THE SOCIETY FOR OF THE ALIMENTARY TRACT

54th Annual Meeting

May 17-21, 2013 Orange County Convention Center Orlando, Florida

ABSTRACT SUPPLEMENT Table of Contents

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

Sunday Plenary, Video, and Quick Shot Session Abstracts ...... 6

Monday Plenary, Video, and Quick Shot Session Abstracts ...... 22

Tuesday Plenary Session Abstracts ...... 50

Sunday Poster Session Abstracts ...... 59

Monday Poster Session Abstracts ...... 112

Tuesday Poster Session Abstracts ...... 166 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

PROGRAM BOOK ABSTRACT SUPPLEMENT

FIFTY-FOURTH ANNUAL MEETING Orange County Convention Center Orlando, Florida May 17–21, 2013 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Schedule-at-a-Glance

FRI, MAY 17, 2013 SATURDAY, MAY 18, 2013

300 208ABC Other 6:30 AM 6:45 AM 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM NAFLD DDW CCS:

11:00 AM Therapeutic 11:15 AM Approaches in 11:30 AM

11:45 AM (by invitation only) 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM RESIDENTS & FELLOWS RESEARCH CONFERENCE 1:45 PM 2:00 PM 2:15 PM MAINTENANCE OF CERTIFICATION COURSE:

2:30 PM Evidence Based Treatment of Colorectal Diseases 2:45 PM of IBD DDW CCS: 3:00 PM Endoscopic

3:15 PM Evaluation & Mgt 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM Barrett's 5:00 PM DDW CCS:

5:15 PM Controversies in 5:30 PM 5:45 PM

2 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Schedule-at-a-Glance

SUNDAY, MAY 19, 2013 Exhibit 300 308D 303ABC 304AB Other Hall 6:30 AM 6:45 AM 7:00 AM 7:15 AM 7:30 AM OPENING SESSION 7:45 AM 8:00 AM PRESIDENTIAL 8:15 AM PLENARY A 8:30 AM (PLENARY SESSION I)

8:45 AM DDW

9:00 AM COMBINED RESEARCH PRESIDENTIAL IBD FORUM: 9:15 AM ADDRESS 9:30 AM 9:45 AM 10:00 AM 10:15 AM PRESIDENTIAL 10:30 AM PLENARY B 10:45 AM (PLENARY SESSION II) Syndrome 11:00 AM DDW CCS: Tx of Metabolic

11:15 AM GUEST ORATOR as 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM MEET-THE- LUNCHEON

1:30 PM PROFESSOR 1:45 PM 2:00 PM 2:15 PM 2:30 PM

2:45 PM Mets Lesions

3:00 PM GI SURGERY of Benign DEBATES A: HIPEC; HIPEC; A: DEBATES Synch Colorectal Liver CONTROVERSIES IN CONTROVERSIES 3:15 PM DDW CCS: Mgt Cancer

3:30 PM POSTER SESSION I (authors available @ posters 12:00 PM - 2:00 PM) 3:45 PM VIDEO SESSION I

4:00 PM STATE-OF-THE-ART CONFERENCE: Evolving PLENARY SESSION III 4:15 PM Management in Pancreatic 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM

3 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Schedule-at-a-Glance

MONDAY, MAY 20, 2013 Exhibit 300 308D 303ABC 304AB Other Hall 6:30 AM 6:45 AM 7:00 AM

7:15 AM EXPERT WITH THE

7:30 AM BREAKFAST 7:45 AM 8:00 AM 8:15 AM

8:30 AM WARD Rectal CA CLINICAL Trans-Anal Surgery for ROUNDS I: 8:45 AM THE MOVIES BREAKFAST AT PANEL PUBLIC VIDEO SESSION II:

9:00 AM POLICY & 9:15 AM ADVOCACY 9:30 AM 9:45 AM 10:00 AM CA Parenchymal Resection for 10:15 AM SYMPOSIUM: III Metastatic Colorectal SSAT/AHPBA JOINT JOINT SSAT/AHPBA QUICK QUICK Preservation in Hepatic 10:30 AM SHOTS VIDEO PLENARY SESSION I SESSION 10:45 AM SESSION IV Post-Op IBD Patient 11:00 AM STATE-OF- DDW CCS:

11:15 AM THE-ART in Complications 11:30 AM LECTURE 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1: Writing WRITERS MEET-THE- LUNCHEON WORKSHOP 1:30 PM PROFESSOR 1:45 PM 2:00 PM 2:15 PM 2:30 PM II QUICK QUICK SHOTS

2:45 PM SESSION Cirrhosis DEBATES B: B: DEBATES 3:00 PM GI SURGERY of Sx Risk in of Sx Risk Patients with Adenocarcinoma; PLENARY DDW CCS: Mgt Resectable SESSION V 3:15 PM IN CONTROVERSIES

3:30 PM POSTER SESSION II (authors available @ posters 12:00 PM - 2:00 PM) 3:45 PM Mgt of JOINT JOINT Disease

4:00 PM Diverticular SSAT/ASCRS 4:15 PM SYMPOSIUM: 4:30 PM III WARD WARD QUICK SHOTS Pancreas CLINICAL SESSION Cysts of the the of Cysts 4:45 PM ROUNDS II:

5:00 PM DDW CCS: Myotomy or POEM Botox, Balloon, Lap 5:15 PM Achalasia Treatment: 5:30 PM ANNUAL MEETING

5:45 PM BUSINESS

4 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Schedule-at-a-Glance

TUESDAY, MAY 21, 2013 Exhibit 308D 303ABC 304AB Other Hall 6:30 AM 6:45 AM 7:00 AM

7:15 AM EXPERT WITH THE

7:30 AM BREAKFAST 7:45 AM 8:00 AM 8:15 AM 8:30 AM B'FAST GI Leaks

8:45 AM Early Cancer PLENARY 9:00 AM Pancreatic DDW CCS: SESSION VI SSAT/ISDS JOINT

9:15 AM SYMPOSIUM: Mgt of 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM Necrosis

11:00 AM Pancreatic DDW CCS: 11:15 AM 11:30 AM PANEL & QUALITY OUTCOMES OUTCOMES PLENARY SESSION VII

11:45 AM HEALTH CARE 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM WRITERS MEET-THE- LUNCHEON 2: Reviewing WORKSHOP 1:30 PM PROFESSOR 1:45 PM 2:00 PM 2:15 PM SSAT/SAGES JOINT GI Surgery Complications GI 2:30 PM LUNCHEON SYMPOSIUM:

2:45 PM Upper from Complex Mgt & Rescue Tumors 3:00 PM Junction

3:15 PM DDW CCS: GE

3:30 PM BEST OF DDW POSTER SESSION III (authors available @ posters 12:00 PM - 2:00 PM) 3:45 PM . 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM

5 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. 6indicates a video presentation scheduled during a Plenary Session. Sunday, May 19, 2013 8:00 AM – 9:00 AM 303ABC PRESIDENTIAL PLENARY A (PLENARY SESSION I)

199 benign lesions. E3 and E4 were expressed at extremely low levels in all patients. Compared to IPMN alone, E6 levels Clinical Signifi cance of Serum COL6A3 Isoforms in were signifi cantly higher in PDA (p = 0.0036). There were Pancreatic Ductal Adenocarcinoma no signifi cant differences between E6 levels in IPMN and Christopher Y. Kang, Dierdre Axell-House, Pranay Soni, Normal sera (p = 0.59). Using a logistic regression model, Galina Chipitsyna, Konrad Sarosiek, Mazhar Al-Zoubi, Hwyda A. we found that for each increasing unit of log E6 COL6A3, Arafat, Charles J. Yeo patients are 9.5 times more likely to harbor a cancer rather Surgery, Thomas Jefferson University, Philadelphia, PA than a benign lesion, 95% CI (2.4, 38.1), p = 0.002. The area under the ROC curve, AUC, was 0.72. Knocking down E3 INTRODUCTION: Type VI collagen (COL6) forms a or E4 or E6 with isoform-specifi c siRNA resulted in reduced microfi brillar network associated with type I collagen fi brils PDA cell migration and invasion and concomitant reduc- and constitutes a major component of the prominent des- tion of the expression of several infl ammation and angio- moplastic reaction in pancreatic ductal adenocarcinoma genesis-related genes, such as MMP-9, OPN, MCP-1 and (PDA). We have demonstrated recently that a subunit of VEGF. Interestingly, knocking down any of the 3 isoforms COL6, COL6A3, is expressed in high levels in PDA tissue. resulted in increased expression of TNF-alpha. We also showed that COL6A3 gene undergoes tumor-spe- cifi c alternative splicing to produce 3 isoforms E3, E4 and CONCLUSIONS: Our data show for the fi rst time the E6 that are tumor tissue-specifi c. The aim of this study is to potential clinical signifi cance of circulating E6 COL6A3 lev- investigate the diagnostic value and clinical signifi cance of els in the diagnosis of pancreatic malignancy. Our in vitro circulating COL6A3 isoforms mRNA in PDA. data suggests a role for COL6A3 isoforms in PDA progres- sion and metastatic potential. METHODS: Serum samples were obtained from patients that underwent pancreatic resection at a single institution  between 2006 and 2009. COL6A3 levels in the sera from 200 patients with pathologically confi rmed PDA (n = = 40), Treatment Sequencing for Resectable Pancreatic intraductal papillary mucinous neoplasms (IPMN) (n = 20), Cancer: Infl uence of Early Metastases and Surgical and chronic pancreatitis (n = 10) were analyzed by real time Complications on Multimodality Therapy Completion PCR using isoform-specifi c primers for E3, E4 and E6. In Rates and Survival addition, sera from age-matched healthy volunteers were 1 2 1 analyzed (n = 30). The prediction levels for malignancy Ching-Wei D. Tzeng , Daniel E. Abbott , Jeffrey E. Lee , 1 1 1 were determined by the area under the receiver operating Peter W. Pisters , Jason B. Fleming , Jean-Nicolas Vauthey , characteristic curve (AUC). In vitro, wound healing, cell Matthew Katz1 proliferation and soft-agar colony formation assays evalu- 1. Department of Surgical Oncology, The University of Texas MD ated the functional impact of each isoform in PDA cells Anderson Cancer Center, Houston, TX; 2. Surgical Oncology, (MIAPACA-2 and ASP-C-1) transfected with isoform-specifi c University of Cincinnati, Cincinnati, OH siRNA. A panel of infl ammation- and invasion/angiogene- INTRODUCTION: Multimodality therapy (MMT) is impor- sis-related genes was also evaluated. tant to the long-term survival of patients with resectable RESULTS: Circulating E6 mRNA levels were signifi cantly pancreatic adenocarcinoma (PDAC), but its completion can (p = 0.006) elevated in PDA patients when compared to all be hindered by early cancer progression or by treatment

6 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

complications. We sought to compare the infl uence of each CONCLUSIONS: Completion of multimodality therapy of these factors on the MMT completion rates of operable is strongly associated with improved survival of operable patients with resectable PDAC treated with either a neoad- patients with resectable PDAC. Even in the highly selected Abstracts Sunday juvant (NT) or surgery-fi rst (SF) sequencing strategy. cohort evaluated in this study, early cancer progression METHODS: We retrospectively evaluated all patients and PMC negatively impacted MMT completion rates and with PDAC at our institution from 2002–2007, who had OS, particularly among SF patients. Thus, NT sequencing 1) a radiographically resectable pancreatic head tumor, 2) remains a valuable alternative to SF sequencing for tumor a performance status (PS) and comorbidities suitable for biology evaluation and patient selection. immediate surgery, and 3) a carbohydrate antigen (CA) 19-9 <1000 U/ml. MMT was defi ned as resection before or 201 after completion of planned pre- or post-operative therapy. Early Referral for 24-Hour Esophageal pH Monitoring Postoperative major complications (PMC) were defi ned as Is More Cost-Effective Than Prolonged Use of Clavien Grade ≥3. Disease progression was considered early when it developed within 3 months in SF patients or prior Proton Pump Inhibitors in Patients with Suspected to planned resection in NT patients. Reasons for and rates Gastroesophageal Refl ux Disease of failure to complete MMT, 90-day PMC, and overall sur- David Kleiman1, Toni Beninato1, Brian P. Bosworth2, vival (OS) were compared between the two cohorts. Laurent Brunaud4, Thomas Ciecierega3, Carl V. Crawford2, 2 1 1 RESULTS: 112 NT and 58 SF patients met inclusion cri- Brian G. Turner , Thomas J. Fahey , Rasa Zarnegar teria. 92/112 (82%) NT and 33/56 (59%) SF patients with 1. Surgery, New York Presbyterian Hospital – Weill Cornell Medical complete follow-up completed MMT (p < 0.001). NT College, New York, NY; 2. Medicine, New York Presbyterian patients did not complete MMT due to early progression (n Hospital – Weill Cornell Medical College, New York, NY; 3. = 13, including 8 nontherapeutic ) and PS (n = Pediatrics, New York Presbyterian Hospital – Weill Cornell Medical 7). SF patients did not complete MMT due to early progres- College, New York, NY; 4. Surgery, University Hospital Nancy, sion (n = 10), PMC (n = 6), and PS (n = 3); 4 SF patients also Brabois, France underwent nontherapeutic due to metastases. BACKGROUND: Gastroesophageal refl ux disease (GERD) affects nearly 25% of adults, but the diagnostic algorithm remains controversial. Most guidelines recommend an empiric 8-week trial of proton-pump inhibitors (PPIs), but many patients remain on PPIs for much longer periods. Twenty-four hour esophageal pH monitoring can help rule out GERD and avoid the unnecessary cost and risks of pro- longed PPI use. We hypothesized that performing pH moni- toring promptly after an 8-week PPI trial would be a more cost-effective strategy than prolonged courses of PPIs. METHODS: A cost model was created from a third-party payer perspective over a 10-year period. Average wholesale unit prices of generic and name-brand PPIs were obtained from the 2012 Micromedex Redbook®. Low-dose (20 mg daily) generic PPI and high-dose (40 mg twice daily) name- brand PPI costs were used as the low-end and high-end PPI costs, respectively. The cost of 24-hour pH monitoring and manometry was obtained from 2012 Medicare fees. Manometry was necessary to determine esophageal func- Among all patients, those who completed MMT lived lon- tion and for appropriate positioning of the pH probe. A ger than those who did not (36 vs. 11 mo, p < 0.001). The cohort of 100 patients who underwent pH monitoring at median OS durations of all NT and SF patients (NT 28 vs. an academic institution was retrospectively reviewed for SF 21 mo, p = 0.082), the subset in each cohort who com- type of GERD symptoms and duration of PPI use prior to pleted MMT (NT 36 vs. SF 36 mo, p = 0.565), and the subset pH monitoring. The sensitivity of 24-hour pH monitoring in each cohort who did not complete MMT (NT 11 vs SF 13 by literature review ranged from 30% to 96%. The cost of mo, p = 0.325) were not statistically different. unnecessary PPIs was subtracted from the cost of pH moni- toring for all patients to evaluate the cost-effectiveness. The rate of PMC did not differ between NT and SF groups (19% vs. 17%, p = 0.782). SF patients with no PMC had a RESULTS: The weekly cost of PPIs ranged from $29.06 71% (31/44) MMT completion rate vs. 25% (2/8) after PMC to $107.70, and the cost of 24-hour pH monitoring was (p = 0.014). When resected NT patients suffered PMC, there $690. The cost of PPI therapy reaches equivalence with pH was no signifi cant decrease in OS (36 vs. 30 mo, p = 0.934), monitoring after 6.4 to 23.7 weeks, depending on the PPI in contrast to the negative effect of PMC in SF patients (26 regimen. Patients who experienced esophageal and extra- vs. 10 mo, p < 0.001). esophageal GERD symptoms reported a median of 208 and

7 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

52 weeks of PPI use, respectively, prior to referral. The cohort was prescribed a total of 21,411 weeks of PPIs beyond the 202 initial 8-week trial, 32% of which were for patients who had Risk Factors Associated with 30-Day Readmissions in a negative 24-hour pH monitoring study and were therefore Major Gastrointestinal Resections unnecessary. If the sensitivity of pH monitoring was 100%, performing pH monitoring on all patients after an 8-week Kristin N. Kelly, James C. Iannuzzi, Aaron S. Rickles, PPI trial would have saved between $1,966 and $7,285 per Veerabhadram Garimella, John R. Monson, Fergal Fleming patient over 10 years. This strategy remains cost-effective Surgical Health Outcomes & Research Enterprise, Division of as long as the sensitivity of pH monitoring is above 35% Colorectal Surgery, Department of Surgery, University of Rochester (Figure 1). In this model, since patients with extra-esopha- Medical Center, Rochester, NY geal GERD symptoms were referred a median of 156 weeks PURPOSE: Preventable readmissions represent a major sooner than patients with esophageal symptoms, the cost burden on the health care system and by risk stratifying savings were less (Table 1). patients resources can be directed to prevent these costly complications. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day readmissions in gastrointestinal (GI) resections. METHODS: Inpatients undergoing major GI surgery were selected from the 2011 ACS National Surgical Qual- ity Improvement Program prospectively collected database. Procedures were classifi ed into esophageal, gastric, small bowel, large bowel, liver, and pancreatic resections using Common Procedural Terminology codes. Postoperative complications were divided into pre- and post-discharge groups by comparing time to complication and discharge. Operative times were grouped by 75th percentile (≥4 hours). Univariate analysis using Chi-square, Mann Whitney-U, and Student’s T-test were used to compare patient comor- bidities, surgical characteristics, and postoperative compli- Table 1: Estimated Range of Cost Savings Over 10-Years cations with 30-day unplanned readmission rates. Factors (Per Patient) of Performing Early 24-Hour pH Monitoring with a p < 0.1 were included in multivariate logistic regres- Across the Range of Reported Sensitivity for Diagnosing GERD sion. Odds ratios (OR) and 95% confi dence intervals (CI) are reported and p-value < 0.05 was considered statistically (1) (1) 30% Sensitivity 96% Sensitivity signifi cant. (2) All patients –$100.31 to $1,495.45 $1,196.99 to $6,303.43 RESULTS: For 43,894 patients undergoing GI resection, the Esophageal –$59.57(2) to $1,646.44 $1,327.37 to $6,786.61 overall 30-day unplanned readmission rate was 12.0% rang- symptoms ing from 11.4% for colorectal resections to 15.7% for pan- Extra-esophageal –$299.23(2) to $758.25 $560.47 to $3,940.09 creatic resections. Median postoperative length of stay was symptoms longer in the readmission group (7 vs. 6 days p < 0.0001). (1)Range of savings from low-dose generic PPI to high-dose name-brand PPI, Major predictors of 30-day readmissions included pre-dis- (2)Negative values refl ect additional cost over 10-years. charge major complications (OR = 1.28; CI: 1.14,1.44, p < 0.0001), preoperative steroid use (OR = 1.62; CI: 1.39,1.89, CONCLUSIONS: Most patients are maintained on PPIs for p < 0.0001), operative time ≥4 hours (OR = 1.61; CI: periods greatly surpassing the cost-equivalence point with 1.45,1.78, p < 0.0001) and discharge to a facility other than 24-hour esophageal pH monitoring. Early referral for pH home (OR = 1.48; CI: 1.28,1.70, p < 0.0001). Other factors monitoring after a brief empiric PPI trial may result in sub- associated with increased readmission included dependent stantial cost savings for patients with both esophageal and functional status, open surgery, pulmonary comorbidity, extra-esophageal GERD symptoms. neurologic comorbidity, higher ASA score, diabetes, and preoperative anemia (table 1). Post-discharge major and minor complications were highly correlated with 30-day readmission rates (OR = 59.3; CI: 52.2,67.3, p < 0.0001 and OR = 6.3; 95% CI: 5.8,6.9, p < 0.0001) and not included in the fi nal model.

8 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1: Factors Associated with Unplanned 30-Day Readmissions Following GI Resection

Risk Factor % Readmitted Adjusted OR 95% CI p-Value Abstracts Preoperative Steroid use 18.6 v 11.5 1.62 1.39, 1.89 <0.0001 Sunday Operative time (4 hrs vs. <4hrs) 15.4 v 12.8 1.61 1.45, 1.78 <0.0001 Discharge Destination (Facility vs. Home) 15.1 v 11.6 1.48 1.28, 1.70 <0.0001 Open Surgery 13.1 v 9.1 1.46 1.30, 1.63 <0.0001 Pre-discharge Major Complication 14.9 v 11.1 1.28 1.14, 1.44 <0.0001 Neurologic Comorbidity 15.2 v 11.9 1.26 1.06, 1.51 0.01 Pulmonary Comorbidity 14.2 v 11.5 1.22 1.03, 1.45 0.02 Dependent Functional Status 15.8 v 11.8 1.24 1.01, 1.51 0.037 ASA (3/4 vs 1/2) 13.5 v 9.9 1.17 1.06, 1.30 0.002 Pre-discharge Minor Complication 12.8 v 11.9 1.16 0.98, 1.38 0.077 Diabetes 13.8 v 11.6 1.13 1.01, 1.27 0.032 Preoperative Anemia (HCT < 36) 13.5 v 11.3 1.11 1.01, 1.22 0.024

CONCLUSIONS: Unplanned 30-day readmissions repre- could inform resource utilization and post-operative care sent a major medical and fi nancial concern, but some may to help prevent readmissions in select high-risk GI surgical be foreseeable and thus preventable. Although previous patients. studies have identifi ed major complications as a strong risk Logistic regression model also controlled for age, hepatic factor for readmissions, this might represent an overesti- insuffi ciency, cardiac comorbidity, renal insuffi ciency, mate of the risk due to confounding by including post-dis- wound class, smoking, bleeding disorder, chemotherapy/ charge complications that may in fact cause, not predict, radiation, weight loss, preoperative sepsis, and LOS. readmissions. This model provides insight into factors that

8:00 AM – 9:30 AM 203AB DDW COMBINED RESEARCH FORUM (AGA-ACCREDITED) IBD

203 205 Mesenchymal Stem Cell Transplantation Improves Intestinal Barrier Dysfunction Measured with Confocal Chronic Colitis-Associated Cholangitis Through Endomicroscopy in Macroscopically Normal Mucosa Inhibiting the Activity of LPS/TLR4 Can Predict Requirement for Treatment Escalation X. Zhang1, G. Niu1, L. Liu1, H. Li1, J. Guo1, J. Song1, Y. Liu1, K. Liu1, J. Mill1, B. Wong2, C.P. Selinger1, V.C. Kariyawasam1, S. Chen2 N. Merrett1,3, R.W. Leong1, 2 1. Department of Gastroentology, The Second Hospital of Hebei 1. Gastroenterology and Liver Services, Bankstown and Concord Medical University, Shijiazhuang City, China; 2. Division of Hospitals, Concord, NSW, Australia; 2. Faculty of Medicine, The Pediatric Infectious Diseases and Immunology, Burns and Allen University of New South Wales, Sydney, NSW, Australia; Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 3. Gastroenterology and Liver Services, University of Western Sydney, Sydney, NSW, Australia 204 IL-10-Producing Mucosal B Cells Attenuate T Cell- Mediated Colitis Through Induction of Tr-1 Cells Y. Mishima1, B. Liu1, C. Karp2, R.B. Sartor1 1. CGIBD, University of North Carolina, Chapel Hill, NC; 2. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

9 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

206 Link Between VEGF Expression, Angiogenesis and Infl ammation in Pediatric Crohn’s Disease Jennifer L. Knod1, Kelly M. Crawford1, Mary R. Dusing1, Artur Chernoguz1, Margaret H. Collins2, Jason Frischer1 1. Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2. Division of Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH PURPOSE: Early-onset Crohn’s disease (CD) accounts for 25% of cases but is distinct from adult-onset CD by a more severe disease activity index, increased immunosuppressant requirement, and more extensive intestinal involvement. The pathogenic link between chronic infl ammatory dis- eases and angiogenesis prompted investigations into its role in infl ammatory bowel disease. We hypothesize that VEGF driven angiogenesis plays a signifi cant role in Crohn’s dis- ease infl ammation. METHODS: Pediatric patients (n = 13), ages 12 to 16, at our institution having undergone resection involving the terminal ileum for CD were compared to controls (n = 5) with non-infl ammatory indications for resection. Addition- ally, from each Crohn’s pathology specimen, infl amed and non-infl amed ileum were obtained for comparison. Sam- ples were evaluated for infl ammation using the Crohn’s Histology Index of Severity (range 0–13) and for microves- sel density by quantitative endothelial cell immunohisto- Figure 1: Infl ammation score (range 0–13) of infl amed pediatric Crohn’s chemistry using CD31. Corresponding tissues were assessed for VEGF-A mRNA and protein expression by RT-PCR and disease ileum increased compared to both non-infl ammed Crohn’s Western blot respectively. Results expressed as mean ± SEM diseae and control. Results expressed as mean ± SEM (*P < 0.001). were analyzed for signifi cance (P ? 0.05) by ANOVA and Stu- dent’s t-test. RESULTS: Infl ammation scores were signifi cantly increased (Figure 1) between infl amed CD and controls (5.8 ± 0.7 vs 0.62 ± 0.38, P < 0.001), and between paired infl amed and non-infl amed ileum (5.8 ± 0.7 vs 1.2 ± 0.6, P < 0.001). Increased microvessel density was observed in both infl amed and non-infl amed CD groups compared to con- trols (infl amed 24,955 ± 3,202 μm2, non-infl amed 18,719 ± 2,050 μm2, control 9,032 ± 1,474 μm2), with statistical signifi cance (P = 0.008) only present between infl amed CD and control subjects (Figure 2). Expression of tissue VEGF- A mRNA was upregulated in CD (CD 8.5 ± 2.51 vs control 2.32 ± 0.58, P = 0.034), and was associated with an increased trend in VEGF-A protein levels (VEGF/GAPDH, CD 3.96 vs control 2.20, P = 0.53). CONCLUSION: Angiogenesis is associated with pediatric Crohn’s disease as observed by increased microvessel den- sity that correlates with greater infl ammation in resected ileal specimens. At the molecular level, we demonstrate elevated VEGF transcription and protein levels, which implicates a VEGF pathway for angiogenesis associated infl ammation in early-onset Crohn’s disease. Further inves- tigations regarding mechanism of angiogenesis, its relation- ship to infl ammation, and effectiveness of anti-angiogenic therapies are warranted. Figure 2: Microvessel density (MVD) in pediatric Crohn’s disease ileum (infl amed and non-infl amed) increased compared to control, detected by CD 31 quantitative immunohistochemical staining. Results expressed as mean ± SEM (*P = 0.008).

10 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

10:15 AM – 11:00 AM

303ABC Abstracts Sunday PRESIDENTIAL PLENARY B (PLENARY SESSION II)

363 CONCLUSIONS: PVE is safe and effective in inducing hypertrophy in patients with small FLR and allows 2/3 of Safety and Effi cacy of Portal Vein Embolization patients with inadequate FLR the opportunity for curative Before Planned Major : An Institutional resection. Experience of 358 Patients Junichi Shindoh1, Ching-Wei D. Tzeng1, Thomas Aloia1, 364 Steven Curley1, Giuseppe Zimmitti1, Steven Y. Huang2, Armeen Mahvash2, Sanjay Gupta2, Michael J. Wallace2, Gastric Emptying, Ensuing GLP-1 Release and Insulin Jean-Nicolas Vauthey1 Sensitivity After Partial : 1. Surgical Oncology, University of Texas MD Anderson Cancer Improved Glycemic Control in Cases Without Pylorus Center, Houston, TX; 2. Diagnostic Radiology, University of Texas Preservation (Whipple Procedure) 1 2 1 MDAnderson Cancer Center, Houston, TX Johannes Miholic , Marlene Wewalka , Stefan Harmuth , Jens J. Holst3 INTRODUCTION: Portal vein embolization (PVE) induces 1. Department of Surgery, Medical University of Vienna, Vienna, hypertrophy of the future liver remnant (FLR) in patients Austria; 2. Gastroenterology, Department of Internal Medicine with unfavorable tumor distribution and low calculated standardized FLR (sFLR). We sought to evaluate the safety III – Medical University of Vienna, Vienna, Austria; 3. The and effi cacy of PVE. Panum Institute, Department of Medical Physiology, University of Copenhagen, Copenhagen, Denmark METHODS: We evaluated 358 consecutive patients who underwent PVE before intended major hepatectomy from OBJECTIVE: Investigate the relationship between gastric 1995–2012. Diagnoses, morbidity, degree of hypertrophy emptying, postprandial GLP-1 and insulin sensitivity after (DH), and post-PVE resectability were evaluated in the pancreaticoduodenectomy (PD). whole study period and compared over time. BACKGROUND: Abnormal glucose regulation is highly RESULTS: The diseases treated included colorectal liver prevalent in patients with pancreatic neoplasm, and metastases (CLM, 217, 61%), hepatocellular carcinoma (49, resolves in some after PD, the cause of which is unclear. The 14%), extrahepatic biliary cancers (31, 9%), neuroendocrine procedure is carried out with pylorus preservation (PPPD) metastases (25, 7%), intrahepatic cholangiocarcinoma (13, or with distal (Whipple procedure). Acceler- 3%), and others (23, 6%). Right PVE alone was performed in ated gastric emptying, and ensuing enhanced release of 31% of cases; due to tumor distribution and to the necessity glucagon-like peptide-1 (GLP-1) conceivably play a role of resecting segment IV, right PVE with segment IV PVE was in glucose metabolism after PD. Any procedure associated required in 66% of patients. The fi rst-session PVE success with accelerated gastric emptying might improve glycemic rate was 98%. Post-PVE complications occurred in 12/358 control. It was the purpose of this study to shed light on the patients (3%), with portal vein thrombosis occurring in relationship between gastric emptying, GLP-1 and glycemic 6 (2%) patients. Median pre-PVE standardized FLR (sFLR) control after PPPD and the Whipple procedure. was 19% (inter-quartile range, IQR, 15.0–25.9). Median METHODS. A 75 g oral glucose tolerance test was carried out post-PVE sFLR was 30% (IQR, 22.5–38.2). Of 358 patients in tumor free subjects, 13 having undergone PPPD, and in 13 who underwent PVE, 282 (79%) were taken to the operat- after the Whipple procedure (Table1). Gastric emptying was ing room with 240/358 (67%) undergoing curative hepa- measured by the paracetamol absorption method. Plasma tectomy. Post-hepatectomy major complications occurred concentrations of glucose, insulin, GLP-1, and paracetamol in 62/240 (26%) patients, with postoperative hepatic insuf- were measured at baseline, 10, 20, 30 60, 90, 120, 150, and fi ciency (PHI) in 20/240 (8%) and a 90-day liver-related 180 minutes. Homeostasis model assessment-estimated insu- mortality rate of 9/240 (4%). Over the 18-year study period, lin resistance (HOMA-IR) and oral glucose insulin sensitivity the rate of PVE performed for CLM increased from 39% were calculated from glucose and insulin concentrations. before 2005 to 78% in 2010–12. The use of preoperative chemotherapy and long-duration (>12 weeks) chemother- RESULTS. Patients with Whipple procedure as compared apy increased from 26% to 86% and from 16% to 43%, to PPPD had accelerated gastric emptying (p = 0.01) which respectively, in that time frame (all p < 0.001). However, correlated with early (0–60 min.) integrated GLP-1 (AUC30; despite increased preoperative chemotherapy usage, PHI r2 = 0.61; p = 0.02) and insulin sensitivity (r2 = 0.41; p = and 90-day liver-related mortality rates improved over the 0.026), and inversely with HOMA insulin resistance (r2 = last decade (11% and 4%, respectively before 2010 vs. 3% 0.17; p = 0.033). 2 of 13 Whipple patients (15%) as com- and 3%, in 2010–12). pared to 7 of 13 after PPPD (54%) had postload glucose

11 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

concentrations (i.e. 120 minutes postmeal) ≥200 mg/dl (p < METHODS: A cost-effectiveness decision tree was cre- 0.05). None of 13 (0%) after Whipple procedure but 4 of 13 ated using TreeAge (Figure 1). Assigned probabilities were (31%) after PPPD had fasting glucose concentrations ≥126 derived from published literature. The decision point com- mg/dl (p < 0.05). pared extended duration thromboprophylaxis with low CONCLUSIONS. Gastric emptying was accelerated after molecular weight heparin for 21 days after discharge to Whipple procedure as compared to patients who have inpatient-prophylaxis alone, with base case assumptions undergone pylorus preserving PD, resulting in higher post- (Table 1) based on an abdominal oncologic resection with- prandial GLP-1 concentrations and insulin sensitivity and out complications in a 45 year-old male. The end points improved glycemic control. were pulmonary embolism or deep vein thrombosis with attendant costs and assigned effectiveness evaluated by Whipple PPPD P-Value Quality Adjusted Life Years (QALY). Willingness to pay was Age (yr) 61 (32–70) 62 (48–66) NS set at $50,000/QALY. Sensitivity analyses were performed to Interval (mo) 31 (7–199) 19 (5–107) NS assess uncertainty within the model, with particular inter- est in the threshold for cost-effectiveness based on VTE Gastr. Emptying (Integr.parac. 495 (309–860) 319 (230–601) 0.01 30 min) incidence. Early integ. GLP-1 (30 min) 2880 (920–9205) 1740 (340–3215) 0.03 Fasting glucose (mg/dl) 91 (75–123) 108 (83–170) 0.02 Insulin resistance (HOMA-IR) 0.6 (0.22–1.75) 0.8 (0.6–5.8) 0.02 Insulin sensitivity (OGIS 180) 488 (310–568) 406 (265–500) 0.009

365 Extended Duration Thromboprophylaxis Cost- Effectiveness in Abdominal Surgery J.C. Iannuzzi1, A.S. Rickles1, J.G. Dolan2, F. Fleming1, J.R. Monson1, K. Noyes1 1. Surgical Health Outcomes & Research Enterprise, Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY. 2. Community and Preventative Figure 1: Decision Tree. Health, University of Rochester Medical Center, Rochester, NY RESULTS: Given base case assumptions with VTE probabil- BACKGROUND: Post-discharge thromboprophylaxis is ity of 4%, extended duration thromboprophylaxis had an the practice of prescribing antithrombotic therapy for 21 incremental cost effectiveness ratio of $8123/QALY, which days after discharge, commonly used in surgical patients was considered cost-effective. The results were robust to who are at high risk for venothromboembolism (VTE). sensitivity analysis with the highest uncertainty associated Multiple consensus guidelines recommend extended dura- with VTE incidence and medication cost. The threshold for tion thromboprophylaxis (EDTPPX) after major abdominal the relative cost-effectiveness was a VTE incidence exceed- oncologic resections based on randomized clinical trials ing 2.53%. demonstrating a signifi cant reduction in VTE events after surgical discharge in these patients. While the National CONCLUSIONS: Given the base case assumptions, Comprehensive Cancer Network suggests all major abdom- extended prophylaxis is more cost effective than inpatient inal oncologic resections receive EDTPPX, the American prophylaxis alone, and the threshold for its use should be College of Chest Physicians suggests an individualized cases where the estimated VTE risk exceeds 2.53%. These risk assessment, with only high risk patients undergoing fi ndings should inform future guidelines’ defi nition of oncologic resections suggested to receive EDTPPX, how- “high risk” and individualized risk scores should be devel- ever, high risk is not currently defi ned. The threshold for oped to predict patient likelihood of post-discharge VTE. high risk ought to be informed by when it is cost-effective These results can lead to specifi c individualized EDTPPX to provide EDTPPX, which has not previously been estab- application. lished. In order to further inform current guidelines this study sought to determine the VTE incidence threshold for the cost-effectiveness of low molecular weight heparin for 4 weeks after surgery as compared to inpatient prophylaxis only.

12 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1: Baseline Model Assumptions and Sensitivity Analysis

Variable Baseline Probability Sensitivity Range Cost ($,2010) Cost Range ($) Utility (Range) Abstracts VTE 0.04 0.001–0.3 N/A N/A N/A Sunday DVT 0.923 0–.0923 10,804 3371–22,748 0.84 (0.7–0.931) PE 0.077 0.077–1 16,644 6443–25,554 0.76 (0.6–0.89) LMWH 0.22 0.22–0.7 885.99 357–885.99 0.98 (0.9–.099) No VTE 0.96 0.7–0.999 680 0–680 1 VTE = Venothromboembolism, DVT = Deep Vein Thrombosis, PE = Pulmonary Embolism, LMWH = Low Molecular Weight Heparin

2:00 PM – 4:00 PM 300 VIDEO SESSION I

437 439 Robotic Assisted Median Arcuate Ligament Release Endoscopic Removal of a Laparoscopic Adjustable Martin J. Dib, Mark P. Callery, Marc Schermerhorn, Gastric Band That Is Eroded A. James Moser Aurora D. Pryor, Dana A. Telem, Joshua Karas, Surgery, BIDMC, Boston, MA Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia 40-year-old female with chronic abdominal pain and pre- Surgery, Stony Brook University Medical Center, Stony Brook, NY operative aortography consistent with median arcuate This is a case of a 52-year-old male with history of morbid ligament syndrome. Ports and a laparoscopic liver retrac- obesity status-post Laparoscopic Band at an outside hospi- tor are placed. After docking the robot, the left gastric vein tal complicated by port infection and band erosion. Fol- is divided. The left gastric artery is encircled with a vessel lowing port removal, the patient presented for removal of loop to apply inferior traction and identify the common the laparoscopic band. Due to the extent of the intra-gastric hepatic artery of the celiac trunk. The left lateral border of band erosion, total endoscopic removal was attempted suc- the celiac trunk is dissected. Hook cautery and LigaSure is cesfully. This case highlights the mechanism of endoscopic used to divide the left crus of the diaphragm. Finally, cir- removal of the band, challenges encountered, and tech- cumferential skeletonization of the aorta at the entrance of niques to navigate these obstacles. The patient tolerated the celiac trunk is achieved. removal of the band, was started on a liquid diet immedi- ately, and was discharged on post-operative day one. 438 Enucleation of Hepatic Neuroendocrine Tumor 440 Metastases Totally Laparoscopic Left Colonic Resection with Nicholas N. Nissen, Vijay G. Menon Intracorporeal Anastomosis Cedars-Sinai Medical Center, Los Angeles, CA Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin Neuroendocrine tumors (NET) represent a unique type of Surgery, The Mount Sinai School of Medicine, New York, NY hepatic metastasis. These tumors tend to be well encapsu- This video demonstrates two complementary laparoscopic lated and generally carry a favorable prognosis. Many of cases, each focusing on techniques for intracorporeal anas- these patients will require repeated hepatic interventions tomosis. The fi rst is an elective sigmoid resection for history over a period of several decades. Surgical enucleation of of uncomplicated diverticulitis. It uses an end-to-side intra- hepatic NETs is a technique that is not often employed corporeal anastomosis performed with a circular stapler. but that holds great potential for preservation of maximal The second is a left hemicolectomy, performed for descend- hepatic parenchyma, while carrying a low risk of injury ing colon cancer. It employs a side-to-side intracorporeal to underlying vascular and biliary structures. This video anastomosis performed with a linear stapler and sewn com- describes the application of enucleation to patients with mon enterotomy. Totally laparoscopic colonic resection NET metastases and addresses patient selection, surgical with intracorporeal anastomosis can facilitate resection techniques and management of complications. in obese patients, as well as improve cosmesis and wound complications by reducing incision length for extraction.

13 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

441 443 Laparoscopic Central and Laparoscopic Repair of a Large Right Sided Morgagni’s Pancreaticogastrostomy for the Management of a Proximally Migrated Pancreatic Stent David Lawrence1, Yuhsin V. Wu2, Michael J. Rosen1,2 Marc G. Mesleh1, Frank Lukens2, Michael B. Wallace2, 1. Case Western Reserve University, Cleveland, OH; 2. Surgery, Horacio J. Asbun1, John Stauffer1 University Hospitals, Cleveland, OH 1. General Surgery, Mayo Clinic Jacksonville, Jacksonville, FL; Morgagni’s are rare congenital anterior diaphrag- 2. Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, FL matic hernias for which the optimal method of repair is A 43 year old female had a pancreatic stent placed during unknown. This video presents a morbidly obese patient with ERCP for elevated LFTs. The stent migrated proximally into oxygen dependent chronic obstructive pulmonary disease the pancreas and was unable to be retrieved with multiple and a Morgagni’s hernia that compresses her entire right endoscopic attempts. After several episodes of pancreatitis, lung. Omentum and colon are seen herniating through she was evaluated for surgical retrieval. A laparoscopic cen- the 10x15cm defect. Through a laparoscopic approach the tral pancreatectomy was performed to remove the stent, and intra-abdominal contents were reduced, the defect primar- a pancreaticogastrostomy was created for reconstruction. ily closed, and re-enforced with mesh. After the repair, the patient had signifi cant improvements in pulmonary status. 442 Laparoscopic repair with mesh re-enforcement is a viable and easily accomplished approach for Morgagni’s hernia Diffi cult Diverticulits and Failed Anastomosis: Troubles repair. and More Troubles Barry Salky Surgery, Mount Sinai Hospital, New York, NY This is a 68 year old female with mulitiple episodes of diverticulitis documented on CT scans. Dyspareunia is a recent symptom. This video demonstates several techni- cal challenges assoiciated with chronic diverticulitis. After completion of the descending rectal anastomosis, a leak was detected and the video demostrates one technique of recovery in a diffi cult clinical situation.

2:00 PM – 4:45 PM 308D PLENARY SESSION III

445 staging system, lymph node ratio (LNR), and overall sur- vival (OS) from date of diagnosis were analyzed. Median Modern Chemotherapy Mitigates Adverse Prognostic follow-up was 19 months (range, 1–211 months). Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer RESULTS: The number of positive regional nodes and LNR 1 1 2 correlated with the presence of multiple sites of distant Yun Shin Chun , Steven Cohen , John H. Donohue , metastases (p < 0.001). Survival was signifi cantly associ- 1 1 2 Barbara Burtness , Michael J. Hall , David M. Nagorney ated with number of positive nodes and LNR, with median 1. Fox Chase Cancer Center, Philadelphia, PA; 2. Mayo Clinic, OS of 36 months with negative regional nodes, compared Rochester, MN to 17 months with ≥7 positive nodes (p < 0.001). Among BACKGROUND: In colorectal cancer, the involvement 315 patients treated with modern oxaliplatin- or irinote- of regional lymph nodes with metastasis is an established can-based chemotherapy after colorectal resection, survival prognostic factor. However, the impact of the number of was not signifi cantly associated with number of positive positive regional nodes on patient outcome with stage IV regional nodes (p = 0.072) or LNR (p = 0.34). The number disease is not well-defi ned. of regional nodal metastases correlated with OS among 249 patients who underwent resection of liver metastases but METHODS: A retrospective review was performed of 869 lost prognostic signifi cance in the subset of 105 patients patients at two tertiary referral centers with synchronous who underwent hepatectomy with perioperative modern stage IV colorectal cancer who underwent resection of their chemotherapy. primary tumors. Associations between number of positive regional lymph nodes stratifi ed by the 7th edition AJCC

14 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL Abstracts Sunday

CONCLUSIONS: In stage IV colorectal cancer, increasing 447 number of positive regional lymph nodes and LNR corre- late with multiple sites of distant metastases and poorer sur- Night Time Is Not the Right Time: Increased Risk of vival. The number of metastatic regional lymph nodes loses Complications After Laparoscopic at prognostic signifi cance with modern chemotherapy, partic- Night ularly in patients undergoing resection of liver metastases. Uma R. Phatak, Curtis J. Wray, Debbie Lew, Richard Escamilla, Winston M. Chan, Tien C. Ko, Lillian S. Kao Surgery, University of Texas Health Science Center, Houston, TX 6 446 Evidence from a large national database has shown that Totally Laparoscopic Cytoreductive Surgery and performance of non-emergent general surgery procedures at night does not predispose patients to increased morbid- Hyperthermic Intraperitoneal Chemotherapy for ity or mortality. However, these results may not be gener- Mucinous Adneocarcinoma of the Appendix alizable to high risk populations of medically underserved Cherif Boutros, Nader Hanna patients. We hypothesized that performance of laparoscopic Division of Surgical Oncology, University of Maryland, cholecystectomy (LC) at night in such a population would Baltimore, MD be associated with increased post-operative complications. Open cytoreductive Surgery (CRS) and heated intraperito- We conducted an IRB approved single center retrospective neal chemotherapy (HIPEC) has emerged as the procedure review of consecutive LC patients between October 2010 of choice for mucinous adenocarcinoma of the appendix and May 2011 at a safety-net hospital in Houston, TX. (MAA), however is associated with substantial morbidity. Data were collected regarding demographics, date and site We present a case of a totally laparoscopic R0- CRS-HIPEC of diagnosis (defi ned as fi rst imaging study demonstrat- for MAA. CRS included: right hemicolectomy, omentec- ing gallstones), number of biliary-related admissions and tomy, cholecystectomy, bilateral salpingo-oopherectomy, emergency room (ER) visits between diagnosis and surgery, excision of the round and falciform ligaments and strip- length of stay (LOS) for each admission, dates and types of ping of the of the right diaphragm; followed procedures, dates and types of imaging studies, and 30-day by HIPEC through single infl ow and outfl ow catheters. OR postoperative complications (bile leak/biloma, common time was 380 mns and EBL was 100 mL. There was no post- injury, retained stone, superfi cial surgical site operative morbidity. The patient was discharged home on infection, organ space abscess, pneumonia, readmission, postoperative day 8. and death). We defi ned “night” as 7PM to 7AM. Statistical analyses were done using STATA 12 (College Station, TX).

15 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

During the 8-month period, 580 patients received LC and hazards. We compared survival of patients with thrombosis incision times were available for 549. Of these 38% (n = of the mesenteric venous system to that of patients with 208) were elective and 62% (n = 341) were non-elective. A patent reconstructions. majority were female (n = 460, 84%) and Latino (n = 456, 83%). There were 196 LC performed at night of which 186 were non-elective and 10 were elective. Of the 353 daytime LCs, 198 were elective and 155 were non-elective. There were 35 complications in 22 patients (4 elective, 18 non- elective). Multivariate analysis revealed age (OR 1.05, 95% CI 1.01 to 1.08, p = 0.003) and LC at night (OR 3.1, 95% CI 1.3 to 7.6, p = 0.012) to be associated with increased risk of complications. The predicted probability of a complication increased three fold for older patients who received LC at night (Figure). Age and performance of LC at night were predictive of an increased risk of complications among medically under- served patients treated at a high volume safety net hospi- tal with limited resources. Restricting performance of LCs to the daytime in high risk patients, such as the elderly, may lead to improved outcomes in this challenging clinical setting.

Predicted probability of complication after LC at night by age.

448 Short-Term But Not Long-Term Patency of Venous Reconstruction During Pancreatic Resection Predicts Survival Irmina Gawlas, Irene Epelboym, Megan Winner, Joseph DiNorcia, Yanghee Woo, James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf Department of Surgery, Columbia University, New York, NY BACKGROUND: Pancreatic surgery with concomitant vascular reconstruction is being performed with increas- RESULTS: Between 1994 and 2011, 203 pancreatic opera- ing frequency, and offers the benefi ts of surgical resection tions requiring venous reconstruction were performed. Of to patients with locally advanced disease. The technique these, 106 (52.2%) included resection of the portal vein (PV), is not standardized, however, and the short and long-term 59 (29.1%) included the superior mesenteric vein (SMV) patency rates and the clinical signifi cance of thrombosis of only, and in 38 (18.7%) patients, the confl uence of the PV a reconstructed venous system are unknown. and SMV was resected. Segmental resection was performed in 131 (64.5%), and 72 (35.5%) underwent tangential resec- METHODS: We reviewed clinical and operative character- tion. Ninety-seven veins (47.8%) were repaired primar- istics as well as follow up records of patients who under- ily, 67 (33.0%) were repaired using a venous interposition went pancreatic resections requiring venous resection and graft, and 34 (16.8%) were repaired using an autologous reconstruction from 1994 to 2011. We sought to identify vein patch. Acute thrombosis occurred in 9 (4.4%) cases, predictors of acute (occurring within 30 days) thrombosis and was signifi cantly associated with increased periopera- of the venous reconstructions using logistic regression, and tive mortality (22.2% versus 4.6%, p = 0.023). After exclud- predictors of late loss of patency using Cox-proportional ing cases of perioperative mortality, acute thrombosis was

16 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

associated with decreased median survival (7.1 versus 15.9 RESULTS: Nineteen patients had carcinoid syndrome and months, p = 0.011) and increased hazard of death (HR 8.6, all had dramatic improvement after surgery, with complete

CI 3.7–19.9, p < 0.001). These events were more common resolution in 11 (58%) cases. Overall there were 8 complica- Abstracts Sunday in cases of total or subtotal resection compared to Whipple tions of Clavien grade >2 including bile leak requiring ERCP or distal resections (22.2 versus 2.7%, p < 0.001). Long- (n = 2) and repeat laparotomy (n = 4). There was no 30-day term follow-up imaging was available for 138 patients at a mortality. Median length of stay was 7 days. Overall sur- median of 11.7 months. Of these, 43 (31.2%) experienced vival for the entire cohort at 1, 3 and 5 years was 95%, 82% a loss of patency of the portal venous system at a median and 82%, while the progression free survival at 1, 3 and 5 of 9.5 months; the majority of these were associated with years was 77%, 37% and 28%. In the 22 patients under- tumor recurrence. Independent predictors of late loss of going near total surgical CR, no patient required repeat patency were age under 65 (HR 2.2, CI 1.2–4.1, p = 0.015) hepatic intervention within 12 months. In the 25 patients and segmental resection (HR 3.3, CI 1.5–7.2, p = 0.002). undergoing partial surgical CR, 18 (72%) went on to receive Later loss of patency was not associated with decreased postoperative hepatic treatments within 12 months. Pro- median survival (18.1 versus 16.8 months, p = 0.455) or gression free survival was similar in patients whether they increased hazard of death (HR 1.3, CI 0.8–2.1, p = 0.375). underwent total CR or partial CR with staged hepatic treat- CONCLUSIONS: Acute thrombosis of the reconstructed ment. Patients who failed to undergo postoperative hepatic portal venous system after pancreatic surgery is clinically therapy (n = 7) were at increased risk of progression com- signifi cant; it is associated with increased perioperative pared either to patients with near total CR (HR = 3.10, P = mortality, and even when non-fatal, is associated with 0.044) or partial CR and staged liver treatment (HR = 3.37, decreased survival. Late loss of patency occurs in one-third P = 0.029) (Figure). of patients but does not affect survival.

449 Simultaneous Surgical Resection of Primary and Metastatic Carcinoid and Neuroendocrine Tumors Is Both Safe and Effective Nicholas N. Nissen1, Vijay G. Menon1, Edward M. Wolin2, Run Yu2, James M. Mirocha3, Alagappan Annamalai1, Deepti Dhall4, Ashley Wachsman5, Marc L. Friedman5, Steven D. Colquhoun1 1. Hepatobiliary and Pancreatic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA; 2. Carcinoid and Neuroendocrine Tumor Program, Cedars-Sinai Medical Center, Los Angeles, CA; 3. Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA; 4. Pathology, Cedars-Sinai Medical Center, Los Angeles, CA; 5. Radiology, Cedars-Sinai Medical Center, Los Angeles, CA INTRODUCTION: Management strategies for patients Progression Free Survival Related to Type of Cytoreductive Treatment. with carcinoid and neuroendocrine tumors (CNETs) gen- erally include removal of the primary tumor and cytore- CONCLUSION: To our knowledge this series represents the duction (CR) of metastatic tumor burden, both to improve largest single center report of simultaneous resection of pri- survival and control symptoms. Patients with synchronous mary abdominal CNETs and hepatic metastases in the lit- presentation of primary tumors and hepatic metastases erature. Our results demonstrate that this surgical approach present a unique challenge. We reviewed our experience is safe and effective in expert hands. In patients undergo- with simultaneous surgical removal of primary abdominal ing near total hepatic CR, which made up almost half of CNETs and hepatic metastases. our series, no additional hepatic treatments were required PATIENTS: Forty-seven patients underwent simultaneous over the next year, which in turn demonstrates the effective hepatic resection and removal of either small bowel carci- consolidation of treatments into a single surgical endeavor. noid (n = 32) or pancreatic NET (n = 15) by two experi- In remaining patients, resection of the primary tumor com- enced hepatobiliary surgeons as part of a multidisciplinary bined with partial hepatic CR combined with postoperative CNET treatment group. Surgical details are shown in the hepatic therapy was equally effective. A multidisciplinary Table. In 22 patients, surgery was undertaken with a goal of and multimodal approach is essential in these patients. near total surgical CR, while in 25 patients partial surgical CR was performed as part of a plan to include postoperative hepatic arterial or ablative therapy. Tumor progression was categorized using RECIST criteria.

17 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Variables Associated with Simultaneous Resection >0.8). MRE accuracy for infl ammation, thickening, steno- sis, abscess and fi stula were all above 85% in per-patient Type of Primary Surgery analysis. In 68/75 cases (90.7%) both approach and strategy Small 21 were correctly predicted by MRE. Conversely, in 7/75 cases Right Hemicolectomy 12 (9.3%, 3 false positives: 2 enterocolic fi stulas and 1 anasto- Segmental or Distal Pancreatic Resection 11 motic stricture; and 4 false negatives: 3 enteric fi stulas with Pancreaticoduodenectomy 3 colon, duodenum and bladder and 1 enteromesial abscess) Type of Liver Surgery surgical strategy (type of resection or , n = 5) Major Resection of 3 or more segments 9 and/or surgical approach (conversion from to Segmental Resection (1 or 2) 11 open surgery, n = 2) changed due to discordance with MRE Multiple Wedge Resections and Enucleations 27 fi ndings. Largest Liver Tumor size (cm) 4.9 (mean); 3.5 (median); CONCLUSION: Preoperative MRE correctly predicts surgi- 0.6–17 (range) cal strategy in the majority of patients undergoing surgery No. of liver lesions resected; 5.5 (mean); 3 (median); for complicated CD. MRE is especially valuable before lapa- 1–28 (range) roscopic surgery, since unrecognized lesions may lead to Grade; High: Intermediate: Low: N/s 4.3%: 27.7%: 51.1%: 17% conversion to open surgery. Differentiation; Poor: Well: N/s 4.3%: 82.9%: 12.8% Positive Lymph nodes (%) 78.6% 451 R0 Resection (%) 57.4% Bilobar Resection (%) 55.3% Tumor Size Does Not Dictate Prognosis After Resection for Hepatocellular Carcinoma: Results from a Large Western Series 450 Michael D. Kluger1,2, Andrea Belli2, Alexis Laurent2, Daniel Azoulay2, Daniel Cherqui1,2 Value of Preoperative Magnetic Resonance Enterography 1. Division of Hepatobiliary Surgery and , to Predict Surgical Findings and to Guide Decisions in New York-Presbyterian Hospital Weill Cornell Medical College, Crohn’s Disease: A Prospective Study New York, NY; 2. Service de Chirurgie Digestive et Hépatobiliaire, 1,2 3 1,2 Antonino Spinelli , Gionata Fiorino , Piero Bazzi , Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris – 4 1 1 Cristiana Bonifacio , Matteo Sacchi , Sarah De Bastiani , Université Paris-Est, Créteil, France Andrea Gatti1, Alberto Malesci2,3, Luca Balzarini4, INTRODUCTION: Operative management remains the Laurent Peyrin-Biroulet5, Marco Montorsi1,2, Silvio Danese3 gold standard approach for hepatocellular carcinoma 1. Department of Surgery, Istituto Clinico Humanitas, Rozzano (HCC). Resection is the preferred treatment in patients Milano, Italy; 2. Dip. di Biotecnologie Mediche e Medicina without cirrhosis, with transplantation being the best Traslazionale, Università degli Studi di Milano, Milano, Italy; option for decompensated cirrhotics. This study evaluated 3. Department of Gastroenterology, Istituto Clinico Humanitas, underlying liver disease, operative factors and histopatho- Rozzano Milano, Italy; 4. Department of Radiology, Istituto logical characteristics on overall and recurrence-free sur- Clinico Humanitas, Rozzano Milano, Italy; 5. Department of vival in 313 patients undergoing liver resection for HCC at Hepato Gastroenterology, University of Nancy, Nancy, France a single Western center. BACKGROUND: Surgery is still required for many patients METHODS: Patients who underwent liver resection for with Crohn’s disease (CD). Intraoperative detection of new HCC between 3/89 and 9/10 were studied. Patients were lesions is common and may lead to a change in the planned not excluded based on tumor size, extent of fi brosis, or approach (laparoscopic or open surgery) and strategy (type etiology of underlying liver disease. As indications for of resection or strictureplasty). Whether magnetic reso- treatment are mostly based on tumor size, patients were nance enterography (MRE) can be used to optimize surgi- stratifi ed by diameter: <50 mm, 50–100 mm and >100 mm. cal planning and to guide decision-making in CD patients Patients with Child’s A cirrhosis, no esophageal varices, and undergoing surgery is currently unclear. a platelet count ≥100 × 10^9/L were directed toward resec- tion. Kaplan-Meier and Cox regression methodology were METHODS: Seventy-fi ve consecutive patients with com- utilized. plicated CD who were candidates for surgery were pro- spectively enrolled. MRE was performed according to RESULTS: 36% had tumors <50 mm, 36% had tumors a standardized protocol within 30 days before surgery. 50–100 mm, and 28% had tumors >100 mm. Patients with Two experienced radiologists blindly and independently larger tumors were more likely to have normal underlying assessed MRE images. Radiological fi ndings were correlated liver parenchyma: 43% >100 mm, 15% 50–100 mm and 1% with intraoperatively detected lesions. Analysis included <50 mm (p < 0.001). 77% underwent an open and 23% a MRE accuracy (per-segment and per-patient) and change in laparoscopic procedure (p < 0.001). Major hepatectomies surgical strategy due to discordance with MRE fi ndings. comprised 56%, anatomic resections 87%, and R0 88% of resections. There was no signifi cant difference in Clavien RESULTS: Surgery was performed laparoscopically in 39/75 3–5 complications among the groups (p = 0.78), 16% over- pts (52%; conversion to open surgery 6/39, 15%). Concor- all. This rate decreased in the second decade of our expe- dance rate among observers was excellent (kappa value rience. For example, the mortality rate between 3/89 and

18 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

12/99 was 14%, and 5% through 9/10 (p < 0.008). Median overall survival was 60 months, with 1- and 5-year over- all survival rates of 76% and 50%. On multivariate analy- Abstracts Sunday ses, intra-operative transfusion (HR = 2.60), cirrhosis (HR = 2.42), salvage transplantation (HR = 0.23), poorly differ- entiated tumor (HR = 2.04), satellite lesions (HR = 1.68), microvascular invasion (HR = 1.48), and AFP > 200 (HR = 1.53) were signifi cant predictors of survival. Median time to recurrence was 20-months, with 1- and 5-year recurrence- free survival rates of 61% and 28%. By multivariate analyses intra-operative transfusion (HR = 2.15), poorly differenti- ated tumor (HR = 1.87), cirrhosis (HR = 1.69) and micro- vascular invasion (HR = 1.71) independently impacted recurrence-free survival. CONCLUSION: It is demonstrated that resection is a safe and readily available treatment for any size HCC in properly selected patients in the modern era of liver surgery. Tumor size did not independently impact recurrence or survival on multivariate analyses, whereas tumor histopathology and background parenchyma did. The current investiga- tion adds to a growing body of literature supporting that HCC tumor biology and the condition of the non-tumor parenchyma should be given greater consideration in con- sidering resection in this era of organ shortage.

Table 1: Clinical Characteristics, Operative Details and Pathologic Characteristics of Patients with HCC Undergoing Resection

Figure 1: Overall and recurrence-free survival among patients resected for hepatocellular carcinoma stratifi ed by tumor size.

19 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

452 6 453 Analysis of a Single-Series Learning Curve for Peroral Peroral Endoscopic Myotomy (POEM) Feasible as Esophageal Myotomy (POEM) Reoperation Following Ezra N. Teitelbaum, Byron F. Santos, Fahd O. Arafat, Amy K. Yetasook1, Jin-cheng Zhao1,2, Woody Denham1,2, Nathaniel J. Soper, Eric S. Hungness John G. Linn1, Michael B. Ujiki1,2 Northwestern University, Chicago, IL 1. Minimally Invasive Surgery, NorthShore University BACKGROUND: Peroral esophageal myotomy (POEM) is a HealthSystem, Evanston, IL; 2. Department of Surgery, University novel endoscopic operation for the treatment of achalasia. of Chicago, Chicago, IL The operator learning curve for POEM and patient factors Peroral Endoscopic Myotomy (POEM) is a promising new associated with operative diffi culty are not known. treatment for achalasia. We present three cases of recurrent METHODS: A single-institution prospective POEM out- achalasia after failed therapy with reoperation by POEM. comes database was analyzed. All POEM procedures were Additionally, we also demonstrate our technique with performed conjointly by the same two surgeons. Associa- a patient who underwent POEM after failed endoscopic tions between preoperative patient variables (series case intervention and laparoscopic Heller myotomy (LHM) with number, gender, age, BMI, ASA class, prior treatment with reoperation by POEM. This case series illustrates feasbility dilation or Botox, symptom duration, manometric pres- of completing a peroral minimally invasive approach in the sures, achalasia subtype) and operative outcomes (proce- management of recurrent achalasia. dure time, tunnel length, myotomy length, number of clips used for closure, EBL, mucosal perforation, need to decom- 454 press pneumoperitoneum) were tested using bivariate lin- ear correlation. To assess for changes in effi ciency over the Idiopathic Pulmonary Fibrosis and Gastroesophageal course of the series, the total procedure time and the time Refl ux: Implications for Treatment required for each individual procedural step (submucosal Marco E. Allaix1, P. Marco Fisichella2, Fernando A. Herbella1, access, tunnel creation, myotomy, and mucosal closure) Marco G. Patti1 were tested for best fi t to linear, logarithmic, and exponen- 1. Department of Surgery, Center for Esophageal Diseases, tial regression curves using case number as the dependent variable. A subgroup analysis of treatment-naïve patients University of Chicago Pritzker School of Medicine, Chicago, IL; was secondarily performed. 2. Department of Surgery, Swallowing Center, Loyola University Chicago, Stritch School of Medicine, Maywood, IL RESULTS: 30 patients underwent POEM, of which 26 were treatment-naïve. Preoperative symptom duration was posi- BACKGROUND: While the pathogenesis of idiopathic tively associated with increased operative time (r^2 = .55, pulmonary fi brosis (IPF) is multifactorial, it has been shown p < .01). Prior achalasia treatment and EGJ resting pressure that the prevalence of abnormal refl ux (GERD) is very high, were both positively associated with operative time at a and that antirefl ux surgery may affect the progression of trend level (p = .08 for both). Case number correlated nega- this disease. tively with the number of clips required for closure (r^2 = AIMS: The aims of this study were to compare in a group of –.51, p < .01), whereas duration of symptoms was positively patients with GERD and a group of patients with GERD and correlated with clip number (r^2 = .40, p < .05). Case num- IPF: a) the clinical presentation; b) the esophageal function ber correlated negatively, whereas duration of symptoms as defi ned by high resolution manometry; and c) the refl ux correlated positively, with occurrence of a mucosal perfo- ration, both at a trend level (p = .06 and .07). Myotomy profi le by dual sensor pH monitoring. length proximal to the EGJ increased over the course of the PATIENTS AND METHODS: We compared the clinical series (r^2 = .44, p = .02), whereas there was no change presentation, the esophageal function and the refl ux profi le in myotomy length distal to the EGJ. Total procedure time in 80 patients with GERD and in 22 patients with GERD and time to perform tunnel creation, myotomy and muco- and IPF. sal closure did not change over the course of the series. Sub- RESULTS: Data are expressed as mean ± SD. mucosal access time decreased over the course of the series (r^2 = .22, p < .01) with best fi t to a logarithmic curve. CONCLUSIONS: The results of this study show that in In treatment-naïve patients only, mucosal closure time patients with GERD and IPF: a) heartburn is present in less decreased over the series (r^2 = .17, p = .03) with best fi t to than 60% of patients; b) with the exception of a weaker an exponential curve. UES, the esophageal function is preserved; and c) proximal CONCLUSIONS: In this POEM series, the time needed to refl ux is more common, and in the supine position it is access the submucosa and the number of clips required to coupled with a slower acid clearance. Because these factors close the mucosotomy both decreased with experience. expose IPF patients to the risk of aspiration, antirefl ux sur- Myotomy length proximal to the EGJ increased with expe- gery should be considered early in the course of the disease. rience. Total procedure time did not change over the course of the series, and may not be an important marker of proce- dural skill for POEM. Longer symptom duration and prior endoscopic treatment may result in increased operative diffi culty.

20 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

GERD GERD + IPF sigmoid-shaped mega-esophagus (stage 4) were excluded. (80 Patients) (22 Patients) P Value Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, Abstracts Age (years) 55.7 ± 15 61.3 ± 8.9 0.098 Sunday Gender (male), N (%) 31 (38.8) 13 (59.1) 0.143 , and esophageal-manometry were performed, Heartburn, N (%) 67 (83.8) 13 (59.1) 0.028 before and 6 months after the treatment. Patients were clas- sifi ed in three age brackets: group A (≤45 years), group B LES pressure (mmHg) 19.9 ± 9.7 20.5 ± 11.9 0.807 (45–70) and group C (≥70). Treatment was defi ned as a fail- Normal peristalsis, 51 (63.8) 14 (63.6) 0.810 th N (%) ure if the postoperative symptom-score was >10 percentile of the preoperative score (i.e. > 8). Hypotensive UES, 6 (7.5) 7 (31.8) 0.008 N (%) RESULTS: We consecutively performed the LHD as pri- % time <4, total Distal 9.7 ± 6.6 12.7 ± 13.6 0.149 mary treatment in 514 achalasia patients, 272 (53%) in Proximal 0.9 ± 1.1 2.5 ± 6.9 0.047 group A, 208 (40.4%) in group B and 34 (6.6%) in group C. Acid clearance, total 85.3 ± 65.2 137.5 ± 112.4 0.006 The mortality was nil; the conversion and morbidity rates (seconds) Distal 42.4 ± 67.1 169.9 ± 406.8 0.008 were both 1.2% with no-difference in the 3 groups. Proximal % time <4, supine 10.5 ± 12.8 8.6 ± 17.1 0.569 Group C patients had higher preoperative symptom scores Distal Proximal 0.5 ± 1.2 2.9 ± 7.6 0.007 (p = 0.02), while the symptom duration was similar in all Acid clearance, supine 181.1 ± 270.1 171.5 ± 259.9 0.882 groups. At a median follow-up of 40 months (IQR 15–80), (seconds) Distal 47.6 ± 72.3 899.1 ± 1668.1 <0.001 the median of symptom scores was signifi cantly lower after Proximal surgery (18 [IQR 14–20] vs 0 [IQR 0–3]; p < 0.0001). The median of resting LES pressure decreased from 27 mmHg (IQR 19–36) to 11 mmHg (IQR 8–14) (p < 0.001) and the 455 residual LES pressure from 10 mmHg (IQR 5–17) to 3 mmHg (QR: 1–5) (p < 0.001). No statistically signifi cant differences Laparoscopic Heller Myotomy Can Be Used as Primary emerged between the 3 groups in any of these aspects. Therapy for Esophageal Achalasia Regardless of Age Mucosal tears occurred in 16 patients (3%): 5 (1.8%) in Renato Salvador1, Mario Costantini1, Francesco Cavallin1, 1 1 1 group A; 8 (3.9%) in group B; and 3 (8.9%) in group C (p Elena Finotti , Cristina Longo , Michela Di Giunta , = 0.06). The postoperative hospital stay was slightly lon- 1 1 1 Nicola Passuello , Loredana Nicoletti , Giovanni Capovilla , ger for group C (p = 0.06). The treatment failure rate was Stefano Merigliano1, Ermanno Ancona1, Giovanni Zaninotto1 quite similar: 31 failures in group A (11.4%), 19 in group B 1. Department of Surgical and Gastroenterological Sciences, (9.1%) and 2 in group C (5.9%) (p = 0.55) (table). The fail- Clinica Chirurgica 3, University of Padova, Padova, Italy ures were seen more in manometric-pattern III (22.2%, p = BACKGROUND: Laparoscopic Heller-Dor (LHD) surgery is 0.002). All the patients whose surgical treatment failed were the current treatment of choice for patients with esopha- treated with pneumatic dilations. The overall success rate geal achalasia, but elderly patients are generally referred of this combined treatment was therefore 98.4% (507/515). for less invasive treatments (pneumatic-dilations or botu- Postoperative 24-hour pH-monitoring was abnormal in 16 linum-toxin injections). The aim was to assess the effect of patients (6.6%): 7 patients were in group A, 6 in group B age on the surgical outcome of patients receiving laparo- and 3 in group C (p: n.s.). scopic Heller-Dor as primary treatment. DISCUSSION: LHD is often performed in old patients as METHODS: We evaluated the patients who underwent sur- a “last resource”, after other treatments have failed. Given gery from 1992 to January 2012 . Patients who had already our high success and low complication rate, this study sup- been treated for esophageal achalasia and patients with ports the use of LHD as the fi rst treatment of achalasia in elderly patients with an acceptable surgical risk.

Table: Postoperative Findings in the Three Groups. Data Are Shown as Median and IQR (in Brackets)

Group A (45 Yrs) Group B (45–70 Yrs) Group C (70 Yrs) n = 272 n = 208 n = 34 p Value Postoperative symptom score 0 (0–3) 0 (0–3) 0 (0–3) 0.89 Postoperative chest pain score 0 (0–0) 0 (0–0) 0 (0–0) 0.11 LES resting pressure (mmHg) 10 (8–13) 12 (8–17) 10 (7–14) 0.07 LES residual pressure (mmHg) 3 (1–5) 3 (2–6) 2 (1–4) 0.21 Esophageal diameter (mm) 20 (18–27) 22 (20–25) 22 (20–25) 0.95 Mucosa tear 5 (1.8%) 8 (3.9%) 3 (8.9%) 0.06 Postoperative hospital stay (days) 3 (3–4) 3 (3–4) 3 (3–6) 0.06 Failures 31 (11.4%) 19 (9.1%) 2 (5.9%) 0.55

21 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Monday, May 20, 2013 7:30 AM – 9:15 AM 303ABC VIDEO SESSION II: BREAKFAST AT THE MOVIES

507 510 Laparoscopic Enucleation of Benign and Low Grade Transanal Minimally Invasive Surgery Assisted Single Hepatic Lesions Incision Low Anterior Resection with Total Mesorectal Nicholas N. Nissen, Vichin Puri, Vijay G. Menon Excision (TAMIS Assisted LAR TME) in a Cadaver Model Cedars-Sinai Medical Center, Los Angeles, CA Elisabeth C. McLemore1, Alisa M. Coker1, Bikash Devaraj1, 1 1 1 1 Enucleation is a technique which can be applied to benign Jeffrey Chakedis , Ali Maawy , Tazo Inui , Mark A. Talamini , and low grade lesions of the liver such as select neuroendo- Santiago Horgan1, Michael R. Peterson2, Patricia Sylla3, crine tumors (NET), cysts, hemangiomas and focal nodular Sonia Ramamoorthy1 hyperplasia. The benefi ts of enucleation include the preser- 1. Surgery, UC San Diego, La Jolla, CA; 2. Pathology, UC vation of maximal hepatic parenchyma, as well as the low San Diego, La Jolla, CA; 3. Surgery, Massachusetts General, likelihood that underlying vascular or biliary structures will Boston, MA be compromised. A laparoscopic approach to enucleation not only offers the benefi ts of minimal access surgery, but The purpose of this video is to demonstrate the feasibility also allows simultaneous access to multiple regions of the of an innovative technique for the surgical management of abdomen. This may be ideal for managing certain scenarios rectal cancer: trans anal minimally invasive surgery assisted such as the patient with distal pancreatic NET and synchro- low anterior resection with total mesorectal excision nous liver metastases. Illustrative cases are shown. (TAMIS assisted LAR TME) in a cadaver model. Trans anal LAR via natural orifi ce translumenal endoscopic surgery (NOTES) has been reported in cadaveric series using rigid 508 transanal platforms. This procedure has not been described Use of Fluorescence Angiography During 2-Field using a combination of a single incision laparoscopy and Minimally Invasive TAMIS trans anal endoscopic platform. Herein, we describe C. Daniel Smith, Steven P. Bowers the fi rst cadaveric series of TAMIS assisted laparoscopic LAR with TME. Surgery, Mayo Clinic Florida, Jacksonville, FL This video depicts the use of fl uorescence angiography 511 using the SPY technology to assess the perfusion of the gas- tric conduit during 2-fi eld minimally invasive technology. Central Pancreatectomy with Pancreatogastrostomy for The SPY allowed real-time visualization of the perfusion of Traumatic Transection of the Pancreas the gastric conduit and subsequent esophagogastrostomy. Farzad Alemi, Jonathan Carter, Carlos U. Corvera The tip of the conduit was found to have poor perfusion Surgery, UCSF, San Francisco, CA based on the fl uorescence imaging and was resected. The distal end of the gastric conduit at the anastomosis showed A 22 year-old man sustained abdominal trauma resulting good perfusion. in complete transection of the pancreas at the neck of the gland. Pancreatic ascites and mesenteric hematoma was found at exploration. Given the normalcy of the distal 509 pancreatic remnant, a central pancreatectomy and pan- Surgical Treatment Options for Delayed Gastric creatogastrostomy was done. The operation entailed 1) Emptying partial mobilization of the distal pancreatic remnant, 2) Nathan Lytle, Juan Toro, Ankit Patel, Jahnavi Srinivasan, cannulation and stenting of the pancreatic duct, 3) oppos- ing anterior and posterior gastrotomies, and 4) a two-layer, S. Scott Davis, Edward Lin interrupted anastomosis. The proximally transected seg- Surgery, Emory University, Atlanta, GA ment was treated with biologic adhesive and wide drainage. Delayed gastric emptying is a common problem that is Postoperatively the patient exhibited normal digestion and seen by both gastroenterologists and general surgeons. glucose homeostasis. Poor gastric emptying from outlet obstruction or diabetic, post-surgical, and idiopathic gastroparesis can be diffi cult to treat. This video demonstrates four surgical options for treatment. Gastric stimulator, duodenojejunostomy, pylo- roplasty, and distal gastrectomy are shown demonstrating technique, and indications for each are discussed.

22 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

512 513 Laparoscopic Hilar Resection with Roux-en-Y Robotic Assisted Laparoscopic Total Proctocolectomy Hepatico- with Ileal Pouch Anal Anastomosis Juan Toro, Nathan Lytle, Ankit Patel, S. Scott Davis, Mehraneh D. Jafari, Alessio Pigazzi, Michael J. Stamos Edward Lin, Juan M. Sarmiento Surgery, University of California, Irvine, Orange, CA Surgery, Emory University, Atlanta, GA This is a 38 year old female with polyposis syndrome. A Several series demonstrate the safety and feasibility of laparoscopic total is performed in a medial to laparoscopy for complex hepatobiliary procedures. These lateral fashion. The ielocolic vessels, middle colic vessels, reports show the results of laparoscopic liver resections for and inferior mesenteric vessels are divided. The four arm different types of neoplasms and benign diseases such as Di Vinci robot is docked and a total proctocolectomy is car- choledochal cysts. However, the adoption of laparoscopic ried out to the level of the dentate line. The distal Abstracts resection with common bile duct excision is still uncom- is transected and the specimen removed through a Pfan- Monday mon due to technical complexity and longer operative nenstiel incision. An ileal J-pouch is created and an end to times. We perform laparoscopic extended end ileo-anal anastomosis is performed. Pathology revealed with biliary reconstructions using minimally invasive surgi- colonic polyposis with no evidence of malignancy. cal technique. In this video, we demonstrate our technique for right and left extended hepatectomies with Roux-en- Y hepaticojejunostomy. This approach allows superior visualization.

9:45 AM – 11:00 AM 308D PLENARY SESSION IV

587 addition, data on hospital setting (teaching-research hospi- tals vs. community hospitals) were collected and analyzed. Trends in the Surgical Treatment of Pancreatic The Cochran-Armitage test for trend was used to assess Adenocarcinoma changes in treatment over time. Siavash Raigani1, John Ammori2, Julian Kim2, Jeffrey Hardacre2 RESULTS: 47, 086 patients with stage 1–2 pancreatic ade- 1. Department of Surgery, CWRU School of Medicine, Cleveland, nocarcinoma were included in the analysis. Between 2003– OH; 2. Department of Surgery, University Hospitals Case Medical 2009, the use of surgery alone as fi rst course treatment of Center, Cleveland, OH stage 2 disease decreased signifi cantly at both teaching- INTRODUCTION: Multiple prospective, randomized trials research hospitals and community hospitals by nearly 25% have demonstrated that the addition of adjuvant therapy (p < 0.0001 for both cases). In the same period, the use of after surgical resection of pancreatic cancer improves sur- chemotherapy in addition to surgery as treatment of stage vival compared to surgery alone. However, the optimal type 1 and 2 disease increased two-fold at both types of hospi- of adjuvant therapy, chemotherapy alone or chemotherapy tals (p < 0.0001 for all cases). Treatment with surgery plus combined with chemoradiation therapy, remains con- chemoradiation decreased signifi cantly for both stages in troversial. Our aim was to determine whether the type of both hospital settings by approximately 30% (p < 0.05 for adjuvant therapy for pancreatic cancer given in the United all cases). Non-surgical treatment for stage 2 disease was States has changed by examining treatment trends using surprisingly high and signifi cantly increased over time (p the National Cancer Data Base. < 0.0001 for both), ranging from approximately 30–37% at teaching-research hospitals and 40–49% at community METHODS: The National Cancer Data Base (NCDB) is a hospitals. national oncology outcomes database for over 1,500 Com- mission on Cancer-accredited cancer programs. Patients CONCLUSION: Data from the NCDB from 2003–2009 diagnosed with stage 1–2 pancreatic adenocarcinoma illustrate changes in the adjuvant treatment of pancreatic between 2003–2009 were selected from the NCDB Hospital cancer. There is an alarmingly high rate of non-surgical Comparison Benchmark Reports. Attention was paid to the therapy for stage 1 and 2 disease. The use of chemother- initial treatment regimen, such as surgery alone, surgery apy alone as adjuvant therapy increased whereas the use of plus chemotherapy, or surgery plus chemoradiation. In multimodality therapy decreased.

23 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Surgery Surgery Plus Surgery Plus No Surgical Only Chemotherapy Chemoradiation Therapy Percent Percent Cochran- Change Cochran- Percent Cochran- Change Cochran- Armitage Test Between Armitage Test Change Armitage Test Between Armitage Test Percent Change for Trend 2003 and for Trend between 2003 for Trend 2003 and for Trend Between 2003 and p Value 2009 p Value and 2009 p Value 2009 p Value 2009 Stage 1 Teaching-Research 0.1069 –3.14% <.0001 235.48% 0.0006 –27.70% 0.162 –1.42% Hospitals Community Hospitals 0.6323 –10.86% <.0001 261.12% 0.0002 –35.31% 0.145 3.53% Stage 2 Teaching-Research <.0001 –23.05% <.0001 229.31% <.0001 –34.21% <.0001 16.89% Hospitals Community Hospitals <.0001 –23.97% <.0001 174.81% <.0001 –30.35% <.0001 15.94% No Surgical Therapy includes no fi rst course therapy, chemotherapy only and chemoradiation only

588 RESULTS: The overall incidence of adenocarcinoma of the esophagus and the gastric cardia increased from 13.4 per Does the Incidence of Adenocarcinoma of the million in 1973 to 51.4 per million in 2009, a nearly 400% Esophagus and Gastric Cardia Continue to Rise in increase. Jointpoint analysis demonstrated that the yearly the 21st Century? increase in incidence has slowed somewhat from 1.27 per Attila Dubecz1, Norbert Solymosi2, Michael Schweigert1, million before 1987 to 0.97 between 1987–1997 and 0.65 Rudolf J. Stadlhuber1, Hubert J. Stein1, Jeffrey H. Peters3 after 1997. Stage-specifi c analyses suggests, that incidence 1. Surgery, Klinikum Nurnberg, Nuremberg, Germany; of early stages has actually declined after 2001 with a yearly 2. Faculty of Veterinary Science, Szent Istvan University, Budapest, decrease of 0.22. The percentage of patients diagnosed with Hungary; 3. Division of Thoracic and Foregut Surgery, Department early cancer declined after 2000 and remained under 2.5% through the study period. Regression analysis showed a of Surgery, University of Rochester School of Medicine and substantially higher correlation of incidence of adenocarci- Dentistry, Rochester, NY noma of the esophagus and the gastric cardia with popula- BACKGROUND: The rising incidence and histologic tion (r2 = 0.95) than with time (r2 = 0.65). change to adenocarcinoma in esophageal cancer over CONCLUSION: The incidence of esophageal adenocarci- the past four decades has been among the most dramatic noma continues to rise in the 21st century in the United changes ever observed in human cancer. Recent reports States. A signifi cant linear correlation of incidence with have suggested that its increasing incidence may have pla- total population was found. teaued over the past decade. Our aim was to examine the latest trends in esophageal adenocarcinoma incidence and analyze its correlation with time and population density. PATIENTS AND METHODS: We used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to identify all patients with ade- nocarcinoma of the esophagus and gastric cardia between 1973 and 2009. Both overall and stage specifi c trends in incidence were analyzed using joinpoint regression. The correlation of incidence with time and total population within the geographic areas covered by SEER was analyzed by linear regression.

24 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

589 590 Reoperative Intervention in Patients with Mesh at Infl uence of Ethnicity on the Effi cacy and Utilization Hiatus Is Associated with High Morbidity and High of Bariatric Surgery in the United States Incidence of Esophageal Resection: Single Center Ranjan Sudan1, Deborah Winegar2, Steven Thomas3, Experience John M. Morton4 Kalyana C. Nandipati, Maria Bye, Se Ryung Yamamoto, 1. Department of Surgery, Duke University Medical Center, Pradeep K. Pallati, Tommy H. Lee, sumeet K. mittal Durham, NC; 2. Department of Clinical Affairs, LipoScience, Creighton University, Omaha, NE Raleigh, NC; 3. Department of Biostatistics and Bioinformatics, BACKGROUND: Increasing use of mesh for hiatus repair Duke University, Durham, NC; 4. Department of Surgery, Stanford during anti-refl ux surgery has been reported. Re-operative University, Palo Alto, CA intervention with previously placed mesh is technically BACKGROUND: In the US more blacks than whites are Abstracts more challenging. The aim of this study is to present a severely obese (26% vs. 15%) and suffer from hypertension Monday single Center experience with reoperative intervention in (40% vs. 27%). Prior studies examining the infl uence of patients with previous mesh at hiatus and outcomes in this race on bariatric surgery have been from single-institution subset of patients. or small cohorts. This is the fi rst study to examine dispari- METHODS: After Institutional review board approval pro- ties in national patterns of utilization and the infl uence of spectively maintained database was retrospectively queried ethnicity on outcomes after Roux-en-Y gastric bypass sur- to identify patients who underwent re-operative interven- gery (RYGB) from the large multi-institutional prospective tion between 2003 to 2012 and had mesh placed at a previ- database for the American Society for Bariatric and Meta- ous hiatal hernia procedure. Patient charts were reviewed bolic Surgery. and variables collected included demographics, indications, METHODS: All research-consented white, black or His- operative details (initial and reoperative) and postoperative panic patients undergoing RYGB between 6/2007 and complications. 10/2011 and eligible for one year of follow-up were RESULTS: Twenty-six patients met inclusion criteria included. Other races were excluded. Descriptive statistics and form the cohort for the study. There were 14 females were used for demographic information. Multivariate logis- with a mean age of 58.3 + 29.2 years. Synthetic mesh was tic and normal regression models examined relationships placed in 15 (58%) patients, while the remaining 11 had between race and outcomes, controlling for age, gender, bio-prosthetic mesh. Mean duration of re-operative inter- baseline BMI and comorbid conditions. Races were com- vention since the last surgery was 22 (1–52) months. Dys- pared using a t-test for continuous variables and Pearson phagia (57%) was the most common presentation while 4 chi-square test for categorical variables. Reported p-values patients had mesh erosion. Recurrent hiatus hernia (2 to 7 were adjusted for the false discovery rate (FDR) to control cm) was noted in 16 (62%) patients. Nine patients (35%) for multiple testing. underwent redo fundoplication, 8 (31%) were converted RESULTS: The racial distribution of the 135,262 study to Roux en Y gastrojejunostomy, 3 (12%) underwent dis- patients was 79% white, 12% black, and 9% Hispanic. tal esophagectomy with esophago-jejunostomy, 5 (19%) Among the blacks undergoing RYGB only 15% were male had subtotal esophagectomy with gastric pull-up and one whereas 22% of the white and Hispanic patients were patient underwent substernal gastric pull-up for esophageal men. Compared to whites, blacks were younger (42.8 ± bypass with interval esophagectomy. The mean operative 10.6 vs. 46.3 ± 11.6 yrs.), heavier BMI (50.2 ± 9.2 vs. 47.6 time was 250 + 70.1 min, the median blood loss was 150 ± 8.0 kg/m2 and more often hypertensive (58% vs. 53%) ml (50–1650 ml). Reoperative intervention was performed at baseline. Although mortality rates within 30 days were with laparoscopic approach in 50% (13/26) of the patients, equivalent for all races (0.23–0.26%), serious adverse events laparoscopy converted to laparotomy in 12% (3/26) of the were higher for blacks (3.65%) versus whites (3.19%) and patients, laparotomy was performed in 34% (9/26) and tho- Hispanics (2.01%). At 1 year, mean BMI decreased markedly racotomy was performed in 1 patient. There was no post- to 35.0 ± 7.5 for blacks, 31.6 ± 6.73 for whites and 32.6 ± operative mortality. Major complications were noted in 6 7.0 kg/m2 for Hispanics. However, the percentage decrease patients. Mean ICU stay was 6 days and hospital stay was in BMI from baseline was lower for blacks (-30%) compared 14 days. to whites (-34%) and Hispanics (–32%). Similarly, hyper- CONCLUSION: Reoperative intervention in patients with tension decreased from 57% to 37% (blacks), 53% to 27% mesh at hiatus is associated with a high (>35%) need for (whites) and 42% to 29% (Hispanics) but, the percentage esophageal resection. More than half the patients also had decline was less for blacks (-35%) versus whites (–49%) and a recurrent hiatal hernia. Caution is advised in liberal use of Hispanics (–50%). Resolution of diabetes also demonstrated mesh for hiatoplasty. a similar pattern for blacks (59%) versus whites (65%) and Hispanics (61%). Racial differences in outcomes for weight loss and major comorbid conditions persisted after adjust- ment for baseline characteristics (p values and odds ratios are in Table1).

25 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Effect of Ehnicity on Outcomes at 1 Year

Black vs. Hispanic Black vs. White Hispanic vs. White Outcomes P-value PPM (95% CI) P-value PPM (95% CI P-value PPM (95% CI BMI 1 <.0001 1.23 (1.04, 1.42) <.0001 1.77 (1.65, 1.89) <.0001 0.54 (0.38, 0.71) Excess Body Weight (kg) <.0001 2.00 (1.59, 2.42) 0.0155 0.50 (0.14, 0.87) <.0001 –1.50 (–1.73, –1.28) Outcomes P-value OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) GERD 0.7875 1.05 (0.91, 1.20) 0.0095 0.87 (0.79, 0.96) 0.0056 0.83 (0.74, 0.93) Diabetes 0.8914 0.98 (0.82, 1.17) 0.0258 1.15 (1.03, 1.28) 0.0661 1.17 (1.02, 1.35) Hypertension <.0001 1.66 (1.44, 1.90) <.0001 1.69 (1.57, 1.83) 0.7339 1.02 (0.90, 1.16) Obstructive Sleep Apnea Syndrome 0.8914 1.02 (0.86, 1.21) 0.9332 .00 (0.89, 1.11) 0.7339 0.97 (0.84, 1.13)

CONCLUSIONS: Race exerts a signifi cant infl uence on out- clinical database to supplement perioperative data. Read- comes after RYGB. Despite lower effi cacy in blacks, overall missions unrelated to the index admission were omitted. benefi ts from RYGB were signifi cant. Given the higher prev- RESULTS: We identifi ed 173 (16%) patients who required alence of obesity in blacks, bariatric surgery is underutilized readmission after PD within the study period. The readmis- by this group (particularly males). Higher baseline BMI and sion rate was higher in the 2nd half of the decade when com- more frequent hypertension in blacks indicate need for ear- pared to the 1st half (18.6% vs 12.3%, p = 0.003), despite a lier surgical intervention. stable 7 day median length of stay. Readmitted patients were Outcomes are fi t with a generalized linear model control- analyzed against those without readmissions after PD. The ling, sex, age, current tobacco use, prior medical history, demographics and tumor pathology of both groups did not and current BMI unless noted. Reported p-values were differ signifi cantly. In the multivariate logistic regression adjusted with FDR. 1 The covariate BMI was replaced with analysis, preoperative albumin ≤3.5 (19% vs 11%, OR 1.6, p baseline BMI PPM: Predicted population marginal mean = 0.046), multi-visceral resection at time of PD (3% vs 0.6%, difference. OR 11.9, p = 0.031) and a length of initial hospital stay >7 days (59% vs 43%, OR 1.6, p = 0.043) were independently 591 associated with readmissions. There were no postoperative biochemical variables that were predictive of readmissions. Understanding Hospital Readmissions After Fifty percent (n = 87) of the readmissions occurred within 7 Pancreaticoduodenectomy: Can We Prevent Them? days from initial operative discharge. The reasons for early A 10-Year Contemporary Experience with 1173 Patients and late (>7 days) readmissions differed; ileus, delayed gas- at the Massachusetts General Hospital tric emptying and pneumonia were more common in early Zhi Ven Fong, Klaus Sahora, Seefeld J. Kimberly, readmissions, whereas wound infection, failure to thrive Cristina R. Ferrone, Sarah P. Thayer, Andrew L. Warshaw, and intraabdominal hemorrhage were associated with late Keith D. Lillemoe, Matthew M. Hutter, Carlos Fernandez-del readmissions. The incidence of readmissions due to pan- creatic fi stulas and intraabdominal abscesses were equally Castillo distributed between both time frames. General Surgery, Massachusetts General Hospital, Boston, MA CONCLUSION: The frequency of readmission after PD is INTRODUCTION: The morbidity and mortality of pancre- 16%, and has been on the uptrend over the last decade. aticoduodenectomy (PD) have signifi cantly decreased over Poor preoperative nutritional status and the complexity of the past decades to the point that they are no longer the initial resection were independently associated with hospi- sole indicators of quality and safety. In recent times, hospi- tal readmissions after PD. Further efforts should be centered tal readmission is increasingly used as a quality metric for on preventing early readmissions, which constitute half of surgical performance, and has direct implications on health all readmissions. care costs. We sought to delineate the natural history and predictive factors of readmissions after PD. METHODS: The clinicopathologic and long-term follow- up data of 1173 consecutive patients who underwent PD between August 2002 and August 2012 at a single institu- tion were reviewed. The NSQIP database was linked with our

26 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

9:45 AM – 11:00 AM 300 QUICK SHOTS SESSION I

592 594 Does Intramesorectal Proctectomy Affect Overall Adenovirus-Mediated Interferon Therapy Sensitized Complication Rates Compared to Standard Total Chemotherapy and Radiation for Pancreatic Cancer in Mesorectal Excision in Patients with Ulcerative Colitis? Vitro and in Vivo Models Abstracts Caitlin W. Hicks1,2, Richard A. Hodin1, Lieba R. Savitt1, Joohee Han1, Yoshiaki Miura1, Leonard Armstrong1, Monday Liliana Bordeianou1 Ryan M. Ryan M Shanley2, Xianghua Luo2, Eric H. Jensen1, 1. Department of Surgery, Massachusetts General Hospital, Edward W. Greeno3, Selwyn M. Vickers1, Masato Yamamoto1, Boston, MA; 2. Department of Surgery, The Johns Hopkins Julia Davydova1 Hospital, Baltimore, MD 1. Surgery, University of Minnesota, Minneapolis, MN; PURPOSE: In patients with ulcerative colitis (UC), intrame- 2. Division of Biostatistics, University of Minnesota, Minneapolis, sorectal proctectomy involves close dissection along the MN; 3. Medicine – Hematology, Oncology and Transplantation, rectal wall with concomitant rectal eversion (IMP/RE). In University of Minnesota, Minneapolis, MN contrast, standard total mesorectal excision (TME) involves Interferon- (IFN) in conjunction with chemoradiother- close dissection along the pelvic wall with an intraabdom- apy has emerged as a promising treatment for pancreatic inal stapled rectal transection above the levator muscles. adenocarcinoma. However, despite encouraging survival Our goal was to compare surgical outcomes among UC results (e.g. a 5-year survival rate of 55% in a phase II trial patients following IMP versus TME (Figure). by the Virginia Mason study group evaluating adjuvant METHODS: All patients undergoing IPAA surgery for active chemotherapy, immunotherapy and external-beam radia- UC at a tertiary referral hospital over a 10.5-year period tion for resected PDAC), utilization of this regimen has (09/2000-04/2011) were included in analysis. Univari- been impeded by systemic toxicity of IFN. ate analysis (T-tests and chi square tests) and step-wise fi t To circumvent these problems, we engineered a novel infec- regression modeling were used to compare complications tivity-enhanced oncolytic adenoviral vectors for high-level rates among patients undergoing IMP vs. TME procedures. targeted IFN expression (Ad-IFN). We hypothesized that RESULTS: Of 201 patients identifi ed for inclusion in a new therapeutic modality combining an Ad-IFN with the study, 119 (59%) underwent IMP/RE. Age, race, gen- chemoradiation would overcome the major drawbacks of der, smoking status, disease comorbidity, steroid or other IFN-based regimens. The adenovirus-mediated tumor-selec- immunomodulator use, surgical urgency, severity of disease tive expression of IFN will eliminate systemic toxicity of on pathology, and surgical staging were similar between cytokine, while massive IFN expression via replication- groups (p = ns). IMP/RE patients underwent fewer laparo- competent vector will yield an extended response. In this scopic procedures (2% vs. 37%, p < 0.0001) based on sur- study, we combined this vector with chemo- and radiother- geon preference. On univariate analysis, IMP/RE patients apy and analyzed its therapeutic ability in vitro and in vivo had fewer total perioperative complications (0.9 ± 0.1 vs. models. 1.4 ± 0.1, p = 0.02), but no differences in abdominal sepsis, The in vitro assays revealed that combination of Ad-IFN post-operative length-of stay, or hospital readmissions (p = with chemotherapeutics (5-FU, gemcitabine, cisplatin) and ns). However, in a step-wise regression model accounting X-ray radiation killed human and hamster pancreatic can- for age, co-morbidities, disease severity, pre-operative medi- cer cells signifi cantly better than either of the single treat- cations, operative technique, and follow-up time (mean 5.5 ments. Furthermore, we established pancreatic tumors in ± 0.2 years), both anastamotic leak rate [OR –0.56 (95% CI immunocompetent hamsters and discovered that combi- 0.33, 0.99); p = 0.04] and overall post-operative combined nation of Ad-IFN with either 5FU or radiation (8 Gy and pouch-related and infectious complications were lower in 20 Gy were tested) resulted in remarkable tumor shrinkage the IMP/RE group (2.0 ± 0.2 vs. 2.6 ± 0.2, p = 0.03). and was signifi cantly superior to radiation and 5-FU alone CONCLUSIONS: IMP/RE appears to be associated with or both of these combined. The triple-therapy (Ad-IFN+X- fewer overall post-operative complications than TME in ray+5-FU) outperformed all treatment groups. The evalua- patients with UC. This may be a refl ection of smaller free tion of the survival rate also showed statistically signifi cant space within the pelvis and/or the ability to invert the rec- improvement in groups treated with dual (Ad-IFN+X-ray) tal stump staple line during concomitant rectal eversion. and triple (Ad-IFN+X-ray+5-FU) therapies versus conven- However, further studies on functional and long-term out- tional approaches (radiation or/and 5FU). comes are needed.

27 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Our results support the impact of Ad-mediated IFN to 596 sensitize chemotherapy and radiation for pancreatic can- cer. This strategy may expand clinical use of the robust and Laparascopic Pyloroplasty: A Promising Treatment for promising IFN-based multimodal therapy to meet the press- Refractory Gastroparesis ing continued need for PDAC treatment. Katie Farah, Elie Aoun, Elizabeth Dovec, Sheri A. Mancini The Western Pennsylvania Allegheny Health System, 595 Pittsburgh, PA Planned Delay of Contrast Swallow Study and Oral INTRODUCTION: Gastroparesis is a chronic debilitating Intake After Minimally Invasive Esophagectomy digestive disorder characterized by a delay in gastric emp- tying. Nausea, vomiting, abdominal pain, and bloating Reduces the Anastomotic Leak Rate and Hospital are characteristic of the disease and signifi cantly affect the Length of Stay patient’s quality of life. Medical therapy is limited to very John S. Bolton, William C. Conway few agents most of which are limited by their side effect Surgery, Ochsner Clinic, New Orleans, LA profi le. Various surgical techniques for the treatment of INTRODUCTION: With the increasing use of minimally gastroparesis are invasive, not as effective, and have high invasive esophagectomy (MIE) and early hospital discharge, complication rates. We describe our experience with lapa- the timing and role of postoperative contrast swallow study roscopic pyloroplasty as a therapeutic alternative for the (SS) has become increasingly problematic. We systemati- treatment of gastroparesis. cally evaluated a policy of delayed SS and oral intake after PATIENTS AND METHODS: 22 patients with refractory MIE until the second postoperative week, approximately gastroparesis were enrolled in this prospective study and one week after hospital discharge. underwent minimally invasive pyloroplasty. Pre- and post- METHODS: Between Sept 2007 and October 2012, 143 operative gastric emptying study (GES), Gastroparesis Car- consecutive patients undergoing MIE were evaluated for dinal Symptom Index (GCSI©2003 Johnson & Johnson), inclusion in the study. Patients with obvious clinical or and complications were recorded. radiographic leak by d 7 were excluded from the study. Our RESULTS: 21 patients underwent laparoscopic pyloro- study group consisted of 30 patients (Late Eaters) whose SS plasty and one patient was converted to open laparotomy. and po intake were intentionally delayed (20 patients) until The mean duration of the procedure was 106 ± 25 minutes. a week after hospital discharge or were delayed by postop The average length of stay was 2.9 ± 1.2 days. There were events (10 patients) which made early SS and institution or no major complications linked to the surgical procedure. At oral feeds impractical. The study group was compared to a one month follow up, 16/22 (72.7%) patients noted over- control group who were deemed ready to have SS done and all improvement in their symptoms. At six months, 19/22 po intake started while in the hospital on postop day 5-7. (86.3%) patients showed improvement in their GES. The Primary endpoints studied were the anastomotic leak rate GES results normalized in 18/22 (81.8%) patients at one (ALR) and the hospital length of stay (LOS). year. The T1/2 decreased from 392 to 110 minutes (p = RESULTS: Data are shown in Table 1. 0.001). Signifi cant improvements were noted on all items of the GCSI score at one year post-operative visit (Table 1). CONCLUSION: After MIE, a policy of early hospital dis- charge nil per os, delaying SS and resumption of oral intake Gastroparesis Cardinal Symptom Index (GCSI) Pre and to about two weeks postoperatively, signifi cantly reduces Post-Op Data hospital LOS and anastomotic leak rate. Early institution or oral feeds after MIE appears to increase ALR. Symptom Pre-Op Score Post-Op Score p- Value Nausea 4.45 1.41 <0.001 Table 1 Retching 3.00 0.55 <0.001 Postop Day on which Vomiting 3.14 0.64 <0.001 SS Done and Oral Intake Anastomotic Hospital Length Fullness 4.73 2.32 <0.001 Begun (Median) Leak Rate of Stay Unable to fi nish a meal 4.41 1.55 <0.001 Early Eaters D6 22% (20/91) D8 Feeling full 4.68 2.05 <0.001 (n = 91) Loss of appetite 4.41 1.36 <0.001 Late Eaters D12 3% (1/30) D6 Bloating 4.73 2.05 <0.001 (n = 30) Stomach visibly bigger 3.73 1.45 <0.001 p < 0.05 p < 0.05 p < 0.05 CONCLUSION: Laparoscopic pyloroplasty is an effective, minimally invasive, and safe surgical alternative in patients with refractory gastroparesis who either fail or are intoler- ant of medical therapy. While our results are very promis- ing, larger studies are needed to further evaluate its role.

28 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

597 RESULTS: Between 2006 and 2010, 316 pancreatectomy cases were reported to NSQIP by our institution. Two hun- Limitations of NSQIP in Reporting Complications for dred and forty-nine were reviewed in detail, among them Patients Undergoing Pancreactectomy: Underscoring 145 (58.2%) Whipples, 19 (7.6%) total , the Need for a Pancreas-Specifi c Module 65 (26.1%) distal pancreatectomies, and 15 (6.0%) central Irene Epelboym, Irmina Gawlas, James A. Lee, Beth Schrope, or partial resections. Median age was 65.7, males comprised John A. Chabot, John D. Allendorf 41.5% of the group, and 74.3% of patients were Cauca- Surgery, Columbia University Medical Center, New York, NY sian. Overall rate of complications reported by NSQIP was 44.0%, compared with 55.0% in our review, however dis- BACKGROUND: Administrative databases are used with cordance was observed in 73 (29.3%) cases (p < 0.001), increased frequency for reporting hospital-specifi c and including 24 cases of reporting a complication where nationwide trends and outcomes after various surgical pro- there was not one, and 49 cases of missed complication. cedures in order to improve quality of surgical care. NSQIP

Most frequently reported event was postoperative bleed- Abstracts is a risk-adjusted case-weighted complication tracking ini- ing requiring transfusion (22.7%), however true incidence Monday tiative that reports 30-day outcomes from more than 400 of postoperative bleeding was actually 19.0%, with NSQIP academic and community institutions in the United States missing 27 (57.5%) and incorrectly reporting 36 (64.3%), p alone. However, the accuracy of reported events specifi c to < 0.001. Four procedures unrelated to the index operation pancreatic surgery has never been reported in depth. were recorded as reoperation events. While a pancreas-spe- METHODS: We retrospectively reviewed a randomly cifi c module does not yet exist, NSQIP reports a 7.6% rate selected subset of patients, the information on whose post- of organ-space surgical site infections; when compared with operative course was originally reported through NSQIP. our institutional rate of Grade B and C postoperative fi stula Preoperative characteristics, operative data, and postopera- (8.8%), we observed discordance 6% of the time, p<0.001. tive events were recorded after review of electronic medical Delayed gastric emptying, a common post-pancreatectomy records including physician and nursing notes, operative morbidity, was not captured at all. Additionally, there were room records and anesthesiologist reports. We compared signifi cant inaccuracies in reporting urinary tract infec- categorical variables using chi-square or Fischer’s exact test tions, postoperative pneumonia, wound complications, and continuous variables using Student’s t-test. and postoperative sepsis, with discordance rates of 4.4%, 3.2%, 3.6%, and 6.8%, respectively. CONCLUSIONS: NSQIP data is an important and valu- able tool for evaluating quality of surgical care, however pancreatectomy-specifi c postoperative events are often mis- classifi ed, underscoring the need for a hepatopancreatobil- iary-specifi c module to better capture key outcomes in this complex and unique patient population.

29 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

598 respectively compared to 72.5, 60.1, and 80.5 for M-Ab (p < 0.001). The Chi-Ab demonstrated improved specifi city as Chimeric Antibodies to CEA Improve Detection of evident by the lower signal intensity in normal human tis- Human Colon Cancer in Orthotopic Mouse Models sue samples compared to M-Ab (normal colon tissue: 4.3 vs Cristina A. Metildi1, Sharmeela Kaushal1, George A. Luiken2, 5.4; normal pancreas tissue: 1.5 vs 2.7) indicating decreased Mark A. Talamini1, Robert M. Hoffman1,3, Michael Bouvet1 binding of Chi-Ab. The chimeric CEA antibody was also 1. Surgery, University of California San Diego, La Jolla, CA; accurate in labeling human colon cancer in mouse xeno- 2. OncoFluor, San Diego, CA; 3. AntiCancer, Inc., San Diego, CA grafts enabling improved detection of tumor margins for more effective resection, increasing the R0 resection rate Positive surgical margins after colorectal cancer surgery from 86% to 96%. are strong predictors for higher local recurrence rates and poor overall survival. Currently, no real-time, reliable detec- The chimeric form of our fl uorophore-conjugated CEA anti- tion assays for positive surgical margins at the time of sur- body has more effective labeling of human CEA-expressing gery exist. We have previously shown improved detection cancer in tissue arrays and in our xenograft mouse models and resection of primary pancreatic cancer with a mouse- of human colon cancer. The improved sensitivity and speci- derived fl uorophore-conjugated antibody against the tumor fi city of the chimeric fl uorophore-conjugated antibody is antigen CEA in open laparotomies in mouse models. The clinically translatable. aim of this study was to demonstrate improved sensitivity The top left panel is an illustration of the steps required and specifi city of a new chimerized antibody against CEA to convert a mouse antibody to a human antibody. Before in detection of CEA-expressing colon cancer for improved fully humanizing the antibody, we tested the chimeric anti- resection in xenograft mouse models. body on normal tissue and CEA-expressing colon tissue Mouse models of human colon cancer were established with samples, comparing its labeling sensitivity and specifi city fragments of a CEA-expressing patient colon tumor. Two to the mouse antibody. The bottom left panel shows that a to four weeks after implantation, mice were randomized brighter signal is obtained by labeling the tumor with the to fl uorescence-guided surgery (FGS) or bright-fi eld surgery chimeric antibody, as compared to the mouse antibody. (BS). Mice in the FGS group received tail vein injections of Also, there is less labeling on normal tissue with the chi- the chimeric anti-CEA-Alexa-488 antibody 24 hours prior meric antibody. The two panels on the right illustrate the to resection. Pre- and postoperative images were obtained improved detection of CEA-expressing colon tumor in our to assess for completeness of resection. Mice were then fol- mouse models with the chimeric antibody. lowed for 6 months postoperatively to assess for recurrence and overall survival. At termination, all tumor lesions were 599 harvested and evaluated histologically. The chimeric anti- body was also tested on frozen tumor and normal tissue Endoscopic Submucosal Dissection for Early Neoplasia arrays comparing it to the mouse antibody. of the Foregut: A North American Perspective Jonathan Cools-Lartigue, Lorenzo E. Ferri Surgery, McGill University, Montreal, QC, Canada INTRODUCTION: Endoscopic resection as an organ spar- ing option in the management of early cancers of the fore- gut is becoming increasingly accepted. In North America, endoscopic mucosal resection (EMR) is the technique pri- marily employed. However lesions greater than 1 cm fre- quently require piecemeal resection with EMR, resulting in a high rate of local recurrence. Endoscopic Submucosal Dissection (ESD) allows for the en-bloc removal of larger tumors, however there is very limited data of this procedure in North America. We present our experience as one of the only centers in North America routinely performing ESD for neoplasia of the foregut. METHODS: A prospectively maintained database of all patients with early neoplasia of the foregut managed in a busy North American centre was reviewed for patients undergoing ESD. Patient characteristics, endoscopic/post- The chimeric antibody directed against CEA demonstrated endoscopy outcomes, pathologic features, and oncologic improved sensitivity and specifi city in labeling CEA- outcomes were captured. Data presented as median(range). expressing tumor compared to the mouse antibody. The fl uorophore conjugation effi ciency to the chimeric CEA RESULTS: From 5/2009–11/2012 twenty patients (74 antibody (Chi-Ab) was 2-fold higher than the mouse CEA (38–85)yrs: 16M/4F) underwent ESD for neoplasia in the antibody (M-Ab). On frozen tumor tissue arrays, the signal gastric antrum (10), body (2), cardia (6), or esophagus (2). intensity of the Chi-Ab was signifi cantly brighter compared General anesthesia was performed in the majority (19/20) to the M-Ab indicating improved binding to tumor tis- and endoscopy time was 75 (30–330) minutes. The fi rst sue. For colon, pancreas and lung tumor samples, the sig- 5 cases were longer than the last 15 (235(132–330) vs 75 nal intensity with the Chi-Ab was 94.1, 85.3, and 106.1, (30–240) minutes). Median lesion size was 2.25 (0.6-5) cm

30 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

and most underwent en-bloc resection (18/20). Perforation CONCLUSION: In this study, CAW concentrated mainly in occurred in 3 patients, which was repaired by endoscopy (2) surgical specimen extraction sites, and port-related compli- or by laparoscopy (1). Bleeding requiring repeat endoscopy cations were uncommon. occurred in 1 pt. Length of stay was 2 (1–7) days, there were no re-admissions. Final pathology revealed invasive cancer 601 in 13 (ADC = 9, SCC = 3, NET = 1: T1a = 9, T1b = 3, T2 = 1)) and adenoma with dysplasia in 7. Complete resection (R0) Intraoperative Testing Following EEA Stapling, and the was achieved in 18/20, the 2 incomplete resection cases Implications for Postoperative Anastomotic Leaks underwent laparoscopic resection. There is no evidence of Jake G. Prigoff, Adam C. Fields, Sapna Rustagi, recurrence at 5 (1–41) months follow-up. Celia M. Divino CONCLUSIONS: Although technically challenging, endo- Mount Sinai School of Medicine, New York, NY scopic submucosal dissection for neoplastic lesions of the INTRODUCTION: Anastomotic leaks will occur in roughly Abstracts upper GI tract is effective, feasible, and can be safely applied 3-10% of surgical procedures that include an end-to-end Monday in a North American setting. anastomosis (EEA). To prevent leaks, surgeons evaluate the doughnuts removed from the autosutures and perform 600 maneuvers to assess the viability of the anastomosis includ- ing air-leak tests, beta-dine leak tests, and rigid sigmoidos- How Frequent Are Complications of the Abdominal copies. This study will evaluate the effi cacy of these tests to Wall After Laparoscopic Colorectal Surgery? determine if they are valid. Alejandro J. Zarate, Camila Estay, Udo Kronberg, METHODS: A cohort of 44 surgical patients (ages 18–92; Claudio Wainstein, Francisco López-Köstner 25 male) who presented to The Mount Sinai Medical Center Colorectal Unit, Clinica las Condes, Santiago, Chile between 2005 and 2012 with anastomotic leaks were com- BACKGROUND: At present, advantages of laparoscopic pared to a case control group of 86 patients without postop- colorectal surgery (LCRS) over a conventional approach erative leaks. Only anastomoses distal to the splenic fl exure have been demonstrated, mostly due to a reduced morbid- and created by employing an EEA stapler were included, ity and hospital stay. This has encouraged the development as those anastomoses are testable via beta-dine, air-leak, of new minimally invasive techniques like single incision rigid , and doughnut observation. Air-tests laparoscopic surgery, which are thought to have further and beta-dine tests for left hemicolectomies were excluded. benefi ts over LCRS especially due to reduction of the num- Patient demographics, surgical procedures, reoperations, ber of incisions on the abdominal wall. However, there is pathologic fi ndings, and outcomes of the intraoperative only few information available regarding complications on tests were reviewed. All statistical analyses were performed the abdominal wall (CAW) after LCRS. using SPSS v20 software. PURPOSE: To analyze CAW in patients undergoing LCRS. Table 1 METHODS: Patients were selected from our prospectively Post-Operative Leak No Post-Operative Leak maintained database of LCRS, operated between July 2007 Test Result (Number Of Patients) (Number Of Patients) and July 2012. Following a standardized protocol, the surgi- Positive Air-Leak Positive 1 0 1 0 2 1 2 0 cal specimen was extracted using an Alexis retractor to pro- Beta-dine Incomplete tect surgical site, and incisions of 10 mm were sutured both Doughnuts Positive Rigid aponeurosis and skin, while 5 mm incisions only had skin Sigmoidoscopy closure. Patients with anastomosis leak and/or deep surgical Negative Air-Leak 25 9 43 15 66 29 81 13 site infection were included. Information of demographic, Negative Beta-dine operative and follow-up data was analyzed using chi square Complete Doughnuts and t of Student tests. Negative Rigid Sigmoidoscopy RESULTS: In 455 patients that underwent LCRS during the above-mentioned period, 16 (3.7%) had ≥ 1 CAW. Eight patients (1.9%) had an incisional surgical site infection Table 2 (SSI), six (1.4%) had an abdominal wall hematoma, three (0.7%) presented an incisional hernia, and two (0.5%) had Positive Negative a covered evisceration during early follow-up. Frequency of Specifi city Predictive Predictive CAW was similar in patients operated secondary to diver- Test Sensitivity (%) (%) Value (%) Value (%) ticular disease and those with malignancy. Every SSI, hema- Air-Leak 3.85 97.06 33.33 72.53 toma and incisional hernia developed in surgical specimen Beta-dine 0.0 96.67 0.0 76.32 extraction site, with no signifi cant differences between EEA Doughnut 2.27 97.59 33.33 65.32 periumbilical and suprapubic incision (SSI p = 0.15; Hema- Integrity toma p = 0.990; Incisional hernia p = 0.08). Two out of three Rigid 0.0 100 - 46.43 patients with incisional hernia had a prior SSI. When ana- Sigmoidoscopy lyzing morbidity associated with ports, there was 1 (0.08%) covered evisceration in 1,180 incisions of 5 mm ports, and another one in the 890 incisions of 10 mm ports (0.11%).

31 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: The procedures included low anterior resection histopathological diagnosis. Available published data (50.0%), left hemicolectomy (15.9%), sigmoid resection seems to indicate that there is an incongruency between (29.5%), and ilio-anal pull through (13.6%). Procedures of sonographic diagnosis and the actual surgical pathology of the control group were equivalent ±7%. Beta-dine and air- gastric subepithelial lesions with a reported accuracy that leak tests, as well as doughnut observation, were more likely ranges between 20% and 84%. in the control group, and rigid sigmoidoscopies less likely. AIM: To compare the diagnosis suggested by sonographic Table 1 displays the true positives, true negatives, false posi- evaluation of various subepithelial lesions throughout the tives, and false negatives. Table 2 has their corresponding GI tract with the histological description of tissue speci- sensitivities and specifi cities. mens obtained by endoscopic mucosal resection (EMR). CONCLUSIONS: A combination of EEA doughnut integ- METHODS: Patients who underwent endoscopic mucosal rity and an air-leak test show the highest predictive value. resection for a suspected subepithelial lesion were retro- However, the high rates of false negatives and correspond- spectively identifi ed from 2009 to 2012 at two university ing low sensitivities of these tests show their inability to hospitals. The diagnosis made at the time of the endoscopic correctly identify the patients who will ultimately have ultrasound prior to EMR was compared with the diagnosis anastomotic leaks. made from the specimen obtained after EMR. 602 RESULTS: Twenty-three patients (12M, 11F) with a mean age of 58yrs (range 36–82 yrs) were identifi ed who under- The Pathologic Diagnosis of Subepithelial Lesions of went both EUS and EMR for subepithelial lesions of the GI the GI Tract Based Solely on Sonographic Features tract. The location of the lesions were: esophagus 1, stom- Correlates Poorly with Histopathological Diagnosis ach 13, duodenum 6, rectum 3. EUS based diagnosis was Obtained by Mucosal Resection only 61% accurate when compared with the histopatho- Andrew Jatskiv1, Gabriel H. Lee1, Laura Rosenkranz1, logical diagnosis obtained via EMR. (Table 1) Sandeep Patel1, Kenneth Sirinek2 CONCLUSION: Except for the rectum, there is poor cor- 1. Medicine, UTHSCSA, San Antonio, TX; 2. Surgery, UTHSCSA, relation between the sonographic and histopathological San Antonio, TX diagnosis of subepithelial lesions of the GI Tract. Based on these fi ndings, clinical decision making protocols that rely BACKGROUND: Subepithelial lesions are incidentally solely on endoscopic sonographic fi ndings for pathologic found during routine endoscopy of the gastrointestinal diagnosis are fl awed and may lead to unnecessary surgical (GI) tract. Endoscopic ultrasonography (EUS) has become procedures. All subepithelial lesions of the GI Tract should the preferred non-invasive technique in evaluating these undergo endoscopic mucosal resection for a defi nitive his- subepithelial lesions. It is assumed that it provides valuable topathological diagnosis to direct appropriate treatment. information such as size, echotexture, layer of origin and features of invasion which may correlate with a particular

EUS Diagnosis Histologic Diagnosis Age Sex Esophagus (1) Duplication Cyst Granular Cell Tumor 36 F

Stomach (13) Carcinoid Carcinoid 48 F Carcinoid Carcinoid 82 F Carcinoid Carcinoid 59 M Carcinoid Carcinoid 60 M Carcinoid Oxyntic Gastric Mucosa 46 F Carcinoid Gastric Adenoma 55 M Granular Cell Tumor Granular Cell Tumor 61 M Granular Cell Tumor Pancreatic Heterotopia 54 M Granular Cell Tumor Lipoma 81 F Infl ammatory nodule Infl ammatory nodule 63 F Pancreatic Heterotopia GIST 63 F Pancreatic Heterotopia Pancreatic Heterotopia 44 F Pancreatic heterotopia Pancreatic Heterotopia 71 M

Duodenum (6) Pancreatic Heterotopia Carcinoid 44 F Carcinoid Carcinoid 75 M GIST Leiomyoma 58 M Infl ammatory nodule Ectopic Salivary gland tissue 52 F Infl ammatory nodule Infl ammatory nodule 54 M Carcinoid Carcinoid 51 M

Rectum (3) Infl ammatory nodule Infl ammatory nodule 73 M Carcinoid Carcinoid 47 F GIST GIST 61 M

32 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

603 CRC and 249 (11.6%) had early-onset CRC. 1,447 patients (67.4%) were Caucasian, 111 (5.2%) African American, and Characteristics of Early-Onset Colorectal Cancer 589 (25.4%) Asian. Tumor was located in the appendix in Kidist Yimam, Richard E. Shaw, Christine Wong, 21 (1%), cecum in 275 (12.8%), ascending colon in 207 Joyce Louie, Edward W. Holt, Michael S. Verhille, (9.6%), hepatic fl exure in 102 (4.8%), transverse colon in Taehyun P. Chung, Michael Abel 134 (6.2%), splenic fl exure in 79 (3.7%), descending colon California Pacifi c Medical Center, San Francisco, CA in 90(4.2%), sigmoid colon in 431 (20.1%), rectosigmoid junction in 166 (7.1%), and rectum in 592 (27.7%). At BACKGROUND: Colorectal cancer (CRC) diagnosed at diagnosis, 170 patients (7.9%) had carcinoma in situ, 553 or before age 50 (early-onset) is increasing in the United (25.8%) stage I, 57 (24.1%) stage 2, 489 (22.8%) stage 3, States. Early-onset CRC is associated with more advanced and 291 (13.6%) stage 4. The prevalence of early-onset CRC stage disease at diagnosis compared to CRC diagnosed at or increased from 11.4% to 16% during the study period (p after 50 years of age (late-onset).

= 0.157). Patients with early-onset CRC had more rectal Abstracts PURPOSE: To compare the occurrence of early-onset and tumors than patients with late-onset CRC (48.6% vs. 33.3%, Monday late-onset CRC at our center from 2000 to 2011 and iden- p < 0.001), higher rate of recurrence (34.7% vs. 23.6%, p < tify characteristics associated with early-onset CRC. 0.001), and more advanced tumor stage at diagnosis (p < METHODS: We retrospectively studied all patients diag- 0.001). Independent predictors of early-onset CRC included nosed with CRC at our center from January 2000 to Janu- 1st (aOR 1.8 (1.1–2.9), p = 0.016) and 2nd (aOR 5.4 (2.9– ary 2011 using our cancer registry database. Patients were 10.1), p < 0.001) degree family history of CRC and receiving defi ned as early-onset or late-onset CRC based on age at chemotherapy (aOR 3.5 (2.44–5.43), P < 0.001). History of diagnosis. Additional variables were recorded including smoking, cancer in sigmoid colon, and stage 1 and 2 dis- demographic data, personal or family history of CRC or eases were less associated with early-onset CRC on the mul- other cancers, alcohol and tobacco use, tumor location by tivariate analysis. colonic subdivision and tumor stage at diagnosis. Univari- CONCLUSION: Patients with early-onset CRC had more ate analysis (Pearson’s Chi-square or Kendall’s tau-b tests) rectal tumors, more advanced stage disease at diagnosis and was used to identify factors associated with early onset CRC. a higher rate of recurrence. These patients more frequently Multivariate analysis (Cox proportional hazards regression) had a family history of CRC but less frequently had a his- determined independent predictors of early-onset CRC. tory of smoking. Early-onset CRC is an aggressive disease RESULTS: We identifi ed total 2,147 patients, of these, that portends a poor prognosis. Further work is merited to 1,057(49.2%) were male, 1,898 (88.4%) had late-onset identify additional risk factors for this disease.

10:00 AM – 11:00 AM 304AB VIDEO SESSION III

604 605 Robotic Assisted Single Incision Ileocolic Resection Dual-Scope Endoscopic Resection of Benign GE Using Standard Robotic Instrumentation and a Junction Tumors (with Video) Single Incision Laparoscopy Surgery (SILS) Port Edwin O. Onkendi1, Larissa Fujii2, Michael J. Levy2, Jennifer Hrabe, Anthony R. Cyr, John W. Cromwell, Christopher J. Gostout2, Juliane Bingener1 John Byrn 1. Surgery, Mayo Clinic, Rochester, MN, Rochester, MN; Surgery, University of Iowa, Iowa City, IA 2. Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, We present a representative case from our initial experi- Rochester, MN ence with robotic single incision colectomy. This ileoco- Surgical resection for benign subepithelial tumors near lic resection was performed in a 20 year old female with the gastroesophageal junction is diffi cult, often leading to medically refractory fi brostenotic Crohn’s disease. The per- esophagectomy. Here we demonstrate the feasibility of a ceived advantages of robotic single incision surgery over novel technique of dual endoscopic resection using retro- laparoscopic single incision surgery are: improved visual- fl exed standard adult upper endoscope and second smaller ization, a surgeon-controlled camera platform, and wristed caliber (baby) endoscope to resect benign GE junction leio- instrumentation. myomas (2-6 cm size) in four patients. Maneuvering the small caliber endoscope allowed off-axis retraction of the mass while the adult endoscope was used to carry out the dissection from the submucosal tissue. Our experience highlights the feasibility of this minimally inva- sive approach by enabling triangulation using endoscopic tools.

33 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

606 607 Pass the Courvoisier’s: Laparoscopic Extrahepatic Bile eTAMIS: Transanal Minimally Invasive Surgical Duct Resection with Roux-en-Y Hepaticojejunostomy Submucosal Excision of a Large, Circumferential, Rebecca Kowalski1, Niket Sonpal2, Jennifer Montes1, Rectal Adenoma with Endoscopic Visualization Paresh C. Shah1 Elisabeth C. McLemore, Alisa M. Coker, Peter T. Yu, 1. Surgery, Lenox Hill Hospital, Northshore-LIJ Health System, Garth R. Jacobsen, Mark A. Talamini, Sonia Ramamoorthy, Hofstra Medical School, New York, NY; 2. Medicine, Lenox Hill Santiago Horgan Hospital, Northshore-LIJ Health System, Hofstra Medical School, Surgery, UC San Diego, La Jolla, CA New York, NY TECHNICAL POINTS ADDRESSED: Transanal endolu- We present an 82 year old man with obstructive jaundice, minal surgical techniques can be employed to safely and dark urine and pale stools. On presentation his total biliru- completely remove a large, circumferential rectal adenoma. bin was 12.4. CT of the abdomen and pelvis showed dilated This video demonstrates the benefi ts of combining endo- intrahepatic and common bile ducts with a 1.4 x 2.3 × 2.0 scopic visualization and submucosal injection with mini- cm mass at the junction of the neck and cys- mally invasive endoluminal surgery using a soft, disposable tic duct. He underwent laparoscopic extrahepatic bile duct transanal access platform. resection with Roux-en-Y hepaticojejunostomy. Pathology CASE HISTORY: A 51 year old female was found to have demonstrated a 2.5 × 1.5 x 1.0 cm moderately-differentiated a circumferential rectal mass extending from 3cm to 11 cm adenocarcinoma of the gallbladder with 4 negative lymph on fl exible endoscopy and non-invasive transrectal ultra- nodes. Staging was determined to be T2 N0 (Stage II). sound (uT0N0). Final pathology revealed a 8.5 × 6.2 × 1.5 cm tubulovillous adenoma with high grade dysplasia and negative margins.

2:00 PM – 3:00 PM 303ABC QUICK SHOTS SESSION II

707 RESULTS: 664 patients (m:f = 136:526; median age 44.2 years [range 18–66], average BMI 45.6 [range 33.1–76.9]) Is Esophago-Gastro-Duodenoscopy Prior to Roux-en-Y underwent preoperative EGD. In 341 cases no abnormalities Gastric Bypass Mandatory? were found (A), 115 patients had fi ndings that did not have Usha K. Coblijn, Arvid Schigt, Sjoerd D. Kuiken, consequences (B1), 112 patients needed HP eradication Pieter Scholten, Sjoerd M. Lagarde, Bart A. van Wagensveld therapy (B2), 87 patients needed preoperative treatment by Sint Lucas Andreas Ziekenhuis, Haarlem, Netherlands proton pump inhibitors (B3), and 6 patients needed follow up EGD prior to surgery (C). For one patient the operation BACKGROUND and study aims: Roux-Y Gastric Bypass was cancelled because preoperative EGD showed Barrett’s is one of the most frequently used techniques in surgery esophagus with carcinoma (D). When all abnormalities for morbidly obese patients. Postoperative anatomy is are taken into account, baselines show a signifi cant differ- altered by exclusion of the remnant stomach which makes ence for age, gender, hypertension and alcohol consump- this organ inaccessible for future Esophago-gastro-duode- tion. The number of performed EGD’s to fi nd one serious noscopy (EGD). There is no consensus about preoperative abnormality (requiring a follow up EGD and/or postponing assessment of the stomach. Some institutions choose to or cancelling the operation) is 94,5. The estimated costs of investigate the future remnant stomach by EGD, others do one EGD (including personnel costs but without sedation, not. Aim of the present study is to quantify the yield of pre- admission and possible complications) is approximately operative EGD in a bariatric center of excellence. 385 US dollar. METHODS: Patients, who were planned for laparoscopic CONCLUSION: Based on our results and those in literature Roux-Y Gastric Bypass (LRYGB) from December 2007 until it can be concluded that routine assessment by EGD prior to August 2012, were all screened by EGD in advance. These laparoscopic Roux-Y Gastric Bypass should be abandoned. fi les were retrospectively reviewed for EGD outcome, co- In this selected series, risk factors for abnormalities are age, morbidities, medication and other patient characteristic. gender, hypertension and alcohol consumption. The num- All these data were analyzed using a statistical program. ber of EGD’s needed to perform to fi nd one abnormality A two sided P value of <0.05 was considered statistically that requires treatment is high, with equal high costs. signifi cant.

34 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

708 709 Upper Endoscopy Prior to Bariatric Surgery: Do Visual Perioperative Blood Transfusion Reduces Survival Findings Accurately Predict Mucosal and Anatomical in Patients with Pancreatic Adenocarcinoma: A Pathology? Multi-Institutional Study of 698 Patients Craig D. Kolasch, Kristian T. Dacey, Eric Boyle, Jeffrey M. Sutton1, David Kooby2, Gregory C. Wilson1, Amanda Walters, Keith S. Gersin, Dimitrios Stefanidis, Dennis J. Hanseman1, Shishir K. Maithel2, David J. Bentrem3,4, Timothy Kuwada Sharon M. Weber5, Clifford S. Cho5, Emily Winslow5, Carolinas Medical Center, Charlotte, NC Charles R. Scoggins6, Robert C. Martin6, Hong Jin Kim7, 8 8 1 BACKGROUND: Evaluation of upper GI mucosa and anat- Nipun Merchant , Alex Parikh , Daniel E. Abbott , omy is important prior to bariatric surgery. Esophagogastro- Michael J. Edwards1, Syed A. Ahmad1 duodenoscopy (EGD) can diagnose H.pylori infection (HP), 1. Surgery, University of Cincinnati College of Medicine, Cincinnati, Abstracts mucosal infl ammation and hiatal hernia (HH). HP can be OH; 2. Surgery, Emory University School of Medicine, Atlanta, GA; Monday treated preoperatively and the degree of GERD and HH may 3. Surgery, Northwestern University Feinberg School of Medicine, infl uence the choice of bariatric procedure. Mucosal biopsy Chicago, IL; 4. Surgery, Jesse Brown Veterans Affairs Medical adds to the cost of EGD and some endoscopists do not “rou- Center, Chicago, IL; 5. Surgery, University of Wisconsin School of tinely” biopsy for HP if the gastric mucosa appears normal. Medicine and Public Health, Madison, WI; 6. Surgery, University The goal of this study was to determine the relationship of Louisville School of Medicine, Louisville, KY; 7. Surgery, between gross visual fi ndings on EGD and histopathology. We also examined the ability of EGD to accurately diagnose University of North Carolina School of Medicine, Chapel Hill, NC; hiatal hernia. 8. Surgery, Vanderbilt University School of Medicine, Nashville, TN METHOD: A retrospective review of prospectively col- INTRODUCTION: In this multi-institutional study of lected data of a single surgeon (TSK) series of laparoscopic patients undergoing pancreaticoduodenectomy (PD) for non revisional bariatric procedures at a center of excellence pancreatic adenocarcinoma, we sought to identify factors between 2010-2012. Preoperative EGD was performed on associated with a perioperative blood transfusion require- all patients. Patients without a gastric biopsy were excluded ment. In addition, we investigated the hypothesis that from analysis. Endoscopic appearance (gross) was consid- receiving blood transfusion reduces long-term survival in ered positive if there were any signs of infl ammation or this patient population. hiatal hernia. The gross and histological appearances were METHODS: A retrospective chart review was performed compared. Biopsy results (histology) and laparoscopic eval- across six high-volume institutions to identify patients uation of the hiatus were considered the gold standard Sen- who underwent PD between 2005 and 2010. Data collec- sitivity (SS) and specifi city (SP) of the gross EGD appearance tion included patient demographics, perioperative fac- were calculated. tors, transfusion status, and survival data. For statistical RESULTS: There were 274 patients in the study group. analysis, patients were then grouped according to whether Mean age and BMI were 42.8 and 43.3 respectively. The they received 0, 1-2, or >2 units of packed red blood cells majority of the patients were female (88%). Procedures (pRBCs). included: 189 laparoscopic gastric bypass, 69 laparoscopic RESULTS: Among 698 patients identifi ed, 168 (24%) and 16 laparoscopic adjustable gastric required blood transfusion. 105 (15%) received 1–2 units bands. There were 57 HH confi rmed at the time of surgery and 63 (9%) received >2 units (range 0–25 units). Patient (20%). Preoperative EGD identifi ed 21 of these (SS = .37, SP demographics associated with an increased transfusion = .86). H. pylori was identifi ed in 34 patients (12.5%); 19 of requirement included age, smoking status, and heart dis- these patients had gross infl ammatory changes on EGD (SS ease (all p < 0.03). Operative variables associated with an = .56, SP = .58). Gross gastric infl ammatory changes were increased transfusion requirement included operative time, identifi ed in 63/125 patients that had histological gastritis estimated blood loss, tumor size, and R1/R2 margin status (SS = .50, SP = .64). There were 12 patients with histological (all p < 0.03). Postoperative complications were not associ- GERD, 8 of these patients had grossly infl amed esophageal ated with transfusion requirement. However, those patients mucosa (SS = .67, SP = .24). who received transfusions experienced a longer length of CONCLUSION: EGD prior to bariatric surgery can provide stay (p = 0.0009) as well as increased rate of readmission important information that may alter preoperative inter- within 90 days (p = 0.002). The median survival of patients ventions and infl uence the choice of bariatric procedure. who received >2 units of pRBCs was signifi cantly less than Our fi ndings suggest that the gross appearance during EGD those who received either 0 or 1–2 units (10.2 months vs. is unreliable for detecting histological infl ammation, infec- 18.4 or 18.9 months, p = 0.0002). A multivariate model tion (HP) and HH. Thus, we recommend routine gastric including margin status, nodal involvement, tumor size, biopsies to maximize H. pylori detection during EGD. Fur- and transfusion status identifi ed the transfusion of >2 units thermore, if the presence of a hiatal hernia could change of pRBCs as an independent predictor of reduced survival a procedural recommendation, a complimentary upper GI (HR 1.56, p = 0.03). evaluation should be considered.

35 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSIONS: This multi-institutional study represents tiveness of modern chemotherapeutic regimens and the the largest series to date analyzing the effects of pRBC trans- high operative mortality in this population, further studies fusion in patients undergoing PD for pancreatic adenocar- are needed to evaluate the role of and timing of resection of cinoma. The transfusion rate in this series is less than what the primary tumor. has been previously reported. Our data confi rm that blood transfusion confers a negative impact on long-term survival 711 in this patient population. These results can be utilized as a benchmark for future studies. Transplant Versus Resection for the Management of Hepatocellular Carcinoma in the Post-2006 MELD 710 Exception Era at a Single Institution in the Southeast UNOS Region Trends in Resection and Chemotherapy in Patients Malcolm H. Squires1, Steven Hanish2, Sarah B. Fisher1, with Stage IV Colorectal Cancer Cristen Garrett2, David Kooby1, Juan M. Sarmiento3, 1 1 1,2 Gabriela Vargas , Kristin Sheffi eld , Abhishek Parmar , Kenneth Cardona1, Stuart J. Knechtle2, Maria C. Russell1, 1 1 1 Yimei Han , Taylor S. Riall , KImberly M. Brown Joseph F. Magliocca2, Andrew B. Adams2, Charles A. Staley1, 1. General Surgery, University of Texas Medical Branch, Galveston, Shishir K. Maithel1 TX; 2. General Surgery, USCF East Bay, Oakland, CA 1. Department of Surgery, Division of Surgical Oncology, Winship INTRODUCTION: Patterns and trends in the use of mod- Cancer Institute, Emory University, Atlanta, GA; 2. Department ern chemotherapeutic regimens, primary tumor resection, of Surgery, Division of Liver Transplantation, Emory Transplant and the relative timing of chemotherapy and resection in Center, Emory University, Atlanta, GA; 3. Department of Surgery, older patients with stage IV colorectal cancer (CRC) have Division of General and GI Surgery, Emory University, Atlanta, GA not been evaluated. BACKGROUND: Optimal management of hepatocellular METHODS: We used Texas Cancer Registry-Medicare carcinoma (HCC) in the post-2006 MELD (Model for End linked data (2001–2007) to identify patients 66 and older Stage Liver Disease) exception era remains controversial with stage IV colorectal cancer (N = 3,343). Time trends and is regionally dependent. We compared outcomes for in resection of the primary tumor and receipt of chemo- patients undergoing liver transplant versus resection at a therapy were determined. We defi ned chemotherapy regi- single institution in a UNOS region with short wait times mens as “standard” (5-fl uorouracil (5-FU)/leucovorin (LV)) for organ availability. or “modern” (oxaliplatin or irinotecan plus 5-FU/LV or bevacizumab). METHODS: All patients who underwent resection of HCC between 1/00 and 8/12 were identifi ed. Inclusion of RESULTS: The mean age of patients was 76.9 ± 7.2 years, patients who underwent transplant was limited to those 53.3% were female, and 80.9% were white. 87.7% of can- after 1/06, when the MELD exception policy for HCC based cers were in the colon and 25.7% of tumors were poorly dif- on the (MC) was universally incorporated ferentiated histologically. Liver metastases, lung metastases, into UNOS organ allocation. Primary outcomes were over- and carcinomatosis were documented in 72.8%, 32.3% and all survival (OS) and recurrence-free survival (RFS). 36.3% of patients, respectively. 37.4% were treated with both chemotherapy and resection, 26.4% had resection RESULTS: 259 patients were identifi ed, of whom 133 only, 11.8% had chemotherapy only, and 24.4% had no underwent transplant and 126 underwent resection. Trans- treatment. Resection of the primary tumor was performed plant patients had a higher incidence of hepatitis C (67% vs in 63.8% of patients, of which 24.3% were emergent. After 29%, p < 0.001), a greater median raw MELD score (15 vs 8, excluding emergent procedures, resection decreased from p < 0.001), and smaller tumor size (2.4 vs 7.0 cm, p < 0.001). 59.9% to 53.0% between the early (2001–2002) and late All 133 patients who underwent transplant met MC, while (2006–2007) study periods (P = 0.007). In patients undergo- 37 (29%) who underwent resection met MC. Of these 37 ing elective resection and chemotherapy (N=1015), resec- patients, 26 had preserved liver function with a raw MELD tion was done prior to chemotherapy in 88.5% of patients. score ≤8. Median follow-up time was 30 mos. Median wait 30-day post-operative mortality for all patients undergoing time to transplant was 55 days (1-321); no patients dropped resection of the primary tumor was 13.5% and 10.7% for off the waitlist while awaiting an organ. elective resection. Chemotherapy was given to 49.2% of Transplant compared to resection was associated with patients and was stable over time. However, in patients who improved OS (median not reached (MNR) vs 28.7 mos, p received chemotherapy, the use of oxaliplatin or irinotecan < 0.001) and greater RFS (MNR vs 17.4 mos, p < 0.001). plus 5-FU/LV increased from 53.3% in 2001 to 89.7% in When compared to the 37 patients within MC who under- 2007 (P < 0.0001). After approval of bevacizumab for meta- went resection, transplant demonstrated a trend towards static CRC in 2004, its use increased from 0.5% to 30.8% improved OS (MNR vs 57.4 mos, p = 0.065) and greater from 2001–2004 and from 30.8% to 55.8% from 2004-2007 RFS (MNR vs 35.2 mos, p < 0.001; Figure). Of these 37 (P<0.0001). patients who underwent resection, 11 (30%) have under- CONCLUSIONS: In patients with stage IV colorectal can- gone salvage procedures for recurrence of HCC versus only cer, modern chemotherapeutic regimens have been rapidly 4 (3%) transplant patients. Compared to resection patients adopted over the last decade. Concomitantly, there has within MC with a raw MELD score ≤8 (n = 26), transplant been a decrease in resection rates. Given the increased effec- demonstrated similar OS (MNR vs 57.4 mos, p = 0.84) but

36 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

greater RFS (MNR vs 17.6 mos, p < 0.001). For patients RESULTS: Forty-one incisional hernia repairs met our with hepatitis C, those undergoing transplant (n = 89) had inclusion criteria. Alloderm was used in 21 (51.2%) cases improved outcomes compared to the 19 patients who met and Permacol was utilized in 20 (48.8%) cases. Seventeen MC and underwent resection (OS: MNR vs 47.9 mos, p = patients (41.5%) developed a recurrent hernia at a mean 0.04; RFS: MNR vs 16.2 mos, p < 0.001). interval of 10.4 months from surgery. Hernias repaired with Alloderm recurred in 47.6% (10 of 21) patients, while Per- macol repairs recurred in 35% (7 of 20) of cases (p = 0.412). Infectious complications necessitating surgical interven- tion developed in 9 cases (22%). Hernias repaired using the bridging technique revealed an 87.5% recurrence rate (7 of 8), while underlay fi xation of the mesh with native fascial reapproximation led to recurrence in only 31.3% of the

cases (10 of 32). Abstracts Monday CONCLUSION: Our results demonstrate relatively high rates of recurrence when performing a single stage ventral in a contaminated fi eld with biologic mesh. Permacol and Alloderm showed similar results in this series. This rate is signifi cantly higher than typically reported in literature, likely due to longer follow-up and relatively high patient acuity, and calls into question the cost-effectiveness of the use of biologic mesh in a single stage repair for con- CONCLUSION: In a region with short wait times for organ taminated recurrent hernias vs the older approach of using availability, liver transplant is associated with improved a lightweight absorbable synthetic with a second-stage survival compared to resection for HCC. For patients defi nitive repair. within Milan criteria, transplant appears to confer an onco- Table 1: Characteristics of Patients Undergoing Hernia Repair with logic advantage as well, even in those with preserved liver Biologic Mesh in an Infected Field function. For patients within Milan criteria with hepa- titis C, transplant is associated with improved survival Overall Alloderm Permacol p-Value and decreased recurrence when compared to resection. N 412120— Transplant should be considered for all patients meeting Gender, Males 39% 30% 48% 0.248 Milan criteria, particularly those with hepatitis C, when Age, years 58.7 (11) 56.8 (8) 60.7 (14) 0.094 being managed in a region with short wait times for organ Mesh positioning 78/20/2 62/33/5 95/5/0 0.037 availability. (%underlay/inlay/ onlay) 712 Length of stay, days 6.1 (2) 6.8 (2) 5.4 (2) 0.024 Recurrenc rate 41.5% 47.6% 35% 0.412 Biologic Mesh in a Contaminated Field: Infected Mesh Interval to recurrence, 10.4 (7) 9.0 (7) 12.4 (8) 0.370 Removal and Hernia Repair in a Single-Stage months Jeffrey Mino, Rosebel Monteiro, Steven Rosenblatt Duration of follow-up, 16.1 (15) 17.0 (15) 15.3 (16) 0.790 General Surgery, Cleveland Clinic, Cleveland, OH months PURPOSE: High rates of recurrence and infectious compli- Data presented as means (SD), or percentages where indicated cations are associated with the repair of hernias with syn- thetic mesh in a contaminated surgical fi eld. Biologic mesh Table 2: Mesh Positioning and Recurrence Rates: is believed to reduce the rates of these complications. We Permacol vs. Alloderm compared the performance of two widely available bioma- terials, Permacol and Alloderm, in a single-stage procedure Overall Alloderm Permacol of infected mesh removal and hernia repair. N 412120 Underlay 32 13 19 METHODS: All patients who underwent a single-stage Recurrence (%) 10 (31.3) 4 (30.8) 6 (31.6) incisional hernia repair with replacement of an infected Inlay 8 7 1 synthetic mesh by a biologic mesh were identifi ed. Data retrieved included patient demographics, details of current Recurrence (%) 7 (87.5) 6 (85.7) 1 (100) hernia repair with biologic mesh, post-operative complica- Onlay 1 1 0 tions, and hernia recurrence. Recurrence (%) 0 (0) 0 (0) 0 (0)

37 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

713 714 Predictors of Bile Duct Injury During Laparoscopic Molecular Pathological Phenotypes and Outcome in Cholecystectomy: Experience from Two Hospitals Pancreatic Ductal Adenocarcinoma Curtis J. Wray1, John A. Harvin1, Uma R. Phatak1, Nigel B. Jamieson1, Mohamed A. Mohamed1, Karin Oien2, Lillian S. Kao1, Tien C. Ko1, Taylor S. Riall2 Fraser Duthie2, Euan J. Dickson1, Ross Carter1, Colin McKay1 1. Surgery, University of Texas Medical School at Houston, 1. West of Scotland Pancreatic Unit, Glasgow University Houston, TX; 2. Surgery, University of Texas Medical Branch, Department of Surgery, Glasgow Royal Infi rmary, Glasgow, Galveston, TX Lanarkshire, United Kingdom; 2. Department of Pathology, INTRODUCTION: Bile duct injuries (BDI) during laparo- Southern General Hospital, University of Glasgow, Glasgow, United scopic cholecystectomy (LC) are a devastating complica- Kingdom tion. Due to the infrequent occurrence of BDIs, predictive INTRODUCTION: Individuals with pancreatic ductal factors are not well-understood. We hypothesized increased adenocarcinoma (PDAC) demonstrate a generally poor out- age is a risk factor for BDI. come following resection. Molecular profi ling has previ- METHODS: IRB-approved review of LC at two safety- ously enhanced the identifi cation of phenotypic subtypes net hospitals from 2005-2011. LC cases were coded elec- of ampullary adenocarcinoma. Furthermore an intestinal tive (same day surgery) or non-elective (admitted through subtype of PDAC has been described however the prognos- emergency room). Morbidity/mortality conferences, hospi- tic impact of this variant has not been described in detail. tal records and prospective data were used to identify BDIs. We sought to better characterize the intestinal subgroup of The Strasberg classifi cation was used to defi ne BDI. We cre- PDAC and assess the impact on outcome. ated a multivariate regression model to identify predictors METHODS: We assessed the potential clinical utility of of BDI. molecular pathological phenotypes defi ned using a com- RESULTS: 2896 LCs (n = 2370 female n = 526 male) were bination of histopathology and protein expression (CDX2 performed at two hospitals. 52% of cases were elective. 120 [caudal-type homeodomain transcription factor 2]—an cases were converted to an open operation. Males had a intestinal marker and MUC1—a pancreaticobiliary marker) higher mean age (years) than females (47 ± 15 vs 39 ± 14, assessed by immunohistochemistry (Figure 1) in 95 patients p = 0.01). 40 BDIs were identifi ed. The most common BDI who underwent operative resection for PDAC by pancreati- was type A (N = 27, women = 14 vs men = 13), followed by coduodenectomy at a single institution over a 12 year time E3 (N = 4), D (N = 4), E2 (N = 3) and C (N = 2). Predictors of period. A tissue microarray was used with at least 4 cores BDI included: Age (OR 1.44, 95%–CI 1.10-1.89), male gen- evaluated for each tumor for protein expression analysis in der (OR 3.07 95%–CI 1.83–5.12) and non-elective operation addition to whole section analysis of tumor morphology. (OR 5.11 95%–CI 1.16–22.5). The predicted probability of Care was taken to exclude all other periampullary malig- BDI increased with advancing ages, but more so for men nancies from the analysis. who underwent non-elective LCs (see graph). RESULTS: In addition to prognostic impact of T stage, lymph node status, resection margin status, perineural inva- sion and vascular invasion, a small proportion of tumors had features of an intestinal histological subtype (13%) and a more favorable prognosis. CDX2 and MUC1 expression were signifi cant prognostic variables. Patients with CDX2 negative tumors had a signifi cantly shorter survival (Hazard ratio [HR] = 2.77, 95%CI: 1.5–5.2, P = 0.002 as did those with MUC1 positive tumors (HR = 2.89, 95%CI: 1.7–4.9, P < 0.0001 – no survivors at 24 months). Patients with CDX2 negative/MUC1 negative tumors had an intermediate out- come (Figure 1). In a multivariate analysis lymph node involvement, vascular invasion, positive MUC1 expression and loss of CDX2 expression were independent predictors of poor outcome. CONCLUSION: Morphological determination of intesti- CONCLUSIONS: The risk of major or minor BDIs is signifi - nal subtype of PDAC has clinical relevance. Furthermore cant in older males undergoing non-elective LCs. Increased maintenance of CDX2 expression identifi es a group of risk of BDIs, due to increase age and emergency surgery, PDAC patients with a relatively good outcome while MUC1 should be risk factors considered when discussing the need expression identifi ed patients with a very poor outcome. and timing of elective LC, especially with male patients. When combined histopathological and molecular criteria Earlier referral and interventions aimed at decreasing the defi ne clinically relevant phenotypes of PDAC with signifi - percentage of emergency LCs may decrease the incidence cant implications for prognostication, current therapeutic of BDIs. strategies and may facilitate future trial design.

38 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

develop VTE after discharge. We aim to characterize the risk of post-discharge VTE after colorectal surgery and risk fac- tors that may suggest the need for the consideration of an extended postoperative VTE prophylaxis beyond the hos- pital phase. METHODS: The ACS-NSQIP dataset from 2005–2007 was used to identity patients undergoing colectomy or proctec- tomy. Patients who developed deep venous thrombosis or pulmonary embolism were identifi ed and sorted into pre or post discharge events. Univariate and multivariate analysis was done to identify risk factors for post-discharge VTE. RESULTS: 30,900 patients undergoing laparoscopic and Abstracts open resection of the colon and rectum for benign and Monday malignant conditions were identifi ed. 567 patients devel- oped DVT with 149 (26%) diagnosed post-discharge. 232 cases of pulmonary embolism were identifi ed with 82 Figure 1. Kaplan-Meier survival curves demonstrating stratifi cation of (35%) diagnosed post-discharge. Factors associated with the the 95 patient PDAC cohort according to CDX2 and MUC1 expression post-discharge risk for VTE included open vs. laparoscopic surgery (0.77% vs. 0.47%, p < 0.05), no resident vs. presence assessed by immunohistochemistry. of resident (0.91% vs. 0.62%, p < 0.05), steroid use (1.5% vs. 0.61%, p < 0.05), reoperation (1.3% vs. 0.65%, p < 0.05), 715 BMI > 30 (p < 0.05) and higher ASA class (p < 0.05). Venous Thromboembolism (VTE) After Colorectal CONCLUSION: A substantial fraction of overall VTE (DVT Surgery: Making the Case for Continuing Prophylaxis and PE) occurs post-discharge in patients undergoing After Discharge in High-Risk Patients colorectal resection, this risk higher in patients with higher Vikram Attaluri, Jeffrey Hammel, Pokala R. Kiran ASA class, on perioperative steroids and undergoing open Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH surgery and reoperation. These fi ndings strongly support the consideration of extension of VTE prophylaxis to the PURPOSE: SCIP measures target prophylaxis for venous post-discharge (at home) period after colorectal resection in thromboembolism (VTE), during the hospital phase for patients with these identifi ed risk factors. patients undergoing surgery; some patients nevertheless

Univariate Analysis for Post-Discharge VTE

Variable Overall N=30900 No Post-Discharge VTE Post-Discharge VTE p Value Age <70 yrs Age >70 ys 20150 (65.2%) 10750 (34.8%) 20018 (99.3%) 10672 (99.3%) 132 (0.66%) 78 (0.73%) 0.47 Female Male 15961 (51.7%) 14936 (48.3%) 15855 (99.3%) 14832 (99.3%) 106 (0.66%) 104 (0.70%) 0.73 Colectomy Proctectomy 28328 (91.7%) 2572 (8.3%) 28131 (99.3%) 2559 (99.5%) 197 (0.70%) 13 (0.51%) 0.26 Laparoscopic Open 8966 (29.2%) 21764 (70.8%) 8924 (99.5%) 21596 (99.2%) 42 (0.47%) 168 (0.77%) 0.004* No Resident Resident 7044 (22.9%) 23679 (77.1%) 6980 (99.1%) 23533 (99.4%) 64 (0.91%) 146 (0.62%) 0.009* No Metastatic Cancer Metastatic Cancer 29410 (95.2%) 1490 (4.8%) 29213 (99.3%) 1477 (99.1%) 197 (0.67%) 13 (0.87%) 0.35 No Steroid Use Steroid Use 28437 (92.0%) 2463 (8.0%) 28263 (99.4%) 2427 (98.5%) 174 (0.61%) 36 (1.5%) <0.001* No Sepsis SIRS Sepsis Septic Shock 26460 (85.6%) 2729 (8.8%) 26287 (99.3%) 2702 (99.0%) 173 (0.65%) 27 (0.99%) 0.049* 826 (2.7%) 885 (2.9%) 818 (99.0%) 883 (99.8%) 8 (0.97%) 2 (0.23%) No Operation within 30 days Operation 23421 (96.6%) 819 (3.4%) 23269 (99.4%) 808 (98.7%) 152 (0.65%) 11 (1.3%) 0.019* within 30 days No emergency surgery Emergency surgery 25904 (83.8%) 4996 (16.2%) 25733 (99.3%) 4957 (99.2%) 171 (0.66%) 39 (0.78%) 0.34 ASA Class 1-No Disturb 2-Mild Disturb 3-Severe 1047 (3.4%) 14338 (46.4%) 1042 (99.5%) 14256 (99.4%) 5 (0.48%) 82 (0.57%) 0.037 Disturb 4-Life Threat 5-Moribund 12591 (40.8%) 2692 (8.7%) 12483 (99.1%) 2678 (99.5%) 108 (0.86%) 14 (0.52%) 220 (0.71%) 219 (99.5%) 1 (0.45%) * signifi cant

39 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

2:00 PM – 3:45 PM 308D PLENARY SESSION V

778 independent function (OR-1.92, p < 0.001), and intraopera- tive transfusion≥4 units (OR-2.14, p < 0.001). Independent Morbidity and Mortality After Pancreatico- factors associated with mortality included: anesthesia risk duodenectomy in Patients with Borderline score > 3 (OR-2.27, p = 0.025), age ≥ 80 (OR-2.83, p < 0.001), Resectable Type C Clinical Classifi cation lack of independent function (OR-2.89, p = 0.002), and Ching-Wei D. Tzeng1, Matthew Katz1, Jason B. Fleming1, intraoperative transfusion ≥4 units (OR-2.80, p = 0.003). Holly M. Holmes3, Jeffrey E. Lee1, Peter W. Pisters1, Jean-Nicolas Vauthey1, Gauri R. Varadhachary2, Robert A. Wolff2, James Abbruzzese2, Thomas Aloia1 1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; 2. Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; 3. Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX BACKGROUND: We previously described the clinical classifi cation of patients with resectable pancreatic tumor anatomy but marginal performance status (PS) or revers- ible comorbidities as “borderline resectable type C” (BR-C for condition/comorbidity). This study was designed to analyze the nationwide incidence and risk factors for post- pancreaticoduodenectomy (PD) morbidity/mortality in patients who could be classifi ed as BR-C. METHODS: All elective PDs were evaluated in the 2005–10 ACS-NSQIP database. BR-C was defi ned by the following: age ≥ 80, lack of independent function, pulmonary disease, ascites/varices, recent myocardial infarction/angina, stroke CONCLUSIONS: These data confi rm that a large number history, steroid use, weight loss >10%, and/or preoperative of medically high-risk patients are being treated with PD. sepsis. Clinical variables potentially associated with 30-day These BR-C patients were at higher risk for and less able morbidity/mortality were analyzed, with a focus on the to be rescued from major morbidity, with higher rates of development of postoperative major complications defi ned mortality from potentially reversible risk factors. These data as: pneumonia, re-intubation/ventilation >48 hr, renal fail- suggest the need for optimization of comorbidities and for ure, cardiovascular event, sepsis, re-operation, dehiscence, increased utilization of prehabilitation to address nutri- organ space infection, and venous thromboembolism. tional and conditioning defi cits before PD. RESULTS: Of 8,266 PDs, 3,033 (36.7%) involved patients with BR-C classifi cation. Analysis of preoperative variables 779 determined that BR-C patients were more likely to have abnormal preoperative lab values (albumin, liver function Value of Frailty and Nutritional Status Assessment in tests, leukocytosis, coagulation, hematocrit, uremia, creati- Predicting Perioperative Mortality in Gastric Cancer nine, all p≤0.002) and need for preoperative hospitaliza- Surgery tion (23.6% vs. 12.3%, p < 0.001). Despite similar operative Juul Tegels, Michiel de Maat, Karel Hulsewé, times (≥360 min in 47.2% BR-C vs. 49.2% non-BR-C, p = Anton G. Hoofwijk, Jan H. Stoot 0.081), BR-C patients were more likely to suffer major Surgery, Orbis Medical Center, Sittard-Geleen, Netherlands complications (30.8% vs. 25.9%, p < 0.001) and mortality BACKGROUND: Reported perioperative mortality in gas- (4.1% vs. 2.3%, p < 0.001). In addition, BR-C patients with tric cancer surgery is relatively high (4–16%). This may major complications suffered a 50% higher mortality rate be due increased patient age and poor condition related compared to non-BR-C patients with major complications to advanced tumor stage at time of diagnosis. Comorbid- (11.5% vs. 7.7%, p < 0.001). For BR-C patients, multivari- ity and age are currently the main factors associated with ate analysis identifi ed the following risk factors for major the risk of surgical mortality however their predictive complications: albumin < 3.5g/dL (odds ratio, OR-1.24, p value is limited. Better preoperative evaluation tools have = 0.036), dyspnea (OR-1.71, p < 0.001), preoperative sepsis become warranted for better patient selection and prevent- (OR-1.89, p = 0.001), age ≥ 80 (OR-1.56, p < 0.001), lack of ing unnecessary surgery related mortality. The aim of the

40 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

study was to investigate the additional value of frailty and METHODS: Three hundred and fi fteen patients who nutritional status assessment for predicting perioperative underwent laparoscopic anti-refl ux surgery at the Univer- performance. sity of Nebraska Medical Center between 2002 and 2012 METHODS: Patients in our hospital are screened for frailty were included in this study. Patient data including pre and at admission using a scoring questionnaire to assess their post-operative studies and symptom questionnaires were GFI (Groningen Frailty Indicator) which entails Activities of prospectively collected and the database was used to ana- Daily Living, self-perceived physical and mental fi tness and lyze postoperative outcomes. Statistical analysis includ- multipharmacy. Further, nutritional status is assessed using ing multivariate regression models were used to compare SNAQ (Short Nutritional Assessment Questionnaire). We patient factors and their effect on outcomes. evaluated in a retrospective analysis whether these scores RESULTS: A total of 302 Nissen fundoplications, 24 redo were associated with 30-day mortality considering standard fundopliations, 11 Toupet and 2 Dor procedures were per- clinicopathological parameters. formed. Mean BMI was 31%. The median follow up was Abstracts RESULTS: From January 2005 to September 2012 180 68 (6–130) months. There were 3 reoperations (0.9%) for Monday patients underwent surgery for gastric cancer with an over- recurrent symptoms. Mesh was used in 210 cases where all 30-day mortality of 8.3%. Complete GFI and SNAQ hiatal hernia was larger than 2 cm. Median preoperative scores were available in 127 (71%) and 160 (89%) cases DeMeester score was 60.5 which decreased to 6 (p < 0.05). respectively. Univariate analysis showed a cumulative mor- Heartburn (N = 264) improved in 245 (92%), regurgitation tality risk in association with increasing GFI score (P < (N = 264) improved in 256 (97%) and dysphagia (N = 253) 0.001). Patients with a GFI ≥ 3 (n = 30, 24%) had a mortal- improved in 227 (89%). Atypical presentation such as pul- ity rate of 23.3% versus 5.2% in the lower GFI group (OR monary and throat symptoms only, improved in 82% of 4.0, 95% CI 1.1 to 14.1, P = 0.03). This was independent patients. Radiographic studies were available in 60% of the from patient age, ASA classifi cation, tumor stage and type patients with mean follow up of 1.5 years with evidence of surgery. SNAQ score ≥1 (n = 98, 61%) was associated with of overall recurrence of 7% (21% in hiatal hernia >5 cm). a mortality rate of 13.3% versus 3.2% in the group that Of those with recurrence over 91% were asymptomatic at scored 0 (OR 5.1, 95% CI 1.1 to 23.8, P = 0.04). This was follow up. Male gender, advanced age, size of hiatal hernia, also independent for patients age, type of surgery, tumor and preoperative BMI are independent predictors of worse stage and ASA classifi cation. Patients who were in the group outcomes. of both GFI ≥3 and SNAQ ≥1 (n = 25, 19%) had a mortality CONCLUSIONS: Antirefl ux surgery is effective in control- rate of 28% versus 6% in the remaining patients (OR 6.1, ling symptoms of refl ux and correction of hiatal hernia in 95% CI 1.7 to 22.4, P = 0.006). This fi nding was also inde- long term follow up of greater than 5 years. The durability pendent for patients age, type of surgery, tumor stage and of this procedure can be affected by large hiatal hernia and ASA classifi cation. high BMI and male sex. Overall patients were very satisfi ed DISCUSSION: This is the fi rst study that shows a signifi - with the operation even after 10 years of follow up. cant relation between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple scoring questionnaire. This information may be of value in 6 781 the preoperative decision making for selecting patients who would optimally benefi t from surgery for gastric cancer. Retroesophageal Fundic Wrap Incarceration: A Late Complication After Nissen Fundoplication Margaret M. McGuire, Erik G. Lough, Donald R. Czerniach, 780 John J. Kelly, Philip Cohen Surgery, University of Massachusetts, Worcester, MA Long Term Patient Outcomes After Laparoscopic This video illustrates the laparoscopic treatment of a late Antirefl ux Procedures retroesophageal fundic wrap incarceration in a patient who Anton Simorov, Ajay Ranade, Jeremy P. Parcells, had undergone laparoscopic Nissen fundoplication. Our Dmitry Oleynikov patient presented to the emergency room 3 years after a Surgery, UNMC, Omaha, NE Nissen fundoplication with epigastric pain, back pain and BACKGROUND: Laparoscopic antirefl ux surgery with or early satiety. Imaging revealed gastric outlet obstruction. without large hiatal hernia has been shown to have good Endoscopy showed a friable mucosa with patchy necrosis. short term outcomes. However, limited data are available On laparoscopic exploration the fundic wrap was found on long term outcomes of greater than 5 years. The aim incarcerated, due to rotation beyond 360 degrees through of this study is to review functional and symptomatic out- the retroesophageal space, and lying on top of the greater comes of anitrefl ux surgery in a large tertiary referral medi- curve of the stomach. After dissection and reduction of the cal center. wrap the incarcerated portion was necrotic and required resection.

41 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

782 783 The Association of Proton Pump Inhibitor Use on the Pancreatic Morphological Changes in a Long-Term Incidence of Erosive Esophagitis Follow-Up After First Episode of Acute Alcoholic Steven P. Bowers1, Armando Rosales-Velderrain1,2, Pancreatitis Marc G. Mesleh1, Horacio J. Asbun1, John Stauffer1, Eric J. Lam1, Jussi Nikkola2, Irina C. Rinta-Kiikka1, Sari Raty1, Johanna Mauricia Buchanan1, Jeffrey Ferrell1, Li-Ling Iem1, Laukkarinen1, Riitta Lappalainen-Lehto1, Satu Järvinen1, Ross F. Goldberg1, C. Daniel Smith1 Hanna Seppänen1, Isto Nordback1, Juhani Sand1 1. Surgery, Mayo Clinic, Florida, Jacksonville, FL; 2. General 1. Department of Gastroenterology and Alimentary Tract Surgery, Surgery, Cleveland Clinic Florida, Weston, FL Tampere University Hospital, Tampere, Finland; 2. School of BACKGROUND: Erosive esophagitis (EE) is experimen- Medicine, University of Tampere, Tampere, Finland tally and epidemiologically linked to Barrett’s esophagus OBJECTIVE: Long-term morphological changes induced (BE) and esophageal adenocarcinoma (EAC). The authors by a single episode of alcohol pancreatitis are not known. speculated that the increased availability of proton pump Our aim was to study these morphological changes in secre- inhibitor (PPI) medications may alter the epidemiology of tin stimulated MRCP (S-MRCP) after the fi rst episode of erosive refl ux disease. alcohol associated acute pancreatitis, and to evaluate the METHODS: Between 1991 and 2009, 18,000 inhabitants risk factors and the possible protective factors that might be of Olmsted County, Minnesota were identifi ed by the Roch- associated with later chronic fi ndings. ester Epidemiology Project as having undergone diagnostic PATIENTS AND METHODS: In this prospective follow- upper endoscopy (EGD). A review of medical records was up study S-MRCP-imaging was performed for 44 (41 M, 3F, performed on a random 10% sample of cases. Incidence of mean age 46 (25–68) years) patients who survived their fi rst EE was calculated based on the initial EGD of each case, and episode of alcohol associated pancreatitis. Pancreatic mor- was correlated with demographic and medical history data. phology was evaluated at 3 months, and at 2, 7 and 9 years RESULTS: Of the 1792 records reviewed, the incidence of after hospitalization. Recurrent attacks of pancreatitis were EE was 22.3% (by LA Classifi cation: Grade D, 0.9%; Grade studied and pancreatic function was monitored by labo- C, 2.8%; Grade B, 6.8%; Grade A, 11.8%). EE was associ- ratory tests. Patients’ alcohol consumption was evaluated ated strongly with male gender, but not with patient age or with questionnaires, laboratory markers and self-estimated obesity. PPI use history among cases signifi cantly increased alcohol consumption via interview. Smoking and BMI were throughout the study, from 7% in the period 1991–1997 annually recorded. to 25% in 1998–2003 to 42% in the period 2004–2009. RESULTS: At 3 months 32% of the patients had nor- Rates of EE in the time periods were 26%, 22%, and 21% mal fi ndings in S-MRCP, 52% had acute and 16% chronic respectively. Cases with history of PPI use had signifi cantly changes. At seven years, S-MRCP was performed to 36 lower incidence of EE (PPI use, 18%; no PPI use, 26%; p patients, with normal fi ndings in 53%, the rest (47%) hav- = 0.004, Fisher’s exact test), despite higher likelihood of ing chronic fi ndings. Pancreatic cyst was present in 36%, refl ux-related complaints. Including analysis of 1354 sub- parenchymal changes in 28% and atrophy in 28% of the sequent EGD in 676 cases, 7.5% of all cases had fi nding of cases. 7/36 (19%) patients demonstrated new chronic fi nd- endoscopically suspected esophageal metaplasia (ESEM) on ings after two years. There were no changes in the pan- any EGD; BE/EAC was found in 3.5% of all cases. ESEM and creas in the attending patients between 7 and 9 years (18 BE/EAC were each present at initial EGD or followed EE in patients). If chronic changes were present at 3 months after 90%. diagnosis, they would show in later S-MRCPs also. 45% CONCLUSIONS: Early treatment of refl ux symptoms of the patients who had only acute fi ndings at 3 months with PPI medication may be protective of development resolved to normal in 7 years, but the rest (55%) showed of erosive esophagitis and may decrease the likelihood of chronic changes later on. 22% of the patients who attended future development of Barrett’s esophagus and esophageal the seventh year S-MRCP had gone through a recurrent epi- adenocarcinoma. sode of acute pancreatitis (mean 22 (2–60) months), and 8% had a clinical diagnosis of chronic pancreatitis. At 7 years, 88% of patients with recurrences had chronic fi ndings in S-MRCP versus 36% with non-recurrent pancreatitis (p = 0.02). 6 (17%) patients maintained abstinence through the follow-up (mean 8.7 (7–9.1) years), but even one of these developed pancreatic atrophy. Out of the non-abstinent patients who didn’t have recurrences, 4/22 (18%) developed new fi ndings in the follow-up S-MRCP (NS). Heavy smok- ing didn’t show correlation to increased chronic changes compared to non-smoking in univariate analysis. CONCLUSIONS: Morphological pancreatic changes increase with recurrent episodes of acute pancreatitis. How- ever, even a single episode of acute alcoholic pancreatitis may induce chronic morphological changes in a long-term follow-up.

42 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

were directly attributable to pancreatic fi stula. Increasing 784 FRS scores (0–10) correlated well with CR-POPF develop- A Multi-Institutional External Validation of the Fistula ment (p < 0.001), with an area under the curve of 0.716. Risk Score for Pancreaticoduodenectomy When segregated by FRS risk groups, CR-POPFs occurred 1 2 in Low, Moderate and High Risk patients 6.6%, 12.9% and Benjamin C. Miller , John D. Christein , 28.6% of the time respectively (fi gure). Clinical outcomes 3 1 4 Stephen W. Behrman , Jeffrey A. Drebin , Wande B. Pratt , Mark including complications, length of stay, and readmission P. Callery4, Charles M. Vollmer1 rates, also increased across risk groups (Table). 1. Hospital of the University of Pennsylvania, Philadelphia, PA; 2. University of Alabama, Birmingham Medical Center, Birmingham, AL; 3. University of Tennessee Health Science Center, Memphis, TN; 4. Beth Israel Deaconess Medical Center, Boston, MA Abstracts

BACKGROUND: Accurate prediction of postoperative Monday pancreatic fi stula (POPF) after pancreaticoduodenectomy (PD) would help tailor optimal intra- and postoperative management of this morbid complication. Distinct risk factors for ISGPF clinically relevant fi stulas (CR-POPF), previously identifi ed as small duct size, soft gland texture, high-risk pathology, and increased blood loss, are best dis- cerned intraoperatively. The Fistula Risk Score (FRS), a 10 point scale derived at a single institution, relies on weighted infl uence of these four variables and has been shown to effectively predict (area under the curve of 0.942) CR-POPF development and its consequences. External validation of this tool would confi rm its universal applicability. CONCLUSION: This multi-institutional experience con- METHODS: From 2001–2012, 594 PDs with pancreatojeju- fi rms the Fistula Risk Score as a valid tool for predicting the nostomy reconstruction were performed by four pancreatic development of CR-POPF in patients undergoing pancre- surgical specialists at three institutions. POPFs, when they aticoduodenectomy. Patients devoid of any risk factors did occurred, were graded by ISGPF standards as biochemical not develop a CR-POPF, and the rate of CR-POPF approxi- (Grade A) or clinically relevant (Grades B and C). The FRS mately doubles with each subsequent risk zone. The lower was calculated for each patient and clinical outcomes were value of the area under the curve in this analysis is attribut- evaluated across four discrete categories (Negligible Risk, able to the decreased rate of CR-POPF observed in the high 0 points; Low Risk, 1–2 points; Moderate Risk, 3–6 points; risk group (29% vs. 89% originally). This difference might High Risk, 7–10 points). Receiver operator curve analysis be ascribed to variations in operative technique, postopera- was performed to judge model validity. tive management styles, patient characteristics, and a larger sample size in the current study. Despite this, the FRS is RESULTS: 142 patients developed any sort of POPF, of validated as an accurate prediction tool, with widespread which 68 were CR-POPF (11.4% overall: 8.9% Grade B, applicability, which can be readily translated into common 2.5% Grade C). There were 21 overall deaths, six of which practice.

Risk Profi le (Model Score) Variable Negligible Risk (0 points) Low Risk (1–2 Points) Moderate Risk (3–6 Points) High Risk (7–10 Points) p-Value Patients, n (% Total) 63 (10.6) 166 (27.9) 302 (50.9) 63 (10.6) – POPF, n (%) 1 (1.6) 19 (11.4) 90 (29.8) 32 (50.8) <.001 ISGPF Classifi cation, n (%) No fi stula 62 (98.4) 147 (88.6) 212 (70.2) 31 (49.2) <.001 Grade A 1 (1.6) 8 (4.8) 51 (16.9) 14 (22.2) <.001 Grade B – 9 (5.4) 29 (9.6) 15 (23.8) <.001 Grade C – 2 (1.2) 10 (3.3) 3 (4.8) <.001 CR-POPF, n (%) – 11 (6.6) 39 (12.9) 18 (28.6) <.001 Any complication, n (%) 32 (50.8) 97 (58.4) 216 (71.5) 54 (85.6) <.001 Length of stay, median 8 9 10 11 <.001 Readmission, n (%) 10 (15.9) 24 (14.5) 51 (16.9) 21 (33.3) <.001

43 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

4:00 PM – 5:00 PM 308D QUICK SHOTS SESSION III

785 Preexisting comorbidities such as chronic renal insuffi - ciency and infl ammatory bowel need to be considered in Impact of Key Factors of Enhanced Recovery Pathway predicting adverse outcomes after minimally invasive and Preexisting Comorbidities on Complications and colorectal surgery, while ASA was not suffi cient as a risk- Length of Stay Following Colorectal Surgery adjustment factor. Marianne Huebner1,2, David W. Larson1, Robert R. Cima1, Elizabeth Habermann1 786 1. Surgery, Mayo Clinic, Rochester, MN; 2. Statistics, Michigan Impact of a Standardized Surgical Safety Checklist on State University, East Lansing, MI Operative Effi ciency, Direct Operative Cost and Patient BACKGROUND: Patient and case complexity infl uence Outcomes Following Laparoscopic Incisional Hernia colorectal surgery outcomes. Success using enhanced recov- Repair ery pathways (ERP) after surgery requires assessing both Claire L. Isbell, Rahila Essani, Harry T. Papaconstantinou patient-factors risk adjustment as well as compliance with pathway elements. Surgery, Scott & White Memorial Hospital, Temple, TX METHODS: During 2011, 535 minimally invasive colorec- INTRODUCTION: The Surgical Safety Checklist (SSC) has tal surgery patients enrolled in an ERP protocol at a single been introduced as a proven tool to signifi cantly improve institution were reviewed. Patient comorbidities at admis- patient safety and outcomes through effective communica- sion and compliance with key ERP elements were captured tion of the surgical team. It has been suggested that the SSC using billing data and prospectively-collected data, respec- can reduce healthcare associated cost through reduction tively. The association of American. in postoperative complications. However, the impact of a SSC on operating room (OR) cost is not known. This study Society of Anaesthesiologists Physical Status classifi cation compares outcomes and direct OR costs for laparoscopic (ASA), comorbidities, and ERP element compliance were incisional hernia repair (LIHR) before and after implemen- considered in logistic regression models to predict length tation of a standardized SSC. of stay (LOS). A prolonged LOS was defi ned as 9 days or longer. Competing risk models were used to examine the METHODS: In September 2010, our institution imple- impact of factors on in-hospital outcomes. Surgery was mented a standardized SSC. We retrospectively reviewed the initial state, discharge the endpoint, and occurrence of all patients that underwent LIHR at our hospital for 1-year complications a time-dependent intermediate state. prior (PRE) and 1-year after (POST) implementation. Demo- graphic data included age, sex, BMI, ASA score and previous RESULTS: Compliance with the ERP protocol diet and fl uid laparotomy. Measures of OR effi ciency and cost included management was 76%. Surgical complications occurred in operative times (OT), implant cost and total direct OR cost 16% of the patients, with Ileus being the most common (TDORC). There was no change in vendor contract pric- (12%), and 9% of the patients had a prolonged LOS. The ing during the timeframe of this study. Outcomes included majority of patients had at least one comorbidity, includ- length of hospital stay (LOS), and 30-day morbidity and ing infl ammatory bowel diseases (IBD, 36%), chronic renal mortality rates. Statistical analysis by student’s t-test and insuffi ciency (5%) heart disease (9%), diabetes (9%), or Fisher’s exact test where appropriate. COPD (11%). An ASA score 3 or 4 was present in in 19%. Chronic renal insuffi ciency, IBD, conversion to open, and RESULTS: A total of 154 patients were identifi ed; 79 PRE non-compliance with ERP diet/fl uid protocol were risk fac- and 75 POST group. There were no signifi cant differences tors for occurrence of complications (c-index = 0.74) and between groups for age (p = 0.9), gender (p = 0.7), BMI (p = prolonged length of stay (c-index = 0.78). Using ASA in 0.7), ASA score (p = 0.4) and previous laparotomy (p = 0.9). place of other comorbidities or excluding diet/fl uid compli- Although mean OT was 12 min shorter in the POST group, ance reduced the predictive value of the models (c-index the difference was not signifi cant (176.1 vs. 164.5; min p = 0.67 for complications and 0.70 for prolonged LOS). In a 0.2). However, was a signifi cant reduction in implant cost competing risk model chronic renal insuffi ciency, IBD, ($2081 vs. $879; p = 0.02) and TDORC ($3630 vs. $2463; p non-compliance with diet/fl uid ERP protocol were predic- = 0.03) in the POST group. There was no difference in LOS tors of a longer LOS. (1.5 vs.1.6 days p = 0.8), surgical site infection rate (2.5% vs. 4%; p=0.9, total complication rates (18.1% vs. 12.8%; p = CONCLUSION: In the era of ERP diet/fl uid management 0.4), readmission (3.8% vs. 9.3%; p = 0.28) and reoperation compliance leads to predictably earlier recognition and rates (3.8% vs. 5.3%; p = 0.9) between groups. There was treatment of complications and thus shorter LOS. one death reported in the study.

44 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

CONCLUSIONS: Our data indicate that implementation of METHOD: The capacity of CSC sphere formation was a standardized SSC is associated with a signifi cant reduction tested in a human HCC cell line, Hep3B (derived from in implant cost and TDORC for patients undergoing LIHR. an 8-year-old black patient). The CSC sphere condition We speculate that these cost savings are a direct result of an medium was the DMEM/F12 medium (1:1) supplied with 20 improvement in effective communication between surgical ng/ml of EGF and 20 ng/ml of bFGF. Flow cytometery were team members regarding special equipment and implant performed using CSCs surface antigens (including, CD133, needs for these complex cases. Further studies are required CD90, CD44, and EpCAM). To test the ability of CSCs for to determine the impact of our SSC on direct OR cost at an tumor formation, an orthotopic model was developed using institutional level. nude BALB-B/C. Tumor inoculation were performed using Hep3B cells and Hep3B CSCs at 2 × 106 per injection. The 787 mice were assessed for tumor formation at 4 weeks. Flow cytometery were performed in the cells isolated from tumor Molecular Predictors of Recurrent Hepatocellular

tissue to test CSCs surface antigens mentioned above. Abstracts Cancer: Role of Cancer Stem Cells Monday RESULTS: Sphere forming Hep3B cells were successfully Prejesh Philips, Xuanyi Li, Yan Li, Suping Li, induced and confi rmed to contain CSCs morphology. Com- Erik M. Dunki-Jacobs, Robert C. Martin pared to the regular cultured Hep3B cells, Hep3B sphere Surgical Oncology, University of Louisville, Louisville, KY cells demonstrated signifi cantly higher surface antigens. BACKGROUND: Recurrence rates after either resection of CD44 was expressed by 74.25% of CSC vs. 59.79% regular hepatocellular carcinoma (HCC) or liver transplantation Hep3B cells (difference of 24.46%, p value = 0.029). With occur in 25 to 75% of patients. HCC recurrence has been regards to EPCAM expression the CSC cells expressed 1.6% thought to be driven by cancer stem cells (CSCs). Under- versus 0.51% expressed by regular Hep 3b cells (p value = standing the role CSCs play in HCC recurrence will provide 0.02). This enhanced expression dropped down to near the important information to improve prognosis and better baseline when the Hep3B sphere re-cultured in standard defi ne adjuvant therapy. nutrient rich medium. CD44 and EPCAM expression was noted at 60.1% and 0.6%, which was not signifi cantly dif- AIM: To demonstrate that HCC cells can dedifferenti- ferent compared to regular Hep3b cells (p = 0.87 and 0.8) ate into CSCs, which contribute to HCC is an important but was signifi cantly lower compared to CSC cells (p = resource. 0.03 and 0.0.05). In the orthotpoic injection liver, Hep3B sphere demonstrated a signifi cantly higher tumor prolifera- tion rate compared to non-sphere Hep3B cells. The tumor weights are as follows: 389 mg ± 65 (Hep3B sphere) vs 94 mg ± 32 (Hep3B cells). CONCLUSIONS: Hep3B cells show the capacity of CSC induction in nutritionally stressed phase. Hep3B derived CSC can not only differentiate into HCC cells when sup- plied with nutrient rich medium, but also form tumor when inoculate into mouse liver. The study is on the way to investigate the signaling such as Wnt pathway to evaluate the clinical relevant biomarkers of CSCs in HCC patients.

Hep3B expression of CD 44 (sphere forming) left (FITC +ve 74.25%) versus control Hep3B cells right (59.79%).

45 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

788 789 Long-Term Quality of Life After Oesophagectomy for Surgery for Gallbladder Cancer in the US: Greater Need Cancer: Comparison of Cervical Versus Mediastinal for Radical Cholecystectomy and Maximal Lymph Anastomoses Node Clearance John M. Bennett1, Justin C. Wormald2, Marc Van Leuven1, Thuy B. Tran, Vijay G. Menon, Nicholas N. Nissen Michael P. Lewis1 Cedars-Sinai Medical Center, Los Angeles, CA 1. General Surgery, Norfolk and Norwich University Hospital, BACKGROUND: Gallbladder cancer (GBC) is an uncom- Norwich, Norfolk, United Kingdom; 2. Norwich Medical School, mon cancer with poor overall survival and frequent local Norwich, Norfolk, United Kingdom and metastatic relapse. GBC is often identifi ed incidentally BACKGROUND: With recent improvements in neoadju- after cholecystectomy, in which case reoperation with por- vant therapy and earlier diagnosis, long-term survival after tal lymph node dissection (LND) is frequently performed. oesophagectomy for adenocarcinoma is becoming more The value of LND both for its staging and therapeutic value frequent. With longer survival the quality of life (QOL) continues to be debated. In particular, the optimal extent of of patients post resection has thus become a greater prior- lymph node clearance is unclear. ity. There has been extensive debate focusing on the long METHODS: The Surveillance, Epidemiology, and End term effects of different sites for surgical anastomosis. We Results (SEER) database was queried for patients diagnosed aimed to examine if long-term post-oesophagectomy QOL with GBC. Overall survival was analyzed using the Kaplan- is affected by the site of the surgical anastomosis. Meier method and compared using Log rank testing. Cox METHOD: Following local ethics Committee approval proportional hazard modeling was used in multivariate QORTC C-30 and OG-25 QOL questionnaires were sent to analysis to identify predictors of survival using age, type patients who had survived post-oesophagectomy patients of surgery (simple vs radical cholecystectomy), adjuvant for greater than 3 years. The data was analysed in subsets treatment, stage, and number of lymph nodes examined. dependant on the site of oesophago-gastric anastomosis In addition, the contribution to survival of minimal LND – either thoracic or cervical. No patients in either group (min-LND; 1–3 LN removed) vs maximal LND (max-LND; underwent formal pyloroplasty. Data was analysed using >3 LN removed) was evaluated separately within each of the student’s t-test on SPSS statistical software. QORTC tumor Stages I-IIIB. Predictors that patients would undergo C-30 data was compared against the reference tables for max-LND were also evaluated. oesophageal cancer pre-treatment. RESULTS: A total of 12,962 patients with gallbladder can- RESULTS: A total of 60 patients responded (82%) with a cer were identifi ed. We included 11,113 patients without median time post-surgery of 6.1 years (range 3–12 years). distant metastases in our analysis. Multivariate analysis Cervical and thoracic anastomosis subgroups were equiva- of Stage I-IIIB GBC demonstrated that strong predictors lent in terms of age at time of surgery, time post op and can- of improved survival are early tumor status, negative LNs cer stage. No signifi cant QOL difference was noted between and adjuvant treatments (p < 0.001 for all). Predictors of cervical or chest anastomosis groups for any functional or worse overall survival are simple cholecystectomy (HR 1.74; symptom score, especially focusing on dysphagia (OG25, p < 0.001) and minimal LND (HR 2.56; p < 0.001). When p = 0.24), odynophagia (OG 25, p = 0.68) and swallowing evaluated by tumor stage, the extent of LN removal did not problems (OG25, p = 0.73). The patients’ overall general signifi cantly affect mean overall survival of Stage I GBC. health (QL2) score was 72.0 ± 19.43 compared with 71.2 ± In contrast, the extent of LND for GBC was signifi cantly 22.4 for the general population (QORTC reference tables). associated with improved overall survival of patients with Functional indices and symptom scores are improved for Stage II (T2N0), Stage IIIA (T3N0) and Stage IIIB (T1-3,N1) our cohort compared to the QORTC oesophageal cancer disease (p < 0.01 for all; see Table). reference baseline except symptom scores for diarrhoea and Comparison of Survival by Stage and Extent of Lymph Node dyspnoea which worsen post-operatively. Dissection DISCUSSION: There is no signifi cant difference in QOL scores between oesophagectomy patients with cervical or Stage Minimal LND – OS Maximal LND – OS p Value thoracic anastomosis long term post-surgery. QOL in long- I 50.5 mo 58.2 mo 0.196 term survivors after oesophagectomy compares favourably II 40.8 mo 57.4 mo <0.001 with QORTC reference data for both pre-treatment oesoph- IIIA 27.2 mo 43.2 mo 0.01 ageal cancer and baseline general population data in our IIIB 21.2 mo 31.9 mo <0.001 cohort, possibly due to the absence of pylorplasty. Further OS – Overall Survival, LND – Lymph Node dissection, mo – months. prospective QOL data collection is required to elucidate any Overall Survival of Stage II Disease Related to Extent of Lymph Node Dissection long-term differences between the two anastomosis sites.

46 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

790 Factors Associated with Healing of the Perineal Wound After Proctectomy in Crohn’s Disease Patients Faisel Elagili, Scott A. Strong, Pokala R. Kiran Colorectal surgery, Cleveland Clinic, Cleveland, OH BACKGROUND: For patients with Crohn’s disease (CD) undergoing proctectomy with or without colectomy and end , while the procedure may relieve debilitat- ing symptoms and improve quality of life, postoperative perineal wound complications can be a persistent problem. The aim of our study is to assess perineal wound healing Abstracts

in patients with CD who undergo proctectomy or procto- Monday colectomy with end ileostomy and to evaluate the infl uence of various factors including types of perineal dissection on eventual wound healing. PATIENTS AND METHODS: Data for patients with CD who underwent total proctocolectomy or proctectomy with end ileostomy from 1995–2012 were reviewed. Peri- neal wound healing was classifi ed as follows: Early healing The likelihood that max-LND was performed was predicted (within 12 weeks), delayed healing (between 12 weeks and by younger age (p < 0.001), as well as T4 tumor status com- 6 months) and persistent sinus (unhealed >6 months). pared to T1-3 (p < .001). No LNs were recovered in 74%, RESULT: For 139 patients (63% female), mean age 41 ± 60% and 50% of patients with Stage I, II and III disease 13 years, perineal wound healed by 12 weeks in 74 (53%) respectively. patients, delayed healing occurred in 36 (25.9%) patients, CONCLUSIONS: This is the largest population-based study and in 29 (20.9%) patients, there was a persistent sinus. Per- of patients with GBC in the literature. Not surprisingly, ineal dissection was either intersphincteric or extrasphinc- early tumor stage and adjuvant therapy correlate with sur- teric depending upon the extent of perineal Crohn’s/sepsis, vival. In addition we found radical cholecystectomy and extensive disease managed by leaving the wounds open. maximal LND correlate with survival even in node negative Factors associated with a signifi cantly greater risk for peri- patients (Stage II and IIIA). Our results support an approach neal sinus were age (p < 0.001), surgical management of of radical cholecystectomy and extensive LN dissection for perineal wound by open drainage (p = 0.04), high fi stula Stage II and III disease, and also suggest that many patients (p=0.01), preoperative perineal sepsis/disease (p = 0.001) in the US with GBC are currently surgically undertreated. and smoking at time of surgery (p = 0.03). On multivari- These patients may not be receiving the best chance for ate analysis, the only factor associated with delayed healing control of an otherwise diffi cult disease. Finally, the finding and persistent sinus was preoperative perineal sepsis and that LND benefi ts patients with N0 disease raises questions disease (P = 0.001). about current methods of LN analysis. CONCLUSION: The perineal wound after proctectomy or proctocolectomy for CD is associated with poor healing and poses a particular challenge for patients with exten- sive preoperative perineal disease or sepsis. These fi ndings support a preoperative discussion that examines potential outcomes and the consideration of measures such as the initial creation of a defunctioning ostomy, control/drain- age of local sepsis and appropriate medical treatment prior to proctectomy in CD patients considered to be at high risk for perineal wound problems.

47 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

791 CONCLUSIONS: Patients with increased esophageal acid exposure at both the proximal and distal probes tended to Dual Probe pH Monitoring Is Not Useful in Patients have more severe refl ux disease with hernias larger than with Refl ux Disease and Respiratory Symptoms 3 cm in size, erosive esophagitis and Barrett’s esophagus. Stephanie G. Worrell, Steven R. DeMeester, Evan T. Alicuben, Isolated abnormal proximal acid exposure was uncommon, Christina L. Greene, Daniel S. Oh, Jeffrey A. Hagen and was not associated with different symptoms. These Keck School of Medicine of Univeristy of Southern California, fi ndings suggest that dual probe pH monitoring does not Los Angeles, CA signifi cantly improve the ability to detect patients with refl ux disease that might be related to respiratory symptoms INTRODUCTION: The etiology of respiratory symptoms compared to standard pH monitoring in the distal esopha- such as cough, hoarseness, and asthma is often multi-fac- gus. Consequently, there is little added benefi t to monitor torial. Gastroesophageal refl ux can cause or contribute to patients with a dual probe pH system. these symptoms. Typically pH monitoring is done to iden- tify patients in whom refl ux may be related to respiratory symptoms. A dual probe study has been recommended for 792 these patients based on prior studies showing that approxi- Hospital Center Effect for Laparoscopic Colectomy mately 17% will have abnormal acid exposure only at the Among Elderly Stage I-III Colon Cancer Patients proximal probe. The aim of this study was to determine Zhiyuan Zheng2, Nader Hanna1, Eberechukwu Onukwugha2, the frequency of isolated abnormal proximal acid exposure, Kaloyan A. Bikov2, C. Daniel Mullins2 and to evaluate symptoms and endoscopic fi ndings associ- ated with distal versus proximal acid refl ux. 1. Surgery, University of Maryland School of Medicine, Baltimore, MD; 2. Pharmaceutical Health Services Research Department, METHODS: We reviewed the records of all patients that University of Maryland School of medicine, Baltimore, MD had dual probe pH testing from January 1999 to Novem- ber 2012. Only patients with complete foregut evaluation OBJECTIVE: To investigate hospital level variation in including endoscopy, video esophagram, and motility were short-term laparoscopic colectomy outcomes among stage included. Increased esophageal acid exposure was defi ned I-III elderly colon cancer patients. as a DeMeester composite score of >14.76 in the distal probe BACKGROUND: Surgical outcomes are associated with and >16.4 in the proximal probe. Dual probe pH catheters patient and surgeon characteristics. If outcomes are also with sensors spaced 10, 15 or 18 cm apart were selected impacted by the specifi c hospital where the surgery occurs, such that the proximal probe would be as close as possible there is a hospital center effect (HCE). Previous studies of to the upper esophageal sphincter in each patient. laparoscopic focus on patient, provider and RESULTS: From 425 total patients 256 (60%) had increased hospital characteristics, ignoring potential HCE. esophageal acid exposure on dual probe pH testing. Pre- Subgroup Analyses for Hospital Center Effect on Short-Term senting symptoms in these patients were heartburn (73%), Outcomes of Laparoscopic Colectomy regurgitation (60%), cough (54%), hoarseness (50%), or asthma (24%). The location of abnormal refl ux was at the Not Affi liated distal probe only in 133 patients (31%), at the proximal High Volume Colorectal Affi liated with with Medical probe only in 11 patients (3%) and at both probes in 112 Hospitals (≥30) Surgeons Medical School School patients (26%). There was no signifi cant difference in the N of Hospitals 43 119 196* 281 prevalence of cough, hoarseness or asthma based on loca- N of Patients 1661 1020 2397 2220 tion of the abnormal acid exposure. Abnormal acid expo- MIRR for LOS 1.24 (<0.001) 1.62 (<0.001) 1.21 (<0.001) 1.46 (<0.001) sure at both the proximal and distal probes was most likely (P-value) to occur in patients with a hiatal hernia larger than 3 cm MOR for 1.96 (0.004) NA 2.09 (0.022) 1.63 (0.132) in size [Table]. In-hospital Mortality (P-value) * There are 12 hospitals who changed their medical school affi liation during the study period. Therefore, these hospitals appeared in both affi liated and not affi liated with medical schools. METHODS: The Surveillance, Epidemiology and End Results (SEER)-Medicare dataset was used to identify stage I-III colon cancer patients in 2003 to 2007 with laparo- scopic colectomies. Multilevel model regressions were uti- lized to study potential HCE for length of stay (LOS), 30-day re-hospitalization, and in-hospital mortality, adjusting for patient, surgeon and hospital level characteristics. To quan- tify the impact of HCE, we calculated median instantaneous rate ratio (MIRR) for LOS and median odds ratio (MOR) for in-hospital mortality and 30-day re-hospitalization. Sensitivity analyses were also conducted for high volume/ medical school affi liated hospitals and colorectal surgeons.

48 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

793 Usefulness of Bowel Sound Auscultation: A Prospective Evaluation Seth Felder, Zuri A. Murrell, Phillip Fleshner Surgery, Cedars-Sinai Medical Center, Los Angeles, CA BACKGROUND: Although the auscultation of bowel sounds is considered an essential component of an ade- quate physical examination, its clinical value remains largely unstudied and subjective. The aim of this study was to determine whether an accurate diagnosis of mechani- cal small bowel obstruction, postoperative ileus, or normal Abstracts

controls is possible based on bowel sound characteristics. Monday METHODS: Using an electronic stethoscope (3M Littmann Model 3200) with sound amplifi cation capabilities and a computer Bluetooth interface, bowel sounds of healthy vol- unteers (n = 10), patients with a CT diagnosed mechanical small bowel obstruction demonstrated by a transition point and confi rmed at surgery (n = 10), and patients with post- operative ileus (n = 10) were recorded for 30 seconds while lying in the supine position. The bowel sounds were trans- ferred into a computer and then replayed randomly through high defi nition speakers to study physicians blinded to the clinical scenario. A total of 45 recordings were played con- secutively, with 15 of the recordings duplicated. A survey was taken just prior to the recording playback assessing each physician’s perceived level of expertise interpreting bowel sounds. Study physicians were instructed to catego- rize the patient recording as normal, obstructed, ileus, or not sure. RESULTS: Study physicians (n = 28) included 4 medical students on a surgical service, 8 surgical interns, 4 senior surgical residents, and 12 surgical attendings. Most par- ticipants (64%) stated they rarely listened to bowel sounds in their training or clinical practice. Almost all (96%) Joint impact of HCE and selected patient level characteristics on LOS (A) responded they knew what normal bowel sounds should and in-hospital mortality (B). sound like, but were less confi dent in what obstructive bowel sounds should sound like (71%). Study participants correctly diagnosed the clinical scenario in a median of RESULTS: The multilevel analyses based on 4,617 patients 11 (range, 5–16) of the 45 recordings (23%). A median of from 465 hospitals documented signifi cant HCEs for LOS 2 (range, 0–22) responses were ‘not sure.’ Normal bowel (MIRR = 1.36; p < .001) and in-hospital mortality (MOR = sounds were correctly identifi ed 29% of the time with a 1.72; p = 0.037), but no HCE for 30-day re-hospitalization. positive predictive value (PPV) of 22%. Obstructive bowel For patients with CCI = 3+, MIRR rose to 2.27 for LOS and sounds were correctly identifi ed 24% of the time with a PPV MOR rose to 6.87 for in-hospital mortality. The sensitivity of 26%. Postoperative ileus was correctly identifi ed 20% of analyses confi rmed our fi ndings. HCE was signifi cant for the time with a PPV of 39%. No difference was found in LOS in all subgroup analyses, and was signifi cant for in- diagnostic accuracy between levels of training. For par- hospital mortality for high volume/medical school affi li- ticipants responding he/she was ‘always able’ to identify ated hospitals. normal or obstructive bowel sounds if present, accuracy of CONCLUSION: HCE is an important source of variation diagnosis was 32% and 29%, respectively. Fixed-marginal for laparoscopic colectomy short-term outcomes, and it is inter-observer kappa value was only 0.17. still signifi cant when patient, provider and hospital level CONCLUSION: Auscultation of bowel sounds is not a use- characteristics are adjusted. HEC exists for both LOS and in- ful clinical practice when trying to differentiate normal hospital mortality. The fi ndings are robust to high volume/ versus ileus versus obstruction. Based on our results, the lis- medical school affi liated hospitals and colorectal surgeons. tener usually arrives at an incorrect diagnosis, and the low HCE is a potential area to improve the quality of care for inter-observer agreement further suggests the inaccuracy of stage I-III laparoscopic colon cancer patients. utilizing bowel sounds for clinical purposes. Routinely lis- tening to bowel sounds should be abandoned.

49 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tuesday, May 21, 2013 8:00 AM – 9:30 AM 308D PLENARY SESSION VI

858 0.007) and MODS manifestations (P = 0.005). These fi nd- ings held in the subgroup with biliary bacteria; and HDL Plasma Lipids and Biliary Infections: Decreased Levels independently correlated with illness severity even among of HDL Are Associated with More Severe Biliary patients with bacterial-laden CBD stones. Infections: A Multivariate Analysis Lygia Stewart1,2, Gary Jarvis3, Lawrence Way1 1. Surgery, UCSF, San Francisco, CA; 2. Surgery, SF VA Medical Center, San Francisco, CA; 3. Infectious Disease and Laparotory Medicine, SF VA Medical Center, San Francisco, CA We, and others, have previously identifi ed factors associated with severe biliary infections: biliary bacteria, age, sex, cho- ledocholithiasis, pigment stones. Recently we reported that a low/normal BMI was associated with more severe biliary infections. To understand this association, we studied cor- relations between plasma lipid levels and biliary infections. METHODS: 475 patients with gallstones were studied; 410 men, 65 women; average age 62 (range 17–104). Gallstones, bile, and blood (as applicable) were cultured, Stone type recorded. Illness severity was classifi ed as: none (no infl am- matory manifestations), SIRS (fever, leukocytosis), severe (abscess, cholangitis, empyema), or MODS (bacteremia, hypotension, organ failure). Using bivariate and multivari- ate analysis, we examined associations between lipid levels (HDL, LDL, Triglycerides – obtained prior to the acute ill- ness) and: BMI, biliary bacteria, bacteremia, gallstone type, illness severity. In the multivariate analysis we used factors associated with biliary infections (age, sex, biliary bacteria, CONCLUSION: This study demonstrates the importance pigment stones, choledocholithiasis). of plasma lipids to biliary infections. Increased LDL levels RESULTS: On bivariate analysis (Table), BMI correlated favored cholesterol (rather than pigment) gallstone forma- with HDL and Trig (P < 0.003). LDL inversely correlated tion, and were more often associated with a sterile biliary with biliary bacteria (P = 0.002) and pigment stones (P = tract. HDL levels, however, seemed to dictate the course 0.0001); while HDL and LDL inversely correlated with bac- of the biliary infection; patients with low HDL levels had teremia (P < 0.03). HDL and LDL inversely correlated with signifi cantly more severe biliary infections. Even among increasing infection severity (P < 0.02) and MODS mani- patients with bacterial-laden CBD stones, those with high festations (P < 0.006). On Multivariate analysis of factors HDL levels had a mild illness, while those with low HDL associated with pigment stones and biliary bacteria, LDL levels more often had MODS manifestations. This data sug- inversely correlated with pigment stones (P = 0.001) and gest that HDL may be protective in biliary infections; and biliary bacteria (P = 0.017). Multivariate analysis of factors that patients with biliary infections and low HDL levels associated with biliary infection severity revealed HDL as may need a more aggressive clinical approach. This is the the most important lipid (Figure); only HDL inversely inde- fi rst study to demonstrate the importance of plasma lipid pendently correlated with biliary infection severity (P = levels to the severity of biliary infections.

50 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Bivariate Analysis: Lipids and Biliary Infections

HDL LDL Triglycerides N mg/dl P Value mg/dl P value mg/dl P Value Stone Type Pigment 244 42 NS 96 0.0001 156 NS Cholesterol or Mixed Chol 231 43 120 164 Biliary Bacteria Bacteria 238 42 NS 101 0.002 150 0.046 Sterile 237 43 116 174 Bacteremia Bacteremia 39 36 0.017 85 0.006 131 NS Sterile blood 436 43 109 163 MODS fi ndings (pts with biliary bacteria) Present 72 35 0.0001 89 0.006 149 NS None 166 45 105 150 MODS fi ndings (pts with bacterial-laden CBD stones) Present 42 33 0.005 86 0.074 153 NS None 65 46 103 151

6 859 in mice have been diffi cult to establish due to the techni- cal diffi culty and high mortality associated with esophageal Laparoscopic-Assisted ERCP After in such small animals. The limited mouse models Surgery for Choledocholithiasis that have been described lack adequate molecular charac- Jonathan Carter, Jennifer Kaplan, Steve Elliott, terization to confi rm the development of Barrett’s metapla- Stanley J. Rogers, John P. Cello sia. We now describe the development and characterization Abstracts

Department of Surgery, UCSF, San Francisco, CA of Barrett’s-like columnar metaplasia in mice that have Tuesday refl ux esophagitis induced by esophagojejunostomy (EJ). Gastric bypass is common in the United States and is often performed without synchronous cholecystectomy. The METHODS: To induce refl ux, we performed EJ in twenty resultant rapid weight loss can lead to gallstones in up C57Bl/6 mice weighing 15 to 33 grams. At various time to 40% of patients, some of whom will develop choledo- points thereafter, the distal esophagus was removed, par- cholithiasis. Treatment of choledocholithiasis after gastric affi n-embedded, sectioned, and mounted on slides, which bypass is problematic because the long Roux limb is impos- were stained with H&E and with Alcian blue. Immuno- sible to navigate with a standard side-viewing endoscope histochemistry was performed to determine expression of passed through the mouth. Sox-9 (a columnar cell transcription factor expressed in human Barrett’s metaplasia) and the columnar cell cyto- We demonstrate a simple technique to perform ERCP after keratin (CK) 18. CK14 (an esophageal squamous cell cyto- gastric bypass by laparoscopically providing access to the keratin) was used as a control. We evaluated the specimens gastric remnant. The purpose is to familiarize surgeons and for squamous basal cell and papillary hyperplasia typical of endoscopists with the technique, as many will encounter refl ux esophagitis, as well as for columnar metaplasia. patients such as this in everyday practice. RESULTS: Procedural mortality was 40% for the fi rst 10 860 animals, but dropped to 20% for the next 10 animals. At 13 weeks after EJ, erosive esophagitis with prominent Development and Characterization of a Surgical, Mouse squamous basal cell and papillary hyperplasia was pres- Model of Refl ux Esophagitis and Barrett’s Esophagus ent in all animals. Columnar metaplasia, with goblet Thai H. Pham1, David H. Wang2, Robert M. Genta3, cells that stained with Alcian blue, developed by week 34. Rhonda F. Souza2, Stuart J. Spechler2 The columnar metaplasia expressed CK18, but not CK14. 1. Surgery, North Texas VAMC; UT Southwestern Medical Center, Intense expression of Sox-9 was detected in areas of colum- Dallas, TX; 2. Medicine, North Texas VAMC; UT Southwestern nar metaplasia. In the squamous epithelium close to the EJ anastomosis, furthermore, Sox-9 expression was seen in Medical Center, Dallas, TX; 3. Pathology, North Texas VAMC; UT scattered basal cells, whereas squamous epithelium further Southwestern Medical Center, Dallas, TX from the anastomosis did not exhibit Sox-9 expression. INTRODUCTION: To study the molecular mechanisms CONCLUSIONS: EJ can be performed successfully in underlying how refl ux esophagitis causes Barrett’s metapla- C57Bl/6 mice, causing refl ux esophagitis and, later, goblet sia, an appropriate animal model is desirable. A number of cell-containing columnar metaplasia that expresses CK18 surgical, rat models of GERD and Barrett’s esophagus are and Sox-9. These data suggest that this surgical, mouse available, but genetic engineering of rats is not accom- model recapitulates the phenotypic and molecular changes plished readily. In contrast, constitutive and conditional seen in human Barrett’s esophagus. Thus, we have estab- transgenic mice as well as knockout allele mice can be lished a relevant and genetically-modifi able model for engineered readily and, therefore, mouse models would be studying the molecular pathogenesis of Barrett’s esophagus. highly advantageous for studying the molecular pathogen- esis of GERD and Barrett’s esophagus. Surgical refl ux models

51 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

(normal, smooth shift, unilateral narrowing, bilateral nar- 861 rowing without collaterals, bilateral narrowing with collat- A Standardized Radiographic Assessment of the Tumor- erals). Findings were correlated to the need for venous Vein Interface Predicts the Need for Venous Resection resection at pancreatectomy and to the presence of histo- logic venous invasion. and the Presence of Histologic Venous Invasion in Borderline Resectable Pancreatic Cancer RESULTS: 266 patients underwent pancreaticoduodenec- Hop S. Tran Cao1, Aparna Balachandran2, Huamin Wang3, tomy and met inclusion criteria, of whom 99 required con- comitant resection of the SMV-PV. Greatest sensitivity for Jason B. Fleming1, Jeffrey E. Lee1, Peter W. Pisters1, Matthew Katz1 predicting SMV-PV resection was achieved by an interface 1. Surgical Oncology, U.T. MD Anderson Cancer Center, Houston, threshold of abutment (sensitivity 91.9%, negative predic- TX; 2. Diagnostic Radiology, U.T. MD Anderson Cancer Center, tive value 87.9%), whereas excellent specifi city was reached Houston, TX; 3. Pathology, U.T. MD Anderson Cancer Center, with a threshold of encasement (97.6%, positive predic- Houston, TX tive value 89.7%). Among patients who underwent venous BACKGROUND: Venous resection may be required to resection, vessel encasement was associated with a 78.3% achieve complete resection of pancreatic cancers (PC). We rate of histologic SMV-PV invasion; this rate increased to have previously shown that histologic invasion of the supe- 90% when the vein was occluded. The Ishikawa system, rior mesenteric vein-portal vein (SMV-PV) is associated with while more detailed, offered no advantage in predicting the poor prognosis following resection. Using high-defi nition need for SMV-PV resection and was less accurate in predict- multidetector computed tomography (CT), we sought to ing histologic venous invasion. Subset analyses performed evaluate the ability of two commonly-used sets of radio- for patients who received neoadjuvant chemoradiation and graphic criteria to predict the need for SMV-PV resection for those who did not yielded similar fi ndings. at pancreatectomy and the histologic presence of SMV-PV CONCLUSIONS: A simple radiographic classifi cation invasion. system that categorizes the extent of the tumor-SMV-PV METHODS: All patients who underwent pancreaticoduo- interface accurately predicts the need for SMV-PV resec- denectomy for PC between 2004 and 2011 at the authors’ tion at pancreatectomy, and correlates with the pathologic institution were identifi ed. Preoperative pancreatic protocol involvement of the resected vein. To assist in treatment CT images were re-reviewed to characterize the interface planning, a standardized description of this anatomic rela- between the tumor and SMV-PV (no interface, abutment tionship should be routinely performed for patients with [≤180 degrees], encasement [>180 degrees], occlusion) and borderline resectable tumors. the appearance of the SMV-PV using Ishikawa criteria

Correlation of Radiographic Assessment of Tumor-Vessel Relationship to Surgical and Pathologic Outcomes

Tumor-Vessel Interface* Vessel Appearance** Radiographic-Surgical Correlation CT cut-off 0 1 2 3 1 2 3 4 5 Number of patients 266 200 39 11 266 166 96 30 29 Sensitivity N/A 91.9 35.4 10.1 N/ A 85.9 66.7 27.3 27.3 Specifi city N/A 34.7 97.6 99.4 N/A 51.5 82.0 98.2 98.8 PPV N/A 45.5 89.7 90.9 N/A 51.2 68.8 90.0 93.1 NPV N/A 87.9 71.8 65.1 N/A 86.0 80.6 69.5 69.6 Accuracy N/A 56.0 74.4 66.2 N/A 71.8 76.3 71.8 72.2 Radiographic-Pathologic Correlation CT value 0 1 2 3 1 2 3 4 5 Number of venous resection 8 56 25 10 14 19 39 0 27 Histologic venous invasion (%) 33.3 64.6 78.3 90.0 54.5 52.9 69.7 -- 84.6 CT – computed tomography; PPV – positive predictive value; NPV – negative predictive value. *Tumor-SMV-PV interface scale – 0: no interface, 1: abutment (180°), 2: encasement (>180°), 3: occlusion. **SMV-PV appearance based on the Ishikawa system –1: normal, 2: smooth shift, 3: unilateral narrowing, 4: bilateral narrowing without collaterals, 5: bilateral narrowing or occlusion with collaterals.

52 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

862 863 Depth of Submucosal Tumor Infi ltration and Its High Resolution Manometry Classifi cations for Relevance in Lymphatic Metastasis Formation for T1b Idiopathic Achalasia in Patients with Chagas Disease Squamous-Cell and Adenocarcinomas of the Esophagus Esophagopathy Michael F. Nentwich1, Katharina von Loga1,2, Matthias Reeh1, Fernando P. Vicentine1, Fernando A. Herbella1, Guido Sauter2, Thomas Rösch3, Jakob R. Izbicki1, Luciana C. Silva1, Marco E. Allaix2, Marco G. Patti2 Dean Bogoevski1 1. HSP – Unifesp, São Paulo, Brazil; 2. University of Chicago 1. General, Visceral and Thoracic Surgery, University Clinic Pritzker School of Medicine, CHicago, IL Hamburg-Eppendorf, Hamburg, Germany; 2. Department of BACKGROUND: Idiopatic achalasia (IA) and Chagas dis- Pathology, University Clinic Eppendorf, Hamburg, Germany; ease esophagopathy (CDE) share several similarities; how- 3. Clinic for Interdisciplinary Endoskopy, University Clinic ever, some differences between the 2 diseases have been Eppendorf, Hamburg, Germany noticed. The comparison between IA and CDE is important BACKGROUND: Surgical resection for early esophageal to evaluate if treatment options and their results can be carcinoma has been challenged by less invasive endoscopic accepted universally. High-resolution manometry (HRM) approaches. As lymph node involvement, one of the major has proved a better diagnostic tool compared to conven- factors infl uencing patients’ overall survival cannot be tional manometry. The study of IA patients with the aid of assessed by endoscopic resection, selecting patients in need HRM allowed the creation of new classifi cations of the dis- for surgical intervention according to their risk of lym- ease with apparent correlation with treatment outcomes, as phatic spread is mandatory. proposed by the Chicago and Rochester groups. The clinical application of HRM parameters in patients with CDE is still OBJECTIVE: The aim of this study was to evaluate submu-

elusive. This study aims to evaluate HRM classifi cations for Abstracts cosal layer thickness, depth of submucosal tumor infi ltra- idiopathic achalasia in patients with CDE. Tuesday tion and tumor length as well as lymphatic invasion in T1b esophageal carcinomas for its predictiveness on lymphatic METHODS: We studied 86 patients with achalasia: 45 metastasis formation. patients with CDE (54% females, mean age 55.8 ± 14.7 years) and 41 patients with IA (58% females, mean age 49.0 METHODS: Histopathological specimens following sur- ± 19 5 years). All patients underwent a HRM when Chicago gical resection for T1b esophageal carcinomas were re- and Rochester classifi cations for achalasia were applied and evaluated for overall submucosal layer thickness, depth a barium esophagram to measure esophageal dilatation. of submucosal tumor infi ltration, tumor length as well as lymphatic and vascular infi ltration. A ratio of overall sub- RESULTS: The Chicago classifi cation was present in IA: mucosal layer thickness and depth of submucosal tumor Chicago I: 32%, Chicago II: 66% and Chicago III: 2%; In infi ltration was calculated and this proportion of submuco- CDE: Chicago I: 49%, Chicago II: 51% and Chicago III: 0% sal invasion was used to form sub-categories either in thirds (p = 0.178). The Rochester classifi cation was present in IA: or in halfs of total submucosal gauge. Infl uence of submu- Rochester I: 2%, Rochester II: 66% and Rochester III: 32%; cosal invasion as well as tumor length on lymphatic metas- In CDE: Rochester I: 0%, Rochester II: 51% and Rochester tasis formation and overall survival was assessed. III: 49% (p = 0.178). CDE patients had more pronounced degrees of esophageal dilatation (p < 0.0001). The degree of RESULTS: A total of 67 Patients with pT1b tumors were esophageal dilatation did not correlate with neither classi- analyzed, including 36 adenocarcinomas (53.7%) and 31 fi cation (p = 0.2); however, an indirect correlation between squamous-cell carcinomas (46.3%). Lymph node involve- esophageal body pressure amplitude and the degree of ment was seen in 20.9% (14/67) patients. Overall mean esophageal dilatation was noticed (p = 0.001). In 9 (10%) thickness of submucosal layer was 5.07 mm (SD 1.53 mm). patients the HRM pattern changed during the test from Overall proportion of submucosal infi ltration was calculated Chicago I to II. as 64.79% (SD 29.2%). Comparison of overall proportion of submucosal infi ltration between patients with (62.81%, CONCLUSION: Our results show that: (a) HRM classifi ca- range 17–97%) and without (65.31%, range 2–99%) lymph tions for IA can be applied in patients with CDE and (b) node involvement did not show signifi cant differences (p = HRM classifi cations did not correlate with the degree of 0.698 Mann-Whitney-U). On log-regression models, only esophageal dilatation. The secondary fi ndings of our study the presence of lymphangioinvasion and tumor length suggest that HRM classifi cations may refl ect esophageal was signifi cantly associated with positive lymph node repletion and pressurization instead of muscular contrac- involvement. tion. The correlation between manometric fi ndings and treatment outcomes for CDE needs to be answered in a near CONCLUSION: As depth of submucosal tumor infi ltration future. did not correlate with the formation of lymph node metas- tases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted whenever the tumor invades the submucosal layer.

53 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

9:30 AM – 12:00 PM 308D PLENARY SESSION VII

910 6 911 Does Preoperative Imaging Accurately Predict Main Spleen Preserving Laparoscopic Distal Pancreatectomy Duct Involvement in Intraductal Papillary Mucinous for a Solid Pseudopapillary Tumor in a Male Patient Neoplasm (This Video Demonstrates Technical Details of a Rare Morgan R. Barron1, Joshua A. Waters1, Janak A. Parikh1, Tumor of the Pancreas in a Male Patient. Only Few John DeWitt2, Mohammad A. Al-Haddad2, Eugene P. Ceppa1, Cases Have Been Reported in Males) Michael G. House1, Nicholas J. Zyromski1, Attila Nakeeb1, Bestoun H. Ahmed, Reginald L. Griffi n, Ziad Awad, Henry A. Pitt1, C. Max Schmidt1 Carmine Volpe, Michael S. Nussbaum 1. Surgery, Indiana University School of Medicine, Indianapolis, Surgery, University of Florida College of Medicine/Jacksonville, IN; 2. Gastroenterology, Indiana University School of Medicine, Jacksonville, FL Indianapolis, IN A 31-y-old patient had a blunt abdominal trauma. CT scan OBJECTIVE: Main pancreatic duct (MPD) involvement showed an incidental tumor in the body of the pancreas. is a well-demonstrated risk factor for malignancy in intra- EUS-guided cytology was Solid pseudopapillary tumor. ductal papillary mucinous neoplasm (IPMN). Preoperative Patient in right semi-lateral position. Division of gastrocolic radiographic determination of IPMN type (main, mixed, or omentum. Release of splenic fl exure of the colon. Transec- branch) is relied upon heavily in preoperative oncologic tion of the body of the pancreas after separating splenic risk stratifi cation. We hypothesize that preoperative radio- vessels. Separation of the pancreas from the vessels. Extrac- graphic assessment of MPD involvement in IPMN is an tion of the specimen in a pouch. Operative time: 170 min- accurate predictor of pathologic MPD involvement. utes. Blood loss: 50 ml. Tolerated food on day 2. Discharged on day 4. Pathology: 6x5 cm tumor like FNA result with METHODS: Data regarding all patients undergoing resec- clear margins .In conclusion: Laparoscopic spleen preserv- tion for IPMN at a single, academic institution between ing approach is feasible in the management of this tumor. 1992 and 2012 were gathered prospectively. Retrospec- tive analysis of imaging, clinical, and pathologic data was  undertaken. Preoperative classifi cation of IPMN type was 912 based on cross-sectional imaging (CT or MRI). High Fat Diet Enhances Villus Growth During RESULTS: Three-hundred and sixty four patients under- Adaptation After Massive Small Bowel Resection went resection for IPMN. Of these, 335 had adequate data Pamela M. Choi, Raphael C. Sun, Jun Guo, on both radiographic and pathologic parameters for com- Christopher R. Erwin, Brad Warner parison. Of 184 suspected branch duct (BD) IPMN, 35 Department of Pediatric Surgery, Washington University, (19%) demonstrated MPD involvement on fi nal pathology. St. Louis, MO Of 84 mixed-type (MT) IPMN 16 (19%) demonstrated no MPD involvement. Of 68 suspected main duct (MD) IPMN BACKGROUND: Adaptation is a compensatory process 13 (19%) demonstrated no MPD involvement. Of 35 of 184 following small bowel resection (SBR) that results in vil- (19%) that had a suspected BD IPMN but were found to lus growth and enhanced mucosal surface area. In prior have MPD involvement on pathology, 12 (34%) had inva- studies, High Fat Diet (HFD) had been shown to enhance sive carcinoma. Alternatively, in patients with suspected adaptation responses if fed immediately following SBR. The MD or MT IPMN who ultimately were found to have no purpose of this study was to determine if HFD could further main duct involvement on pathology 2 (7%) demonstrated enhance villus growth after resection-induced adaptation invasive carcinoma. had already taken place. CONCLUSION: In resected IPMN, MPD involvement has METHODS: C57/Bl6 mice, aged 6–8 weeks, underwent been demonstrated as an independent risk factor for inva- a 50% proximal SBR or sham operation (bowel transec- sive cancer. Preoperative radiographic IPMN type correlates tion with reanastomosis alone) and then provided a stan- with fi nal pathology in 81% of patients. In addition, risk of dard rodent liquid diet (LD) ad lib. After a typical period invasive carcinoma correlates with pathologic presence (or of adaptation (7 days), SBR and sham-operated mice were absence) of main duct involvement. Consequently, preop- randomized to receive either LD or HFD (42% kcal/fat) erative imaging for oncologic risk stratifi cation may over or for an additional 7 days. Mice were individual caged, and under weigh risk in up to one in fi ve patients. food intake and feces output were measured daily. Mice were then harvested, and was collected for analysis.

54 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: Prospectively collected clinicopathologic and perioperative data on adult patients undergoing liver resec- tion between 1/1/2003–7/31/2011 were retrospectively reviewed to assess incidence of and risk factors for postop- erative VTE within 30 days. Risk factors for PP were ana- lyzed using multivariable logistic regression. RESULTS: Of 2198 patients undergoing hepatectomy, median age was 60 years, and 49% were female. Median BMI was 27, preoperative chemotherapy was given to 997 patients (45%), and a history of prior VTE was present in 67 patients (3%). Major hepatectomy (MH, defi ned as ≥4 seg- ments) was performed in 716 patients (33%) and another concomitant organ resection in 556 (25%). EBL was ≥600 cc in 580 patients (27%), and liv±er steatosis was noted in 142 (18%). Median peak INR within 7 days after surgery was 1.4 (peak INR ≥1.5 in 32%), and median platelet count nadir was 154k (platelet nadir <100k in 12%). PP was started on Figure 1: Villus Height Measurements after SBR or Sham Operations. day 0/1 (immediate) in 815 patients (37%), day 2–5 (early) RESULTS: There were no differences in caloric intake or in 481 (22%), and later or never (late/none) in 902 (41%). stool output between any of the groups. However, Sham Use of any (immediate or early) PP was less common with mice had increased weight gain compared to SBR mice MH (50% vs 63%, P < 0.001), EBL ≥ 600 cc (54% vs 61%, P independent of diet. As shown in Figure 1, adaptation = 0.002), and peak INR ≥ 1.5 (54% vs 62%, P = 0.001). VTE

occurred in both SBR groups, however the SBR/HFD had occurred in 57 patients (overall: 2.6%; immediate: 2.2%; Abstracts signifi cantly increased villus height compared to SBR/LD. early: 1.9%; late/none: 3.3%; P = 0.2). VTE was associated Tuesday When compared to their sham counterparts, there was a with age ≥60 (3.9% vs 1.3%, P < 0.001), MH (4.2% vs 1.8%, 102.3% increase in villus height in the HFD group com- P = 0.001), EBL ≥ 600 cc (4.8% vs 1.7%, P < 0.001), and peak pared to only 42.6% in the LD group. Real-Time PCR was INR ≥ 1.5 (5.2% vs 1.5%, P < 0.001), but not gender, BMI, performed from mRNA of isolated intestinal villus cells, preoperative chemotherapy, history of VTE, other organ and CD36 expression was markedly elevated after high fat resection, liver steatosis, or nadir platelet count <100k (all diet (greater than 50-fold) in the SBR/HFD group compared P > 0.05). There was no signifi cant time trend in VTE inci- with SBR/LD mice. dence. On multivariable analysis, age, EBL, and peak INR remained signifi cant predictors of VTE (Table). CONCLUSION: While a week-long exposure to increased enteral fat alone did not affect villus morphology in sham- CONCLUSIONS: Counterintuitively, higher INR, but not operated mice, HFD signifi cantly increased villus growth in use of postoperative PP, was associated with VTE within 30 the setting of resection-induced adaptation. These data sup- days after hepatectomy. INR alone may not be an accurate port the clinical utility of enteral fat in augmenting adap- indicator of coagulation status after hepatectomy. The role tation responses in patients who have been subjected to of PP after hepatectomy requires prospective validation. massive SBR. Increased expression of CD36 suggests a pos- Multivariable Logistic Regression Analysis of Risk Factors for VTE sible mechanistic role in dietary fat metabolism and villus growth in the setting of short gut syndrome. Variable Odds Ratio 95% CI P-Value Age 60 years 3.06 1.65–5.70 0.001 913 Pharmacologic prophylaxis Pharmacologic Prophylaxis, Postoperative INR, and Late/None Ref. 0.4 Early (Day 2–5) 0.63 0.29–1.35 Risk of Venous Thromboembolism After Hepatectomy Immediate (Day 0/1) 0.78 0.42–1.45 Hari Nathan, Matthew J. Weiss, Ronald P. DeMatteo, Major hepatectomy 1.19 0.63–2.22 0.6 Peter J. Allen, T.P. Kingham, Yuman Fong, William R. Jarnagin, EBL 600 cc 2.09 1.18–3.69 0.01 Michael D’Angelica Peak INR 1.5 3.03 1.58–5.79 0.001 Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, MD Ref.: Referent INTRODUCTION: Pharmacologic prophylaxis (PP) against venous thromboembolism (VTE) is often withheld after hepatectomy due to bleeding risk or perceived coagulopa- thy related to INR and platelet count, but its role has been inadequately studied. We sought to characterize VTE risk and defi ne the role of PP after hepatectomy.

55 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

 Table 1: Outcomes of Patients with Curative Esophagectomy Alone 914 Compared to Those with Esophagectomyand Lung Resection. Data Clinical Signifi cance of Incidental Pulmonary Nodules Presented as Median (Range) and N (%). * = p < 0.05 in Esophageal Cancer Patients Esophagectomy Esophagectomy and 1,2 1,2 1,2 Amin Madani , Lorenzo E. Ferri , Jonathan Spicer , Only (E) Lung Resection (EL) 2 David S. Mulder (N = 275) (N = 33) 1. General Surgery, McGill University, Montreal, ON, Canada; Age 62 (43–78) 65 (24–91) 2. Thoracic Surgery, McGill University, Montreal, QC, Canada Gender (% M) 73% 76% Incidental pulmonary nodules are frequently identi- Smoking History 130 (47%) * 25 (77%) * fi ed during staging investigations for esophageal cancer Pulmonary Complications 70 (25%) 6 (19%) patients. However, the clinical signifi cance of such nodules Anastamosis Leak 26 (9%) 2 (6%) is unclear and may bias treatment decisions towards pallia- Overall Complications 151 (55%) 15 (45%) tive options. This study is aimed to determine the value of Estimated Blood Loss 310 mL (100–3500) 300 mL (150–2000) an aggressive surgical approach in patients with esophageal Length of Stay 11 days (5–185) 10 days (7–86) cancer and incidental pulmonary nodules. Operative Time 285 min (100–600) 310 min (220–510) From 2005–2012, a prospectively entered institutional Post-Operative Mortality 9 (3%) 1 (3%) clinical database of esophageal cancer patients was accessed to identify patients with incidental pulmonary nodules.  Those patients who underwent combined esophageal and 915 lung resection (EL) were compared to those who had esoph- Internal Hernia After Laparoscopic Roux-en-Y Gastric agectomy alone (E) in terms of demographics, tumor char- Bypass acteristics and peri-operative outcomes. Fishers exact and Ayman Obeid1, David M. Breland1, Richard Stahl1, MWU-test determined signifi cance (*p < 0.05). Ronald H. Clements2, Jayleen M. Grams1 During the study period, 424 patients were treated for 1. Surgery, University of Alabama at Birmingham, Birmingham, esophageal cancer, of which 93 (22%) had lung nodules. AL; 2. Surgery, Vanderbilt University, Nashville, TN Of these, 29 (31%) were treated non-surgically either due to their poor performance status or extra-pulmonary distant INTRODUCTION: Although laparoscopic Roux-en-Y gas- metastasis on CT and/or PET. The remaining 64 patients tric bypass (LRYGB) has decreased morbidity compared to had no evidence of extra-pulmonary metastasis and under- the open approach, it was initially associated with a higher went neo-adjuvant therapy (35 (55%)) followed by curative rate of internal hernia (IH). This study investigated the en-bloc esophagectomy (with lung resection, 33 (50%), or impact of mesenteric defect closure on the rate and charac- without lung resection, 31 (47%) as per a tumor board con- teristics of IH after LRYGB. sensus). Of 33 lung resections, there were 27 benign lesions METHODS: Retrospective review was conducted on all (mostly granulomas or fi brotic scars), 4 primary stage I lung patients undergoing LRYGB from 2001–2011. Only patients cancers and 2 metastases (1 esophageal cancer and 1 renal who had all defects closed (DC) or all defects not closed cell carcinoma). Of the 31 patients with lung nodules who (DnC) were included. Patients with an incidentally iden- underwent curative esophagectomy without lung resec- tifi ed IH during another operation were excluded. Data tion, only 1 (3.2%) showed interval size increase on fol- collected included demographics, clinical presentation, low-up imaging (median 9 months (3–40)). A total of 308 operative details, and postoperative course. Data were ana- patients underwent a curative esophagectomy, of which lyzed using SPSS (version 16) statistical software. 33 had a combined esophagectomy and wedge lung resec- tion (EL) and 275 had an esophagectomy alone (E). There RESULTS: Of 1160 patients who underwent LRYGB from were no differences in age or gender, but the EL group had 2001–2011, 914 met inclusion criteria [DC = 663 (72.5%) more smokers (EL:25 (77%) vs E:130 (47%) *). There was no patients and DnC = 251 (27.5%)]. Median follow-up was difference in pulmonary complications, anastomotic leak, 24.3 (range 0.5–93.3) vs 31.7 months (range 0.5–131) in DC overall complications, operative time, blood loss, length-of- vs DnC, respectively (p < 0.0001). A total of 46 patients stay, or post-operative mortality (Table 1). (5%) developed a symptomatic IH [25 (3.8%) in DC vs 21 (8.4%) in DnC group, p = 0.005]. This remained statistically The presence of incidental pulmonary nodules in the signifi cant on multivariate analysis (p = 0.0098, OR 0.44; absence of extra-pulmonary metastases in esophageal can- 95% CI 0.24–0.82). Nineteen patients (42.2%) presented for cer patients are rarely distant metastases, and should not emergent or urgent repair and 26 (57.8%) for elective repair. bias caregivers towards palliative therapy. In addition, The most common symptom was chronic post-prandial should a nodule be of uncertain etiology, resection of lung abdominal pain (53.4%), followed by abdominal pain with nodules during the esophagectomy is safe. nausea ± vomiting (35.6%), acute abdominal pain ± nau- sea and vomiting (8.8%), and an acute abdomen (2.2%).

56 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Median time to presentation from LRYGB was 16.6 (range (10%), or high (13%). Positive margins for EMR, LR, and PD 3.1–71.9) vs 33.5 months (range 10–103) in the DC vs DnC were identifi ed in 66%, 29% and 3%, respectively. Median group, respectively (p < 0.001). At the time of IH repair there follow-up was 27 months. The 3 year recurrence-free sur- was no signifi cant difference in BMI or % EWL between vival (RFS) rate was 83% and there were no differences in the two groups. All patients underwent CT scan which RFS between the three different treatment groups. Tumors was consistent with IH in 26 patients (57.5%), suggestive were smaller in the EMR group (p = 0.005) and more likely in 7 (15.6%), showed small bowel obstruction in 4 (8.9%), to have a positive margin compared to the LR and PD group and was negative in 8 (17.8%). The majority of IH repairs (p < 0.001). In all patients, RFS was better in low grade were performed laparoscopically (86.7%) vs open (13.3%). tumors as compared to those that were high or intermedi- Intra-operatively, 71 herniation sites were identifi ed. In the ate (p = 0.04). Negative margin status and negative lymph DC group, there were 23 (67.6%) pseudo-Peterson’s and 11 nodes were not associated with better RFS. Morbidity after (32.4%) meso-mesoenteric defects. In the DnC group, there EMR, LR, and PD was 0%, 24%, and 41% respectively. were 5 (13.5%) mesocolic, 15 (40.5%) Peterson’s, 2 (5.4%) pseudo-Peterson’s, and 15 (40.5%) meso-mesenteric defects. Table I Median OR time was 104 minutes (range 75–180). Median EMR LR PD length of stay was 1 day (range 0.5–32). One patient who Variable (n = 12) (n = 35) (n = 30) p Value presented in extremis died after being hospitalized else- Tumor Size (cm) 0.6 + 0.5 1.8 + 1.4 1.9 + 1.1 0.005 where for 3 days with the incorrect diagnosis. One patient 18/28 Low Grade Tumor* 9/10 (90%) 28/33 (84%) NS had IH recurrence 11.5 and 14.2 months after initial repair. (64%) CONCLUSIONS: Complications of IH can be devastating Positive Resection Margin 8/12 (66%) 9/31 (29%) 1/30 (3%) <0.001 and closure of mesenteric defects during LRYGB signifi - 18/29 Positive Lymph Nodes NA 5/17 (29%) 0.03 cantly lowers IH rate. A high index of suspicion must be (62%)

maintained since symptoms may be nonspecifi c and imag- Recurrence 1/12 (8%) 6/35 (17%) 5/30 (17%) NS Abstracts Tuesday ing may be negative in nearly 20% of patients. *pathology specimens were unavailable for review of grade in 6 patients  916 CONCLUSIONS: EMR, LR, and PD are all effective treat- Tumor Grade, Not Extent of Resection, Is Associated ment approaches for duodenal neuroendocrine tumors. with Recurrence-Free Survival in Patients with Tumor grade is associated with recurrence-free survival but Duodenal Neuroendocrine Tumors not lymph node or margin status. When feasible, a less Brian Untch, Laura H. Tang, Keisha Bonner, Kevin K. Roggin, aggressive surgical approach to treat duodenal neuroendo- crine tumors should be considered. Michael D’Angelica, Ronald P. DeMatteo, William R. Jarnagin, T.P. Kingham 6 917 Surgery, Memorial Sloan-Kettering Cancer Center, New York, IL BACKGROUND: Duodenal neuroendocrine tumors are Laparoscopic Pancreas Sparing Segmental Resection of rare and few studies exist to guide surgical management. the Distal Duodenum for GIST Endoscopic mucosal resection (EMR), local duodenal resec- Robert Sung, Diana J. McPhee, Paresh C. Shah tion (LR), and pancreaticoduodenectomy (PD) are typically Lenox Hill Hospital, New York, NY performed as primary treatment. This study identifi es fac- This is a laparoscopic pancreas sparing, segmental resection tors associated with recurrence after resection. of the distal duodenum for a GIST. A 65 year old female METHODS: A retrospective, single institution review was presented with GI bleeding, the diagnosis and initial bleed- performed between 1987 and 2011 on patients with a patho- ing control were done endoscopically. Imaging confi rmed logic diagnosis of duodenal neuroendocrine tumor. Biopsy location and vascular supply. We begin with an extended and surgical specimens were independently reviewed by a Kocher maneuver to the ligament of Treitz. The tumor is pathologist. Tumor grade was assigned based on WHO 2010 identifi ed and the duodenum freed from the superior mes- criteria (KI-67 and/or mitoses per high power fi eld). enteric vessels. An extraserosal dissecton off the pancreas is RESULTS: Seventy-seven patients with a median age of done using ultrasonic shears. The jejunum is divided at the 60 had resectable duodenal neuroendocrine tumors. Based ligament, the duodenum divided just distal to the ampulla. on pathologic review, there were 9 somatostatinomas, 18 A two-layer handsewn anastomosis is created. Pathol- gastrinomas, and 49 not otherwise specifi ed. In the entire ogy demonstrated a 3.9 cm low-grade GIST with negative group, 12 underwent EMR, 35 had LR, and 30 underwent margins. PD (Table). Tumors were graded as low (77%), intermediate

57 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

918 919 Overexpressing TNF-alpha in Pancreatic Ductal Adenocarcinoma Cells and Fibroblasts Modifi es Does Resident Experience Affect Outcomes in Complex Cell Survival and Reduces Fatty Acid Synthesis via Abdominal Surgery? 1 1 1 Downregulation of Sterol Regulatory Element Binding Daniel Relles , Richard Burkhart , Michael J. Pucci , 2 1 1 Protein-1 and Activation of Acetyl COA Carboxylase Jocelyn Sendecki , Renee Tholey , Ross E. Drueding , 1 1 1 Mazhar Al-Zoubi, Galina Chipitsyna, Konrad Sarosiek, Patricia K. Sauter , Eugene P. Kennedy , Jordan M. Winter , 1 1 Christopher Y. Kang, Charles J. Yeo, Hwyda A. Arafat Harish Lavu , Charles J. Yeo Surgery, Thomas Jefferson University, Philadelphia, PA 1. Surgery, Thomas Jefferson University, Philadelphia, PA; 2. Biostatistics, Thomas Jefferson University, Philadelphia, PA INTRODUCTION: The effect of TNF- on pancreatic tumorigenesis is controversial due to the differential sig- BACKGROUND: For complex abdominal operations, the naling pathways initiated after binding its receptors TNFR1 infl uence of provider and hospital volume on surgical out- and TNFR2. TNFR1 activation by TNF- leads to cell apop- comes has been described. The impact of resident experi- tosis, whereas TNFR2 signaling is believed to be involved ence is less well understood. in cell survival through the activation of NF kappa B. TNF- METHODS: We reviewed perioperative outcomes after gene delivery has been suggested as a potentially useful pancreaticoduodenectomy (PD) at a single high-volume therapeutic approach to improve gemcitabine treatment center between 2006 and 2012. Resident participation and of pancreatic ductal adenocarcinoma (PDA), but its exact outcomes were collected in a prospectively maintained mechanism of action is not clearly understood. Although database. Resident experience was defi ned as post-graduate TNF- has been shown to increase the expression of the year (PGY) and number of PDs performed. lipogenesis promoting enzyme, fatty acid synthase (FAS) in RESULTS: Twenty-nine residents and four attending sur- liver steatosis, its impact on de novo lipogenesis in tumor geons completed 681 PDs. The overall complication rate cells has not been determined. In this study, we investigated was 44%; PD-specifi c complications (defi ned as pancreatic effect of TNF- on fatty acid synthase (FAS) in PDA cells and fi stula, delayed gastric emptying, bile leak, abscess, and in fi broblasts as part of the tumor micro-environment. wound infection) occurred in 28% and were signifi cantly METHODS: PDA cells (MIAPACA-2 and AsPC-1) and the more common when the fi rst assistant was a PGY 4 rather fi broblast cell line, hTERT-BJ were transfected with TNF than a PGY 5 or 6 (44% vs. 27%, p = 0.016). Logistic regres- gene by lentivirus-vector transduction. Control cells were sion demonstrated that as residents perform more cases, transfected with the empty vector. FAS mRNA and pro- PD-specifi c complications decrease (OR = 0.97, p < 0.01). tein were analyzed by real time PCR and Western blot- For a resident’s fi rst case, the predicted probability of a PD- ting, respectively. Total- and phospho-AMPK, total- and specifi c complication is 27%; this rate decreases to 19% by phospho-Acetyl CoA carboxylase (ACC), FAS, and LKB/ case 15 (Figure 1). STK11 were analyzed by Western immunoblotting. The effects of TNF- on sterol regulatory element binding pro- tein-1, SREBP-1, the transcription factor responsible for FAS transcription, LKB1/STK11 (a tumor suppressor and the established upstream regulator of AMPK) and ACC (the downstream target of AMPK and the rate-limiting enzyme of fatty acid synthesis) were evaluated by real time PCR. MTT and Wound healing assays were used to determine cell survival and migration, respectively. RESULTS: TNF- signifi cantly (P < 0.05) reduced PDA and fi broblast cell survival and migration. This was associ- ated with signifi cant reduction of FAS mRNA and protein expression levels in PDA cells (P = 0.02) but not the fi bro- blasts. Cells overexpressing TNF- also showed signifi cantly (p < 0.05) reduced SREBP-1 and ACC. Reduction of FAS by TNF-was inhibited when either SREBP-1 or ACC was knocked down by siRNA. No signifi cant differences were seen in AMPK phosphorylation in cells that overexpress CONCLUSIONS: We highlight the impact of resident TNF-. involvement in complex abdominal operations, demon- CONCLUSION: Our data demonstrate a previously unknown strating that as residents build experience with PD, patient involvement of TNF- in PDA and microenvironment lipo- outcomes improve. This is consistent with volume-outcome genesis and suggest that targeted introduction of intratu- relationships for attending physicians and high-volume mor TNF- can have the potential as a novel therapeutic hospitals. Complex cases provide unparalleled learning anti-lipogenic agent in human PDA. opportunities and remain an important component of sur- gical training. Maximizing resident repetitive exposure to complex surgical procedures benefi ts both the patient and the trainee.

58 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

POSTER SESSION DETAIL Printed as submitted by the authors.  indicates a poster featured in a Poster Tour (ticketed session with complimentary but limited registration):

Sunday, May 19, 2013, 11:00 – 11:45 AM: Esophageal and Stomach

Monday, May 20, 2013, 11:00 – 11:45 AM: HPB

Tuesday, May 21, 2013, 11:00 – 11:45 AM: Small Bowel and Colon-Rectal indicates a Poster of Distinction. Sunday, May 19, 2013 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 West Hall A POSTER SESSION I (NON-CME)

Basic: Colon-Rectal completed the tasks using the same grasper but with scissors capable of shaft articulation up to 85 degrees. Outcomes were the standard FLS metrics of time and error (deviation as a percentage of total circle area). Instrument switches Su1794 Poster Abstracts between hands and TEM position adjustments were also Effect of Instrument Type on Transanal Endoscopic recorded. Overall group outcomes were compared using Microsurgery (TEM) Learning Curves t-tests. Mixed models were used to compare changes over Sunday Ezra N. Teitelbaum, Fahd O. Arafat, Brittany Lapin, the 10 runs. Anne M. Boller Northwestern University, Chicago, IL BACKGROUND: The transanal endoscopic microsurgery (TEM) proctoscope is used to resect benign and early-stage malignant rectal tumors, and has received recent attention as a potential platform for transanal natural orifi ce surgery. No study has evaluated the effectiveness of different instru- mentation types for TEM surgery. We tested whether learn- ing curves for surgical novices using a TEM proctoscope would be improved with the use of scissors with shaft artic- ulation. Additionally, we compared TEM and laparoscopic learning curves for the same task. METHODS: Medical students were randomized into three study groups: laparoscopic (LAP), TEM rigid (TEM-R), and TEM articulating (TEM-A). All groups completed the Fun- damentals of Laparoscopic Surgery (FLS) circle-cut task 10 times. The LAP group completed the task using an FLS box-trainer and a standard laparoscopic grasper and rigid laparoscopic scissors. The TEM-R group completed the task using the same instruments but through a TEM procto- Procedure time versus run number. scope within a custom TEM box-trainer. The TEM-A group

59 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: 33 subjects were randomized, 11 to each group. Expression intensity ranged from weak to strong, whereas Overall mean task time was shorter for the LAP group than VEGFR3 and EGFR showed only weak expression in esopha- both the TEM-R and TEM-A groups (200 vs. 362 and 417 geal samples. PDGFR expression was observed in esopha- seconds; p < .001) (See Figure). Subjects in all three groups geal and gastric samples. Specimen showed intermediate to showed improvement in time over the 10 runs (coeffi cient strong expression. PDGFR expression was seen in esopha- estimates –33, –62, and –61; p < .001 for each group). The geal, gastric and colonic samples. Intensities varied from LAP group made fewer errors than the TEM-R group, but weak to strong. KGFR was expressed in all intestinal samples not the TEM-A group (7% vs. 10% vs. 8% circle area; p = and revealed expression intensities from weak to strong. .02 LAP vs. TEM-R). The LAP and TEM-A group made fewer CONCLUSION: Our results reveal a high expression rate errors over time (coeffi cient estimates –0.6 and –0.7; p < .01 of growth factor receptors in the rat intestine and facilitate for both), whereas the TEM-R group had a trend towards methodic experimental studies on gastrointestinal anasto- increased errors (coeffi cient estimate 0.4; p = 0.1). The LAP motic healing in rat models using the positive impact of group switched instruments between hands during fewer specifi c growth factors. runs than both the TEM-R and TEM-A groups (9% vs. 30% vs. 24% of runs; p < .01). The TEM-A group adjusted the proctoscope position during fewer runs than the TEM-R Basic: Pancreas group (36% vs. 54% of runs; p = .01). CONCLUSIONS: A LAP approach results in faster circle-cut  Su1796 task times than a TEM approach. While times were simi- lar, TEM procedures using articulating scissors may result in Histone Deacetylase Inhibition (HDAC) by Vorinostat fewer errors and less need to adjust proctoscope position as Sensitizes Pancreatic Cancer Cells to TRAIL Induced compared with rigid scissors. These results can be used to Cell Death develop specifi c curricula and training strategies for TEM surgery. Rohit Chugh, Vikas Dudeja, Osama Alsaied, Sulagna Banerjee, Veena Sangwan, Ashok Saluja, Selwyn M. Vickers Surgery, Basic and Translational Research Lab, Minneapolis, MN Basic: Esophageal INTRODUCTION: Pancreatic cancer is one of the most lethal human malignancies with fi ve-year survival of less Su1795 than 5% because of its resistance to most conventional che- motherapies like gemcitabine and other novel anti-cancer Growth Factor Receptors in the therapies like TRAIL. Histone deacetylase (HDAC) inhibitors of the Rat: New Targets for Improved Anastomotic are a new and promising drug family with strong antican- Healing? cer activity. The aim of the current study was to evaluate Daniel G. Drescher, Laura Kulzer, Carl Christoph Schimanski, whether inhibition of histone deacetylase sensitizes pancre- atic cancer to TRAIL induced cell death. Hauke Lang, Ines Gockel University of Mainz, Mainz, Germany METHODS: Highly aggressive metastatic pancreatic cancer cell lines (S2VP10, Capan-1) were treated with the HDAC BACKGROUND: Anastomotic leakage after gastrointestinal inhibitor, Vorinostat (0–5μM), TRAIL (0–40 ng/ml) or a com- surgery is a signifi cant cause of morbidity and mortality. bination of Vorinostat and TRAIL for 12–72 h. The effect on In particular, esophagogastric and colorectal anastomoses cell viability was evaluated using a WST-8 cell viability assay are vulnerable to leakage, resulting in an increased need (Dojindo Labs), apoptosis (caspase 3, 8 and 9 activation) for reoperation and a high risk of subsequent anastomotic was evaluated using Caspase Glo assay kit (Promega). stenosis formation and fi stula. Studies in well-established experimental rodent models showed a positive impact RESULTS: HDAC inhibition markedly increased TRAIL of growth factors on anastomotic wound healing. So far, induced cell death in both pancreatic cancer cell lines eval- methodic investigations on the expression profi le of growth uated. Viability, data expressed as % of Control (untreated factor receptors in the gastrointestinal tract do not exist. cells), mean ± SEM. S2VP10 (48 h): Vorinostat (5μM) – 64.5 ± 0.1%, TRAIL (20 ng/ml) – 95.13 ± 0.825%, Vorinostat MATERIAL AND METHODS: We investigated the co- (5μM) + TRAIL (20 ng/ml) – 41 ± 0.8%. HDAC inhibition expression pattern of vascular growth factor receptor markedly augmented Caspase 3 activation in response to (VEGFR1-3), epidermal growth factor receptor (EGFR), plate-   TRAIL. Caspase 3, data expressed as % of Control, mean let-derived growth factor receptor (PDGFR / ) and kerati- ± SEM. S2VP10 24 h: Vorinostat (5μM) – 206.1 ± 12.07%, nocyte growth factor receptor (KGFR) in the rat intestine. TRAIL (20 ng/ml) – 159.6 ± 1.2%, Vorinostat (5μM) + TRAIL Additional, IHC staining was applied for confi rmation of (20 ng/ml) – 2187.4 ± 77.62%. expression and analysis of growth factor receptor localisation.   CONCLUSION: Inhibition of Histone deacetylases sensi- RESULTS: VEGFR1-3, EGFR, PDGFR / and KGFR expres- tizes pancreatic cancer cells to TRAIL induced apoptosis and sion in rat intestinal samples revealed varying transcription cell death. Combination of HDAC inhibition and TRAIL has intensities. VEGFR1 expression was observed in all samples immense potential to emerge as novel therapeutic strategy and varied from intermediate to strong. VEGFR2 expres- against pancreatic cancer. sion was found in esophageal, gastric and colonic samples.

60 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1797 Clinical: Biliary Concepts for the Periampullary Carcinoma Enigma from Clinico-Pathologic Analysis of 198 Patients Su1590 Peter Bronsert1, Ilona Kohler1, Martin Werner1, Frank Makowiec2, Laura H. Tang3, Ulrich T. Hopt2, Tobias Keck2, Laparoscopic Cholecystectomy in Patients on Ulrich F. Wellner2 Clopidogrel: Is It Safe? 1Pathological Institute, University of Freiburg, Freiburg, Germany; Richard Frazee, Stephen Abernathy 2Department of Surgery, University of Freiburg, Freiburg, Germany; Surgery, Scott & White Healthcare, Temple, TX 3Department of Pathology, Memorial Sloan-Kettering Cancer Center, BACKGROUND: Clopidogrel is a common antiplatelet New York, NY medication for patients with coronary, peripheral, and cere- brovascular disease. Many surgeons recommend cessation AIMS: Periampullary adenocarcinomas comprise pancre- of Clopidogrel prior to surgery to avoid bleeding complica- atic ductal (PDAC), distal bile duct (DBDAC), ampullary tions. Clopidogrel cessation however, is associated with an (AMPAC) and duodenal (DUOAC) adenocarcinoma. The increased risk of thrombotic events up to 3 months after epithelia of these anatomical structures share a common cessation. We review our experience with laparoscopic cho- embryologic origin from the foregut. While there seem to lecystectomy in patients who remained on Clopidogrel in be signifi cant differences regarding tumor biology, the clas- the perioperative period. sifi cation, grading, staging and treatment of these entities remains a matter of substantial debate. Due to the anatomi- METHODS: An IRB approved retrospective review of cal complexity of the periampullary region, there is still patients having laparoscopic cholecystectomy from 2008– considerable debate on how carcinomas and their precur- 2012 while on Clopidogrel was performed. Patient demo- sor lesions arising in this region should be classifi ed. Our graphics, indication for surgery, ASA score, operative time, study aimed at a detailed analysis of clinical, pathological conversion to open cholecystectomy, estimated blood loss, and immunohistochemical parameters for assessment of length of stay, morbidity and mortality were reviewed. tumor biology and identifi cation of prognostic factors after RESULTS: Thirty-one patients (13 women and 18 men) resection of periampullary carcinomas. underwent laparoscopic cholecystectomy while on Clopi- MATERIAL AND METHODS: 198 patients who had resec- dogrel. Sixteen were performed in an elective setting and tion of periampullary adenocarcinoma from 2001 to 2011 fi fteen were done as emergency/urgent operations. ASA were identifi ed. All tissue samples were processed by a stan- score was 2 in four patients (13%), 3 in twenty-four patients dardized protocol for pathological workup of pancreatoduo- (77%), and 4 in three patients (10%). Two patients (6%) denectomy specimen. Archived Hematoxylin-Eosin stained were converted from laparoscopic to open cholecystectomy Poster Abstracts slides were reevaluated by three experienced pathologists due to indistinct anatomy in acute cholecystitis. Average

for accuracy of diagnosis. For the growthpattern, three operating time was 71 minutes (27–129 minutes). Average Sunday typical subtypes were defi ned: intestinal, pancreatobiliary, estimated blood loss was 48 ml (1–300 ml). Morbidity was mixed intestinal-pancreatobiliary and Poorly-differentiated experienced in 22.5% of patients, and two 30 day mortali- carcinomas. Additionally for immunohistochemical sub- ties occurred (6%) secondary to cardiovascular complica- typing of the growth pattern CK7, CK20 and CDX2 staining tions. Length of stay averaged 3 days (outpatient – 15 days). were performed for each slide. Furthermore we established CONCLUSIONS: Laparoscopic cholecystectomy performed a modifi ed tumorgrading system. on patients taking Clopidogrel did not produce clinically RESULTS: 127 patients had PDAC, 39 had AMPAC, 23 signifi cant operative blood loss. Conversion to open cho- had DBDAC and nine had a DUOAC. The distribution of lecystectomy, morbidity and mortality were higher in this subtypes was signifi cantly different among the carcinoma patient population but appear to be more related to patient groups. Tumor location, histological subtype and grading comorbidities than the effects of the Clopidogrel. Recom- were highly signifi cant predictors of survival (p < 0.001). In mendations for Clopidogrel cessation prior to laparoscopic accordance, a high CK7 expression and a low CDX2 expres- cholecystectomy should be reconsidered. sion, which characterize PB differentiation, were signifi cant predictors of poor survival. Only histological subtype, grad- ing and lymph node ratio were found to represent indepen- dent predictors of survival in multivariate analysis. CONCLUSIONS: Our results demonstrate that there should be a change in the pathological management of making diagnoses in periampullary carcinomas. By multivariate analysis, traditional parameters as tumorlocation, TNM classifi cation lost their prominence as a source of prognos- ticating survival of periampullary carcinoma. Therefore, we recommend comprising the histological subtype and our adjusted histological grading for a better valuation of survival.

61 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1591 Su1592 Diagnostic Accuracy of Preoperative Multidetector- Elevated Perioperative Serum CA 19-9 Level Is an Row Computed Tomography Imaging in Predicting Independent Predictor of Poor Outcome in Patients Microscopic Curative Resection of Hepatobiliary with Resectable Cholangiocarcinoma and Pancreatic Malignancy: A Prospective Naru Kondo, Yoshiaki Murakami, Kenichiro Uemura, Multi-Institutional Study Takeshi Sudo, Yasushi Hashimoto, Hayato Sasaki, Kenjiro Okada, Kazuaki Shimada1, Yoshito Takeuchi2, Masaru Konishi3, Taijiro Sueda Tatsushi Kobayashi4, Akio Saiura5, Kiyoshi Matsueda6, Surgery, Hiroshima University, Hiroshima, Japan Tsuyoshi Sano7, Hideyuki Kanemoto8, Katsuhiko Uesaka8 BACKGROUND: Prognosis of cholangiocarcinoma is still 1Hepatobiliary and Pancreatic Surgery, National Cancer Center unsatisfactory, and identifi cation of predictive marker of Hospital, Tokyo, Japan; 2Diagnostic Radiology, National Cancer survival after surgical resection is important to establish the Center Hospital, Tokyo, Japan; 3Division of Digestive Surgery, perioperative therapeutic strategy for cholangiocarcinoma. National Cancer Center Hospital East, Kasiwa, Japan; 4Diagnostic Impact of perioerative serum carbohydrate antigen 19-9 Radiology, National Cancer Center Hospital East, Kasiwa, Japan; (CA19-9) levels on survival of patients with resectable chol- angiocarcinoma is still unclear. 5Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan; 6Diagnostic Radiology, PURPOSE: The purpose of this study was to investi- Cancer Institute Hospital, Japanese Foundation for Cancer Research, gate whether perioerative serum CA19-9 levels can pre- Tokyo, Japan; 7Gastroenterological Surgery, Aichi Cancer Center dict survival of patients underwent surgical resection for cholangiocarcinoma. Hospital, Tokyo, Japan; 8Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Tokyo, Japan METHODS: One hundred and six patients with cholangio- carcinoma including 33 with intrahepatic, 48 with perihi- PURPOSE: To assess the accuracy of preoperative diagno- lar and 25 with distal cholangiocarcinoma who underwent sis of hepatobiliary and pancreatic malignancy with mul- surgical resection between 2002 and 2012 were eligible for tidetector-row computed tomography (MDCT) to predict this study. Preoperative biliary drainage was performed for microscopic curative resection. the patients with obstructive jaundice. Preoperative serum DESIGN AND SETTINGS: Prospective observational study CA19-9 levels were measured after biliary drainage, and of hepatobiliary and pancreatic malignancy resected postoperative serum CA19-9 levels were measured about 4 between November 2007 and December 2008, in 5 Cancer weeks after operation. The relationships between clinico- Center Hospitals in Japan. pathological factors including perioperative serum CA19-9 PARTICIPANTS: 271 consecutive patients with highly levels and overall survival (OS) were analyzed with univari- suspected and potential resectable hepatobiliary and pan- ate and multivariate analyses. creatic malignancy undergoing MDCT judged fi t for lapa- RESULTS: Preoperative CA19-9 levels were signifi cantly rotomy were studied. higher in patients with moderately and poorly differenti- MAIN OUTCOMES MEASURES: Sensitivity and specifi c- ated adenocarcinoma than in those with well differentiated ity of MDCT predicting a microscopic curative resection adenocarcinoma (P = 0.009), and in patients with UICC based on the histopathological examination of presence or stage I/II than those with III/IV (P = 0.008). In contrast, absence of tumors at the margin of the specimen. there was no signifi cant difference between postoperative CA19-9 and any other clinicopathological factors. Univari- RESULTS: 164 patients of 217 macroscopic resectable ate analysis revealed postoperative adjuvant chemotherapy patients (75.6%) with hepatobiliary and pancreatic malig- (P = 0.03), residual tumor factor status (P = 0.01), patho- nancy underwent microscopic curative resection. MDCT logical differentiation (P = 0.02), UICC pT stage (P = 0.009), predicted clear margin resections in 146 patients (89.0%). lymph node metastasis (P < 0.001) and UICC fi nal stage Sensitivity for prediction of microscopic curative resection (P = 0.001) were signifi cantly associated with OS. In addi- by MDCT in perihilar cholangiocarcinoma, gallbladder car- tion, differences in OS were signifi cant between groups cinoma, middle/lower bile duct carcinoma, and pancreatic divided on the basis of two preoperative CA19-9 cutoff val- carcinoma was 64.7% [CI,52.3–78.9%], 90.9% [CI,90.9– ues (37 and 200 U/ml), and three postoperative CA19-9 cut- 97.29%], 95.5% [CI,97.7–99.1%], and 89.7% [CI,86.3– off values (37, 100 and 200 U/ml). In multivariate analysis, 93.1%], respectively. On the other hand, specifi city was no postoperative adjuvant chemotherapy (odds ratio [OR], 30.8% [CI, 14.5–49.3%], 0%, 33.3% [CI, 14.4–42.4%], and 3.02: 95% confi dence interval [CI], 1.54–5.89; P = 0.001), 36.4% [CI, 21.5–51.6%], respectively. lymph node metastasis (OR, 3.96; 95% CI, 1.91–8.48; P < CONCLUSIONS: Expert radiologists in hepatobiliary and 0.001), preoperative CA19-9 (≥200 IU/ml) (OR, 2.27; 95% pancreatic disease could not predict microscopic curative CI, 1.10–4.61; P = 0.03) and postoperative CA19-9 (≥37 IU/ resection in patients with perihilar cholangiocarcinoma. ml) (OR, 6.88; 95% CI, 3.36–14.41; P < 0.001) were identi- Even if MDCT predict a possibility of surgical margin posi- fi ed as independent predictors for OS. tive resections, surgery seems to be not always contraindi- CONCLUSION: Perioperative serum CA19-9 levels predict cated in hepatobiliary and pancreatic malignancy, because the survival of patients with resectable cholangiocarci- the accurate preoperative diagnosis with MDCT has still noma, and they may contribute to establishment of new remained diffi cult. therapeutic strategy, as perioperative treatment can be opti- mized based on its value.

62 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1593 Su1594 Stapling the Cystic Duct During Laparoscopic Diagnostic Utility of Magnetic Resonance Cholecystectomy Results in Increased Rates of Cholangiopancreatography (MRCP) in Patients Unintended Post-Operative ERCP with Intermediate Probability of Cholidocholithiasis Irene Epelboym2, Florita Martin1, Megan Winner2, Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng, Zachary L. Gleit2, Michael D. Kluger1,2 Sreenivasa S. Jonnalagadda 1Division of Hepatobiliary Surgery and Liver Transplantation, New University of Missouri Kansas City School of Medicine, Kansas City, MO York-Presbyterian Hospital Weill Cornell Medical College, New York, BACKGROUND: Patients with symptomatic cholelithia- NY; 2Surgery, Columbia University Medical Center, New York, NY sis and suspected choledocholithiasis can be risk stratifi ed BACKGROUND: Since the advent of laparoscopic cholescys- into a low (<10%), intermediate (10–50%) or high probabil- tectomy in 1987, there have not been noteworthy changes ity (>50%) of having CBD stone disease based on clinical in technique for ligation and transection of cystic artery and predictors. Guidelines recommend laparoscopic cholecys- duct: metal clips and sharp transection. Laparoscopic sta- tectomy for patients with low probability of common bile plers (LS) have been suggested as a safe alternative in severe duct (CBD) stone, pre-operative Endoscopic retrograde infl ammation or when the cystic duct appears too wide for cholangiopancreatography (ERCP) for high probability of complete clip occlusion. We hypothesized an increased rate CBD stone and pre-operative Endoscopic ultrasound (EUS) of adverse postoperative events following use of LS. or Magnetic resonance cholangiopancreatography (MRCP) or Intra-operative (IOC) for intermediate METHODS: All patients who underwent laparoscopic probability of cholidocholithiasis. In patients with interme- cholecystectomy for biliary colic, cholecystitis, pancreati- diate probability, ERCP is often deferred due to its potential tis or choledocholithiasis at our institution were identifi ed complications and MRCP is commonly performed as EUS using billing records. Operative notes were reviewed for use is not widely available. However, the diagnostic utility of of LS. A 2:1 control group was selected using propensity MRCP in this sub set of patients is not well defi ned in clini- score matching on age, gender and operative diagnosis. cal practice. Presenting features, operative characteristics and postop- erative outcomes were analyzed. Continuous variables were METHODS: Charts of all patients admitted with symptom- compared using Student’s t-test. Categorical variables were atic cholelithiasis that had cholecystectomy and underwent compared using chi-square or Fisher’s exact test. Prediction prior MRCP for cholidocholithiasis between the periods of models were constructed using logistic regression. Jan 2007 and Oct 2012 at an academic tertiary referral cen- ter were reviewed. Of these, patients who met the criteria RESULTS: Between 1997 and 2009, LS was used in 58

for intermediate likelihood of CBD stone and underwent Poster Abstracts (0.9%) of 6272 patients. These were matched to 116 patients preoperative MRCP, IOC or pre/post-operative ERCP were in whom cystic duct was divided between metal clips (MC). included in the study. Patients with any intrinsic liver dis- Sunday Differences in age, gender, race, ASA status, admission ease, or hepato-biliary malignancy or <18 years of age were diagnosis, as well as in presence of leukocytosis, hyperbili- excluded. Pertinent demographic, clinical, biochemical and rubinemia, or elevation in pancreatic enzymes were not sta- ultrasound parameters were collected by three investigators. tistically signifi cant (p > 0.05) between LS and MC groups, though LS was used more often in acute compared with RESULTS: Of a total of 330 patients, 125 met the inclusion elective cases (40% vs. 24%, p = 0.05). Compared with MC, criteria for intermediate probability and were included in average intraoperative blood loss (50 vs 25 ml, p < 0.001) fi nal analysis. Mean age of all patients was 52 ± 21 years and postoperative length of stay (2 vs 1 day, p = 0.016) with 37% males (n = 46). Eighty four patients had IOC and were both signifi cantly greater for LS. When intraoperative sixty patients had ERCP. MRCP was positive for CBD stone cholangiography (IOC) was attempted, successful cannula- in only 26.4% of patients (n = 33/125). CBD stone was pres- tion was achieved in only 2 of 8 (25%) LS cases, versus 28 ent in 33% (n = 41/125) patients as confi rmed by either of 31 (90%) controls (p < 0.001). Patients in the LS group IOC (n = 11/84) or ERCP (n = 32/60). False positive rate of required post-operative ERCP for clinically evident post- MRCP was 36% (12/33) and false negative rate was 21% (n operative choledocholithiasis at twice the rate of those in = 20/92). Sensitivity and specifi city of MRCP in detection of the MC group (p = 0.009). Controlling for preoperative and impacted stone was 51% and 85% respectively. Positive pre- demographic factors, LS remained the only statistically sig- dictive and negative predictive values were 63% and 78% nifi cant predictor of requiring postoperative ERCP (OR = respectively. 4.0, p = 0.03). There were no bile duct injuries. CONCLUSION: MRCP has a poor sensitivity in patients CONCLUSIONS: Stapling of the cystic duct during lapa- with intermediate likelihood of cholidocholithiasis. Intra- roscopic cholescystectomy is associated with an increased operative cholangiography is recommended for defi nitive need for unintended postoperative ERCP. We suspect this evaluation for a residual bile duct stone in this sub group. is secondary to passage of stone fragments into the com- mon bile duct after crushing by the stapler, or leaving a remnant infundibulum/neck after incomplete dissection and stapling. Prior to using a stapling device, we advocate for more meticulous dissection or conversion to open cho- lescystectomy in order to complete the operation safely and with minimal postoperative complications.

63 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1595 and underwent either pre/post-operative endoscopic retro- grade cholangiography (ERC) or intraoperative cholangiog- Trends in Liver Biochemistries: Are They a Better raphy (IOC) were included in the study. Patients with any Predictors Than MRCP in Evaluation of Patients with intrinsic liver disease, or hepato-biliary malignancy were Intermediate Probability of Choledocholithiasis? excluded. Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng, RESULTS: Of a total of 330 patients, 125 met the crite- Sreenivasa S. Jonnalagadda ria for intermediate risk group and were included in fi nal University of Missouri Kansas City School of Medicine, Kansas analysis. Mean age of all patients was 52 ± 21 years with City, MO 37% males (n = 46). MRCP was positive for CBD stone in 26.4% of patients (n = 33/125). CBD stone was present in BACKGROUND: Patients with symptomatic cholelithiasis 33% (n = 41/125) patients as confi rmed by either IOC (n and suspected choledocholithiasis can be risk stratifi ed into = 11/84) or ERCP (n = 32/60). Sensitivities, specifi cities, a low (<10%), intermediate (10–50%) or high probability positive and negative predictive values and accuracy of the (>50%) based on clinical predictors. Liver biochemistries tests were calculated for preoperative MRCP, trends in total are the fi rst line tests and any abnormal liver test raises sus- bilirubin alone, alkaline phosphatase (ALP) alone, AST/ALT picion for impacted common bile duct stone. A bilirubin alone, total bilirubin in combination with ALP, total bili- level >4 mg/dl is considered a very strong predictor with rubin in combination with AST/ALT, ALP in combination high probability of CBD stone (>50%). Likewise, bilirubin with AST/ALT, and total bilirubin in combination with ALP level between 1.8–4 mg/dl along with dilated ducts on and AST/ALT for patients with intermediate risk group and ultrasound is considered a very strong predictor. All other for all patients (Table 1). abnormal liver biochemistries other than bilirubin are con- sidered moderate predictor with low probability (<10%). CONCLUSION: The sensitivity of an upward trend in However, predictive value of liver biochemistry trends in hepatic transaminases, alkaline phosphatase and total bili- detecting choledocholithiasis in intermediate probability rubin alone and in different combinations is low although group is not known. some of them are comparable to that of MRCP in detecting CBD stone. MRCP has a high specifi city in detecting CBD METHODS: Charts of all patients admitted with symp- stone and this is matched by an upward trend in AST/ALT tomatic cholelithiasis that had cholecystectomy and under- with a similar specifi city. Thus in the intermediate group, went work up including MRCP for CBD stone evaluation proceeding with ERC may be a better option when an between the periods of Jan 2007 and Oct 2012 at a tertiary upward trend in the AST/ALT, ALP and/or total bilirubin are referral center were reviewed. All patients who received pre- noted, instead of performing a more expensive alternative operative work up for suspected CBD stone including liver diagnostic MRCP testing. biochemistries on 2 occasions with at least 12 hours apart,

Table 1

MRCP T. Bili ALP AST/ALT Bili + ALP Bili + AST/ALT ALP + AST/ALT Bili + ALP + AST/ALT Sensitivity 51 27 49 22 52 43 55 60 Specifi city 85 76 67 83 57 70 60 51 PPV 63 35 43 39 38 40 40 38 NPV 78 67 72 68 71 70 60 51 Accuracy 74.4 60 61 62 56 60 58 54

Su1596 two groups based on days from surgical admission to cho- lecystectomy within 48 hours (Group 1) and after 48 hours Procedure Timing in Cholecystectomy Infl uence (Group 2). Patient demographic, comorbidities and out- Outcome in Patients Admitted for Acute Gallstone come were compared using t-test and chi-square as appro- Disease priate. Regression models were used to adjust for patient Muhammad Asad Khan, Roman Grinberg, John Afthinos, and operative risk factors. Karen E. Gibbs RESULT: Patient demographics and preoperative charac- Staten Island University Hospital, Staten Island, NY teristics of patients are detailed in Table 1. Patients who had delayed procedure (>48 hours) have generally higher post- BACKGROUND: Objective of this study was to exam- operative complications including pneumonia, unplanned ine the effect of delay in cholecystectomy on outcome in intubation, acute renal failure, MI, DVT, sepsis and bleed- patient admitted for acute gallstone disease. ing requiring transfusion (Table 2). Delayed procedure was METHODS: Patient with acute gallstone disease admit- related to higher incidence of re-operation (2.3 vs. 1.7), ted inpatient between 2007–2009 were identifi ed from require prolong postoperative stay (mean 3.6 vs. 2.4 days) American College of Surgeons National Surgical Quality and higher cumulative morbidity (). Mortality was signifi - Improvement Program (NSQIP) database using Interna- antly higher in delayed surgery group even after adjusting tional Classifi cation of disease (ICD-9) diagnosis codes for co-morbidities (A Something missing here? (574-574.91) and (575–575.2). Patients were divided into

64 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1: Patient Characteristics and Co-Morbidites Su1597 Duration of Surgery Within 48 Hours After 48 Hours P Value Gallbladder Perforation and Grade Do Not Affect Number 19484 (66.9%) 9621 (33.1%) Survival in Patients with Incidental Gallbladder Cancer Age 51.8 ± 18 55.1 ± 19 <0.001 Vadim P. Koshenkov1, Tulay Koru-Sengul2, Danny Yakoub1, Diabetes on oral 1614 (8.3%) 958 (10%) <0.001 Alan S. Livingstone1 hypoglycemic 1Surgery, University of Miami, Miami, FL; 2Epidemiology, University of Diabetes on Insulin 870 (4.5%) 732 (7.6%) <0.001 Miami, Miami, FL BMI 30 ± 36 29 ± 9 0.51 Smoking 3840 (19.7%) 1868 (19.4%) 0.561 INTRODUCTION: Gallbladder cancer is the fi fth most Severe COPD 670 (3.4%) 535 (5.6%) <0.001 common malignancy of the gastrointestinal tract and car- CHF 90 (0.5%) 240 (2.5%) <0.001 ries a poor long-term survival, unless the disease is iden- History of MI 69 (0.4%) 86 (0.9%) <0.001 tifi ed early. Most frequently, it is diagnosed incidentally Prior PCI 829 (4.3%) 623 (6.5%) <0.001 after a laparoscopic cholecystectomy for benign gallbladder CABG 977 (5.0%) 820 (8.5%) <0.001 disease. ESRD 163 (0.8%) 211 (2.2%) <0.001 METHODS: A retrospective review was performed for Hypertension 7599 (39.0%) 4658 (48.4%) <0.001 patients with incidental gallbladder cancer (IGC) at two ter- Prior peripheral 189 (1%) 184 (1.9%) <0.001 tiary care referral centers who underwent cholecystectomy revascularization for symptomatic cholelithiasis or cholecystitis from 1/1996 Prior operation within 138 (0.7%) 239 (2.5%) <0.001 to 8/2011. Of the 26572 gallbladders that were removed 30 days during the study period, 67 (0.25%) harbored cancer. Clini- Partially dependent 666 (3.4%) 932 (9.7%) <0.001 copathologic variables such as age, sex, grade, gallbladder Totally dependent 137 (0.7%) 260 (2.7%) <0.001 perforation and stage were assessed for impact on overall Bleeding disorder 787 (4%) 926 (9.6%) <0.001 survival. Steroid Use 389 (2%) 331 (3.4%) <0.001 RESULTS: A total of 67 patients with IGC were identifi ed. Open Cholecystectomy 3931 (20.2%) 2012 (20.9%) 0.146 Laparoscopic cholecystectomy was performed in 58 of these patients. Most patients were female (70.1%), had gallstones Table 2: 30-day Moratliy and Postoperative Complications (91.0%), and 31 were 70 years old or older (46.3%). Tumors were most commonly poorly differentiated (35.8%). Met- Within 48 Hours After 48 Hours astatic disease was detected in 13 (19.4%) patients, while N = 19484 N = 9621 P Value gallbladder perforation occurred in 16 (23.9%) patients. Superfi cial SSI 353 (1.8%) 142 (1.5%) 0.039 Univariate analysis determined that only metastatic disease Poster Abstracts Deep SSI 53 (0.3%) 24 (0.2%) 0.804 had effect on overall survival (HR = 2.76, p = 0.006). Both Organ space SSI 179 (0.9%) 94 (1%) 0.653 univariate and multivariate analyses failed to show the Sunday Wound Dehiscence 50 (0.3%) 34 (0.4%) 0.162 impact of age, sex, grade, and gallbladder perforation on Pneumonia 192 (1%) 143 (1.5%) <0.001 overall survival. Only early T stage independently predicted Unplanned Intubation 174 (0.9%) 144 (1.5%) <0.001 overall survival (HR = 0.06, p = 0.003). Pulmonary Embolism 31 (0.15%) 31 (0.3%) 0.006 DISCUSSION: In patients with IGC, advanced age, male Failure to wean >24 140 (0.7%) 150 (1.6%) <0.001 sex, poorly differentiated tumors and presence of gallblad- hours der perforation did not adversely affect survival. Only Acute renal failure 40 (0.2%) 45 (0.5%) <0.001 advanced stage, be it distant or locoregional, predicted a UTI 173 (0.9%) 141 (1.5%) <0.001 worse overall survival. MI 38 (0.2%) 25 (0.3%) 0.284 Bleeding required 24 (0.1%) 36 (0.4%) <0.001 transfusion DVT 31 (0.2%) 51 (0.5%) <0.001 Sepsis 207 (1.1%) 168 (1.7%) <0.001 Return to OR 337 (1.7%) 220 (2.3%) 0.001 Operative time 86.3 ± 48 88.6 ± 48 <0.001 Days from operation to 2.4 ± 3.7 3.6 ± 5.4 <0.001 discharge Cumulative morbidity 832 (4.3%) 696 (7.2%) <0.001 Mortality 83 (0.4%) 151 (0.6%) <0.001

CONCLUSION: In this retrospective study, delay in sur- gery was related to higher postoperative complications and mortality in patients with acute gallstone disease. These fi ndings demonstrate that medical optimization of patients should be sought expeditiously to decrease potential post- operative complications.

65 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1598 Clinical: Colon-Rectal Insurance Impacts Biliary Disease: A National Study Elizaveta Ragulin-Coyne1, Zeling Chau1, Elan R. Witkowski1, Su1600 Jillian K. Smith1, Sing Chau NG3,1, Mark P. Callery3, Heena P. Santry1, Shimul A. Shah2, Jennifer F. Tseng3,1 Extensive Abdominal Wall Necrotizing Fasciitis 1Department of Surgery, Surgical Outcomes Analysis & Research, and Fournier’s Gangrene Complicating Perforated University of Massachusetts Medical School, Worcester, MA; Appendicitis 2Department of Surgery, University of Cincinnati, Cincinnati, OH; Basem Azab, John Afthinos, Karen E. Gibbs 3Department of Surgery, Beth Israel Deaconess Medical Center, Surgery, Staten Island University Hospital, Staten Island, NY Boston, MA INTRODUCTION: While many randomized trials dem- BACKGROUND: Health care reform emphasizes insurance onstrated the possibility of non-operative management of coverage to improve outcomes. Biliary disease affects all uncomplicated appendicitis, remains the population segments, and its treatment utilizes radiology, standard of care. In distinct contrast, perforated acute appen- GI, and surgical procedures. We hypothesized that insur- dicitis is widely treated non-operatively; supported by many ance affects biliary procedure rates and outcomes. prior studies. Although few reports demonstrated that Fourni- er’s gangren and necrotizing fasciitis are potential complica- METHODS: Nationwide Inpatient Sample 2004–2009 tions of perforated appendicitis, we are reporting the fi rst case was used to identify urgent biliary disease, including acute of abdominal wall necrotizing fasciitis and Fournier’s gan- cholecystitis, duct obstruction, cholangitis. Insurance was grene during the non-operative management of perforated defi ned as private, Medicaid, uninsured. To eliminate Medi- appendicitis in a young healthy gentleman. This case dem- care confounding, patients >64 were excluded. Hospital onstrates the need for close observation and the potential for type was defi ned as for-profi t vs. not-for-profi t. We com- signifi cant disease progression in complicated appendicitis. pared procedures, including cholecystectomy (OR), inter- ventional radiology (IR), and endoscopic (GI). We further CASE REPORT: Our patient is a 23 year-old Afro-Caribbean analyzed hospital characteristics and length of stay (LOS). gentleman with no signifi cant medical history. He pre- Multivariable analyses were performed. sented with a gradual onset of diffuse abdominal pain of 7 days duration, progressively localized to the right lower RESULTS: 1,269,668 weighted patients were identifi ed; abdominal region. On physical exam, the patient was nor- 197,644 uninsured, 244,538 Medicaid, 827,486 private. motensive, pulse 108/minute, temperature 100.1 F, mild Uninsured patients were signifi cantly more likely than pri- distended abdomen and right lower abdominal tenderness vately insured patients to have no intervention; Medicaid with an elevated WBC of 20k/cc. On admission, CT of abdo- patient resembled uninsured [Table]. Within OR, Unin- men and pelvis demonstrated an appendicolith, thickening sured/Medicaid patients were more likely to undergo open of the cecum, a 5.9 × 2.6 × 14.8 cm gas and fl uid containing vs. laparoscopic cholecystectomy. Disparities were more locules in the right lower abdominal quadrant compatible pronounced in for-profi t compared to not-for-profi t hospi- with perforated appendicitis. These locules were not drain- tals. On multivariable analysis, independent predictors for able, with the appearance of an appendicluar mass rather receiving no procedure included older age, nonwhite, rural, than a contained abscess. The patient was admitted to the male, for-profi t hospital, lower-volume center. After mul- hospital for non-operative management which included tivariable adjustment, uninsured patients were 1.6x more intravenous broad spectrum antibiotics and serial abdomi- likely (95% CI 1.5–1.8) to undergo no procedure than pri- nal exams. On hospital-day 4, the patient developed vom- vate patients. iting, more abdominal distension, a scrotal abscess, pulse 120, fever 102 F, WBC decreased to 16k/cc. A repeat CT Biliary Procedures and Outcomes by Insurance demonstrated stable locules of air and fl uid (mostly retro- Uninsured Medicaid Private p-Value peritoneal) and diffuse. No Intervention 11.7% 12.4% 8.1% <0.0001 Abdominal wall edema. The patient underwent a diagnos- Cholecystectomy (OR) 85.7% 84.1% 88.3% <0.0001 tic laparoscopy that was converted to open due to diffi culty Interventional Radiology developing an appropriate working domain. A perforated 1.0% 1.2% 1.3% <0.0001 (IR) appendix adherent to the right pelvic side wall and an extra- Endoscopic (GI) 13.9% 14.3% 13.6% <0.0001 peritoneal purulent collection was noted. After appropriate LOS (median) days 2.2 2.4 1.9 <0.0001 abdominal washout and appendectomy, incision and drain- age of the right hemiscrotal abscess was performed. Postop- CONCLUSIONS: Treatment of biliary tract disease, includ- eratively, the patient had a protracted hospitalization course ing cholecystectomy, varies with insurance. As health care (60 days) consistent with septic shock and multi-system reform ensues, reimbursement becomes bundled and cen- organ failure. The patient’s condition necessitated multiple ter/provider outcomes are increasingly scrutinized, stan- returns to the operative room for debridement of necrotizing dardization of care to refl ect best practices for all patients fasciitis involving the scrotum and most of the lower half of will be essential. his abdominal wall. The patient was also managed by the burn critical care unit for extensive skin loss, received appro- priate wound care (including negative pressure wound dress- ing), and later was covered successfully with skin grafts and was discharged in stable condition.

66 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1601 METHODS: A Pubmed literature search was performed using key search words “robotics”, “colorectal”, “cancer”, Robotics in Colorectal Surgery: A Paradigm Shift? and “laparoscopic”. After exclusions, 13 studies were iden- Fatima G. Wilder, Advaith Bongu, Michael Demyen, tifi ed from 2000–2012. 6 studies were a direct comparison Ravi Chokshi between robotics and laparoscopic surgery for CRC and the Surgery, UMDNJ – University Hospital, Newark, NJ remaining 7 looked only at robotic surgery for CRC. The series of resections were analyzed for demographics, type of INTRODUCTION: Laparoscopic colectomy is the stan- procedure, procedure length (PL), length of stay (LOS), esti- dard of care for primary colorectal cancer (CRC) resections. mated blood loss (EBL), complications, and oncologic out- The benefi ts of robotic techniques have been described comes (Table 1). Non-parametric statistical analyses were throughout the gynecologic and urologic literature, but performed with GraphPad software (La Jolla, CA). the data relating to colorectal cancer resections is still in its infancy. A review of the literature and analysis of outcomes will help us to determine the safety and oncologic value of this technology in CRC.

Table 1. Demographics, Surgical and Pathological Data

Robotic (R) or Male: EBL LOS Nodes PL Path Author/Study Laparoscopic (L) Age** Female (cc) (days) (Number) (Minutes) Conversions Resection (Staging) deSouza R (Hybrid*) 63 28:16 150 5 14 347 2 LAR – 30 APR – 8 Rectal CA, stages IS – 6 unspecifi ed Baik (2008) R 56 8:1 — 7.4 20.1 221 0 TME I – 3 II – 6 Rectal CA Hellan R (Hybrid) 58 21:18 200 4 13 285 1 LAR – 22 CA- 11 0 — 8 I – 13 II – 4 APR – 6 III – 13 IV – 1 All rectal cancer Pigazzi (2006) R (Hybrid) 60 4:2 104 4.5 14 264 0 TME Rectal CA, stages unspecifi ed Kwak R 60 39:20 — — 20 270 0 LAR – 54 IS –5 APR – 0 0 – 3 I – 16 II – 23 III – 13 IV – 4 Rectal CA Koh R 61 13:8 — 6.4 17.8 316 0 APR – 1 Anterior I – 3 II – 6 III – 5 IV – 3 resection – 7 LAR – No cancer found – 2 7 Ultralow anterior resection – 5 Sigmoid Poster Abstracts resection & rectopexy

–1 Sunday Patel R (Hybrid) 58.8 3:2 150 5.4 7 204 0 TME I – 14 II – 4 III – 7 Rectal CA Baek R 63.6 25:16 200 6.5 13.1 296 3 LAR – 33 CA – 2 Rectal CA 0 – 7 I – 12 APR – 6 II – 4 III – 15 IV – 3 Pigazzi (2010) R (Hybrid) 62 87:56 283 8:3 14.1 297 7 Unspecifi ed number of Rectal CA 0 – 18 I – 36 IS vs APR II – 36 III – 53 Spinoglio R 66.7 32:18 — 7.74 22.03 384 2 R Hemi – 18 L Hemi 0 – 3 I – 36 II – 24 III – – 10 Rectal anterior 28 IV – 9 resection w/ total proctectomy – 19 Choi R 58.5 38:12 — 9.2 20.6 304 0 TME Rectal CA 0 – 0 I – 10 II – 19 III – 19 IV – 2 Baik (2009) R (Hybrid) 60.3 37:19 — 5.7 18.4 190 0 TME I – 22 II – 16 III – 18 Pigazzi (2006) L 70 2:4 150 3.6 17 258 0 — Rectal CA, stages unspecifi ed Kwak L 59 42:17 — — 21 228 2 LAR – 52 APR – 6 IS- 1 0 – 3 I – 16 II – 23 III – 12 IV – 5 Bianchi L 62 17:8 — 6 17 237 1 — I – 14 II –7 III – 4 Baek L 63.7 26:16 300 6.6 16.2 315 9 LAR – 33 CA – 2 0 – 3 I – 15 II – 3 III – APR – 6 19 IV – 1 Spinoglio L 68.8 74:86 — 8.31 22.85 266 4 — 0 – 4.8 I – 19.3 II – 33.7 III – 28.9 IV – 13.3 Baik L 63.2 34:23 — 7.6 18.7 191 6 — I–14 II–19 III–24 Bianchi R 69 18:7 — 6.5 18 240 0 TME I–14 II–4 III–7 Rectal CA *Hybrid studies used laparoscope for early dissection (establishing pneumoperitoneum to mobilization of splenic fl exure), w/ robot then used for rectal mobilization and TME **Values reported as median; LAR – Low anterior resection, APR – abdominoperineal resection, CA – coloanal, IS – intersphinteric

67 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: Thirteen studies were identifi ed that directly Su1602 compared the outcomes of laparoscopic and robotic surgery for CRC. When hybrid resections were detailed, laparo- Cancer-Associated Infl ammation in a Cohort of scopic methods were used only for establishing pneumo- Colorectal Cancer Patients with Infl ammatory peritoneum or early dissection. There were no statistically Bowel Disease signifi cant differences between the groups in age, gender Graeme J. Guthrie, Donald C. Mcmillan, Alan K. Foulis, distribution, procedure length, EBL when reported, or LOS Paul G. Horgan, Campbell S. Roxburgh (Table 2). Academic Department of Surgery, University of Glasgow, Glasgow, Table 2: Robotic vs Laparoscopic Outcomes United Kingdom

Robotic Laparoscopic p AIMS: Patients with infl ammatory bowel disease (IBD) who Median age (years) 60.3 (56-69) 63.5 (59-70) 0.09 develop colorectal cancer (CRC) have poorer outcomes, Number of Males 25 (3-87) 30 (2-74) 0.70 reasons for which remain unclear. Cancer-associated- infl ammation is a key determinant of disease progression EBL (ml) 175 (104-283) 225 (150-300) 0.61 and survival in colorectal cancer. Infl ammation measured Nodes (number) 17.8 (7-22.03) 17.9 (16.2-22.85) 0.27 locally and in the systemic circulation, has not previously LOS (days) 6.5 (4-9.2) 6.6 (3.6-8.31) 0.78 been examined in a cohort of Infl ammatory bowel disease- Conversions 0 (0-7) 3 (0-9) 0.06 associated colorectal cancers. The aim of the present study PL (Minutes) 285 (190-384) 247.5 (191-315) 0.27 was to compare clinico-pathological characteristics and EBL – Estimated Blood Loss; LOS – Length of Stay; PL – Procedure Length survival in those with an IBD history and those without. Complications were reported in 10 out of the 13 papers and In particular the role of local and systemic infl ammatory were graded according to the Clavien-Dindo Scale. 100% responses in determining outcome was assessed. of the groups had some type of complication. Of the top METHODS: Patients were identifi ed from a database of 3 complications reported in the robotics group, 20% were colorectal cancer patients undergoing surgery between Grade I, 90% were Grade II and 80% were Grade III. In the 1997–2009. Systemic infl ammation was measured using 4 of 6 laparoscopic groups reporting, 75% of 3 most com- neutrophil:lymphocyte ratio (NLR) and Glasgow Prognos- mon complications were Grade I, 50% Grade II, and 100% tic Score (GPS: C-RP and albumin). Local tumour infl amma- Grade III. The most common complications in both laparo- tion was measured with the Klintrup criteria. scopic and robotic groups were ileus, anastomotic leak and RESULTS: 755 pts were included, 57 of which had Infl am- wound infection. Number of conversions at 3 approached matory bowel disease. IBD patients developed Colorectal signifi cance in the laparoscopic group (p = 0.06). 2 of the 13 cancer at a younger age (64 vs 70 yrs, P < 0.005). Despite papers looked at oncologic outcomes based on recurrence similar stage and tumour location to non-IBD cancers, IBD at follow-up. At 17 months follow-up, the recurrence rate associated tumours displayed higher risk pathology includ- was 5.4% in the robotics cases and 5.5% in the laparoscopic ing poor differentiation (P < 0.001), signet ring cell pathol- group. 1 report looked specifi cally at long-term survival ogy (P < 0.05), serosal involvement (P < 0.005), tumour outcomes with a reported disease-free survival of 77.9% at perforation (<0.001), and high-risk Gloucester prognostic 3 years and overall survival of 97% at 3 years in the robot- index (P < 0.001). Higher-grade local infl ammation (evi- ics groups. denced by Klintrup criteria: P < 0.05) and higher-grade CONCLUSIONS: Robotic colectomy for CRC is still in its systemic infl ammation (evidenced by NLR (P < 0.001) and infancy. However, early data indicates that it is a safe and GPS, P < 0.001) were observed in IBD patients. feasible option in comparison to laparoscopic techniques. Median follow up was 53 months (303 deaths). IBD patients Outcomes may be comparable, but there is need for longer had poorer overall survival (5-year survival 14% vs 41%, P term follow-up and prospective data. < 0.005). When considered with age (HR1.59, P < 0.001), TNM stage (HR1.94, P < 0.001) and GPS (HR1.58, P < 0.001), history of IBD was an independent prognostic fac- tor (HR1.99, P = 0.001). Even within the IBD cohort, local infl ammation (P = 0.003) and systemic infl ammation (GPS, P = 0.001) remained strong predictors of overall survival. CONCLUSIONS: Poorer survival in Infl ammatory bowel disease-associated colorectal cancer may relate to higher frequency of high risk pathological characteristics as well as higher levels of cancer associated infl ammation. Despite this close association, systemic infl ammation remains an independent prognostic factor on multivariate analysis.

68 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1604 versus 309 minutes for RAR + SR (p < 0.001, CI 60.8–135.4). Intra-operative blood loss for RAR was 97.8 mL compared Outcomes for Robotic-Assisted Rectopexy With or to 87.5 mL for RAR + SR (p = 0.924, CI –77.4–89.7). Conver- Without Sigmoid Colon Resection for Rectal Prolapse sion to open procedure occurred twice with RAR and once Hyuma Leland, Sonia Ramamoorthy, Elisabeth C. Mclemore with RAR + SR (p = 0.407). Length of hospitalization aver- Surgery, University of California, San Diego, San Diego, CA aged 3 days for RAR and 4 days for RAR + SR (p = 0.196, CI –0.2–2.2). The mean follow up was 127 days (range 1–72 PURPOSE: Our experience in robotic-assisted rectopexy months). Eight of 10 patients with preoperative constipa- with sigmoid colon resection (RAR + SR) or without sigmoid tion subjectively noted improvement with RAR versus 1 of colon resection (RAR) was reviewed to determine if there 2 patients with RAR + SR (p = 0.455). Six of 10 patients with was a signifi cant difference in intra-operative or postopera- preoperative fecal incontinence had subjectively improved tive outcomes. symptoms with RAR versus 1 of 2 patients with RAR + SR METHODS: We retrospectively reviewed 26 patients that (p = 1.00). Six patients in the RAR group experienced a underwent robotic-assisted rectopexy for rectal prolapse postoperative complication (over-sedation, corneal abra- from 2006 to 2012. Rectopexy is performed with primary sion, atrial fl utter, pulmonary edema, pelvic hematoma, suture pexy and without mesh. Continuous variables were ileus) versus 1 complication (urinary retention) after RAR + analyzed by t-test, while Fisher’s exact test was applied for SR (p = 0.924). There were no mortalities and no complica- categorical data. tions requiring operative intervention. RESULTS: Twenty-two patients underwent RAR and 4 CONCLUSIONS: The majority of patients underwent RAR patients underwent RAR + SR. The average age for study and outcomes for RAR versus RAR + SR were not signifi - participants was 56 years (range 21–78 years) and consisted cantly different in this series with the exception of increased of 4 men and 22 women. Recurrent rectal prolapse occurred operative time for RAR + SR. The recurrence rate was 8% in 2 patients at 3 and 30 months after surgery in the RAR and the complication rate was 27% with the majority of group and no recurrence occurred in the RAR + SR group (p complications being minor complications. = 1.00). The duration of surgery for RAR was 211 minutes

Subjective Subjective Length of Improvement in Improvement in Duration of Blood Loss Conversion Hospitalization Postoperative Postoperative n Recurrence Surgery (Min) (mL) to Open (Days) Constipation Fecal Incontinence Morbidity Mortality RAR 22 2 210.6 97.8 2 3 8 of 10 patients 6 of 10 patients 6 0 RAR + SR 4 0 308.8 87.5 1 4 1 of 2 patients 1 of 2 patients 1 0 Poster Abstracts p value p = 1.00 p < 0.001 p = 0.924 p = 0.407 p = 0.196 p = 0.455 p = 1.00 p = 0.924 p = 1.00 Sunday Su1605 defunctioning stoma created during the original procedure. Patient demographics and comorbidities were listed. Multi- Anastomotic Leak Following Anterior Resection for variate regression analysis was used to compare outcomes Rectal Cancer: Does the Presence of a Defunctioning between cases that had a defunctioning stoma and leaked Stoma Reduce the Burden of a Leak? and cases that leaked but did not have a stoma. Wissam J. Halabi1, Mehraneh D. Jafari1, Vinh Q. Nguyen2, RESULTS: We identifi ed 3,099 anterior resections that Joseph C. Carmichael1, Steven Mills1, Michael J. Stamos1, leaked. A stoma was present in 28.6% of cases, especially Alessio Pigazzi1 in male patients (31.7% vs. 22.7% p < 0.01). When a leak 1Surgery, University of California-Irvine, Orange, CA; 2Statistics, occurred, the presence of a defunctioning stoma did not University of California-Irvine, Irvine, CA reduce mortality (OR = 1.07; 95% CI 0.51–2.27; p = 0.85). However, the presence of a stoma was associated with an OBJECTIVE: To examine if the presence of a defunction- increased risk of infectious complications (OR = 1.50; 95% ing stoma performed during anterior resection for rectal CI 1.24–1.82; p < 0.01), sepsis (OR = 1.58; 95% CI 1.08– cancer affects outcomes when an anastomotic leak occurs. 2.32; p = 0.05), an increased length of stay by 2.46 days (p METHODS: Using the Nationwide inpatient sample 2004– < 0.01). Furthermore patients with a defunctioning stoma 2010, we performed a retrospective review of rectal cancer had lower likelihood of routine discharge (OR = 0.18; 95% cases that underwent anterior resection. We indentifi ed CI 0.14–0.22; p < 0.01). cases that leaked and divided them into two group based on CONCLUSION: The presence of a defunctioning stoma the presence or absence of a defunctioning stoma. All cases does not appear to reduce the burden of anastomotic leak that received a stoma in response to a leak were excluded following anterior resection for rectal cancer. from our analysis. We only included patients who had a

69 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1606 to have surgical management (78.1% vs. 94.8%, p < 0.0005) and less likely to have appendectomy on hospital day 0 or Delay in Management: A Nationwide Study of 1 (56.8% s. 77.6%). The presence of abscess or peritonitis Appendicitis in Patients with Cystic Fibrosis did not differ signifi cantly between the two groups. For Allan Mabardy1, Justin Lee1, Jose L. Piscoya1, Haisar E. Dao2, patients who underwent surgery, CF patients were more Kevin O’Donnell1 likely to undergo right colectomy or ileocecectomy (10.2% 1Saint Elizabeth’s Medical Center, Boston, MA; 2Rhode Island vs. 2.5%, p < 0.0005), more likely to require conversion Hospital, Providence, RI to an open procedure (8.5% vs. 4.4%, p < 0.0005), and more likely to have an iatrogenic injury (3.7% vs. 0.5%, PURPOSE: Acute appendicitis is an uncommon diagno- p < 0.0005). Signifi cantly fewer CF patients were attempted sis in patients with cystic fi brosis (CF). Small studies and laparoscopically (52.8% vs. 58.7%, p = 0.015). The median case reports have shown that affected patients often have a length of hospital stay and total hospital charges were sig- delay in diagnosis and subsequent complications. Our goal nifi cantly higher for CF patients (4 days vs. 2 days; $23,228 was to investigate the delay in diagnosis for patients with vs. $19,251). Multivariate regression analysis demonstrated CF who present with acute appendicitis, the factors that CF patients were more likely to be white, have public insur- might contribute to this delay, and the sequellae of delayed ance, and have admission to a teaching hospital. Patients operative management. with CF who had surgery during hospital day 0 or 1 were less METHODS: Using the Nationwide Inpatient Sample data- likely to require right colectomy or ileocecectomy (7.7% vs. base, all patients in the United States with a diagnosis of 17.7%, p = 0.005). Variables associated with prompt surgi- acute appendicitis were examined during the study years cal management included the non-teaching hospital setting 2005 through 2009. Patients with a diagnosis of CF were (OR 0.446–0.964), non-urban location (0.207–0.989), and compared to patients without CF for demographic and the absence of respiratory manifestations (OR 0.260–0.607). procedural variables, as well as variables related to com- CONCLUSIONS: The management of appendicitis in CF plication and cost. Patients with CF who did not undergo patients differs signifi cantly with that of the general popu- surgical management for acute appendicitis during hospital lation. CF patients are more likely to have a delay in opera- days 0 or 1 were compared against those who had prompt tive management and the resulting sequellae associated surgical management. with a more advanced disease process. Comorbid respira- RESULTS: During the study years 2005 through 2009, tory manifestations of CF are associated with a delay in sur- 1,350,995 patients nationwide were admitted to the hospi- gical management, possibly due to the use of antibiotics in tal with a diagnosis of appendicitis, and of these patients, these patients. 526 had a diagnosis of CF. Patients with CF were less likely

Appendicitis in Patient with Cystic Fibrosis

Cystic Fibrosis General Population Appendectomy on Hospital Day 0 or 1* 55.9% 76.8% OR 0.322–0.454 Iatrogenic Injury** 3.7% 0.5% OR 4.862–13.652 Ileocecectomy or Right Colectomy** 10.2% 2.5% OR 3.246–6.149 Attempted Laparoscopic Appendectomy** 52.8% 58.7% OR 0.649–0.956 Conversion to Open Procedure*** 13.9% 7.1% OR 1.480–3.023 Median Hospital Length of Stay* 4 days 2 days alpha = 0.05 (*) All patients included; (**) All surgical patients included; (***) All laparoscopic patients included

Su1607 AIMS: Literature about this problem is scarce, even unex- isting. Therefore, we want to make a survey of proctologi- Proctological Problems in Relation to Chemotherapy cal problems in patients under chemotherapy, and evaluate Tom Lagaert1, Bruno Vanduyfhuys1, Beatrijs Strubbe1, factors that promote the development of anal disease. 1 1 1 Ingrid Bruggeman , Koen Gorleer , Pieter Hindryckx , METHODS: From March, 15th until November 30th, 2012 Daan De Maeseneer2, Ine Moors3, StéPhanie Laurent1, all patients spontaneously reporting anal complaints at the Karen P. Geboes1, Tessa Kerre3, Simon Van Belle2, different departments of oncology and currently under che- Martine De Vos1, Danny De Looze1 motherapy, are selected for this study. Informed consent is 1Gastroenterology, University Hospital Gent, Gent, Belgium; 2Medical obtained from all patients. The following data are systemat- Oncology, University Hospital Gent, Gent, Belgium; 3Hematology, ically collected: performance status (grade 0 is normal-grade University Hospital Gent, Gent, Belgium 4 is severe), medical history, current oncological disease and chemotherapy, chemotherapy-related toxicity (grade BACKGROUND: In daily practice anal problems in patients 0–4), proctological complaints, diagnosis and outcome. under chemotherapy are often seen, cause signifi cant mor- bidity and are diffi cult to treat.

70 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: Twenty-three people, 14 women and 9 men, RESULTS: Two patients were lost during the follow up. with a mean age of 50 years (range 20–80) are collected. The RNA transcripts for MMP-7 were detected in 31/57 samples main presenting symptom is anal pain (n = 21) and in 2 (54%). Recurrence was diagnosed in 6 out of 55 patients patients anal blood loss. Proctological diagnoses were anal (11%); 4 patients eventually died because of metastases fi ssure (n = 12), external hemorrhoidal thrombosis (n = 3), or peritoneal dissemination. All the 6 patients who had anal abscess (n = 2), anal ulceration (n = 2), internal hemor- relapsed were positive for MMP-7. Sensitivity and specifi c- rhoidal bleeding (n = 2), no diagnosis (n = 2). ity of the test were 100% and 49% respectively. Mean WHO performance status was 1,72 (range 1–4), mean CONCLUSIONS: Positivity of MMP-7 in peritoneal cavity toxicity scores for respectively oral mucositis, nausea-vom- samples could be a novel biomarker for predicting disease iting, diarrhea and constipation are 0,76–0,88–0,94 and recurrence in patients with CRC. 1,50 (ranges 0–4). Patients were under chemotherapy for breast cancer (n = 8), AML (n = 3), renal cell carcinoma (n Su1609 = 2), rectal carcinoma (n = 2), ALL (n = 2), MDS (n = 2), High-Dose Circumferential Chemodenervation (HDCC) sarcoma (n = 1), testis carcinoma (n = 1), aplastic anemia (n = 1) and non-Hodgkin lymphoma (n = 1). of the Internal Anal Sphincter: A New Treatment Modality for Uncomplicated Chronic Anal Fissure CONCLUSION: Anal fi ssure is the most frequent encoun- Porter H. Glover1, James Z. Whatley1, Shou Jiang Tang1, tered proctological problem in patients under chemother- 1 1 1 2 apy. Constipation was the most commonly seen toxicity of Eric D. Davis , Kellen T. Jex , Ruonan Wu , Christopher J. Lahr 1 chemotherapy, while oral mucositis was rarely seen in this Internal Medicine, University of Mississippi Medical Center, Jackson, patient cohorte. Treatment of anal problems is most often MS; 2Surgery, University of Mississippi Medical Center, Jackson, MS conservative, but preventive measures should be directed BACKGROUND: Botulinum toxin injection into the inter- towards prevention of constipation. nal anal sphincter (IAS) is gaining popularity as a second line therapy for chronic anal fi ssures after patients fail med- Su1608 ical therapy. Although lateral internal sphincterotomy (LIS) can achieve a healing rate of 91–95%, it is associated with Peritoneal Expression of Matrilysin Helps Identify Early fecal incontinence of 11%. The dosage of Botulinum toxin Post-Operative Recurrence of Colorectal Cancer reported in the literature ranged from 20–50 IU with no Cristina Fiorani, Giuseppe S. Sica, Carmine Stolfi , more than 3 injection sites and results in a healing rate of Rosa Scaramuzzo, Giorgia Tema, Edoardo Iaculli, Achille Gaspari, 65%–73% and recurrence rate of 35%. We propose a new Giovanni Monteleone injection method of high-dose circumferential chemode- nervation (HDCC) of 100 IU in treating chronic anal fi ssure.

Tor Vergata, Rome, Italy Poster Abstracts BACKGROUND: Recurrence of colorectal cancer (CRC) AIM: We evaluate the fi ssure healing, complication, and following a potentially curative resection is a major chal- recurrence rates with this new method during 6 months Sunday lenging clinical problem. Although detection of tumoral study period after each injection. cells within the peritoneal cavity at the time of surgery METHODS: Between 2008–2012, 75 consecutive patients has been proposed as useful tool to identify patients with (32 Blacks, 42 Whites, 1 Native American) (50 Women, recurrent CRC, the overall low sensitivity of the test has 25 Men) with complete follow-up data were included in hampered its use in the management of such patients. this study. These patients presented with uncomplicated Matrilysin, also termed matrix metalloproteinase (MMP) -7, chronic anal fi ssure and underwent HDCC-IAS by a single is over-expressed by CRC cells and supposed to play a major colorectal surgeon. HDCC is an assisted percuta- role in CRC cell diffusion and metastasis. This study was neous injection involving greater than 8 injection sites in a aimed at determining whether MMP-7 is detectable in the circumferential technique under anesthesia. Follow up data peritoneal cavity of CRC patients undergoing potentially were obtained by chart review and offi ce follow up. curative resection and assessing whether MMP-7 positivity RESULTS: Of the 75 patients, the 1st injection success marks patients who experience CRC recurrence. rate was 90.6% at 3 months follow-up (Table 1). A few MATERIAL AND METHODS: Fifty-seven colorectal can- patients developed transient fl atus or fecal incontinence, cer patients undergoing elective colorectal resection were but shortly resolved. There was no major complication fol- prospectively enrolled from June 2009 to November 2011. lowing HDCC-IAS including hematoma, infection, fl atus, During the surgery, peritoneal cavity was fl ushed with fecal, and urinary incontinence after 1 month. cold saline solution and fl uid was then harvested and used CONCLUSION: HDCC-IAS is a safe and effective method for RNA extraction. MMP-7 RNA expression was assessed for uncomplicated chronic anal fi ssure. It’s effi cacy rivals by RT-PCR using specifi c primers. After surgery, patients reported LIS healing rate without the associated fecal incon- underwent a regular follow up (range 12–26 months) for tinence. In addition, HDCC-IAS demonstrated far superior assessing recurrence. healing rates compared to standard injection method with- out increased complication rate. Key Words: Botulinum toxin, anal fi ssure, injection, high- dose circumferential chemodenvervation (HDCC), internal anal sphincter, lateral internal sphincterotomy (LIS)

71 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1: Treatment of Uncomplicated Chronic Anal Fissures with High-Dose Circumferential Chemodenervation (Hdcc) of the Internal Anal Sphincter

Healing Rate Healing Rate Recurrence Rate Average Healing Time Complications HDCC Sessions (3 Months) (6 Months) (6 Months) (Weeks) (After 1 Month) First injection (n = 75) 90.6% 90.6% 8.0% 6.2 0 Second injection (n = 16) 81.3% 93.8% 0% 7.4 0 3rd Injection (n = 3) 100% 100% 33% 12 0 4th Injection (n = 1) 100% 100% 100% 12 0 5th injection (n = 1) 0% 100% 0% 20 0

Su1610 Su1611 Medication Use and the Risk of Diverticular Postoperative Bleeding After Colon and Rectal Surgery Complications: A Systematic Review by Preoperative Diagnosis: A Nationwide Analysis Charlotte Kvasnovsky1,2, Savvas Papagrigoriadis1, Nitin Kumar1, Ashok Kumar2, Christopher C. Thompson1 Ingvar T. Bjarnason1 1Division of Gastroenterology, Brigham & Women’s Hospital, Boston, 1Department of Colorectal Surgery, King’s College Hospital, London, MA; 2Surgery, Clay County Hospital, Flora, IL 2 United Kingdom; Department of Surgery, University of Maryland BACKGROUND: Colorectal surgery is performed for a wide Medical Center, Baltimore, MD array of gastrointestinal disease, in patients with varied pre- BACKGROUND AND PURPOSE: Serious complications operative fi tness and comorbidity rates. Postoperative out- of colonic diverticula, namely bleeding and perforation, are comes, including bleeding rates, are shaped by preoperative a source of morbidity and mortality. A variety of drugs have diagnosis in addition to operative factors. been implicated in these complications. We present a sys- AIMS: To determine incidence of postoperative bleeding temic review of the literature to assess the importance of after colorectal surgery and analyze outcomes in patients this relationship. with postoperative bleeding by preoperative diagnosis. DATA SOURCES: A systematic review of articles using METHODS: This is a retrospective cohort study using the PubMed and Cochrane Reviews was undertaken in August 2010 Nationwide Inpatient Sample (NIS), a nationally rep- 2012. Search terms included ‘diverticulitis, diverticulum, resentative inpatient database. Adult patients were included diverticulosis, diverticular perforation, diverticular bleed, if they had ICD-9 code for gastrointestinal malignancy, OR ‘lower GI bleed’ AND ‘acetaminophen, anti-thrombotic, ulcerative colitis (UC), Crohn’s disease (CD), ischemic coli- cyclooxygenase-2 inhibitors, cox-2, aspirin, amino salicylic tis (IC), diverticulitis, diverticulosis, or diverticular bleed- acid, ASA, nonsteroidal anti-infl ammatory drugs, NSAID, ing. Inclusion was limited to patients with ICD-9 procedure steroid, corticosteroid, OR calcium channel’. code for colectomy, proctectomy, or . Inclusion STUDY SELECTION AND DATA EXTRACTION: An ini- also required ICD-9 code for intraoperative bleeding, intra- tial search yielded 853 results that were assessed for study operative hematoma, or lower gastrointestinal bleeding design and topicality. A total off 23 articles were included during the postoperative period, as well as postoperative in the review, including 74 subgroup analyses, where drug packed red blood cell transfusion. Charlson Comorbidity usage and specifi c complications were clearly documented. Index was calculated for each patient. Outcomes included Data were extracted on these topics, as well as effect mea- rate of reoperation, incidence of shock, mortality, length of sures found. stay (LOS), and inpatient charge. Statistical signifi cance was established if p < 0.05. DATA SYNTHESIS: We performed a qualitative data syn- thesis with a forest plot when fi ve or more studies compared RESULTS: 214,933 patients met inclusion criteria. Of these, a single medication and similar patient complications. 1528 (0.7%) had postoperative bleeding requiring blood transfusion. Charlson score for patients with postopera- RESULTS: There were increased odds of bleeding with the tive bleeding was 2.4 ± 0.2 vs 2.3 ± 0.1 in patients without use of NSAIDs (range 2.01–12.6), acetaminophen (0–3.75), bleeding. Rate of postoperative bleeding, which was high- aspirin (1.14–3.70), and steroids (0.57–5.40). There were est in patients with IC, is shown by diagnosis in Table 1. increased odds of perforation and abscess formation with Clinical outcomes are shown in Table 2. Reoperation was NSAIDs (1.46–10.3), aspirin (0.66–2.40), steroids (2.17– signifi cantly more frequent after bleeding in each diagnosis 31.9), and opioids (1.80–4.51). except diverticulosis. Shock was more frequent after bleed- LIMITATIONS: Most studies did not describe duration or ing in patients who had surgery for malignancy and IC, but dosage of medications used, nor did they systematically less frequent in patients with diverticular bleeding. Mor- describe the severity of diverticular complications. tality was signifi cantly more frequent after postoperative CONCLUSIONS: A variety of common medications are bleeding in patients with malignancy, CD, diverticulitis, implicated in colonic diverticular complications, rare, but and diverticular bleeding. Hospital outcomes are shown in occasionally devastating outcome in the many patients Table 2. Length of stay was signifi cantly longer after post- with diverticular disease. operative bleeding in patients with malignancy and diver- ticulitis; charge was signifi cantly higher in patients with malignancy, CD, IC, and diverticulitis.

72 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1: Rate of Postoperative Bleeding by Diagnosis CONCLUSION: Preoperative diagnosis is associated with signifi cant differences in outcome in patients with postop- Postoperative erative bleeding after colorectal surgery. Rates of shock and n Bleeding (%) mortality are signifi cantly increased in patients with gas- Malignancy 113,202 0.59 trointestinal malignancy and IC. Mortality is substantially UC 5572 0.25 increased in patients with CD, UC, diverticulitis, and diver- CD 10,032 0.76 ticular bleeding. Further study is needed to better under- IC 11,735 2.95 stand the reasons for this disparity and to develop better Diverticulitis

Table 2: Clinical Outcomes

Reoperation (%) Shock (%) Mortality (%) LOS, Days (95% CI) Charge x1000, USD (95% CI) Bleed No Bleed Bleed No Bleed Bleed No Bleed Bleed No Bleed Bleed No Bleed Malignancy 16.7 * 2.1 3.77 * 0.48 7.68 * 1.93 11 (8.3–14) * 7.5 (7.3–7.6) 110 (84.0–138) * 69.6 (66.4–72.8) UC 35.7 * 3.0 0 0.79 0 1.97 7.9 (5.1–11) 8.6 (8.0–9.3) 96.2 (–11.4–204) 94.4 (83.2–105.6) CD 26.3 * 1.3 0 0.40 13.2 * 0.54 14 (7.0–20) 6.9 (6.6–7.2) 131 (77.0–184) * 67.7 (62.1–73.2) IC 31.2 * 9.3 2.89 * 3.13 36.1 * 17.2 18 (12–25) 13 (12–14) 255 (173–337) * 150 (139–161) Diverticulitis 14.3 * 1.6 0 0.30 8.8 * 1.20 14 (10–19) * 6.9 (6.7–7.0) 140 (97.2–183) * 65.3 (62.3–68.4) Diverticulosis 0 1.2 0 0.34 0 1.46 6.0 (4.3–7.8) 5.9 (5.7–6.1) 51.6 (38.6–64.7) 52.1 (48.9–55.2) Diverticular bleeding 60.0 * 6.2 0 * 8.46 25 * 6.43 25 (10.8–39) 11 (9.9–12) 271 (78.1–465) 129 (118–140) * denotes statistical signifi cance

Su1612 defi ned as major and those that did not require bowel resec- Poster Abstracts tion were defi ned as minor revisions. CI failure was defi ned

Long Term Outcomes of Continent Ileostomy Created as excision of the pouch and formation of an end ileostomy. Sunday in the Pediatric Age Group RESULTS: 49 patients (26 male), median age 18 (12–21) 1 1 1 Erman Aytac , Victor W. Fazio , Hasan Hakan Erem , years and median body mass index 22 (16–38.6) underwent Jennifer Liang1, David W. Dietz1, Marsha H. Kay2, Pokala R. Kiran1 CI. 10 (20%) patients had a CI at the time of total procto- 1Department of Colorectal Surgery, Digestive Disease Institute colectomy. 12 (25%) patients underwent conversion of an Cleveland Clinic, Clevaland, OH; 2Pediatric Gastroenterology, ileoanal pouch (IPAA) to a CI. The majority of the patients Digestive Disease Institute Cleveland Clinic, Clevaland, OH (n = 39, 80%) had ulcerative colitis or indeterminate colitis at the time of CI creation; however Crohn’s disease were BACKGROUND/AIM: Continent ileostomy (CI) is a sur- diagnosed in 4 patients postoperatively. There were no gically created intra-abdominal pouch in patients with intra-operative or early post-operative deaths. One patients a permanent end ileostomy. CI is one of the few surgical who underwent CI excision seven years after CI creation options that may be offered to patients who were fated to due to complicated Crohn’s disease, died ten years after CI live with a permanent ileostomy, but want to avoid a stoma excision. Median follow-up time was 21 (range 1–38) years. appliance at any cost. Data about durability, clinical and Valve slippage (33%), small bowel obstruction (25%), pou- functional outcomes of CI created in pediatric patients are chitis (25%) and fi stula (23%) were the common complica- limited. In this study, we aimed to evaluate our 36-year tions (table). 37 patients (76%) underwent at least 1 revision operative experience on CI in pediatric patients with a 21 procedure after CI creation. 36 (74%) patients underwent year median follow-up. major revision and 6 (12%) patients underwent minor revi- METHODS: Pediatric (≤21 years) * patients undergoing a sions. Median pouch intubation was 6 (range 4–10) times CI procedure at a single institution from 1973–2009 were per day. Pouch failure occurred in 9 (18%) patients with identifi ed. CI revisions that required pouchotomy or re- 7 out of 9 cases being due to complications from Crohn’s construction following total or partial excision of CI were disease.

73 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Primary Diagnosis, Complications and Follow-Up Details METHODS: A systematic review was performed on 31 pub- lished series between 1994 and 2011 describing patients Primary Diagnosis n (%) with CDI requiring surgical intervention. Of the 31 stud- Ulcerative colitis 35 (71%) ies identifi ed, a meta-analysis was performed on 17 stud- Familial adenomatous polyposis 4 (8%) ies that presented comparative data between survivors and Indeterminate colitis 4 (8%) non-survivors of surgical CDI. Independent variable anal- Crohn’s disease 4 (8%) yses were performed for age, gender, preoperative comor- Motility disorder 2 (4%) bidities, preoperative laboratory values, as well as surgical Complications management (total colectomy end ileostomy or TCEI, seg- Valve slippage 16 (33%) mental colectomy, diverting ostomy, or non-therapeutic Small bowel obstruction 12 (25%) laparotomy). Pouchitis 12 (25%) RESULTS: Based on the 31 studies included in the review, Fistula 11 (23%) the overall rate of surgical intervention for patients diag- Diffi cult intubation 9 (18%) nosed with CDI was 1.9%. The mean age of surgical CDI Incontinence 8 (16%) patients was 69 years, and 54% were male. 93.2% of the Leakage 8 (16%) patients with surgical CDI had received antibiotics prior to Valve prolapse 7 (14%) diagnosis, and 59.3% were initially diagnosed with CDI in- Bleeding 4 (8%) hospital. The mean WBC was 29.6 x103/μL. 49.9% required Afferent limb stricture 3 (6%) preoperative vasopressors, and 44.5% had preoperative Ventral hernia 3 (6%) respiratory failure requiring intubation. Overall, 89.2% of Parastomal hernia 2 (4%) patients received a TCEI for CDI. Overall mortality of surgi- Exit conduit stricture 2 (4%) cal CDI patients was 42.5%. Follow up functional details # Among the 17 studies included in the meta-analysis, there Time to fi rst major revision after CI creation (years) 2 (0.5–30) were a total of 621 patients comprised of 367 (59%) survi- Time to fi rst minor revision after creation of CI (years) 2 (0.1–5) vors and 254 (40.9%) non-survivors. The mean age of non- Time to CI excision after CI creation (years) 5 (2–28) survivors was 71.6 years and of survivors was 65.2 years (p = # Results presented as median (range) 0.001). There was no signifi cant difference between dura- tion of symptom onset to surgery between survivors and CONCLUSIONS: CI is safe and durable in pediatric non-survivors. Preoperative vasopressor requirement, respi- patients. Development of Crohn’s disease after CI creation ratory failure (RF), acute renal failure (ARF), multi-organ seems to be a risk factor for failure. Since likelihood of fur- failure (MOF), and recent antibiotic use were independent ther revisions is high, patients with CI should be followed- predictors of postoperative mortality (Table). Non-survivors up regularly. had a signifi cantly lower preoperative albumin compared to survivors (1.66 vs 2.28 g/dL, p = 0.04). Heart rate, WBC, * Council on Child and Adolescent Health. Age Limits of lactate, creatinine were not signifi cantly different between Pediatrics. Pediatrics 1988;81:736. survivors and non-survivors. Finally, the initial type of sur- gical intervention was not predictive of survival. Su1613 CONCLUSION: The initial type of surgical intervention Risk Factors for Mortality for Surgical Clostridium was not predictive of survival. Factors that were predictive Diffi cile Colitis: A Review and Meta-Analysis of mortality from CDI included hypoalbuminemia, septic shock, ARF, RF, and MOF. This study suggests that expedi- Stephanie G. Wood1, Laura Skrip1,2, Hulda M. Einarsdottir1, 1 1 tious surgical intervention prior to end organ failure may Vikram Reddy , Walter Longo lead to improved survival in fulminant CDI. 1Surgery, Yale School of Medicine, New Haven, CT; 2Public Health, Yale School of Medicine, New Haven, CT OBJECTIVE: Clostridium Diffi cile infections (CDI), the most common infectious colitis, have been increasing in incidence and severity over the last decade. Severe CDI that requires surgical intervention is rare but mortality rate is high and poorly prognosticated. In light of a paucity of level I evidence available to direct clinical decision-making, this study aims to identify factors that may predict mortal- ity from severe CDI.

74 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1: Meta-Analysis of Surgical Clostridium Diffi cile Infection Risk Factors for Mortality

Overall Effect I2 Test for Covariate No. of Studies (OR and 95% Confi dence Interval) P Heterogeneity (%) Total Colectomy (TCEI) 14 1.5735 (0.8711, 2.8423) 0.13 14.7 Segmental Colectomy 14 0.6526 (0.3541, 1.2026 0.17 24.5 Other Procedure (Not TCEI) 14 0.6355 (0.3518, 1.1480) 0.13 14.7 Gender 10 1.0017 (0.6720, 1.4932) 0.99 0.0 Vasopressors 10 3.8599 (2.6063, 5.7163) <0.001 12.5 Immunosuppression 9 0.7736 (0.5142, 1.1639) 0.22 0.0 Recent Surgery 7 0.4641 (0.2381, 0.9046) 0.02 17.9 Recent Antibiotic Use 6 4.1599 (1.1733, 14.7486) 0.03 0.0 CRF 6 0.8784 (0.3886, 1.9852) 0.76 0.0 Respiratory Failure 6 6.4230 (3.4633, 11.9121) <0.001 6.0 ARF 5 3.5793 (1.5789, 8.1142) 0.002 16.7 COPD 4 1.4037 (0.5680, 3.4690) 0.46 0.0 Known Cancer 4 2.0196 (0.7804, 5.2264) 0.15 0.0 MOF 4 7.6396 (3.0764, 18.9715) <0.001 20.3 Diagnosis Known Pre-Op 3 0.3884 (0.1034, 1.459) 0.16 0.0 Organ Transplant 3 0.3834 (0.1265, 1.1622) 0.09 0.0 Recurrent c diff 3 1.1434 (0.6079, 2.1505) 0.68 0.0

Su1614 of postoperative packed red blood cell transfusion. Univari- ate logistic regression models were performed to determine Predictors of Bleeding, Reoperation, and Mortality signifi cant predictors, which were entered into multivari- After Colon and Rectal Surgery by Preoperative ate logistic regression models controlling for patient demo- Diagnosis: A Nationwide Analysis graphics and hospital characteristics to obtain adjusted Nitin Kumar1, Ashok Kumar2, Christopher C. Thompson1 odds ratios (AOR). Statistical signifi cance was established if 1Division of Gastroenterology, Brigham & Women’s Hospital, p < 0.05. Boston, MA; 2Surgery, Clay County Hospital, Flora, IL RESULTS: 214,933 patients met inclusion criteria in 2010. Mean age was 60.3 ± 0.2 years and mean Charlson score was Poster Abstracts BACKGROUND: Colorectal surgery is performed for a 1.17 ± 0.04. 1528 patients (0.7%) had postoperative bleed-

wide array of gastrointestinal disease, in patients with var- Sunday ing requiring blood transfusion. 5439 patients (2.53%) ied preoperative fi tness. Preoperative diagnosis, in addition required reoperation during the inpatient admission. 5715 to patient and operative factors, may infl uence the rate of patients (2.66%) experienced mortality during the inpa- postoperative complications. tient admission. AIMS: To determine predictors for bleeding, reoperation, Adjusted odds ratios for predictors of postoperative out- and mortality after colorectal surgery. comes are shown in Table 1. Urgent or emergent admission, METHODS: This is a retrospective cohort study using the age >65, gastrointestinal malignancy, UC, and diverticulo- 2010 Nationwide Inpatient Sample (NIS), a nationally rep- sis were signifi cant predictors of postoperative bleeding. resentative database of inpatient admissions. Adult patients Urgent or emergent admission and IC were signifi cant pre- were included if they had ICD-9 CM code for gastrointes- dictors of reoperation. Urgent or emergent admission, age tinal malignancy, ulcerative colitis (UC), Crohn’s disease >65, and IC were signifi cant predictors of mortality. (CD), ischemic colitis (IC), diverticulitis, diverticulosis, CONCLUSION: Preoperative diagnosis, patient factors, and or diverticular bleeding. Inclusion was limited to patients admission factors have signifi cant association with postop- with ICD-9 CM procedure code for colectomy, proctec- erative outcomes after colorectal surgery. Urgent or emer- tomy, or colostomy. Charlson Comorbidity Index score gent admission, age >65, and ischemic colitis are signifi cant was calculated for each patient. Outcomes included postop- and independent predictors of mortality. Identifi cation of erative bleeding, reoperation, and mortality. Postoperative modifi able factors that increase operative and postoperative bleeding was defi ned as ICD-9 CM code for intraoperative risk in these patient groups would be of benefi t in improv- bleeding, intraoperative hematoma, or lower gastrointesti- ing patient outcomes. nal bleeding during the postoperative period in the setting

75 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1: Multivariable Logistic Regression

Postoperative Bleeding Reoperation Mortality AOR (95% CI) p value AOR (95% CI) p value AOR (95% CI) p value Urgent/emergent 2.8 (2.53–3.12) * <0.01 2.0 (1.75–2.24) * <0.01 3.6 (3.15–4.02) * <0.01 Age >65 1.1 (1.06–1.19) * <0.01 1.1 (0.98–1.20) 0.13 2.5 (2.24–2.79) * <0.01 Malignancy 2.4 (2.17–2.57) * <0.01 0.54 (0.46–0.63) <0.01 0.21 (0.18–0.24) <0.01 UC 2.0 (1.60–2.46) * <0.01 0.90 (0.58–1.38) 0.61 0.49 (0.31–0.78) <0.01 CD 1.1 (0.87–1.29) 0.55 0.45 (0.29–0.69) <0.01 0.19 (0.10–0.34) <0.01 IC 1.1 (0.93–1.21) 0.41 2.3 (1.88–2.72) * <0.01 2.1 (1.83–2.39) * <0.01 Diverticulitis 1.1 (0.96–1.19) 0.21 0.44 (0.37–0.52) <0.01 0.24 (0.20–0.29) <0.01 Diverticulosis 1.7 (1.42–1.96) * <0.01 0.47 (0.29–0.75) <0.01 0.40 (0.26–0.61) <0.01 * denotes signifi cant increase

Su1615 in 9%, and urinary retention occurred in 21%. UTI rates were the same in stent and no stent groups (9% vs. 9%, Risk Factors for Urinary Tract Infection in Rectal p = 1). In multivariate analysis, females older than 65 Surgery Patients (OR 5.2, 95% CI 1.63–16.64), higher estimated blood loss Janet T. Lee, Mark Y. Sun, Genevieve B. Melton, (OR 1.9, 95% CI 1.07–3.37), and a diagnosis of depression Robert D. Madoff, Mary R. Kwaan (OR 4.7, 95% CI 1.58–14.0) were independently associated Department of Surgery, Division of Colon and Rectal Surgery, with UTI (model c = 0.78). UTI + patients were more likely University of Minnesota, Minneapolis, MN to have a prolonged LOS (p = 0.04) and be discharged to a rehab facility (p = 0.01), but not more likely to have associ- PURPOSE: Urinary tract infection (UTI) has been identi- ated major complications (p = 1). fi ed as the most common hospital-acquired infection in the United States. Studies have shown that UTIs are sig- RIsk Factors for UTI in Rectal Surgery Patients nifi cantly more common after colorectal surgery, especially Variable, n (%) UTI + (n = 20) UTI – (n = 204) p-value rectal surgery, compared with other procedures. We hypoth- Age, mean y (SD) 59.7 (16.2) 52.6 (15) 0.05 esized that the use of ureteral stents in rectal surgery would be associated with a higher risk of UTI. We also sought to Female 14 (70) 96 (48) 0.10 examine other risk factors for UTI after rectal surgery. Female age >65 6 (30) 17 (8) 0.01 BMI >30 5 (25) 69 (30) 0.80 METHODS: All patients undergoing rectal resection at a ASA class >3 9 (45) 62 (35) 0.359 tertiary care medical center from 2005 to 2010 were iden- Rectal Cancer 7 (35) 110 (54) 0.16 tifi ed using ICD-9 procedure codes. Patient and procedure Infl ammatory bowel disease 6 (30) 53 (26) 0.79 variables, UTI within 30 days of surgery, urinary retention Depression 7 (35) 20 (10) 0.005 (defi ned by reinsertion of a Foley catheter), major compli- cations, and length of stay (LOS) were identifi ed on retro- Diabetes mellitus 4 (20) 19 (9) 0.13 spective chart review. UTI was defi ned as a positive urine Laparoscopic surgery 3 (15) 25 (12) 0.72 culture with >105 colonies/ml urine with no more than 2 Ureteral Stent 3 (15) 33 (16) 1.0 species of organisms and one of the following: fever >38 EBL* cc (95% CI) 509 [340–760] 330 [290–376] 0.05 degrees C, urgency, frequency, dysuria, or suprapubic ten- Operative duration >300 min 12 (60) 69 (38) 0.06 derness. Prolonged LOS was defi ned as >75th percentile and Urinary retention 6 (30) 41 (20) 0.39 was >10 days in this cohort. Comparisons between groups *EBL was analyzed after logarithmic transformation (ln) to create a normal were made with Student t tests and Fisher exact tests (alpha distribution = 0.05). Multivariable analysis of signifi cant factors (p < 0.2) was performed with stepwise logistic regression. All sta- CONCLUSION: Ureteral stents are not associated with a tistical analyses were performed using SAS 9.2 (Cary, NC). higher rate of UTI in patients undergoing rectal resection. Females older than 65, a higher estimated blood loss, and a RESULTS: We identifi ed 223 patients during the study diagnosis of depression were found to be independent sig- period with age range of 18 to 96 (median 63). There were nifi cant predictors of UTI. We have no clear explanation for 110 (49%) males. Ureteral stents were used in 36 cases why depression would be associated with UTI and it should (16%). The majority of patients had rectal cancer as the be studied further in postoperative patients. primary diagnosis (52%), followed by infl ammatory bowel disease (26%), and rectosigmoid cancer (5%). UTI occurred

76 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1616 surgery, or proctectomy. A Charlson Comorbidity Index score was calculated for each patient. Outcomes included Nationwide Analysis of Postoperative Bleeding After rate of bleeding, rate of reoperation, mortality, and inpa- Colon and Rectal Surgery over the Past Decade: tient charge in 2010 US dollars. Statistical signifi cance was Incidence, Intervention, and Mortality established if p < 0.05. Nitin Kumar1, Ashok Kumar2, Christopher C. Thompson1 RESULTS: 360,091 patients had meeting inclu- 1Division of Gastroenterology, Brigham & Women’s Hospital, sion criteria in 2000 and 381,741 patients had surgeries Boston, MA; 2Clay County Hospital, Flora, IL meeting inclusion criteria in 2010. Rate of postoperative bleeding over time is shown in Table 1. Bleeding decreased BACKGROUND: Colorectal surgery has evolved over the signifi cantly among all surgery types between 2000 and past decade as the laparoscopic era has dawned. The prem- 2010. Reoperation rate and mortality in patients with post- ise of laparoscopic surgery has been that a less invasive operative bleeding in shown in Table 2. Even as bleeding surgical modality might lead to decreased morbidity and rate declined, reoperation rate and mortality rate among health care utilization. patients with postoperative bleeding increased, especially AIMS: To determine the change in rate of bleeding, rate of in open colectomy. However, overall mortality rate for reoperation, mortality, and health care utilization over the patients undergoing colorectal surgery remained stable at past decade in patients with postoperative bleeding after 0.165% in 2000 versus 0.175% in 2010 (p = 0.29). colon and rectal surgery. CONCLUSION: Incidence of postoperative bleeding after METHODS: This is a retrospective cohort study using the colorectal surgery has decreased over the past decade. Lapa- 2000 and the 2010 Nationwide Inpatient Sample (NIS), roscopic colorectal surgery, which has a low postoperative a nationally representative database of inpatient admis- bleeding rate, has accounted for much of the decrease; how- sions. Inclusion was limited to patients with postoperative ever, a signifi cant decrease in bleeding rates was seen after bleeding was defi ned as ICD-9 CM code for intraoperative open colectomy, proctectomy, and colostomy. Although bleeding, intraoperative hematoma, or lower gastrointesti- mortality rates have increased in patients with postopera- nal bleeding during the postoperative period and postop- tive bleeding, overall mortality after colorectal surgery has erative packed red blood cell transfusion. Adult patients been stable. Further development of minimally invasive were included if they had ICD-9 CM procedure code for surgical techniques holds promise for further improve- laparoscopic colectomy, open colectomy, colostomy-related ments in postoperative complication rates.

Table 1: Rate of Postoperative Bleeding by Surgery Type

2000 2010 p Value, Bleeding Rate Poster Abstracts n Postoperative Bleeding (%) n Postoperative Bleeding (%)

Laparoscopic colectomy – – 79,021 0.20 – Sunday Open colectomy 252,225 1.27 191,379 1.16 * <0.01 Proctectomy 47,438 0.57 49,524 0.44 * <0.01 Colostomy 60,428 3.19 61,817 2.13 * <0.01 Overall 360,091 1.50 381,741 1.03 * <0.01 * denotes statistically signifi cant change

Table 2: Reoperation and Mortality in Patients with Postoperative Bleeding

Reoperation (%) Mortality (%) 2000 2010 P value 2000 2010 P Value Laparoscopic colectomy — 43.8 — — 20.0 — Open colectomy 6.8 19.5 * <0.01 10.7 19.9 * <0.01 Proctectomy 4.5 22.5 * <0.01 7.4 8.7 0.60 Colostomy 4.4 15.2 * <0.01 11.9 13.2 0.27 Overall 5.8 27.3 * <0.01 11.0 17.0 * <0.01 * denotes statistically signifi cant change

77 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Esophageal  Su1618 Restaging PET-CT After Neoadjuvant Su1617 Chemoradiotherapy Can Prevent Non-Curative Most Patients with Persistent Symptoms on Acid- Surgical Interventions in Esophageal Cancer Patients Martinus C. Anderegg1, Roelof J. Bennink2, Suppressive Therapy Do Not Have Refl ux as a Cause Hanneke Van Laarhoven3, Jean H. Klinkenbijl1, Maarten C. Hulshof4, of Their Symptoms: a Single Center Study Using Jacques J. Bergman5, Mark I. Van Berge Henegouwen1 Ambulatory Impedance-pH Study 1Surgery, Academic Medical Center, Amsterdam, Netherlands; Pradeep K. Pallati, Se Ryung Yamamoto, Kalyana C. 2Nuclear Medicine, Academic Medical Center, Amsterdam, Nandipati, Tommy H. Lee, Sumeet K. Mittal Netherlands; 3Medical Oncology, Academic Medical Center, Creighton University, Omaha, NE Amsterdam, Netherlands; 4Radiation Oncology, Academic Medical BACKGROUND AND AIMS: Multichannel intra-luminal Center, Amsterdam, Netherlands; 5Gastroenterlogy and Hepatology, impedance (MII) and pH monitoring has been shown to be Academic Medical Center, Amsterdam, Netherlands effi cacious in the evaluation of patients with incomplete BACKGROUND: Esophageal cancer is notorious for its symptom control on proton pump inhibitor (PPI) therapy. rapid dissemination, both locally and to distant sites. Accu- The aim of our study is to evaluate the relationship of typi- rate staging at the time of diagnosis is of crucial importance cal and atypical gastroesophageal refl ux (GER) symptoms to identify patients eligible for curative treatment. For the to frequency of acid and non-acid refl ux (NAR) episodes in vast majority of these patients the preferred strategy con- patients on PPI therapy. sists of neoadjuvant chemoradiotherapy (nCRT) followed METHODS: Patients with persistent GER symptoms who by esophagectomy. Given the aggressive nature of esopha- underwent 24 hour combined MII-pH monitoring while on geal tumours, it is conceivable that in a signifi cant portion PPI therapy form the cohort of the study. Refl ux episodes of patients treated with nCRT, dissemination becomes man- were detected by impedance channels located 3, 5, 7, 9, 15, ifest during this preoperative course (interval metastasis). and 17 cm above the lower esophageal sphincter (LES) and Since metastatic disease is an absolute contraindication for classifi ed into acid or non-acid based on pH data from 5 cm esophagectomy, we added a post-neoadjuvant therapy PET- above the LES. Symptom Index (SI) was considered positive CT (restaging PET-CT) to the standard work-up of patients if >50% of specifi c symptom events were preceded by acid with potentially resectable esophageal carcinoma at initial or non-acid refl ux episodes within five minutes. presentation. RESULTS: Of 63 patients who underwent combined MII- AIM: Determine the value and diagnostic accuracy of PET- pH monitoring on PPI therapy, there were 46 (75%) women CT after neoadjuvant chemoradiotherapy in identifying and the mean age was 51.6 years (range 18–83). Fifty fi ve patients with interval metastases preoperatively. patients reported one or more symptoms during the study, METHODS: From January 2011 until September 2012 all of these 25 (39.7%) patients had a positive SI for at least consecutive esophageal cancer patients deemed eligible one symptom (12 with acid refl ux and 16 with NAR). For for a curative approach with nCRT and surgical resection typical GERD symptoms, 14 (19%) had a positive SI for acid underwent a PET-CT after completion of nCRT (median refl ux, 18 (24%) for NAR, and 43 (58%) had a negative SI. interval 18 days). Staging at initial presentation consisted of For atypical symptoms, 6 (14%) had a positive SI for acid endoscopy with biopsy, endoscopic ultrasonography, exter- refl ux, six (14%) had a positive SI for NAR, and 32 (72%) nal ultrasonography of the neck and a thoracoabdominal had a negative SI. CT scan. A PET scan was not part of the initial staging. Neo- CONCLUSION: Combined MII-pH shows that about 2/3rd adjuvant therapy consisted of 5 cycles of carboplatin AUC of patients complaining of symptoms on PPI therapy do 2, paclitaxel 50 mg/m2 and concurrent radiotherapy (41.4 not have positive symptom index to either acidic and/or Gy). If abnormalities on restaging PET-CT were suspect of non-acidic refl ux while remaining patients can have their metastases, histologic proof was acquired. This study was symptoms attributable to refl ux. approved by the local ethics committee. RESULTS: During the study period a total number of 280 new esophageal cancer patients were analysed at the out- patient clinic. Of these patients 148 underwent a restag- ing PET-CT. The remaining 132 patients were considered ineligible for curative esophagectomy at initial presenta- tion due to comorbidity, unresectable tumours or distant

78 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

metastases (94 cases), refused to undergo surgery (12), were CONCLUSION: Conversion of fundoplication to RYGB is operated without nCRT (13) or did not complete nCRT in performed on patients with a lower than average BMI than our centre (13). In 29 patients (19.6%) restaging PET-CT our typical RYGB cohort and experience signifi cant weight showed abnormalities suspicious for dissemination requir- loss with improvement in comorbid disease. Complications ing additional imaging and/or biopsy, resulting in 16 cases are similar to larger cohorts of patients undergoing RYGB. of proven interval metastasis (10.8%) and a false-positive Although ongoing therapy for acid reduction is common, rate of 8.8% for restaging PET-CT. Of the patients without improvements in GERD symptoms were noted. proven metastatic disease 116 patients have been operated at this time. In 4 of these 116 cases distant metastases were Su1620 detected intraoperatively, leading to a false-negative rate of 3.4%. Esophageal Cancer in the Young: A Population-Based CONCLUSION: 10.8 percent of esophageal cancer patients Analysis of 1095 Patients develop detectable distant metastases during neoadjuvant Attila Dubecz1, Norbert Solymosi2, Michael Schweigert1, chemoradiotherapy. To avoid non-curative resections we Jeffrey H. Peters3, Hubert J. Stein1 advocate restaging PET-CT as part of the standard work-up 1Surgery, Klinikum Nurnberg, Nurnberg, Germany; 2Faculty of of candidates for surgery. Veterinary Science, Szent Istvan University, Budapest, Hungary; 3Division of Thoracic and Foregut Surgery, Department of Surgery,  Su1619 University of Rochester School of Medicine and Dentistry, Rochester, NY Conversion of Fundoplication to Roux-en-Y Gastric BACKGROUND: Controversy exists about the clinical Bypass: Long-Term Results presentation and prognosis of young patients with gastro- intestinal malignancies. The aim of this study was to evalu- Daniel B. Leslie, Nikolaus F. Rasmus, Bridget M. Slusarek, ate population-based demographics and survival of young Barbara K. Sampson, Henry Buchwald, Sayeed Ikramuddin patients with esophageal cancer in the United States. Department of Surgery, University of Minnesota, Minneapolis, MN METHODS: We identifi ed 1,095 patients under 40 years INTRODUCTION: Conversion of Fundoplication to Roux- of age with cancer of the esophagus and the gastric cardia en-Y gastric bypass (RYGB) results in signifi cant weight loss diagnosed between 1973 and 2008 from the Surveillance, and resolution of co-morbid illness, especially gastrointes- Epidemiology, and End Results (SEER) database. Demo- tinal refl ux disease (GERD). This procedure offers alterna- graphic variables and cancer-related survival were assessed tive therapy to patients with recalcitrant GERD following and compared to all patients >40 years old (n = 65,930). a failed fundoplication. To date, very little long-term data Infl uence of available variables on survival was analyzed exists for this revisional procedure. with logistic regression. Poster Abstracts MATERIALS AND METHODS: Patients who underwent RESULTS: Percentage of young patients with esophageal a conversion of fundoplication (Nissen or other) to RYGB cancer is less than 2% and is declining since the 1990s. Sunday between 2000 and 2011 at our academic medical center More than fi fty percent are diagnosed in metastatic stage. were identifi ed. The department’s bariatric surgery data- Only 74% of patients with potentially resectable esophageal base was reviewed for weight loss, the presence of GERD cancer underwent surgery. Median cancer-related survival symptoms and the use of GERD medications. A refl ux and (13 months vs. 11 months) and fi ve-year survival (22% vs. heartburn questionnaire was administered to assess impact 18%) was signifi cantly higher than in older patients. Mul- on quality of life (GERD-HRQL) scores and to determine tivariate-analysis identifi ed surgical treatment (OR: 5.046) postoperative GERD symptoms. as the only as independent predictor of 5-year survival. RESULTS: Twenty eight patients (female/male = 24/4) Percentage of non-white patients, distal cancer and adeno- underwent laparoscopic (n = 17) or open (n = 11) surgery carcinoma were signifi cantly higher when compared to all by 3 different surgeons and mean weight follow-up (100%) patients. was 3 ½ years. Average preoperative BMI and weight were CONCLUSION: Most young patients with esophageal can- 43.1 kg/m2 and 119 kg; 3 patients had BMI below 35 kg/ cer are diagnosed in metastatic stage in the United States. m2. Average length of stay was 4 days. Post-revisional BMI, Survival in patients under 40 years of age is better than in weight, and% excess weight loss were 32.0 kg/m2, 87 kg, older patients. Patients undergoing surgical treatment for and 61%. Resolution of type II diabetes mellitus, hyperten- locoregional cancer have better survival. sion, and hyperlipidemia were noted in 67%, 33%, and 60% of patients, respectively. No major short-term com- plications occurred and there were no mortalities. At least 13 patients (46%) continued to use daily acid reduction medication treatment, and 7 patients reported ongoing GERD symptoms (25%). Indications for GERD therapy also include nonspecifi c abdominal pain, pre-RYGB history of Barrett’s esophagitis, and documented gastrojejunal ulcer. On a ranked scale of no symptoms (0) to incapacitating symptoms (50), mean GERD-HRQL score was 9.5/ 50 fol- lowing surgery.

79 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1621 Su1622 Prevalence of Gastroesophageal Refl ux in Chronic Celiac Nodal Status as Determined by Laparoscopic Obstructive Pulmonary Disease Patients Gastric Ischemic Preconditioning Is Prognostic Henrique Abrahao1, Fernando A. Herbella1, in Locally-Advanced Esophageal Cancer and May Amilcar M. Bigatao2, Jose R. Jardim2, Luciana C. Silva1, Determine Necessity for Completion Esophagectomy Fernando P. Vicentine1, Marco G. Patti3 Sabha Ganai1,2, Michael B. Ujiki1,2, Mark Talamonti1,2, 1Department of Surgery, Federal University of São Paulo, São Paulo, John G. Linn1,2, Amy K. Yetasook1, Joann Carbray1, Brazil; 2Department of Medicine, Division of Pneumology, Federal Marco Zahedi1, Ki Wan Kim1,2, John Howington1,2 University of São Paulo, São Paulo, Brazil; 3Department of Surgery, 1Surgery, NorthShore University HealthSystem, Evanston, IL; University of Chicago, Chicago, IL 2Surgery, The University of Chicago Medicine, Chicago, IL BACKGROUND: The association of gastroesophageal refl ux INTRODUCTION: Laparoscopic gastric preconditioning disease (GERD) and chronic pulmonary disorders has been has theoretical benefi ts of reducing conduit-related morbid- a topic of great interest recently. However, little is known ity by allowing time for the stomach to adapt and/or demar- about GERD in the setting of chronic obstructive pul- cate to ischemic insults prior to staged esophagectomy and monary disease (COPD). This study aims to evaluate in reconstruction. We hypothesized that focused pathological patients with COPD: (a) the prevalence and the sensitivity assessment of celiac lymph nodes during the conditioning of symptoms to diagnose GERD; (b) the pattern of esopha- interval could predict long-term outcomes after esophagec- geal motility; and (c) the prevalence of distal and proximal tomy in patients with locally-advanced esophageal cancer. GERD. METHODS: A single-institutional retrospective review was METHODS: A total of 50 patients with DPOC (as defi ned conducted between 10/2008 and 11/2012, identifying 34 by age >40 years with a FEV1/FVC below 88% of the pre- patients with locally-advanced (clinical Stage IIB/III) esopha- dicted value after bronchodilator use, and no prior history geal cancer who completed staged esophagectomy after lapa- of asthma) underwent symptomatic assessment, high-reso- roscopic preconditioning. Median follow-up was 9 months. lution manometry and dual probe esophageal pH monitor- ing. GERD was defi ned by a DeMeester score >14.7. Proximal RESULTS: Patients were 60 ± 10 years old, 82% male, and refl ux was defi ned by ≥1 episode of proximal refl ux. had a BMI of 24 ± 5 kg/m2. The median interval from pre- conditioning to esophagectomy was 7 days (interquartile RESULTS: GERD was present in 21 (42%) of the total patients. range, IQR, 7–8). Preoperative staging was performed with GERD symptoms were referred by 20 (40%) patients more EUS in 94% and PET in 100%, with 4 (12%) and 30 (88%) than once a month. Symptoms were not predictive of the patients having clinical Stage IIB and III disease, respec- presence of GERD (sensitivity 71%; specifi city 83%). GERD tively. Ninety-one percent of lesions were located in the symptoms presence, esophageal manometry and pHmoni- distal esophagus, GE junction, and/or cardia. Histology toring according to the presence of distal GERD by pHmon- comprised 30 (88%) adenocarcinomas, 3 (9%) squamous itoring results are depicted in Table 1. cell carcinomas, and 1 (3%) adenosquamous carcinoma. Ninety-seven percent of patients completed neoadjuvant GERD + (n = 21) GERD – (n = 29) p therapy, with a pathologic complete response rate of 27%. GERD symptoms 15 (71%) 5 (17%) <0.001 All patients had microscopically-negative margins. The hypotensive LES 8 (39%) 5 (17%) 0.1 median number of lymph nodes resected was 20 (IQR Abnormal peristalsis 2 (9%) 8 (28%) 0.1 16–24), with a median of 5 (IQR 3–6) identifi ed in the Abnormal amplitude 10 (48%) 4 (14%) 0.01 celiac nodal packet harvested during the preconditioning Proximal GERD 20 (95%) 7 (24%) <0.001 stage. Patients with positive celiac lymph nodes (32%) were GERD: gastroesophageal refl ux disease LES: lower esophageal sphincter more likely to have pN2/N3 disease (3 or greater positive nodes) than those with negative celiac nodes (64% versus CONCLUSIONS: These data show that in patients with 9%, p < 0.01). Median disease-free survival by celiac lymph DPOC: 1) GERD is present in almost half of the patients; 2) node status was 18.6 versus 3.7 months (HR 0.22, 95% CI symptoms were insensitive and nonspecifi c for diagnosing 0.06–0.75, p < 0.01). Median overall survival by pN status GERD; 3) a defective LES is not more common in patients was 32.7 months for pN0, 12.2 months for pN1, and 5.6 with GERD leading to the hypothesis that the physiopa- months for pN2/N3 (p < 0.001). On multivariate analysis thology for GERD may be linked to the transthoracic pres- controlling for histology, grade, pathological response to sure gradient in this population; 4) in 95% of the patients therapy, celiac nodal status, and pT status, only pN status with GERD, acid refl uxed into the proximal esophagus. We remained an independent predictor of both disease-free conclude that patients with DPOC should be screened with (p < 0.05) and overall survival (p < 0.01). pH monitoring for GERD.

80 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1623 POEM-Based Endoscopic Treatment of Zenker’s Diverticulum: Minimal Incision Cricopharyngeal Myotomy (CPM) Luke Mccrone1, Kondal R. Kyanam Kabir Baig2, Victoria Gomez2, John D. Casler3, Timothy A. Woodward2 1Internal Medicine, Mayo Clinic Florida, Jacksonville, FL; 2Gastroenterology, Mayo Clinic Florida, Jacksonville, FL; 3Otorhinolaryngology, Mayo Clinic Florida, Jacksonville, FL BACKGROUND: Zenker’s diverticulum (ZD), a posterior outpouching of mucosa through transverse cricophargyn- geal muscle fi bers, has a reported prevalence of 0.01% to 0.11%. ZD is associated with marked morbidity, with symp- toms ranging from halitosis and food regurgitation to aspi- ration pneumonia and cachexia. Therapeutic management of ZD has evolved from open diverticulectomy to rigid endoscopy, and, most recently, fl exible endoscopy utilizing cricophayrngeal myotomy (CPM) with diverticulotomy. Traditional open surgical and rigid endoscopic methods have been associated with high rates of symptomatic reso- lution, with acceptable rates of recurrence. There are, how- ever, associated complications of bleeding and perforation, with these risks being amplifi ed in this comorbid, aged patient population. Building upon the per oral endoscopic myotomy (POEM) A POEM-based minimal incision crico- pharyngeal myotomy (CPM) technique has been devel- oped, using a needle knife to dissect the cricopharyngeal bar by way of a 8 to 10 mm incision within the confi nes of the mucosa without an extended diverticulotomy (See image). Poster Abstracts Sunday

CONCLUSIONS: While the AJCC 7th edition for staging of esophageal cancer has changed the emphasis from the loca- tion of regional lymph node metastasis to the number of positive nodes, our data suggest that esophagectomy may be avoided in patients with positive celiac nodes after neoadju- vant therapy for locally-advanced esophageal cancer. Laparo- scopic preconditioning provides an opportunity to determine celiac nodal status prior to committing to esophagectomy.

Myotomy within minimal incision.

81 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

AIMS: To evaluate the effi cacy of endoscopic minimal inci- METHODS: After IRB approval, we retrospectively queried sion CPM in the treatment of Zenker’s Diverticulum. our prospective database for patients who underwent an Ivor METHODS: Prospectively collected cohort of patients Lewis esophagogastrectomy for esophageal cancer. We iden- undergoing minimal incision needle-knife cricophargyneal tifi ed 220 patients from May 2001 to December 2012. Path- myotomy under monitored anesthesia care at a single cen- way one consisted of 110 patients, operated on between May ter tertiary referral center. 2001 and January 2007, who had contrast examination on postoperative day (POD) # 5, and if no anastomotic leak was Subjects include patients with symptomatic ZD as demon- seen, progression of oral intake from clear liquids on POD#5, strated by radiographic and/or endoscopic evaluation. The full liquids on POD#6 and soft solids on POD#7. They were main outcome measurements consisted of pre- and post discharged on a soft solid postgastrectomy diet. Pathway dysphagia scores (0–4 with 0 as no dysphagia and 4 rep- two consisted of 110 patients operated on between January resenting severe dysphagia) and any post-procedural com- 2007 and December 2012 who had no postoperative contrast plications, as determined by clinical review and telephone swallow, jejunal tube feedings starting POD #1 at 20 cc/hr follow up. advancing 10 cc/12 hours until goal and discharge NPO on RESULTS: From January 2009 to November 2012, 8 jejunal tube feedings only for 1 month then gradual increas- patients underwent minimal incision CPM (see table). The ing oral intake and eliminating tube feedings by 6 weeks mean age was 76 years (range 61–91 years; 63% male). postoperatively. Factors analyzed included demographics, Improvement in dysphagia was seen in 100% of patients, length of stay, complications and weight changes. though complete resolution was seen only in 4 patients RESULTS: Overall there were 188 (85.5%) men; median (50%). As this was a pilot program, all patients were hospi- age was 64 years (range 32–89). Table 1 show the patient talized overnight for observation. Excluding mild subcuta- characteristics overall and of the two pathways. Median neous emphysema in two patients, no procedurally related length of stay was 10days (range 7–98) in pathway one and problems. Time to follow up ranged from 2 weeks to 17 only 7 days (range 5–54) in pathway two. Complication months. rates were similar in the two groups: 37.2% in pathway one Results of Cricopharyngeal Myotomy and 42.7% in pathway two. The anastomotic leak rate was higher in pathway one compared to pathway two: 4.5% vs. Dysphagia Dysphagia 1.8% respectively. There was no difference in the median Case Age/Sex Pre-Procedure Post-Procedure Successful weight loss from discharge to the 6 week follow-up visit 1 84/Male 3 0 Yes between the two groups: 6.8 kg in pathway one patients vs. 2 68/Male 3 1 Yes 6.4 kg in pathway two patients. 3 70/Male 3 1 Yes Patient Characteristics 4 61/Female 2 0 Yes 5 75/Female 2 0 Yes Overall Pathway 1 Pathway 2 6 76/Male 3 1 Yes Characteristic (n = 220) (n = 110) (n = 110) 7 83/Male 2 0 Yes Men (%) 85.5 87.2 83.6 8 91/Female 4 2 Yes Median age (range) 64 (32–89) 64 (32–89) 63 (33–84) Dysphagia Score: 0 = no dysphagia; 1 = able to swallow some solid foods; Preop chemo/XRT (%) 69.1 61.8 76.4 2 = able to swallow only semi-solid foods; 3 = able to swallow liquids only; Clinical Stage IIIA 53.6 51.8 55.5 4 = total dysphagia. Adenocarcinoma (%) 86.8 88.2 85.5 Preop chemo/XRT – Preoperative chemotherapy and radiation therapy CONCLUSION: Minimal incision CPM is effective in man- agement of Zenker’s diverticulum, and demonstrates effec- CONCLUSION: Changing the postoperative nutritional tive resolution of dysphagia. In our case series, no serious management after an Ivor Lewis esophagogastrectomy procedural or post-procedural complications occurred. to no contrast swallow and delaying oral intake for one month results in a shorter length of stay and reduced anas- Su1624 tomotic leaks, but no change in the overall complication rate or early postoperative weight loss. Postoperative Management of Nutrition After Ivor Lewis Esophagogastrectomy for Cancer Laura Trujillo, James Taswell, Mark Allen Mayo Clinic, Rochester, MN OBJECTIVES: Esophagogastrectomy is a complex operation and the postoperative management is variable. We hypothe- sized that waiting 5 days postoperatively to obtain a contrast swallow to start oral intake and then waiting until patients were able to take suffi cient oral intake before discharge pro- longs hospitalization after an Ivor Lewis esophagogastrec- tomy. To examine this hypothesis we analyzed two methods of management of postoperative nutrition after surgery.

82 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1625 Su1626 High-Resolution Impedance Manometry Findings in Surgical Management of Esophageal Perforation: A Patients with Epiphrenic Diverticulum 10-Year Experience Se Ryung Yamamoto, Kalyana C. Nandipati, Paul Goldsmith1, Bilal Alkhaffaf1, Bart Decadt2 Pradeep K. Pallati, Tommy H. Lee, Sumeet K. Mittal 1Manchester Royal Infi rmary, Manchester, United Kingdom; Creighton University, Omaha, NE 2Stepping Hill Hospital, Stockport, United Kingdom AIM: The objective of this study was to evaluate high-resolution INTRODUCTION: The management of esophageal per- impedance manometry (HRIM) fi ndings in patients with foration and mediastinal sepsis is challenging. Treatment esophageal epiphrenic diverticulum. strategies differ between surgical units and as a conse- METHODS: Patients with esophageal epiphrenic diver- quence outcomes can vary widely in this patient group. We ticulum who underwent HRIM between October 2008 and present our 10-year experience of esophageal perforation March 2012 are included in the study. Manometric fi ndings and evolving treatment strategy for this condition. were compared to endoscopic (EGD) and barium swallow METHODS: This was a retrospective review of all esopha- (BS) fi ndings. Patients with previous foregut surgery were geal perforations including both patients with a spontane- excluded. ous or iatrogenic perforation and cases of mediastinal sepsis RESULTS: Six patients (mean age 59.0 years, 3 females) are due to anastomotic leak following cardio-esophagectomy. included in the study. On EGD the diverticulum was 1 to Patients were grouped according to their treatment strategy. 4 cm above the gastro-esophageal junction (GEJ) and the The primary outcome measures were in-hospital death and mouth of diverticulum was 2 to 9 cm in size. Mean lower length of stay (total hospital stay and Intensive Care Unit esophageal sphincter pressure (LESP) and mean Integrated (ICU) stay). relaxation pressure (IRP) were 50.7 mmHg (range 39.2 to RESULTS: In total, thirty-seven patients were included. 61.9 mmHg) and 22.4 mmHg (range 13.8 to 30.8 mmHg) Twenty-fi ve were male with a median age of 59 (range respectively. Achalasia was the most common abnormal- 21–80). Seven patients suffered iatrogenic perforations ity noted in 3 patients (type I = 2 and type II = 1). Two (3 esophageal dilatations, 2 food bolus removal, 2 gastros- additional patients had isolated EGJ obstruction with pre- copy). Eleven patients presented following spontaneous served esophageal motility. One patient had normal IRP esophageal perforations and a further Eighteen suffered but weak peristalsis. A break in peristalsis corresponding to anastomotic leaks following cardio-esophagectomy and the mouth of the diverticulum could be seen in 4 patients. one leak following cardio-myotomy. There was decreased bolus transit in three patients. Twenty-six patients underwent surgery for their perfora- CONCLUSIONS: There is a high prevalence of esophageal tions compared to eleven who were conservatively man- Poster Abstracts outfl ow obstruction and primary peristaltic abnormality in aged. Surgical management involved either thoracotomy patients with epiphrenic diverticulum. This reconfi rms the with primary repair or creation of a controlled fi stula using Sunday need to extend the myotomy down on to the GEJ even in a T-tube (20), cardio-esophagectomy (3) or thoracoscopic patients in whom the diverticulum appears to be well above washout (3). All patients had enteral feeding routes inserted the GEJ. in conjunction with surgery. Conservative management constituted either simple insertion of chest drains (8) or stent placement (3). Death following non-operative management occurred in 4 patients compared to two (36% vs 7% p < 0.05) in those who underwent surgery. CONCLUSION: Urgent operative management is a safe treatment option for patients who have oesophageal per- foration and are fi t to undergo a surgical exploration. Thoracotomy with repair of the perforation over a T-tube with defunctioning , feeding jejunostomy and drainage of the thorax and mediastinum, appears a safe policy and is our preferred approach. Patients with exist- ing esophageal pathology may be considered for emergency cardio-esophagectomy.

83 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1627 use were collected at years 1, 2, 3, 4 and 10 post-procedure. The data were analyzed using a repeated measures analysis Sustained Improvement in GERD-HRQL, Patient of variance to determine whether there was a signifi cant Satisfaction, and Anti-Secretory Drug Use 10-Years temporal trend in the various outcomes. Any signifi cant After Stretta for Medically Refractory GERD effect was sub-analyzed using a Bonferroni-adjusted mul- Mark D. Noar1, Patrick Squires1, Emmanuelle Noar1,2 tiple comparison procedure. 1The Heartburn and Refl ux Center, Endoscopic Microsurgery RESULTS: The total treated pool included 227 patients (136 Associates, Towson, MD; 2School of Medicine, Tulane University, females, 60%). No strictures, perforation, deaths or other New Orleans, LA signifi cant adverse events occurred. Complete follow-up was available for subjects at intervals as follows: 6 months BACKGROUND & AIMS: The Stretta procedure is an (n = 177), 1 year (n = 149), 2 years (n = 98), 3 years (n = effective endoscopic modality for control of GERD symp- 98), 4 years (n = 94), and 10 years (n = 99). Heartburn, toms. However, long term effi cacy and safety at >10 years satisfaction, HRQL and medication use were signifi cantly has not been assessed. We prospectively evaluated the long- improved across the follow-up period (6, 12, 24, 36, 48, and term effi cacy of Stretta at 10-years and assessed anti-secre- 120 months; p < 10–6 for all of the outcomes) and results tory drug use, GERD symptoms, and patient satisfaction. were superior to those achieved for baseline drug therapy METHODS: From 8/2000 to 9/2004, 227 patients with (see Table). inadequate GERD symptom control despite BID PPI under- CONCLUSION: This 10-year, open, single center, prospec- went Stretta and were prospectively enrolled in this study. tive assessment of Stretta for refractory GERD demonstrates All patients had normal esophagogastric anatomy, except a signifi cant and sustained improvement of GERD-HQoL 16 patients with failed Nissen fundoplication and 7 with scores, patient satisfaction, and improved PPI use and vali- large (>3 cm) hiatal hernia. All procedures were performed dates the long-term usefulness of this endoscopic proce- by a single endoscopist in an outpatient setting with con- dure. Patients with variant anatomy such as prior Nissen scious sedation. Baseline and follow-up GERD-HRQL scores fundoplication or large hiatal hernia had a similar response (0–50), heartburn (0–5), satisfaction (0–5) and medication compared to patients with normal anatomy.

Before Treatment, Before Procedure, Parameter off Meds on Meds 0.5 Years 1 Year 2 Years 3 Years 4 Years 10 Years Med Scores 8.3 ± 3.8 4.9 ± 3.9 3.8 ± 3.5 3.7 ± 4.2 4.6 ± 3.6 4.3 ± 3.2 4.7 ± 3.3 GERD Scores 27.8 ± 10.7 21.4 ± 11.5 11.1 ± 10.0 6.9 ± 7.5 5.0 ± 6.9 6.9 ± 8.2 7.3 ± 8.5 8.1 ± 9.9 Satisfaction Scores 1.3 ± 0.9 1.9 ± 1.1 3.4 ± 1.3 3.9 ± 1.3 4.3 ± 1.0 3.8 ± 1.3 3.8 ± 1.3 3.8 ± 1.2

Su1628 METHODS: A query was submitted to the Web of Sci- ence database to fi nd all the publications in the topic of Bibliometric Analysis of the Scientifi c Publications gastroesophageal refl ux in the time period between January About Gastroesophageal Refl ux Disease (GERD) 1954 to December 2011. A total of 18136 references were Between 1954 and 2011 retrieved, these records were then analyzed using biblio- Shahin Ayazi, Thomas J. Watson, Carolyn E. Jones, metric parameters. Virginia R. Litle, Christian G. Peyre, Jeffrey H. Peters RESULTS: Number of publications has increased from Surgery, University of Rochester, Rochester, NY only two papers per year in 1954 to nearly three papers per day in 2011, with more than 700 publications per year in INTRODUCTION: Gastroesophageal refl ux disease (GERD) 21st century. Majority of these publications are in English is an increasingly prevalent health problem. This disease (94%). United States, England and Italy are the most pro- has been the focus of the work of many researchers in the ductive countries with 40%, 7% and 6% of the literature last 50 years, these investigations has led to a transforma- respectively. Eighty percent of the literature in the fi eld is tion in the understanding and treatment of this disease. the result of the work of authors from 10 countries [North However little is known about the characteristics and trends America (2), Europe (6), Japan and Australia], this pattern of the scientifi c publications in this fi eld. The aim of this did not change when the publications from 2000–2011 study is to present a bibliometric analysis of the scientifi c were analyzed separately. publications on gastroesophageal refl ux disease.

84 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: A retrospective database was used to capture the clinico-pathological data of all consecutive curative resections of OGJ adenocarcinomas over the last 10 years in two UK Upper GI Units. Any report with less than 12 lymph nodes was considered inadequate and denoted as (Nx). All cases were re-reported and re-staged according to the 7th TNM staging rules. We compared the impact of the 7th TNM staging rules on neo-staging. Overall survival was analysed using the 6th and 7th TNM staging respectively. Overall sur- vival was sub-stratifi ed into 2 years, 5 years and 10 years post curative resection. Mayo clinic is the institution with the highest number of publications (268), followed by the University of Southern RESULTS: Fifty seven (57) pathology reports confi rm- California (243) and Northwestern University (211). Tom ing oesophago-gastric junctional adenocarcinomas were DeMeester, Joel Richter and Donald Castell are the most reviewed. Adequate lymphadenectomy (minimum of 12 prolifi c authors in this fi eld with 194, 178 and 169 publica- nodes) was noted in 33 patients. Overall stage migration tions respectively. Gastroenterology and American Journal was noted in 36 (63%) reports with the 7th TNM staging. Of of Gastroenterology are the two journals with the highest those who had adequate lymphadenectomy (33), 20 reports number of publications about the GERD. (60.6%) had stage migration. CONCLUSION: Parallel to the rise in the prevalence of the In terms of survival, one patient was lost to follow up and is gastroesophageal refl ux disease, there is an increase in the not included in the analysis for survival. Patients with Stage research performed about refl ux evidenced by the constant 4 disease were not operated on in this cohort. increase in the number of scholarly work published in this 2 year survival (n = 56) using the 7th TNM staging, showed fi eld (Figure). Two thirds of the literature about the GERD an apparent increase in survival by 12.4% in stage 3 disease st has been published in the 21 century. Only a small frac- with a corresponding decrease in survival by 17.8% in stage tion of GERD publications (6.3%) is supported by a funding 2 disease. 5 year survival (n = 34) using the 7th TNM staging, agency. Majority of the literature (80%) is the result of the demonstrated 14.8% increase in survival for stage 3 disease work of the authors from only 10 countries. and a corresponding decrease by 17.6% for stage 2 disease. 10 year survival (n = 10) with the 7th TNM, again demon- Su1629 strated a 30% increase in apparent survival for stage 3 dis- The Better Defi nition of Nodal Staging in the th7 ease and a corresponding decrease by 40% in stage 2 disease. Edition of TNM Manual Does Not Predict Survival For stage 1 disease, there is no signifi cant change in 2 year, Poster Abstracts or Translates Into Better Prognosticating Ability in 5 year and 10 year survival. Sunday Oesophago-Gastric Junctional Adenocarcinoma CONCLUSION: The 7th edition of TNM staging provides Ramesh Y. Kannan, Matthew L. Davies, Carys Jenkins, a detailed documentation of the lymphatic staging. The Majid Rashid, Ashraf M. Rasheed apparent increase in survival in stage 3 disease appears to Minimal Access Surgery, Royal Gwent Hospital, Newport, be compensated for the apparent decrease in survival for United Kingdom stage 2 disease. This better defi ned lymphatic staging does not seem to predict survival or have a superior prognosti- INTRODUCTION: The 7th TNM staging defi nes a mini- cating ability. mum number of nodes, recommends an optimal number for each T stage, emphasizes the prognostic importance of number of regional nodes involved and upstages based on the number of metastatic lymph nodes. AIMS: To study the impact of application of 7th TNM rules on nodal staging (N) of resected and pathologically reported oesophago-gastric junctional (OGJ) adenocarcinomas dur- ing the last 10 years stratifying them according to the 7th edition TNM staging and to compare against the original staging and assess possible impact of nodal neo-staging on survival.

85 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1631 (p < 0.001) and higher stage (p < 0.001) at diagnosis and were less likely to undergo surgical resection (4.9% vs. 18%; Does Surgery Have a Role in the Treatment of Small p < 0.01). In both all-comers as well as those undergo- Cell Cancer of the Esophagus? ing surgical resection, univariate analyses showed a worse Moshim Kukar1, Adrienne Groman1, Graham W. Warren3, survival in patients with small cell esophageal cancer. Usha Malhotra2, Chukwumere Nwogu1, Todd L. Demmy1, However, multivariate analyses adjusting for age, gender, Sai Yendamuri1 grade, stage, race and number of lymph nodes examined 1Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY; did not show a statistically signifi cant association between small cell histology and overall survival in both sets of 2Medical Oncolgy, Roswell Park Cancer Institute, Buffalo, NY; 3 patients. Univariate analysis of patients with small cell can- Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY cer alone demonstrated a signifi cant association of surgery INTRODUCTION: Small cell cancer of the esophagus is with median survival (17 months vs. 7 months; p = 0.002) an uncommon malignancy with perceived poor progno- (Figure 1). sis. Due to its rarity, no large case series has been exam- CONCLUSIONS: This large study of small cell esophageal ined to guide therapeutic decisions. We examined the SEER cancer confi rms the clinical observation that small cell can- database to analyze factors determining outcome of this cer of the esophagus is an aggressive disease. In addition, unusual malignancy. we show that outcomes with this disease are associated METHODS: All patients with esophageal cancer in the with stage of disease and not histology. Therefore, surgical SEER database from 1973–2009 were included. Character- resection for esophageal cancer patients with this histol- istics of patients with and without small cell cancer were ogy should be offered based on stage rather than histology compared. Univariate and multivariate analyses examining alone. the relationship of small cell histology with overall survival (censored at 72 months) were performed in all patients as Su1632 well as those undergoing surgical resection. In addition, only patients with small cell cancer were analyzed to exam- Dissatisfaction After Laparoscopic Heller Myotomy ine the potential benefi t of surgery. Sharona B. Ross, Carrie E. Ryan, Benjamin L. Jacobi, Harold Paul, Kenneth Luberice, Paul Toomey, Alexander Rosemurgy General Surgery, Florida Hospital Tampa, Tampa, FL INTRODUCTION: Laparoscopic Heller myotomy allevi- ates symptoms of achalasia; however, we have observed a small subset of patients who are dissatisfi ed with their experience. This study was undertaken to identify causes of dissatisfaction after laparoscopic Heller myotomy and to identify predictors of dissatisfaction following myotomy. METHODS: With IRB approval, all patients undergoing laparoscopic Heller myotomy at our institution from 1992 to 2012 were prospectively followed. Using a Likert scale patients rated their frequency and severity of symptoms before and after myotomy. Patients graded their experience from “Very Satisfying” to “Very Unsatisfying”. Objective outcomes were determined by esophagography/esophagos- copy. Complaints were derived from postoperative surveys, clinic visits, and phone surveys. Median data are reported. RESULTS: Of the 597 patients undergoing laparoscopic Heller myotomy, 44 (7%) patients reported some level of dissatisfaction following myotomy with follow-up at 32 months. Dissatisfi ed patients were more likely to have Figure 1: Patients with small cell esophageal cancer undergoing undergone prior abdominal operations (45% vs. 28%, p surgical resection (green line) have a better survival than those with = 0.03) and previous myotomies (16% vs. 5%, p = 0.02). no surgical resection (blue line) on univariate analyses. Dissatisfi ed patients also had longer postoperative lengths of stay (2 days vs. 1 day, p = 0.01), generally because of RESULTS: 387 of 64,799 (0.6%) patients with esophageal postoperative complications or exacerbations of preop- cancer had small cell histology. Patients with small cell erative comorbidities. For dissatisfi ed patients, symptom histology were similar in age and race, but had a higher frequency and severity persisted after myotomy and were proportion of females compared to other histologies (40.6% more notable than for satisfi ed patients (p < 0.03 for all; vs. 25.4%; p < 0.001). These patients also had higher grade Figure).

86 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: With IRB approval, patients were prospec- tively followed after Heller myotomy. Patients scored the frequency and severity of their symptoms before and after myotomy using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). The symptom frequency and severity of the fi rst 100 patients undergoing laparo- scopic Heller myotomy with anterior fundoplication were compared to the last 100 LESS patients undergoing LESS Heller myotomy with anterior fundoplication. Median data are reported. RESULTS: 601 Heller myotomies with fundoplications were undertaken between 1992–2012. Of these, 470 (78%) were completed via conventional laparoscopy, 130 (21%) via the LESS approach, and 1 (.1%) as an “open” operation. All of the last 100 patients underwent the LESS approach with anterior fundoplication. The frequency and severity of all preoperative symptoms signifi cantly improved with Figure depicts the disparity of symptom resolution between satisfi ed and either the conventional laparoscopic or LESS approach; dissatisfi ed patients. *denotes symptom improvement after myotomy several postoperative symptoms had superior improve- (p < 0.05). ment with the LESS approach (e.g., vomiting, choking, p = 0.01 for each; Figures 1a, 1b). Those who underwent LESS CONCLUSIONS: Dissatisfaction is fortunately uncommon Heller myotomy with anterior fundoplication also had a after laparoscopic Heller myotomy. Dissatisfaction is directly decreased length of hospital stay (2 vs. 1 day, p < 0.05) and related to persistent severe and frequent symptoms; longer no apparent scars. lengths of stay, previous abdominal operations, and “re-do” CONCLUSIONS: Laparoscopic Heller myotomy provides myotomies predict dissatisfaction. Patients with notable an effi cacious and durable treatment for achalasia. The comorbidities and/or previous abdominal operations, par- LESS technique offers a safe approach with equivalent or ticularly Heller myotomy, are more likely to be dissatisfi ed superior symptom relief and improved cosmesis. Overall after laparoscopic Heller myotomy should be counseled patient satisfaction and durable symptom relief promotes preoperatively. Comorbidities should be addressed preop- laparoscopic Heller myotomy with anterior fundoplication, eratively and for patients with previous notable abdominal particularly using the LESS approach. operations, particularly myotomy, alternatives to laparo- Poster Abstracts scopic Heller myotomy should be considered. Sunday Su1633 A Single Institution’s Journey with Heller Myotomy: Is the Laparo-Endoscopic Single Site (LESS) Approach Best? Alexander Rosemurgy, Thara Salam, Carrie E. Ryan, Graphs illustrate symptom frequency preoperative and postoperatively. Mercedez C. Cruz, Kenneth Luberice, Harold Paul, Figure 1a is specifi c for the fi rst 100 patients undergoing laparoscopic Sharona B. Ross Heller myotomy with anterior fundoplication while Figure 1b is specifi c General Surgery, Florida Hospital Tampa, Tampa, FL for the last 100 patients undergoing LESS Heller myotomy and anterior INTRODUCTION: The surgical treatment of achalasia has fundoplication. evolved from a conventional laparoscopic Heller myotomy to a Laparo-Endoscopic Single Site (LESS) Heller myotomy with anterior fundoplication. This study illustrates our jour- ney with the evolution in technology and instrumentation and details patient outcomes along our journey.

87 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1634 Su1635 Surgical Myotomy Should Be Considered as Primary Surgical Treatment for Achalasia: A NSQIP Analysis Treatment in Elderly Patients with Achalasia Stephanie G. Wood, Edward J. Hannoush, Andrew Duffy, Donald E. Low, Artur M. Bodnar, Sheraz R. Markar Robert Bell, Kurt E. Roberts Department of Thoracic Surgery, Virginia Mason Medical Center, Surgery, Yale School of Medicine, New Haven, CT Seattle, WA INTRODUCTION: There are multiple surgical treatment INTRODUCTION: Achalasia is a rare disease which pre- options for Achalasia, with the laparoscopic approach dominantly affects patients between 25 and 55 years. Older increasingly considered the treatment of choice. We review patients are often not considered for endoscopic manage- the largest number of reported cases of laparoscopic Heller ment due to the perception that they are at higher risk for myotomies to date, from the NSQIP database, and compare surgical therapy. alternative surgical treatments. METHODS: All patients undergoing surgical treatment for METHODS: Using the American College of Surgeons achalasia between 2001 and 2012 were entered into an IRB- National Surgical Quality Improvement Program (NSQIP) approved database. Presenting characteristics and periop- participant use fi les from 2005–2010, patients diagnosed erative outcomes were compared in patients younger and with Achalasia (ICD-9 530.0) who underwent a surgical older than 70 years. Heller myotomy, including open abdominal (CPT 43330), laparoscopic (CPT 43279), open thoracic (CPT 43331), and RESULTS: 99 patients underwent surgical treatment for thoracoscopic (CPT 32665) approaches. As the CPT code for achalasia during the study period. 6 patients (1 > 70, 5 < laparoscopic Heller myotomy was created in 2009, there are 70) underwent esophageal resection and were excluded. 92 none reported before this time. patients underwent Heller myotomy and either Toupet or Dor fundoplication. 17 patients >70 years of age, mean age RESULTS: A total of 978 patients diagnosed with Achalasia was 76.5, range 70–92 years, were compared to 75 patients were identifi ed, of which 663 patients received a laparocopic <70 years. Pre-operative weight loss was similar (mean 15.6 Heller, 239 open Heller, 16 open thoracic, and 60 thoraco- lbs >70 versus 18.7 lbs <70). Patients in the >70 group had scopic myotomies. Overall, 56.8% were male and mean age higher ASA scores (2.58 versus 2.14, p = 0.01) and were more is 52 years (SD ± 16.3). There was no signifi cant difference likely to undergo previous endoscopic therapy (65% versus in age between groups. There was a signifi cant difference in 60%). Patients in the >70 group were less likely to undergo total length of stay between open and laparoscopy Heller laparoscopic surgery (35% versus 79%). Length of operation myotomy groups only, 3.45 vs 2.48 days, p = 0.015. Opera- and blood loss was similar between study groups. Intraop- tive time was signifi cantly different between the open and erative complications were more common in patients <70, laparoscopy Heller myotomy groups only, 146.0 vs 136.27 conversions (3 versus 0), intraoperative mucosal injury min (SD ± 54.9), p 0.018. There only signifi cant difference (3 versus 0). Perioperative complications occurred in 13% in postoperative complications was in superfi cial site infec- of patients <70 and 23.5% of patients >70. Complications tions, with 3 in open heller and 1 in thoracoscopic groups, in the >70 group included transient delirium 2, C. diff coli- p = 0.025. There were no deaths reported. tis 1 and fall 1. Median length of stay was 2 days in patients CONCLUSION: While there is no signifi cant difference in <70 (lap 2 versus open 4.5 days) and 4 days in patients >70 serious post-operative complications, laparoscopic Heller (lap 2 versus open 4 days). There was no mortality in either myotomy has improved length of stay and operative times group. Readmissions were required in one patient in each compared to open, and thoracic approaches. cohort. At mean objective follow-up of 3.8 months, 94% of patients >70 reported excellent (normal swallowing) or good (occasional dysphagia but no regurgitation) results. Clinical: Hepatic Followup was available in 12 patients >70 years at mean 29.1 months. 83% reported they ate a completely normal diet. Residual symptoms included occasional dysphagia Su1636 34%, occasional regurgitation 8%, and periodic heartburn Difference in Outcomes Between Right and Left 42%. No patient had required additional surgical or endo- Hepatectomy in Patients Undergoing Hepatic Resection scopic therapy and all patients indicated they would have 1 1 2 the operation again. Mashaal Dhir , Lynette M. Smith , George Dittrick , Quan P. Ly1, Aaron R. Sasson1, Chandrakanth Are1 CONCLUSIONS: Elderly patients with achalasia can 1University of Nebraska Medical Center, Omaha, NE; 2Surgery, undergo surgical myotomy and partial fundoplication Nebraska Methodist Hospital, Omaha, NE safely and with excellent results comparable to younger patients. These older patients should be given the opportu- BACKGROUND: Several studies have documented the nity to discuss surgical treatment with an experienced sur- safety of liver resections. Although right hepatectomy is geon at the time of their initial presentation. felt to be associated with higher mortality and morbidity, data on the difference in outcomes between right and left hepatectomy is scarce. The aim of the current study is to analyze the difference in outcomes between right and left hepatectomy in patients undergoing hepatic resection.

88 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODOLOGY: All patients undergoing right (primary Su1639 CPT code 47130) and left hepatectomy (primary CPT code 47125) were extracted from the National Surgical Qual- Modifi ed FOLFOX6 and Bevacizumab as Neoadjuvant ity Improvement Program (NSQIP) database (2005–2010). Chemotherapy for Patients with Potentially Curable Benign and malignant diagnoses (ICD-9 155.0, 155.1, 155.2 Bilobar Liver Metastases from Colorectal Cancer and 197.7) were determined from the database. The data Atsuyuki Maeda, Masatoshi Isogai, Yuji Kaneoka was analyzed to determine differences in outcomes between Digestive Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan right and left hepatectomy by using the chi square test or Fisher’s exact test as appropriate. OBJECTIVE: Even though patients with colorectal cancer (CRC) and liver metastases have a poor prognosis, they can RESULTS: A total of 2311 patients who underwent right benefi t from perioperative chemotherapy and complete or left hepatectomy were identifi ed of whom 1680 patients extirpation of the disease. Oxaliplatin based chemotherapy were noted to have a malignant diagnosis. (Table 1) Patients with bevacizumab has been widely reported to improve that underwent right hepatectomy were noted to be have a outcomes with metastatic CRC. However, its impact on sur- higher mortality rate when compared to left hepatectomy gical complications and survival benefi t after liver resection (all patients: right vs left—4.24% vs 1%, P < 0.001 and for remains to be determined. patients with malignancy: right vs left—4.52% vs 1.09%, P < 0.001). Right hepatectomy was also associated with sig- PATIENTS AND METHODS: Nineteen patients with nifi cantly higher incidence of several other complications potentially curable bilobar metastases from CRC were eli- such as organ space infections, pneumonia, unplanned re- gible for this single-center, nonrandomized trial during a intubation, pulmonary embolism, failure to wean off the period between September 2008 and August 2012 (NAC ventilator, renal insuffi ciency, urinary tract infection, blood group). The study group consisted of 13 men and 6 women, transfusion, deep venous thrombosis and sepsis (P value < with median age of 63 (range 52 to 79) years. Eligible cri- 0.05). teria included synchronous liver metastases and metastatic liver disease developed within one year after resection of the primary lesions. Patients received biweekly oxaliplatin, 5-fl uorouracil, and folic acid (FOLFOX6) plus bevacizumab therapy. The sixth cycle of neoadjuvant chemotherapy (NAC) did not include bevacizumab, resulting in 4 weeks window-time between the last administration of bevaci- zumab and hepatectomy. Over all survival (OS) and pro- gression free survival (PFS) were compared with 27 patients

who underwent hepateictomies for bilober metastasis dur- Poster Abstracts ing 2002 and 2008 (non NAC group).

RESULTS: Synchronous liver diseases were observed in 14 Sunday (73%). Although objective response to NAC was achieved in 6 patients (32%), 16 patients (84%) underwent liver resection. The liver surgery included 4 hemihepatecitomies, 5 sectorectomies, and 7 partial resections of the liver with median operative time of 186 minutes and median blood loss of 340 mL without blood transfusion. Any postopera- tive morbidity or morbidity was observed. One- and three- year OS of the NAC group were 100% and 56% (MST 43 months), and those of the non-NAC group were 93% and 49% (MST 31 months), respectively (P = 0.47). DFS of the two groups were not different (P = 0.50). Among the hepa- tectomized of NAC group, 10 patients (60%) developed recurrence with median relapse free time of 16.6 months. Initial recurrent deposits were observed in remaining liver in 4 patients, lung in 3, lymph nodes in 3, and peritoneum in 1 (redundant included). CONCLUSION: The results of our study demonstrate that CONCLUSION: Our data suggest that FOLFOX6 and beva- mortality and morbidity after right hepatectomy remains cizumab can be safely administered until 4 weeks before signifi cantly higher than left hepatectomy. liver resection in patients with liver metastases from CRC without increasing perioperative complications. Although no contributions to OS and DFS were observed, control of liver recurrence may be achieved. Adjuvant therapies and further study is needed to defi ne the survival benefi t of NAC with FOLFOX6 plus bevacizumab in patients with potentially curable bilobar metastases from CRC.

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Su1640 Su1641 Hepatectomy for Liver Metastases from Gastric and Portal Venous Thrombosis After Distal Pancreatectomy: Esophageal Cancer: Tumor Biology and Surgical Results Risk Factors and Outcomes Defi ne Outcome Ashwin S. Kamath1, Michael L. Kendrick1, Michael G. Sarr1, Andreas Andreou1, Luca Viganò2, Giuseppe Zimmitti2, David M. Nagorney1, Robert Mcbane2, Michael B. Farnell1, Martin Dreyer1, Jean-Nicolas Vauthey3, Peter Neuhaus1, Kaye M. Reid Lombardo1, Florencia G. Que1 Daniel Seehofer1, Lorenzo Capussotti2, Sven-Christian Schmidt1 1General Surgery, Mayo Clinic, Rochester MN, Rochester, MN; 1Department of General, Visceral and Transplant Surgery, Charité 2Cardiovascular Diseases, Mayo Clinic, Rochester MN, Rochester, MN – Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, AIM: Outcomes of patients developing portal vein (PV) Germany; 2Department of HPB and Digestive Surgery, Ospedale thrombosis (PVT) after distal pancreatectomy (DP) are Mauriziano “Umberto I”, Turin, Italy; 3Surgical Oncology, The unknown. The goal of this study was to identify risk fac- University of Texas MDAnderson Cancer Center, Houston, TX tors for PVT and describe the long term outcomes in these patients. BACKGROUND: The role of hepatectomy for patients with liver metastases from gastric and esophageal cancer METHODS: Patients undergoing DP without repair or (GELM) is not well defi ned. The present study examined reconstruction of the PV between 2001 and 2011 were the morbidity, mortality and long-term survival after liver included. Patients that showed evidence of PVT on pre- resection for GELM. operative imaging were excluded from the study. Location and extent of thrombosis was determined by postoperative PATIENTS AND METHODS: Clinicopathological data of CT or ultrasound imaging in all patients. Evidence of sys- patients who underwent hepatectomy for GELM between temic thrombosis (if present) in addition to PVT was also 1987 and 2012 at two European high-volume hepatobiliary documented. centers were assessed and predictors of overall survival were identifi ed. RESULTS: In the study period, 991 patients underwent DP and 21 (2.1%) patients were diagnosed with PVT. Pancreatic RESULTS: Fourty-six patients underwent liver resection neoplasm was the most frequent indication for operation for GELM. The primary tumor was located in the stom- (n = 11). Thrombus occurred in the main PV in 15 and the ach and in distal esophagus in 40 and 6 cases, respectively. right branch of the PV in 8 patients. Complete PV occlusion GELM were synchronous to primary tumor in 33 patients occurred in 9 patients with a median time to diagnosis of and multiple in 18 patients. In 13 cases, major hepatec- 16 days (range 5–85 days). Seventeen patients were antico- tomy (resection ≥3 liver segments) was performed. Thirty- agulated for a median duration of 6 months (range 3.3–36 day postoperative morbidity and mortality rates were 33% months) after the diagnosis of PVT. Over a median follow and 2%, respectively. After a median follow-up time of up of 22 months, resolution of PVT occurred in 7 patients. 76 months (range 1–135), 1, 3 and 5 year overall survival Predictors of non-resolution of PVT included anesthesia rates were 70%, 40% and 27%, respectively. Outcomes time >180 minutes (p = 0.025), DM type II (p = 0.03), BMI were comparable between the two centers. At univariate >30 Kg/m2 (p = 0.03), occlusive PVT (p < 0.001), or throm- analysis, primary tumor invasion of other organs (T4) (P = bus in a sectoral branch (p = 0.02). Anticoagulation therapy 0.004), poorly differentiated carcinoma (P = 0.006), posi- did not infl uence the frequency of thrombus resolution tive lymph node metastases, (P = 0.006), the need for blood and was complicated by gastrointestinal hemorrhage in 4 transfusions at hepatectomy (P = 0.02), major hepatectomy patients. There was no mortality as a direct result of PVT or (P = 0.017) and major posthepatectomy complications (P anticoagulation. = 0.001) were associated with worse overall survival after liver resection. Independent risk factors for shorter overall CONCLUSION: PVT after distal pancreatectomy is a rare survival identifi ed in multivariate analysis included poorly complication. Serious complications as a direct result of differentiated carcinoma (hazard ratio [HR] = 3.1, 95% con- PVT in this setting are uncommon and are not dependent fi dence interval [CI] = 1.17–8.15, P = 0.022), major hepa- on thrombus resolution. Although anticoagulation does tectomy (HR = 3.0, 95% CI = 1.22–7.39, P = 0.017) and not appear to infl uence the rate of PVT resolution in this major posthepatectomy complications (HR = 4.1, 95% CI = small retrospective series, we support the use of anticoagu- 1.31–12.57, P = 0.015). lation until larger, controlled-studies defi ne clear advan- tages or disadvantages. CONCLUSIONS: liver resection should be considered in selected patients with GELM. Patients with poor differen- tiated tumor and those who require major hepatectomy because of more advanced disease derive the least benefi t from this approach.

90 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Clinical: Pancreas CONCLUSION: PET is a more sensitive modality for iden- tifying metastatic disease than CT or MRI, however, it has a lower specifi city and lower positive predictive value. While  Su1642 PET identifi ed an additional 5.6% of patients with occult metastatic disease, it is likely that unresectability would Positron Emission Tomography (PET) Has Limited have been established at diagnostic laparoscopy, thus not Utility in Preoperative Staging of Pancreatic saving an unnecessary resection. We therefore conclude Adenocarcinoma that PET has limited utility in workup of patients who Peter Einersen1, Irene Epelboym1, Megan Winner1, already undergo CT or MRI as part of initial staging of pan- David Leung2, John A. Chabot1, John D. Allendorf1 creatic adenocarcinoma. 1Surgery, Columbia University Medical Center, New York, NY; 2Radiology, Columbia University Medical Center, New York, NY Su1644 BACKGROUND: Utility of positron emission tomography Human Equilibrate Nucleoside Transporter 1 (PET) as an adjunctive imaging modality to CT or MRI in Expression Predicts Survival of Pancreatic Cancer evaluating resectability of pancreatic cancer is a subject of Patients Trated with Gemcitabine-Based Adjuvant controversy. In this study, we seek to assess the utility of PET in identifying occult metastatic disease, as well as evaluate Chemotherapy After Resection 1 2 1 predictive value of maximum standard uptake value (SUV) Toshiyuki Moriya , Shigemi Fuyama , Yukinori Kamio , with respect to tumor resectability and patient survival. Koichiro Ozawa1, Shigeo Hasegawa1, Masaomi Mizutani1, Takayuki Higashi1, Moriyoshi Yokoyama1, Osamu Usuba1 METHODS: Cross sectional imaging, clinical course, oper- 1 ative outcomes, and overall survival of all patients who pre- Surgery, Okitama Public General Hospital, Kawanishi, Japan; 2 sented with pancreatic adenocarcinoma and had PET scan Pathology, Okitama Public General Hospital, Kawanishi, Japan in workup were reviewed retrospectively. Resectability was BACKGROUND: Gemcitabine is promising adjuvant che- assessed based on established criteria. Continuous variables motherapy for patients with resected pancreatic cancer. were compared using Student’s t-test or ANOVA. Categori- Human equilibrative nucleotide transporter-1 (hENT1) is cal variables were compared using chi-square or Fisher’s the major transporter responsible for gemcitabine uptake exact test. Prediction models were constructed using linear into cells. The aim of the current study is to investigate or logistic regression where appropriate. whether hENT1 expression can predict the survival of pan- RESULTS: Complete imaging and follow-up data was avail- creatic cancer patients treated with adjuvant gemcitabine- able for 123 patients evaluated from 2005 to 2011. Of this based chemotherapy after pancreatic resection. cohort, 36 patients (29%) were thought to be free of extra- METHODS: Immunohistochemical hENT1 expression was Poster Abstracts pancreatic disease and offered resection, 21 (17%) had met- analyzed in 19 resected pancreatic cancer patients received astatic disease, and 66 (53%) were deemed locally advanced gemcitabine-based adjuvant chemotherapy. Relation- Sunday and referred for neoadjuvant therapy. PET and CT/MRI were ships between various clinicopathological factors includ- concordant in 108 (88%) cases, however metastatic lesions ing hENT1 expression and patient survival were examined were identifi ed in 7 (5.6%) patients deemed resectable by using univariate and multivariate analysis. CT or MRI. Among those offered immediate resection, 5 RESULTS: Sixteen (84%) patients highly expressed hENT1. (14%) patients had occult metastatic disease identifi ed at Patients with low expression of hENT1 showed signifi cantly diagnostic laparoscopy, including 3 previously identifi ed by worth outcome than high expression group [2-year survival: nonconcordant PETs and 2 missed by false negative PETs. 0% for low expression group vs. 60% for high expression False positive PETs led to unnecessary procedures delaying group; HR 8.72, 95% confi dence interval (CI) 1.70–44.76, p surgery for 3 (8.3%) patients who went on to resection. In a = 0.009] (Figure), although low hENT1 expression was not cohort of patients thought to be free of metastatic disease, independent prognostic factor by multivariate analysis (HR in terms of detecting metastases, overall sensitivity and 4.41, 95% CI 0.71–27.39, p = 0.111). Other prognostic fac- specifi city of PET were 89.3% and 85.1%, respectively, com- tor was only AJCC stage [2-year survival 0% (III, IV) vs. 64% pared with 62.5% and 93.5% for CT and 61.5% and 100.0% (I, II), HR 6.24, 95% CI 1.35–28.85, p = 0.0192]. Tumor size, for MRI. Positive predictive value and negative predictive lymph node metastasis, and residual tumor (R1 vs R0) did value of PET were 64.1% and 96.4% respectively, compared not reach signifi cant prognostic factor, although the trend with 75.0% and 88.9% for CT and 100.0% and 91.9% for was observed. MRI. Average difference in maximum SUV of resectable and unresectable lesions was not statistically signifi cant (5.65 CONCLUSIONS: Low expression of hENT1 strongly indi- vs. 6.5, p = 0.224), nor was maximum SUV a statistically cated worth outcome of patients treated with adjuvant signifi cant predictor of survival (p = 0.18). gemcitabine-based chemotherapy after pancreatic resec- tion. Gemcitabine-based adjuvant chemotherapy may be useful for only high expression of hENT1. The new adju- vant chemotherapy except gemcitabine might be necessary for patients with low expression of hENT1.

91 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1645 central or total pancreatectomy. The median sCr value was 0.86 (0.30–14.1). 18 patients (1.7%) had severe CKD and 31 The Effect of Preoperative Renal Insuffi ciency on patients (2.9%) had sCr ≥ 1.8. Complications occurred in Postoperative Outcomes Following Pancreatic 622 patients (58.6%), major complications in 198 (18.7%), Resection: A Single Institution Experience of 1061 and respiratory failure in 48 (4.5%). Both severe CKD and Consecutive Patients sCr ≥ 1.8 were associated with any complication, major complications, and respiratory failure on UV analysis. On Malcolm H. Squires1, Vishes V. Mehta1, Sarah B. Fisher1, 1 1 2 MV analysis, severe CKD was associated with increased Neha L. Lad , David Kooby , Juan M. Sarmiento , complications (HR 5.5; 95% CI: 1.3–25.5; p = 0.02) and 1 1 1 Kenneth Cardona , Maria C. Russell , Charles A. Staley , respiratory failure (HR 6.1; 95% CI: 1.8–20.5; p = 0.03), Shishir K. Maithel1 but not major complications. Using sCr ≥ 1.8 as a surro- 1Department of Surgery, Division of Surgical Oncology, Winship gate marker for renal insuffi ciency, patients with sCr ≥ 1.8 Cancer Institute, Emory University, Atlanta, GA; 2Department of had increased risk of any complication (HR 3.5; 95% CI: Surgery, Division of General and GI Surgery, Emory University, 1.3–9.3; p = 0.01), major complications (HR 2.2; 95% CI: Atlanta, GA 1.04–4.8; p = 0.04), and respiratory failure (HR 4.7; 95% CI: 1.8–12.6; p = 0.002, Table). Among patients undergoing BACKGROUND: Chronic kidney disease (CKD) is known Whipple, sCr ≥ 1.8 remained associated with any complica- to adversely affect outcomes after cardiac and vascular sur- tion (HR 3.6; 95% CI: 1.03–12.9, p = 0.05) and respiratory gery. We examined the effect of preoperative renal insuf- failure (HR 3.9; 95% CI: 1.2–12.8; p = 0.03), and demon- fi ciency on postoperative outcomes following pancreatic strated a trend towards increased major complications (HR resection. 2.3; 95% CI: 0.9–6.0; p = 0.10). Among patients undergo- METHODS: All patients who underwent pancreatic resec- ing distal pancreatectomy, sCr ≥ 1.8 demonstrated a trend tion at a single institution between 1/2005 and 7/2012 were towards increased complications (HR 6.8; 95% CI: 0.8–54.6; identifi ed. Creatinine clearance (CrCl) was estimated by the p = 0.07), was not prognostic for major complications, but MDRD (Modifi cation of Diet in Renal Disease) formula. remained a signifi cant risk factor for respiratory failure (HR Severe CKD was defi ned as CrCl < 30 mL/min (CKD stages 15.4; 95% CI: 2.2–106.3; p = 0.006). 4–5). Renal function also was analyzed by using serum cre- CONCLUSION: Few patients with signifi cant renal insuf- atinine (sCr) dichotomized at 1.8 mg/dL. Primary outcomes fi ciency are operative candidates for pancreatic resection. were any complication within 30 days, Clavien Class III-V Severe CKD (stages 4–5) is associated with increased risk of major complication, and respiratory failure. Multivariate complication and respiratory failure, but may be of limited (MV) models for each endpoint were constructed by includ- clinical utility. Serum creatinine ≥1.8 mg/dL may serve as a ing all variables with a p-value ≤0.1 on univariate (UV) useful surrogate marker of renal insuffi ciency and identifi es analysis. patients at signifi cantly increased risk of any complication, RESULTS: 1061 patients were identifi ed; 709 underwent major complication, and respiratory failure after pancreatic pancreaticoduodenectomy (Whipple), 307 distal, and 45 resection.

Multivariate Analysis of all Pancreatic Resections (n = 1061)

Any Complications Major (Clavien III-V) Complications Respiratory Failure Variable HR (95% CI) p–value Variable HR (95% CI) p–value Variable HR (95% CI) p–value sCr 1.8 3.5 (1.3–9.3) 0.01 sCr 1.8 2.2 (1.04–4.8) 0.04 sCr 1.8 4.7 (1.8–12.6) 0.002 Age 1.01 (1.001–1.02) 0.04 Age 1.01 0.10 Age 1.02 0.17 (0.99–1.02) (0.99–1.05) HTN 1.1 (0.9–1.5) 0.41 HTN 1.3 (0.9–1.8) 0.17 HTN 1.4 (0.7–2.7) 0.35 Intra-op transfusion 1.8 (0.9–3.4) 0.06 Intra–op transfusion 1.8 (0.9–3.3 0.07 Intra–op transfusion 2.2 (0.8–6.0) 0.12 Male gender 1.4 (1.1–1.9) 0.01 COPD 2.3 (1.03–5.3) 0.04 Pre-op biliary stent 1.4 (1.1–1.9) 0.01 Albumin <3 2.1 (1.2–3.9) 0.02 Intra-op drain placement 1.5 (1.1–1.9) 0.003 HR, hazard ratio; CI, confi dence interval; sCr, serum creatinine (in mg/dL); HTN, hypertension.

92 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1647 CONCLUSION: Clinical factors affecting survival were pre- operative abdominal pain and hypertension. Intraoperative Clinicopathologic Features Infl uencing Survival in factors affecting survival were EBL and the need for blood Patients with Resected Pancreatic Adenocarcinoma transfusions. The only pathological factor affecting survival by Pancreaticoduodenectomy was LNR. Finally, an uncomplicated postoperative course Cynthia Weber1, Eileen Bock1, Michael G. Hurtuk1, was positively correlated with survival. Gerard Abood1, Margo Shoup2, Jack Pickleman1, Gerard V. Aranha1 Su1648 1 Surgical Oncology, Loyola University Medical Center, Maywood, IL; A Comparison of the 2-Year Longitudinal Impact of 2 Surgery, Cadence Health, Winfi eld, IL Surgical Versus Endoscopic Pancreatic Pseudocyst OBJECTIVE: To determine clinicopathological features Drainage on Healthcare Utilization and Morbidity that infl uence survival in patients with resected pancreatic Jennifer M. Whittington, Scott D. Stevens, Daniel L. adenocarcinoma. Davenport, Austin Ward, Andrew C. Bernard, Shaun P. Mckenzie METHODS: A retrospective review of a prospective data- University of Kentucky, Lexington, KY base was conducted for patients undergoing pancreatico- INTRODUCTION: Previous reports have concluded that duodenectomy for pancreatic adenocarcinoma at a single endoscopic drainage (endo) of pancreatic pseudocysts has institution from December 1993 to December 2010. Clini- an advantage over surgical cystgastostomy (open) in terms copathologic features and cancer related outcomes were of both costs and morbidity. No study to date has looked collected. The cohort was then analyzed for clinicopatho- longitudinally at the overall benefi t of these two strategies. logical features infl uencing survival at 6 months, 1 year, 3 The purpose of our study was to compare 2-year resource years, and 5 years. utilization and morbidity between endo and open treat- RESULTS: A total of 246 patients underwent pancreatico- ment of pancreatic pseudocyst. duodenectomy for pancreatic adenocarcinoma. The cohort METHODS: This study is a single center retrospective case was comprised of 128 males (52%) and 118 females (48%), review of patients treated between September 2004 and with a median age of 68 years. Median operative time was December 2011 for pancreatic pseudocyst. We extracted 6.25 hours with a median blood loss of 800 cc. Median hos- clinical data from the initial procedure related admission pital length of stay was 8 days. A total of 7 patients (2.8%) along with post-procedure emergency department (ED) required re-operation and 9% of patients were readmitted visits and hospital readmissions for up to two years. We within 30 days for postoperative issues. The 30-day mortal- calculated a composite morbidity scale ranging from 1) no ity rate was 2.4% (n = 6).

intervention to 2) minor intervention (antibiotics), 3) read- Poster Abstracts There was a total of 101 associated complications in the mission, 4) repeat procedure or ICU care, to 5) death. Fish-

postoperative period, with grade 3 or less accounting for er’s exact tests, t tests and Mann-Whitney U tests were used Sunday 79% of the observed complications, based on the Dindo/ to compare characteristics between the two groups where Clavien complication scoring system. In regards to pan- appropriate. creaticoduodenectomy specifi c complications, 29 (11.8%) RESULTS: We identifi ed 45 patients who had undergone experienced delayed gastric emptying, 17 (6.9%) developed drainage procedures, 17 endo and 28 open. Three endo an anastomotic leak, with ISGPF grade A/B accounting for patients who required conversion to open were classifi ed as the majority of leaks observed (6%). Overall survival of the endo by intention to treat. Median follow up for the study cohort was 85%, 63%, 25%, and 15% at 6 months, 1 year, was 24 months. The two groups had similar etiologies, age, 3 years, and 5 years respectively, with a median survival of gender and clinical risks (table). The open group had more 17 months. multicysts and cysts with debris on imaging, but not sig- Using multivariate logistic regression, clinical factors that nifi cantly so. There was a trend toward more gastric varices infl uenced survival were abdominal pain and preoperative in the endo group (29.4% vs. 7.1%, P = .09) but venous HTN, where the presence of pain preoperatively negatively thromboses were similar in both groups (58.8% vs. 57.1%). correlated with survival at 3 years (p = 0.021), and the pres- While initial morbidity was higher in the open group, read- ence of preoperative hypertension was negatively correlated mission occurred more than twice as often in endo patients with survival at 6 months, 3 years, and 5 years (p = 0.012, (70.6% vs. 32.1%, P = .02) and total 2-year hospital days p = 0.013, p = 0.019). Intraoperative estimated blood loss did not differ signifi cantly in the two groups (p = 0.23). (EBL) showed a negative correlation with survival at 3 years There was a trend towards increased procedural readmis- (p = 0.02), and the need for intraoperative blood transfu- sions in the endo group (p = 0.07). In the open group, two sion was negatively correlated with survival at 3 years and patients required subsequent repair of ventral hernias and 5 years (p = 0.012 and p = 0.019). The only pathologic fac- one patient required two surgeries for postoperative vari- tor to have a negative impact on survival was lymph node ceal bleeding. In the endo group three patients required ratio (LNR), which correlated with decreased survival at repeat percutaneous drainage and one required repeat endo 6 months, 1 year, and 3 years (p = 0.033, p = 0.035, p = drainage in addition to the three conversions to open men- 0.01). Those who had no postoperative complications had tioned above. higher odds of being alive at 6 months (p = 0.002)

93 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Patient Characteristics, Imaging and Outcomes insuffi ciency, representing fat absorptive disturbance was defi ned as percent of cumulative 7-hour 13CO2 exhalation Variable Endo Open P-value (% dose 13C cum 7 h) <5%. Relationship with histological No. Patients 17 28 degree of islet cells at cut margin and postoperative HbA1c Male/Female 11/6 20/8 0.74 alteration were analyzed. In this study, diabetic patients Mean age, y (S.D.) 47.2 (11.3) 50.3 (13.7) 0.42 were identifi ed as treatment with insulin or oral hypoglyce- Current Smoker, Diabetes, COPD 13 (76.5%) 25 (89.3%) 0.40 mic medications or HbA1c level ≥ 6.9% (NGSP). and/or Cardiac History RESULTS: Preoperatively, 14 patients (35%) were diabetes Etiology 1.00 and 26 patients (65%) were non-diabetes. In non-diabetes Anatomic 8 (47.1%) 14 (50.0%) 26 patients, 12 patients (46%) developed impaired glucose EtOH 8 (47.1%) 11 (39.3%) tolerance within one year after DP. 8 patients were adminis- Other (HLD/Trauma) 1 (5.9%) 3 (10.7%) trated oral hypoglycemic medications, one patient needed Imaging insulin treatment and other 3 patients were not adminis- Venous Thrombosis 10 (58.8%) 16 (57.1%) 1.00 trated any medication. Differences in % dose 13C cum 7 Gastric Varices 5 (29.4%) 2 (7.1%) 0.09 h were not signifi cantly between patients with DP (9.7 ± Multiple Cysts 2 (11.8%) 9 (32.1%) 0.29 3.2%) and healthy controls (13.3 ± 5.9%). No healthy con- Debris in Cysts 8 (47.1%) 18 (64.3%) 0.35 trols had pancreatic exocrine insuffi ciency if the diagno- Outcomes sis was based on a % dose 13 C cum 7 h less than 5%. In Readmitted 12 (70.6%) 9 (32.1%) 0.02 patients after DP operation, only one patient was 5% % Procedural Readmission (s) 7 (41.2%) 4 (14.3%) 0.07 dose 13 C cum 7 h less than 5%. In the 26 pre-OP non-DM ED visit (s) 5 (29.4%) 3 (10.7%) 0.23 patients the average percentage of islet cells at cut margin Total Hospital Days Overall, 13.6 (18.0) 19.7 (39.7) 0.49 was signifi cantly lower in the post-OP DM group than in mean (S.D.) the post-OP non-DM group (1.5 ± 0.7% vs 3.5 ± 1.5%, P = Median Morbidity Score 4 (1.5–4) 2 (1–4) 0.24 0.01). The average area ratio of islet cells at cut margin was (Interquartile Range) correlated with postoperative HbA1c level (P = 0.025). CONCLUSION: Differences of fat absorptive function were CONCLUSIONS: While endoscopic drainage of pancre- not signifi cant between patients with DP and healthy con- atic pseudocysts may result in less initial procedure related trols. Perioperative histological degree of islet cells at cut morbidity and length of stay, it is associated with increased margin is predictive of glucose metabolism insuffi ciency readmissions, increased procedure related admissions due after distal pancreatectomy (DP). to treatment failure and does not provide signifi cant benefi t in overall hospital days when compared to surgical drain- Su1650 age. Further studies are necessary to select which patients are optimal candidates for each approach. Preoperative Prediction of the “High-Risk Pancreas” by Artifi cial Neuronal Network Analysis of over 450 Su1649 Pancreatoduodenectomies Hryhoriy Lapshyn1, Frank Makowiec1, Dirk Bausch1,2, Histological Degree of Islet Cells at Cut Margin Ulrich T. Hopt1, Tobias Keck1,2, Ulrich Wellner1,2 Indicates Postoperative Glucose Metabolism 1Clinic for General and Visceral Surgery, University of Freiburg Medical Insuffi ciency After Distal Pancreatectomy Center, Freiburg, Germany; 2Surgery, University Hospital of Schleswig- 1,2 2 2 Masahiko Morifuji , Yoshiaki Murakami , Kenichiro Uemura , Holstein Campus Lübeck, Lübeck, Germany Takeshi Sudo2, Yasushi Hashimoto2, Taijiro Sueda2, Akio Sakamoto1 INTRODUCTION: Pancreatoduodenectomy (PD) has 1Internal Medicine, Sanmu Medical Center, Chiba, Japan; 2Surgery, become a standard operation with low mortality in high- Hiroshima University, Hiroshima, Japan volume centers, however perioperative morbidity remains BACKGROUND: Pancreatogenic diabetes after pancre- substantial, mainly due to postoperative pancreatic fi stula atectomy is of growing importance due to the increasing (POPF). Development of preoperative protective measures life expectancy of pancreatectomized patients. This study is hampered by a lack of strictly preoperative risk stratifi ca- aimed to investigate whether perioperative histological tion. Predictive power of single parameters can be enhanced degree of islet cells at cut margin are predictive of endocrine by optimally weighed combination of risk factors in an arti- pancreatic function after distal pancreatectomy (DP). fi cial neuronal network (ANN). MATERIALS AND METHODS: This study included con- METHODS: A panel of clinical and radiological parameters secutive 40 patients who underwent distal pancreatectomy were assessed retrospectively from patients with pancreato- (DP). The percent of islet cells of each pancreas was deter- duodenectomy in our institution and risk factors analysis mined via histological examination of resected specimen at for the endpoint POPF (clinically relevant Grade B/C of pancreatic cut margin. Pre and postoperative HbA1c levels ISGPS defi nition) were identifi ed. Preoperatively available were measured in blood samples to assess postoperative glu- parameters were used for prediction of a high risk pancreas cose metabolism insuffi ciency. For assessing post operative in an ANN. Internal validation of the thereby identifi ed risk fat absorptive function after DP, non-invasive 13C-mixed group was performed by testing for POPF and other rele- triglyceride breath test (13C-MTG-T), labeled long chain vant complications. triglyceride mixture was performed. Pancreatic exocrine

94 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: A total of 471 patients with PD operated from colonization in the surgical drain. In the patients without 2001 to 2012 were included. Out of twelve clinical and bacteria in surgical drain, only 1% of the patients devel- radiological risk factors for POPF B/C, the most powerful oped CR-POPFs, while 29% of the patients with bacteria in was a soft pancreas. When an ANN was trained to predict a surgical drain developed CR-POPFs (p < 0.01). Moreover, in soft high-risk pancreas, correct prediction was achieved in the patients without hyperamylasemia and no bacterial col- 83% in the test group. Patients predicted to have a high- onization in the surgical drain, no patients developed CR- risk pancreas had a signifi cantly higher rate of POPF and POPF, while 60% of the patients with CR-POPF had both severe complications compared to the low-risk group (POPF hyperamylasemia and bacterial colonization in the surgical B/C (38% vs 8%, p = 0.000), intraabdominal abscess (23% drain (p < 0.01). vs 10%, p = 0.000), severe complications (26% vs 13%, p CONCLUSION: Bacterial infection in addition to activa- = 0.003), severe postpancreatectomy hemorrhage (18% vs tion of pancreatic enzyme around the pancreatico-enteric 6%, p = 0.012)), as well as a fi ve-fold elevated mortality (5% anastomosis might play an important role in the patho- vs 1%, p = 0.034). genic mechanism of CR-POPF after PD. Prevention of post- CONCLUSION: Clinical and radiological parameters com- operative pancreatitis of remnant pancreas with infection bined in an ANN model can correctly predict a high-risk pan- control might be an area of focus for reducing the incidence creas and severe complications already before the operation. of CR-POPF after PD.

Su1651 Su1652 Activation of Pancreatic Enzyme Plus Bacterial Evolution of the Treatment of Gastroduodenal Artery Infection Plays an Important Role in the Pathogenic Pseudoaneurysms and Mesenteric Arterial Hemorrhage Mechanism of Clinically Relevant POPF After Following Pancreaticoduodenectomy Pancreaticoduodenectomy Joseph Chen1, Laura Findeiss2, Aram N. Demirjian1, Kenichiro Uemura, Yoshiaki Murakami, Takeshi Sudo, David K. Imagawa1 Yasushi Hashimoto, Naru Kondo, Naoya Nakagawa, 1Surgery, University of California-Irvine, Orange, CA; 2Radiology, Hayato Sasaki, Kenjiro Okada, Hiroki Ohge, Taijiro Sueda University of California-Irvine, Orange, CA Surgery, Hiroshima University, Hiroshima, Japan INTRODUCTION: Postoperative mortality in high vol- BACKGROUND: Postoperative pancreatic fi stula (POPF) ume centers for pancreaticoduodenectomy (Whipple) has after pancreaticoduodenectomy (PD) is relatively common, decreased to less than 4%. Late postoperative bleeding and remains a major cause of morbidity and surgical mor- occurs in 0.5–5% of cases, with reported mortality rates of tality. However, the underlying pathogenic mechanism of up to 60%. Poster Abstracts POPF, with the exception of technical error, still remains PATIENTS/METHODS: This is a retrospective analysis of unclear. We previously reported that postoperative pancre- 313 patients who underwent pancreaticoduodenectomy Sunday atitis after PD plays an important role in the pathogenic from 2003–2012 at our institution, a high-volume, multi- mechanism of POPF after PD. We hypothesized that the disciplinary hepato-pancreato-biliary center. The main out- bacterial infection in addition to the activation of pancre- come measure was mortality. atic enzyme around the pancreatico-enteric anastomosis could be associated with occurrence of clinically relevant RESULTS: From 2003–2012, 10 out of 313 patients (3%) POPF (CR-POPF) after PD. presented with delayed major hemorrhage following pan- creaticoduodenectomy, occurring between postoperative OBJECTIVES: We retrospectively analyzed the possible days 6–18. Visceral arteries known to be affected were the association of postoperative pancreatitis, bacterial coloni- gastroduodenal artery (GDA) (4), hepatic artery (3), and zation in the surgical drain, and CR-POPF after PD using the pancreaticoduodenal artery (1). 5 patients presented prospectively collected data base. with gastrointestinal hemorrhage and 5 patients presented METHODS: 250 consecutive patients undergoing PD were with hemoperitoneum. 1 patient underwent immediate included. All patients were administered prophylactic anti- operative intervention, 2 patients underwent immediate biotics, which were selected based on perioperative bile cul- operation followed by percutaneous intervention by inter- tures. POPFs were diagnosed by International Study Group ventional radiology (IR). Immediate IR intervention was Pancreatic Fistula (ISGPF) criteria. Hyperamylasemia was performed in 7 patients. Mortality from GDA/visceral arte- defi ned as serum amylase more than 3 times the upper limit rial hemorrhage occurred in 1 patient (10%). of the reference value. Closed suction drains were inserted CONCLUSION: Delayed mesenteric arterial hemorrhage along the pancreatico-enteric anastomosis, and surgical following pancreaticoduodenectomy requires early recogni- drains were examined bacteriologically when they were tion and management. The mortality rate in our early expe- removed. rience with immediate operative intervention was 33%. A RESULTS: Of 250 patients, 23% developed POPF; Grade modifi ed operative technique led to preservation a long A in 16%, Grade B in 6%, and Grade C in 1%. A total of GDA stump and use of a large metallic clip as a radiographic 32% of the patients had hyperamylasemia on postopera- marker/guide. This was found to aid in easier and quicker IR tive day (POD) 1, and the presence of hyperamylasemia localization and coiling or stenting of the bleeding vessel. on POD1 was closely associated with the development of The mortality rate has decreased to 0% in patients undergo- POPF (p < 0.01). A total of 43% of the patients had bacterial ing immediate IR intervention.

95 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1653 Su1655 Trends in Pancreatic Surgery: Indications, Operative Is Frozen Section Histopathology of Any Value in Techniques and Postoperative Outcome of 1120 Patients Undergoing Resection of Intraductal Papillary Pancreatic Resections Mucinous Neoplasms? Frank Makowiec, Tobias Keck, Ulrich ADAM, Hartwig Riediger, Daniel Joyce, Gavin A. Falk, Kevin M. El-Hayek, Sricharan Uwe A. Wittel, Ulrich F. Wellner, Ulrich T. Hopt Chalikonda, Gareth Morris-Stiff, Matthew Walsh Department of Surgery, University of Freiburg, Freiburg, Germany Department of General Surgery, Section of Surgical Oncology/HPB, Low mortality rates after pancreatic resection (PaRes) have Cleveland Clinic Foundation, Cleveland, OH been reported by many centers. Hospital volume, sur- INTRODUCTION: Intraductal papillary mucinous neo- geon volume and adequate management of complications plasms (IPMN) are cystic lesions of the pancreas that follow are factors contributing to a better outcome. The aim of a step-wise dysplastic sequence from adenoma to invasive our study was to evaluate trends in indications, operative adenocarcinoma. Obtaining a frozen section (FS) at the time techniques and postoperative outcome in more than 1100 of pancreatic resection could be important to determine PaRes performed in our institution since 1994. whether additional resection of the remnant is required. METHODS: 1120 PaRes were performed since 1994. The The aim of this study is to report the correlation between FS vast majority of the operations was performed by three of the pancreatic neck and fi nal histopathology for patients surgeons. The perioperative data were documented in a with IPMN including those with IPMN carcinomas. pancreatic database. For our analyses the study period was METHODS: The departmental pancreatic cyst database subclassifi ed into three periods (A 1994–2001/n = 363; B was interrogated to identify all patients with a histopatho- 2001–2006/n = 305; C since 2007/n = 452). logical diagnosis of IPMN with or without pancreatic ade- RESULTS: 81% of the PaRes were personally performed by nocarcinoma arising from within the IPMN. The degree one of the 3 principal surgeons. The average annual number of dysplasia on the fi nal pathology report was classifi ed as of PaRes increased from 52 (period A) to 80 (C; n = 107 in high (HGD), moderate (MGD), or low (LGD. Frozen section 2011). The median age increased from 51 (A) to 65 years (C; results were reviewed with particular reference to identifi - p < 0.001). In the entire group (n = 1120) indications for sur- cation of invasive carcinoma or high-grade dysplasia and gery were pancreatic/periampullary cancer (49%), chronic these fi ndings were compared to fi nal histopathological pancreatitis (CP; 33%) and various other lesions (18%). The fi ndings, and related to patient outcome. percentage of PaRes for CP decreased from over 50% in period RESULTS: During the period January 2000 to December A to 17% (C; p < 0.01). In contrast the frequency of IPMNs 2011, 121 patients underwent resection, consisting of 41 increased from below 1% (A) to 8% (C; p < 0.05). About two patients with an invasive carcinoma and 80 with IPMN thirds of the operations were pancreaticoduodenectomies alone: HGD [n = 18]; MGD [n = 14]; and LGD [n = 48] (most PPPD). Due to the lower numbers of operations for CP (on fi nal pathology). There were 70 females and 51 males the rates of duodenum-preserving resections decreased from with a median age of 68 years (IQR: 58–73). Of the patients 18% (A) to 4% (C; p < 0.05). A more aggressive approach with IPMN carcinomas, 36 (88%) had a FS. Carcinoma or in some patients with cancer and more resected IPMNs led HGD was seen at the transaction margin on FS in 4 patients to an increase in total pancreatectomies during the study undergoing pancreatoduodenectomy leading to 4 extended period from 1% (A) to 6% (C). The frequency of mesenterico- resections, 2 of which were total pancreatectomies. There portal vein resections increased from 8% (A) to 20% (C; p < was 1 false-positive for invasive cancer that was found to 0.01). Distal resections were performed in 17%. Laparoscopic be non invasive on fi nal pathology and 1 false-negative for pancreatic head and distal resections were introduced by one HGD/invasive carcinoma on frozen section that was found surgeon in period C and were performed in 4.7% of all cases to be an invasive cancer on fi nal pathology. For those with (12% of the cases in period C). Overall mortality was 2.4% IPMN alone, 64 had frozen section analysis performed. and comparable in the 3 periods (2.8%, 2.0%, 2.4%; p = 0.8). None had carcinoma/HGD at the transection margin on FS The 3 principal surgeons in our series also had comparable or on subsequent histopathology. 3 patients in this group mortality rates (1.9–3.4%; p = 0.41). Overall complication died of IPMN-related carcinomas in their remnant pan- rates increased from 42% (A) to 56% (C; p < 0.01). The rate creas. 2 had HGD on their initial resection and 1 had only of pancreatic leak grade B/C also increased from 5% (A) to LGD, and all developed the subsequent cancers away from 12% (C; p < 0.01) but the frequencies of relaparotomies were the transaction margin. comparable (10–14%; n.s.) CONCLUSIONS: Frozen section analysis allows identifi ca- CONCLUSIONS: Operative mortality in our high-volume tion of foci of carcinoma or HGD at the transection margin institutional series of more than 1100 pancreatic resections during pancreatic resection for IPMN that should result in was low throughout the study period. Mortality remained further resection. However, the development of progressive low despite a more aggressive surgical approach to (malig- disease in the pancreatic remnants of patients without ini- nant) pancreatic disease (more extended resections, more tial evidence of carcinoma means that radiological surveil- vein resections, older patients). An increased overall mor- lance is required for this cohort. bidity may be explained by more clinically relevant pan- creatic fi stulas (more patients with soft pancreas) and better documentation (many patients in randomized studies after period A).

96 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1656 Su1657 Endoscopic and Surgical Alternatives to Central Pancreatic Resection Pancreaticoduodenectomy and Distal Pancreatectomy Vichin Puri, Vijay G. Menon, Alagappan Annamalai, Jennifer K. Plichta, Eileen Bock, Michael G. Hurtuk, Nicholas N. Nissen Gerard Abood, Gerard V. Aranha Hepatobiliary and Pancreatic Surgery, Cedars-Sinai Medical Center, Surgery Department, Loyola University Medical Center, Maywood, IL Los Angeles, CA PURPOSE: While standard resections such as pancreati- INTRODUCTION: Central pancreatectomy (CP) is an coduodenectomy and distal pancreatectomy are necessary uncommon technique used to treat select pancreatic for malignant disease, low grade tumors and benign lesions pathology. We evaluated the utility and safety of CP over a of the pancreas and duodenum present a unique surgical 10 year time span at a single institution. dilemma. Select patients may benefi t from non-standard METHODS: Review of prospective database (single sur- resections (NSR) which preserve parenchyma and function, geon) from 2003–2012. CP comprised 9% of all pancreatic and thus may avoid the potential complications inherently resections during this period (total of 310). related to more traditional resections. Here, we describe our experience with NSR of various pancreatic and duodenal RESULTS: Thirty patients underwent CP for diagnoses lesions. including neuroendocrine tumor (n = 12), cystic neoplasm (n = 9) and benign stricture (n = 9). Distal pancreatic con- METHODS: A retrospective review of a prospectively col- tinuity was established by pancreaticogastrostomy (n = 7), lected database of 777 patients who underwent resections pancreaticojejunostomy (n = 13), dual pancreaticoenteros- of pancreatic and duodenal lesions between 1999 and tomy (n = 9) or primary pancreatico-pancreatostomy (n = 2012 was conducted. Of these, 45 patients underwent NSR, 1). Major complications were limited to 4 patients (13%) defi ned as pancreatic or duodenal resections excluding stan- who required re-laparotomy or percutaneous drainage. Five dard pancreaticoduodenectomy or distal pancreatectomy. patients (17%) developed postoperative pancreatic fi stu- Clinicopathologic features and outcomes were assessed. lae, of which 3 (10%) were ISGPF grade B/C. There was no RESULTS: In sum, 26 males and 19 females were evaluated; peri-operative mortality. At mean follow-up of 29 months, median age 64 years (range 30–87) and median follow-up no patients have developed recurrent tumor. Two patients 4.4 years (range 0.3–13.3 years). Preoperatively, 32 patients (7%) developed diabetes and no patient has exocrine insuf- underwent EGD, 33 EUS, and 39 CT scans. The median fi ciency. The frequency of CP has remained constant over lesion size was 2.3 cm (range 0.7–9 cm). The various types the study time period, but patients operated in the more of NSR included: 16 pancreas-sparing duodenectomies, 9 recent 5-year period were more likely to have more proxi- central pancreatectomies, 9 enucleations, 6 ampullectomies, mal pathology (pancreatic head) and to undergo dual pan- Poster Abstracts 4 transduodenal polypectomies, and 1 endoscopic polypec- creatic anastomosis (Figure).

tomy. The fi nal pathologic diagnoses included: 12 villous Sunday adenomas, 7 neuroendocrine tumors, 5 mucinous cystad- enomas, 5 stromal tumors, 4 duodenal carcinomas, 3 serous cystadenomas, 3 tubular adenomas, 2 lymphoepithelial cysts, 2 IPMNs, and 2 other pathologies. EUS was 100% accurate in predicting depth of mucosal invasion, while EGD and CT were 100% accurate in identifying the lesion location. Furthermore, the overall accuracy of pre-operative imaging in selecting appropriate patients amenable to NSR was 100%. Overall, fi ve patients developed post-procedure complications (10.9%). Of the central pancreatectomies (n = 9), three developed pancreatic fi stulas (33%), although no patients developed diabetes or steatorrhea. One patient had a subsequent episode of pancreatitis following ampullec- tomy, and one developed a pancreatic pseudocyst requiring endoscopic drainage following enucleation. There were no peri-operative mortalities. Of the four patients with duo- Central Pancreatectomy Managed with Dual Pancreatic-Enteric denal carcinomas, all underwent pancreas-sparing duode- Anastomosis. nectomy, and the overall survival was 50% at the time of CONCLUSION: Central pancreatectomy is a safe and valu- analysis (deaths occurred at 1.7 and 4 years; follow-up for able option for management of select proximal pancreatic two survivors was 4.1 and 11.7 years). pathology and is associated with a low rate of long term CONCLUSION: Based on our fi ndings, EGD, CT, and EUS endocrine or exocrine insuffi ciency. Pancreatic fi stula and were 100% accurate in selecting appropriate patients for surgical complication rates are signifi cant but not prohibi- NSR. Therefore, proper selection of patients using certain tive. Novel reconstruction techniques such as those applied imaging modalities may allow some patients to achieve on our series may allow greater application of this tech- adequate resection, while avoiding more complicated and nique to more proximal pancreatic lesions. morbid procedures, such as pancreaticoduodenectomy or distal pancreatectomy.

97 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1658 Impact of Pancreatoduodenectomy Complications on Adjuvant Therapy and Long-Term Outcomes for Pancreatic Adenocarcinoma Janak A. Parikh, Tarek Ajam, Attila Nakeeb, Nicholas J. Zyromski, C. Max Schmidt, Eugene P. Ceppa, Henry A. Pitt, Michael G. House Surgery, Indiana University Hospital, Indianapolis, IN BACKGROUND: Postoperative morbidity is associated with poor long-term outcomes for gastrointestinal cancers. The purpose of this study is to determine the extent to which postoperative complications after pancreatoduode- nectomy for pancreatic adenocarcinoma impact adjuvant therapy and overall survival. METHODS: Over a fi ve year period ending December 2009, 310 consecutive pancreatoduodenectomies for adenocarci- noma were performed at a single institution. Retrospective review of a prospective patient database including data on patient, operative, and tumor factors along with postopera- tive Clavien-Dindo (CD) classifi ed complications, receipt of adjuvant therapy, and survival was performed. Associations with overall survival (OS), estimated by the Kaplan-Meier method, were analyzed with log-rank testing. RESULTS: Patients were predominantly male (57%) and Caucasian (96%) with a median age at operation of 66 years (36–96 years). Median operative time was 325 min- utes and median blood loss was 675 mL. Sixty-three percent of patients had lymph node metastasis on fi nal pathology. Thirty-day mortality rate was 3.2%. Major postoperative morbidity, defi ned as CD III-IV complications, were recorded for 40 (13%) patients, while minor complications (CD I-II) occurred in 155 (50%) of patients. Overall, 64% of patients received adjuvant chemotherapy or chemoradiotherapy, of which 5% received neoadjuvant chemoradiotherapy. Adju- vant therapy was administered to 76% of patients with no CONCLUSIONS: Major complications after pancreatoduo- postoperative morbidity versus 63% and 42% of patients denectomy alter plans for adjuvant therapy for pancreatic with minor or major complications, respectively (p = adenocarcinoma. Unlike other gastrointestinal cancers, 0.02). Median OS for the cohort was 18.3 months (0–116 postoperative morbidity is not associated with poor long- months). Improved median overall and 5-year survival (20 term outcomes for pancreatic adenocarcinoma. months and 21%, respectively) for patients with no post- operative morbidity was not signifi cantly different to the survival observed for patients with complications (18.8 months and 18% respectively), p = 0.36 (Figure 1). Median OS and 5-year survival for patients who received adjuvant therapy was 21 months and 18%, respectively, versus 15.5 months and 17% for patient who did not receive adjuvant therapy, p = 0.27 (Figure 2).

98 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1659 Su1660 Impact of Laparoscopic Approach on Postoperative Pain Pre-Operative Lovenox Does Not Increase Blood Loss and Opioid Consumption After Pancreatoduodenectomy During Pancreaticoduodenectomy Compared to Naru Kondo, Michael B. Farnell, Florencia G. Que, Heparin David M. Nagorney, Kaye M. Reid Lombardo, John H. Donohue, Shoichiro A. Tanaka, William C. Conway, Satvik Jhamb, Michael L. Kendrick John S. Bolton Mayo Clinic, Rochester, MN Surgical Oncology, Ochsner Medical Center, New Orleans, LA BACKGROUND: Although laparoscopic approaches are BACKGROUND: Pancreaticoduodenectomy (PD) is a generally considered to result in reduced postoperative lengthy surgical procedure often done for malignancy, pain compared to open approaches, objective evaluation of both risk factors for DVT/PE, which also carries a signifi cant amount of opioid consumption has not been evaluated for bleeding risk. We sought to determine if bleeding compli- pancreaticoduodenectomy. cations were increased with pre-operatively administered AIM: The aim of this study was to investigate if total laparo- Lovenox, a drug given once daily and shown to have excel- scopic pancreaticoduodenectomy (TLPD) results in reduced lent DVT/PE risk reduction, compared with pre-operative opioid consumption over open pancreaticoduodenectomy Heparin. (OPD). METHODS: IRB approved retrospective chart review was METHODS: A single-institutional retrospective cohort undertaken to collect data on all patients undergoing PD study of all patients having undergone pancreaticoduode- from 1/1/08–12/31/11. Data points included demographic nectomy between 2007 and 2010 was performed. Postoper- information, surgical details, and peri-operative outcomes, ative pain was evaluated by calculating opioid consumption focusing on estimated blood loss (EBL) and blood usage. from postoperative day (POD) 1 to POD 5. Five forms of DVT/PE prophylaxis consisted of either 5,000units subcu- narcotic analgesics were used including: morphine, hydro- taneous Heparin or 40 mg subcutaneous Lovenox given morphine, oxicodone, hydrocodone and fentanyl. To allow pre-operatively. comparison, narcotic consumption was converted to mor- RESULTS: The 158 patients undergoing PD had a mean phine equivalents using a standard conversion. Daily and age of 65 (range 40–85), 52% were men, and 11% received total opioid consumption after PD was compared between neoadjuvant treatment. 21.5% of the cases included major the LPD and (OPD) groups. Risk factors for increased total vascular resection, and average BMI was 27.5 (15.2–47). 52% opioid consumption were evaluated using univariate and (82) of the patients had pancreatic adenocarcinoma, 5% (8) multivariate analyses. duodenal adenocarcinoma, and 7% (11) IPMN. There was RESULTS: Five hundred and twelve consecutive patients no difference in mean EBL between the 92 patients receiv- Poster Abstracts (LPD n = 123, OPD n = 390) were included in this study. ing pre-op Heparin (731 + 525 ml) and the 35 patients Six patients (5%) with conversion to OPD were included in receiving pre-op Lovenox (794 + 634 ml, p = 0.58). Bleeding Sunday LPD group based on intent-to-treat. Daily opioid consump- complications and overall blood usage were also not signifi - tion of the LPD group was signifi cantly less than that of cantly different between the 2 groups (p > 0.05). OPD group from POD 2 through POD 5, and total opioid CONCLUSIONS: Pre-operatively administered Lovenox consumption of LPD group was also signifi cantly less (LPD: was not associated with an increase in EBL during PD 5.3 ± 6.4 mg/kg, OPD: 7.3 ± 9.4 mg/kg, P = 0.007). Multivar- compared with Heparin. Overall blood usage was also not iate analysis revealed that younger age (<65 years old) (HR increased. This, along with once daily dosing and improved 1.89, 95% CI 1.29–2.79, P = 0.001), no preoperative diabe- effi cacy make Lovenox and attractive option for DVT/PE tes mellitus (HR 1.74, 95% CI 1.10–2.80, P = 0.01), PD for prophylaxis during PD. chronic pancreatitis (HR 2.87, 95% CI 1.18–7.51, P = 0.02), OPD (HR 2.01, 95% CI 1.26–3.27, P = 0.003) and postop- erative major complication (Grade III-V) (HR 2.30, 95% CI 1.36–3.91, P = 0.001) were independently associated with increased opioid consumption after PD (total opioid con- sumption >6 mg/kg). CONCLUSION: Patients undergoing TLPD have lless opioid consumption compared to those with the open approach. Younger age, absence of diabetes, chronic pancreatitis indi- cation and major postoperative complications are indepen- dent predictors of increased opioid consumption. These fi ndings warrant further evaluation as to the potential clini- cal impact of reduced pain and less opioid consumption on patient-specifi c advantages including early recovery and better quality of life after pancreaticoduodenectomy.

99 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Clinical: Small Bowel CONCLUSION: In CD patients undergoing ileocecal resec- tion, male gender, open surgery, a long course of disease, and low postoperative hemoglobin levels are risk factors Su1661 to develop postoperative complications. Other potential risk factors, such as age, body mass index, low preoperative Risk Factors for Postoperative Complications After protein or albumin levels, the use of steroids or biologicals, Ileocecal Resection in Patients with Crohn’s Disease and NOD2 mutations had no effect on the development of Michael S. Kasparek1, Sophie Zehl1, Mario Mueller1, postoperative complications in the patient group analyzed. Stephan Brand3, Martin E. Kreis2 1Department of Surgery, Ludwig-Maximilians-University Munich, Su1662 Munich, Germany; 2Department of Surgery, Charité, Berlin, Germany; The First Validated Nomogram to Predict 30-Day 3Department of Internal Medicine II, Ludwig-Maximilinas-University Munich, Munich, Germany Mortality Following Surgery for Small Bowel Obstruction BACKGROUND: After colorectal resections, patients with Wissam J. Halabi1, Mehraneh D. Jafari1, Vinh Q. Nguyen2, infl ammatory bowel diseases may develop postoperative 1 1 1 complications. Our aim was to identify specifi c risk factors Joseph C. Carmichael , Steven Mills , Alessio Pigazzi , 1 for postoperative complications in patients who underwent Michael J. Stamos ileocecal resection due to Crohn’s disease (CD). 1Surgery, University of California-Irvine, Orange, CA; 2Statistics, University of California-Irvine, Irvine, CA METHODS: We identifi ed CD patients who underwent ileocecal resection in the time period from 2001 to 2010 OBJECTIVE: Surgery for small bowel obstruction (SBO) is in our hospital’s IBD patient register. Patients’ charts associated with signifi cant mortality and surgeons are being were reviewed for details regarding the type of surgical increasingly faced with complicated cases that have several procedure performed, complications related to the sur- risk factors for fatal outcomes. To date, there have been no gical procedure and the overall peri- and postoperative studies examining the interaction of several risk factors course of the disease. In addition, all patients were geno- and their additive effect on mortality. Our aim was to con- typed for the three main CD-associated NOD2 variants struct a comprehensive and validated model that takes into p.Arg702Trp (rs2066844), p.Gly908Arg (rs2066847), and account all the factors that predict mortality in patients p.Leu1007fsX1008 (rs2066847). undergoing surgery for SBO. RESULTS: 155 CD patients (54% female, age 35 [15–69] DESIGN: Using the ACS-NSQIP database from 2005 to years (median [range]) were identifi ed who underwent 2010, we conducted a retrospective review of SBO cases ileocecal resection. In 63 patients, laparoscopic ileocecal caused by adhesions or incarcerated hernias that under- resection was performed, while 92 patients underwent an went operative management. With 30-day mortality as the open ileocecal resection. 32 minor complications (wound primary endpoint, a predictive model was built using 52 infection: n = 17 (11%); prolonged postoperative ileus: n = presurgical, 8 surgical and 16 postsurgical variables. We 10 (6%); urinary tract infection: n = 5 (3%)) and 34 major split the data into two sets: training set (75%) and a valida- complications (intraabdominal abscess formation: n = 15 tion set (25%). The LASSO algorithm for logistic regression (10%); anastomotic leak: n = 12 (8%); hemorrhage: n = 5 was applied to the training set with 10-fold cross-validation (3%), enterocutaneous fi stula: n = 2 (1%)) occurred in 41 and the 1-SE rule used to select predictive variables. The patients (26%), while 114 patients (74%) had an unevent- ROC curve and the AUC statistic were used to test our mod- ful postoperative course. Open surgery (open surgery in el’s predictive ability. complicated group: 80% vs. open surgery in uncomplicated RESULTS: A total of 17,379 cases of surgical SBO cases were group: 52%; p = 0.002) and male gender (male gender in identifi ed. The cause of SBO was attributed to Adhesions complicated group: 63% vs. male gender in uncomplicated in 74% of cases whereas incarcerated hernia accounted for group: 40%; p = 0.018) were associated with postopera- the remaining 26%. The 30-day mortality was 5.7%. LASSO tive complications. Patients with major complications had identifi ed several predictors of mortality listed in the table. a longer course of CD (8 [0-–31] vs. no complications: 4 The following factors were not found to predict mortality: [0–30] years; p = 0.024), a lower postoperative hemoglo- gender, obesity, smoking, diabetes, emergency surgery, sur- bin level (10.3 ± 0.4 vs. 11.5 ± 0.2 g/dl; mean ± SEM; p gery day, disease type, and the use of laparoscopy. Thirty- = 0.038), and a trend towards a lower postoperative total day mortality can be predicted via the following equation: protein level (3.8 ± 0.3 vs. 5.2 ± 0.4; p = 0.051). Other fac- ex/(1 + ex) where x in the sum of coeffi cients. The predic- tors such as preoperative laboratory results, age, body mass tive model performed well with a high predictive power index, nicotine consumption, use of steroids or biologicals, and an AUC = 0.92. as well as presence of CD-associated NOD2 mutations had no effect on the incidence of postoperative complications (all p = n.s.).

100 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Predictors of Mortality Following Surgery for SBO: Coeffi cients and Su1663 Odds Ratios Serum C-Reactive Protein As Predictor of Recurrence in Coeffi cient Odds Ratios Patients Undergoing Ileo-Colonic Resection for Crohn’s Intercept –6.30 Disease: Results of a Longitudinal Prospective Study Preoperative Factors: ASA V 1.66 5.27 Edoardo Iaculli, Cristina Fiorani, Sara Onali, Giorgia Tema, ASA IV 0.82 2.27 Roberto Pezzuto, Livia Biancone, Rosa Scaramuzzo, Disseminated cancer 0.80 2.24 Khrystyna Porokhnavets, Achille Gaspari, Giuseppe S. Sica Ventilator dependence 0.78 2.18 Tor Vergata, Rome, Italy Septic shock 0.75 2.12 Dialysis dependence 0.40 1.50 BACKGROUND: Previous studies have evaluated the abil- Sepsis 0.38 1.46 ity of biological markers to detect disease relapse in Crohn’s Peripheral vascular disease 0.28 1.32 disease (CD). Yet no studies have targeted a method to BUN > 40 0.24 1.27 anticipate recurrence after surgical resection. C-Reactive Ascites 0.21 1.23 Protein (CRP) is a valuable marker for predicting the out- come of several diseases including CD. The exact role of COPD 0.18 1.19 CRP as a prognostic factor for future recurrence in CD is not Weight loss > 10% 0.08 1.09 yet determined. Moreover no data are available investigat- Age (absolute number 0.04 1.04 ing specifi c CRP modifi cations in these patients following multiplied by coeffi cient) surgery. Pneumonia 0.03 1.03 Creatinine > 1.2 0.02 1.02 OBJECTIVE: of present study was to determine the peri- Hematocrit > 38 0.02 1.02 operative behaviour of the CRP in CD patients undergoing Operative Factors: Bowel 0.51 1.66 elective ileo-cecal resection. Our hypothesis is that peri- Gangrene operative CRP changes are disease-specifi c and therefore Bowel Resection 0.15 1.16 could detect subset of patient with more aggressive disease. Contaminated Case 0.07 1.07 Secondary objective was to investigate the role of CRP as a Postoperative Factors: Shock 1.64 5.18 potential early prognostic marker for future recurrence. CVA 1.05 2.87 METHODS: 52 patients undergoing IC resection for CD Acute Renal Failure 0.90 2.47 were prospectively enrolled. Serial CRP levels were assessed Re-Intubation 0.71 2.03 perioperatively: time 0, postoperative day (POD) 1 and POD Myocardial Infarction 0.64 1.89 6. CD patients’ perioperative CRP fi ndings were compared Poster Abstracts Bleeding 0.17 1.18 against same interval assessments of two control groups Return to OR 0.11 1.12 undergoing right colectomy and appendicectomy. Crohn’s Sunday Failure to wean 0.05 1.06 Disease Activity Index (CDAI) and Rutgeerts’ score (RS) were evaluated for recurrence during 3 year follow-up protocol. Coeffi cients can be added together RESULTS: As expected, in all 3 groups CRP signifi cantly CONCLUSION: This is to date the most powerful and the increased 24 hours after surgery vs baseline but the increase only validated nomogram to predict 30-day mortality fol- was signifi cantly higher in CD patients than in controls lowing surgery for SBO. This model represents an easy-to- (p < 0.001). Comparing to control groups CRP remained use tool for surgeons to risk-stratify and counsel patients remarkably high in CD (mean 32.2 mg/L) at POD 6. Dif- and can be used as a quality outcome measure. Implement- ference between groups was statistical signifi cant (p 0.03). ing strategies to modify certain risk factors may lower mor- All CD patients evaluated at 3 year follow up were in clini- tality in surgical SBO cases. cal remission. Endoscopic recurrence (RS > 2) was found in 51% at 1 year and in 42% at 3 years. Possible relation between endoscopic recurrence rate or severity and peri- operative CRP levels was investigated: multivariate ordinal regression showed that postoperative increment of CRP is a prognostic factor of recurrence at 3 years. CONCLUSION: Present preliminary data show disease- specifi c perioperative CRP levels for CD patients that refl ect immunomodulation impairment involved in disease eti- ology. The degree of such immunitary change and con- sequent severity of disease might be explored early after surgery by determining CRP alterations. Data from larger series can confi rm that perioperative CRP levels might be considered a novel prognostic factors of surgical recurrence.

101 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Su1664 Su1665 Predictors of Recurrence and Post Recurrence Survival Adenomas of the Ampulla of Vater: A Comparison of in Patients with Resected Ampullary Adenocarcinoma Outcomes of Operative and Endoscopic Resections Irene Epelboym1, Susan Hsiao2, James A. Lee1, Beth Schrope1, Edwin O. Onkendi1, Jordan Rosedahl2, William S. Harmsen2, John A. Chabot1, Helen Remotti2, John D. Allendorf1 Florencia G. Que1 1Surgery, Columbia University Medical Center, New York, NY; 1Surgery, Mayo Clinic, Rochester, MN, Rochester, MN; 2Biomedical 2Pathology, Columbia University Medical Center, New York, NY Statistics and Informatics, Mayo Clinic, Rochester, MN, Rochester, MN BACKGROUND: Ampullary neoplasms are a rare subset of BACKGROUND: Data comparing operative and endo- intestinal cancers, the only treatment for which is complete scopic resection of adenomas of the ampulla of Vater is surgical resection. Controversy exists, however, with regard limited. We reviewed our experience in the treatment of to need for and type of adjuvant therapy. The management adenomas of the ampulla of Vater and compared the opera- approach is even less clear for those patients in whom the dis- tive and endoscopic approaches. ease recurs. In this report, we aim to determine patient and METHODS: Retrospective review of all patients in the gas- histological factors predictive of recurrence, and to describe trointestinal endoscopy and surgical databases treated for the survival experience of those with recurrent disease. adenomas of ampulla of Vater at our institution from 1992 METHODS: Patients who underwent surgical resection for to 2009. Clinicopathologic factors, morbidity, mortality, ampullary adenocarcinoma at our institution were identi- recurrence and survival of patients treated by endoscopic fi ed, and histological diagnosis was confi rmed by inde- and surgical resection were comparatively analyzed. pendent pathologist review. Presenting features, operative RESULTS: A total of 137 patients (mean age 59.3 yrs), characteristics, postoperative outcomes, and overall and were treated for adenomas of the ampulla of Vater; 75 disease free survival were evaluated. Selected resection spec- (55%) males, follow up 91% (mean 4.6 years). The adeno- imens were stained for presence of CK7, CK20, and CDX2 mas were tubular in 55 (40%) patients, tubulovillous in 62 using standard methods. (45%) and villous in 20 (15%). Obstructive jaundice was Continuous variables were compared using Student’s t-test. more common in the operative resection group (p < 0.01)). Categorical variables were compared using chi-square or Endoscopic resection was performed in 100 (73%) patients; Fisher’s exact test. Predictors of recurrence were analyzed operative resection was performed in 37 (27%). Sixty seven using logistic regression. Survival was evaluated using percent of patients required only 1 endoscopic resection Kaplan-Meier method, and differences among groups were [piecemeal resection in 24 (36%)], while 33 (24%) required assessed by log-rank test. 2 or more resections (range 2–5). Patients who underwent RESULTS: Between 1990 and 2011, 79 patients underwent operative resection often had larger tumors >3.6 cm (p < pancreaticoduodenectomy for ampullary adenocarcinoma. 0.001) or intraductal extension (p = 0.04). Intraductal Thirty patients received adjuvant chemotherapy, which was extension and ulceration had no effect on recurrence (p gemcitabine based for 29 (96.6%). Among 74 R0 resections, values = 0.62, 1.0) in both groups. Postoperative compli- there were 24 cases of recurrence over 273 person-years cations occurred in 48% of patients; post-endoscopic com- (median follow-up 28.7 months, median time to recurrence plications in 30% of patients (p = .09). Post endoscopic 8.7 months). Four (16.7%) were in the surgical bed and 20 resection complications included bleeding in 18 (7 required (83.3%) distantly, predominantly in the liver. In univariable transfusion or endoscopic or angiographic intervention); analysis, no single demographic or clinical characteristic, pancreatitis (mild in 11; severe necrotizing in 1); ampul- nor histologic staining pattern, was a statistically signifi - lary obstruction from edema or blood clot in 2 and duode- cant predictor of recurrence. Lymph node positivity was nal perforation in 1. Postoperative complications included signifi cant in univariable but not in multivariable analysis, pancreatic leak (9), surgical site infection (4), anastomotic and pathologic T stage was unassociated with recurrence. leak (3), delayed gastric emptying (2), myocardial ischemia Recurrent disease was managed by surgical resection in 2 or dysrhythmia (2), and renal failure (1). One patient died cases, one local and one metastatic, after which the patients of pancreatic leak with MOSF following operative resection survived 15.8 and 3.4 months, respectively. Fifteen patients of a 6 cm sessile adenoma (mortality of 2%). Endoscopic received chemotherapy (either 5FU or gemcitabine based) resection was associated with a 3-fold higher risk of recur- only. Systemic therapy was not offered to 2 patients. Post- rences than operative resection, 5% of which were invasive recurrence survival was not signifi cantly different among cancers in both groups. Performing 2 or more endoscopic those who had surgery, chemotherapy, or no treatment (8.8 resections for complete tumor removal relative to 1 com- vs 8.0 vs 3.9 months, p = 0.39). Additionally, among those plete initial resection was associated with 5 times higher who received chemotherapy, difference in median post- risk of recurrence (p < 0.001). recurrence survival was not statistically signifi cant in 5FU CONCLUSION: Endoscopic resection of adenomas of compared with gemcitabine groups (16 vs 3.5 months, p = ampulla of Vater is associated with a 3-fold higher recur- 0.107). rence rate than operative resection; recurrences may be CONCLUSIONS: Optimal treatment approach for recur- invasive. There is a 5-fold higher risk of recurrence if 2 or rent ampullary adenocarcinoma remains unclear. Survival more endoscopic resections are needed for complete tumor is equivalent whether surgical resection or systemic chemo- removal as compared to one complete initial resection. therapy is employed, and no single cytotoxic protocol is Operative resection is associated with lower recurrence rates associated with improved outcome. for larger tumors and tumors with intraductal extension.

102 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Su1666 Clinical Outcomes for Neuroendocrine Tumors of the Duodenum and Ampulla of Vater: A Population-Based Study Reese W. Randle, Shuja Ahmed, Naeem A. Newman, Clancy J. Clark General Surgery, Wake Forest Baptist Health, Winston Salem, NC BACKGROUND: Neuroendocrine tumors (NETs) of the duodenum are quite rare representing only 4% of all car- cinoid tumors. Limited single-institution case series indi- cated that ampullary NETs have worse survival than NETs located in the duodenum. The aim of the current study was to evaluate the overall survival (OS) of patients with ampul- lary NETs compared to patients with duodenal NETs using a population based registry. METHODS: We conducted a retrospective comparative cohort study using the Surveillance, Epidemiology, and End Results (SEER) registry from 1988 to 2009. Patients with Su1667 pathology confi rmed NETs of the duodenum and ampulla of Vater were identifi ed, and overall survival was evaluated Laparoscopic vs. Open Bilateral Inguinal Hernia Repair: using Kaplan-Meier estimates and Cox proportional hazard A NSQIP Analysis regression. Multi-variable survival analyses included covari- Muhammad Asad Khan, Roman Grinberg, John Afthinos, ates with p < 0.1 and less than 10% of data missing. Karen E. Gibbs RESULTS: The study cohort included 1360 (92%) patients Staten Island University Hospital, Staten Island, NY with duodenal NETs and 120 (8%) with ampullary NETs. Ampullary NETs were larger (median tumor size 18 vs. 10 OBJECTIVES: Laparoscopic inguinal herniorrhaphy was mm, p < 0.001), higher grade (poorly and undifferentiated introduced into surgical practice in 1990. It has shown a tumor 42% vs. 12%, p < 0.001), and higher SEER historic great deal of promise and was shown to allow quicker and stage (distant metastasis 18% vs. 9%, p < 0.001) than duo- more thorough assessment and repair of bilateral groin denal NETs. Ampullary NETs were also more likely to be hernias. However the evolution of tension-free open repair Poster Abstracts resected (78% vs. 60%, p < 0.001). OS was signifi cantly with mesh allows use of local or regional anesthesia and is worse for patients with ampullary NETs than for patients associated with rapid recovery and a low recurrence rate. We Sunday with duodenal NETs (median OS 98 vs. 143 months; HR sought to compare a large number of patients and compare 1.38, 95% CI 1.02–1.86, p = 0.037). For resected patients national trends and outcomes between these approaches. (n = 878), OS was similar between ampullary and duode- METHODS: The NSQIP database was queried for laparo- nal NETs (median OS 182 vs. 164 months; HR 1.42, 95% scopic or open bilateral inguinal hernia repair. Age, gender CI 0.96–2.09, p = 0.078). Using univariate survival analy- and comorbidities were quantifi ed and outcomes data col- ses, signifi cant predictors for worse OS in resected patients lected. Specifi cally, morbidity, mortality, length of stay and included older age (p < 0.001), larger tumor size (p = 0.035), operative times were examined. Statistical analysis was then higher grade (p < 0.001), higher SEER historic stage (p < performed. A p-value of <0.05 was considered signifi cant. 0.001), and radiation treatment (p = 0.003). After adjust- RESULTS: A total of 4985 patients were identifi ed, of ing for signifi cant predictors of OS, ampullary NETs had sig- which 2025 patients underwent open repair of bilateral nifi cantly worse OS than duodenal NETs (HR 1.63, 95% CI inguinal hernia and 2960 patients underwent laparoscopic 1.05–2.53, p = 0.031). repair. CONCLUSIONS: NETs of the ampulla of Vater are more CONCLUSIONS: Nationally, 59.4% of bilateral hernias advanced at presentation and have worse OS than duode- were repaired laparoscopically. More patients with diabetes, nal NETs. After controlling for signifi cant predictors of OS, HTN and history of CABG underwent open repair. Laparo- tumor location remained an independent predictor of OS scopic and open approaches have a similar complication in resected patients. profi le. Operative time was shorter in the laparoscopic group (75.9 ± 35 vs. 85.2 ± 38.3 min, p < 0.001) as was length of stay (0.18 ± 1.1 vs. 0.409 ± 3.0 days, p < 0.001).

103 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Table 1: Patient Comorbidites neoadjuvant therapeutic concepts (QCGC’07/09) and com- pared to former data obtained in a study with similar design Open Repair Laparoscopic (EGGCS’02) but no neoadjuvant treatment arm. N = 2025 Repair N = 2960 P-Value Male gender 1877 (92.7%) 2825 (95.4%) <.001 RESULTS: From 01/01/2007–12/31/2009, 2,897 patients Diabetes on oral 96 (4.7%) 101 (3.4%) 0.013 from 141 hospitals were enrolled in the study with the Diabetes on Insulin 23 (1.1%) 20 (0.7%) 0.013 following rates (QCGC’07/09 [EGGCS’02: n = 1,139 patients]): Resection (91.2 [87.1]%), gastrectomy (74.5 HTN 742 (36.6) 834 (28.2%) <0.001 [79.8]%), R0-resection (82.8 [82.3]%) explorative lapa- CHF in 30 days 2 (0.1%) 2 (0.1%) 1 rotomy (4.9 [6.3]%), UICC-III/IV (45.2 [41.8]%), hospital History of MI in 6 months 1 (0%) 2 (0.1%) 1 lethality (6.0 [8.3]%) & esophagojejunal anastomotic insuf- Prior PCI 117 (5.8%) 109 (3.7%) .001 fi ciency (6.0 [5.8]%). Prior CABG 123 (6.1%) 105 (3.5%) <.001 PAD 13 (0.6%) 12 (0.4%) 0.308 • After inauguration of multimodal procedures (n = 498; 18%) ESRD 10 (0.5%) 9 (0.3%) 0.350 Smoker 409 (20.2%) 566 (19.1%) 0.363 — the proportion of patients with no or only pallia- Bleeding disorder 46 (2.3%) 34 (1.1%) .003 tive surgical intervention decreased considerably— ASA III or above 25 (1.2%) 14 (0.5%) .005 palliative rate (no R0-resection, i.e., palliative or no operation: In 2002 [40%] vs. 2007–2009 [24.5%]); Table 2: Patient Outcome and Complications — hospital lethality (overall, 6%/with neoadjuvant chemotherapy, 3.4%) and peri- & postoperative Laparoscopic morbidity did not increase; Open Repair Repair N = 2025 N = 2960 P-Value — 4.4% (n = 23/521) of patients with neoadjuvant Superfi cial SSI 8 (0.4%) 8 (0.4%) 1 treatment could not be resected. Deep incisional SSI 1 (0%) 0 0.406 • There were no changes of the distribution of tumor sites Pneumonia 4 (0.2%) 3 (0.1%) 0.452 and stages (according to UICC classifi cation), in particu- Unplanned Intubation 1 (0%) 2 (0.1%) 1 lar, no reduction of advanced tumor stages. PE 1 (0%) 2 (0.1%) 1 • Gastrectomy rate decreased from 79.8 to 74.5%—the Return to OR 19 (0.9%) 24 (0.8%) 0.643 supposed reduction of radicality at the primary tumor ARF 0 (0%) 2 (0.1%) 0.517 lesion was associated with an extension of lymphade- UTI 6 (0.3%) 9 (0.3%) 1 nectomy compared with 2002–D1: 11.9% (n = 245/2,052 MI 0 1 1 resected patients with curative intention); D2: 79.5%; DVT 3 (0.1%) 3 (0.1%) 0.135 D3/4: 5.7/2.8%. Operative time (min) 85.2 ± 38.3 75.9 ± 35 <0.001 • Two trends continued: Predominating esophagojejunal Length of stay (days) 0.409 ± 3.0 0.18 ± 1.1 <0.001 stapler anastomosis, 96% (pouch: Approx. 20%). Mortality 2 (0.1%) 0 (0%) 0.165 • A hospital-volume effect could not be observed. • A postoperative adjuvant chemotherapy (only patients Clinical: Stomach without neoadjuvant treatment) received 15.8% of the patients (n = 327). • The 5-year survival rate of the whole patient group  Su1668 (including curative & palliative intention) increased Outcome of the Surgical Treatment of Gastric Cancer from 40.0% up to 48.5% but, in particular, in stage II–in stage IV: Increase from 3.5 to 11.3%). After Inauguration of the Neoadjuvant Concept Using a Systematic Multicenter Prospective Clinical CONCLUSION: After inauguration of multimodal con- cepts, there was an effective improval of the overall survival Observational Study without increased perioperative risk in the daily clinical care Frank Meyer1, Karsten Ridwelski2, Lutz Meyer3, Henry Ptok4, of gastric cancer; however, patients undergoing endoscopic Ingo Gastinger4, Hans Lippert1 tumor ablation & exclusively palliative chemotherapy were 1Department of Surgery, University Hospital, Magdeburg, Germany; not included. 2Department of Surgery, Municipal Hospital, Magdeburg, Germany; 3Department of Surgery, Municipal Hospital, Plauen, Germany; 4Department of Surgery, Municipal Hospital, Cottbus, Germany AIM & Methods: By means of a systematic multicenter prospective observational study, quality of surgical care for a representative group of patients with gastric cancer in daily clinical practice was investigated after inauguration of

104 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

 Su1669 10, 15, 20, 30, 40, 50, 60, 75, 90, 105, 120, 135, 150, 165, 180 minutes after meal. 13CO2 content was measured by The Tolerance to Volume Load, But Not the Reservoir or infrared spectrophotometry. Wagner-Nelson analysis was Emptying Capacity, Refl ects the Patients’ Living States performed on measured data. The reservoir and emptying After Gastrectomy capacity of the remnant stomach were calculated as reten- Koji Nakada, Masahiko Kawamura, Hideo Konishi, Taizo Iwasaki, tion rate at 5 minutes after meal (RR5) and half emptying Keishiro Murakami, Fumiaki Yano, Kazuto Tsuboi, time (T1/2), respectively. For drink test, mineral water (10 ml/kg) was ingested for 5 min at equal rate. The severity Yoshio Ishibashi, Norio Mitsumori, Nobuyoshi N. Hanyu, and the duration of abdominal symptoms caused by DT Hideyuki Kashiwagi, Noburo Omura, Katsuhiko Yanaga was scored 0 (none) to 3 (severe) and 0 (none) to 4 (more Surgery, The Jikei University School of Medicine, Tokyo, Japan than 30 minutes), respectively. The tolerance to volume Upper gastrointestinal tract has various physiological roles, load was assessed by DT total score (the sum of both sever- such as, the capacity to store or empty the ingested food by ity and duration scores). The questionnaire was performed the stomach, and the tolerance to volume load to receive a to examine the ingested amount of food per meal, the fre- certain amount of food by the upper gastrointestinal tract quency of daily meals, the change in body weight and the as a whole. The gastric surgery may alter these physiologi- restriction to daily life. cal properties, and then, could impair the patient’s living The multivariable analysis was performed to explore the states. However, the information about this concern is effect of physiological properties on patients’ living states limited. after gastrectomy. AIM: To study the effect of physiological properties of the RESULTS: (Table 1) The reservoir and emptying capac- upper gastrointestinal tract on patients’ living states after ity of the remnant stomach had no effect on patients’ gastrectomy. living states. The impairment in the tolerance to volume METHODS: 13C-acetate breath test (13-BT), drink test load (higher scores) resulted in reduced meal amount and (DT) and the questionnaire had performed in the patients restricted daily life. The frequency of daily meal was higher [n = 53] who received conventional gastrectomy (total in the patients with total gastrectomy. with Roux-en-Y [TG; n = 17], distal with Billroth-I [n = CONCLUSION: The tolerance to volume load by DT, but 17], distal with Roux-en-Y [n = 19]). For 13-BT, liquid meal not the reservoir or emptying capacity by 13C-BT, refl ected (200kcal/200 ml) mixed with 100 mg of 13C-acetate sodium the patients’ living states after gastrectomy. salt was given. Breath samples were collected before and 5,

Table 1: The Effect of Physiological Properties on Patients’ Living States After Gastrectomy Poster Abstracts Ingested Amount of Food Frequency of Daily Meals Change in Body Weight Restriction to Daily Life

p-Value p-Value p-Value OR (95% CI) p-Value Sunday RR5 (%) — NS — NS — NS — NS T1/2 (min) — NS — NS — NS — NS DT tolal score –0.436 0.0012* – NS –0.269 0.0561 1.48 (1.09–2.01) 0.0128* Type of gastrectomy [TG] — NS 0.395 0.0062* –0.274 0.0671 — NS R2 0.294 0.260 0.168 0.144 * p < 0.05

105 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

 Su1670 Su1671 Predictors of Cardiopulmonary Complications Long Term Recurrence and Survival Rates in Following Bariatric Surgery Gastrointestinal Stromal Tumours (GISTs) Treated Chris S. Crowe, Trit Garg, Natalia Leva, Homero Rivas, by Minimally Invasive Surgery John M. Morton Evangelos S. Photi1, Helen Stubbings2, Laszlo Igali3, Surgery, Stanford University, Stanford, CA Edward Cheong3, Allan Clark1, Michael P. Lewis3 1 INTRODUCTION: Bariatric surgery provides effective and Medicine, Norwich Medical School, Norwich, United Kingdom; enduring weight loss as well as resolution of comorbid dis- 2Oncology Department, Norfolk and Norwich University Hospital, ease. Many bariatric patients suffer from cardiopulmonary Norwich, United Kingdom; 3Oesophagogastric Cancer Centre, Norfolk conditions prior to surgery and receive relief from these and Norwich University Hospital, Norwich, United Kingdom comorbidities following surgery. However; little is known INTRODUCTION: Gastrointestinal Stromal Tumours about what predicts cardiopulmonary complications in (GISTs) are the most frequently occurring sarcoma of the GI these already at risk patients. This study analyzes risk fac- tract. Current treatment usually involves resection of the tors for cardiopulmonary complication for bariatric surgery. tumour with consideration of adjuvant imatinib, depend- METHODS: Over a 10-year period at a single academic insti- ing on the risk of recurrence. Complete R0 resection is an tution, 1634 patients underwent one of three procedures: important aspect of surgery though the surgical or patho- Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable logical margin required is unclear. Laparoscopic resection is gastric banding. Complications were analyzed during a used increasingly for these tumours. We aimed to examine 90-day post-operative window. Cardiopulmonary compli- the risk of recurrence, both local and metastatic, after lapa- cations included DVT/PE, myocardial infarction, arrhyth- roscopic resection with a macroscopic 10 mm margin. Risk mia, and cerebrovascular accident. Non-cardiopulmonary of relapse can be estimated based on Miettinen and Lasota complications included anastomotic leak/intra-abdominal criteria and this can also be used to guide frequency of clini- abscess, bowel obstruction, pneumonia, bleeding, and cal follow-up and imaging. ulcer/stricture. Pre-op biochemical cardiac risk values, METHODS: From the upper GI tumour database we iden- demographics, and anthropometric features were collected tifi ed primary non-metastatic GISTs of the upper GI tract prospectively Pre-op biochemical risk factors were matched treated by laparoscopic local resection. Cases were then to post-operative values to calculate percent change. Con- graded for risk of progression based on histopathological tinuous variables were analyzed by student t-test. P-values fi ndings using criteria such as tumour size, location within ≤ 0.05 were considered signifi cant. All analyses were per- the GI tract and number of mitoses. This produced 5 risk formed using Stata/SE statistica software, release 12. groups: high, moderate, low, very low and no risk of pro- RESULTS: Of 12 preoperative characteristics included in gressive disease. Time to event was then calculated for each the regression model, HDL ≤ 40 (OR 2.40, 95% CI (1.11– patient, the event being either death due to GIST, GIST 5.19)), high-sensitivity C-reactive protein ≥ 11 (OR 2.22, recurrence (as evidenced on follow up CT abdomen/pelvis), 95% CI (1.05–4.67)), Age ≥ 50 (OR 2.72, 95% CI (1.31– or being recurrence free up to the end of the study. 5.63)), and BMI ≥ 50 (OR 2.31, 95% CI (1.12–4.76)) were RESULTS: A total of 90 patients with primary upper gastro- found to be signifi cant predictors of cardiopulmonary intestinal GISTs were identifi ed from March 2000 to October complication. Furthermore, these features were not found 2012. The site of occurrence was gastric in 77 cases, small to be signifi cant predictors of non-cardiopulmonary com- bowel in 11 cases, duodenal in 1 case and oesophageal in 1 plication. At 12 months after surgery, those experiencing a case. Patients underwent surgical resection via a laparoscopic cardiopulmonary complication had a 9% improvement in approach where possible with a standard local resection mar- HDL compared to 23% improvements in those experienc- gin of 10 mm (R0). Follow up was for a mean of 4.5 years. ing a non-cardiopulmonary complication or no complica- tion at all. Individual t-tests comparing cardiopulmonary Three patients in the high risk group who died of disease complication to non-cardiopulmonary complication and developed distant metastases (two patients with liver and no complication were all signifi cant. A logistic regression one with peritoneal disease). Two other patients in the was used to show that incidence of a cardiopulmonary same group developed recurrence (one patient with liver complication, baseline HDL ≤40, age ≥ 50, and BMI ≥ 50 are and one with ileum/bladder metastases) but remain alive. all individual predictors for a negative percent change in One patient in the moderate risk group died of omental HDL at 12 months. metastases. Two other patients developed liver metastases, one of whom died of thyroid cancer whilst on imatinib CONCLUSION: HDL, hs-C-reactive protein, age, and BMI therapy and the other remains alive on imatinib therapy were all found to be signifi cant predictors of cardiopul- monary complication. HDL, which is cardio-protective, The low and very low risk groups had a 10 year progression showed reduced post-op improvement in patients with car- free survival of 100% with no incidences of GIST related diopulmonary complications at 1 year. This study clearly death. identifi es factors that infl uence a patient’s risk of cardiopul- monary complication after bariatric surgery.

106 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

GIST Related Deaths and Recurrences for Each Risk Group predictors of LN metastasis. Tumor size, site, degree of dif- ferentiation, and perineural invasion status did not predict Number of GIST Number of GIST LN metastasis. The presence of LVI was the only factor that Risk Group Number Related Deaths Recurrences signifi cantly predicted LN metastasis on multivariate analy- High 11 3 2 sis, as well as a signifi cantly worse 5-year disease-specifi c Moderate 11 1 2 survival. T1a tumors without LVI had a 4.3% rate of posi- Low 31 0 0 tive LN, whereas T1b tumors with LVI had a 64.3% rate of Very low 32 0 0 positive LN. No risk 5 0 0 CONCLUSIONS: T1 gastric cancers limited to the mucosa, without evidence of LVI, and N0 on EUS can be safely considered for limited resection. However, given an unac- ceptably high incidence of LN metastasis, any T1 gastric cancer with submucosal invasion, LVI, or N + by EUS should undergo radical resection with lymphadenectomy.

Su1674 Laparoscopic Sleeve Gastrectomy as a Revision from Laparoscopic : One Year Results Melissa Bagloo, Beth Schrope Surgery, Columbia University, New York, NY BACKGROUND: Laparoscopic adjustable gastric banding CONCLUSION: A 10 mm surgical margin results in no (LAGB) is known to have a considerable revisional surgery local recurrence at up to 10 years. The low distant recur- rate, reported from 10% to 40 + %. Mechanical complica- rence rate suggests that these tumours can safely be treated tions such as band slip, esophageal dilation or development laparoscopically with an R0 resection using a surgical mar- of a hiatal hernia can lead to symptoms of GERD, dyspha- gin of 10 mm. Distant recurrence is relatively low even in gia, and epigastric pain; weight loss failure/regain are also the high risk group for such tumours. prevalent factors that lead patients to seek surgical revision. Weight loss data for conversion to sleeve gastrectomy is Su1672 sparse. We present our initial series of patients who have undergone revision from LAGB to laparoscopic sleeve gas- Poster Abstracts Predictors of Lymph Node Involvement in T1 Gastric trectomy (LSG). Carcinoma

METHODS: A prospectively maintained clinical database Sunday Rima Ahmad1, Benjamin H. Schmidt1, Nicole J. Look Hong1, 2 2 3 was reviewed retrospectively. Data were reviewed for the Jonathan D. Schoenfeld , Jennifer Y. Wo , Eunice L. Kwak , period August 2010 to August 2012. Data collected included 3 3 2 Lawrence S. Blaszkowsky , David P. Ryan , Ted Hong , indication for revision, and degree of weight reduction. David W. Rattner1, John T. Mullen1 Indications for revision included slipped LAGB, epigastric 1Surgery, Massachusetts General Hospital, Boston, MA; 2Radiation pain, dysphagia, GERD, emesis, and weight loss failure or Oncology, Massachusetts General Hospital, Boston, MA; 3Medical weight regain. All candidates met NIH criteria for bariat- Oncology, Massachusetts General Hospital, Boston, MA ric surgery. Patients underwent laparoscopic gastric band removal and conversion to sleeve gastrectomy either in one BACKGROUND: The application of endoscopic and local or two stages. Operative technique was similar in all cases. resections for early gastric cancers is limited by the pres- ence of regional lymph node (LN) metastases. We sought to RESULTS: Twenty patients (17 female, 3 male) underwent determine the incidence and predictors of LN metastases in revision from LAGB to LSG between August 2010 to August patients with early gastric cancer. 2012 by two surgeons (MB and BS). A one-stage procedure was done in 14 patients (70%), while two-stage procedure METHODS: A total of 71 patients with pT1 gastric ade- was done in 6 patients (30%). Mean preoperative weight nocarcinoma underwent radical surgery without neoadju- and BMI before the original LAGB placement were 281.7 vant therapy at our institution between 1995 and 2011. (220–373) lb and 46.70 (39.01–56.57) kg/m2, respectively. Preoperative endoscopic ultrasound (EUS) staging was per- Mean weight, BMI and % excess weight loss (% EWL) at formed on 17 patients. Clinicopathologic factors predicting the nadir of the LAGB were 220.77 (156–322) lb, 37.33 regional LN metastases were analyzed. (30.63–51.75) kg/m2, and 43.55% (13.95–66.60) respec- RESULTS: LN metastases were present in 2 of 28 (7.1%) tively. The average interval between LAGB placement and T1a tumors and 14 of 43 (32.6%) T1b tumors, for an over- LSG was 4.79 (1.74–7.71) years. Mean preoperative weight all rate of nodal positivity of 23%. The median number of and BMI before conversion to LSG were 261.3 (197–360) lb examined LN for the entire cohort was 15, including 20 for and 42.62 (35.07–54.96) kg/m2, respectively. Mean % EWL LN-positive patients and 15 for LN-negative patients. On was 21.41%, 31.82%, and 39.02% at 3, 6, and 12 months, univariate analysis, the presence of submucosal tumor inva- respectively. Data was available for 9, 14, and 15 patients sion (p = 0.012), lymphovascular invasion (LVI) (p < 0.001), at the 3, 6, and 12 month time points, respectively. There and positive nodal status by EUS (p < 0.001) were signifi cant were no mortalities.

107 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

DISCUSSION: Our data indicates that revisional surgery > C: TT = 44.3%; TC = 43.9%; CC = 11.7%, –765G > C: GG from LAGB to LSG at one year averages 39.02% EWL (range = 58.3%; GC = 31.7%; CC = 1.3%). A high frequency of 0% to 70.92%). Published data for primary LSG have shown the wild genotype Cox-2 –765GG and polymorphic geno- results of approximately 60% EWL (ranges reported approx- type Cox-2 –1195GG and VEGF-A –634CC was found in imately 30% to 80%) at one year. Our preliminary data sug- an Asiatic (mostly Japanese) population. VEGF-A –2578C gests that weight loss after conversion from LAGB to LSG > A, and –460T > C were associated to familial history of may not result in weight loss equivalent to primary LSG. cancer. There were associations between wild homozygous This relatively small number of patients does not allow VEGF-A (–2578CC; –460TT; –634GG; + 936 CC), and wild comment as to the etiology of the relatively poor weight homozygous Cox-2 (–1195AA; 8437TT; 765GG) SNPs with loss seen here, although factors such as nadir weight loss pre-operative CEA, histological type, peritumoral depos- achieved with the band, interval between banding and its, perineural and angiolymphatics invasion, lymph node sleeve (one or two stage), preoperative LSG weight, or oth- metastases or pN, and stage IV disease, p < 0.04. Wild homo- ers, may provide insight as more data becomes available. zygous genotype of VEGF-A and Cox-2 were signifi cantly correlated with a worst progression-free survival and overall survival when compared to the combined heterozygous or Translational Science: Colon-Rectal recessive genotypes in a multivariate analysis. CONCLUSIONS: 1. Wild homozygous VEGF-A and Cox-2 Su2127 SNPs were associated to disease progression and survival in patients with advanced colorectal cancer; 2. VEGF-A and Wild Homozygous VEGF-A and Cox-2 Gene Cox-2 SNPs may be useful markers of aggressiveness in Polymorphisms Are Associated to Worst Prognosis in these patients; 3. Molecular data may orientate the appro- Patients with Colorectal Cancer (CRC) priate target therapy in novel clinical trials. Michele T. TomitãO1, Guilherme C. Cotti1, Marcia S. Kubrusly1, Evelise Pelegrinelli- Zaidan1, Adriana V. Safatle-Ribeiro1, Su2128 2 3 1 Rosely A. Patzina , José Eluf-Neto , Ivan Cecconello , Age, Gender, and Folate Metabolism Polymorphisms Sergio C. Nahas1, Ulysses Ribeiro1 Infl uence on Gene Promoter Methylation in CRC 1Gastroenterology, University of São Paulo, São Paulo, SP, Brazil; 2Pathology, University of São Paulo, São Paulo, Brazil; 3Preventive Patients 1 1 1 Medicine, University of São Paulo, São Paulo, Brazil Francesca Migheli , Andrea Stoccoro , Fabio Coppedè , Lucia Migliore1, Roberto Spisni2, Marco Biricotti2, BACKGROUND: The vascular endothelial growth factor- Alessandra Failli3, Annalisa Legitimo3, Rita Consolini3 A (VEGF-A) and Cyclooxygenase-2 (Cox-2) polymorphisms 1Translational Research and New Technologies in Medicine and have been implicated in colorectal cancer (CRC). VEGF-A and Cox-2 polymorphisms might modify the levels of pro- Surgery, Division of Medical Genetics, University of Pisa, Italy, 2 tein expression and may have a considerable infl uence on Pisa, Italy; Surgical Pathology, University of Pisa, Italy, Pisa, disease phenotype, which may have important clinical/ Italy; 3Clinical and Experimental Medicine, Division of Pediatrics genomic implications. (Laboratory of Immunology), University of Pisa, Italy, Pisa, Italy AIMS: To evaluate single nucleotide polymorphisms (SNPs) Colorectal cancer (CRC) is the third most common can- in the VEGF-A, and Cox-2 genes and their prognostic val- cer in men and the second in women worldwide. Almost ues for patients operated on for CRC; and to investigate 60% of the cases occur in developed regions. CRC arises possible interactions between these genetic variations and from a multistep process that involves an accumulation clinicopathologic characteristics in CRC. of mutations/epimutations in tumor suppressor genes and protooncogenes. DNA methylation is an important METHODS: VEGF-A and Cox-2 SNPs have been analyzed control program that modulates gene expression in the in 230 prospective patients who underwent surgical resec- organism. Genome-wide hypomethylation and promoter- tion, and had a minimum of 5 years follow-up. DNA was specifi c hypermethylation are thought to contribute to age- isolated from leukocyte using extraction and purifi cation related pathologies. Moreover female sex hormones have kit, followed by amplifi cation by polymerase chain reaction been implicated in the etiology of several women’s cancers (PCR). Real-time analysis was used for genotyping VEGF-A and may participate in different pathways associated with and Cox-2 SNPs through the TaqMan ® SNP Genotyping distinct DNA methylation signatures. Folates are essential Assay. nutrients whose metabolism is required for the produc- RESULTS: We determined frequencies of four VEGF-A tion of S-adenosylmethionine (SAM), the major intracellu- biallelic SNPs with twelve haplotypes: (–2578 C > A: CC = lar methylating agent, and for the synthesis of DNA and 36.1%; CA = 46.1%; AA = 17.8%; –460T > C: TT = 34.3%; RNA precursors. Impairments in folate metabolism might TC = 45.7%; CC = 20%; –634G > C: GG = 48.7%; GC = result in increased frequency of point mutations as well 40.4%; CC = 10.9%; + 936 C > T: CC = 74.3%; CT = 23.5%; as altered methylation of tumor suppressor genes, thereby TT = 2.2%), and three COX-2 SNPs with nine haplotypes contributing to cancer initiation and progression. Reduced (–1195A > G: AA = 63.5%; AG = 31.3%; GG = 5.2%; 8437T folate levels have been associated with increased CRC risk

108 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

in healthy people, whilst increased folate availability is squamous cell cancer of the esophagus (SCC) we performed believed to enhance CRC progression in individuals har- next generation sequencing (NGS) approaches on a wide set bouring preneoplastic lesions. There is increasing interest in of tumor-derived DNA from histological classifi ed EAC and understanding the correlation among folate availability, its SCC biopsies. metabolism, and the methylation levels of tumor suppres- Whole exome analysis was performed on 16 DNA sam- sor genes in CRC tissues. For this purpose we collected 104 ples from histological characterised esophageal cancer (n CRC patients and searched for correlation among clinico- = 8) and the corresponding non-tumor biopsies (n = 8). pathological characteristics, common polymorphisms of Extracted DNA was applied to NimbleGen capture exon genes participating in folate metabolism (MTHFR 677 C > T, hybridisation, adapter ligation and subsequent deep MTHFR 1298A > C, MTR 2756A > G, MTRR 66A > G, TYMS sequencing on an Illumina HiSeq platform. After tumor 28 bp repeats, TYMS 1494 6 bp del, RFC1 80A > G, DNMT3B macrodissection, DNA from additional 147 formalin-fi xed –149 C > T, and DNMT –579 G > T) and promoter methyla- and paraffi n-embedded (FFPE) EAC and SEC biopsies was tion of APC, MGMT, hMLH1, RASSF1A, CDKN2A, tumor extracted using the Qiagen M48 robotic system. After suppressor genes. Genotyping was performed by means of DNA quality control, multiplex PCR libraries, representing PCR/RFLP technique and DNA methylation analyses by tumor-relevant genetic loci, were prepared from 50 quality means of methylation-sensitive high resolution melting controlled EAC and SCC DNA samples. Multiplex libraries (MS-HRM). A precise value of gene promoter methylation were analyzed for more than 2000 putative driver muta- was obtained by means of an algorithm recently developed tions by next generation sequencing on the MiSeq Illumina by us. MGMT and hMLH1 methylation levels showed a platform. signifi cant positive correlation with aging and female gen- der. Moreover, some interesting correlation among folate 745 putative driver mutations in 657 genetic loci were metabolism polymorphisms and promoter methylation found in a fi rst whole exome screening step. p53 hot spot levels were found. No signifi cant association among pro- mutations occurred in two third of the esophageal cancers. moter methylation and CRC location, stage and tumor size In addition to the p53 mutations, whole exome analysis was found. Only a borderline association between TNM identifi ed more than two mutation hits in genes for the stage IV and increased hMLH1 methylation and TNM stage regulatory phosphatase unit, an adhesion P-cadherin and III and a higher RASSF1A methylation (with respect to the cycline kinase 12. These mutations were also addressed by other stages) have been observed. The study of epigenetic conventional Sanger sequencing. Subsequently, DNA sam- marks to better understand colorectal carcinogenesis and ples from 147 SCC and EAC were studied. Analyses of a hot to identify new tools for diagnosis and prognosis as well as spot cancer panel in 50 samples, that had passed the qual- for therapeutic interventions is then extremely promising. ity control, confi rmed high frequency of p53 mutations, but a lack of K-Ras mutations. In addition, a set of further mutations such as in PIC3CA, PP2R1B, and PPP1R1B were Poster Abstracts Translational Science: Esophageal shown, whose clinical relevance has to be addressed in future studies. Sunday Su2129 NGS is a sensitive method in evaluation of the mutation status of esophageal cancer, providing the opportunity to Whole Exome Sequencing Revealed Putative Driver detect a wide range of genetic alterations, which have to Mutations in Esophageal Cancer be linked to cancer progression, therapeutic outcome and Peter P. Grimminger1, Martin Peifer2,4, Roman Thomas4, personalized treatment options in future studies. Martin K. Maus1, Jan Brabender3, Arnulf H. HöLscher1, Reinhard BüTtner5, Margarete Odenthal5 1Department of General-, Visceral- and Tumor Surgery, University Clinic Cologne, Cologne, Germany; 2Department of Translational Genomics, University of Cologne, Cologne, Germany; 3General- and Visceral Surgery, St. Antonius Hospital, Cologne, Germany; 4Cologne Center for Genomics, University of Cologne, Cologne, Germany; 5Pathology, University of Cologne, Cologne, Germany Esophageal cancer is one of the most common malignancies in the Western world with increasing incidence of esopha- geal adenocarcinoma (EAC). Despite improvements in stag- ing, surgical procedures, and post-operative treatments, the overall survival of patients with esophageal cancer remains low. In order to evaluate the mutation status of EAC and

109 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Other

Su2130 Outcomes of Lung Transplant Patients with Severe GI Complications Loretta Erhunmwunsee1, Jennifer M. Hanna2, Anthony Castleberry2, Matthew Hartwig1, Christopher R. Mantyh2 1Cardiothoracic Surgery, Duke University Medical Center, Durham, NC; 2General Surgery, Duke University Medical Center, Durham, NC

PURPOSE: The incidence of gastrointestinal (GI) com- CONCLUSIONS: There is a high incidence of GI complica- plications after Lung Transplantation (LTx) is not well tions in patients who undergo LTx. Recipients who suffer a described. This study attempts to identify the incidence of GI complication after LTx have diminished overall survival. GI complications after LTx, characterize the risk factors that Total ICU days was an independent factor associated with lead to GI complications, and then determine the impact of having a GI complication. GI complications on post-transplant outcomes. METHODS: A prospective database of patients who under- Su2131 went LTx between 2005 and 2011 was queried. General- ized linear regression was used to determine risk factors Per-Umbilical Laparoscopic Access for developing GI complications. A multivariable Cox Roger H. Pozzo, Rodrigo Arrangoiz, Fernando Cordera, regression model was developed to predict the impact of Enrique Luque-De-LEóN, Eduardo Moreno, Manuel Munoz Juarez GI complications and other factors on the survival of these Surgery, American British Cowdray Medical Center, D.F., Mexico patients. INTRODUCTION: The advent of laparoscopic surgery is RESULTS: During the study period 543 patients under- one of the most important advances in modern surgical went LTx. 137 GI complications (Table 1) occurred in 124 of technique. In order to perform laparoscopic procedures it these patients. 62 of these patients subsequently underwent is necessary to access the peritoneal cavity and establish a operative management of their GI complication. Patients pneumoperitoneum. Placement of the fi rst port remains who had a GI complication had a statistically signifi cant a critical and unavoidable step in laparoscopic surgery. In worse 5 year survival (51% vs 65%) when compared to order to minimize complications associated with placement those who did not have a GI complication (p = 0.006) ( Fig- of the fi rst trocar, several techniques have been reported. ure 1). On univariable analysis, having a diagnosis of cystic Herein we describe the per-umbilical technique (PUT) fi brosis (p = 0.03), ischemic time (p = .05), total length of approach developed by our surgical group that takes advan- stay (LOS) (p = 0.0008), total ICU days (p = 0.0004) and an tage of the anatomical defect left by the umbilical vessels elevated FK level (p = .005) were associated with having at the umbilicus after birth. PUT provides a quick, safe, and a GI complication after transplantation. On multivariable reliable initial surgical access to the peritoneal cavity that analysis, total ICU days (OR = 1.005, 95% CI 1.003–1.007) has produced excellent functional and cosmetic results. was an independent factor associated with having a GI complication. METHODS: Retrospective cohort of patients who under- went various laparoscopic procedures by our surgical group GI Complication Incidence using PUT for access to the peritoneum from January 2000 to September 2012 at the ABC Medical Center, in Mexico N = 124 patients Total Number Number that Went to OR City. Patients with prior midline laparotomy involving C diff colitis 26 (19%) 0 the umbilicus were excluded, but not those with previous Biliary 22 (16%) 20 (91%) transverse umbilical herniorraphies. Perforation/Leak 13 (9.5%) 10 (76.9%) RESULTS: Within that timeframe there were 963 patients Diverticulitis 11 (8%) 9 (81.8%) (M = 419; F = 544) with an average age of 40 years (range: GI Bleed 10 (7.3%) 0 15–83). With a median follow up time of 6-years In our Gastroduodenal ulcer 9 (6.6%) 0 cohort no complications occurred during the insertion of Esophageal candidiasis 9 (6.6%) 0 the fi rst trocar. A small abdominal wall defect, were the Slipped Nissen 6 (4.4%) 6 (100%) obliterated umbilical vessels cross the musculoaponeurotic SBO 5 (3.6%) 4 (80%) layer, was identifi ed in all patients except those with a pre- Bleed -Non-GI 5 (3.6%) 3 (50%) vious surgical procedure at this site. Postoperative compli- Ischemic Colitis 4 (3%) 2 (50%) cations occurred in 39 patients (1.5%) of which the main Retroperitoneal abscess 2 (1.5%) 2 (100%) one was postoperative seroma (N = 24 patients). Superfi cial Eneterocutaneous Fistula 2 (1.5%) 1 (50%) surgical site infection occurred in eight patients (0.84%), Miscellaneous 13 (9.5%) 5 (38.5%) hematoma in two patients (0.21%), and incisional hernia Total 137 62 (46%) at the umbilical port site occurred in fi ve patients (0.51%). The average time to place the fi rst trocar using PUT was 1.5 minutes (range: 1–7 minutes).

110 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

CONCLUSION: We describe a modifi ed open technique liver resulting in a robust reduction of the expression of that has not been previously reported in the literature for genes involved in liver bile acids synthesis (CYP7A1) and placement of the fi rst trocar taking advantage of a constant uptake and secretion (NTCP, MRP2, MRP3, OST/) ulti- anatomical defect left by the obliterated umbilical vessels mately leading to reduced bile acid concentrations in the which is almost universally present. The PUT is quick, safe, blood. In addition, IT repressed the liver expression of neo- reliable, simple, and easy to learn. It is associated with min- glucogenetic (PECK) and lipogenetic (FAS, SREBP1c) genes. imal morbidity and has excellent cosmetic results. Based IT enhanced FGF-15 mRNA expression in the intestine and on our experience, we believe that this method provides this effect was further enhanced by CDCA (Figure). Activa- surgeons with an effective and safe way to insert the fi rst tion of intestinal FXR associates with an improvement of trocar and we recommend it as a routine procedure for the OGTT and with a reduction of glucose plasma levels. accessing the peritoneal cavity for abdominal laparoscopic surgery.

Translational Science: Small Bowel

Su2132 Dissociation of Activity of Ileal and Liver FXR Mediates Metabolic Effects in a Rodent Model of Bariatric Surgery Andrea Mencarelli1, Chiara Santorelli2, Luigina Graziosi2, laudio D’Amore1, Barbara Renga1, Sabrina Cipriani1, Eleonora Distrutti3, Annibale Donini2, Stefano Fiorucci1 1Medicina Clinica e Sperimentale, University of Perugia, Perugia, Italy; 2Dipartimento di Scienze Chirurgiche, University of Perugia, Perugia, Italy; 3Azienda ospedaliera di Perugia, Perugia, Italy BACKGROUND: The global growing burden of obesity and type 2 diabetes mellitus is widely recognized as one of the most challenging threats to public health. Bariatric surgery represents a potentially useful strategy for manage- Poster Abstracts ment of diabetes and obesity. FXR is a bile acid activated

receptors expressed in entero-hepatic tissues. Sunday AIMS: Here we have investigated whether bariatric surgery activates liver and intestinal bile acids activated receptors and how these receptor regulate metabolic adaptation to surgery. METHODS: Wistar rats were followed for 7 months after Ileal interposition (IT) or sham operation. In the last week animals were challenged with CDCA, 10 mg/kg, a FXR ligand. RESULTS: IT selectively increases intestinal expression/ activity of FXR and liver X receptor (LXR), as demonstrated CONCLUSIONS: These fi ndings provide a mechanistic by increasing expression of theirs target genes in the intes- explanation to the metabolic effects exerted by bariatric tine including FGF-15 and ABCG5/8, respectively. In con- surgery and provide a model for investigating the effect of trast, IT selectively repressed FXR and LXR activity in the selective activation of intestinal FXR.

111 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Monday, May 20, 2013 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 West Hall A POSTER SESSION I (NON-CME)

Basic: Colon-Rectal 373.2) was signifi cantly higher than the BCD group result (295.6, CI: 276.0, 306.6; p < 0.0001). Similarly, for IL8, the median PreOp CRC level (pg/ml) (17.3, CI 17.8, 22.8) was Mo1834 higher than the BCD groups outcome (14.2, CI: 12.8, 16.8; p < 0.001). Of note no correlation was found between ANG Plasma Levels of the Proangiogenic Proteins or IL8 plasma levels and cancer stage. Angiogenin and Interleukin-8 Are Signifi cantly CONCLUSION: The median PreOp plasma ANG and Increased in Patients with Colorectal Cancer IL8 levels in the CRC group were modestly increased M.C. Shantha Kumara H1, Hiromichi Miyagaki1,2, (21–25%) vs. the BCD patients. ANG and IL8 shed from Xiaohong Yan1, Elizabeth Myers1, Sonali A. Herath1, tumors expressing these proteins may be responsible for Sahani De Silva1, Linda Njoh1, Vesna Cekic1, Richard L. Whelan1 the increase. Alternate sources may be neovascularization 1Surgery, St Luke Roosevelt Hospital, New york, NY; and infl ammation at the tumor site. Further study of larger 2Gastroenterological Surgery, Oska University, Suita, Japan groups with concomitant tumor analysis would help deter- mine the clinical relevance, if any, of these changes, the INTRODUCTION: It has been shown that the proangio- source of the added protein and would better defi ne the genic proteins angiogenin (ANG) and interleukin-8 (IL8) relationship between cancer stage and blood levels. are produced by endothelial cells (EC), fi broblasts and peripheral blood cells. Also, some colon, breast, and pros- Mo1835 tate cancers have been shown to over express ANG and IL8. EC surface actins are receptors for ANG; the binding of ANG Intestinal Permeability Is Increased During to actin on EC’s promotes degradation of the basement Postoperative Ileus in Mice membrane which facilitates EC migration, an essential Xue Zhao2, Till M. Macheroux2, Michael S. Kasparek2, early step in angiogenesis. EC’s also express the IL-8 recep- Mario Mueller2,3, Martin E. Kreis1 tors CXCR1 and CXCR2; tumor derived IL8, via binding to 1 these receptors, in an autocrine fashion, enhances tumor Surgery (CBF), Charité University Medicine, Berlin, Germany; 2 3 cell proliferation and survival and also promotes patho- Surgery, University of Munich, Munich, Germany; Gastroenterology, logic angiogenesis. IL8’s pro-angiogenic effects are inde- University of Zuerich, Zuerich, Switzerland pendent of VEGF. Plasma ANG and IL8 levels in patients INTRODUCTION: Pathophysiology of postoperative ileus with colorectal cancer (CRC) have not been well studied. (POI) involves an intestinal infl ammatory response. One This study’s purpose was to compare preoperative (PreOp) potential mechanism is translocation of macromolecules plasma ANG and IL8 levels in patients with CRC and benign from the gut lumen. We aimed to investigate whether the colonic diseases (BCD). time course of translocation is dependent on molecular METHOD: Patients undergoing colorectal resection for weight. CRC or BCD prospectively enrolled in an IRB approved tis- METHODS: C57Bl6 mice were deeply anesthetized by sue/data bank, for whom PreOp plasma was available, were isofl urane inhalation and gavaged with fl ourescein iso- studied. Clinical, operative and pathologic data were col- thiocyanate conjugated dextrane (FITC-dextrane, 4.4 kDa) lected. Plasma ANG (ng/ml) and IL8 (pg/ml) levels were and horseradish peroxidase (HRP, 40 kDa). One hour later, determined via ELISA in duplicate and reported as median a mini-laparotomy was performed and the small intes- 95% CI. Levels between groups were compared by the tine manipulated in standardized fashion to induce POI, Mann-Whitney test (signifi cance p < 0.05). while control animals received sham laparotomy without RESULTS: A total of 122 CRC (66% colon, 34% rectal) manipulation. Intestinal permeability was assessed in POI and 96 BCD (adenoma 50%, diverticulitis 47%, other 3%) animals or sham controls 1, 3 and 9 hours later in different patients were included. Plasma stores (PreOp samples) did subgroups (each n = 6). For this purpose blood was taken not permit both assays to be done for all patients. In regards by right ventricular puncture and serum concentrations of to ANG, 86 CRC and 80 BCD patients were studied while FITC-dextrane and HRP determined by spectrophotometry. the IL8 assay included 73 CRC and 62 BCD patients. The Data are mean ± SEM. median PreOp CRC ANG level (ng/ml) (339.9, CI: 339.6,

112 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: Serum levels of FITC-dextrane (4.4 kDa) in ng/ml; Basic: Hepatic *p < 0.05; **p < 0.001 POI vs. sham Sham 72 ± 5 83 ± 2 56 ± 6 (1 h/3 h/9 h) Mo1837 POI 120 ± 8* 183 ± 22** 65 ± 5 (1 h/3 h/9 h) Benefi cial Effects of Diazoxide on Hepatic Ischemia/ Serum levels of horse radish peroxidase (40 kDa) in ng/ml; *p < 0.05 POI vs. sham. Sham 198 ± 18 240 ± 29 226 ± 24 (1 Reperfusion Injury h/3 h/9 h) POI 350 ± 38* 388 ± 38* 300 ± 28 (1 h/3 h/9 h). Mateus A. Nogueira, ANA Maria M. Coelho, Sandra N. Sampietre, Nilza A. Molan, Rosely A. Patzina, Luiz C. D’Albuquerque, CONCLUSIONS: Intestinal permeability for macromol- ecules was already increased a few hours after induction Marcel C. Machado of postoperative ileus. This appeared to be independent of Gastroenterology, University of São Paulo, São Paulo, Brazil their molecular weight. Translocation of macromolcules BACKGROUND/AIM: Pretreatment with diazoxide, an into the intestinal wall early after induction of postop- opening mitoKATP, increases tissue tolerance against isch- eraitve ileus is a potential trigger of subsequet intestinal emia/reperfusion (I/R) injury, however, there are no prior infl ammatory responses. studies of the role of diazoxide on hepatic I/R injury. In the Supported by the Else Kröner-Fresenius Stiftung 2011_A214. present study, we evaluated the effect of diazoxide on local and systemic liver I/R process. METHODS: Wistar male rats underwent partial liver isch- Basic: Esophageal emia performed by clamping the pedicle from medium and left anterior lateral segments during an hour under mechan- Mo1836 ical ventilation. They were divided into 2 groups: Control Group (n = 26): rats received saline and Diazoxide Group Bile Acid at Low pH Can Cause Dilatation of (n = 26): rats received IV diazoxide (3.5 mg/kg) 15 minutes Inter-Cellular Spaces in In Vitro Stratifi ed Primary before liver reperfusion. Four and 24 hours after reperfu- Esophageal Cells, Possibly by Modulating WNT and sion, blood were collected for determinations of AST, ALT, TNF-, IL-6, IL-10, and TGF1. Liver tissues were assembled BMP Signaling for mitochondrial oxidation and phosphorylation, malo- 1 4 2 3 Sayak Ghatak , Marie Reveiller , Liana Toia , Andrei Ivanov , ndialdehyde (MDA) content, and histologic analysis. Pul- Tony Godfrey2, Jeffrey H. Peters2 monary vascular permeability and myeloperoxidade (MPO) 1Biology, University of Rochester, Rochester, NY; 2Surgery, University of were also determined. 3 Rochester, Rochester, NY; Human and Molecular Genetics, Virginia RESULTS: Four hours after reperfusion Diazoxide Group 4 Commonwealth University Medical Center, Richmond, VA; Medicine presented elevation of AST, ALT, TNF-, IL-6, IL-10 and and Pathology, NYU Langone Medical Center, New York, NY TGF1 serum levels signifi cantly lower than Control Group The pathognomonic feature of refl ux esophagitis second- (p < 0.05). A signifi cant reduction on liver MDA content and ary to gastro-esophageal refl ux disease is the presence of on mitochondrial dysfunction were observed in Diazoxide dilated intercellular spaces in the stratifi ed squamous lining Group compared to Control Group (p < 0.05). No differ- of the esophagus. Bile acid is a major constituent of gastro- ences in pulmonary vascular permeability and MPO activ- esophageal refl uxate. In our present study, we developed a ity were observed between groups. Twenty four hours after novel in vitro transwell culture model for stratifi ed esopha- reperfusion Diazoxide Group showed a reduction of AST, geal squamous epithelium. We grew h-TERT transformed ALT, and TGF1 serum levels when compared to Control group (p < 0.05). primary esophageal cell line EPC1 on polyester transwell Poster Abstracts surfaces, apically and basally supplemented with calcium CONCLUSION: Diazoxide maintains liver mitochondrial enriched media, and observed that the EPC1 cells gradually function, increases liver tolerance to I/R injury, and reduces Monday stratify into a 11-layered squamous epithelium in 7 days. systemic infl ammatory response. These effects require fur- This epithelium also demonstrated well-formed cell junc- ther evaluations for using in a clinical setting. tions, essential for formation of the stratifi ed epithelium. When the EPC1 cells on transwells were treated with a com- Grants from FAPESP2010/19078-1 bination of bile acid and pH5, there was loss of epithelial barrier function. Electron microscopy and confocal imag- ing of the cell junctions showed disruption of adherens junction, tight junction and desmosomes, thus leading to dilated intercellular spaces. At the cellular level, the combi- nation of bile acid and pH5 induced -catenin phosphory- lation and reduced SMAD-1/5/8 phosphorylation, both of which can lead to loss of cell junction proteins. In conclu- sion, combination of bile acid at low pH in our trasnwell culture model mimicked the effects of gastro-esophageal refl ux in vivo, possibly by modulating WNT and BMP sig- naling pathways.

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Basic: Pancreas  Mo1839 Osteopontin (OPN) Isoforms, Diabetes, Obesity, and  Mo1838 Cancer: What’s One Got to Do with the Other? A New PTK6 Regulates Migration and Invasion of Pancreatic Role for OPN Konrad Sarosiek, Elizabeth Jones, Galina Chipitsyna, Cancer Cells with ERK1/2 Dependent Pathway Mazhar AL-Zoubi, Shivam Saxena, Christopher Y. Kang, Hiroaki Ono, Hiromichi Ito, Marc D. Basson Ankit V. Gandhi, David Tichansky, Charles J. Yeo, Hwyda A. Arafat Surgery, Michigan State University, East Lansing, MI Surgery, Thomas Jefferson University, Philadelphia, PA BACKGROUND: Protein Tyrosine Kinase 6 (PTK6) is a non- BACKGROUND: Alternative splicing of osteopontin (OPN) receptor type tyrosine kinase, known to be overexpressed in produces three splice variants: OPNa, OPNb, and OPNc. We various cancers including pancreatic cancer. The biological have previously demonstrated a role for OPNc in pancreatic role of PTK6 in cancer remains unclear. We hypothesized ductal adenocarcinoma (PDA) infl ammation and proposed that PTK6 is a key regulator of pancreatic cancer invasion. its potential as a novel therapeutic target to reduce PDA- METHODS: We used 3 cell lines derived from human pan- associated infl ammation. The aims of this study were to creatic cancers, BxPC3, Panc1, and MIAPaCa2. PTK6 expres- examine the expression pattern of OPN splice variants in sion and activation were evaluated using western blotting. sera from patients with pancreatic lesions and to determine PTK6 expression was manipulated using siRNA gene silenc- their correlation with the presence of systemic infl amma- ing or transfection of expression vector. Cellular migra- tory conditions, such as obesity and diabetes. In addition, tion and invasion were evaluated using a Boyden chamber the functional signifi cance of the individual isoforms was transmigration assay without or with Matrigel, respectively. evaluated. Downstream signals associated with the effect of PTK6 on METHODS: Serum samples were obtained from 90 patients cellular migration and invasion were assayed using western undergoing pancreatic surgery at a single institution. blotting and a specifi c small molecule inhibitor. Patients were grouped into 8 subgroups based on the disease RESULTS: Pancreatic cancer cell lines expressed PTK6 at process and presence of obesity and/or diabetes. Sera from various levels; BXPC3 expressed PTK6 robustly, while Panc1 age-matched healthy volunteers were analyzed (n = 29). and MIAPaCa2 expressed much lower levels of PTK6. In Real-time polymerase chain reaction and ultraviolet light all 3 cell lines, suppression of PTK6 expression by siRNA illumination of ethidium-bromide gel staining were used signifi cantly reducted both cellular motility and invasion to examine the OPN mRNA and its individual isoforms. In through matrigel (0.59/0.49 fold for BXPC3, 0.61/0.62 vitro, wound healing, cell proliferation and soft-agar colony for Panc1, 0.42/0.39 for MIAPaCa2, respectively, p < 0.05 formation assays evaluated the functional impact of each for each). In contrast, forced over-expression of PTK6 by isoform in PDA cells transfected with isoform-specifi c cDNA. transfection of a PTK6 expression vector in Panc1 and A panel of infl ammation-related genes was also analyzed. MIAPaCa2 cells signifi cantly increased cellular migration RESULTS: Sera were obtained from PDA patients (mean age and invasion (1.57/1.67 fold for Panc1, and 1.44/1.57 for 66 ± 1.12 (SE) years; 40 male). Histopathology confi rmed MIAPaCa2, respectively, p < 0.05). Gene silencing of PTK6 PDA in 58 patients, IPMN in 32. Diabetes (type 2) alone was reduced the activation of ERK1/2, but not AKT and STAT3, detected in 13 PDA and 4 IPMN patients and in combina- while overexpression of PTK6 increased ERK1/2 activation. tion with obesity in 5 PDA and 1 IPMN patients. In PDA When the cells were treated with U0126, a specifi c inhibi- only, the presence of OPNb was seen in 33% of the patients’ tor of ERK1/2, the effect of PTK6 overexpression on cellular sera, OPNc in 48%, with both being present in 15%. The migration/invasion was completely abolished. presence of diabetes and/or obesity was associated with CONCLUSION: PTK6 regulates cellular migration and complete disappearance of OPNb and only expression of invasion in pancreatic cancer, via the MAPK/ERK signaling OPNc (82% of PDA diabetics, 100% of obese PDA patients, pathway. Our fi ndings suggest that PTK6 may be a novel and 100% of obese diabetic patients with PDA). No OPNb therapeutic target for pancreatic cancer. or c was detected in the normal sera. OPNc had a signifi cant association with presence of systemic infl ammation (OR = 6.8 [1.7–65, 95% CI]; p < 0.05). In vitro studies show that overexpression of OPNb and c isoforms signifi cantly (P < 0.05) and (P < 0.02), respectively, increased the activity of PDA cells in soft-agar colony formation and wound healing assays compared with controls. CONCLUSIONS: Our data show for the fi rst time the sig- nifi cant association between OPN splice variant c (OPNc) and the presence of systemic infl ammation in patients with obesity and/or diabetes. In vitro data suggest that increased OPNc expression in PDA cells is associated with increased migration capacity. Unraveling the functional role of OPNc in systemic infl ammation is essential to understanding its signifi cance as a marker and a therapeutic target during metastasis development in PDA.

114 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1840 Clinical: Biliary Local and Systemic Effects of Aging on Acute Pancreatitis  Mo1687 ANA Maria M. Coelho1, Marcel C. Machado1, Sandra N. Sampietre1, Nilza A. Molan1, Inneke M. Van Der Introperative Cholangiogram Reduces Risk of Bile Heijden2, José Eduardo M. Cunha1, Luiz C. D’Albuquerque1 Duct Injury During Cholecystectomy: Results from a 1Gastroenterology, University of São Paulo, São Paulo, Brazil; National Quality Registry 2Infectious Diseases, University of São Paulo, São Paulo, Brazil BjöRn TöRnqvist, Cecilia STRöMberg, Lars Enochsson, Magnus Nilsson BACKGROUND/AIM: Acute pancreatitis (AP) is associ- Department of Clinical Science, Intervention and Technology, ated with high morbidity and mortality rates. Aging process has been found to infl uence the course and outcome of AP. Karolinska Institutet, Stockholm, Sweden The aim of this study was to evaluate the local and systemic BACKGROUND: Bile duct injury during cholecystectomy effects of aging on severity of AP in an experimental model. is a dreaded complication. Regarding prevention, the iden- METHODS: AP was induced in male Wistar rats by intra- tifi cation of patient and procedure-related risk factors are ductal 2.5% taurocholate injection and divided into 2 essential. The protective effect of intraoperative cholangio- experimental groups: GI (n = 20): Young (3 month old gam has been controversial and widely debated due to lack rats), and GII (n = 20): Older (18 month old rats). Two of conclusive studies. The aim of this study is to identify and 24 hours after AP blood were collected for determina- risk factors for bile duct injury at cholecystectomy using the tions of amylase, AST, ALT, urea, creatinine, glucose, and highly valid Swedish national registry for gallstone surgery, of plasma ileal fatty acid binding protein (I-FABP). TNF- GallRiks, where more than 90% of the Swedish cholecystec- and IL-6 levels were determined in serum and ascitic fl uid. tomies are registered. Liver mitochondrial oxidation and phosphorylation and METHODS: All in GallRiks, from the malondialdehyde (MDA) contents, and pulmonar myelo- start of the registry on May 1 2005 until December 31 2010 peroxidade (MPO) activity were also performed. Bacterial were included. Patient, institutional and procedure related translocation was evaluated by bacterial cultures of pan- risk factors for iatrogenic bile duct injury were analysed creas expressed in colony-forming units (CFU) per gram. using multivariate logistic regression. The intention to use RESULTS: A signifi cant increase in serum amylase, AST, intraoperative cholangiogram was defi ned as performed or ALT, urea, creatinine, glucose, I-FABP, and IL-6 levels, and attempted cholangiogram, thus using the intention-to-do a reduction in serum and ascitic fl uid TNF- levels were approach. observed in the elder group compared to the young group RESULTS: Among 51 041 cholecystectomies, 747 (1.46%) (p < 0.05). Liver mitochondrial dysfunction, MDA con- bile duct injuries ranging from minor to major lesions were tents, and pulmonary MPO activity were increased in the identifi ed. Patients with acute cholecystitis had a 25% older group compared to the young group (p < 0.05). Also, increased risk of bile duct injury compared to patients with- a signifi cant increase in positive bacterial cultures obtained out cholecystitis (OR 1.25 (95% CI 1.04 to 1.49)) Addition- from pancreas tissue in older group was signifi cantly ally, the risk of severe bile duct injuries (transections of major increased compared to young rats (p < 0.05). ducts with loss of ductal tissue or lesions above the hepatic CONCLUSION: This study demonstrated that aging confl uence) were doubled among patients with acute cho- infl uences the course of acute pancreatitis evidenced by lecystitis (OR 2.13 (95% CI 0.96 to 4.75)). The intention to increased local and systemic lesions and the increased in use intraoperative cholangiogram reduced the overall risk bacterial translocation. These fi ndings may have signifi cant of bile duct injury by 25% (OR 0.75 (95% CI 0.62 to 0.92)) Poster Abstracts therapeutic implication in the clinical setting. and the risk of severe bile duct injuries by 66% (OR 0.44

(95% CI 0.30 to 0.63)). The association between intended Monday intraoperative cholangiogram and the reduction in risk of bile duct injury were most prominent among patients with ongoing acute cholecystitis. This group had a risk reduction of 56% (OR 0.44 (95% CI 0.30 to 0.63)). CONCLUSIONS: In this study, using the highly valid Swedish national registry for gallstone surgery, risk factors for iatrogenic bile duct injury during cholecystectomy were analysed. Patients with acute cholecystitis were at higher risk for bile duct injury. Intention to use intraoperative cholangiogram reduced bile duct injury rates in general and severe injuries in particular. The most noticeable protective effect of intraoperative cholangiogram was seen among patients with acute cholecystitis. The main contribution of this study is the intention-to-do data on intraoperative cholangiogram, and the results suggest that routine use of intraoperative cholangiogram at cholecystectomy may be benefi cial.

115 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1689 Outcome in the Partial and Complete Injury Groups Post-Cholecystectomy Acute Bile Duct Injuries Partial Injury Complete Injury Vinay K. Kapoor, Anand Prakash, Rajneesh K. Singh, n = 121 n = 44 n = 77 P Value Anu Behari, Ashok Kumar, Rajan Saxena Fistula closure 37 (84%) 43 (57%) p = 0.001 Surgical Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Stricture formation 20 (45%) 70 (92%) p = 0.000 Medical Sciences (SGPGIMS), Lucknow, India * 5 out of the 126 patients whose injury could be classifi ed as partial or complete died and are excluded. INTRODUCTION: Gall stone disease is common in north India and cholecystectomy is one of the commonest opera- Outcome Based on Adverse Factors tions performed. Bile duct injury (BDI) is a not uncommon but dangerous complication of cholecystectomy, more so of No. of Adverse Factors Fistula Closure Stricture Formation laparoscopic cholecystectomy (LC). We have reviewed our 0 (n = 9) 9 (100%) 1 (11%) experience with management of acute BDI. 1 (n = 18) 17 (94%) 9 (50%) PATIENTS: Retrospective analysis of 146 patients with 2 or 3 (n = 77) 54 (70%) 64 (84%) post-cholecystectomy acute BDI referred to and managed >3 (n = 34) 15 (44%) 30 (91%) at a tertiary level healthcare facility over 18 years and in Total (n = 138*) 95 (69%) 104 (75%) whom follow up information was available. Patients who * 8 Patients died due to complications of acute BDI and are excluded. presented with BDI due to non-cholecystectomy proce- dures and those with established benign biliary strictures (BBS) were excluded from this analysis. Mo1690 RESULTS: There were 47 males and 99 female patients with Hepatolithiasis: Transhepatic Team Management a mean age of 40 (range 12–71) years. The index surgery was Janak A. Parikh1, Henry A. Pitt1, Joal D. Beane1, open cholecystectomy in 103, open cholecystectomy with Matthew S. Johnson2 common bile duct (CBD) exploration in 9 and laparoscopic 1Surgery, IN University School of Medicine, Indianapolis, IN; cholecystectomy in 34 patients. Patients were referred to us 2 at a median of 20 (range 0–730) days after cholecystectomy. Radiology, Indiana University School of Medicne, Indianapolis, IA 51 out of 146 (35%) patients had one or more pre-referral BACKGROUND: Intrahepatic stones are very uncommon interventions (surgical 26, percutaneous 17, endoscopic 2 in Western societies. In comparison, hepatolithiasis occurs and combinations 6). Based on isotope scintigraphy (58), more frequently in Southeast Asia because of the high prev- cholangiography (52) or both (24), BDI could be classifi ed alence of congenital biliary cysts and hepatobiliary para- as partial (n = 46, 37%) or complete (80, 63%) in 126/146 sites. Many Asian patients present with advanced disease patients. Based on their clinical presentation, the patients which is usually managed with left hepatectomy. In North with BDI were classifi ed into external biliary fi stula EBF (n America both the underlying biliary pathology and the tim- = 69), biloma (n = 49), bile peritonitis (n = 21) and bile ing of presentation differ, but management has not been ascites (n = 7). 52 patients were managed conservatively, 41 standardized, in part, because of the rarity of the disease. had percutaneous intervention, 7 had endoscopic interven- This analysis documents the etiology, presentation and out- tion, 26 were operated and 20 had combination of these comes of a transhepatic team approach for management of procedures. 8 (6%) patients (6 with bile peritonitis) died hepatolithiasis at a Western referral center. due to the complications of BDI. Fistula closed in 95/ 138 METHODS: The records of patients with hepatolithiasis (69%) surviving patients and 104/ 138 (75%) formed a bili- managed by interventional radiologists (IR) and surgeons ary stricture (37/44 88% and 20/44 45% in partial injury from 2002 through 2012 were reviewed. Surgery was under- vs. 43/77 57% and 70/77 92% in complete injury). Open taken when required to repair the biliary pathology and/or cholecystectomy as the index procedure, jaundice at pre- when the stone burden was extensive. All but one patient sentation, complete injury, delayed (>20 days) referral and were managed with 20F transhepatic stent (s) placed either high (>350 ml) fi stula output were predictors for persistence percutaneously or during surgery. Choledochoscopy was of fi stula and development of biliary stricture. If more than performed in almost all patients either percutaneously or 3 adverse factors were present, the biliary fi stula persisted in intraoperatively to assist with stone removal. Laser litho- more than 70% of the cases and biliary stricture developed tripsy and balloon dilation were undertaken for diffi cult in more than 90% of cases. stones and strictures. Transhepatic stents were removed CONCLUSION: Post-cholecystectomy BDI is associated when patients were stone and stricture free. A successful with signifi cant morbidity and even mortality. Manage- outcome was defi ned as stent removal without symptoms ment and outcome of post-cholecystectomy BDI depends requiring more procedures. on the clinical presentation and whether the injury is par- RESULTS: Seventy-four patients were managed by IR alone tial or complete. The short term and long term outcome of (66%) or by IR and surgery (34%). The mean age was 55.6 the acute BDI in terms of fi stula closure and development years, and 51.4% were women. The majority of patients were of biliary stricture could be predicted based on presence of Caucasian (80%), and only fi ve (7%) were Asian. Underly- adverse factors. ing biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty

116 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

patients (27%) had biliary cirrhosis, and 17 of these patients patients and the common hepatic artery in 1, and perineu- developed hepatolithiasis after undergoing orthotopic liver ral invasion was mostly recognized. The median operation transplantation. Fifteen additional patients (20%) had a time and blood loss were 554 min. (range, 438 to 1025) and prior biliary-enteric anastomosis. Upper abdominal pain 1392 ml (610 to 2900), respectively. Median graft length (65%), cholangitis (47%) and jaundice (34%) were the most and reconstruction time were 3 cm (2 to 4) and 24 min. common presenting symptoms. The median number of IR (19 to 30), respectively, and the hepatic artery reconstruc- procedures was 11, and choledochoscopy (88%) laser litho- tion spent 28 min. (14 to 60). Morbidity occurred in 50% tripsy (68%) and balloon dilation (47%) were performed and 2 patients (1 HLPD and 1 HL) died in hospital for liver frequently. Surgical management included cholangio- or abscess and MRSA septemia. Median and 5-year survivals of hepatico-jejunostomy in 22 patients (88%) and hepatec- all patients were 24 months and 33.3% (2 patients survived tomy in one (4%). Recurrent stone and stricture rates were over 5 years). both 26% and were managed with further biliary stenting. CONCLUSION: Despite the small number of the subjects, None of the patients have developed a cholangiocarcinoma en bloc resection of HDL actually brought the favorable with a median follow-up of 29 months. results for intractable diseases. This strategy can be justifi ed CONCLUSIONS: A combined interventional radiologic for the rigorously selected patients. and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing Mo1692 hepatolithiasis. This approach preserves hepatic paren- chyma and prevents malignant degeneration. Extended Hepatectomy with Portal and Hepatic Artery Resection for Advanced Perihilar Cholangiocarcinoma Mo1691 Minoru Esaki, Kazuaki Shimada, Shutaro Hori, Yoji Kishi, Satoshi Nara, Tomoo Kosuge En Bloc Resection of Hepatoduodenal Ligament for Hepato-Biliary pancreatic Surgery, National Cancer Center Hospital, Advanced Biliary Malignancy Tokyo, Japan Yuji Kaneoka, Atsuyuki Maeda, Masatoshi Isogai Surgery, Ogaki Municipal Hospital, Ogaki, Japan OBJECTIVES: The aim of this study was to clarify short- and long-term outcome of extended hepatectomy with por- From 1996, en bloc resection of the hepatoduodenal liga- tal vein resection (PVR) or hepatic artery resection (HAR) ment (HDL) concomitant with the neighboring organs had for perihilar cholangiocarcinoma. been adapted for advanced biliary malignancy to achieve R0 (histological curative) resection. Preoperative indication METHODS: Patients with perihilar cholangiocarcinoma for this drastic surgery is a locally advanced disease involv- who underwent resection between January 2000 and ing the portal trunk and bilateral hepatic arteries without December 2011 for perihilar cholangiocarcinoma were the distant metastases. The portal vein was reconstructed analyzed retrospectively. Operative variables, mortality, by the autologous vein graft and the hepatic artery was morbidity, and survival were compared among standard reconstructed by the gastroduodenal or middle colic artery resection with no PVR and no HAR (S group), with PVR because the long segmental resections of the vessels were without HAR (PV group) and with HAR (HA group). mandatory. RESULTS: A total 230 patients underwent surgical resec- PATIENTS: This study comprised of 12 patients with 5 tion for perihilar cholangiocarcinoma, 172 (75%) in S gallbladder carcinomas (GBC) and 7 cholangiocarcinomas group, 37 (16%) in PV group, and 21 (9.1%) in HA group (CCC). Mean age of the patients was 62 years (range, 43 were enrolled. Operative time and blood loss were 633 min- to 71); 7 females and 5 males. HLPD (hepato-ligamento- utes and 1415 ml in S group, 665 and 2028 in PV group, Poster Abstracts pancreatoduodenectomy) was applied for 5 GBC and 2 775 and 2076 ml in HA group, respectively. Those with PV and HA group were signifi cantly more than in those with S

CCC, and HL (hepato-ligamentectomy) for 5 CCC. PD was Monday added when massive HDL invasion was apparent. About group (both P = 0.04). Mortality and more than grade IIIa the extent of hepatic resection, 1 right trisectionectomy, complications occurred in 4 (2.3%) and 17 (9.9%) patients 4 right hepatectomies, and 2 left hepatectomies in HLPD; with S group, in 0 and 5 (14%) with PV group and 0 and 1 right hepatectomy and 4 left hepatectomies in HL, and 3 (14%) with HA group. The rates of more than Grade IIIa total caudate lobectomy was routinely performed. Surgical complications were comparable among 3 groups. Overall technique and outcome of the patients were investigated 5-year survival rate and median survival time were 49% and retrospectively. 47.5 months in S group, 22 and 25.0 in PV group, 21 and 21.4 in HA group. There was signifi cant difference in sur- Timing of vascular reconstruction: The portal vein resection vival in patients between S and PV, S and HA group, respec- and reconstruction was performed before the extirpation of tively. Especially, patients in HA group with R1 (surgical the specimen, namely, just after the division of the hepatic margin positive) or with severe perineural infi ltration were ducts, and then the residual hepatic transection was fol- associated with unsatisfactory prognosis, which were not lowed. The right external iliac vein was always used for the survived for more than 3 years. graft. Contrary, the hepatic artery reconstruction was fol- lowed after the extirpation of the specimen. CONCLUSIONS: PVR and HAR for advanced perihilar cholangiocarcinoma were feasible. It can provide a favor- RESULTS: R0 resection was achieved in 9 out of 12 patients able prognosis in selected patients of advanced perihilar (75%). Positive margin was found in the hepatic duct in 2 cholangiocarcinoma.

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Mo1693 Mo1694 Percutaneous Transhepatic Gallbladder Drainage Major Bile Duct Injury Requiring Operative Without Cholecystectomy Is Optimum Procedure in Reconstruction After Laparoscopic Cholecystectomy: A High-Risk Patients National Perspective, 2001–2009 Masanori Akada1,2, Michinaga Takahashi1, Tatsuya Ueno1, Taranjeet Kaur, Brian S. Diggs, Brett C. Sheppard, Shun Sato1, Shinji Goto1, Kyohei Ariake1, Shinpei Maeda1, John G. Hunter, James P. Dolan Hiroo Naito1 General Surgery, Oregon Health & Science University, Portland, OR 1 2 Surgery, South Miyagi Medical Center, Miyagi, Japan; Surgery, OBJECTIVE: Major bile duct injury (BDI) after laparo- Tohoku University, Sendai, Japan scopic cholecystectomy (LC) remains a serious concern. According to Tokyo Guidelines 2007 for the magagemant of This study was done to determine the national incidence acute cholecystitis, early cholecystectomy has been recom- and mortality for major BDI requiring operative reconstruc- mended as fi rst option. However percutaneous transhepatic tion after LC in the United States during the years 2001– gallbladder drainage (PTGBD) is available for patients with 2009. Our results were compared to previously publish moderate or severe acute cholecystitis. After PTGBD, while major BDI rates after LC reported between 1991 and 2000. most patients undergo cholecystectomy, some patients DESIGN: Using the Nationwide Inpatient Sample of more are treated by drainage alone, especially in very elder or than 4 million patients who underwent cholecystectomy high-risk patients. The indication of cholecystectomy after for the years 2001–2009, we used procedure-specifi c codes PTGBD remains unclear. to measure national estimates for LC. We then calculated MATERIALS AND METHODS: Medical records of 340 biliary reconstruction procedures that occurred after LC. patients who were admitted to our hospital with acute cho- Biliary reconstruction performed as part of another primary lecystitis between November 2006 and October 2011 were procedure was excluded. Finally, we analyzed incidence and reviewed. mortality rates associated with biliary reconstruction. RESULTS: Sixty-six patients underwent PTGBD under RESULTS: The percentage of cholecystectomies performed ultrasonographic guidance. Thirty-two patients underwent laparoscopically has increased over time from 71% in cholecystectomy after PTGBD (Group A), and 34 patients 2001 to 78% in 2009. The associated mortality rate for LC were treated by drainage alone (Group B). Because all the was 0.56% in 2001 and 0.42% in 2009 (p = 0.002). The patients of Group B suffered from severe medical problems incidence of BDI requiring reconstruction after LC was such as cardiovascular disease, neurologic disease, and 0.11% compared to 0.15% during 1991–2000 (p < 0.001). dementia, they were not considered as indications for sur- The average mortality rate for patients undergoing biliary gery under general anesthesia. reconstruction was 4.3% vs. 4.5% (p = 0.576) as reported previously. All patients were categorized as moderate or severe cho- lecystitis. Average age of Group A and Group B were 74 CONCLUSIONS: The incidence of major BDI requiring and 83. One patient of each group died (3.1% and 2.9%) reconstruction after LC has decreased slightly compared to without discharge from the hospital. Rate of acalculous that seen between 1991 and 2000. In addition, associated cholecystitis was 25% and 38%, respectively. Cholecystitis mortality rates are similar. This suggests that BDI requiring recurred in four patients of Group B (12%) and all of them reconstruction after LC has attained a consistently low rate were calculous. No signifi cant difference was noted in the between 2001 and 2009. prognosis of the two groups. CONCLUSION: Though the recurrence rate of Group B was not negligible, total prognosis of each group was not signifi - cant. Therefore, PTGBD without cholecystectomy is likely to be acceptable for high-risk patients with acute cholecys- titis, and cholecystectomy should be reserved for a salvage procedure after recurrence.

118 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1695 CONCLUSION: Percutaneous remains a valuable tool to treat cholecystitis in high risk popula- Percutaneous Cholecystostomy Placement in a tions. This study illustrates that cholecystostomy tube High Risk Population with Acute Cholecystitis placement can be the defi nitive treatment for acute cho- Ariana M. Winder, Joseph A. Blansfi eld, Valerie Erath, lecystitis in high risk populations. Further studies will be Todd Ellison, Nicole Woll, Marie A. Hunsinger, Mohsen M. needed to delineate which patients will eventually need a Shabahang, John A. Semian, Mohanbabu B. Alaparthi cholecystectomy. Surgical Oncology, Geisinger Medical Center, Danville, PA BACKGROUND: The standard of care for cholecystitis is Clinical: Colon-Rectal cholecystectomy, however in high risk surgical patients the mortality rate from cholecystectomy can be as high as 18 to 30%. An alternative for this population is placement of Mo1696 a percutaneous transhepatic cholecystostomy which allows Congenital Pouch Colon: A Clinical Study for cholecystectomy electively, under more stable condi- Kewal K. Maudar tions. The goal of this study was to evaluate cholecystos- 1G.I. Surgery, Bhopal Memorial Hospital & Research Centre, Bhopal, tomy use at our institution, study predictors of success 2 with this treatment in high risk patients, and study which India; Paediatric Surgery, Gandhi Medical College, Bhopal, India patients were treated defi nitively with cholecystomy tube INTRODUCTION: Congenital pouch colon (CPC) is a placement. rare supralevator anorectal anomaly in which the whole of METHODS: All patients who underwent cholecystostomy colon or part of the colon is replaced by a pouch like dila- tube placement between 2007 and 2012 were included in tation. The pouch ends blindly with urogenital tract com- this study. Electronic health records were retrospectively munication. The present study highlights the incidence, reviewed to delineate factors related to cholecystostomy classifi cation and management of CPC failure based on two criteria: the need for cholecystectomy METHODS: 104 cases of congenital pouch colon managed within 14 days of cholecystostomy placement or death from Jan, 2000 to Oct, 2012 were reviewed. 83 male and 21 within 30 days following cholecystostomy. female neonates were operated for CPC. RESULTS: Seventy-six patients (32 women, 42%) with a RESULTS: CPC accounts for 12.55% of all anorectal mal- mean age of 67 years old (range: 24–94) underwent chole- formations (ARM) and 23.33% of high ARM. The average cystostomy during the study period. The patients had an age of presentation was 2.16 days; 28.5% with poor general average of three comorbid conditions. Overall, 53 (70%) condition. Preoperative diagnosis of CPC was possible in patients treated with cholecystostomy experienced clini- 71% of cases in our study. Sixty-four percent (n = 36) of cal success as defi ned above. Twenty-three patients (30%) cases had incomplete pouch colon while 35% (n = 20) had underwent cholecystostomy tube placement that was complete pouch colon. As initial procedures for incomplete a clinical failure. Of these, 6 patients (8% of the entire CPC included right transverse colostomy done in 40%, and cohort) needed cholecystectomy within 14 days of cho- colostomy at descending colon just proximal to pouch in lecystostomy. Twenty patients (29% of the entire cohort) 10%. Ileostomy in 20% & window colostomy in 30% was died within 30 days of the procedure (3 patients failed both done for complete CPC. As defi nitive procedures; pouch criteria). A uni-variate analysis was performed to determine excision and abdomino-perineal pull-through of colon was if there were certain patient characteristics that would pre- done in 53, coloplasty & abdomino-perineal pull-through dict cholecystostomy treatment failure but the only statisti- of coloplasty colon was done in 15, & pouch excision &

cally signifi cant indicators for risk of death within 30 days abdomino-perineal pull-through of terminal ileum was Poster Abstracts were intensive care unit (ICU) admission (p = 0.001) and done in 20 cases. patients who had shock or sepsis (p = 0.02). Other clinical CONCLUSION(S): Staged Surgical procedures were safe Monday factors did not prove to be predictive of success including with overall mortality of 17%. comorbidities, method of presentation, imaging character- istics, antibiotic usage, bile cultures, and American Society of Anesthesiologists (ASA) physical status classifi cation. Of the 76 total patients, 24 (31.6%) had a cholecystectomy an average of 66 days following cholecystostomy place- ment (Interquartile range: 19, 71). Of the 53 patients who experienced initial clinical success, 35 patients (66% of these patients) were defi nitively treated and did not need a cholecystectomy.

119 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1697 Colonic Disasters Approached by Emergent Total Colectomy: Lessons Learned from 120 Consecutive Cases Michael Schweigert1, Attila Dubecz1, Norbert Solymosi2, Hubert J. Stein3, Dietmar Ofner1 1Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; 2Szent István University, Budapest, Hungary; 3Department of Surgery, Paracelsus Medical University, Salzburg, Austria OBJECTIVE: Diverse abdominal emergencies result in irreversible devitalization of the colon. Mainly the very elderly are affected. Morbidity and mortality are signifi cant while adequate surgical strategies are still controversially discussed. Aim of this study is to investigate the outcome of emergent complete colectomy with special respect to results in the very elderly. MATERIAL AND METHODS: Records of 120 consecutive patients who underwent emergent subtotal or total colec- tomy at a German tertiary referral hospital were reviewed in a retrospective study. Indication groups as well as age groups were formed for statistical analysis. RESULTS: There were 73 male and 47 female patients with a mean age of 70 years. Altogether 81 total and 39 subto- tal colectomies were performed for mainly ischemia related infarction (62), obstructing carcinoma (17), fulminant diverticulitis (10), ulcerative colitis (9) and pseu- domembranous colitis (7). Mean ASA score was 3.47. Severe sepsis or even septic shock was present in 82 cases. In-hospital-mortality was 42. Col- ectomy for ischemic bowel infarction showed signifi cant higher mortality than for pseudomembranous colitis (p = 0.018) whereas there were no further signifi cant differences amidst the indication groups. Between the age groups there was neither signifi cant difference in mortality nor in prevalence of sepsis. However, sepsis (OR: 16.81; 95% CI 3.89–153.32; p < 0.001), ASA score ≥4 (OR: 5.84; 95% CI: 2.33–16.00; p < 0.001) and total colectomy (OR: 4.40; 95% CI: 1.57–14.12; p = 0.02) were associated with higher mortality. CONCLUSIONS: Emergent colectomy provides a practi- cal solution for a wide range of heterogeneous abdominal Figure 1: Ischemic colitis with transmural infarction Fig 1a shows emergencies resulting in colonic disintegration and necro- complete gangrene of the colon in an 82-year-old man. The specimen sis. Outcome depends on the underlying disease, ASA score, is ischemic and necrotic from cecum to sigmoid colon. Fig 1b shows extent of colonic resection and presence of sepsis whereas a colectomy specimen from a 78-year-old woman. Easily visible are age shows no signifi cant infl uence. Therefore, we conclude multiple black colored sections resembling transmural gangrene. that advanced age itself should not be regarded as contrain- dication for emergent colectomy.

120 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1698 A Comparison of Tumour and Host Determinants of Outcome in Screen Detected Versus Non-Screen Detected Colorectal Cancer: A Contemporaneous Study David Mansouri1, Donald C. Mcmillan1, Campbell S. Roxburgh1, Emilia Crighton2, Paul G. Horgan1 1Academic Department of Surgery, University of Glasgow, Glasgow, United Kingdom; 2Public Health Directorate, NHS Greater Glasgow & Clyde, Glasgow, United Kingdom BACKGROUND: Screening for colorectal cancer using the faecal occult blood test (FOBt) has been shown to reduce cancer specifi c mortality through the detection of early stage disease. However, it is recognised that there are addi- tional tumour factors, such as the presence of venous inva- sion, and host factors, including the systemic infl ammatory response, that are key determinants of outcome indepen- dent of stage. To date, the prevalence of such factors has not been examined in screen-detected colorectal cancer (1). AIM: The aim of this study was to compare the prevalence of tumour and host determinants of outcome in patients with screen detected (SD) and non-screen detected (NSD) colorectal cancer in a contemporaneous group. METHODS: All patients who underwent potentially cura- tive surgery for colorectal cancer either via the national FOBt screening programme (SD) or presented symptomati- cally in a single institution (NSD) between May 2009 and April 2011 were identifi ed from prospectively maintained databases. RESULTS: A total of 394 (288 SD, 106 NSD) patients were identifi ed. Compared with the NSD patients, SD patients were more likely to be younger (p < 0.001) and have tumours that were colonic (p = 0.001), left sided (p < 0.001) and of an earlier stage (50% Dukes A vs 17% Dukes A, p < 0.001). When high risk tumour features were examined, vascular invasion (p = 0.023), margin involvement (p = 0.009), poor differentiation (p = 0.009) and tumour per- foration (p = 0.093) were all less likely to be present in SD tumours. The systemic infl ammatory response, as measured by the Neutrophil to Lymphocyte Ratio (NLR), was elevated in signifi cantly less SD patients than NSD patients (NLR > 5 Poster Abstracts in 7% vs 24%, p < 0.001). In addition, less SD patients were anaemic (22% vs 50%, p < 0.001). Monday When node negative patients were examined indepen- dently (n = 242;177 SD, 65 NSD), the differences in both the tumour and host determinants of outcome remained. SD patients had less evidence of vascular invasion (p = 0.034), margin involvement (p = 0.039) and tumour perforation (p = 0.059), in addition to having a lower systemic infl am- Figure 2: Acutely obstructing carcinoma of the left colon Due to acute matory response (NLR > 5 in 7% vs 23%, p < 0.001) and less large bowel obstruction the abdomen is monstrously distended. Fig 2a anaemia (18% vs 54%, p < 0.001) than NSD patients. shows the female patient already placed in supine position ready for CONCLUSIONS: The results from this study suggest that, surgery. The large intestine is bulging out immediately after laparotomy compared with NSD tumours, SD tumours, in addition to (Fig 2b). Serosal rupture and bursting of the tenia (arrows) are clearly being of an earlier stage, have more favourable tumour visible. Some parts of the distended colon show ischemic lesions. Fig 2c pathological features. Furthermore, adverse host prognostic shows the specimen following total colectomy. An acutely obstructing factors such as the presence of anaemia and an elevated carcinoma of the sigmoid colon (arrow) was causative for the ileus. Again systemic infl ammatory response are also less likely to be serosal tears and bursting is obvious. present in patients with SD tumours.

121 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

REFERENCES: However, data on their effect on infective complications 1. Mansouri D, et al. Screening for colorectal cancer: What and the systemic infl ammatory response remains limited. is the impact on the determinants of outcome? Crit Rev Recent studies have shown that the magnitude of the sys- Oncol Hematol. 2012. Epub September 2012. temic infl ammatory response following surgery predicts the development of infective complications. The aim of the Comparison of Tumour and Host Determinants of Outcome in present study was to assess the impact of enhanced recov- Screen Detected vs. Non-Screen Detected Colorectal Cancer ery on the rate of infective complications, and the sys- temic infl ammatory response, following colorectal cancer Screen Non-Screen resection. Detected Detected n (%) n (%) p-Value METHODS: Patients undergoing elective resection for colorectal cancer were included in the study (n = 310). The 288 (100) 106 (100) patients were admitted to one of two independent colorec- Tumour stage tal units. One unit employed enhanced recovery procedures A 144 (50) 17 (17) (n = 150), the other used conventional care (n = 160). From B 67 (23) 50 (47) a prospectively maintained database, data on postoperative C 70 (24) 31 (29) infective complications and C-reactive protein concentra- D 7 (2) 8 (8) <0.001 tions on postoperative days 1 to 5 was extracted. Vascular invasion (a) RESULTS: A total of 310 patients were included. Age and Y/N 121 (42)/160 (56) 61 (58)/43 (41) 0.023 sex were similar in both groups. Co-morbidity, as demon- Peritoneal involvement strated by ASA scores, was signifi cantly less in the enhanced Y/N 11 (4)/277 (96) 22 (21)/85 (79) <0.001 recovery group, and there were also fewer rectal cancers as Margin involvement well as earlier tumour stage (p = 0.005, p = 0.030, and p = Y/N 6 (2)/282 (98) 8 (8)/98 (92) 0.009 0.008 respectively). In the enhanced recovery group length Tumour perforation of stay was signifi cantly shorter and laparoscopic surgery Y/N 2 (1)/286 (99) 3 (3)/103 (97) 0.093 was used in approximately 30% of cases (both p < 0.001). Poorly differentiated The method of perioperative care was not signifi cantly asso- Y/N 6 (2)/282 (98) 8 (8)/98 (92) 0.009 ciated with a difference in the rate of postoperative infec- Neutrophil:Lymphocyte tive complications, or C-reactive protein on postoperative Ratio (b) days 1 to 5. ≥ 5/<5 16 (7)/230 (93) 25 (24)/79 (76) <0.001 When patients with rectal cancers were excluded from fur- Anaemia (b) ther analysis (n = 211), age, sex and tumour stage were sim- Y/N 53 (22)/193 (78) 52 (50)/52 (50) <0.001 ilar in both groups. Co-morbidity remained signifi cantly less in the enhanced recovery group (p = 0.024), length of [a. n = 385 (98%): b. n = 350 (89%)] stay was signifi cantly shorter and laparoscopic surgery was used in 30% of cases (both p < 0.001). Enhanced recovery Mo1699 was signifi cantly associated with a reduction in the devel- opment of pneumonia following elective surgery for colon Infective Complications Following Colorectal Cancer cancer (p = 0.028), but was not associated with a signifi cant Resection: Enhanced Recovery Confers No Advantage difference in the systemic infl ammatory response following on postoperative days 1 to 5. over Conventional Care Michelle L. Ramanathan1, Graham Mackay2, CONCLUSION: Enhanced recovery was associated with Jonathan J. Platt1, Paul G. Horgan1, Donald C. Mcmillan1 a signifi cant reduction in length of hospital stay. In con- trast, the post-operative systemic infl ammatory response 1Department of Surgery, University of Glasgow, Glasgow, United 2 was similar in the conventional care and enhanced recov- Kingdom; Department of Surgery, Glasgow Royal Infi rmary, Glasgow, ery groups. Overall complication rates, both infective and United Kingdom non-infective, were also similar. Enhanced recovery does AIM: Enhanced recovery after surgery programmes aim to not appear to be associated with a reduction in the postop- attenuate the stress response to surgery and are said to be erative systemic infl ammatory response or overall infective associated with reduced hospital morbidity and mortality. complications.

122 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1700 ability to tolerate a diet or resolution of obstructive symp- toms (successful treatment), rates of re-obstruction, hospital Palliative Surgery for Malignant Bowel Obstruction: length of stay, and quality of life. We excluded case studies A Systematic Review with fewer than 5 patients, studies of operations with cura- Terrah J. Paul Olson1, Carolyn Pinkerton2, Karen J. Brasel2, tive rather than palliative intent, studies of percutaneous Margaret L. Schwarze3 procedures, and studies where outcomes of benign obstruc- 1General Surgery, University of Wisconsin Hospital and Clinics, tion could not be separated from malignant. Madison, WI; 2Surgery, Medical College of Wisconsin, Milwaukee, RESULTS: We screened 2347 titles and selected 109 articles WI; 3Division of Vascular Surgery, University of Wisconsin School of for review. Fifteen studies fi t our inclusion and exclusion Medicine and Public Health, Madison, WI criteria. Survival and post-operative outcomes are summa- rized in the table. Median postoperative survival was low OBJECTIVES: Malignant bowel obstruction (MBO) from (range 36 days-7.9 months) while postoperative mortality peritoneal metastasis has a grim prognosis regardless of the was high (range 6–32%). Complications included wound primary cancer. Patients presenting with MBO have a life dehiscence, enterocutaneous fi stulae, sepsis, pulmonary expectancy of weeks to months. When conservative treat- emboli, and cardiopulmonary complications. Median ments such as medications and gastric drainage are inad- lengths of stay ranged from 13–25 days. Rates of re-obstruc- equate, palliative surgery may provide symptomatic relief. tion varied widely (range 6–47%). No studies reported qual- Morbidity and mortality after surgery for MBO is high, and ity of life postoperatively. effects of palliative surgery on patients’ quality of life are not well characterized. We performed a systematic review to DISCUSSION: This review highlights postoperative out- better characterize palliative surgery outcomes for patients comes that can be used preoperatively to inform surgical with MBO to guide decision making about the value of sur- decision making for MBO. Given the high mortality and gery and associated postoperative interventions in the set- substantial length of stay relative to overall survival, a thor- ting of incurable cancer. ough discussion of the patient’s values and goals is advis- able. Patients should be apprised of the modest chance of MATERIALS AND METHODS: We searched PubMed, resuming a diet or relieving symptoms. Because 30–40% of EMBASE, CINAHL Plus, Cochrane Library, Web of Knowl- these terminally ill patients will experience serious compli- edge, and Google Scholar from inception through August cations, patients should discuss whether aggressive man- 2012 for all available literature in all languages. We included agement of postoperative complications is in line with their studies reporting outcomes after open or laparoscopic sur- goals. Additionally, this study highlights a profound lack of gery for bowel obstruction from peritoneal metastases from attention to patient-centered outcomes for palliative surgi- any primary malignancy. Outcomes of interest included sur- cal therapy. vival, postoperative mortality, postoperative complications,

Table: Outcomes After Palliative Surgery for Malignant Bowel Obstruction

Post-Operative Post-Operative Study N Malignancy Survival Mortality Complications Successful Treatment Abbas 2006, 2007 79 CRC*, GYN†, other Median 5 months 10% (8/79) 35% (28/79) Not reported Blair 2001 63 CRC, non-GYN other Median 3 months 21% (13/63) 44% (28/63) 45% (29/63) Lau 1993 30 CRC Not reported 17% (5/30) 27% (8/30) Not reported Mäkelä 1991 85 CRC, GYN, other Median 3 months 22% (19/85) 42% (36/85) 55% (47/85) (range 0–144 months) Turnbull 1989 89 CRC, non-GYN other Median 98 days 13% (12/89) 44% (39/89) 74% (66/89) Poster Abstracts (range 1 day–2.5 years) Van Ooijen 1993 20 GYN, CRC, other Median 36 days Not reported 5% (1/20) Not reported Monday (range 3–151 days Wong 2009 27 CRC, GYN, other Not reported 15% (4/27) Not reported 85% (23/27) Bais 1995 19 Ovarian Median 109 days 11% (2/19) 32% (6/19) 68% (13/19) (range 15–775 days) Kim 2009 23 Ovarian Not reported Not reported 13% (3/23) 48% (11/23) Kolomainen 2012 90 Ovarian Median 90.5 days 18% (16/90) 27% (24/90) 66% (59/90) (range <1 day–6 years) Lund 1989 25 Ovarian Median 68 days 32% (8/25) 32% (8/25) 20% (5/25) (range 7–919 days) Mangili 2005 27 Ovarian Not reported 22% (6/27) 33% (9/27) 59% (16/27) Piver 1982 60 Ovarian Median 2.5 months 17% (10/60) 31% (19/60) Not reported (range <1–27 months) Pothuri 2003 64 Ovarian Median 7.9 months 6% (4/64) 23% (15/64) 58% (37/64) Rubin 1989 52 Ovarian Median 5.8 months 17% (9/52) 15% (8/52) 65% (34/52) (range 0.02–37 months) *Colorectal cancer †Gynecologic malignancies including ovarian, cervical, uterine, and endometrial cancers

123 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1701 Surgical Stricturoplasty in the Treatment of Pouch Strictures Xian-Rui Wu1, Saurabh Mukewar2, Pokala R. Kiran1, Feza H. Remzi1, Bo Shen2 1Departments of Colorectal Surgery, Cleveland Clinic, Cleveland, OH; 2Department of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, OH OBJECTIVE: To evaluate the effi cacy of stricturoplasty in the treatment of pouch strictures in comparison with endo- scopic balloon dilation. CONCLUSIONS: Patients with pouch strictures had a SUMMARY BACKGROUND DATA: There was only one similar overall pouch survival after being treated with stric- case report on surgical stricturosplasty in treating pouch turoplasty and endoscopic balloon dilation. Surgical stric- strictures. turoplasty tended to have a better stricture-free survival benefi t. METHODS: Consecutive infl ammatory bowel disease (IBD) patients with ileal pouch strictures seen in our Pou- chitis Clinic from 2002–2012 were studied. Effi cacy and Mo1702 safety were evaluated with both univariate and multivari- Outpatient Anal Exploration and Fistula Treatment in ate analysis. Patients with Symptomatic Peri-Anal Crohn’s Disease: RESULTS: A total of 167 patients met the inclusion criteria, Preliminary Report including 16 (9.6%) who had surgical stricturoplasty and Rosa Scaramuzzo, Edoardo Iaculli, Cristina Fiorani, 151 (90.4%) had at least one endoscopic stricture dilation Livia Biancone, Giovanna Del Vecchio Blanco, Sara Di Carlo, therapy. Ninety-four patients (56.3%) were male, with a mean age at the diagnosis of pouch strictures of 41.6 ± 13.2 Giuseppe S. Sica years. Fifty-one patients (30.5%) had multiple pouch stric- Tor Vergata, Rome, Italy tures, and pouch inlet strictures occurred in 100 (59.9%). BACKGROUND: One third of Crohn’s disease (CD) The mean length of pouch strictures was 1.2 ± 0.6 cm. No patients presents fi stula in ano. Peri-anal disease (PAD) in difference was identifi ed between the stricturoplasty and CD patients can be clinically asymptomatic or extremely dilation groups in clinicopathological variables, except for severe. Gold standard in the diagnosis and treatment of degree of strictures (P = 0.019). After a mean follow-up of 4.1 symptomatic PAD in CD is the exploration of the ± 2.6 years, pouch stricture recurred in 92 patients (55.1%) and distal rectum under anesthesia (EUA). This procedure is and 21 (12.6%) developed pouch failure. The time interval generally offered as a day case surgery. Giving the shortage between the procedure and pouch stricture recurrence or of resources, it is not always possible to proceed as planned, pouch failure was longer in the stricturoplasty group than and an incorrect timing may well represent a relevant issue in the dilation group (P < 0.001). Although patients in the in the clinical management of these patients. two groups had a similar overall pouch survival (5-year In a prospective longitudinal study we aimed to assess the overall-pouch-survival: 83.1% vs. 82.0%), patients treated feasibility of an outpatient assessment and treatment of with stricturoplasty seemed to bear a better pouch stricture- symptomatic PAD in CD patients. free survival than those with endoscopic balloon dilation (5-year pouch-stricture-free-survival: 39.8% vs. 33.1%). METHODS: All CD patients under regular follow-up at There was no difference in complication rates between the our Infl ammatory Bowel Disease referral center, presenting two groups. with symptomatic PAD, were offered surgical consultation. Data of patients seen between February 2010 until April Table: Multivariate Analysis of the Risk Factors Associated with Overall 2011 were collected for the purpose of the study. All clinical Pouch Survival and Pouch Stricture-Free Survival information, including previous EUA and\or records from Characteristic Hazard Ratio 95% CI P Value Magnetic Resonance Imaging and endoscopic ultrasound were reviewed. Outpatient anal canal exploration (OE) Overall Pouch Survival and treatment was undertaken during the specialist surgi- Postop use of biologics (yes vs no) 6.249 2.296–17.012 <0.001 cal consultation. Fistula were classifi ed according to Park’s Degree of stricture (3 vs 1 or 2) 4.125 1.707–9.970 0.002 classifi cation; type of outpatient treatment and compliance Post-IPAA complications (yes vs no) 5.528 2.038–14.995 0.001 were recorded and pain was assessed by VAS scale at the Treatment modality (stricturoplasty vs 0.974 0.205–4.632 0.973 time of the procedure. Patients were followed up in the sur- endoscopic balloon dilation) gical clinic for 12 months. Pouch Stricture-free Survival Number of stricture (2 vs 1) 4.827 3.167–7.356 <0.001 RESULTS: During the study period, 26 CD patients with Degree of stricture (3 vs 1 or 2) 2.005 1.239–3.245 0.005 symptomatic PAD were referred to the surgical outpatient clinic. All the 26 non selected patients were offered surgi- Treatment modality (stricturoplasty vs 0.548 0.279–1.075 0.080 endoscopic balloon dilation) cal exploration. Compliance was excellent as none refused the proposed treatment. It was possible to perform a full

124 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

OE in 23 (88%) patients. In Table 1 are reported details of CONCLUSIONS. From this preliminary experience, OE procedure and fi ndings. In 23 patients (88%) it was possible and fi stula treatment because of symptomatic PAD in CD to complete OE of the anal canal and distal rectum. Out seems to be feasible in referral centers, with results compa- of these 23 patients in 20 (87%) a surgical procedure was rable with most EUA series. undertaken (77% of the grand total).

Results of the Study According to Park’s Classifi cation

Imaging Concordance Outpatents Treatment VAS Relapse After # of Exams with Imaging Type of Fistula # % Setonage Drainage # of Treatment (Median 0–10) Procedure # (%) MRI US MRI US Suprasphinteric 7 (6) *, (1) ** 30 2 (28%) 4 (57%) 1 (14%) 1.57 (0–3) 1 (14%) 2 1 1/2 1/1 Intersphinteric 4 (3) * 17 3 (75%) 1 (25%) 0 2.25 (1–4) 0 1 0 1/1 -– Extrasphinteric 6 (2) *, 26 5 (83%) 0 1 (17%) 1.7 (1–3) 3 (50%) 4 0 3/1 -– Trans-sphinteric 3 (1) * 12 2 (66%) 0 1 (33%) 1.7 (0–4) 0 2 1 1/2 1/1 Rectovaginal 2 (1) *, (2) ** 9 2 (100%) 0 0 2.5 (2–3) 0 1 1 1/1 1/1 Unclassifi ed 2 (1) * 9 0 2 (100%) 0 1 (1–1) 0 1 0 0/1 – () * fi stula relapsed after previous treatment () ** fi stula with more than one tract

Mo1703 observed a subclinical myopathy characterized by an abnor- mal distribution of myonuclei relocated from the periphery Clinical Profi le and Skeletal Muscle Histopathology inside the myofi ber, and by the presence of regenerating of Patients Affected with Early Diagnosed Colorectal muscle fi bers. The percentage of myofi bers with abnormally Cancer: Diagnostic and Prognostic Markers of Disease? located myonuclei was signifi cantly higher in patients Mario Gruppo1, Nicoletta Adami2, Sandra Zampieri2, (median = 9%) compared to controls (median = 2.7%) (p = Roberto Rizzato1, Mario Bernardo3, Benedetto Mungo1, 0.0002). Moreover, the percentage of regenerating myofi - ber expressing the MHC-emb and N-CAM biomarkers was Renato Salvador1, Lino Polese1, Stefano Merigliano1 1 higher in patients compared to controls (MHC-emb posi- Department of Surgical, Oncological and Gastroenterological tive 14,6% vs 5,9% p = n.s; N-CAM positive 31,7% vs 5,9%, 2 Sciences, University Hospital of Padua, Padova, Italy; Department p = 0.04) (Table 1). No correlations were found between of Biomedical Sciences, University Hospital of Padua, Padova, Italy; the histopathological fi ndings of the skeletal muscle and 3Department of Emergency, Anaesthesiology and Intensive care, clinico-serological characteristics of the patients. We found University of Tor Vergata, Rome, Italy an inverse correlation between the number of abnormally BACKGROUND: Skeletal muscle in patients with cancer nucleated myofi bers and the presence of lymph node undergoes many morphological changes due to immuno- metastasis (N + ) (ñ) = -0.64 (p = 0.002). Myofi bers atrophy infl ammatory factors of tumor origin and/or to the phar- wasn’t observed. The ATPase analyses of skeletal muscle macologic treatment of the disease. The latest event of biopsies from patients and controls showed a higher per- these changes is cancer cachexia. centage of fast type fi bers in skeletal muscle biopsies from cancer patients compared to controls (56% vs 46%, p = The aim of our study was to investigate the clinical charac- 0.06) (Table 1). Interestingly, the internally nucleated myo- teristics and the histopathologic features of skeletal muscle fi bers were predominantly of fast type (Figure 1). and excised tumor from patients affected with colorectal Poster Abstracts cancer at diagnosis in order to possibly identify clinical fac- Table 1: Histopathological Features of Rectus Abdominis Muscle Biopsies tors associated to myopathic features that could be used as Monday Patients Controls p predictive biomarkers of disease progression. Mean myofi ber diameter (m) 51.1 50.3 n.s. PATIENTS AND METHODS: Morphometric studies and Abnormally nucleated myofi bers (%) 9 2.7 0.0002 immunohistochemical analyses were performed on intraop- Type II fi bers (%) 56 46 0.06 erative rectus abdominis muscle biopsies from weight stable MHC-emb positive myofi bers (%, no.) 14.6 (6) 5,9 (1) n.s patients with an early diagnosis of colorectal cancer, before N-CAM positive myofi bers (%, no.) 31.7 (3) 5,9 (1) 0.04 systemic or radiant therapies, with no signs of muscle weak- MHC-emb embryonic myosin heavy chain; N-CAM neural cell adhesion molecule; ness or myopathies. The correlation between histopatho- n.s. not signifi cant. logic fi ndings of skeletal muscle biopsies, resected tumor, and clinico-serological characteristics was investigated. RESULTS: 44 patients and 17 controls affected with non- infl ammatory benign diseases, were recruited for the study. In the skeletal muscle biopsies from cancer patients, we

125 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

analyze categorical variables and a Mann-Whitney test used for continuous variables. A forward logistic regression was utilized to identify factors independently associated with the need for reoperation using all available covariates, with a p-value <0.05 considered to be statistically signifi cant. RESULTS: 61 patients met study inclusion criteria. Median age of the study cohort was 45 (range, 14–92) years, and included 32 males (53%). Indications for surgery were infl ammatory bowel disease (n = 25), cancer (n = 15), small bowel obstruction (n = 9), and other conditions (n = 12). Anastomotic types included enterocolic (n = 17), enteroenteric (n = 16), enteroanal (n = 14), colorectal (n Figure 1: A and B: ATPase staining after preincubation at pH 4.35, of = 8), colocolonic (n = 4) and coloanal (n = 2). Twenty- two patients (36%) had an infraperitoneal anastomosis. 50 cross sections from control (A) and patient (B) muscle biopsies. Fast- patients (82%) successfully underwent therapeutic PD of a type fi bers are visualized as light, while slow-twitch fi bers are dark. perianastomotic fl uid collection, with median follow-up of Fast fi bers are predominant in cancer patients muscle biopsies and 16 months. 11 patients (18%), at a median interval of 16 preferentially show internal nuclei (arrowhead). Calibration bar = 100 m. days, required reoperation following PD. A forward logis- tic regression showed cardiopulmonary disease (p = 0.03) CONCLUSIONS: Patients affected with colorectal cancer and cancer surgery (p = 0.01) to be factors independently display early signs of a subclinical myopathy, character- associated with the need for reoperation. Level of the anas- ized by abnormally nucleated and regenerating myofi bers, tomosis, initial fecal diversion/stoma, fl uid collection size that is inversely associated with the presence of lymph and microbiology of aspirate did not predict failure of PD. node metastasis. Additional follow-up studies are needed to CONCLUSION: Cardiopulmonary disease and cancer sur- clarify this association, but our observation could provide gery appear to be independent predictors for failure of PD new diagnostic biomarker of disease progression in specifi c and the need for reoperation following symptomatic GI subgroup of patients. anastomotic leak. For patients without these risk factors, PD is a valuable tool for managing anastomotic leaks con- Mo1704 servatively with a high degree of success. Risk Factors for Failure of Percutaneous Drainage Mo1706 and Need for Re-Operation Following Symptomatic Gastrointestinal Anastomotic Leak The Impact of Laparoscopic Versus Open Approach on Seth Felder, Galinos Barmparas, Zuri A. Murrell, Phillip Fleshner Re-Operation Rate After Segmental Colectomy Surgery, Cedars-Sinai Medical Center, Los Angeles, CA Paul Speicher, Betty Jiang, John Migaly BACKGROUND: Anastomotic leak is a devastating com- Surgery, Duke University Medical Center, Durham, NC plication following gastrointestinal (GI) surgery. Few stud- BACKGROUND: Unplanned return to the operating room ies have evaluated the role of CT-guided percutaneous has recently gained favor as a reliable indicator of surgery- drainage (PD) in the management of these leaks. The aim specifi c complications. Despite this, reoperation rate has of this study was to defi ne predictive clinical, laboratory, not been well studied as a primary outcome when compar- radiographic, or operative factors for CT-guided PD failure ing laparoscopic with open approaches for colorectal resec- of symptomatic anastomotic leaks after GI surgery. tion. The goal of this study was to determine the impact of METHODS: A 10-year retrospective review of an interven- a laparoscopic approach on rate of reoperation after elective tional radiology database was conducted to identify patients segmental colectomy. with symptomatic anastomotic leak after undergoing GI METHODS: The NSQIP Participant Use Data File for 2005– surgery. Inclusion criteria were patients having small bowel 2011 was used to retrospectively identify all patients who or colorectal surgery, the operating surgeon documenting underwent either open or laparoscopic segmental colon clinical concern for postoperative anastomotic leak, a sup- resection for neoplasms, diverticular disease, and polyp porting CT demonstrating a fl uid collection adjacent to an disease. To capture only elective cases, the following were anastomosis, and the use of PD as initial therapy. Exclusion excluded: emergency cases, ASA class 5 (moribund patient criteria included patients undergoing foregut surgery, con- who is not expected to survive without the operation), and comitantly undergoing hepatobiliary or pancreatic anasto- preoperative sepsis. The primary outcome measure was rate moses, and/or solid organ resection. Patient characteristics of early return to the operating room, defi ned in NSQIP (clinical, laboratory, radiographic, operative) following as returns to the operating room within the 30-day post- a technically successful PD who then failed and required operative period. A multiple logistic regression model was reoperation for anastomotic leak were compared to those constructed to determine the independent effect of surgical successfully treated with PD. Fisher’s exact test was used to approach on rates of unplanned reoperation.

126 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: Between 2005 and 2011, a total of 39,897 with inconclusive results. Using a large administrative data- patients were identifi ed who met the study inclusion cri- set, we found that for segmental colectomy, laparoscopic teria. Preoperative characteristics between open and lapa- approach was associated with a small but statistically sig- roscopic groups were similar, despite being statistically nifi cant decrease in odds of return to the operating room. signifi cant due to very large sample sizes (Table 1). A total Reoperation is a relatively rare but costly complication after of 1,726 reoperations (4.3%) were identifi ed. In the open elective segmental colectomy, and remains a potential area approach group, 852 of 16,644 patients (5.1%) required for signifi cant quality improvement. reoperation, compared to 874 of 23,253 patients (3.8%) in Adjusted for the following pre-operative variables: age, the laparoscopic group. After adjusting for potential con- gender, smoking status, body mass index, alcohol use, founders, laparoscopic colorectal resection was found to functional independence level, do-not-resuscitate status, have an adjusted odds ratio of 0.82 (95% CI 0.74 to 0.92, p medical comorbidities (bleeding disorders, COPD, CAD, = 0.001) as compared to the traditional open approach for CHF, dyspnea, renal failure), case contamination, operative risk of return to the operating room. time, disseminated malignancy, pre-operative weight loss, DISCUSSION: Numerous studies have included reoperation chemotherapy, radiation therapy, ASA class 3 or greater, rate as a univariate secondary endpoint when comparing resident assistance in OR. laparoscopic versus open approach to colorectal procedures,

Preoperative and Intra-Operative Characteristics

Characteristic Surgical Approach Open (n = 16,644) Laparoscopic (n = 23,253) p-value Age (median) in years 67 (56,77) 65 (55,74) <0.001 Female gender 8752 (52.7%) 12045 (52.0%) 0.181 Smoking status 2967 (17.8%) 3367 (14.5%) <0.001 Preoperative dyspnea 2134 (12.8%) 2209 (9.5%) <0.001 Do-not-resuscitate order 169 (1.1%) 79 (0.4%) <0.001 Diabetes mellitus 2885 (17.3%) 3403 (14.6%) <0.001 Chronic steroid use 509 (3.1%) 481 (2.1%) <0.001 Non-independent functional status 996 (6.0%) 553 (2.4%) <0.001 Alcohol > 2 drinks/day 569 (3.8%) 704 (3.5%) 0.17 History of COPD 1106 (6.6%) 1015 (4.4%) <0.001 History of CAD 1865 (12.5%) 1953 (9.8%) <0.001 History of CHF 199 (1.2%) 138 (0.6%) <0.001 Dialysis-dependent preoperatively 122 (0.7%) 82 (0.4%) <0.001 Disseminated malignancy 965 (5.8%) 450 (1.9%) <0.001 >10% weight loss in last 6 months 1008 (6.1%) 545 (2.3%) <0.001 Bleeding disorder 767 (4.6%) 622 (2.7%) <0.001 Preoperative transfusion 240 (1.4%) 152 (0.7%) <0.001 Chemotherapy in 30 days preop 155 (1.0%) 75 (0.4%) <0.001 Poster Abstracts Radiation therapy in 90 days preop 51 (0.3%) 25 (0.1%) <0.001 Preoperative ventilator dependence 11 (0.1%) 2 (<0.1%) 0.002 Monday Resident participation in OR 8774 (60.3%) 11680 (60.1%) 0.71 Contaminated or dirty case 2715 (16.3%) 1884 (8.1%) <0.001 ASA class 3 or greater 9117 (54.8%) 9395 (40.4%) <0.001 Operative time (median) 131 (95,181) 141 (107,184) <0.001

Multivariable Logistic Regression for Postoperative Outcomes Following Laparoscopic Approach

95% Confi dence Interval Complication Odds Ratio Lower Upper p-Value Return to the operating room within 30 days 0.82 0.74 0.92 0.001 Superfi cial surgical site infection 0.64 0.59 0.70 <0.001 Deep incisional surgical site infection 0.50 0.40 0.63 <0.001 Organ space surgical site infection 0.76 0.66 0.88 <0.001 Post-operative sepsis 0.61 0.53 0.69 <0.001 All-cause 30-day mortality 0.58 0.47 0.73 <0.001

127 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1707 Mo1708 Insurance Affects Readmission After GI Surgery: A Local Excision of T1 and T2 Rectal Cancer: Proceed Longitudinal Analysis with Caution Zeling Chau1,2, Elan R. Witkowski1, Sing Chau NG2, Mohamed M. Elmessiry, Antonio Maya, Giovanna Da Silva, Elizaveta Ragulin-Coyne1, Heena P. Santry1, Tara S. Kent3, Steven Wexner, Mariana Berho A. James Moser2, Mark P. Callery3, Jennifer F. Tseng1,2 Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 1 Department of General Surgery, University of Massachusetts, PURPOSE: The purpose of this study was to compare the Worcester, MA; 2Division of Surgical Oncology, Beth Israel Medical results of local excision (LE) with total mesorectal excision Center – Harvard Medical School, Boston, MA; 3Department of (TME) of early rectal cancer Surgery, Beth Israel Medical Center – Harvard Medical School, METHODS: After IRB approval, medical records of patients Boston, MA with T1, T2 N0M0 rectal adenocarcinoma treated by cura- BACKGROUND: Hospital readmission rates are increas- tive LE or TME without preoperative radiotherapy from ingly used to measure quality of care. The impact of 2004 to 2012 were reviewed. Chi-square and ANOVA tests insurance on postoperative readmission rates is not well were used to compare categorical and continuous variables, characterized. We aimed to determine the impact of insur- respectively. Survival rates were compared using Kaplan- ance on short-term readmissions for GI surgery. Mayer test METHODS: Florida State Inpatient Database queried to RESULTS: 153 patients were included in the study, 79 identify all esophageal, gastric, pancreas, liver and colon underwent TME and 74 LE. The two groups were similar resections performed for cancer during 2007–2009. Patients in regards to age, gender, BMI, ASA score, co-morbidities, <18, ≥65 or with Medicare excluded to reduce the effect of tumor location, size, grade and stage. In TME, the mean Medicare confounding. Annual surgical volume calculated operative time was prolonged (196 vs. 77 min, P < 0.00), by tertiles. Readmission defi ned as inpatient admission ≤30 the mean estimated blood loss was signifi cantly more (214 days from index discharge. Univariate and multivariate vs. 26 ml, P < 0.00) and hospital stay was signifi cantly analyses performed by chi-square and logistic regression. increased (7.4 vs. 2.5 days, P < 0.001). No patient had stoma For all, p-values <0.05 considered signifi cant. after LE compared to 48.7% after TME (P = 0.00). Postopera- tive infection was more common after TME (21.6 vs. 0%, RESULTS: 7585 patients underwent esophageal, gastric, P = 0.00). Margins were involved by tumor in 13.5% after pancreas, liver and colon resections 2007–2009. Of those LE compared to 0% after TME (P = 0.00). 13.5% of patients 137 (1.8%) were esophagectomies, 516 (6.8%) gastrecto- treated initially by LE were re-operated for unfavorable his- mies, 458 (6.0%) pancreatectomies, 444 (5.9%) hepatecto- tological fi ndings and 4.1% had residual tumor. The mean mies and 6137 (80.9%) colectomies. Mean patient age was follow up period was 35 months). In 56 patients with pT1, 53.8 years. In all, 5549 patients (73%) had private insur- there was no mortality and although not statistically sig- ance, 894 (11.8%) Medicaid, and 1142 (15.1%) uninsured. nifi cant an increase in local recurrence after LE vs TME of Medicaid patients had worse overall outcomes, including 16.1 vs. 5.3%; P 0.20 and an increase in the estimated dis- mortality, LOS, complications and readmission rates (Table). ease-free survival (DFS) after TME 76.6 vs. 62.8% (P = 0.18). Overall 30-day readmission rate was 11.2% and increased In 68 patients with pT2, local recurrence was signifi cantly over the study period from 10.5 to 11.9%. Medicaid had the higher after LE (42.8 vs 6.3%, P 0.00), the estimated DFS highest readmission rates at 13.9% followed by uninsured was higher after TME 81.5 vs. 44.5% (P = 0.003). However, 11.9% and private 10.6%. In multivariable analysis, Med- there was no difference in the estimated overall survival, icaid insurance (OR 1.3 95% CI 1.1–1.7), increased patient 82.8% vs. 79.4% ( P = 0.93) comorbidities (OR 1.3 95% CI 1.0–1.5), and high volume hospitals (OR 1.4 95% CI 1.2–1.7) demonstrated associa- CONCLUSIONS: LE of early rectal cancer is associated with tions with readmission. a higher rate of local recurrence rates and decreased DFS. These disadvantages are especially signifi cant for T2 lesions. Table: Outcomes by Insurance Caution must be exercised when contemplating LE. Mortality Mean LOS Complications Readmission (%) (Days) (%) Rates (%) Medicaid 7.2 13.0 35.1 13.9 Uninsured 4.4 10.5 28 11.9 Private 3.7 8.5 23.7 10.6

CONCLUSION: Early readmissions after GI surgery remain high. Multiple factors, potentially including case complex- ity and patient population, may make high-volume hos- pitals such as academic hospitals particularly vulnerable. With the rise of global payments and Accountable Care Organizations, understanding and preventing readmission, including reducing insurance-related disparities, will be of paramount importance.

128 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1709 μ-receptor antagonist, has been demonstrated to accelerate GI recovery and reduce LOS after open bowel surgery in fi ve Outcomes of Survival in Converted Laparoscopic multicenter prospective, randomized controlled trials when Resections for Colorectal Malignancy over a 10-Year utilized in the setting of enhanced recovery pathways. Period Despite the relatively high cost of the drug, large case con- Arthur Yushuva, Andres X. Samayoa, Iswanto Sucandy, trol studies have estimated reductions in total hospital costs Soo Kim, Mark Zebley, Steven A. Fassler in patients receiving Alvimopan but based upon regional cost data. The purpose of this study was to evaluate clinical Colorectal Surgery, Abington Memorial Hospital, Abington, PA and economic outcomes (direct costs) for Alvimopan use in BACKGROUND: Laparoscopic colorectal surgery has com- laparoscopic surgery at a single institution. parable oncologic outcomes compared to open resections METHODS: The medical records at Huntington Hospital for cancer. The outcomes in patients undergoing laparo- were queried retrospectively between January 2010 and scopic conversions have been questioned by confl icting June 2012 for all patients ≥18 years of age who underwent reports. In a previous report published in 2008 we found no elective, laparoscopic small bowel, colon and/or rectal resec- change in overall survival in patients undergoing conver- tions with anastomoses (with/without diverting stomas). sion of a laparoscopic procedure for colorectal carcinoma. Patient who required TPN or end ostomies were excluded. However, the long-term outcomes are still uncertain due Patients were collected from a cohort of two surgeons who to limited number of publications. The present study is a frequently use Alvimopan. Characteristics of patients who 10-year follow-up of prospectively collected database to received Alvimopan were compared with historical controls evaluate the effect of conversion on long-term survival. of patients who did not receive Alvimopan. Outcome mea- METHODS: A retrospective review of prospectively col- sures including LOS, complications, readmission rates, and lected database of patients undergoing laparoscopic resec- direct hospital costs were compared. tion for colorectal cancer between January 1998 and June RESULTS: In this 27-month period, 94 patients under- 2009 in a single institution. The cohort was divided into went laparoscopic resections. Surgical indications included two groups: patients with successfully completed laparo- cancer (n = 46, 49%) and diverticulitis (n = 31, 33%) with scopic colectomy (LAP) and those whose colectomy was the remaining 17 (18%) consisting of infl ammatory bowel converted to open (CON). Only patients with stages 1–3 disease, colostomy reversal, and rectal prolapse. The mean were included. Patients with metastatic diseases where age of all patients was 62.5 ± 12.6 years, and 54 (57%) were excluded from the study. The overall survival was compared female. The laparoscopic procedures included 31 (33%) using Kaplan-Meier analysis. right colon resections, 56 (60%) left, sigmoid or low ante- RESULTS: A total of 425 patients were divided into 388 rior colon resections, 3 (3%) reversal of , and in the LAP group and 37 in CON group. There was no dif- 4 (4%) small bowel resections. There were no differences ference in age, gender, stage, number of harvested nodes between the groups for these parameters. For these cohorts and length of follow up between two groups (p > 0.288). of patients, use of this drug was associated with shorter LOS There was a signifi cant increase in median blood loss for and reduced total direct hospital costs (net of drug costs, CON group (350 ml vs. 100 ml; p < 0.001), increased length see Table 1). There were no differences between the groups of procedure (135 vs. 109.5 min; p < 0.001) and increased in mortality, GI morbidity, superfi cial or deep surgical site length of hospital stay in CON group (6 vs. 3 days; p < infections, or rates of reoperation or readmission. 0.001). Survival at 2, 3 and 5 years was: 84%, 79%, and 72%, respectively for the LAP group and 70%, 68%, and Laparoscopic Resections 62% in the CON group (Long-rank test: 0.016). Control Alvimopan

CONCLUSION: The results of this study propose that there n = 55 (mean) n = 39 (mean) Difference p-Value Poster Abstracts may be a survival disadvantage in patients requiring a con- LOS (days,SD) 5 ± 2.2 3.9 ± 1.5 –1.1 days 0.007 version for laparoscopic resection for colorectal malignancy. Direct Hospital 10091 ± 4038 8558 ± 2038 –$1533 0.032 Monday Cost ($,SD) Mo1710 CONCLUSIONS: Consistent with the tightly controlled Alvimopan Use Is Associated with Reduced Length of RCTs in open bowel resections showing a reduction in post- Stay and Direct Hospital Costs in Laparoscopic Bowel operative ileus and LOS, broadened use of Alvimopan in Resections laparoscopic surgery was associated with a reduction in LOS Aaron G. Lewis, Troy M. Maynor, Lisa Arnot, John Goeders, and direct hospital costs without increasing complication Ken Wong, Verenice Palestina, Gabriel Akopian, David Lourie, rates. Howard S. Kaufman Huntington Memorial Hospital, Pasadena, CA INTRODUCTION: Time to recovery of GI function is a major determinant of length of stay (LOS) in patients undergoing intestinal resection. Alvimopan, a selective gut

129 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1711 Mo1712 Lymph-Nodes Harvest Might Be Ameliorated by The Effects of Advanced Age on Post-Operative Ex-Vivo Intra-Arterial Methylene Blue Dye Injection Morbidity and Mortality Following Cytoreductive After Colorectal Cancer Surgery Surgery with Hyperthermic Intraperitoneal Pierpaolo Sileri, Luana Franceschilli, Ilaria C. Ciangola, Chemotherapy Federico Perrone, Nicola Di Lorenzo, Claudio Arcudi, Sarah J. Mcpartland, Martin D. Goodman Achille Gaspari Surgery, Tufts Medical Center, Shrewsbury, MA Surgery, University of Rome Tor Vergata, Rome, Italy INTRODUCTION: Cytoreductive surgery with heated INTRODUCTION: Lymph node (LN) assessment has a crit- intraperitoneal chemotherapy (CRS-HIPEC) can pro- ical role in staging colorectal cancer thus infl uence 5-year long survival in patients with advanced gastrointestinal survival rates. Despite this, several studies have shown that neoplasms confi ned to the peritoneal cavity. To date, no the nodal harvest is highly variable and often inadequate. prospective studies have addressed the feasibility of this In this study we retrospectively evaluated the adequacy of procedure in patients of advanced age. As a population, LN assessment in our institution and, prospectively, we patients of advanced age are at higher risk for perioperative evaluated if ex-vivo intra-arterial methylene blue dye injec- complications following any major abdominal surgery. It tion results in a better and more accurate lymph-nodes har- has been suggested in the literature that advanced age may vest at standard pathology dissection. We also correlated be a contraindication to this potentially life-saving proce- these with oncologic staging and outcome. dure. We sought to better quantify the effects of advanced METHODS: Inclusion criteria were: elective CRC sur- age on outcomes following CRS-HIPEC. gery (R-colectomy, L-colectomy, rectal anterior resection, METHODS: All patients who underwent pre-operative abdominal perineal excision); no prior colorectal surgery; evaluation for CRS-HIPEC from 2007 to 2012 were reviewed no preoperative evidence of distant metastatic disease; no for inclusion in the study. Patients for whom adequate previously undetected liver metastasis, advanced disease cytoreduction could not be achieved (and therefore intra- or carcinosis at surgery. We retrospectively analyzed 146 peritoneal chemotherapy was not provided) were excluded patients who underwent colorectal cancer resection from from the study. The patients for whom CRS-HIPEC was per- 5/2005 to 8/2009 to assess LNs counts (expressed in per- formed were subsequently grouped and analyzed accord- centages; <8 or 12 LNs). Prospectively, a total of 204 con- ing to age at time of surgery. Demographic, operative, and secutive patients with primary resectable were studied: after post-operative data was prospectively collected. Informed surgery, retrieved specimens were ex-vivo injected (98) or consent was obtained and the study received institutional not (106) with methylene blue die and sent for standard review board approval. pathology. Lymph-nodes were grouped into four categories RESULTS: Complete follow-up information was available according to the size: <1 mm,1–2 mm, 2–4 mm and greater for 99 patients. There were no statistically signifi cant dif- than 4 mm. Mann-Whitney and Student t-test were used ferences in 30-day mortality. Table 1 summarizes measured for statistical analysis. outcomes. Older patients had longer lengths of stay. Differ- RESULTS: In our retrospective cohort of patients mean ences in cardiac and pulmonary function were most affected number of retrieved LNs was 17 ± 7 being <8 LNs in 19% of by age. Patients over age 70 were less likely to be extubated cases and <12 LNs in 40% with similar percentages among in the fi rst 24 hours following surgery. Cardiac arrhythmia different type of resections. (i.e. atrial fi brillation) and post-operative delirium were After blue injection, the average lymph-node harvest was seen more often in patients over age 70. There were no sta- 18 ± 6 (range 9–33) in the stained group and 13 ± 7 (range tistically signifi cant differences among age groups regard- 4–34) in the unstained. Despite this trend, the difference ing infection, post-operative transfusion requirement, renal was signifi cant only after anterior resection and abdomi- dysfunction, or thrombotic/thromboembolic events. noperineal excision. Methylene blue injection signifi cantly CONCLUSIONS: Patients of advanced age are more likely reduced the risk of inadequate LNs harvest (LNs <8: 17% to develop pulmonary complications, cardiac dysrhyth- to 0; LNs <12:30% to 12%). Gender, age (> or < 80 years mias, and delirium following CRS-HIPEC, as compared to old), BMI (< or > 28 kgs/m2) and open or laparoscopic sur- younger patients. This may contribute to overall longer gery did not infl uence the count. Lower LN counts were lengths of stay for patients of advanced age following this observed in both groups after neo-adjuvant radiotherapy. procedure. However, in our analysis, differences in mor- The largest difference was found in size groups between 1 bidity between age groups had no effect on post-operative and 4 mm causing a shift in size distribution toward smaller mortality. We conclude that CRS-HIPEC can be safely per- lymph-nodes retrieval. formed in patients of advanced age. CONCLUSIONS: Ex-vivo intra-arterial methylene blue dye injection augments lymph-nodes retrieval thus allowing a more accurate colorectal cancer staging and possibly the oncologic outcome.

130 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

p value p Value p Value Group I – <50 [Group I vs. Group II – [Group II vs. Group III – [Group III vs. Group IV – >70 Years Group IV] 50–59.9 Years Group IV] 60–69.9 Years Group IV] Years Total LOS (days) 9.77 0.035 9.5 0.098 12.59 0.42 16.91 Total ICU LOS (days) 4.03 0.81 4.03 0.54 2.42 0.18 3.27 Extubated within 24 hrs of surgery 38.5% 0.19 25.9% 0.029 45.4% 0.63 18.2% Mechanical ventilation >48 hrs 7.7% 0.32 11.1% 0.57 4.5% 0.21 18.2% Wound infection 5.1% 0.45 0 – 9.1% 0.32 0 Intra-abdominal infection 15.4% 0.67 3.7% 0.46 13.6% 0.78 9.1% Post-operative pRBC transfusion 33.3% 0.47 48.1% 0.88 50% 0.81 45.4% Deep vein thrombosis 5.1% 0.63 0 0.12 9.1% 1.00 9.1% Pulmonary embolism 0 -– 0 -– 4.5% 0.32 0 Acute kidney injury (creatinine 5.1% 0.45 7.4% 0.37 0 – 0 >2.0) Cardiac arrhythmia 2.6% 0.007 3.7% 0.032 4.5% 0.063 27.3% Acute myocardial infarction 0 -– 0 – 0 – 0 Post-operative delirium 2.6% 0.056 3.7% 0.079 0 0.061 9.1% LOS = length of stay

Clinical: Esophageal RESULTS: Twenty-four (34%) patients had an AEG I, 43 (61%) an AEG II and 4 (5%) patients an AEG III. A primary tumor resection was performed in 59 (83%) patients while  Mo1714 12 (17%) patients initially received a neoadjuvant therapy. There was a signifi cant correlation between cN + -category Gastroesophageal Junction Tumors Clinically Staged and neoadjuvant therapy (10/23 with cN + versus 2/48 cT2: Accuracy of Staging Results and Therapeutic with cN0-Kategorie; p < 0.001). Primary resected patients Consequences at Two Academic Centers showed the following pT-/pN-categories: pT1 22%, pT2 Daniel Vallbohmer1, Susanne Blank2, Leila Sisic2, 59%, pT3 19%, pN0 39% and pN + 56%, whereas clinical and histopathological pN-category consisted in 55% of the Sebastian Kraus1, Andreas Krieg1, Wolfram T. Knoefel1, 2 2 patients. Neoadjuvant treated patients showed the follow- Markus W. Buchler , Katja Ott ing pT-/pN-categories: 1Department of Surgery, University of Dusseldorf, Dusseldorf, Germany; 2Department of Surgery, University of Heidelberg, ypT0 25%, ypT1 25%, ypT2 50%, ypN0 50% and ypN + 42%. The overall survival of primary resected patients com- Heidelberg, Germany pared patients undergoing neoadjuvant therapy was not BACKGROUND: Multimodality treatment options in signifi cantly different. In addition, no signifi cant survival locally advanced (cT3/4) tumors of the gastroesophageal benefi t was detected in patients with cN + -status receiving junction (AEG) have been established over the last years. neoadjuvant therapy. However, the therapeutic approach in patients with clini- CONCLUSIONS: The accuracy of clinical staging in cally staged cT2 tumors remains highly controversial. At patients with cT2 tumors of the gastroesophageal junction this, the most important determinant is the accuracy of

is poor. As in primary resected patients over- and understag- Poster Abstracts clinical staging and fi nal histopathological report. There- ing balance each other, pre-therapeutic over-staging occurs fore, we aimed to evaluate the association of clinical and

in about 50% of the patients. A neoadjuvant therapy can Monday histopathological staging in patients with cT2 tumors in not generally recommended in this patient group. respect of possible therapeutic consequences. PATIENTS AND METHODS: Between 2001 and 2011 71 patients with AEG were clinically staged cT2 (cN0 = 48; cN + = 23) based on endoscopy, endosonography and com- puted tomography. All study patients underwent surgical resection (R0 resection rate: 96%). Statistical analyses were performed using an established database.

131 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

 Mo1715 Outcomes of Esophagectomy for Esophageal Achalasia in the United States Daniela Molena, Miloslawa Stem, Anne O. Lidor Surgery, Johns Hopkins University School of Medicine, Baltimore, MD BACKGROUND: While the outcomes after Heller myot- omy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. METHODS: This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000–2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (Group 1) were compared to patients with esophageal cancer who underwent esophagectomy (Group 2) during the same time period. Primary outcome was in-hospital mortality. Second- ary outcomes included length of stay (LOS), post-operative Mo1716 complications and total hospital charges. A propensity- matched analysis was conducted comparing these same Comparison of Long Term Survival After Endoscopic outcomes between Group 1 and well-matched controls in Resection vs. Ablation in Early Esophageal Cancer: An Group 2 during the same era. Analysis of Surveillance Epidemiology and End Results RESULTS: Among 43,668 patients admitted with a pri- Data mary diagnosis of achalasia, 963 (2.2%) underwent esoph- Attila Dubecz1, Norbert Solymosi2, Rudolf J. Stadlhuber1, agectomy. The overall in-hospital mortality in Group 1 1 3 1 was 2.7%. The most common post-operative complica- Michael Schweigert , Jeffrey H. Peters , Hubert J. Stein 1 2 tions in this group were pneumonia (17%) and pulmonary Surgery, Klinikum Nurnberg, Nurnberg, Germany; Faculty of compromise (29%). During the same time period, 18,003 Veterinary Science, Szent Istvan University, Budapest, Hungary; patients with esophageal cancer underwent esophagec- 3Division of Thoracic and Foregut Surgery, Department of Surgery, tomy. Patients in Group 1 were younger, healthier, and had University of Rochester School of Medicine and Dentistry, Rochester, NY a lower mortality when compared to Group 2. Post opera- BACKGROUND: Safety and effi cacy of endoscopic therapy tive LOS and complications were similar in both groups, for early esophageal cancer is well established but long-term although hospital charges were signifi cantly higher in outcomes are not available. Our objective was to assess and Group 1. (Table 1). The most common surgical procedure compare long-term survival in patients with early esopha- was a partial esophagectomy in both groups. The number geal cancer managed with either endoscopic mucosal resec- of colon interpositions was higher in Group 1 (1% versus tion (EMR) or ablative treatments (AT). 4%, p = 0.0001). The propensity matched analysis showed a trend toward a higher mortality in Group 2 (7.8% versus METHODS: We identifi ed 495 patients with endoscopi- 2.9%, p = 0.08). Among patients who died in both groups cally treated early adenocarcinoma of the esophagus and the most common associated diagnosis codes were respira- the gastric cardia diagnosed between 1998 and 2009 from tory complications and sepsis. Older male patients had the the Surveillance, Epidemiology, and End Results (SEER) highest mortality among patients with achalasia. database. Demographic variables and cancer-related sur- vival were assessed. CONCLUSION: This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. RESULTS: Almost 80% of all patients were male. Average In these patients, unadjusted mortality is statistically lower age was 66.5y. Forty-percent of the patients had T1a cancer. than in patients with esophageal cancer, while operative More than 88% of the patients were treated with EMR. Aver- morbidity appears comparable. In a propensity matched age follow-up was 33.6 months. Although fi ve-year cancer analysis, there remains a trend toward lower mortality in related survival was slightly superior after AT (81% vs.78%; Group 1. Based on these data, esophagectomy can be con- p < 0.001), ten-year survival rates were signifi cantly better sidered a safe option, and surgeons should not be hindered in patients undergoing EMR (78% vs. 61%; p < 0.001). by a perceived notion of prohibitive operative risk in this CONCLUSION: Patients with early esophageal cancer man- patient population. aged with EMR have superior long-term survival compared to those treated with ablative therapies.

132 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1717 Mo1718 Diagnosis and Surgical Treatment of Esophageal Esophagectomy for Cancer Can Be Performed Carcinoma with Coexistent Intrathoracic Great Vessel Safely and with Good Perioperative Outcomes in Anomalies Octagenerians Long-Qi Chen, Zhongxi Niu Vadim P. Koshenkov1, Tulay Koru-Sengul2, Angela T. Prescott1, Thoracic Surgery, West China Hospital, Sichuan University, Carlo Maria Rosati1, Monika E. Freiser1, Danny Yakoub1, Chengdu, China Alan S. Livingstone1 1 2 OBJECTIVE: Intrathoracic great vessels accompany the Surgery, University of Miami, Miami, FL; Epidemiology, University of full course of the esophagus in chest. The anomalies of Miami, Miami, FL these vessels can not only result in dysphagia symptom by INTRODUCTION: The number of elderly patients that are direct compression, but also make the resection of esopha- being diagnosed with cancer in the United States has risen, geal cancer more diffi cult due to the malformation or even as lifespan has increased. Consequently, octogenarians are direct invasion of these vessels. The aim of this study is to now considered more frequently for operations with high summarize our experience in diagnosis and surgical treat- rates of mortality and morbidity, such as esophagectomy. ment on 7 patients with esophageal cancer and coexistent Inconsistent data exists regarding the outcomes of esopha- intrathoracic great vessel anomalies. gectomy in this population group. METHODS: From January 2007 through November 2012, METHODS: A retrospective review was performed for 1032 patients with esophageal carcinoma underwent cure patients that had undergone esophagectomy for cancer at a intent esophagectomy. Among them there were 7 patients tertiary care referral center from 1/2000 to 6/2012. Clinico- with coexistent intrathoracic great vessel anomalies pathologic factors and survival data for octogenarians were (0.68%), including aberrant right subclavian artery (ARSA) analyzed and compared to patients who were 79 years old in 3 patients, abnormal left brachiocephalic vein drainage or younger. in 2, right aortic arch (RAA) in 1 and aortic isthmus pseu- doaneurysm in 1. They were 6 males and 1 female, with an RESULTS: Among the 34 patients who met the inclusion average age of 58.42 years. Their examination fi ndings and criteria, 21 (61.8%) had comorbidities. Of these, pre-exist- surgical treatment result were retrospectively analyzed. ing cardiac disease was identifi ed in 16 (47.1%), pulmonary in 6 (17.6%) and diabetes mellitus in 3 (8.8%). Median age RESULTS: The vessel anomalies were all missed on pre- was 82, 76.5% were male, 76.5% had adenocarcinoma that operative routine esophageal barium study and endoscopy. was distal (88.3%), and 50.0% of tumors were poorly dif- They were mostly identifi ed by enhanced chest CT, some ferentiated. Stages 0 through III were observed in 2 (5.9%), with the help of 3D vessel reconstruction or angiogram. 6 (17.6%), 9 (26.5%) and 17 (50.0%) patients, respec- During operation, the aortic malformation needed addi- tively. Neoadjuvant chemotherapy or chemoradiotherapy tional management: patient with RAA had ductus arteriu- was administered to 25 (73.5%) patients, with 12 (48.0%) sus ligation and dissection to facilitate the mobilization of undergoing downstaging. Transhiatal esophagectomy was the esophagus via left thoracotomy, while the aortic pseu- performed in 28 (82.4%) patients, with an r0 resection in 31 doaneurysm underwent endovascular stent implantation (91.2%). Median length of stay (LOS) was 10 days. Mortal- before esophagectomy via right thoracotomy. All the other ity and morbidity rates were 5.9% and 44.1%. These were anomalies did not need special treatment, while caution not signifi cantly different from 10 days, 4.4% and 46.1%, was needed when performed lymphadenectomy due to respectively, for a group of 293 patients that were 79 years the varied right recurrent laryngeal nerve or abnormal vein old or younger. Cardiac, pulmonary, and infectious com- drainage. Besides, the thoracic duct was routinely ligated. plications were encountered in 17.6%, 14.7%, and 2.9%, Poster Abstracts All patients were recovered and discharged unevenly. respectively. Anastomotic leak occurred in 5 (14.7%)

CONCLUSION: The intrathoracic great vessel anoma- patients, and reoperation rate was 2.9%. Median, 3-year, Monday lies that coexisted with esophageal carcinoma are easily and 5-year survival were 21 months, 55.9%, and 37.1% neglected on esophageal barium study or endoscopy. There- respectively. Overall survival was worse for octogenarians fore, enhanced chest CT should be a preoperative routine when compared to younger patients (p < 0.0001) (Figure 1). examination, with additional angiogram or 3D reconstruc- CONCLUSION: Mortality, morbidity and length of stay in tion. The vessel anomaly might interfere the mobilization octogenarians were comparable to patients who were 79 of the esophagus and need be clarifi ed before the opera- years old or younger, while the overall survival was worse. tion. Some need pretreatment like ductus arteriusus liga- With appropriate patient selection, good perioperative out- tion or endovascular stent implantation to facilitate the comes can be accomplished in octogenarians undergoing esophageal mobilization. A careful lymphadenectomy and esophagectomy for cancer. prophylactic ligation of thoracic duct are recommended to avoid associated complications. If necessary, the abnormal vessel can be dissected to prevent uncontrolled bleeding.

133 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: Of the 1105 patients studied, 237 (21%) had an elevated IRP. Sixty four percent were female with a mean age of 56.8 ± 15.4 years. Mechanical causes of obstruction were most common (100/237, 42%) including postopera- tive in 50, large hiatal hernia in 48 and esophageal can- cer in 2. Achalasia was present in 75 patients (32%). The remaining 62 (26%) had an elevated IRP without evidence of mechanical obstruction. Dysphagia was the primary presenting symptom in 85% of patients in the achalasia group, 31% of the mechanical group and 13% of the func- tional group (p < 0.009). Interestingly, upper respiratory symptoms were signifi cantly more common in patients with functional outfl ow obstruction (26% vs. 1% achalasia and 4% mechanical, p < 0.001). The mean IRP also var- ied amongst the clinical groups, highest in achalasia 31.0 ± 11.7 mmHg, intermediate in mechanical obstruction (23.5 ± 8.6 mmHg) and lowest in the functional group (18.7 ± 3.8 mmHg) p < 0.001. A similar pattern was seen in the mean intra-bolus pressures 28.6 ± 15.0 mmHg, 20.1 ± 7.4 mmHg and 14.9 ± 4.0 mmHg, respectively. Nearly 40% (22/57) of the patents with functional outfl ow obstruction parameters were pH positive suggesting GE barrier failure despite the manometric fi ndings. Fundoplication was performed in 9 Figure 1 of these 22 patients (41%) with good response. Five of the remaining functional patients underwent treatment; myot- Mo1719 omy in one and Botox in 4. The Clinical Spectrum of Esophagogastric Junction Outfl ow Obstruction Identifi ed via High Resolution Manometry Poochong Timratana, Michal J. Lada, Dylan R. Nieman, Michelle S. Han, Christian G. Peyre, Carolyn E. Jones, Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester Medical Center, Rochester, NY INTRODUCTION: The identifi cation of esophagogas- tric junction (EGJ) outfl ow obstruction via high resolu- tion manometry (HRM) is increasingly common and of unclear clinical signifi cance. The objective of this study was to review the HRM characteristics of EGJ outfl ow obstruc- tion and to assess how this diagnosis translates into clinical practice. CONCLUSIONS: The predominant etiologies of EGJ out- METHODS: A retrospective review was conducted of fl ow obstruction are mechanical obstruction and achalasia. 1105 symptomatic patients who underwent HRM between Mechanical causes should be excluded before functional 9/09 and 8/12. EGJ outfl ow obstruction was defi ned as an outfl ow obstruction is diagnosed and treated. HRM param- elevated 4 second lower esophageal sphincter integrated eters of functional outfl ow obstruction may be present in a relaxation pressure (IRP). Patients with elevated IRP were subset of patients with pH positive GERD. The ideal man- divided into 3 groups: achalasia, mechanical obstruction agement of patients with symptomatic functional obstruc- (large hiatal hernia, postoperative and neoplasia) and func- tion remains unclear. tional obstruction (no obvious underlying cause). Clinical and demographic data, presenting symptoms, upper endo- scopic fi ndings, treatment and post-treatment outcomes were compared among the groups.

134 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1720 operative (mean OR duration 4.6 (SD 1.5) hours, 42% Ivor- Lewis, 22% minimally-invasive) characteristics between Economic Impact of an Enhanced Recovery Pathway pre- and post-pathway groups. Median LOS was lower in for Esophagectomy the post-pathway group (pre 10 [IQR 9–17] vs. post 8 [IQR Lawrence Lee1, Chao LI1, Lorenzo E. Ferri1, Nicolas Robert1, 7–17] days, p = 0.011). There was no difference in 30-day Franco Carli2, David S. Mulder1, Gerald M. Fried1, Liane S. Feldman1 complications between the two groups (pre 62% vs. post 1Surgery, McGill University Health Centre, Montreal, QC, Canada; 59%, p = 0.803), and overall mortality was low (1%, 1/106). 2Anaesthesia, McGill University Health Centre, Montreal, QC, Canada The median costs of the on-course and minor deviation groups were signifi cantly lower after implementation of the PURPOSE: Surgical care pathways can improve quality ERP (Table 2). The overall cost savings per patient (WAM- and effi ciency of care but require signifi cant resources to C -WAMC ) was $1472. implement and maintain. Payers require information about pre post cost when deciding whether to adopt new quality initia- Table 1: Defi nition of Deviation-Based Cost Modeling Groups tives. Data have been lacking to support the cost-effective- Deviation Hospital Course Clinical Impact ness of enhanced recovery pathways (ERP) for complex th procedures, such as esophagectomy. The objective of this On-course LOS 50 percentile None or minor severity (Clavien I-II) th th study was to investigate the impact of ERP on medical costs Minor LOS = 50 to 75 percentile None or minor severity (Clavien I-II) th for esophagectomy. Moderate LOS >75 percentile Any None or minor severity (Clavien I-II) hospital duration Moderate severity (Clavien IIIa) METHODS: All patients undergoing elective esophagec- Major Any hospital duration Major severity (Clavien IIIb-V) tomy for malignancy or high-grade dysplasia from 2009 LOS = length of stay to 2011 at a single high-volume university hospital were identifi ed from a prospective database. From June 2010, Table 2: Economic Impact of ERP Using Deviation-Based all patients were enrolled in a 7-day multidisciplinary ERP incorporating printed patient education material and struc- Cost Modeling tured daily care plans with indications for intensive care Pre-Pathway Post-Pathway admission, early structured mobilization, diet and drain (n = 47) (n = 59) p-Value management. Thirty-day morbidity and mortality were Deviation mix, % (n) 0.559 graded using the Clavien classifi cation. Total medical costs On-course 47% (22) 56% (33) (derived by micro-costing and including overhead, but Minor 19% (9) 13% (8) excluding physician fees) were calculated from an institu- tional perspective, and expressed in 2011 Canadian dol- Moderate 15% (7) 12% (7) lars ($CAD). Deviation-based cost modeling, a validated Major 19% (9) 19% (11) method to compare the clinical and economic impact Median costs, $CAD of clinical pathways, was used to compare costs between [IQR] the pre- and post-pathway groups. Patients were classifi ed On-course $12 195 [11 303, 13 364] $11 225 [9 964, 12 260] 0.024 into four deviation groups based on length of stay (LOS) Minor deviation $16 698 [15 094, 21 937] $13 120 [12 222, 15 672] 0.021 and postoperative morbidity (Table 1). Median costs and Moderate deviation $21 459 [18 022, 22 627] $25 432 [22 837, 31 709] 0.035 interquartile range (IQR) were calculated for each devia- Major deviation $33 190 [24 378, 73 888] $31 709 [24 330, 44 588] 0.732 tion group, and weighted according to relative proportion Weighted-average $18 457 $16 985 of each deviation to provide the weighted-average median median cost, $CAD cost (WAMC) per patient. ERP = enhanced recovery pathway

RESULTS: A total of 106 patients were included for Poster Abstracts CONCLUSIONS: A multidisciplinary ERP for esophagec- analysis (47 pre-pathway, 59 post-pathway). There were tomy was associated with signifi cant cost-savings without

no differences in patient (mean age 64 (SD 10) years, 80% Monday increase in morbidity or mortality. male), pathologic (81% adenocarcinoma, 75% received neoadjuvant therapy, 38% stage I-II, 55% stage III-IV), and

135 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1721 Mo1722 Can an Effective Nissen Fundoplication Improve the Laparoscopic Nissen – Hill Hybrid: A Promising Weak Motility of Barrett’s Esophagus? Solution for Type III Para-Esophageal Hernia Angela FalcãO, Sergio Szachnowicz, Rubens A. Sallum, Ralph W. Aye, Aditya Gupta, Jorge A. Huaco-Cateriano, Francisco C. Seguro, Ary Nasi, Julio R. Rocha, Ivan Cecconello Alexander S. Farivar, Eric VallièRes, Brian E. Louie Department of Gastroenterology, Esophageal Surgical Division – Division of Thoracic Surgery, Swedish Medical Center and Cancer University of São Paulo Medical School – Brazil, São Paulo, Brazil Institute, Seattle, WA BACKGROUND: Abnormal esophageal motility is frequent BACKGROUND: High rates of recurrence have been in Barrett’s esophagus (BE); isn’t yet clear if is a primary reported in patients after traditional repair of Type III para- abnormality or a consequence of injury. Non-propagated esophageal hernia (PEH), ranging from 10% at 6 months to contractions, simultaneous or low amplitude contractions 60% radiographic recurrence at 5 years. This study evalu- compromise esophageal clearance. That suggests extension ates a new Hybrid antirefl ux operation that combines the of the infl ammatory process to the muscle layer, affecting components of Nissen fundoplication and the Hill repair, esophageal motility. Surgical treatment would decrease the in managing these challenging hernias. infl ammation of the esophageal mucosa improving the METHODS: We performed a prospective study on the change in esophageal motor function. 1st 50 consecutive patients undergoing Hybrid repair for OBJECTIVE: Access the effect of antirefl ux surgery on symptomatic Type III PEH, from July 2006 to Oct 2009. IRB esophageal motility in patients with Barrett’s esophagus approval was obtained. Demographic, operative, clinical with esophageal motility disorder. and quality of life data were collected. Manometry, EGD, METHODS: We evaluated 20 consecutive Barrett’s patients UGI, and 48-hour pH testing were obtained pre-opera- operated with esophageal dismotility. Inclusion criteria tively and at midterm (MT: 6–12 months post-operative) were: 12 months of minimum follow-up, asymptomatic follow-up. Quality of life was measured with QOLRAD and patients out of PPIs, with endoscopy study without esopha- Dysphagia Severity Scores (DSS) pre-operatively, and post- gitis and topic fundoplication. operatively at short term (ST: 1–3 months) as well as MT follow-up. RESULTS: Thirteen patients were male (65%), the mean age was 54.95 ( ± 3.53) years, the lenght of Barrett esopha- RESULTS: Fifty patients (age 42–85 years, mean 66) with gus was 3.7 ( ± 0.56). Follow-up was 76.2 ( ± 9.27) months symptomatic PEH (mean hernia size = 7 cm) underwent the in average. The 24-hour pH monitoring after antirefl ux Hybrid repair and were followed for an average of 19.8 ± 15 surgery showed a signifi cant reduction or absence acid months (range 3–62 months). There was no 30-day or in- refl ux (p < 0.01). Before surgery the manometric evaluation hospital mortality. There were 5 major morbidities: 1 intra- showed 17 patients (85%) with LES hypotonia, 12 patients operative bougie perforation repaired laparoscopically, 1 (60%) had esophageal body hypocontractility, two patients limited intra-op bleed, 1 early reoperation for esophageal (10%) had nutcracker esophagus and four patients (20%) obstruction, 1 re-admission with myocardial infarction, had abnormal esophageal peristalsis (IEM). There was an and 1 gastrotomy repaired laparoscopically. There were 2 increase in the LESRP compared with preoperative values deaths noted in MT follow-up, both unrelated to the pri- in 70% of the patients, the mean LESRP was 10.99 ( ± 1.92) mary procedure. Follow up data were available for 40/50 before and 14.93 ( ± 1.33) after ARS (p 0.024). After ARS (80%) patients. On MT follow up, 33/38 (87%) patients had 40% of patients with hypocontractility showed an increase resolution of dysphagia, and 35/38 (92%) had resolution of in amplitude of the peristaltic contractions in distal esoph- heartburn. There was 1 clinical recurrence (2.5%) requiring agus and thease, 30% returned to normal values; both reoperation at 3 years, and 3 (7.5%) asymptomatic radio- patients with nutcracker esophagus have normalised con- graphic fundic herniations. All recurrences had an intact, traction amplitude (p = 0.021). intra-abdominal gastro-esophageal junction (GEJ) and no objective evidence of refl ux. Five patients (12.5%) had Five patients (25%) showed worsening of contraction dysphagia on MT follow-up; 3 (7.5%) underwent dilation amplitude and 15% remained with severe hypocontractil- with symptom resolution. Two patients (5%) had resumed ity. Four patients (20%) who had normal esophageal peri- anti-secretory medications, without objective evidence of stalsis before ARS evoluated with aperistalsis or IEM after refl ux. Mean DeMeester scores improved from 56.6 to 6.7 ARS. Three patients (15%) with abnormal esophageal peri- (p = 0.008). Lower esophageal sphincter pressure showed stalsis showed improvement and normalized the esoopha- no change (22.1 to 20.9, p = 0.98). QOLRAD improved both geal peristalsis (p = 0.201). in ST (3.1 to 5.7, p < 0.001) and MT (3.1 to 6.6, p < 0.001) CONCLUSION: At least 50% of patients with BE with follow up, as did the DSS (27.2 to 41.7, p < 0.001). impaired esophageal motility who underwent surgery had improvement of the esophageal motility disoderes, 40% reached normal values and patients with nutcracker esoph- agus showed normalization of contractility.

136 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

CONCLUSIONS: Laparoscopic Nissen-Hill hybrid is an METHODS: From our prospectively maintained database, effective repair for patients with PEH. It anchors the GEJ we retrospectively reviewed all patients who underwent securely in the abdomen, combining the axial integrity of Neoadjuvant chemoradiotherapy for resectable esophageal the Hill repair with the radial strength of the Nissen. Early cancer between November 1999 and December 2010 at clinical as well as radiologic recurrence rates are lower than Division of surgical gastroenterology, Dept of General sur- those reported for Nissen fundoplication, with symptom gery, PGIMER, Chandigarh. Out of total 188 patients with control equal to or exceeding the traditional anti refl ux carcinoma esophagus, 117 patients underwent Neoadjuvant procedures. Long-term follow-up and direct comparisons to chemoradiotherapy (NACRT).104 patients had squamous other repairs are needed. cell carcinoma (SCC) and 13 patients had adenocarcinoma (ADC). Mean interval between NACRT and surgery rest of Hybrid Repair for PEH: Results the patients was 44.36days .Patients were divided into 3 Parameter Pre-Op Post-Op p-Value groups on the basis of timing to surgery: group I, ≤30 days LESP 22.13 ± 14.63 20.9 ± 9.77 0.98 (n = 52); group II, 31to 60 days (n = 56); and group III, 61 QOLRAD (Pre op to ST) 3.13 ± 1.85 5.74 ± 1.16 <0.0001 to 90 days (n = 11). The Cox regression model and Kaplan- Meier plots were used to analyze the data. QOLRAD (Pre op to MT) 3.13 ± 1.85 6.6 ± 0.68 <0.0001 DSS 27.19 ± 16.58 41.67 ± 7.18 <0.0001 RESULTS: Groups were comparable in terms of patient DeMeester Score 56.6 ± 41.63 6.67 ± 7.14 0.008 and tumor characteristics. Difference in Overall survival and disease free survival in three groups of patient was not statistically signifi cant. The Mean (±SD) and median (95% Mo1723 CI) overall survival in these three groups of patient was 34.9 (6.9) months & 16 (7–24) months, 42.2 (8.24) months & Does Delayed Surgery Have an Impact on Outcome 23 (12–33) months and 14.2 (1.96) months & 12 (9.3–14.6) After Neoadjuvant Chemoradiotherapy (NACRT) in months respectively (P = 0.6). The Mean ( ± SE) and median Patients with Carcinoma Esophagus? (95% CI) disease free survival in these three groups of Rajesh Gupta1, Sunil D. Shenvi1, Yalakanti R. Babu1, patient was 31 (6.73) months & 12 (4–19) months,43 (9,4) Saurabh Kalia1, Rajinder Singh1, Rakesh Kapoor2, months&17 (6–27) months and 18 (2) months &10 months Surinder S. Rana3, Deepak K. Bhasin3 respectively (P = 0.2). Patients in group III had better relief in dysphagia, better weight gain and higher rates of patho- 1Surgical Gastroenterology Division, Postgraduate Institute of 2 logical complete response without any signifi cant increase Medical Education and Research, Chandigarh, India; Radiation in post operative complication and recurrence. Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 3Gastroenterology, Postgraduate Institute of CONCLUSION: Delayed surgery after NACRT does not compromise the outcomes of patients with locally advanced Medical Education and Research, Chandigarh, India carcinoma esophagus. OBJECTIVE: Esophagectomy is usually recommended within 4 to 6 weeks after completion of Neoadjuvant chemoradiotherapy (NACRT). However, because of vari- ous logistic factors, the surgery can get delayed. Aim of this study was to evaluate whether delayed surgery after NACRT affects postoperative outcomes in patients with locally advanced carcinoma esophagus. Poster Abstracts Monday

137 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1724 Prospective Study of Quality of Life After Laparoscopic Paraesophageal Hernia Repair with Bio-Prosthetic Mesh Kashif A. Zuberi1, Qingwen Kawaji2, Michael R. Marohn1, Miloslawa Stem1, Richard M. Fleming1, Michael Schweitzer1, Kimberley E. Steele1, Anne O. Lidor1 1Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD INTRODUCTION: Laparoscopic repair of paraesophageal hernia (PEH) with bio-prosthetic mesh (BP) has been shown to result in excellent relief of symptoms and improved qual- ity of life (QOL) despite a relatively high recurrence rate. We evaluated our patient population to determine if change in quality of life is related to recurrence as well as specifi c risk factors that may increase the probability of recurrence after repair of PEH. CONCLUSION: Our analysis of difference in symptom METHODS AND PROCEDURES: This is an analysis of scores after laparoscopic PEH repair suggests that signifi cant data derived from an ongoing prospective study. From worsening occurs with radiologically recurrent hernias >2 4/2009 to 10/2012, we enrolled 99 patients who underwent cm with respect to early satiety and dysphagia. We were elective laparoscopic PEH (type III) repair with BP (Veri- unable to demonstrate at one year follow up if any specifi c tas® collagen matrix, Synovis®, St. Paul MN) buttressed risk factors increase the incidence of recurrence. Overall, over a primary cruroplasty. All patients underwent Nissen patients with recurrent PEHs continue to experience excel- fundoplication. A validated GERD-specifi c QOL tool was lent QOL and rarely require re-operation. administered to patients before, and at 2 and 12 months post-operatively. UGI was performed at one year and recur- Mo1725 rence was defi ned as a PEH greater than 2 cm. A single radiologist blinded to patient information read all stud- Long Term Outcomes of Re-Do Fundoplication in ies. Demographic factors, comorbidities, and preoperative Elderly (>65 Years) Patients: A Single Center Experience esophago-gastric testing were analyzed as possible indica- Parth K. Shah, Tommy H. Lee, Se Ryung Yamamoto, tors for recurrence. Approriate statistical analysis was used Pradeep K. Pallati, Kalyana C. Nandipati, Sumeet K. Mittal to compare variables. Univariate logistic regression was Creighton University, Omaha, NE used to examine risk factors. BACKGROUND: Re-do fundoplication (RF) is reported to RESULTS: Overall 99 patients were analyzed. Median age improve quality of life and patient satisfaction in more than was 61.3 years (range 24–89) with 64.65% women. Of 99 80% of patients with failed fundoplication. However, the patients, 10 were not available for follow up and 50 reached role of re-do fundoplication in elderly (>65 years) patients their one year milestone and also underwent interval UGI. is not well reported in the literature. The aim of this study Four patients required reoperation, of which only one was was to assess long term outcomes of RF in elderly patients. for symptomatic recurrent PEH. The overall preoperative, 2 month, and 1 year QOL scores were 28.49, 9.99, and 10.78 METHODS: A retrospective review of patients ≥65 years respectively (p = 0.00). Our recurrence rate was 30% (n = of age who underwent RF at a single institution by a single 15) at a mean follow up of 425 days (range 234–802). The surgeon for recurrent GERD (2004–2008) was performed. compared mean QOL scores between the preoperative, two Patients were contacted at 1, 3, 5, 7 and 10 year intervals month, and one year follow-up were all statistically signifi - after surgery and administered a standard symptom ques- cant. The symptoms of early satiety and dysphagia did not tionnaire. Symptom assessment was done using a 0–3 scale, improve in the patients in whom a recurrence was detected, and grade 2–3 symptoms considered to be signifi cant. otherwise there was signifi cant improvement in all other Patients were also asked to grade their satisfaction with sur- individual symptoms assessed in the QOL tool. There was gery on a scale of 1–10. no association between diabetes, smoking history, the use of , or previous abdominal surgery and PEH recurrence. Preoperative testing with manometry and gas- tric emptying studies were statistically unable to identify patients at risk of recurrence.

138 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: Of 114 patients undergoing RF during the and more advanced technology resulting in a more costly period, 31 elderly patients (27%) were included in the study procedure. The purpose of this study was to determine the group. The mean age was 72 years (65–85 years) with 22 cost difference between MIE and OE. (70%) women. Heartburn and dysphagia were the most METHOD: One hundred and forty one consecutive cases common indications for a re-operative procedure with 15 of esophagectomies were reviewed at a single institution patients (48%) and 14 patients (45%) patients, respectively. between May 2005 and Jan 2012. We excluded in hospital Recurrent hiatal hernia was noted in 17 (55%) patients. mortalities and MIEs which were converted to OE. The MIE Laparoscopic Nissen fundoplication was the original sur- category consisted of laparoscopic Ivor-Lewis esophagec- gery in 23 (75%) patients. Toupet fundoplication was the tomies and laparoscopic 3-hole esophagectomies. The OE most common re-operative procedure (17 patients–55%). category consisted of transhiatal esophagectomies. A pro- The majority (65%) of RF were completed laparoscopically. pensity score and quantile regression was used to estimate Additionally, there were 4 laparoscopic to open surgery adjusted median costs associated with all esophagectomies. conversions and 4 thoracic procedures. Intra-operative vis- Propensity scores for MIE vs OE were modeled by logistic cus perforation and solid organ injury were identifi ed in regression and adjusted for BMI, smoking status, American 26% (8 patients) and 10% (3 patients), respectively. Major Society of Anesthesiology score, coronary artery disease, post-operative complications were noted in 10 patients (2 hyperlipidemia, hypertension, chronic obstructive pulmo- arrhythmia, 3 post-operative leaks, 1 post-operative bleed- nary disease, gastroesophageal refl ux disease, diabetes and ing and 4 pulmonary). One patient required return to the neoadjuvant therapy. Data considered for the comparison operating room on POD#3 for a leak. Median ICU and analysis were: general surgeon’s time, thoracic surgeon’s total hospital stay were 6 (range 1–45) days and 6 (range time, anesthesiologist’s time, medications administered, 2–55) days, respectively. There was no 30 day or in-hospital surgical equipment, Intensive Care Unit [ICU] cost, inter- mortality. Greater than fi ve year follow-up was available mediate ICU cost and general fl oor cost. for 17 patients (mean of 72 months). Four patients died in the interim from unrelated causes. Moderate to severe RESULTS: One hundred and eleven esophagectomies (lap- symptoms were reported by a total of 5 patients (29%) (3 aroscopic = 78, open = 33) were included in the study. Of the heartburn, 2 regurgitation, 1 dysphagia and chest pain in 78 MIE patients, two patients underwent laparoscopic Ivor none). Seven patients were on acid suppressive medica- Lewis Esophagectomy and 76 patients underwent thora- tions. Excellent satisfaction (grade 8-10) was reported by 13 scopic 3-hole esophagectomy which made up the major- (77%) patients and good (grade 6–7) by 3 (18%) patients. ity of MIE cases. All 33 OE patients underwent transhiatal The majority (88%) of patients stated that they would rec- esophagectomies. Ten patients were converted from MIE to ommend the procedure to a friend if needed. OE and were excluded from the study. Fourteen patients underwent a hybrid esophagectomy and were excluded CONCLUSION: RF can be safely performed laparoscopically from the study. Six hospital mortalities were excluded from in the majority of patients ≥65 years of age for recurrent the study. The median operative time was 488 (range, 299– GERD after initial fundoplication. The long-term post-oper- 651) minutes for MIE vs 266 (range, 146–542) minutes for ative outcomes in this subset of patients are satisfactory OE. Median ICU stay for both groups was 3 days. Median though associated with high peri-operative morbidity. Hospital stay was 9 (range, 5–62) days for MIE vs 10 (range, 7–56) days for OE. Perioperative morbidity was 32.6% for Mo1726 MIE vs 48.5% for OE. The estimated median total cost asso- Laparoscopic Versus Open Esophagectomy: A Clinical ciated with an MIE procedure was $20,898.97 vs $22,577.66 for OE. The difference was substantial $1,678.69 (95% CI and Cost Analysis $-788.14-$6938.10); however, there was insuffi cient data to 1 1 2

Wei Phin Tan , Zhi Ven Fong , Scott W. Cowan , suggest statistical signifi cance. Poster Abstracts Nathaniel R. Evans2, ADAM Berger1, Scott W. Keith3, 1 1 4 CONCLUSIONS: A systematic, prospective study analyzing Karen A. Chojnacki , Francesco Palazzo , Laura Pizzi , cost differences between MIE and OE is required to better Monday 1 Ernest L. Rosato delineate true economic differences. 1Department of General Surgery, Thomas Jefferson University, Philadelphia, PA; 2Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA; 3Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA; 4Division of Pharmacy and Outcomes Research, Thomas Jefferson University, Philadelphia, PA Minimally invasive esophagectomy (MIE) is reported to result in decreased length of hospital stay, blood loss and pul- monary complications compared to open esophagectomy (OE). However, MIE requires a longer operative duration

139 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1727 fl ux repair and also has potential for staple line dehiscence. An alternative is to use a Hill gastropexy to lengthen the Comparing the Post-Operative Manometric esophagus and combine it with a Nissen fundoplication, Characteristics of the Laparoscopic Nissen thus maintaining the intraabdominal position, preventing Fundoplication and the Laparoscopic Hill Repair acid refl ux, preserving motility and avoiding a staple line. Richard C. Wiseman1, Ralph W. Aye1, Lee L. Swanstrom2, We compared these two repairs to determine if a combined Alexander S. Farivar1, Brian E. Louie1 Nissen Hill (NH) was equivalent to a Collis Nissen (CN). 1Division of Thoracic Surgery, Swedish Medical Center and Cancer METHODS: We performed a retrospective review of con- Institute, Seattle, WA; 2The Oregon Clinic, Portland, OR secutive patients with short esophagus undergoing either primary laparoscopic CN or NH repairs between 2007 and BACKGROUND: The Laparoscopic Nissen Fundoplication 2012 from a prospectively collected database. Short esopha- (LNF) and the Laparoscopic Hill Repair (LHR), in which the gus was defi ned as less than 2 cm of intraabdominal length gastroesophageal junction is fi xed to the preaortic fascia, after mobilization above the inferior pulmonary veins and were shown in a recent randomized trial to be equivalent prior to crural closure. CN was performed via wedge fun- in controlling uncomplicated GERD at 12 months. Mano- dectomy to lengthen the esophagus whereas NH used 2 metrically, the LNF achieved a statistically signifi cant Hill gastropexy sutures to provide intraabdominal length. increase in LES pressure; whereas, LHR did not. This study A standard Nissen fundoplication was added to both. aims to further evaluate the post-operative high resolution All patients underwent physiologic testing before and 6 manometry studies from this trial to determine if differ- months post op with quality of life (QOL) assessment at ences between the two repairs can explain the resultant each visit. GERD control. RESULTS: A short esophagus was identifi ed in 38 patients. METHODS: Of 46 LNF patients and 56 LHR patients who Three were excluded: transthoracic CN (1) and revision Nis- were randomized, there were 16 LNF patients and 20 LHR sen to NH (2). Thus, 14 underwent CN and 21 NH. The patients with available post-op manometric testing. High groups had similar demographics, GERD history, size of Resolution Manometry (HRM) was performed using the hiatal hernia and prior stricture. There was no mortality Manoscan system and analyzed using ManoView (V2.0) or major morbidity. No staple leaks occurred with CN. At Software. Manometries were interpreted by a single clini- mean follow up of 6 months, % time pH <4 was 4.6 for cian, blinded to the procedure performed using the Chi- CN vs. 1.5 for NH; Mean DeMeester scores were 20.4 vs. cago classifi cation. 6.8 respectively. There were two abnormal DMS in the CN RESULTS: The overall LES length among LNF and LHR group and one in the NH group. One CN patient reported groups was similar. (2.7 vs 2.3, p = 0.15). However, the mean persistent symptoms and was placed back on PPI therapy intra-abdominal LES length after LNF was longer (1.8 vs 1.2, while none required PPI therapy in the NH group. Endo- p = 0.047) than after LHR. The integrated relaxation pres- scopic esophagitis was seen only in the CN group (3/14). sures were also similar (11.7 vs 10.7, p = 0.54). The percent One radiographic hernia recurrence was seen in each group; peristalsis was similar with 91% achieving 100% peristalsis both were small and asymptomatic with normal DeMeester with distal amplitudes of 91 and 89 mm Hg respectively. scores and did not require PPIs. Dysphagia scores improved The distal contractile integral was 2299 compared to 2087 from pre- to postop in the NH group (31 to 42) but not in (p = 0.66). the CN group (38 to 36). QOL improved from pre op and DISCUSSION: Post-operative manometric analysis using was similar post op across the groups: QOLRAD (6 vs. 7), high resolution manometry was unable to detect measurable GERD-HRQL (10.3 vs. 5.8) in the CN and NH. differences between the LNF and LHR to explain how each CONCLUSIONS: The CN and NH repairs achieved excellent repair results in GERD control. The difference in intraabdom- early results in the surgical management of short esopha- inal LES length likely refl ects the difference in the anatomy gus. Radiographic recurrences were similar, but the CN had of the gastroesophageal junction after reconstruction. more frequent abnormal distal esophageal acid exposure, more endoscopic evidence of esophagitis and some persis- Mo1728 tent dysphagia. The NH is an acceptable alternative to CN.

A Combined Nissen Fundoplication with Hill Gastroplasty Mo1729 Is an Alternative to Collis-Nissen Repair in the Treatment of Short Esophagus Safety and Symptom Control Effi cacy of ePTFE-mesh Zeljka Jutric, Brian E. Louie, Alexander S. Farivar, in Hiatal Hernia Repair with Nissen Fundoplication for Eric VallièRes, Ralph W. Aye Gastroesophageal Refl ux Division of Thoracic Surgery, Swedish Medical Center and Cancer Johannes Miholic, Emanuel Sporn, Alexander Di Monte Institute, Seattle, WA Medical University of Vienna, Vienna, Austria OBJECTIVES: The short esophagus is a challenging prob- BACKGROUND: Preoperative hiatal hernia ≥3 cm is asso- lem resulting from long standing refl ux, stricture, and/or ciated with a threefold relative risk for refl ux symptom hiatal hernia. Standard treatment lengthens the esopha- recurrence after fundoplication without mesh. This report gus with a added to an antirefl ux repair. assesses the short-term safety and effi cacy of ePTFE mesh This however places acid secreting mucosa in an aperistal- used for repair of herniae ≥3 cm in length in Nissen fundo- tic segment of tubularized stomach at or above the antire- plication for samptomatic refl ux.

140 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

PATIENTS AND METHODS: 22 Patients with gastro- Mo1731 esophageal refl ux disease and typical symptoms respond- ing at least in part to PPI therapy were entered into a pilot Incomplete Lower Esophageal Sphincter Relaxation study. Inclusion criteria comprised also endoscopic evidence on High-Resolution Manometry Is an Independent of erosions and/or abnormal esophageal acid exposure, Predictor of Solid Diet Failure in Post-Roux-en-Y Gastric and a hiatal hernia of ≥3 cm in length. Study endpoints Bypass Patients were the time to recurrence of refl ux symptoms and the Shikha Mangla1, ANA C. Tuyama1, Robert Burakoff1, postoperative incidence of dysphagia with ensuing inter- 2 1 1 vention. A cohort of 45 patients having undergone fundo- David B. Lautz , Christopher C. Thompson , Walter W. Chan 1 plication without mesh for refl ux with hiatal hernia from Gastroenterology, Brigham and Women’s Hospital, Boston, MA; 1996–2007, who have been carefully audited for symptom 2Bariatric Surgery, Emerson Hospital, Concord, MA recurrence served as a comparison group. The study popu- BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an lation underwent Nissen fundoplication with tension free effective surgery for weight loss in obese patients. Current repair of the hiatus using a Goretex® dual mesh in inlay guidelines recommend advancement to regular diet in 1–2 technique secured by single non-absorbable sutures. The months post-RYGB. Failure to advance or dietary intoler- patients were contacted at 1, 3, and 6 months postop, and ance may have clinical and nutritional implications. A prior 6 monthly therafter. A symptom recurrence was defi ned by study suggested that up to 30% of post-RYGB patients may heartburn and/or regurgitation more frequently than once develop dysphagia. RYGB may affect the Vagal innervation a week and/or the need for PPI treatment to control refl ux to the esophagus, and the resultant esophageal dysmotility symptoms. A signifi cant dysphagia was defi ned as swallow- may play a role in post-RYGB dietary complications. Under- ing diffi culites severe enough that the patient accepted an standing esophageal motor functions by high-resolution offered intervention: endoscopy or endoscopic dilatation. manometry (HRM) and their association with dietary out- The patient characteristics are shown in Table 1. come post-RYGB may allow more effective, targeted ther- Patients and Results apy for symptoms and dietary complications. AIM: To investigate the association between esophageal Variable Mesh (n = 22) Controls (n = 45) motor dysfunctions on HRM and intolerance to solid diet Age 54 (34–70) 57 (27–74) among post-RYGB patients. Gender (M:F ratio) 1.1 2.5 METHODS: This was a retrospective cohort study of post- Hiatal hernia (cm) 5 (3–8) 5 (3–10) RYGB patients who underwent HRM at a tertiary care cen- Sympt recurrences 0/22 13/45 (29%) ter in 6/2007–5/2012. Patients with underlying esophageal Overall follow-up 15 mo (2–44) 115 mo (12–183) dysmotility pre-RYGB, HRM performed less than 2 months Time to recurrence .. 32 mo (10–115) after RYGB, or need for parenteral or tube feeding were excluded. The primary outcome was diet at the time of HRM Symptom Recurrence Rates (liquid [LD] vs solid [SD]). Esophageal motor characteristics were extracted from HRM. Fisher-exact or chi-squared test Estimated Rate Of Recurrence for binary variables and student’s t-test for continuous vari- 12 mo 36 mo 120 mo ables were used to assess for differences between LD and SD No mesh 5% 12% 30% groups. Multivariate analysis was performed using forward PTFE 0 .. .. stepwise logistic regression. RESULTS: 63 patients met inclusion criteria (age 51 ± 10.3 RESULTS: No conversions, revisions, or reoperations were yrs, 91% F), and 21 subjects (33.3%) could only tolerate LD. suffered in the study group. Following a mean follow-up of Poster Abstracts Patients on LD were more likely to have at least one abnor- 18  12 months no symptom recurrences were encountered mal parameter on HRM than those on SD (61.9% vs 28.6%, in the study group. Two patients reported dysphagia, in Monday p = 0.01). Univariate analyses showed that elevated basal one resolved after endoscopy, the other requiring two dila- lower esophageal sphincter (LES) pressure (9.52% vs 0%, p tations. The Weibull parametric analysis of symptom free = 0.04), incomplete LES relaxation (22% vs 0%, p = 0.04), survival revealed a borderline signifi cant (p = 0.09) infl u- increased esophageal body contraction amplitude (119 ± 56 ence in favor of of mesh and the recurrence rate estimates vs 93 ± 41 mmHg, p = 0.05), and dysphagia (52% vs 16%, in the control group as follows: 1 year: 5%, 3 years 12%, p = 0.003) were signifi cantly associated with LD. On mul- and 5 years: 30%. tivariate analysis, incomplete LES relaxation remained an COMMENT: ePTFE mesh for narrowing the hiatus in hiatal indepedent predictor for LD (OR 11.73, p = 0.02). hernia repair with Nissen Fundoplication seems safe and effective. The difference in recurrence rates as compared to a historical control group with otherwise identical opera- tive technique is not (yet?) signifi cant. If the promising results should sustain, inlay application in hiatal hernia should be profi cient to further improve the performance of fundoplication.

141 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSIONS: Post-RYGB patients unable to tolerate SD CONCLUSIONS: For HCC patients within Milan criteria, are more likely to have abnormal fi ndings on HRM. Incom- transplantation is associated with a lower recurrence rate, plete LES relaxation is independently associated with LD but not a signifi cantly improved overall survival. Patients use, while other hypermotility patterns (hypertensive LES outside of Milan criteria had a signifi cantly poorer OS and increased esophageal body contraction) are also more when compared to patients within Milan criteria who were prevalent. In addition to pouch or anastomotic abnormali- resected or transplanted, refl ecting a more aggressive dis- ties, esophageal motor dysfunction should be considered in ease biology. assessing post-RYGB patients’ failure to tolerate SD. HRM should play a role in evaluating post-RYGB dietary compli- Mo1733 cations. Future studies should examine the potential causes of this dysfunction and explore the effect of therapies tar- Infl uence of Preoperative Laboratory Values on geting LES relaxation on clinical and dietary outcome. Perioperative Mortality Following Hepatic Resection for Malignancy Clinical: Hepatic Mashaal Dhir1, Lynette M. Smith1, George Dittrick2, Quan P. Ly1, Aaron R. Sasson1, Chandrakanth Are1 1University of Nebraska Medical Center, Omaha, NE; 2Surgery,  Mo1732 Nebraska Methodist Hospital, Omaha, NE Transplantation for HCC Improves Progression Free BACKGROUND: Abnormal preoperative laboratory values Survival But Not Overall Survival When Compared to have been associated with increased mortality in patients Resection undergoing hepatic resection for malignancy. However, cutoff values for these preoperative labs have been defi ned Rafael Pieretti-Vanmarcke1,2, Hui Zheng3,2, Nahel Elias1,2, 1,2 1,2 1,2 arbitrarily. The aim of the current study was to identify David L. Berger , Kenneth Tanabe , Keith D. Lillemoe , cut off values for these preoperative laboratory denomina- 1,2 Cristina R. Ferrone tors which can help identify patients at increased risk of 1Department of Surgery, Massachusetts General Hospital, Boston, MA; mortality. 2Harvard Medical School, Boston, MA; 3Biostatistics, Massachusetts METHODS: Patient undergoing liver resection for malig- General Hospital, Boston, MA nancy (primary and secondary) were extracted from 2005– OBJECTIVE: To compare the outcomes of patients with 2010 National Surgical Quality Improvement Database. We hepatocellular carcinoma (HCC) undergoing either liver determined the optimal cutoffs for each laboratory denom- transplantation (LT) or resection (LR). inator using the classifi cation and regression tree analysis METHODS: A single institution retrospective analysis of (CART), and the “party” package for conditional inference 327 HCC patients treated between 8/1991–12/2011. trees in R. Patients were classifi ed according to the cutoffs determined from CART analysis and logistic regression RESULTS: A total of 327 patients with HCC underwent sur- analysis was used to fi t a multivariate model, with backward gical treatment of whom 79% were male, 19% had hepatitis variable selection. B and 44% hepatitis C. Patients underwent transplantation (n = 138) or surgical resection (n = 189). Of the resected RESULTS: A total of 4812 patients who underwent liver patients 126 did not meet the Milan Criteria (MC) while resections for malignancy were included. Statistically signif- 63 patients were within MC. When comparing resected icant association was seen between increased 30 day mor- patients within MC to transplanted patients the median tality and preoperative laboratory values including serum Na  135 meq/L, BUN >19 mg/dl, serum creatinine >1.68 tumor diameter was 3.2 cm and 3.0 cm, respectively. Recur-  rence rates were 57% for resected patients within MC and mg/dl, serum albumin 2.6 g/dl, bilirubin >1.8 mg/dl, 13% for LT patients (P < 0.0001). The model end-stage liver SGOT >50 IU/L, alkaline phosphatase of >149 IU/L, WBC >10,790/ul, Hct  28, and INR >1.1. In a multivariate logis- disease (MELD) score median was 7 for resected patients  within MC and 10 for LT patients. The median overall sur- tic regression model, albumin 2.6, SGOT > 50, INR > 1.1, vival (OS) was 40 months for both resected and transplanted BUN > 19, and alkaline phosphatase > 149 are independent patients. The OS at 1, 3, and 5 years was 47%, 40%, and 23% predictors of 30 day mortality with an area under the curve for resected patients within MC and 59%, 49%, and 33% for of 0.77. transplanted patients. (p = ns). Signifi cant clinicopathologic CONCLUSIONS: Cutoff laboratory values defi ned in the factors predicting survival were age, size of lesion, lympho- current study may help identify patients who are at higher vascular invasion, Patients outside of MC who were resected risk of mortality from hepatic resections. had a signifi cantly decreased survival compared to patients within MC and those who were transplanted.

142 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1734 heterogeneity or growth over time (120, 81%), a cancer his- tory (113, 76%), and/or symptoms (39, 26%). The majority Resected Splenic Masses Discovered on Imaging Are of patients underwent a preoperative CT (138), although Frequently Malignant: A Review of 148 Cases PET (25), MRI (23), and ultrasound (8), were also included Ciaran T. Bradley, Amudhan Pugalenthi, Vivian E. Strong, in patient evaluations. Among the resected spleens, the William R. Jarnagin, Daniel G. Coit, T.P. Kingham majority had a malignant mass (93, 63%). 90% were paren- Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY chymal metastases, including ovarian cancer (39, 42%), followed by melanoma (14, 15%) and colorectal cancer (9, BACKGROUND: Solid and cystic splenic masses discov- 10%). While the majority of the patients with malignant ered on imaging studies often pose diagnostic and man- splenic lesions had a previous history of cancer (85 of 93; agement dilemmas. This study analyses a large series of 91%), among those patients without a previous history of splenectomies to identify preoperative factors associated cancer (n = 35), most had benign lesions (77%). On multi- with malignant splenic masses. variate analysis of several clinicopathologic factors, a previ- METHODS: Pathology records at a single institution ous history of cancer was the only independent predictor were reviewed for all splenectomies. Those performed as of malignancy in the splenic lesion (odds ratio 6.3; 95% a component of a larger resection, for lymphoma stag- CI, 2.32–16.97; p = 0.00). Imaging described as “suspicious ing, or debulking for a surface malignancy were excluded. for malignancy” by the radiologist (e.g. by virtue of hetero- Demographic and clinicopathologic factors were obtained. geneity) or lesions that enlarged on interval scans did not Univariate and multivariate analyses identifi ed factors asso- correlate with malignancy in the spleen. ciated with an increased risk of malignancy. CONCLUSION: While the spleen is an uncommon site of RESULTS: Between 1986 and 2012, 2,745 patients under- malignant disease, resected splenic masses are frequently went splenectomy. 148 were performed for splenic lesions malignant, especially in patients with a previous history of identifi ed on abdominal scans. The indication for resec- cancer. tion included suspicious imaging characteristics such as

Factors Associate with Malignancy in Resected Splenic Masses

Univariate Multivariate Variable Odds Ratio 95% CI P-value Odds Ratio 95% CI P-value Sex (M v. F) 0.424 0.20.8 0.018 0.472 0.21-1.06 0.70 Age 1.018 0.99–1.04 0.098 Symptomatic 0.593 0.24–1.45 0.253 Previous history of cancer 10.2 4.17–25.1 0.000 6.28 2.32-16.97 0.000 Imaging \”suspicious for malignancy\” 1.24 0.54–2.85 0.601 Increasing size 0.745 0.32–1.71 0.489

Mo1735 features of patients who survived more than 5 years were compared with those died within 5 years. Analysis of Clinicopathological Factors Contributing RESULTS: Of all 113 patients underwent surgical resec- an Actual 5 Year Survival After Hepatectomy for tion, 33 patients (29.2%) survived more than 5 years. Intrahepatic Cholangiocarcinoma Poster Abstracts In univariate analysis, MF type (p = 0.015), preservation Shutaro Hori1, Kazuaki Shimada1, Satoshi Nara1, Minoru Esaki1,

1 1 2 of extra bile duct resection (p = 0.014), operation with- Monday Yoji Kishi , Tomoo Kosuge , Hidenori Ojima out blood transfusion (p = 0.001), absence of intrahepatic 1 Hepatobiliary and Pancreatic Surgery Division, National Cancer metastasis (p = 0.006), absence of vascular invasion (p = Center Hospital, Tokyo, Japan; 2Pathology Division, National Cancer 0.022), negative lymph node involvement (p < 0.001), and Center Hospital, Tokyo, Japan microscopic curative resection (p = 0.001) were signifi - BACKGROUND: Hepatectomy is the only chance of cure cantly related to 5 year survival. for patient with intrahepatic cholangiocarcinoma (ICC), Multivariate analysis showed that operation without blood because there is a lack of other effective treatments for transfusion, absence of intrahepatic metastasis and nega- achieving an actual 5 year survival. However clinicopatho- tive lymph node involvement were independent factors logical feature predicting 5-year survival after hepatectomy associated with survival for more than 5 years, with odds has not been well clarifi ed. ratios (95% confi dence interval) of 6.743 (1.784–25.491; p METHODS: 113 consecutive ICC patients with mass-form- = 0.005), 4.302 (1.391–13.306; p = 0.011), 3.886 (1.401– ing (MF) macroscopic tumor type and MF plus periductal 10.664; p = 0.009), respectively. infi ltrating (PI) type, who underwent surgical resection at CONCLUSION: In MF and MF + PI type of ICC, hepatec- a single institution between January 1990 and December tomy without blood transfusion, absence of intrahepatic 2006, were retrospectively analyzed. Patients who died of metastasis and negative lymph node involvement signifi - unknown causes, and who was lost to follow up within 5 cantly contribute an actual 5 year survival. year were excluded from the study. The clinicopathologic

143 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1736 Hepatic Metastasectomy Offers Improves Local Tumor Control Among Patients with Recurrent Colorectal Metastases Victor M. Zaydfudim1, Jeffrey S. Scow1, Grant D. Schmit2, Guido M. Sclabas1, Benzon Dy1, David M. Nagorney1 1Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 2Department of Radiology, Mayo Clinic, Rochester, MN INTRODUCTION: Hepatic metastasectomy is an accepted treatment strategy for patients with colorectal metastases to the liver with demonstrated improvement in survival. Abla- tive strategies have been proposed for patients with recur- rent liver metastases to avoid pitfalls of re-operative liver resection. The aim of this study was to evaluate the survival benefi t of repeat metastasectomy and to compare hepatic resection to radiofrequency ablation (RFA) among patients CONCLUSIONS: Metastasectomy offers improved local with recurrent hepatic metastases. tumor control among patients with recurrent hepatic METHODS: Patients continuously followed for primary colorectal metastases and should remain the preferred treat- colorectal malignancy, as well as, treatment of initial and ment strategy for these patients. Majority of the patients recurrent colorectal metastases to the liver between 1992 with recurrent hepatic metastases are candidates for sub- and 2008 were included in this retrospective cohort study. segmental metastasectomy. Clinical variables were compared between patients treated with hepatic resection, hepatic ablation, or both treatment modalities for recurrent hepatic colorectal metastases. Inde- Clinical: Pancreas pendent radiologist, blinded to other covariates, catego- rized hepatic disease recurrence as local recurrence adjacent  to the site of resection/ablation or new metastases. Mo1737 RESULTS: Ninety-three patients (median age 60 years The Effect of Splenectomy on Complication Rates After (range 33–89), 57% male) were treated for recurrent hepatic Distal Pancreatectomy: A Meta-Analysis metastases: 46 underwent recurrent hepatic resection, 38 Noah Rozich, Angel Matos, Alison Gegios, Emily Winslow underwent RFA, and 9 underwent both treatment modali- Department of Surgery, University of Wisconsin, Madison, WI ties. Initial colorectal tumor stage, hepatic burden of ini- tial liver metastases, anatomic resections of initial liver BACKGROUND: Distal pancreatectomy is being per- metastases, and disease free interval between primary resec- formed more commonly for patients with benign fi ndings, tion and treatment of recurrent metastases did not differ and minimally invasive techniques are frequently applied between recurrent treatment groups (all p ≥ 0.259). There in this population. As a result, the role of spleen preserva- was no difference in use of systemic therapy for treat- tion during distal pancreatectomy has been debated. Many ment of initial and recurrent hepatic metastases (all p ≥ confl icting and under-powered case series have been pub- 0.105). Only 19% of patients treated with RFA had more lished but no randomized trial comparing these techniques than one hepatic metastasis, compared to 33% of resected has been initiated. As a result, there is signifi cant contro- patients, and 100% of patients treated with both modalities versy about the impact of splenectomy on distal pancre- (p < 0.001). Among patients treated with hepatic metas- atectomy complication rates. We therefore undertook a tasectomy, 15% underwent anatomic resection of ≥2 seg- systematic review and subsequent meta-analysis in order to ments, while 85% underwent sub-segmental resections. provide objective evidence to this debate. 32 patients (34%) developed local re-recurrence at hepatic METHODS: A comprehensive search for published English- treatment site during a median of 12 months (range 1–142 literature studies of left pancreatectomy from 1980–2012 months) follow-up with cross-sectional imaging after treat- was undertaken. All studies were screened for our inclu- ment of recurrent metastases. At 1- and 5- year follow-up, sion criteria: > than 10 pts, non-traumatic indication, treat- local recurrence rates were lowest among patients treated ment of spleen detailed, and postoperative complications with hepatic metastasectomy compared to RFA and both described in relation to treatment of spleen. Two genera- treatment modalities: 17% vs. 41% vs. 75% at 1 year and tions of ancestral searching was used. When multiple series 36% vs. 52% vs. 100% at 5 years, respectively (p < 0.001, from a single institution were encountered, the largest and Figure). Overall survival did not differ between treatment highest quality series was selected for inclusion. Continu- groups (p = 0.730). ous variables were calculated as a variable weighted by the proportion of patients in each study.

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RESULTS: More than 1000 articles were found using the Mo1738 initial search criteria, and after detailed review, 52 stud- ies with 3355 patients were included. Of these, 15 studies Risk-Benefi t Assessment of the Use of Intraperitoneal including 1482 patients both compared distal pancreatico- Drainage After Pancreaticoduodenectomy splenectomy (DPS) to spleen-preserving distal pancreatec- Pablo E. Serrano, Peter T. Kim, Gulav Naman, Hassan AL-Ali, tomy (SPDP) and detailed postoperative complications. Sean Cleary, Paul D. Greig, Ian D. Mcgilvray, This group is the focus of this report. The mean age was Carol-Anne Moulton, Steven Gallinger, Alice C. Wei 52.8 years, and 41% were male. A wide variety of patho- Surgery, Princes Margaret Cancer Centre, Toronto General Hospital, logic diagnoses were included with 37.4% being for cystic University of Toronto, Toronto, ON, Canada disease, 21.2% pancreatitis, 16.8% neuroendocrine tumors, and only 9.4% pancreatic cancer. When the groups were BACKGROUND: Prophylactic intraperitoneal closed-suc- compared, there were more with pancreatitis in the SPDP tion drains after pancreaticoduodenectomy (PD) are widely group, and more with pancreatic cancer in the DPS group used even though its value is not well determined due to (Table 1). Weighted values for length of surgery and length the limited number of studies available to date. The main of stay were similar, but there was a trend towards higher objective of this study is to analyze the risk-benefi t associa- blood loss in the DPS group. When postoperative compli- tion of prophylactic drainage after PD. cations were analyzed, there was no signifi cant difference METHODS: This is a retrospective cohort study of 635 between groups (see Table). Importantly, there was no dif- patients who underwent a PD from January 1, 2000 to ference in rates of infectious complications, pancreatic fi s- December 31, 2010. Analyses of the clinical, pathological tulae, or thrombotic complications. Notably, spleen related and surgical outcomes of patients who had a closed-suction complications (infarcts or delayed splenectomy) occurred drain placed during PD were compared to those patients in 8.8% of patients with splenic preservation. without drain.

DP with DP with Spleen RESULTS: Median age was 63 years (17 to 84). The majority Splenectomy (DPS) Preservation (SPDP) p Value of PD were performed for periampullary cancer (547/635, Demographics 86%) with 258/635, 40.7% pancreatic adenocarcinomas. There were 368/635, 58% patients in the drain group and Number 948 534 267/635, 42% without drain. During the fi rst 6 years of the Mean age (yrs) 54.3 51.7 NA cohort, 160/190, 84% patients had a drain placed during PD Gender (% male) 44.4% 32.8% 0.0003 vs. 253/445, 57% in the last 6 years, odds ratio (OR) 3.9, 95% Diagnosis (n,%) confi dence interval (CI): 2.5 to 6.3; p < 0.01. Demographic, Pancreatitis 140 (19.7%) 111 (25.3%) 0.044 surgical and pathologic characteristics were similar between Pancreatic cancer 82 (11.5%) 10 (2.3%) 0.0001 groups. There was no difference in the overall complication Cystic disease 269 (37.8%) 186 (42.5%) NS rate (278/635, 43.8%; 45.7 vs. 42.2; p = 0.4), major complica- Operative Variables tion rate/Clavien-Dindo Class ≥3 (110/635, 17.3%; 18.2 vs. Length of surgery (min) 198.8 181.7 NA 14.7; p = 0.3), 90-day/in-hospital mortality rate (8/635, 1.3%; Estimated Blood Loss 499.9 303.7 NA 1.1 vs. 1.4; p = 0.7) and pancreatic leak rate (50/368, 12.1%; (mL) 13.6% vs. 10.1%; p = 0.18. Patients with a diagnosis of pan- Length of hospital stay 10.4 8.9 NA creatic cancer had a much lower pancreatic leak rate com- (days) pared to patients without pancreatic cancer, 5.6% vs. 16.4%, OR 3.3, 95% CI: 1.8 to 6.6; p < 0.01; without any difference Postoperative Complication (n, %) in the percentage of patients that had a drain placed in this Pancreatic leak 208 (21.9%) 113 (21.2%) NS group (65% vs. 59%; p = 0.1). Median length of hospital stay

Infectiouscomplications 64 (6.8%) 26 (4.9% ) NS was longer for the drain group, (10 vs. 9 days, p = 0.04); also, Poster Abstracts Thrombotic 9 (0.95%) 3 (0.56%) NS patients with drain that developed a complication had a sig- complications nifi cantly longer hospital stay than those without drain who Monday Hemorrhagic 13 (1.4%) 5 (0.94%) NS also developed a complication (20 vs. 16 days, p = 0.04). complications Intraperitoneal drainage did not alter the risk of wound infec- Reoperation 28 (2.95%) 16 (3.0%) NS tion (67/635, 10.8%, 11.3 vs. 9.2; p = 0.4), intra-abdominal Mortality 6 (0.6%) 2 (0.4%) NS abscess (79/635, 14.3%, 15.3 vs. 11.2; p = 0.1), re-interven- Spleen-related NA 47 (8.8%) NA tion (69/635, 12.2%, 12.7 vs. 10.6; p = 0.4) or reoperation complication (16/635, 3.4%, 3.3 vs. 1.8; p = 0.2) after PD. CONCLUSION: The use of prophylactic intraperitoneal CONCLUSION: Although DPS is performed more often closed-suction drains does not alter the postoperative com- in patients with malignancy and may have slightly higher plication or mortality rate after PD. The similar pancreatic blood loss, this meta-analysis does not demonstrate any leak and intra-abdominal abscess rate along with the compa- increase in complication rates when compared SPDP. In rable risk of postoperative interventional radiology drainage fact, the 9% complication rate related to spleen preserva- or surgical exploration between groups suggests that there tion raises the question of if organ preservation offers any is no increased benefi t from the use of prophylactic closed- substantive advantage. suction drainage after PD, therefore its role warrants further discussion.

145 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1739 Effi cacy of Wrapping the Pancreatic Stump with a Bioabsorbable Sheet and Fibrin Glue After Distal Pancreatectomy Daisuke Ban, Kota Sato, Satoshi Matsumura, Takumi Irie, Takanori Ochiai, Atsushi Kudo, Noriaki Nakamura, Shinji Tanaka Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan BACKGROUND: Distal pancreatectomy (DP) is a simple operative procedure. However, morbidity associated with pancreatic fi stula has remained unresolved. In 25 of 70 DPs, we wrapped the pancreatic stump in a bioabsorbable sheet with fi brin glue. The aim of this study was to evaluate the effi cacy of our wrapping method. METHOD: Between January 2006 and October 2012, 70 laparoscopic and open patients underwent DP. Pancreatic stump closure was achieved with a stapler or by conven- tional hand-sewn closure. In the wrapping group, the pan- Mo1740 creatic stumps were wrapped with a polyglycolic acid felt bioabsorbable sheet (0.15 mm thick), and fi brin glue was Predictors of Same Hospital Readmission Versus sprayed onto the wrapped stump. Pancreatic fi stulas were Readmission to Another Hospital After Surgery for classifi ed according to the grading system of ISGPF. The pri- Pancreatic Cancer: A SEER-Medicare Study mary endpoint was the occurrence of a clinical pancreatic Marquita R. Decker1,2, David Y. Greenblatt2, Chee P. Lin1, fi stula, including Grade B and C. Jeffrey A. Havlena1,2, R Scott Saunders1, Sara Fernandes-Taylor1,2, RESULT: Of the patients, 25 (36%) underwent pancreatic Noelle K. Loconte3,2, Heather B. Neuman1, Sharon M. Weber1, stump wrapping, and 45 (64%) had no additional treat- Maureen A. Smith2, Amy Kind3,2, Caprice C. Greenberg1,2, ment after pancreatic stump closure (non-wrapped-). In Emily Winslow1 the wrapped group, Grade A, B, and C pancreatic fi stulas 1Department of Surgery, University of Wisconsin, Madison, WI; occurred in 7 (28%), 2 (8%), and 0 patients, respectively. In 2Health Innovation Program, University of Wisconsin, Madison, WI; the non-wrapped group, Grade A, B, and C pancreatic fi s- 3 tulas occurred in 6 (13%), 17 (38%), and 1 (2%) of subjects, Department of Medicine, University of Wisconsin, Madison, WI respectively. The incidence of clinical pancreatic fi stula OBJECTIVE: Patients who undergo pancreatic surgery are in wrapped patients was signifi cantly lower than that in among those at the highest risk for readmission. Evidence unwrapped patients (p = 0.004). The average of the amylase suggests that same hospital readmission is less costly than value in pancreatic drains in the unwrapped and wrapped readmission to another hospital. The objective of this study group was 3893 IU/L and 15562 IU/L on postoperative day was to identify modifi able and non-modifi able predictors (POD) 1, 1401 IU/L and 1736 IU/L on POD 3, respectively. of same versus other hospital readmission among patients On POD 1, the drain amylase value in wrapped patients who undergo surgery for pancreatic cancer. was signifi cantly lower than that in unwrapped patients (p METHODS: Medicare benefi ciaries who underwent major = 0.004). Other clinical features and treatments including pancreatic resection from 2000 to 2008 were identifi ed age, sex, body mass index, primary disease, American Soci- from the Surveillance, Epidemiology, and End Results- ety of Anesthesiologists classifi cation, previous laparotomy, Medicare database. Demographics, co-morbidities, cancer- intraoperative bleeding, operation time, laparoscopic sur- related and treatment-related variables as well as hospital gery, stump closure method, and blood transfusion were characteristics were examined. Using multivariable logistic not signifi cantly related to pancreatic fistula. regression, predictors of readmission were identifi ed and CONCLUSION: The present study suggests that a bioab- then compared to predictors of same versus other hospital sorbable sheet with fi brin glue wrapping has advantages readmission. after distal pancreatectomy and may reduce the incidence RESULTS: Of 2,486 patients, 512 (21%) were readmitted of pancreatic fi stula. within 30days of discharge. One thousand six hundred eighty fi ve (68%) had their surgery at an academic medi- cal center and 607 (24%) at a National Cancer Institutes (NCI) -designated cancer center. One thousand six hundred forty two (66%) had an initial length of stay greater than 10 days and 471 (19%) were discharged to a skilled nursing facility (SNF). Predictors of readmission included severity of co-morbidities (Charlson Comorbiditiy Score ≥3: OR 1.54 [95% CI 1.08–2.2] p = 0.017), initial length of stay greater than 10 days (OR 1.66 [95% CI 1.32–2.17] p < 0.001), and

146 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

discharge to a SNF (OR 1.50 [1.15–1.95] p = 0.003). Of the Mo1741 readmitted patients, 387 (76%) returned to the same hos- pital while 125 (24%) were readmitted to another hospital. Bridging the Gap in Hospital Accounting: Acute After controlling for co-morbidities, neoadjuvant radiation Pancreatitis 2001–2009 and chemotherapy, and other treatment-related variables, Kenneth W. Bueltmann, Kenneth Laube, Marek Rudnicki readmission to another hospital was more likely for patients Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL if time from diagnosis to surgery was greater than 60 days (OR 3.80 [95% CI 1.67 –8.68] p = 0.005). Readmission to INTRODUCTION: Acute pancreatitis (AP) was found in another hospital was also more likely if the hospital where the discharge records of 461,302 patients in 2010 accord- the pancreatic surgery occurred was an NCI-designated can- ing to the National Inpatient Sample (NIS). This illness was cer center (OR 1.91 [95% CI 1.11 –3.28], p = 0.019) or if concurrently present in 288,597 discharges as the primary it was affi liated with a medical school (OR 2.31 [95% CI diagnosis. The fi nancial ramifi cations of the disease have 1.10–4.83] p = 0.027). increased dramatically over the last decade, exceeding $9 billion in total aggregate charges. This refl ects the “national CONCLUSIONS: Readmission is common in patients who bill” for AP treatments. $3 billion in costs were directly undergo surgery for pancreatic cancer, and almost 1 in 4 related to discharges coded for primary AP in 2010. This readmitted patients go to another hospital. Risk factors for study will explore the fi nancial aspects of inpatient AP diag- 30-day readmission include comorbidities and a compli- nosis over time and characterize these observations at the cated post-operative course resulting in prolonged length National level. of stay and discharge to a skilled nursing facility. Predic- tors of readmission to another hospital relate to prolonged METHODS: The NIS database and cost-charge ratio (CCR) time from diagnosis to surgery and pancreatic surgery at fi les were utilized in conjunction with SAS 9.3 for all analy- a tertiary care hospital. This study identifi es the group of ses. The weighted group averages (GAPIIC) include both patients who are likely referred for resection from their operating and capital-related costs and were used to calcu- local setting to a tertiary care center as a target for interven- late charges and costs from the total charge records. Inde- tions to prevent or redirect readmissions. pendent means and standard errors were generated from the costs and charges columns for each discharge in the Multivariable Analysis Identifying Predictors of Readmission to years 2001 and 2009. Results were tabulated and relative Another Hospital After Pancreatic Surgery changes over the time period and their associated statistical signifi cances were calculated using the NIS Z-test calculator. Explanatory Variables Adjusted OR 95% CI P Value RESULTS: The number of discharges for all diagnoses of AP Age 0.314 (ICD-9 Code 5770) increased 34% from 330,664 to 441,455 66–69 Reference from the year 2001 to 2009 (p < .001). Primary diagnosis of 70–74 1.26 (0.64 –2.49) AP represented 221,664 and 274,119, respectively, a 24% 75–79 1.30 (0.66 – 2.59) increase thereof (p < .001). Lengths of stay for primary AP 80 + 2.02 (0.95 – 4.29) diagnoses in this same time period decreased from 6.1 to Time From Diagnosis To Surgery 0.005 5.1 days (–16%, p < .001). Gender distribution was found <30 days Reference to be equivocal. GAPIIC average fell 5.2 percent from 2001 30 to 60days 1.58 (0.85 – 2.91) to 2009 (p < .001). Total average charges for all adult AP >60 days 3.80 (1.67 – 8.68) diagnoses increased 73%, $25,073 to $43,410 (p < .001), Hospitalizations In Previous Year 0.767 while average costs increased 31% from $11,257 to $14,769 0 Reference (p < .001). The difference between hospital charges and ser- vice costs increased 107%, from $13,815 to $28,641 (p <

1 0.85 (0.48 – 1.50) Poster Abstracts 2 0.71 (0.35 – 1.44) .001). Aggregate charges for primary AP diagnosis increased from $4,279,659,980 to $8,581,512,698, a 101% change 3 + 1.01 (0.50 – 2.03) Monday Initial Length of Stay 0.113 (p < .001). <10days Reference CONCLUSION: This study fi nds an increasing gap between 10 + days 1.54 (0.88 – 2.71) hospital costs and charges for treatment of AP. Although Index Hospital Med School 2.31 (1.10 – 4.83) 0.027 costs appear to be managed, charges are dramatically Affi liation infl ated. The inherent power of the NIS has provided evi- Index Hospital Number of Beds 0.687 dence that healthcare providers have controlled the treat- <300 0.75 (0.32 – 1.75) ment costs of AP in the last decade. Increased transparency 300–600 0.82 (0.49 – 1.36) and movement towards accountability in medical care >600 Reference demands further clarifi cation. Continued investigations Index Hospital NCI Designation 1.91 (1.11 – 3.28) 0.019 may reveal that the fi scal cliff which confronts the health- Index Hospital Available Hospice 0.70 (0.43–1.14) 0.148 care industry is not a matter of care generated cost, but may refl ect an intrinsic lack of effi ciency in insurance premiums, Neoadjuvant Chemo or 0.72 (0.25 – 2.07) 0.734 Radiation administration, and overhead. DischargeTo Skilled Nursing 0.60 (0.33 – 1.06) 0.077 Facility *Controlled for stage at diagnosis and diabetes mellitus in addition to above listed variables

147 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1742 Mo1743 Clinico-Pathological Features of Solid Pseudopapillary Risk Factors and Management of Postpancreatectomy Neoplasms of the Pancreas Hemorrhage in over 1000 Pancreatic Resections Pablo E. Serrano1, Hassan AL-Ali1, Steven Gallinger1, Ulrich Wellner1,2, Frank Makowiec1, Hryhoriy Lapshyn1, Ian D. Mcgilvray1, Carol-Anne Moulton1, Alice C. Wei1, Dirk Bausch1,2, Ulrich T. Hopt1, Tobias Keck1,2 Stefano Serra2, Sean Cleary1 1Clinic for General and Visceral Surgery, University of Freiburg 1Surgery, Princes Margaret Cancer Centre, Toronto General Hospital, Medical Center, Freiburg, Germany; 2Department of Surgery, University University of Toronto, Toronto, ON, Canada; 2Pathology, Toronto Hospital of Schleswig-Holstein Campus Lübeck, Lübeck, Germany General Hospital, University of Toronto, Toronto, ON, Canada INTRODUCTION: Postpancreatectomy Hemorrhage (PPH) BACKGROUND: Solid pseudopapillary neoplasms (SPN) is a rare but relevant complication after pancreatic resec- are rare pancreatic tumors with low malignant potential. tions. The aim of this study was to analyze risk factors and management of PPH in a large patient collective. METHODS: This is a retrospective analysis of 24 patients with a diagnosis of SPN who underwent resection. The METHODS: The study was carried out retrospectively on main objective of this study was to describe the clinico- the basis of a prospectively maintained database. Patients pathological features and surgical management of SPN. with major pancreatic resections were included. PPH was defi ned according to the ISGPS. For statistical analysis, SPSS RESULTS: Median age at diagnosis was 35.5 years (13 to Software Version 20 was used. 64). Most patients were female, 20/24, 83%. Most patients, 14/24, 58% were symptomatic at diagnosis, (11/24, RESULTS: From 1994 to 2012, n = 1082 Patienten aged 9 79% had abdominal pain). Median tumor size was 4.7 bis 89 years were included (729 pancreatoduodenektomies cm (2.1 to 12) with 15/24, 62.5% occurring in the body (PD), 188 distal pancreatic resections, 123 duodenum-pre- or tail and 9/24, 37.5% in the head or neck of the pan- serving procedures and 42 pankreatectomies). Incidence of creas. Most tumors were solid and cystic in nature (18/24, PPH was 7% and 3% for severe (Grade C) PPH, 90% were 75%), without calcifi cations (6/24, 25%) and encapsulated late (>24 h postOP) PPH and about half of PPH had an intra- (16/24, 70%). There were 8/24, 33% pancreaticoduodenec- luminal origin. tomies, 4/24, 17% spleen-preserving distal pancreatecto- With Grade C PPH, mortality rose signifi cantly to over 30% mies, 10/24, 42% distal pancreatectomy-splenectomy and (overall 1.3%). Primary management consisted in endo- 2/24, 8% central pancreatectomies. Major complications scopic, angiographic and operative intervention. For severe occurred in 3/24, 12.5% patients, with 6/24, 25% pancreatic PPH, success rate of non-operative therapy was around leak rate (5/6, 83% ISGPF-type A leak). All cases displayed 50%. Risk factors for PPH were higher age and BMI and  strong -catenin, CD56, progesterone receptor, alpha-1 pancreatic fi stula (POPF). Pancreatogastrostomy (PG) in PD antitrypsin and neuron-specifi c-enolase staining with loss had a signifi cantly higher incidence of PPH than pancreato- of E-cadherin. Most cases stained positive for vimentin jejunostomy (PJ) mostly due to intraluminal PPH from the (11/12, 92%) and CD10 (14/15, 93%). Three SPN were con- PG site. However, mortality after occurrence of PPH was sig- sidered malignant, 3 developed liver metastases, 2 of which nifi cantly lower with PG (8% vs 28%, p < 0.05) compared to were initially found at presentation and 2 had local recur- PJ, and PG was independently associated with lower overall rence in the retroperitoneum. Two patients had evidence mortality survival in multivariate analysis, while age, POPF of lymphovascular invasion; one of them had lymph node and PPH were the relevant risk factors for death. involvement and eventually developed liver metastases. Curative resection of metastases was offered to 2 of the 3 CONCLUSIONS: PPH is a major determinant of mortality patients, the other patient died of disseminated metastatic risk in pancreatic surgery. Non-operative management is disease 5 years after diagnosis of recurrence, 10 years after successful in about half of cases of severe PPH. Intraluminal initial pancreatic resection. Chemotherapy (gemcitabine PPH is more frequent with PG, however mortality after PPH and erlotinib) was given to only one patient with unre- and overall mortality were signifi cantly reduced with PG. sectable metastatic disease. Median follow-up period was 30 months (4 to 129), 21/24, 87.5% patients did not have Mo1744 recurrence and all patients except one were alive at the end of the study period. Mortality of Severe Acute Pancreatitis (SAP) Patients with Infected Necrosis or Persistent Organ Failure CONCLUSIONS: SPN are tumors with a low but real malig- nant potential. Metastases and lymphovascular invasion Is High But May Be Reduced by Specialist Care and are the only features that can predict an aggressive behav- Innovative Therapeutic Modalities ior. Resection of liver metastases can offer cure to some of Omer Jalil, Rami Radwan, Aamer F. Iqbal, Chirag Patel, these patients with aggressive SPN. Ashraf M. Rasheed Dempartment of Surgery, Royal Gwent Hospital, Newport, United Kingdom INTRODUCTION: Severe acute pancreatitis (SAP) is best supported in high dependency or intensive therapy units (HDU or ITU) setting and associated with high mortality and morbidity despite best efforts at attaining early diagno- sis and timely intervention.

148 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

AIM: To study management and disease-related mortality Mo1745 of patients admitted to ITU with SAP with specifi c emphasis on the group that succumbed to the disease in an attempt Peri-Operative Epidural May Not Be the Preferred to understand the circumstances that lead to this event and Form of Analgesia in Select Patients Undergoing identify interventions that may have abrogated this even- Pancreaticoduodenectomy tuality and indicators that may have predicted the fate of Trevor Axelrod1, Bernardino M. Mendez2, Gerard Abood2, these patients. James Sinacore1, Gerard V. Aranha2, Margo Shoup3 METHODS: Retrospective case per case detailed analy- 1Loyola University Chicago Stritch School of Medicine, Maywood, IL; sis of management and outcome of consecutive patients 2Surgery, Loyola University Medical Center, Maywood, IL; 3Surgery, admitted to ITU with SAP during the period of 2007–2010. Cadence Healthcare, Warrenville, IL Medical records were reviewed by a single abstractor (OJ) for patient characteristics and disease severity scoring. The INTRODUCTION: Over the past decade, epidural analge- development of necrosis, infected necrosis (IN) or organ sia and anesthesia (EAA) has become the preferred method failure (OF) was recorded. Patients were classifi ed into of pain management for major abdominal surgery. With group I (No necrosis, No OF), group II (sterile necrosis or regards to pancreaticoduodenectomy (PD), the superior transient OF), group III (IN or persistent OF) and group IV form of analgesia, as evidenced by their respective non- (infected necrosis and persistent OF). The hospital course analgesic outcomes, has been debated. In this study, we of the four groups were studied in relation to fl uid resus- compare postoperative morbidity and mortality with EAA citation, use and type of prophylactic or therapeutic, use and IV analgesia in patients who underwent PD. We also of prophylactic anti-fungal, early introduction of enteral examine preoperative factors that lead to epidural discon- feeding, radiological/surgical intervention and any post- tinuation and the consequence of premature epidural dis- intervention complications. continuation on morbidity and mortality. RESULTS: 51 patients admitted to ITU with SAP (APACHE METHODS: A retrospective review of a prospective data- II > 8, modifi ed Glasgow score > 3) during the period of base of PDs performed at a single institution was conducted 2007–2010. All cases fulfi lled the Atlanta criteria of SAP. for the time period between January 2007 and July 2011. Median age: 66 ± 17.5. SAP was alcohol induced in 12% Patients receiving IV analgesia (group A) were compared and due to gallstones in 59% of patients. No cause was with patients receiving EAA alone or in conjunction with identifi ed in 25% of patients. Median hospital stay and ITU IV analgesia (group B). Endpoints included mortality, major stay were 14 and 3.23 days respectively. Forty one patients postoperative complications, postoperative hypotension, (80%) received antibiotics and thirty fi ve patients (69%) postoperative fl uid requirements, length of stay, and hospi- had nutrition support but neither of them seems to have tal readmission within 30 days. Multivariate logistic regres- a signifi cant impact on survival (p = 0.6 and 0.06 respec- sion was performed to measure the predictive success of tively). The overall mortality rate during the study period epidural analgesia in comparison to IV analgesia for each (3 years) was 38% (n–19) above national average of 30%. endpoint, as well as to measure the predictive success of All 7 patients in group IV died; 5 had necrosectomy and 1 preoperative parameters including age, gender, BMI, surgi- had CT guided drainage of infected acute fl uid collection. cal indication, and comorbidity. Using these same preoper- ative parameters, Classifi cation and regression tree (CART) Outcome (death) was statistically correlated with organ analysis for predictive modeling was used to determine dysfunction criteria (Atlanta criteria and APACHE II score). predictors of epidural failure. Chi-Squared analysis was also performed to compare patients who had epidural failure Group Total Number Mortality % Mortality with the rest of group B using the previously assessed mor- I (No N & No OF) 12 0/12 0% bidity and mortality endpoints. Poster Abstracts II (SN or Transient OF) 2 0/2 0% RESULTS: Of the 163 patients reviewed, 14 (9%) were in III (IN or Persistent OF) 30 12/30 40% group A and 149 (91%) were in group B. Endpoints were Monday IV (IN & Persistent OF) 7 7/7 100% similar between the two groups, however 22 patients (15%) in group B had their epidural discontinued early due to CONCLUSION: While the presence of ‘IN or persistent either severe hypotension or epidural malfunction. Within OF’ in SAP (group III) is associated with high mortality, this group, patients older than 72 and with a BMI less than the combination of ‘IN and persistent OF’ (group IV) is or equal to 20 had their epidural discontinued in 80% of uniformly fatal. Further research is necessary to confi rm cases compared with 12% of patients not meeting this fi ndings in our study and to explore ways of optimising criteria. There was no signifi cant difference in endpoints patients in group III to improve survival. between the 22 patients that had their epidural discontin- ued prematurely and the other 127 patients in group B who did not require premature epidural discontinuation. CONCLUSION: EAA may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction. How- ever, premature epidural discontinuation was not associ- ated with increased morbidity and mortality. Prospective randomized trials are warranted to further determine if EAA should be avoided in this specifi c population.

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Mo1746 Mo1747 Postoperative Serum Amylase Predicts Pancreatic Signifi cance of Radiographic Splenic Vessel Fistula Following Pancreaticoduodenectomy Involvement in Pancreatic Ductal Adenocarcinoma Jordan M. Cloyd, Brendan Visser, George A. Poultsides, (PDAC) of the Body and Tail Zachary Kastenberg, Jeffrey A. Norton Nathaniel B. Paull1, Geraldine Chen2, Adnan Alseidi1, Surgery, Stanford University, Stanford, CA Thomas R. Biehl1, Ravi Moonka1, Scott Helton1, David Coy2, BACKGROUND: Pancreatic fi stula (PF) is the most com- Flavio G. Rocha1 mon complication following pancreaticoduodenectomy 1Surgery, Virginia Mason Medical Center, Seattle, WA; 2Radiology, (PD) and is associated with high morbidity. Despite this, Virginia Mason Medical Center, Seattle, WA few preoperative or perioperative risk factors have been OBJECTIVES: Major abodminal vessel invasion by PDAC identifi ed. In this study, we measured the postoperative in the head of the gland typically represents more advanced serum amylase level and studied its ability to predict the disease not amenable to surgical resection. During distal development of PF. pancreatectomy for PDAC of the body or tail, the splenic METHODS: A retrospective review of 176 consecutive PD vessels are routinely removed for tumor clearance and performed by one surgeon between 2006 and 2011 was lymphadenectomy. However, little is known about the bio- conducted. Preoperative demographic, perioperative data logic signifi cance of splenic artery and vein involvement in and clinical outcomes were recorded. Comparison statistics PDAC of the body or tail and we hypothesize that it may be and logistic regression were used to analyze the association an adverse prognostic factor. between the serum amylase on postoperative day one and METHODS: All cases of distal pancreatectomy for PDAC the development of PF. PF was defi ned and scored based on at a single institution between 2000–2010 were retrospec- the International Study Group on Pancreatic Fistula. tively reviewed from an IRB-approved database. Preopera- RESULTS: 146 of 176 consecutive PD cases (83.0%) had tive computed tomography (CT) imaging was re-reviewed serum amylase on postoperative day one recorded. 27 of by a single radiologist and splenic artery and vein involve- the 146 developed a PF (18.5%): 6 type A, 19 type B and 2 ment was graded as none, abutment, encasement or occlu- type C. Patients with a PF had a mean serum amylase on sion. Demographic, laboratory, operative, pathological, and postoperative day one of 659 ± 581 compared to 246 ± 368 outcome data were collected and correlated to the degree in control patients (p < 0.001). Patients with leaks were also of splenic vessel involvement. Statistical analysis was per- younger (60.3 ± 11.3 vs 65.5 ± 11.1, p < 0.05), less likely formed using a Chi-Square with Fisher’s exact test and sur- to have pancreatic adenocarcinoma (40.7% vs 68.9%, p < vival compared by the method of Kaplan-Meier with log 0.05) and less likely to have a duct-to-mucosa anastomo- rank test. sis (63.0% vs 88.2%, p < 0.01). A serum amylase of 140 RESULTS: 46 patients were identifi ed, of which 44 had U/L, the laboratory’s upper limit of normal, was empirically preoperative cross-sectional imaging available for evalua- chosen as the cutoff value in order to maximize sensitivity tion to make up the study cohort. 39 (89%) patients had while maintaining specifi city. On logistic regression analy- radiographic tumor involvement of the splenic vein (23 sis, a serum amylase > 140 U/L on postoperative day one abutment, 6 encasement, 10 occlusion) while 32 (73%) was strongly associated with developing a PF (OR 5.48, 95% patients had tumor involvement of the splenic artery CI 1.94–15.44) as was receiving an intussuscepting anasto- (20 abutment, 12 encasement, none with occlusion). 28 mosis (OR 4.41, 95% CI 1.69–11.52). Greater age (OR 0.96, patients had both arterial and splenic involvement while 95% CI 0.93–1.00) and a diagnosis of adenocarcinoma (OR three patients had neither. There was no signifi cant differ- 0.31, 95% CI 0.13–0.71) were associated with not develop- ence in margin positivity, perineural or lymphovascular ing PF. Sensitivity and specifi city of a postoperative serum invasion between patients with or without splenic vessel amylase > 140 U/L was 81.5% and 55.5%, respectively. Posi- involvement. However, splenic artery encasement corre- tive and negative predictive values were 29.3% and 93.0%, lated with lymph node positivity (p < 0.02). Splenic artery respectively. but not vein encasement or occlusion was associated with a CONCLUSIONS: An abnormally elevated serum amylase signifi cantly worse overall survival (OS) when compared to on postoperative day one following PD is associated with a abutment or no involvement (median OS 15 months vs 31 fi ve-fold higher risk of developing a pancreatic fi stula. This months, p < 0.04). readily available and inexpensive test may assist in the ear- CONCLUSIONS: Patients with PDAC of the body or tail lier detection of pancreatic fi stula. presenting with radiographic encasement of the splenic artery but not the vein have a worse prognosis and should be considered for additional treatment such as neoadjuvant therapy prior to an attempt at resection.

150 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1748 Mo1749 Outcomes of Surgery for Chronic Pancreatitis Patients with Familial Pancreatitis Have a Better Rajesh Gupta1, Sunil D. Shenvi1, Rajinder Singh1, Quality of Life After Total Pancreatectomy with Islet Surinder S. Rana1,2, Deepak K. Bhasin2 Autotransplantation 1Surgical Gastroenterology Division, Postgraduate Institute of Medical Stefanie M. Owczarski1, Katherine A. Morgan1, David B. Adams1, Education and Research, Chandigarh, India; 2Gastroenterology, Hongjun Wang1, Jeffrey J. Borckardt2, Alok Madan2 Postgraduate Institute of Medical Education and Research, 1Surgery, MUSC, Charleston, SC; 2Psychiatry and Behavioral Sciences, Chandigarh, India MUSC, Charleston, SC INTRODUCTION: Debilitating abdominal pain remains INTRODUCTION: Familial pancreatitis (FP) patients the most common presentation of chronic pancreatitis and live with debilitating pain from a young age and have an the treatment remains challenging. This study analyzed the increased risk of developing pancreas cancer. Quality of life outcome of surgery in patients with chronic pancreatitis. (QOL) following total pancreatectomy with islet autotrans- PATIENTS AND METHODS: We retrospective reviewed plantation (TPIAT) in this patient population is not well details of patients undergoing surgery for chronic pancre- understood. atitis between January 2002 and June 2013 at Division of METHODS: A prospectively collected database of patients Surgical Gastroeneterology, PGIMER, Chandigarh. A total undergoing TPIAT for FP was reviewed over a 1 year period. of 60 patients were admitted for surgery, however, surgery Data pertaining to insulin requirements and diabetes con- was not performed in fi ve due to medical reasons.Indica- trol, pain scores, and SF-12 physical quality of life (pQOL) tions for surgery was pain in 51 patients, gastric outlet and mental health QOL (mhQOL) (normal population 50, obstruction in 2 and bleeding in 2 patients. SD 10) in the perioperative period were reviewed. QOL is RESULTS: 38/60 were males and mean age was 37 (SD ± improved if the result increases by at least 3 points or is > or 12.94). 22 patients were alcoholics and 17 were smokers. = to 35. Approval from the IRB was obtained. 47 patients were on oral and 10 patients were on intrave- RESULTS: Thirteen patients (6 males, median age 21, range nous analgesics while 3 did not require regular analgesics. 12–50) underwent TPIAT for FP. Average time from diagno- 10 patients had diabetes mellitus and 11 had steatorrhea sis to surgery was 10 years. Physical QOL (pQOL) changed preoperatively. 39 patients underwent Frey’s procedure from 35 pre-op to 39 at 6 months and 49 at 1 year. Mental while Whipple’s procedure was done in 6 and Izbicki’s pro- health QOL (mh QOL) changed from 46 pre-op to 45 at cedure was done in two. LPJ was done in two while bipolar 6 months and 41 at 1 year. Average pain score decreased ligation and distal pancreatectomy with splenectomy (for from 3 pre-op to 2 at 6 months and at 1 year after surgery. splenic artery pseudo aneurysm) was done in another two. 4/13 (30%) of patients were diabetics prior to surgery, 2 Roux-en-y cystojejunostomy performed in 2. Three patients were insulin diabetics and took 10 and 40 units of insulin underwent reoperation for poor pain control; 2 patient daily (u/D), and 2 were non-insulin diabetics. Number of with LPJ done previously underwent Frey’s procedure after islets transplanted averaged 186,297 (3,667–580,224). All 2 years while one patient who had undergone Frey’s proce- patients required insulin post-op and averaged 26 u/D at dure underwent Whipple’s procedure after 4 years. 6 months and 32 u/D at 1 year following surgery. Average There were no in hospital mortalities. 4 patients died dur- HbA1C was 5.7 pre-op, 8 at 6 months, and 8.2 at 1 year. ing follow up; cause being alcoholic cirrhosis in 2, suicide CONCLUSION: TPIAT effectively improves physical QOL in 1 and diabetic ketoacidosis with sepsis in another. Two in patients with FP despite all patients requiring daily insu- patients had postoperative intraluminal bleed and one lin after surgery. Mental Health QOL remains normal after needed re-exploration. After a mean follow up of 23.9 surgery. More experience is needed to better understand Poster Abstracts months ± SE 23.6 months (median: 13 months; range 1 to optimal timing of surgery but earlier referral may improve 84 months); 54% of patients reported excellent pain relief, endocrine outcomes. Monday 20% patients reported good pain relief and 11.4% patients had fair pain relief (on regular oral pain killers). Two patients developed new onset diabetes controlled by diet and medications, while in 4 patients diabetes worsened.5 patients had new onset stetorrhea which was transient in all and settled with dietarymodifi cation in two and enzyme supplementation in another three. CONCLUSIONS: Tailored surgery for chronic pancreati- tis has excellent benefi t in pain relief without signifi cant increase in functional abnormalities. Frey’s procedure was the commonest surgery performed in the present study.

151 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1750 Lesion with Vascular Invasion: Distribution, Characteristics and Complications Irreversible Electroporation of Unresectable Soft Tissue Tumors with Vascular Invasion High-Grade Prejesh Philips1, Susan Ellis1, David A. Hays2, Complications Complications P Value# Govindarajan Narayanan3, Erik M. Dunki-Jacobs1, Liver (17) 3 (17.6%) 2 (11.7%) 0.2/0.3 Robert C. Martin1 Pancreas (84) 37 (44%) 17 (20.2%) 0.007/0.2 1Surgical Oncology, University of Louisville, Louisville, KY; CRHM* (11) 0 0 0.01/0.02 2 Pancreatic adenocarcinoma 38 (50%) 16 (21%) <0.000/ 0.1 Department of Radiology, Baptist Little rock, Little Rock, AR; (76) 3 Radiology, University of Miami, Miami, FL Laparotomy Access (81) 39 (48.1%) 20 (24.7%) <0.000/0.002 INTRODUCTION: IRE is a novel technique, which delivers Percutaneous access (33) 3 (9%) 1 (3%) <0.000/0.005 localized electric current using peri-tumoral probes causing (lower CR) * irreversible cell membrane damage and cell death. Due to Concurrent major 27 (48%) 13 (23%) 0.02/0.07 its non-thermal action, it is ideally suited for tumors with abdominal procedure (56) vascular invasion. This study was designed to evaluate the Target Size (yes vs. no, cm) 3.8 vs. 3.5 3.65 vs. 3.6 0.1 safety and effi cacy of IRE in peri-vascular tumors. Length of stay (yes vs. no, 10.6 vs. 4.7 15 vs. 5.4 <0.000/<0.000 Days) METHODS: Analysis of 107 consecutive patients over 7 institutions with tumoral vascular invasion (defi ned as <5 PMH Diabetes (20) 13 (65%) 7 (35%) 0.009/0.05 mm from major vessel) was done from a prospective multi- Radiation (47) 24 (51%) 12 (25.5%) 0.01/0.1 institutional registry. Safety parameters, complications and Prior Ablation/resection (17) 1 (5.2%) 0 0.01/ 0.002 effi cacy were evaluated. Patients without follow-up or those # p value signifi cant <0.05 CR Complication rate CRHM Colorectal Hepatic unfi t for general anesthesia were excluded. metastasis RESULTS: A total of 117 procedures were performed for 84 pancreatic and 17 liver lesions among others. Majority had Mo1751 prior chemotherapy (82,76.7%) or local treatment such as radiation 47 (44%), other ablations (11,10.2%) or emboli- Clinical Signifi cance of Portomesenteric Vein zation therapy (10,9.3%). Percutaneous access for IRE was Abutment Among Patients with Pancreatic Ductal used in 32 (27%) patients while laparotomy access was Adenocarcinoma used in 81 (69%). Concurrent major abdominal procedures Victor M. Zaydfudim1, Kengo Asai1, Clancy J. Clark1, were performed in 56 (61%). Vascular invasion was either Christina M. Wood-Wentz2, Heather J. Wiste2, to the portal vein (n = 82), hepatic vein (n = 6), SMA/SMV David M. Nagorney1, Michael B. Farnell1, Michael L. Kendrick1 (n = 24) or celiac axis (n = 6). Procedure time (Median 170 1 mins) was signifi cantly higher in patients with concurrent Division of Gastroenterologic and General Surgery, Mayo Clinic, 2 major surgery (195 vs. 114 minutes, p < 0.000). Per patient, Rochester, MN; Division of Biomedical Statistics and Informatics, median 2 lesions of 3.5 cm target size and tumor size of 3 × Mayo Clinic, Rochester, MN 2 × 2.75 cm were ablated. Overall Morbidity rate was 36.7%, INTRODUCTION: The defi nition of borderline resectable attributable complication rate was 16.2% and high-grade (> pancreatic head ductal adenocarcinoma has been scruti- Grade 3) complication rate was 5.1%. Three vascular com- nized in recent investigations and alterations to practice plications (SMV, portal vein and Hepatic artery thrombus) guidelines have been proposed. Current controversy ques- and 2 peri-procedure deaths (one unrelated) were seen. Dia- tions the ability to achieve a margin-negative resection and betes (p = 0.05), pancreatic lesions (p < 0.001), prior radia- equivalent survival among patients with portomesenteric tion (p = 0.01) and concurrent major procedures (p = 0.02) vein involvement. The aim of this study was to evaluate were associated risk factors. Incomplete ablation was seen operative resectability of patients with portomesenteric in 7 (6%) patients. Median follow up was 12 months with vein involvement and to correlate the extent of venous LRFS was 9.2 months. involvement with survival. CONCLUSION This is the largest study of any interstitial ablation in tumors with vascular invasion. The low vascu- lar and IRE-related complication rates high ablation rate demonstrates IRE’s safety effi cacy in these locally advanced tumors with vascular invasion.

152 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: All consecutive patients who underwent pan- Mo1752 creaticoduodenectomy for pancreatic adenocarcinoma at a single institution from 2000 to 2007 were included in this Does Weight Affect Outcomes Following Total retrospective study. Patients who received neoadjuvant Pancreatectomy with Islet Autotransplantation? treatment prior to resection and patients with arterial abut- Stefanie M. Owczarski1, Katherine A. Morgan1, David B. Adams1, ment were excluded. Venous involvement was categorized Hongjun Wang1, Joseph Romagnuolo3, Kelley Martin3, using pre-operative cross-sectional imaging as 1) none, 2) Jeffrey J. Borckardt2, Alok Madan2 portomesenteric vein (PMV) abutment <180°, 3) PMV abut- 1Surgery, MUSC, Charleston, SC; 2Psychiatry and Behavioral Sciences, ment ≥180°, and 4) PMV impingement/occlusion. Univari- MUSC, Charleston, SC; 3Gastroenterology and Hepatology, MUSC, ate logistic regression and Cox proportional hazards models were constructed. All four levels of venous involvement Charleston, SC were compared to each other; Benjamini-Hochberg method INTRODUCTION: The incidence of weight loss follow- was used to adjust for multiple comparisons. ing total pancreatectomy with islet autotransplantation RESULTS: 290 patients (median age 68 years (range for chronic pancreatitis and its effect on insulin require- 38–90), 58% male) underwent pancreaticoduodenectomy. ments and Quality of life (QOL) post-operatively is poorly 30- and 90- day mortality was 0.7% and 1.7%, respectively. understood. 117 patients (40%) had venous involvement: 73 abutment METHOD: A prospectively collected, IRB approved data- <180°, 21 abutment ≥180°, and 23 PMV impingement/ base at a single institution was reviewed. Patients with a occlusion. Margin negative resection was achieved in 83% BMI greater than or equal to 25 were compared to those of patients without venous involvement compared to 73% with a BMI less than 25 prior to surgery. Data pertaining patients with abutment <180° (p = 0.09), 29% of patients islet yield, insulin requirements, laboratory results, and with abutment ≥180° (p < 0.01), and 52% of patients with quality of life (QOL) were reviewed at 6 months and 1 year PMV impingement/occlusion (p < 0.01). Patients with following surgery. The SF12 survey was used to asses QOL abutment <180° were more likely to have margin negative (normal population 50, SD 10). QOL is improved if the resection than patients with abutment ≥180° (p < 0.01). result increases by at least 3 points or is > or = to 35. Retroperitoneal margin was positive in 15%, 16%, 48%, RESULTS: 100 consecutive patients were reviewed (78 and 30% among the patient groups. Patients with abutment females, average age 42) from March 2009 to present. 19 ≥180° had more frequent positive retroperitoneal margins patients were omitted due to lack of at least 6 month post- than patients without venous involvement or abutment op data and 12 patients were omitted who were insulin <180° (both p≤0.01). 58 patients (20%) required PMV resec- diabetics pre-op. 42/69 patients (60%) were overweight tion and reconstruction: 7% of patients without venous or obese prior to surgery (BMI > 25), with an average BMI involvement compared to 36% with abutment <180°, 43% pre-op of 30, prealbumin 23, A1C 5.5, pQOL 25, mhQOL with abutment ≥180°, and 48% with PMV impingement/ 36, and took no insulin prior to surgery. Their median islet occlusion (all p < 0.01). There were no signifi cant group yield was 244,781 IEQ and 3,316 IEQ/kG (range 14,312– differences in recurrence-free and overall survival (all p ≥ 1,168,725 IEQ, 234–16,009 IEQ/Kg). At 1 year post-op, 0.09). their BMI decreased to 25, and prealbumin was 17, A1C CONCLUSIONS: Portomesenteric vein abutment ≥180° 7.6, pQOL 34, mhQOL 41, mean daily insulin 21 u. 34/42 is associated with signifi cantly higher risk of margin posi- (80%) of these overweight patients had a sustained post- tive resection. While patients without venous involvement operative weight loss of at least 10% of their pre-op weight. and patients with vein abutment <180° can be explored for Comparatively, the patients who had a BMI < 25 prior to curative resection, patients with PMV abutment ≥180° and surgery (n = 27) were found to have an average BMI 20 impingement/occlusion might benefi t from neoadjuvant pre-op, prealbumin 21, A1C 5.6, pQOL 26, mhQOL 36, and Poster Abstracts therapy. took no insulin prior to surgery. Their median islet yield

was 150,168 IEQ and 2,370 IEQ/Kg (range 16,266–816,425 Monday IEQ, 312–15404 IEQ/Kg). At 1 year post-op, their BMI was 19, Pre-albumin 15, A1C 7.1, pQOL 35, mhQOL 41, and they averaged 10 u/D insulin. The difference in insulin requirements between the two groups is statistically signifi - cant (p = 0.042). CONCLUSION: Patients who are overweight or obese prior to TPIAT require more insulin following surgery even though they have higher islet yield and experience signifi - cant weight loss compared to those who are not overweight prior to surgery. Both groups experienced an improved physical and mental health QOL following TPIAT.

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Mo1753 Taken together, these results suggest that PHH3 may pro- vide a more accurate assessment of mitotic rate in PNET. Improving the Detection of Mitoses in Pancreatic Additional studies are currently underway to expand this Neuroendocrine Tumors Using Phosphohistone H3 cohort to assess mitotic rate determined by PHH3 stain Stephanie L. Goff1, Matteo Ligorio3, Jennifer A. Wargo1, compared to Ki-67 with several different observers. Zachary Cooper1, Dennie T. Frederick1, Francesco Sabbatino3, Vikram Deshpande2, Cristina R. Ferrone3 1Surgical Oncology, Massachusetts General Hospital, Boston, MA; 2Pathology, Massachusetts General Hospital, Boston, MA; 3General Surgery, Massachusetts General Hospital, Boston, MA Pancreatic neuroendocrine tumors (PNET) are being diag- nosed with greater frequency and have a widely variable natural history. Recent advances in staging for PNET incor- porate the mitotic rate for tumors identifi ed on hematoxy- lin and eosin stains (H&E), dividing lesions into low grade, intermediate grade, and high grade based on mitotic rate. This staging system can help with prognostic information, and may also guide adjuvant treatment, but is reliant on an accurate assessment of mitotic count. By H&E, mitotic fi g- ures can be diffi cult to identify and require an experienced histopathologist for accurate enumeration. Proliferative index, as measured by Ki-67, is also used in PNET but may over-represent actual mitotic fi gures since this also captures Pancreatic neuroendocrine tumor stained with anti-phosphohistone3 the G1 phase. More recently, staining with phosphohistone (PHH3) antibody highlighting mitotic fi gures. H3 (PHH3) has been described for use in identifying mitotic fi gures in malignancies such as melanoma and glioblas- toma. PHH3 is exclusively expressed in the mitotic phase of the cell cycle thus yields a much more accurate representa- tion of mitotic rate in tumors. Our hypothesis was that an anti-PHH3 antibody can more accurately identify mitotic rates in pancreatic neuroendocrine tumors (PNET) than traditional H&E staining. This will result in more accurate staging and will improve patient management. Histologic sections from 77 patients with PNET were stained with both H&E and anti-PHH3 antibodies and were reviewed by a blinded histopathologist to assess total mitotic count. Tumors were graded by number of mitoses Correlation with clinical outcome with mitotic rate as determined by H&E and correlated with clinical outcome. and PHH3. The results demonstrate a signifi cantly higher number of mitoses identifi ed using the PHH3 stain compared to H&E (p < 0.05). In this patient population, traditional H&E staining did not correlate with survival, but PHH3 staining for <2 mitoses was highly sensitive for clinical outcome. (p < 0.05, mean follow-up >36 months).

154 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1754 The Role of Adjuvant Chemoradiotherapy in Pancreatobiliary Versus Intestinal Subtypes of Ampullary Cancers Sanjay S. Reddy, Harry S. Cooper, Karen Ruth, Yun Shin Chun, James C. Watson, John P. Hoffman Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA BACKGROUND: Ampullary cancers traditionally have had more favorable outcomes than tumors in the pancreatic head. Current literature suggests the use of adjuvant thera- pies may be of benefi t in populations with certain high risk features. Whether adjuvant therapies in specifi c histologi- cal subtypes infl uence outcomes has remained unanswered. METHODS: We retrospectively analyzed 44 patients from 1996–2010 at a dedicated cancer center. Pathological stage, histological subtypes (pancreatobiliary (PB) versus intesti- nal (INT)), margin status, lymphovascular invasion (LVI), perineural invasion (PNI), overall survival (OS) and disease free survival (DFS) were analyzed. Kaplan-Meier meth- ods were used to estimate survival, and differences were assessed using the log rank and Wilcoxon tests. We looked at differences in survival by histological subtype within the adjuvant chemoradiotherapy (ACRT) and surgery only sub- groups, accounting for stage. RESULTS: Of 44 patients, 15 were male and 29 female; average age was 64. Twenty patients underwent a classic pancreatoduodenectomy (PD), and 24 a pylorus preserv- ing PD. Nine percent of patients were pathologic stage IA, 18% IB, 23% IIA, 36% IIB, and 14% III. Upon review by a senior pathologist, 25 patients were found to have a PB histology, 18 INT, and 1 mixed. LVI and PNI were found in 32% and 25%. Neoadjuvant chemoradiation was given to 3 patients. ACRT was given to 15 patients, adjuvant chemo- therapy to 5, and adjuvant radiation to 2. Nineteen patients underwent surgical resection with no other modality. OS at 2 years was 75% for PB compared to 70% for INT; at 5 CONCLUSIONS: The use of ACRT in patients with ampul- years, 63% and 46%, respectively (p = 0.11). Within the lary tumors may be more important for survival than histo- ACRT group, the PB patients had improved OS than INT logic type. Larger studies will be needed to distinguish the (p = 0.027). DFS at 2 years was 63% for PB compared to effects of adjuvant therapy from those on histologic type.

59% for INT; at 5 years, 58% and 28% (p = 0.05). Within the Poster Abstracts ACRT group, the PB patients had improved DFS than INT

(p = 0.01). The choice between gemcitabine versus 5 fl uo- Monday rouracil (5FU) based regimens did not reach statistical sig- nifi cance when comparing survival. Comparing stage, IIBs showed improved OS and DFS than IIAs (p = 0.05,0.006). Within IIBs, ACRT improved OS irrespective of histology (p = 0.010). Stratifying PB patients within the IIB group, OS and DFS were improved compared to its intestinal variant when ACRT was given (p = 0.03,0.02).

155 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1755 Clinical: Small Bowel Does Time Interval Between Chemoradiation and Surgery Affect Outcomes in Pancreatic Cancer? Mo1756 1 2 1 Kathryn T. Chen , Karthik Devarajan , John P. Hoffman Gastrointestinal Stromal Tumors of Extraintestinal 1 Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA; Origin: Prognosis Based on Location 2Biostatistics, Fox Chase Cancer Center, Philadelphia, PA Joyce Wong, Ciara E. Calitri, Gang Han, Anthony P. Conley, INTRODUCTION: Neoadjuvant chemoradiation given for Ricardo J. Gonzalez locally advanced pancreatic cancer is recognized to improve Surgery, Moffi tt Cancer Center, Tampa, FL respectability rates, and response to therapy has also been shown to be a prognostic factor. There is no data in the BACKGROUND: While gastrointestinal stromal tumors literature regarding time interval between chemoradiation (GIST) commonly arise from a gastric or intestinal (INT) and surgery, and response rates. We sought to evaluate the location, extraintestinal GIST (E-INT) have been described. relationship between time interval from radiation therapy This study addresses the clinical and prognostic differences and pathologic response. in GIST arising from the stomach or intestinal tract as well as extraintestinal or unknown (UNK) locations. METHODS: We retrospectively analyzed the records of 55 METHODS: A prospectively maintained single-institution patients who underwent neoadjuvant chemoradiation for database of patients with the diagnosis of GIST was borderline resectable pancreatic cancers prior to defi nitive reviewed. Demographics, pathologic factors and survival resection. Patients either proceeded directly to resection were analyzed using Pearson’s chi-square test, Fishers exact following chemoradiation or continued on chemotherapy test, or Kaplan Meier curves where applicable. depending on CA19-9 and pathologic response. We divided patients into three groups with respect to time interval RESULTS: From 1990–2011, 282 patients with patho- between completion of chemoradiation and resection: A logic confi rmation of GIST were referred to our center. The (0–10 weeks), B (10–20 weeks), and C (>20 weeks). Patho- majority were male (56%) and Caucasian (83%). Tumors logic response was defi ned as major (>95% fibrosis), partial were commonly of gastric (N = 148, 52%) or INT (100, 35%) (50–94% fi brosis), or minor (<50% fibrosis). origin. Less commonly, GIST arose from an E-INT (22, 8%) or unknown (UNK, 12, 4%) location. Multivariate analy- RESULTS: There were 32 patients in group A, 9 patients sis stratifi ed by tumor origin showed that age varied across in group B, and 14 patients in groups C. There was no sig- groups, with E-INT GIST found in older patients (median nifi cant difference between the groups with respect to age age 69 vs. 65 years for gastric, 60 for INT, and 64 for UNK, or CA19-9 at diagnosis. The median post-chemoradiation p = 0.03). Tumor size was also greater in the E-INT group: CA19-9 was signifi cantly higher for group C compared to median size 13 cm vs. 6.4 cm in gastric, 7.6 cm in INT, and group A, but there was no subsequent difference in the 8.6 cm in UNK, p = 0.05. Gender, ethnicity, and tumor median pre-operative CA19-9. There was no difference with mitotic rate were similar across groups. Additionally, use of regards to R0 resection between all three groups. Patients neoadjuvant or adjuvant therapy was similar across groups. in groups B and C were signifi cantly more likely to have a Ultimately, 84% of gastric GIST underwent surgical explo- major response than in group A (p < 0.026). ration vs. 93% INT, 82% E-INT, and 50% of UNK-primary CONCLUSION: There is no detriment in prolonged time GIST. Nearly 10% of gastric and INT GIST were unresectable interval between neoadjuvant chemoradiation and defi ni- at surgery, vs. 44% E-INT. GIST of E-INT location also had tive resection provided there is ongoing chemotherapy. higher rates of margin-positive resections, versus those of In our series, patients with a time interval greater than 20 gastric or INT origin (56% vs. 12% and 24%, respectively, P < weeks were more likely to have a major response to neoad- 0.0001). The median follow-up was 77 months. Unknown juvant therapy prior to surgery. primary and E-INT GIST exhibited a worse median OS (42 and 38 months, respectively), while INT or gastric GIST had better median OS (86 and 79 months, respectively, P < 0.05). Smaller tumor size, negative surgical margins, lower mitotic rate, and use of tyrosine kinase inhibitors all posi- tively impacted OS. 35% of gastric GIST developed recurrent disease vs. 61% INT and E-INT, and 100% of UNK primary GIST. Only mitotic rate and mutational status affected DFS; univariate analysis demonstrated mitotic rate > 10/50 high power fi elds and PDGFRA mutations were associated with worse DFS (P < 0.05). However, disease free survival (DFS) did not differ according to tumor origin. CONCLUSION: Although GISTs are considered to have variable malignant potential, E-INT and UNK GIST are more likely to be unresectable at presentation and to develop disease recurrence. Extraintestinal and unknown primary GIST have a worse OS. This may be due to a signifi cantly larger tumor size and advanced stage at presentation that may prohibit effective surgical resection.

156 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo1757 Mo1758 Diagnostic Strategy for Acute Abdomen Caused Ileo-Cecal Resection in Crohn’s Disease Patients: by Perforation of the Gastrointestinal Tract: Can Clinical Impact on Quality of Life and Nutrition Computed Tomography Detect Perforated Site Even Giuseppe S. Sica, Silvia Di Pardo, Edoardo Iaculli, in the Small and Large Bowel? Cristina Fiorani, Andrea Divizia, Emanuele Picone, Tatsuya Ueno1, Michinaga Takahashi1, Shinji Goto1, Achille Gaspari, Livia Biancone Shun Sato1, Masanori Akada1, Kyohei Ariake1, Shinpei Maeda1, Tor Vergata, Rome, Italy Takashi Hirosawa1, Masato Katahira1, Chikashi Shibata2, BACKGROUND: Relationship between surgery, quality of Hiroo Naito1 life (QoL) and nutrition in Crohn’s Disease (CD) patients is 1Surgery, Southmiyagi Medical Center, Shibata-gun, Japan; 2Surgery, unclear. Aim of the study was to evaluate the consequences Tohoku University Hospital, Sendai, Japan of surgical resection on the QoL with particular regard to nutritional aspects, of a consecutive group of CD patients Due to advanced technology, computed tomography (CT) under regular follow up. scan can make more precise diagnosis than ever even in the fi eld of gastrointestinal (GI) tract. We previously reported METHODS: Eighty consecutive patients undergoing ileo- accuracy rate of CT in diagnosing perforated gastro and cecal resection were randomly selected from database. duodenal ulcer, was more than 90%, which means that GI Patients were divided into 2 groups: A laparoscopic and B endoscopy and/or upper GI series are not required to con- open resection. Body Mass Index (BMI), biochemical lev- fi rm the perforated sites of upper GI tract in most cases. It’s els of albumin, creatinine, urea, cholesterol, triglycerides, still uncertain, however, whether or not CT scan can accu- serum iron, ferritin and complete blood count (Hb hemo- rately detect perforated site in patients (Pts) with small and globin and Ht hematocrit) were recorded before surgery large bowel perforation (SLBP). and 6 and 12 months after the operation. The Student t test was performed in order to fi nd differences before and AIM: To clarify how precisely CT scan can detect perforated after surgery. Patients were also asked to fi ll out the spe- site in SLBP, and if CT scan can differentiate gastroduodenal cifi c IBDQ-QoL questionnaire and a second multiple choice perforation (GDP) from SLBP. questionnaire designed to specifi cally evaluate nutritional METHOD: Since 2002 to 2010, Medical records of Pts with aspects. GDP and SLBP who underwent laparotomy or laparoscopic RESULTS: Data from 68 patients (31group A and 37 group operation, were retrospectively reviewed. B) were completed in order to make comparisons. The two RESULTS: one hundred and fi fty-eight Pts (92 for GDP and groups were homogeneous in term of gender, age and dura- 66 for SLBP) were operated for GDP and SLBP. Gastric can- tion of disease. BMI signifi cantly increase after surgery in cer, gastric ulcer, and duodenal ulcer induced the perfora- the short and long term in group A (p 0.002 and 0.0001) tion in all GDP Pts. Causes of SLBP were idiopathic (20 Pts), and at 12 moths in group B (p 0.003). Albumin levels also cancer-related perforation (15), diverticulum (8), trauma showed a signifi cant increase in both groups 6 months after (7), foreign body (6), and others (10). Accuracy rate of CT surgery (A:p = 0.0001 and B:p = 0.015), whilst a further scan in diagnosing site for GDP was 93.3%. On the other increase at 12 months is seen only in group A (p = 0.04). hand, the accuracy rate in SLBP was 84.6% (70.4% for small Serum iron level is increased 12 months after I-C resection bowel and 89.7% for large bowel), and the rate decreased (group A p = 0.003; group B p = 0.02), and so is the Hb level to 57.1% when limited to trauma. Two Pts who underwent (group A p = 0.02; group B p = 0.05). Signifi cant differences laparotomy after diagnosed as SLBP on CT scan, had no in Ht were visible at 12 month only in group A (p = 0.02). perforation. One of them had trauma, and the other was Thirty-fi ve patients (68.5%) fi lled the IBDQ-QoL question- Poster Abstracts fi nally diagnosed as pneumatosis intestinalis. There were naire. Mean score was 163/224 with no differences between no Pts who were at fi rst diagnosed as GDP, but had actually the two groups. All patients fi lled the nutritional based Monday SLBP. Mortality rate of GDP was 7.6%, while that of total questionnaire: 52% before surgery but only 9.5% after after SLBP, idiopathic, cancer-related, diverticulum, and trauma- ileo-cecal resection were forced on a specifi c diet. 71.5% of related perforation, were 18.2%, 15.0%, 40.0%, 25.0%, and patients believe its QoL improved after ileo-cecal resection, 0.0% respectively. whilst 20% sees no differences and 8.5% a worsening. No CONCLUSION: When compared to GDP, accuracy rate to signifi cant differences were noted between groups. detect perforated site in SLBP, was decreased, especially in CONCLUSION: QoL, with particular regard to nutritional small bowel and trauma-related perforation. This decrease aspects seems ameliorate after ileo-cecal resection in CD might be associated with little infl ammatory change such as patients. Laparoscopic surgery may play a role in the mid- edema at perforated site soon after trauma and little intra- dle and long term outcome probably thanks to the short- luminal gas in the small bowel. When SLBP is suspected est recovery time and the favorable acceptation among on CT scan, early or laparoscopic patients. examination should be considered. Once GDP is detected on CT scan, surgical or conservative therapy should be started as soon as possible. Gastrointestinal endoscopy and/ or upper GI series were considered unnecessary in GDP.

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Mo1759 Mo1760 Role of Gastrografi n Challenge in Early Postoperative Assessment of Postoperative Complications in Small Bowel Obstruction Patients with IBD: A Single Academic Medical Center Mohammad A. Khasawneh1, Maria L. Martinez Ugarte2, Experience Eric J. Dozois2, Michael P. Bannon1, Martin D. Zielinski1 Samantha J. Quade, Joshua Mourot, Anita Afzali, 1Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, Mika N. Sinanan, Scott D. Lee, Jie Kate Hu, Christopher J. Park MN; 2Colon and Rectal Surgery, Mayo Clinic, Rochester, MN General Surgery, University of Washington, Seattle, WA INTRODUCTION: Early small bowel obstruction (ESBO) BACKGROUND: In Chrons Disease approximately 70% following abdominal surgery presents a diagnostic and ther- of all patients will ultimately require surgical intervention. apeutic challenge. Abdominal imaging using Gastrografi n Previous literature indicates that 30% of patients have post- (GG), has been shown to have diagnostic and therapeutic operative complications. Pre operative nutrition with TPN properties when used in the setting of small bowel obstruc- has also been controversial. tion outside the early postoperative period (>6 weeks). We Our retrospective review demographics and patient charac- hypothesize that a GG challenge will reduce need for re- teristics were documented and both preoperative and surgi- exploration in patients with ESBO. cal characteristics were identifi ed to ascertain if the results METHODS: Patients with ESBO (<6 weeks following from a single institution were congruent with the previous abdominal surgery) who underwent a GG challenge published literature. between 2010–2012 were case controlled, based on age ± 5 PURPOSE: Assessment of post operative complications, and sex, to an equal number of patients that did not receive pre operative predictive factors and need for reoperation a GG challenge. Groups were compared to assess differences and reinstitution of medical therapy in IBD. in rates of reoperation for obstruction. METHODS: Retrospective review of 57 patients charts who RESULTS: 105 patients with ESBO who received a GG underwent surgical intervention for IBD. Patients undergo- challenge. There were 76 males in each group (72%) with ing surgical resection were included in the initial analysis. an average age of 64 years (range, 59–68). An open or lapa- roscopic approach in the index operation was done equally Pre operative surgical characteristics, nutrition and surgical between groups (67% vs 70% and 33% vs 30%, respectively indication for intervention were analyzed. p = 0.44). The mean time from surgery to GG challenge The need for reoperation and reinstitution of medical ther- was (11.3, range = 9.8–12.9) days. There was no difference apy was based on patient symptoms and an endoscopic between groups in the rate of re-operation (12% vs 9%, p = evaluation, which included a Rutgeerts score. 0.48), days from surgery to re-operation (9.1 [range 4.2–14] vs 13.5 [range 7.9–19.2], p = 0.23), morbidity (35% vs 42%, RESULTS: 57 patients [current analysis] 51% female, mean p = 0.23), and mortality (8% vs 7%, p = 0.78). Hospital age 45 years, 30% of patients had undergone prior resec- length of stay was greater in patients who received GG tion. 77% Chrons Disease. (18.2 vs 11.5, p = 0.0001) days. There were no GG aspi- Patient characteristics included 46% smoking, anatomi- ration events. . There were more patients that received cal site of disease 44% TI disease, small bowel in 17% and abdominal computed tomography in the GG group (74% colonic in 30%. Medical Therapy included Biologics in vs 45%, p = 0.0001), of these patients, the GG group were 53%, IM 38% and steroids in 43%. more likely to have a transition point (55% vs 33%, p = Albumin mean 3.5g/dL [postoperative early complications: 0.01).The GG challenge had a positive predictive value of mean 3.3 g/dL, no complications 3.6 g/dL]. 91%, negative predictive value of 50%, sensitivity of 96% and specifi city of 30% to predict ESBO resolution without Preoperative TPN 84% with an associated overall complica- operative intervention. tion rate 31%. CONCLUSION: Use of the GG challenge in the immedi- SURGICAL INDICATION: Stricture/Obstruction 39%, Fistula ate postoperative period appeared to be safe. There was no 19%, Refractory to medications 21%, Abscess 5%, Perfora- difference, however, in the rate of re-exploration between tion 2%. groups. Further study in a prospective, randomized fashion is needed to elucidate the effects of GG in ESBO.

158 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Surgical Operation: Ileocolectomy 35%, TI resection 5%, stricturoplasty 4% and the remaining small bowel resection. Type of anastomosis Hand Sewn end-to-end 58% patients [41% complication rate], side to end 18% [57% complica- tion rate] and stapled end to end 24% [complication rate 67%]. Perioperative blood transfusion was required in 5% patients, 100% patients had complications. Operative Blood Loss no complication 82 cc and complica- tion 232 cc mean. Perioperative length of stay mean 8 days [5.6 vs. 12.2 with post operative complication]. Overall Complication rate was 39%. Anastomotic leak rate 4%, Bowel obstruction 5%, prolonged ileus defi ned as >5 days 18%, Abscess formation 5%, Superfi cial wound infec- tion 7% [no deep wound infections], UTI 5%, DVT 2%, PE 0%, Hernia 2%. Reoperation required in 20% of patients.

CONCLUSIONS: Surgical Intervention for IBD can be asso- ciated with high morbidity and high rates of further medi- cal and surgical intervention. Initial data analysis it appears that factors associated with a higher post operative compli- cation rate are Albumin < 3.3, Perioperative Blood transfu- sion and stapled anastomosis. Poster Abstracts Monday

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Mo1761 Table 2: Postoperative Outcome and Complications Laparoscopic vs. Open Unilateral Inguinal Hernia Open Repair Laparoscopic Repair Repairs: A NSQIP Analysis N = 25192 N = 4563 P-Value Muhammad Asad Khan, Roman Grinberg, John Afthinos, Superfi cial SSI 87 (0.3%) 13 (0.3%) 0.572 Karen E. Gibbs Deep incisional SSI 18 (0.1%) 2 (0.0%) 0.757 Staten Island University Hospital, Staten Island, NY Organ space SSI 11 (0.0%) 0 0.392 Wound disruption 10 (0.0%) 1 (0.0%) 1 OBJECTIVES: Open inguinal hernia repair has been the Pneumonia 27 (0.1%) 1 (0.0%) 0.112 mainstay in both elective and emergent hernias for most of Unplanned Intubation 16 (0.1%) 1 (0.0%) 0.498 surgical history. The advancement of laparoscopic hernia PE 14 (0.1%) 2 (0%) 1 repair has challenged this notion; however few trials have Failure to extubate 7 (0.0%) 1 (0%) 1 compared the laparoscopic approach to open. We sought Return to OR 177 (0.7%) 24 (0.5%) 0.204 to query the NSQIP database to amass a large number of patients to better characterize patent comorbidities and ARF 5 (0%) 0 1 outcomes of both approaches. Cardiac arrest 59 (0.2%) 0 0.600 MI 14 (0.1%) 2 (0%) 1.0 METHODS: The NSQIP database was queried for laparo- DVT 19 (0.1%) 1 (0.0%) 0.246 scopic or open inguinal hernia repair for unilateral her- Sepsis 26 (0.1%) 2 (0%) 0.3 nias from 2007 to 2009. Age, gender and comorbidities Neuro complication 16 (0.1%) 2 (0%) 1 were quantifi ed and outcomes data collected. Specifi cally, Overall morbidity 141 (0.5%) 12 (0%) .012 morbidity, mortality, length of stay and operative times were examined. Statistical analysis was then performed. A Operative time (mins 58.6 ± 26.9 59.2 ± 31.3 0.183 p-value of <0.05 was considered signifi cant. Hospital stay (days) 0.27 ± 3.9 0.16 ± 1.2 <0.001 Mortality 18 (0.1%) 1 (0%) 0.342 RESULTS: A total of 29,755 patients were identifi ed, out of which 25,192 underwent open hernia repair, while 4,563 CONCLUSIONS: Our study revealed that only 15% of uni- underwent laparoscopic repair. lateral hernias were repaired laparoscopically. The more CONCLUSIONS: Our study revealed that only 15% of uni- diverse anesthetic choices available for open repair allowed lateral hernias were repaired laparoscopically. The more patients with signifi cant comorbidities to undergo hernia diverse anesthetic choices available for open repair allowed repair. Despite this there was an increased overall rate of patients with signifi cant comorbidities to undergo hernia morbidity (0.5% vs. 0.2%, p = 0.012). Other outcomes mea- repair. Despite this there was an increased overall rate of sures were not different except for length of stay, which was morbidity (0.5% vs. 0.2%, p = 0.012). Other outcomes mea- longer for the open group. sures were not different except for length of stay, which was longer for the open group. Mo1762 Table 1: Patient Comorbdities Long-Term Outcomes Following Endoscopic vs. Open Repair Laproscopic Repair Transduodenal Ampullectomies for Ampullary N = 25192 N = 4563 P-Value Adenomas Age 55.9 ± 17.3 52.3 ± 16.1 <.001 Abhishek Mathur2, Sharona B. Ross1, Carrie E. Ryan1, Male gender 22668 (90%) 4155 (91.1%) 0.026 Kenneth Luberice1, Franka Co1, Paul Toomey1, Arthi Sanjeevi2, Diabetes on oral 1190 (4.7%) 143 (3.1%) <.001 Patrick Brady2, Alexander Rosemurgy1 Diabetes on Insulin 383 (1.5%) 36 (0.8%) <.001 1General Surgery, Florida Hospital Tampa, Tampa, FL; 2Morsani HTN 8987 (35.7%) 1314 (28.8%) <.001 College of Medicine, Tampa, FL COPD 727 (2.9%) 59 (1.3%) <.001 INTRODUCTION: The increased application of screen- CHF in 30 days 41 (0.2%) 4 (0.1%) 0.301 ing and diagnostic upper endoscopy has increased the History of MI in 6 35 (0.1%) 1 (0.0%) 0.035 frequency of identifying premalignant ampullary lesions. months These premalignant lesions need extirpation to derail the Prior PCI 1334 (5.3%) 167 (3.7%) <.001 adenoma➝carcinoma sequence. Extirpative ampullectomy, Prior CABG 1414 (5.6%) 168 (3.7%) <.001 whether endoscopic or operative, should be defi nitive treat- PAD 189 (0.8%) 189 (0.8%) .005 ment. However, the recurrence rates after polypectomy and ESRD 133 (0.5%) 13 (0.3%) 0.033 the number of interventions to rid the polyp are not estab- BMI 26.3 ± 4.3 26.5 ± 4.3 0.006 lished. We undertook this study to determine the utility Anesthesia type 16776 (66.6%) 534 4473 (98.0%) 5 (0.1%) <0.001 of and long-term outcomes after endoscopic vs. operative General Local MAC (2.1%) 6414 (25.5%) 73 (1.6%) 8 (0.2%) ampullectomy. Spinal 979 (3.9%) ASA III or above 378 (1.5%) 23 (0.1%) <.001 METHODS: From 2002 to 2011, 35 patients underwent Bleeding disorder 567 (2.3%) 63 (1.4%) <.001 operative transduodenal ampullectomy and 38 patients Partially Dependent 200 (0.8%) 16 (0.4%) 0.001 underwent endoscopic ampullectomy per American Society Steroid use 345 (1.4%) 36 (0.8%) .001 for Gastrointestinal Endoscopy (ASGE) guidelines. Median data are presented. Smoker 5054 (20.1%) 772 (16.9%) <.001

160 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: Patients undergoing operative vs. endoscopic RESULTS: There was no difference between the 2 groups therapy were similar in gender, age, BMI, and pretreatment with regard to background factors. In the HDS group, oper- evaluation. Transduodenal ampullectomy was undertaken ative time was shorter (113 ± 20 min. v.s. 153 ± 37 min., for larger polyps than endoscopic polypectomy (2.1 cm p < 0.01) and blood loss was less (97 ± 90 ml v.s. 161 ± 121 vs. 1.5 cm respectively, p < 0.001). 97% of transduodenal ml, p < 0.01) than in the HS group. Postoperative anasto- ampullectomies had microscopically negative (R0) mar- motic bleeding occurred in 4 cases of the HDS group and gins whereas 50% of endoscopic ampullectomies had R0 signifi cantly more than in the HS group (12.9% v.s. 0%, margins. 16/38 (42%) patients treated endoscopically were p < 0.01).All 4 cases needed blood transfusion and 1 case without disease at last follow-up, though 5 patients were that was unresponsive to conservative management needed lost to follow-up, 1 patient underwent a pancreaticoduo- endoscopic hemostasis the day after surgery. Anastomotic denectomy for cancer, and one patient died; 15/38 (39%) leakage occurred in 1 case of the HDS group. There were no had residual or recurrent disease despite numerous endo- differences in hospital stay and mortality rate. scopic reinterventions. 29/35 (82%) of patients treated with CONCLUSIONS: HDS reduced operative time and blood transduodenal ampullectomy were without disease at last loss, but increased postoperative anastomotic bleeding. It follow-up, though despite R0 margins at resection, 5/35 is important that we confi rm the hemostasis of bleeding (14%) patients had recurrent or persistent disease; 1 patient from the staple line during surgery and perform endoscopic underwent a pancreaticoduodenectomy for cancer and 1 hemostasis immediately if bleeding is unresponsive to con- patient died. servative management. CONCLUSIONS: After endoscopic ampullectomy, residual disease is common and recurrence is frequent and much Mo1764 higher than after transduodenal ampullectomy. The endo- scopic approach is further encumbered by patients lost to Preoperative Chemotherapy Results in Unpredictable follow-up. Despite vigilant endoscopic follow-up, whatever Response in Gastric Cancer: No Magic Bullet the approach for the ampullectomy, cancer will be encoun- Houssam Osman, Mandy L. Rice, Tanyss L. Winston, tered. This is not an “apples to oranges” comparison, but Ashley Thomas, Dhiresh R. Jeyarajah rather a “big apples to small apples” comparison that does Surgery, Methodist Dallas Medical Center, Dallas, TX not justify endoscopic ampullectomy rather than trans- duodenal ampullectomy, except under circumstances more INTRODUCTION: Neoadjuvant chemotherapy for locally stringent than proposed by the ASGE (e.g., smaller tumors advanced gastric cancer was proposed as treatment modal- more amenable to complete extirpation). Further data is ity to improve survival. The chemotherapy treatment effect needed to justify application of endoscopic ampullectomy is evaluated in the surgical specimen and divided based on using ASGE guidelines. the degree of dead tumor cells into 4 categories; no effect, mild effect, moderate effect, and signifi cant effect. We pres- ent our experience with neoadjuvant chemotherapy in Clinical: Stomach patients with gastric carcinoma. METHOD: 25 patients with distal esophageal, gastro- Mo1763 esophageal junction (GEJ), and gastric carcinoma who underwent neoadjuvant chemotherapy between January Hemi-Double Stapling Technique Versus Hand-Suture 2011 and August 2012 have been identifi ed retrospectively for Billroth-I Gastroduodenostomy: An Analysis of in our cancer registry. Chemotherapy regimens and num- 84 Consecutive Patients ber of cycles were reviewed and the histological treatment

Akira Ouchi, Masahiko Asano, Keiya Aono, Tetsuya Watanabe, effects were then compared. Poster Abstracts Yudai Kato RESULTS: No histological treatment effect was identifi ed Department of Surgery, Chita City Hospital, Aichi, Japan in one patient (4%) with GEJ tumor who received 3 cycles Monday of Epirubicin, Cisplatin, and 5-Fluorouracil. Mild treatment BACKGROUND AND AIMS: Hemi-double stapling (HDS) effect was noted in 9 patients (36%); 7 patients received for Billroth-I gastroduodenostomy is a simple technique 2 preoperative cycles and 2 patients received 3 cycles. 9 and it has many advantages including reduced operative patients (36%) were found to have moderate treatment time and equalization of surgical technique, while poten- effect; 4 of them received 2 cycles, 3 patients received 3 tial complications including anastomotic bleeding and cycles, one received 4 cycles, and one received 5 cycles. Sig- stricture. The aim of this study was to retrospectively evalu- nifi cant treatment effect was identifi ed in 6 patients (24%); ate the surgical outcome and complications of HDS com- half of them received 2 cycles while 2 patients received 3 pared to hand-suture (HS). cycles, and one patient received 6 cycles of Oxaliplatin and METHODS: We analyzed 84 patients divided into 2 groups, Xeloda. HDS group with 31 patients and HS group with 53 patients, CONCLUSION: The response of gastric cancer to preop- who underwent B-I reconstruction in open distal gastrec- erative chemotherapy cannot be predicted based on che- tomy between October 2002 and September 2012 in our motherapy regimen or number of cycles received. 40% of hospital. patients experienced no or minimal effect. Further studies are needed to evaluate the correlation between the treat- ment effect grade and survival benefi t.

161 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo1765 RESULTS: The study population consisted of 25 (37.9%) Asians, 24 (36.4%) Caucasians, 11 (16.7%) Hispanics, 7 The Development of Ulcer Disease After Roux-en-Y (10.6%) African-Americans. The incidence of lymph node Gastric Bypass metastasis was 3.1% in Asians and 17.1% in non-Asians, Usha K. Coblijn, Sjoerd D. Kuiken, Sjoerd M. Lagarde, respectively. Nine patients underwent EMR and 58 patients Bart A. Van Wagensveld underwent gastrectomy with LN dissection. Among the Sint Lucas Andreas Ziekenhuis, Amsterdam, Netherlands latter group, eight (13.8%) patients had LN metastasis. Subgroup analysis comparing the histopathologic charac- BACKGROUND/AIMS: With the growing performance teristics of T1b with T1a EGC was performed; nine (36.0%) of bariatric surgery a subsequent increase in complications patients with T1a and 11 (40.7%) patients with T1b had associated with this surgical procedure takes place. This diffuse type histology (p = 0.26). The incidence of lymph research focuses at marginal ulceration (MU) after (laparo- node metastasis was 4.0% with T1a in comparison to 25.9% scopic) Roux-en Y Gastric Bypass surgery (LRYGB). Aim of with T1b (p = 0.03). The survival rate for the T1b group this study was to asses the incidence, symptoms, mecha- (92.6%) did not differ signifi cantly from that of the T1a nism and treatment of MU after LRYGB surgery. group (93.5%) during the follow-up period. METHODS: All fi les of patients who underwent a LRYGB CONCLUSIONS: EGC in Asian Americans is less likely were searched for signs of abdominal pain, epigastric burn, to be associated with LN metastases than non-Asian EGC nausea or other symptoms of ulcer disease. Also symptoms regardless of depth or histotype. In our small series with of (perforated) MU as acute abdominal pain, vomiting, ethnic diversity, patients with T1b EGC had signifi cantly melaena and haematemesis were scored. Possible contrib- higher LN metastasis rate but did not have a signifi cantly uting factors were identifi ed. Results of medical and surgical different survival rate from those with T1a, indicating that treatment were evaluated. gastrectomy with LN dissection should remain the standard RESULTS: 419 patients underwent LRYGB. 26 (6.2%) of strategy for T1b EGC. them developed MU of which fi ve (1.2%) presented with perforation. The use of non-steroidal infl ammatory drugs Mo1767 (NSAIDs), smoking and prednisolon- inhalation corticoste- roids signifi cantly contributed to the development of MU. Development and Validation of PGSAS-45, an Five patients needed reoperation. All other patients could Integrated Questionnaire to Assess Postgastrectomy be treated conservative with proton pump inhibitors occa- Syndrome sionally together with Ulcogant®. Koji Nakada1,12, Masami Ikeda2,12, Masazumi Takahashi3,12, CONCLUSION: Marginal ulceration after LRYGB is more Shinichi Kinami4,12, Masashi Yoshida5,12, Yoshikazu Uenosono6,12, frequently being recognized as a major problem due to the Yoshiyuki Kawashima7,12, Atsushi Oshio8, Yoshimi Suzukamo9, increase in bariatric procedures. The use of nicotine and Masanori Terashima10,12, Yasuhiro Kodera11,12 NSAIDs must be stopped and inhalation corticosteroids 1Surgery, The Jikei University School of Medicine, Tokyo, Japan; should be minimized. 2Asama General Hospital, Saku, Japan; 3Yokohama Municipal Citizen`s Hospital, Yokohama, Japan; 4Kanazawa Medical School, Mo1766 Kanazawa, Japan; 5International University of Health and Welfare, Current Treatment Strategy for Early Gastric Cancer at Mita Hospital, Tokyo, Japan; 6Kagoshima University Graduate School a New York Urban Medical Center of Medicine, Kagoshima, Japan; 7Saitama Cancer Center, Saitama, 8 9 Shinichi Fukuhara, Marissa M. Montgomery, Japan; Waseda University, Tokyo, Japan; Tohoku University 10 Steven T. Brower, Martin S. Karpeh Graduate School of Medicine, Sendai, Japan; Shizuoka Cancer 11 Department of Surgery, Beth Israel Medical Center, New York, NY Center, Shizuoka, Japan; Nagoya University Graduate School of Medicine, Nagoya, Japan; 12Japan Postgastrectomy Syndrome Working BACKGROUND: Gastrectomy with lymph node (LN) dis- Party, Tokyo, Japan section was considered as the gold standard for early gastric cancer (EGC) in the past. However, expansion of the criteria BACKGROUND: Postgastrectomy syndrome (PGS) is for endoscopic treatment has been currently proposed. This common after gastrectomy. Information regarding actual study aims to investigate the histopathologic determinants details of the PGS and their relation to surgical procedures, and outcomes of EGC in order to redefi ne the current treat- however, is limited possibly due to the fact that optimal ment strategy. instrument to assess PGS is lacking. A questionnaire, Post- gastrectomy Syndrome Assessment Scale (PGSAS) -45, was METHODS: The gastric cancer tumor registry at our insti- therefore developed by a voluntary group, Japan Postgas- tution was reviewed. Sixty-seven patients were identifi ed trectomy Syndrome Working Party. PGSAS-45 was designed who underwent either endoscopic mucosal resection (EMR) to assess severity of the PGS, the status of oral food intake or gastrectomy for EGC or high grade dysplasia between and degree of recovery in terms of social roles, and impact 2006 and 2011. A retrospective analysis was performed of these factors on patients’ well-being. on the medical records of these patients. Mean follow-up period was 21 ± 18 (1–73) months.

162 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: PGSAS-45 is an integrated questionnaire con- Mo1770 sisting of 45 items including items selectively taken with permission from the standardized generic QOL question- Depression, Anxiety, and Stress Reduction After naire SF-8 (8 items) and the symptom-specifi c QOL ques- Bariatric Surgery tionnaire gastrointestinal symptom rating scale (GSRS; 15 Natalia Leva, Chris S. Crowe, Nayna A. Lodhia, John M. Morton items). Items selected from an item pool as being clinical Surgery, Stanford University, Stanford, CA relevant by 47 gastric surgeons were added to these to con- stitute the PGSAS-45. In the current study, 52 institutions INTRODUCTION: Bariatric surgery is an effective and were involved in “Postgastrectomy Syndrome Assessment enduring therapy for weight loss and comorbidity remis- Study (PGSAS)”, a nation-wide study to validate PGSAS-45, sion. This study assesses patients’ depression, anxiety, and in which a total of 2520 PGSAS-45 questionnaires (86% of stress before and after bariatric surgery utilizing the DASS those that were originally sent out) were retrieved from questionnaire. the patients who received either of the six different types METHODS: Demographic, preoperative, and three-month of gastrectomy procedures. Of these, 1516 questionnaires postop data were prospectively collected for 135 consecu- retrieved from the patients who received conventional tive surgeries at a single academic institution. Before sur- gastrectomy (total with Roux-en-Y [n = 393], distal with gery and at a 3 months post op, the DASS questionnaire was Billroth-I [n = 909], distal with Roux-en-Y [n = 475]) were administered. Weight, anthropometric features, and demo- statistically analyzed. graphic data were collected. DASS scores were compared to RESULTS: The 23 symptom items of PGSAS-45 was com- demographic, preop, and postop data by student T-test and posed of seven symptom subscales (SS), ‘esophageal refl ux chi-squared analysis for continuous and dichotomous vari- SS’, ‘abdominal pain SS’, ‘meal-related distress SS’, ‘indiges- ables respectively using GraphPad Prisim 6. tion SS’, ‘diarrhea SS’, ‘constipation SS’ and ‘dumping SS’ RESULTS: All 135 patients completed preoperative DASS by factor analysis. The seven symptom subscales and other questionnaires. Of these, 93 patients were at or beyond the two domains, ‘quality of ingestion SS’ and ‘dissatisfaction 3-month postoperative time point. 55% of these patients for daily life SS’, had good internal consistency in terms of completed their 3-month questionnaires. Patient demo- Cronbach’s alpha (.65–.88). graphics included an average BMI 45, age 47, 51% white, Multiple regression analysis demonstrated that the sum of and 4 total preoperative comorbidities. Depression, anxi- newly added 8 symptoms had larger impact [Beta] com- ety, stress, and total DASS scores reduced signifi cantly at pared to the sum of 15 symptoms of GSRS, in ingestion 3 months when all patients were analyzed. When divided (.32, .02), ability for working (.35, .09), loss in body weight by surgery type, those undergoing gastric bypass showed (.24, .07), physical component summary (PCS) (.35, .17) signifi cant reduction in all measures. Patients undergoing and dissatisfaction for daily life SS (.60, .11). sleeve gastrectomy only improved their stress scores (p = 0.031) while patients undergoing gastric banding improved The associations between patient’s condition (symptoms, their stress (p = 0.016) and total DASS (p = 0.05) scores. ingestion, ability for working) and HRQOL (PCS and men- Depression was self-reported in 49% of patients. Those that tal component summary [MCS] of SF-8, dissatisfaction for reported depression pre-operatively had signifi cantly higher daily life SS) was evident. The effect size [Beta, R2] was depression specifi c scores than those without self-reported medium to large for all domains (.32 to .60, all p < 0.0001). depression (p = 0.045). Anxiety and stress specifi c scores, CONCLUSIONS: The results indicated that the PGSAS-45 as well as total DASS scores, were not signifi cantly different provides a valid and reliable integrated measurement of between those with and without self-reported depression QOL in gastrectomized patients. (all p values >0.252). Three months after surgery, those with pre-operative self-reported depression had greater percent reduction in all scores, although none of these differences Poster Abstracts were signifi cant. Monday BMI, weight, and excess weight loss were found to have no correlation to reduction of DASS scores. Waist circumfer- ence reduction, however, was correlated with reduction in depression specifi c (p = 0.096) and anxiety specifi c (p = 0.011) scores. CONCLUSION: Weight loss surgery provides promis- ing reductions in DASS scores, even at the 3-month time point. Those with depression scored higher at baseline, but fortunately had greater improvement of those scores at 3-months. Waist circumference was also found to be associ- ated with change in DASS scores.

163 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Colon-Rectal

Mo2130 Minimally Invasive Full Thickness Colonic Resection: A Novel Localised Excision Procedure Adela Brigic1, Paul D. Sibbons2, Chris H. Fraser1, Susan K. Clark1, Robin H. Kennedy1 1Department of Surgery, St. Mark’s Hospital and Academic Institute, Harrow, United Kingdom; 2Northwick Park Institute for Medical Research, Northwest London Hospitals NHS Trust, Harrow, United Kingdom AIMS: Worldwide introduction of the bowel cancer screen- ing programmes has lead to an increase in the number of patients diagnosed with complex, benign colonic polyps unsuitable for endoscopic resection. A signifi cant propor- tion is referred for hemicolectomy, which is associated with signifi cant risk of morbidity and mortality. To address this and improve clinical outcomes, we modifi ed a previously reported full thickness laparo-endoscopic excision (FLEX) technique developed in our institution. METHODS: Following a series of ex-vivo experiments to standardise procedural steps, surgery was performed in fi ve 70-kg pigs. A simulated colonic polyp was created by Figure 1: Full-thickness colonic specimen with APC marks delineating endoscopic injection of Spot® and the clearance margin was delineated by circumferential placement of mucosal clearance margin. argon plasma coagulator (APC) marks. Full thickness ever- sion of the colonic wall that contains the simulated lesion was achieved by endoscopic placement of prototype Brace- Bars (BBs). The everted segment was excised using a linear laparoscopic stapler placed below the BBs. The fi rst pig was terminated immediately and others 8 days after surgery. RESULTS: Procedure duration was defi ned from placement of mucosal APC marks to specimen excision with a median time of 26 min (range 20–31 min). All excised specimens contained three pairs of BBs delineating clearance margin with a median diameter of 5.1 cm (range 4.5–6.3 cm). Postoperative recovery in survival animals was uneventful and post-mortem examination demonstrated well-healed resection sites with no evidence of intra-abdominal infec- tion or inadvertent organ damage. Endoscopic evaluation of anastomoses at post-mortem examination excluded ste- nosis. Histological assessment of the partial circumferential anastomosis showed primary closure by mucosal abuttal and regeneration together with restoration of continuity of submucosa. CONCLUSIONS: This proof-of-concept survival study has demonstrated the feasibility of safely achieving full thick- ness colonic specimens exceeding 5 cm in diameter. Accu- rate placement of endoscopic BBs ensures completeness of excision, reducing the risk of recurrence or residual disease Figure 2: Endoscopic examination of the excision site 8 days post while laparoscopic overview avoids collateral damage. procedure. This is the fi rst localized excision technique described to date suitable for translational study in humans as an alter- native to hemicolectomy. The ability to preserve mesenteric vasculature and colonic length is likely to result in less mor- bidity and mortality, reduced treatment costs and better functional outcomes.

164 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Mo2131 Translational Science: Other Risk Factors for Postoperative Ileus in Patients Undergoing Laparoscopic Colorectal Surgery Mo2132 1 1 1 Udo Kronberg , Vivian Parada , Alejandro J. Zarate , Accurate Haemodynamic and Image Based Assessment 2 1 1 Magdalena Castro , Valentina Salvador , Claudio Wainstein , of Blunt Traumatic Splenic Injury May Identify Those Francisco LóPez-KöStner1 Who Will Benefi t from a Conservative Approach 1Colorectal Unit, Clinica Las Condes, Santiago, Chile; 2Academic Chris Brown, Rami Radwan, Karen Litton, David Fleming, Research Unit, Clinica Las Condes, Santiago, Chile Ashraf M. Rasheed INTRODUCTION: Postoperative ileus (POI) after lapa- General/Upper GI Surgery, Gwent Institute for Minimal Access Surgery, roscopic colorectal surgery leads to increased anxiety for Newport, United Kingdom patients and caregivers, and is associated with prolonged hospital stay and increased costs. The aim of this study is to INTRODUCTION: Recognition of overwhelming post- investigate pre-, intra- and postoperative risk factors associ- splenectomy infection in splenectomized patients led to ated with the development of POI in patients undergoing greater efforts to conserve splenic tissue following blunt laparoscopic colorectal surgery. trauma. Nonoperative management (NOM) of splenic trauma has emerged as a means to enhance splenic salvage. PATIENTS AND METHODS: Patients undergoing lapa- Accurate assessment of haemodynamic stability and injury roscopic colectomy between January 2008 and January severity are prerequisites to safety of such approach. Identi- 2012 were identifi ed from a prospectively maintained lapa- fi cation of splenic injuries that require early surgical repair roscopic database. Clinical, metabolic and pharmacologic or removal is vital. data were obtained retrospectively by reviewing the clini- cal charts. Patients with rectal resection were excluded. POI AIM: To study the management of traumatic splenic injury was defi ned as absence of bowel function for 5 or more at our institution and compare it against published guide- days, or the need for reinsertion of a nasogastric tube after lines from SSAT (Society for Surgery of the Alimentary Tract) starting oral diet in the absence of mechanical obstruction. and AAST (American Association for Surgery in Trauma) in Factors associated with POI were analyzed using Chi-square relation to assessment, indications for splenectomy and or Fisher’s exact test for categorical variables, Mann-Whit- role of NOM in absence of associated injuries. ney U test for continuous variables. A multivariate analysis METHODS: A retrospective database was constructed to was carried out by logistic regression. P-values <0.05 were include splenic injuries admitted over a 10 year period. considered statistically signifi cant, and Odds Ratios were Cases were captured by searching the electronic CT scan calculated with a 95% confi dence interval. reports database for those containing the words “splenic RESULTS: Complete data were obtained from a total of injury/rupture/haematoma/laceration” and the surgical 167 patients, with a median age of 50 years (i: 15–90), and database for operations coded as “Splenectomy/Splenor- a slight male predominance (55%). POI was observed in rhaphy”. Cases were cross-checked against splenic pathol- 24/167 patients (14,3%). On univariate analysis, some pre- ogy specimens’ reports. Cases not associated with traumatic operative factors were signifi cantly related to POI, such as injury were excluded. A range of parameters were assessed higher age (p = 0,0007), higher ASA status (p = 0,003), pre- and compared against published guidance from both operative diagnose (cancer vs. no cancer; p = 0,002), and SSAT and AAST. All index and follow up CT images were history of previous abdominal surgery (p = 0,019). BMI re-reviewed and re-graded by a radiologist blinded to the was not related to POI, neither as continuous variable nor outcome. The neo-CT reports with haemodynamic and ≥ haematologic status was compared with actual manage- as categorized factor (<30 vs. 30). Among the intra- and Poster Abstracts postoperative factors, a longer OR time (p = 0,003) as well ment and fi nal outcome. as a lower postoperative potassium level (p = 0,0004) were RESULTS: 48 cases of blunt traumatic splenic injury were Monday observed in patients suffering from POI. Neither the amount identifi ed; RTA was the most frequent mechanism of injury. of intraoperative opioids nor the use of postoperative mor- 38 underwent splenectomy while 10 were managed con- phin-based PCA was related to POI. On multivariate analy- servatively. CT assessment was performed in all cases bar 4 sis, previous abdominal surgery (OR 2,83, CI 1,067–7,832), who were taken straight for resuscitative laparotomy. AAST OR time (OR 1,007; CI 1,0011–1,0142) and postoperative grading of the severity of splenic injury was reported in potassium levels (OR 0,0199; CI 0,064–0,6219) showed to 8.3% of cases. Repeat imaging was sought in 60% of those be independently associated to POI. cases initially managed conservatively with 7.8% having CONCLUSION: POI after laparoscopic colectomy is asso- subsequent splenectomy. Average duration of observation ciated with specifi c preoperative, intraoperative and post- was 0.8 days (0–8) in splenectomy group verses 10.1 days operative factors. Minimizing or addressing these factors (3–23) in the successful conservative management group. may be expected to reduce the incidence of this common There was a single mortality in this cohort due to associated complication. head injury. CONCLUSIONS: CT grading of splenic injury is under- reported and splenectomy is over-represented in this cohort. Protocol-based management and CT grading of all splenic injuries is recommended and will aid in identifying those who may benefi t from a safe conservative approach.

165 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Mo2133 5 cm. The male to female ratio was 1:1.6 and the average age and cyst size were 56 years and 1.7 cm respectively. Management of Splenic Cysts: Does Size Really Matter? Seventy-seven of these patients underwent follow up imag- Christopher Kenney, Yumiko E. Hoeger, Amy K. Yetasook, ing over a mean period of 29 months. Average cyst size John G. Linn, Woody Denham, Joann Carbray, Michael B. Ujiki decreased to 1.5 cm yielding a growth rate of –0.23 cm/ Surgery, NorthShore University HealthSystem, Evanston, IL month. There were no complications related to the pres- ence of the cyst during the observation period. PURPOSE: To observe the natural history of splenic cysts and evaluate their management options. Twenty-three patients had a cyst size greater than 5 cm. The male to female ratio was 1:3 and the average age and cyst METHODS: One hundred and eighty-two patients were size were 50 years and 7.8 cm respectively. Sixteen of these identifi ed from an IRB-approved database search with patients underwent follow up imaging over a mean period radiologic evidence of a splenic cyst over an 11-year period. of 45 months. Average cyst size decreased to 7.4 cm yield- We subdivided these patients into those who underwent ing a growth rate of –0.04 cm/month. One patient, a 95 intervention and those who did not. The patients who year-old female, with a stable cyst size at 15 months follow were observed with serial imaging were further divided up later presented with a ruptured cyst and died during the into those whose cyst size was greater or less than 5 cm. All same admission. Her cause of death was not confi rmed to patient records were reviewed for history, diagnostic stud- be related to cyst rupture. ies, operative intervention and outcomes. CONCLUSIONS: This study presents the largest single series RESULTS: In the current study, 182 patients were diag- to date of patients with splenic cysts managed by aspiration, nosed with a splenic cyst and eight (4.4%) were included in operative intervention, or observation. We noted, as have the intervention group. In this group, all were female with others, that percutaneous drainage has a high recurrence mean age and cyst size of 27 years and 7.3 cm respectively. rate. In addition, we did not fi nd any malignant lesions in Five of these patients underwent percutaneous aspiration as the operative specimens and noted a negative growth rate a fi rst intervention, all of which eventually were operatively in those cysts that were followed with serial imaging. Our resected or drained. Pathologic examination of resected data suggest that the management of splenic cysts should specimens demonstrated benign lesions in all cases. be comprised of reserving aspiration for those who are not The non-intervention group was comprised of 174 patients surgical candidates, resecting lesions that are truly symp- who were stratifi ed by cyst size greater or less than 5 cm. tomatic and observing those that are not, regardless of size. One hundred and fi fty-one patients had a cyst size less than Tuesday, May 21, 2013 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 West Hall A POSTER SESSION I (NON-CME)

Basic: Colon-Rectal deal with infection. Also, tumor growth has been shown in murine studies to be increased after surgical trauma. Cell- mediated immunosuppression after resection of a primary Tu1755 tumor may impair the host’s ability to eradicate or contain residual tumors cells. This microarray study of perioperative Microarray Analysis of T-Lymphocyte Gene Expression T-lymphocyte (TLC) gene expression was undertaken in an After Colorectal Resection effort to better understand the impact of colorectal resec- M.C. Shantha Kumara H1, Xiaohong Yan1, Hiromichi Miyagaki1,2, tion (CR) on cell-mediated immune function. Sonali A. Herath1, Vesna Cekic1, Richard L. Whelan1 METHOD: Patients who underwent elective laparoscopic 1Surgery, St Luke Roosevelt Hospital, New york, NY; right hemicolectomy (RHC) for benign colonic disease 2Gastroenterological Surgery, Osaka University, Suita, Japan (BCD) who had enrolled in an IRB approved blood/data bank for whom frozen pre- and postoperative TLC’s were INTRODUCTION: Previous studies have established that available were eligible for this study. Benign pathology surgical trauma is associated with signifi cant transient alter- patients were chosen in order to determine the impact of ations in cell-mediated immune function. Surgery-related surgical trauma alone, independent of the potential effects immunosuppression may impact the patient’s ability to of a cancer on immune function. Preoperative (PreOp)

166 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

and postoperative day1 (POD1) blood samples were uti- METHODS: A total gastrectomy followed by esophago- lized. TLC’s were isolated from the blood using a combi- jejunostomy was performed on rats in order to induce nation of gradient centrifugation and magnetic micro-bead chronic duodenal content refl ux esophagitis. The animals separation. TLC’s were subsequently lysed and total RNA were sacrifi ced sequentially, at the 20th, 30th and 40th week extracted. cRNA was made from RNA hybridized to HG- after surgery and their esophagi were examined. Primary U133APLUS oligonucleotide array. PreOp vs POD1 expres- antibodies against CD68 (pan-macrophage; BMA Bio), sion data was analyzed via Limma paired analysis to fi nd CD163 (M2; AbD Serotec), pStat3 (Cell Signaling), Foxp3 differently expressed genes. (p > 0.05 signifi cant) and con- (Treg; eBioscience) were used to evaluate the expression and sistency of signifi cance was analyzed via Empirical Bayes localization of the infl ammatory response. statistics (B > 0 Sig.). Clinical data is presented as mean ± SD. RESULTS: At 20–30 weeks post-surgery, squamous pro- RESULTS: Nineteen patients (12 males/7 female, mean age liferative hyperplasia (PHP) and Barrett’s metaplasia (BM) 65.8 ± 12.8 years) met the entry criteria. The mean inci- were observed. Adenocarcinoma (ADC) associated BM sion length was 7.8 ± 3.5 cm and mean length of stay was (Figure 1A,B) and squamous cell carcinoma (SCC) were 6.3 ± 2.6 days. All TLC expression data met the affymetrix observed 40 weeks post-surgery. Numerous CD68 positive data QC standards. A total of 39 genes showed signifi cant macrophages were identifi ed surrounding PHP and BM at changes on POD1; 21were up-regulated and 18 were down 20 weeks and surrounding ADC and SCC after 40 weeks regulated (B = 0.05–5.3). The expression changes of 7 genes (Figure 1C). In contrast, few CD163 positive macrophages in this group were strongly signifi cant (ABCG-1, TMEM49, infi ltrated into the PHP, BM, ADC and SCC after 40 weeks FAM100B and PIM1 were upregulated and IFI44L, STAT1 (Figure 1D). The PHP, BM, ADC and SCC lesions exhibited and UCP2 were down regulated; P = 0.02 and B = 4.1–5.3). some pStat3-positive cells (Figure 1E). A few Foxp3-positive Enrichment analysis confi rmed that these gene changes cells were detected near carcinoma lesions after 40 weeks were likely to have signifi cant effects on 7 signaling path- (Figure 1F). ways and 3 functional categories i.e.; cell proliferation, hematological function and immune response. CONCLUSION: Surgical trauma affected gene expression of circulating TLC’s in the immediate postoperative period. Altered gene expression may impact TLC growth and prolif- eration as well as immune function. These changes must be validated at the protein level and additional patients stud- ied. Also, the duration of these changes, after surgery, must be determined. Finally, a similar study in cancer patients is also needed.

Basic: Esophageal

Tu1756 CONCLUSIONS: Our data showed that macrophages The Infl ammatory Microenvironment in Duodeno- infi ltrate the esophagus at the early infl ammatory stage of Esophageal Refl ux Induced Esophageal Carcinogenesis carcinogenesis. In the infl ammatory microenvironment, in a Sequential Rat Model characteristic of the activated pStat3 pathway, M2 pheno- type macrophages infi ltrate and contribute to tumor devel- Tomoharu Miyashita1,2, Masayoshi Munemoto1, 2 2 1 opment. Furthermore, Treg was induced by tumor relating Furhawn A. Shah , John W. Harmon , Takashi Fujimura , to process of carcinogenesis. Daisuke Matsui1, Masanobu Oshima3, Tetsuo Ohta1 1Department of Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan; 2Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD; 3Division of Genetics, Cancer Research Institute, Kanazawa University, Kanazawa, Japan BACKGROUND: Macrophages play an important role in tumorigenesis. Macrophages are polarized to either the clas- sical M1 type or alternative M2 type. Tumor-associated mac- Poster Abstracts rophages (TAMs) are polarized to M2 or M2-like types and have been shown to promote the progression and metas- Tuesday tasis of cancer. We hypothesized that TAMs in an infl am- matory microenvironment induced by duodenal content refl ux without carcinogens may promote the development of esophageal carcinomas.

167 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1757 Patients with Patients with Upright Refl ux Only Bipositional Positional Changes in the Gastroesophageal Valve (n = 16) Refl ux (n = 31) p May Explain Why Upright Refl ux Occurs Earlier Than % Male 13% 55% 0.006 Bipositional Refl ux Age 57 50 0.18 Ben M. Hunt, Ralph W. Aye, Oliver J. Wagner, BMI 31 30 0.76 Alexander S. Farivar, Brian E. Louie % with atypical symptoms 63% 53% 0.76 Thoracic Surgery, Swedish Medical Center and Cancer Institute, % with respiratory 56% 47% 0.94 Seattle, WA symptoms INTRODUCTION: The severity of gastroesophageal refl ux Abnormal GEJ shape on 48% 57% 0.05 endoscopy disease (GERD) has been shown to correlate with the Hill classifi cation of the gastroesophageal valve (GEV). As GERD % with positive 56% 97% 0.001 DeMeester score worsens and the GEV deteriorates, patients progress from upright to bipositional refl ux. We hypothesized that there Acid exposure upright 6% 14% 0.0004 may be signifi cant changes in the confi guration and func- Acid exposure supine 8% 2% 0.0003 tion of the GEV depending on patient position as an expla- Upright (n = 47) Recumbent (n = 47) p nation for the earlier occurrence of upright GERD. Hill Grade 2.9 2.4 0.002 Abnormal GEJ shape on 64% 46% 0.0003 METHODS: We prospectively enrolled 47 consecutive endoscopy patients with refl ux symptoms in an IRB-approved obser- LES basal pressure 14.7 8.3 0.006 vational study. Patients with prior foregut surgery or hiatal (mmHg) hernias >4 cm were excluded. Manometry was performed Acid exposure (% of time) 11% 6% 0.00007 in upright, right lateral decubitus, and left lateral decubitus positions. Endoscopy was started in left lateral semi-recum- bent position, and patients were repositioned upright part- way through the endoscopy. Photographs were obtained Basic: Hepatic of the GEV for grading in each position. During 48-hour ambulatory pH testing, information was gathered on Tu1758 whether patients were upright or supine. Outcomes were analyzed by type of GERD: upright or bipositional, and also Sirt1/PGC1a/Nrf2 Pathways Mediate Improvements in by patient position. Oxidative Stress in Rat Liver After RYGB RESULTS: There were 16 patients with upright and 31 Yanhua Peng, James Z. Lee, Michel Murr, Steven Rakita with bipositional GERD. Age, BMI, atypical GERD symp- College of Medicine, University of South Florida, Tampa, FL toms, and respiratory symptoms were not signifi cantly dif- BACKGROUNDS: Oxidative and infl ammatory stress in ferent between the groups except that patients with purely the liver contributes to liver injury, increased cardiovascu- upright refl ux were more likely to be female. Patients with lar risk and insulin resistance. Our previous study shows bipositional refl ux on pH testing were more likely to have that Roux-en-Y Gastric Bypass (RYGB) improves oxidative a deformed gastroesophageal valve on endoscopy in either stress in liver through Nrf2, an important transcription fac- position (see Table). There were no signifi cant manomet- tor for anti-oxidative stress. We also found that LKB/AMPK/ ric differences between the groups. On pH testing, patients Sirt1 expression was increased in liver after RYGB. Here, we with predominately upright refl ux had less esophageal acid postulate that Sirt1 and Nrf2 work synergistically to attenu- exposure by every measure (including number of patients ate oxidative and infl ammatory stress in the liver after with a positive DeMeester score) than patients with biposi- RYGB on obese rats. tional refl ux (see Table). METHODS: Expression of TNF, IL-6, glutathione-S-trans- Endoscopically, Hill grade and other measures of valve ferase (GST), Sirt1, PGC1, Nrf1, and Nrf2 within the liver deformity worsened when patients moved from a semi- was measured in rats from RYGB and sham weight-matched recumbent to an upright position. Manometrically, LES control cohorts. The nuclear to cytosolic ratios of Sirt1, mean basal pressure, LES mean residual pressure, and UES Nrf2, and NF-B were measured as well. A corresponding set mean basal pressure were higher in the upright position of in vitro experiments were done in the Kuffper cell line compared to either left lateral or right lateral position. LES RKC1. The cells were treated with glucose and/or fatty acids length and hiatal hernia length did not change based on in different doses to mimic gluocotoxicity and lipotoxicity. position. On pH testing, all patients had more acid expo- The cells were then treated with siRNA to knock down Sirt1. sure when upright than when supine (see Table). Afterwards, the expression levels and ratios of the above CONCLUSION: Patients with primarily upright refl ux on mentioned factors were measured. pH testing had a more normal refl ux barrier than those with bipositional refl ux, both endoscopically and on pH testing. Endoscopically, the GEV becomes deformed when patients are moved to the upright position and functionally there is more esophageal acid exposure when patients are upright. These fi ndings suggest that positional changes in the GEV may be responsible for the earlier onset of upright refl ux.

168 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: RYGB up-regulated Sirt1, PGC1, Nrf1, Nrf2 and Tu1760 GST in liver (p < 0.001), decreased NF-B, TNF, IL-6 and NOX2/4 (p < 0.001) compared to the sham weight match Podoplanin Expressing Fibroblasts Enhance the Tumor control. In RKC1 cells, Sirt1 depletion down-regulated Progression of Invasive Ductal Carcinoma of Pancreas, PGC1, Nrf1, Nrf2 and GST (p < 0.001). In contrast NF-B, and Podoplanin Expression Was Affected by Cultured  TNF , IL-6 NOX2/4 (p < 0.001) were increased signifi cantly. Condition CONCLUSIONS: We suggest that the Sirt1/PGC1/ Nrf1/ Koji Shindo1, Shinichi Aishima1, Kenoki Ohuchida2, Nrf2 pathways in liver may help to attenuate oxidative and Kazuhiro Mizumoto2, Masao Tanaka2, Yoshinao ODA1 infl ammatory stress after RYGB procedure. Correcting the 1Anatomic Pathology, Graduate School of Medical Sciences, dysregulation of these molecules will benefi t patients with Kyushu University, Fukuoka, Japan; 2Surgery and Oncology, Graduate obesity-induced metabolic syndromes. School of Medical Sciences, Kyushu University, Fukuoka, Japan BACKGROUND: An interaction between cancer cells and Basic: Pancreas surrounded cancer associated fi broblasts (CAFs) plays an important role in the progress of cancer. Pancreatic cancer is characterized by a growth of abundant fi brous or connec- Tu1759 tive tissue, called “desmoplasia”, and hypovascular environ- A CD166 Negative Subpopulation of Pancreatic Cancer ment inducing hypoxic and undernutritional condition. In Cells Has Strong Invasive and Migratory Activity pancreatic cancer, CD10 + myofi broblast-like activated Pan- creatic Stellate Cells (PSCs) enhance the progression of pan- Kenji Fujiwara1, Kenoki Ohuchida1, Koji Shindo1,2, 1 1 1 1 creatic cancer by secreting high levels of MMP3 (Ikenaga, Daiki Eguchi , Shingo Kozono , Takao Ohtsuka , Shunichi Takahata , et al. Gastroenterology 2010). Podoplanin, usually used as 2 1 1 Shinichi Aishima , Kazuhiro Mizumoto , Masao Tanaka a lymphatic vessels marker (D2-40), had been described as 1Departments of Surgery and Oncology, Graduate School of Medical a predictor of prognosis in various types of cancer when it Sciences, Kyushu University, Fukuoka, Japan; 2Department of was expressed in involved stromal fi broblasts. Anatomic Pathology, Graduate School of Medical Sciences, Kyushu METHODS: We investigated Podoplanin expression in University, Fukuoka, Japan fi broblasts involved in pancreatic cancerous tissue using BACKGROUND: CD166 expression is correlated with immunohistochemistry (IHC). We established primary prognosis in several cancers. However, its signifi cance in cultured fi broblasts as CAFs of fresh pancreatic adeno- pancreatic cancer is not clear. The aim of this study is to carcinoma tissue by out-growth method, and analyzed clarify the signifi cance of CD166 expression in pancreatic Podoplanin expression of CAFs using qRT-PCR and fl ow cancer. cytometry. We sorted CAFs by Magnetic Activated Cell Sort- ing (MACS) according to the expression of Podoplanin, and METHODS: We performed fl ow cytometry to analyze compared Podoplanin + CAFs with Podoplanin- CAFs by expression of CD166 in pancreatic cancer cell lines. We also migration assay and invasion assay in co-culture with pan- analyzed the functional differences between CD166 + and creatic cancer cell lines. In addition, we performed qRT-PCR CD166– cells using invasion, migration and proliferation to elucidate differentiation between them. We also com- assays. We performed immunohistochemistry to investi- pared Podoplanin high-expressing CAFs with Podoplanin gate CD166 expression in surgically resected pancreatic knocked down CAFs by siRNA to clarify the own func- cancer tissues. tion of Podoplanin. Next, we investigated the Podoplanin RESULTS: In fl ow cytometry, CD166 was expressed in pan- inducible condition by a time course of expression analysis creatic cancer cells in wide range (0–99.5%). In invasion using total starvation medium (EBSS), and DMEM added by assay, the invasiveness of CD166- cells was greater than that recombinant growth factors or several percentages of FBS. of CD166 + cancer cells (p < 0.05). In migration assay, the RESULTS: IHC showed that the frequency of Podoplanin migratory activity of CD166– cells was greater than that of expression (>30%) in fi broblasts was associated with lym- CD166 + cancer cells (p < 0.05). In proliferation assay, there phatic invasion, venous invasion, tumor size (>3 cm), his- was no signifi cant difference between CD166 + pancreatic tological grade, pT, and a shorter survival time (P < 0.001). cancer cells and CD166– cells. The analysis of real-time Podoplanin expression in cultured CAFs showed heteroge- quantitative RT-PCR revealed that epithelial-mesenchymal neity (ranging from 0 to 95%) by fl ow cytometry. Podo- transition activator Zeb1 mRNA was over-expressed in planin + CAFs showed signifi cantly high expression of CD166- cells (p < 0.001 compared with that in CD166 + CD10 and MMP3 compared with Podoplanin- CAFs, and cells). In immunohistochemistry, there was no signifi cant

co-culture experiments using sorted CAFs showed that Poster Abstracts difference in prognosis between CD166 high staining group Podoplanin + CAFs enhanced the ability of cancer cells in (15 patients; 48.4%) and CD166 low staining group (16

migration and invasion compared with Podoplanin- CAFs Tuesday patients; 51.6%). (P < 0.05), while knock down of Podoplanin showed no CONCLUSION: Our fi ndings suggest that CD166- cells effect on migration and invasion assay. Podoplanin expres- exhibit more aggressive behavior and activation of Zeb1 sion in CAFs was up-regulated in the condition of starva- may play a role in this behavior, although further investi- tion and lower concentration of growth factors or FBS. gation is needed.

169 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: Despite Podoplanin in CAFs had no func- CONCLUSIONS: A transparent validated national regis- tion of own to affect cancer cells, Podoplanin + CAFs try with good compliance is a valuable tool to analyze and enhanced the progression of pancreatic cancer cells by co- improve treatment strategies in benign surgery with low expression of CD10 and MMP3. Podoplanin expression was complication rates. up-regulated in the condition of starvation and lower con- REFERENCES centration of growth factors or FBS. 1. Enochsson L et al. Gastrointestinal endoscopy 2010;72 (6): 1175–1184, 1184 e1171–1173. Clinical: Biliary 2. Lundstrom P et al. Journal of gastrointestinal surgery 2010;14 (2):329–334. Tu1507 3. Palsson SH et al. ISRN gastroenterology 2011;2011: Online Transparency, Validation and Implementation 507389. of Research Findings: Cornerstones in Building a 4. Persson G et al. The British journal of surgery 2012;99 Quality Registry—Report from the Swedish Registry of (7):979–986. Gallstone Surgery and ERCP 5. Tornqvist B et al. BMJ 2012;345: e6457. Lars Enochsson1, Gunnar Persson2 1Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Tu1508 Karolinska Institutet, Stockholm, Sweden; 2Department of Surgery, Creation and Evaluation of a Novel Device for County Hospital Ryhov, Jönköping, Sweden Rapid and Safe Removal of the Gallbladder Through BACKGROUND: Cholecystectomy (laparoscopic or open) Laparoscopic Port Sites is one of the most frequent operations performed by gen- Joshua M. Judge1, Gina Petroni2, William H. Guilford3, eral surgeons. Since the complication rate is low it has been Craig L. Slingluff1, Peter T. Hallowell1 diffi cult to evaluate the effects of different treatment strate- 1Surgery, University of Virginia, Charlottesville, VA; 2Public Health gies on the outcome due to lack of statistical power. This is 3 in contrast to major surgery like in pancreatic or esophageal Sciences, University of Virginia, Charlottesville, VA; Biomedical cancer where high complication rates make it easier to ana- Engineering, University of Virginia, Charlottesville, VA lyze the effects of major treatment changes. The Swedish OBJECTIVE: To obtain preliminary data on the safety Registry of Gallstone Surgery and ERCP (GallRiks) started in and usefulness of a novel device for extracting large and 2005 in order to be able to monitor the effect of different diffi cult-to-remove during laparoscopic treatment strategies on the outcome. The aim of this paper cholecystectomy. is to present the impact that data from the registry has had BACKGROUND: A common source of frustration during in changing treatment strategies in cholecystectomy in laparoscopic cholecystectomy involves extraction of the Sweden. gallbladder through a port site smaller than the gallbladder METHODS: GallRiks is Supported by The National Board itself. Current techniques risk rupture of the bag or gall- of Health and Welfare and The Swedish Surgical Society. bladder and can be time consuming, leading to increased There are approximately 60,000 cholecystectomies and procedural cost. We developed and tested a novel device for 40,000 ERCP registered in the database during the period the safe, minimal enlargement of laparoscopic port sites to 2005–2011. Data are validated at every hospital in Sweden extract large, stone-fi lled gallbladders from the abdomen. every third year to ensure good data quality. Each hospi- This device is a stainless-steel device with a vertical retrac- tal has access to online reports where the outcome of their tion blade and a linear aperture in the handle that admits cholecystectomies and ERCP is compared with Sweden as a scalpel, which can be advanced along the back side of the a whole. The compliance of the registry in Sweden is good vertical blade, enabling a controlled sharp enlargement of (>85%). the laparoscopic port site and rapid removal of the gallblad- RESULTS: This validated database has led to the initia- der. Additionally, we sought to estimate the proportion of tion of many research projects. The results are published patients whose gallbladders are diffi cult to extract from the in peer-reviewed scientifi c journals as well as presented at abdomen. local meetings for users and general presentations at the METHODS: This IRB-approved, single institutional, single annual Swedish surgical week. The fi ndings appear to have surgeon study was offered to patients presenting for lapa- an impact on treatment strategies. Thus,the use of antibi- roscopic cholecystectomy with diagnoses high risk for dif- otic prophylaxis decreased in Sweden from 23% to 14% fi cult gallbladder extraction (those with cholelithiasis with after the publication of Lundström (2) that showed this or without complicating features). When gallbladder extrac- to be ineffective in elective cholecystectomy. The admin- tion was attempted, if successful without enlargement of istration of thromboembolic prophylaxis has decreased by the port site, the device was not used. If the gallbladder 18% after presentation of a study by Persson (4) proving could not be removed with gentle traction on the speci- this to increase bleeding complications in laparoscopic men bag, and enlargement of the port site was considered, cholecystectomy. the device was used. The time required for extraction, from

170 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

insertion of the device until complete specimen removal, METHODS: The Nationwide Inpatient Sample was searched was recorded. The study surgeon provided Likert scores for for gallstone ileus patients (ICD-9 = 560.31) from 1998– perceived utility of the device in each case. Patients were 2010. Only patients who underwent intestinal enterotomy seen in follow-up irrespective of device use and assessed for (ICD-9 45.00–45.03) were included in this study. Variables pain level, cosmetic effect, and infectious complications. studied were age, sex, length of stay, hospital teaching sta- tus, hospital charges, mortality, diagnoses and procedures. Time for Extraction of Gallbladder with Use of Extraction Device Data for patients who underwent cholecystectomy during Mean (Sec) Median (Sec) Range (Sec) their hospital stay (ICD-9 51.21–51.24) were compared to Prototype (patients 1–8) 120 70 27–416 patients who did not. Final device (patients 9–20) 24 24 10–42 RESULTS: Over 13 years, 4,253 patients were hospitalized Total (n = 20) 63 32 10–416 with gallstone ileus and had an intestinal enterotomy with a mean of 327 cases per year. Mean age was 74.9 years; 1,234 were male (29%) and 3,019 were female (71%). 861 patients (20.2%) underwent cholecystectomy during the same hos- pital visit. 89.8% underwent open cholecystectomy, 6.3% open partial cholecystectomy, 3.5% laparoscopic cholecys- tectomy and 0.5% laparoscopic partial cholecystectomy. Mean mortality rate was 6.1%. Diagnoses and mortality rates associated with increased risk of death were aspiration pneumonia (37.3%), septicemia (31.3%), respiratory failure (28.1%), pneumonia (27.5%), acidosis (19.9%), heart failure (16.9%), COPD (14.4%), mental disorders (12.6%), atrial fi brillation (12.0%) and post-operative infection (11.1%). Comparison of Cholecystectomy and No Cholecystectomy

Cholecystectomy No Cholecystectomy Length of Stay (Days) 14.8 11.6 Oblique view from the top of the device. Hospital Charges $75,009 $53,208 Mortality 10.4% 5.0% RESULTS: Thirty-nine patients were enrolled in the study. For twenty (51%) there was diffi culty extracting the gall- bladder, requiring use of the device. Average extraction time for the fi rst 8 patients was 120 seconds. After a planned interim analysis, an improved device was produced and used in the next 12 patients, for whom the average extrac- tion time was 24 seconds. There were no adverse events. Post-operative pain rating and incision cosmesis scores were comparable between patients with or without use of the device. No wound infections or other wound complica- tions were encountered. CONCLUSION: Diffi cult gallbladder extraction during laparoscopic cholecystectomy occurs in a large proportion of patients. The study device can safely and rapidly extract impacted gallbladders through the abdominal wall port site and is judged a useful tool by the study surgeon.

Tu1509 CONCLUSION: Gallstone ileus is more common in older Gallstone Ileus: Impact of Cholecystectomy During the women and was mostly treated by enterotomy alone. How- Initial Hospital Visit ever, 20% of patients underwent cholecystectomy during Greg Burgoyne, Richard Heitmiller their initial hospital visit. Most patients who underwent

Department of Surgery, MedStar Union Memorial Hospital, Baltimore, MD cholecystectomy underwent an open procedure. The length Poster Abstracts of stay, hospital charges and mortality rate were all greater INTRODUCTION: Gallstone ileus is a challenging and

in patients who underwent a cholecystectomy during their Tuesday uncommon disease process. No guidelines have been estab- initial hospital stay. The mortality rate is also increased in lished regarding the timing of cholecystectomy in the man- patients who have underlying co-morbid conditions or agement of gallstone ileus. We review a national database who develop infectious complications such as septicemia, to evaluate the impact patients undergoing cholecystec- pneumonia and wound infections. tomy in their initial hospital stay.

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Tu1510 Tu1511 Clear Anterior and Posterior View of Calot’s Triangle, Does Initial Laparoscopic Cholecystectomy Infl uence Display of Critical View of Safety and Demonstration the Outcomes of Defi nitive Oncologic Resection for of Cystic Duct-Gallbladder Junction Are Necessary to Gallbladder Cancer? Prevent Intraoperative Cystic Duct Misidentifi cation Rana M. Ballo, Mina Saeed, Shaun Daly, Maria C. Mora Pinzon, During Laparoscopic Cholecystectomy Amanda B. Francescatti, Steven D. Bines, Keith W. Millikan, Chris Brown, Rami Radwan, Ashraf M. Rasheed Jonathan Myers, Minh B. Luu General/Upper GI Surgery, Gwent Institute for Minimal Access Surgery, General Surgery, Rush University Medical Center, Chicago, IL Newport, United Kingdom BACKGROUND: Incidentally discovered gallbladder can- INTRODUCTION: Bile duct injury (BDI) is the most seri- cer after routine laparoscopic cholecystectomy (LC) com- ous of all complications during laparoscopic cholecystec- monly requires a completion operation for proper oncologic tomy (LC). It leads to signifi cant mortality and morbidity, resection. There are concerns that a LC prior to defi nitive even following a successful repair. Misidentifi cation of the resection may negatively affect perioperative morbidity and bile duct as a cystic duct is the main cause of ductal injury. survival. We aim to compare perioperative outcomes and Despite recognition of the importance of correct cystic duct survival between patients undergoing a single, initial onco- identifi cation in prevention of BDI, the UK practice lacks an logic resection versus those whose gallbladder cancer is agreed systematic method for “Safe Cystic Duct Identifi ca- incidentally diagnosed after LC, therefore requiring staged, tion”. The aim of this questionnaire is to survey terms used completion surgery. to describe the techniques utilised for intra-operative ana- METHODS: An observational, cohort study of patients tomical identifi cation of the cystic duct among practising undergoing resection of gallbladder cancer was conducted UK hepatobiliary surgeons and members of ALS (Associa- between 2003 and 2012. Twenty patients were evaluated tion of Laparoscopic Surgeons). based on the operative treatment required: single, initial METHOD: A postal questionnaire and an electronic one oncologic resection (n = 9) or staged, completion onco- were sent to all UK specialist hepatobiliary surgeons and to logic resection (n = 11). Pre-operatively, all single surgery ALS members respectively. The questionnaire was designed patients were suspected to have gallbladder cancer, while to allow the user to select the descriptive terms that best none of the staged operation patients were suspected to fi t the method used for cystic duct identifi cation during have gallbladder cancer. Nineteen patients received a radi- LC. The survey was constructed utilizing SAGE’s (Society of cal cholecystectomy, segment IV, V liver resection, and American Gastrointestinal and Endoscopic Surgeons) rec- porta hepatis lymphadenectomy. Univariate analysis of ommendations and included “Triangle of Calot is Displayed patient demographics, perioperative outcomes and overall Clearly”, “Triangle of Calot is Displayed Clearly Anteriorly survival were compared using SPSS analytical software v.20 and Posteriorly”, “Confl uence of Cystic to Common Hepatic and statistical signifi cance was defi ned as p < 0.05. Duct Displayed”, “Infundibular Technique Utilized”, “and Critical View of Safety Demonstrated”. Surgeons were RESULTS: Patient demographics were similar between invited to add any comments or recommendations. the two groups. Post-operative staging was not statistically different and consisted of one unknown, two stage I, four RESULTS: 74 postal questionnaires (72.5% return) from stage II, one stage IIIA, eleven stage IIIB and two stage IV. consultant HPB surgeons were completed and returned. Mean operative time for defi nitive R0 resection was 221.2 The most prevalent descriptive term or terms used to minutes for single and 248.0 minutes for staged surgery describe intraoperative cystic duct identifi cation meth- (p = 0.555). Median blood loss was greater in staged than odology included “triangle of Calot is displayed clearly single surgery (900 mL versus 750 mL, respectively) but was anteriorly and posteriorly” and “critical view of safety dem- not signifi cant (p = 0.23). Furthermore, the increased blood onstrated” (72% selection rate) followed by “infundibular technique utilized” (49% selection rate). The majority of loss did not lead to a signifi cantly greater number of units additional comments related to utilization of intra-oper- of blood transfused, mean of 1.75 units for staged versus ative fl uorocholangiography when anatomy is in doubt 0.73 units for single surgery (p = 0.18). No 30-day post- and to avoid clipping or cutting until the anatomy is clear. operative complications occurred in patients receiving sin- 133 electronic questionnaires were completed by 6 Clini- gle surgery compared to three complications in the staged cal Fellows (4.5%), 28 ST/SpRs (21.2%) and 98 Consultants surgery group (p = 0.089). The single surgery group had (74.2%). The frequency of descriptive terms used was as fol- one 30-day mortality. Although the 1-year survival rate for low: ‘Calot’s Triangle identifi ed & Demonstrated’ (70.8%) single surgery patients was 28.6% versus 57.1% in staged followed by ‘Demonstration of Strasberg’s Critical View of patients (p = 0.592), the 2-year survival rate was 14.3% for Safety’ (24.2%) and lastly ‘Infundibular technique’ (5%). both groups (p = 0.999). Median survival for single surgery patients was 15.4 months versus 14.4 months for staged CONCLUSION: Clear anterior and posterior view of Calot’s surgery patients (p = 0.255). triangle, display of critical view of safety and demonstra- tion of cystic duct-gallbladder Junction (infundibular tech- CONCLUSION: Single versus staged resection of gall- nique) are necessary to prevent intraoperative cystic duct bladder cancer demonstrates no signifi cant difference on misidentifi cation during laparoscopic cholecystectomy. perioperative morbidity or survival. Therefore, initial lapa- roscopic cholecystectomy does not appear to infl uence the Intra-operative fl uorocholangiography is recommended outcomes of defi nitive oncologic resection for gallbladder when anatomical identifi cation is in doubt and no clipping cancer. or cutting is performed until the anatomy is verifi ed.

172 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1513 Tu1514 Short Term Outcome Results Support Safety and Trends in the Management of Acute Cholecystitis: Effectiveness of a Single Stage Laparoscopic Common Prevalence of Percutaneous Cholecystostomy and Bile Duct Clearance and Cholecystectomy for Delayed Cholecystectomy in an Elderly Population Concomitant Chole- and Choledocholithiasis John D. Cull2, Dahlia Rice2, Alexander J. Czubak1, Rahulpreet Singh, Ashraf Rasheed Eric C. Brown1, Jose M. Velasco1,2 Upper GI Surgery, Royal Gwent Hospital, Newport, United Kingdom 1Surgery, NorthShore University Health System, Skokie, IL; 2Surgery, OBJECTIVES: To assess the outcome of laparoscopic clear- Rush University Medical Center, Chicago, IL ance of common bile duct stones at an advanced laparo- BACKGROUND: Management of patients with acute cho- scopic unit in South Wales. lecystitis (AC) remains controversial. Published guidelines METHOD: A prospective database was constructed to recommend early laparoscopic cholecystectomy (LC) as capture data on laparoscopic common bile duct clearance the preferred treatment option. Percutaneous cholecystos- cases and included demographics, imaging, indications, tomy tubes (PCT) had been primarily used in the setting of technique, ductal access route, success rate, operating time, patients with serious comorbidities, severe cholecystitis in duration of hospital stay, bile leakage, sub-phrenic collec- the elderly, and in cases where LC can be technically chal- tion, biliary peritonitis and postoperative jaundice. lenging. We reviewed our experience in the management of AC in the elderly to identify factors that could infl uence RESULTS: Sixty (60) consecutive patients who had an outcomes; specifi cally, the prevalence of PCT, the timing of attempt at concomitant laparoscopic cholecystectomy cholecystectomy, and adherence to published guidelines in and common bile duct clearance populated the database. their management. (7/60) cases were performed following a failed endoscopic clearance. METHODS: A retrospective review of 806 elderly patients (>65) with the primary diagnosis of biliary disease was per- Complete laparoscopic clearance was achieved in (44/60) formed from 2009 through 2011. ICD-9 codes were used. 73.3% of attempted cases, 11/60 (18.3%) were converted Patients were divided into three groups: PCT (Group 1), to open (due to impacted stone or other intra operative early cholecystectomy (Group 2), and late cholecystectomy diffi culties) and cleared completely; (6/60) 10% failed (Group 3). All three groups were compared with respect laparoscopic clearance and was referred to post operative to outcome measures and covariates. Logistic regression endoscopic therapy. 5/60 cases were performed follow- and Fisher exact test were used to determine statistical ing emergency admission and other 55/60 were planned signifi cance. procedures. RESULTS: We reviewed 265 patients with a histologic diag- Trans-cystic approach was utilised in 34/60 (56.6%) and nosis of AC. Out of 75 patients who initially had PCT, 64 was successful in 27/34 (79.4%) but failed in 4/34 (11.7%) (24%) underwent interval cholecystectomy, 74 (28%) early and converted to open with successful clearance in 1, the cholecystectomy, and 127 (48%) delayed cholecystectomy. remaining 3/34 (8.8%) referred for post operative ERCP. The mean age of patients was 77 with no statistical differ- Trans-choledochotomy clearance was used in 26/60 (43.3%) ence among groups. Patients in Group 1 were more likely cases and succeeded in 19/26 (73.3%) and converted to to have ASA scores of 4 when compared to those in Groups open in 7/26 (26%) with successful clearance in all. 2 and 3 (p = 0.04). After removing those with an ASA of 4, no signifi cant difference existed among the three groups A total of 11 cases (18%) failed complete clearance laparo- with regard to covariates. Regarding outcomes, there was scopically and converted to open and 8 out of the 11 were no difference in conversion rates, biliary leak, bowel injury, completely cleared. need for reoperation, or 30 days mortality among the three T- tube was used in 2/26 (7.6%) choledochotomy cases and groups. Overall conversion rate in the three groups was lead to a longer hospital stay. 11% with no statistical signifi cance between groups. Com- A Total of 4 (19%) patients had post operative complica- pared to Group 2, patients in Group 1 were fi ve times more tions, 2 bile leaks, 1 post operative bleed and 1 dislodgment likely (p = 0.04) and those in Group 3 were four times more of T -tube. There was no mortality. likely (p = 0.06) to have a recurrent episode of pancreatitis, cholecystitis and/or cholangitis from the time of diagnosis CONCLUSION: Laparoscopic common bile duct clearance until operation. during cholecystectomy followed by ERCP for failure of ductal clearance is probably the optimal approach. Short term outcome results support the safety and effectiveness Poster Abstracts of laparoscopic CBD clearance approach; but a careful long term outcome and clinical and biochemical follow up for Tuesday all patients undergoing such a procedure is required.

173 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: Eighty-four patients, mean age 55, 56% female, mean BMI 31, were enrolled in the study. Preoperatively 81, and at postoperative time points 66, 59 and 59 patients provided scores for each question for analysis. The pain VAS scale revealed statistically and clinically signifi cant differences from baseline (mean 1.8 + 2.4) to postopera- tive day one (mean 4.5 + 2.5) and 7 (mean 2.4 + 2.1) (p < 0.0001). Overall scores did not reveal signifi cant changes. The PROMIS physical subscale and physical T score revealed clinically and statistically signifi cant differences from baseline (14.2 + 2.9/46.8 + 7.7) to POD 1 (12.6 + 3/ 41.8 + 8.3) (p 0.0067/ 0.0038), driven by answers to a ques- tion about everyday physical activities (p = 0.0001). The LASA scores revealed signifi cant differences from baseline for pain frequency (p = 0.0017) and severity (p = 0.0009) whereas fatigue was not different. When change from base- line within subject was assessed, 83% of subjects reported a clinically meaningful worsening in PROMIS physical T score on POD 1, which persisted in 73% of patients to POD CONCLUSION: Despite guidelines recommending early 7. In addition to pain and LASA fatigue and social activity cholecystectomy, patients in our study were more likely to items were clinically worse in 20% of the patients at POD 7. have their cholecystectomy delayed after a course of anti- biotics or PCT (24%). Patients undergoing PCT placement CONCLUSION: Overall quality of life scores with 7-day or delayed cholecystectomy did not have a lower conver- recall had limited discrimination for the impact of mini- sion rate when compared to those who underwent early mally invasive procedures. Single items appear more prom- cholecystectomy, and they were more likely to have recur- ising and change from baseline as a group and within rent episodes of AC/pancreatitis or cholangitis. Based on subject revealed clinically signifi cant fl uctuation in QOL, our review, patients who are medically fi t for an operation especially within the fi rst 7 days postop. should undergo early cholecystectomy since interval chole- cystectomy is not associated with better outcomes. Future Clinical: Colon-Rectal studies will be aimed at looking at resource utilization and overall cost in these patients.  Tu1516 Tu1515 Pre-Diagnosis Aspirin and Statin Use Up-Regulates the PROMIS for Laparoscopy Local Infl ammatory Response in Colorectal Cancer: Juliane Bingener, Jeff Sloan, David Farley Implications for Neoadjuvant Treatment Division of General Surgery, Mayo Clinic – Rochester, Rochester, MN James H. Park, Colin H. Richards, Donald C. Mcmillan, INTRODUCTION: As morbidity outcomes have signifi cant Paul G. Horgan, Campbell S. Roxburgh limitations when comparing minimally invasive surgical Academic Department of Surgery, University of Glasgow, Glasgow, procedures, recent trials reported on quality of life out- United Kingdom comes after different cholecystectomy procedures. These INTRODUCTION: Increasing evidence suggests a role for trials did not demonstrate differences of global quality of nonsteroidal anti-infl ammatory drugs (NSAIDs) including life instruments such as SF 36 at one month postopera- aspirin and statins as adjuvant treatment in colorectal can- tively. We wanted to test the performance of an NIH-spon- cer (CRC), with reduced recurrence and improved survival sored Patient-Reported Outcomes Measures Information in long-term users. Whether this is due to manipulation of System (PROMIS) with previously validated, standardized CRC-associated infl ammation is unclear. Systemic infl am- PRO measures for use with minimally invasive procedures. mation, a stage independent predictor of outcome may be METHODS: From May 2011 through Nov 2012, patients down-regulated by NSAIDs [1]. Furthermore, local infl am- undergoing basic or advanced laparoscopic procedures mation measured by tumour immune cell infi ltration, an agreed to participate in this IRB approved study. The PRO- independent predictor of disease-free survival, may be up- MIS global health short form, validated for 7-day recall and regulated by pre-operative NSAID administration[2]. previously used for 24-hour recall, the Linear Analog Self OBJECTIVE: In a cohort of patients with cancer associ- Assessment (LASA), validated for 24 hour recall and the ated local and systemic infl ammatory responses, the aim 10 mm visual analog scale (VAS) for pain assessment were was to examine whether aspirin (75 mg) and statins pre- obtained preoperatively, 4 hrs after surgery and on post- scribed for cardiovascular disease infl uenced CRC-associ- operative day 1 and 7. Each tool was scored and both the ated infl ammation. composite scores and single item responses were compared over time using the Kruskal Wallis test.

174 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: A retrospective case note review of a prospec- to no medication there was a signifi cant increase in inva- tively collected CRC database was performed to ascertain sive margin and overall CD3 + infi ltration with aspirin or pre-diagnosis prescription of aspirin and statins; the effect of combined use (margin: 42.1%, 60%, 100%, p = 0.007; over- aspirin alone or combined aspirin and statin use on the sys- all: 51.7%, 83.3%, 100%, p = 0.007) and a non-signifi cant temic (C-reactive protein, albumin, neutrophil:lymphocyte trend towards increased FOXP3 + and CD8 + margin, stro- ratio and modifi ed Glasgow Prognostic score) and local mal and overall infi ltration. (assessment of peritumoural infl ammatory infi ltrate using CONCLUSION: Although K-M grade did not differ, tumour Klintrup-Mäkinen (K-M) grade; assessment of T-lympho- infi ltration of T-lymphocytes was increased by aspirin and cyte (CD3 + ), regulatory T-cell (FOXP3 + ) and cytotoxic statins, particularly in patients with early stage disease. T-cell (CD8 + ) infi ltration at the invasive margin, within Whether commencing these agents following diagnosis, the stroma and overall) infl ammatory responses were particularly in patients with an attenuated local infl amma- examined. tory response, results in similar changes prior to surgery RESULTS: Data for 434 patients were available [Table 1]. and the subsequent oncological implications remains to be Pathological variables were similar and systemic infl am- determined. Studies to examine whether anti-infl ammatory mation did not differ between groups. Data on the local agents can manipulate colorectal cancer associated infl am- infl ammatory profi le were available for 164 patients. mation are warranted. Although K-M did not differ, aspirin and combined use REFERENCES were associated with increased tumour margin and over- all infi ltration of CD3 + lymphocytes. This association was 1. McMillan DC. Proc Nutr Soc. 2008;67 (3):257–6. stronger in patients with local disease (T1-3,N0); compared 2. Lönnroth C, et al. Cancer Immun. 2008;8:5.

Table 1: Patient, Tumour And Infl ammatory Characteristics of Patients with Primary Operable Colorectal Cancer (N = 434) According to Pre- Diagnosis Use of Aspirin or Aspirin And Statin Use

No Medication Aspirin Alone Aspirin and Statin P-Value Patient Variables Male/Female 147 (49)/154 (51) 25 (60)/17 (40) 45 (49)/46 (51) 0.725 Colon/Rectal 178 (60)/119 (40) 23 (55)/19 (45) 53 (59)/37 (41) 0.77 Neoadjuvant therapy (No/Yes) 261 (89)/32 (11) 37 (90)/4 (10) 82 (92)/7 (8) 0.403 Ischaemic heart disease (No/Yes) 198 (93)/14 (7) 17 (68)/8 (32) 22 (29)/53 (71) <0.005 Ever smoked (current and ex/never) 111 (55)/92 (45) 5 (21)/19 (79) 27 (37)/46 (63) 0.003 Systemic Infl ammatory Response CRP > 10 mg/L (No/Yes) 199 (66)/101 (34) 27 (64)/15 (36) 64 (70)/27 (30) 0.535 mGPS (0/1/2) 200 (66)/69 (23) /32 (11) 27 (64)/10 (24)/5 (12) 64 (71)/14 (15)/13 (14) 0.974 NLR > 5 (No/Yes) 132 (86)/22 (14) 14 (61)/9 (39) 54 (89)/7 (11) 0.975 Local Infl ammatory Response K-M Grade (Weak/Strong) 97 (67)/48 (33) 8 (47)/9 (53) 16 (67)/8 (33) 0.615 CD3 + Margin (Weak/Strong) 67 (59)/47 (41) 7 (41)/10 (59) 5 (33)/10 (67) 0.032 CD3 + Stroma (Weak/Strong) 65 (56)/52 (44) 9 (50)/9 (50) 6 (37)/10 (63) 0.175 CD3 + Overall (Weak/Strong) 57 (49)/60 (51) 6 (33)/12 (67) 3 (19)/13 (81) 0.014 FOXP3 + Overall (Weak/Strong) 55 (48)/59 (52) 7 (41)/10 (59) 7 (47)/8 (53) 0.758 CD8 + Overall (Weak/Strong) 61 (53)/54 (47) 9 (53)/8 (47) 7 (47)/8 (53) 0.682 All values given as number of patients (%).Total patient numbers vary due to incomplete data. CRP – C-reactive protein. mGPS: modifi ed Glasgow Prognostic Score. mGPS is a cumulative score based on CRP and albumin; a score of 1 is given if patients has CRP > 10 mg/L, 2 if CRP > 10 mg/L and albumin <35g/L. NLR- Neutrophil:lymphocyte ratio Poster Abstracts Tuesday

175 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

 Tu1517  Tu1518 Increasing the Number of Lymph Nodes Examined Smoking Adversely Affects Colon Cancer Survival and After Colectomy Does Not Improve Colon Cancer Relapse Rates Staging Kellie L. Mathis1, Erin Green2, Daniel J. Sargent2, Cristina N. Budde, Daniel O. Herzig, Kim C. Lu, Brian S. Diggs, Lisa Boardman2, Paul J. Limburg2, Stephen N. Thibodeau2, Karen Deveney, Vassiliki L. Tsikitis Rajesh Pendlimari2, Heidi Nelson1 Surgery, OHSU, Portland, OR 1Surgery, Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN OBJECTIVES: Current quality initiatives call for examina- OBJECTIVE: To test the hypothesis that ever smokers tion of a minimum of 12 lymph nodes in curative colon would suffer more recurrences and worse overall and dis- cancer resections. The aim of this study was to determine if ease-free survival than never smokers following colon cancer the number of nodes resected has been increasing, and if an resection. increasing number of resected nodes correlates with upstag- SUMMARY BACKGROUND DATA: Smoking is associ- ing of tumors and improved survival. ated with an increased risk of developing colon polyps, DESIGN: Review of Surveillance, Epidemiology and End specifi cally aggressive polyps, as well as an increased risk Results (SEER) data from years 2004–2009 was performed. of colon cancer. Large database studies have shown an All patients who underwent colon cancer resection during increased risk of colon cancer mortality among smokers, this date range were analyzed. Number of nodes retrieved, but it is not clear whether this risk is related to differences patient stage, and survival by stage were examined. Mul- in the biology/aggressiveness of the disease or differences in tivariate analysis was performed, examining stage, cancer clinical response to treatment. site, age, and number of nodes retrieved. METHODS: The medical records of 2540 patients with RESULTS: A total of 131,301 patients met inclusion cri- resected stage I-III colon cancers treated at a single institu- teria. An average number of nodes analyzed increased tion were reviewed. Demographics, tumor and surgical vari- sequentially with each year examined, from 12 in 2004 ables, and follow-up information were recorded. Univariate to 16 in 2009. Despite greater number of nodes obtained and multivariate analyses were performed to examine pre- and analyzed, there was no clinically signifi cant change in dictors of overall and disease-free survival as well as time to stage, overall survival, or survival by stage. On multivari- recurrence of colon cancer. ate analysis, controlling for stage and site of disease, there RESULTS: Tumor variables and chemotherapy administra- was improved survival with increasing nodal retrieval (haz- tion were similar among smokers and nonsmokers. Overall ard ratio 0.9840 for each additional node removed, 95% CI survival was signifi cantly higher for never smokers com- 0.9829–0.9852, p < 0.001). pared to ever smokers (5 year OS 79.8% nonsmokers ver- sus 72.3% ever smokers, p < 0.0001; HR 1.51, 95% CI 1.30 –1.74). Disease free survival was signifi cantly higher for nonsmokers compared to smokers. Time to cancer recur- rence was also signifi cantly infl uenced by smoking status. Smoking status remained a poor prognostic factor in mul- tivariate models for overall and disease-free survival as well as time to recurrence. Multivariate Predictors of Disease-Free and Overall Survival

Disease-Free Survival Factor Hazard Ratio 95% CI p value Any smoking 1.460 1.269–1.679 <0.0001 Stage I 1.00 (referent) Stage II 1.303 1.090–1.557 0.0036 Stage III 2.212 1.776–2.754 <0.0001 Chemotherapy 0.703 0.573–0.863 0.0007 Colon cancer stage expressed as a percent of cases each year. Diabetes 1.181 0.987–1.421 0.0796 CONCLUSION: The current quality initiative has suc- Age 1.046 1.038–1.054 <0.0001 ceeded in increasing the number of nodes examined in Overall Survival colon cancer resections, but has not led to upstaging of Factor Hazard Ratio 95% CI p value tumors. The improved survival seen with higher node Any smoking 1.506 1.301–1.742 <0.0001 counts was independent of stage, site of disease, or patient Stage I 1.00 (referent) age. This suggests that patient related immunologic factors Stage II 1.257 1.047–1.509 0.0142 might explain the relationship rather than the quality of the surgical resection. The current quality initiative needs Stage III 2.221 1.772–2.783 <0.0001 to be investigated further to determine if surgical quality Chemotherapy 0.585 0.470–0.728 <0.0001 or non-modifi able patient factors are responsible for the Diabetes 1.206 0.994–1.464 0.0578 improvement in survival. Age 1.058 1.048–1.065 <0.0001

176 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

CONCLUSIONS: This study confi rms that ever smokers Tu1520 have worse colon cancer outcomes than never smokers. Surgeons should refer all smokers with colon polyps or can- Pneumoperitoneum Following Abdominal Surgery: cers for smoking cessation programs. Can We Distinguish Benign vs. Problematic? I. Michael Leitman1, Marissa M. Montgomery1, Joseph E. Sabat1,  Tu1519 Laura Bernstein1, Burton Surick1, Barbara Zeifer2, Hristina Natcheva2, Franklin Nwoke2, Charles S. Holland1, High Defi nition Increases Adenoma Anthony Sorrentino1 Detection Rate 1Surgery, Albert Einsteil College of Medicine-Beth Israel Medical Nezar Jrebi, Theodor Asgeirsson, Rebecca E. Hoedema, Center, New York, NY; 2Radiology, Albert Einstein College of Donald G. Kim, Nadav Dujovny, Ryan Figg, Martin Luchtefeld Medicine – Beth Israel Medical Cener, New Yotk, NY Ferguson Clinic, Grand Rapids, MI INTRODUCTION: Pneumoperitoneum seen on postop- BACKGROUND: The adenoma detection rate (ADR) is a erative imaging presents a diagnostic dilemma. It can be quality indicator for colonoscopy. High defi nition (HD) a normal fi nding secondary to air that was introduced at imaging has been reported to increase polyp detection rates. surgery, which typically resolves in a matter of days. On OBJECTIVE: The primary objective of this study was to the other hand, it could also represent a sign of a perfo- compare polyp detection rate (PDR) and adenoma detec- rated viscus or an anastomotic leak, which might require re- tion rate (ADR) before and after the implementation of HD operation. Distinguishing one from the other is critical to colonoscopy. successful management. This study examines clinical and radiological fi ndings in order to determine which are able METHODS: A retrospective chart review was performed on to facilitate the distinction of benign versus pathological two groups of patients aged 48–55 years old, who under- postoperative pneumoperitoneum. went fi rst time screening colonoscopy. The fi rst group had their screening with standard defi nition (SD) colonoscopy METHODS: A retrospective analysis of medical records in the fi rst 6 months of 2011. The second group had their from a large urban teaching hospital was performed. Imag- screening with HD colonoscopy during the fi rst six months ing studies reporting “pneumoperitoneum,” “free air,” and of 2012. We compared age, gender, PDR, ADR, average size “free intraperitoneal air,” from July 2006 through June 2012 of adenomatous polyps. Statistical analysis was performed were selected for review. The cases were divided into three with Fischer’s Exact Test and Pearson Chi-Square. groups: patients who ultimately were returned to the oper- ating room and had fi ndings requiring operative interven- RESULTS: 1268 patients were involved in the study (634 tion, those who were returned to surgery but did not have in each group). PDR (35.3% vs 45%, p < 0.001) and ADR evidence of pathology requiring operative intervention, (19.1% vs 25.4%, p = 0.007) were higher in the HD group. and those who were managed expectantly. Demographic, The average size of adenomatous polyp were the same in physical fi ndings and laboratory studies were recorded. The two groups (0.57 vs 0.55, p = 0.63). When polyps were cat- radiological studies were reviewed in an attempt to quan- egorized into size groups there was no difference in ADR tify the amount of free intra-peritoneal air. between the two timeframes (<5 mm in size ( 45.5% vs 41%), 5–10 mm ( 46.6% vs 56%) and >10 mm (7.7% vs 2.6%), p = 0.15). Polyps were most commonly seen in sig- moid (30.6% vs 30.4%). Multiple polyps (25.6% vs 29%, p = 0.51) were more detected in the HD group. CONCLUSION: Screening colonoscopy with high defi ni- tion technology signifi cantly improved both PDR and ADR. The clinical signifi cance of these fi ndings is unclear but could be justifi ed if fi ndings result in reduction of interval colon cancer rates. Poster Abstracts Tuesday

CT scan with contrast on sixth postoperative day following laparoscopic sleeve resection demonstrating free air over the liver and around spleen.

177 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

RESULTS: 68 patients were found to have postopera- METHODS: Cancer-specifi c mortality was obtained from tive pneumoperitoneum after abdominal surgery. Twenty our prospectively maintained cancer registry database.1534 patients (29%) underwent re-exploration because of pre- patients were diagnosed with CRC between 2005 and sumed intra-abdominal complication and the remain- December 2009. Patients were included if they had a com- der of patients were managed by observation alone. Nine plete blood count with differential before any modality of patients had prior open surgery and 11 had minimally treatment (surgery or chemotherapy). Exclusion criteria invasive abdominal procedures. At surgery, 14 patients were: absence of differential blood count before treatment, (70%) were found to have pathologic conditions requiring patients with bowel obstruction on presentation, patients intervention. The other six were explored but were found with hematoproliferative disease, evidence of infection to have conditions that could have been managed with- at the time of presentation, those treated with steroid or out re-exploration. The patients in each group were similar immunosuppressive medications. Two independent physi- with regard to age, gender vital signs, pain score, physical cians reviewed the charts for the demographic, presenta- fi ndings, amount of free air or open vs. laparoscopic proce- tion, laboratory, pathological, management and outcome dure. However, patients requiring re-operation were found variables. Patients were then divided into fi ve equal quin- to have pneumoperitoneum 5.7 days after initial surgery tiles according to their pretreatment monocyte count [1st compared to postoperative 2.7 days for those that could Mono quintile (Mono ≤0.4k/cc) = 125 patients, 2nd quintile be managed expectantly (P = 0.004). 15% of the patients (Mono 0.41–0.5k/cc) = 114 patients, 3rd quintile (Mono undergoing re-operation died compared to 19% who were 0.51–0.69k/cc) = 108 patients, 4th quintile (Mono 0.7–0.8k/ managed without surgery (P > 0.05), none of which were cc) = 127 patients and the 5th Mono quintile (Mono ≥ 0.81 related to intra-abdominal pathology. None of the other k/cc) = 113 patients]. variables were found to be signifi cantly different between RESULTS: A total of 587 patients met the inclusion criteria. groups. The 5th monocyte quintile had a signifi cant higher 4-year CONCLUSIONS: This study suggests that patients with mortality compared to the 1st and 2nd monocyte quintiles postoperative free air still present a diagnostic and thera- (38/113 = 34% vs. 23/125 = 18% and 17/114 = 15%, p val- peutic challenge. However, free air several days follow- ues 0.008 and 0.001 according to Fisher’s exact two-tailed ing surgery may provide an indication that this fi nding test). In multivariate analysis including the cancer stage, should be of greater concern. Such patients have a greater monocyte count was independent predictor of survival likelihood of requiring reoperation for the treatment of a (Hazard ratio of 1.35, 95% Confi dence interval 1.11–1.64, postoperative complication. p = 0.0003). Figure 1 illustrated the trend of higher mortal- ity along the monocyte quintiles.

Tu1521 Pretreatment Elevated Peripheral Blood Monocyte Count Is a Negative Predictor of 4-Year Cancer-Related Mortality in Colorectal Cancer Patients Basem Azab, Neeraj Shah, Steven Vonfrolio, William Lu, Karen E. Gibbs, Scott W. Bloom Surgery, Staten Island University Hospital, Staten Island, NY BACKGROUND: Infl ammation plays a major role in can- cer biology and outcomes. Studies have demonstrated that tumors with increased tumor-infi ltrating monocyte counts are associated with tumor angiogenesis and degradation of extracellular matrix, which increases potential of metasta- Figure 1: The 4-year cancer-related mortality according to the sis. Moreover, prior studies demonstrated the association pretreatment peripheral blood monocyte count among colorectal cancer between elevated peripheral blood monocyte and cancer- patients. related survival in various cancer populations (colorectal, ovarian, mesothelioma, melanoma, leukemia and others). CONCLUSION: Elevated pretreatment circulating mono- The prior studies evaluated the monocyte count in the met- cyte count was a signifi cant predictor of long-term cancer astatic colorectal cancer patients had limited studies sizes specifi c survival among colorectal cancer patients. (<100 cases). The aim of this study is to ascertain the value of using the circulating monocyte count to predict cancer related survival among colorectal cancer patients.

178 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1522 Tu1523 Antibiotics Alone as Initial Treatment of Sigmoid Transanal Rectal Tumor Excision Using the SILS Device Diverticulitis Complicated by Peridiverticular Abscess Angelo Stuto1, Francesca Da Pozzo2, Andrea Braini1, Instead of Percutaneous Drainage Alessandro Favero1 Faisel Elagili, Luca Stocchi, Pokala R. Kiran 11st Surgical Department, Az. Osp “SMA”, Pordenone, Italy; Colorectal Surgery, Cleveland clinic, Cleveland, OH 2General Surgery, Trieste University, Trieste, Italy BACKGROUND: There is limited data assessing the effec- Rectal Resection with Total Mesorectal Excision (TME) is tiveness of antibiotic treatment as sole initial therapy (ABX) nowadays the standard of care for rectal turmors. How- instead of percutaneous drainage (PCD) in patients with ever local excision of early low risk stage (T1s-T1 with G1 large abscess complicating diverticulitis. The aim of our or SM1) could be a safe alternative. Recent literature data’s study was to evaluate outcomes for patients initially treated support this minimally invasive approach. Transanal Endo- with PCD vs. those for patients initially treated with ABX. scopic Microsurgery (TEM), introduced by Buess, is a mini- mally invasive procedure for removal rectal lesions that METHODS: All patients with a diagnosis of abscess ≥3 cm need dedicated tools. TEM is a safe procedure in terms of in diameter associated with sigmoid diverticulitis admit- low recurrence rate and correct oncological outcome but ted to our institution from 1994–2012 were identifi ed suffer from high cost, long learning curve and possibility from an institutional, IRB-approved diverticular database. of sphinteric damage induced by rigid protoscope. To avoid All patients ultimately underwent surgery. One hundred these problems we present a technique for transanal exci- fourteen patients were initially treated with PCD and 32 sion using a single-incision laparosocpic port. In SILS-TEM patients were initially treated with ABX. Patients treated technique standard laparoscopic instruments are used and with PCD alone or requiring emergent surgery at admission the soft and smaller device prevent sphinteric damage. We were excluded. propose SILS-TEM for Tis or T1 Rectal Tumor located from 4 RESULTS: Patient characteristics are summarized in the to 12 cm from the anal verge. In all the cases nodal involve- table and were similar except for larger abscess diameter in ment was exclude by Transanal Ultrasound and MRI. In the PCD group. Reasons for ABX included technical inabil- selected patients we also propose SILS-TEM in case of T3N0 ity for PCD based on CT images (n = 15) and surgeon pref- with a complete or nearly complete (less than 20% of Resid- erence (n = 17). All ABX patients requiring urgent surgery ual Cancer Cells at re-staging) response at neo-adiuvant had continued symptoms. No PCD was attempted in this therapy (performed within a controlled study protocol). In group. Reasons for urgent surgery in the PCD group besides 12 months experience we performed 10 SILS-TEM: 8 for Tis continued symptoms (n = 16) were technical failure of or T1 uNo and 2 for complete neoadiuvant RT-CT response attempted PCD (n = 4) and PCD-related small bowel injury cases. No mayor intraop or post-op complications were (n = 1). The two groups had similar incidence of elective showed. 8 of 10 patients required a prolonged antibiothic surgery, comparable postoperative outcomes and stoma cre- therapy. Hospital discharge was from day 2 to day 4 with ation rates. 1 case of readmission for pain and minor rectal wounds problem. Variables PCD (n = 114) ABX (n = 32) P value Age (years) 57 ± 13 57 ± 12 0.9 SILS-TEM is a safety and feasible technique for selected Abscess diameter (cm) 7.1 ± 2.6 5.9 ± 4.0 0.001 early stage rectal tumors. The technique is easy to perform and require a short learning curve expecially for surgeons Intrabdominal/pelvic location 49/65 15/17 0.37 with laparoscopic skills. No additional costs are needed and Urgent surgery for failure of 21 (18%) 8 (25%) 0.21 initial treatment patient comfort is improved. Elective surgery 93 (82%) 24 (75%) 0.2 Mortality 3 (2.6%) 0 1 Morbidity 42/114 (37%) 11/32 (34%) 0.77 Postoperative abdomino-pelvic 6 (5%) 2 (6%) 1 abscess Anastomotic leak 3/94 (3%) 2/26 (7%) 0.5 Overall stoma rate 51 (45%) 11 (34%) 0.3 Permanent stoma rate 16 (14%) 4 (13%) 0.7 Length of hospital stay (days) 8.2 ± 6.2 9.5 ± 11.1 0.6

CONCLUSION: Selected patients with peridiverticular Poster Abstracts abscess can be initially treated with antibiotics without Tuesday adverse consequences on the timing of their operations, requirements for stoma creation and postoperative morbidity.

179 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1524 Tu1525 Oversewing Staple-Lines in Primary Ileocolic Resections Long-Term Outcomes of Stenting as a Bridge to Surgery for Crohn’s Disease May Reduce Anastomotic for Acute Left-Sided Malignant Colonic Obstruction Complication Rates Fayez A. Quereshy1,2, Jensen T. Poon2, Wai-Lun Law2 Maria Widmar, Emily Steinhagen, Dustin Cummings, 1Department of Surgical Oncology, University Health Network, Adrian J. Greenstein, Alexander J. Greenstein University of Toronto, Toronto, ON, Canada; 2Department of Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY Queen Mary Hospital, University of Hong Kong, Hong Kong INTRODUCTION: The safety of stapled anastomoses in INTRODUCTION: Stenting as a bridge to surgery has been resections for Crohn’s Disease (CD) has been supported by increasingly applied in cases of acute left-sided colonic previous studies as producing comparable if not lower anas- obstruction. This study aims to evaluate both the short and tomotic leak rates. Nevertheless, the overall rate of anasto- long-term outcomes associated with colonic stenting as a motic complications in this cohort remains higher than for bridge to surgery in patients with obstructing adenocarci- non-CD patients. Reinforcing staple-lines by oversewing is noma of the colon. one method which may prevent these complications; how- METHODS: Patients with potentially curable acute left- ever, the effi cacy of this practice has not been established. sided colonic obstruction treated with stenting as a bridge METHODS: We performed a retrospective review from to surgery (28) or with emergency surgical resection (39) 2007–2012 of all patients with Crohn’s Disease who from January 1998 to December 2008 were identifi ed using underwent primary ileocolic resections (ICR) with stapled a prospectively maintained database. Short-term data on anastomoses by faculty at The Mount Sinai Hospital. Base- post-operative mortality, morbidity, necessity of intensive line characteristics including age, length of stay, opera- care, and length of hospital stay were compared. Disease- tive approach and additional procedures (preoperative free and overall survival data were also analyzed. abscess drainage, additional intraoperative resections) were RESULTS: Patients within the two study arms had similar assessed. Major anastomotic complications (MACs) were demographic profi les. Patients receiving preoperative stent- defi ned as leak, disruption, abscess requiring drainage or ing had a higher likelihood of a laparoscopic resection (P < reoperation within 30 days. Other postoperative complica- 0.001). Further, the emergency surgery group had a higher tions (OPCs) were defi ned as ileus, obstruction resolving rate of post-operative complications (P = 0.024), rate of ICU with conservative treatment, wound infection, pneumonia, admission (P = 0.013), and longer total length of stay (9 vs. anastomotic hemorrhage and ureteral injury. Chi-square 12 days, P = 0.001). With a median follow-up of 26.5 and and student’s t-test were used to determine baseline differ- 31.3 months for the stenting and surgical resection groups ences between the groups, and a logistic regression analysis respectively, there was no difference in overall and disease- was used to identify signifi cant predictors of MACs. free survival (overall survival = 30 vs 31 months, P = 0.858; RESULTS: A total of 225 patients were studied, 119 with DFS = 13 vs 12 months, P = 0.989). As well, there was no non-oversewn and 106 with oversewn stapled anastomoses. difference in the rate of systemic recurrences (8 vs. 13, P = Twelve surgeons were represented. Non-oversewn and over- 0.991). sewn groups were similar in age (34.3 vs. 35.2 years), post- operative length of stay (6.0 vs. 6.4 days), and additional procedures (32% vs. 39.6%). More patients in the non-over- sewn group underwent laparoscopic-assisted procedures than in the oversewn group (79% vs. 45.3%, p < 0.001). Overall complication rates (20.2% and 22.6%) and the inci- dence of OPCs were comparable in both groups, includ- ing similar rates of small bowel obstruction and ileus. The incidence of MACs was signifi cantly lower in the oversewn group (2% vs. 13.9%, p = 0.004). There were 7 confi rmed anastomotic leaks in the non-oversewn group versus none in the oversewn group. Multivariate analysis confi rmed that oversewing was an independent predictor of reduced MACs (p < 0.0001) whereas approach (laparoscopic versus open) was not. CONCLUSION: Oversewing staple-lines in primary ileoco- lic resections for Crohn’s Disease may reduce the rate of major anastomotic complications. The major anastomotic complication rate of 2% in the oversewn group closely par- allels that of non-CD patients.

180 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

A 30-year old healthy Ashkenazi Jewish white male pre- sented with intermittent left upper quadrant pain and cramping for the better part of a year. Pain was reported to last from several hours to days and was not associated with diet, bowel function, or activity. Physical examination was unremarkable. Computed tomography of the abdo- men and pelvis revealed pneumatosis of the left colon with associated blebs/bullae. Subsequent colonoscopy defi ned numerous submucosal blebs in his left colon extending to the splenic fl exure. Conservative management was insti- tuted consisting of an elemental diet and 3 months of oral Flagyl. Overall symptomology improved and repeat sigmoidoscopic examination demonstrated a decrease in pneumatosis cystoides coli.

CONCLUSION: Stenting as a bridge to surgery is a safe treat- ment strategy in the management of patients with acute left-sided colonic obstruction with improved short-term outcomes and comparable long-term oncologic results. Further studies are necessary to fully address the utility of colonic stenting as a bridge to curative surgery and to estab- lish its defi nitive role as a treatment strategy

Tu1526 Pneumatosis Cystoides Coli: A Case Report and Review of the Literature Ambar Matta Surgery, TriHealth, Cincinnati, OH Pneumatosis cystoides coli is an extremely rare condition with scattered cases reported in the literature. The etiology CT abd/pelvis images, colonosopcy fi ndings. is largely unknown though hypothesized to be bacterial, pulmonary, or mechanical in origin. Management options depend on the clinical presentation. Surgical intervention is typically reserved for those who ultimately fail conserva- tive management or present in a more urgent or emergent manner. Poster Abstracts Tuesday

181 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1527 Tu1528 Colonic Stents as Bridge to Elective Surgery Versus Construction of Permanent Ileostomy After Restorative Emergency Surgery for Left Sided Malignant Colonic Proctocolectomy for Ulcerative Colitis Obstruction: A Meta-Analysis of Randomized Munenori Nagao, Chikashi Shibata, Hitoshi Ogawa, Controlled Trials Sho Haneda, Shinobu Ohnuma, Hiroyuki Sasaki, Atsushi Kohyama, Naga Swetha Samji1, Sudhir Duvuru1, Anupama Inaganti1, Takeshi Naitoh, Koh Miura, Michiaki Unno Rajan Kanth1, Mainor R. Antillon2, Praveen K. Roy1 GI Surgery, Tohoku University, Sendai, Japan 1Internal Medicine, Marshfi eld clinic, Marshfi eld, WI; BACKGROUND: Restorative proctocolectomy with ileal- 2Gastroenterology and Hepatology, Oschner Clinic, New Orleans, LA pouch anal (canal) anastomosis (IA (C) A) is the standard pro- PURPOSE: Emergency surgery is a traditional treatment cedure for ulcerative colitis (UC). However, some patients option for patients with malignant left sided colonic require permanent ileostomy because of some complications obstruction which involves defunctioning stoma with or after IAA. without primary anastomosis. Colonic stenting as a bridge AIM: The aim of this study was to clarify the incidence and to elective surgery has been proposed as an alternative clinical feature of the patients who necessitated permanent to emergency surgery. Recent randomized controlled tri- ileostomy after IAA for UC. als have assessed the effi cacy of colonic stents as a bridge to elective surgery compared to emergency surgery in the METHODS: Medical records of the patients who under- management of malignant colonic obstruction. We per- went permanent ileostomy after IAA for UC were reviewed formed a meta-analysis of the RCT’s to compare the effi cacy retrospectively. There were 251 patients who underwent and safety of stent compared to emergency surgery in left IAA in our department since 1987, and 11 patients (4.4%) sided colonic obstruction. necessitated permanent ileosotomy therafater. We com- pared backgrounds between patients who required perma- METHODS: Cochrane Central Register of Controlled Tri- nent ileostomy (N = 11; ileostomy group) and those who als & Database of Systematic Reviews, PubMed, and recent did not (N = 240; control group). Patients in ileostomy abstracts from major conference proceedings were searched group were divided into 3 subgroups based on indications (through 11/12).All the studies assessing the effi cacy of for constructing ileostomy; intractable anal or ano-vaginal colonic stent as a bridge to elective surgery compared to fi stula (Group A, N = 4), stricture of IAA (Group B, N = 4), emergency surgery are included. Standard forms were and severe fecal incontinence (Group C, N = 3). We com- used to extract data by two independent reviewers. Data pared clinical features among these 3 subgroups. regarding the following outcomes were extracted-number of primary anastomosis, overall stoma rate, success rate, RESULTS: There were no differences between ileostomy complication rate, infection rate, number of patients with and control groups in the age undergoing IAA, the mean anastomosis leakage and mortality rate. period from diagnosis as UC to surgical treatment, indi- RESULTS: Seven studies met the inclusion criteria (n cation for surgical treatment, severity and spread of UC. = 341). Mean age ranged from 62–74 yrs. Studies were (Thus, no specifi c background was found for patients reported from China, UK, Spain, Singapore, France, Neth- requiring permanent ileostomy after IAA.) The mean age erlands. Colon stents used were Wallfl ex of 25 mm and (range) undergoing IAA in group A, B, and C was 25 (17– Wallstent of 22 mm diameter. All patients had malignant 36), 37 (21–48), and 48 (29–66), respectively. The mean left sided colon obstruction. Success rate (defi ned as clinical time interval (range) bewteen the closure of temporary cov- relief of obstruction) was higher in surgery group compared ering ileostomy and contruction of permanent ileostomy to stent group (OR 18.8 95% CI 6.15–57.89, p < 0.0001). in group A, B, and C was 9.5 (3–23 years), 5.8 (2 months—9 Primary anastomosis rate was signifi cantly higher in stent years), and 2.3 (1 month—5 years) years, respectively. Thus group compared to emergency surgery group (OR 2.8 95% patients who required permanent ileostomy because of fi s- CI 1.6–4.7, p = 0.0001). Overall stoma rate was lower in tula tended to undergo IAA at relatively young age and had stent group (OR 0.39 95% CI 0.19–0.8, p = 0.01). Overall long time interval, while those who necessitated permanent complication rate was signifi cantly lower in stent group ileostomy because of fecal incontinence tended to undergo compared to surgery group (OR 0.30 95% CI 0.12–0.72, p = IAA at relatively old age and had short time interval. 0.007). There was no signifi cant decrease in infection rate CONCLUSIONS: These results indicate that, in patients in stent group compared to surgery group (OR 0.54 95% necessitating permanent ileostomy after IAA for UC, the 0.24–1.19, p = 0.12). There was no signifi cant difference surgical indication for permanent ileostomy was associated in anastomosis leak between two groups (OR 0.73 95% CI- with age undergoing IAA and time interval between the 0.18–2.9, p = 0.67). No signifi cant difference in mortality closure of temporary ileostomy and the contruction of per- rate observed between two groups (OR 0.95 95% CI-0.41– manent ileostomy. The Long term follow-up is important, 2.18, p = 0.91). because some patients required permanent ileostomy over CONCLUSION: Success rate (relief of obstruction) was 20 years after restorative proctocolectomy for UC. higher in emergency surgery group compared to stent group. Primary anastomosis rate, overall stoma rate and complication rate was lower in stent group compared to surgery group. There was no signifi cant difference in infec- tion rate, anastomosis leak and mortality rate in between the two groups.

182 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1529 Tu1531 Stapled Loop Ileostomy Closure: Does Stapler Length Anoscopic Surveillance to Prevent Malignant Matter? Progression of Anal Intraepithelial Neoplasia in HIV Rahul Narang, Sudhir Kalaskar, Hoong-Yin Chong, Patients: Is a Simple Approach Effective? Rama Ganga, Giovanna Da Silva, Steven Wexner, Eric G. Weiss Harkanwar S. Gill1, Juan Poggio1, Andrew Raissis1, Colorectal Surgery, Cleveland Clinic Florida, Weston, FL Jeffrey M. Jacobson2, David E. Stein1 PURPOSE: Complications have been reported following 1Division of Colorectal Surgery, Drexel University College of Medicine, loop both sutured and stapled loop ileostomy closure; any Philadelphia, PA; 2Infectious Disease, Internal Medicine, Drexel association between linear cutting stapler (LCS) length and University College of Medicine, Philadelphia, PA postoperative complications remains unclear. Therefore, PURPOSE: The incidence of Anal Intraepithelial Neoplasia the aim of this study was to compare the outcomes of sta- (AIN) has risen in HIV patients, and places those patients pled loop ileostomy closure performed with different LCS at risk for the development of anal cancer. The gold stan- lengths. dard for surveillance and therapy is unclear. The aim of this METHODS: Medical records of consecutive patients who study was to determine whether physical examination with underwent stapled loop ileostomy closure from 2006 to anoscopic surveillance in HIV patients diagnosed with AIN 2012 were reviewed from an IRB-approved database. Three is effective at preventing progression to anal cancer. different LCS lengths were evaluated: 55, 75, and 100 mm. METHOD: A retrospective review of HIV positive patients Method of common enterotomy closure, LCS staple height, with AIN, treated with excision and fulguration, was con- pre-operative steroid use, index operative time and method ducted between 2006 through 2012 at our institution. Only of access (laparotomy or laparoscopy), and duration of time patients with at least one year follow up from index evalu- from the index operation to ileostomy closure were evalu- ation, documented physical examination and anoscopy ated. Outcome measures included complications, resolution fi ndings, and pathology were included for analysis. of ileus (defi ned by passage of fl atus and bowel movement with toleration of a diet) and length of hospitalization. Uni- RESULTS: Thirty six patients met inclusion criteria. The variate and multivariate analyses were performed. mean age was 41.2 yrs and mean follow up was 30.2 months (12–65 months). 15 patients (41.6%) had AIN I, 10 (27.7%) RESULTS: 350 patients (55% males) of a mean age of 46 had AIN II and 11 (30.5%) had AIN III. 26 patients (72.2%) (15–89) years were included. LCS anastomosis was per- had repeat procedures. Four patients (11.1%) progressed formed using 55 mm in 20%, 75 mm in 50%, and 100 mm from low grade to high-grade intraepithelial neoplasia (AIN in 30% of patients. The common apical enterotomy was III). One patient (2.7%) with AIN III developed invasive closed with a LCS, linear stapler (TA) or sutures. Per sur- carcinoma while under surveillance, and was successfully geons’ preference, the stapler cartridge was blue (2.5 mm treated with chemoradiation. Complications were seen in thickness) in 60% and green (3.8 mm thickness) in 40% of two patients (5.5%). patients. The overall complication rate was 24%, including postoperative ileus 17% (n = 59), wound infection 5% (n = CONCLUSION: Physical examination with routine anos- 17), and anastomotic leak 1% (n = 5). LCS length was not copy is a simple, safe and effective method for AIN surveil- associated with ileus (p = 0.49), however patients in whom lance. The progression rates to anal cancer in this cohort the 100 mm LCS was used had an average one day earlier (2.7%) were compared with those published in high-resolu- resolution of ileus: postoperative day (POD) 2 vs 3 (range tion anoscopy surveillance programs (<2%). This is a sim- 2 to 15) days, p = 0.02) and one day shorter hospitaliza- ple approach that does not require specialized equipment. tion: (POD 3 (range 2 to 33 days), p = 0.04). Incidences Randomized trials with longer follow up are required before of post-operative complications did not differ according to a standard can be set. LCS length when evaluating patients BMI (p = .81), pre- operative steroid use (p = 0.92), staple height (p = .74), or method for common enterotomy closure (p = 0.99). There were no differences between ileus resolution or length of hospitalization and operative time for either the index pro- cedure or the ilesotomy closure or index operation method of access. CONCLUSIONS: The 100-mm LCS was associated with more rapid resolution of ileus and a shorter duration of hos- Poster Abstracts pitalization than were the 55 mm or 75 mm LCSs. Tuesday

183 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1532 Emergency Department Presentation, Admission and Surgical Intervention for Colonic Diverticulitis Eric B. Schneider1, Aparajita Singh2, Shalini Selvarajah1, Jonathan E. Efron1, Anne O. Lidor1 1Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 2Gastroenterology, University of California, San Francisco, San Francisco, CA BACKGROUND: Most previous population-based studies of diverticulitis are limited to patients aged 65 years and older. Using a nationally representative sample of emer- gency department (ED) visits, we sought to describe ED pre- sentation and outcomes among patients of all ages with a primary diagnosis of diverticulitis. METHODS: In a retrospective cross-sectional study, the 2009 Nationwide Emergency Department Sample was que- ried and patients presenting with a primary diagnosis of colonic diverticulitis were isolated. Demographic variables CONCLUSION: Nearly two-thirds of patients presenting admission to inpatient status and surgical intervention for ED treatment of colonic diverticulitis were under age were compared between patients younger than 65 vs. those 65. Just over half of all ED patients were admitted to inpa- 65 or older. Standard descriptive statistical analyses were tient care, and approximately 6% of all ED visits for diver- used and multivariable logistic regression models control- ticulitis resulted in colectomy. Older women demonstrated ling for gender examined inpatient admission. Unadjusted increased odds of surgical resection compared with their logistic regression stratifi ed by gender examined surgical younger counterparts. There was no difference in the odds intervention. of resection across age groups in men. RESULTS: A total of 28,861,047 ED visits were examined, of which 67,697 (0.23%) occurred among patients with pri- Tu1533 mary colonic diverticulitis. The median age of ED patients was 57 years and female patients were older than males: Potential Factors Associated with the De Novo 61.5 vs. 53.7 years of age, respectively (p < 0.001). The Development of Crohn’s Disease of the Small Intestine majority of patients, 43,859 (64.8%) were under 65. Patient in Ulcerative Colitis Patients Undergoing Ileoanal gender distribution differed signifi cantly between the two age groups with 49.5% of patients under 65 being female Pouch 1 2 vs. 68.5% among those 65 or older (p < 0.001). Overall, Peng Du , Bo Shen 36,840 (54.4%) patients were admitted to inpatient status 1Colorectal Surgery, Cleveland Clinic, Cleveland, OH; 2Department of with older patients more likely to be admitted than those Astroenterology/Hepatology, Cleveland Clinic, Cleveland, OH under age 65 (64.7% vs. 48.8% respectively, p < 0.001). BACKGROUND: While the majority of ulcerative colitis 3,816 patients underwent colon resection, representing (UC) patients who undergo total proctocolectomy (TPC) 10.45% of admitted inpatients or 5.6% of all ED patients. with ileal pouch-anal anastomosis (IPAA) have favorable There was no difference between the proportions of outcomes, a proportion may subsequently develop Crohn’s younger and older inpatients undergoing surgical resection disease of the pouch or small intestine de novo that per- (10.5% vs. 10.2% respectively, p = 0.368). Overall, sigmoid sists even after a permanent ileostomy. The aim of the colectomy (73.4%) and left hemi-colectomy (16.7%) were study is to evaluate potential factors associated with the de the most common procedures. In multivariable analysis, novo development of CD of the small intestine proximal the odds of inpatient admission was higher among older to an ileostomy created for pouch failure in patients who patients (OR 1.90, 95% CI 1.84–1.97) and, females (OR undergo IPAA. 1.05, 95% CI 1.02–1.09). In unadjusted analysis of admitted inpatients stratifi ed by gender, older males demonstrated similar odds of surgical resection compared with younger males (OR 0.93 95% CI 0.83–1.03); however, older females demonstrated 24% increased odds of resection compared with those younger than 65 (OR 1.24 95% CI 1.13–1.36).

184 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

METHODS: UC patients who underwent TPC/IPAA and Table 1: Postoperative Outcomes Statistics: Secondary vs. Primary subsequent long-term/permanent ileostomy (secondary ileostomy) creation for a failed ileal pouch were compared to those who underwent TPC/end ileostomy (primary ileos- Secondary Primary tomy). A total of 123 eligible patients were identifi ed from All cases Ileostomy Ileostomy our Pouch Registry (primary ileostomy group, N = 57 and Variables (N = 123) Group (N = 66) Group (N = 57) P Value secondary ileostomy group, N = 66). Demographic and De novo small bowel 35 30 (45.5%) 5 (8.8%) <0.001 clinical variables were compared. Outcomes including the CD development of CD, non-CD related strictures, the require- CD-related stricture 28 23 (34.8%) 5 (8.8%) 0.001 ment of the use of CD-related medications, ileostomy- Non-CD-related 15 13 (19.7%) 2 (3.5%) 0.006 associated hospitalization, ileostomy failure with stoma stricture revision or relocation, and short-gut syndrome were com- Stoma relocation/ 19 15 (22.7%) 4 (7.0%) 0.016 pared. Step-wise logistic regression models were used. revision Postoperative steroid 9 8 (12.1%) 1 (1.8%) 0.037 RESULTS: The median follow-up for the cohort was 5 use (range: 2.0–8.0) years. Eighteen pre-stoma factors were com- Postoperative 12 11 (16.7%) 1 (1.8%) 0.005 pared between the secondary ileostomy and the primary immunomodulator use ileostomy groups. Younger age at diagnosis and surgery of Postoperative 12 10 (15.2%) 2 (3.5%) 0.030 UC, family history of IBD, extensive UC, toxic megacolon/ anti-TNF biological fulminant colitis, preoperative symptom of severe diarrhea therapy (more than 10 times per day), preoperative anti-TNF bio- Parastomal hernia 19 14 (21.2%) 5 (8.8%) 0.057 logical therapy, arthralgia/arthropathy, and staged surgery Stoma prolapse 8 6 (9.1%) 2 (3.5%) 0.284 were more common in patients who underwent secondary Small bowel 37 32 (48.5%) 5 (8.8%) <0.001 ileostomy after a failed pouch, than those in the primary obstruction ileostomy group (p < 0.05). There were no differences in Small bowel resection/ 40 32 (48.5%) 8 (14.0%) <0.001 smoking, body mass index, preoperative steroid/immu- stricturoplasty for nomodulators use, preoperative history of anemia/blood strictures transfusion, duration from UC diagnosis to colectomy, Short-gut syndrome 4 3 (4.5%) 1 (1.8%) 0.623 and indication of colectomy (refractory UC vs. neoplasia) Postoperative TPN 10 8 (12.1%) 2 (3.5%) 0.104 between the two groups (p > 0.05). Adverse outcomes in use both groups are listed in Table 1. Risk factors for de novo Ileostomy-associated 47 38 (57.6%) 9 (15.8%) <0.001 small bowel CD on logistic regression model are listed in hospitalization Table 2. Post-enterocutaneous 9 6 (9.1%) 3 (5.3%) 0.502 fi stula CONCLUSIONS: Some patients with underlying UC who develop pouch failure develop CD of the small intestine that might indicate or contribute to an ileostomy. Knowl- Table 2: Risk Factors for De Novo CD in Patients with Primary Ileostomy edge of the factors associated with development of CD after or Secondary Ileostomy: Multivariable Logistic Analysis IPAA may allow for an informed choice when evaluating patients for IPAA vs. TPC/EI. 95% Confi dence Variables N Odds Ratio Interval P Value Secondary ileostomy 30 (85.7%) 8.229 2.432–27.845 0.001 Family history of IBD 23 (65.7%) 9.144 3.133–26.688 <0.001 History of preoperative 17 (51.5%) 3.716 1.232–11.209 0.020 weight loss Age at surgery 123 0.986 0.951–1.022 0.450 Age at diagnosis of UC 123 0.974 0.937–1.012 0.178 History of preoperative 11 (31.4%) 2.806 0.768–10.260 0.119 transfusion Poster Abstracts Tuesday

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Tu1534 RESULTS: A total of 73,516 CR pts were identifi ed; the breakdown as per BMI was UN, 2,180, 3%; NO, 67,732, Morbidity and Outcomes of Colorectal Surgery in the 92%; MO, 3,604, 4.9%. In the UN group there is a signifi - Underweight Population: Results from the American cantly higher proportion of colitis/enteritis pts (UN 20.4%, College of Surgeons National Surgical Quality NO 9%, MO 5.2%) and obstruction/volvulus pts (UN 8.3%, Improvement Program (ACSNSQIP) Database NO 3.3%, MO 2.5%) as well as a much lower proportion of diverticulitis cases (UN 8.4%, NO 21.1%, MO 23.4%). The Rebecca Rhee, Hiromichi Miyagaki, Xiaohong Yan, percent of UN cancer pts (44%) was modestly but signifi - M.C. Shantha Kumara H., Linda Njoh, Vesna Cekic, cantly lower than the NO (47%) or MO (47.6%) groups yet Richard L. Whelan the UN group had more disseminated cases. More UN pts Surgery, St. Luke’s Roosevelt Hospital, New York, NY reported weight loss (21.6%) than in the NO (4.7%) or MO PURPOSE: Whereas, the impact of morbid obesity on (1.7%) groups. Also, more UN pts (13.6%) were on steroids colorectal resection (CR) outcomes has been studied, there (vs NO, 6.1%; MO, 4.5%, p < 0.05). Finally, the UN group is limited data concerning CR outcomes in the underweight had a signifi cantly lower mean albumin level and hemato- population (BMI < 18.5). This study’s goal was to assess the crit. Signifi cantly fewer UN CR’s were done using laparo- underweight population (UN) that comes to CR and CR- scopic (LAP) methods than in the other groups (UN 34%, related morbidity. NO 45%, MO 39%). There were also more total colectomies and Hartman’s procedures in UN group (p < 0.05). There METHODS: The ACS NSQIP database was queried from were signifi cantly more complications in the underweight 2005–2010 for the CR codes. Patients (pts) who, preopera- group (UN) (20.4%) than in the NO group (15.6%), yet, tively (preop), were ventilator dependent, ASA 5, hypoten- there was no difference between the UN and MO groups sive, had SIRS, sepsis, and emergent surgery were excluded. (20.1%). The UN group’s rate of transfusions, sepsis, and Pts were divided into 3 BMI groups: UN, BMI < 18.5; Nor- reoperations were higher than noted in the NO group. Of mal/Obese (NO), BMI ≥ 18.5 to ≤40; and morbidly obese note, there were signifi cantly fewer superfi cial surgical site (MO), BMI > 40. Demographic parameters were assessed as wound infections in the UN vs the other 2 groups (UN well as surgical indications, comorbidities, preop laboratory 5.6%, NO 8.1%, MO 16%). data, and complications (including surgical site infections (SSI), transfusions, reoperation, etc). The statistical meth- CONCLUSIONS: The complication rate was notably higher ods used were two sample for population proportions for in the UN group which may be related to the higher inci- categorical variables and Wilcoxon rank sum tests for con- dence of colitis and obstruction cases and the greater per- tinuous variables. centage of pts with weight loss and steroid use all of which are associated with high complication rates. Diverticulitis is rare in UN pts. For unclear reasons laparoscopic methods were used less often in the UN group.

UN vs. NO UN vs. MO UN (n = 2180) NO (n = 67732) MO (n = 3604) P Value P Value Gender Male/Female 700/ 1480 33712/ 34020 1334/ 2270 <.0001 0.00016 Age Median (range) 62 (16–90) 63 (19–90) 58 (16–90) 0.0034 <.0001 Indication Malignant Neoplasm 960 31805 1716 0.0071 0.0083 Benign Neoplasm 169 8494 497 <.0001 <.0001 Diverticular Disease 183 14283 843 <.0001 <.0001 Colitis/enteritis 444 6092 187 <.0001 <.0001 Obstruction/voluvulus 180 2208 90 <.0001 <.0001 Rectal Prolapse 68 861 10 <.0001 <.0001 Perforation/ hemorrhage 13 254 21 n.s. n.s. Other Benign Disease 163 3735 240 Comorbidities Current smoker 630 11950 569 <.0001 <.0001 Steroid intake 297 4134 161 <.0001 <.0001 Weight loss in last 6 mo 470 3206 63 <.0001 <.0001 Disseminated cancer 124 2548 93 n.s. <.0001 Preoperative data Hematocrit (Mean ± SD) 35.8 ± 5.3 38.3 ± 5.4 38.1 ± 5.3 <.0001 n.s. Albumin (Mean ± SD) 3.5 ± 0.8 3.8 ± 0.6 3.7 ± 0.6 <.0001 <.0001 UN; underweight group (BMI <18.5), NO; Normal/Obese (BMI 18.5 to 40), MO; morbidly obese (BMI > 40), n.s.; not signifi cant

186 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

UN vs. NO UN vs. MO UN (n = 2180) NO (n = 67732) MO (n = 3604) P value P value Surgical Procedure

Laparoscopic Surgery 742 30682 1409 <0.0001 <0.0001 Abdominoperinial Resection 2 118 7 n.s. n.s. Coloproctectomy 231 5891 242 0.0020 <0.0001 Hartmann Procedure 95 1877 106 <0.0001 0.0044 Partial colectomy 1197 44214 2472 n.s. n.s. Partial colectomy with removal 436 11217 595 <0.0001 0.0008 of terminal ileum Total colectomy 219 4415 182 <0.0001 <0.0001 Complications Major complication 445 10539 723 <.0001 n.s. Re-operation 156 3521 227 <.0001 n.s. Superfi cial SSI 121 5464 578 <.0001 <.0001 Bleeding/Transfusions 81 1545 95 <.0001 0.0203 Sepsis 116 2639 195 0.0008 n.s. Septic Shock 45 1026 81 0.0394 n.s. UN; underweight group (BMI <18.5), NO; Normal/Obese (BMI 18.5 to 40), MO; morbidly obese (BMI > 40), n.s.; not signifi cant, SSI; surgical site infections

Clinical: Esophageal

 Tu1535 Endoscopic Ultrasound Staging of Stenotic Esophageal Cancers May Be Unnecessary to Determine the Need for Neoadjuvant Therapy Stephanie G. Worrell, Daniel S. OH, Christina L. Greene, Steven R. Demeester, Jeffrey A. Hagen Keck School of Medicine of Univeristy of Southern California, Los Angeles, CA INTRODUCTION: Endoscopic ultrasound (EUS) is an essential component of pre-operative staging for esopha- geal cancer. EUS is used to determine which patients should have primary endoscopic or surgical therapy and which should have neoadjuvant therapy prior to resection. How- ever, when the EUS endoscope cannot traverse a tumor, the role of pre-dilatation is controversial. Esophageal dilation of malignant strictures is associated with potential complica- RESULTS: A total of 27 patients (22 male: 5 female) had tions including perforation in 15% of cases. The aim of this a tumor that would not accommodate the EUS endoscope study was to determine the pathologic stage of esophageal and proceeded directly to esophagectomy without induc- cancer treated by primary surgery without induction ther- tion therapy. The histology was adenocarcinoma in all apy when the EUS endoscope could not pass. We hypoth- patients. The stages of the patients are shown [Table]. The esized that when the EUS endoscope cannot traverse the majority of tumors were T3 (24/27, 89%) and the median tumor, locally advanced disease (stage III) is present, and number of metastatic nodes was 6. There were no stage I these patients should proceed to neoadjuvant therapy with- tumors, 15% (4/27) were stage II, 81% (22/27) were stage out the need for pre-dilatation and EUS staging. III, and 4% (1/27) were stage IV due to a resected solitary lung metastasis. METHODS: A retrospective single-institution review was Poster Abstracts conducted of all patients with esophageal cancer under- CONCLUSION: Tumors that cannot be assessed with an going esophagectomy from August 1988 to June 2012. EUS endoscope due to tumor stenosis will have locally Tuesday Patients who received neoadjuvant therapy were excluded. advanced disease that could benefi t from neoadjuvant ther- The EUS reports were reviewed to determine which patients apy in 85% of cases. In these situations, pre-dilatation of had a tumor that could not accommodate an EUS endo- the tumor with EUS staging could be omitted when consid- scope, and the patients who then proceeded directly to ering the risk of potential complications, such as esopha- esophagectomy were included for analysis. The pathology geal perforation. results of these patients were classifi ed based on the revised 7th edition AJCC staging system.

187 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1536 Jackhammer Esophagus in High Resolution Manometry: Clinical Features and Surgical Implications Michal J. Lada, Dylan R. Nieman, Michelle S. Han, Poochong Timratana, Christian G. Peyre, Carolyn E. Jones, Thomas J. Watson, Jeffrey H. Peters University of Rochester Medical Center, Rochester, NY INTRODUCTION: The clinical signifi cance of Jackham- mer Esophagus, an uncommon esophageal motility disor- der characterized by repetitive high amplitude esophageal CONCLUSIONS: Jackhammer esophagus is an uncommon contractions, is unclear. It has been increasingly identifi ed motility disorder diagnosed in 3.5% of patients with esopha- since the introduction of High Resolution Manometry. This geal symptoms. Affl icted patients are predominantly female study assessed the clinical features and surgical implica- and present with chest pain, likely owing to the intensity tions of a diagnosis of Jackhammer Esophagus (JE) via High of the esophageal contractions. Patients with isolated JE are Resolution Manometry (HRM). managed medically with a constellation of agents including METHODS: The clinical records and HRM data of 1216 CCBs and nitrates. For patients with JE and concomitant consecutive patients undergoing HRM between 12/2009 refl ux or hiatal hernia, Nissen Fundoplication is an effective and 9/2012 were reviewed. Patients with previous foregut treatment regardless of the motility fi ndings. surgery, classic achalasia and distal esophageal spasm were excluded. Jackhammer esophagus was defi ned according Tu1537 to the most recent Chicago Classifi cation as ≥1 swallow with distal contractile integral (DCI) > 8000 mmHg*cm*s. Is Gastric Decompression Necessary for Patient HRM variables were compared with 35 normal volunteers Receiving Esophagectomy and Gastric Transposition? via Mann-Whitney U-Test for non-parametric univariate Yang Hu analysis. Department of Thoracic Surgery, West China Hospital, Sichuan RESULTS: Forty-two patients (3.5%) met HRM criteria for University, Chengdu, China  JE, 71% were female with a mean age 59.0 11.8 years. The BACKGROUND: Gastric decompression (GD) after esoph- most common presenting symptoms were chest pain (30%), agectomy and gastric transposition could drainage the gas- heartburn (14%) and dysphagia (14%). Other less common tric juice and air retented in intrathoracic stomach, thus symptoms included regurgitation, abdominal pain, nausea, could prevent the dilation of the stomach, reduce anasto- cough and shortness of breath. Compared with 35 healthy motic tension and extenuate gastroesophageal regurgita- volunteers, patients with JE not only had signifi cantly ele- tion (GER). Theoretically, this could benefi t the healing vated DCI, but also higher mean lower esophageal sphincter of anastomosis. So GD is routinely used in patients with resting pressure, intrabolus pressure and integrated relax- esophageal cancer after operation. But is GD really neces- ation pressure (IRP), (Table). The median number of indi- sary? The dilation of intrathoracic stomach could be pre- vidual swallows with DCI > 8000 mmHg*cm*s per patient vented by gastric tube and a new measure named stomach was 3.5 (IQR 2.0–6.0). Overall, the IRP was normal in 23 embedment. Moreover, the postoperative volume of gas- (55%) and elevated in 19 (45%). An elevated IRP and/or tric decompression is usually less than 300 ml/d, however positive pH study, suggestive of JE being a secondary motil- the volumn of gastric juice production is about 2L/d. We ity disorder, was present in 27 of 42 patients. Hiatal Hernia thought this trivial 300 ml fl uid might won’t cause severe (HH), identifi ed endoscopically, was present in 18 patients GER even it hadn’t been drainaged. So GD might be no lon- (43%). Abnormal esophageal acid exposure was found in 12 ger essential for surgical patients with esophageal cancer. patients of whom 4 had elevated IRP (range 18.2–19.8). Of The aim of this study is to confi rm this presumption. the 33 patients treated medically, 30 were trialed on com- binations of calcium channel blockers (CCB), nitrates or METHODS: Totally 147 patient were enrolled in this proton-pump inhibitors (PPI) and 3 received Botox. Eight study. All patient received esophagectomy and gastric tube patients underwent Nissen Fundoplication ± hiatal hernia reconstruction. After anastomosis, intrathoracic stomach repair and 1 patient underwent a distal myotomy. Com- was embedded into posterior mediastinum with a medical plete resolution of chest pain or heartburn was encountered sealant glue. This glue could fi x stomach with the organ in all post-surgical patients, with a median follow-up of 20 surround it and therefore can prevent the dilation of the days (range 14–364). stomach. Patient were randomly divided into GD group and non-gastric decompression group (NGD). Nasogastric tube was inserted in operation for patient in GD group, and removed 4 days after operation. However 4 patients in GD group failed to insert nasogastric tube then be reassigned to NGD group. Finally we got 72 patient in GD group and 75 patient in NGD group.

188 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Indices compared between groups include Overall experi- ing surgical incision was performed, the OES in NGD group ence score (OES, with a 1–10 score system on the 3rd day was signifi cant better than that in GD group (p < 0.05). after operation), maximum transverse diameter of intratho- This outcome indicate that GD couldn’t extenuate GER, racic stomach (MTD, with CT, at the level of inferior pul- prevent the dilation of the stomach, reduce complication monary vein on the 3rd day after operation), severity of GER rate, shorten hospital stay. On the contrary, it diminish the (with a GER symptom questionnaire on the 3rd day after short-term postoperative life quality. operation), the need for insert/reinsert nasogastric tube CONCLUSIONS: GD is no longer necessary for patient after operation, the application of stomach dynamic medi- receiving esophagectomy and gastric transposition after the cine, pneumonia, anastomostic leakage and postoperative application of gastric tube and stomach embedment. We hospital stay. don’t need to consider GD as a routine for patient who is RESULTS: No difference was found between groups in any not in high risk of anstomostic leakage. index except for the OES. When stratifi ed analysis accord-

Indices Between Groups

GD Group NGD Group p Value Age 62.2 ± 7.5 64.7 ± 5.9 0.782 Gender (M/F) 66/6 68/7 0.831 Tumor Location (medien/lower) 47/25 52/23 0.725 TNM Staging 3/7/27/35 2/9/31/33 0.859 (0/I/II/III) Overall Experience Score Sweet procedure group n = 43 6.2 ± 2.6 n = 41 7.5 ± 2.4 <0.001 Ivor-Lewis procedure group n = 29 6.1 ± 3.1 n = 34 7.2 ± 3.5 0.001 Maximum Transverse Diameter of Intrathoracic Stomach (cm) Sweet procedure group n = 43 7.5 ± 2.1 n = 41 7.7 ± 1.8 0.135 Ivor-Lewis procedure group n = 29 8.1 ± 2.5 n = 34 8.2 ± 2.1 0.398 Severity of Gastroesophageal Refl ux (0/1/2) Sweet procedure group n = 43 40/3/0 n = 41 38/3/0 1.000 Ivor-Lewis procedure group n = 29 26/3/0 n = 34 30 /4/0 1.000 Need for Insert/Reinsert Nasogastric Tube (n) Sweet procedure group n = 43 1 n = 41 0 1.000 Ivor-Lewis procedure group n = 29 2 n = 34 1 0.590 Application of Stomach Dynamic Medicine (n) Sweet procedure group n = 43 5 n = 41 6 0.754 Ivor-Lewis procedure group n = 29 5 n = 34 5 1.000 Pneumonia (n) Sweet procedure group n = 43 1 n = 41 1 1.000 Ivor-Lewis procedure group n = 29 0 n = 34 1 1.000 Anastomostic Leakage (n) Sweet procedure group n = 43 0 n = 41 0 — Ivor-Lewis procedure group n = 29 0 n = 34 0 — Postoperative Hospital Stay (d) Sweet procedure group n = 43 10.3 ± 1.8 n = 41 10.5 ± 2.3 0.691 Ivor-Lewis procedure group n = 29 11.0 ± 2.7 n = 34 11.4 ± 2.1 0.295 Poster Abstracts Tuesday

189 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1538 Toward Improved Staging of Esophageal Adenocarcinoma in the Era of Neoadjuvant Chemotherapy: Lymph Node Harvest and Lymph Node Positivity Ratio Provide Better Survival Models Dylan R. Nieman, Michal J. Lada, Michelle S. Han, Poochong Timratana, Christian G. Peyre, Carolyn E. Jones, Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester, Rochester, NY INTRODUCTION: As pre-operative chemoradiation fol- lowed by esophagectomy has become standard therapy in patients with resectable esophageal adenocarcinoma (EAC), traditional pathological staging has become a less use- ful prognostic tool. The 7th edition of the American Joint Commission on Cancer (AJCC7) staging system for EAC is derived from data on patients undergoing esophagectomy without neoadjuvant therapy and classifi es lymph node status by the number of involved lymph nodes. Lymph node harvest (LNH) and lymph node positivity ratio (LNPR) have been suggested to be prognostic indicators but have not found widespread support. In an effort to develop a valid staging model in the era of neoadjuvant therapy, we compared the predictive value of LNH and LNPR to AJCC7 staging in a large cohort of patients undergoing resection CONCLUSION: For patients receiving neoadjuvant ther- for EAC. apy, both LNH and LNPR are more predictive of survival METHODS: The study population consisted of 316 patients than the number of lymph node metastases detected in who underwent R0 esophagectomy for EAC from 1/00 to esophagectomy specimens. A minimum LNH of 15 is nec- 12/11 (86% male; mean age 64.0 ± 10.3 years). Survival essary to establish reliable N0 staging in this cohort. functions were estimated using the Kaplan-Meier method. Classifi cation thresholds for both LNPR and LNH were Tu1539 derived by recursive partitioning using conditional infer- ence trees comparing survival functions. Based on these What Is the Optimal Time to Measure Lower analyses, LNPR was stratifi ed and Cox proportional hazards Esophageal Sphincter Parameters in High Resolution regression models were used to compare predictive value of Impedance Manometry? lymph node categorization strata. Michelle S. Han, Dylan R. Nieman, Michal J. Lada, RESULTS: Median lymph node harvest was 12 (IQR 7–20). Poochong Timratana, Christian G. Peyre, Carolyn E. Jones, 51% of patients were N0, 29% N1, 13% N2. Median overall Thomas J. Watson, Jeffrey H. Peters survival was 63.4 months (95% CI 40.6–92.3) and 5-year Surgery, University of Rochester Medical Center, Rochester, NY overall survival was 50.7% (95% CI 45.0–57.2). Eighty-three INTRODUCTION: Resting parameters of the lower esoph- patients (26%) received neoadjuvant chemotherapy, radia- ageal sphincter are customarily measured in a “landmark” tion therapy or both. In patients who received neoadju- frame at the onset of a high resolution impedance motil- vant therapy and had no lymph node metastasis identifi ed ity (HRIM) study. We hypothesized that measurement at (40/83; 48%), recursive partitioning analysis yielded a LNH the completion of the study may give more representative threshold of 15 for discrimination of survival functions. values. We assessed the utility of a dual-landmark frame LNH ≥ 15 was associated with a signifi cant survival advan- approach in HRIM interpretation and its effect on patient tage (3-year survival 95 vs. 38%; p = 0.000022). Similarly, diagnostic classifi cation. recursive partitioning analysis yielded LNPR categories of less than 20%, 20–40%, or greater than 40% as signifi cantly METHODS: 50 consecutive HRIM studies were analyzed discriminant of survival functions. In patients who received independently by 4 experienced esophageal fellows. The neoadjuvant therapy, LNPR was more predictive of survival overall and intra-abdominal length of the lower esopha- than number of positive lymph nodes as categorized by geal sphincter (LES), mean LES resting pressure (LESP), inte- AJCC7 (p = 0.00018 vs. 0.033). In the 256 patients who grated relaxation pressure (IRP), intra-bolus pressure (IBP), received no neoadjuvant therapy, LNH was not a signifi cant mean upper esophageal sphincter pressure (UESP), and Chi- predictor of survival after node negative resection, although cago Classifi cation diagnoses were recorded for each HRIM LNPR was a stronger predictor of survival than the current reading. Each of these parameters was measured using the nodal staging system (p-value 0.000015 vs. 0.05). conventional method of a landmark frame at the onset of

190 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

the study and again using a similar 30-second frame at the Tu1540 end of the 10-swallow study. Previous data have shown excellent intra-class correlation coeffi cients among these 4 Prognostic Factors After Esophagectomy for Squamous readers for HRIM parameters, EGJ diagnosis and esophageal Cell Carcinoma of the Esophagus: Does Tumor Location body diagnosis. Wilcoxon signed-rank test was used to ana- Matter? lyze the concordance of the measurements based on the Tsz Ting Law1, Kwan Kit Chan1, Daniel Tong1, Fion S. Chan1, early or late landmark frames. Wai Ho Wong1, Lai Wan Dora Kwong2, Simon Law1 RESULTS: There were no differences in LES overall length, 1Surgery, University of Hong Kong, Hong Kong, Hong Kong; 2Clinical intra-abdominal length, IBP or IRP comparing early vs. late Oncology, University of Hong Kong, Hong Kong, Hong Kong landmark measurement. Both lower and upper esophageal sphincter resting pressure were signifi cantly lower when OBJECTIVE: To compare the clinicopathological features measured at the end of the study (Table). These fi ndings and prognostic factors of supracarinal esophageal cancer resulted in re-classifi cation of LESP in 12% of studies, 3 each versus infracarinal tumors. from hypertensive LES to normal and normal to hypoten- BACKGROUND: Supracarinal tumor location is presumed sive. In 8% (n = 4), IRP measurement changed from normal to have worse prognosis because of unfavorable anatomy (<14.7 mmHg) to abnormal, refl ecting functional outfl ow for surgical resection, and more diffi culty in achieving neg- obstruction. Manometric evidence of a hiatal hernia that ative lateral as well as proximal margins. With increasing was present in an early landmark frame was not seen in the use of neoadjuvant therapies however, the impact of tumor late landmark frame in 14%. location may be lessened and this has not been adequately studied. High Resolution Impedance Manometry Diagnostic Variables, Dual-Landmark Frame Approach METHODS: From January 1990 to December 2011, 1130 patients with esophageal cancer underwent resection, 668 Difference (59.1%) of whom with intrathoracic squamous cell carci- Diagnostic Variable (Mean) 95% CI P-value* nomas were analyzed. Eighty-fi ve (12.7%) patients had LES length (cm) –0.03 (–0.23–0.18) 0.8205 supracarinal tumor (group A). Clinico-pathological features Intra–abdominal LES length (cm) 0.03 (–0.34–0.39) 0.2238 were compared with those located more distally (group B). LESP (mmHg) –3.86 (–5.93––1.79) 0.0006* Multivariate analyses were performed to identify prognos- IBP (mmHg) 0.07 (–1.2–1.36) 0.2745 tic factors. IRP (mmHg) 0.01 (–0.93–0.95) 0.3616 RESULTS: More patients in group A received neoadjuvant UESP (mmHg) –17.2 (–26.0––8.50) <0.0001* chemotherapy or chemoradiotherapy (CRT) (50.6% vs. LES: Lower Esophageal Sphincter; LESP: Mean LES Resting Pressure; 36.4%, p = 0.012). Operation took longer (300 mins vs. 275 IBP: Intra-bolus Pressure; IRP: Integrated Relaxation Pressure; mins, p = 0.006), and postoperative vocal cord palsies were UESP: Mean Upper Esophageal Sphincter Pressure; more frequent (24.7% vs. 8.4%, p < 0.01). Other compli- Mean: The average differences between the late and early landmark frame cations did not differ and in-hospital mortality rates were measurements; CI: Confi dence Interval; 3.5% and 3.3% respectively, p = 0.896. R0 resection was *Wilcoxon signed-rank test P-value <0.05 achieved in 69.4% and 72% respectively, p = 0.615. Median survival was 15.6 and 20.5 months respectively, p = 0.973. CONCLUSIONS: A decrease in both upper and lower esoph- Multivariate analysis showed that R1/2 resection (R1/2 vs. ageal sphincter resting pressure with time is observed dur- R0, HR = 2.43, 95% CI = 1.94–3.04), male gender (male ing the routine course of HRM studies. This decrease affects vs. female, HR = 1.45, 95% CI = 1.14–1.85) and higher (y) classifi cation of sphincter parameters in a meaningful sub- pTNM stage (stage III/IV vs. 0/I/II/T0N1, HR = 1.61, 95% CI set of patients. A dual-landmark frame approach should be = 1.17–2.21) were unfavorable prognostic factors; but not considered when routinely analyzing HRIM studies. tumor location. When only group A patients were analyzed, R1/2 resection (R1/2 vs. R0, HR = 3.73, CI = 1.86–7.46) and the absence of neoadjuvant chemotherapy or chemoradio- therapy (no CRT vs. CRT, HR = 2.2, CI = 1.20–4.05) were poor prognostic factors. CONCLUSIONS: In the modern era of effective neoad- juvant therapies, survival of patients with supracarinal tumors is not inferior. Surgery however is more complicated and more vocal cord palsies result. The use of neoadjuvant therapies is a favorable prognostic factor for such cancers. Poster Abstracts Tuesday

191 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1542 PATIENTS AND METHODS: The records of all patients who underwent a thoracic endovascular aortic repair Long Follow-Up in Patients with Barrett’s Esophagus between 2004 and 2012 were reviewed. Patients readmitted Submitted to Fundoplication: What Is the Importance to the hospital for aortoesophageal fi stula were identifi ed. of the Endoscopic Surveillance? The data about demographics, symptoms, clinical manage- Sergio Szachnowicz, Francisco C. Seguro, Rubens A. Sallum, ment, surgical or endoscopic therapy and follow-up were Angela FalcãO, Julio R. Rocha, Ary Nasi, Ivan Cecconello reported. Department of Gastroenterology, Esophageal Surgical Division – University of São Paulo Medical School – Brazil, São Paulo, Brazil BACKGROUND: Barrett’s esophagus is associated to esoph- ageal adenocarcinoma. Endoscopic surveillance of patients treated surgically or clinically allows early detection of can- cer. Some authors concluded that surveillance is not cost- effective and does not reduce mortality from cancer. AIM: We analyze effi cacy of endoscopic surveillance in patients with Barrett’s esophagus submitted to fundoplication. METHODS: from January 1980 to November 2012, 221 patients with Barrett’s esophagus were submitted to fun- doplication to control refl ux. Of those, 196 were followed (mean 82 months) . All patients in our service had rou- tine endoscopic examination each 2 years with multiple biopsies. RESULTS: Ten patients (8.9%) showed Barrett’s endoscopic regression. Three patients (2.6%) were diagnosed with esophageal adenocarcinoma in this series. Two underwent prolonged pH monitoring that showed no acid refl ux. They were asymptomatic and had diagnostic of early adenocar- RESULTS: Of the 268 patients who underwent a thoracic cinoma during routine endoscopy 2 (2) and 6 years after endovascular aortic repair, nine patients (3,4%), in a median fundoplication. All underwent transhiatal esophagectomy age of 64 years (IQR 49–77), developed an aortoesophageal and are alive (12 to 56 months). fi stula after a median time of 2.4 month (IQR 1–16). The clinical symptom was sudden massive hematemesis in four CONCLUSION: Besides the related low cost-effectiveness patients, fever and elevated makers of infl ammation in five of endoscopy surveillance, cancer was detected during fol- patients and abdominal pain in one patient. Aortoesopha- low up of Barrett’s patients submitted to a successful antire- geal fi stula was identifi ed by esophago-gastro-duodenos- fl ux procedure allowing early diagnosis and cure. copy. Of the nine patients, two patients (22%) underwent an esophagectomy with gastric pull-up, one patient an Tu1544 esophagectomy with a delayed colon interposition and the remaining six patients underwent an endoscopic implanta- Aortoesophageal Fistula After Thoracic Endovascular tion of a self-expanding esophageal stents. The two patients Aortic Repair after esophagectomy and gastric pull-up are alive with a Renate Reinhardt1, Wolfgang Niebel1, Gernot M. Kaiser1, median survival of six and 12 month. The remaining seven Alexander Dechene2, Andreas Paul1, Arzu Oezcelik1 patients all died due to fatal re-bleeding or mediastinitis in 1Surgery, University of Essen, Essen, Germany; 2Gastroenterology and a median time of 12 month after the diagnosis of aorto- Hepatology, University of Essen, Essen, Germany esophageal fi stula. INTRODUCTION: The aortoesophageal fi stula is a rare but CONCLUSION: Aortoesophageal fi stula is a fatal complica- devastating complication after thoracic endovascular aortic tion after thoracic endovascular aortic repair. Early diagno- repair. There are no clear data in the literature about the sis is essential for the survival of the patients. In our patient optimal therapy of this complication. The aim of this study population was the surgical therapy associated with a better was to report the characteristics, therapy and outcomes of outcome. our patients with aortoesophageal fi stula after endovascular aortic repair.

192 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1545 Tu1546 An Analysis of Predictive Factors and Clinical Sarcopenia: Signifi cant Independent Risk Factor for Outcomes of Pleural Tears During Laparoscopic Poor Survival Following Esophageal Resection Esophageal Surgery Aaron S. Rickles2, James C. Iannuzzi2, Dylan R. Nieman1, Ezra N. Teitelbaum1, Thomas K. Varghese2, Eric S. Hungness1, Michal J. Lada1, Kristin N. Kelly2, Fergal Fleming2, Nathaniel J. Soper1 Jeffrey H. Peters1, John R. Monson2 1Northwestern University, Chicago, IL; 2University of Washington, 1Surgery, University of Rochester, Rochester, NY; 2Department of Seattle, WA Surgery, Surgical Health Outcomes & Research Enterprise, University BACKGROUND: Laparoscopic operations on the esopha- of Rochester, Rochester, NY gus, including paraesophageal hernia (PEH) repair, fundo- PURPOSE: Sarcopenia has been linked to poor survival plication for gastroesophageal refl ux, and myotomy for in several types of cancer including breast, pancreatic, and achalasia, involve dissecting and opening of the diaph- colorectal. This study examines the effect of sarcopenia on gramatic crura and mobilizing the mediastinal esophagus. survival outcomes after esophagectomy for cancer. During these maneuvers, tears in the mediastinal pleura can METHODS: A retrospective chart review was performed occur, resulting in capnothorax, and, potentially, hemody- on patients who underwent esophageal resection between namic or respiratory instability. The incidence of intraop- erative pleural tears, their clinical signifi cance, and factors 2005–2012. Pre-operative CT imaging was used to measure predictive of occurrence have not been studied. total body fat, abdominal fat, and muscle mass. Muscle mass area at the level of the third lumbar vertebrae (psoas, METHODS: A single-surgeon prospective database of lapa- erector spinae, and abdominal muscles) was normalized for roscopic operations on the esophagus was analyzed. Dur- patient height and sarcopenia was defi ned by sex-specifi c ing each operation, the presence of any recognized pleural values as previously described (38.5 cm2/m2 for females, tear was recorded, as were any hemodynamic or respiratory and 52.4 cm2/m2 for males). Data was collected on patient, changes that occurred as a result. These data, along with the tumor, and treatment characteristics. Kaplan-Meier survival primary operator (resident, fellow, or attending), procedure curves and Cox Proportional Hazards were used to analyze duration, need for adhesiolysis, EBL, other complications, the primary endpoint of overall survival over 5 years. and length of stay were all recorded prospectively. RESULTS: Out of 271 esophageal resections, 131 cases had RESULTS: 382 laparoscopic operations were performed: CT scans available for analysis, of which 53 patients died 64 PEH repairs, 199 Nissen fundoplications, and 119 Heller over a median follow-up of 22 months. 32.1% (n = 42) of myotomies. 57 (15%) cases were re-do procedures. Pleural patients met criteria for sarcopenia and on average sarcope- tears occurred in 44 (12%) cases, of which 13 (30% of pleu- nic patients were older (67 yo. vs. 61 yo., p = 0.002), had ral tears, 3% of all cases) resulted in a transient increase less total fat (4168 cm3 vs. 4963 cm3, p = 0.033) and less in peak airway pressures, decrease in oxygen saturation, or 3 3 decrease in blood pressure. All 13 cases of hemodynamic abdominal fat (1524 cm vs. 1876 cm , p = 0.043), however and/or respiratory instability were resolved successfully there was no statistically signifi cant difference in waist cir- by decreasing the abdominal insuffl ation pressure to <10 cumference or body mass index between the two groups. mmHg. In no case was intra or postoperative tube thoracos- There was also no difference between sarcopenic and non- tomy insertion required. Comparing cases with or without sarcopenic groups based on gender, smoking status, comor- a pleural tear, there were no differences in rates of other bidities, presentation, tumor stage, resection margin status, complications (5 vs. 12%; p = ns) or length of stay (mean number of locoregional lymph node metastases, leak rates, 1.4 vs. 1.3 days). The incidence of pleural tears was sig- length of hospital stay, and use of neoadjuvant or adjuvant nifi cantly different for each procedure: PEH repair (36%), therapy. On Kaplan-Meier analysis sarcopenic patients had Nissen (11%) and Heller (3%) (p < .05 for each paired com- signifi cantly worse overall survival compared to patients parison). Re-do and primary operations had a similar inci- with normal muscle mass (log rank = 0.012, Figure 1). 5-year dence of pleural tears (12% vs. 11%; p = ns). The level of overall survival was 62% for patients with normal muscle training of the primary operator did not affect the pleural mass and 33% for patients with sarcopenia. After adjusting tear rate (resident: 8%, fellow: 14%, attending: 12%, p = for differences in patient age and body fat composition in ns). When patient demographics were compared between cox-proportional survival analysis, patients with sarcopenia cases with and without pleural tears there were no differ- had twice the risk of death over fi ve years as compared to ences in gender distribution, age, or BMI. Cases with and patients with normal muscle mass [HR = 2.00; 95% CI = those without pleural tears did not differ in terms of length, (1.13,3.56), p = 0.018]. EBL, or need for adhesiolysis. CONCLUSION: Sarcopenia predicts worse overall survival Poster Abstracts CONCLUSIONS: In this series of laparoscopic esophageal after esophagectomy for cancer. While sarcopenia itself operations, pleural tears occurred in 12% of cases. Nearly offers substantial prognostic value, these fi ndings under- Tuesday a third of pleural tears caused transient hemodynamic or score the importance of optimizing patient nutrition and respiratory changes, but in all cases these were success- exercise status as part of the comprehensive cancer care to fully managed by decreasing insuffl ation pressure without improve survival in this vulnerable population. need for tube thoracostomy. Pleural tears occurred more frequently during PEH repair, but there do not appear to be other demographic or operative predictors of increased occurrence.

193 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

METHODS: Using the Surveillance Epidemiology and End Results (SEER) database, we identifi ed all patients diagnosed with EAC/GEJAC during the years 2000–2009. Patients were stratifi ed by age: <40 years, 40–60 years, or >60 years. Patients <40 years were then compared to those >60 years, and survival outcomes were assessed by the Kaplan-Meier method and Cox-regression. RESULTS: Of 15, 816 patients with EAC/GEJAC diagnosed during the study period, 67.3% (n = 10,641) were >60 years, and 1.7% (n = 269) were <40 years old. The inci- dence rates in both cohorts did not change over the study period. When compared to the older cohort, patients <40 years were more likely to be male (p < 0.0001), present with AJCC stage III/IV disease, p < 0.0001), and receive both radiation and surgery for curative intent (29 vs. 13.6%, p < 0.001). Patients <40 years had signifi cantly better median overall survival (OS) and median disease-specifi c survival (DSS): 15 vs. 10 months and 14 vs. 12 months, respectively; p < 0.0001. Stratifying by AJCC stage, younger patients had superior DSS regardless of stage: stage I: Not reached (NR) vs. 55 months, p < 0.0001; stage II: NR vs. 25 months, Figure 1: Kaplan-Meier analysis of overall survival for sarcopenic (red) p < 0.001, stage III: 19 vs. 15 months, p < 0.0001; stage IV: 10 vs. 6 months, p < 0.0001. When stratifying by therapy and non-sarcopenic (blue) patients following esophageal resection for delivered, younger patients had superior DSS in the surgery cancer (Log Rank Test = 0.012). only cohort (NR vs. 59 months, p = 0.003) and similar sur- vival in the surgery + radiation and radiation alone cohorts. Cox regression confi rmed age <40 is an independent pre- Tu1547 dictor of both improved OS (p < 0.0001) and improved DSS Esophageal and Gastroesophageal Adenocarcinoma (p = 0.0007). in Young Patients: A Call for a Continued Aggressive CONCLUSIONS: Based on analysis of the SEER registry, Approach to Both Diagnosis and Treatment while EAC/GEJAC remains a rare entity in patients <40 Katherine E. Campbell1, Bin Huang2, Jing Guo2, years of age, these patients can be expected to have supe- rior outcomes as compared to older cohorts, especially with Timothy W. Mullett3, Jeremiah T. Martin3, B. Mark Evers4, 5 early diagnosis. An aggressive approach to both early diag- Shaun P. Mckenzie nosis and treatment of this disease should continue regard- 1 Surgery-General Surgery, University of Kentucky, Lexington, KY; less of age 2Biostatistics, University of Kentucky, Lexington, KY; 3Surgery – Cardiothoracic Surgery, University of Kentucky, Lexington, KY; 4Markey Cancer Center, University of Kentucky, Lexington, KY; 5Surgery – Surgical Oncoloty, University of Kentucky, Lexington, KY BACKGROUND: The development of esophageal or gas- troesophageal junction adenocarcinoma (EAC/GEJAC) in patients less than 40 years of age is thought to be associated with a more aggressive tumor biology and a worse outcome compared to patients over 40 years. Our objective was to determine the impact of younger age on survival of EAC/ GEJAC utilizing a nationwide patient registry.

5-Year Overall and Disease-Specifi c Survival for EAC/GEJAC by Age and AJCC Stage

AJCC Stage All Stages Stage l Stage II Stage III Stage IV Median 5-Year Median 5-Year Median 5-Year Median 5-Year (Months) Survival (Months) Survival (Months) Survival (months) Survival p Value Overall Survival <40 years 15 0.22 NR 0.83 NR 0.54 16 0.06 8 0.06 >60 years 10 0.15 31 0.36 21 0.24 14 0.12 6 0.02 <0.0001 Disease-specifi c Survival <40 years 14 0.24 NR 0.65 NR 0.52 19 0.00 10 0.05 >60 years 12 0.20 57 0.48 25 0.30 15 0.15 6 0.02 <0.0001 NR = Not reached

194 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1548 Tu1549 Ligation of Ileocolic Artery Improves the Vascularity Combined Surgical/Endoscopic (Hybrid) Management of Future Ileocolonic Conduit for Corrosive Injury of Acute Esophageal Perforation: A New Technique of Esophagus Intra-Operative Stabilization of Endoscopically Placed Pradeep Rebala1, Yoganand Dadge1, Subramanyeshwar T. Rao1, Stents G.V. Rao1, Jagdish Rampal3, Piyal Nag3, Duvvuru N. Reddy2 Artur M. Bodnar1, Andrew S. Ross2, Shayan Irani2, S. Ian Gan2, 1Surgical Gastroenterology, Asian Institute of Gastroenterology, Donald E. Low1 Hyderabad, India; 2Medical Gastroenterology, Asian Institute of 1Department of Thoracic Surgery, Virginia Mason Medical Center, Gastroenterology, Hyderabad, India; 3Department of GI Radiology, Seattle, WA; 2Department of Gastroenterology, Virginia Mason Asian Institute of Gastroenterology, Hyderabad, India Medical Center, Seattle, WA BACKGROUND: Between June 2005 and January 2010, 47 BACKGROUND: Endoscopic techniques, particularly patients underwent ileocolonic pullup for corrosive esoph- stents, are increasingly utilized for acute management of ageal injury with one death. Of these 46 patients surviving esophageal perforation. However, migration remains a prob- 9 (19.5%) had anastomotic leak and 22 (47.8%) developed lem and extensive chest or abdominal contamination and anastomotic stricture. The cause of these strictures and placement of enteric drainage or feeding tubes often neces- leak was attributed to ischaemia . Hence we hypothesized sitates open or minimally invasive surgical procedures. This that ligation of ileocolic artery (ICA) improves collateral report describes a method of surgical stent stabilization to blood supply to the future ileocolonic conduit and in turn simplify recovery by decreasing stent migration rates. decreases the anastomotic leak and stricture rate. METHODS: All patients presenting with esophageal perfo- METHODS: A prospective comparative study was con- ration between 1991 and 2012 were prospectively entered ducted between January 2010 to June 2012. All patients into an IRB-approved database. A total of 101 patients were with acute corrosive injuries (grade II and III) who were treated for esophageal perforation during the study period. potential candidates for esophageal replacement surgery Five patients had combined surgical and endoscopic and willing to undergo ICA ligation at the time of FJ were (hybrid) treatment including placement of transesophageal included in Group A. During the above period, patients or transgastric suture for intra-operative stent stabilization. who did not undergo ICA ligation and underwent ileoco- RESULTS: The study group comprised 5 patients who lonic interposition were taken as control group (Group B). were referred to our institution between December 2005 All patients in group A, multislice CECT angiogram was and June 2012, mean age 52.6 (range 32–75). Two had iat- done before ICA ligation, 7 days following ICA ligation rogenic (1 dilation, 1 post Nissen) and 3 had Boerhaave’s and before ileocolonic interposition to document objective perforations. Four patients presented at >24 hours and improvement in collateral circulation. endoscopic examination documented perforations in the All patients underwent ileocolonic pull up via retrosternal distal esophagus 3, and EG junction 2. Four patients had route after a minimum period of six months following cor- abdominal approaches, 1 had a right thoracotomy. Three rosive ingestion. Oral contrast study was done on postop- patients had primary repairs and all had drainage as well erative day 10 and oral feed was started if there was no leak. as placement of gastrostomy and jejunostomy tubes. Stents All were followed up every 3 weeks for 3 months and every were placed intra-operatively, 3 Wallstents, 1 Niti-S and 1 month for another 3 months. Barium swallow was done at Celestin tube. All stents were stabilized with transgastric or 3 weeks to document status of anastomosis. Symptomatic transesophageal chromic sutures. No signifi cant migration patients with documented anastomotic stricture were sub- occurred. Post-op barium studies done on Day 3–8 showed jected for endoscopic dilation. no leak in 4 patients and a small leak communicating with a drain in 1 patient. Stents were removed post-operatively RESULTS: Out of twenty three patients with ileocolonic at 4–8 weeks (mean 5.4). Stent removal was straightforward pull up during the study period, 5 were excluded from the and no complications associated with stabilization sutures analysis (2 died and 3 did not complete 6 months follow were identifi ed. One patient had a small residual fistula up). Out of the remaining 18 patients considered for evalu- which communicated to a drain. All patients recovered ation, 6 were in group A and 12 were in group B. uneventfully. Mean LOS was 22 days, range 7–54. Demographic data and level of stricture was not statisti- CONCLUSION: Acute management of esophageal perfora- cally signifi cant in both the groups. Four patients in group tion is increasingly multidisciplinary. Selected patients will B required tracheostomy, none of the patients in group A continue to require surgical management for drainage or required tracheostomy. CECT angiogram showed improve- enteral feeding. Hybrid procedures provide a simple addi- Poster Abstracts ment in collateral circulation in all Group A patients. No tional treatment option in selected patients. Surgical stent patient in group A had anastomotic leak and anastamotic stabilization can be done safely and decreases the incidence Tuesday stricture, where as in Group B, 3/12 (25%) had anasto- of stent migration, which can decrease the need for addi- motic leak and 4/12 (33.3%) had anastamotic stricture tional procedures and improve outcomes in these complex requiring dilatation. patients.

CONCLUSION: Ligation of ileocolic artery improves the vascularity of future ileocolonic conduit and in turn decreases anastomotic leak and stricture rate.

195 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1550 Clinical: Hepatic Safety and Effi cacy of Outpatient Percutaneous Endoscopic Gastrostomy for Patients with Head Tu1555 and Neck Cancer Results of 100 Consecutive Repeat Hepatectomies for Julia M. Boll, Shaun Daly, Jill Smolevitz, Maria C. Mora Pinzon, Amanda B. Francescatti, Jonathan Myers, Steven D. Bines, Recurrent Colorectal Liver Metastases Hannes P. Neeff1, Oliver Drognitz1, Andrea Klock1, Minh B. Luu 2 1 1 General Surgery, Rush University Medical Center, Chicago, IL Peter Bronsert , Ulrich T. Hopt , Frank Makowiec 1Department of Surgery, University of Freiburg, Freiburg, Germany; BACKGROUND: Percutaneous endoscopic gastrostomy 2Department of Pathology, University of Freiburg, Freiburg, Germany (PEG) is commonly used to provide enteral nutrition for patients with head and neck cancer undergoing radiation INTRODUCTION: Recurrent colorectal liver metastases and chemotherapy. The aim of the study was to evaluate (CRC-LM) are a common phenomenon. This has become the effi cacy and safety of PEG tube placement in these more and more evident with the advent of multimodal patients in an ambulatory setting. therapies in combination with increased hepatic resection rates of CRC-LM. METHODS: An observational, cohort study was con- ducted to identify patients who underwent a PEG proce- Since complete surgical resection remains the only chance dure between 2008 and 2012. Inclusion criteria included for cure, even in advanced colorectal cancer, outcomes after patients diagnosed with head and neck cancer undergoing repeat hepatectomies for CRC-LM have to be evaluated in outpatient PEG placement. Patient demographics and peri- order to introduce this concept into standard clinical care. operative outcomes were analyzed using SPSS analytical PATIENTS AND METHODS: Since 1999 100 repeat predictive software. hepatic resections (62% wedge/segmental, 38% hemihepa- RESULTS: During this study 52 PEG tubes were placed tectomy or greater) have been performed for recurrent CRC- in patients with head/neck cancer as an outpatient pro- LM in 88 patients. Repeat hepatic resection was carried out cedure. There were no signifi cant differences in primary after a median interval of 1.25 years. Resection criteria were malignancy site. 28.8% were female and 71.2% were male, not different from fi rst liver resections. Chemotherapy with ages ranging from 19–82 and a median age of 58. including biological agents was given in 89% before repeat Three patients (5.8%) were admitted post-procedure due hepatectomy. to the senior author’s judgment. There were no procedure This was done in neoadjuvant intent in 38%. 50% of cases related 30-day complications. One patient was re-admitted with neoadjuvant treatment were receiving biological for dehydration unrelated to the PEG placement. Seven agents. (13.5%) patients sought further care for pain control. Five RESULTS: Margin negative hepatic resection was achieved patients (9.6%) made one post-operative phone call to the in 80%. Overall margin negative resection was 70%. Mor- clinic compared to three (5.8%) who made more than one. tality was 3.0%. Complications rates were 52% overall, There were six patients (11.5%) with long-term complaints; including infection (17%), need for operative re interven- three complained of discharge, three of abdominal wall tion (12%) and hepatic failure (i.e. bilirubin > 6.0 mg/dl) pain, and one of a cracked PEG tube. There were no mor- (5%). Overall fi ve-year survival rate after fi rst repeat hepatic talities within thirty days. resection (n = 85) was 50.3%. In univariate analysis, pri- CONCLUSION: This study demonstrates that placement of mary tumor stage (p < 0.04), major hepatic surgery (p = PEG tubes in patients with diagnosed head and neck cancer 0.05), postoperative complications (p = 0.05) and overall can be accomplished safely and effectively in an outpatient margin negative resection including extrahepatic sites (p = setting. Complication rates were low and patient complaints 0.05) were predictors of survival. Multivariately, primary T were successfully managed without re-admission. Acknowl- stage (p < 0.05) and tumor size (p < 0.03) were independent edging the safety profi le of ambulatory PEG tube placement predictors of survival. by general surgeons could lead to an increased percentage of patients avoiding hospitalization and its subsequent risk of nosocomial complications and increased cost.

196 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

CONCLUSION: Despite high rates of recurrence, results RESULTS: The base case analysis of a 45 year-old patient after repeat hepatic resection remain encouraging in terms with compensated cirrhosis, a BMI of 45 kg/m2 and no of 5-year survival rates. Even under challenging surgical weight-loss intervention revealed an average survival of conditions, repeat hepatectomies can be performed safely 7.93 years. Patients transitioned into lower weight classes with a high rate of local margin negative resections. Specifi c fastest in the RYGB simulation. The average survival for risk factors for patients with recurrent CRC-LM undergoing the weight loss simulations were 9.14, 8.84, and 8.16 years repeat hepatectomies could not be found as they resemble for RYGB, AGB, and diet and exercise, respectively. Sensi- general risk factors for metastatic colorectal disease. Repeat tivity analysis of initial BMI revealed that RYGB increased heaptic resections for recurrent CRC-LM should increas- life expectancy compared to AGB in all patients that were ingly be offered to patients who meet standard hepatic severely or morbidly obese (all BMIs greater than 35 kg/m2) resection criteria. and in all patients with a BMI greater that 36.98 kg/m2 compared to one year diet and exercise. Tu1556 Weight-Loss Interventions for Morbidly Obese Patients with Compensated Cirrhosis: A Markov Decision Analysis Model Bianca Bromberger1, Kristoffel Dumon2, Rashikh A. Choudhury1, Paige Porrett2, Kenric Murayama2 1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 2Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA PURPOSE: With the rising prevalence of obesity, nonal- coholic steatohepatitis is an increasingly common cause of cirrhosis and indication for liver transplantation. How- ever, since many centers require that patients maintain a BMI <40 kg/m2 to be eligible for transplantation, many morbidly obese patients are excluded from this life-saving therapy. It is currently unknown which weight loss inter- ventions should be utilized in morbidly obese cirrhotic Sensitivity analysis of survival post-weight loss intervention based on patients in order to improve transplantation candidacy. initial BMI. This study therefore aimed to compare the effi cacy of three methods of weight loss in morbidly obese patients with compensated cirrhosis [Roux-en-Y gastric bypass (RYGB), CONCLUSION: In morbidly obese patients with compen- Adjustable Gastric Banding (AGB), and one year of diet sated cirrhosis, RYGB is the most effective means to decrease and exercise]. We hypothesized that the faster and more BMI. Importantly, this intervention leads to increased signifi cant weight loss achieved by RYGB would increase life expectancy in this population, potentially because of life expectancy. improved access to liver transplantation and/or impact on disease progression. METHODS: A Markov state transition model was devel- oped to assess the survival benefi t of undergoing RYGB, AGB or one year of diet and exercise in morbidly obese patients with compensated cirrhosis. The model assumed that a BMI < 40 kg/m2 was required for patients to be listed for transplantation. State transition values were obtained from the literature in order to best estimate the rates of weight loss, progression of disease, wait-listing and trans- plantation. The model was analyzed using decision analysis software (TreeAge Pro 2012). Base-case and sensitivity anal- yses of pre-intervention BMI and peri-operative mortality were performed. Poster Abstracts Tuesday

197 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1557 CONCLUSION: Standardization of complex procedures begins with breaking down the process into measureable Detecting Performance Variance in Complex Surgical components. LRH can be performed consistently and repro- Procedures: Analysis of a Step-Wise Technique for ducibly using the same approach of a step-wise technique. Laparoscopic Right Hepatectomy Parenchyma transection had the most variation, and this Juan Toro, Nathan Lytle, Ankit Patel, John F. Sweeney, could be explained by intrinsic liver factors (organ thick- Rachel M. Owen, Edward Lin, Juan M. Sarmiento ness, fat content, cirrhosis, etc). The identifi cation of ways to narrow the variance in parenchyma transection, when Surgery, Emory University, Atlanta, GA possible, became our fi rst focus. Using SS and LM manu- BACKGROUND: Laparoscopic Right Hepatectomy (LRH) facturing quality tools in surgery allows the surgeon to is a technically challenging operation. Complex surgical critically analyze performance and implement specifi c procedures can be improved by standardization of opera- improvement goals. tive technique and uniformity of operating room (OR) practice, and accomplished by implementation of manu- facturing productivity tools such as Six Sigma (SS) and Lean Clinical: Pancreas Management (LM). Using these strategies allow us to mea- sure performance effi ciency, detect unwanted variances, and implement process improvement. Tu1560 METHODS: We performed formal LRH beginning in 2008 Cystic Lesions of the Pancreas: Resection Versus in the same way we performed the open approach. The Surveillance procedure was deconstructed into seven major step-wise Halle Beitollahi1, Valerie Erath1, Haiyan Sun3, Nicole Woll1, components (right hepatic artery ligation/transection, right David L. Diehl2, Amitpal S. Johal2, Joseph A. Blansfi eld1, portal vein ligation/transection, retrohepatic IVC dissec- Mohsen M. Shabahang1 tion, triangular ligament takedown, right hepatic vein liga- 1General Surgery, Geisinger Medical Center, Danville, PA; tion/transection, parenchyma transection, hemostasis-bile 2Gastroenterology, Geisinger Medical Center, Danville, PA; 3Center leak check) established by two surgeons. All LRHs followed the same surgical sequence, device use, and OR protocol. for Health Research, Geisinger Health System, Danville, PA A non-participating surgeon reviewed the video recordings INTRODUCTION: Pancreatic cysts remain a challenge of the procedures to determine total operative time and with respect to diagnosis and management. Pancreatic cysts the time for each component step. The variances (standard are detected with increased frequency because of the wide- deviation) of each operation were calculated (average time spread use of advanced imaging modalities. The aim of the in minutes ± SD). study was to perform a clinical comparison of patients with RESULTS: After implementation of LM for our LRH, 30 pancreatic cysts who underwent resection versus imaging randomly selected video recordings of the procedure surveillance and differentiate between clinical, imaging, (excluding biliary reconstruction) were reviewed. The mean biochemical and pathologic characteristics. total operative time was 114 ± 25 min. The most effi cient METHODS: This was a retrospective review of adult steps of the procedure were IVC dissection (mean 8 ± 3 min) patients with cystic lesions of the pancreas treated in a and right hepatic vein ligation (mean 9 ± 5). The longest single health system between January 2002 and September and also the step with the highest standard deviation was 2009. Endoscopic ultrasound (EUS) was required for inclu- parenchyma transection (35 ± 12). The other steps were sion. An encounter was defi ned as a clinical visit in which performed with minimal variations (Table 1). There were pancreatic imaging was performed. Imaging modalities no intraoperative complications or conversions to open included were EUS, with or without fi ne needle aspiration technique. (FNA), computed tomography (CT), magnetic resonance (MR) and endoscopic retrograde cholangiopancreatography Table 1: LRH Total Operative Time and Steps Times (n = 30) * (ERCP). Symptoms were defi ned as weight loss or abdomi- Standard nal pain. Demographics, clinical characteristics, imaging Step Mean Deviation Median Range features, biochemical analysis, procedure, pathology and Total operative time 114 ± 25 114 78–177 follow up intervals were analyzed. Only encounters prior Right hepatic artery ligation 18 ± 8 17 6–37 to resection were included in the analysis for the resection Right portal vein ligation 15 ± 4 15 7–25 group. Right lobe mobilization 12 ± 4 11 7–28 IVC dissection 8 ± 3 7 3–15 Right hepatic vein ligation 9 ± 5 8 4–22 Parenchyma transection 35 ± 12 32 21–65 Hemostasis/Bile leak checking 16 ± 11 14 4–52 * Time in minutes

198 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: The fi nal analysis included 262 patients, 58 in Tu1561 the resection group (22.1%) and 204 in the surveillance group (77.8%). Demographics, clinical features and follow Pancreatic Insuffi ciency Following Pancreatic Resection up analysis are included in Table 1; p values and interquar- Travis P. Webb, Joseph A. Blansfi eld, Mohsen M. Shabahang tile range (IQR) have been included. The median time to Surgical oncology, Geisinger Medical Center, Danville, PA resection from fi rst encounter was 85.5 days; 52 patients BACKGROUND: Pancreatic insuffi ciency (PI), in the form (89.6%) underwent resection within one year of fi rst of endocrine or exocrine insuffi ciency, is a well-known encounter. The most common cyst locations were the pan- complication following pancreatic surgery. Despite this, the creatic body and tail (53%). The median number of cysts by exact incidence is not known and reported rates are widely CT was one in both the resection and surveillance groups. disparate. The median initial cyst size by CT in millimeters was 31 in the resection group and 21.5 in the surveillance group (p HYPOTHESIS/OBJECTIVES: To determine and compare < 0.001). The presence of septation (p = 0.216) or a solid rates of endocrine and exocrine insuffi ciency following pan- component (p = 0.957) were not signifi cantly different creaticoduodenectomy (PD) and left pancreatectomy (LP). between groups. Median cyst fl uid carcinoembryonic anti- DESIGN: Retrospective cohort. gen (CEA) level (ng/ml) was 293.9 in the resection group and 19.8 in the surveillance group (p = 0.006). Median SETTING: Single institution, tertiary care center. cyst fl uid amylase (U/L) was 72.5 in the resection group PATIENTS AND METHODS: Data from 129 consecutive and 5096 in the surveillance group (p = 0.007). Pathologic patients who underwent PD and LP over a six year period analysis of resected specimens demonstrated 29% of lesions (1/2006–12/2011) were retrospectively reviewed. Exocrine were malignant, 26% had dysplasia and 45% were benign. insuffi ciency was defi ned as need for pancreatic enzymes In the resection group the most common diagnoses were (PE) following resection. Endocrine insuffi ciency was pseudocyst (22.4%) and adenocarcinoma (18.9%) and the defi ned as new onset or worsening diabetes mellitus (DM). most frequent procedure was distal pancreatectomy (50%). RESULTS: There were 129 patients that underwent pan- Table 1: Demographic and Clinical Characteristics of Patients Who creatic resection: 68 PD, 61 LP. New onset exocrine insuf- Underwent Resection Versus Surveillance fi ciency for the entire cohort was 28% (32 of 129 patients). Exocrine insuffi ciency was signifi cantly higher in the PD Total Resection Surveillance cohort versus LP (42.6% (n = 29) vs. 4.9% (n = 3), p < Characteristic N = 262 N = 58 N = 204 P Value 0.001). A signifi cant portion of the population had endo- Female (%) 158 (60.31%) 31 (53.45%) 127 (62.25%) 0.226 crine insuffi ciency preoperatively (32.6%, n = 42). New Deceased (%) 70 (26.72%) 17 (29.31%) 53 (25.98%) 0.613 onset or worsening DM was diagnosed in 16.2% (n = 11) of Symptomatic (%) 169 (64.5%) 41 (70.69%) 128 (62.75%) 0.264 PD patients compared to 24.6% (n = 15) of LP patients but Median age at 66 (55, 75) 61 (49, 72) 67.5 (55.5, 76) 0.027 this was not statistically signifi cant (p = 0.16). New onset PI diagnosis in years in any form occurred in 40.3% of patients (52 out of 129). (IQR) This was statistically higher in PD patients at 50% (n = 34) Median number of 3 (2, 5) 2 (1, 3) 3 (2, 5) <0.001 vs 29.5% (n = 18) for LP, (p = 0.02). encounters (range CONCLUSION: Pancreatic insuffi ciency occurs frequently 1–15) (IQR) after pancreatic resection and patients should be counseled Median interval 4.13 (1.73, 1.87 (0.83, 4.73) 4.63 (1.93, 11.69) <0.001 accordingly preoperatively. Clinicians should have a low between encounters 10.5) in months (IQR) threshold to diagnose and treat exocrine and endocrine Median follow up in 10 (1.1, 30.8) 1.17 (0, 6.9) 16 (3, 35.5) <0.001 insuffi ciency in the postoperative pancreatic resection months (IQR) patient.

CONCLUSION: The data suggests patients who require resection can be identifi ed early. This is based primarily on cyst size and elevated cyst fl uid CEA. Patients who under- went resection had fewer encounters at shorter intervals. Poster Abstracts Tuesday

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Tu1562 Preoperative Normogram to Predict Discharge Disposition Following Pancreatic Resection for Malignancy Bhavin C. Shah1, Lynette M. Smith2, Chandrakanth Are1 1Surgery, University of Nebraska Medical Center, Omaha, NE; 2Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE BACKGROUND: The aim of this study was to develop a preoperative normogram to predict thedischarge status fol- lowing pancreatic resection for malignancy. METHODS: The Nationwide Inpatient Sample (NIS) data- base (2000–2009) was used. Discharge disposition was categorized as routine (home without any assistance) or non-routine (discharge to home with assistance or to skilled facility). Multivariate logistic regression model was used to identify variables infl uencing discharge disposition and a normogram was created. The training set (2000–2005) was used to develop the model which was further validated using the validation set (2006–2009). RESULTS: A weighted total of 21250 patients (2000–2005) were used to create a predictive model and 20390 patients (2006–2009) were used to validate it. The mean total points for the 2000–2005 dataset was 134.7 (SE = 1.25), which correspond to approximately a 42% non-routine discharge which is similar to the actual observed non-routine dis- charge rate of 43%. The normogram was validated using the NIS 2006–2009 dataset. The mean total points for the 2006–2009 sample is 128.5 (SE = 1.70) with an observed non-routine discharge rate of 46%. The concordance index was found to be 0.67 (95% confi dence interval of 0.65 to 069). Calibration plots of the normogram revealed agree- ment between the observed non-routine discharge prob- Calibration plots for Normogram dataset (2000–2005) and Validation abilities versus the model predicted non-routine discharge Dataset (2006–2009). probability. (Figure: 1) CONCLUSION: This preoperative normogram may accu- rately predict the chance of a non routine discharge follow- ing pancreatic resection for malignancy and may be used as an adjunctive clinical tool in the preoperative counseling of these patients.

200 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1563 Tu1564 Pancreatico-Duodenectomy with High Quality Results Predictors of Lymph Node Metastases and Impact in a Medium Volume Centre: What Are the Australian on Survival in Resected Pancreatic Neuroendocrine Defi nitions of Low Volume? Tumors: A Single Center Experience Jonathan S. Gani, Ephream C. Lye, Donna Gillies Joyce Wong, William J. Fulp, Jonathan R. Strosberg, Surgery, John Hunter Hospital, New Lambton Heights, NSW, Australia Larry Kvols, Pamela Hodul INTRODUCTION: Controversy about pancreatico-duo- Surgery, Moffi tt Cancer Center, Tampa, FL denectomy (PD) has persisted since it was fi rst performed BACKGROUND: Currently, staging for pancreatic neu- by Kausch a century ago and later popularised by Whipple. roendocrine tumors (PNET) considers tumor size, lymph Evidence that a certain critical caseload volume is required node status, and histologic differentiation. However, the to undertake this kind of surgery with low mortality has predictive value of these factors as related to overall sur- been the subject of some debate. Defi nitions of high and vival (OS) remains unclear. This study reviews predictors of low volume centres and surgeons have been proposed but lymph node (LN) metastases and the impact on survival for they differ greatly between health systems and counties. resected PNET. The objective of this analysis was to determine whether it METHODS: A prospectively maintained database of is possible to deliver pancreatico-duodenectomy at global patients treated for PNET was reviewed. Patients undergo- standards in a regional city and to see if we can help defi ne ing surgical resection without evidence of metastatic dis- the minimum acceptable number of procedures annually ease at time of resection were included in this analysis. compatible with providing such a service. Chi-Square Test was used to compare categorical variables and LN metastases, and Wilcoxon Rank Sum Test was used METHODS: A ten year retrospective study from the period for continuous variables, both with the exact method using of October 2002 to October 2012 was undertaken in the Monte Carlo estimation. Univariate and multivariate anal- 1 public and 2 private hospitals in Newcastle Australia ysis was performed with Cox proportional hazard models where all the PDs for a regional population of 840000 were and survival calculated with Kaplan Meier curves. performed. RESULTS: From 1999–2012, 150 patients underwent surgi- RESULTS: 123 pancreatico-duodenectomies were per- cal resection for PNET. The majority (53%) were male, with formed in this period. The mean number of operations a median age of 56 years (range 17–82). Incidentally dis- performed each year including all hospitals combined was covered PNET was the most common presentation (42%), 12.3. This is equivalent to a medium volume centre by followed by abdominal pain (32%). Tumors were uncom- European defi nitions. The number of operations per sur- monly functional (7%). Distal pancreatectomy was per- geon per annum ranged from 0.2 per year to 5.8. formed in 58%; pancreaticoduodenectomy in 29%, and 83.7% of patients suffered no signifi cant complications, 30 enucleation in 7%. Of 113 (75%) patients with LN data day mortality was 4.1%. Signifi cant differences were found available for review, 32 (28%) had positive LN (LN + ). Both between surgeons total signifi cant complication rates age and lymph node retrieval differed in the LN negative which ranged from 8.6% to 50%. 30 day mortality ranged (LN 0) vs. LN + group, with younger median age (53 years) from 0% to 50%. 3 surgeons performed >3 operations per and higher median LN count (9 vs. 6) in the LN + group, p = year. These were all designated medium volume surgeons 0.05 and p = 0.04, respectively. Univariate analysis showed gender, race, clinical presentation, surgery type, and tumor and they performed 91% of all PDs in this series (112/123). size was not predictive of LN + . Presence of perineural (p = The 3 other surgeons performed 9% (11/123) and were des- 0.016) and lymphovascular (p < 0.001) invasion, however, ignated very low volume surgeons. One hospital performed was more common in LN +. With multivariate analysis, only 4 PDs during the study period and was designated a only poor/moderate differentiation predicted LN +, with very low volume hospital (<1 case per annum). When the an odds ratio of 7.3 (95% CI: 1.9, 27.6). Median follow-up data from medium volume surgeons and medium volume for the cohort was 52 months; estimated median OS was hospitals was compared with the data from very low vol- 225 months with 5-year OS of 90%. Multivariate analysis ume surgeons and hospitals there was a statistically signifi - identifi ed older age at diagnosis and poor/moderate differ- cant difference in overall complication rates and mortality. entiation as factors that negatively impacted OS. 52 (35%) Exclusion of the low volume surgeons and the low volume patients developed recurrent disease; the majority recurred institution was associated with a 1.9% 30 day mortality, a with distant metastases (N = 46, 88%), with liver being the 12% signifi cant morbidity and a 31% actuarial 5 year sur- most common site. Of those who recurred, 25 (48%) had vival for periampullary malignancy. received adjuvant therapy following resection. Estimated CONCLUSION: There are both surgeon and hospital vol- median disease free survival (DFS) was 74 months. Only Poster Abstracts ume effects on outcome after PD. We have demonstrated poor/moderate differentiation affected DFS. Tumor size and that specialised Upper GI/HPB surgeons can achieve pan- LN + did not signifi cantly impact survival. Tuesday creatico-duodenectomy results in a medium volume centre RESULTS: PNET is an uncommon entity with an unclear equivalent to those achieved high volume centres. prognosis based on variables commonly factored into the staging criteria. In this study, tumor size did not predict LN +; furthermore, LN + did not predict a worse OS or DFS. Tumor differentiation appears to be more important in determining prognosis for resected PNET.

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Tu1565 CONCLUSIONS: In this very large multi-institution data set, 30-day mortality for splenectomy for hematologic dis- Morbidity and Mortality Associated with Elective eases is as high as 2.1% and is associated with an overall Splenectomy for Hematologic Disorders complication rate of 12% for patients with benign con- Naina Bagrodia, Philip M. Spanheimer, Mary E. Belding- ditions and 20% for malignancy. Immediate infectious Schmitt, Howe R. James, James J. Mezhir complications are common following splenectomy for Surgery, University of Iowa, Iowa City, IA these conditions. A multivariate analysis is underway to determine the specifi c variables that can account for the OBJECTIVE: Published rates of complications for sple- signifi cant morbidity and mortality from splenectomy for nectomy are very low, however these are single institution hematologic disorders. series focused on many primary splenic conditions. Our objective is to evaluate complications following splenec- tomy for benign and malignant hematologic disorders to Tu1567 help guide decision making and informed consent for this Perioperative Outcome After Pancreatic Head procedure. Resections: Consecutive Single Surgeon Series in a METHODS: A review of the ACS-NSQIP data set for sple- Specialized University Hospital and in a Community nectomy performed from 2006–2009 was performed. Pre- Hospital operative clinicopathologic variables and postoperative Ulrich Adam1, Hartwig Riediger1, Ulrich F. Wellner2, complications were evaluated. Patients included for analy- 2 2 2 sis had a primary diagnosis of a benign (hemolytic anemia, Tobias Keck , Ulrich T. Hopt , Frank Makowiec 1 thrombocytopenia) or a malignant (leukemia and lym- Department of Surgery, Humboldt-Klinikum, Berlin, Germany; phoma) hematologic condition. Non-elective procedures or 2Department of Surgery, University of Freiburg, Freiburg, Germany splenectomy performed in addition to another major pro- Hospital and surgeon volume are potential factors infl uenc- cedure (e.g., colectomy) were excluded. ing postoperative mortality and morbidity after pancreatic RESULTS: There were 4,859 splenectomy procedures col- resection. Data on perioperative outcomes of individual lected from ACS-NSQIP data set during the time period surgeons in different institutions, however, are scarce. We evaluated, and 1,762 met criteria for analysis. 1,379 (78.3%) evaluated the postoperative outcome after pancreatic head operations were for benign conditions while the remain- resections (PHR) performed by a high-volume pancreatic ing 383 (21.7%) were for malignant disease. Patients with surgeon in a high volume university department and (later) benign conditions were younger, female, more commonly in a community hospital (with almost no prior institutional diabetic, had higher BMI, and were more often on steroids experience with pancreatic surgery). preoperatively. Patients with benign disease also had bet- METHODS: We compared the results after PHR personally ter overall preoperative performance status compared to performed by a single surgeon between 2001 and 10/2006 patients with malignancy. Patients with benign disease in a specialized unit of a German University hospital (n = more often had laparoscopic procedures (81.8% vs. 39.1%, 86; DeptA) with the results after PHR performed in a Com- p < 0.0001). munity hospital between 11/2006 and 2012 (n = 135; Overall mortality at 30 days was 1.6% (n = 29) and was DeptB). Before the study period (-2001) the surgeon already not signifi cantly different for malignant (2.1%) vs. benign had a personal caseload of > 200 PHR. In addition to the 221 (1.5%) disease. The overall complication rate was 13.6% and PHR analyzed here the surgeon also had teached further > was higher for patients with malignant disease (19.6%) vs. 150 PHR to residents and consulting surgeons. The same benign disease (11.9%, p = 0.0002) (Table). Infectious com- surgical and perioperative techniques were applied in both plications (superfi cial and deep SSI, UTI, sepsis, and pneu- series (e.g. abdominal drains, early enteral feeding, pancre- monia) predominated in patients with malignancy (16.0% aticojejunostomy or pancreaticogastrostomy in PPPD) with vs. 9.1% for patients with benign disease, p = 0.0002). the exception of the use of pancreatic duct drains in some patients in DeptB). The data of both series were prospec- Complications from Splenectomy for Hematologic Disorders tively recorded in SPSS-databases. Malignant Benign Disease Disease Variable n = 1,379 n (%) n = 383 n (%) p-Value Overall 30-day Mortality 21 (1.5) 8 (2.1) 0.37 Overall Morbidity 164 (11.9) 75 (19.6) 0.0002 Infectious Complications 125 (9.1) 61 (16.0) 0.0002 DVT/PE 33 (2.4) 11 (2.8) 0.58 Transfusion 30 (2.2) 15 (3.9) 0.06 Reoperation 43 (3.1) 12 (3.1) 0.87 Length of Stay 3 (6–11) 5 (8–10) 0.0005 (median days, range)

202 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: The median age of the patients was lower in RESULTS: DeptA (59 years vs. 67 years in DeptB; p < 0.001). Indica- The following situations were identifi ed and some patients tions for PHR (DeptA n = 86/DeptB n = 135) were pancre- presented more than one: atic/periampullary cancer (58%/55%), chronic pancreatitis 1. Issues involving surgical informed consent process (31%/28%) and various others (11%/17%). Most PHR were (information, refusal to proposed treatment, cognitive PPPD (62%/74%) but the percentage of duodenum-pre- status and competency, surrogates role in future deci- serving PHR decreased in DeptB (26% vs 14%). Vein resec- sions): 35 (33.33%) tions were performed in 17%/21% (n.s.). Mortality rate was 3.5% in DeptA and 3.7% in DeptB (n.s.). Any complication 2. Implementation of palliative care: 21 (20%) occurred in 48%/55% (p = 0.25). Pancreatic leak (any grade) 3. Advance directives: 15 (14.28%) was present in 26%/24% (n.s.) but grade C leaks were more frequent in DeptA (8% vs 3% in DeptB; p < 0.05). Using the 4. Advice regarding alternative treatments and “miracle expanded Accordion classifi cation complications grade 3 or cures”: 13 (12.38%) higher were documented in 14% (DeptA) or 16% (DeptB; 5. Futile treatments: 7 (6.66%) n.s.). 6. DNR orders: 6 ( 5.71%) CONCLUSIONS: Surgeon volume and a high individual 7. Truth telling: 4 (3.80%) experience, respectively, contribute to low mortality and acceptable complication rates after pancreatic head resec- 8. Challenges to develop a trustful surgeon-patient rela- tion. This personal experience may allow for favorable tionship: 2 (1.90%) postoperative outcomes after PHR even in a program with 9. Surgical residents participation in the procedure. almost no prior experience with pancreatic resections. 2 (1.90%) All the confl icts were managed satisfactorily, no need for Tu1568 change of surgical teams was required and no professional Ethical Confl icts in the Surgical Treatment of liability claims were fi led in the following 23 months. Gastrointestinal Malignancies CONCLUSIONS: Alberto R. Ferreres, Anibal J. Rondan, Marcelo Fasano, — Ethical guidelines and expertise are needed in the man- Natalia Bongiovi, Gustavo Alarcia, Alejo S. Ferreres, agement of gastrointestinal malignancies to achieve ade- Rosana Trapani quate and patient-oriented decision making. Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina — Surgical decision making in these diseases need to include patient preferences, quality of life and contex- INTRODUCTION: Surgical care of patients with diagno- tual issues to provide sound surgical judgement, with sis of gastrointestinal malignancies involve ethical confi cts preeminence of respect for autonomy. and decision making to manage these issues requires spe- cifi c knowledge and expertise. The four ethical principles as — Ethical confl icts will probably increase in the future and introduced by Beauchamp and Childress (respect for auton- surgical ethics knowledge will prove to be at the core of omy, benefi cence, non malefi cence and justice) provide a surgical training. framework for the solution of these issues when arising in — A change of paradigm is envisioned to achieve and pro- clinical practice. vide an optimal surgical care: from the curative model OBJECTIVE: To examine prospectively the incidence and with the goal of curing to the palliative model with the the cause of ethical confl icts which lead to a surgical ethics concern to relief suffering. consultation during the process of surgical care of patients with diagnosis of gastrointestinal malignancies. METHODS: A total of 105 ethical confl icts through the treatment care of 100 patients with gastrointestinal malig- nancies (of a total of 488) were identifi ed during 2010. Mean age was 58.2 ± 13.7 years (range: 28 to 96), 56 were females. Two of the authors with expertise in surgical ethics participated when intervention was requested and assisted with the confl ict management and resolution. Poster Abstracts Tuesday

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Tu1569 Impact of Margin Clearance on Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: What Is a “True” Negative Margin? Yasushi Hashimoto, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Naru Kondo, Taijiro Sueda Department of Surgery, Applied Life Sciences Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan BACKGROUND: Microscopic involvement of a resection margin by tumor is associated with a poor prognosis. It is unclear whether a proximity to resection margins by tumor confers a survival benefi t over margin involved R1 resection of their pancreatic ductal adenocarcinoma (PDAC) after pancreticoduodenectomy (PD). The aim is to better under- stand the impact of resection status on clinical and patho- logic staging, and long-term survival after PD for PDAC, and to explore the prognostic signifi cance of a proximity to surgical margins. METHODS: We assessed the relationships between mar- gin involvement (R1), the proximity to resection margins (R0-close) and outcome in a cohort of 124 consecutive patients who underwent PD for PDAC between 2002 and 2012. Resected specimens were analyzed according to the improved standardized pathology protocol which included CONCLUSIONS: These data demonstrate that a margin permanent section analysis of the surgical margins. R0-close clearance of more than 1-mm is important for long-term margin was defi ned as tumor within 1-mm of the resection survival in a subgroup of patients. Complete histologic margins and a patient with a margin of greater than 1-mm evaluation of the resected PD specimens is important for was defi ned as R0-wide margin. Follow-up data on overall prognosis in patients with PDAC who underwent PD. More and disease-free survival, presence and site of tumor recur- aggressive therapeutic approaches that target locoregional rence were examined. disease such as neoadjuvant radiation therapy may be ben- RESULTS: Of the 124 patients, the resection margins were efi cial in patients with close surgical margins. positive (R1) in 30 (24%) and negative (R0) in 94 patients (76%) including 38 patients (31%) with an R0-close resec- Tu1570 tion. Patients with R1 resections had an unfavorable sur- vival compared with those with R0 resections (median, 18 Surgical Management of Pancreatic Neuroendocrine vs 35 months; P < 0.01), but survival with R0-close margin Tumors: A Single Institution Experience were comparable to R1 resections: but both groups had a Jeff Kim, Aram N. Demirjian, David K. Imagawa signifi cantly shorter survival than patients with R0-wide Surgery, University of California-Irvine, Orange, CA margins (18 vs 32 vs 44 months, respectively; P = 0.02). Disease-free survival was shorter in R1/R0-close margins INTRODUCTION: Pancreatic neuroendocrine tumors comparing to R0-wide group (median, 12 vs 19 months; P (PancNET) are a comparatively rare, diverse group of neo- = 0.04). By multivariate analysis, predictors of R1/R0-close plasms that account for 1–3% of all pancreatic tumors. margins were patients underwent portal vein resection and While surgery is clearly the fi rst line therapy for patients larger tumor size of greater than 20-mm. The pattern of with disease amenable to resection at any stage of presenta- tumor recurrence had a greater rate of regional metastases tion, there are currently many surgical options. Due to both in the R1/R0-close margins group comparing to patients the diversity and rarity of the disease, there are limited data with R0-wide margins (48% vs 14%; P = 0.01). on different surgical outcomes and thus no clearly estab- lished guidelines supporting one surgical management option over another exists. OBJECTIVE: To identify differences in surgical outcomes of PancNET patients treated with various surgical approaches that may contribute to better management decisions in these patients.

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PARTICIPANTS: Retrospective study of forty-four patients from further analysis. All other patients received defi nitive with histologically confi rmed diagnosis of pancreatic neu- surgical intervention with margin free resection of local roendocrine tumor, surgically evaluated at the University of tumor. In one case of enucleation, patient was subsequently California Irvine Medical Center (UCI-MC) between Janu- taken back for distal pancreatectomy with splenectomy after ary 2003 and August of 2012. Surgical procedures included surgical pathology showed positive margins. There was one both traditional radical resections, such as a Whipple’s pro- Stage IV patient with metastatic liver disease who received cedure, total pancreatectomy and distal pancreatectomy cytoreductive surgery along with regional adjuvant proce- with splenectomy, as well as organ sparing procedures, dures for liver lesions. All 40 patients are still currently alive such as distal/segmental pancreatectomy without splenec- with median follow-up of 55.9 month from date of surgery. tomy and enucleation. These procedures were performed One patient who presented with Stage IIB disease recurred via open, laparoscopic, hand-assisted laparoscopic and with hepatic disease at 4 months. robotic assisted approaches. AJCC criteria were used for CONCLUSION: This data suggests achieving margin free tumor staging. resection of local tumor regardless of tumor stage, surgical RESULTS: Defi nitive surgical intervention were aborted method and approach leads to excellent 5 year survival rate in four patients with metastatic disease during laparoscopy with progression free disease. due to deemed marginal surgical benefi t and were excluded

Distal Pancreatectomy Tumor Stage Enucleation Distal Pancreatectomy with Splenectomy Total Pancreatectomy Whipple IA 2 3 13 0 3 IB 0 1 6 0 2 II 0 0 2 1 3 III 0 0 0 0 3 IV 0 0 1 0 0 Total 2 4 22 1 11

Tu1571 evidence of new lesion 10 patients were received additional loco-regional therapy including 4 resections (2 straightfor- Role of Additional Loco-Regional Therapy for Long- ward, 2 after CRT), 6 CRT with S1. With a median follow up Term Chemo-Responder by Gemcitabine with S1 for of 17.3 months (7.4–27.2 months) all 10 chemo-responder Advanced Pancreatic Cancer: A Pilot Study with additional loco-regional therapy are alive, while a Keita Wada1, Keiji Sano1, Hodaka Amano1, Fumihiko Miura1, median survival time for 13 non-responders was 8.7 months Naoyuki Toyota1, Yoshiko Aoyagi1, Koji Takeshita3, (Figure 1). Pathologic response of 4 responders with surgical resection was 50%, 85%, 90%, 90%, respectively. Fukuo Kondo2, Tadahiro Takada1 1Surgery, Teikyo University, Tokyo, Japan; 2Pathology, Teikyo University, Tokyo, Japan; 3Radiology, Teikyo University, Tokyo, Japan BACKGROUND: Recent advances in adjuvant therapy in pancreatic adenocarcinoma (PDAC) prolong survival and increasingly come to encounter long-term chemo- responder without developing new lesions. Is loco-regional therapy such as chemoradiotherapy and/or surgical resec- tion valid for those patients? METHODS: Since April 2010 twenty-eight patients with advanced PDAC (17 locally-advanced, and 11 metastatic) were treated by Gemcitabine with S1 (GS) as a fi rst-line anti-cancer therapy. Reevaluation was performed at 3- and 6-month after administration of GS therapy and loco- regional therapy was considered if new lesions were not developed. Survival was compared between subgroups according to clinical response and additional loco-regional therapy. Pathologic response was investigated among those Poster Abstracts with surgical resection. CONCLUSION: Although non-randomized data with short follow-up period, additional loco-regional therapy for long- Tuesday RESULTS: GS therapy was feasible with limited toxic- term chemo-responder by Gemcitabine with S1 seems fea- ity. Clinical response of GS was no CR, 7 PRs (25%), 8 SDs sible option for advanced PDAC. (29%), and 13 PDs (46%), accounting response rate of 25% and disease control rate of 54%. Among 15 patients without

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Tu1573 CONCLUSIONS: Metal stents should be considered ini- tially in patients with malignant biliary obstruction A Comparative Analysis of Plastic Versus Metal from borderline resectable pancreatic cancer undergoing Endoscopic Biliary Stents in Borderline Resectable extended neoadjuvant chemotherapy due to a decreased Pancreatic Cancer Patients Undergoing Extended rate of complications and increase in patency. Neoadjuvant Chemotherapy Rachel E. Heneghan1, John B. Rose1, Adnan Alseidi1, Tu1574 1 1 1 Thomas R. Biehl , Ravi Moonka , Flavio G. Rocha , Plasma Cancer Antigen 19-9 (CA19-9) Levels 1 2 2 2 John A. Ryan , S. Ian Gan , Michael Gluck , Shayan Irani , Differentiate Patients with Intraductal Papillary Andrew S. Ross2, Vincent J. Picozzi3, Richard A. Kozarek2, Mucinous Neoplasm (IPMN) Carcinomas from Those Scott Helton1 1Surgery, Virginia Mason Medical Center, Seattle, WA; with IPMN Alone Daniel Joyce, Gavin A. Falk, Kevin M. El-Hayek, 2Gastroenterology, Virginia Mason Medical Center, Seattle, WA; Sricharan Chalikonda, Gareth Morris-Stiff, Matthew Walsh 3Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Endoscopic biliary stenting is widely accepted as a treatment for malignant biliary obstruction INTRODUCTION: Invasive adenocarcinoma is a recog- from pancreatic cancer. While it is well-established that nized complication of IPMN in particular when the dis- patency with metal stents is superior to plastic stents in ease affects the main pancreatic duct, however, invasive patients with malignant biliary obstruction, their relative carcinoma or high grade dysplasia (HGD) are often only clinical effi cacy in patients with borderline resectable pan- recognized during histopathological examination of resec- creatic cancer undergoing extended neoadjuvant chemo- tion specimens. CA19-9 is frequently used in the diagnostic therapy (>6 months) is unknown. We hypothesized that in work-up of pancreatic adenocarcinoma but has not been this patient population, initial metal stent placement for well-investigated in IPMN, whereas carcinoembryonic anti- malignant biliary obstruction is associated with a decreased gen (CEA) is routinely evaluated. The aim of this study was incidence of biliary complications compared to plastic to evaluate the role of CA19-9 in differentiating between stents. IPMN carcinomas, IPMN with high-grade dysplasia (HGD) and IPMN with low/moderate (LGD&MGD) dysplasia. METHODS: All patients with biopsy-proven borderline resectable pancreatic cancer by AHPBA/SSO consensus METHODS: The departmental pancreatic cyst database was criteria were identifi ed prospectively over a 4-year period interrogated to identify all patients with a histopathologi- (2008–2012). Patients who did not require biliary stent- cal diagnosis of IPMN. Patients were sub-divided into three ing were excluded from analysis. A retrospective review of categories based on the degree of neoplastic change: IPMN all stented patients was performed. Patient demographics, carcinoma; IPMN HGD; and IPMN LGD&MGD. Ca19-9 lev- stent history, complications, need for exchange, and time els were assessed in relation to the 3 categories. to operation were analyzed. RESULTS: During the period January 2000 to December RESULTS: Of the 62 patients with borderline resectable 2011, 121 patients underwent pancreatic resection for pancreatic cancer, 40 (65%) required preoperative endo- IPMN. The post operative diagnoses consisted of: IPMN scopic biliary stenting for malignant obstruction. Twenty- [n = 41] carcinoma, IPMN HGD [n = 18]; and IPMN LGD/ fi ve of the 40 patients (63%) had plastic stents placed MGD [n = 62]. 58.3% of patients with IPMN carcinoma initially. Twenty-one of the 40 patients (53%) were initially and 18.8% of patients with HGD had an elevated CA19-9, stented at an outside hospital. Complications requiring whereas 9.3% of those with IPMN LGD/MGD had elevated stent exchange (cholangitis, pancreatitis, abscess, cholecys- levels (see Table 1). The sensitivity and specifi city of CA 19-9 titis, biliary obstruction) occurred signifi cantly more often for IPMN carcinoma or HGD in this group was 58.3% and in patients with initial plastic stents (76% vs. 13.5%; p = 88.14% respectively (see Table 2). Overall, of 28 patients .001). Mean functional stent time (defi ned as time from with a CA19-9 above the limit of normal [that being 37 placement to exchange, resection, or death) was signifi - IU/L], 24 (85.7%) had an associated carcinoma or HGD. cantly longer in the metal stent cohort (363 vs. 176 days; p = 0.015). There was no statistical difference in patient age, sex, tumor size, time to resection, resectability between metal and plastic stent cohorts. The occurrence of stent- related complications did not impact resectability.

206 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Table 1 RESULTS: A total of 820 patients underwent DP, of which 147 (18%) had a pancreatic leak. Leaks were classifi ed as Median Percentage Grade A, B, and C in 57%, 42%, and 1% respectively. The Number CA19-9 (IQR) > ULN median age at the time of surgery was 59 years (Range IPMN carcinoma 41 50 (13–136) 58.3% 15–90 years) and 53% were males. Clinical characteristics of IPMN HGD 18 20 (11–51) 18.8% patients with regard to age, sex, BMI, smoking status, benign IPMN LGD/MEG 62 18 (9–25) 9.3% or malignant disease, diabetic status, or blood transfusion IQR = Inter-quartile range; ULN = Upper limit of normal did not differ signifi cantly among the grades of pancreatic leak. Intra-operative administration of hetastarch was asso- Table 2 ciated with CSL (p = 0.045). The pancreas was transected using the stapler in 51.9%, electrocautery 34.6%, ultrasonic IPMN Carcinoma/HGD IPMN carcinoma scalpel 8.4%, saline coupled radio frequency ablation (RFA) Sensitivity 58.3% 46.25% 3.17% and scalpel 1.8%. The visible pancreatic duct and/ Specifi city 88.14% 90.7% or parenchyma were oversewn in 73%. In 21.6%, pancre- Positive likelihood ratio 4.92 4.96 atic stump was treated with the RFA device. Clinically sig- Negative likelihood ratio 0.47 0.59 nifi cant leak was seen in 3.4% of patients whose pancreas Positive predictive value 37.89 54.74 was transected with a stapler and oversewn versus 15.3% Negative predictive value 75.00 85.71 of patients in whose pancreas was stapled. Patients whose pancreas was transected using the scalpel or an energy CONCLUSIONS: CA19-9 would appear to be a useful test device and treated with RFA had a 13.3% CSL rate. Pan- in the assessment of IPMN and the identifi cation of an ele- creas transected using a stapler and the stump treated with vated level of this tumour marker indicates a signifi cant risk RFA had a 19.2% CSL rate, whereas oversewing a pancreatic of associated carcinoma or HGD, even if there is no radio- margin that had been treated with the RFA device had a logical evidence of cancer 28.6% clinically signifi cant leak rate. A patient with tran- sected margin treated with oversewn relative to a patient Tu1575 whose pancreas transected with stapler and oversewn was at highest risk for CSL [p = <0.001, OR 11.5 (CI 3.1–42.4)]. Pancreatic Stump Leak After Distal Pancreatectomy: In univariate models, the use of the RFA device and over- Predictors and Outcomes sewing of the pancreatic duct were predictors of a CSL (p < 0.05). On evaluating various modes of transection, there Ashwin S. Kamath1, Florencia G. Que1, William S. Harmsen2, 1 1 1 was interaction of RFA with oversewing and stapling with Saada A. Seidu , Dilpreet Singh , Christian Arroyo Alonso oversewing of the pancreatic stump (p < 0.001)]. 1General Surgery, Mayo Clinic, Rochester MN, Rochester, MN; 2Biomedical Statistics and Informatics, Mayo Clinic, Rochester MN, CONCLUSION: Among various methods available for pan- creatic transection during DP, many of them recent tech- Rochester, MN nologies, none have a clinical superiority. Using the stapler INTRODUCTION: Clinically signifi cant pancreatic leak to transect the pancreas has a higher rate of clinically sig- continues to complicate distal pancreatectomies (DP). We nifi cant leak as compared to treating the transected stump report the outcomes of various methods of pancreatic tran- with RFA. Using the RFA device in addition to a stapler or section and management of the pancreatic stump at our oversewing the transected margin has a higher rate of clini- institution. cally signifi cant leak and should not be attempted. Ran- METHODS: Retrospective review of all patients undergo- domized trials of newer technologies to help solve this age ing DP from 01/1999 to 07/2010. Leaks were retrospectively old dilemma are necessary. classifi ed according to the strict ISGPF guidelines. Grade B and C leaks were grouped as clinically signifi cant (CSL). Poster Abstracts Tuesday

207 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1576 predictor of complications and early mortality for patients undergoing surgical operations. The Surgical APGAR was Surgical APGAR Score Does Not Predict initially found to correlate with major complications fol- Morbidity and Mortality for Patients Undergoing lowing pancreaticoduodenectomy; however, this study Pancreaticoduodenectomy for Pancreatic refutes these fi ndings. Herein, we show that the Surgical Adenocarcinoma APGAR does not predict major morbidity or mortality for patients undergoing pancreaticoduodenectomy for pan- Paul Toomey, Sharona B. Ross, Charles Tkach, creatic adenocarcinoma. Still, intuitively, patients benefi t Nicholas J. Sarabalis, Kenneth Luberice, Kaulin Jani, from short operations without hemodynamic instability Alexander Rosemurgy and blood loss or transfusions. General Surgery, Florida Hospital Tampa, Tampa, FL INTRODUCTION: The Surgical APGAR was published Tu1577 in 2007 as a simple method for predicting postoperative morbidity and mortality for patients undergoing General Rectus Abdominis Atrophy After Ventral Abdominal Surgery operations. The Surgical APGAR consists of three Incisions: Midline Versus Chevron objective measures of an individual’s intraoperative course: Yalini Vigneswaran, Mark Talamonti, Steve Haggerty, the lowest heart rate, the lowest mean arterial blood pres- John G. Linn, Woody Denham, Mathew Zapf, Joann Carbray, sure (MAP), and the estimated blood loss (EBL). The Surgical Michael B. Ujiki APGAR was shown to predict major morbidities for patients Surgery, NorthShore University HealthSystem, Evanston, IL undergoing pancreaticoduodenectomy; the purpose of this study was to validate that the Surgical APGAR predicts PURPOSE: To investigate rectus atrophy after abdominal major morbidity and mortality for patients undergoing surgery through a midline versus Chevron incision. pancreaticoduodenectomy for pancreatic adenocarcinoma. METHODS: We performed a retrospective analysis of all METHODS: Patients who underwent pancreaticoduo- patients that underwent open pancreaticobiliary surgery at denectomy for pancreatic adenocarcinoma from 1991– our institution between 2007 and 2011. Of the 210 patients 2012 are prospectively followed. Anesthesia records were included in the study, 180 underwent an operation through reviewed and the lowest heart rate, lowest MAP, and the a midline incision and 30 through a Chevron incision. The EBL of the operations were recorded. The Surgical APGAR two groups were defi ned by patient demographics, preop- scores were calculated using the proposed algorithm. Major erative albumin, diagnosis, type of operation and adjuvant morbidities were classifi ed using Clavien scores and the therapies. We measured rectus abdominis muscle thickness in-hospital mortality was assessed. Data are presented as on preoperative and follow-up CT scans to calculate per- median, mean ± standard deviation. Correlations were cal- cent atrophy of the muscle after surgery. We additionally culated using logistic regression analysis and p-values <0.05 recorded incisional hernias as reported by the radiologist were considered signifi cant. on the postoperative CT scan. RESULTS: 392 patients underwent pancreaticoduodenec- RESULTS: The two groups, midline and chevron, had tomy for pancreatic adenocarcinoma. The median lowest patient populations of similar characteristics with average heart rate was 64, 64 ± 10.5, the median lowest MAP was 64 follow up of 18.1 and 24.5 months respectively. The mid- mmHg, 63 mmHg ± 7.9, the estimated blood loss was 500 line group demonstrated signifi cantly less average rectus bpm, 650 bpm ± 601.3, and the Surgical APGAR was 6, 6 ± atrophy, 2.90% compared to the chevron group with 21.8% 1.4. The lowest heart rate, lowest MAP, or EBL did not inde- atrophy (p < 0.001). Additionally there was no statistical pendently or in combination correlate with Clavien scores. difference between the number of incisional hernias on There was no correlation between Surgical APGAR and Cla- CT scan for the midline group, 8.33% versus 6.67% in the vien scores (Table: p = NS) or mortality. chevron (p = 0.76). CONCLUSIONS: Patients who underwent an open opera- tion through a midline incision demonstrated signifi cantly less atrophy as compared to those patients who underwent an operation through a Chevron incision. This resulting atrophy is most likely secondary to the disruption of the intercostal nerves and innervation to the rectus abdominis CONCLUSIONS: Pancreatic cancer is the fourth leading with Chevron incisions, which is avoided during midline cause of cancer death in the United States and has the incisions. Additionally our results showed there was no sig- highest fatality rate. Complications with pancreaticoduo- nifi cant difference between the groups for other morbidities denectomy for pancreatic adenocarcinoma remain high such as incisional hernias. Thus from our experience a mid- and contribute to poor survival. Scoring systems to predict line incision is associated with less postoperative changes complications after surgical intervention have been devel- and should be the preferred abdominal incision. Additional oped but have been cumbersome to calculate, inaccurate, studies may be conducted to further evaluate the morbidity and impractical. The introduction of the uniquely simple associated with rectus abdominis atrophy. Surgical APGAR provided hope for a practical prospective

208 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1578 Clinical: Small Bowel The Incidence of Pancreatic Fistula Following Distal Pancreatectomy for Cancer Rises with Increased  Tu1579 Manipulation of the Pancreatic Remnant Nursing Homes: No Place for Bowel Obstructions with Alan A. Thomay1, Victor H. Barnica2, James C. Watson1, Karen Ruth1, John P. Hoffman1 Hernias 1Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA; Justin Lee, Peter E. Miller, Allan Mabardy, Alan W. Hackford, 2Surgery, Mercy Health Medical Center, Philadelphia, PA Kevin O’Donnell Surgery, St. Elizabeth Medical Ceneter, Tufts University School of INTRODUCTION: Recent advances in operative tech- Medicine, Boston, MA nique and post-operative care have resulted in low mortal- ity following distal pancreatectomy (DP). However, rates of INTRODUCTION: Best practices encourage early diagno- pancreatic fi stula (PF) remain as high as 40%. This study sis and treatment of bowel obstruction due to abdominal was performed to determine trends for pancreatic rem- wall hernias. Delay in care is associated with incarceration nant closure and identify potential risk factors for PF at our and potential strangulation. The purpose of this study was institution. to compare outcomes of bowel obstruction due to abdomi- nal wall hernias in elderly patients living in long-term care METHODS: Data from every patient undergoing DP from facilities (LCF). 2007 to present were retrospectively reviewed. Primary out- come was PF, classifi ed according to ISGPF. Other variables METHODS: The Nationwide Inpatient Sample for 2009 included patient demographics, neoadjuvant therapy, oper- was used to identify hospitalizations due to bowel obstruc- ative details, complications, and pathologic examination. tion with abdominal wall hernias (age > 65). Outcomes Differences in variables by PF status were assessed with Chi- of gangrenous bowel and bowel resection were compared square, Fisher exact, and t-tests as appropriate. A p-value based on whether the patients were transferred from LCF. < .05 was considered signifi cant. Economic analysis included length of stay (LOS) and total hospital charges (THC). Multivariate logistic regression RESULTS: 89 patients underwent DP during the study analysis was used to identify independent risk factors for interval, 79% of which had pathologically confi rmed gangrenous bowel or bowel resection. malignancy with the most common being pancreatic duc- tal (21%) and renal cell (17%). Mean age was 61 years, 79% RESULTS: 30,828 bowel obstruction with hernia cases were were Caucasian, 50% were male, and 1/3 were obese (BMI > identifi ed. Patients living in LCF were more likely to pres- 30). Only 25% received chemotherapy and 11% radiation. ent with gangrenous bowel (5.8% vs 2.2%, OR 2.734, P = Operatively, 74% had concomitant splenectomy, 48% had 0.008). LCF patients were also more likely to require bowel at least one other procedure, and 95% had a drain. Pan- resection (24.5% vs 15.7%, OR 1.750, P = 0.003). Mortal- creatic transection was accomplished by: electrocautery ity was signifi cantly higher for the LFC patients (13.0% vs alone (12.4%), transection and oversewn (39.3%), stapled 3.7%, OR 3.906, P < 0.001). Gangrenous bowel or bowel (36.0%), stapled and oversewn (12.4%). Mean hospital resection resulted in increased median LOS (9 days vs 4 length of stay was 8.3 days, but increased by 3 full days if days) and mean THC ($88,611 vs $44,987, P < 0.001). Mul- PF was present (10.2 vs 6.9 days). Overall PF rate was 43%, tivariate logistic regression analysis adjusting for Medicare with 2/3 requiring percutaneous intervention. PF rate was coverage, poorest median income, urban location, psychi- no different in the electrocautery alone (37.1%), transec- atric disorders, and depression found LCF residence to be tion and oversewn (36.4%), and stapled (40.6%) groups. an independent risk factor for gangrenous bowel or bowel However, the rate of PF was nearly double in the stapled resection (OR 2.766, P < 0.001). and oversewn cohort (72.7%) with no difference if omen- CONCLUSION: Patients with bowel obstruction due tum was used to cover the remnant. to abdominal hernias living in LCF are at a signifi cantly CONCLUSIONS: The ideal closure method for the pancre- increased risk of developing gangrenous bowel and requir- atic remnant following DP remains unknown. These data ing bowel resection. Potential delay in diagnosis may con- demonstrate that PF incidence rises with increased manipu- tribute to delay in presentation resulting in signifi cant lation of the pancreatic remnant. Thus, when utilizing a morbidity and mortally. stapled closure, separate ligation of the pancreatic duct should be avoided. Poster Abstracts Tuesday

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Tu1580 Features of Patients Undergoing Re-Exploration Early Post-Operative Small Bowel Obstruction: Open vs. Features Open n = 130 Lap n = 59 P Laparoscopic Active malignancy 42% 12% <0.01 Naeem Goussous, Kevin M. Kemp, Michael P. Bannon, Days to reoperation 13 10 0.02 Michael L. Kendrick, Boris Srvantstyan, Martin D. Zielinski Severe complications 24% 10% 0.03 Mayo Clinic, Rochester, MN Minor complications 18% 23% 0.40 Re-reoperation 6% 7% 0.87 OBJECTIVE: The window for safe re-operation in early Mortality 5% 0% 0.09 post-operative (<6 weeks) small bowel obstruction (SBO) Days after reoperation 10 9 0.02 is short and intimately dependent on elapsed time from Persistent SBO at 6 weeks 8% 0% 0.03 the initial operation. Laparoscopic procedures create Focal cause of obstruction 63% 85% <0.01 fewer infl ammatory changes than open laparotomies. We hypothesize that it is safer to re-operate for early SBO after Strangulation obstruction 2% 7% 0.21 laparoscopic procedures than open. EC Fistula 2% 0% 0.24 Enterotomy 7% 12% 0.44 METHODS: Review of patients who underwent explora- tion for early post-operative SBO from 2003 to 2009 at a ter- CONCLUSION: Initial laparoscopic approaches confer a tiary referral center. Based on the initial operation, patients lower rate of adhesive disease and severity of complications were classifi ed as ‘open’ or ‘laparoscopic’. The Revised compared to open when operating for early post-operative Accordion Severity Grading System was used to defi ne com- SBO. Reoperation should be undertaken prior to 14 days, plications as minor (1–2) or severe (3–6). P < 0.05 was con- particularly after open procedures, as the complication sidered signifi cant. severity continues to increase as time elapses from the date RESULTS: There were 189 patients (age 55 years, 48% of initial operative intervention. male); 130 open and 59 laparoscopic. Adhesive disease was the most common cause of early SBO with the open group Tu1581 having the greatest rate (tables 1 and 2). The open group also had a greater rate of malignancy, days to re-operation, Laparoscopic Versus Open Surgical Management of severity of complications, length of stay after re-operation Small Bowel Obstruction: An Analysis of Short-Term (LOS) and persistent SBO at 6 weeks. There was no dif- Outcomes ference in the rates of minor complications, enterotomy, Fady Saleh1, Timothy Jackson1,2, Allan Okrainec1,2 strangulation, re-reoperation, enterocutaneous fi stula and 1General Surgery, University Health Network, Toronto, ON, Canada; mortality. 25% of the laparoscopic procedures were suc- 2 cessfully completed laparoscopically at the reoperation and Surgery, University of Toronto, Toronto, ON, Canada were more commonly caused by a focal source. 82 patients BACKGROUND: The application of laparoscopy in acute (63 open, 19 laparoscopic) underwent reexploration ≥14 care surgery continues to expand. Adhesive small bowel days. Within this subgroup, there were more severe compli- obstruction has traditionally been managed via an open cations (25% vs 5%) after open procedures with equivalent approach although appropriately selected patients may mortality (4% vs 0%). benefi t from laparoscopy. Causes for Early Post-Operative SBO OBJECTIVE: The objective of this study is was to compare short-term post-operative outcomes in patients with adhe- Early Post-Op sive small bowel obstruction (SBO) treated laparoscopically SBO Cause Open n = 130 Lap n = 59 P versus with laparotomy. Adhesive 65% 42% <0.01 METHODS: Using the (2005–2010) ACS NSQIP Partici- External hernia 16% 27% 0.08 pant Use Files, patients with a post-operative diagnosis Internal hernia 8% 10% 0.57 of adhesive SBO were selected for inclusion in this study. Stricture 5% 14% 0.03 Patients were excluded if they had a bowel resection or Volvulus 5% 7% 0.54 other concomitant procedures. Data on cases converted to Malignant 1% 0% 0.34 laparotomy was not available. Both univariate analyses and multivariate logistic regression were performed to compare the open and laparoscopic groups for 30-day morbidity and mortality outcomes.

210 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

RESULTS: 4,760 patients with adhesive SBO were identi- Tu1582 fi ed in the dataset: 3,847 (80.1%) treated with laparotomy, and 919 (19.3%) via a laparoscopic approach. Mean opera- Laparoscopic Hand Assited Small Bowel Resection for tive time was similar in both groups. There were a total of Carcinoid Tumor: Are Outcomes Equivalent to the 275 (7.2%) wound infections in the open group compared Open Technique? to 6 (0.7%) in the laparoscopic group corresponding to an Tarek Waked, Wael Khreiss, Florencia G. Que OR (95% CI, P-value) of 11.7 (5.30–32.35, P < 0.001). The Mayo Clinic, Rochester, MN mortality and overall complications were 87 (2.3%) and 877 (22.8%) in the open group compared to 7 (0.6%) and INTRODUCTION: Small bowel carcinoids account for 91 (9.9%), with respective unadjusted OR 3.02 (1.40–7.76, 42% of neuroendocrine tumors within the GI tract. The P = 0.003) and 2.70 (2.14–3.42, P < 0.001). Using our mul- fi nding of these tumors should be followed by an in-depth tivariate model, the adjusted OR for overall complications search for additional primary tumors which may be found was 2.27 (1.80–2.87, P < 0.001) favoring the laparoscopic in a third of patients. These can only be detected by close group. The mean post-operative length of stay was 8.4 days inspection and palpation in many cases. Traditionally, lapa- after the open approach, compared to 3.8 after the laparo- roscopic resections are regarded as inadequate since they scopic approach (P < 0.001). negate the ability to evaluate the small bowel in a tactile fashion and therefore carry the risk of incomplete resection Table of 30-Day Post-Operative Complications and missed primary tumors. Here we present a retrospective review from a single institution by comparing laparoscopic Laparoscopic Unadjusted hand assisted (LHA) and open small bowel resection for car- Complication Open N (%) N (%) OR (95% CI) P-Value cinoid tumor. Wound 275 (7.2) 6 (0.7) 11.7 (5.30–32.35) P<0.001 Infectious 459 (12.0) 53 (5.8) 2.2 (1.65–3.03) P<0.001 METHODS: A retrospective review of 243 patients that Respiratory 155 (4.0) 10 (1.1) 3.8 (2.01–8.16) P<0.001 underwent either open or laparoscopic hand assisted small Thromboembolic 72 (1.9) 7 (0.76) 2.49 (1.14–6.23) P = 0.018 bowel resection for carcinoid tumor between October 1999 Renal 33 (0.9) 0 (0.0) N/A P = 0.005 and October 2010 was performed. The incidence of carcinoid related postoperative diarrhea, mean number of tumors Neurologic 15 (0.4) 3 (0.3) 1.20 (0.34–6.46) P = 0.778 resected, mean number of lymph nodes resected and Cardiac 40 (1.0) 6 (0.7) 1.60 (0.67–4.64) P = 0.279 median disease free survival was compared between both Bleeding 85 (2.2) 6 (0.7) 3.44 (1.51–9.68) P = 0.002 groups. Mortality 87 (2.3) 7 (0.6) 3.02 (1.40, 7.76) P = 0.0033 Major 643 (16.7) 81 (8.8) 2.08 (1.62, 2.69) P<0.001 RESULTS: A total of 243 patients were included in this Complications cohort: (225 open, 18 Laparoscopic hand-assisted). Median Overall 877 (22.8) 91 (9.9) 2.70 (2.14, 3.42) P<0.001 follow up was 670 days. Mean number of resected primary Complications tumors was 3.4 and 5.3 for open and LHA, respectively (p value = 0.03) . Mean number of resected lymph nodes CONCLUSION: In patients where laparoscopy was feasible, was comparable among the groups (11 for open and 14 for the laparoscopic approach resulted in signifi cantly fewer LHA, p value = 0.23). Postoperative carcinoid related diar- complications and shorter length of stay. This should be rhea was also comparable among both groups (open 49%, interpreted within the context of a retrospective study with LHA 61%, p value = 1.0). The 5 year disease free survival was inherent selection bias, inability to control for all patient 58.5% for the open group and 67.7% for the LHA group (p characteristics, and the inability to identify patients who value = 0.18). There was no statistical signifi cance between required conversion from the laparoscopic approach. Fur- the groups in mean number of lymph nodes resected, post- ther work is needed to better defi ne appropriate patient operative diarrhea, or 5 year disease free survival, however, selection criteria to guide the broader application of lapa- there was a statistical difference in the mean number of roscopy in the treatment of SBO. resected tumors favoring the LHA group. CONCLUSION: Laparoscopic hand assisted small bowel resection for carcinoid tumors is a safe alternative with comparable outcomes to the open technique. Poster Abstracts Tuesday

211 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1583 2000 2005 2010 Mortality Associated with Postoperative Bleeding Number of RYGB Surgery Any RYGB 23,697 88,571 71,199 in Patients Undergoing Roux-en-Y Gastric Bypass: A Open RYGB 100% 27% 10% Nationwide Analysis over a Decade Laparoscopic RYGB 0% 73% 90% Marwan Abougergi, Nitin Kumar, John R. Saltzman, Median age (IQR) 41 (33–48) 42 (34–51) 44 (35–53) Christopher C. Thompson Female 84% 82% 79% Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA Charlson 0: 67% 1: 25% 2: 5% 0: 57% 1: 34% 2: 7% 0: 50% 1: 37% INTRODUCTION: Bariatric gastric bypass surgery tech- comorbidity index 2: 10% niques have evolved over the past decade in an effort to Teaching hospital 79% 55% 58% minimize complications. One serious immediate complica- Urban hospital 98% 97% 92% tion after Roux-en-Y gastric bypass (RYGB) is postoperative Postoperative Bleeding bleeding. We examined the impact of postoperative bleed- Any RYGB 1.8% (426 patients) 2.2% (1956 patients) 2.4% (1681 ing on patient outcomes after RYGB and studied the trend patients) over the past decade. Open RYGB 1.8% (426 patients) 3.1% (751 patients) 5.6% (412 METHODS: We used the Nationwide Inpatient Sample patients) (NIS) to calculate outcomes every 5 years from 2000 to 2010. Laparoscopic RYGB — 1.9% (1209 patients) 2.0% (1269 The NIS is the largest nationally representative publically patients) available inpatient database in the United States. Patients Bleeding-attributable 4.1% 1.64% 1.9% were included if they had an ICD-9 CM code indicating risk of death an open or laparoscopic RYGB. Exclusion criteria were age Bleeding-attributable 0.0% 1.8% 2.0% risk of shock <18, previous weight loss surgery, history of a GI malig- nancy, infl ammatory bowel disease, infectious colitis, and Reoperation for 26.6% 14.8% 6.8% bleeding non-elective admission. Signifi cant bleeding was defi ned as Endoscopy for 5.0% 8.9% 3.5% ICD-9 CM code for packed red blood cell transfusion post- bleeding operatively. Bleeding-related endoscopy rate was defi ned as Bleeding-attributable 3.1 1325 2.1 4010 2.2 3681 the difference in percent endoscopy between patients with LOS (median, days): and without postoperative bleeding. Additional length of Bleeding-attributable stay and additional charge were defi ned as the difference in LOS (patient-days): median length of stay and charge, respectively, between the Bleeding-attributable Median: $34,722 Median:$17,191 Total: Median: patients with and without postoperative bleeding. Charge hospitalization Total: $14,791,572 $33,625,596 $22,104 Total: was adjusted for infl ation using the consumer price index, charge (Indexed $ 37,156,824 and is presented in 2010 US dollars. Comorbidities were to 2010 USD) identifi ed using the Charlson comorbidity index. RESULTS: The incidence of RYGB increased markedly CONCLUSION: The number of patients undergoing RYGB from 2000 to 2005, and then stablized from 2005 to 2010. has substantially increased from 2000 to 2005, and has since The proportion of laparoscopic RYGB has increased from stabilized. The postoperative bleeding rate has increased 0% in 2000 to 90% in 2010. Although the mean age has substantially since 2000, but bleeding-attributable mortal- remained consistent, age distribution has broadened over ity, rate of endoscopy and rate of reoperation for bleeding time, and the comorbidity burden has grown. Over time, has decreased. The total length of stay and fi nancial bur- the proportion of surgeries done at teaching or urban hos- den of postoperative bleeding in patients undergoing RYGB pitals decreased. Postoperative bleeding rate increased by continue to increase. 33% between 2000 and 2010, as did the bleeding-attribut- able risk of shock. However, bleeding-attributable mortality decreased over time, as did the rate of endoscopy and reop- eration for bleeding. Additional length of stay secondary to postoperative bleeding has decreased over time; however, total length of stay and total fi nancial burden related to postoperative bleeding have increased steadily and in 2010 they were 3681 person-days and $37 million, respectively (Table 1).

212 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1584 Tu1585 Minimally Invasive Approach to Small Bowel Laparoscopic vs. Open Recurrent Inguinal Hernia Resection: An Opportunity for Improved Patient Repair: A NSQIP Analysis Outcomes and Mortality Based Upon the ACS-NSQIP Muhammad Asad Khan, Roman Grinberg, John Afthinos, Database Karen E. Gibbs Andrew M. Popoff, Shaun Daly, John D. Cull, Staten Island University Hospital, Staten Island, NY Amanda B. Francescatti, Louis Fogg, Jonathan Myers, OBJECTIVES: Inguinal hernia recurrence after surgical Keith W. Millikan, Steven D. Bines, Minh B. Luu repair is still a rather common occurrence in large pub- General Surgery, Rush University Medical Center, Chicago, IL lished series. Current data indicates rate of recurrence rang- ing 0.2–10%. The optimal approach for repair of a recurrent PURPOSE: Small bowel resection is a commonly per- inguinal hernia is still in question. formed surgical procedure for both benign and malignant disease. The advantages of laparoscopic versus open surgery We sought to query the NSQIP database to ascertain the are well established in the literature; however, a majority national trends in the approach to recurrent non-obstructed of small bowel resections are performed using an open inguinal hernias. technique. To date, no study has reviewed the ACS-NSQIP METHODS: The NSQIP database was queried for laparo- database to determine the utilization of laparoscopy for scopic or open recurrent inguinal hernia repair from 2007 small bowel resection nationally. The purpose of this study to 2009. Age, gender and comorbidities were quantifi ed and is to determine the incidence of laparoscopic small bowel outcomes data collected. Specifi cally, morbidity, mortality, resection and to compare the safety of a minimally invasive length of stay and operative times were examined. Statis- technique to an open technique. tical analysis was then performed. A p-value of <0.05 was METHODS: A retrospective, cohort study was performed considered signifi cant. comparing patients undergoing a minimally invasive small RESULTS: A total of 3874 patients were identifi ed who bowel resection to an open technique. Patients were identi- were diagnosed with recurrence of inguinal hernia, out fi ed utilizing a CPT code driven search of the ACS-NSQIP of which 2692 underwent open hernia repair, while 1182 database between 2007 and 2011. Demographic charac- underwent laparoscopic repair. teristics and postoperative complications were evaluated between the two groups. Univariate analysis was performed Open Repair Laparoscopic Repair with signifi cance defi ned as a p-value ≤ 0.05. N = 2692 N = 1182 P-Value RESULTS: 19,344 patients underwent a small bowel resec- Age 60.4 ± 15.7 57.1 ± 14.9 <.001 tion. Of these patients, 1,719 (9%) underwent a laparo- Male gender 2539 (94.3%) 1117 (94.5%) 0.880 scopic small bowel resection and 17,625 (91%) underwent Diabetes on Insulin 40 (1.5%) 10 (0.8%) 0.020 an open resection. The mean age of patients in the mini- HTN 1111 (41.3%) 390 (33%) <.001 mally invasive group was 57.5 compared to 62.7 years in COPD 97 (3.6%) 21 (1.8%) .002 the open group. A majority of patients undergoing small CHF in 30 days 6 (0.2%) 0 0.187 bowel resection were female (54%) and of the patients who History of MI in 6 months 4 (0.1%) 1 (0.1%) 1 underwent laparoscopic small bowel resection, 54% were Prior PCI 182 (6.8%) 49 (4.1%) 0.001 female. The mean body mass index in the minimally inva- Prior CABG 208 (7.7%) 54 (4.6%) <.001 sive versus open groups was 27.3 and 27.4, respectively. PAD 23 (0.9%) 5 (0.4%) 0.215 There was a statistically signifi cant lower rate of complica- ESRD 20 (0.7%) 2 (0.2%) .034 tions in the minimally invasive group (p = 0.001). In the Smoker 502 (18.6%) 206 (17.4%) 0.391 minimally invasive group, the risk ratio for a postoperative Steroid use 42 (1.6%) 14 (1.2%) 0.465 wound infection compared to the open approach was 0.31 Partially Dependent 28 (1.0%) 2 (0.2%) 0.015 (0.24–0.40), for postoperative sepsis was 0.39 (0.28–0.53), Totally Dependent 4 (0.1%) 1 (0.1%) 0.015 for postoperative septic shock was 0.24 (0.10–0.37), for BMI 26.2 ± 4.2 26.4 ± 4.3 0.309 postoperative pneumonia was 0.36 (0.26–0.50), for postop- erative myocardial infarction was 0.43 (0.22–0.8) and for ASA III or above 46 (1.7%) 12 (1.0%) 0.114 postoperative DVT requiring therapy was 0.31 (0.16–0.57). The in-hospital 30-day mortality rate for a minimally inva- Open Repair Laparoscopic Repair sive resection was 1.7% compared to 6.4% for an open N = 2692 N = 1182 P-Value resection (p = 0.001). Superfi cial SSI 9 (0.3%) 5 (0.4%) 0.772 Poster Abstracts CONCLUSION: Despite the advantages of minimally Deep incisional SSI 2 (0.1%) 1 (0.1%) 1 invasive surgery, a large majority of operations for the Pneumonia 2 (0.1%) 1 (0.1%) 1 Tuesday resection of small bowel are performed via a traditional Return to OR 24 (0.9%) 8 (0.7%) 0.568 open approach. This discrepancy is likely not explained UTI 9 (0.3%) 8 (0.7%) 0.184 entirely by patient factors. The data suggest an opportu- MI 1 (0%) 0 1 nity for improved patient outcomes and improved mortal- DVT 7 (0.3%) 0 0.214 ity rates with widespread adoption of minimally invasive Operative time (min) 65.7 ± 34 72 ± 36 <0.001 approaches to small bowel resection. Length of stay (days) 0.25 ± 0.91 0.30 ± 1.6 0.281

213 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

CONCLUSION: It appears that 30% of recurrent inguinal RESULTS: In the third group—ketamine hydrochloride, hernias were repaired laparoscopically. Both laparoscopic the average length of stay (ALOS) was 6 days, in the second and open approaches to repair of recurrent inguinal non- group—hospitalist, it was 6.5 days and in the fi rst group— obstructed hernias have comparable profi le of patient non-hospitalist, ALOS was 10 days. There was no statisti- population, safety and complications. The fi nal choice of cal difference for the adjunctive ketamine hydrochloride surgical approach should be made based on the surgeon’s group than the hospitalist service (p = 0.753) and but the preference. ketamine (and also as previously reported, the hospitalist) were signifi cantly lower than the non-hospitalist Surgery/ Clinical: Stomach GI service (SOC) group (p = 0.010.) (See Table). Ketamine Tu1586 Patient Service Mean of LOS ± SD P Value Non-hospitalist with ketamine 6.0 ± 3.4 ------Adjunctive Ketamine Therapy May Help Reduce Length hydrochloride of Stay in Selected Patients Undergoing Foregut Surgery Hospitalist service 6.5 ± 5.3 0.75 Shuja Yousuf2, Yana Nikitina2, Ike Eriator3, Kenneith Oswalt3, Non-hospitalist service 10 ± 4.7 0.01 Timothy J. Beacham3, Anand Prem3, Wanda J. Keahey6, Archana Kedar2, Mubina Isani5, Thomas S. Helling4, CONCLUSION: We conclude that adjunct low dose ket- Christopher J. Lahr4, Thomas L. Abell1 amine hydrochloride may reduce the length of stay in 1Digestive Diseases, University of Louisville Medical Center, Louisville, patients with gastroparesis, many of who have a chronic pain disorder, when undergoing foregut surgery. KY; 2Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; 3Anesthesiology, University of Mississippi Medical Center, Jackson, MS; 4Surgery, University of Mississippi Medical Center, Tu1588 Jackson, MS; 5Surgery, University of North Carolina, Chapel Hill, NC; Vitamin D Defi ciency Is a Risk Factor for Persistent 6Medication Management Specialists Inc, Jackson, MS Type 2 Diabetes After Roux-en-Y Gastric Bypass BACKGROUND: We have previously reported that the Andrew A. Taitano, Brian Binetti, Tejinder P. Singh, length of stay (LOS) for the postoperative elective gastric Avinash S. Bhakta electric stimulation (GES) for gastroparesis (Gp) patients is General Surgery, Albany Medical Center, Albany, NY reduced when admitted to a hospitalist service, campared to INTRODUCTION: A growing body of evidence links vita- traditional standard of care (SOC) Surgery/GI service. One min D defi ciency to obesity as well as metabolic syndrome issue for prolonged LOS for postoperative Gp patients has and insulin resistance. Vitamin D defi ciency and insuffi - been post-operative pain and ketamine hydrochloride has ciency is common in patients after gastric bypass surgery, been shown, when used adjunctively, to assist in pain man- though little is known about its relationship to glycemic agement. Since underlying chronic and pre-existant pain control in this population. often often is aoosciated with prolonged LOS in patients undergoing surgical intervention for GES, we examined METHODS: Between January 2005 and December 2011, whether the use of low dose ketamine hydrochloride could 203 patients with type 2 diabetes mellitus (T2DM) under- further reduce LOS in gastroparesis (GP) patients undergo- went laparoscopic roux-en-y gastric bypass (LRYGBP) at our ing GES placement. institution. We retrospectively evaluated demographics, hemoglobin A1C levels, 25-hydroxy vitamin D levels, and METHODOLOGY: Using a pre-established and ongo- medication lists. ing database, we examined three groups of patients, all undergoing the identical operation for placement of gas- RESULTS: Average age was 49.8, average duration of tric electrical stimulators: the fi rst group–16 patients on a T2DM was 7.9 years, 74.5% were women, and 89.2% of the combined Surgery/GI service with the use of adjunctive patients were caucasian. Average length of follow-up was ketamine hydrochloride, via an anesthesia based care pro- 2.8 years. Postoperative pharmacologic therapy for T2DM tocol (the ketamine group): the second group–16 patients and/or hemoglobin A1c levels above 6.9 were seen in 24.7% receiving hospitalist service care post-operatively (hospital- of patients at last follow-up. Postoperative vitamin D lev- ist group), and the third group –16 patients on a combined els consistently under 30 ng/mL were seen in 13.0% of Surgery/Gastroenterology (GI) service receiving standards patients. These patients were more than twice as likely to of care (SOC) without the use of ketamine hydrochloride have persistent T2DM at last follow-up (RR 2.24, CI 1.31 to (non-hosptalist group). Patients receiving ketamine hydro- 3.88, p < 0.01). chloride were matched, by primary diagnosis and IDI- CONCLUSION: Postoperative vitamin D insuffi ciency and OMS scores for health resource utilization (NGM 2005; 17: defi ciency is associated with persistence of T2DM after gas- 35–43), with the other 2 groups. All data were analyzed by tric bypass surgery. Aggressive supplementation with vita- group, reported as mean and standard deviation values, and min D may improve outcomes in these patients. compared by student t-tests.

214 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu1589 Tu1590 Endoscopic Management Options for Strictured Vertical Is There Optimal Surgery Time After Endoscopic Banded Gastroplasty Resection in Early Gastric Cancer? Nathan E. Conway1, Lee L. Swanstrom2, Kevin M. Reavis2 Da Hyun Jung1, Moo Jung Kim1, Jie-Hyun Kim1, Yong Chan Lee2, 1Providence Cancer Center, Portland, OR; 2Gastrointestinal & Jong Won Kim3, Seung Ho Choi3, Woo Jin Hyung4, Sung Hoon Noh4, Minimally Invasive Surgery, The Oregon Clinic, Portland, OR Young Hoon Youn1, Hyojin Park1, Sang in Lee1 1 INTRODUCTION: Vertical banded gastroplasty (VBG) is Department of Internal Medicine, Gangnam Severance Hospital, a restrictive bariatric procedure performed by creating a Yonsei University College of Medicine, Seoul, Republic of Korea; stapled proximal gastric pouch with a lesser curvature out- 2Internal Medicine, Yonsei University College of Medicine, Seoul, let, reinforced with a prosthetic band. Popular in the 1980s, Republic of Korea; 3Surgery, Gangnam Severance Hospital, Yonsei this procedure can result in a fi xed outlet obstruction and University College of Medicine, Seoul, Republic of Korea; 4Surgery, progressive pouch dilation over time. The standard method Yonsei University College of Medicine, Seoul, Republic of Korea of revision has traditionally been a complex and diffi cult operation. We report our experience with endoscopic man- BACKGROUND/AIMS: Endoscopic resection (ER) is agement of strictured VBG. being increasingly recognized worldwide as a major cura- tive option for selected cases of early gastric cancer (EGC). METHODS: Three patients with previous VBG presented However, additive surgery is mandatory for the cases that with persistent nausea and vomiting. All underwent pre- have undergone non-curative ER. The aim of this study was operative workup demonstrating high-grade gastric pouch to evaluate the effect of the time interval between ER and outlet obstruction. Endoscopic gastric band division was surgery on oncological safety and surgical outcomes. planned for all patients. An endoscope was passed tran- sorally and was used to identify the common wall between METHODS: We analyzed 154 patients who underwent the gastric pouch and distal stomach; this was marked with additive gastrectomy after ER due to non-curative resection a submucosal injection of blue dye to maintain orienta- between January 2007 and December 2011 at Severance and tion. Using a combination of a needle knife cautery and Gangnam Severance Hospital. Patients were divided into 2 a pull type sphincterotome for both antegrade and retro- groups according to the median time interval between ER grade approaches, an incision was made from the strictured and additive surgery such as group A (≤ 29days) and group opening along the stapled common wall of the stomach. In B (>29 days). We retrospectively evaluated the clinicopath- one case, the gastric band was unable to be divided in this ological characteristics, clinical outcomes, and operative/ manner, as it was probably polypropylene vs silastic. In this postoperative outcomes. We also analyzed subgroup which case, an endoscopic gastrogastrostomy was performed from underwent gastrectomy by experienced surgeons. Expe- the proximal pouch to the distal stomach, using the staple rienced surgeon was defi ned as surgeon with more than line of the gastroplasty as a landmark. A second endoscope fi ve years of surgical experience for gastrectomy in order to was used to provide transillumination and improved visual- adjust surgeon’s experience factor. ization, similar to the technique used in the creation of per- RESULTS: Of the 154 patients, 78 (50.6%) were in group A cutaneous endoscopic gastrostomy tubes. An opening was and 76 (49.4%) in group B. There was no difference of clini- made by a direct puncture between the proximal pouch and copathologic characteristics and oncological recurrence the distal stomach directly through the staple line using the except for tumor size (A: 2.49 ± 1.63 cm vs. B: 1.81 ± 1.16 needle knife. Using the dual endoscopes, we were able to cm, P = 0.002). Operation time (A: 222.41 ± 79.26 min vs. visualize entry of the needle knife into the distal stomach B: 175.46 ± 71.88 min, P < 0.001), estimated intra-operative across the common wall. This tunnel was dilated with a 12 blood loss (A: 152.21 ± 217.64 cc vs. B: 68.01 ± 164.16 cc, mm endoscopic balloon over a wire followed by placement P = 0.007), time to start liquid diet (A: 3.27 ± 1.20 day vs. of a 105 mm (length) by 23 mm (diameter) fully covered B: 2.70 ± 1.03 day, P = 0.002), post-operative hospital day stent. (A: 10.50 ± 9.37 day vs. B: 7.17 ± 4.49 day, P = 0.006), and RESULTS: The procedure was well tolerated. Operative time of hemovac removal (A: 3.79 ± 3.17 day vs. B: 2.28 ± time was between 35 and 135 min. Upper gastrointestinal 3.66 day, P = 0.007) were statistically different between two contrast studies on the fi rst postoperative day revealed reso- groups. There were no local recurrence and 3 cases of dis- lution of the outlet obstruction. All patients were discharged tant recurrence during follow-up period (A: 22.81 ± 14.55 within three days. The patients tolerated resumption of diet vs. B 30.61 ± 17.27, P = 0.003). The surgical time of 3 cases and are doing well 6 weeks following the procedures. The was 8 days, 8 days, and 100 days after ER, respectively. The stent was removed after 9 weeks without sequelae. results was also similar in subgroup which underwent gas-

trectomy by experienced surgeons. Poster Abstracts CONCLUSIONS: Endoscopic reversal of VBG is feasible and safe. The material from which the band was fash- CONCLUSIONS: The time interval between ER and addi- Tuesday ioned directly affected the ease and ability with which it tive surgery may be associated with operative and post- was divided; soft silastic was easy and polypropylene mesh operative outcomes though there is no association with impossible to divide, which necessitated direct puncture oncological recurrence. A large-scale prospective study and though the common gastric wall. The biliary sphinctero- long term follow-up should be necessary to recommend the tome was well suited for the procedure and the use of two optimal surgery time after ER in EGC. upper endoscopes permitted safe transillumination for the procedure.

215 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Tu1591 Tu1592 Provides Superior Intermediate-Term Hand Grip Strength, Depression, Anxiety, and Stress in Weight Loss Compared to Gastric Bypass in the Super- a Bariatric Surgery Population Obese (BMI > 50 kg/m2) Natalia Leva, Carl Dambkowski, Chris S. Crowe, Marc A. Ward1, Yong Huang2, John C. Alverdy1, John M. Morton Vivek N. Prachand1 Surgery, Stanford University, Stanford, CA 1Surgery, University of Chicago Medicine, Chicago, IL; 2University of BACKGROUND: Abnormal hand grip strength has been Chicago, Chicago, IL associated with increased mortality and depressive/anxiety OBJECTIVES: Although Roux-en-Y gastric bypass (RYGB) disorders. This study’s aim is to determine a relationship is the most common bariatric operation performed in between hand grip strength, weight loss, BMI, comorbidi- the U.S., recent data suggest inadequate weight loss rates ties, and depression, anxiety, and stress in a bariatric sur- approaching 40% in super-obese patients (BMI > 50 kg/ gery population. m2). We previously reported the fi rst large single institu- METHODS AND PROCEDURES: Demographic, preop, tion series directly comparing the short-term weight-loss and 3 month postop data were prospectively collected on outcomes in super-obese patients following biliopancreatic 35 consecutive laparoscopic surgeries (18 roux-en-Y-gastric diversion with duodenal switch (DS) and RYGB up to 3 years bypass, 15 sleeve gastrectomy, and 2 adjustable gastric following the operation. Here we report an intermediate- band) at a single academic institution. At each clinic visit, term analysis of this comparison up to 8 years after surgery. patients enrolled in the study participated in a hand grip METHODS: All super-obese patients undergoing DS or strength test using a hand dynamometer. Participants also RYGB between August 2002 to October 2005 were identi- fi lled out a Depression, Anxiety, Stress Scales (DASS) Survey fi ed from a prospective database. Two sample t-tests were preoperatively and 3 months postop. Demographic, weight used to compare weight loss, decrease in BMI, and excess loss, absolute hand grip strength, and hand grip as a per- body weight loss (EBWL) after surgery. Chi-squared analy- centage of established norms were compared to DASS scores sis was used to determine the rate of successful weight loss by student t-tests and regression analyses using GraphPad (EBWL > 50%) at all time points. Prism6 software. RESULTS: 350 super-obese patients [DS (n = 198), RYGB (n RESULTS: At 3 months postop, 74.3% of patients com- = 152) were identifi ed. There was an equal 30 day mortality pleted hand grip and survey tests. Patient demographics between the two groups (DS, 1 of 198; RYGB, 0 of 152; P not included an average BMI 46.1, age 43.7, 52.6% white, and signifi cant). A total of 6 additional patients were excluded 3.9 total preoperative comorbidities. Major pre-op comor- from the analysis (5 DS patients underwent revision due to bidities included hypertension 55.3%, diabetes 39.5%, nutritional issues, 1 RYGB was converted to DS for insuf- hyperlipidemia 44.7%, sleep apnea 47.4%, and depression fi cient weight loss). There was a signifi cantly lower BMI 26.3%. Average operative time was 134.2 minutes. Hand following the DS procedure compared to the RYGB at all grip strength was maintained at 3 months postop despite time points (4yr, 33 vs. 39; 5–6yr 33 vs39; yr7–8, 36vs 41). massive weight loss. No correlation was found between Total weight loss and % EBWL were also statistically greater preoperative hand grip strength and percent excess weight for the DS. In addition, the likelihood to achieve successful loss at 3 months (r2 = 0.0014; p = 0.42). Participants with weight loss (EBWL > 50%) is signifi cantly greater following hand grip strength below normal had lower operative times the DS at all time points (4yr, 83% vs. 56%; 5–6yr 86% vs (111.2 ± 35.9) than those with hand grip strength above 48%; yr7–8, 68% vs 22%). normal (154.8 ± 43.3; p < 0.01). Moreover, a positive cor- relation was observed between adjusted preoperative hand CONCLUSIONS: DS has superior intermediate-term weight grip strength and operative time, with greater adjusted loss outcomes in the super-obese compared to the RYGB. hand grip strength correlating with longer operative time (r2 = 0.193; p < 0.01). BMI alone, however, was not cor- related with operative time (r2 = 0.0262; p = 0.16). A rela- tionship was observed between preop hand grip strength and preoperative total DASS score, with weaker hand grip correlating to higher (worse) DASS scores (p < 0.01). Fur- thermore, greater improvements in hand grip strength 3 months postop correlated with greater improvements in DASS score (p < 0.01). CONCLUSIONS: Hand grip had a positive relationship with operative time independent of BMI. Greater hand grip strength was correlated with lower DASS scores preop- eratively and at 3 months postoperatively. Improvements in hand grip strength were correlated with improvements in DASS scores suggesting that bariatric surgery patients’ hand grip strength might be a marker for their psychologi- cal strength. Further investigation will reveal associations between hand grip and longer-term weight loss and comor- bidity improvement.

216 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Translational Science: Colon-Rectal

 Tu2131 The Clinical Utility of the Local Infl ammatory Response in Colorectal Cancer Colin H. Richards1, Campbell S. Roxburgh1, Arfon G. Powell1, Alan K. Foulis2, Paul G. Horgan1, Donald C. Mcmillan1 1Department of Surgery, Glasgow University, Glasgow, United Kingdom; 2Department of Pathology, University of Glasgow, Glasgow, United Kingdom BACKGROUND: The host immune response is important in the prevention of tumour progression in solid organ cancers but is not utilised in clinical practice. The aim was to evaluate the clinical utility of the local infl ammatory response in patients with colorectal cancer. METHODS: Three hundred and sixty-fi ve patients with primary operable colorectal cancer were included. The local infl ammatory response was assessed using three differ- ent methods; (1) individual immune cells (CD3 +, CD8 +, CD45R0 +, FOXP3 + ); (2) a composite immunohistochem- Figure 1: Kaplan-Meier survival curves demonstrating the cancer istry-based score (Galon Immune Score); (3) a histopatho- specifi c survival of patients with primary operable colorectal cancer logical assessment (Klintrup-Makinen grade). Relationships according to the application of proposed immune scores. Clockwise from with tumour and host characteristics were established and top left; CD + IM, CD8 + CCN, K-M grade and the Galon Immune Score the prognostic value of each method compared. (strong to weak infi ltration are shown top to bottom). RESULTS: A strong infi ltration of tumour infi ltrating lymphoctyes (TIL’s) was associated with improved cancer CONCLUSION: A coordinated adaptive immune response specifi c survival. When specifi c T-cell subtypes were con- is an important factor in predicting outcome in patients sidered, CD3 + was the strongest predictor of survival at with colorectal cancer. By comparing different methodolo- both the invasive margin (CD3 + IM) and tumour stroma gies we have provided a foundation on which to develop a (CD3 + ST) while CD8 + was the strongest predictor in the standardised approach for assessing tumour infl ammatory cancer cell nests (CD8 + CCN). Infi ltration of TIL’s was cell infi ltrate. associated with early tumour stage, an expanding growth pattern and lower levels of venous invasion but was not infl uenced by host characteristics or systemic infl amma- tion. The Galon Immune Score and the Klintrup-Makinen grade were strongly related to individual T-cell infi ltration and all three methods exhibited similar survival relation- ships in both node-positive and node-negative disease. Poster Abstracts Tuesday

217 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT

Translational Science: Other value (NPV) for the mortality and bowel ischemia were ana- lyzed. PASW Statistics 18 was utilized for statistical analysis. RESULTS: Two hundred and two patients who had Tu2132 recorded preoperative serum lactate (s) were included in Can Serum Lactate Predict the Outcome of Patients the study. The preoperative serum lactate was checked only Who Underwent Emergent Exploratory Laparotomy for once in 130 patients and more than once in 72 patients. For patients with serial lactates, the trend over time was Acute Abdomen? recorded. Postoperative diagnoses were small bowel Kaori Ito, Cheryl Anderson, Marc D. Basson obstruction (n = 67, 33%), large bowel obstruction (n = 44, Surgery, Michigan State University, East Lansing, MI 22%), bowel ischemia (n = 38, 19%), perforated gastric or BACKGROUND: Serum lactate is a biomarker that pre- duodenal ulcers (n = 31, 15%), colonic perforation (n = 13, dicts mortality in patients with non-cardiogenic circulatory 6%), acute diverticulitis (n = 19, 9%), others (n = 21, 10%), shock like sepsis or severe trauma. Some reports suggest and negative exploration (n = 3, 1%). There were 34 (17%) using the serum lactate to predict the prognosis in patients postoperative in-hospital mortalities (The median time with acute abdomen, but this is not well understood. We between surgery to death: 6.5 days [Range: 0–102]). All 3 hypothesized that the preoperative serum lactate level patients who underwent negative laparotomy had a normal can help to predict the postoperative outcome in patients serum lactate (s) preoperatively. As shown on Table 1, the undergoing exploratory laparotomy for acute abdomen. persistent abnormal or up-trending serum lactate was seen more frequently in patients in who died in hospital after METHODS: Medical records of 293 consecutive patients exploration (53% vs 26%, p = 0.002); as well as, in patients who underwent emergent exploratory laparotomy for acute with bowel ischemia (46% vs 28%, p = 0.090) . The serum abdomen from 2007 through 2010 were reviewed. Patients’ lactate had the similar specifi city and NPV to SIRS score, demographics, preoperative laboratory tests including ASA class and WBC; however, had the lower sensitivities white blood cell counts (WBC), serum lactate, postopera- than other factors. tive diagnosis, Systemic Infl ammatory Response Syndrome (SIRS) Score, the American Society of Anesthesiologists CONCLUSION: Normal or down-trending serum lactate (ASA) physical status classifi cation, postoperative in-hospi- strongly predicts postoperative survival in patients who tal mortality were reviewed. These factors were compared undergo emergent exploratory laparotomy for acute abdo- between patient who died in hospital after the exploration men, although persistently elevated serum lactate does not and who survived, as well as between patients with bowel necessarily predict mortality. It may be useful prognostic ischemia and without bowel ischemia. Sensitivity, specifi c- information for patients and families if combined with ity, positive predictive value (PPV), and negative predictive other factors.

Table 1

WBC (cells/L) Lactate Persistent SIRS Score 2 ASA class 4 or 5 >12,000 or <4,000 Abnormal or Trend Up No Yes No Yes No Yes No Yes Mortality Survived 96 9 127 5 100 11 124 18 Died 69 24 36 28 64 22 44 16 P value 0.001 <0.0001 0.003 0.002 Sensitivity, Specifi city, 73%, 58%, 26%, 91% 85%, 78%, 44%, 96% 67%, 61%, 26%, 90% 53%, 74%, 29%, 89% PPV, NPV Bowel Ischemia No 86 19 116 16 95 16 118 22 Yes 74 19 43 21 64 22 46 16 P value 0.677 0.001 0.049 0.09 Sensitivity, Specifi city, 50%, 54%, 20%, 82% 57%, 73%, 33%, 88% 58%, 60%, 26%, 86% 42%, 72%, 26%, 84% PPV, NPV

218 54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL

Tu2133 Translational Science: Stomach Anatomic Landmarks as a Reliable and Reproducible Guide for the Laparoscopic Sleeve Gastrectomy Tu2134 Peter Nau, David B. Lautz, Ozanan R. Meireles Mesothelin Expression and Its Clinicopathological MGH, Boston, MA and Prognostic Signifi cance in Gastric and Gastro- INTRODUCTION: Medical attempts at durable weight loss Esophageal Junction Cancer are fraught with failures related to durability and lack of Hugo Santos-Sousa1,2, Lara Marcos-Silva3, JoãO Pinto-De-Sousa1,2, clinically signifi cant outcomes. Metabolic surgery promotes Leonor David3,4, José Costa-Maia1 long-term weight loss and resolution or improvement of 1Department of Surgery, Centro Hospitalar de Sao Joao, Porto, obesity-related comorbidities. The laparoscopic sleeve gas- 2 trectomy (LSG) is currently the fastest growing metabolic Portugal; Department of Surgery, University of Porto Medical School, 3 procedure in the world. Standardization of the procedure Porto, Portugal; Institute of Molecular Pathology and Immunology has yet to be adopted by the bariatric surgical society. We of the University of Porto (IPATIMUP), Porto, Portugal; 4University of have identifi ed reliable anatomic landmarks for the safe Porto Medical School, Porto, Portugal and reproducible creation of the gastric sleeve independent BACKGROUND: Mesothelin (MSN) is expressed both in of body habitus. normal mesothelium and in several types of malignant METHODS: Anatomic landmarks identifi ed include the tumors. In recent literature there are confl icting results on pylorus, location of the incisura, the crossing lesser curva- the role of MSN expression in gastric cancer. In this study ture vessels, the left crus and the angle of His. The proce- we evaluated the clinicopathological and prognostic signifi - dure begins by lysing the gastrocolic ligament beginning cance of MSN expression in gastric and gastro-esophageal 6–8 cm from the pylorus with the Harmonic Scalpel. This junction (GEJ) cancer. location coincides with the transition between the gastric METHODS: Tissue specimens from 104 gastric and GEJ body and antrum based on anatomic landmarks from the cancer patients who were submitted to surgical resection incisura angularis and vagus nerve. Dissection is continued in our institution were immunohistochemically evaluated. proximally ligating the short gastric vessels and posterior The intensity of MSN expression in tumor cells was ana- gastric attachments from the retroperitoneum to facilitate lyzed and the location of immunostaining was classifi ed exposure of the left crus and mobilization of the stomach. into membrane and/or cytoplasmic expression. Belsey’s fat pad is then dissected so as to identify the angle RESULTS: MSN was positive in 42 (40.4%) cases and MSN of His and expose the gastroesophageal junction to ensure expression was correlated with tumor location (61.3% of GEJ proper stapler placement while dividing the stomach. A 1.2 cancers), macroscopic appearance (48,8% of fungating and cm (36 French) gastroscope is then used as a guide to iden- ulcer-fungating tumors), Lauren histological classifi cation tify the boundaries of the lesser curvature as excess adipose (52% of intestinal type tumors), tumor invasion depth (pT, tissue often obscures this landmark. A linear stapler is used 7th edition of TNM classifi cation) [57.5% of T4a tumors], to divide the stomach. Variable staple heights decreasing lymph-node metastasis (pN) [46.3% of positive lymph node from 4.1 mm to 3.5 mm are used as the transection line metastasis] and pathological stage. The cytoplasmic MSN moves cephalad. Using the angle of His as the target of the expression, which was identifi ed in 39 cases, was correlated proximal staple line eliminates the risk of retained fundus, with the same clinicopathological features of overall MSN creating a gastric sleeve with the same caliber as the esopha- expression and furthermore to the presence (41.1%) of lym- gus. The transection margin is then inspected for integrity phatic invasion. On the other hand, the membrane MSN during gastroscopy and positive pressure pneumogastrium expression was observed in 23 cases and was correlated only for identifi cation of leaks and discerning of sleeve anatomy. with tumor location and Lauren classifi cation. For the sur- CONCLUSION: Obesity has become a problem of epidemic vival analysis, only 89 cases of R0 resection were included (4 proportions in westernized societies. As the LSG becomes cases of gastric stump tumors were excluded of this analy- more commonplace, standardization will be essential for sis). The median follow-up of this group of patients was 20.5 safe, reliable and reproducible results. Arbitrary bougie (1–252) months (mos) and the median overall survival was 21 mos (5-year and 10-year survival were 32.5% and 30.7%, sizing has been the classic approach for calibrating sleeve respectively). Despite that the survival curves according to size. This technique has the potential to result in dyspha- MSN expression were different (18 vs. 34 mos; p = 0.07), gia and refl ux when to narrow or suboptimal weight loss if only the cytoplasmic MSN expression was signifi cantly asso- too wide. Moreover, the inclusion of remnant fundus at the ciated (p = 0.024) to poorer survival (15 vs. 26 mos). Multi- gastroesophageal junction may be susceptible to enlarge- variate analysis revealed that cytoplasmic MSN expression ment with an associated s ataple line failure. Using the was one of the independent prognostic factors (HR 1.769; Poster Abstracts endoscope and the aforementioned anatomic visual cues 95% CI 1.00–3.13; p = 0.05) together with pT, macroscopic have been successfully used to tailor a gastric sleeve with a appearance and venous invasion. Tuesday caliber mirroring that of the esophagus and without a gas- tric cuff at the proximal margin. CONCLUSIONS: MSN expression in gastric and GEJ can- cer was correlated with several clinicopathological fea- tures (namely GEJ location, fungating and ulcer-fungating tumors, intestinal type, serosal invasion, lymph node metastasis) and cytoplasmic MSN expression was an inde- pendent prognostic factor in R0 cases of our series.

219

2014 ANNUAL MEETING

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

May 2–6, 2014, Chicago, Illinois

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 the Orange County Convention Center West Building unless otherwise indicated. indicates a ticketed session requiring a separate registration and fee.  indicates a session offering CME with self-assessment.

FRIDAY, MAY 17, 2013 10:00 AM – 11:00 AM VIDEO SESSION III 304AB 7:30 AM – 2:45 PM RESIDENTS & FELLOWS RESEARCH CONFERENCE 300 10:00 AM – 11:30 AM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia A) By invitation only) (AGA-Accredited) Managing Post-Operative Complications in the IBD Patient SATURDAY, MAY 18, 2013 Sponsored by: AGA, SSAT, ASGE 11:00 AM – 11:45 AM MAJA AND FRANK G. MOODY STATE-OF-THE-ART LECTURE 303ABC 8:00 AM – 4:55 PM MAINTENANCE OF CERTIFICATION COURSE 208ABC Cholecystectomy: Can We Do Better? Evidence Based Treatment of Colorectal Diseases 11:00 AM – 11:45 AM DDW POSTER TOUR: HPB (non-CME) West Hall A 10:00 AM – 11:30 AM DDW COMBINED CLINICAL SYMPOSIUM 110 (AASLD-Accredited) 12:00 PM – 2:00 PM POSTER SESSION II (non-CME) West Hall A Therapeutic Approaches in NAFLD Sponsored by: AASLD, AGA, SSAT 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Enhance Recovery Protocols for Elective Colon and Rectal Surgery 205B 2:00 PM – 3:30 PM DDW COMBINED CLINICAL SYMPOSIUM 420 (Chapin Theater) Writers Workshop Part 1: Writing 205A (ASGE-Accredited) Endoscopic Evaluation and Management of IBD 2:00 PM – 3:00 PM QUICK SHOTS SESSION II 303ABC Sponsored by: ASGE, AGA, SSAT 2:00 PM – 3:30 PM CONTROVERSIES IN GI SURGERY B 304AB 4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIUM 420 (Chapin Theater) DEBATE 3: Preoperative Therapy for Resectable (ASGE-Accredited) Pancreas Adenocarcinoma: Timing Matters Addressing the Controversies in Barrett’s Esophagus DEBATE 4: Nissen Fundoplication: Does It Create Sponsored by: ASGE, SSAT, AGA More Problems than It Solves?

2:00 PM – 3:30 PM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia BC) SUNDAY, MAY 19, 2013 (AASLD-Accredited) Management of Surgical Risk in Patients with Cirrhosis 7:30 AM – 8:00 AM OPENING SESSION 303ABC Sponsored by: AASLD, SSAT 8:00 AM – 9:00 AM PRESIDENTIAL PLENARY A (PLENARY SESSION I) 303ABC 2:00 PM – 3:45 PM PLENARY SESSION V 308D 8:00 AM – 9:30 AM DDW COMBINED RESEARCH FORUM 203AB (AGA-Accredited) 3:00 PM – 4:30 PM SSAT/ASCRS JOINT SYMPOSIUM 303ABC IBD Evolving Issues and Strategies in the Managment of Diverticular Disease

9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS 303ABC 4:00 PM – 5:00 PM CLINICAL WARD ROUNDS II 304AB Peer Review Cysts of the Pancreas: Observe, Resect, or Drain— How to Pick the Right Option for Every Patient … the First Time 10:00 AM – 11:30 AM DDW COMBINED CLINICAL SYMPOSIUM 420 (Chapin Theater) (AGA-Accredited) 4:00 PM – 5:00 PM QUICK SHOTS SESSION III 308D Bariatric Surgery as the Treatment of Metabolic Syndrome 4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia A) Sponsored by: AGA, SSAT, AASLD Achalasia Treatment: Botox, Balloon, LAP Myotomy, or POEM Sponsored by: SSAT, ASGE, AGA 10:15 AM – 11:00 AM PRESIDENTIAL PLENARY B (PLENARY SESSION II) 303ABC

11:00 AM – 11:45 AM DORIS AND JOHN L. CAMERON GUEST ORATION 303ABC 5:00 PM – 6:00 PM ANNUAL BUSINESS MEETING (Members Only) 303ABC AMA: Looking to the Future 7:00 PM – 9:00 PM MEMBERS RECEPTION Cuba Libre Restaurant 11:00 AM – 11:45 AM DDW POSTER TOUR: West Hall A ESOPHAGEAL AND STOMACH (non-CME) TUESDAY, MAY 21, 2013 12:00 PM – 2:00 PM POSTER SESSION I (non-CME) West Hall A 6:30 AM – 7:45 AM BREAKFAST WITH THE EXPERT 104A Complex Paraesophageal Hernia Repair: 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEON 203AB Tricks for the Giant Hiatus Key Steps to Do It Safely Operative and Endoscopic Management of Benign Biliary Stenosis 7:30 AM – 9:30 AM SSAT/ISDS JOINT BREAKFAST SYMPOSIUM 303ABC You Did Your Best, and It Still Leaked! Modern Management of GI Leaks 2:00 PM – 3:30 PM CONTROVERSIES IN GI SURGERY A 304AB DEBATE 1: HIPEC: Critical in the Management 8:00 AM – 9:30 AM PLENARY SESSION VI 308D of Peritoneal Surface Malignancies? DEBATE 2: Reverse Approach (Liver Resection First) in Patients 8:00 AM – 9:30 AM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia BC) with Synchronous Colorectal Liver Metastases (AGA-Accredited) Diagnosis and Management of Early Pancreatic Cancer 2:00 PM – 3:30 PM DDW COMBINED CLINICAL SYMPOSIUM 420 (Chapin Theater) Management of Benign Liver Lesions 9:30 AM – 12:00 PM PLENARY SESSION VII 308D Sponsored by: SSAT, AASLD, AGA 10:00 AM – 11:30 AM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia BC) 2:00 PM – 4:00 PM VIDEO SESSION I 300 (ASGE-Accredited) Management of Pancreatic Necrosis: When to Scope, Poke, or Cut 2:00 PM – 4:30 PM STATE-OF-THE-ART CONFERENCE 303ABC Sponsored by: ASGE, SSAT, AGA Evolving Management in Pancreatic Cancer 10:30 AM – 12:00 PM SSAT HEALTH CARE QUALITY & OUTCOMES COMMITTEE PANEL 304AB 2:00 PM – 4:45 PM PLENARY SESSION III 308D If You Cannot Measure It, You Cannot Improve It: Developing a Quality Metric for Complex GI Surgery MONDAY, MAY 20, 2013 11:00 AM – 11:45 AM DDW POSTER TOUR: SMALL BOWEL West Hall A 6:30 AM – 7:45 AM BREAKFAST WITH THE EXPERT 205C AND COLON-RECTAL (non-CME) Primer for the General Surgeon and Management of the Bariatric Surgery Patient 12:00 PM – 2:00 PM POSTER SESSION III (non-CME) West Hall A

7:30 AM – 9:15 AM VIDEO SESSION II: BREAKFAST AT THE MOVIES 303ABC 12:00 PM – 3:00 PM KELLY AND CARLOS PELLEGRINI SSAT/SAGES 303ABC JOINT LUNCHEON SYMPOSIUM 8:00 AM – 9:00 AM CLINICAL WARD ROUNDS I 304AB Management and Rescue from Complications Following Role of Trans-Anal Surgery for Rectal Cancer Complex Upper GI Surgery: Stents, Clips, and Beyond 8:00 AM – 9:30 AM SSAT PUBLIC POLICY AND ADVOCACY COMMITTEE PANEL 308D Will There Be a General Surgeon When You Need One? 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEON 205A Solutions and Taking Back General Surgery Writers Workshop Part 2: Reviewing

9:15 AM – 10:45 AM SSAT/AHPBA JOINT SYMPOSIUM 303ABC 2:00 PM – 3:30 PM DDW COMBINED CLINICAL SYMPOSIUM 415 (Valencia BC) Strategies for Parenchymal Preservation in Patients Current Multi-Modality Approach to GE Junction Tumors Undergoing Hepatic Resection for Metastatic Colorectal Cancer Sponsored by: SSAT, ASGE, AGA

9:45 AM – 11:00 AM PLENARY SESSION IV 308D 2:00 PM – 4:00 PM BEST OF DDW 2013 (non-CME) 304AB

9:45 AM – 11:00 AM QUICK SHOTS SESSION I 300