Surg Endosc DOI 10.1007/s00464-015-4130-0

and Other Interventional Techniques

2015 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 15–18 April 2015 Poster Presentations

 Springer Science+Business Media New York 2015

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Aspirin-Mediated Colorectal Cancer Prevention: How Does it Work?

Study of Bladder Carcinoma Grade at First Presentation in Tertiary Hospital

Alexandra Anker, Tobias Welponer, Sami Judeeba, MD, John Geibel, DSc, MD, MSc, Yale Medical School, Department of Surgery

Muhammad Nadeem, Observer, Nauman Ahmed, PGR, Abdul Basit Niazi, PGR, Mayo Hospital

Introduction: Many studies prove the effect of aspirin on reducing the risk of colorectal cancer, polyps and adenoma in terms of incidence and recurrence especially among FAP patients. In fact, there is some evidence that aspirin prevents hereditary non-polyposis colorectal cancer. Experts are still arguing about the optimal dose and duration of aspirin to exert its anti-tumorigenic activity. Some studies however could demonstrate a benefit with any type of NSAID at any dose.

Introduction: Bladder cancer is one of the most common diseases treated by the urologists. Bladder cancer is the second most common cancer of the genitourinary tract and the second most common cause of death among genitourinary tumours after prostate cancer. The stage of urinary bladder cancer is an important factor in determining prognosis of the disease. Material and Method: In this cross sectional study, sixty patients of urinary bladder carcinoma were selected from outdoor department of Urology, Unit II, Mayo Hospital Lahore. All bladder cancer cases were recorded and evaluated. Available investigations and operation notes were studied to evaluate the diagnosed cases for stage and grade of bladder cancer over a period of one year. Results: The mean age of the patients was 57.1±12.4 years. There were 53 (88.3%) male and 7 (11.7%) female patients. In the distribution of patients by cystoscopy finding, there were 26 (43.3%) patients who had bladder growth on left side, 23 (38.3%) patients had bladder growths on right side, 6 (10.0%) patients had bladder growth on large and small, 5 (8.3%) patients had multiple papillary growths. In the bladder growth grading, 11 (18.3%) patients had grade I, 41 (68.3%) patients had grade II and 8 (13.3%) patients had grade III bladder growth. Conclusion: It is concluded from this study that patients with bladder cancer are diagnosed at a relatively early stage. However, the situation can be improved further by adopting proper screening programs and initiating early management.

In our study we try to improve our understanding of the mechanism by which aspirin decreases the risk of colorectal cancer as it is still unclear. We analyzed the impact of low-dose Aspirin (7.9 lM) on crypt cells of rat distal colon with particular focus on Na+/H+ exchanger (NHE) activity and pH changes. Materials and Methods: Male Sprague-Dawley rats weighing 325–425 g were dissected according to approved protocols of the Animal and Use Committee at Yale University. Isolated crypt cells from rat distal colon were transferred to a coverslip that was pretreated with the fibrin sealant Cell-Tak. The coverslip was attached to a perfusion chamber and incubated at room temperature for 18 min with HEPES-buffered Ringer solution containing 10 lM of BCECF-AM (2’,7’-bis-(Carboxyethyl)-5(6’)-carboxyfluorescein Acetoxymethyl Ester, Santa Cruz Biotech) a fluorescent indicator for the measurement of intracellular pH. Afterwards the chamber was placed on the temperaturecontrolled (37C) stage of an inverted microscope (Olympus IX71). A minimum of two midportion regions of each crypt were selected and monitored using a digital monitoring system during the experiment. BCECF was excited at 490 nm ± 10 nm and 440 nm ± 10 nm and the resultant fluorescent emission signal was measured at 535 nm ± 10 nm every 15 s using a digital camera and specific software (Metafluor). The cells were perfused continuously with each of the following solutions for at least 5 minutes: standard HEPES full-sodium buffer solution—30 mM NH4Cl solution (initial alkalization of the cell)—sodium-free HEPES solution (acidification of the cell)—reperfusion with standard HEPES full-sodium solution. NHE activity was determined by monitoring pH recovery (d pHi/s) during reperfusion. To calculate pHi values from image data (intensity ratio 490/440) cells were calibrated using the high-K+/Nigericin calibration technique. It could be demonstrated that crypts exposed to Aspirin show a significantly higher rate of recovery compared to a control without Aspirin.

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Referencing CT Scans Through a Headmounted Optical Display During Laparoscopic Surgery

Effect of Yoga Practice on Laparoscopic Surgery Outcomes: Results of a Randomized Control Study

Helena M Mentis, PhD1, Ahmed Rahim, BS2, Pierre R Theodore, MD2, 1University of Maryland, Baltimore County, 2University of California San Francisco

Brij B Agarwal, MD1, Juhil D Nanavati, MBBS1, Nayan Agarwal, MBBSS2, Kumar Manish, DNB1, Naveen Sharma, MD2, 1Ganga Ram Institute of Postgraduate Medical Education & Research and Sir Ganga Ram Hospital, India, 2University College of Medical Sciences, University of Delhi, India

Introduction: With the increasing use of imaging systems in the OR, each with its own display, it is an ever-growing challenge to have the required image on the appropriate display. Having the required CT scans or X-rays in the surgeon’s field of view without having to adjust the orientation of displays or turn away from the patient would provide an immense benefit in maintaining attention on the patient and task. This would provide a benefit in both OR design as well as surgical outcomes. We present here a head-mounted optical display to show CT scans to assist in laparoscopic surgery. Methods and Procedures: For this trial, the Vuzix M100 was used. As opposed to the Google Glass, where information is projected onto a transparent ‘window’, The Vuzix M100 uses a miniature color-LCD that presents the image without visual interference. An external portable battery pack enabled the surgeon to use the device for extended periods of time. The head-mounted optical display has been used in 40 complex minimally invasive cardiothoracic surgeries – i.e. CT images would be needed intraoperatively. A CT image chosen by the operating surgeon was preloaded onto the headmounted optical display’s computer to be placed in the periphery of the surgeon’s point of view and referenced when needed. The surgeon took notes after each use to capture benefits and hindrances to the display’s use (Fig. 1). Results: Having the images at the surgeon’s disposal was deemed quick and easy to use. For instance, in using the system to pinpoint the exact location of a lesion that was buried deep in the lung, the surgeon was able to glance at the images displayed on the system and then quickly reorient his vision back to the laparoscopic video. There was no record of fatigue from wearing the device throughout the surgery. It was also noted that, as the display was not in the direct line of site, it did not obstruct the field of vision. When needed, it was easy to glance over and switch attention between head-mounted optical display and endoscopic display across the table. The system’s hindrances were due to its design for consumer markets as opposed to one specifically designed for surgery. First, the display’s default is to enter standby after two minutes. In those situations, a nurse was called over to reactivate the display by touching the power button on the side. Second, there was no sterile mechanism for cycling through CT scans. Finally, the head mounted optical device competed for space with glasses, loupes, or a facemask. Conclusions: Although there were some hindrances, the head-mounted optical display was useful for complicated laparoscopic cases. However, further work needs to be conducted in order to seamlessly integrate the display into the OR. The most important feature that we are addressing is the use of verbal commands and gestures to interact with the images and the display.

Introduction: We have earlier reported patient reported outcomes (PRO) related benefits of Yoga practice (YP) in laparoscopic surgery (LS) in a non-randomized study. We undertook a prospective blinded study for impact of YP on outcomes with laparoscopic cholecystectomy (LC) as an index LS. Methods and Procedures: An open ended triple blind randomized study of consecutive unselected consenting candidates for elective LC. Randomization by external research coordinators (blind to peri-operative observations) into Group A and Group B. Standard techniques of LC followed by operating surgeons (blind to pre & postoperative parameters / observations). Prospective data being collected online auto-locking Hospital Information System. Conclusions: The codes will be broken at study completion (Jan 2014–Dec 2014) & the appropriately analyzed results will be presented & discussed Metrics for study points Post Operative (PO) PROs

Scale Used

Day (D)/week(W)/Month(M)

Pain (POP)

100 point VAS

D1,D3,D10,W3

Nausea & vomiting (PONV)

6 point PONV

D1,D3,D10,W3

Fatigue (POF)

84 point MFIS

D1,D3,D10,W3

Quality of Sleep (QoS)

21 point Pittsburg

W3

GIQoL

144 point GIQoL

M3

Activity Resumed (AR)

Days

D

Biochemical Markers Studied; Starting at 1st Incision i.e. 0 Hour (H) Marker

Molecule

Time

Cytokines

IL-6, HS-CRP, TNF-

H0, H4, H24

LiverEnzyme

SGOT,SGPT,ALP,GGT

H0, H4, H24

Results:PROs ; Mean (Range) (Group A, n=52 Group B, n=45) Study Point

Group A

Group B

POP

35.47 (10–86), 23.80 (6–79), 14.13 (4–75), 6.40 (2–32)

34.53 (20–50), 19.62 (12–33), 9.08 (6–14), 3.62 (2–7)

PONV

0.53 (0–3), 0.27 (0–2), 0.13 (0–2), 0.00 (0–0)

0.31 (0–1), 0.08 (0–1), 0.0 (0–0), 0.0 (0–0)

MFIS

26.87 (16–62), 18.33 (10–56), 11.90 (4–44), 5.00 (2–12)

24.31 (13–45), 16.92 (10–42), 8.77 (5–16), 4.23 (2–10)

PSS

10.33 (7–17)

7.23 (2–13)

GiQoL

23.53 (14–40)

17.31 (12–26)

A Novel Adaptive Localization Technique for Wireless Capsule Endoscopy

AR

7.27 (3–36)

5.08 (3–7)

IL-6 (pg/mL)

6.32 (1.55–9.77), 31.26 (4.68–202.63), 51.58 (4.08–291.57)

2.46 (0.38–3.4), 11.42 (3.5–31.06), 13.5 (2.1–38.3)

Hamed Farhadi1, Esmaeil S. Nadimi2, Javid Atai3, Kaveh Pahlavan4, Mikael Skoglund1, Vahid Tarokh5, 1KTH Royal Institute of Technology, 2University of Southern Denmark, 3The University of Sydney, 4Worcester Polytechnic Institute, 5Harvard University

HS-CRP (mg/ dL)

1.63 (0.02–16.07), 1.85 (0.03–16.1), 5.66 (0.6–16.47)

0.20 (0.01–0.66), 0.35 (0.04–1.62), 3.13 (0.44–14.47)

TNF- (pg/ mL)

11.02 (7.7–18.8), 16.10 (8.9–39.1), 19.01 (9.1–61.9)

8.62 (1.66–15.8), 11.41 (7–17.2), 12.48 (9.2–15.2)

Fig. 1

The Vusix M100 head-mounted optical display: diagram (on left) and in use (on right)

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Objective of the Technology: Wireless capsule endoscopy (WCE) is an emerging technique to enhance Gastroenterologists information about the patient’s G.I. tract. Localization of capsule inside human body in this case is an active area of research. This can be thought of as a subdomain of micro and bio-robotics fields and also that of localization in heterogeneous media. If capsule and micro-robot localization problem in human body is solved, then it may potentially lead to less invasive G.I. diseases treatments and other micro-robot assisted medical procedures. Description of the Method: We propose a novel technique that uses RF signals radiated from the capsule to determine its location. In the proposed technique, multiple receiver elements on the body surface receive noisy versions of the RF signals radiated from the capsule, and an algorithm computes the location of the capsule using these set of received signals. For the purpose of location estimation, the signal propagation inside human body is characterized using an approximate linear model. The model parameters change slowly as the capsule navigates inside the heterogeneous medium of human body. We have designed an adaptive localization algorithm based on expectation maximization (EM) technique that tracks changes in the propagation environment and updates/improves the estimated locations. Preliminary Results: The accuracy of the proposed technique has been verified using numerical simulations. The preliminary results show that the proposed method significantly outperforms the non-adaptive localization techniques existing in the literature. Conclusion/Expectations: The proposed technique will help Gastroenterologists specialists to use WCE not only to discover medical problems inside the G.I. track, but also to know where the problems are exactly located. This will enable the next generations of WCE systems in which a capsule can be used to conduct certain surgeries in specific locations; to deliver drug to a desired point; or to collect tissue samples from a location of interest inside the G.I. track.

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SGOT

21.09 (14–44), 52.09 (27–78), 43.18 (30–79)

24.47 (13–37), 70.27 (23–428), 37.87 (19–101)

SGPT

28.45 (9–154), 47.18 (21–85), 44.55 (25–71)

23.13 (12–43), 47.73 (14–167), 41.87 (14–130)

ALP

85.55 (40–314), 88.18 (44–249), 88.18 (43–241)

74.40 (28–131), 75.80 (28–125), 74.67 (28–124)

GGT

35.82 (9–253), 33.64 (13–180), (35.82 (10–174)

20.20 (5–101), 23.13 (5–83), 21.73 (8–81)

Surg Endosc

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Understanding Pyloric Sphincter Activity Using a Distensibility Technique

HIV Related Anal Canal Squamous Cell Carcinoma Refractory to Chemo Radiation Needing Abdominoperineal Resection is a Locally Aggressive Disease Requiring Muscle Flap

Jorge Alberto Arroyo Vazquez, MD1, Per-Ola Park, MD, Professor1, Maria Bergstrom, MD, PhD1, Steven Bligh2, Barry P McMahon, PhD2, 1Dept of Surgery, South Alvsborg Hospital & Gothenburg University, 2Trinity Academic Gastroenterology Group, Trinity College & Tallaght Hospital, Dublin, Ireland Background: Limited data is available to fully describe the function of the pyloric sphincter. It is clear that its primary role is in gastric emptying and the control of stomach contents. Stent treatment of duodenal perforated ulcers has been tried out with good clinical results but stent migration has occurred in a few cases. Our theory is that the stent itself causes an increased pressure in the pyloric sphincter initiating emptying sphincteric actions. The aim of the study was to investigate whether distending the pyloric sphincter with the functional lumen imaging probe (FLIP) would provide a better understanding of the pyloric sphincter physiology. The effect of Neostigmine on the sphincter function was also studied. Method: Four female pigs (40–50 kg) were acquired for the study which had ethical approval. The pigs were anaesthetised and gastroscoped. The EndoFLIPTM Catheter EF-353 (Crospon, Galway, Ireland) was inserted through the scope and placed in the pylorus. To aid positioning a small volume of 20 to 30 ml was filled into the catheter and probe position was adjusted by viewing the EndoFLIP screen and observing the hourglass shape. It was decided that the optimal position would be when the probes 16 measurement were straddling the pyloric sphincter so that the central measurements represent the narrowest region in the middle. Stepwise volume controlled distensions to balloon fill volumes of 20 ml, 30 ml, 40 ml and 50 ml were carried out. The volumes were maintained for 1 min and the complete step protocol was repeated. 1.5 mg of neostigmine was then administered intravenously and no measurements were taken for 5 minutes to allow for the effect of the drug to occur. The stepwise volume controlled distensions were then repeated. Results: The EndoFLIP catheter could successfully be inserted into the pylorus and infused with a liquid volume. Initial distensions clearly indicated that it was easy to locate the probe straddling the pylorus. Patterns of motility observed at all bag volume levels indicated a constant rhythmic opening of the narrowest region in the pyloric sphincter while simultaneous a drop in pressure in the bag was observed, indicating that the movement was specifically of an opening and closing nature and not similar to peristaltic wave movement observed in other parts of the GI tract. Plots of narrowest CSA (Cross Sectional Area) and bag pressure during the 1 minute volume hold period indicated that as volume increased the opening patterns grew larger and the pressure increased, consistent with a valvular region that is relatively compliant. A plot of distensibility at the step volumes before and after neostigmine administration indicates that the pylorus becomes more distensible after the administration. Conclusion: The FLIP can easily be used through a gastroscope for assessing the pyloric sphincter physiology. The sphincter seems to be compliant; it relaxes more and opens more widely after larger volume distensions. This might influence pyloric actions during stent treatment. Possibly larger and stronger stents induce more emptying activity leading to more stent migration.

Ben Selvan, MD1, Andrew Zheng2, David Stein, MD1, Juan L Poggio, MD1, 1Drexel University College of Medicne, 2Jefferson College of Medicine Background: Anal canal squamous cell carcinoma (SCC) historically has a complete response rate up to 80–90% and average Cd4 count at the time of diagnosis is above 300. Failed or recurrent tumors following modified Nigro treatment requiring muscle flap to cover the perianal skin defect is limited in the literature. More over the relationship between Cd4 count and predicting the aggressive nature of the tumor is limited. Methods: This is a retrospective study from 2011- 2014 on patients diagnosed with HIV related SCC of the anal canal who failed modified chemoradiation therapy requiring abdomino perineal resection (APR). We analyzed factors such as smoking, CD4 count, grade of tumor, HARRT therapy and extent of the perianal skin involvement at the time of diagnosis of anal SCC. We also compared the average perianal skin involvement between HIV and non HIV patients requiring APR. Results: There were four patients who met these criteria and three were males and one female; all were active smokers and non complaint on HAART. We had two non HIV patient requiring APR as control and were smokers as well. The average CD4 count at the time of diagnosis was 245[range; 189–285]. All the initial biopsy showed well to moderately differentiated tumors. The average time of developing anal SCC was 13 years following the diagnosis of HIV. The indication for surgery was persistent disease after completion/refractory to Nigro protocol except one patient who had recurrence. The surgery done was APR with wide local excision of the perianal skin. The defect was so large to close primarily and it needed a muscle flap to cover. Vertical rectus abdominus flap with skin [VRAM] was used as local muscle flap. They all were dedifferentiated from moderate to poor grade tumors at the final APR resection specimen. The perianal skin involvement was limited at the time of initial diagnosis but all four had extensive perianal skin involvement at the time of surgery and was progressive. There were multiple satellite nodules on the skin making a wider excision in HIV patients than non HIV patients. The average perianal skin involvement by tumor was 108.6 square centimeters [range; 39–225] and 10 square centimeters [range; 12–8] in non HIV patient. Conclusion: Though this series is limited by small numbers, Squamous cell carcinoma of the anal canal in HIV patients which is refractory to the Nigro protocol is associated with low CD4 counts (less than 250) and it dedifferentiates to a more aggressive tumor with extensive skin involvement requiring a muscle flap to cover the defect. This observation needs further clinical study and research to identify a genetic/molecular marker which could predict a refractory anal scc so an alternate chemo based treatment or upfront surgery could be considered.

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Single Incision Laparoscopic Right Colectomy Could be Better than the Standard Approach in Patients with Colon Cancer

Submucousal Injection of Carbon Nanoparticles Preoperatively Improves Lymph Node Staging Accuracy in Rectal Cancer Following Neoadjuvant Chemoradiotherapy

Elie K Chouillard, MD, PhD, Laura Montana, MD, Vanessa Caroni, MD, Ronald Daher, MD, Paris Poissy Medical Center Background: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging surgical approach. However, human applications of ‘‘pure’’ NOTES techniques in are still slowed down by major technical hurdles. Concomitantly, ‘‘Hybrid’’ variants of NOTES and single incision laparoscopy have been increasingly reported. By further reducing the invasiveness of the standard laparoscopic approach, we may further reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and ultimately preserve cosmesis. Such techniques have been applied to many procedures including colorectal surgery. The aim of this study is to compare the short-term results of single incision laparoscopic right colectomy (SIRC) to the standard laparoscopic right colectomy (LRC) in patients with colorectal cancer. Methods: SIRC was attempted in 54 patients (Group A) with colon adenocarcinoma. Exclusion criteria were emergency setting (i.e., obstruction, perforation), poor general status (ASA score [ 3), and a history of major abdominal surgery. Right colectomy was performed using a transumbilical incision with a special platform. The patients were retrospectively matched according to gender, body mass index (BMI), and ASA score, with 56 other patients who had LRC for adenocarcinoma during the same study period (Group B). Results: The procedure was completed in 50 patients (92.6 %) in Group A. In 4 patients, conversion to standard laparoscopy (2 patients) or laparotomy (2 patients) occurred. In Group B, no conversion to open surgery occurred. The mean operative time was 119 minutes (range, 50–245) in the Group A and 109 minutes (range, 65–285) in the Group B, respectively (p[0.05). No mortality occurred in either group The operative morbidity rate was 7.4 % and 11.1 %, in Group A and B, respectively (p[0.05). No hemorrhage, no surgical site infection and no fistula were encountered in either groups. The mean length of hospital stay was 4.7 days (range, 3–14) in Group A and 6.9 days (range, 4–13) In Group B, respectively (p \ 0.05). Group A patients used significantly less level III pain killers as compared to patients with group B. Histological parameters of the oncological quality of the resection (margins, completeness, nodes retrieval) were similar in both groups. The average global hospitalization cost was 5898 euros per patient in Group A and 7145 euros in Group B (p\ 0.05). Conclusion: SIRC for selected patients with colon adenocarcinoma was found to be sure and feasible as compared to SRC in matched patients with the same disease. It may even offer advantages including less post operative pain, shortened hospital stay, and less cost.

Yanan Wang, PhD1, Haijun Deng, PhD1, Hongyuan Chen, MD2, Hao Liu1, Jun Yan, PhD1, Qi Xue1, Hao Chen1, Guoxin Li1, 1Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China, 2Department of Gastrointestinal Surgery, Fujian Provincial Hospital, Fuzhou, China Purpose: To evaluate the association between the number of node harvested and the rate of node positivity, and the effect of carbon nanoparticles on improving lymph node detection and staging accuracy in patients who received neoadjuvant chemoradiotherapy followed by curative resection. Methods: One hundred and fifty-two patients with rectal cancer treated with neoadjuvant chemoradiaothepapy and curative resection were included for analysis. Of these, 45 patients underwent carbon nanoparticles injection one day before surgery (carbon nanoparticles group), while the others underwent surgery only (control group). Logistic regression model was used to explore the relationship between the number of lymph node retrieved and the node positivity. The number and positivity of lymph node harvested were compared between the carbon nanoparticles group and the control group. Results: The proportion of patients with node-positive raised gradually from 11.3% in patients with 1–4 nodes harvested to 33.4% in patients with 16–44 nodes harvested. Multivariate logistic regression analysis revealed that the number of lymph node harvested was an independent risk factor for the node positivity (6–9 vs. 1–5: OR = 5.19, 95% CI = 1.00–26.99, p = 0.050; 10–16 vs. 1–5: OR=10.56, 95% CI=2.17–51.47, p = 0.004; 16–44 vs. 1–5: OR=6.89, 95% CI=6.42–33.54, p = 0.017). The mean number of lymph node harvested was 21.2 in carbon nanoparticles group and 8.9 in the control group (p = 0.002). The percentage of patients with positive lymph node increased from 21.5% in the control group to 31.1% in carbon nanoparticle group (p = 0.038). Conclusions: The lymph node positivity is significantly associated with the number of lymph node harvested in patients with rectal cancer following neoadjuvant therapy. Submucousal injection of carbon nanoparticles preoperatively could increase the number of lymph node retrieval and the rate of node positivity. Keyword: Carbon nanoparticles, Rectal cancer, Lymph node, Neoadjuvant chemoradiotherapy

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P040

Laparoscopic Peritoneal Aspiration and Drainage of Complicated Diverticulitis – A Single Center Experience

The Results of Laparoscopic Total Colectomy with Ileal J-Pouch Anal Anastomosis for Ulcerative Colitis

Sharique Nazir, MD, Aaron Lee, DO, Laurence Diggs, BA, Alex Bulanov, MS, Michael Timoney, MD, FACS, George Ferzli, MD, FACS, Lutheran medical center

Tomoya Abe, Takeshi Naito, Munenori Nagao, Kazuhiro Watanabe, Hiroaki Musha, Shinobu Onuma, Naoki Tanaka, Katsuyoshi Kudo, Hideaki Karasawa, Takanori Morikawa, Kei Nakagawa, Takaho Okada, Hiroki Hayashi, Hiroshi Yoshida, Fuyuhiko Motoi, Yu Katayose, Michiaki Unno, Tohoku University Hospital

Introduction: The aim of this study was to evaluate the results of the laparoscopic aspiration and drainage in the management of complicated diverticulitis not amenable to IR drainage from 2012–2014. We wanted to assess its potential as an alternative to open surgery and diverting ostomy. The management of this condition has greatly evolved since the introduction of laparoscopic peritoneal lavage in 1996. This less invasive option has become increasingly popular but the standard of care for Hinchey III diverticulitis remains a resection with diversion. Yet for cases where feculant material is not found in the peritoneum, peritoneal lavage is being described as a suitable bridging procedure to reduce the morbidity and mortality associated with performing colectomy with diversion. We are interested in evaluating the effectiveness of the aspiration of purulent material and the placement of drains instead of aggressive lavage of the entire abdominal cavity. Our hypothesis is that lavage of the entire abdomen has a potential risk of bacterial seeding, and the aspiration would minimize the risk with equal benefit. Methods: We performed a retrospective chart review of all patients who went to the operating room with a diagnosis of complicated diverticulitis. We excluded all patients who had Hinchey IV, all patients who underwent intraoperative washout and all those who had a colectomy. Five patients fit our criteria. They underwent laparoscopic peritoneal aspiration for Hinchey III diverticulitis. Data recorded included demographics, operative details, length of hospital stay, complications, and the incidence of interval colectomy. Primary endpoints were operative success, resolution of symptoms and the avoidance of colostomy. Technique: The steps involved in the procedure is accessing the peritoneal cavity, placement of two 5 mm ports and 10 mm port for a 30 degree camera, lysing of inflammatory tissue causing adhesions, thorough laparoscopic inspection of the abdomen, localization with aspiration of the collection and placement of 2 closed suction drains exiting from 5 mm port site. Results: Of the 5 patients selected, 3 were male and 2 were female. The average age was 57.2 years. 2 patients were Caucasian and 3 were mixed race. The average operative time was 59.6 minutes and the average hospital length of stay was 3.8 days. One patient presented on post-operative day 8 with abdominal pain and a residual abscess which was treated with 3 days of IV antibiotics. All surgeries were successful in managing the acute exacerbation of Hinchey III diverticulitis. 2 patients eventually had interval colectomies. Discussion: At our center we successfully performed 5 laparoscopic aspirations with drain placement in patients for whom peritoneal lavage would otherwise have been considered as an alternative to colectomy. We saw no complications related to the laparoscopic technique in our study. We propose that in a carefully selected population, it is worth examining whether aspiration has equivalent outcomes to lavage in cases where IR drainage is not possible.

Background: Nowadays, ulcerative colitis (UC) is the basically treated by conservative medication therapy which is represented by anti-inflammatory drugs, or by immunological treatment such as anti-TNF alpha agents. However, it often requires surgical intervention when the medical treatment is failed or other emergent complications occur. Since UC is the young onset disease and its incidence is higher in women, the minimally invasive surgery would have great impact on their QOL. We have been, therefore, performing a laparoscopic total colectomy (LTC) with ileal J-pouch anal anastomosis (IAA) for UC since 2001. In the early days, procedures were mostly performed by a hand-assisted laparoscopic approach, and then we turned to adopt the laparoscopic approach for elective surgery cases. In this study, we verify the efficacy of LTC compared to open or hand-assisted approach. Patients & Methods: UC patients who underwent total colectomy with IAA from 2001 through 2013 in our institute were included in this study. Of those patients, operative outcomes and morbidity were assessed retrospectively. Results: A total of 58 patients were included; an open total colectomy (OTC) was performed on 18 patients, a handassisted laparoscopic surgery (HALS) on 31 and a laparoscopic procedure on 9. Among these cases, a mean age of patients are highest in the OTC group (OTC, HALS and LTC: 51.9±14.0, 35.3±12.4 and 35.6±16.7 year-old), and a duration of operation was also shortest in the OTC group (409±91, 472±94 and 505±100 min, respectively). Estimated blood loss was seemed lower in LTS group, though it was not statistically significant. The incidence of postoperative intestinal obstruction was significantly higher in the LTC group (OTC, HALS and LTC: 5.6%, 19.4% and 55.6%). Main cause of the intestinal obstruction was twisting and bending of the ileum around loop ileostomy. It might be due to the feature of less adhesion in a laparoscopic surgery. It was treated by stenting Foley catheter into the ileum from the ileostomy avoiding reoperation. There were no significant differences regarding other complication incidences or a length of postoperative hospital stay among groups. Conclusion: Although the incidence of postoperative intestinal obstruction was high, the laparoscopic total colectomy with IAA seems effective and would be beneficial for patients’ QOL.

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P041

Laparoscopic Complete Mesocolic Excision via Combining Median-to-Lateral and Anterior-to-Median Approaches for Transvers Colon Cancer

What is the Impact of Co-Morbidities in the Outcomes of Laparoscopic Surgery for Elderly Patients with Colorectal Cancer

Shinichiro Mori, Kenji Baba, Yoshiaki Kita, Masayuki Yanagi, Yasuto Uchikado, Takaaki Arigami, Yoshikazu Uenosono, Yuko Mataki, Hiroshi Okumura, Akihiro Nakajo, Kosei Maemura, Sumiya Ishigami, Shoji Natsugoe, Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima

Yu Sato, MD, Giovanna DaSilva, MD, Eric G Weiss, Steven D Wexner, MD, Cleveland Clinic Florida

Introduction: Many large randomized trials of laparoscopic colectomy have shown short-term benefits and oncologically safety for colon cancer excluded patients with transverse colon cancer. So laparoscopic colectomy for transverse colon cancer is still a surgically challenging procedure because of its complex anatomy, being few previously reports mentioned the surgical strategy. We have evaluated the safety and feasibility of laparoscopic complete mesocolic excision (CME) via combining median-to-lateral and anterior-to-median (MLAM) approaches based on embryology of mesocolon in the treatment of transverse colon cancer. Methods and Procedures: Patients: We retrospectively analyzed 11 consecutive patients with transverse colon cancer. Laparoscopic CME via combining MLAM approaches were performed between July 2010 and June 2014. We used video recordings of the procedure to assess the quality of the surgery and completeness of CME. We also assessed operative data, pathological findings, length of large bowel resected, complications, BMI, length of hospital stay. Surgical Procedure: All patients were administered general anesthesia and placed in the lithotomy position. A pneumoperitoneum was maintained at 10 mm Hg using CO2. Median-to-lateral approach was performed by dissecting the mesocolon above SMV and proceeded along the duodenum. After the embryological tissue planes comprising Told’s and pre-renal fascia had been exposed, a wide separation between the pancreatic head and transverse mesocolon was achieved. Dissection proceeded along the SMV, exposing the gastrocolic trunk of Henle (GCT) from median. Then, the middle colic artery was identified arising SMA with dissecting lymph nodes, and the vessels were cut at the root of its branches. Next, an anterior-to-median approach was performed by dissecting the greater omentum of the greater omentum. The fusion fascia was detached between the omentum and transverse mesocolon based on embryology. And the hepatic and splenic flexures were mobilized. The accessory middle colic veins were carefully dissected with 3-D recognition of GCT or middle colic veins via combining MLAM approaches. The transverse mesocolon dissected below the lower edge of the pancreas. And then, a minilaparotomy was performed via the umbilicus, the incision being approximately 4 cm in diameter. The excised specimen was extracted through this incision with wound protection, after which extracorporeal functional end-to-end anastomosis was performed using linear staplers. Results: All patients had undergone en bloc resection of the enveloped parietal planes. Five and six patients graded mesocolic and intra-mesocolic plane, respectively. These 6 patients graded intra-mesocolic plane underwent high ligation of the root of its branches. Four, zero, four, and three patients had T1, T2, T3, and T4 tumors, respectively. The median number of lymph nodes retrieved was 21.8, lymph node metastasis being identified one patient. The mean length of large bowel resected was 21 cm. The mean operative time and intraoperative blood loss were 299 min and 41 mL, respectively. No intraoperative complications occurred in any patient. One patient had postoperative complication. The mean BMI was 23.6 kg/m2. The median postoperative hospital stay was 15 days. Conclusions: Laparoscopic CME via MLAM approaches based on embryology is a safe and feasible procedure for transverse colon cancer.

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Background: Laparoscopic surgery for colorectal cancer in elderly and high-risk patients has proven to be safe and beneficial, with more favorable short-term results. This study evaluated the impact of co-morbidities in the short-term outcomes of elderly patients undergoing laparoscopic resection for colorectal cancer. Methods: After IRB approval, 303 consecutive patients [65 years of age who underwent curative laparoscopic resection for colorectal cancer between January 2000 and June 2014 were included. Co-morbidity was quantified by using the Charlson Comorbidity Index (CCI). Low risk (CCI2, Group A, n=149) and high-risk (3CCI, Group B, n=154) patients were compared relative to short-term outcomes. Results: Group A included 87 males/62 females with a mean age of 75.6 (range, 65–93) years; the majority had rightsided tumors and stage 3 cancers [51 (34%) and 46 (30.8%), respectively]. Group B included 100 males/54 females with a mean age of 76.9 (range, 65–96) years; the majority had right-sided tumors and stage 3 cancers [65 (42.2%) and 54 (35%), respectively]. Overall, there were 302 comorbities (23 in Group A, 279 in Group B). The most common were myocardial infarction (7 and 66, respectively), chronic pulmonary disease (6 and 44, respectively), diabetes (3 and 47, respectively), and peripheral vascular disease in (3 and 30, respectively) (p \ 0.05 for all). There were no significant differences in the number of lymph nodes dissected, mean operative time, or blood loss between the two groups. The number of transfused patients (13.1% vs. 21.1%; P = 0.09), complication rate (56.1% vs. 66.9%; P = 0.059), and length of postoperative stay (7.8 vs. 9.1 days; P = 0.071) tended to be higher in Group B, but also not statistically significant. Conclusions: Laparoscopic surgery for colorectal cancer in elderly patients with a high co-morbidity index can be performed safely and without increasing short-term complications and postoperative hospital stay.

Surg Endosc

P042

P043

Short-term Outcomes After Open Versus Laparoscopic Restorative Proctocolectomy in Patients with Colonic Polyposis: an Assessment from the ACS NSQIP Database

Outcomes for Single-Incision Laparoscopic Colorectal Surgery in Obese Patients: a Case Matched Study

Erman Aytac, Ozgen Isik, Feza H Remzi, James M Church, Hermann Kessler, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, OH Introduction: Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with familial adenomatous polyposis (FAP) and a profuse colorectal phenotype. Laparoscopic techniques have potential advantages for young patients undergoing colectomy and have been applied to this surgery. However, data confirming these potential benefits are limited. In this study, we aim to compare the short-term outcomes of open versus laparoscopic RP in patients with colonic polyposis by using a large, nationwide surgical database. Methods and Procedures: Since there are no specific ICD codes for familial polyposis syndromes in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients who underwent RP/IPAA (CPT codes: 44158,44211) and had been coded as colonic polyposis (ICD-9:211.3) between 2005 and 2012 were included. Demographics, peri-operative and short-term surgical outcomes were compared between the open and laparoscopic groups. Continuous data are presented as median (interquartile range) and categorical data as percentage. Results: 135 patients had laparoscopic and 106 patients had open RP. The groups were similar in demographic, medical and lifestyle factors, with similar age [30 (22–41) vs. 32(24–46), p = 0.26], male gender (49.6 vs. 61.3%, p = 0.07), BMI [27(23–31) vs. 28 (23–33, p = 0.43], and ASA (I–II) score (78.5 vs. 76.4%, p = 0.70). Diabetes was more frequent with patients undergoing open surgery (2.2 vs. 10.4%, p = 0.01). The probability of mortality [0.0007(0.0004–0.0016) vs. 0.0008(0.0005–0.0018), p = 0.14] was comparable between the groups, but the probability of morbidity was higher in open cases [0.15 (0.11–0.19) vs. 0.18 (0.15–0.25), p \ .0001],possibly because of the increased incidence of diabetes. Operating time [307(249–393)vs. 242(194–319), p \ .0001] was longer in the laparoscopic group. Requirement of transfusion (2 vs. 5 %, p = 0.31), length of stay [6(5–9) vs. 7(5–9), p = 0.07] and postoperative complication rates were comparable between the groups (Table). Conclusions: Historical data show that laparoscopic RP offers smaller incisions and less pain to patients with FAP. In this study, the nationwide data demonstrated this can be achieved without an increase in postoperative morbidity.

Postoperative outcomes Laparoscopic (%) (n=135)

Open (%) (n=106)

P value

Wound class 0.50

Madhu Ragupathi, MD, Deborah S Keller, MS, MD, Javier Nieto, MD, Sergio Ibarra, MD, Juan R Flores-Gonzales, MD, Ali Mahmood, MD, Thomas B Pickron, MD, FACS, Eric M Haas, MD, FACS, FASCRS, Colorectal Surgical Associates Introduction: Our objective was to evaluate the feasibility and efficacy of Single-incision Laparoscopic Colectomy (SILC) in obese patients. SILC is safe and feasible for treating benign and malignant colorectal disease. SILC offers several patient-related benefits over multiport laparoscopy. However, its use in obese patients has been limited due to concerns of greater technical difficulty, oncologic compromise, and higher complication and conversion rates. Methods and Procedures: Review of a prospective database identified elective SILC patients from 2009–2013. Patients were stratified into obese (BMI C30 kg/m2) and non-obese cohorts (BMI \30 kg/m2), then matched on age, gender, diagnosis, and operative procedure. Demographic and perioperative outcome data were evaluated. The primary outcome measures were conversion, operative time, length of stay (LOS), complications, and readmissions for each cohort. Results: 160 patients were evaluated- 80 in each cohort. Patients were similar in age (p = 0.93), gender (p = 1), prior abdominal surgery (p = 0.11), indication for surgery (p = 1), and procedure (p = 1). The obese cohort had significantly higher BMI (p \ 0.001) and ASA scores (p \ 0.001). Operative time (176.9±64.0 min vs. 144.4±47.2 min, p \ 0.001), blood loss (89.0±139.5 ml vs. 51.6±38.0 ml, p \ 0.001), and final incision length (4.0±1.5 cm vs. 3.5±1.1 cm, p = 0.008) were significantly higher in the obese. However, specimen length (p = 0.31) and lymph node harvest (p = 0.76) were comparable between cohorts for malignant cases. Furthermore, there was no significant differences in LOS (p = 0.33), conversion rates (p = 0.41), postoperative complications (p = 0.30), or readmission rates (p = 1). Conclusions: Single-incision laparoscopic colectomy is safe and feasible in obese patients for benign and malignant disease. Cases are technically challenging and require advanced laparoscopic skills. In the obese, where higher morbidity rates are typically associated with surgical outcomes, SILC may offer a practical approach to optimize patient outcomes in colorectal surgery.

Outcomes for Non-obese and Obese Patients Undergoing SILC

Non-obese (n=80)

Obese (n=80)

p-value

Mean BMI (SD, kg/m2)

22.8±2.3

33.4±3.2

0.001*

I

4 (5.0%)

1 (1.3%)

II

56 (70.0%)

34 (43.0%

III

20 (20.0%)

43 (54.4%)

IV

0 (0.0%)

1 (1.3%)

ASA (n,%)

0.001*

1–2

89.6

92.5

3–4

10.4

7.5

Superficial SSI

2.7

3.8

0.73

Intraoperative complications (n,%)

2 (2.5%)

1 (1.3%)

0.56

Deep incisional SSI

3.7

3.8

0.98

Conversion (n,%)

2 (2.5%)

4 (5.0%)

0.41

Organ space SSI

5.2

8.5

0.31

Mean Length of Stay (SD, days)

3.7±2.1

4.1±2.2

0.33

Dehiscence

0

1.9

0.19

Postoperative complications (n,%)

6 (7.5%)

10 (12.5%)

0.30

Pneumonia

0.7

0.9

[0.99

Reoperations (n,%)

2 (2.5%)

1 (1.3%)

0.56

Pulmonary embolism

0

0.9

0.44

Readmissions (n,%)

3 (3.8%)

3 (3.8%)

1.0

Progressive renal insufficiency

0

1.9

0.19

Acute renal failure

0

0.9

0.44

Urinary infection

6.7

7.6

Cerebrovascular accident

0.7

0

Bleeding

2.2

4.7

0.31

DVT requiring therapy

1.5

0.9

[0.99

Sepsis

8.2

9.4

0.73

Septic shock

0

0.9

0.44

Return to operating room

7.4

3.8

0.23

0.81 [0.99

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P044

P046

Plasma Levels of Keratinocyte Growth Factor, a Proangiogenic Protein, are Significantly Elevated for 3 Weeks After Minimally Invasive Colorectal Resection (MICR) for Cancer

Association Between Prolonged Ileus and Type of Colon Resection in Colon Cancer Surgery

Hmc Shantha Kumara, PhD1, Hiromichi Miyagaki, MD PhD2, David Giata, BS1, Xiaohong Yan, PhD1, Linda Njoh, PhD1, Cekic Vesna, RN1, Melissa M Alvarez-Downing, MD1, Richard L Whelan, MD1, 1 Department of Surgery, Mount Sinai Roosevelt Hospital, New York, NY 10019, USA, 2Department of Gastroenterological surgery, Osaka University, Osaka, 565-0871 Japan Introduction: Human Keratinocyte Growth Factor (KGF), also known as Fibroblast Growth Factor (FGF) 7, is a single chain, heparin-binding FGF family protein. KGF is produced by cells of mesenchymal origin yet has its effect on epithelial cell subpopulations, keratinocytes for example, which express the KGF cell surface receptor (KGF-R) which has tyrosine kinase activity. It is thought to be a paracrine promoter of epithelial cell proliferation and differentiation. KGF also plays a role in the epithelialization phase of wound healing during which keratinocytes line the wound. KGF expression has been noted in colorectal cancers (CRC) and is thought to support tumor cell proliferation and invasion. Overexpression of endogenous KGF has been noted in well differentiated CRC and is associated with increased VEGF-A production. MICR has been associated with persistent proangiogenic plasma protein changes that may stimulate the growth of residual cancer after surgery. Surgery’s impact on KGF levels is unknown. This study’s purpose was to evaluate plasma KGF levels during the first month after MICR for CRC. Method: CRC patients enrolled in an IRB approved data/plasma bank who underwent elective MICR for whom plasma samples were available were studied. Clinical and pathologic data were reviewed. Blood samples were collected preoperatively (preop) and at a variety of post-operative (postop) time points. Plasma was isolated and stored at -80C. Late samples were bundled into 7 day blocks and considered as single time points. KGF levels (pg/ml) were determined in duplicate via ELISA and reported as mean± SD. The paired t-test was used for statistical analysis (significance p \ 0.008 after Bonferroni correction). Results: Preop and, at least, 1 late postop plasma sample were available for 80 MICR CRC patients (colon 61%; rectal 39%; 37 male /43 female, mean age 65.8± 13.3 years). The mean incision length was 6.5±2.6 cm, mean operative time 295.0± 129.9 min, and mean length of stay was 6.5±2.6 days. The final cancer staging breakdown was; Stage I, 29%, Stage II, 34%, stage III, 32% and stage IV, 5%. The mean preop KGF level was 17.7± 8.3 pg/ml. When compared to preop levels, significantly elevated (p \ 0.0001) mean levels (pg/ml) were noted on postoperative day (POD) 1 (24.7± 12.8; n=80), POD 3 (27.3±18.3, n=76), POD7-13 (23.4±12.6, n=50), and POD14-20 (23.6±12.1, n=33). No significant difference in plasma KGF levels were noted for the POD 21-27 (19.2 ±6.6, n=15, p = .03) and POD28-34 (vs. PreOp, p = 0.3) time blocks. Conclusion: Plasma KGF levels were significantly elevated over baseline for 3 weeks after MICR for CRC. The early rise after surgery may be due to the short lived acute inflammatory response, however, the elevation noted during weeks 2 and 3 may is more likely related to wound healing in which KGF plays a role. The KGF increase, together with similar persistent post MICR elevations in blood levels of VEGF, PlGF, ANG2, etc. may stimulate angiogenesis in residual tumor deposits after surgery. Further investigation is needed.

P045 Laparoscopic-Dominant Abdominoperineal Resection for Low Rectal Cancer Bo Feng, MD, Minhua Zheng, MD, Surgery Department of Ruijin Hospital, Shanghai, China Recent advances in laparoscopic instruments and techniques allow transabdominal transection of levator muscles under direct vision. Therefore, a laparoscopic-dominant APR becomes possible. This approach offers a transabdominal individualized transection of levator muscle, lowers the meeting level down to the ischiorectal fat, and at the same time provides guidance for the extent of perineal resection. The resection line therefore is predominantly determined by the laparoscopic procedure, rather than a synchronous approach. In this way, a more precise, less invasive procedure depending tumor stage and patient characteristics can be provided. We present our 30 cases experience of this laparoscopic-dominant APR with a high definition quality videos as well as drawings. Technical tips are shown in the video. During laparoscopic-dominant APR, a patient-tailored surgery can be provided according to tumor size and invasion (T-stage) pre-assessed by MRI and finally determined by intra-operative exploration. For tumors located below the levator hiatus, the transection line is kept outside musculus pubococcygeus to leave more musculus illiococcygeus for direct closure. For tumors situated above the levator hiatus, levators should be removed at their origins at the tumor side, while more muscles are kept on the other side to facilitate perineal reconstruction. Extensive resection of coccyx and sacral 4–5 might necessary for caudally grown tumors while an exenterative surgery is often required for anteriorly located lesions.

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Zhobin Moghadamyeghaneh, MD, Joseph C Carmichael, MD, Steven D Mills, MD, Alessio Pigazzi, MD, Michael J Stamos, MD, University of California, Irvine Background: There is limited data regarding the surgical factors associated with prolonged postoperative ileus in colon surgery. We sought to compare prolonged postoperative ileus in different kinds of colon resection and bowel anastomosis in patients with the diagnosis of colon cancer. Method: The NSQIP databases were used to examine the clinical data of patients undergoing colon resection with the diagnosis of colon cancer in 2012. Multivariate regression analysis was performed to compare different resections regarding prolonged ileus (no return of bowel function in 7 days). Results: We sampled a total of 3,920 patients who underwent colon resections. A total of 14.7% of the patients had prolonged ileus. Patients who had prolonged ileus had more than three times increased rate of anastomotic leak (AOR: 3.01, P\0.01). The highest rate of prolonged postoperative ileus existed in total colectomy with ileorectal anastomosis (27.2%) followed by segmental colonic resection with colocolonic anastomosis (15.2%). The lowest rate of prolonged ileus followed sigmoidectomy with colorectal anastomosis (13%). In multivariate analysis, compared to sigmoidectomy with colorectal anastomosis, total colectomy with ileorectal anastomosis procedure had significantly higher risk of prolonged ileus (AOR: 2.89, P \ 0.01). Also, factors such as hypoalbuminemia (AOR: 1.55, P \ 0.01), open surgery (AOR: 1.79, P \ 0.01), and non-elective surgery (AOR: 1.38, P \ 0.01) were associated with prolonged ileus. Conclusion: Prolonged ileus is a common condition following colon resection (incidence rate of 14.7%). Patients with prolonged ileus had three times higher rate of anastomotic leak, which points out the need to consider a leak in any patient with prolonged ileus. Following a colon resection for cancer, total colectomy with ileorectal anastomosis and sigmoidectomy have the highest and the lowest rates respectively, of prolonged postoperative ileus.

Surg Endosc

P047

P048

Laparoscopic Management of Splenic Flexure Volvulus: a Case Report

Endoscopic Mucosal Resection for Curative Excision of Large Capolyps

Hernan R Reyes-Sepulveda, MD, Marco A Juarez-Parra, MD, Ricardo Cuellar-Tamez, MD, Ulises Caballero-de la Pen´a, MD, Jessica S Cordova-Chavez, MD, Christus Mugerza Alta Especialidad / Universidad de Monterrey

Karukurichi S Venkatesh, MD, Sandra Yee, MD, Tri-City Colo-Rectal Surgery, Ltd.

Introduction: Colonic volvulus is defined as an axial twist of the colon along its mesentery, it accounts for 2–4% of large bowel obstruction. The most common site for volvulus is the sigmoid colon followed by the caecum, splenic flexure is the least common site with only 1–3% of cases. Splenic flexure is ligament-fixated to the abdominal wall in most individuals, congenital absence or acquired laxity of these ligaments predispose for torsion. Reports have been published in all age groups. Clinical presentation vary from insidious abdominal distention with obstipation to acute abdominal pain and guarding due to vascular compromise. Suspicion is raised on the plain radiograph where a markedly dilated air-filled colon is visualized in the left upper quadrant. Abdominal CT-scan is the study of choice to define the level, degree of volvulus as well as vascular compromise. We present a case of uncomplicated splenic flexure volvulus that was initially managed by laparoscopic detorsion and posteriorly with left hemi-colectomy. Case Report: A 25 year-old otherwise healthy male presented to the emergency department with a five-day history of nausea, dull abdominal pain on his left flank and bloating. He had a history of chronic constipation and recurrent abdominal colic. Past medical history was unremarkable. On examination, his abdomen was distended and mildly tender to palpation without any signs of peritoneal irritation. Laboratory tests were within normal parameters. A plain abdominal radiograph showed markedly dilation of the transverse and descending colon with the presence of fluid levels and absence of air in the distal colon and rectum. An abdominal CT-scan demonstrated a grossly dilated bowel with a transition zone distal to the splenic flexure with associated collapse of the distal GI tract. A nasogastric tube was placed and the patient was scheduled for a diagnostic laparoscopy the same day of addition. A 10 mm trocar was inserted thought the umbilicus two additional 5 mm trocars were placed on the left lower abdominal region. A markedly dilated transverse colon and a 180 splenic flexure volvulus was observed; also the absence of splenocolic and phrenocolic ligaments was noted. Because no signs of isquemia, gangrene, perforation or intraperitoneal contamination were found, conservative treatment was considered feasible. Derotation was achieved by means of traction and the patient was left for observation. Due to the absence of clinical and radiological resolution after 72 hours, a laparoscopic left hemi-colectomy was planned. A trans-operative colonoscopy was performed for endoscopic decompression. Vascular control was achieved with bipolar energy, the specimen was removed thought a mini-pfannestiel incision and an end-to-end colo-rectal anastomosis with a circular stapler was created. He had an uneventful postoperative recovery. Conclusion: Splenic flexure volvulus is a rare disease with less than 25 cases reported in the English literature. Although endoscopic decompression can be performed in the hemodynamically stable patient, surgical resection is the primary definitive treatment. To our knowledge this is the first reported case of a patient managed with minimally invasive techniques.

Out of 122 patients with histologically proven benign polyps of the colon, two centimeters or over, 108 patients were deemed suitable for curative endoscopic excision, after careful selection process, over a 40 month period. Eight patients underwent lap-assisted colonoscopic excision of polyps and were excluded from the study. The polyps were four centimeters or larger in 40 patients. The age range of this group of 100 patients is 25 to 83 years. The polyps were located in the left colon in 64 percent of the patients. Polyps of the rectum were excluded from this study. Technique: In 78 percent of the patients, the procedure was performed in the operating suite with IV sedation, using propofol given by anesthesiologist. The rest were performed in an ambulatory surgical center. Both small and large snares were used in all patients. The polyp excision was achieved with submucosal lift using saline and overlapping multiple passages of the snare. Piecemeal excision with snare was used for larger polyps. The snare was held tight at the polyp base for one to two minutes, depending on the size of the polyp segment that was caught. Wide fulguration of the surrounding mucosa was then performed. Submucosal injection of epinephrine was used around the polyp base at the end of the procedure. All patients were discharged after two hour stay in the recovery room. No immediate or delayed perforations occurred. One patient had immediate bleeding following excision, controlled with hemoclip, requiring the lone admission to the hospital overnight. In four patients we were unable to excise the polyp curatively. One patient age 83 had opted not to do anything further. One patient had another attempt at endoscopic excision at another institution, which also failed, resulting in laparoscopic resection. The other two patients underwent laparoscopic resection. Results: Of patients with successful excision, three patients required colon resection due to invasive carcinoma extending to the margin of resection. Five patients had superficial invasive cancer, 5–10% of the volume of the polyp without submucosal involvement. Ten patients had high grade dysplasia. All patients were followed with another colonoscopy at three months and at one year. Three patients had recurrences at excision site requiring successful reexcision and fulguration at three months. Conclusion: Large polypoid lesions of the colon can be successfully curatively excised using endoscopic mucosal resection.

P049 Tumor Size Does not Affect Survival in Stage 1 Colorectal Cancer Patients Onur Kutlu, MD, Milad Mohammadi, MD, Steven Garcia, MD, Mark Williams, MD, Sharmila Dissanaike, MD, TTUHSC-Lubbock

,

Background: The current standard for staging colorectal cancer includes tumor depth, nodal status and metastases. It is known that prognosis is highly affected by the latter two of the staging model. For many different cancers tumor size is important in determining survival and treatment. The effect of tumor size on prognosis in colorectal cancers is an area of discussion. Our aim was to evaluate the significance of tumor size on survival in patients with T1 and T2 colorectal cancers with negative nodes and no metastatic disease from the primary colorectal cancer. Methods: Binary logistic regression and Cox regression models were utilized to identify factors affecting survival. Surveillance epidemiology and end results database (SEER) was queried for patients diagnosed with histologically proven colorectal cancer between the years of 2004–2008. Our criteria for patient sampling included T1 and T2 tumors with a known size, negative nodal status, known CEA values, and no known metastasis. Age criteria included patients between 20 and 85. Patients were required to have minimum of 1 month follow-up. Those who were lost to follow up were excluded from the study. Results: 11,585 patients were identified. 51.7% were male and 48.3% were female, 18.4% of the patients died at the end of 60 months. Mean tumor size was 51 (1–98) mm, CEA was elevated in 21.6% of the patients. Tumor status was as follows; Tis 3.6%, T1 32.4%, T2 64%. Factors affecting survival were CEA elevation and age over 40. Effects of tumor size, T status, sex were not found to be significant in survival (p = 0.07). Conclusion: Many tumors have a correlation between size and survival. We studied survival in patients with colorectal cancer that had not invaded into the serosa (T1-T2) who were node negative and had no metastasis (Stage 1). Our analyses have shown that the size of the tumor did not have statistically significant impact on the survival of patients with T1-T2 lesions that had no metastasis or nodal involvement after curative surgical intervention.

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Surg Endosc

P050

P052

Is Laparoscopic Appendectomy Safe in Appendicular Mass

Use of Fluorescent Angiography in Mucosal Advancement Procedures: a Small Series

Abdul Razqque Shaikh, Liaquat University of Medical Health & Sciences Jamshoro Pakistan Objectives: To evaluate the safety and efficacy of laparoscopic treatment of appendicular mass Materials & Methods: A prospective study was conducted at Liaquat University of Medical Health & Sciences Jamshoro Pakistan and a private hospital from January 2011 to December 2013 on all adult cases of appendicular mass treated by laparoscopy. Results: Total cases of acute appendicitis were 231, out of which appendicular mass were 30 cases (12.98%). Males were 19 and females were 11 cases. Age ranged from 25 to 60 years (median 35 yeas). Operation time was 100 minutes (Range 60–150 min.).There was one (3.33%) conversion to open. Postoperative stay was 4 days (range 3–6). Resumption of diet was on second day (1–3). Postoperative complications were wound infection in 2 cases (6.45%), intra abdominal abscess in one case (3.33%) and prolonged ileus in one case (3.33%). Conclusion: Appendicular mass can be treated by laparoscopy safely and avoids the second hospital admission

Jacquelyn S Turner, MD, Carolyn Moore, Clarence Clark, Morehouse School of Medicine Background: Rectal mucosal advancement procedures are commonly used for perianal fistulas and in the setting of circumferential mucosal prolapse. These procedures can have up to a 30% early complication rate with flap separation likely attributed to poor profusion or technical error. Here, we describe two cases where endoscopic florescent angiography and near infrared illumination (NIR) using indocyanine green (ICG) was utilized to assess mucosal flap profusion prior to repairs of complex recurrent anal fistulas and rectal mucosal prolapse. Methods: Two cases were retrospectively reviewed. To better understand the presentation, management and outcomes surrounding these cases, a literature search was performed. Results: Case A is a 23-year-old man with HIV and a history of prior incision and drainage procedures for perianal abscesses with seton placement for complex fistula- in-ano. For definitive treatment, two simultaneous full thickness rectal mucosal advancement flaps were performed. Each flap was evaluated by intra-operative NIR and fluorescent angiography using a PINPOINT (Novadaq, Ontario, Canada) device. One flap was angiographically assessed after flap fixation and the other was assessed before flap fixation. Poor perfusion was noted by the PINPOINT device in the former flap and adequate perfusion was noted in the latter flap. Flap separation was noted in the former flap upon postoperative evaluation while adequate healing was noted in the latter flap. Case B, a 35-year-old man with prior laparoscopic sigmoid colectomy with rectopexy for full thickness rectal prolapse, was taken to the operating room for mucosal prolapse repair one year from his original surgery. PINPOINT was utilized to assess perfusion of the mucosal sleeve after mobilization up to the most proximal area of redundant mucosa. Upon evaluation using the PINPOINT device, a clear demarcation was noted for a point of mucosal transection. After the anastomosis was created, perfusion of each end of the anastomosis was re-confirmed with PINPOINT. No known complications were noted on immediate follow up. Conclusion: Rectal mucosal advancement procedures can be technically challenging especially after complex, recurring diseases due to a compromise of microvascular perfusion. The PINPOINT device is a tool to assess microvascular perfusion in these difficult situations. Ultimately, this angiographic device helps to guide intra-operative decisions to help reduce post-operative complications as it relates to compromised microvascular perfusion and ultimately improve patient outcomes.

P051

P053

Minimally Invasive Approach for Full Thickness Rectal Prolapse is not Associated with Improved Recurrence Rates

Colo-Rectal Cancer in Port Harcourt Nigeria: a Multicentre Analysis of Lower Gastro-Intestinal Endoscopies

Tarek K Jalouta, MD, M Luchtefeld, MD, M Dull, J Ogilvie, MD, D Kim, R Figg, MD, R Duojnvy, MD, R Hoedema, MD, H Slay, MD, N Jrebi, MD, Spectrum Health

Emeka Ray-Offor, MBBS, FWACS, FMAS, DMAS1, Njideka C Aneke, MBBS2, Patrick O Igwe, MBBS1, Jacob M Adotey, FRCS1, 1 University of Port Harcourt Teaching Hospital Port Harcourt Rivers State Nigeria, 2Oak Endoscopy Centre Port Harcourt Rivers State Nigeria

Background: Despite the multiplicity of surgical options for rectal prolapse, there is no clear superior repair. Given the rise of newer techniques and approaches we sought to evaluate the changing surgical choices over time and compare their recurrence rates. Methods: We retrospectively identified 421 patients from a single institution who underwent repair for rectal prolapse over a 13-year period. Cases were classified based on surgical approach (abdominal – [laparoscopic vs. open] or perineal) and time of repair. Follow-up data were recorded from the electronic medical record or via telephone survey. Results: For the entire cohort, 64.8% (n=273) of patients underwent a perineal approach. Of the abdominal approaches, 45.8% (n=67) were done with minimally invasive approaches, 55.4% (n=81) were open. There were 9.3% who were lost to follow-up and the recurrence free survival rate was 81.2% at four years (95% CI: 76.5–85.9). When divided into three time frames (early, mid and late) there were significantly more laparoscopic cases performed (when compared to open) in the late period compared to early (56% vs. 28%, respectively; p = 0.006). There were an equal number of perineal cases performed in the early and late time periods (68% vs 62%, respectively; p = 0.30). The recurrence free survival rate between the early and late time periods did not reach statistical significance (2.2; 95% CI: 0.94–5.0). Conclusion: Despite the shift towards a minimally invasive approach for rectal prolapse, recurrence rates have not significantly changed.

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Introduction: Colorectal cancer (CRC) is a major cause of cancer mortality in countries of Europe, North America, Australia and Asia. A low incidence in Africa has been reported, albeit, an adenoma-carcinoma sequence is not disputed. Colonoscopy is the gold standard for investigating diseases of the colon but not common practice in our environment. Aims: To study colonic diseases in our environment from an endoscopy perspective highlighting the incidence of precancerous and cancerous colonic lesions. Patients and Method: A prospective study of all consecutive patients who were referred to two private health facilities with Endoscopy units for lower gastro-intestinal endoscopy from June 2013 to July 2014. Variables studied were; sociodemographics, indication, endoscopic/histopathologic findings and outcome of CRC patients. Data were collated and analysed using SPSS version Results: A total of 40 flexible lower GI endoscopies were performed during the study period. There were 34 males and 6 females with age range of 27 to 86 years and a mean of 52.2 SD 14.8 years. Screening was the indication for endoscopy in only one case. CRC was confirmed in 4(10%) cases with 3(8%) cases of polyps (inflammatory) and 1(3%)ulcerative colitis seen. All cases of colon cancer were advanced lesions with 3 left sided colonic lesions and a rectal cancer with liver metastases. Obstructed cases had colostomy preceding other treatment; one case had stoma created via laparoscopy. Conclusion: Late presentation of CRC and rarity of premalignant lesions are the trend in our environment. A screening program with the benefit of early detection and probable cure is necessary. Keywords: Colorectal cancer, colonoscopy.

Surg Endosc

P054

P055

Is Laparoscopic Colectomy for Cancer Really Beneficial in Octogenarians?

Laparoscopic Versus Open Right Hemicolectomy: a Single Centre Experience

Leonardo de Castro Duraes, PhD, MD1, Luca Stocchi, MD1, Meagan Costedio, MD1, David Dietz, MD1, Emre Gorgun, MD1, Matthew F Kalady, MD1, Herman Kessler, MD1, Xiaobo Liu2, Feza Remzi, MD1, 1Colorectal Surgery Department - Digestive Disease Institute - Cleveland Clinic Foundation, Ohio, 2Quantitative Health Sciences - Lerner Research Institute - Cleveland Clinic Foundation, Ohio Background: Laparoscopic colectomy for cancer is associated with recovery benefits and similar oncologic outcomes when compared to open procedures. Octogenarians are a special segment of the population in which the use of laparoscopy has not been well established. The aim of this study was to compare outcomes after laparoscopic vs. open surgery with curative intent for colon cancer in octogenarians. Methods: An institutional database was queried to identify patients older than 80 years-old with stages I-III colon adenocarcinoma, operated with curative intent between 2000 and 2012. Exclusion criteria were emergency surgery, inflammatory bowel disease, hereditary colorectal neoplasm, and other malignancies. Univariate, multivariate, and Kaplan-Meier survival analyses were performed to compare perioperative and oncologic outcomes of laparoscopic colectomy vs. open colectomy and assess possible association with a number of patient-related, disease-related and treatment-related factors. P \ 0.05 was considered statistically significant. Results: 225 patients fulfilled the inclusion criteria. Laparoscopy was used in 27.1% of the procedures. The conversion rate was 16.4%. Patients treated with laparoscopy were significantly older than patients treated with open surgery. There were otherwise no differences in gender, BMI, ASA and pathological stage between the groups. Perioperative morbidity, mortality and oncological outcomes were also comparable. Patients undergoing laparoscopic surgery had reduced length of hospital stay when compared with the open group (p = 0.033). Multivariate analysis indicated male gender (OR=1.87, 95% CI, 1.03–3.40, p = 0.03) as the only independent factor associated with increased morbidity, while pathological stage III (OR=7.28, 95% CI, 1.53–34.61, p = 0.01) was the only independent factor associated with cancer-specific survival. Conclusion: Laparoscopy can be safely offered to selected octogenarians for treatment of colon cancer with curative intent and is associated with recovery benefits.

M A Gok, S J Ward, M M Sadat, U A Khan, Macclesfield District General Hospital Introduction: Colorectal cancer is the 3rd most commonest maligancy in men & women in the UK representing 13% of all new cancers in 2010. Right sided cancers (appendix, caecum, ascending & transverse colon) contribute to a 3rd of colorectal maligancies. The aim of the study is to assess right hemicoloectomies carried out at a district general hospital. Materials & Methods: This is a retrospective study carried out since 2008 at Macclesfiedl District General Hospital. Descriptive demography, co-morbidities, histopathology & surgical outcomes were evaluated for all right hemicolectomies (laparoscopic, open & emergency cases). Discussion: Laparoscopic Rt Hemi has advantage of minimal invasion, earlier recovery, lower rates of wound complications, shorter hospital stay & comparable survival rates of Open Rt Hemi. The prolonged operative time is attributed to the use of laparoscopy. Em Rt Hemi had a poorer survival as patients were generally ill (ASA 3) with sepsis.

Results Lap Rt Hemi (n=93)

Open Rt Hemi (n=118)

Em Rt Hemi (n =75)

Kruskal-Wallis test (p value)

Age (yrs)

74.8

72.3

70.0

NS

Sex (M:F)

41:52

67:51

33:42

NS

ASA

2

2

3

\0.05

Weight (kg)

67.6

80.4

68.6

\0.05

BMI

24.5

27.0

25.0

\0.05

Appendix/Ileum

1

2

1

Caecum

51

60

32

Ascending colon

22

23

12

Transverse colon

19

33

30

Op time (min)

145.8

107.1

118.6

0.019

LN harvest (n)

16

16.5

14

NS

70 (42.7)

0.67

Diverticulosis (n)

14

14

13

NS

25.6 (4.6)

0.276

Synchronous tumours (n)

10

31

9

\0.05

0.26

LOS (days)

7

9

11

\0.05

Laparoscopy

Open

Patients

61

164

Age(mean/sd)

85.7 (3.7)

84.5 (3.6)

Gender - Male n(%)

28 (45.9)

BMI(mean/sd)

25.9 (4.0)

Pathological Stage n(%)

p value

\0.05

Stage I

20 (32.8)

37 (22.6)

small bowel length (mm)

92.2

92.7

124.1

\0.05

Stage II

26 (42.6)

75 (45.7)

large bowel length (mm)

218.5

231.8

309.5

NS

Stage III

15 (24.6)

52 (31.7)

1st year survival

95.1

90.5

73.7

logrank p \ 0.05

3rd year survival

82.2

76.5

49.9

logrank p \ 0.05

5th year survival

69.4

71.7

45.4

logrank p \ 0.05

Complications Overall

28 (45.9)

55 (33.5)

0.087

Intraoperative

2 (3.3)

10 (6.1)

0.40

Postoperative

27 (44.3)

52 (31.7)

0.079

30 day mortality n(%)

2 (3.3)

13 (7.9)

0.21

5-year Overall Survival (95% CI)

42.2% (19.1%-65.3%)

42.1% (33.8%-50.3%)

0.115

5-year Disease Free Survival (95% CI)

39.5% (17.5%-61.5%)

39.8% (31.6%-48.0%)

0.126

5-year Cancer Specific Survival (95% CI)

90.0% (76.5%-100%)

85.2% (78.2%-92.2%)

0.325

5-year Overall Recurrence (95% CI)

19.1% (4.1%-34.1%)

11.7% (5.5%-17.8%)

0.767

Length of stay (days) – median, mean(sd)

7, 9.1 (8.1)

8, 10.2 (6.9)

0.033

P056 The Safety of Laparoscopic Surgery for Colorectal Cancer in Patients Older than 80 Years Sang-Hong Choi, Seung-Hoon Lee, Song-Yi Yang, Seung-Hyun Lee, Byung-Kwon Ahn, Sung-Uhn Baek, Department of Surgery, Kosin University College of Medicine Purpose: Laparoscopic surgery has accepted as a standard procedure for colorectal cancer, and become popular. Colorectal cancer usually presents in the elderly patients. The aim of this study is to evaluate the safety of laparoscopic surgery for colorectal cancer in the elderly patients. Methods: We retrospectively reviewed 49 patients older than 80 years of age, who underwent surgery for colorectal cancer from Jan. 2008 to Jun. 2012. The patients was divided into the open group (N=22) and the laparoscopic group (N=27). Patient who underwent emergency operations were excluded. Medical records were reviewed for demographics, operative risk factors, operation methods, intra-operative blood loss, postoperative day of gas out, postoperative hospital stay, complications. Results: Between the open group and the laparoscopic group, there was no significant difference in age, sex ratio, comorbidities, American Society of Anestheology (ASA) score, revised cardiac risk index, tumor location, operation methods. Postoperative hospital stay (16 days vs. 8.8 days, p = 0.000), gas out (4 days vs. 3 days, p = 0.037), estimated blood loss (236 ml vs. 103 ml, p = 0.003) were different significantly. Operation time (168 min vs. 140 min, p = 0.139) and complications were not different significantly. Conclusion: For patients older than 80 years, laparoscopic surgery had a shorter hospital stay, earlier gas out and less intra-operative blood loss than open surgery. Complications were not different significantly in the both groups. Therefore, the laparoscopic surgery for colorectal cancer in elderly patients is a safe and acceptable procedure.

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P057

P059

Surgical Site Infection Impact of Pelvic Exenteration Procedure

Effect of Surgery type on Tumor Growth

Zhobin Moghadamyeghaneh, MD, Michael J Stamos, MD, University of California, Irvine

˜ z2, Ibrahim Ethem GeA ˜ im3, Fikret Sahin4, Ebru Esen1, Siyar ErsA ˜ –zlem Kavak5, Mustafa Ertek6, Mustafa Filik5, Atilla Elhan7, A 1 Ankara University Medikal Faculty Surgical Oncology Department, 2 Ankara Numune Research and Training Hospital, 3Ankara University Medical Faculty General Surgery Department, 4Ankara University Medical Faculty Medical Microbiology Department, Ankara, Turkey, 5Ankara University Medical Faculty Nuclear Medicine Department, Ankara, Turkey, 6Diskapi Yildirim Beyazit Egitim Arastirma Hastanesi Klinik Mikrobiyoloji ve Enfeksiyon Hastaliklari, 7Ankara University Medical Faculty Medical Biostatistics Department, Ankara, Turkey

Background and Hypothesis: There is limited data available on the surgical site infection (SSI) of patients following debulking operation of pelvic exenteration. NHSN includes these patients under the broad category of colectomy. We sought to compare surgical site infection in patients with pelvic exenteration procedure and conventional rectal resections. Design and Methods: The NSQIP databases were used to examine the clinical data of rectal cancer patients undergoing elective resection between 2010 and 2012 with wound class 2 (clean contaminated). We separated the patients into two groups of underwent pelvic exenteration and conventional proctectomy resections. Multivariate regression analysis with adjustment of the results with demographic factors and 15 preoperative comorbid conditions was performed in comparing surgical site infection complications. Results: We sampled a total of 1,536 patients who underwent rectal resection. Of these, 229 (14.9%) patients underwent pelvic exenteration. In multivariate analysis after adjustment patients who underwent pelvic exenteration had more than two times higher rates of organ space SSI (AOR: 2.08, P \ 0.05) and superficial SSI (AOR: 2.08, P= P \ 0.05). Also, postoperative sepsis (AOR: 2.57, P\0.05) and septic shock (AOR: 3.82, P\0.05) were higher in patients who underwent pelvic exenteration. Conclusion: Patients undergoing pelvic exenteration have more than twice rates of organ space and superficial surgical site infections compared to conventional rectal resections. Also, they have increased risk of postoperative sepsis and septic shock complications. Specific consideration to infectious complications is recommended for these patients.

Purpose: Between laparoscopic and open surgery for tumoral organisms, after laparoscopic surgery immune system of organism suppresses lesser, for this reason, by some, it is believed that after surgery the remaining tumor cells grow more slowly. The aim of this study is to investigate the effects of laparoscopic and open surgery to tumor growth and activity. Methods: Five- to six- weeks- old female, thirty, BALB/C mice were used for this study. 2.59106 CT- 26 tumor cells were inoculated intradermally in the dorsal skin of mice. The mice were randomised in three groups, every group included ten animals. 1. group; control group, 2. group; open surgery model, 3. group; three port laparoscopy model. After administration of anestesia to 1. group, no operation was made. After administration of anesthesia to 2. group, 3 cm laparotomy was made and waited for 20 minutes then skin and fascia closed. After administration of anesthesia to 3. group, 18 gauge needle inserted to abdomen and CO2 pneumoperitoneum was created, then 2 more 18 gauge needles were inserted. For 15 minutes a pressure of 2 to 4 mmHg was maintained. At fifteenth minute 5 mm mini insicion was made, wait for 5 minutes and then skin and fascia closed. At 12th hour we have received tail vein blood and IL-6 levels were measured. At fourteenth day visible tumor nodules grew up. Long and short tumor diameters milimetrically measured. At fifteenth day, under anesthesia PET was taken. Same day all animals were sacrificed and tumors en- block resected and weighed. Results: There was no statically significant difference for 3 group’s tumor weights. There was no statically significant difference in tumor long and short diameters for laparoscopic and laparotomy groups. Diameters of the two groups were statistically significantly longer than the control group. There was no statically significant difference in SUVmax values for laparoscopic and laparotomy groups. SUVmax values of the two groups were statistically significantly higher than the control group. There was no statically significant difference in IL-6 values for laparoscopic and laparotomy groups. IL-6 values of the two groups were statistically significantly higher than the control group Conclusions: In occlusion, there was no significant difference for IL-6, SUVmax values, weight and tumor size between laparoscopy and laparotomy groups. In later periods, with larger groups and more parameters, experiments will provide clearer and more reliable results.

P058

P060

Procedure and the Benefit of Laparoscopic Suture Rectopexy for Overt Rectal Prolaps in Comparison with Transperineal Procedures

Single Center Comparative Study of Oncologic Outcome in Laparoscopic Versus Open Rectal Cancer Surgery

Nagahide Matsubara, MD, Kiyoshi Tsukamoto, MD, Mie Yoshimura, MD, Michiko Hamanaka, MD, Naohito Beppu, Naohiro Tomita, MD, Hyogo College of Medicine Introduction: Several procedures have been designed and applied to treat overt rectal prolapse. Transperineal procedures, such as Miwa-Gantz, Altemeier and Delorme operations, are associated with less morbidity, but higher rate of recurrence. Transabdominal procedures include a variety of rectopexies with the use of prosthesis or sutures and with or without resection of the redundant sigmoid colon, which are all approached by laparoscopy in recent years. Traditional prosthesis rectopexies are sometimes associated with increased rate of constipation. Resection sutuererectopexy seems to be associated with the best functional results, particular in patients with slow transit constipation and diverticular disease, however, risk for suture insufficiency is always the problem for the elderly patients and, thus, must be avoided. We prefer simple suture rectopexy method recently and compared the results of other procedures conducted in our institute. Method and Procedures: From 1990 to January 2012, 44 patients with rectal prolapse were operated in our institution, including 9 Miwa-Gantz operation, 15 Altemeier method, and 13 rectopexy (11 by laparoscopic and 2 by open procedure). Complications per and postoperative as well as patient satisfaction for laparoscopic rectopexy were assessed. Results: The mean operative time was 162 min in rectopexy and mean blood loss was 87 ml. The postoperative complication rate was 14% corresponding bowel obstruction and recurrence (distance complication). With a mean follow-up of 40.7 months, 86% patients declared themselves satisfied with the intervention. Discussion and Conclusion: Our results confirm the feasibility of the laparoscopic rectopexy with a quality of life improvement.

123

Amir Taheri, MD, Erica Haase, MD, Cliff Sample, MD, University of Alberta Background: Colorectal adenocarcinoma is the third most common site for new cancers and death in both men and women. The unique anatomy of the rectum, with its retroperitoneal location in a narrow pelvis and proximity to the urogenital organs, autonomic nerves, and anal sphincters, makes surgical access relatively difficult. Prognosis in rectal cancer including the mortality, recurrence and disease free survival is tightly related to adequacy of TME, number of lymph nodes harvested and margin status. In recent years, laparoscopy has gained worldwide interest as a method of rectal cancer surgery. Several prospective randomized control trials has compared laparoscopic versus open technique for TME resection, showing the advantages of laparoscopic surgery in terms of a shorter hospital stay, decreased postop ileus while having equivalent survival and recurrence rate. In this study, we will compare oncologic outcome of open versus laparoscopic rectal cancer surgery in a high volume center. Hypothesis: Laparoscopic TME resection for rectal cancer is oncologically safe and there is no difference in TME adequacy, margin status and number of harvested lymph nodes. Methods: All adult patients with rectal cancer who had elective TME resection from 2005–2013 at Grey Nuns hospital, Edmonton, with no evidence of locally advanced or metastatic disease pre or intra-operatively, were identified and reviewed. Oncologic outcome including TME adequacy, margin status and harvested Lymph node numbers were compared using chi square and exact fisher test. Results: 159 patients with TME resection were included in our study and their pathologic results were reviewed. 119 patients (74%) had open and 40 (26%) had laparoscopic TME resection. Only one patient in open group had inadequate TME resection with no statistically significant difference between both groups (P value: 0.55). There were 3 patients (%2.7) with positive distal margin in open group who had re excision and none in laparoscopic group. There was no positive CRM in both groups. No significant difference between two groups were detected (P value: 0.57). Average number of 18.3 lymph nodes in open and 17.7 in laparoscopic group were harvested and no statistically significant difference was observed between the two groups (P value: 0.45). Discussion: TME resection can be used as a valuable tool for grading the surgeon and an excellent tool to audit the center. Laparoscopic TME resection should be done by an experienced team in a high volume center and is oncologically safe.

Surg Endosc

P061

P063

New Approach to the Modified Extralavator Abdominoperineal Resection for Low Rectal Cancer with Direct Wound Closure

Impact of Previous Abdominal Surgery on Laparoscopic Colon Cancer Surgery

Eun Jung Park, MD, Seung Hyuk Baik, MD, PhD, Jeonghyun Kang, MD, Byung Soh Min, MD, PhD, Kang Young Lee, MD, PhD, Nam Kyu Kim, MD, PhD, Seung-Kook Sohn, MD, PhD, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea

Takeshi Naitoh, MD, FACS, Shinobu Ohnuma, MD, PhD, Tomoya Abe, MD, PhD, Munenori Nagao, MD, PhD, Hiroyuki Sasaki, MD, PhD, Kazuhiro Watanabe, MD, PhD, Hideaki Karasawa, MD, PhD, Hiroaki Musha, MD, PhD, Naoki Tanaka, MD, PhD, Katsuyoshi Kudo, MD, PhD, Fumie Ikezawa, MD, PhD, Kei Nakagawa, MD, PhD, Takanori Morikawa, MD, PhD, Hiroshi Yoshida, MD, PhD, Fuyuhiko Motoi, MD, PhD, Yu Katayose, MD, PhD, Michiaki Unno, MD, PhD, Department of Surgery, Tohoku University Graduate School of Medicine

Introduction: This study aims to demonstrate a new surgical procedure for the modified extralevator abdominoperineal resection, which satisfies both an extended cylindrical resection and a convenient perineal wound closure by modification of the surgical dissection plane. Methods and Procedures: From September 2011 to February 2014, 12 consecutive patients (5 males and 7 females) underwent the modified extralevator APR in Severance Hospital, Yonsei University College of Medicine, South Korea. Patients with T3/4 low rectal cancer or positive lymph nodes received preoperative chemoradiotherapy for down-staging before surgery. Surgical procedures were performed by open, laparoscopic or robotic surgeries with informed consents. Intraoperative and postoperative outcomes were evaluated. Pathologic outcomes were assessed for the oncologic results. Results: The mean age was 55.3±15.1 years and body mass index was 21.8±3.1 kg/m2. Ten patients (83.3%) received preoperative chemoradiotherapy. The operations were performed by 5 cases of laparoscopic surgery, 6 cases of open surgery, and 1 case of robotic surgery. The mean operation time was 258.8±58.0 min. There were no conversions and no tumor perforations. Days to 1st soft diet was 4.7±3.4 days, and the mean hospital stay was 11.2±4.7 days. Postoperative complications were 2 cases of grade I, 2 cases of grade II and 1 case of grade III. There was 1 patient (8.3%) with a positive circumferential resection margin and there was 1 case of local recurrence. The modified extralevator APR was performed by three steps: the abdominal dissection, the perineal dissection and the perineal wound closure. Conclusion: The modified extralevator APR was feasible and safe for patients with low rectal cancer or anal cancer with extended perineal dissection and convenient direct wound closure by modification of the surgical plane. The surgical procedures were feasible in open, laparoscopic and robotic surgeries. In spite of the decreasing numbers of patients who underwent APR due to the development of sphincter-saving surgeries, a new approach to overcome the previous limitations of APR should be considered (Fig. 1).

Fig. 1

The surgical dissection plane. A, conventional APR. B, extralevator APR. C, the modified extralevator APR

Backgrounds: A history of previous abdominal surgery often has some influences on performability of laparoscopic procedures. Severe adhesion of bowels to the operative scar or adhesion between bowels would be a problem and surgeons could not often help converting to the conventional procedures. On the other hand, the recent progress of laparoscopic equipment makes several complicated procedures feasible to perform without conversion to open surgeries. The high-definition image system, for example, helps to recognize detail anatomies that lead to precise dissection. Some energy devices are useful to perform precise dissection, as well. In this study, we aimed to assess if previous abdominal surgery history had influence on the performability of laparoscopic colon cancer surgery in a retrospective way. Patients & Methods: Since July 2008 to June 2013, ninety-nine cases of colon cancer were operated laparoscopically. Forty-four cases had history of previous abdominal surgery. Of those we assessed operative outcome such as operative time, estimated blood loss, and perioperative morbidity compared to patients who do not have previous abdominal surgery. Results: Distribution of tumor localization is as follows: 14 in cecum, 25 in ascending colon, 16 in transverse colon, 5 in descending colon, and 39 in sigmoid colon. Median age of patients was 69 year-old, and male female ratio was 55:44. Of those 44 cases had previous abdominal surgery. Multiple procedures were done in 12 cases, and 4 cases had three times history of abdominal surgery prior to colon cancer surgery. Types of previous abdominal surgery were as follows: 33 appendectomy, 13 gynecological procedures, 4 cholecystectomy, 4 gastrectomy, 1 colectomy, 1 nephrectomy, 1 abdominal aortic replacement, 1 liver resection, and 2 miscellaneous procedures. Six of those procedures were done by laparoscopic technique. One cases of no-previous-surgery (NPS) group was converted to open surgery, while no conversion was seen in previous-surgery (PS) group. Operative time was 205 min. in NPS group while 209 min. in PS group. Estimated blood loss was 47 ml and 59 ml, respectively. No difference was seen in both operative time and blood loss. Postoperative hospital stay was not prolonged, as well: 11.0 days vs. 11.8 days. Postoperative complication was seen in 7 cases: 4 surgical site infections, 2 pneumonia, and 1 ileus. Of those, 6 cases were of NPS group. No anastomotic leakage was seen in both groups. In cases of right side colon cancer, difference of operative time and blood loss between groups was minimum (215 min. in NPS group vs. 206 min. in PS group, 73 ml in NPS group and 60 ml in PS group). However, in cases of left side colon, these differences were slightly enhanced though it is not significant (189 min. in NPS group and 205 min. in PS group, 24 ml in NPS group and 42 ml in PS group). Conclusion: In these series, previous abdominal surgery, on the whole, does not affect to the operative outcome. However, in left colon cancer cases, operative time and blood loss might be influenced by previous abdominal surgery history.

P062 A New Protection Device Could Avoid Intestinal Adhesion in a Pre-Stage Ileostomy in a Rabbit Model Xiaocheng Zhu, MD, Linsen Shi, Chao Li, MD, Song Meng, MD, Hui Wang, Yadong Han, Department of General Surgery Affiliated Hospital of Xuzhou Medical College P. R. China Background: Anastomotic leakage was one of the most dreaded complications after colorectal surgery. Almost every surgeon has faced the intraoperative dilemma of whether to divert in colorectal surgery because of its advantages and disadvantages. To avoid the dilemma, some surgeons use a technique, a prophylactic preplaced ileum loop attached to right low abdominal subcutaneously (a pre-stage ileostomy,Ghost Ileostomy). This technique can help them to perform ileostomy when there is anatomotic leak or reverse the loop if patients recover well. However, the technique is not widely accepted because the adhesions between ileum loop and abdominal wall lead to much inconvenient during later ileostomy or ileum loop reversal. To solve this, we design a device (patent 201420335556.1) that can avoid the adhesion and surgeon can easily do ileostomy or the loop reversal. Objectives: The study was designed to evaluate a new type of protection device for preplaced ileum loop, which could avoid the intestinal adhesion caused by traditional method of preplaced ileum loop. Methods: A total of 21 adult New Zealand rabbits were divided into three groups: Control (C) group (n=7), traditional prophylactic preplaced ileum loop(T) group, and prophylactic preplaced ileum loop with our protection device(D) group. In group C, open and close right low abdominal wall without touching intestine; In group T, the ileum was placed in the subcutaneous of right low abdomen and supported by a latex ring; In group D, the ileum was fixed subcutaneously with the protection device (a device contains of a main part that can cover preplaced ileum and a auxiliary part that can attach the device to abdominal wall). At postoperative day 14, rabbits were sacrificed and en bloc of ileum loop and regional abdominal wall were harvested. Adhesions were examined macroscopically, microscopically, and degree of adhesions was scored (Blauer and Collins score). The concentration of hydroxyproline, a collagen protein precursor, was measured. Results: Group D has less adhesion from gross appearance and significant lower Blauer and Collins score than group T (p = 0.005). Total microscopic score (inflammation, fibroblastic activity and vascular proliferation.) of the group D was significantly lower than that of the group T (p = 0.004, 0.001 and 0.01). The concentration of hydroxyproline in the group D was lower compared to the group T (p =0.003). Conclusions: The new protection device appear to effectively prevent adhesions between preplaced ileum loop and abdominal wall, which might be used safely and conveniently for Ghost ileostomy, also might avoid unnecessary ileostomy. Keywords: Colorectal surgery; Preplaced ileum loop; Protection device; Adhesions

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P064

P065

Colonic Sarcoidosis: a Diagnostic Dilemma

Totally Laparoscopic Colon Surgery: Single Group Experience

Ramon A Brown, MD, Jason Kempenich, MD, Keesler Medical Center General Surgery Residency Program

˜ n Gil-Ortiz, MD1, Javier Gilberto Lozano-Dubernard, MD1, RamA Lopez-Gutierrez, MD1, Gustavo Reyes-Rodriguez, MD1, Fidel RuizHealy, MD2, 1Hospital Angeles del Pedregal, Mexico City, Mexico, 2 Centro Hospitalario Sanatorio Durango, Mexico City, Mexico

Introduction: Sarcoidosis is a multisystemic granulomatous disease of unknown cause in which more than 90% of patients exhibit mediastinal and hilar lymph node enlargement or parenchymal lung disease. The diagnosis of sarcoidosis is based on compatible clinical and radiographic findings supported by histologic evidence of non-caseating granulomas in one or more organs in the absence of any foreign particles or organisms. Intestinal manifestations of sarcoidosis are rare with few case reports in the literature. Furthermore, the estimated incidence of colonic manifestations is less than 1% of cases involving the gastrointestinal tract. We report a case of a 61-year-old male who presents with colonic polyposis with associated ulcerated non-obstructing mass in the ascending colon found incidentally on screening colonoscopy. Case Description: A 61-year-old male with history of colonic polyps presented for routine screening colonoscopy. His past medical history was significant for hypertension and pulmonary sarcoidosis with no active pulmonary sequela. At colonoscopy a 5 mm sessile polyp was found adjacent to an infiltrative, ulcerated non-obstructing mass in the midascending colon that encompassed approximately one third of the circumference of the lumen. Biopsies of the mass and the polyp were taken with cold forceps and sent for pathologic analysis. Pathologic diagnosis of the specimens demonstrated a tubular adenoma and chronic inflammation, with granulation tissue with reactive epithelial changes with no evidence of dysplasia or malignancy. A CT scan of the chest abdomen and pelvis was obtained which demonstrated no evidence of metastasis or mesenteric lymphadenopathy; however, calcified mediastinal lymph nodes were present. Preoperative labs were obtained including a carcinoembryonic antigen (CEA) all of which were within normal limits including a CEA of 2.2. At follow-up right hemicolectomy was recommended due to the presence of an endoscopically unrespectable mass to rule out malignancy. The patient was taken to the operative theatre for laparoscopic right hemicolectomy with no significant intraoperative or postoperative complications. The pathologic specimen yielded twenty-four lymph nodes with and a 2.2 9 2.2 cm ulcerated mass with rolled borders with in the right colon specimen. The tissue within and around the mass as well as the lymph node samples demonstrated chronic inflammation with well formed, non-caseating granulomas, which were PAS, GMC and AFB negative. Discussion: Colonic manifestations of sarcoidosis are rare and its presentation is widely variable, creating a diagnostic dilemma. The management of this disease can be equally perplexing when the disease masquerades as a potentially malignant lesion. Non-operative management of biopsy proven colonic sarcoidosis with systemic corticosteroids is effective. However, in these instances where endoscopy identifies a potential carcinoma, yet pathology fails to rule out malignancy, the surgeon must proceed with the intent to treat cancer with oncologic resection of the affected portion of the colon.

Introduction: Laparoscopic procedures have been reaching all surgical specialties, performing the most difficult operations and replacing open surgery as the golden standard. We started in 1995 with laparoscopic colectomy. The aim was to decrease the surgical trauma by reducing the incision size on the abdominal wall. Results have been reduction in hospitalization time, post-operative recovery, pain and return to normal life. Methods: In a ten-year period (1995–2014), retrospective study of charts of patients who underwent total laparoscopic colorectal surgery were reviewed. One hundred ten surgical procedures were performed in 49 male (mean 49 years) and 61 female patients (mean 50 years). Forty eight patients were treated for complicated left colon diverticular disease, 24 for megacolon, 8 for volvulus, 6 for non complicated diverticular disease, 3 for colostomy closure, 3 for right colon complicated diverticular disease, and 18 patients for benign and malignant tumors, perforation, ileostomy closure, anastomotic stenosis, necrotic colitis and other diseases. Results: Mean surgical time was 180 minutes, mean blood loss 100 cc; oral intake 24 hours after surgery and mean hospitalization time was 3 days. No mortality was reported and complications were encountered in nine patients. Complication were 1 abdominal wall abscess, 1 incisional hernia, 1 intestinal occlusion, 3 anastomosis stenosis (only one required surgical intervention), 1 perforation due to a radiological procedure; 1 anastomosis leak and 1 postoperative bleeding managed with transfusion. All cases were performed by totally laparoscopic, intracorporeal anastomosis and extraction of surgical specimen through the anus. Six patients (5.4%) required an abdominal incision to extract the specimen because size did not allow anal extraction. Conclusion: Laparoscopic colectomy is a feasible and replicable technique rapidly gaining favor among patients, surgeons and industry. Our experience is positive in terms of complications, postoperative pain and patient satisfaction. Further comparative studies between open and laparoscopic surgery are necessary in order to keep evaluating its real value in terms of advantages and disadvantages in colorectal surgery. Keywords: Laparoscopic colon surgery.

P066 Malignant Colorectal Resections: a Single Centre Experience M A Gok, S J Ward, M M Sadat, U A Khan, Macclesfield District General Hospital Introduction: Colorectal Cancer (CRC) is the 3rd common cancer in the UK in men & women, accounting for 13% on new cancer cases in 2010 (incidence of 40695). Surgery in the main treatment & usually undertaken within 6 months of presentation. The aim of the study is to assess colorectal malignant resections at a single institution. Materials & Methods: This is a retrospective study carried out since January 2007 at Macclesfield District General Hospital. Descriptive demography, co-morbidities, histopathology and surgical outcomes were evaluated for all malignant colorectal resections. Results CRC resections (n=740)

Ages (yrs) (mean ± SE)

,

71.1 ± 0.4

Sex (M:F)

406:334

ASA (median)

2

Weight (kg) (mean ± SE)

73.9 ± 0.8

BMI (mean ± SE)

25.9 ± 0.2

Appendix / Ileum (n)

19

Caecum (n)

148

Ascending colon (n)

60

Transverse colon (n)

82

Descending colon (n)

22

Sigmoid (n)

157

Rectosigmoid (n)

40

Rectum (n)

212

Operation Time (min) (mean)

155.3 ± 2.6

Small bowel length (mm)

101.0 ± 5.2

Large bowel length (mm)

263.7 ± 13.4

LN harvest (median ± IQR)

14 ± 4

Diverticulosis (n)

161

IBD (n)

15

Synchronous tumours (n)

108

Ileostomy/colostomy

211

LOS (days) (median ± IQR)

9 + 3.5

Survival rates (1st, 3rd & 5th yrs) (%)

87.8%, 75.1%, 68.6%

Dukes A (1st, 3rd & 5th yrs) (%)

96.1%, 90.9%, 84.0%

Dukes B (1st 3rd & 5th yrs) (%)

90.8%, 83.5%, 79.2%

Dukes C (1st, 3rd & 5th yrs) (%)

82.5%, 61.2%, 53.8%

Discussion: Left sided colon cancer represents almost 2/3 rds (58.2 %) of the CRC. There is predominance of CRC in men. Survival rates drop with progression of disease (Dukes / TNM classification). CRC cancer should be managed in the multi-disciplinary setting.

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P067

P069

Hand-Assisted Laparoscopic Versus Open Colectomy: an Assessment from NSQIP Procedure-Targeted Cohort

A Fortuitous Failure: Recurrent Perforated Appendicitis Resulting in Early Stage Diagnosis of Mixed Goblet-Cell Carcinoid-Adenocarcinoma of the Appendix

Cigdem Benlice, MD1, Meagan Costedio, MD1, Luca Stocchi, MD1, Xiaobo Liu, MS2, Maher A Abbas, MD3, Emre Gorgun, MD1, 1 Cleveland Clinic, Digestive Disease Institute, Department of Colorectal Surgery, 2Cleveland Clinic, Department of Quantitative Health Sciences, 3Cleveland Clinic Abu Dhabi, Digestive Disease Institute Introduction: Hand-assisted laparoscopic surgery (HALS) has gained acceptance as a viable option for patients undergoing colorectal resection. However the data remains limited on the potential advantages of HALS compared to open surgery. The purpose of this study was to compare the perioperative outcomes of patients who underwent colorectal resection with HALS or open surgery. Methods: A database review was conducted using the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).Patients were classified into two groups according to the final surgical approach: HALS vs. Open (planned). Groups were matched (1:1) based on NSQIP-derived morbidity and mortality probabilities. Multivariate logistic regression analysis was used for group comparison. Results: 3506 cases were reviewed (1753 patients in each group). Operative time was significantly longer in the HALS group [163 (36–684) vs. 141 (30–1006) minutes, p \ 0.001]. Length of hospital stay was longer in the Open group [6 (1–112) days vs. 5 (1–79), p \ 0.001]. After adjustment for the listed comorbid conditions using logistic regression, overall morbidity and ileus rates were significantly higher in the Open group [(22.7% vs. 25.9%, OR: 1.5, p = 0.0001) and (10.5% vs. 14.3%, OR: 1.3, p = 0.02), respectively]. Superficial and deep surgical site infection rates were comparable between the 2 groups (p = 0.08 and 0.13, respectively). Multivariable analysis showed that the following independent risk factors were associated with postoperative morbidity: open surgery, ASA class III and IV, disseminated cancer, preoperative steroid use, and presence of bleeding disorder (Table 1). Conclusion: NSQIP targeted data demonstrated several short-term advantages to HALS compared to open colorectal resection including a shorter length of stay, less complications, and lower rate of ileus. Further adoption of the HALS technique will have significant positive impact on short-term outcomes following colectomy.

Table 1

Independent risk factors associated with postoperative morbidity

Factor

Odds Ratio

95% CI

P-value

Open vs. HALS

1.457

1.205–1.762

0.0001

Disseminated cancer (Yes vs. No)

1.744

1.285–2.368

0.0004

Steroid use (Yes vs. No)

1.582

1.16–2.156

0.0037

Bleeding disorder (Yes vs. No)

1.571

1.059–2.331

0.0249

II vs. I

1.376

0.713–2.658

0.3414

III vs. I

2.118

1.087–4.125

0.0273

IV vs. I

2.403

1.093–5.282

0.0291

John L Fletcher, MD, Alfred F Trappey, MD, Michelle L Josey, MD, Kevin J Krauland, MD, Valerie G Sams, MD, San Antonio Military Medical Center Introduction: Appendiceal neoplasms are a rare, though well-recognized, cause of perforated appendicitis. Adenocarcinoma of the appendix represents 0.5% of all gastrointestinal malignancies and includes subtypes of mucinous (55%), colonic type (34%), and carcinoid-adenocarcinoma (11%) which has mixed morphology. The histomorphologic spectrum varies from predominantly classical carcinoid to predominantly adenocarcinoma and when discovered, these tumors are often found at late stage which generally connotes a poor prognosis. Case: A 47-year old male with 24 hours of acute onset right lower quadrant pain, nausea, vomiting and leukocytosis was diagnosed with perforated appendicitis following a CT scan which demonstrated a peri-appendiceal abscess and phlegmon. He was started on IV antibiotics, admitted to the hospital and underwent percutaneous drain placement in interventional radiology. His leukocytosis resolved and he was discharged to home with oral antibiotics. Following continued improvement and a decrease in his drain output the drain was removed. Thirty days after his initial diagnosis and 2 weeks after drain removal he returned to the emergency room with a recurrence of his pain, leukocytosis and fever. Due to failure of non-operative management (NOM) he underwent laparoscopic appendectomy, admission with IV antibiotics with an uncomplicated post-operative course. Intraoperative findings were notable for a phlegmonous collection of tissues with mucinous drainage adherent to the clearly perforated appendix. Final pathology demonstrated a mixed goblet cell carcinoid-adenocarcinoma with significant signet-ring cell component which extended to the staple line. The tumor demonstrated aggressive features with lymphovascular invasion and perineural invasion with an initial pathologic staging of pT2pN0pMX. Tumor markers, a CT scan of the chest, an esophagoduodenoscopy and colonoscopy were performed without evidence of metastatic disease. Consequently he underwent diagnostic laparoscopy which showed no evidence of intraperitoneal disease and a formal laparoscopic, hand-assisted right hemicolectomy was performed. His post-operative course has been uncomplicated and his final pathologic staging remained putting him at stage I disease with all margins clear and no positive lymph nodes or intraperitoneal disease. The patient is currently being followed with surveillance tumor markers and imaging to monitor for recurrence of disease. Due to the early stage of disease, the patient will not undergo systemic chemotherapy or intraperitoneal chemotherapy. To our knowledge based on an exhaustive review, this represents the earliest stage of carcinoid-adenocarcinoma described in the literature. Discussion: Malignancy remains a rare, though complicated, etiology of appendicitis in the adult population. With NOM for perforated appendicitis an increasingly accepted practice, recurrence or failure of NOM should raise the surgeon’s suspicion for malignancy and a low-threshold for appendectomy should be maintained.

\.0001

ASA

HALS: Hand-Assisted Laparoscopic Colectomy, CI: Confidence Interval, ASA: American Society of Anesthesiologists

P068

P070

Feasibility and Technical Aspects Of Single-Port Laparoscopic Surgery for Colorectal Cancers

A Pilot Study for the Evaluation of the Safety and the Efficacy of Transanal Total Mesorectal Excision

Kozo Konishi, Gen Hidaka, Osamu Miura, Hofu Institute of Gastroenterology

Sung Chan Park,, Dae Kyung Sohn, Min Jung Kim, Kyung Su Han, Hee Jin Chang, Jae Hwan Oh, National Cancer Center

Introduction: Single-port laparoscopic surgery (SPLS)is more difficult than conventional multi-port laparoscopic surgery. There have been a limited number of reports of SPLS procedures in colorectal disease. We analyzed the feasibility of this procedure for colorectal cancers and to estimate its difficulty. Methods and Procedures: We analyzed cancer cases retrospectively collected data from 220 consecutive patients who underwent single-port laparoscopic surgery at our institution. Patient and tumor characteristics, procedures of lymph node dissection, short term results of operation were analyzed. Results: Forty-three single-incision laparoscopic colectomies were performed (28 right colectomies, 3 transverse colic resections, 9 sigmoidectomies, and 3 anterior resection). No conversions to open resection occurred. An additional port was required in 3 patients. Mean incision length was 4.2 cm (range, 2.5–6) blood loss was 48 g, and operative time was 145 minutes. Complications included 2 wound infection. Mean lymph node harvest was 15 (range, 10–27). In rectal resection, much technical difficulties were encountered compared than right colectomies. Conclusions: Our data demonstrate that single-incision laparoscopic colectomies for colorectal cancers were safe and oncologically feasible in selected patients by experienced surgeons.

Introduction: Transabdominal approach for resection of low rectal tumor has been considered as a highly demanding procedure because of the confined anatomy and bony angulations particularly in males with a narrow pelvis or obese patients. For this reason, many surgeons tried ‘‘down-to-up’’ transanal approach for rectal dissection. The objective of this study was to evaluate the safety and the efficacy of transanal total mesorectal excision (TME). Methods and Procedures: Twelve patients with node negative rectal cancer located 4–12 cm from the anal verge were enrolled in this pilot study. We used GelPOINT Path (Applied Medical) for transanal approach. For transabdominal approach, OctoportTM (Dalim) was used at the presumed ileostomy site, and additional ports were used if necessary. The primary endpoint was TME quality and secondary endpoints were 30-day postoperative complications, number of harvested lymph nodes, and oncologic outcomes (2-year local recurrence free survival, 5-year survival). Results: From September 2013 to October 2014, 7 male patients and 5 female patients underwent transanal TME. The tumors were located in 6.7±2.1 cm from the anal verge, and 4 (33.3%) of the patients underwent preoperative chemoradiotherapy. Mean age of patients was 62.3±10.1, and BMI was 24.5±2.8. Mean operation time was 119.2±48.5 min, and estimated blood loss was 117.8±135.5 ml, and there was no intraoperative complication and conversion. Pathologic examination showed 11 cases (91.7%) of complete or near complete TME quality, and 1 case of incomplete TME quality. Distal resection margin and circumferential resection margin were 2.6±2.4 cm, and 9.5±0.4 mm respectively. Mean number of harvested lymph nodes was 15.8±4.0. Mean length of hospital stay was 11.6±5.0 days. There was no postoperative mortality, and minor postoperative complication occurred in 6 patients. All the complications were Clavien-Dindo Grade I or II, including 2 cases of urinary dysfunction, 3 cases of postoperative transient ileus, and 1 case of wound abscess. Conclusions: In this pilot study, a high-quality of TME was possible in most of patients without serious complication. Transanal TME for rectal cancer patients was feasible and oncolongically safe procedure. Further investigations are necessary to evaluate its long-term oncologic safety and to clarify its indications.

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P071

P073

Impact of Surgical Approach on Short Term Outcomes After Colectomy in Elderly Patients: a National SURGICAL Quality Improvement Program Database Analysis (2005–2012)

Don’t Fear the Learning Curve for Robotic Colorectal Surgery: a Young Surgeon’s Experience

Umashankkar Kannan, MD, Vemuru Sunil K Reddy, MD, Amarnath Mukerji, MD, Brian Gilchrist, Ajay Shah, Vellore S Parithivel, Daniel Farkas, Bronx Lebanon Hospital Center, Bronx, NY Background: Laparoscopic colectomy has shown comparable outcomes with open colectomy. Its role in the elderly is not well studied. The objective of this retrospective study is to compare the 30 day outcomes after laparoscopic versus open approach for colectomy in patients aged 65 years and over. Methods: The American College of surgeons—National Surgical quality Improvement program (ACS- NSQIP) database for the years 2005–2012 was queried for all patients 65 years and older who underwent colectomy. Comparison between the laparoscopic and open groups was performed using the Chi-Square test and Fisher’s exact test for discrete variables and Students’ t-test for continuous variables. In addition to aggregate analysis, Propensity score 1:1 matching using the nearest- neighbour method was performed to reduce the selection bias. p \ 0.05 was considered significant and Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable. Results: We identified 37,358 elderly patients who underwent colectomy. Thirty five percent (12, 881) of the cases were done laparoscopically. In the aggregate cohort, Open approach was associated with higher overall morbidity (39% vs 17%) and Mortality (6% vs 1.6%). In the matched cohort after propensity matching, Open approach still had higher overall morbidity (26% vs 17%) and mortality (3 % vs 1.6%). The open approach was also associated with higher cardiac, pulmonary and renal complications. Laparoscopic approach was associated with shorter length of stay (6.7 days vs 11 days in aggregate cohort and 9.6 days in the matched cohort). Conclusions: Using the ACS- NSQIP database, laparoscopic approach for colectomy has favorable short term outcomes with lesser overall morbidity, mortality, shorter length of stay in the elderly patients.

P072 Risk Factors for Surgical Site Infection (SSI) in Open and Laparoscopic Hartmann’s Closure: a Multivariate Analysis Iyare Esemuede, MD, Alan Harzman, MD, Syed Husain, MD, Ohio State University Background: Hartmann’s reversal is increasingly being recognized as a high-morbidity procedure. The aim of this study is to identify risk factors for SSI in the era of increasing utilization of minimally invasive techniques. Methods: An analysis of the National Surgical Quality Improvement Program database was done from 2006–2012 and patients undergoing open or laparoscopic Hartmann reversals were identified. Emergency operations were excluded. Risk factors for SSI were compared between the two groups and included gender, age, resident involvement, Body Mass Index, diabetes mellitus, tobacco use, steroid use, chemotherapy, radiation therapy, and American Society of Anesthesiologists class. The incidence of SSI was assessed and a multivariate analysis was done to assess the strongest risk factors for it in the patient cohort using SPSS statistical software. Results: We identified 7970 patients who underwent Hartmann’s closure. Of these, 1431 (18%) were done laparoscopically. The SSI rate in the overall population was 13.6%, with 14.9% in those undergoing open surgery and 8% with laparoscopic procedures. Obese patients and smokers had the highest incidences of SSI (18% and 17.5% respectively). On univariate analysis, open surgery, age\65, resident involvement, BMI[30, tobacco use, and OR time[180 minutes were significant predictors of SSI and remained so on multivariate analysis. Odds ratios for SSI with open surgery and obesity were 1.8 and 1.6 respectively (p \0.001). Diabetes and steroid use were not significant risk factors. Conclusion: Hartmann’s closure is a procedure with an increased risk of SSI when compared to other colorectal procedures. The current study helps to identify patients at increased risk of SSI after surgery. Furthermore, our findings indicate that laparoscopy can significantly reduce SSI, particularly in obese patients.

SSI (%)

Univariate p-value

Odds Ratio

Multivariate p-value

Gender (male)

13.7

0.9

-

-

Age \ 65

14.8

0.02

1.2

0.014

Resident Involved

15.4

\0.001

1.4

\0.001

Laproscopy

8

\0.001

0.5

\0.001

BMI [ 30

18

\0.001

1.6

\0.001

Diabetes

15.9

0.18

-

-

Tobacco

17.5

\0.001

1.4

\0.001

Chemotherapy

9.4

0.22

-

-

Radiation

15.9

0.39

-

-

ASA 3–5

14.9

0.03

1.2

0.01

OR time [180 mins

16.8

\0.001

1.3

\0.001

Steroids

15.6

0.3

-

-

123

Imad Qayyum, MD, David Mateo de Acosta, MD, Brant Clatterbuck, David L Crawford, MD, FACS, Steven S Tsoraides, MD, University of Illinois College of Medicine, Peoria Introduction: Many reports have documented the learning curve for robotic colorectal surgery. Little exists describing the experience of a junior surgeon recently out of training. Methods and Procedures: A retrospective review of consecutive robotic colorectal resections performed by a single surgeon during the first two years of practice (October 2011–October 2013) was performed. A total of 50 cases were performed using the robot. After exclusion of rectopexy and right-sided procedures, 45 cases were reviewed including sigmoid & anterior resection, low anterior resection, and abdominal perineal resection. NCCN guidelines were followed in the management of all malignancies. The surgeon’s exposure to robotics during training included 9 console cases during general surgery residency, and additional cases as first assistant. Nine assistant cases were experienced during colorectal residency. The initial 10 cases in the series were performed utilizing an experienced senior partner as the first assistant. The subsequent cases were typically performed with a surgical resident or surgical technologist as first assistant. On occasion, an attending surgeon performed a procedure in combination with the junior surgeon. Cases were routinely executed in a total robotic fashion. A transition occurred to a two-dock technique from a single-dock technique during the study phase. The splenic flexure is routinely mobilized during low anterior resections and most anterior/sigmoid resections. Patients were selected based on surgeon preference. The robotic approach is the preferred approach for rectal surgery and all included cases were considered elective. Very few elective open rectal cases were scheduled during the study period. Results: Total operative time for included cases was 313 min, with a mean docking time of 36 min and mean console time of 148 min. When comparing the first half of cases to the second half with a paired t-test, calculated p values suggested no significant difference was found: Total mean operative time 324 min vs. 302 min. Mean docking time 36 min vs. 36 min. Mean console time 139 min vs. 157 min. Mean lymph node retrieval across the series was 14.5 nodes: 16.2 nodes vs. 12.9 nodes, with this difference being statistically insignificant. Conversion to open surgery occurred in 1 case due to extensive adhesions and bulky tumor size. Addition of a hand port or mini-laparotomy was planned in 3 cases and added at the time of surgery in an additional 6 cases. There were 6 patients with postoperative complication of significance. There was no 30-day mortality. Conclusion: Junior colorectal surgeons can perform total Robotic Colorectal Resection with comparable efficiency to published data. This is especially relevant in light of our total robotic experience in contrast to other reported ‘‘hybrid’’ techniques. Although more extensive data are required, our experience shows that a junior surgeon may not encounter a steep learning curve in adopting robotics. Our times compare favorably to previously published data and our lymph node retrieval within resected specimens is appropriate. Earlier exposure to robotics during training and early assistance from experienced senior surgeons may be the key to this success.

Surg Endosc

P074

P075

Outcomes with Use of Transanal Hemorrhoidal Dearterialization(THD) for Management of Hemorrhoids in a Colon and Rectal Practice

Single-Port Laparoscopic Colorectal Surgery Experience

Beth-Ann Shanker, MD, Joseph Gallagher, MD, Andrea Ferrara, MD, Samuel DeJesus, MD, Paul Williamson, MD, Mark Soliman, MD, Renee Mueller, MD, Colon and Rectal Clinic of Orlando Introduction: Transanal Hemorrhoidal Dearterialization (THD) is a less invasive technology for treatment of hemorrhoids. THD uses a proctoscope with a Doppler probe to identify branches of the superior hemorrhoidal artery for ligation. We report our outcomes on a series of patients who have undergone this procedure which includes ligation & mucosal pexy of hemorrhoids. Methods: This is a retrospective case series of patients who have undergone THD from April of 2012—July of 2014 at a private practice clinic with 7 board certified colon & rectal specialists. Complications & recurrences are reported. Results: Over a 27 month period, 920 hemorrhoid procedures were performed. 117 (12.7%) were THD procedures. Data was available on 107 patients. Conclusions: We present a large retrospective case series of 107 patients who underwent THD. 17 had recurrences (15.7%) and 10 required additional interventions (9.3%). This recurrence rate is on par with other publications. Complications such as bleeding and urinary retention are comparable to other procedures.

Characteristics of Patients Age

56.7 (25–80)

BMI

(28.22)

Gender

58F (54.3%) 49 M (45.8%)

Previous hemorrhoid surgery

34 (31%)

Rafael Garcia, MD, Anwar Medellin, MD, Maria Isabel, MD, ˜ o, MD, Javier Carrera, MD, Fernando Arias, MD Eduardo LondoA ˜ n Santa Fe de Bogota Hospital Universitario FundaciA Introduction: The number of single-port laparoscopic procedures had been growing in recent years, increasing with it the number of diseases that can be treated by this approach. Colorectal surgery is a good example of this discipline and can offer an appropriate management of benign and malignant diseases. Objective: Our aim is to show experience accumulated by the Colorectal Surgery Group in Single-Port Laparoscopic in Fundacio´n Santafe de Bogota in all the patients with both benign and malignant diseases treated with this approach. Also, we want to describe the demographic characteristics of these patients, and identify the results and outcomes of this procedure. Material and Methods: It is a retrospective evaluation of all patients that underwent single port laparoscopic colorectal surgery, between January 2009 and December 2013, including patients with both benign and malignant disease and those who required conversions. Outcomes are identified and analyzed. Results: 103 patients underwent single-port laparoscopic surgery during specified dates. The mean numbers of surgery per years was 20. The mean age of the patients was 61 years and the majority were women (59%). 35% of patients had previous abdominal surgery. The more frequent procedure was right hemicolectomy in 68.9%. 70% of patients were operated for malignant disease, with most of them being T3 and T4 cases (73%). Right colon cancer was the most common pathology in 36% of cases and the most common histopathology report was moderately differentiated adenocarcinoma (36.9 %). The most common benign disease was diverticular disease in 10.7%. The mean operative time, was 117 minutes. The estimated blood loss was 92 cc. Only 6.7% patients required conversion, two of them were converted to one accessory port, two to conventional multiport laparoscopic surgery, and three to open surgery. The length stay was 4.7 days. Postoperative complications were 4.8% patients had ileus, two% patients had wound infection. The only reported mortality was for pulmonary embolism. Conclusion: In our experience, single port laparoscopic colorectal surgery can be performed with similar results compared to conventional multiport laparoscopic surgery, arguably with the benefits of this approach. Our results were similar to those reported in the literature. It requires a careful selection of patients and extensive experience in laparoscopic surgery. Further studies with larger series are needed to establish more benefits of this approach over conventional laparoscopic surgery.

Outcomes of THD by Grade of Hemorrhoids & Time Intervals Grade

Complications \ 2 weeks

Complications 2.1 weeks to 3 months

Complications [ 3 months

I (5)

1 procitits

1 Bleeding

1 Pruitis

1 constipation

1 Rectal bleeding

3 urinary retentions

2 Recurrences: (1 RBL)

2 pain

3 Constipation

2 Recurrence (1 THD, 1 hemorrhoidectomy)

1 drainage

3 Rectal bleeding (1 C scope)

1 N/V

1 Pruitis

1 constipation

1 Pain

II (39)

1 Fecal Incontinence 1 Thrombosed hemorrhoid

2 Pruitis 2 Rectal bleeding 2 Fecal Incontinence 1 Fissure (LIS) 1 Constipation

P076

1 Levator Spasm 1 Fistula II/III (15)

1 pain medication refill

1 Pain

1 Recurrence (obs)

1 fever

1 rectal bleeding

1 Pruitis

1 residual skin tag

1 skin tag removed in office

1 Pain 1 Levator Spasm

III (45)

2 urinary retention

6 Recurrence (1 THD, 3 RBL, 1 Delorme)

5 Recurrence (2 THD, 3 obs)

2 pain

2 Pain

2 Fissures

1 OR for gangrene

2 Rectal bleeding (1 C scope)

1 Fecal Incontinence

1 drainage

1 Constipation

1 Herpes infection

1 burning

1 Tenesmus

1 IBS exacerbation

1 Burning

1 dehiscence

1 Drainage

1 pressure and swelling

1 Fissure 1 Thrombosed hemorrhoid

IV (3)

0

0

1 Recurrence

Double Mimickry: Perforated Sigmoid Colon Cancer Presenting as Acute Appendicitis in a 34 Year-Old Woman Alejandro Rodriguez-Garcia, MD, Roberto Alatorre-Adame, MD, Roman Gonzalez-Ruvalcaba, MD, Eduardo Flores-Villalba, MD, ˜ cnologico de Monterrey TA Introduction: Colon cancer may present in a number of ways, often times mimicking acute diverticulitis, with or without formation of an intra-abdominal abscess. Case Report: We report the case of a previously healthy 34 year old female who presented to the ER complaining of abdominal pain in the RLQ. Upon examination the patient was tachycardic and febrile. Tenderness was noted in the right lower quadrant, along with resistance in the right iliac fossa. A CBC showed left shift, and ultrasound was compatible with acute appendicitis. The patient was taken to the OR for laparoscopic appendectomy. Upon laparoscopy, free liquid was noted in the abdomen. The appendix was grossly normal. An inflammatory process was noted in the left lower quadrant. The patient was deemed to have acute diverticulitis and underwent appendectomy with peritoneal lavage. A drain was placed in the LLQ. After an uneventful recovery, colonoscopy was performed at 1 month post-op. A large mass was noted in the sigmoid colon; biopsy confirmed a tubule-villous dysplastic lesion. Following this, laparoscopic left colectomy was performed. Pathology showed stage IIIB adenocarcinoma. No K-ras mutation was found. The patient is well at 3 year follow-up. Discussion: Although cancer of the sigmoid colon may mimick acute diverticulitis, it is rare for it to cause right-sided pain. In this case, the patient was incorrectly thought to have diverticular disease after observing normal appendix. Follow-up colonoscopy was key in ascertaining the correct diagnosis.

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P077

P079

Comparison of Open, Laparoscopic, and Robotic Approaches for Total Abdominal Colectomy

Financial Implications of Laparoscopic Abdominoperineal Excision of the Rectum and Factors Influencing its Uptake in the United States: an Analysis of 22,792 Patients

Zhobin Moghadamyeghaneh, MD, Mark H Hanna, MD, Grace Hwang, MD, Joseph C Carmichael, MD, Alessio Pigazzi, MD, Michael J Stamos, MD, Steven D Mills, MD, University of California, Irvine Background: There is limited data regarding comparison of robotic approach surgery with open and laparoscopic approaches in colorectal surgery. We sought to compare outcomes of patients who underwent total abdominal colectomy according to three approaches; laparoscopic, open, and robotic. Method: The NIS databases were used to examine the clinical data of patients undergoing total colectomy procedure during 2009–2012. Multivariate regression analysis was performed to compare the three surgical approaches. Results: We sampled a total of 34,437 patients who underwent total colectomy. Of these, 26086(75.8%) had an open operation, while 9580(27.8%) had a minimally invasive approach (9339 laparoscopic surgery, and 242 robotic surgery). Overall, 54.6% of patients were admitted electively. The most common indication for operation was ulcerative colitis (54.2%) followed by diverticulosis (20.6%) and colon cancer (20.1%). Conversion rate of laparoscopic surgery to open was 13.6% and robotic procedures did not have any conversions. The median length of hospitalization for minimally invasive procedures was 7 days (6 days robotic and 7 days laparoscopic), while the median length of hospitalization length of patients who underwent open colectomy was significantly higher (10 vs. 7 days, P \ 0.01). Following multivariate analysis of data, mortality risk (AOR: 3.90, P \ 0.01) and postoperative complications of respiratory failure (AOR: 4.29, P\ 0.01), pneumonia (AOR: 2.43, P\ 0.01), and myocardial infarction (AOR: 2.10, P \ 0.01) were significantly higher in open compared to minimally invasive approaches. However, there was no significant difference in intra-abdominal abscess/ anastomosis leakage between open colectomy and minimally invasive approaches (AOR: 1.11, P = 0.26). Conclusion: Minimally invasive approach to total colectomy is safe, with the advantage of lower mortality, morbidity, and hospitalization length compared to an open approach. There is no significant difference in intra-abdominal abscess/ anastomosis leakage between open and minimally invasive approaches. Robotic approach to total colectomy procedure had the advantage of a significantly lower conversion rate compared to laparoscopic approach.

Jamie Murphy, BChir, PhD, FRCS1, Tonia M Young-Fadok, MS, MD2, 1St. Mark’s Hospital, 2Mayo Clinic Introduction: Laparoscopic abdominoperineal resection (APR) of the rectum is a technically demanding procedure, which is thought to be associated with faster patient recovery and improved cosmesis. Evidence assessing the cost associated with laparoscopic APR, however, is limited. Similarly, factors influencing the uptake of this procedure remain poorly understood. The purpose of this population-based study was to determine the cost associated with laparoscopic APR and assess which variables influence the availability of this technique throughout the United States. Methods: The Nationwide Inpatient Sample database was used to sample admissions for laparoscopic or open APR during the period 2008–2012. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification coding. Univariate analyses were performed. Results: A total of 22,792 (mean age: 61.9 ± 1.5; male: 13,028; female: 9,764) admissions were identified. The use of laparoscopy increased from 21% in 2008 to 33% in 2012 (p \ 0.0054). A laparoscopic approach was demonstrated to decrease mean length of stay by 2.8 ± 0.23 days (p\0.0001), mean hospital costs by 3,648±894 dollars (p = 0.0008), mean aggregate costs by 5,579 ± 4,203 dollars (p = 0.0144) and the need for discharge to nursing / rehabilitation facilities postoperatively (p = 0.0004). Utilisation of home health services did not differ between patients undergoing open or laparoscopic surgery. Gender did not appear to influence surgical approach; however, an increased use of laparoscopy was noted for younger patients (p = 0.0244). While patients from low-income families were more likely to undergo open surgery (p = 0.0116), insurance status did not predict surgical approach. Patients undergoing procedures at major metropolitan centres (p = 0.0249) and private not-for profit institutions (p = 0.0031) were more likely to undergo a laparoscopic approach. Hospital size was not associated with surgical approach. Geographic variations were noted in the availability of laparoscopic APR, with the lowest rates in the Northeast and highest rates in the south (p = 0.0208). Conclusion: Throughout the United States as a whole laparoscopic APR was associated with significant decreases in length of stay and hospital / aggregate charges when compared with an open approach. Despite these benefits patients from older age groups, low-income families and rural areas were less likely to be offered laparoscopic resection. In future centralisation of APR to high volume centres with a specialist interest in laparoscopy may confer significant benefits for patients and decrease costs for health maintenance and preferred provider organisations.

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Creative Colostomy: a Simple, Very Cost-Effective Method of Creating Diverting Colostomy

Wound Disruption Following Colorectal Operations

Karukurichi S Venkatesh, MD1, P S Ramanujam, MD2, Sandra Yee, MD1, 1Tri-City Colo-Rectal Surgery, Ltd., 2West Valley Colon & Rectal Surgery Aim: A simple, very cost-effective way of creating colostomy is performed with a single incision, through which the colon is brought out and colostomy is matured. Material and Methods: 71 consecutive colostomies were performed over a 60 month period, by three colorectal surgeons, for the purpose of diversion due to non-healing perineal wound, ie decubitus ulcer, suppurative perineal infections, fecal incontinence, obstructing pelvic tumors like colorectal and gynecological malignancies, and in preparation of definitive surgeries for non-healing rectovaginal and rectouretheral fistulae. The age incidence varied between 26 and 86 years. BMI ranged from 20 to 41. There was a preponderance of females over males. A comparative analysis of patients’ hospital stay and costs was performed between this method of creating the colostomy and laparoscopic-assisted colostomy during the same time period. The laparoscopic-assisted colostomies were performed by 3 colorectal surgical partners in our group. The procedure was performed with an excision of a circular piece of skin that was marked for the colostomy site and mobilizing the sigmoid colon and maturing the colostomy with occasional tightening of the fascia if necessary. The average surgical time was 28 minutes, ranging from 17 to 45 minutes. One patient did require midline 5 cm incision to release the adhesions to bring the colon up to the skin surface, and was considered a lone failure with this technique. There were no immediate complications. By the third post-operative day, all patients were discharged, transferred to an extended care facility, or were treated with definitive surgery. The operating room costs for our patients were significantly lower when compared to laparoscopic-assisted diverting colostomy done during the same time period at our hospital. Complications: Three patients had prolapse of the colostomy, treated with a belt, and two patients developed a small bowel obstruction due to herniation at the colostomy site, one requiring surgery. Conclusion: This simple method of creating colostomy is described, which is very cost-effective, safe, and reliable.

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Zhobin Moghadamyeghaneh, MD, Joseph C Carmichael, MD, Steven D Mills, MD, Alessio Pigazzi, MD, Michael J Stamos, MD, University of California, Irvine Objectives: Postoperative wound disruption is associated with high morbidity and mortality. We sought to identify risk factors and outcomes of wound disruption following colorectal resection. Methods: The NSQIP database was used to examine the clinical data of patients undergoing colorectal resection from 2005–2011 with wound class 2(clean contaminated) who had postoperative wound disruption. Wound disruption is defined by NSQIP as separation of the layers of surgical wound with disruption of the fascia. Multivariate regression analysis was performed to identify risk factors. Results: We sampled a total of 83,872 patients who underwent colorectal resection, and had clean contaminated wounds. The incidence of postoperative wound disruption was 1.4%. Wound infection occurred in 37% of the patients with wound disruption (41% had wound infection prior to wound disruption, 46% had wound disruption and infection diagnosed the same day, and 13% had wound disruption prior to wound infection) . After adjustment the mortality rate of patients who had wound disruption was more than two times greater than patients without wound disruption (4.7% vs. 2.1%, AOR: 2.32, P \ 0.01). In multivariate analysis preoperative comorbidities have correlation with wound disruption include: COPD (AOR: 2.51, P\0.01), need for dialysis (AOR: 2.53, P\0.01), dependency before surgery (AOR: 2.46, P \ 0.01), weight loss (AOR: 1.51, P \ 0.01), smoking (AOR: 1.60, P \ 0.01), ascites (AOR: 1.80, P \ 0.01), and disseminated cancer (AOR: 1.62, P \0.01). The risk of wound disruption increases in emergently admitted patients (AOR: 2.18, P \ 0.01). Other postsurgical complications were also increased in the presence of wound disruption (P\0.01): septic shock (AOR: 7, P\0.01), sepsis (AOR: 6.9, P\0.01), pneumonia (AOR: 6.1, P\0.01), and intra-abdominal infection (AOR: 5.7, P \ 0.01). Conclusion: Wound disruption occurs in 1.4% of colorectal resections. Patients with wound disruption are more likely to have COPD, ascites, weight loss, and renal failure. Emergently admitted patients have higher risk of postoperative wound disruption compared to non-emergent admitted patients. In the presence of wound disruption, the risk of postoperative complications increases, especially infectious complications.

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Combined Approach of Full Thickness Disc Excision of Deep Endometriosis Nodules Infiltrating the Rectum

Total Medial Approach for Complete Mesocolic Excision of Advanced Transverse Colon Cancer; How to Approach Easily Ensuring Oncological Safety

Horace Roman, MD, PhD, Emmanuel Huet, MD, PD, Valerie Bridoux, MD, PhD, Jean-Jacques Tuech, MD, PhD, Rouen University Hospital, France Objective: To report a personal case series of patients presenting with deep endometriosis of the rectum managed by combined laparoscopic-transanal/transvaginal full thickness disc excision of the rectum. Methods: Patients managed using this procedure from June 2009 to September 2014 at Rouen University Hospital, France, were prospectively included in the series. The technique began by laparoscopic deep shaving of the rectum, followed by transanal full thickness disc excision of the shaved rectal area, using either EEA circular or Contour Transtar staplers. In patients with large resection of the vagina, the disc excision of the rectum could be carried out transvaginally. Prospective recording of pre-, intra- and postoperative data was performed, and digestive function was assessed using KESS and GIQLI questionnaires. Results: Fifty patients having benefited from disc excision were included during 57 months, representing 16.8% of 298 patients managed for colorectal endometriosis. Mean (SD) follow up was 20 months (18). 88% of patients enrolled in the series were nullipara and 34% were known to be infertile. 76% reported preoperative defecation pain, 52% cyclic diarrhea and 54% cyclic constipation. Mean (SD) age, AFSr, KESS and GIQLI scores were respectively 29 (3.7) years, 56 (31), 13.1 (6.3) and 86 (23). The largest nodule diameter measured [=3 cm in 73% of cases and \=2 cm in 27%. Operative time was 260 (98) min. Disc excision was performed transanally using the Contour transtar stapler in 18 cases (36%), using the EEA circular stapler in 30 cases (60%) and directly transvaginally in 2 cases (4%). Associated procedures were performed, such as resection of sigmoid colon (6%), disc excision of sigmoid colon (10%), small bowel resection (2%), cecum resection (2%), excision of the vagina (62%), bladder resection (4%), ureter resection (4%) and ovarian endometriosis cyst ablation using plasma energy (38%). Discontinuous stoma was carried out in 58%. The mean (SD) diameter of discs removed was 45 mm (16), with a range from 25 to 90 mm. Two rectovaginal fistulae occurred (4%) and were repaired after 3 months with favorable outcomes. Transitory bladder atony was recorded in 14%. Two complications related to colostoma required secondary surgical procedures (4%). Assessment of digestive function was performed preoperatively (n=50), at 1 year (n=25) and at 3 years postoperatively (n=10). This showed a significant improvement in KESS score (P = 0.003) and GIQLI score (P \ 0.001), and a major decrease in the rate of patients with defecation pain (P \ 0.001), constipation (P \ 0.001) and diarrhea (P \ 0.001). Among patients with pregnancy intention, the rate of pregnancy was 80%, and that of ‘‘take home baby’’ 60%, with a rate of spontaneous conception as high as 63%. Conclusion: Full thickness disc excision of rectal nodules represents a valuable alternative to colorectal resection in young patients with deep endometriosis infiltrating the rectum. Postoperative unfavorable events and mid term functional outcomes are encouraging, while the pregnancy rate appears among the highest reported in the literature.

Masato Kondo, Kobe City Medical Center General Hospital Introduction: The laparoscopic surgery for advanced transverse colon cancer is still controversial in terms of technical difficulty caused by anatomical complexity around duodenum and pancreas including vascular abnormalities of middle colic vessels. We aim to describe in detail our ordered, sequential laparoscopic approach for advanced transverse colon cancer under total medial approach ensuring the theory of complete mesocolic excision and central vessels ligation. Procedures: We place five trocars, one is umbilical endoscopy port, and other four ports are placed at the square under modified lithotomy position with both arms alongside the body. At first, we expose superior mesenteric vein at the root of ileocolic vessels, and continuing to dissect and visualize the anterior side of the duodenum, pancreas head, and gastrocolic trunk along superior mesenteric vessels under medial approach. After accessory right colic vein is cut, right gastroepiploic vein can be easily taken down and separated from the transverse mosocolic fascia using ultrasonic coagulating devices on the right side of middle colic vessels. Secondly, we cut the transverse mesocolic fascia at the lower edge of the pancreas body just above Treitz ligament, and open omental bursa on the left side of middle colic vessels. Then we can do lymphadenectomy and cut the root of middle colic vessels easily and safely from the right and left side, that we call pinsers movement. Central vessels ligation is done under total medial approach before mobilizing the transverse colon without injuring the duodenum and pancreas head and body. Finally, we mobilize the hepatic-flexure and splenic-flexure by almost medial-to-lateral approach and transect the greater omentum. The transverse colon can be mobilized, cut, and anastomosed intracorporeally or extracorporeally. Results: From November 2012 to April 2014, There were 138 patients with colon cancer operated laparoscopically, and 20 cases of advanced transverse colon cancer were all operated under this method. There was no conversion to open surgery and no postoperative complications more than Grade 3 in the Clavien-Dindo classification. Conclusions: This approach leads to early ligation of tumor feeding vessels and complete mesocolic excision can be done preventing exposure of potentially positive lymph nodes before mobilizing the transverse colon. We believe this method is easy to learn, established, and also safe and feasible in oncology as a non-touch isolation technique for advanced transverse colon cancer.

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Minimally Invasive Colorectal Resection (MICR) is Associated with Significantly Elevated Plasma Osteopontin Levels During the First Month After Surgery Which may Promote Cancer Recurrence and Metastasis

Initial Utilization of Patient Health Portal is Low in Colorectal Practice

Hmc Shantha Kuamra, PhD1, Hiromichi Miyagaki, MDPhD2, Sajith A Herath, BS1, David Gaita, BS1, Xiaohong Yan, PhD1, Linda Njoh, PhD1, Vesna Cekic, RN1, Nipa D Gandhi, MD1, Richard L Whelan, MD1, 1Deaprtment of Surgery, Mount Sinai Roosevelt Hospital Center, New York, USA, 2Department of Gastroenterological surgery, Osaka University, Osaka, 565-0871 Japan Introduction: Osteopontin (OPN), also known as early T lymphocyte activation-1, is an integrin binding phosphorylated glycoprotein secreted by activated macrophages and leukocytes; it is found in extracellular fluids, sites of inflammation and in the bone marrow. Various forms of CD44 serve as receptors for OPN. OPN mediates cell-matrix and cell-cell communication to support adhesion and targeted migration. OPN, expressed by a number of cancers including colorectal cancer, enhances tumor progression and angiogenesis via the PI3K/AKT and ERK mediated pathways in concert with VEGF. OPN also plays a role in wound healing (tissue remodeling) and OPN mutant rodents exhibit impaired wound healing. The impact of MICR for colorectal cancer (CRC) on plasma OPN levels is unknown. This study’s goal was to assess blood levels during the first month after MICR for CRC. Method: Patients undergoing MICR (laparoscopic assisted + hand-assisted lap.) for CRC who were enrolled in an IRB approved tissue/prospective data bank for whom preoperative (PreOp) and postoperative (postop) plasma were available were eligible. Only patients for whom PreOp, Postop Day (POD) 1, POD 3 and at least 1 late postop plasma sample (POD7-34) were available were studied. The late samples were bundled into 4 time periods (POD7-13, POD14-20, POD21-27, and POD 28-34) and considered as single time points. OPN levels were determined in duplicate via ELISA and the results reported as mean ±SD. The paired t-test was used for analysis (significance, p \ 0.008 post Bonferroni correction). Results: A total of 101 CRC patients (63% colon, 37% rectal) met the study criteria (51 male/49 female, mean age 65.2±13.3 years). Mean incision length was 7.7±3.3 cm; operative time was 288.8± 118.3 min and LOS was 6.6±3.9 days. The final cancer stage breakdown follows; I (n=26), II (n=37), III (n=34) and IV (n=4). The mean PreOp OPN level was 89.2±36.8 (ng/ml) for the entire group. Significantly elevated (p\0.001) mean plasma levels were detected on POD1 (198.0 ±67.4; n=101), POD 3 (186.0±76, n=101), POD7-13 (154.1±70.2, n=70), POD14-20 (146.7±53.4, n=32), and POD 21-27 (123.0±56.9, n=25). There was no significant difference noted when the POD 27-34 and PreOp results. Conclusion: Plasma OPN levels are significantly elevated over baseline for a month after MICR for CRC. The increase in OPN levels early in the first week after MICR may be related to the acute inflammatory response that follows surgery. The persistent elevation noted during weeks 2–4, however, may be a systemic manifestation of wound healing in which OPN plays a role. This elevation, together with similar post MICR persistent elevations in levels of VEGF, ANG2, sVCAM, etc, may promote angiogenesis in residual tumor deposits early after MICR. Further studies are warranted.

Julia Zakhaleva, MD1, Andrea Ferrara, MD2, Joseph Gallagher, MD2, Paul Williamson, MD2, Samuel DeJesus, MD2, Renee Mueller, MD2, Mark Soliman, MD2, Reid Vegeler, MD2, Allen Ghlandian, MD2, 1 Orlando Regional Medical Center, 2Colon & Rectal Clinic of Orlando Introduction: Patient portals have the potential to improve both quality and access to health care by enabling patients to communicate with their provider, access their medical records, schedule appointments, refill prescriptions, and pay bills. They can increase care efficiency by actively engaging patients and their families. Moreover, the adaption of patient portals fits a number of the meaningful use criteria for Stage 1 established by the Centers for Medicare and Medicaid Services. The goal of this study was to examine the implementation and promotion of a health portal in the multi-partner surgical subspecialty practice. Methods and Procedures: A retrospective review of electronic health records (EHR) was conducted. The patient portal came online in August 2013. Patients were notified about its existence by a sign in the waiting area and a mailed letter until March 2013. From March 2013 to August 2014 patients were also reminded about the portal by the office staff with a written notice at each office visit. Patients created their account from a link on the practice website. An additional verification code needed to be obtained through EHR for the portal to become active. The chi square test, t-test, and Fisher’s exact test were used for statistical analysis. Results: The total number of patients seen was 4041. The number of patients notified by a sign and a letter was 2067 (51.15%). Only 104 patients (5.03%) used the portal initially, while 223 patients (11.3%) used the portal after a personalized reminder, resulting in a statistically significant difference (p\0.01). There was equal gender distribution in both groups, with 54.28% women before March 2013 and 53.35% women afterwards. A statistically significant difference in age distribution between female and male patients was identified (p \ 0.01). When analyzed in the subgroups divided by gender and age (younger than 21, from 22 to 40, from 41 to 64, older than 65), there was no significant difference between women and men of different age groups in the portal utilization (p = 0.07). Overall, patients averaged 2 visits, while patients with portals averaged 2.8 visits (p = 0.437). There was a statistically significant difference in the diagnoses distribution between all patients and patients with portals (p \ 0.01), with limited number of patients with benign anorectal condition (8.0% vs. 20.3%) accessing the portal. Conclusion: Personalized reminders about the health portal increased the number of patients who started using this resource. Their distribution was equal between the genders and age groups. However, the overall number of patients of utilizing the portal was only 11.3%. Perhaps, a surgical subspecialty practice attracts a relatively low volume of chronic patients who would benefit the most from the portal. Nonetheless, there is a need for more education and recruitment of patients into health portals.

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Lower Anterior Resection for Rectal Cancer with Situs Inversus Totalis

Geographic Trends in Minimally Invasive Surgery for Colorectal Cancer

Yoshikage Inoue, MD, Akiyoshi Kanazawa, PhD, Kitano Hospital

Emmanuel M Gabriel, MD, PhD, Pragatheeshwar Thirunavukarasu, MD, Kristopher Attwood, PhD, Boris Kuvshinoff, MD, Steven Hochwald, MD, Steven Nurkin, MD

Introduction: Situs inversus totalis is a rare congenital abnormality. We successfully performed laparoscopic lower anterior resection for Rectal Cancer with Situs inversus totalis by creating a safe and oncologically sufficient strategy before and during surgery. Case Presentation: A 68 year old man presented at our hospital with the diagnosis of Rectal cancer detected by lower endoscopy. Preoperative computed tomography showed Situs inversus totalis without lung or liver metastasis. The preoperative diagnosis was cStage3b (cT3, cN1, cM0). The benefit of laparoscopic surgery is most apparent for rectal surgery since the pelvic cavity is small, especially for men. Therefore, we performed laparoscopic lower anterior resection with lymph node dissection. Because the rectum is a bilaterally symmetric organ itself, surgery can be done if the lymph node dissection, which is the unsymmetrical part of surgery, can be performed safely. The surgical strategy consisted of image rehearsal with three dimensional CT angiography of inferior mesenteric artery preoperatively, lymph node dissection from the left side of the patient, and sufficient abruption of the mesorectum from the usual right side of the patient during surgery. The patient was discharged without any complications on postoperative day 9. Histological examination disclosed stage3c (pT3, pN2b, cM0). Three months after operation, he is taking adjuvant chemotherapy without recurrent rectal cancer. Conclusion: Laparoscopic lower anterior resection for Rectal cancer with Situs inversus totalis can be considered as a feasible and safe procedure with a well-planned strategy.

Roswell Park Cancer Institute Introduction: Studies have shown increasing trends in the use of minimally invasive laparoscopic surgery for the treatment of colorectal cancer (CRC). With the increasing incorporation of robotics into general surgery and surgical oncology, we sought to characterize the national trends of robotic surgery in patients with CRC. Methods: We utilized the National Cancer Database (NCDB) to identify patients with CRC from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Multivariate analysis was performed to investigate differences between geographic location and surgical approach. The NCDB divides geographic location into 9 regions within the US. The New England states were used as the reference variable for comparison in our multivariate analysis. Results: A total of 156,115 patients were identified, of whom 74.1% had cancer of the colon, 7.3% of the rectosigmoid junction and 18.6% of the rectum. Overall, the initial surgical approach included 58.7% open, 39.1% laparoscopic and 2.2% robotic. On multivariate analysis, the New England states (CT, MA, ME, NH, RI, VT) had the highest rates of laparoscopic surgery across each cancer subgroup as indicated by lower odds ratios (OR) for each of the remaining geographic locations. In contrast, the geographic trends for robotic surgery were more diverse. For colon cancer, patients in the East South Central region (AL, KY, MS, TN) were most likely to undergo robotic surgery (OR 1.633, 95% CI 1.117–2.388). For rectal cancer, patients in the East North Central region (IL, IN, MI, OH, WI) had the highest likelihood of robotic surgery (OR 1.809, 95% CI 1.262–2.594). Patients with rectosigmoid cancer in the Mountain region (AZ, CO, ID, MT, NM, NV, UT, WY) had the highest OR for robotic surgery (OR 2.118, 95% CI 0.895–5.0123), although this association was not statistically significant. Conclusions: Minimally invasive surgical approaches for CRC comprise over 40% of procedures. Patients in the New England region were more likely to have a laparoscopic approach for all CRC. The use of the robotic approach was more varied geographically according to the location of the primary tumor.

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Does the Distance from the Anal Verge of Extraperitoneal Rectal Tumors Affect the Postoperative and Oncologic Outcomes?

Laparoscopic Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis for Familial Adenomatous Polyposis is Safe in ShortTerm Outcomes Compare with Open Surgery

Francisco Schlottmann, Manuel Maya, Alejandro Sanchez Ruiz, ˜ s Rotholtz, Sebastian Guckenheimer, Maximiliano Bun, NicolA ˜ ¡n of Buenos Aires Hospital AlemA Introduction: There is weak evidence that in patients with rectal cancer the distance from the anal verge of the lesion affects the postoperative and oncologic outcomes. Those with low rectal cancer would present higher rate of complications and worse oncologic prognosis. The aim of this study is to evaluate whether the distance from the anal verge of extraperitoneal rectal tumors affects the outcomes. Methods and Procedures: In this retrospective study, patients with extraperitoneal rectal tumors undergoing laparoscopic surgery during the period 2003–2012 were included. The cohort was divided into two groups according to the height of the tumor; G1: Low rectal cancer (0–7 cm) and G2: Medium rectal cancer (7–12 cm). A subanalysis was performed over G1 according to the surgery in abdominoperineal resection (APR) or low anterior resection (LAR). Demographic variables, surgical results, recovery parameters and oncologic outcomes were analyzed. Statistical analysis through the X2 test, T test and one factor anova was performed using SPSS v20. Results: In the period 87 patients were operated of which 56.3 % were men. The mean age was 64 (29 -87) years. Forty (46 %) belonged to G1 and 47 (54 %) to G2. Mean follow-up was 42.1 (6–102) months. The number of patients who received neoadjuvant therapy was higher in G1 (G1: 61 % vs G2: 32 %, p: 0.006). Surgeries performed were 10 (12 %) APR, 68 (78 %) LAR and 9 (10 %) LAR with intersphincteric dissection. A trend to higher conversion in G2 was recorded. There was no difference in recovery parameters between the two groups. While no differences were found in postoperative and oncologic results between both groups, patients in G1 undergoing APR had a major complications rate (p: 0.017) and a greater long term recurrence (p: 0.06) Conclusion: The height of the tumor does not affect the outcomes except those subject to APR.

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Kiyoshi Tsukamoto, MD, PhD, Nagahide Matsubara, MdD, PhD, Masashi Takemura, MD, PhD, Masafumi Noda, MdD, PhD, Tomoki Yamano, MD, PhD, Naohito Beppu, MD, Mie Yoshimura, MD, Masayoshi Kobayashi, MD, Michiko Hamanaka, MD, Naohiro Tomita, MD, PhD, Department of Surgery, Hyogo College of Medicine Introduction: The aim of this study was to compare the short-term outcomes of laparoscopic (Lap) and open restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) for patients with familial adenomatous polyposis (FAP) in a single institute in Japan. IPAA is now standard operation for patients with FAP. Herein we report the shortterm outcomes of Lap vs. open IPAA for FAP and some noteworthy points of Lap IPAA. Methods and Procedure: Retrospectively collected data from 72 patients who underwent IPAA for FAP at Hyogo College of Medicine from 2000–2014 was analysed. Short-term outcomes of patients who underwent Lap (n=14) and open (n=48) procedures are compared. Results: Mean operation time was significantly longer in Lap compared with open (436 and 247 mins p \ 0.001). Mean hospital stay was significantly shorter in Lap compared to open (21 and 27 days respectively p \ 0.01). There was no significant difference either in blood loss (220 and 180 ml p = 0.09), anastomotic leakage (3/14 and 1/48 p = 0.05), rate of one-staged operation (64.3 and 81.3 % p = 0.33) or post-operative bowel obstruction (1/14 and 3/48 p = 0.62) between the two groups (all data are Lap and open). Although, there are no significant differences, Lap procedure tends to increase anastomotic leakage and decrease the rate of one-staged operation. In Lap procedure, it is rather difficult to confirm ileal pouch long enough to come down to anal verge. And also it is not easy to lead ileal pouch down to anal via pelvic cavity. As a consequence of our early experience of Lap procedure, where unplanned twostaged operation was required in one patient due to peritoneal faecal soiling originating from the anal stump after removal of the resected colon and rectum from abdominal cavity, after this experience, we have modified our surgical procedure. Conclusions: In conclusion, Lap IPAA can be performed safely in patients with FAP. Shorter postoperative stay and superior cosmetic results further support the adoption of Lap approach. However, there are some different aspects to be careful compared with open surgery. We present some noteworthy points of Lap IPAA for patients with FAP.

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Laparoscopic Versus Open Resection for T4 Colon Cancer: a Case-Matched Control Study

Use the Third Arm: a Reliable and Relevant Way to Teach Robotics

Li-Yong Huang, Xinxiang Li, San-Jun Cai, Guo-Xiang Cai, Ye Xu, Fudan University Shanghai Cancer Center

Jeffrey R Watkins, MD, Houssam G Osman, MD, Rohan Jeyarajah, MD, Methodist Dallas Medical Center

Background: Laparoscopic resection for T4 colon cancer is still not recommended as the treatment of choice because of high risk of conversion, postoperative complication, and early recurrence. In this study, we analyzed the short- and long-term survival outcomes after laparoscopic surgery (LS) for T4 colon cancer compared with open surgery (OS). Methods: From a prospectively collected database, 102 patients with histologically proven T4 colon cancer who had undergone laparoscopic resection from April 2009 to April 2013 were identified. LS were matched 1:1 to OS during the same period by age, gender, American Society of Anesthesiologists class, body mass index, and type of surgery. Data were analyzed using Fisher’s exact, chi-square, and Kaplan–Meier estimates. P-value \ 0.05 was considered statistically significant. Results: The conversion rate was 7%. Less operative blood loss (P\0.001), longer operation time (P = 0.001), earlier return to bowel function (P\0.001) and shorter postoperative hospital stay (P =0.001) were observed in the LS group. A similar number of lymph nodes were harvested (P = 0.905) and the R0 resection rate (P = 0.755) was not different in the two groups. There was no difference with respect to operative morbidity and mortality between LS and OS. The local recurrence, overall survival, and disease-free survival were also similar between the two groups during a median follow-up period of 30 moths (range: 12–60 moths). Conclusions: Laparoscopic resection for T4 colon cancer is safe and feasible, with similar local recurrence rate and equivalent oncologic survival compared with open approach. These findings support that the T4 colon cancer should not be an absolute contraindication to laparoscopic surgery in the hands of an experienced laparoscopic surgeon.

Introduction: Transitioning from open to laparoscopic surgery involved trial and error as surgeons learned their boundaries of teaching in a remote environment. The transition to robotics has been more thoughtful, but not as intuitive to many. As faculty surgeons get trained in robotics, there is generally a year-long hiatus in trainee participation. We describe a method of robotic education involving the use of the third arm, allowing for faculty and trainee growth together. Methods and Procedures: A tertiary care center with a surgical fellowship and residency was the backdrop for this trial program. The surgeon himself was recently trained and the aim was to gain personal robotic experience without compromising the trainees in the program. The third arm was used on every robotic case that was performed by this surgeon at the institution. These cases consisted of cholecystectomy, paraesophageal hernia, esophagectomy and Heller myotomy. The trainee was then transitioned from the third arm to arms one and two. Results: Trainees all completed the online and simulated training modules prior to any console work. Thereafter, using the third arm on every case, the trainee was placed in the dual console position. This was instead of the bedside laparoscopic assistant, which was felt to not provide robotic-specific experience. As the trainee showed competence in the assistant role, including finger-clutch and arm control proficiency, the surgeon handed over two operating arms and while himself taking the third arm. Using this technique of graduated responsibility and robotic-specific training, trainees were able to graduate to dual arm work quickly. Moreover, both the faculty and the trainee obtained robotspecific experience together. Conclusions: The use of the third arm allows for a graduated progression in robotic training. The third arm allows for robot-specific training which we believe is superior and more relevant than bedside laparoscopic assistant position. This method allows for an expedient transition to dual-arm surgeon role for trainees, and a parallel learning curve for faculty and trainee. We would propose a multi-center trial to look at this mode of robotic training.

P090

P092

Efficacy of Single Port Laparoscopic Colectomies for Colon Cancer Using 3D Visualization with Cordless Ultrasonic Dissection Device

Teaching Peroral Endoscopic Myotomy (POEM) to Practicing Surgeons: an ‘‘Into the fire’’ Pre-/Post-Test Curriculum

Toshimasa Yatsuoka, Yusuke Nishizawa, Yoji Nishimura, Katsumi Amikura, Yoshiyuki Kawashima, Hirohiko Sakamoto, Yoichi Tanaka, Kazuhisa Ehara, MD, Saitama Cancer Center Introduction: Single port laparoscopic colectomies (SILC) has developed from an effort to minimize tissue injury, reduce morbidity, and preserve cosmesis. While SILC is more difficult than standard laparoscopic surgery, the newest advancements in terms of surgical instrumentation, including three-dimensional computed tomography (3DCT), threedimensional (3D) laparoscopic visual systems and cordless hand-held ultrasonic cautery cutting devices, have permitted SILC surgery to become even more feasible. Our aim was to review our experience and short-term outcomes with SILC since its introduction at our institution. We demonstrate the efficacy of SILC using 3D visualization with cordless ultrasonic dissection device for colon cancer. Methods and Procedures: We retrospectively reviewed consecutive SILC performed by a single surgeon from Dec 2010 to Sep 2014. The surgeon performed SILC with 3D systems using a cordless hand-held ultrasonic cautery cutting device and standard laparoscopic instrumentation. Preoperative 3D images of the major regional vessels were routinely described. The Demographic data, intraoperative parameters, and postoperative outcomes were analyzed and compared with case-matched standard laparoscopic colectomies (LAC). Results: Of the planned 22 SILC cases, 17 (88%) were completed with a single incision, whereas 4 required an additional port placement and one case were converted to HALS procedure. The largest incision length was significantly shorter for the SILC group (SILC 4.3 cm vs. LAC 5.5 cm, P = 0.0151). Compared to the LAC group operative time was shorter (SILC 224 min vs. LAC 246 min) and estimated blood loss was lesser (SILC 47 ml vs. LAC 75 m), but the differences were not statistically significant. There were no statistically significant differences between two groups with respect to harvest lymph node and length of hospital stay. There were no intraoperative complications in SILC procedures. All patients recovered uneventfully. Conclusions: Preoperative 3D-CT, intraoperative 3D laparoscopic visual systems and the cordless ultrasonic dissection device have been advanced to enhance SILC skills. Our preliminary results show that this approach can be adopted in a safe and efficacious manner while using advanced surgical instrumentation

Matthew A Zapf, BA1, Maria A Cassera, BS2, Lee L Swanstrom, MD2, Michael B Ujiki, MD3, 1Loyola Stritch School of Medicine, 2 The Oregon Clinic, 3NorthShore University HealthSystem Introduction: PerOral Endoscopic Myotomy (POEM) is growing due to efficacious results in achalasia and expanding indications. We evaluated a methodology for teaching a new procedure like POEM to experienced practitioners. Methods: Three POEM courses were taught by nine experienced POEM endosurgeons at two independent simulation laboratories. The courses consisted of a knowledge-based quiz, demographics and feedback surveys, lectures on patient selection, technique, and troubleshooting as well as POEM procedural simulation on live porcine and ex-plant models. A scoring sheet assessed POEM performance with a likert-like scale measuring equipment setup, mucosotomy, endoscope navigation, visualization, myotomy, and closure. A pre-/post-test design forced participants to attempt the POEM procedure on an ex-plant model and take a knowledge based quiz before lectures and the question & answer session. Post-testing was conducted at the conclusion of the course and feedback was assessed. Results: Thirty-two participants with varying degrees of experience in upper-GI endoscopy (Range: 50–200+; median: 200+) and laparoscopic achalasia cases (Range: 0–200+; median: 26–50) completed the POEM course. Participants improved knowledge quiz scores from 68.3% pre-test to 84.7% post-test (p \ 0.01). POEM performance increased from 14.2 to 25.2 (p \ 0.001) with the greatest gains in mucosotomy (2.6 v 4.4 p \ 0.01) and closure (2.1 v 4.5 p \ 0.01). Participants rated the ex-vivo model as very good (4.4 ± 0.7) and live porcine model as excellent (4.9 ± 0.2). They praised the pre-/post-test design as very helpful (4.4 ± 0.8) and most appreciated the troubleshooting portion of the lecture series. Ninety-five percent of subjects stated achieving all of their learning goals. Conclusions: A multimodal curriculum with procedural pre-testing was an effective curricular design for teaching POEM to experienced practitioners. This curriculum methodology may be useful for teaching emerging procedures in the future.

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P093

P095

Training Surgical Residents to Perform Critical Care Focused Echocardiography

Effectiveness of Robotic Simulation Training

Heidi J Miller, MD, MPH, Katarzyna Wolanin, MD, Pak S Leung, MD, Albert Einstein Healhcare Network Background: The ability of surgical residents to obtain data regarding a patient’s changing volume status can be valuable for guiding decisions regarding patient care and resuscitation in a surgical intensive care unit. The focused rapid echocardiographic evaluation (FREE) has been shown to be a reliable compliment to the use of invasive monitoring systems. Our objective was to show the efficacy of a short-course training session in teaching residents to obtain, understand and interpret echocardiography. Methods: Surgical residents completed a written pre-test covering ultrasound physics, FREE technique and the clinical interpretation. They participated in a didactic and practical training session. They were tested on their ability to complete a point of care echo exam on a healthy subject. A written post-test exam was completed at the end of the didactic sessions. Data was stratified by PGY status and self-reported comfort with ultrasound prior to the study. Results: There was significant improvement (mean increased by 25%) between the pre- and post-test evaluations in ultrasound basics, identification and clinical interpretation of FREE images. There was no difference as stratified by PGY status or by self-reported comfort with ultrasonography. All participants were able to obtain and correctly orient the four views of FREE, identify anatomic landmarks and utilize the M-mode. Conclusion: A half-day didactic and hands on course in echocardiography can prepare surgical residents to use focused rapid echocardiographic evaluation to aid in patient care. These skills can then be transferred into a critical care setting to inform decisions on use of vasopressors, fluid resuscitation and cardiac support.

P094 Face Validation of the Virtual Electrosurgery Skill Trainer (VEST) Ganesh Sankaranarayanan, PhD1, Baichun Li, MS2, Amie Miller, MD3, Hussna Wakily, MD4, Stephanie B Jones, MD4, Steven Schwaitzberg, MD5, Daniel B Jones, MD, MS4, Suvranu De, ScD1, Jaisa Olasky, MD6, 1Rensselaer Polytechnic Institute, 2School of Mechanical Engineering and Automation, Northeastern University, Sheyang, China, 3Boon Shaft School of Medicine, Wright State University, Dayton, Ohio, 4Beth Israel Deaconess Medical Center, Boston, MA, 5Cambridge Health Alliance, Cambridge, MA, 6Mount Auburn Hospital, Cambridge, MA Introduction: Electrosurgery is a modality that is widely used by surgeons to coagulate, dissect and ablate tissues. The use of electrosurgery devices has resulted in injuries, OR fires and even death. It has been established that even expert surgeons lack knowledge in the proper and safe usage of these devices. To address this knowledge gap, SAGES has established the FUSE (The Fundamental Use of Surgical Energy) program. Complementing the SAGES FUSE initiative, we have developed the Virtual Electrosurgery Skill Trainer (VEST), which is designed to train subjects in the cognitive and motor skills necessary to safely operate electrosurgical devices and to understand the tissue effects, using 3D interactive and self-learning simulation. The objective of this study is to asses the face validity of the VEST simulator. Methods and Procedures: Sixty three subjects were recruited at the Learning Center of the 2014 SAGES annual meeting. All subjects completed the monopolar electrosurgery module on the VEST simulator, which defines the electrical waveforms used in electrosurgery and describes the effects of different power settings on the tissue. At the end of the study, subjects filled in a 5-point Likert scale questions that assessed the face validity. Results: The subjects response were grouped into two groups, FUSE experience (n = 15) and no FUSE experience (n = 48). The median scores for both the groups responses for all the questions were 4 or higher with questions on effectiveness of VEST in aiding learning electrosurgery fundamentals was rated at 5. Subjects also rated with high confidence (median score of 5) on using the simulator in their skills lab and also recommend it to their peers. MannWhitney U test on the responses between the two groups showed no significant difference (p [ 0.05) indicating a general agreement. 46 % of the respondents preferred VEST compared to 52 % who preferred animal model and 2 % preferred both for training in electrosurgery. Conclusion: This study demonstrated the face validity of the VEST  simulator. High scores showed that the simulator was realistic in reproducing the tissue effects and the features were adequate enough to provide high realism. The self-learning instructional material was also found to be very useful in learning the fundamentals of electrosurgery.

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Jeffry T Zern, MD, Christiana Care Health System Introduction: Development of an objective, standardized training experience including simulation would allow advanced laparoscopic surgeons to become proficient with the da Vinci robotic platform and lead to improved patient outcomes. Robotic surgery enables surgeons to perform highly complex procedures through minimally invasive modalities. Although this is an extension of basic surgical principles, a steep learning curve exists to master this technology. Training requirements were established using robotic simulators to ensure that all surgeons possessed a standard level of proficiency prior to performing surgery on patients. The MIMIC and the daVinci backpack simulators were used. They allow surgeons to practice robotic skills without affecting patient care. The simulator grades the surgeon on multiple parameters and requires skill advancement in order to obtain an expected score. Methods and Procedures: An educational training curriculum included the following components: 1. Intuitive/daVinci on line learning modules. 2. Two specialty specific case observations. 3. Simulator drills–10 exercises to teach specific robotic tasks. A passing score of 90% for each of the 10 drills was set to ensure a standard for proficiency. These were grouped regarding surgical tasks including: A. EndoWrist manipulation and camera control B. Third arm control C. Needle control D. Energy and dissection 4. Intuitive/daVinci guided animate porcine operative training, followed rapidly by first live proctored cases to avoid skill decay. 5. Three proctored cases. 6. Retrospective review of ten successful cases. 7. Requirement to complete 15 basic cases prior to advanced cases. Results: Eight advanced laparoscopic surgeons participated, spending 6.4 to 8.1 hours performing simulation drills. The first 208 general surgical procedures performed at our institution used the daVinci Si robot and were evaluated for this study. Overall results have been outstanding with no robotic specific complications to date. This compares to other surgical disciplines at our institution that started robotic surgery without the benefit of simulation training and had conversion and complication rates of over 8%. Seven conversions occurred from robotic to laparoscopic modality due to anatomic issues, positioning of the robotic arms relative to target anatomy, inflammation of target tissues and unexpected findings which changed operative plans. Two patients were converted from robotic to open surgery, one due to the presence of gangrenous cholecystitis and the second due to anatomic issues, specifically obesity during a low anterior colon resection. Robotic to laparoscopic conversion rate 3.4% Robotic to open surgery conversion rate 0.96% Robotic specific complications 0% Conclusion: This project demonstrates that robotic surgeons who have trained through a curriculum including simulation are well prepared to begin robotic surgery. Surgeons operating with the daVinci robotic platform routinely are able to maintain their skills better than infrequent users and novices. Simulation drills could also be used to demonstrate competency if a surgeon has not used the robot for an extended period of time. Mastery of the daVinci robot will allow surgeons to provide safe and effective care for their patients.

Surg Endosc

P096

P097

Single Incision Transumbilical Laparoscopic-Assisted Appendectomy Performed by Surgical Residents is Safe and Feasible

The Performance and Impact of Rural Minimally Invasive Surgery Fellowships

1

2

1

Kazuhiro Endo, MD , Dai Kujirai, MD , HIroharu Shinozaki, MD , Hinako Maeda, MD1, Hiroki Ozawa, MD1, Yuriko Kiriya, MD1, Tadashi Matsuoka, MD1, Ryo Nakanishi, MD1, Yuko Kumagai, MD1, Takashi Ishida, MD1, Toshiaki Terauchi, MD1, Masaru Kimata, MD1, Kenji Kobayashi, MD1, Naohiro Sata, MD3, 1Saiseikai Utsunomiya Hospital, Department of Surgery, 2Keio University, Department of Emergency medicine, 3Jichi Medical University, Department of Surgery Introduction: The aim of this study is to compare the clinical outcomes of single incision transumbilical laparoscopicassisted appendectomy performed by surgical residents and staff surgeons. Patients and Methods: We examined clinical factors and outcomes of 131 laparoscopic appendectomy procedures performed from January 2011 to June 2014 retrospectively. During the study period, 13 residents and six boardcertified staff surgeons performed the procedures. All operations performed by residents were supervised by staff surgeons. Appendicitis was diagnosed by physical findings, blood tests, and computed tomography scan. The following characteristics were compared for operations performed by residents and by staff surgeons: gender, age, body mass index, ASA score, temperature, white blood cell count, CRP level, and presence of fecal stones and abscesses. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared by the two groups. Results were compared using the chi-squared test and statistical significance was set at p \ 0.05. Surgical Procedure: Three 5 mm ports were inserted through a 2 cm umbilical incision. After pneumoperitoneum was induced, the appendix was identified, and the ileocecum was mobilized. The appendix was removed through the umbilical incision and the mesoappendix was ligated and dissected under direct visualization. The appendiceal root was ligated and dissected, and the stump inverted. Results: Preoperative white blood cell counts in the resident-operated group is significantly higher than patients operated by staff surgeons. (14.0 vs 10.8 (9103 /mm3), p = 0.007) There is no other significant difference in clinical variables between the two groups. Patient outcomes show that estimated blood loss is significantly higher and operative time tended to be longer in the resident group. No other significant difference is observed. Conclusion: Single incision laparoscopic appendectomy performed by residents is associated with slightly increased estimated blood loss and longer operative times. There are no significant differences in the rate of operative complications or postoperative course between the two groups. Single incision laparoscopic appendectomy performed by residents is safe and feasible and is recommended as part of surgical training.

Resident (n=103)

Staff (n=28)

p-value

James Patrick Ryan, MD1, Andrew J Borgert, PhD2, Kara J Kallies, MS2, Lea M Carlson, RNC1, Howard McCollister, MD1, Paul A Severson, MD1, Shanu N Kothari, MD3, 1Minnesota Institute for Minimally Invasive Surgery, 2Gundersen Medical Foundation, 3 Gundersen Health System Background: Despite evidence demonstrating similar operative experience in rural and urban residency programs, operative experience in rural fellowship programs is largely unknown. In addition, rural surgical care in the United States has been increasingly challenged by both a shortage of graduating residents remaining in general surgery as well as an urban/rural maldistribution adversely affecting access to surgery for rural populations. Two of the most rural minimally invasive surgery (MIS)/Bariatric fellowships are located in the upper Midwest. We hypothesized that these two programs would offer a similar operative experience to other U.S. programs in more urban locations, and that receiving fellowship training in a rural location would increase the likelihood of entering a rural surgical practice. Methods: The 2011–2012, 2012–2013, and 2013–2014 fellowship case logs from two rural Midwest programs were compared to case logs from 23 U.S. MIS/Bariatric programs. All 17 rural Midwest fellowship graduates completed a survey describing their fellowship experience and current practice. Statistical analysis included Wilcoxon Rank Sum test. Results: Mean case volumes for rural Midwest fellows vs. other U.S. programs are reported in Table 1. Case volumes for advanced MIS and bariatric procedures were similar. Mean endoscopy volume was significantly higher among rural Midwest fellows as this is a large component of one of these fellowships. All (100%) rural Midwest fellows reported an adequate number of cases as operating surgeon during fellowship. 94% reported that their fellowship training was extremely beneficial to their career, and 1 (6%) reported it to be somewhat beneficial. 53% of graduated fellows currently practice in a rural area, despite only 6% having an interest in rural practice prior to fellowship. Only one fellow (6%) participated in rural surgery training during residency. Conclusions: Rural Midwest MIS/Bariatric fellowship programs offer a similar operative experience to other U.S. programs. A greater volume of endoscopy cases was observed in rural Midwest fellowships, which is particularly needed in rural hospitals. Fellowship training in a rural location results in highly trained specialist surgeons establishing advanced MIS and bariatric practices in rural locations. Rural fellowships can be valuable resources in alleviating the rural manpower shortage while improving access to quality surgical care for rural populations.

Table 1

Mean case volumes by procedure

Case type

Rural Midwest Programs (N = 2) Mean±SD

U.S. programs (N = 23)

P-value

Endoscopy

443.3±351.7

104.9±82.4

0.01

Bariatric

124.0±21.4

150.5±55.2

0.21

Foregut

51.7±19.0

67.2±33.7

0.29

Hepatobiliary

49.5±28.7

47.9±43.0

0.63

Operative time (min)

86

72.03

0.056

Abdominal wall

49.0±22.9

58.2±29.7

0.58

Estimated blood loss (ml)

23.44

9.75

0.031

22.7±5.1

20.0±13.9

0.29

Additional port insertion

14 (13.6%)

3 (10.7%)

0.691

Peritoneum, omentum, mesentery

0.24

1 (3.6%)

Colorectal

16.1±18.1

2 (1.9%)

0.612

16.8±6.8

Conversion to open surgery

Appendix

13.5±6.7

6.5±8.6

0.01

0 (0%)

0.604

12.8±2.9

11.5±8.1

0.18

3.5±5.2

7.1±6.4

0.08

Intraoperative complications

1 (1%)

Postoperative hospital stay(days)

4.34

4.67

0.515

Small intestine

Postoperative complications

5 (4.9%)

1 (3.6%)

0.775

Solid organ

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P098

P100

Recognition of Prior Learning: a Promising Tool in the Selection of Surgical Trainees; a Laparoscopic Simulation Study

Construct Validity of a Training Model for Laparoscopic Heller Myotomy and Dor Fundoplication Using the Goals Score

Salim Abunnaja1, C. Keith White, MD1, Shohan Shetty, MD2, J Alexander Palesty, MD, FACS1, 1Saint Mary’s Hospital, 2 UT Southwestern Medical Center

Omar Bellorin, MD, Sharma Saurabh, MD, Alexander RamirezValderrama, MD, Paul Lee, MD, New York Hospital Queens / Weill Cornell Medical College

Introduction: Recognition of Prior Learning (RPL) is a process commonly used by the military, aviation, industry, and training institutions for a variety of purposes, most significantly, recruitment and career planning. Continued advancement in surgical education, including more minimally invasive and robotic assisted surgeries, may allow RPL to assist selection committees in their evaluation of the technical competitiveness of surgical candidates. We aim to determine if RPL through objective skills testing can be used as a component of surgical candidates evaluation. Methods: Seventy medical students (34 male & 36 female) from five medical schools participated in this study using a Lap Sim virtual reality simulator (Surgical Science, Goteborg, Sweden). A validated curriculum for training general surgery residents was used. The surgical training curriculum consisted of three tasks: coordination, grasping, and lifting and grasping. The participants completed a survey after completion of the tasks for the evaluation of data points such as an interest in a surgical career. Performance was scored and learning curves were computer-generated. The results were analyzed using ANOVA and unpaired t-tests. Results: Based on the computer generated scores and overall repetitions, 14 participants had above average skill (21%), 35 had average skill (53%) and 17 had below average skill (26%). Four students were excluded due to previous practice on our simulation system. When groups were broken down into those with surgical interests and those without, there were no overall significant differences. However, the number of participants with below average skills was significantly lower in students interested in surgical training (13%) when compared to those with no interest in surgical training (32%). In addition, there were more participants with average scores in the surgical group (65%) as compared to the non-surgical group (47%). Conclusions: Application of RPL through skills testing using virtual reality simulators may be an additional selection criterion for surgical training selection committees. Additionally, this may allow prospective trainees to realize their limitations or learn which skills need to be improved upon, or maybe even reconsider their field of choice. Our results reveal the use of a standardized laparoscopic training simulator curriculum can differentiate between participants with differing levels of skill. The decision to pursue a surgical career may have affected the prior learning of these individuals and the increased skill performance.

Introduction: The aim of this study is to determinate the capability of a training model for laparoscopic Heller-Dor Myotomy to discriminate between different levels of laparoscopic expertise (construct validity) using the GOALS scale. Laparoscopic training demands practice so efficiency in the operating room can be achieved. Several training models have been developed to bridge the learning curve in different laparoscopic procedures. The transfer of laparoscopic skills from training models to real surgical procedures has been proven. We developed a low-cost model of laparoscopic Heller-Dor myotomy for advanced laparoscopic training. The global operative assessment of laparoscopic skills (GOALS) score is a 5-item global rating scale developed to evaluate intraoperative laparoscopic skills by direct observation. The five domains include depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. This scale has been used to perform construct validity of several laparoscopic training models with reliable results Methods and Procedures: The performance of two groups with different levels of expertise in laparoscopy, novices (junior surgical residents \50 laparoscopic procedures) and experts (senior surgical residents [ 200 laparoscopic procedures) were assessed. All participants were instructed to perform two tasks (esophageal myotomy and fundoplication) using a video tutorial. Novices received a hands-on session of intracorporeal knot tying prior evaluation on the training model. All the performances were recorded in a digital format. A laparoscopic expert who was blinded to subject’s identity evaluated the recordings using the valid and reliable GOALS scale. Autonomy, one of the 5 items of GOALS was removed since the evaluator and the trainee did not have interaction. The time required to finish each task was also recorded. Performance was compared using the Mann-Whitney U-test (p \ .05 was significant). Results: Twenty subjects were evaluated, ten in each group, using the GOALS score. The time required finishing the two tasks was also assessed. The mean total GOALS score for novices was 7.5 points (SD: 1.64), and 13.9 points (SD: 1.66) for experts (p \ .05). The expert group was superior in each domain of the GOALS score compared to novices: depth perception (mean: 3.3 vs 2 p\ .05), bimanual dexterity (mean 3.4 vs 2.1 p\ .05), efficiency (mean 3.4 vs 1.7 p \.05) and tissue handling (mean 3.6 vs 1.7 p\.05). With regards to time, experts were superior in task one (mean 9.7 vs 14.9 min p \ .05) and task 2 (mean 24 vs 47.1 min p \ .05) compared to novices. Conclusions: Construct validity for the inanimate laparoscopic Heller-Dor Myotomy training model was demonstrated. Therefore, it is a useful tool in the development and evaluation of the resident and fellow in training. The model can be used as well by dedicated foregut surgeons to improve laparoscopic skills.

P099 The Impact of Text Pager Implementation on an Urban Hospital Surgical Service Jennifer A Montes, MD, MPH, Deo Davis, Sam Johnson, Robert A Andrews, MD, Yuriy Dudiy, MD, North Shore LIJ Lenox Hill Hospital Introduction: Numerical pagers are the current modality used to facilitate non-verbal communication between nurses and physicians. However, they are hindered by their inability to convey information beyond a callback number leaving the recipient uninformed about the nature of the page, its urgency or who generated the page. To address these issues, technological advancements such as text pagers have been developed to increase the efficacy and quality of communication amongst medical professionals. Drawing on this research, this study was designed to evaluate the effects of implementing alphanumeric pagers on the surgical service of an urban hospital. Specifically, to see if alphanumeric pagers decrease the number of pages and interruptions, increase quality of communication and improve general quality of life. Methods and Procedures: This study was conducted utilizing a pre-intervention/post-intervention survey design at a 652 bed urban facility to observe the effectiveness of using alphanumeric pagers in comparison to traditional pagers. Thirteen first level surgical team members (STM) were surveyed prior to the implementation of the Alpha pagers, and then again following the 5-month integration period. The data was collected and entered into an excel spreadsheet both at baseline and five months after the implementation of the alpha-numeric pager system. Statistical analysis was performed using the SPSS statistical package (Versions 20.0, SPSS, Chicago, Illinois). Paired t-test was used to compare the mean before and after employment of alphanumeric pagers. Results: An analysis of pre-intervention data was compared with post intervention data with regard to several factors including: number of pages and interruptions per day, overall communication efficacy and general quality of life. Preintervention, pages received per day averaged 12.23 pages for existing order renewals and 4.23 pages post-intervention, which was a decrease of 65.41% (p = .063). An average of 16.46 new non-emergent pages were received per day pre and an average of 8.62 post, a decrease of 62.58% (p = .076) The number of interruptions was assessed by STM on a scale of 5 being very often and 1 being never. Pre-intervention STM members ranked frequency of interruptions at an average of 3.23 per day while post-intervention was scaled at 2.38, a decrease of 26.19% (p = .699). Lastly, an overall improvement was observed in interdepartmental communication when STM were asked to rank the quality of communication on a scale of 10 being excellent and 1 being poor. Pre-intervention, STM rated communication efficacy at 6.15, however post-intervention STM recorded communication to be 7.39, an improvement of 20.00%. Using the same scale, the general quality of life according to the STM improved 18.18% (p = .308). Conclusion: The data obtained from this study indicates that overall alphanumeric pagers provide an efficient method of communication having reduced the number of pages, increasing the quality of communication and improving the general quality of life. To reach definitive conclusions regarding pager interruption, surveys should be redistributed, with detailed questions, following a longer integration period. Limitations of the study include small setting, short integration period and subjective surveys. Though there were limitations, the results acquired show that alphanumeric pagers have improved communication overall.

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P101

P103

Novel Device for Targeting Tumors in Laparoscopic Radiofrequency Ablation: a Learning Curve Study

Prospective Validation of Robotic Surgery Simulator for General Surgeons

William J Brown, MS1, Maria A Cassera, BS2, Zeljka Jutric, MD2, Paul D Hansen, MD2, Chet W Hammill, MD, MS, MCR2, 1Meharry Medical College, 2Providence Cancer Center

Beatriz Martin-Perez, MD, Sergio Larach, MD, Paula Veldhius, Lawna Hunter, BA, Pablo Arnoletti, MD, Matthew Albert, MD, Steve Eubanks, MD, Sebastian De la Fuente, MD, Florida Hospital

Introduction: Precise needle placement within the liver is essential during hepatic ablation procedures. Tumor targeting is typically performed under ultrasound guidance, however, this can be challenging. A novel 3-D guidance system, has been developed to aid in accurate needle placement during ablation. Methods: Five novices and five experienced hepatobiliary surgeons were recruited for participation. Using an agar block with a strategically placed analog tumor, participants targeted the tumor under four controlled conditions: in-line with the ultrasound plane (0 degrees off-axis) using ultrasound alone, in-line with the ultrasound plane using 3-D guidance, off-axis to the ultrasound plane (45 degrees off-axis) using ultrasound alone, and off-axis to the ultrasound plane using 3-D guidance. Time to target the tumor, the number of withdrawals required to accurately target the center of the tumor, and the National Aeronautics and Space Administration Task Load Index (NASA-TLX) were collected. The NASA-TLX is an established tool for measurement of mental workload. Initial and final parameters for each of the four conditions were compared using a within-subjects paired t-test. Results: Results for mean time to target tumor, mean number of withdrawals, and mean NASA-TLX score are reported in Table 1. A significant reduction was seen in the number of required withdrawals in all situations when using the 3-D guidance. Mental workload was similar initially, but was significantly lower using 3-D guidance after proficiency was achieved. The only difference in targeting time was in the initial trials when approaching the target from 45 degrees off-axis. Conclusion: Although 3-D guidance did not reduce targeting time substantially, it did reduce the number of required withdrawals, potentially decreasing complications and decreased mental workload after proficiency was achieved.

Background: Several studies have shown that short-phase training on virtual simulators improves technical performance in minimally invasive surgery, allowing trainees to gain experience before embarking on clinical responsibilities. However, the utility of robotic simulators for surgeons seeking robotic surgery proficiency is less clear. The Mimic dV-Trainer (MdVT) is a virtual reality robotic surgery simulator based upon the daVinci surgical system. The purpose of this study was to prospectively validate the MdVT system for general surgeons. Methods: IRB approval was obtained at Florida Hospital Orlando. Surgeons at different stages in their careers and medical students were recruited to participate in this prospective study. Consented subjects were divided in two groups based upon their previous robotic experience: Group 1-No previous experience (NE); Group 2-Previous experience (E). Participants were asked to perform two rounds of 4 exercises each. Demographic data and performing scores were recorded. Score values were based on a 100 point scale. P values \ 0.05 were considered statistically significant. Results: A total of twenty (n=20) subjects were recruited; 13 in the NE group and 7 in the E group. Experience in the E group ranged from 1 to 125 prior robotic cases. Eighty percent of the participants were males, and 80% were righthanded. The NE group was comprised of 8 medical students, 2 residents, 1 fellow and 2 attending surgeons while the E group included 4 attendings and 3 fellows. Fifty percent of the E group played video-games on a regular basis while only 38% of the NE group did. The NE group showed significantly worse baseline performance scores compared to the E group in camera targeting (29 vs 65, p = 0.005) and energy dissection (39 vs 56, p = 0.028). Differences in the scores between groups were still noted on the second round for peg board (66 vs 80, p = 0.04) and energy dissection (42 vs 60, p = 0.04). During the second round of exercises, significant improvements were noted in the NE group in peg transfer (53 vs 66, p = 0.012), camera targeting (29 vs 48, p = 0.029), and thread (39 vs 48, p = 0.028). Improvements in accuracy were noted in the E group only for peg transfer exercise (63 vs 80, p = 0.015), although most exercises were done more rapidly in the E group during the second round. Conclusions: Repetition of exercises in a robotic simulator allowed both experienced and non-experienced operators to improve proficiency. Validation of a dedicated curriculum in robotic surgery using simulators has the potential to improve performance for surgeons interested in acquiring robotic skills.

In Line (0 degrees off-axis)

First Trial

p-value

Last Trial

p-value

117.4

0.234

93.5

0.412

Mean Time(seconds): Ultrasound Guidance 3-D Guidance

71.2

55.8

Mean Number of Withdrawals: Ultrasound Guidance 3-D Guidance

4.6

0.003

1.1

4.1

0.009

0.1

Mean Mental Workload Score: Ultrasound Guidance 3-D Guidance Out of Line (45 degrees off-axis)

48.7

0.213

42.7

47.3

0.017

24.3

First Trial

p-value

Last Trial

p-value

82.5

0.031

129.2

0.158

Mean Time(seconds): Ultrasound Guidance 3-D Guidance

31.2

17.8

Mean Number of Withdrawals: Ultrasound Guidance 3-D Guidance

2.2

0.003

0.6

5.9

0.009

0.1

Mean Mental Workload Score: Ultrasound Guidance 3-D Guidance

48.6 34.5

0.054

49.3

0.0002

20.4

P102 Comparison of Operative Times in a New Surgical Residency with and Without Laparoscopic Simulator Training Asha Bale, MD, Lindsay Hallas, DO, Joshua R Klein, DO, Palisades Medical Center Objective: Hospitals starting new surgical residency programs must accept higher operative times to support teaching in the operating room. Simulation labs are increasingly used by many training programs in order to improve resident laparoscopy skills. This study was done to determine the effect of resident participation on operative time for laparoscopic cholecystectomy and laparoscopic appendectomy, and examine if the availability of a laparoscopic simulation lab would improve resident operative time. Methods: A new surgical residency program was started at Palisades Medical Center in 2012. We collected information on laparoscopic cholecystectomy and laparoscopic appendectomy performed from 2011- 2014 from the hospital operating room database. Operative time was recorded for three groups: July 2011- June 2012 when operations were performed by attending surgeons only (AS), July 2012- June 2013 when residents scrubbed with attendings (AR) and July 2013- June 2014, when simulation lab was introduced (ARS). Patient age, sex, ASA score and diagnosis were recorded. Data was analyzed using ANOVA. Results: In groups AS, AR and ARS there were 113, 155 and 161 laparoscopic cholecystectomies and 69, 63 and 81 laparoscopic appendectomies performed respectively. Operative time was significantly shorter in AS when compared to AR and ARS for both laparoscopic cholecystectomy (47 v 62 v 61 mins, p \ .01) and for laparoscopic appendectomy (30 v 44 v 40 mins, p \ .01). AR and ARS had similar operative time for both procedures. For laparoscopic cholecystectomy, operative time increased with increasing ASA score in all three groups. In all groups there was no significant difference in average age or sex. Conclusion: Resident participation increases operative time for laparoscopic cholecystectomy and laparoscopic appendectomy in teaching hospitals. Increasing patient ASA score is associated with higher operative time. A simulation lab with no structured educational program does not appear to be sufficient in improving laparoscopic skills. This study suggests that implementation of a more formal curriculum in the laparoscopy simulation lab with attending supervision is necessary to improve skills learning in trainees.

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Surg Endosc

P104

P106

Long-term Knowledge Retention Following Simulation-Based Training for Electrosurgery: 1 Year Follow-up of a RandomizedControlled Trial

Taxonomy of Instructions Given to Residents in Laparoscopic Cholecystectomy

1

1

Amin Madani, MD , Yusuke Watanabe, MD , Melina C Vassiliou, MD1, Pascal Fuchshuber, MD2, Daniel B Jones, MD3, Steven D Schwaitzberg, MD4, Gerald M Fried, MD1, Liane S Feldman, MD1, 1 McGill University, 2Kaiser Medical Center, 3Beth Israel Deaconess Medical Center, 4Cambridge Health Alliance Introduction: Simulation can add significant educational value to surgical curricula. A single institution study suggested that adding a goal-directed hands-on simulation to SAGES’ Fundamental Use of Surgical EnergyTM (FUSE) program improves surgical trainees’ knowledge of electrosurgery (ES) up to 3 months after training. However, it is unclear if this improvement persists long-term. The purpose of this study was to estimate the extent to which adding a goal-directed benchtop simulation to the FUSE curriculum improves knowledge of the safe use of ES amongst surgical trainees 1 year later. Methods and Procedures: As previously reported, surgical residents participated in a 1-hour didactic ES course, based on the FUSE curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediate, 3 months and at 1 year) knowledge of the safe use of ES was assessed using a 35-item multiple-choice examinations. Data are expressed as % (N) and median [25th percentile; 75th percentile]. Results: 56 (29 control; 27 Sim) surgical trainees participated. Drop-out rates were 26% (20) in the Sim group and 30% (20) in the control group (p = 0.45) at 1 year. After an initial improvement of total score on the exam immediately after the curriculum (Figure 1), knowledge performance declined progressively in both groups, but remained higher in the Sim Group at 1 year (70% [61;74] vs 60% [31;71], p = 0.02). Compared to baseline, total score after 1 year was significantly greater in the Sim group (70% [61;74] vs 49% [43;57], p \ 0.01), but similar in the control group (60% [31;71] vs 45% [34;52], p = 0.25). At 1 year, the majority of participants (88% (35)) either ‘‘Agree’’ or ‘‘Strongly Agree’’ that the curriculum has changed their attitude and practices when using energy-based devices over the past 12 months, with a trend towards a higher proportion in the Sim group ‘‘Strongly’’ agreeing compared to the control group (30% (6) vs 10% (2), p = 0.11). Conclusion: A 2-hour FUSE-based curriculum improves surgical trainees’ long-term knowledge in the safe use of ES devices only when combined with a structured and interactive bench-top simulation. However, even with the use of simulation, retention of knowledge eventually declines after a single session despite ongoing clinical use of ES devices. This suggests the need for ongoing and deliberate educational activities to reinforce the safe use of surgical energy.

Yuanyuan Feng, MS1, Christopher Wong, MS1, Helena Mentis, PhD1, Adrian Park, MD2, 1University of Maryland, Baltimore County, 2 Anne Arundel Medical Center Introduction: Laparoscopic simulation-based training has been focused on surgical skills training. The purpose of this study was to identify and categorize the explicit directional instructions made by attending surgeons to their residents in the OR in order to make recommendations for further simulation systems design. We hypothesize that OR-based laparoscopic surgery training is focused more on instructing residents in how to use the laparoscope and view the laparoscopic video. Methods and Procedures: This study is based on video recordings of ten laparoscopic cholecystectomies. The cases included three different attending surgeons and three different PGY4 residents in different combinations of the two groups. These videos displayed both the external audio/video showing the interaction between the attending and the resident as well as the internal video captured by the laparoscopic recorder. The data analysis was focused on identifying and comparing explicit instructions given by attending surgeons to their assisting resident. Results: Of the total 2269 instructions given in the ten cases observed, the guidance in the OR is categorized into two categories – the instrument-control guidance (42.04%) and the gaze guidance (57.96%). In the instrument-control guidance, attending surgeons provided instructions to residents on how to move surgical instruments, how to handle the instruments, and where to apply the instruments. In the gaze guidance, attending surgeons illustrated the exact points that residents should look on the laparoscopic video, sometimes using gestures pointing on the screen and often releasing their own instruments to point to the display. The result of Wilcoxon signed-rank test on the frequencies of instructions normalized by the duration of each case shows that the frequency of gaze guidance is significantly higher than that of the instrument-control guidance (p = 0.005), with a large effect size (r = 0.61) (Figure 1). Conclusions: Our results present two major categories of instructions in OR-based laparoscopic training. These findings indicate that the focus of laparoscopic simulation training should include gaze guidance as well as skills guidance. Our findings could also suggest that novel approaches be designed to support gaze guidance by the attending in the OR. Finally, further steps can be taken to examine the physical and cognitive challenges for attending surgeons to show the residents what to see and the cognitive challenges for the residents in adopting the expert medical gaze during surgery.

Fig. 1

Boxplots of two categories of instructions

Fig. 1 Total score (%) on the multiple-choice examination during pre-curriculum (PRE), immediate post-curriculum (POST), 3 months follow-up and 1 year follow-up periods

P105

P107

Sages Mini Med School: Inspiring High School Students Through Early Exposure to the Field of Surgery

Development of the Surgical Assistance Score (SAS)

James C Rosser, MD, FACS1, Charles Jacobs, BS2, Raymond Price, MD, FACS3, 1Advanced Laparoscopic Surgeons; UCF College of Medicine, 2UCF College of Medicine, 3Intermountain Health Care Objective: The SAGES Mini Med School (MMS) was designed to expose high school students to the field of surgery through mentoring, knowledge exchange and hands-on experience through simulation. This abstract profiles the description, performance metrics and satisfaction queries of this innovative effort. Methods: 74 high school students, grades 9–12, were subjected to the SAGES Mini Med School program. The program consists of four components. There is an emotive introduction session followed by a visit to the exhibits in the SAGES learning center. A skills laboratory and an interactive finals competition are conducted and students who perform with distinction are recognized. The student’s surgical skills session consists of exercises associated with the development of open and laparoscopic surgical skills. The lab includes a warm up with the validated Super Monkey Ball video game 26, Pea Drop exercise 13, Peg Transfer drill 27, open knot tying station, and open instrument tie station. Participants’ performance data is collected. In addition, pre and post surveys track satisfaction results. Results: The results of the surgical skills lab were as follows. For the Super Monkey Ball task, 58 students attempted the drill with an average score of 26.2 (SD=31.6; Range=0–120; Median=15). Fifty-eight students attempted the Surgeon’s Knot and Pea Drop exercises with average times of 18 seconds (SD=40.3; Range=4–287; Median=9) and 55.2 seconds (SD=23.6; Range=22–173; Median=47.5) respectively. The Instrument Tie and Peg Pass stations had 56 students with average times of 25.8 (SD=9.3; Range=13–72; Median=24) and 216.9 seconds (SD=90.0; Range=56–446; Median=220) respectively. The results from the satisfaction surveys were overwhelmingly positive. Sixty-six (93%) agreed that the Mini Med School made them more likely to consider a career in medicine with 3 students rating ‘‘neutral’’ and only 2 disagreeing. When asked if the program made them more likely to consider a career in surgery, 63 (89%) agreed with 6 rating ‘‘neutral’’ and 2 disagreeing. All 71 respondents (100%) said that they would recommend the program to others. Conclusion: In 2020, there will be a shortage of 85,000 physicians in the US. Early recruitment of future physicians is critical if we are to address this issue successfully. The SAGES Mini Med School was highly successful in promoting the consideration of medicine as a career and in particular the field of surgery. The results also showed that high school students can engage in surgical skills training very early in their academic careers. This could have an effect on both recruitment and accelerated skill acquisition. It is imperative that we continue to assess the impact of the Mini Med School Program with long-term studies to reveal whether the influence persists over time and results in students entering medical careers.

123

Susannah M Wyles, MD, PhD1, Edward Kim, MD1, Eric Haas2, Nabil Tariq3, Bidhan B Das4, Michael Snyder4, Brian J Dunkin3, 1UCSF, 2 Colorectal Surgical Associates, 3Houston Methodist Hospital, 4 Colon and Rectal Clinic of Houston Introduction: It is widely acknowledged that prior to being a good surgeon it is necessary to learn the skills of surgical assistance, and that the degree of difficulty of an operation can be largely dependent on the ability of the assistant. The aim of this study was to determine the necessary assistance skills and to develop an assessment tool that could be used to map trainees’ progress, and also to guide feedback on their performance. Methods and Procedures: A survey regarding operative assistance was distributed electronically to the surgical department at a large US teaching institution. Free text boxed allowed for open suggestions of desirable qualities in a surgical assistant. These items were collated, and using the Delphi process, lists were sent to expert laparoscopic and general surgeons from multiple institutions. The perceived importance of each item was ranked using a 5-point Likert scale. Items scoring less than 3 were removed. Repeat lists were sent until consensus was reached. Results: 84 surveys were completed over a 4 week period (69% response rate), by a range of attendings and residents. 206 items were suggested as requirements for surgical assistance. On review by two researchers, these were reduced to 25 due to repetition or overlap of meaning. 5 experts rated the items, and reached consensus after 2 rounds of the Delphi process. After the first round, two new items were introduced, five items were summarized to one, one was reworded then accepted and one was rejected. A 22 item assessment form was then created. Requirements were grouped into ‘‘surgeon focused’’, ‘‘knowledge’’, ‘‘skills’’, ‘‘operative view’’, ‘‘safety’’ and ‘‘learning points’’. There was also a free text box at the end of the assessment for further comments. Conclusions: A novel tool has been developed to assess surgical assistance. The next steps would be to pilot the tool to assess its acceptability, feasibility and validity.

Surg Endosc

P108

P110

Education and Introduction of Laparoscopic Gastrectomy. The Importance of the First Assistant

Comparison of Correlations of Two Console Based Video Games with Validated MIS Partial Tasks and Intracorporeal Suturing

Ryohei Watanabe, MD, PhD, Yoichi Nakamura, Sayaka Nagao, Kazuhiro Takabayashi, Toshiyuki Enomoto, Koji Asai, Manabu Watanabe, Yoshihisa Saida, Shinya Kusachi, Jiro Nagao, Toho University Ohashi Medical center, Department of Surgery

James Jr. C Rosser, MD, FACS1, Xinwei Liu, BS2, 1Celebration Hospital, 2University of Central Florida, College of Medicine

We started laparoscopy-assisted gastrectomy (LAG) for gastric cancer in 2012. As a result of improved educational method during the 3 periods (period: 1. 2. 3), operation time was significantly reduced. We report our educational method for LAG. (Methods) Operator of the every cases was qualified surgeon of japan society for endoscopic surgery. First assistant doctor was secured during 3 period. Period 1: 5 cases of first introduction. Operator educates assistant doctor during operation. Period 2: 12 cases. After creation a surgical procedure manual of LAG for scrub nurse, teach it for scrub nurse. Period 3: 10 cases. After creation a surgical procedure manual for doctor, and teach it to assistant doctor. I let the preparation and review to assistant doctor using surgical procedure manual and video. (Results) 27 cases, Male 15:Female 12, mean BMI 23 (18–29), LADG 26 cases, LATG 1 case, lymph node dissection: D1+8a, 9, 11p, vagus nerve preservation rates: hepatic branch 100%, hepatic and celiac branch 88.9%, postoperative length of stay: mean 9 days (7–21). Period 1: operation time 356 minutes, amount of bleeding 4 ml. Period 2: operation time 324 minutes, amount of bleeding 16 ml. Period 3: operation time 287 minutes, amount of bleeding 14 ml. We also count the time of operator’s procedure and the time of 1st assistant doctor’s procedure. The time of 1st assistant doctor’s procedure is decreased significantly, although the time of operator’s procedure is almost same during 3 periods. (Conclusion) Result in the improvement of education for the surgical nurse, assistant doctors, operation time was reduced stepwise significantly during 3 periods.

Objective: High costs, lack of realism, and poor participant utilization are inherent shortcomings in simulators used for laparoscopic skill training. The use of video games, which can offer engaging and entertaining properties, could change the way surgeons and surgical residents learn and perform. Underground, a video game for the Nintendo Wii U video game console was designed to simulate laparoscopic tasks through innovative controllers that simulate laparoscopic graspers. This abstract profiles the comparison of correlations between previously validated Super Monkey Ball and recently introduced Underground video game to multiple validated tasks used for developing basic and advanced laparoscopic skills. Methods: Sixty-eight participants, 53 residents and 15 attendings (49 men and 19 women) with a mean age of 35 years and a mean experience of 3 years (SD=3.0) and an average of 444 cases (SD=942) performed both Super Monkey Ball and Underground exercises. In Super Monkey Ball, the player used a small thumb joystick to tilt through various levels as the monkey in a ball rolls around a tilting tract. In the game Underground, players used the Wii console and modified Wii Remotes (designed to simulate laparoscopic graspers) to move two robotic arms to manipulate the environment. The other tasks evaluated included FLS Peg Pass, Pea Drop Drill, and intracorporeal suturing. Results: Spearman’s Rank correlations were conducted looking at performance scores of Super Monkey Ball, and Underground video games compared to three validated laparoscopic training exercises. The Super Monkey Ball score had a moderate correlation to intracorporeal suturing (rho = 0.39, p \ 0.01), and the final score involving all three tasks, (rho = 0.39, p \ 0.01), but low correlations to Pea Drop Drill and FLS Peg Transfer (rho = 0.11, 0.18, p \ 0.01). The Underground score had very little correlation with intracorporeal suturing and final score (rho = 0.09, 0.13, p \ 0.01). However, there were correlations between Underground score and Pea Drop Drill, and FLS Peg Transfer (rho = 0.24, 0.27, p \ 0.01, respectively). All data were analyzed using Statistical Package for the Social Sciences (SPSS) and correlations with a value of p \ 0.01 were considered significant. Conclusion: Simulation has been proven to be very helpful in minimally invasive surgical training but accessibility and lack of participant interest have proven to be a hindrance. Super Monkey Ball (SMB) and now Underground (U) offer two validated video game titles that have correlation to laparoscopic skill development and may address both challenges. In this study, SMB had a very significant correlation with the clinical task of intracorporeal suturing. Underground demonstrated more of a correlation with basic skill partial tasks. It is unclear from this study as to the cause of this finding. At this point, our conclusion would be that both are effective for laparoscopic skill training, and they should be used in tandem rather than alone.

P109

P111

Simulation of Single Port Endoscopic Surgery: Comparative Study of Two- with Three-Dimensional Video System

Development of a Formative Feedback Tool for Advanced Laparoscopic Suturing

Kook Nam Han, MD, PhD, Hyun Koo Kim, MD, PhD, Hyun Joo Lee, RN, Young Ho Choi, MD, PhD, Korea University Guro Hospital, Korean University College of Medicine

Katherine M McKendy, MD1, Yusuke Watanabe, MD1, Elif Bilgic2, Ghada Enani, MBBS2, Mo Yu Lanny Li2, Talla Raja2, Munshi Amani, MD1, Rajesh Aggarwal, MBBS, MA, PhD1, Liane S Feldman, MD1, Gerald M Fried, MD1, Melina C Vassiliou, MD, MEd1, 1McGill University Health Centre, 2McGill University

Introduction: Usual video systems for endoscopic surgery provide the surgeon a two-dimensional image (2D). This study aimed to evaluate performances of a three-dimensional (3D) video system compared with 2D system on the simulation for single-port surgery training. Methods and Procedures: We conducted a simulation program for single port endoscopic surgery using 2D and 3D high definition system. The program included three basic surgical tasks; 1) ring transfer, 2) needle passing through 3-mm hole, 3) suturing through tailor-made skin suturing plate, through 3-cm single port training module (Fig. 1). We evaluated the time to completion and success or failure within limited time in each tasks. Results: 19 trainee who had not experienced endoscopic or robotic surgery, performed three simulation tasks under 2D and 3D system respectively. 18 participants (94.7%) in task 1 and 2, 14 (73.7%) in task 3, showed improved performance and spent less time to complete the tasks using 3D system (Fig. 2). On post-surveillances, trainee indicated that the advantages of 3D system compared to 2D was easier depth perception of structures (n=11, 57.9%), improved handling of instruments (n=8, 42.1%). All participants were not disturbed by wearing glasses for 3D vision or had not felt severe eye discomfort during the simulation. Conclusions: Three-dimensional video system showed improved procedural time and better performance compared to two-dimensional system during simulation for single port endoscopic surgery. It should facillitate the single port surgery to enable more complex procedures and could help to expand the users interested in single port surgery.***

Fig. 1 A simulation of single port endoscopic surgery using three dimensional video system. A Simulation setting, B task 1, 2, 3

Fig. 2 Comparison of time to completion: 2D versus 3d video system

Introduction: Commonly used metrics to assess performance of simulated laparoscopic skills in a box trainer focus on time and accuracy. These measures, however, do not provide meaningful information to trainees about how to improve their skills. The aim of this mixed methods study was to develop a tool that could be used to provide residents with specific, formative feedback about their laparoscopic suturing skills. Methods and Procedures: We videotaped senior surgical residents (PGY3–5) and MIS-trained surgeons performing 3 advanced laparoscopic suturing tasks: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). After completing the tasks, the surgeons were asked to comment on the key technical aspects that were important for the completion of each task, and to provide feedback on the videotaped performance of a novice completing the tasks. Interviews were performed until saturation was reached. They were then transcribed, and common themes regarding advanced suturing skills and decision-making were extracted to generate a feedback rubric for each of the tasks. The feedback tool (FT) was then used to assess the videotaped performances of residents and MIS-trained surgeons by two blinded independent raters. A two-way random effects model was used to calculate the single-rater intra-class correlation coefficient (ICC), expressed as: ICC (95% confidence interval). The correlation between the combined score for time and accuracy and the FT score was calculated for each of the tasks. Median and interquartile ranges (IQR) are expressed as: Medians[IQR], p-value. Results: Seven MIS surgeons were interviewed. From these interviews, a feedback rubric was generated for each of the tasks; NH consisted of 10 items, UT 18, and CS 20. Each item was classified according to one of 7 key principles that emerged from the interview data: depth perception, safety, bimanual dexterity, exposure, tissue handling, instrument manipulation, and forward planning. Performance was graded on a 3-point Likert scale (‘‘does well’’, ‘‘needs some improvement’’, an ‘‘does poorly’’) and scores were calculated as an equally weighted sum of the points. The FT was then used to assess the video performance of residents and experts on all of the tasks: 16 resident and 11 expert videos were assessed for NH, 12 residents and 11 experts for UT, and 16 resident and 11 expert for CS. ICCs for NH, UT, and CS were 0.90 (0.79–0.95), 0.87 (0.73–0.95) and 0.90 (0.76–0.95) respectively. Scores were found to correlate strongly with combined time and accuracy measurements for UT (0.82, p \ 0.01) and CS (0.81, p \ 0.01), and moderately for NH (0.65, p \ 0.01). MIS surgeons also performed significantly better than senior residents on UT (experts: 29.5[26.5–33] vs. novices: 23.75[19.6–29.1], p = 0.02) and CS (experts: 34.5[30–36.5] vs. novices 26[21.4–29], p = 0.05), while scores on NH were similar (experts: 13.5[11–15.5] vs. novices 12.8[9.5–15.5], p = 0.57). Conclusions: We developed a specific, comprehensive tool for providing feedback about advanced laparoscopic suturing skills. The FT demonstrates evidence for validity as a measure of suturing skills and experience, and also provides meaningful guidance to trainees about how to improve their skills and engage in more deliberate and efficient practice.

123

Surg Endosc

P112

P113

Validating Novel Portable Three-Dimensional Models Based on Mistels for Training And Evaluation of Laparoscopic Skills. Are They Good Enough to Prepare Surgeons for 2D and 3D Based Laparoscopic Surgery?

Canadian Participation in Sages Resident Courses is Associated with Higher Rate of Society Membership

Alpa J Morawala, MBBS, MSc1, Walid S Elbakbak, MBBCh, MSc, MRCS1, Badriya Alaraimi, MD, MSc, MRCS2, Bijendra Patel, FRCS2, 1Queen Mary University of London, Bart Cancer Institute, 2 Royal London Hospital Introduction: This study is commenced to establish validity of newly developed 3D models using (MISTELS) criteria for objective assessments and training of laparoscopic skills in 3D, and to compare proficiency criteria with 2D. Materials and Methods: Laparoscopic experts involved in designing 3D models. Models were built to use inside a training box. Total 21 subjects [10 novices, 7 intermediates, 4 experts] followed the training flow comprises of three sets of repetitions of an improved FLS tasks (Peg transfers, Ligating Endoloop, Intracorporeal suture, Pattern-cutting) and an additional new task (Creating Zig-zag loop). Novices initiated study with 3D followed by 2D, whereas other two groups started with 2D then 3D. Total scores and total errors were measured. Total score calculated by subtracting penalty score from performance time. Lower score reflects better performance. Student’s t test used to compare the data (mean value of total score) of each group. Results: Longer performance time with higher errors (Table 2) noticed in novices and intermediates in both visions. Fewer errors (Table 2) and less time observed in experts. Each group performed significantly better in 3D. In addition, a group started the study in 3D showed an improvement when asked to perform in 2D. Statistically significant differences (Table 1) found between skilled (Expert) and non-skilled group (Novices/ Intermediates). Using Likert scale (1–5); candidates rated models (face validity); 3.3 in 2D and 4.3 in 3D (better depth perception). Conclusions: We have effectively established the construct validity of novel models for both visual modalities. Hence, models can be successfully used for simulation training in both visual modalities. 3D vision allows remarkable improvement in performance and error rates compared to the 2D vision. Importantly, advanced laparoscopic skills learned with 3D models allow transferrable skills from 3D to 2D. , , , , ,

Table 1

P value for Total score

Expert Vs. Intermediate

Expert Vs. Novice

2D

0.02

0.00

3D

0.08

0.00

Expert Vs. Intermediate

Expert Vs. Novice

2D

0.04

0.03

3D

0.18

0.39

Nava Aslani, MD, MHSc, FRCSC, Nawar A Alkhamesi, MD, PhD, FRCS, FRCSEd, FRCSC, Christopher M Schlachta, MD, CSTAR/ London Health Sciences Centre, Department of Surgery, Western University, LONDON, CANADA Introduction: Our goal was to determine whether participation in the Canadian resident courses endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) would be associated with eventual membership in SAGES. Methods: Information on Canadian SAGES resident course attendance was obtained from course registration records and cross-referenced with the SAGES membership office. The number of trainees who were eligible to take any of the Canadian SAEGS resident courses offered between 2008 and 2014 was calculated from publicly available data from the Canadian Resident Matching Service (CaRMS). Descriptive statistics and Chi Square test were used for comparisons where appropriate. Results: Between the years of 2008 and 2013, eight Basic and six Advanced Canadian SAGES resident courses on endoscopic surgery were offered. There were a total of 217 course participants, with 20 individuals taking more than one course. Seventeen individuals who took a Basic course went on to take an Advanced course afterwards. In total, 925 Canadian residency trainees were eligible to take a Canadian SAGES course, 195 (21%) of whom joined SAGES as Candidate members. There was a significantly higher rate of SAGES membership amongst Canadian residents who attended a SAGES course as compared to those who did not (38.7% vs. 16.3%, p \ 0.001). Seventy-seven individuals who took a SAGES course joined the society either immediately before (11) or after (66) the course. The rate of membership was not different for those taking multiple courses. Percentage of attendees who became members after the course did not differ between Advanced (32.4%) and Basic (33.1%) course participants despite the fact that membership in SAGES is a non-enforced pre-requisite for enrollment in an Advanced course. A further 14 (7%) of course attendees expressed interest in joining SAGES but did not complete the application process, a slightly higher percentage than the 4% who expressed interest among non-attendees (p = 0.116). All except one member joined SAGES as Candidate members and 73 upgraded their membership to an Active membership once they were eligible. Amongst the members in the Active category 32.9% were previous SAGES course attendees. Conclusion: Participation in Canadian SAGES resident courses is associated with a higher rate of SAGES membership by attendees. Membership rates do not appear to be influenced by course level.

P value for total error

P114 ‘‘See One, Do One, Teach One’’: Inadequacies of Current Methods to Train Surgeons in Hernia Repair Table 2

Adrian Park, MD1, Hamid R Zahiri, DO1, Carla Pugh, MD2, Melina Vassiliou, MD3, Guy R Voeller, MD4

Total Error Mean value (task 1–5)

GROUPS

Total errors (mean) 2D

Total errors (mean) 3D

NOVICES

2.2

1.9

INTERMEDIATES

1.9

0.7

EXPERTS

1.1

0.5

123

1

Anne Arundel Medical Center, 2University of Wisconsin, 3McGill University, 4University of Tennessee Introduction: In an effort to improve the quality of hernia care and patient outcomes, SAGES is developing an educational program for surgeons. Training in hernia repair is still too widely characterized by the ‘‘see one, do one, teach one’’ model. The most efficient and effective educational programs are based on an assessment of learner needs and current training gaps. The goal of this study was to perform a needs assessment focused on surgical training to guide the creation of a curriculum intended to improve the care of hernia patients. Methods: This mixed methods study conducted by the SAGES Hernia Task Force (HTF) incorporated the use of selected interviews in addition to an online survey. Subjects were asked about their perceived deficits in resident training to care for hernia patients, preferred training topics about hernias, ideal learning modalities and education development. Results: 18 HTF members, 27 chief residents and fellows, and 31 surgical residents were interviewed. Among the HTF members, there was consensus that residency exposes trainees to a wide spectrum of hernia repairs by a variety of surgeons. They cited outdated materials, techniques and paucity of feedback as barriers to effective hernia education. Additionally, they identified the ‘‘see one, do one, teach one’’ method of training as prevalent and clearly inadequate. The topics least addressed were system-based approach to hernia care (46%) and patient outcomes (62%). Residents considered preoperative and intraoperative decision-making (90%), complications (94%) and technical approach for repairs (98%) to be well taught during training. Instructional methods used in residency include assisted/supervised surgery (96%), web-based learning (24%), and simulation (30%). Residents’ preferred learning methods included simulation (82%), web based training (61%), hands on laboratory (54%) and videos (47%), in addition to supervised surgery. Trainees reported their most desired training topics as basic techniques for inguinal and ventral hernia repairs (41%) vs. 68% who wanted advanced technical training. These numbers mirror those reported by attending surgeons, 36% and 71%, respectively. Conclusions: Consensus exists among HTF members and surgical trainees regarding the lack of standardization in training and care, inadequate patient follow-up and poor outcome measures for hernia repair. A comprehensive, dynamic and flexible educational program using a variety of instructional methods to address key deficits in the care of hernia patients would be welcomed by surgeons.

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P117

Evaluation and Impressions of a Smartphone Camera Setup for the Laparoscopic Box Trainer

The Impact of a National Laparoscopic Skills Competition on Use Of Surgical Simulators

Ibrahim I Jabbour, MD, MPH, Shohan Shetty, MD, Michael Russo, MD, UT Southwestern Medical Center, Dallas, TX

Greig L McCreery, MD, BESc1, Christopher M Schlachta, MD2, 1 London Health Sciences Centre; Western University, 2Canadian Surgical Technologies and Advanced Robotics (CSTAR); London HSC; Western University

Introduction: Simulation training can shorten learning curves, improve technical skills, and expedite competency. Studies have shown skills learned in the simulated environment are transferable to the operating room. Residency programs are incorporating simulation into the resident curriculum to supplement the hands-on experience gained in the operating room. One of the most widely used simulation tools is the laparoscopic box trainer (LBT). Trainees use them to practice several skills including the Fundamentals of Laparoscopic Surgery (FLS) tasks. The Ethicon TASKit trainer is one such portable LBT meant for use by trainees at home or while on a rotation where a simulation laboratory is unavailable. Portable box trainers however are expensive and not available to all residency programs. One of the more expensive and cumbersome components of the LBT setup is the installation of the web camera with its computer software. The objective of this study was to develop and evaluate a smartphone camera setup instead of the conventional web camera for the LBT. We utilized a smartphone with either a wired or wireless connection to a monitor rather than the conventional setup. The purpose of this study was to explore resident perceptions and preferences regarding options for LBT camera setup. Methods and Procedures: In all, 52 medical students and surgical residents with various degrees of laparoscopic experience participated in this study. Participants were instructed on setting up the LBT using the included web camera and software, and the wired and wireless (smartphone to home streaming device) configurations of the smartphone camera. Both conventional and smartphone setups utilized the same computer monitor. Participants completed a validated FLS task (peg transfer) utilizing each setup, then completed a Likert scale online questionnaire assessing comfort, effectiveness, ease of setup, practicality, image quality, and camera functionality. Statistical analysis was done using a paired t-test. Results: Thirty-seven novices and fifteen surgical residents volunteered to participate. All 52 participants owned a smartphone. Eighty-seven (86.5%) percent of participants believe training at home will improve their laparoscopic skills and 90.4% said they would practice at home if able. All survey parameters including comfort (3.65 vs. 4.33; p\ 0.05), effectiveness (3.65 vs. 4.31; p \ 0.05), ease of setup (3.50 vs. 4.60; p \ 0.05), practicality (3.52 vs. 4.60; p \ 0.05), image quality (3.15 vs. 4.48; p \ 0.05), and camera functionality (3.25 vs. 4.31; p \ 0.05) were in favor of the smartphone over the conventional setup. 90.4% of participants preferred the smartphone setup whereas only 5.7% preferred the conventional web camera setup. In comparison of the wired and wireless smartphone setups, 59.6% preferred wireless, 17.3% preferred wired, and the remaining 23.1% were undecided. Conclusions: Both laparoscopic novices and surgical residents prefer the smartphone camera setup over the web camera for configuration of a portable LBT. A low-cost, easy-to-use portable LBT that uses a smartphone and monitor, which most learners already have at home, may be superior to conventional methods and lead to wider utilization among participants. Furthermore, the LBT without the web camera may be more affordable for residency programs.

Introduction: Dedicated practice using laparoscopic simulators has been shown to improve intra-operative performance. Yet, voluntary utilization is minimal. An annual national laparoscopic suturing competition has been held in Canada since 2009, employing the concept of ‘‘serious games’’ to enhance residents’ use of simulation. We hypothesize that competition amongst peers with the opportunity to compete at the national level positively influences residents’ reported use of laparoscopic skills simulations. Methods: A web-based survey was distributed via email to assess the relationship between current Canadian General Surgery residents’ reported use of laparoscopic simulation and participation in skills competition. Secondary outcomes included assessing attitudes regarding simulation training, factors limiting use of simulation, and associations between competition level and reported simulator usage. Comparator groups were analyzed using statistical tests of distribution (chi-square, Fishers exact test) and correlation (Pearson’s, Spearman’s) using SPSS. Results: One hundred ninety (23%) of an estimated 826 potential participants responded. 59% were male. PGY 1 through PGY5 training levels were well represented, ranging from 15% of responses from PGY5 trainees to 25% of PGY3’s. PGY6 residents made up only 2.6% of responses. 60% reported performing less than fifty laparoscopic surgeries as the primary operator, and 83% rated their laparoscopic abilities as novice or intermediate. 79% agreed or strongly agreed that use of simulation practice improves intra-operative performance; 71% that it is an efficient use of time; and 72% that simulation should be a mandatory component of training. The most common factors limiting use of simulation training were lack of time (90%), and lack of after-hours access (33%). Lack of interest was cited by 15% of respondents. 58% reported employing simulator practice less than once per month, and 18% reported never using a simulator. Reported duration of simulator use in the prior 6 months was less than one hour for 37%, up to 5 hours for 28% and up to ten hours for 20%. 73.2% had participated in some form of laparoscopic skills competition. Of those, only 51% agreed or strongly agreed that the opportunity to compete was motivation to utilize skills trainers (45% of all respondents). No association was found between those with competition experience and frequency (more or less than once per month, p = 1.0) or duration (more or less than 5 hours, p = 0.169) of simulator use. However, 83% of those who had competed at the national level reported greater than 5 hours of simulator use in the previous 6 months compared to those with no competition experience (26%), local competition (40%) and local national-qualifying competition (23%) (p \ 0.001). Similar results were found with respect to frequency of simulation practice. Conclusions: This study does not support the hypothesis that the opportunity for skills competition increases voluntary use of simulation-based training amongst all residents. Indeed, only that minority of individuals competing at the national level demonstrated significantly higher simulation use. Despite low reported use, attitudes towards simulation training were generally positive. Lack of time and access were the most commonly cited factors limiting simulator use.

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Knowledge Transfer and Translation: Empowering Weight Loss Surgery Patients with Website and Social Media

Increasing Compliance with the Who Surgical Safety Checklist – a Regional Health System’s Experience

Diana Lawlor, MN, RN, NP, James Ellsmere, MD, MSc, FRCSC, FACS, Maureen Tilley, PDt, BScAHN, Capital Health

Matthew E Gitelis, BS, Adelaide Kaczynski, BS, Torin Shear, MD, Mark Deshur, MD, Annalyn Chiu, Mohammad I Beig, BBA, Meredith Sefa, Jonathan Silverstein, MD, Michael B Ujiki, MD, orthShore University HealthSystem

Despite Nova Scotia having the second highest prevalence of Type 2 DM and Obesity in Canada, funding to support more than 1800 patients on a wait list for weight loss surgery at any given time falls short. The Capital Health Weight Loss Surgery team which consists of one surgeon, one endocrinologist, one nurse practitioner (part time 0.7 FTE), one dieititan (part time 0.3 FTE), one psychologist (part time 0.1 FTE), one physiotherapist (part time 0.1 FTE) and 1 booking clerk (0.1 FTE) has worked to create an informative website to assist patients to prepare for weight loss surgery. They have also supported post surgery weight loss surgery patients to create a Facebook support group for pre and post surgery patients at Capital Health. Supportive information is posted on the CDHA Obesity Network pertaining to the qualifications for surgery, the surgical procedure, preparing for surgery and post surgery expectations. It also incorporates useful tips and education on making lifestyle changes mostly related to physical activity and nutrition. Patients are directed to go to this website, print off the information, assemble it in a binder and study it prior to meeting the team at the first clinic titled ’’What Is Weight Loss Surgery’’. Among this information is a pre clinic quiz and in-depth health assessment to complete. The aim is to assist in gaining insight and knowledge regarding program information discussed at this first clinic meeting, to fully consider their health and reflect on their personal decision and goals in making lifestyle changes and pursuing surgery. This also encourages patients to have an opportunity to communicate and obtain support from their practitioners and other healthcare professionals in their community prior to their one-on-one meeting with the weight loss surgery team. Patients communicate feeling prepared for what to expect and recognize the website as a key tool to enhance knowledge with team supported documents/articles. Healthcare professionals can refer to the website for information on the referral process and surgical qualifications, as well as, gain knowledge of the weight loss surgery program in order to best support their patients. The FaceBook group is run by team selected leaders of patients who have progressed well in weight loss surgery. The group is specific to Capital Health patients such that to be involved in the group participants must be Capital Health Weight Loss Surgery Patients. Patients communicate appreciating this peer-to-peer support network at all stages of their weight loss surgery journey. This poster will focus on the Capital Health website components/ information supplied and communication process/connection to the FaceBook support group. We feel it is a cost effective, efficient means of assisting patients to access key knowledge and support while empowering them to be active in accessing information and connections to support them in their weight loss surgery journey.

Background: In 2009, NorthShore University HealthSystem adapted the World Health Organization (WHO) Surgical Safety Checklist (SSC) at each of its four hospitals. Despite evidence that SSC reduces intraoperative mistakes and increases patient safety, compliance was found to be low with the paper form. In fiscal year (FY) 2013, NorthShore integrated the SSC into the electronic medical record (EMR). The aim was to increase communication between operating room (OR) personnel and to encourage best practices during the natural workflow of surgeons, anesthesiologists, and nurses. The purpose of this study was to examine the impact of an electronic SSC on compliance and patient safety. Methods: An anonymous OR observer selected cases at random and evaluated the compliance rate prior to the rollout of the electronic SSC. At the end of FY 2014, an electronic audit was performed to assess the compliance rate from data residing in the EMR. Random OR observations were also performed throughout FY 2014. Perioperative risk events, such as consent issues, incorrect counts, wrong site, and wrong procedure were compared before and after the electronic SSC rollout. A perceptions survey was also administered to NorthShore OR personnel. Results: Compliance increased from 48% (n=167) to 94% (n=1015; p \ 0.001) after the SSC was integrated into the EMR. Surgeons (91% vs. 99%; p \ 0.001), anesthesiologists (89% vs. 100%; p \ 0.001), and nurses (55% vs. 95%; p \0.001) demonstrated an increase in compliance. A comparison between risk events in FY 2013 and FY 2014 showed a 32% decrease (p \ 0.01). Hospital wide indicators including length of stay and 30 day readmissions were trending lower. In a survey to assess the OR personnel’s perceptions, 76% of surgeons, 86% of anesthesiologists, and 88% of nurses believed the electronic SSC will have a positive impact on patient safety. Conclusion: The WHO SSC is a validated tool to increase patient safety and reduce intraoperative complications. The electronic SSC has demonstrated an increased compliance rate, a reduced number of risk events, and most OR personnel believe it will have a positive impact on patient safety.

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Does 3D Vision Make a Difference in Laparoscopic Skills Acquisition? A Randomized Controlled Trial

Demonstrated Proficiency in Fundamentals of Laparoscopic Surgery Skills may Require Fewer Repetitions

Jirong Lu, MBBS, MRCS, Jesse Hu, MBBS, FRCS, Wee Boon Tan, MBBS, FRCS, Davide Lomanto, MD, PhD, FAMS, National University Hospital, Singapore

Albert Y Huang, MD, Victor Wilcox, MD, Brian Dunkin, Houston Methodist

Introduction: The recent advancements of three-dimensional (3D) laparoscopic systems have led to studies showing improved performance in simulated laparoscopic tasks. However, little has been done to see if 3D laparoscopic systems help improve the training of novices. This study aims to investigate if training using 3D laparoscopic systems can enhance the acquisition of laparoscopic skills in simulated tasks in novices. Methods and Procedures: A three-arm prospective randomized trial was performed to compare the effect of training utilizing a 3D camera against a conventional two-dimensional (2D) camera on pre and post training test scores. 47 laparoscopy-naı¨ve medical students were tested on 3 validated tasks (ring transfer, precision cutting and intracorporeal suturing) from the Fundamentals of Laparoscopic Surgery (FLS) task set. A total score aggregated time taken with an added time penalty for failure to complete the task and for precision errors. Testing and training were performed using the same modality in two of the arms (either in 3D or 2D). Participants in the third arm were tested in 2D but completed the training in 3D (2D/3D). Results: Across all three arms, training significantly improved test scores in all three tasks (p \ 0.001). Analysis of variance showed a significant difference between the arms for post-training test score (p = 0.007) and percentage improvement (p \ 0.001) in the precision cutting task only. Post hoc analysis with Bonferroni correction showed the superiority of the 3D arm over the others (3D [ 2D [ 2D/3D). This trend was also seen in the other 2 tasks but did not reach statistical significance (Table 1). Conclusion: 3D laparoscopy improved acquisition of skills in simulated laparoscopic tasks in novices in one of the three tasks. However, differing modalities during testing and training may lead to poorer improvement among novices. This should be taken in consideration when 3D laparoscopy systems are employed in surgical education in novices.

Table 1

Comparison of training scores and percentage improvement in scores between 3D. 2D and 2D/3D

arms Arms

3D

2D

2D/3D

p*

Ring Transfer Pre-training Test (s)

230.1 ± 67.5

252.0 ± 65.6

259.3 ± 70.3

0.457

Post-training Test (s)

126.7 ± 28.8

148.2 ± 42.7

157.3 ± 35.1

0.057

42.0 ± 16.9

39.1 ± 16.9

37.4 ± 12.6

0.709

Pre-training Test (s)

298.4 ± 49.1

309.5 ± 53.7

273.1 ± 59.6

0.169

Post-training Test (s)

149.9 ± 48.4*

203.0 ± 46.0*

197.1 ± 51.1

0.007

49.8 ± 15.8*

33.7 ± 14.1*

26.1 ± 17.4

\0.001

Percentage Improvement (%) Precision Cutting

Percentage Improvement (%) Intracoporeal Suturing Pre-training Test (s)

676.1 ± 80.1

697.3 ± 47.6

654.4 ± 108.5

0.364

Post-training Test (s)

448.8 ± 132.1

493.1 ± 173.4

458.8 ± 186.4

0.740

32.6 ± 22.4

29.9 ± 22.8

28.9 ± 28.3

0.910

Percentage Improvement (%)



Introduction: We demonstrate that once achieving proficiency threshold in two consecutive attempts, surgery trainees practicing intracorporeal suturing in a FLS training box are able to reliably maintain adequate proficiency scores. The current methodology for laparoscopic skills training is to have trainees reach a level of proficiency in large part based on a goal time frame in which to complete the target task. Following the UT Southwestern FLS training protocol, to successfully complete a task a trainee must do it within the goal time frame two times consecutively. This must be followed by 10 successful repetitions (nonconsecutive) for reinforcement (‘‘2 + 10’’). This is the standard sign-off for residents in general surgery as they practice for FLS certification. Through our single-institution study, we show that once residents are able to achieve two consecutive proficiency scores, they are able to maintain that level of skill with few if any non-proficient scores on the following repetitions. Methods and Procedures: 13 PGY 1 and 2 residents were voluntarily enrolled in the study and given the task of training to proficiency in intracorporeal suturing using the standardized FLS training box. The residents had little to no laparoscopic experience prior to the initiation of the study and so were truly learning as they performed the task. Using the UT Southwestern FLS training protocol, the goal for each resident was to achieve a proficiency score of 112 seconds or less on two consecutive repetitions and then on 10 subsequent attempts (non-consecutive) to be considered proficient and to complete the task. Anonymized demographic data such as laparoscopic experience and PGY level were collected on each participant. The time (in seconds) for each task attempt were recorded by a proctor. Results: Of the 13 trainees tested, 8 reached and maintained proficiency after achieving two consecutive successful attempts. 2 participants did not achieve proficiency during the study, 1 stopped after having two consecutive attempts below the goal time of 112 seconds and 2 did not complete the study. 4 of the 8 trainees that reached proficiency according to the UT Southwestern protocol continued to maintain scores of 112 seconds or less 90 % of the time with 3 of those residents maintaining proficiency level 100 % of the time. The remaining 4 trainees were able to maintain that score for 71–85 % of the time. Prior to completing two consecutive attempts below 112 seconds, the 4 trainees with the proficiency percentages in the 71–85 % range after the two consecutive attempts below the goal time, two participants achieve a single time below 112 seconds. There was a significant increase in successful repetitions from the moment the two successful consecutive attempts were made. Conclusions: Our observation shows that trainees consistently and reliably maintain adequate proficiency levels following achieving two consecutive proficient scores. We propose that trainees must demonstrate proof of proficiency retention through maintenance of proficient scores on another occasion separate from the day of reaching the consecutive proficient scores.

P121 A Systematic Review of Validation Methods for Virtual Reality Simulators Ali N Bahsoun1, Michael Mahgerefteh2, Alice Lee2, Jean Nehme3, Andre Chow3, 1King’s College London, 2Imperial College London, 3 Touch Surgery

One-way ANOVA with Bonferroni correction (* p\0.05 between 3D and 2D. p \0.05 between 3D and 2D/3D Objective: To provide a structured overview on validation methods for surgical simulators as a basis for developing a unified validation process that can be used to establish evidence based training. Background: In the current literature there are various methods used to assess the validity of surgical simulators. At present, validation is left to the authors’ discretion, as there is no standardised path that can be used by researchers as a framework for investigating the validity of simulators. Methods: The authors performed a systematic literature review on PubMed to identify articles in the past 10 years that sought to validate a surgical simulator. Results: A total of 84 articles were identified with 136 validation attempts and 2908 participants. The articles included 69 construct validation studies, 35 face validations, 22 content validations, and nine concurrent validation studies. Only one paper attempted predictive validation. Content of the papers showed little consistency between studies in several areas, including definitions of validation types, categorization of expertise levels, determination of appropriate participant numbers and even statistical tests used. Conclusions: There is little consensus what on validation methods and even definitions between authors. There is also no guidance or recommendations from policy makers. A clear process needs to be set up for investigating surgical simulators prior to curricular integration.

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Videotape Review Program to Enhance Resident Training in Laparoscopic Inguinal Hernia Repairs

A Multicenter Needs Assessment for Improvements in MIS and Flexible Endoscopy Training for Surgery Residents

Ryota Tanaka, MD, PhD, Yalini Vigneswaran, MD, John Linn, MD, JoAnn Carbray, BA, Woody Denham, MD, Stephen Haggerty, Michael Ujiki, MD, Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University HealthSystem

Aimee K Gardner, PhD1, Ross E Willis, PhD2, Brian J Dunkin, MD3, Kent R Van Sickle, MD2, Kimberly M Brown, MD4, Michael S Truitt, MD5, John M Uecker, MD6, Lonnie Gentry7, Daniel J Scott, MD1, 1University of Texas Southwestern Medical Center, 2University of Texas Health Sciences Center San Antonio, 3Houston Methodist Hospital, 4University of Texas Medical Branch, 5Dallas Methodist Hospital, 6University of Texas Medical Center at Austin, 7Baylor University Medical Center at Dallas

Introduction: The purpose of this study was to determine if a standardized video review program for residents can improve clinical operative performance scores. Methods: Participation was voluntarily offered to surgical residents at all levels of training rotating on the minimally invasive service at our institution. Surgical residents were randomized to either the video review group or no video review group. Every participant in the video review group underwent video reviews with a coach for thirty minutes once a week during their one-month rotation. Throughout the month a blinded trained observer evaluated the performance of all participants in the operating room using validated assessment tools, the Global Operative Assessment of Laparoscopic Skills-Groin Hernia (GOALS-GH) and visual analogue scale (VAS). The amount of time that the resident spent as chief surgeon was recorded for each case. Participants were additionally surveyed with confidence of the skills questionnaires at the beginning and the end of the month. One-way analysis of variance was used to compare scores between the video and the no video review groups. Within each group GOALS-GH and VAS scores were also compared between scores during the first 10 days of the month and those during the last 10 days of the month. Differences were considered statistically significant for p values less than 0.05. Results: A total of 10 residents were randomized to the video review group (n = 5) or the no video review group (n = 5). We observed significantly higher GOALS-GH scores at the end of the month in the video review group as compared to the no video review group (Fig. 1; p = 0.01). All participants in the video group had improvement of scores at the end of the month with statistically significant improvement in one of the five items, hernia sac identification and reduction (p = 0.03). The video review group demonstrated significant improvement in VAS at the end of the month (p = 0.01) whereas the no video review group showed a decline in VAS. The video review group had a significant increase in both the fraction of time the residents spent as chief surgeon (p = 0.002) and in confidence questionnaire scores (p = 0.04). Conclusion: Video review with a coach proved to be beneficial for residents when learning laparoscopic inguinal hernia repairs as demonstrated on GOALS-GH, VAS and self-reports of acquired skills. We conclude systematic video review is a good supplemental tool in the resident surgical training curriculum.

Fig. 1

Background: Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of Minimally Invasive Surgery (MIS) and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing these procedures. The purpose of this study was to determine resident and faculty perceptions regarding training and competency in MIS and flexible endoscopy with the goal of identifying training needs and to solicit input on curriculum design. Methods: Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery & gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol. Results: Ninety-five faculty (14.9 ± 12.8 years in practice, 100 % perform MIS, 68 % perform flexible endoscopy) and 121 residents (26 PGY1, 27 PGY2, 21 PGY3, 26 PGY4, 21 PGY5) responded, with response rates of 65 % and 51 %, respectively. Faculty reported that the quality of incoming interns was no different than 10 years ago, but the quality of graduating residents was slightly worse. Faculty indicated the importance (scale 1–5, 5 very important) for graduates to be competent in basic (4.7 ± 1.0) and advanced (4.1 ± 1.0) MIS and diagnostic (4.1 ± 1.2) and therapeutic (3.0 ± 1.2) endoscopy. Residents and faculty reported increasing autonomy as PGY level increased but that autonomy was limited for advanced MIS and therapeutic endoscopy, with PGY5s performing less than 60 % of these procedures. PGY5s and faculty rated trainee ability to perform 34 different procedures independently at graduation. PGY5s and faculty reported this level of competency as 89 % and 86 % for basic MIS, 21 % and 14 % for advanced MIS (26 % and 16 % for 8 most common operations), 83 % and 63 % for diagnostic endoscopy, and 27 % and 21 % for therapeutic endoscopy, respectively. PGY5s indicated that they would need a fellowship to be comfortable offering basic MIS (5 % said yes), advanced MIS (52 %), diagnostic endoscopy (5 %), and therapeutic endoscopy (62 %). Residents reported that clinical experience, didactic lectures, and SCORE modules were the most common curricular components for MIS, whereas clinical experience, virtual reality simulators, and physical models were more common for endoscopy. The ideal MIS curriculum as designed by faculty would include the following: clinical experience (48 % of time), physical simulators (12 %), live animal models (12 %), virtual reality simulators (8 %), videos (9 %), other (11 %). For endoscopy, components would include clinical experience (52 %), virtual reality simulators (15 %), physical simulators (10 %), live animal models (9 %), videos (7 %), and other (7 %). The ideal curriculum sculpted by residents followed these same trends, but with more time dedicated to clinical experience. Conclusions: These data indicate that both residents and faculty perceive significant competency gaps for both MIS and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. The development of improved training methods in these areas is encouraged.

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P125

Stylized Laparoscopic Anterior Resection in Our Hospital – For Surgical Residents to Easily Understand

Goal Setting Program in Surgical Training Curriculum to Improve Laparoscopic Skills

Takeshi Yanagita, Makio Mike, Hirotaka Honjo, Nobuyasu Kano, Hiroshi Kusanagi, Kameda Medical Center

Ryota Tanaka, MD, PhD, Yalini Vigneswaran, MD, Francis DeAsis, BS, BA, JoAnn Carbray, BA, Alexandre Derevianko, MD, Michael Ujiki, MD, Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University HealthSystem

Introduction: Endoscopic surgery has been widely accepted in various surgical fields, and an increasing number of colorectal surgeries are being performed mainly by the laparoscopic technique. It is true that, in some situations, surgical procedures can be performed by laparoscopic techniques more easily and efficiently than by those of open surgery because of excellent visualization and identification of anatomic structure. But it is very confusing for the surgical residents, because they must learn laparoscopic procedures, as well as open procedures. It is very important for the educators to make these procedures easy to understand by stylizing. In our hospital, laparoscopic surgery including laparoscopic low anterior resection (LAR) has been stylized so that unexperienced surgical residents can understand anatomical membrane structures from the viewpoint of education. Methods: Five ports of the same size are created at the same site, regardless of the location of tumors. The infraumbilical site (12-mm) is used as a camera port. A 12-mm trocar is placed at the right lower quadrant, and another 12-mm trocar is placed at the right abdomen, superior to the level of the umbilicus. Two 12-mm ports are created at the left side and at the left lower quadrant, which are symmetrical with the right ones. When an operator does not have much experience, initially, he/she carries out lateral-to-medial mobilization to get used to manipulating a grasper and a dissector. Once familiarized, the operator begins with medial-to-lateral mobilization. In almost all cases, the inferior mesenteric artery was transected after the left colic artery branched. A first assistant retracts the rectum upward, keeping traction, and the dissection of rectum is continued into the pelvis along with the fascia propria of the rectum, preserving the hypogastric nerves and pelvic plexus as far as possible. Posterior dissection of the rectum always precedes anterior dissection. Then, on the anterior portion, dissection is carried out behind the Denonvilliers’ fascia. While the first assistant retracts the rectum cranially, the operator identifies and dissects the limit of lateral ligament and mesorectum. The operator identifies and enters the loose layer between the longitudinal muscle of the rectum and mesorectum, and cut the mesorectum. The rectum is then transected with a linear stapler. The specimen is pulled out through the extended left lower quadrant port site. End-to-end double-stapling technique anastomosis is carried. The Mann-Whitney U test was used to compare perioperative factors (age, sex, BMI, ASA-PS, TNM stage, tumor size, location, operative duration, blood loss, open conversion, complication, and hospital stay) between surgical residents and senior surgeons. Result: Sixty-six patients underwent laparoscopic LAR by twelve surgical residents under the supervision of the experienced surgeon. Operative durations were significantly different (P = 0.04), comparing surgical residents with senior surgeons, but other perioperative factors were not significantly different. Conclusion: Usage of peculiar techniques of laparoscopic procedure can make LAR easier and more efficient. However, the stylized setting of the ports and the similar operative field and procedure to open surgery can help surgical residents understand clearly and perform safely both laparoscopic and open procedures.

Introduction: The purpose of this study was to determine whether a goal setting program integrated into a surgical training curriculum would improve performance on Fundamentals of Laparoscopic Surgery (FLS) testing and confidence with laparoscopic surgical skills. Methods: Beginning in 2013, medical students and general surgery residents at all levels of training were enrolled in the study and evaluated on the five FLS tasks at our center. Trainees were randomized to one of the following three goal-setting groups. Trainees were either given no time goals for each FLS task (No Goals), time goals that were the best time scores reported in the literature for each task (Expert) or the mean time scores reported for passing each task seen in the literature (Mean). All trainees were evaluated with the FLS score sheet, a confidence survey and time scores for each task both prior to and after the assignment. The associations of categorical variables in demographic data were analyzed using one-way analysis of variance. Scores were compared between groups using t-test. The differences were considered to be statistically significant if the p value was less than 0.05. Results: A total of 23 medical students and 21 residents were enrolled in the study. Matched for level of training, we observed on average higher FLS score improvement for the Mean group (27.1 points) than the Expert (25.1 points) and No Goals (22.8 points) groups. Confidence survey scores improved more in the Expert group than the Mean and No Goals groups. For time scores, no participants achieved the expert time goals on evaluations before or after the program. Overall we noted time score improvements were higher for the Mean group than the Expert or the No Goals group on three of the five tasks (peg transfer, pattern cutting and intracorporeal suturing) (Table 1). Adjusted for level of training, time score improvements for pattern cutting were statistically greater for the Mean group than No Goals group (p = 0.02). However time score improvements for extracorporeal suture task were statistically greater for the Expert group compared to the Mean group (p = 0.02). We additionally observed that when excluding residents, the students in the Mean group demonstrated statistically higher time scores than the Expert group for intracorporeal suturing (p = 0.04). Conclusion: Trainees given an achievable goal, as we saw with the Mean group, will achieve higher improvement in total standardized FLS scores as well as time scores in the several tasks as compared to trainees given expert goals or no goals. Although not statistically higher for all tasks, there was a clear trend towards higher scores for the Mean group. Thus we conclude that trainees should be given achievable goals to enhance success in mastering specific surgical skills, especially during simulation.

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P128

Face Validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST(TM))

Efficiency, Learning Curve and Skill Transfer in Robotic vs. Laparoscopic Simulation Training: A Randomized Controlled Trial Between Medical Students and Surgical Residents

Kurt Roberts, MD, FACS1, Denis Dorozhkin, PhD2, Woojin Ahn, PhD2, Tansel Halic, PhD3, Ganesh Sankaranarayanan, PhD2, Suvranu De, ScD2, 1Yale School of Medicine, 2Rensselaer Polytechnic Institute, 3University of Central Arkansas Introduction: Virtual Translumenal Endoscopic Surgical Trainer (VTESTTM) is the first virtual reality simulator for the Natural Orifice Translumenal Endoscopic Surgery (NOTES). VTESTTM was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the simulator was face validated at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. A subsequent evaluation study to assess the face validity of the latest VTESTTM version was performed. Methods and Procedures: A total of twelve subjects with varying NOTES experience (6 experts and 6 novices) participated in this Institutional Review Board (IRB) approved study. The study took place at the 2014 NOSCAR summit. The subjects were asked to perform the hybrid transvaginal NOTES cholecystectomy procedure on VTESTTM. The subjects were then asked to answer a 5-point Likert scale feedback questionnaire consisting of fifteen questions: (1) realism of the anatomy, (2) realism in identification of the Calot’s triangle, (3) simulator interface realism, (4) rigid scope navigation realism, (5) instrument handling realism, (6) overall realism of the blunt dissection task, (7) overall realism of the gallbladder removal task, (8) overall realism compared to the traditional laparoscopic tasks, (9) force feedback quality, (10) usefulness of the force feedback in performing the tasks (11) usefulness in learning hand-eye coordination (12) usefulness in learning ambidexterity skills, (13) overall usefulness in learning the fundamental NOTES skills (14) trustworthiness of the simulator in quantifying accurate measures of performance (15) trustworthiness of the simulator in providing different hand-eye coordination compared to traditional two-port laparoscopic approach. Results: Overall subjects rated 9 of the questions above 3 or greater (60 %), including the realism of the anatomical features, interface and the tasks (Table 1). However, the results also show that further improvements are needed in blunt dissection and the force feedback quality. The corresponding functionality was newly developed for the 2014 NOSCAR summit, so a certain level of criticism was expected. These points are being addressed in the next iteration of the simulator. Conclusions: The face validity of the latest version of the virtual reality NOTES simulator VTESTTM was successfully established on many aspects of the simulation. Further refinements are currently taking place in order to improve the VTESTTM simulator based on the face validation feedback.

Table 1

Sahil Gambhir, BMSc, Caroline Moon, BS, Rama Gupta, BS, Pam Haan, RN, BSN, Cheryl Anderson, RN, BSN, MSA, Alan Davis, PhD, Terry McLeod, RN, BSN, Deb Collier, RN, BSN, MA, Nashwa Khogali, DO, MSA, David Henry, MD, Derek Ornelas, MD, Srinivas Kavuturu, MD, Michigan State University Introduction: Our study objective is to evaluate efficiency, learning curve and transference of simulation skills among novice medical students and to compare with novice surgical residents. Methods and Procedures: Novice medical students (no previous laparoscopic or robotic experience) were randomized to one of two groups to assess peg transfer skills using the da Vinci robotic system and Fundamentals of Laparoscopic (FLS) Surgery trainer box. The sequence (robotic then laparoscopic or vice-versa) was crossed over to assess the transfer of skills. Each group performed 10 practice repetitions before testing in standard forward alignment. Novice surgical residents (no robotic experience) were tested in peg transfer tasks only using the da Vinci robotic system. Peg transfer was also tested in reverse alignment for all three groups. The criterion for learning was to accomplish the task in less than 90 seconds twice in a row, with no errors. Group test scores were compared using ANOVA and the unpaired t-test. Results:

Medical Students (n = 40) FLS Peg Transfer

Overall Test Scores (seconds) Learning Curve (sessions) Reverse Alignment Scores (seconds)

Robotic Peg Transfer

p-value

80.8 + 18.9

72.3 + 22.2

8.0 + 2.4

6.0 + 2.7

\0.001

148.9 + 49.7

\0.001

Medical Students

p-value

300.0 + 0.0

0.031

Descriptive statistics obtained from the questionnaire study

#

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Mean

3.3

3.4

3.6

3.5

2.8

2.3

3.3

2.9

2.5

2.7

3.2

3.0

3.3

2.9

3.6

SD

0.90

0.92

0.81

0.82

0.87

0.67

0.67

0.74

0.52

0.90

0.87

0.89

0.79

0.90

0.50

Medical Students vs. Residents (n = 10) Residents

P127

Forward test scores (seconds) Forward learning curve (sessions) Reverse test scores (seconds)

67.1 + 12.3

72.3 + 22.2

4.4 + 3.2

6.0 + 2.7

0.478 0.121

148.9 + 49.7

157.5 + 43.2

0.626

Validation of Visual-Spatial Secondary Task (VSST) to Assess Automaticity in Laparoscopic Skills Richard Castillo, MD1, Juan Alvarado, MD1, Cristo´bal Maiz, MD1, ˜ is Jarufe, MD1, Billeke Pablo, MD, PhD2, Andrea Vega, RN1, NicolA Camilo Boza, MD1, 1Escuela de Medicina, Pontificia Universidad Cato´lica de Chile, 2Universidad del Desarrollo de Chile Introduction: Our objective was to assess reliability and validity of a visual-spatial secondary task (VSST) as a method to measure automaticity on basic simulated laparoscopic skill model. In motor skill acquisition, expertise is defined by automaticity. The highest level of performance with less cognitive and attentional resources characterizes this stage, allowing experts to perform multiple tasks. Conventional validated parameters, as operative time, objective assessment skills scales (OSATS) and movement economy, are insufficient. There is literature about using a VSST as an attention indicator that correlates with the automaticity level. Methods: Novices with approved FLS (n = 11) and laparoscopy experts (n = 4) were enrolled for an experimental study and measured under dual tasks conditions. Each participant performed the test giving priority to the primary task while at the same time they responded to a VSST. The primary task consisted of four laparoscopic stitches (LS) on a bench-model. The VSST was a screen that showed different patters that the surgeon had to recognize and press a pedal while doing the stitches (PsychoPsy software, Python, MacOS). Novices were overtrained on LS until reach at least 100 repetitions and were retested. Participants were video recorded and then assessed by two blinded evaluators who measured operative time and OSATS. These scores were considered indicators of quality for the primary task. The VSST performance was measured by the detectability index (DI), which is a correlation between correct and wrong detections. A reliable evaluation was defined as two measures of DI with less than 10 % of difference, maintaining the performance on the primary task (operative time \ 110seg and OSATS [ 17points). Results: Novice achieved reliable measure of the test after 2 (2–5) repetitions on the pre-evaluation and 3.75 (2–5) on the post-evaluation (p = 0.04); while laparoscopy experts did it after 3.5 (3–4) repetitions. Proficiency scores of primary task (defined previously) were accomplished on every measure for novices (pre-post overtraining) and experts. Expert performance on VSST was DI 0.78 (0.69–0.87). Novice performance was significantly better on post-evaluation [DI-pre 0.48 (0.06–0.71) vs DI-post 0.78 (0.48–0.95), p = 0.003]. Overtraining consisted on 140 (100–210) repetitions of LS for all novices, made on 8 hours (3–15). By categorizing DI based on expert performance, novices with DI-post [ 0.65 achieve better OSATS score and less operative time than novices with DI-post \ 0.65 (p = 0.007 and p = 0.089, respectively) Conclusion: Measuring of automaticity is feasible by using a VSST. This instrument is reliable and has a face, content and construct validity. A detectability index over 0.65 may be a cut-off point correlated with high standard performance on the primary task. This instrument measured performance on laparoscopic skills, and along with conventional indicators, better define advance levels of expertise. More studies are required applying this VSST to achieve external validity by reproducing our results.

123

When assessing transfer of skill from laparoscopic to robotic or vice versa, there is no significant difference between the medical students and the residents (p = 0.368). Conclusions: Novice medical students performed significantly better on robotic peg transfer tasks (in forward and reverse alignment) when compared to tasks performed on the FLS trainer box. Among students completing peg transfer tasks, robotic participants had a significantly shorter learning curve than participants using the FLS trainer box. No significant difference was noted between residents and students on robotic peg transfer skills. Reverse alignment peg transfer was found to be significantly easier on robotics vs. FLS trainer box. We found no evidence of transference of skills between laparoscopic and robotics approaches.

Surg Endosc

P129

P131

The Feasibility and Safety of Laparoscopic Interval Appendectomy for Appendiceal Abscess

Utilizing Mini Laparoscopy for Cholecystectomy on the Acute Care Surgery Service

Atsushi Kohyama, MD1, Takeshi Naito2, Hirohumi Ichikawa1, Kazuaki Hatsugai1, Masato Ohara1, Shigeru Ottomo1, Izuru Minemura1, Daisuke Takeyama1, Akefumi Sato1, Kentaro Shima1, Yusuke Gokon1, Iwao Kaneda1, 1Department of Surgery, Ishinomaki Red Cross Hospital, 2Department of Surgery, Tohoku University Graduate School of

F A Morfesis, MD1, Brian P Rose, MS, MPH1, Dominic L Storto, DO1, Elizabeth Schob, BA2, 1Owen Drive Surgical Clinic of Fayetteville, 2University of North Carolina-Charlotte

Background: Although treatment for appendiceal abscess is primarily surgery, operative procedures are sometimes complicated and we often have great difficulties in dealing with postoperative complications. Recently clinical reports on interval appendectomy for appendiceal abscess are encountered, which comprises conservative therapy followed by elective appendectomy. Purpose: The purpose of this study is to evaluate the feasibility and safety of laparoscopic interval appendectomy for appendiceal abscess. Patients and Methods: Since April 2011 to September 2014, a total of 487 cases with appendicitis were operated in our institute. Among them, 16 patients with appendiceal abscess were treated with conservative treatment, followed by laparoscopic interval appendectomy. We retrospectively evaluated the feasibility and safety of this operation’s therapy. Results: Ten of the patients were male and 6 of them were female, and their ages ranged from 9 to 86 (47.3 on average). Conservative treatment was successful in 15 of the 16 patients (93.8 %) with a hospital stay of 9.4 days on average. Meropenem was administered to 11 patients. The other antibiotics were used as follows: tazobactam / piperacillin for 2 cases and cefmetazole for 2 other cases, levofloxacin for the remaining case. The conservative therapy failed in one case because recurrence of inflammation occurred prior to the operation. One patient required percutaneous abscess drainage under the ultrasonography guidance before the operation while other patietnts did not. The median interval period prior to surgery was 79 days. Of those 15 patients, 13 underwent elective laparoscopic interval appendectomy, and 2 underwent laparoscopic partial resection of the cecum. The median operation time was 138 minutes and mean estimated blood loss was 54 ml. The median postoperative hospital stay was 4 days. No complication occurred in any of the appendectomized patients. We used three ports for 15 of the patients, and we needed additional one port for traction in the remaining patient case. There were no conversions to open surgery. Conclusion: Nonsurgical treatment for appendiceal abscess is a safe and effective therapy and laparoscopic interval appendectomy can be performed safely.

Introduction: The use of mini laparoscopic instruments in cholecystectomy has been well described in the prior literature, however the role that it might play in acute care surgery settings remains uncertain. In this small pilot investigation, we examine the efficacy of a hybrid mini laparoscopic approach in patients presenting for management of acute cholecystitis in a community hospital setting. Methods: Three (3) 3 mm ports were utilized in the right upper quadrant and sub-xyphoid process respectively. A 5 mm camera port was also used. A retrospective analysis was done to examine post-operative outcome measures including pain, infection, narcotic use, length of stay, complication, and hospital readmission. Results: The average age of the cohort was 52.75 years (27–74) with an average body mass index (BMI) of 27.44 (22.70–36.30). Half of the sample (50 %) reported having prior, intra-abdominal surgery. There were no post-op infections 0 (0 %) and only 1 (6.25 %) ileus. There were 5 (31.25 %) patients that reported post-op pain requiring hydrocodone or oxycodone greater than 5 post operative days. There was 1 (6.25 %) readmission and 2 (12.50 %) complications. There was 1 (6.25 %) common bile duct leak and 1 (6.25 %) incisional hernia. The average length of stay in the hospital was 2.19 days (0–6). Conclusions: The use of the a hybrid technique for mini laparoscopic surgery can be applied in an acute care surgery setting with favorable outcomes. This technique must be further investigated to determine a specific role in the future.

P130

P132

Therapeutic Laparoscopy for Penetrating Anterior Abdominal Trauma; A Safe Addition to the Diagnostic and Treatment Algorithm

Rapid Growth in the Use of Secure Messaging in a Patient Portal by Surgical Providers

Salvatore Docimo, Jr., DO, MS, Alyssa Butt, BS, Vadim Meytes, Christopher Zambrano, Fausto Vinces, Michael Timoney, George Ferzli, Lutheran Medical Center Introduction: The algorithm for the management of penetrating anterior abdominal injury (PAAI) is not clearly defined. The definitive diagnostic and therapeutic modality in penetrating anterior abdominal injury (PAAI) is exploratory laparotomy (EL), but it carries a morbidity and mortality up to 20 % and 5 %. Previous studies have shown that 30–50 % of all stab wounds do not penetrate the peritoneum and the non-therapeutic laparotomy rate is as high as 70 %. In an effort to reduce the morbidity associated with negative exploratory laparotomy, we retrospectively studied the use of laparoscopy as both a diagnostic tool, as well as a means of providing definitive therapy for PAAI in a Level I Trauma Center where the trauma surgeons have a high level of laparoscopic training. We also sought to determine if previous laparoscopic fellowship training and a low injury severity score (ISS) was associated with the use of laparoscopy in the treatment of PAAI. Methods and Procedures: We performed a retrospective review of trauma cases that underwent a DL at a Level I trauma center from 2008 to 2014. Inclusion criteria included all trauma patients who underwent diagnostic laparoscopy following PAAI. Exclusion criteria included: trauma patients above the below the age of 12, Glasgow Coma Scale (GSC) \ 8, and hemodynamic instability. We divided our study group into patients who underwent: DL only, DL with conversion to EL (DL/EL), and DL with subsequent therapeutic laparoscopy (DL/TL). Endpoint outcomes were: missed injury, post-operative complications, length of stay (LOS), and avoidance of negative laparotomies. Results: Thirty patients with PAAI were included and underwent initial DL. Patients had an average: age of 30, BMI of 25.75, injury severity score (ISS) of 6.24 and, GCS of 15. FAST exam was performed in 18 (60 %) patients with four (13.3 %) having positive findings. No positive FAST exams were noted in DL group; 3 positive FAST exams were noted in the DL/TL group; and 1 positive FAST in the DL/EL group. The ISS of the DL, DL/TL, and DL/EL groups were 8.5, 11, and 12.28 (p = 0.204; 95 % CI). Nine (30 %) cases required no intervention and remained DL. Fourteen (47 %) cases underwent laparoscopic therapeutic intervention (hematoma evacuation, and visceral, mesentery, diaphgragm, or abdominal wall repair). Seven (23 %) cases underwent conversion to EL. Average LOS for the DL, DL/TL, and DL/EL groups were 3.78, 2.5, and 6.28 days (p = 0.044; 95 % CI). Post-operative complications included one ileus in a DL case. No missed injuries in the DL or DL/TL groups were noted. Conclusion: Therapeutic laparoscopy should be considered as an addition to the algorithm of management of PAAI. A trauma surgeon with advanced laparoscopic training may utilize laparoscopy, as both, a diagnostic and therapeutic modality for a subset of stable patients with PAAI. The difference in ISS for each group was not statistically significant and did not play a role in determining laparoscopic versus open therapies. In our study, laparoscopy in PAAI significantly decreased the incidence of negative laparotomy, avoided the complications associated with EL, and significantly decreased the hospital LOS.

Gretchen P Jackson, MD, PhD, Sharon E Davis, MS, Jared E Shenson, Qingxia Chen, PhD, Robert M Cronin, MD, Vanderbilt University Background: Adoption of secure patient-provider messaging through online patient portals has increased substantially in recent years due to Affordable Care Act incentives and consumer demand. Secure messaging is an evolving form of outpatient interaction through which clinical care is delivered; it can enhance communication, increase patient satisfaction, and improve outcomes, but may also increase physician workload. Most research about secure messaging and patient portals has been conducted in primary care and medical specialties, and little is known about their use by surgeons. Methods: We characterized the adoption of secure messaging through a patient portal by surgical providers and measured the growth of secure messaging as a form of outpatient interaction across surgical specialties. We specifically studied messaging use because this portal function can be attributed to a specific specialty, and its use across specialties can be adjusted by the volume of traditional outpatient encounters (i.e., clinic visits). We determined the number of surgical clinic visits and patient-initiated secure messages sent to surgical specialties in the first three years (2008 to 2010) after deployment of a patient portal in adult and pediatric specialties at an academic medical center. We calculated the proportion of all outpatient interactions (i.e., clinic visits or secure message threads) done through secure messaging over time and used logistic regression models to compare the likelihood of message-based versus clinic outpatient interaction across surgical specialties. Results: Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 portal messages: 12,070 in 2008; 31,404 in 2009; and 40,438 in 2010. A large number of unique portal users (n = 19,605) and surgical providers (n = 412) participated in these message exchanges. Surgical specialties receiving the most messages were otolaryngology (16,877; 20.1 %), orthopedics (14,278; 17.0 %), urology (9,075; 10.8 %), and general surgery (8,082; 9.6 %), while vascular surgery (680; 0.8 %), pediatric surgery (179; 0.2 %), and burn surgery (5; \0.1 %) received the fewest. The proportion of outpatient interaction conducted through secure messaging increased significantly from 5.4 % in 2008 to 12.5 % in 2009 and 15.1 % in 2010 (p \ 0.001). The proportion of surgical outpatient interaction done through secure messaging increased for all specialties and was highest for heart and lung transplantation (75.1 %); kidney, pancreas and liver transplantation (69.5 %); and general surgery (48.7 %) in 2010. Heart and lung transplantation experienced the most rapid growth in the proportion of outpatient interaction through secure messaging, followed by general surgery which experienced faster growth than all other specialties (p \ 0.01). Conclusions: This study demonstrates rapid adoption of secure messaging by a spectrum of surgical providers as well as significant growth in the use of secure messaging for outpatient interaction. In only three years after widespread portal deployment, the volume of secure messaging exceeded face-to-face clinic encounters for some surgical specialties. As patient portal adoption increases, surgeons can expect to participate in growing numbers of online interactions, especially in specialties with long-term follow up, such as transplantation. Additional research is needed to understand the types of care delivered through patient portals and to develop models for reimbursement of online care.

123

Surg Endosc

P133

P134

Laparoscopic Small Bowel Resection for Adult Ileoileal Intussusception Secondary to Inflammatory Fibroid Polyp

Which Symptoms are Significant for the Patients of a Suspected Acute Appendicitis with Right Lower Quadrant Pain?

Chebrolu Gowthami, Dr. Pari Muthukumar, Dr. Jayanth Leo, Dr. Vishwanath M Pai, Sri Ramachandra University

Ali Kagan Coskun, MD1, Oner Mentes, MD1, Rahman Senocak, MD1, Sahin Kaymak, MD1, Subutay Peker, MD1, Yasemin Yavuz2, Ali Harlak, MD1, Orhan Kozak, MD1, 1GATA, 2Ankara University

Adult Intussusception is a very rare condition accounting for 1 % of all adult bowel obstruction and 5 % of all cases of intussusception. Adult Intussusception is almost always due to a demonstrable underlying pathology primarily caused by tumors. 80 % of the tumors associated with small bowel intussusception are benign. Inflammatory fibroid polyps are rare, benign, polypoidal lesions originating in the submucosa of the gastrointestinal tract most commonly seen in the stomach. They seldom are found to be lead point lesions for cases of intussusception. We report an unusual case of Adult Ileoileal Intussusception secondary to an Inflammatory Fibroid Polyp. A 34 year old female presented to the emergency department with chief complaints of acute abdominal pain associated with vomiting for a duration of 10 days and constipation for the last 2 days. She had no known comorbidities and gave no history of previous abdominal surgeries. At presentation, she was tachycardiac with upper abdominal distension, diffuse abdominal tenderness and hyperactive bowel sounds. All her baseline investigations were normal. Xray abdomen showed multiple air fluid level. CECT abdomen revealed an ileoileal intussusception in the proximal ileum. Over diagnostic laparoscopy, ileoileal intussusception was confirmed following which a laparoscopic resection and anastomosis of small bowel intussusception was performed. The specimen was sent for histopathological study and immunohistochemistry was done where the features favoured the aetiology of intussusception to be an inflammatory fibroid polyp. This case report highlights the fact that intussusception is an extremely rare cause of adult intestinal obstruction and inflammatory fibroid polyp is one of the least common causes of the same. Given the risks of underlying malignancy and vascular compromise, once adult intussusception is diagnosed, the treatment is operative resection.

Any delay or incorrect management of acute appendicitis could cause an increase for morbidity and mortality with an elevation of healthcare costs. Therefore in order to diagnose acute appendicitis correctly at early stage, contribution of the improved scoring system is important. This study aimed to investigate the reliability of different scores of acute appendicitis for local population and to evaluate the most significant symptoms of patients with right lower quadrant pain. Methods: Two hundred and two patients suspected of acute appendicitis aged 18–69 were included in this retrospective study. The patients data for calculating the scores of Ohmann, Lintula, Alvarado and Eskelinen were taken from hospital records and surgeons notes. The most significant symptoms of patients with right lower quadrant pain were evaluated. Results: The mean age of patients (75.2 % males, 24.8 % females) was 26.2 ± 7.1 years. ROC curve analysis was performed and area under the curve was 0.867 for Ohmann score, 0.685 for Lintula score, 0.797 for Alvarado score and 0.731 for Eskelinen score. When we evaluated the symptoms of the patients with right lower quadrant pain, the most significant symptoms were three. They are steady pain, white blood cell count [10500, bowel sounds (absent, tingling or high-pitched bowel). ROC curve analyses were also performed for them, area under the curve was 0.956 Conclusion: Patients with symptoms of right lower quadrant steady pain, white blood cell count [10500, bowel sounds (absent, tingling or high-pitched bowel) should be examined particularly and followed up carefully to avoid morbidity and mortality. By using these parameters, a decrease in the negative appendicectomy rate and correct management could be provided.

P135 Totally Laparoscopic Resection of Primary Fallopian Tube Adenocarcinoma Guillermo Peralta, Denisse Lorena Sepu´lveda, MD, Zanndor del ˜ azReal-Romo, MD, Roberto Alatorre, MD, Jose´ Antonio DA Elizondo, MD, Instituto Tecnolo´gico de Estudios Superiores de Monterrey Primary carcinoma of the fallopian tube is a rare disease that shares similar clinical and histological features of epithelial ovarian tumor. These tumors has an extremely low incidence of 0.3 to 1 %, especially malignant tumors. Most cases are diagnosed in women over 50 years. Female patient in the seventh decade of life, with abdominal pain of three months duration. She had history of hysterectomy, apparently secondary to uterine fibroids. The patient reported pain in the right iliac fossa and hypogastrium, stabbing, cramping without irradiation. USG reports mixed mass that appears to be composed of residual ovarian stroma, coupled with expansion of the tube and probable small follicles or ovarian cysts. Its outline is well defined with respect to the neighboring fat imaging appearance seems to correspond to a benign structure. CT was achieved suggesting right hydrosalpinx. CA -125 was increased. Laparoscopic lysis of adhesions and right salpiooforectomy was performed. Pathology reported fallopian tube adenocarcinoma. Orthmann described the first reported case in 1888 is considered to be a clinical triad of hydrosalpinx, pelvic pain and a pelvic mass. The clinical diagnosis is very difficult due to a higher index of suspicion of endometrial carcinoma in postmenopausal patients with vaginal bleeding. The finding of a complex or solid adnexal mass with worrisome features for malignancy usually require surgery for definitive histological diagnosis. The marker CA 125 is elevated in many patients. The treatment involves a combination of surgical excision and chemotherapy. The case presented here was challenge in the diagnosis and is one of the few cases reported in Latin America.

123

Surg Endosc

P136

P138

A Study on the Skills of Laparoscopic Resection of Bursa Omentalis and Lymph Node Scavenging with Radical Gastrectomy

Sharp Foreign Body Ingestion: Laparoscopic and Conservative Management: 2 Case Reports

Wan Jin, GI Department GuangDong TCM Hospital Objective: To inquire into the feasibility, operation skills and short-term effect of laparoscopic resection of bursa omentalis and lymph node scavenging with radical gastrectomy. Method: Using the clinical data of 18 patients who received laparoscopic resection of bursa omentalis with radical gastrectomy in the Gastrointestinal Surgery of our hospital during the period from Jan., 2012 to Jan., 2014, we make retrospective analysis and analyze their operation time, bursa omentalis resection time, amount of bleeding during operation, postoperative complications related to operation, length of stay, the number of lymph node scavenging and short-term follow-up results. Result: All these 18 patients successfully received resection of bursa omentalis and no one received conversion to open surgery, with the operation time being (289.3 ± 30.3) min, the bursa omentalis resection time being (46.1 ± 18.6) min, the amount of bleeding being (35.5 ± 6.5) ml, no case suffering from postoperative complications (Pancreatic fistula, anastomotic fistula, intestinal obstruction) or being dead, and no case being dead in a follow-up time of half a year. Conclusion: For advanced gastric carcinoma, laparoscopic resection of bursa omentalis and lymph node scavenging with radical gastrectomy is feasible. In addition to meeting the requirement that the operator should be skilled and experienced in open bursa omentalis resection and have well-knit basic skills in using laparoscope, attention also must be paid to the operation team construction

Alexandre C Stanescu, MD1, Marius Nedelcu, MD2, Iannis Rotas, MD3, Bernard Vincent, MD1, 1CH Albertville, 2CHU Strasbourg, 3 HFR Fribourg Introduction: Most of the blunt foreign bodies pass through the digestive tract uneventfully. The reported rate of complication of the ingested sharp foreign bodies is about 1 %. In adults, the complications are more frequent identified in elderly, alcohol abuse history, or mentally impaired persons. About 70 % of accidental ingestion of sharp foreign bodies, in normal adults, is dentures or other dentistry appliances. Case Reports: We report here 2 cases of patients, a 70 years old man and a 76 years old woman, presenting with sharp foreign body ingestion. In the first case, the patient presented an acute abdomen. The CT scan revealed the presence of a sharp dentistry appliance and caecal perforation. The laparoscopic exploration showed an appendix base perforation and laparoscopic appendectomy and partial resection of the cecum has been performed. The post-operative period was uneventful and the patient has been discharged after 72 hrs; the second case of an elderly female patient who swallowed, by accident, a needle. The plain X-ray exams were irrelevant and the both the bronchoscopy and gastroscopy were negative. A low dose CT scan has been performed and the needle has been identified at the left colic flexure. Since the patient was asymptomatic, clinical observation has been decided. The needle was naturally eliminated and the patient has been discharged after 48 hrs. Conclusion: In the most cases (80–90 %), the gastrointestinal foreign bodies are naturally eliminated. However, for the ingestion of sharp foreign bodies the clinical observation is highly recommendable. In case of impactation or obstruction endoscopic retrieval is indicated. In case of complications (1 %), as perforation, the laparoscopic surgical management is feasible and safe

P137

P139

Successful Management for Perforated Peptic Ulcer with Massive Pneumoperitoneum by Laparoscopic Repair: Case Report

Presentation and Management of Metastatic Gastrointestinal Stromal Tumors - A Case Series and Review of Literature

Kenji Okumura, MD1, Tadao Kubota, MD1, Alan T Lefor, MD2, Junji Machi, MD3, Akihiro Kishida, MD1, 1Department of Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Japan, 2Department of Surgery, Jichi Medical University, Tochigi, Japan, 3Department of Surgery, University of Hawaii, HI

Andrea Zelisko, MD, Anselm Tintinu, MD, Andrew Fenton, MD, FACS, Walter Chlysta, MD, FACS, Akron General Medical Center

Introduction: Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is one of the most common indications for emergent surgery. Successful laparoscopic management of massive pneumoperitoneum from PPU has not been previously reported. Case Report: A 61-year-old Japanese man with a history of peptic ulcer disease was admitted with severe diffuse abdominal pain. On examination, he had a temperature of 38.0 C, blood pressure of 132/87 mmHg, and a heart rate of 69 bpm. Abdominal examination showed extremely bloating and tenderness centrally in the left upper quadrant. Chest and abdominal X-ray revealed a massive free air in the peritoneum. Computed tomography scan of the abdomen showed a massive free air in the peritoneum without ascites. Since he was hemodynamically stable, we planned for emergent laparoscopy. A 5-mm hole was seen at lessor sac of the stomach. Laparoscopic repair by three ports was done by omentum plug to close the gastric defect. He discharged on postoperative day 7 without any complications. Esophago-gastroduodenoscopy showed gastric ulcer without malignancy and helicobacter pylori antibodies were positive, and then he took medication for eradication of it. Discussion: Management of PPU has still been challenging and laparoscopic management has been getting common, however, successful laparoscopic management of massive pneumoperitoneum due to gastric perforation has not yet been reported. Safety and effectiveness of laparoscopic repair for PPU has been equivalent in hemodynamically stable patient. Conclusion: We present the successful laparoscopic management of pneumoperitoneum due to gastric perforation. The laparoscopic approach for PPU should be considered in hemodynamically stable patients even if with massive pneumoperitoneum.

Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial benign neoplasms of the gastrointestinal (GI) tract and the incidence of GISTs has been increasing with recent studies reporting an incidence rate of *12 per million. The clinical presentation of GISTs is highly variable depending on a multitude of characteristic features. We report on three patients with atypical clinical presentations with unusual features of GIST and highlight their treatment course. Case 1: 30-year-old healthy female presented three days after a vaginal delivery with abdominal pain and distension. She was found to have acute blood loss anemia (hemoglobin of 5.7 g/dL) but had no reports of GI bleeding. A CT scan revealed a large heterogenous, necrotic mass in her left abdomen and lesions in her liver. She was treated with surgical resection and medical therapy with imatinib as an outpatient. Case 2: 89-year-old male presented to the emergency department with a complete GI obstruction. A mass was found on CT scan and he was taken to surgery for treatment and removal of the mass. Surgery revealed metastatic disease, lymph node involvement, and small bowel primary. The patient was referred to oncology for medical treatment. Case 3: 64-year-old male presented with increasing abdominal pain and distension. CT scan was obtained that showed a mass in the abdominopelvic area. Repeat imaging for worsening clinical status demonstrated an increasing amount of free air and fluid. The patient was taken to surgery for excision of the mass, primary anastomosis, and diverting ileostomy. He was treated medically with imatinib and had no signs of recurrent disease.

Tumor Characteristics Size

TNM

Type

Metastasis

Positive Markers

Negative Markers

1

17 9 11 9 16 cm

pT4pNXpM1

mixed spindleepithelioid

Liver

cKIT, DOG-1, vimentin

actin, S100, cytokeratin, EMA

2

15 9 10 cm

pT4pN1pM1

spindle

LN,

cKIT-11, CD117, DOG-1

muscle specific acin, calretinin, D862

cKIT, CD117, CD34, vimentin

AE1/AE3, SMA, S100, desmin

omentum, mesentery 3

15 9 14.5 9 10.6 cm

pT4pN0pM1

spindle

intraabdominal, renal, liver

About 75 % of GISTs are discovered incidentally and are less than 4 cm in diameter. Of those that present clinically, the most common symptoms include GI hemorrhage and nonspecific abdominal pain. Obstruction is an uncommon presentation as these lesions have a tendency to grow in an extraluminal fashion. It has been postulated that the incidence of emergent presentations with GIST has increased. The majority of GIST lesions are benign (70–80 %), however, all GISTs have the potential to become malignant. The incidence of metastasis at presentation of malignant GISTs can approach 50 % as described in large clinical series. The liver is the most common metastatic site at presentation. And even though metastases to bone, lung, and lymph nodes have been described, they are distinctly uncommon. Because of the variable presentations and progressions of GISTs, it’s important to be knowledgeable of this disease process and the indicated combined surgical and medical treatment.

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P142

Evaluation of Mean Platelet Volume as a Diagnostic Biomarker in Acute Appendicitis

Incisional Negative Pressure Wound Therapy in a General Surgery Practice: Analysis of Effectiveness and Cost

Hasan Erdem1, Recep Aktimur2, Suleyman Cetinkunar1, Enver Reyhan1, Cihan Gokler1, Oktay Irkorucu1, Selim Sozen3, 1Adana Numune Education and Research Hospital, Department of General Surgery, Adana, Turkey, 2Samsun Education and Research Hospital, Department of General Surgery, Samsun, Turkey, 3Namik Kemal University, Faculty of Medicine, Department of General Surgery, Tekirdag, Turkey

Benjamin N Gayed, MD, Paul P Szotek, Indiana University School of Medicine

Background: Diagnosis of acute appendicitis remains to be challenging with up to 30 % negative exploration rates. In addition to careful clinical history and physical examination, we still need easily applicable, cheap and effective biomarker. Patients and Methods: A retrospective case-controlled study was designed in two groups, both containing 100 patients, acute appendicitis and control. Leukocyte count, neutrophil percentage, platelet count and meal platelet volume (MPV) were compared. Results: MPV values for acute appendicitis and control groups were 7.4 ± 0.9 fL (5.6–10.6) and 9.1 ± 1.6 fL (5.1–13.1). For the diagnosis of acute appendicitis, ROC analysis revealed 74 % sensitivity and 75 % specificity for a cut-off value of 7.95 fL of MPV, however, the diagnostic value of leukocyte count and/or neutrophil ratio was superior. Conclusion: Our results suggest that, MPV value is an important parameter in the diagnosis of acute appendicitis, but in terms of sensitivity and specificity, leukocyte count and/or neutrophil percentage is superior. Keywords: Acute appendicitis; mean platelet volume; sensitivity; specificity

Background: Surgical site infections add significant cost to post-operative care and prolong hospitalization. Negative pressure wound therapy applied over loosely approximated incisions (incisional NPWT) has gained traction in recent years as an effective method to reduce surgical site infections (SSI). To date, few studies have evaluated cost effectiveness of this technique. Objective: The purposes of this study are (1) to determine the effectiveness of incisional NPWT to reduce SSI in a general surgery practice including a mix of elective and emergency cases, and (2) to perform a cost analysis based on SSI reduction. Methods: A single surgeon utilized incisional NPWT for 100 consecutive patients undergoing laparotomy between 2012 and 2014 following a standardized protocol. We performed a retrospective review of these cases to describe the population and evaluate the incidence of SSI after incisional NPWT application. Mortality in the first week of the postoperative period or return to the OR unrelated to SSI were excluded. Cost analysis included daily cost for NPWT equipment compared to the cost of complications gathered from published data. Results: The most commonly performed operations in this series included ventral hernia repair, exploration for hollow viscus perforation and exploration for bowel obstruction (n = 91). The average age of this population was 60.3 (±15.1) and average BMI was 30.9 (±8.3). Fifty-five percent of cases were elective, 6.6 % were related to trauma, and 22.0 % were scheduled returns to the operating room for open abdomen in the setting of trauma or critical illness. Overall SSI rate was 2.2 %. When looking at individual wound classes, there were zero SSI’s (0 %) in class 1 (clean) wounds, 1 SSI (4.76 %) in class 2 (clean-contaminated) wounds, zero SSI’s (0 %) in class 3 (contaminated) wounds, and 1 SSI (3.9 %) in class 4 (dirty) wounds. Incisional NPWT costs were $100/day including direct costs for the pump, sponge, adhesive and tubing, totalling $1,000 per patient including pulse lavage equipment routinely used as part of the closure. Conclusions: This study further supports existing literature demonstrating a significant reduction in SSI rates with the use of incisional NPWT. In addition, outcomes in this population suggest that incisional NPWT is cost effective in a general surgery population, particularly in class 3 and 4 wounds. Routine application of incisional NPWT yielded $24,720 of cost savings with class 3 and 4 wounds in this series of 100 patients when compared to contemporary published rates of SSI incidence relative to wound class as well as published estimates of additional costs incurred by SSI. This cost estimate does not account for standard care costs averted by avoiding open wounds, often including dressings and home care expenses. A larger, prospective series looking at class 3 and 4 laparotomy wounds closed with incisional NPWT could more accurately capture SSI rates, improving cost savings estimates and helping to determine whether this technique should be considered a routine part of surgical care in this population.

P141

P143

Steroids are Independently Associated with Mortality in Patients Requiring Emergent Surgery for Acute Diverticulitis

A Novel, Minimally Invasive Approach to Assure Hemostasis for Intercostal Bleeding After Trauma

Megan Sippey, MD, Mark Manwaring, MD, Kevin Kasten, MD, Anthony Mozer, MD, Marysia Grzybowski, PhD, John Pender, MD, William Chapman, MD, Walter Pofahl, MD, Konstantinos Spaniolas, MD, East Carolina University

Jacob Glaser, MD, Habeeba Park, MD, Nathan Schmoekel, DO, Joseph Dubose, MD, Thomas Scalea, MD, Deborah Stein, MD, MPH, University of Maryland Shock Trauma Center

Introduction: Overall mortality from diverticulitis has plateaued over the past decade. Case reports and small case series suggest patients with diverticular disease taking chronic corticosteroids are predisposed to perforation and their ability to contain early stages of perforation may be impaired. However, no large scale study has examined this population. The aim of this study was to assess the relationship between chronic corticosteroid use and mortality in patients with acute diverticulitis. Methods: Patients undergoing emergent surgery for acute diverticulitis from 2005 to 2012 were identified from the ACS-NSQIP database. Demographics, co-morbidities, pre-operative lab values, operative procedures and 30-day outcomes were analyzed. Multivariate logistic regression was used with mortality as the dependent variable. Results: A total of 3,636 patients underwent emergent surgery for acute diverticulitis between 2005 and 2012; 48.9 % were male with mean age of 62.63 ± 14.21 years and BMI of 29.44 ± 7.13. Overall 30-day mortality was 6.6 % and steroid use was present in 572 (15.7 %) patients. Mortality was higher in those taking steroids for chronic conditions (17.5 % vs. 4.6 %, p \ 0.0001). Advanced age, vascular, cardiac, pulmonary, neurological, hepatic, renal disease, recent chemotherapy and diabetes were more prevalent in those who died. After controlling for confounding baseline variables, steroid use (OR 2.389, 95 % CI 1.557–3.666, p \ 0.0001), along with neurological, pulmonary, hepatic disease and preoperative chemotherapy, was independently associated with mortality in patients requiring emergent surgery for acute diverticulitis. The overall model had a strong ability to discriminate between patients who died and survived (c = 0.86, p \ 0.0001). Laparoscopic approach was utilized in 182 (5.0 %) patients in this emergent setting, though when compared to the open approach in this population, mortality was similar (3.2 % vs 2.0 %, p = 0.5286). Conclusions: Chronic steroid use among patients treated with emergent surgery for acute diverticulitis is frequent and is associated with 17.5 % mortality. Surgeons need to inform patients of realistic expectations prior to surgery. Though infrequently used in the emergent setting, the laparoscopic approach is not associated with a difference in mortality for acute diverticulitis in those taking chronic corticosteroids. Keywords: Corticosteroids, Acute Diverticulitis, Mortality

123

Introduction: A major complication of blunt thoracic trauma is arterial bleeding, often due to rib fracture and associated injury to an intercostal artery. Tube thoracostomy reliably addresses most bleeding, but many patients are left with retained hemothorax, and are pron to re bleeding events. A variety of methods have been identified to deal with these injuries, including thoracotomy. Identification and ligation of a bleeding intercostal artery can be difficult during thoracotomy, particularly when the bleeding is not active. A less morbid approach includes VATS, but often with this approach definitive vascular control of the intercostal arteries is not addressed. This increases the risk of rebleeding. We present a novel minimally invasive technique for definitive vascular ligation during VATS. Case Presentation: A 46 year old female sustained multiple rib fractures and associated hemothorax after blunt trauma. The patient was treated with tube thoracostomy, and remained stable. Follow up X rays reveal a retained hemothorax, and early VATS was performed. This approach is necessary to address retained hemothorax and offer definitive fixation of the presumed intercostal bleeding. Technique: During a standard VATS approach, a suture passer is used to encircle the fractured ribs through 2 mm multiplestab incisions. The fracture is proximally and distally encompassed, as well as one level of rib above and below the fracture. These are tied extracorporeally. This is all done under direct vision, with the intracorporeal assistance of previously placed instruments. Conclusions: Effective clearance of retained hemothorax can be achieved through a VATS approach. Definitive vascular control of intercostal vessels, using percutaneous ligation across the area of rib fractures, can be done with little added morbidity. This technique allows for definitive vascular fixation, maximizing the benefits of a minimally invasive approach, without the additional morbidity of thoracotomy.

Surg Endosc

P144

P146

Intussusception from a Shelled Peanut Phytobezoar

Predictors of Sepsis in Laparoscopic Cholecystectomy for Acute Cholecystitis

Aela P Vely, MD, Harry L Anderson, III, MD, Luke O Pesonen, MD, Emily K Wilczak, Mary-Anne Purtill, MD, Theodore John, MD, Andrew T Catanzaro, MD, Stevany L Peters, MD, St. Joseph Mercy Ann Arbor Although common in children, intussusception in adults is rare. It accounts for approximately 5 % of the total incidence of intussusception and less than 5 % of cases of intestinal obstruction. In adults, approximately 90 % of cases of intussusception are associated with a pathologic lesion, which typically functions as the lead point for the intussusceptum. Our case is a 37 year old male, who was otherwise healthy with no prior abdominal operations, who presented with less than 24 hours of right lower quadrant pain which was constant with colicky patterns. Eight hours prior to onset of his pain, he reported eating 2 small bags of salted, shelled peanuts, in which he ate the entire peanut - shell and all. His pain was not associated with nausea, vomiting, abdominal distention or diarrhea. He had evidence of complete obstruction, with no flatus or bowel movements since the onset of pain. He was afebrile, and physical examination revealed localized right lower quadrant pain but no evidence of peritonitis. Laboratory evaluation demonstrated a leukocytosis of 12,100 WBC/mm3. Computed tomography (CT) scanning with oral contrast revealed evidence of intussusception of the distal ileum into the cecum (arrow). Given his immediate dietary history of shelled peanut ingestion prior to development of his symptoms, he was admitted to the hospital with intravenous hydration, and nothing per mouth. The following morning, his exam improved significantly. A repeat abdominal X-ray in the morning showed migration of the oral contrast into the transverse colon. Colonoscopy performed the next day showed no masses and a normal colon, with localized inflammation near the ileocecal valve. The colonoscope was advanced beyond the ileocecal valve into the terminal ileum, with no other pathologic findings. Biopsy of the ileocecal valve area showed only inflammation.

L J Blair, MD, C R Huntington, MD, T C Cox, MD, T Prasad, MA, A E Lincourt, PhD, MBA, V A Augenstein, MD, FACS, B Todd Heniford, MD, FACS, Carolinas Medical Center Introduction: Sepsis is a devastating postoperative consequence and carries a high mortality. The objective of this study was to examine a common general surgery procedure, laparoscopic cholecystectomy, and identify risk factors which could potentially predict risk of sepsis preoperatively. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005–2012 for patients who developed sepsis postoperatively following laparoscopic cholecystectomy for acute cholecystitis. Patients with evidence of systemic inflammatory response syndrome or sepsis present preoperatively were excluded. Data was analyzed using standard statistical methods including the chi square test for categorical variables and Wilcoxon two-sample test for continuous variables. Results: Over an eight year time period, 12,387 patients underwent laparoscopic cholecystectomy for acute cholecystitis. The incidence of postoperative sepsis in this population was 0.60 % (n = 75). Patients who developed sepsis postoperatively were older with a decreased body mass index (BMI) and were more likely to have associated comorbidities including diabetes, and an elevated Charlson Comorbidity Index (CCI) (p \ 0.01); see Table 1. Patients who developed sepsis had lower preoperative albumin and increased operative time (p \ 0.0001). A multiple logistic regression model with age, race, gender, BMI, preoperative albumin, CCI score, and operative time as covariates supported the conclusions from univariate analyses. Overall LOS was elevated in the sepsis group, 7.9 ± 12.9 days versus 1.3 ± 4.6 days (p \ 0.0001). There was a trend toward increased in-hospital interval between admission and operation in patients who developed postoperative sepsis (3.2 ± 13.2 days versus 1.1 ± 3.9 days, p = 0.05). Conclusions: Predictors of postoperative sepsis in laparoscopic cholecystectomy include older age, associated comorbidities, decreased preoperative albumin, increased operative time, and a trend toward increased in-hospital interval prior to surgery.

Table 1

NSQIP characteristics of postoperative sepsis and no sepsis groups Sepsis (n = 75)

Cases of intussusception not associated with a pathologic lesion are uncommon. Azar and Berger (1997) reported 58 adult patients from 1964 to 1993 who underwent an operation, and were given a postoperative diagnosis of intussusception. In that series, 93 % were found to be associated with a pathologic lesion, with the remaining cases (7 %) due to idiopathic intussusception. A majority of the cases (44 out of 58) were enteric intussusception, and 48 % of the lesions were malignant. For the cases of colonic intussusception (14 out of 58), a similar number (43 %) of these lesions were malignant. The management of intussusception in adults is primarily surgical, given the high association of malignant pathology. A PubMed search of intussusception due to bezoar revealed only one case report (Calero et al., 2014), and in that report, the patient underwent small bowel resection, with the finding of intussusception of the mid-jejunum due to an intestinal bezoar. In our case report, the patient gave a clear history of antecedent ingestion of the entirety of peanuts within the shell, for which the CT scan was diagnostic for the intussusception and the accompanying phytobezoar. Employing subsequent colonoscopy with examination of the terminal ileum confirmed absence of other pathology.

No Sepsis (n = 12,312)

P value

Age (years)

65.2 ± 16

49.5 ± 17.5

0.0001

BMI (kg/m2)

29.2 ± 7.7

31.1 ± 7.6

0.0137

Diabetes (% patients)

36 %

11 %

0.0001

Hypertension (% patients)

63 %

35 %

0.0001

COPD (% patients)

8%

2%

0.002

CHF (% patients)

4%

0.4 %

0.001

Renal failure (% patients)

1%

0.09 %

0.002

Chronic steroid use (% patients)

11 %

2%

0.0001

Charlson Comorbidity Index

1.3 ± 2.3

0.3 ± 0.8

0.0001

PreOp Albumin

3.3 ± 0.6

3.8 ± 0.6

0.0001

Length of Stay (days)

7.6 ± 8.6

2.5 ± 4.7

0.0001

Operative time (minutes)

96 ± 49

74 ± 40

0.0001

In-Hospital time to OR (days)

3.2 ± 13.2

1.1 ± 3.9

0.0536

P145 Laparoscopic Management of Small Bowel Obstruction Secondary to Herniation Through Uterine Broad Ligament Dawit Worku, MD, MSc, MRCSEd, Abdulzahra Hussain, FRCSI, FRCSEng, Airedale Hospital NHS Foundation Trust A healthy 37 year old multiparous woman presented to an emergency department with one day history of nausea, repeated vomiting, abdominal distension and obstipation. She had no previous history of abdominal surgery. On examination, she was reporting significant pain but was maintaining normal vital signs. Her abdomen was distended, with mild tenderness in the lower quadrants and hyperactive bowel sounds. The results of basic laboratory investigations (i.e., complete blood count, electrolyte panel and inflammatory markers) were normal. Computed tomography showed dilated loops of distal small bowel with transition area in the right pelvis, consistent with complete obstruction of the small bowel. Initially, she was managed conservatively with intravenous fluids, nasogastric tube and nothing by mouth for the first 24 hours. When the conservative treatment failed, diagnostic laparoscopy was carried out. The findings were internal herniation of small bowel loops through a 6 cm defect in the uterine broad ligament, between the round ligament and right adnexa. After reduction of the herniated bowel, the broad ligament defect was closed with intracorporeal suturing to prevent recurrence. The patient made an uneventful recovery post operatively and was discharged home few days later. Herniation through a defect in the uterine broad ligament remains an uncommon cause of intestinal obstruction, accounting for about 4 %–7 % of internal hernias. Thus, it poses a significant diagnostic challenge pre-operatively. However, the possibility of internal herniation through a defect in the broad ligament should be considered in women presenting with obstruction of the small bowel when more common causes (i.e., adhesions, neoplasms, groin hernias) have been excluded. Defects of the broad ligament may be either acquired or congenital. Acquired causes include trauma resulting from pregnancy or delivery, pelvic inflammatory disease or surgery is an acquired cause. In nulliparous patients, such defects may result from spontaneous rupture of cystic structures within the broad ligament that are thought to be congenital remnants of the mesonephric or mullerian ducts. Herniation or obstruction of the small bowel is the most commonly reported complication. The management of small bowel obstruction secondary to herniation through broad ligament is operative, once conservative options are exhausted. A Trendelenburg position intraoperatively can assist in gentle reduction of incarcerated contents. Non viable bowel should be resected. Prevention of recurrent small bowel obstruction can be achieved by either closure of the defect (i.e. using clips or suture) or by dividing the broad ligament completely. As this case demonstrates, small bowel obstruction due to herniation through uterine broad ligaments can safely be managed laparoscopically.

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P148

Emergency Versus Elective Colorectal Resections Management: A Single Centre Experience

Laparoscopic Sub-total Colectomy with Anti-peristaltic Ileosigmoid Anastomosis (Zhu’s Operation) for the Treatment of Slow-Transit Constipation? Therapeutic Evaluation (36 Cases Report)

M A Gok, S J Ward, M M Sadat, U A Khan, Macclesfield District General Hospital Introduction: Colorectal cancer (CRC) is the 3rd most common & the 2nd most lethal cancer in men & women in the UK. Colorectal cancer presents as a surgical emergency in \30 % of cases; obstruction, perforation, abdominal pain, haemorrhage or sepsis. Emergency CRC has been associated with high post-operative morbidity & mortality. The aim of the study is to assess emergency colorectal malignant resections a District General Hospital Materials and Methods: This is a retrospective study carried out since January 2008 at Macclesfield District General Hospital. Patient factors, histopathology & surgical outcomes were evaluated for all emergency colorectal resections. A cohort of elective maligant colorectal resections carried out since 2008 were recruited as controls. Discussion: CRC is more common in males; however emergency presentation of CRC is less predictable. Prolonged operative time in elective cases is attributed to the use of laparoscopy. Emergency CRC patients were generally ill patients (ASA 3) with sepsis. The greater LB specimen size reflects more diseased LB resections in the emergency CRC resections. Consequently the survival was poorer in the emergency CRC resections. This study supports the bowel screening initiatives to detect early CRC’s.

Results Emergency CRC (n = 144)

Elective CRC (n = 595)

Mann Whitney U test (p value)

Age (yrs)

70.5

71.2

NS

Sex (M:F)

66:78

340:255

\0.05

ASA

3

2

\0.05

Weight (kg)

69.3

74.8

\0.05

BMI

24.9

26.9

NS

Appendix / Ileum

10

8

Caecum

37

113

Ascending

12

48

Transverse

27

55

Descending

12

Objective: To assess the operative outcomes after laparoscopic subtotal colectomy with antiperistaltic ileosigmoid anastomosis (ZHU’s operation or LSCAISA) for the slow-transit constipation. Methods: Reviewed January 2009 and May 2014 the patients with slow-transit constipation underwent laparoscopic subtotal colectomy with antiperistaltic. The following pre-operative information were collected: the number of preoperative bowel movements, constipation intervals, the frequency of using laxative, the variation rang of weight. The following postoperative information were collected: the number of postoperative bowel movements, peri-operative complications (incision infection, pneumonia, fistula of intestine, perilymph fistula), forwards complications (malnutrition, bellyache, intestinal obstruction), Wexner score and degree of postoperative satisfaction. Results: 36 patients were counted. Half month after the operation, bowel frequency was a mean of 7 ± 2 daily, with a semi-liquid stool consistency. Three months after the operation, bowel frequency was a mean of 4 ± 2 daily, with a semi-solid stool consistency. Six months after the operation, bowel frequency was a mean of 3 ± 1 daily, with a solid stool consistency mostly. One year after the operation, bowel frequency was a mean of 2 ± 1 daily, with a solid stool consistency mostly. One patient’s bowel frequency was a mean of 10 daily after six months? One elderly female patient get pneumonia in the peri-operative period and two fat patients present incision infection. Four patients occur postoperative paroxysmal bellyache. Two patients got ileus and two patients got Perilymph fistula. There were no short-term or long-term complications in the other patients. 69.4 % patients reported a great satisfaction, 13.9 % patients expressed satisfaction and 16.7 % showed basically satisfaction. The mean preoperative Wexner’s score was 20.5 ± 3.7, which decreased to an average post-operative score of 4.8 ± 2.3 a year later (Tables 1, 2, 3). Conclusions: laparoscope sub-total colectomy with anti-peristaltic ileosigmoid anastomosis for the slow-transit constipation seemed to be a safe and effective procedure for selected patients. However, long-term symptomatic and functional outcome need further study. ClinicalTrials.gov ID: NCT02147574

Table 1

Clinical characteristics

Age (yr)

10

46 (18–73)

Gender

Sigmoid

33

123

Rectosigmoid

7

34

Rectum

6

204

Stoma

38

172

NS

Op Time (min)

122.2

163.1

\ 0.05

Small bowel length (mm)

118.2

93.7

NS

266.4

Anlong Zhu, The First Affiliated Hospital of Harbin Medical University

Male/female

6/30

Operation

\ 0.05

Large bowel length (mm)

333.3

Diverticulosis (n)

30

Synchronous tumours (n)

15

93

LN harvest (median)

13

14

NS

LOS (days)

11

9

\ 0.05

NS NS

1st yr survival

69.3 %

92.1 %

Logrank p \ 0.05

3rd yr survival

47.9 %

81.5 %

Logrank p \ 0.05

5th yr survival

42.7 %

75.3 %

Logrank p \ 0.05

Subtotal Colectomy with Anti-peristaltic ileosigmoid anastomosis

36

Unite STARR

2

Operation time (min)

140 ± 20

Hospital stay (day)

9±1

Bleeding volume (ml)

70 ± 30

Length of abdominal incision (cm)

5 ± 0.5

Follow-up duration (mo)

14

Table 2

Postoperative complication and management

Complication management Early (B 1 mo)

8 (27.8)

Postoperative ileus operation

1 (2.7)

Wound infection conservative

2 (5.6)

Perilymph fistula conservative

2 (5.6)

Pneumonia conservative

1 (2.7)

Paroxysmal bellyache conservative

4 (11.2)

Late (C1 mo)

3 (8.3)

Ileus operation (adhesiolysis)

1 (2.7)

Paroxysmal bellyache conservative

2 (5.6)

Table 3

123

No. ( %)

Postoperative patients’ satisfaction

Degree of satisfaction

No. ( %)

A great satisfaction

25 (69.4)

Satisfaction

5 (13.9)

Basically satisfaction

6 (16.7)

Poor

0 (0)

Surg Endosc

P149

P151

Subtotal Cholecystectomy Versus Total Cholecystectomy for Technically Difficult Cholecystitis

Emergency Surgery: Role of Diagnostic Laparoscopy

V.v. Grubnik, Prof, V.v. Ilyashenko, PhD, M.v. Prikupenko, V.v. Grubnik, Odessa National Medical University Introduction: In severe cholecystitis laparoscopic cholecystectomy (LC) can be technically difficult with a high risk of duct and arterial injury. To prevent injury, conversion to open cholecystectomy (OC) is usually made. Another solution is performing of laparoscopic subtotal cholecystectomy (LSTC). Aim of the study was to investigate the safety and complications of laparoscopic subtotal cholecystectomy (LSTC) compared to conversion to OC for technically difficult cholecystitis. Methods and Procedures: A retrospective review of 5708 LC performed from 2005 to 2013 in single center was done. In the 1st period, from 2005 to 2008, 2720 LC were performed. In technical difficulties conversion to OC was done. In the 2nd period, from 2009 to 2013, 2988 LC were performed. In technical difficulties LSTC was done. Results: During the 1st period, there were 127 patients (4.7 %) with technically difficult LC whom conversion to OC was done. Complication rate among these patients was 23 %, bile duct injuries were detected in 3 patients (2.4 %), mortality was 1.6 %. During the 2nd period, there were 84 patients with technically difficult LC, thus LSTC was performed for 69 patients of them. Therefore, conversion to OC was made for the remaining 15 patients (0.5 %). There were no bile duct injuries and no mortality in these patients. Complication rate after LSTC was 8.7 %. Quality of life was assessed 6–48 months after surgery in 102 patients whom conversion to OC was done, and in 58 patients whom LSTC was done. Quality of life was better in patients after LSTC. Conclusions: LSTC is good alternative to conversion to OC in complicated cases. It is good solution to prevent bile duct injury and save a principle of minimally invasive procedure in technically difficult LC, especially in high risk patients.

Ahmad Mirza, Ian Welch, The University Hospital of South Manchester, Manchester, UK Introduction: In emergency surgical practice the use of diagnostic laparoscopy has increased significantly. It helps in both the diagnostic and therapeutic management of surgical conditions avoiding the use of laparotomy. The aim of our study was to identify the use of diagnostic laparoscopy and the subsequent management of acute surgical abdominal conditions and their outcome at our institute. Methods: We collected data over six years from 2008 to 2014 of patients undergoing diagnostic laparoscopy. The study included all patients undergoing diagnostic laparoscopy when the initial imaging both ultrasound abdomen and pelvis and computerised tomography scans were negative. The study also included patients who may or may not have elevated inflammatory markers (raised white cell count and C-reactive protein). We collected data for pre-operative (demographic details, laboratory investigations and radiological imaging), operative (laparoscopic and conversion to open, operative details) and post-operative course (histological report, inpatient stay, recovery and post-operative follow-up). Results: The study identified 182 patients who underwent diagnostic laparoscopic. The female (N = 123, 68 %) to male (n = 59, 32 %) ratio was 2.2. The median age was 49 years (range 7 to 79 years). 86 (47 %) patients had positive diagnostic laparoscopies which identified significant intra-abdominal pathology (acute appendicitis = 53, ovarian cyst rupture = 17, ovarian torsion = 7, endometriosis = 4, bowel adhesions = 5). 8 (4 %) patients required conversion to laparotomy due to the extent of intra-abdominal pathology. The median inpatient hospital stay was 2 days (range 1 to 36 days). 96 (53 %) diagnostic laparoscopies were inconclusive and failed to identify any abdominal pathology and these patients were subsequently discharged. 27 (15 %) of patients with negative diagnostic laparoscopies were readmitted with ongoing symptoms of abdominal pain over a median follow-up period of 6 months (range 1 to 13 months). Only 5 (3 %) of these patients who were readmitted with abdominal pain were found to have an abdominal pathology and underwent a laparoscopic operation (n = 3 appendicitis, n = 2 ovarian cysts). The overall complication rate was 11 % (lower respiratory tract infections 4 %, wound infections 5 % and urine infection 2 %). Conclusions: Diagnostic laparoscopic surgery can be safely performed in patients who still have abdominal signs and symptoms despite all negative laboratory and imaging investigations. Though these patients require careful selection as represented from our series that nearly half the patients had negative diagnostic laparoscopy. Diagnostic laparoscopy in acute surgical emergency has significant role to play in situations when both inital laboratory and radiological investigations are negative.

P150

P152

Prediction of Open Conversion in Laparoscopic Appendectomy in the Aged Population: A Neural Network Approach

Palliative Alleviation of Gastric Outlet Obstruction in Terminal Patients with Advanced Incurable Cancers Using Self-Expanding Metallic Stents. Can We Predict Outcome?

Stephen P Gadomski, BS1, Eric S Wise, MD1, Kyle M Hocking, PhD1, Stephen M Kavic, MD2, Colleen M Brophy, MD2, 1Vanderbilt University Medical Center, 2University of Maryland Medical Center Introduction: In many surgical practices, laparoscopic appendectomy (LA) has become the procedure of choice for acute appendicitis. Recent data suggests that in certain subsets of the population such as the elderly, LA is associated with less cost and improved postoperative outcomes. However, the cost and morbidity associated with conversion to an open procedure presents a legitimate concern. An artificial neural network (ANN) is a computational model in which rationally selected input variables can train the system to predict a given outcome, with discriminant ability superior to multivariate logistic regression (MLR). In this investigation, we aim to use ANN modeling to predict conversion from laparoscopic to open appendectomy using known and available pre-operative variables, in patients over 55 years of age. Methods: Using Synthetic Derivative (SD), a single-institution de-identified electronic medical record, patients over 55 who underwent laparoscopic appendectomy for acute appendicitis were identified using directed CPT and ICD code searches. Preoperative variables including demographics, comorbidities, symptoms at presentation and imaging were noted. All variables underwent univariate and multivariate screen for independent association with conversion. These factors were then input into a 4-node back-propagation training ANN (Fig. 1A). The ANN output is between 0–1, with 1 representing the highest probability of conversion. Receiver operating characteristic (ROC) curves were generated for both training and validation sets, and Actual vs. ANN-Predicted plots were generated as well. Results: 117 patients were identified as having undergone initial LA for acute appendicitis. The conversion rate was 12.8 % (15/117). Of the screened preoperative factors, female gender, black race, length of symptoms prior to presentation (LOSx), platelet count and CT evidence of free fluid were found to be associated with conversion in both univariate and multivariate screen (P \ 0.1). 70 patients with all five variables known were included in the ANN; 56 patients were randomly chosen for the training set, and 14 were held for the validation set. Using ANN modeling, prediction of conversion generated an area under the curve (AUC) of 0.9531 ± 0.05 in the training set (Fig. 1B), and 1.0000 in the validation set. Actual vs. ANN-Predicted plots generated for the training (Fig. 1C) and validation sets were generated, with r2 values of 0.8823 and 0.8171, and root mean square error (RMSE) values of 0.1200 and 0.1497, respectively. Conclusions: Female gender and black race were found to be associated with conversion to open appendectomy. In addition, factors that may reflect the degree intra-abdominal inflammation, including free fluid on CT, platelet count and LOSx, were also associated with conversion. Using ANN modeling methodology, surgical candidates at high risk for conversion from laparoscopic to open appendectomy can be effectively identified, allowing for optimized patient counseling and pre-operative decision making.

Helene Wu¨rtz, MD, Søren I Abramsson, MD, Mohammad Abdul Ghani, MD, Lars S Jørgensen, MD, Poul B Thorsen, MD, PhD, Jan M Krzak, MD, Sygehus Lillebaelt, Kolding, Denmark Introduction: Malignancies leading to gastric outlet obstruction (GOO) may be alleviated with endoscopically placed self-expanding metallic stents (SEMS). Is it possible to predict any difference in survival? Objective: The primary objective of this study was to show that endoscopic placement of SEMS is a feasible option in alleviating gastric obstruction in patients with different types of advanced incurable malignancies. Secondary, the objective was to clarify whether overall survival was different in the groups identified. Method: Over a 5-year period (January 2009 to September 2014), 43 patients with GOO, caused by different types of incurable advanced malignancies, underwent endoscopic placement of a SEMS. In this single-center study, charts from patients were reviewed retrospectively, and survival rates were compared. Three patients were excluded from this study. One patient was ‘‘outlier’’ with an uncertain pathology report, and two other patients as they are still alive today. There were no exclusions due to co-morbidity despite many of patients reached the end stage of the disease. Patients were divided into two groups; patients with incurable advanced pancreatic cancer (P-group) and patients with other incurable advanced gynaecological and gastrointestinal cancers (A-group). Statistical analyses included T-tests for continuous variables distributed normally, and Mann-Whitney Ranksum tests for continuous variables not-normally distributed. Cox proportional hazard and Kaplan Meier plots were used for survival analyses Results: Total number of patients in the study was 40; 16 patients in the P-group and 24 patients in the A-group. Median survival after stent placement was overall 54 days. Survival was higher in P-group with a median of 111 (IQR 34–159) days compared to A-group with a median of 45 (IQR 27–76). In the P-group, there were no technical failures, except one clinical failure. In the A-group there was 1 technical failure (duodenal rupture resulting in death), and 2 clinical failures. One patient needed a second stent placed for full alleviation of the stenosis in the first few days after stent placement, and two others needed second stent placement due to tumor ingrowth few months later. One patient was treated operatively with laparoscopic gastroenteroanastomosis two months later. Mean age in the whole study population was 69.9 and did not differ between the two groups. The AUC in our Kaplan-Meier plot shows a difference in post-operative survival favoring patients with pancreatic cancer. Comparing the two groups with survival analysis (Cox proportional hazard) shows a hazard rate ratio of 2.3 (95 % CI 1.1–4.5). The software packages SPSS and STATA were used for the statistical analyses. Conclusion: Alleviation of GOO with placement of SEMS in patients with advanced incurable cancers seems to be a successful choice of palliation. There seems to be a statistically significant higher survival in pancreatic cancer patients compared to other types of abdominal cancers.

Fig. 1

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Terminal Ileostomy and on-Table Enteroscopy for Retrieval of Foreign Bodies - A Novel Approach to Avoid a Midline Laparotomy in the Difficult Abdomen

The Pursuit of the ‘Ideal’ Submucosal Injection

Shadi Al-Bahri, MD, Esther Cha, MD, Gregory B Burgoyne, MD, MedStar Union Memorial Hospital Introduction: With any abdominal surgery in a difficult abdomen, the procedure is filled with potential hazards. In addition to a prolonged operative time, there is a risk of enterotomy or damage to blood vessels and ureters. An irradiated pelvis increases this risk and may cause additional morbidity such as delayed healing. An impacted foreign body can also be a challenging problem to deal with alone but when combined with a difficult abdomen can make the problem impossible. Case Report: A 67 year-old male presented with a small bowel obstruction and CT scan imaging revealed a foreign body impacted in the ileum approximately 20 cm proximal to the ileocecal valve. The patient had a history of prostate cancer with radiation to the pelvis and thereafter developed perforated diverticulitis, requiring Hartmann’s colostomy. Later he underwent a colostomy take-down but developed wound infection and dehiscence resulting in an incisional hernia which was repaired. The patient was treated conservatively with NGT decompression but the foreign body did not move and operative intervention was undertaken. Due to the extensive scarring of his midline abdomen, a right sided transverse incision was used to retrieve the foreign body. An appendectomy was performed to avoid return into the abdomen and an attempt was made to insert the colonoscope was inserted through the appendostomy but this was unsuccessful. An enterotomy was made in the terminal ileum and the endoscope was advanced to the foreign body which was retrieved with a snare. The foreign body was found to be a 3.5 cm piece of bone. There was mucosal ulceration but no evidence of perforation. The patient tolerated the procedure well, and diet was resumed upon return of bowel function. There were no post-operative complications. Discussion: Foreign body ingestion is a rare cause of small bowel obstruction, and exploration and retrieval is recommended if the obstruction does not resolve or if the bowels perforate. The method of retrieval depends on the site of the foreign body. Upper endoscopy can be used proximally. Colonoscopy can be used for colonic foreign bodies. Fortunately, in the small bowel, the terminal ileum is the narrowest part and most likely the site of impaction. Operative retrieval is easier if there are no prior abdominal interventions. An irradiated pelvis or abdomen, multiple prior procedures and a frozen abdomen warrant an alternative approach. As it can be difficult or impossible to access the ileum using a colonoscope transanally, a limited right-sided transverse incision can be employed through virgin territory allowing immediate access to the cecum and terminal ileum through which endoscopic retrieval could be performed. A review of the literature to date did not yield any other descriptions of this approach for foreign body retrieval, however, an appendostomy and endoscopy to rule out malignancy in patients with right sided diverticulitis has been documented. Conclusion: Consideration should be given to foreign body retrieval through an appendostomy or ileostomy if a midline laparotomy is considered too high risk in the setting of pelvic irradiation and multiple prior abdominal surgeries.

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Introduction: Traditional surgical methods for treating serious digestive diseases, such as colorectal cancer, although widely employed across the Western world, carry with them significant risks. The endoluminal approach describes the method of treating pathology, such as benign polyps, by methods such as Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD). In addition, collective therapeutic approaches such as Combined Endoscopic and Laparoscopic Surgery (CELS) may be used to overcome the limitations and challenges of EMR and ESD, whilst still obviating intestinal resection and anastomosis. Through injecting agents into the submucosal intestinal layer, we may improve the margin of safety, but this field is highly underdeveloped with Saline Solution (SS) being the primary submucosal injection agent (SMIA) used worldwide. Endoluminal ultrasonography has enabled higher levels of tissue discrimination and anatomical appreciation, and such a SMIAs ability to further enhance this feature is desirable. Aims: The purpose of this study was to investigate the ability of twelve established and novel SMIAs - including normal saline, hyaluronic acid and thermo-sensitive polymers (TSP) - as well as some combinations of those agents, to create a durable submucosal cushion. In addition we assessed the SMIAs ability to change the ultrasonogaphic (US) characteristics. Methods: Fresh ex-vivo calf rectum was used. One-millilitre of the twelve SMIA agents were injected into the submucosal space, ten times per SMIA. Height loss over one hour was measured as a proxy for the agents’ ability to create a durable submucosal cushion. Height loss for each solution was plotted and Area Under the Curve (AUC) analysis was undertaken by taking the best-fit line integral equation. Percentage of an ideal agent was then calculated. One-hundred percent being a SMIA that preserves it’s initial height over one hour. US views were also taken to assess the SMIAs ability to modulate anatomical appreciation (a BK medical ultrasound 800 system was used). Results: SS exhibited the worst maintenance of ideal agent height at 54 % after 1 hour, followed by an aqueous solution of carboxymethylcellulose (55 %). An equal combination of saline solution, hyaluronic acid and aqueous carboxymethylcellulose performed the best with 87 % (p \ 0.01 compared to SS) maintenance of height, closely followed by TSP (86 %, p \ 0.01). Using direct visual and grey scale analysis, a clear variation in an SMIAs ability to demarcate intestinal anatomical layers using ultrasound was demonstrated, with TSP appearing to readily separate the mucosal layer from deeper structures. Conclusions: Novel and combination SMIAs yielded significantly superior results to SS, particularly with regards to persistent mucosal elevation - the most important feature of an SMIA. This factor combined with the possibilities of novel therapeutic agent seeding and auto-dissection (as seen in US analysis) makes TSP one of the most likely, ideal SMIAs. Interestingly, SMIAs that displayed poor individual outcomes, exhibited superior results when used in combination - likely due to synergistic chemical effects. Further studies are needed to build on these promising results and expand this under-developed field.

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Factors Affecting Colonoscopy Completion 1

2

1

Fahad Alasfarq, MD , Yousef Almuhanna, MD , Fatema Alotaibi , 1 Department of Surgery - Faculty of Medicine - Kuwait, 2General Surgery Resident - State of Kuwait Introduction: Colonoscopy is a common non-invasive procedure, widely conducted for a diagnostic and therapeutic reasons. It is defined as a lower gastrointestinal endoscopy, passing the scope through the anal verge, all to the way to the cecum, thus it allows thorough examination of the rectum, colon, and distal part of the ileum, with the privilege of taking biopsies when needed. The aim of this study is to find a correlation between the procedure and the factors that may affect its completion. Methods: A prospective study was conducted of 500 patients who have visited the clinics for colonoscopy. A complete colonoscopy was defined as a scope capable of reaching the cecum. Incomplete colonoscopy was defined as inability to reach the cecum or poor visualization of the colon/ ileocecal valve. All of these patients had a colonoscopy as an elective procedure. Preprocedure factors that were tested include BMI, co-morbid diseases, and history of abdominal surgery. Intraprocedure factors include bowel preparation, heart rate and oxygen saturation. Results: Those 500 patients were studied over a period of 12 months, January to December 2013. The median age of patients was 44 (15–85) and 57 % were males. Factors affecting procedure completion were categorized into preprocedure and intra-procedure factors. History of abdominal surgeries, co-morbid conditions, and body mass index were used as pre-procedure factors. Whereas oxygen saturation, heart rate, and bowel preparation were used as intraprocedure factors. Most incomplete procedures were seen among overweight BMI patients, in 7 % of those with history of abdominal surgeries, and in 14 % of patients with co-morbid conditions. In regards to intra-procedure factors, complete colonoscopies has gone from 72 % in adequate bowel preparation to 16 % in inadequate bowel preparation. Heart rate and oxygen saturation did not add any change to the procedure completion. Conclusion: Many factors affect the completion of colonoscopies. Despite the absence of statistical significance upon studying many factors, bowel preparation maintains its importance and significance to complete the procedure, and can be put into a scoring system that would predict the likelihood of completing the procedure.

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S K Sharma1, K Nakajima2, G Abdalla2, A Levin3, J F Cornhill1, J W Milsom1, 1Minimally Invasive New Technologies, Weill Cornell Medical College & New York Presbyterian Hospital, 2Section of Colon and Rectal Surgery, Weill Cornell Medical College & New York Presbyterian Hospital, 3Rockefeller University, New York

Transoral Incisionless Fundoplication for Refractory GERD: A Community Practice Experience Aliu Sanni, MD1, Ifeoma Oriala, BS2, Phillip Yun, BA3, Mateo Guarderas, BS4, Christian Cruz, MD1, Angel Farinas, MD1, Angelina Postoev, MD1, Christopher Ibikunle, MD, FACS1, 1Georgia Surgicare/University of Georgia, 2International American University, 3 GRU/UGA Medical Partnership, 4Universidad San Francisco de Quito Introduction: Adequate control of refractory regurgitation and esophageal manifestations experienced by chronic gastroesophageal reflux disease (GERD) patients on long term Proton Pump Inhibitors (PPI) has remained a major therapeutic concern. Several prospective and retrospective studies have supported the use of Transoral Incisionless Fundoplication (TIF) performed with the EsophyX device as a method of treating these symptoms and potentially eliminating patient’s dependence on PPIs. The aim of this study was to review the efficacy and outcome of TIF treatment of symptomatic patients at our facility. Methods: Patients with refractory GERD symptoms following long term PPI treatment and small hiatal hernias (\3 cm) diagnosed on endoscopy were enrolled onto this study between January 2012 and December 2013. The TIF procedure was performed using established protocols. Subjective and objective outcomes were evaluated with the GERD-Health Related Quality of Life (GERD-HRQL), Reflux Symptom Index (RSI) and patient satisfaction questionnaires before and after the procedure. The competency of the fundoplication was evaluated by endoscopy. Statistical analysis was performed by using the student t-test for continuous data with a p-value \0.05 determined as statistically significant. Results: A total of 44 patients underwent the TIF procedure in this time frame. The mean age and BMI were 57 years & 30.3 kg/m2 respectively. 31 of 44 patients (70 %) were female. There were no peri-operative complications reported. Objective symptoms using the GERD-HRQL (17.5 vs. 6.6; p \ 0.05) and RSI scores (20.1 vs. 8.42; p \ 0.05) were significantly improved following the TIF procedure. At a median follow up of 6 months (range = 4–18), up to 42 patients (95.5 %) reported partial or complete resolution of their primary symptoms. 80 % of the patients were satisfied with the overall outcome of the procedure. Conclusion: Among selected patients with refractory GERD symptoms with a small hiatal hernia, TIF performed using the Esophyx device provides complete symptom relief in the majority of patients.

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A Novel Add-On Device Improves Stabilisation and Visualisation During Colonoscopy

Complication of Dislodged Gastrostomy Foley Catheter. A Case Report and Review of the Literature

S K Sharma1, A Datta1, A Nguyen1, C D Dillon1, L Lefebvre1, G Silberhumer2, J F Cornhill1, J W Milsom1, 1Minimally Invasive New Technologies, Weill Cornell Medical College & New York Presbyterian Hospitaln, 2Medical University Vienna, Department of Surgery, Vienna, Austria

Dean Kristl, MD, Abubaker A Ali, MD, Charles E Lucas, MD, Choichi Sugawa, MD, Wayne State University

Introduction: Colonoscopy (CY) is the gold standard for detection and prevention of colorectal cancer (CRC), with an estimated fourteen million procedures performed annually in the USA alone. Despite widespread use, CY has technical challenges including lack of stability relative to the intestinal wall (requiring repetitive adjustment or additional personnel to assist the endoscopist) and poor visualisation (requiring continuous gas insufflation with patient discomfort). Indeed, these technical difficulties may be major contributory factors to the significant number (up to 30 %) of colonic polyps missed during CY. Additionally, more complex CY procedures such as Endoscopic Submucosal Dissection (ESD) and Combined Endoscopic and Laparoscopic Surgery (CELS) are permitting avoidance of major surgery in many patients. The Endoscopic Surgical Platform (ESP) was developed to overcome some challenges of conventional CY, facilitate advancement of surgical procedures into the endoscopic domain and improve patient outcomes. ESP is a novel doubleballoon endoscopic add-on device that can be incorporated onto commercially available colonoscopes. Aims: Assess ESP’s in-vitro capability during CY to:

• •

Improve stability Improve visualization

Methods: In this study, we used an Olympus pediatric colonoscope (PCF-H180AL), an ESP device, silicone colon model with 1 centimetre (cm) markers placed with indelible ink and Kyoto-Kagaku colonoscopic trainer. The student’s t-test was used to determine statistical significance unless otherwise stated. The following variables were measured with and without ESP added onto the colonoscope: Completion in reaching the Kyoto-Kagaku Model (KKM) ‘caecum’ Time to reach KKM ‘caecum’ Stability of CS tip upon applying a 5 centimetre (cm) longitudinal traction force to the CS externally ‘Mucosal’ surface area visualized Insufflation time to distend colon to a level deemed clinically acceptable to the endoscopist Results: There was no migration of the CS tip using ESP versus 60 cm without ESP upon longitudinal traction (p \ 0.0001). ESP use significantly increased the ‘mucosal’ surface area visualised to approximately 50 cm2, from 34.6 cm2 and 39 cm2 (straight and flexure segment of intestine model respectively, p \ 0.0001). The time taken to reach a clinically acceptable level of visualisation was significantly reduced using the ESP device – 15.6 and 19.3 seconds versus 35 and 57 seconds (straight and flexure segment of intestine model respectively, p \ 0.0001). CS functionality was preserved in its entirety whilst using ESP. Conclusions: The addition of the ESP device to commercially available colonoscopes significantly enhances it’s functionality, through improved visualisation and stability. This may have direct benefits in both current and future surgical applications of CY. Further in-vivo studies are required to expand on these promising results.

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a very common method for enteral nutrition. Accidental dislodgement of PEG tube is a common complication. Soon after dislodgement, Foley catheters are often placed through the mature gastrocutaneous fistula to prevent tract closure until more definitive replacement occurs. This report describes a patient in whom the replacement Foley catheter migrated distally and required colonoscopic retrieval. Case Report: A 65 year old male with a past medical history of bilateral adrenal adenoma, stroke, dementia, and dysphagia was transferred from a nursing home due to a missing feeding tube. Previously he had a PEG tube placed for dysphagia. It became dislodged several weeks after placement and was replaced with a Foley catheter. The patient arrived in the emergency department with normal vital signs. Physical examination showed a soft, non-distended, and non-tender abdomen with a gastrocutaneous fistula and no Foley catheter. Abdominal x-rays showed a tubular structure in the right upper quadrant, without pneumoperitoneum. CT scan showed a Foley catheter in the proximal jejunum without obstruction. The patient was admitted, kept NPO, given IV fluids, and underwent push enteroscopy due to concerns the inflated catheter bulb would not pass the ileocecal valve. The scope was advanced approximately 70 cm beyond the ligament of Treitz and the catheter was not visualized. The patient remained asymptomatic and was observed for seven days while being administered laxatives and enemas. Plans were made to perform colonoscopy and, if this failed, to perform exploratory laparotomy. Colonoscopy revealed a Foley catheter with inflated balloon in the ileocecal region. It was retrieved uneventfully with a snare. The patient was then discharged back to the nursing home. Discussion: PEG tubes, introduced in the 1980s, have become a widely used technique of enteral feeding. A major complication of PEG placement is dislodgement, reported in 12.8 % of cases in a recent retrospective study. A mature gastrocutaneous fistula tract forms in approximately 2–3 weeks but can narrow and even close in hours once a tube is dislodged. If no gastrostomy tube is accessible, a Foley catheter is a good alternative to prevent tract closure. Complications of balloon catheter replacement include obstruction, ulcers, or intussusception. These are due to the tube lacking an external fixation device. This case illustrates distal Foley migration. This complication has been described and has been treated by either percutaneous puncture of the balloon or operative exploration. Despite having an inflated balloon, this patient did not have obstruction. Retrieval of the migrated catheter was achieved without operative exploration. Morbidity of Foley catheter replacement of dislodged PEG tubes is sparse. They are a cheap and effective way to maintain a patent gastrocutaneous tract. However, the expense associated with their complications can be avoided with prompt replacement by a formal gastrostomy tube. ER physicians should be aware of this as they are often the first health care provider to see these problems.

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Preoperative Flexible Upper Endoscopy and Its Validity in Bariatric Surgery in a VA Population

Upper Gastro-Intestinal Endoscopy in Port Harcourt Nigeria: Update

David D O’Mara, Nikeeta Wilson, PAC, Juanita A Thomas, MSN, RN, Michelle K Savu, MD, FACS, Audie L. Murphy VA Hospital, STVHCS

Emeka Ray-Offor, MBBSFWACSFMASDMAS1, Ipalibo S Wokoma2, G Gbanador, FACS3, A E Ihekwaba2, 1University of Port Harcourt Teaching Hospital/Oak Endoscopy Centre Port Harcourt Nigeria, 2Dept of Internal Medicine University of Port Harcourt teaching Hospital Nigeria, 3Shawsand Medical Center Port Harcourt Rivers State Nigeria

Objective/Background: Bariatric surgery is one of the most frequently performed general surgical procedures in the US although its performance is limited within the VA system. There is however some debate as to whether routine preoperative flexible upper endoscopy (FUE) is necessary in the evaluation of the bariatric surgery patient. We examined the findings of preoperative FUE in a VA bariatric surgery patient population to better determine the validity of its routine use in this population. Methods: This is retrospective study of prospective data collected in the bariatric surgery patient population using a computerized patient medical record data-base (CPRS) in the South Texas VA system between December 2012 until September 2014. All patients received routine preoperative FUE evaluation and then proceeded to have a bariatric surgery procedure, either laparoscopic gastric sleeve or bypass. The FUE and surgery were performed by a single surgeon provider. Means are expressed +/- standard deviation. Results: A total of 31 bariatric surgery patients underwent preoperative FUE at the South Texas VAHCS. There were 17 males and 14 female patients. Average age of patients was 45 years old (age range 27–61) exhibiting a preoperative mean BMI of 42.4 +/- 5 kg/m2 (n = 31). Postoperatively the mean BMI decreased to 32.6 +/- 3 at 3 months (n = 17); and 30.6 +/- 3 at 6 months (n = 14). Out of the 31 patients, 35 % had positive findings on FUE delineated in Table 1. The results of the FUE changed the intended surgical intervention in 2/31 patients (6 %)). Conclusion: In our VA patient population, preoperative flexible upper endoscopy revealed pathology in 35 % of patients, all of which required treatment (either preoperative medical or surgical treatment). Furthermore, several patients had significant pathology, which impacted the choice of surgical procedure. Therefore we conclude, in the VA population, routine preoperative upper endoscopic is a useful and valid procedure and should be performed on all patients undergoing bariatric surgery.

Table 1

(no caption)

Pathology

Individuals (%)

H. pylori

4/31 (13 %)

Gastritis

1/31 (3 %)

Intestinal Metaplasia (Barretts)

2/31 (6 %)

Gastric Ulcer

2/31 (6 %)

Gastric Stromal Tumor

1/31 (3 %)

Hiatal Hernia

1/31 (3 %)

Introduction: Oesophagogastroduodenoscopy (OGD) is the gold standard for investigating disease conditions of the upper digestive tract. There is geographic distribution of pathologies even in a country; accurate data is the bane of development strategies more so for developing countries. This collaborative study between gastro-intestinal surgeons and gastroenterologists is designed to update the existing data in our environment. Aims: To formulate a regional endoscopy registry for the purpose of studying differential diagnosis of upper gastrointestinal pathologies and the outcome of endoscopic treatment, as a framework for enhancing the practice of endoscopy Patients and Method: A retrospective study was done of all OGDs performed in health facilities with functional endoscopy units in Port Harcourt metropolis, South-south Nigeria from January 2012 to September 2014. A questionnaire was distributed to endoscopists practicing in Port Harcourt (2 General Surgeons and 3 Gastroenterologists) to complete relevant details of all the OGDs done during the study period and return forms via electronic mail. Data collected included: sociodemographics, indication for OGD, anaesthesia, endoscopic finding, histopathology report for biopsry specimen and outcome. Analysis was with SPSS version 20 Results: There were 219 OGDs performed during the study period. One hundred and four were males and 115 females with a male to female ratio of 1:1. The age range was from 5 to 82 years. Epigastric pain was the most common indication for OGD. The use of conscious sedation with local anaesthesia to pharyngeal mucosa was the routine practice. The most common endoscopic finding was gastritis. Mucosal biopsies were performed in 109 (50 %) cases with chronic gastritis the most common histopathology. Duodenum was intubated in 209 (99.5 %) cases and interventions performed included injection sclerotherapy, variceal banding and fundoplication. Conclusion: Epigastric pain is the leading indication for OGD with benign inflammatory gastric lesions especially in the antrum the most common endoscopic finding. The practice of OGD is safe and there is the need for more trained endoscopists. Keywords: Upper gastrointestinal tract, oesophagogastroduodenoscopy

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Review of Outcomes from a Single Center Experience with Endoscopic Mucosal Resection for Intramucosal Adenocarcinoma of the Esophagus and Barrett’s Esophagus, A Canadian Experience

A Proposed Curriculum for Endoscopic Retrograde Cholangiopancreatography (ERCP) Training During General Surgery Residency

Tami Yamashita, MD, FRCSC, Harry Henteleff, MD, MSc, FRCSC, FACS, FCCP, Drew Bethune, MD, MSc, FRCSC, FCCP, James Ellsmere, MD, MSc, FRCSC, Dalhousie University Introduction: Endoscopic mucosal resection (EMR) is increasingly being used as first line treatment for Barrett’s esophagus (BE) with dysplastic changes and intramucosal adenocarcinoma (IMC). At our center, patients are selected for endoscopic therapy and surveillance for high-grade dysplasia and IMC using a collaborative approach between therapeutic endoscopists and thoracic surgeons. We hypothesize that our outcomes are consistent with the emerging literature supporting this strategy. Methods: Between October 2010 to August 2014, 30 consecutive patients underwent EMR for BE with dysplastic changes and IMC. A retrospective chart review was performed on these patients to assess: complications, eradication of dysplasia, and progression of disease. EMR was performed using the Duette Multi-Band Mucosectomy device (Cook Medical, Bloomington, IN). Results: Of the 30 study patients, 17 were referred with BE, 12 were initially referred for IMC, 1 was referred for palliative management of invasive adenocarcinoma. Of the group with BE, 15 patients had high-grade dysplasia (HGD), one patient had low-grade dysplasia and one had intermediate dysplasia. Median follow-up was 363 days. Fifteen patients were referred with HGD, and complete eradication of dysplasia was achieved in 12 patients (80 %). Three patients with HGD did not achieve pathologic remission: one died from acute leukemia, one was lost to follow-up, and one with a long segment HGD was referred for RF ablation therapy. None of the patients referred for EMR for dysplastic changes developed invasive esophageal cancer. Of the 12 patients referred for IMC, 4 were found to have invasive adenocarcinoma based on the EMR specimen and were referred for esophagectomy. Eight patients with an EMR confirmed diagnosis of IMC were successfully managed with EMR and endoscopic surveillance, with complete eradication of dysplasia in all these patients. Complications were minimal with 2 patients developing esophageal strictures, which were successfully managed with dilatation. There were no cases of perforation or post-operative hemorrhage. Conclusion: Our multidisciplinary experience supports that EMR can be safely performed as a first line treatment for patients with BE with dysplastic changes and intramucosal adenocarcinoma (IMC).

Cory Richardson, MD, Maris Jones, MD, Charles R St. Hill, MD, MSc, Matthew Johnson, MD, Jenny Lam, Nathan Ozobia, MD, FACS, University of Nevada School of Medicine Introduction: Increased interest in surgeon-performed ERCP has prompted surgical endoscopy fellowships to incorporate ERCP into their training. In 2007, SAGES published guidelines for training in diagnostic and therapeutic ERCP. Since then, our institution has established an ERCP training program for select residents and fellows and has reported on the completion of this program and acquisition of independent credentialing by the conclusion of fellowship. Presented here is a curriculum showing the same can be accomplished during the five years of a residency program with a surgical endoscopy pathway. Methods: Yearly objectives were identified and residents with a specific interest in incorporating ERCP into their practice were selected.

Year 1 Introduced to the concept of ERCP and its incorporation into surgical practice. ERCP related research is expected. Begin performing EGD’s, PEG tubes, and colonoscopies. Year 2 Increase focus on performing lap choles, with emphasis on IOCs, which promotes proficient laparoscopic ductal cannulation. Perform simulated ERCPs in a skills lab setting. Year 3 Perform ERCPs with direct supervision. Procedural autonomy begins with scope manipulation and progresses towards cannulation and cholangiogram interpretation. Supine, semi-prone, and prone positions are utilized. Year 4 Perform advanced cannulation techniques, selective ductal cannulation, and focus on therapeutic papillotomy, stone extraction, and stent placement. Year 5 Perform all aspects of diagnostic and therapeutic ERCP. Advanced cannulation techniques and selective cannulation of the CBD and PD are performed. Stone extraction techniques are mastered. Papillotomy, balloon dilatation, biopsies, and CBD and pancreatic stenting are performed. ERCP performed for a variety of indications including stones, iatrogenic injuries, malignant pathology, and traumatic hepatopancreaticobiliary injuries.

A didactic curriculum was completed that included instruction in safe cannulation techniques, use of fluoroscopy, interpretation of cholangiography, indications for therapeutic interventions, and management of complications. Instruction complemented the surgical training program and a parallel progression occurred between surgical and endoscopic training in regards to knowledge base, patient management, operative experience, complexity of procedures, and autonomy. Metrics for competency included completion of the didactic curriculum, proficiency in perioperative care, management of complications, proficiency in performing diagnostic and therapeutic procedures, and achieving a successful cannulation rate of [90 % in the final year of training. Results: Residents in the pathway have successfully completed this ERCP curriculum during their 5-year general surgery residency. The ERCP program instructor has submitted recommendations for the first resident’s unrestricted credentialing to the hospital credentialing committee, having performed over 200 ERCPs. Conclusions: It is possible to train select surgical residents to independently perform diagnostic and therapeutic ERCP by the end of the PGY-5 year. Because a specific number of procedures does not indicate competency, it should be the discretion of the instructing faculty to determine when a resident should be considered for independent privileging in advanced therapeutic ERCP, and their recommendation and rationale should be submitted to the residency program director and hospital credentialing committee.

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Case Report of Delayed Esophageal Blast Injury Treated Non-operatively with Esophageal Stent

A Textile Sensor Using Piezoelectric Fibres for Measuring Dynamic Compression of a Bowel Stent

Stephanie Sea, MD, Kasia Wolanin, MD, Heidi Miller, MD, Jorge Uribe, Jay Strain, MD, Mark Kaplan, MD, Pak Leung, Albert Einstein Medical Center

˜ zquez, MD1, Maria Bergstrom1, Anna Jorge Alberto Arroyo VA 2 Vahlberg , Anja Lund, DTech2, Per-Ola Park1, 1Dept of Surgery, South Alvsborg Hospital & Gothenburg University, 2Swedish School of textiles, University of Boras, Boras, Sweden

The management of traumatic esophageal injury is highly controversial in the literature, especially management after a delayed presentation. We report a case of a 25-year-old male who presented to the ER as a Level 1 trauma with multiple gun shot wounds to the left and right chest, as well as several extremity wounds. Initial upright CXR revealed a right hemothorax and a right chest tube was placed with 900 cc bloody output. Vital signs were stable and the patient underwent a CT of his chest to identify the potential pathway of the bullet. Afterwards the patient was taken to the operating room for a right thoracotomy, right upper lobe wedge resection and an exploration of the posterior mediastinum and esophagus. No additional injuries were noted at that time and the patient was transferred to the SICU for resuscitation. On hospital day #4, the patient underwent a fluoroscopic swallow study that was negative for an esophageal leak and the patient’s diet was advanced. On hospital day #7, the patient was noted to have copious purulent drainage from his chest tubes. The patient appeared clinically septic and underwent a left thoracotomy with decortication and placement of chest tubes. A subsequent swallow study demonstrated a new proximal esophageal leak. The patient was placed on antibiotics, kept NPO and TPN was initiated. The patient clinically improved and we felt there was adequate source control with good drainage from both sides of the chest. Two weeks after the initial injury he was started on tube feeds to optimize his nutritional status. On hospital day #18, the patient underwent an EGD that demonstrated an esophageal perforation and a stent was placed. Intermittently he underwent swallow studies to assess the integrity of his esophagus on an outpatient basis. On post-injury day #78, the patient had his stent removed. His swallow study was negative, the diet was initiated and the chest tube was later removed. Our case demonstrates the management of a delayed esophageal blast injury successfully completed with conservative management and stent placement.

Introduction: Covered Stents are increasingly used for treatment of postoperative or ulcer-caused gastro-intestinal leaks. Covered stents used for these treatments carry a risk of migration that potentially can create grave clinical situations. It may be assumed that the shape and mechanical properties of the stent together with the geometrical response of the stent to bowel movements will affect the probability of migration. These factors have not yet been studied due to lack of adequate models. Here we introduce novel piezoelectric textile fibres integrated in a stent. The piezoelectric fibres have the ability to generate an electric voltage in response to elongation and their function as sensors for bowel and stent movements was investigated. Methods: Piezoelectric fibres were melt spun as previously reported. They were coated with a conductive silicone, Elastosil LR 3162 A/B (Wacker Chemie AG) which constitutes the outer electrode, and then manually inserted/sewn into an uncovered Dodenal Hanarostent (M.I. Tech). The experiment was conducted in two phases. (1) Bench-top: The stent was subjected to dynamic compression using in-house constructed rings, and the fibres’ piezoelectric outputs with respect to the position and amplitude of compression was measured using an oscilloscope (PicoScope 5442 A). (2) In vivo in a non-survival pig model: The stent was placed in the pig-pylorus through laparotomy and gastrotomy. The stomach was closed with suture and the leads from the piezoelectric fibers were brought out to the oscilloscope. Piezo-electric out-put was measured during 30 minutes both at base line and then after Neostigmine stimulation. Results: Ex-vivo compressions of the stent caused the piezoelectric fibres to generate a voltage. Different compression forces generated different voltages. In vivo testing in pig pylorus: base line voltage out-put measurements showed correlation to visible pyloric contractions. When stimulated with Neostigmine increased out-put voltages were recorded during increased pyloric activity. Conclusion: The present study indicates that piezoelectric fibres integrated in a stent will be able to sense bowel movements. With refinements of this model including calibration and signal interpretation, a sensor-stent is expected to be useful as a tool to study the effect of stents on intestinal motility in general, and to evaluate this effect as a function of the geometry and mechanical properties of the stent.

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The Endoscopic Stent Management of Anastomotic Leaks Following Upper Gastrointestinal Surgery

Endoscopic Intervention in Management of Per Oral Endoscopic Myotomy Complications

Cici Zhang, MD, Kevin Hutchingson, Lucy Martinek, MD, Julio Teixiera, MD, Lenox Hill Hospital

Matthew L Dong, MD, MPH, Matthew Davis, MD, Amit Bhatt, MD, Jeffrey Ponsky, MD, Matthew Kroh, MD, Cleveland Clinic

Introduction: Endoscopically placed, self-expandable stents have become an increasingly accepted technique for the management of anastamotic complications. The objective of our study was to determine the success of endoscopically stents in patients with anastomotic, staple line leaks, fistulas and strictures. Methods: A retrospective review of patients who had undergone endoscopic stent placement for the management of complications after various foregut procedures was conducted. All stents were anchored endoscopically with 4–0 Prolene and evaluated with upper GI studies. Twenty patients were included in the study and none were excluded. The data was analyzed using SPSS software. Results: From September 2005 to August 2014, twenty-one patients (14 were female, mean age of 44) developed anastomotic complication after foregut surgery (leak = 14, fistula = 4, stricture = 4). One patient had a stricture and a fistula. Fourteen patients were referred from other surgeons and eighteen were bariatric patients. Leaks were diagnosed by CT scan and confirmed on endoscopic visualization. Symptomatic improvements were found in 19 patients (90 %), 16 (76 %) had resumption of oral diet in 48 hours, and 10 (50 %) patients had stent related morbidity. There were seven stents migrations that required stent exchange. Two patients died due to unrelated causes. Chi-square analysis demonstrated significant benefit in stent management of leaks compared to strictures and fistulas (p = 0.010) and increased morbidity of using stents in patients with fistulas (p = 0.011). Conclusion: Gastrointestinal leaks after foregut surgery remain a primary cause of serious morbidity and mortality in both bariatric population as well as the general surgical patients. The advent of endoscopic stent has revolutionalized the management of anastomotic complications following foregut surgery, in particular, bariatric surgery. In 2013, an estimated over 13,000 stents were sold from one company alone for the management of foregut complications. In our experience, stents have shown be safe and viable method to expedite enteral nutrition, facilitate healing and improve symptomatic outcome in patients with leaks and strictures.

Introduction: Achalasia is an esophageal dysmotility disorder, affecting approximately 1 in 100,000 people, and is characterized by inadequate or impaired relaxation of the lower esophageal sphincter, with absent or disordered peristalsis of the esophagus. It can result in debilitating dysphagia, odynophagia, regurgitation, and in severe cases, weight loss and malnutrition. Medical therapy, consisting of calcium channel blockers and nitrates, can provide some symptomatic relief in early or mild achalasia or in patients with contraindications to endoscopic or surgical intervention. Endoscopic balloon dilation of the LES is often effective, but the resultant scarring can make future surgical interventions more difficult and carries an approximately 4 % perforation rate. Endoscopic injection of botulinum toxin can provide some mechanical relief, but the effects are transient, generally lasting 3–6 months. Surgical options for achalasia include open or laparoscopic Heller myotomy. More recently, per oral endoscopic myotomy (POEM) has begun to gain traction at select centers. Early results show that in capable hands, POEM is an effective and safe therapy for achalasia, with the advantage of shorter hospital stay and no incisions, but the rate of complications, and the management thereof, is not well described. The purpose of this study is to provide useful techniques for managing intra-operative and post-operative complications arising from POEM. Methods and Procedures: We describe the management of three patients who underwent POEM, who each had a different complication, one intraoperative and two postoperative. Results: Our first patient had an inadvertent second mucosotomy, at the distal end of the submucosal tract. This was recognized at the time of its creation. The mucosotomy was closed with a series of endoscopic clips. Following this, intraoperative fluoroscopy showed no leakage of contrast. A routine post-operative upper GI series also demonstrated no leak. The patient had an uneventful post-operative recovery. The second patient had findings of incomplete closure of his mucosotomy and a persistent submucosal tract on postoperative upper GI series. He was initially managed with total parenteral nutrition but was readmitted with dysphagia and upper abdominal and chest pain. He was treated endoscopically, with two overlapping fully covered esophageal stents, which were left in place for one week. Follow up studies showed closure of this tract. The third patient had an uneventful POEM and recovery but was readmitted on postoperative day 10 with an upper gastrointestinal bleed. This was initially low volume but became significant shortly after his arrival. Endoscopy showed no active bleeding at the time of the procedure and a partially covered esophageal stent was placed. This was removed after three days and repeat endoscopy showed no evidence of continued bleeding and an intact mucosotomy closure site. Conclusions: POEM is a novel procedure for incision-less surgical management of achalasia. Early results are encouraging that it is safe and effective, but due to small case numbers, descriptions of techniques for management of post-operative and intra-operative complications are few. Both endoscopic stenting and clipping are useful tools and should be considered in troubleshooting pathways although their specific applications have yet to be determined.

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Does Annual Colonoscopy Volume Predict Adverse Events, Patient Comfort, or Use of Sedation?

Esophageal Perforation After Segstaken-Blakemore Tube Placement Treated with Esophageal Stenting

M Lougheed, M Borgaonkar, D Pace, C Marcoux, B Evans, D Boone, J McGrath, Memorial University, Faculty of Medicine, St. John’s, NL

Mitesh B Patel, MD, Seyed Gaskari, MD, Samer Alkaade, MD, Saint Louis University School of Medicine

Introduction: The objective of this study is to determine if annual colonoscopy volume of endoscopists is related to the risk of adverse events, patient comfort, and the amount of sedation used. There is some debate about whether these factors are related to the experience of the endoscopist. Methods: A retrospective cohort study was performed on 3235 patients who underwent colonoscopy in the city of St. John’s, NL between January and June 2012. Using the electronic medical record system, including the endoscopy procedure report, the nursing record of the endoscopy, and the pathology report, data on subjects were collected on adverse events, including cardiorespiratory compromise (hypoxia – saturation \ 85 %; hypotension – blood pressure \ 90/50 or \ 20 % of baseline), perforation, bleeding (immediate or delayed 14 days), or death. Data were also collected on patient comfort during the procedure as noted by the endoscopy nurse and the total amount of Fentanyl and Versed used for sedation. SPSS was used for analysis. Endoscopists were divided into quintiles based on annual case volume (1st 0–149; 2nd 150–249; 3rd 250–301, 4th 302–530, 5th [ 530). Chi-squared tests were performed to see if there was a difference in adverse events and patient comfort (comfortable vs. uncomfortable). ANOVA was performed to compare the use of sedation between the quintiles. Results: Mean age was 58.4 years with 55.8 % of the group being female. A total of 13 surgeons and 8 gastroenterologists were studied. There was a linear reduction in the rate of hypoxia from the 2nd to 5th quintiles, from 16.1 % to 3.6 %, p \ 0.001 (1st quintile 10.2 %). There was also a linear reduction in the rate of hypotension from the 2nd to 5th quintiles, from 29.0 % to 9.9 %, p \ 0.001 (1st quintile 11.8 %). There was no significant difference found between quintiles in terms of reversal agents used, risk of immediate or delayed bleeding, perforation, or death within 30 days. There was a significant difference in the percentage of patients who reported discomfort between the 1st and 2nd quintiles (46.5 % vs 32.2 %, p \ 0.001), with the other quintiles the same as the second. There was a significant difference between the 4th and 5th quintiles in Fentanyl use (99.8 mcg vs 88.9 mcg, p \ 0.001, with the other quintiles the same as the fourth. There was also a significant difference between the 4th and 5th quintiles in Versed use (3.4 mg vs 2.8 mg, p \ 0.001), with the other quintiles the same as the fourth. Conclusion: Higher annual colonoscopy volume is associated with less hypoxia and hypotension. It is also associated with less patient discomfort, and less sedation. This study did not show an effect of annual volume on use of a reversal agent, risk of bleeding, perforation, or death.

Case Report: Treatment of esophageal perforation remains a challenging problem. Options include diversion, resection, primary repair, or stenting across defects, however esophageal perforations carry a high mortality rate ranging from 10 % to 40 %. Esophageal perforation can be caused by iatrogenic injury, Boerhaave syndrome, and traumatic perforation by swallowed foreign bodies and blunt trauma. We present a case of a large esophageal perforation after inflation of a Sengstaken-Blakemore (SB) tube in the esophagus treated with esophageal stenting. A 48-year-old male with history of HCV cirrhosis, complicated by recurrent bleeding esophageal varices, presented to an outside hospital after a day of hematemesis and was found to have a hemoglobin of 5.9. He underwent variceal banding, however he continued to have hematemesis and underwent subsequent SB tube placement. He was then transferred to our center where the tube was found to be proximally displaced. An EGD showed adherent clots from 30 cm from incisors to 43 cm. Soon after EGD he developed hypotension and hypoxia and was found to have hemopneumothorax of the left lung and a chest tube was placed. He later underwent video-assisted thoracoscopic surgery and was found to have a large esophageal perforation surrounded by necrotic tissue that was not amendable to surgical repair. Percutaneous gastrostomy and jejunostomy tubes, and a Blake drain positioned posteriorly to the esophagus were placed. GI was consulted intra-operatively and esophageal stenting was performed. He required repeat EGD on post operative days 5 and 11 due to increased mediastinal drain output. Additional esophageal stents were placed on each EGD and he continued jejunostomy tube feeding. He had resolution of his esophageal perforation on repeat esophagram on postoperative day 35 and esophageal stents were removed on day 49. Esophageal perforation is a rare complication from SB tube placement. Mortality rates for esophageal perforation range from 10–40 %. Diagnosis can be made by chest X-ray or CT, esophagography, or EGD. Despite morbidity of esophageal perforation, there is no ‘gold standard’ for management. Surgical interventions are often used in effort to achieve lower mortality rates. Endoscopic clipping has been described in literature for patients with small lesions between 10 mm and 25 mm. It is important to recognize esophageal perforations as a complication of SB placement and to consider esophageal stenting as a safe and effective treatment option for patients who are unable to undergo surgical correction due to poor tissue viability or other co-morbidities.

P168 Safety and Efficacy of Poem for Treatment of Achalasia: A Systematic Review of the Literature Oscar M Crespin, MD1, Louis Liu, MD2, Parmar Ambica2, Timothy D Jackson, MD1, Eran Shlomovitz3, Allan E Okrainec1, 1Division of General Surgery University Health Network, University of Toronto, 2Division of Gastroenterology University Health Network, University of Toronto, 3Divisionof General Surgery and Interventional Radi University Health Network, University of Toronto. Introduction: Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. Although initial results have been encouraging, laparoscopic Heller myotomy (LHM) and pneumatic dilation (PMD) are currently considered the standar of care. Over the last 8 years nearly 4,000 POEM have been performed worldwide but no randomized control trials have been reported. The purpose of this study is to perform a systematic review of the literature to evaluate efficacy and safety of the procedure. Methods: Evidence Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non indexed citations were searched for POEM studies using the keywords: esophageal achalasia, peroral endoscopic myotomy, endoscopy, natural orifice surgery, laparoscopic Heller myotomy and related terms. Articles published in the year 1946 to September 2014 with no language restrictions were included. Two authors reviewed the results from this search to exclude studies: (a) without abstracts (b) performed only in animals (c) tutorial, narrative (d) with less than 10 cases (e) where achalasia and POEM terms were not mentioned (f) that did not address efficacy and safety outcomes of interest. A third reviewer resolved any disagreements in pair review. Figure 1 outlines the process of paired review. Results: 33 studies including 1,273 POEM procedures were identified. Five (15 %) compared POEM with LHM, two (6 %) evaluated results in patients with previous Heller myotomies and one (3 %) in patients with previous PMD. No RCTs were available in the literature. Whitin available cohort studies, perioperative complications and postoperative symptom relief (using Eckardt score) were uniformly reported in 26 studies (79 %). Pre and post manometric parameters were reported in 23 (70 %). Quality of life was assessed in eight studies (24 %). Long term follow up was lacking, median 7 months range 1 to 31. Conclusion: Preliminary data suggests POEM may offer a safe and effective alternative for the treatment of Achalasia. Initial reports demonstrate short term success comparable to LHM and PMD. RCTs, long term follow up is needed. Consistent reporting of symptoms, manometric findings and efficacy is required in future study designs.

Fig. 1

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Two Weird Intragastric Balloon Cases

A Comparison Between Two Methods for Tumor Localization During Totally Laparoscopic Distal Gastrectomy in the Patients with Gastric Cancer

Baris D Yildiz, MD, Ankara Numune Teaching Hospital Introduction: The most widely studied of the minimally invasive endoscopic therapies for obesity is the gastric balloon (GB). Here we describe two cases of endoscopic balloon placement in which balloons did not inflate properly without causing any immediate or long term complications. Case 1: 36 years old female patient applied to our out patient clinic for treatment of her obesity. Her body mass index was 41.1 kg/m2. Under sedation Heliosphere BAG (Helioscopie, Vienne, France) was inserted orally into the stomach. The usual sequence of the procedure involves pulling the string holding two edges of the plastic envelope covering the balloon and inflating the balloon with 550 cc of air. When this sequence is followed the balloon takes a uniform round shape. But in our case there was a part on the balloon which did not expand. Our efforts to inflate this portion using more air were unsuccessful so we ended the procedure. A postoperative plain upright abdominal X-ray showed irregular balloon sitting inside fundus (Figures available). The patient did not have any immediate postoperative problems and was discharged. She had lost only 7 kg at that time thus her percent excess weight loss (%EWL) was 6.6 % at six month post procedure. When examined the appearance of deflated balloon was normal without any abnormal structural findings. Case 2: 43 years old male patient presented to our obesity clinic. The same procedures as described for Case 1 were applied and again the balloon did not fully inflate (Figures available). Five and half months after balloon placement he was called in and the balloon was taken out. He had lost only 8 kg at that time thus his %EWL was 5 %. Discussion: Intragastric balloon was developed as a minimally invasive alternative to surgical treatment of obesity. The question whether it is worth wasting time and money on GB trying to induce weight loss in obese individuals is still debated. In our country, Heliosphere BAG balloons cost around $1000 per piece and state medical insurance only pays for one piece if the patient fully qualifies for the treatment. Thus if GB placement is unsuccessful patient does not have a chance for a second balloon. So for both cases we faced a dilemma of either extracting the balloon out our keeping it inside. Fortunately both patients did not face any complications. Median weight loss of 15–17 kg and up to %32 EWL were reported for GB by different authors. Our patients had much lower weight loss and %EWL when compared to these results. We are certain about the amount of air we filled the balloons with. So volume of balloons can not be a factor in this failed weight loss. Conclusion: Structure of the intragastric balloon might influence %EWL and manufacturers must be vigilant about errors in production line and upgrade product technology for better outcomes. It might not be cost effective using intragastric balloon for preparation for a definitive obesity surgery procedure in developing countries.

Introduction: TLDG (totally laparoscopic distal gastrectomy) has several advantages over LADG (laparoscopy assisted distal gastrectomy). However, one of critical issues about TLDG is intraoperative tumor localization. The aim of this study is to compare two methods for tumor localization during TLDG in the patients with gastric cancer. Methods and Procedures: We retrospectively reviewed the medical records from a prospectively collected database of 36 patients who underwent TLDG from July, 2013 to September, 2014 in a single center. The patients were classified into two groups: Radiography group including the patients underwent intraoperative tumor localization by the radiographic imaging, and Endoscopy group including the patients in whom intraoperative endoscopy was performed for localizing the tumor sites. The clinical outcomes were compared between two groups. Results: Radiography and Endoscopy groups included 15 (41.7 %) and 21 (58.3 %) patients, respectively. Mean operation time was longer in Radiography group than in Endoscopy (328.7 ± 52.5 and 262.0 ± 47.4 minutes, respectively, p \ 0.001). Moreover, mean localization time was also longer in Radiography group than in Endoscopy (21.7 ± 12.8 and 7.6 ± 2.9 minutes, respectively, p = 0.001). In addition, mean hospital stay was longer in Radiography group than in Endoscopy (8.1 ± 0.9 and 9.4 ± 2.7 days, respectively, p = 0.040). However, there were no statistically significant differences between two groups in the incidence of complication (26.7 and 23.8 %, respectively, p = 0.845). Conclusions: If intraoperative endoscopy is performed by a sufficiently trained surgeon, there is no evidence that intraoperative endoscopic localization is inferior than radiographic in terms of the safety. Moreover, the recovery can be facilitated by reducing the operation time, as the surgeon performs intraoperative endoscopy.

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A Comparison on Early Outcomes of Per-oral Endoscopic Myotomy (Poem) and Laparoscopic Heller Myotomy

Robotic vs Laparoscopic Nissen Fundoplication: A Retrospective Case Control Study

Thanasan Pratumrat, MD, Max S Jitraphongsathorn, MD, Virachai Mahatharadol, MD, Jerasak Wannaprasert, MD, Thawee Ratanachuek, MD, Poochong Timratana, MD, Rajavithi Hospital

Jan-Holly L Nicolas, MD, Renzo Garberoglio, MD, Esther Wu, MD, David B Nelson, MD, Kamran Samakar, MD, Marcos J Michelotti, MD, Keith R Scharf, DO, Jason M Wallen, MD, Loma Linda University Medical Center

Introduction: Achalasia is a rare esophageal motility disorder. The gold standard of treatment is Laparoscopic Heller Myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a novel endoscopic treatment. There had only been a few studies comparing POEM with LHM. The aim of this study was to report the early outcomes of per-oral endoscopic myotomy (POEM) compared with Laparoscopic Heller Myotomy (LHM) in Rajavithi Hospital. Methods and Procedures: A retrospective review of 33 patients who underwent POEM and LHM in our institution from April 2007 to February 2014. The patient’s data was collected by a chart review and a questionnaire by phone call. Eckardt score was collected preoperatively, 3 months and 6 months postoperatively. Variables were analyzed by standard descriptive statistics, student T-test, fisher’s exact test or Mann-Whitney test. The primary outcome was symptom improvement compared in both groups. The secondary outcome was rate of complications. Results: There were 33 patients with a diagnosis of achalasia, 10 patients underwent POEM, 23 patients underwent LHM and Dor fundoplication was performed in only 13 patients (56.5 %). The median age, operative time and symptom duration were compared between the POEM group and the LHM group with the result of 38.5 yr (19–59) vs 48 yr (27–72) P = 0.08, 155 min (40–295) vs 135 min (80–250) P = 0.63, 42 mo (7–72) vs 24 mo (6–180) P = 0.58, respectively. The median follow up time was longer in the LHM group (42 mo vs 13.5 mo, P = 0.0025). The median length of stay (LOS) was longer in the POEM group (8 vs 6 days, P = 0.0036). All patients had an ASA score of 1 and 2. Comparison of the mean Eckardt score between the POEM group and the LHM group at preoperatively, 3 mo and 6 mo postoperatively were 7.4 ± 2.1 vs 7.1 ± 1.4 P = 0.639, 1.0 ± 1.0 vs 1.9 ± 1.2 P = 0.025, 1.2 ± 1.1 vs 1.6 ± 1.3 P = 0.208, respectively. Comparison of the mean dysphagia score between the POEM group and the LHM group at preoperatively, 3 mo and 6 mo postoperatively were 2.9 ± 0.3 vs 2.8 ± 0.3 P = 0.593, 0.5 ± 0.8 vs 1.0 ± 0.5 P = 0.009, 0.8 ± 0.9 vs 0.8 ± 0.6 P = 0.463, respectively. Treatment success (Eckart score B 3) in the POEM group and the LHM group were 100 % and 91.3 % at 3 mo and 6 mo follow-up. Heart burn symptoms presented postoperatively in the POEM group in 1 patient (10 %) while LHM with fundoplication in 2/13 (15.4 %) and LHM without fundoplication in 4/10 (40 %). Minor complications in the POEM group were found in 3 patients (30 %), an esophageal mucosal tear in one, a tear at the hypopharynx in one and esophageal wall necrosis in one that improved with conservative treatment. Capnoperitoneum was found in 2 patients (20 %) in the POEM group. One patient (4 %) in LHM group had an esophageal mucosal tear and was repaired intraoperatively. There was no postoperative mortality. Conclusions: POEM and LHM have similar relief in patient symptoms in the early period. Minor complications can be resolved by using endoscopic and conservative treatment. POEM is comparable with LHM in safety and efficacy in the treatment of achalasia.

Chang Min Lee, Jun-Min Cho, You-Jin Jang, Sung-Soo Park, Seong-Heum Park, Seung-Joo Kim, Young-Jae Mok, Chong-Suk Kim, Jong-Han Kim, Korea University Medical Center

Introduction: The emergence of robotic-assisted general surgical procedures continues to grow as literature on safety and feasibility becomes available. There is a little data comparing the safety and efficacy of robotic-assisted Nissen fundoplication (RN) versus conventional laparoscopic Nissen fundoplication (LN). Objective: To compare the safety, efficacy, and feasibility RN versus LN. Participants: A multi-surgeon, prospectively maintained database was used to identify 25 patients who underwent RN during the time period between April 2013 and August 2014. A case matched cohort of 16 LN performed during that same time period was identified for comparison. The RN cohort consisted of 19 females (76 %), with a mean age of 55.1 years, and a mean BMI of 28.8. The LN cohort consisted of 10 females (62.5 %), with a mean age of 60 years, and a mean BMI of 28.7. Results: There was no statistical difference in demographic data between the two groups (including age, gender, and BMI). A hiatal hernia was identified in 68 % of patients undergoing RN on either UGI study or EGD compared to 88 % in the LN cohort. The mean operative time for the RN cohort was 256 minutes compared to 277 for the LN cohort (p = 0.26). The mean estimated blood loss for the RN cohort was 26.2 mL compared to 26.6 mL for the LN cohort (p = 0.95). The mean hospital length of stay for the RN cohort was 2.2 days compared to 1.9 for the LN cohort (p = 0.4). There was one return to hospital in the RN cohort and there were no intraoperative complications or mortalities in either group. The mean follow up for the RN cohort was 240 days versus 465 days in the LN cohort (p = 0.0009). Outcomes after Nissen fundoplication were similar in terms of anti-reflux medication use and reflux symptoms. Conclusion: In our retrospective case control study there was no significant difference in operative time, estimated blood loss, hospital length of stay, or complication rate between the RN and LN cohorts. There was a statistically significant difference in mean follow up period between the two cohorts likely attributable to selection bias in selecting our matched cohort.

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Can Resting Metabolic Rate (RMR) be Accurately Measured in the Obese Population and Is It a Predictor of Postoperative Weight Loss in Patients Undergoing Laparoscopic Vertical Sleeve Gastrectomy (VSG)?

Per-oral Endoscopic Myotomy: The Preferred Method of Myotomy in the Morbidly Obese

Andrew R Brownlee, MD, Erica N Bromberg, BA, Deodate Davis, BA, Mitchel Roslin, MD, FACS, Lenox Hill Hospital Introduction: Weight loss and gain are due to an imbalance of energy consumption and utilization. The impact of RMR on weight loss following VSG is unknown. As a result we wanted to answer whether a morbidly obese cohort has higher or lower RMR, if VSG increases resting energy expenditure thus reducing the predicted reduction in RMR with weight loss and if those with a faster preoperative metabolic rate will loose more weight postoperatively. Methods: Fifty patients who underwent a VSG had their RMR measured preoperatively and at intervals of 1, 3 and 6 months post-op using an indirect calorimeter. Hey were made NPO for five hours prior the study. Predicted RMRs were determined using the Harris-Benedict equation. Results: There were 37 females and 13 males with a mean preoperative BMI of 42.8. The ratio of actual to predicted RMR preoperatively was 0.96. There was no statistically significant difference in the actual and predicted RMR at any time point. The quartile of patients with the highest RMR was on average 19 % above predicted. These patients lost 18 % of their total body weight (TBW) at the longest point of follow-up while the patients with the lowest quartile RMR were, on average 27 % below predicted and lost 20 % of their TBW. Conclusion: Measured RMR is not significantly different than predicted in this cohort. Decline in RMR following VSG occurs as would be predicted, indicating that VSG does not increase resting energy expenditure. Individuals with higher than predicted metabolic rates do not loose more weight post-VSG suggesting that other post-operative factors are responsible for weight loss rather than intrinsic metabolic rate.

Angela Laface, MD, David Bromberg, MD, Steven B Clayton, MD, Joel Richter, MD, Vic Velanovich, MD, University of South Florida Introduction: Achalasia, which was previously a disease of patients of low or normal weight, is now being diagnosed in patients who are morbidly obese. This poses challenges in surgical treatment as visualization of the esophageal hiatus can be compromised in such patients and the risk of postoperative hiatal hernia is greater. In addition, morbidly obese patients would be candidate for bariatric surgery and prior hiatal surgery may be compromised by a laparoscopic Heller myotomy with or without a Dor fundoplication. Per-oral endoscopic myotomy (POEM) may offer an alternative to Heller myotomy avoid these issues. We report two morbidly obese achalasia patients who were treated with POEM to illustrate these points. Case 1: A 46 year old male who initially weighed over 500 lbs. developed dysphagia. This was both to solids and liquids. He lost over 60 lbs. because of this and it greatly interfered with his professional activities. His body mass index (BMI) was 64 kg/m2. He was also considered bariatric surgery. He was evaluated and found to have type 2 achalasia. His pretreatment achalasia symptom score (best score 10, worst score 31), was 19. He underwent POEM without complications. He was discharged to home the next day. On follow-up, he reported complete resolution of his dysphagia symptoms. His postoperative symptom score was 13. Several months later, he went on to a laparoscopic gastric bypass. Case 2: A 60 year old male with multiple medical problems including coronary artery disease status post coronary stenting and multiple sclerosis, leading to being wheelchair bound, developed dysphagia to solids and liquids. His BMI was 45 kg/m2. He underwent an evaluation and was found to have type I achalasia. His pretreatment achalasia symptoms score was 27. He underwent a POEM procedure without complications. He was discharge to home the next day. On follow-up, he reported great improvement in his symptoms. His postoperative symptoms score was 13. Discussion: These cases illustrate the advantages of POEM over laparoscopic Heller myotomy in the morbidly obese patient. Not only is operating in a difficult to visualized field avoided, so it leaving an unaltered field for subsequent bariatric surgery an advantage. In addition, as pneumoperitoneum is avoided, there is less cardiovascular stress in patient with cardiac disease. POEM should be consider the preferred method of myotomy in the morbidly obese

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A Thoracoscopic and/or Laparoscopic Approach to Epiphrenic Diverticula Is an Alternative to Thoracotomy

Comparison of Laparoscopy-Assisted by Open Distal Gastrectomy with Lymph Node Dissection for Stage I Gastric Cancer in the Elderly (over 80 Years Old)

Virginie Achim, MD, Ralph W Aye, MD, Brian Louie, MD, Alex Farivar, MD, Swedish Medical Center, Division of Thoracic and Esophageal Surgery Introduction: The traditional approach to epiphrenic diverticula is thoracotomy, diverticulectomy, and myotomy to address dysmotility with/without partial fundoplication. A laparoscopic approach has been advocated but access to higher diverticula is problematic. We hypothesized a thoracoscopic and/or laparoscopic approach may overcome these challenges and sought to review our results. Methods and Procedures: A retrospective review from 2004 to 2013 identified 13 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck above the GEJ: group A \ 5 cm, group B [ 5 cm. Preoperative studies including EGD, manometry, and UGI, presenting symptoms, location and size of the diverticulum, as well as type of surgery performed were recorded. Post-operative complications, mortality, and clinical outcomes using quality of life metrics (QOLRAD, GERD-HRQL and Eckardt score) and objective testing were assessed. Mean follow up was 19 months. Results: A motility disorder was identified in 11/13. The mean size of the diverticulum was 2.7 cm (2–4 cm); and the mean height above the GEJ was 5 cm (0–12 cm); there were 7 (54 %) in group A and 6 (46 %) in group B. Group A patients underwent laparoscopic diverticulectomy, myotomy and partial fundoplication. The intended procedure in group B was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication. This was completed in 3 but myotomy was compromised in 3 due to prior myotomy and adhesions, and bleeding from platelet inhibition. All 3 had staple line leaks resulting in 1 death. At a mean follow of 19 months, the median QOLRAD scores improved from 3.29 to 5.97; GERD-HRQL improved from 22.5 to 13.5, and Eckardt scores improved from 6.14 to 1.5. Conclusions: A minimally invasive strategy for epiphrenic diverticula based on location of the diverticulum above the GEJ and utilizing selective thoracoscopy for higher diverticula was successful and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher failure.

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Yoshiyuki Kiyasu, MD, Hiroshi Kusanagi, MD, PhD, Nobuyasu Kano, Kameda Medical Center Background: Recently, the safety of laparoscopy-assisted distal gastrectomy (LADG) with lymph node dissection for early stage gastric cancer is considered to be equal with open distal gastrectomy (ODG). But in the elderly, patient only, the safety of LADG compared with ODG has not been established yet. To evaluate short term surgical safety, the outcome and the postoperative course of LADG was compared with that of ODG only in the elderly. Methods: During 2000–2013, 70 patients with Stage I gastric cancer received radical distal gastrectomy, where LADG was undergone in 21 patients, and ODG was undergone in 49 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between these groups. Data were retrieved from the database at our hospital retrospectively. Results: Between LADG group and ODG group, Sex (men/ female): 12/9 vs. 23/26, Age: 81 (80–87) vs. 82 (80–86), Body mass index (BMI): 23.6 (16.7–33.3) vs. 21.9 (16.2–32.3), American Society of Anesthesiology class (class 2/ class 3): 17/4 vs. 39/10 were not significantly different. LADG group had longer operative time [220 (151–343) min vs. 181 (92–343) min, P = 0.0013], but less blood loss [70 (20–640) ml vs. 190 (50–1380) ml, P = 0.0010] and shorter postoperative stay [11 (9–34) days vs. 15 (8–48) days, P = 0.0093]. Postoperative morbidities and mortalities were not significantly different between these two groups. Conclusion: Our data confirmed that for elderly people, the safety of LADG is not significantly different, compared with ODG. Moreover, In terms of blood loss and recovery after surgery, LADG proved to be superior to ODG, like many previous studies for younger patients.

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P180

Systematic Review and Meta-Analysis of Totally Laparoscopic and Laparoscopic Assisted Distal Gastrectomy for Gastric Cancer

Acute on Chronic Gastric Volvulus: Often a Delayed Diagnosis

Ke Chen, Yucheng Zhou, Yiping Mou, MD, FACS, Xiaowu Xu, MD, Yu Pan, Di Wu, Renchao Zhang, MD, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University Objective: To compare the safety and minimally invasive effect of totally laparoscopic distal gastrectomy (TLDG) and laparoscopic assisted distal gastrectomy (LADG) for gastric cancer by meta-analysis. Methods: The literature databases before September 2014 were extensively searched to retrieve the comparative studies of TLDG and LADG with a relevance of study goal. The data of operation time, blood loss, time to flatus, time to first oral intake, postoperative hospital stay, postoperative morbidity, pain score and the level of C-reactive protein (CRP) were analyzed. The statistical analysis was performed by RevMan 5.1 software. Results: There are seven studies meeting the inclusion criteria for meta-analysis. A total of 1738 cases with gastric cancer, of whom 727 underwent TLDG and 1056 underwent LADG, were included in this meta-analysis. Comparing with LADG, TLDG experienced less blood loss [weighted mean difference (WMD) = 22.86 ml, 95 % confidence interval (CI): 12.00–33.72, P \ 0.01)], less times of analgesic requirement (WMD = 0.58, 95 % CI: 0.35–0.81, P \ 0.01), less pain score on postoperative day 1 and day 3 (day1: WMD = 0.60, 95 % CI: 0.20–0.99, P \ 0.01; day3: WMD = 0.36, 95 % CI: 0.24–0.48, P \ 0.01), earlier time to first oral intake (WMD = 0.66 d, 95 % CI: 0.13–1.19, P = 0.01). The operation time, postoperative hospital stay, overall morbidity and anastomosis-related morbidity were similar between these two groups. Conclusions: TLDG is a safe and feasible procedure. It has several advantages over LADG including less blood loss, less pain, quicker recovery and lower inflammatory response in the early stage after surgery.

Christine Lovato, MD, Giovanni Begossi, MD, Gregory BroderickVilla, MD, Rupert Horoupian, MD, Ajay Upadhyay, MD, First Surgical Consultants Introduction: Acute on chronic gastric volvulus is a life threatening condition potentially associated with a high mortality rate. Because of the vague nature of presenting symptoms, this disease can be easily confused with a medical condition and surgical evaluation is often delayed. We are presenting our clinical series of nine patients diagnosed and treated at our institution. Methods: Nine patients presenting with acute on chronic gastric volvulus underwent surgical intervention at our institution from 2006–2013. Pre-operative symptoms including duration and type, if known, as well as comorbidities, operative details and post-operative complications were analyzed. Results: Mean age was 76 years (64–89 years). Six were male, 3 were female. All surgeries were performed during the same hospitalization and two were considered emergent, performed within 24 hours of admission. The mean duration of symptoms was 89 days (4–180 days), seven had been worked up as a medical etiology on previous admissions and sent home. Seven repairs were completed laparoscopically, one open and one laparoscopic requiring conversion. Mean operative time was 182 minutes (140–308 minutes). There was one death in the immediate postoperative period related to sepsis from gastric ischemia. Post-operative complications included 2 patients with acute renal insufficiency, two patients with anemia requiring blood transfusion, one intra-abdominal abscess, and one decubitus ulcer. One patient developed a late anastomotic stricture requiring dilation. Conclusion: Acute on chronic gastric volvulus is a rare condition that can be misdiagnosed. High level of suspicion and early surgical referral should be always considered. Surgery represents the standard of care with laparoscopy being often an effective approach with reasonable mortality and morbidity.

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P181

Intraoperative Assessment of Esophagogastric Junction Distensibility During Heller Myotomy with Endoluminal Functional Lumen Imaging Probe Device (EndoFLIP)

Effect of Nissen Fundoplication Applied at the Learning Period on Quality of Life

Reece K DeHaan, BA, Matthew J Frelich, MS, Matthew I Goldblatt, MD, Andrew S Kastenmeier, MD, Jon C Gould, MD, Medical College of Wisconsin Background: We sought to characterize the changes in EGJ distensibility at various intervals during Heller Myotomy with Dor fundoplication for the treatment of Achalasia. Intraoperative measurements were correlated with postoperative outcomes. Achalasia is a relatively rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, poor bolus clearance with swallowing and decreased distensibility in untreated patients. Methods and Procedures: This study is a retrospective review of prospectively maintained data. All patients underwent Heller myotomy for achalasia over a 10-month period. A novel functional luminal imaging probe, EndoFLIP, utilizing impedance planimetry and a bag that can be filled with varying amounts of saline solution was used for intraoperative measurements. Minimum esophageal diameter (Dmin), cross-sectional areas (CSA) and EGJ distensibility index (DI) were measured at 30 mL and 40 mL distension volumes prior to abdominal insufflation, post myotomy, and after the completion of a Dor fundoplication using EndoFLIP. DI (CSA/Pressure) is defined as the narrowest CSA and the corresponding pressure expressed in mm2/mmHg. Symptomatic outcomes were assessed up to two months post-op using the validated Achalasia Severity Questionnaire (ASQ) and Eckhardt Score. A WilcoxonSigned rank test was performed to assess significance. Results: A total of 10 patients underwent Heller myotomy during the study interval. Mean age was 56 ± 19 years. Mean BMI was 30.5 ± 9.8 kg/m2. One patient underwent a takedown of a previous fundoplication followed by reoperative Heller Myotomy and one patient had a hiatal hernia. All measures except intrabag pressure increased significantly from pre-insufflation to post myotomy for both 30 and 40 mL distension volumes (Table 1). All measures except intrabag preassure and the 30 mL distensibility index also increased significantly from pre-insufflation to postfundoplication for both volumes (Table 1). Mean ASQ score improved from 74.8 during the preoperative visit to 28.9 at 2 months postop while mean Eckhardt score improved from 8.8 to 3.0. Conclusions: Minimum esophageal diameter and EGJ distensibility increase significantly with Heller myotomy for achalasia. Symptom scores improved dramatically in all patients. Further study is necessary to determine if intraoperative EGJ distensibility testing can be used to identify patients at risk for inferior symptomatic outcomes following surgery and ultimately to allow surgeons to tailor the extent of the myotomy on an individual basis guided by EGJ distensibility metrics.

Table 1

Ali Kagan Coskun, MD, Taner Yigit, MD, Subutay Peker, MD, Ali Harlak, Orhan Kozak, MD, GATA Introduction: Gastroesophageal reflux disease is caused by chronic reflux of stomach contents through esophagus. There are many options for the treatment of gastroesophageal reflux disease such as lifestyle modifications, medications, and surgery. The optimal surgical treatment for chronic severe gastroesophageal reflux disease is Nissen fundoplication. This study aimed to evaluate the quality of life following a learning period of laparoscopic Nissen fundoplication by assessing long-term outcomes Methods: Patients had an operation of Nissen fundoplication for gastroesophageal reflux disease were included in the study. Quality of life was evaluated with SF-36 questionnaires. The questionnaires were applied for the patients who had an operation more than 3 years ago with telephone contact. Results: Twenty two patients answered the SF-36 questionnaire completely. The mean age of patients (77.3 % males, 22.7 % females) was 39.6 ± 9.1 years. The mean time period after the operation was 58.5 ± 10.2 months. There weren’t any dysphagia and gas-bloat syndrome. SF-36 questionnaire revealed a significant improvement. 21 patients (95.4 %) were completely satisfied. Conclusion: Whether the patient was operated by a surgeon at the learning period or not, Nissen fundoplication is safe and effective for the treatment of gastroesophageal reflux disease by providing a better quality of life.

EndoFLIP variables reported as mean (range)

Measurement

Dmin (mm)

CSA (mm2)

Intrabag Pressure (mmHg)

DI (mm2/mmHg)

Pre-insufflation (30 mL)

5.8 ± 1.2

26.6 ± 12.0

24.3 ± 14.8

1.43 ± 0.90

Post myotomy (30 mL)

10.4 ± 1.5*

88.1 ± 24.8*

25.7 ± 7.9

3.58 ± 1.22*

Post fundoplication (30 mL)

7.2 ± 1.6*

42.6 ± 18.9*

24.5 ± 8.0

1.71 ± 0.44

Pre-insufflation (40 mL)

7.9 ± 3.0

44.4 ± 21.3

33.3 ± 10.2

1.33 ± 0.51

Post myotomy (40 mL)

13.3 ± 1.9*

126.3 ± 59.1*

29.5 ± 8.6

4.97 ± 1.48*

9.8 ± 1.8*

78.4 ± 28.1*

30.8 ± 7.0

2.49 ± 0.51*

Post fundoplication (40 mL)

Significant differences from pre-insufflation are noted (* = pB0.05)

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Symptomatic Outcomes and Side Effects Following Fundoplication According to Gastroesophageal Junction Integrity

Outcomes After Gastrectomies in Metastatic Gastric Cancer

Max Schumm, BS, Matt Frelich, MS, M Goldblatt, MD, J Wallace, MD, PhD, A Kastenmeier, MD, J Gould, MD, Medical College of Wisconsin Background: Gastroesophageal reflux disease (GERD) is an extremely common condition. Laparoscopic fundoplication, for medically refractory cases is widely underutilized – partly due to concerns about potential side effects such as bloating, belching, and dysphagia. The severity of these side effects may vary depending on preoperative variables, namely the integrity of the gastroesophageal junction (GEJ). This study seeks to determine if patients with a normal lower esophageal sphincter (normal LES pressure, total length, and abdominal length) experience more side effects or a decreased disease-specific quality of life when compared to patients with a disrupted GEJ prior to and following fundoplication for GERD. Methods: This study is a retrospective review of prospectively maintained data. All patients underwent primary laparoscopic fundoplication for GERD at Froedtert Hospital from June 2014–May 2014. Preoperative clinical information including high-resolution esophageal manometry was entered into an IRB-approved clinical data registry. Patients were dichotomously grouped based on manometry: (1) competent defined by normal LES pressure, abdominal and total length, (2) incompetent with/without hiatal hernia (one or more abnormalities of LES compared to group 1). Symptomatic outcomes were collected up to one year using the Gastrointestinal Quality of Life Index (GIQLI) and GERD-Health Related Quality of Life (GERD-HRQL) questionnaires. Results: A total of 34 patients underwent primary fundoplication during the study interval. Thirty-two Nissen (94 %) and two (6 %) Toupet fundoplications were included. Patient characteristics did not differ significantly between the groups (age, sex, BMI, ethnicity, esophagitis, DeMeester Score). In the different groups, no significant difference in GIQLI or GERD-HRQL was detected preoperatively or postoperatively (Table 1). There were no intraoperative complications. Conclusion: In this small retrospective review, patients with an intact gastroesophageal junction at the time of fundoplication for GERD experience similar outcomes/side effects as patients with a disputed GEJ. We believe that an intact GEJ in the presence of medically refractory symptoms in patients with proven GERD (positive pH, esophagitis) is not a contraindication to surgery and that these patients do just as well following antireflux surgery.

Table 1

Introduction: Stomach cancer is the third leading cause of cancer death worldwide. The five year observed survival rate of metastatic gastric cancer is around 4 %. The role of surgery for metastatic gastric cancer is still controversial. Our objective is to investigate the outcomes of the metastatic gastric cancer patients who underwent gastrectomies. Methods: A retrospective review of patients who underwent gastrectomies for metastatic stomach cancer in Seoul National University Bundang Hospital, Korea from May 2003 to September 2013 was done using a prospectively collected gastric cancer database and electronic medical records. Results: Total 4303 patients underwent gastrectomies for gastric cancer during the study period. 153 patients with the newly diagnosed metastatic gastric cancers were included in the study. 80 (52.3 %) had poorly differentiated adenocarcinoma. 29 (19 %) had distant lymph node metastasis only. 143 (93.5 %) received systemic chemotherapy and 140 (91.5 %) had open gastrectomies. 89 (58.2 %) underwent debulking gastrectomies and 86 (56.2 %) had combined resection of organs. 18 (11.8 %) received intra-operative chemotherapy. The mean age of the patients was 57.37 ± 13.61. Mean operative time was 216.09 ± 67.16 mins. Median length of stay was 11 days (range 5–80). The 30 days post-operative mortality rate was 1.31 % (n = 2). The median overall survival for all patients was 17.5 months (range 0.8–56.2). The 1 year and 3 year overall survival rates were 64.5 % and 26 % respectively. The median overall survival between laparoscopic (32.95 % CI 5.24–58.77) versus open (17.1, 95 % CI 13.76–20.44) (p = 0.228) as well as distant lymph node only (18.7, 95 % CI 9.4–27.9) versus other metastasis (17.4, 95 % CI 12–22.8) (p = 0.4) were not statistically significant. Systemic chemotherapy (HR 0.359, p = 0.007) and R0 intent of surgery (HR 0.499, p = 0.002) were significantly related to improved overall survival. Conclusions: Our study suggests that there is a beneficial role of surgery in some of the metastatic gastric cancer patients. The systemic chemotherapy and R0 intent of surgery can improve overall survival of those patients. Welldesigned prospective clinical studies are needed to confirm our observations.

Quality of life GERD-HRQL (Score, 0–50)

GIQLI (Score, 0–144)

Preop

2wk

2mo

Competent (n = 8)

33.25 (8.8)

4.9 (2.0)

2.0 (2.0)

Incompetent (n = 26)

27.5 (8.5)

9.6 (8.2)

9.0 (9.6)

0.23

0.24

p-value

Aung Myint Oo, MD1, Young Suk Park, MD2, Dong Joon Shin, MD2, Do Hyun Jung, MD2, Sang Yong Son, MD2, Sang Hoon Ahn, MD2, Do Joong Park, MD, PhD2, Hyung Ho Kim, MD, PhD2, 1Department of General Surgery, Tan Tock Seng Hospital, Singapore, 2Department of Surgery, Seoul National University Bundang Hospital, Korea

0.24

6mo

Preop

2wk

2mo

6mo

9.0 (8.7)

75.5 (19.5)

99.8 (11.4)

105.2 (8.6)

94.5 (36.9)

10.8 (10.5)

73.8 (19.6)

92.3 (16.7)

0.80

0.88

0.36

86.4 (26.7)

91.0 (24.2)

0.26

0.85

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P185

Surgical Treatment Outcomes of Laparoscopic Gastrectomy for Advanced Gastric Cancer as Conversion Surgery

Laparoscopic Redo Fundoplication Improves Disease-Specific and Global Quality of Life Following Failed Laparoscopic or Open Fundoplication

Yoshiyuki Kawakami, PhD, Hidenori Fujii, PhD, Yuki Hirose, PhD, Japanese Red Cross Fukui Hospital Aims: We previously reported that laparoscopic gastrectomy for advanced gastric cancer could be feasible with some difficult situation such in cases with D2 lymph node dissection for metastasis. Thus we introduced laparoscopic surgery after chemotherapy for unresectable gastric cancer as conversion surgery. It is expected that our technique could be useful for treating these cases. Methods: From April of 2010 to March of 2014, 79 consecutive patients with advanced gastric cancer diagnosed as cStage IIIA/IIIB/IV were indicated for chemotherapy regimen of Docetaxel/CDDP/TS1 (DCS), CDDP/TS1 (CS), Docetaxel/TS1 (DS). We conducted to study our technique of laparoscopic gastrectomy as conversion surgery for 2 patients expected for R0/R1 resection. Results: Clinical records of 79 cases of gastrectomy for advanced gastric cancer (From April of 2010 to March of 2014) were analyzed retrospectively in background factors, operative time and number of dissected lymph nodes, length of hospital stay. Of them, Average age: 66.8, Male/Female: 22/ 7, Primary factors of unresectability were distant metastasis for lymph node (N factor) 4 cases, metastasis for peritoneum (P factor) 3, liver metastasis (H factor) 7. DCS: 1/CS: 20/DS: 8. Average periods for chemotherapy were 2 kur (DCS)/4.7(CS)/5.8(DS). Evaluation according to RECIST were PR/SD: 1 case/0(DCS), 11/1(CS), 4/0(DS). Histological therapeutic values of primary tumor were G2: 0 case/G1b: 0/G1a: 0/G0: 1(DCS), G2: 2/G1b: 6/G1a9/G0: 3(CS) and G2: 2/G1b: 0/G1a: 2/G0: 4(DS). R0 resection: 1 case (DCS), 6(CS), 3(DS), R1 resection: 0(DCS), 5(CS), 2(DS) and R2 resection: 0(DCS), 8(CS), 3(DS). R0 resection and down staging with 1 case (DCS), 5(CS) and 2(DS), G2 with 2 cases (CS) and 2(DSC). Our 2 male cases of average age of 61.0, had primary factor of unresectability of liver metastasis (H factor). Chemotherapy regimen was CS for 1 with G0 and DS for 1 with G1a. The average number of dissected lymph nodes was 8 in both cases and the median operative time was 189 min. and 289 in each. While in open surgery group the average number of dissected lymph nodes was 12 in DCS treated group, 29.4(CS) and 16.6(DS) in each. The median operative time was 322(DCS), 249(CS) and 208(DS). No major postoperative complications were observed in laparoscopic surgery cases. Conclusions: We conclude that our technique for laparoscopic surgery after chemotherapy for unresectable gastric cancer as conversion surgery could be useful for reducing invasiveness while keeping a safety and an oncologic curative effect as an attractive advantage in managing this condition.

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Sara E Martin del Campo, MD, MS, Andrew J Suzo, BS, Jeffrey W Hazey, MD, Kyle A Perry, MD, The Ohio State University Wexner Medical Center Introduction: Redo fundoplication following failed anti-reflux surgery has been shown to improve patient symptoms; however, its impact on patient quality of life remains unclear. We hypothesized that laparoscopic redo fundoplication improves disease-specific and global quality of life in patients with recurrent symptoms following failed laparoscopic or open fundoplication. Methods and Procedures: A retrospective review of a prospective database was conducted for patients undergoing redo fundoplication between August 2009 and June 2014. Outcomes of interest included symptom and quality of life scores, operative time, blood loss, complications, and subsequent procedures. Reflux symptoms and quality of life were assessed using the validated Gastro-Esophageal Reflux Symptom Score (GERSS), Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire, and the global quality of life Short Form-36 (SF-36). Dysphagia was measured on a 5 point Likert scale. Initial post-operative data were collected in the clinic setting, and follow-up was obtained by telephone questionnaire, with a median follow-up interval of 14.5 (2–40) months. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate, and a p-value of \ 0.05 was considered statistically significant. Results: Forty-six patients underwent laparoscopic redo fundoplication during the study period, 8 (17 %) following open fundoplication. Mean age was 46 ± 13 years, with a mean BMI of 29.5 ± 5.7 kg/m2, and 36 (78 %) patients were female. Patients underwent surgery for symptomatic recurrent paraesophageal hernia (n = 11, 24 %), recurrent GERD (n = 18, 39 %), or postoperative dysphagia (n = 17, 37 %), and the median time to reoperation was 3.5 (0–14) years. Mean operative time following laparoscopic repair was 139 ± 41 minutes compared to 163 ± 51 minutes following open fundoplication (p = 0.16). The median length of stay was 2 (1–15) days, and did not differ between patients with previous laparoscopic or open fundoplication. There were no perioperative mortalities, and one patient required conversion to an open procedure following previous laparoscopic fundoplication. Overall, 8 (17.3 %) patients experienced complications, including 1 patient following previous open fundoplication. Two patients with previous laparoscopic fundoplication required reoperation. Seventy-five percent of patients reported significant dysphagia at baseline compared to 25 % post-operatively (p = 0.004). Median dysphagia scores decreased from 4.5 (0–5) to 1 (0–5, p = 0.023), and 9 (20 %) patients underwent an endoscopic dilation following redo fundoplication. GERSS improved from 41 (2–68) at baseline to 10 (0–55) at follow-up (p \ 0.001), and GERD-HRQL scores improved from 30 (3–47) at baseline to 6 (0–45) at follow-up (p \ 0.001). SF-36 scores demonstrated a significant improvement in general health (p = 0.016) and a trend toward improved physical function (p = 0.079) in the post-operative period, but these improvements were not statistically significant at longer-term follow-up. Overall, 89 % of patients reported satisfaction with their operation, and 95 % reported that they would have the operation performed again given the benefit of hindsight. Conclusions: While associated with long operative times and significant complications, laparoscopic redo fundoplication produces durable improvement in reflux symptoms and disease-specific quality of life, as well as high patient satisfaction in patients following failed laparoscopic or open fundoplication.

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P187

Impact of Sleeve Gastrectomy on Gastroesophageal Reflux Disease in a Morbidly Obese Population Undergoing Bariatric Surgery

Long-Term Outcomes of Laparoscopic Paraesophageal Hernia Repair - Primary Repair vs. Mesh Buttress Repair: A Retrospective Chart Review

Le´Shon Hendricks, MD, Emanuela Alvarenga, MD, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS, Cleveland Clinic Florida

Blaire Anderson, MD, Rani Al-Sairafi, MD, Clifford Sample, MD, University of Alberta

Objectives: To analyze the incidence of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) and to compare the results in patients with preexisting and de novo GERD. Methods: We performed a retrospective review of primary sleeve gastrectomy cases performed at Cleveland Clinic Florida from 2005–2013. We compared patients that had LSGs with preexisting and de novo GERD. Results: A total of 919 patients underwent LSG. GERD was present in 38 patients (4 %) of the LSG cohort. In this cohort we identified two groups: Group A consists of 25 patients (3 %) with new onset of GERD and Group B with 13 patients (1 %) that had GERD before LSG. The diagnosis of GERD in Groups A and B was derived by symptoms and history of Proton Pump Inhibitor (PPI) treatment and/ or Upper Gastrointestinal Endoscopy (UGI) and Esophagogastroduodenoscopy (EGD); 3 patients (8 %) in addition also had pH manometry. In Group A, diagnosis based on: symptoms/ history of PPI treatment = 11 patients (44 %), UGI = 3 patients (12 %), EGD = 11 patients (44 %) and pH Manometry = 0 patients (0 %). In Group B, diagnosis based on: symptoms/ history of PPI treatment = 10 patients (77 %), UGI = 0 patients (0 %), EGD = 3 patients (23 %) and pH Manometry = 3 patients (23 %). Group A developed symptoms between 1 month and 60 months (mean of 24 months). In comparison, Group B had 6 patients (46 %) with worsening reflux symptoms at 12–78 Months (mean of 48 months) and 7 patients (54 %) reported no change of symptoms post LSG. In Group A, 1 patient (4 %) underwent simultaneous hiatal hernia repair. In Group B, 3 patients (23 %) underwent simultaneous hiatal hernia repair, with no proof of improvement of GERD. In the treatment for Group A, 1 patient (4 %) was managed with over the counter drugs, 17 patients (68 %) were treated with low dose PPI, 6 patients (24 %) with high dose PPI and 1 patient (4 %) was lost to failure of follow up. The treatment for Group B consisted of 9 patients (69 %) treated with low dose PPI and 4 patients (31 %) with high dose PPI. When medical management was unsuccessful in Groups A and B, Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) was performed. In Group A 1 patient (4 %) required LRYGB and Group B 3 patients (23 %) required LRYGB. In looking at the outcome of surgical management, the 1 patient (4 %) needing conversion in Group A did not have complete resolution of GERD symptoms after LRYGB. Of the 3 patients (23 %) needing conversion in Group B, 2 patients (67 %) had complete resolution of GERD symptoms after LRYGB (Figs. 1, 2, 3, 4, 5). Conclusion: In our study 3 % of patients developed de novo GERD (Group A), but most responded to either low or high dose PPI with 4 % needing conversion to LRYGB. Of the 1 % of patients with preexisting GERD (Group B), 23 % required conversion to LRYGB because of failure of medical treatment of which 67 % was resolved after conversion. Repair of pre-existing hiatal hernia did not seem to have an impact on postoperative GERD symptoms.

Objective: Paraesophageal hernia occurs due to weakness in the physiologic sphincter of the diaphragmatic crura. Laparoscopic surgical repair is universally accepted as the standard of care for treatment. Technique and fixation approach remain controversial with both primary tissue repairs and buttressed mesh repairs currently utilized. High rates of anatomic recurrence have been reported; however symptomatic recurrence is less common. Recurrence rates for primary repair range from 20 % to 42 %, while those for mesh repair are \10 %. This being said, mesh repair has been associated with dysphagia secondary to reactive fibrosis as well as occasional esophageal erosion, ulceration, and stricture. A previously published abstract from this center reported a statistically significant difference in anatomic recurrence rates with comparable operative time, favoring mesh repair. Recently long-term follow-up studies have revealed equivalent symptom recurrence and rate of complications between groups. Therefore, the goal of this study is to investigate the durability of different methods of paraesophageal hernia repair with longer term follow-up. Methods: The charts of 176 adults who underwent paraesophageal hernia repair by a single surgeon with either primary repair (PR) or buttressed mesh repair (BMR) between July 2004 and July 2014 were reviewed retrospectively. Operative time, incidence of postoperative complications, symptom questionnaire scores, and anatomic recurrence as determined by post-operative radiologic or endoscopic studies were evaluated. Operative characteristics and postoperative outcomes were compared using the chi-square test for nominal variables and Student’s t-test for continuous variables. Results: The mean patient age was 56.0 + 14.5 years and female percentage was 57.1 %. Buttressed mesh repair was implemented in 52.8 % of patients, 81.7 % of mesh was biologic prosthesis (small intestinal submucosa). Operative time (PR 122 + 42 min; BMR 120 + 42 min, P = 0.21) and post-operative complications (PR 20.5 %; BMR 24.7 %, P = 0.39) were comparable. At median follow-up of 12 weeks postoperatively (range 0 to 204 weeks) 137 patients (77.4 %) completed a reflux symptom questionnaire. In the BMR group 38.9 % of patients reported symptoms including heartburn, regurgitation, pain, fullness, dysphagia, and cough; compared to only 8.4 % in the PR group (P \ 0.0001). Radiologic or endoscopic recurrence rate was 15.7 % in the PR group and 15.1 % in the BMR group (P = 0.91). Conclusion: Primary tissue repair alone appears to result in comparable operative time, complication rate, and anatomic recurrence when compared to BMR. Superior results were found for PR when symptom recurrence was analyzed. Buttressed mesh repairs may not be justifiable given the increased cost of this additional step.

P188 Long-Term Functional Outcomes of Laparoscopic Resection for Gastric Gastrointestinal Stromal Tumors (GIST) Jeremy Dressler, Francesco Palazzo, Seth Stake, Asadulla Chaudhary, Adam Berger, Karen Chojnacki, Ernest Rosato, Michael J Pucci, Thomas Jefferson University Fig. 1

In LSG Cohort 3 % developed GERD, 1 % has per-existing GERD and in 96 % no GERD was diagnosed

Introduction: Laparoscopic resection has become the treatment of choice for small to medium sized gastric GIST. While longer-term oncologic data are available, quality of life outcomes are less known. Methods: Our IRB-approved prospectively maintained database was queried for patients who underwent laparoscopic gastric GIST resection from 2003–2013. Demographics, perioperative, and oncologic outcomes were collected and analyzed. Patients were contacted and asked to complete a quality of life survey consisting of the following measures: change in weight, change in appetite, early satiety, heartburn, persistent cough, chest pain, dysphagia, and regurgitation utilizing a Likert scale (1 = decrease, 3 = no change, 5 = increase). Patients also completed the Gastrointestinal Quality of Life Index (GIQLI). Results: A total of 69 patients were identified. Demographic and oncologic outcomes can be found in Table 1. Thirty-six patients completed the survey. Patients reported no change in any of the quality of life measures except for chest pain and regurgitation, although present in a minimal number of patients (3 and 4 patients respectively). The mean GIQLI score was 126.9 (validated score in normal healthy individuals equals 125.8). Conclusion: In this moderate-sized cohort, laparoscopic resection of gastric GIST appears to have minimal to no effect on quality of life outcomes, with GIQLI scores comparable to healthy individuals. This technique allows for safe and durable resection of gastric GIST without significant functional sequelae.

Fig. 2

In LSG Cohort with per-existing GERD 54 % had no change in GERD symptoms, 0 % has decrease in GERD symptoms and 46 % had an increase of GERD symptoms

Table 1

Fig. 3

Twenty five of the nine hundred and nineteen patients that developed GERD reported symptoms mostly within first year and fourth year after LSG (Mean of symptom occurrence at 2 years)

Patients (n)

69

Gender - male (%)

32 (46 %)

Age

62 years (22–89)

Length of stay

4.4 days (1–34)

Tumor size

3.98 cm (0.5–11.5)

Wedge Resection

67 (97 %)

Estimated Blood Loss

39 ml (10–500)

R0 Resection

69 (100 %)

Adjuvant Gleevac

7 (10 %)

Tumor Recurrence

1 (1.5 %)

Mean Follow-up

39.2 months (0–110.6)

Dead From Disease

0 (0 %)

Fig. 4

Six of the thirteen patients with preexisting GERD in the LSG cohort reported increased symptoms after surgery at a mean of 4 years

Fig. 5

In de novo patients 68 % were treated with low dose PPI, 24 % on high dose and 8 % not treated with PPI. In pre-existing GERD patients 69 % were treated with low dose PPI, 31 % on high dose and 0 % not treated

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P189

P191

The Long Term Outcomes of Laparoscopic Intragastric Surgery for Gastric Gastrointestinal Stromal Tumors

Does the Nissen-Hill Hybrid Repair Reduce Recurrence Rates for Uncomplicated GERD

Ken Hagiwara, Department of Digestive Surgery. Nihon University School of Medicine

Andreas M Schneider, MD, Ralph Aye, MD, Alex Farivar, MD, Eric ˜¨ res, MD, FRCSC, Candice Wilshire, MD, Brian Louie, MD, ValliA Swedish Medical Center

Backgroud: Laparoscopic intragastric resection (LIGR) became a good surgical option with its gastric functional preservation for intraluminal growth gastric gastrointestinal stromal tumors (GISTs). However, the long-term oncological and functional outcomes were unknown. Objective: The aim of this study were to evaluate the long-term outcome of LIGR for intraluminal type of GISTs. Methods: Between Jan. 2005 and Aug. 2014, a total of 11 consecutive patients undergoing laparoscopic intragastric resection for gastric GISTs in our hospital were enrolled in this study. Survival, recurrence, digestive complaint and endscopic finding were analyzed retrospectively. Follow-up assessment included abdominal CT scans every 6 months for first 2 years and yearly thereafter and endoscopy yearly. Adjuvant chemotherapy was not performed. We used Miettnen’s risk classification. Results: Patients (11 cases; 2 males and 9 females) with a median age of 70 years (range 39–84) were evaluated. The tumors were located in upper tied in all cases. The procedures included conventional approach (3 ports) in 2 cases and single port access approach in 9 cases. LIGR was possible in all case. The median operative time was 90 min (range 68–157) and the blood loss was a little. Tumors were resected successfully without tumor rupture, major peri-operative complications nor conversions to the open surgery. Mortality rate was 0 %. The median postoperative stay was 7 days (range 4–9). The median size of tumor was 30 mm (range7–48) and very low risk group was 2 cases and low risk group was 9 cases. No esophagitis was seen in endscopic finding at one year after surgery. No recurrence and no gastrointestinal complaint occurred during a median follow-up period of 32 months. Conclusions: Our study supports the evidence that laparoscopic intragastric resection for GISTs which is intraluminal type, less than 5 cm and located in upper third of stomach is feasible, safe, and effective on long-term clinical outcomes.

Introduction: In a prospective randomized controlled multi-institution trial (RCT) comparing the Nissen (LNF) and Hill (LHR) repairs we were able to show that the two repairs were equivalent in the surgical treatment of uncomplicated gastroesophageal reflux disease (GERD). However recurrence patterns differed, reflecting the inherent weakness in each repair. We therefore combined critical features of each repair to create a laparoscopic Nissen-Hill Hybrid operation (HYB). Its safety and feasibility have been studied in a separate trial. This study aims to evaluate clinical and objective outcomes of the HYB in comparison to the two established repairs. Methods: 51 consecutive patients with uncomplicated GERD (hiatal hernia (HH) \ 5 cm, normal esophageal motility, \2 cm Barrett’s metaplasia) underwent HYB in a prospective trial between 6/2011 and 12/2013. Preoperative and postoperative evaluation was standardized in accordance with the RCT and included 3 quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia) which were administered preoperatively and postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6–12 months. Endoscopy, manometry, pH testing and barium swallow were obtained preoperatively and at 6–12 months. Results were then compared retrospectively with the two cohorts from our prior RCT, which included 46 LNF and 56 LHR patients. Results: Demographic features such as age, BMI, ASA, length of stay, follow up, as well as the pre-operative clinical HH size, lower esophageal residual pressures (rLESP), esophageal motility, pH, and DeMeester (DM) score were comparable between the 3 groups. 51 patients underwent HYB repair; 44 patients were available for MT analysis. Mean follow up for HYB, LNF and LHR was 21.1, 15.3 and 18.3 months. The mortality rate was 0 %. Major complications included: intraoperative gastrotomy (HYB = 1, LNF = 2, LHR = 1), bleeding [ 200 cc (HYB = 0, LNF = 1, LHR = 2) and dilatation for dysphagia (HYB = 3, LNF = 1, LHR = 4). Postoperative QOL metrics QOLRAD and GERD-HRQL were significantly improved and equivalent between groups. MT dysphagia score was significantly better for HYB (39.1) compared to LNF (34.0) but not the LHR (36.5) group (p = 0.055). Objective Outcomes: pH and DeMeester scores were significantly improved and equivalent between groups. LESP was significantly higher in LNF (26.2) compared to the LHR (19.7) but remained comparable to the HYB (26.4); rLESP, however, was statistically higher in the HYB group (16.7) LNF (8.2) and LHR (10.0) (p = 0.014). Resumption of PPI’s was comparable between HYB (13.6), LNF (5.26 %) and LHR (9.62 %) (Yates p value = 0.65). There were two reoperations each in the LNF and LHR groups for failure and recurrent reflux. In the HYB group radiographic studies showed 2 herniations [ 2 cm on UGI, with one patient having resumed PPI’s despite negative pH testing and the other with mild symptoms not requiring intervention. There were no re-operations in the HYB group Conclusion: Our investigation shows that at mid-term follow up, the HYB repair results in equivalent clinical and objective outcomes compared to the LNF and LHR for uncomplicated GERD, though the recurrence rate may be lower. Dysphagia was significantly better than LNF, though rLESP was higher. Long-term follow up is necessary.

P190

P192

A Dysphagia/Odynophagia Survey Tool for Magnetic Augmentation of the Lower Esophageal Sphincter for Gastroesophageal Reflux Disease

Superior Mesenteric Artery Syndrome (SMAS), Case Report with Literature Review

Zachary Hanson, Heidi Ryan, MD, Audriene May, MS, Shawn Tsuda, MD, FACS, University of Nevada School of Medicine Background: The LINX Reflux Management SystemTM is a novel procedure for the management of medically refractory or complicated GERD. Dysphagia is the most common symptom associated with the implantation of this device. Odynophagia can be either an associated or a distinct complication postoperatively. This study describes patients’ swallowing-related symptoms and its impact on quality of life after the LINXTM surgery. Methods: A modified survey was developed to assess severity of dysphagia and odynophagia. The custom survey was administered, in addition to the validated SWAL-QOL, to patients who underwent the LINXTM procedure at an academic center. Patient and operative characteristics were obtained by retrospective medical records review. Results: Eight patients, who underwent the LINXTM procedure, completed the surveys at 5–38 weeks postoperatively. According to the modified survey, all patients reported dysphagia (median score = 3), whereas 75 % reported odynophagia (median score = 3) at respective week of survey completion. There is no correlation between odynophagia and dysphagia. The median total SWAL-QOL score is 90.3 and median symptom score is 87.5. There was no correlation between follow-up time and swallowing outcomes. Conclusion: Postoperative dysphagia and odynophagia may be distinct symptoms as characterized using our modified survey complemented with the SWAL-QOL. Most patients reported occurrence of swallowing problems at only a few times per week and similar severity of symptoms to healthy individuals reported in the literature. Swallowing outcomes appear to have little impact on patients’ quality of life.

123

Asem Ghasoup, MD, FACS, MRCPS, Turki Al Qurashi, MD, Mohammed Widenly, MD, MRCS, Marwan Abu Farah, Security Forces Hospital-Makkah Index Word: Superior Mesenteric artery, Aorto-mesenteric angle, Duodenojejunal anastomosis. Superior mesenteric artery syndrome (SMAS), first described by Rokitanskini in 1861, superior mesenteric artery normally forms an angle of approximately 45 between Abdominal aorta and third part of duodenum passing through this angle. In SMAS, the Patients have a narrow aortomesenteric angle in the range of 6 to 11 (mean = 8) leading to high intestinal obstruction. The diagnosis of SMAS is always by exclusion of all possible common causes. Epigastric fullness, post prandial pain, voluminous bilious vomiting, and weight loss are the most common symptoms. These symptoms are due to compression of the third part of the duodenum against the posterior structures by a narrow angled SMA. Surgery is always indicated if the non-surgical management fails. We report one case of SMA syndrome in 15 years old female who presented with epigastric pain, bilious vomiting and rapid weight loss resulting in severe duodenal compression that necessitated surgical treatment, patient underwent laparoscopic duodenojejunal bypass surgery to relieve the symptoms. Conclusion: Superior mesenteric artery syndrome (SMAS) is a rare condition caused by compression of the transverse portion of the duodenum between the superior mesenteric artery (SMA) and the aorta. Symptoms are non-specific and the diagnosis depends on high index of suspicion. This condition can be diagnosed by CT scan and it is an acceptable method for diagnosis and can be replace the arteriogram in confirming the diagnosis. Conservative management may be sufficient in early cases. Laparoscopic Duodenojejunostomy is the surgical treatment of choice

Surg Endosc

P193

P195

Rigid Endoscopic Cricopharyngeal Myotomy is Feasible, Safe and Highly Effective in the Treatment of Symptomatic Zenker’s Diverticulum

Indications for and Outcomes of Reoperation After Paraesophageal Hernia Repair

Tanveer Zamani, MD, FRCSI, Matthew Plank, PAC, James Dove, BA, Marie Hunsinger, RN, Anthony T Petrick, MD, FACS, FSSO, Geisinger Medical Center, Danville PA Introduction: Conventional surgical approaches to the treatment of Zenker’s diverticulum (ZD) are effective but risk perforation and nerve injury. Rigid and flexible endoscopic approaches to the treatment of ZD have been described using cutting and energy delivery. These are associated with a significant rate of perforation. We report our 12-year experience with rigid endoscopic stapling (RES) for the treatment of Zenker’s diverticulum. Methods: Cricopharyngeal myotomy (CPM) for the treatment of symptomatic ZD by rigid endo-stapling (RES) device was planned in 24 patients between October 1, 2002 and May 31, 2014. Procedures were performed by a single surgeon at Geisinger Medical Center. Data was collected as a retrospective cohort study. Demographic data included age, gender, and comorbidities. Outcomes data included conversion rates, complications, length of stay (LOS), change in ZD-related symptoms and recurrence. A standardized dysphagia score system (0 to 4) was used as a tool by which the patients quantified symptomatic improvement. Results: Of the 24 patients with symptomatic ZD, 13 were men and 11 were women with a mean age of 81.5 years (57–89). One patient underwent conversion to an open CPM and pexy and was excluded from analysis. All patients had general anesthesia. For the remaining 23 patients, mean LOS was 2.1 days. Two patients had LOS of greater than 2 days (5, 16 days). One due to advanced age and need for supervised home care. This patient had no complications. The second patient had recurrent aspiration. Three patients had anatomy that precluded endoscopic stapling including the patient that had an open procedure. Four patients (17.4 %) had complications (Table 1). Of the 21 patients who had successful RES, there were 2 minor complications (5 %). There were NO esophageal leaks. All 21 patients undergoing successful RES showed symptomatic improvement within 2 weeks. At last follow up (mean = 6.8 months; range 0.5–12 months) complete symptom resolution was documented in 18 patients (85.7 %). Recurrence occurred in 3 (14.3 %) patients and all 3 patients had a repeat RES with complete resolution of symptoms. Conclusions: When performed by an experienced surgeon, CPM using a RES technique is feasible and safe. Compared to CPM by flexible endoscopy with the use of energy for cutting the cricopharyngeus, our study reports lower rates of recurrence and esophageal leak. Major complications including perforation, abscesses or vocal cord paralysis were not observed. The technique is more limited by patient factors than the flexible endoscopic technique, but was successfully completed in 87.5 % of patients. In these patients RES seems to be safer and more effective.

Table 1 Complications

Pt (n)/24

Cause

Aborted (Anatomy)

1

Limited neck extension prevented exposure

Aborted (Aspiration)

1

Associated with complex esophageal motility disorder

Aborted bleeding

1

Laceration of gum to frenulum

Minor post-op bleeding

1

Lateral tongue superficial laceration

Fracture of dental bridge

1

Trauma related to Weerda laryngoscope

Yves Borbely, MD, Andrew Wright, MD, Brant K Oelschlager, MD, Carlos Pellegrini, MD, Department of Surgery, University of Washington Introduction: Paraesophageal Hernia (PEH) repair is technically challenging. Recurrence is common although most recurrences do not require re-operation. There are little published data on indications for redo PEH repair, or on outcomes of re-operation. Methods: All patients who underwent operation for recurrent PEH at a single, high-volume tertiary care center between 01/2005 and 12/2013 were analyzed. Data were obtained from a prospectively maintained database and systematic patient questionnaires. Results: Forty-six patients had surgery for recurrent PEH. Median time from initial repair was 65.2 months (range 2.7–234.5). Multiple prior attempts at repair were seen in 14 patients. Median age was 58.9 years (30.6–87.5) with a median BMI of 28.4 kg/m2 (21.3–50.3); 29 patients (63 %) were ASA C 3, 24 patients (52 %) had a Charlson Comorbidity Index [ 3. The main presenting symptom was dysphagia in 59 %, pain in 17 %, heartburn in 22 % and respiratory in 2 %. Anemia was present in 5 patients; 8 (20 %) had Cameron’s ulcers. At reoperation, the most common abnormality found was large ([10 cm) hiatus (34 patients), followed by previously unresected sac (17), wrap created using the gastric body rather than fundus (21 patients[CP1]), disrupted wrap (9), redundant fundus (8), slipped wrap (4), twisted wrap (3), 2 or more fundoplications (3), and too-tight hiatal closure (1). Closure was deemed difficult in 20 patients. Four patients underwent gastropexy to relieve volvulus only, 40 underwent repair of PEH with redo fundoplication, and in 2 a gastrectomy was performed. All operations started laparoscopically, 2 were converted to open. Three operations were emergent (2 PEH repair, 1 reduction of volvulus). No mesh was used in 10 patients, biologic mesh in 35, and Gore-Tex mesh was used in 1. Relaxing incisions in the diaphragm were needed in 4 patients and 5 had an esophageal lengthening procedure (vagotomy). Mean OR time was 227 ± 112 min. Median length of stay was 2d (range 2–88d). Perioperative (\ 30d) morbidity consisted of 9 Clavien grade I complications (19.6 %), [CP2] 10 grade II (21.7 %), 3 grade III (6.5 %), and 4 grade IV (8.7 %). There were 2 deaths (4.3 %). Readmission rate was 10.8 % (dysphagia in 4 patients, pain in 1). Follow-up C 3 months (median 11 months, range 3–91) was available for 38 (83 %) patients. Dysphagia improved in 87 %, heartburn in 79 %, pain in 61 % and respiratory symptoms in 70 %. One patient developed new onset dysphagia post-op. Diarrhea improved in 2 patients, was persistent in 2, and was a new symptoms in 8, while bloating improved in 8 patients, persisted in 3, and was new in 5. Radiologic follow-up (n = 22) revealed 9 recurrences \ 2 cm (41 %), [CP3] none of which required re-operation. One patient recurred with herniation of small bowel through a relaxing incision, which required re-operation. Two patients developed incisional hernias requiring repair. Conclusions: Re-operation after PEH repair is a complex operation in medically compromised patients. The indications and findings are varied. Most patients have a good outcome, but substantial morbidity and mortality can occur even in a high volume center.

P194 Laparoscopic Repair of Giant Hiatal Hernias with a New Type of Prosthesis: Mid-Term Results V.v. Grubnik, Prof, A.v. Malynovskyi, PhD, Odessa National Medical University Introduction: Current techniques of laparoscopic mesh repair of giant hiatal hernias are not effective as rate of recurrence reach 40 %. Thus, creation of fundamentally new methods of prosthetic hiatal repair is necessary. The aim of the study was to assess long-term results of laparoscopic tension-free repair of giant hiatal hernias with a new prosthesis. Methods and Procedures: From 2010 to 2013, 44 laparoscopic repairs of giant hiatal hernias were performed. From them, 42 patients were followed within mean period of 20.5 ± 3.8 months (range, 14–28) using questionnaires, barium study, endoscopic examinations, and 24 h pH testing. Mean hiatal surface area (HSA) was 37.5 ± 15.6 cm2 (range, 21.7–75.4). Posterior tension-free hiatal repair was performed with new prosthesis - Rebound HRD-Hiatus hernia (Minnesota Medical Development, Inc., USA) which was fixed to crura with 3–5 separated sutures. The prosthesis is heart-shaped lightweight polytetrafluorethylene (PTFE) mesh with peripheral nitinol frame. Key advantages of this revolutionary technique are: 1. Peripheral nitinol frame maintaines week tissues of the diaphragm, and, thus, prevents recurrence, 2. Easy fixation, 3. Small risk of oesophageal complications as prosthesis is made from new generation of lightweight PTFE. Results: All procedures were successfully completed. Mean time of fixation of the prosthesis was 24.8 ± 5.6 min (range, 15–35). There were no intra-operative complications associated with the repair. There were 2 symptomatic reflux recurrences (4.7 %), and 3 false (i.e. small, \2 cm) anatomical recurrences (7.1 %). True anatomical recurrences, and oesophageal strictures and erosions were absent. Conclusions: This fundamentally new method of laparoscopic repair of giant hiatal hernias is safe and provides absence of true anatomical recurrences in mid-term follow-up period. It apparently requires thorough assessment in long-term follow-up period, with further comparison with other techniques including randomized controlled trials.

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P196

P198

Manometric Changes to the Lower Esophageal Sphincter Following Magnetic Sphincter Augmentation in Patients with Gastroesophageal Reflux Disease

Introduction of the LinxÒ Reflux Management System in a Community Heartburn Center

Heather F Warren, MD, Brian E Louie, MD, MPH, Alexander S Farivar, MD, Candice Wilshire, MD, Ralph W Aye, MD, Swedish Cancer Institute and Medical Center Background: Magnetic Sphincter Augmentation (MSA) has been shown to effectively control gastroesophageal reflux disease (GERD) in patients without Barrett’s esophagus, with normal motility,\3 cm hiatal hernia, and BMI \ 35 kg/ m2. The underlying mechanism of the magnetic sphincter is based on the concept that a loose ligature increases the gastric pressure threshold required to open the lower esophageal sphincter (LES); however the exact mechanism of action is unknown. To date, no one has evaluated the physiologic effect of MSA on the LES or esophageal body function. We sought to compare the preoperative and postoperative manometric measurements for patients undergoing MSA. Methods: A single institution retrospective case control study of manometric changes following MSA. Highresolution manometry (ManoScan, 36 channels of circumferential pressure sensors and 18 impedance channels) was performed prior to, and 6–12 months following MSA. Data included preoperative and postoperative changes in time pH \ 4, DeMeester scores, GERD Health Related Quality of Life (GERD HRQL) and high- resolution manometry measurements. Results: Nineteen patients underwent pre and post-operative evaluation. Clinically, there were significant improvements in the preoperative versus postoperative GERD measurements of percentage of time pH \ 4 (11.3 % versus 3.6 %, p \ 0.01), DeMeester scores (38 versus 11.7, p \ 0.01) and GERD HRQL (21 versus 5, p \ 0.01) following MSA. Manometry findings demonstrated significant changes in the LES, including total and intra-abdominal length and integrated relaxation pressure (Table 1). Conclusions: Following magnetic sphincter implantation, the LES characteristics appear to be undergo improvement in all metrics. The manometric changes in the LES occur without significant change to the esophageal body. Understanding the physiologic manometric changes following MSA, and how these relate to changes in reflux and clinical outcomes, may further elucidate the pathophysiologic characteristics of GERD and illuminate ways to optimize disease treatment.

Table 1

Meghan Woody, MPH1, Kaitlin Willems, BS1, Hannah Vassaur, PAC2, Caleb J Wheeless, BS2, F. Paul Buckley, III, MD, FACS2, 1 Texas A&M Health Science Center, 2Scott & White Healthcare Introduction: The LINX Reflux Management System was FDA approved for use in patients with objectively proven gastro-esophageal reflux disease (GERD) and who continue to suffer despite maximum medical therapy. While multiple reports of its successful introduction and use in academic settings exist, we report our experience in a high volume community based reflux center. Methods and Procedures: The first 50 consecutive cases performed by a single surgeon were reviewed. Descriptive analysis was conducted for demographic data and operative outcomes, including operative time, hospital length of stay, complications, morbidity, and anti-secretory medication use. Comparison was made for GERD health related quality of life (HQRL) scores before and after surgery. Results: All patients undergoing surgery had objectively confirmed GERD, normal esophageal function, and a hiatal hernia less than 3 centimeters in size. There were no intra-operative complications. There was a single peri-operative complication related to a secondary procedure, and there were no peri-operative complications, readmissions, erosions or reoperations related to LINXplacement. Average operative time was 49 minutes. Mean length of stay was 0.14 days. Over an average follow up of 8 months (range 2 to 17), average GERD HQRL scores improved significantly from 25 to 6 (p-value \ 0.0001). 90 percent of patients remained off anti-secretory medication. Dysphagia was the most common post-operative complaint and while usually self-limiting, did result in a 10 % dilation rate. Conclusions: The LINX Reflux Management System is a safe and effective treatment for medically refractory GERD with significant improvement in the quality of life for these difficult to manage patients. Our results mirror other groups reporting their data relative to GERD HQRL scores, elimination of anti-secretory medication use, operative times, and dysphagia rates. The procedure can be safely and successfully introduced into the community setting by high-volume foregut surgeons.

Preoperative and postoperative manometry measurements following magnetic sphincter augmentation Preoperative

Postoperative

P value

LES Length (cm)

2.4

3.2

\0.01

Intra abdominal LES Length (cm)

1.0

2.1

\0.01

LES Basal Pressure (mmHg)

19.3

25.4

LES Integrated Relaxation Pressure (mmHg)

6.9

16

\0.01

0.06

Distal Wave Amplitude (mmHg)

74.2

103.4

\0.07

Distal Contractile Integral (mmHg-cm-s)

2158

2666

0.27

Peristalsis ( %)

92

100

0.16

P197

P199

Solo Single-Incision Laparoscopic Total Gastrectomy With D1 + Lymph Node Dissection for Proximal Early Gastric Cancer

Symptomatic and Radiographic Outcomes After Biologic Mesh Repair for Paraesophageal Hernia Repair

Sang Hoon Ahn, Do Joong Park, PhD, Hyung-Ho Kim, PhD, Department of Surgery, Seoul National University Bundang Hospital

Thomas Wade, MD, Mary Quasebarth, Sara Baalman, L. Michael Brunt, MD, Washington University in St Louis

Introduction: Single-incision total gastrectomy was reported first time in 2013 by our institution. However, it is difficult to perform intracoporeal esophagojejunostomy because of clashes between laparoscopic intruments and scope. Herein, we present the solo pure single-incision laparoscopic total gastrectomy (SITG) with D1 + lymph node dissection for early gastric cancer. Methods: From September 2013 to November 2013, 2 patients with early gastric cancer underwent solo SITG with D1+ lymph node dissection at Seoul National University Bundang Hospital. We use a commercial manual laparoscopic scope holder (laparostat, CIVCO, Iowa, U.S.), 10 mm flexible videoscope through the 2.5 cm umbilical incision. All procedures were done by the operator alone. Usual D1+ lymph node dissection and total gastrectomy was performed without any additional support. After the specimen confirmation, modified semi-loop esophago-jejunostomy using unaided stapling closure method was made by laparoscopic linear staplers. Results: The operations were finished without any accidental event or laparoscopic conversion or additional ports. Each patient’s body mass index was 22.3 and 25.6 kg/m2. The operative time was 190 and 215 minutes, respectively. The Estimated blood loss was 50 and 100 mL, respectively. Final pathologic outcomes were pT1bN0 (0/63) and pT1bN2 (4/99), respectively. All patients were discharged with no complication and complaints on the postoperative sixth day. The postoperative cosmetic result from this operation was excellent. Conclusions: These two cases demonstrated the technical possibility of solo SITG and modified semi-loop esophagojejunostomy. Further experience and research are required to confirm the safety and feasibility of solo SITG.

Introduction: The use of biologic mesh repair during laparoscopic paraesophageal hernia (PEH) repair has been associated with lower recurrence rate at 6 months but an increased recurrence rate up to 5 years after surgery. Few studies have correlated symptomatic outcomes and radiographic recurrences at or beyond one year follow-up. The purpose of this study was to evaluate patient centered outcomes and the rate of recurrent hiatal hernia C 1 year after PEH repair with biologic mesh. Methods and Procedures: A retrospective review of all primary PEH repairs with biologic mesh by one surgeon from 2003 to August 2013 was performed. All PEH repairs were performed with primary sutured cruroplasty with a biologic mesh buttress. Esophageal lengthening using a wedge fundectomy was performed selectively for short esophagus. Standardized symptom score sheets were completed pre-operatively and at follow-up visits for 5 GERD-related symptoms (dysphagia liquids, dysphagia solids, heartburn, chest pain, regurgitation); scoring used a composite of frequency and severity of symptoms on a 5 point Likert scale (maximum score 80). Barium esophagram was performed in all patients at one year and subsequently as clinically indicated. Data are mean ± SD and statistical analysis is by non-paired students t test. Results: Primary PEH repairs with biologic mesh were performed in 138 patients; esophageal lengthening was performed in 50 of these cases (48 %). One year barium swallow was completed in 104 patients (75.4 %) Fourteen of 104 patients (13 %) had evidence of recurrent hernia on barium swallow within the first year. An additional 16/104 (15 %) patients had a recurrent hernia on barium swallow at 2–5 years post operation. Symptom score sheets were completed at 1 year or more after the operation in 74/104 (71 %) patients. The average symptom score preoperatively was 8.5; at one year postoperatively it was 3.6 ± 9.8 for patients without radiologic recurrence and 1.0 ± 1.3 for those with a radiologic recurrence (p = 0.91). Patients who developed a recurrent hernia at 2–5 years had a mean symptom score at 1 year of 7.3 ± 17.1 compared to 2.0 ± 5.5 in patients who did not develop recurrence (p \ 0.11). Most recurrent hernias were small (2 cm) and only 4 patients (3.8 %) required reoperation over a mean follow-up period of 24 months. Conclusions: Recurrent hiatal hernia is common after PEH repair but most do not require reoperation. Symptom scores did not correlate with radiologic recurrence of PEH at one year. However, patients with increased symptom scores at 1 year follow up may be more likely develop a recurrent hernia at 2–5 years. These patients may benefit from more frequent follow-up and imaging.

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Surg Endosc

P200

P202

An Evaluation of Management of Perforated Ulcers at a Community Hospital

The Utilization of Laparoscopy in the Treatment of Achalasia: An Outcomes Analysis Using ACS-NSQIP Data

Julian D Maendel, MD, William B Hooks, MD, William W Hope, MD, Ashley Adams, MD, New Hanover Regional Medical Center

Chetan V Aher, MD, John C Kubasiak, MD, Imke Janssen, PhD, Daniel J Deziel, MD, Keith W Millikan, MD, Jonathan A Myers, MD, Minh B Luu, MD, Rush University Medical Center

Although less common than in previous eras, perforated gastric and duodenal ulcers can be a challenging problem for general surgeons. Multiple surgical options exist for treatment. While the role of omental patch using the laparoscopic approach is well established in the treatment of marginal ulcers, recent reports have touted its benefits in treating other gastric and duodenal perforated ulcers. The purpose of this study is to evaluate our community hospital’s approach, outcomes, and utilization of the laparoscopic approach to the management of these non-marginal perforated ulcers. A retrospective review of all patients with perforated ulcers from 10/2008 to 8/2014 was performed. Marginal ulcers were excluded. Demographic information, clinical presentation, operative management, and outcomes were recorded. Patients undergoing laparoscopic management were compared to those undergoing open repair. Data was reported in means, standard deviations, counts and frequencies. During the study period, 42 patients underwent surgical treatment for perforated gastric (31) and duodenal (11) ulcers. 20 were excluded as they not meet study criteria. The average age was 64.8 (range 21–94) and 56.4 % were male. 31 patients had at least 1 comorbidity with the most common being HTN, CAD, and GERD, and average wbc on admission was 14.1 (range 2.7–28.5). Shock (SBP \ 90) was present on admission in 13.5 %, with 43.1 % reporting symptoms for greater than 24 hours prior to admission. NSAID use was positive in 51 % and EtOH use in 23.5 %. Laparoscopic approach was performed in 27.9 % with a 50 % conversion rate. Reasons for conversion were inadequate visualization in 50 % and other in 50 %. Average operative time was 108 minutes (range 24 to 305). Overall mortality rate was 14 % and average length of postoperative hospital stay was 13.2 days (range 5 to 44). Perforated ulcers are a rare surgical emergency for general surgeons. The majority of patients at our institution undergo open repair, despite recent literature showing favorable outcomes using the laparoscopic approach in select patient populations. This study demonstrates hesitancy among general surgeons at this institution to use laparoscopy in omental patch repair of perforated duodenal and gastric ulcers, and a high conversion rate when laparoscopy is employed. We posit that this is due to a combination of surgeon lack of familiarity with the laparoscopic approach for this indication, and perhaps a need for better patient selection.

Introduction: Laparoscopic Heller myotomy (LM) has been shown in previous meta-analyses and case series from high-volume centers to have fewer complications, decreased length of stay, and better patient satisfaction when compared with open Heller myotomy (OM) for the treatment of achalasia. Overall utilization of laparoscopy, mortality, and morbidity rates from the ACS-NSQIP dataset have not been reported for the treatment of achalasia. Methods: A retrospective review of the ACS-NSQIP database from 2009–2012 was conducted. All patients diagnosed with achalasia undergoing LM vs. OM were included. The primary outcome was utilization of laparoscopy. Secondary outcomes were mortality and associated 30-day morbidity, which included return to OR, surgical site infection, postoperative pneumonia, urinary tract infection, transfusion, and sepsis. Outcomes were compared using chi-square tests for categorical variables and 2-sided t-tests for continuous variables. Secondary outcomes (mortality and complications) were further analyzed using logistic regression analysis. Results: Within the study period, 1,465 patients undergoing trans-abdominal operative intervention for achalasia were identified. LM was performed on 92 % of patients. There were no differences in patient comorbidities and demographics between the LM and OM groups. The overall mortality was 0.15 % for LM and 0 % for OM. The overall morbidity was 3.5 % for LM and 4.8 % for OM. In the logistic regression model analysis, overall complication rates were not statistically different (p = 0.49). There were no differences in return to OR, surgical site infection, postoperative pneumonia, urinary tract infection, transfusion or sepsis. Conclusion: According the ACS-NSQIP dataset, utilization of laparoscopy in the treatment of achalasia is 92 %. Despite the high adoption rate of laparoscopy in the treatment of achalasia, no statistically significant difference in perioperative outcomes was demonstrated.

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Electrical Stimulation of the LES - An Emerging Therapy for GERD Patients with Failed Esophageal Persitalsis

Retrospective Comparison Between Reduced Port Laparoscopic Distal Gastrectomy and Usual 5 Port One for Early Gastric Cancer

Alejandro Nieponice, MD, PhD, Juan M Riganti, MD, Franco F Ciotola, MD, Claudio Bilder, MD, Andres DiTaranto, MD, Fabio Nachman, MD, Adolfo E Badaloni, MD, Fundacion Favaloro Introduction: Antireflux surgery for GERD associated with failed peristalsis can be a challenge. Traditional antireflux surgery such as Nissen fundoplication is associated with high rates of dysphagia and Roux-en-y reconstruction is a significantly more invasive procedure. Partial fundoplications are traditionally employed but are not as effective in controlling reflux. Electrical stimulation of the LES (LES-EST) has emerged as a new alternative for the treatment of GERD. Briefly, the technology involves a laparoscopically implantable neurostimulator with two electrodes implanted at the LES that provide programmed electrical stimuli to improve LES function. Open-label trials report successful control of symptoms, near elimination of dependence on acid suppression medications and significant improvement of esophageal acid exposure up to three-year follow-up. Manometric studies reveal no negative effect on LES relaxation, making it an attractive treatment option for GERD patients with failed peristalsis. We report the outcome of LES-EST in 3 such patients. Methods: Three patients (mean age = 58; men = 2) diagnosed with severe GERD and failed peristalsis (aperistalsis -2; failed peristalsis -1); were found eligible for LES-EST and agreed to undergo the procedure. Peristalsis was assessed with high resolution manometry and reflux disease was diagnosed with Multichannel Intraluminal Impedance-pH testing (MII-pH). The LES Stimulation system (EndoStim, BV, The Hague, The Netherlands) was implanted using standard technique (Surg Endosc. 2013;27:1083–92) and stimulation was delivered in 12, 30 minute sessions of 5 mA, 215usec, at 20 Hz. Postop follow-up endpoints included clinical symptoms, PPI intake, HRM, MIIpH and Barium Swallow. Mean follow-up was 6 months (2–10). Results: Surgical implant was completed successfully LES-EST was initiated in all cases. At their last follow-up (8, 6 and 2 months after implantation), all patients were free of GERD symptoms and medication use with no dysphagia associated with LES-EST. First patients with aperistalsis showed normalization of his MII-pH reflux events, a 50 % improvement in his LES pressure (LES-EEP 7 mmHg at baseline to 10.5 mm Hg at 6 month) and improvement in esophageal body function with 40 % peristaltic contractions at follow-up (0 % baseline). The patient with frequent failed peristalsis showed normal barium swallow with no emptying delay and no spontaneous reflux. The third patient with aperistalsis was free of GERD symptoms and off-PPI medications at her 2 month follow-up and awaits 6 month esophageal function evaluation. Conclusions: Our small case-series represents the first report of successful use of LES-EST in patients with GERD associated with severe esophageal dysmotility. Early results confirm that LES-EST is a safe and effective treatment modality in such patients without any associated dysphagia in this particular patient population. The lack of dysphagia is particularly encouraging. Further experience is required to fully assess the role of LES-EST in this difficult group of patients

Koji Hattori, MDPhD, Takashi Ohmura, MDPhD, Yuji Koba, MD, Ken Kawamoto, MD, Yasuhiro Takemoto, MD, Higashiyamato Hospital Background: Since 2009 we had performed Single Incision Laparoscopic Cholecystectomy in 200 cases. We recognize this procedure for patients to prefer to. So in a few cases we tried to perform Laparoscopic Distal Gastrectomy for early gastric cancers with the procedures of Single Incision Laparoscopic Surgery. But these procedures have several problems for example difficult handling without keeping of triangular formation and high cost. We should consider to design the well-balanced methods between patients satisfaction and procedures difficulties and cost. Then we had constructed the new procedures with the concept of Reduced Port Surgery and some ideas. So we compared those procedures of Reduced Port Laparoscopic Distal Gasrectomy (RPLDG: n = 11) with ones of Usual 5 port Laparoscopic Distal Gasrectomy (5PLDG: n = 12) in the retrospective study. Furthermore, some comparisons were made with those in several cases of Single Incision Laparoscopic Distal Gasrectomy (SILDG: n = 2). Methods: The study enrolled 23 patients who were diagnosed clinical stage ?–? and were operated from April 2009 to June 2013 by author. Data measures were operative time, estimated blood loss, length of hospital stay, adverse events, conversions to 5PLDG or laparotomy, pain and patient satisfaction. Operative Procedure: RPLDG: We make a 25 mm vertical incision in the navel. Through the incision we insert two 5 mm ports, for the left hand forceps and the scope. And we make a left middle abdominal incision for a 12 mm port using the right hand forceps or the stapler. We mainly use a oblique-viewing endoscope and straight forceps. So we can prevent the scope and the left hand forceps from interfering in each other. Because the right hand forceps is inserted at the separated position from the navel incision, without using bent forcepses we are able to work under keeping the triangular formation. One or two needle devices usually are required to revolve the organs. After cutting the stomach by linear staplers, the specimen is taken out through the navel wound. And Billroth? reconstruction is performed with Delta anastomosis procedure under laparoscope. Results: No cases in the both groups had adverse events and were converted to other laparoscopic approaches or laparotomy. The two study groups did not differ in terms of patient demographics. The RPLDG group had a statistically significant longer operative time than the 5PLDG group (301 vs 248 min.), by the way SILDG group (348 min.) had a longest time than both groups, but no difference in operative blood loss and hospital stay. And there was no difference in the pain score. After 3 months later from operation abdominal scars of all patients in the RPLDG group were hardly recognized and these patients had grate satisfactions with their surprises. Both groups were almost same cost to use disposable goods. Conclusion/Perspective: Compared with 5PLDG, RPLDG is a feasible approach with comparable operative outcomes. We think that longer operative time of RPLDG group is acceptable and RPLDG is well-balanced procedures.

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Intraoperative Assessment of Esophagogastric Junction Distensibility During Laparoscopic Fundoplication with Endoluminal Functional Lumen Imaging Probe Device (EndoFLIP)

Intracorporeal Esophagojejunostomy by Hand-Sewn Suture under View of Laparoscopy During Total Laparoscopic Total Gastrectomy: Primary Result of 34 Cases

Elizabeth A Schoenfeldt1, Matthew J Frelich, MS2, Reece K DeHaan, BA2, Jon C Gould, MD2, 1UW-Madison, 2Medical College of Wisconsin Background: The goal in antireflux surgery is to re-establish a competent barrier to prevent excessive reflux of gastric contents into the esophagus. We sought to characterize the changes in esophagogastric junction distensibility that occurs in patients during the various stages of antireflux surgery. Methods and Procedures: This is a retrospective review of prospectively maintained data. All patients underwent laparoscopic fundoplication at the Medical College of Wisconsin between September 2013 and August 2014. A novel functional luminal imaging probe, EndoFLIP, which uses impedance planimetry with 16 electrodes at 5 mm increments within a bag that can be filled with varying amounts of saline solution was used for intraoperative measurements. Minimum esophageal diameter (Dmin), cross-sectional areas (CSA) and EGJ distensibility index (DI) were measured at 30 mL and 40 mL distension volumes prior to abdominal insufflation, after complete dissection at the esophageal hiatus, and after completion of the fundoplication using EndoFLIP. DI is defined as the narrowest CSA and the corresponding pressure expressed in mm2/mmHg. A Wilcoxon-Signed rank test was performed to assess significance. Results: A total of 28 patients underwent fundoplication during the study interval [11 primary Nissen (39 %), 1 primary Toupet partial fundoplication (4 %), and 16 reoperative fundoplications (57 %). Mean age was 56.4 years (± 13.0) and mean BMI was 28.6 kg/m2 (±5.0). Overall, Dmin and CSA decreased from prior to surgery to completion of the fundoplication. Intrabag pressure at a given volume increased following fundoplication. The distensibility index decreased significantly with the addition of the fundoplication (Table 1). Conclusions: Laparoscopic fundoplication results in a decrease in EGJ distensibility in patients with GERD. Longterm follow-up with the addition of symptomatic outcomes may ultimately allow surgeons to tailor the fundoplication based on objective, intraoperative feedback in a manner than minimizes post-operative side effects such as dysphagia, bloating, and difficulty belching.

Table 1

Yiping Mou, MD, FACS, Xiaowu Xu, MD, Ke Chen, Yu Pan, Yucheng Zhou, Di Wu, Sir Run Run Shaw Hospital, Zhejiang University Background: Although laparoscopic surgery is more and more frequently performed for the treatment of gastric cancer, total laparoscopic total gastrectomy (TLTG) is not widely performed because of its technical difficulty in intracorporeal esophagojejunostomy. Most of the intracorporeal esophagojejunostomy are performed with end-end anastomosis (EEA) or endoscopic liner stapler. We developed an intracorporeal esophagojejunostomy just by handsewn suture under view of laparoscopy, here we evaluated it’s safety and efficacy. Methods: From September 2012 to September 2014, 34 consecutive patients with upper and middle gastric cancer underwent TLTG using this intracorporeal esophagojejunostomy by the same surgical term. This procedure is performed after transection of the abdominal esophagus with endoscopic liner stapler, the sample was sent to frozen examination ensuring the margin is negative. Then, the jejunum was transected and the distal jejunal loop was brought up to reach the esophageal stump. The jejunum was anchored to the esophageal stump by several serosal muscularis interrupted sutures placed to the posterior layer of the esophageal stump. The esophageal stump was opened again and a similar size incision was made on the anti-mesenteric side of the jejunum. Then full-thickness continuous suture for the posterior wall and the anterior wall was carried out under view of laparoscopy. Results: The mean operation time of TLTG was 241.5 minutes, the mean anastomotic time was 43.2 minutes. There was no case conversion to an open procedure. Therstatus was observed at 3.5 days, and liquid diet was started at 4.6 days, and the mean postoperative hospital stay was 9.5 days. No postoperative complications related to anastomosis occurred. Conclusions: Esophagojejunostomy by hand-sewn suture under view of laparoscopy can be performed safely by experienced laparoscopic surgeon. It has the advantages of cheap and safe because of suture under direct view of laparoscopy.

EndoFLIP variables reported as mean ± (SD) Dmin (mm)

CSA (mm2)

Pre-insufflation (30 mL)

7.1 (1.6)

40.2 (16.9)

25.0 (11.4)

Takedown Hiatus (30 mL)

7.6 (2.7)

48.5 (26.5)

29.1 (14.6)

1.8 (1.2)

Post fundoplication (30 mL)

7.0 (1.4)**

38.3 (14.4)**

*32.7 (11.1)

*1.3 (0.8)**

Measurement

Pre-insufflation (40 mL) Takedown Hiatus (40 mL) Post fundoplication (40 mL)

Intrabag Pressure (mmHg)

DI (mm2/mmHg) 2.0 (1.6)

9.8 (2.1)

76.0 (30.5)

31.5 (12.1)

2.9 (2.1)

10.7 (3.2)

91.1 (45.6)

35.4 (14.2)

2.9 (2.4)

*41.6 (9.3)**

*1.8 (0.9)**

9.5 (2.2)**

69.6 (21.7)**

* indicates p \ 0.05 for Post-fundoplication compared to pre-insufflation. ** indicates p \ 0.05 for Takedown Hiatus compared to Post-fundoplication

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Comparison of Surgical Procedures Performed in Patients Undergoing First Redo vs Repeat Redo Anti-reflux Surgery

Intra-operative Complications in Patients undergoing First Redo vs Repeat Redo Anti-reflux Surgery

Harit Kapoor, MBBS, Pradeep Pallati, MD, Shunsuke Akimoto, MD, Kalyana Nandipatti, MD, Tommy H Lee, MD, Sumeet K Mittal, MD, Creighton University

Harit Kapoor, MBBS, Pradeep Pallati, MD, Shunsuke Akimoto, MD, Kalyana Nandipatti, MD, Tommy H Lee, MD, Sumeet K Mittal, MD, Creighton University

Background: A subset of patients with anti-reflux surgery require re-operative intervention. Re-operative intervention is associated with higher intra-operative complications when compared to primary fundoplication. Some patients may have recurrent failure and may require re-intervention which may have an even higher risk of complications. The aim of this study was to compare the operative anti-reflux procedures performed in patients who underwent first redo-antireflux surgery (Group A) with those who underwent re-operative anti-reflux surgery after at least one previous failed redo procedure (Group B) at our institution. Methods: All patients undergoing anti-reflux procedures are entered in a prospectively maintained database. After Institutional Review Board approval, database was reviewed to identify patients who underwent redo-anti-reflux surgery between July 2003 and July 2014. These patients were divided into two groups, one group who underwent their first redo procedure (Group A) and another group with patients who underwent their 2nd (or greater) redo antireflux procedure (Group B). Data variables analyzed include demographics, surgical procedures performed, use of mesh for hiatal approximation and use of additional esophageal lengthening procedure. Chi square test and t-tests were used to compare the various variables among the groups. Results: A total of 285 (254 with first redo, 24 with second redo, 5 with third redo and 1 each with fourth and fifth redo) underwent re-operative intervention during the study period. Group A had 254 patients (Redo-fundoplication, 69 %; Redo-Roux-n-Y, 31 %) and Group B had 31 patients (Redo-fundoplication, 64.5 %; Redo-Roux-n-Y, 35.5 %). Both groups had similar mean ages, BMI and sex distribution. Percentage of patients who underwent Roux-n-Y gastrojejunostomy were similar in both groups. In those patients who underwent redo-fundoplication, Toupet (44.6 % vs 50 %) and Nissen (37.7 % vs 20 %) were the most commonly performed in both the groups. Although not reaching statistical significance, laparoscopic approach was utilized much more in group A compared to group B (72 % vs 38.7 %). No difference was found with regards to use Collis gastroplasty (11.8 % vs 9.7 %). Conclusion: Laparoscopic approach can be acceptably undertaken while performing first redo-anti-reflux procedure but second or greater re-operative revisions are more likely to need open approaches.

Background: A subset of patients with anti-reflux surgery require re-operative intervention. Re-operative intervention is associated with higher intra-operative complications when compared to primary fundoplication. Some patients may have recurrent failure and may require re-intervention which may have an even higher risk of complications. The aim of this study was to compare the patterns of intraoperative complications in patients who underwent first redo-antireflux surgery (Group A) with those who underwent re-operative anti-reflux surgery after at least one previous failed redo procedure (Group B) at our institution. Methods: All patients undergoing anti-reflux procedures are entered in a prospectively maintained database. After Institutional Review Board approval, database was reviewed to identify patients who underwent redo-anti-reflux surgery between July 2003 and July 2014. These patients were divided into two groups, one group who underwent their first redo procedure (Group A) and another group with patients who underwent their 2nd (or greater) redo antireflux procedure (Group B). Data variables analyzed include demographics, surgical technique, operative time, estimated blood loss, hospital stay and intraoperative injuries which include perforation, solid organ injury and vagal injury. Chi square test and t-tests were used to compare the various variables among the groups. Results: A total of 285 (254 with first redo, 24 with second redo, 5 with third redo and 1 each with fourth and fifth redo) underwent re-operative intervention during the study period. Group A had 254 patients (Redo-fundoplication, 69 %; Redo-Roux-n-Y, 31 %) and Group B had 31 patients (Redo-fundoplication, 64.5 %; Redo-Roux-n-Y, 35.5 %). Both groups had similar mean ages, BMI and sex distribution. There was no significant difference in the types of fundoplication performed and approach utilized in either group. Greater number of patients had esophageal shortening in group B (16.1 % vs 9.1 %). Group B had significantly higher mean intraoperative time (224 min vs 202.9 min; p \ 0.01) and estimated blood loss (397.5 ml vs 307 ml; p \ 0.01). Among complications, the rates of intra-operative visceral perforations were significantly higher in group B (48 % versus 20.9 %; p \ 0.01) while there is no significant difference in the number of reported vagal injuries or solid organ injuries between the two groups. The median hospital stay was significantly longer in group B as compared to group A (7 d vs 3 d; p \ 0.01). Conclusion: Rate of intraoperative perforations and blood loss are significantly higher in patients undergoing their second (or greater) redo-anti-reflux surgery when compared with patients undergoing first redo-anti-reflux procedure.

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Operative Morbidity Increases with Body Mass Index in Antireflux Surgery

Is Helicobacter Pylori Associated with a Higher Risk Complication Rate in Sleeve Gastrectomy?

Michael B Goldberg, MD1, Radhika Smith, MD1, Colleen Gaughan, MD2, Huaqing Zhao, PhD1, Michael Smith, MD1, Henry Parkman, MD1, Daniel T Dempsey, MD3, Abbas E Abbas, MD1, 1Temple University Hospital, 2Abington Memorial Hospital, 3Hospital of the University of Pennsylvania

Raquel Gonzalez-Heredia, MD, PhD, Veronica Tirado, MD, Neil Patel, BS, Mario Masrur, MD, Melissa Murphey, DNP, NP-C, Enrique F Elli, MD, FACS, UIC

Purpose: Minimally invasive esophageal fundoplication is a well-established treatment for medically refractory gastroesophageal reflux disease (GERD), although its safety and efficacy in obese patients is debated. It is uncertain whether a greater body mass index (BMI) portends increased complications or inferior symptom relief postoperatively. In this study, we describe the effect of BMI on outcomes following minimally invasive antireflux surgery. Methods: All patients who underwent minimally invasive surgery for GERD from 2003–2013 at a single institution were retrospectively reviewed. Data was collected on patient demographics, comorbid conditions, preoperative symptoms, operative characteristics, complications, and follow up. Results: 176 patients underwent laparoscopic (169) and robotic (6) Nissen (119), Toupet (47), and Dor (12) fundoplications for a primary diagnosis of GERD. Of these patients, 21 % (37) were normal weight (BMI 16.1–25), 36 % (64) were overweight (BMI 25–29), and 43 % (75) were obese (BMI 29–47.2). There was no difference in operative time, conversion to open surgery, length of stay, time to oral diet, operative complications, or postoperative morbidity among these groups. However, when using logistic regression analysis controlled for age and relevant comorbidities, each 1-unit increase in BMI predicted a 9.5 % increased risk of morbidity at 30 days (p = 0.035). BMI did not impact postoperative symptoms or acid suppression medication usage at long-term follow-up (mean = 70 weeks). Conclusions: Increased BMI is associated with a statistically significant increased risk of morbidity at 30 days after MIF. Despite this, long-term efficacy is not different. Obese patients with GERD must be carefully selected for esophageal fundoplication and actively monitored for postoperative complications.

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Introduction: Few studies have reported the prevalence and consequences of infection with Helicobacter Pylori (H. pylori) among obese patients undergoing sleeve gastrectomy. It is important to determine if H. pylori infection could increase complications or influence outcomes. This study reviewed whether infection with H. pylori based on the microscopic identification within the gastric specimen has any association with post-operative leaks. Secondarily, this study also examined whether there was any difference in outcome related to post-operative % Excess Weight Loss (%EWL). Material and Methods: In this retrospective study, we reviewed the pathology reports of 400 patients who underwent sleeve gastrectomy between 2008 and 2013 at our institution. Data examined also included the preoperative body mass index (BMI), comorbidities, operative time, length of stay at hospital, perioperative and post-operative complications and %EWL in the follow-up period. Results: All 400 patients underwent a minimally invasive sleeve gastrectomy (SG). In 68 of 400 patients (17 %), H. pylori was positive in the specimen. In the H. pylori positive group, 68 patients were eligible for follow-up; and 27, 22, 11, 15 and 2 patients were seen at 6 months, 1 year, 2 years, 3 years and [ 3 years follow-up, respectively. In the H. pylori negative group, 341 patients were eligible for follow-up; and 153, 97, 40, 12 and 19 patients were seen at 6 months, 1 year, 2 years, 3 years and [ 3 years follow-up, respectively. No perioperative and post-operative (30 days) complications were registered in the H. pylori positive group. There was one post-operative leak which required an intervention in the H. pylori negative group. No others complications were reported in patients during the 36 months of follow-up. There were no significant differences comparing both groups regarding %EWL at 6, 12, 24, 36 and [ 36 months follow-up. Conclusions: In our study, the prevalence of H. pylori infection among sleeve gastrectomy patient was 17 %. In this small subset of patients with postoperative leaks, the gastric specimens were negative for H. pylori. In addition, H. pylori did not seem to have an influence on post-operative outcomes such as %EWL.

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Hill Repair After Gastric Bypass: A Case Series 1

2

2

Simon C Chow, MD , Emily Speer, MD , Amber Shada, MD , Valerie J Halpin, MD1, Lee L Swanstrom, MD2, Kevin M Reavis2, 1 Legacy Good Samaritan Medical Center, 2Providence Portland Medical Center Introduction: The symptoms of gastroesophaeal reflux disease (GERD) are frequently improved following roux-en-Y gastric bypass, however 10 to 30 % of patients have persistent or new GERD post bypass. Traditional fundoplication is not an option due to surgical disconnection of the fundus from the esophagogastric junction. Endoluminal solutions are restricted to radiofrequency treatments and efficacy of this treatment is often compromised by anatomic issues including hiatal hernia. The laparoscopic Hill repair is an anti-reflux procedure with proven durability for long-term relief of gastroesophageal reflux disease which utilizes anatomy within a few centimeters of the esophagogastric junction. We present clinical outcomes of patients with refractory GERD post-gastric bypass who underwent Hill repair. Methods: A retrospective review of prospectively collected data was performed. Data collection was approved by the institutional IRB. Data including age, gender, pre- and post-gastric bypass weight and body mass index (BMI), excess weight loss (EWL), details of the surgeries, time between gastric bypass and Hill repair, gastric acid suppression medication use, and preoperative esophageal physiology tests including esophagogastroduodenoscopy (EGD), manometry, upper gastrointestinal radiologic studies, and BRAVO or impedance pH results was analyzed. A GERD symptom questionnaire with Likert scale was administered to the patients preoperatively and 1 month postoperatively. Morbidity and mortality data at 30 days was also collected. Results: There were 3 patients who had undergone Hill repair after gastric bypass for refractory GERD. All patients were treated with maximum dose proton pump inhibitors and had refractory symptoms (heartburn, volume regurgitation). Mean BMI prior to gastric bypass was 43.2. The mean time between gastric bypass and Hill repair was 3.7 years, during which they had a mean EWL of 59.1 %. At the time of Hill repair they had a mean age of 54.4 years and mean BMI of 32.2. Pre-operative manometry revealed: baseline lower esophageal sphincter (LES) pressure 19.8, residual LES pressure 4.3 (mmHg), integrated relaxation pressure (IRP) 8.4 [mean values]. Two of the patients underwent impedance pH testing and the mean distal catheter results were: 18.5 acidic episodes, 17 non-acidic episodes and a composite DeMeester score of 43.5. The 3rd patient underwent Bravo pH testing and had 146 reflux episodes with an overall DeMeester score of 39.2. All three patients had small (2–3 cm) hiatal hernias which were concomitantly repaired at the time of Hill repair. Two patients also underwent truncal vagotomy, 1 patient had a revision of the gastrojejunostomy anastomosis with partial gastrectomy for pouch dilatation, and 1 patient had esophageal balloon dilation for gastrojejunostomy stricture. Length of stay was between 1–4 days. Preoperatively, all patients had severe continuous heartburn and reflux episodes throughout the day and night on symptom assessment form. One patient complained of occasional (1–2 times/week) chest pain and dysphagia to solid foods. Postoperatively at 1 month, there was complete symptom resolution reported in all patients. There were no 30-day complications. Conclusion: The Hill repair is a safe and effective treatment for refractory GERD in post bypass patients who have documented disease.

Use of Biologic Keyhole Mesh in Large Paraesophageal Hernias: A Safe Technique with Low Rates of Dysphagia Jeffrey R Watkins, MD, Houssam G Osman, MD, Ernest L Dunn, MD, Michael S Truitt, MD, Rohan Jeyarajah, MD, Methodist Dallas Medical Center Introduction: The purpose of our study is to identify the incidence of dysphagia in a series of patients who underwent laparoscopic paraesophageal hernia repair (LPEHR) with placement of keyhole biologic mesh. Improved outcomes have been shown with LPEHR over open techniques but there is still much debate as to the placement of mesh. Biologic mesh has shown great promise, but only the U-shaped onlay has been extensively studied. A paucity of data exists on the application of biologic mesh in a keyhole configuration, however, despite the potential for improved outcomes. Post-operative dysphagia has historically been a concern of this procedure and subsequently slowed the adoption of keyhole mesh. The advent of a new generation of biologic mesh has renewed interest in application of keyhole mesh. Methods and Procedures: We reviewed 30 consecutive patients over a two-year period who underwent LPEHR with primary suture cruroplasty, Dor fundoplication, gastrostomy tube placement and human acellular dermal matrix keyhole mesh reinforcement. All procedures were performed by a single surgeon. Patient charts were reviewed and any complaints of post-operative reflux or dysphagia were noted. Any post-operative hernia on imaging was defined as radiographic recurrence. Results: Of the thirty consecutive patients who underwent LPEHR, three patients (10 %) had preoperative dysphagia that was mild. All three of these patients had unchanged dysphagia after LPEHR with keyhole mesh. Return of mild reflux symptoms occurred in 6 (20 %) patients, of which only two had radiographic recurrence demonstrated as a a small amount of stomach about the hiatus. Repeat imaging was performed in 11 (37 %) patients at a mean follow-up of 8 months with two demonstrating radiographic recurrence. All hernias were classified as large type 3 hiatal hernias on pre-operative imaging. Overall mean follow-up was 7 months (2–27 months). Average age was 64 (31–83) while average BMI was 30 (23–39). There were no post-operative complications and no patients required re-operation. Conclusions: Laparoscopic paraesophageal hernia repair with biologic keyhole mesh reinforcement has low recurrence rates with minimal post-operative dysphagia. The traditional belief that keyhole mesh has a higher incidence of dysphagia is not a concern with the new generation of biologic mesh. We advocate using keyhole mesh in patients with large paraesophageal hernia.

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Transoral Incisionless fundoplication and Laparoscopic Nissen Fundoplication Provide Similar Improvements in Reflux DiseseSpecific Quality of Life: A 1 Year case Control Study

Is Fundoplication Necessary Following Heller Myotomy?

Matthew R Pittman1, Jennifer S Schwartz1, Sara E Martin del Campo1, W. Scott Melvin2, Kyle A Perry1, 1The Ohio State University Medical Center, 2Montefiore Medical Center Introduction: Laparoscopic Nissen fundoplication (LNF) is the standard of care for surgical management of gastroesophageal reflux disease (GERD). Transoral incisionless fundoplication (TIF) offers an endoscopic alternative that enhances the gastroesophageal flap valve and may represent a more physiologic antireflux barrier. To date, studies comparing these procedures are lacking. The objective of this study was to compare the efficacy and side effects associated with LNF and TIF in patients with symptomatic GERD. Methods and Procedures: We performed a review of all patients undergoing LNF and TIF for objectively confirmed GERD between 2010 and 2014. Patients with hiatal hernias larger than 2 centimeters, esophageal strictures, Los Angeles class C or D esophagitis, or Barrett’s esophagus were excluded from the study. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire. Dysphagia and bloating were measured on a 5 point Likert scale. Baseline and initial post-operative data were collected in the clinic setting. Follow-up was obtained by telephone questionnaire, with a median follow-up interval of 12 (6–48) months. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate, and a p-value of \0.05 was considered statistically significant. Results: During the study period, 42 patients underwent LNF and 19 underwent TIF. The groups did not differ in terms of age (48 versus 48, p = 0.87), gender (69 % female versus 53 %, p = 0.26), BMI (27 versus 29, p = 0.33), hiatal hernia (57 % versus 53 %, p = 0.79), esophagitis (28 % versus 26 %, p = 1.0), DeMeester score (40 versus 43, p = 0.57) or GERD symptoms scores. Preoperative symptoms were also similar for significant heartburn (75.0 % versus 66.7 %, p = 0.71) and bloating (65.6 % versus 66.7, p = 1.0). LNF required 84 ± 3 minutes to perform compared to 56 ± 3 minutes for TIF (p \ 0.01), and median length of stay was 1 day for both procedures (p = 0.09). Complications occurred in 1 (2 %) patient following LNF and 2 (10 %) following TIF, including one esophageal leak requiring thoracotomy and decortication. GERD-HRQL improved significantly following both LNF (31.5 to 4, p \ 0.01) and TIF (24.5 to 3.5, p \ 0.01), with no difference in the postoperative scores (p = 0.90). At follow-up, 12 % of patients were using anti-secretory medications compared to 23 % following TIF (p = 0.39). Twenty-eight percent of patients following LNF reported significant dysphagia at follow-up compared to 8 % of TIF patients (p = 0.23). Significant bloating occurred in 52 % and 17 % of patients respectively (p = 0.07). Both LNF and TIF were associated with high rates of patient satisfaction (84 % and 92 % p = 0.629). Conclusion: TIF produces similar improvements in disease-specific quality of life as those seen with LNF and both procedures are associated with high levels of patient satisfaction at 1 year follow-up. Though a higher proportion of patients following TIF tend to require anti-secretory medications, there is a trend toward decreased rates of postoperative bloating and dysphagia. TIF is associated with shorter operative times than LNF and a short length of hospital stay, but it is a surgical procedure that has potential for serious complications. Finally, larger follow-up studies are required to establish the long-term efficacy of TIF.

Reece K DeHaan, BA, Matthew J Frelich, MS, Matthew I Goldblatt, MD, Andrew S Kastenmeier, MD, Jon C Gould, MD, Medical College of Wisconsin Background: We sought to determine the impact of selective fundoplication following Heller myotomy on symptomatic outcomes and side effects of Heller myotomy for achalasia. Previous studies have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the distal esophagus when compared to myotomy without fundoplication. In these studies a full hiatal dissection was performed in each treatment arm, disrupting the natural anatomic reflux barrier. Several recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection is performed and the angle of His is preserved. Methods and Procedures: This study is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, a limited hiatal dissection was performed anteriorly (lateral and posterior phrenoesophageal attachments preserved). Symptomatic outcomes were assessed up to two years post-op using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and GERD-HRQL (Health Related Quality of Life) questionnaires. A Wilcoxon rank-sum test was performed to compare the symptom scores between the two groups preoperatively, at 6 months post-op and at over 12 months post-op Results: A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection and Dor anterior partial fundoplication (Table 1). Patient characteristics did not differ between the 2 study groups (age, sex, BMI, Chicago Classification, duration of symptoms, and symptom scores preoperatively). Symptom scores and patient satisfaction did not differ postoperatively (Table 1). Conclusions: Heller myotomy with full hiatal dissection and partial fundoplication was associated with similar improvement in achalasia symptoms, gastrointestinal disease-related and GERD-related quality of life outcomes up to one year post-op to that seen with limited hiatal dissection and no fundoplication. Our study is limited by the retrospective nature and small sample size. Further study (including pH studies) is necessary to determine if fundoplication is a necessary step in selected patients in whom a limited hiatal dissection is possible.

Table 1

Mean symptom scores by group and p-values for Wilcoxon rank-sum test

Event (Score range from best possible score to worst)

HM + LHD (n = 10)

HM + FHD and Dor (n = 21)

P value

ASQ Preop (0–100)

64.6

64.0

0.48

ASQ 6 month (0–100)

39.0

30.6

0.23

ASQ [ 12 month (0–100)

42.3

34.0

0.57

GERD-HRQL Preop (0–50)

22.8

25.9

0.50

9.0

7.7

1.00

GERD-HRQL [ 12 month (0–50)

10.2

17.4

0.21

GIQLI Preop (144–0)

77.8

81.1

0.87

GIQLI 6 month (144–0)

96.0

114.4

0.24

107.2

88.8

0.14

GERD-HRQL 6 month (0–50)

GIQLI [ 12 month (144–0)

P214 Various Methods of Laparoscopic Resection of Gastric Submucosal Tumor Accoding to Location and Growth Pattern Ji Hoon Jo, MD, Young Il Choi, MD, Ji Young Yoo, MD, Seung Hoon Lee, MD, Sang Hong Choi, MD, Ki Young Yoon, Kyung Won Seo, MD, Song I Yang, MD, Kosin University College of Medicine Background: Laparoscopic resection of gastric SMT near Esophagogastric junction (EGJ) or pylorus is a demanding surgical technique. This study aimed to assess various methods of laparoscopic resection could be applied according to the location and the growth pattern of the gastric SMT. Methods: Between March 2012 and June 2014, 29 patients with gastric SMT who underwent laparoscopic resection were included. The patients’ demographics, clinicopathologic and perioperative data were reviewed. Results: Among 29 patients had attempted laparoscopic approach, open conversions were 2 cases. Conventional wedge resection including eversion technique was performed in 14 cases, single port intragastric resection in 8, laparoscopic-endoscopic collaborating surgery in 3, each one case of stomach segmental resection, distal gastrectomy, total gastrectomy and wedge resection with prophylactic antireflux surgery. Postoperative complications were reported in 2 cases. (staple line bleeing in 1 and delayed gastric emptying in 1) Gastrointestinal stromal tumors were 21 cases (72.4 %), and benign spindle cell tumor were 3 cases. For tumors located within 5 cm to EGJ or pylorus, more nonconventional resection methods were observed. (p = 0.009) And more endophytic tumor growth was observed in this group (p = 0.000). Conclusion: Various methods of laparoscopic resection would be necessary for variously located gastric submucosal tumor. Especially for tumors located near to EGJ or pylorus and to be endophytic growth, various methods are needed to avoid aggressive resection.

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P217

Sport’s Hernia and Biologic Mesh

Abdominal Wall Ultrasound to Substantiate Diagnostic and Treatment Algorithms of Inguinal Hernia

David S Edelman, MD, Baptist Health, Doctor’s Hospital The syndrome, Gilmore’s Groin, was described in 1980. In 1992, the term ‘‘Sport’s Hernia’’ was coined and many surgeons have elucidated their approach to the painful condition in athletes. More recently, a growing number of surgeons have implemented laparoscopic mesh repair on these patients. Over 2000 laparoscopic hernia repairs have been performed by the author. A review of the data base found 133 patients who had Biologic Mesh used as part of the Sport’s hernia repair. The data was analyzed retrospectively. There were 106 males and 27 females treated. Age averaged 36.28 years (range 16–74). OR time averaged 31.14 minutes (range 15–60). There were 54 right, 49 left and 30 bilateral repairs. Adductor longus microelongation with biologic was done in 19 patients and 12 of these patients have PPM used to repair the floor of the inguinal canal. Ten patients (6 %) did not get complete improvement or developed recurrent pain. One patient had a seroma develop in the adductor repair. Biologic mesh can be used successfully for the laparoscopic repair of the posterior inguinal floor (transversalis fascia, conjoined tendon, internal ring) and open adductor repair for Sport’s Hernias. The diagnosis and treatment of Sport’s Hernias will be reviewed at presentation.

Abhijit Mahanta, MD, MS, DMAS, FMAS, Fedor Ilchenko, Professor, DM, Crimea State Medical University Introduction: This study analyzes the clinical features and feasibility of ultrasound findings of the inguinal regions to justify diagnostic and treatment algorithm for patients with inguinal hernia. Materials and Methods: Total 51 male patients with inguinal hernia were examined in age group of 28 to 56 years. Besides general clinical examination, they underwent ultra sound of groin area with real time linear transducer with frequency of 3.5–7.0 MHz scan speed. The study were conducted with a full urinary bladder. Initially the linea alba, rectus and lateral anterior abdominal muscle groups of abdominal wall were investigated. All the layers of the abdominal wall and the point of fixation to the pubic bone were visualized. On both sides, the inguinal triangle height was defined and also evaluated the condition and size of external and internal inguinal rings. The hernia sac (its contours clearly defined on pressure and coughing) and its contents were identified. Iliac vessels were visualized. To visualize the external inguinal ring sensor were placed parallel to the outer edge of the rectus muscle in the projection of the medial inguinal fossa. For visualization of the internal inguinal ring sensor were placed lateral to external iliac vessels and perpendicular to the inguinal ligament. Ultrasound signs of inguinal hernia was inguinal triangle with a visualization of the hernia sac, wide internal inguinal ring in the area of ?? the neck of the hernia sac visualized in oblique hernias. Results of the Study: According to physical examination and ultrasound findings following types of hernias were diagnosed: I oblique hernia with extended inner ring -5 patients; II oblique hernia with extended inner ring - 34 patients; III oblique hernia with disrupted inner ring - 6 patients; IV direct hernia with a large posterior wall defect in 2 patients; V direct hernia with a small rear wall defect - 8 patients; VI combination of oblique and direct hernias - 1 patient; VII femoral hernia – 1 patient; VIII - recurrent hernia - 6 patients. All patients were performed Totally Extra Peritoneal hernia repair (???). In 9 patients with type III hernia - 6 patients; IV type - 2 patients, and type VI - 1 patient mesh was fixed to the pubis symphysis, transverse fascia and hernia repair was performed. During the operation, data obtained in ultrasound was confirmed in 42 patients (84.3 %). 9 Patients were also diagnosed with bilateral inguinal hernia, which was not diagnosed during physical examination. Conclusions: 1. Ultrasound of groin is a informative method to diagnose the type of inguinal hernia. The obtained data on the characteristics echo anatomy of abdominal wall can be used to select individual methods of hernia repair in a specific patient. 2. In patients with inguinal hernias types III, IV, and VI, repair of internal inguinal ring is advisable to carry out the and fixation of the implant to the ilio-pubic region with continuous absorbable suture. Fixation with fibrin glue can also be carried out.

P216

P218

Mesh Fixation with Takers or No Fixation in Laparoscopic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair. A Prospective Trial

Improving Post-operative Pain in Patients Undergoing Laparoscopic Ventral Hernia Repair

Rahul Naik, MBBS, MS, Gen, Surgery, DNB, G, I, Surg, Rahul Hospital, Surat Background: Controversy exists regarding whether it is necessary to secure the mesh prosthesis during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. It is unknown whether fixing the mesh affects recurrence rate, incidence of neuralgia. Methods: We conducted a prospective trial comparing fixed with takers against non fixed laparoscopic TAPP inguinal hernia repairs in a series of 100 consecutive patients undergoing elective inguinal hernia repair at our hospital between January 2011 and June 2013. Results: In all, 50 non fixed and 50 taker fixed were performed in 85 patients. Patients were evaluated at a follow-up of 12 months. There was no statistical difference in the incidence of recurrence (0 to 50 non fixed, 1 to 50 fixed). The overall recurrence rate was 1 %. There was no significant difference in operative time, chronic pain or neuralgia between the two groups. Conclusion: It is not necessary to secure the mesh during laparoscopic TAPP inguinal hernia repair. It doesn’t affect post operative pain or neuralgia.

Issa Mirmehdi, MD1, Bruce Ramshaw, MD2, 1Halifax Health, 2 Surgical Momentum Introduction: Various attempts have been made to improve post-operative pain in patients undergoing laparoscopic ventral hernia repair. Despite these attempts, this operation can be very painful and require several days in the hospital. Methods: Clinical Quality Improvement (CQI) was implemented for a hernia program and included defining dynamic care processes based on the entire cycle of care for patients undergoing laparoscopic ventral hernia repair. We also defined outcome measures that determined the value of care. For this attempted process improvement, the two objective outcome measures that were collected were the length of hospital stay and the requirements for postoperative IV and PO narcotic analgesics. The subjective variable was post-operative pain. 85 consecutive patients undergoing laparoscopic ventral hernia repair were included in this process improvement attempt. Results: Analysis of data revealed that post-operative pain was the primary factor contributing to prolonged hospital stay and the requirement for a significant amount of narcotic analgesics. An evidence-based process improvement attempt was initiated after the 54th patient. The process improvement attempt included performing a pre-operative transversus abdominis plane (TAP) block to attempt to anesthetize the abdominal wall and help to control postoperative pain. The pre-operative TAP block was performed in 31 patients. Comparing the pre- and post- TAP block groups, the length of hospital stay decreased by 24 % and total narcotic analgesics requirements decreased by 44 %. Conclusion: Implementing the principles of CQI can improve the value of care. In this example, length of stay and post-operative narcotic analgesic requirements were decreased after initiating a pre-operative TAP block. More examples of process improvement attempts using the principles of CQI will help demonstrate the validity of this approach.

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P221

Incisional Hernia Repair in Patients of CAPD: Optimizing Outcomes Based on the New Sages Guidelines

Laparoscopic Incisional Hernia Repair After Colorectal Surgery. Is it Possible to Maintain a Mini-invasive Approach?

Brian P Rose, MS, MPH, F A Morfesis, MD, Owen Drive Surgical Clinic of Fayetteville, PLLC

Emmanuel E Sadava, MD, Francisco Schlottmann, MD, Manuel E Maya, MD, Ana L Campos Arbulu´, MD, Natalia A Ferrentino, MD, Alejandro G Canelas, MD, Maximiliano E Bun, MD, Nicolas A Rotholtz, MD, Hospital Alema´n de Buenos Aires

Introduction: The use of a mesh material for the repair of incisional hernias in high-risk patients is often debated. To date, numerous products and techniques exists for the repair of such abdominal wall hernias. Patients on continuous ambulatory peritoneal dialysis (CAPD) represent a unique sub-group of these high-risk patients in which definitive treatment of their hernia is implicit to maintaining outpatient CAPD therapy. In this case series, we describe our institutions experience with hernia repair in CAPD patients based upon the recent SAGES guidelines for Peritoneal Dialysis Access Surgery. Methods: PD patients who presented with a primary or incisional (trocar site) defect were offered elective open repair using a biologic graft of surgeon choice. The biologic grafts utilized include Strattice (acellular porcine dermis), Permacol (cross-linked porcine dermis), and XenMatrix (cross-linked porcine dermis). Upon repair of the abdominal wall defect, patients were placed on hemodialysis for variable periods. Retrospective chart review was then conducted. Results: N = 2 patients underwent repair with acellular porcine dermis, both of which returning to peritoneal dialysis post-repair (mean 9.2 weeks). N = 1 patients underwent repair using a heavily cross-linked porcine dermis without complication and also was able to resume peritoneal dialysis readily (7 weeks). This patient has since had n = 2 recurrences requiring further surgery using a non-cross linked acellular dermal product (post renal transplantation). Lastly, n = 1 patient underwent repair utilizing a moderately cross-linked porcine dermis and developed an enterocutaneous fistula (EC), however this only required bowel rest, not explantation of the allograft. This patient was continued on hemodialysis only. Conclusions: This small, long-term case series is consistent with the recommendations put forth by SAGES suggesting that concomitant hernias should be fixed timely in CAPD patients in order for those patients to minimize risks of dialysate leak, thus no longer making them acceptable candidates for therapy.

P220 Evaluation of Peritoneal Closure Techniques Following Laparoscopic and Robotic Inguinal Hernia Surgery with Mesh Implantation Marc R Leduc, MD, Jeffry T Zern, MD, Christiana Care Health System Introduction: Since it was first introduced, Laparoscopic inguinal hernia repair using the Trans-abdominal preperitoneal approach (TAPP) has been described as a safe modality for repair of inguinal hernias. Perhaps the main difference between TAPP and other types of inguinal hernia repair is that TAPP inherently involves the creation of a peritoneal defect. Over the years many methods for the closure of this defect have been introduced. More recently these techniques have involved the use of barbed, self-anchoring suture devices. There have been several reports of complications associated with the use of barbed sutures. This study compares the use of barbed suture since their introduction at our institution with that of all other peritoneal closures. Methods: We conducted a retrospective review of all of the laparoscopic and robotic TAPP repairs performed at our institution between January 2012 and September 2014. We evaluated the type of peritoneal closure and any associated complications. Results: In total we evaluated 234 patients who underwent 294 hernia repairs. The age range of the patients was from 21 to 92 years old with an average age of 55 years old. 8.5 % of the patients were female (20/234), and 91.5 % were Male (214/234). The types of hernias repaired included indirect, direct, pantaloon, recurrent or unspecified. The surgeries were performed by a total of 15 different surgeons. Types of mesh used in the hernia repairs included 3D Max (52.9 %), Ultrapro (41.0 %), PhysioMesh (3.4 %), Proceed (0.8 %) and Polyprophylene (1.9 %). 19 of the 234 (8.1 %) cases were performed with the use of the DaVinci Robotic System. Methods to close the peritoneal opening included the EMS Stapler 54.1 % (159/294), Endopath Tacker 0.6 % (2/294), Ligamax 0.6 % (2/294), Protack 1 % (3/394), Secure Strap 9.8 % (29/294), Surgidac endo-stitch 0.3 % (1/294), Stratafix suture 6.1 % (18/294) and V-lock suture 22.1 % (65/294). In total 83 closures or 28.2 % were performed with barbed suture. There were no cases of small bowel obstruction noted with any method of peritoneal closure. There was 1 case of bleeding from the peritoneal closure with barbed suture requiring return to the operating room. Complication rates at 1.2 % and 0 % were not statistically significant (p = 0.11). There were a total of 4 recurrences. Conclusion: The use of barbed sutures for closure of the peritoneum is a relatively new method that is becoming more popular at our institution. Its increasing use has been multifactorial. Robotic inguinal hernia repair is being performed more frequently and barbed suture has been the preferred method of peritoneal closure in these cases. In addition the EMS stapler, which had been the most common method of closure, has now become unavailable. We found no statistical difference between the operative complications following various methods of peritoneal closure. The bleeding complication we observed is a potential risk to all closure methods. We found no complications that can be considered a direct result of the barbed suture. We conclude that barbed suture is a safe and effective method to close the peritoneal defect in trans-abdominal pre-peritoneal inguinal hernia repairs.

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Introduction: Although several benefits had been described in laparoscopic surgery, hernia formation at trocar and specimen retrieving sites is not uncommon. Mini-invasive approach to treat this complication may reduce postoperative morbidity. However, there is lack of evidence concerning laparoscopic repair of incisional hernia after laparoscopic colorectal surgery (LCRS). The aim of this study was to evaluate the feasibility and the results of laparoscopic incisional hernia repair after laparoscopic colorectal surgery compared with open approach. Methods and Procedures: From May 2001 to March 2014 all charts of consecutive patients who underwent LCRS and developed incisional hernia were evaluated. Patients who had incisional hernia after open colorectal resection were included in an intention-to-treat analysis. Those patients with paraostomal hernias and those with less than 6 months of follow up were excluded. Patients were divided in two groups: laparoscopic repair group (LR) or open repair group (OR). Decision making on the approach was based on surgeon´s discretion. Demographics, operative factors and 30-day postoperative complications were analyzed. Results: During the period of the study 1290 LCRS were performed. An incisional ventral hernia rate of 7 % was found and a total of 82 incisional hernia repairs were performed. In 49 patients (60 %) an open approach was performed and there were 33 laparoscopic repairs (2 converted to open due to small bowel injury). Demographics included age of 62 ± 14,8 years, 65 % were male and the average body mass index was 27,4 ± 5,2 kg/m2. Smoking and chronic obstructive pulmonary disease were more frequent in LR (LR: 54 % vs OR: 26 %, p = 0.02; LR: 42 % vs OR: 12 %, p \ 0.01; respectively). There were 6 % (8 patients) of trocar-site incisional hernias and no difference was found with comparing midline and off-midline incisions (p = NS). Mean defect size was: 56 (4–527) cm2 and no significant difference between groups was identified (LR: 48 cm2 vs OR: 64 cm2; p = NS). Average operative time was 107 (45–240) minutes (LR: 93 min vs OR: 116 min, p = 0.02). The open approach showed a higher rate of postoperative complications (OR: 51 % vs LR: 18 %, P = 0.003) and longer hospital stay (OR: 2,77 ± 4 d vs LR: 0,7 ± 0.4 d; p = 0.02). The recurrence rate was 15 % (12 patients, 6 each group; p = NS) with a follow up of 48 (r: 6–141) months. Conclusions: Laparoscopic approach for incisional hernia repair after LCRS seems to be safe and feasible, maintaining benefits of mini-invasive surgery as well. In addition, patients who received laparoscopic approach showed lower postoperative complications and reduction in length of hospital stay. These observations suggest that miniinvasive surgery may be the initial approach in patients that develop an incisional hernia after LCRS and prospective investigations are warranted.

Surg Endosc

P222

P223

Use of Biologic Material for Grade 2 Ventral Hernia Repair, Is it Worth the Cost?

Ventral Hernia Repair with Porcine Dermis Collagen Implant: The Cleveland Clinic Experience

Shoshana Hacker, MD, Bradley Putty, Bharti Jasra, Brian Holt, Saint Louis University Hospital

Mena Boules, MD, Ricard Corcelles, MD, PhD, Ramona Ilie, MD, Connor Wathen, BS, Andrea Zelisko, MD, Dvir Froylich, MD, Kevin El-Hayek, MD, John Rodriguez, MD, Stacy Brethauer, MD, Steven Rosenblatt, MD, Matthew Kroh, MD, Cleveland Clinic

Introduction: Ventral hernias are one of the most common surgical complications general surgeons face today, with more than 1 million abdominal wall hernia repairs performed in the US each year. While mesh reinforcement of ventral hernia repair is accepted as the standard of care to reduce recurrence rates, the choice of mesh type remains a dilemma for many surgeons. In an attempt to assist in better defining preoperative risk, the Ventral Hernia Working Group has stratified cases into a 4-tier grading system based on risk of developing a surgical site complication. Although the group recommends consideration of biologic mesh use in high risk grade 3 and 4 hernias, and synthetic mesh for low risk grade 1 hernias, no clear recommendations are made for the moderate risk grade 2 hernias. We sought to evaluate the outcomes of grade 2 hernia repairs in our institution based on employment of synthetic versus biologic mesh. Hypothesis: There is no significant reduction in infection or non-infectious surgical site occurrence (SSO) rates between grade 2 ventral hernia repairs using biologic mesh as compared to synthetic mesh. Methods: A retrospective analysis of ventral hernia repairs performed between 2004 and 2013 at a single academic institution was conducted. Demographic data to include medical comorbidities such as American Society of Anesthesiologists class, smoking, obesity, diabetes, COPD, steroid use, and previous wound infection were gathered, and subjects meeting the Modified Hernia Grading Scale criteria for grade 2 were selected. Subjects were divided based on use of synthetic versus biologic mesh use. Primary endpoints included SSO and infection, and recurrence was analyzed as a secondary endpoint. Results: A total of 158 subjects underwent repair of a grade 2 ventral hernia (102 with synthetic mesh vs. 56 with biologic mesh). Demographics were similar between synthetic and biologic groups, with no significant differences in age (51.5 vs 51.8), male gender (49 % vs 55 %), diabetes (23.5 % vs 17.9 %), obesity (45 % vs 34 %), immunocompromised (5 % vs 9 %), or ASA class (2.6 vs 2.6). The synthetic group was more likely to include higher BMI (34.1 vs 30.1, p \ .01) and smokers (45.1 % vs 21.4 %, p \ .01), though COPD was not significantly different (12.8 % vs 3.6 %, p = .09). Mean follow up was 450 days. There were no differences in infection (11.8 % vs 7.1 %, p = .36), non-infectious SSO (12.7 % vs 10.7 %, p = .71), or recurrence (18.4 % vs 13.5 %, p = .44).

Introduction: Ventral hernia repair (VHR) is a common procedure, which continues to challenge general surgeons due to the complexity of repair. Outcomes of VHR are attributed to multifactorial characteristics including but not limited to the patients co-morbid disease, surgical approach, and material used for closure of the defect. This study aims to evaluate the outcomes and utilization of a specific porcine dermis collagen implant (PDCI) (Permacol) during VHR. To the best of our knowledge, this is the largest retrospective single institutional study evaluating this implant to date. Methods: Records of 5485 patients that underwent VHR repairs from June 1995 to August 2014 were analyzed retrospectively. Data collected included baseline patient demographics, peri-operative parameters, surgical approach, additional procedures during VHR, post-operative complications, recurrence rates, and follow-up time. Parameters were analyzed using paired and unpaired students t-test for continuous variables and Chi-square test for categorical variables. Uni- and multivariate analyses were used to assess the risk factors for ventral hernia recurrence after PDCI. Results: 361 Patients were identified to have received PDCI for VHR during the 9-year study period. The cohort had a male-to-female ratio of 164:197, mean age of 56.7 ± 12.5 years; mean body mass index (BMI) of 33.0 ± 9.9 kg/m2. American Society of Anesthesiologist (ASA) classification of the patients’ distribution was: class I (1.3 %), class II (29.6 %), class III (61.7 %) and class IV (7.5 %). At baseline, a total of 179 (49.5 %) had hypertension (HTN), 88 (24.3 %) diabetes, 59 (16.3 %) were under immunosuppressive or steroids treatment, 52 (14.4 %) had coronary artery disease (CAD), 35 (9.6 %) chronic pulmonary obstructive disease (COPD), and 75 (20.7 %) were active smokers. Primary VHR with PDCI was performed in 210 patients (58.1 %), while recurrent repair was performed in 151 patients (41.9 %). Additionally, the mean number of previous VHR was 0.4 ± 0.5 (range 0–5). Open surgery was performed in 347 (96.1 %) patients. PDCI surgical placement method was onlay (n = 76, 21.0 %), sublay/underlay (n = 256, 70.9 %), inlay (n = 26, 7.2 %), and not specified (n = 3, 0.8 %). Component separation technique was reported in 148 (40.9 %) patients. Mean PDCI size was 297.7 ± 180.7 cm2. Concomitant surgical procedures were performed in 173 (47.9 %) patients and included; colorectal (n = 47), stoma related (n = 30), both (colorectal and stoma, n = 32), and others (n = 64). Mean operative time and estimated blood loss was 244.4 ± 129.0 minutes and 274.2 ± 384.1 mL, respectively. Early post-operative complications (first 30 days) were reported in 141 (39.0 %) of patients, with wound infection (26.9 %), seroma (13.4 %), and postoperative ileus (12.7 %) as the most frequent. The re-operation rate less than 30 days was 3.3 % (n = 12). After 16.3 ± 20.3 (max: 105) months follow-up, hernia recurrence was documented in 63 (17.4 %) of the 361 patients. Multivariate regression analysis of all variables confirmed age (p = 0.05), male gender (p = 0.04), and reoperation at first 30 days (p = 0.02) as predictive factors of recurrence. Conclusion: PDCI surgical implant is a relatively safe alternative in VHRs in patients undergoing concomitant surgical procedures. Age, male gender, and re-operation during the first 30 days, should be considered as predictors of recurrence.

P224 Feasibility of Robotic Inguinal Hernia Repair, a Single Institution Experience Jose E Escobar Dominguez, MD, Rupa Seetharamaiah, MD, Charan Donkor, MD, Jorge Rabaza, MD, FACS, Anthony M Gonzalez, MD, FACS, FASMBS, Baptist Health South Florida Introduction: As the discipline of laparoscopic surgery has grown technology has been developed to facilitate the performance of minimally invasive hernia repair. The current Guidelines for laparoscopic (TAPP) and Endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)] published in 2011 draw important conclusions about many points of interest in the management of laparoscopic hernia repair. Since the development of robotic inguinal hernia is recent, it is not surprising that these guidelines do not mention it. Most of the published literature regarding robotic inguinal hernia repair has been performed by urologists who have dealt with this entity in a concomitant way during radical prostatectomies. General surgeons, who perform the vast majority of inguinal herniorrhaphies worldwide, have yet to describe the role of robotic inguinal hernia repair. Methods: A retrospective chart review was performed on patients who had a robotic inguinal hernia repair from January 2014 to August 2014 at Baptist Health South Florida. Patient demographics, past medical history, previous surgeries and details related to the surgical procedure were collected. In addition, perioperative outcomes and complications were noted. The reason the robotic approach was selected for each patient was documented. Results: A total of 51 hernias were repaired in 29 patients who underwent robotic TAPP inguinal hernia repair with a prosthetic mesh using the daVinci platform (Intuitive Surgical Inc). Among them 22 had bilateral robotic herniorrhaphies. The mean age was 59.83 (SD 14.94), with a BMI of 25.84 (SD 5.38). There were 28 male patients and 1 female. Previous medical history consisted of Hypertension in 18 patients, arrhythmia in 3, and chronic renal insufficiency in 2. The primary reason for robotic approach was previous abdominal surgery in 9 cases (31.03 %), recurrent inguinal hernia in 6 cases (20.7 %), incarcerated hernia in 4 cases (13.79 %), obstetric/gynecological surgery in 1 case (3.45 %), and surgeon’s choice in 9 cases (31.03 %). The mean surgical time was 102.55 min (SD 36.47 min). Perioperative surgical complications included hematoma in 2 patients (6.9 %), 1 seroma (3.45 %), 1 urinary retention (3.45 %) and 1 surgical site infection (3.45 %), which resolved with oral antibiotics. Chronic postoperative complications included the persistence of hematomas in 2 patients (6.9 %). Same day discharge was achieved in 23 patients (79 %) with a mean length of stay of 8:39 h (SD 1:55 h). Neither mortality nor conversion to open surgery occurred. No recurrences were noted in the first 30 day post operative period. Conclusions: This early experience has demonstrated that the Robotic Transabdominal Preperitoneal (TAPP) inguinal hernia repair is a safe and versatile approach that allows the general surgeon to perform this procedure in challenging surgical scenarios. Large prospective randomized trials are needed to compare this approach to other minimally invasive choices for inguinal hernia repair.

Conclusion: The use of biologic mesh in the repair of grade 2 ventral hernia defects is not associated with a significantly lower incidence of infectious or non-infectious SSO compared with synthetic mesh. No evidence of improved recurrence rates was seen when comparing biologic mesh vs synthetic mesh in grade 2 ventral hernia patients at our institution. With the rising costs of healthcare and the uncertainty of which mesh to use in grade 2 patients, we hope this study can help guide the clinician in the appropriate selection of mesh in grade 2 ventral hernia repair.

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Abdominal Wall Reconstruction Utilizing XCM Biologic Tissue Matrix

Robotic, Laparoscopic Inguinal Hernia Repair

Rachel Andrew, MD, Ryan Juza, MD, Ann Rogers, MD, Jerome LynSue, MD, Randy Haluck, MD, Eric Pauli, MD, Penn State Hershey Medical Center Introduction: The purpose of this study was to report the results of abdominal wall reconstruction (AWR) with XCM Biologic Matrix (Synthes, West Chester, PA) in Ventral Hernia Working Group Class 3 and 4 herniorraphy. Methods: Patients undergoing AWR with XCM were identified from a prospectively collected database. XCM was utilized in two ways: definitive reconstruction with posterior component separation (PCS) or bridged repair (BR) during complex gastrointestinal (GI) reconstruction in the presence of large ventral hernias. Results: Seven patients (6 female) underwent AWR with XCM; 5 BR, 2 PCS. Six cases involved GI contamination, one involved infected mesh. Mean patient age was 58 years (range 35–73). The average defect size was 476 cm2 for PCS, 191 cm2 for BR. Complications included one surgical site occurrence managed conservatively in PCS patients and three surgical site infections (SSI) in BR patients, two requiring surgical intervention without mesh excision. Mean follow up time was thirteen months for PCS, six months for BR. One PCS patient (50 %) had a hernia recurrence at one year. This patient’s BMI was 45, and medically supervised weight loss was arranged prior to attempting another repair. Two BR patients (40 %) have recurrent hernias; both had SSI and neither are definitive repair candidates. Conclusion: This is the first multi-patient report of the use of XCM for AWR. In PCS repair, short term data suggest a low recurrence rate. Consistent with the literature, BR has a higher recurrence rate. There were no instances of chronic mesh infection. XCM performs similar to other biologic meshes in AWR.

David S Edelman, MD, Doctor’s Hospital, Coral Gables, Florida Introduction: Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and an earlier return to normal activity. Concurrent robotic inguinal hernia repair at the time of prostatectomy has been shown to have a lower recurrence rate than open repair. Robotic surgery has improved high definition visualization and articulating instruments with enhanced dexterity which could improve outcomes. A series of robotic, laparoscopic inguinal hernia repairs with mesh is presented. Methods: Three hundred thirty-five laparoscopic inguinal hernia repair operations were performed from April 2012 through August 2014. There have been 79 cases of robotic TAPP procedures done during that time. Hospital records and follow up care were reviewed. Hernias were sutured closed, re-inforced with a 12 9 15 cm PPM mesh and sealed with fibrin sealant. Results: Age averaged 57.3 years (41–75 years). Ninety percent were male. Two patients had concomitant umbilical hernia repair with mesh. ASA class averaged 2.1 with co-morbidities of hypertension, hypercholesterolemia and GERD being the most common associated conditions. OR time ranged from 35–120 minutes with a average of 69.7 minutes. OR time has continued to decrease as experience has increased. One patient with a large scrotal hernia was converted to an open repair. There were no complications but one recurrence has been documented. Conclusions: Robotic, laparoscopic inguinal hernia repair is safe and effective. OR times are longer than standard laparoscopic repair but has decreased with experience. With the increased use of robotics for hysterectomy and prostatectomy and the known presence of inguinal hernias, it is important that General Surgeons have the expertise to safely repair inguinal hernias with robotics.

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Combined Endoscopic and Conservative Treatment for Complicated Sportsman Hernia

Utility of Chest X-ray in Diagnosing Paraesophageal Hernia

Moshe Dudai, MD, Hernia Excellence, Ramat Aviv Medical Center, Tel Aviv Sport Groin injuries are very common among athletes but also in sport active people, treating in part conservatively and in part by Endoscopic surgery. Making the diagnosis for selecting the right treatment it is a challenge but in some of the cases you will need both of the treatments. There are well defined two kinds of Sport Groin Injury (SGI); the Sportsman Hernia (SH) – Posterior Wall Deficiency (PWD) and the Athletes Pubalgia (AP) – Pubic Bone Stress Injury (PBSI). The different criteria for diagnosis and treatment of this two SGI were clearly described in the Guiltiness for Sportsman Hernia as chapter of the International Endo Hernia guidelines published in Surgical Endoscopy 2011. In general the symptoms of SH are more lateral in the groin, sharp pain radiated to the inner tight aspect with neurologic characteristic, while the AP is more central, dull continues pain with inflammatory characteristic. The background pathology of SH is sport trauma causing small and irreversible tears and weakening of the posterior inguinal wall facial sheets and the adjusted tendons while in the AP there is a stress injury with edema and inflammatory process in the Symphysis Pubis, Pubic bone and ligaments including the tendons of the attached muscles; Rectus, Pyramidal and Adductors. Beside of different findings by anamnesis and physical examination, Dynamic US can demonstrate the SH pathology and MRI the AP pathology. According to the SH guiltiness and the recent update, surgery is superior to conservative treatment for SH –Level 1A of evidence- and Endoscopic Total Extra Peritoneal (TEP) retro- pubic and posterior wall mesh placement is the recommended treatment for SH with excellent results - Level 1A of evidence-. On the other hand conservative treatment of Active Isometric Weight Bering Exercises (AIWBE) is recommended for AP when quit all recovered in 8–12 weeks –Level 1A of evidence-. In our experience we found that part of the athletes presenting with findings of both types of SGI with different level of severity. SH is expressed bilateral in all but PBSI expressed in different level of severity; grade 1–5. We were impressed that the SH was the first injury and because the athlete continue with extreme sport activities on top of the SH injury, others PBSI be caused. We worked in cooperation with physiotherapist to build up a program that is a combination of Endoscopic TEP posterior wall repair and reinforcement by mesh combined with muscles sport rehabilitation. We had found that the more effective and shorter recovery combination is starting with the surgery, repairing and giving strength to the groin that act as an anchor for the active healing process of the muscles and tendons. Athletes suffered from SGI have to be diagnosed correctly of the subtype injury for selecting conservative or the surgical way of treatment. Some of the athletes having both SH and AP, in these combined treatments of Endoscopy with muscles sport rehabilitation has to be tailored to the severity of the injuries. Selecting the right treatment secures excellent results.

Abdullah Alenazi1, Lawrence Stein2, Jana Taylor2, Nayef Alqahtani2, Melina Vassiliou1, Liane Feldman1, Pepa Kaneva1, Amin Madani1, Gerald Fried1, 1Departments of Surgery, McGill University Health Center. Montreal, Canada, 2Departments of Diagnostic Radiology, McGill University Health Center. Montreal, Canada Background: While barium contrast (Ba) is the most commonly used method in the diagnosis of paraesophageal hernias (PEH), it is impractical for long-term patient follow-up post repair, given its cost, radiation exposure, procedure time and lack of patient compliance. PEH’s can be visible on chest X-ray (CXR) specially when they are large in size, however it’s diagnostic accuracy is unknown. The purpose of this study was to determine the accuracy of CXR for the diagnosis of PEH in two clinical settings: 1) patients without PEH surgery to measure the accuracy of CXR as a diagnostic tool and 2) patients after PEH surgical repair, to evaluate the accuracy of CXR as a follow up surveillance method. Methodology: A retrospective case-control study was conducted between 1997 to 2014, including patients who were evaluated with both Ba and CXR within 6 months apart. The setting without PEH surgery was composed of preoperative patients who were identified from a database of foregut surgery and diagnosed with a PEH by Ba; symptomatic patients evaluated for PEH using Ba were randomly selected from a large institutional database as their controls. The post-operative setting included patients who were identified from the foregut surgery database, underwent PEH surgical repair and had Ba as well as CXR studies[4 weeks after surgery. Three radiologists evaluated the CXR’s for the presence or absence of PEH on a dichotomous (yes/no) scale. They had different levels of experience (R1: 40 years; R2: 10 years; R3: current radiology fellow), and were blinded to the diagnosis and patient identity. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy of CXR in diagnosing PEH were calculated using Ba as the gold standard. Data are shown as Median [75th percentile–25th percentile]. Results: Eighty-nine adult patients were assessed. Fifty-four cases were included in the setting of patients without PEH surgery (27 preoperative patients with PEH; 27 control patients without PEH); thirty-five patients were included in the post-operative setting (13 with PEH recurrence; 22 without PEH recurrence); the median time of the CXRs taken after surgical repair was 5 [2–8] months. The diagnostic accuracy of CXR was similar among experienced radiologists when used as a diagnostic tool (92 % vs 92 %), but varied when used in the post-operative setting to detect recurrences (71 % vs 82 %). However, when experienced radiologists agreed on the diagnosis; the sensitivity, specificity, PPV, NPV, and accuracy were higher in both clinical settings (Table 1). Conclusion: This pilot study provides data to support the utility of CXR in the diagnosis of PEH. An agreement between the interpretations of the CXR between 2 experienced radiologists can enhance the accuracy of this technique in postoperative patients. Based on these results, a prospective study evaluating the accuracy of serial CXR assessment in diagnosing postoperative PEH recurrence is justified.

Table 1

Test characteristics of chest X-ray (CXR) in the diagnosis of paraesophageal hernia (PEH), using barium findings as the gold standard reference Patients without PEH surgery

Patients after PEH repair

R1

R2

R3

R1

R2

R3

Sensitivity

89 %

93 %

89 %

62 %

69 %

62 %

Specificity

96 %

93 %

74 %

77 %

91 %

46 %

Accuracy

92 %

92 %

81 %

71 %

82 %

51 %

PPV

96 %

93 %

77 %

62 %

82 %

40 %

NPV

90 %

93 %

87 %

77 %

83 %

67 %

Results are portrayed for 2 clinical settings: (1) Patients without PEH surgery and (2) Patients after PEH surgical repair R1: Radiologist with 40 years experience. R2: Radiologist with 10 years experience. R3: Current radiology fello. PPV: Positive predictive value. NPV: Negative predictive value

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Surgical Site Infections Following Ventral Hernia Repair: Does Operative Approach Matter?

Laparoscopic Repair of Incisional Hernia After Kidney Transplantation: A Case Report

Sara A Hennessy, MD2, Tjasa Hranjec, MD, MS1, Peter T Hallowell, MD2, Bruce D Schirmer, MD2, 2University of Virginia, 1University of Southwestern Texas

Hernan R Reyes-Sepulveda, MD, Sebastian Arana-Garza, MD, Marco A Juarez-Parra, MD, Ulises Caballero-de la Pen˜a, MD, Christus Mugerza Alta Especialidad/Universidad de Monterrey

Introduction: Approximately 3–13 % of patients with abdominal surgery develop a ventral hernia and over 350,000 ventral hernias are repaired annually. A surgical site infection (SSI) after ventral hernia repair (VHR), either open or laparoscopic, is a highly morbid complication associated with increasing health care costs, hernia recurrences, mesh infections and their complications. With the many advances in preoperative, operative and post-operative care the current incidence of surgical sites infections after laparoscopic VHR is unclear. We hypothesized that the incidence of surgical site infections is significantly reduced with a laparoscopic ventral hernia repair. Methods and Procedures: The prospectively collected American College of Surgeons’ National Surgical Quality Improvement Program database was retrospectively reviewed for all VHRs with mesh between January 2011 and May 2014 at a single institution. Patients who underwent laparoscopic VHR and open VHR were compared by univariate analysis using Wilcoxon rank sum, Chi-square, and Fisher’s exact tests where appropriate. A multivariate logistic regression was performed to identify independent predictors of all surgical site infections (superficial, deep and organ space SSI). Results: Of 591 patients, 338 (57 %) had a laparoscopic VHR and 253 (43 %) had an open VHR. Patients undergoing a laparoscopic VHR had a significantly lower incidence of all surgical site infections at 30-day follow up, including superficial SSI, deep SSI and organ space SSI (Table 1). There was no significant difference in 30-day re-admission or mortality between laparoscopic and open VHRs. Patients undergoing open VHR had a higher incidence of postoperative bleeding requiring transfusion as compared to laparoscopic VHR (2.7 % vs 0.2 %, p \ 0.001). On multivariate analysis (C statistic = 0.822) a laparoscopic ventral hernia repair was protective against all surgical site infections (OR 0.18, p = 0.01). Conclusion: A laparoscopic VHR is independently associated with a lower risk of all surgical site infections with a current incidence of 1.8 %. A laparoscopic repair should be performed in all eligible cases to decrease overall morbidity and healthcare costs.

Introduction: Transplant patients are at increased risk for hernia formation due to the impairment in normal collagen synthesis and wound healing process inherent to postoperative immunosuppressive therapy. After kidney transplantation, the incisional hernia formation ranges from 1.6 to 18 % and most of the cases presented within the first 5 years post-transplant. In the general population, hernia recurrence after primary repair approaches 50 %, the addition of mesh has lowered that number to about 6–29 %. Several authors have demonstrated the safe use of prosthetic material in the immunosuppressed host. Nevertheless, implantation of mesh by open techniques requires a large incision and wide dissection of soft tissue contributing to an increase at risk for seroma, abscess and incomplete mesh integration. Laparoscopic surgery offers reduced tissue trauma that translates into lower risk for postoperative complications. As for now, there is only few evidence on minimally invasive ventral hernia repair this population. Case report: A 60 year-old female with long history of hypertension was detected to be having chronic renal failure in 2000; she progressed to end-stage renal disease two years later and started on maintenance hemodialysis. She underwent a heterotopic cadaveric renal in 2003, graft was placed in an extra-peritoneal fashion in the right iliac fossa through a ‘‘J-shaped’’ incision. She was on chronic immunosuppressive therapy. Three years after surgery, she noted a progressive painless protrusion on her right flank. She underwent an open hernia repair with polypropylene mesh placement that complicated with incomplete mesh integration. In 2010, prosthetic material was removed and primary approximation performed with recurrence at six months post-op. She expressed chronic abdominal pain and social inhibition from her appearance. On examination, at the upper edge of the transplant scar, a giant 30 9 20 cm soft mass extending from the costal margin to the right iliac fossa was palpable. The rest of the examination was unremarkable. Abdominal CT scan demonstrated a migration of omentum and small bowel into the hernia sac. The patient was scheduled for an IPOM repair. Veress needle was inserted at Palmer’s point for creation of pneumoperitoneum and three trocars were placed at the left middle clavicular line. A 12 cm wall defect was observed with the transplanted kidney located at the lower edge. The hernia sac contents were completely reduced and adherensiolysis performed with bipolar energy. A polypropylene mesh with hydrogel barrier (Ventralight, Davol Inc.) was introduced, prosthesis corners were anchored with transfacial prolene sutures and circumferentially fixated to the abdominal wall with absorbable tackers. The post-operative course presented no further complications and the patient was discharged on PO day 3. At three months-follow up the patient no protrusion or recurrence has been noted. Conclusion: Compared to early surgical complication (graft rejection, vascular or urological complication), incisional hernias have a minor impact on patient and graft survival however, it has a deleterious role on patient quality of life. Postoperative wound complications are minimized with laparoscopic hernia repair with low recurrence and morbidity rates. Incisional hernia can then be safely repaired with minimally invasive techniques in the transplant population.

Table 1 Laparoscopic VHR (n = 338)

Open VHR (n = 253)

p value*

Superficial incisional SSI

3 (0.9 %)

11 (4.4 %)

0.006

Deep incisional SSI

1 (0.3 %)

20 (7.9 %)

\0.0001

Organ space SSI

2 (0.6 %)

8 (3.2 %)

0.017

All SSI

6 (1.8 %)

39 (15.4 %)

\0.0001

* Significance p \ 0.05

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Ventral Hernia Repair Utilizing Centrality Bars Mesh with Balloon Anchor System: A New 3 Trocar Technique Reducing Pain and Recurrence Post-operatively

Anterior Component Separation for Repair of Incisional Hernias: A Review of One Surgeons Experience

Ragui W Sadek, MD, FACS, Andrew M Wassef, BS, Rutgers Robert Wood Johnson Medical School Background: Ventral hernias (VH) account for 25 % of abdominal wall hernias with a greater prevalence in female patients. Being one of the most common procedures amongst general surgeons, laparoscopic repair of ventral hernias spurs quite the debate with respect to the topic of trocar placement. Trocar placement is seldom thought to be a function of a severely reduced rate of VH recurrence. Yet, placement of trocars ispilateral to the VH may lead to an increased rate of recurrence and pain post operatively. The following study tests a new contralateral 3 trocar technique utilizing centrality bars mesh with a balloon anchoring system in comparison to a standard laparoscopic VHR technique. We propose a 3 trocar contralateral technique is sufficient for reducing the rate of recurrence, while decreasing complications postoperatively in comparison to patients who have ispilateral trocar placement. Methods: The following study includes prospecting patients from January of 2009 to December of 2013. Patients were categorized in two groups, Group A (n = 15) consisted of patients we underwent VHR with ispilateral trocar placement. Group B (n = 20) included patients who underwent VHR with contralateral trocar placement. All patients were accessed for quality of life, pain, use of narcotics, postoperative narcotic analgesia, length of hospital stay, complications following surgery, and rate of VH recurrence. Results: Patients in Group A and B showed a statically significant difference in the rate of VH recurrence with respect to each other (P = 0.1). Group A Patients had 3 VH recurrences (20 %), while Group B has had 2 VH recurrences (10 %). Patients in Group A, and B showed no notable difference in the length of hospital stay (avg = 8.7 hrs), or the QOF of patients (p = .001). Patients in Group A and Group B showed no notable difference in postoperative narcotic analgesia in the PACU (p = 0.01). Patients reported significantly greater pain in Group B than Group A (p = 0.09). The average follow-up time was 3–32 months, (median = 27). There were no complications during surgery for either Group A or B. Conclusions: Contralateral 3 trocar placement utilizing centrality bars mesh and dissecting balloon, as apposed to a traditional ispilateral trocar placement VH repair, significantly minimizes postoperative pain, and leads to a significant reduction in VH recurrence. Contralateral versus Ispilateral placement of trocars does not have any effect on the length of hospital stay, the amount of postoperative narcotic analgesia in the PACU, the QOF of patients postoperatively, nor the rate of complications during surgery.

David J Ryan, MD, Monica Gustafson, MD, Pellini Brian, MD, Randall Kimball, Ibrahim M Daoud, St. Francis Hospital Introduction: The repair of large incisional hernias is a daunting problem for a surgeon to face. Component separation with placement of a retro-rectus underlay mesh has been an important method allowing one to close the fascia tension free while also having underlay mesh reinforcement. This study reviews the data of one surgeon at a single institution from 2010 to 2014. The purpose of this review is to assess the successes and failures of an anterior component separation over a 4 year period. Methods and Procedures: We present a review of 86 case of anterior component separation from February 2010 to July 2014. Laparoscopic and open component separations were complete by a single surgeon at a single institution over this time period. Data was reviewed specifically identifying cases of infection, seroma formation and recurrence. Complications were identified in the immediate post operative inpatient period and in the follow up outpatient period. Results: Eighty six patients were included in the study. Seventy seven (90 %) underwent a laparoscopic component separation, six (7 %) had an open component separation, and 3 (3 %) had a combined approach. The median preoperative defect was 10.5 cm (6–29 cm). The median age of the patients was 57 (16–83) years. Three (3 %) recurrences occurred and all were within a year of the initial hernia repair. 1 patient eviscerated in the immediate post operative period. Ten (11 %) patients had persistent drainage or seromas. Ten (11 %) patients had evidence of cellulitis post operatively while 2 patients developed post operative abdominal wall abscesses requiring drainage and 2 patients developed abdominal skin necrosis requiring debridement. Conclusion: Review of this data demonstrates that over a follow up period of up to four years, anterior component separation is an effective repair of a large incisional hernia. The majority of the post operative complications can be managed simply with antibiotics or observation with a small percentage requiring intervention. With a 3.5 % recurrence rate over a follow up range from three months to four years this procedure clearly provides an adequate repair of complicated hernias. The infections wound complications are of a similar rate as one would expect form similar laparotomy procedures. The dead-space created during the separation does subject one to post operative seromas which occurred in 11 % of cases despite drainage of the dead-space at the time of surgery.

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Fibrin Sealant to Assist in Umbilical Reduction Following Laparoscopic Umbilical Hernia Repair

Incidence of Port Site Hernia Following Single Site Laparoscopic and Robotic Cholecystectomy

David Ryan, MD, Ibrahim M Daoud, MD, Saint Francis Hospital

Robert L Autin, MD, Tejinder P Singh, MD, Brian Binetti, MD, Albany Medical Center

Objective: Laparoscopic repair of an umbilical hernia provides a quality repair with demonstrated benefits. Patients on occasion are dissatisfied however with the immediate post operative results as the umbilicus is still protruding as a result of a seroma or skin laxity. This is not a problem for an open repair as one has the ability to suture the umbilical stalk to the fascia or underlying mesh. This is not feasible using laparoscopy. We propose an undescribed method of securing the umbilical skin to the fascia or underlying tissue with use of a fibrin sealant. Description of Methods: In three patients who have undergone standard laparoscopic umbilical hernia repairs we have reduced the umbilical stalk to the underlying fascia or mesh with help of a fibrin sealant. After placement to the mesh and removal of the ports an 11 blade is used to make a small opening in the flaccid umbilical skin. Through the opening four milliliters of a fibrin sealant are injected using a needle tip into the subcutaneous tissue surrounding the umbilicus. The umbilicus is then reduced and packed with gauze. A sterile, nonpermeable dressing is applied. A small needle is then injected into the umbilicus and the air aspirated creating a firm pressure dressing at the umbilicus. This dressing is left in place until the first post operative visit. Preliminary Results: The three patients we have applied this technique to have been pleased with the cosmetic results and none have developed post operative seromas. Conclusions/Expectations: Although the number of patients is small we have seen impressive cosmetic results in the immediate post operative period. We expect that the further use of the technique will continue to show good cosmetic outcomes. In addition, given the obliteration of a potential space with the reduction of the umbilicus we anticipate that patients will have fewer and smaller seromas in the post operative period.

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Introduction: The incidence of Port Site Hernia (PSH) after Single Site Laparoscopic cholecystectomy (SSLC) and Single Site Robotic Cholecystectomy (SSRC) is known to be higher than for standard laparoscopic cholecystectomy. There is limited data regarding both the incidence of PSH following SSLC versus SSRC and the risk factors that can increase the risk of this complication. Methods and Procedure: All patients from 6/26/2009 to 5/19/2010 at a single academic hospital undergoing SSLC were retrospectively compared to all patients undergoing SSRC from 4/30/2012 to 3/23/2013. The rates of PSH were evaluated for both groups after follow up of no less than 3 months after surgery. There were 27 patients in both the SSLC group and the SSRC group. Results: 6/27(22.2 %) of the patients in the SSLC group developed PSH. Within this group, 5/13(38.4 %) of those with either prior midline laparotomy or umbilical laparoscopic incisions developed PSH. Only 1/14(7.1 %) of those with no prior midline laparotomy or umbilical laparoscopic incision developed PSH. 3/27(11.1 %) of the patients in the SSRC group developed PSH. Within this group, 2/16(12.6 %) of those with either prior midline laparotomy or umbilical laparoscopic incisions developed PSH. 1/11(9.1 %) of those with no prior midline laparotomy or umbilical laparoscopic incision developed PSH. The combined results of both the SSLC and SSRC groups are as follows. 9/54(16.7 %) developed PSH. Of those who had prior laparotomy or umbilical laparoscopic incision, 7/29(24.3 %) developed PSH. Of those who no prior umbilical incisions, only 2/25(8 %) developed PSH. Conclusion: Although these data show a trend of lesser incidence of PSH in SSRC vs SSLC, more data is needed to draw a statistically significant conclusion that could alter practice standards. However, we see a much higher incidence of PSH in both the SSLC and SSRC groups for those patients who have had prior umbilical incisions from either laparotomy or laparoscopy. With the accumulation of more data, we may be better able to decide if either SSLC or SSRC is appropriate for patients who have had prior umbilical incisions.

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Comparison of Recurrence Rate Between Slit Mesh and Non-slit Mesh in Laparoscopic Totally Extra Peritoneal Inguinal Hernia Repair

Primary Closure of Hiatal Defects Using a Unidirectional Barbed Suture With and Without the Use of Mesh

Chatree Maimun, MD, Sarrath Sutthipong, MD, Poschong Suesat, MD, Petch Kasetsuwan, Panot Yimcharoen, MD, Bhumibol Adulyadej Hospital

Abraham Betancourt, MD, Abraham Abdemur, MD, Armando Rosales-Velderrain, MD, Emanuele LoMenzo, MD, FACS, Samuel Szomstein, MD, FACS, Raul J Rosenthal, MD, FACS, Cleveland Clinic Florida

Background: The aim of this study was to compare the recurrence rate between slit mesh and non-slit Prolene mesh in laparoscopic totally extra peritoneal (TEP) inguinal hernia repair. Materials and Methods: Ninety-five patients were diagnosed with inguinal hernia in our institute, they underwent laparoscopic TEP inguinal hernia repair were retrospectively reviewed. The characteristic of patient included demographic data, length of stay, follow-up time and recurrence symptoms were reviewed and interviewed. They were divided into two groups. The first group was the patients who underwent laparoscopic TEP inguinal hernia repair with non-slit Prolene mesh, the second were the patients who underwent surgery with slit Prolene mesh. Results: From January 2009 to December 2013, 95 patients (89 M, 6 F) underwent laparoscopic TEP inguinal hernia repair. There were 38 patients (37 M, 1 F) in the first group with the mean age of 61.6 + 16.0 years (17–81), 16 patients were unilateral and the rest were bilateral hernia. There were 57 patients (52 M, 5 F) in the second group with the mean age of 63.2 +14.6 years (33–84), 41 patients were unilateral, and the rest were bilateral hernia. The recurrence rate of the first group (non-slit mesh) was 3 in 38 patients (7.89 %) with mean follow up time 28.7 +10.6 months (10–64) and the another group (slit mesh) was 3 in 57 patients (5.26 %) with mean follow up time 19.0 + 5.2 months (9–28). The length of stay was 5.5 + 1.9 days (3–13) in first group and 4.7 + 1.9 days (3–13) in the second. There was no difference of the recurrence rate (p = 0.605) in both groups. Conclusions: There is no statistical significance difference between both groups in the recurrence rate post laparoscopic TEP inguinal hernia repair. However better study design and long term follow up in laparoscopic inguinal hernia repair is expected.

Introduction: Closure of diaphragmatic Hiatal defects is one of the most demanding procedures performed laparoscopically with a reported high recurrence rate. Mesh reinforcement in combination with non-absorbable suture has been proposed in order to solve this problem. Methods: Between 2010 and 2012, patients who underwent laparoscopic hiatal hernia repair were retrospectively reviewed. Patients were assessed with office visits and by telephone with the gastroesophageal reflux disease-health related quality of life scale (GERD-HRQL). Results: Sixty-four patients underwent laparoscopic hiatal hernia repair over a 2 years period. In 34 patients the hiatal closure was performed using unidirectional non-absorbable barbed suture alone, while in 30 patients the hiatal closure was obtained with the aid of non- absorbable barbed suture and reinforced with mesh. Type I, II, III and IV hernia was identified, 17, 21, 20 and 6 patients respectively. Nissen fundoplication was used as antireflux procedure in 96.88 % of the patients. Operative time was 68.13 ± 12.74 min (mean ± SD) in the non-absorbable barbed suture group vs. 90.7 ± 20.76 min in non-absorbable barbed suture reinforced with mesh (p = 0.0007). Twenty-six patients out of 64 (40.6 %) were assessed by telephone with the GERD-HRQL. Twenty-five reported been satisfied with their condition after surgery. Two patients in the barbed suture plus mesh group presented long-term dysphagia both been treated conservatively. No recurrences were noted in either groups. Conclusion: Closure of the Hiatal hernia with running Quills suture is feasible and enhances patient safety, operative time, as well as technical considerations.

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Two Ports Laparoscopic Inguinal Hernia Repair in Children

Novel Surgical Paradigm and Technique: Applying Physics to Incisional/Ventral Hernia Repairs

Medhat Ibrahim, MD, RCMC Introduction: Several laparoscopic treatment techniques have developed over the last two decades, designed for improving the outcome. The various techniques differ in their approach to the inguinal internal ring, suturing and knotting techniques, number of ports used in the procedures, endoscopic instruments used, and mode of dissection of the hernia sac, extracorporeal and intracorporeal suturing and knotting techniques. Patients and Surgical Technique: From April 2009 to April 2013, 90 children were subjected to surgery and Undergone two port laparoscopic repair of inguinal hernia in children. Technique feasibility in relation to others modalities of repair was the aim of this work. 90 children including 75 males and 15 females underwent surgery. Hernia in 55 cases was right-sided and in 15 left-sided. Two patients were recurrent hernia following open hernia repair. 70(77.7 %) cases were suffering unilateral hernia and 20(22.2 %) patients had bilateral hernia. Out of the 20 cases 5 cases were diagnosed by laparoscope (25 %) The patient’s median age was 18 months. The mean operative time for unilateral repairs was (15 to 20 minutes) and bilateral was (21 to 30 minutes). There was no conversion. The complications were, one case was recurrent right inguinal hernia and second was stitch sinus. Discussion: The results confirm the safety and efficacy of two ports laparoscopic hernia repair in congenital inguinal hernia in relation to other modalities of treatment.

Francis Baccay, MD, Hanna Alemayehu, MD, Jai P Singh, MD, Irene J Lo, Arpit Amin, MD, Alexander Harrington, MBA, Hunter Benvenuti, MD, David Y Cho, Finny George, Sarah P Cate, MD, Westchester Medical Center Introduction: Outcomes from a patient series based on the laws of physics are presented to support a novel incisional/ ventral hernia reconstruction. The technique incorporates multiple symmetric suture lines for dispersement of incurred forces. Multiple symmetric suture lines are the prominent distinction of this original repair. Methods and Procedures: A total of 88 consecutive patients with incisional/ventral hernias were repaired. All hernias were repaired using open bilateral components separation. Biologic grafts were placed either in the retro-rectus preperitoneal or retro-rectus intra-peritoneal position. Results: There are no recurrences or re-admissions. Mean age is 62.2 yr (16–84 yr), mean body mass index of 37.2 kg/m2 (19.5–56.8 kg/m2), mean follow-up is 27.6 months (4–88mo), mean hernia size 492 cm2 (48–1200 cm2) and mean length of stay is 4.6 days (2–10 days). Wound infection rate is 3.4 % (3/88). Conclusion: The novel paradigm and technique emphasizes the manner in which the reinforcing material is sutured to the abdominal wall, rather than the material itself. This innovative technique utilizes multiple symmetric suture lines for dissipation of horizontal and vertical eccentric forces. The increased surface approximation decreases dead space and movement between the biologic graft and patient tissues allowing for optimal incorporation.

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Laparoscopic Repair of Subxiphoid Hernias: A New Technique for Mesh Fixation

The Use of Simultaneous Transversus Abdominus Muscle Release (TAR) for Repair of Adbominal Wall Defect After Soft Tissue Tumor Excision

David Ryan, MD, Ibrahim M Daoud, MD, St. Francis Hospital Objective: Superior epigastric and subxiphoid hernias pose a difficult problem for repair. In an open repair the immobility of the tissues makes approximating the fascia difficult. In a laparoscopic repair, one often is unable to fix the superior or superior lateral aspect of the mesh to the abdominal wall as this can overlap the diaphragm, costal margin or pericardium. We describe a technique of fixating the mesh inferiorly with a standard tacking device and using a fibrin sealant to adhere the superior portion of the mesh. Description of Methods: Laparoscopic access to the abdomen is attainted with a midline 12 mm trochar and 5 mm trochars in each side of the abdomen. The falciform ligament is taken off the abdominal wall using a vessel sealing device. The herniating contents are then reduced completely into the abdomen. 5 cm of tissue are cleared in all directions of the defect, as this is the overlap we seek. This typically includes freeing the left lateral segment of the liver. An appropriate mesh is elevated to the abdominal wall and tacked in place inferiorly and laterally up to the level that it is safe (the costal margin in our cases). A fibrin sealant is then placed on the anterior surface of the unsecured mesh and it is elevated to the abdominal wall. Preliminary Results: Five hernias requiring this technique have been repaired since 2011. All involved had herniation of fat within the falciform ligament causing life limiting discomfort. Two of the defects abutted the xiphoid process and the hernia sac was adjacent to the pericardium. All patients have reported improvement from their preoperative symptoms and no recurrences have been note with the shortest follow up of six months. Conclusions/Expectations: This is a method that we have not seen formally described but we have found it successful in treating multiple difficult hernias. Although we do not propose a fibrin sealant to be equivalent to a tack or transfascial suture, we have found it to be successful in these particular cases where those options are not plausible. The position of the liver to maintain the mesh position on the abdominal wall likely has assisted in the success of the technique. Further study and follow up are essential to determine the long term success of this technique as well as if it may be applied to other areas that standard methods of fixation may not be safe. At this time, the authors have not applied the technique to other areas of the abdomen.

P240 Laparoscopic Removal of Mesh for Inguinodynia Following Laparoscopic Inguinal Hernia Repair Douglas Fenton-Lee, MB, BS, FRACS1, John Garvey, BSc, MB, BS, DPhil, FRACS, FACS, CIME2, Kurt Verscheur, MB, BS, FRACS1, John Read, MB, BS, FRANZCR, DDU3, 1St Vincents Hospital, Sydney, 2Groin Pain Clinic, 3Castlereagh Sports Imaging Inguinodynia following laparoscopic hernia repair is thought to occur in X % of patients. The majority of patients with severe pain are managed conservatively with analgesia and neuomodulators prescribed by practitioners working in ‘‘pain clinics’’ with varying success. The aim of managing these patients is to improve their quality of life and in some instances enable them to return to normal activity. The work up of these patients requires a thorough history, clinical examination and musculoskeletal imaging. Even after such investigation the only option left is removal of the mesh and tacs. We have laparoscopically removed 6 meshes and tacs with no significant morbidity. All patients have had a significant clinical improvement of their pain. We have not performed neurectomy or placed another mesh at the time of mesh explantation. Conclusion: Laparoscopic mesh removal for inguinodynia can be performed with minimal morbidity. We believe that this should be offered to patients who suffer inguinodynia as it will allow patients to be managed with less medication.

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Jeffrey A Blatnik, MD1, Eric M Pauli, MD2, John Ammori, MD1, Julian Kim, MD1, Yuri Novitsky, MD1, 1University Hospitals Case Medical Center, 2Penn State Hershey Medical Center Introduction: Abdominal wall tumors are a rare soft tissue tumor known to occur in the abdominal wall musculature. Such types of tumors include desmoid tumors with low risk of metastasis, but high local recurrence; and soft tissue sarcomas which have varying degrees of aggression. The current standard for treatment involves surgical resection with negative margins. As a result, many patients are left with large muscular defects and high risk for herniation. The transversus abdominis muscle release is a method of ventral hernia repair which allows for midline advancement and the placement of extraperitoneal mesh while minimizing large skin flaps. We report a case series of the TAR method of hernia repair for the reconstruction of full thickness abdominal wall muscular defects following resection of abdominal wall tumors. Methods: Patients with large abdominal wall tumors who underwent oncologic resection leaving them with full thickness muscular defects were evaluated. At the time of initial operation resection of the tumor was performed with preservation of soft tissue and skin when possible. Following tumor resection a TAR was used to create an extraperitoneal plane. This is performed by taking down the posterior rectus sheath (when preserved) laterally to approximately 1 cm medial to the linea semiluminaris. The posterior sheath is then incised along the length of the abdomen to enter an extraperitoneal plane and continued laterally to the psoas muscle. Following closure of the posterior sheath, the remaining muscular defect is reinforced with a large piece of synthetic mesh. Patients were followed for tumor recurrence and longevity of hernia repair. Results: A total of 5 patients (40 % male) with an average age of 42 years and BMI of 27.5 underwent surgical resection. The average tumor size was 15 cm 9 10 cm 9 8 cm. Following tumor resection a TAR was performed which allowed the creation of an extraperitoneal plan for all patients regardless of tumor size. When possible the remaining abdominal muscle was secured in the midline to the underlying mesh in an effort to prevent further retraction laterally. Skin and soft tissue were preserved and closed in multiple layers over the mesh. One patient who underwent additional abdominal resection at the same time suffered minor wound morbidity, but did not require mesh removal. The average follow-up was 10 months, and there is no evidence of hernia recurrence and 60 % of patients remain tumor free. Conclusion: The use of TAR for immediate reconstruction following resection of abdominal wall tumors provides a good option for reinforcement in a challenging reconstructive field. This technique allows for wide placement of synthetic mesh, low risk for herniation and low wound morbidity.

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Traumatic Parahiatal Hernia Containing Remnant Stomach 1

2 1

Ruchir Puri, MD , Steven P Bowers, MD , Mayo Clinic Health System, 2Mayo Clinic, Florida Introduction: Laparoscopic Roux en Y Gastric Bypass (LRYGB) is the commonest procedure performed for morbid obesity generally with good results. Some of the known surgical complications include anastomotic leaks, small bowel obstruction which includes internal hernias through the Petersen’s defect. We present a previously unreported complication of a traumatic parahiatal diaphragmatic hernia containing an incarcerated remnant stomach. Case Report: The patient is a forty five year old female who presented with two weeks of severe left chest pain which worsened over two days. This was associated with severe nausea and retching. She had a prior history of LRYGB done in Mexico four years ago, apparently with a hiatal hernia repair. She was reportedly lifting a heavy couch prior to the onset of symptoms. She was hemodynamically stable with a benign abdominal exam. CT scan revealed the remnant stomach to be in the left chest (Fig. 1). Of note she had a CT scan two years earlier for back pain where no diaphragmatic hernia was noted. A preoperative swallow study confirmed the roux limb to be in an appropriate position. She taken to the OR for laparoscopic repair of the left diaphragmatic hernia where the hiatus appeared normal and majority of the remnant stomach was incarcerated and herniated into the chest (Fig. 2). We had to convert to open due to the inability to reduce the stomach laparoscopically. The patient had a 4 9 4 cm. defect 2 cm. lateral to the hiatus with minimal adhesions (Figs. 3, 4). There was no sac suggesting a recent incarceration and the stomach was viable. The defect was closed with multiple figure of eight Ethibond sutures and a gastrostomy tube was placed in the remnant stomach after reduction. Her postoperative course was uneventful except for an asymptomatic left sided effusion which was managed nonoperatively. She was started on a diet once she had return of bowel function and she was discharged home on postoperative day five. At the time of discharge she was still experiencing some gastroparesis in the remnant and was venting the gastrostomy tube about twice a day. Conclusion: Incarceration of the remnant stomach through a diaphragmatic defect is a rare, previously unreported complication following a LRYGB. Prompt surgical intervention is warranted to prevent strangulation of the remnant stomach.

Optimal Methods of Laparoscopic Repair of Incisional Ventral Hernia V.v. Grubnik, K.o. Vorotyntseva, Odessa National Medical University, Ukraine Introduction: Many articles have shown that laparoscopic repair of ventral hernia is preferred over open repair. The aim of the study was to compare different types of mesh and fixation methods for laparoscopic incisional ventral hernia repair. Methods and Procedures: Prospective randomized controlled study was conducted from 2008 to 2013. Total enrollment was 63 patients (men - 24, women – 39) with a mean age of 45.9 ± 10.6 (22–72). They were prospectively randomized into two arms: arm I included 32 patients where lightweight PTFEe mesh with peripheral nitinol frame (Rebound, MMDI, Inc.) was used, arm II included 31 patients (composite PTFEe mesh (Dualmesh, Gore, Inc.). In arm I mesh was fixed to abdominal wall using only 3–4 transfascial sutures. In arm II mesh was fixed with double row of spiral tackers. Two groups of patients were statistically comparable by demographic data, symptom scores, and size of the defects. Results: The mean mesh fixation time was higher in arm II (27.8 min ± 6.8 versus 41.1 min ± 10.9, p \ 0.001). The mean operative time was also higher in arm II (68.5 ± 8.2 min versus 108.2 ± 12.8 min, p \ 0.001). There were 2 conversions to open repair in arm I and in arm II. The pain score was significantly less at 24 and 48 hours in arm I compared to arm II (mean visual analog scale score, 2.74 vs. 3.82, p \ 0.01). The rate of complications was 9.4 % (3 patients) in arm I and 12.9 % (4 patients) in arm II (p [ 0.05). Recurrence rate at mean follow-up of 36 months was 6.25 % (2 patients) in arm I, and 9.6 % (3 patients) in arm II (p [ 0.05). Conclusions: The new type of meshes with nitinol frame is better for laparoscopic repair of incisional ventral hernia in terms of recurrence rate. Fixation of this mesh is very simple. We consider that the new type of prosthesis can significantly improve results of laparoscopic incisional hernia repair.

Fig. 1

P244 Laparoscopic Ventral Hernia Repair Hideaki Tsutsumida, Mitsunobu Uto, Mari Kamimura, Toshiro Kamimura, Kamimura Hospital

Fig. 2

We have experienced 21 cases of laparoscopic ventral hernia repair (LVHR) since its introduction to our hospital in October 2011. These cases included 7 male and 14 female patients, and their average age and average BMI were 72-years-old (range: 35–87 years) and 25.9 (range: 17.4–39.7), respectively. We have used several types of mesh, i.e., C-QUR Edge for 8 patients, ProLiteULTRA for 1 patient (with suprapubic hernia that developed concomitant with direct inguinal hernia, for which the mesh was fixed in the preperitoneal cavity), VentrioTM for 9 patients, VENTRALIGHTTM ST for 1 patient, and COMPOSIXTM for 1 patient. As a tucker, ProTackTM and SorbaFixTM, an absorbable tucker, were used for 11 and 10 patients, respectively. Essentially, we inserted the first port for LVHR via the umbilical region in all patients. In 18 of the 21 patients, the umbilicus was included in the hernia orifice. For these 18 patients, the first port (12-mm port) was inserted into the hernia orifice. Although the duration to insufflation was 236 seconds, which was longer than that in normal laparoscopic surgery, there were no complications, such as damage to the intestine and surgical site infection (SSI). In addition, the site was covered by mesh and port site hernia could be prevented after insertion of a sole 12-mm port in the hernia orifice in LVHR. We examined LVHR in the 21 patients at our hospital and report the routine surgical procedures.

Fig. 3

Fig. 4

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Pneumothorax as a Delayed Complication of Laparoscopic Extraperitoneal Bilateral Inguinal Hernia Repair

The Use of Biodesign Mesh in the Treatment of Hiatal Hernia and Gastroesophageal Reflux Disease. Texas Endosurgery Institute Experience

Sean Satey, MD, Emilio Alonso, MD, Afshin Molkara, MD, FACS, Yong-Kwon Lee, MD, FACS, University of California, Riverside Objective: Totally transabdominal extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are two techniques used for laparoscopic inguinal hernia repair (LIHR). LIHR has been associated with decreased length of stay, return to normal activity, and postoperative complications when compared to its open counterpart. Complications of LIHR are well documented; however, the development of pneumothorax, pneumomediastinum and subcutaneous emphysema are rarely reported. These potentially lethal complications must be diagnosed and managed immediately. The objective of this paper is to present an unexpected case of pneumothorax after a bilateral LIHR with a review of the literature. Methods: A 56-year-old man, ASA 2, with bilateral inguinal hernia was admitted for elective inguinal hernia repair using the TEP approach. After an uneventful intubation, the standard TEP repair was performed using three midline trocars. Upon emergence from anesthesia, the patient became tachypneic and tachycardic, requiring esmolol for heart rate control. His oxygen saturation declined to the mid 80 s and he was noted to have poor respiratory effort despite being fully reversed. Respirations were assisted until tidal volumes improved. Upon extubation, the patient immediately reported severe chest pain on inspiration. He was placed on supplemental oxygen at 10 L/min to maintain oxygen saturation in the mid 90 s. Stat EKG, CXR, ABG and cardiac enzymes were obtained in the PACU. ABG demonstrated pH 7.306, PCO2 44.2, PaO2 76.5 and HCO3 21.6. EKG indicated minimal ST elevations in V1–V3. Serial CKMB was within normal limits. Serial Troponin I was 0.017, 0.641, and 0.442. Cardiology was consulted and conservative medical management was recommended. Chest x-ray indicated a 15 % right-sided apical pneumothorax. High flow oxygen was continued and weaned as tolerated by time of discharge. Serial chest x-rays indicated resolution of the pneumothorax by post-operative day (POD) two. The patient was discharged on POD 4 with uneventful surgery and cardiology follow up visits. Conclusion: While the development of pneumothorax, pneumomediastinum and subcutaneous emphysema are rarely reported, their occurrence may result in potentially lethal situations that require emergent diagnosis and management. Review of the limited literature suggests that the procedure duration and pre-peritoneal insufflation pressure positively correlate to the development of these complications. TEP and TAPP approaches to LIHR are generally safe. However, a low threshold of suspicion should be used in patients who present with intra-operative hemodynamic instability and/ or post-operative tachypnea, tachycardia and chest pain. Pneumothorax, pneumomediastinum and subcutaneous emphysema are rare but serious complications of LIHR.

Miguel A Hernandez, MD, Morris E Franklin Jr., MD, FACS, Texas Endosurgery Institute Introduction: Different randomized studies have demonstrated the need to use a prosthesis in the repair of a hiatal hernia. Recurrence rates drop dramatically when a mesh is applied. However there is still controversy regarding what prosthesis should be used and how to place it. Methods: From January 2001 to September 2014, all patients having hiatal hernia and gastroesophageal reflux disease that underwent laparoscopic hiatal hernia repair with porcine-bowel submucosa mesh (Biodesign) placement were prospectively studied. Indications for the use of prosthetic material included: recurrent hiatal hernia, crus defect [5 cm, obesity, chronic pulmonary disease, impaired healing (lupus, [80 years old), and incarcerated hernia. Results: One hundred and eighty patients were analyzed, 49 % of patients were female and 51 % male; the mean age was 60.1 years (32–91 years). Mean operating time was 167 minutes with a range of 75–400 minutes. EBL was 28 ml (50–100 ml). One third of patients (34 %) had extensive adhesions present within the hiatal hernia. One patient required conversion secondary to these adhesions. All the patients had a follow up of 6 months, 91 % of 1 year, 83 % of 2 years, 65 % of 3 years 52 % of 4 years and more than 5 years 39 %. Recurrence was seen in only one patient (0.5 %). There were no complications related to prostheses placement. The mortality rate was 0 %. Conclusions: Laparoscopic placement of Biodesign in the hiatus, at the time of laparoscopic repair, is a safe and effective measure to prevent recurrence of hiatal hernia.

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Petit’s Hernia, 1 Case Report and Literature Review

Perforated Appendicitis in Amyand’s Hernia Repaired with Biological Mesh: A Case Report

Mauricio Zuluaga Zuluaga, DO, Ivo Siljic, DO, Hospital Universitario del Valle Background/Objectives: Lumbar hernias are rare sumamentes less than 1 % and reported rarely. Hernias that occur through the superior lumbar space or Grynfelt-Lesshaft, as this is more consistent and larger, often appear more frequently than those produced through the triangle of Petit. The objective of our job is to report laparoscopic management of a lumbar petit’s hernia. Methods Patient: 58 Years female who left back pain consultation by efforts associated intestinal and feel this noise level indicator with episodes of intestinal obstruction. background pathological hypertension, obesity was made of abdomen scans which showed lumbar hernia in the triangle of petit containing a defect with the blind of 5 cm hernia. laparoscopic approach was made of the patient with mesh placement with good prostheses without evidence evolution and hernia recurrence 1 month before surgery monitoring patient. Conclusions: The lumbar hernia are rare. Laparoscopic repair this is an alternative to handle this kind of pathology in obese patients with comorbidities. There are few reports of cases in the literature on laparoscopic repair of this pathology

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Ibrahim I Jabbour, MD, MPH, Samuel E Kirkendall, MD, Shohan Shetty, MD, Nancy Puzziferri, MD, UT Southwestern Medical Center (Dallas, TX) Introduction: Amyand’s hernia is an extremely rare condition in which the appendix is found in the inguinal hernia sac. The first report of Amyand’s hernia in 1735, was described in an 11-year-old boy with concurrent ruptured appendicitis. Since that time less than two hundred cases of Amyand’s hernia have been reported in the literature. In adults, the overall incidence of a normal appendix in the hernia sac is approximately 1 %, whereas appendicitis in the hernia sac is approximately 0.1 %. We report a case of Amyand’s hernia with perforated appendicitis found in a 60-year-old male, which was repaired using biological mesh. Case Report: A 60-year-old male with no pertinent past medical or surgical history presented with three days of worsening right groin pain and swelling. The swelling in the right groin was tender and without skin changes. Computed tomography of the abdomen showed an inflamed appendix incarcerated into the right inguinal canal with likely perforation. Initially a diagnostic laparoscopy was performed which revealed an incarcerated appendix that could not be reduced into the peritoneal cavity. An open right inguinal hernia repair was subsequently performed in the Lichtenstein fashion using Strattice Reconstructive Tissue Matrix (Lifecell, Branchburg, NJ). Postoperatively the patient had minimal cellulitis at the surgical site. He improved with intravenous antibiotic therapy and had an uneventful postoperative course. At short-term follow-up there were no signs of infection or hernia recurrence. Discussion: Classically, acute appendicitis is thought to be caused by luminal obstruction. However, in Amyand’s hernia with appendicitis there are two proposed mechanisms. Inflammation of the appendix may lead to edema in the internal ring and subsequent incarceration and obstruction of the appendix. Another etiology may start with the contraction of abdominal muscles in the inguinal canal leading to incarceration of a normal appendix. This ultimately leads to ischemia and the inflammatory cascade with bacterial overgrowth. Peritonitis is unlikely to occur because the hernia sac acts as a barrier to the purulent material. Inguinal hernia repairs with mesh have been shown to have a decreased recurrence compared to primary tissue repair. Synthetic mesh is generally avoided in an infected or contaminated field. Some surgeons however, advocate synthetic mesh repair after thorough intraoperative irrigation and perioperative antibiotics. We preferred to use a biological mesh in the contaminated field to avoid postoperative infection and hernia recurrence, though clinical trials are lacking in this area. Conclusion: Amyand’s hernia with ruptured appendicitis is a rare clinical entity. We report a case of a perforated appendix within a right inguinal hernia, which was repaired using biological mesh in a contaminated field with no sign of infection or recurrence at short-term follow-up.

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Laparoscopic Hiatal Hernia Repair with a Composite Mesh

Metastatic Invasive Lobular Carcinoma of the Breast to Hernia Mesh: A Case Report

Daniel Gomez, MD, Pedro Villadiego, MD, Cesar Guevara, MD, Cristian Gomez, MD, CPO Introduction: Primary repair of hiatal hernias has a high rate of recurrence making the use of mesh for this procedure a valid alternative in order to reduce this rate. Its indication, types, or technique to use are still manner of controversy. Objectives: We present a consecutives case series of laparoscopic hiatal hernia repair using a single type of composite mesh (PARIETEX, Covidien). Methods: 13 patients underwent laparoscopic hiatal hernia repair using a single type of composite mesh (PARIETEX, Covidien) in a prı´vate practice clinic in Colombia (November 2013–August 2014). Re´cords were reviewed for demographic data, type and size of hernias, mean operative time, length of hospital stay and intra or postoperative complications. Results: All procedures were carried out successfully Endoscopic size of all hiatal hernias average [3 cm and the most common type found was type 3 Mean operative time: 92.6 minutes Mean hospital stay: 26.3 hours No conversions No hernia recurrence in follow up We registered no major complications or re-intervention Conclusion: There are few available data supporting the use of mesh for laparoscopic hiatal hernia repair, and despite the good results showed in those well design studies controversies remain respect to in which cases use it, type of mesh, configuration respect to hiatus and esophagus or technique for anchorage. At this point no firm recommendation can be make, however as we showed in this serie, one strong message persists and this is that there is a clear tendency to recurrence when mesh it is not used for larger hiatus defects.

Kahyun Yoon-Flannery, DO, MPH1, Jonathan Nguyen, DO1, Kristina Quiambao, BA1, Nasser I Youssef, MD2, 1Rowan-SOM, 2Our Lady of Lourdes Medical Center Breast cancer is the second leading cause of cancer deaths in women. In 2014, it is estimated that there will be 232,670 new cases of breast cancer and an estimated 40,000 people will die of this disease. About 60.8 % of breast cancer is diagnosed at the local stage, with a 5-year survival of 98.5 %. In contrast, 5 % of breast cancer cases are diagnosed with metastasis, with a 5-year survival of 25 %. Invasive lobular carcinoma of the breast, sometimes referred to as the infiltrating lobular carcinoma, is the second most common cause of breast cancer, following invasive ductal carcinoma. The sites of metastatic spread differ between infiltrating ductal carcinoma and invasive lobular carcinoma. While in infiltrating ductal carcinoma, the common sites of metastatic disease are in the lung, bones, and liver, in invasive lobular carcinoma, metastatic disease has been reported in the GI tract, peritoneum, and retroperitoneum. Little data exists about metastasis of lobular carcinoma cells to inorganic materials. We present a case report in a 68 yo female with T2N2aMx metastatic invasive lobular carcinoma of the breast who presented with metastasis in her abdominal hernia mesh one year after her mastectomy.

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Laparoscopic Versus Open Ventral Hernia Repair in Obese Patients - A Long Term Follow Up

Paraesophageal Hernia Repair Without Wrapping or Mesh: Primary Diaphram Repair is Sufficient and Does Not Increase Risk of Recurrence: 87 Patient Met-Analysis

Dvir Froylich, MD, Miriam Segal, MD, Adam Weinstein, MD, Kamal Hatib, MD, Eitan Shiloni, MD, David Hazzan Hazzan, MD, Carmel Medical Center Background: Obese (body mass index (BMI)[30 kg/m2) patients undergoing ventral hernia repair (VHR), are known to have a greater risk of peri-operative morbidity, as well as recurrence. A laparoscopic approach is thought to reduce the possible complications associated with this cohort of patients. The aim of this study is to analyze the peri-operative complications and recurrence rates after laparoscopic ventral hernia repair (LVHR) in this specific population, in comparison to patients that have undergone an open repair. Methods: Patients with a BMI [30 kg/m2, who had undergone either a primary or incisional ventral hernia repair (VHR) between 2004 and 2012 were analyzed retrospectively. Patients that underwent an emergent operation, or repair for more than one recurrence were excluded. Data collected included demographics, peri-operative complications, and recurrence rates were compared between the two approaches. Hernia size was divided to three categories (small, medium and large). Prospective evaluation of recurrence in these patients was conducted through physical examinations, and through pre-existing imaging modalities primarily CT scans upon availability. Results: A total of 186 patients that had undergone VHR were included, 37 of them had LVHR. The following parameters of age, gender, ASA score, BMI, and rates of primary or incisional ventral hernia repair were constant in both groups. Majority of the laparoscopic repairs in comparison to open repairs were conducted on large sized hernias (48.6 % (LVHR) vs. 28.9 % (open repair) (p = 0.022)). Operative duration was significantly longer in LVHR (102 vs. 67 min (p \ 0.0001)). No significant differences are reported in our data in regards to peri-operative complications (18.9 % vs. 20.1 %, p = 0.86). However, there were higher wound related complications in the open group (8.1 % vs. 16.7 %, p = 0.187). After a mean follow-up period of 50 (LVHR) and 62 (open repair) months (p = 0.42) the recurrence rates were greater in the open approach, but didn’t report statistical significance (18.9 % vs. 27 %, p = 0.285). Furthermore, a conditional logistic regression analysis that accounts for the difference in followup time revealed that younger age was an independent risk factor for hernia recurrence (p = 0.013). In addition, open repair was found to be a predictor for hernia recurrence (O.R 2.7, C.I 0.88–8.24). Conclusion: This study found hernia recurrence and wound related complications to be more likely in obese patients who undergo an open hernia repair. We believe the laparoscopic approach should be considered as the preferred technique for VHR in obese patients.

Ragui W Sadek, MD, FACS, Andrew M Wassef, BS, Rutgers Robert Wood Johnson Medical School Background: Controversy exists among surgeons whether wrapping and buttressing of the diaphragm reduce rate the of recurrence of paraesophageal/hiatal hernia (HH), in comparison to simple primary repair of the diaphragm. From 2010 to 2013, 87 laparoscopic hiatal hernia repairs (HHR) were performed, 26 with wrapping and buttressing, and 61 just with primary repair of the diaphragm. We propose primary repair of the diaphragm is sufficient to reduce rate of recurrence to levels rivaling paraesophageal hernia repairs performed with wrapping and buttressing techniques. Methods: All patients who have received a HHR from January of 2010 to December of 2013 were examined. Patients were then separated into groups depending on the technique performed for HHR. Group A (n = 61) consisted of patients who received primary diaphragmatic repair of HH. Group B (n = 26) consisted of patients who receive HHR with buttressing and wrapping techniques. Patients were assessed for current clinical symptoms, general quality of life following surgery 1–4 years postoperatively (QOL) and determined the possibility of a recurrence if symptoms of HH still persisted following HHR by a gastrointestinal series (UGI). HH recurrence was marked by the greatest measured vertical height of stomach being 2 cm or more above the diaphragm. Results: There was a median follow-up of 41 months (range 7 to 59 months). In Group A 4 patients were diagnosed with recurrent HH (RHH) (6.6 %), while Group B 8 patients were diagnosed with RHH (30.1 %). There was no statistically significant difference (p = 0.04) in relevant symptoms or QOL between patients undergoing primary repair and buttressed/wrapping repair of HH. There were no strictures, dysphagia, or other complications related to the use of buttressing or wrapping techniques. Conclusions: There does not appear to be a higher rate of complications or side effects following PR or wrapping/ buttressing repair of HH. PR of HH can have a lower comparative rate of recurrence when compared to buttressing and wrapping techniques. It is important to note that PR of HH using a standard laparoscopic technique will not retrieve such results. A new technique for PR of HH was utilized involving the dissection of the ventral and dorsal diaphragmatic hiatus with suture closures at opposing ends of the diaphragm.

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Patients Satisfaction Post Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair with External Fixation Versus Post Internal Fixation

Laparoscopic Versus Open Central Pancreatectomy: Clinical Outcomes and Pancreatic Function Analysis

M S Abdelhamid, MD1, Ahmed M Sadat, MD1, Tamer M Nabil, MD1, Mohamed S Abdelbasset, MD1, Amr M Ali, MD1, Hesham A Nafady, md1, Mmesoha H Abdelmola, MD1, Ahmed Z Gharib, MD2, Adel M Abdulla, MD2, Assad F Salama, MD3, 1Bani swif university -faculty of medicine, 26th October university, 3Theodor Bilharz Purpose: To find out which is more satisfactory to the patients external fixation or internal fixation Background: TAPP with external fixation is a new technique in which there is a marked reduction in the cost without affecting the outcome. Methods: In 80 patients the mesh were fixed from the interior using staples while in the other 80 patients it is fixed to the exterior using prolene threads (Abdelhamid Technique). Patients: A prospective study for laparoscopic TAPP inguinal hernia repair on 160 patients between September 2008 until May 2013 and we follow the patients till May 2014. In 80 we fixed the mesh to the exterior and in another 80 from the interior. There were 90 patients with direct inguinal hernia 45 done through external fixation (gp1) another 45 through internal fixation of the mesh (gp2), 70 patients with indirect inguinal hernia 35 external fixation (gp3) 35 internal fixation (gp4). We follow the patients for recurrence, impulse on cough, inguinal pain and sense of discomfort. Results: The operative time ranged from 35–70 minutes for external fixation, 30–60 minutes for internal fixation. During this period we did not encounter any recurrence, but in group 1 there is one patient complained of impulse on cough and in group 2 there were three had the same complain. Regarding pain non of the external fixation patients complained of groin pain while in group 2 there were two and in group 4 there were two patients complained of groin pain. Conclusion: In addition to much reduction in the cost, external fixation is associated with no groin pain compared to internal fixation and much less incidence of impulse of cough making this technique more acceptable to the patients Keywords: Laparoscopic transabdominal preperitoneal inguinal hernia repair; Mesh fixation; Cost; Stapling.

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Yiping Mou, MD, FACS, Xiaowu Xu, MD, Renchao Zhang, MD, Weiwei Jin, MD, Jiafei Yan, MD, Miaozun Zhang, MD, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University Background: The studies on laparoscopic central pancreatectomy (LCP) versus open central pancreatectomy (OCP) have not been presented in the literature to date. This study aimed to compare perioperative outcomes of patients undergoing LCP and OCP and to assess the pancreatic function after LCP. Methods: A retrospective study was performed for patients who underwent LCP or OCP between 1997 and 2013. The patients’ demographic data, operative results, pathological reports, hospital courses, morbidity and mortality, and follow-up data (including pancreatic function) were compared between these two groups. Results: Forty-one central pancreatectomy (laparoscopic = 12, open = 29) were performed during the study period. The operating time (282.9 ± 28.6 vs 280.4 ± 74.8 min, P = 0.876) were similar between these two groups. The intraoperative blood loss [50(30–300) vs 250(50–1200) ml, P = 0.000] was less in the LCP group. Mortality, morbidity (58.3 % vs 65.5 %, P = 0.938), pancreatic fistula rates (Cgrade B: 25 % vs 37.9 %, P = 0.665) were similar between the two groups. There were no significant difference in endocrine (9.1 % vs 16 %) or exocrine (0 vs 8.0 %) dysfunction between the two groups (P [ 0.05). For the LCP group, the comparison of the pre- and postoperative endocrine or exocrine function didn’t reveal any significant difference in terms of fasting blood glucose, insulin, C-peptide, Fecal elastase-1(P [ 0.05). Conclusions: LCP is both a safe and feasible approach with pancreatic function-preserving.

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Incidental Finding of Gallbladder Carcinoma 1

Primary Hepatic Carcinoid Tumor 1

Asem Ghasoup, MD, FACS, MRCPS , Turki Al Qurashi, MD , Omar Sadieh, MD, FACS, MRCPS2, Mohammed Widenly, MD1, Marwan Abu Farah, MD1, 1Security Forces Hospital-Makkah, 2Saad Specialty Hospital

Guillermo Peralta, MD, Gabriela Arredondo, Medical, Student, Eduardo Flores, MD, Zanndor del Real-Romo, Cesar Jaurrieta, Carlos ˜ -guez-Montalvo, Instituto Tecnolo´gico de Estudios Superiores RodrA de Monterrey

Keywords: Gall Bladder; Incidental gallbladder cancer; Laparoscopic cholecystectomy. Background: Carcinoma of the gallbladder is the fifth most common gastrointestinal malignancy (and the most common of the biliary tract) and is usually discovered accidentally. Gallbladder carcinoma is diagnosed pathologically in 0.3–1.5 % of cholecystectomy specimens. Aim and Objectives: To evaluate the impact of incidental gallbladder cancer on surgical experience and to establish the overall rate of gallbladder carcinoma. Methods: We retrospectively evaluated all consecutive cholecystectomies performed in our ward from (2007–2012) in order to Determine the incidence of gallbladder carcinoma and to identify common characteristics of this particular group of patients. Results: Of the 580 cholecystectomies performed in our ward from 2007–2012, gallbladder carcinoma was diagnosed in six patients (1.03 %) but was not suspected prior to surgery in any of them. In accordance with the literature, the occurrence in women (4/6) was higher than in men (2/6). The mean age was 64 years (range 55–90). The most common symptom was abdominal pain; the majority (5/6) had cholelithiasis, and the pathologic report confirmed the diagnosis of adenocarcinoma in all six patients. Conclusions: The overall incidence of unsuspected gallbladder carcinoma in our series was 1.03 %. We could not find any common characteristics for this particular group of patients when compared to patients with non-malignant pathology.

Neuroendocrine tumors are neoplasms that originate from the cells of the neuroendocrine system; depending on the site of origin, hormonal production and differentiation can present an extensive clinical behavior; the clinical manifestations include episodic flushing, wheezing, diarrhea, abdominal pain, and eventual right-sided heart failure. These tumors can be found in a range of organs; most of them, nearly 90 %, occur within the gastrointestinal tract, the most common sites of primary disease are the appendix (35 %), small intestine (25 %) and rectum (12 %). Metastases from these tumours frequently involve the liver. Primary hepatic carcinoid tumors are extremely rare, and their origin is not well known, there are several theories which include that chronic inflammation in the biliary system may initiate intestinal metaplasia, another possible explanation is that they originate from ectopic pancreatic or adrenal tissues found within the liver. A 63-year-old woman was hospitalized with a history of intermittent diarrhea of about a year of evolution, associated to weight loss of 8 kg during the same period. An ultrasonogram showed an 8 9 7.5 cm complex cystic mass in the right hepatic lobe. MRI and CT SCAN findings were compatible with hydatid tumor vs hemangioma. Tumor markers and liver enzymes were within normal limits. Right hepatectomy was performed without complications. Microscopic findings revealed a carcinoid tumor. Postoperatively a PET SCAN was achieved without showing any other primary tumors. A diagnosis of a hepatic carcinoid is far more likely to be a metastasis from the gastrointestinal tract than a true primary. Nonetheless, primary hepatic carcinoids need to be differentiated from metastatic lesions to institute appropriate treatment. Clinically, primary lesions are characterized, in most cases, by the absence of an overt endocrine syndrome. Liver carcinoid tumors are usually solitary. The diagnosis of hepatic primary carcinoid is rarely suspected preoperatively. Ultrasound, computed tomography, MRI and angiography findings are sometimes useful in distinguishing carcinoid from other tumours. CT with intravenous contrast and MRI with gadolinium often show tumour enhancement, highlighting tumour hypervascularity. The diagnosis of hepatic carcinoid tumor is mainly based on histological and immunohistochemistry examination. The differentiation between primary and secondary hepatic carcinoid tumor it cannot be made by histology alone; it involves intensive imaging, and follow up. Surgical resection is the preferred treatment for PHCT and has provided favorable outcomes. One study showed that postoperative 1-, 5-, and 10-year survival rates were 88 %, 80 % and 68 %, respectively. As far as we know, this is the first case of primary liver carcinoid tumor reported in our country.

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Laparoscopic Cholecystectomy in Geriatric Patients

Plex Celiac Neurolysis Laparoscopically in Patients with Advanced Pancreatic Cancer and Gastric, Description of the Technique

Burhan Mayir, Yeliz Akpınar Mayir, Cemal Ozben Ensari, Umut Rıza Gunduz, Arif Aslaner, Ugur Dogan, Tugrul Cakir, Umit Koc, Mehmet Tahir Oruc, Antalya Training and Research Hospital, Department of General Surgery Introduction: Postoperative morbidity and mortality are more frequent in the ageing than in the young population due to reasons such as decreased organ function, accompanying disorders, and malnutrition. Laparoscopic interventions on the elderly patients can be additional causes of morbidity and mortality The purpose of this study was to assess the safety of laparoscopic cholecystectomy (LC) in the aged and the very aged patients Materials and Method: The patients were studied in 3 groups based on age. Group 1 consisted of patients aged under 65, Group 2 comprised patients of age 65–79, and Group 3 comprised patients of age 80 and over. Each group included 50 consecutive patients who had undergone LC in our clinic. Results: There were differences between the groups in terms of the preoperative levels of hemoglobin and albumin, the ASA score, presence of hypertension, presence of coroner artery disease (CAD), presence of chronic obstructive pulmonary disease (COPD), length of hospitalization, rate of emergency cholecystectomy, and the morbidity rate. Morbidity was seen in 13 (8.7 %) patients, with pulmonary complications in 6, cardiac complications in 5, and infectious complications in 2. There was no mortality in the study groups. The rate of morbidity was significantly higher in patients aged over 80 than in the other patients (p = 0.001). The presence rates of COPD, CAD, low hemoglobin, low albumin, and high ASA score were found to be higher in patients with morbidity. The logistic regression analysis showed that the presence of COPD and low albumin level were associated with morbidity. Discussion: Very old patients for whom cholecystectomy has been planned, LC could be performed safely. Laparoscopic cholecystectomy should be performed after a thorough evaluation of the patients and fulfilling the required preparations, since the most important factors associated with morbidity and mortality are co-existing disorders and the nutritional status.

Uriel Cardona, DO1, Mauricio Zuluaga Zuluaga, DO2, Ivo Siljic, DO2, Juan Valencia, DO1, 1Saludcoop Clinica, 2Hospital Universitario del Valle Background: Patients with advanced gastrointestinal cancer are difficult management and therapeutic choices are limited, celiac neurolysis complex is offered as an option for pain control for these patients. Methods: Is described below the laparoscopic technique neurolysis of the celiac plexus. Patient is placed in French position, the surgeon is located between the patient’s legs and the assistant on the right. The 10 mm umbilical trocar is placed, another 10 mm trocar in the right flank, and a 5 mm trocar in the left flank. Diagnostic laparoscopy is performed, the lesser curvature of the stomach is identified, the left gastric artery emerging from the celiac trunk. A pericranial catheter 22 is inserted through the trocar of 10 mm on the right flank and 20 ml of alcohol 95 % (1/2) is instilled on each side of the emergence of the celiac trunk, verifying that it is not performing an arterial puncture. Removal is done under direct vision of the catheter and the procedure ends. Conclusions: Neurolysis of the celiac plex laparoscopically is an easy, cheap and safe technique, and is offered as an alternative for palliative management of patients with advanced gastrointestinal cancer.

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Wandering Gallbladder: A Case Report with Literature Review

The Role of the Bile Drainage Tube ‘C-Tube’ During Laparoscopic Common Bile Duct Exploration (LCBDE)

Miroslav Kopp, DO1, Nathan Cornish2, Sharique Nazir, MD1, 1 Lutheran Medical Center, 2New York Institute of Technology College of Osteopathic Medicine Introduction: Several variations in the anatomy of the biliary tree have been described in the literature. One such variation is a wandering gallbladder that is typically attached to surrounding structures only by the cystic duct and its mesentery. Its characteristic propensity for torsion places it at risk for necrosis and may present as an acute abdomen. There have been less than 10 reports of wandering gallbladder in the literature. The case of a 51-year-old male with right upper quadrant pain is presented. The possible clinical implications of this finding are discussed. Case Report: A 51 year old male from Pakistan with a medical history significant for hypertension, GERD, high cholesterol, and renal stones presented to the Emergency Room with a chief complaint of right upper quadrant abdominal pain. Physical examination was remarkable for tenderness to palpation in the right upper quadrant. Abdominal ultrasound was significant for a mildly distended gallbladder with small gallstones in the gallbladder fundus, no gallbladder wall thickening or pericholecystic fluid, and no intrahepatic or extrahepatic biliary dilation. The patient had a history of biliary stones but had refused surgery in the past. The patient was discharged home with a diagnosis of cholelithiasis and scheduled for laparoscopic cholecystectomy as an outpatient. The patient was taken to the operating room for laparoscopic cholecystectomy. Upon entering the abdominal cavity a gallbladder was not seen in the gallbladder fossa. It was attached to the cystic duct, thickened with a long mesentery and not attached to the liver. There were no signs of torsion. The patient was treated successfully and discharged home with an uncomplicated hospital course. Discussion: Free-floating or wandering gallbladder was first reported by Wendel in 1898. Since that time, over 500 cases of gallbladder torsion have been reported in the literature yet only approximately 10 cases of wandering gallbladder have been reported. Preoperative diagnosis is challenging because the clinical presentation can be variable with recurrent episodes of abdominal pain. The gallbladder is attached to the liver only by a mesentery and the cystic duct. This anatomic variant leads to hypermobility of the fundus and body of the gallbladder along its vertical axis. Torsion of the gallbladder occurs when it twists axially, with the subsequent occlusion of bile and/or blood supply. Early diagnosis of gallbladder torsion is important to avoid the complication of perforation and bilious peritonitis. The treatment for gallbladder torsion is a cholecystectomy. A literature review revealed limited reports on wandering gallbladder and to our knowledge no reports of cholecystectomy for wandering gallbladder found incidentally exist (Figs. 1, 2).

Fig. 1

Free floating GB in omentum

Fig. 2

GB with retrograde dissection

Yoshihide Chino, PhD, Masaki Fujimura, PhD, Isao Sato, MD, Hajime Yamasaki, PhD, Makoto Mizutani, PhD, Tomotake Tabata, MD, Shigeyoshi Shimaoka, MD, Tomoyuki Tagi, PhD, Minoru IIda, PhD, Daiichi Towakai Hospital Endoscopic Surgery Center Introduction: With the advent of laparoscopic procedures, laparoscopic common bile duct exploration (LCBDE) has played an important role in the treatment of CBDS. To avoid bile-originated complications, T tube is usually used during LCBDE in Western countries. However, in Japan C-tube is often used for bile drainage after hepato-biliaric surgery. The aim of the current study was to show the role of C-tube during LCBDE in our institute. Methods: C-tube is a type of bile drainage tube, produced by Dr Fujimura in 1980. It is fixed to the cystic duct with an elastic band. Closing the duct with an elastic band as soon as C-tube is removed prevents bile leakage from the stump of the cystic duct. Between 2004 and 2014, 360 patients underwent LCBDE in our hospital. Postoperative bile drainage was carried out via C-tube in 92 % patients. Routine intra-operative and post-operative cholangiographies via C-tube were performed. The points evaluated were: operation time, blood loss, post operative day of C-tube removal, length of hospital stays, CBD stone clearance rate, morbidity and mortality. Results: There were 183 male and 177 female patients. Their mean age was 70 ± 13 years. Mean operation time, blood loss, postoperative C-tube removal time and hospital stays were 197 ± 60 min, 17 ± 38 ml, 4.9 ± 2.5 days and 9.2 ± 8.3 days respectively. The CBD stone clearance rate was 98.0 %. The missed stone rate was 2.5 % and recurrent stone rate 3.0 %. Missed stones were clearly distinguished from recurrent stones using post-operative cholangiographies. One patient who had missed stones was treated with GTN (Glyceryl trinitrate) infusion via C-tube. 0.8 % bile leakage occurred. There was no CBD stricture or bile leak-originated peritonitis. C-tube caused problems in 1.3 % of cases. However there was no major morbidity. The mortality rate was 0.5 %. Conclusion: Experience in our institute has shown C-tube to be a safe and feasible drainage tube to reduce LCBDE complications and shorten hospital stays.

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A Novel Technique for Laparoscopic Distal Pancreatectomy with Splenectomy

Sphincter of Oddi Dysfunction After Bariatric Surgery and Trends in Management

Masayasu Aikawa, MD, Mitsuo Miyazawa, MD, Shingo Ishida, MD, Yukihiro Watanabe, MD, Katsuya Okada, MD, Kojun Okamoto, MD, Shigeki Yamaguchi, MD, Isamu Koyama, MD, Saitama Medical University, International Medical Center

John N Afthinos, MD, Roman Grinberg, MD, Karen E Gibbs, MD, Staten Island University Hospital

In laparoscopic distal pancreatectomy with splenectomy, extension of the wound is needed to extract the spleen, as the spleen is larger than the pancreas. In the present report, we describe a new technique for safe extraction of the distal pancreas along with the spleen, wherein the spleen is stored in the bag under air insufflation and the pancreas and spleen are then laparoscopically divided. This technique was employed in three cases. The patients were placed in the split-leg position and general anesthesia was administered. Moreover, we placed a camera port in the umbilical region and 4 trocars in the upper abdominal region. After the lesion was confirmed via ultrasonography, the pancreas body was divided along with the splenic vein and splenic artery. The splenic artery was then clipped and cut. The pancreas body was divided using a linear tri-stapler and reinforcement material. Thereafter, an extraction bag (Endo CatchIITM) was inserted through the umbilical wound into the abdominal cavity for storage of the pancreas body and spleen. The mouth of the bag was extracted from the abdominal cavity. Thereafter, the umbilical wound was extended by 2.0 cm, and a SILS portTM was placed at the mouth of the bag. An air insufflation into the bag could obtain sufficient working space divide the pancreas body and spleen within the bag. If the spleen was too large, it was divided into three or four portions to enable easy extraction from the abdominal cavity without the need for extending the wound. The average total duration of the operation was 398 (range, 317–412) minutes and the average duration of extraction was 64 (range, 31–92) minutes. The extracted specimens could be used for pathological staging. No operation-related complications were noted. The patients were discharged from the hospital on an average of 9 (range, 7–27) days after the operation. Through this novel method, we could perform laparoscopic distal pancreatectomy with splenectomy in a safe manner, without extending the wound size to more than 2 cm.

Introduction: Sphincter of Oddi dysfunction (SOD) is a rare disorder which can be difficult to diagnose and treat. It has been identified in patients who have undergone gastric bypass. Many times, testing is negative for any significant abnormalities, yet significant upper abdominal pain and interruption of daily life occurs frequently. We sought to query a large national database to better characterize patients with SOD with a focus on patients who have had weight loss surgery. Methods: The NIS Database was queried for 2005–2010 for all patients admitted with a diagnosis of sphincter of Oddi spasm (ICD-9 M 576.5). The patients were characterized for their age, gender, comorbid conditions and a history of prior bariatric surgery. We evaluated any interventions performed. Multivariate regression analyses were performed to identify factors predicting an intervention. Results: A total of 3,601 patients were identified, of which 116 (3.2 %) had a history of bariatric surgery (BHx). The majority of the BHx subgroup was female (96 %). None of the BHx patients (0 %) had documented enzymatic or transaminase abnormalities. ERCP was the most common procedure performed (19 %) with laparoscopic cholecystectomy being performed on 14 %. Nearly 9 % underwent a diagnostic laparoscopy (DL). BHx was the strongest predictor of DL with an OR 18.8 (p \ 0.0001). Discussion: SOD is a rare admitting diagnosis. The BHx subgroup seems to demonstrate a type III SOD, as evidenced by the lack of serum transaminase and enzymatic abnormalities. The pain distribution and severity may mimic internal hernia, which warrants a DL in the patient with a history of gastric bypass. If the DL is negative, SOD should be included in the differential diagnosis of severe, episodic upper abdominal pain in this patient population.

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The Utility of Two Incisional Laparoscopic Unroofing of Liver Cysts Compared with Single Incisional Laparoscopic Surgery

A Survey to Assess Surgeon Experience with, and Barriers to Performing, Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis

Jun Hanaoka, MD, PhD, Hideki Kawasaki, MD, PhD, Masamitsu Harada, MDPhD, Hiromi Otani, MD, PhD, Masahiko Fujii, MD, PhD, Kazunori Tokuda, MD, Ehime Prefectural Central Hospital Background: The aim of this study is to introduce some operative skills of laparoscopic unroofing of liver cysts by 2 incision, and its utility compared with single incisional surgery in the treatment of huge liver cysts. Operating Method: Single incisional unroofing of liver cysts: The patients were placed in left hemi-lateral decubitus position for right lobe lesion of liver cysts. On the one hand, the patients were placed in dorsal position for left lobe lesion. Umbilical fold was cut about 2.5 cm, then GelPOINT mini (Applied Medical, Rancho Santa Margarita, CA) was inserted in the umbilical incision. Three ports for GelPOINT were set in a triangle position. Laparoscope was inserted in the caudal port. Left port was used for SILS forceps (COVIDIEN), and right port was used for energy device like LigaSure 5 mm Blunt tip Laparoscopic Instrument (COVIDIEN) or HARMONIC ACE (ETHICON). Liver cysts were cut by energy device. After unroofing the liver cysts, whole area of inner cavity were cauterized by laparoscopic electrical cautery. And resected specimen was extracted by plastic bag from umbilical wound. The 5 mm drain was inserted in the cavity at epigastric region. Two incisional unroofing of liver cysts: After inserting of GelPOINT, one more port (5 mm) was added at epigastric region. Above mentioned energy devices were used by the added port, and liver cysts were treated in the same manner. Patients and Methods: From April 2009 to August 2014, 9 patients underwent laparoscopic liver cyst unroofing in Ehime prefectural central hospital, Japan. All the clinical data were retrospectively analyzed. Seven liver cyst patients were received two incisional laparoscopic liver cyst unroofing at our hospital, and 2 liver cyst patients were received single incisional laparoscopic liver cyst unroofing. Patient background like age, sex, body height, body weight, BMI, nature of cyst, hepatic functional reserve, etc, was analyzed. And the factor about surgery like blood loss and operative time. Moreover, recovery time of gastrointestinal function, volume of postoperative drainage, postoperative drainage time, postoperative hospitalization time, and postoperative recurrence rate were compared between the two groups. Results: There were no differences in patient background between two groups. In the factor of surgery, operative time was significantly shorter and blood loss was lesser in the 2 incisional unroofing group. There was no difference in recovery time of gastrointestinal function, volume of postoperative drainage, postoperative drainage time, postoperative hospitalization time, and postoperative recurrence rate. Moreover, because the drain was inserted by using the wound of 5 mm of the epigastric port, final scar after two incisional surgery was same with single incisional surgery. Conclusion: Compared with single incisional unroofing of liver cysts, two incisional unroofing of liver cysts was safety and speedy. Moreover, because the scar of two incisional unroofing of liver cysts was same with single incisional surgery, it is recommended method for huge liver cysts.

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Ezra N Teitelbaum, MD, MEd1, Nathaniel J Soper, MD1, Pratik Patel, BS1, Byron F Santos, MD2, Eric S Hungness, MD1, 1Northwestern University, 2Dartmouth-Hitchcock Medical Center Introduction: Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy remains an underutilized treatment for choledocholithiasis, despite demonstrated clinical advantages over the two-stage approach of ERCP plus laparoscopic cholecystectomy. In order to better understand the etiology of this underutilization, we surveyed surgeons regarding their experience with LCBDE and barriers that prevent them from performing the procedure. Methods: Attending surgeons were surveyed at two academic conferences (American College of Surgeons and SAGES) prior to participating in LCBDE courses or visiting the SAGES ‘‘learning-center’’. Participants received no LCBDE teaching prior to completing the survey. Subjects were queried regarding their prior experience with LCBDE and Likert-type questions were used to assess their confidence in performing the procedure, their evaluation of LCBDE in relation to ERCP, and barriers that currently prevent them from performing LCBDE. Surgeon factors that were associated with increased utilization of LCBDE were analyzed using a Spearman’s correlation test. Results: 117 surgeons were surveyed. Participants had a median of 8 years in practice (range 1–40 years) and a mix of practice settings (20 % university, 21 % university-affiliated, 53 % community, 6 % other). 35 % had completed a minimally-invasive fellowship. During their residencies, participants had performed a median of 0 LCBDEs (mean 1, range 0–10) and those who had completed a minimally-invasive fellowship had also performed a median of 0 LCBDEs during fellowship (mean 2, range 0–20). In the entirety of their post-training practice, those surveyed had performed a median of 2 LCBDEs (range 0–600) and a median of 0 in the last year (range 0–20). 77 % stated they employed ERCP more often than LCBDE for initial treatment of choledocholithiasis. Regarding their technical ability, 45 % of surgeons indicated they ‘‘agree’’ or ‘‘strongly agree’’ with the statement, ‘‘I can effectively and safely perform a transcystic LCBDE’’, and that proportion was only 27 % for transcholedochal LCBDE. When comparing LCBDE and ERCP, participants indicated that LCBDE was superior with respect to hospital length of stay and cost, whereas the two approaches were equivalent in terms of stone clearance and safety. The most significant barriers to performing LCBDE in the surgeons’ current practice were inadequate OR staff familiarity with the procedure (mean 3.1, scale 1–5), not having the necessary instruments available (mean 3.0), and their own limited technical ability (mean 2.8). Less significant barriers were added procedure time (mean 2.3) and poor financial compensation (1.7). Surgeons with more years in practice had higher confidence in their ability to perform LCBDE (r = .28, p \ .01), as did those who had completed a fellowship (r = .18, p = .06), but those factors were not associated with actually performing more LCBDEs in the past year. However, more frequent use of intraoperative cholangiogram was associated with performing more LCBDEs (r = .22, p \ .05). Conclusions: In this cohort, surgeons had little experience with LCBDE during either training or practice and were not confident in their ability perform the procedure. Lack of surgeon and OR staff training, as well as instrument availability, were the main barriers to utilization. These results can be used to guide future LCBDE-specific curricula and training.

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Simultaneous Cholecystectomy and ERCP: An Option Omitted in the Current Choledocolithiasis Management Guidelines

Effect of Surgical Energy Usage on Clinical Pathway of Laparoscopic Cholecystectomy: Results of a Triple Blind Randomized Study

J V Harmon, MD, PhD1, R Mallick, MD1, K Rank, MD2, C Ronstrom, BS3, M Arain, MD4, M L Freeman, MD4, 1University of Minnesota Department of Surgery, 2University of Minnesota Department of Medicine, 3University of Minnesota Medical School, 4 University of Minnesota Department of Medicine, Division of Gastroenterology Introduction: We report the feasibility and safety of performing laparoscopic cholecystectomy and ERCP as a singlestage procedure in comparison to performing these procedures sequentially as two separate procedures for the management of choledocholithiasis. The option for performing these procedures under the same anesthetic is often overlooked. Guidelines for management of choledocolithiasis that omit the option for simultaneous laparoscopic cholecystectomy and ERCP include those endorsed by: SAGES, British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and Association of Laparoscopic Surgeons. In our academic hospital setting, performing single-stage laparoscopic cholecystectomy and ERCP procedures is an option given our active ERCP group. Methods and Procedures: Using the electronic medical record system, we retrospectively reviewed outcomes for patients undergoing both ERCP and laparoscopic cholecystectomy for choledocholithiasis from April 2011 until September 2013. We identified 18 patients who underwent these procedures simultaneously under a single anesthetic and compared the patient outcomes to those in a cohort of 30 consecutive control patients from the same time period who underwent these procedures sequentially under two separate anesthetics. The data was analyzed using Fisher’s exact test; all tests were two-tailed. Results: Patient demographic characteristics including age, gender, and ASA scores were similar between the two groups. The average combined operative time for simultaneous procedures was 142 ± 66 minutes, while the average combined operative time for the sequential procedures was 129 ± 39 minutes; the difference in average total operative times was not statistically significant. The average total anesthesia times were not significantly different between the two cohorts: the average total anesthesia time was 227 ± 67 minutes for those done simultaneously, and 238 ± 51 minutes when these procedures were performed separately. Median hospital length of stay was 5 days for both groups; there was no statistically significant difference between the average lengths of stay for the two groups. There was no difference in the rates of major complications between the two groups. Conversion to open surgery did not occur in either group. There were no bile duct injuries, and 30 day mortality was zero in both groups. Conclusions: Performing cholecystectomy and ERCP during a single anesthetic is feasible given the active ERCP service at our academic hospital. During simultaneous procedures, we found it advantageous to perform the laparoscopic cholecystectomy first to avoid limiting exposure and visibility during laparoscopic surgery due to intraluminal endoscopic CO2 insufflation associated with ERCP procedures. Recent guidelines for the care of patients with choledocolithiasis should include the option to perform laparoscopic cholecystectomy and ERCP during the same anesthetic.

Brij B Agarwal, MS1, Juhil D Nanavati, MBBS1, Nayan Agarwal, MBBS, S2, Kumar Manish, DNB1, Satish Saluja, MD1, Naveen Sharma, MS2, 1Ganga Ram Institute of Postgraduate Medical Education and Research and Sir Ganga Ram Hospital India, 2 University College of Medical Sciences, University of Delhi, India Introduction: Elective Laparoscopic Cholecystectomy (LC) is an ambulatory or day care surgery. Postoperative morbidity can prolong hospitalisation upsetting the fasttrack clinical pathways. We studied the impact of using surgical energy (USE) in LC on existing fasttrack LC clinical pathway protocols. Methods and Procedures: An open ended triple blind randomized study of consecutive unselected consenting LC candidates for standard ambulatory (discharge ability\4 hours) clinical pathway protocol. Randomization by external research coordinators (blind to peri-operative observations) into Group A and Group B. Standard techniques of LC with/without USE followed by surgeons (blind to pre-postoperative parameters / observations) for the group allocated. The data being collected by blinded non-operative research coordinators & stored online in auto-locking Hospital Information System (HIS). Prospective data will be analyzed at completion. The HIS data & randomization codes will be available to the blinded investigators in January 2015. The results from January 2014–December 2014 will be presented. Conclusions: Appropriately analyzed results will be presented & discussed at the meeting

Clinical Pathway related data-Group A (n = 121) Group B (n = 116) Study Point

Group A

Group B

Operating time-Average (mins)

31.36

22.51

Iatrogenic Gallbladder (GB) Perforation [IGbP] (%)

38.9

9.4

By dissecting instrument % of IGbP

85.71

10.5

By Grasping instrument % of IGbP

14.29

89.5

GB bed surface hemostatic aid used-%

33.05

46.55

Index Bile duct Injury %

0.8

0

Significant ShoulderTipPain [ 24 Hrs- %

66.67

19.82

Peritonism [ 24 Hrs.- %

27.78

5.48

Postoperative Mean hospitalisation_Hours

6.72

5.5

5.78

0

(excludes duct injury & rehospitalisation)

P266

Rehospitalisation-% Metrics used for post-operative clinical outcomes

Is ERCP Aided by Trans-Cystic Wire During Laparoscopic Cholecystectomy Safer and Faster than if Performed Separately?

PostOperative (PO)

ScaleUsed

Day (D)/Week (W)/Month (M) D1, D3, D10, W3

Wesley B Jones, MDMS, Mathew T Epps, MDMS, Greenville Health System

Pain (POP)

100pointVAS

Nause-Vomit (PONV)

6point PONV

D1, D3, D10, W3

Fatigue (POF)

84point MIFS

D1, D3, D10, W3

In a previous study we showed that diagnostic ERCP performed either before or after laparoscopic cholecystectomy (LC) had a significant rate of pancreatitis and unnecessary procedures. Therefore, we have begun using intra-operative ERCP in the event of positive cholangiography to limit the use of diagnostic ERCP. To aid in cannulation of the ampulla a wire was passed down the cystic duct into the duodenum at the time of LC. We hypothesized that this would lead to shorter total operative times, less complications, and fewer unnecessary procedures. The purpose of our study was to test that hypothesis, comparing those patients who had intra-operative ERCP to those who had ERCP separately from LC. We performed a retrospective review from a prospective database of 987 patients who had ERCP by a single surgeon between July 2011 and July 2014. Patients who had single-stage laparo-endoscopic rendezvous (LERV) were compared to those who had a two-staged approach with ERCP either before or after LC. Variables examined included: incidence of unnecessary procedures, time to complete ERCP, total operative time, post-procedural pancreatitis (PEP), and hospital length of stay (LOS). In total 152 patients were included in the study (29 in the LERV group and 123 in the two staged approach group). Fifty-seven patients had their LC at outside facilities. There were significantly fewer unnecessary procedures in the LERV group (0 %) compared to the two-staged approach (15.5 % p = 0.025). Total operative time was significantly greater in the LERV group (136 min) in comparison to the two-staged group (102 min; P = 0.003). The mean operative time for ERCP was not significantly different between the LERV group (31 min) and the two-staged group (33 min; P = 0.83). No significant difference in PEP existed between either the LERV group (8 %) or the two-stage group (14 %; P = 0.49). Similarly, LOS did not significantly differ between LERV group and the two-staged approach (5 days and 6.2 days, respectively; P = 0.355). Despite the fact that total operative times were significantly increased in the LERV group with no significant decrease in PEP or LOS, we believe LERV does result in fewer unnecessary procedures and their associated complications.

Sleep Quality (QoL)

21point PSS

W3

GIQoL

144point GIQoL

M3

ActivityResumed (AR)

Days

D…

Results: Outcomes- Group A (n=121) Group B (n=116) Group A

Group B

POP

39.72 (20–86), 25.66 (11–79), 14.11 (5–75), 6 (2–32)

26.6 (10–40), 15 (6–26), 7.6 (4–14), 3.5 (2–7)

PONV

0.5 (0–3), 0.28 (0–2), 0.11 (0–2), 0

0.3 (0–1), 0 (0–0), 0 (0–0), 0

MIFS

28.83 (16–62), 19.94 (10–56), 12.30 (5–44), 5.5 (3–12)

20 (13–32), 13.6 (10–22), 7 (4–10), 3.1 (2–7)

PSS

9.56 (2–17)

7.7 (5–11)

GIQoL

23.5 (12–40)

15.5 (12–20)

AR

7.95 (3–36)

4.6 (3–7)

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P268

P270

Laparoscopic Pancreaticoduodenectomy: A Novel Approach with Experience of 60 Cases

Usage of a Soft-Coagulation Device for Hemostasis of Total Laparoscopic Hepatectomy: Detachment and Transection of Blood Vessels Using a Monopolar Soft-Coagulation Device

Weiwei Jin, MD, Yiping Mou, MD, FACS, Xiaowu Xu, MD, Renchao Zhang, MD, Miaozun Zhang, MD, Jiafei Yan, MD, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University Background: There is an increasing interest in laparoscopic pancreaticoduodenectomy (LPD), but it is still performed in ‘‘expert’’ hands at selected centers. One issue to promote LPD widespread is how to simply the procedure in a scientific manner to shorten the operative time, which may need an attempt to perfect the surgical steps adjusted to the view of laparoscopy. Methods: A novel approach with the advantages of visual field ‘below-up’ around the axis of the mesenteric-portal vein was performed between September 2012 and September 2014 in our center. The flow of resection is designed from caudad to cephalad, from anterior to posterior, from left to right, so the resections are done with the jejunum, stomach, pancreatic neck, Kocher maneuver, the uncinate process, common bile duct in order. Results: Laparoscopic pancreaticoduodenectomy with this novel approach was performed on 60 consecutive patients. The mean age was 58.8 years and BMI was 23.67 kg/mm. The mean operative time was 370.4 minutes with 171.27 minutes for resection, 50.39 minutes for pancreaticojejunostomy, 39.19 minutes for hepaticojejunostomy, 23.43 minutes for gastrojejunostomy. The mean blood loss was 195.09 ml. The mean tumor size was 4.07 cm and the mean number of havested lymph nodes was 19.48. Pathologic diagnosis were pancreatic adenocarcinoma (n = 17), cholangiocarcinoma (n = 6), periampullary adnocarcinoma (n = 18), gastric cancer (n = 1), pancreatic neuroendocrine neoplasm (n = 3), pancreatic intraductal papillary mucinous neoplasm (n = 3), pancreatic mucinous cystadenoma (n = 6), pancreatic solid pseudopaillary neoplasm (n = 1) duodenal interstitialoma (n = 3), chronic pancreatitis with a suspicious mass lesion (n = 2). Perioperative morbidity occurred in 17 patients and included pancreatic fistula (n = 8), bile fistula (n = 1), bleeding (n = 5), wound complication (n = 3). There was no perioperative mortality. The median length of hospital stay was 14 days. Conclusions: Laparoscopic pancreaticoduodenectomy with this novel approach with the advantages of visual field ‘‘below-up’’ around the axis of the mesenteric-portal vein is safe and feasible without repeated steps which may shorten the operative time.

Mitsuo Miyazawa, MD, FACS, Masayasu Aikawa, MD, Katsuya Okada, Yukihoro Watanabe, Kojun Okamoto, Shigeki Yamaguchi, Isamu Koyama, Saitama Medical University International Medical Center Among intraoperative complications of total laparoscopic hepatectomy (TLH), venous hemorrhage is the most frequent and difficult-to-treat complication. We developed hepatocyte crush method: (HeCM) using a monopolar softcoagulation devices for not only hemostasis, but also detachment of blood vessels. The aim of this prospective, nonrandomized study was to investigate the potential contribution of a monopolar soft-coagulation device to the limitation of intraoperative blood loss in patients undergoing TLH. Methods: From January 2008 to July 2014 at our department, TEH was performed in 150 cases, including 140 cases of partial hepatectomy and 5 cases of lateral sectionectomy of the left hepatic lobe. We keep the following points in mind for the procedure of partial hepatectomy using a monopolar soft-coagulation device for hepatocellular carcinoma. 1) For detachment of the vein, a monopolar soft-coagulation device is pressed on the resection surface of the liver to crush hepatocytes (hepatocyte crush method: HeCM). 2) Regarding the area around the hepatic vein, holes from which the branches of the hepatic vein fall out are identified with a monopolar soft-coagulation device (while dripping water) and closed. Results: The blood loss was 62.0 (0–500) ml. The operative time was 207 (127–468) minutes. The duration of hospital stay after surgery was 7.6 (3–21) days. Postoperative complications occurred in 5 cases (intraabdominal abscess, wound infection, intraabdominal hemorrhage, bile duct stricture [stricture of B2 and B3 after resection of a tumor in S4], and umbilical hernia in one case each). The peak aspartate aminotransferase (AST) level was 320 (57–1,964) IU/ L. Although there were cases showing high AST levels, no sign of hepatic failure was observed during the perioperative period in any case. Conclusion and Discussion: The use of a monopolar soft-coagulation device (HeCM) improves surgical results with minimal blood loss and low rate morbidity.

P269

P271

Role of Laparoscopy in Management of Liver Hydatid Disease: A Tertiary Care Institute Experience

Fully Robotic Whipple Vs Open: Early Experience

Ravinder Pal Singh Babra, MBBSMS, Jaspal Singh, MBBS, MS, DNB, Atul Mishra, MBBS, MS, Ashish Ahuja, MBBS, MS, Amandeep Nar, MBBS, MS, Ashvind Bawa, MBBS, MS, Dayanand Medical College & Hospital Ludhiana Punjab India Introduction: Laparoscopic methods with their low morbidity have nearly replaced open surgical methods including the treatment of hepatic hydatid disease. Numbers of cases have been reported for successful laparoscopic management of hepatic cyst including laparoscopic management of complex and parasitic cyst. Methods and Procedures: Twenty one consecutive patients with liver hydatid cyst were considered for laparoscopic treatment from April 2007 to April 2012. Preoperative work up included abdominal ultra sound and contrast enhanced computer tomography scan of abdomen. Immunological tests for confirmation of hydatid disease were also carried. Diagnosis of liver hydatid was based on imaging studies and clinical suspicion. All patients were treated preoperatively with albendazole. Patient undergoing surgery had laparoscopic cyst evacuation after its sterilization and deroofing and suction drainage of the cavity and omentoplasty where required. Results: Twenty one patients (M 14: F 7) with liver hydatid cysts underwent laparoscopic surgery. Average operative time was 125 minutes. Most of patients had only single cyst. The right lobe of liver was most commonly involved. Mean cyst size was 8.2 cm (range; 5.2 cm to 16.2 cm). Cyst was bilateral in four patients. In 86 % simple evacuation of the hydatid cyst using wide bore suction was done. In 12.5 % this was followed by left lobectomy. The remnant cavity was dealt with omentoplasty. Average follow up period is 2.8 years. There has been no recurrence rate. Conclusion: With proper patient selection laparoscopic management of hydatid cyst of the liver is a feasible option. We found laparoscopic treatment to be having optimum efficacy for preventing spillage, evacuating hydatid cyst contents, performing trans cystic fenestration and for dealing with cyst biliary communication.

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Alejandro Mejia, MD, Jose R Soto, Stephen S Cheng, MD, Carlos Fasola, MD, Tarek Kahn, Richard Dickerman, MD, Methodist Dallas Medical Center Minimally Invasive whipple has been offered at selective centers with results comparable to the open technique. Adoption of robotic surgery in HPB is still limited and viewed with skepticism. In this study, the early results of operative outcomes are compared for open (OW) and robotic whipples (RW) at a single HPB practice. Methods: After the completion of robotic training in July 2013, every consecutive whipple case was compared for both techniques at a single practice until September 2014. RW were performed using the DaVinci Si system. A prospectively maintained database was analyzed for OR and patient variables. Results: A total of 14 RW and 12 OW were performed in the study period. Clinical variables are shown in Table 1. Complications in the RW group include 2 conversions to open due to bleeding, one postop fluid collection requiring drainage and one cirrhotic patient who developed ascitis which was controlled with diuretics. No mortality has been observed in either group. Conclusion: RW has been successfully introduced at a single HPB practice. Patients undergoing RW demonstrated shorter LOS which was not statistically significant but clinically significant. Despite longer OR times the RW had comparable outcomes to the OW. OR times have progressively decreased as the learning curve improves to comparable published times for larger series. Further studies are needed to compare costs and oncologic survival in the RW patients.

Table 1 RW (n = 14)

OW (n = 12)

P

Age

67.3 ± 8

62 ± 10

NS

G (M/F)

10/4

7/5

NS

BMI

27 ± 5

27.2 ± 5

NS

LOS (days)

6.5 ± 3.6

9.3 ± 5.9

NS (0.14)

Transfusion

4

5

NS

OR time (min)

434 ± 111

234 ± 75

\0.001

Complications

4

4

NS

Surg Endosc

P272

P274

Laparoscopic Cholecystectomy in Mauritania About 742 Cases

Laparoscopic Ultrasound Still has a Role in the Staging of Pancreatic Cancer: A Systematic Review of the Literature

Ahmedou Moulaye IDRISS, National Hospital Center Introduction: Biliary lithiasis is known to be rare in Africa. In Mauritania the frequency of this pathology is related to some traditional customs such as gavage. The authors report a retrospective descriptive study of 742 patients with gallstones. The aim of the study is to assess the care and the profile of gallstones in general surgery department at the Sheikh Zayed hospital in Nouakchott (Mauritania) on 12 years, period from September 2001 to September 2013. Patients and Methods: Over a period of 12 years 742 files were included. Databases were statistically analyzed by SPSS and the variables studied were: age, gender, ethnicity, previous history, clinical biology, US and Scanner, type of intervention, route first, and postoperative length of stay. Results: There were operated 742 patients for gallbladder disease between September 2001 to September 2013, including 553 women and 189 men, sex ratio 2.9. The average age was 48.8 years, with a range of 16–76 years. 112 patients had a medical history is 15.09 %. All patients were symptomatic and had an ultrasound in less than 3 weeks before surgery. The final diagnosis was 532 single vesicular lithiasis, acute cholecystitis 206 and 4 gallbladder polyps. The intervention was initially carried out by three trocars, trocar was a 4th placed 68 times the demand. The procedure was converted to conventional route 98 times or 13.2 %. This conversion was present especially at the beginning of our experience. The dissection was the same as in conventional route, dissection of Calot’s triangle the cystic duct was cut between two ligatures clips. Cholecystectomy was considered laborious 208 times, 314 times simpler and unspecified 122 times. 8 patients had a rebound in 24 or 48 hours. It deplored 4 deaths. The immediate postoperative course was uneventful in 636 cases out of 41 infections wall on the outlet of the gallbladder quickly curbed by local care and antibiotics. Distant suites: lost 477 seen after 1 month, 2 patients were operated to 7 years for hernia on the outlet of the bladder. 37 patients were seen in the long term, 6 of these patients had small hernias on the outlet of the gallbladder, 2 of which were made ?? at 5 years and 7 years. Conclusion: Cholelithiasis is common Mauritania, its early care is needed to avoid the occurrence of complications and reduce the percentage of deaths. And its management laparoscopic load still requires awareness of surgeons and patients because it is feasible in our context but human resourse and matriels are limited. Keywords: Biliary lithiasis; Cholecystitis; Laparoscopy; Ultrasound.

Jordan Levy1, Mehdi Tahiri, MD1, Geva Maimon, PhD1, Tsafrir Vanounou, MD, MBA2, Simon Bergman, MD, MSc1, 1Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, 2Hepatobiliary and Pancreatic Surgery, Jewish General Hospital, McGill University, Montreal, Canada Background: In the last 10 years, the reported incidence of non-curative laparotomies for pancreatic cancer, using standard imaging techniques for preoperative staging, is 20 %–50 %. The objectives of this study are 1) to determine the diagnostic accuracy of laparoscopic ultrasound (LUS) in assessing resectability of pancreatic tumors; 2) to compare LUS to standard pre-operative imaging; 3) to determine how the accuracy of these modalities has evolved over time. Methods: A systematic review was carried out with the following search terms: laparoscopic ultrasound, staging, pancreas, tumor and pancreatic cancer. We systematically searched the EMBASE and Medline databases through September 2014. Inclusion criteria were: prospective studies investigating the accuracy of LUS in determining resectability of pancreatic tumors in patients who had undergone standard imaging procedures. Standard imaging consisted of computed tomography complemented in certain studies by endoscopic ultrasound, transabdominal ultrasound, ERCP and MRI. To account for recent technological advances in imaging techniques, a comparison between modalities was carried out for studies published in the last five years. Results: 99 studies were initially identified and 19 prospective studies (1,573 patients) were included. LUS correctly predicted resectability in 79 % (41 %–100 %) compared to 55 % (29 %–85 %) for standard imaging. Overall, in patients deemed resectable by standard imaging, LUS prevented non-curative laparotomies in 33 %. Of those, the most frequent LUS findings precluding resection were liver metastases (16 %) and vascular involvement (15 %), and a change in diagnosis from malignant to benign (9 %). LUS had a morbidity rate of 0.8 % with no mortalities. Between 2009–2014 (3 studies), the diagnostic accuracy of LUS and standard imaging was 96 % (87–100 %) and 68 % (33 %– 88 %), respectively. In the only prospective study comparing LUS to multidimensional CT, the accuracy was 100 % vs. 78 %, respectively. Conclusion: The addition of LUS to standard pre-operative imaging improves diagnostic accuracy compared to standard imaging alone and may decrease the number of non-therapeutic laparotomies for pancreatic cancer. Even in the most recent studies, there seems to be a benefit to LUS as a staging modality.

P273 Gallbladder Stone Disease (GSD) and Its Complications Anibal J. Rondan, Marcelo Fasano, Rosana Trapani, Gustavo C Alarcia, Pablo J Miguel, Julieta Camelione, Alberto R. Ferreres, Bocalandro Background: GSD is one of the most frequent disorders affecting the gastrointestinal tract; its incidence in the adult population is above 58 % for females and around 42 % for males. Race and ethnicity play a major role in its development, more frequent in hispanics and native descendents. Objective: Analyze the incidence, clinical presentation and course and prognosis of GSD in our patients. Methods and Materials: After approval of our institutional IRB a retrospective analysis of a prospective database of the patients admitted to the Division of Gastrointestinal Surgery of the University of Buenos Aires ‘‘Dr. Carlos A Bocalandro’’ Hospital. between January 2010 and January 2014, 4500 patients were admitted with diagnosis of GSD and/or its complications; 3456 (76.8 %) were female and 1044 (23.2 %) were male. 3825 (85 %) of our patients were younger than 60 years. Our guidelines include a minimal invasive approach for the treatment of this illness and its complications Results: 3465 (77 %) patients were admitted for elective surgery (lap. chole. with intraoperative cholangiogram and/ or CBD exploration), 1035 (23 %) Patients were admitted for emergency surgery, who were scheduled for emergency surgery, 34 patients (3.28 %) needed Percutaneus drainage cholecystostomy. Lap. chole. was completed in 4263 (94.74 %), IOC was performed in 3897 cases (86.66 %). The remaining 244 (5.42 %) patients required conversion (right subcostal incision) due to: a) Mirizzi’s syndrome: 15 (0.33 %), b) Cholecystocolonic fistula: 5 (0.11 %), C) Cholecystoduodenal fistula: 8 (0.17 %), d) Intraoperative complications (bleeding, liver laceration): 216 (4.8 %). Incidence of CBD stones, biliary duct injury, POP Complications: a) Surgical site infection: 38 (0.84 %), b) Intraabdominal collections: 12 (0.26 %), c) Retained CBD stones: 56 (1.24 %), d) No bile duct injuries were registered. Conclusions: The spectrum of BSD, its progress and complications impose a prompt diagnosis and surgical treatment in order to correct symptoms, prevent complications and avoid disability and sequelae. Elective treatment should be recommended when repeated gallstone symptoms have occurred before the development of acute cholecystitis and related complications. Our results on large number of patients are similar to other series in the newer literature. The incidence of complications decreases with growing laparoscopic experience.

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P275

P277

Laparoscopic Cholecystectomy in Situs Inversus Totalis with Literature Review

Case Report and Literature Review of Spilled Gallstones During Laparoscopic Cholecystectomy

Turki Al Qurashi, MD1, Asem Ghasoup, MD, FACS, MRCPS1, Omar Sadieh, MD, FACS, MRCPS2, Abdul Rahman Al Abas, MD1, 1 Security Forces Hospital-Makkah, 2Saad Specialty Hospital

Sami S Judeeba, MD, Abdulelah M Alhawsawi, MD, MBBS, RCPSC, FACS, DABS, Majid M Mansouri, MBBS, FRCSC, RCSPC, King Abdulaziz University

Keywords: Left sided gallbladder; Laparoscopic cholecystectomy; Situs inversus; Sigle port. Introduction: Laparoscopic cholecystectomy is one of the most common surgical procedures carried out in the world nowadays. While anatomical abnormalities of the biliary system are common; abnormal location of the gallbladder is extremely rare. In published literatures, there is only around 40 cases reported in the pre-laparoscopic era and almost the same number of cases performed with standard laparoscopic cholecystectomy for patients with situs inversus. Patients and Methods: In this study, three patients were diagnosed as situs inversus totalis with cholelithiasis, all patients underwent full history taking, complete physical examination, abdominal ultrasound, computerized tomography (CT) and Laboratory investigation that includes; complete blood count, liver functions and coagulation profile. Technique and Results: Laparoscopic cholecystectomy performed for the first case with the 4-trocar Technique, the second case 3-trocar technique and the last one using single port technique. The operative team and laparoscopic devices were located in the theater as a mirror image configuration of normal laparoscopic cholecystectomy. The pneumoperitoneum (CO2) insufflated through veress needle at the subumblical incission maintainig pressure around 12 mmHg. The mean operative time was 30 ± 20.7 minutes with no significant blood loss. All patients passed uneventful postoperative course without any complication and discharged home on the first day post surgery. Conclusion: Laparoscopic cholecystectomy, convention or single port incision, for patients with situs inversus totalis is feasible and can be safely performed in the presence of an experienced surgeon.

Introduction: Laparoscopic cholecystectomy is becoming the gold standard for surgical removal of the gallbladder. About 5 % to 40 % of people who had laparoscopic cholecystectomy experienced a persistent abdominal pain to the extent of gastric upset, change in bowel habit & nausea or recurrent vomiting. Causes for this post laparoscopic cholecystectomy pain are many, and spilled gallstones is rare cause. Spilled gallstones can lead to formation of inflammatory Pseudotumor which can mimic malignancy over years with imaging study. Case Report: A 52 year old male patient who presented with 2 years history of persistent epigastric pain, change in bowel habit, and significant weight loss for more than 15 kg over the same period. The patient had a laparoscopic cholecystectomy 7 years ago. The procedure was not straight forward and followed by placement of a draining tube that stayed for 17 days until the patient was discharged from hospital. He had uneventful postoperative course until the time of his presentation to us. His laboratory findings are in normal limits including LFT, CBC & tumor marker as well. Colonoscopy show no gross pathology and upper GI endoscopy is normal as well. Ultrasound abdomen revealed well defined cystic structure and subcapsular liver nodule. Patient planned for further imaging study may lead to what is going on. A CT abdomen was done and shows liver lesion at segment #6 that goes with hemangioma. Also a nodule is seen in the subcapsular region of the left hepatic lobe. A multiple ill-defined nonenhancing intraperitoneal lesion adjacent to the hepatic flexure is also seen in the subcapsular region of the right hepatic lobe. A small soft tissue masses is seen at the anterior abdominal cavity indenting the left hepatic lobe. Multiple variable sizes nodules are seen within the peritoneal cavity. Multiplanar multi sequential liver MRI images were obtained and confirms the nature of hemangioma that is seen in the CT scan on liver segment #6. Also Multiple lesion around the liver which is hypointense on the T1 sequences, and shows a target appearance on the T2 sequences. A CT guided biopsy attempts to take tissue biopsy from the nodules but histopathology is reported as inconclusive result. The patient was planned for diagnostic laparoscopy and to obtain multiple biopsies. Upon laparoscopic exploration using open technique for inserting first & other trocar under direct vision, a minimal adhesion was noticed and was released using Harmonic Ultracision. There was no omental or peritoneal gross pathology. We took multiple biopsies from the peritoneal nodules that was matched to the CT scan findings and sent to the frozen section and reveal no pathological diagnosis or malignant cell. Then we moved toward the suspected nodules at gall bladder fossea, around right liver lobe and to the nodule that is subcapsular and anterior to the liver. We found that these nodules are a spilled stone grossly and most likely is from previous cholecystectomy. Histopathology is reported as omental fat with foreign body giant cell reaction and bile pigment that is seen under microscope.

P276

P278

Laparoscopic Splenectomy for Idiopathic Thrombocytopenic Purpura Using Legeart Method

Common Bile Duct Obstruction Due To Migrated Gallbladder Stone During Laparoscopic Cholecystectomy

Takeshi Aoki, Takeshi Naitoh, Takanori Morikawa, Katsuyoshi Kudoh, Shinobu Ohnuma, Naoki Tanaka, Tomoya Abe, Hiroaki Musha, Michiaki Unno, Department of Surgery, Tohoku University Graduate School of Medicine

Sung Won Jung, MD, Dong-Sik Kim, Young Dong Yu, Sung Ock Suh, Korea University Medical Center

We have innovated a novel surgical procedure for Laparoscopic splenectomy (LS), which is called as Left gastrioepiploic artery traction (LeGEART) method, mainly for idiopathic thrombocytopenic purpura (ITP). Background: Since the first report of LS in 19911, LS is considered as the one of the standard technique for patients requiring an elective splenectomy. In our institution, LS was first undertaken in 1996. Since then, LS have been performed mostly for patients with hematological disorder, especially idiopathic thrombocytopenic purpura (ITP). In LS, pancreatic fistula is most serious postoperative complication. Therefore, we have innovated safety technique for LS. Material and Surgical Technique: This method has two concepts. One is not to damage the pancreas, and another not to remain the accessory spleens. In this method, the pedicle containing left gastro-epiploic vessels has been towed in the direction of ventral side by assistant’s forceps. The distance between the pancreatic tail and splenic hilum is prolonged and the triangle shape, formed by pancreatic tail, spleen, and Gerota’ fascia, makes it easy to insert the linear stapler toward the upper site of the splenic hilum, under good traction without damaging the pancreatic tissue. On the other hand, accessory spleens are congenital foci of healthy splenic tissue that are separate from the main body of the spleen. In our current cases, most frequent places of accessory spleens were splenic hilum and inferior pole of spleen, and 30 % of cases accessory spleens were placed in the left side of greater omentum. It is very important not to remain the accessory spleen for ITP’s operation. So we have dissected greater omentum together using LeGEART method. Conclusion: We believe that LeGEART method will simplify the LS, especially for ITP.

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Objective: Occasionally, common bile duct (CBD) obstruction is occurred after laparoscopic cholecystectomy (LC) and migrated gallbladder stone during LC is one of the reasons. The aim of this study is to identify risk factors of gallbladder stone migration during LC. Methods: Between May of 2000 and December of 2013, 3054 patients were underwent LC for gallbladder stone and these patients are revealed without CBD stone before LC. Among of these patients, 95 patients experienced CBD obstruction due to migrated gallbladder stone during LC. Baseline characteristics of patients, operation-related parameters and pathologic findings were compared in the two groups (Obstruction, n = 95; No obstruction, n = 2959) and univariate and multivariate analysis were performed to find risk factors for gallbladder stone migration. Results: The baseline characteristics of patients such as sex, age and underlying disease were similar in the two groups. Preoperative dilatation of cystic duct or CBD, number of stones, combined GB polyp and gallbladder wall thickening were not related to gallbladder stone migration. In univariate analysis, largest size of stone (lesser than 3 mm; 42 % vs 11 %, p = 0.03) and operation time (over than 70 min; 61 % vs 19 %, p = 0.04) were identified for risk factors to gallbladder stone migration. But, in the multivariate analysis, only largest size of stone (lesser than 3 mm; odds ratio 2.4, 95 % confidence interval 1.51–4.73, p = 0.04) was related to stone migration. Conclusion: Our data suggest that better effort is essential to avoid migration of gallbladder stone to CBD during LC for small size gallbladder stone.

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P281

The Usefulness of Reduced Port Cholecystectomy Using the Two 2.4 mm Fine Forceps Directly Penetrating the Abdominal Wall

Robotic Pancreatic Surgery in a Community Hospital Setting: Our Initial Experience

Kazunori Tokuda, MD, Jun Hanaoka, MD, PhD, Hideki Kawasaki, MD, PhD, Masamitsu Harada, MD, PhD, Hiromi Ootani, MD, Masahiko Fujii, MD, PhD, Ehime Prefectural Central Hospital

Hetal D Patel, MD1, Rachel E Martin, MD1, Stan C Hewlett, MD, FACS2, 1Baptist Health System of Alabama, 2Princeton Surgical Specialists

Background: In recent years, although the reduced port operation method which is excellent in cosmetics, such as SILS, is spread, therefore, the problem that safety is sacrificed or operation difficulty rises has arisen. This study examined the usefulness of reduced port cholecystectomy using the two 2.4 mm fine forceps directly penetrating the abdominal wall, which is performed by 21 mm of total surgical wound length, and shows the unique method of insert of the 2.4 mm fine forceps whose tip has 5 mm in diameter. Method: From January 2013 to June 2014, one hundred sixty patients performed laparoscopic cholecystectomy in Ehime Prefectural Central Hospital. These 160 patients were divided into two groups. The one group (four port group; n = 153) is performed by conventional American style of laparoscopic cholecystectomy, which was used 4 ports, and the another group (two port group; n = 7) is performed by 2 ports (12 mm umbilical port and 5 mm epigastric regional port) and two 2.4 mm fine forceps (End Relief, Hope Denshi Corporation, Chiba, Japan) for the assistants gallbladder holding and the operators left-hand handling that is inserted into the abdominal cavity directly. Endo Relief has 5 mm tip, however, by inserting in antidromic nature into the abdominal cavity from a 5 mm epigastric port, and deriving the shaft of a handle part out of the abdominal cavity in using a shaft guide, even if a tip is large, without using a port, it can insert into the abdominal cavity directly. Operation factors and complications were examined in both groups. Result: In 2 port group, the time taken to create the fine forceps in a body in 2 port groups was an average of 4 minutes for three operators. Compared with other 2 mm forceps, stiffness has been improved markedly and operator did not feel operation stress. Although total surgical wound length of 4 port group is 30 mm, that of 2 port group is 21 mm in theory, respectively. Moreover, since the wound of 5 mm port part spread in a circle, real surgical wound length is more expanded. A significant difference was not observed in operation time and the amount of blood loss. Complications like bile leakage, bleeding, and surgical infection were not observed in 2 port group. Therefore, hospital stay didn’t show the significant difference in both groups. And actual 2 port laparoscopic cholecystectomy is shown in the video. Conclusion: Laparoscopic cholecystectomy using the two 2.4 mm fine forceps makes the minimum destruction of a body wall, and is excellent in postoperative esthetic outcome and pain control, and also eases the operator’s surgical burden, compared with conventional style of laparoscopic cholecystectomy by using 4 port.

Introduction: Robotic pancreatic surgery at a community hospital is viable and produces safe operative outcomes. A current trend in surgery is to utilize a robotic surgical system for complex abdominal operations. This is not limited to academic institutions. The use of the robot allows for more precise manipulation of instruments and tissue. The 3-D, HD visualization of the console allows for safer dissection while providing an ergonomic advantage to the surgeon. This technology has been slowly integrated into general surgery, but is now used for virtually every type of surgery while maintaining safety and improving patient satisfaction. In our community hospital, its role has now expanded to pancreatic surgery. Robotics promises to facilitate the transition of surgical pancreatic care from traditional open to minimally invasive surgery. There is a relative void in the surgical literature regarding robotic pancreatic surgery which is becoming more popular in many centers across North America. Methods: A retrospective chart review of the initial forty-two robotic assisted pancreatic procedures were examined. These encompassed any type of pancreatic resection for suspected malignancy including pancreatoduodenectomy and distal pancreatectomy with or without splenectomy. The length of stay, operative blood loss, leak rates, lymph node count, successful oncological resection and a conversion to open procedure were examined. Data extracted and means reported. Results: Since late 2010 there were over 40 patients that underwent robotic pancreas surgery. All were deemed resectable by preoperative imaging studies. Of these cases, there were a few unresectable at time of surgery secondary to extrapancreatic disease and instead received palliative bypass or no further operation. Of the remaining cases, the results were also favorable. Conclusions: Robotic pancreatic surgery offers patients reduced operative blood loss with acceptable morbidity and mortality while providing the benefits of minimally invasive surgery.

P280 Near-Infrared Fluorescent Cholangiography Does Not Facilitate the Identification of Biliary Anatomy in Acute Cholecystitis During Laparoscopic Cholecystectomy Jennifer Schwartz, MD1, Sylvester Osayi, MD1, Michael P Meara, MD1, Peter Muscarella, MD1, Kyle A Perry, MD1, Umer I Chaudhry, MD2, Daniel A Eiferman, MD1, W. Scott Melvin, MD3, Jeffrey W Hazey1, Vimal K Narula, MD1, 1The Ohio State University Wexner Medical Center, 2Kaiser Permanente, San Diego, CA, 3Montefiore Medical Center Background: Intraoperative cholangiography (IOC) is the gold standard for identification of biliary anatomy during laparoscopic cholecystectomy. A previous study performed by Osayi et al demonstrated the Near-infrared fluorescence cholangiography (NIRF-C), which allows for imaging of biliary anatomy in real-time, was an effective alternative to IOC for patients with symptomatic biliary disease who underwent elective laparoscopic cholecystectomy. This study is to assess the efficacy of NIRF-C for identification of biliary anatomy in the acute cholecystitis. Methods: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used identify extrahepatic biliary structures before and after dissection of Calot’s triangle. Routine intraoperative cholangiogram (IOC) was performed in each case. Identification of biliary structures and NIRF-C was evaluated. Results: 6 Patients underwent laparoscopic cholecystectomy for acute cholecystitis with NIRF-C and IOC. Mean age and BMI were 50 years and 31.14 kg/m2 respectively. IOC was only able to be completed in 3/6 (50 %) of patients, with 2/3 (66 %) patients with complete biliary anatomy visualization. In the patients where IOC was able to be performed, NIRF-C was significantly faster than IOC (1.08 vs 17.87 minutes). NIRF-C did not visualize the biliary structures in 6/6 (100 %) of patients prior to dissection of the anatomy. Complete biliary anatomy visualization, including right and left hepatic ducts, common hepatic, cystic duct, and common bile duct, failed in all 6 patients (100 %). After final dissection, the common hepatic duct and common bile duct were visualized in 2 patients and the cyst duct visualized in 3 patients. Visualization did not always correlate with ability to perform cholangiogram, as 1 patient had partial biliary visualization with NIRF-C despite inability to perform IOC. No adverse events were observed with NIRF-C. Conclusions: Acute cholecystitis can make visualization of the biliary system quite difficult and a method for identification of structures in this setting is of particular interest. While NIRF-C was promising for identification of biliary anatomy in the elective setting for non-acute gallbladder pathology, it does not appear to assist with identification of complete biliary anatomy with acute inflammation. IOC still remains the gold standard in this subset of patients.

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Knotless Choledochoraphy with Barbed Suture, Safe and Feasible 1

1

1

Luis C Fernandez, MD , A Toriz, MD , J Hernandez, MD , A Cuendis, MD2, C F Cervantes, MD3, 1Hospital General Zona Norte Puebla, 2Hospital General ‘‘Dr. Manuel Gea Gonzalez’’, 3Hospital General ISSSTE Puebla Purpose: Our purpose was to describe the safety and feasibility of a running continuous unidirectional barbed suture (V-Loc, Covidien, Mansfield, MA) for primary common bile duct closure at laparoscopic common bile duct exploration (LCBDE). Introduction: Nowadays, LCBDE is actually the best approach for treating complex cases of common bile duct lithiasis or cases where the endoscopic retrograde cholangiopancreatography (ERCP) has failed. Also, it continues to gain widespread popularity among surgeons who want to avoid the risks of ERCP. It is clear that the primary closure of the common bile duct must be preferred, over the T-tube drainage. The actual technical aspects offer room for improvements. The ideal bile duct suture that should offer a: -material with an apropiate absorbable time, non traumatic needle/thread, minimally inflamatory response. -simple technique ideal for avoiding bile leaks, without compromising tissue perfusion or bile filtration. This suture hasn’t been found. We turn our sight on barbed suture, for which recently various fields of surgery have become interested in, which now has a series of studies that support it for wide uses, which offers a secure tension-free tissue approximation and that has demonstrated closure equivalence with maxon (monofilament polyglyconate), but with faster anastomotic times. We started using this suture under the hypothesis that by its characteristics, it could fulfill the requirements of an ideal bile duct suture postulating an easier, safer and efficient reconstruction based on: -material characteristics, ideal for biliary surgery -easier and faster techniques -non isquemic, knotless, running simple suture Herein, we present our initial series with this novel technique. Methods: Between July 2012 and July 2014, 54 consecutive patients with bile duct stones underwent LCBDE by a single surgeon, upon the completion of the exploration, 50 patients had primary common bile duct closure, 3 reconstruction with hepaticojejunostomy and one reconstruction with choledochoduodenostomy, using knotless unidirectional barbed 3-0 V-Loc 90 suture. All of the sutures were performed without knot tying. Perioperative outcomes and 30-day complications were recorded. Surgical criteria are shown in Fig. 1. Outcomes Measures: Prospective data was collected for standard perioperative variables, demographic, etiology, preoperative findings, surgical findings (diagnosis and bile duct size), bleeding, rate of convertion, adverse events, reconstruction times (recorded at video playback for all cases), postoperatory hospital stay, VAS pain score, bile leak, infection, reintervention or death. All patients have being followed closely after their hospital discharge and will be followed for at least 3 years. Patients demographics, characteristics and postoperative outcomes are shown in Tables 1, 2 and 3 respectively. The procedure in all patients was successfully performed with no intra-operative complications. There were no bile leaks in the 54 patients, or other postoperative complications as infection, need for reintervention or death. Conclusion: The use of unidirectional knotless barbed suture (V-Loc 90) is safe, feasible and effective on LCBDE for primary common bile duct closure. The biliary leak rate is acceptably low and comparable to the reported in the literature. This is report on the initial experience that needs further clinical trials. Nothing to disclose.

Laparoscopic Left Lateral Sectionectomy Can be Standard Operation Even in Patients with Cirrhosis Chami Im, Jai Young Cho, Ho-Seong Han, Yoo-Seok Yoon, YoungRok Choi, Woohyung Lee, Departments of Surgery, Seoul National University Bundang Hospital Background: Laparoscopic treatment is considered as standard procedure for left lateral sectionectomy (LLS), showing better outcome compared to open LLS. However, laparoscopic LLL in patients with cirrhosis is still controversial. Methods: We evaluated data of 107 patients who underwent laparoscopic LLS between July 2003 and July 2013. The patients were classified into two groups according to the presence of pathologically proven cirrhosis or not; group A (presence of cirrhosis; n = 22) and group B (absence of cirrhosis; n = 85). Intraoperative and postoperative functional outcomes were compared between two groups. And we analyzed surgical and oncological outcomes of laparoscopic LLS for hepatocellular carcinoma (HCC). Results: There were no differences between two groups in terms of median operation time and blood loss (P = 0.960 and 0.144, respectively). The rate of transfusion was also similar between two groups (13.6 % vs. 7.06 %; P = 0.387). Conversion to laparotomy occurred in no patient in group A and one patients in group B (1.18 %; P = 1.000). Postoperative peak results of total bilirubin was higher in group A than group B (median 1.3 mg/dL vs. 1.10 mg/dL; P = 0.023), while there was no difference in postoperative complication rate (18.18 % vs. 22.35 %; P = 0.778) and hospital stay (7 days vs. 7 days; P = 0.719). No statistically significant difference in disease free survival (P = 0.988) and overall survival (P = 0.409) between the cirrhotic and non-cirrhotic groups in HCC. When compared with open LLS in study period (n = 12), there was no difference in the complications (21.5 % vs 41.67 %; P = 0.080), operation time (165 min vs 190 min; P = 0.505), blood loss (200 mL vs 300 mL; P = 0.173), transfusion rate (9 % vs 1 %; P = 1.00) and hospital day (7 days vs 7 days; P = 0.381) between laparoscopic and open LLS groups. Conclusion: Laparoscopic LLS could be standard operation even in patients with cirrhosis.

P284 Fig. 1

Surgical criteria

Table 1

Demographic data

Mean

Sex

Ergonomic Implications of Variations in Sub-Xyphoid Port Placement During Laparoscopic Cholecystectomy

IQR

Lawrence N Cetrulo, MD, Pak Leung, MD, Amit Joshi, MD, Einstein Medical Center Philadelphia

23 male 31 female

Age

47.4

19–81

BMI

24.02

19–31.5

Comorbidities Hypertension

IQR: Interquantile range

Table 2

Table 3

Patients characteristics

19

Diabetes

12

Others

8

Primary choledocholithiasis

21

Secondary choledocholithiasis

29

Mirizzi

3

Intraductal polyps

1

Upper abdominal surgery

25

Lower abdominal surgery

34

Pre-Op ERCP prosthesis

20

Postoperative outcomes Choledochoraphy (50)

Biliary bypass (4)

Mean

IQR

Mean

IQR

Bile ducts diameter (mm)

12.46

(10–14)

17–25

(15–20)

Reconstruction time (mins)

12.38

(7–20)

34.75

(19–45)

Length of PO stay

1.42 days

(1–4)

3.75 days

(3–4)

Pain VAS-24 hrs

3.74

(3–5)

5.25

(5–6)

Est. blood loss

43.6 cc

(30–120)

106 cc

(80–140)

bile leak

0

0

Infection

0

0

Reintervention

0

0

Death

0

0

Follow up (months)

16.08

IQR: Interquantile range

123

(3–25)

23.5

(19–28)

Introduction: Laparoscopic cholecystectomy is one of the most common laparoscopic procedures performed worldwide. Prior research has been devoted to ergonomics and operator comfort during laparoscopic surgery. Our aim was to determine if altering the placement of the subxyphoid port had any effect on ergonomics, comfort, and operative time during laparoscopic cholecystectomy. Methods: Two surgeons at a teaching hospital measured the angle between the port and the skin of the subxyphoid port during twenty-five consecutive laparoscopic cholecystectomies. One surgeon (surgeon A) placed the subxyphoid port in the midline three to five centimeters below the xyphoid process. The other (surgeon B) placed the sub-xyphoid port on the lateral border of the Left rectus abdominus muscle, three to five centimeters inferior to the costal margin. We measured the angle between the port and the skin with a grasper touching the infundibulum of the gallbladder. We also measured the distance to the gallbladder through that port, the operative time, estimated blood loss, BMI, and patient age. Results: There was a significant discrepancy between the angles using each technique. Each individual surgeons felt more comfortable with his preferred technique. Surgeon A’s angle between the skin and the port ranged between 30–60 degrees while surgeon B’s angle ranged between 15–30 degrees. There was no difference in overall operative time or estimated blood loss. Discussion: This is a small prospective case series analyzing whether port placement has an effect on case performance and operator comfort. We found that there was a significant difference in the angle of interest between the two surgeons. Extrapolated from this, we found that posturing of the arm and wrist was different as well. This study also reveals that with no difference in operative time or blood loss, port placement at the left epigastric position does not negatively affect the procedure. We plan to examine whether port angulation affects performance during validated laparascopic simulation tasks such as the peg transfer test and the ring cutting test among surgical trainees.

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Acute Gallstone Pancreatitis in the Elderly: Laparoscopic Biliary Surgery is Safe and Feasible Without Pre-operative Imaging

Two Port Laparoscopic Cholecystectomy Using 10 mm Umblical Port and 5 mm Epigastric Port with Standard Instruments

Ahmad Mirza, Haitham Qandeel, Samer Zino, Ahmad Nassar, Monklands District General Hospital, Airdrie, United Kingdom

Dp Singh, MBBSMS, Ashwani Kumar, Government Medical College and Rajindra Hospital, Patiala. India

Introduction: The surgical management of acute gallstone pancreatitis (AGSP) in the elderly is a challenging clinical situation. Our aim was to assess single-session laparoscopic management of acute gallstone pancreatitis in patients C 70 years. Methods: We collected data prospectively for patients undergoing laparoscopic biliary surgery over 20 years (N = 4408) was analysed. We reviewed the data for patients aged C70 years diagnosed and underwent surgical management for. Results: A total of 46 patients were identified. The mean age was 75 years. 75 % were females. 97 % were emergency admissions, and 53 % were jaundiced. ASA score was 2 in 46 % and 3 in 37 %. Initial conservative management was followed by surgery in the majority according to the local protocol. MRCP was requested in three cases and only two patients underwent pre-operative ERCP. We perform intra-operative cholangiography routinely. Common bile duct stones were identified in 14 cases (30 %); all extracted laparoscopically. The mean surgical time was 65 mins (20 to 195 mins). The average inpatient hospital stay was 7 days (range 2 to 46 days). All but one patient were treated during the index admission. There were no post-operative complications, readmissions or deaths. Conclusions: Single session management of acute pancreatitis in the elderly patients is preferable to and safer than staged management. Laparoscopic bile duct exploration can be performed when necessary, allowing optimal utilisation of resources such as MRCP and ERCP. It reduces hospital stay, number of admissions and presentation to resolution intervals.

Ever since the advent of Laparoscopic Cholecystectomy, where in, it has established itself as the Gold Standard in the management of Gall Bladder disease, the effort has been to decrease the size of the incisions and the number of the ports. This is based on the fact that port site complications are directly proportional to the incision size and their number. We, From Department of Surgery, Medical College Patiala, Punjab, India, will be presenting our technique of doing Laparoscopic Cholecystectomy using 10 mm transumblical Camera port and 5 mm epigastric operating port. We use two Traction sutures, one at the fundus and the other at the Hartmann’s Pouch to open the subhepatic space and the Calots Triangle. The dissection is more or less similar to the standard Laparoscopic Cholecystectomy. Instead of Liga Clips we use Extracorporeal knotting for handling of the Cystic duct and the Cystic Artery. We also use energy source for tackling the Cystic Artery in some cases to save time. The specimen is delivered in a bag retrograde through the camera port. We have experience of over 500 cases with minimal conversion rate (3 %) to Three or Four Port Laparoscopic Cholecystectomy (in difficult cases). We have found the requirement of analgesia in these cases is much less, and cosmetic appearance is excellent. Since this procedure doesn’t require specialised equipments / instruments, we recommend its feasibility for Cholecystectomy.

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Total Sharp Dissection for Laparoscopic Cholecystectomies

‘‘The Black Liver Case’’

Daniel Gomez, MD, Pedro Villadiego, MD, Cesar Guevara, MD, Cristian Gomez, MD, CPO

Sergio Rojas-ortega, MD, Emina Pasic, MD, Rachid Cesin, MD, Gerardo Reed, MD, Hospital Angeles Puebla

Introducction: Laparoscopic cholecystectomy is a minimally invasive and highly effective technique that have become the current standard of care for gallstone disease. Several minimally invasive aproaches have been developed such as hı´brid procedures, single port or minilaparoscopy between others, showing no great differences respect acute and long term complications when compared with the standard procedure. Objective: We present a case series of Laparoscopic cholecystectomies describing a total sharp dissecction for this procedure. Methods: We performed 317 consecutives laparoscopic cholecystectomies in a single institution (November 2013– September 2014) by using a total scissors sharp disecction from the cholecystoduodenal ligament until getting a security critical view as described. Re´cords were reviewed for demographic data, mean operative time, length of hospital stay and intra or postoperative complications. Results: 317 patients were performed 237 females, 80 males All procedures were carried out succesfully Mean operative time: 23.7 minutes Mean hospital stay: 8.6 hours outpatient care No conversions We registered no major complications or re-intervention Conclusions: Laparoscopic cholecystectomies has become the standard of care for gallstone disease because of all the benefits described in current literature, however complications rates remains statistically steady no matter technology has advanced sinced it was first introduced the laparoscopic aproach. In our series we have come back to an old fashion way to perform this procedure, sorprisingly founding that the classic technique for cholecystectomy still proof to be safe and low morbid.

25 y.o. female presenting with jaundice and right upper cuadrant abdominal pain. Liver function test with direct hyperbilirubinaemia and normal enzymes. (BD 2.5 mg/dl, BI 0.7 mg/dl, AST 75 u., ALT 65 u., Alk P 80 u.) Ultrasound with microlithiasis and acute cholecystitis. During laparoscopy we found a ‘‘black liver’’ and performed cholangiography, cholecystectomy and liver biopsy. Histopathology:

Hereditary Hiperbilirubinaemia: DUBIN - JOHNSON Syndrome PHOTOS:

1. 2.

BLACK LIVER during Laparoscopy LIVER BIOPSY microphotograph

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Clinical Comparison of Laparoscopic Distal Pancreatectomy With or Without Splenectomy: Clinical Outcomes and Splenic Function Analysis

Iatrogenic Biliary Injuries: Multidisciplinary Management in a Major Tertiary Referral Center

Xiaowu Xu, MD, Renchao Zhang, MD, Yiping Mou, MD, FACS, Weiwei Jin, MD, Jiafei Yan, MD, Miaozun Zhang, MD, Chaojie Huang, MD, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University Background: The studies on spleen-preserving laparoscopic distal pancreatectomy (SP-LDP) versus laparoscopic distal pancreatosplenectomy (LDPS) have not been as readily available. This study aimed to compare perioperative outcomes of patients undergoing SP-LDP and LDPS and to assess the function of spleen salvage. Methods: A retrospective study was performed for patients who underwent SP-LDP or LDPS between 2004 and 2013. The patients’ demographic data, operative results, pathological reports, hospital courses, morbidity and mortality, and follow-up data (including splenic function) were compared between these two groups. Results: 114 cases were included in this study (SP-LDP = 34, LDPS = 70). There were no significant differences in the operating time (173.3 ± 46.4 vs 193.9 ± 54.4 min, P = 0.635) and intraoperative blood loss (154.1 ± 174.8 vs 223.6 ± 186.6 ml, P = 0.079) between these two groups. Mortality, morbidity (41.2 % vs 38.6 %, P = 0.946), pancreatic fistula rates (Cgrade B: 11.8 % vs 15.7 %, P = 0.958) were similar between the two groups. On postoperative days 14, LDPS group had more cases of PLT C300 * 109/L than the SP - LDP group (46.7 % vs 84.3 %, P = 0.000). Four patients (11.8 %) developed spleen focal infarction, 3 patients (8.8 %) with splenic vein stenosis or occlusion. The other patients were with normal patency of the splenic vessels. The score in vitality of SF-36 was higher in the SP-LDP group (82.5 ± 14.4 vs 68.9 ± 11.4, P = 0.046). Conclusions: SP-LDP is a procedure as safe and feasible as LDPS and could preserve the splenic function.

Ibrahim A Salama, MDPhD, Department of Hepatobiliary Surgery, National Liver Institute, Menophyia University, Egypt Background: Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcome of such injuries have been shown in cases managed in a specialized center. Objective: Evaluatation of biliary injuries management in major referral hepatobiliary center. Patients and Methods: Four hundred seventy two consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major Hepatobiliary center in Egypt over 10 years period using endoscopy in 232 patients, percutaneous techniques in 42 patients and surgery in 198 patients. Results: Endoscopy was very successful initial treatment of 232 patients (49 %) with mild/moderate biliary leakage (68 %) and biliary stricture (47 %) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8 %). However, surgery was needed in 198 (42 %) for major duct transection, ligation, major leakage and massive stricture. Surgery was urgently in 62 patients and electively in136 patients. Hepaticojejunostomy was done in most of cases with transanastomatic stents. One mortality after surgery due to biliary sepsis and postoperative Stricture was in 3 cases (1.5 %) treated with percutaneous dilation and stenting. Conclusion: Management of biliary injuries much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center. Keywords: Bile Duct injury; Laparoscopy; Multidisciplinary treatment; Cholecystectomy.

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P292

Rigid Choledochoscopy in Laparoscopic CBD Exploration (LCBDE) Ensures Near 100 % Stone Clearance – A 12 Year Single Centre Experience

Transumbilical Single-Incision Laparoscopic Deroofing for Hepatic and Splenic Cysts

Anubhav Vindal, MS, MRCSEd, FAIS, FCLS1, Pawanindra Lal, MSFRCSEd, FRCSGlasg, FRCSEngFACS1, Jagdish Chander, MS, FCLS2, 1Division of Minimal Access Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, 2Department of Surgical Sciences, Jaypee Hospital, NOIDA, UP Introduction: Characteristics of common bile duct stones (CBDS) seen in the Asian population are very different from those seen in the west. The stones are very frequently multiple, large in size, and impacted and the CBD is often hugely dilated. It is because of these reasons that extraction of these stones by the endoscopic modalities poses considerable challenge. We present our experience of laparoscopic CBD exploration over a 12 year period, which is the largest single centre experience from South East Asia. Methods: Over a 12 year period between 2003 and 2014, 250 patients with documented CBDS were treated laparoscopically using the trans-choledochal approach at a tertiary care teaching hospital in New Delhi. All the patients with gallstones presenting to surgical out patient department underwent basic investigations to screen them for CBDS, which was then confirmed on magnetic resonance cholangio pancreatography (MRCP). All the patients were operated through the standard 5 port technique described previously by the authors. A transcholedochal approach was utilized in all the patients. Intraoperative choledochoscopy was performed in all patients using a rigid 8/10F ureteroscope, to visualize and remove the CBDS and to check for the completion of removal at the end of the procedure. The calculi were extracted under direct vision using various techniques like Dormia basket, fragmentation using intra-corporeal Holmium laser lithotripsy and flushing the fragments into duodenum. The CBD was closed with or without drainage according to the merits of each case. Results: There were 47 males and 203 females with age ranging from 18 to 70 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 144.9 ± 22.3 min (range 90–220 min) and the mean intraoperative blood loss was 113.4 ± 75.6 ml. There were 7 conversions to open procedures. Rigid choledochoscopy was used in all the patients and complete clearance of CBD was achieved in nearly all the patients (98.4 %). The CBD was closed over a T tube in 36 patients (14.8 %), over an endobiliary stent (10F) in 102 patients (41.9 %) and primarily without any drainage in 76 patients (31.2 %). Twenty nine patients (11.9 %) underwent a choledochoduodenostomy due to a grossly dilated CBD with or without impacted CBDS. Twenty patients (8 %) had nonfatal postoperative complications and there was one postoperative mortality (0.4 %). Four patients had retained stone (1.6 %) and one patient developed a recurrent stone (0.4 %). All were managed effectively with endoscopic means. The mean post-operative hospital stay was 4.1 days (range 2 to 33 days). Conclusion: The authors believe that the use of a rigid ureteroscope for choledochoscopy in laparoscopic CBD exploration (LCBDE) provides a near 100 % stone clearance rate even in patients with large and impacted CBD stones.

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Takeshi Gocho, MD, Takeyuki Misawa, MD, PhD, Koichiro Haruki, MD, PhD, Ryota Saito, MD, PhD, Tadashi Akiba, MD, PhD, Katsuhiko Yanaga, MD, PhD, Jikei University School of Medicine Background and Objective: Laparoscopic deroofing has become a standard approach for symptomatic hepatic and splenic cysts because of the low recurrence rate and minimal postoperative pain. Recent interest in better cosmetic outcomes promoted single incision laparoscopic surgery (SILS) in a variety of target organs including deroofing of hepatic and splenic cysts. The aim of this study was to assess the feasibility and safety of single-incision laparoscopic (SIL) deroofing of hepatic and splenic cysts. Patients and Methods: Between February 2010 and Ausugt 2014, we performed 13 cases of SIL deroofing for symptomatic hepatic (11 cases) and splenic (2 cases) cysts. A SILSTM port was placed through a single intraumbilical skin incision. A flexible 5-mm laparoscope and an articulating grasper were used in addition to standard laparoscopic instruments. The cyst wall was dissected using a 5-mm bipolar vessel sealer. Results: The patients’ median age was 57 (range, 29–73) years, and all but one was female. The median size of the cyst was 11.0 (range, 10.0–15.2) cm. SIL deroofing was successfully performed in all patients, and none required additional port or conversion to open surgery. Intraoperative blood loss was minimal in all cases. Median operative time was 145 (range, 100–152) min. A drain was inserted only in the first patient. Diet intake was started from the first postoperative day and all patients were discharged uneventfully with the mean hospital stay of 3.2 ± 0.4 days. Median postoperative follow-up of 27 (range, 6–52) months did not reveal any complications nor recurrence. Postoperatively, the umbilical incision was almost unnoticeable in all cases. Conclusion: SIL deroofing is technically feasible and has cosmetic benefit for patients with symptomatic hepatic and splenic cysts.

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Recurrent Right Flank Abscess as a Manifestation of Retained Gallstone and Novel Technique of Retrieval Using CT Guided Needle as Marker

Factors Influencing Conversion and Complications of Elective Laparoscopic Cholecystectomy in a Nigerian Hospital

Manthan Makadia, MD1, Dhruv Patel2, Stanley Ogu, MD1, Aniket Sakharpe, MD1, Abdul Badr, MD1, 1Easton Hospital, 2Drexel University Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for the past 15 years, however the incidence of complications from lost gallstones has not changed significantly despite the advanced experience of general surgeons. During laparoscopic cholecystectomy, the gallbladder can perforate upon detachment from the liver or during its retrieval through the trocar site in up to 40 % of cases. Gallstones can be dropped into the peritoneal cavity around the liver, within the abdominal wall, or between small intestines in up to 30 % of cases. In roughly 0.5–6 % of LC cases, the gallstones left behind can lead to complications. These complications have been shown to cause inflammation, abscesses, peritonitis and even adhesions, inflammatory reactions, abscesses or peritonitis. We present a case of a 75-year-old male who was admitted with recurrent right flank abscess with draining sinus one year following laparoscopic cholecystectomy. Computerized tomography (CT) scan evaluation showed displaced gallstones in Morrison’s pouch. Hereby we describe the novel approach of CT-guided needle placement and subsequent exploration of the patient’s 10th and 11th rib interspace with extraction of two displaced gallstones in the subhepatic region with adjacent inflammatory process.

Adewale O Adisa, MBChB, FWACS, FMCS, DMAS, Olalekan Olaseinde, FWACS, Olusegun I Alatise, FWACS, FMCS, MSc, Oladejo Lawal, FMCS, FWACS, Obafemi Awolowo University Objective: To determine factors that influence conversion to open surgery and occurrence of intra and postoperative complications following elective laparoscopic cholecystectomy. Method: All patients undergoing elective laparoscopic cholecystectomy at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria from January 2009 through September 2013 were prospectively evaluated. Socio-demographic and anthropometric data were obtained and occurrence of conversions, intraoperative and postoperative complications were documented. Results: Seventy-two patients, including 60(83.3 %) females and 12(16.7 %) males with an age range 18–82 years (Mean 45.6 yr) had elective laparoscopic cholecystectomy within the study period. Chronic calculous cholecystitis was the commonest indication (61 %), with acute inflammation in 11(%) patients. Gallbladder wall thickness was normal (=3 mm) in 47(65.3 %), thick (4–9 mm) in 17(23.6 %) and very thick (=10 mm) in 8(11.1 %) patients. Gallbladder mucocele was encountered in 9(%), gallbladder empyema in 4(%) and gangrenous gallbladder in 2(%) cases. Six (8.3 %) procedures were converted to open laparotomy, bile duct injury occurred in 2(2.8 %) and port site infections in 4(5.6 %) cases. No mortality was recorded in this series. Conversion was significantly associated with gallbladder wall thickness and acute calculous cholecystitis. Conclusion: Acute calculous cholecystitis and a thickened gallbladder wall may significantly influence conversion of laparoscopic cholecystectomy to open procedure and may serve as preoperative predictors.

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Laparoscopic Treatment of Hydatid Cyst of the Liver: A Single Institutional Experience

Effective and Cost Efficient Model for Diabetes Screening/ Diagnosis and Assessment of Diabetic Management in a Community-Based, Third-World Setting

Ibrahim A Salama, MDPhD1, Mohammed Elhosany, MD2, Elamir M Amir3, 1Deaprtment of Hepatobiliary Surgery, National Liver Institute, Menophyia University, Egypt, 2Department of Radiology, National Liver Institute, Menophyia University, Egypt, 3Department of Parsitology, National Liver Institute, Menophyia University, Egypt Objective: The aim of this study was to evaluate the safety and efficacy of laparoscopic ally treated hydatid cysts of the liver in our institutional experience. Methods: from 2006 to 2009, 28 patients underwent laparoscopic treatment of the hydatid cysts of the liver in National Liver Institute, Menophyia University. All patients had chest –X-ray, abdominal ultrasound, CT abdomen, chest, brain and hydatid serology. The different stages of procedure were the same as in open surgery, puncture, Aspiration, injection of scoilocidal agent, re-aspiration, removal the proligerous membrane and deroofing, or pericystectomy. Results: The patient’s age range (7–66 years). The number of the cysts ranged from (1 to 8) hydatid cysts with diameter range from (40 mm to190 mm). 2 patients had associated splenic cysts and one patient had associated lung hydatid cyst. Conversion to open in one case (3.5 %) the case was associated with splenic cyst (splenectomy was done). No mortality. Morbidity in one case in the form of biliary leak treated by ERCP and stent. The mean operative time 65 minutes. Follow-up was carried out from 6 to 38 months (mean 14 months). There was no relapse of the disease. Conclusion: Laparoscopy considered as a safe and excellent approach for the treatment of hydatid cysts of the liver. Keywords: Hydatid cyst; laparoscopic resection; Laparoscopic Hydatid deroofing.

Mustafa H Alibhai, MD1, Mufadal M Moosabhoy, MD2, Elizabeth Littlejohn, MD3, Rebecca Lipton, PhD3, 1BMI of Texas, 2Hindsdale Pediatric Associates, 3University of Chicago Background: Diabetes prevalence is expected to increase from 2.8 % in 2000 to 4.8 % in 2030. Point-of-Care (POC) Hemoglobin A1c (A1C) testing kits developed in 2008 and ADA guidelines from 2009 for diagnostic use of A1C made it plausible to use POC A1C kits for community-based diabetes screening and evaluation of known diabetic management in a developing country. Methods: In 2009 & 2010, diabetes screening was performed in Gujarat, India at medical camps held during Muslim sermons led by Dawoodi Bohra Muslim leader, Dr. Syedna Mohammed Burhanuddin (TUS). People C 40 yrs old and/ or with known diabetes could participate. All were tested for random blood glucose (RBG). Those with RBG C 200 mg/dl or known diabetes received POC A1C testing, body mass index (BMI), blood pressure, and physician consultation. All were given educational pamphlets and their test results. Results: No Prior Diabetes: 3,453 participants were screened. 169 (4.9 %) had RBG C 200 mg/dl. 151 had A1C testing, of which 50 (33 %) had pre-diabetes levels (A1C = 5.7–6.4 %) and 72 (48 %) had diagnostic levels (A1C C 6.5 %). 51 % tested were overweight and 18 % obese by BMI measurement. Known Diabetes: 1,128 had RBG testing with a mean result of 225 mg/dl. 803 had A1C testing, of which 67 % had uncontrolled diabetes (A1C C 7.0 %) and 21.5 % had poorly controlled diabetes (A1C C 9.5 %). 46 % were overweight and 24 % obese. Cost in India to identify each likely new pre-diabetes or diabetes patient was only $13.61 and to identify each poorly controlled diabetes patient was $8.02. Conclusions: Using POC RBG and A1C tests was effective and efficient to screen for diabetes and identify poorly controlled diabetes in a community-based setting. The high percentage of uncontrolled diabetes shows the need for frequent testing and teaching platforms like this one to reinforce proper diabetes management. On-site physician intervention could then be effective to develop care plans and provide targeted teaching and follow up.

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A Developing Country Reuse of Disposable Surgical Equipments & Infectious Rates

The Monopolar ‘‘Bovie’’ Instrument: Pattern of Use Analysis

Said D Elias, MD1, Henry Lin, MD2, 1Peltier General Hospital, 2 Naval Hospital Camp LeJeune Introduction: Surgery in developing countries can be hindered by the limited monetary funds, especially in the era with significant utilization of disposable surgical instruments. Objectives: To review the infectious complications of the practice of utilization of decontamination instead of full sterilization in a hospital located in a developing country. Methods: Unable to afford developed country sterilization standards, Peltier General Hospital in Djibouti resorted to decontamination of instruments, including typically disposable electrocautery devices. Case series of 7 years from 2007–2014 were collected & analyzed for infectious complication rates. Results: Through large variety of cases, including gastrointestinal surgery, urology, thoracic, vascular, gynecology, thyroid, skin, & other soft tissue surgery, there was approximately a 7 % infectious complication rate associated with decontamination method (but not full sterilization technique) & no standardized pre-operative antibiotics, higher than historical rates of 1.5 % for clean surgical cases & 7.7 % for clean contaminated cases. Conclusion: Although developing countries may sometimes use decontamination rather than sterilization techniques, this practice increases overall infectious complications post-operatively.

Lauren R Wilson, MD, Nicole T Townsend, MD, Thomas N Robinson, MD, University of Colorado Department of Surgery Background: The monopolar ‘‘Bovie’’ instrument is ubiquitous. It is used by all surgical specialties on almost all surgical cases. The power delivered by the monopolar generator provides the end-user with a variety of settings to achieve different tissue effects, however patterns of use are unknown. The PURPOSE of this study is to determine the patterns with which surgeons use the monopolar instrument. Study Design: We collected retrospective electronic data on consecutive activations of the monopolar instrument from four separate medical centers’ electrosurgical generator units. Outcome variables included generator power in Watts (W), generator mode setting (cut, coagulation [coag], or blend), and duration of activation in seconds (s). Statistical analysis included non-parametric unpaired t-test for continuous variables and chi-square test for dichotomous variables. Results: 6,666 Consecutive monopolar instrument activations were analyzed over 39 generator units. Generator Power: The most common power setting was 30 Watts (22 % of activations, n = 1,494) and settings of 25–35 W were used 50 % of the time (n = 3,334). When using coag mode, the average power setting was 39 ± 16 W. When using cut mode, the average power was significantly higher at 60 W (39 ± 16 W v. 60 ± 71 W; p \ 0.0001). Similar to cut mode, average power settings on blend mode were significantly higher at 54 W (39 ± 16 W v. 54 ± 64 W; p \ 0.0001). Generator Mode: The most common monopolar mode was coag (high voltage, 6 % duty cycle), used 84.8 % (n = 5,654) of the time, and significantly more frequently than both other modes. In comparison, cut mode (low voltage, 100 % duty cycle) was used 10.9 % (n = 728) of the time, while blend mode (variation in voltage and duty cycle to produce desired clinical effects of coaglation v. cutting) was used only 4.3 % (n = 284) of the time (5,654 coag activations v. 1,112 non-coag activations; p \ 0.0001). Although both were used significantly less than coag, cut was used more significantly than blend (cut activations v. blend activations, p \ 0.0001). Activation Time: Average activation time for coag mode was significantly longer than cut (3 ± 3 s v. 2 ± 2 s p \ 0.0001) or blend (3 ± 3 s v. 2 ± 2 s, p \ 0.0001) modes. Cut mode and blend mode activation times were not significantly different (2 ± 2 s v. 2 ± 2 s, p = 1.000). Conclusions: The monopolar instrument is repetitively used on the same power and mode settings. The single power setting of 30 Watts is used 22 % of the time with settings of 25–35 W used for half of all activations. Coagulation mode is used in 85 % of activations. These findings suggest that this instrument, which contains advanced technology with flexible settings, is underutilized by the surgical community. Use of multiple settings can help the surgeon achieve a range of tissue effects, including dessication, fulguration, and vaporization, which can improve tissue cutting and hemostasis. Improved understanding of these patterns of use can identify what additional settings could be used to achieve desired tissue effects. This study may imply that surgeons need additional training in non-standard settings of the monopolar instrument.

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Disparities in Treatment of Biliary Disease at an Urban SafetyNet Hospital

First Human Experience Using the Dynamic Laparoscopic Novatract (TM) Retractor. Initial Experience of 18 Patients

Thomas P McIntyre, MD, Felix Ho, BS, Muthukumar Muthusamy, MD, Kings County Hospital Center

Iswanto Sucandy, MD, Andrew J Duffy, MD, FACS, Geoffrey Nadzam, MD, Kurt E Roberts, MD, FACS, Yale University

Introduction: It has been well described that patient payer status and racial differences may account for disparities in treatment for benign biliary disease, resulting in lower rates of laparoscopic cholecystectomy and increased nonoperative management. We conducted a retrospective chart review of patients who received cholecystectomy for benign biliary disease at an urban safety-net hospital. Our objective was to characterize the management of benign biliary disease in a population that may be at a high risk for suffering from disparities in care. Methods: We examined records of 130 patients who received cholecystectomy at our institution between February 2009 and February 2012 for benign biliary disease. We recorded demographic data (age, sex, race, payer status, zip code), diagnosis at surgery, time from initial presentation with biliary disease to surgery (definitive treatment), length of stay post surgery and in total, number of ED visits, and total number of inpatient admissions. Results: At our urban public hospital 61.5 % of patients had Medicaid, 16.9 % had private insurance, 13.8 % were uninsured and 6.9 % had Medicare. 81.5 % of our patients were black, 14.6 % were Hispanic, 0.7 % were white, and 3.1 % were not identified as a particular race. Indications for cholecystectomy were symptomatic cholelithiasis (46.2 %), acute cholecystitis (20.0 %), choledocolithiasis (15.4 %), gallstone pancreatitis (12.3 %), and combined acute cholecystitis with pancreatitis (6.2 %). All patients underwent laparoscopic cholecystectomy, with a 2.3 % open conversion rate. 54.6 % of patients had an outpatient procedure. The average number of ED visits for all diagnoses was 1.57 and 38 % of all patients made repeat visits. Average time from initial presentation to surgery for all diagnoses was 188.8 days. Patients spent an average of 4.85 days as inpatients for all admissions for treatment of benign biliary disease. Conclusion: National trends and practice guidelines recommend urgent or elective cholecystectomy for most benign biliary disease. The majority of our patients are African American and poor, based upon our high rates of uninsured and Medicaid patients, and therefore at risk for disparities in care. In this population we found that there is a delay in patients receiving cholecystectomy as definitive treatment for benign biliary disease as reflected by a long time lapse between diagnosis and surgery, a significant number of repeat ER visits and a high cumulative number of days spent in the hospital. Further research is warranted to directly address the magnitude of this disparity and develop interventions to reduce it.

Objective: The concept of reducing the number of transabdominal access ports has been criticized for violating basic tenets of traditional multiport laparoscopy. The potential benefits of natural orifice translumenal endoscopic surgery, reduced port surgery, and laparoendoscopic single-site surgery include decreased postoperative pain, improved cosmesis, less hernias and fewer wound-related complications. However, the technical challenges associated with these access methods have not been adequately addressed by advancement in instrumentations. We describe our initial experience with the NovaTractTM Laparoscopic Dynamic Retractor (NovaTract Surgical, Inc, Madison, CT). Methods: A retrospective review of a prospectively maintained database of all patients who underwent two-port laparoscopic cholecystectomy between September 2013 and July 2014 using the NovaTractTM retractor was performed. The patients were equally divided into 3 groups (Group A, B, C) based on the order of case performed, as an effort to evaluate potential learning curve. Statistical analysis was performed using analysis of variance (ANOVA) with p-value \ .05 is considered statistically significant. Results: Eighteen consecutive patients (Female:Male = 14:4) underwent successful two-port laparoscopic cholecystectomy with a preoperative diagnosis of symptomatic cholelithiasis. Mean age was 39.9 years (range: 22–72) with mean BMI of 28.1 kg/m2 (range: 21–39.4). All cases were scheduled electively after an appropriate informed consent. The overall mean operative time was 65 minutes (range: 42–105), with Group A 70 minutes, Group B 65 minutes, and Group C 58 minutes (p = .58). All cases were completed laparoscopically without open conversion. There were no intra- or postoperative complications. All patients were discharged on the same day of surgery. Final pathology reports were consistent with cholelithiasis and chronic cholecystitis in all patients. No complications have been noted during postoperative follow-up. All patients have returned to their routine activities within 2 weeks after the cholecystectomy. Conclusions: The NovaTractTM Laparoscopic Dynamic Retractor appears to have met the initial objectives. It is safe and easy to use with minimal learning curve, reflected by standard operative time for a laparocopic cholecystectomy using only two ports. It allows surgical approach to mimic the conventional laparoscopic technique, while reducing the number of dedicated retraction ports.

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Ergonomic Analysis of Small-Caliber Trans-Nasal Gastroduodenoscopy and Proposed Solutions to Ergonomic Problems

The Alimentary Canal Suture by the Laparoscopic Surgery Using V-Loc Thread

Kazuhiko Shinohara, MD, PhD, Tokyo University of Technology

Shigehiko Yagi, MD, Makoato Shirai, MD, Masanori Hottchi, MD, Ehime Prefectural Central Hospital

Background and Objective: Implementation of small-caliber trans-nasal gastroduodenoscopy (NGS) for the diagnosis of upper gastrointestinal disease has become widespread in Japan because it is associated with minimal discomfort. However, there has been some resistance to its implementation from physicians and nurses because its impact on workflow. We compared the workflow of physicians and nurses during NGS and conventional trans-oral gastroduonenoscopy (OGS) from an ergonomic standpoint. Methods: The caliber of the NGS was 5.9 mm and that of the OGS was 10 mm. Endoscopic examination was performed under local anesthesia applied to the nasopharyngeal mucosa. The endoscope was inserted to the second portion of the duodenum, and the duodenum, stomach, esophagus and pharynx were closely observed. Both examinations were performed in 20 patients by the same physician, who has 30 years’ clinical experience. Workflow and ergonomic problems were investigated by process analysis methods from industrial engineering and by questionnaire. Results: The number of preparatory processes was doubled for NGS. The additional processes affected the nurses and included administration of vasoconstrictors via nasal cannula and local anesthesia via vaporizer. The number of processes for examination by NGS were the same as for OGS, but the mean examination times without biopsy maneuvers were much longer for NGS at 234.0 s (SD = 118, n = 20) than for OGS at 120.1 s (SD = 31.6, n = 20). These differences resulted from decreased suction and insufflation compared with OGS. Additional ergonomic problems associated with NGS that affected the physicians included spatial orientation of the nasal and upper pharyngeal cavities, impaired maneuverability of the small-caliber shaft, and poor maneuverability of the NGS biopsy forceps due to their small caliber. Discussion: We found that NGS entailed additional preparatory work of the nasal cavity and caused maneuverability problems with its small-caliber endoscope and accessory devices. For smooth and safe implementation of NGS to examine for gastrointestinal disease, the ergonomic problems can be resolved by developing a packaged preparation kit, providing appropriate training through simulation, augmenting power for suction and insufflation, and providing adequate holding devices, accessory devices, and gloves for the small-caliber endoscope. Further analysis of the workflow of the medical staff involved is required.

V-Loc180 (A closure device) is the Pori Glico Nate suture. Since this thread is absorbency, application to the part which requires the junction over a long period of time (three weeks or more) is not recommended. Moreover, the safety and validity of this thread are not established alimentary canal anastomosis. However, this suture can be simply used in a continuous suture, and is considered that that power is demonstrated by laparoscopic surgery. We have done auxiliary use of this V-Loc180 in an alimentary canal suture. The Contents: 15 Stomach-walls defective part closing in a Laparoscopy Endoscopy Cooperative Surgery operation, 12 closing of the entry hole in the Roux-Y anastomosis of a Laparoscopy Assisted Distal Gastrectomy, one Stomach jejunum anastomosis which can set Billroth 1 reconstruction of Laparoscopic Distal Gastrectomy, one stomach jejunum anastomosis in a Laparoscopic Assisted Proximal Gastrectomy, and the functional some parts anastomosis of Laparoscopic Total Gastrectomy, and one stomach jejunum bypass surgery. Although it was an in general good result, failure of the sutures was produced in Billroth 1 anastomosis. It was a part which seldom requires tension about other anastomosis and a suture. Although the objective number could not be shown, when it was a part which does not require tension as an impression, the possibility which can be used was safely suggested also to the alimentary canal. Case accumulation evaluation is due to be performed from now on.

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A Comparative Assessment of Novel Mini Laparoscopic Tools

Post Marketing Anaylsis of a Novel, Cordless Ultrasonic Dissector

Emily Dorian, Francis J DeAsis, BS, BA, Ryota Tanaka, MD, PhD, Brittany Lapin, MPH, Robert Amesbury, JoAnn M Carbray, BS, Michael B Ujiki, MD, NorthShore University HealthSystem Evanston Hospital

Erin H Baker, MD, Jessica M Drummond, RN, Ramanathan M Seshadri, MD, Wendel Naumann, MD, Dimitrios Stefanidis, MD, Iain H McKillop, PhD, Ryan Z Swan, MD, John B Martinie, MD, David A Iannitti, MD, Carolinas Medical Center

Background: Mini laparoscopy (ML) is an emerging minimally invasive technique that aims to improve upon standard laparoscopy in the areas of tissue trauma, pain and cosmesis. ML instruments are 3 mm in diameter or less compared to traditional 5 mm diameter laparoscopic instruments. The miniaturized instruments accommodate mini ports and small trocar incisions that aim to improve outcomes. The objective of this study was to determine if there was a difference in functionality between two novel ML instruments when compared to standard laparoscopic tools. The primary difference between the ML instruments was assembly, as both tools use different methods for the operator to change the toolhead. Differences between the ML instruments and the standard instruments were assessed in a simulated surgical environment. Methods: Eighteen participants (5 novices, 10 residents, 3 attendings) were recruited for this IRB-approved study in a surgical simulation training center. After completing a demographics sheet, participants were shown how to assemble the ML tools. Group A ML tools were assembled intracorporeally, while Group B ML tools were assembled extracorporeally. Then, using standard laparoscopic graspers, ML graspers or a combination of both, each participant performed 3 basic laparoscopic training tasks: a Peg Transfer (based on the Fundamentals of Laparoscopic SurgeryTM Program), Rubber Band Stretch, and Tootsie RollTM Unwrapping. Participants were scored based on time to task completion. Assembly and disassembly time of the ML graspers was also recorded. Following each round of tasks, participants completed a survey evaluating the ML graspers with respect to standard laparoscopic graspers. Chi-square test, Analysis of Variance (ANOVA) and Tukey’s post-hoc test was used to analyze the data. Results: On average, a novice had zero laparoscopic experience, residents had between 25–50 cases, and attendings had over 1000 cases (p B .0001). When comparing task times, both ML tools performed at the level of the standard laparoscopic graspers in all participant groups (Table 1). Group A tools were quicker to assemble and disassemble versus Group B tools (Table 1). According to post-task surveys, all participant groups indicated that both sets of ML graspers were comparable to the standard graspers when evaluated on Maneuverability, Strength, Efficiency, Structure, and Overall Function. Conclusion: In a non-clinical setting, ML instruments perform at the level of standard laparoscopic tools. The ML tools with intracorporeal assembly were also quicker to assemble than those with extracorporeal assembly.

Introduction: Tissue dissection and vessel sealing in the operating room can be performed using a variety of energy sources and surgical devices. SonicisionTM is a cordless ultrasonic dissector and vessel sealer for use in laparoscopic and open surgery. We describe the post marketing analysis of this novel device in a variety of general and gynecological procedures. Methods: Patients undergoing laparoscopic and open general surgical and gynecologic procedures were prospectively screened and consented for participation in the study. Data collected included patient demographics, device activations including number of seals, device failures, seal failures, patient complications and follow up. Surgeons were surveyed following each case regarding ease of use, intraoperative visualization, and device failures using a Likert scale. Data was analyzed using standard statistical methods, appropriate to the variable type. Descriptive statistics used to describe the study population included means, standard deviation, counts, and percentages. Results: Eighty two patients were consented and participated in the study. The most frequently performed procedures were bilateral salpingo-oophorectomy (28), total laparoscopic hysterectomy (24), and cholecystectomy (13). Combined procedures were frequently performed including pancreatecomy, splenectomy, small bowel resection, and cystgastrostomy. Mean age was 54.2 years and there were 65 (79.2 %) females. The most frequent number of device activations per case was between 26–50 (36.6 %). There was one device failure related to a battery housing component. Battery change during the procedure occurred in 5 cases, of which 3 were felt to be due to incomplete charge in sterile processing prior to the procedure. On average, battery change was required after 90.6 (16–220) device activations. However, in cases in which a fully charged battery was used, battery change was required after 185 device activations. There were 4 failed seals out of 3,594 total estimated seals (0.11 %). Failed seals were felt to be due to thickened, scarred tissue not amenable to device jaw compression. Failed vessel sealing required use of an alternative device for hemostasis in 3 cases. There were no patient intraoperative or postoperative complications felt to be related to the device. Overall, surgeons felt the device was extremely easy to use (97.6 %) and no visual obstruction due to steam from the device was encountered (95 %). Ninety five percent of surgeons felt the device was beneficial for soft tissue dissection and vessel sealing. Conclusion: SonicisionTM is safe and effective for use in dissection of soft tissues and vessel sealing in a variety of laparoscopic and open general gastrointestinal and gynecologic procedures. In this study, there were no complications related to the device itself. The remarkable cordless design of this device significantly enhances its ease of use with overall excellent effectiveness.

Table 1

Task and construction times (mean ± SD) Group A

Group B

Standard

p-value

Peg Transfer (sec)

127.9 ± 71.5

108.9 ± 38.1

100.9 ± 44.3

0.303

Rubber Band Stretch (sec)

148.7 ± 78.9

182.7 ± 98.4

134.0 ± 101.4

0.285

Tootsie RollTM Unwrapping (sec)

127.4 ± 76.9

110.9 ± 43.8

129.5 ± 76.1

0.664

Assembly (sec)

38.53 ± 29.22

74.42 ± 24.70

n/a

\.0001

Disassembly (sec)

27.32 ± 24.12

39.81 ± 33.24

n/a

0.02

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Novel Use of Spy Elite in Esophagectomy with Colonic Interposition Graft

Safety and Efficacy of an Electrothermal Bipolar Vessel-Sealing Device in Sealing and Division of the Inferior Mesenteric Vessels in Minimal Invasive Colorectal Surgery

Jeffrey R Watkins, MD, Houssam G Osman, MD, Rohan Jeyarajah, MD, Methodist Dallas Medical Center Introduction: We present a series of three patients who underwent colonic interposition grafts with vascular evaluation using the Spy Elite imaging system. Gastric pull-up is the preferred method for reconstruction following esophagectomy, but when the stomach is not a suitable conduit colonic interposition is can be performed. Colonic interposition procedures are more complex than gastric pull-up and carry higher morbidity. The anastomotic leak after colonic interposition in the literature ranges from 0–47 %. SPY Elite is an intraoperative perfusion assessment system that enables surgeons to visualize and evaluate tissue perfusion in real-time with a great degree of accuracy. While its use is well-documented in the evaluation of other gastrointestinal anastamoses, there are currently no reports of its application in colonic interpostition grafts. Cases Presentation: Trans-hiatal esophagectomy with colonic interposition was performed in three patients: a 58 year-old female (patient 1) with gastroesophageal junction tumor extending into the proximal stomach and the thoracic esophagus, a 61 year-old male (patient 2) with a gastroesophageal junction tumor, and a 50 year-old male (patient 3) with chronic esophageal stricture secondary to gastroesophageal caustic injury. Gastroesophagectomy was performed in standard trans-hiatal fashion in all cases. The right colon was prepared for interposition along with the middle colic pedicle and the ileocolic vessels were ligated. While the colonic conduit perfusion appeared to be adequate on visual inspection in all three patients, this was further evaluated using the SPY Elite system. The conduit and the cecum appeared well vascularized in patient 1 and 2 during SPY visualization, but the conduit in patient 3 appeared less vascularized. Colo-esophageal anastomosis was performed using a linear stapler and oversewn. A contrast study was performed postoperatively to evaluate the anastomosis. No clinical or radiological leak was noted in the patients with appropriate perfusion as determined by Spy Elite visualization. A radiological leak was noted however, in the patient with abnormal Spy Elite visualization. This was treated conservatively and required no further intervention. Conclusion: Anastomotic leak is a major complication after esophagectomy and colonic interposition. Conduit ischemia is an important risk factor for anastomotic leak. The use of SPY Elite may accurately assess the conduit perfusion and provide information to aid with intraoperative decision to avoid this complication.

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Ajit Pai, MDMChMRCS, George Melich, MD, Slawomir J Marecik, MD, FACS, FASCRS, John J Park, MD, FACS, FASCRS, Leela M Prasad, MD, FACSFASCRSFRCS, Advocate Lutheran General Hospital Background: Energy devices are being increasingly used for dissection and vessel sealing in minimally invasive surgery. The latest generations of these devices’ are designated as electrothermal bipolar vessel sealing devices (EBVS). Our objective was to assess the safety and effectiveness of the EnSealTM bipolar energy device in sealing and division of the inferior mesenteric vessels in minimal invasive colorectal surgery. Methods: Patients undergoing minimally invasive left colonic and rectal resections where EnSealTM was used for dissection and division of inferior mesenteric vessels were identified in a prospectively maintained database. Minimal invasive techniques included laparoscopic and robotic operations between August 2007 and October 2011. Patient demographics, type of operation, peroperative complications such as inadequate sealing of vessels and post-operative complications and blood transfusion requirements were recorded. Results: 400 consecutive patients were included in the study. Mean age was 57 years (range 10–97). Male to female ratio was 1.3:1. Procedures included low anterior resection (69 %), ultralow anterior resection with colo-anal anastomosis (12 %), abdominoperineal resection (4 %), ileal pouch anal anastomosis (6 %), proctocolectomy (5 %) and subtotal colectomy (4 %). Indications for surgery were colorectal malignancy (47 %), complicated diverticular disease (33 %), inflammatory bowel disease (9 %) and the remainder were performed for adenomas, rectal prolapse, endometriosis, familial adenomatosis polyposis, and Clostridium difficile colitis. The EBVS was used on 386 inferior mesenteric arteries and 305 inferior mesenteric veins. In 14 of 400 patients, the device was not used to divide the Inferior mesenteric artery (IMA) because of inflamed and thickened mesentery. The EnSealTM was also not used to divide the Inferior mesenteric vein (IMV) at its origin in 95 patients without malignancy and with a lax left colon. Six patients (1.5 %) had controllable immediate intra operative bleeding from the IMA stump (Table 1). None required conversion to an open procedure. Conclusions: The EnsealTM energy device is extremely safe for sealing inferior mesenteric vessels in minimally invasive colorectal surgery. It has additional utility as a blunt dissector to develop tissue planes and as a retractor. Failure to seal vessels with bleeding complications is rare, immediate and easily controlled. Thermal injuries to the bowel or ureter did not occur in this study.

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Which Causes More Ergonomic Stress: Laparoscopic or Open Surgery?

Does Patient BMI Affect Ergonomics of Laparoscopic Surgery?

Robert Wang, Zhe Liang, Ahmed M Zihni, MD, MPH, Shuddhadeb Ray, MD, Michael M Awad, MD, PhD, Washington University School of Medicine

Zhe Liang, BS, Robert Wang, BS, Ahmed M Zihni, MD, MPH, Shuddhadeb Ray, MD, Michael M Awad, MD, PhD, Washington University School of Medicine

Introduction: As the number of procedures performed laparoscopically has increased dramatically over the last few decades, there is an increasing awareness of the unique ergonomic challenges experienced by the laparoscopic surgeon. Compared to similar open surgeries, laparoscopic procedures are limited by the fulcrum effect, the general lack of articulating instruments, and the adoption of a less mobile posture. On the other hand, the use of laparoscopy allows the surgeon to operate in an upright position without having to lean over the site of incision. Subjective studies of surgeons who perform laparoscopy report a near universal incidence of chronic musculoskeletal pain and injury. To date, the ergonomic stress of laparoscopy compared to open surgery has not been objectively measured. The purpose of this study is to quantify and compare the ergonomic stress experienced by a surgeon while performing open versus laparoscopic portions of a procedure. We hypothesize that a surgeon will experience greater ergonomic strain when performing laparoscopic surgery than when performing open surgery. Methods and Procedures: We designed a prospective study to measure upper body muscle activation during the laparoscopic and open portions of sigmoid colectomies in a single surgeon. A sample of five cases were recorded over a two-month time span (June to July 2014). Each case contained significant portions of laparoscopic and open surgery (average duration of laparoscopic surgery was 89.7 min; average duration of open surgery was 84.1 min). Using a wireless electromyography (EMG) system, we obtained whole-case EMG tracings from the subject’s left and right biceps, triceps, deltoid, and trapezius muscles. After normalization to a maximum voltage of contraction (MVC), these EMG tracings were used to calculate average muscle activation during the open and laparoscopic segments of each procedure. Paired Student’s T-test was used to compare the average muscle activation between the two groups (*p \ 0.05 considered statistically significant). Results: Significant reductions of mean muscle activation in laparoscopic compared to open procedures were noted for the left triceps (34.7 %), left deltoid (45.8 %), left trapezius (53.6 %), right triceps (37.3 %) and right trapezius (54.0 %). There were no statistically significant changes of mean muscle activations in the left biceps, right biceps and right deltoid between open and laparoscopic portions of the procedures.

Conclusion: Contrary to our hypothesis, the laparoscopic approach provided ergonomic benefit in several upper body muscle groups compared to the open approach. This may be due to the greater reach of laparoscopic instruments and camera in the lower abdomen/pelvis. Patient body habitus may also have less of an effect in the laparoscopic compared to open approach. Performing the study in a single subject allowed for control of inter-surgeon variability. Analysis of paired data of open and laparoscopic portions within individual procedures helped control for variability in patient factors (e.g., body habitus, degree of difficulty). Future studies with multiple subjects and different types of procedures are planned to further investigate these findings.

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Introduction: The objective of this study was to quantify the ergonomic impact of patient BMI on surgeons’ upper body muscle groups during laparoscopic surgery. Laparoscopic surgery has become the treatment of choice for many common procedures including hernia repairs, bariatric surgeries, and cholecystectomies. However, laparoscopic surgery creates unique ergonomic challenges for the surgeon with the potential to cause pain or injury. Studies have shown that the majority of surgeons who routinely perform laparoscopic procedures experience at least occasional upper body pain or stiffness during surgery, with the neck and back being the most frequent areas of discomfort. Contributors to poor surgeon ergonomics include prolonged operative duration, limited mobility, and poor mechanical efficiency of laparoscopic tools. As obesity rates continue to rise in the United States, we sought to quantify how patient BMI might influence ergonomic stress. We hypothesize that ergonomic stress for the surgeon will be greater for obese patients compared to non-obese patients. Methods and Procedures: We designed a prospective study to measure surgeon upper body muscle activation during laparoscopic surgery. Five attending surgeons experienced in laparoscopic surgery ([500 laparoscopic procedures performed) were recruited to participate, and provided data from a total of 24 laparoscopic surgeries performed over a period of two months (June to July 2014). Using a wireless electromyography (EMG) system, we obtained whole-case EMG traces from each surgeon’s biceps, triceps, deltoid, and trapezius muscles. After normalization to a maximum voltage of contraction (MVC), these EMG tracings were used to calculate average muscle activation for the laparoscopic portions of each procedure. Subjects were also asked to complete the NASA Task Load Index (NTLX) survey following each case as a subjective measure of task difficulty. Student’s T-test was used to compare average muscle activation and NTLX survey scores between patient groups with a BMI greater than 30 with those with a BMI less than 30 (p \ 0.05 considered statistically significant). Results: Twenty-four procedures including hernia repairs (n = 8), bariatric surgeries (n = 6), combination hernia/ bariatric (n = 6), sigmoid colectomy (n = 1), cholecystectomy (n = 1), and exploratory removal of an infected mesh (n = 1) were analyzed. There were 11 patients with BMI less than 30 and 13 patients with BMI greater than 30. There was no significant difference in average muscle activation during laparoscopic surgery in patients with BMI greater than 30 compared with patients with a BMI less than 30. There was also no significant difference in NTLX when comparing the two groups.

Conclusions: Surprisingly, in our study patient obesity did not appear to affect surgeon ergonomics in laparoscopic procedures. Both muscle activation and perceived task difficulty appear to be independent of patient BMI. Compared to open surgery, the laparoscopic approach may be less affected by patient BMI. This may be due to the additional ergonomic stressors encountered in open surgery, including limited working space, smaller field of view, the added strain of retraction, and suboptimal surgeon posture. Further studies are necessary to confirm this potential ergonomic advantage of laparoscopic surgery over open surgery.

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Display Optimization of Indocyanine Green Cholangiography (ICG) Imaging

Insurance Status Influences Weight Loss and Complication Rates Following Bariatric Surgery

Jeff T Flinn, MSc1, Ramon Berguer, MD2, Caroline G Cao, PhD1, 1 Wright State University, 2Walnut Creek Surgical Associates

Linden A Karas, MD1, Madhu Siddeswarappa, MD1, Stephen D Slane, PhD2, Prashanth Ramachandra, MD1, 1Mercy Catholic Medical Center, 2Cleveland State University

Introduction: Intraoperative cholangiogram is frequently used to visualize the biliary system during laparoscopic cholecystectomies. However, an alternative imaging technique, Indocyanine Green (ICG) cholangiography, is potentially safer as it does not require radiation or catheterization of the cystic duct. An ICG imaging system prototype has been developed that can be coupled directly to an existing laparoscope. Preliminary evaluation reveals that image quality varies over time. Further refinements of the prototype are possible only with increasing development costs. The goal of this research was to optimize the ICG imaging display, post-hoc, by systematically manipulating visual parameters of the display and measuring the effect on perceived image quality. Methods and Procedures: Three images, each with a similar view of the juncture where the cystic duct and the common bile duct (CBD) join, were extracted from the video produced by the ICG imaging prototype. Each image was selected based on its image quality (one low-, one medium-, and one high-quality image) and served as a standard for comparison. Comparison images were created from each standard image by digitally manipulating brightness and/ or contrast in 8 % increments in the range of 0–24 %, resulting in 16 comparison images per standard. Six observers viewed pairs of images, one after the other, on a computer monitor. One image was the standard image, and the other was a comparison image, presented in a random order. Each observer completed 16 blocks of trials, where a block consisted of a randomized ordering of the 48 standard-comparison combinations, for a total of 768 trials. The observers’ task for each trial was to decide which image was perceived as having better image quality. ‘‘Better’’ was defined as being the image in which the juncture where the cystic duct and CBD join could be most clearly differentiated from the surrounding tissue. The number of times that observers chose each comparison image over the standard image was measured. Results: When a comparison image was chosen more frequently than the standard, then the manipulation of contrast and/or brightness was perceived to enhance image quality. Likewise, when the standard was chosen more frequently, then the manipulation degraded perceived quality. In general, the results showed that increases in brightness (8–16 %) and/or contrast (16–24 %) enhanced both low- and medium-quality images. Corresponding manipulations to the highquality images resulted in only modest enhancements or even slight degradation. Conclusion: The low- and medium-quality images were the images most in need of improvement and were, in fact, the images most improved by the brightness and contrast manipulations. Although commensurate improvements were not found for the high-quality image, it was already of superior quality initially and thus its enhancement (or slight degradation) would have a lower impact on the overall image quality of the display. Therefore, a moderate increase in brightness and/or contrast can increase the overall clinical utility of ICG imaging and may be a more economical alternative to extensive development and refinement of the prototype.

Background: Insurance status has often been used as a marker of socioeconomic status since private insurance typically implies employment or private income. Martin et al (June, 1991) found that private insurance was linked to fewer post-operative medical and psychiatric complications following bariatric surgery. However, in that group’s comparison, weight loss outcomes were similar between patients with private and publicly funded insurance. This study sought to determine if insurance status impacts weight loss outcomes and complication rates in a cohort of bariatric surgery patients. Methods: A retrospective chart review was performed of all patients who underwent bariatric procedures by two surgeons at a community hospital Bariatric Center of Excellence in Philadelphia, PA. Surgeries included laparoscopic and open gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass, and revisional procedures occurring between February 2012 and April 2014. Demographic information, type of insurance, number and type of medical co-morbidity, duration of anesthesia, length of hospital stay (LOS), post-operative complications, and initial weight and BMI as well as percent excess weight loss (% EWL) at three, six, nine, 12, and 18 months were obtained. Statistical analysis was performed using Student’s T-test. Results: Of 402 total patients, 163 carried private insurance and 239 carried publicly funded insurance. Duration of anesthesia was significantly longer (t = 3.7, p = 0.00) and patient age was significantly older (t = 2.823, p = 0.005), while LOS was not significantly different (t = 0.52, p = 0.6) in patients with public insurance compared with private. Publicly insured patients also had a greater number of baseline co-morbid medical conditions (t = 8.17, p = 0.001) than those with private insurance. Patients with publicly funded health insurance had significantly less weight loss at three months post-operatively (t = -2.549, p = 0.011) through 18 months post-operatively (t = -3.138, p = 0.002) when measured as %EWL. Initial (t = 2.305, p = 0.022) and post-operative BMI were also significantly greater in patients with publicly funded insurance (t = 3.061, p = 0.002 at 18 months). Also, complication rates were significantly greater in the group with public insurance (t = 2.957, p = 0.003). Conclusion: Preoperative insurance status may influence weight loss outcomes and complication rates following bariatric surgery. This study suggests that the patients who carry private insurance lose more weight and have fewer complications postoperatively when compared to patients who have publicly funded insurance. However, this publicly insured population tended to be older, have more co-morbidities and longer surgery times that those with private insurance. This data introduces the concern that socioeconomic status may affect weight loss outcomes and complication rates after bariatric surgery.

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A Novel Laparoscopic Trainer Box of the Size Same as LetterSize

Dietary Intake and Quality of Life After Laparoscopic Sleeve Gastrectomy

Hiroshi Kawahira, MD, PhD1, Naoyuki Hanari, MD, PhD2, Hisashi Gunji, MD, PhD2, Ryoichi Nakamura, PhD1, Shinichi Okazumi3, Hisahiro Matsubara, MD, PhD2, 1Center for Frontier Engineering, Chiba University, 2Department of Frontier Surgery, Chiba University Graduate School of Medicine, 3Department of Surgery, Toho University Medical Center Sakura Hospital

Jennifer Bowser, MSc, PDt1, N Theresa Glanville, PhD, PDt2, James Ellsmere, MD1, 1QEII Health Sciences Centre, 2Mount Saint Vincent University

Background/Purpose: Daily practice is important to master basic and advanced skills for laparoscopic surgery. FLS Trainer System (VTI Medical Inc, MA) was developed in collaboration with SAGES for surgical residents and practicing surgeons in the US. We developed a novel laparoscopic trainer box developed with a Japanese industry for more reasonable price and less space occupancy. Material/Methods: We set development objectives as follows: portable, the size same as iPad, reasonable price less than 300 US dollars. We recruited industries at the matching meeting held by the Osaka Chamber Commerce and Industry in Japan on December 2012. We met all of the industries which are interested in to produce a new trainer box, and one of the industries were chosen on March 2013. Our trainer box system was composed of a training box made of acrylic plate, Hi-Vision web camera as a scope, laptop PC as a monitor. A suturing pad is included in the trainer kit. Result: We had designed and developed several trials and began to sell our trainer box from November 2013. The price is about 300 US dollars. Our trainer box proved movable during training, because of the size. We attached lubber stoppers to take measures. About 40 trainer boxes have been sold in Japan. Reputations from the users are mostly favorable. Discussion/Conclusion: We have developed a new portable trainer box with reasonable price. We set up the development objectives and in collaboration with an industry for a effective trainer box.

Laparoscopic sleeve gastrectomy (LSG) bariatric surgery decreases total volume of food consumed by morbidity obese patients. The objective of this research was to determine the adequacy of nutritional intake and the impact of weight loss on quality of life of patients [1 year after LSG. All patients (n = 72) who had surgery between December 2008 and March 2010 were asked to complete a four day food records and the Bariatric Quality of Life questionnaire (BQL). For the 19 patients who participated (26 % response rate), excess weight loss was 53.9 + 20.3 %. Energy and protein intakes were 1256 + 384.5 kilocalories and 77.3 + 17.5 g per day respectively. Patients \ 50 years lost more weight, had higher BQL scores, and consumed less energy than those [50 years. Based on dietary intake alone, all patients were at risk of inadequate intake of at least one micronutrient but there was no consistent biochemical evidence of deficiency. Ninety-five percent of patients reported taking a multi-vitamin/mineral supplement. Patients undergoing LSG would benefit from dietary counselling on ways to maximize nutrient intake from food. Older patients would benefit from guidance on ways to increase energy expenditure through resistance and nonweight-bearing exercise.

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Previous Weight Loss as a Predictor of Weight Loss Outcomes After Laparoscopic Adjustable Gastric Banding

Endoscopic Stomal Revisions with the Overstitch Device A Multi-Center Experience

Monica Sethi, MD, Melissa Beitner, MBBS, Melissa Magrath, BA, Bradley F Schwack, MD, Marina S Kurian, MD, George A Fielding, MD, Christine J Ren-Fielding, MD, New York University School of Medicine

Garrett Friedman, MD, Jan-Holly L Nicolas, MD, Renzo Garberoglio, MD, Kamran Samakar, MD, Marcos J Michelotti, MD, Keith R Scharf, DO, Loma Linda University Medical Center

Introduction: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The primary objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary laparoscopic adjustable gastric banding patients. Methods: A retrospective cohort study was designed from a prospectively-collected database at a single institution. There were 999 patients who underwent primary LAGB between June 2010 and December 2011 who were considered for this study. Inclusion criteria consisted of age C18 years, initial body mass index (BMI) C35 kg/m2, intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery and patients without a recorded maximum previous weight loss were excluded. Data obtained included preoperative demographics, BMI, comorbidities, maximum amount of previous weight loss, and number of previous weight loss attempts, as well as postoperative weight (lbs), BMI, and percent excess weight loss (%EWL), at 12, 18, and 24 months postoperatively. The primary outcomes were mean %EWL, percent that achieve weight loss success (%EWL C 40), and percent with suboptimal weight loss (%EWL \ 20) at 2 years post-LAGB. Statistical analysis was performed using SAS, with tests including chi-square, ANOVA, linear and logistic regression. Results: Of the 999 patients, 462 primary LAGB patients met criteria. Mean previous weight loss was 29.7 lbs (SD = 27.6, range = [0,175]). These patients were divided into four previous weight loss groups (0 lbs, 1–20 lbs, 21–50 lbs, [50 lbs) for analysis. Baseline patient characteristics between the four groups demonstrated that patients with the greatest previous weight loss ([50 lbs) were more likely to be male (p = 0.01) and had higher baseline weight/BMI (p \ 0.0001). There were no differences in comorbidity or operative time between the groups. In order to account for the baseline differences between the four previous weight loss groups, an adjusted model was used for analysis, controlling for age, gender, baseline BMI, and band type. In the adjusted model, those with [50 lbs of previous weight loss had 8.8 % EWL, 6.7 % EWL, and 5.0 % EWL more than those with 0, 1–20, and 21–50 lbs of previous weight loss, respectively (p \ 0.0001) [Table 1]. Patients with [50 lbs of previous weight loss were more likely to achieve weight loss success ([40 % EWL) at 2 years post-LAGB (p = 0.047), and were less likely to have suboptimal weight loss (\20 % EWL) at 2 years post-LAGB (p = 0.027). Conclusion: Previous weight loss is a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

Table 1

Post-LAGB weight loss outcomes compared between previous weight loss groups after adjusting for age, gender, BMI, and band type Amount of previous weight loss

p-value

0 N = 33

1–20 N = 205

21–50 N = 154

[50 N = 70

Mean %EWL (SE) at 2y

40.1 (±3.3)

42.2 (±1.3)

43.9 (±1.5)

48.9 (±2.3)

\0.0001

%WL success (C40 % EWL at 2y)

45.5 %

53.6 %

51.2 %

70.5 %

0.047

%WL suboptimal (C20 % EWL at 2y)

19.2 %

10.2 %

14.1 %

2.8 %

0.027

*Adjusted estimates of %EWL

The estimates were calculated assuming the average for gender, age, BMI, and band type across the entire population (e.g. 71.9 % female, age = 41.9 years) SE Standard error, EWL excess weight loss, WL weight loss

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Background: Weight regain or inadequate weight loss after Roux-en-Y gastric bypass (RYGB) has been associated with dilation of the gastrojejunal anastomosis. Endoluminal approaches for stoma reduction have been hypothesized as a strategy to improve weight loss after RYGB. This study examines a two-institution experience with one such procedure, using the OverStitch (Apollo Endosurgery, Austin TX) device for endoluminal revision of the gastrojejunal stoma. Objective: To examine the safety and efficacy of OverStitch endoluminal revision of the gastrojejunal stoma as a salvage procedure after RYGB. Methods: A retrospective review of an IRB-approved prospective database identified 9 patients that underwent endoscopic stomal revision at either Loma Linda University Medical Center or Loma Linda Veterans Administration Hospital between July 2013 and September 2014. Percent excess body weight loss was the primary measured endpoint. Results: Nine consecutive patients underwent endoscopic stomal revisions using the Overstitch device; five were performed at Loma Linda Veterans Administration Hospital and four at Loma Linda University Medical Center. All patients demonstrated weight loss at their first post-operative visit, ranging between 2.3 and 18.2 kg (mean time to first post-op visit = 17.5 days). Average percent excess body weight loss (%EBWL) at the first post-operative visit was 14.3 %. At the time of submission for publication (mean follow-up time = 273 days), average %EBWL was 19.8 % (average % excess BMI loss = 19.4 %). Complications following intervention included one patient with new onset hypoglycemia amenable to diet modification. There was no mortality. Conclusion: In our series, patients experienced modest short-term weight loss results, which is consistent with previously published series. (Mikami et al. published their results with endoscopic gastric pouch plication utilizing Stomaphyx in 2010, showing 10.6 % EBWL at 1 month and 13.1 % at 2 months after intervention, while Horgan et al’s. multi-center study represents perhaps the largest patient group of this kind, showing 18 % EBWL at 6 months.) This weight loss, however, is likely multifactorial, as the procedure not only reduces the size of the GJ stoma but also represents a ‘‘reset’’ of the patient’s diet and psychological milieu. Our experience suggests that endoluminal stomal revisions using Overstitch provide modest but acceptable short-term weight loss and should be considered a safe and efficacious option for bypass patients with inadequate weight loss or weight gain. Long-term studies are required to determine whether endoscopic revision provides truly durable weight loss to patients.

P315 Laparoscopic Roux-en-Y Gastric Bypass Vs Laparoscopic Sleeve Gastrectomy for Weight Reduction in Super Obese Patient: A Retrospective Review Pondech Vichajarn, MD, Narong Boonyagard, MD, Pakkavuth Chansawangphuvana, MD, Krit Kittisin, MD, Suppa-ut Pungpapong, MD, Chadin Tharavej, MD, Patpong Navicharern, MD, Suthep Udomsawaengsup, MD, Chulalongkorn University Background: Many of studies showed effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) in excess weight loss (EWL) for morbid obesity patients but there were few studies in super obese patients. The comparison between effectiveness of LRYGB and laparoscopic sleeve gastrectomy (LSG) also had limit data. Objective: This study was designed to compare effectiveness of reduction of excess weight after bariatric surgery between LRYGB and LSG in super obese patients. Methods: Medical records of morbid obesity patients with BMI 50 kg/m2 or more who underwent LRYGB or LSG at least 12 month previously were retrospectively reviewed. Baseline characteristics, body mass index (BMI), comorbidities, complications were observed. Percent of EWL at 1,3,6,9 and 12 months of both groups were compared as the primary end point. Results: Ninety two patients with BMI 50 kg/m2 or more were retrospectively reviewed. Forty one patients were performed LRYGB and 51 were performed LSG. There was no difference in baseline characteristics of both groups. Mean age was nearly 33 years old. Patients who were performed LSG have tend to be female more than in LRYGB group (58.82 % vs 41.46 %) but it was not significantly different. Average BMI was comparable in both groups (58.09 ± 8.07 for LRYGB and 61.0 ± 9.80 for LSG). There was no conversion to open surgery in this study. At one year follow up mean percent EWL were 63.07 ± 13.79 for LRYGB and 53.12 ± 14.74 for LSG, the difference reached statistical significance (p = 0.007). Significant difference of percent EWL had been showed at the first three months of follow up (32.69 ± 9.77 for LRYGB vs 27.89 ± 8.89 for LSG, p = 0.032). There was no fatal complication in this study. Three major postoperative complications were found, one was bleeding from staple line after performed LSG, the other one was bleeding at gastrojejunostomy anastomosis and the last one was edematous of anastomosis that caused acute postoperative obstruction in LRYGB groups. Conclusion: Both LRYGB and LSG are safe and effective procedure for reduce excessive weight in super obese patients. However LRYGB can provide percent EWL better than LSG at one year follow up.

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Institutional Improvement in Weight Loss Following Laparoscopic Sleeve Gastrectomy

Severe Calcium Malabsorption Following Biliopancreatic Diversion with Duodenal Switch. Case Report and Management

Christopher W Mangieri, MD, Matthew Strode, DO, William Sherman, MD, Yong Choi, MD, Byron Faler, MD, Dwight D. Eisenhower, Army Medical Center

Ibrahim M Ibrahim, MD, Jeffrey W Strain, MD, Celines MoralesRibeiro, MD, Englewood Hospital & Medical Center

Background: Laparoscopic sleeve gastrectomy (LSG) is a recent addition to the bariatric surgery armamentarium. It has been well demonstrated to be an efficacious stand-alone bariatric procedure in regards to weight loss and comorbidity improvement. This study evaluates the progress of our initial experience with LSG at Dwight D. Eisenhower Army Medical Center (DDEAMC) during the time period of 2008–2010. Methods: This is a retrospective review of prospective data from our LSG caseload at DDEAMC from 2008–2010. During that time, we performed 159 LSG. In our review, we compared data between our first operative year of experience with LSG (2008) and our third year of experience (2010). We compared data for up to 3 years postoperatively. Our focus endpoint was in post-operative weight loss, specifically percentage of excess body weight loss (%EWL) and percentage of excess BMI loss (%EBL). Results: We found an institutional improvement in our %EWL and %EBL rates as our collective experience increased with LSG. There was a mean increase in %EWL of 14 % and mean increase of %EBL of 22 % when we compared our first year of surgical experience to our third year of experience with LSG. We also found that as an institution in our first year performing LSG, we attained an average of \50 % EWL which is often cited as a benchmark level for ‘‘success’’ following bariatric surgery. By our third year of experience with LSG, however, we did achieve [50 % EWL at all years of post-operative follow-up. Conclusion: As an institution, we achieved improvement in our weight loss results with LSG as the collective experience increased. Since there was no identifiable technical or patient related factor which could adequately account for this, we hypothesize that several factors could have contributed to this observation. A surgical mentorship program and the institution of formal and more rigorous pre- and post-operative nutritional education are possible causes. Overall, our surgeons performing LSG benefited from the collective experience of the institution regardless of whether they had established experience with LSG or if they recently started performing the procedure. This study demonstrates that institutional experience is a significant factor in weight loss results with LSG.

Calcium is normally absorbed actively by transcellular transport in the duodenum and passively in the jejunum and ileum (and to a much lesser extent in the colon) when dietary Calcium levels are elevated. Biliopancreatic diversion with duodenal switch (BPD-DS) bypasses the active mechanism rendering the patient dependent on passive absorption via a short ileal segment. 65 year old female was requiring increasing (and eventually intolerable) amounts of oral Calcium and Vitamin D during the ten years following BPD-DS surgery. She was also gaining weight due to enlarged sleeve. She underwent laparoscopic proximal entero-enterostomy between the alimentary and the biliopancreatic limbs (thus lengthening the common channel) and simultaneous revision of the sleeve. At two years follow-up the patient lost her (excess) regained weight and was taking minimal bariatric supplements with marked subjective improvement in her quality of life. Restoring the absorptive capacity of the small bowel with one simple anastomosis avoids the more complex procedure of reversing the duodenal switch or lengthening the common channel. This approach may be applicable to other severe deficiencies of nutrients dependent on small bowel absorption.

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Sleeve Vs Plication; Non Randomized Study of 1145 Cases

Laparoscopic Adjustable Gastric Band Around Open Gastric Bypass - A Safe and Effective Alternative to Stapled Revisional Surgery

Ali Fardoun, FACS, Emirates International Hospital Introduction: Gastric plication has a big popularity and acceptace between patient as the less complicated and save procedure. This study of 1145 cases os sleeve and plication is done to give the results after 3 years of follow up. Method: 175 Patients between 34 to 43 BMI were done for gastric Plication and 970 cases of sleeve between 34 to 70 BMI were done under their request and with 3 hears follow up.’ Results: Leak ocurred in one case out of 175 of leak while we had 3 cases in 970 cases of sleeve. No pulmonary embolism or death ocurred in all groups. Nausea and vomiting were more in plication. No bleeding ocurrred in plication and 4 in sleeve. Video and detaied study is available

Hans J Schmidt, MD1, Edmund W Lee, BA2, Richard C Novack, Jr., MD1, Amit Trivedi, MD1, Sebastian Eid, MD1, Douglas R Ewing, MD1, 1Hackensack University Medical Center, 2Rutgers-New Jersey Medical School Introduction: Roux-en-Y gastric bypass (RYGB) performed through open laparotomy was considered the gold standard operation for the treatment of morbid obesity for over two decades. Surgeons versed in the laparoscopic technique may find revisional surgery after open bypass challenging. Moreover, ‘‘banded –bypass’’ was a technique employed by some open surgeons, incorporating mesh band placement around the pouch to prevent dilatation. Obesity is a chronic condition and some patients may fail to lose adequate weight while others regain some or all of the weight that they have lost. Treatments for failure of gastric bypass include revision of the pouch/anastomosis, increasing the length of the roux limb, and conversion to a more radical procedure. While often successful, these procedures can be technically challenging after prior laparotomy and subject to significant intra-abdominal complications. Laparoscopic adjustable gastric band (LAGB) placement has been used as a salvage procedure around the previous RYGB but there is little data in the literature regarding open RYGB or long-term success rates. Methods: We cross referenced our bariatric surgery data base with patients who presented with weight gain after open bypass. All patients had a barium esophagram. Patients with gastrogastic fistula or clealy inadequate fundus reduction were treated with stapled revision. We then focused on that group who underwent open RYGB as the initial procedure and had pouch and/or anastomotic dilatation. Finally, we performed a phone interview with any patient that had not been seen in the office within the past year to inquire about their current condition. Results: We reviewed 3094 LAGB cases placed since 2001. A total of 31 bands were placed around a RYGB performed as open surgery. Eleven of the 31 patients were ‘‘banded-bypass’’. All 31 band cases were completed laparoscopically with no conversion to open or peri-operative complications. Patients have been followed for an average (mean) of 2 years, with 6 patients being followed for greater than 5 years, the longest being 10 years. Of these 31 bands, 4 (12.9 %) have been removed, 3 due to dysphagia. There were no slips or erosions. The average pre-RYGB BMI was 58.4 which decreased to 31.8 post RYGB. At the time of band, the pre-LAGB BMI was 45.7 which decreased to 37.5 at the present time. When looking at the ‘‘banded-bypass: sub-group, the pre-RYGB BMI was 61.0 which decreased to 32.2 post-RYGB. Their pre-LAGB BMI was 46.7 which decreased to 39.0 at the present time. Conclusion: This study shows that LAGB is a safe alternative to complex revisional surgery in patients failing open gastric bypass. It can be performed safely, often as a same day procedure. Long term follow-up demonstrates that the band removal rate is lower then some reported rates for primary LAGB. Furthermore, LAGB around prior open RYGB shows sustainable weight loss results over a period of time, and can be effective even for those subset of patients who had a ‘‘banded-bypass’’ during the initial surgery.

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Roux-en-Y Gastric Bypass (RYGB) for Failed Laparoscopic Fundoplication

Do Specimen Dimensions Effect Outcome in Sleeve Gastrectomy?

Mena Boules, MD, Julie Chang, MD, Ricard Corcelles, MD, PhD, Christopher Daigle, MD, Kevin El-Hayek, MD, Stacy Brethauer, MD, Matthew Kroh, MD, Cleveland Clinic Introduction: Gastro esophageal reflux disease (GERD) is estimated to affect 40 % of the population in the United States. In appropriate patients, laparoscopic fundoplication is currently considered to be the anti-reflux procedure of choice, with successful re-establishment of G-E junction physiology. Failure rates are reportedly between 2 % and 30 %. Obesity, technical approach of repair, and anatomical variation of each patient are associated with operative failure and recurrent GERD. Recent reports suggest re-operative fundoplication is associated with poorer results than primary operations. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an option for selected patients who have failed initial fundoplication. This study aims to evaluate the outcomes of patients who have undergone LRYGB after prior fundoplication failure. Methods: Records of 23 patients who underwent laparoscopic takedown of failed fundoplication with conversion to LRYGB from March 2007 to October 2013 were analyzed retrospectively. Data collected included baseline patient demographics, peri-operative parameters, intra and post-operative complications, follow-up time, symptom control, and recurrence. The primary endpoint studied was symptom relief, whereas recurrence and technical success were analyzed as secondary endpoints. Results: Twenty-three patients who had undergone 33 prior anti-reflux procedures (range: 1 to 4) underwent LRYGB for failed fundoplication during the 6-year study period. The cohort had a male-to-female ratio of 6:17, mean age of 53.3 ± 9.6 years; mean body mass index (BMI) of 35.7 ± 7.1 kg/m2 (range: 25.1 to 54.1 kg/m2), and mean number of comorbidities of 4.9 ± 2.3. Major comorbidities were: hiatal hernia (73.9 %), hypertension (56.5 %), dyslipidemia (52.1 %), obstructive sleep apnea (26 %), diabetes (17.3 %), chronic obstructive pulmonary disease (8.6 %), and chronic peptic ulcer disease (8.6 %). Prior to LRYGB 20 patients were on anti-secretory agents specifically proton pump inhibitors (PPI) (n = 16, 69.5 %) and histamine blockers (n = 4, 17.3 %). Evidence of anatomic failure as defined by recurrent hiatal hernia was seen in 74 % of patients. The operations were performed laparoscopically in 18 (78.2 %) cases and open in 5 (21.8 %). Mean operative time and estimated blood loss was 272.7 ± 112.3 minutes and 346.7 ± 639.8 mL, respectively. Early postoperative complications (30 days) occurred in 3 patients and included anastomotic leakage (n = 2, 8 %), and wound infection (n = 1, 4 %). The reoperation rate was 4.3 %, and there were no mortalities. After a mean follow-up of 20.9 ± 20.8 months (range 0–73 months), 3 (13.0 %) patients complained of persistent dysphagia, and 1 (4.3 %) reported regurgitation. No GERD-related symptoms were reported; however, 10 patients continued with anti-secretory medication (PPI n = 7, H2 blockers n = 3) for early continuation of GERD symptoms post-operatively which resolved within 7–10 days post-operatively. Upper gastro-intestinal series (UGI) and/or esophagogastroduodenoscopy (EGD) were performed in 9 patients (39 %), for surveillance of anastomotic integrity (n = 2), nausea (n = 1), dysphagia (n = 4), and abdominal pain (n = 3). No hernia recurrence was demonstrated at an average of 15.5 ± 19.1 months (rang e 0–47 months). Conclusion: Conversion of failed fundoplication to RYGB can be performed with acceptable peri-operative morbidity and reasonable long-term control of GERD symptoms. Overall operative and peri-operative morbidity is higher in this population when compared to patients undergoing primary RYGB.

Introduction: Since its introduction sleeve gastrectomy has become the most commonly performed resection for obesity. Percent excess weight loss is the major determinant of outcome in obesity surgery. Aim: To analyze if the dimensions of the gastric specimen has effect on percent excess weight loss in sleeve gastrectomy. Patients and Methods: 41 patients who had sleeve gastrectomy by the same surgeon between 2012 and 2014 were followed prospectively. Dimensions of surgical pathology specimens were measured as long axis, short axis and thickness. A score is derived by multiplying these dimensions. Patients were called in for follow up and percent excess weight losses are measured. Results: Lower percent excess weight losses were noted with lower dimension scores. Conclusion: Higher dimension score might mean removal of more ghrelin producing tissue thus more effective induction of satiety.

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P321 Sleeve Gastrectomy for Type 2 Diabetic Obese Patients 1

1

2

Marcos Berry, MD , Lionel Urrutia, MD , Patricio Lamoza , Alfredo Molina1, Rodolfo Lahsen1, Shirley Marquina1, 1Clinica Las Condes, 2 Hospital de Maipu Introduction: Morbidly obese patients with T2DM who undergo bariatric surgery have improvement or remission of their diabetes. We report our results in terms of type 2 diabetes (T2DM) control in obese patients after laparoscopic sleeve gastrectomy (LSG), analyzing the excess weight loss (EWL%), metabolic performance after surgery, and morbi-mortality. Aim: Evaluate the results of metabolic control in the treatment of obese patients with T2DM undergoing LSG. Methods: A prospective case series of obese, well-controlled T2DM patients underwent LSG consecutively between April 2006 and December 2013. Results: 95 Patients (5.92 %) from a universe of 1605 subjected to LSG, 56 male and 39 female, mean age 49.48 years (24–70), were operated upon and underwent follow-up for a mean of 36 months (3–85). Mean preoperative BMI versus follow-up BMI were 36.43(30.2–51) and 26.2(24–28), respectively, and the mean EWL% was 77.57 %. Mean preoperative fasting glucose levels and HbA1C decreased from 144,53 mg % (84–250) to 95.1 mg % (70–120) and from 7 % (5.2–11.6) to 5.79 % (5.3–6.9), respectively. At follow-up, 89 % of patients did not require further oral treatment for diabetes, while 11 % witnessed a significant decrease in dosage of medication and/or were being progressively tapered off of medication. Comorbidities: hemoperitoneum 1.05 % and perigastric hematoma 1.05 %; no mortality. Discussion: LSG is a safe and an effective surgery for mild and well controlled T2DM patients, achieving a very good metabolic control. Further follow-up is necessary to evaluate long term results and may provide valuable information in optimizing patient selection for this procedure. Keywords: Bariatric surgery; Morbid obesity; Sleeve gastrectomy; Remission; Type two diabetes.

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Baris D Yildiz, Ankara Numune Teaching Hospital

Through the Leak Transpyloric Tube Treatment of Gastric Sleeve Leak Elizabeth Z Colsen, MD, Daniel B Leslie, MD, Sayeed Ikramuddin, MD, University of Minnesota Objective of the Technique: Laparoscopic sleeve gastrectomy is the most common weight loss operation performed in the United States with low mortality and a few complications. However staple line leak is associated with high morbidity. Management strategies have included stents, endoscopic clips, fibrin glue, and percutaneous drainage with parenteral nutrition. These approaches do not definitively control the leak nor do they adequately address the physiologic processes associated with ongoing leakage. We sought to develop a standardized technique that controls leak and prevents functional obstruction while providing enteral nutritional support. Description of the Technique: A gastrojejunostomy (GJ) tube is placed though the leak site using laparoscopy (lap), endoscopy (endo), and fluoroscopy (fluoro). The operation begins with lap exploration. Endo and fluoro are used to locate the leak. A pediatric endoscope is advanced transorally through the leak into the peritoneal cavity. Under lap guidance a wire is placed through the endoscope and pulled through the future GJ tube site. A 18 Fr GJ tube with 45 cm extension is fed over a wire through the skin into the leak site and brought out the mouth. An adult endoscope is used to place the GJ though the sleeve into the jejunum. The gastric balloon occludes the leak. A drain is placed if abscess cavity is present. The 18Fr GJ tube is replaced with a 18 Fr red rubber Robinson (RR) tube approximately 4 weeks later using endo and fluoro. This is exchanged for a 16 Fr RR 4 weeks later as an outpatient (endo and fluoro). The final exchange to a 14 Fr RR tube is performed in interventional radiology. The final tube is removed 4 weeks later. Drainage via the gastric port diverts stomach acid and facilitates healing. The jejunostomy tube stents the sleeve and pylorus preventing functional sleeve obstruction. Patients receive feeding through the jejunostomy port /RR tube immediately after placement. This avoids need for total parenteral nutrition via central line with its associated cost and complications. Patients are able to return to normal daily activities after the second tube exchange. Preliminary Results: This procedure has been performed on 9 patients. The patients were 43 ± 16 yrs. old. The average (avg) days to leak were 18 ± 18 days (range 4–50). The avg days until lap placed GJ tube was 65 ± 74 days (range 4–179). The avg time for GJ tube placement to removal of all tubes was 88 ± 21 days (range 60–114). Two patients had the 18 Fr GJ tube pulled at 60 days. All tubes have been removed. One patient had persistent gastrocutaneous fistula repaired with endoscopic clip. The remaining patients have no further leakage. Conclusions: Our tertiary care institution is a referral site for sleeve leaks. Endoscopically placed stents and clips have been used in the past. However, issues with stent migration and patient complaints of pain limited effectiveness of treatment. Our new technique is predictable, reproducible, and standardized. It also provides patient satisfaction with outpatient management which is crucial in today’s health care environment.

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The Effect of Bariatric Surgery on Employment Status and Mobility

Gender Influence in Bariatric Surgery Outcomes: Sleeve Gastrectomy and Gastric Bypass

Jean-Eric Tarride, BA, MA, PhD1, Ruth Breau, BA2, Dennis Hong, MD, MSc, FRCSC, FACS1, Scott Gmora, MD, FRCSC1, Mehran Anvari, MB, BS, PhD, FRCSC, FACS1, 1McMaster University, 2 The Centre for Surgical Invention and Innovation

Martin A Berducci, MD, Jorge Nefa, Alberto Gallo, MD, Magali Sanchez, MD, Natalia Pampillon, Lic, Viviana Lasagni, Lic, Cecilia Penutto, Sonia Omelanczuk, Mariela Abaurre, Lic, Romina Palma, Lic, Alejandra Ojeda, MD, Pablo E Omelanczuk, MD, Clinica Quirurgica

Introduction: A common perception exists that there is a higher rate of unemployment among morbidly obese patients. The question therefore arose as to whether bariatric surgery is beneficial to patients’ work and productivity. In addition, few studies have documented the impact of bariatric surgery on mobility. To better inform physicians, patients and decision makers, a sub-study of the Ontario Bariatric Registry was conducted to evaluate the impact of bariatric surgery on employment status and mobility. Methods and Procedures: To meet the objectives of the study, a survey was sent to all patients who underwent bariatric surgery at St Joseph Healthcare Hamilton, Ontario, Canada and who completed one year follow-up. Participants were invited to document their employment status at time of surgery and one year after surgery. In addition, patients documented any change in their employment status during the one-year time period prior to and after the surgery. Patients also completed the EQ-5D, a health-related quality of life questionnaire, to measure five domains including mobility. Statistical comparisons between time periods were conducted using t-tests for continuous variables and chi-squared tests for dichotomous variables. Results: Out of 309 patients with one-year follow-up, 137 (44 %) returned the questionnaire of whom 92 % were female. Almost three-quarters of the participants were working full time (61 %) or part time (13 %) at time of surgery and 9 % were on short (1 %) or long-term (8 %) disability. The remaining individuals were either retired (9 %) or looking for work/working from home/attending school/other (8 %). Overall, there were no major changes in employment status at one-year following bariatric surgery with 62 % working full time, 15 % working part time and 6 % on disability. However more individuals reported a change in their employment status within one-year following surgery (26 %) compared to one-year prior to the surgery (9 %) (p = 0.0003). Of these individuals who reported a change over the one-year following surgery, the majority started a new job (47 %) or increased their work hours (32 %). In terms of mobility, 70 % of participants had slight (34 %), moderate (29 %) or severe problems (7 %) walking at time of surgery compared to only 10 % at 1 year following surgery (p \ 0.001). Similar statistically significant improvements were also seen in the other domains of the EQ-5D (e.g. self-care, usual activities, discomfort and anxiety/depression). Conclusions: Bariatric surgery has a major impact on mobility. Alternative to common perception, many bariatric patients are working full time pre and post-surgery. More research is warranted to better understand if the changes in employment status following bariatric registry translate into better occupations and income.

Introduction: The long-term efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in the treatment of morbid obesity has been proven both as a first-stage for super-obese patients and as a definitive procedure. Nonetheless, laparoscopic sleeve gastrectomy (LSG) is becoming the favorite bariatric procedure worldwide. The effect of gender on weight loss after bariatric surgery has not been well established in the literature despite being noted in every day practice. The aim of this study was to assess whether gender influences on long-term weight loss after bariatric surgery. Methods: A retrospective, comparative analysis was performed of 632 patients who underwent RYGB and LSG between 2005 and 2014 at Hospital Italiano, Mendoza, Argentina. Patients were then divided into groups based on type of surgical procedure and gender. Demographics, perioperative data, early (\30 days) and late ([30 days) complications, re-interventions, mortality and %EWL at 12 and 24 months were compared. Results: We included 343 LSG patients (72.8 % female) and 289 RYGB patients (80.2 % female). The mean age and initial BMI were similar in LSG and RYGB groups (46.6 ± 11.7 and 45.4 ± 8.8, and 41.1 ± 9.1 and 45.9 ± 6.4, respectively). The operating time was significantly shorter in the LSG group than for RYGB group (92.7 ± 21.2 minutes vs. 174.4 ± 31 minutes, p \ 0.001). The conversion rate was 0 % in both groups. There were 3 (1.03 %) major complications following LSG and 7 (2.42 %) after RYGB (p = 0.999). All required laparoscopic reoperations. There was one death in the RYGB group. In the female group, %EWL after 12 and 24 months was better in RYGB group than LSG group (12 months: 66.5 vs. 60.2, p = 0.012; 24 months: 65.7 vs. 54.3, p = 0.016, respectively). In contrast, in the male group the %EWL was not significantly different between RYGB and LSG (12 months: 66.4 vs. 67.8; 24 months: 67.5 vs. 62.1, respectively) (Table 1). Conclusion: RYGB is more effective than LSG in terms of weight loss in the female population. Interestingly, this difference was not observed in the male group. We believe that RYGB should be considered as the primary bariatric procedure for obese female patients seeking weight loss surgery.

Table 1

Percentage of EWL in males and females at 12 and 24 months Females

P325

LSG

RYGB

p Value

LSG

RYGB

p Value

43.8

45.3

NS

48.3

47.4

NS

%EWL 12 M

60.2

66.5

0.012

67.8

66.4

NS

%EWL 24 M

54.3

65.7

0.016

62.1

67.5

NS

Initial BMi

Laparoscopic Roux-en-Y Gastric Bypass in the Elderly Simon C Chow, MD, Kevin M Reavis, Emma J Patterson, MD, Jay C Jan, MD, Valerie J Halpin, MD, Legacy Good Samaritan Medical Center

Males

Background: The literature is divided with respect to outcomes regarding laparoscopic Roux-en-Y gastric bypass surgery in the elderly. Some studies have demonstrated excess weight loss and complication rates comparable to the non-elderly population, whilst other studies have shown increased mortality. Furthermore, some centers/surgeons may be hesitant operating on elderly patients as there may be a perceived increased perioperative risk. The aim of this study is to analyze the safety of gastric bypass in patients at our institution, comparing patients aged 65 years (OVER65) and over versus patients under 65 (UNDER65). Methods: A retrospective analysis of a prospectively maintained database of all patients who had undergone gastric bypass between July 2008 and June 2014 was performed. The variables analyzed included demographics, comorbidities, and 30-day complication rates. Serious complications were considered Clavien III and above with the need for reintervention and included anastomotic leaks, gastrointestinal or intraabdominal bleeds, marginal ulcers and strictures, bowel obstruction and intraabdominal abscesses. Logistical regression was used for statistical analysis. Statistical significance was defined at p \ 0.05. Results: There were a total of 1247 subjects who had a gastric bypass, of which 186 were in the OVER65 group. The OVER65 group had higher rate of comorbidities including diabetes, hypertension, dyslipidemia compared to the UNDER65 group (Table 1): On logistic regression diabetes, hypertension or obstructive sleep did not affect the overall complication rate (p [ 0.05). The presence of dyslipidemia did correlate with increased risk of complications (p = 0.04). There was a trend towards an increased complication rate associated with age, but this did not meet statistical significance. There was no mortality in either group. Conclusions: Laparoscopic Roux-en-Y gastric bypass performed in patients over 65 years of age is a safe procedure. The 30-day morbidity and mortality are not significantly different between the OVER65 and UNDER65 groups at our institution.

Table 1 OVER65

UNDER65

P value

Number

186

1086



Age in years (range)

67.9 (65–75)

46.3 (18–64)

0.007*

BMI (kg/m2)

44.4

46.9

0.76

Diabetes

62.4 %

42.2 %

\0.001*

Hypertension

81.2 %

55.5 %

\0.001*

Dyslipidemia

65.1 %

32.4 %

\0.001*

Obstructive sleep apnea

81.7 %

72 %

0.15

Patients with complications

16 (8.6 %)

54 (5.1 %)

0.058

Patients with Clavien class III and above complications

8 (4.3 %)

29 (2.7 %)

0.25

Mortality

0

0



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Preliminary Report on Home Nurse Visits for Prevention of Readmission for Dehydration Following Bariatric Surgery

Predictors of Successful Weight Loss Following Bariatric Surgery Linden A Karas, MD1, Madhu Siddeswarappa, MD1, Jean-Gabriel Coignet, BA1, Stephen D Slane, PhD2, Prashanth Ramachandra, MD1, 1 Mercy Catholic Medical Center, 2Cleveland State University

Linden A Karas, MD1, Shannon Schultz, MD1, Madhu Siddeswarappa, MD1, Stephen D Slane, PhD2, Prashanth Ramachandra, MD1, Adam Goldenberg, MD1, 1Mercy Catholic Medical Center, 2Cleveland State University Introduction: While bariatric surgery lowers overall health care costs, high readmission rates have insurance companies questioning its cost effectiveness. Studies led by J. Saunders (2008), B. Hong (2012), and T.A. Kellogg (2009) have shown readmission rates of 0.6 %–24.2 % following bariatric surgery at high volume centers. The most common preventable cause of readmission is dehydration caused by nausea/vomiting and abdominal pain. Mercy Bariatrics in Philadelphia, PA, designed an innovative home nursing program to assess for early signs and symptoms of dehydration during the first month following bariatric surgery. Upon diagnosis, nursing initiates treatment with home intravenous fluid infusion or refers refractory or severely dehydrated patients to the hospital for further evaluation and treatment. The goal is to decrease 30-day hospital readmissions. Methods: Mercy Bariatrics, a community hospital-based Bariatric Center of Excellence is currently enrolling all eligible bariatric surgery patients into a prospective study that examines readmission outcomes for patients followed by home health care nurses for one month post-operatively. The following is a preliminary analysis of those patients enrolled in the study between January 2014 and August 2014, compared with a retrospective sample of patients who underwent surgery between May 2012 and August 2013 and were not followed by home nurses. A Chi-square test compared overall 30-day readmission rates and 30-day readmission rates due to dehydration before and after implementation of the home nursing program. Results: Through a survey of medical records including 393 past bariatric patients, the all-cause hospital readmission rate was 14.3 % within 30 days of bariatric surgery, with dehydration accounting for 46 % of these admissions. A preliminary analysis of 30-day hospital readmissions following the implementation of the home nursing program yielded a 13.8 % all-cause readmission rate with dehydration accounting for 26.6 % (N = 94 patients assessed). Five of the enrolled patients were found to be dehydrated; two of these received home hydration, and one was able to avoid hospital readmission due to this treatment. The other three dehydrated patients were referred directly to the hospital for evaluation. Though the rate of readmissions due to dehydration is trending down by approximately 30 % (6.6 % preenrollment compared to 4.3 % post-enrollment), there is no statistically significant difference in all-cause readmission rates (p = 0.646) or readmissions due to dehydration (p = 0.545) after implementation of the home nursing program. Conclusions: The preliminary analysis shows a trend towards decreased 30-day hospital readmissions after implementation of the home care program, but it was not statistically significant. At this early date, the power of the study is low. Further enrollment over the next two to three months is needed to make this finding significant. The study is also limited because home hydration was not attempted with all dehydrated patients. However, home hydration will become more common as the visiting nurse service expands over the next several months. Increasing use of home hydration and larger enrollment numbers may show that home nurse visits can decrease readmission rates for dehydration, and thereby decrease health care costs.

Objective: Recent research has focused on both pre- and post-surgical behavioral factors as they influence weight loss outcomes after bariatric surgery, and there has been a shift away from examining demographic indicators, and intraoperative and early post-surgical factors as predictors of surgical outcome (A.H. Robinson et al in 2014, M Livhits et al in 2011). Therefore, the objective of this study was to determine which demographic and medical variables predict successful weight loss outcomes following bariatric surgery in a socially diverse patient population. Methods: An analysis was performed of a retrospectively compiled database of all patients who have undergone bariatric surgery (including laparoscopic and open gastric banding, sleeve gastrectomy, Roux en Y gastric bypass, and revisional bariatric surgery) between February 2012 and March 2014 at a community hospital Bariatric Center of Excellence in Philadelphia, PA. Factors examined included age (mean 44.37, SD 11.9), gender, ethnicity, type of surgery, duration of anesthesia (mean 230 minutes, SD 70.8), American Society of Anesthesiologist (ASA) class, hospital length of stay (LOS) (mean 2.8 days, SD 4.7), public versus private insurance (which may indicate socioeconomic status), marital status, and number (mean 3.9, SD 2) and type of preoperative medical co-morbidity. Weight loss outcomes were collected as % excess weight loss (%EWL), % excess BMI loss (%EBMI), actual weight preoperatively and post-operatively, and actual initial and post-operative BMI during a follow up period of three months to two years. Regression analysis was performed to determine factors predictive of better weight loss outcomes. Results: Shorter duration of anesthesia (DOA), younger age, type of insurance (private better than public), and Caucasian race predicted significantly better weight loss following all types of bariatric surgery at one year. These three factors together accounted for 9.4 % of variance in %EWL, 2.3 % of variance in %EBMI, 12.8 % of variance in actual weight, and 6.4 % of variance in actual BMI at one year. Further, these four variables continued to be strong statistically significant predictive factors at 1.5 years, predicting 2.1–17 % of the variance the different markers of weight loss studied. Finally, a discriminative function test was performed confirming the above results; shorter DOA, younger age, private insurance, and Caucasian race correctly predicted successful post-operative weight loss at one and 1.5 years (defined as greater than or equal to 50 % EWL) in 85 % of cases. Conclusion: As opposed to subjective behavioral factors, this study presents static preoperative demographic and surgical variables that can be used to predict successful weight loss following bariatric surgery. The identification of these strongly predictive elements may improve patient selection and intraoperative decision-making for bariatric surgery.

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Bougie Caliber Effect on Excess Body Weight Loss and Postoperative Complications Following Laparoscopic Sleeve Gastrectomy: A 1-Year Follow-Up

Influence of Depression on Bariatric Surgery Outcomes

Mark Jonker, MD, Jonathan Miller, BS, John Kelly, MD, Donald Czerniach, MD, Philip Cohen, MD, Richard Perugini, MD, University of Massachusetts Medical School Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most commonly performed weight loss operation in recent years. When compared to Roux-en-Y gastric bypass, there is a theoretical reduction in long term complications such as bowel obstruction, vitamin deficiency, and anastomotic ulceration. LSG appears to be associated with a higher rate of staple line leak. While there is no accepted standard technique for LSG, there is a suggestion that use of a Bougie C40-Fr is associated with a lower risk of staple line leak. The aim of this study was to determine the effect of bougie caliber on weight loss and immediate post-operative complications following LSG. Methods: All individuals who underwent LSG at our institution from July 2010 to June 2014 were entered into a database. Data included demographics (age, gender, weight, BMI, EBW), comorbidities (hypertension, type 2 diabetes mellitus, hypercholesterolemia, esophageal reflux disease, obstructive sleep apnea), metabolic profiles (fasting insulin and glucose, Homeostatic model of assessment, Hemoglobin A1c), postoperative length of stay (LOS), complications, and readmission. We followed percent excess body weight loss (%EBW) at follow-up. We analyzed data by dividing patients into two groups based on the size of the Bougie used during the operations [40-Fr (N = 60) and B38Fr(N = 285)]. Data was compared via T-test. Results: There were no significant differences between the 2 groups in regards to age, gender, preoperative weight, or BMI. There were no statistically significant differences between the 40-Fr and B38-Fr Bougie groups in post-operative bleeding (10.0 vs. 5.3 %), leak (0.0 vs. 1.4 %), nausea/vomiting (18.3 vs. 10.2 %), or readmission (6.7 vs. 5.6 %). The %EBW differed significantly between the 2 groups at 6-month follow-up but not at other time points (Table 1). Conclusions: Using a 40-Fr bougie for LSG had no impact on short-term post-operative morbidity in this series. No staple line leaks occurred when the larger Bougie was used, though this finding is not significant and may be due to small sample size. Use of 40-Fr Bougie is associated with lower %EBW at six months postoperatively. Continued follow-up of this data will determine if these trends are significant, and, if so, suggest a trade-off between risk of leak and %EBW lost postoperatively.

Table 1

%EBW ± SD at post-operative times for 40-Fr and B38-Fr Bougie groups 40-Fr

B38-Fr

p value

2 weeks

13.7 ± 3.6

12.6 ± 4.4

0.069

6 weeks

21.6 ± 5.9

23.0 ± 6.2

0.150

6 months

39.0 ± 12.6

45.0 ± 12.9

*0.017

1 year

43.6 ± 7.2

51.2 ± 20.4

0.276

123

Tara Mokhtari, Archana Nair, Sophia Koontz, Eric Luedke, John Morton, Stanford University Introduction: Morbid obesity is a leading public health concern in the United States and predisposes to the development of numerous comorbid conditions. Additionally, depression is commonly seen in the obese. The development of depression in this population, while complex and multifactorial, has also been attributed to poor body image, low self-esteem, and discrimination. This study examines the occurrence and time-course of depression in a bariatric population and explores the impact of depression on bariatric surgery outcomes utilizing the Beck Depression Inventory-II (BDI-II) questionnaire. Methods and Procedures: Demographic, anthropometric, and standard lab data were prospectively collected for 231 consecutive bariatric patients undergoing either laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), or adjustable gastric banding (LAGB) at a single academic institution preoperatively and 12-months postoperatively. Prior to surgery and at all postoperative follow-up clinic visits, study participants completed the BDI-II questionnaire, a 21 item self-reported, multiple-choice questionnaire validated to assess depression (sensitivity 81 %, specificity 92 %). BDI-II scores range from 0 to 63, with scores from 0–10 considered normal mood variation and scores C11 indicating mood disturbance and depression (higher scores demonstrate greater depression). Preoperative participant characteristics and postoperative weight-loss outcomes were compared to BDI-II scores with one-way ANOVA for continuous variables, chi-squared analysis for categorical variables, and regression analysis using STATA software release 12. Results: At the time of data analysis, 51.2 % of participants at the 6-month time point had completed their 6-month BDI-II questionnaire. Study participant demographics preoperatively showed an average age of 47.8 years, 55 % Caucasian, and 72.9 % female. Among the three bariatric procedures, surgical cases were 51.4 % LRYGB, 40.0 % LSG, and 8.6 % LAGB. Average BDI-II scores were 10.89 ± 0.82 preoperatively, 5.71 ± 0.58 at 3-months, and 6.15 ± 0.97 at 6-months postop. Preoperatively, 59.3 % of participants had normal BDI-II scores while 40.7 % had elevated scores indicating some degree of depression. BDI-II scores revealed that preoperatively, 19.9 % of patients had mild mood disturbance (11B BDI-II C16), 9.1 % had borderline clinical depression (17B BDI-II C20), and 11.7 % had moderate, severe, or extreme depression (BDI-II C21). By 6-months postop, participants with normal BDI-II scores jumped to 81.0 %. In analyzing the predictive nature of BDI-II scores on weight loss following bariatric surgery, BDI-II scores at 3-months and 6-months did not predict patients’ percent excess weight loss (%EWL) at the corresponding time points. Similarly, preoperative BDI-II scores were not significant predictors of %EWL at 3-months (b = 0.0746, p = 0.597, R2 = 0.5971) or at 6-months postop (b = -0.109, p = 0.598, R2 = 0.0034). Conclusions: BDI-II scores identified depression to be a considerable concern among the obese population seeking bariatric surgery. However, BDI-II scores were not found to be significantly predictive of %EWL in this analysis. Therefore, while bariatric clinicians and surgeons should be vigilant of depression in their patients, its negative effects on post-surgical outcomes may not pose a significant concern. Additional investigation is warranted to determine the predictive nature of the BDI-II questionnaire on surgical outcomes.

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Complete Resolution of Gastroparesis Following Laparoscopic Vertical Sleeve Gastrectomy: Revisiting the Discussion on How Sleeve Gastrectomy Works

Quality of Follow-Up: A Systematic Review of the Bariatric Surgery Research

Bankole Samuel, MD, Kofi Atiemo, MD, Miller John, Bsc, Perugini Richard, MD, University of Massachussetts Introduction: Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure. Its mechanism of action is debated. One theory held is that the narrow gastric tube retards the flow of nutrients through the stomach; alternatively, some evidence suggests LSG results in augmented gastric emptying. A resolution of this question is important. We present a case report of LSG in a severely obese individual with documented gastroparesis. Methods: Case report and literature review using pubmed. Search terms included gastroparesis, LSG and gastric emptying. Results: A 50-year-old severely obese woman 339 lbs and Body mass index (BMI) 51 with idiopathic gastroparesis was referred for LSG. Symptoms included nausea and regurgitation refractory to dietary measures, erythromycin, metoclopramide and botox injection of the pylorus. Preoperatively 0 % of a 30 cc scrambled egg meal labeled with Tc99 sulfur colloid had left the stomach after 120 minutes. Our standard technique was employed for LSG, and included resection of the greater curvature of the stomach beginning 6 cm proximal to the pylorus with a 40-Fr bougie was used as a sizer. Six weeks postoperatively 50 % of an equivalent meal had left the stomach after 90 minutes. She also reported resolution of her symptoms. At 6 months she remained symptom free and weighed 257 pounds (BMI 39)

Paper

Patient number

Bougie size (French)

Distance from pylorus (cm)

Buttress/ over sewing

Study

Meal

Gastric emptying increased Yes

Bauman et al

5

32

5 or 6

Not stated

MRI

Water

Michalsky et al

4

36

2.5

None

Tc 99

Egg

Yes

Braghetto et al

20

32

2

Not stated

Tc 99

Water/Egg

Yes

Melissas et al

9

34

7

Oversewing

Tc 99

Hamburger

Yes

Shah et al

23

Not stated

Not stated

Not stated

Contrast swallow study

Contrast

Yes

Fallatah et al

15

40

7

None

Tc 99

Fallatah et al

11

40

4

None

Tc 99

Egg

No

Bernstine et al

19

48

6

Oversewing

Tc 99

Bread/Water

No

Egg

Yes

Noah J Switzer, BSc, MD, Shaheed Merani, Daniel Skubleny, Xinzhe Shi, Jean-Se´bastien Pelletier, Richdeep Gill, Daniel Birch, Christopher de Gara, Arya Sharma, Shahzeer Karmali, University of Alberta Introduction: Follow-up is a major concern for interpreting results, especially in light of evolving surgical techniques. McMaster Evidence-Based Criteria for High Quality Studies states that follow-up for clinical studies of prevention or treatment should have follow-up of at least 80 %. Bariatric surgery is a fast growing surgical field of great interest in the academic world, however the quality of follow up in a general sense remains unknown. This study, to our knowledge, is the first in the literature to systematically review the bariatric surgery literature with regards to adequacy of patient follow up. Methods: A complete search of PubMed using the search terms gastric bypass, (obesity AND surgery) OR bariatric surgery, weight loss OR weight OR BMI OR body mass index. Due to the large amount of gastric bypass studies, the publication time was restricted to a range of five years (2007–2012), the language was limited to English, and only one major database, PubMed, was explored. Inclusion criteria included all English speaking RCTs, Cohort, Case-control, and case series studies with adult patients undergoing gastric bypass procedure between the years 2007–2012. The primary outcome was loss to follow up (LTF) at 12 months and at the endpoint of the study. Secondary outcomes included length of follow up at analysis, number of patients enrolled in RYGB arm and total study, country of study origin, number of centers involved in the study, impact factor of publishing journal. McMaster Evidence-Based Criteria for High Quality Studies was used to assess the follow-up data and a Meta-regression was performed to identify indicators of high quality studies. Results: 103 papers were included in the review. The average follow up time for all studies was 29.5 months (range 4–120) For 12 month follow-up, only 41/103 (40 %) of papers had adequate patient follow-up, 22/103 (21 %) failed to meet the McMaster criteria and 40/103 (39 %) failed to report any follow-up results. For follow-up at study end, only 40/103 (39 %) of papers had adequate patient follow-up, 42/103 (41 %) failed to meet the McMaster criteria and 21/103 (20 %) failed to report any follow-up results. On average, 15 % of patients were lost to follow-up at 12 months and 29 % were lost to follow-up at the study’s end. The meta-analysis separated the patients into two groups: all patients enrolled in the study and patients only enrolled in the gastric bypass portion of the study (when applicable). Only study duration (p = 0.004) and if the study was performed in the United States of America (p = 0.007) were predictive factors of meeting the McMaster criteria for high quality follow-up. The impact factor of the publishing journal (p = 0.49), number of centres involved (p = 0.255) and study type (p = 0.722) were not predictive. Conclusion: Follow up after bariatric surgery is underwhelming with only approximately 40 % of studies meeting criteria for adequate follow-up. On average, nearly 30 % of patients are lost to follow-up at study’s end. This is the first paper to systematically review the literature on follow-up after bariatric surgery.

Discussion: Increased gastric emptying following LSG is evident from our case and is supported by a majority of reported studies. Literature suggests the size of gastric sleeve and the amount of preserved antrum impact the effect on gastric emptying. If increased gastric emptying is indeed the underlying mechanism for weight loss, it may not be necessary to construct increasingly smaller sleeves which have been associated with a greater leak rate. To date studies are small and differ in surgical technique. Large, standardized, randomized studies are needed.

P332 Remission of Type 2 Diabetes Mellitus 1 Year After Bariatric Surgery in Severely Obese Patients Narong Boonyagard, MD, Pondech Vichajarn, Pakkavuth Chanswangphuvana, Krit Kitisin, Suppa-ut Pungpapong, Chadin Tharavej, Patpong Navicharern, Suthep Udomsawaengsup, King Chulalongkorn Memorial Hospital Background & Objective: Remission of Type 2 Diabetes mellitus (T2DM) after bariatric surgery was reported in many studies. Different types of bariatric operations offered varying degrees of T2DM remission. Our objective was to evaluate the effect of laparoscopic bariatric surgery on the control of T2DM in severely obese (BMI 35–50) patients at 1 year follow up in Thai population by comparing Laparoscopic Roux-en-Y gastric bypass (LRYGB) with Laparoscopic sleeve gastrectomy (LSG). Methods: We analyzed the data concerning 142 severely obese (BMI 35–50) who operated LRYGB or LSG between June 2006 and August 2013. Among them, 38 patients had diabetes before surgery and were included in the study, 22 had LRYGB and 16 had LSG. Evolutions of weight, BMI, percentage of excess weight loss (%EWL) and remission or improvement of T2DM were recorded during the first year of follow-up. Result: At one year after surgery all patient with T2DM were improved and 74 % of patients presented with remission. Comparing between two groups, there was no significant difference between the groups in age, sex and BMI. There was no significant difference in term of 1-year T2DM remission between two groups (78 % vs. 67 % p = 0.57). But LRYGB achieved higher %EWL than LSG (76.8 % ± 20.8 vs. 54.8 % ± 24.4 p = 0.044). Conclusion: Bariatric surgery is effective for the improvement and remission of diabetes in patients who are severely obese. There was no significant difference in T2DM remission between the 2 techniques. So, severely obese with diabetes patients should be considered for laparoscopic obesity surgery as an early intervention.

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Long Term Outcomes for Laparoscopic Bariatric Procedures in the Super–Super Obese (BMI [60 KG/M2): A Retrospective Review

Effect of Gastric Bypass Procedure for the Type 2 Diabetes Patients with BMI \35 KG/M2

Sharique Nazir, MD, Laurence Diggs, BA, Alex Bulanov, MS, George Ferzli, MD, FACS, Lutheran Medical Center

Ke Gong, Nengwei Zhang, Dexiao Du, Bin Zhu, Dongbo Lian, Zhen Zhang, Beijing Shijitan Hospital, Capital Medical University, Beijing, China

Background: Obesity is associated with serious comorbidities. Only bariatric surgery has been proven to definitively treat this condition. Our focus here is the management of the super-super obese (SSO) whose Body Mass Index (kg/ m2) is defined as greater than 60. Bariatric surgery is not commonly undertaken in this group due to perceived increased operative risks including higher incidence of comorbidities and heightened technical challenges such as exposing visceral fat, retracting the fatty liver, strong torque applied to instruments, increased thickness of the abdominal wall and reduced ability to attain adequate peritoneal insufflation. Most sources recommend only bariatric surgeons with at least 50 cases attempt such procedures. Numerous studies report increased rates of complications, OR time and length of stay (LOS) when performing bariatric surgery on the SSO. Our goal was to evaluate the overall outcomes of laparoscopic bariatric surgeries performed on SSO patients at our institution. Methods: We selected SSO patients who underwent bariatric surgery between 2004 and 2013 at a 500 bed community hospital. A retrospective chart review was done on a total of 93 patients. We recorded the type of procedure, OR time, peri-operative complications, LOS, weight change and co-morbidity reduction. Success of the surgery was evaluated as the percentage of preoperative excess weight lost (i.e. the post-operative weight change divided by the difference between the preoperative weight and their ideal body weight as defined by a BMI of 22.5). Results: 40 men and 53 women with mean age of 38 years (18–62 yrs) underwent laparoscopic bariatric surgery. 73 of the procedures were Roux-en-Y, 7 were sleeve gastrectomies and 13 were gastric bands. Mean preoperative weight was 188.2 kg (141–356 kg) with an associated BMI of 64 kg/m2 (60–83 kg/m2) whereas mean postoperative weight was 133.1 kg (70–234 kg) with an associated BMI of 46.5 kg/m2 (26–68 kg/m2). Overall mean %EWL at 1 year was 44 % (5–100 %) with 26 % for the lap bands, 38 % for sleeve gastrectomy, and 47 % for RNY. Mean OR time and LOS were 112 minutes (35–325 mins) and 67 hours (23–312 hrs). No complications were associated with the surgeries and there were no in-hospital mortalities. We reviewed patient follow-ups at 6 months (42 patients), 12 months (43), 2 years (22), 3 years (11), 4 years (1), 5 years (2) and 6 years (1). Of those who had long-term follow-ups, 37 % reported improvement in obstructive sleep apnea, 53 % in diabetes mellitus, 50 % in GERD, 28 % in hypertension, 29 % in asthma, 13 % in hypercholesterolemia, and 6 % in osteoarthritis. Conclusions: Laparoscopic bariatric surgery in the SSO is safe and effective when performed by experienced surgeons. It produces excellent outcomes with considerable excess weight loss and improvement of comorbidities with acceptable OR time and LOS. Further research must compare outcomes to those of the morbidly obese patients. For the SSO, medical assistance and life-style modification alone are often ineffective. We recommend that these individuals get a RNY procedure regardless of dietary habits (e.g. sugar intake) as it is more effective. Close follow-up and encouragement have been shown to improve outcomes.

Objectives: The aim of this study is to investigate the benefits on glycemic control following gastric bypass (GBP) for the type 2 diabetes (T2DM) patients with BMI \35 kg/m2. Methods: Thirty-four patients suffering from T2DM undergo laparoscopic gastric bypass surgery at Beijing Shijitan Hospital, Capital Medical University from June 2010 to April 2014 and were enrolled this study. The serum items including glucose, insulin and glycosylated haemoglobin (HbA1c) of all patients were measured before and after surgery and the results were analyzed. Results: 34 patients, the mean BMI was 29.50 ± 2.88 kg/m2 before surgery, suffered from T2DM underwent GBP surgery successfully (a mean age of 44 years), 14 were male and 20 were female. The patients were followed up 6–12 months. No major complications. The mean BMI was 24.10 ± 3.67 kg/m2 after surgery. The mean fasting blood glucose of all patients was 10.06 ± 3.30 mmol/L (normal 3.90–6.10 mmol/L) before surgery and was significantly decreased (6.85 ± 2.48 mmol/L) (P \ 0.001) after surgery. The 0.5hr-, 1hr-, 2hr-, 3hr- postprandail blood glucose were also decreased respectively (P \ 0.001) in all patients after surgery. The fasting serum insulin was 15.50 ± 10. 34 lIU/ml before surgery and was 6.85 ± 2.48 lIU/ml after surgery. The mean 2hr-, 3hr- postprandail serum insulin of all patients was significantly decreased after surgery compared with those before surgery (P \ 0.001). Compared before and after surgery, there were no statistical difference in the levels of 0.5hr-, 1hr- postprandail serum insulin respectively in all patients (P [ 0.05). HbA1c of all patients dropped from an average of 8.8 % (normal 4.8–6.0 %) preoperatively to 6.5 % post operatively. Conclusions: This research shows that gastric bypass surgery in the T2DM patients with BMI\35 kg/m2 is a safe and effective procedure for glycemic control and the further study with long-term, large sample are needed.

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Laparoscopic Sleeve Gastrectomy Produces Significant Excess Weight Loss in Both Morbidly Obese and Super Obese Patients – Initial Experience from a Tertiary Care University Teaching Hospital

Symptomatic Reflux After Bariatric Surgery: What Can We Expect?

Pawanindra Lal, MSFRCSEdFRCSGlasgFRCSEngFACS, Anubhav Vindal, MSMRCSEd, FCLS, Lovenish Bains, MSFCLS, Division of Minimal Access Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi Introduction: Surgical treatment of morbid obesity comprises of restrictive, malabsorptive and combined restrictive and malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG) has evolved as a stand-alone procedures for treatment of morbid obesity in obese & super-obese patients. We present our initial experience with laparoscopic sleeve gastrectomy from a tertiary care university teaching hospital in a developing country. Methods and Procedures: Over a period of 3 years, LSG was performed in 50 patients attending the metabolic surgery clinic of a tertiary care university teaching hospital. The standard 5 port technique was used and the gastric sleeve was fashioned over a 36 F bougie. The patients were orally allowed on first post operative day after performing an oral contrast study to check for any staple line leaks. Patients were evaluated for operative time, intra and post operative complications, post-operative recovery and hospital stay. All patients were periodically assessed for weight loss, resolution of comorbidities and nutritional deficiencies on follow up. Results: Out of the 50 patients, 13 were males and 37 were females with an average age of 37.04 years (range 21–54). The average BMI was 47.19 (range 34.89–65.43). There were 37 morbidly obese patients with an average BMI of 44.18 (range 34.89–49.9) and 13 super obese patients with an average BMI of 53.47 (range 50.22–65.43). All the patients had one or more comorbidities at the time of presentation, including hypertension, diabetes mellitus, hypothyroidism, obstructive sleep apnoea and osteoarthritis. In the post operative period, no patient had wound infection, chest complications, staple line bleeding or leak. One patient had an iatrogenic rupture of the lower oesophagus due to inadvertent inflation of the balloon of the gastric bougie in the lower oesophagus. Another patient had drain erosion into the gastrooesophageal junction with a resultant oesophageal fistula formation. Both were managed conservatively with endoscopic means. There was instant resolution of hypertension and diabetes in all the patients with no patient requiring any medications post operatively. The mean percent excess weight loss was 29.13 at 6 weeks (range 9.6–50), 41.47 at 3 months (range 25.93–67.3), 53.62 at 6 months (range 37.28–78.8), 64.75 at 12 months (range 43.6–90.38), 67.69 at 18 months (range 33.33–85.41) and 59.82 at 24 months (range 23.66–86.2). Fifteen patients were evaluated for nutritional deficiencies at follow up. Vitamin D deficiency was found in 7 patients at 6 weeks, in 4 patients at 6 months and in 2 patients at 12 months. Vitamin B12 deficiency was seen in 2 patients at 6 weeks, in 5 patients at 3 months, in 2 patients at 6 months and in 1 patient at 12 months. Iron deficiency was seen in 5 patients at 6 months. All patients experienced significant improvement in quality of life. Conclusions: LSG was found to be an effective and safe procedure for achieving excess weight loss, resolving comorbidities, and improving the quality of life in both morbidly obese and super obese patients.

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Abel E Bello, MD, Leena Khaitan, MD, University Hospitals Case Surgery Introduction: Restrictive bariatric procedures such as Sleeve Gastrectomy (SG), Adjustable Gastric Banding (LGB) and Vertical Band Gastroplasty (VBG) have been associated with worsening reflux symptoms in patients with and without pre-existing disease, but data is conflicting. Roux-En-Y Gastric Bypass (RYGB) has been the procedure of choice for treating gastroesophageal reflux disease (GERD) in the morbidly obese, and also a revision option for patients with GERD after weight loss surgery (WLS). There is no clear consensus on the best treatment option for bariatric patients that develop symptomatic GERD. We present a series of bariatric patients with post-operative symptomatic GERD and how manometry findings helped to guide treatment. Methods: A retrospective review was performed from 2006–2014 of all consecutive patients with primary complaint of GERD following WLS. Patients with upper endoscopy, esophagogram and manometry were included for analysis. Data on demographics, preoperative and postoperative symptoms, weight loss, and procedure details were collected. Previous surgeries were performed at outside hospitals. Data were kept in secure database. Statistical analysis performed using SPSSV22. Results: Nine patients met the inclusion criteria. All patients had prior restrictive WLS as either initial or secondary procedure. Four patients had 1 prior foregut procedure. Initial WLS were 5 SG, 2 VBG and 2 LGB. Six patients had dysphagia. Mean BMI at presentation was 43.13 ± 3.86. Mean Follow up 50.66 ± 32.35 months. Excess Weight Loss (EWL) at presentation from WLS (Mean 37.55 ± 10.07 %) which improved after revision (Mean 47.21 ± 10.34 %). Esophageal peristalsis was normal in 8/9 patients. 7 patients had revisional surgery. Of those with prior SG, 1 had hiatal hernia repair and 3 had removal of fundus with conversion to RYGBP. The remaining 1 SG patient on manometry has short intraabdominal LES, transient relaxation with otherwise normal LESP, bolus transit and peristalsis and is awaiting HH repair. Of the 2 Prior VBG, 1 had conversion to RYGBP and 1 not wanting surgery. All RYGB conversions had high-pressure zone distal to LES noted on high-resolution manometry (HRM). One patient had LGB removal without conversion. All had resolution of symptoms after revisional surgery and procedures were completed laparoscopically. Pre-existing GERD and previous PPI use was associated with post-op dysphagia after WLS (p = 0.018), but not with LES pressure abnormalities or esophageal dysmotility (p = 0.59 and 0.35 respectively). Bolus transit was comparable between all patients. Not all patients required conversion to RYGBP to treat the reflux and dysphagia. Conclusion: Treatments for reflux after WLS should be tailored to the cause of the problem. A high pressure zone distal to the LES seen on HRM is helpful in identifying those patients requiring conversion to RYGBP for revision. Others may just have HH repair if LES pressure normal. Thus, manometry can help to guide the surgeon in choosing the best treatment option for patients with GERD after WLS. Revisional surgery in these patients also significantly improves weight loss.

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The Efficacy of Gallbladder Dissolution Therapy Following Bariatric Surgery: A Systematic Review

Hiatal Hernias and Repair in Bariatric Surgery Patients: The Impact of Preoperative Imaging

Taylor J Smart, MD1, Noah J Switzer, MD1, Richdeep S Gill, MD, PhD, FRCSC1, Xinzhe Shi, MPH2, Christopher de Gara, MD, FRCSC1, Daniel W Birch, MD, FRCSC1, Shahzeer Karmali, MD, MPH, FRCSC1, 1Department of Surgery, University of Alberta, 2 Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital

Ashley Mooney, MD1, Stephen S McNatt, MD1, Adam Reid, MD2, Myron S Powell, MD1, 1Wake Forest School of Medicine, 2Southern Illinois University School of Medicine

Objective: Bariatric surgery leads to significant weight reduction in the morbidly obese. However, rapid weight loss has been associated with an increased risk for the development of gallstones. Different modalities have been advocated to manage this complication including synchronous cholecystectomy, prophylactic medical therapy and high-fat diets. The purpose of this study is to systematically review the literature on the benefit of using gallstone dissolution medical therapy as prophylaxis therapy following bariatric surgery. Methods: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms ‘‘bariatric or gastric bypass’’ AND ‘‘gall bladder, or gallstone, or cholecystitis, or cholecystectomy, or bile, or biliary’’ was completed. All randomized controlled trials, non-randomized comparison study, and case series were included. All human studies limited to English were included. Two independent reviewers screened abstracts, reviewed full text versions of all studies classified and extracted data. All studies included in the systematic review were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias (RoB) tools. Disagreements were resolved by re-extraction, or third party adjudication. 1928 titles were identified through primary search and 826 titles or abstracts were screened after removing duplicates. Results: 28 articles consisting of 32,147 patients were included in the systematic review. The group with no dissolution therapy had a mean incidence of cholelithiasis postoperatively of 31.5 %, 30.8 %, 9.1 % at 6 months, 12 months, and 24 months respectively. In the group of patients who did receive dissolution therapy, patients had a lower mean incidence of cholelithiasis following bariatric surgery of 5.3 %, 24.9 %, and 5 % at those same intervals. The mean incidence of cholecystectomy in the no dissolution therapy group was 5.3 %, 9.7 %, and 4.8 % at 6 months, 12 months, and 24 months respectively. Those who did receive dissolution therapy had a lower mean incidence of cholecystectomy of 0 %, 14.6 %, and 4.7 % at those same intervals. Conclusion: Prophylactic gallbladder dissolution therapy following bariatric surgery appears to be correlated with a decreased incidence of gallstones and need for cholecystectomy. Further primary studies are needed to evaluate this therapy to significance.

Introduction: Hiatal hernias in obese and morbidly obese patients seeking weight loss surgery have been reported to occur at a rate of nearly 40 %. Based on the International Sleeve Gastrectomy Expert Panel Consensus Statement of 2012, our group started routine UGI imaging evaluation for sleeve gastrectomy (SG) patients. Our Roux-en-Y gastric bypass (RYGB) patients were not routinely evaluated with UGI. We aimed to analyze the effect of imaging in both SG and RYGB populations to determine its relevance in the identification and repair of hiatal hernias. Methods: 1,141 patients were analyzed by retrospective chart review from July 2008 to August 2014 at our institution. Only first time SG and RYGB operations for the indication of weight loss were included. We assessed for gender, BMI, and UGI evaluation. Prevalence of hiatal hernia was derived. We calculated rates of HHR correlated with UGI findings. Chi square and Fischer exact test were used to compare the two groups. Results: The groups consisted of 796 RYGB and 345 SG patients. Of the RYGB group, 134 (17 %) patients underwent HHR compared to 118 (34 %) patients in the SG group, p \ 0.001. UGI evaluation was completed in 55 (7 %) of the RYGB group and 265 (77 %) of the SG group. UGI evaluation identified HH in 50 % of those studied. Of the RYGB patients with an UGI, 33 (60 %) had positive findings for hiatal hernia (HH) while 127 (48 %) of the SG patients with an UGI had positive findings for HH. The rate of HHR in those evaluated with UGI was equal between the two groups, 38 % (21 of 55 RYGB and 100 of 265 SG, p = 0.9). The rate of HHR by intraoperative identification alone was not different between the two groups, 15 % RYGB (113 of 741) and 23 % SG (18 of 80), p = 0.1. The false negative rate of UGI was 11 % in RYGB and 4 % in SG, p \ 0.05. The rate of no HHR with a positive UGI was 33 % in RYGB and 14 % in SG, p \ 0.002. The rate of no HHR with a negative UGI was 29 % in RYGB and 48 % in SG, p \ 0.05. The rate of HHR with a positive UGI was 27 % in RYGB and 34 % in SG, p = 0.4. A positive UGI lead to a significantly higher rate of HHR than intraoperative assessment alone, 33 % vs 19 %, p \ 0.001, regardless of the type of surgery. Conclusion: Hiatal hernias are common in patients seeking bariatric surgery. A standard for the preoperative evaluation of weight loss surgery patients has been elusive. Given that hiatal hernia is a risk factor for reflux and that GERD is the most common complication after sleeve gastrectomy, preoperative evaluation for hiatal hernia should be the standard. The significance of hiatal hernia in RYGB is not as clear. We recommend routine UGI in SG patients in order to identify hiatal hernias that will be missed on intraoperative evaluation alone.

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Micronutrient and Metabolic Status in Morbidly Obese Patients Undergoing Bariatric Surgery in a University Bariatric Program

Excess Weight Loss in Laparoscopic Gastric Plication: To Plicate or Not to Plicate

Iswanto Sucandy, MD, Kurt E Roberts, MD, Geoffrey Nadzam, MD, Andrew J Duffy, MD, Yale University

M S Abdelhamid, MD1, Ahmed M Sadat, MD1, Ayman R Abdelhaseeb, MD1, Tamer M Nabil, MD1, Mohamed S Abdelbasset, MD1, Amr M Ali, MD1, Hesham A Nafady1, Khalid A Shawky, MD1, Mohamed H Abdelmola, MD1, Adel M Abdullah, MD2, Ahmed Z Ghrib, MD2, Assad F Salama, MD3, 1Bani Swif University, 2October 6th University, 3Theodor Bilharz

Background: Bariatric surgery is the most effective long-term treatment for morbid obesity and its associated conditions. Post-operative bariatric surgery patients are known to be at risk for nutritional deficiencies and resulting complications, however, few studies have evaluated nutritional and metabolic status for obesity surgery patients at their preoperative baseline. The objective of this study is to evaluate micronutrient, vitamin, nutritional markers, and metabolic status in patients preparing to undergo their primary bariatric surgery. Methods: A retrospective review of 225 patients who underwent laparoscopic bariatric operations [Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and adjustable gastric banding (AGB)], with preoperative nutritional assessments, between June 2013 and July 2014 was performed. Patients undergoing revisional procedures were excluded from the analysis. Patient’s age, gender, BMI (body mass index), hemoglobin, calcium, albumin, iron, zinc, magnesium, phosphorus, folic acid, and vitamin B12 and D levels were prospectively collected and analyzed as part of the preoperative routine evaluation. Diabetic and dyslipidemic markers were also evaluated to better assess preoperative metabolic health status of these patients. These were collected in fasting patients. Results: 225 patients (63 RYGB, 153 VSG, 9 AGB) were included in this study with mean age of 43.2 years old (range 15–72), BMI 46.4 kg/m2 (range 35.3–81.4), and gender distribution of 80 % female. Deficiencies were found in 22.6 % of patients for iron, 19.9 % for zinc, 10.7 % for calcium, 12.8 % for phosphorus, 8.4 % for magnesium, and 10.4 % for folic acid. In term of preoperative nutritional markers, 13.3 % of patients were found to be anemic and 5 % were hypoalbuminemic. In the vitamin analysis, 41.7 % of subjects had vitamin D deficiency and 1.2 % had vitamin B12 deficiency. In the metabolic status assessment, 32 % of patients had diabetes mellitus based on HgbA1c value of [6 %, 22.8 % had hypercholesterolemia, 55.4 % had elevated low density lipoprotein (LDL), and 26.8 % had hypertriglyceridemia based on lipid panels. Conclusions: Pre-bariatric surgery patients demonstrate preoperative micronutrient and vitamin deficiencies, especially for iron, zinc, and vitamin D, in significant proportions. Diabetes and dyslipidemia are common, as previously noted. Protein malnutrition and iron deficiency anemia are notable is 5 % and 13.3 % of patients, despite their morbidly obesity status. Optimization of nutritional deficiencies preoperatively may be important in surgical recovery and long-term health. The relation to longitudinal nutritional status in these patients after bariatric surgery needs to be further elucidated with structured follow-up.

Objective: To find is it worth or not to plicate in relation to EBW loss Patients: 47 were enrolled in the study between May 2012 till May 2013 with follow up till May 2014 with BMI of 38–65 Method: LGP was done to all using two rows of continuous o prolene thread aided with harmonic scalpel. BMI and EBW were calculated prior to LGP then EBW Loss was estimated at six months and one year. The following scale was applied regarding EBW loss 0–14 % failure, 15 %–39 % poor, 40 %–69 % medium, 70 % or more excellent outcome, while regain of 10 % or more marked as regain . Results: We had one (2.1 %) deplication, six (12.7 %) regained weight, two (4.2 %) failures, fourteen (29.7 %) poor, sixteen (34 %) medium outcome and eight (17 %) with excellent outcome regarding EBW loss. Conclusion: It is very difficult to roll out LGP, we found it worth to do LGP although only 17 % got excellent EBW loss and 34 % got medium EBW loss which were acceptable to those patients which represent more than 50 % of our patients. This acceptance was supported by the low cost, safety and the potential reversibility of the procedure . Keywords: Laparoscopic gastric plication-Excess body weight loss

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Revision of Failed Restrictive Procedures to Laparoscopic Roux En Y Gastric Bypass (LRYGB) in Single Stage Compared to Primary LRYGB

Does Preoperative Weight Change Predict Postoperative Weight Loss After Laparoscopic Sleeve Gastrectomy?

Maha K Ibrahim, MD1, Mohammed B Al Hadad, MD1, Ahmed Maasher, MD1, Anas Mihchieh, MD2, Maria Margarita, RN1, Abdelrahman A Nimeri, MD, FACS, FASMBS1, 1Sheikh Khalifa Medical City, 2Cairo University College of Medicine Background: Weight recidivism is not uncommon after restrictive bariatric surgeries including laparoscopic adjustable gastric band (LAGB), vertical banded gastroplasty (VBG) and laparoscopic sleeve gastrectomy (LSG). Theoretically if a patient fails a restrictive bariatric procedure, then conversion to another restrictive procedure should be avoided. We present herein our experience in converting failed restrictive bariatric procedures to LRYGB compared to our primary LRYGB series. Methods: We reviewed our prospectively maintained database for all LRYGB following a failed restrictive procedure and our primary LRYGB performed from September 2009–2014. IRB approval was obtained. Our strategy is to convert failed restrictive bariatric procedures to LRYGB in one stage. Results: A total of 720 bariatric procedures were performed including 65 revisional LRYGB and 354 primary LRYGB cases. Revisional LRYGB included 49 cases of conversion of a failed LAGB, 10 and 6 cases of conversion of failed LSG and VBG respectively. Mean BMI for revisional and primary LRYGB was 46.5 and 48 kg/m respectively. Mortality rate in the entire series was 0 %. Leak rate in revisional and primary LRYGB was 1.5 % and 0.6 % respectively. Rate of DVT, PE and portal vein thrombosis was 0 % in revisional LRYGB and 0.6 %, 0.3 % and 0.6 % in primary LRYGB. Bleeding requiring blood transfusion or reoperation in revisional LRYGB was 0 % and in primary LRYGB was 0.6 % and 0.6 %. Stenosis rate in revisional and primary LRYGB was 1.5 % and 0.3 % respectively. Pneumonia and UTI rates in revisional LRYGB were 0 % and in primary LRYGB was 0.3 % and 0.3 % respectively. Readmission in revisional and primary LRYGB was 7.7 % and 2.8 % respectively. The excess weight loss at one year for our revisional and primary LRYGB was 60 % and 76 % respectively. Conclusion: Our data suggest that revision of failed restrictive procedures to LRYGB is safe and effective but has a lower Excess weight loss at one year compared to primary LRYGB.

William E Sherman, MD, Aaron E Lane, MD, Christopher W Mangieri, MD, Yong U Choi, MD, Byron J Faler, MD, Dwight D. Eisenhower Army Medical Center Introduction: Some institutions and insurance providers mandate preoperative weight loss prior to bariatric surgery. Previous studies of patients who have undergone laparoscopic Roux-en-Y gastric bypass suggest little to no correlation between preoperative weight loss and postoperative weight loss. A literature search found no studies investigating this question in patients who have undergone laparoscopic sleeve gastrectomy. Therefore, the objectives of this study were to examine the impact of preoperative weight loss on postoperative weight loss in these patients as well as any effect on length of surgery. Methods and Procedures: After obtaining institution review board approval, a retrospective analysis was performed on patients undergoing laparoscopic sleeve gastrectomy at our institution between 2010 and 2012. Patients were grouped based on preoperative weight gain or loss. Preoperative weight change was defined as the difference in weight upon entering our multidisciplinary bariatric surgery pathway and weight at the time of surgery. Analysis of Variance (ANOVA) and linear regression analysis were used to study the correlation between preoperative BMI change and amount of postoperative BMI change in these groups. The operative times for each group were also examined. Results: Of 141 patients with at least one year follow-up, 72 lost weight preoperatively (mean BMI decrease of 2.8 %), 6 maintained weight, and 64 gained weight preoperatively (mean BMI increase of 1.8 %). Comparison between the two groups showed no statistical difference in initial BMI, BMI at time of surgery, or length of time from initial weigh-in to time of surgery (duration of bariatric pathway). Percentage of excess BMI loss (%EBMIL) at 1 year was not statistically different between those who lost weight and those who gained weight preoperatively (74.2 % vs 73.4 %, respectively, p = 0.42). A linear regression analysis demonstrated that percent change in BMI from initial visit to surgery does not correlate with change in BMI at 1 year postoperatively (p = 0.77). Mean operative times were 96.9 minutes and 95.6 minutes for those who lost weight and those who gained weight, respectively. Preoperative BMI change did not correlate with length of surgery (p = 0.87). Conclusion: The results of this study demonstrate that preoperative weight loss is not a reliable predictor of postoperative weight loss after laparoscopic sleeve gastrectomy. Losing weight preoperatively also did not predict shorter operative time. Thus, potential patients who otherwise meet indications for bariatric surgery should not be denied this procedure based on inability to lose weight preoperatively.

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Remedial Foregut Operations Involving Bariatric Surgery

Comparison of the Efficacy of Standard Bariatric Surgical Procedures on Saudi Population Using the Bariatric Analysis and Reporting Outcome System (Baros)

B R Veenstra, MD, S Lynch, MD, M Buchanan, J A Stauffer, MD, H J Asbun, MD, C D Smith, MD, S P Bowers, MD, Mayo Clinic of Florida Introduction: For credentialing purposes, revisional bariatric operations are considered to be conversion of one bariatric operation to another, presumably for weight loss failure. It is our experience at a low volume bariatric, but high volume foregut center, that this does not represent the full spectrum of remedial foregut operations involving bariatric surgery. Methods and Procedures: We identified from our Foregut Registry 93 patients who underwent 96 elective, major remedial foregut operations involving bariatric surgery between May of 2008 and September of 2014. We identified three groups: prior bariatric operation and bariatric re-operation (B-B, n = 66), prior bariatric operation and nonbariatric foregut re-operation (B-NB, n = 19), and prior non-bariatric foregut operation and bariatric re-operation (NB-B, n = 11). A surgical history including Roux en y Gastric Bypass (RYGB, n = 37), Vertical Banded Gastroplasty (VBG, n = 20), Adjustable Gastric Band (LAGB, n = 19), Sleeve Gastrectomy (SG, n = 6), and Horizontal Gastroplasty (n = 3) represent prior bariatric operations, while a history of Nissen (n = 9) or Toupet fundoplication (n = 2) represent prior non-bariatric foregut operations. Bariatric re-operations included RYGB (n = 44), revision of RYGB (n = 22), and SG (n = 11). Non-bariatric foregut re-operations included completion gastrectomy with esophagojejunostomy (n = 6), gastrogastrostomy (n = 5), remnant gastrectomy (n = 4), thoracoabdominal esophagogastrectomy (n = 2), gastric seromyotomy (n = 1) and Heller myotomy (n = 1). Results: There was no 6 month mortality and no patient required unplanned or emergent re-operation. Post-operative leak occurred in three patients. Post-operative (within 6 months) interventions (n = 13) were required after 11 operations: diagnostic EGD (n = 4), endoscopic dilation (n = 2), endoscopic injection of fibrin glue to fistula tract (n = 2), endoscopic placement of stent (n = 2), CT guided drain placement (n = 2), and placement of gastrostomy tube (n = 1). The requirement for post-operative intervention was the same in the B-B and NB-B groups (both 9 %), with a trend towards higher post-operative intervention in the B-NB group (21 %, p = 0.22, Fisher’s Exact Test). Of the 96 total operations, 45 were ‘‘conversion’’ operations, with only 19 solely for failed weight loss. Conclusions: Our study demonstrates that less than half of remedial bariatric operations at our institution were conversion operations, with only a small percentage done solely for failed weight loss (19 %). There is a significant overlap between remedial foregut and remedial bariatric surgery. Bariatric patients requiring a non-bariatric foregut reoperation may signify a population of patients requiring a higher complexity of care. As such, credentialing for revisional bariatric surgery should reflect this.

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A Al-Kadi, MD, FRCSC, M Al-Naami, MD, FRCSC, Zr Siddiqui, MD, Qassim University Obesity is a chronic disease that has reached epidemic proportions globally. WHO estimated that 700 million population will be obese worldwide in 2015 compared to 300 million reported in 2005. In Saudi Arabia, an overall obesity prevalence is progressively increasing from 20 % in 1996, to 35 % in 2005, up to 52 % in 2013 with 20,000 deaths per year due to obesity and related comorbidities. Compared to different weight loss methods and programs, bariatric surgery proved to be the most effective and sustainable weight loss procedures, in addition to improvement of co-morbidities and quality of life. The aim of this study is to assess outcomes of standard bariatric surgical procedures using the Bariatric Analysis and Reporting Outcome System (BAROS). Methods: The questionnaire of BAROS was translated into Arabic language and validated before its use to collect the data from the patients who had bariatric surgeries from March 2010 to December 2012 at two institutions. Data was analyzed and scored against three outcomes; excess weight loss, cure or improvement of comorbidities, and quality of life changes. Results: A total of the 270 patients were included; 79 underwent Laparoscopic Roux-en-Y gastric Bypass Procedure (LRYGBP), 159 had Laparoscopic Sleeve Gastrectomy (LSG), and 32 had Laparoscopic Adjustable Gastric Banding (LAGB); with an overall female to male ratio of 2.5:1, 0.8:1, 1.3:1; and an average age of 36.41 ± 8.87, 31.87 ± 9.83, 34.75 ± 11.24 for the three procedures respectively. The average excess weight loss (EWL) was 67.94 %, 75.82 %, and 81.65 % against each procedure respectively. In patients with more than 1 year of follow-up, comorbidities were improved (64.0 %, 48.8 % & 57.1 %) or resolved (36.0 %,51.2 % & 42.9 %) with 95 % reported significant improvement in quality of life . Overall excellent\very good\good outcomes group scoring was achieved in 62 (78.5 %), 133 (83.65 %), and 18 (56.25 %) patients, with failure reported only by 4 (5 %) patients. Major complications were noted in 7.8 %, 5.7 %, and 6.25 % patients; and minor complications in 5.1 %, 11.3 %, and 12.5 % patients against the three procedures respectively; with no reported mortality. Conclusion: Standard bariatric procedures are very effective in reducing and sustaining excess body weight, for cure and improvement of co-morbidities, and quality of life improvement in morbidly obese Saudi population with different degrees of impact and outcome that can be beneficial in selecting appropriate procedure for appropriate indications and patients. LRYGB seems to work better for co-morbid diseases, LSG works well for excess weight loss as well as LAGB in selected patients.

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Sleeve Gastrectomy in More Than 60 Years for Morbid Obesity 1

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Elie K Chouillard, MD, PhD , Salman Alsabah, MD , Georges Khoury, MD3, 1PARIS Poissy Medical Center, 2AMIRI Hospital Kuwait City, 3RIZK Hospital Beirut In France, age over 60 years has traditionally been considered as a relative contraindication to bariatric surgery. However, many reports showed that surgery for morbid obesity has favorable results. We compared early outcome of laparoscopic sleeve gastrectomy (LSG) in patients over 60 years on a case-control basis with \40 years patients. Methods: From November 2005 to November 2013, 530 patients underwent laparoscopic sleeve gastrectomy. Of these, 70 patients (13.2 %) were [60 years. Outcomes in terms of perioperative complications, short-term and medium-term weight loss, remission or improvement of co-morbidities and medication requirements were extracted from our prospective database. The study group was retrospectively matched with 70 patients \40 years old who had LSG during the study period. Matching criteria included BMI, number of preoperative comorbidities, and the ASA score. Results: Ninety-days mortality was 0 % in both groups. Operative morbidity rate was similar in both groups (7.1 % versus 10 % according to Clavien-Dindo classification) (p [ 0.05). At 6 months postsurgery, older patients had lost 52 % percent of excess weight compared to 53 % in the younger group (P = 0. 8). At 12 months, Excess weight loss was 55 % (Group [60 years) versus 68 % (Group \40 years), respectively (p = 0.025). The comorbidities pattern was identical in both groups. Quality of life scores were comparable in both groups. Conclusion: LSG is a safe and effective treatment for morbid obesity in patients [60 years old. No additional mortality or morbidity was induced by age. Daily medication requirements and co-morbidities decrease significantly and identically in boths groups.

The Use of Total Parenteral Nutrition in Patients Following Bariatric Surgery Kevin D Helling, MD, Kamran Samakar, MD, Eric Sheu, MD, PhD, Malcolm Robinson, MD, Scott A Shikora, MD, Ashley Vernon, MD, David Spector, MD, Ali Tavakkoli, MD, Brigham and Women’s Hospital Introduction: While the safety of bariatric surgery has increased significantly, complications do arise which necessitate the use of Total Parenteral Nutrition (TPN). The safety of TPN in this patient cohort is not studied. We therefore studied the outcomes of a group of patients who required TPN following bariatric surgery. Methods and Procedures: The TPN database at our institution was queried and 24 consecutive cases of TPN usage identified. All patients had bariatric surgery between 12/2008 and 10/2010. Patient demographics, type of operation performed, indications for and duration of TPN therapy, as well complications arising from TPN administration were recorded. Results: Twenty-two of the 24 patients underwent revisionary bariatric operations prior to initiation of TPN. Two patients underwent primary bariatric operations, both with significant non-bariatric surgical history requiring extensive adhesiolysis at the time of bariatric operation. Fifteen patients required subsequent operations following the index procedure. Of those, 8 patients needed one additional operation, 3 patients underwent two subsequent operations, and 4 patients required four additional operations. Complications leading to TPN use included anastomotic leak (10), gastric perforation from band erosion (2), pancreatitis (2), ulcer (3), GI bleed (2), small bowel internal herniation (1), omental necrosis and chronic abdominal pain (1), and an inability to tolerate diet (1). Both primary operation patients developed enterocutaneous fistulae (2). Average duration of TPN use was 55 days (6–299). Average length of time between the inciting operation and initiation of TPN was 19 days. TPN was given via PICC line in 21 patients and temporary indwelling central venous catheters in 3 patients. Of PICC line patients, 6 developed line infections (29 %). Three experienced upper extremity venous thrombosis (14 %). No line related complications occurred in the central line patients. Conclusion: In this group of bariatric TPN patients, all underwent complex high risk bariatric operations. The most common complication requiring the use of TPN was anastomotic leak. Many of the patients required subsequent operations after the index procedure. TPN use with indwelling peripheral line was a risk factor for line infection and upper extremity venous thrombosis. Further study of the risk factors for, and consequences of TPN usage in the bariatric surgery patient population is warranted.

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A Retrospective Study on the Pre-Operative Demographic, Behavioral, and Medical Predictors of Weight Loss in Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

Non-alcoholic Fatty Liver Disease Resolution Following Sleeve Gastrectomy

Matthew D Cooper, MD, Kathleen Kromer-Baker, PhD, That N Tran, MD, Maria Chun, PhD, Racquel S Bueno, MD, Cedric Lorenzo, MD, University of Hawaii Introduction: Multiple studies have demonstrated the efficacy of bariatric surgery in producing long term weight loss and resolution of medical comorbidities. Success after laparoscopic Roux-en-Y gastric bypass (LRYGB) is usually defined as a 50 % or greater loss of excess body weight (EWL) at 1 year after surgery. Failure of a patient to achieve expected weight loss after gastric bypass is a frustrating and difficult problem for both patients and surgeons. If a better method of predicting a patient’s potential for success or failure were available then pre- and post-operative interventions could be instituted to optimize weight loss efforts. This study aims to determine the factors that would identify patients most likely to benefit from surgery in order to optimize resource allocation, manage patients’ expectations, and avoid exposing patients unlikely to benefit from surgery to its inherent risks. Methods: This study involved a retrospective chart review of 373 patients who underwent LRYGB from January 1, 2006 to December 31, 2009. Within this group, 202 were excluded for failure to attend adequate medical follow-up or incomplete demographic data. The final sample consisted of 171 participants. Variables were analyzed using linear and multivariate regression. Covariates were additionally tested for associations with %EWL using quantile regression, adjusted for gender, age, original BMI, and Caucasian ethnicity. Results: Factors significantly predictive of greater %EWL included Caucasian ethnicity, lower initial BMI, less prior alcohol use, and lack of dyslipidemia. Surprisingly, having a greater number of antihypertensive medications, presence of dyspnea of exertion, and obstructive sleep apnea were also predictive of greater %EWL after LRYGB. Increased preoperative pain and select health conditions were associated with less successful %EWL. These conditions included metabolic syndrome, diabetes, dyslipidemia, fasting hyperglycemia, anxiety, pain, gout, and kidney disease. Conclusion: Results show that certain demographic characteristics and health conditions can positively or negatively affect patient outcomes after LRYGB. These associations may be used to further improve patient selection, manage patient’s expectations, direct preoperative psychological and medical therapy, and improve postoperative patient care. However, further study is needed to explain why a patient’s specific profile would positively or negatively affect their weight loss after LRYGB.

Sulaiman Almazeedi, MD, Ardeshir Algooneh, Salman Al-Sabah, FRCSC, Maha Ahmed, Amiri Hospital Introduction: Non-alcoholic fatty liver disease (NAFLD), a disease highly prevalent among the morbidly obese population, is today one of the most common causes of chronic liver disease. The purpose of this study is to observe the effect of laparoscopic sleeve gastrectomy (LSG) on the resolution of NAFLD. Methods and Procedures: A retrospective study was conducted of 84 patients diagnosed with NAFLD prior to undergoing LSG. The diagnosis of NAFLD was achieved based on transabdominal ultrasonographic imaging as per the 2012 joint guidelines for the diagnosis of NAFLD (American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology). The patients had follow-up anthropometric measurements and were re-evaluated with post-operative ultrasounds at different time frames to assess for the resolution of the disease. Results: The median age of the patients was 44 (17–62) and 66.7 % were female. Average time since surgery was 3.3 years (range 1–5 years). The mean pre and post-operative BMI were 46.6 ± 7.8 and 33.0 ± 7.1 respectively, with a mean percent excess weight loss (%EWL) of 55.7 % ± 23.0. A total of 47 (56 %) patients showed complete resolution of NAFLD post-operatively. Multivariate analysis showed a significant resolution of NAFLD in patients achieving [50 % EWL (OR 10.1; p \ 0.001) after controlling for age and sex. Conclusion: Weight loss after LSG effectively resolved NAFLD in more than half of the obese patients in this study, and can prove to be a useful tool in tackling the disease in the future.

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The Feasibility of Laparoscopic Roux-en-Y-Gastric Bypass Versus Laparoscopic Re-Sleeve Gastrectomy as Conversional Procedures After Failed Laparoscopic Sleeve Gastrectomy

Long Term Outcomes of Obesity Related Comorbidities After Roux-en-Y Gastric Bypass in VA Patients

Nourah Alsharqawi, Salman Alsabah, Ahmed Almulla, Shehab Ekrouf, Saud Al Subaie, Talib Jumaa, Al Amiri Hospital Background: Laparoscopic Sleeve Gastrectomy (LSG) is gaining popularity worldwide due to its success on a short term basis. However, long term follow up results included insufficient weight loss and weight regain that required surgical intervention. Laparoscopic Roux-en-Y-Gastric Bypass (LRYGB) and Laparoscopic Re-sleeve Gastrectomy (LRSG) are currently being studied as conversional techniques for failed LSG. This study aims at assessing the success rate of these conversional techniques. Methods: A retrospective analysis of 1300 patients underwent LSG from February 2009 to October 2012 in AlAmiri Hospital, Kuwait, of which 11 patients underwent LRYGB and 9 patients underwent LRSG. Data included length of stay, percentage of excessive weight loss (EWL%), and Body Mass Index (BMI). Results: A total of 11 patients underwent conversion from LSG to LRYGB due to insufficient weight loss (73 %) and weight regain (27 %) after a mean interval of 4 years and 9 patients underwent conversion from LSG to LRSG due to insufficient weight loss after a mean interval of 2.5 years. Mean age was 35 years, 85 % were females. The mean weight and BMI prior to LSG for the LRYGB and LRSG patients were 128 kg and 49 kg and 142 kg and 50, respectively. The EWL% after the initial LSG was 46 % and 35.1 %, for the LRYGB and LRSG, respectively. There were no complications recorded. Mean length of stay in hospital was 3 days and 2 days after LRYGB and LRSG, respectively. Results of conversion of LSG to LRYGB involved a mean end weight and EWL% of 90 kg and 63 % respectively over an interval of 9 months. Results of LSRG involved a mean end weight, and EWL% of 84, and 48.9 % respectively over a period of one year. A significant increase in EWL% from LSG to LRYGB was recorded with a p-value of 0.009. In addition, a significant increase in EWL% from LSG to LRSG was documented with a p-value of 0.05. A comparison of the EWL% of LRYGB and LRSG for failed primary LSG was not significant with a p-value of 0.097. Conclusion: Both LRYGB and LRSG groups demonstrated a significant reduction in weight. However, the LRYGB group illustrated more weight loss. These results have been recorded on a short term basis. Larger and longer follow up studies are required to validate the results.

P351 Intraoperative Finding of Liver Cirrhosis in Bariatric Surgery, the Role of Sleeve Gastrectomy: A Report of Two Consecutive Cases Miguel A Zapata Martinez, MD, Julio C Gallardo Baez, MD, Ulises Caballero-de la Pen˜a, MD, Marco A Juarez-Parra, MD, David J Orozco-Agent, MD, Jeronimo Monterrubio-Rodriguez, MD, Hospital Christus Muguerza Sur – Universidad de Monterrey Introduction: Obesity is a reported risk factor for non-alcoholic steatohepatitis (NASH), which is a common cause of cirrhosis. The estimated prevalence of nonalcoholic fatty liver disease (NAFLD) ranges from 84 %–96 % and for NASH 25 %–55 %. Up to 25 % of patients with NASH will progress to liver cirrhosis. Cirrhosis is recognized incidentally in 1.4 % of patients undergoing elective bariatric surgery. Even though the marked improvement in liver fibrosis after laparoscopic Roux-en-Y gastric bypass (LRYGB), concern exists about the inaccessible gastric remnant if variceal bleeding occurs or if endoscopic access to the biliary tree is necessary. Laparoscopic sleeve gastrectomy (SG) has demonstrated to be well-tolerated in cirrhotic patients and can be as a risk reduction procedure. However, mortality rates are increased in cirrhotic patients undergoing bariatric surgery from 0.3 % to 1.2 %. We present 2 cases of patients scheduled for LRYGB in who the intraoperative finding of a cirrhotic liver change the surgical conduct. Case Report: A 38-year-old female with personal pathologic history of type II diabetes, hypothyroidism, morbid obesity, and NASH; BMI 51.6. A 39-year-old male with chronic alcoholism and multiple tattoos; BMI 40.3. Both patients were referred for LRYGB and preoperatory laboratory test results were within normal parameters. Upon entering the abdominal cavity, dilated gastro-epiploic vessels, and a multinodular liver were found. With these findings the surgical procedure was changed to a sleeve gastrectomy on both patients. After cutting the gastroepiploic and short gastric vessels with bipolar energy, the gastric sleeve was manufactured using six golden lineal staplers, then a hemostatic running polyglycolic acid suture was placed. Pneumatic methylene blue test was performed without evidence of leaks. Liver wedge biopsies were taken and a drain placed. They were admitted to the surgical ward, with NPO for 1 day, started liquid diet on the second day and a had a hidrosoluble contrast test was ordered, without evidence of leaks. They were discharged on PO day 3 on clear liquid diet. Pathological analysis demonstrated liver cirrhosis in both patients. Conclusion: Liver cirrhosis has an eightfold increase of risk for mortality and morbidity after abdominal surgery and most of the patients have concomitant comorbidities like metabolic syndrome and cardiovascular disease. Mal absorptive changes and GI tract modification associated with LRYGB might put these patient at risk for further complications. Weight loss achieved with laparoscopic bariatric surgery in patients with cirrhosis offers a better outcome of their comorbidities, and even normalization in liver histology. Sleeve gastrectomy as a mainly restrictive procedure, is a safer option in patients with liver cirrhosis with reduction of the complication rate.

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Shohan Shetty, MD, Jaime P Almandoz, MD, Ibrahim I Jabbour, MD, MPH, Nancy Puzziferri, MD, UT Southwestern Medical Center (Dallas, TX) Introduction: Obese patients in the Veterans Affairs (VA) Health Care System who undergo bariatric surgery differ from their civilian counterparts, as they are predominantly men, older aged, carry greater obesity related comorbidity burden and are of lower socioeconomic status. While studies have shown bariatric surgery significantly improves glycemic control and cardiometabolic risk factors, there is limited longitudinal data from the Veteran population. This study evaluated the long-term outcomes of VA patients following Roux-en-Y Gastric Bypass (RYGB) in regards to weight loss, type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia. Methods: A retrospective review was conducted on consecutive patients diagnosed with T2DM who underwent RYGB at the VA North Texas Health Care System between 2003 and 2011. Data collection included demographics, absolute weight, body mass index (BMI), associated diagnoses, medications, and remission rates. Remission was defined as: hemoglobin A1c (HgbA1c) \6.5 %, without medications for T2DM; blood pressure \140/90 mmHg without medications for hypertension; and cholesterol \200 mg/dl, high density lipoprotein (HDL) [40 mg/dl, low density lipoprotein (LDL) \160 mg/dl, and triglycerides \200 mg/dl, without medications for hyperlipidemia. Outcome means for absolute weight and BMI were compared by t test. Reported p values are 2-sided and considered significant at \0.05. Results: Eighty-five T2DM patients (73 % males; mean age 54 years) underwent RYGB. Mean pre-operative weight and BMI were 151 kg (range 103–229 kg) and 49 kg/m2 (range 35–81 kg/m2), respectively. Ninety-two percent of patients also had hypertension and 84 % had hyperlipidemia. All diagnoses were made by referral physicians, documented on the medical record, and treated with medication. At 4 years post-operation, with 80 % follow-up, the mean weight was 107 kg (± 57 SD; p \ 0.001) and mean BMI 46.2 kg/m2 (± 7.2 SD; p \ 0.05). Preoperative mean HbA1c of 6.9 % (±1.2 SD) decreased to 6.3 % (±1.4 SD; p \ 0.01) postoperatively. Twenty-seven patients (31 %) had remission of T2DM. Mean blood pressures did not meaningfully differ after RYGB (133/73 pre- versus 129/75 mmHg post-operation). Twelve patients (15 %) had remission of hypertension. Cholesterol and LDL levels did not decrease significantly post-operation (172 to 159 mg/dl; p = 0.06 and 92 to 82 mg/dl; p = 0.11, respectively). HDL and triglycerides changed significantly after RYGB (42–54 mg/dl; p \ 0.001, and 198 to 124 mg/dl; p \ 0.001 respectively). The remission rate for hyperlipidemia was 15 %. Conclusions: Long-term follow-up of VA patients with obesity and T2DM who underwent RYGB demonstrated significant and durable weight loss with marked improvement in obesity-related comorbidities including glycemic control, hypertension, and hyperlipidemia.

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Management Algorithm for Leaks After Laparoscopic Sleeve Gastrectomy

Does Insurance Status Influence Bariatric Surgery Outcomes?

Abdelrahman A Nimeri, MD, FACS, FASMBS, Ahmed O Maasher, MD, Maha Ibrahim, MD, Mohammed Al Haddad, MD, Sheikh Khalifa Medical City Introduction: Laparoscopic sleeve gastrectomy (LSG) is an acceptable primary operation for morbid obesity. Leak after LSG is one of the most serious complications. However, all leaks after LSG are not the same and they differ based on the timing of presentation, and presence of peritonitis or distal stricture. Different management strategies have been described including endoscopic stents, or surgical correction. However, no clear algorithm has been described for management. Objectives: Describe our experience in managing leaks after LSG and describe our management algorithm. Methods: We reviewed our prospectively maintained database for all LSG performed and all leaks after LSG treated at BMI Abu Dhabi from September 2009 to 2014. In addition, we reviewed the literature for management strategies for patients with leaks after LSG including endoscopic and operative strategies. Leaks are considered early in the first 6 weeks and chronic after 12 weeks of LSG. The corner stone in our managment is enteral feeding through a nasojejunal feeding or jejunostomy tube. In addition, the timing of the leak, the presence of a distal stenosis/stricture and the presence of peritonitis dictate our management approach. Our initial evaluation includes gastrograffin studies, CT of the Abdomen and upper endoscopy. All chronic leaks and early leaks with distal stenosis not amenable to endoscopic stening were treated with optimization followed by laparoscopic Roux en Y esophago jejunostomy. Early leaks with or without peritonitis were treated with laparoscopy drainage and jejunostomy feeding and endoscopic stents respectively. Results: Between September 2009 and 2014 we performed 236 LSG procedures without a leak. During the same time period we treated 15 patients with leaks after LSG referred to our unit according to our management strategy described above. Three patients were treated with laparoscopic esophago jejunostomy without complications. Eight patients were treated with exploration and jejunostomy tube placement and the remaining patients were treated conservatively with or without stents. All patients were started on enteral and sent home once their sepsis is controlled. Our success rate with endoscopic stents was 50 % while our success rate after operative correction was 100 %. Our mortality rate was zero. Conclusion: All leaks after LSG are not the same. The management strategy at BMI Abu Dhabi depends on enteral feeding, the timing of presentation, and presence of peritonits stiricture.

Tara Mokhtari, Archana Nair, Narges Karmini, Dan Azagury, Homero Rivas, John Morton, Stanford University Introduction: Bariatric surgery remains an enduring treatment to achieve long-term weight loss in the morbidly obese. While insurance now widely covers bariatric procedures, the relationship between insurance type and weight loss remains unclear. This study aims to evaluate the impact of insurance status on outcomes following three laparoscopic bariatric surgeries: Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric banding (LAGB). Methods and Procedures: At a single academic institution, 1136 patients undergoing bariatric surgery were included in this prospective study. Pre- and post-operatively, demographic information, anthropometric measurements, standard lab data, and insurance status were collected. Patients were placed into one of four groups based on insurance status: 1) Private (P); 2) Medicare \55 years old (y/o) (M \55); 3) Medicare C55 years old (M C55); and 4) Medicaid (MC). Comparison of pre- and post-operative weights, comorbidity resolution rates, and standard lab data was accomplished with one-way ANOVA and chi-squared analysis as appropriate for continuous and categorical variables respectively. All analysis was performed using STATA software release 12. Results: In this cohort, insurance distribution was 81.7 % Private, 4.9 % Medicare\55 y/o, 6.9 % Medicare C55 y/o, and 6.5 % Medicaid. Preoperative data revealed that as expected, patients in the M C55 group were older (average ages, P: 45.6, M \55: 42.8, M C55: 59.2, MC: 40.3, p \ 0.000). Preoperative rates of comorbid conditions varied by insurance, with Medicare C55y/o having the highest rate of diabetes (53.9 %, p = 0.004), and Medicaid having the highest rate of hypertension (83.3 %, p \ 0.000). There was no significant difference in preoperative rates of hyperlipidemia. There were no differences in complication or readmission rates among the four groups. Postoperatively, patients in all insurance classes achieved substantial weight loss. There was no statistical difference in 12-month percent excess weight loss (%EWL) based on insurance status, however Medicare patients\55 y/o trended to achieve lower %EWL than other insurance classes (P: 69.9 %, M \55: 64.3 %, M C55: 65.2 %, MC: 71.9 %, p = 0.142). Across insurance types, Medicare \ 55 y/o had the highest BMIs both preoperatively (average BMI = 49.3, p \ 0.000) and postoperatively (average BMI = 34.29, p = 0.032). Medicaid patients, although few in number, saw significantly higher resolution rates of comorbid conditions including hypertension (91 %, p = 0.021), hypercholesterolemia (90 %, p = 0.036), and diabetes (94 %, p = 0.028). Medicare patients of all ages experienced the lowest resolution rates for these three comorbidities. Interestingly, at 12-months there was no significant difference in biochemical markers of these comorbid conditions including HbA1c, fasting glucose, LDL, HDL, Triglycerides, and Triglyceride/HDL ratio among the four insurance classes. Conclusion: This study showed that 12-months following surgery, patients in all four insurance categories experienced considerable weight reduction and improvements in obesity-related comorbidities.

P355 Stricture Rates After Gastric Bypass with Hand Sewn Anastomosis Javier J Flores, BS, Providence Memorial Hospital Background: Anastomotic strictures at the gastrojejunal anastomosis are relatively common after a gastric bypass. There are three different ways to perform a gastrojejunal (GJ) anastomosis; circular stapled, linear stapled and hand sewn. The circular stapled technique obviously provides the most standard diameter and the other two techniques can be standardized by using a bougie to calibrate the diameter of the anastomosis. However they all have the possibility to stricture. This requires a dilation, whether pneumatic or with a tapered dialator. This study examines the stricture rate of a hand sewn GJ over a 4 year period and evaluates potential contributing factors. Methods: A prospectively maintained database was used to retrospectively evaluate patient outcomes at our bariatric center. This included data on complications. This database was evaluated for strictures. The gastric bypasses were performed over a 4 year period by a single surgeon. The technique remained standard over the study period. This was a 2 layered hand sewn anastomosis with 4 different sutures of 2.0 Vicryl. The patients chart was then examined for radiographic studies, endoscopies, treatment and outcomes. Patient characteristics were also evaluated. Inclusion criteria were primary laparoscopic gastric bypasses. Exclusion criteria were revisions, conversions to open procedures and combined procedures. Results: In the period from 2010–2013 there were 418 primary laparoscopic gastric bypasses. The overall stricture rate was 3.3 % with 14 patients. This varied by year from a low of 2.4 % in 2010 to 6.7 % in 2011. The average time to stricture was 57.5 days with a standard deviation of 28.5. All patients responded to pneumatic dilation. Conclusions: A two layered hand sewn anastomosis has an acceptable rate of stricture. These strictures are early and respond well to pneumatic endoscopic dilation.

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P356

P358

Revisional Versus Primary Bariatric Surgery in a Publicly Funded Program

The Utility of Helicobacter Pylori Immunoglobulin G (IgG) and IgA Serologic Testing in Predicting Endoscopic Biopsy Results Prior to Bariatric Surgery

Caroline E Sheppard, BSc1, Courtney Fulton, MD2, Daniel W Birch, MSc, MD, FRCSC1, Shahzeer Karmali, MD, FRCSC, FACP1, Christopher J de Gara, MB, MS, FRCS, Ed, Eng, C, FACS, FFStd, Ed2, 1University of Alberta, CAMIS, 2University of Alberta Introduction: Revisional surgery has become an important component of addressing weight regain and complications following primary bariatric surgery. A specialized multidisciplinary revision clinic has been developed to intake patients that require revisional bariatric surgery. The objective of this project will be to analyse the revisional clinic process, review revision and complication rates compared to primary bariatric surgery, and inform future programming and resource allocation in a provincial approach to obesity management and bariatric surgery. Methods: A retrospective chart review of 529 Bariatric Revision clinic patients was completed from 2010 to 2014. Results: Patients were 90 % female and 47.9 ± 10.1 years of age. Initial BMI was 42.6 ± 11.0 compared to a BMI of 44.2 ± 8.6 before primary bariatric surgery. Patients returned seeking revisional surgery 2 to 17 years after primary surgery. The majority had either a primary vertical banded gastroplasty (VBG) (50 %) or a laparoscopic adjustable gastric band (LAGB) (25 %); 12 % had already undergone some type of revision. Most primary surgeries were performed in Alberta (56 %); however, over one third were medical tourists. Patients presented to the revision clinic either because of weight regain (64 %), dysphagia (26 %), other complications (12 %), and/or malnutrition (3 %). Bands were removed in 38 % of LAGB patients within 3.5 years of insertion. Only 16 % of patients followed through the primary clinic required a band removal. Revisional surgery was performed in 15 % of patients after 9 months upon entering the revision clinic. Twelve months after surgery patients had a BMI of 33.6 ± 8.3 compared to 33.5 ± 7.7 12 months after primary surgery. The complication rate after primary and revisional surgery was 20 % and 36 % respectively with wound infection being the primary complaint, and 28 % of revisional procedures required additional surgery. Conclusions: A bariatric revision clinic manages a wide variety of very complex patients, distinct from patients seen in a primary clinic. A minority (20 %) of patients were surgical candidates because of exceedingly complex medical, surgical and mental health comorbidities. A significant number of these patients are referred because of lack of resources or are medical tourists with complex medical management. While revisional procedures have an increased complication rate compared to primary bariatric surgery, revisional surgery is integral for significantly decreasing weight regain and addressing both postoperative complications and poor lifestyle recidivism. Therefore, resources are necessary to support revision surgery for this complex group of patients.

Brigid P O’Holleran, Anna R Ibele, MD, Rebecca M Kohler, PAC, Eric T Volckmann, MD, University of Utah Introduction: In bariatric surgery, there is a lack of consensus regarding indications and methods for preoperative evaluation for Helicobacter pylori. We decided to review our current practice for H. pylori testing and create a protocol that would improve our efficiency and cost-savings. We propose that by increasing our threshold for obtaining endoscopic biopsies by using a serologic value higher than our institution’s laboratory cutoff for H. pylori seropositivity, we could avoid the need for unnecessary biopsy and treatment and lower the cost of preoperative patient evaluation. Methods and Procedures: We performed a retrospective review of the EMR of 135 patients undergoing bariatric surgery at our institution from February 2011 to September 2014. Charts were reviewed for preoperative H pylori serology and endoscopy results. Preoperative quantitative IgG and IgA levels were recorded as well as endoscopic biopsy results. Eight patients did not have records of preoperative H. pylori serology and were excluded. We used our institution’s reference range for positive serology (value greater than 1.7 ElisaValue (EV)) to determine the sensitivity and specificity of H. pylori IgG and IgA levels for detecting positive histology on endoscopic biopsy. We then compared the sensitivity and specificity of IgG and IgA levels using 4.0EV, a value higher than our institution’s laboratory cutoff for positive serology. Results: There were 71 patients who had no endoscopic biopsy, and were excluded from the sensitivity and specificity calculations in addition to the eight patients with no preoperative serology. Of the 55 patients who met inclusion criteria, 10 patients had positive biopsy for H. pylori while the remaining 45 had negative biopsy results. The sensitivity and specificity of IgA using 1.7EV as the positive cutoff were 60 % and 66.67 %. Using 1.7EV for IgG revealed a sensitivity and specificity of 90 % and 66.67 % respectively. Finally, using the proposed increased IgG level of 4.0, the specificity of the test increased to 91 % while the sensitivity of the test remained stable at 90 %. Conclusions: The study results show that using a higher H. pylori serology level to trigger preoperative endoscopic biopsy will result in fewer unnecessary biopsies and thus potential cost-savings. At our institution, our current practice is to obtain both IgG and IgA serology preoperatively. For those with an elevated IgG or IgA level, it is our standard to perform an endoscopic biopsy. Based on our analysis, an IgG level of 4.0EV is more specific than the laboratory cutoff of 1.7EV, with equivalent sensitivity to the laboratory threshold for positivity. IgG levels at our proposed positivity threshold and the standard laboratory threshold were both more sensitive and specific than IgA in predicting a positive biopsy result. Additional sample size is necessary to validate our results, but we propose that to lower cost, an IgG level of 4.0 may be a better threshold to determine need for an endoscopic biopsy as part of the preoperative workup. Furthermore, unnecessary laboratory fees can be avoided by drawing only an IgG level preoperatively as IgG was a better predictor of active disease than IgA.

P357

P359

Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Weight Results After Surgery

Laparoscopic Sleeve Gastrectomy (LSG) & Neuropathy

E Raga, A Molina, F Sabench, M Parı´s, M Herna´ndez, A Sa´nchez, S Blanco, A Mun˜oz, E Homs, J Sa´nchez, Ml Pia´ana, Daniel Del Castilo, Hospital Universitari Sant Joan de Reus. Universitat Rovira i Virgili Objectives: To describe the weight evolution along three years after surgery in patients undergoing Laparoscopic Sleeve Gastrectomy (LSG) and Roux-Y gastric Bypass (RYGB) in our center. Material and Methods: Retrospective review of patients treated between 2005 and 2010. Weight evolution was assessed by the following indicators: total weight (kg), body mass index and percentage of excess BMI lost (PEBMIL). Results: 297 patients (23.6 %?, 76.4 %?), mean age 46.5 years, mean weight 127.2 kg and mean BMI 48.1 kg/m2. A total of 175 LSG and 122 RYGB were performed. Before surgery in LSG group: mean weight 132.1 kg (95 % CI 128.3–135.8) and mean BMI 49.7 kg/m2 (95 % CI 48.4–51.0). One year after surgery: mean weight 93.6 kg (CI 90.5–96.7), mean BMI 35.5 kg/m2 (CI 34.4–36.5) and a PEBMIL 56.3 % (CI 50.5–62.1). Two years after surgery: mean weight 92.3 kg (CI 88.5–96.0), mean BMI 35.2 kg/m2 (CI 33.9–36.5) and the PEBMIL 56.6 % (CI 47.8–65.5). Three years after surgery: mean weight 93.5 kg (95 % CI 89.5–97.5), mean BMI 35.9 kg/m2 (CI 34.4–37.4) and 47.0 % PEBMIL (CI 30.2–63.7). Before surgery in RYGB group: mean weight 120.3 kg (CI 117.4–123.1) and mean BMI 45.8 kg/m2 (CI 44.9–46.7). One year after surgery: mean weight 81.7 kg (CI 79.1–84.3), mean BMI 31.3 kg/m2 (CI 30.5–32.2) and a PEBMIL 70.6 % (CI 66.8–74.3). Two years after surgery: mean weight 78.7 kg (CI 75.8–81.6), mean BMI 30.2 kg/m2 (CI 29.2–31.2) and PEBMIL 76.9 % (CI 72.9–81.0). Three years after surgery: mean weight 80.2 kg (CI 77.1–83.4), mean BMI 30.9 kg/m2 (CI 29.7–32.1) and 73.5 % PEBMIL (CI: 68.6–78.4). Comparing the two techniques according PEBMIL, a significant differences at year, two years and three years were found (p \ 0.05). Conclusions: Patients undergoing RYGB have better weight evolution valued according PEBMIL and BMI during the 3 years analyzed, and the maximum peak was recorded two years after surgery. PEBMIL in LSG is smaller although the results remain within quality standards. This is because LSG is performed as a first surgical step in most cases.

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Almaha Alsabah1, Salman Alsabah, MBA, FRCSC, FACS2, Waleed Renno, PhD1, Suleiman Alsabah, PhD1, Ahmed Alserri, PhD1, 1 Kuwait University, 2Ministry of Health Introduction: Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity as the leading bariatric procedure for the treatment of morbid obesity. A serious complication of LSG is neuropathy, unfortunately, little is known in terms of its risk factors. Due to an increase in obesity and rising numbers of bariatric surgeries, neurologic complications have become increasingly recognized. Aim: This study aims to examine the biochemical, hormonal, and genetic factors that are associated with neuropathy in patients post LSG. Materials and Methods: A retrospective study of 1700 morbidly obese patients who underwent LSG at Al-Amiri Hospital, Kuwait (2008–2014). 32 patients where included in the study; 16 patients with neuropathy, 16 patients without neuropathy. Diagnostic tools to determine the underlying causes of neuropathy including radiology reports, nerve conduction velocity (NCV) and physical examination as well as vitamin deficiencies. Moreover, blood samples to examine biomarkers through genetic analysis as well as hormones involved in neuropathy (GLP-1). DNA extraction and genotyping was performed by RT-PCR. Comparison between two groups was done by t test and Mann–Whitney Test. Results: The median age of neuropathic group is 33 (15 female, 1 male) while the control group was 25.5 (11 female, 5 male). Median onset of neuropathic symptoms was at 5 months after sleeve gastrectomy (3–18 months). Median follow up for neuropathic group was 17 months while control group was 29 months. The neuropathic and control group’s median preoperative weight was 128 kg (range 74–202 kg) & 119 kg (range 88–180 kg), respectively with a median BMI of 48.5 kg/h2 (range 39.7–63.3 kg/h2) & 46.6 kg/h2 (range 38.3–57.4 kg/h2) respectively. T test of means for BMI showed no significance (P = 0.1). There was no significant difference (p value 0.6) between two groups in regards to % excess weight loss post LSG at 12 months (61 %, 65 %). B12 levels were different between the groups (p value 0.005), where means of vitamin b12 in neuropathic and control groups 336, 154 pg/mL, respectively. There was no significant difference in GLP1 levels between two groups (p [ 0.05value). Mean of GLP-1 in neuropathic and control groups were 2834 and 2880, respectively. A single nucleotide polymorphism (SNP) (rs6234) in the proprotein convertase (PCSK1) was investigated. Conclusion: Our preliminary data showed neuropathic group lower levels of vitamin B12 post operatively and are older in age than the non-neuropathic group. There were no differences between patients who developed neuropathy after sleeve and those who did not in terms of preoperative BMI, excess weight loss % at 1 year, and GLP-1 levels. However, larger data is required to validate our results.

Surg Endosc

P360

P362

Incidence of Gastrointestinal Stromal Tumors is Drastically Increased in Morbidly Obese Patients

Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy

Jennifer E Baker, BA, Amy Rosenbluth, MD, James Buwen, DO, Michael R Kammerer, MD, Alec C Beekley, MD, David S Tichansky, MD, Thomas Jefferson University Hospital

E Raga, F Sabench, M Vives, A Molina, M Herna´ndez, S Blanco, M Parı´s, A Sa´nchez, A Mun˜oz, Daniel Del Castilo, Hospital Universitari Sant Joan de Reus. Universitat Rovira i Virgili

Introduction: Obesity is a risk factor for a multitude of cancers. The underlying cause of this association is, at least partly, related to the chronic inflammatory state of obesity. GastroIntestinal Stromal Tumors (GISTs) have a reported incidence of 10–20 per million in the general population. While GISTs have not been directly associated with obesity, observed incidence is seemingly greater than the previously reported data. The purpose of this study was to determine the true incidence of GIST in morbidly obese patients. Methods: A retrospective review was performed on prospectively collected data of consecutive laparoscopic bariatric procedures from 8/12 to 6/13. Thorough intra-operative examination of the stomach to identify possible pathology was performed during each case, and the procedure was modified if necessary. All sleeve resection specimens were routinely sent to Pathology for microscopic examination. Results: 209 consecutive patients undergoing primary laparoscopic bariatric procedures at our institution were included in the study. All patients denied symptoms common of GIST (abdominal pain, nausea, vomiting, palpable mass, or blood in the stool/vomit) in the preoperative period and no patients had GISTs definitively identified on preoperative endoscopy. Five pathology-proven GISTs were found in 4 patients (1.9 %). Half of these patients required modification of their procedure to achieve oncologically appropriate resection margin. Conclusions: Bariatric surgery patients have a dramatically greater incidence of GIST than previously reported in the general population (1.9 % vs. 0.001 %). During bariatric surgery, meticulous examination of the stomach should be performed to facilitate resection of asymptomatic GISTs before they become clinically relevant.

Introduction: Laparoscopic Sleeve gastrectomy (LSG) has gained prominence as a single option for their results in terms of weight loss and improvement of comorbidities. The leakage of the staple line is an important cause of morbidity and mortality. Its management depends on the severity and clinical presentation. Our goal is to identify factors that may predispose to the occurrence of postoperative leaks. Also, describe a diagnostic/therapeutic algorithm for its management, reviewing the cases occurred in our University Hospital. Methods: A retrospective observational study of patients undergoing LSG from 2005 to 2012. 207 LSG were performed, using a bougie of 38 Fr. Distance from the pylorus of 5 cm. In all cases, reinforce of the suture line was used. Intraoperative leakage test with Blue methylene and an oral Barium study at 24 postoperative hours were performed in all patients. Results: 8 patients of 207 had a gastric leak (3.8 %). Mean age of 41.9 years and preoperative BMI 48.5 ± 4 kg/m2. 50 % of patients with DM2 and 87.5 % with hypertension. 62.5 % (n = 5) patients who had a gastric leak, had a previous surgical history of appendectomy or cholecystectomy. 37.5 % (n = 3) leaks were detected by barium test, 12.5 % (n = 1) with upper digestive endoscopy and 50 % (n = 4) by CT scan. The presentation time was early (\2nd day of surgery) in 62.5 % of patients (n = 5). The therapeutic management was conservative by drainage in 6 patients. Two patients required reoperation: one had a sepsis and an exploratory laparoscopy was performed with placement of a new drain again. In another patient an endoscopic stent was placed at 11th postoperative day due to a late leak following to haemoperitoneum; No cases of mortality. Conclusions: Gastric leak after LSG is a complication whose management should be based on clinical presentation and the diagnostic suspicion. The presence of comorbidities or previous surgery may be an important factor to take into account for this complication. The systematic placement of drainage allows treating conservatively most patients, reserving surgery when conservative measures have failed or when the patient has an acute abdomen or a sepsis.

P361

P363

Bariatric Tourism: A Nationwide Value Assessment 1

1

Hans F Fuchs, MD , Ryan C Broderick, MD , Cristina R Harnsberger, MD1, David C Chang, PhD2, Bryan J Sandler, MD3, Santiago Horgan, MD1, Garth R Jacobsen, MD1, 1Center for the Future of Surgery, University of California, San Diego, 2 Massachusetts General Hospital, Department of Surgery, Codman Center, Harvard Medical School, 3Center for the Future of Surgery, University of California, San Diego; VA San Diego Healthcare Syst Introduction: Bariatric tourism is a recognized phenomenon, as many patients chose to undergo bariatric surgery abroad. Less expenses drive this rising market, rather than lower complication rates. The aim of this study is to determine the variation of charges, mortality, and length of stay (LOS) in bariatric surgery on a national level. Methods: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Obese patients who underwent open or laparoscopic gastric bypass or sleeve gastrectomy were identified by ICD-9 codes and then subdivided by state. Patients \18 years were excluded. Outcomes included mortality, length of stay (LOS), and total charges. Univariate, bivariate, and multivariate analyses were performed. Results were adjusted for age, race, gender, Charlson comorbidity index, state, patient income level, and insurance status. Results: From 1998–2011, 209,106 patients underwent inpatient bariatric surgery (91 % gastric bypass, 9 % sleeve gastrectomy). Mean hospital charges were $43,399, mean LOS 3.0 days, and mean in-hospital mortality rate 0.22 %. Comparing to California, adjusted total hospital charges were significantly higher only in Nebraska (+$26,273; P \ 0.05). Nearly all other states had lower charges, for example, bariatric surgery in New York was $38,317 less (P \ 0.05). However, in-hospital mortality was higher in nearly all other states compared to California. Significant differences in LOS were found in New York (+0.26d), Florida (+0.32d), and Nevada (-1.54d).

Nutrient Deficiencies After Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy: A Comparative Study Pakkavuth Chanswangphuvana, MD, Narong Boonyagard, MD, Pondech Vichajarn, MD, Ajjana Techagumpuch, MD, Suppa-ut Pungpapong, MD, Krit Kitisin, MD, Chadin Tharavej, MD, Patpong Navicharern, MD, Suthep Udomsawaengsup, MD, MIS Unit, Department of Surgery, Faculty of Medicine, Chulalongkorn University, BKK, THAILAND Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) was the preferred bariatric procedure in terms of weight loss and remission of co-morbidities, however nutrient deficiencies were common. Laparoscopic Sleeve Gastrectomy (LSG) was increasing in popularity with remarkable effectiveness and less nutrient deficiencies. Objective: We determine the amount of pre-operative nutrient deficiencies in morbidly obese patients and compare nutritional status during the first post-operative year between LRYGB and LSG. Methods: One hundred and seventy-seven patients underwent Bariatric procedures between January 2011 and December 2013 were assigned to a standardized follow-up program. Data of interest were pre-operative nutrient status, percent of excess weight loss (%EWL) at 1 year and nutrient deficiencies during the first post-operative year. Deficiencies were supplemented when found and excluded from the analysis. Results: One hundred and fifty morbidly obese patients with completion of blood withdrawal pre-operatively and during the first post-operative year were included in the study (64 LRYGB and 78 LSG). Pre-operative nutrient deficiencies were found in 29 patients including 2 iron deficiency and 28 vitamin D deficiency. Post-operative nutrient deficiencies had no significant difference between both groups (45.1 % in LRYGB vs 39.1 %, p = 0.629) with significantly higher %EWL at 1 year in LRYGB (71.9 % in LRYGB vs 53.1 %, p \ 0.001). Subgroup analysis of iron, folate, vitamin B12 and vitamin D deficiencies showed no significant difference between both groups, however %EWL at 1 year were also significantly higher in LRYGB (p \ 0.001). Conclusion: Nutrient deficiencies in morbidly obese patients are common in Thai Population that should be concerned and supplemented before undergoing bariatric procedures. Nutrient deficiencies after Laparoscopic Roux-en-Y Gastric bypass occur frequently but are comparable with those of Laparoscopic Sleeve Gastrectomy, however significant weight loss at 1-year follow-up is preferable in Laparoscopic Roux-en-Y Gastric Bypass.

Conclusion: Patients undergoing bariatric surgery in the U.S. are subject to highly variable hospital charges, with differences in mortality and LOS across states. There are trade-offs between expenses and outcomes within the U.S., and thus, caution should be exercised when engaging in bariatric tourism for monetary reasons.

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P364

P365

Need for Non-elective Re-Operation After Bariatric Surgery Over Time: A Retrospective Single Site Cohort Study

Successful Weight Loss After Sleeve Gastrectomy: Sex Matters

Erin Thompson, MD, Farida Bounoua, MD, Lisa Ferrigno, MD, MPH, Jonathan Grotts, MS, David Thoman, MD, Marc Zerey, MD, Santa Barbara Cottage Hospital Introduction: Bariatric surgery can be an efficacious intervention for long term weight loss and improvement of associated comorbidities, but patients may require subsequent surgical intervention, sometimes emergently, for some time to come. As more patients undergoing bariatric procedures and time since their index procedure accrue, characterizing such risk will be important. Our goal was to evaluate the rate of non-elective reoperation after bariatric procedures performed at a single site over time and to better characterize that risk. Methods and Procedures: This was a retrospective review at a single community medical center which is a Bariatric Center of Excellence and a participant in the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. All index procedures and subsequent re-operations were identified from January, 2009 through January, 2014. Index procedures were laparoscopic Roux-en-Y gastric bypass (LGBP), sleeve gastrectomy (SG), or adjustable gastric banding (GB). All non-elective abdominal re-operations were then classified as related or not to the index bariatric procedure. To account for variability in follow-up time, data were analyzed using Kaplan-Meier Curves and Cox Proportional Hazard modeling. Results: Of 1306 index bariatric procedures, there were 229 abdominal reoperations; 119 of these were non-elective and 86 of these were related to the index procedure. The average age at baseline bariatric surgery was 43.8 ± 12.6 years old with 245 (19 %) males. The Kaplan Meier curve demonstrating the cumulative first reoperation rate for each bariatric procedure is in Fig. 1; rates by procedure and time are in Table 1. Compared to gastric banding, those who had LGBP had increased risk of non-elective re-operation (HR = 5.1; p \ 0.01); most of this effect was as a result of procedures deemed bariatric related. The most frequent diagnoses and re-operations by index procedure are listed in Table 2. Conclusion: Our rates of re-operation are similar to those previously presented in the literature. Rates of urgent reoperation related to the index procedure are low but sustained over time for those who received a LGBP which may be a consideration for some patients when choosing a suitable bariatric intervention.

Fig. 1

Kaplan Meier curves of cumulative rates of first re-operation by index bariatric procedure

Table 1

Cumulative reoperation rates by time since index bariatric procedure

Time

GB (n = 234)

LGBP (n = 771)

SG (n = 301)

1 yr

1%

7%

4%

2 yr

2%

12 %

4%

3 yr

3%

15 %

4%

4 yr

3%

16 %

4%

5 yr

3%

18 %

NA %

Table 2

Most frequent re-operations and diagnoses by index procedure LGBP (n = 102)

SG (n = 11)

GB (n = 6)

Internal hernia

35

0

0

Cholelithiasis related

17

5

1

Obstruction

15

0

0

Abdominal pain

9

2

0

Perforated ulcer

7

0

0

Anastomotic leak

4

0

0

Bleeding

2

2

0

Abdominal wall hernia

4

0

1

Slipped band

0

0

4

Internal hernia repair

35

0

0

Cholecystectomy

17

6

1

LOA

14

0

0

Ulcer related

9

0

0

Dx lap, neg

7

1

0

JJ revision

5

0

0

Hematoma evacuation

1

2

0

Band removal

0

0

4

Diagnosis

Procedure

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Daliya B AlMohammad Ali1, Sulaiman Almazeedi1, Salman Al-sabah1, Ahmed Al-serri2, 1Amiri Hospital, 2 Kuwait University Introduction: A common dispute within bariatric surgery is inconsistencies in achieving adequate weight loss. Many factors may play a role, and this paper aims to observe some of the predictors of successful excess weight loss postsleeve gastrectomy. Methods: 190 women and 78 men underwent sleeve gastrectomy in Al-Amiri Hospital in Kuwait, with weight measurements taken at 2 weeks, 3 months, 6 months and 12 months after surgery. Two groups were created, those that achieved [50 % excess weight loss (%EWL) compared to those \50 % EWL one year post-op. The variables investigated were age, sex, pre-surgical BMI, and follow-up appointment attendance. Results: The mean age of participants in this study was 33.98 (SD = 12.04 years), and the majority were female (71 %). The mean BMI was 47.32 kg/m2 (SD = 9.8 kg/m2) Age, male gender, pre-surgical BMI, and more frequent follow-up appointment attendance were all significant predictors of achieving [50 % EWL at 12 months (Table 1). Pre-surgical BMI appeared to be the strongest predictor variable with an OR of 0.93 (95 % CI 0.89–0.96), p \ 0.001. Our data showed no statistical differences (P [ 0.05) between mean age of females (34.5 ± 11.8 years) and males (32.5 ± 12.5 years). There was similar follow-up attendance between males and females 63 % and 68 % respectively (p [ 0.05). Conclusion: It is evident that numerous factors contribute to whether or not bariatric patients attain successful weight loss post-operatively. Younger age, male gender, lower pre-surgical BMI and more frequent follow-ups all seem to be important predictors of patients achieving [50 % EWL in 12 months after sleeve gastrectomy.

Table 1

Binary Logistic regression analysis of predictors of %EWL (\50 % vs [50 %) at 12 months (2012–2013)

Variable

OR and 95 % CI

P-value

Age

0.95 (0.92–0.98)

0.001

Sex

4.1 (1.5–11.22)

0.006

Pre-Surgical BMI

0.93 (0.89–0.96)

0.000085

Follow Up

3.02 (1.42–6.4)

0.004

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Laparoscopic Sleeve Gastrectomy: Bougie or No Bougie, Follow the End of the Vessels

Marijuana Consumption Leads to Lower Weight Loss Following Laparoscopic Sleeve Gastrectomy

Rabih Nemr, MD, M Kopp, DO, C Vulpe, MD, George Ferzli, MD, Lutheran Medical Center

Moneer E Almadani, MD, Cristina R Harnsberger, MD, Ryan C Broderick, MD, Hans F Fuchs, MD, Joshua Langert, MD, Christopher Ducoin, MD, Bryan J Sandler, MD, Santiago Horgan, Garth R Jacobsen, Alberto S Gallo, MD, University of California San Diego UCSD

Introduction: Laparoscopic sleeve gastrectomy (LSG) has been extensively performed worldwide; however, standardization of the technique is lacking. The variability of the surgical technique and subsequent sleeve shape usually depends on the bougie used and the starting point of resection in relation to the pylorus. Our study evaluated a new technique that relies on patient-specific anatomic landmarks, following the lesser curvature vessels, to guide the surgeon in shaping the gastric tube. This technique leaves a stomach remnant individualized to each patient based on his or her specific anatomy. Methods and Procedures: The patient is placed in a supine position. No urinary catheter is inserted. Pneumoperitoneum is established using the Veress needle approach. Standard trocar placement is done but may be changed per surgeon preference. The pylorus is identified by its color as well the prepyloric vein. The greater curvature of the stomach is mobilized using the LigaSure device up to the angle of His. The resection starts approximately 2 cm proximal to the pylorus. The surgeon staples the stomach along the end of the lesser curvature vessels up to the angle of His using buttressed staples. Extreme care is taken not to narrow the incisura angularis. As the gastroesophageal junction is approached, a 32-Fr tube is inserted, thus ensuring that the resection is at the edge of the junction fat pad without incorporating it. We analyzed retrospectively collected data of all patients who underwent LSG from June 2010 to December 2012. Patients with incomplete charts and follow-up of less than 180 days were excluded. The procedure was performed by either of two surgeons. Age, sex, height, ethnicity, preoperative weight, last available postoperative weight, OR time, intraoperative and postoperative complications, length of hospital stay and length of follow-up were recorded. BMI and percent excess weight loss were calculated. Microsoft Excel was used for data recording and statistical analysis. Results: Data from 95 patients (79 women, 16 men) were analyzed. Mean age was 39 years (range 19–66 years). Mean preoperative BMI was 46.9 kg (range 37.8–76.8 kg). The average percent excess weight loss at 180 days after surgery was 46 % and at 360 days 47 %. Mean OR time was 79 minutes. There were no reported intraoperative complications. 2 patients had postoperative port site bleeding requiring blood transfusion. 1 patient had intra-abdominal hematoma secondary to splenic bleed. None of the patients required return to the OR. The average length of hospital stay was 2.5 days. Conclusion: Standardization of the sleeve gastrectomy by following the ‘‘end of the vessel’’ technique offers patientrelated landmarks rather than bougie-related sizing. It is safe and produces acceptable and similar weight loss compared to published data. Starting line Gastric tube with forming fold Posterior view GE Junction view

Introduction: Broader acceptance and legalization of both recreational and medical marijuana use is occurring in the United States. Although it is known to stimulate appetite, the influence of marijuana use on body mass index (BMI) is disputed in literature. Data is scarce regarding the effect of marijuana use in patients who undergo bariatric surgery, and thus, our aim was to determine whether its use has an effect on weight loss following laparoscopic sleeve gastrectomy (LSG). Methods: Patients that underwent LSG were identified retrospectively using a prospectively maintained database. All patients were evaluated preoperatively by a multidisciplinary team, which includes a psychological stability evaluation to undergo surgery. Patients were included if they used marijuana preoperatively, either illicit or prescribed, and these patients were compared to those without marijuana use. An exclusion criterion was the usage of other illicit substance. Primary endpoint was percent excess weight loss (%EWL) at 3, 6, and 12 months, and secondary endpoints included intraoperative blood loss, operative time, length of hospitalization, and complications. Results: Between May, 2006 and August, 2014, 250 patients underwent LSG. Of this cohort, 8 patients (3.2 %) were identified that used marijuana preoperatively. Eleven patients were excluded as they abuse other than marijuana. BMI at initial clinic visit was significantly higher in those who used marijuana compared to those who did not, with a mean of 55.93 vs. 46.93 (p = 0.010). %EWL was significantly lower in those who used marijuana compared to those who did not at 6 and 12 months follow-up with means of 31.0 % vs. 47.1 % (p = 0.042), and 33.3 % vs. 54.9 % (p = 0.002), respectively (Fig. 1). All secondary endpoints were similar between the two groups. Conclusion: Our series demonstrates that patients who use marijuana prior to LSG have a significantly lower %EWL.

Fig. 1

%EWL

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Short-Term Results of One Stage Conversion of Failed Adjustable Gastric Band to Gastric Bypass or Vertical Sleeve Gastrectomy

A Retrospective, Case-Matched Comparison of Weight Loss and Follow-Up Among Roux-en-Y Gastric Bypass Patients Under 25 Years of Age Compared to an Older Cohort

Pornthep D Prathanvanich, MD, FRCST, FACS, Bipan Chand, MD, FACS, FASMBS, FASGE, Loyola University Medical Center Background: All bariatric operations have the potential of inadequate weight loss and developing complications. The adjustable gastric band (AGB) has less short-term complications but often requires a revision. Surgical revisions include rebanding or more often a conversion to another bariatric operation. However, re-intervention has a three- to fivefold higher morbidity rate when compared to primary bariatric surgery. The aim of this study is to determine the feasibility and outcomes of a one-stage conversion of failed AGB to either gastric bypass or vertical sleeve gastrectomy. Method: This is a retrospective study of 15 patients who underwent conversion to LRYGB {N = 12} and LSG {N = 3} as a one stage procedure after failed AGB. Failures can be grouped into either weight recidivism (N = 10) and a device-related complication (N = 5; one port site infection and four gastric band slips). Weight recidivism can be classified into weight regain (gain of 20 % of maximum weight lost){N = 5} or inadequate weight loss (defined as %EWL \50 %) {N = 5}. All patients underwent preoperative preparation with counseling into etiology of failure, upper endoscopy and contrast imaging. Four patients had a type 3b slip without band erosion. All other patients had a normal upper endoscopy and contrast study. All patients had fluid removal from the system to allow for symptom improvement in patients with a band slip and regurgitation or dyspepsia in overtly tight systems. This maneuver also allowed the proximal gastric pouch to normalize in size and potentially offering better tissue characteristics. Preoperative weight loss was mandated and patients lost a mean of 6.3 ± 0.98 kg before surgery. Result: Between April 2013 to July 2014, 15 consecutive patients (Female = 13, mean body mass index: BMI = 48.89 ± 6.14 kg/m2) had a conversion from failed AGB to another bariatric operation. The technical difficulty often centered on gastric pouch creation during gastric bypass or gastric resection during sleeve gastrectomy. Each operation was planned as a one stage and all completed in this manner. This decision to proceed as a one stage was also determined intra-operatively. Factors affecting completion included gastric viability and adequate exposure. The gastric fundus required resection in 5/12 of LRYGB patients. The mean operative time was 151 minutes with no intraoperative complications. Two post-op complications occurred early and included one port site hernia and one Peterson’s hernia. Mean follow up time was 7.73 months with an excess weight loss of 35.50 ± 14.40 %. Conclusion: The conversion from AGB to LRYGB or LSG, as a one-stage procedure, is technically feasible and can safely be performed in select patients. Extensive preoperative planning and good intraoperative surgical judgment can minimize complications related to gastric pouch creation during gastric bypass and sleeve formation. Strategies must be employed to allow for adequate gastric tissue compliance and vascularity. Fundic resection may be required in select cases.

Ann M Rogers, MD1, Patrick Vincent2, Eugene Won, MD3, Tung Tran, MD4, Gail Ortenzi, RN1, 1Penn State Hershey Medical Center, 2 Penn State College of Medicine, 3University of California, Irvine, Dept of Surgery, 4Washington Hospital Center, Dept. of Surgery Background: The frontal cortex is among the last areas of the brain to fully develop. It houses higher functions such as impulse control, planning and working memory, the bases for mature judgment. Risk-taking behavior, need for novelty, and need for peer affirmation are well described in adolescents. Neuroimaging studies demonstrate that the adolescent brain continues to mature into the mid-20s. Bariatric surgery is offered to adolescents of adult size and adult bone age, who are shown to be able to make informed decisions. The impetus to study our patient population under age 25 derived from the above-cited neuroscience literature on brain maturity, to help design a program taking into account the differences found in younger patients in order to best serve their needs. Methods: After obtaining approval from the Institutional Review Board of the Pennsylvania State University College of Medicine, we performed a retrospective chart review of all patients undergoing laparoscopic Roux-en-Y gastric bypass at the Hershey Medical Center between the years of 2007–2011. 766 patients were included in the analysis. Every patient under 25 years of age was matched with a patient[25 year old who most closely approximated the same preoperative gender, body mass index, and comorbidities. We evaluated percent excess weight loss (%EWL) and percent body mass index loss (%BMIL) between the groups at one, two and three years after surgery. We also collected data on attendance at scheduled follow-up visits. Results: The mean age of the total cohort of patients in our study was 44 and the mean preoperative BMI was 46.9. There were relatively few patients in the under-25 age group (n = 19). In this group, the mean age was 21.85 (range 18.2–24.9) and the mean BMI was 47.81 (range 41–63), with 18 females (94.7 %) and one male (5.3 %). In our matched cohort of patients 25 or older, the mean age was 48.32 (range 34.7–65.34) and BMI 47.83 (range 41–63.8). There was a statistically significant difference in age between the groups, but not between preoperative BMIs. While follow-up was poor for both groups at all points in time, there was a statistically significant difference in follow-up at the one-year point after surgery, with about 37 % of the younger patients coming for their one-year visit compared to about 74 % of the older patients. Follow-up at the two- and three-year points was lower for the younger patients, but there was not a statistical difference. Of those who followed up, there was no statistically significant difference in %EWL or %BMIL between the two groups at any point. Conclusions: Based on this preliminary, limited data, there is unlikely to be a significant difference in weight loss from gastric bypass between older and younger patients. However, younger patients’ compliance with follow-up, for a variety of reasons, will be less good. New modalities, such as email and texting services, may facilitate appropriate evaluations.

Demographic and outcome data First visit BMI (kg/m2 ± SD)

48.89 ± 6.14

Presurgical BMI (kg/m2 ± SD)

47.10 ± 5.82

Last FU BMI (kg/m2 ± SD)

39.47 ± 5.89

Excess weight loss (% ± SD)

35.50 ± 14.40

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A Comparison of Short-Term Morbidity in Laparoscopic Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass

Bariatric Surgery in the Elderly is Associated with Similar Surgical Morbidity and Significant Long Term Health Benefits

Pei-Wen Lim MD, Jonathan E Miller, Richard Perugini MD, John J Kelly MD, Donald Czerniach MD, Philip Cohen MD, UMass Memorial Medical Center

Uri Kaplan1, Scott Penner2, Forough Farrokhyar1, Scott Gmora1, Dennis Hong1, Mehran Anvari1, 1Mcmaster University, 2Dalhousie University

Background: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity and is presently the most commonly performed bariatric procedure in the United States. One explanation for this shift is the view of LSG as a generally safer alternative to Roux-en-Y Gastric Bypass (RYGB) with regards to short-term complications (hemorrhage, staple line leak) and long-term complications (anastomotic ulcer, intestinal obstruction, micronutrient deficiency). We sought to conduct a systematic review comparing our initial series of LSG to a concurrent series of RYGB to evaluate short-term morbidity between these two procedures. Methods: A registry was conducted of patients (n = 345) who underwent LSG at UMass Memorial Health Care between July 2010 and June 2014. Data included demographics and comorbidities, metabolic status, length of stay, operative technique, rates of complication and readmission, and excess bodyweight loss at postoperative follow-up. Rates of complication and readmission for our concurrent RYGB series (n = 1210) were extracted from the MBSAQIP 30-day occurrence rate report. Univariate analysis was utilized to compare rate of transfusion, readmission, leak, DVT/PE, and mortality. Results: Barring rate of leak, no other statistically significant differences in rate of postoperative complication were identified between procedures. Leak occurred more frequently in our LSG series (1.2 % vs. 0.1 %, p = 0.01). Rate of transfusion (2.9 % in LSG and 2.1 % in RYGB, p = 0.41), rate of readmission (5.8 % in LSG and 6.7 % in RYGB, p = 0.62), rate of DVT/PE (0.9 % in LSG and 0.3 % in RYGB, p = 0.19), and mortality (0.3 % in LSG and 0 % in RYGB, p = 0.22) did not vary significantly between LSG and RYGB. Conclusion: The hypothesis that LSG has a lower rate of short-term complications than RYGB is not supported by our inception series. The higher rate of leak associated with LSG, a significant complication of this procedure, highlights the importance of investigating strategies that may diminish this risk in the future.

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Background: Older age ([60) has been a relative contraindication for bariatric surgery due to an increased risk of complications. Recent data shows that this may not be the case, and in fact reveals some encouraging results. Methods: The Ontario Bariatric Registry is a prospective data registry recording the peri-operative and postoperative outcomes of all patients undergoing bariatric surgery in 5 Centers of Excellence and 4 Assessment centers across the province. We compared operative and postoperative outcomes of bariatric surgery in patients over the age of 60 with outcomes of younger patients who had undergone Laparoscopic Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) between January 2010 and May 2013. Results: 3166 patients underwent LRYGB or LSG between January 2010 and May 2013 and completed their one year follow-up. 204 (6.5 %) of these patients were greater than 60 years of age. Of these, 175 (85.8 %) underwent LRYGB and 29 (14.2 %) had LSG. Demographics of patients over 60 were the same as those in the younger cohort, except for a higher number of males in the older population (59 (28.9 %) vs. 452 (15.3 %) (p \ 0.001)). No significant difference was noted in the rate of peri-operative and post-operative complications (15 % in the younger cohort versus 13.8 % in patients [60 years of age (p = 0.889)). The average percentage of excess weight loss was significantly higher in the younger population (60.72 % vs. 56.25 % (p \ 0.05)). This difference was not significant in the population that underwent LSG. The total reduction in the amount of medication use for management of comorbidities such as diabetes mellitus, hypertension and hypercholesterimia after bariatric surgery was significantly higher in the older patients (-0.91 vs -2.03 (p \ 0.001)). A sub-analysis of age groups above the age of 60 did not showed any difference in results (ages 61–65 and above 65). Conclusion: In patients above the age of 60, Laparoscopic bariatric surgery is a safe and effective. LSG has the same effect on weight loss as LRYGB in the older patients. There is a trend towards improvement of cardiovascular disease and diabetes mellitus after LRYGB in the older population as inflicted from the reduction in the amount of medication. Preliminary results show that the risk and benefit of bariatric procedures for patients between the ages of 61–65 is the same as of patients between the ages of 65–69.

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The Effect of RS9939609 FTO Gene Polymorphism on Weight Loss After Laparoscopic Sleeve Gastrectomy

Laparoscopic Three-Port Sleeve Gastrectomy: A Single Institution Case Series

˜ §ekir§2, Ozgur Erkal3, Arif Aslaner2, Bulent Ozgur Balasar1, Tugrul A 4 5 ˜ A§ekir§ , Mehmet Uyar , Nurullah Bulbuller, Ass, Prof, Dr2, Mehmet Tahir Oruc¸, Ass, Prof, Dr2, 1Department of Medical Genetics, Dr Faruk Su¨kan Maternity and Pediatric Hospital, Konya, TURKEY, 2 General Surgery Department, Antalya Training and Research Hospital, Muratpas¸ a, Antalya, TURKEY, 3Medical Genetics, Antalya Training and Research Hospital, Muratpas¸ a, Antalya, TURKEY, 4 Radiology, Antalya Training and Research Hospital, Muratpas¸ a, Antalya, TURKEY., 5Public Health, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, TURKEY

Ricard Corcelles, MD, PhD, Dvir Froylich, MD, Mena Boules, MD, Christopher R Daigle, MD, Philip R Schauer, MD, Thomas Rogulaz, MD, PhD, Cleveland Clinic

Purpose: Remarkable differences in weight loss have been observed in obese patients undergoing laparoscopic sleeve gastrectomy (LSG). These high variations might be partly explained by genetic factors. The rs9939609 fat mass and obesity-associated gene (FTO) polymorphism has been implicated in the susceptibility of obesity. We aimed to explore the effects of the rs9939609 FTO gene polymorphism on weight loss among severely obese patients applying for laparoscopic sleeve gastrectomy (LSG). Material and Methods: All individuals were analyzed for the FTO rs9939609 gene polymorphism. A total of 74 morbid obese patients (20 male, 54 female) were operated. Body weight and body mass index (BMI) were measured at before LSG and after surgery at the 6th month. Results: Twenty-eight patients (37.8 %) had genotype TT (wild type allel), 36 patients (48.6 %) had genotype TA and 10 patients (13.5 %) had genotype AA. In both wild type group and mutant group, BMI and weight levels decreased at the 6th month after surgery. Initial excess weight percent loss (IEWL) at 6 months of follow up was similar in both groups. Conclusion: Our data showed that the rs9939609 FTO gene polymorphism is not a useful genetic test prior to LSG to help clinicians predicting the weight loss for severely obese patients in short-term follow up. Keywords: rs9939609 gene; polymorphism; FTO; laparoscopic sleeve gastrectomy; weight loss

Background: Further minimization of abdominal wall trauma during laparoscopic bariatric surgery is a topic of great interest. Reducing the number of trocars may provide superior cosmetic results with less pain and shorter length of stay (LOS). However, it remains unclear if this approach compromises safety or effectiveness of weight loss. The aim of this study is to report initial safety and feasibility results using a 3-port minimally invasive sleeve gastrectomy technique. Methods: A retrospective review of patients who underwent laparoscopic 3-port sleeve gastrectomy (3PSG) at our institution was conducted. Patient demographics, intraoperative parameters and perioperative outcomes were extracted and analyzed. Postoperative data was obtained from routine follow-up history and physical examination. Results: From May 2013 to April 2014, forty-five morbidly obese patients underwent 3PSG. The cohort had a male-tofemale ratio of 20:25, mean age of 47.4 ± 11.6 years, and a mean preoperative Body Mass Index (BMI) of 47.6 ± 9.7 kg/m2. The mean number of comorbidities was 4 (range 0–8) and the mean ASA score was 2.82 (range 1–4). Mean procedural duration and blood loss were 165 ± 31.9 minutes and 27.0 ± 31.8 cc, respectively. Eight patients (17 %) required 1 additional trocar. Two cases (4.4 %) had an Intraoperative complication (staple line bleeding and splenic capsule laceration). Two (4.4 %) postoperative complications were encountered (wound infection and axillary vein thrombosis). The mean LOS was 2.7 (range 2–7) days. At a mean follow-up of 5 month (range 0.4–11.7), the cohort had a mean BMI of 40.0 ± 9.26 kg/m2, which corresponded to a mean excess weight loss of 36.0 ± 18.1 %. There were no trocar site hernias. All patients were highly satisfied with the final cosmetic result. Conclusion: Laparoscopic 3-port sleeve gastrectomy appears to be a safe and feasible technique for performing sleeve gastrectomy. While further long-term research is needed, it appears to have significant benefits, mainly patient satisfaction and potentially less pain.

P373 Do T2DM Super–Super Obese Patients Benefit from Bariatric Surgery? Raquel Gonzalez-Heredia MD. PhD, Valeria Valbuena, BS, Mario Masrur, MD, Kristin Patton, MD, Crystal Hernandez, BS, Melissa Murphey, DNP, NP-C, Lisa Sanchez-Johnsen PhD, Enrique F Elli, MD, FACS, UCI Introduction: Among the population of obese adults (BMI [30 kg/m2), the super–super obese (BMI [ 60 kg/m2) present particular challenges for the bariatric surgeon. Surgical management of these patients has been associated with higher morbidity and mortality. A major morbidity in relation to super super-obesity, type 2 diabetes mellitus (T2DM), increases the probability of unsustainable weight loss goals and surgical risk. The aim for this study is to evaluate the effects of bariatric surgery on the major morbidity rate of T2DM in super-super obese patients and not super–super obese patients. Materials and Methods: This study is a nonrandomized, controlled, retrospective review of 750 patients who underwent bariatric surgery at the University of Illinois Health and Science System from January 2008 to June 2014. Patients were divided in two groups regarding BMI. Super–super obese patients (BMI[60 kg/m2) in Group 1 and notsuper-super obese patients (BMI \60 kg/m2) in Group 2. Patient demographics, comorbidities, postoperative morbidity and mortality, operating time, length of stay, and % excess weight loss (%EWL) were reviewed. The association with T2DM was uniquely studied in both groups prior to and after surgery. The improvement in T2DM was noted if the patient had a decrease in daily medications at 24 months after surgery. Statistical analysis was performed comparing aforementioned data related to T2DM and %EWL at 24 months follow up between the two groups using T-test student and Chi-square test as needed. Results: The super-super obese group comprised a total of 89 patients (%12) with a mean age, at the time of surgery, of 38.9 years (standard deviation [SD] ± 10.2). The not super-super obese group included 661 patients (88 %) with a mean age of 42.3 years (SD ± 10.3) and statistical differences between the two groups (p = 0.003). The prevalence of T2DM in the super-super obese group was 33.7 % (SD ± 0.5) prior to surgery with no statistical differences comparing to the not super-super obese group with a prevalence of 64.7 % (p = 0.478). There were no statistical differences in postoperative complications or length of stay between the groups. At 24 months follow up, the decrease in T2DM medications was compared between the super-super obese patients and the not-super-super obese patients. The mean decrease in T2DM medications for the super-super obese patients was 17.9 % and that was statistically different (p = 0.018) from the mean decrease in T2DM medications for the not-super-super obese patients (7.7 %). The mean excess weight loss values (%EWL) at 24 months was 51.8 % (SD ± 19.9 kg/m2) in the super-super obese patients with no statistical differences (p = 0.123) comparing with the not-super-super obese patients (EWL = 60 % SD ± 26.9 kg/m2). Conclusions: Overall bariatric surgery is a safe and effective procedure for the management of super-super obese patients. Results showed a better improvement of T2DM in the super-super obese patients in comparison to the not super–super patients.

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The Surgical Apgar Score is Not Associated with Post-Operative Outcomes in Patients Undergoing Bariatric Surgery

Laparoscopic Sleeve Gastrectomy at a Small Canadian Center: 30-Day Complication Rates

Lin M Riccio, MD, Beth E Turrentine, PhD, RN, Amir K Abdel Malek, Bruce D Schirmer, MD, Peter T Hallowell, MD, University of Virginia

Vanessa Falk, David Pace, Laurie Twells, Chris Smith, Darryl Boone, Raleen Murphy, Kendra Lester, Debbie Gregory, Memorial University of Newfoundland

Introduction: The Surgical Apgar Score was developed and validated across a wide breadth of surgical subspecialties. It is a simple, useful tool to identify patients at high risk of developing post-operative complications by using readily available intraoperative data. Similar to the Apgar score used in obstetrics, the Surgical Apgar Score is a point scoring system, and lower scores are associated with worse outcomes. To date, there has been no study that has examined the utility of the Surgical Apgar score in patients undergoing bariatric surgery. We hypothesize that lower Surgical Apgar Scores are associated with higher rates of post-operative complications in patients undergoing bariatric surgery. Methods: We performed an analysis of the National Surgical Quality Improvement Program data for 800 consecutive patients undergoing bariatric surgery at a single academic medical center from 2009 to 2013. Patients were divided into two cohorts, those who were identified in NSQIP as having a post-operative complication, and those without complications. Using intraoperative measurements available on the anesthesia database, Surgical Apgar Scores were calculated for each patient. Surgical Apgar scores were then compared between cohorts. Statistical analysis included Student’s t-test for comparing means and Fishers exact test for categorical variables. Results: Of the 800 patients identified in NSQIP, 121 (15.1 %) patients developed post-operative complications. There were two deaths (0.25 %). Patient characteristics, types of bariatric operations, and outcomes are summarized in Table 1. Surgical Apgar Scores were similar between the two group (7.06 in patients with complications versus 7.27 in those without, p = 0.12). Conclusion: Surgical Apgar Scores are not lower in patients with complications after bariatric surgery.

Introduction: Newfoundland is a small province with the highest rate of obesity and associated comorbidities among Canadian provinces. The provincial bariatric surgery program has performed laparoscopic sleeve gastrectomy (LSG) since 2011. This retrospective study aims to examine our center’s 30-day postoperative complication rates. Methods: Between May 2011 and December 2013, 188 patients underwent LSG. Three bariatric surgeons carried out all procedures. A chart review was conducted to examine patient demographics and 30-day post-operative complications. Statistical analysis was performed in SPSS (Version 21). Results: All procedures were successfully completed laparoscopically. No mortalities occurred. The mean age of this population was 43.4 years (range 22–70 years) with 81.9 % of patients being female. The mean preoperative BMI was 49.3 kg/m2 (range 35.4 k–67.4 kg/m2). Obesity- related comorbidities included hypertension (54.3 %), obstructive sleep apnea (46.3 %), diabetes (37.8 %), gastroesophageal reflux (36.2 %), documented cardiovascular disease (4.8 %), osteoarthritis (36.7 %), and dyslipidemia (36.7 %). Furthermore, 36.7 % of patients reported a psychiatric diagnosis such as depression and anxiety. The mean length of stay was 2.18 days (range 1–16 days). The overall 30-day complication rate was 14.9 %. Major complications included four patients with bleeding requiring blood transfusions (2.1 %), one stricture (0.5 %) successfully treated with a single bougie dilation, two patients with a pulmonary embolus (1.1 %) and three patients with staple line leaks (1.6 %), one of which required early re-operation and one treated with endoscopic stenting. Minor complications included urinary retention (one patient), dehydration necessitating intravenous fluids (four patients), two patients developed a rash treated with medications (1.1 %), and 11 patients (5.9 %) had a post-operative course complicated by infection, including superficial wound infection, otitis media, and UTI. Frequency of gastrointestinal reflux increased from 36.2 % to 44.7 % (p-value = 0.051) post LSG. Conclusion: The overall complication rate in this study is similar to published data from larger academic centers (0 to 29 %). The current leak rate of 1.6 % is well within the up to 5 % quoted in the literature. This study supports the performance of bariatric surgery within small centers.

Table 1

Patient characteristics, procedures, outcomes Patients with complications (n = 121)

Patients without complications (n = 679)

p Value

\0.001

Patient characteristics Age, mean (SD)

49.87 (8.98)

43.09 (10.08)

Female, n (%)

88 (72.73)

541 (79.68)

0.09

African American, n (%)

28 (23.14)

117 (17.23)

0.13

Body mass index, mean (SD)

50.31 (9.96)

48.45 (9.61)

0.05

Diabetes, n (%)

58 (47.93)

236 (34.76)

0.01

Hypertension, n (%)

96 (79.34)

419 (61.71)

\0.001

Pulmonary disease, n (%)

55 (45.45)

257 (7.60)

\0.001

Creatinine C1.3, n (%)

13 (10.74)

0 (0)

\0.001

Type of operation 0.76

Laparoscopic gastric bypass, n (%)

72 (59.50)

391 (57.58)

Open gastric bypass, n (%)

25 (20.66)

34 (5.01)

\0.001

Laparoscopic gastric band n (%)

6 (4.96)

155 (22.83)

\0.001

Laparoscopic gastric sleeve, n (%)

18 (14.88)

99 (14.58)

0.88

Outcomes 30 Day Mortality, n (% of total cohort)

2 (0.25 %)

0

Surgical Apgar Score

7.06

7.27

0.12

P376 Internal Hernia After GBP, Systematic Closure of Peterson and Jejunojejunostomy During the Primary Surgery is the Ultimate Treatment and Prevention of Internal Hernia Wissam Fakih, MD, Al Seef Hospital Introduction: Internal hernia is one of the serious complications after gastric by pass, it causes recurrent attacks of abdominal pain and if left untreated it can lead to small bowel necrosis snd gangrene. CTScan is the gold standard test for the diagnosis, although a normal study does not exclude the diagnosis. Systematic closure of potential spaces may eliminate completely the occurrence of internal hernia. Objectives: Morbidity and mortality of internal hernia after gastric by pass can reach 60 % if left untreated and if small bowel strangulation occurs. Early diagnosis and appropriate management can eliminate this chance and cure the patient. Primary closure during the initial surgery is the routine in our practice. Methods: Retrospective study was based on 2187 cases of gastric by pass between August 2009 and August 2013. Results: 468 cases were done without closure and the remaining with primary closure. Internal hernia occurred in about 12.6 % in the first group (58 cases) and 0 % in the second group. 72 % had CTScan chowing the internal hernia, with or without free fluid in the abdomen. None of the cases presented with bowel perforation or gangrene. 36 cases with peterson space hernia. 12 cases with jejuno-jejunostomy hernia. 3 cases where the small bowel herniated through both spaces. 5 cases presented in 3rd trimester and had internal hernia diagnosed with MRI. Almost all patients were symptomatic. Almost all of them had lymphatic obstruction at the mesentery site with or without chyloperitoneum. Results: Internal hernia is a fatal complication after gastric by pass if left untreated. The cornerstone of treatment is based on high index of suspicion with or without radiologic confirmation. In case of doubt, diagnostic laparoscopy in mandatory done on urgent or elective bases depending on the severity of symptoms upon presentation. Prevention of this complication is routine closure of potential spaces during the primary surgery.

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P378 Robotic Vertical Sleeve Gastrectomy: Outcomes and CostAnalysis of 411 Cases Brett L Ecker, MD1, Richard Maduka, BS2, Andre Ramdon, MD1, Daniel T Dempsey, MD1, Kristoffel R Dumon1, Noel N Williams1, 1 University of Pennsylvania, 2Perelman School of Medicine at University of Pennsylvania Introduction: Robotic technology is increasingly prevalent in bariatric surgery yet there are few published cohort analyses of the robotic sleeve gastrectomy to date. We sought to evaluate the experience of a single high-volume bariatric practice in a teaching hospital in order to accurately characterize the procedure’s outcomes, potential benefits, and its feasibility as a teaching model for surgical residents. Methods and Procedures: Following IRB approval, all patients who underwent robotic sleeve gastrectomy at our institution between September 1, 2011 and April 30, 2014 were identified from a prospectively maintained administrative database. Hospital records were evaluated for patient demographics, operative time, robot usage time, estimated blood loss, operative complications, postoperative morbidity and mortality, and direct and supply costs of the procedure. Analysis of data was performed using SPSS 22.0 statistical analysis software (SPSS Inc., Chicago, IL, USA). Results: A total of 411 patients successfully underwent robotic sleeve gastrectomy. Mean operative time was 75.1 ± 23.9 minutes (range 32.0–175.5 min) with an associated mean robot usage time of 63.9 minutes (range 30.0–122.0 min). Mean estimated blood loss was 47.8 mL and no patients (0 %) required an intra-operative blood transfusion. 90-day morbidities included reoperation (0.72 %), bleeding complications (0.48 %), leak (0.24 %), stricture (0.97 %), need for blood transfusion (3.86 %), surgical site infection (1.69 %), DVT (0.48 %), and PE (0.48 %). Mortality was 0.00 %. Introduction of the new technologic platform required approximately twenty cases prior to institutional proficiency. Resident proficiency in the robotic platform as measured by mean operative time of the resident cohort was achieved after five cases. Subset analysis for fiscal year 2014 demonstrated an increase in supply cost with the robotic interface (p = 0.01) but no difference in mean direct cost for laparoscopic sleeve gastrectomy versus robotic sleeve gastrectomy. Conclusions: Robotic sleeve gastrectomy is a safe procedure with minimal morbidity that can be instituted without increased direct cost as compared to its laparoscopic equivalent. The robotic platform is a valuable component of resident education.

Surg Endosc

P379

P381

Specimen Retrieval Bag in Laparoscopic Sleeve Gastrectomy Does Not Reduce Wound Complications

Successful Management of Staples Line Leaks After Sleeve Gastrectomy

Jingjing L Sherman, MD, Dani O Gonzalez, MD, James Yoon, BA, Edward Chin, MD, Subhash Kini, MD, Daniel Herron, MD, William Inabnet, MD, Scott Q Ng, MD, Mount Sinai

Matthew Benenati1, Michael De France2, Rahul Sharma2, Lou Balsama, DO3, 1Anne Arundel Medical Center, 2Rowan University, 3 Kennedy University Hospital

Introduction: Obesity has been demonstrated to be a risk factor for surgical site infections in certain procedures. Laparoscopic sleeve gastrectomy is a clean contaminated procedure with wound infection rate of about 1 %. Wound infections after bariatric surgery are no longer reimbursed by the Center for Medicare and Medicaid Services. The use of a specimen retrieval bag in a laparoscopic sleeve gastrectomy may help prevent wound infections. We performed a retrospective study to determine whether these devices help to decrease wound complications after laparoscopic sleeve gastrectomy. Methods: A bariatric database from Mount Sinai Hospital between January 2008 and December 2012 was retrospectively analyzed to identify patients who underwent laparoscopic sleeve gastrectomy. Patients were divided into Group 1, where a specimen retrieval bag was utilized, and Group 2, where the specimen was directly retrieved through the largest incision. Demographics, preoperative comorbidities, intraoperative variables and post-operative outcomes were compared between the two groups using Chi -square and student t-tests. Results: A total of 239 patients underwent primary laparoscopic sleeve gastrectomy, with 37 patients in Group 1 and 202 in Group 2. There were no differences in sex, age, BMI, ASA and comorbidities between groups. All patients received preoperative prophylactic antibiotics. There was no difference in wound infection between Group 1 and Group 2, 0 % and 0.5 %, respectively (p = 1). There was no difference in trochar site hernia between the Group 1 and Group 2, 0 % and 1 %, respectively (p = 1). Operative time and length of stay were not different between the two groups. Other complications including bleeding, death and readmission were similar between the two groups. Conclusions: Specimen retrieval bags do not appear to prevent wound infections in laparoscopic sleeve gastrectomy patients. Randomized studies are necessary in order to determine their value for this use.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a standalone procedure which is gaining broad acceptance in the field of bariatric surgery, where it has been shown to be effective in weight loss and the reduction of obesity related comorbid conditions. A staple line leak (SLL) post-LSG is one of the most serious complications associated with the procedure. The aim of this study was to examine post-LSG rates and characteristics using a retrospective cohort analysis at a single community-based Bariatric Center of Excellence. Methods: Three hundred eighty two patients who underwent bariatric surgery between January 2007 and June 2014 and experienced any sort of post-surgical complication were identified. Of these, 12 cases were identified as having developed SSLs. Data collected from hospital records and outpatient records for both surgical and gastroenterology offices included patient demographics, operative, and post-operative characteristics. The day of diagnosis of SSL was determined by the first study or procedure that identified the leak. Resolution was determined by the removal of a stent or catheter or resolution of clinical signs and symptoms (Tables 1, 2, 3). Results: The patients experiencing SLL post-LSG had a mean age of 46.25 (range 19–66) and mean BMI of 46.3. Post-operative timing of leaks had a mean of 21 days and a median of 15 days (range 1–57). CT scans had a 100 % sensitivity in showing evidence of an SLL while upper GI series showed a sensitivity of 50 %. Mean time from diagnosis to treatment of SLL was 1.8 days. Patients required 42.4 days between diagnosis and resolution of the complication (range 5–90). Patients with a follow-up interval of 12 months ± 1 month (n = 7) showed an average weight loss of 72 % .

Conclusions: SLL is a feared complication post-LSG. While a great deal of attention has been paid to complication rates, less data is available on the timeframes for diagnosis and treatment as well as the long term consequences on weight loss. Based on this study, patients may be counseled that in the event of a SLL, the average lengthening of treatment is 42 days, and that they can expect to still attain their goal weight loss.

Table 1

Demographics

P380 Distance From Bariatric Centres of Excellence is not Associated with Higher Postoperative Complication and Readmission Rates Aristithes G Doumouras, MD, Fady Saleh, MD, MPH, Scott Gmora, MD, Mehran Anvari, MD, Dennis Hong, MD, MSc, McMaster University Background: The Ontario Bariatric Network services a population of 12.8 million in an area equivalent in size to California, Oregon, Washington and Nevada combined through just 4 bariatric surgery Centers of Excellence (COE). This study investigates whether the COE model impacts complication and readmission rates for patients traveling great distances for bariatric surgery. Methods: This study identified all patients aged [18 who received bariatric surgery from April 2009 until March 2012. The exposure of interest was distance from patients’ primary residence, approximated using Forward Sortation Areas - which utilizes the first three characters of a patient’s postal code, to the bariatric COE. Outcomes of interest were overall complication rate during a patient’s initial admission or readmission within 30 days of the index procedure and readmission rate within 30 days of the index procedure. Univariable and multivariable logistic regression were used to examine the impact of distance on patient outcomes. Because health resource allocation in Ontario is determined based on geographic Local Health Integration Networks (LHINs), whether a patient resided within a LHIN with a COE (versus not) was also examined with respect to complication and readmission rate. Results: 5,007 patients were identified for inclusion in this study. 416 (8.3 %) patients underwent a sleeve gastrectomy while 4,591 (91.7 %) had a gastric bypass. Overall 98.1 % had a laparoscopic procedure. The mean distance from patient residence to the COE where bariatric surgery occurred was 117.2 km (SD 168.5) and the majority of patients did not reside within a LHIN with a COE, 3,192 (63.8 %). Patients living 100 km or more from COE had a lower complication and readmission rate, 10.4 % and 5.0 % respectively, compared to 12.3 % and 6.6 % for those who lived closer; P value 0.055 and 0.025 respectively. Patients living within a LHIN without a COE also had a lower complication (10.7 % versus 13.4 %) and readmission (5.9 % versus 6.5 %) rate compared to those who did, P Value 0.003 and 0.429 respectively. After multivariable adjustment for procedure type and important patient characteristics, the odds of a complication for each 10 km increase in distance from a COE was Odds Ratio 1.00 [95 % Confidence Interval (CI): 0.99, 1.01; P = 0.986] while the OR of complication for those outside a LHIN with a COE compared to those within was 0.77 (95 % CI: 0.63, 0.93; P Value 0.003). With regards to readmission, the OR for every 10 km increase in distance from a COE was 0.99 (95 % CI: 0.98, 1.00; P = 0.082) while for those living outside a LHIN with a COE compared to those within was 1.00 (95 % CI: 0.77, 1.30; P = 0.982). Conclusion: It appears that the COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients living further away receive appropriate short-term care.

Patient

Age

Gender

BMI

1

19

F

49.3

2

30

F

45.7

3

35

F

42.4

4

44

M

57.4

5

47

F

43.3

6

48

F

51.5

7

51

F

42.2

8

51

M

47.5

9

53

F

41.9

10

54

F

45.1

11

57

F

44.4

12

66

F

44.9

BMI body mass index

Table 2

POD to diagnosis, treatment and resolution

Patient

POD of diagnosis

Days from diagnosis to treatment

Days from treatment to resolution

Resolution criteria

1

1

0

5

2

9

1

48

Stent removal

3

27

0

63

Stent removal

4

12

0

68

EGD

5

17

0

56

Drain removal

6

23

1

14

Drain removal

7

35

1

20

Stent removal

8

10

3

65

Symptoms

9

57

1

90

Stent removal

10

12

4

32

Drain removal

11

38

1

19

Symptoms

12

12

10

29

Stent removal/UGI

Symptoms

POD postoperative day

Table 3

Excess weight loss

Patient

Weight check interval (years)

Excess weight loss (%)

1.

0.99

74.76

2.

0.92

84.59

3.

0.25

21.73

4.

0.99

61.01

5.

1.01

74.96

6.

0.95

52.81

7.

1.67

55.66

8.

0.30

44.86

9.

0.96

85.04

10.

0.99

70.73

11.

1.51

45.50

12.

0.22

22.66

123

Surg Endosc

P382

P384

Incidental Gastric Glomus Tumor After Laparoscopic Sleeve Gastrectomy

Outcomes of Cholecystectomy in Gastric Bypass and Normal Anatomy Patients with Biliary Symptoms But Normal Diagnostic Studies. An Institutional Experience of Biliary Normoand Hyperkinesia

Mehmet Tahir Oruc¸, Ass, Prof, Dr, Tugrul Cakir, Erdem Can Yardimci, Arif Aslaner, Alkan Sakar, Antalya Training and Research Hospital Introduction: Gastric glomus tumors are unusual benign subepithelial mesenchymal neoplasm of modified smooth muscle cells representing a neoplastic counterpart of glomus bodies and they could not be diagnosed preoperatively. Case Report: A 38 years old woman was admitted to our clinic complaining for morbid obesity. Routine preoperative evaluation such as laboratory analysis, abdominal ultrasonography and upper gastrointestinal endoscopy were made. She underwent classical Laparoscopic Sleeve Gastrectomy. Postoperative course was uneventful and she discharged for outpatient control. Histopathology report revealed as gastric glomus tumor with 0.8 cm in diameters. No further treatment was done and she lost 28 kg at the postoperative sixth month. Here we present the case of gastric glomus tumor that was diagnosed incidentally after LSG. Keywords: glomus tumor; stomach; laparoscopic sleeve gastrectomy; incidental.

Cheickna Diarra, MD, Susana Ho, MS, Jerome Lynsue, MD, Eric M Pauli, MD, Ann M Rogers, MD, Penn State Hershey Medical Center Background: Biliary dyskinesia, or low gallbladder ejection fraction (GBEF), is a recognized indication for cholecystectomy, as is symptomatic cholelithiasis. However, there is a paucity of literature investigating patients with biliary symptoms, normal gallbladder ultrasounds, and normal or high ejection fraction on Hepatobiliary Iminodiacetic Acid (HIDA) scan. Because abdominal pain is not uncommon after gastric bypass, and because the gastrointestinal anatomy and physiology are altered after this rearrangement, central abdominal pain may be appropriately investigated through surgical exploration. In our series of bypass patients undergoing diagnostic laparoscopy for biliary symptoms but with ‘‘normal’’ preoperative studies, it was the rule to find gallbladder pathology. Based on this series of bypass patients, we then sought to also study this phenomenon in patients with normal anatomy, normal studies, and biliary symptoms. Methods: All gastric bypass and normal anatomy patients who underwent cholecystectomy at a single institution between July 1, 2007 and December 31, 2013 were evaluated by chart review after IRB approval. Patients with abnormal ultrasounds (stones or cholecystitis) or who had low GBEF (\35 %) were excluded. 31 patients with biliary symptoms, normal ultrasounds and normal or high GBEF were identified and studied. At our institution, ‘‘normal’’ GBEF is defined as 35 % or higher and there is no set range for ‘‘hyperkinesia’’. We set a ‘‘high’’ GBEF as 65 % or higher, based on the few related studies in the literature. Results: All 31 patients underwent laparoscopic cholecystectomy without postoperative complications. This included single-incision, single-incision robotic, 3-port and 4-port laparoscopic operations. 24 patients had GBEF C65 % (mean 86.6 %, range 66–98), 6 patients had GBEF between 35 % and 65 % on HIDA scan (mean 47.8 %, range 35–60), and one patient was said to have ‘‘brisk’’ ejection (GBEF is not calculated on in-patients at our institution). Pathology reports were reviewed; only 2 (6.45 %) patients had a normal gallbladder, 23 (74 %) had chronic cholecystitis without gallstones, and 6 (19.3 %) had chronic cholecystitis with unsuspected gallstones. Of the patients reported to have gallbladder polyps on preoperative ultrasound, none were found to actually have polyps. All patients were seen in follow-up 4 to 6 weeks postoperatively. Patients were queried for ongoing pain, and all had complete resolution of symptoms after surgery. Conclusions: In this series of gastric bypass and normal anatomy patients with biliary symptoms but normal studies, cholecystectomy led to symptomatic relief in 100 % of patients. 93.5 % also had unexpected pathologic biliary findings. It may be appropriate in patients with symptoms referable to the biliary tract to offer cholecystectomy, even in the face of normal ultrasounds and normal or elevated gallbladder ejection fractions.

P383

P385

Hospital Readmission, Healthcare Follow-Up, and Weight Loss After Bariatric Surgery in Patients with a DSM-IV Axis-I Psychiatric Diagnosis

Laparoscopic Sleeve Gastrectomy is Effective and Safe Treatment in Thai Adolescent Morbid Obesity Patients

1

1

2 1

Eric P Kubat, MD , Nina Bellatorre, RN , Dan Eisenberg, MD , Palo Alto VA Health Care System, 2Palo Alto VA Health Care System and Stanford School of Medicine Objective: A preoperative psychosocial assessment of patients seeking bariatric surgery is common in bariatric surgical practice. However, there is no consensus as to the postoperative effect of a psychiatric diagnosis. Our objective was to determine whether a DSM-IV Axis-I diagnosis impacts early postoperative readmission rates, followup rates, and weight loss after bariatric surgery. Methods: We performed a retrospective review of a prospective bariatric surgery database at a university-affiliated Veterans Affairs medical center. Demographics, readmission rates, healthcare system follow-up and weight loss were compared between cohorts, with and without a DSM-IV Axis-I psychiatric diagnosis. Significant differences between the cohorts were determined using Fisher’s exact test and t-test. A significant difference was determined by p \ 0.05. Results: From 2002–2014, 249 patients underwent bariatric surgery (49.8 % gastric bypass, 50.2 % laparoscopic sleeve gastrectomy). Of these, 78 % were male, mean age was 53 years, and mean preoperative body mass index (BMI) was 45.8 kg/m2. A DSM-IV Axis-I psychiatric diagnosis was present in 143 (57.4 %) of the patients at the time of surgery (PD group), while 106 (42.6 %) of the patients had no psychiatric diagnosis (NPD group). The most common Axis-I diagnoses were major depression in 84 patients (58.7 %), post-traumatic stress disorder in 52 patients (36.3 %), and alcohol dependence/polysubstance abuse in 30 patients (21 %). Seventy six patients (53.1 %) carried two or more Axis-I diagnoses. There was no significant difference in the mean age (52.6 and 53.6 years, p = 0.406) and mean BMI (45.4 kg/m2 and 46.5 kg/m2, p = 0.259) between the PD and NPD groups, respectively. Early hospital readmission rates (within 30 days) after bariatric surgery were similar; 2.7 % in the PD group compared to 2.8 % in the NPD group. Follow-up within the healthcare system at 1, 3 and 5 years postoperatively was 97.5 %, 90.0 %, and 83.1 % in the PD cohort, and 96.7 %, 82.9 %, and 66.0 % in NPD cohort. These differences were not statistically significant at 1 and 3 years (p = 0.653 and 0.236). However, the 5-year follow-up in the PD group was significantly higher (p = 0.046). Percent excess weight loss in the PD group was 63.7 %, 62.4 %, and 60.2 % at 1, 3, and 5 years, respectively. This was not significantly different from the NPD group with 59.8 %, 55.6 %, and 54.0 % at 1 (p = 0.261), 3 (p = 0.139) and 5 years (p = 0.228), respectively. Conclusions: The majority of patients at this Veterans Affairs medical center had a DSM IV Axis-I psychiatric diagnosis at the time of bariatric surgery. Patients with a psychiatric diagnosis undergoing bariatric surgery have a low early readmission rate, a high rate of postoperative follow up, and similar postoperative weight loss compared to patients without a concurrent psychiatric diagnosis. A DSM IV Axis-I psychiatric diagnosis should not be a barrier to access of bariatric surgery.

123

Suriya Punchai, MD, FRCST1, Jakrapan Wittayapairoj, MD, FRCST1, Krisada Paonariang, MD, FRCST1, Kriangsak Jenwithisuk, MD, FRCST1, O-tur Saeseaw, MD, FRCST1, Suthep Udomsawaengsup, MD, FRCST2, Chaiyut Thanapaisal, MD, FRCST1, 1Khon Kaen University, Thailand, 2Chulalongkorn University Introduction: Obesity is a worldwide epidemic and the prevalence is rapidly increasing among adolescents too. Laparoscopic sleeve gastrectomy (LSG) is effective treatment for morbid obesity in term of long term sustained weight loss and improvement comorbidity diseases. But bariatric surgery in adolescent patients is controversial. This study aims to evaluate the safety and effectiveness of laparoscopic sleeve gastrectomy in adolescent morbid obesity patients. Method: A retrospective study was conducted of patients aged 15–18 who underwent LSG from July 2012 to August 2014 at Srinagarind Hospital, Khon Kaen University, Khon Kean, Thailand. Collected data included age, sex, BMI, postoperative complications, percentage of excess weight loss (%EWL) at 1 month, 3 months, 6 months, 1 year and 2 years postoperatively and resolution of comorbidity diseases. Results: 11 patients with median age of 17 years (range; 15–18) underwent LSG. Of these, 4 were females and 7 were males. The mean preoperative body weight was 143.3 kg (range; 90–233) with a body mass index (BMI) of 50.9 (range; 35.2–74.1). No postoperative complication and mortality were recorded. The %EWL at 1 month, 3 months, 6 months, 1 year and 2 years was 26.67 %, 44.71 %, 53.93 %, 63.15 % and 64.35 %, respectively. There were 8 patients (72.7 %) with comorbidity diseases: 8 cases of sleep apnea, 3 cases of diabetes, 3 cases of hypertension and 3 cases of dyslipidemia. The resolution rate of sleep apnea is 87.5 %. The resolution rate of diabetes, hypertension and dyslipidemia are 100 %. Conclusion: Laparoscopic sleeve gastrectomy is safe and effective bariatric procedure in Thai adolescent morbid obesity patients. It can significantly weight loss and resolution of comorbidity diseases.

Surg Endosc

P386

P388

Diabetes Mellitus is the Most Significant Predictor of Excess Weight Loss in Laparoscopic Adjustable Gastric Banding in the Aged Population

Weight-Loss Outcomes of SpiderÒ Sleeve Gastrectomy at 6-Months Compared to Traditional Laparoscopic Technique

Sarwat Ahmad, MD2, Eric S Wise, MD1, Kyle M Hocking, PhD1, Colleen M Brophy, MD1, Stephen M Kavic, MD2, 2University of Maryland, 1Vanderbilt University Medical Center Introduction: Laparoscopic adjustable gastric banding (LAGB) is a safe, effective and reversible alternative to small bowel reconstruction procedures in surgical weight loss. One of the benefits of this gastric restrictive procedure is its reduction in comorbidities, particularly diabetes mellitus (DM), concomitant with the associated loss of excess body weight. The inherent Catch-22 in LAGB patients, however, is that the presence of DM preoperatively has been proposed to adversely affect successful weight loss. The aim of this study is to assess the influence of DM in excess weight loss after LAGB in the aged population, a cohort that is both understudied and has a higher baseline prevalence of the condition. Methods: 127 patients greater than 50 years of age who underwent LAGB from 2006–2012 at a single institution were reviewed using the Synthetic Derivative database. In addition to DM, additional factors with a previously validated association with excess weight loss were noted, including race, gender, pre-operative BMI, hypertension (HTN), psychiatric disorder and weight change in the 6 months prior to operation. End points were excess weight loss at 6 and 12 months post-operatively. Factors associated with endpoints on univariate screen (p \ 0.10) were incorporated into a multivariate model. P \ 0.05 was used to indicate statistical significance. Results: The mean age of the 127 patients was 60.2 ± 5.7 years. Within the cohort, 100/127 (72.7 %) patients were female, 10/127 (7.9 %) were black and 63/127 (49.6 %) had DM. Patients had a mean excess weight loss of 26.2 ± 12.0 % and 30.3 ± 18.9 % at 6 and 12 months post-operatively, respectively. The cohort without DM had greater 6 and 12 month excess weight loss than those without DM (29.8 ± 12.8 % vs. 22.5 ± 9.8 %, and 35.0 ± 18.7 vs. 25.8 ± 18.0 %, respectively). In univariate analysis, black race, pre-operative BMI and DM were associated with decreased excess weight loss at 6 months; male gender, HTN, preoperative weight loss and DM were associated with a decreased excess weight loss at 12 months. In a multivariate linear regression model, negative predictors of excess weight loss were the presence of preoperative weight loss (p = 0.0192) and DM (p = 0.0141) at 6 months, and only DM (p = 0.0023) at 12 months. Conclusions: The presence of DM is the primary factor preventing excess weight loss in LAGB for patients over the age of 50. This finding may provide beneficial prognostic information to aged patients considering LAGB.

Kathryn B Muir, MD, William V Rice, MD, William Beaumont Army Medical Center Introduction: Laparoscopic sleeve gastrectomy (LSG) has become an acceptable primary stand-alone procedure for metabolic and weight-loss surgery. Traditional LSG involves multiple small abdominal incisions, similar to traditional laparoscopic cholecystectomy. Sleeve gastrectomy has also been performed using the single incision laparoscopic surgery (SILS) technique, to minimize scarring and improve ultimate cosmetic outcome. SILS is technically challenging due to the crossover of instruments. Recently, the single port instrument delivery extended reach (SPIDER) surgical system has been introduced as another single incision modality for performing sleeve gastrectomy. This system minimizes the number of incisions needed while eliminating the technical challenges of instrument crossover. Use of this technique has been reported previously, however, outcomes of SPIDER sleeve gastrectomy have not been compared to outcomes of traditional LSG. We hypothesized SPIDER sleeve gastrectomy would not be inferior to traditional LSG. Methods and Procedures: We performed a retrospective review of a prospectively collected database involving patients undergoing surgery between Aug 2011 and Sep 2013. All cases were performed by a single bariatric surgeon and at a single institution. Thirty-two patients underwent SPIDER sleeve gastrectomy versus thirty who underwent LSG. Our primary outcomes were change in BMI and percent excess weight loss (%EWL) at 6 months postoperatively. Secondary outcomes included length of operative time, intraoperative estimated blood loss (EBL), and overall complications. Results: The demographics of our patients were examined and the only significant difference between the cohorts was mean initial BMI (SPIDER = 42.1, LSG = 46.5, p \ 0.001). At 6 months post-operatively, mean %EWL was higher in the SPIDER cohort (59.1 %) than in the LSG cohort (48.3 %) (p \ 0.005). This corresponded with an overall lower mean BMI in the SPIDER cohort at 6-months versus those who underwent traditional LSG (31.1 and 35.5, respectively, p \ 0.0001). At the 6 month post-operative interval, despite differences in initial BMI, the overall change in BMI in each cohort was equivalent (SPIDER = 11.1, LSG = 11.0, p = 0.94). Mean operative time was longer in SPIDER sleeve gastrectomy (107.4 min) compared to LSG (87.4 min) (p \ 0.001). EBL was not different between the two techniques (32.1 mL and 32.3 mL, p = 0.94). With regard to complications, there was one post-operative hemorrhage in each group; one surgical site infection in the LSG cohort, and one negative diagnostic laparoscopy in the SPIDER cohort due to uncharacteristic abdominal pain on post-operative day #1. Conclusions: Based on the results at 6 months post-operatively, SPIDER sleeve gastrectomy is not inferior to LSG with regard to decrease in BMI or %EWL. The increased %EWL observed in the SPIDER cohort is likely due to patient selection bias given the use of a new technique, though other explanations cannot be excluded. This retrospective study shows that the SPIDER technique is a viable alternative to traditional LSG with regard to weight-loss outcomes.

P387

P389

The Evolution of Treatment for Laparoscopic Sleeve Gastrectomy Staple Line Leak: A Single Institution’s Experience

Bariatric Surgery and Biliary Disease: Does the Type of Surgery Play a Role?

Jill L Gorsuch, DO, MPH, David Podkameni, MD, Albert Y Chen, MD, Emil T Graf, MD, Flavia Soto, MD, Banner Gateway

Colin B Webb, MD, Patricia L Eichhorn, MD, Clarissa Sutter, Joseph A Ewing, MS, Allyson L Hale, John D Scott, MD, Greenville Health System

Introduction: Laparoscopic sleeve gastrectomy (LSG) has become a standard procedure in the bariatric surgeons’ armamentarium for obesity surgery. Recognized as a standalone procedure, there has been a recent increase in the number of procedures performed. As the number of cases increase, so do the number of complications. Staple line leak can be a devastating morbidity, which can consume health care resources as well as be detrimental to the patient. Just as the technique for the LSG has evolved, so have the treatment methods for the management of post-operative leak. According to the International sleeve gastrectomy expert panel consensus statement from Rosenthal in 2012, initial intervention included surgical exploration, drainage, esophageal stenting and possible conversion to Roux-en-Y bypass. Over the scope endoscopic endoclip is a new technique not part of the algorithm that is becoming more widely used with positive results. This is a case series of interventions for successful treatment of staple line leak status post LSG at a single Center of Excellence institution. Methods and Procedures: This is a case series for a single institution. Four bariatric surgeons’ cases were reviewed from 2012–2014 using office records, and hospital medical records. Only laparoscopic sleeve gastrectomy cases were included in this review. The complications were encountered at both the home institution, as well as in patients transferred from out of state or out of the country. Results: During the study period from 2012–2014 there were 490 LSG performed. At the institution, a total of 7 leaks (1.4 %) were documented at 30-day follow-up, and 1 (0.2 %) documented greater than 30 days. One leak was transferred from an outside hospital, and had LSG performed outside of the country. Of the 9 leaks over the 2-year time period, two were successfully treated by conservative management including interventional radiology drainage, intravenous antibiotics and parenteral or enteral nutritional support. The average length of treatment to resolution was 29 (22–35) days. One patient has had conservative and endoscopic management with complete resolution in 30 days with IR drainage and EGD with over the scope endoclip. Six of the patients had exploratory laparoscopy with washout and drain placement. Within this population 3 of the 6 patients also had post procedure endoscopy with over the scope endoclip. One patient had an endoscopic stent. One patient had fibrin glue endoscopically injected into the fistula Five of the 6 patients had resolution with an average of 50 (13–118) days. One patient is still receiving treatment. Conclusion: LSG leak is a devastating complication with treatment options that are continually evolving. The improving technology has allowed for more minimally invasive approaches including esophageal stenting and endoscopic clipping allowing for less morbidity during the intervention. Our institution has utilized these new techniques in our treatment regimen for successful closure of LSG leaks.

Introduction: Biliary disease is a common complication in bariatric surgery patients. The purpose of this study is to determine whether an association exists between the type of bariatric surgery performed and the incidence of biliary disease. Methods and Procedures: We retrospectively reviewed all vertical sleeve gastrectomy (n = 300), Roux en-Y gastric bypass (n = 2120), and gastric lap band procedures (134) performed at our institution between 2002 and 2012. Primary endpoints included the type of surgery, the incidence of biliary disease, the percent of excess weight loss (EWL), and the number of days between bariatric surgery and the cholecystectomy. The type of surgery, the incidence of biliary disease, and the number of days/dates were collected via chart reviews. Incidence of biliary disease was identified by subsequent cholecystectomy. The EWL was measured by the percent change in body mass index (BMI); patients BMIs were recorded at the time of the bariatric surgery and at the time of presentation with biliary disease. Chi square tests were used to test differences in incidence of biliary disease, median weight loss, and median time to cholecystectomy. P-values [0.05 were considered indicative of statistical significance. Results: Roughly 5.2 % (7 of 134) of our gastric lap band patients developed biliary disease and required subsequent cholecystecomies, compared to 3.9 % (82 of 2120) for Roux en-Y gastric bypass and 2.3 % (7 of 300) for sleeve gastrectomies. Our results showed no statistical difference in the incidence of biliary disease by type of bariatric surgery (p-value = 0.279). Furthermore, we found no statistical difference in the median percent of excess weight loss (p-value = 0.446) or in the median number of days (p-value = 0.296) by type of surgery, as shown in Table 1. Conclusions: Our results suggest there to be no association between the type of bariatric surgery performed and the incidence of biliary disease.

Table 1

Change in BMI and time between surgeries, by bariatric surgery Bypass

Sleeve

Band

P-value

Total procedures

2120

300

134

Cholecystectomies (%)

82 (3.9)

7 (2.9)

7 (5.2)

0.279

Change in BMI, median (IQR)

27 (18.3, 36.5)

15 (13.6, 22.9)

23.8 (23.4, 24.8)

0.446

Time between (days), median (IQR)

343 (142, 632)

219 (126.5, 292)

624 (329.5, 837)

0.296

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Prediction of Excess Weight Loss After Laparoscopic Roux-en-Y Gastric Bypass Using an Artificial Neural Network

The Incidental Finding of Gastrointestinal Stromal Tumors in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Chart Review from a High-Volume Bariatric Center

Eric S Wise, MD1, Kyle M Hocking, ME, PhD1, Stephen M Kavic, MD2, Colleen M Brophy, MD1, 1Vanderbilt University, 2University of Maryland Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has become the gold standard for surgical weight loss in the morbidly obese. The success of LRYGB may be measured by excess weight loss (EWL), and several variables have been identified as independent pre-operative predictors of EWL. However, current models of estimating EWL, based on multivariate regression analysis, are poorly prognostic. Artificial neural networks (ANN) are advanced, continually adapting computational systems taught to identify complex non-linear relationships among variables correlated with an outcome. We used ANN modeling to derive a reasonable estimate of expected postoperative weight loss using known pre-operative variables. Additionally, we used ANN modeling to predict whether 50 % excess weight loss will be achieved by one year postoperatively. Methods: 1621 patients who have undergone bariatric LRYGB with a Roux limb \150 cm from 2004–2013 were reviewed. Of these, 647 patients had sufficient data for analysis. Endpoints were %EWL at 180 and 365 days (EWL180 and EWL365, respectively). Previously validated pre-operative factors were analyzed, including age; race; gender; pre-operative BMI (BMI0); hemoglobin; and previous diagnosis of hypertension (HTN), diabetes mellitus (DM), or psychiatric disorder. Variables associated with EWL in bivariate analysis (P \ 0.1) were included in multivariate linear regression (MLR). Variables significant in MLR (P \ 0.05) were input into five-node backpropagation ANNs (ANN180 and ANN365 [Fig. 1A]). The ANN output is an estimation of %EWL. Using ANN modeling, a receiver operating characteristic curve was generated to predict 50 % EWL at 365 days. Results: The average patient age was 47.0 ± 11.0 years, and the average BMI0 was 48.5 ± 8.5 kg/m2. In bivariate analysis, EWL180 was associated with hemoglobin, DM, HTN, BMI0, male gender and black race. EWL365 was associated with these factors with the addition of age. In MLR, independent risk factors for decreased EWL180 included DM (P \ 0.0001), HTN (P = 0.0022), higher BMI0 (P \ 0.0001), male gender (P = 0.0311) and black race (P \ 0.0001). For EWL365, independent risk factors were DM, HTN, higher BMI0, black race, male gender (all P \ 0.0001) and advanced age (P = 0.0237). Actual vs. ANN-Predicted EWL plots were generated for EWL180 and EWL365 (Fig. 1B), with Pearson r correlation coefficients of 0.5567 and 0.5479, respectively (P \ 0.0001). ANN prediction of benchmark 50 % EWL at 365 days generated an area under the curve of 0.7454 ± 0.02 in the training set (n = 518, Fig. 1C), and 0.7796 ± 0.04 (n = 129) in the validation set. A prototype web-based EWL estimator was then designed. Conclusions: Successful postsurgical weight loss is dependent on multiple preoperative and postoperative factors. The ANN model demonstrated age, DM, HTN, BMI0, black race and male gender as independent markers for a less successful operation. Using an easily obtainable and quantifiable subset of independent pre-operative predictors, an ANN model allows for development of a patient-centered tool with which to obtain an optimized estimate of postsurgical EWL at 6 and 12 months. Bariatric surgeons may opt to incorporate this model as a screening tool, or for patients to access, to assess the likelihood of meeting their goals.

Dina Podolsky, MD1, Azam Qureshi, MD2, Mujjahid Abbas3, W. Scott Melvin, MD, FACS1, Diego Camacho, MD, FACS1, 1 Montefiore Medical Center, 2Georgia Regents University, 3 Louis Stokes VA Medical Center Introduction: Gastrointestinal stromal tumors (GISTs) represent approximately 1 % of all GI tumors and are the most frequently diagnosed mesenchymal tumors of the alimentary tract. According to the Surveillance, Epidemiology, and End Result (SEER) cancer data registry, between 1993 and 2002 the incidence of GIST in the United States was 0.32 per 100,000 people. To compare this to the incidence in the obese population, we performed a retrospective electronic medical records review on all patients undergoing laparoscopic sleeve gastrectomy for the treatment of obesity at Montefiore Medical Center. Methods: From January 1st, 2009 to December 31st, 2013, all patients who underwent a laparoscopic sleeve gastrectomy for the treatment of obesity were included in this investigation. All patients met the criteria defined by the NIH consensus statement of 1912. All procedures were done by three surgeons (DC, JC, and PV) at the Montefiore Medical Center. A retrospective chart review was performed to determine the incidence of gastrointestinal stromal tumors in our study population. For patient’s with GIST on pathology, results of their pre-operative abdominal sonogram, demographic data, past medical history, medication lists, hospital stay, complications, and follow up were reviewed. Results: A total of 8 (1.1 %) patients were found to have GISTs on pathology out of a total 721 patients. The majority of the GISTs were spindle type, low-grade and very-low risk, and all were benign. The average size of the tumor was 0.76 cm and all were below 2 cm. There were no post-operative complications and average hospital stay was 4 days. Two of the 8 patients required follow up surveillance with upper endoscopy, which remained negative for malignancy. Only 1 patient had a personal history of cancer (carcinoid, lung), and one patient had a family history of cancer (mother, breast). Fifty-percent were on pre-operative PPI therapy. One patient had a history of alcohol abuse and was sober for approximately 10 years at the time of surgery. Four patients had a history of smoking cigarettes although none were actively smoking at the time of surgery. Only one patient presented with pre-operative abdominal symptoms of pain and heaviness; all others were asymptomatic at time of presentation. Finally, all pre-operative abdominal sonograms were negative for any intra-abdominal pathology. Conclusion: Our study found the incidence of GIST in the obese population to be more than three-times the reported incidence in the general population. This finding is limited by the fact that the incidence of GIST in the general population is most likely under-reported due to the asymptomatic and benign nature of these tumors. Nonetheless, we can conclude that when found, these tumors are likely to be small with benign characteristics, and that in this setting, a laparoscopic sleeve gastrectomy can effectively serve as a complete surgical resection of a patient’s tumor burden.

Fig. 1

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Laparoscopic Greater Curvature Plication, Our Initial Experience

Remission of Type 2 Diabetes Mellitus After Laparoscopic Sleeve Gastrectomy: Experience from Kuwait

Nathan Roberts, MD, Matthew Musielak, MD, Lisa Longshore, CNP, Trace Curry, MD, Jewish Hospital

Sulaiman Almazeedi, Salman Al-Sabah, Amiri Hospital

Introduction: With an estimated 15 million Americans morbidly obese and the numbers growing, bariatric surgery’s role will continue. The primary mechanisms through which bariatric surgery achieves its outcomes are through the mechanical restriction of food intake, reduction in the absorption of ingested foods, or a combination of both. In addition to these malabsorptive and restrictive mechanisms, hormonal changes also play a role. Roux-en-Y Gastric Bypass (RYGB) and Vertical sleeve gastrectomy (VSG) are approaches commonly used in bariatric practice. Although these procedures have proven to be good therapeutic options for some patients, they are not without complications. Laparoscopic greater curvature plication (LGCP) offers a restrictive procedure similar to VSG, with the potential of fewer complications. Methods & Procedure: A retrospective review was performed on patients undergoing (LGCP) from March 2011– December 2011. A two layer plication was performed. The initial plication row was created starting 2 cm distal to the gastro esophageal junction taking seromuscular bites with 2-0 silk suture spaced 2 cm apart ending 5 cm proximal to the pylorus. The second plication was created over a 40 F Bougie using a running 2-0 Prolene. Repairs were inspected and a tension free plication ensured. Postoperative visits assed complications, weight loss and overall satisfaction with their results. Results: A total of 11 female patients underwent (LGCP) with an average age of 41 and BMI of 39. One patient was excluded as they never returned for follow up. A second patient was included for 1 month follow up, however due to the fact of leaving the country they were lost to long term follow up. Overall we had an 18 % loss of long term follow up. Zero patients required reoperation and there was zero thirty day morbidity or mortality. Average hospital stay was 24–36 hrs. At 1 month follow up the average excess weight loss (%EWL) was 17.3 (12.8–35.1). At 3 month follow up the average %EWL was 19.5 and at 36 months the average %EWL was 39.5. The most common complaints were nausea, reflux and epigastric pain, all self-resolving. Conclusion: In recent years there has been an increasing trend in the number of VSG performed. LGCP promotes weight loss via a restrictive approach in a similar fashion to VSG without resection or creation of a staple line. VSG as a primary bariatric procedure shows comparable results to RYGB in regards to weight loss, with improvements in comorbidities. These results are not without associated risks; wound infections, leak, stricture, re-operation or mortality. LGCP is notably similar to VSG in that it generates a gastric tube, but does so without gastric resection and with a reduced risk profile. In our series LGCP provided an average %EWL of 39.5 at 3 year follow up without associated morbidity. Although relatively new in its surgical life in the United States, LGCP offers an alternative restrictive procedure. Further randomized trials will be needed for adequate assessment and comparison to current bariatric techniques.

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Introduction: Type 2 diabetes mellitus (T2DM) comprises 90 % of diabetics and is largely the result of excess body weight. There is rising evidence in the literature to suggest that laparoscopic sleeve gastrectomy (LSG) produces effective weight loss and improves obesity-related co-morbidities such as T2DM. The purpose of the study is to observe the effectiveness of LSG in the remission of T2DM. Methods and Procedures: A retrospective study of 107 diabetic obese patients who underwent LSG at Al-Amiri Hospital from October 2008 to October 2012 was conducted. The pre and postoperative diabetic status, body mass index, and percent excess weight loss (%EWL) of the patients were retrieved and analyzed. Results: The mean age of the patients was 42 years ± 10.4 and 68 % were females. Median preoperative BMI was 46 kg/m2 (30– 87) and median postoperative follow up period was 18 (2–48) months. Pre and postoperative fasting blood glucose and HbA1C were measured. Resolution and improvement of T2DM was 53.3 % (n = 57) and 38.3 % (n = 41), respectively. The %EWL was 72 % at 1 year and 73 % at 4 years and median postoperative BMI was 33 kg/m2 (20–61). Duration based analysis showed that most of the resolved patients had diabetes for less than 5 years. Conclusion: LSG resulted in total remission of T2DM in more than half of the patients and is more effective for the treatment of patients with short-term duration of the disease.

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Bioabsorbable Staple Line Reinforcement and the Prevention of Strictures and Marginal Ulcers

Is There a Relationship Between Age and Weight Loss on Patients Undergoing Laparoscopic Sleeve Gastrectomy?

Thomas D Martin, MD, Kirstie S Van Ry, MD, Dimitri Stefanidis, MD, PhD, Timothy S Kuwada, MD, Keith S Gersin, MD, Carolinas Medical Center

Mehmet Tahir Oruc, Prof, Burhan Mayir, Erdem Can YArdimci, Alkan Sakar, Arif Aslaner, Onur Ozener, Tugrul Cakir, Antalya Training and Research Hospital, Department of General Surgery

Introduction: Gastrojejunal anastomotic (GJA) ulcers and strictures occur in up to 3–31 % and 0.6–16 % of patients respectively after laparoscopic Roux-en-Y gastric bypass (LRYGB), and may lead to significant morbidity. The purpose of this study was to evaluate the impact of bioabsorbable staple line reinforcement on the GJA stricture and marginal ulcer rates. We hypothesized that reinforcement would decrease the incidence of marginal ulceration and anastomotic strictures. Methods: Retrospective review of prospectively collected data on consecutive patients undergoing LRYGB before and after the introduction of GORE Seamguard circular reinforcement between March 2012 and August 2014. All procedures were performed by one surgeon using identical techniques and equipment. A transgastric 25 mm EEA stapler (Ethicon Endosurgery, Cincinnati, OH) was used for all gastrojejunal anastomoses. Post-operative endoscopic procedures were completed by the same surgeon; indications included severe dysphagia or GERD symptoms unresponsive to pharmacologic therapy. Marginal ulcers were defined as those seen on endoscopy. Anastomotic strictures were defined as requiring pneumatic balloon dilation. Patient characteristics including age, gender, BMI, co-morbidities, and subsequent endoscopic findings were recorded. Marginal ulceration and anastomotic stricture rates were compared between the two groups, those with and without Seamguard reinforcement. Time from operation to endoscopic diagnosis of anastomotic stricture or marginal ulcer was also analyzed. Results: 95 patients had Seamguard reinforcement of the GJA while 105 did not during the study period. The patient characteristics between the two groups were similar. Marginal ulcer rate in the reinforced group was 8.4 % compared to 8.9 % in the unreinforced group (p = 0.9) and anastomotic stricture rates were 4.2 % and 5 %, respectively (p [ 0.9). Three patients in the unreinforced group developed concomitant marginal ulcers and anastomotic strictures whereas no patients in the reinforced group developed both complications. Average time from operation to endoscopic diagnosis of anastomotic strictures was 75 days in the reinforced group compared to 78 days (p = 0.8) in the unreinforced group; for marginal ulcers average time was 109 days versus 85 days, respectively (p = 0.5). Conclusion: In our experience, the use of circular bioabsorbable staple line reinforcement at the gastrojejunal anastomosis during LRYGB did not reduce rates of anastomotic stricture or marginal ulceration. There were no anastomotic bleeding complications in either group. Given the limited number of patients, a larger sample size may be needed to detect a difference between the two groups. More evidence is needed to determine the value of GJA reinforcement.

Introduction: With the increasing rate on obesity, different surgical procedures started to perform in these patients. Nowadays, bariatric surgery is considered as a reliable and effective method in the treatment of morbid obesity. In this present study, we aimed to investigate whether that was a relationship between the weight loss and age on patients who underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity. Materials and Methods: In our clinic, patients who underwent LSG and who has the data on the sixth month of follow-up were included in the study. Patients’ age, preoperative body weight, height and the rate of weight loss at the sixth months were recorded. Patients were evaluated by dividing patients into two groups of over and below 30 years old. All data was installed to SPSS 18.0 (Chicago, USA) program. The t-test was used for comparisons between groups. A value of p \ 0.05 was accepted as statistical significance. Results: 69 patients who came to control at the sixth months after surgery were included to study. 52 of the patients (75 %) were female and 17 (25 %) were male. 50 patients were over 30 years old and 19 patients were below 30 years old. The patients of two groups have similar preoperative body weight and BMI. The weight loss at the sixth month was 7–57 kg (mean: 32.16 ± 11.7) in patients over 30 years old and 25 to 60 kg (mean : 39.63 ± 10.0) in patients below 30 years old, respectively. The difference was statistically significant according to amount of weight loss at the sixth month (p:0,019). The decrease on BMI at the sixth month was 2.4 to 17.8 kg/m2 (mean: 11.46 ± 3.8) in patients over 30 years old and 7.0 to 19.6 kg/m2 (mean: 13.61 ± 3.9) in patients below 30 years old, respectively. The difference was statistically significant (p:0.043). Discussion: In our study, we investigated the difference between preoperative age and weight loss at the postoperative sixth month. According to the results of the statistical analysis, statistically significant more weight loss was seen in patients below 30 years old and a significant reduction on BMI was seen.

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Comparative Effectiveness of Gastric Bypass, Sleeve Gastrectomy and Gastric Banding in Patients Enrolled in a Population-Based Bariatric Program: Prospective Cohort Study with Two Year Follow-Up

Improvement of Gastroesophageal Reflux Disease After Bariatric Surgery

Richdeep S Gill, MD, PhD1, Sameer Apte, MD2, Sumit R Majumdar, MD2, Calypse Agborsangaya2, Christian F Rueda-Clausen, MD2, Daniel W Birch, MD1, Shahzeer Karmali, MD1, Scott Klarenbach, MD2, Arya Sharma, MD2, Raj Padwal, MD2, 1Center of the Advancement of Minimally Invasive Surgery (CAMIS), 2 University of Albeta Background: Bariatric care is increasingly being delivered in Canada within publicly funded regional programs. The optimal bariatric surgical procedure for severely obese individuals receiving bariatric care is currently unknown. The objective of this population-based prospective cohort study was to compare the effectiveness of laparoscopic Roux-enY gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in severely obese patients. Methods: 150 consecutive patients (51 LRYGB; 51 LSG; 48 LAGB) from the population-representative, publicly funded Edmonton Weight Wise bariatric program were examined. The primary outcome was weight change (kg). Between-group changes were analyzed using multivariable regression adjusted for age, sex, and baseline weight. Lastobservation-carried-forward imputation was used for missing data. Results: At baseline, mean age was 43.5 ± 9.5 years, 87.3 % were females and overall preoperative BMI was 46.2 ± 7.4 kg/m2. Absolute (kg) and relative (% of baseline) mean weight losses were 36.6 ± 19.5 kg (26.1 ± 12.2 %) for LRYGB, 21.4 ± 16.0 kg (16.4 ± 11.6 %) in for LSG, and 7.0 ± 9.7 kg (5.8 ± 7.9 %) for LAGB (p \ 0.0001 for between-group comparisons) at 2-years. Change in BMI was significantly greater in the LRYGB (-13.0 ± 6.6 kg/m2) group compared to both the LSG -7.6 ± 5.7 kg/m2) and the LAGB (-2.6 ± 3.5 kg/ m2) groups (p \ 0.0001 for between-group comparisons). In addition, change in BMI was significantly greater in the LSG group compared to the LAGB group (p \ 0.05). Hypertension, diabetes, and dyslipidemia prevalence’s decreased to a significantly greater degree with LRYGB compared to LAGB (p \ 0.05). Conclusion: In a publicly funded bariatric surgery program providing population-based bariatric care to severely obese individuals, LRYGB and LSG demonstrated greater weight loss than LAGB. LRYGB was more effective than LAGB in improving obesity-related comorbidities.

Patrick E LeMasters, MD, Lindsay Cumella, BS, J Choi, MD, P Vemulapalli, MD, S Melvin, MD, D Camacho, MD, Montefiore Medical Center Introduction: The objective of this study is to analyze the effect of gastric bypass (GB) and sleeve gastrectomy (SG) on patients with preoperative gastroesophageal reflux disease (GERD). Methods: We retrospectively reviewed the charts of patients that had bariatric surgery from 2009 to 2013 to identify those with preoperative GERD. The charts were then examined at 1 year postoperatively to identify the status of their GERD symptoms. This was evaluated to be worse, not changed, improved, or resolved and given respective scores of 1, 2, 3, or