these for pancreatic cancer. The aim of this study is to explore the shortcomings, we performed the fi rst systematic meta-anal- short-term results of the new regimen of NACRT using S-1 ysis in this subject. followed by surgical resection. METHODS: A systematic English literature review was per- PATIENTS: Among 103 consecutive patients with poten- formed using Pubmed database. All related articles compar- tially resectable pancreatic cancer between January 2006 ing central and distal pancreatectomy from 1990 to 2010 and September 2010, 43 patients were classifi ed as adjuvant were reviewed. The end-point was to compare peri-opera- group between Jan. 2006 and Sep 2008, and 34 patients tive complication rate and long-term outcomes (new onset who underwent NACRT between Oct 2008 and Sep 2010 or worsening diabetes, tumor recurrence) after each proce- were classifi ed as NACRT group. The regimen of NACRT dure. Meta-analysis was performed based on random-effect was consisted of S-1 (orally twice daily, 5days in a week, model. 80mg/m2/day) and concurrent radiotherapy (total of 50.4 RESULTS: Gy). The primary endpoint was the frequency of patho- Eight eligible studies were found, including logical curative resection (R0). All patients who under- 615 patients (CP: 343, DP: 272). Both groups were similar went pancreatectomy were planned to receive adjuvant (age, sex, baseline pancreatitis, and incidence of IPMN and chemotherapy. malignancy on fi nal pathology). Baseline DM was higher in DP group (Odds Ratio: 0.35). Short term outcomes: CP RESULTS: The overall response rate and disease control was associated with longer Operative time (257 vs. 232min, rate in NACRT group were 18% and 88.0%, respectively. P: 0.34) and less blood loss (378 vs. 651ml, P: 0.0006). Hos- There was no difference in resection rate between NACRT pital stay was longer (12.75 vs. 9.63 days, P: 0.0038) and and adjuvant groups (30/34 vs 36/43). Other organ resec- pancreatic fi stula rate was higher in CP compared with DP tion including vascular resection was done for 17 of 36 (OR: 1.6, P: 0.04). Incidence of types B and C pancreatic patients in adjuvant group and for 19 of 30 patients in fi stulas were similar in two groups (OR: 1.3, P 0.44). The NACRT group. The primary end point analysis of this study rate of new onset diabetes (OR: 0.11, P: 0.00) or worsen- demonstrated that in accordance with our study hypothe- ing diabetes (OR: 0.03, P: 0.00) was signifi cantly lower in sis, NACRT followed by surgical resection improved R0 rate the CP. There was no difference in tumor recurrence rate in NACRT group compared with adjuvant group (28/30 vs in both groups. 21/36, p = 0.005). The number of metastatic lymph nodes in NACRT group was signifi cantly lower than in adjuvant group (p = 0.0363). On the comparisons of extension of metastatic lymph nodes, the frequency of N0/1 in NACRT group was also higher than in adjuvant group (p = 0.041). There were no signifi cant differences in mortality and morbidity except intractable ascites between two groups. The rate of intractable ascites in NACRT group was signifi cantly higher than in adjuvant group (8/22 vs 2/34, p = 0.035). The frequency of local relapse in NACRT group was signifi - cantly lower than in adjuvant group at 1year after surgical resection (0% vs 26%, p = 0.021). CONCLUSION: NACRT using S-1 can improve the rate of pathologically curative resection and the number and extension of metastatic lymph nodes in patients with T3/4 pancreatic cancer, resulting in better local control.

189 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

of 25 months (CI 95% 19.5–30.8) compared to 30.5 months (CI 95% 25.7–35.2) for those without complications (P = 0.144). Adjuvant treatment was administered in 70.5% of patients with abdominal complications and in the 82% of those with an uneventful postoperative course (P = 0.010). On multivariable analysis factors independently associated with survival were: the presence of abdominal complications (HR 1.40; P = 0.009), adjuvant treatment (HR 0.628; P = 0.001), N1 status (HR 1.93; P < 0.0001), R1 resection (HR 1.87; P < 0.0001), G3 vs G1 (HR 4.33; P < 0.0001) and G2 vs G1 (HR 2.99; P = 0.005). CONCLUSIONS: Postoperative abdominal complications are independent predictors of survival after resection for PDAC. The mechanism behind this association may be related to an immunologic impairment due to surgical complications and to a lower rate of adjuvant therapy administration in this subgroup.

CONCLUSION: Our analysis suggests that CP is associ- Tu1785 ated with lower rate of pancreaticogenic diabetes. This will justify for slight increase in operative time, pancreatic fi s- Splenic Vein Thrombosis Is Associated with Specifi c tula rate, and length of hospital stay. Preservation of unin- Increased Complications and Reduced Survival in volved pancreas leads to conservation of the pancreatic Patients Undergoing Distal Pancreatectomy for function and make CP a good alternative to more radical Pancreatic Ductal Adenocarcinoma distal pancreatectomy for benign and low-grade malignant Nishi Dedania, Nidhi Agrawal, Matthew Klinge, Salil Gabale, neoplasms. Jordan M. Winter, Leonidas Koniaris, Ernest L. Rosato, Patricia K. Sauter, Eugene P. Kennedy, Charles J. Yeo, Harish Lavu* Tu1784 Department of Surgery, Thomas Jefferson University, Philadelphia, PA The Presence of Abdominal Complications Is an INTRODUCTION: Distal pancreatectomy and splenec- Independent Predictor of Poor Survival After Resection tomy (DPS) is the procedure of choice for the surgical treat- for Pancreatic Cancer ment of ductal adenocarcinoma (PDA) localized to the Stefano Crippa*1,2, Stefano Partelli1,2, Claudio Bassis1, body and tail of the pancreas. Due to a lack of early symp- Domenico Tamburrino1, Giuliano Barugola1,2, Riccardo F. Rossato1, toms, patients with distal pancreatic lesions can present at Silvia Laiti1, Anna Neri1, Massimo Falconi1,2 an advanced disease stage with large tumors. Splenic vein thrombosis (SVT) can occur in these patients secondary to 1. Department of Surgery, Università di Verona, Verona, Italy; direct tumor invasion or peri-tumoral infl ammation. SVT is 2. Department of Surgery, Ospedale Sacro Cuore-Don Calabria, most commonly associated with chronic pancreatitis and Negrar, Italy little is known regarding its implications for patients with BACKGROUND: Postoperative complications signifi cantly PDA. This study documents our institution’s experience affect disease-specifi c survival (DSS) after surgery for differ- with SVT in patients undergoing DPS for PDA and exam- ent tumors. The aim of the study is to assess the impact on ines it’s effect on postoperative outcomes. survival of postoperative course after surgery for pancreatic METHODS: In this retrospective cohort study, we queried ductal adenocarcinoma (PDAC). our pancreatic surgery database to identify all patients who METHODS: Retrospective analysis of 431 patients who underwent DPS from October 2005 to June 2011. These underwent pancreatic resections with curative intent (R0-R1) cases were evaluated for evidence of preoperative SVT for PDAC between 2000 and 2009. through review of clinical records and imaging studies (CT, MRI, endoscopic ultrasound). Perioperative outcomes for RESULTS: Surgical procedures included pancreaticoduo- patients undergoing DPS for PDA with and without SVT denectomy (n = 347, 80.5%), distal pancreatectomy (n = were compared. 68, 16%) and total pancreatectomy (n = 16, 3.5%). Overall morbidity was 37%. In-hospital or 30-day mortality rate RESULTS: A total of 284 DPS were performed during the was 1.6%. Overall, 132 patients (31%) had abdominal com- study period. Of these, 70 were for patients with PDA and plications, including 72 (17%) patients with pancreatic fi s- were distributed into 27 (39%) who had preoperative SVT tula and 46 (10.5%) with abdominal collections/abscesses. and 43 (61%) who did not. Both groups had similar demo- The median length of stay (LOS) was 10 days (IQR 8;15). graphic characteristics (Table). The median estimated blood Patients with abdominal complications had a signifi cantly loss was signifi cantly higher in the SVT group versus the higher LOS (15 vs 9.5 days, P < 0.0001). The median DSS non- SVT group (675mL vs. 250mL, p < 0.001). Although for the entire cohort was 28.4 months (CI 95% 24.5–32.3). the overall morbidity rate was similar between groups (48% Patients with abdominal complications had a median DSS vs 56%, p = NS respectively), the group with SVT had signifi cantly higher rates of serious complications, such as

190 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

pancreatic fi stula (33% vs 7%, p < 0.01) and delayed gas- ever, one-year survival for patients with SVT was reduced tric emptying (15% vs 0%, p < 0.05). Tumor pathology was compared to the non-SVT group (52% vs 76%, p = 0.08), a similar between groups with the SVT group having 67% difference that approached signifi cance. T3 stage and 52% lymph node positive tumors while the CONCLUSIONS: DPS for PDA can be performed safely non-SVT group had 56% T3 stage and 56% lymph node in patients with preoperative SVT, but our fi ndings reveal positive tumors. The median postoperative length of stay higher rates of intraoperative blood loss, pancreatectomy- in the hospital (6 days) and readmission rates (30% vs 28%, specifi c complications, and suggests lower long term sur- p = NS) were similar between groups. Neither group had vival rates. a perioperative mortality within 30 days of surgery. How-

Total n (%) SVT n (%) Without SVT n (%) p-Value Total 70 (100%) 27 (39%) 43 (61%) Preoperative Demographics Age (years) 67 63 68 <0.05 Male 42 (60%) 18 (67%) 24 (56%) NS BMI 26.1 24.5 26.9 NS DM 20 (29%) 7 (26%) 13 (30%) NS Tobacco Use* 26 (36%) 10 (37%) 16 (37%) NS EBL* (ml) 400 675 250 <0.0001 Complications** Any Complication 37 (53%) 13 (48%) 24 (56%) NS P. Fistula 12 (17%) 9 (33%) 3 (7%) <0.01 DGE 4 (6%) 4 (15%) 0 (0%) <0.05 Chyle Leak 3 (4%) 1 (4%) 2 (5%) NS Intra-abdominal Abscess 4 (6%) 2 (7%) 2 (5%) NS Cardiac 6 (9%) 1 (4%) 5 (12%) NS UTI 5 (7%) 4 (15%) 1 (2%) NS Wound Infection 11 (16%) 4 (15%) 7 (16%) NS Sepsis 3 (4%) 2 (7%) 1 (2%) NS C. diff. colitis 2 (3%) 0 (0%) 2 (5%) NS DVT/PE 3 (4%) 2 (7%) 1 (2%) NS Pulmonary 6 (9%) 1 (4%) 5 (12%) NS Length of Postoperative Hospital Stay (days) 6 6 6 NS Pathology T3 Stage 42 (60%) 18 (67%) 24 (56%) NS Lymph Node Positive 38 (54%) 14 (52%) 24 (56%) NS Readmission 20 (29%) 8 (30%) 12 (28%) NS 1-year Overall Survival*** 36 (67%) 11 (52%) 25 (76%) NS DM, Diabetes Mellitus; EBL, Estimated Blood Loss; SVT, Splenic Vein Thrombosis; P. Fistula, Pancreatic Fistula; UTI, Urinary Tract Infection; DGE, Delayed Gastric Emptying; C. diff. colitis, Clostridium difﬁ cile colitis; DVT/PE, Deep Vein Thrombosis/Pulmonary Embolism. All values represent medians. *Tobacco Use data not available for 2 patients, EBL data not available for 4 patients. Total numbers for these variables exclude these patients **Number of patients with one or more complications. ***Only includes patients with date of surgery from 10/2005–06/2011.

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Tu1786 Tu1787 Hepaticojejunostomy Leaks Following Parenteral Nutrition After Pancreatoduodenectomy: Pancreaticoduodenectomy: A Closer Look at a Rare Who Needs It? Complication Ian K. Ferries*, Michael G. House, Thomas Z. Hayward, Richard Burkhart*, Salil Gabale, Danielle Pineda, Patricia K. Sauter, C. Max Schmidt, Nicholas J. Zyromski, Attila Nakeeb, Ernest L. Rosato, Leonidas Koniaris, Harish Lavu, Eugene P. Kennedy, Keith D. Lillemoe, Thomas J. Howard, Henry A. Pitt Charles J. Yeo, Jordan M. Winter Surgery, Indiana University School of Medicine, Indianapolis, IN Department of Surgery and the Jefferson Pancreas, Biliary, and Related BACKGROUND: The impact of proactive nutritional Cancer Center, Thomas Jefferson University, Philadelphia, PA repletion in reducing postoperative morbidity in patients BACKGROUND: Hepaticojejunostomy (HJ) leaks after undergoing pancreatoduodenectomy (PD) remains poorly pancreaticoduodenectomy (PD) are poorly characterized in understood. This study analyzes the clinical factors which the literature, in contrast to more commonly encountered are associated with the utilization of parenteral nutrition complications such as pancreaticojejunostomy (PJ) leaks. (PN) after PD. METHODS: METHODS: We reviewed 650 consecutive PDs performed Between 2005 and 2009, 600 consecutive at our institution between 2005 and 2011 and categorized patients who underwent PD were included in the analy- patients according to whether or not they experienced an sis. The most common indications for PD were adenocarci- HJ leak. Leaks were identifi ed on either transhepatic-chol- noma (n = 249, 41%), pancreatitis (n = 88, 15%), and cystic angiography or an abdominal drain contrast study. Preop- neoplasms (n = 83, 14%). Two-way statistical comparisons erative variables were analyzed to identify risk factors for were performed between patients who did (+PN) or did not an HJ leak. The clinical presentation, morbidity, and treat- (-PN) receive postoperative parenteral nutrition within 30 ment plan were examined in detail. days of PD. RESULTS: RESULTS: An HJ leak was identifi ed in 14 patients (2.2%), Pylorus-preserving PD was performed in 491 whereas 87 patients (13.5%) in the cohort developed a PJ patients (82%), and a classic PD in 109 (18%). Opera- leak. Univariate analysis demonstrated that low preop- tive mortality occurred in 18 (3%) patients. One hundred erative albumin was the only pre- or intraoperative factor twenty-two (20%) patients were prescribed PN at a median found to be associated with increased risk of HJ leaks (3.5 of 8 days (range, 1–19) after PD. The median duration of PN vs. 4.0 mg/dL no leak; p = 0.001). Six of 14 patients (43%) usage was 9 days (range, 1–246). There were no differences had a preoperatively placed endostent in the common bile in age, gender, renal function, operative time, or blood duct. Patients typically presented on the 6th postopera- loss between the +PN and -PN groups. Patients requiring tive day (range: 1 to 14 days), and in all cases a diagno- PN had lower preoperative (2.80 v. 2.93 g/dl, p = 0.03) and sis was made prior to hospital discharge. Presenting signs hospital discharge (2.05 v. 2.32 g/dl, p < 0.001) albumin and symptoms included leukocytosis (86%, median 15.3, levels. Higher preoperative total bilirubin levels were asso- range 6.6 to 26.1), increased abdominal pain (64%), fever ciated with postoperative PN usage (2.95, +PN v. 2.14 mg/ (43%), failure to tolerate a diet (36%), abdominal disten- dl, -PN, p = 0.02). Operative outcomes with regards to post- sion (21%), and bilious drainage from the abdominal drain operative PN utilization are listed in the table. Forty-seven (21%). Thirteen of 14 patients were managed with a percu- percent of the patients who developed delayed gastric emp- taneous intervention. Seven patients were managed with tying (DGE) required PN. PD was complicated by a pancre- a percutaneous transhepatic biliary drain and six patients atic fi stula (all grades) in 13% of patients, 35% of whom required manipulation of an intraoperatively placed sur- required PN. gical drain. No patients required surgical intervention. In Postop All Major Re- Pancreatic addition to the HJ leak, patients also frequently developed PN Complications Complications Operation Fistula DGE a wound infection (71%), PJ leak (43%), and sepsis (29%). The median length of stay was 18 days (range: 16 to 55), No 198 (41%) 25 (26%) 20 (4%) 51 (10%) 44 as compared to 8 days in patients without an HJ leak (p = (n = 478) (9%) 0.000). Readmission rates were 26% in the HJ leak group Yes 79 (65%) 68 (56%) 18 (14%) 27 (21%) 39 and 15% in the total cohort (p = NS). There was a single (n = 122) (32%) 90-day mortality in the HJ group (7%) as compared to 17 p–value <0.001 <0.001 <0.01 0.001 <0.001 (2.7%) in the entire cohort (p = 0.356). CONCLUSIONS: HJ leaks are rare complications after PD CONCLUSIONS: Postoperative parenteral nutrition is and can result in substantial morbidity with increased required frequently in patients undergoing pancreatoduo- length of hospital stay. However, early recognition with denectomy. Strong associations between poor nutritional effective drainage typically results in a full recovery, with- parameters, postoperative morbidity, and PN utilization out the need for surgical intervention when skilled inter- emphasize the crucial role of adequate nutrition in achiev- ventional services are available. Low volume leaks are ing good surgical outcomes. Establishing enteral nutritional managed with effective abdominal drainage, while larger access at the time of PD should be considered in patients at leaks may require placement of a transhepatic biliary drain- risk for postoperative complications. age catheter.

192 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1788 CONCLUSION: 13C-MTG-T as well as residual pancreatic exocrine cells represented by histological degree of pancre- Fat Absorptive Function After Pylorus Preserving atic exocrine cells at cut margin, reliably show long-term Pancreatoduodenectomy Assessed by 13C-Labeled fat absorptive function after PPPD. Glucose metabolism Mixed Triglyceride Breath Test disturbance is also related to post operative fat absorption. Masahiko Morifuji*1, Yoshiaki Murakami2, Kenichiro Uemura2, Takeshi Sudo2, Yasushi Hashimoto2, Taijiro Sueda2, Tu1789 1 Akio Sakamoto Autoimmune Pancreatitis (AIP): Short and Long- 1. Sanmu Medical Center, Chiba, Japan; 2. Department of Surgery, Term Outcomes in Patients Treated Initially by Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan Pancreaticoduodenectomy, a Comparative Study Greg Roberts*1, Lee Mchenry3, Romil Saxena2, Seth A. Moore4, BACKGROUND: Long-term survival after pancreatic sur- Thomas J. Howard1 gery has increased gradually due to recent improvements 1. Surgery, Indiana University Medical Center, Indianapolis, IN; in surgical techniques and experiences; therefore, postop- 2. Pathology, Indiana University Medical Center, Indianapolis, IN; erative evaluation of fat absorption and glucose metabolism disturbances is important. We have been reported 3. Gastroenterology, Indiana University Medical Center, Indianapolis, that the non-invasive 13C-mixed triglyceride breath test IN; 4. Gastroenterology, Ohio State University School of Medicine, (13C-MTG-T), labelled long chain triglyceride mixture can Columbus, OH reliably diagnose pancreatic exocrine insuffi ciency (Surgery, INTRODUCTION: Autoimmune pancreatitis (AIP) is a rare, 2009). In this study, we investigate fat absorptive function benign infl ammatory disease that clinically and radio- in patients status post pylorus preserving pancreatoduode- graphically mimics pancreatic adenocarcinoma (PA). When nectomy (PPPD) with pancreaticogastrostomy (PG) recon- diagnosed, AIP responds well to steroid therapy, but can struction more than 12 months after the procedure. recur in either the pancreas or biliary system. The inability METHODS: 13C-MTG-T (200 mg 13C-MTG, 20 g fat, to accurately distinguish between these two diseases leads and breath samples over 7 hours) was performed for 52 many AIP patients to undergo initial pancreaticoduodenec- patients undergoing PPPD with PG reconstruction and 12 tomy. While a 25% disease recurrence rate following steroid healthy volunteers, forming our control group. Pancreatic therapy in AIP is well established, disease recurrence rates exocrine insuffi ciency was defi ned as percent of cumula- following initial pancreaticoduodenectomy (PD) remains tive 7-hour 13CO2 exhalation (% dose 13C cum 7 h) <5%, unknown. assessed by 13C-MTG-T. Sections from the surgical pan- METHODS: With IRB authorization, 10 patients over a creatic cut margin were used for histological assessment. 10 yr period (1999–2009) with pathologically confi rmed The degree of pancreatic exocrine cells was calculated as AIP treated with PD were identifi ed. The study group was ratio of the pancreatic exocrine cells area to total area mea- matched against two comparison groups of patients with sured in the entire section. We analyze the relationship idiopathic chronic pancreatitis (CP) or PA. Clinical presenta- between 13C-MTG-T as a measure of pancreatic exocrine tion, operative variables, and postoperative clinical courses insuffi ciency postoperatively and the degree of pancreatic were analyzed. Long-term follow-up, along with quality exocrine cells by histology as well as the development of of life (QOL) data using a validated instrument {Gastroin- diabetes mellitus (DM) as a measure of pancreatic endo- testinal Symptom Rating Scale (GSRS)} given by structured crine insuffi ciency. telephone survey were analyzed. Appropriate statistical tests RESULTS: % dose 13C cum 7 h was signifi cantly lower in were applied for nominal and ordinal variables. patients with PPPD (6.8 ± 4.8%) than in healthy controls RESULTS: The AIP group was 50% male with a mean age of (15.5 ± 6.0%; P < 0.01). Pancreatic exocrine insuffi ciency 62 (40–77) yrs. Presenting symptoms were similar between assessed by 13C-MTG-T (% dose 13C cum 7 h < 5%) was the AIP and PA groups. All groups (AIP, CP, PA) had similar observed in 20 patients (38%) in PPPD group but none in gland morphology on radiographic imaging. Fifty percent the control group. Of the 52 patients undergoing PPPD, of the AIP group had atypia on preoperative FNA biopsy. the histological degree of pancreatic exocrine cells was sig- No AIP pts were diagnosed preoperatively and none had a nifi cantly higher in patients with% dose 13C cum 7 h ≥ history of autoimmune diseases. No statistically signifi cant 5% (81.7 ± 5.4%) than those with <5% (67.8 ± 8.5%; P = differences were found in operative times, blood loss, peri- 0.01). Patients with pancreatic insuffi ciency (% dose 13C operative morbidity or mortality (90-day) rates between cum 7 h <5%) signifi cantly decreased body mass index groups. Mean follow-up for the AIP group was 42 (4.5–83.2) at 12 months after PPPD comparing to those with% dose months. Three AIP patients (30%) had disease recurrence: 13C cum 7h ≥ 5% (–10.9 ± 8.4% vs +0.9 ± 9%; P < 010). 2 with jaundice and 1 with pancreatitis, at a mean time of 6 patients had been diagnosed with DM prior to under- 7.7 (1.6–12.1) months postop. All 3 were treated with ste- going the procedure, and, of the remaining 46 patients, roids and 2 had an additional recurrence once the steroids 5 (11%) became diabetic after the procedure. Patients with were stopped. Six patients (60%) had no recurrence during DM demonstrated signifi cantly lower% dose 13C cum 7 h follow-up of whom 2 were treated with postoperative “pro- comparing to patients without DM (5.9 ± 4.3% vs. 10.5 ± phylactic” steroids. One patient’s recurrence status remains 5.2%; P < 0.01). unknown. Long-term rates of diabetes mellitus, pancreatic

193 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

exocrine defi ciency, and GSRS scores [AIP (N = 5); 33 (20– excluded patients who received narcotics within 7 days 59): CP (N = 3); 28 (18–45)] were similar between AIP and before their surgery in this group. All Alvimopan patients CP groups. received their fi rst dose immediately preoperatively. CONCLUSION:Preoperative diagnosis of AIP remains RESULTS: When comparing the two groups, signifi cance uncommon in our experience in patients with a pancreatic was noted for the mean length of hospital stay (P = 0.0483), head mass and no history of autoimmune disease. PD in mean time to fi rst clear liquid diet (P = 0.00212), and mean AIP is as safe an operation as it is for CP or PA. AIP recur- time to fi rst soft/solid food diet (P = 0.0406). There was no rence following PD is approximately 30%, with similar signifi cant difference noted between age, BMI, Co-morbid- long-term postoperative QOL as patients with CP. ity, and mean time to fi rst bowel movement (see Table 1). CONCLUSION: With a comparison between the Alvimo- Tu1790 pan and non-Alvimopan group, we recognize a signifi cant Alvimopan Patients Show Signifi cant Improvement in decrease in the length of hospital stay with a possible cost benefi t, due to a signifi cantly earlier intake of diet in the Recovery Post Pancreaticoduodenectomy Surgeries Alvimopan’s group. We believe with a radical procedure, Elizabeth T. Liu*, Veeraiah Siripurapu, Tanyss L. Winston, such as pancreaticoduodenectomy, Alvimopan results in Dhiresh R. Jeyarajah earlier recovery. Surgery, Methodist Dallas Medical Center, Dallas, TX INTRODUCTION: In recent publications, Alvimopan Tu1791 has been shown to improve gastrointestinal recovery in Total Pancreatectomy with Islet Autotransplantation patients who are undergoing bowel resections. We intend to see if patients undergoing Pancreaticoduodenectomies, a for Chronic Pancreatitis: Who Is Undergoing This major surgical resection, and who were administered Alvi- Radical Procedure? mopan demonstrate a signifi cant improvement in bowel Katherine A. Morgan*, Stefanie M. Owczarski, Jingwen Zhang, movement recovery, fi rst intake of clear liquid diet, and Patrick Mauldin, Amy R. Wilson, David B. Adams fi rst intake of soft/solid food diet; compared to patients not Medical University of South Carolina, Charleston, SC administered with Alvimopan. BACKGROUND: Total pancreatectomy with islet autotransplantation (TPIAT) is utilized for management of Table 1: Patients Treated with Alvimopan and No Alvimopan intractable pain due to chronic pancreatitis. Patient selec- No tion is a major factor in improving clinical outcomes. Alvimopan Alvimopan P-Value Identifying characteristics of the population undergoing TPIAT is an important step in defi ning the patient selection Number of Patients 15 30 process. Mean Age 67.6 65.3 P = 0.430 [NS] METHODS: Inpatient and outpatient data were reviewed Mean BMI 25.4 24.9 P = 0.738 [NS] retrospectively utilizing a prospectively collected database Mean Co Morbidity 2.53 2.53 P = 1.00 [NS] (TPIAT patients) and a hospital administrative database (TPIAT patients and controls). Data from 70 TPIAT patients Mean Length of Hospital Stay 12 14.6 P = 0.0483 [S] were compared to a random sampling of 140 controls (with (days) pancreatitis, total population 1,889). For all patients, data Meant Time to 1st Bowel 6 6.77 P = 0.148 [NS] were captured from January 2008 forward, allowing for Movement (days) 14 months prior to the fi rst TPIAT patient in March 2009. Mean Time to 1st Clear Liquid 6 7.63 P = 0.00212 [S] Patients were considered to have a particular co-morbid- Diet (days) ity if they had 1inpatient ICD-9 or ≥2 outpatient ICD-9s recorded in the data. ICD-9 codes captured pre and post- Mean Time to 1st soft/solid 8.67 9.9 P = 0.0406 [S] transplant were not distinguished for transplant patients. food diet (days) Non-MUSC data was not available for this analysis. Fish- *[S] Signiﬁ cant *[NS] Not Signiﬁ cant er’s exact test was used to determine differences between groups, signifi cance determined at 0.05. METHODS: From a retrospective review of 255 pancreati- RESULTS: coduodenectomy patients under a single surgeon between TPIAT patients were more likely to be women years 2005–2011, 23 patients in 2011 were given Alvimo- (p < 0.001), younger (p < 0.005) and more frequently white pan. After excluding patients who received narcotics within (p < 0.003) than controls. A higher proportion of TPIAT 7 days before their surgery and after excluding Whipple- patients had drug dependence (p < 0.0001) and depression pylorus preserving, 15 Whipple-standard patients were left (p < 0.0001), compared to controls. Conversely controls to analyze. For every one patient who was given Alvimo- more likely had hypertension (p = 0.0050) and renal failure pan, we found 2 patients who shared similar age, BMI, and (p = 0.0031). pathology diagnosis and same Co-Morbidity and pT stage. CONCLUSIONS: Patients undergoing TPIAT differ from We collected 30 patients ranging from years (2005–2011) the overall population of patients with chronic pancreatitis. who met these criteria, were not given Alvimopan, and Depression and narcotic dependence are important consid- who underwent a Whipple-standard procedure. We also erations in the selection of candidates for the procedure and are disorders which need targeted postoperative therapy.

194 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1792 Patient and Tumor Characteristics Neoadjuvant Chemoradiotherapy for Locally Advanced Age in years Pancreas Cancer Does Not Lead to Radiologic Tumor Median (range) 64 (45–78) Regression Gender:% (n) Vikas Dudeja*1, Sidney P. Walker2, Edward W. Greeno3, Eric H. Jensen1 Male 69% (11) 1. Surgery, University of Minnesota, Minnespolis, MN; 2. Radiology, Female 31% (5) University of Minnesota, Minneapolis, MN; 3Medical Oncology, Explored before neoadjuvant chemoradiation:% (n) University of Minnesota, Minneapolis, MN Yes 31% (5) INTRODUCTION: Neo-adjuvant chemo-radiotherapy No 69% (11) is proposed to improve resectability of locally-advanced/ borderline-resectable pancreas cancer (LAPC). The ability Location of tumor:% (n) of neo-adjuvant therapy to provide tumor regression has Head 69% (11) not been reported. Body 18% (3) METHODS: We reviewed pre and post treatment CT scans of patients undergoing neo-adjuvant chemo-radiotherapy Tail 13% (2) (cisplatin, interferon-alpha, 5-FU, radiation) in a phase II Tumor size (mean ± SD) clinical trial for LAPC between 2005 and 2008. Response to Pre-Treatment 3.85 ± 1.92 (NS) therapy and rates of surgical resection were assessed. Post-Treatment 3.39 ± 1.81 RESULTS: 16 patients (median age 64years, males 69%) received neo-adjuvant therapy for LAPC during 2005–08 Tumor extension at presentation:% (n) (Table). Mean tumor size before neo-adjuvant treatment Borderline Resectable 62.5% (10) was 3.85 cm. Indications for neo-adjuvant treatment Locally Advanced 37.5% (5) included one or more of the following: Involvement of superior mesenteric artery (SMA) (≤180 degree-3 patients, CA 19–9 levels: >180 degree-1 patient), celiac axis (CA) (≤180 degree-2 Pre-Treatment 1436 ± 772 (NS) patients, >180 degree-3 patients), hepatic artery (HA) (>180 degree-6 patients), and/or superior mesenteric vein/por- Post-Treatment 772 ± 220 tal vein (SMV/PV) (≤180 degree-6 patients, >180 degree-7 Tumor density in Hounsfi eld units patients). Regression of major vascular involvement, i.e. Pre-Treatment 60.4 ± 6.5 (NS) un-encasement or regression of abutment of any involved vessels was not observed in any patients. Pre-treatment Post-Treatment 58.2 ± 6.9 and post-treatment CA19-9 levels as well as tumor density Radiological Response:% (n) (Hounsfi eld units) were not statistically different. 50% of patients with borderline resectable disease (tumor involv- Regression 6.25% (1) ing ≤180 degree circumference of the SMA; short-segment Stable 56.25% (9) encasement/abutment of the common HA; or tumor-asso- Progression 37.5% (5) ciated deformity, abutment or short-segment occlusion of SMV/PV that was amenable to vascular resection and recon- Surgical resection of cancer after neo-adjuvant struction) and none of the patients with locally advanced chemoradiation:% (n) un-resectable pancreatic cancer (vascular involvement Yes 31% (5) more than that described for borderline resectable pancre- No 69% (11) atic cancer) eventually underwent surgical resection. Out of 5 patients who eventually underwent resection, 4 had Patients undergoing surgical resection classifi ed by macroscopic tumor and 1 had only microscopic tumor. tumor extension at presentation:% (n) CONCLUSION(S): Neo-adjuvant treatment does not pro- Borderline Resectable 50% (5) vide tumor regression of LAPC with major vascular involve- Locally Advanced 0% (0) ment. Patient selection for neo-adjuvant trial enrollment Pathologic response in those undergoing resection should remain focused on borderline disease which may (n = 5) have potential for surgical resection. Macroscopic tumor 4 Microscopic tumor only 1 NS: non signifi cant.

195 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1793 Tu1794 National Database Research Beyond ICD-9 Codes: Early Enteral Nutrition Support Does Not Improve Evaluating Post-Pancreatectomy Diabetes Using Postoperative Outcome in Patients After Whipple Pharmacy Claims Resection Elan R. Witkowski*1, Elizaveta Ragulin-Coyne1, Zeling Chau1, Mario Muller*, Paul Karanicolas, Natalie G. Coburn, Sing Chau NG1, Heena P. Santry1, Shimul A. Shah1, Calvin H. Law Jennifer F. Tseng1,2 Department of Surgery, Torornto, ON, Canada 1. Surgical Outcomes Analysis & Research (SOAR), University INTRODUCTION: Pancraeticoduodenectomy (Whipple of Massachusetts Medical School, Worcester, MA; 2. Beth Israel procedure) is still associated with a signifi cant postopera- Deaconess Medical Center, Harvard Medical School, Boston, MA tive complication rate. There is evidence that early enteral BACKGROUND: Large databases are central tools in nutrition support may reduce postoperative septic compli- surgical research, but the utility of certain diagnosis and cations. However, the true value of early enteral nutrition procedure codes may be limited. Diabetes can occur after support is still controversial. The aim of the present study pancreatic cancer (PC) resection, but being insulin-depen- was to investigate the postoperative outcome of Whipple dent vs. non-insulin-dependent may impact quality of patients with and without early enteral nutrition support. life more than the simple diabetes/no diabetes dichotomy PATIENTS AND METHODS: By using a prospective insti- would suggest. We demonstrate novel use of the newly tutional database, we identifi ed 202 patients from 2001 available Medicare Part D pharmacy claims as an improved through 2009 undergoing Whipple procedure. 121 patients method of describing the presence and clinical impact of matched the inclusion criteria such as non-pylorus preserv- post-pancreatectomy diabetes mellitus. ing Whipple and assessment by a clinical dietitian within METHODS: Patients (pts) who underwent PC resection 48 hours post-operatively. 67 of 121 (55.4%) patients between 5/1/07 and 5/1/08 were identifi ed in the SEER- received early enteral nutrition support, whereas 54 of 121 Medicare linked database, including Part D. Neuroendo- (44.6%) patients had no early nutrition support (control crine pts, pts who died during their index hospitalization, group). Postoperative course, morbidity and mortality were and pts without continuous Part D were excluded. Claims recorded and analyzed. for insulin and oral hypoglycemic medications were iden- RESULTS: No signifi cant differences were found in the tifi ed during three intervals: (1) four months prior to postoperative course of the patients. Median length of operation until the day prior to operation, (2) postopera- hospital stay was 15 in the early nutrition support group tive day 0–60, and (3) >60 days after operation. Based on compared to 14 days in the control group. Postoperative preoperative diabetes status, probabilities of developing leak rate was 13.8% with and 14.8% without early enteral oral-med-dependent or insulin-dependent DM were calcu- nutrition support (P = 0.964). 11 (13.4%) patients in the lated. These results were compared to results determined by early enteral support group developed postoperative organ ICD-9 diagnosis code. failure compared to 9 (11%) in the control group. Overall RESULTS: After screening 455 patients, a cohort of 123 mortality was 4.9%. There was no difference in mortality patients met the inclusion criteria. Using ICD9 codes, 53 within the two groups (4% vs. 5%, P = 0.881). 33 patients patients (43.1%) were identifi ed as having preoperative (33.3%) in the control group needed total parenteral nutri- diabetes, of whom 37 (30.1%) had preop claims for dia- tion initiation which was signifi cant higher compared to betic medications. All patients who received treatment had the 9 patients (13.4%) in the early nutrition support group an ICD9 diabetes diagnosis coded. Among these patients, (P < 0.05). 29 (23.6%) took oral hypoglycemics and 19 (15.5%) took CONCLUSION: Early enteral nutrition support is not asso- insulin preoperatively, with some overlap between groups. ciated with lower rates of postoperative morbidity and mor- Postoperative diabetes (>60 days) was examined in 114 tality and does not enhance postoperative recovery after patients with survival suffi cient for analysis. Using ICD9 Whipple resection. However, TPN initation is less likely codes, 75 patients (65.8%) were identifi ed as diabetic. Part in the early enteral nurtrion support group and might be D claims indicated that 67 (58.8%) never required medica- therefore usefull to reduce risks associated with TPN. tion, 19 (16.7%) required only oral hypoglycemics, and 28 (24.6%) insulin. Only 13 patients (11.4%) developed a new insulin requirement. CONCLUSIONS: Administrative database research is limited by the quality and clinical relevance of available data. Our pilot study demonstrates a novel use of outpatient pharmacy claims to defi ne medication-dependent diabetes after pancreatic cancer resection. The utilization of pharmacy claims may augment researchers’ ability to detect the presence of various diseases and ascertain both their clinical relevance and potential quality of life impact.

196 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Clinical: Small Bowel Tu1797 Early Complications Following Diverting Loop Tu1795 Ileostomy: An Audit of 182 Consecutive Patients with a Special Emphasis on Preoperative Risk Stratifi cation Surgical Therapy for Gastrointestinal Stromal Tumors Alexandre Descloux1,3, Annelies Schnider2, Markus Weber2,1, (GIST) of the Duodenum *1,2 * Matthias Turina Jens Hoeppner , Goran Marjanovic, Birte Kulemann, 1. University of Zürich, Zürich, Switzerland; 2. Surgery, Triemlispital, Frank Makowiec, Ulrich T. Hopt Zurich, Switzerland; 3. Surgery, Kantonsspital Baden, Baden, Department of Surgery, University of Freiburg, Freiburg, Germany Switzerland BACKGROUND: GIST of the duodenum are rare and rep- INTRODUCTION: Diverting loop ileostomy is commonly resent only a small subgroup of all GIST. Up to now, various used for a variety of indications in general surgery and surgical procedures have been described for their treatment. is generally considered a safe technique. However, some Both radical resections by pancreaticoduodenectomy and patients develop ostomy-related complications necessitat- limited local resections are performed. This retrospective ing revision surgery or early ostomy closure. The aim of analysis was conducted for the evaluation of the results of this study was to better defi ne the incidence and nature of radical and limited resections for duodenal GIST. early complications in relation to specifi c risk factors, and METHODS: We retrospectively reviewed the medical to recognize patients at risk in order to avoid preventable records of all patients which were surgically treated for duo- complications. denal GIST at our medical institution between 2002 and METHODS: Single-center case-control study including all 2011. patients undergoing a protective loop ileostomy between RESULTS: Nine Patients (5M/4F) with am median age 2001 and 2009. Complications were necrosis and retrac- of 58 years were surgically treated. The median follow-up tion, peristomal infection, parastomal herniation, bowel period was 45 month (range 6–111 month). Most often obstruction, and individual problems related to postopera- the initial symptom was gastrointestinal bleeding in 5 of tive ostomy care. Risk factors analyzed included age, gen- 9 patients (56%). Tumors were found in all 4 parts of the der, urgency of surgery, underlying pathology, body mass duodenum, with most frequent location at the descend- index, steroid use, diabetes mellitus, alcohol abuse, previ- ing part of the duodenum in 4 of 9 patients (44%). In one ous abdominal operations, dementia, renal insuffi ciency, patient the resection of the GIST was done by pancreati- infl ammatory bowel disease (IBD), and chronic obstructive coduodenectomy. Eight patients were treated by wedge or pulmonary disease (COPD). Univariate and subsequent segmental resections of the duodenum. One of these lim- multivariate analysis were performed using SPSS 18.0. ited resections was done minimally invasive; seven were RESULTS: 182 patients (43% female) were included, the done in open fashion. The median diameter of the tumors majority of which (68%) were admitted for elective colorec- was 54 mm (14–110 mm). Seven resections showed micro- tal resections. Early complications were recorded in 16% of scopically negative transsection margins (R0), two showed all cases (with 0% mortality), and occurred most frequently positive margins (R1). During follow up no patient devel- following emergency resections for obstructive colorectal oped local recurrence. The one patient in who underwent cancer (44.4% complications) and perforated diverticulitis pancreaticoduodenectomy died due to progressive dis- (18.7% complications). Median delay until ostomy closure ease with hepatic metastasis but without evidence of local was 74 (6–343) days in patients without and 51 (4–182) recurrence. Another patient died of cardiac disease in com- days in patients with complications. Problems with inad- plete remission. Seven out of the nine patients are alive equate ostomy care (7.7%) were the main reason for early disease-free. stoma closure. Parastomal herniation and peristomal infec- CONCLUSION: In patients with duodenal GIST, limited tion occurred in 2.7% and 2.2%, respectively. Steroid use, surgical resection with microscopically negative margins, diabetes mellitus, IBD, COPD and asthma were each associ- but interestingly also with microscopically positive margins ated with an increased risk for early ostomy complications leads to very good local and systemic disease-free survival. and premature ostomy closure. CONCLUSIONS: The incidence of early complications after ileostomy formation is high, indicating the need for well-defi ned indications for this procedure. Patients admitted for emergency surgery due to colonic obstruction are at greatest risk for ostomy-related morbidity, especially those suffering from comorbidities such as diabetes. The most frequent complication is an overwhelmed patient unable to deal safely and appropriately with his ostomy. Home support with trained ostomy nurses should be encouraged in all ostomy patients to avoid premature ostomy closure.

197 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Stomach Table 1: Subsequent Surgical Procedures and Complications After GES Insertion Tu1798 Nutrition Central Access for TPN 21 Surgical Outcomes After Gastric Electric Stimulator PEG/ Gastrostomy Tube 19 Placement for Refractory Gastroparesis Deborah Keller*1, Daniel Boucek1, Abhinav Sankineni2, Jejunostomy Tube 33 John E. Meilahn1, Henry P. Parkman2, Sean Harbison1 G-J Tube 4 1. Surgery, Temple University Hospital, Philadelphia, PA; SUBTOTAL 72 2. Medicine, Temple University Hospital, Philadelphia, PA GES Explanted BACKGROUND: Gastric electric stimulation (GES) is No Relief of Symptoms 11 used for refractory symptoms of gastroparesis. Although improvement in symptoms has been reported with GES, Mechanical Device Issues 9 few studies have described the need for additional surgery Persistent Infection 4 after placement of gastric stimulators. The aim of this study was to evaluate the surgical outcomes of a large series of Stimulator eroded through skin 3 GES at a single institution. Secondary goals were to deter- Symptoms improved 2 mine the need for additional surgery after insertion of GES. SUBTOTAL 29 METHODS: A retrospective review of a prospective data- Revisions/ Surgical Complications base was performed for patients undergoing GES placement for refractory gastroparesis at our single institution Revision of stimulator in subcutaneous pocket 21 from 10/2000 to 10/2011. Demographic and clinical infor- Incisional hernia repair 4 mation was gathered from medical records. Battery failure 3 RESULTS: 266 patients had a GES implanted at our insti- Laparotomy for Small Bowel Obstruction 2 tution over the 11-year period. Medical records were available for 233 patients, with long-term outcome data for 74. Lead erosion 2 All had delayed gastric emptying and refractory symptoms Colectomy for Colitis 1 despite aggressive medical therapy. The mean age was 38 years (range 18–67), and 80% were female. The mean BMI Takedown enterocutaneous ﬁ stula 1 was 24.8 ± 6.7 (SD), and pre-operative albumin level was SUBTOTAL 34 4.1 ± 0.7 (SD). The most frequent etiologies for gastropa- Non-Operative Surgical Complications resis were idiopathic (51.1%) and diabetic (42.9%). Com- mon co-morbidities included depression/ anxiety (14.9%), Wound Infection 5 chronic renal insuffi ciency (8.1%), and treated hypothy- Small Bowel Obstruction 4 roidism (6.8%). GES were placed by 1 of 2 surgeons using Hematoma 2 a standardized surgical procedure and post-operative protocol. Mortality during the follow-up period was 2.1%, all Bleeding from Gastrostomy tube site 1 unrelated to the procedure. The overall clinical outcomes Suture Granuloma 1 for GES were favorable, with 70% of patients reporting improved symptoms. However, in a subset of patients, read- Enterocutaneous Fistula 1 missions were common, with 90/233 patients re-presenting SUBTOTAL 14 mainly for gastroparetic symptoms. The mean number of re-admissions for these 90 patients was 4.4 (range, 1–41). CONCLUSIONS: Although there is symptomatic improve- Additional surgery for nutrition was common- 45/233 ment in most patients undergoing GES for refractory gas- patients required at least 1 procedure for nutritional access troparesis, a signifi cant number of patients (34%) required post-GES insertion. Reoperations were performed for device additional surgery after GES placement. This need for issues and surgical complications, including revision of additional surgery was most frequently for surgical nutri- GES stimulator in subcutaneous pocket (21), incisional tion (53%) for ongoing gastroparesis symptoms. Removal hernia (4), battery failure (3), lead erosion (2), and small was performed in 12% of patients and revision of the GES bowel obstruction (2). 12% of patients (29/233) had the pocket in 9% of patients. Despite these additional surger- GES explanted, mainly for continued gastroparetic symp- ies, the majority of patients report good overall outcomes toms (11), mechanical issues (9), and infection (4). for GES.

198 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1799 Tu1800 Current Problems in General and GI Surgery for Effect of Bariatric Surgery on Comorbidities vs Medical Super-Old Patients with Age over 85 Years Treatment in a Cohort of Morbidly Obese Patients: A Tatsuya Ueno*1, Michinaga Takahashi1, Shinji Goto1, Shun Sato1, Prospective Study Masanori Akada1, Kyohei Ariake1, Minoru Kobayashi1, Paolo Gentileschi*, Marco D’Eletto, Stefano D’ Ugo, Mara Chikashi Shibata2, Hiroo Naito1 Capperucci, Domenico Benavoli, Pierpaolo Sileri, Achille Gaspari 1. Surgery, South Miyagi Medical Center, Miyagi-Pref, Japan; General Surgery, University of Rome Tor Vergata, Roma, Italy 2. Surgery, Tohoku University, Sendai, Japan BACKGROUND: Aim of this study was to evaluate the INTRODUCTION: As it is being common in Japan to per- role of bariatric surgery in a population of morbidly obese form surgery in patients over 85 years old, postoperative patients versus a medical treated cohort. We prospectively complications such as pneumonia, heart failure, dementia, compared patients submitted to surgery with a cohort of and bedridden status become big problems for patients and surgically fi t patients waiting for surgery and not operated their family. Although some prognostic scoring systems for extra surgical reasons. such as POSSUM score are available, these scoring systems MATERIALS AND METHODS: We divided the patients do not precisely predict the postoperative complications. into two groups: not operated (group A) and operated Aim of the present study was to evaluate mortality and (group B). The recruitment of the patients started in Janu- morbidity after the surgery and consider surgical indica- ary 2003 and the study ended in November 2011. Median tion in super-old patients. follow-up was 29.2 months (range 13.8–105.3 months) for METHODS: We retrospectively reviewed 222 patients who group A and 38.2 months (range 11.8–106.7 months) for underwent surgery from 2003 to 2010 at the age over 85 group B. Two hundred eighty-nine patients (M = 80; F = years and analyzed postoperative mortality and morbid- 209) entered the study, 81 in group A (M = 16; F = 65) and ity rate. In our hospital, indications of surgery in super-old 208 in group B (M = 64; F = 144). In group B, we performed patients were, 1) informed consent from patient and his/ laparoscopic gastric bypass in 100 patients, laparoscopic her family and 2) good pulmonary and cardiac function to sleeve gastrectomy in 71 patients and laparoscopic gastric tolerate operation. We evaluated POSSUM score for infor- banding in 37. Mortality, variation of BMI and comorbidi- mation, and poor POSSUM score was not considered as an ties (diabetes, hypertension, obstructive sleep apnea syn- absolute contraindication. drome and need for pharmacologic treatment) have been RESULTS: Among 222 operations, emergent operations evaluated in both groups. were 114, while elective operations were 108. Diseases RESULTS: Initial BMI was 41.5 ± 5.9 Kg/m2 for group A for operation were gastric cancer in 24, colorectal can- and 42.2 ± 7.0 Kg/m2 at last follow up visit (p = 0.56). The cer in 49, cholecystolithiasis in 9, inguinal hernia in 19 difference of comorbidities in group A are shown in Table patients. Emergent operations included perforation of GI 1. Four patients in group A (4.9%) died during the follow tract for 26, acute cholecystitis for 22, intestinal obstruc- up for heart attack. tion for 21, inguinal hernia for 20, acute appendicitis for Initial BMI for group B was 46.6 ± 7.0 Kg/m2 and 30.9 ± 6.4 10, and colorectal cancer for 7 patients. Mortality and mor- Kg/m2 at the end of the follow up period (p < 0.001). Varia- bidity rates in elective surgery were 1.9% (2 patients) and tion of comorbidities during follow-up are shown in Table 1. 31.5% (34 patients), respectively, while those in emergent There was one death in group B. operation increased to 14.9% (17 patients) and 58.4% (66 patients) (p < 0.01 vs. elective operation), respectively. Pul- The difference between the two groups at last follow up monary complications were observed in 5 (1.9%) and 24 visit are shown in Table 2. (21.1%) patients in elective and emergent surgeries, respectively. In 19 patients with postoperative deaths, 15 (79.4%) suffered from pulmonary diseases including aspiration pneumonia. Mortality rate in patients with pulmonary complications increased to 51.7% in elective and emergent operations. In patients undergoing operations for upper GI tract, pulmonary complications were observed in 8.3% in elective operations and 42.9% (3/7) in emergent operations, and all 3 patients died of pulmonary complications. CONCLUSIONS: In super-old patients, mortality and morbidity rates in emergent operations were high compared to those in elective operations. These results indicate importance of preoperative estimation in super-old patients, and indication of the operation should be carefully considered in patients with poor pulmonary function.

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Table 1 Tu1801 Medical Treatment First Visit Last Follow-Up Primary Squamous Cell Carcinoma of the Stomach: Group (n° pts) Visit p Case Report and Literature Review Diabetes 18 23 0.37 Mohummed R. Khani*, Antonio I. Picon Hypertension 22 25 0.61 Surgery, Staten Island University Hospital, Staten Island, NY BACKGROUND: Obstructive Sleep 10 14 0.39 Primary gastric squamous cell carcinoma Apnea Syndrome (PGSCC) is extremely rare, it accounts for 0.2% of all gastric carcinomas with fewer than one hundred cases have been Pharmacologic 26 32 0.33 reported in the literature. treatment CASE PRESENTATION: We report a case of 70-year-old Last Follow-Up Pre-Operative After Surgery male who presented with melena and hypotension the Surgery group (n° pts) (n° pts) p same day he was discharged home after undergoing aortic valve replacement. He referred a 15 lb weight loss over few Diabetes 64 9 <0.001 months. His past medical history is signifi cant for smok- Hypertension 96 25 <0.001 ing (60 pack-year) and aortic stenosis. His physical exam was unremarkable. Esophago-gastro-duodenoscopy (EGD) Obstructive Sleep 21 2 <0.001 Apnea revealed a fi ve-centimeter ulcerated mass in the fundus of the stomach, 2 cm from gastroesophageal junction without Pharmacologic 106 29 <0.001 active bleeding. Imaging of the abdomen revealed a 7 × 4 treatment cm mass in the fundus of the stomach with no evidence of locoregional extension or distant metastasis. Biopsy Table 2 was not attempted. He was taken to the operating room and intraoperatively the mass was locally invading the Group A (81 pts) Group B (208 pts) p left hemidiaphragm. He underwent partial left diaphrag- BMI 42.2 ± 7.0 30.9 ± 6.4 <0.001 matic resection, total gastrectomy with Roux-en-Y esophago-jejunostomy and feeding tube jejunostomy insertion. Diabetes 23 9 <0.001 Histological studies revealed infi ltrating moderately differ- Hypertension 25 25 <0.001 entiated gastric squamous cell carcinoma with free margins resection, one perigastric lymph node was positive for met- Obstructive Sleep 14 2 <0.001 Apnea Syndrome astatic disease, for a T4, N1, and M0 disease. Immunohisto- chemical studies result was positive for cytokeratin 5/6, P63 Pharmacologic 32 29 <0.001 and negative for CD117, CK20, and P16. He is currently treatment undergoing chemoradiation therapy. Mortality 4 1 = 0.02 CONCLUSION: Primary gastric squamous cell carcinoma is more common in men with peak incidence in 6th decade. CONCLUSION: We observed no signifi cant changes in Most of the data available regarding PGSCC are case reports weight loss and comorbidities in group A during the follow and no clear pathogenesis of this tumor has been reported. up. In group B we observed a signifi cant reduction of BMI PGSCC is considered an aggressive tumor due to higher and all comorbidities. We observed signifi cant changes in incidence of lymphovascular and serosal invasion which BMI and comorbidities variation between the two groups. are responsible for poor prognosis. Aggressive approach In our study bariatric surgery infl uences the natural his- with radical surgical resection is recommended in the tory of morbidly obese patients, determining a reduction absence of distant metastasis. Surgery followed by com- of BMI, comorbidities and mortality. bined adjuvant chemoradiation is recommended despite the absence of adequate data to support this strategy.

200 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1802 Tu1803 Laparoscopic Bariatric Surgery Is Safe in Patients with Recurrence Pattern of Gastric Cancer After Curative Mild to Moderate Pulmonary Hypertension Gastrectomy Hernan Urrego*, William S. Richardson, James Wooldridge Wee Boon Tan* General Surgery, Ochsner Clinical Foundation, New Orleans, LA Department of General Surgery, Singapore National University BACKGROUND: Pulmonary hypertension (PH) has sig- Hospital, Singapore, Singapore nifi cant perioperative risks that may outweigh the benefi t Radical surgery with D2 extended lymphadenectomy of elective surgery. There is very little data on laprascopic together with various regimens of peri- or post-operative surgery in the setting of PH. Our objective was to look at adjuvant therapy have been shown to be effective for our outcomes of bariatric surgery in patients with PH. advanced gastric cancer. We aim to evaluate the outcomes METHODS: A retrospective review of a prospectively gath- of patients who underwent intended curative gastrectomy ered database of all bariatric procedures was conducted for in our institution and our recurrence rate and pattern. patients treated from 2007–2011. All patients with PH who All patients who underwent radical gastrectomy with cura- underwent a bariatric procedure were reviewed for their tive intent were selected from a prospective gastric cancer preoperative evaluation, intra-operative monitoring and database at the National University Hospital, Singapore. management, post-operative care, and clinic follow up. Each patient was discussed at a multidisciplinary tumor RESULTS: 809 bariatric procedures were performed from meeting where decision on adjuvant therapy was made. 2007–2011, 5 patients (0.6%), 3 males and 2 females, had Patients were followed up at regular intervals. Postopera- PH. 2 patients had Type 1 PH, 2 had Type III PH, and the tive complications and recurrence were recorded. Survival fi nal patient did not have information on the etiology. The and cause of death were confi rmed with national registry. mean PAP of the 5 patients was 40 mmHG (range 25–60). Between year 2000–2010, 645 patients with gastric cancer The mean age of the patients was 58 years of age, and were treated in our hospital. 274 patients underwent radi- the mean BMI was 52. 3 laparoscopic Roux-N-Y, 1 laparo- cal surgery with curative intent. The median age was 69 scopic sleeve gastrectomy, and 1 laparoscopic band were (range: 19–89) and 67% are males. Most tumors were in performed. Invasive monitoring, arterial line and/or pul- antrum (53%) or body (28%) and proximal tumors were monary catheter, was used in 2 patients with mean PAP found in 19% of patients. Subtotal and total gastrectomies ≥40. There were no intra-operative complications and only were performed in 70% and 30% of patients respectively. one patient had a long term complication; band slipped R0 resection was achieved in 252 patients (92%). 195 (71%) and underwent removal. The mean length of stay was 2 and 79 (29%) patients underwent extended lymphade- days and mean follow up was 8 months. Mean excess body nectomy (D2 or D1+) or limited lymphadenectomy (D1) weight loss (EBL) at 3 months was 29% (N = 5), at 6 months respectively, according to Japanese Gastric Cancer Treat- was 42% (N = 4), and at 1 year 35% (N = 2). Over an average ment Guideline 2010. There were 7 (2.5%) peri-operative of 6 months, exercise tolerance in all 3 Roux-N-Y patients deaths. Lymph nodes were harvested by pathologists and was doubled in terms of length of exercise time and dis- the median number was 25 for D2/D1+ (range: 15–64) and tance walking, and remained the same in the other two. 18 (range: 3–25) for D1 respectively. Pathological staging Postoperative pulmonary hypertension follow up with (American Joint Committee on Cancer [AJCC] 7th edition) 2d echo was only performed in one patient. A decrease of was as follows: I, 24%; II, 22%; III, 43%; IV, 10%. Peri-oper- mean PAP from 39 to 26, 1 year after surgery, without con- ative chemotherapy, postoperative chemo-radiotherapy comitant change in medical therapy was demonstrated. and postoperative chemotherapy were received by 23, 39 CONCLUSIONS: Laparoscopic surgery seems safe in and 21 patients respectively. Median follow-up was 25 patients with pulmonary hypertension without signifi cant months. Tumor recurrence occurred in 31% of our patients morbidity, mortality or increased length of stay. Invasive and the sites of recurrence were: local (29%); lymph nodes monitoring in patients with mean PAP >25 mmHG <40 (15%); peritoneum (23%); hematogenous (33%). The over- mmHG may not be necessary. Exercise tolerance improves all median survival and recurrence free survival are 25 and in most patients. EBL was modest but few patients had 1 21 months respectively. Factors predictive of recurrence year follow up. Further research is needed to determine pattern will be analyzed and the results will be presented. long term weight loss, improvement in comorbidities and Prognosis of gastric cancer remains poor despite earlier improvement in PH. detection and improvement in treatment modalities. Recur- rence is the most important factor associated with death after curative gastrectomy. Various disease and treatment factors may help to predict the pattern of recurrence and thus provide a tailored treatment guide for our patients.

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Tu1804 Tu1805 Surgical Treatment of Gastrointestinal Stromal Tumors Management of Synchronous Primary (GIST) of the Stomach: Data Analysis of the East Adenocarcinoma and Carcinoid Tumor of the Stomach German Gastric Cancer Study (“EGGC Study 02”) Maithao LE*, Rebecca Nelson, Rebecca Wiatrek, Steven L. Chen, Meyer Frank*1,5, Karsten Ridwelski2,5, Lutz Meyer3,5, Joseph Kim Uwe Schmidt6,5, Henry Ptok4,5, Hans Lippert1,5, Ingo Gastinger5 General & Oncologic Surgery, City of Hope, Duarte, CA 1. Department of General, Abdominal & Vascular Surgery, University INTRODUCTION: Patients with gastric adenocarcinoma Hospital, Magdeburg, Germany; 2. Department of General & with concurrent primary gastric carcinoid are rarely Abdominal Surgery, Municipal Hospital, Magdeburg, Germany; observed. Since little is known about the course of synchro- 3. Department of Surgery, Municipal Hospital, Plauen, Germany; nous disease, our objective was to compare the outcomes 4. Department of Surgery, Municipal Hospital, Cottbus, Germany; of patients with concurrent gastric adenocarcinoma and 5. Institute for Quality Assurance in Operative Medicine, University primary gastric carcinoid with patients harboring isolated Hospital, Magdeburg, Germany; 6. StatConsult, StaConsult, gastric adenocarcinoma. Magdeburg, Germany METHODS: Patients surgically treated for concurrent primary gastric adenocarcinoma and carcinoid tumors BACKGROUND: Within the East German Gastric Can- from1973 to 2008 were identifi ed from the Surveillance, cer Study (“EGGC 02”), 1,199 gastric tumor lesions were Epidemiology, and End Results (SEER) database. These documented. As a separate tumor entity, gastrointestinal patients were case-matched 3:1 with isolated gastric adeno- stromal tumors (GIST, n = 55) were compared with gastric carcinoma patients for year of diagnosis, age, stage, type of adenocarcinomas. The evaluation aimed, in particular, on surgery, and receipt of radiation. Clinical and pathologic early postoperative and oncosurgical outcome as a param- characteristics and survival were compared between the eter for the quality of surgical results. In near future, data two cohorts. of a re-initiated, currently ongoing study over a 3-year time period (n = approximately 300 patients) can be compared RESULTS: Our investigation identifi ed 32 patients treated to elucidate what (neo-)adjuvant treatment can addition- for concurrent gastric adenocarcinoma and primary gastric ally achieve with regard to the oncosurgical outcome of carcinoid. During the same period, 84 932 cases of isolated gastric GIST patients. gastric adenocarcinoma were diagnosed. After case-matching, patient demographics and tumor characteristics were PATIENTS AND METHODS: A systematic clinical multi- similar, with the exception of gender, whereby synchro- centre observational study design with prospective items in nous tumor patients were more likely to be female (p = a well characterized area (East Germany) was used includ- 0.038). Kaplan-Meier curves were constructed to compare ing hospitals of each level of surgical care. survival between the 2 cohorts, but no difference in sur- RESULTS: From January 01 to December 31, 2002, data of vival was observed (5-year survival, 60 vs 47 months, p = 1,199 patients with gastric tumor lesions from 80 hospitals 0.52). Univariate and multivariate analysis showed that were documented. Ninety fi ve% of 1,139 gastric carcino- synchronous disease was not a predictor of poor outcome mas were preoperatively diagnosed with histologic inves- (p = NS). tigation whereas this rate was 47.3% in 55 GISTs. 61.8% of CONCLUSIONS: Development of synchronous gastric the GIST patients were treated with local wedge resections adenocarcinoma and carcinoid tumor is extremely rare. or with a limited approach. The rate of radical surgical Nevertheless, our results indicate that patients with syn- interventions (30%; e.g., gastrectomy, multivisceral resec- chronous disease fare similarly to patients with isolated tion) was relatively high. The surgical results achieved by gastric adenocarcinoma. Therefore, our results suggest operation alone showing i) a hospital mortality of 1.8%, that the prognosis of patients with synchronous disease and ii) a 5-year-survival rate of 78% (follow-up investiga- is primarily driven by appropriate management of gastric tion period, 67 months; including 90.9% of all patients) adenocarcinoma. compared with gastric carcinoma (30.6%, 70 months and 87.4%, respectively) are acceptable. DISCUSSION: Results achieved by surgical intervention alone as reported can serve as an appropriate basis for the initiation and comparison of multimodal therapeutic concepts with the (neo-)adjuvant use of the tyrosin kinase inhibitor Imatinib according to the currently relevant guidelines (as being expected soon by novel data on patients treated surgically including [neo-]adjuvant protocols). Related to the exclusively surgical aspects of gastric GIST treatment, it appears to be indicated to achieve a reduction of the, in part, surgical overtreatment using such protocols including a signifi cant improval of the preoperative diagnostic rate in clarifying gastric GIST appropriately for an adequate therapeutic approach.

202 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Tu1806 Tu1808 Laparoscopic Resection of Gastric Gastrointestinal Does Helicobacter Pylori Migrate with Proton Pump Stromal Tumours Is Safe and Effective Inhibitor Use? Rabih Wassel*1, Yasser Abdulaal1, Haythem Ali1, Ashraf M. Rasheed2 Joshua W. Long*, Ayman Obeid, Manasi S. Kakade, 1. Maidstone Cancer Centre, Maidstone Hospital, Maidstone, United Jayleen M. Grams, Allison A. Gullick, Mary T. Hawn Kingdom; 2. Gwent Institute for Minimal Access Surgery, Royal Gwent Surgery, UAB, Birmingham, AL Hospital, Newport, United Kingdom INTRODUCTION: Laparoscopic paraesophageal hernia INTRODUCTION: Minimal access surgical therapy is the (PEH) repair has classically been performed using a fun- emerging gold standard technique for treatment of gastric doplication as an adjunct to aid in resolution of refl ux. gastrointestinal stromal tumours (GISTs). Despite the above However, fundoplication can be a morbid procedure with there continue to be lack of guidance or standardisation of long term complaints of bloating and dysphagia. Optimal the techniques. performance of the fundoplication requires the wrap to be OBJECTIVES: To assess the safety, effectiveness and func- around the esophagus and in the abdominal cavity. Slipped tional outcomes of a minimal access surgical strategy for and herniated fundoplication following PEH repair contrib- gastric GISTs. ute to symptoms associated with recurrence. Alternatively, lateral gastropexy (LGP) can be used with PEH repair. The METHODS: Thirty eight symptomatic gastric GISTs diag- purpose of this study was to determine whether LGP was nosed during the years 2006–2010 satisfi ed the inclusion criteria for minimal access surgical resection. All proce- an effective alternative in preventing postoperative mor- dures were performed according to an agreed surgical strat- bidity and still promoting resolution of symptoms when egy based on the anatomical location of the gastric lesions. compared to fundoplication. The size, site, histology, resection margin, complications, METHODS: A retrospective review was performed of hospital stay, functional outcome, recurrence rate, survival patients who underwent PEH repair with fundoplication and mutational analysis of the 38 consecutive resections ± LGP (45%) or with LGP alone (55%) from 2005 to 2011. were maintained on a prospective computerised database. Inclusion criteria consisted of all patients with symptom- All entered data was validated by the operating surgeon atic type II, III or recurrent PEH. There were 71 patients and the reporting pathologist. who met inclusion criteria. Preoperative GI symptom score RESULTS: Twenty nine patients (76%) underwent a lap- surveys, esophogram, and esophagogastroscopy were used aroscopic extra-gastric tangential resection while seven to determine clinical symptoms and to diagnose gastro- patients (18%) underwent a posterior trans-gastric resec- esophageal refl ux, esophageal dysmotility, and aspiration. tion, and two had a distal gastrectomy (5%). There were no Postoperatively, GI symptom score surveys were used to conversions to open, no major intra-operative complica- evaluate for clinical symptoms and repeat esophogram tions and no episodes of tumour rupture. There were no and/or esophogastroscopy was performed in these symp- major immediate or early complications of surgery. Com- tomatic patients. Data were then recorded and compared plete resection (R0) was achieved in 100% of cases with a using chi square analysis with SAS statistical software (ver- mean lesion size of 44 mm (range 20–90 mm). sion 9.2). There was no peri-operative (30 day or in-hospital) mortal- RESULTS: Fundoplication at the time of PEH was more ity and the mean post-operative length of stay was 5.6 days. The median follow-up for the surviving population (37/38 frequently performed in younger patients (59 ± 13 v 70 ± or 97.4%) is 24.5 months with a range of 4–77 months with- 13 years, p < 0.001), those with preoperative symptomatic out any reported dysphagia, refl ux, dumping syndrome refl ux (97% v 55%, p < 0.001), and those with a prior fun- or any CT evidence of disease recurrence. 25/26 (96.2%) doplication (44% v 21%, p = 0.035). The median length of the low risk group remain alive with a median follow of stay was 2 days for each group, and there were 11 post- up of 24.5 months (range 4–77 months). The 8 patients operative complications. Fundoplication had 2 complica- in the intermediate risk group remain alive (100%) with a tions (mean age 47 years) and LGP had 9 (mean age 72 median follow-up of 51 months (range 20–77 months) and years), but this was not statistically signifi cant. Postopera- the 4 high risk group patients remain alive (100%) with a tively, fundoplication and LGP had improvement of their median follow-up of 15 months (range 8–24 months). The preoperative refl ux symptoms (93% each), although a sig- only death in this series occurred in the low risk group at nifi cantly greater number of patients experienced early 11 months secondary to a dissecting thoracic aneurysm. complete resolution of refl ux after fundoplication (80% CONCLUSION: Most gastric GISTs are resected by simple v 48%, p = 0.011). LGP demonstrated a trend toward an tangential excision. Lesions close to gastro-oesophageal absence of postoperative dysphagia (76% v 54%, p = 0.063) junction are best suited for laparoscopic intra-gastric or chest pain (81% v 63%, 0.099), although these were not excision to ensure complete resection while maintaining signifi cant. LGP did result in decreased complaints of post- oesophageal patency and sphincteric competency. Juxta- procedure nausea and/or vomiting (5% v 33%, p = 0.047). pyloric endophytic lesions are best treated via an anterior CONCLUSION: In older patients with diminished esopha- gastrotomy or by extra-gastric tangential excision if exo- geal motility and non-refl ux dominant symptoms, PEH phytic. This anatomic and function-based strategy for min- repair without fundoplication does not result in complaints imal access surgical resection of gastric GISTs conserve the of post-operative refl ux. Consideration for LGP with PEH organ and preserve its function leading to a quicker recov- repair may be warranted to minimize postoperative mor- ery and a better quality of life without breaching oncologi- bidity associated with fundoplication in elderly patients. cal principles.

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Translational Science: Colon-Rectal In those experiments, complete remission was obtained in 4/7 cases. Response to other drugs was again individual between xenografted cells. Tu2062 CONCLUSION: Here, we describe the successful establish- Establishment and Characterization of Three ment of three new MSI+ CRC cell lines. These well-char- Microsatellite-Instable Cell Lines Derived from acterized and low-passage lines provide a useful tool for subsequent investigating the biological characteristics of Sporadic and Inherited Primary Colorectal Carcinomas MSI+ CRCs, both of sporadic and hereditary origin. Addi- Claudia Maletzki1, Ernst Klar1, Friedrich Prall2, Michael tionally, matched EBV-transformed B cell lines are available Linnebacher*1 for comparative genetic studies. 1. General Surgery, University of Rostock, Rostock, Germany; 2. Institute of Pathology, University of Rostock, Rostock, Germany Tu2064 BACKGROUND: Microsatellite instability (MSI) is detected Development of a Novel Murine Model of Portal Vein in about 15% of all colorectal cancers (CRC). In order to identify new biomarkers that potentially allow for evalu- Catheterization as a Strategy to Analyze ating the response to new cytostatic drugs, pre-clinical in Liver-Directed Therapies for Colorectal Cancer vitro models are mandatory. We here describe the success- Metastasis ful establishment and comprehensive characterization of Joe Valentino*1,2, Piotr Rychahou1,2, W.C. Mustain1,2, B. Mark three patient-derived MSI+ cell lines along with their cor- Evers1,2 responding xenografts. 1. Markey Cancer Center, University of Kentucky, Lexington, KY; 2. METHODS: Three primary CRC cell lines (HROC24, Department of Surgery, University of Kentucky, Lexington, KY HROC87, and HROC113) were established from a total of INTRODUCTION: Colorectal cancer (CRC) is the second ten clinicopathological well defi ned MSI+ cases. Cells were leading cause of cancer deaths in the US. Despite prog- comprehensively characterized by phenotype, morphol- ress in earlier stage disease, survival has only minimally ogy, growth kinetics and molecular profi le. Subsequently, improved in patients with systemic metastases (Stage IV), the response to clinically relevant chemotherapeutics was which occur primarily to the liver; therefore, more effec- examined in vitro and in vivo. tive and targeted therapies are required. Small interfering RNA (siRNA) provides a highly selective method to target mutated pathways; however, its use is complicated by the inability to specifi cally target tumor cells. The purpose of this study was to: i) develop a novel murine model of portal vein catheterization for the chronic delivery of therapeutic agents to liver metastases, and ii) determine the utility of epithelial cell adhesion molecule (EpCAM) as a selective target for siRNA delivery to CRC metastases. METHODS: i) To establish a chronic portal vein catheterization model, a midline laparotomy was performed in 2 mo-old Balb/C mice and a 1.2F catheter inserted into the portal vein. Distribution of portal venous fl ow and catheter patency was evaluated using fl uorescently-labeled micro- Morphology of established MSI+ cell lines spheres. Uptake of siRNA within the liver was tested using DY-547-labeled siRNA followed by IVIS imaging 4h post RESULTS: Two of the MSI+ cell lines derived from sporadic injection. For metastatic studies, splenic injection of CT26 CRC showing CIMP-H (HROC24: APCmut p53wt, K-raswt, murine colon cancer cells, transfected with a luciferase vec- B-rafmut, HROC87: APCwt p53mut, K-raswt, B-rafmut), tor, was performed and metastasis confi rmed 10d later by whereas one cell line (HROC113: APCwt p53wt, K-rasmut, IVIS imaging; siRNA delivery to liver metastases was con- B-rafwt) was HNPCC-associated. All cell lines were char- fi rmed using DY547-labeled siRNA and fl uorescent micros- acterized as epithelial (EpCAM+, CEACAM+) tumor cells copy. ii) The presence of EpCAM was evaluated using IHC secreting different levels of cytokines. Response to chemo- staining of microarrays containing a total of 89 normal therapeutics was different between cell lines when analyz- colon samples, 129 primary CRCs, 4 liver metastases and a ing in vitro and in vivo. Generally, the HNPCC-derived normal liver specimen. HROC113P cells tended to be more resistant than the RESULTS: i) Fluorescence was noted throughout the sporadic MSI+ lines in vitro. However, when tested in majority of the liver following injection of the micro- nude mice, most pronounced effects were observed for spheres thereby confi rming excellent distribution; micro- HROC113P, especially following gemcitabine treatment. sphere injection at 2 wks confi rmed catheter patency. Portal

204 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

venous injection of DY547-labeled siRNA demonstrated a high level of fl uorescence throughout the entire liver. In the metastatic model, fl uorescent microscopy confi rmed the presence of siRNA within the liver metastases demonstrating effective delivery to metastatic lesions. ii) EpCAM staining was absent in normal hepatocytes; mild staining was present in the biliary radicals. All primary CRCs and liver metastases stained strongly for EpCAM. CONCLUSIONS: Liver directed therapy provides an effective method for the delivery of siRNA to CRC metastases. Furthermore, the presence of EpCAM on the cell surface of CRC metastases, but not normal liver, may provide a method to selectively target hepatic metastases of epithelial origin. This targeted delivery, combined with the specifi c effects of siRNA, would provide a highly selective therapeutic strategy for treatment of CRC metastasis. Figure 1 Translational Science: Esophageal

Tu2065 In Rats After Esophagojejunostomy, Refl ux Esophagitis Is Accompanied by the Expression of SOX-9 in Basal Cells of the Squamous Epithelium and in Barrett’s Metaplasia Thai H. Pham*, David H. Wang, Robert M. Genta, Shelby D. Melton, Chunhua Yu, Stuart J. Spechler, Rhonda F. Souza, William Neumann Surgery, North Texas VAMC; UT Southwestern Medical Center, Dallas, TX INTRODUCTION: Metaplasia involves the change from one adult cell type into another that is phenotypically dif- Figure 2 ferent, but that is often of similar embryonic origin. The embryonic esophagus initially is lined by columnar cells RESULTS: At 8 weeks after EJ, erosive esophagitis with that are replaced by squamous cells as maturation proceeds. prominent squamous basal cell and papillary hyperplasia Barrett’s metaplasia involves the change from esophageal was present in all animals. In addition, some of the squa- squamous cells back into columnar cells in the setting of mous cells appeared to produce mucin, which was present gastroesophageal refl ux disease. SOX-9, a transcription fac- both within and between cells. At 8 weeks, non-dysplastic tor that regulates the development of columnar cell mor- Barrett’s metaplasia, dysplastic Barrett’s metaplasia, and phological features, is expressed in Barrett’s metaplasia and adenocarcinoma were found in 4, 3 and 1 of the 5 rats, in the mouse embryonic, columnar-lined esophagus, but respectively (Figure 1B-D). Similar histologic fi ndings were not in the normal adult squamous-lined esophagus. Fur- seen at the later time points but not in sham-operated ani- thermore, forced expression of SOX-9 in cultured esopha- mals (Figure 1A). SOX-9 was expressed by basal cells of the geal squamous cells induces a columnar phenotype. We squamous epithelium close to the EJ anastomosis (Figure sought to determine whether SOX-9 expression is involved 2A), but not in squamous epithelium further from the anas- in the development of Barrett’s metaplasia in rats that have tomosis. Intense expression of SOX-9 was detected in areas refl ux esophagitis induced by esophagojejunostomy (EJ). of non-dysplastic Barrett’s metaplasia (Figure 2B). Control METHODS: Groups of 5 Sprague-Dawley rats were sacri- animals did not show any esophageal SOX-9 expression. fi ced at 8, 10, 16, and 24 weeks after EJ. The distal esophagus CONCLUSIONS: In rats after esophagojejunostomy, the was removed, sectioned, paraffi n-embedded and mounted development of refl ux esophagitis is accompanied by on slides, which were stained with H&E for histological eval- expression of SOX-9 in the basal cell layer of esophageal uation; immunohistochemistry was performed to determine squamous epithelium near the anastomosis. In addition, SOX-9 protein expression. We evaluated the specimens for SOX-9 is expressed in Barrett’s metaplasia in this rat model. 1) squamous basal cell and papillary hyperplasia, 2) Barrett’s These data suggest that this is a relevant model for studying metaplasia with and without dysplasia, and 3) adenocar- the role of SOX-9 in the development of Barrett’s esopha- cinoma. SOX-9 expression was assessed only in squamous gus and esophageal adenocarcinoma. epithelium and in non-dysplastic Barrett’s metaplasia. Sham- operated animals were used as controls.

205 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu2066 Translational Science: Other AKT Expression Is Associated with Degree of Pathologic Response in Adenocarcinoma of the Esophagus Treated Tu2067 with Neoadjuvant Therapy Nurses Attitudes Towards Women Surgeons Maki Yamamoto*1, Jill Weber1, Ravi Shridhar2, Sarah Hoffe2, Sharona B. Ross*1,2, Franka Co2, Krishen Patel2, Kenneth Luberice2, Khaldoun Almhanna1, Richard Karl1, Ken L. Meredith1 Harold Paul2, Alexander S. Rosemurgy2 1. Gastrointestinal Oncology, Moffi tt Cancer Center, Tampa, FL; 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa General 2. Radiation Oncology, Moffi tt Cancer Center, Tampa, FL Hospital, Tampa, FL OBJECTIVE: Neoadjuvant chemoradiation (NCRT) has INTRODUCTION: Best surgical care involves a team become standard in the treatment of locally advanced approach; nurses are an integral part of the team. Inter- esophageal cancer with survival correlated to degree of actions between surgeons and nurses impact the working pathologic response. The activation of the PI3K/Akt/mTOR environment and, potentially, quality of care. Given the pathway plays an important role in tumorigenesis and growing number of women surgeons, this study was under- resistance to anticancer drugs. The aim of this study was taken to determine the attitudes of nurses towards women to elucidate the role of the Akt/mTOR pathway in chemo- surgeons. resistance and the prognosis of patients with esophageal adenocarcinoma cell carcinoma (AC) who received NCRT. METHODS: Nurses in a tertiary care university-affi liated hospital were queried about their attitudes toward women METHODS: After IRB approval, a prospective trial was surgeons utilizing a validated questionnaire. instituted in which patients with locally advance esophageal requiring NCRT were consented for endoscopic biop- RESULTS: 135 nurses, 93% women and 80% Caucasian, sies of normal and tumor tissue prior to instituting therapy. were queried; 60% had been nurses for more than 10 The tissues underwent gene expression profi ling using the years and 25% for 1–5 years. Relative to men surgeons, Affymetrix 133 Plus 2.0 Gene chip. SAM method was used 60% of nurses believe that women surgeons interact dif- to analyze signifi cant differentially expression of AKT ferently with them and 86% feel women surgeons are as within normal and tumor tissue. Expression was then cor- reliable. 60% of nurses believe men surgeons have better related to degree of pathologic response. All patients were doctor-nurse relationships. Relative to men surgeons, 79% treated with NCRT followed by esophagectomy. Pathologic of nurses feel women surgeons are “good surgeons”, 80% complete response (pCR) was defi ned as no residual tumor, feel women surgeons are confi dent in their skills, and 49% partial pathologic response (pPR) as a 50% reduction in believe that women surgeons bring “something unique tumor size or nodal down-staging, and non-response (pNR) to Surgery.” 38% of nurses feel women surgeons have the as no difference between pre-operative and post-operative same opportunities for advancement as men, 38% feel that stage based upon endoscopic ultrasound. the discipline of Surgery is sexist against women surgeons, and 50% believe the discipline of Surgery is responsible RESULTS: Nineteen patients with adenocarcinoma had for women leaving the fi eld, which is perceived as a fre- biopsies of normal and tumor tissue that were subsequently quent event; 72% of nurses think there are too few women analyzed via microarray. Comparisons of expressions surgeons. between normal and tumor revealed consistently signifi cant overexpression of AKT in tumor tissues p = 0.007. We iden- CONCLUSIONS: A signifi cant number of nurses believe tifi ed 10 patients exhibiting pathologic complete response, women surgeons interact differently with them and 6 partial pathologic response, and 3 non-responders. When patients; the majority of nurses believe they have better comparing the expression of AKT between normal and doctor-nurse relationships with men surgeons and that tumor tissue in those ultimately designated as pCR, there women surgeons have inferior surgeon-patient relation- persisted a signifi cant over-expression of AKT in the tumor ships. Most, but not all, nurses see admirable qualities in tissues p = 01. However in analyzing the degree of expres- women surgeons; the majority of, though not all, nurses sion between pathologic response to NCRT we consistently believe women surgeons are as “good,” confi dent, capable, demonstrated a linear correlation between the expression and reliable as men surgeons. Less than half of the nurses of AKT and degree of pathologic response. Partial and non believe women surgeons bring “something unique to Sur- pathologic responders consistently had higher expressions gery”. Many nurses believe women surgeons have reduced of AKT compared to pCR with the non-responders consis- opportunities in Surgery and that Surgery is sexist against tently illustrating the highest expression of AKT. women surgeons. Most nurses believe Surgery promotes women to leave Surgery and there are too few women CONCLUSIONS: AKT is overexpressed in patients with surgeons. Nurses note discrimination in Surgery against adenocarcinoma of the esophagus. Moreover, pathologic women surgeons and a notable number, though a minor- response to neoadjuvant chemoradiation may be cor- ity, are biased against women surgeons. Intervention in related with degree of AKT expression. Additional data is the work place is warranted to improve the perception of needed to clarify this relationship further and potentially nurses towards women surgeons. add targeted therapies to the neoadjuvant regimen.

206 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA

Translational Science: Small Bowel Translational Science: Stomach

Tu2068 Tu2069 Does Small Intestinal Atresia Impact on Amino Acid Gastric Bypass and Duodenal Switch Cause Body and Monosaccharide Transporter Expression in the Weight Loss Through Different Mechanisms in Rats Newborn Gut? Yosuke Kodama*1, Helene Johannessen1, Marianne W. Furnes1, Raphael N. Vuille-Dit-Bille*1, Simone M. Camargo1, Chun-Mei Zhao1, Gjermund Johnsen2, Ronald MåRvik2, Luca Mariotta1, Tom Sasse1, Eva E. Kummer1, Schirin Hunziker1, Baard Kulseng2,1, Duan Chen1 Luca Emmenegger1, Ueli MöHrlen2, Martin Meuli2, 1. Department of Cancer Research and Molecular Medicine, NTNU, FrançOis Verrey1 Trondheim, Norway; 2. Department of Surgery, St. Olav’s Hospital, 1. Institute of Physiology, University of Zurich, Zurich, Switzerland; Trondheim University Hospital, Trondheim, Norway 2. Pediatric Surgery, Childrens Hospital of Zurich, Zurich, Switzerland BACKGROUND/AIM: It is still a challenge how to select BACKGROUND: Intestinal segments distal to congenital the most suitable surgical procedure for each individual atresia have been suggested to be immature due to lack of obese patient. Both gastric bypass (GB) and duodenal switch luminal access of amniotic fl uid (before birth) and nutri- associated with sleeve gastrectomy (DS) have been widely tion (after birth). Whether the concomitant defi ciency of used as bariatric surgery, and DS appears to be superior to luminal amino acids (AA) and glucose (Glc) has an impact GB, particularly for morbid obesity. The aim of the present on small intestinal amino acid- and glucose transporter study was to compare these procedures with respect to the expression, has never been tested. mechanisms leading to body weight loss in rats. PATIENTS AND METHODS: We therefore analyzed pro- METHODS: Male Sprague-Dawley rats were subjected to tein- (by immunofl urescence) and mRNA (by Real time GB, DS, or laparotomy (as controls) and followed for 2–14 RT-PCR) expression of several AA- and Glc transporters weeks by an open-circuit indirect calorimeter composed in proximal and distal to small intestinal atresia in human comprehensive laboratory animal monitoring system and newborns. To assess transporter function, we measured adiabatic bomb calorimeter. radiolabeled AA- and Glc uptake into small intestinal RESULTS: Body weight loss was greater after DS than GB. enterozytes located proximal and distal to the atretic seg- Calorie intake in terms of kcal/day/rat, kcal/day/100 g body ment. Furthermore villus morpholgy was analyzed by weight, and kcal/meal was reduced after DS but not GB. Hematoxylin-Eosin staining. The fecal energy content (expressed as J/g) was increased RESULTS: Proximal sections showed morphological after DS but not after GB. Energy expenditure (kcal/hr/100 changes from normal intestinal architecture, consisting of g body weight) was increased during nighttime at 3 weeks villus atrophy and hemorrhages, necrotic areas and some and then during daytime at 14 weeks after GB. The energy lymphid aggregates within the lamina propria, whereas expenditure was increased both at 2 weeks (during day- distal sections showed physiologic morphology. Prelimi- time) and 8 weeks (during both daytime and nighttime) nary results indicate a similar mRNA expression distal and after DS. Respiratory exchange ratio, i.e., VCO2/VO2, was proximal to small intestinal atresia for amino acid-, dipep- unchanged after GB, but reduced after DS. Serum ghrelin tide-, monosaccharide- and fatty acid transporters, as well levels were reduced at 3 weeks after GB but no longer after- as for genes belonging to the Renin Angiotensin System wards. Serum CCK levels were greatly increased at least at (RAS). Protein expression of the amino acid transporter 8 weeks after DS. B0AT1 and its accessory RAS Protein Angiotensin Convert- CONCLUSION: GB induced body weight loss by increasing Enzyme 2 (ACE2), was similar in proximal- and distal ing energy expenditure, whereas DS induced body weight segments. Radiolabeled uptake measurements showed a loss by reducing food intake (probably due to hyperCCK- slight decrease in proximal sodium-independent Glucose- emia), causing malabsorption, and increasing both fat and Glutamine uptake, when compared to distal transport. metabolism and energy expenditure. CONCLUSIONS: With respect to the genes and proteins ACKNOWLEDGEMENTS: The research leading to these tested, the absence of intestinal continuity in case of Small results has received funding from the Central Norway Intestinal Atresia seems not to affect epithelial gene and Regional FUGE programme, Central Norway Regional protein expression or function. This indicates amino acid- Health Authority, and the European Union Seventh Frame- and monosaccharide transporter development indepen- work Programme (FP7/2007–2013) under grant agreement dently of luminal components. n°266408.

207

2013 ANNUAL MEETING

Be sure to join us for next year’s Annual Meeting— mark your calendars now!

May 17–21, 2013, Orlando, FL

SSAT 500 Cummings Center, Suite 4550 Beverly, MA 01915 Telephone: (978) 927-8330 Facsimile: (978) 524-8890 E-Mail: [email protected] Web Site: www.ssat.com SCHEDULE-AT-A-GLANCE All rooms at San Diego Convention Center unless otherwise indicated.

indicates a ticketed session requiring a separate registration and fee.

FRIDAY, 5/18/2012 10:00 AM – 11:15 AM PLENARY SESSION IV 27b 7:30 AM – 2:30 PM RESIDENTS & FELLOWS RESEARCH CONFERENCE 28ab 10:00 AM – 11:15 AM QUICK SHOTS SESSION I 26ab (by invitation only) 10:00 AM – 11:15 AM VIDEO SESSION III: HPB & FOREGUT VIDEOS 28cd 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 20a SATURDAY, 5/19/2012 Functional Disorders of the Esophagus 8:00 AM – 4:35 PM MAINTENANCE OF CERTIFICATION COURSE 28abcd Sponsored by: SSAT, AGA, ASGE Evidence Based Treatment of 11:15 AM – 12:00 PM DORIS AND JOHN L. CAMERON GUEST ORATION 28ab Hepatopancreatobiliary Diseases Bringing Health Information to Life 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 6a 12:00 PM – 2:00 PM POSTER SESSION II (non-CME) Halls C-G (ASGE-accredited) 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Treatment of Early Gastrointestinal Cancer: Cystic Tumors of the Pancreas: To Operate or Not? 9 When is it Safe? Diverticulitis: Two and Out or Not? 10 Sponsored by:ASGE, SSAT 2:15 PM – 3:15 PM QUICK SHOTS SESSION II 28ab 10:30 AM – 12:00 PM DDW COMBINED TRANSLATIONAL SYMPOSIUM 7ab 2:15 PM – 3:45 PM CONTROVERSIES IN GI SURGERY B 28cd (AGA-accredited) Debate 3: Ban the Band? Which is the Best Probiotics in Health and Disease Operation for Morbid Obiesity? Sponsored by: AGA, AASLD, ASGE, SSAT Debate 4: 360 vs. Partial Fundoplication: Which is the Standard for GERD? SUNDAY, 5/20/2012 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20a 7:45 AM – 8:15 AM OPENING SESSION 28ab (AGA-accredited) Multidisciplinary Management of Complicated 8:15 AM – 9:15 AM PRESIDENTIAL PLENARY A (PLENARY SESSION I) 28ab Crohn’s Disease 8:30 AM – 10:00 AM DDW COMBINED CLINICAL SYMPOSIUM 31abc Sponsored by: AGA, SSAT, ASGE (ASGE-accredited) 2:15 PM – 4:00 PM PLENARY SESSION V 27b Management of the Patient at High Risk for Colon Cancer 3:15 PM – 4:45 AM SSAT/ASCRS JOINT SYMPOSIUM 28ab Sponsored by: ASGE, SSAT Controversies in Surgery for Ulcerative Colitis 9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS 28ab 4:00 PM – 5:00 PM CLINICAL WARD ROUNDS III 28cd Relationships Matter The GI Surgeon and Endoscopy: Case Presentations Where the Endoscope Matters 10:30 AM – 11:15 AM PRESIDENTIAL PLENARY B (PLENARY SESSION II) 28ab 4:00 PM – 5:00 PM QUICK SHOTS SESSION III 27b 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 32ab (AGA-accredited) 4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc Gastrointestinal Management of the Pancreatic Cystic Neoplasms and IPMN Patient With Obesity Sponsored by: SSAT, AGA Sponsored by: AGA, ASGE, SSAT, AASLD 5:00 PM – 6:00 PM ANNUAL BUSINESS MEETING (non-CME) 28ab 11:15 AM – 12:00 PM MAJA AND FRANK G. MOODY 28ab 7:00 PM – 9:00 PM MEMBERS RECEPTION The Don Room at El Cortez STATE-OF-THE-ART LECTURE The Treatment of Obesity: How Science CAN Influence Public Policy TUESDAY, 5/22/2012 12:00 PM – 2:00 PM POSTER SESSION I (non-CME) Halls C-G 7:30 AM – 9:30 AM SSAT/ISDS JOINT BREAKFAST SYMPOSIUM 28ab Optimizing Outcomes for Our Patients: 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Data and Practice: Combining Perioperative Patient Operative Therapies for GERD: What are the Options? 28cd Management and Expert Technical Tips The Difficult Gallbladder: Tricks to Get Out of Trouble 29d 8:00 AM – 9:30 AM PLENARY SESSION VI 27b 2:15 PM – 3:45 PM CONTROVERSIES IN GI SURGERY A 28cd Debate 1: C. Difficile Colitis: Ileostomy and 8:30 AM – 10:00 AM DDW COMBINED CLINICAL SYMPOSIUM 20bc Lavage vs. Resection (AASLD-accredited) Debate 2: Is Surgical Intervention for Cystic Management of HCC: Chemotherapy, Neoplasms of the Pancreas Being Overutilized? Reduction of Tumor Load, or Transplant? Sponsored by: AASLD, SSAT 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20a Management of Fecal Incontinence 9:30 AM – 12:00 PM PLENARY SESSION VII 27b Sponsored by: SSAT, AGA, ASGE 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc 2:15 PM – 4:30 PM VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND 26ab (AGA-accredited) ADVANCED LAPAROSCOPIC GI SURGERY Can You Eliminate Barrett’s Esophagus? Sponsored by: AGA, ASGE, SSAT 2:15 PM – 4:45 PM STATE-OF-THE-ART CONFERENCE 28ab Technological Advances in the Surgical 10:30 AM – 12:00 PM SSAT HEALTH CARE QUALITY & 28cd Treatment of Colon and Rectal Cancer OUTCOMES COMMITTEE PANEL Three Ways to Bend thd Cost Curve in GI 2:15 PM – 5:00 PM PLENARY SESSION III 27b Surgery Without Sacrificing Quality 4:00 PM – 5:00 PM CLINICAL WARD ROUNDS I 28cd 12:00 PM – 2:00 PM POSTER SESSION III (non-CME) Halls C-G The Difficult Bile Duct Stone: Case Presentations and Tricks of the Trade 12:00 PM – 3:00 PM KELLY AND CARLOS PELLEGRINI SSAT/ 28ab SAGES JOINT LUNCHEON SYMPOSIUM Current Concepts and Controversies in Foregut Motility MONDAY, 5/21/2012 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS 7:30 AM – 9:15 AM VIDEO SESSION II: BREAKFAST AT THE MOVIES 28ab CBD Stones: Laparoscopic or Endoscopic? 7ab 8:30 AM – 9:30 AM CLINICAL WARD ROUNDS II 28cd Modern Staging and Treatment of Rectal Cancer 26ab Diverticulitis: Lavage and Resection— 2:00 PM – 4:00 PM BEST OF DDW 2012 (non-CME) 28cd Which Treatment When? 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc 8:30 AM – 10:00 AM SSAT PUBLIC POLICY AND ADVOCACY 27b (ASGE-accredited) COMMITTEE PANEL Endoscopic Biliary Complications: What Can You Do? Will There Be a General Surgeon When You Need One? Sponsored by: ASGE, SSAT 9:30 AM – 11:00 AM SSAT/AHPBA JOINT SYMPOSIUM 28ab Evaluation and Treatment of Benign Liver Neoplasms