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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 53rd Annual Meeting May 18-22, 2012 San Diego Convention Center San Diego, California Program Book Abstract Supplement Table of Contents Schedule-at-a-Glance .............................................................................................................2 Sunday Plenary and Video Session Abstracts ........................................................................4 Monday Plenary and Video Session Abstracts .....................................................................17 Tuesday Plenary, Video, and Quick Shot Session Abstracts.................................................51 Sunday Poster Session Abstracts ..........................................................................................61 Monday Poster Session Abstracts .......................................................................................110 Tuesday Poster Session Abstracts .......................................................................................158 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT PROGRAM BOOK ABSTRACT SUPPLEMENT FIFTY-THIRD ANNUAL MEETING San Diego Convention Center San Diego, California May 18–22, 2012 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM VIDEO SESSION I: 2 PRESIDENTIAL ADDRESS PRESIDENTIAL PLENARY B (PLENARY SESSION II) STATE-OF-THE-ART LECTURE DDW CCS: GI Mgt of Pt w/Obesity DDW CCS: Mgt of Pt @ High Risk for Colon CA PRESIDENTIAL PLENARY A (PLENARY SESSION I) MEET-THEPROFESSOR LUNCHEONS Exhibit Hall DDW CCS: Mgt of Fecal Incontinence 28cd POSTER SESSION I (authors available @ posters 12:00 PM - 2:00 PM) 28ab Difficult Bile Duct Stone 27b CONTROVERSIES IN GI SURGERY DEBATES A: C Diff Colitis; Pancreatic Cystic Neoplasms 26ab CLINICAL WARD ROUNDS I: SATURDAY, MAY 19, 2012 STATE-OF-THE-ART CONFERENCE: Technological Advances in the Surgical Treatment of Colon and Rectal Cancer PLENARY SESSION III Other Robotic, Endoscopic, & Adv. Laparoscopic GI Sx 28abcd DDW CTS: Probiotics in Health & Disease 28ab DDW CCS: Tx of Early GI CA FRI, MAY 18, 2012 MAINTENANCE OF CERTIFICATION COURSE: Evidence Based Treatment of Hepatopancreatobiliary Diseases RESIDENTS & FELLOWS RESEARCH CONFERENCE (by invitation only) THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Schedule-at-a-Glance SUNDAY, MAY 20, 2012 Other OPENING SESSION MEET-THEPROFESSOR LUNCHEONS 3 BEST OF DDW DDW CCS: Can You Eliminate Barrett's? DDW CCS: Mgt of HCC TUESDAY, MAY 22, 2012 Exhibit 28cd Hall MEET-THEPROFESSOR LUNCHEONS 28ab DDW CCS: Endoscopic Biliary Complications POSTER SESSION III (authors available @ posters 12:00 PM - 2:00 PM) HEALTH CARE & QUALITY OUTCOMES PANEL: GI Sx Cost Curve 27b SSAT/ISDS JOINT B'FAST SYMPOSIUM: Optimizing Outcomes Other PLENARY SESSION VII DDW CCS: Disorders of the Esophagus MONDAY, MAY 21, 2012 SSAT/SAGES JOINT LUNCHEON SYMPOSIUM: Foregut Motility DDW CCS: Mgt of Complicated Crohn's PLENARY SESSION VI CLINICAL WARD ROUNDS I: Diverticulitis Exhibit Hall Pancreatic Cystic Neoplasms & IPMN GUEST ORATION POSTER SESSION II (authors available @ posters 12:00 PM - 2:00 PM) VIDEO SESSION III: HPB & Foregut VIDEO SESSION II: BREAKFAST AT THE MOVIES 28cd DDW CCS: GI Sx & Endoscopy CONTROVERSIES IN GI SURGERY DEBATES B: Band / Morbid Obesity; 360 v Partial Fundoplication / GERD Benign Liver Neoplasms SSAT/AHPBA JOINT SYMPOSIUM: PUBLIC POLICY & ADVOCACY PANEL 28ab CLINICAL WARD ROUNDS III: QUICK SSAT/ASCRS SHOTS JOINT SYMPOSIUM: SESSION Ulcerative Colitis II PLENARY SESSION IV 27b ANNUAL BUSINESS MEETING PLENARY SESSION V 26ab QUICK SHOTS SESSION III 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM QUICK SHOTS SESSION I 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Schedule-at-a-Glance Other THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT SSAT PLENARY, VIDEO, AND QUICK SHOT ABSTRACTS Printed as submitted by the authors. indicates a paper that is also being presented at the Residents & Fellows Research Conference. Participation in and attendance at this conference is by invitation only. indicates a video presentation scheduled during a Plenary Session. Sunday, May 20, 2012 8:15 AM – 9:15 AM 28ab PRESIDENTIAL PLENARY A (PLENARY SESSION I) 287 provided an additional six million patient visits. Texas hospitals have saved $100 million /year which has allowed them to deliver more charity care ($500 million/year), expand patient safety programs (58%), subsidize shortfalls in government programs such as Medicaid (46%), raise salaries for nurses and increase nurse staffing (46%), and maintain, improve or add new equipment (39%). In conclusion, medical liability reform enacted by the Texas Legislature in 2003, has afforded Texans an increased ability to access health care and would appear to be an ideal tort reform template for adoption by the other 49 states. Texas Tort Reform Increased Access to Health Care Ronald M. Stewart1, Lisa Rocheleau2, Kenneth Sirinek1 1. Surgery, UTHSCSA, San Antonio, TX; 2. Boone & Rocheleau, San Antonio, TX Prior reports have confirmed that comprehensive tort reform in Texas (2003) has resulted in fewer malpractice claims and lawsuits against physicians and a reduction in the cost of both insurance premiums and the associated litigation fees. We hypothesize that Texas medical liability reforms have achieved the Legislature’s intent of improving statewide access to critical health care services. The positive impact on physician manpower has been monumental with 21,000+ new medical licenses issued since tort reform (62% for past 3 years compared to the 3 years pre-tort reform). The number of new licenses issued by the Texas Medical Board in 2008 was 3,600 (a record high) compared to 2000 for the year 2001 (lowest for the preceding 10 years). Eight in ten Texas hospitals have reported that it is now easier to recruit medical specialists in the wake of tort reform. Since 2003, 218 new obstetricians have come to Texas with 27% practicing in medically underserved areas and all 254 counties now have at least one obstetrician. Similar increases have occurred in neurosurgery, emergency medicine, cardiology, cardiovascular surgery, orthopedic surgery, pediatrics, and geriatrics. Eleven counties have their first general surgeon and 24 counties have added at least one general surgeon. The Rio Grande Valley, a former hotbed of medical malpractice claims, has seen an influx of 220 physicians. Although impossible to document except from medical society hearsay, there has been a positive manpower impact from the physicians who reversed their decision to retire as a result of tort reform implementation. The Texas Medical Association has estimated that this additional physician manpower since tort reform has 288 Enhancement of the Small Bowel Obstruction Model with the Use of the Gastrografin Challenge Test Naeem Goussous, Patrick W. Eiken, Micheal P.P.Bannon, Martin D. Zielinski Mayo Clinic, Rochester, MN BACKGROUND: Based on previous published data on small bowel obstruction (SBO) management, a three feature model has been adopted in our institution predicting the need for exploration. Obstipation combined with mesenteric edema and lack of the small bowel feces sign on computed tomography (CT) were associated with the need for exploration. Patients with 2 or less features were managed non-operatively and administered a Gastrografin (GG) challenge. HYPOTHESIS: We hypothesize that the (GG) challenge test, when used in combination with the predictive model, will decrease the rate of explorations in patients not meeting the criteria for immediate operation. METHODS: IRB approval was obtained to review patients admitted with SBO from November 2010 to September 2011. Presenting with signs of strangulation or all three fea- 4 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA tures, and those who had an abdominal operation within 6 weeks of admission were excluded. All patients had an abdominal/pelvic CT scan and GG challenge upon diagnosis. GG patients were compared to historic controls managed without the GG (July to December 2009). Successful GG challenge was considered as the presence of contrast in the colon after an 8 hour plain abdominal film or a bowel motion. Data is presented as medians or percentages. Significance was considered at p < 0.05. 290 Attila Dubecz1, Michael Schweigert1, Rudolf J. Stadlhuber1, Norbert Solymosi2, Jeffrey H. Peters3, Hubert J. Stein1 1. Surgery, Klinikum Nurnberg, Nurnberg, Germany; 2. Veterinary Medicine, Szent István University, Budapest, Hungary; 3. Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY RESULTS: One hundred and thirty three patients with a diagnosis of SBO were identified (47% male) with 54 receiving GG (study) and 79 historic control patients. There was no difference in age (71 vs 65 years), prior SBO (52% vs 47%), diabetes mellitus (20% vs 18%), history of malignancy (35% vs 41%) or cardiac disease (29% vs 37%). Both groups had similar number of previous abdominal operations (2 vs 2). The presence of mesenteric edema (67% vs 76%), the lack of small bowel feces sign (50% vs 48%) and obstipation (24% vs 22%) were similar in both groups. Patients in the GG group had a lower rate of abdominal exploration (26% vs 43% p = 0.044) and fewer complications (11% vs 33% p = 0.004) compared to the control group. There was an equivalent number of strangulation obstructions (4% vs 10%), bowel perforation (4% vs 4%), length of hospital stay (4 vs 7 days), days from admission to operation (5 vs 3) and mortality (9% vs 6%). 46 patients had a successful GG challenge with 8 failures. There was a higher rate of exploration in patients with a failed challenge compared to those who passed (88% vs 15%, p < 0.001). BACKGROUND: The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objective was to evaluate the time-trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample. METHODS: Using the National Cancer Institute’s Surveillance Epidemiology and End Results-Database (1998– 2008), a total of 342,792 patients with surgically treated GI malignancy(esophagus: 13,471; stomach: 21,094; small bowel: 10,588; colon: 243,982; rectum: 41,683; pancreas: 11,974) were identified. Adequate lymphadenectomy was defined based on review of pusblished data and was defined as: 23 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum and 12 pancreas. The median number of lymph nodes removed and prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the 10 study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy. CONCLUSION: The use of the GG challenge enhanced the SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate operation. Patients who failed the GG challenge test were much more likely to undergo exploration. RESULTS: The median number of excised nodes improved over the decade of study in all types of cancer; esophagus: from 7–13, stomach 9–12, small bowel 3–6, colon 9–15, rectum 8–13 and pancreas 7–11. Further the percentage of patients with an adequate lymphadenectomy (median 42.3% for all types) steadily increased and those with zero nodes removed (median 7.1% for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2008, the percentage of patients with adequate lymphadenectomy was 16.4% for esophagus, 37.4% for stomach, 31.4% for small intestine, 72.7% for colon, 58.2% for rectum and 49.9% for pancreas. Men, non-white race, patients >65 yrs, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < .0001). 289 Laparoscopic Total Gastrectomy with Multi-Organ Resection for Large Gastric Cancer Amanda K. Arrington, Marjun Philip N. Duldulao, Alessio Pigazzi, Joseph Kim Surgical Oncology, City of Hope National Medical Center, Duarte, CA Despite the wide acceptance of laparoscopic surgical techniques, its use for higher staged gastric cancer has been limited. Laparoscopic total gastrectomy poses many complex challenges, in particular the construction of the esophagojejunal anastomosis. This video shows the resection of a large gastric cancer in an otherwise healthy 53 yo male that required total gastrectomy, distal pancreatectomy, splenectomy, and transverse colectomy. Thus multi-organ resection and total gastrectomy, including the construction of an esophagojejunal anastomosis, can safely and efficiently be performed laparoscopically. CONCLUSIONS: Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the United States although the median number of resected nodes increased over the last ten years. Gender, socioeconomic and racial disparities in receiving adequate lymphadenectomy were observed. 5 Sunday Abstracts Time-Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: A Population-Based Analysis of 342,792 Patients THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 10:30 AM – 11:15 AM 28ab PRESIDENTIAL PLENARY B (PLENARY SESSION II) 372 ment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox’s multiple hazards regression. Hiatal Hernia, Barrett’s Esophagus and Long-Term Symptom Control After Laparoscopic Fundoplication for Gastresophageal Reflux RESULTS: According to Kaplan-Meier estimates the rate of reflux symptom recurrence was 15% after 108 months, 11% in cases without intestinal metaplasia, but 43% in patients with long-segment (33 cm) Barrett’s esophagus (BE; p < 0.0001). Reflux symptoms recurred in 22% of cases with a hiatal hernia (HH) 33 cm before operation, but only in 7% with smaller or absent HH (p = 0.005). Multivariate analysis revealed a relative risk of 6.6 (CI 3.0) for longsegment BE and of 3.0 (CI 1.7) for HH 33 cm. A strong statistical interaction was found between HH 33 cm and long-segment BE: the small group (n = 18) of cases exhibiting both risk factors revealed an exaggerated recurrence rate of 72% at 108 months. Joumanah Hafez1,2, Johannes Lenglinger2, Friedrich Wrba3, Marcus Hudec4, Christiane Wischin2, Johannes Miholic2 1. Department of ENT, Martin Luther University Halle, Medical Faculty, Halle/Saale, Germany; 2. Department of Surgery, Medical University Vienna, Vienna, Austria; 3. Department of Pathology, Medical University Vienna, Vienna, Austria; 4. Department of Scientific Computing, University of Vienna, Vienna, Austria OBJECTIVE: To determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors. DESIGN, SETTING AND PATIENTS: A cohort of 271 patients, operated at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102 months (range, 12 to 158). CONCLUSIONS: Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85%) patients. HH 33 cm and long-segment BE materialized as independent prognostic factors favoring recurrence. MAIN OUTCOME MEASURES: The time between operation and recurrence of reflux symptoms (i.e. time to treat- Univariate Analysis of Putative Risk Factors for Symptom Recurrence Variable n % Recurrence After 36 Months % Recurrence After 108 Months All patients 271 7% 15% Total (Nissen) n = 197 7% 16% Partial (Toupet) n = 74 7% 14% Mode of fundoplication 0.49 Intestinal metaplasia DeMeester’s score Hiatal hernia Contraction amplitudes p-Value (Log-Rank Test) <0.001 Absent n = 199 3% 11% Short segment BE n = 43 12% 16% Long segment BE n = 29 28% 43% <50 n = 209 5% 10% ≥50 n = 62 15% 28% <3 cm n = 93 5% 7% >3 cm n = 153 10% 22% <62 mmHg n = 131 10% 19% >62 n = 138 6% 12% Gender, age, LES pressure and operation time period were not significant. 6 0.001 0.005 0.07 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Variable Risk Ratio Lower CL Upper CL p-Value HH ≥ 3 cm 3.8 1.7 10.2 <0.001 BE ≥ 3 cm 6.6 3.1 13.5 <0.001 Nissen vs. Toupet 1.0 0.7 1.5 0.91 Propensity score 0.97 0.6 1.2 0.85 CONCLUSIONS: Ventral hernia repair is associated with overall financial losses. Inpatient synthetic mesh repairs are essentially budget neutral. Outpatient repairs and inpatient repairs without mesh result in net financial losses. Inpatient biologic mesh repairs result in a negative contribution margin and striking net financial losses. Cost-effective strategies for managing ventral hernias in a tertiary care environment need to be developed in light of the financial implications of this patient population. 373 374 Financial Implications of Ventral Hernia Repair at an Academic Institution Impact of MRSA Nasal Colonization on Surgical Site Infections Following Major Gastrointestinal Surgery Drew Reynolds, Daniel L. Davenport, Ryan L. Korosec, J. Scott Roth Department of Surgery, University of Kentucky, Lexington, KY Harry T. Papaconstantinou, Marcela Ramirez, Michelle Marchessault, Cara Govednik-Horny, Daniel Jupiter Surgery, Scott & White Memorial Hospital, Temple, TX INTRODUCTION: Complicated ventral hernias are often referred to tertiary care centers. Hospital costs associated with complex hernia repairs include direct costs (mesh materials, supplies, non-surgeon labor costs), and indirect costs (facility fees, equipment depreciation, and unallocated labor). Operative supplies including mesh represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts. We aim to evaluate the cost-effectiveness of complex abdominal wall hernia repair at a tertiary care referral facility. PURPOSE: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization is increasing, and is an important pathogen in surgical site infections (SSI). Nasal-swab testing is effective for identifying patients with MRSA colonization, and has been shown to be predictive of SSI in cardiac and orthopedic surgery cases. However, the role of MRSA colonization on SSI following major gastrointestinal (GI) surgery is not known. The purpose of this study is to determine if MRSA colonization affects SSI after major GI surgery. METHODS: Cost data on all consecutive open ventral hernia repairs (CPT Codes 49560, 49561, 49565, and 49566) performed between July 1, 2008 and May 31, 2011 were analyzed. Cases were analyzed based upon hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. We examined median net revenue, direct costs, contribution margin, indirect costs, and net profit/loss. Among primary hernia repairs, cost data was further analyzed based upon mesh utilization (no mesh, synthetic, or biologic). METHODS: In 12/2007, we began universal nasal swab testing for MRSA colonization within 24 hrs of admission. MRSA-colonized patients were placed on contact precautions and isolated. We retrospectively reviewed the charts of all patients undergoing major GI surgery (esophagus, stomach, hepatobiliary, pancreatic, duodenum, small bowel, colon and rectum) from 12/2007 to 8/2009. Patients were grouped according to nasal swab test results as MRSAcolonized (MRSA+), methicillin-sensitive Staphylococcus aureus-colonized (MSSA+) or not colonized (Negative). Data analyzed included demographics, incidence of SSI, organisms cultured from the wound, length of hospital stay (LOS) and mortality. RESULTS: 415 patients underwent ventral hernia repair (353 inpatient, 62 outpatient). 173 patients underwent ventral hernia repair as the primary procedure. 180 patients underwent hernia repair as a secondary procedure. Median net revenue ($17,310 vs. $10,360, p < 0.01) and net losses (3,430 vs. 1,700, p < 0.01) were significantly greater for those who underwent hernia repair as a secondary procedure. Among primary ventral hernia repairs, 46 were repaired without mesh; 79 were repaired with synthetic mesh and 48 with biologic mesh. Median direct costs for cases performed without mesh were $5,432; median direct costs for those using synthetic and biologic mesh were $7,590 and $16,970, respectively (p < .01). Median net losses for repairs without mesh were $500. Median net profit of $60 was observed for synthetic mesh based repairs. The median contribution margin for cases utilizing biologic mesh was –$4,560 and the median net financial RESULTS: A total of 1137 patients were identified and grouped according to nasal swab results; 897 (78.9%) Negative, 167 (14.7%) MSSA+, and 73 (6.4%) MRSA+. The mean age was 59.5 years, 44.5% were men, 47.9% had colon or rectal operations, and 9% were emergent operations. There with no significant difference between groups. There were 101 patients identified with SSI (8.9%), and the MRSA+ group was associated with a higher rate of SSI when compared to Negative and MSSA+ groups (13.7% vs. 9.4% vs. 4.2%; p < 0.05). Wound culture results were identified in 92 (91.1%) patients with SSI. When SSI was present the MRSA+ group had a significantly higher rate of MRSA positive wound cultures when compared to non-MRSA colonized patients (70% [7/10] vs. 8.5% [7/82]; p < 0.0001). 7 Sunday Abstracts loss was $8,370. Outpatient ventral hernia repairs with and without synthetic mesh resulted in median net losses of $1,560 and $230, respectively. Multivariate Analysis (Cox’s Multiple Hazards Model) of Prognostic Factors for Time to Symptom Recurrence THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT The mean LOS was 12.5 days for MRSA+ group, and was 4 days longer than Negative and MSSA+ groups (8.8 and 7.6 days, respectively; p < 0.001). Although the presence of SSI significantly increased LOS from 6.2 days to 15.7 days (p <0.001), there was no difference in LOS for patients with SSI between nasal swab groups (p = 9.2). Overall mortality was 4.0% (45/1137) and deaths were evenly distributed between nasal-swab groups. CONCLUSIONS: Our data suggest that MRSA nasal colonization is associated with a longer LOS and an increase in incidence of SSI in patients undergoing major GI surgery. Furthermore, when SSI occurred, MRSA nasal colonization was strongly predictive of MRSA-associated SSI. Preoperative nasal swab test with decolonization of MRSA+ patients may decrease LOS and reduce the incidence of MRSA-associated SSI after major GI surgery. A cost benefit analysis is required. 2:15 PM – 4:30 PM 26ab VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND ADVANCED LAPAROSCOPIC GI SURGERY 519 521 Robotic Assisted Excision of Pelvic Neurofibroma Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S): A Simplified Duodenal Switch with Metabolic Orientation Celeste Y. Kang, Alessio Pigazzi Surgery, University of California Irvine School of Medicine, Irvine, CA Andrés Sánchez-Pernaute, Miguel Angel Rubio Herrera, Elia Pérez-Aguirre, Pablo Talavera, Antonio J. Torres Surgery, Hospital Clínico San Carlos, Madrid, Madrid, Spain A 55 year old male with a recent history of left renal cell carcinoma underwent laparoscopic partial nephrectomy. During the work up, a 3 cm pelvic mass was also found. A robotic assisted excision of the pelvic mass was performed. The rectum was mobilized by entering the presacral plane between the mesorectum and the presacral fascia. The dissection was carried down distally to the level of the pelvic floor until a cystic mass was noted. The mass was carefully dissected out using monopolar and bipolar cautery until the mass was excised in its entirety. Final pathology revealed a benign neurofibroma. This video emphasizes the technique, feasibility and safety of this procedure. Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S is a simplified duodenal switch in which a loop duodeno-ileostomy is performed instead of the classical Roux-en-Y diversion. The preservation of the pylorus makes unnecessary the bile diversion. The operation is simpler, shorter and has the advantage of less number of anastomosis and no mesenteric opening. SADI-S has been performed in our Department since May-2007 over more than 100 patients. The mean long-term excess weight is around 100%, with only 1% of failures and 3% cases of recurrent hypoproteinemia. Long remission of diabetes is obtained in more than 90% of the cases. 520 Single Incision Laparoscopic Right Hemicolectomy with Intracorporeal Anastomosis 522 Celeste Y. Kang, Steven Mills, Alessio Pigazzi Surgery, University of California Irvine, Orange, CA Robotic-Assisted Esophageal Epiphrenic Diverticulectomy, Myotomy and Dor Hemi-Fundoplication A 69 year old female with a tubular adenoma near the hepatic flexure undergoes a single incision laparoscopic right hemicolectomy. Using a 3 cm periumbilical incision and a single access port is inserted. The colon is mobilized in a medial to lateral fashion. The ileocolic pedicle and the right branch of the middle colic artery are divided. The bowel is divided proximally and distally. The specimen is removed though the single port with no need to lengthen the incision. A 60 mm linear stapler is used to create a side to side anastomosis. The enterotomy is closed intracorporeally in two layers. This video emphasizes the feasibility of intracorporeal anastomosis during single access colectomy. Daniel K. Tong, Simon Law, Fion S. Chan Surgery, The University of Hong Kong, Hong Kong, Hong Kong A 57-year-old woman presented with intermittent dysphagia and occasional regurgitation for 6 months. Pre-intervention investigations included contrast upper GI study, endoscopy and manometry that showed a 4 cm epiphrenic diverticulum located at the lower esophagus facing the right side. Manometry revealed an increased lower esophageal sphincter resting pressure. Diverticulectomy, myotomy and Dor hemi-fundoplication was performed using Robotic-assistance. The operative steps included isolation of the diverticulum with sparing of the vagi, diverticulectomy by using a linear stapler, anterior myotomy and a Dor 180 degree anterior hemi-fundoplication. 8 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 523 Laparoscopic Reversal of Roux-en-Y Gastric Bypass to Treat Recalcitrant Hyperinsulinemic Hypoglycemia Jacob A. Greenberg1, Dawn B. Davis2, Haggi Mazeh1, Guilherme M. Campos1 1. Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; 2. Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI The video presents technical steps for Laparoscopic Reversal of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy, and results of pre and post-op metabolic testing. The patient underwent RYGB at another institution (BMI 46). Two years after RYGB (BMI 25), presented with recalcitrant hyperinsulinemic hypoglycemia episodes and hypoglycemia unawareness. A laparoscopic gastrostomy was placed in the excluded stomach. A meal test (MT) administered orally and through the gastrostomy showed altered insulin and glycemic responses through the RYGB. Laparoscopic reversal was performed. Patient symptoms subsided; and 6 months later (BMI 29), a MT showed normal insulin and glycemic profiles. 526 Per-Oral Endoscopic Myotomy (POEM): Techniques for Successful Submucosal Dissection Eric M. Pauli, Jeffrey M. Marks, Jeffrey L. Ponsky Surgery, University Hospitals Case Medical Center, Cleveland, OH Recently, a new endoscopic method for reducing lower esophageal sphincter pressure in achalasia patients, per-oral endoscopic myotomy (POEM), has been developed. The most difficult part of POEM is the submucosal dissection, which spatially separates the mucosa and the musculature and provides an intact tissue plane for secure esophageal closure. The purpose of this video is to review six technical pearls identified over our series of POEM patients that permit successful, reproducible creation of the submucosal tunnel. 524 Transanal NOTES Sigmoidectomy in a Cadaver Model Ezra N. Teitelbaum, Fahd O. Arafat, Byron F. Santos, Eric S. Hungness, Anne M. Boller Surgery, Northwestern, Chicago, IL 527 This video shows a transanal hybrid natural orifice transluminal endoscopic surgery (NOTES) sigmoidectomy performed in a cadaver model using a TEM proctoscope. We employ a combined laparoscopic and endoscopic technique to place a stapler anvil in the proximal colon prior to initiation of colon dissection. This allows for a completely intra-corporeal anastomosis to be performed without the need for colon exteriorization. Techniques for occluding the rectal lumen with a purse-string suture, performing a full thickness dissection at the rectosigmoid junction, and creating a colorectal anastomosis through the TEM proctoscope are also shown. Thoracoscopic Esophageal Leiomyoma Enucleation Jason Richardson, Ninh T. Nguyen Surgery, University of California Irvine Medical Center, Orange, CA This is a video presentation of a patient who was incidentally found to have an esophageal mass. EUS revealed a 25 × 14 mm hypoechoic submucosal lesion at 28–30 cm arising from the muscularis propria with normal overlying mucosa and no obvious nodal involvement. FNA demonstrated spindle cells. A thoracoscopic enucleation was performed and is featured in this video. Final path was consistent with leiomyoma. Port positioning, endoscopy, esophageal mobilization, mass enucleation, and muscular layer reapproximation are featured in this video. 525 Robotic-Assisted Transduodenal Resection of Ampullary Tumor with Bile and Pancreatic Duct Reconstruction John Prodromo1, Mehmet F. Can3, Jennifer R. Bonfili3, Dev Patel1, Herbert Zeh1,2, A. James Moser1,2 1. University of Pittsburgh School of Medicine, Pittsburgh, PA; 2. Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 3. University of Pittsburgh Medical Center, Pittsburgh, PA A 75 year old woman presented with recurrent pancreatitis and endoscopic evidence of a duodenal papillary mass that did not show high grade dysplasia extending up the 9 Sunday Abstracts common bile duct. Follow up after endoscopic ampullectomy demonstrated recurrence of the lesion. The adenoma was then resected using a robotic-assisted transduodenal approach with bile and pancreatic duct reconstruction. This case demonstrates the ability to establish precise excisional margins and to remove lesions that cannot be resected endoscopically via the use of robotic assistance. This method demonstrates an alternative option to avoid the morbidity associated with pancreaticoduodenectomy for benign lesions. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 2:15 PM – 5:00 PM 27b PLENARY SESSION III CONCLUSION: IOC remains a frequently used procedure. In a national study, most surgeons appear to be using IOC selectively. A 10% minority of surgeons appear to approach IOC as mandatory. Intriguingly, a surgeon’s routine use of IOC is correlated with increased rates of post-surgical procedures, and is associated with increased overall complications, with no additional decrease in CBD injury rate. Further studies are warranted to determine if additional surgeon, patient, or perioperative factors contribute to the apparently unhelpful effect of compulsory IOC. 528 Is Routine Intraoperative Cholangiogram Necessary in the 21st Century? A National View Elizaveta Ragulin-Coyne1, Elan R. Witkowski1, Zeling Chau1, Sing Chau Ng1, Heena P. Santry1, Mark P. Callery2, Shimul A. Shah1, Jennifer F. Tseng1,2 1. Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA; 2. Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 528a INTRODUCTION: Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, as the “critical view of safety” technique has become widespread, current practice and outcomes of IOC are unclear. Quality Assessment in Pancreatic Surgery: What Might Tomorrow Require? Brian T. Kalish1, Charles M. Vollmer2, Tara S. Kent1, William H. Nealon3, Jennifer F. Tseng1, Mark P. Callery1 1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2. Surgery, University of Pennsylvania, Philadelphia, PA; 3. Surgery, Vanderbilt University, Nashville, TN METHODS: Nationwide Inpatient Sample 2004–2009 was queried for patients with acute/urgent biliary disease undergoing laparoscopic and/or open cholecystectomy; IOC was quantified. We limited analyses to states with consistent coding of provider and hospital ID data, and excluded surgeons performing <10 cholecystectomies/year. We dichotomized surgeons into a high-IOC group (top 10%, using yearly ratio of IOC/cholecystectomy frequency) vs. standard group (lower 90%). Our outcomes included bile duct injury, overall complications, in-hospital mortality, length of stay (LOS), use of additional studies such as endoscopic retrograde cholangiopancreatography (ERCP), and hospitalization cost. Statistical analysis included weighted univariable and multivariable analysis, and Cochran-Armitage trend test. INTRODUCTION: The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. Traditional quality metrics in high-acuity surgery (volume and mortality) cannot alone measure or satisfy these domains. We asked experts in pancreatic surgery (PS) whether broader quality metrics are needed, how important they might be, and whether they align to contemporary IOM healthcare quality domains. METHODS: Together with a professional market research firm, we created and distributed a web-based survey to pancreatic surgeons. These experts were identified through PS specialty societies, and verified by survey demographics. Respondents (Rpds) ranked 62 proposed PS quality metrics on level of importance (LoI). Next, Rpds aligned each metric to one or more IOM quality domains (MDA, multidomain alignment). Descriptive statistics were used to summarize responses. To calculate and rank relative quality scores, points were awarded for LoI (4-Essential, 3-Very important, 2-Somewhat important, 1-A Little important, 0-Not important) and MDA (1 point/each aligned domain). LoI Scores and MDA Scores for a given quality metric were averaged together to render a Total Quality Score (TQS = LoI + MDA/2) normalized to a 100-point scale. RESULTS: 518488 nationally weighted patients underwent cholecystectomy; 33.9% had IOC. Over time, IOCs utilization increased (31% to 34%, p < 0.0001), annual number of cholecystectomies remained stable. 12,527 non-weighted annual surgeon volumes were included in analysis. On average, each surgeon performed 31.9 cholecystectomies and 7.9 IOCs annually, with mean annual surgeon-specific IOC/CCY ratio of 0.23. The high-IOC (top 10%) group used IOC for 100% of cases. Of note, 25% of surgeons used IOC for at least half of cases. Comparing high-IOC group to standard group, high-IOC had no difference in bile duct injury (0.25% vs. 0.27% for standard group, p = 0.2; a higher rate of overall complications: 7.2% vs. 6.9%, p = 0.04; and no difference in mortality 0.4% vs. 0.4% p = 0.8). Patients of high-IOC surgeons had shorter LOS, 3.9 vs. 4.2 days, p = 0.002, and were more likely to use additional procedures: ERCP 16.0% vs. 13.1%, p = <0.0001. RESULTS: 106 surgeons (21%) completed the survey (82% North America and 84% Academic). On average, Rpds and their institutions perform 43 and 114 pancreatic operations 10 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 530 High Grade Dysplasia and Adenocarcinoma Are Frequent in Side-Branch Intraductal Papillary Mucinous Neoplasm Measuring Less Than 3 cm on Endoscopic Ultrasound Joyce Wong1, Jill Weber1, Barbara A. Centeno3, Shivakumar Vignesh2, Cynthia L. Harris2, Jason B. Klapman2, Pamela Hodul1 1. Surgery, H. Lee Moffitt Cancer Center, Tampa, FL; 2. Gastroenterology, H. Lee Moffitt Cancer Center, Tampa, FL; 3. Pathology, H. Lee Moffitt Cancer Center, Tampa, FL BACKGROUND: Surgical resection for intraductal papillary mucinous neoplasm (IPMN) of the pancreas has increased over the last decade. While IPMN with main duct communication are generally recommended for resection, indications for resection of side-branch IPMN (SDIPMN) have been less clear. We reviewed our single-institutional experience with SDIPMN and indications for resection. METHODS: Patients who underwent resection for IPMN were identified from a prospectively maintained IRB approved database. Patients with main pancreatic duct communication were excluded. Outcome, clinical and pathologic characteristics were correlated with endoscopic ultrasound (EUS) findings. RESULTS: From 2000 to 2010, 105 patients who underwent pre-operative EUS evaluation and resection for SDIPMN were identified. The mean age was within the sixth decade of life, and there was a slight female predominance (55% vs. 45%). The most common presenting symptom was abdominal pain (N = 47, 45%), followed by jaundice (N = 24, 23%) and weight loss (N = 24, 23%). Only 10 patients (10%) were asymptomatic at presentation; 8 (80%) had suspicious features on EUS. Of the total cohort, few patients had intracystic septations (N = 27, 26%) or presence of mural nodules (N = 2, 2%) on EUS. Of 39 patients who had invasive pancreatic ductal adenocarcinoma (PDAC) on final pathology, EUS-fine needle aspiration (EUS-FNA) demonstrated malignancy in only 21 (54%). CONCLUSIONS: We propose a 12-item “Quality Scorecard” for PS based on rank-scoring of quality metrics that PS experts view as both highly important and aligned with more than one IOM healthcare quality domain. While the actual performance thresholds for these metrics require further definition and validation, they may reveal quality to an extent that volume and mortality alone cannot. Top Pancreatic Surgery “Quality Scorecard” Metrics by Total Quality Score (TQS) Metric TQS Multidisciplinary services for pancreatic diseases 63 Major complication rate 60 Peri-operative mortality (0–90 days) 59 Overall complication rate 57 Incidence of post-operative hemorrhage 55 Venous thromboembolism (VTE) prophylaxis 54 Patients with malignancy who undergo adjuvant therapy 54 Readmission rates (30 day, 90 day, total) 54 Incidence of post-operative pancreatic fistula 54 Timely and appropriate peri-operative antibiotics 53 Survival rates (1 yr and 5 yr post-operative) 52 Timing from diagnosis to surgical consultation 51 EUS evaluation of cyst size was correlated with final pathology. Of 70 patients with EUS cyst size <3 cm, 12 (17%) had a pre-operative EUS diagnosis of malignancy. Final pathology revealed 24 (34%) to have PDAC: 1 of 7 (14%) patients with cyst size <1 cm, 2 of 19 (11%) with cyst size 1–2 cm, and 21of 44 (48%) with cyst size 2–3 cm. 15 of 35 (43%) patients with cyst size >3 cm had PDAC on final pathology. Of the patients with cyst size <3 cm, 16 (23%) had high-grade dysplasia on final pathology: 3 of 7 (43%) with cyst size <1 cm, 3 of 19 (16%) with cyst size 1–2 cm, and 10 of 44 (23%) with cyst size 2–3 cm. Seven of 35 (20%) patients with cyst size >3 cm had high-grade dysplasia on final pathology. Although overall survival (OS) at 48 months stratified by EUS cyst size did not significantly differ between groups, patients with PDAC on final pathology had significantly 11 Sunday Abstracts per year, respectively. By descriptive analysis, 90% of Rpds indicated a definite or probable need for improved quality metrics in PS. 81% of Rpds indicated a definite or probable value for a “Quality Scorecard” in PS. Of 13 PS quality metrics rated as Essential by >25% Rpds, 10 aligned most strongly to the IOM Safety domain. 22/62 proposed metrics aligned to more than 1.75 IOM Domains, and were rated by >50% Rpds as High LoI (Essential or Very Important; Figure). 12 proposed scorecard metrics (Table) emerged with the highest TQS. Those related to mortality, to the rate and severity of complications, and to access to multidisciplinary services for pancreatic disease had the highest TQS. Technical and peri-operative metrics had intermediate TQS. Metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT worse OS compared to non-invasive pathology. A total of 8 patients (8%) developed recurrent disease, all of whom had PDAC on final pathology. and sporadic IBD. 4. Alteration of the ZO-1 protein by the SNP may lead to conformational changes or alterations in binding sites that make it resistant to degradation in IBD. Further study of the changes in the ZO-1 protein by a mutation at rs260526 may lead to a better understanding of the role of ZO-1 in IBD. CONCLUSION: EUS is a helpful modality for the diagnostic evaluation of SDIPMN. Considering the high incidence of malignancy as well as high-grade dysplasia in SDIPMN greater than 2 cm, EUS features should be used in conjunction with other clinical criteria to guide management decisions. Patients with SDIPMN greater than 2 cm that do not undergo surgical resection may benefit from more intensive surveillance. 532 Ostomy Creation Significantly Increases ER Visits and Hospital Readmission After Colorectal Resection Lisa S. Poritz1, Arthur Berg2 1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA; 2. Biostatistics and Bioinformatics, The Milton S. Hershey Medical Center, Hershey, PA 531 Mutation in ZO-1 Is Associated with Protection from Familial Inflammatory Bowel Disease INTRODUCTION: Readmission after colorectal (CR) surgery continues to be a significant problem and quality of care issue. The purpose of this study was to identify factors predictive of readmission after CR surgery. Lisa S. Poritz, Leonard R. Harris, Arthur Berg, Tara M. Connelly, John P. Hegarty, Sue Deiling, Zhenwu Lin, Rishabh Sehgal Surgery, The Milton S. Hershey Medical Center, Hershey, PA INTRODUCTION: Inflammatory bowel disease (IBD) is thought to occur due to an environmental insult in a genetically susceptible individual. Multiple genetic variants have been identified to be associated with IBD. The tight junction complex (TJ) is part of the intestinal epithelial barrier and has been shown to be altered in patients with IBD. The purpose of this study was to identify genetic variants in the TJ complex that may be associated with IBD. METHODS: 30% (computer generated list) of the records of all patients admitted to the CR service at our institution from July 2008—June 2011 were reviewed for patients undergoing colorectal resection. Patients who died within 60 days of surgery or were discharged to hospice were excluded. All others were then subdivided into 2 groups: those patients that were either re-admitted or visited the emergency room (ER) within 60 days after discharge and those patients that did not. Additional data abstracted from the medical record included total length of stay (LOS), post-operative LOS (POD), diagnosis subcategorized into malignant, diverticulitis, IBD, other benign disease; procedure subcategorized into colon resection, rectal resection, combined resection; presence of an ostomy, laparoscopic or open (converted procedures were in the open category), surgeon, admission type (urgent/emergent or elective), and patient age. Univariate and multivariate analysis was performed. METHODS: DNA from members of our IBD registry was previously collected and stored. Initially 284 members of our IBD registry and non-diseased controls underwent genotyping for 25 TJ single nucleotide polymorphisms (SNP) on an IlluminaTM platform. Genes studied coded for both transmembrane and membrane associated proteins. Based on initial screening results, a total of 670 IBD patients and non-diseased controls were genotyped for the rs260526 SNP by polymerase chain reaction (PCR). IBD patients were subdivided into familial (at least one family member with IBD besides the index patient) or sporadic (no family members with IBD). Three genetic models (general, additive, and dominant) were used to quantify the initial genotyping. For rs260526, groups were compared with a two-sided Fisher’s exact test. RESULTS: 242 patients met criteria. Data is shown in the table. 74 (30.6%) patients were readmitted or visited the ER within 60 days of discharge. Diagnosis, type of resection, approach (lap vs open), age, and type of admission were not different between patients readmitted and those that were not. Presence of an ostomy (ileostomy or colostomy) was the most significant factor associated with readmission, with 77% of the readmitted patients having an ostomy (p = 0.0000014). Surgeon performing the procedure, LOS, and POD, were also significant factors determining readmission on univariate analysis and all remained statistically significant on multivariate analysis. The most common reasons for readmission were nausea, vomiting, abdominal pain, and dehydration. 53/74 (72%) of the readmitted patients had at least one of these as their diagnosis. 129/242 (53%) of the patients in this series had an ostomy post-operatively, likely due to the large number of patients with IBD and rectal cancer. Emergent or urgent procedures were not a significant risk factor for ostomy creation. The image shows probability of readmission with increasing LOS for patients with and ostomy (top curve) and without (bottom curve). Bands are 95% confidence intervals. RESULTS: Of the 25 initial SNPs only rs260526, a SNP in the ZO-1 gene, was shown to be statistically significant by all three genetic models when comparing IBD patients to non-diseased controls. ZO-1 is a key protein in the TJ complex and has been shown to be altered in IBD. Therefore, additional IBD patients and non-diseased controls were genotyped for rs260526 by PCR. When the IBD patients were subdivided, this ZO-1 SNP was found to be statistically significant when comparing patients with familial IBD to non-diseased controls, p = 0.0213, OR = 0.468, Cl = [0.225, 0.911]). The mutation was more common in the non-diseased controls, and therefore protective against IBD. CONCLUSIONS: 1. Of all the TJ SNPs studied, only a mutation in the ZO-1 gene was associated with IBD. 2. This SNP was found to be protective against the development of familial IBD. Lack of significance of this SNP in sporadic IBD supports a different pathogenesis for familial 12 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 533 Costs Associated with Colorectal Resection: Does Body Mass Index and Obesity Adversely Impact Resource Utilization? John P. Cullen, Pokala R. Kiran, Ryan Williams Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Obesity rates have soared drastically in recent years and complications of obesity lead to increased health-care costs. Whether costs after colorectal surgery are specifically higher for obese patients has however not previously been assessed. The aim of this study was to compare direct costs for obese and non-obese patients undergoing colon resection. Probability of Readmission: Top line: with ostomy, bottom line: without ostomy Shaded areas are 95% confidence intervals Readmission No Readmission 74 168 55.12 ± 1.94 55.71 ± 1.20 IBD 27 45 Malignancy 30 77 Diverticulitis 8 33 Other Benign 9 13 Colon 44 117 Rectal 27 44 Multiple 3 7 43/14/17 56/16/95 0.0000034 Total patients Age (years, mean ± standard error) Diagnosis p value METHODS: All patients undergoing elective open partial colectomy at a single high-volume colorectal unit over the last 3 years were identified. Patients with metastatic malignancy were excluded. Patients were stratified based on increasing body mass index (BMI) and matched for age, gender and ASA class. Data relating to operation, length of stay (LOS) and complications and costs were compared. Subgroup analysis was performed on underweight and morbidly (BMI >40) obese patients. 0.562 0.138 Type of resection 0.255 RESULTS: A total of 285 complete charts for patient undergoing partial colon resection were reviewed. Groups were similar with regards to age, gender, ASA class and procedure. Cancer and diverticulitis were the main diagnoses across all groups, except for the underweight group, where Crohn’s disease predominated and this group was excluded from further analysis. Mean LOS was similar between groups. Obese patients had greater mean hospital costs ($14803) than non-obese ($12992) but this difference was not significant (p = 0.82). Wound infection rate approached 45% in the morbidly obese group and was only 8% in patients who were not obese. The overall morbidity, wound infection and costs progressively increased with increasing BMI (table). Morbidly obese patients had significantly increased overall morbidity and costs when compared to non obese patients (p = 0.04). Ostomy Ileostomy/colostomy/no ostomy Any ostomy/no ostomy 57/17 72/95 0.0000014 Open/Laparoscopic 50/24 117/50 0.762 A 22 75 B 14 28 C 9 26 D 29 38 LOS (days, mean ± standard error) 11.22 ± 1.22 7.49 ± 0.30 0.00608 POD (days, mean ± standard error) 9.81 ± 1.09 6.79 ± 0.24 0.0168 Surgeon 0.0395 Admission type CONCLUSION: For patients undergoing elective colon resection, obesity leads to increased direct costs, with the morbidly obese having the greatest costs. The increased costs are likely due both to operating room costs and to the increasing higher overall morbidity, especially wound infection associated with increasing BMI. This risk should be accounted for in future health care policy including reimbursement and resource allocation strategies. 0.363 Emergent/urgent 16 28 elective 56 140 13 Sunday Abstracts CONCLUSIONS: The most significant predictive factor for readmission in this study was an ostomy. Ostomies are frequently used with elective and urgent CR and decreasing their use may not be prudent. However, the creation of each ostomy should be evaluated for necessity by the surgeon. Quality improvement projects should be directed at assessing readiness of ostomy patients for discharge and adequacy of support at home. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Group Underweight (n = 18) Non Obese (n = 185) Obese (n = 64) Morbidly obese (n = 18) BMI (kg/m2) <20 20–30 31–39 40–64 Age (years) 53 58.7 60.3 56.7 ASA class 1.7 2.3 2.5 2.6 Gender (% female) 55% 50% 55% 60% Overall Morbidity 26% 35% 31% 72% Wound infection 4% 8% 11% 44% Total Direct Costs ($) 11450 12992 14803 (p = 0.82) 18980 (p = 0.04) Nursing Costs ($) 2320 2498 3061 (p = 0.02) 2903 (p = 0.17) OR costs ($) 678 1007 1127 (p = 0.78) 2340 (p < 0.01) Pharmacy Costs ($) 972 751 1274 (p = 0.09) 1307 (p = 0.03) with complications following non-operative management including bowel obstruction, fistula, clostridium difficile infection and lower GI bleed. 534 Natural History of Acute Diverticulitis: Low Risk of Recurrence Following Non-Operative Management in a Population-Based Study CONCLUSION: Conservative management of diverticulitis results in a low rate of recurrence, further supporting a non-operative approach. The only predictor of recurrence was patient comorbidity. Non-operative management is associated with a low rate of complications. Jennifer D. Stanger, George Roxin, Anthony R. MacLean, William D. Buie Department of Surgery, University of Calgary, Calgary, AB, Canada 535 BACKGROUND: The natural history of acute diverticulitis remains poorly understood, and the role of surgical intervention is controversial. The purpose of this study was to determine the rates of recurrence and associated complications following non-operative management of acute diverticulitis in a population-based setting. Visceral Fat Volume Better Than BMI at Risk Stratifying Colorectal Cancer Patients Aaron S. Rickles, James C. Iannuzzi, Andrew-Paul Deeb, Fergal Fleming, John R. Monson Surgery, University of Rochester, Rochester, NY METHODS: All patients admitted to an adult hospital in a large urban area between January 2007 and March 2010 were identified using a health records search (ICD-10 codes K 572, 573, 578 and 579). Patients who underwent emergency surgery were excluded. Demographic, clinical, radiologic, treatment, complication and recurrence data were collected. Data was analysed with logistic regression; a twosided p-value of 0.05 was considered significant. INTRODUCTION: The extent to which obesity effects colorectal cancer outcomes has been inconsistent in the literature, which may be a result of BMI being a poor descriptor of fat distribution. Compared to subcutaneous adipose tissue, visceral adipose tissue is more metabolically active, leading to a chronic inflammatory state and increasing the risk for diabetes, cardiovascular disease, and tumorigenesis. In addition, men and women distribute fat differently, thus leading to differences in outcomes based on BMI. The aim of this study is to describe the effect of visceral obesity on colorectal cancer outcomes between gender groups. RESULTS: A total of 645 patients presented with acute diverticulitis. 502 patients were managed non-operatively (49 percutaneous drains, 456 antibiotics). Median age of patients was 55 (range 24–103), 51% of patients were female, median follow-up was 34 months (range 14–50). Seventy eight patients (15.5%) required acute readmission to hospital, of which 67 (85.9%) were related to recurrent diverticulitis. 14 (20.9%) patients required urgent surgical intervention. Of the remaining 53 patients managed non-operatively, 8 (15.1%) required a second acute readmission (6 due to recurrent diverticulitis, 2 requiring surgery). On univariate analysis only a Charlson Comorbidity score of 1 or greater was a predictor of recurrence (p = 0.02). Of the 559 total admissions for diverticulitis managed non-operatively, there were 51 (9.1%) in hospital complications (Dindo-Clavien grade 1 = 20, grade 2 = 25, grade 3 = 6). 10 (1.9%) patients were readmitted to hospital METHODS: We conducted a retrospective chart review of colorectal cancer patients who underwent surgery at our institution between 2003 and 2010. Patient selection was restricted to those who had a pre-operative CT scan of the abdomen and pelvis. Exclusion criteria included emergency surgery, metastatic cancer, and patients with IBD or HNPCC. CT scans were used to measure visceral fat volume (VFV) using Carestream PACS 10.2 (Carestream Health, inc.). Patients with a BMI ≥30 were considered obese and viscerally obese patients were defined as those with a VFV greater than the mean. Linear regression was used to ana- 14 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: A total of 233 patients met inclusion criteria, 75 Stage I (32%), 77 Stage II (33%), and 81 Stage III (35%). The mean age was 67, mean BMI 28.5, and mean VFV 1637 cm3. There was no significant difference in BMI between males and females (28.1 vs. 28.9, p = 0.294), however males had significantly more visceral fat than females (1867 cm3 vs. 1371 cm3, p = 0.0001). In addition, BMI proved to be a poor descriptor of visceral obesity on linear regression (r2 = 0.314, see Figure1). When analyzing disease free survival at three years (DFS3yr) there was no difference between obese and non-obese patients based on BMI. When analyzing outcomes based on VFV, non-obese females with Stage II cancer had significantly better DFS3 yr compared to viscerally obese females (86.3% vs. 60.0%, p = 0.034) although there was no significant difference in DFS3 yr amongst males. METHODS: Patients ≥18 years of age treated at our institution for CDC of any severity were consecutively enrolled. CDC was defined as symptoms of colitis with a positive PCR stool test. Each bacterial isolate was studied for virulence factors: tcdC mutation, binary toxin and ribotype 027 by PCR, and the presence of toxins A and B using restriction fragment length polymorphism. Chi Square tests, t-tests and logistic and linear regression were used to determine which virulence factors predicted the number of recurrent episodes and the need for admission to the hospital for treatment. RESULTS: Sixty-nine patients (male: 57%) were studied, with a mean age of 64 ± 13 years. Twenty-one (30%) patients were initially diagnosed as outpatients, while the remainder developed CDC during hospitalization. A majority of patients harbored at least one virulence factor (Table 1). There was no difference (p > 0.05) between virulence factors among inpatients and outpatients. Binary toxin was the single virulence factor independently associated with CDC recurrence (p = 0.02). A higher number of CDC recurrences was also observed with toxin A (p = 0.01) and tcdC mutation (p = 0.001) when either was present with binary toxin, with the combination of binary toxin and tcdC mutation being the strongest predictor, increasing the number of recurrences by an average of two episodes. The need for hospital admission for CDC recurrence was strongly associated with tcdC mutation (p = 0.04), binary toxin (p = 0.02) and ribotype 027 (p = 0.02). The combination of toxins A, B and binary toxin exerted an additive effect by increasing risk of readmission three-fold when all three toxins were present (p = 0.02). No resistance to metronidazole or vancomycin was encountered based on measurement of minimum inhibitory concentrations. Figure 1: Linear regression of Visceral fat Volume and BMI. CONCLUSION: This novel method for risk stratification demonstrates that visceral obesity decreases three year disease free survival for women with stage II colorectal cancer and should be considered in the discussion of chemotherapy use in these patients. Further study is necessary to delineate the effect of visceral obesity in men at various stages of colorectal cancer. Association of Virulence Factors with Recurrence And Admission for C. Difficile Colitis Incidence (n = 69) Association with Recurrence (p Value) Association with Admission (p Value) 61 (88%) 0.56 0.78 Virulence Factor Toxin A 536 Predicting Recurrence of C. difficile Colitis Using Bacterial Virulence Factors: Binary Toxin Is the Key David B. Stewart, Arthur Berg, John P. Hegarty Surgery/Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, PA Toxin B 66 (96%) 0.73 0.60 Binary toxin 42 (61%) 0.02 0.02 tcdC mutation 39 (56%) 0.18 0.04 Ribotype 027 26 (38%) 0.32 0.02 CONCLUSIONS: 1) Binary toxin is an independent predictor of CDC recurrence, which has not previously been reported. 2) The combination of binary toxin and tcdC mutation is associated with the highest number of CDC recurrences, such that their combined presence is associated with a 70% recurrence rate. 3) C. difficile which produces binary toxin may require longer antibiotic regimens to prevent disease recurrence. BACKGROUND: Recurrence of C. difficile colitis (CDC) is common, yet the ability to predict CDC recurrences is virtually non-existent. Certain C. difficile virulence factors have been implicated in the development of severe forms of CDC, including toxins A and B, binary toxin, tcdC mutation (leading to higher toxin production) and certain strains of the bacteria such as ribotype 027. However, the 15 Sunday Abstracts role these factors play in the development of CDC recurrence is unknown. This study tested the hypothesis that bacterial virulence factors predict CDC recurrence and the need for admission to the hospital. lyze the correlation between BMI and VFV, and independent sample t-test and Kaplan-Meier survival curves were used for outcome analysis. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 537 Table 1: Comparison of Mean Serosal EGG Values of Primary vs. Replacement GES in Gastroparesis Patients Long-Term Effects of Gastric Stimulation on Gastric Electrical Physiology Patrick A. Williams1, Yana Nikitina1, Thomas L. Abell1, Christopher J. Lahr2, Thomas S. Helling2 1. Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; 2. Surgery, University of Mississippi Medical Center, Jackson, MS Frequency Amplitude Primary Serosal EGG 5.27 0.33 40 Replacement Serosal EGG 3.75 0.3 24.3 0.000002 0.66 0.002 2.7–3.3 0.50 <10 p-value Normal EGG values Freq/Amp INTRODUCTION: This study evaluates the modeling of gastric electrophysiology (GEP) tracings during long term gastric electrical stimulation (GES) for gastroparesis (GP). Electrogastrography (EGG) via serosal recordings was performed on gastroparesis patients through stimulator leads prior to stimulation and again with stimulator off at time of stimulator replacement for battery depletion. We hypothesized that serosal EGG may change over time representing gastric remodeling from GES. PATIENTS: 66 patients with gastroparesis underwent placement of gastric stimulator for refractory symptoms. EGG was performed after the gastric leads were placed but before stimulation was begun. Patients underwent continuous stimulation until pacer batteries depleted and the stimulator was then replaced. At the time of stimulator replacement, after the stimulator was removed, but before the new pacemaker was attached, serosal EGG was again performed using the gastric leads. Mean age at initial GES placement was 44 years (range: 8–76); current mean age is 49; the majority of the subjects were female (n = 52, 79%). Only a minority had diabetes-induced gastroparesis (n = 16, 24%); the remainder were either idiopathic, post-surgical, or sarcoidosis-induced. Figure 1 CONCLUSION: Long-term gastric stimulation causes improvement in basal unstimulated gastric frequency towards normal. 538 METHODS: At the time of GES placement, mucosal EGG is performed through the GES leads. Once the GES battery expires, it is replaced. At the time of replacement, EGG is performed again, and GEP tracings are repeated. Multivisceral Transplantation: Expanding Indications and Improving Outcomes Richard S. Mangus, A. Joseph Tector, Rodrigo M. Vianna Indiana University School of Medicine, Indianapolis, IN RESULTS: After a mean of 3.9 years (46 months) of GES therapy, the mean unstimulated baseline frequency for gastroparesis patients before initial GES therapy was 5.27 cycles/min (SD = 1.89) and declined to 3.75 (1.58) after replacement (p = 0.000001), with a mean baseline frequency decrease of 0.03/month (Table 1, Figure 1). The mean amplitude was 0.33 mV (0.39) before initial GES therapy and decreased to 0.30 (0.34) afterward (p = 0.66). The frequency/amplitude ratio was 40.0 (40.7) before initial GES therapy and decreased favorably to 24.3 (25) afterward (p = 0.002). INTRODUCTION: Multivisceral transplantation (MVT) includes the simultaneous transplantation of multiple abdominal viscera including the stomach, duodenum, pancreas and small intestine, with (MVT) or without the liver (Modified MVT or MMVT). This study reviews the changing indications and outcomes for this procedure over a 7-year period at a university medical center. METHODS: This study is a retrospective case review of multivisceral transplants performed between 2004 and 2010 at a single center. All cases were either MVT or MMVT, and included a simultaneous kidney transplant, if indicated. Graft failure was defined as loss of the graft or complete loss of function. Graft function was monitored by laboratory values and serial endoscopy with biopsy. 16 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 50% patient survival during the period from 2004 to 2007, followed by a 75% patient survival during the period from 2008 to 2010. Primary complications included rejection (45% MMVT and 15% MVT), infection (>90% in the first year), graft versus host disease and post-transplant lymphoproliferative disorder. RESULTS: During the study period, 92 patients received 100 transplants including 85 MVT and 15 MMVT. There were 19 patients who received a simultaneous kidney graft. There were 24 pediatric and 76 adult recipients (range 4 months to 66 years). Indications included short gut with liver failure, cirrhosis with complete portal mesenteric thrombosis, slow growing central abdominal tumors, intestinal pseudoobstruction and frozen abdomen. All patients received antibody-based induction immunosuppression with calcineurin inhibitor-based maintenance immunosuppression. At a median follow-up of 36 months, 1-, 3and 5-year graft survival is 75%, 64% and 64%. There was a learning curve with this complex procedure resulting in a CONCLUSION: Indications for MVT and MMVT have broadened to include patients with slow growing tumors, complete portomesenteric thrombosis and abdominal catastrophes not amenable to other surgical therapy. Outcomes continue to improve with many patients returning to full functional status and enjoying long-term survival. 7:30 AM – 9:15 AM 28ab VIDEO SESSION II: BREAKFAST AT THE MOVIES 582 583 Right Hepatectomy with Caval Thrombectomy After Neoadjiuvant Therapy-TACE and Sorafenib-for HCC with Caval Thrombosis Hybrid Laparoscopic Total Colectomy/Robotic Extralevator Abdominoperineal Resection Celeste Y. Kang, Alessio Pigazzi Surgery, University of California Irvine, Orange, CA Alfredo Guglielmi, Andrea Ruzzenente, Elisabeth Baldiotti, Tommaso Campagnaro, Calogero Iacono Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy A 26 year old female with a large cecal polyp and rectal adenocarcinoma involving the spincter in the setting of newly discovered familial adenomatous polyposis undergoes a hybrid laparoscopic/robotic total colectomy with extralevator abdominoperineal resection. An oncologic colon resection with high vessel ligation is performed laparoscopically followed by robotic e-APR. Total mesorectal excision is performed and the levator fibers are divided at their origin laterally on the pelvic side wall. The dissection is carried out in the ischiorectal space as far distally as possible utilizing the robotic arms. This video emphasizes the technique, feasibility and safety of this procedure. A patient affected by HCV-related cirrhosis and multiple HCC in the right hepatic lobe with caval vein thrombosis is described. Considered the good response to treatment with TACE and sorafenib, the patient underwent to right hepatectomy and caval thrombectomy with anterior approach and total vascular exclusion. The specimen revealed complete necrosis of hepatic nodules and caval thrombus. After one year, recurrence appeared near the surgical margin, successfully treated with RFA. Six months later, CT scan revealed three HCC nodules in the left lobe. A TACE was performed with complete response. Two years after surgery, the patient is alive and without recurrence. 17 Monday Abstracts Monday, May 21, 2012 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 584 587 Per-Oral Esophageal Myotomy (POEM) and Subsequent Salvage Laparoscopic Heller Myotomy Laparo-Endoscopic Transgastric Resection of a Submucosal Mass at the Gastro-Esophageal Junction Ezra N. Teitelbaum, Nathaniel J. Soper, Eric S. Hungness Surgery, Northwestern University, Chicago, IL Neil Ghushe, Parambir S. Dulai, Thadeus Trus Dartmouth-Hitchcock Medical Center, Lebanon, NH This video shows two procedures performed on the same patient: a per-oral esophageal myotomy (POEM) and subsequent salvage laparoscopic Heller myotomy after recurrence of dysphagia. The POEM portion illustrates the key steps of this novel procedure and shows intra-operative bleeding that may have led to the patient’s eventual clinical failure. The patient underwent a laparoscopic Heller myotomy four months later which is shown in the second part. We see that the prior POEM had not created significant mediastinal or submucosal adhesions. This is the first evidence that patients who fail POEM can then undergo laparoscopic Heller myotomy without significant added operative difficulty. The management of gastric submucosal masses adjacent to the gastro-esophageal junction presents an interesting therapeutic challenge. Wedge resection is not possible in this location without compromising the lower esophageal sphincter or esophagus. Endoscopic submucosal dissection provides an inadequate deep tissue margin. We present a combined laparo-endoscopic approach for transgastric resection of this type of lesion. 581 The Standardization of Laparo-Endoscopic Single Site (LESS) Cholecystectomy Sharona B. Ross1,2, Alexander S. Rosemurgy2, Michael H. Albrink1,2, Edward Choung2, Scott F. Gallagher10, Jonathan M. Hernandez1, Santiago Horgan 14,18, Michael Kia20, Jeffrey M. Marks6, Jose Martinez17, Yoav Mintz12, Harold Paul2, Aurora D. Pryor3, David W. Rattner7,8, Homero Rivas9, Kurt E. Roberts5, Eugene Rubach15, Steven D. Schwaitzberg8,19, Lee L. Swanstrom16, John F. Sweeney11, Erik Wilson13, Harry Zemon4, Natan Zundel21 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa General Hospital, Tampa, FL; 3. Surgery, Stony Brook University, New York, NY; 4. Surgery, North Shore Lij Hospital, New Hyde Park, NY; 5. Surgery, Yale Medical Group, New Haven, CT; 6. Surgery, University Hospitals Case Medical Center, Cleveland, OH; 7. Surgery, Massachusetts General Hospital, Boston, MA; 8. Surgery, Harvard Medical Group, Boston, MA; 9. Surgery, Stanford School of Medicine, Stanford, CA; 10. Surgery, Forsyth Medical Center, Winston-Salem, NC; 11. Surgery, Emory University, Atlanta, GA; 12. Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Jerusalem, Israel; 13. Surgery, The University of Texas Medical School at Houston, Houston, TX; 14. Surgery, University of California, San Diego, CA; 15. Surgery, New Jersey Medical School, Newark, NJ; 16. The Oregon Clinic, Portland, OR; 17. Surgery, University of Miami Health Systems, Miami, FL; 18. Surgery, UC San Diego Medical Center, San Diego, CA; 19. Cambridge Health Alliance, Cambridge, MA; 20. Surgery, McLaren Regional Medical Hospital, Flint, MI; 21. Florida International University College of Medicine, Miami, FL 585 Hiatal Mesh: When the Crura Cannot Be Closed Tatyan M. Clarke, Ross F. Goldberg, Armando Rosales-Velderrain, Steven P. Bowers Surgery, Mayo Clinc – Florida, Jacksonville, FL The value of mesh-buttress over approximated crural musculature in hiatal hernia repair remains a topic of continued research and debate. However, there are situations in which mesh use is essential. When the crura are fibrotic, immobile, or damaged, and in the case of unusually large defects, crural re-approximation is not feasible and a meshbridge repair is indicated. Presented here are 3 cases where mesh is deemed necessary and appropriate. First, a case of fibrotic crura after hiatal hernia recurrence. The second case describes the technique of repair for a large para-hiatal hernia. The final case demonstrates repair of hiatal hernia occurring years after transhiatal esophagectomy. 586 Minimally-Invasive Robot-Assisted Modified Appleby Resection for Pancreatic Adenocarcinoma Joel Baumgartner, Mehmet F. Can, Herbert Zeh, A. James Moser University of Pittsburgh Medical Center, Pittsburgh, PA Selected patients with pancreatic adenocarcinoma involving the celiac trunk may derive prolonged survival benefit from surgical resection. We report two patients who underwent robot-assisted modified Appleby resection after chemoradiation. Median age was 82. Median duration of surgery was 374 minutes, median EBL 225 and 11 day length of stay. Surgical margins were negative in both patients. The most severe morbidity was Clavien grade 3 gastric ischemia that resolved with bowel rest. The other patient had an ISGPF grade C pancreatic leak requiring endoscopic drainage. Robot-assisted minimally invasive modified Appleby resection can be completed safely with acceptable morbidity and mortality. This video presents a standardized approach to LESS cholecystectomy. Bupivacaine was injected at the umbilicus. A 12 mm vertical incision was made. A 4-trocar port was inserted. A 5 mm deflectable tip laparoscope was utilized. With specific placement as denoted in the video, a bariatric length grasper and a bent grasper retracted the gallbladder. A window was developed between the gallbladder and the liver bed, promoting the “critical view.” The cystic duct and artery were divided and the gallbladder removed. The diaphragm was irrigated with bupivacaine solution. The umbilical defect was closed in a figure-of-eight fashion. This video promotes a standardized approach to LESS cholecystectomy. 18 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 10:00 AM – 11:15 AM 27b PLENARY SESSION IV Robotic-Assisted Rectal Dissection for Restorative Proctectomy for Ulcerative Colitis Brian Bello, Marie C. Ziesat, Konstantin Umanskiy, Alessandro Fichera The University of Chicago Medical Center, Chicago, IL Robotic-assisted rectal dissection for cancer has been welldescribed, but experience in patients with inflammatory bowel disease is lacking. The inflamed, friable tissue of the ulcerative colitis patient adds an element of complexity to the rectal dissection during a restorative proctectomy. Robotic assistance can aid in visualization and maneuvering within the limited space of a narrow pelvis. At our institution, we use the robot to safely perform the complete circumferential rectal dissection in patients with inflammatory bowel disease. We depict a robotic-assisted rectal dissection during a restorative proctectomy in a thirty-one year old female patient with ulcerative colitis. RESULTS: 85 patients were identified that had complete PPI/H2 data available. The data is shown in the table. There was a statistically significant increase in the use of daily PPI/ H2 in patients without pouchitis. There was also a statistically significant increase in the use of antacids more than one time per week in patients without pouchitis. There was no association between the use of PPI/H2 and the use of antacids. Occasional use of PPI/H2 did not alter the rate of pouchitis. None of the other variables were statistically significantly different between groups (see Table). 669 Chronic Use of PPI and H2 Antagonists Decreases the Risk of Pouchitis After IPAA for Ulcerative Colitis Lisa S. Poritz1, Rishabh Sehgal1, Arthur Berg3, Lacee Laufenberg1, Christine Choi1, Emmanuelle Williams2 1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA; 2. Gastroeneterology, The Milton S. Hershey Medical Center, Hershey, PA; 3. Biostatistics and Bioinformatics, The Milton S. Hershey Medical Center, Hershey, PA No Pouchitis Pouchitis PPI/H2 antagoinist: Never (Y/N) 26/20 28/11 0.178 PPI/H2 antagoinist: Daily (Y/N) 15/31 5/34 0.041 PPI/H2 antagoinist: Occasional (Y/N) 5/41 6/32 0.534 Antacid use (<1/week/ ≥1/week) 22/12 24/3 0.0381 PSC (Y/N) 5/25 2/24 0.436 Extraintestinal manifestations (Y/N) 14/21 14/13 0.443 Smoking Never INTRODUCTION: Pouchitis is one of the most common long term complications after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC). One common theory of pathogenesis is bacterial overgrowth in the pouch. Proton pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric acid. The change in pH of the stomach effluent caused by anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known to be associated with small bowel bacterial overgrowth. We hypothesize that chronic use of PPI or H2 antagonists will alter the incidence of pouchitis after IPAA for UC. p Value 0.568 25 18 Quit 7 8 Current 3 1 Use of Probiotics (Y/N) 7/37 11/26 Use of NSAIDS > 1/week (Y/N) 14/21 8/19 0.435 Use of fiber supplementation (Y/N) 7/28 8/19 0.257 Use of anti-diarrheal medication (Y/N) 19/16 14/13 1 Use of immunosuppressive medications (Y/N) 5/30 4/23 1 0.182 CONCLUSIONS: 1) Our data suggests that the daily use of PPI or H2 antagonists is associated with a decreased risk of pouchitis and may be protective against pouchitis in patients with IPAA for UC. 2) Occasional use of these agents did not seem to afford the same protection. 3. Regular antacid use provided similar protection as PPI and H2 antagonists. 4. This data suggests that altering the acid content/pH of the GI tract may influence the development of pouchitis, possibly by altering the bacterial flora. Further work to identify the changes in fecal flora is warranted. METHODS: Patients who had undergone IPAA for UC at least 2 years ago were identified from our familial inflammatory bowel disease registry. They were classified as having no history of pouchitis (no attacks of pouchitis since IPAA 2 or more years ago) or pouchitis (documented episodes of pouchitis in the medical record by biopsy and/ or endoscopy and response to antibiotic therapy). Patients were then contacted and questioned about use of PPI, H2, and antacids. PPI and H2 were classified as never used, daily use, or occasional use (1/month-2/week). Antacid use 19 Monday Abstracts was classified as less or more than once a week. Patients were also questioned about known risk factors for pouchitis including tobacco use, extraintestinal manifestations of IBD, primary sclerosing cholangitis (PSC) and the use of NSAIDS. Data on the use of fiber supplementation, antidiarrheal medications, probiotics, and immunosuppressive medications was also obtained. Two-sided Fisher’s exact test was used to compare groups. 668 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 670 RESULTS: Of the 308 BDI: 223 (72%) were active (ActBDI), 77 (25%) were passive (PassBDI), and 8 (3%) followed CBDE with T-tube. The level of biliary injury is shown in the second table; injury to proximal bile ducts was more common with ActBDI. Fewer PassBDI (16%) than ActBDI (34%) were recognized intra-op (P = 0.006). Factors limiting visibility (inflammation, bleeding, etc) were more common in PassBDI (Table); while what were thought to be abnormal anatomic findings (additional ductal/tubular structures, arteries, vessels, abnormal biliary anatomy) were more common in ActBDI (Table). The surgeon’s intraoperative sense-making also differed: a deliberate search for possible BDI was more common in ActBDI than in PassBDI (Table); cases were more commonly opened for compromised visibility with PassBDI (Table); and ActBDI were more commonly identified intra-op among all BDI cases as well among those converted to a laparotomy. Certain cues inhibited BDI detection. Detection of all BDI was less common in cases with bleeding (9% vs 36%, bleeding vs none, P < 0.0001), and when multiple factors limited visibility (BDI detection: 35% no visibility issues, 28% one issue, but only 11% with two or more factors limiting visibility, P < 0.0001). The Prevention of Laparoscopic Bile Duct Injuries: Delineation of the Principal Active and Passive Mechanisms of Bile Duct Injury Lygia Stewart1,2, John G. Hunter3, Lawrence Way2 1. Surgery, UCSF / SF VAMC, San Francisco, CA; 2. Surgery, UCSF, San Francisco, CA; 3. Surgery, OHSU, Portland, OR INTRODUCTION: The most common mechanism of major bile duct injury (BDI) involves misidentification of the CBD as the cystic duct, which is then deliberately transected. A common, but less frequent, mechanism occurs when the hepatic duct is injured during dissection in the triangle of Calot that is unknowingly too close to the common hepatic duct. Both mechanisms involve misperception, but one is active and the other passive. We analyzed the two to find clues that would help improve prevention. METHODS: 433 lap cholecystectomies (125 uncomplicated, 308 BDI) were studied. BDI were categorized according to the type: active (deliberate transection of common bile duct mistaken for the cystic duct) and passive (lateral injuries during dissection too close to the common hepatic duct). Operative reports were examined for sensemaking cues and clinical factors. Active and Passive BDI Characteristics Visibility Issues Irregular Anatomic Cues Surgeon Sensemaking Active BDI N = 223 Passive BDI N = 77 No BDI N = 125 P Value Bleeding 35 (17%)* 28 (36%)* 7 (6%)* <0.0001 Inflammation 75 (34%) 45 (58%)* 39 (31%) <0.0001 One or more 81 (36%) 63 (82%)* 43 (34%) <0.0001 Extra/Abnormal Artery or Vessel 87 (39%)* 18 (23%)* 11 (9%)* <0.02 Extra Bile Duct/Tubular Structure 59 (26%)* 3 (4%) 1 (1%) <0.0001 Abnormal Biliary Anatomy 76 (34%)* 13 (17%) 11 (9%) <0.008 Search BDI 43 (19%)* 4 (5%) 0 0.006 Identify BDI 75 (34%)* 12 (16%) 0 0.004 Open visibility issues 15 (7%) 20 (26%)* 0 <0.0001 Open concern anatomy/BDI 17 (8%) 1 (1%) 0 0.085 18/32 (56%)* 5/21 (23%) — 0.026 BDI identify w/conv open * Significant factors BDI = bile duct injury Distribution of Injuries Above Bifurcation Involvement Lobar Ducts Isolated Right Ductal Injury 30(13%) 26(12%) 11(5%) 17(8%) 57(74%) 6(8%) 1(1%) 0 13(17%) 8(100%) 0 0 0 0 CBD/CHD Bifurcation Active BDI 139(62%) Passive BDI BDI after T-tube 20 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 670a Gastroesophageal Reflux Disease (GERD) and Antireflux Surgery (ARS): What Is the Proper Preoperative Work-Up? N = 134 Reflux score GERD+ (78 pts) GERD– (56 pts) p 48 ± 37 6±4 <0.0001§ Brian L. Bello, Marco Zoccali, Roberto Gullo, Arunas E. Gasparaitis, Mustafa Hussain, Fernando A. Herbella, Marco G. Patti University of Chicago, Chicago, IL Heartburn (57) 73% (35) 62% 0.193* Regurgitation (48) 61% (26) 46% 0.083* Dysphagia (39) 50% (31) 55% 0.540* BACKGROUND: Many surgeons feel comfortable performing ARS on the basis of symptomatic evaluation, endoscopy and esophageal manometry, while a pH monitoring is seldom obtained. Reflux on BE (37) 47% (17) 30% 0.047* Hiatal Hernia on BE (31) 40% (18) 32% 0.368* Esophagitis (6) 16% (5) 20% 0.477* AIMS: To analyze the sensitivity and specificity of symptoms, barium esophagogram, endoscopy and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS. LES pressure (mmHg) 18 ± 10 25 ± 26 0.37§ (53) 68% (45) 80% 0.110* Normal peristalsis §Wilcoxon-Mann Whitney test; *Chi-square test; BE = barium esophagram; LES = lower esophageal sphincter; reflux score normal <14.7 Continuous variables are expressed as mean ± standard deviation. PATIENTS AND METHODS: 134 patients referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, barium esophagogram and manometry. Ambulatory 24 hour pH monitoring was performed preoperatively in all of them. CONCLUSIONS: The results of this study showed that: (a) symptoms were unreliable in diagnosing GERD; (b) the presence of reflux or hernia on esophagogram did not correlate with reflux on pH monitoring; (c) endoscopy had low sensitivity and specificity; and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. We conclude that ambulatory pH monitoring should be routinely performed in the preoperative workup of patients suspected of having GERD in order to avoid useless ARS. RESULTS: Based on the presence or absence of GERD on pH monitoring, patients were divided into two groups: GERD+ (n = 78) and GERD– (n = 56). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. 21 Monday Abstracts There was no difference in the incidence of symptoms between the two groups (p = NS). Within the GERD+ group, 37 patients (47%) had reflux at the esophagogram and 41 (53%) had no reflux. Among the GERD- patients, 17 (30%) had reflux and 39 (70%) had no reflux. Therefore, the sensitivity of esophagogram was 47% and the specificity was 70%. A hiatal hernia was present in 40% and 32% of patients respectively. Esophagitis was found at endoscopy in 16% of GERD+ patients and in 20% of GERD- patients, accounting for a sensitivity of 16% and a specificity of 80%. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or the quality of peristalsis. Ambulatory 24-hour pH monitoring clearly separated the 2 groups (Table). CONCLUSIONS: This study highlights differences in BDI mechanisms and possible means of prevention. Most surgeons are aware of the perceptual trap of misidentifying the CBD for the cystic duct, but passive injury has been less completely elucidated. These data show that PassBDI were less often detected, and identification of all BDI was hindered when visibility was impaired (mainly by bleeding or inflammation). Thus, when the surgeon’s attention was occupied by inflammation or bleeding, consideration of an injury to the bile duct was inhibited. Increased emphasis on this risk factor should help prevent passive injury to the common hepatic duct. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 672 desaturation (RAD) was defined as the first O2 desaturation event occurring within a 5-minute interval following a reflux episode. Values are expressed as median ±IQR. A Novel Method for the Diagnosis of Reflux-Related Respiratory Symptoms: Normalization of RefluxAssociated Oxygen Desaturations Following Nissen Fundoplication and Establishment of Normal Values RESULTS: Patients with typical symptoms had a median of 65, those with respiratory symptoms 64 and normal subjects 26 distal reflux events/24 hours. There was no significant difference in reflux events extending proximally in the 3 groups; 47% (380/804) typical, 45% (1411/3166) respiratory and 41% (114/276) in normal subjects. The number of distal reflux events associated with O2 desaturation was significantly greater in patients with respiratory symptoms 14 (9–20) than those with typical symptoms 5 (1–6; p < 0.001) or normal subjects 2 (1–5; p < 0.001). This was also true for the number of proximal RADs: 7 (4–13) in patients with respiratory symptoms versus 2 (0–3; p < 0.001) with typical symptoms and 1 (0–2; p < 0.001) in normals. Repeat study in 8 post-Nissen patients showed marked improvement with RADs approaching those of normal subjects in 6/8; 20 (9–20) distal pre-operative versus 3 (2–5; p = 0.05) post-operative; and 12 (2–15) proximal pre-operative versus 2 (0–2) post-operative. Two post-operative patients were found to have recurrent GERD; minimal improvement and/or worsening in the number of RADs were identified in each patient. Using a threshold of 95th %tile of normal subjects, the number of RADs equaled or exceeded normal in 81% (38/47) of patients with respiratory symptoms. Candice L. Wilshire, Renato Salvador, Boris Sepesi, Stefan Niebisch, Thomas J. Watson, Virginia R. Litle, Christian G. Peyre, Carolyn E. Jones, Jeffrey H. Peters Thoracic and Foregut Surgery, University of Rochester Medical Center, Rochester, NY BACKGROUND: Current diagnostic techniques aimed at establishing gastroesophageal reflux disease (GERD) as the underlying cause in patients presenting with respiratory symptoms are poor. We previously reported preliminary data suggesting that quantifying the association between reflux events and oxygen desaturation may be a useful discriminatory test. The aim of this study was to further refine the proof of principle by assessing whether antireflux surgery normalizes reflux-associated desaturations and to establish normal values. METHODS: Forty seven patients with GERD-related respiratory symptoms, 10 with typical symptoms, and 11 normal subjects underwent simultaneous 24-hour multichannel intraluminal impedance (MII)-pH and pulse-oximetry monitoring. Eight patients returned for post-Nissen studies. Acid reflux episodes were defined as pH <4 5 cm (distal) or 20 cm (proximal) above LES and non-acid episodes as a drop ≥50% from baseline in impedance 3, 5, 7 or 9 cm above LES (distal) and 15 or 17 cm above LES (proximal). Oxygen (O2) desaturation events were defined as a drop in O2 saturation <90%, or a decrease ≥6%. Reflux-associated CONCLUSIONS: These data provide further proof of principle that measurement of the association between reflux events and oxygen desaturation may be a useful discriminatory test in GERD patients presenting with primary respiratory symptoms, and may predict response to antireflux surgery. 10:00 AM – 11:15 AM 26ab QUICK SHOTS SESSION I extent, including portal vein invasion and lobar atrophy, has been proposed. The aim of this study was to evaluate current staging systems for hilar cholangiocarcinoma and identify clinical factors associated with improved survival. 673 Staging and Survival of Resected Hilar Cholangiocarcinoma: An Analysis of 80 Consecutive Patients METHODS: In this retrospective cohort study, clinical and pathologic characteristics were obtained for all resected patients with Bismuth-Corlette Type IIIa and IIIb hilar cholangiocarcinoma from 1993 to 2011. Patients were stratified by the 7th edition AJCC TNM staging parameters and by the modified Blumgart staging system which includes portal vein invasion and presence of lobar atrophy. Univariate and multivariate analyses were used to test effects of clinicopathologic factors and staging systems on overall survival. Victor M. Zaydfudim, Clancy J. Clark, Michael L. Kendrick, Florencia G. Que, Kaye M. Reid Lombardo, John H. Donohue, Michael B. Farnell, David M. Nagorney Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN INTRODUCTION: Predicting long-term survival in hilar cholangiocarcinoma is difficult. The revised AJCC staging system has not been extensively evaluated and may not correlate with clinical outcomes. An alternative staging system which incorporates factors related to local tumor 22 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 674 RESULTS: Eighty consecutive patients (median age 64 years (range 36–82), 64% male) underwent an anatomic hepatectomy with a bile duct resection and reconstruction for Bismuth-Corlette IIIa (51%) and Bismuth-Corlette IIIb (49%) cholangiocarcinoma. Margin negative resection was achieved in 94% of resections; 30-day mortality was 10%. Median follow-up was 26 months (range 0–181 months) with overall median survival of 34 months. Twenty-three percent of the patients had well-differentiated cholangiocarcinoma. The AJCC staging system stratified patients into following groups: T1–26%, T2–58%, T3–16%; N0–61%, N1–39%; Stage I-20%, Stage II-30%, Stage III-50%. None of the patients had distant metastases at the time of resection. Kaplan-Meier estimates did not demonstrate an association between survival and AJCC staging parameters (all p ≥ 0.121). Blumgart staging system stratified patients into following groups: Blumgart T1–58%, Blumgart T2–41%; one patient had a Blumgart T3 cholangiocarcinoma with invasion into portal vein bifurcation. Univariate analyses demonstrated an association of survival with tumor grade (p = 0.033) and Blumgart T-stage (p = 0.010). One- and fiveyear survival estimates for Blumgart T1 and Blumgart T2/ T3 were 86% and 47% vs. 74% and 17% (p = 0.010). After adjusting for tumor grade, Blumgart T2/T3 stage correlated with increased likelihood of mortality (HR = 1.93, 95%CI: 1.09–3.42, p = 0.024). Value Analysis of Single Incision Laparoscopic Cholecystectomy Michael Cameron, Vic Velanovich Surgery, University of South Florida, Tampa, FL METHODS: The direct supply costs for both SILS-C and LC from our institution were obtained. In addition, the extant literature on SILS-C was review for operating room costs, as well as measures of quality pertaining to pain control and cosmesis were obtained. The incremental costs of each unit of improvement in quality were calculated. RESULTS: The direct supply costs of SILS-C was $1,582.90 compared to $753.30 for LC. Published operating room costs were $2,109 for SILS-C compared to $2,069 for LC. However, average reimbursement was $5,602 for SILSC compared to $6,403 for LC. Assessment of pain varied among study, however, standardizing assessment of pain across studies was done, with SILS-C having a 0.1 unit improvement, for a cost of $400 per unit improvement using published operating room costs. Assessment of cosmesis yield a cost for unit improvement varied between $32-$40. These costs would be more is just the direct supply costs were the primary driver of value and reimbursement is less. CONCLUSIONS: It does not appear that SILS-C provides value for the patient and hospital. Improved pain control and cosmesis is not consistent among studies published, and the costs for each unit improvement variable depending on which costs data are important, but consistently higher. Couple this with less reimbursement, the value of SILS-C is questionable. CONCLUSIONS: While the current AJCC TNM staging system did not predict survival in the current study, the Blumgart staging system which emphasizes portal vein invasion and lobar atrophy predicted overall survival independent of other clinical and pathologic factors. Inclusion of lobar atrophy into the T classification might improve accuracy of the AJCC system, and help define prognosis in patients with hilar cholangiocarcinoma. 23 Monday Abstracts BACKGROUND: Single incision laparoscopic surgery (SILS), particularly laparoscopic cholecystectomy (SILS-C), has been advocated as both a means of improving standard 4-port laparoscopic cholecystectomy (LC) and as a stepping-stone to natural orifice trans-luminal endoscopic surgery (NOTES). Data has been conflicting as to whether SILS-C accomplishes its main goals of improved cosmesis and less pain, while meeting all other requirements of a cholecystectomy. We performed a value analysis of SILS-C compared to standard LC using the generally accepted definition of value = quality/costs. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 675 676 A Randomised, Single Blind Study of Miniports (3 mm) Versus Conventional Ports in Laparoscopic Cholecystectomy A Tool for Risk Adjusting Colorectal Surgery Pay for Performance Models: Cr-POSSUM Scoring Mark Bignell, Edward Cheong, Michael P. Lewis, Michael Rhodes General Surgery, Norfolk and Norwich University Hospital, Norwich, United Kingdom Jasna Coralic, Kirthi Kolli, Anjali S. Kumar Section of Colon and Rectal Surgery, Washington Hospital Center, Washington, DC INTRODUCTION: Single incision laparoscopic cholecystectomy (SILC) is said to provide improved cosmesis with a reduction in postoperative pain, but involves a change in operative technique. We have conducted a single-blind, randomised controlled trial study of cosmetic outcome and post-operative pain comparing laparoscopic cholecystectomy (LC) using either 3 mm or 5 mm ports. BACKGROUND: Pay for performance (P4P) models are an emerging way of holding physician payment accountable for quality of care. Current reimbursement methods entail standard payments based solely on procedure performed. As P4P models are instituted, the current payment system does not account for individual patient morbidity and mortality risks. METHODS: 80 patients with symptomatic gallstones were recruited from a single centre and randomised to a LC using either a 10 mm and three 5 mm ports (control) or a 5 mm port and three 3 mm ports. The 5 mm port was extended as necessary at the end of the operation to facilitate removal of the gallbladder. Operative details, time and pain scores at 1h, 6h, and 1 week and analgesia required in the 1st week were collected. HYPOTHESIS: A simplistic, validated, peri-operative risk stratification score (Cr-POSSUM) for lower intestinal surgeries can be used as a risk adjustment tool for reimbursement integrating expected outcomes. METHODS: We analyzed single institution retrospective data for four colorectal and three surgical oncology surgeons over a systematic period spanning from 2006–2010 for colorectal cases and captured data for 179 patients. CrPOSSUM scores were calculated for each patient and t-test analyses were performed using STATA10. Statistical analysis was undertaken using a paired t-test or fisher’s exact test as appropriate. RESULTS: Cr-POSSUM scores for each organ system had broad ranges for small bowel (0.38–25.98), colon (0.68– 57.56), rectal (2.30–40.83), and cytoreduction (4.17–24.84) surgeries which attest to the vast array of patient mortality despite undergoing similar surgeries. As expected, there was a significant difference in scores among those who had post-operative complications and those who did not (p < 0.005). Cytoreductive and rectal surgery had a significant difference in Cr-POSSUM score (p < 0.001) when compared to other organ systems. Surgeons whose practice involved a high percentage of cytoreductive and/or rectal surgeries had higher mean Cr-POSSUM scores (p < 0.005) and higher complication rates. RESULTS: 40 patients were recruited to each group. The mean age of the 3 mm group was 53 (±14) compared to 52 (±12) in the control group (p = 0.89). There were 11 males in the 3 mm group vs. 4 in the control group. One patient in the control group was converted to open whilst 2 patients in the 3 mm group had a 3 mm port converted to a 5 mm port and 4 patients required the insertion of a 10 mm and 5 mm ports. The mean operative time was 49 minutes (±12, range 24–120 mins) in the 3 mm group versus 46 minutes (±19, range 21–124 mins) in the control group (p = 0.40). There was no statistical difference in the day case rate between the 2 groups. The pain scores in the 3 mm group at 1h, 6h, and 1 week were 2.5 ± 2.1, 3.2 ± 2.2, and 0.8 ± 2.2 versus 4.2 ± 2.9, 3.3 ± 2.4, and 2.1 ± 2.4 in the control group (p Value = 0.003, 0.63, and 0.002). The mean daily analgesia score, calculated using the WHO pain ladder to attribute each class of analgesia a value, was 3.47 (± 3.2) in the 3 mm group vs 5.21 (±4.8) in the control group (p = 0.008). CONCLUSION: When evaluating a surgeon’s performance based on outcomes, the Cr-POSSUM score should be used for risk adjustment in P4P models for lower intestinal surgeries. Current reimbursement systems to not account for individual patient risk. CONCLUSION: The use of 3 mm ports is technically feasible in patients undergoing LC for gallstones with comparable operating times to conventional LC with reduced pain scores and need for analgesia. 24 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CRPOSSUM n Mean Cr-POSSUM Score (Range) P-value % Post-Op Complications small bowel 29 4.1 (0.4–26.0) 0.09 34% colon 65 5.6 (0.7–57.6) 0.3 29% rectal 27 7.9 ( 2.3–40.8) 0.2 40% cytoreduction 35 9.8 (4.2–24.8) 0.002 37% CRS Doctor 1 (26% rectal) 27 6.6 (0.3–40.8) 0.8 56% CRS Doctor 2 (20% rectal) 53 5.8 (0.3–57.6) 0.5 28% Organ System Highest Volume Physicians (case volume %) 25 4.8 (0.5–19.6) 0.3 16% Surg Onc Doctor 2 (94% cytoreduction) 37 9.3 (0.7–24.8) 0.007 39% Monday Abstracts Surg Onc Doctor 1 (8% rectal) RESULTS: For pts with local and regional CC, 181,035 had confirmed LN examinations. For Stages I-III, there has been a dramatic improvement in compliance for pts with >12 LNs harvested over the recent two 5-yr periods (19, 21, 18% respectively, p < 0.0001) whereas previously only a 5–7% increase occurred over time (see Table). This rise in compliance had the greatest effect on the increased survival trend for stage II CC with minimal change for those with Stage I and Stage III CC. Irrespective of LN examined there has been a significant increase in OS for all stages over time (p < .0001). 677 A 21-Year Analysis of Lymph Node Trends in Colon Cancer: Do Quality Measures Really Matter? Danielle M. Hari1, Alexander Stojadinovic2,3, Anna M. Leung1, Connie Chiu1, Myung-Shin Sim1, Anton Bilchik4,5 1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica, CA; 2. Surgery, Walter Reed National Military Medical Center, Bethesda, MD; 3. Surgery, United States Military Cancer Institute, Bethesda, MD; 4. Surgery, California Oncology Research Institute, Santa Monica, CA; 5. Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA CONCLUSIONS: In the largest time-dependent assessment of LN examination in CC, significant improvements in surgical quality measures have occurred over the past decade for Stage I, II and III. These measures have translated into improvements in OS particularly for Stage II disease. LN yield alone is not an adequate QM for pts with stage I and III CC. BACKGROUND: Lymph node (LN) number has been endorsed as a quality measure (QM) in colon cancer (CC) because of the impact on survival. However, the current mandate requiring >12 LNs has been questioned. We evaluated whether compliance of this QM has improved and whether this has impacted overall survival (OS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Database was queried to identify patients (pts) with pathologically confirmed, localized and regional CC (Stage I-III) diagnosed between 1988 and 2008. Interval trends in lymph node (LN) harvest and OS were evaluated over time (Year Strata (YS): 1988–1993, 1994–1998, 1999–2003 and 2004–2008). 1988–1993 > 12 LN (% Pts) Stage I 15.84% Stage II Stage III 1994–1998 5-yr OS > 12 LN (% Pts) 76.45% 19.04% 36.16% 68.69% 50.57% 45.54% 1999–2003 5-yr OS > 12 LN (% Pts) 78.22% 25.72% 40.79% 70.24% 47.13% 48.57% 25 2004–2008 5-yr OS > 12 LN (% Pts) 5-yr OS 80.54% 44.44% 83.27% 46.21% 71.67% 66.88% 74.26% 52.80% 52.80% 70.65% 56.96% THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 678 METHODS: After IRB approval, we conducted a retrospective review of all gracilis muscle transpositions performed for complex fistulas and perineal defects from 1/2001– 9/2011. Patients were divided into three groups: rectovaginal fistulas, rectourethral fistulas and perineal defects. Recognizing Risk: Colectomy in the Growing Chronic Renal Failure Population James C. Iannuzzi, Andrew-Paul Deeb, Abhiram Sharma, Aaron S. Rickles, John R. Monson, Fergal Fleming University of Rochester Medical Center, Rochester, NY RESULTS: 97 gracilis transpositions were performed in 86 patients. 43 interpositions were performed in 33 females for rectovaginal fistulas and 5 for pouch-vaginal fistulas; 52% had a mean of 1.5 (1–4) failed repairs prior to gracilis interposition. The overall success rate was 89%; with an 18% post-operative complication rate. 4 patients required a second gracilis interposition. All Crohn’s disease-associated fistulas (7) healed; however 42% required further procedures. 48 interpositions were performed in 42 males for rectourethral fistulas primarily due to prostate cancer treatment (95%); 29% had a mean of 1.2 (1–3) failed repairs prior to gracilis interposition. The overall success rate was 95%; with a 26% post-operative complication rate. 6 patients required a second gracilis interposition. 6 transpositions were performed for reconstruction of perineal defects in 2 females and 4 males; 33% had a mean of 1.5 (1–3) failed repairs prior to gracilis transposition. The overall success rate was 100% with a 33% complication rate. BACKGROUND: Projections indicate that the number of people living with chronic end stage renal disease (ESRD) will double in the next 10 years. An increasing incidence portends a growing surgical challenge given the high risk from immunosuppression, haemostatic abnormality, and nutritional deficiency secondary to renal failure. There exists a paucity of high quality data on the ESRD population in abdominal surgery. The authors sought to define the risk of elective colectomy in ESRD using a large and representative national clinical database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from years 2005 to 2010 for all colectomies. Patient demographics, preoperative risk factors and intraoperative variables were recorded. The primary end point was mortality at 30 days in dialysis dependent chronic renal failure patients. Chronic renal failure was defined by dialysis use prior to index admission excluding patients with acute kidney injury within 48 hours of colectomy. Univariate (chisquared), and multivariate analysis (linear regression) were performed to determine predictors of mortality. CONCLUSION: Gracilis muscle transposition is a versatile and effective technique for treatment of complex fistulas and reconstruction of perineal defects. 680 RESULTS: The study population included 1685 ESRD patients undergoing colectomy, 750 were elective and 935 emergent. Median age was 65, median ASA score was 4 and there were 850 men (50.4%). Overall mortality and morbidity was 27.5% and 54.9%. Emergent surgery was associated with an increased mortality {36.3% vs. 16.5% (p > 0.0001)} and morbidity {66.5% vs. 40.4% (p > 0.0001)} when compared to elective surgery. Eight factors were independent predictors of 30-day mortality: age greater then 75, functional status, pulmonary, cardiac, hepatic, neurologic comorbidity, intraoperative time, and hypoalbuminemia. Hypoalbuminemia doubled the mortality risk (odds ratio 2.0 95% CI [1.4, 3.2]). Hospital Readmission for Fluid and Electrolyte Abnormalities Following Ileostomy Construction: Preventable or Unpredictable? CONCLUSION: This study demonstrates that colorectal surgery in ESRD confers a greater morbidity and mortality than previously described. Preoperative optimization of other organ systems and nutritional status will reduce the event rate in elective surgery in patients with ESRD. METHODS: Retrospective chart review was performed on patients who had an ileostomy created for any surgical disease by two board-certified colorectal surgeons at a single tertiary institution January 2008—June 2011. Dana M. Hayden, Maria C. Mora P, Amanda B. Francescatti, Sarah C. Edquist, Matthew R. Malczewski, Jennifer M. Jolley, Marc I. Brand, Theodore J. Saclarides General Surgery, Rush University Medical Center, Chicago, IL BACKGROUND: Ileostomy creation has perioperative and postoperative complications, including re-hospitalization for fluid and electrolyte abnormalities. Although several studies have identified predictors of this morbidity, readmission rates remain high. RESULTS: 154 patients were included in this study; 71 (46.1%) were female. The mean age and BMI were 49 (range 16–91 years) and 26.9 (13–52), respectively. The most common indications for ileostomy creation were cancer (39.6%) and inflammatory bowel disease (48.1%). 115 (74.7%) patients had loop ileostomies constructed; 80 (51.9%) were performed laparoscopically and 7.8% were created emergently. The readmission rate for fluid and electrolyte abnormalities was 20.1%, which was 43.7% of total re-hospitalizations. Gender, older age, and BMI were not associated with readmission. Laparoscopy, loop ileostomy and emergency surgery were also not predictive. 679 Gracilis Transposition Is a Good Option for the Treatment of Complex Perianal Fistulas and Unhealed Perineal Wounds Marylise Boutros, Karla Arancibia, Neha Hippalgaonkar, Fabio Potenti, Giovanna DaSilva, Steven Wexner Colorectal Surgery, CCF, Weston, FL PURPOSE: We reviewed our experience with gracilis transposition for treatment of complex fistulas and reconstruction of perineal defects. 26 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA of life—at 1 year after treatment. Secondary outcome measures included retreatment, generic quality of life (SF-36), achalasia symptoms, esophageal emptying quantified by timed barium esophagram (TBE), and abnormal 24 hour ambulatory esophageal pH monitoring (24h pH, as defined by pH <4.0 for >4.0% of the total time). We enrolled sufficient subjects to detect a clinically significant difference between treatment groups (20 points in the 0–100 ASQ scale). Patients were analyzed according to their assigned treatment group. Follow up data were available for 22 subjects who were initially assigned to PD and 23 who were assigned to HM. There were no major differences between the groups at baseline. Five subjects required re-treatment, all of whom were initially assigned to PD (22.7%, 95% confidence interval [CI] 7.8% to 45.4% as compared with 0%, 95% CI 0% to 14.8%, P = 0.02). The mean improvement in ASQ at 1 year, analyzing the last pre-re-treatment observation for re-treated subjects, was 20.9 (standard deviation [SD] 18.0) among PD patients as compared with 27.5 (SD 21.1) among HM patients (mean difference 6.6, 95% CI–5.2 to 18.4). Six months after treatment, the mean improvement in TBE percent emptying after 5 minutes was 30.4% among PD patients as compared with 19.7% among HM patients (mean difference 10.7%, 95% CI–16.7% to 38.2%). Among patients who had 24h pH at 6 months, none treated by HM had abnormal acid exposure (95% CI 0% to 16.8%) as compared with 9.1% (95% CI 1.1% to 29.2%) among PD patients (P = 0.17). None of the changes in measured symptoms or quality of life scores were significantly different between treatment groups. The reduction in lower esophageal sphincter resting pressure was significantly larger among patients assigned to HM (25.5 mmHg [SD14.4] as compared with 14.2 mmHg [SD 17.6], mean difference 11.3 mmHg, 95% CI 0.4 mmHg to 22.2 mmHg). CONCLUSIONS: Our results show that only neoadjuvant therapy was significantly associated with hospitalization for fluid and electrolyte abnormalities. Therefore, this morbidity does not appear to be preventable. Our study implies that home regimen and follow-up are the main determinants of readmission. Prospective studies focused on diligent stoma monitoring by patients and physicians may be the key to decreasing readmission rates. 680a Randomized Controlled Trial of Disease-Specific Quality of Life After Laparoscopic Heller Myotomy and Pneumatic Dilatation for Newly Diagnosed Achalasia Among healthy patients newly diagnosed with achalasia, HM does not result in a clinically significant improvement in quality of life as compared with PD. Patients treated initially by PD are significantly more likely to require re-treatment as compared with patients treated initially by HM. David R. Urbach , Gail E. Darling , Nicholas E. Diamant , Paul P. Kortan1, George A. Tomlinson1, Wayne Deitel1, Audrey Laporte1 1. University of Toronto, Toronto, ON, Canada; 2. Queen’s University, Kingston, ON, Canada 1 1 2 Pneumatic dilatation and laparoscopic Heller myotomy with partial fundoplication are both commonly performed for the treatment of achalasia. It is not known whether one procedure is superior with respect to disease-specific quality of life. We randomly assigned 50 healthy persons aged 18 years or older who were newly diagnosed with achalasia to either laparoscopic Heller myotomy with partial fundoplication (HM) or to pneumatic dilatation (PD) with a 30 mm balloon at 4 Canadian cities (Kingston, Toronto, Edmonton and Calgary). The primary outcome measure was the Achalasia Severity Questionnaire (ASQ) score—a validated disease-specific measure of health related quality 27 Monday Abstracts Inflammatory bowel disease and specifically Crohn’s disease were not significant, nor was previous intestinal resection. Cancer was strongly associated with readmission (X2 = 4.73, p = 0.03) as was neoadjuvant therapy (X2 = 9.20, p = 0.01); after logistic regression, only neoadjuvant remained significant. Examination of potential predictors showed preoperative use of narcotics, fiber, stool softeners, laxatives and anti-diarrheals were not predictive. Preoperative and discharge renal function, sodium and magnesium levels were not significantly associated; however, increased mean potassium level upon discharge trended toward significance (4.21 versus 4.05, p = 0.089). Stoma and urine output on the day of discharge were not associated with readmission; number of days with ileostomy output >1500 ml/24 hours was also not significant. Length of hospitalization, postoperative ileus, obstruction or sepsis was not predictive. Postoperative chemotherapy and radiation were not statistically significant. 52 (34%) patients were given anti-diarrheals and 22 (14.4%) were given fiber supplements; neither correlated with readmission. 103 (66.9%) patients had stoma reversal; 4 had ileostomy closure early, but only 2 of these patients were readmitted for fluid and electrolyte abnormalities. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 683 682 Comparison of Perioperative Outcomes After Per-Oral Esophageal Myotomy (POEM) and Laparoscopic Heller Myotomy Iron Deficiency Anemia Is a Common Presenting Issue with Giant Paraesophageal Hernia and Resolves Following Repair Eric S. Hungness1, Ezra N. Teitelbaum1, Byron F. Santos1, Fahd O. Arafat1, John E. Pandolfino2, Nathaniel J. Soper1 1. Surgery, Northwestern University, Chicago, IL; 2. Gastroenterology, Northwestern University, Chicago, IL Philip W. Carrott, Sheraz Markar, Jean Hong, Donald Low Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA BACKGROUND: Giant Paraesophageal hiatal hernias (PEH) are most commonly associated with symptoms of chest pain, early satiety and GERD. However, Iron-deficiency anemia is an under-appreciated condition associated with giant PEH. The aim of this study was to evaluate the incidence of iron-deficiency anemia in a cohort of patients with giant PEH and assess the incidence of resolution associated with operative PEH repair. INTRODUCTION: Per-oral esophageal myotomy (POEM) is a novel procedure for the treatment of achalasia creating a myotomy across the esophagogastric junction (EGJ) without skin incisions. To date, no study has compared POEM perioperative outcomes with the surgical standard-of-care, laparoscopic Heller myotomy (LHM). METHODS: A review was conducted of a single-institution database to compare outcomes after POEM and LHM. 11 patients underwent POEM from 8/2010—11/2011 under the following IRB-approved inclusion criteria: age 18–85, no prior treatment for achalasia, and non-sigmoid esophagus. 50 patients were identified who had undergone LHM from 3/2004—7/2011 and fit these same criteria. T-tests and Fisher exact tests were used to compare results. METHODS: Between 2000 and 2010, 270 patients underwent operative repair of PEH and were prospectively entered into an IRB-approved database. From this cohort, 123 (45.6%) patients demonstrated a pre-existing diagnosis of iron-deficiency anemia. 77 patients had a documented pre-operative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up Hb level at least 3 months following surgery and constituted the study population. RESULTS: There were 7 (64%) and 26 (52%) male patients in the POEM and LHM groups respectively (p = ns). POEM patients were younger (36 ± 11 vs. 50 ± 16 years; p < 0.01). BMI and ASA classifications were similar. There was no difference in duration of symptoms prior to surgery (2 ±5 vs. 2 ± 3 years). POEM and LHM had similar procedure times (121 ± 42 vs. 126 ± 29 min; p = ns). POEM had less EBL (≤10 ml in all cases vs. 91 ± 55 ml; p < .001) but LHM had longer myotomy lengths (8.0 ± 1.1 vs. 8.5 ± 0.7 cm; p = .04). Pain scores were similar on the day of surgery (3.3 ± 3.1 vs. 2.1 ± 2.3; p = ns) and on POD#1 (2.5 ± 2.8 vs. 2.1 ± 2.3; p = ns). Patients used similar amounts of narcotics on the day of surgery (4.8 ± 5.2 vs. 2.8 ± 4.3 mg morphine equivalents; p = ns) and POD#1 (6.9 ± 7.7 vs. 4.6 ± 5; p = ns) despite the fact that fewer POEM patients received ketorolac (18% vs. 78%; p < .001) due to concern for potential post-op bleeding in the sub-mucosal tunnel. Length of stay was similar (2.3 ± 3.6 vs. 1.6 ± 2.9 days; p = ns) and all POEM patients except for one were discharged by POD#2. No mortalities and 1 major complication occurred in each group: a POEM patient had a contained leak at the EGJ requiring laparoscopic drain placement and a LHM patient had a delayed esophageal leak requiring thoracotomy for drainage and repair. 3 (27%) minor complications occurred in POEM patients, compared with 7 (14%) in LHM patients (p = ns). Per-protocol post-op high-resolution manometry (HRM) and timed barium esophagram (TBE) at six weeks showed that POEM patients had decreased basal expiratory EGJ pressures (12 ± 7 vs. 25 ± 10 mmHg, p = .04) and relaxation pressures (15 ± 3 vs. 29 ± 17 mmHg, p < .05) and decreased contrast column heights at 1, 2 and 5-minutes (4, 2 and 2 vs. 17, 16 and 11 cm), although only significantly at 1 and 2-minutes (p = .02 and .004). LHM patients did not routinely undergo repeat HRM or TBE. RESULTS: From the cohort of 77 patients with documented pre-operative iron-deficiency anemia, 72 (94%) underwent elective PEH repair, with a median age was 75 (range 39–91). Cameron erosions were endoscopically documented preoperatively in 25 patients (32%). The average preoperative Hb value was 11.8 (7.6–16). Postoperatively at 3–12 month follow-up, the average Hb level was 13.2 (10.7–17), and at more than 1 year follow-up it was 13.6 (9.2–17.2) (P < 0.05). Furthermore 90% of patients had a rise in post-operative hemoglobin level by at least 1g/dL. Anemia was fully resolved postoperatively (Hb ≥ 12.0 in females, ≥14.0 in males) in 55 (71%) patients. This resolution was observed more commonly in women (40/50, 80%) than men (15/27, 56%, P < 0.05). Also younger patients (<70 years) were more likely to resolve their anemia (29/33 vs. 26/44; P < 0.05) and have a greater post-operative Hb (14.0 vs. 13.0 g/dL; P < 0.05) than older patients. 40 patients required preoperative iron supplementation, 29 (73%) were able to discontinue iron following surgery. There was no significant difference in the resolution of anemia in patients with or without Cameron erosions (19/25 vs. 36/52, p = 0.54). CONCLUSION: This single institution study shows a high incidence of iron-deficiency anemia (45.6%) in patients with giant PEH. Elective repair results in resolution of the anemia and discontinuation of iron supplementation therapy, in more than 70% of patients. This improvement in Hb is independent of the presence of pre-operative Cameron erosions. This study demonstrates the clinical and potential economic benefits of elective PEH repair of patients with Giant PEH and iron-deficiency anemia. 28 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSIONS: POEM is a feasible procedure for creating an endoscopic myotomy for the treatment of achalasia. POEM and LHM appear to have similar perioperative outcomes. Further data are needed to define and compare long-term functional outcomes after POEM. esophagus parameters were recorded by giving 10 swallows of 5 mL of water at 30-second intervals. The analysis was performed with the commercial dedicated software. Fourteen individuals also underwent a concomitant transnasal pharyngoscopy. 684 RESULTS: Manometric parameters are depicted in Table 1. The correlation between HRM plots and pharyngeal anatomic landmarks is shown in Figure 1. Anatomo-Physiology of the Pharyngo-Upper Esophageal Area in Volunteers at the Light of High Resolution Manometry: Defining Normal Values Monday Abstracts Luciana C. Silva1, Fernando A. Herbella1, Luciano R. Neves1, Fernando P. Vicentine1, Sebastião Pannocchia1, Marco G. Patti2 1. UNIFESP, Sao Paulo, São Paulo, Brazil; 2. Department of Surgery, University of Chicago, Chicago, IL INTRODUCTION: High resolution manometry (HRM) is a recent and valuable tool in the assessment of esophageal motility. The experience with this technology in the evaluation of pharyngeal and upper esophageal disorders is still incipient. This study aims to: (a) define normal values for pharyngo-upper esophageal motility, and (b) correlate HRM plots with pharyngeal anatomic landmarks. METHODS: 29 healthy individuals (mean age 30 years, 62% males) underwent HRM with a solid-state catheter with 36 circumferential sensors spaced 1 cm apart positioned to record from the base of the tongue to the esophagus. Pharyngeal, upper esophageal sphincter and proximal CONCLUSION: Normal values for pharyngeal, upper esophageal sphincter and proximal esophagus parameters have been determined. These results may be applied in future studies. Manometric Values Pharynx Upper Esophageal Sphincter Proximal Esophagus Peak pressure at 2 cm above mid UES 203,8 (160–225,6) Basal pressure 88,5 (65,72–119,55) Amplitude 2 cm below mid UES 64,3 (51,7–100,4) Contraction duration at 2 cm above mid UES 471 (349–697) Residual pressure 4,1 (0,85–-7,77) Amplitude 4 cm below mid UES 65,7 (45,7–76,5) Start at 2 cm above mid UES to UES start –494 (–541 –419) Relaxation time to nadir 198 (169,7–264) Amplitude 6 cm below mid UES 35,05 (18,8–47,3) Start at 2 cm above mid UES to UES nadir -235 (-355– –181) Ralaxation duration 698,5 (629,7–773,2) Start at 2 cm above mid UES to UES end 212 (183–269) Recovery duration 475 (380,2–561,5) Data presented as median (interquartile range) 29 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 10:00 AM – 11:15 AM 28cd VIDEO SESSION III: HPB & FOREGUT VIDEOS 685 First, laparoscopic hepatoduodenal lymphadenectomy was performed. Lymphadenectomy started at proper hepatic artery and continued towards celiac artery. Next, liver segment IVb and V were resected laparoscopically with a 2 cm margin. Robotic Assisted Duval Procedure for Pancreas Divisum and Cystic Neoplasm John Rodriguez, Sricharan Chalikonda, Au Bui, Jessica Titus, Matthew Walsh Surgery, Cleveland Clinic, Cleveland, OH The patient was discharged home in 2 days. Pathology: no evidence of tumor in liver or lymph nodes. We present the case of a 35 year old female that was referred for management of recurrent pancreatitis. On pre-operative evaluation she was found to have pancreas divisum with a long narrowed segment of the main pancreatic duct. On further review of MRCP images, a cystic lesion was found in the proximal duct. Our therapeutic goals consisted of resection of the cystic lesion and drainage of the proximal duct. She was taken to the operating room and a robotic assisted Duval procedure was successfully completed. We believe that this approach is safe and offers the benefits of minimally invasive surgery for this complex pathology. 688 Laparo-Endoscopic Single Site (LESS) Distal Pancreatectomy and Splenectomy with Extraction Port Alexander S. Rosemurgy2, Harold Paul2, Krishen Patel2, Edward Choung2, Sharona B. Ross1,2 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa General Hospital, Tampa, FL This is a video of a single incision distal pancreatectomy with splenectomy. A 12 mm vertical incision was made at the umbilicus. A 5 mm deflectable tip laparoscope was utilized. The stomach was mobilized and the gastrocolic omentum was divided. A retractor lifted the liver and the dissection was carried along the inferior border of the pancreas toward the caudal tip of the spleen. The pancreas was divided utilizing a reinforced laparoscopic linear stapler. The specimen was delivered via extraction bag using a 2.2 cm lateral incision. The diaphragm was irrigated with bupivacaine solution. The umbilicus was closed in a figure-ofeight fashion. There was no notable scar. 686 A Year in the Life of a Tubulovillous Adenoma: Combined Endoscopic and Laparoscopic Management Niket Sonpal, Amit Jain, Patrick Saitta, Truptesh H. Kothari, Gregory B. Haber, Paresh C. Shah Lenox Hill Hospital, Hauppauge, NY A 39-year-old male with a large symptomatic tubulovillous adenoma of the first and second portion of the duodenum was initially managed by endoscopic submucosal resection (EMR). The majority of the adenoma was excised by EMR in two stages. However, follow up endoscopy revealed persistent adenoma with regrowth to about 30% circumferential involvement of the duodenum and proximity to the ampulla. A laparoscopic trans-duodenal local resection was then performed with primary repair of the medial and lateral duodenum avoiding a pancreaticoduodenectomy with excellent oncologic and clinical results. 689 Transduodenal Resection of a Ampullary Adenoma Robert Grützmann, Marius Distler Surgery, University Hospital Dresden, Dresden, Germany Ampullary tumors display a favorable prognosis compared with other periampullary tumors. This prognostic difference can be attributed to the early presentation and easy diagnosis by upper gastrointestinal endoscopy and simultaneous histological verification and to biological differences that may determine the prognostic superiority of these tumors. The therapy of choice is complete resection. In benign cases this can be achieved either by endoscopic resection or surgical transduodenal resection, whereas malignant tumors should be treated with a pancreatic head resection and lymphadenectomy. Here we describe the technique of transduodenal resection of a adenoma of the papilla of Vater. 687 Laparoscopic Partial Hepatectomy with Hepatoduodenal Lymphadenectomy for Early Gallbladder Cancer Ziad Awad, Keyur A. Chavda University of florida, Jacksonville, FL Our case is 61year old female with T1b adenocarcinoma of gallbladder found incidentally after laparoscopic cholecystectomy for chronic cholecystitis. CT scan showed no evidence of liver lesion. Two 12 mm and four 5 mm ports were used. 30 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 2:15 PM – 3:15 PM 28ab QUICK SHOTS SESSION II Post Roux-en-Y Gastric Bypass Biliary Dilation: Natural Process or Significant Entity? Kevin M. El-Hayek1, Poochong Timratana1, Joseph Meranda2, Hideharu Shimizu1, Bipan Chand1 1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH; 2. Imaging Institute, Cleveland Clinic, Cleveland, OH 728 BACKGROUND: Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology, that latter of which is problematic to manage because access to the biliary tree following gastric bypass often requires specialized care due to altered anatomy. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter. First Time Colonoscopy in the Elderly Yields a High Rate of Curable Colorectal Cancer Therese Kerwel1, Theodor Asgeirsson2, Donald G. Kim2, Nadav Dujovny2, Rebecca Hoedema2, Heather Slay2, Ryan Figg2, Martin Luchtefeld2 1. Department of Colorectal Surgery, Grand Rapids Medical Education Partners/MSU, Grand Rapids, MI; 2. Department of Colorectal Surgery, Spectrum Health Medical Group/Ferguson Clinic, Grand Rapids, MI METHODS: Using an IRB approved database, patients who underwent laparoscopic Roux-en Y gastric bypass from 6/1/2010 and 9/30/2011 were evaluated. Those with imaging both before and at least 3 months after gastric bypass were analyzed. Patients who underwent remote cholecystectomy prior to gastric bypass during this time period were included in subgroup analysis. Data collected included patient demographics, operative details, post-operative weight loss, and time interval between surgery and second imaging. Indications for post-operative imaging included abdominal symptoms. For purposes of this study, all imaging was re-reviewed by a radiologist whereby the common hepatic duct was measured at the level of the porta hepatis to determine interval changes. PURPOSE: The use of screening colonoscopy in the elderly has become controversial with the USPSTF recommendation against routine screening in adults aged 76 to 85 years as well as lack of Medicare reimbursement. However, early detection of colorectal cancer in healthy elderly patients may prevent morbidity and mortality from late presentation. This study aims to determine cancer detection rates in the elderly undergoing outpatient index colonoscopy and cancer detection for repeat colonoscopy in the same population. METHODS: We identified 903 outpatient exams in patients 76 to 85 years over a 2-year period (1/09–12/10). Patient demographics, exam indication and gross findings were noted. Inpatient and outpatient charts were reviewed for the pathology reports and previous history of colonoscopy in the subjects. RESULTS: A total of 551 patients underwent Roux-en Y gastric bypass during the study period. Of these, 82 had biliary imaging both before and after surgery. Thirty-three patients had post-operative imaging at least 3 months following gastric bypass. Mean age was 44 years (21–65) and 79% were female. There were 8 patients who had remote cholecystectomy prior to gastric bypass and 25 patients with gallbladders. In all 33 patients, mean hepatic duct diameter was 5.2 ± 2 mm and 7.1 ± 2.6 mm pre-operatively and post-operatively respectively (p < 0.01). Patients with prior cholecystectomy had hepatic duct diameters of 7.9 ± 1.3 mm and 9.5 ± 3.5 mm pre-operatively and post-operatively respectively (p = 0.3). Patients who had not previously undergone cholecystectomy had hepatic duct diameters of 4.3 ± 1.1 mm and 6.4 ± 1.8 mm pre-operatively and postoperatively respectively (p < 0.01). Overall excess weight loss was 26.8% at a mean follow-up of 8 months (3–14). RESULTS: Indications for all exams were as follows: screening (19.7%), surveillance (34.0%), symptom clarification (25.6%), and multiple symptoms or indications (12.0%). Carcinoma detection rate was 2.3%, adenoma detection rate 23.8% and normal exam or insignificant polyps 70.3%. Among patients documented to be undergoing colonoscopy for the first time, the carcinoma detection rate was 9.4% (5/53), this was statistically significant when compared to the rest of the group who had all previously had a colonoscopy (P = 0.01). Carcinoma detection rate was 5.4% if the previous colonoscopy was 10+ years prior. 63% of the carcinomas found in the index colonoscopy group and in patients undergoing repeat colonoscopy 10+ years 31 Monday Abstracts CONCLUSIONS: Hepatic duct diameter increases after Rouxen Y gastric bypass. Patients with prior cholecystectomy have a trend toward increased hepatic duct diameter, though this change was not statistically significant. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary dilation and help to redefine what is considered normal and abnormal in this population. 727 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT later were stage 1 or 2 and 38% were in stage 3. There were no cases with metastasis. Subjects who had a previous colonoscopy within 3 years and 4–5 yrs ago had a 2.8% (6/213) and 0% carcinoma detection rate respectively. When colonoscopies are stratified by indication, anemia had the highest yield with 3.9% rate of carcinoma followed by GI blood loss at 3.3%. Indications predicting a low yield were single symptoms such as altered bowel habits, abdominal pain or weight loss (rate 0%). Screening and surveillance had rates of 1.7% and 2.3%, respectively. appendicitis (n = 22,50%), followed by nonspecific abdominal pain (n = 10, 22.7%), increasing abdominal girth, and incidental diagnosis (n = 5, 11.4%). Nineteen patients (43.2%) had a CT score of zero, 20 patients (45.5%) had a socre of one, and 5 patients (11.4%) a score of two. The mean PCI was 8.2 (range 0–27). A total of 22(50%) patients were upstaged when surgically explored, mostly in patients with a CT score of zero (n = 6, 27.3%) and one (n = 13, 59.1%). Preoperative variables including age, sex, tumor marker levels, PCI score, or presentation with a perforated appendix did not predict upstaging of disease burden. Estimated blood loss and PCI were associated with upstaging (OR = 1.007, 1.782 and p-value = 0.023, 0.0007 respectively). For the entire cohort, the median survival was 22 months. Patients with CT score zero had a 25th percentile survival of 34 months, compared to those with a score of 1 (23 months), and a score of two (18 months). With a median follow-up 23 months, twenty two patients (50%) remain disease free, 11 patients (25%) are alive with disease and 8 patients have died due to disease recurrence. CONCLUSIONS: The majority of outpatient exams in the elderly reveal insignificant findings, demanding too much from limited resources. However, detection of carcinoma according to timing of the most recent exam has a much higher yield than indication. The highest rates of carcinoma are among elderly patients undergoing outpatient colonoscopy for the first time or after more than 10 years and results in acceptable rates of curative colorectal cancer resection. Early detection should reduce the morbidity of late presentation and surgical emergencies often seen in this population. Further guidelines designed to efficiently utilize resources should focus on minimizing redundant exams unlikely to yield significant results while supporting screening exams with high yield. CONCLUSION: Accurate assessment of disease burden for early stage PMP remains challenging. Our data indicates that approximately 50% of patients with no evidence of disease or minimal amount of disease can be upstaged at surgery. Based on this we recommend laparoscopic exploration and possible cytoreductive surgery and hyperthermic chemoperfusion (HIPEC) for all patients with appendiceal cancer. 729 Pre-Operative Imaging Does Not Accurately Stage Patients with Early Stage Appendiceal Cancer Mohammed A. Alzahrani, Hanseman Dennis, Jeffrey Sussman, Syed A. Ahmad Surgical Oncology, University of Cincinnati, Cincinnati, OH 730 Pelvic Radiation Increases the Risk of Ileal Pouch Failure in Patients with Colorectal Cancer Complicating Inflammatory Bowel Disease INTRODUCTION: Pseudomyxoma perotenei(PMP)is a rare clinical entity that mainly originates from appendiceal tumors. A subset of patients are referred after management of their primary tumor (i.e.appendectomy) for evaluation of cytoreductive surgery (CRS)and hyperthermic intraperitoneal chemoperfusion(HIPEC).Some of these patients have no visible disease on radiographic imaging and the value of further surgery in this subset remains controversial. Xianrui Wu1, Pokala R. Kiran1, Feza H. Remzi1, Saurabh Mukewar2, Bo Shen2 1. Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH; 2. Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: The impact of preoperative radiation therapy on pouch function and survival has NOT been studied in ulcerative colitis (UC) patients with colorectal cancer (CRC) who undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The aim of this study was to evaluate pouch outcomes in UC-CRC-IPAA patients with or without preoperative radiation therapy. METHODS: Our single institution’s Peritoneal Cancer Database was reviewed over a ten year period.During this time over 200 patients were treated with appendiceal cancer.We identified 44 patients who meet the criteria for none or minimal residual disease at pre-operative imaging. A CT scoring system incorporating the peritoneal carcinomatosis index (PCI) was devised where a score of zero denoted a normal scan, a score of one signified a possible minimal disease, and a score of two denotes a more obvious localized disease. This cohort of patients was reviewed for basic demographic,clinical,and pathological features. Operative treatment and postoperative course were also highlighted. METHODS: Patients with UC-CRC who underwent restorative proctocolectomy with IPAA from 1984–2009 were evaluated. Patients who underwent IPAA for medically refractory IBD or familial adenomatous polyposis, and patients whose initial pouch configuration was other than J or S type were excluded. Pouch failure was defined as the requirement of permanent diversion or pouch excision. The effect of pelvic radiation on pouch related outcomes was evaluated. RESULTS: Forty four patients, 15 males and 29 females, with a mean age of 50.4 years met the inclusion criteria for none or minimal disease according to the proposed CT score. The commonest initial presentation was acute 32 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA All Cases Without Pelvic Radiation With Pelvic Radiation 63 52 11 Adenocarcinoma 54 44 (84.6%) 10 (90.9%) Mucinous adenocarcinoma 9 8 (15.4%) 1 (9.1%) Synchronous dysplasia, n (%) 34 31 (59.6%) 3 (27.3%) Characteristic Number of patients Histologic type, n (%) P Value 0.69 Histologic grade of tumor, n (%), 0.051 0.43 Poor 20 16 (32.7%) 4 (50.0%) Well to moderate 37 33 (67.3%) 4 (50.0%) Tumor location, n (%) 0.005 Rectum 26 17 (32.7%) 9 (81.8%) Colon 37 35 (67.3%) 2 (18.2%) 0 + I + II 35 33 (63.5%) 2 (18.2%) III + IV 28 19 (36.5%) 9 (81.8%) Neo-adjuvant chemotherapy, n (%) 6 0 (0.0%) 6 (54.5%) <0.001 Adjuvant chemotherapy, n (%) 26 29 (36.5%) 7 (63.6%) 0.176 TNM stage, n (%) 0.008 Configuration of pouch, n (%) 0.10 J pouch 50 39 (75.0%) 11 (100.0%) S pouch 13 13 (25.0%) 0 (0.0%) Method of anastomosis, n (%) CONCLUSIONS: Pelvic radiation even before IPAA creation is significantly associated with poor pouch outcomes in this small sample-sized, yet the largest study in the literature. This information needs to be considered and discussed with patients with prior RT undergoing IPAA. Further, the potential oncological benefits of chemo-radiation should be carefully balanced against any potential adverse effects on functional results on a case by case basis when deciding management of UC patients with CRC. 0.73 Stapled 31 25 (51.0%) 6 (60.0%) Hand-sewn 28 24 (49.0%) 4 (40.0%) Hospitalization, days 8.1±3.5 8.0±3.6 8.1±2.8 0.95 Pelvic abscess, n (%) 9 7 (14.9%) 2 (22.2%) 0.63 Pouch fistula/sinus, n (%) 8 7 (14.9%) 1 (11.1%) 0.77 Pouch stricture, n (%) 16 14 (29.8%) 2 (22.2%) 0.72 Chronic pouchitis, n (%) 18 12 (25.5%) 6 (66.7%) 0.024 Pouch/ATZ neoplasia, n (%) 7 6 (12.8%) 1 (11.1%) 0.89 33 Monday Abstracts RESULTS: A total of 63 pouch patients with confirmed UC-CRC were included (37 male and 26 female). Mean age at pouch surgery was 46.9 ± 10.6 years. Of the 63 patients, loop ileostomy was not closed in 2 patients, and 5 were lost to follow-up. Of the 56 patients eligible for final analysis, 9 patients received pelvic radiation. Among them, 5 patients had neo-adjuvant radiation, 2 received adjuvant radiation after colectomy but before IPAA, while 2 had prior radiation for previous cervical cancer. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7–322.2) months, and 4 (30.8%) of them had radiation therapy. Causes of pouch failure included pouch/anal transition zone (ATZ) cancer (n = 4), chronic pouchitis (n = 3), pouch stricture (n = 3), pelvic abscess (n = 2), and incontinence (n = 1). Pelvic radiation correlated significantly with chronic pouchitis (p = 0.024). There was, however, no association between pelvic radiation and pouch/ATZ cancer, pouch stricture, pelvic abscess, and pouch fistula/sinus (p > 0.05, Table). Kaplan-Meier analysis revealed that pelvic radiation was associated with poor pouch outcome (logrank test, P < 0.001, Figure). The impact of pelvic radiation on pouch outcome was further confirmed in the subgroup analysis of rectal cancer patients (log-rank test, P = 0.020, Figure). Demographic and Clinicopathological Characteristics THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 731 cally sizes to the esophageal lumen. One to two ablations were performed in separate areas in each patient in mucosa proximal to the tumor. After resection, the ablation sites were removed as a full-thickness block and examined histologically by a central study pathologist. Symptoms were assessed prior to ablation, on the day of and 3 days after the procedure using a standardized questionnaire with a 10-point scale. Initial Human Experience with a Novel Throughthe-Scope Cryoballoon Device for Mucosal Ablation Steven R. DeMeester1, Omar Awais3, Jacques J. Bergman2, Kimberly S. Grant1, Blair A. Jobe3, Stefan Niebisch4, Jeffrey H. Peters4, Dirk Schölvinck2, Mark I. van Berge Henegouwen2, Bas L. Weusten2 1. Surgery, Univ. of Southern California, Los Angeles, CA; 2. Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; 3. Surgery, University of Pittsburgh, Pittsburgh, PA; 4. Surgery, University of Rochester, Rochester, NY RESULTS: Twenty-one ablations were performed in 13 patients for 6, 10, 12 or 14 seconds, and the esophagus was removed 0, 4 or 7 days after the procedure. The ablation was in squamous mucosa in 12 patients and in dysplastic Barrett’s in 1 patient. There were no adverse events and no perforations. No pain was present in 78% of patients the day of the procedure and in 89% of patients 3 days after the procedure. The mean scores for pain on the day of and at 3 days after the procedure were 0.89 and 0.2 respectively. Swallowing difficulty was present in 11% on the day of and in 22% at 3 days after the procedure. The mean scores for swallowing difficulty on the day of and at 3 days after the procedure were 0.3 and 0.6 respectively. Details of the histology are shown (Table). INTRODUCTION: Ablation of Barrett’s with high-grade dysplasia has become standard. The most common ablation technique uses radiofrequency energy, but a drawback is the requirement that the devices be used either separate from or attached to the outside of an endoscope. An alternative is cryoablation, but current cryotherapy devices are cumbersome, require gastric venting, and ablation depth is difficult to standardize. A device that goes down the working channel of an endoscope that delivers a uniform and reproducible ablation would potentially be safer and more user-friendly. The aim of this study was to assess depth of injury related to time of ablation using a novel throughthe-scope balloon-based cryotherapy device. CONCLUSIONS: Ablation with a novel cryoballoon device for 10–14 seconds results in substantial mucosal injury with minimal pain or impaired swallowing. Depth of necrosis was maximal at day 4 and was typically into the superficial muscularis propria. By 7 days the injury was resolving, a finding similar to previous work with this device in animals. Major advantages of this device include the ability to standardize the ablation along with the ease of use and quickness of the procedure. Future studies will assess the risk of stricture and efficacy for Barrett’s ablation with this device. METHODS: Patients with esophageal cancer were enrolled in a multi-center prospective trial evaluating a novel cryoballoon ablation device prior to esophagectomy. The device is a through-the-scope, highly compliant balloon catheter that is inflated and cooled by an inert refrigerant delivered from a handheld unit. The balloon automati- Day (Post-Esophagectomy) 0 0 0 0 4 4 4 7 7 7 Ablation time (sec) 6 10 12 14 10 12 14 10 12 14 n 1 1 1 4 4 2 5 1 1 1 30% 80% 50% 3.75% (0–10) 64% (25–90) 80% (65–95) 68% (50–80) 15% 0 100% Circumferential mucoscal ablation; Avg and (range) when n>1 Depth of necrosis* Avg, (range) 1 1 1 1 (0–1) 3 (3–3) 3 (2–4) 3 (2–4) 1 1 2 Adjacent injury* Avg, (range) 0 0 0 1 (0–1) 2 (0–3) 3 (2–4) 2 (0–3) 0 0 2 *Key: 0 = no necrosis; 1 = necrosis only involving mucosa including or superficial to muscularis mucosa; 2 = necrosis into but not through submucosa; 3 = necrosis into superficial muscularis propria; 4 = necrosis involving full-thickness of muscularis propria, no perforation 34 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 732 733 A Multicenter Randomized Trial Comparing Two Ablation Regimens for Focal Radiofrequency Ablation of Barrett’s Mucosa Using the HALO90 System Indirect Costs of Mortality and Morbidity and Direct Economic Costs in a Randomized Controlled Trial of Emergency Therapy of Bleeding Esophageal Varices in Cirrhosis Marshall J. Orloff1, Jon I. Isenberg1, Florin Vaida2, Henry O. Wheeler1, Kevin Haynes1, Horacio Jinich-Brook1, Roderick C. Rapier1, Robert J. Hye1, Wendy Max3 1. Surgery, University of California, San Diego, San Diego, CA; 2. Family and Preventive Medicine/Biostatistics and Bioinformatics, University of California, San Diego, San Diego, CA; 3. Institute for Health and Aging, University of California, San Francisco, San Francisco, CA OBJECTIVE(S): Economic cost is an important measure of effectiveness of treatment of cirrhosis and bleeding esophageal varices (BEV). There have been no reports of costs of any form of emergency treatment of BEV. We examined costs of care in a randomized controlled trial (RCT) that compared endoscopic sclerotherapy (EST) (n = 106) to emergency portacaval shunt (EPCS) (n = 105), in unselected, consecutive patients (“all comers”). BACKGROUND: The currently recommended regimen for endoscopic focal radiofrequency ablation (RFA) of Barrett’s esophagus (BE) comprises two applications of energy, cleaning of the device and ablation zone, and two additional applications of energy. A simplified regimen may be of clinical utility, if it were faster, easier and equally safe and effective. METHODS: Diagnostic workup and treatment were undertaken within 8 hours. Crossover rescue treatment was applied when primary therapy failed according to clearly defined criteria. 96% of patients underwent 10+ years follow-up, or until death. AIM: To compare the efficacy of two focal RFA regimens. METHODS: In 3 centers, consecutive patients scheduled for endoscopic focal RFA of BE were enrolled having flat type BE with at least 2 BE islands or mosaic groups of islands (each less than the surface area of two HALO90 ablation catheters). Targeted BE areas were paired according to similar size: one of each area was randomized to the ’standard’ regimen (2 × 15J/cm2-clean-2 × 15J/cm2) or “simplified” regimen (3 × 15J/cm2-no clean), allocating the second area automatically to the other regimen. The % surface area of each target was scored at 2 months by the endoscopist, who was blinded to patient and regimen type. Patients underwent RFA every 2 months until complete histological response of each targeted BE area was achieved for neoplasia and intestinal metaplasia (CR-N; CR-IM). Primary outcome: CR-IM for each target at 2 months (non-inferiority defined as <20% difference in the paired proportions, sample size calculated at 46 pairs). Secondary outcome: surface regression (%) for each target at 2 months. Indirect costs measured by the economic value of premature death (mortality) and by days lost from work (morbidity) were determined from tables of life expectancy, average earnings at each age, labor force participation rates, and an integrating computer program. Direct costs were determined from complete data on all inpatient and outpatient charges by hospitals and physicians for 10 years. RESULTS: Indirect costs were significantly lower following EPCS than after EST (p < 0.001) based on (1) costs of mortality measured by shortened life expectancy; and (2) costs of morbidity incurred by days lost from productive activities. When added to direct costs (hospitalization, outpatient care, physician services), total costs following EPCS were significantly lower than after EST (p < 0.001). RESULTS: Forty-five equivalent pairs of target BE areas were randomized by Dec ’11, in 40 patients (29 male, age 64 ± 12 years, BE C4M7). The proportion of targets showing CR-IM at 2 months after focal-RFA was 30/45 (66.7%) for standard and 33/45 (73.3%) for simplified: a difference of 6.7% (95%CI–12.2 to +25.6). The median surface regression for each target at 2 months was 100% in both groups, whereas for not completely eradicated areas this was 77.5% (IQR50–90)% for standard and 75% (IQR50–90) for simplified (p = 1.0). No complications occurred. By Dec ’11, CR-IM and CR-N was achieved in 91.1% (31/34) and 100% of patients, whereas 7 patients are under treatment. CONCLUSIONS: In this RCT of emergency treatment of BEV in cirrhosis with regular follow-up for 9.6 to 10+ years, indirect costs (mortality and morbidity) were significantly lower following EPCS than after EST. Combining indirect and direct costs, overall costs of EPCS were significantly less than costs of EST. Results of this first reported analysis of economic costs of emergency treatment of BEV, when added to other benefits of EPCS observed in this RCT, provide support for EPCS as a first-line emergency treatment of BEV. CONCLUSIONS: The results of this multicenter randomized trial suggest that a simplified 3x15J/cm2 focal ablation regimen is not inferior to the standard regimen. Therefore, the simplified regimen may be recommended for residual Barrett’s islands. 35 Monday Abstracts Frederike G. van Vilsteren1, Lorenza Alvarez Herrero2, Roos E. Pouw1, Kai Yi N. Phoa1, Carine Sondermeijer1, Mike Visser3, Fiebo J. ten Kate3, Mark I. van Berge Henegouwen4, Bas L. Weusten2, Erik J. Schoon5, Jacques J. Bergman1 1. Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 2. Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands; 3. Pathology, Academic Medical Center, Amsterdam, Netherlands; 4. Surgery, Academic Medical Center, Amsterdam, Netherlands; 5. Gastroenterology, Catharina Ziekenhuis, Eindhoven, Netherlands THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT bined procedures were less common in 2009 compared to 2005 (OR; 95% CI, 0.7; 0.5, 0.8), and RYGB+C patients were more likely to receive an open operation (4.9; 4.4, 5.5), to have a severe ASA score (1.2; 1.0, 1.3), and be functionally dependent (2.1; 1.4, 3.0). Post-operatively, the percentage of RYGB+C patients experiencing a major complication was significantly greater compared to RYGB alone patients (6.6% vs 4.9%, P < 0.001). While risk was increased for RYGB+C patients for developing septic shock (P = 0.02), acute renal failure (P = 0.01), prolonged intubation (P = 0.001), and return to the operating room (P < 0.001) on univariate analysis, only return to the operating room was significant in multivariate adjustment models (1.3; 1.0, 1.7). Overall, RYGB+C was a risk factor for predicting major adverse events following laparoscopic procedures but not open (Table). Prolonged LOS was more common among RYGB+C patients who underwent either laparoscopic (13.5% vs 9.5%, P < 0.001) or open (14.1% vs 9.6%, P < 0.001) RYGB following adjustment (Table). Overall mortality at 30-days (0.2%) was low and did not vary with concomitant cholecystectomy (0.35% RYGB+C vs 0.19% RYGB alone, P = 0.16) following adjustment for confounding variables (Table). 734 Does Concomitant Cholecystectomy at Time of Roux-en-Y Gastric Bypass Impact Adverse Operative Outcomes? Robert B. Dorman1, Wei Zhong2, Anasooya A. Abraham1, Sayeed Ikramuddin1, Waddah B. Al-Refaie1, Daniel B. Leslie1, Elizabeth Habermann1 1. Surgery, University of Minnesota, Minneapolis, MN; 2. Biostatistics, University of Minnesota, Minneapolis, MN BACKGROUND: Previous investigations of the short-term operative outcomes associated with a concomitant cholecystectomy at time of Roux-en-Y gastric bypass (RYGB) for obesity are mixed and confined to the biases of singlecenter experiences. Using a robust multi-hospital surgical database, we sought to determine the influence of concomitant cholecystectomy (RYGB+C), hypothesizing that the addition of cholecystectomy will adversely impact operative outcomes following RYGB. METHODS: Patients who underwent a RYGB were identified in the 2005–2009 American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) database. Demographic and outcome variables were compared between patients that underwent RYGB alone versus RYGB+C using univariate analysis. Multivariate logistic regression with adjustment for confounding variables was utilized to identify risk factors for major adverse events, prolonged length of stay (PLOS), and mortality at 30 days. Prolonged LOS was defined as those who experienced a hospital stay beyond the 90th percentile. CONCLUSION: The risk for major adverse events is significantly greater for RYGB+C patients following laparoscopic procedures, and the risk for PLOS is greater for RYGB+C patients following both open and laparoscopic procedures. While thirty-day mortality was greater, it was not significantly associated with concomitant cholecystectomy. The short-term risks identified in this study can assist in decision making when considering concomitant cholecystectomy at the time of RYGB. RESULTS: We identified 32,946 patients who underwent RYGB; of these, 1,731 (5.2%) underwent RYGB+C. Com- Predictors of Major Complications, PLOS, and Mortality After RYGB Major Events+ N = 32880 Open OR (95% CI) N = 4276 Laparoscopic OR (95% CI) N = 28604 Prolonged Length of Stay+ N = 32880 OR (95% CI) 30-Day Mortality N = 32946 OR (95% CI) 0.8 (0.6, 1.2) 1.3 (1.0, 1.7) 1.5 (1.3, 1.8) 1.2 (0.5, 2.9) Ref. 1.3 (1.0, 1.7) 0.9 (0.5, 1.6) Ref. 1.2 (1.0, 1.4) 1.2 (0.9, 1.7) Ref. 1.3 (1.2, 1.5) 1.9 (1.5, 2.2) Ref. 1.4 (0.8, 2.4) 2.3 (0.9, 5.9) Ref. 1.4 (0.9, 1.9) 1.3 (0.9, 1.9) 1.8 (1.2, 2.5) Ref. 1.0 (0.8, 1.2) 1.3 (1.0, 1.6) 1.3 (1.0, 1.6) Ref. 1.1 (1.0, 1.2) 1.4 (1.2, 1.6) 1.6 (1.4, 1.8) Ref. 1.9 (0.8, 4.5) 2.1 (0.8, 5.3) 3.8 (1.7, 8.6) — — 0.9 (0.8, 1.0) 2.2 (1.3, 3.8) Diabetes 1.3 (1.0, 1.7) 1.0 (0.9, 1.1) 1.1 (1.0, 1.2) 2.1 (1.2, 3.5) Cardiac Co-morb. 1.6 (1.0, 2.5) 1.2 (0.9, 1.6) 1.4 (1.2, 1.7) 3.3 (1.7, 6.6) Total Events N (%) 366 (8.5) 1224 (4.3) 3213 (9.8) 66 (0.2) C-Index of model 0.61 0.58 0.62 0.77 Predictors RYGB+C vs RYGB Alone Age (Years) 35–49 50–64 ≥65 BMI (kg/m2) 45–49 50–54 55–59 ≥ 60 Open Surgery Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index; Co-morb., co-morbidities. Significant values are bolded and italicized. Variables also adjusted for include, but are not limited to, race, sex, pulmonary comorbidities as well as preoperative liver enzymes, white blood cell count, hemoglobin, albumin, and sodium. Prolonged LOS was defined as those who experienced a hospital stay beyond the 90th percentile. Note: +Only patients discharged alive were included. 36 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 735 hemoglobin values were respectively 5.3%, 5.2%, 5.4%, and 5.4%. 94% of diabetics with more than 1 year follow up were under no treatment; glycemia was under 100 mg/dl in 88% of them and glycated hemoglobin under 6% in 92% of them. The rate of dyslipemia fell from 64 to 20%. No vomits or alkaline reflux have been observed. Mean number of daily bowel movements is 2.5. Five patients suffered at least one episode of clinical hypoproteinemia, and 3 of them presented it recurrently. Two patients have been revised to a Roux-en-Y duodenal switch with a 3 meter alimentary limb and a 2 meter common channel. Now no patient has suffered any intestinal obstruction. Weight Loss and Metabolic Profiles of Obese Patients After Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Andrés Sánchez-Pernaute1, Miguel Angel Rubio-Herrera2, Pablo Talavera1, Elia Pérez-Aguirre1, Antonio J. Torres García1 1. Surgery, Hospital Clínico San Carlos, Madrid, Spain, Madrid, Madrid, Spain; 2. Endocrinology, Hospital Clínico San Carlos, Madrid, Madrid, Spain Monday Abstracts INTRODUCTION: Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a simplified duodenal switch in which the duodeno-ileal diversion is performed in one loop at 200 to 250 cm from the ileo-cecal valve. Theoretical advantages of the technique are a shorter operative time, the reduction to only one anastomosis and the non-opening of the mesentery. AIM: To analyze the weight evolution and the improvement of the metabolic profiles of obese patients submitted to SADI-S. PATIENTS AND METHODS: 102 patients have been submitted to SADI-S as a primary bariatric operation consecutively since May–2007 (Clinical Trials NCT01463904). There were 64 women and 38 men. Mean age was 48 years (22–71), mean weight 119 kg (72–164) and mean excess weight 53 kg (27–99). There were 65 type-2 diabetics, 41% of them on insulin therapy. Mean preoperative glycemia was 153 mg/dl and mean glycated hemoglobin 9.5%. There were 64 patients with dyslipemia and 57 patients had criteria of metabolic syndrome. The operation was performed laparoscopically in 96% of the cases. The sleeve gastric resection was always performed over a 54 French bougie; the duodeno-ileal anastomosis was performed at 200 cm from the cecum in the first 50 patients and at 250 cm in the next 52, to decrease the 6% rate of clinical hypoproteinemia. One self-limited anastomotic leak and 2 gastric leaks were registered. There were no postoperative deaths. CONCLUSIONS: SADI-S is a simplified duodenal switch that offers a satisfactory weight loss and very good metabolic results. The preservation of the pylorus makes unnecessary the performance of a Roux-en-Y diversion. The technique reduces operative time and postoperative complications, in the short term by reducing the number of intestinal anastomosis and in the long term by decreasing the possibility of internal hernia. RESULTS: Mean excess-weight loss was 78% at 6 months, 94% at 1 year, 100% at 2 years, 93% at 3 years and 108% at 4 years. Only one patient failed to achieve a 50% excessweight loss. Mean glycemia fell to 94 mg/dl in the first year, 93 mg/dl in the second one, 91 mg/dl in the third and 95 mg/dl in the fourth postoperative year. Mean glycated 37 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 736 patients was 2. In two patients there was complete resolution of the leak, one requiring a second clip placement. The third patient had a contained leak following clip placement that was followed clinically, follow up swallow study at six days showed improvement, and she was discharged home. Two patients had gastro-gastric fistulas following roux-en-y gastric bypass surgery. One of these patients had complete resolution of the fistula. The other had initial success but the clip displaced and fistula recurred. Two patients presented with anastomotic leak following colon resection. In one case the patient had extensive adhesions resulting in a rigid colon and the Ovesco system on a pediatric scope was too large to reach the fistula, so the procedure was aborted. In the second case, the leak was successfully treated with a single clip. Three patients were successfully treated for esophageal perforation. One had a 9 mm mid-esophageal perforation that required staged placement of two clips. One had two separate distal esophageal perforation sites, each requiring one clip. The final esophageal perforation was treated with a single clip. The average operative time for clip placement was 61 minutes. There were no complications. Initial Experience with an Innovative Endoscopic Clipping System Alisa M. Coker1, Marcos Michelotti1, Nikolai A. Bildzukewicz1, Takayuki Dotai1, Luciano Antozzi1, Geylor A. Acosta1, Santiago Horgan1, Bryan J. Sandler1, Mark A. Talamini1, Thomas J. Savides2, Garth R. Jacobsen1 1. Surgery, UCSD, La Jolla, CA; 2. Gastroenterology, UCSD, La Jolla, CA Introduction: There are few options available for treatment of fistulas, leaks, and perforations endoscopically. Here we describe our experience with a new endoscopic clipping system. METHODS: A retrospective review of all cases using the Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tuebingen, Germany) between August 2011 and November 2011. Resolution of leak was determined by a swallow study or CT scan. RESULTS: The system was utilized in ten patients with clinically significant gastrointestinal surgical complications. Three patients were referred for treatment of gastric leaks following a sleeve gastrectomy, two had post-operative colonic leaks, two had gastro-gastric fistulas following roux-en-y gastric bypass, and three had esophageal perforations. All three gastric leaks occurred just distal to the GE junction and each had undergone previous attempts at treatment with other endoscopic methods. The average number of over the scope clips placed in these three CONCLUSIONS: This over the scope endoscopic clip system is simple to use, safe, and successful in approximating tissue to treat traditionally difficult surgical complications. There is a potential for broad applications of this new technology. Further experience and longer follow up are needed to assess its indications as related to defect size and location. 2:15 PM – 4:00 PM 27b PLENARY SESSION V based on the surgeon’s assessment of resectability at laparoscopic staging, (e.g. mobile tumors and low lymph node burden). Our study aim was to determine whether survival is impacted by a selective approach to treatment that includes minimally invasive esophagectomy (MIE) alone. 806 Propensity Matched Analysis of Surgeon-Driven Treatment Allocation for Locoregionally Advanced Esophageal and Gastroesophageal Junction Adenocarcinoma METHODS: Patients with stage II or higher EG adenocarcinoma treated with MIE (n = 375; 1997–2009) were reviewed. Demographics, comorbidities, tumor and treatment variables were abstracted. To determine the probability of treatment assignment to either induction therapy followed by MIE (E-) or to MIE alone (E+), propensity scores were calculated. Variables are listed in Table 1. Complete data for the propensity variables were available in 280 patients and 80 closely matched pairs (n = 160) were generated. Data missingness was random; survival relevant variables in excluded patients did not differ significantly from the included patients. Hazard ratios for death were calculated by stratified Cox proportional-hazards regression model after controlling for age, gender, BMI, smoking history and age adjusted CCI. Haris Zahoor , James D. Luketich , Thomas Murphy , Michael Gibson2, Manisha Shende1, Dan Winger3, Tyler J. Foxwell1, Blair A. Jobe1, Katie S. Nason1 1. Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; 2. Medicine, University of Pittsburgh, Pittsburgh, PA; 3. Clinical and Translational Science Institute (CTSI), University of Pittsburgh, Pittsburgh, PA 2 1 1 BACKGROUND: Attempts to define the optimal treatment strategy for resectable but locoregionally advanced esophagogastric (EG) adenocarcinoma have yielded conflicting results. As a result of high local failure rates, most thoracic oncologists favor induction therapy followed by surgery. In our center, a selective approach has been used 38 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA single-incision trocar system, a complete mediastinal dissection of the esophagus can be accomplished under direct vision. This can be performed simultaneously with the abdominal portion of the esophagectomy. This allows for a shorter operative time, eliminating the need for single-lung ventilation, and reducing the risk for postoperative pulmonary complications by avoiding the pleural cavity. Thank you for considering this video. RESULTS: MIE was the primary therapy in 47% (n = 178) of patients and induction therapy in 53% (n = 197; 51% chemotherapy alone and 49% chemoradiation). Chemotherapy included cisplatin (61%), 5-FU (76%), and paclitaxel (42%). Complete response following induction therapy was confirmed at MIE in 13%; 44% were node-negative at resection compared to 20% for MIE alone. Median number of lymph nodes examined was 21 (IQR 15, 29). Median time to follow-up was 23 months (IQR 11, 38). Adjuvant therapy was given to 53% of patients following MIE. In the 80 matched pairs, there were 117 deaths (73%; median 18 months, IQR 9, 29). Surgery as primary mode of treatment was not associated with significantly different hazard for death after adjusting for age, sex, BMI, smoking history and age-adjusted Charlson Comorbidity index (0.96; 95% CI 0.58–1.6). Complete response was not associated with a significant improvement in median survival (19 versus 17 months; p = 0.24). 808 Nicholas J. Shaheen1, William J. Bulsiewicz1, William D. Lyday2, George Triadafilopoulos3, Herbert C. Wolfsen4, Srinadh Komanduri5, Gary W. Chmielewski6, Atilla Ertan7, F. Scott Corbett8, Daniel S. Camara9, Richard I. Rothstein10, Bergein F. Overholt11 1. Division of Digestive Diseases, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC; 2. Atlanta Gastroenterology Associates, Atlanta, GA; 3. Stanford University School of Medicine, Palo Alto, CA; 4. Mayo Clinic Florida, Jacksonville, FL; 5. Northwestern Memorial Hospital, Chicago, IL; 6. Rush University Medical Center, Chicago, IL; 7. University of Texas Health, Houston, TX; 8. Sarasota Memorial Hospital, Sarasota, FL; 9. Sisters of Charity Hospital, Buffalo, NY; 10. Dartmouth-Hitchcock Medical Center, Lebanon, NH; 11. Gastrointestinal Associates, Knoxville, TN Variables Included in Propensity Matching Age Body Mass Indes Smoking History Pack-years smoked Sex Surgeon Alcohol use Gerd history Histologically confirmed Barrett’s History of MI History of CHF History of CABG or coronary stent History of vascular disease History of renal failure History of diabetes requiring treatment History of pulmonary disease History of stroke or TIA History of malignancy other than current History of metastaatic cancer History of liver disease Final pretreatment clinical stage Operation status Prior esophageal surgery Esophageal cancer location BACKGROUND: Ongoing acid and bile reflux are hypothesized to impair healing and squamous re-epithelialization after treatment of Barrett’s esophagus (BE) with radiofrequency ablation (RFA). It is unclear if prior fundoplication improves subsequent safety and/or efficacy of ablation. We used data from a nationwide registry of patients treated with RFA for BE to assess the relationship between prior fundoplication and these outcomes. CONCLUSION: We found that a selective approach to treatment of EG adenocarcinoma does not negatively impact patient survival. Complete response rates to induction therapy in this series were not associated with improved survival. Our data suggest that surgeon-driven treatment allocation for locoregionally advanced esophagogastric adenocarcinoma, including aggressive lymph node dissection, is a reasonable alternative to treating all patients with induction therapy. METHODS: The U.S. RFA Registry is a prospective study of patients with BE treated with RFA at 148 institutions (113 community-based, 35 academic-affiliated). Information collected in the registry includes demographic data, histology prior to treatment, endoscopic findings, date and number of treatment sessions, ablation outcomes, and complications. Medical therapy with proton pump inhibitors was used in subjects without fundoplication. Our safety cohort consisted of all patients treated with RFA, while our efficacy cohort was restricted to subjects who had biopsies ≥12 months after RFA treatment initiation. Complete eradication of intestinal metaplasia (CEIM) was achieved if last biopsies demonstrated no IM. We compared safety and efficacy outcomes between those with a history of fundoplication and those undergoing medical management, using parametric tests. Safety outcomes included rates of stricture, bleeding, and hospitalization. Efficacy outcomes included CEIM, complete eradication of dysplasia (CED), and number of treatment sessions to CEIM. Efficacy results are reported for the full cohort and stratified as non-dysplastic BE (NDBE) versus dysplastic BE. 807 Transcervical Videoscopic Esophageal Dissection in a Two-Field Minimally Invasive Esophagectomy Ross F. Goldberg, Tatyan M. Clarke, Armando Rosales-Velderrain, John Stauffer, Horacio J. Asbun, C. Daniel Smith, Steven P. Bowers Surgery, Mayo Clinic – Florida, Jacksonville, FL This video report demonstrates a patient undergoing a 2-field minimally invasive esophagectomy using a transcervical videoscopic esophageal dissection. Using a modified 39 Monday Abstracts Prior Fundoplication Does Not Improve Subsequent Safety or Efficacy Outcomes of Radiofrequency Ablation (RFA): Results from the U.S. RFA Registry THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT RESULTS: Among 5,539 patients receiving RFA, 318 (5.7%) had a prior fundoplication. Of these subjects, 0.9% developed stricture after RFA and 1.3% were hospitalized. There were no perforations or clinically significant bleeding in the fundoplication group. Rates of stricture, bleeding, and hospitalization were not statistically different (p>0.05) between patients with and without prior fundoplication (see Table). In all, 2,135 of 5,539 (39%) had biopsy data available after 12 months. CEIM and CED were achieved in 78% and 93% of subjects with a fundoplication, and 72% and 87% of subjects without a fundoplication, respectively (p > 0.05 for both comparisons). Subjects with prior fun doplication had similar rates of CED, CEIM, and number of RFA sessions for eradication when compared to those without prior fundoplication (see table). CONCLUSIONS: In the largest reported cohort of patients treated with RFA for BE, RFA in subjects with a prior fundoplication was safe and effective. However, prior fundoplication was not associated with improved efficacy or reduced number of ablation sessions, when compared to medical management using proton pump inhibitors. Safety and Efficacy Outcomes Among Patients with and without Fundoplication Prior to Treatment with RFA. Complication Rates Per Patient Efficacy for all Subjects Fundoplication Medical Therapy N 318 5221 Stricture 0.9% 2.2% 0.14 Bleeding 0 0.4% 0.27 0.18 Hospitalization 1.3% 0.6% N 139 1996 CEIM 78% 72% 0.18 93% 87% 0.13 2.8 (1.6) 2.8 (1.6) 0.91 CED RFA treatment sessions, mean (SD) Efficacy for Nondysplastic BE N CEIM RFA treatment sessions, mean (SD) Efficacy for Dysplastic BE and IMC p-value N 79 875 80% 81% 0.72 2.7 (1.8) 2.6 (1.6) 0.68 60 1121 CEIM 75% 65% 0.13 CED 93% 87% 0.13 3.0 (1.4) 3.0 (1.6) 0.90 RFA treatment sessions, mean (SD) Complications and outcomes were also compared. Sociodemographic factors were examined as effectors of surgery location. 809 Nationwide Inpatient Sample: Have Antireflux Procedures Undergone Regionalization? RESULTS: A total of 11804 cases were performed in T1 and 8856 in T2. In T1, 41.0% of procedures were performed in a HVC vs 35.4% in T2. LVC rates increased with time: 20.53% vs. 26.87% (p < 0.0001). Rural hospitals had decreased surgical volume (19.10% vs. 10.33%, p < 0.0001), while all urban hospitals increased volumes: teaching (48.23% vs. 51.03%, p < 0.0001) and non-teaching (32.67% vs. 38.64%, p < 0.0001). Using multivariate regression, the following were predictors of surgery at a LVC in T1: non-caucasian race (OR 1.42, p < 0.0001), emergent admission (OR 2.24, p < 0.0001), living in a zip code with low median income (OR 1.52 lowest vs. highest, p = 0.0039), increasing age (p = 0.0002), and increasing concurrent diagnosis number (p = 0.0029). In T2, emergent admission (OR 1.34, p = 0.038), low median income (OR 1.69 highest vs lowest, p < 0.0001), and number of concurrent diagnoses (p = 0.034) Paul D. Colavita, Igor Belyansky, Amanda Walters, Sofiane El Djouzi, Alla Zemlyak, Amy E. Lincourt, B. Todd Heniford General Surgery, Carolinas Medical Center, Charlotte, NC INTRODUCTION: With improved outcomes demonstrated at high volume centers, many complex surgical procedures have migrated to large, specialized hospitals. The purpose of this study is to examine the extent of regionalization and outcomes in anti-reflux surgery. METHODS: The Nationwide Inpatient Sample (NIS) data were analyzed from 1998–99 (T1) and 2008–09 (T2) for all antireflux operations in patients with gastroesophageal reflux symptoms using ICD-9-CM codes. Hospitals were stratified into high-, mid-, and low-volume centers (HVC, MVC, LVC) based on annual antireflux surgery volume. 40 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSION: Despite improved results at HVCs, LVCs have increased their percentage of antireflux operations over time. The urban non-teaching hospitals have experienced the largest gains in caseload. Overall complication rates have increased with time, possibly due to noted increased incidence of comorbidities in the patients seeking antireflux surgery. After controlling for confounding variables, complications remain more likely in LVCs. Regionalization has not occurred over time, but may improve outcomes if supported. 810 Improved Long-Term Survival After Major Resection for Hepatocellular Carcinoma: A Multicenter Analysis Based on a New Definition of Major Hepatectomy Andreas Andreou1, Jean-Nicolas Vauthey1, Daniel Cherqui2, Eddie Abdalla1, Steven Wei1, Steven Curley1, Alexis Laurent2, Ronnie Poon3, Jacques Belghiti4, David M. Nagorney5, Thomas Aloia1 1. Surgical Oncology, MD Anderson Cancer Center, Houston, TX; 2. Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Hôpital Henri Mondor, Créteil, France; 3. Department of Surgery, University of Hong Kong/Queen Mary Hospital, Hong Kong, China; 4. Department of Surgery, Hôpital Beaujon, Clichy, France; 5. Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN BACKGROUND: Advances in the surgical management of hepatocellular carcinoma (HCC) have expanded the indications for curative hepatectomy, including more extensive liver resections. The purpose of this study was to examine long-term survival trends for patients treated with major hepatectomy for HCC. Improved Survivals After Major Resection of HCC Over Time CONCLUSIONS: This multinational, long-term HCC survival analysis indicates that expansion of surgical indications to include major hepatectomy is justified by the significant improvement in outcomes over the past 3 decades observed in both the East and the West. PATIENTS AND METHODS: Clinicopathologic data for 1115 patients with HCC who underwent hepatectomy between 1981 and 2008 at 5 hepatobiliary centers in France, China, and the USA were assessed. In addition to other performance metrics, outcomes were evaluated using resection of ≥4 liver segments as a novel definition of major hepatectomy. 41 Monday Abstracts RESULTS: Major hepatectomy was performed in 539 patients. In the major hepatectomy group, median tumor size was 10 cm (range:1–27 cm) and 22% of the patients had bilateral lesions. The TNM Stage distribution included 29% Stage I, 31% Stage II, 38% Stage III, and 2% Stage IV. The postoperative histologic examination indicated that chronic liver disease was present in 35% of the patients and microvascular tumor invasion was identified in 60% of the patients. The 90-day postoperative mortality rate was 4%. After a median follow-up time of 63 months, the 5-year overall survival rate was 40%. Patients treated with right hepatectomy (n = 332) and those requiring extended hepatectomy (n = 207) had similar 90-day postoperative mortality rates (4% and 4%, respectively, P = .976) and 5-year overall survival rates (42% and 36%, respectively, P = .523). Overall survival and postoperative mortality rates after major hepatectomy were similar among the participating countries (P > .1) and improved over time with 5-year survival rates of 30%, 40%, and 51% for the years 1981–1989, 1990–1999, and the most recent era of 2000–2008, respectively (P = .004) (Figure). Factors that were associated with worse survivals included AFP level >1000 ng/mL, tumor size >5 cm, presence of major vascular invasion, presence of extrahepatic metastases, positive surgical margins, and earlier time period in which the major hepatectomy was performed (all MV P < 0.05). were independent predictors of antireflux surgery at a LVC. In T2, mean LOS at a LVC was 4.0 days vs 3.3days at a HVC (p < 0.0001), but this was not significant in multivariate analysis. Total charges were lower at a LVC ($38000 vs $41000, p = 0.0032) in multivariate analysis. Complication rates increased at all centers with time, but were twice as common in LVCs (6.39% vs. 3.16% at HVCs, p < 0.0001) in T2. Controlling for confounding variables, complications remained more likely in LVCs (T1: OR 1.71, p < 0.0001, T2: OR 1.49, p < 0.0001). In hospital mortality decreased in all centers with time and did not differ significantly in either era. Patients at all centers have increased their mean number of concurrent diagnoses over time(3.92 vs 6.70, p < 0.0001). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 811 812 Bariatric Surgery: Still Have an Appetite? Circadian Genes in Pancreatic Ductal Adenocarcinoma: Alterations and Clinical Correlations Nayna A. Lodhia, Jaffer M. Kattan, Dylan Gwaltney, Margaret M. Nkansah, Shushmita Ahmed, John M. Morton Stanford School of Medicine, Palo Alto, CA Daniel Relles, Galina Chipitsyna, Terry Hyslop, Charles J. Yeo, Hwyda A. Arafat Surgery, Thomas Jefferson University, Philadelphia, PA INTRODUCTION: Understanding eating patterns in patients following laparoscopic roux-en-Y-gastric bypass (LRYGB) is important to determine long term success. The purpose of this study was to analyze changes eating habits of patients following LRYGB using the three-factor eating questionnaire (TFEQ-R18). BACKGROUND: The circadian rhythm regulates various metabolic processes, physiologic homeostasis and behavior. Epidemiologic studies have demonstrated that disruption of the circadian rhythm is associated with cancer development and tumor progression. Several circadian clock genes with tightly connected transcriptional feedback loops have been implicated in loss of cell cycle control, impaired DNA damage repair, and subsequent tumor formation in multiple cancer models. However, the direct links between aberrant circadian clock gene expression and human pancreatic ductal adenocarcinoma (PDA) have not been elucidated. In this study, we investigated the expression profiles of several circadian clock genes in PDA. METHODS: Demographic, preoperative, three, six and twelve month postoperative data were prospectively obtained for 204 consecutive laparoscopic RNYGB patients at a single academic institution. All patients enrolled in the study completed the three-factor eating questionnaire (TFEQ-R18), an 18 question inventory that measures 3 aspects of eating behavior: cognitive restraint, uncontrolled eating, and emotional eating at each clinic visit. Higher scores in each category indicate a higher degree of restraint or eating pattern. Patients were compared on the basis of age, gender and body-mass index (BMI). Data at pre-operative and TFEQ-R18 scores were analyzed with a one way ANOVA for continuous variables and chi-squared analysis for dichotomous variables using Stata/IC 11.1 and R2.13.1 software. METHODS: We analyzed the expression of 10 circadian clock genes in matched invasive human PDA (n = 62) and surrounding adjacent tissues and in benign lesions (n = 10). Quantitative real-time polymerase chain reaction (qPCR) was used to examine the following core clock genes: (BMAL, Clock, Cry1, Cry2, CK1E, Per1, Per2, Per3, Timeless, Timeless-interacting protein). Gene expression levels were correlated with clinicopathological parameters. Receiver operator curve (ROC) analysis was completed using logistic regression based on individual circadian genes measured in tumor and benign samples, and is reported as area under the ROC curve (AUC). Spearman correlation was used to assess the relationship between circadian genes within tumor samples. Univariable Cox models were completed to assess survival of PDA patients, using the median gene expression level as stratification factor. RESULTS: Patient mean demographics included BMI 47, age 47, 65% white, income $62,100, 78% with private insurance, and 4 total preoperative comorbidities. Comorbidities included 43% with diabetes, 69% with hypertension, 53% with hyperlipidemia, 46% with GERD, 48% with sleep apnea, and 41% with depression. By 3 months postoperative, patients saw a significant reduction from their preoperative BMI to 42.3 kg/m2 (p < 0.01). Patients saw a significant improvement in cognitive restraint from preoperative to 3, 6 and 12 months postoperative (54.1, 76.8, 73.5, 74.4; p < 0.001); uncontrolled eating (39.3, 10.7, 13.0, 16.7; p < 0.001); and emotional eating (44.6, 14.0, 16.0, 22.5; p < 0.001). Patients over the age of 50 years had a significantly higher emotional eating score at 3 months postoperative (10.0 versus 19.6, p = 0.01); however, these differences were no longer significant at 6 months postoperative. RESULTS: In the tumor tissue of PDA patients, compared to their matched adjacent tissue, expression levels of all circadian genes were significantly lower (P < 0.05). Benign tissues also expressed significantly (P < 0.05) higher levels of all circadian genes when compared to malignant lesions. Spearman correlations of all 10 genes in tumors showed significant correlations of their expression levels ranging from 0.57 to 0.93, p < 0.001 in all cases. Univariable survival analysis indicated that Per2 (p = 0.004), Per3 (p = 0.007), Cry2 (p = 0.016), Tim (p = 0.016) and CK1E (p = 0.024) are significantly related to survival. CONCLUSIONS: Patients undergoing LRYGB see significant improvements in their cognitive restraint, uncontrolled eating and emotional eating as early as 3 months postoperative, at which point their TFEQ-R18 scores are within population norms for healthy weight individuals. Eating behaviors may portend future weight maintenance success. CONCLUSIONS: Our results reveal for the first time a disturbed transcription of several circadian genes in PDA. Elevation of the gene levels in the benign and matched adjacent tissues may be indicative of their role during the process of tumorigenesis. Altered expression of Per2, Per3, Cry2, Tim and CK1E in PDA provides the basis for future studies to explore their validity as predictive markers of the outcomes and survival in PDA patients. 42 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 4:00 PM – 5:00 PM 27b QUICK SHOTS SESSION III 813 814 Repeat Hepatectomy for Recurrent Liver Metastasis from Gastric Carcinoma Akio Saiura, Nobuyuki Takemura, Rintaro Koga, Junichi Arita, Yoshihiro Ono, Ryuji Yoshioka Cancer Institute Hospital, Tokyo, Japan Mathias Worni1, Christopher R. Mantyh1, Igor Akushevich2, Ricardo Pietrobon1, Bryan M. Clary1 1. Surgery, Duke University Medical Center, Durham, NC; 2. Center for Population Health and Aging, Duke University Medical Center, Durham, NC BACKGROUND: The efficacy of repeat hepatectomy for recurrent colorectal liver metastases has been widely accepted as a treatment of potential cure. However, indication for hepatectomy in cases of gastric cancer liver metastasis (GLM) remains unclear. Moreover, no benefits have been reported of repeat hepatectomy for intrahepatic recurrence of GLM. The aim of this study is to clarify the survival benefit of hepatectomy for primary and recurrent GLM. BACKGROUND: The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. Although simultaneous colorectal/liver resection (SCLR) is an attractive option, the safety of this strategy has not been explored outside of small single institutional experiences. The goal of this investigation was to compare perioperative outcomes of SCLR with isolated resections utilizing a more inclusive national clinical database. AIM: The objective of this retrospective study is to clarify the indications for and benefit of primary and repeat hepatectomy for GLM. METHODS: Seventy-three patients underwent hepatectomies for GLM with curative intent from January 1993 to January 2011. Curative surgery was performed in 64 patients and repeat hepatectomy was done in 14 of 35 patients with intrahepatic recurrence; in total, 78 liver resections were performed. Clinicopathological factors were evaluated by univariate and multivariate analysis among patients who received curative resection for those affecting survival. METHODS: National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was examined to construct descriptive statistics and risk-adjusted generalized linear models. These were used to compare 30-day postoperative outcomes among patients undergoing SCLR with colorectal resections (CR) and liver resections (LR) only in patients with metastatic colorectal cancer. RESULTS: The cancer-specific 1-, 3-, and 5-year survival rates after curative hepatectomy (n = 64) for GLM were 87, 50, and 37%, respectively, with a median survival of 34 months. By multivariate analysis, serosal invasion of the primary gastric cancer and larger tumor (>5 cm in diameter) were found to be independent indicators of poor prognosis. Forty-three patients developed postoperative recurrence (67%) after the curative resection for GLM. Intrahepatic recurrence occurred in 37 patients, corresponding to 86% of all patients with recurrence. A repeat hepatectomy for intrahepatic recurrence was performed in 14 patients (40%) based on the same indication as initial hepatectomy for GLM. The actuarial 1-, 3-, and 5-year cancer-specific survival rates after second hepatectomy were 71, 47, and 47%, respectively, with a median survival of 30 months. Three patients have survived more than 5 years after the repeat hepatectomy. RESULTS: 3,983 patients with metastatic colorectal cancer were identified who underwent SCLR (192), LR (1,857) or CR (1,934). Minor differences in patient demographics were noted. Patients undergoing SCLR were younger compared to CR and LR with mean ages of 40.4 years (SD: 10.8), 45.5 (13.5), and 41.7 (11.7), respectively (p < 0.001). Mean number of comorbidities in the SCLR group was 0.63 (SD: 0.89), in the CR group 0.87 (1.01), and 0.74 (0.89) in the LR group (p < 0.001). Rectal resection was performed in 45 (23.4%) SCLR-patients and 269 (13.9%) CR-patients (p < 0.001). Major hepatectomy (≥ three segments) was performed in 69 (35.9%) SCLR-patients and 774 (41.7%) of LR-patients (p = 0.12). Median operation time was significantly longer for SCLR 273 minutes (95% CI: 253–295), in comparison to CR (172 minutes, 95% CI: 167–176) and LR (223 minutes, 95% CI:217–229). Median length of hospital stay was significantly longer for SCLR (9.5 days, 95% CI: 8.7–10.4) than CR (8.1 days, 95% CI: 7.8–8.3) and LR (6.5 days, 95% CI: 6.3–6.6). Patients in the SCLR group were more likely to experience postoperative complications (risk-adjusted mean CONCLUSIONS: GLM patients with tumors <5 cm in diameter and without serosal invasion of the primary gastric cancer are the best candidate for hepatectomy. Repeat hepatectomy for recurrent GLM offers a chance of cure as that after the primary hepatectomy. 43 Monday Abstracts Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT number of complications: 0.69, 95% CI: 0.47–0.90) compared to CR (0.44, 95% CI: 0.39–0.49) and LR (0.34, 95% CI: 0.30–38) (p < 0.001 for CR and LR versus SCLR). Excess complications were dominated by infectious and cardiopulmonary issues (Table). Mortality in patients undergoing SCLR was not increased compared to patients undergoing LR. significantly higher than for CR and LR. In addition, the median operation time and hospital stay is longer for SCLR than for CR and LR only. However, higher short-term adverse outcomes in patients undergoing SCLR might be acceptable since anesthetic risk is decreased and adjuvant consolidating chemotherapy regimens can be conducted earlier. Additional population-based investigations are necessary to prove that SCLR is widely beneficial. DISCUSSION: Among hospitals reporting outcomes to NSQIP the risk of 30-day adverse outcomes for SCLR is CR (n = 1,934, 48.6%)* LR (n = 1,857, 46.6%)* SCLR (n = 192, 4.8%)* Risk-adjusted OR (95% CI) # Superficial surgical site infection 168 (8.7) 79 (4.3) 14 (7.3) 1.20 (0.62–2.32) 0.53 (0.27–1.04) 0.59 0.07 Incisional surgical site infection 48 (2.5) 13 (0.7) 13 (6.8) 0.42 (0.18–0.98) 0.14 (0.05–0.35) 0.05 <0.001 Organ space site infection 100 (5.2) 95 (5.1) 24 (12.5) 0.41 (0.24–0.69) 0.33 (0.19–0.56) 0.001 <0.001 Any surgical site infection 291 (15.1) 181 (9.8) 45 (23.4) 0.64 (0.42–0.97) 0.35 (0.23–0.53) 0.04 <0.001 Cardiopulmonary complication 120 (6.2) 108 (5.8) 19 (9.9) 0.37 (0.21–0.66) 0.43 (0.25–0.77) 0.001 0.004 Renal/urinary complication 129 (6.7) 85 (4.6) 15 (7.8) 0.59 (0.31–1.10) 0.54 (0.28–1.02) 0.09 0.06 p-Value DVT/pulmonary embolism 59 (3.1) 45 (2.4) 7 (3.7) N/A 0.38ç Septic complication 173 (9.0) 133 (7.2) 26 (13.5) 0.43 (0.26–0.71) 0.39 (0.24–0.64) 0.001 <0.001 Mortality Intraoperative use of red blood cell products 89 (4.6) 23 (1.2) 2 (1.0) N/A <0.001ç 305 (15.8) 452 (24.3) 53 (27.6) 0.41 (0.27–0.62) 1.12 (0.75–1.67) <0.001 0.58 *Numbers are given as counts and %. # Reference category SCLR, first estimate CR vs SCLR, second estimate LR vs SCLR. Adjustment for: sex, race, age, BMI, comorbidity, dyspnea, ASA score, preoperative weight loss, preoperative radio-/chemotherapy, wound classification, hypoalbuminemia, hypercreatininemia, anemia, and hyponatremia. ç Chi-square test. hepatectomy after preoperative chemotherapy and clarify which patients can take advantage from use of CE-IOUS. 815 Usefulness of Contrast-Enhanced Intraoperative Ultrasonography in Colorectal Liver Metastases After Preoperative Chemotherapy METHODS: From January 2011 to August 2011 25 patients with CRLM, after preoperative chemotherapy, underwent IOUS and CE-IOUS during hepatectomy. These findings were compared with preoperative staging imaging, performed with contrast-enhanced ultrasonography (CE-US), CT and/or MRI. Andrea Ruzzenente, Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti, Marco Costa, Elisabeth Baldiotti, Calogero Iacono, Alfredo Guglielmi Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy RESULTS: Preoperative staging imaging detected a total of 40 metastatic lesions in 25 patients. In 7 patients (28%), IOUS detected 19 missed hepatic nodules for a total of 59 lesions (detection rate higher of 47.5% than preoperative imaging). In 9 patients (36%), CE-IOUS detected further 6 nodules for a total of 65 hepatic lesions detected (detection rate higher of 10.2% than preoperative imaging and IOUS). All these new detected lesions were removed by an additional resection and histopathologically diagnosed as metastases. Moreover, at univariate analysis we found three factors significantly correlated to dectection of new nodules with CE-IOUS: more than three metastasis before chemotherapy (p = 0.022), complete response to chemotherapy (p = 0.03) and size of nodules less than 20 mm after chemotherapy (p = 0.008). BACKGROUND AND AIM: Hepatic resection is the only treatment offering a chance of long-term survival for patients with colorectal liver metastases (CRLM). Preoperative chemotherapy improves survival and resectability but reduces accuracy of preoperative staging due to reduction of size or disappearing of the metastases. Intraoperative Ultrasonography (IOUS) is considered the standard method of intraoperative staging. Contrast-enhanced intraoperative ultrasonography (CE-IOUS), using second generation contrast agents, seems to improve detection of liver metastases after preoperative chemotherapy. The aim of this study is to evaluate the ability of CE-IOUS in detecting metastases in patients with CRLM during 44 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA soft glands. Patients randomized to the FF group had a leak rate of 20% as compared with 19.6% in the SS group (p = 1.000). Fistula grades in both groups were similar: 1A, 8B, and 1C compared to 1A, 8B and 1C in the FF and SS groups respectively. Complication rates were comparable between the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group (28% vs. 17.6%, p = 0.243). Based on conditional probability calculations with 52.5% of enrollment, the probability of success of the trial given the current trend fell below 50%, and the trial was ended. CONCLUSION: In patients who undergo surgery for CRLM, CE-IOUS improves the sensitivity of IOUS to detect liver metastases enhancing the rate of treatment with curative intent. Patients with multiple nodules, patients who achieve complete response or with nodule size less than 20 mm after chemotherapy can take advantage with use of CE-IOUS. 816 Table 1. Demographics of Patients in the Study (FF) and Control (SS) Group, Showing no Significant Differences Timothy I. Carter1, Zhi Ven Fong1, Terry Hyslop2, Harish Lavu1, Wei Phin Tan1, Jeffrey Hardacre3, Eugene P. Kennedy1, Charles J. Yeo1, Ernest L. Rosato1 1. Surgery, Thomas Jefferson University, Philadelphia, PA; 2. Department of Pharmacology and Experimental Therapeutics, Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA; 3. Surgery, Case Western Reserve University, Cleveland, OH FF (n = 50) SS (n = 51) p-Value Male 22 19 0.546 Female 28 32 0.546 47 41 0.072 Gender Race OBJECTIVE: The objective of the study was to assess the efficacy of two pancreatic remnant closure techniques— stapled/sutured closure versus stapled/sutured closure plus falciform patch and fibrin glue reinforcement—in the setting of a prospective randomized, controlled trial, with the primary endpoint being pancreatic fistula. White SUMMARY AND BACKGROUND DATA: Pancreatic stump leak following left sided resection remains common. Despite multiple and varied techniques for closure, the leak rate averages 30%. A retrospective review by Ferrone et al. detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue. Black 1 3 0.617 Asian 0 1 1.000 Unknown 2 6 Median 62.5 65.0 Mean 62.0 62.3 Range 29–84 20–82 Age 0.969 Table 2. Clinical Outcomes of Patients in the Study (FF) and Control (SS) Group, Showing no Significant Differences METHODS: Between April 2008 and October 2011, all willing patients undergoing distal pancreatectomy at the authors’ institutions, were consented and enrolled at the preoperative office visit. Patients were intraoperatively stratified as “hard” or “soft” glands and randomized to one of two groups: (1) closure utilizing standard stapling, suturing, or both (SS) versus (2) stapled, sutured, or both plus fibrin glue and falciform ligament patch (FF). The trial design and power analysis (α = 0.05, β = 0.2, power 80%, chi-square test) assumed the FF intervention would reduce the endpoint (pancreatic fistula) from 30% to 15% and yielded an accrual goal of 190 patients. Secondary endpoints included length of stay, mortality, readmission, and ISGPF fistula grade. FF (n = 50) SS (n = 51) p-Value Grade A 1 1 1.000 Grade B 8 8 1.000 1 1 1.000 5.0 5.0 — Pancreatic Fistulas Grade C Postoperative Hospital Stay (days, median) RESULTS: The trial accrued 109 patients, 55 in the control group and 54 in the experimental group. Enrollment was closed early, following an interim analysis and futility calculation. Due to insufficient enrollment, patients stratified as having a “hard” gland were excluded (n = 8) from analysis, leaving 101 patients in the soft stratum. The pancreatic leak rate was 19.8% (20 patients) for patients with Mortality 1 0 0.495 Readmissions 14 9 0.243 CONCLUSION: The addition of a falciform ligament patch and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula in patients undergoing distal pancreatectomy. (ClinicalTrials.gov number NCT00889213) 45 Monday Abstracts A Dual-Institution Randomized Controlled Trial of Remnant Closure After Distal Pancreatectomy: Does the Addition of Falciform Patch and Fibrin Glue Improve Outcomes? THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 817 The Prognostic Influence of Resection Margin Clearance Following Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma Nigel B. Jamieson, Nigel Chan, Euan J. Dickson, Colin McKay, Ross Carter West of Scotland Pancreatic Unit, Glasgow University Department of Surgery, Glasgow Royal Infirmary, Glasgow, Lanarkshire, United Kingdom INTRODUCTION: The poor overall survival associated with pancreatic ductal adenocarcinoma (PDAC) despite complete resection suggests that occult metastatic disease is present in most at the time of surgery. Resection margin involvement (R1) following resection is an established poor prognostic factor. However the definition of an R1 resection varies and the impact of margin clearance on outcome has not been examined in detail. Kaplan Meier survival curves illustrating that a cut-off of greater than 1.5 mm identifies a subgroup of patents (15%) with pancreatic ductal adenocarcinoma with a good prognostic outcome following resection by pancreaticoduodenectomy. METHODS: In a cohort of 215 consecutive patients who underwent pancreaticoduodenectomy for PDAC with curative intent at a single institution between 1996–2010, the prognostic significance of the proximity of margin clearance was investigated. Microscopic margin clearance was stratified by 0.5 mm increments from tumor present to greater that 2 mm. Groups were dichotomized into clear and involved groups according to the different R1 definitions. Multivariate survival analysis was used to establish independent prognostic factors. Clearance of individual margins was also considered. 818 Incidence of Systemic Inflammatory Response Syndrome After Total Laparoscopic Pancreatoduodenectomy: A Comparison with Open Pancreatoduodenectomy Naru Kondo, Clancy J. Clark, Florencia G. Que, Kaye M. Reid Lombardo, David M. Nagorney, John H. Donohue, Michael B. Farnell, Michael L. Kendrick Mayo Clinic, Rochester, MN RESULTS: Stratification of the minimal clearance distance revealed that there was no significant difference in the outcome of patients with tumor ≤1 mm from the margin when compared to those with tumor ≤0.5 mm from the margin (P = 0.67, Log-rank test). For the 32 patients (15%) where the tumor was >1.5 mm from the closest involved margin there was a significantly prolonged overall survival (median 49.0 months 95% confidence interval: 25.7–72.3, P < 0.0001, Log-rank test, Figure 1). This cut-off represented the optimum distance for predicting long-term survival. BACKGROUND: Although feasibility of total laparoscopic pancreatoduodenectomy (TLPD) has been established, a large scale study comparing the invasiveness of TLPD with open pancreatoduodenectomy (OPD) has never reported. PURPOSE: The purpose of this study was to investigate if TLPD can reduce the postoperative incidence of systemic inflammatory response syndrome (SIRS) compared with OPD. METHODS: A single-institutional retrospective cohort study of all pancreaticoduodenectomy patients between 2007 and 2010 was performed. The incidence of SIRS was measured three times a day (at the nearest point of 8, 16 and 24 o’clock) from postoperative day (POD) 1 to POD 5. The incidence of SIRS on each POD was defined by meeting the criteria of SIRS at two or more points out of the daily three measurement points. Perioperative outcomes including the incidence of SIRS were compared between TLPD and OPD group. The relationship between the clinicopathological factors and the incidence of postoperative SIRS was investigated using univariate and multivariate analyses. CONCLUSION: These results demonstrate that margin clearance by at least 1.5 mm identifies a subgroup of patients with a particularly good outcome. Stratification of patients into future clinical trials based upon the degree of margin clearance may identify those patients likely to benefit from adjuvant therapy. 46 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Recurrence-free survival among R0 resections for IPMN with at least three months follow up, stratified by invasive pathology. Non-invasive IPMN includes adenoma (76), borderline or moderate dysplasia (36), and carcinoma in situ(30). Median follow up was 30.8 months (502 person-years). Invasive IPMN was more likely to recur than non-invasive tumors (HR 3.7, 95% CI 1.7–8.4), with a median time to recurrence of 13.5 months. Of the 17 non-invasive IPMNs that recurred, four recurred with invasive disease. RESULTS: Two hundred and eight patients underwent resection for IPMN. At presentation, 57% were symptomatic, 20% had a mural nodule or an associated mass, and median cyst size was 1.8 cm. Sixty-eight (32.7%) operations for high grade disease were performed, of which 33 revealed invasive carcinoma. Among 165 R0 resections with greater than three months of follow-up we have observed 26 cases of recurrent disease over 502 personyears (median follow-up time 30.8 months). Nine (39%) patients originally diagnosed with invasive carcinoma and 17 (12%) patients originally diagnosed with non-invasive IPMN have recurred. Of the latter, four (23.5%) recurred as invasive carcinoma. Most disease recurred locally (25/26) but three individuals had concurrent metastatic disease at the first observation of recurrence. Median time from initial treatment to recurrence was 18.2 months, but ranged from 3.7 to 126.8 months. Invasive tumors were more likely to recur (HR 3.7, p = 0.002) with a median time to recurrence of 13.5 months. Among non-invasive tumors, no single histologic feature—including dysplastic changes at the surgical margin or distant from the primary tumor— meaningfully predicted recurrence. Seven patients had a completion pancreatectomy on average 22.7 months after their initial surgery. Of these, three had low grade or moderate dysplasia on final pathology and have survived greater than 34 months after the second operation, compared with median survival of 14.4 months after diagnosis of recurrent, invasive IPMN. CONCLUSION: TLPD independently reduced the early incidence of SIRS after pancreatoduodenectomy. The laparoscopic approach to pancreatoduodenectomy appears to provide an advantage of less invasiveness compared with the open approach especially in patients that do not develop postoperative complications. 819 Predictors of Recurrence in Intraductal Papillary Mucinous Neoplasm: Experience with 208 Pancreatic Resections Megan Winner, Irene Epelboym, Joseph DiNorcia, Minna K. Lee, James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is being diagnosed and resected with increasing frequency, but little long-term data exist to guide postoperative management of surgically treated patients. METHODS: We examined all patients who underwent surgical resection for IPMN between January 1997 and April 2011 at our institution. IPMN was categorized as noninvasive low grade (adenoma and borderline dysplasia), non-invasive high grade (carcinoma in situ), or invasive. Histologic features of primary and recurrent disease were examined and we evaluated predictors of recurrence using Kaplan Meier curves and Cox proportional hazards models. CONCLUSIONS: Invasive IPMN has a high risk of recurrence, but even low grade tumors may recur with high grade disease. IPMN can recur remote from the time of primary surgery and no histologic feature beyond invasion predicts recurrence risk. Most recurrence is local and completion pancreatectomy can be associated with excellent survival if recurrent disease is identified early. We therefore recommend that surveillance of the remnant pancreas continue after primary resection for all tumor types. 47 Monday Abstracts RESULTS: Five hundred twenty-seven consecutive patients (TLPD n = 125, OPD n = 402) were included in study. Six patients (5%) with conversion to OPD were included in TLPD group based on intent-to-treat. The reasons for conversion were the possibility of major venous resection (n = 3), bleeding (n = 1), severe adhesion (n = 1) and expected difficult reconstruction (n = 1). Compared with patients in the OPD group, those in the TLPD group had significantly less preoperative clinical jaundice (42% vs. 53%, P = 0.03), less adenocarcinoma (58% vs. 70%, P = 0.01), and smaller pancreatic duct size (3.7 mm vs. 4.2 mm, P = 0.002). Median estimated blood loss was less for the TLPD group than the OPD group (200ml vs. 600ml, P < 0.001). However, there were no differences in postoperative complication (62% vs. 67%, P = 0.3) or clinically relevant pancreatic leak (21% vs. 21%, P = 0.8). The incidence of SIRS in the TLPD group was significantly less than that of OPD group on POD 1 (9% vs. 24%, P < 0.001). Within a subset of 179 patients without postoperative complication, the incidence of SIRS in the TLPD group was significantly less than that of OPD group on POD 1 (2% vs. 13%, P = 0.01) and POD 2 (4% vs. 15%, P = 0.03). Multivariate analysis revealed that increased body mass index (> 27) (HR 1.7, 95% CI 1.1 - 2.6, P = 0.005), OPD (HR 1.8, 95% CI 1.1 - 2.9, P = 0.01) and postoperative complication (HR 2.3, 95% CI 1.4 - 3.7, P < 0.001) were independently associated with SIRS on POD 1 and/or 2. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 820 821 Survival Following Resection of Well-Differentiated Pancreatic Neuroendocrine Tumors: Examining the New 2010 WHO Classification Mechanisms of GLUT2 Activation in Rats In Vivo: Absence of Evidence for PKC Dependency Rizwan M. Chaudhry1,2, Mohamed M. Abdelfatah2, Alok Garg2, Judith A. Duenes2, Michael G. Sarr1,2 1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology Research Unit, Mayo Clinic, Rochester, MN Toshiyuki Moriya , Timothy R. Donahue , Oscar J. Hines , James J. Farrell3, Howard A. Reber2, David Dawson4 1. First Department of Surgery, Yamagata University, Yamagata, Japan; 2. Department of Surgery, University of California Los Angeles, Los Angeles, CA; 3. Department of Medicine, University of California Los Angeles, Los Angeles, CA; 4. Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA 1,2 2 2 Absorption of glucose at concentrations exceeding the capacity of sodium glucose co-transporter 1 (SGLT1) is attributed to the recruitment of GLUT2 at the apical membrane of enterocytes in vivo. Protein kinase C (PKC) has been implicated in this process in cell culture and in vitro. HYPOTHESIS: Activating and inhibiting protein kinase C (PKC) will increase and decrease, respectively, GLUT2mediated glucose absorption via a mechanism dependent on the microtubular cytoskeleton. Introduction: In 2010 the WHO adopted a new grading system for neuroendocrine neoplasms (NET) of foregut origin based on proliferation determined by mitotic count and Ki67 index. Using a large single-institution cohort of resected pancreatic NETs (PNETs), we have retrospectively examined the prognostic value of the WHO 2010 classification system, the prior WHO classification system and AJCC stage for well-differentiated neuroendocrine tumors of the pancreas. AIM: To explore the role of PKC in activating GLUT2mediated glucose absorption. METHODS: Isosmolar glucose-containing solutions were perfused through isolated, 30-cm segments of jejunum in anesthetized rats. Carrier-mediated glucose uptake was measured in 10 mM and 100 mM glucose solutions (n = 6 rats, each) with and without 10 μM chelerythrine (PKC inhibitor), 200 nM PMA (PKC activator), and 10 μM nocodazole (microtubule disruptor). Carrier-mediated absorption of glucose was calculated by the difference in amount infused minus the amount recovered after subtracting passive absorption (3H-L-glucose) and expressed as mean±SEM; n = 6. After ending the experiment, the mucosa was harvested rapidly in 4°C temperature; brush border membranes were isolated and subjected to Western blot analysis. METHODS: Search of pathology archives identified 114 patients who underwent pancreatic resection for PNETs at UCLA Medical Center from 1991–2009. Retrospective review of medical, surgical, and pathology databases was performed. Correlations between patient survival and various clinicopathologic factors were determined. RESULTS: By univariate analysis, significant predictors of disease-specific survival (DSS) in PNETs included positive margin status (p = 0.019, HR 7.73, 95%CI [1.392–43.01]), and AJCC stage (Stage I, IIA versus IIB, IV, p = 0.043, HR 6.87, 95% CI [1.06–37.41]). Individually, tumor size, perineural invasion, vascular invasion and functional tumor status were not significant predictors of DSS in the patient cohort. In our cohort, the new WHO 2010 classification scheme did not significantly predict DSS for well-differentiated PNETs (G1 PNETs versus G2 PNETs, p = 0.085, HR 5.35, 95% CI [0.60–48.10]). In contrast, the prior WHO 2000 classification scheme was a significant predictor of DSS (1.0 + 1.1 PNETs versus 2.0 PNETs, p = 0.048, HR 6.90, 95% CI [1.12–39.62]). We also examined whether WHO 2010 classification and AJCC staging parameters could be used in combination to better stratify patients into groups of variable prognostic significance. In stratified analysis of those patients with node-positive disease, G1 vs. G2 status showed a non-significant trend towards predicting patient survival after resection (p = 0.13, HR 5.2, 95%CI [0.6–43.9]). RESULTS: Inhibition of PKC with chelerythrine chloride at the 10 and 100 mM glucose concentrations resulted in a small decrease in carrier-mediated absorption from 2.3 ± 0.2 to 1.9 ± 0.3 μmol/min/30-cm intestine (p < 0.0001) and 10.8 ± 1.8 to 9.0 ± 1.7 μmol/min, respectively. PMA (PKC stimulant) also decreased absorption at the 10 and 100 mM perfusates (1.9 ± 0.1 to 1.6 ± 0.2; p < 0.003 and 13.7 ± 1.2 to 11.6 ± 1.5, respectively). Nocodazole (microtubular disruption) decreased carrier-mediated uptake at 10 mM glucose from 2.1 ± 0.2 to 1.7 ± 0.2 (p < 0.0008) and from 13.5 ± 1.6 to 12.9 ± 1.5 at 100 mM glucose. No significant changes were observed at the 100 mM glucose perfusate with all three pharmacologic agents. Western blots of isolated brush border membranes showed no difference in GLUT2 levels at the 10 and 100 mM glucose concentrations. CONCLUSIONS: Activation and/or inhibition of protein kinase C and disruption of microtubular architecture had minimal effect at the concentration of luminal glucose when GLUT2 should be maximally translocated. Other intracellular pathways (such as activation of sweet taste receptors or voltage-gated Ca2+ channels) may be responsible for increasing GLUT2 activity at the apical membrane. (Support: NIH Grant DK39337 [MGS]). CONCLUSIONS: Consideration of both AJCC staging parameters and WHO 2010 G grade may be useful for the accurate prediction of DSS in resected, well-differentiated PNET, particularly for those patients with node-positive disease. Our findings in this retrospective analysis of a single institution cohort of PNET warrant further prospective analysis in a larger patient cohort. 48 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 822 Hypoxic Recovery Following Massive Small Bowel Resection as Measured by Photoacoustic Microscopy Kathryn J. Rowland1, Junjie Yao2, Lidai Wang2, Christopher R. Erwin1, Lihong Wang2, Brad Warner1 1. Pediatric Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO; 2. Biomedical Engineering, Washington University in St. Louis, St. Louis, MO Figure 1. * p < 0.05 vs pre-values METHODS: OR-PAM was used to record vessel diameter, blood flow, and sO2 of the terminal mesenteric arteriole and accompanying vein within the intestinal wall of C57B6 mice following a 50% proximal SBR. Measurements were taken on post-operative day (POD) 1 (n = 3), POD 3 (n = 3), and POD 7 (n = 6) and compared to pre-operative values (n = 7) and immediately following SBR (10 minutes; n = 7). All measurements were made 6 cm proximal to the ileocecal junction and are presented as mean ±SE. A p value ≤ 0.05 was considered significant. RESULTS: Arterial and venous sO2 dropped immediately following SBR, as demonstrated in Figure 1. Compared with pre-operative values, significantly lower arterial and venous sO2 measurements persisted on POD1. By POD3, the arterial sO2 recovered to pre-operative values, however venous sO2 remained significantly lower than pre-operative values. This low venous sO2 persisted on POD7. Arterial and venous blood flow decreased significantly immediately post-SBR, as demonstrated in Figure 2. This trend persisted on POD1. By POD3 arterial blood flow recovered to preoperative levels, however, venous blood flow significantly exceeded pre-operative levels. This enhanced venous blood flow persisted on POD7. Figure 2. * p < 0.05 vs pre-values CONCLUSION: Massive SBR results in a relative hypoxic state within the remnant bowel characterized by a significant reduction in both intestinal blood flow and sO2 . Although hemodynamic recovery is observed by POD3, a low venous sO2 consistent with increased tissue oxygen utilization persisted through POD7. These changes may contribute to villus angiogenesis via triggers for genes related to a hypoxic milieu. 49 Monday Abstracts PURPOSE: Massive small bowel resection (SBR) results in an adaptive response within the remnant bowel and is associated with villus angiogenesis. Using optical-resolution photoacoustic microscopy (OR-PAM), a non-invasive, labelfree, high-resolution hybrid in vivo imaging modality, we have recently demonstrated an immediate (within 10 minutes) reduction in both intestinal blood flow and arterial and venous oxygen saturation (sO2) after SBR. The present study sought to determine the duration of resectioninduced intestinal hemodynamic alterations. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 822a METHODS: This retrospective cohort study comprised 79 MMR gene mutation carriers (18 MLH1, 55 MSH2, 4 MSH6 and 2 PMS2) from the Colon Cancer Family Registry who had a surgical resection for their first primary rectal cancer. Age-dependent cumulative risks of metachronous colon cancer were calculated using the Kaplan-Meier method. Risk factors for metachronous colon cancer were assessed using a Cox proportional hazards regression. Metachronous Colorectal Cancer Risk Following Surgery for First Rectal Cancer in Mismatch Repair Gene Mutation Carriers Aung Ko Win1, Susan Parry2,3, Bryan Parry4, Matthew F. Kalady5, Finlay A. Macrae6, Noralane M. Lindor7, Robert W. Haile8, Polly A. Newcomb9, Loïc Le Marchand 10, Steven Gallinger11,12, John Hopper1, Mark A. Jenkins1 1. Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Carlton, VIC, Australia; 2. New Zealand Familial Gastrointestinal Cancer Registry, Auckland City Hospital, Auckland, New Zealand; 3. Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand; 4. Colorectal Surgical Unit, Auckland City Hospital, Auckland, New Zealand; 5. Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 6. Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Parkville, VIC, Australia; 7. Department of Medical Genetics, Mayo Clinic, Rochester, MN; 8. Department of Preventive Medicine, University of Southern California, Los Angeles, CA; 9. Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA; 10. University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI; 11. Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; 12. Cancer Care Ontario, Toronto, ON, Canada RESULTS: During 866 person-years of observation (median 9 years; range 1–32 years) since diagnosis of first rectal cancer, a total of 21 (27%) carriers were diagnosed with metachronous colon cancer (incidence 24.2; 95% CI 15.8–37.2 per 1000 person-years). Incidence for carriers who had an anterior resection (26.8; 95% CI 15.5–46.1 per 1000 person-years) was not different from that for carriers who had an abdominoperineal resection (21.0; 95% CI 10.5–42.1 per 1000 person-years) (P = 0.1). Cumulative risk of metachronous colon cancer was 19% (95% CI 9–31%) at 10 years, 47% (95% CI 31–68%) at 20 years and 69% (95% CI 45–89%) at 30 years after surgical resection. There was no difference in the frequency of surveillance colonoscopy between the two types of surgery (one colonoscopy per 1.1 (95% CI 0.9–1.2) years after anterior resection vs. one colonoscopy per 1.4 (95% CI 1.0–1.8) years after abdominoperineal resection). CONCLUSIONS: For carriers of MMR gene mutations diagnosed with rectal cancer, the metachronous colon cancer risk is substantial and mirrors that seen for carriers who have undergone segmental resection for primary colon cancer, despite the majority continuing to receive frequent surveillance colonoscopy. Whereas total colectomy for primary colon cancer in mutation carriers is appropriate, for primary rectal cases this strategy has major implications for continence and need for stoma. Nevertheless, given the high metachronous risk, this procedure needs serious consideration especially for younger patients. BACKGROUND: Metachronous colorectal cancer risk for Lynch syndrome patients with primary colon cancer is high and total colectomy is the preferred option. However if the index primary cancer is in the rectum, management advice is complicated by considerations of worsening bowel function or stoma formation. To aid surgical decision-making, we estimated the risk of metachronous colon cancer for Lynch syndrome patients who underwent either anterior resection or abdominoperineal resection for primary rectal cancer. 50 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tuesday, May 22, 2012 8:00 AM – 9:30 AM 27b PLENARY SESSION VI 920 86% and compares favorably to 69% in historical controls. Subgroup analysis showed that patients receiving 300 million cells per dose tended toward a longer OS compared to those receiving 100 million cells per dose, 96% vs. 80% (p = 0.053). As of this analysis, median overall survival has not been reached. Algenpantucel-L was well tolerated with no grade 4 or 5 adverse events. There were nine grade 3 adverse events directly or possibly due to the immunotherapy. The most common adverse events were injection site pain and induration. Addition of Algenpantucel-L Immunotherapy to Standard Adjuvant Therapy for Pancreatic Cancer: A Phase 2 Study CONCLUSION: Addition of algenpantucel-L to standard adjuvant therapy for resected pancreatic cancer may improve survival. A multi-institutional, phase 3 study began patient enrollment in May 2010. BACKGROUND: Pancreatic cancer portends a poor prognosis with ~4% long-term survival. Among the estimated 20% of patients who have resectable disease, the 1/3/5-year survival rates approximate only 70%/30%/18%, even with adjuvant therapy. Better treatment options are needed, and addition of algenpantucel-L immunotherapy to standard adjuvant therapy is proposed to improve prospects for survival. Algenpantucel-L is composed of irradiated, live, allogeneic human pancreatic cancer cells expressing the enzyme α-1,3 galactosyl transferase (α-GT), which is the major barrier to xenotransplantation from lower mammals to humans (e.g., hyperacute rejection). Up to 2% of circulating human antibodies are directed against the α-GT epitope of algenpantucel-L and are the proposed mechanism of initiating the anti-tumor immune response. 921 Hereditary Pancreatitis: Endoscopic and Surgical Management Eugene P. Ceppa1, Henry A. Pitt1, JoAnna Hunter1, Charles Leys1, Nicholas J. Zyromski1, Frederick J. Rescorla1, Kumar Sandrasegaran2, Evan L. Fogel3, Lee McHenry3, James L. Watkins3, Stuart Sherman3, Glen A. Lehman3 1. Surgery, IN University School of Medicine, Indianapolis, IN; 2. Radiology, IN University School of Medicine, Indianapolis, IN; 3. Gastroenterology, IN University School of Medicine, Indianapolis, IN INTRODUCTION: Hereditary pancreatitis is a very rare cause of chronic pancreatic inflammation. In recent years the genetic mutations leading to hereditary pancreatitis have been characterized. Patients with hereditary pancreatitis present in childhood and, as adults, are reported to have an extremely high risk of pancreatic cancer. However, the rarity of this disorder has resulted in a gap in clinical knowledge. Therefore, the aims of this analysis are to characterize a large series of patients with hereditary pancreatitis and to establish clinical guidelines. METHODS: Open-label, dose-finding, multi-institutional Phase 2 study evaluating algenpantucel-L (100 or 300 million cells per dose) + standard adjuvant therapy (RTOG9704, JAMA, 2008: gemcitabine + 5-FU-XRT) for pancreatic cancer patients undergoing R0/R1 resection. Disease-free survival (DFS) was the primary endpoint with overall survival (OS) and toxicity being secondary endpoints. RESULTS: 70 patients with a 21-month median follow-up received gemcitabine + 5-FU-XRT + algenpantucel-L (mean 12 doses, range 1–14). Demographics and prognostic factors: median age 62 years, 47% female, 81% lymph node positive, median tumor size 3.2 cm (range 2–15 cm; 25% > 4 cm), and 17% post-operative CA 19–9 ≥180. The primary endpoints of median and 12-month DFS were 14.3 months and 63%, respectively, for the entire cohort. These compare favorably to rates of 11.4 months and <50% in historical controls treated with standard adjuvant therapy alone. Subgroup analysis showed that patients receiving 300 million cells per dose had a longer 12-month DFS compared to those receiving 100 million cells per dose, 81% vs. 52% (p = 0.02). Overall survival at one year in the entire cohort was METHODS: Pediatric and adult endoscopic, surgical, radiologic and genetic databases were searched from 1994–2011. Patients with chronic pancreatitis and genetic mutations for PRSS-1 or SPINK-1 as well as those with a significant family history of chronic pancreatitis were included. Patients with chronic pancreatitis due to other causes, idiopathic pancreatitis without a positive family history, and familial pancreatic cancer were excluded. Data were gathered on genetic testing, endoscopic and surgical management as well as the occurrence of pancreatic cancer. RESULTS: Eighty-six patients were identified, and the mean age at presentation was 17 years. Forty-four (51%) 51 Tuesday Abstracts Jeffrey M. Hardacre1, Mary Mulcahy2, William Small2, Mark Talamonti3, Jennifer Obel3, Caio S. Rocha-Lima4, Howard Safran5, Heinz-Joseph Lenz6, Elena G. Chiorean7 1. University Hospitals Case Medical Center, Cleveland, OH; 2. Northwestern University, Chicago, IL; 3. Northshore University Helath System, Evanston, IL; 4. University of Miami, Miami, FL; 5. Brown University, Providence, RI; 6. University of Southern California, Los Angeles, CA; 7. Indiana University, Indianapolis, IN THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT were female. Genetic testing confirmed the diagnosis in 38 families (44%) while 48 patients (56%) had a significant family history. In recent years adult patients were counseled to avoid tobacco and alcohol. Eighty patients (93%) with a median age of 15 years were managed endoscopically with sphincterotomy (69%), stone removal (31%) and/or stenting of pancreatic duct strictures (85%). In recent years endoscopic ultrasound was performed in 13 patients (15%) to screen for cancer. Twenty-nine patients (34%) have undergone 35 operations at a mean age of 19 years. Surgery included 15 drainage procedures (lateral pancreaticojejunostomy-9, cystenterostomy-3, Duval-2, sphincteroplasty-1) and 20 resections (proximal-10, distal-9, total-1). Islet transplantation was performed in the one patient who underwent a total pancreatectomy. While 22 patients (26%) were older than 40 years, only one 67 year old man developed pancreatic cancer and died. The remaining 85 patients are all alive and cancer free. (CC3–4) occurred more commonly after TP (29%) than DP (28%), LPJ (10%), or PD (10%) (p < 0.01). Resections with IAT did not have a higher overall (66% v. 53%) (p > 0.05) nor severe (20% v. 16%) complication rate than those without IAT (p > 0.05). Specifically looking at PD with and without IAT, length of stay (14 v. 10) and complication rate (72% v. 46%) appeared to be higher, but neither reached statistical significance (both p > 0.05). There was no difference in complication rate between TP-IAT and PDIAT (67% v. 72%) (p > 0.05). Overall (CC1–5) and severe (CC3–4) complication rate was similar when all pancreatic resections with IAT (65% and 20%) and those without IAT (53% and 16%) were compared to those undergoing PD for pancreatic cancer (n = 133, 65% and 20%) (all p > 0.05). Reoperation for bleeding after IAT was not different than after PD for pancreatic cancer (p > 0.05). Partial portal vein thrombosis (4%)after IAT and had no long term sequelae. CONCLUSIONS: Many children and young adults with hereditary pancreatitis can be managed initially with endoscopic therapy. When surgery is undertaken, the procedure should be tailored to the pancreatic anatomy and the cancer risk. With aggressive endoscopic and surgical management as well as avoidance of cocarcinogens the incidence of pancreatic cancer is surprisingly low in patients with hereditary pancreatitis. CONCLUSIONS: Operations for chronic pancreatitis are well established and pose no greater risk than resections, specifically PD, for malignancy. Complication rates remain formidable and mortality rates are low. Improvements to quality of life after IAT have been documented; furthermore, the addition of IAT to resections for chronic pancreatitis adds no risk when compared to those for malignancy. At institutions with capability, IAT should be offered to patients during resection for chronic pancreatitis. 923 924 Islet Cell Autotransplantation and Morbidity After Operations for Chronic Pancreatitis Venous Involvement During Pancreaticoduodenectomy: Is There a Need for Redefinition of “Borderline Resectable Disease”? John C. McAuliffe, Sandre F. McNeal, Manasi S. Kakade, Brandon A. Singletary, John D. Christein University of Alabama at Birmingham, Birmingham, AL Kaitlyn J. Kelly1, David Kooby3, Alex Parikh4, Clifford S. Cho1, Emily Winslow1, Charles R. Scoggins2, Syed A. Ahmad5, Robert C. Martin2, Shishir K. Maithel3, Hong Jin Kim6, Nipun Merchant4, Sharon M. Weber1 1. Surgery, University of Wisconsin, Madison, WI; 2. Surgery, University of Louisville, Louisville, KY; 3. Surgery, Emory University, Atlanta, GA; 4. Surgery, Vanderbilt University, Nashville, TN; 5. Surgery, University of Cincinnati, Cincinnati, OH; 6. Surgery, University of North Carolina, Chapel Hill, NC BACKGROUND: Quality of life studies after pancreatic resection and islet cell autotransplantation have shown improvement and already been published. Mortality rates have improved, but morbidity remains high after pancreatic operations, in particular total pancreatectomy (TP) and pancreaticoduodenectomy (PD). Few studies have evaluated outcomes after pancreatic operations specifically for chronic pancreatitis, with or without islet cell autotransplantation (IAT), and compared these to operations for pancreatic cancer. INTRODUCTION: The consensus definition of borderline resectable pancreas cancer includes patients with any venous (SMV-PV) or limited arterial (SMA or GDA/ CHA) involvement. Recent recommendations suggest that patients with borderline resectable pancreatic adenocarcinoma should receive neoadjuvant therapy to increase the likelihood of achieving R0 resection. It is established that a subset of patients with limited venous involvement can achieve R0 resection by utilizing vein resection. This study compares outcome of patients who underwent pancreaticoduodenectomy with (VR-PD) or without (PD) vein resection, and is unique because none received neoadjuvant therapy. METHODS: A retrospective review for patients undergoing operation for chronic pancreatitis from 2005–2011 by a single surgeon at an academic center. Morbidity was evaluated to 90 days according to the Clavien Classification (CC). Patients undergoing pancreatic resection with IAT were evaluated as a subgroup. Both groups were compared to those undergoing similar operations for pancreatic cancer. Statistical analysis was applied. RESULTS: Of the 200 patients (55% men, mean age 49 years), ninety-eight underwent resection alone (65 PD, 27 distal (DP) and 6 TP), 67 underwent resection with IAT (47 TP, 18 PD, 2 DP), and 22 underwent drainage with lateral pancreaticojejunostomy (LPJ). There was no mortality; however, the overall morbidity rate was 55% (CC 1–5) and 29% of these experienced a more severe complication requiring intervention (CC 3–4). Severe complications METHODS: A large, multi-institutional database of patients who underwent PD without neoadjuvant therapy was reviewed. Patients who required vein resection due to SMVPV involvement by tumor were compared to those who underwent PD without vein resection. 52 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Multivariate Analysis of Demographic, Pathologic, and Operative Factors for Patients Undergoing PD for Adenocarcinoma that May Influence Disease Free (DFS) and Overall Survival (OS) DFS OS Factor HR 95% CI P HR 95% CI P Tumor Size (cm) 1.00 0.90–1.10 0.97 1.01 0.92–1.10 0.85 Tumor Grade <0.05 <0.01 Well 1.66 1.07–2.57 1.93 1.33–2.81 Moderate 1.93 0.77–4.85 1.74 0.80–3.81 Poor 2.06 1.24–3.42 3.03 1.97–4.64 Positive Lymph Nodes 1.57 1.18–2.09 <0.01 1.56 1.22–1.99 0.01 Vein Involvement 1.15 0.78–1.68 0.83 1.20 0.87–1.63 0.26 R1 Margin 1.26 0.94–1.70 0.09 1.80 1.39–2.30 <0.01 Blood Loss (mL) 1.00 — 0.01 1.00 — <0.01 Adjuvant Chemo 1.19 0.89–1.57 0.25 0.74 0.58–0.94 <0.01 METHODS: We reviewed the medical records of all patients with pancreatic ductal adenocarcinoma who underwent pancreaticoduodenectomy (PD) at our institution between March 1992 and March 2011. We identified patients who received neoadjuvant (NA) therapy or required major vascular resection and evaluated demographics, operative characteristics, morbidity, mortality, and survival. Student’s t- or Mann-Whitney U tests and Chi-squared or Fisher’s exact tests were used to compare continuous and categorical variables, respectively. Kaplan-Meier curves and Cox proportional hazards models were used to compare survival. CONCLUSION: This is the largest modern series examining patients with borderline resectable pancreas cancer due to SMV-PV involvement, none of whom received neoadjuvant therapy. This cohort of patients with vein involvement selected for up-front surgical resection demonstrates that oncologic outcomes, including R0 rate, local recurrence rate, and DFS, were not compromised when vein resection was required. These data suggest that up-front surgical resection is an appropriate option for patients with isolated vein involvement and calls into question the inclusion of all SMV-PV involvement within the definition of “borderline resectable disease.” 925 Neoadjuvant Therapy and Vascular Resection During Pancreaticoduodenectomy: Shifting the Survival Curve for Patients with Locally Advanced Pancreatic Cancer Neoadjuvant (NA) therapy and vascular resection can bring select patients with initially locally unresectable pancreatic cancer to pancreaticoduodenectomy with a significant survival benefit. In this series, median survival of resected NA patients was similar to resected non-NA patients (24.9 months vs. 19.3 months, p>0.05) and longer than non-NA patients aborted for locally advanced disease (24.9 months vs. 8.9 months, p < 0.05). Median survival of NA patients aborted for locally advanced disease was 13.3 months. Joseph DiNorcia, Megan Winner, Minna K. Lee, Irene Epelboym, James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf Surgery, Columbia University College of Physicians and Surgeons, New York, NY BACKGROUND: Neoadjuvant chemoradiation therapy and more aggressive surgery with vascular resection are two strategies to bring patients with locally advanced pancreatic cancer to the operating room for potential cure. 53 Tuesday Abstracts RESULTS: Of 492 total patients, 70 (14%) underwent VR-PD and 422 (86%) underwent PD. There was no difference in R0 resection (66% VR-PD vs. 75% PD, p = 0.11) or local recurrence rate (18% VR-PD vs. 14% PD, p = 0.33), at a median follow up of 16 months (range 3.0–129.7). There was no difference in median DFS (10.1 months VR-PD vs. 15.2 months PD, p = NS, HR 1.24 (0.94–1.64)). Positive margin, increased EBL, advanced tumor grade, and lymph node involvement, but not vein involvement, were independent predictors of DFS. These same factors, as well as use of adjuvant therapy, predicted OS (see Table above). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT RESULTS: A total of 600 patients were brought to the operating room for attempted resection. One hundred fifty-four (25.6%) had received NA therapy for initially unresectable disease whereas 446 (74.4%) were explored at presentation. One hundred twenty-four (80.5%) NA patients underwent successful PD compared to 340 (76.5%) non-NA patients. The NA patients were younger (62.7 years vs. 67.5 years, p < 0.001), more often had prior resection attempts (26.6% vs. 0.9%, p < 0.001), had longer median operative times (390 min vs. 328 min, p < 0.001), and had higher median estimated blood loss (1500mL vs. 1000mL, p < 0.001) than non-NA patients. There were no statistically significant differences in R0 resection rate (82.3% vs. 78.2%, p = 0.34), median length of stay (9 days vs. 10 days, p = 0.16), morbidity (50% vs. 49.4%, p = 0.91), or mortality (6.5% vs. 2.7%, p = 0.09) between the two groups. Sixty-one percent of NA patients versus 18.8% non-NA patients required vascular resection (p < 0.001), therefore a subset analysis was performed. PD with vascular resection resulted in increased morbidity (54.9% vs. 33.7%, p < 0.001) and mortality (1.8% vs. 6.3%, p = 0.008), but similar R0 resection rates (74% vs. 81%, p = 0.07) and lengths of stay (10 days vs. 9 days, p = 0.07) compared to standard PD. Median survival of resected NA patients was similar to resected non-NA patients (24.9 months vs. 19.3 months, p>0.05) and significantly longer than non-NA patients aborted for locally advanced disease (24.9 months vs. 8.9 months, p < 0.05). NA patients who required vascular resection had longer survival than nonNA patients who required vascular resection (23.6 months vs. 14.4 months, p < 0.05). CONCLUSION: Many patients with locally advanced pancreatic cancer can be brought to resection through NA therapy and vascular resection with acceptable morbidity and mortality. These patients have significantly improved survival over patients deemed locally inoperable by traditional criteria. 9:30 AM – 12:00 PM 27b PLENARY SESSION VII 1004 age or reoperation. Hemorrhage was defined as bleeding requiring reoperation. Hepatic insufficiency was defined as a peak serum bilirubin level of >7mg/dL at any time postoperatively. Greater Complexity of Liver Surgery Is Not Associated with an Increased Incidence of Liver Related Complications Except for Bile Leak: An Experience with 2628 Consecutive Resections RESULTS: 2628 hepatic resections were performed between 1997 and 2011 with a 90 day morbidity of 37% and mortality of 2%. Comparison of case type between the later and earlier cohorts revealed an increase in complexity over time as evidenced by the greater number of re-resections (11.2% vs 4.3%; p < 0.001), second stage resection(4.0% vs 0.9%; p < 0.001) and extended right hepatectomies (18.4% vs 14.9%; p = .017) and increasing use of preoperative portal vein embolization (9.1% vs 5.9%; p = 0.002) in the later group. Despite this, the incidence of abdominal collection (2.1% vs 3.4%; p = .031) and hemorrhage (0.3% vs 0.9%; p = .045) decreased and the incidence of hepatic insufficiency (2.6% vs 3.1%; p = 0.41) remained stable. In contrast, the rate of bile leak increased (5.9% vs 3.7%; p = 0.011). For the entire cohort, bile leak was associated with increased 90 day mortality (11.1% vs 1.8%; p < 0.001) and increased length of stay (mean 13 vs 8 days; p < 0.001). Independent predictors of bile leak included bile duct resection (OR 3.9; p < 0.001), resection of >3 segments (OR 3.1; p < 0.001), second stage resection (OR 2.5; p = 0.019) and intraoperative blood loss> 1 liter (OR 1.9; p = 0.019). Robert E. Roses, Giuseppe Zimmitti, Thomas Aloia, Andreas Andreou, Steven Curley, Jean-Nicolas Vauthey Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX BACKGROUND: Advances in technique, technology and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver related complications. METHODS: A large prospectively maintained single institution database of patients who underwent hepatic resection was utilized to identify the incidence of liver related complications. Patients were divided into two groups of equal size: an earlier group and a later group (surgery performed before or after 5/18/2006). Patient characteristics and perioperative factors were compared between the two groups. Abdominal collection was defined as a non-bilious fluid collection requiring drainage. Bile leak was defined as bilious drainage from the postoperative drain or incision for 3 days or more, or a bilious collection requiring drain- 54 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 1005 Effect of the Artificial Sweetener, Acesulfame Potassium, a Sweet Taste Receptor Agonist, on Glucose Uptake in Small Intestinal Cell Lines Ye Zheng2, Michael G. Sarr1,2 1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology Research Unit, Mayo Clinic, Rochester, MN Activation of sweet taste receptors may enhance glucose uptake several fold in rat intestine. AIM: To explore mechanisms of sweet taste receptor activation in glucose uptake in 3 intestinal cell lines. HYPOTHESIS: The artificial sweetener, acesulfame potassium (AceK), increases glucose uptake via activating sweet taste receptors to induce translocation GLUT2 to the apical membrane through the PLC βII pathway. Complexity of Liver Surgery Liver Related Complications 0.5–50 mM glucose with and without 10 mM AceK. 14C-Dglucose was used to measure stereospecific, transportermediated uptake and 3H-L-glucose to measure passive uptake with or without the inhibitors 10 μM U-73122, a PLC βII inhibitor, 10 μM chelerythrine, a PKC inhibitor, and 2 μM cytochalasin B, a microtubular system disrupter. Glucose uptake was stopped by adding ice-cold PBS; cells were washed with PBS 2 times and solubilized with 0.1 N NaOH. All experiments were done on at least 3 separate occasions in triplicate. CONCLUSIONS: Despite an increasing complexity of liver surgery, the rates of liver related complications have remained stable or decreased. An important exception to this is bile leak which has increased in incidence and is now a major cause of surgical morbidity. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leak is indicated. RESULTS: In Caco-2 and RIE-1 cells, 10 mM AceK increased carrier-mediated glucose uptake by 20–30% at apical glucose concentrations >25 mM (p < 0.05), but not in the lesser glucose concentrations (<10 mM) nor at 1-min or 10-min incubations. U-73122, a PLC βII inhibitor, inhibited glucose uptake at the greater (>25 mM) glucose concentrations during the 5-min incubation; chelerythrine and cytochalasin B had similar effects. No effect was seen in IEC-6 cells. CONCLUSION: The artificial sweetener AceK, a known sweet taste receptor agonist, has no effect on glucose uptake in low (<25 mM) glucose concentrations, but increased glucose uptake at greater concentrations (> 25 mM) in our cell culture models when GLUT2 translocation occurs. The role of artificial sweeteners on glucose uptake appears to act in part by effects on the enterocyte itself. (Support: NIH DK39337-MGS) 55 Tuesday Abstracts METHODS: Caco-2, RIE-1, and IEC-6 cells (human, rat, and rat intestinal cell lines) were seeded on a 24-well plate at a density of 4x104 cells/cm2 in growth culture media and left to differentiate for 15 days after confluence. Caco-2 and RIE-1 cells express GLUT2, while IEC-6 cells do not. Cells were starved from glucose for 1 h and pre-incubated with and without 10 mM AceK for 30 min. Glucose uptake was measured by incubating the cells for 1 to 10 min with THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 1006 LIR + ERAS (n = 20) LIR + CC (n = 70) p Time to first flatus (days—mean ± SD) 1.7 ± 0.7 2.8 ± 1.5 0.002* Antonino Spinelli1, Piero Bazzi1, Matteo Sacchi1, Silvio Danese3, Gionata Fiorino3, Lorenzo Gentilini5, Alberto Malesci4, Gilberto Poggioli5, Marco Montorsi1,2 1. Department of Surgery, Istituto Clinico Humanitas IRCCS, Rozzano Milano, Italy; 2. Department of Surgery, University of Milan, Milano, Italy; 3. IBD Unit – Department of Gastroenterology, Istituto Clinico Humanitas IRCCS, Rozzano Milano, Italy; 4. Department of Gastroenterology, Istituto Clinico Humanitas IRCCS, Rozzano Milano, Italy; 5. Department of Surgery, Policlinico S. Orsola – Malpighi – University of Bologna, Bologna, Italy Time to first bowel movement (days—mean ± SD) 3.0 ± 0.9 3.6 ± 1.1 0.03* Postoperative length of stay (days—mean ± SD) 5.3 ± 1.6 6.8 ± 3.1 0.04* Total length of stay (days—mean ± SD) 5.3 ± 1.6 7.9 ± 3.4 0.001* Postoperative pain: VAS Score > 3 on p.o. day 1 (n; %) 8; 40% 19; 27.1% n.s.° Postoperative pain: VAS Score > 3 on p.o. day 2 2; 10% 4; 5.7% n.s.° BACKGROUND: Two major innovations have drastically modified colorectal surgery over the last 20 years: laparoscopy and the introduction of multimodal integrated perioperative programs (ERAS, Enhanced Recovery After Surgery, also known as Fast Track programs). ERAS applies evidence-based concepts to perioperative care of surgical patients: it aims to reduce surgical stress, allowing a faster and smoother postoperative recovery. A recent RCT proved that the combination of laparoscopy with ERAS represents the best option for colorectal cancer patients. There are surprisingly no data on Crohn’s disease (CD) patients treated by laparoscopy and ERAS program. Major complication rate (bleeding, leakage, abdominal abscess) 3; 15% 7; 10% n.s.° Minor complication rate (ileus, intraluminal bleeding, wound infection) 2; 10% 10; 14.3% n.s.° Readmissions within 30 days from discharge 0; 0% 2; 2.8% n.s.° Combination of Laparoscopy and Enhanced Recovery Program Improves Outcomes After Ileocecal Resection for Crohn’s Disease * t-test; ° 2-test 1007 METHODS: Twenty consecutive patients planned for ileocecal resection due to stricturing CD at two IBD referral centers were prospectively enrolled. Patients underwent laparoscopic ileocecal resection (LIR) and were treated according to ERAS program (LIR+ERAS group): no preoperative bowel preparation nor fasting, no nasogastric tubes, no abdominal drains, early removal of urinary catheters, early feeding and mobilization, multimodal opioid-free analgesia and restrictive perioperative fluid management. Enrolled patients were compared with 70 patients treated by LIR and conventional care (CC) (LIR+CC group), matched for age, sex, disease presentation, BMI, ASA score, preoperative therapy. Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms RESULTS: See Table. METHODS: A retrospective analysis was conducted on patients with attempted laparoscopic resection (n = 69) and open resection (n = 25) of submucosal neoplasms of the stomach from October 2002 through October 2011. Nonparametric statistical tests were used for comparisons between groups. Sabha Ganai1, Vivek N. Prachand1, Mitchell C. Posner1, John C. Alverdy1, Eugene A. Choi1, Irving Waxman1, Marco G. Patti, Kevin K. Roggin Department of Surgery, The University of Chicago, Chicago, IL INTRODUCTION: While minimally-invasive techniques have an integral role in foregut surgery, their optimal use in the resection of gastric neoplasms awaits validation in clinical practice. We hypothesized that conversion of operations to open could be predicted by specific anatomical and pathological factors. CONCLUSION: This is the first experience combining laparoscopic surgery with integrated multimodal ERAS protocols on CD patients. Our data showed a significantly faster return of normal bowel function and shorter hospital stay for the LIR+ERAS group. This suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients. 56 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Laparoscopic (n = 62) Symptoms: – Asymptomatic – GI bleed – Reflux/Dyspepsia – Dysphagia – Abdominal Pain Neoadjuvant Imatinib Conversion (n = 7) Open (n = 25) p 14 (24%) 23 (39%) 8 (14%) 0 14 (24%) 1 (14%) 2 (29%) 1 (14%) 0 3 (43%) 1 (4%) 8 (32%) 2 (8%) 1 (4%) 13 (52%) 0.01 2 (3%) 2 (29%) 6 (24%) 0.005 Preoperative Size (cm) 3.5 ± 1.8 7.7 ± 5.4 9.5 ± 7.1 <0.0001 Pathological Size (cm) 4.0 ± 2.2 7.6 ± 5.0 8.5 ± 6.2 0.0004 Operative Time (min) 145 ± 60 246 ± 84 231 ± 96 <0.0001 Estimated blood loss (mL) 35 ± 70 376 ± 422 373 ± 280 <0.0001 51 (82%) 3 (5%) 4 (7%) 1 (2%) 2 (3%) 0 1 (2%) 3 (43%) 1 (14%) 3 (43%) 0 0 0 0 9 (36%) 4 (16%) 7 (28%) 2 (8%) 1 (4%) 1 (4%) 1 (4%) 0.0003 3.5 ± 3.9 6.4 ± 1.1 8.7 ± 5.8 <0.0001 Accordian Severity Score 0 – no complications 1 – minor (wound, foley) 2 – minor (PRBCs, Abx, TPN) 3 – Endoscopic / IR Intervention 4 – Operative Intervention 5 – MSOF 6 – Death Hospital length of stay (days) 1008 Minimally Invasive Approach GE Junction and Esophageal GIST Jon Gould1, Andrew Kastenmeier1, Mario Gasparri2 1. Minimally Invasive General Surgery, Medical College of Wisconsin, Milwaukee, WI; 2. Thoracic Surgery, Medical College of Wisconsin, Milwaukee, WI Gastrointestinal stromal tumors are rare neoplasms of uncertain malignant potential. The most common site of origin is the stomach. Approximately 5% of all GISTs originate from the esophagus. Traditional management of gastric GIST is wedge resection to grossly negative margins. Tumors located at the GE junction are difficult to resect without impairing esophageal emptying. Tumors in the esophagus cannot be resected with wedge resection techniques. Rather than performing an esophagectomy, enucleation of low-risk lesions may be appropriate. We present a video demonstrating the laparoscopic resection of two GIST lesions in difficult anatomic locations: the GE junction and the distal esophagus. CONCLUSIONS: Selection for laparoscopic versus open resection appears to be influenced by factors including tumor size, multivisceral involvement, and the need for gastric reconstruction. Conversion to open is also more likely with tumors in a posterior location. Laparoscopic gastric resection has decreased morbidity, operative time, and hospital length of stay and is appropriate in well-selected patients with gastric submucosal neoplasms. 57 Tuesday Abstracts RESULTS: Patients were 63 ± 14 years old, 52% male, and had a BMI of 29.5 ± 7.3 kg/m2. Diagnostic endoscopic ultrasound use was greater in the laparoscopic group than the open (86% vs. 64%, p < 0.05). Lesions in the laparoscopic and open cohorts included gastrointestinal stromal tumors (71% vs. 88%), leiomyomas (9% vs. 12%), schwannomas (9% vs. 0), and other (11% vs. 0). There were 7 (10%) conversions to open in the laparoscopic group. Posterior location was a predictor of conversion (71% vs. 32%, p < 0.01) and selection for an open technique (67%, p < 0.01). There were no other predictors of conversion by location of the mass along the stomach. Conversions (29%) and open resections (40%) were more likely to have multivisceral involvement than the laparoscopically-treated patients (2%, p < 0.0001). Combined laparoendoscopic approaches were used in 10% of laparoscopic procedures (n = 62), which included wedge or sleeve resection in 47 (76%), transgastric wedge resection in 5 (8%), submucosal resection in 3 (5%), midbody gastrectomy in 2 (4%), antrectomy in 1 (2%), and other in 4 (6%). Patients selected for open resection were more likely to require a gastroenteric anastomosis in comparison to patients initially selected for a laparoscopic approach (40% vs. 4%, p < 0.0001). Significant differences in tumor size, operative time, morbidity, and length of stay were noted between groups (refer to Table, p < 0.001). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT 1009 1010 Epigenetic Modulation of Adhesion and Proliferation Pathways by Methionine Deficiency Attenuates Potential for Dissemination of Gastric Cancer Cells Adjuvant Radiation Therapy and Lymph Node Dissection in Esophageal Cancer: A SEER Database Analysis Ravi Shridhar2, Jill Weber1, Sarah Hoffe2, Khaldoun Almhanna1, Richard Karl1, Ken L. Meredith1 1. Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL; 2. Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL Luigina Graziosi , Andrea Mencarelli , Barbara Renga , Emanuel Cavazzoni2, Angela Bruno1, Chiara Santorelli2, Emanuele Rosati2, Stefano Fiorucci1, Annibale Donini2 1. Medicina Clinica e Sperimentale, University of Perugia, Perugia, Italy; 2. Dipartimento di Scienze Chirurgiche, Radiologiche e Odontostomatologiche, University of Perugia, Perugia, Italy 2 1 1 Objectives: The number of lymph nodes removed during esophagectomy and the impact on survival remains undefined. We sought to determine the effects of post-operative radiation therapy and lymph node dissection on survival in esophageal cancer. BACKGROUND: Methionine dependency is a feature unique to cancer cells, as demonstrated by their inability to grow in a methionine depleted environment even if the medium is supplemented with homocysteine, the immediate precursor of methionine. Treatment of disseminated gastric cancer is unsatisfactory and gastric tumors are frequently chemoresistant. METHODS: We performed an analysis of patients who underwent esophagectomy for cancer from the SEER database between 2004–2008 to determine association of adjuvant radiation and lymph node dissection on survival. Patients treated with neoadjuvant radiation were excluded. Survival curves were calculated according to the Kaplan-Meier method with log-rank analysis. Multivariate analysis (MVA) was performed by the Cox proportional hazard model. AIM: To investigate the effect of methionine deficiency in rodent models of gastric cancer dissemination. MATERIAL AND METHODS: Moderate (MKN74) and poorly differentiated (MKN45 and KatoIII) human gastric cancer cell lines were used for these studies. To generate models of experimental peritoneal carcinomatosis (10 days) and xenograft model (65 days), these cell lines were injected intraperitoneally or subcutaneously, respectively, in NODSCID mice. For in vitro studies cells were growth in a complete medium with 10% bovine dyalized serum in a methionine free medium containing homocysteine(MetHcy+) or a medium containing methionine but depleted of homocytesine (Met+Hcy-). Three-days in vitro culture In vitro of MKN45,MKN74 and KATOIII cells in a methionine deficient medium inhibited cell proliferation by 70-% and induced cell apoptosis. In addition, culturing cells in a methionine free medium reduced cell adhesion and migration significantly in comparison to Met+Hcy- medium (p < 0.05). Finally, by microarray designed to analyze the methylation of promoter CpG-islets, we found that methionine deficiency reduced the promoter methilation of E-Cadherin and secreted frizzled-related protein 2 (SFRP-2) by 50%, two genes involved in the gastric cancer cell adhesion and proliferation, respectively. RESULTS: We identified 2109 patients who met inclusion criteria. There were 467 and 1642 patients treated with and without radiation. Radiation was associated with increased survival in stage III patients (HR 0.71; 95% CI: 0.56 - 0.90; p = 0.005), no benefit in stage II (p = 0.075) and IV (p = 0.913) patients, and decreased survival in stage I patients (HR 2.73: 95% CI: 1.76 - 4.22; p < 0.0001). Univariate analysis revealed that radiation therapy was associated with a survival benefit in node positive (N1) patients while it was associated with a detriment in survival for node negative (N0) patients. The median and 3 year survival with and without radiation is 23 months and 34%, and 20 months and 26.7%, respectively (p = 0.0225) for N1 patients and the 3-year survival with and without radiation is 48.8% and 68.8%, respectively (p < 0.0001) for N0 patients. In node negative patients, removing <12 versus >12 lymph nodes (HR 1.316; 95% CI 1.060 - 1.634; p = 0.013) and <15 versus >15 (HR 1.313; 95% CI: 1.032 - 1.670; p = 0.027) was associated with increased mortality. Similarly, in node positive patients, removing <8 versus >8 (HR 1.325; 95% CI 1.066– 1.646; p = 0.011), <10 versus >10 (HR 1.311; 95% CI 1.069–1.608; p = 0.009), <12 versus >12 (HR 1.299; 95% CI 1.066– 1.582; p = 0.009), <15 versus >15 (HR 1.258; 95% CI 1.031– 1.535; p = 0.024), and <20 versus >20 (HR 1.325; 95% CI 1.056–1.662; p = 0.015) was associated with increased mortality. In node negative patients, age and tumor stage, were prognostic for worse survival, while gender and number of lymph nodes removed were prognostic for better survival. Adjuvant radiation, tumor location, and histopathology were not prognostic for survival. In node positive patients, age and tumor stage were associated with increased mortality while number of lymph nodes removed and adjuvant radiation were associated with decreased mortality. Gender, tumor location, and histopathology were not prognostic for survival in node positive patients. CONCLUSIONS: Our experimental data suggest that a deficient methionine diet might affect neoplastic tumor growth by regulation of cell cycle, inducing apoptosis and decreasing cellular adhesion and migration. CONCLUSION: The number of lymph nodes removed in esophageal cancer is associated with increased survival. The benefit of adjuvant radiation therapy on survival in esophageal cancer is limited to N1 patients. RESULTS: In the xenograft models induced by subcutaneous implantation of MNK45 and MNK74 cells, two cycles of methionine deficient diet (from day 20 to 27 and from day 34 to 41) reduced the tumor growth, measured on day 70, by 50% (p < 0.05 versus control diet). In the model of peritoneal carcinomatosis, induced by MNK45 cells injection, a cycle of methionine deficient diet for 10 days reduced peritoneal nodules from 27.0 ± 3.68 to 6.7 ± 0.8 (p < 0.05). The intraperitoneal injection of MNK74 cells precultured for 3 days in a Met-Hcy+ medium almost abrogated peritoneal dissemination (p < 0.05 versus Met+Hcy- medium precultured group). 58 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA 1012 1011 Health-Related Quality of Life in Patients Esophageal Cancer: Predictors Analysis at the Different Steps of Treatment Extent of Lymphadenectomy Does Not Predict Survival in Patients Treated with Primary Esophagectomy Joyce Wong, Jill Weber, Khaldoun Almhanna, Sarah Hoffe, Ravi Shridhar, Ken L. Meredith Surgery, H. Lee Moffitt Cancer Center, Tampa, FL Marco Scarpa1, Luca Saadeh1, Alessandra Fasolo1, Rita Alfieri1, Matteo Cagol1, Giovanni Zaninotto2, Ermanno Ancona2, Carlo Castoro1 1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS), Padova, Italy; 2. Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy BACKGROUND: The number of lymph nodes resected and its impact on survival for patients with esophageal cancer remains undefined. Current guidelines recommend extended lymphadenectomy in patients not receiving neoadjuvant therapy. We reviewed our single institutional experience with nodal harvest for esophageal cancer in a non-neoadjuvant therapy setting. BACKGROUND: The main outcome parameters in esophageal oncology have traditionally been morbidity and mortality but recent improvements in the treatment of esophageal cancer suggest to take in consideration quality of life. Esophagectomy is associated with significant deterioration of the health related quality of life, which persists during the follow-up period. The aim of this study was to analyze quality of life before and after esophagectomy for esophageal cancer and to identify possible predictors of quality of life at the different steps of the treatment. Patients and methods One hundred twenty six consecutive patients presenting with esophageal cancer at the Oncological Surgery Unit of the Veneto Institute of Oncology have been enrolled in this prospective study from 2009 to 2011. The patients answered to three quality of life questionnaires at diagnosis of esophageal cancer, after the neoadjuvant therapy, after surgery and at 1, 3, 6 and 12 months after surgery. The questionnaires were administered during the hospitalization and outpatient visits. The questionnaires were the Italian version of the QLQ-C30, QLQ-OES18 and IN-PATSAT32 models, developed by the European Organization for Research and Treatment of Cancer (EORTC). Univariate and multivariate analysis were performed. RESULTS: We identified 246 patients who underwent esophagectomy as initial treatment. The mean age was 65 years ±10 years. The majority of patients were male (87%). Ivor-Lewis esophagectomy was performed for 71%, minimally-invasive esophagectomy for 15%, transhiatal esophagectomy for 12%, and three-field esophagectomy for 2%. At 60 month follow-up, there was no statistically significant difference in overall survival (OS) or disease free survival (DFS) between patients with < vs. >5 LN resected (p = 0.74 and p = 0.67, respectively) or in the < vs. >10 (p = 0.33, p = 0.11), 12 (p = 0.82, p = 0.90), 15 (p = 0.45, p = 0.79), or 20 (p = 0.72, p = 0.86) resected LN groups. Patients were then sub-divided into node positive and node negative cohorts and stratified by nodal harvest. In the subgroups of patients with node-negative and node-positive disease, OS and DFS also did not significantly differ between groups with respect to number of nodes resected (p>0.05). A total of 49 (20%) patients developed recurrent disease; however recurrence was not statistically associated with number of LN resected (p > 0.05). RESULTS: Global quality of life (QL2 item) improved after neoadjuvant therapy compared to the baseline levels, it decreased immediately after surgery (p = 0.06) and then it improved after 1 year (p = 0.03). At diagnosis, QL2 item correlated significantly with tumor size, gender and dysphagia but none of these items was an independent predictor at multivariate analysis. After neoadjuvant therapy, only age revealed to be an independent predictor of good quality of life (b = 0.33, p = 0.02). After surgery, gastroenterological complications of radiochemotherapy were independent predictor of poor quality of life (b = – 0.33, p = 0.04). One year after esophagectomy postoperative complications were independent predictor of poor quality of life at this stage (b = – 0.63, p = 0.01). Dysphagia (DYS item) improved dramatically after surgery (p < 0.01). After surgery DYS was independently predicted by the presence of skin complication of chemo radiation, hospital stay duration and the use of jejunostomy (b = 0.33, p = 0.04, b = 0.40, p = 0.04 and b = -0.45, p = 0.02, respectively). CONCLUSION: We found no impact of extent of lymphadenectomy on overall or disease free survival in patients treated with esophagectomy without neoadjuvant therapy. In addition, the number of nodes resected at esophagectomy did not affect recurrence rates. Current recommendations for increased nodal resection during esophagectomy in patients not receiving neoadjuvant therapy may not improve patient outcomes, and this phenomenon warrants further investigation. 59 Tuesday Abstracts METHODS: Patients who underwent esophagectomy as primary therapy were indentified from a prospectively maintained database consisting of 704 patients who underwent esophagectomy. Patients were stratified by number of lymph nodes (LN) resected: >5, 10, 12, 15, or 20. Survival, clinical and pathologic parameters were analyzed with Kaplan-Meier curves, chi-square or Fisher’s exact tests where appropriate. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSIONS: Even if in the short-term quality of life seems to be negatively influenced by esophagectomy after 12 months the scale returns to baseline levels. However, the minimally invasive techniques do not seem to confer special benefits. On the contrary, dysphagia improve significantly after esophagectomy. Older patients seem to cope more easily with neoadjuvant therapy while complications of chemo radiation and of surgery deeply affect quality of life at different stage of the natural history of the disease. chief component. Presently, there is no simple in vitro culture system of human esophageal cells that can be used to observe the morphological and molecular effects of bile acid and low pH on a stratified epithelium. In this study, we showed that h-TERT-transformed primary esophageal squamous cells (EPC1) form a 10–11 layered stratified epithelium when grown on polyester trans-well filters apically and basally supplemented with keratinocyte serum-free media with 0.6 mM Ca+2. This stratified epithelium shows epithelial barrier function and expresses squamous specific genes like GRHL-1, K10, KDAP, DSG1, and IVL. Moreover, when exposed to bile acids at pH5 in short pulses, EPC1 cells demonstrate reduction in the stratification layers and in the expression of squamous specific genes. The epithelium also exhibits loss of barrier function possibly due to disruption of desmosomal junctions and phosphorylationactivation of epidermal growth factor receptor (EGFR) and down-stream pathways. In addition, the epithelium starts expressing columnar specific transcription factor CDX2 as early as day 3 of treatment. These results indicate that bile acid at low pH is responsible for skewing the differentiation status of stratified squamous esophageal epithelium in vitro to a more columnar type possibly by initiating a mucosal restitution response through activation of EGFR signaling. 1013 Bile Acid at Low pH Reduces the Squamous Differentiation and Induces Columnar Differentiation of Primary Esophageal Cells, Possibly by Activating EGFR Signaling Sayak Ghatak1,2 1. Biology, University of Rochester, Rochester, NY; 2. Surgery, University of Rochester, Rochester, NY Esophageal Adenocarcinoma is the fastest growing cancer in the United States and is the sixth leading cause of cancerrelated death. In its precancerous lesion, Barrett’s Esophagus, the normal squamous epithelium of the esophagus undergoes columnar metaplasia due to long-term exposure to reflux contents of which bile acid at acidic pH is the 60 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA POSTER SESSION DETAIL Printed as submitted by the authors. indicates a Poster of Distinction. Sunday, May 20, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM. 12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME) Basic: Colon-Rectal Total purified RNA was isolated from tissue samples and cDNA synthesized. CDH3 expression was analyzed by quantitative PCR (QPCR) using the SYBR Green platform. Tumor expressions levels were determined and compared to expression levels in normal colonic tissue and PLC. CDH3 expression in other normal organs was also assessed. Tumors with expression levels 0.1% or more than the PLC result were considered positive. Plasma CDH3 levels were determined via ELISA in pts for whom PreOp blood samples were available. Plasma CDH3 levels and tumor QPCR levels were correlated (P < 0.05). Colon and rectal tumor expression levels were also compared (p < 0.05). Su2020 The Tumor Associated Antigen P-Cadherin (CDH3) in Colorectal Cancer Holds Promise as a Prognostic Marker Rather Than as Specific Immunotherapy Target RESULTS: A total of 77 paired CRC and normal colon specimens (36 M/ 41 F, age 67.3 ± 14.5) were assessed (82% colon, 18% rectal; Cancer Stage 2, 44; Stage 3, 33). All tumors (100%) had CDH3 expression levels over 0.1% of the PLC level and, also, a tumor to normal colon ratio greater than 1.Expression ratios in 25 tumors were above 100 and in 19 tumors were in the 50–100 range. CDH3 expression was noted in 8/20 normal organ tissues. There was a positive correlation between tumor CDH3 QPCR and PreOp CDH3 blood levels (n = 57, P = 0.038). Expression levels were significantly higher in rectal vs. colon tumors (p = 0.019). INTRODUCTION: Placental-Cadherin, type 1 (CDH3) is a cell adhesion molecule that plays a role in cellular localization and tissue integrity. Because CDH3 is highly expressed by the placenta (PLC) it holds promise as a cancer testis antigen and, possibly, a vaccine target. Its expression profile in normal tissues has not been well studied, to date. Up-regulation of CDH3 expression has been reported in esophageal, pancreatic, bladder, prostate, melanoma, and breast cancer; expression levels in colorectal cancer (CRC) remain poorly characterized. This study’s aims were: 1) to evaluate CDH3 expression in CRC tumors and other tissues as well as to assess preoperative plasma CDH3 levels and 2) to determine if CDH3 holds promise as a vaccine target. CONCLUSION: All tumors over expressed CDH3 as judged by RT-PCR when compared to normal colon tissue; tumor expression was also greater than 0.1% of PLC expression levels. Unfortunately, CDH3 was expressed by other normal organs, thus, it is not a promising vaccine target or a cancer testis antigen. Of note, appreciable plasma CDH3 levels were noted and the correlation between plasma and tumor CDH3 levels suggests CDH3 may have value as a prognostic marker. A larger study is needed to determine if plasma and/or tumor expression levels correlate with T, N, or final tumor stage. METHODS: An IRB approved plasma and tumor bank was utilized. CRC patients (pts) for whom tumor and normal colon tissue samples were available were enrolled. Demographic and pathologic data were collected prospectively. Tumor samples were OCT embedded and stored at –80C°. 61 Sunday Poster Abstracts C.M. Shantha Kumara H*1, Otavia L. Caballero2, Sonali A. Herath1, Tao Su3, Aqeel Ahmed3, Linda Njoh1, Vesna Cekic1, Richard L. Whelan1 1. Surgery, St. Luke Roosevelt Hospital, New York, NY; 2. Ludwig Collaborative Laboratory for Cancer Biology and Therapy Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; 3. Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su2021 Basic: Esophageal The Tumor Suppressive Effects of HPP1 via STAT Signaling in Colon Cancer Are Abrogated by Site-Directed Mutation of Its EGF-Like Domain Su2023 Development of a Robust Stricture Model to Assess Therapeutic Interventions Following Circumferential Endoscopic Esophageal Submucosal Dissection Abul Elahi*, Whalen Clark, Jonathan M. Hernandez, Jian Wang, Yaping Tu, Leigh Ann Humphries, David Shibata H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL Eric M. Pauli*1, Steve J. Schomisch1, Amitabh Chak2, Jeffrey L. Ponsky1, Jeffrey M. Marks1 1. Surgery, University Hospitals Case Medical Center, Cleveland, OH; 2. Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: The novel tumor suppressor gene, HPP1 is downregulated in over 80% of colorectal cancers and mediates its effects by alterations in STAT (Signal Transducer and Activator of Transcription) signaling. HPP1 is a secreted transmembrane protein that contains a single Epidermal Growth Factor (EGF)-like domain which differs from EGF by having a His instead of an Arg at what is thought to be a critical amino acid (AA) site. We sought to investigate the impact of targeted site-directed mutagenesis at this AA site on HPP1’s biologic behavior. INTRODUCTION: Circumferential endoscopic esophageal submucosal dissection (EESD) for high grade dysplasia or early cancer provides an intact specimen for histology, offers less-invasive therapy than esophagectomy and potentially allows one-step en bloc eradication of Barrett’s esophagus. As such, the technique holds potential for staging, treating and preventing esophageal cancer. However, aggressive stricture formation after EESD has limited its clinical use. We hypothesized that an in vivo esophageal stricture model could be developed to assess endoscopic interventions designed to prevent stricture formation following EESD. METHODS: Site-directed mutagenesis technology was utilized to create a mutated HPP1 construct substituting an Arg moiety in the place of His at site 299 in its EGF-like domain. Computed 3-D protein folding models demonstrate no alterations in the overall configuration of HPP1 as a result of this mutation. Full-length wild-type HPP1, the mutated HPP1 (H299R) and empty vector control were transfected into the HPP1 non-expressing HCT116 colon cancer cell line. Biologic effects on STAT signaling were assessed by RT-PCR and Western Blot analyses. Effects on proliferation and anchorage-independent growth were evaluated by MTT and soft agar assays respectively. METHODS: Five swine were utilized in this study. Under anesthesia, a flexible endoscope with a band ligator and snare was used to circumferentially incise the mucosal layer 20 cm proximal to the lower esophageal sphincter. An approximately 10 cm circumferential segment of tissue was dissected free from the underlying muscle and excised using electrocautery and snare. Weekly barium esophagograms evaluated for reduction in esophageal diameter and assessed stricture length and proximal dilation. Animals were followed clinically and were euthanized when the stricture exceeded 80% and they were unable to gain weight (despite high-calorie liquid diet). A blinded pathologist evaluated EESD and necropsy specimens. RESULTS: We have previously demonstrated that HPP1 overexpression results in a substantial reduction in proliferation, growth in soft agar and tumorigenicity. These effects are associated with activation of suppressive STAT1 and –2 with down regulation of oncogenic STAT3, –5 and –6. Transfection of HPP1 H299R resulted in a reversal of this profile with a reduction in activated STAT1 and –2 and increased phosphorylation of STAT3, –4 and –5. Moreover, forced expression of mutated HPP1 abrogated tumor suppressive behavior with increased cell proliferation (Optical Density-OD: 0.78 ± 0.18 vs.; 0.33 ± 0.13 p ≤ 0.001) and colony formation in soft agar (543 ± 20 vs 2 ± 1 colonies; p ≤ 0.001) as compared to wild-type HPP1 transfectants. Cell growth parameters were similar between HPP1 H299R and EV control transfectants (OD 0.75 ± 0.07; 591 ± 176 colonies; P = NS). RESULTS: Resected specimens ranged from 90–110 mm in length. Histology confirmed uniform en bloc mucosal resection down to the superficial submucosa. All five animals rapidly developed strictures following EESD. At one week, animals demonstrated a 62.2 ± 12.9% reduction in luminal diameter, longitudinal shortening to 77.6 ± 12.4% of the original resected length with dilation in the proximal esophagus to 128 ± 6.2% baseline diameter. By two weeks, animals demonstrated a 77.7 ± 12.1% reduction in luminal diameter, longitudinal shortening to 62.7 ± 12.3% of the original resected length with dilation in the proximal esophagus to 174.8 ± 27.3%. Based on criteria, no animal survived beyond the third week of study. There was no correlation between resected specimen length and the degree of luminal narrowing or survival. Stricture zone histology showed unepitheliazed submucosa with abundant PMNs, fibrosis and neovascularization. CONCLUSION: The EGF-like domain of HPP1 is essential for its tumor suppressive effects with the Histidine moiety at position 299 being critical for mediating its associated biologic and molecular signaling effects. Therapeutic targeting of the erbB family of receptors is of great interest and our findings may lead to a greater understanding of the complex and sometimes contradictory nature of their associated signaling pathways. 62 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSIONS: We describe the successful development of an esophageal stricture model. EESD in the porcine esophagus removes specimens of uniform length and depth without damaging the underlying muscule. Circumferential EESD results in clinically significant stricture formation within weeks. Esophagograms demonstrated uniform reduction in luminal diameter in the area of resection with concomitant proximal esophageal dilation. Histology confirmed the presence of inflammation and fibrosis. Future areas of investigation will focus on endoscopic methods to alleviate or prevent stricture formation following EESD. Su2025 Basic: Pancreas INTRODUCTION: Severe acute pancreatitis (AP) may lead to serious complications, with high mortality rates. Although several clinical and radiological scores and biochemical markers can determine if an episode of AP is severe, there is not available a precise predictor for the severity of the pancreatitis, which could allow an early intensive management of those patients. Our group has focused on the study of serum ecto-nucleotidase activity (NTPD-ases) and purine levels, and their possible role as predictor of severity in AP. Extracellular nucleotides play significant role in inflammation in peripheral circulation, and their serum levels are partially controlled by NTPDases. Consequently, those enzymes act as regulatory elements in inflammation, hydrolyzing nucleotides. However, results from our main experiments have shown an intriguing data, which could point to a possible marker of severity in AP, with a promising clinical use. Positive Correlation Between Serum Phosphate Levels and Acute Pancreatitis Severity in a Rat Model of Pancreatitis Induced by Sodium Taurocholate Guilherme D. Mazzini*1,2, Daniel T. Jost1, Rafael Machoseki1, Mateus A. Zeni1, Luiz V. Portela1, Maria I. Edelweiss2, Diogo O. Souza1, Alessandro B. Osvaldt2 1. Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; 2. Gastrointestinal Surgery, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil Su2024 Aging Is Related to Increased Intestinal Damage and Bacterial Translocation in Acute Pancreatitis in Rats ANA Maria M. Coelho*1, Marcel C. Machado1, Sandra N. Sampietre1, Nilza A. Molan1, Inneke M. Van Der Heijden2, José Eduardo M. Cunha1, Luiz C. D’Albuquerque1 1. Gastroenterology, University of São Paulo, São Paulo, Brazil; 2. Infectious Diseases, University of São Paulo, São Paulo, Brazil METHODS: The local ethics committee approved the study. AP was induced in 20 Wistar male rats, age 90–120 days, by retrograde infusion of sodium taurocholate in the pancreatic duct. Ten sham-operated animals were submitted to median laparotomy and closure. There were 5 absolute control animals. Blood was collected from the tail before surgery (time 0) and after 3h and from cardiac puncture at 12h, when pancreas were excised and fixed in formalin for histopathology. AP diagnosis was made based on amylase serum levels, determined by a colorimetric assay, and severity was graded by histopathology, using a validated scale (from 0 to 28 points). As a control for the colorimetric assay to determine NTPD-ase activity (measured by phosphate release), in each serum sample the basal phosphate levels were measured. These values produced interesting data, and will be presented here. METHODS: AP was induced in male Wistar rats by intraductal 2.5% taurocholate injection and divided into 2 experimental groups: GI (n = 20): Young (3 month old rats), and GII (n = 20): Older (18 month old rats). Two and 24 hours after AP blood were collected for determinations of plasma ileal fatty acid binding protein (I-FABP), and biochemical markers: amylase, AST, ALT, urea, creatinine, and glucose. Pulmonar myeloperoxidade (MPO) activity was also performed. Bacterial translocation was evaluated by bacterial cultures of pancreas expressed in colony-forming units (CFU) per gram. Results: Four animals from AP group died before 12h. Additional 2 animals from AP group were excluded from the analysis due to invalid results. Serum amylase was diagnostic of AP in pancreatitis group, at 3h and 12h. Severity score in AP group was 19.0 ± 4.9 (mean ± SD). Basal phosphate levels at 12 h were significantly higher than 0h and 3 h in AP group, and significantly higher than 0h, 3 h and 12 h, in sham and control groups, which did not present significant alterations in phosphate levels along the experiment (Figure 1). Additionally, in AP group, phosphate levels at 12 h showed a positive correlation with the severity of the pancreatitis, r = 0.74 (Pearson’s coefficient, p = 0.02) (Figure 2). RESULTS: A significant increase in serum amylase, AST, ALT, urea, creatinine, and I-FABP levels was observed in the older group compared to the young group (p < 0.05). Pulmonar myeloperoxidade (MPO) activity was also increased in the older group compared to the young group (p < 0.05). Compared to young rats, rate of positive bacterial cultures obtained from pancreas cultures in the older rats was significantly increased. CONCLUSION: This study demonstrated that aging is associated to an increased distant organ damaged and bacterial translocation, and that plasma level of I-FABP is an important marker of bacterial translocation. 63 Sunday Poster Abstracts BACKGROUND/AIM: Acute pancreatitis (AP) in elderly patients in spite of similar occurrence of local complications is followed by a substantial increase in multiple organ failure possibly due to increased bacterial translocation. Intestinal mucosal barrier may be damage with increased permeability promoting bacterial translocation. Intestinal fatty acid binding protein (I-FABP), a 15-kd protein located at the intestinal mucosa may leak out of damaged intestinal mucosal cells to the peripheral circulation. Therefore, plasma levels of I-FABP may be an indication of bacterial translocation. The aim of the present study was to evaluate the effect of aging on intestinal damage, bacterial translocation, and organ failures in AP. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT extensively studied, whereas very little data exists regarding the role of IL-33 in anti-tumor immune responses. No study has been performed to address the direct effect of IL-33 on tumor cell proliferation or apoptosis. METHODS: In the present study, clonogenic survival assay, immunohistochemistry (IHC), TUNEL staining, proliferation and caspase-3 activity kits were used to evaluate the effects of IL-33 on cell survival, proliferation and apoptosis of a pancreatic cancer cell line, MiaPaCa-2. We further investigated the possible molecular mechanisms by using RT-PCR, IHC, and Western blot. RESULTS: We found that the percentage of colonies of MiaPaCa-2 cells, PCNA+ cells and the OD value of cancer cells were all decreased after incubation with IL-33. TUNEL+ cells and the relative caspase-3 activity in cancer cells were increased in the presence of IL-33. The antiproliferative effect of IL-33 on cancer cells correlated with downregulation of pro-proliferative molecule cdk2 and cdk4 and upregulation of anti-proliferative molecule p15, p21 and p53. The pro-apoptotic effect of IL-33 correlated with downregulation of anti-apoptotic molecule FLIP and upregulation of pro-apoptotic molecule TRAIL. Figure 1: Serum phosphate levels in AP group at 12h is significantly higher then other times and other groups. * p < 0,5 by ANOVA. CONCLUSIONS: IL-33 inhibits proliferation and induces of apoptosis of pancreatic cancer cells in vivo. Manipulation of the IL-33/ST2 pathway might be a promising strategy to treat pancreatic cancer. Basic: Small Bowel Su2027 Histone Deacetylase Inhibitors Decrease Postoperative Adhesions with a Single Intraoperative Dose by Targeting Early Events in Adhesiogenesis Figure 2: Correlation between AP severity and serum phosphate levels at 12h. (Pearson’s coefficient r = 0.74, p = 0.02) Michael R. Cassidy*, Joseph J. Gallant, Alan C. Sherburne, Holly K. Sheldon, Melanie L. Gainsbury, Arthur F. Stucchi, James M. Becker Surgery, Boston University Medical Center, Boston, MA DISCUSSION: Our group brings preliminary experimental results with a novel approach to the assessment of severe AP. Although the strong correlation between pancreatitis severity and serum phosphate levels was observed late in the course of the experimental pancreatitis, it could be usefully evaluated in experimental and clinical studies. INTRODUCTION: Postoperative (postop) adhesions are a formidable source of morbidity, and previous studies in our laboratory have shown that peritoneal inflammation and reduced peritoneal fibrinolysis contribute to adhesiogenesis. Histone deacetylase inhibitors (HDACIs) including valproic acid (VPA), suberoylanilide hydroxamic acid (SAHA), and MS-275 modulate protein acetylation and gene transcription, and have anti-inflammatory and antiproliferative properties that we hypothesized could reduce postop adhesions. Su2026 IL-33 Inhibits Proliferation and Induces of Apoptosis of Pancreatic Cancer Cells Michael Nicholl*1,2, Yujiang Fang1,2, Elizabeth J. Herrick1, Kathryn M. Cook1 1. Surgery, University of Missouri, Columbia, MO; 2. Surgical Oncology, Ellis Fischel Cancer Center, Columbia, MO METHODS: 42 male rats underwent laparotomy with creation of 6 peritoneal ischemic buttons to induce adhesions. A single intraperitoneal (IP) dose of 50mg/kg VPA, 50mg/kg SAHA, or 10 mg/kg MS-275 was administered intraoperatively (intraop). Control animals received vehicle alone. To BACKGROUND: IL-33, a member of the IL-1 cytokine family, acts in both an autocrine and paracrine manner by binding its receptor, ST2. The role of IL-33 in host immune responses to infectious pathogens and allergens has been 64 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA evaluate for a critical window of opportunity for intervention, an additional 25 rats underwent ischemic button creation with either an intraop or a delayed IP dose of VPA at 1, 3, or 6 hours postop. On postop day 7, adhesions were quantified as percent of ischemic buttons with adhesions. To investigate mechanism, ischemic buttons were created in 24 rats and either VPA or saline was administered in one intraop dose. 8 untreated rats served as non-operated controls. 3 or 24 hours later, peritoneal fluid was collected and fibrinolytic activity was measured in a kinetic assay for tissue plasminogen activator, and peritoneal tissue was collected for RNA extraction and real-time PCR. and increased oxidative stress are implicated in adhesiogenesis. Peritoneal fibrinolytic activity, determined by tissue plasminogen activator (tPA) activity, is modulated by the mesothelial RAS. We hypothesized that losartan, by blocking the angiotensin II receptor (AIIR) and modulating the peritoneal RAS, could reduce adhesions. METHODS: Wistar rats (n = 50) were randomized to nonoperative controls (NonOp), operative controls (Op + Saline) or intraperitoneal (IP) administration of losartan (Op + Losartan). Operated rats were administered either 1-ml normal saline or losartan (100mg/kg) via IP injection 6-hrs pre-operatively, intra-operatively, 6- and 12-hrs post-operatively. Adhesions were induced using our ischemic button model and scored on POD7. Additional rats were sacrificed on POD1 for peritoneal tissue analysis of 8-isoprostane (a marker of oxidative stress) by ELISA and AIIR mRNA by PCR. AIIR protein expression was studied by immunohistochemical staining. Peritoneal fluid was also collected on POD1 to measure tPA activity by kinetic assay. Additionally, an in vitro study of AIIR MAP-Kinase signaling was performed using primary rat peritoneal mesothelial cells treated with angiotensin II (AII), losartan (Los), or angiotensin II + losartan (AII+Los) and downstream phosphoERK levels were measured via Western blot. RESULTS: A single intraop dose of VPA significantly reduced adhesions by 45% relative to vehicle controls (39.4 ± 4.1% vs 71.3 ± 4.4%, p < 0.001). Similarly, single intraop doses of SAHA and MS-275 reduced postoperative adhesions by 48% (44.4 ± 8.2% vs 86.1 ± 5.1%) and by 45% (47.2 ± 5.1% vs 86.1 ± 5.1%), respectively (p < 0.001). Delayed doses of VPA at 1, 3, or 6 hours postop did not reduce adhesions (73.3 ± 4.1%, 66.7 ± 9.1%, 63.3 ± 6.2% vs 73.3 ± 4.1%). In operated animals, peritoneal fibrinolytic activity at 3 and at 24 hours postop was not significantly different between animals administered saline and VPA (6.99U/ml vs 6.75U/ ml and 2.61U/ml vs 2.08U/ml). There was no differential regulation of gene transcription for IL-6, HIF-1a, tissue factor, or PAI-1 at 3 or at 24 hours postop with administration of VPA versus saline. CONCLUSIONS: Three different HDACIs significantly reduce postop adhesions with very comparable efficacy, suggesting a similar mechanism of action. That the efficacy of VPA is limited to intraop administration only, with delayed administration of even 1 hour postop having no effect, suggests that HDACIs target very early events in adhesiogenesis that are unrelated to previously described mechanisms such as fibrinolytic activity or transcription of inflammatory regulators. These data further indicate that HDACIs reduce adhesions by a novel mechanism needing further investigation. Su2028 The Angiotensin II Receptor Blocker (ARB) Losartan Decreases Post-Operative Intraabdominal Adhesions by Modulating Renin-Angiotensin System (RAS) and Oxidative Stress Pathways CONCLUSIONS: Losartan significantly reduces intraabdominal adhesions, suggesting a novel mode-of action for this ARB. Both regulation of peritoneal fibrinolytic activity by RAS and attenuation of postoperative peritoneal oxidative stress are implicated. Melanie L. Gainsbury*, Holly K. Sheldon, Michael R. Cassidy, Daniel I. Chu, Stanley Heydrick, Somdutta Mitra, Arthur F. Stucchi, James M. Becker Surgery, Boston University Medical Center, Boston, MA INTRODUCTION: Post-operative intraabdominal adhesions are a major source of morbidity and our understanding of their formation remains incomplete. Our laboratory has previously shown that reduced peritoneal fibrinolysis 65 Sunday Poster Abstracts RESULTS: Losartan significantly decreased adhesion formation by 73.3% compared to Op+Saline (16.7 ± 4.6 vs. 62.5 ± 4.2%, p < 0.001). While surgery increased tPA activity levels by 1.7-fold compared with NonOp, Op + Losartan further increased tPA 1.4-fold compared to Op + Saline (0.56 ± 0.01 vs. 0.95 ± 0.18 vs. 2.24 ± 0.5 U/ml, p < 0.05). AIIR mRNA levels were upregulated 5.1-fold in Op + Losartan compared to Op + Saline (31.9 ± 2.0 vs. 6.3 ± 0.5 fold change of NonOp, p < 0.01). Immunohistochemical analysis also showed increased AIIR staining of peritoneal mesothelial cells in Op + Losartan compared to Op + Saline. While in vitro rat peritoneal mesothelial cells administered AII showed a 95-fold increase in phospho-ERK protein levels compared to controls, the addition of losartan (AII + Los) attenuated this response by 70% (1 vs. 95.0 ± 19.2 vs. 28.5 ± 8.2 fold change of NonOp, p < 0.05). The oxidative stress biomarker 8-isoprostane was reduced by 45% in Op + Losartan versus Op + Saline (8.4 ± 0.7 vs. 4.6 ± 0.6 ng/mg protein, p < 0.05). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Biliary 9%, or when the probability that a retained CBD stone would eventually become symptomatic was less than 60%. Similarly, if the sensitivity, specificity, or technical success of an IOC fell below 78%, 54%, or 80%, LC alone was the preferred strategy. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost effective than universal MRCP or ERCP, irrespective of presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. Su1497 MRCP Is Not a Cost Effective Strategy in Management of Common Bile Duct Stones Irene Epelboym*, Megan Winner, John D. Allendorf Surgery, New York Presbyterian, Columbia University, New York, NY BACKGROUND: Few formal cost effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches in the management of choledocholithiasis. METHODS: Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case we assumed a 10% probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal MRCP, universal ERCP, laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. CONCLUSIONS: LC with routine IOC is the preferred strategy in a cost effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios. Su1498 The Role of Intraoperative Fluorocholangiography During the Advance Laparoscopic Cholecystectomy Era Harsha Jayamanne*, Jonathan Lloyd-Evans, Ashraf M. Rasheed Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom INTRODUCTION: Intra-operative fluorocholangiography (IOF) allows real time demonstration of biliary anatomy and identification of common bile duct stones irrespective of size or site of the stones. However, routine use of IOF for detection of unsuspected choledocholithiasis ignited a debate during the open era that continued into the current laparoscopic era. Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic retrograde cholangiography pancreatography (ERCP)/ endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and re-ignited the debate in the clinical utility of pre-operative magnetic resonance cholangiography (MRCP) and laparoscopic IOF. Aims: To assess indications and utilization of IOF during laparoscopic cholecystectomy at Aneurin Bevan Health Board and to compare its clinical utility to MRCP in order to evaluate -their impact on patients management. METHODS: All the laparoscopic cholecystectomy (LC) procedures performed during the period of January 2008 to 2010 were retrieved from computerized database. We examined the indications and findings of IOF and MRCP and their impact on the treatment strategy. RESULTS: The most effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10% risk of asymptomatic choledocholithiasis was LCIOC. This was followed closely by MRCP, LC alone, and ERCP; expected values of success in each strategy did not differ in a clinically meaningful way. Varying the prevalence of asymptomatic choledocholithaisis or the probability that retained stones would eventually cause symptomatic biliary obstruction did not affect the optimal strategy. When procedure and hospitalization costs were taken into consideration, LCIOC was the most cost effective approach, followed by laparoscopic cholecystectomy. LC was preferred when the prevalence of asymptomatic choledocholithiasis fell below RESULTS: A total of 700 consecutive cases of LCs were performed. Liver enzymes were elevated in 273 of 700 (39%) patients. MRCP was carried out in 139 of 700 (20%) patients. A hundred and eighteen patients (118) had pre operative MRCP, while 21 patients had postoperative MRCP. Forty two (42) patients (6%) underwent ERCP, half of these (21/42) were performed before surgery and other half was performed after it. A total of 182 (26%) underwent IOF during LC. 66 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Choledocholithiasis was noted in 46 patients (6.6%), 70% of the 46 were detected by MRCP and 30% by IOC. MRCP reported common bile duct stones (CBDS) in 32 (27%). IOC was performed in 21 patients who had a negative MRCP revealing a stone in a single case. chemotherapy, 19 (60%) underwent only chemotherapy, while 8 (25%) received supportive care. In patients affected by ICC, Five patients (16%) received surgical treatment, 13 (41%) chemo- or radiotherapy and 14 (43%) only supportive care. Regarding the impact of treatment on survival, the median survivals in patients submitted to surgery, chemotherapy or supportive care were 45.5, 12.5, and 2.9 months respectively (p < 0.05). A hundred and three ((18.4%) of 558 patients who did not undergo MRCP had IOF and stones were seen in 13/103 patients (2.3%). Eleven patients out of the 13 went on to have a successful single-stage laparoscopic clearance. CONCLUSIONS: Recurrence after liver resection with curative intent is correlated to a poor prognosis. When feasible, aggressive treatment with radical resection of recurrence can improve the prognosis in these patients. CONCLUSIONS: MRCP is an accurate non-invasive diagnostic and triaging modality while IOF remains to be the gold standard when CBD stones are suspected. IOF document site and size of known CBD stones and detect unsuspected ones in patients, who may benefit from a single stage laparoscopic common bile duct clearance. A leaner preoperative choledocholithiasis predictability criterion is desirable to reduce the redundancy in MRCP and IOF utilization. Su1500 Experiences from the Use of Peroral CholangioPancreaticoscopy as a Routine Diagnostic Work Up Tool in a Tertiary Referral Center Lars Enochsson*1,2, Lars R. Lundell2,1, Fredrik Swahn1,2, Matthias Loehr1,2, Urban Arnelo1,2 1. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; 2. Karolinska Institutet, CLINTEC, Stockholm, Sweden Su1499 Risk Factors, Pattern of Onset and Result of Treatment of Recurrence After Liver Resection of Peri-Hilar and Intrahepatic Cholangiocarcinoma AIM: The aim of this study was to clarify the risk factors, the pattern of occurrence and the results of treatment of recurrence in patients affected by cholangiocarcinoma submitted to surgical resection for peri-hilar (PCC) and intrahepatic cholangiocarcinoma (ICC). METHODS: Between 2007 and 2010, 167 SOPOC examinations have been performed using the SpyGlass system. As we got more familair with the system there was a gradual increase in the number of examinations over the years (19 (2007); 45 (2008); 50 (2009); 53 (2010)). In all 28% of the patients were referred to us from other centers. In 145 (91.8%) of the examinations the complete system including the optical probe (SpyGlass) and the access and delivery catheter (SpyScope) was used. In the remaining 8.2% the SpyGlass was introduced through a sphincterotome catheter. METHODS: We retrospectively analyzed the clinicopathologic data of 132 patients submitted to liver resection with curative intent from January 1990 to July 2011, 71 of whom affected by PCC and 61 withICC. Thirty-two patients for both groups developed recurrence during the follow-up period (45% and 52.5%, respectively). We estimated the risk factors, the onset pattern of recurrence and the impact of treatment on survival in these patients. RESULTS: The 3- and 5-year disease-free survival was 41% and 21% for both groups (p = 0.35). Among the patients affected by PCC, 11 (34%) developed intrahepatic recurrence, 5 (15%) developed peritoneal carcinomatosis, 4 (13%) anastomotic and 4 (13%) lymph-nodal recurrence. Percutaneous transhepatic biliary drainage catheter tract recurrence occurred in 3 patients (9%). At univariate analysis, the tumor size, the macroscopical portal involvement and elevated serum level of Ca 19.9 were significantly associated with recurrence. In the intrahepatic cholangiocarcinoma group, 19 patients (59%) developed intrahepatic recurrence. Five factors were significantly associated with recurrence at univariate analysis in this group: tumor size, serum level of Ca 19.9 and CEA, multifocal disease at resection and grading. The overall 3-year survival after recurrence was 17%. The type of treatment was different between two groups. In patients with PCC, 5 (9%) patients were submitted to surgical treatment of recurrence followed by RESULTS: 167 examinations were completed in 161 patients. Among these were 56.3% males (mean age 58.4; range 21–87) and 43.7% females (mean age 61.5; range 23–89). There were 104 (62.3%) examinations of the biliary, 45 (26.9%) of the pancreatic duct system and in 18 cases (10.8%) the ampullary tract. The optical quality of the examination was considered to be good in 90.8%, fair in 6.1% and inadequate in the remaining 3.1%. The overall postoperative complication rate of the ERCP examinations with SpyGlass was 13.3%. Postoperative complications, however, differed significantly depending on which tract that was investigated since postop complication rates were 12.6% in the biliary, 20.0% in the pancreatic and 0% in the ampullary region. The diagnostic gain was in the biliary system 82.7%, in the pancreatic duct system 68.9% and 100% in the ampullary region. 67 Sunday Poster Abstracts BACKGROUND: Although there are a variety of modalities to diagnose pathology within the pancreatobiliary ductal tract the introduction of the single-operator peroral cholangio-pancreaticoscopy (SOPOC), SpyGlass Direct Visualization System has added a significant contribution to the diagnostic arsenal. At Karolinska University Hospital we have since 2007 used the system as an integrated part of the diagnostic work up programme. The aim of this paper is to describe our experiences and define its role in clinical practice. Andrea Ruzzenente*, Alessandro Valdegamberi, Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti, Calogero Iacono, Alfredo Guglielmi Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSION: The single-operator SpyGlass Direct Visualization System offers a valuable diagnostic aid with significant gains in both the biliary as well as the pancreatic duct system. The large variation in postprocedural complication rates suggests the room for preventive measures which requires further studies. significantly greater OR prep, operative, emergence and PACU time was required for patients undergoing the TVC approach. This retrospective analysis of transvaginal cholecystectomy patients suggests that there is indeed less postoperative pain measured by the reduced opioid use after transvaginal NOTES cholecystectomy. Su1501 Su1502 Transvaginal NOTES Cholecystectomy: Retrospective Analysis of Immediate Post-Operative Pain Follow-Up of Ultrasound–Detected Gallbladder Polypoid Lesions Stephanie Wood*, Nalini Vadivelu, Mikhael Hosni, Susan Dabu-Bondoc, Feng Dai, Lucian Panait, Robert Bell, Andrew Duffy, Walter Longo, Kurt E. Roberts Surgery, Yale School of Medicine, New Haven, CT Amir Kambal*, Chris Brown, Ramesh Y. Kannan, Omer Jalil, Abu Feroz, Ashraf M. Rasheed Royal Gwent Hospital, Newport, United Kingdom OBJECTIVES: Gallbladder polyps are reported in 5% of screening ultrasonography (US). The majority are benign, however some do have a malignant potential. The preoperative confirmation of the nature of these lesions is “difficult” and the optimal management remains to be ill-defined INTRODUCTION: Transvaginal cholecystectomy (TVC) is the most common Natural Orifice Transluminal Surgery (NOTES) performed in women to date yet there is a paucity of data on intraoperative and immediate post operative pain management. Previous studies have demonstrated that NOTES procedures are associated with less post-operative pain and faster recovery times. We analyzed the intraoperative and postoperative opioid use for TVC compared to traditional 4-port laparoscopic cholecystectomies (LC) during the last 2 years in our facility. AIMS: To determine the nature and assess the current clinical pathways for the ultrasound-detected gallbladder polyps (GBP) and propose a follow -up and a therapeutic strategy based on size and symptomatology METHODS: A retrospective search of the US database for “polyp” in gallbladder for the period between January 1st 2009 and Dec 31st 2010 was conducted. A database was then constructed including demographics, clinical presentation, principal symptoms, management and pathology. Histologic findings were analyzed in patients who underwent cholecystectomy. The electronic medical records were searched to check the clinical outcome, pathologic data and follow-up arrangements METHODS: We performed a retrospective analysis of the last 20 TVC to the last 20 LC patients at our facility. We compared demographics, intraoperative and postoperative opioid use and times in the operating room and in the Post Anesthesia Care Unit (PACU). The opioid use is described in the morphine equivalent (mg). We obtained data from electronically recorded anesthesia records of the perioperative period. RESULTS: There were no significant differences between the average age and BMI between the LC (41years, 30kg/ m2) vs. TVC (40years, 30kg/m2) groups (p = 0.9; p = 0.88). The average time of patient in the operating room was significantly greater for the TVC (115.3 ± 20.2 min) compared to LC (88.4 ± 21.6 min, p = 0.002). The OR preparation time (TV: 36.2 ± 8.1min vs. LC: 22.5 ± 5.1; p < 0.001), operative time (TV: 115.3 ± 21.6 min vs. LC: 82.4 ± 19.8 min; p < 0.001) and emergence time (TV: 17 min vs. LC: 10.5 min; p = 0.04) were significantly greater for the TVC compared to LC. The OR opioid use was significantly greater for the TV group (TV: 31.8 ± 10.7mg vs. LC: 25.6 ± 6.9mg; p = 0.04), however, after adjusting for OR time the difference in OR opioid between two groups becomes non-significant (p = 0.09). Interestingly, while the average (PACU) time was significantly greater for the TVC group (195.7 ± 88.9 min vs. 141.7 ± 61.6 min, p = 0.03), the average opioid use with significantly less for the TV group (0mg, range 0–2.5) compared to LC group (6.3mg, range 0–9.5), p = 0.01. The overall opioid use (OR + PACU) was not significantly different between the groups (TV: 33.6 ± 10.1mg vs. LC: 31.6 ± 7.3mg; p = 0.48). The average PACU pain Visual Analogue Pain Score was not statistically significantly different between the TVC and LC groups (p = 0.51). RESULTS: Ultrasound detected gallbladder polyps were reported in 347 patients, 214 female and 133 males with an age range between 14–93 yrs, (Median 5, IQR = 41–58). Polyps were found during the course of investigation for the possibility of gallbladder disease in 125 patients (36%). The rest were incidental finding during investigation of other illnesses. The majority of referrals for the US came from primary care (60%), the rest came from hospital physicians in (24%) and surgeons in (13%) of cases. Forty two percent of the reports made no mention of polyp actual size and 39% reported the polypoid lesion to be <10 mm without giving the actual size. The actual size was reported in only 12% of cases. Eighteen patients (5%) underwent laparoscopic cholecystectomy revealing neoplastic polyps (adenoma) in 2 cases and one case turned out to be invasive adenocarcinoma. Sixty six cases (19%) were under poorly defined surveillance and only 5 had follow up scans and more than 70% of the patients had no plans for follow up CONCLUSION: Our preliminary data confirm that the majority of the US detected “polypoid lesions” are incidental findings and are not true epithelial polyps. The majority of patients with symptomatic polyps who underwent cholecystectomy had cholelithiasis on histology. The current management strategy of asymptomatic polyps relies on its size and hence must be included in the US report which was poorly complied with in this series. Small (<10 mm) asymptomatic polyps need CONCLUSION: There was significantly less use of opioids in the PACU period for the TVC group despite no difference shown in Visual Analogue Pain scores. Additionally, 68 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1504 better characterisation by magnetic resonance imaging (MRI) and/or endoluminal ultrasound (EUS), while those >10 mm should be offered cholecystectomy. A well defined long term follow up of patients is necessary to allow better understanding of this pathological entity and a nationwide registry or large longitudinal observational study is warranted as these might represent a missed opportunity for early detection of cancer. Biliary Stone Disease (BSD) and Its Complications in Patients Under 25 Years Anibal Rondan*, Rafael A. Redondo, Mauricio Ramirez, Mariano Gimenez, Marcelo Fasano, Alberto R. Ferreres Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina INTRODUCTION: BSD is one of the most frequent disorders affecting the gastrointestinal tract; its incidence in the adult population is above 25% for females and around 10% for males. Race and ethnicity play a major role in its development, more frequent in hispanics and native descendents. In some latinamerican countries (Chile, Bolivia, Colombia) the incidence of gallbladder cancer is the highest in the world. A high incidence of these conditions and its complications has been found in the younger population. Su1503 Incidence of Cystic Duct Stones During Laparoscopic Cholecystectomy Amir Kambal*, Tomos Richards, Harsha Jayamanne, Zeyad A. Sallami, Ashraf M. Rasheed, Taha R. Lazim Royal Gwent Hospital, Newport, United Kingdom OBJECTIVE: With the advent of the Laparoscopic Cholecystectomy (LC) era, the loss of tactile element hindered the detection of cystic duct stones (CDS) during surgery. These stones are implicated in the post cholecystectomy pain syndrome, failure of the insertion of intra-oprative cholangiogram (IOC) catheter and the subsequent development of common bile duct (CBD) stones. The preoperative imaging rarely detects their presence. The aim of this analysis is to quantify the frequency of the incidental finding of CDS during LC and to emphasise the importance of the awareness of it in our routine practise. OBJECTIVE: analyze the incidence, clinical presentation and course and prognosis of BSD in patients under 25 years. METHODS AND MATERIALS: After approval of our institutional IRB a retrospective analysis of medical records of patients who underwent admission for BSD at our single institution between January 2005 and January 2011 was performed. 5377 patients were admitted for BSD and/or its complications, being 591 (10.99%) under 25 years with a median age of 20 (range 12/24). 449 (76%) were female and 9 patients were pregnant at the time of clinical onset of symptoms. Our guidelines included a minimal invasive approach for treatment of illness and complications. RESULTS: 457 (77.33%) patients were admitted for elective surgery (laparoscopic cholecystectomy with intraoperative cholangiogram and/or CBD exploration) and the previous medical history included: acute pancreatitis in 56 (12.25%), pancreatic pseudocysts in 3 (0.65%), acute cholecystitis in 12 (2.62%), common bile duct stones in 32 (7.00%). Laparoscopic cholecystectomy was completed in 433 (94.74%), intraoperative cholangiography was achieved in 397 cases (86.66%). The remaining 24 patients required conversión through a right subcostal incisión due to: Mirizzi’s síndrome (3), cholecystocolonic fistula (2), cholecystoduodenal fistula (2), CBD multiple stones, intense adhesions, intraoperative complications (bleeding, liver laceration). The other 134 (22.67%) were admitted as emergency cases. The initial diagnosis was: acute cholecystitis (75), acute colangitis (55), liver abscess (4). The treatment was the following: laparoscopic cholecystectomy 75, ERCP with papillotomy and stone removal, and percutaneous drainage. Postoperative complications were the following:surgical site infection (5%), intraabdominal collections (2%), retained CBD stones (1%). No bile duct injuries were registered. RESULTS: The study included 330 patients; 80 male and 250 females. Age ranged between 16 to 88 years (Median 50, IQR: 36,62). In 266 patients no CDS were detected. However, in 64 (19%) patients CDS were identified using the above technique; 28 (45%) having a single stone. The remaining 36 (55%) patients had more than one stone with a maximum detected number of 7 stones in the cystic duct. Preoperative imaging failed to detect CDS in the majority of cases. Of those 64 patients with CDS, 47 (75%) showed deranged liver function tests at some stage of their disease prior to surgery. In comparison, of the 266 patients with no CDS, 152 (57%) also demonstrated abnormal liver function tests. CONCLUSIONS: the spectrum of BSD, its progress and complications in the young population imposes a prompt diagnosis and surgical treatment in order to correct symptoms, prevent complications and avoid sequelae and disability. Pregnant patients poises a clinical management and challenge, mainly in the first trimester pregnancies. DISCUSSION: The results demonstrate the fact pre-operative investigations are not helpful in diagnosing cystic duct stones. Their occurrence is common. In order to detect CDS, specific intra-operative vigilance is needed. Careful upward milking of the cystic duct before applying clips is a simple, safe and effective way of detecting and extracting these stones. This study changed our practice as this procedure is now included in all our Laparoscopic Cholecystectomies. 69 Sunday Poster Abstracts METHOD: A cohort of consecutive patients undergoing LC during the period from November 2006 to May 2010 were included. Data was collected prospectively. Their liver function tests were documented in the preoperative period. The procedure entailed careful dissection of the cystic duct to the proximity of common bile duct. A clip was then placed at the gall bladder and cystic duct junction. If an IOC was required, the cystic duct was opened in the routine fashion. A partially closed endoclip was then used to milk the cystic duct towards the gallbladder; any CDS encountered were retrieved and documented. If IOC was not indicated, the cystic duct was milked prior to the application of gallbladder/cystic clip. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Colon-Rectal Su1506 Su1505 Quality of Life After Surgery for Colorectal Cancer: A Multicentric Prospective Study Loretta Di Cristofaro1, Cesare Ruffolo2, Matteo Cortinovis2, Alessandra Fasolo3, Maurizio Massa1, Rita Alfieri3, Matteo Cagol3, Luca Saadeh3, Aurelio F. Costa1, Nicolò Bassi2, Carlo Castoro3, Marco Scarpa*3 1. Department of Surgery, Montepulciano Hospital, Montepulciano, Italy; 2. II Department of Surgery (IV unit), Regional Hospital Cà Foncello, Treviso, Treviso, Italy; 3. Department of Surgery, Veneto Oncological Institute (IOV-IRCCS), Padova, Italy The Prognostic Value of Plasma TIMP-1 in Resectable Colorectal Cancer: A Prospective Validation Study Hans J. Nielsen*1, Nils BrüNner2, IB J. Christensen3 1. Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark; 2. Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Denmark; 3. Finsen Laboratory, University of Copenhagen, Copenhagen, Denmark BACKGROUND: Results from retrospective studies show that preoperative plasma TIMP-1 and CEA levels carry independent prognostic information of patients with primary CRC. The purpose of the present, prospective study was to validate the prognostic value of preoperative plasma TIMP-1 and CEA in patients with primary CRC. BACKGROUND: The aims of this multicentric prospective study were to assess the postoperative quality of life in patients who had colonic resection for colorectal cancer and to determine its positive and negative predictors. PATIENTS AND METHODS: One hundred and four patients were enrolled in this study: 68 consecutive patients who had undergone laparoscopic assisted colonic resection, and 31 patients who had open colonic resection. The patients answered to three questionnaires about their generic quality of life (EORTC QLQ-C30), their disease specific quality of life (EORTC CR29) and about their treatment satisfaction (EORTC IN-PATSAT32) at admission and one month after surgery. Non-parametric tests and forward stepwise multiple regression analysis were used for statistical analysis. METHODS: Blood samples were collected before surgery from 297 patients with stage I-IV disease. TIMP-1 and CEA levels were determined in ETDA plasma using an automated platform (ArchitectÒ, Abbott Laboratories, Chicago, USA). The Cox proportional hazards model was used with TIMP-1 and CEA on a continous scale (log base 2) adjusted for clinical covariates. The endpoints were overall survival (OS) and disease-free survival—time from operation to any event (DFS). RESULTS: Of the 297 patients 118 were females and 179 males with a median age of 70 (32–79) years. Using the TNM stage 50 had stage I, 91 stage II, 70 stage III and 86 stage IV distributed as 180 with colonic and 117 with rectal cancer. The median observation period was 6.1 (5.2–7.3) years and 162 deaths were recorded. In a multivariate analysis including age, gender, stage, localization, plasma TIMP-1 and CEA it was shown that plasma TIMP-1 had independent, significant prognostic value: HR = 2.9; 95% CI: 2.0–4.8; p < 0.0001, whereas the value of CEA was nonsignificant. Restricting the analysis to stages II and III and patients not receiving adjuvant chemotherapy plasma TIMP-1 had independent, significant prognostic value: HR = 2.9; 95% CI: 1.3–6.8; p = 0.013, whereas the value of CEA was non-significant. Analysis including those patients, who received adjuvant chemotherapy, showed that neither plasma TIMP-1 nor CEA had any prognostic value. This indicates that adjuvant chemotherapy may be efficient to patients with high plasma TIMP-1 levels. Similar analysis of patients with stages II and III and focus on DFS as the endpoint could not demonstrate significant results. RESULTS: Generic quality of life in the first post operative month as well as patients satisfaction were similar in patients who had minimally invasive colonic resection and in those who had open surgery. Body image was better in patients who had minimally invasive colonic resection (p = 0.03). In the postoperative period the role functioning decreased significantly (p = 0.04) while the emotional functioning improved (p < 0.01) compared to the preoperative assessment. Anastomotic leakage and post operative psychiatric complication (i.e. depression) were the only independent negative predictors of postoperative global quality of life (β = –0.44, p = 0.001 and ß = –30, p = 0.008, respectively). Doctors availability was the only positive predictor of postoperative global quality of life (β = 0.33, p = 0.002) CONCLUSIONS: Although patients who had minimally invasive surgery reported a better body image their global quality of life did not seem to be positively influenced by this improved surgical technique. Postoperative quality of life is affected by postoperative complication but can be improved by positive relationship with the surgeons in charge. These effects seemed help patients to accept the burden of surgery. CONCLUSION: The present results achieved in a prospective study confirm that preoperative plasma TIMP-1 has independent prognostic value. In addition, the results suggest that patients with stage II or III and high plasma TIMP-1 values have particular benefit of adjuvant chemotherapy. The results must however be confirmed in prospective studies with inclusion of sufficient numbers of patients to confirm the results. 70 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1507 Su1508 Single-Site Laparoscopic Colorectal Surgery Provides Similar Costs to Patients and Hospitals Compared to Standard Laparoscopic Surgery The Impact of a Dedicated Acute Care Surgery Clinical Care Pathway for Suspected Appendicitis on Diagnostic Imaging and Flow Through the Emergency Department Evangelos Messaris*, Arthur Berg, David B. Stewart Colon and Rectal Surgery, PennState University, Hershey, PA Chad G. Ball*, Elijah Dixon, Anthony R. Maclean, May Lynn Quan, Gilaad G. Kaplan, Francis R. Sutherland Surgery, University of Calgary, Calgary, AB, Canada BACKGROUND: Single-site laparoscopy provides an alternative minimally invasive approach to standard laparoscopy. There is currently no published data comparing costs for patients and hospitals accrued by these two techniques for colorectal surgery. We provide cost comparisons between single-site and standard laparoscopic colorectal surgeries performed at a single institution. PURPOSE: The widespread implementation of Acute Care Surgery (ACS) services dedicated to urgent surgical issues has led to significant improvements in both patient flow and care. Despite these advancements, the use of diagnostic computed tomography (CT) continues to increase across all diagnoses. Given the high incidence of appendicitis, the primary aim of this study was to evaluate the impact of implementing an ACS clinical care pathway dedicated to suspected appendicitis on the timing and use of CT, as well as on patient flow through the emergency department (ED). METHODS: An IRB approved, retrospective review of all standard (SDL) and single-site laparoscopic (SSL) colon and rectal resections performed from 2008–2011 was undertaken. Two-sided Mann-Whitney U tests and two-sided Fisher’s exact tests were used to evaluate continuous and discrete variables, respectively, comparing total hospital charges to patients, costs to the hospital and hospital payments received. Charges to patients were further subcategorized by charges accrued from the operating room, from room and board, pharmacy, radiology and emergency department visits. All monetary units were inflation adjusted to represent 2011 US dollar value. METHODS: All adults within a large urban health care system (Calgary, Alberta, Canada) who presented to any ED (3 hospitals) with a diagnosis of suspected, or actual, appendicitis were analyzed. Three distinct time periods (3 months duration each) were compared (pre-implementation, post implementation, and 12 months (follow-up) post implementation). The pathway assessment included history and physical examination, laboratory testing, and potentially CT or ultrasound). Standard statistical methodology was employed (p < 0.05 = significance). RESULTS: Among 1168 ED consultations for “appendicitis” at 3 large centers, 877 (75%) were admitted to the Acute Care Surgery service. This included 349 (pre-implementation), 392 (post-implementation), and 427 (6 month follow-up) patients. Overall, 83% of all patients underwent surgery in less than 6 hours (time between admission request and procedure). There was a significant decrease in the mean wait time from CT scan request to actual CT scan with the implementation of the pathway at all sites (197 vs. 143 minutes; p < 0.05). This improvement was sustained at all sites at the 12-month follow-up period (131 minutes; p < 0.05). The percentage of CT scans performed in less than 2 hours increased from 3% to 42% with the pathway implementation (p < 0.05). The pathway included a short course oral contrast load of 1–2 hours. No decrease in the total number of CT scans (p > 0.05) or in the pattern of ultrasonography was noted (p > 0.05). The clinical pathway also resulted in a shorter wait time from ED triage to surgical procedure (697 vs. 642 minutes; p < 0.05). CONCLUSIONS: Implementation of a clinical care pathway dedicated to suspected appendicitis (based on Alvarado score and/or imaging) can decrease the time to both CT scan and surgical intervention. CONCLUSION: Adopting a single-site laparoscopic approach for colon and rectal surgery provides for similar lengths of hospital stay and similar costs to patients and hospitals compared to standard laparoscopic surgery. Conversion from SSL to open surgery is more costly to hospitals and patients than are conversions from SDL to open surgery, which may suggest that patients at high risk for requiring conversion to laparotomy should not be offered SSL. 71 Sunday Poster Abstracts RESULTS: A total of 167 SDL and 47 SSL cases were identified. Compared to SSL, SDL surgeries were associated with longer median times in the operating room (SSL: 190 min vs. SDL: 233 min; p = 0.01) as well as longer median times for completion of surgery (SSL: 128 min vs. SDL:183 min, p = 0.009). Despite these differences, median operating room costs were similar (SSL: $6,110 vs. SDL: $6,460; p = 0.36). Median postoperative length of hospital stay was similar for SSL (3.5 days) and SDL (4 day; p = 0.87), with no significant differences with respect to patient room charges (SSL: $3,080 vs. SDL: $3,940; p = 0.59). There was no significant difference between SSL and SDL with respect to total patient charges (SSL: $33,700 vs. SDL: $32,100; p = 0.06), costs to the hospital (SSL: $12,100 vs. SDL: $12,300; p = 0.48) and actual hospital payments received (SSL: $16,100 vs. SDL: $17,200; p = 0.9). There were no significant differences between the two groups with respect to radiology, pharmacy or emergency department charges. Among laparoscopic cases requiring conversion to laparotomy, SSL and SDL had similar median operating room costs (SSL: $6,990 vs. SDL: $6,560; p = 0.32), though SSL was found to have approximately two-fold higher median overall patient charges (SSL: $76,497 vs. SDL: $41,392; p = 0.006) and costs to the hospital (SSL: $29,837 vs. SDL: $16,111; p = 0.01) compared to SDL. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1509 ference was statistically significant (interaction p-value = 0.011). Body mass index (BMI) was an important risk factor for wound infection after both laparoscopic and open IPAA (p = 0.035 and p < 0.001, respectively). Surgeon, number of surgery stages and pulmonary co-morbidities were all associated with wound infection in open but not in laparoscopic surgery (table). Interaction analysis did not reveal significant differences for these factors. Diabetes mellitus was strongly associated with increased wound infection after open (p < 0.001) but not laparoscopic IPAA (p = 0.26). Interaction analysis suggested the presence of a difference between laparoscopic and open IPAA for this risk factor, although not statistically significant (interaction p = 0.1). For functional outcomes, no differences were seen in risk factors for pouch failure between laparoscopic and open IPAA for both bowel frequency and incontinence after 3 years of follow-up. Laparoscopic or Open Ileal Pouch-Anal Anastomosis (IPAA): Which Approach to Use and When? Usama Ahmed Ali*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran Cleveland Clinic Foundation, Cleveland, OH PURPOSE: To determine whether different factors determine poor pouch-related outcomes after IPAA by the laparoscopic and open approaches. METHODS: Cohort study based on a prospectively collected database of IPAA patients operated from 1998–2010. Primary study outcomes were pouch failure and pelvic sepsis. Secondary outcomes were wound infection, small bowel obstruction and functional outcomes (bowel frequency and incontinence). Regression analysis evaluating the interaction of potential risk factors with operative technique (open vs. laparoscopic) was performed to identify differences in risk factors between the 2 techniques. CONCLUSION: Although risk factors for poor outcome after laparoscopic and open IPAA are largely similar, some differences do exist. In patients with a higher ASA grade, the laparoscopic approach is associated with a greater risk of pelvic sepsis after IPAA. However, patients with high risk of wound infection, e.g. diabetes, benefit from the laparoscopic approach since this may decrease the influence of predisposing risk factors. This novel analysis elaborating specific benefits of the two procedures will likely additionally help guide clinicians and patients decide upon the best approach when discussing the operative strategy prior to IPAA. RESULTS: Of 1962 patients, 224 (11.4%) underwent laparoscopic and 1738 (88.6%) open IPAA. Laparoscopic patients were younger (36 vs. 40 years, p = 0.014), had lower BMI (25.3 vs. 26.3 kg/m2, p = 0.004) with fewer ASA III patients (9.1% vs. 19.1%, p = 0.003). Pouch failure was observed in 61 (3.1%) patients (laparoscopic: 2.7%, open: 3.2%, p = 0.9). On multivariate analysis, no differences were seen in risk factors for pouch failure between laparoscopic and open IPAA. Increased ASA-classification was associated with a higher rate of pelvic sepsis after laparoscopic (p = 0.017), but not open IPAA (p = 0.51), this dif- Comparison of Risk Factors Between Laparoscopic and Open IPAA Pelvic Sepsis Wound Infection Association with Lap (p-value) Association with Open (p-value) Interaction P-Value* Age at Surgery 0.103 0.294 0.25 BMI 0.863 0.967 0.88 Diagnosis 0.765 0.0603 0.36 Duration of disease 0.838 0.500 0.65 ASA classification 0.0166 0.506 0.011 Surgeon 0.784 0.130 0.36 Association with Lap (p-value) Association with Open (p-Value) Interaction P-Value* 0.630 0.0423 0.81 0.0350 0.00098 0.19 0.166 0.419 0.25 0.178 0.498 0.29 0.952 0.287 0.72 0.300 0.00285 0.9 Number of Surgery Stages 0.638 0.281 0.87 0.796 0.0110 0.86 Immunosuppressive drugs 0.566 0.174 0.31 0.283 0.793 0.35 Diabetes 0.227 0.583 0.28 0.264 0.00098 0.1 Cardiac co-morbidities 0.843 0.243 0.61 0.937 0.140 0.65 Pulmonary co-morbidites 0.749 0.0225 0.27 0.887 0.0102 0.33 ASA: American Society of Anesthesiologists. BMI: body mass index. IPAA: ileal pouch anal anastomosis. Lap: laparoscopic. * Due to the conservative nature of interaction analysis, the significance level used for identifying interactions was 0.10, which is warranted to achieve a prudent balance of probabilities between type I and type II errors. 72 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1510 Su1511 Pre-Operative Colonoscopic Localization of Tumour with Tattoo: A Re-Audit of Current Practice at a District General Hospital Right Sided Diverticulitis (RSD): Highly Successful Non-Operative Management and Low Recurrence Rate Juan E. Arminan*, George Roxin, Jennifer D. Stanger, Anthony R. Maclean, William D. Buie General Surgery, University of Calgary, Calgary, AB, Canada Akshay Kansagra, Sofoklis Panteleimonitis*, Ugo Ihedioha, Alison Luther, John Isherwood, John Evans, Peter Kang General Surgery, Northampton General Hospital, Northampton, United Kingdom BACKGROUND: RSD, defined as diverticulitis involving the colon proximal to the splenic flexure, is uncommon in western countries. A low index of suspicion could affect the diagnosis and management of these patients. The purpose of this study was to examine presentation, treatment and outcome of patients admitted with RSD in a large urban area. INTRODUCTION: Preoperative localisation of tumour is an essential requirement in Laparoscopic colorectal surgery. Tattooing guidelines should be simple to follow and consistent for all lesions irrespective of the location of the tumour. METHODS: The health records of all patients admitted with diverticulitis between January 2007 and March 2010 were reviewed and the subset of patients admitted with RSD was identified. Records were reviewed looking at demographic, clinical, radiologic, treatment and outcome factors. OUR RECOMMENDATIONS WERE: To place at least two spots of tattoo distal to each lesion, and clearly document site of tattoo with respect to tumour in the endoscopy report. RESULTS: 715 patients presented with acute diverticulitis, 68 had RSD (9.5%). Median age was 45 years (range 19 to 92 yrs), 58.8% were female, median follow up 29.5 months (range 12 to 50). 60 patients (88.2%) presented with uncomplicated and 8 (11.8%) with complicated diverticulitis. METHOD: We conducted a prospective audit of endoscopic tattooing of colorectal tumours resected in our hospital from February 2010 to January 2011. It was felt that the current guidelines were too complicated, leading to higher rates of inaccurate tattooing. Thereafter new guidelines were developed and subsequent practice reaudited. 59 patients (86.7%) had a CT scan. 10 of these (14.7%) required surgery due to diagnostic uncertainty (2 incidental appendectomies, 8 segmental resections). 49 patients (83.1%) had CT diagnosis of RSD and were successfully treated non-operatively. RESULTS: 2010: 37 patients in total were identified. 14 were not tattooed. 3 patients had a tattoo which was inaccurate. 13 had accurate and well documented tattoos. 7 patients had tattoos of unknown accuracy. Of the 55 patients whose RSD was treated without segmental resection, 1 was readmitted with recurrent diverticulitis at 2 weeks and underwent elective resection. Of those patients which were tattooed and seen at surgery, 78.6% were accurate and clearly documented in 2011 compared to 56.5% in 2010 (p = 0.2124). 33 patients (60%) underwent subsequent colonoscopy at a mean of 3.5 months from admission, no alternate diagnoses found. Of those patients which were tattooed and seen at surgery, 14.2% had unknown accuracy (not clearly documented) in 2011, compared to 30.4% in 2010 (p = 0.3032). CONCLUSIONS: CT scan is accurate at diagnosing RSD. Once diagnosed, it can be successfully treated non-operatively. Risk of recurrent RSD following non operative management is very low. Of those patients which were tattooed and seen at surgery 7.14% were deemed inaccurate (tattoo in wrong place) in 2011, compared to 13.04% in 2010 (p = 0.6043). CONCLUSION: The simpler method of tattooing all tumours distally has improved the accuracy of tattooing. 73 Sunday Poster Abstracts 9 patients (13.2%) had surgery without imaging for presumed appendicitis (4 incidental appendectomies, 5 segmental resections). Post-operative morbidity was only 2.8%. 2011: 24 patients in total were identified. 6 patients were not tattooed. 4 patients had no tattoos visible at operation. 1 patient had a tattoo which was inaccurate. 11 patients had accurate and well documented tattoos. 2 patients had tattoos of unknown accuracy. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1512 CONCLUSION: At a high-volume specialized colorectal unit, proctectomy can be performed with similar longterm oncologic outcomes and ability to restore intestinal continuity in obese patients when compared with the nonobese. The increased technical complexity expected in obese patients likely explains the associated increased use of NCRT and occurrence of anastomotic leak in obese when compared with non-obese patients. Impact of Obesity on Operation Performed, Complications and Long Term Outcomes in Terms of Restoration of Intestinal Continuity for Patients with Mid and Low Rectal Cancer Erman Aytac*, Ian C. Lavery, Matthew F. Kalady, Pokala R. Kiran Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease Institute, Cleveland, OH Characteristics of the Groups PURPOSE: The impact of obesity per se on the surgical strategy i.e. sphincter sacrifice (abdominoperineal resection, APR) vs. restorative rectal resection (RRR), perioperative outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low rectal cancer. We compare these outcomes for obese and non-obese patients with mid and low rectal cancer undergoing surgery. Age Gender (male) ASA score‡ 2 Body mass index (kg/m ) METHODS: All patients undergoing curative surgery for mid or low rectal adenocarcinoma at a single institution from 1976–2011 were identified from a prospective cancer database. Obese and non-obese patients were matched 1:2 for age, gender, ASA class, location (low or mid rectum) and stage of tumor. Demographics, use of neoadjuvant chemoradiothrapy (NCRT) and adjuvant therapy, operative and perioperative outcomes, pathology, longterm outcomes including oncologic outcomes and whether or not restoration of intestinal continuity was performed were compared. Tumor location (low/mid rectum) Obese (n = 157) P Value 62.2 ± 10.2 61.6 ± 10.7 0.62 230 115 1 3 (1–4) 3 (1–4) 1 24.9 ± 3.6 35.7 ± 4.6 <.0001 120/194 60/97 1 Neoadjuvant chemoradiation 121 (38.5%) 76 (48.4%) 0.048 Restorative rectal resection 241 (76.8%) 121 (77.1%) 1 Postoperative hospital stay 8.2 ± 5.7 8.6 ± 5.3 0.23 Reoperation 16 (5.1%) 9 (5.7%) 0.83 3 (1%) 2 (1.3%) 1 13 (4.1%) 12 (7.6%) 0.13 Early period postoperative mortality Readmission RESULTS: 157 obese patients and 314 non-obese patients, mean age 62 years at proctectomy were included. The groups were similar for matched characteristics. NCRT rate was higher in obese patients (p = 0.048). A similar proportion of non-obese and obese patients underwent RRR (p = 1) while postoperative hospital stay (p = 0.23) and 30-day postoperative reoperation (p = 0.83), mortality (p = 1) and readmissions (p = 0. 13) was similar. Non-obese and obese patients also had similar tumor differentiation (p = 0.92) and lymph nodes examined (p = 0.64). Anastomotic leak was greater in obese patients (p = 0.0003). End colostomy could not been reversed in 8 cases (3 obese and 5 non-obese, p = 1) after a Hartmann’s procedure which was performed as the initial curative intervention. During follow up, a loop ileostomy was created after an ileal pouch anal anastomosis, because of pouch failure and two cases (1 obese and 1 nonobese, p = 1) received a permanent stoma after secondary operations for recurrences. Cancer specific mortality (p = 0.55) and local recurrence (p = 0.56) were similar for non-obese and obese patients after similar mean follow up time of 5 years for both groups (p = 0.4). Non Obese (n = 314) Follow up (years) 5.3 ± 4.5 5 ± 4.2 0.4 Local recurrence 10 (3.2%) 3 (1.9%) 0.56 Cancer specific mortality 40 (12.7%) 25 (15.9%) 0.55 9 (2.9%) 7 (4.5%) 0.69 3 (1%) 1 (0.9%) 1 Wound infection 12 (3.8%) 12 (7.6%) 0.11 Stoma complication 1 (0.3%) 1 (0.6%) 1 Anastomotic leak* 5 (2.1%) 14 (8.9%) 0.0003 Complications Bleeding Ureteral injury ‡ median (range) *The cases, which had no anastomosis, excluded from the leak percentage calculation 74 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1513 Su1514 Stoma Reversal in Patients Who Underwent Low Anterior Resection and Diversion Stoma for Rectal Cancer Robotic Low Anterior Resection with Trans-Anal vs.Trans-Abdominal Extraction Christopher R. Oxner*, Julian Sanchez, Rebecca Nelson, Joseph Kim, Julio Garcia-Aguilar City of Hope, Duarte, CA Wong-Hoi She*, Jensen T. Poon, Wai-Lun Law, Joe K. Fan Department of Surgery, The University of Hong Kong, Hong Kong, Hong Kong BACKGROUND: Recently, there have been many studies initiated to validate robotic TME. Also, there have been a variety of minimally invasive extraction techniques for protocolectomy ranging from trans-abdominal to transvaginal. However, there has been little comparison of robotic techniques combined with completely minimally invasive approach. The goal of this study was to describe our experience with robotic TME for very low rectal adenocarcinoma and compare trans-abdominal vs. trans-anal extraction. BACKGROUND: Defunctioning ileostomy or colostomy is usually used to protect a high-risk anastomosis after low anterior resection for rectal cancer. Although the stoma is usually considered temporary, many a time, closure of the stoma is not performed because of various reasons. We aimed to review the incidence of reversal of stoma in patients after low anterior resection (LAR) with a diversion stoma. The factors associated with non stomal closure were analyzed. METHODS: Five hundred and eighty-five patients who underwent LAR and diversion stoma from January 1999 to December 2010 were reviewed from our prospective collected database. LAR was performed with either laparoscopic or open approach. Diversion stoma was performed when the anastomosis was within 5 cm from the anal verge. Contrast enema was performed to assess the integrity of the anastomosis before closure. Patients’ characteristics, disease status, operative details and adjuvant treatment were reviewed. The reasons for not closing the stoma were also studied. Demographic and Operative Comparisons Age AJCC Stage ASA 56.9 ( ± 9.1) 59.6 ( ± 12.2) 0.4468 3 (21.4%) 9 (22.5%) 0.9045 1 5 (35.7%) 11 (27.5%) 2 1 (7.1%) 4 (10%) 3 5 (35.7%) 14 (35%) 4 0 (0%) 2 (5%) 2 6 (42.9%) 21 (52.5%) 3 0.5346 8 (57.1%) 19 (47.5%) 29.7 ( ± 4.6) 27.6 ( ± 4.6) 0.1499 Conversion to Open 0 (0%) 3 (7.5%) 0.2917 Days to Regular Diet 1.5 ( ± 0.5) 2.8 ( ± 3.3) 0.1413 241.1 ( ± 146) 235.1 ( ± 179.5) 0.9117 Nodes Harvested 14.3 ( ± 4.7) 13.8 ( ± 5.6) 0.7545 Length of Stay 4.6 ( ± 2.9) 7.7 ( ± 8) 0.1678 Distance from Anal Verge 4.8 ( ± 2.2) 6.8 ( ± 2.7) 0.0196 Operative Time 351.1 ( ± 71.6) 290.9 ( ± 83.7) 0.0200 Positive Nodes 1.1 ( ± 3.7) 1.7 ( ± 3.1) 0.6046 Complications 3 (21.4%) 15 (37.5%) 0.2723 EBL Robotic Time Gender Tumor Size 75 p-Value 0 BMI CONCLUSIONS: The temporary stoma after low anterior resection may become permanent in some patients. Over half of the patients who did not undergo closure of stoma were due to reasons other than anastomotic complications. Preoperative radiation therapy is associated with a higher chance of not closing the stoma. Thus a careful assessment of the disease status and general condition of the patient before deciding the use of a diversion stoma is recommended. Abdominal Extraction 64.4 ( ± 26.6) Male 12 (85.7%) 27 (67.5%) Female 2 (14.3%) 13 (32.5%) 1.7 ( ± 2.3) 2.6 ( ± 1.4) 0.1089 Sunday Poster Abstracts RESULTS: Closure of stoma after initial LAR was performed in 469 patients. The median age was 67.3 months and duration between the two operations was 6.1 months. The remaining patients (n = 111, 19.1%) did not undergo stoma closure. The reasons for unable underwent closure were broadly divided into two categories, anastomoticrelated (47.7%) and non-anastomotic-related (52.3%). Of those anastomotic-related, persistent leakage, fistula and stricture composed 79.2% (n = 42/53); while disease progression (n = 39/58, 67.2%) predominated in nonanastomotic related group. Pre-operative radiotherapy significantly decreased the chance of subsequent closure of stoma (26/84, 31.0%, p = 0.001). Adjuvant chemotherapy did not have any adverse effect to the closure of stoma nor post-operative complications. The result of closure of ileostomy and colostomy were similar in terms of the types and incidences of post-operative. Anal Extraction THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT METHODS: This is a single institution, retrospective review comparing patients from December 2005 till August 2011 who underwent robotic TME for rectal adenocarcinoma with coloanal anastomosis. The patients were stratified into two groups, trans-abdominal extraction or trans-anal extraction. Data were then collected on operative outcomes, complications, pathological specimen, etc. These groups were then compared using chi-square and t-test. METHODS: All patients seen in the academic practice of two colorectal surgeons were administered the EORTC-C30 questionnaire between January 2009 and October 2011. The EORTC-C30 is a disease specific questionnaire that was designed to measure QOL in cancer patients but has also been used extensively to measure QOL of patients with benign colorectal diseases. Four hundred and ninety-four surveys were returned (response rate 78%). One hundred and twenty four patients were evaluated for complaints related to HD and represented the study cohort while 61 patients who were asymptomatic as measured by the symptom scales were used as the control group (majority of these patients had presented for screening colonoscopies). The minimally important difference (MID) which is defined as the smallest difference in scores of a QOL instrument that is considered clinically significant, was estimated by calculating the Cohen’s D effect size of the mean differences. RESULTS: Fifty four patients underwent robotic TME with low anastomosis. 40 had a trans-abdominal extraction and 14 a trans-anal extraction. Patient demographics, BMI, blood loss, ileus, anastomotic leak rate, hospital stay, and days to regular diet were not significantly different. However, there was a significant difference observed in operative time and distance from the anal verge (p-value < 0.05). Operative time for trans-anal was 350 ± 71 minutes compared to 290 ± 80 minutes for trans-abdominal. The transanal group average distance from the anal verge was 4.8 cm while the average distance for the trans-abdominal group 6.8 cm for the with a p-value of 0.0196. Hospital stay differed from 4.6 ± 3 days vs. 7.7 ± 8 days for the trans-anal and trans-abdominal groups respectively but did not reach clinical significance. RESULTS: Gender, age and marital status were similar between the 2 groups. Mean difference in functional scales between patients with HD and asymptomatic patients was 16 points and corresponded to a mean Cohen’s D of 0.42 (moderate effect size) and was considered the MID. Patients with HD had significantly worse QOL on all measured functional scales compared to asymptomatic patients (Table). Common presenting complaints for HD included rectal bleeding (67%), pain (38%), change in bowel habits (21%) and discharge (10%). Among the patients with HD there were no clinically significant differences in overall QOL of patients with and without symptoms of rectal bleeding (70 vs. 70), rectal pain (65 vs. 73) and rectal discharge (59 vs. 71). However patients with change in bowel habits had clinically significant worse overall QOL compared to patients not reporting this symptom (57 vs. 73). CONCLUSIONS: The feasibility of robotic TME has already been proven while its validity although early is comparable to laparoscopic TME. Furthermore, very low tumors amenable to sphincter preservation can lend themselves to a trans-anal extraction without compromising on operative and short term outcomes. In light of these equivocal results, this technique may be a more favorable option in patients when it is more difficult to get an adequate distal margin such as patients with a narrow pelvis (men), patient subsets with larger body habitus, or very low tumors. While the feasibility of trans-anal extraction is clear, larger numbers, prospective data, and patient stratification will be required to prove if there exists patient benefit to this technique. Comparison of QOL of Patients with HD versus Asymptomatic Patients Su1516 Quality of Life of Patients Presenting with Hemmorhoidal Disease: The Importance of Using the Right Tool for the Right Question to Get the Right Answer Vriti Advani*, Margaret Boehler, Jan Rakinic, Imran Hassan Surgery, Southern Illinois University School of Medicine, Springfield, IL INTRODUCTION: Based on clinical experience hemmorhoidal disease (HD) is considered to have a significant impact on patient quality of life (QOL). However there have been only two published studies that have measured QOL in patients with HD and both were unable to detect a significant impact of HD on QOL using generic QOL instruments. We hypothesized that HD and its related symptoms have a negative impact on patient QOL and that this could be detected if the appropriate QOL instrument was used. Patients with HD Asymptomatic Patients Global Health Status/ QOL 67.9 (22.2) 87.0 (15.9) Physical Functioning 87.2 (17.4) 99.0 (4.2) Role Functioning 80.3 (28.4) 99.4 (4.3) Emotional Functioning 75.5 (23.2) 93.5 (11.3) Cognitive Functioning 84.4 (20.6) 96.8 (9.5) Social Functioning 78.8 (30.0) 94.1 (20.7) CONCLUSION: HD and its related symptoms have a negative impact on patient QOL that is measurable with the use of the appropriate QOL instruments. Monitoring resolution of symptoms during treatment of hemmorhoidal disease is essential to offset their impact on QOL. 76 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA resection by providing bowel rest. This mantra has been historically scrutinized for the potential risk of retaining a permanent stoma without reducing the need for bowel resection. Recent data demonstrate the usefulness of antiTNFα therapy in inducing and maintaining remission in Crohn’s disease, but its effect on pediatric colonic Crohn’s patients is unclear. We hypothesized anti-TNFα therapy in conjunction with temporary fecal diversion would induce remission and reduce the need for bowel resection in medically refractory pediatric colorectal Crohn’s disease, ultimately, allowing successful restoration of bowel continuity. Su1517 Impact of Opioid-Related Adverse Events (ORAE) on Length of Stay (LOS) and Hospital Costs in Patients Undergoing a Laparoscopic Colectomy Sonia Ramamoorthy* UCSD, La Jolla, CA PURPOSE: Laparoscopic colectomy results in decreased postoperative ileus, pain, and disability, and can therefore lead to a shorter length of hospital stay (LOS) and reduced costs of care. As opioids are often used in the treatment of postsurgical pain, this retrospective analysis, a subset of data from a large health economics and outcomes research project, examined the impact of opioid-related adverse events (ORAEs) on LOS and hospital costs for patients who underwent laparoscopic colectomy procedures. METHODS: Following IRB approval, records of Crohn’s disease patients who underwent fecal diversion, between July 2006 and April 2011, at our institution were reviewed. Analysis focused on the clinical course and medical therapy in the perioperative periods, and long term results. Outcomes were analyzed using Fisher’s exact test. METHODS: Over a 2-year period, 9/1/2008 through 9/30/2010, approximately 10 million annual hospital discharges were reviewed from a large national database including over 450 hospitals. Data on opioid usage, ORAEs, LOS, and hospital costs were reviewed for some of the most common surgeries in the US: open colectomy, laparoscopic colectomy, laparoscopic cholecystectomy, total abdominal hysterectomy and hip replacement, and populations were matched at a 3:1 ratio for age, gender, and APR severity of illness. Statistical analysis was performed on 181,283 matched hospital discharges after surgery, including 12,620 matched laparoscopic colectomies. RESULTS: Of the 12,620 matched laparoscopic colectomies reviewed, mean unadjusted LOS for patients who had an ORAE was 7.7 days compared to 6.2 days for patients without an ORAE (P < 0.0001). Similarly, unadjusted mean total costs for patients with an ORAE were significantly higher than for patients who did not have an ORAE ($18,322 vs $15,720, respectively; P < 0.0001). CONCLUSION: Patients who had a laparoscopic colectomy and experienced an ORAE had a longer LOS and higher total cost than similar patients who did not experience an ORAE. As the benefits of laparoscopic surgery include reduced LOS and cost, reducing the use of opioids and their consequent ORAEs would be expected to result in greater maintenance of those benefits. CONCLUSIONS: Despite therapeutic advances, particularly the advent of anti-TNFα agents, fecal diversion in pediatric patients with colorectal or perianal Crohn’s disease is ultimately associated with a low rate of restoration and maintenance of intestinal continuity. Proximal diversion does not obviate the need for colonic resection in this patient population. Counseling families regarding temporary fecal diversion in pediatric patients with Crohn’s colitis requires tempered optimism in ultimately regaining intestinal continuity. Su1518 Role of Fecal Diversion in Pediatric Colorectal Crohn’s Disease in the Era of Anti-TNF-α Therapy Artur Chernoguz*1, Richard Falcone1, Jaimie D. Nathan1, Shehzad A. Saeed2, Lee Denson2, Daniel Von Allmen1, Jason Frischer1 1. Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2. Gastroenterology, Hepatology, & Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH PURPOSE: Colonic Crohn’s disease is a therapeutic challenge in up to 80% of pediatric patients. Temporary fecal diversion aims to induce remission and avoid colonic 77 Sunday Poster Abstracts RESULTS: Eleven patients with colorectal or perianal Crohn’s disease had undergone proximal fecal diversion with either ileostomy (81.8%) or colostomy (18.2%) between July 2006 and April 2011. Average follow-up was 27.4 months (4.0–61.4 months) and average age at diversion was 15.1 years (7–21 years). A diversion procedure reduced the number of patients requiring corticosteroids from 10 (90.9%) to 7 (63.6%), but this was not statistically significant (p = 0.3). Seven patients (63.6%) required segmental colon resections and 2 (18.2%) required proctocolectomy. Restoration of continuity was performed in 8 (72.7%) patients after an average of 9.7 months (3.0–15.1 months). Four of the 5 patients (80%) treated with an antiTNFα (Tumor Necrosis Factor) agent after diversion and 4 of the 6 patients (66.7%) off anti-TNFα therapy underwent restoration of continuity (p = 1.0). However, three patients (37.5%) required re-diversion (2 in the anti-TNFα group and 1 in the non-anti-TNFα-treated patients; p = 1.0). At the conclusion of the follow-up period only 5 (45.5%) of the patients retained intestinal continuity. Complications secondary to the original ostomy occurred in 9.1% of patients and in 66.7% of the re-diverted patients. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1520 Clinical: Esophageal Surgical Approach to Perineal Dissection Does Not Influence Radial Margin After Abdominoperineal Resection Su1521 Neoadjuvant Therapy Influences Lymph Node Ratios and Overall Survival Without Decreasing Total Node Harvest Sekhar Dharmarajan*, Bashar Safar, James W. Fleshman, Matthew Mutch, ELISA H. Birnbaum, Steven R. Hunt Surgery, Washington Univ, St. Louis, MO Renato S. Luna*, James P. Dolan, Brian S. Diggs, Nathan W. Bronson, Miriam Douthit, John G. Hunter General Surgery, OHSU, Portland, OR PURPOSE: Positive radial margins and intraoperative rectal perforation adversely affect outcome after abdominoperineal resection (APR) for low rectal cancer. Use of the prone jackknife position during the perineal dissection may improve exposure and therefore oncologic outcome. Our purpose was to determine whether performing the perineal dissection of APR in prone jackknife versus lithotomy position improves radial margin clearance and reduces intraoperative rectal perforations. BACKGROUND: There has been considerable debate around the influence of neoadjuvant therapy on lymph node harvest and the prognostic value of this information following esophagectomy for esophageal adenocarcinoma. The purpose of this study was to evaluate the effects of neoadjuvant therapy in the number of lymph node harvested, lymph node ratio and survival after esophagectomy. METHODS: An IRB-approved retrospective review of 130 cases of APRs over 8 years was performed after excluding patients with no radial margin reported, non-adenocarcinoma pathology, and pelvic exenterations. Primary endpoints of radial margin and intraoperative rectal perforation were obtained from pathology reports. Data on patient demographics, preoperative staging, preoperative therapy, and intraoperative positioning was obtained. Statistical analysis was performed using t test or Fisher’s exact test with significance set at p < 0.05. METHODS: A single center retrospective analysis of 169 patients who underwent esophagectomy for esophageal adenocarcinoma was performed. Patients were divided in two groups: one group underwent neoadjuvant treatment prior to surgery (NEO) and another group underwent surgery only. (SURG). RESULTS: One hundred and three patients (61%) underwent neoadjuvant therapy (NEO) prior to resection. The mean age was 66 years (39–89), and 83 (82%) were treated with 2 or 3 field esophagectomy. Sixty six patients were treated with surgery alone (SURG). The mean age was 70 years (39–89) in this group, and 28 (44%) were treated with 2 or 3 field esophagectomy (p < 0.001). The median number of nodes harvested in the NEO group and SURG group was 14.0 and 11.5 respectively (p = 0.11). Looking soley at those undergoing 2 or 3 field esophagectomy in NEO to SURG groups, the median number of lymph nodes harvested was 16 and 15.5 respectively. In the NEO group the median number of lymph nodes harvested was 14.5 for complete responders, 16 for incomplete responders, 12 for non-responders, and 13 in those who were pathologically upstaged (p = 0.252). The in-hospital mortality was 5% in the NEO group and 3% in the SURG group (p = 0.56). The median lymph node ratio was 0 for complete responders, 0 for incomplete responders, 0.055 for non-responders and 0.125 for upstaged patients (p < 0.001). Survival was influenced by the number of positive lymph nodes harvested in both groups (p < 0.001). Survival was significantly improved by neoadjuvant therapy in stage III patients and in patients with N1 disease (p < 0.001 and p = 0.03, respectively). RESULTS: Perineal dissection was performed in prone jackknife position in 65 patients and in lithotomy position in 65 patients. There were no significant differences between these groups in terms of patient gender, age, percent receiving preoperative therapy, distance of tumor from dentate line, or preoperative stage. There was no significant difference in mean radial margin between patients whose perineal dissection was performed in the prone jackknife versus lithotomy position (0.54 cm vs. 0.56 cm, p = 0.76). The percent of positive radial margins in each group was not significantly different (17% vs. 13%, p = 0.62) and the percent of intraoperative rectal perforations in each group also did not differ (13% vs. 24%, p = 0.35). There was a trend toward decreased operative time in lithotomy (196 min vs. 222 min, p = 0.12). CONCLUSIONS: APR with perineal dissection performed in prone jackknife position is associated with longer operative times compared to lithotomy position and does not appear to confer any oncologic advantage with respect to radial margin clearance or intraoperative rectal perforation. CONCLUSION: At esophagectomy, the total number of lymph nodes harvested was not significantly influenced by neoadjuvant treatment or by the pathologic response to treatment. The number of positive lymph nodes was similar in both groups, but the lymph nodes ratio are inversely related to the response to neoadjuvant therapy. The only negative prognostic marker identified was presence of nodal disease. Neoadjuvant therapy improved survival in this group. 78 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1522 shock. A limitation is the inability to distinguish between traditional versus thoracoscopic approaches; the impact of a minimally invasive thoracic approach remains unclear. Esophagectomies Employing Thoracic Incisions Carry Increased Pulmonary Morbidity Neil H. Bhayani*1, Aditya Gupta2, Ashwin A. Kurian1, Maria A. Cassera3, Kevin M. Reavis3, Christy M. Dunst3, Lee L. Swanstrom3 1. Providence Portland Cancer Center, Portland, OR; 2. Legacy Weight Management Clinic, Portland, OR; 3. The Oregon Clinic, Portland, OR Su1523 The Status of the Lower Esophageal Sphincter at Rest and the Degree of Esophageal Acid Exposure in Patients with Gastroesophageal Reflux Disease Shahin Ayazi*1, Jeffrey A. Hagen1, Joerg Zehetner1, Kimberly S. Grant1, Michael Hermansson1, Arzu Oezcelik1, Steven R. Demeester1, John C. Lipham1, Daniel S. OH1, Michael M. Kline2, Tom R. Demeester1 1. Surgery, University of Southern California, Los Angeles, CA; 2. Medicine/Gastroenterology, University of Southern California, Los Angeles, CA INTRODUCTION: A thoracic approach is not required for all esophagectomies. Some research suggests an increased risk of pulmonary morbidity when a thoracic incision is used. We studied the impact of a thoracic incision on complications after esophagectomy through a national database. This represents the largest analysis of pulmonary morbidity after esophagectomy. METHODS: The National Surgical Quality Improvement Project (NSQIP) database was queried for non-emergent esophagectomies with reconstruction from 2005–2010. Patients with metastatic disease were excluded. Patient who underwent trans-hiatal esophagectomy (THE) were compared to those who had a thoracic incision. The THORACIC group was patients with Ivor-Lewis (thoracic & abdominal incisions) or McKeown (cervical, abdominal & thoracic incisions) techniques. The primary outcome was pulmonary morbidity; secondary outcomes were death, overall morbidity, infection, and thrombo-embolic complications. Multivariable regression models controlled for age, smoking, chronic obstructive pulmonary disease, hypertension, diabetes, American Society of Anesthesiology class 3 or higher, malignancy, and preoperative weight loss. INTRODUCTION: A manometrically normal lower esophageal sphincter (LES) is necessary to protect the esophagus from exposure to gastric juice. Manometric measurements related to the competency of the LES are resting pressure, overall length, and the length exposed to the environmental pressure of the abdomen. We hypothesized that the magnitude of the esophageal acid exposure is related to the degree of permanent deterioration of the LES. RESULTS: Of 1568 patients, 717 (46%) underwent THE and 851 (54%) were in the THORACIC group (487/31% Ivor-Lewis & 364/23% McKeown). The overall population was 80% male, with a mean age of 63 years. Patients undergoing THE were older (p = 0.02). Pre-operative co-morbidities were similar except for more diabetes (16% v. 11%, p = 0.02) in the THORACIC group. Malignancy was more common in THORACIC patients, 91% v. 87% (p = 0.01). Overall, morbidity was 46.5% and mortality was 3.1% without a difference between groups. Length of stay was 1.6 days shorter (p = 0.009) for THE patients. On multivariable analysis, the use of a thoracic incision was associated with an increase in pneumonia (47%, p = 0.007), ventilator dependence >48 hours (34%, p = 0.04), and septic shock (86%, p = 0.001). Mortality, surgical site infections, and thromboembolic events were similar. On subgroup analysis of the THORACIC group, the McKeown approach increased the odds of superficial surgical site infection by 71% (p = 0.02) but showed similar odds of septic shock compared to the Ivor-Lewis technique. RESULTS: The final study group consisted of 918 patients (58% male, median age 53 and median BMI 28.3) who met the inclusion criteria and had an abnormal 24-hour composite pH score as objective evidence for GERD. Of these 406 (44%) had grade 0, 152 (17%) grade 1, 272 (30%) grade 2 and 88 (9%) grade 3 LES. Corresponding values for the median (IQR) composite pH score were 30.9 (20.6– 46.5), 39.5 (23.1–57.8), 42.0 (27.0–75.1) and 63.2 (31.8– 90.2) respectively (p < 0.0001, Kruskal-Wallis test). Patients with a normal LES at rest had less esophageal acid exposure compared to those with one or more LES manometric abnormalities (30.9 vs. 42.2, p < 0.0001, Mann-Whitney U-test). The values for all three LES components, irrespective of the LES grade, were inversely correlated to the composite pH score: total length (r = –0.23), abdominal length (r = –0.22) and resting pressure (r = –0.28), (p < 0.0001 for all 3 analyses). The most common abnormal manometric finding was a short overall length and the least common was a hypotensive LES pressure. CONCLUSION: Esophagectomies carry an acceptable mortality rate but have significant morbidity. We show that the thoracic incision is associated with increased pneumonia, ventilator dependence, and septic shock. This septic shock is unlikely due to anastamotic leaks, given the similar among of septic shock between McKeown and Ivor-Lewis patients. When appropriate, avoiding a thoracic incision may decrease pulmonary morbidity and resulting septic 79 Sunday Poster Abstracts METHODS: The records of 2,723 patients referred to our esophageal function laboratory for the assessment of reflux symptoms between 1998–2008 were reviewed. Those with a named motility disorder or previous foregut surgery were excluded. The study population consisted of the remaining patients, who had a detailed assessment of their LES with slow motorized pull-through manometry and an abnormal 24-hour pH monitoring study off acid suppression therapy. The LES was graded on a scale of 0–3, according to the number of abnormal LES components on manometry using previously defined normal values for resting pressure (<5.1 mmHg), overall length (<2.7 cm) and abdominal length (<1.4 cm). Grade 0 indicated all components were normal; 1, only one component abnormal; 2, two components abnormal; 3, all three components abnormal. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSION: Permanent manometric abnormalities of the LES measured at rest are associated with increased esophageal acid exposure. The degree of acid exposure is related to the extent of the manometric abnormalities. Forty four percent of the GERD patients have a normal LES measured at rest despite having increased esophageal acid exposure. These patients have the lowest esophageal acid exposure and are likely to have transient manometric abnormalities of the LES during periods of activity. margins (p < 0.001) and LNR >0.1 (p < 0.001) significantly worsened prognosis. In multivariate analysis a LNR >0.1 (p < 0.001; RR 11), no response to neoT (p < 0.01; RR 1.6) and SCC (p < 0.02; RR 1.5) were independent negative prognostic factors. Compared to SCC patients with AC had higher rates of positive margins (10% vs 4%) and LNR >0.1 (43% vs 16%). CONCLUSIONS: Tumorbiological parameters (histological type, LN-ratio) influenced prognosis after resection of esophageal cancer. Response to neoadjuvant therapy independently improved the outcome and contributed to the clearly better outcome achieved in the later study period. Su1524 Response to Neoadjuvant Therapy and the Lymph Node Ratio (LNR) Are the Strongest Prognostic Factors After Esophageal Resection for Cancer Su1525 Frank Makowiec*1, Peter Baier1, Peter Bronsert2, Jens Hoeppner1, Hannes P. Neeff1, Tobias Keck1, Michael Henke3, Ulrich T. Hopt1 1. Department of Surgery, University of Freiburg, Freiburg, Germany; 2. Pathological Institute, University of Freiburg, Freiburg, Germany; 3. Department of Radiation Oncology, University of Freiburg, Freiburg, Germany Surgical and Endoscopic Treatments for Achalasia: A Single Institution Comparison of 190 Patients INTRODUCTION: The exact role of neoadjuvant therapy (neoT) including its prognostic influence in esophageal cancer is still under debate. Pooled data (metaanalysis) suggest a prognostic advantage of neoT but definitve data are lacking. We analyzed our institutional experience with resected esophageal cancer including the effect of neodjuvant therapy on long-term outcome. BACKGROUND: Controversy still remains as to whether an endoscopic or surgical approach should be primary treatment for patients with achalasia. We report our experience with endoscopic and surgical treatments in patients with achalasia over a 10-year period. Amy K. Yetasook*1, John G. Linn1, Woody Denham1,2, Joann Carbray1, Michael B. Ujiki1,2 1. Surgery, NorthShore University HealthSystem, Evanston, IL; 2. Surgery, University of Chicago, Chicago, IL METHODS: Retrospective analysis of electronic medical records was gathered from 190 patients with confirmed achalasia between January 1, 2000 and August 9, 2011. Demographics, data from motility studies, peri-operative intervention data, endoscopic intervention data, the use of a proton pump inhibitor (PPI), and presence of symptoms (dysphagia and GERD-related symptoms) throughout their course of treatment from clinical visits were collected. METHODS: We evaluated overall survival in 304 patients undergoing esophageal resection between 1988 and 2010 (patients with hospital mortality excluded). 53% had squamous cell (SCC) and 46% adenocarcinoma (AC). Indications for neoT were in general T-stage >2 and/or positively staged lymph nodes. Tumors were in the lower third in 64%. 66% of the patients underwent neoT (60% chemoradiation 36 Gy+FU+Cisplatin; 6% chemotherapy alone). The proportion of neoT increased from 16% in the first third to 78% in the last third of the study period. In pathological analysis the median number of examined nodes was 17; 43% were node positive. Survival was analyzed by the Kaplan-Meier- and Cox-models. RESULTS: In our surgical cohort, 72 patients underwent various types of procedures (surgical myotomy with or without a full or partial fundoplication), with 8 (11%) patients having more than one surgical admission for a total of 80 surgical interventions. Thirty-two percent of the surgical patients underwent prior endoscopic treatment. In our endoscopic cohort, 76 patients underwent only endoscopic treatments (balloon dilation, botulinum injection or both) with 53 (70%) patients undergoing multiple treatments for a total of 174 endoscopic interventions. The remaining 42 patients did not have an endoscopic or surgical intervention, or did not have adequate follow up. The endoscopic-only managed patients underwent a mean of 3 ( ± 2) and a median of 2 (range 1–8) interventions. There was no statistically significant difference between groups when comparing BMI, smoking status, pre-intervention mean resting lower esophageal sphincter (LES) pressures, pre-intervention mean lower esophageal sphincter (LES) relaxation pressure, or use of a PPI. Patients in the surgical cohort were significantly younger at 56.3 years versus 72.7 years (P < 0.001). Endoscopic-only managed patients had both significantly more dysphagia (42.1% versus 16.7%, P < 0.005) and GERD-related symptoms (72.6% versus 15.3%, P < 0.005) throughout and after their course of treatment as compared to the surgical group. The mean period RESULTS: The proportion of patients with AC increased from 22% (first third) to 61% (last third of the study period). After neoT 81% of the patients showed partial or total response. Patients without neoT had more frequently positive margins (13% vs 4% after neoT; p < 0.01). Postoperative nodal disease was independent on neoT (40% after neoT vs 50% without neoT) although patients in the neoT group had more frequently positive nodes in pretherapeutical staging (71% vs 39% in patients without neoT; p < 0.01). Overall 5-year survival (5y-Surv) was 36% and improved clearly during the study period (5y-Surv 14% until 1994; 35% 1994–2001; 49% since 2002; p < 0.001), parallel to an increased use of neoT. This significant improvement in survival over time was also seen in the subgroups of patients with SCC (p < 0.01) and AC (p < 0.001). 5y-Surv in patients with response (any/total) was 52%/60%, but only 19% in patients without response/without neoT (p < 0.001). In further univariate analysis positive nodes (p < 0.001), positive 80 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA between the first and second endoscopic procedures was significantly less at 2.5 ( ± 4.79) years as compared to 16.34 (± 15.9) years in between a first and second surgery for achalasia (P < 0.05). Patients in the endoscopic cohort had comparable average follow-up course of 7.26 (± 6.72) versus 7.35 (± 8.47) years compared to the surgical cohort. Thirtyday morbidity in the surgical cohort was 6.9% (5 patients) versus 1.3% (1 patient) and there were no mortalities. 14 (17.5%). Manometric evidence of functional outflow obstruction (elevated intra-bolus pressure and/or elevated 4-second integrated relaxation pressure) was present in 29/80 (36.3%) of patients. One patient met the manometric criteria for Achalasia. Manometric evidence of the sliding component of the PEH was present in 17/21 (81%) with a mean length of 4.1 ± 2.1 cm. Overall LES length was short in 14/21 (67%) patients, 19/21 (91%) had a shortened intra-abdominal segment and 2/21 (10%) were hypertensive at rest. CONCLUSION: Surgery may offer a more efficacious option for patients with achalasia than endoscopic treatment alone with less need for repeated interventions and significant relief of symptoms. CONCLUSION: Significant abnormalities of esophageal body function are present in a large percentage (56%) of patients with paraesophageal hiatal hernia. Nineteen percent have severely compromised circular muscle strength. These data suggest that HRM should be included in the preoperative evaluation of patients with PEH whenever possible. Su1526 High Resolution Motility Assessment of the Esophageal Body in Patients with Paraesophagel Hiatal Hernia Su1527 Stefan Niebisch*, Marek Polomsky, Candice L. Wilshire, Carolyn E. Jones, Virginia R. Litle, Christian G. Peyre, Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester Medical Center, Rochester, NY Efficacy and Safety of Self-Expanding Plastic Stent (SEPS) in the Management of Esophageal Disorders Yuk Law*, Daniel K. Tong, Simon Law Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong INTRODUCTION: Self-expanding plastic stent (SEPS) was introduced in recent years. Because it is easily removed endoscopically, it can be used to treat both malignant and benign disorders of the esophagus; including strictures, fistulae and perforations. The present study evaluates our experience in the use of SEPS, assessing its efficacy and safety. METHODS: A prospectively collected database of the use of SEPS from 2007 to 2011 was retrospectively reviewed. Treatment efficacy was evaluated by comparing the preand post-stenting dysphagia score in patients who had esophageal strictures. Success of sealing of fistulae and perforations was also assessed. Short-term and long-term complications were analyzed. METHODS: Eighty patients (mean age 64.5 ± 11.9 years; mean BMI 30.7 ± 5.8; 65% female), with endoscopic and/ or radiographic type III hiatal hernia, who underwent preoperative High Resolution Manometry (HRM) from December 2006 to October 2011 formed the study population. All studies were analyzed using current esophageal body motility classifications and current analysis software (ManoViewTM v2.0.1). Assessment of the lower esophageal sphincter (LES) was possible in 21 patients (26%) in which the catheter was passed through the diaphragmatic crura into the intra-abdominal cavity. All manometry parameters were referenced to normal-values previously established in our institution. RESULTS: A total of 30 stents were inserted for 23 patients (20 men and 3 women). The median age was 69 yrs (range 51–85). Indications included benign stricture (20%, n = 6), malignant stricture (20%, n = 6), tracheo-esophageal fistula (10%, n = 3), post esophagectomy anastomotic leak (16.7%, n = 5) and benign perforation (33.3%, n = 10). For patients with stricture (both benign and malignant, n = 10), the median dysphagia score improved from a pretreatment score of 3 (liquid diet) to post-treatment score of 2 (semisolid diet), p < 0.001. SEPS provided satisfactory sealing in all 3 patients who had tracheo-esophageal fistulae; none required additional intervention. Of the 5 patients with anastomotic leak, 3 were successfully managed by SEPS with sealing of leak after stenting. Closure was not achieved in the other 2, who required subsequent surgical management. In the 5 patients who had benign perforation, all had adequate sealing by SEPS and recovered. One patient required 5 stents in total because of repeated stent migration. RESULTS: Esophageal body function including wave propagation and circular muscle strength was normal in 35/80 (44%) of patients. A simultaneous/spastic contraction pattern (distal latency <4.5 sec and/or contractile front velocity >9 cm/s) was present in 14/80 (17.5%) and abnormal contraction strength (overall distal contractile integral <500 mmHg•cm•s, weak peristalsis with peristaltic defects and/or frequent failed peristalsis) in another 81 Sunday Poster Abstracts INTRODUCTION: The clinical management of patients with large type III paraesophageal hiatal hernia (PEH) in both elective and urgent circumstances has become quite common. Repair of PEH now accounts for 30–50% of fundoplications in high volume centers. Given the primary focus on hernia repair, and not gastro-esophageal reflux (GERD), the utility of esophageal motility in patients with PEH is unclear. Furthermore, the availability of esophageal motility testing, emergent presentation of patients and complex anatomy making catheter placement difficult, all limit the routine use of preoperative motility. The aim of this study was to characterize preoperative esophageal function in patients with PEH and to determine the prevalence of esophageal dysmotility which might impact surgical approach. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tracheal compression occurred in one patient under benign perforation group immediately upon SEPS deployment. The SEPS was removed and the lesion was successfully managed using another SEPS of shorter length. This was the only short-term complication identified in present study. For delayed complications, migration was most frequently observed (40%, n = 12). Other delayed complications included food bolus obstruction (10%, n = 3), erosion to surrounding structure (0%, n = 0) and tumor ingrowth (3.3%, n = 1) were infrequently seen. pathological response (pCR) to NACRT in 18 (18.9%) and 75 (64.1%) had partial response. No patient with adenocarcinoma had pCR. Overall survival in these patients who underwent Neoadjuvant chemoradiotherapy and subsequently surgery was 65.4% at 1 yr, 28.7% at 3 yr, 19.1% in 5 yrs. 11 patients are still alive at the time of analysis of our data. Out of 87 patients, 62 patients were on regular follow up. Disease free survival (DFS) in these patients was 53.2% at 1 yr, 19.4% at 3 yr, 12.9% at 5 yr (Mean 26.87months and median was 13 months).On analyzing factors affecting survival; only those patients who had complete pathological response to NACRT had statistically significant survival compared to patients who had no response or partial response to NACRT (DFS median 21 months vs. 12 months, p – 0.019). Out of 62 patients who were on regular follow up, 51 (43.6%) had documented recurrence before death with most common site of recurrence being lung CONCLUSION: SEPS is a worthy alternative to metal stent in malignant disease and has emerged as a new tool for managing anastomotic leaks and benign perforations with a high success rate. Migration remains a major concern. Su1528 Impact of Neoadjuvant Chemoradiotherapy on Survival in Carcinoma Esophagus: A Decade’s Experience CONCLSION: With NACRT we could achieve mean survival of 33 ± 5.39 months in carcinoma esophagus. 12% of patients developed complications of NACRT. Patient with complete pathological response and smaller lesions were found to have better survival by multivariate analysis Rajesh Gupta*1, Sunil D. Shenvi1, Rakesh Kapoor2, Surinder S. Rana3, Deepak K. Bhasin3 1. Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2. Radiation Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 3. Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India Su1529 Is Idiopathic Pulmonary Fibrosis Really Idiopathic?: Patterns of Reflux Analyzed by Bi-Positional HighResolution Manometry and Hypopharyngeal Multichannel Intraluminal Impedance BACKGROUND: Neoadjuvant chemoradiotherapy followed by surgery has become standard of care at most of the centres. Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA OBJECTIVE: To assess the impact of Neoadjuvant chemoradiotherapy on survival in patients with locally advanced carcinoma esophagus. MATERIALS AND METHODS: From our prospectively maintained database, we retrospectively reviewed all patients who underwent Neoadjuvant chemoradiotherapy for resectable esophageal cancer between November 1999 and December 2010. BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a diffuse fibrotic lung disease of unknown etiology. The association between IPF and gastroesophageal reflux disease (GERD) has been suggested. The objective of this study was to determine the prevalence of GERD and assess the proximity of reflux events in patients with histologically proven IPF. RESULTS: Out of total 188 patients with carcinoma esophagus, 117 patients underwent Neoadjuvant chemoradiotherapy (NACRT).104 patients had squamous cell carcinoma (SCC) and 13 patients had adenocarcinoma (ADC). 15 (12.8%) patients developed complications on CRT and 4 (3.4%) patients died as a consequence of complications. Out of all the patients who underwent NACRT, 22 patients did not undergo surgery (4 deaths on CRT, two had progression of disease, 7 patients were not willing for surgery, 9 patients were lost to follow up). Mean interval between NACRT and surgery was 44.36 days. 95 patients underwent surgery with curative intent [82 underwent Transhiatal esophagectomy, 7 underwent Tran thoracic esophagectomy, 6 underwent open assessment and closure for intrabdominal metastatic disease. On assessing final histopathology of all patients who underwent curative resection, we found complete METHODS: This is a retrospective review of prospectively collected data for patients with histologically confirmed IPF (via lung biopsy) who underwent objective esophageal physiology testing including bi-positional high-resolution manometry (HRM) and hypopharyngeal multichannel intraluminal impedance (HMII). In bi-positional HRM, 10 swallows with 5ml water each were delivered in the supine position; this was followed by 5 additional swallows in the upright position. Defective LES was defined as either LES pressure of <5.0 mmHg, total length of LES of <2.4 cm or intra-abdominal length of LES of <0.9 cm. Abnormal esophageal motility was considered present when failed swallows ≥30% and/or mean wave amplitude <30 mmHg was present. HMII used a specialized impedance catheter to measure the proximal reflux events such as laryngopharyn- 82 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA geal reflux (LPR) and full column reflux (reflux 2 cm distal to the upper esophageal sphincter). Based on the previous study of healthy subjects, abnormal proximal exposure was considered present when laryngopharyngeal reflux (≥1/day) and/or proximal esophageal reflux (≥5/day) were present. METHODS: The records of all patients who were diagnosed with esophageal perforation between 2004 and 2011 were reviewed. Patients who underwent primary surgery were compared to patients who were treated endoscopically. RESULTS: The study population consisted of 47 patients with a median age of 64 years. Cervical perforation was seen in 9 patients (19%), thoracic in 25 (53%) and abdominal in 13 (28%). The cause of perforation was iatrogenic in 29 patients (62%) and spontaneous in 17 (38%). The median time to diagnosis was 12 hours. The size of the perforation was >10 mm in all cases. Surgical therapy (primary repair or esophagectomy) was performed in 26 patients (55%); 6 cervical, 11 thoracic and 9 abdominal perforations. Definitive endoscopic therapy (stent implantation or primary closure with clips) was performed in 21 patients (45%); 3 cervical, 14 thoracic and 4 abdominal perforations. Of these 47 patients, 16 (36%) died after a median time of one month. The mortality rate was significantly higher in patients with thoracic perforation who underwent endoscopic therapy (Table). There was no significant difference between the groups regarding time to diagnosis, perforation size and cause of perforation. RESULTS: From October 2009 to June 2011, 37 patients with IPF (male 22, female 15) including 8 patients who had undergone lung transplant prior to objective esophageal testing were examined. Mean age and BMI were 62 years (range, 41–78) and 27.6 (range, 14.8–38.1), respectively. Two patients were excluded from this study due to lack of HMII. All patients except two were symptomatic; 26 had predominately pulmonary symptoms such as cough and 9 had isolated typical GERD symptoms such as heartburn and regurgitation. Abnormal proximal exposure was present in 19/35 (54%) patients. Esophageal mucosal injury such as esophagitis and Barrett’s esophagus and/or hiatal hernia was found in 28/32 (88%) patients. However, 29/35 (83%) patients had a negative DeMeester score. All patients with IPF had reflux predominately in the upright position. Bi-positional HRM increased the diagnostic yield of defective LES from 78% (supine) to 93% (upright). Sixteen patients (50%) had abnormal esophageal motility including aperistaltic esophagus (n = 9). Mortality of Patients who Underwent Surgical Therapy Compared to Patients Who Underwent Endoscopically Therapy CONCLUSION: A large number of patients with IPF have objective evidence of GERD without typical symptoms. Proximal reflux was common despite a frequently negative DeMeester score. Reflux events occurred primarily in the upright position and this was associated with a decrease in LES integrity when examined with bi-positional HRM. Endoscopic Therapy p-Value* Cervical Perforation 1/6 patients (16%) 0/3 patients (0%) 0.3 Thoracic Perforation 3/11 patients (27%) 10/14 patients (71%) 0.04 Abdominal Perforation 2/9 patients (22%) 0/4 patients (0%) 1.0 Su1530 CONCLUSION: The results of the study suggest that thoracic perforation of the esophagus can not be managed endoscopically and thus should be treated with early surgery, independently from the cause of perforation or time to diagnosis. Cervical or abdominal perforation can be treated endoscopically in a high proportion of patients. The Multidisciplinary Management of Esophageal Perforations Arzu Oezcelik*1, Andreas Paul1, Renate Reinhardt1, Mark Sandfort1, Guido Gerken2, Alexander Dechene2 1. General, Visceral and Transplantation Surgery, University of Essen, Essen, Germany; 2. Internal Medicine, Gastroenterology and Hepatology, University of Essen, Essen, Germany BACKGROUND: Perforation of the esophagus is a challenging problem and can induce devastating complications. Although there are endoscopic and surgical treatment options available, the optimal management strategy remains unclear. The aim of this study was to evaluate the treatment and outcome of patients with esophageal perforations in an academic referral centre with a multidisciplinary specialist group for esophageal diseases. 83 Sunday Poster Abstracts Surgical Therapy THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1531 Hybrid Ivor-Lewis Oesophagogastrectomy: Results of the First 100 Cases and a Novel Way of Analysing Performance Geoffrey Roberts*, Adriana Rotundo, Priyantha Siriwardana, Cheuk Bong Tang, Michael Harvey, Sritharan S. Kadirkamanathan Upper GI Surgery, MEHT, Chelmsford, United Kingdom INTRODUCTION: The surgical management of oesophago-gastric cancer in the UK has recently been centralised to high volume surgical cancer centres. Increasing attention has been paid to measuring surgical outcomes and monitoring performance. The authors demonstrate results from a UK surgical cancer centre and present a novel technique for monitoring outcomes in “real-time”. METHODS: A prospectively collected database was used to identify the first consecutive 100 oesophagectomies performed using a “hybrid” technique (laparoscopic abdominal approach, open thoracic approach) in the Unit. The cumulative sum (CUSUM) technique was applied to examine the incidence of clinically relevant anastomotic leaks and 30-day post-operative deaths. CONCLUSIONS: The early learning curve results from a UK surgical cancer centre show acceptable 30 day mortality and anastomotic leak rates. The CUSUM technique is a viable method of observing trends in anastomotic leak rates and mortality, highlighting when the rates rise above an unacceptable level which would then trigger internal audit. CUSUM analysis could be further refined with the use of a risk stratification tool, such as O-POSSUM. These tools could be implemented in a prospective fashion, allowing “real-time” assessment of periods of varying performance. Cumulative sum (CUSUM) techniques, originally developed as industrial control techniques, have the potential to provide rigorous, “real-time” monitoring of surgical outcomes. Already used in cleft surgery and burns intensive care, CUSUM compares actual to predicted outcome rates on a case-by-case basis. The technique described plots case number on the x-axis versus the actual minus predicted outcome rate on the y-axis. The graph is not allowed to pass below the y = 0 point, preventing periods of good performance maskng a period of poor performance. A period of performance “as predicted” would be represented by a horizontal line, a period of worsening performance as a rising line and vice versa. The setting of “alarm points”, i.e. the y value at which performance warrants review, means the unit can perform that review at the time of the worsened outcomes and make immediate changes. Su1532 Outcomes After Transhiatal and Transthoracic Esophagectomy for Esophageal Cancer Christopher S. Davis, Eileen Bock*, Kirstyn E. Brownson, Cynthia Weber, P. Marco Fisichella, Margo Shoup, Gerard V. Aranha Surgery, Loyola University Chicago, Health Sciences Campus, Maywood, IL RESULTS: Ninety-seven cases were completed laparoscopically, with three converted to open procedures. Mean age was 66.4 years (SD 9.2). Median length of inpatient stay was 15 days. The 30-day mortality was 5%. BACKGROUND: Controversy persists as to the preferred operative approach to esophageal cancer. Therefore, we investigated the peri-operative, short-term, and mid-term outcomes between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) at our institution. The crude anastomotic leak rate was 6%. CUSUM analysis of the incidence of leaks (Figure 1) demonstrated a peak at case 65. This however did not breach the alarm line at two leaks above the expected rate. CUSUM analysis of mortality revealed two peaks, neither of which breached the alarm line at two point five deaths above predicted. 84 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1533 METHODS: We conducted a retrospective review of 114 patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those patients who underwent THE or TTE we compared: a) clinical characteristics; b) pathologic findings; and c) outcomes. Parametric and non-parametric tests of significance were performed, and survival was determined by Kaplan-Meier analysis. Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Esophagogastric Carcinoma David Bowrey1, Achal Khanna*1, Alex M. Reece-Smith2, Anne Thomas3, Simon Parsons2 1. Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; 2. Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; 3. Oncology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom RESULTS: We identified 32 patients who underwent THE, and 82 patients who underwent TTE. Age, gender, race/ethnicity, alcohol and tobacco use, weight loss and body mass index at the time of surgery, operative risk, chemoradiation regimen, tumor stage, and pathologic findings were similar between groups. Those who underwent THE had a greater intra-operative blood loss (p = 0.003), required more intraoperative blood transfusions (p < 0.0001), spent a longer time on the ventilator (p < 0.0001) and in the intensive care unit (p = 0.002), and had a higher 30-day mortality (p = 0.023). Likewise, those who underwent THE had a greater prevalence of post-operative vocal cord dysfunction (17% vs 3%, p = 0.027) and anastomotic leak (29% vs. 1%, p < 0.0001). Compared to THE, patients undergoing TTE had a greater number of lymph nodes sampled (mean 13.0 vs 13.6, respectively) and frequency of lymph nodes positive for carcinoma (29% vs 35%, respectively). Finally, survival at 3-years was significantly less after THE than after TTE (26% vs. 53%, p = 0.035), as was overall 5-year survival (p = 0.039) (Figure 1). BACKGROUND: The association between venous thromboembolism and chemotherapy for esophagogastric cancer is well known in patients treated with palliative intent. Whether this risk extends to the neoadjuvant and perioperative setting is unclear. METHODS: Retrospective interrogation of databases of patients receiving perioperative chemotherapy for potentially curative intent at the Leicester (2006–2011) and Nottingham (2004–2011) esophagogastric cancer centres. CONCLUSIONS: Eleven percent of patients treated with potentially curative intent will develop venous thromboembolism. This adverse event can occur at any time during the patient journey. In contrast to the commonly held view, this did not translate into a poorer prognosis. CONCLUSIONS: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach. 85 Sunday Poster Abstracts RESULTS: Thromboembolic events were diagnosed in 42 of 384 patients (11%), 16 (4%) at presentation, 14 (4%) during neodjuvant chemotherapy and 12 (3%) in the postoperative period. By site these comprised catheter-related axillary vein thrombosis in 6 patients, deep venous thrombosis in 16 patients and pulmonary embolism in 16 patients. All of the pulmonary emboli were incidental findings on staging CT imaging. There was no correlation between the risk of thromboembolism and chemotherapy regimen. Seven of the 42 patients (17%) who developed thromboembolism did not proceed to surgery because of deterioration in performance status. Thromboembolic disease resulted in a non-significant increase in the interval between chemotherapy and surgery, but did not influence either length of hospital stay or survival. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1535 Su1536 Methylene Blue (MB) Test Versus Contrast Study (CS) in the Detection of Anastomotic Leak Following Oesogephactomy: A Prospective Study of 58 Patients Defining the Learning Curve for Robotic-Assisted Esophagogastrectomy Jonathan M. Hernandez*, Jill Weber, Khaldoun Almhanna, Sarah Hoffe, Ravi Shridhar, Richard Karl, Ken L. Meredith Surgery, H. Lee Moffitt Cancer Center, Tampa, FL Adriana Rotundo*, Geoffrey Roberts, Francesco Pata, Geoff Pratt, Michael Harvey, Cheuk Bong Tang, Sritharan S. Kadirkamanathan Upper GI Surgery, MEHT, Chelmsford, United Kingdom INTRODUCTION: The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the “learning curve” for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety. BACKGROUND: Anastomotic leak is a serious complication following oesophagectomy. It is associated with considerable morbidity and mortality. The aim of our study was to compare the accuracy of MB and CS (Gastrografin) in detecting anastomotic leaks after Ivor-Lewis oesophagectomy. METHODS: We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. METHODS: The study included 58 patients who underwent laparoscopic assisted Ivor-Lewis oesophagectomy from September 2009 to November 2011. All patients had intra-thoracic oesophago-gastric anastomosis, end to side using an endoscopic circular stapler (CDH © Ethicon EndoSurgery, Inc.2010). The integrity of the anastomosis was checked on day 5 using both MB and CS. 100ml of Gastrografin was used in the CS which was performed by an experienced oesophageal radiologist. 10 ml of MB diluted in 200ml of water was given orally to test the anastomosis. The CS was performed before the MB test and was reviewed by the radiologist who was blinded to the results of MB. MB test was considered positive when the dye was seen in the chest drain in less than 30 minutes. The leak was considered clinically significant if there was evidence of sepsis. Chi square test was used to assess the difference between the two investigations RESULTS: Fifty-two patients (41 (78.8%) male: 11 (22.2%) female) of mean age 66.2 ± 8.8 years underwent roboticassisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 35 (67.3%) patients. A significant reduction in operative times (p < 0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No significant reduction in the number of procedures requiring conversions to open operations was observed. Complication rates were low, and not significantly different between any 10-patient cohort, although no complications occurred in the final 10-patient cohort. However the frequency of complications decreased significantly after 28 cases: 9 (32.1%) vs 3 (12.5%) p = 0.04. There were no in hospital mortalities. RESULTS: There were 37 males and 21 females with median age of 65 (range 43–78). Anastomotic leaks was diagnosed in 6 patients (10.3%). In 4 cases the leak was considered clinically significant (7%). MB detected all 4 significant leaks. CS detected 5 leaks, 3 clinical and 2 non-clinical, but was reported as a normal study in 1 of the clinically significant leak. All patients recovered with conservative management. There was no significant difference between MB and CS in diagnosing anastomotic leaks (p = ns). CONCLUSIONS: For surgeons proficient in performing minimally invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. However this may be increased in surgeons transitioning from an open approach. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts and appear to be less then smaller previously published series. In addition, there is a decrease in frequency of complications after 28 cases. CONCLUSION: Our study shows no difference between CS and MB in detecting anastomtic leaks. MB might be a more convenient investigation and could be used in a ward setting without the need for radiology. It could well form part of the strategy of enhanced recovery after surgery (ERAS) programme following oesophageal surgery. 86 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Clinical: Hepatic Su1538 Su1537 Single Hepatocellular Carcinoma Less Than 3 cm in Cirrhotic Livers: Is Resection Better Than Ablation? Marco Massani1, Cesare Ruffolo1, Luca Bonariol1, Ezio Caratozzolo1, Marco Scarpa*2, Francesco Calia Di Pinto1, Francesco E. D’Amico1, Bruno Pauletti1, Giuseppe Battistella3, Nicolò Bassi1 1. II Department of Surgery (IV unit), Regional Hospital Cà Foncello, Treviso, Treviso, Italy; 2. Department of Surgery, Veneto Oncological Institute, Padova, Italy; 3. Statistics and Epidemiology Service, Regional Hospital “Cà Foncello”, Treviso, Italy Risk Factors for Postoperative Mortality After General Surgery in 231 Patients with Liver Cirrhosis Frank Makowiec*1, Hans-Christian Spangenberg2, Tobias Keck1, Ulrich T. Hopt1, Hannes P. Neeff1 1. Department of Surgery, University of Freiburg, Freiburg, Germany; 2. Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most frequent tumors and it is the predominant primitive liver cancer and in most cases associated with cirrhosis, regardless of the etiology. INTRODUCTION: Postoperative mortality rates after surgery in patients with liver cirrhosis are high. Risk factors for mortality may help planning therapy in those high risk patients. We, therefore, evaluated/updated potential risk factors (including Child- and MELD-scores) for perioperative mortality after more than 200 operations in patients with cirrhosis performed during the last decade. AIM: The purpose of this study was to compare the overall survival after percutaneous ablation and resection in patients with a single HCC lesion measuring less than 3 cm in diameter originating on liver cirrhosis. Patients and methods From January 1999 to December 2008 556 consecutive patients were evaluated in our center for HCC. Only patients with cirrhosis and a single nodule <3 cm were taken into consideration: 48 underwent liver resection and 51 treated with percutaneous procedures. RESULTS: The minimum follow up was 20 months. The survival rate of resected patients was significantly higher compared to the ablated patients (p = 0.0006). Child A was a protective factor for both groups (p = 0.0001) and HCV positive patients had worse outcomes (p = 0.005). Moreover, age and survival were significantly associated to resected patients (p = 0.0195). Early recurrence occurred in 3 patients after resection and in 7 after ablation. RESULTS: Overall postoperative mortality was 17%. In univariate analysis the CHILD classification (mortality: 6% Child A; 11% Child B, 45% Child C; p < 0.001), higher/ increasing MELD score (p < 0.001), higher/increasing ASA score (p < 0.001), emergency procedures (35% vs 5% elective; p < 0.001), major procedures (p < 0.02), need for transfusions (36% vs 4% in patients without transfusions; p < 0.001) and various preoperative laboratory values (anemia, thrombocytopenia, hyponatremia; all p < 0.05) were associated with increased mortality. In multivariate risk factor analyses blood transfusions (p < 0.001; RR 7), ASA score (p < 0.01), Child class (p < 0.02) and a thrombocytopenia (p < 0.02) were independent predictors for mortality. The MELD score, emergent procedures and extent of surgery showed a trend but did not significantly predict mortality in the multivariate model. CONCLUSIONS: This experience confirmed that in case of single nodule <3 cm in cirrhosis resection must be considered as the primary choice for all patients with adequate functional reserve. Nevertheless the ablative treatment can be considered a good second line option since it ensure good results in terms of survival. CONCLUSIONS: Patients requiring blood transfusions have a very high risk for mortality. Preoperative liver function and co-morbidity also predict early mortality after surgery. In our series the CHILD score was a better predictor for postoperative mortality than the MELD-score. 87 Sunday Poster Abstracts METHODS: Since 2001 231 various general surgical procedures (80% intraabdominal, 20% abdominal wall) were performed in patients with liver cirrhosis (38% emergent). Cirrhosis was classified according to Child (41% A; 38% B, 21% C) and MELD-score (median 11). Procedures were subclassified as major (laparotomy with resection) or minor (abdominal wall, ‘minor’ laparotomy, laparoscopy). Univariate and multivariate (binary logistic regression) analysis was undertaken to identify risk factors for mortality. Multivariate analysis was performed in different models to exclude collinearity due to overlapping parameters (Child, MELD, laboratory values). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1539 Clinical: Pancreas Safety and Outcomes Following Resection of Colorectal Cancer Liver Metastases in the Era of FOLFOX Su1542 Ilia Gur*1, Jesse A. Wagner1, Brett C. Sheppard4, Susan L. Orloff2, Gina M. Vaccaro3, Charles D. Lopez3, Brian S. Diggs4, Kevin G. Billingsley1 1. Surgical Oncology, OHSU, Portland, OR; 2. Abdominal Organ Transplantation, OHSU, Portland, OR; 3. Hematology, Oncology, OHSU, Portland, OR; 4. General Surgery, OHSU, Portland, OR Underuse of Surgical Therapy of Gastrointestinal Cancer in the United States Attila Dubecz*1, Norbert Solymosi2, Michael Schweigert1, Rudolf J. Stadlhuber1, Jeffrey H. Peters3, Hubert J. Stein1 1. Surgery, Klinikum Nürnberg, Nuremberg, Germany; 2. Veterinary Medicine, Szent István University, Budapest, Hungary; 3. Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY OBJECTIVE: Report the safety and outcomes following the introduction of routine periopereative multiagent chemotherapy in the multidisciplinary treatment of patients with colorectal liver metastases (CRLM). BACKGROUND: Surgery is the mainstay of curative therapy for most localized gastrointestinal (GI) malignancies. Our objective was to evaluate the utilization of surgery in non-metastatic GI cancer and identify factors predicting failure to undergo surgery. BACKGROUND: Increasingly preoperative chemotherapy is integrated into the management of patients with liver metastases. This strategy has likely expanded the number of surgical candidates but postoperative safety and survival have not been clearly defined. METHODS: Using the National Cancer Institute’s Surveillance Epidemiology and End Results-Database (1998–2008), a total of 331,911 patients (esophagus: 20,475; stomach: 18,585; small bowel: 2,647; colon: 184,675; rectum: 45,599; liver: 24,318; pancreas: 35,612) were identified with nonmetastatic cancer. The rate of surgical therapy in each type was calculated. Multivariate logistic regression was employed to identify factors predicting failure to undergo surgical therapy. Reason for no surgery and the impact of surgery on survival were also assessed. METHODS: We performed a retrospective review of all patients undergoing liver resections for metastatic colorectal cancer between 2003 and 2011 in a single academic oncology center. Demographic data, tumor characteristics, chemotherapy, details of surgical procedure, complications and survival were analyzed. RESULTS: The study population consisted of 158 patients that underwent 169 liver operations. 11 (6.9%) patients had repeat resections. Median length of follow up from a first liver resection was 22.3 months. 87 (55%) patients presented with synchronous lesions. 114 patients (72%) underwent chemotherapy prior to the liver resection (of them 68% FOLFOX, 12% FOLFIRI). Mean size of the lesions 3.97 cm (0.2 -18 cm) .Preoperative Portal Vein Embolization was utilized in 16 (10.1%) patients Overall survival was 89%, 57% and 17% at 1, 3 and 5 years respectively. Median survival was 42.8 months. Perioperative mortality (30, 60 and 90 days respectively) was 1.26%, 1.89% and 2.53%. Overall complication rate was 24% (5%–liver related) The complication rate was not significantly different if patients had preoperative chemotherapy (27% no chemotherapy, 24% with chemotherapy). Mean length of stay was 8.68 days. On univariate analysis negative predictors of survival included positive margins, >3 lesions, patient age >70 years. On a multivariate analysis only the presence of >3 lesions predicted poor survival. RESULTS: Surgical resection for locoregional cancer was surprisingly low for cancers of the liver (27%), pancreas (32%), and esophagus (56%). Cancers of the colon (91%) rectum (72%) stomach (78%) and small intestine (74%) had higher rates although as many as one quarter of patients did not undergo surgical resection. The primary reason for not undergoing surgery was classified as “not recommended” in from 1–49% of the patients again highest in pancreas (49%), liver (47%) and esophagus (26%). Men, non-white race, patients >80 yrs, or those undergoing surgical therapy later in the study period and living in areas with high poverty rates were significantly less likely to receive surgical treatment (all p < .0001). Median survival in patients who did not undergo surgical resection was significantly better than those with metastatic disease (9 vs 6, p < 0.0001) but far worse than patients who underwent surgery for locoregional disease (96 vs 9, p < 0.0001). CONCLUSIONS: When viewed from a national perspective the rates of surgical resection for locoregional GI cancer vary considerably. These data suggest that operative therapy in esophageal, liver and pancreatic cancer is particularly underutilized. CONCLUSIONS: In recent years preoperative oxaliplatinbased chemotherapy has become commonplace in the management of patients with resectable CRLM. Our results suggest that even with chemotherapy and resection only a subset of patients remain disease free after 5 years. However, even in high risk patient with multiple lesions, preoperative chemotherapy may be administered safely without increase in postoperative complications. These results support the use of perioperative chemotherapy particularly in patients with multifocal (>3 lesions) metastatic disease in the liver. 88 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1543 Su1544 Serum Lipid Levels Are Associated with the Severity of Acute Pancreatitis Intra-Abdominal Pressure in Acute Pancreatitis: Canary in Coal Mine? Result After a Rigorous Validation Protocol Jahangir Khan, Isto Nordback, Juhani Sand* Tampere University Hospital, Tampere, Finland Vimal Bhandar*, Sumit Budania, Jiten Jaipuria Surgery, VMMC & Safdarjung Hospital, New Delhi, India AIMS: Serum lipid concentrations are known to react during acute disease. In this study, we sought to measure changes in the serum lipid profile during acute pancreatitis and whether these changes were associated with the severity of the disease. INTRODUCTION: Intra-abdominal hypertension [I.A.H.] is increasingly reported in patients with severe acute pancreatitis [S.A.P.] and is associated with significantly higher mortality rates. Though a clear causal relationship could not be demonstrated, some reports show excellent outcomes in pancreatitis patients undergoing abdominal decompression suggesting that I.A.H. may be a target for early intervention. Many studies however highlight the issue of I.A.H. in patients with severe disease with absence of data in those with mild disease making it confusing to conclusively recommend whether Intra-abdominal Pressure measurement should be a routine in all patients. METHODS: We analyzed 233 patients hospitalized for acute pancreatitis between 1995–1995. All etiologies of acute pancreatitis were included, as were patients with their first acute pancreatitis or recurrencies. Serum samples were obtained during the first days after admission and further follow-up samples were obtained later during the course of the disease. In most cases (n = 203, 87%), samples were available from the first two days of hospitalization. The serum total cholesterol, HDL-cholesterol and triglyceride levels were measured enzymatically and the concentrations of serum LDL-cholesterol were calculated using the Friedewald formula. AIMS AND OBJECTIVES: The present study was undertaken to evaluate Intra-abdominal Pressure as a marker of severity in acute pancreatitis and to ascertain the relationship between I.A.H. and development of complications in patients with S.A.P. MATERIAL AND METHOD: A total of 40 patients [24 male, 16 female] fulfilling the inclusion criteria were selected in the study. Selected patients were further enrolled into two groups [Group 1: Mild Pancreatitis, n = 24 and Group 2: Severe pancreatitis, n = 16] based on the definitions given in the Atlanta Symposium. Group 2 patients were further categorized into two sub-groups depending upon the presence and absence of raised intra-abdominal pressure [Group 2a: consistently raised I.A.P. >12 mmHg and Group 2b: not satisfying above criteria, no elevations in I.A.P.]. OBSERVATIONS: Development of intra-abdominal hypertension was noted to be an early phenomenon in patients with S.A.P. The positive and negative predictive value of I.A.H. in developings S.A.P. were 100% and 75% respectively. Sensitivity of I.A.H. in identifying those with severe pancreatitis was 50% while the specificity was 100%. Patients with S.A.P. and I.A.H. also had significantly higher APACHE-2 Scores, a higher CT severity index and increased incidence of persistent SIRS, organ failure, occurrence of pleural effusions, intra-abdominal collections and overall mortality. CONCLUSIONS: Serum lipid concentrations react during acute pancreatitis. The levels of serum total cholesterol, HDL-cholesterol and LDL-cholesterol are significantly lower in patients with severe acute pancreatitis and are associated with in-hospital mortality and longer hospital stay. These changes are already present during the early stages of the disease and are similar in all etiologies of acute pancreatitis. Furthermore, the changes observed are present even later during the course of the disease. Further studies are needed to study the mechanisms of this association. 89 Sunday Poster Abstracts RESULTS: The most common etiology for acute pancreatitis was alcohol use (n = 131, 56%), followed by biliary (n = 48, 21%) and idiopathic (n = 36, 16%) pancreatitis. 64 (28%) patients had a severe pancreatitis, with 13 (6%) mortalities. Serum total cholesterol, HDL-cholesterol and LDL-cholesterol measured within 2 days of admission were significantly lower in patients with severe pancreatitis and associated with in-hospital mortalities and longer hospitalization (p < 0.05). In subgroup analysis, the findings remained statistically significant in patients with alcohol induced acute pancreatitis, though were similar with all etiologies. Furthermore, these findings were evident even later during the course of the disease. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Table 1 MEAN APACHE 2 SCORE Mean CT Severity index Maximum I.A.P. SIRS >48 hr Organ Failure Pleural Effusion Length of Hospital Stay Ascites/Fluid Collections Total Entire population 6.6 3.5 8.05 12 8 6 7.92 6 40 Patients with mild pancreatitis: GROUP 1 4.4 1.62 4.36 0 0 1 5.66 0 24 Patients with severe pancreatitis: GROUP 2 10 6.31 13.81 12 8 5 11.31 6 16 Patients with severe pancreatitis and I.A.H. GROUP 2a 13.6 8.37 19.37 8 8 5 15.12 5 8 Patients with severe pancreatitis and no I.A.H. GROUP 2B 6.4 4.25 8.25 4 0 0 7.5 1 8 Patients with A.C.S. 18 10 26.66 3 3 3 6.33 3 3 Population Table 2: Comparison of Presence of I.A.H., Presence of Pleural Effusion and A.P.A.C.H.E. 2 Score >8 [in the Initial 24 Hours] in Identifying Patients with Severe Pancreatitis Patients with Severe Pancreatitis Sensitivity Specificity Positive Predictive Value Negative Predictive Value 50% 100% 100% 75% Presence of APACHE 2 SCORE >8 68.70% 83.30% 73.33% 80% Presence of pleural effusion 31.25% 95.8% 83.33% 67.64% Presence of I.A.H. Su1545 CONCLUSIONS: Presence of I.A.H. in the setting of S.A.P. is associated with a higher incidence of complications including pancreatic necrosis, persistent SIRS, organ failure, pleural effusions, intra-abdominal collections, longer duration of hospital stay, mortality and thus intra-abdominal pressure measurement may have a definite place in being used as a predictive marker for severe disease. Reconsideration of Safety and Efficacy of Pancreaticoduodenectomy for Periampullary Cancers in Elderly Patients Aged ≥80 Years Seiji Oguro*, Kazuaki Shimada, Yoji Kishi, Satoshi Nara, Minoru Esaki, Tomoo Kosuge Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan REFERENCES: 1. De Waele JJ, Hoste E, Blot SI et al Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care 2005;9: R452–57. BACKGROUND: Given that the life expectancy is increasingly becoming longer, safety and efficacy of pancreaticoduodenectomy for periampullary cancers in elderly patients is a great clinical concern. Over the last decade many reports have described outcome of pancreaticoduodenectomy in elderly patients, but the results are still inconsistent. 2. Adish Basu. A low cost technique for measuring the intraabdominal pressure in non-industrialized countries. Ann R Coll Engl 2007;89:431–37. METHODS: From a database of all the patients with periampullary cancers undergoing pancreaticoduodenectomy between 2001 and 2009, the patients over 80 years were identified. Perioperative characteristics, postoperative complications, mortality, and a long-term survival were retrospectively compared between the patients aged 80 and older, and the patients younger than 80 years. 90 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: Among a total of 561 patients undergoing pancreaticoduodenectomy, 22 patients (3.9%) were over 80 years. The pathological diagnosis in the elderly patients consisted of as follows; pancreatic cancer (n = 8), bile duct cancer (n = 5), ampullary neoplasm (n = 5), intraductal papillary mucinous neoplasm (n = 3), and gallbladder cancer (n = 1). The elderly patients had a higher ASA score (P = 0.02) than the younger patients, but there was no significant difference in operative time (455 vs 520 minutes; P = 0.08), and blood loss (654 vs 838 ml; P = 0.38). The mortality rate was 4.5% in the elderly patients and 0.9% in the younger patients, though the difference was not statistically significant (p = 0.106). Although the incidence of postoperative pancreatic fistula and delayed gastric emptying were similar between the two groups, that of intraabdominal abscess, intraabdominal hemorrhage, pneumonia and ascites in the elderly patients (22.7%, 18.2%, 9.1% and 4.5%, respectively) were higher than in the younger patients (6.9%, 2.2%, 0.6% and 0.2%, respectively). The rate of grade IIIa or higher complication (Clavien-Dindo classification) was 27.3% in the elderly patients and 6.3% in the younger patients (P = 0.008). There was no significant difference in overall survival between the two groups. Among the elderly patients, the median survival for those with pancreatic cancer was significantly shorter than that with non-pancreatic cancer. (P = 0.003) important role in adjuvant chemotherapy for not only unresectable but also resected pancreatic carcinoma. However, the problem is that a substantial number of patients have a resistance to gemcitabine. The aim of this study was to clarify which is more useful as a predictive marker of adjuvant gemcitabine-based chemotherapy for pancreatic carcinoma after surgical resection, intratumoral human equilibrative nucleoside transporter 1 (hENT1) or ribonucleotide reductase regulatory subunit M1 (RRM1) expression. METHODS: Intratumoral hENT1 and RRM1 expression were examined by immunohistochemistry in 109 pancreatic carcinoma patients who received adjuvant gemcitabine-based chemotherapy after surgical resection from January 2002 to May 2011. Relationships between clinicopathological factors, including hENT1 and RRM1 expression, and disease free or overall survival (DFS or OS) were evaluated by univariate and multivariate analyses. This study was a retrospective analysis on retrospectively collected tissue and data. CONCLUSIONS: Pancreaticoduodenectomy in patients aged 80 and older should be indicated carefully, because of the higher incidence of the severe postoperative complications. Pancreaticoduodenectomy for pancreatic cancer in elderly patients could not provide a satisfactory outcome in terms of a long-term survival compared with that for non-pancreatic cancers. CONCLUSIONS: Both hENT1 and RRM1 expression is useful as a predictive marker of adjuvant gemcitabine-based chemotherapy for pancreatic carcinoma after surgical resection. In addition, combined analysis of the two is even more useful. Su1546 Which Is More Useful as a Predictive Marker of Adjuvant Gemcitabine-Based Chemotherapy for Pancreatic Carcinoma After Surgical Resection, Human Equilibrative Nucleoside Transporter 1 or Ribonucleotide Reductase Regulatory Subunit M1 Expression? Naoya Nakagawa*, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Naru Kondo, Hironori Kobayashi, Hiroki Ohge, Taijiro Sueda Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan BACKGROUND/OBJECTIVE: Although postoperative adjuvant chemotherapy for pancreatic carcinoma improves survival in some patients, the efficacy varies by individuals, and the results remain unsatisfying. Gemcitabine plays an 91 Sunday Poster Abstracts RESULTS: High intratumoral hENT1 and RRM1 expression was observed in 78 (72%) and 44 (40%) cases, respectively. DFS rates for all 109 patients were 59% at 1 year, 42% at 2 years, and 26% at 5 years, and OS rates were 81% at 1 year, 61% at 2 years, and 31% at 5 years, respectively. In univariate analysis, both hENT1 and RRM1 expression were significantly associated with DFS (hENT1: P = 0.004, RRM1: P = 0.011) and OS (hENT1: P = 0.001, RRM1: P = 0.040). In multivariate analysis, the both were identified as independent factors for DFS (hENT1: P = 0.001, RRM1: P = 0.009) and OS (hENT1: P = 0.001, RRM1: P = 0.019). The evaluation of the combination of the both was also identified as a powerful independent predictor for DFS (P < 0.001) and OS (P < 0.001). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1547 advanced age, complications, lack of jaundice, and IPMN. Early tumor progression was identified in seven of these patients. Four principal reasons for unutilized therapy were identified (Table). These segregated into two disparate groups—Poor Clinical Outcomes (2/3rds) and Therapy Not Elected (1/3rd), which demonstrated a marked median survival difference (6.0 mo vs. 62.6 mo respectively; p < 0.001, Graph). The Therapy Not Elected group was characterized by favorable tumor biology. The Poor Clinical Outcome group contained two-thirds of all Major complications (Clavien 3b-5) in this entire series. When scrutinized further by multivariate analysis, the only preoperative factors associated with this group were older age and COPD, and this cohort could not be discriminated by preoperative risk scoring systems. Failure to Receive Adjuvant Therapy Following Resection for Pancreatic Cancer: Patterns and Implications Russell S. Lewis*1, Jeffrey A. Drebin1, Mark P. Callery2, Douglas L. Fraker1, Tara S. Kent2, Jenna Gates1, Charles M. Vollmer1 1. Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA; 2. Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA INTRODUCTION: Although adjuvant therapy optimizes the prognosis for resected pancreatic ductal adenocarcinoma (PDAC), literature indicates that this approach is not applied in up to half of patients. This has prompted some to advocate preoperative adjuvant therapy to ensure receipt of all elements of multidisciplinary oncologic care. We sought to identify the frequency, reasons, and predictors of unutilized post-operative adjuvant therapy in a multidisciplinary, specialty setting. METHODS: A database containing PDAC resections performed at two institutions over a decade (2001–2011) was studied. Eligible patients who did not undergo adjuvant therapy were identified and categorized based on the rationale for not receiving treatment. Demographics, perioperative features, tumor characteristics, and surgical risk scores (ASA, POSSUM, Charlson, SOAR) were analyzed by univariate analysis and multivariate regression to assess factors associated with these untreated patients, focusing further on a subset that displayed poor clinical outcomes. CONCLUSIONS: This series demonstrates that the vast majority of PDAC patients can receive post-operative adjuvant therapy following surgical resection. There are various reasons for non-utilization, not all of which represent inadequate care. The ability to employ adjuvant therapy is predicated on optimal surgical outcomes. Pre-operative prediction of the minority of patients with poor outcomes that prevent adjuvant treatment, using current risk assessment models, remains elusive. RESULTS: Of 412 resected PDAC patients 336 (82%) received some form of postoperative treatment, while only 52 (including 90 d mortalities, N = 7) did not. Treated patients had median, 1- & 5-year survivals of 23.5 mo, 80% & 25%, compared to 9.4 mo, 44% & 22% in the Untreated group (p < .001). 24 patients whose treatment status is unknown exhibited equivalent survival to the treated cohort (19.3 mo, 78% & 17%; p = .296). Characteristics of the Untreated cohort by multivariate analysis were Patients Who Did Not Receive Adjuvant Therapy after Pancreatic Resection—Categorized by Reasons Frequency Survival n % Median (mo) 1 yr 3 yr <P ALIGN = \“left\”>Poor Clinical Outcome 34 65.4 6.0 24% 5% n/a <P ALIGN = \“left\”>1. Early Death (90d) 7 13.5 1.8 0% 0% 0% <P ALIGN = \“left\”>2. Diminished Functional Capacity (Complications/Early Recurrence) 27 51.9 6.9 31% 7% n/a <P ALIGN = \“left\”>Therapy Not Elected 18 34.6 62.6 82% 66% 54% <P ALIGN = \“left\”>3. Declined Against Medical Advice—Patient’s Choice 8 15.4 10.4 57% 0% 0% <P ALIGN = \“left\”>4. Deemed Unnecessary—Physician’s Choice 10 19.2 Not Reached 100% 100% 82% <P ALIGN = \“left\”>Total 52 100.0 9.4 44% 27% 22% 92 5 yr 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1548 CONCLUSION: While the presence of infected necrosis or persistent organ failure in SAP (group III) is associated with high mortality, the combination of “infected necrosis and persistent organ failure” (group IV) is uniformly fatal. Further research is necessary to confirm the findings in our study and to explore ways of optimising patients in group III to improve survival. Retrospective Audit of Management of Patients Admitted to Intensive Care Unit (ITU) with Severe Acute Pancreatitis (SAP) Omer Jalil*, Chirag Patel, Aamer F. Iqbal, Amir Kambal, Ashraf M. Rasheed Royal Gwent Hospital, Upper GI Surgery, Newport, United Kingdom Su1549 INTRODUCTION: Atlanta classification stratifies acute pancreatitis (AP) into mild and severe. Severe acute pancreatitis (SAP) is best managed in HDU or ITU setting and associated with high mortality and morbidity despite best efforts at attaining early diagnosis and timely intervention. Rare Benign Cystic Lesions of the Pancreas Mimicking Premalignant Neoplastic Cysts Nidhi Agrawal, Nishi Dedania, Sean O’Donnell, Ross Mazo, Jordan M. Winter, Eugene P. Kennedy, Charles J. Yeo, Harish Lavu* Department of Surgery, Thomas Jefferson University, Philadelphia, PA AIM: To compare management strategies and mortality of patients admitted to ITU with SAP against national standards and study the group who succumbed to their disease in detail in an attempt to define the circumstances that lead to this event and identify the most accurate prognostic indicators in this group of patients. INTRODUCTION: Given the increased use of crosssectional radiologic imaging in recent years, cystic lesions of the pancreas are now being diagnosed with greater frequency. The majority of these lesions are premalignant cystic neoplasms of the pancreas, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs). While pseudocysts account for most of the remainder, there are a number of rare, benign cystic lesions of the pancreas that can mimic neoplastic cysts. The objective of this study was to review a single institution’s experience with these benign cystic lesions of the pancreas. METHODS: Retrospective audit of management and outcome of consecutive patients admitted to ITU with SAP during the period of 2007–2010. The development of necrosis, infected necrosis (IN) or organ failure (OF) was recorded. Patients were classified into group I (No necrosis or OF), group II (sterile necrosis or transient OF), group III (IN or persistent OF) and group IV (infected necrosis and persistent OF). The four groups were compared regarding the clinical course, radiological/surgical intervention, any post-intervention complications, use of antibiotics/ antifungal and nutritional support. RESULTS: Fifty one (51) patients were admitted to ITU with SAP (APACHE II >8, modified Glasgow score >3) during the period of 2007–2010. All cases fulfilled the Atlanta criteria of SAP. Median age: 66 ± 17.5. The pancreatitis was alcohol induced in 12% and due to gallstones in 59% of patients; no cause was found in 25% of patients. Median ITU stay was 3.23 days. The overall mortality rate during the study period (3 years) was 38% (n-19) above national standard of 30%. All 7 patients in group IV died, 5 of them underwent necrosectomy and 1 had CT guided drainage of infected acute fluid collection. The table shows the total number of patients and respective mortality of SAP in all four groups. Forty one patients (80%) received antibiotics and 35 patients (69%) had nutritional support but neither of them seems to have a significant impact on survival (p = 0.6 and 0.06 respectively). Outcome (death) correlated with organ dysfunction criteria (Atlanta criteria and APACHE II score). RESULTS: Thirteen patients (1.5%) out of a total of 170 pancreatic operations performed for cystic disease were found to have non-neoplastic cystic lesions of the pancreas (9 distal pancreatectomies, 4 pylorus-preserving pancreaticoduodenectomies). Preoperative imaging revealed primary lesions in all patients, 6 of which were found incidentally. Preoperative clinical and imaging studies suggested that 11 lesions were consistent with mucinous neoplasms and 2 with pancreatic adenocarcinoma. However, postoperative pathology revealed 5 patients with ductal retention cysts, 4 squamoid cysts, 1 mucinous non-neoplastic cyst, 1 congenital ciliated foregut cyst, 1 endometrial cyst, and 1 lymphoepithelial cyst. Two patients had complications postoperatively, 1 pancreatic fistula and 1 superior mesenteric vein thrombosis, both of which resolved with conservative management. All patients remain disease free with median follow up of 2 years post resection. The Mortaltiy of SAP in the Different Groups Group Total Number Mortality % of Mortality 0% I 12 0 II 2 0 0% III 30 12 40% IV 7 7 100% 93 Sunday Poster Abstracts METHODS: We conducted a retrospective analysis of all patients who underwent surgical resection for pancreatic lesions from 2005–2011 at our institution. Out of a total of 947 pancreatic resections, we isolated those cases performed for benign cystic disease and then examined the clinicopathological data on these patients. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Table 1: Clinicopathological Data of 13 Patients with Non-neoplastic Cystic Lesions of the Pancreas Patient Age Sex Pre-op Symptoms Pre-Op Imaging EUS Results Procedure Pathology 1 78 F Abdominal Pain CT Not Performed PPPD Squamoid Cyst 2 66 M None CT, MRI Not Performed DPS w/ partial Left Hepatectomy Squamoid Cyst, Hepatocellular Carcinoma 3 80 F None CT, MRI Not Performed DPS w/ partial Right Hepatectomy Ductal Retention Cyst, Cholangiocarcinoma 4 49 F None CT Epithelial Cells DP Ductal Retention Cyst 5 56 F Pancreatitis CT No cells obtained DPS Ductal Retention Cyst 6 37 M Pancreatitis CT Epithelial Cells PPPD Squamoid Cyst 7 65 M None CT, MRI Mucin DPS Congenital Ciliated Foregut Cyst 8 32 F Abdominal Pain CT Amylase, Elevated CEA DPS Endometrial Cyst 9 72 F None CT Not Performed Laproscopic DP Squamoid Cyst 10 77 F Abdominal Pain MRI Atypical PPPD Ductal Retention Cyst 11 52 F Nausea CT Mucin PPPD Mucinous Non-neoplastic Cyst 12 46 F Pancreatitis CT Not Performed DPS Ductal Retention Cyst 13 69 M None CT, MRI Not Performed DPS Lymphoepithelial cyst PPPD, Pylorus- preserving Pancreaticoduodenectomy; DPS, Distal Pancreatectomy & Splenectomy; DP, Spleen-preserving Distal Pancreatectomy CONCLUSIONS: While pseudocysts tend to reflect inflammation and necrosis of the pancreas, there exist rare nonneoplastic cystic lesions that may not be associated with any underlying disease process. In our institutional experience, these lesions are often indistinguishable from premalignant cystic neoplasms of the pancreas preoperatively despite advances in diagnostic imaging and endoscopic ultrasound fluid analysis. Although it is possible to safely perform pancreatic resection in these patients, it is unnecessary if the patient is asymptomatic. It is important to recognize the existence of these entities to aid in avoiding surgical resection when not clinically indicated. METHODS: A retrospective chart review of 40 patients undergoing robotic distal pancreatic resections between 2006 and 2010 was performed. Data was collected for demographics, clinical presentation, perioperative course, histology, and survival. Comparisons were performed between two groups of patients undergoing robotic spleen preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (SDP). Survival analysis was performed using the Kaplan-Meier method. RESULTS: Twelve patients underwent SPDP compared to 28 SDP patients. The two groups were similar in the distribution of their clinical characteristics, including ASA class. There were no significant differences between SPDP and SDP groups in respect to the operative time (181 vs. 210 min, p = 0.09), blood loss (151 vs. 174 ml, p = 0.95) and perioperative blood transfusions (n = 1, 8% vs. n = 0, p = 0.30). The incidence of postoperative Clavien grade I and II complications (n = 4, 33% vs. n = 10, 36% p = 0.99), Clavien grade III and IV complications (n = 2, 17% vs. n = 0, p = 0.09) and clinically significant pancreatic fistulas (n = 0 vs. n = 2, 7%, p = 0.99) also did not differ between the two groups. There were no perioperative mortalities. There was no significant difference in the incidence of malignancy (n = 3, 25% vs. n = 10, 36% p = 0.71) and median length of hospital stay (4.5 vs. 5 d, p = 0.49). One and two year survival rates were also similar in both groups (1 y = 86% vs. 88%, 2 y = 86% vs. 68%, p = 0.34). Su1550 Robotic Spleen Preserving Distal Pancreatectomy Is Safe and Feasible Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2 1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ BACKGROUND: Robotic assisted minimal invasive approach has the potential to overcome the limitations of conventional laparosopic pancreatic resections. We analyzed the outcomes of robotic distal pancreatectomies performed at our institution to demonstrate the safety and feasibility of spleen preservation during distal pancreas resections. 94 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1551 CONCLUSION: Robotic spleen preserving distal pancreatectomy is a safe and feasible surgery with similar perioperative and survival outcomes when compared to distal pancreatectomy with splenic resection. Quality Measures Have Improved Survival in Pancreatic Cancer: A 21-Year Population-Based Study Danielle M. Hari*1, Connie Chiu1, Anna M. Leung1, Stacey Stern1, Anton Bilchik2,3 1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica, CA; 2. Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA; 3. Surgical Oncology, California Oncology Research Institute, Santa Monica, CA Perioperative and Survival Outcomes Spleen Preserving Distal Pancreatectomy (SPDP, n = 12) Distal Pancreatectomy with Splenectomy (SDP, n = 28) P-Value Operative time (min) 181 210 0.09 Estimated blood loss (ml) 151 174 0.95 Perioperative blood transfusion 1 0 0.30 Clavien grade I or II complications 4 (33%) 10 (36%) 0.99 Clavien grade III or IV complications 2 (17%) 0 0.09 0 2 (7%) 0.99 Clinically significant pancreatic fistula ISGPF§ grade B or C 4.5 5 0.49 1 year survival 86% 88% 0.34 2 year survival 86% 68% 0.34 § DESIGN, SETTING, PATIENTS: Data from the National Cancer Institute’s Surveillance, Epidemiology and End Results program (1988–2008) were used to identity 12,772 patients who underwent surgical resection for adenocarcinoma of the pancreas. Patients were stratified according to number of lymph nodes (LNs) examined over time. MAIN OUTCOME MEASURES: Examination of LNs over time (year stratums (YS) 1988–1993, 1994–1998, 1999–2003 and 2003–2008) and correlation with overall survival (OS). RESULTS: Patients with at least 15 LNs (n = 2867) have increased over time (by YS: 10%, 14%, 17% & 33%, p < 0.0001). While the LN positivity rate has increased so has OS (Table 1, p < 0.0001). Median OS per LN stratum (1–9, 10–14 or >15) for localized (Stage I), regional (Stage II & III) and distant (Stage IV) disease increased over time: local (32, 33 and 54 months); regional (14, 16 & 18 months) and distant (9, 11 and 12 months). CONCLUSIONS: In the largest study evaluating pancreatic resection for pancreas cancer, significant improvements in surgical quality measures have occurred over the past two decades. This may be contributing to a dramatic improvement in overall survival. ISGPF: International study group definition of postoperative pancreatic fistula. Histopathology Distal Spleen Preserving Pancreatectomy Distal Pancreatectomy with Splenectomy (SPDP, n = 12) (SDP, n = 28) Pancreatic Carcinoma 3 (25%) Neuroendocrine tumor 4 (33%) IPMN 1 (8%) 5 (18%) Other benign neoplasms 3 (25%) 6 (21%) 0 0 Chronic Pancreatitis 10 (36%) Node Positivity Rate and Overall Survival (*Only Includes Patients with ≥1 LN Examined) P-Value % with ≥15 LN Examined % Node Positive* 1-yr OS 1988–1993 1318 131 (10%) 55% 42.9% 16.4% 12.4% 1994–1998 1799 242 (14%) 56% 51.8% 19.9% 13.8% 1999–2003 4419 770 (17%) 58% 55.0% 22.0% 15.5% 2004–2008 5236 1724 (33%) 62% 68.7% 30.4% 22.0% 0.71 Year N= Stratum (YS) 12,772 4 (14%) 95 3-yr OS 5-yr OS Sunday Poster Abstracts Median length of hospital stay (days) OBJECTIVE: To evaluate whether quality measures have improved overall survival for pancreatic adenocarcinoma after surgical resection over two decades. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1552 Su1553 Indicator for Proper Management of Surgical Drains Following Pancreaticoduodenectomy Autologous Islet Cell Transplantation After Extended/ Total Pancreatectomy for Treatment of Chronic Pancreatitis: A Single Institution Experience Kenichiro Uemura*, Yoshiaki Murakami, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Hiroki Ohge, Taijiro Sueda Surgery, Hiroshima Univ, Hiroshima, Japan Avinash Agarwal*, Linda Langman, Preeti Chhabra, Bartholomew Kane, Harry Dorn-Arias, Kenneth L. Brayman University of Virginia, Charlottesville, VA BACKGROUND AND OBJECTIVES: Recent reports suggested that early removal of surgical drains following pancreaticoduodenectomy (PD) reduce the postoperative complications including postoperative pancreatic fistulas (POPFs) with decreased hospital stay and costs. However, the indicator for proper drain management still remains unclear. The aim of this study was to identify the indicators for proper drain management after PD. OBJECTIVE: To describe the safety and efficacy of autologous pancreatic islet transplants following an extended/ total pancreatectomy as a treatment for chronic pancreatitis. METHODS: Between January 2007 and October 2011, fifteen patients underwent an extended pancreatectomy for definitive treatment of chronic pancreatitis. Pancreata were surgically removed by the transplant division and sent to the islet processing facility. The islets were isolated using the Ricordi method, purified using Biocoll gradient and loaded into a sterile infusion bag containing transplant media for infusion. Three different enzymes were used for transplants since 2007. METHODS: Prospectively collected data from 200 consecutive patients who underwent PD were evaluated. (86 females and 114 males, median age 66 years; range 19–88). The pancreatic anastomosis was reconstructed with a two-layered duct-to-mucosa pancreaticogastrostomy with internal stent. POPF was assessed using the criteria of International Study Group Pancreatic Fistula (ISGPF). The surgical complications were classified according to the Clavien-Dindo (C-D) classification. Predictive clinical factors for clinically relevant POPFs (Grade B and C) were analyzed by logistic regression analysis. Management of surgical drains was also analyzed. RESULTS: Nine patients underwent total pancreatectomy with six cases of near-total pancreatectomy. Mean age was 38 years (range 15–62) with a male to female ratio of 6:9. Fourteen of fifteen patients received and tolerated autologous islet cell infusion. One patient did not receive islet infusion secondary to infectious concerns. The mean islet equivalents were 202,903 ± 100,108 Islet equivalents (IEQs) with mean IEQ/kg of 3,016 ± 1571 IEQ/kg. One year and three year actuarial patient survival was 100% and 91% (one case of bacteremia). There was low morbidity associated with pancreatectomy with autologous islet cell transplantation (no portal thrombosis, one pancreatic leak, one SMA injury). No patients required insulin prior to surgery. At mean follow up of 23 ± 18 months, six patients (43%) remain insulin independent (two patients require oral hypoglycemics). Eight patients have a mean insulin requirement of only 6 ± 5 U/day. At one month follow-up, 13 patients (93%) had detectable c-peptide (mean 1.7 ± 1.4 ng/mL). Overall, all patients reported a significant decrease in pain and narcotic requirements. RESULTS: Of 200 patients, 44 developed pancreatic fistulas; grade A in 29 patients, grade B in 12, and grade C in 3. Thus, clinically relevant POPFs were occurred in 15 (8%). Severe surgical complications (over C-D classification Grade3) were occurred in 17 (9%). By univariate analysis, drain amylase on postoperative day (POD) 2, 3, 4, 5, the color of surgical drain fluid (dark red) on POD1,3,4, WBC on POD3,4, serum C-reactive protein (CRP) on POD 3,4, and body temperature on POD3,4,5 were found to be significantly associated with clinically relevant POPFs (p < 0.05). By multivariate analysis on POD4, the color of surgical drain fluid (dark red) [p = 0.01, Odds ratio 9.8, 95%CI 1.7–58.3] and serum CRP [p = 0.03, Odds ratio 1.2, 95% CI 1.1–1.4] were found to be independent predictive factors for clinically relevant POPFs. CONCLUSIONS: Autologous islet transplantation after extensive pancreatic resection for chronic pancreatitis is a safe and successful procedure. It offers definitive treatment of their diseased pancreas without the morbidity of brittle diabetes. The financial burden of chronic pancreatitis and poor health associated with diabetes can be successfully mitigated with pancreatectomy followed by isolation and autologous transplantation of insulin producing islet clusters. Ideally, patients should be offered this therapy earlier to decrease chronic abdominal pain and preserve endogenous endocrine function. Based on the receiver operating characteristic curve analysis, serum CRP >15.6 mg/dl on POD 4 displayed the optimal sensitivity (80%) and specificity (87%). In the patients with serous fluid in surgical drain, and serum CRP levels <15.6 mg/dl on POD4 (n = 163, drains to be removed on POD5), clinically relevant POPFs were occurred in 2 (1%). 5 patients (3%) required additional percutaneous drainage. Severe surgical complications were occurred in 12 (7%). On the other hand, in the patients with the dark red fluid in surgical drain, or serum CRP levels >15.6mg/dl on POD4 (n = 37, drains to be removed on POD6 or longer), clinically relevant POPFs were occurred in 13 (35%). 5 patients (14%) required additional percutaneous drainage. Severe surgical complications were occurred in 6 (16%) including one surgical mortality. CONCLUSIONS: A combination of serum CRP levels and the color of surgical drain fluid on POD4 may be indicators for proper management of surgically placed drains following PD. 96 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1554 Su1555 National Trends in Resection of the Distal Pancreas The Association Between Survival and the Pathologic Features of Peri-Ampullary Tumors Varies Over Time Armando Rosales-Velderrain*, Steven P. Bowers, Ross F. Goldberg, Tatyan M. Clarke, Mauricia Buchanan, John Stauffer, Horacio J. Asbun General Surgery, Mayo Clinic Florida, Jacksonville, FL Jennifer K. Plichta*1, Anjali S. Godambe2, Zachary C. Fridirici3, Sherri Yong2, Margo Shoup1, Gerard V. Aranha1 1. Surgery, Loyola University, Maywood, IL; 2. Pathology, Loyola University, Maywood, IL; 3. Stritch School of Medicine, Loyola University, Maywood, IL BACKGROUND: The authors queried three national patient care databases evaluating what data is available to assess the current status and trends for distal pancreatectomy (DP). INTRODUCTION: Several pathologic features of periampullary tumors (of the pancreas, ampulla, distal common bile duct, and duodenum) have been shown to be correlated with survival following resection. We aim to evaluate the association between survival and both perineural invasion and the lymph node ratio at multiple time-points. METHODS: From the National Inpatient Sample (NIS, 2003–9), the National Surgical Quality Improvement Project (NSQIP, 2005–10), and the Surveillance Epidemiology and End Results (SEER, 2003–9) DP were identified using appropriate diagnostic and procedural ICD-9 (NIS) and CPT codes (NSQIP). Utilization of minimally invasive surgery (MIS) was defined by ICD-9 procedure code (NIS) but it could not be differentiated if done for resection or diagnosis which was followed by an open resection. We assessed trends in patient demographics, surgical approach, outcome metrics, hospital demographics and surgical volume, and oncologic outcomes. METHODS: A retrospective chart review identified 147 patients with periampullary adenocarcinoma tumors who underwent attempted curative resection (pancreaticoduodenectomy) between 1/1/2003 and 12/31/2008. The Social Security Death Index was utilized to determine current living status. Clinical and pathologic features were assessed from the medical record, and the data were analyzed using univariate and multivariate analyses. RESULTS: Of the 141 patients identified, there were 71 males and 70 females with an average age of 67 years. The median follow-up was 1.7 years (vs. 5.4 years for survivors alone), and the crude overall survival was 33% at the end of the follow-up period. Most tumors were pancreatic in origin (57% vs. 26% ampullary, 8.5% distal common bile duct, and 8.5% duodenum). The average tumor size was 2.9 cm, and an R0 resection was achieved in 70% of patients. On average, 20 lymph nodes were identified in a surgical specimen, and at least one lymph node was positive in 66% of patients. The median lymph node ratio was 18%, while 70% of tumors demonstrated perineural invasion. At 1 year follow-up, 25% of patients had expired, which increased to 60% by 3 years. Using univariate analyses, 1 year mortality was independently associated with age, tumor size, margin status, lymph node status, lymph node ratio, and perineural invasion. Multivariate analysis also revealed a significant association between 1 year mortality and the lymph node ratio (OR 1.4, p = 0.037), after adjusting for age, tumor size, and margin status. Perineural invasion and lymph node status were no longer significant in similar analyses at 1 year. However, there was a significant association between 3 year mortality and both lymph node ratio (OR 2.6, p < 0.001) and perineural invasion (OR 4.9, p < 0.001), after controlling for age, tumor size, and margin status. Notably, perineural invasion had a stronger association with overall mortality (HR 2.56, p = 0.001) than the lymph node ratio (HR 1.35, p < 0.001), after adjusting for age, tumor size, and margin status. Stepwise selection modeling of overall mortality again revealed a stronger association with perineural invasion than the lymph node ratio (HR 2.42 vs. 1.34), which also included age and tumor size. CONCLUSIONS: Each database shows unique aspects of the trends in DP, demonstrating their individual advantages and weaknesses. There appears to be an overall underutilization of laparoscopy for distal pancreatectomy across the United States despite the benefits demonstrated on multiple published series. CONCLUSIONS: Survival appears to be more closely related to lymph node ratio within the first year following surgery, while longer follow-up periods demonstrated a stronger association between survival and perineural invasion at both 3 years follow-up and in overall survival. 97 Sunday Poster Abstracts RESULTS: NIS, NSQIP and SEER identified 4242, 2681 and 1259 distal pancreatectomy resections, respectively. Mean age was 60.8 years (NIS) and 61.9 years (NSQIP). There was a female predominance, (NIS 62%, NSQIP 59%, SEER 55%). Mean BMI was 28.0 and 13% of patients had BMI >35 (NSQIP). There was no significant change of BMI or frequency of BMI >35 over the course of study. MIS was utilized in 15% of operations and splenectomy was performed in 72% (NIS). The use of MIS did not change significantly over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). The mean length of stay (LOS) was significantly longer in patients with malignancy vs. benign disease (10.1 vs. 8.4 days, p < 0.001, NIS; and 8.6 vs. 7.4 days, p < 0.001, NSQIP) and LOS was reduced in resections for malignancy where MIS was used (NIS). Mean hospital charges were $137,723.27 (NIS) and were not significantly different between MIS and open resection. The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but MIS was not more likely to be used in teaching hospitals. Mean annual hospital volume for hospitals performing resection was less than one case per year (NIS). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%), and were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased.Over the time course of the study, there was significant increase in lymph node (LN) harvest at resection for malignant disease but distribution of histologic type (ductal 30%, IMPN 21%, NET 15% and islet cell tumor 7%) was unchanged. One-year survival (mean 76.4%) was also unchanged (SEER). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1556 Su1557 Epidural Use During Pancreaticoduodenectomy Major Complication and Open Approach Are Predictors of Prolonged Hospital Stay After Pancreaticoduodenectomy Nicolas Zea*1, William C. Conway1, Garret Owen2, Darryl Schuitevoerder1, Adrianna C. Dornelles3, John S. Bolton1 1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA; 2. Anesthesia, Ochsner Clinic Foundation, New Orleans, LA; 3. Center for Health Research, Ochsner Clinic Foundation, New Orleans, LA Michael J. Ferrara*, Naru Kondo, Florencia G. Que, Michael B. Farnell, John H. Donohue, David M. Nagorney, Kaye M. Reid Lombardo, Michael L. Kendrick Mayo Clinic, Rochester, MN INTRODUCTION: While multiple studies report favorable outcomes with epidural anesthesia and analgesia (EAA) use during major abdominal surgery, there is limited data in regards to EAA use during pancreatic head resection. A recent switch from EAA to narcotic PCA with OnQ pain catheters, allowed us to critically evaluate outcomes in patients undergoing a Whipple procedure with and without an epidural catheter. BACKGROUND: Length of hospital stay is frequently reported to be reduced with laparoscopic approaches. Few studies have accounted for readmission hospital days which may obviate any perceived benefit. The aim of this study was to evaluate the impact of total laparoscopic approach and other clinicopathologic factors on length of index hospital stay, readmission rates and total hospital days after pancreaticoduodenectomy. METHODS: After obtaining IRB approval, a retrospective chart review of 100 pancreaticoduodenectomies (PD) was performed; this included our most recent 50 patients without EAA use, and the last 50 patients with EAA just before we discontinued using this device, with all cases spanning from March of 2008 to July of 2011. Peri-operative and immediate post-operative clinical outcomes were compared. METHODS: A retrospective review of clinical, pathologic and outcomes data was performed for all patients undergoing pancreaticoduodenectomy from January 2007 through December 2010 at a single institution. Initial hospital stay, readmission rates, and total hospital stay (initial hospital days plus readmission days) were compared between total laparoscopic pancreaticoduodenectomy (TLPD) and open pancreaticoduodenectomy (OPD). The relationship between the clinicopathological factors and total hospital stay was investigated using univariate and multivariate analyses. RESULTS: For obvious reasons, but not without importance, EAA patients had longer time from anesthesia start time to surgery start time (p = 0.004). The EAA group had significantly higher rates of intra-operative hypotension (p = 0.001), and revealed a trend towards a higher intra-operative blood transfusion rate (56% EAA vs. 38%, p = 0.071). No statistical significance was found between groups in terms of length of surgery, estimated blood loss, or intra-operative fluid administration. Post-operatively, EAA patients had a significant delay in diet initiation (8 days vs 5.6 days, p = 0.015), and a higher requirement of post-operative fluid administration on post-op day # 1 (3,983 ml VS. 3,088.1 ml, p = 0.001). Although the overall morbidity rate was similar between the two groups, the EAA group had higher rates of urinary tract infections (5/50 VS. 1/50), and intraabdominal abscess (5/50 VS. 0/50). 10 of 50 (20%) patients in the EAA group had premature discontinuation of epidural catheter secondary to hypotension or inadequate pain control. Length of stay was similar between the two groups (EAA- 17 days VS. PCA- 15.1 days, p > 0.05). RESULTS: A total of 527 patients were identified having undergone TLPD (n = 125) or OPD (n = 402). There were no differences in mean age, BMI or ASA Score. A malignant diagnosis was more common in patients undergoing OPD (80% vs. 68%, p = 0.004), however, there were no differences in overall or pancreas specific postoperative complication rates. Median length of hospital stay was less for the laparoscopic group (7 vs. 10 days, p < 0.001). Hospital readmission within 30 days was observed in 16% and was not different between the TLPD and OPD groups (14% vs. 17%, p = 0.4) Common diagnoses on readmission included pancreatic fistula (25%), delayed gastric emptying (21%), and abdominal collection or abscess (20%). Of patients requiring readmission, 62% had Clavien grade 3 or 4 complications diagnosed during initial hospitalization or at subsequent readmission. Median length of readmission hospital stay was 5 days for both TLPD and OPD groups. When accounting for readmission days, total hospital days were less for patients undergoing TLPD compared to OPD (8 vs.11, p < 0.001). Multivariate analysis demonstrated that Clavien Grade ≥3) complication (HR 6.9, 95% CI 4.3–11.5, P < 0.001) and open approach (HR 2.5, 95% CI 1.5–4.4, P < 0.001) were independent predictors of prolonged total hospital stay. CONCLUSIONS: In the current study, EAA during PD was associated with a delay in surgery start time, increased episodes of intra-operative hypotension, a trend toward increased intra-operative blood transfusion and a 20% device failure rate. While pain relief may be excellent with EAA, these issues must be considered when selecting a perioperative pain control strategy. CONCLUSIONS: Compared with open approaches, TLDP results in shorter hospital stay, similar readmission rates and less total hospital days. Major complication and open approach are independent predictors of prolonged total hospital stay. Limitations of this study include potential selection bias as noted by a higher incidence of malignancy in the open group. The impact of reduced hospital stay on cost and patient-specific advantages such as improvement in quality of life needs to be evaluated. 98 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1558 after R1 resection (Figure). Among patients treated with preoperative therapy, median overall survival was 26 and 15 months with negative margin width of >1 mm and ≤1 mm, respectively (p = 0.002). Width of negative margin did not significantly affect survival among patients who did not receive preoperative therapy. Defining Resection Margins in Pancreatic Cancer After Neoadjuvant Chemoradiotherapy Alan A. Thomay*, John P. Hoffman, Yun Shin Chun Fox Chase Cancer Center, Philadelphia, PA BACKGROUND: Although surgical margin status is an established prognostic factor after resection of pancreatic adenocarcinoma, there is no consensus on what constitutes R0 versus R1 resection. R1 resection is defined in North America as the presence of cancer cells at a resection margin and in Europe, as tumor up to 1 mm from a resection margin. We sought to determine the association between width of resection margin and recurrence rates and survival. CONCLUSIONS: Resection margin status is associated with overall survival but not local recurrence rates. Width of negative margin >1 mm is a significant prognostic factor among patients treated with neoadjuvant therapy but not among patients undergoing upfront surgery. METHODS: Retrospective analysis was performed of 301 consecutive patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreatic head or uncinate process at a single institution over a 20 year period (1991–2011). Adenocarcinomas arising within IPMN or mucinous cystadenomas were excluded. Analyzed variables included age, sex, margin status, use of neoadjuvant therapy, recurrence, and survival. A p value <0.05 was considered significant. Su1559 Clinical: Small Bowel Somatostatin Analogues for the Treatment of Enterocutaneous Fistulas: A Systematic Review and Meta-Analysis Shaun Coughlin* Surgery, University of Western Ontario, London, ON, Canada BACKGROUND: Enterocutaneous fistulas are abnormal connections between the skin and gastrointestinal tract that most commonly occur following surgery. Somatostatin analogues have been used in their treatment. Our objective was to determine if somatostatin analogues shorten the time to closure of post-operative enterocutaneous fistuals compared to placebo. RESULTS: Our initial search yielded 720 studies, of which 8 RCTs ultimately met eligibility criteria and were included in this review. Somatostatin analogues significantly decreased the time to closure of fistulas compared to placebo (Weighted mean difference (WMD) –6.37 days [95% CI –8.33, –4.42]). The duration of hospital stay was also significantly decreased with somatostatin analogue treatment (WMD –4.53 days [95% CI –8.29, –0.77]). No difference in mortality was identified with somatostatin treatment (Relative risk 0.87 [95% CI 0.49 to 1.55]). RESULTS: Of the 301 patients, 102 (34%) received preoperative chemoradiation, and 199 did not. The resection margin was grossly positive (R2) in 4 patients (1%), microscopically positive (R1) in 108 (36%), negative by ≤1 mm in 54 (18%), and negative by >1 mm in 135 (45%). Resection margin status did not correlate with rates of local or distant recurrence (p > 0.05). Overall survival was similar among patients with negative margin width of ≤1 mm vs. >1 mm, with median survival rates of 19 and 21 months, respectively, contrasted with a median survival of 13 months CONCLUSION: Somatostatin analogues appear to decrease the duration of enterocutaneous fistuals and duration of hospital stay while no mortality benefit was identified. The quality of evidence for outcomes in this review ranged from low to moderate. Future, large, blinded randomized controlled trials would be useful in improving the confidence in the treatment effects identified in this systematic review and meta-analysis. 99 Sunday Poster Abstracts METHODS: We searched Medline, EMBase, The Cochrane Central Register of Controlled Trials, as well as reference lists of textbooks and relevant articles for randomized controlled trials comparing somatostatin analogues to control in the treatment of post-operative enterocutaneous fistulas. We systematically assessed trials for eligibility and validity, and extracted data in duplicate. We pooled data across studies using a random effects model. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT ondary outcome complication rates. The average length of post-operative stay was similar in all groups. Use of steroids was not associated with a difference in EPC or length of stay in any group, removing patients on budesonide alone had no effect. However, a greater proportion of ALLT pts were on steroids 43.4% vs. 18.4%, p = 0.001 compared to the IM group at the time of surgery. Su1560 Timing of Pre-Operative Anti-Tumor Necrosis Factor Therapy Does Not Affect Early Post-Operative Complication Rates in Inflammatory Bowel Disease Patients Undergoing Intestinal Resection Parin N. Desai, Anil Sharma, Amar S. Naik, Mary F. Otterson, Yelena Zadvornova, Lilani P. Perera, Nanda Venu, Daniel J. Stein* Medical College of Wisconsin, Milwaukee, WI INTRODUCTION: Patients with moderate to severe inflammatory bowel disease (IBD) have a high likelihood of being exposed to anti-tumor necrosis factor (TNF) therapy as well as undergoing an operative resection. Studies looking at preoperative anti-TNF therapy effects on the early post-operative period have shown contradictory findings. Some physicians time operations with the nadir of the antiTNF therapy to minimize their immunosuppressive effect; however it is unclear if this practice improves outcomes. AIMS: 1) Determine early post-operative complication (EPC) rates in IBD patients on anti-TNF therapy compared to patients on immunomodulators (IM) alone and 2) assess the effect of remote versus immediate anti-TNF pre-operative therapy on EPC rates. METHODS: A retrospective review of a prospectively collected database of pts with IBD who underwent resection of small or large intestine from July 1st, 2005 to July 1st, 2010 was performed. Main outcome of interest was the combined EPC rate, defined as any of the following secondary outcomes: infection, anastomotic leak, re-admission, reoperation, thrombosis, acute kidney injury (AKI), ileus, or new drain within 30 days after surgery. All pts on antiTNF therapy (ALLT) were compared to pts on IM alone. The ALLT group was divided into remote preoperative (RP) and immediate preoperative (IP) groups; pts receiving a TNF dose greater than and less than ½ of their dosing interval prior to the operation, respectively. RESULTS: A total of 114 pts (60% F; 86.8% Crohn’s Disease) had resections, 76 ALLT pts (46 IP and 30 RP pts) and 38 IM pts. All groups were similar in terms of age, gender, race, smoking, and disease duration; except ALLT had a higher prevalence of penetrating CD than the IM group (43% vs. 29.4%; p = 0.05). Comparison of the ALLT to the IM alone group showed no difference (43.4% vs. 26.3%, p = 0.08) in terms of the combined EPC rates, or in individual secondary outcome rates. Comparison of the IP and RP groups showed no significant difference (21.7% vs. 30.0% p = 0.16) in the combined EPC rate, or in individual sec- CONCLUSION: Despite an increased likelihood of being exposed to steroids and having more severe CD, patients on pre-operative anti-TNF therapy had similar EPC rates compared to IM only patients. Further investigation of anti TNF therapy timing in the pre-operative period is warranted to recognize its contribution to EPC rates and to optimize treatment in the peri-operative period. Su1561 Endoscopic Ultrasound (EUS) Evaluation in the Surgical Treatment of Duodenal and Peri-Ampullary Adenomas Lilian C. Azih*1, Brett L. Broussard1, Milind A. Phadnis2,4, Martin J. Heslin1, Mohamad A. Eloubeidi3,2, Shyam Varadarajulu2, Juan Pablo Arnoletti1 1. General Surgery, University of Alabama Birmingham, Birmingham, AL; 2. Gastroenterology, University of Alabama Birmingham, Birmingham, AL; 3. Gastroenterology, American University of Beirut, Beirut, Lebanon; 4. Biostatistics, University of Alabama, Birmingham, AL INTRODUCTION: Precise characterization of benign duodenal and peri-ampullary tumors, offers a diagnostic challenge to reliably distinguish adenomas from malignant lesions and render the possibility of trans-duodenal resection. EUS has emerged as a useful technique in assessing tumor depth of invasion and is often employed at our institution when planning therapeutic approach. We performed a retrospective review of patients with benign duodenal and peri-ampullary adenomas who underwent preoperative EUS to determine the accuracy of this technique in predicting the absence of muscular invasion and also to analyze outcomes associated with endoscopic and trans-duodenal surgical resection. METHODS: Records of 111 patients seen at our institution over the last 10 years with post-operative pathological diagnosis of benign ampullary and duodenal adenomas were identified and reviewed. We analyzed information on patient gender, age, tumor location and size, EUS results, type of resection performed, final pathology findings and incidence of local tumor recurrence. 100 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 periampullary lesions and 18 duodenal lesions. In 38 (81%) patients, EUS reliably identified absence of sub mucosal and muscularis invasion. In 4 cases, EUS underestimated sub mucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. Type of resection performed included endoscopic resection in 25 cases, partial duodenectomy in 6 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. There were 6 local recurrences (13%; median follow-up = 20 months) 4 of which were in patients with Familial Adenomatous Polyposis (FAP). The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 6), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2),. Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intraabdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. CONCLUSION: EUS can accurately predict depth of mucosal invasion in 81% of benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection with acceptable local control rates sparing the need for more extensive operations. Su1562 Daniel I. Chu*, Melanie L. Gainsbury, Lauren A. Howard, Arthur F. Stucchi, James M. Becker Department of Surgery, Boston University Medical Center, Boston, MA BACKGROUND: Adhesive-related intestinal obstructions (AIOs) are a significant cause of morbidity and mortality for the surgical patient. Classical surgical teaching advocates a watchful waiting period of 2-days before operating on an AIO, but it remains unclear whether an early or late DESIGN: Patients undergoing adhesiolysis for intestinal obstruction were identified from the 2007 Nationwide Inpatient Sample (n = 8,034,632) and stratified to early (≤2 days from admission) vs. late (>2 days) adhesiolysis. The primary outcome comparison was in-hospital mortality and secondary outcomes were post-operative complications (POCs), post-operative length of stay (PLOS) and in-hospital cost. Propensity score methods were used to balance patient characteristics before making outcome comparisons. As a secondary analysis, different cut-off days (from 1 and 3 to 10 days post-admission) of adhesiolysis were used to redefine early versus late groups and reanalyzed for the above outcomes. RESULTS: From 5,443 patients who underwent adhesiolysis for AIOs in the United States in 2007, 53% and 47% underwent early and late adhesiolysis, respectively. Late adhesiolysis patients were older (65.0 vs. 60.1), differed in insurance (55.4% vs. 44.4% Medicare-covered), and had 14 co-morbidities with increased frequency compared to the early group (p < 0.05). After adjustment by propensity score methods, no difference in mortality (odds ratio [OR] 0.95, 95% confidence-intervals [CI] 0.67–1.36, p = 0.79) or POCs (OR 1.01, 95%CI 0.89–1.14, p = 0.91) was observed between the two groups. Patients undergoing late adhesiolysis, however, had increased PLOS (9.8% increase in days, p < 0.001) and in-hospital cost (41.9% increase in cost, p < 0.001) compared to the early group. Repeat analysis with redefined early and late adhesiolysis groups at different procedure days showed that mortality significantly increased when adhesiolysis was performed 8 days after admission (OR 2.06, 95% CI 1.21–3.53, p < 0.01) while no differences in POCs were observed. CONCLUSIONS: These data suggest that the historicallybased 2-day time limit of waiting is not associated with increased mortality or POCs for those patients undergoing adhesiolysis for an AIO, but instead is associated with increased PLOS and in-hospital cost. Risk of mortality was found to increase after 8 days of admission, and future studies will need to better understand this observation. 101 Sunday Poster Abstracts Early Versus Late Adhesiolysis for Adhesive-Related Intestinal Obstruction: A Nationwide Analysis of Inpatient Outcomes adhesiolysis is most beneficial and cost-effective. Our aim was to compare the clinical and cost outcomes of early versus late adhesiolysis for AIOs. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Stomach Su1563 Evaluation and Treatment of Gastric Stimulator Failure Nancy Salloum*1, Micah R. Walker1, Patrick A. Williams1, Yana Nikitina1, Thomas S. Helling2, Thomas L. Abell1, Christopher J. Lahr2, James Griffith1 1. Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; 2. Surgery, University of Mississippi Medical Center, Jackson, MS INTRODUCTION: Some patients who undergo gastric electrical stimulation (GES) for gastroparesis (GP) develop recurrent symptoms i.e.: vomiting, nausea, early satiety, bloating, and abdominal pain despite an initial good result, replete with a functioning stimulator and unbroken leads. This study evaluates treatment for these patients, which includes temporary stimulation at a new gastric location and if symptoms are relieved this is followed by implantation of new leads and stimulator. We expect symptom scores to significantly decrease in the control group; we hypothesize that the symptom scores will also show a significant decrease in the replacement group. PATIENTS: 15 patients with recurrent symptoms after placement of GES have undergone surgical insertions of a new gastric electrical stimulation (GES) system. Of the 15 replacement surgeries, 10 (67%) were female, 5 were male (33%) (mean age of all: 45), and 3 (20%) had diabetesinduced gastroparesis; the remainder (80%) were either idiopathic, post-surgical, or sarcoidosis-induced. Of 87 patients without recurrent symptoms after placement of GES who have not needed a replacement, 15 were selected as the control arm, matched by the three variables of investigator-derived independent outcome score (IDIOMS), baseline symptom scores before initial GES implantation, and etiology of disease (i.e. diabetic or idiopathic). METHODS: Each patient met specific indications to receive GES replacement surgery. All patients had a preoperative diagnosis of either diabetic or idiopathic, drug-refractory, or post-surgical gastroparesis, and disordered gastric emptying with significant weight change. Patients with failed GES were evaluated over a 1–2 week period with insertion of a temporary endoscopic gastric stimulator. Patients with a positive response to temporary stimulation undergo GES replacement surgery. Common gastroparesis symptoms were evaluated before and after gastric pacemaker replacement using the Likert score system 0–4. These symptoms include vomiting, nausea, epigastric pain, early satiety and bloating. RESULTS: See Tables 1 and 2. Total score of symptoms improved for 12 out of the 15 (80%) patients that underwent the GES replacement surgery. The frequency, amplitude, freq/amplitude ratio (FAR), and gastric emptying times (GET) are displayed to reinforce physiological similarity between the two groups. CONCLUSION: Trial gastric mucosal electrical stimulation followed by implantation of new leads and stimulator successfully salvages the majority of patients whose gastric electrical stimulator is no longer relieving symptoms. Table 1: Comparison of Mean Pre-Op and Mean Post-Op Symptom Scores Replacement (n = 15) Mean of Pre-Op Scores Mean of Post-Op Scores Difference in Symptom Scores p-Value of Difference Vomiting ± SD 3.2 ± 1.3 2.1 ± 1.3 1.2 0.001 Nausea ± SD 3.9 ± 0.3 3.3 ± 1.1 0.6 0.088 Early satiety ± SD 3.3 ± 0.6 2.4 ± 1.5 0.9 0.041 Bloating ± SD 3.3 ± 0.6 2.5 ± 1.5 0.8 0.057 Epigastric pain ± SD 3.6 ± 0.6 3.3 ± 1.4 0.3 0.24 Total Score ± SD No Replacement (n = 15) 17.3 ± 1.6 13.6 ± 3.7 3.6 0.017 Mean of Pre-Op Scores Mean of Post-Op Scores Difference in Symptom Scores p-value of Difference 0.019 Vomiting ± SD 3.0 ± 0.9 2.0 ± 1.5 1.0 Nausea ± SD 3.2 ± 1.2 3.0 ± 0.9 0.2 0.5 Early satiety ± SD 3.1 ± 1.0 2.4 ± 1.1 0.7 0.019 Bloating ± SD 2.8 ± 1.2 2.6 ± 1.1 0.2 0.7 Epigastric pain ± SD 3.1 ± 1.4 3.0 ± 1.2 0.1 0.88 Total Score ± SD 15.8 ± 3.6 12.3 ± 3.5 3.5 0.011 Table 2: Comparison of Mean EGG Values Frequency ± SD Replacement (n = 15) No Replacement (n = 15) p-value Normal EGG values 5.5 ± 3.0 5.8 ± 1.5 0.73 2.7–3.3 Amplitude ± SD 0.44 ± 0.6 0.6 ± 0.6 0.54 0.5 Freq/amp ratio ± SD 31.2 ± 31.5 32.4 ± 42.3 0.94 <10 Gastric emptying time (GET), 1;2;4 hr (%) 72, 49, 25 76, 48, 22 0.61, 0.96, 0.77 Total GET (%) ± SD 146 ± 59 146 ± 60 0.99 Table is displayed to reinforce physiological similarity between the two groups. 102 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Su1564 Su1565 Thromboembolic Events After Laparoscopic Adjustable Gastric Band: Identification of High-Risk Factors Changes in Quality of Life Before Roux-en-Y Gastric Bypass for Morbidity Obesity and After a Short and Long Term Follow-Up Chad Gonczy*, Imran Hassan, Sajida Ahad, Stephen Markwell SIU School of Medicine, Springfield, IL INTRODUCTION: In-hospital prophylaxis against thromboembolic events (TE) is considered routine for patients after laparoscopic adjustable gastric band (LAGB) for morbid obesity due to the increased risk of TE in this patient population. However, there are limited data regarding the benefit of extending this prophylaxis beyond discharge. Utilizing the American College of Surgeons-National Surgery Quality Improvement Project (ACS-NSQIP) database, we analyzed patients undergoing LAGB to determine the incidence of pre- and post-discharge TE and associated risk factors. METHODS: Patients undergoing LAGB between 2005–2009 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology code for LAGB. Univariate comparison and regression analysis of demographics and comorbidities of patients with and without TE were performed to determine independent risk factors for the development of TE. INTRODUCTION: Roux-en-Y gastric bypass is considered an effective therapy for weight loss although weight regain may be observed in a long-term follow-up. It is unclear if quality of life is sustained in a long-term follow-up when weight regain occurs. METHODS: Three groups were studied: Group A—50 patients (88% females, age 51, BMI 37Kg/m2, time of follow-up 112 months) submitted to Roux-en-Y gastric bypass more than 7 years, Group B—50 patients (82% females, age 44, BMI 31Kg/m2, time of follow-up 17 months) submitted to Roux-en-Y gastric bypass 1–2 years, Group C—50 patients (80% females, age 42, BMI 47Kg/m2) morbid obese in the pre-operative period. We use the MOS 36-Item ShortForm Health Survey (SF-36) to analyze the quality of life differences among the 3 groups. RESULTS: Groups were similar for gender. Group A was older than the other groups due to the time from operation. BMI was significantly lower for Group B compared to Group C and higher for Group A compared to Group B. SF-36 parameters are depicted in Table 1 on next page. Physical Functioning, Social Functioning, Emotional Problems and Mental Health were not different when the 3 groups were compared (p = 1). Role Functioning, Pain, General Health Perceptions and Vitality showed an increase after the operation and a significant decrease at the 7 year follow-up (p < 0.0001) (Figure). Significant Independent Risk Factors After LAGB Risk Factor Odds Ratio P-value Transfusion in OR 101.24 <0.0001 Cardiac Complications Excluding PE 27.95 <0.0001 Reoperation 17.71 <0.0001 Non-caucasian 3.28 0.01 Age ≥40 years 6.27 0.02 OR Time 2.58 0.05 CONCLUSION: The 30-day incidence of thromboembolic events after LAGB in ACS-NSQIP hospitals is exceedingly low, although the majority of these events occur following discharge. Certain patients are at higher risk for TE, and may represent a cohort that could benefit from extended post-operative prophylaxis. CONCLUSIONS: Some Quality of Life parameters are not changed by Roux-en-Y gastric bypass while others are improved by the operation even though a significant decreased is noted at a long term follow-up. 103 Sunday Poster Abstracts RESULTS: During the study period, 16,015 patients underwent LGB, of whom 19 (0.12%) developed a TE (10 (0.062%) developed a pulmonary embolus, 11 (0.069%) developed a deep-vein thrombosis, and 2 developed both) within 30 days of surgery. Eighty percent of the pulmonary embolisms and ninety-one percent of the deep venous thromboses were diagnosed after discharge. On regression analysis several patient characteristics, medical comorbidities and postoperative complications were independently associated with increased risk of TE. (Table) Rafael M. Laurino Neto*, Fernando A. Herbella Federal University of São Paulo, São Paulo, Brazil THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Table 1: SF-36 Concepts for the 3 Groups Role Functioning Physical Functioning Pain General Health Perceptions Vitality Social Functioning Emotional Problems Mental Health Group A 77 (50–88) 75 (6–100) 51 (22–70) 72 (58–84) 55 (40–75) 68 (40–87) 66 (33–100) 66 (48–83) Group B 95 (86–100) 100 (75–100) 84 (61–100) 92 (87–100) 85 (75–90) 100 (87–100) 100 (100–100) 90 (80–92) Group C 50 (25–68) 37 (0–75) 41 (31–74) 54 (40–75) 40 (30–70) 56 (37–84) 33 (0–100) 58 (33–75) Data presented as median (interquartile range 25–75). Su1567 Laparoscopic Gastric Pacer Therapy for Medical Refractory Diabetic and Idiopathic Gastroparesis Poochong Timratana*1, Kevin M. El-Hayek1,2, Hideharu Shimizu1, Matthew Kroh1,2, Bipan Chand1 1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH; 2. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH BACKGROUND: Gastroparesis is a disorder of chronic nausea and vomiting that may result in failure to thrive. Etiologies are multifactorial, but most often are classified as diabetic, idiopathic, post-surgical, or medication induced. Several large series have shown efficacy of gastric pacer implantation in certain groups with gastric dysfunction. However, laparotomy is often employed for placement. The aim of this study is to review outcomes of all patients who underwent gastric pacer therapy regardless of etiology. METHODS: Patients who underwent gastric pacer (Enterra Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming between March 2001 and November 2011 were analyzed. Data reviewed included demographics, pre-operative symptoms, operative technique, and post-operative symptom and nutritional improvement. RESULTS: A total of 113 patients underwent gastric pacer placement during the study period. Mean age was 40 years (19–88) and 83% of patients were female. Operations were completed laparoscopically in 110/111 cases, with one conversion to laparotomy due to severe adhesions. Two cases involved pacer revision for battery replacement. Gastroparesis symptoms were present for a mean duration of 4.8 years prior to surgery (1–20). Surgical intervention was only offered for patients with medical refractory diabetic and idiopathic gastroparesis. Prior to implantation, thirtythree patients were on supplemental nutrition (23 on jejunal feeds and 10 on total parental nutrition). There were no operative or immediate peri-operative complications. Battery depletion occurred in 6 patients at a mean interval of 75 months. Pacer malfunction occurred in 4 cases. Two of these cases required removal secondary to lead erosion, 1 underwent conversion to Roux-en Y gastric bypass, and 1 had no therapy. At a mean follow-up of 24 months, symptom improvement was achieved in 91 patients (80%) and was similar for both the diabetic and idiopathic subgroups. Post-operatively, 15 of 23 patients were able to discontinue supplemental nutrition. BMI increased in both the idiopathic and diabetic cohorts (see Graph 1 and 2). Four patients underwent conversion to laparoscopic Roux-en-Y gastric bypass for persistent poorly controlled symptoms and morbid obesity with associated comorbidities. Symptom control was achieved in 2 of these patients with an overall mean excess weight loss of 22% (8–39) at 7 month follow-up (3–12). CONCLUSION: Gastric pacer placement is feasible using a laparoscopic approach. Medical refractory gastroparesis in the diabetic and idiopathic groups had significant symptom improvement with no difference between the two groups. Gastric pacing may decrease the need for ongoing supplemental nutrition. Su1568 Assessment of Muscular Loss After Bariatric Surgery Through Bioimpedancy Wilson R. Freitas*, Paulo Kassab, Roberto D. Cordts Filho, Elias J. Ilias, Osvaldo A. Castro, Fabio Thuler, Paulo G. Porto, Carlos A. Malheiros Surgery, Santa Casa São Paulo Medical School, São Paulo, Brazil BACKGROUND: The evident weight loss observed during the first six months after bariatric surgery is due to the reduction in body fat and muscular mass. There is, however, the need to keep track the body composition of obese patients during this period of time in order to monitor the different body composition fractions such as water, fat-free mass, and fat. Bioimpedancy is a useful tool to assess body composition and a portable and easy-to-use alternative to determine variations of these fractions in obese patients during their weight loss period. METHODS: Thirty-six morbid obese patients were subjected to gastroplasty with silastic ring and Roux-en-Y distal gastric bypass, and their percentages of fat, water, and fat-free mass were measured the day before the surgery, as well as 2, 4, and 6 months after the surgery. A four-channel Bioelectrical Body Composition Analyzer, which measures the difference between upper right limb and lower right limb was used. 104 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: The results indicated a pattern in the measurements obtained in all cases. A linear reduction of the average fat content was observed, ranging from 50.9% at the pre-operatory to 40.8% 6 months after the surgery. The results also showed a linear reduction of average BMI, which varied from 55.1 kg/m2 to 37.7 kg/m2 in 6 months, and a linear increase of water content varying from 35.9% to 43.4% during the same period. Although there was a decrease in the total fat-free mass (76.9 kg to 62.7 kg), an increase in its percentage relative to the total weight (49.1% to 58.9%) was observed during the study. CONCLUSIONS: Bioimpedancy measurements carried out up to 6 months after the surgery did not reveal significant loss in muscular mass, indicating only a minor effect of malnutrition associated to weight loss, and an increase in the percentage of fat-free mass relative to the total weight. Su1569 Timing of Resolution of Comorbidities in Patients with Laparoscopic Adjustable Gastric Banding (LAGB) N = 698 David A. Nguyen*, Grace J. Kim, Regina M. Ramos, Carson D. Liu Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA INTRODUCTION: Bariatric surgery has been shown to be an effective solution for sustainable weight loss in the morbidly obese. This study aims to investigate the impact of LAGB on weight loss and obesity comorbidities (diabetes, hypertension, sleep apnea, and hypercholesterolemia). RESULTS: Analysis reveals that the first two years after LAGB are most critical for excess weight loss. The average percentage excess weight loss achieved was 54.2% ± 3.6% at year one, 67.9% ± 4.5% at year two, and 74.3% ± 7.5% at year three after band implantation. Average change in body mass index was 11.9 kg/m2 ± 1.6 kg/m2. Resolutions of comorbidities were analyzed each year after band implantation. Diabetes was resolved in 49% of the patients at year one, 58% at year two, and 61% at year three. Hypertension was resolved in 37% of the patients at year one, 45% at year two, and 53% at three. Obstructive sleep apnea was resolved in 63% of the patients at one, 76% at year two, and 91% at year three. Hypercholesterolemia was resolved in 45% of the patients at year one, 59% at year two, and 65% at year three. Of note, many patients continued their cholesterol medications with normal levels post-operatively. There was no mortality in the span of four years of the study. CONCLUSION: We are reporting a four year consecutive data with no deaths and resolution of comorbidities were observed to be long lasting in correlation with their weight loss. We are reporting continued weight loss Su1570 Is Laproscopic Single Stage Bilio-Pancreatic Diversion Safe in the Super-Morbidly Obese? Sidhbh Gallagher*, Gintaras Antanavicius, Iswanto Sucandy, Amarita Klar, Fernando Bonanni Department of Surgery, Abington Memorial Hospital, Abington, PA BACKGROUND: It is hypothesized that the morbidity and mortality of laproscopic bilio-pancreatic diversion with duodenal switch (LBPD/DS) are likely to increase with increasing body mass index (BMI), especially when >50 kg/m(2). Some authors, therefore, advocate a two-stage approach to this procedure in the super-morbidly obese. We hypothesize that a BMI ≥50 kg/m(2) does not significantly influence peri-operative morbidity with this procedure. METHODS: A prospective database of all patients who underwent laproscopic/robotic bilio-pancreatic diversion with duodenal switch between January 2009 and September 2011 was analyzed. Two groups were identified: those with BMI <50 kg/m(2) (Group 1) and those with BMI ≥50 kg/m(2) (Group 2). Patient demographics, length of procedure (LOP), intra-operative complications, conversion to open rates and postoperative outcomes, including 30-day complication rate, rate of re-operation at 30 days, rate of other interventions, length of stay (LOS) and readmission were compared. T-test and Fischer’s exact test were used where appropriate. P-values <0.05 were considered significant. RESULTS: 226 patients underwent (LBPD/DS). Mean patient age was 44.9 years (range: 20–72). 170 (75%) of patients were female. Mean BMI was 50.2 kg/m(2) (range: 37.2–68.8). 127 had BMI <50 kg/m(2) (Group 1), and 99 had a BMI ≥50 kg/m(2) (Group 2). The LOP in Group 1 was 296 minutes and 287 minutes in Group 2 (p = 0.25). The rate of conversion to open was 3% in Group 2 and 1.5% in Group 1 (p = 0.65). There were no mortalities. Only one intra-operative complication occurred in Group 1; none in Group 2. The rate of stenosis requiring endoscopic intervention was 0.7% in Group 1 and 1% in Group 2 (p = 1.0). Two leaks occurred in Group 1; no patient in Group 2 developed these complications. One patient in Group 2 developed pulmonary embolism. The rates of all other complications resulting in a longer LOS were 11% in Group 1 and 8% in Group 2 (p = 0.50). The 30-day re-operation rate was 3% in Group 1 and 1% in Group 2 (p = 0.39). The rate of re-intervention (endoscopic or percutaneous) was 1.57% in Group 1 and 1% in Group 2 (p = 1.0). The mean LOS was 3.97 days for Group 1 and 3.67 for Group 2 (p = 0.34). The 30-day readmission rate was 11% in Group 1 and 10% in Group 2 (p = 1.00). CONCLUSION: BMI ≥50 kg/m(2) does not increase intraoperative or postoperative complications at 30 days in ( LBPD/DS ). No significant differences were noted between the 2 groups in any of the outcomes. A single-stage procedure can be safely offered to patients with BMI ≥50 kg/m(2). 105 Sunday Poster Abstracts METHODS: 698 patients with average preoperative BMI of 42.1 ± 6.5 were retrospectively analyzed through electronic medical records from 2007–2011. Of those patients, 18.3% were men and 81.7% were women, with a mean age of 43. Resolution of comorbidities and weight loss were analyzed at three different intervals after band implantation (after year one, year two, and year three). All adjustments were performed in clinic setting without fluoroscopy. Analysis was performed with ANOVA. *P < 0.05 considered statistical significance. and improvement of co-morbid conditions are years after implantation of the adjustable gastric band. Lifestyle changes which include diet, exercise, and stress management in addition to follow up with the adjustable gastric band are key components in resolution of medical co-morbidities. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Su1571 Su1572 Laparoscopic Median Arcuate Ligament Release: Are We Improving Symptoms? Is Weight Loss Correlated with Race in Laparoscopic Adjustable Gastric Banding (LAGB) Patients? Yes Grace J. Kim*, David A. Nguyen, Regina M. Ramos, Carson D. Liu Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA Kevin M. El-Hayek1, Jessica Titus*1, Au Bui1, Tara M. Mastracci2, Matthew Kroh1 1. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2. Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH BACKGROUND: Median arcuate ligament syndrome is a rare disorder characterized by abdominal pain, weight loss, and isolated celiac stenosis. Though the diagnosis is often difficult to determine, it can be made with vascular ultrasound, axial imaging with angiography, or formal angiography. Several reports have shown that surgical release of the median arcuate ligament is a durable and effective treatment option for symptomatic patients. We present our experience using a laparoscopic approach for this particularly uncommon problem. METHODS: This is a prospectively collected, retrospective analysis of 14 patients at our institution. Between March 2007 and June 2011, patients treated with laparoscopic median arcuate ligament release were analyzed. Data collected included patient demographics, pre-operative symptoms, operative approach, and post-operative outcomes. Pre-operative evaluation included vascular ultrasound or axial imaging (CT or MR angiography) in all cases. Minimally invasive surgical options included laparoscopy and robotic assisted laparoscopy. Endovascular management was used in select cases. Using an IRB approved database, patients were then contacted to complete a post-operative survey aimed at assessing resolution of symptoms and overall satisfaction. RESULTS: The mean age was 34 years (17–68) and 92% of patients were female. Mean pre-operative BMI was 24.1 kg/m2 (19–32) and 64% of patients had prior abdominal surgery. Mean celiac velocity was 374 cm/s (210–600). Preoperative CT angiogram was performed on 10 patients with 7 patients demonstrating celiac stenosis. Thirteen patients had laparoscopic median arcuate ligament release while 1 patient had robotic assisted laparoscopic release. Mean operating time was 184 minutes (79–473) and average estimated blood loss was 229 cc (5–2000). There were two intra-operative complications. One was an aortic injury and another was an ulnar artery occlusion from endovascular stenting. The aortic injury occurred with the robotic assisted approach and required a laparotomy for vascular repair. All other cases were completed laparoscopically. Eleven patients had post-operative vascular ultrasounds with a mean velocity of 215 cm/s (135–306). Mean postoperative BMI was 24.7 (18–32). Response rate for the post-operative survey was 79% at a mean follow-up of 16.5 months (5–32.6). All but one patient experienced complete resolution of symptoms with no persistent pain. CONCLUSION: Laparoscopic release of the median arcuate ligament is a safe, feasible and effective means of managing median arcuate ligament syndrome. Post-operative symptomatic relief is seen in the vast majority of patients undergoing this procedure. INTRODUCTION: Variability of percentage excess weight loss (%EWL) in LAGB patients can be influenced by many preoperative factors, such as gender, race/ethnicity, and age. We hypothesize that race/ethnicity plays an important predictor in the post-operative weight loss. METHODS: A retrospective analysis of 428 patients using electronic medical record was performed to assess differential %EWL for patients across a period of three years post-band implantation, with an average of 1.53 years for all groups and no significant differences between ethnic groups. Average initial BMI is 42 ± 5. ANOVA was used to analyze data and P < 0.05 considered significant. RESULTS: Percent excess weight loss (EWL) are reported for the following racial groups. Asians lost the most, followed by Caucasians, the Hispanics and finally African Americans. The Caucasian group lost 66.33% ± 2.4%%EWL (N = 209); the Asian group lost 88.6% ± 7.7 %EWL (N = 23); the Hispanic group (50.2% ± 2.3%; P = 1.5E-05, N = 123), and African American group lost 44.4% ± 3.3%; P = 9.96E06, (N = 73). Furthermore, the average number of adjustments was 6 for the Caucasian group, 5 for the Asian group, and 4 for the Hispanic and African American groups. CONCLUSION: Our findings suggest that weight loss outcome for LAGB may be related to a patient’s race/ethnicity. Patients in the Caucasian group have significantly more adjustments than any other group. Excess weight loss is correlated with race and number of adjustments as well as willingness to diet and exercise. Cultural differences in types of food and exercise is also important in weight loss outcome. Translational Science: Colon-Rectal Su2094 Surgeon Leadership Enables Development of a Colorectal Cancer Biorepository Miriam Douthit, Vassiliki L. Tsikitis, Kim C. Lu, Daniel O. Herzig* Department of Surgery, Oregon Health and Science University, Portland, OR BACKGROUND: A cancer biorepository that links a patient’s demographic, clinico-pathologic and tissue molecular profile data is critical for translational research to develop personalized cancer treatment. We hypothesize that a surgeon-directed biorepository optimizes the collection of all necessary elements needed to build a complete, robust research resource. 106 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA METHODS: All colorectal cancer patients treated at a university medical center and its affiliates were eligible for inclusion in the biorepository. All patients signed an Institutional Review Board-approved genetic consent form and medical release authorization. Data was collected from: an 18-page personal and family health questionnaire completed by the patient; a prospectively maintained clinical database which included oncologic outcomes; and molecular testing. Specimen collection for the biorepository included: serum, plasma and peripheral blood mononuclear cells as well as tumor and normal tissue maintained as snap frozen samples, cryovials and paraffin blocks. The patient cohort was divided into a surgeon-referred group and a clinician-referred group. The groups were analyzed with the primary outcome variable as complete collection of data (clinical data, blood samples and tissue collection). Statistical analysis was performed using Student’s t-test. CONCLUSION: Surgeon-directed enrollment in a biorepository improves the ability to collect blood and tissue samples in conjunction with demographic and clinicpathologic data. Surgeons should take a leadership role in the development of tumor biorepositories. Su2095 Bacterial Genomic Sequences Within Submucosal Tissues Suggest Distinct Populations Within the Crohn’s Disease Spectrum Brian R. Davis*1, Rod Chiodini2, William Chamberlin2, Jerzy Sarosiek2, Richard Mccallum2 1. Surgery, Texas Tech University Health Sciences Center, El Paso, TX; 2. Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX Bacteria have been suspected in the etiopathogenesis of Crohn’s disease (CD). Over 80% of intestinal microbial flora represent unidentified species for which plasmid-mediated 107 Sunday Poster Abstracts RESULTS: Since inception of the program in 2006, 452 patients were approached to join the registry and 430 (95%) patients have been enrolled. Of these, 124 patients were referred by their surgeon and consented at the time of surgery, and 306 patients were consented in a clinical setting or over the telephone. Of patients referred by their surgeon, tumor tissue, blood samples and clinical data were obtained in 119 patients; conversely, in patients referred by oncologists or other clinicians the combination of tumor tissue, blood samples and clinical data were obtained in 133 patients (96% vs. 43.5%, p < 0.05). A total of 257 tissue samples were obtained from all patients. Additional testing has been performed on 228 specimens including immunohistochemistry, microsatellite testing, and genotype mutational analysis. virulence factors exist. Molecular biology allows detection of virulence-associated genes independent of species. Because of transmural inflammation in CD, we hypothesize that submucosal bacterial populations are more relevant to chronic inflammatory disease as opposed to mucosal or luminal populations. The purpose is to determine prevalence of virulent genes and/or infectious agents in submucosal tissues from patients with disease and controls using genomic markers in a comparative assay. Submucosal tissues were obtained from fresh surgical specimens by manual excision and digestion of mucosal layers. DNA was extracted by a modification of the Human Microbiome Project protocol and assayed for 30 virulence genes and/or unique genomic sequences representing 16 distinct bacterial species using quantitative real-time PCR (qPCR). All positive results were repeated, and all qPCR products were verified by gel electrophoresis and sequencing of the PCR amplicon product. Non-Inflammatory Bowel Disease (nIBD) controls represented negative margins of colon cancer patients. A positive result was assigned only if results were reproducible and the PCR product was at least 97% homologous to the known sequence. Tissues from 11 patients with Crohn’s disease and 7 controls have been examined. The intestinal intimin (eaeA) invasion gene of enteropathogenic E. coli and the InvA invasion gene of Salmonella were detected predominately in Crohn’s disease (6/11–55%). The absence of other sequences suggests these plasmid-mediated invasion genes may not be associated with either E. coli or Salmonella. In the absence of eaeA and InvA invasion genes, M. paratuberculosis associated sequences were detected in 4/11 (36%) of CD submucosal tissues. Virulence-associated genes were not identified in one suspected Crohn’s patient (1/11, 9%). The eaeA invasion gene was detected in only 1/7 nIBD controls (14%). Other virulence-associated genes and/or infectious agents sought in our assay system were randomly detected in both study populations. This study examines and reports on the bacterial populations within submucosal tissues as opposed to the mucosal and/or luminal microbiome. Preliminary data suggests the existence of a submucosal microbiome in both normal and diseased intestinal tissue. CD may be divided into 2 distinct populations based on presence/ absence of adhesion/invasion genes or the presence of M. paratuberculosis-associated sequences. Future efforts focus on confirming these findings in populations from various geographical locations. Confirmation of these findings could have ramifications to the care of CD by the implementation of targeted therapy based on the submucosal microbiome-type. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Translational Science: Esophageal Translational Science: Small Bowel Su2096 Su2097 Evaluation of Clinical Predictors of Epcam Over-Expression in Patients with Esophageal Adenocarcinoma Evidence for the Hindgut Hypothesis After Ileal Interposition Associated with Sleeve Gastrectomy: Increased Number of GLP-1-Producing Cells in Interposed Ileum and Pancreatic Islets in Rats Erik M. Dunki-Jacobs*, Yan LI, Charles R. Scoggins, Kelly M. Mcmasters, Glenda Callender, Robert C. Martin Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY INTRODUCTION: Epithelial Cell Adhesion Molecule (EpCAM) is a transmembrane glycoprotein expressed by human epithelial cells. EpCAM is known to be involved in cell-cell adhesion, proliferation, differentiation and apoptosis. The aim of this study was to evaluate the clinical predictors of EpCAM over-expression in patients with resected esophageal adenocarcinoma (EAC). METHODS: EpCAM expression was assessed using immunohistochemical (IHC) staining in patients undergoing esophagogastrectomy for EAC. EpCAM expression was classified as low (<10%), intermediate (11–60%), or high (>60%). EpCAM expression in malignant tissue was compared to expression in benign esophageal tissue harvested approximately 1–2 cm from the margin of the tumor. Age, gender, TNM stage at diagnosis, and presence of neoadjuvant therapy were evaluated as possible clinical predictors of increased EpCAM expression. Disease-free survival (DFS) and overall survival (OS) were evaluated. RESULTS: The median age of the patient population was 61 years. Pre-operative TNM stage distribution was n = 3, n = 4, and n = 6, for stages 1, 2, and 3 respectively. 62% of patients underwent neoadjuvant therapy. Low, intermediate, and high EpCAM expression in malignant tissue occurred in 61%, 31%, and 8% of patients respectively and in 77%, 23%, and 0% of benign adjacent tissue respectively. EpCAM expression in malignant tissue was not shown to be significantly higher than EpCAM expression in benign adjacent tissue (p = 0.3). Clinical variables of age, TNM stage at diagnosis, and neoadjuvant therapy did not predict level of EpCAM expression (p = 0.9, p = 0.4, and p = 0.6 respectively). Median DFS and OS were 12 months and 28 months respectively. DFS and OS did not correlate with EpCAM expression (p = 0.6 and p = 0.6 respectively). Median survival after recurrence was 1 month and did not correlate with EpCAM expression (p = 0.6). Complete response to neoadjuvant therapy based on postoperative pathologic stage was associated with an increased level of EpCAM expression (p = .02). CONCLUSION: EpCAM expression is significantly increased in patients who have complete response to neoadjuvant therapy. Further evaluation is needed to better characterize the relationship between EpCAM over-expression and pathologic response to neoadjuvant therapy for EAC. Helene Johannessen*1, Yosuke Kodama1, Chun-Mei Zhao1, Gjermund Johnsen2, Ronald MåRvik2, Baard Kulseng2,1, Duan Chen1 1. Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 2. Department of Surgery, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway BACKGROUND/AIM: Based on the hindgut hypothesis, ileal interposition with sleeve gastrectomy (II-SG) has been proposed as a procedure in metabolic surgery. The aim of the present study was to study the underlying mechanism of II-SG in rats. METHODS: Male Sprague-Dawley rats were subjected to laparotomy, ileal interposition (II), sleeve gastrectomy (SG), or II-SG. Metabolic parameters were monitored by an open-circuit indirect calorimeter composed in comprehensive laboratory animal monitoring system. The number of GLP-1-producing cells was examined by quantitative immunohistochemistry RESULTS: After II alone, satiety ratio i.e., intermeal interval/meal size, was reduced while calorie intake was increased at two weeks postoperatively. Respiratory exchange ratio, i.e., VCO2/VO2, was increased to above 1.0 (i.e., carbohydrate metabolism) during both daytime and nighttime two and six weeks postoperatively. After SG alone, satiety ratio and respiratory exchange ratio were unchanged, and the number of GLP-1-producing cells was not increased in the ileum (in terms of volume density), but increased in the pancreatic islets (number of cells per islet). After II-SG, rate of eating was reduced, while meal duration (minutes/ gram) was increased during both daytime and nighttime at two and six weeks postoperatively. The number of GLP1-producing cells increased by about 2.5-fold in the interposed ileum, and also increased to the same extent in the pancreatic islets as seen after SG alone. The increased GLP1-producing cells in the pancreas were distributed around the insulin-producing cells. CONCLUSION: The present study provides evidence that II-SG stimulates GLP-1 production not only in the interposed ileum (to act by endocrine mechanism) but also in the pancreatic islets (to act on the cells by paracrine mechanism), leading to the metabolic beneficial effects and the altered eating behavior as manifested by eating slowly. ACKNOWLEDGMENTS: The research leading to these results has received funding from the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement n°266408, the Faculty of Medicine, Norwegian University of Science and Technology, and the Central Norway Regional Health Authority. 108 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Translational Science: Stomach Su2098 Overexpression of ADP-Ribosylation Factor 1 (ARF1) in Human Gastric Cancer and Its Clinicopathological Significance Chia-Siu Wang*1, Kwang-Huei Lin2 1. Department of General Surgery, Chang Gung Memorial Hospital, Chiayi, Putz City, Taiwan; 2. Department of Biochemisty, Chang Gung University, Taoyuen, Taiwan BACKGROUND: Gastric cancer is the second most common cancer worldwide and the sixth leading cause of cancer-related death in Taiwan. Biomarkers are investigated to improve early detection and patient survival. Previously, ARF1 was identified as one of the strongest upregulated proteins by using proteomic technique: two-dimensional (2D) gel electrophoresis combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. ARF1 belongs to the Ras superfamily or GTP-binding protein family and has been shown to enhance cell proliferation. DISCUSSION & CONCLUSION: ARF, a family of small GTP-binding proteins, play important roles in intracellular trafficking in animal and yeast cells. Over-expression of ARF1 in cancer cells has been reported in human breast cancer cells. ARF1 regulates breast cancer cell growth and invasion during cancer progression. Our data demonstrated that expression of ARF1 is associated with tumor progression and survival outcome. And, it might be a potential prognostic marker for gastric cancer. These findings collectively support the utility of ARF1 as a potential prognostic marker for gastric cancer and its role in cell invasion. 109 Sunday Poster Abstracts SUBJECTS & METHODS: A total of 110 patients (69 males, 41 females; median age: 66 years, range 28–86 years) with gastric cancer undergoing gastrectomy were enrolled into this study. Real-time quantitative RT-PCR, western blot analysis and immunohistochemistry (IHC) on resected specimens were used to confirm the ARF1 overexpression in surgical patients. The clinical significance of ARF1 expression was evaluated by clinicopathological correlations and patient’s suruvial outcome. To establish the specific function of ARF1 in human gastric cancer, isogenic ARF1-overexpressing cell lines were prepared. RESULTS: Expression of ARF1 mRNA was significantly upregulated in 67.2% of gastric cancer patients by using Real-time quantitative RT-PCR test. Paired comparison of IHC study for ARF1 revealed that the IHC scores of cancerous tissues were higher than those of the nontumorous counterparts in 76.5% of patients. Elevated ARF1 expression was strongly correlated with lymph node metastasis (p = 0.008), serosal invasion (p = 0.046), lymphatic invasion (p = 0.035) and pathological staging (p = 0.010). Moreover, the 5-year survival rate for the lower ARF1 expression group (n = 50; IHC score <90) was higher than that of the higher expression group (n = 60; IHC score ≥90) (log rank p = 0.0228). Our functional studies also demonstrate that ARF1-overexpressing clones display enhanced cell proliferation, migration and invasion. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Monday, May 21, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM. 12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME) Basic: Biliary CONCLUSION: A significant number of patients continue to experience symptoms following laparoscopic cholecystectomy. In patients were pain was the most troublesome symptom pre-operatively, significant symptomatic improvement was noted. Similarly, those patients that experienced symptoms more dyspeptic in nature pre-operatively were less likely to be symptom free following LC. A careful biliary history, a focused physical examination and a thorough pre-operative assessment must be carried out prior to LC to rule out conditions that masquerade as gallbladder disease. Mo1874 Persistent Symptoms Following Cholecystectomy Is Unacceptably High and in Need of Further Evaluation Rami Radwan*, Chris Brown, Jonathan Lloyd-Evans, Chirag Patel, Omer Jalil, Ashraf M. Rasheed Minimal Access Surgery, Royal Gwent Hospital, Newport, United Kingdom INTRODUCTION: Up to 20% of patients undergoing cholecystectomy continue to experience symptoms. We consider such results unacceptably high and in need of further evaluation. Objectives: To identify the biliary symptoms for which the cholecystectomy was carried out and then determine the prevalence and the nature of persistent symptoms following cholecystectomy in a cohort of 500 consecutive cases. METHODS: A validated pre-operative symptoms survey was completed at the time of listing of 500 consecutive laparoscopic cholecystectomies (LC) followed by a follow up phone survey 12 weeks after the procedure to record the nature, severity and frequency of symptoms experienced pre- and post-operatively. A detailed clinical profiling was carried out on all patients with persistent biliary symptoms. RESULTS: All patients had at least 2 symptoms pre-operatively and 337 (67.4%) had 3 or more. The most common symptoms pre-operatively were abdominal pain (93.8%), nausea (65.8%), pain related to food (54.4%) and bloating (48.6%). A total of 90 patients were symptomatic post-operatively. Eighty one patients (16.2%) complained of abdominal pain, while 63 (12.6%) patients also experienced associated dyspeptic symptoms. Seventy three patients (14.6%) developed 1 or more new symptoms post-operatively, the most common being heartburn found in 34 (6.8%) and abdominal bloating in 29 (5.8%). Sixty patients underwent further investigation following LC; 36 patients went on to have a secondary diagnosis made, the most common (13/36) being hiatus hernia, seven patients were found to have a retained common bile duct stone. Overall, there was no significant difference in histology among patients post-operatively. Basic: Colon-Rectal Mo1875 Human Growth Hormone (hGH) Abolishes the Negative Effects of Everolimus on Intestinal Anastomotic Healing Markus A. KüPer*, JüRgen Weinreich, Frank Traub, Alfred KöNigsrainer, Stefan Beckert Department for General, Visceral and Transplant Surgery, University of Tübingen, Tübingen, Germany INTRODUCTION: The mTOR-inhibitor everolimus inhibits healing of intestinal anastomoses by interfering with the inflammatory phase of healing and reducing collagen deposition. Aim of this study was to investigate whether the simultaneous administration of everolimus and hGH abolishes the negative effects of everolimus on anastomotic healing. METHODS: 48 male Sprague-Dawley-rats were randomized to three groups of 16 animals each (I: vehicle; II: everolimus 3mg/kg p.o.; III: everolimus 3mg/kg p.o. + hGH 2,5mg/kg s.c.). Animals were pre-treated with hGH and/or everolimus daily for seven days. Then a standard anastomosis was created in the descending colon and treatment was continued for another seven days. The anastomosis was resected in toto and mechanical, biochemical and histological parameters of intestinal healing were assessed. RESULTS: Anastomotic bursting pressure was significantly reduced by everolimus and a simultaneous treatment with hGH resulted in considerably higher values (I: 134 ± 19, II: 85 ± 25, III: 114 ± 25 mmHg; p < 0,05 I vs. II; p = 0,09 110 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA I vs. III and II vs. III) Hydroxyproline concentration was significantly increased by hGH compared to everolimus alone (I: 14,9 ± 2,5, II: 8,9 ± 3,6, III: 11,9 ± 2,8 μg/mg; p < 0,05 I vs. II/III and II vs. III). The number of MPO-positive cells was reduced significantly by hGH compared to everolimus alone (I: 10 ± 1, II: 15 ± 3, III: 9 ± 2 n/sqmm; p < 0,05 I vs II und II vs. III), while the number of PCNA-positive cells were increased by hGH (I: 28 ± 3, II: 12 ± 3, III: 26 ± 12 /sqmm; p < 0,05 I vs. II und II vs. III). Corresponding to these biochemical findings, HE-histology revealed significantly increased amount of granulation tissue in hGHtreated animals. CONCLUSION: The inhibitory effects of everolimus on intestinal wound healing can be partially neutralized by simultaneous treatment with human growth hormone. hGH-treatment addresses both the inflammatory phase as well as collagen deposition. Mo1876 Mo1877 Intra-Abdominal Adipose Tissue as a Major Source of IL-6 During Acute Experimental Colitis W.C. Mustain*1,2, Marlene E. Starr1,2, Daiki Okamura1,2, B. Mark Evers1,2, Hiroshi Saito1,2 1. Markey Cancer Center, University of Kentucky, Lexington, KY; 2. Department of Surgery, University of Kentucky, Lexington, KY INTRODUCTION: Adipose tissue has been shown to produce a number of inflammatory cytokines and may play a role in the development and progression of several inflammatory diseases. Accumulation of intra-abdominal fat correlates more strongly with inflammatory disease states than does total body fat, suggesting depot-specific differences in the inflammatory potential of adipose tissue. In inflammatory bowel disease specifically, recent clinical studies suggest that patients with increased intra-abdominal fat may suffer a more aggressive clinical course. OBJECTIVE: The purpose of the present study was to evaluate the significance of inflammatory cytokine production by various adipose tissue depots during acute experimental colitis. Intestinal Permeability for Macromolecules Following Mechanical Ileus in Mice Xue Zhao, Till Macheroux, Michael S. Kasparek, Mario H. Mueller, Martin E. Kreis* Surgery, University of Munich, Munich, Germany INTRODUCTION: Acute mechanical ileus is a frequent disorder seen in general surgery which—if untreated—terminates in peritonitis secondary bacterial translocation. We aimed to investigate the time course of changes in gut permeability during acute mechanical ileus for molecules of different molecular weight. RESULTS: At 3 hours after the beginning of mechanical ileus, the FITC-dextrane concentration was 187 ± 7.6 ng/ml in ileus animals and 147 ± 8.1 ng/ml in sham controls (p < 0.05), while it was 86 ± 8.9 and 62 ± 0.8 ng/ml at the 9 hour time point (p < 0.05). For the bigger molecule, HRP, concentrations at 3 hours were 5.6 ± 3.6 ng/ml in ileus animals and 4.1 ± 1.6 ng/ml in sham controls which was not different. At 9 hours the serum concentrations were 23.0 ± 4.3 ng/ml in ileus animals which was higher compared to 9.0 ± 3.1 ng/ml in sham controls (p < 0.05). CONCLUSIONS: Intestinal permeability for macromolecules increases a few hours after acute mechanical ileus. It seems that soon after the beginning of mechanical ileus, intestinal permeability is increased for small-sized molecules, while it takes a few hours more until it is also increased for bigger sized molecules. RESULTS: Histologic evidence of colitis and significantly increased plasma IL-6 levels were evident by Day 7 and peaked at Day 14. Changes in cytokine expression within the colon occurred earlier, with significant increases in TNF-a, IL-1b, and IL-6 mRNA all evident by Day 3 (P = 0.016). Of the cytokines analyzed, IL-6 in the colon exhibited the most profound increase with colitis, with levels at Day 7 increased 230-fold from baseline (P = 0.002). Analysis of adipose tissues from this time point revealed that while IL-6 mRNA expression in mesenteric and epididymal adipose tissue was significantly increased compared to controls, 8.6-fold (P = 0.016) and 3.8-fold (P = 0.004) respectively, no increase in subcutaneous adipose tissue IL-6 mRNA was observed. Multi-tissue analysis at this time point revealed that mesenteric and epididymal adipose tissue expressed significantly more IL-6 mRNA than the kidney or the liver, whose levels of IL-6 did not increase significantly from baseline. CONCLUSIONS: This study demonstrates that intraabdominal adipose tissue is a major source of IL-6 during acute experimental colitis. The time course analysis suggests that intra-abdominal fat may have a significant impact on plasma IL-6 levels. Unlike the mesentery, the epididymal fat pad is not contiguous with the inflamed bowel and does not contain the venous or lymphatic drainage of the affected bowel. This suggests a tissue-specific response by the intra-abdominal adipose tissue, rather than merely a local lymphoid reaction to tissue damage in the colon. 111 Monday Poster Abstracts METHODS: C57Bl6 mice were anesthetized by isoflurane inhalation and gavaged with flourescein isothiocyanate conjugated dextrane (FITC-dextrane, 4.4 kDa) and horseradish peroxidase (HRP, 40 kDa). After a mini- laparotomy, the small intestine was ligated approximately 5 cm distal to the ligament of Treitz, while controls received a minilaparotomy only. Intestinal permeability was assessed in ileus animals or controls 3 and 9 hours later in different subgroups (each n = 4). For this purpose blood was taken by right ventricular puncture and serum concentrations of FITC-dextrane and HRP determined by spectrophotometry. Data are mean ± SEM. METHODS: Colitis was induced in C57BL mice by addition of 2% dextran sulfate sodium (DSS) to drinking water for 5 days. Mice were sacrificed at Day 3, 7, 14, and 21 following initiation of DSS treatment. Control mice were sacrificed prior to initiation of treatment. Plasma cytokine levels at time of sacrifice were analyzed by multiplex assays. Colonic tissue damage was evaluated histologically by H&E staining. Tissue levels of cytokine mRNA were compared between the colon, 3 adipose tissue depots (mesenteric, epididymal, and subcutaneous), kidney, and liver by qRT-PCR. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Basic: Esophageal Mo1879 EGFR in Gastroesophageal Reflux Disease, Barrett’s Esophagus, and Esophageal Adenocarcinoma Guilherme Pretto*1,2, Richard R. Gurski1,2, Daniel Navarini1, Marcelo Binato1, Luise Meurer2, Laura Z. Costamilan2, Guilherme D. Mazzini2, Gabriela G. Costa1 1. Programa de Pós-Graduação em Cirurgia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; 2. Digestive Surgery, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common pathology with a wide range clinical and endoscopic manifestations whose underlying mechanisms are not well understood. Epidermal growth factor receptor (EGFR), found in the epithelium of the digestive tract, plays an important role in epithelial repair and shows increased expression in a number of different neoplasms, including esophageal tumors. OBJECTIVES: To evaluate EGFR expression using immunohistochemistry in esophageal biopsies obtained from patients with GERD, Barrett’s esophagus, and adenocarcinoma of the esophagus. METHODS: EGFR expression was immunohistochemically determined in biopsies from 194 patients with symptoms suggestive of GERD or adenocarcinoma of the esophagus seen at two Brazilian university hospitals between January 2003 and December 2008. Based on histopathological analysis, patients were divided into three groups: GERD, Barrett’s esophagus and adenocarcinoma of the esophagus. EGFR expression was considered positive when staining was detected in the membrane. Figure 1: Esophageal biopsy from a patient with Barrett’s esophagus, positive for EGFR expression RESULTS: Mean age was 55.25 years (30–90). Patients with GERD (n = 127) accounted for 65.5% of the sample, compared with 12.4% (n = 24) of patients with Barrett’s esophagus and 22.2% (n = 43) of patients with esophageal adenocarcinoma. Immunohistochemical analysis was positive for EGFR in 19.1% of the patients (37/194), divided as follows: 8.7% (11/127) in the GERD group, 25% (6/24) in the Barrett’s esophagus group, and 46.5% (20/43) in the esophageal adenocarcinoma group. Statistical analysis revealed significant differences between the three groups (p = 0.0001). Figure 2: Immunohistochemical expression of EGFR in the three groups assessed. CONCLUSIONS: GERD patients showed lower levels of EGFR expression than patients with Barrett’s esophagus or patients with adenocarcinoma of the esophagus, suggesting a direct relationship between EGFR expression and disease progression. KEYWORDS: EGFR, GERD, adenocarcinoma, esophagus, Barrett’s esophagus. Basic: Pancreas Mo1880 Effects of Intravenous Administration of Pentoxifylline in Pancreatic Ischemia/Reperfusion Injury Edmond R. Campion, ANA Maria M. Coelho*, Marcel C. Machado, Sandra N. Sampietre, Nilza A. Molan, José Jukemura, Luiz C. D’Albuquerque Gastroenterology, University of São Paulo, São Paulo, Brazil BACKGROUND/AIM: Therapeutics strategies to reduce pancreatic ischemic/reperfusion injury (I/R) might improve the outcome of human pancreatic-kidney transplantation. Pentoxifylline (PTX) beside its hemorrheologic effects has an anti-inflammatory effect by inhibiting NF-kappaB activation. We have previously demonstrated that PTX had anti-inflammatory response in acute pancreatitis and liver ischemia/reperfusion models. We have hypothesized that PTX could reduce pancreatic, renal lesions and the systemic inflammatory response in pancreatic I/R injury. The aim of this study was to evaluate the effect of PTX administration in a rat model of pancreatic I/R injury METHODS: Pancreatic ischemia was performed in Wistar rats during one hour by clamping the splenic vessels under mechanical ventilation. The vascular clamp was removed 1 hour after ischemia and pancreatic revascularization was achieved, followed by 4h or 24h of reperfusion. The animals submitted to ischemic/reperfusion were randomly divided into 2 groups: Group C (n = 20): control, rats received saline solution IV, 45 minutes after ischemia, and Group P (n = 20): rats received PTX (25mg/Kg) IV, 45 minutes after ischemia. Four and twenty four hours after reperfusion blood were collected for determinations of amylase, creatinine, TNF-α, IL-6, and IL-10. Pancreatic malondialdehyde (MDA) content was also performed. After 24 hours of reperfusion pulmonary tissues were assembled for myeloperoxidade (MPO) analyses. 112 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: A significant reduction in serum TNF-α, IL-6, IL-10, and creatinine levels was observed in PTX group compared to control group (p < 0.05). No differences in pancreatic MDA content and in serum amylase levels were observed between two groups. Twenty-four hours after ischemia it was not observed any significant difference in the results of lung myeloperoxidase activity (MPO). CONCLUSION: Pentoxifylline administration reduced the systemic inflammatory response and renal dysfunction in pancreatic I/R injury and could be a useful tool in pancreaskidney transplantation Mo1881 The Expression of Putative Pancreatic Stem Cell Marker DCAMKL-1 Is Elevated in Early Stage Pancreatic Adenocarcinoma Patients that DCAMKL-1 mRNA levels in adjacent tissues are significantly higher than the respective tumor tissues. DCAMKL-1 mRNA levels were higher in the adjacent tissues compared to the respective tumor tissues of stage II (7-fold) and stage III (2.7-fold) patients. Furthermore, we observed increased DCAMKL-1 immunostaining in all stages of cancer compared to controls. Although there were no significant differences between the stages, we observed increased stromal staining compared to the epithelium within the specimens. CONCLUSION: These data suggest that DCAMKL-1 is increased in all stages of pancreatic cancer tissues. Additionally, the higher DCAMKL-1 level in the tissue adjacent to the tumor may suggest a premalignant condition in this tissue. Furthermore, DCAMKL-1 is elevated in plasma of stage I and II patients, suggesting that it may potentially be used as a biomarker for the early detection of pancreatic cancer. Mo1882 Jeremy J. Johnson*1, Dongfeng Qu2, Sripathi M. Sureban2,3, Randal May2,3, Stanley Lightfoot5, Lewis A. Hassell5, Shubham Pant4, Russell G. Postier1,3, Courtney W. Houchen2,3 1. Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; 2. Medicine/Gastroenterology, OUHSC, Oklahoma City, OK; 3. Veterans Affairs Medical Center, Oklahoma City, OK; 4. Medicine/Hematology and Oncology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; 5. Pathology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK DNA Methylation as a Biomarker System for Pancreatic Adenocarcinoma Qi Huang*2, ADAM A. Golas2, Zhongmin Guo2, Kenneth P. Nephew2, Michael G. House1,2 1. Surgery, Indiana University School of Medicine, Indianapolis, IN; 2. Biology, Indiana University, Bloomington, IN BACKGROUND: Pancreatic ductal adenocarcinoma carries a grave prognosis with the majority of patients presenting with locally advanced or metastatic disease. Patients diagnosed with early stage pancreatic cancer are often candidates for surgical resection and have improved overall 5 year survival. Doublecortin and CaM kinase-like-1 (DCAMKL-1), a microtubule-associated kinase, is a putative intestinal and pancreatic stem cell marker. We have previously demonstrated that DCAMKL-1 is upregulated in multiple cancers. The aims of this study are to determine the plasma expression level of DCAMKL-1 in pancreatic cancer patients by stage, and to measure the tissue expression level of DCAMKL-1 in this patient population. RESULTS: We observed greater than a 2.5-fold increase in plasma DCAMKL-1 in patients with stage I pancreatic cancer compared to controls by Western blot analysis (p < 0.05). We also observed increased DCAMKL-1 expression by ELISA: stage I (3.42-fold, p = 0.07); II (4.1-fold, p < 0.05); III (2.06-fold, p > 0.05) and IV (1.15-fold, p > 0.05). There were similar DCAMKL-1 mRNA expression levels in both stage II and III tumor tissues (n = 8). Interestingly, we found METHODS: Isolated DNA samples from primary PDAC and individually matched adjacent normal tissue from 37 patients who underwent operative resection were analyzed. The methylation status of 6 gene promoters (RASSF1A, MGMT, GSTP1, APC, P16/CDKN2A, and NEFL) was determined by quantitative methylation-specific PCR (QMSP). Promoter site methylation levels were calculated and correlated with clinical, pathologic, and outcome factors. RESULTS: Hypermethylation of the neurofilament light chain (NEFL) gene was significantly higher in PDAC compared to matched adjacent normal tissue (p < 0.01). Promoter methylation levels of APC in PDAC correlated with overall survival, HR = 1.004 (95% CI, 1.001–1.007), and APC gene hypermethylation in matched normal tissue was associated with death within one year after resection (OR 0.073; 95% CI, 0.007–0.724). Promoter methylation of APC in host normal tissue along with APC methylation levels of primary tumors and surgical resection margin status can be used to evaluate the risk of death within one year after resection with a predictive accuracy of 87%. CONCLUSION: Hypermethylation of the promoter region of candidate tumor suppressor genes in patients with pancreatic adenocarcinoma treated by operative resection is associated with early recurrence and death. Larger scale studies will be necessary to validate patterns of gene methylation as a potential cancer-specific molecular marker system related to outcomes for pancreatic cancer. 113 Monday Poster Abstracts METHODS: Purified plasma samples from controls (n = 10) and stage I (n = 9), II (n = 15), III (n = 14) and IV (n = 11) pancreatic cancer patients were subjected to Western blot and ELISA analysis. Surgical cancer specimens and normal pancreas (commercial tissue array) were immunostained for DCAMKL-1. An independent pathologist scored the immunohistochemical staining based on intensity and tissue involvement. Samples of tumor and adjacent normal tissue from pancreatic surgical specimens were homogenized. Total RNA isolated from these samples was subjected to real-time PCR to measure mRNA expression levels. BACKGROUND: Reliable biomarkers to predict prognosis are lacking for patients with pancreatic ductal adenocarcinoma (PDAC) who are being considered for appropriate multimodality treatment. The aim of this study was to investigate aberrant hypermethylation of a candidate set of tumor suppressor genes as a potential cancer-specific molecular marker system related to outcomes for patients with resected PDAC. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Basic: Small Bowel were observed, these changes appear not to be specific for POI, as they occurred also in SC, without delayed intestinal transit or inflammation. However, these postoperative changes in α-adrenergic neurotransmission might still participate in disturbances of postoperative bowel function. DFG KA2329/5–1 Mo1884 Changes in Neurotransmission via α1- and α2-Receptors During Postoperative Ileus in Rat Bernhard Stoklas*, Brigitte Goetz, Petra Benhaqi, Martin E. Kreis, Michael S. Kasparek Department of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany Basic: Stomach BACKGROUND: The role of α-receptors in control of intestinal motility is poorly understood. We aimed to study the mechanism of action of α1- and α2-agonists and to investigate changes in α-adrenergic neurotransmission potentially participating in pathophysiology of POI. METHODS: Circular, jejunal muscle strips (n = 8/rat) were obtained from male Sprague Dawley rats (n = 6/group). Groups: Naïve controls (NC), sham controls 12h and 3d after laparotomy to study combined effects of anesthesia and laparotomy (SC12h, SC3d), and rats 12h and 3d after laparotomy and small bowel manipulation (P12h, P3d) to induce POI. Dose-dependent effects of α1-agonist phenylephrine (10–8–10–5M) and α2-agonist clonidine (3 × 10–8–3 × 10–5M) without and with TTX (blocking enteric nerves; 10–6M), L-NIL (blocking inducible nitric oxide-synthase; 3 × 10–5M) and nimesulide (blocking cyclooxygenase-2; 10–5M), or α-receptor antagonist phentolamine (10–5M) were studied. Intestinal transit was studied by charcoal gavage ([%] small bowel passed by marker). Histology in whole mounts was performed for myeloperoxidase positive cells (MPO), macrophages, and mastcells (cells/mm2). Data: mean ± SEM. RESULTS: Phenylephrine and clonidine caused dosedependent inhibition in all groups (p < 0.05). Phenylephrine-induced inhibition was increased only in SC3d (p < 0.05 vs NC). TTX reduced phenylephrine-induced inhibition in NC, P3d, and SC3d (all p < 0.05 vs without TTX), while L-NIL and nimesulide had no effect on phenylephrine-induced inhibition (p = NS vs without L-NIL and nimesulide). Clonidine-induced inhibition was reduced in P3d and SC12h (p < 0.05 vs NC). TTX reduced clonidineinduced inhibition in NC while it increased the clonidineeffect in P3d (both p < 0.05 vs without TTX). L-NIL and nimesulide reduced clonidine-induced inhibition in P12h, SC12h, and SC3d (all p < 0.05 vs without L-NIL and nimesulide). Phentolamine prevented phenylephrine- and clonidine-induced inhibition in all groups (all p < 0.05). Intestinal transit was delayed only in P12h (P12h 28 ± 3; NC 54 ± 2%; p < 0.05 vs NC). MPO positive cells and mast cells were increased in P12h and P3d, but not in sham controls (MPO: NC 12 ± 2; P12h 908 ± 125; P3d 828 ± 84; mastcells: NC 19 ± 4; P12h 639 ± 174; P3d 1137 ± 225; all p < 0.05 vs NC). Macrophages were elevated in only P3d (NC 369 ± 30; P3d 1274 ± 237; p < 0.05 vs NC). CONCLUSION: We demonstrated that contractile activity can be inhibited via α1- and α2-receptors and that this effect is in parted mediated via enteric nerves. Although postoperative changes in α1- and α2-adrenergic neurotransmission Mo1885 Intratumoral Epcam Expression in Gastric Cancer: A Potential Prognostic Marker and Therapeutic Target Daniel Vallbohmer*1, Agnieszka Dulian1, Feride KröPil1, Andreas Krieg1, Stephan E. Baldus2, Wolfram T. Knoefel1, Nikolas H. Stoecklein1 1. Department of General, Visceral and Paediatric Surgery, University of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology, University of Dusseldorf, Dusseldorf, Germany INTRODUCTION: Intratumoral expression of the epithelial cellular adhesion molecule (EpCAM) is of great prognostic impact in various malignant tumors. However, less data about its role in gastric cancer is available. Therefore, we investigated the expression patterns of EpCAM in this malignancy and its prognostic impact on gastric cancer patients undergoing primary surgical therapy. PATIENTS AND METHODS: The intratumoral protein expression of EpCAM was assessed in 163 gastric cancer patients undergoing primary surgical therapy (61 diffuse-, 62 intestinal-, 32 mixed-type and 8 unclassified tumors) by immunohistochemistry, using the monoclonal antibody Ber-EP4. Intensity of staining was classified according the HercepTest-Score as a standardized scoring system. Afterwards intratumoral EpCAM expression patterns were correlated with clinicopathologic parameters including overall survival. RESULTS: EpCAM expression was observed in 77% of the tumors. Of these, 58% (n = 74) presented a homogeneous intratumoral EpCAM expression while 42% presented a difference between the centre and invasion front of the tumor. Interestingly, tumors with high EpCAM expression in the invasion front were associated with a significantly higher proportion of lymph node metastases and lower median overall survival (p = 0.03; p = 0.001). This observation was significantly (p = 0.04) higher in diffuse type of gastric cancers compared to the intestinal type. Multivariate survival analysis identified high EpCAM expression in the invasion front as an independent prognostic factor (Cox-Regression analysis). CONCLUSION: Intratumoral EpCAM expression in the invasion front was associated with a significant decrease in overall survival of patients with gastric cancer. Considering the discontenting results of the current neoadjuvant/adjuvant concepts for gastric cancer patients, EpCAM might provide a promising target for a neoadjuvant/adjuvant immunotherapy. 114 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Clinical: Biliary Mo1455 Extended Left Hepatic Trisectionectomy as a Feasible Surgical Procedure for Advanced Perihilar Cholangiocarcinoma Minoru Esaki*1, Kazuaki Shimada1, Seiji Oguro1, Yoji Kishi1, Satoshi Nara1, Tomoo Kosuge1, Yoshihiro Sakamoto2, Tsuyoshi Sano3 1. Hepato-biliary pancreatic surgery, National Cancer Center Hospital, Tokyo, Japan; 2. Hepato-Biliary-Pancreatic Surgery Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; 3. Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan OBJECTIVES: The aim of this study was to clarify the short and long term outcome of extended left hepatic trisectionectomy (LT) for perihilar cholangiocarcinoma. METHODS: Patients with perihilar cholangiocarcinoma who underwent LT between January 2000 and October 2010 for perihilar cholangiocarcinoma were analyzed retrospectively. Operative variables, mortality, morbidity, recurrence sites and survival of three groups were compared among LT, right hemihepatectomy (RH) and left hemihepatectomy (LH). RESULTS: A total 203 patients underwent surgical resection for perihilar cholangiocarcinoma, 22 (11%) of whom underwent LT, 79 (39%) underwent RH, and 84 (41%) underwent LH. No mortality occurred, but 17 patients had morbidity. Operative time and blood loss were 655 ± 142 minutes and 2100 ± 1080 ml, respectively. Blood loss in patients with LT was significantly more than in those with LH (2100ml versus 1300ml; P = 0.017). The incidence of Grade IIIa complication in patients with LT was significant higher than RH and LH (P = 0.044 and P = 0.014), but Grade IIIb and IV complication did not occur in patients with LT. Overall 5-year survival rate was 40% with median survival of 45.8 years. There was no significant difference in survival in patients between LT and other two procedures. CONCLUSIONS: LT for perihilar cholangiocarcinoma is feasible and can provide a comparable prognosis for advanced perihilar cholangiocarcinoma originating from left hepatic duct or segment 4 especially extending to the root of the right anterior portal pedicle or confluence of the anterior and posterior branch of the bile duct. Mo1456 Audit of the Use of Critical View of Safety and Infundibular Cystic Technique in Cystic Duct Identification in Laparoscopic Cholecystectomy Anokha Oomman*1,2, Ashraf M. Rasheed2, Karthic Rajaram2, Krithika Murugan2 1. Withybush General Hospital, Haverfordwest, United Kingdom; 2. Gwent Institute of Minimal Access Surgery, Royal Gwent Hospital, Newport, United Kingdom INTRODUCTION: The commonest cause of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is the confusion of bile duct with cystic duct. Operation notes must include the anatomical rationale by which the cystic duct was conclusively identified. AIM: To examine the quality of documentation and the terms used to describe the method/methods utilised to identify the cystic duct during laparoscopic cholecystectomy. 115 Monday Poster Abstracts METHOD: The documentation of the method/s used for cystic duct identification was examined in 322 consecutive non-converted LCs that were carried out between the months of August 2010 and January 2011. Non-protocolised operation notes were studied and stratified into different groups according to the descriptive terms used. The strata included: 1). No documentation of the method used, 2). Calot’s triangle was dissected or demonstrated, 3) Infundibular or infundibulo-cystic technique used, 4). Critical view of safety (CVS) demonstrated, 5) Intra-operative cholangiogram used, or 6) Other methods. RESULTS: Demonstration of the critical view of safety was documented in (4/310) 1.3% of the cases. Infundibular or infundibulo-cystic technique was used to define the cystic duct in (9/310) 3.4% of the notes. Calot’s triangle was mentioned in (255/310) 82.3% of the notes. In (43/310) 13.9% of cases, the cystic artery and duct were mentioned without any reference to critical view of safety, infundibular/ infundibulo-cystic technique or Calot’s triangle. CONCLUSION: Written documentation of the method of cystic duct identification in the operation notes during LC is sub-optimal. We, hence recommend standardization of the cholecystectomy operative report, inclusion of a video clip and/or photo image using digital information and communication in medicine (DICOM) to complement the textual operation notes and move towards structured computerised input that links to the picture archiving and communication system (PACS). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1457 CONCLUSION: Complications, particularly stent occlusion, occur frequently after PBD in patients scheduled to undergo PD for malignancy. Compared to PS, SEMS do not impact on the incidence of major postoperative complications and may be cost-effective as first-line endobiliary drainage given the high incidence of early stent occlusion with PS. Self-Expandable Metallic Stents Do Not Impact on the Frequency of Complications Related to Preoperative Biliary Drainage or Subsequent Pancreatoduodenectomy Wesley D. Leung*1, Gregory A. Cote1, Damien M. Tan1, Joshua A. Waters2, C. Max Schmidt2, Stuart Sherman1, Glen A. Lehman1, Evan L. Fogel1, James L. Watkins1, Lee Mchenry1, Michael G. House2 1. Gastroenterology, Indiana University, Indianapolis, IN; 2. Surgery, Indiana University School of Medicine, Indianapolis, IN Mo1458 The Influence of Analgesia, Antiemetics and Operative Factors on Admission Following Cholecystectomy: A Retrospective Review BACKGROUND: Preoperative endobiliary drainage (PBD) is commonly performed in patients with malignant obstruction for whom operative resection is eventually planned. The aim of this study was to compare the safety of pancreatoduodenectomy (PD) following PBD with selfexpandable metallic stents (SEMS) versus standard plastic stents (PS). METHODS: We conducted a single center, retrospective cohort study of patients undergoing PBD followed by PD for periampullary cancer between January 1998 and December 2009. Patients were excluded if PBD was solely performed at a different facility because details regarding PBD complications and stent type were unavailable. To determine the potential impact of SEMS on PBD and postoperative outcomes, we compare patient characteristics as well as PBD and postoperative complications between groups. If patients had more than one PBD procedure, we present complications during 1) any PBD and 2) the last PBD procedure. SEMS were routine placed at least 1 cm from the hepatic bifurcation. Variables are presented as simple proportions or medians, with two-way statistical comparisons (Fisher’s exact or Mann-Whitney-U test). RESULTS: We identified 147 patients who underwent PBD and then PD at our center, 17 (12%) of who underwent placement of a fully covered (10) or uncovered (7) SEMS. Among PS patients, 74% had a 10Fr PS placed during their final PBD. In all patients, 29% had previously undergone 1 (25%) or 2 (4%) PBDs with PS. Neoadjuvant therapy was used in 8.0% of PBD and 17.6% of SEMS patients (p = 0.20). Including previous PBD attempts, patients had at least one failed PBD (17%) or other complication (18%) including early stent occlusion (n = 22), pancreatitis (n = 1) and perforation (n = 1). Complications specific to the last PBD were similar (5.9% v. 7.1%, p = 0.85) in SEMS and PS patients, with no cases of early stent occlusion in the SEMS group. The median number of PBD procedures was significantly greater in SEMS v. PS, 2 v. 1, p < 0.001; no SEMS cases required repeat PBD. The median time from last PBD to surgery was longer in SEMS v. PS patients, 31 v. 18 days, p = 0.004. Postoperative complications Clavien grade ≥3 occurred in 22% of SEMS versus 11% of PS patients, p = 0.37. Infection-specific complications after PD were similar in the SEMS (11.1%) and PS groups, 26.8%, p = 0.31. Perioperative cholangitis occurred in one SEMS patient while one postoperative bile leak was recorded in the PS group. Median postoperative length of stay was similar in SEMS and PS patients, 8.5 v. 8.0 days; p = 0.87. Mark Bignell*, Anna Bayston, David Nunn, Michael P. Lewis General Surgery, Norfolk and Norwich university Hospital, Norwich, United Kingdom INTRODUCTION: Laparoscopic cholecystectomy is the most commonly performed elective abdominal operation and can be performed as a day case procedure. However day case rates in the UK vary widely between hospitals with figures ranging from 6.4% to 50% with higher performing centres feeling rates up to 70% are achievable. The reasons for such disparity between hospitals is multifactorial and therefore a retrospective review was undertaken to determine if any perioperative factors influenced length of stay. METHODS: 100 patients (50 day case and 50 overnight stay) who underwent elective laparoscopic cholecystectomy were subjected to a medical note review. Information on operative time, duration, surgeon, anaesthetist, patient demographics and perioperative medication such as the use of opiates and antiemetics were collected. Statistical analysis was undertaken using a Fishers’ exact test. RESULTS: The mean age in the day case group was 48 years compared to 55 years in the overnight group (NS). There were 12 males in the day case group compared to 13 in the overnight group. The mean ASA was 2 in both groups (range 1–2 in each group). 80% (n = 40) of day case patients had an anaesthetic start time before 12pm compared to 48% (n = 24) in the overnight group (p = 0.0016). Intraoperative morphine was used in 40% (n = 20) of day case patients compared to 68% (n = 34) of overnight patients (p = 0.0088) whilst this use changed to 6% (n = 3) and 26% (n = 13) respectively in recovery (p = 0.0122). The use of fentanyl was not statistically significant between the two groups intraoperatively or in recovery (88% versus 86% intraoperatively and 52% versus 60% in recovery). Dexamethasone was used in 92% (n = 46) of day case patients intraoperatively compared to 70% (n = 35) in the overnight group (p = 0.0095). The use of ondansetron was not significantly different between the two groups. CONCLUSION: Anaesthetic start time and the use of fentanyl and dexamethasone are associated with a shorter stay in hospital whilst the use of morphine either intraoperatively or in recovery leads to a longer length of stay following elective laparoscopic cholecystectomy. 116 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1459 Perioperative Outcomes of Patients Undergoing Laparoscopic Cholecystectomy: The Critical Impact of Age and Operative Status Sajida Ahad, Ibrahim B. Cetindag, Stephen Markwell, Imran Hassan* SIU School of Medicine, Springfield, IL INTRODUCTION: We evaluated the perioperative outcomes of patients undergoing elective and emergency laparoscopic cholecystectomy (LC) who were <80 and >80 years of age. PATIENTS AND METHODS: Patients undergoing LC for benign disease between 2005 and 2010 were identified from the ACS-NSQIP participant use file (PUF) utilizing the current procedural terminology (CPT) codes for LC with and without intraoperative cholangiogram. Patients undergoing any other procedure except a LC as identified by the CPT codes were excluded. A procedure was considered an emergency if so designated by the surgeon or anesthesiologist or if surgery was performed no later than 12 hours after the patient was admitted to the hospital or after the onset of related preoperative symptoms. Outcome measures analyzed included 30-day mortality, return to operating room, serious morbidity and overall morbidity. Serious morbidity was defined as having documentation of one of the following complications: organ space surgical site infection (SSI), wound dehiscence, neurologic event (cerebrovascular accident or coma lasting more than 24 hours) cardiac arrest, myocardial infarction, bleeding requiring transfusion of more than 4 units of packed red cells or whole blood, pulmonary embolism, ventilator dependence more than 48 hours, progressive or acute renal insufficiency, and sepsis or septic shock. Overall morbidity was defined as having documentation of a serious morbidity or at least one of the following complications: superficial SSI, deep SSI, pneumonia, unplanned intubation (without preoperative ventilator dependence), urinary tract infection, peripheral neurological deficit and deep vein thrombosis. Preoperative variables including patient characteristics and co-morbidities and postoperative outcomes were compared by age groups (<80 vs. >80 years) and operation status (elective vs. emergency). Multiple logistic regression was used to assess the influence of age and operation status on outcomes after accounting for available covariates. RESULTS: During the study period 91,034 patients underwent LC, which represented 90% of patients undergoing a LC in the database. Patients older than 80 years were likely to have more preoperative comorbidities and worse perioperative outcomes, however the outcomes were much worse when they underwent emergency surgery. These unadjusted comparisons persisted in the multivariable analysis. Male gender and presence of medical comorbidities were also independently associated with worse perioperative outcomes. (Table) CONCLUSIONS: Patients older than 80 years of age have more medical comorbidities and worse perioperative outcomes, particularly if they undergo emergency LC. These patients represent a high risk group and therefore in emergency situations, a non operative approach should be initially considered if feasible. Elective LC Emergency LC ≤80 Years (n = 79,641) >80 Years (n = 3,277) ≤80 Years (n = 7,679) >80 Years (n = 437) 30-day mortality 0.1 1.7 0.4 5.3 Serious morbidity 0.9 4 2 10 Overall morbidity 2.5 7 4 14 Return to OR 1 1.6 1.2 2.8 Male Gender 25 40 31 45 Diabetic 10 18 10 19 Pulmonary disease 7 20 5 19 Bivariate Comparisions* 98 85 96 75 30-Day Mortality Serious Morbidity Overall Morbidity Return to OR Emergency vs. elective 2.3 (1.6–3.2) 2 (1.6–2.2) 1.6 (1.4–1.7) 1.3 (1.0–1.6) >80 vs.≤80 Logistic regression** 2.7 (2.0–3.7) 1.3 (1.1–1.6) 1.3 (1.2–1.5) NS Male vs. female NS 1.5 (1.4–1.7) 1.1 (1.0–1.2) 1.3 (1.1–1.5) Diabetes vs. No diabetes NS 1.3 (1.2–1.5) 1.3 (1.2–1.5) 1.2 (1–1.5) Pulmonary disease vs. No pulmonary disease 2.3 (1.7–1.9) 1.6 (1.4–1.9) 1.5 (1.3–1.6) NS Cardiac disease vs. No cardiac disease 1.4 (1.0–1.9) NS NS 1.3 (1.1–1.6) * All values are expressed in percentage. ** Odds ratio (95% confidence interval) NS = Not Significant 117 Monday Poster Abstracts Independent functional status THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1460 results and the importance of early surgical intervention for improved outcomes in patients with cholecystitis, especially when focusing on efficient resource utilization, it would be advisable to proceed to cholecystectomy immediately following positive ultrasound findings without the delay or expense of a confirmatory HIDA scan. Is HIDA Scan Necessary for Sonographically Suspicious Cholecystitis? Irina Bernescu*, Tomer Davidov Surgery, Robert Wood Johnson UMDNJ, New Brunswick, NJ INTRODUCTION: Gallbladder disease is a common and escalating problem, particularly in the United States and other developed countries, where a variety of modifiable factors (including diet, alcohol consumption, and activity level) come into play. It is estimated that 20–25 million Americans have gallstones, representing 10–15% of the adult population. Of these, approximately 20% become symptomatic at some point, causing cholecystitis to account for 3–9% of hospital admissions for acute abdominal pain, with 1–3% requiring removal of the gallbladder. The progressively increasing prevalence of gallbladder disease represents a major health burden, with direct plus indirect costs of approximately $6.2 billion annually in the United States. In this context, the timely and efficient diagnosis of cholecystitis is of paramount importance, as length of hospital stay and multiple diagnostic tests for each patient are major contributors to the cost of treating gallbladder disease. Currently, abdominal ultrasound is the study of choice for diagnosing cholelithiasis, while HIDA scan is the study of choice for diagnosing cholecystitis. However, our study had the goal of determining whether patients with suspected cholecystitis on ultrasound benefitted from subsequently having a HIDA scan to clarify diagnosis. METHODS: We retrospectively reviewed patients evaluated for presumed cholecystitis between 2007 and 2010, through the Emergency Department of our 600-bed academic medical center. We identified 154 patients who underwent abdominal ultrasound and HIDA scan, and proceeded to cholecystectomy on the same admission. Ultrasound results were compared to those of HIDA scan. The pathology findings of the cholecystectomy were used as the gold standard for the diagnosis of cholecystitis. RESULTS: Statistical analysis revealed that abdominal ultrasound had 47% sensitivity for cholecystitis, with a positive predictive value of 96%. HIDA scan had a sensitivity of 62% for cholecystitis, with a positive predictive value of 96%. CONCLUSIONS: Our study confirmed previous findings related to the superior sensitivity of HIDA scan in diagnosing cholecystitis. However, we also showed that both ultrasound and HIDA scan have a positive predictive value of 96%, suggesting that a HIDA scan would not provide additional diagnostic benefit in a patient with sonographic findings consistent with cholecystitis. Based on these Mo1461 Costs Associated with Delayed Cholecystectomy After a Biliary Migration Charles MéNard*, René-Paul Beauchamp Gastro-Enterology, Sherbrooke, Sherbrooke, QC, Canada Biliary migration treated with ERCP alone carries an increased risk ok recurrent biliary event compared to cholecystectomy. It is our impression that delayed gallbladder removal also imposes additionnal costs to healthcare. Charts from1600 patients with a primary diagnosis of biliary migration, cholangitis, biliary pancreatitis or gallstone-related obstructive jaundice event between 1994 and 2008 in a single community-based teaching hospital were reviewed. Minor aged patients, one-day elective surgery at the first diagnosis of a biliary event and excessive lenght of stay were excluded.The costs of hospital care was calculated using consultation fees, procedure costs, hospital stay and clinical support related costs. Totals costs related to the biliary event when the cholecystectomy was performed at the initial event were compared to the total health care costs of postponed cholecystectomy. Surprisingly, biliary event-related costs of initial cholecystectomy ($CAN 15 531.53) was slightly higher (but non-significantly) than later cholecystectomy ($CAN 14 822,70), even when readmission and ERCP occured inbetween for recurrent biliary complication. This unsuspected twist may be driven by the longer lenght of stay during the initial event caused by delays related to imaging, ERCP and other tests done before the surgery. It is possible that in a different health care setting where procedural costs are much higher, the economic weight of late cholecystectomy would have leaned if favor of faster access to surgery. Readmission for new biliary complication occured significantly more often during the lenght of the study when cholecystectomy was delayed (17%) compared with initial cholecystectomy (7.5%), imposing unnecessary inconvenience to patients and increased technical and human burden to the health care system. Late cholecystectomy does not seem to impose additionnal costs over first episode cholecystectomy in Quebec health care system but is associated with increased admission for relapsing biliary events. 118 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Clinical: Colon-Rectal Mo1464 Mo1462 Impact of Operative Duration on Postoperative Pulmonary Complications Among Patients Undergoing Complex Gastrointestinal Procedures Colostomy vs. Ileostomy: An ACS-NSQIP Evaluation of Complications from Diverting Stoma Reversal Rachel M. Owen*, Sebastian D. Perez, John F. Sweeney Surgery, Emory University, Atlanta, GA Dhruvil R. Shah*1, Yueju LI2, Laurel Beckett2, David Wisner1, Steve R. Martinez1, Vijay P. Khatri1 1. Surgery, University of California Davis, Sacramento, CA; 2. Public Health Sciences, University of California, Davis, CA BACKGROUND: The optimal method of fecal diversion remains controversial as either colostomy or ileostomy may be sufficient. Perioperative outcomes associated with subsequent stoma reversal may inform the decision of which diversion method to use. Our aim was to evaluate perioperative morbidity and mortality associated with colostomy and ileostomy reversal. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent diverting stoma reversal between 2005 and 2008. Patients were excluded if the type of stoma reversal could not be ascertained via CPT or ICD-9 code. Outcomes evaluated included overall morbidity (≥1 serious complication), mortality, wound infections, and total surgical length of stay. Multivariate analysis identified patient- and procedure-related risk factors associated with each outcome. We reported adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). CONCLUSION: Colostomy reversal is associated with increased overall morbidity, wound infections, and nearly twice the operative time compared to ileostomy reversal. These factors should be considered when deciding which type of diverting stoma to perform. METHODS: We queried American College of Surgeons National Surgical Quality Improvement Program 2009 Participant User File for patients who underwent elective open colectomy, hepatectomy, or pancreatectomy. For this study, PPC was defined as pneumonia, prolonged mechanical ventilation greater than 48 hours, and unplanned reintubation. Patients both with and without PPCs were evaluated for operative duration, length of hospital stay, and 30-day mortality. The impact of operative duration on the risk of PPC was evaluated using logistic regression models with PPC occurrence as an outcome and operative time (in hours) as the predictor. A model was also run controlling for preoperative functional status and American Society of Anesthesiologist (ASA) class to account for differences in preoperative patient acuity. RESULTS: 8620 cases (5523 colectomies, 915 hepatectomies, and 2182 pancreatectomies) were reviewed. 456 patients (5.3%) experienced at least one PPC. For operations less than 480 minutes, each 60-minute increase in operative time was associated with a 13% increased risk of PPC (OR 1.133; 95% CI, 1.077–1.192). For operations exceeding 480 minutes, each additional 60 minutes of operative time beyond 8 hours was associated with a 30% increased risk of PPC (OR 1.296; 95% CI, 1.143–1.470). Controlling for differences in operative procedures did not affect regression modeling. Thirty-day mortality occurred in 54 (0.7%) patients without PPC, whereas 72 patients (15.7%) with one or more PPC died postoperatively. Overall, patients with one or more PPC were 28 times more likely to die than those who did not have a PPC (OR 28.3, p < 0.0001). The average length of stay for patients with at least one PPC was nearly three times as long as those without PPCs (20.08 vs. 7.43 days, respectively; p < 0.0001). CONCLUSIONS: Operative duration is independently associated with increased risk of PPC in patients undergoing complex gastrointestinal procedures, thus indirectly leading to increased postoperative mortality and longer hospital stays. 119 Monday Poster Abstracts RESULTS: A total of 5190 patients met inclusion criteria. There were 2188 colostomy reversals and 3002 ileostomy reversals. The colostomy reversal group had a significantly higher median operative time (151 min vs. 75 min, p < 0.01). The number of contaminated and dirty wounds was similar between both types of stoma reversal (49% vs. 49). There was no significant difference in mortality, median surgical length of stay, or re-operation rates. On multivariate analysis, the following preoperative factors were significant predictors of postoperative morbidity: Cr >2.0 (aOR 1.99, 95% CI :1.33–2.93), WBC between 10–20 (aOR 1.44, 95% CI:1.13–1.81), moderate exertional dyspnea (aOR 1.94, 95% CI: 1.47–2.53), and ASA status greater than 3 (aOR 1.79, 95% CI:1.53–2.10). Colostomy reversal was also associated with higher odds of overall morbidity (aOR 1.28, 95% CI:1.08–1.50) and wound infections (aOR 1.70, 95% CI :1.39–2.07). BACKGROUND: Postoperative pulmonary complications (PPC) are associated with higher healthcare costs, prolonged hospital stays, and increased morbidity and mortality than that of other postoperative complications. Many studies have demonstrated that prolonged operative duration is associated with increased postoperative morbidity and mortality. To our knowledge, the direct impact of operative duration on PPCs has not been specifically analyzed. We hypothesize that longer operative times are independently associated with an increased risk of PPCs in patients undergoing complex gastrointestinal procedures. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1465 Mo1466 Microlaparoscopic Colectomy: Initial Experience Longer LOS Yet Similar Return of BM for Hand-Assisted (vs. Laparoscopic) Colorectal Resection Patients Who Had a Higher BMI and Risk Profile Christopher Foglia*, Stuart L. Blackwood, Pierre F. Saldinger Surgery, Danbury Hospital, Danbury, CT INTRODUCTION: There has been a recent trend toward decreasing surgical invasiveness by minimizing incision size using single incision laparoscopic surgery. The technique and tools for performing this type of surgery are completely different from conventional laparoscopic surgery thus generating a steep learning curve and increased operative time. We have explored the use of microlaparoscopy in colon surgery to minimize the trauma of surgery without the need for learning an entirely new skill set. METHODS: A retrospective review of all microlaparoscopic segmental colectomies performed by a single surgeon over a 28 month period at a teaching hospital was conducted. Microlaparoscopic surgery was defined as the use of 3 mm trocars in addition to a 12 mm Hasson umbilical incision, which was later widened for specimen extraction. Cases were excluded if the decision to use either a GelPort, or standard laparoscopic instruments was made at the outset of the case. RESULTS: 38 patients underwent microlaparoscopic colectomy for cancer (n = 14), polyps (n = 7), diverticulitis (n = 14), Crohn’s disease (n = 2) and volvulus (n = 1). Six patients (16%) required conversion: 2 to limited laparotomy, 3 to a hand assisted approach through an 8 cm pfannenstiel incision, and 1 where a 3 mm port was upsized to 12 mm. Reasons for conversion included: difficult visualization, inadvertent colotomy, excessive visceral fat, adhesions, inadequate reach of 3 mm instruments, need for use of a right lower quadrant GIA stapler, and one positive intra-op leak test. In patients who had resection for cancer, average lymph node harvest was 25 (range 14–70 nodes). Patients who were completed with microlaparoscopic technique had an average extraction incision length of 3.8 cm (range 3.0–6.5 cm) and on average two additional 3 mm port sites. Right colon resections had on average a shorter operative time (181 minutes) when compared to left colon resections (253 minutes). Median length of stay was 4 days (range 3–13 days). 5 patients experienced a total of 10 post operative complications. These included CDiff, AFib, CHF, pneumonia, acute renal insufficiency, respiratory failure, DVT, wound infection, GI bleed, recurrence of colovesical fistula, and one anastomotic leak 2 weeks postoperatively that was managed non-operatively. Thirty day mortality rate was 0/38 CONCLUSION: Microlaparoscopic colectomy is safe and feasible. It offers a minimally invasive technique that reduces incision length while using similar techniques as standard laparoscopic colectomy. Future advances may continue the trend toward reducing instrument size, thus reducing trauma to the patient while preserving a technique that has already taken years to infiltrate common practice for colon surgery. Samer Naffouje*1, Sonali A. Herath1, M.C. Shantha Kumara H1, Xiaohong Yan1, Joon Ho Jang1, Linda Njoh1, Elizabeth Myers1, Tromp Wouter1, Vesna Cekic1, Daniel L. Feingold2, Richard L. Whelan1,2 1. Department of Surgery, St. Luke’s Roosevelt Hospital Center, New York, NY; 2. Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY INTRODUCTION: Most minimally invasive surgery (MIS) surgeons utilize Laparoscopic Assisted (LA) or HandAssisted (HA) colorectal resection methods; the majority do not use both methods. This review of the experience of a group of MIS surgeons who embrace both methods selectively for sigmoid resection (SR) was begun in an attempt to identify factor(s) that influence the choice of surgical method. It was believed that the selective use of LA and HA methods would allow more cases to be done using MIS methods. METHODS: A retrospective review of SR data from 2 institutions over a 10 year period was carried out. Demographic data as well as comorbidities, indications, operative data, and short term results were reviewed. RESULTS: A total of 536 SR patients (pts) were identified, the methods used were: LA, 286 pts (53.4%); HA, 172 (32.1%); and Open (OP), 78 (14.5%). SR indications were cancer in 206 pts (38.4%) and benign problems (diverticulitis, polyps, IBD, etc) in 330 pts (61.6%). The HA group’s mean BMI (29.04 ± 6.18) was significantly greater than the mean BMI of the LA (25.85 ± 5.35) and OP (25.88 ± 5.53) groups (p < 0.0001 for both comparisons). In regards to benign SR’s, the HA group had significantly more high risk patients (HRP) than the LA group but significantly fewer HRP’s than the OP group (Charlson Comorbidity Index). In the cancer pts there was a trend toward more HRP’s in the HA vs. the LA group (p = 0.074). Notably more OP pts required transfusions (34.6%) than LA (8.3%) or HA (7%) pts (p < 0.0001 for both). The mean incision lengths (IL) were: LA, 6.59 ± 4.18 cm; HA, 9.82 ± 3.57 cm; and OP, 19.35 ± 5.94 cm (p < 0.05 for all). The mean time to first flatus (FL) and mean time to first bowel movement (BM) were significantly shorter for the LA (FL, 2.60 days; BM, 3.09 days) and HA groups (FL, 2.70 days; BM, 3.30 days) when compared to the OP group’s results (FL, 3.76 days; BM, 4.11 days). The HA mean length of stay (LOS) of 7.12 ± 5.0 days was longer than for the LA pts (6.14 ± 3.8 days; p = 0.03) yet shorter than the OP LOS (11.5 ± 10.6 days; p < 0.0001). The overall morbidity rate for the three methods was: LA, 24.5%; HA, 38.4%, and OP, 48.7% (LA vs. OP; p = 0.002, LA vs. HA; p = 0.0021). The leak/abscess rates were: LA, 2.1%; HA, 2.9%; and OP, 3.8% (p = ns for all). There was no difference in the wound infection, bleeding, or cardiac complication rates. 120 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSIONS: The majority of SR’s were done using LA methods whereas HA methods were used for about 1/3 of cases. HA methods were used for higher BMI and higher risk pts (vs. LA patients). The HA LOS was 1 day longer than the LA group yet the HA and LA return of bowel function was similar. Except for BMI, the OP pts were the most challenging. Utilization of both HA and LA methods allows the great majority of SR cases to be done using MIS methods. Mo1467 Predictors of Successful Pelvic Reoperations in Colorectal Surgery: A Multivariate Analysis Emanuela Silva*, Marylise Boutros, Ricardo Aliendre, Fabio Potenti, Giovanna Dasilva, Steven Wexner Colorectal Surgery, Cleveland Clinic Florida, Weston, FL Predictors of successful outcomes following reoperative pelvic surgery are poorly defined. We aim to identify predictors of successful pelvic colorectal reoperations. After IRB approval, we identified all patients from our prospective database who underwent re-operative pelvic surgery from 01/02–07/11. Patient demographics and clinical variables were confirmed by chart review. Primary outcome was the overall complication rate; including early (≤30 day) and late (>30 day) complications, and the secondary outcome was diverting stoma closure [SC]. Chi-square and student’s t test were performed. All variables with p < 0.1 on univariate analysis were included in multivariate cox regression analysis. Mo1468 Ethnicity Defines the Risk of Crohn’s Disease of the Ileoanal Pouch Saurabh Mukewar*1, Xianrui Wu3, Rocio Lopez4, Pokala R. Kiran2, Feza H. Remzi2, Bo Shen3 1. Cleveland Clinic Foundation, Ohio, Cleveland, OH; 2. Colorectal Surgery, Cleveland Clinic Foundation, Ohio, Cleveland, OH; 3. Gastroenterology and Hepatology, Cleveland Clinic Foundation, Ohio, Cleveland, OH; 4. Quantitative Health Sciences, Cleveland Clinic Foundation, Ohio, Cleveland, OH BACKGROUND: A few previous paired studies (including ours) showed that African-American (AA) and HispanicAmerican (HA) had similar pouch related outcomes after ileal pouch-anal anastomosis (IPAA). There is no previous data on pouch outcomes for Indian-American (IA) patients. Further, whether ethinicity differentially influences pouch related outcomes after IPAA has not been investigated. AIM: To compare differences in outcomes after IPAA for ulcerative colitis (UC) for AA, HA, IA and Caucasian-American patients. METHODS: From a prospectively maintained Pouchitis Database, this historical cohort study identified and compared UC patients with different racial background (AA, HA, IA or Caucasian-american) who underwent IPAA. Pouch patients with familial adenomatous polyposis, and those with unknown or mixed racial background were excluded. CD of the pouch was diagnosed based on a combined assessment of endoscopic, histologic, and radiographic features. A total of 25 demographic and clinical variables were evaluated with both univariate and multivariable analyses. RESULTS: There were 22 IA, 26 AA, 37 HA and 822 Caucasian-American patients. Results of unvariable and multivariable analyses associated with characteristics and outcomes for the various groups are shown in the following Tables 1 and 2, respectively. CONCLUSION: Significant differences in the disease course of UC before colectomy such as disease extent, use of immunomodulator or biologics, and duration of UC exist between the various ethnic groups. Racial background is independently associated with the risk for developing CD of pouch with AA patients having a 11-fold and CaucasianAmericans an 8-fold higher risk of developing CD of pouch compared to IA UC patients undergoing IPAA surgery. 121 Monday Poster Abstracts 254 pelvic reoperations (mean age 52 years, 47% male) were performed, including 104 with establishment of intestinal continuity. The most common diagnoses were: mucosal ulcerative colitis (35%), rectal cancer (24%), diverticulitis (18%), Crohn’s disease (6%) and familial adenomatous polyposis (6%). The most common initial operations performed were: total proctocolectomy with ileoanal pouch anastomosis [IPAA] (41%), resection with colorectal anastomosis (27%) and resection with coloanal anastomosis (17%). Indications for reoperation included: anastomotic leak (53%), fistula (14%), anastomotic stricture (10%), IPAA dysfunction (11%) and recurrent cancer (8%). The overall complication rate after reoperation was 20%; 8% early and 12% late. On multivariate regression, BMI ≥ 25 kg/m2 (p < 0.03) and anastomotic complications (leak, fistula or stricture) as the indication for reoperation (p < 0.0001) were independent predictors of complications. Intraoperative complications during initial operation (p < 0.002) and steroids at the time of reoperation (p < 0.01) were independent predictors of early and late complications, respectively. 104 patients underwent reoperation with re-establishment of intestinal continuity with an overall complication rate of 19% (8% early and 11% late). 88% had an ileostomy at time of reoperation, of whom 71% underwent SC. Complications after reoperation delayed time to SC (380 vs. 196 days, p < 0.05). On multivariate regression, IPAA (p < 0.0001) and ASA class I (p < 0.03) were independent predictors of SC; while rectal cancer (p < 0.005) and diverticulitis (p < 0.02) as the initial indication for operation, and coloanal anastomosis at initial operation (p < 0.03) were independent negative predictors of SC. Despite the complexity of pelvic colorectal reoperations, in experienced hands, the overall complication rate is low. Whenever possible, patients should be counseled to taper steroids and reach ideal BMI prior to undergoing pelvic reoperative surgery. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Table 1: Risk Factors for Post-Op Development of CD of the Pouch: Multivariable Logistic Regression Analysis Odds Ratio (95% Confidence Interval) p-Value African-American vs. Indian-American Factor 11.2 (1.1, 1507.3 0.012 Caucasian-American vs. Indian-American 8.1 (1.10, 1040.0) 0.008 Hispanic-American vs. Indian-American 4.2 (0.40, 572.0) 0.091 Age at time of pouch creation (5 yr. increase) 0.87 (0.81, 0.93) <0.0001 Pouch duration (5 yr. increase) 1.2 (1.08, 1.4) 0.002 Pre-operative diagnosis: CD vs. UC 6.6 (2.2, 21.5) 0.001 Family history of CD 2.0 (1.06, 3.6) 0.035 Table 2: Descriptive Characteristics of IPAA Patients Based on Racial Background Caucasian-American (N = 822) African-American (N = 26) Indian-American (N = 22) Hispanic-American (N = 37) p-Value Male 458 (55.7) 13 (50.0) 10 (45.5) 23 (62.2) 0.59 Age at time of diagnosis (yrs.) 27.6 ± 12.4 28.0 ± 11.1 28.7 ± 10.3 24.4 ± 13.2 0.45 Age at time of IPAA surgery (yrs.) 36.2 ± 13.9 33.3 ± 11.6 36.7 ± 11.9 32.9 ± 13.5 0.39 Factor Current age (yrs.) 46.2 ± 14.2 39.5 ± 9.3 43.7 ± 13.5 41.9 ± 15.0 0.027 Duration of UC from diagnosis to IPAA surgery (yrs.) 6.0[2.0,12.0] 5.0[2.0,7.0] 5.5[4.0,12.0] 8.0[2.0,11.0] 0.56 . Never 630 (76.6) 24 (92.3) 22 (100.0) 27 (73.0) . Ex-smoker 9 (24.3) Smoking 0.026 122 (14.8) 2 (7.7) 0 . Current smoker 70 (8.5) 0 0 1 (2.7) Chronic NSAID use 50 (6.1) 5 (19.2) 1 (4.5) 2 (5.4) 0.058 179 (21.8) 1 (3.8) 1 (4.5) 10 (27.0) 0.026 Family history IBD CD 53 (6.4) 0 0 1 (2.7) 0.25 UC 132 (16.1) 1 (3.8) 1 (4.5) 9 (24.3) 0.073 . Refractory to medical therapy 716 (87.1) 26 (100.0) 20 (90.9) 29 (78.4) . Dysplasia 106 (12.9) 0 2 (9.1) 8 (21.6) Indication for colectomy 0.083 Pre-operative diagnosis 0.53 . UC 744 (90.5) 26 (100.0) 21 (95.5) 35 (94.6) . IC 66 (8.0) 0 1 (4.5) 1 (2.7) . CD 12 (1.5) 0 0 1 (2.7) 777 (94.5) 3 22 (84.6) 15 (71.4)1 35 (94.6) . Left-sided colitis/Proctitis 45 (5.5) 4 (15.4) 6 (28.6) 2 (5.4) Fulminant colitis 88 (10.7) 0 3 (13.6) 4 (10.8) Extent of ulcerative colitis . Pancolitis <0.001 122 0.34 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Caucasian-American (N = 822) African-American (N = 26) Indian-American (N = 22) Hispanic-American (N = 37) Pre-operative use of biologics 70 (8.5) 4 (15.4) 5 (22.7) 4 03 0.015 Number of visits to pouch clinic 2.0 [1.00,3.0] 3,4 1.00 [1.00,2.0] 1.00 [1.00,2.0] 1 1.00 [0.00,2.0] 1 <0.001 .J 767 (93.4) 26 (100.0) 21 (95.5) 36 (97.3) .S 25 (3.0) 0 0 0 . Other 29 (3.5) 0 1 (4.5) 1 (2.7) .1 28 (3.4) 0 0 0 .2 626 (76.2) 22 (84.6) 16 (84.2) 30 (81.1) .3 120 (14.6) 3 (11.5) 3 (15.8) 5 (13.5) Factor Pouch type p-Value 0.7 Stage of pouch surgery 0.85 . 4 or redo pouch 48 (5.8) 1 (3.8) 0 0 Post-operative use of immunomodulator 88 (10.7) 2 (7.7) 1 (4.5) 2 (5.4) 0.55 Post-operative use of biologics 75 (9.1) 2 (7.7) 1 (4.5) 1 (2.7) 0.5 Autoimmune disease 115 (14.0) 4 (15.4) 0 3 (8.1) 0.2 Primary sclerosing cholangitis 43 (5.2) 1 (3.8) 1 (4.5) 1 (2.7) 0.9 Liver transplantation 8 (0.97) 1 (3.8) 0 1 (2.7) 0.39 Significant comorbidities 65 (7.9) 3 (11.5) 0 2 (5.4) 0.44 . Normal pouch 82 (10.0)4 5 (19.2) 7 (31.8) 13 (35.1) 1 . Irritable pouch syndrome 142 (17.3) 4 (15.4) 1 (4.5) 5 (13.5) . Active pouchitis 164 (20.0) 5 (19.2) 7 (31.8) 6 (16.2) Final diagnosis 0.003 . Refractory pouchitis 107 (13.0) 1 (3.8) 3 (15.8) 5 (13.5) . Crohn’s pouch 164 (20.0) 5 (19.2) 0 4 (10.8) . Cuffitis 83 (10.1) 2 (7.7) 1 (4.5) 2 (5.4) . Surgical complications 78 (9.5) 4 (15.4) 3 (15.8) 2 (5.4) . Anismus 2 (0.24) 0 0 0 Extra-intestinal manifestations 314 (38.2) 7 (26.9) 6 (27.3) 9 (24.3) 0.16 Post-op hospitalization 133 (16.2) 4 (15.4) 6 (27.3) 8 (21.6) 0.46 Pouch failure 62 (7.5) 3 (11.5) 4 (18.2) 2 (5.4) 0.24 9.0 [5.0,14.0] 2,3 4.5 [2.0,10.0] 1 4.0 [2.0,10.0] 1 9.0 [4.0,13.0] <0.001 Values presented as Mean ± SD with ANOVA; Median [P25, P75] or Median (min, max) with Kruskal-Wallis test, or N (%) with Pearson’s chi-square test unless otherwise stated. 1 Significantly different from Caucasian Significantly different from African-Am 3 Significantly different from Indian 4 Significantly different from Hispanic 2 123 Monday Poster Abstracts Follow up of Pouch Failure (yrs.) THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1469 Intestinal Surgery for Crohn’s Disease: Role of Preoperative Therapy in Postoperative Outcome Marco Scarpa*1, Matteo Martinato2, Anna Pozza2, Cesare Ruffolo3, Giorgia Maran2, Renata D’Incà2, Romeo Bardini2, Imerio Angriman2 1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS), Padova, Italy; 2. Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy; 3. IV Unit of Surgery, Ospedale Regionale “Ca’ Foncello”, Treviso, Italy INTRODUCTION: During their life, 80% of patients affected by Crohn’s disease (CD) require at least one surgical procedure. All CD patients assume lifelong medical therapy and this therapy may have several severe side effects that can affect the outcome after surgery. The aim of this study was to evaluate the role of preoperative medical therapy in the outcome of intestinal surgery for CD. PATIENTS AND METHODS: In our department, 453 surgical procedures for intestinal CD were performed from 1982 to 2011. Adequate data about preoperative therapy (6 months before the operation) were available for 100 patients that were thus enrolled in this retrospective study. They were 40 women and their median age was 35 (IQR: 18–44). The median CD duration was 92 (IQR: 33–160) months and 26 patients presented a fistulizing phenotype. Medical therapy before the operation (use and dose of sulphasalazine, mesalazine, azathioprine, prednisone, beclometasone, budesonide, anti-TNFalpha) was used as possible predictor of postoperative outcome. Surgical predictors (video assisted intestinal surgery, strictureplasty, stoma creation, ileal resection and colonic resection) as well as clinical predictors (age, gender, CD duration, activity and localization, recurrent CD) were also evaluated. Outcome measures were medical and surgical complication, reoperation, day of first bowel movement, postoperative hospital stay. Univariate and multivariate analysis were performed. RESULTS: Preoperative rectal administration of beclometasone was the only independent predictor of the anastomotic leak (beta = 0.36, p < 0.001) in a model that also included minimally invasive surgery, colonic resection, obstructing phenotype, type of suture and end-to-end anastomosis (R2 = 0.29, p < 0.001). Preoperative therapy with budesonide was the only independent predictor of the delayed canalization after surgery (beta = 0.44, p < 0.001) in a model that also included minimally invasive surgery, patients gender, disease activity, ileocolonic resection, stricturoplasty, and therapy with mesalazine and beclometasone (R2 = 0.29, p = 0.003). Postoperative rectal bleeding was independently predicted by azathioprine dose (beta = 0.29, p = 0.012) while reoperation in the first month was independently predicted by the use of budesonide (beta = 0.25, p = 0.044). No adverse effect on surgical outcome were observed after the use of anti TNFalpha therapies. CONCLUSIONS: Severe CD require adequate and important medical therapy thus this is an almost unavoidable variable affecting the surgical outcome of these patients. Curiously enough, “topic” steroids seemed to be associated to poor outcome after intestinal surgery while oral steroid seemed to not affect it. Azathioprine association to postoperative rectal bleeding may be due to a decreased platelets count that sometimes occurs during the use of this immunomodulator . Mo1470 Factors Associated with Long-Term Quality of Life (QL) After Ileocolic Resection (ICR) for Crohn’s Disease Felipe Bellolio*1,4, Zane Cohen1,4, Helen M. Macrae1,4, J. Charles Victor2, Brenda I. O’Connor4, Harden Huang4, Robin S. Mcleod1,3 1. Surgery, University of Toronto, Toronto, ON, Canada; 2. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; 3. Health Policy, Managment and Evaluation, University of Toronto, Toronto, ON, Canada; 4. Zane Cohen Centre for Digestive Diseases, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada INTRODUCTION: ICR is the most commonly performed procedure in patients with Crohn’s disease yet there are few reports regarding long term QL and factors associated with it. PATIENTS AND METHODS: All patients who had ICR between 1990 and 2010 were identified from a prospectively maintained IBD database. A12 item questionnaire which included questions regarding current status, use of postoperative medications, tobacco history, need for further surgery, fertility (in females) as well as the short version of the IBDQ [scores ranging from 1 (poorest) to 7 (best)] were mailed to all patients. Uni and multivariate analyses were performed to determine factors associated with QL. RESULTS: Of 434 patients surveyed, 206 (47.5%) (mean age 33.9 ± 12.3 years at the time of surgery; 122 women) responded. Eighty-six (41.7%) received postoperative maintenance therapy and 25 (12.1%) are current smokers. Overall, 88 (42.7%) patients reported having recurrent disease of which 71 (80.6%) were clinical recurrences and 17 (19.8%) required surgery, 15 of them resection of the previous ileocolic anastomosis. Eighteen (15%) of the 119 females who responded stated they had fertility problems (at least one episode longer than 12 months trying to get pregnant) although 17 were ultimately successful in becoming pregnant. The mean SIBQ score was 5.2 ± 1.3 with scores ranging from 1.4 to 7.0 in the four domains. On multivariate analysis only recurrence of Crohn’s disease (p < 0.001) and the absence of penetrating disease at the original surgery (p = 0.039) were associated with decreased SIBD scores. CONCLUSIONS: Most patients have a good QL following ICR. However non-penetrating disease at surgery and disease recurrence appear to negatively impact on QL. 124 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1471 Mo1472 Is Laparoscopic Resection for Recurrent Disease Beneficial in Patients with Previous Intestinal Resection for Crohn’s Disease Through Midline Laparotomy? A Case-Matched Study Nervosa Anorexia Leads to Defaecatory Disorders Compared to General Population Erman Aytac*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease Institute, Cleveland, OH BACKGROUND: Patients undergoing abdominal surgery for Crohn’s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic vs. open resection in patients with previous intestinal resection for Crohn’s through a midline laparotomy is controversial. METHODS: Patients with previous open resection for intestinal Crohn’s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997–2011 were case-matched with open counterparts based on age (±5 years), gender, body mass index (±2 kg/m2), ASA score, surgical procedure and year of surgery (±3 years).Groups were compared using chi-square or Fisher exact tests for categorical and the Wilcoxon rank sum test for quantitative data. CONCLUSIONS: Bowel resection for recurrent Crohn’s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced but there are no clear recovery advantages when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated. BACKGROUND: We have previously shown that Defaecatory Disorders (DDs) can be as high as 60% in obese patients and are reversed after bariatric surgery. Conversely, similar data on DDs in patients with nervosa anorexia have been overlooked. In this case-control study we evaluated the prevalence and type of DDs in patients with nervosa anorexia. PATIENTS AND METHODS: A questionnaire-based study was proposed to patients with nervosa anorexia. Data included mean body mass index (BMI), demographics, past medical, surgical and obstetrics histories, as well as eating disorders duration. Wexner Constipation Score (WCS) and the Faecal Incontinence Severity Index (FISI) questionnaires were used to evaluate constipation and incontinence. For the purpose of this study, we considered clinically relevant a WCS ≥5 and a FISI score ≥10. Data were compared to a matched control group with 18 < BMI >28. RESULTS: a total of 32 anorexia patients (group A) accepted the study and 30 patients filled the questionnaires as matched control-group (group B). Overall, in group A mean BMI was 17 ± 3 Kg/mq(2)(range 12–23); mean illness duration 5 ± 3 (range 1–13); mean WCS was 10 ± 5 (range 2–22), while mean FISI score was 6 ± 8 (range 0–38). Overall, 90% of these patients reported DDs according to the above-mentioned scores. Thirty patients (94%) had WCS ≥5. Eleven patients (34%) had FISI score ≥10. While eleven patients (34%) reported combined abnormal scores. In Group B, mean BMI 21 ± 3 (range 18–28); mean WCS was 3.8 ± 3 (range 0–10), while FISI score was 0. Overall, 53% of these patients reported DDs according to the above-mentioned scores. Sixteen patients (53%) had WCS ≥5. None had FISI score ≥10. In group A, according to the illness duration (<5 years/>5 years) we found a statistical significance in terms of WCS ≥5 and FISI score ≥10 (p < 0.0001, p < 0.02). According to the WCS ≥5, we found a statistical significance between the two groups (p < 0.0001). CONCLUSION: Defaecatory Disorders are common in anorexia nervosa patients compared to general population. The risk of DDs increases with anorexia nervosa duration. 125 Monday Poster Abstracts RESULTS: 26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (1), extended right colectomy (1) and stricturoplasty (n = 1) were wellmatched to 26 patients undergoing open surgery. The number of previous operations, steroid use, and incidence of hypertension, diabetes, cardiopulmonary, neurological, renal and hepatic comorbidities were comparable in the 2 groups. There were no deaths and 3 patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 ± 83 vs. 158 ± 42 minutes, p = 0.94), estimated blood loss (222 ± 181 vs. 427 ± 589 ml, p = 0.32), overall morbidity (39% vs. 69%, p = 0.051), reoperation rates (8% vs. 0, p = 0.5), postoperative return to bowel function (3.5 ± 1.4 vs. 3.9 ± 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 vs. 6.9 ± 3.5 days, p = 0.12) and readmission rates (8% vs. 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 vs. 27%, p = 0.01). Pierpaolo Sileri1, Iacoangeli Fabrizio2, Federica Starr2, Luana Franceschilli*1, Elisabetta De Luca1, Alessandra Di Giorgio1, Marilena Raniolo1, Maria Irene Bellini1, Stefano D’ Ugo1, Achille Gaspari1 1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Internal Medicine, University of Rome, Tor Vergata, Rome, Italy THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1473 Mo1475 Role of Metastatic Lymph Node Ratio as a Prognostic Index in Colorectal Cancer Surgery Does Laparoscopic Colectomy Have Reduced PostOperative Morbidity and Mortality in Octogenarians Compared to Open? Pierpaolo Sileri1, Stefano D’ Ugo*1, Giulio P. Angelucci1, Luana Franceschilli1, Marco D’Eletto1, Mara Capperucci1, Vincenzo Formica2, Giampiero Palmieri3, Nicola Di Lorenzo1, Achille Gaspari1 1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Oncology, University of Rome, Tor Vergata, Rome, Italy; 3. Pathology, University of Rome, Tor Vergata, Rome, Italy Roman Grinberg, Muhammad Asad Khan*, John Afthinos, Karen E. Gibbs Surgery, Staten Island University Hospital, Staten Island, NY BACKGROUND: The ratio of metastatic to total retrieved nodes, defined Lymph Node Ratio (LNR), has shown a better prognostic significance in several gastrointestinal cancers compared to the absolute number of positive lymph nodes. The aim of this study was to assess the value of LNR on long-term outcome of patients submitted to colorectal surgery for malignancies. METHODS: Clinical and pathologic data of patients underwent colorectal surgery for resectable cancer at our Department of Surgical Sciences were routinely and prospectively inserted in a database between January 2003 and August 2011 . We reviewed the total number of lymph nodes retrieved in the surgical specimen and the number of lymphatic metastasis. The value of the LNR was compared with the long term outcome for each patients, and the prognostic significance of LNR evaluated using the KaplanMeier survival curve and the log-rank test. RESULTS: From an overall database of 1004 patients we selected two hundred and thirty patients (51.3% male, 48.6% female) that fulfilled the study criteria. The mean age of the study group was 68.4 ± 10.5 years. The type of surgery performed were right colectomy in 72 patients (31.3%), left colectomy in 73 patients (31.7%), anterior resection or miles procedure in 79 patients (34.3%) and other procedures in 6 patients ( 2.6%). Ten patients (4.3%) were T1 staged, 30 (13.1%) were T2, 167 (72.6%) were T3 and 23 (10%) were T4. The mean number of lymph node retrieved were 13.6 ± 6.9 and 89 patients (38.7%) were node positive with a mean metastatic lymph node number of 1,4 ± 2.7. Since LNR increase as a function of metastatic lymph node number we found that a LNR between 0.1 and 0.2 compared to LNR major than 0.2 has a significant difference in predicting the long term outcome of these patients ( p = 0.04). CONCLUSION: After colorectal cancer surgery the LNR is an accurate prognostic factor in node-positive patients in long term overall survival and disease free survival. OBJECTIVES: The benefits of laparoscopic colectomy are well described in the literature and its use has been continually increasing. Given the sharp rise in the octogenarian population from longer life expectancy, they will make up a larger proportion of patients which are cared for by surgeons. We wished to compare the outcomes of laparoscopic and open colon resections in this distinct and challenging age group. METHODS: Using the ACS-NSQIP database, we identified all elective laparoscopic colectomies performed between 2007 and 2009 in patients ≥80 years of age. Preoperative co-morbidities, operative time, length of hospitalization and perioperative mortality and morbidity were compared between the two groups using chi-square and independent t-test as appropriate. RESULTS: A total of 3,898 patients ≥80 years old were identified who underwent a colectomy with primary anastomosis. Of these, 1,123 (28.8%) patients underwent laparoscopic colectomy while 2775 (71.2%) patients underwent open colectomy. There were no statistically significant differences between the laparoscopic and open groups in terms of comorbidities. The only statistically significant complications were cardiac arrest, superficial wound complication and sepsis, all of which were higher in the open group. There was otherwise no statistically significant difference in surgical wound complications between open and laparoscopic group. There was no difference in operative times between the two groups. Length of stay (7.9 ± 7 days vs. 10.8 ± 8.1 days, p < 0.001) and rate of major complications was significantly less in the laparoscopic group (12.9% vs. 17.9%, p < 0.001). The post-operative mortality rate was similar in both groups (3.2% vs. 3.3% for laparoscopic vs. open, respectively, p = 0.05). CONCLUSION: Minimally invasive colectomy in patients ≥80 years old reduces length of stay and major postoperative complications when compared to the open approach. However, mortality is not different. This suggests that laparoscopic colectomy has potential benefits for octogenarians and should be considered as the approach of choice when feasible. 126 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1476 Mo1477 Does the Laparoscopic Approach to Colectomy Lessen the Post-Operative Complications in Octogenarians? Endoscopic Resection of Rectal NETs: Establishing Guidelines for Oncologic Endpoints Muhammad Asad Khan*, Roman Grinberg, John Afthinos, Karen E. Gibbs Surgery, Staten Island University Hospital, Staten Island, NY Thomas Curran*1, Vitaliy Y. Poylin1, Robert M. Najarian2, Deborah Nagle1 1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2. Pathology, Beth Israel Deaconess Medical Center, Boston, MA OBJECTIVES: The percentage of octogenarians in the population is increasing and these patients are now more commonly seen in surgical practice. Colonic pathology is a major disease entity for which surgical therapy is sought by this age group. Octogenarians are more susceptible to complications and mortality after colectomy given their high incidence of comorbid factors and decreased physiologic reserve. There have been conflicting reports in the literature regarding the outcomes of this population with respect to laparoscopic colectomy. We sought to evaluate this using a national database sample. METHODS: Using the ACS-NSQIP database, we identified all elective laparoscopic colectomies performed between 2007 and 2009 in patients ≥80 years of age. Preoperative co-morbidities, operative time, length of hospitalization and perioperative mortality and morbidity were compared between the two groups using chi-square and independent t-test as appropriate. A multivariate logistic regression analysis was used to analyze potential factors contributing to post-operative morbidity and mortality. CONCLUSION: Despite the potential benefits derived from a laparoscopic approach, octogenarians had a higher morbidity and mortality rate. Independent risk factors which increased the probability of complications post-operatively were defined. These must be weighed carefully in the riskbenefit analysis of an octogenarian about to undergo an elective colectomy. Interestingly, the presence of ascites was the strongest predictor of mortality in this analysis. METHODS: All pathologically confirmed, endoscopically diagnosed rectal NETs at a tertiary care center from 2000 to 2010 were retrospectively reviewed. Clinical data from were evaluated. Pathologic criteria including tumor size, margin status, mitotic rate, depth of invasion, lymphovascular invasion and other factors were considered. RESULTS: 40 patients (21 male) with rectal NETs were identified. Mean age was 55 years (range: 31.8–73.9 years). Mean follow up was 44 months (range: 1–122 months). A majority (68%) were asymptomatic, undergoing colonoscopy for general screening. 27 (68%) underwent whole endoscopic resection while the remainder underwent piecemeal resection (N = 9) or biopsy (N = 4). Mitotic rate was <2 mitoses per high-powered field in 29 (97%). Mean tumor size was 0.9 cm (range 0.2–2.5 cm). Margin positive patients (N = 18) showed no residual disease on re-resection in 11 cases (2 TEM, 9 endoscopic); 3 had remaining disease managed endoscopically and 3 went to OR for resection of large or deeply invasive tumors. Indeterminate margin patients (N = 11) showed no residual disease in 6 cases; 2 had remaining disease managed endoscopically, 3 went to OR for resection of large/deeply invasive tumors, 1 died of other causes before follow up. Negative margin patients (N = 7) had no further interventions or no residual disease in 5 cases; 1 had residual disease managed endoscopically and 1 went to the OR for resection for large size. Tumor size was not significantly different between groups. Overall, 31 patients with mean tumor size 0.8 cm (max 2.0 cm) were managed with endoscopy alone; 23 required 2 procedures while 8 required single procedure. None of these had recurrent disease. 9 patients required surgery (3 proctectomy, 3 transanal excision, 3 TEM) with most common indication being size 2 cm or greater. 1 node positive patient developed distant metastasis. CONCLUSIONS: This retrospective study suggests that patients with rectal NETs less than 2 cm and without evidence of nodal disease on imaging may safely undergo endoscopic management alone if subsequent surveillance biopsy demonstrates no residual disease. Positive margin status in endoscopically resected rectal NETs may not reflect residual disease and should not be used alone as an indication for surgery. Larger, prospective trials will be needed to further investigate these findings. 127 Monday Poster Abstracts RESULTS: We identified 16,536 patients, of which 2,155 patients (13%) were ≥80 years and 14,381 patients (87%) were <80 years old. Elective laparoscopic colectomy of any type with primary anastomosis was accomplished in each case. Independent predictors associated with a significantly increased rate of mortality were male gender (AOR 2.12), age above 80 years (AOR 2.92), dyspnea on exertion and rest (AOR 1.75 and 5.85 respectively), partially and completely dependent functional status (AOR 3.4 and 3 respectively), COPD (AOR 2.08), HTN (AOR 2.68), previous cardiac surgery (AOR 2.07), >10% weight loss (AOR 2.3), ASA III/IV (AOR 2.9), ascites (AOR 23.3). In the immediate postoperative period the group of patients ≥80 years had a higher incidence of PE (1.1% vs. 0.3%), failure to wean and subsequent reintubation (2.2% vs. 0.9% and 2.9% vs. 1.1% respectively), cardiac arrest (0.6% vs. 0.2%) and septic shock (2.4% vs. 0.8%). There was no difference in terms of wound-related complications in both groups. Operative time was found to be shorter for patients ≥80 years (141 vs. 161 min), but reoperation rate within 30 days was higher (AOR 3). The rate of major complications and death were also higher (AOR 1.73 and 6 respectively). BACKGROUND: Neuroendocrine tumors (NETs) of the rectum are often indolent in nature with metastatic potential related to grade and size of the primary tumor. Endoscopic management of small NETs may be appropriate though uncertain oncologic adequacy of resection frequently leads to more invasive procedures. This study aims to delineate adequate oncologic endpoints for management of rectal NETs by endoscopic means alone. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Esophageal CONCLUSION: This study demonstrates that delirium is a risk factor for complicated post-operative recovery and increased treatment costs following esophagectomy, and furthermore that age is independently predictive of its development. Focused screening will allow targeted preventative strategies to be employed in the peri-operative period to reduce complications and cost associated with delirium. Mo1478 The Clinical and Economic Cost of Delirium Following Surgical Resection for Esophageal Malignancy Sheraz Markar*1, Alan Karthikesalingam2, Donald Low1 1. Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA; 2. Department of Outcome Research, St George’s Hospital, London, United Kingdom Mo1479 BACKGROUND: Delirium is an under-estimated and serious complication following major surgery, particularly in the elderly population. The aim of this study was to identify pre-operative risk factors for delirium following esophagectomy for malignancy, and investigate its impact upon short and long-term outcome. METHODS: All patients undergoing esophagectomy for cancer between 1991 and 2011 had information prospectively entered in an IRB-approved database. Patients were divided into two groups based upon the presence or absence of clinically-significant post-operative delirium, and were compared with respect to use of neoadjuvant therapy, medical co-morbidities, operative outcomes, post-operative complications, overall cost and survival. For the purposes of this study delirium was defined as an acute fluctuating confusional state that required intervention. RESULTS: 500 patients were included in this analysis; 46 (9.2%) patients with post-operative delirium and 454 patients without. Age was significantly increased (71 ± 8.12 yrs vs. 63 ± 10.86 yrs) and BMI was reduced (25 ± 4.24 vs. 27 ± 4.82 kg/m2) in the delirium group. There were no significant differences in cardiac, pulmonary or renal co-morbidities, however ASA grade was significantly increased in the delirium group (2.83 ± 0.44 vs. 2.62 ± 0.54). There were no significant differences between the groups in the use of neoadjuvant therapy. Analysis demonstrated that delirium was associated with a significantly longer hospital (13.98 ± 7.54 vs. 10.88 ± 5.67 days) and ICU stay (3.59 ± 3.82 vs. 2.68 ± 16.92 days). Furthermore post-operative delirium was associated with a significantly increased incidence of post-operative pneumonia (21.74% vs. 7.93%), pneumothorax (10.87% vs. 2.64%), re-intubation (10.87% vs. 1.76%) and increased overall treatment costs ($28223 ± 13018 vs. $22702 ± 9689; P < 0.05). Age was the only pre-operative predictor of post-operative delirium in multivariate modeling (Odds ratio = 1.08; 95% C.I. = 1.04–1.12, P < 0.05). Patients were followed up for an average of approximately 4 years. There was no significant difference between the groups in overall survival (1105 ± 910 days vs. 1273 ± 1428; P = 0.28) and there was no difference in Kaplan Meier curve distribution between the groups. The Incidence of Hiatal Hernia After Minimally Invasive Esophagectomy Nathan W. Bronson*, James P. Dolan, Renato A. Luna, Brian S. Diggs, John G. Hunter Department of General Surgery, Oregon Health and Science University, Portland, OR INTRODUCTION: Minimally invasive esophagectomy (MIE) has evolved as a means to minimize the morbidity of an operation which is traditionally associated with significant morbidity and mortality. Given recent reports of increased hiatal herniation after robot assisted esophagectomy, we intended to describe the incidence and outcomes of hiatal hernia in a large cohort of post-MIE patients. METHODS: Clinical follow up data on one hundred and fourteen patients who had undergone minimally invasive esophagectomy between 2000 and 2011 was retrospectively reviewed. Imaging findings derived from routine computed tomography (CT) scans of the chest and abdomen were used to establish the diagnosis of hiatal herniation after minimally invasive esophagectomy. Age, gender, comorbid conditions, clinical tumor stage, specimen size, length and cost of hospital admissions, presenting complaint for hiatal hernia, operation performed to correct hiatal herniation, and mortality were all recorded for analysis. RESULTS: Of the 114 patients identified in the database who underwent MIE, a total of 8 were identified with postoperative hiatal herniation (7% incidence). Five of these patients were asymptomatic. One of the three symptomatic patients presented with a perforated colon in the chest. One patient complained of abdominal pain, nausea and vomiting, and a final patient complained of gastric outlet obstruction with chest and neck fullness. All patients except the one who presented emergently were repaired laparoscopically on an elective basis. The average length of stay associated with hiatal hernia repair in this setting was 5 days at an average expense of $40,785 (range $25,264– $83,953). At follow-up only 1 patient complained of symptoms associated with reflux. CONCLUSION: Hiatal herniation is not a rare event after MIE. It is also associated with a large health care cost and may be lethal. Most occurrences appear to be asymptomatic and if detected, can be repaired with good resolution of symptoms and minimal associated morbidity. 128 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1480 Mo1481 The Utility of Esophageal Stents as an Adjunct in the Perioperative Management of Cancer of the Esophagus The Impact of Impedance (MII) Testing on Patient Selection for Anti-Reflux Surgery in the Setting of a Normal 24-Hour pH Test Nicolas Zea*1, John Bolton1,2, Lisa L. Wang2, Abbas Abbas1,2 1. Department of Surgery, Ochsner Health Systems, New Orleans, LA; 2. Department of Surgery, The University of Queensland, Australia School of Medicine, Brisbane, QLD, Australia INTRODUCTION: Esophageal stents (ES) may be used as an adjunct in the management of patients with resectable cancer of the esophagus (EC) to improve nutritional status during neoadjuvant therapy, or to manage postoperative anastomotic leaks or strictures. We describe our experience with the use of ES in a consecutive series of 97 patients undergoing resection of EC between September of 2007 and March of 2011. METHODS: This is a retrospective record review with IRB approval. All patients receiving ES at our institution for whom follow up is available are included. The indication for ES placement was noted and the clinical effectiveness was determined: did the ES successfully resolve the clinical problem for which it was placed? CONCLUSIONS: The effectiveness of ES placement for preop nutritional stabilization (20%) and resolution of postop leak (31%) is low. ES for postop anastomotic stricture is moderately effective (57%). The high proportion of patients with cervical anastomoses in our patient population predisposes to ES migration; in addition, the prevalence of foregut symptoms with neoadjuvant therapy limits the effectiveness of preop ES. BACKGROUND: Gastroesophageal reflux (GER) has been defined as abnormal acid exposure in the distal esophagus as measured by 24 hr pH testing. However, there is a subset of patients who present with classic reflux symptoms but have a normal pH test. These patients present a treatment dilemma for the esophageal surgeon as anti-reflux surgery (ARS) based on symptoms alone has often been associated with unpredictable outcomes. Non-acid reflux has been suggested as a valid indication for ARS in certain subsets of patients as identified by multi-channel intraluminal impedance (MII) testing . However, there is a paucity of data regarding the incorporation of this modality in routine surgical decision making. The aim of this study is to evaluate the impact of MII-pH testing in a high volume ARS practice. METHODS: Routine pH-MII testing was incorporated in our esophageal testing laboratory in 2010. Prospectively collected data for all patients who underwent standard laparoscopic Nissen fundoplication from 2004–2010 was reviewed. Patients with partial fundoplication, gastroparesis, paraesophageal hernia, redo ARS or Collis gastroplasty were excluded. Patients were divided into 2 groups (pH-ONLY, pH-MII) based on the type of testing they had before surgery. Standardized symptom assessment scores (pre and postoperative), indication for operation and pH and pH-MII results were analyzed. Total number of referrals for ARS with normal preoperative pH testing was recorded for comparison. RESULTS: Three hundred five ARS patients were analyzed (250 pH-ONLY, 55 pH-MII). In the pH ONLY group, 17/250 (6.8%) underwent ARS despite a normal preoperative pH test compared to 13/55 (23.6%) in the pH-MII group (p = 0.0004). The average number of referrals for ARS with normal preoperative pH testing was 50/yr and did not change with the introduction of pH-MII testing but annual rate of ARS in patients with a normal preoperative pH increased from 4/50 (8%) to 12/50 (24%) (p = 0.03). Primary symptoms for patients with normal pH were similar for both groups. The most common surgical indications were similar between groups: esophagitis, large-volume regurgitation, and symptom correlation (pH-ONLY) or positive symptom index (pH-MII). The MII testing influenced the decision to operate in seventy-seven percent of patients in the pH-MII group (6/13 abnormal reflux events, 4 positive symptom index) and the remainder (3/13) had biopsy proven esophagitis. The symptom scores for heartburn, regurgitation, and chest pain were improved after surgery in both groups (p < 0.05). CONCLUSIONS: Conventional pH testing has been the gold standard for selecting patients for ARS. In patients with normal 24-hour pH testing, the addition of impedance resulted in a 3-fold increase in patients identified as appropriate surgical candidates. 129 Monday Poster Abstracts RESULTS: Among 97 consecutive patient undergoing resection of EC, 46 patients received ES for the following indications: to improve preoperative nutritional status (25 patients), for postoperative anastomotic leak (13 patients), and for postoperative anastomotic stricture (14 patients). 9 patients had multiple ES placed at different time points for multiple indications. ES deployment was technically successful in all patients. Preop ES: Swallowing symptoms improved in 52% of patients; however, nutritional status deteriorated in 80%, with a median weight loss of 15 lbs and median decrease in serum albumin of .4gms/dl. ES migration, which occurred in 64%, and upper gastrointestinal symptoms, which occurred in 72% of patients receiving neoadjuvant therapy, limited the effectiveness of preop ES. ES for postop leak: Postop leak occurred in the neck in 10 patients and in the chest in 3 patients. ES effectively sealed the leak and allowed prompt (within 48 hrs) resolution of oral intake in only 4/13 patients (31%). Early ES migration (7 patients) and the presence of limited conduit necrosis (2 patients) was associated with ES failure. ES for postop stricture: 12 of the 14 strictures for which stents were deployed were in the neck and 2 were in the thorax. 57% of patients had sustained relief of dysphagia and required a median of only one subsequent intervention for stricture. Stent failure occurred in 43%, due to early migration (4 patients), pharyngeal or mediastinal pain (1 patient each), or bilious vomiting (2 patients). ES migrated prematurely in 11/14 patients, including 6/8 successfully treated patients and 5/6 unsuccessfully treated patients. Ashwin A. Kurian*1, Ahmed Sharata2, Neil H. Bhayani1, Kevin M. Reavis2, Christy M. Dunst2, Lee L. Swanstrom2 1. Providence Portland, Portland, OR; 2. GMIS, Oregon Clinic, Portland, OR THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1482 Table 1: The Prediction Accuracies of the Proposed Automatic Cancer Staging Model for Esophageal Cancer Based on Different Editions of AJCC Cancer Staging Ssystem Automatic Cancer Staging for Esophageal Pathological Reports by Text Mining and Data Mining: Comparison Between AJCC 6th and 7th Editions Yung-Han Sun*1,2, Chih-Cheng Hsieh1,3, Chun-Hsien Chen1,2, Shih-Wei Lin1,2 1. Department of Surgery, Taipei-Veterans General Hospital, Taipei, Taiwan; 2. Department of Information Management, Chang Gung University, Taoyuan, Taiwan; 3. School of Medicine, National Yang-Ming University, Taipei, Taiwan Cell type BACKGROUNDS: Cancer staging by manual interpretation of pathological report is very time-consuming. In our previous research, text mining and data mining techniques were applied to automatic staging of esophageal cancer for pathological reports according to the 6th edition American Joint Committee on Cancer (AJCC) cancer staging system. Since the staging system is updated every several years, how to quickly and accurately transform the old stages into new stages becomes an important issue. The nodal status for esophageal cancer staging in the 6th edition was just grouped into positive (N1) and negative (N0), but it was different in the 7th edition. The aim of this study was to compare the results of the automatic cancer staging model using new staging edition with those based on the old staging edition. METHODS: Pathological reports of 234 patients undergone esophagectomy were collected in this study. All the pathological reports were collected and entered into Access database as text file. The reports were compuationally converted into weighted frequency vectors of keywords by using text mining techniques to analyze cancer staging related keywords in the reports. Lymph node metastasis status N of a pathology report were derived from the total number of positive lymph nodes and the distal metastasis status (M) were also modified by analyzing the text keywords of the pathology report computationally. J48 decision tree learning algorithm was used to train the classification model for cancer staging. One third of the data was used for training and two thirds of the data was used for testing in evaluating the prediction performance of the model. RESULTS: The results were shown in Table 1. The prediction accuracies for cell type and T status nearly did not change, and the prediction accuracies for N and M status reached 91.9% and 95.3% respectively. Comparison with the accuracies for predicting N and M status based on the 6th edition of AJCC cancer staging guideline, those based on the new edition decreased just a little. Based on 7th Edition Based on 6th Edition 97.5% 97.5% Tumor Depth status (T) 88.5% 88.5% Lymph node metastasis status (N) 91.9% 95.0% Distant metastasis status (M) 95.3% 96.3% CONCLUSIONS: This study provides a computational model for automatic cancer staging of esophageal pathological reports according to the 7th edition American Joint Committee on Cancer (AJCC) cancer staging system. In the future, we hope to apply this automatic cancer staging model to pathological reports of other cancers and collect clinical data for other text file reports. Mo1483 pH-Symptom Indices Do Not Predict Symptom Improvement After Antireflux Surgery Stefan Niebisch*, Candice L. Wilshire, Carolyn E. Jones, Virginia R. Litle, Christian G. Peyre, Thomas J. Watson, Jeffrey H. Peters Department of Surgery, University of Rochester Medical Center, Rochester, NY INTRODUCTION: Prospective randomized trials document long term relief of gastro-esophageal reflux (GERD) symptoms in 85% of patients following antireflux surgery. One of the key challenges, in the decision to pursue antireflux surgery, is assuring that the patients symptoms are actually caused by GERD. Mathematical calculations of the relationship of reflux events to the occurrence of symptoms have been proposed as a mechanism to support GERD as the underlying cause of both typical and atypical reflux symptoms. The symptom index (SI) and Symptom Association Probability (SAP) are the most commonly calculated measures in clinical use. The clinical utility of these measures is unclear and unexplored with respect to antireflux surgery. METHODS: The study population included 66 patients (mean age 52.6 years; 58% female) undergoing laparoscopic fundoplication from November 2006 to October 2011. All were pH-positive (DeMeester Score >14.72) with either cough, heartburn and/or regurgitation, in which SI (positive ≥50%) and SAP (positive ≥95%) were calculated pre-op. Symptom outcome after surgery was categorized as ‘improvement’, ‘no change’ and ‘worsening’ in their symptoms. All available data were logged into SPSS (version 18) for statistical analyses. 130 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: At the time of pH testing heartburn was recorded in 51 (84%), regurgitation in 22 (33%) and cough in 21 (32%) patients. One or both symptom indices were positive in 85% (56/66) and both negative in 15% (10/66) of the patients. Cough was significantly less associated with positive SI and/or SAP when compared to heartburn and regurgitation (SI 19% vs. 72.5% and 81.8%; p < 0.0001; SAP 33.3% vs. 78.4% and 68.2%; p = 0.0007 and p = 0.0337 respectively). Overall, 93% (62/66) of patients reported improvement in their symptoms which was independent of a positive or negative SI or SAP. Eighty percent of patients (8/10) with negative SI and SAP pre-op improved compared to 87% (54/62) with positive SI and/or SAP (p = 0.6217). There was no significant difference in symptom improvement between atypical and typical symptoms; patients with heartburn improved in 98%, regurgitation in 95.5% and cough in 85.7% (p = 0.072). CONCLUSION: These data show that symptom improvement following antireflux surgery is independent of the commonly used 24hour pH symptom indices SI and SAP. Atypical symptoms such as cough are less likely associated with a positive symptom index, particularly when compared to typical symptoms such as heartburn and regurgitation. duration was 302 min (150–465min). The operative procedures and route of reconstruction of these 57 patients were listed in Table 1 and 2 respectively. The reasons of using colonic interposition included: stomach was involved by tumor (n = 18 (31.6%)), prior gastrectomy (n = 34 (59.6%)), presence of peptic ulcer (n = 3 (5.3%)) and other (n = 2 (3.5%)). There were 6 (10.5%) had conduit gangrene required re-exploration. Nine (15.8%) patients had either clinical or subclinical anastomotic leakage. The median survival was 34.8 months (17–52 months). The 30-day mortality rate was 3.5% (n = 2) and the hospital mortality rate was 15.8% (n = 9). Presence of major post-operative medical complications such as stroke or myocardial infarction (p = 0.026, HR 2.114, 95%CI 1.094–4.084) was identified to be predictive factor for poor survival. Table 1. Operative Procedures of 57 Patients had Colonic Interposition in Esophagectomy for Esophageal Cancer with Curative Intent Procedures Pharyngolaryngoesophagectomy 5 (8.8) Transhiatal 9 (15.8) Minimally invasive esophagectomy Mo1484 Operative Outcomes of Colonic Interposition in the Treatment of Esophageal Cancer: A Three Decades Experience Daniel K. Tong , Simon Law, Fion S. Chan Surgery, The University of Hong Kong, Hong Kong, Hong Kong * BACKGROUND: Colonic interposition is the treatment of choice when the stomach cannot be used as a substitute for reconstruction after esophagectomy for esophageal cancer. The aim of present study was to review our experience on colonic interposition. N = 57 (100%) 2 (3.5) 3 phase esophagectomy 13 (22.8) Lewis Tanner esophagectomy 18 (31.6) Staged 5 (8.8) Other 5 (8.8) Table 2. Route of Reconstruction of 57 Patients who had Colonic Interposition in Esophagectomy for Esophageal Cancer with Curative Intent PATIENT AND METHODS: A prospectively collected database on patients with esophageal cancer from 1982– 2010 was reviewed. Outcomes of these patients were analyzed. The indications, morbidity, mortality, long-term survival and potential predictive factors were evaluated. Route of Reconstruction Right chest 6 (10.5) RESULTS: A total of 119 patients were found to have colon harvested for management of esophageal cancer. Of whom, 62 had palliative bypass surgery and 46 (74.2%) were performed in 80s, 16 (25.8%) in 90s, and none in 00s. The role of bypass surgery become less popular was probably due to the availability of less invasive palliative modalities such as stenting. For the remaining 57 patients, the median age was 64 (28–82) and 49 (86%) were male. The median blood loss was 850ml (150–2500ml), and the median operative Orthotopic 29 (50.9) Subcutaneous Retrosternal N = 57 (100%) 3 (5.3) 19 (33.3) 131 Monday Poster Abstracts CONCLUSIONS: The role of bypass surgery using colon for esophageal cancer management is fading. Colonic interposition remained an important treatment option in patients with prior gastrectomy or when the stomach was invaded by the tumor. The operative procedure was complex and could associated with high morbidity rate. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1485 Mo1486 Short-Term Outcome of Antireflux Surgery on Patients with Chronic Cough and Abnormal Proximal Exposure as Measured by Hypopharyngeal Multichannel Intraluminal Impedance PET-CT for Response Assessment of Neoadjuvant Chemoradiation in Locally Advanced Squamous Cell Carcinoma Esophagus: Initial Experience from Tertiary Referral Center in North India Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA Saurabh Kalia*, Prasanna Chandrasekaran, Rajesh Gupta, Ganga R. Verma, Rakesh Kapoor, Bhagwant Rai Mittal, Rakesh K. Vasishta, Rajinder Singh PGIMER, Chandigarh, India, Chandigarh, India BACKGROUND: Chronic cough can be caused by direct exposure of gastric refluxates to the aerodigestive tract. The treatment outcome has been conflicting due to the lack of objective testing to directly measure the proximal extent of gastric refluxates. The objective of this study was to evaluate the proximity of reflux events in patients with chronic cough and to assess the outcome of antireflux surgery (ARS) on patients, who were selected based on the presence of abnormal proximal exposure as measured by hypopharyngeal multichannel intraluminal impedance (HMII). METHODS: This is a retrospective review of symptomatic patients who were referred for the evaluation of gastroesophageal reflux disease (GERD) and subsequently underwent HMII with a specialized catheter to measure proximal reflux events such as laryngopharyngeal reflux (LPR) and full column reflux (reflux 2 cm distal to the upper esophageal sphincter) at our institution. Chronic cough was defined as persistent cough with unknown etiology, which lasted for more than 6 months. Patients with positive Tb test and a history of seasonal allergy or pulmonary diseases such as asthma and pulmonary fibrosis were excluded. Based on HMII, abnormal proximal exposure was defined as LPR ≥1/day and/or full column reflux ≥5/day. Patients with abnormal proximal exposure subsequently underwent ARS. The outcomes were reviewed. RESULTS: From October 2009 to June 2011, 314 symptomatic patients underwent HMII at our institution. Of 314, 55 patients were identified as having chronic cough with unknown etiology (male 16, female 39). Mean age and BMI were 57 years and 30.3, respectively. Six patients were excluded because of inadequate information available. Of the remaining 49 patients, 36 patients were found to have LPR ≥1/day (n = 10, range 1–12/day) and/or full column reflux ≥5/day (n = 35, range 5–32/day). Of these 36 patients with abnormal proximal exposure, 33 (92%) patients were found to have either endoscopic evidence of esophageal mucosal injury such as esophagitis or Barrett’s esophagus, radiographic evidence of hiatal hernia or PPI dependence. However, 67% (24/36) of patients had a negative DeMeester score. Of these 33 patients with abnormal proximal exposure and objective evidence of GERD, 14 patients subsequently underwent ARS including Nissen (n = 8), Dor (n = 2), Toupet (n = 1) and esophagojejunostomy (n = 3), and 12 patients (86%) had a complete resolution of cough and 2 (14%) had a significant improvement at a mean follow-up of 4 months (range, 0.5–12 months). CONCLUSIONS: Abnormal proximal exposure as measured by HMII is likely to be associated with objective evidence of GERD in patients with chronic cough regardless of whether there is a positive DeMeester score. Presence of abnormal proximal exposure could be an indicator of successful ARS for patients with chronic cough. INTRODUCTION: Neoadjuvant chemoradiation is a part of multimodality management of locally advanced carcinoma esophagus. 18F FDG PET-CT (PET-CT) has been evaluated for assessing the response to neoadjuvant therapy and correlated with the prognosis in various studies with inconsistent results. We report our experience from prospectively collected data at tertiary referral center from North India. METHODS: We reviewed prospective data of 34 patients of potentially resectable squamous cell carcinoma esophagus from Feb 2010 to Nov 2011 at our institute. All patients (M:F 1.6:1, mean age 51 years) had locally advanced squamous cell carcinoma of middle and lower 1/3rd esophagus (Stage T2–4NxM0) on initial staging with CECT thorax and abdomen ± PET-CT. Patients with good performance score underwent Neoadjuvant chemoradiation (NACRT) protocol including Cisplatin (30 mg/m2) + 5FU (500mg/m2)from Day1 to Day4 and EBRT 30 Gy/10#/over 2 weeks. Restaging was done with PET-CT after >4 weeks after completion of NACRT. All resectable patients underwent transhiatal/ transthoracic esophagectomy without formal lymphadenectomy. Histomorphological regression was graded as per four tiered scheme described by CAP Cancer Protocol for Esophageal carcinoma (TRG 0 and 1 as complete and moderate response respectively and TRG 2 and 3 as minimal and poor response respectively)by single experienced pathologist blinded to clinical data. Post NACRT PET-CT Standard uptake value (SUVmax) and percentage change of SUVmax was correlated with tumor regression (TRG 0 and 1). RESULTS: Transhiatal esophagectomy was done in 30 patients and Transthoracic esophagectomy in 2 patients. Two patients had metastatic disease at surgery. Mean SUVmax was 13.6 and 6.45 for Pre NACRT and Post NACRT respectively suggesting metabolic response to therapy. Tumor regression (TRG 0 and 1) was seen in 12 (35.3%) patients. The percentage decrease in SUVmax >80% correlated with tumor regression with sensitivity, specificity, PPV, NPV and accuracy of 71.4%, 92.8%, 83.3%, 80% and 85.7% respectively. Post NACRT SUVmax <4.0 correlated with tumor regression with sensitivity, specificity, PPV, NPV and accuracy of 83.3%, 86.3%, 76.9%, 90.4% and 85% respectively 132 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA METHODS: All patients (pts) undergoing esophagectomy from 2005–11 for malignant disease at a North American university hospital were identified from a prospectively collected database. All patients were subject to BE within the first week postoperatively. Patients were dichotomized according to whether they had an AL or not and the sensitivity and specificity of barium swallow was determined. In pts who had an AL, the relationship between barium swallow results and time to AL, hospital length of stay, and start of enteral feeding was determined. Furthermore, the effect of BE results on postoperative management, defined as cessation of enteral feeding, additional interventions, or delay in discharge was recorded. Data are expressed as median (range). Mann Whitney U and Fischer’s exact test determined significance (*p < 0.05). Figure 1: PET-CT images with complete metabolic response in a 72 year old male Figure 2: Gross and Microscopic tumor regression (Complete pathological response) CAP TRG 0 in the same patient. CONCLUSIONS: 18F FDG PET/CT is 85% accurate in response assessment of Neoadjuvant Chemoradiation for squamous cell carcinoma esophagus. Mo1487 Routine Barium Esophagram Has Minimal Impact on the Post-Operative Management of Patients Undergoing Esophagectomy for Esophageal Cancer Maxime Noreau-Nguyen*, Jonathan Cools-Lartigue, David S. Mulder, Lorenzo E. Ferri Surgery, McGill University, Montreal, QC, Canada CONCLUSIONS: Barium esophagram has a poor sensitivity in the detection of anstamotic leak and has minimal impact in the postoperative management of patients undergoing esophagectomy for malignant disease. The routine use of contrast esophagograms after esophageal resection should be abandoned. 133 Monday Poster Abstracts INTRODUCTION: Esophagectomy is currently the treatment modality of choice in patients with esophageal carcinoma. Post-operatively, routine fluoroscopic imaging with barium sulfate is employed in order to detect occult anastamotic leaks (AL) prior to resumption of enteral feeding. This modality is plagued by a low sensitivity, and its routine use has been called into question. Accordingly, we sought to demonstrate the clinical impact of routine barium esophagography (BE) in the post-operative management of patients undergoing esophagectomy for malignant disease. RESULTS: Two-hundred and twenty-seven pts underwent esophagectomy over the study period. Twenty-nine pts (12.8%) developed an AL, of which 12 (41.4%) had a positive BE, 11 (37.9%)had a negative BE and the remaining 6 (20.7%) were not subject to BE and were diagnosed either clinically (1/6), by CT (4/6), or endoscopically (1/6). AL in pts with a negative BE was confirmed either clinically (4/11 pts), by CT (5/11 pts), endoscopically (1/11 pts), or at reoperation (1/11 pts). In pts who had an AL, those with a positive BE leaked earlier than those with a negative BE (POD 7 (2–8) vs POD 10.5 (6–22)* respectively). The sensitivity and specificity of barium BE in this series was 36.3% and 99.7% respectively. Result of BE in pts with an AL did not correlate with hospital length of stay or date of commencement of enteral feeding. Overall, BE altered postoperative management in 6/227 (2.6%) pts with 4/227 (1.7%) pts undergoing further testing which went on to confirm a leak. Conversely 2/227 (0.9%) pts demonstrated clinically insignificant AL, having their discharge delayed without additional intervention. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1488 CONCLUSIONS: This study shows for the first time an effective endoscopic treatment for GERD patients. The new developed Medigus stapling device can endoscopically create an anterior fundoplication. The procedure under general anesthesia showed acceptable complications (6%), high efficacy rates (74%) and can be recommended for patients with small hernias. Effective Endoscopic Treatment of Gastroesophageal Reflux Disease Using a New Endoscopic Stapling System Results of a Prospective Controlled Multicenter Tria Aviel Roy-Shapira*1,2, Amol Bapaye1, Ralf Kiesslich1, Santiago Horgan1, Sebastian F. Schoppmann1, Johannes Zacherl1, Luigi Bonavina1, Glen A. Lehman1 1. Surgery A, Soroka Univesity Hospital, Beer Sheva, Israel; 2. Critical Care Medicine, Soroka University Hospital, Beer Sheva, Israel Mo1489 Resolution of Anemia Following Repair of Giant Paraesophageal Hernias INTRODUCTION: A new system which is designed for transoral endoscopic treatment of Gastro Esophageal Reflux Disease (GERD) was tested in a multicenter study. The device is a flexible video endoscope coupled with a surgical stapler and an ultrasonic range finder. The device can endoscopically create an anterior fundoplication. Aim of the current prospective controlled multicenter trial was to evaluate safety and efficiency of the newly developed endoscopic stapling device in GERD patients with small hernias. METHODS: Inclusion criteria moderate to severe GERD with response to PPI treatment, abnormal 24h esophageal acid exposure and Hill gastro-esophageal valve grade ≥II. Patients with significant comorbidities, esophageal motility disorders and hiatal hernia >3 cm were excluded. Procedures were performed under general anesthesia at 5 centers using positive end expiratory pressure (PEEP) to optimum reduction of the hernia. Anterior fundoplication was performed with two or three stapling sites between the esophagus and the stomach under control of the ultrasonic range finder. Patients were followed at 1, 2 and 4 weeks for safety and at 6 months for efficacy. The primary outcome of the study was safety and reduction of the off PPI GERD Health Related Quality of Life scores (GERD-HRQL) score by at least 50%. Secondary outcome criteria were elimination or reduction of PPI use, improvement in 24h acid exposure and Hill valve grade. RESULTS: 67 patients were finally treated as per protocol. Primary outcome—Safety: There were 2 occult perforations (pneumomediastinum—asymptomatic and empyema— chest tube drainage) and one case of bleeding (treated endoscopically). Hospital stay was prolonged in another patient due to signs of infection. Additional adverse events occurred in 12 patients, were mostly related to elevated inflammatory markers in the first 24–48h post procedure and did not appear to carry any clinical significance. They were more common when only two rather than three staplings had been placed. PRIMARY OUTCOME—EFFICACY: 74% patients (50/67) met the primary success criterion—50% reduction in GERDHRQL scores. The median scores drooped from baseline of 29 to 6 at six months post-procedure (p < 0.001). Acid exposure normalized in 49% (33/67) subjects and improved in additional 18% (12/67). PPI usage reduced by ≥50% in 85% (57/67) patients (p < 0.001,. 73% patients (46/63) demonstrated an improved flap valve angle at 6 months. Michael Hermansson*, Steven R. Demeester, Joerg Zehetner, Kimberly S. Grant, Daniel S. OH, Tom R. Demeester, Jeffrey A. Hagen Surgery, Keck medical center of USC, University of Southern California, Los Angeles, CA BACKGROUND AND AIM: The association between anemia and paraesophageal hernia (PEH) was reported in 1931. Nonetheless, extensive evaluation for a source of bleeding in patients with anemia and PEH is common. The aim of this study was to evaluate the prevalence of anemia in patients with PEH and the impact of surgical PEH repair on anemia. METHODS: A retrospective chart review was performed of all patients who underwent primary repair of a PEH with 50% or more of the stomach in the chest between May 1998 and January 2010. Patients with incomplete or missing records were excluded. Patients with a history of anemia were contacted postoperatively and the status of their anemia was determined. RESULTS: There were 118 patients that met the inclusion criteria. A history of anemia was present in 41 patients (35%), and these patients formed the study group. There were 14 males (34%) and 27 females (66%). The mean age was 64 years. The median duration of anemia prior to PEH repair was 4 years. Treatment for anemia consisted of oral iron supplements (n = 17), intravenous iron infusions (n = 2) and blood transfusions (n = 11). Evaluations for anemia consisted of upper endoscopy (n = 41), colonoscopy (n = 20), capsule enteroscopy (n = 3), push enteroscopy (n = 1), and tagged red blood scan (n = 2). In the 41 patients with preoperative anemia detailed postoperative follow-up was available in 23 patients (56%). The median follow-up for these 23 patients was 59 months (range 25–133). Resolution of anemia occurred in 18 patients (78%). In 5 patients anemia has persisted and they remain on oral iron supplements. The median follow-up in these patients did not differ from those with resolution of their anemia. No patient has required a blood transfusion or intravenous iron infusion after PEH repair. A recurrent hernia was found in 2 of those 5 patients CONCLUSION: Anemia is common in patients with a giant PEH, and surgical PEH repair resolved the anemia in 78% of patients. Therefore, repair of a giant PEH is indicated in patients with anemia. Extensive evaluations for an alternative explanation for the anemia in patients with a giant PEH are unlikely to be useful. 134 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1490 Mo1491 Annual CT Scans Do Not Improve Survival Following Oesphagectomy for Cancer: A Follow Up Study of 126 Patients Influence of Postoperative Morbidity on Longterm Cancer Survival After Esophagogastric Surgery David Bowrey, Steve Satheesan*, Sukhbir Ubhi, Amar Eltweri Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom Stefan S. Antonowicz*, Bruno Lorenzi, Adriana Rotundo, Cheuk Bong Tang, Michael Harvey, Sritharan S. Kadirkamanathan Upper GI Surgery, MEHT, Chelmsford, United Kingdom BACKGROUND: Evidence for the best approach to followup after oesophagectomy for cancer is scant and conflicting. Routine computer tomography scanning (CT) remains an integral part of oesophageal cancer follow up, despite recurrences often being signposted by symptoms and other mechanisms first. Additionally, there is wide variation in the frequency of CT scanning schedule owing to resource pressures and anecdotally perceived benefit. AIMS: We sought to determine how useful routine CT scanning was in detecting treatable stages of recurrence in an Upper Gastrointestinal cancer centre. METHODS: We performed a retrospective review of 126 consecutive patients who have undergone oesophagectomy between 2001 and 2009. Annual CT-scan was part of the routine follow-up in all patients. Two patients were lost to follow-up. Outcome data was focused on recurrence and mortality. Data was analysed using chi squared for binomial comparisons, the method of Kaplan-Meier for survival estimates, and the log-rank statistic to compare survival between cohorts. METHODS: Retrospective review of patients undergoing esophagogastric resection for carcinoma during the years 2006–2010 at our institution. Minimum follow-up of 12 months was required. RESULTS: The study population was 164 patients (110 male) of median age 64 years (range 32–84). 84 underwent esophagectomy, 80 gastrectomy. Ninety-nine received neoadjuvant chemotherapy. The 90-day, 1-year and 3-year survivals were 92%, 84% and 49% respectively. Sixty-nine patients (42%) developed postoperative complications (commonest: pneumonia 19%, anastomotic leak 7%, wound infection 6%). None of tumor site (esophagus vs. stomach, p = 0.73), length of ITU stay (<3 days vs. >3 days, p = 0.50) or development of postoperative complications (p = 0.70) influenced longterm prognosis. The only two factors that influenced longterm outcome were UICC stage (p < 0.001) and circumferential resection margin (positive vs. negative, p < 0.001). CONCLUSIONS: Patients experiencing postoperative morbidity can expect the same longterm oncologic outcome as those not suffering these early setbacks. CONCLUSION: Routine CT appeared to detect preclinical recurrences only in a handful of patients who had undergone oesophagectomy. The majority of recurrences were diagnosed when patients presented with symptoms. Our data suggests that routine CT scanning in asymptomatic patients may not add any survival benefit. A well-designed prospective study may give a definitive answer. 135 Monday Poster Abstracts RESULTS: Recurrence was detected in 46 cases (37%). Median time to recurrence was 9 months (range 1–108 months). Median time to death from radiological confirmation of recurrence was 4 months (range 1–18 months), increasing to 13 months (range 6–18 months) if the patient subsequently underwent an interventional therapy (2 = 25.63, log-rank p < 0.001). In nine cases, the recurrences were loco-regional; the remainder had a systemic component. In 12 cases CT detected recurrence in asymptomatic patients; in the remaining 34, suspicious symptoms or tumour marker rise prompted further investigation. Routine-detected recurrences were not more likely to have further interventional treatment for their cancer (Fisher, p = 0.519), nor did it confer survival benefit (log-rank, p = 0.532). Subgroup analysis by neo-adjuvant therapy, preoperative stage and resection status further confirmed this. BACKGROUND: Previous studies have shown that postoperative adverse events after colorectal resection predict a poor prognosis with early cancer relapse. The aim of this study was to report the outcome of patients undergoing esophagogastric resection to assess the influence of in-hospital factors on longterm cancer survival. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Hepatic Mo1492 Symptomatic and Radiographic Evaluation of Hiatal Hernia Recurrence Following Laparoscopic Paraesophageal Hernia Repair with Polyester Composite Mesh Reinforcement Mo1493 Safety of a Multimodal Enhanced Recovery Pathway in Liver Resection Surgery Jeffrey Eakin, Mark Wendling*, Dean J. Mikami, Bradley Needleman, W.S. Melvin, Kyle A. Perry Division of General and Gastrointestinal Surgery, The Ohio State University Medical Center, Columbus, OH INTRODUCTION: Laparoscopic paraesophageal hernia repair (LPEHR) is the preferred treatment for symptomatic paraesophageal hiatal hernia in specialized centers. LPEHR has yielded excellent perioperative outcomes and symptom control; however, it has been associated with high radiographic recurrence rates. Hiatal reinforcement with PTFE mesh prevents hernia recurrence, but is associated with unacceptable mesh related complications. Conversely, bioabsorbable mesh placement has proven safe, but failed to produce long term reductions in hiatal hernia recurrence. The primary objective of this study was to review a single institution experience to evaluate the initial safety and efficacy of LPEHR with crural reinforcement using a polyester composite mesh. METHODS: A retrospective review of patients undergoing LPEHR from 2006–2011 was conducted under an institutional review board approved protocol. All patients who underwent LPEHR with placement of polyester composite mesh were contacted for study enrollment. Long-term follow-up evaluation was performed in person or by telephone questionnaire. Outcomes included barium esophagram, GERD health related quality of life (GERD-HRQL) assessment, and patient satisfaction with their operation. Significant reflux was defined as a GERD-HRQL score >12. RESULTS: Between 2006 and 2011, 175 patients underwent LPEHR, and polyester composite mesh was used for hiatal reinforcement in 29 cases. Twenty (70%) patients completed the questionnaires, and 12 (41%) patients returned for a post-operative barium esophagram to assess for hernia recurrence. The median follow-up interval was 29.5 (6–66) months, and esophagrams were performed at a median of 34 (9–66) months following LPEHR. There were no mesh related complications within the study group. Eight of the twelve patients (75%) who underwent a radiographic evaluation with barium had evidence of recurrence. The incidence of significant reflux was 15%. There was no significant difference between the median GERDHRQL scores between those with radiographic recurrence and those without (p = 0.732). Fifteen percent (n = 3) of patients reported moderate to severe dysphasia, and esophagram demonstrated a recurrent hiatal hernia in each case. Eighty-one percent of patients polled reported being satisfied with their surgery, and 86% reported that they would, with the benefit of hindsight, have their surgery again. CONCLUSIONS: LPEHR with polyester composite mesh reinforcement provides durable symptomatic relief with high levels of patient satisfaction at intermediate followup. No mesh related complications or side effects occurred in this series. While anatomic hiatal hernia recurrence detected by routine post-operative imaging is common, most of these are asymptomatic and do not correlate with patient symptoms or dissatisfaction with the operation. Clancy J. Clark*1, Shahzad M. Ali1,3, ADAM K. Jacob2, David M. Nagorney1 1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 2. Anesthesiology, Mayo Clinic, Rochester, MN; 3. 2nd Department of Medicine, University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic BACKGROUND: Implementation of enhanced recovery and fast-tract care pathways in colorectal surgery have demonstrated decreased overall cost and length of stay (LOS) while resulting in no significant increase in perioperative morbidity and readmission rate. Similar pathways are yet established for liver surgery due to concern for perioperative coagulopathy, hepatic dysfunction, and perioperative volume management. The aim of this study was to evaluate the safety of an enhanced recovery pathway (ERP) for patients undergoing open liver resection. METHODS: A single-institution, observational cohort study was performed by comparing the clinical outcomes of patients treated before and after implementation of an ERP. The ERP included pre-operative oral celecoxib and gabapentin, standardized anesthetic including general anesthesia, intrathecal analgesia, and postoperative nausea prophylaxis, and a standardized post-operative care regimen. Clinical outcomes including morbidity, mortality, reoperation, LOS, and readmission rate were compared between ERP and non-ERP cohorts on an intention-to-treat basis. RESULTS: A total of 126 patients (ERP = 53, non-ERP = 73) were included in the study. Patient characteristics and operative details including ASA (p = 0.71), diagnosis (p = 0.32), type of liver resection (p = 0.86), and estimated blood loss (p = 0.81) were similar between groups. Overall complication rate was slightly lower in the ERP cohort, but not statistically significant (28.3% vs. 37.0%, p = 0.86). Before and after pathway implementation, the median LOS remained identical (5 days vs. 5 days, p = 0.71). No differences were identified for reoperation rate (2.7% vs 3.8%, p = 1.00), complication requiring ICU transfer (13.7% vs. 7.6%, p = 0.40), or readmission (2.7% vs 3.8%, p = 1.00). After adjusting for age, type of resection, and ASA, ERP and non-ERP patients had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.06) or LOS greater than 5 days (OR 1.21, 95% CI 0.18–2.62, p = 0.62). CONCLUSIONS: Routine use of a multimodal ERP is safe and is not associated with increased the post-operative morbidity after major open liver resection. However, the current study found that LOS was unchanged for patients treated with an ERP compared to conventional management. 136 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1494 Mo1495 Prediction of Survival After Surgery in Patients with Liver Cirrhosis Patterns and Prognostic Significance of Lymph-Node Dissection for Surgical Treatment of Peri-Hilar and Intrahepatic Cholangiocarcinoma Hannes P. Neeff*1, Hans-Christian Spangenberg2, Tobias Keck1, Ulrich T. Hopt1, Frank Makowiec1 1. Department of Surgery, University of Freiburg, Freiburg, Germany; 2. Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany Andrea Ruzzenente*, Tommaso Campagnaro, Alessandro Valdegamberi, Francesca Bertuzzo, Fabio Bagante, Calogero Iacono, Alfredo Guglielmi Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy INTRODUCTION: Patients with cirrhosis have an increased risk of postoperative mortality. In addition, patients with cirrhosis per se have a reduced life expectancy. Little is known about the combined effect of these reduced outcomes after surgery. We thus evaluated early and longterm survival after surgery in patients with cirrhosis. BACKGROUND: Lymph node (LN) metastasis is a major negative prognostic factor for intrahepatic (ICC) and perihilar (PCC) cholangiocarcinoma. Prognostic significance of LN dissection (LND), number of metastatic LN, LN stations and lymph-node ratio (LNR) are still under debate for cholangiocarcinoma. METHODS: For prediction of long-term outcome we evaluated survival after general surgical procedures performed during the last decade by two different approaches: I) Actuarial survival was estimated in 180 patients after surgery (thus including postoperative deaths) and II) Survival was analyzed separately in 143 patients who were discharged after postoperative treatment (i.e. patients without in-hospital mortality) and with survival information available. Survival was analyzed by actuarial methods, risk factors were assessed univariately (log rank) and multivariately (Cox regression, multiple models). AIMS: The aims of this study are to evaluate the prognostic value of LND, of the number of LNs harvested, of number of positive LNs, of LN stations and of LNR in ICC and PCC. CONCLUSIONS: Long-term survival in patients with liver cirrhosis requiring general surgery is poor. In the entire patient group poor liver function and, in part, factors influencing postoperative mortality like comorbidity (ASA) or thrombocytopenia are prognostic factors. In patients surviving the early postoperative period the long-term outcome is determined mainly by the natural course and severity of liver disease (MELD better than Child). RESULTS: One hundrend and thirty patients were submitted to surgical resection with curative intent; 61 were ICC and 69 PCC. Lymph-node dissection (LND) was performed in 71% of patients with ICC and in 96% with PCC. Median survival of patients with 0, 1 to 3 and more than 3 LNs retrieved was respectively 31, 37 and 36 months for ICC (p = 0.53) and 3, 18 and 34 for PCC (p < 0.01), respectively. Median survival of patients with negative LN (N0) and with LN metastasis (N+) was 43 and 19 months in ICC (p = 0.03) and 42 and 20 months in PCC (p = 0.01), respectively. Median survival of patients with up to 3 N+ and more than 3 N+ was 52 and 7 months in ICC (p < 0.01), and 26 and 11 months in PCC (p < 0.01). Median survival of patients with LNR up to 0.25 and greater than 0.25 was 42 and 14 months in ICC (p = 0.01), and 37 and 11 months in PCC, respectively (p < 0.01). At multivariate survival analysis LNR and macroscopic vascular invasion were significantly related to survival with hazard ratios of 3.00 (95% CI 1.69– 5.34; p < 0.001) and of 1.90 (95% CI 1.17–3.07; p = 0.009) respectively. CONCLUSIONS: LN metastasis is a major prognostic factor for survival after surgical resection of ICC and PCC. Lymphadenectomy should be performed because number of LN retrieved and LNR showed high prognostic value. LNR can stratify patients with positive LNs and identify patients with not favourable prognosis that might be feasible of adiuvant therapy. 137 Monday Poster Abstracts RESULTS: I) Survival in all 180 operated patients was 54% after one and 25% after 5 years (median survival 1.24 years). In univariate analysis the CHILD-score (p < 0.001), MELD-score (p < 0.001), ASA-score (p = 0.05), emergency procedures (p < 0.001), viral hepatitis (p < 0.01 vs alcoholic/ other origin), hyponatremia (p < 0.01) and major procedures (p < 0.03 vs minor) were associated with decreased survival. In multivariate analysis CHILD- (p < 0.02) and MELD-score (p < 0.001), ASA-class (p < 0.01), preoperative hyponatremia and thrombocytopenia were independently associated with poor prognosis. II) Survival in 143 patients discharged after surgery was 68% after one and 32% after 5 years (median survival 2.8 years). Long-term survival (univariately) correlated with CHILD- and MELDscores (p < 0.01/ < 0.001), (preoperative) hyponatremia (p < 0.01) and ASA class (p < 0.05). In multivariate analysis the MELD-score (p < 0.001) and hyponatremia (p < 0.01) but not significantly the CHILD-score (p = 0.06) or ASAclass independently predicted the outcome after hospital discharge. Neither an underlying malignant disease nor age nor emergency operations independently correlated with long-term survival. METHODS: Extension of LND, according with Japanese Society of Biliary Surgery (JSBS), number and status of harvested LNs were retrospectively evaluated in patients cholangiocarcinoma submitted to surgical resection with curative intent between 1990 and December 2010. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1496 Serum Markers for Predicting Surgical Outcomes in Patients with Cirrhosis Edward Chu, Andrew N. Harrington, Malika Garg*, Celia M. Divino Surgery, The Mount Sinai School of Medicine, New York, NY INTRODUCTION: Predictors of post-operative outcomes for patients with liver disease who undergo general surgical procedures have not been adequately assessed. Coagulation status consisting of a complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT) and international normalized ratio (INR) is the only routinely measured preoperative screening tool. Child-Pugh and Model for End-Stage Liver Disease (MELD) scores have also been used to estimate perioperative risk but with inconsistent results. The aim of this study is to identify if certain serum assays of the liver function panel and hematological parameters are associated with increased morbidity and mortality in cirrhotic patients who undergo abdominal surgery. METHODS: After receiving IRB approval, a retrospective chart review was performed which identified 83 cirrhotic patients who underwent 89 abdominal surgical procedures between 2001 and 2008 at Mount Sinai Medical Center. Pre-operative demographic information, comorbidities, etiology of cirrhosis, and serum test results consisting of PT, PTT, INR, CBC, liver function panel, blood urea nitrogen (BUN), and creatinine (Cr) were collected. The primary endpoint was 30-day post-operative mortality. The secondary endpoint was development of post-operative complication prior to discharge, 30-day readmission or 30-day re-operation. Univariate analysis was performed using chi square test and Student’s t test. Associations with p values less than 0.05 were considered significant. Table 1. Mortality and Complication Rate RESULTS: The primary endpoint occurred in 6.7% (n = 6) of operations and was significantly associated with platelet count <80, hemoglobin (Hb) <10, total protein (TP) <6, lactate dehydrogenase >220, albumin <2.8, INR >1.4, and Cr >1.2, and total bilirubin (TB) >2. The secondary endpoint occurred in 42.7% (n = 38) of operations and was significantly associated with Hg <10, TP <6, albumin <2.8, INR >1.4, and TB >2. Transaminases (AST and ALT), alkaline phosphatase, white blood count and gamma-glutamyltransferase showed no significant association with the primary or secondary endpoint. CONCLUSION: The current classification systems utilized for risk stratification in cirrhotic patients undergoing general surgery are not optimal. Preliminary analysis shows candidate serum markers for predicting 30 day complication and mortality rate. These additional indicators can be used to supplement the Child-Pugh and MELD scores in assessing surgical outcomes. Clinical: Pancreas Mo1498 Quality of Life in Patients After Total Pancreatectomy Is Comparable to Quality of Life in Patients After a Partial Pancreatic Resection Irene Epelboym*, Megan Winner, Joseph Dinorcia, Minna K. Lee, James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf Surgery, New York Presbyterian, Columbia University, New York, NY BACKGROUND: Quality of life after total pancreatectomy is perceived to be poor secondary to insulin-dependent diabetes and pancreatic insufficiency. As a result, surgeons may be reluctant to offer this treatment for benign and premalignant diseases. METHODS: We retrospectively reviewed a prospectively maintained database of pancreatic operations and identified patients who underwent a total pancreatectomy between 1994 and 2011 at our institution. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Quality of life was assessed using institutional questionnaires and validated general, pancreatic disease-related, and diabetes-related instruments (EORTC QLQ-C30, EORTC-PAN26, ADD-QOL) in patients alive at the time of analysis, and compared with frequency-matched controls, patients after a pancreaticoduodenectomy. Continuous variables were compared using Student’s t-test or ANOVA. Categorical variables were compared using chi-square or Fisher’s exact test. RESULTS: Between 1994 and 2011, 77 total pancreatectomies were performed, 39 for benign or premalignant, and 38 for malignant disease. Overall morbidity after total pancreatectomy was 49%, but only 12 (16%) patients experienced a major complication. Perioperative mortality was 2.6%. At the time of this study, 33 (43%) patients were alive and 25 agreed to participate in the survey; final 138 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA results represent aggregate responses of 15 (10 benign and premalignant, 5 malignant). Mean time between surgery and survey administration was 3.2 years. Scores were compared with 14 matched patients who underwent pancreaticoduodenectomy (10 benign and premalignant, 4 malignant; 8 with postoperative diabetes). There were no statistically significant differences in quality of life in the global health, functional status, or symptom domains of the EORTC QLQ-C30 or in the pancreatic disease-specific EORTC-PAN26 between total and partial pancreatectomy patients, regardless of final pathology. Total pancreatectomy patients had slightly but not significantly higher incidence of hypoglycemic events as compared to partial pancreatectomy patients with postoperative diabetes. The negative impact of diabetes as assessed by the ADD-QOL did not differ between total and partial pancreatectomy patients. Life domains most negatively impacted by diabetes involved travel and physical activity, while self-confidence, friendships and personal relationships, motivation, and feelings about the future remained unaffected. Defining Quality for Distal Pancreatectomy: Does the Laparoscopic Approach Protect Patients from Poor Quality Outcomes? Marshall Baker*1,2, Karen L. Sherman3, Amanda V. Hayman3, Richard Prinz1,2, David J. Bentrem3, Mark Talamonti1,2 1. Surgery, NorthShore University Health System, Evanston, IL; 2. Surgery, University of Chicago, Pritzker School of Medicine, Chicago, IL; 3Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL OBJECTIVES: Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage the complication. We seek to define a quality outcome for distal pancreatectomy (DP) and determine if laparoscopic distal pancreatectomy (LDP) affords an improvement in quality relative to open distal pancreatectomy (ODP). METHODS: Inpatient and office charts for patients undergoing either ODP or LDP between January 2006 and December 2009 were reviewed to capture all complications and 90-day readmission events. Clavien-Dindo grade IIIb, IV and V complications were classified as severe adverse postoperative outcomes (SAPO). II and IIIa complications requiring either prolonged overall lengths of stay (>2 standard deviations beyond the mean for patients undergoing ODP without complication) including readmissions or more than one interventional procedure were also classified as SAPOs. All others were considered minor adverse outcomes (MAPO). RESULTS: 127 patients underwent DP. 63 (49%) had a complication. 91% of DP patients had a complication of low/ moderate Clavien-Dindo grade (I, II, IIIa) or no complication. Using our re-classification, however, 24.8% had what was considered to be a poor quality outcome (SAPO) while 75.2% had a high quality outcome (MAPO or no complication). Of the patients undergoing DP, 77 underwent ODP and 50 underwent LDP. Compared to patients undergoing ODP, patients undergoing LDP were statistically less likely to have ductal adenocarcinoma (4% vs. 26%, p < 0.01) and tended to have smaller tumors (3.1 + 0.36 cm vs. 3.9 + 0.26 cm, p = 0.05). Those undergoing LDP did also demonstrate, however, lower volumes of intraoperative blood loss (234+30.1 mLs vs 752 + 152.7 mLs, p < 0.01), lower rates of postoperative transfusion (2% vs 20%, p < 0.01), lower rates of postoperative morbidity (35% vs 58%, p < 0.01), shorter initial postoperative lengths of stay (4.1 + 0.23 vs 8.3 + 0.7 days, p < 0.01), shorter overall lengths of stay including 90-day readmissions (6.1 + 0.9 days vs. 10.51 + 0.9 days, p < 0.01), and were less likely to have a poor quality (SAPO) outcome (15% vs 31%, p = 0.02)than those undergoing ODP. There were no statistical differences between the two groups in regard to age, presenting symptoms, incidence of diabetes, chronic pancreatitis or comorbid cardiopulmonary disease, preoperative albumin, operative time, the rate of readmission or of pancreatic fistula. CONCLUSIONS: Generic grading systems underestimate the severity of some complications following distal pancreatectomy. Using a procedure specific metric for quality following distal pancreatectomy, LDP affords a higher quality postoperative outcome than ODP resulting in shorter initial and overall lengths of stay, a lower incidence of postoperative transfusion and a lower incidence of severe adverse postoperative outcomes. 139 Monday Poster Abstracts CONCLUSIONS: While total pancreatectomy-induced diabetes negatively impacts select activities and functions, overall quality of life is comparable to that of patients after a partial pancreatic resection. Mo1499 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1500 Mo1501 Clinical Pathway for Pancreaticoduodenectomy Improves Short Term Outcomes at a Rural Tertiary Care Center Postoperative Systemic Inflammatory Response Syndrome Is a Predictor of Major Complication After Pancreatoduodenectomy Halle Beitollahi*, Erica L. Case, Nicole L. Woll, Mohsen M. Shabahang, Angela Huttenstine, Kathy J. Gorton, Marie A. Hunsinger, Joseph A. Blansfield General Surgery, Geisinger Medical Center, Danville, PA Naru Kondo*, Clancy J. Clark, Florencia G. Que, Kaye M. Reid Lombardo, David M. Nagorney, John H. Donohue, Michael B. Farnell, Michael L. Kendrick Mayo Clinic, Rochester, MN INTRODUCTION: Pancreaticoduodenectomy (PD) is a complex procedure with historically high rates of morbidity but can be performed efficiently at high volume centers. Clinical pathways increase efficiency for multiple operations including PD and have been shown to decrease length of stay and cost of PD at academic institutions. Our goal was to study implementation of a clinical pathway for PD at a rural tertiary care center to determine if length of stay decreased post implementation. BACKGROUND: Pancreatoduodenectomy (PD) has long been associated with high rates of morbidity and mortality. Identification of early predictors of postoperative complications is important to minimize the morbidity of PD. METHODS: Patient outcomes prior to and following implementation of a PD clinical pathway were studied between January 2006 and February 2011. Thirty five patients underwent PD prior to implementation of the clinical pathway and twenty two underwent PD after implementation. Primary outcomes included hospital length of stay and intensive care unit length of stay; operative time and estimated blood loss were analyzed as well. The pathway consists of pre-established daily goals; implementation began at the pre-operative visit and goals were set for the operative and the post-operative course. RESULTS: The two groups were well matched in terms of age, gender, BMI, and histology. The primary outcome was length of stay, determined to be 14 days prior to pathway implementation and 7 days following pathway implementation (p < 0.0001). Operative time was also statistically shorter in the pathway group. There was no statistically significant difference in length of intensive care unit stay between the two groups. CONCLUSION: Implementation of a clinical pathway for PD is possible at a rural tertiary care center. Following our pathway led to more reproducible post operative care. At our institution this pathway led to a decrease in length of stay and thereby improved short term patient outcomes. OBJECTIVE: To assess the usefulness of systemic inflammatory response syndrome (SIRS) as a predictor of major complications after PD. HYPOTHESES: 1) Early SIRS (postoperative day [POD] ≤3) can predict major complications after PD. 2) Late SIRS (POD 4–7) can predict late major complications (≥POD 8) after PD. METHODS: A retrospective cohort study of 527 consecutive patients who underwent PD between 2007 and 2010 was performed. Incidence of SIRS was investigated three times a day (at the nearest point of 8, 16 and 24 o’clock) from POD 1 to POD 7. SIRS was diagnosed based on the standard criteria including body temperature, heart rate, respiratory rate and white blood cell count. A day of SIRS was defined by meeting the criteria of SIRS at two or more points during the same day. Postoperative incidence of SIRS was classified into two groups: Early SIRS (at least one day of SIRS between POD 1 and 3), and Late SIRS (at least one SIRS positive day between POD 4 and 7). The relationship between clinicopathological factors, Early and Late SIRS, and major complications was evaluated by univariate and multivariate analyses. RESULTS: Early and Late SIRS presented in 193 (37%) and 121 (23%) patients, respectively. Major complications were observed in 149 patients (28%) with72 (13%) patients developing late. Sixty-day mortality was 1.3%. Total number of days with SIRS was associated with severity of complication (P < 0.001). Incidence of Early SIRS was associated with postoperative major complication (P < 0.001) with a sensitivity and specificity of 57% and 71%, respectively. Multivariate analysis demonstrated that the incidence of Early SIRS (HR 2.5, 95% CI, 1.6–3.9, P < 0.001), soft pancreatic texture (HR 2.4, 95% CI 1.4–3.8, P < 0.001), and prolonged operative time (>360 min) (HR1.6, 95% CI 1.1–2.5, P = 0.02) were independent risk factors for major complications after PD. For late complications, multivariate analysis demonstrated that Late SIRS (HR 3.6, 95% CI 1.8–7.1, P < 0.001), soft pancreatic texture (HR 2.1, 95% CI 1.1–4.1, P = 0.01), and male patients (HR, 1.9, 95% CI 1.1–3.6, P = 0.02) were identified as independent risk factors. CONCLUSION: In a large cohort of pancreaticoduodenectomy patients, early postoperative SIRS (POD ≤ 3) was an independent predictor of major complications after PD; and, similarly, Late SIRS (POD 4–7) independently predicted late major complications (≥POD 8). 140 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1502 Bioabsorbable Staple Line Reinforcement Reduces Risk of Fistula Following Pancreatic Resection Eric H. Jensen*1, Ming Teng2, Jessica Chowaniec2 1. Surgery, University of Minnesota Medical Center, Minneapolis, MN; 2. Covidien, New Haven, CT BACKGROUND: Pancreatic fistula remains a common post-surgical complication following stapled pancreatic transection. Surgical staple line reinforcement with bioabsorbable materials has grown in popularity in recent years with hopes that they may reduce pancreatic leaks. We sought to determine whether staple line reinforcement reduces risk of pancreatic fistula compared to bare metal staples. to REINF. Heterogeneity was calculated for prospective, retrospective and combined data. Prospective data had a Q-statistic of 0.44 with I2 of 0, consistent with low heterogeneity. In contrast, retrospective data had Q-statistic of 11.62 (p-value 0.02) with I2 of 66, indicative of moderate to severe heterogeneity. This is consistent with our observation that prospective studies all identified similar increased RR of leak with STPL technique, while there was conflicting data in the retrospective group. A forest plot summarizing the relative risk of pancreatic fistula for the 5 prospective studies is shown in Figure 1. METHODS: We performed a meta-analysis of existing data regarding pancreatic fistula following stapled pancreatic transection, comparing bare metal staples to reinforced staple loads. RESULTS: We identified 10 manuscripts between 2007 and 2009 reporting outcomes following stapled division of the pancreas, comparing bare staples (STPL) to reinforced staples (REINF). Five retrospective reviews and 5 prospective case series were included (Table 1). A total of 483 stapled pancreatic resections are included in this meta-analysis. Of these, 234 (48%) were REINF and 249 (52%) were STPL. Out of 483 cases, there were a total of 100 documented pancreatic leaks (21%). Sixty-one leaks were reported out of 249 STPL divisions (24%), while 39 leaks were reported following REINF division (17%). The overall relative risk of developing a pancreatic fistula following distal pancreatectomy was not significantly different comparing STPL to REINF when all studies were combined (RR 1.00 95%CI 0.65–1.53). We further evaluated the data stratifying by study design (prospective or retrospective). In doing this, we found that prospective studies reported a significantly higher risk of pancreatic fistula with STPL compared to REINF technique (RR 14.45, 95% CI 3.15–66.21). Both fixed and random effects models for the retrospective data revealed similar RR for pancreatic fistula comparing STPL Figure 1: Forest Plot summarizing prospective studies to date. Metaanalysis indicates significantly increased risk of pancreatic leak with bare staples (STPL) compared to reinforced staple loads (REINF). CONCLUSION: We have identified a significant reduction in risk of pancreatic fistula comparing reinforced to bare staples. Ideally, a randomized clinical trial should be performed to validate our observations. In the absence of that, however, reinforced staples should be the preferred method of pancreatic stump closure following distal pancreatectomy. Study Type Study (Year) Prospective Rotellar (2008) Retrospective STPL Total STPL Leaks REINF Total REINF Leaks 2 2 (100%) 7 0 (0%) Pugliese (2008) 6 4 (67%) 7 0 (0%) Melotti (2007) 51 16 (31%) 7 0 (0%) Thaker (2007) 11 4 (36%) 29 1 (3%) Jiminez (2007) 18 7 (39%) 13 0 (0%) Yamamoto (2009) 25 5 (20%) 47 2 (4%) Johnson (2009) 44 7 (16%) 70 7 (10%) Ferrone (2008) 41 10 (24%) 45 15 (33%) Guzman (2009) 15 3 (20%) 15 11 (73%) Laxa (2008) 21 3 (14%) 9 3 (33%) 141 Monday Poster Abstracts Table 1: Summary of Studies Included in this Meta-Analysis with Total Number of Pancreatic Surgeries and Pancreatic Leaks Identified THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1503 The results are summarized in the following Table. Indications for Total Pancreatectomy and Islet Auto-Infusion Beyond Chronic Pancreatitis with Intractable Pain TP + IAI for Indications Other Than Intractable Pain in Chronic Pancreatitis Luis F. Lara1, Marlon F. Levy*2,4, Morihito Takita4,5, Shinichi Matsumoto4,5, Daniel C. Demarco3,4 1. Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL; 2. Division of Gastroenterology, Baylor All Saints Medical Center, Fort Worth, TX; 3. Division of Gastroenterology, Baylor University Medical Center at Dallas, Dallas, TX; 4. Baylor Regional Transplant Institute, Dallas, TX; 5Baylor Research Institute, Dallas, TX BACKGROUND/AIMS: Total pancreatectomy with islet auto-infusion (TP + IAI) is effective in selected patients with chronic pancreatitis (CP) who have intractable pain unresponsive to medical and interventional therapies. IAI can maintain adequate glycemic control, possibly insulin independence, and has been used in selected cases following total pancreatectomy for IPMN, pancreas trauma or pancreas necrosis with persistent leak. We report our experience with TP + IAI for indications beyond chronic pancreatitis. METHODS: TP + IAI has been performed since 2006 at BUMC. Pancreata are preserved using chilled ET-Kyoto solution and using the oxygen-charged static two layer method. Digestion is by the modified Ricordi method, and purified when over 10 ml of tissue is obtained and then injected into the portal vein. A SUITO index of >10 and islet yield of 500,000 correlates with increased insulin independence. Patients who had the procedure for a diagnosis other than chronic pancreatitis and intractable pain were selected from the IRB approved database. RESULTS: Thirty seven patients had a TP + IAI since 2006; 34 patients had CP confirmed by CT/MRI and/or EUS/ ERCP, endoscopic secretin stimulated pancreas function testing (ePFT) and histology. Three patients had the procedure for other indications and are reported. Patient 1: 32 y/o F with idiopathic recurrent acute pancreatitis (IRAP)resulting in multiorgan failure (MOF), ARDS and ventilator dependency with each attack. EUS/ERCP were not diagnostic of CP, ePFT was normal. No evidence of endocrine/exocrine failure. No genetic mutations found. Decision to perform TP + IAI after last admission with 2 month hospitalization with MOF. Patient 2: 31 y/o M with hereditary chronic pancreatitis (HP) with PRSS1 (R122H) mutation, mother with CP and PRSS1, 2 family members with CP, 2 family members with pancreas cancer (<55 y/o). Intermittent pain exacerbations treated mostly at home. Decision to perform procedure due to known mutation and family history of cancer. Patient 3: 62 y/o F with ampullary adenoma, recurrent high grade dysplasia despite repeated ampullectomies complicated by pancreas necrosis, and distal pancreatectomy with persistent leak. Decision to perform procedure as a completion pancreatectomy was expected. Patient 1 Patient 2 Patient 3 basal c-peptide 1.8 ng/ml 0.9 ng/ml 0.5 ng/ml basal SUITO index 73 46.6 6.6 Total islet yield (IE) 500,351 212,463 Impossible to remove head of pancreas IE/kg 4313 3708 post IAI c-peptide 0.7 ng/ml 0.5 ng/ml post IAI SUITO index 10.5 5.8 Insulin need *Partial *Partial TP = total pancreatectomy; IAI = islet auto-infusion; *Partial = c-peptide measurable but insulin needed for glycemic control CONCLUSIONS: The pt with IRAP had a higher c-peptide, SUITO index and islet yield compared to the patient with HP, but post-procedure c-peptide and glycemic control were similar. Despite purity of the pancreas extract ductal cells could have been injected into the portal vein, which was explained to the patient with HP and who consented. As TP + IAI becomes more routine studies are needed to understand its application beyond treatment of intractable pain and glycemic control in CP. Mo1504 Does Pancreatic Stump Closure Method Influence Fistula Rate After Distal Pancreatectomy Eugene P. Ceppa*, Robert M. Mccurdy, Molly Kilbane, Attila Nakeeb, C. Max Schmidt, Nicholas J. Zyromski, Keith D. Lillemoe, Henry A. Pitt, Michael G. House Surgery, Indiana University Medical Center, Indianapolis, IN INTRODUCTION: Pancreatic fistula (PF) remains the primary morbidity following distal pancreatectomy (DP). Previous studies have reported specific methods of parenchymal transection and sealing in an effort to decrease the PF rate with highly variable results. The aim of this study was to determine the pancreatic fistula rate following various sealing methods. METHODS: All cases of DP were reviewed at a single highvolume institution between January 2008 and June 2011. Sealing method of the pancreatic stump was used to create operation groups (suture, staple, or saline linked radiofrequency (SLRF)). All cases were monitored with complete 30-day outcomes through the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Two and three-way statistical analyses were performed among the operation groups. 142 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: Two hundred and three patients underwent DP over the 42-month period. The most common diagnoses included pancreatitis (32%), adenocarcinoma (19%), and IPMN (13%) which did not differ significantly among the 3 operation groups. The suture, staple, and SLRF groups included 90 (44%), 61 (30%), and 52 (26%) patients, respectively. Operative technique included open (68%) and minimally invasive (32%) approaches and did not differ among the stump sealing groups. Thirty-six patients (59%) within the staple group received staple line reinforcement with bioabsorbable material. Postoperative outcomes for the three groups of patients are summarized in the table. Overall complications and PFs were similar in each group. Operative technique was not associated with the need for carryover outpatient drainage, postoperative interventional drain placement, or hospital readmission. SLRF, N = 52 Staple, N = 61 Suture, N = 90 p-Value* Overall complications 16 (31%) 23 (38%) 35 (39%) 0.61 Pancreatic fistula 13 (25%) 16 (26%) 23 (26%) 0.95 Panc fistula grade B/C 6 (11%) 11 (18%) 15 (17%) 0.60 Home drain 4 (8%) 10 (16%) 15 (17%) 0.29 IR drainage procedure 6 (11%) 6 (10%) 13 (14%) 0.71 30d hosp readmission 7 (14%) 14 (23%) 17 (19%) 0.44 *Chi-square correlations among all three groups CONCLUSIONS: Postoperative outcomes after distal pancreatectomy are unaffected by the use of SLRF sealing of the pancreatic stump when compared to traditional suture or reinforced stapling techniques. A randomized clinical trial comparing these three operative techniques may not demonstrate a difference that is clinically significant. Mo1505 Reduction in Delayed Gastric Emptying Following Non-Pylorus Preserving Pancreaticoduodenectomy by Addition of Braun Enteroenterostomy Mehrdad Nikfarjam* Surgery, University of Melbourne, Melbourne, VIC, Australia BACKGROUND: Delayed gastric emptying (DGE) is a major cause of morbidity following pancreaticoduodenectomy (PD), with various factors implicated in its development. The influence of operative technique on the occurrence of DGE is controversial. The impact of a Braun enteroenterostomy (BE) in reconstruction following classic PD was assessed. METHODS: Forty-four consecutive patients undergoing non-pylorus preserving PD from August 2009 to November 2011 by a single surgeon were included in this study. The first twenty patients had a standard antecolic gastrojejunal anastomosis. The subsequent twenty-four patients had an antecolic gastrojejunal anastomosis with the addition of a BE. The groups were compared and complications assessed according to criteria set by the International Study Group of Pancreatic Surgery (ISGPS). RESULTS: Patient characteristics between the groups were similar as was the extent of surgery and tumour and pancreatic characteristics. The median estimated blood loss was greater in the standard reconstruction group (450 ml (100–1500) vs 325 (100–1500 ml) p = 0.04). All other operative factors, including intra-operative blood transfusions were similar between the two groups. The DGE rate in the BE was significantly lower than the standard reconstruction group (1 (4%)versus 7 (35%); p = 0.015). In the standard group, 6 of 7 cases of DGE were Class C in nature. The pancreatic fistula rate in the BE group was similar to the standard reconstruction group (4 (21% versus 5 (29%); p = 0.706) as was the median length of hospital stay (10 days (7–38) vs 15 (7–45); p = 0.291). On assessing factors associated with DGE, the BE technique was the only significant factor in this study. 143 Monday Poster Abstracts CONCLUSION: The use of BE following non-pylorus preserving PD appears to results in a significant reduction in DGE. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1506 Mo1507 Duct-to-Mucosa Pancreaticogastrostomy Reduces Postoperative Pancreatic Stump Leak Rates After Distal Pancreatectomy Risk Factors, Hospital Cost, and Complications Associated with Transfusion in Elective Pancreatectomy Yasushi Hashimoto*, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Akira Nakashima, Taijiro Sueda Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan Raphael C. Sun*1, Anna M. Button2, Brian J. Smith2, Hisakazu Hoshi1, Richard F. Leblond3, Howe R. James1, James J. Mezhir1 1. Surgery, University of Iowa, Iowa City, IA; 2. Biostatistics, University of Iowa, Iowa City, IA; 3. Internal Medicine, University of Iowa, Iowa City, IA BACKGROUND: Pancreatic stump leak is the major source of morbidity after distal pancreatectomy. We hypothesized that a duct-to-mucosa pancreaticogastrostomy after distal pancreatectomy (DP-PG) can decrease pancreatic fistula (PF) rates when compared to hand-sewn or staple closure. Since 2008, we conducted the nonrandomized cohort study with a prospective DP-PG group, forming our experimental group, and a retrospective control group undergoing handsewn closure. The aim of this study is to analyze the safety and efficacy of this method. METHODS: DP-PG was intended to prevent PF after DP in 30 patients between April 2008 and November 2011. A historical control group was composed of 30 consecutive patients undergoing hand-sewn closure between January 2005 and March 2008. Main outcome measure was incidence of PF which was defined and graded according to the International Study Group on Pancreatic Surgery (ISGPS) classification. Secondary measures were complications which were assessed by the Clavien classification and postoperative hospital length of stay. Two groups were compared using Kruskal-Wallis test or chi-square tests. RESULTS: Overall, a cohort of 60 patients underwent DP between 2005 and 2011. In the DP-PG group (n = 30), none PF was observed in 19 patients (63%), Grade A was 10 (33%), Grade B was 1 (3%), and Grade C was none. In the control group (n = 30), none PF was observed in 17 patients (57%), Grade A was 7 (23%), Grade B was 5 (17%), and Grade C was 1 (3%). Therefore the clinically-relevant PF (ISGPS Grade B/C) rate was significantly lower in the DP-PG group (3%) comparing to the control group (20%; P = 0.01). Re-operation was required for one patient in both groups, but no one was due to PF. The mortality was zero in both groups. The operative time was slightly longer in the DP-PG group (median, 237 min) comparing to the control group (198min, P = 0.05). The Clavien III-V severe complications were observed in 2 patients (7%; none for PF) in the DP-PG group, but in 4 patients (13%) in the control group. Development of a pancreatic leak resulted in prolonged hospital stays: 20 days in the DP-PG group vs. 29 days in the control group (P = 0.03). The advantage of this technique is that pancreatic juice leaking from smaller branches on the cut surface which cannot be drained through the remnant main duct directly passes into the stomach and also allows decompress the intraductal pressure through the anastomosis. CONCLUSIONS: Drainage through the pancreatic stump provided by duct-to-mucosa pancreaticogastrostomy after distal pancreatectomy (DP-PG) appears to have abruptly reduced clinically-relevant PF (ISPGS Grade B/C) rate and hospital stay. The economic impact of lower leak rates is reflected in lower morbidity rate and significantly shorter hospital stays. The results of our study should be validated in a randomized controlled trial. BACKGROUND: There is now increased awareness of the detrimental effects of transfusion in elective general surgical procedures. Our objectives are to determine 1) which preoperative clinical variables can predict the need for intraoperative transfusion and 2) the impact of transfusion on hospital costs and complications in pancreatectomy. METHODS: Using our prospective institutional and ACSNSQIP database, we identified 173 patients who had elective pancreatectomy from 9/2007 to 9/2011. Univariate and multivariate analyses were performed using 24 preoperative clinical variables to identify risk factors associated with transfusion. Preoperative severity of illness (SOI) and mortality risk were determined using the Agency for Health Research and Quality (AHRQ) Risk Adjustment Score, a standardized metric used by the University Health System Consortium. Hospital costs and operative complications were also evaluated. RESULTS: Patients had left pancreatectomy (n = 60) or pancreaticoduodenectomy (n = 113) to treat malignant (n = 134) or benign (n = 39) disease. Median OR time was 7.4 hours (2.4–12.3). Median LOS was 10 days (4–77) and 51 patients (29%) spent at least one night in the ICU. 98 patients (56.6%) had a complication and 90-day mortality was 2.9% (n = 5). SOI at admission was minor in 21 patients (12.1%), moderate in 59 (34.1%), and major/extreme in 43 (24.8%). Risk of mortality at admission was: minor (n = 91, 53%), moderate (n = 58, 34%), and major (n = 24, 14%). There were 78 patients (45%) who received at least 1 unit of blood and the median number of intraoperative transfusions was 3.0 units (1–55); 11 of these patients (6.4%) also received plasma. Mean total hospital costs observed was $39,434 ($13,285-$251,157). Compared to patients who did not receive a transfusion, those who received at least one blood product had a higher mean hospital cost and hospital charges (Table 1). Among transfused patients, 65% (n = 51) experienced at least one complication vs. 49% (n = 47) of patients not transfused (p = 0.036), including infectious complications and pancreatic fistula/leak/abscess (Table). In multivariate analysis, independent predictors of increased transfusion likelihood included lower hematocrit, increased BMI, and worse AHRQ SOI and mortality risk scores. Age, gender, comorbidities, diagnosis, ASA class, procedure, OR time, and ICU stay were not independent predictors of transfusion risk. 144 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Table 1: Cost and Complications Associated with Transfusion in Pancreatectomy Transfusion Hospital Cost p-Value (a) Hospital Charges p-value (a) Infectious Complication p-Value (b) Grade III Pancreatic Fistula/Leak/Abscess p-Value (b) Yes No $53,239 $28,099 <0.0001 $123,978 $66,023 <0.0001 46% 18% <0.0001 22% 3% 0.001 *p-values determined using (a) two-sample t-tests and (b) chi-square tests. CONCLUSIONS: Blood transfusion is associated with increased hospital cost and morbidity in pancreatectomy. Factors associated with increased risk for transfusion such as preoperative hematocrit, BMI and AHRQ scores can be utilized to stratify patients in clinical trials and inform patients of their risk for transfusion. Further research is needed to determine the extent to which transfusion contributes to morbidity and cost independently of SOI. Mo1508 Laparoscopic Distal Pancreatectomy for Benign and Malignant Lesions: A Nationwide Analysis of Patient Outcomes Hop S. Tran Cao*, David Chang, Andrew M. Lowy, Michael Bouvet, Mark A. Talamini, Jason K. Sicklick Department of Surgery, University of California, San Diego, La Jolla, CA BACKGROUND: Laparoscopic distal pancreatectomy (LDP) was first reported in 1996. Since then, all publications evaluating LDP have consisted of single center or multi-institutional case series. We hypothesized that a national database inquiry could offer insight into the indications and outcomes of LDP. METHODS: The Nationwide Inpatient Sample was queried for patients undergoing LDP for benign and malignant pancreatic lesions from 1998 to 2009. Univariate and multivariate analyses were performed using logistic regression models, adjusting for age, gender, ethnicity, and comorbidities. CONCLUSIONS: The reported experiences of single or multiple institutions with LDP for cancerous lesions of the pancreas remain limited. We now report the nationwide experience and outcomes of LDP for patients with benign and malignant pancreatic diseases utilizing a national database. We show that patients undergoing LDP for pancreatic cancer tend to be older, have more comorbities, and are more likely to undergo concurrent splenectomy. However, on multivariate analyses, this does not result in increased in-hospital morbidity or mortality rates. In summary, the application of laparoscopic distal pancreatic resections for malignancies has emerged as a feasible and safe approach with comparable outcomes to resections performed for benign pancreatic lesions. However, long-term oncological outcomes need to be better studied before this technique can be widely accepted as standard of care. 145 Monday Poster Abstracts RESULTS: 1,908 LDPs were performed between 1998 and 2009. 506 cases were excluded due to unclearly coded ICD-9 diagnoses. The remaining 1,402 LDPs were coded for benign (57.8%) or malignant (42.2%) diseases of the pancreas. The groups were similar for gender, ethnicity, and in-hospital mortality rates but cancer patients were on average 6.9 years older (P = 0.0001) and had higher Charlson comorbidity indices (scores ≥2: 75.5% vs. 50.8%, P = 0.0001). On univariate analyses, patients undergoing LDPs for malignancies had longer lengths of stay (8.95 vs. 6.89 days, P = 0.02), higher overall complication rates (34.4% vs. 22.0%, P = 0.045), more inadvertent organ injuries (5.5% vs. 1.1%, P = 0.03), higher splenectomy rates (93.8% vs. 71.4%, P < 0.0001) and increased requirements for blood transfusions (15.8 vs. 6.6%, P = 0.019). On multivariate analyses, LDPs performed for cancer were associated with a statistically significant increase in the incidence of splenectomy (OR 5.92, 95% CI 2.32–15.1). In contrast, there were no differences in individual complication rates, including fistulae, infections/abscesses, hemorrhage/hematomas, inadvertent organ injuries, wound complications, organ dysfunction, thromboembolic events, or in-hospital mortality based upon disease indication for LDP. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1509 Contemporary Treatment and Outcomes of Periampullary Adenocarcinomas at a Single Institution Vei Shaun Siow*, Zhi Ven Fong, Harish Lavu, Eugene P. Kennedy, Patricia K. Sauter, Leonidas Koniaris, Ernest L. Rosato, Charles J. Yeo, Jordan M. Winter Thomas Jefferson University Hospital, Philadelphia, PA INTRODUCTION: Periampullary adenocarcinoma (PA) is the most common indication for pancreaticoduodenectomy (PD). The four cancers that comprise the PAs include pancreatic ductal (PDA), ampullary (AA), distal common bile duct (CBDA), and duodenal adenocarcinoma (DA). While PDA has been studied extensively, it is unclear whether these data are applicable to the rarer PAs. METHODS: We queried our institutional PD database for patients treated for PA from November 2005 to October 2011. Out of 650 resections, 390 (60%) patients had PA. Clinicopathologic data were analyzed, and statistical comparisons between PA subtypes were made with respect to PDA, unless otherwise indicated. We aimed to identify the differences in the biology, natural history, and treatment patterns between PAs. RESULTS: The 390 resected PAs included 293 (75%) PDAs, 48 (12%) AAs, 28 (7%) distal CBDAs, and 21 (5%) DAs. Preoperative CA 19–9 levels were elevated in 76% of patients with PDA, 56% with distal CBDs (p = 0.04), 62% with AA (p = 0.071), and 55% with DA (p = 0.06). In general, resected PDAs and CBDAs had the more aggressive pathologic features. Specifically, perineural invasion was identified in 92% of PDAs, 93% of distal CBDAs (p = 1.0), 51% of AAs (p < 0.0001) and 34% of DAs (p < 0.0001). Lymph node metastases were identified in 74% of PDAs, 50% of distal CBDAs (p = 0.013) 60% of AAs (p = 0.05) and 57% of DAs (p = 0.1). Documented recurrence patterns were available in a subset of patients (22%) followed at our own institution. Due to the small number of patients, non-pancreatic PAs were analyzed together. The site of first recurrence was the surgical bed in 24% of PDAs and 20% of non-pancreatic PAs. A distant metastasis was identified in 76% of PDAs and 80% of non-pancreatic PAs (p = 1.0). With regards to treatment patterns at our institution (N = 158 with treatment data), patients with PDA and distal CBDAs are virtually always treated with adjuvant gemcitabine (91%), as compared to the other two subtypes (55%, p < 0.0001) which are frequently treated with a 5-FU based regimen. The median and 2-year survivals associated with each PA were (Figure): PDA, 19 months and 39%; CBDA, 18 months and 37% (p = 0.8); AA, 43 months and 65% (p = 0.002); and DA, median not reached and 67% (p = 0.04). After adjusting for lymph node metastases, AA was still more favorable than PDA (hazard ratio = 0.73, p = 0.01) while DA showed a trend but was not significantly more favorable (hazard ratio, 0.8, p = 0.1). Kaplan-Meier survival curves for patients with periampullary adenocarcinoma. CONCLUSIONS: These findings support the notion that PAs are a heterogeneous group. As compared to AAs and DAs, PDAs had more aggressive pathologic features and worse long-term survival. In addition, CA19–9 was a more sensitive test for PDAs than the non-pancreatic PAs. Our practice patterns approach pancreatobiliary cancers primarily with gemcitabine-based treatment, which differs from the approach with the other subtypes. Mo1511 Predictive Factors of Pancreatic Fistula and Postoperative Complications After Pancreatic Resections in Two High Volume Centers: Comparison Between Posterior Invagination and Duct-to-Mucosa Pancreaticogastrostomy Filippo Scopelliti*1, Giovanni Butturini1, Carlo Frola2, Mohammad Abu Hilal2, Claudio Bassi1 1. Department of Surgery, Verona University, Verona, Italy; 2. Hepato Pancreatico Biliary Surgery Unit, Southampton General Hospital, Southampton, United Kingdom INTRODUCTION: Pancreatic fistula (PF) is a major complication after pancreatic resections. Well known risk factors are soft pancreatic remnant and small duct. The most widely used techniques to reconstruct the pancreo-digestive continuity are pancreojejunostomy (PJ) and pancreogastrostomy (PG), either executable by invagination or duct-to-mucosa. Unlike PJ, there are no studies evaluating short term outcome and PF rate comparing invagination versus duct-to-mucosa PG. METHODS: In this dual-institution retrospective study, 345 patients, reconstructed by invagination or duct-tomucosa PG after pancreatic resections, were stratified in two groups by the type of PG performed. The invagination group consists of 173 patients from 2000 and 2010 at the same institution, selected for having soft pancreatic remnant. The duct-to-mucosa group consists of 172 consecutive patients from 2007 and 2010 at the other institution. Primary end point was to compare the two groups in terms of postoperative complications, including PF rate and grad- 146 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA ing, as defined by the International Study Group of Pancreatic Fistula. Secondary end point was the assessment of possible predictive risk factors of PF, unrelated to the type of anastomosis. RESULTS: No differences in demographic data between the two groups were found except of the median age, significantly higher in duct-to-mucosa group (67 vs 62 years; P = 0,001). In invagination group 90,1% of patients had a soft pancreatic remnant vs 48,2% in the duct-to-mucosa group (P = 0,0001). There were 47 PFs (27,2%) in the invagination group and 44 (25,6%) in the duct-to-mucosa group (P = NS). Furthermore no differences in PF grading were found. The patient in duct-to-mucosa group experienced abdominal collections in 42 cases (24,2%) respect of the 18 patients (10,4%) in the invagination group (P = 0,001). Also delayed gastric emptying rate was significantly higher in duct-to-mucosa group, 44 cases (25,6%) respect of the 10 (5,8%) in the invagination group (P = 0,0001). Mortality was 0% in invagination group and 4,1% (7 cases) in ductto-mucosa group, but this difference may be due to the higher median age of this population respect of the invagination group. In multivariate analysis for PF, independent risk factors, unrelated to the type of anastomosis, included sex male (P = 0,0001), soft pancreatic remnant (P = 0,0001) and small pancreatic duct (P = 0,005). CONCLUSIONS: The type of pancreogastrostomy does not significantly influence the overall postoperative complication rate or incidence of PF. However, abdominal collections and delayed gastric emptying are significantly reduced in patients treated by invagination PG. Furthermore invagination seems to be safer than duct-to-mucosa in case of soft pancreatic remnant. In addition, soft pancreatic remnant and small duct can be confirmed as independent risk factors for PF. Mo1512 Pancreaticoduodenectomy at High Volume Centers: Surgeon Volume Goes Beyond the Leapfrog Criteria Abhishek Mathur*1, Kenneth Luberice2, Edward Choung2, Sharona B. Ross1, Alexander S. Rosemurgy2 1. Surgery, University of South Florida, Tampa, FL; 2. Surgery, Tampa General Medical Group Tampa General Hospital, Tampa, FL INTRODUCTION: The Leapfrog Group has stated that outcomes after high-risk procedures, like pancreaticoduodenectomy, are superior at high-volume hospitals. High-volume hospitals are inexorably intertwined to high-volume surgeons; however, high-volume hospitals also have low-volume surgeons. This study was undertaken to determine if outcomes after pancreaticoduodenectomy are different for highvolume vs. low-volume surgeons at high-volume hospitals. METHODS: High-volume hospitals for pancreaticoduodenectomy (defined by the Leapfrog Group as ≥12/year) were identified from the State of Florida Agency for Health Care Administration database for a 33-month period ending in October 2010. In these centers, outcomes for high-volume surgeons (undertaking ≥12 pancraetoduodenectomies per year) were compared to those of low-volume surgeons (undertaking <12 pancraetoduodenectomies per year). Median data are presented. Figure 1: Invagination PG # of Surgeons # of PD’s LOS (days) In-Hospital Mortality Hospital Charge ($) High-Volume Hospitals 55 928 11 (15 ± 14) 4.09% 99,409 ( $142,578 ± 153,064) High-Volume Surgeons 10 705 10 (15 ± 14) 2.83% 98,848 ( $133,218 ± 136,379) Low-Volume Surgeons 45 223 12 (17 ± 14)* 8.07%* 100,289 ( $172,166 ± 194,142)* *p < 0.01 vs. High-Volume Surgeons Figure 2: Duct-to-mucosa PG 147 Monday Poster Abstracts RESULTS: 55 surgeons undertook 928 pancreaticoduodenectomies at 6 high-volume hospitals; 10 surgeons were high-volume surgeons. High-volume surgeons in these high-volume hospitals had shorter lengths of stay (LOS), lower in-hospital mortality, and lower hospital costs (p < 0.001) than low-volume surgeons (Table). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSIONS: Within high-volume hospitals, high-volume surgeons have superior outcomes (including decreased lengths of stay, in-hospital mortality, and cost of care) relative to low-volume surgeons. Outcomes after pancreatecticoduodenectomy at high-volume hospitals are dependent upon surgeon volume; any “hospital affect” is limited and does not benefit low-volume surgeons. complications were identified after any DBE procedure in mean follow-up period of 6 months. Mean procedure time was 89.6 (38–180) minutes and average fluoroscopy time was 173 (15–466) seconds. Clinical: Small Bowel Mo1513 Double Balloon Enteroscopy in Patients with Surgically Altered Bowel Anatomy: Analysis of Large Prospectively Collected Database Mihir K. Patel*1, Victoria Gomez1, Ali Lankarani1, John Stauffer2, Mark E. Stark1, Frank Lukens1 1. Gastroenterology, Mayo Clinic, Jacksonville, FL; 2. Surgery, Mayo Clinic, Jacksonville, FL BACKGROUND: The referral of patients with surgically altered bowel anatomy such as Bariatric surgery, Billroth II surgery, and Roux en Y anastomosis during liver transplants etc. for endoscopic evaluation is rising. The Double Balloon Enteroscopy (DBE) procedure has both diagnostic and therapeutic value in small bowel evaluation in these patients. Reported data on DBE in the patients with surgically altered bowel anatomy is limited. AIM: To evaluate the success rate, diagnostic yield, and safety of DBE procedure in patients with surgically altered bowel anatomy. METHODS: We reviewed our large prospectively collected DBE database from 2006 to 2011. The patients with history of surgically altered bowel anatomy who underwent DBE were included in our study analysis. Patients’ Demographics along with DBE procedure indication, findings and complications were recorded. We used the frequency statistics to calculate the diagnostic yield of the DBE in these patients. RESULTS: A total of 1218 DBE procedures were performed from 2006 to 2011 at our tertiary referral center. Out of these, 64 DBEs (11 DBE-ERCP) performed in 62 patients (73% Female) with surgically altered bowel anatomy were included in our study analysis. Their mean age was 51 (26–77) years and mean BMI was 28.2 (20.3–53.6) kg/m2. Bariatric surgery was the most common 83% (n = 53) type of the surgery for altered bowel anatomy. The most common indication of DBE was abdominal pain and DBE-ERCP was acute cholangitis (see table). The overall procedure success rate for adequate examination of roux limb was 92.2% (59/64). The success rate of DBE–ERCP with adequate examination of pancreato-biliary tree and required therapeutic intervention was 63.3% (n = 7/11). The overall diagnostic yield (pertinent positive findings) of DBE procedure was found to be 64% (n = 41). The diagnostic yield in patients with prior negative imaging and/or capsule endoscopy was found to be 47% (n = 30). The diagnostic yield of small bowel biopsy (targeted or random) was 9.4% (n = 3/32), while the diagnostic yield of small bowel aspirate for bacterial overgrowth was found to be 100% (n = 5/5). No Indications of DBE without ERCP (n = 53 pts) n (%) Persistent abdominal pain Bleeding—Overt Bleeding—Obscure Other 17 (32) 10 (19) 8 (16) 18 (33) Indications of DBE-ERCP (n = 11 pts) n (%) Acute cholangitis Recurrent pancreatitis Biliary Stricture Other 3 (27.3) 2 (18.2) 2 (18.2) 4 (36.3) CONCLUSION: The DBE is a safe procedure and carries very high diagnostic yield in the patients with surgically altered bowel anatomy for various indications. The diagnostic yield remains high even if there are negative radiology tests and/or capsule endoscopy prior to DBE procedure. The diagnostic yield of small bowel aspirate was very high while diagnostic yield of gastrointestinal biopsies were low. In our study, we found fair success rate of DBE with ERCP procedure in terms of adequate examination with required therapeutic intervention. Mo1514 Fifteen Cases of Superior Mesenteric Artery Syndrome: Diagnosis and Surgical Strategies Romeo Bardini1,2, Angelica Ganss1,2, Marinella Menegazzo1,2, Marco Tonello1,2, Imerio Angriman*1,2 1. University of Padova, Padova, Italy; 2. Surgical & Gastroenterologic Science, University of Padova, Padova, Italy INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is a condition caused by duodenal compression between aorta and superior mesenteric artery (SMA). SMAS’s symptoms are nausea, vomiting, post-prandial epigastric pain and weight loss. Computed tomography (CT) angiography and magnetic resonance (MR) angiography are at present the most informative diagnostic technique. Diagnostic criteria are a narrowing in the aorto-mesenteric angle lesser than 22° (normal 28°–65°) and a reduction of the aorto-mesenteric distance to 8 mm or less (normal 10–28 mm). Usually SMAS is not recognized and mistreated. Medical treatment includes pro-motility agents, but surgical approach is advocate in case of conservative treatment failure. METHODS & AIM: Fifteen consecutive patients (11F, 4 M, mean age 45 ± 9 years) who underwent surgical correction of SMAS between 2008 and 2010 have been enrolled in this prospective study. Before operation all patients have been investigated with CT and/or MR angiography with multiplanar three-dimensional reconstructions, EGDS, barium contrast radiography. In patients previously operated for GERD, also pH-metry and esophageal manometry were performed. Postoperative outcome was evaluated considering the following clinical variables: weight, BMI, medical therapy, serum albumine, amylase and lipase. Aim of the study is to evaluate safety, efficacy and outcome of surgical correction of SMAS. 148 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: All the patients enrolled were symptomatic for abdominal pain, nausea and anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreatitis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18° ± 1.8 and distance 4.6 ± 2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 ± 6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improvement in patient weight (pre-operatory mean 50 ± 1 kg, post-operatory mean 55 ± 9 kg p = 0.003) and BMI (preoperatory mean 18.1 ± 3.4 kg, post-operatory mean 20.0 ± 3.4 kg p = 0.004) and there is a significant decreased in need of PPI therapy (p = 0.004). We didn’t observed significant differences, in the outcome, between the two surgical procedures. CONCLUSIONS: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass. Mo1515 Impact of Abdominal Insufflation for Laparoscopy on Intracranial Pressure Tovy H. Kamine*1, Efstathios Papavassiliou2, Benjamin E. Schneider1 1. Surgery, BIDMC, Boston, MA; 2. Neurosurgery, BIDMC, Boston, MA INTRODUCTION: Diagnostic laparoscopy has recently emerged as an alternative to laparotomy in trauma patients. However, the impact of abdominal insufflation on intracranial pressure is not well described outside animal models. We present a retrospective review of patients who underwent a laparoscopic assisted ventriculoperitoneal shunt placement (lap VPS) at our single institution with intraoperative intracranial pressure (ICP) measurements. RESULTS: Nine patients had ICP measurements noted. The mean increase in ICP with insufflation was 7.22 cm H2O (95%CI:5.38–9.07; p < 0.001). The maximum ICP difference was 12.5 cm H2O. The maximum ICP measured in this population with insufflation was 25 cm H2O. None of the baseline data measured had a significant effect on increase in ICP with insufflation. Mo1516 Effects of Preoperative Enteral Glutamine and Arginine in Patients Submitted to Surgical Treatment of Enterocutaneous Fistulas Jose L. Martinez, Enrique Luque-De-LEóN*, Eduardo A. Ferat-Osorio Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI, Mexico DF, Mexico INTRODUCTION: Sepsis remains the main cause of morbidity and mortality in patients with enterocutaneous fistulas (ECF). Although preoperative immunonutrition has shown less infectious complications (IC) in patients with gastrointestinal malignancies submitted to operative treatment, no studies have been done regarding use of these agents in patients with ECF. Our aim was to assess the effects of preoperative enteral glutamine and arginine in patients with ECF who require surgical attempts for its closure. PATIENTS AND METHODS: During a 24 month study period, 38 patients with ECF were operated upon. All had at least 100 cm of proximal small bowel. They were divided in 2 groups: patients in group A (control, n = 20) were managed with our standard preoperative protocol; patients in group B (experimental, n = 18) received oral glutamine (4.5 g/day) and arginine (10 g/day) preoperatively for 7 days. Patient, disease, and operative variables were prospectively collected. Our primary endpoint was IC. Secondary endpoints included ECF recurrence, definitive ECF healing and mortality. Comparisons were made using Students T test for continuous variables and chi-square or Fischers exact test for categorical variables. RESULTS: All patient, disease and operative variables were similar for both groups. IC developed in 8 and 2 patients (groups A and B respectively, p = 0.06). Some patients in group A had more than one IC and thus this difference became more evident when total number of complications per group were calculated (15 vs 2 respectively, p < 0.05). Comparing secondary endpoints for patients in group A vs B, ECF recurred in 8 and 2, respectively (p = 0.06), and definitive ECF closure was achieved in 12 and 16, respectively (p = 0.06). Three patients died in group A, and 1 in group B (from an unrelated non-septic cause), p = 0.60. CONCLUSIONS: Use of preoperative enteral glutamine and arginine seems to provide beneficial effects for patients with ECF submitted to operative treatment. There were less number of total IC and a clear tendency towards less number of patients with IC, less ECF recurrence and more definitive ECF closures and healing. 149 Monday Poster Abstracts METHODS: Retrospective chart review was performed for sequential patients who underwent laparoscopic-assisted VPS placement since 2008. Abdominal insufflation was performed using CO2 to 15 mmHg. ICP was measured through the ventricular catheter with insufflation and desufflation, using a manometer. Baseline data were obtained as well including: age, sex, HTN, CHF, cancer, cirrhosis, renal failure, BMI, and prior abdominal or cranial surgery. Paired t-tests were performed to determine differences between ICP on insufflation and desufflation. Baseline data analyzed using linear regression to the ICP difference. DISCUSSION: ICP was significantly elevated with the insufflation associated with laparoscopy up to a maximum 12.5 cm H2O above the desufflated baseline. These data suggest that laparoscopy should be used cautiously in patients with a baseline elevated ICP or head trauma. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Stomach Mo1518 Mo1517 Correlation Between Gastric Emptying Time and Weight Loss After Silastic Ring Roux-en-y Gastric Bypass Revisional Bariatric Surgery for Weight Regain and Complications Jorge M. Junior1, Fernando Herbella*2, Antonio C. Valezi1, Silvia Brito3 1. Surgery, Uel, Londrina, Brazil; 2. Digestive Surgery, Unifesp, São Paulo, Brazil; 3. Nutrition, Uel, Londrina, Brazil Hideharu Shimizu*, Matthew Kroh, Tomasz Rogula, Bipan Chand, Philip R. Schauer, Stacy A. Brethauer Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH INTRODUCTION: With the increase in the number of bariatric surgery performed every year, there are growing numbers of patients who require revisional surgery due to undesirable results from their primary procedures. Anatomic complications and weight regain are the two most common reasons for pursuing revisional bariatric surgery. METHODS: We conducted a retrospective analysis from a single institution to evaluate medium-term weight loss and complication rates after revisional bariatric procedures. RESULTS: From 01/04 to 01/11, 2918 patients underwent bariatric surgery at our institution. 155 (5%) had revisional surgery. 81% were female. The mean age at revision was 49 and the mean BMI at time of revision was 44. The most common primary procedures were Roux-en-Y gastric bypass (RYGB) (n = 55, 36%), vertical banded gastroplasty (n = 37, 24%), sleeve gastrectomy (SG) (n = 26, 17%), and adjustable gastric banding (AGB) (n = 23, 15). Two groups were defined according to the indication for revision. Group A included patients with unsatisfactory weight loss or regain of co-morbidities (n = 108) and Group B included complications from their primary procedures (n = 47). In group A, majority of the patients (69%) were revised to standard or distal RYGB. Others underwent redo gastrojejunostomy, placement of AGB over a large gastric pouch or stoma, or SG. Mean excess weight loss at 1 year follow up was 56% after revision of primary restrictive procedures and 40% after primary bypass procedures (p < 0.01). At mean follow up of 3 years, EWL was 48% and 37%, respectively (p = 0.08). In group B, 77% of the patients were revised to RYGB. The complications prompting revision (recalcitrant gastrojejunal stricture, refractory marginal ulcer, severe gastroesophageal reflux disease, and malnutrition) were effectively treated by revisional surgery. The mean BMI in Group B was 30 at the time of revision and was 32 at 3 years. Revisional surgery was performed laparoscopically in 121 patients (78%). Major and minor complications were observed in 13 and 17%, respectively, of those who had laparoscopic surgery and 29 and 35%, respectively, of those who had open surgery (p < 0.05). Open revisions had greater blood loss (p < 0.01), and longer length of hospital stay (p < 0.01) compared with laparoscopic revisions. Mortality was seen in 1 patient (0.6%) 5 months after open surgery. CONCLUSION: Revisional bariatric surgery was performed effectively to manage undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed safely in the majority of these patients. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss. PURPOSE: The real importance of gastric pouch emptying time to determine weight loss is still unclear. This study aims to evaluate the association between excess weight loss (EWL) and gastric pouch emptying time of obese subjects who underwent silastic ring Roux-en-Y gastric bypass. METHODS: 159 morbid obesity patients (mean age 41 ± 11 years, 112 females) underwent silastic ring Roux-en-Y gastric bypass and were followed for two years. Gastric pouch emptying time was studied by scintigraphy at 1 and 2 years after the operation. Individuals with diabetes or inability to ingest the test meal in 10 min were excluded. Pearson and Spearman correlation test, analysis of variance, and Bonferroni tests were used in the statistical analysis. RESULTS: Gastric pouch emptying time ranged from 58 to 83 min (mean = 71 min) and 58 to 81 min (mean = 70min) during first and second year, respectively. A positive correlation between weight loss and gastric emptying time at the first year (r = 0.584, p < 0.001) and at the second year of follow-up (r = 0.660, p < 0.001) was found. CONCLUSION: Gastric pouch emptying time was associated with weight loss after silastic ring Roux-en-Y gastric bypass, during the two years follow-up. KEY WORDS: Gastric pouch emptying; weight loss; gastric bypass. Mo1519 Change in National Trends Adversely Impact Survival in Stage IV Gastric Cancer Anna M. Leung*1, Danielle M. Hari1, Connie Chiu1, Anton Bilchik1,2 1. Department of Surgery, John Wayne Cancer Institute, Santa Monica, CA; 2. Surgery, California Oncology Research Institute, Santa Monica, CA BACKGROUND: With more effective systemic chemotherapy, the role for palliative gastrectomy in patients with Stage IV gastric cancer has been questioned. METHODS: Using the National Cancer Data Base we identified 29,655 patients with Stage IV gastric cancer over a 14 year period (1994–2008). Patient demographics, tumor related features, and treatments were analyzed. Overall survival rates were examined using log-rank test power analysis. 150 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Observed Survival for Stage IV Gastric CA OverTime (1994–1997) vs. (1998–2002) Year of Diagnosis Total Patients 1 Year (% Survival) 2 Year (% Survival) 3 Year (% Survival) 4 Year (% Survival) 5 Year (% Survival) 95% Confidence Interval P-Value (1994–1997) 12,132 23.8 12.1 9.1 7.8 6.0 5.6–6.4 p < 0.05 (1998–2002) 17,523 22.6 8.4 5.0 3.6 2.9 2.7–3.2 p < 0.05 RESULTS: There was a decrease in surgical resection from 31.2% in 2000 to 22% in 2008 (p < 0.0001), a decrease in radiation from 20% in 2000 to 18.5% in 2008 (p = 0.0009), and an increase in systemic therapy from 45.5% in 2000 to 55.1% in 2008 (p < 0.001). There were no differences in gender, age, or histology, but there was a decreasing trend of Caucasians diagnosed (p < 0.0001). Survival rates decreased significantly over time p < 0.05 (see Table below). CONCLUSIONS: RYGBP determined profound changes in urinary composition which predisposed to a lithogenic profile. The prevalence of urinary lithiasis increased almost 70% in the postoperative period. A metabolic evaluation for nephrolithiasis is suggested for obese patients following RYGBP. CONCLUSIONS: Over the past 14 years there has been an increase in the use of systemic chemotherapy and a reduction in palliative gastrectomy for stage IV gastric cancer. The negative impact on survival suggests that treatment pathways be reevaluated. Gastric Electrical Stimulation for Symptom Control of Patients with Diabetic, Idiopathic, and Post Surgical Gastroparesis Mo1520 Urinary Evaluation After RYGBP: A Lithogenic Profile with Early Postoperative Increase in the Incidence of Urolithiasis Mo1521 Samira Hasan1, Chad J. Davis*1, Joel C. Hammond1, Thomas V. Nowak2, Lisa Ruehr2, Curtis Ramsey1 1. St. Vincent Hospital, Indianapolis, IN; 2. St. John’s Hospital, Anderson, IN INTRODUCTION: Gastric electrical stimulation has been used for over a decade for symptom control of gastroparesis refractory to medical treatment. Antonio C. Valezi1, Fernando Herbella*2,1, Jorge M. Junior1, Paulo Fuganti1 1. Surgery, Universty of Londrina, Londrina, Brazil; 2. Paulista School of Medicine, São Paulo, Brazil OBJECTIVE: To evaluate long-term symptom control with gastric pacemaker therapy and the relationship to improvement in gastric emptying. PURPOSE: Bariatric surgery is followed by multiple changes of urinary composition with a propensity toward a lithogenic profile. We prospectively studied patients who underwent Roux-en-Y gastric bypass (RYGBP) to assess urinary composition and lithiasis incidence. RESULTS: Median BMI decreased from 44.1kg/m2 to 27.0kg/m2 (p = 0.0001) in the postoperative period. Urinary oxalate (24mg versus 41mg; p = 0.000) and urinary uric acid (545mg versus 645mg; p = 0.000) increased significantly postoperatively (preoperative versus postoperative, respectively). Urinary volume (1310ml versus 930ml; p = 0.000), pH (6.3 versus 6.2; p = 0.019), citrate (268mg versus 170mg; p = 0.000), calcium (195mg versus 105mg; p = 0.000) and magnesium (130mg versus 95mg; p = 0.004) decreased significantly postoperatively (preoperative versus postoperative, respectively). Stone formers increased from 16 (10.6%) to 27 (17.8%) patients in the postoperative analysis (p = 0.001). Predictors for new stone formers after RYGBP were postoperative urinary oxalate (p = 0.015) and uric acid (p = 0.044). RESULTS: Symptom scores for all patients were significantly improved at all follow-up intervals compared to pre-op (P < 0.0001). Patients with idiopathic gastroparesis achieved the same degree of symptom control as diabetic patients. There was no significant change in gastric emptying from pre-op to 6 months or at 1 year post-op. CONCLUSIONS: Symptoms for all patients significantly improved after initiation of gastric electrical stimulator therapy. The improvement continued for up to 5 years postoperatively. Patients with idiopathic gastroparesis had similar symptom improvement as those with diabetic gastroparesis. Despite symptom improvement, gastric emptying, as measured by nuclear scanning, was not significantly changed with gastric electrical stimulation. This observation suggests that gastric stimulation improves symptoms via a mechanism independent of the rate of gastric emptying. 151 Monday Poster Abstracts MATERIALS AND METHODS: One hundred and fifty one obese patients underwent RYGBP and were followed for one year. The analysis comprised two study time points: preoperative (T0) and one year after surgery (T1). They were analyzed for urinary stones, blood tests and 24h-urinary evaluation. Nonparametric tests, logistic regression and multivariate analysis were conducted using SPSS 17. METHODS: A retrospective review of symptom scores and gastric emptying nuclear scans of 117 patients at a single center from 2000 to 2011. The patients included in the study were 55 with diabetic gastroparesis, 55 with idiopathic gastroparesis, and 7 with post-surgical gastroparesis. Symptoms scores were compared for severity and frequency of nausea, vomiting, early satiety, and epigastric pain at pre-op, 6 months, 1 year, 3 years, and 5 years. Gastric emptying scan results from pre-op, 6 months, and 1 year were compared. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Mo1522 Mo1523 GLP-1 Analogues Do Not Improve Remission of Diabetes After Gastric Bypass Newly-Devised Method for Totally Laparoscopic Total Gastrectomy (TLTG), Application Easiness and Cost Effectiveness: The Experience of Over 140 Cases in Single-Institution Andrew A. Taitano*1, Tejinder P. Singh2,1 1. General Surgery, Albany Medical Center, Albany, NY; 2. AMC Bariatric Surgery Group, Albany Medical Center, Albany, NY INTRODUCTION: Surgical treatment for morbid obesity via Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB) leads to weight loss and remission of diabetes in most patients with type 2 diabetes mellitus (T2DM). The outcomes in patients taking GLP-1 analogues for glycemic control are not well understood. We analyzed the rate of remission of T2DM in patients after gastric bypass surgery with respect to the diabetic medications taken preoperatively. METHODS: 157 patients with T2DM were studied. Baseline demographics, hemoglobin A1C levels, and medication lists were evaluated for patients undergoing LRNYGBP between January 2005 and December 2009. RESULTS: The mean age was 50 years, 73.9% were female, mean BMI at surgery was 47.6. Mean follow-up was 2.34 years. 79.0% of patients were off medications for T2DM at last follow-up. 19.1% of patients were on a GLP-1 analogue at the time of surgery. The average preoperative hemoglobin A1c level was higher in this group (6.92 vs 6.80), but no other significant differences were found. The rate of remission of diabetes was not significantly different between patients on a GLP-1 analogue and others (80.0% vs 78.7%). Remission rates did not vary according to the number of anti-diabetic agents taken at the time of surgery (91.1% for 1, 89.6% for 2, 90.0% for 3 or 4). Multivariate regression analysis revealed preoperative insulin use to be the only significant predictor of postoperative T2DM status (RR 5.48, 95% CI 2.91 to 10.30). CONCLUSIONS: The use of GLP-1 analogues in patients who undergo LRNYGBP surgery is not associated with improved glycemic control, lower BMI at the time of surgery, or improved long term outcomes. Preoperative insulin use is a risk-factor for non-remission of T2DM postoperatively. Surgical intervention prior to insulin dependence is needed to maximize long term remission rates. Early surgical intervention for morbidly obese patients with T2DM should be considered instead of escalation of medical management. Hitoshi Satodate*, Haruhiro Inoue, Shin-Ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan INTRODUCTION: Although laparoscopy-assisted distal gastrectomy for gastric cancer is becoming popular procedure especially in Japan and Korea, laparoscopy-assisted total gastrectomy is less common operative procedure. One of the major problems is difficulty of intracorporeal reconstruction, and another problem is cost. We developed TLTG procedures that requirement of disposable instruments is minimal, within the coverage of Japanese insurance system. METHOD: A 12-mm trocar is placed through umbilical incision, and four additional trocars are placed. Only two 12-mm trocar incisions and three 5-mm trocar incisions, including for the camera, are created for this procedure. After thorough mobilization of the abdominal esophagus, the esophagus is divided with stapler, and Orvil is inserted per orally, and the anvil is loaded into the esophageal stump. Then the handpiece of EEA stapler is introduced from the umbilical port incision, and the jejunojejunal anastomosis is also created from the umbilical port incision. RESULTS: We have performed 142 cases of the TLTG with this procedure, and have experienced only one minor anastomotic leakage. No other major problems had occurred. Mean operation time is 231 min. And the mean time for the whole procedures for reconstruction including creation of Roux-en-Y jejunojejunal anastomosis is 53 min. CONCLUSION: Two clear advantages can be mentioned with this method, compare with other techniques. First, this technique can be relatively easily applied for the cancer of the cardia. Second, minimize the use of disposable instruments. Only three linear staplers and one circular stapler are needed, and these are completely covered by insurance. This technique could become the standard methods for reconstruction after TLTG, and facilitate the acceptance of TLTG. And also lead to the hospital benefit. We will show our clinical practice. 152 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Mo1524 of potentially curative cancer resections of the foregut, including esophagus, stomach, liver, and pancreas. Preoperative Chemotherapy in High Risk Gastric Cancer: No Guarantee of Downstaging But Remains Our Best Magic Bullet Veeraiah Siripurapu*, Ashley Mekala, Elizabeth T. Liu, Dhiresh R. Jeyarajah Surgery, Methodist Dallas Medical Center, Dallas, TX INTRODUCTION: With the advent of the MAGIC trial, preoperative chemotherapy is utilized for high risk tumors in gastric cancer (T3 and higher/Node positive tumors). The regimen is often toxic and often necessitates nutritional support with the hope of downstaging these aggressive tumors. We aim to see if our population of high risk tumors receiving preoperative therapy experienced any downstaging in comparison to those who did not. METHODS: The Nationwide Inpatient Sample was queried to identify all esophageal, gastric, liver and pancreas resections performed for cancer during 1998–2009. Annual incidence, major in-hospital postoperative complications, length of stay and in-hospital mortality were evaluated. Univariate and multivariate analysis performed by chi square and logistic regression. For all comparisons, p-values <0.05 were considered statistically significant. AIM: All gastric cancer cases operated on by a single surgeon in the last five years were queried. Of these, only those who had strict clinical staging with radiological imaging/ EUS and who were deemed high risk were included for analysis. Clinical stage was correlated to pathologic stage with a view to see if any tumors were upstaged, downstaged or had complete pathologic response. RESULTS: A total of 27 patients met all criteria. Twelve patients (44%) had tumors designated as Siewert 3 and 1 patient as Siewert 2. Of the 27 patients, 15 (55%) were node positive. Twenty patients (74%) were staged T3 or higher. Ten patients received no preoperative therapy. The major preoperative regimen used was Epirubicin, Cisplatin & 5FU (ECF) or a combination similar such as EOX (78%). Of those who received preoperative therapy, ten patients (58%) were downstaged. There were 4 complete pathologic responses (cPR). All these patients received either ECF or EOX. Tumor location was varied for those with cPR CONCLUSIONS: Complete pathologic response is obtainable in high risk gastric cancer. Downstaging of these tumors happens in 58% of the high risk gastric populace. For those who can tolerate the regimens, this should remain the standard of care until further trials establish different treatment approaches. Foregut Surgery in the Modern Era: A National Survey Zeling Chau*1, Jillian K. Smith1, Elan R. Witkowski1, Elizaveta Ragulin-Coyne1, Sing Chau NG1, Tara S. Kent3, Shimul A. Shah1, Jennifer F. Tseng2,1 1. Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA; 2. Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 3. Department of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA BACKGROUND: Foregut surgery is technically complex. In recent years, increasing attention has been paid to high-stakes surgery outcomes, including mortality and complications. In addition, the use of advanced technology including minimally invasive approaches has been introduced. The current study aims to determine national trends in utilization and outcomes 153 Monday Poster Abstracts Mo1525 RESULTS: 298,871 patients (nationally-weighted) underwent cancer directed foregut surgery 1998–2009. Of those 19,002 (6%) were esophagectomies, 123,198 (41%) were gastrectomies, 62,313 (21%) were hepatectomies and 94,358 (32%) were pancreatectomies. From early years (1998–2000) to late years (2007–2009) use of laparoscopy in foregut surgery increased from 3% to 5%. Laparoscopy in esophagectomy increased the most from 1% to 5%, while its use in hepatectomy remained unchanged at 4%. Gastrectomy and pancreatectomy involving minimally invasive techniques increased from 2% to 5% and 5% to 6%, respectively. For all four foregut surgery types, patient comorbidities increased over time; patients with ≥2 major comorbidities increased from 53% to 64%. Conversely, patient mortality and length of stay (LOS) decreased over time. However, we observed an increase in complications for all sites combined from 22.8% to 24.4%. Laparoscopy was not significantly associated with decreased complications, but was associated with lower mortality when compared to open resection alone 3.1% vs. 5%. Independent predictors of increased complications included older age, gender, higher comorbidity, hospital volume. Older age, male sex, higher comorbidity, low volume center and non-use of laparoscopy were independent predictors of in-hospital mortality. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSION: Foregut surgery in the modern era is being increasingly deployed on sicker patients. While decreased in-hospital mortality and LOS are commendable, complication rates remain substantial and nondecreasing. Minimally invasive techniques have minor but increasing penetrance in foregut surgery. Our results suggest comparable advances and potential pitfalls among major types of foregut surgery in the current era. Translational Science: Colon-Rectal Mo2071 Thromboelastography Delineates Hypercoagulation in an Immunocompentent Murine Model of Metastatic Colon Cancer Karen K. Lo*1,2, Theresa Chin1, Marguerite Kelher3, Martin Mccarter1, Ernest E. Moore2, Christopher Silliman1,3, Carlton C. Barnett2 1. Surgery, University of Colorado, Denver, Aurora, CO; 2. Surgery, Denver Health, Denver, CO; 3. Bonfils Blood Center, Denver, CO Mo1526 What Motivates Weight Loss Surgery Patients? Nayna A. Lodhia*, Jaffer M. Kattan, Dylan Gwaltney, Kate E. Kiely, Shushmita Ahmed, Homero Rivas, John M. Morton Surgery, Stanford University, Stanford, CA BACKGROUND: By better understanding patient motivations, patient education can be individualized for the most effective healthcare possible. The purpose of this study was to evaluate patient motivations for bariatric surgery. METHODS: Preoperative, three, six and twelve month postoperative data were prospectively obtained for 169 consecutive laparoscopic Roux-en Y gastric bypass surgery patients at a single academic institution. All patients were given a standardized multiple choice questionnaire which asked them about their primary motivations for bariatric surgery preoperatively, then 6 and 12 months postoperatively. RESULTS: Better health was the primary motivator preoperatively and at 12 months postoperatively (87, 89%, respectively). A better appearance was a primary motivation for only 15% of patients preoperatively and 20% of patients 12 months postoperative. Within health-related motivations for bariatric surgery, 29% of patients expressed a primary desire to live longer preoperative and, by 12 months postoperatively, this number increased to 38.7% of patients postoperatively. The primary motivation for bariatric surgery from a family perspective was to have more energy with children preoperatively and remained so at 12 months postoperatively (44 to 46%). The second most common familial motivation was to be a healthy role model which did not change from pre- to post-operatively (29.8 to 29.5%). Preoperatively, 65% of patients thought that diet and exercise would be the most important factor to maintain long-term weight loss; however, by 12 months postoperatively, only 56% of patients thought that diet and exercise would be the most important factor. Patients gave an increasingly greater role to surgery as an important factor for weight loss raising its importance from 45% preop to 58% at one year postoperatively. Observed to patient-expected (O:E) ratios of 12 month percent excess weight loss became more accurate as patients progressed from preop to 6 and 12 months postop (0.60, 0.70, 0.78). Pre-operative O:E Ratios of percent excess weight loss were strongly correlated with 12 postoperative excess weight loss (p < 0.001). INTRODUCTION: The association between malignancy and venous thrombosis (VTE) has been well documented since the 1860s. Moreover, it has been demonstrated that perioperative blood transfusions increase the risk of VTE in colon cancer patients. Despite efforts to prevent VTE, current diagnostic tests (INR, PTT, PT, platelet count) are often unreliable. Recently, our lab has demonstrated that Thromboelastography (TEG) is able to better assess coagulation kinetics and direct patient therapy than conventional testing. We hypothesize TEG will delineate coagulation abnormalities in a murine model of transfusion mediated metastatic colon cancer. METHODS: C57/BL6 male mice, age 7–9 weeks, underwent splenic inoculation with 2.5 × 104 MC38 murine colon adenocarcinoma cells. Control mice underwent the same surgery with splenic injection of normal saline. One week after inoculation, all mice were randomized to receive blood transfusion via tail vein injection in the amount of 1 mg/kg or the equivalent dose of normal saline. N ≥ 4 in all groups. Three weeks after cancer inoculation, cardiac puncture was performed and blood was collected with citrate in a 1:10 ratio. TEG was performed on TEG® 5000 Thrombelastograph® Hemostasis Analyzer. Necropsies were then performed: tumors were harvested and metastases were determined. TEG was compared between mice with metastatic cancer with and without transfusion and control mice, who received sham cancer surgery, with and without transfusion. Data were analyzed using ANOVA with p ≤ 0.05 used to determine significance. RESULTS: Mice with cancer that received blood transfusions were found by TEG to have significantly lower R times (4.4 minutes versus 8.5 minutes p = 0.018), K times (1.6 minutes versus 3.3 minutes p = 0.0004), and significantly higher angles (67° versus 52° p = 0.0005), MA (68 mm versus 62 mm p = 0.019), and G (10.7 versus 8.05 dynes/cm2 p = 0.04) when compared to mice who received a sham operation and blood transfusions. TEG value interpretation shown (Table 1); R times demonstrate that mice with metastatic colon cancer form clot significantly faster than mice without cancer (Figure 1). Surprisingly, blood product transfusion did not affect hypercoagulabilty. CONCLUSIONS: Patients had increasingly, more realistic expectations for surgery’s role and ideal weight. Preoperatively, accurate patient expectation of surgical weight loss resulted in better observed post-op weight loss. Patient motivation may be a prime factor for weight loss and should be harnessed for improved outcomes. 154 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA MATERIALS AND METHODS: After obtaining approval from our Animal Ethics Committee, ten pigs were anesthetized using a standard protocol. A midline laparotomy was performed and the terminal ileum identified. Subsequently the intestine was completely sectioned 30 cm proximal to the ileocecal valve. All hand-sewn end-to-end anastomoses were performed by the same surgeon, using interrupted absorbable (3-0 polyglactine 910) sutures and leaving an orifice of 18French in the suture line (as shown in Figure 1). Animal were randomized to the application of a synthetic sealant (polyethylene glycol, group I) or fibrin sealant (group II) on the defect and the suture line. Animal were postoperatively followed for 7 days and prematurely sacrificed if sepsis developed. Otherwise, they underwent a second surgery for revision and the anastomosis was isolated and removed for subsequent histological examination. Fischer’s and Student’s t test was used for statistical analysis. P < 0.05 was considered significant. Table 1: TEG Value Interpretation Value Meaning Decrease Indicates Increase Indicates R Clotting Time, i.e. time (minutes) until the first detectable levels of fibrin clot formation. Generally reflects coagulation factor levels Hypercoagulable Hypocoagulable Factor deficiency, anticoagulant, hypofibrinoginemia K Clot Kinetics. Measures the Hypercoagulable speed to reach clot strength of 20 mm amplitude. Looks at intrinsic clotting factors, fibrinogen, platelet function Hypocoagulable Angle Clot strengthening, rapidity Hypocoagulable Hypercoagulable of fibrin-buildup and clot Hypofibrinogenemia formation, angle of tracing or thrombocytopenia from r to K value. MA, G Overall Clot strength, represents maximum dynamics of fibrin and platelet bonding Hypocoagulable Hypercoagulable Figure 1 RESULTS: Preoperative data was comparable between groups, with no statistical difference. Figure 1: * p = 0.05% p = 0.003 # p = 0.02 Mo2072 Reinforcing the High Risk Intestinal Anastomosis: Experimental Pilot Study Jana Dziaková*1,2, Iris Sanchez Egido1,2, Diego Sierra Barbosa1,2, Julio Mayol1,2 1. Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; 2. Universidad Complutense, Madrid, Spain INTRODUCTION: Anastomotic leakage is one of the causes of increased morbidity and mortality in gastrointestinal and colorectal surgery and it is also associated with elevated costs. The aim of this study was to investigate the effect of synthetic hydrogel sealant and a fibrin sealant on incompetent anastomosis in animal experimental model. DISCUSSION: We present a preliminary study describing a new model of incompetent anastomosis in a large animal, designed to study the effect of sealants and glues on intestinal healing. Our findings show that this is a viable model and that both synthetic and fibrin sealant may be useful in reinforcing incompetent anastomoses. Further studies are needed to understand the role of these products in the prevention of anastomotic leaks. 155 Monday Poster Abstracts CONCLUSION: TEG is able to delineate hypercoagulabilty associated with metastatic colon cancer in an immunocompetent murine model. Receipt of packed red blood cell product did not affect hypercoaguability in this model. As thrombotic events are morbid and potentially mortal, additional investigation of this modality in perioperative management of cancer patients appears warranted. No septic complications developed in any of the study subjects. Only one animal presented a contained wound dehiscence. On the second surgery, macroscopic findings showed no difference between the 2 groups: There was no evidence of diffuse purulent peritonitis or bowel obstruction. One contained anastomotic leak was found in each group (1/5 vs. 1/5, NS). Adhesions between intestinal loops were found 4 animals: 2 in group I and 2 in group II (2/5 vs. 2/5, NS). An inflammatory mass, containing the leak appeared in 1 case (0/5 vs. 1/5, NS). Microscopically, the local inflammatory response, with granulation tissue and local peritonitis was similar in both groups. Continuity of the mucosal layer was observed in 4 of 10 samples, similar in both groups (2/5 vs. 2/5, NS). Epithelial inclusions in the anastomotic line was found in 1 case in group I and in 3 cases in group II (1/5 vs. 3/5, p = 0,26). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Translational Science: Esophageal adverse consequences, hence appropriate training is essential for the safe adoption of this procedure. The objective of this study was to compare swine and fresh human cadavers (FHC) as training models for POEM. Mo2073 Impact of Blood Biomarker of Neoadjuvant Treated Patients with Esophageal Carcinoma Peter P. Grimminger*1, Juliane Bergenthal1, Hakan Alakus1, Martin K. Maus1, Till Herbold1, Elfriede Bollschweiler1, Ralf Metzger1, Arnulf H. HöLscher1, Jan Brabender2 1. Department of General-, Visceral- and Tumor Surgery, University Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery, St. Antonius Hospital, Cologne, Germany The prognostic value of ERCC-1 (excision repair cross Complementing genes), TS (thymidylate synthase) and DPD (dihydropyrimidine dehydrogenase) RNA expression in the blood of patients with esophageal cancer is not known. The aim of this study was to evaluate the significance of these molecular alterations in the blood as a prognostic marker for patients with neoadjuvant treated esophageal cancer. A total of 29 patients with locally advanced esophageal cancer (cT3-T4, Nx, M0) were enrolled in this prospective study. All patients received neoadjuvant radio-chemotherapy followed by a transthoracic resection (curative transthoracic en bloc esophagectomy, RO). Peripheral blood samples were drawn before initiation of therapy. The analysis was performed using quantitative real-time RT-PCR (TaqMan ©). The histomorphological regressionsgrading after neoadjuvant therapy was defined as follows: major response (MaR) = less than 10% vital tumor tissue, minor response (MiR) = more than 10% vital tumor tissue. 19 out of 29 patients (65.5%) had a MiR and 10 (34.5%) had a MaR. The median survival of patients was 2.08 years (0.15–4.53). Among the tested genes, the RNA expression of TS was significantly associated with prognosis of patients. Patients with TS expression above 0.78 had a median survival of 1.1 years (0.21 -3.16) compared to 3.36 years (0.15 to 4.53) in patients with TS expression lower than 0.78 (p = 0.031, log rank test). There was no association between clinical variables (eg, tumor stage, gender, age, etc.) and the RNA expression of TS in the serum. The RNA expression of TS in the blood is a potential prognostic marker in patients with neoadjuvant treated esophageal cancer. The significance of these molecular alterations as non-invasive prognostic marker for esophageal cancer should be evaluated in prospective studies. Mo2074 Training for Per-Oral Endoscopic Myotomy (POEM): Cadavers or Swine? METHODS: Healthy Yorkshire male pigs (40–46 kg) were used for POEM training. Procedures were also performed in male and female FHC during the same time period. A standardized procedure was used in both models. Following submucosal injection of methylene blue dye to mark the distal extent of the dissection, a mucosotomy was made in the mid-esohagus. The endoscope was then inserted into the mucosotomy and a submucosal tunnel bluntly dissected. Endoscopic myotomy of the circular muscle layer from the mid-esophagus to the gastroesophageal junction was performed using a triangular tip knife. The mucosotomy was subsequently closed with endoscopic clips. Following POEM in swine, the animals were sacrificed and necropsy performed to assess for organ injury and myotomy adequacy. In FHC, thoracoscopic and laparoscopic evaluation was performed to assess for pleural violation,organ injury and myotomy adequacy. Adequacy of myotomy was determined by endoscopic transillumination at distal most myotomy site. RESULTS: POEM was performed in 7 acute swine and 6 FHC. In swine, POEM was successfully completed in 5 animals (72%). Two animals (29%) expired during the procedure from cardiopulmonary collapse. In the remaining 5 animals, POEM was uncomplicated with no evidence of complication on necropsy. The average procedure time was 90 minutes (range70–120 minutes). The primary limitation of the swine model related to the attenuated circular muscle of the porcine esophagus which made myotomy technically difficult and pleural violation a frequent complication. No problems closing the myotomy were encountered. In contrast, POEM was successfully performed in all FHC. The average procedure time was 85 minutes (70–120 minutes). Pleural violation was noted in one cadaver. In 4 cadavers, the mucosotomy was inadvertently extended during creation of the submucosal tunnel. The technical limitations of the cadaver model were difficulties with the mucosotomy and submucosal tunnel dissection due to decreased tissue pliability and poor tissue distension. CONCLUSION: Although cadavers are more anatomically relevant as a training model for POEM, creation of the mucosotomy and submucosal tunnel is limited by poor tissue pliability. Conversely, mucosotomy and submucosal tunnel dissection is more easily achieved in an acute swine model, but the myotomy limited by attenuated circular muscle. A hybrid teaching paradigm using both porcine and human cadaver model may be necessary for comprehensive POEM training. Dana A. Telem*1, Ozanan R. Meireles1, Denise W. Gee1, Patricia Sylla1, William R. Brugge2, David W. Rattner1 1. Surgery, Massachusetts General Hospital, Boston, MA; 2. Gastroenterology, Massachusetts General Hospital, Boston, MA BACKGROUND: POEM is a promising totally endoscopic method for treating achalasia. Esophageal perforation and incomplete myotomy are technical errors with severe 156 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Translational Science: Hepatic Mo2075 Triptolide Demonstrates Novel Chemotherapeutic Potential as Single-Agent or Combination Therapy with Sorafenib for Treatment of Hepatocellular Carcinoma Tara C. Krosch*, Veena Sangwan, Sulagna Banerjee, Ashok Saluja, Eric H. Jensen, Selwyn M. Vickers Department of Surgery, University of Minnesota, Minneapolis, MN BACKGROUND: Hepatocellular carcinoma (HCC) is the most common malignant primary liver tumor worldwide. Systemic treatment in advanced disease has been limited to sorafenib, a broad spectrum tyrosine kinase inhibitor, with many adverse side effects and suboptimal outcomes. Our lab has investigated triptolide, a diterpene triepoxide, as a potential chemotherapeutic option. This study evaluates the response of HuH-7 and Hep3B HCC cells to triptolide, with or without combination therapy with sorafenib. METHODS: HuH-7 and Hep3B HCC cell lines were treated in vitro with triptolide and/or sorafenib at varying concentrations. Cell viability (MTT assay), caspase activation (Promega), and Annexin V positivity (Guava Nexin) were then assessed. Real-time PCR was utilized to determine the changes in mRNA levels, and Western blots were used for evaluation of protein expression. Cell death with both treatments resulted in increased caspase-3 activation and Annexin V positivity in both cell lines, confirming apoptosis. Evaluation of mRNA and protein levels in response to triptolide showed significant downregulation of the heat shock protein cascade, with levels of HSF-1 decreased in both cell lines. Downstream expression of HSP70 and HSP27, known upregulated proteins in metastatic HCC disease, were also significantly decreased. Figure 2: HuH-7 HCC cell viability to triptolide and sorafenib combination therapy. HuH-7 HCC cells were treated with low doses of triptolide, sorafenib or combined doses, and viabilty was assessed at 2h-hour intervals. Notably, the combination of 100 nM triptolide and 0.625 uM sorafenib was found to have increased efficacy in comparison to either treatment alone. (N = 2-3, Bars = + SEM). CONCLUSIONS: Treatment of advanced HCC is currently limited to sorafenib therapy, with many adverse side effects and suboptimal outcomes. We have shown that triptolide treatment in vitro induces HCC cell death by apoptosis, with decreased expression of proteins found to be normally upregulated in metastatic disease. While triptolide therapy alone results in significant cell death in Hep3B cells, combination therapy with sorafenib, both at low concentrations, results in notably superior cell death to either treatment alone in the more resistant HuH-7 cells. Our study suggests triptolide may serve as a therapeutic option for advanced HCC. Orthotopic mouse model studies are underway. 157 Monday Poster Abstracts RESULTS: Triptolide and sorafenib were equally effective at reducing cell viability in Hep3B cells, at low concentrations (FIGURE 1). Within 72 hours of 25 nM triptolide treatment, 80% cell death was noted, and similar a reduction in cell viability was seen with 2.5 uM sorafenib. Increased concentrations of either drug achieved minimal increases in cell death. In distinction to the Hep3B cell line, the HuH-7 cells were more resistant to single agent treatment. Sorafenib treatment (2.5 uM) resulted in 70% cell death at 72 hours, whereas triptolide (100 nM) resulted in 40% cell death (Figure 1). Combination therapy was attempted in this cell line. Notably, a significant reduction in cell viability was found using lower concentrations of each drug, in comparison to either drug concentration alone, with less than 20% cell viability at 72 hours (Figure 2). Figure 1: Hep3B and HuH-7 HCC cell viability to triptolide and sorafenib. Hep3B and HuH-7 HCC cells were treated in vitro with varying concentrations of triptolide or sorafenib and viability was assessed at various time points. A concentration of 2.5 uM sorafenib has been equated to a therapeutic plasma concentration in treated patients, with 5 uM used as a supra-therapeutic and likely toxic dose in this experiment. Hep3B HCC cells were susceptible to low doses of triptolide or sorafenib, with significant cell death at 72 hours. HuH-7 cells were less susceptible to treatment. (N = 4, * = p<0.05, Bars = + SEM). THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Translational Science: Stomach gastric cancer pts with non-response to chemotherapy were performed. The Affymetrix assay was done by the guidelines provided by Affymetrix. For statistical evaluation a pathway analysis approach using the KEGG BIOCARTA REACTOM and AMBION database, including 1266 pathways, was performed. Mo2076 SNP Array 6.0 Analysis in Advanced Gastric Cancer Patients Treated with 5-FU and Platinum or Irinotecan Based Chemoradiation Peter P. Grimminger*1, Martin K. Maus1, Frederick Schumacher2, Ralf Metzger1, Jan Brabender3, Arnulf H. HöLscher1, Heinz-Joseph Lenz2 1. Department of General-, Visceral- and Tumor surgery, University Clinic Cologne, Cologne, Germany; 2. Division of Medical Oncology, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, CA; 3. General- and Visceral Surgery, St. Antonius Hospital, Cologne, Germany BACKGROUND: Biochemical pathway SNP’s as possible molecular markers for response prediction in adjuvant chemotherapy in gastric cancer have already been reported. In our study we performed a systematic Single Nucleotide Polymorphism genotyping analysis by Affymetrix SNP 6.0 arrays that interrogates 906,600 single nucleotide polymorphisms. MATERIALS/METHODS: Affymetrix SNP Array 6.0 analysis of 16 gastric cancer pts with response to chemotherapy (5FU + platinum or irinotecan and/or Radiation) and 30 RESULTS: Several hundred SNP were identified with a possible association with response to chemotherapy. However, focusing on biochemical pathways with possible involvement in the efficiency of the chemotherapy treatment 6 pathways of the KEGG database were identified with an association to response to adjuvant treatment. The six identified pathways were: KEGG Colorectal Cancer Pathway (p = 0.0001, FDR = 0.343), Ambion Epithelial Tight Junctions (p = 0.001, FDR = 0.357), Reactome Muscle Contraction (p = 0.001, FDR = 0.331), KEGG Chronic Myeloid Leukemia (p = 0.001, FDR = 0.463), Ambion Transcritptional Regulatory Network in Embryonal Stem Cell (p = 0.006, FDR = 0.553 ) and Biocarta ALK Pathway (p = 0.004, FDR = 0.646). CONCLUSION: The SNP’s of the six identified pathways have a possible impact on response to 5-FU and platinum/ irinotecan based chemoradiation. Our future aim is to identify the key SNP in the pathways which may play the crucial role for treatment response. Future SNP array studies are in process to validate the identified pathways and also the single involved SNPs. Tuesday, May 22, 2012 Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM. 12:00 PM – 2:00 PM Halls C-G POSTER SESSION I (NON-CME) Basic: Colon-Rectal of action of these receptors remains unclear. We studied the role of 5-HT3 and 5-HT4 receptors in colonic transit and peristalsis in guinea pigs in vivo and in vitro. Tu2052 5-HT3 and 5-HT4 Receptors Promote Colonic Peristalsis via Different Mechanisms in Guinea Pigs Irena Gribovskaja-Rupp*, Jung-Myun Kwak, Toku Takahashi, Kirk A. Ludwig Surgery, Medical College of Wisconsin, Milwaukee, WI BACKGROUND: Pelvic surgery may damage extrinsic nerves, resulting in colonic dysmotility and constipation. Adaptation restores motility after extrinsic denervation. We showed that intrinsic 5-HT3 and 5-HT4 receptors are upregulated to compensate for the loss of extrinsic 5-HT3 receptors after parasympathetic denervation in rats (J Surg Res. 2011, 171:510–516). However, the specific mechanism METHODS: For in vivo colonic transit study, 51Cr was infused into the proximal colon after saline, ondansetron (a 5-HT3 receptor antagonist; 1 mg/kg), or GR 125487 (a 5-HT4 receptor antagonist; 1 mg/kg) injection. Three hours later, geometric center (GC) of the 51Cr distribution in the entire colon was calculated. For in vitro studies, distal colonic segments were laid flat in an organ bath with KrebsHenseleit buffer. Oral ends of segments were connected to an infusion syringe, and anal ends to a pressure transducer. Pressure changes in response to luminal infusion (0.2 ml) were recorded in the presence of ondansetron (3 × 10–6 M) or GR 125487 (3 × 10–6 M). In another setting, oral and anal ends were opened and the peristaltic reflex in response to pellet insertion or luminal balloon inflation was studied. 158 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA reduced oral contractions and increased anal contractions. As a result, the ratio of anal/oral contractions was increased to 1.4 ± 0.2 by GR 125487, compared to controls (0.6 ± 0.1; n = 9, p < 0.01). Similarly, L-NAME (a nitric oxide inhibitor, 10–4 M) significantly increased anal contractions (Figure 2). CONCLUSION: Ondansetron impairs colonic transit by lowering the magnitude of peristaltic contractions. GR 125487 impairs colonic transit by generating potent contractions on the anal side. Because L-NAME has a similar effect with GR 125487, it is suggested that 5-HT4 receptors stimulate nitric oxide release distally. In contrast, 5-HT3 receptors stimulate excitatory neurotransmission proximally. Our study offers new insight into the function of 5-HT3 and 5-HT4 receptors in regulating colonic peristalsis. Tu2054 Figure 1: Luminal infusion-induced pressure increase in the presence of ondansetron and GR 125487 of the guinea pig distal colon. Ondansetron reduced, while GR 125487 increased motor responses to luminal infusion (**p < 0.01, n = 4–7). Tumor Growth Is Stimulated After Sham Laparotomy and Is Associated with Enhanced Tumor Angiogenesis and Elevated Serum PDG-BB Levels in Mice Xiaohong Yan*, Joon Ho Jang, Daniel D. Kirchoff, Sonali A. Herath, Linda Njoh, C.M. Shantha Kumara H, Samer Naffouje, Richard L. Whelan St. Luke’s Roosevelt Hospital, New York, NY INTRODUCTION: Surgical trauma-related increased rates of metastasis formation and tumor growth have been noted in murine models. In humans, major abdominal surgery has been associated with persistent proangiogenic plasma protein changes and postoperative plasma been shown to promote Endothelial cell (EC) proliferation, migration, and invasion. The current murine study was done to determine: 1) if tumor angiogenesis and growth was increased after sham laparotomy (SL) vs. anesthesia alone (control, AC) and 2) to assess postoperative (postop) serum levels of four proangiogenic proteins. Figure 2: Magnitude of oral and anal contractions in response to balloon distention of the guinea pig distal colon. Ondansetron significantly reduced both anal and oral contractions. In contrast, GR 125487 or L-NAME significantly decreased the magnitude of oral contraction and increased anal contractions, compared to controls (*p < 0.05, **p < 0.01, n = 4–7). RESULTS: The median tumor volume of the SL group (625.9 mm3) was significantly larger than the AC group result (510.2 mm3, p = 0.01). Also, the SL group’s median tumor mass (0.55g) was greater than that of the AC group (0.35g, p = 0.04). Lastly, a higher microvessel density was found in the SL group tumors (8.5/field) than in the AC group (6.7/field, p = 0.001). Elevated serum PDGF-BB levels were observed in the SL group on POD5 (SL, median level 15.40 ng/ml, vs AC, 8.90 ng/ml, p = 0.002) and POD7 (SL, median 10.85 ng/ml, vs AC, 7.59 ng/ml, p = 0.02). 159 Tuesday Poster Abstracts RESULTS: Colonic transit was impaired by ondansetron (GC = 4.5 ± 0.3, n = 6, p < 0.01) and GR 125487 (GC = 5.3 ± 0.3, n = 7, p < 0.01) compared to controls (GC = 6.8 ± 0.3, n = 10). Ondansetron reduced intraluminal pressure increase by 40 ± 9% (n = 4, p < 0.01), whereas GR 125487 increased it by 76 ± 28% (n = 7, p < 0.01) (Figure 1). Pellet transit time was 46 ± 9 sec (n = 5) in controls, which was completely abolished by ondansetron (n = 4) and prolonged by GR 125487 to 137 ± 41 sec (n = 8, p < 0.05). In response to balloon distention, contractions observed at the anal side were smaller than those at the oral side (n = 8). Ondansetron reduced the magnitude of oral and anal contractions in response to balloon distention. In contrast, GR 125487 METHODS: Fifty BALB/cJ mice were subcutaneously inoculated with syngeneic CT26 colon adenocarcinoma cells on Day 1. On Day-15 the mice were randomized into 2 groups (n = 25/group), one underwent SL and the other anesthesia alone (AC). Tumor Study: On Day-29 the mice were sacrificed and the tumors excised, measured, and weighed. The tumor microvessel density was determined via IHC CD34 staining. Serum Study: Blood samples were taken and serum harvested from a second group of mice that underwent SL or anesthesia alone (total n = 84). The sampling points were: preoperative (Preop), POD1, 3, 5, 7, 10, and 14. Serum levels of FGF, VEGF, sVCAM and PDGFBB were determined via ELISA. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSION: Tumor growth was increased after SL as was tumor angiogenesis and serum PDGF-BB levels. These results support the hypothesis that increased tumor growth after SL may, at least in part, be due to proangiogenic plasma protein alterations that promote tumor angiogenesis. Basic: Esophageal CONCLUSION: Chromosal aberration patterns in lymph node metastases and disseminated tumor cells of patients with esophageal cancer undergoing multimodality therapy are very similar while primary tumors show a different genomic aberration pattern. These individual genetic tumor characteristics might guide future multimodality treatment options in esophageal cancer. Basic: Hepatic Tu2055 Evaluation of Chromosal Aberrations in the Primary Tumor, Lymph Node Metastases and Disseminated Tumor Cells of Patients with Esophageal Cancer: Implications for Anti-Tumoral Therapy? Tu2056 Sevofluorane Reduces Liver Damage Secondary to Ischemic/Reperfusion Injury by a Mechanism Not Related to a Preconditioning Effect Daniel Vallbohmer*1, Sarah Schumacher1, Stephan E. Baldus2, Christian Vay1, Andreas Krieg1, Jan Schulte Am Esch1, Wolfram T. Knoefel1, Nikolas H. Stoecklein1 1. Department of General, Visceral and Paediatric Surgery, University of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology, University of Dusseldorf, Dusseldorf, Germany Fernanda P. Cavalcante, ANA Maria M. Coelho*, Marcel C. Machado, Sandra N. Sampietre, Nilza A. Molan, Eleazar Chaib, Luiz C. D’Albuquerque Gastroenterology, University of São Paulo, São Paulo, Brazil INTRODUCTION: Recent analyses uncovered genetic variations between paired samples from primary gastrointestinal tumors, lymph node metastases and disseminated tumor cells (DTCs). These findings might help to explain individually variable responses to standard (neo-)adjuvant therapies and further suggest that multimodality treatment options in gastrointestinal cancer should be guided by these individual genetic tumor characteristics. Therefore, we assessed the genetic variations in the primary tumor, lymph node metastases and DTCs of patients with esophageal cancer. PATIENTS AND METHODS: In this translational analysis 86 patients with esophageal cancer undergoing multimodality therapy were included. Initially, we established a protocol for double immunofluorescence labeling for simultaneous visualization of epithelial cell adhesion molecule (EpCAM) expression on cytokeratin positive cells for the detection of DTCs in bone marrow and lymph nodes. After isolation of positively stained cells, their genomic DNA was globally amplified using the MSE-adapter PCR method. Finally, we applied comparative genomic hybridization (CGH) for the genome-wide screening of DNAgains/-losses on paired samples from primary tumors, lymph node metastases and DTCs of the study patients. RESULTS: DTCs were detected in 25% of the bone marrow and 38% of the lymph node samples. Interestingly, CGH analysis revealed differences between the numbers of chromosal aberrations in DTCs of the bone marrow compared to the lymph node samples with a higher frequency of aberrations in DTCs in the lymph node samples. In addition, genomic analysis revealed differences in the nature of chromosomal aberrations between primary tumors and corresponding lymph node metastases. Moreover, cluster analysis demonstrated similarities of the aberration spectrum between the DTCs and lymph node metastases while primary tumors showed distinct profiles. BACKGROUND/AIM: Previous studies have demonstrated that sevoflurane protects liver from ischemia/reperfusion (I/R) injury however it was not shown yet if this protection is by preconditioning or if it depends on a continuous administration of the anesthetic during the whole I/R period. In the present study we evaluated the mechanism of the protective effect of sevoflurane in ischemia/reperfusion injury METHODS: Wistar male rats underwent partial liver ischemia performed by clamping the pedicle from medium and left anterior lateral segments. Liver pedicle clamp was removed after 1 hour of partial ischemia. Anesthesia was induced with cetamine and xylazine and rats were intubated and mechanical ventilated. Rats were divided in 3 groups: Group1-Sevo Continued (n = 15): sevoflurane was administered during the whole I/R injury time and animals remained intubated during the whole I/R time, Group 2-Sevo 30 minutes (n = 15): sevoflurane was administered during 30 minutes and discontinued before liver ischemia, and Group-3 Control (n = 15): animals was submitted to I/R and no sevoflurane was administrated. Just as group 2, rats were extubated after reperfusion. Four hours after reperfusion blood was collected for determinations of AST, ALT. Liver tissues were assembled mitochondrial oxidation and phosphorylation and malondialdehyde (MDA) content. Pulmonary vascular permeability and myeloperoxidade (MPO) were also determined. RESULTS: Four hours after reperfusion Sevo Continued group presented elevation of AST and ALT serum levels significantly lower than Sevo 30 minutes and Control groups (p < 0.05). A significant reduction on liver mitochondrial dysfunction and pulmonary vascular permeability was observed in Sevo Continued group compared to Sevo 30 minutes and Control groups (p < 0.05). No differences in liver MDA and pulmonary MPO activity were observed CONCLUSION: Sevoflurane attenuates liver ischemia/ reperfusion injury probably by a mechanism not related to a by preconditioning effect. 160 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Basic: Pancreas Tu2058 Tu2057 LRP6 Overexpression as a Potential Marker of Early Stage Tumor Progression in Pancreatic Ductal Adenocarcinoma Anti-Inflammatory Effects of Hypertonic Saline Solution in Pancreatic Ischemia/Reperfusion Injuries Renato S. Godoy*, ANA Maria M. Coelho, Sandra N. Sampietre, Nilza A. Molan, Oscar M. Takayanagi, Marcel C. Machado, José Jukemura, Luiz C. D’Albuquerque Gastroenterology, University of São Paulo, São Paulo, Brazil BACKGROUND/AIM: Injury caused by ischemia/reperfusion (I/R) may result in pancreatic graft loss in pancreas transplants. Therapeutics strategies to reduce pancreatic I/R injury are extremely important to improve the outcomes of clinical transplantation. We have previously demonstrated that hypertonic saline 7.5% had anti-inflammatory response in acute pancreatitis and liver ischemia/reperfusion models. The aim of this study was to evaluate the effects of hypertonic saline solution 7.5% in I/R pancreatic. METHODS: Pancreatic ischemia was performed in Wistar rats during one hour by clamping the splenic vessels under mechanical ventilation. The vascular clamp was removed 1 hour after ischemia and pancreatic revascularization was achieved, followed by 4h or 24h of reperfusion. The animals divided into 3 groups: Group NT (n = 20): subjected to pancreatic I/R without treatment; Group NS (n = 20): subjected to I/R and treated with normal saline solution (NaCl 0.9%), 15 minutes before reperfusion; Group HTS (n = 20): subjected to I/R pancreatic and treated with hypertonic saline solution (NaCl 7.5%), 15 minutes before reperfusion. Four and twenty four hours after reperfusion blood were collected for determinations of amylase, TNF-α, IL-6, and IL-10, creatinine, urea. Pancreatic malondialdehyde (MDA) content was also performed. After 24hours of reperfusion pulmonary tissues were assembled for myeloperoxidade (MPO) analyses. RESULTS: There was a decrease of inflammatory cytokines in the Group HTS compared with control, NT and NS groups. It was observed a significant decrease in serum urea and creatinine in the animals treated with normal (NS) and hypertonic saline (HTS) compared to not treated animals (NT). The serum amylase levels and the determination of pancreatic MDA showed no significant differences between groups with I/R. CONCLUSIONS: Hypertonic saline solution decreases the systemic inflammatory response by cytokines reduction (TNF-α, IL-6, and IL-10)in pancreatic I/R injury. Further studies will be necessary to prove the clinical benefits in patients subject to pancreatic transplantation. Nicolas Zea1,3, William C. Conway1, John S. Bolton1, Nancy K. Davis6, Cruz Velasco5, Paul B. Fossier4, Jovanny Zabaleta*2,3 1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA; 2. Pediatrics, LSU Health Sciences Center, New Orleans, LA; 3. Stanley S. Scott Cancer Center, LSU Health Sciences Center, New Orleans, LA; 4. School of Medicine, LSU Health Sciences Center, New Orleans, LA; 5. School of Public Health, LSU Health Sciences Center, New Orleans, LA; 6. Anatomic Pathology, Ochsner Clinic Foundation, New Orleans, LA INTRODUCTION: The Wnt-β-Catenin signaling pathway, in particular the canonical pathway, has been implicated in pancreatic ductal adenocarcinoma (PDAC) development. Since mutations in the key intracellular components of this pathway are rare in PDAC, understanding the molecular mechanisms by which the signaling pathway is aberrantly activated, and how it influences tumor behavior, is of utmost importance. In this study, we hypothesized that over-expression of components upstream of the signaling pathway, in particular the Wnt signaling co-receptor LRP6, are involved in PDAC tumorigenesis. METHODS: Twelve lymph node negative (LN–) and twelve lymph node positive (LN+) paraffin embedded tumor tissues were randomly selected to perform screening gene identification via gene chip microarray analysis. Once genes of interest were identified by fold-change, 61 tumor samples were obtained and then subcategorized in terms of lymph node status, survival time, and grade of differentiation and used to validate the results using real-time PCR (RT-PCR). RESULTS: 20,817 genes were investigated with the microarray analysis. Using gene chip microarray software, we removed the background and used scatter graphs to select those genes with at least 2-fold difference (up or down) between LN– and LN+. Further selection by p value (p < 0.05) identified 957 genes significantly different between the two groups. The LRP6 gene expression showed a 2.46fold increase in the LN– when compared to LN+ samples (1192.9 vs 485). RT-PCR for LRP6 in LN– (n = 29) and LN+ (n = 32) confirmed results of the microarray (p-value = 0.00044). In addition, LRP6 showed a trend of over-expression towards tumors of lower grades of differentiation (Table). In terms of survival time, no statistical significance was found between LN– and LN+. Tuesday Poster Abstracts 161 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSIONS: The Wnt signaling co-receptor LRP6 is one of the most upstream genes involved in the Wnt-β-Catenin signaling pathway. Our data shows that LRP6 is significantly over-expressed in patients with negative nodal status, as well as portraying a tendency of over-expression in lower differentiation grades of pancreatic tumor. Our results reflect an overexpression of LRP6 early in the series of tumorigenesis events and depict the importance of further studies to understand its relationship to tumor behavior and prognosis. Difference within Tumor Samples Regarding Grade of Differentiation Gene N Samples Grade Average Fold Induction LRP6 6 na 2.24 1 undifferentiated 2.28 15 poor 2.08 27 moderate 2.45 12 well 3.41 by 55% (4.8 ± 0.16 vs 2.2 ± 0.19; p < 0.05) and 56% (5.0 ± 0.0 vs 2.2 ± 0.2; p < 0.05), respectively compared to WT+S. CONCLUSIONS: These data suggest that the NK-1R mediates leukocyte migration into the peritoneum indicating a new role for the NK-1RA in adhesiogenesis. Tu2060 Sphingosine-1-Phosphate Prevents LPS-Induced Loss of Permeability in Intestinal Epithelial Cells Ruiyun LI*1,2, Alexis D. Smith1,2, Ping Jiang1,2, Lan Liu1,2, Jiang-Yang Wang1,2, Jaladanki N. Rao1,2, Douglas J. Turner1,2 1. University of Maryland, Baltimore, MD; 2. Baltimore VAMC, Baltimore, MD Intestinal epithelial barrier dysfunction results from a wide variety of pathologic conditions; at the gastrointestinal mucosal layer cells must be capable of maintaining barrier integrity, and do this through the interplay of multiple active processes. Previous reports from our lab have shown that Sphingosine-1-phophate (S1P) promotes intestinal epithelial barrier function in part through regulation of barrier proteins, and S1P has also been found to be protective in various pathologic states. Lipopolysaccharide (LPS) has been shown to increase paracellular permeability, and recently, to also decrease intracellular S1P. In the current study we hypothesized that S1P would decrease paracellular permeability upon LPS exposure, and would act in part through regulation of caveolin-1 expression Basic: Small Bowel Tu2059 A Neurokinin-1 Receptor (NK1R) Antagonist (NK-1RA) That Reduces Postoperative Adhesions Reduces the Adhesion Related Chemokines CXCL1(KC) and CXCL2 (MIP-2) and Their Receptor, CXCR2 Hisashi Kosaka*, Michael R. Cassidy, Arthur F. Stucchi, James M. Becker surgery, Boston University School of Medicine, Boston, MA INTRODUCTION: Postoperative adhesions occur in 90–100% of patients after abdominopelvic surgery. We previously showed that adhesiogenesis is associated with leukocyte migration into the peritoneum and that the NK1R plays an important role in adhesiogenesis. The aim of this study was to characterize the temporal changes and the effects of a NK-1RA on the gene expression of the leukocyte chemoattractants CXCL1 and CXCL2 during adhesiogenesis. METHODS: Adhesions were induced in mice using our previously published cecal cauterization model. Wild-type (WT) mice (n = 7/group) were administered saline (WT+S) or a NK-1RA (WT+NK) (25 mg/kg) intraperitoneally at surgery. At 0, 3, and 6-hrs post-operatively, cecal adhesion tissue was measured for CXCL1, CXCL2 and CXCR2 mRNA levels by real-time-PCR. Adhesions were measured on POD 7 (n = 7/group) in WT, WT+NK and CXCR2 knockout (KO) mice. RESULTS: In WT+S mice, CXCL1 and CXCL2 mRNA levels increased at 3-hrs post-operatively compared to non-operated controls (380.8 ± 143 vs 0.04 ± 0.08; p < 0.05; 198.3 ± 105 vs 0.07 ± 0.05; p < 0.05) while CXCR2 mRNA increased at 6-hrs (16.5 ± 2.9 vs 0.17 ± 0.06; p < 0.05). Administration of the NK-1RA significantly reduced mRNA levels of CXCL1 and CXCL2 3hrs post-operatively compared to controls (380.8 ± 143 vs 89.9 ± 23.7; p < 0.05; 198.3 ± 105 vs 22.7 ± 6.2; p < 0.05) while CXCR2 mRNA levels were reduced by 64% (16.5 ± 2.8 vs 5.9 ± 1.6; p < 0.05) at 6hrs. Adhesion formation was reduced in both WT+NK and CXCR2 KO mice IEC-Cdx2L1 (Cdx) differentiated intestinal epithelial cells were utilized. Western blot analysis, real-time PCR, immunohistochemical staining, were utilized by standard techniques. Transwell permeability to C14-mannitol, FITCdextran, and measurement of transepithelial electrical resistance (TEER) were utilized for permeability assessments. Sphingosine Kinase 1 (SphK-1) overexpression stable cell lines were selected in rat intestinal epithelial cells (IECs). SphK-1 activity and S1P production were measured by radioactive isotope assay. LPS-treated (50 mcM) Cdx cells show dramatically increased permeability at 4h, but pretreatment with S1P (0.5 mcM for one hour) was protective of this LPS-induced increase in permeability, and returned permeability to normal levels. S1P also prevented LPS-associated decreases in phosphorylated occludin, and in immunofluorescence studies S1P preserved cortical accumulation of occludin that was disrupted with LPS administration alone. S1P was found to increase levels of toll-like receptor (TLR) 2 in Cdx cells, with no change in levels of TLR4. Similarly, cells stably overexpressing SphK1 demonstrated increased levels of S1P and also increased levels of TLR2 and not TLR4. Cells overexpressing SphK1 and S1P showed dramatically increased plasma membrane levels of Stim1, TRPC1, and the scaffolding protein caveolin-1. Phosphorylated caveolin-1 was significantly decreased with exposure to LPS (5 mcM), however co-treatment with S1P preserved basal caveolin-1 levels. Finally, inhibition of caveolin-1 with siRNA prevented S1P rescue of LPS loss of permeability. Our findings demonstrate that S1P prevents LPS-associated loss of permeability, and this is in part through its ability to prevent LPS-associated loss of caveolin-1. 162 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu2061 Clinical: Biliary Changes in Peptidergic Neurotransmission with VIP and Substance P During Postoperative Ileus in Rat Tu2044 Brigitte Goetz*, Petra Benhaqi, Martin E. Kreis, Michael S. Kasparek Department of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany Abdeen Elfateh2, Tariq Chundrigar2, Bilal O. AL-Jiffry*1,2 1. Surgery, Taif University, Taif, Saudi Arabia; 2. Surgery, AlHada Military Hospital, Taif, Saudi Arabia BACKGROUND: Common bile duct stones (CBDs) are the most common cause of obstructive jaundice and cholangitis. This occurs in about 10% of patients with symptomatic gallstone. This study aimed to find non-invasive preoperative tests for predicting CBDs to select patients for preoperative endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC). METHODS: We conducted a prospective preoperative study on 896 patients with symptomatic gall stones who underwent LC at Al Hada military Hospital, Taif, Saudi Arabia from April 2006 to April 2010. All patients were subjected to clinical, laboratory (LFT) and ultrasound (US) examination. Patients with normal LFTs and US were referred to LC. Patients with jaundice and US proven CBD abnormality (stones, dilatation >7 mm or both) were referred for ERCP for diagnosis confirmation and stone removal, followed by LC. Patients with jaundice and normal US were referred to magnetic resonance cholangiopancreatography (MRCP). When MRCP detected CBDs, the patients were referred for ERCP for confirmation and stone extraction followed by LC. MRCP and ERCP negative cases were subjected to LC with Intraoperative cholangiography (IOC). RESULTS: There were 707/896 patients (78.5%) who had LC without the need for preoperative ERCP or/and MRCP. 193/896 patients (21.5%) were diagnosed to have obstructive jaundice on clinical and laboratory bases. 102/193 (52.8%) had normal bile ducts by US, the other 91 (47.2%) had CBD abnormalities on US. CBDs were found in 23/91 (25.3%), dilatated CBD in 28/91 (30.8%), and 40/91 (40.3%) had dilated CBD with stones. These 91 patients were referred to ERCP. Stones were extracted in 20/23 (87%) who had CBDs, 24/28 (85.7%) with dilated CBD and 38/40 (95%) who had both. The 102 patients with normal CBD on US were referred to MRCP, 70/102 (68.6%) were normal by MRCP and were subjected to LC with IOC. CBDs were detected in 2/70 (2.9%). 32/102 (31.4%) had stones by MRCP and referred to ERCP which detected CBDs in 25/32 (78.2%). When CBD was abnormal, ERCP detected stones in 82/91 patients (90%) and when normal ERCP detected stones in 27/102 (26.5%). MRCP helped avoid un-necessary ERCP in 68/102 (66.7%) with false negative results of 2/102 (1.96%) and false positive results of 7/102 (6.7%). 163 Tuesday Poster Abstracts BACKGROUND: Changes in peptidergic neurotransmission might participate in pathophysiology of postoperative ileus (POI), but have not been studied yet. We aimed to explore changes in neurotransmission with Vasoactive Intestinal Polypeptide (VIP; inhibitory) and Substance P (Sub P; excitatory) during POI. METHODS: Mucosa free, circular, jejunal muscle strips (n = 8/rat) were studied in organ chambers. Six male Sprague Dawley rats were studied per group: Naïve controls (NC), rats 12h (P12h) and 3d (P3d) after laparotomy and standardized small bowel manipulation to induce POI, and sham controls after 12h (SC12h) and 3d (SC3d) to study combined effects of anesthesia and sham laparotomy. Dose-responses to exogenous VIP (10–10–10–7M) and Sub P (3 × 10–10–3 × 10–7M) were studied without and with L-NNA (blocking nitric oxide (NO)-synthase; 10–4M) or L-NIL (selective blocker of inducible NO-synthase; 3 × 10–5M). Effects of endogenously released neurotransmitters were studied during electrical field stimulation (EFS; 20V, 4ms, 3Hz) without and with L-NNA, VIP antagonist ([D-p-Cl-Phe6,Leu17]-VIP; 10–6M), or Sub P antagonist ([D-Pro2,D-Trp7,9]-Sub P; 10–6M). Studies were performed under non-adrenergic, non-cholinergic conditions (propranolol 5 × 10–7M, phentolamine 10–5M, atropine 10–7M). Intestinal transit was measured by charcoal gavage ([%] small bowel passed by marker). Histology for myeloperoxidase positive cells (MPO), macrophages, and mast cells was performed in whole mounts (cells/mm2). Data: mean ± SEM. RESULTS: VIP caused dose-dependent inhibition in all groups (p < 0.05). Inhibition was more pronounced in P12h, P3d, and SC3d (p < 0.05 vs NC). L-NNA reduced VIPinduced inhibition in NC and P12h (p < 0.05), while L-NIL had no effect on VIP responses (p = NS). Sub P caused dosedependent excitation in all groups (p < 0.05), which was reduced in P12h and increased in P3d (both p < 0.05 vs. NC), while it was unaffected in sham controls (p = NS). EFS induced inhibition was more pronounce in P12h (-67 ± 8%) compared to NC (–33 ± 8; p < 0.05). VIP and Sub P antagonists had no effect on EFS responses (all p = NS), while L-NNA prevented EFS-induced inhibition in all groups (all p < 0.05). Intestinal transit was delayed in POI groups and SC12h (P12h 27 ± 2; P3d 40 ± 3; SC12h 48 ± 2%; all p < 0.05 vs NC 60 ± 3%). MPO positive cells and mast cells were increased in P12h and P3d, but not in sham controls (MPO: NC 9 ± 2; P12h 551 ± 86; P3d 579 ± 45; mast cells: NC 21 ± 3; P12h 694 ± 73; P3d 460 ± 10; all p < 0.05 vs NC) and macrophages were increased only in P3d (NC 347 ± 7; P3d 1163 ± 31 p < 0.05 vs NC). CONCLUSION: Induction of POI causes specific changes in neurotransmission with VIP and Sub P that are accompanied by intramural inflammatory response and delayed gastrointestinal transit. Therefore, changes in peptidergic neurotransmission with VIP and Sub P appear to participate in pathophysiology of POI in rat. DFG KA2329/5–1 Non Invasive Pathway to Reduce Negative ERCP in Patients Presented by Obstructive Jaundice with Gallstones THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT CONCLUSION: We have documented a considerably higher incidence of obstructive jaundice in our area, one that makes this simple disease a community health issue. Also, with the small number of MRCP machines most hospitals have a long waiting time facility. Our aim was to find a simple pathway to get the cost-effective balance between MRCP and ERCP. Therefore, patients with obstructive jaundice and abnormal CBD on US are considered of high risk for CBDs and the use of MRCP is not justified. However, if any of the tests were normal MRCP is indicated to decrease the incidence of negative ERCP. Tu2045 Prognostic Impact of Human Equilibrative Nucleoside Transporter 1 Expression in Adjuvant GemcitabineBased Chemotherapy After Surgical Resection for Cholangiocarcinoma vant gemcitabine-based chemotherapy and those who did not was observed among patients with high hENT1 expression (P = 0.002), but not among patients with low hENT1 expression (P = 0.525). Intratumoral hENT1 expression was only an independent predictive factor for patients treated with adjuvant gemcitabine-based chemotherapy by multivariate analysis (P = 0.027). CONCLUSION: High intratumoral hENT1 expression was associated with increased overall survival in patients with cholangiocarcinoma who received adjuvant gemcitabine-based chemotherapy. Intratumoral hENT1 expression may be a potent predictive marker for cholangiocarcinoma patients treated with adjuvant gemcitabinebased chemotherapy. Tu2046 Image Documentation and Textual Operative Description of the Technique and the Findings of Laparoscopic Intraoperative Cholangiography Are Sub-Optimal Hironori Kobayashi , Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Naru Kondo, Hiroki Ohge, Taijiro Sueda Hiroshima Univ, Hiroshima, Japan * OBJECTIVE: Although the prognosis in patients with biliary carcinoma remains poor, adjuvant gemcitabinebased chemotherapy after surgical resection for biliary carcinoma has been shown to improve survival. There have been no reports concerning a useful predictive biomarker in patients with cholangiocarcinoma treated with adjuvant gemcitabine chemotherapy. To clarify the relationship between expression of intratumoral enzymes related to the metabolism of gemcitabine and its derivatives and response to adjuvant chemotherapy with gemcitabine for cholangiocarcinoma, we evaluated human equilibrative nucleoside transporter 1 (hENT1) expression immunohistochemically in resected cholangiocarcinoma tissues. METHODS: Polyclonal antibodies were used to immunostain sections of 105 formalin-fixed paraffin-embedded specimens of cholangiocarcinoma resected between 1989 and 2010. The relationship between intratumoral hENT1 expression and prognosis was evaluated statistically. This study was a retrospective analysis on retrospectively collected tissue and data. RESULTS: Out of 105 patients, 51 (49%) received adjuvant gemcitabine-based chemotherapy. High and low intratumoral hENT1 expression was present in 74 (70%) and 31 (30%) cases, respectively. There were no significant differences in clinicopathological factors between patients with high hENT1 expression and those with low hENT1 expression. Survival of patients with high hENT1 expression was significantly better than that of patients with low hENT1 expression among patients who received adjuvant gemcitabine-based chemotherapy (P = 0.008), but not among patients who did not (P = 0.894). Moreover, a significant difference in survival between patients who received adju- Alex Karran*, Ashleigh Majoe, Ashraf M. Rasheed Gwent Institute of Minimal Access surgery, Newport, United Kingdom BACKGROUND: There is a wealth of data to dispute the role of laparoscopic intra-operative cholangiography (IOC) but there little published literature to describe the optimal technique or to recommend a standardised reporting system. The operative report is a legal document that must contain details of all interventions. AIMS: This study aims to examine the details of the technique of IOC and to audit the quality of the captured images and the content of operative notes in relation to documentation of essential IOC anatomical landmarks METHOD: A retrospective analysis of 100 consecutive laparoscopic intra-operative cholangiograms that were attempted at the Aneurin Bevan Health Board (ABHB) between February 2009 and March 2010 was undertaken. The visualisation of 7 essential anatomical landmarks on captured IOC images and specific reference made to each in the operation notes were assessed. RESULTS: A significant inter-operator variability was noted in the performance and the interpretation of IOC. Only 34% of captured images identified all 7 recognised essential IOC landmarks. The majority (63.8%) of operation notes failed to make reference to all 7 landmarks, with a mean number of landmarks referred to as 1. There was a significant difference (p < 0.001) between landmarks identified on the captured images and their documentation within the operation notes. CONCLUSIONS: This study confirms that laparoscopic IOC is sub-optimally performed and poorly reported. It highlights the need for standardisation of the IOC technique and systematisation of its reporting. 164 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu2047 Is Cholecystostomy a Safe Procedure in Patients with Cirrhosis? Rajiv Jayadevan*1, Malika Garg1, Thomas Schiano2, Celia M. Divino1 1. Surgery, The Mount Sinai School of Medicine, New York, NY; 2. Division of Liver Disease, The Mount Sinai School of Medicine, New York, NY INTRODUCTION: Abdominal surgical intervention in cirrhotic patients is correlated with high mortality due to coagulopathy, bleeding, and sepsis from ascitic breach.1 Although percutaneous cholecystostomy has been advocated as a safer alternative to cholecystectomy in high-risk critically ill patients with concurrent gallbladder disease, no study has focused exclusively on the outcomes of cholecystostomy in patients with cirrhosis. As a result, it is unknown whether the outcomes of cholecystostomy in cirrhotics are as encouraging as those of their non-cirrhotic counterparts. Physicians thus often face a predicament in treating cirrhotic patients with gallbladder disease refractory to medical management. The purpose of this investigation was to determine whether cholecystostomy is a safe and viable option in the treatment of gallbladder disease in patients with cirrhosis. RESULTS: No significant difference in gender, age, race, ASA score, LFTs, duration of tube placement, gallbladder disease, ultrasound findings or CT findings was found between cirrhotic and non-cirrhotic patients. Cirrhotic patients were found to be more likely to have HCV (p = 0.001), ascites (p = 0 .004), jaundice (p = 0.045), and encephalopathy (p = 0.012). While cirrhotic patients had a significantly greater amount of post-operative complications (p < 0.001), e.g. bleeding (p = 0 .041), no significant difference was found in post-operative survival between cirrhotic and non-cirrhotic patients. METHODS: A retrospective chart review was performed which identified 16 cirrhotic and 49 non-cirrhotic patients treated with cholecystostomy tubes between 2000 and 2011. Information investigated included demographics, common comorbidities, markers of disease severity (relevant labs and ASA scores), type of gallbladder and liver disease, post-operative complications, and post-operative survival time. Differences in survival time was assessed with Kaplan-Meier survival analysis. Qualitative and quantitative variables were compared with Chi-square and two independent sample t-tests respectively. REFERENCE: CONCLUSION: Although cirrhotic patients have a greater number of complications than their non-cirrhotic counterparts after cholecystostomy, there is no significant difference in survival between the two types of patient. Cirrhosis does not appear to be a contraindication to performing cholecystostomy, which is an appropriate temporizing procedure for cirrhotic patients with gallbladder disease. 1. Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122 (4):730–735; discussion 735–736. Tuesday Poster Abstracts 165 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu2048 clarify the anatomy in Calot’s triangle. Planned IOC was performed in 58 cases (8.1%): 34 for gallstone pancreatitis, 10 for choledocolithiasis, 9 for biliary colic, 3 for cholangitis, and 1 for primary biliary sclerosis. Dome-Down Dissection Is a Safe and Practical Primary Approach to Laparoscopic Cholecystectomy: Results of a Ten Year Experience Dylan Nieman*1, Neil Ghushe2, Jacob Moalem1, Marabel D. Schneider1, Kendra Klein1, D. Owen Young1, Brandon Stein1, Luke O. Schoeniger1 1. Department of Surgery, University of Rochester, Rochester, NY; 2. Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH PURPOSE: To audit our experience with a dome down technique for laparoscopic cholecystectomy (DDLC) regarding clinical outcomes, safety, and demonstration of the critical view of safety (CVS). METHODS: We reviewed a prospectively collected data set of all patients who underwent cholecystectomy (CCY) from 2000 through 2010 by a single surgeon. All patients were planned for primary DDLC and transection of the cystic artery with a Harmonic Scalpel. Electronic records were queried for additional data. CONCLUSIONS: This 10 year, single-operator experience demonstrates that DDLC is a safe and practical approach to CCY in a diverse group of patients and can be used as a primary approach to laparoscopic cholecystectomy (LC) with a low complication rate. We hypothesize that because this approach requires circumferential visualization of the contents of Calot’s triangle, the CVS is readily identified in all cases. Improved visualization enhances the safety of this approach and has caused some to advocate DDLC as a way to avoid conversion to open CCY in patients with “difficult gallbladders”. We posit that the high rate of bile duct injuries associated with the dawn of laparoscopy, may have been a byproduct of the shift from dome-down to bottomup infundibular dissection rather than the shift from open to laparoscopic techniques, per se. While we acknowledge that experienced surgeons should continue to use techniques with which they have experienced success, we propose a greater role for DDLC as an initial approach to LC in surgical training, to demonstrate the CVS and to allow a safe laparoscopic cholecystectomy in all circumstances. Tu2049 Use the Duodenum, It’s Already There: A Retrospective Cohort Study Comparing Biliary Reconstruction to the Either the Jejunum or Duodenum John B. Rose*, John A. Ryan, Thomas R. Biehl General Surgery, Virginia Mason Medical Center, Seattle, WA BACKGROUND: Surgical reconstruction of the biliary system is required for a variety of reasons. Roux-en-Y jejunal anastomoses (RJA) are the current gold standard for repair. Direct duodenal anastomoses (DDA) are a less common approach, however it has the benefit of operative simplicity and ease of endoscopic evaluation. We compared the outcomes of non-palliative DDA to RJA. The Critical View of Safety in Dome Down Laparoscopic Cholecystectomy: (A) cystic artery (B) cystic duct (C) common bile duct (D) infundibulum of gallbladder (E) gallbladder fossa. RESULTS: 715 consecutive patients (72% female) underwent CCY; 581 (74%) elective, 134 (26%) acute. One (0.14%) required conversion to open CCY; all others underwent DDLC. Five (0.69%) had minor complications: ileus in 2 cases, trocar site hernia in 1. Biloma was found in 2 patients however there were no bile duct injuries or biliary strictures on subsequent evaluation. A single enterotomy occurred during Hasson canula placement in a patient with extensive adhesions; this led to the sole conversion to open CCY. Estimated blood loss was minimal in all cases. Most patients (84%) were discharged on the day of surgery. Length of stay and complication rate did not vary between patients who had acute or elective indications for surgery. The CVS was identified in all (566) patients since 2001, when we began documenting identification or non-identification of the CVS. In cases for which precise operative times were available, DDLC averaged 37 minutes. Intra-operative cholangiogram (IOC) was never needed to METHODS: A retrospective cohort study was performed at a single tertiary care center comparing DDA to RJA between the years 2000 and 2010. Standard patient demographics, complications rates, mortality rates, need for endoscopic or radiologic interventions, and long term outcomes were compared. RESULTS: A total of 105 non palliative reconstructions were performed between 2000 and 2010. 67 DDA and 38 RJA reconstructions were performed in an end-to-side fashion for either bile duct injury, cholangiocarcinoma, choledochal cysts, or benign strictures. The groups were similar with regard to demographics, preoperative diagnoses, postoperative length of stay (7 days vs. 7.5 days), postoperative mortality rates (1.7% vs. 2.9%; P = 0.72), and overall (Grade III or greater) complication rates (47.1% vs. 47.1%; P = 0.83). However, anastomotic related complications (leaks, abscesses/bilomas, or strictures) were fewer in the DDA cohort (11.7% vs. 35.3%; P = 0.01). Of those developing stricture, 5 of 6 in RJA cohort required percutaneous transhepatic access for management, as opposed to only 1 of 3 in the DDA cohort. 166 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSION: Direct duodenal anastomosis is a safe and often preferable method for biliary reconstruction. It may have decreased anastomotic complication rates, while benefiting from easier postoperative endoscopic management. Tu2050 CONCLUSIONS: the colposcopic NOTES access has proved to be safe, with excellent outcomes, no complications and void of sequelae in the gynecologic and sexual aspects. The risks of rectal injury, infection and sexual or pregnancy dysfunctions are considered to be minimal. Tu2051 Gynecologic and Fertility Issues in NOTES Colposcopic Procedures Gallbladder Wall Changes in Patients with and Without Metabolic Syndrome Anibal Rondan*, Rafael A. Redondo, Marcelo Fasano, Mariano Gimenez, Mauricio Ramirez, Alberto R. Ferreres Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina BACKGROUND: the clinical application of NOTES procedures have raised issues regarding the ways of access to the abdomen. The transvaginal access has been long and widely used and eliminates the disadvantages and risks associated with other NOTES approaches. With the development of laparoscopic techniques, the vagina was used not only as a port of entry but also as an excellent channel for removal of surgical specimens. The easy closure of the incision and the minimal risk of infection represent some of the benefits of this access, outweighting the other NOTES alternatives. OBJECTIVE: to present the followup of our first 107 patients who were operated on through a hybrid NOTES transvaginal access METHODS AND MATERIALS: after institutional IRB approval a program of NOTES surgery was started at our single institution in august 2007. Between that date and august 2009 107 procedures were attempted (100 cholecystectomies and 7 appendectomies) with a colposcopic NOTES approach with hybrid technique. The average age was 33.5 years with ranges between 22 to 46. After discharge, refrain from sexual activity was prescribed for 15 days (first 30 patients) and for 30 days in the following patients, due to inobservance. The postoperative follow up included gynecologic assessment at postoperative days 7, 30, 60, 180 and 360. The evaluation included: guided questionnaire, physical examination and colposcopy to assess healing, presence of anatomical injuries, vaginal secretion and other alterations. BACKGROUND: Recent research has described that obesity and high carbohydrates intake increases fat content of the gallbladder, decreases its motility and mucosal absorption, leading to a condition known as steatocholecystitis. Gallstone disease (GD) and the metabolic syndrome (MS) share common risk factors. OBJECTIVE: To identify if MS contributes to the development of functional disorders and wall changes of the gallbladder. METHODS: A Prospective study was conducted from August 2010 to July 2011 on patients with symptomatic gallbladder disease undergoing laparoscopic cholecystectomy. Forty two patients were included and divided into two groups; 22 patients with MS and 20 patients without MS. Family history, risk factors, anthropometric, clinical and laboratory variables were evaluated before surgery. Gallbladder specimens were analyzed, measured and graded by two pathologists at 3 standardized areas (cystic duct, liver bed, free margin and fundus). RESULTS: Thirty three patients who underwent cholecystectomy were female. A family history of GD and MS were present in 90% of patients. Chronic cholecystitis was the most frequent diagnostic (93%). Median weight was 75.5kg ± 14.3 and 67.1kg ± 9.2 for MS and No-MS groups respectively. Gallbladder wall thickness was significantly increased (P = 0.012) in the MS group. This thickness was secondary mainly observed in the cystic duct area of patient with MS. The percentage of fatty infiltration of the gallbladder wall, muscle degeneration and cholesterolosis did not show significant differences between groups. CONCLUSIONS: MS is associated with an increased gallbladder wall thickness. Muscle fibrosis in the cystic duct was the most important wall modification in these patients. In our series, MS was not associated to fat infiltration of the gallbladder wall or cholesterolosis. The systematic assessment proved adequate healing of the vaginal access with no local complications as well as absence of granulomas, hematomas, adhesions or retractions. None of the patients refer dyspareunia. Thirteen patients (12%) got pregnant after the procedure, 10 with a normal birth delivery and 3 cesarean sections, without complications due to the previous access 167 Tuesday Poster Abstracts RESULTS: the cholecystectomy with the NOTES colposcopic hybrid technique could be completed in 99 of the 100 patients (95%). In the remaining case the operation had to be performed laparoscopically due to pelvic adhesions (5 previous cesarean sections). One case ( # 6) required a minilaparotomy through a previous Pfannestiel incision for checking hemostasis of the vaginal cul de sac and 8 required the placement of an additional 2.5 mm trocar. The appendectomy was completed in all 7 cases, in 2 with the placement of an additional 2.3 mm trocar. No major complications were attained. Maria Fernanda Gonzalez-Medina*, Antonio Ramos-De La Medina, Jose Remes-Troche, Gustavo M. Melgarejo Ortiz, Peter Grube Pagola, Isabel Ruiz JuáRez, Alfonso Perez-Morales, Joaquin Valerio-Ureña, Federico B. Roesch Gastrointestinal Surgery and Investigation Department, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Mexico THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Colon-Rectal Tu1746 Tu1745 Predictive Factors of Acute Respiratory Failure in Colon and Rectal Surgery Hossein Masoomi*, Joseph C. Carmichael, Steven Mills, Matthew O. Dolich, Alessio Pigazzi, Michael J. Stamos Surgery (Colorectal Division), University of California, Irvine-Medical Center, Orange, CA Emergent Restorative Surgery for Ulcerative Colitis: Expertise May Matter Most When It’s Hard to Find Caitlin W. Hicks*1,2, Richard A. Hodin1, Liliana Bordeianou1 1. Surgery, Massachusetts General Hospital, Boston, MA; 2. Cleveland Clinic Lerner College of Medicine, Cleveland, OH INTRODUCTION: The aim of our study was to compare outcomes of patients treated with elective vs. urgent surgery for active Ulcerative Colitis (UC) in the hopes of defining modifiable factors that could decrease complications. METHODS: We performed a retrospective review of 179 UC patients undergoing surgery for failure of medical management. Patients treated urgently (while hospitalized) were compared to those treated electively with univariate (chi square, t test) and multivariable regression analyses. RESULTS: Patients undergoing urgent (n = 99) vs. elective (n = 80) surgery were younger (28.3 ± 1.6 vs. 32.6 ± 1.6 years; p = 0.05) with lower mean BMI (22.3 ± 0.1 vs. 25.9 ± 0.6 kg/ m2; p = 0.0001). Significantly more urgent patients were on steroids at the time of surgery (93.5% vs. 66.7%; p < 0.0001). Use of anti-TNF drugs (21.3% vs. 26.3%; p = 0.44) and other immunomodulators (42.5% vs. 43.4%; p = 0.91) were equivalent between the two groups. Urgent patients reported more daily bowel movements at the time of surgery (11.7 ± 0.7 vs. 9.0 ± 0.8; p = 0.01) and had an increased prevalence of severe disease on final pathology (87.5% vs. 73.7%; p = 0.02) compared to patients treated electively. During surgery, urgent and elective patients had similar degrees of hemodynamic stability (mean apgar scores 6.1 ± 0.2 vs. 6.5 ± 0.1; p = 0.1). However, urgent cases had more than a 5-fold increase in the proportion of subtotal colectomies (5.1% vs. 29%; p < 0.0001) and half as many laparoscopic procedures (8.8% vs. 18%; p = 0.07). Postoperatively, patients treated urgently had more short-term complications (1.0 ± 0.3 vs. 0.6 ± 0.2; p = 0.05), but no increase in anastamotic leaks [OR 1.7 (0.5, 6.5); p = 0.26] or in-hospital length-of-stay (7.3 ± 0.5 vs. 6.5 ± 0.4 days; p = 0.21) at their initial operation. Long-term complications, including pouchitis, fistula/abscess, ileus/SBO, stricture, and pouch failure were similar regardless of urgency status (p ≥ 0.08). Multivariate regression analysis controlling for disease severity, steroid use, and infliximab use suggested that short-term complications were attributable to higher BMI in addition to urgent status (p ≤ 0.05). Surgeon inexperience and use of immunomodulators other than infliximab were associated with increased odds of long-term fistula/abscess [OR 5.56 (1.1, 33); p = 0.05) and pouch failure [OR 13.3 (1.75, 318); p = 0.01], respectively. CONCLUSION: Although urgent surgery is associated with an increased number of short-term complications, it does not affect the risk of anastomotic leak, in-hospital lengthof-stay, or long-term complications provided that the surgery is performed by an expert. Weaning from immunomodulators other than infliximab and early transfer to an institution with IBD expertise would likely decrease complications overall for patients undergoing both elective and urgent interventions for severe UC. INTRODUCTION: Postoperative acute respiratory failure (ARF) is a major factor of morbidity and mortality in colon and rectal surgery. OBJECTIVES: To evaluate the prevalance of ARF following colorectal surgery and to evaluate the effect of patient characteristics, comorbidities, pathology, resection type, surgical technique and admission type on ARF in colorectal surgery. METHODS: Using the National Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent colon and rectal resection from 2006–2008. Multivariate regression analysis was performed to identify factors predictive of ARF. RESULTS: A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of acute respiratory failure was 10.42% (elective surgery: 4.51% vs. emergent surgery: 18.59%; p < 0.01). Patients who experienced ARF following colorectal surgery had a significantly higher rate of in-hospital mortality (26.84% vs. 1.90%) and a longer mean length of hospital stay (22.31 days vs. 9.32 days) compared with patients without ARF. Using multivariate regression analysis, patient factors including emergent operation (odds ratio [OR]: 2.91), congestive heart failure (OR, 2.51), alcohol abuse (OR, 2.13), pulmonary hypertension (2.01), chronic renal failure (OR, 2.0), chronic lung disease (OR, 1.96), age over 65 (OR, 1.92), diverticulitis (OR, 1.71), liver disease (OR, 1.66), peripheral vascular disease (OR, 1.58), malignant tumor (OR, 1.53), obesity (OR, 1.41) and ulcerative colitis (OR, 1.25) significantly impacted the risk of ARF. Technical factors including total colectomy (OR: 2.66), open procedure (OR, 1.71), left colectomy (OR, 1.50), and transverse colectomy (OR, 1.41), were also associated with higher risk of ARF. Although male sex (OR: 1.09), teaching hospital (OR, 1.07), Black race (OR: 1.04), and Hispanic race (AOR, 1.03) also had statistically significant impact on rates of ARF, these were less clinically significant than the other factors. There was no association with hypertension, diabetes, smoking, Asian race, sigmoidectomy, proctectomy or Crohn’s disease and ARF. CONCLUSIONS: Respiratory failure is a relatively common complication following colorectal surgery. Emergent surgery is the strongest predictor of acute respiratory failure in colorectal surgery. Surgical approaches such as total colectomy, left colectomy and transverse colectomy, that classically involve upper abdominal incisions, are associated with a higher rate of respiratory failure. 168 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1747 Altered Rectal Tone and Compliance and Hyposensitivity for Non-Noxious Stimuli in Patients with Fecal Incontinence After Anorectal Surgery Richard A. Awad*1, Francisco Flores-Judez2, Santiago Camacho1, Alfredo Serrano1, Evelyn Altamirano1 1. Experimental Medicine and Motility Gastroenterology Service U 107, Mexico City General Hospital, Mexico, Mexico; 2. Surgery Service, Mexico City General Hospital, Mexico, Mexico INTRODUCTION/OBJECTIVES: It is reported that fecal incontinence may present as a late complication of anal fissure (1) or other anorectal procedures, that rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy (2), and that noxious and non-noxious distensions stimulate different afferent nerve pathways (3). This study aimed to search anal sphincter and rectal factors that determine fecal incontinence after anorectal surgery (FIAS). METHODS: Seventeen patients (50 ± 15 years, 11 females) with fecal incontinence (10 ± 15 CI: 3–17 incontinence episodes per week) after anorectal surgery (sphincterotomy = 5, fistulotomy = 5, rectal prolapse = 4, hemorrhoidectomy = 1, others = 2; 2 ± 1 CI:1.2–3.2 years after surgery) were studied [clinical assessment, rectosigmoidoscopy, anorectal manometry (MMS, Netherlands) and barostat (G&J, ON, CA)] and compared with healthy subjects (n = 11, 22 ± 2 years, 10 females for manometry and; n = 10, 25 ± 7 years, three females, for barostat studies). Rectal sensory thresholds, tone and compliance were evaluated with an electronic barostat using the ascending method of limits. Mean ± SD, binominal 95% confidence interval, and nonpaired Student two-tailed t test with alpha = 0.05. RESULTS: (Table). Compared with healthy subjects, FIAS patients showed lesser rectal compliance (p = 0.0129) and rectal tone at lower volume (p = 0.0029). The thresholds for non-noxious stimuli of gas sensation (p = 0.0272) and urge-to-defecate sensation (p = 0.0245) were reported by FIAS patients at higher pressure than healthy subjects. The noxious stimulus of pain was reported by FIAS patients at similar pressure than healthy subjects (p = 0.9). Compared with healthy subjects FIAS patients showed greater anal squeeze pressure (p = 0.041). However, anal resting pressure and rectoanal inhibitory reflex parameters (RAIR) were similar. CONCLUSION: FIAS patients preserve internal anal sphincter function but present with impaired rectal tone and compliance and hyposensitivity for non-noxious stimuli. The results also support the concept that noxious and non-noxious distensions stimulate different afferent nerve pathways and suggest that an impaired afferent nerve pathway and abnormal rectal structure and function are involved in the genesis of fecal incontinence after anorectal surgery. REFERENCES: 1. Levin A et al. Int J Colorectal Dis 2011. 2. Corsetti M et al. J Gastrointest Surg 2009;13:2245–51. 3. Awad RA et al. Gastroenterology 2011;140:S744. Table Variable (Mean ± SD) Fecal Incontinence After Surgery Healthy Subjects 43 ± 42 CI: 23−63 103 ± 51 CI: 71–135* 5 ± 5 CI: 2–7 11 ± 6 CI: 7–16* First sensation (mmHg) 16 ± 4 CI: 14–18 14 ± 5 CI: 10–17 Gas sensation (mmHg) 23 ± 5 CI: 20–25 17 ± 6 CI: 14–21* Urge to defecate (mmHg) 30 ± 8 CI: 25–35 22 ± 7 CI: 17–26* Pain sensation (mmHg) 36 ± 7 CI: 32–40 35 ± 8 CI: 30–41 Tone (ml) Compliance (v/p) 46 ± 25 CI: 34–58 34 ± 22 CI: 21–48 Anal squeeze pressure (mmHg) 87 ± 65 CI: 56–118 43 ± 24 CI: 28–57* 20 ± 7 CI: 17–24 19 ± 5 CI: 16–23 59 ± 17 CI: 51–-67 74 ± 31 CI: 55–93 RAIR duration (s) RAIR relaxation (%) Tuesday Poster Abstracts Anal resting pressure (mmHg) * = p < 0.05 compared with healthy subjects 169 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1748 Tu1749 Laparoscopic Right Hemicolectomy: A Comparison of Natural Orifice vs. Transabdominal Specimen Extraction Colorectal Cancer in Patients Under 50 Years of Age: Frequent and More Often Advanced? Reginald L. Griffin*1, Irfan Qureshi1, Eve Oganesyan1,2, Ziad Awad1 1. University of florida, Jacksonville, FL; 2. LECOM, Bradenton, FL BACKGROUND: Conventional laparoscopic assisted right hemicolectomy (LARH) involves making an abdominal incision to remove the specimen and perform the anastomosis. The skin incision extraction site continues to be a major source of morbidity after both open and LARH, specifically with regard to postoperative pain, wound infection and hernia formation. Totally laparoscopic right hemicolectomy with intracorporeal anastomosis and transvaginal extraction ie. natural orifice specimen extraction (NOSE) eliminates the skin incision extraction site and may possible leads to better outcome compared to LARH. METHODS: Our study reviewed two consecutive case matched cohorts: LARH and NOSE performed during 2007 and 2011. Forty consecutive female patients total were reviewed: 20 LARH and 20 NOSE. The two groups were matched for benign and malignant disease, sex, age, race, American Society of Anesthesiologist (ASA) score, pathology, tumor stage, lymph node (LN) number, body mass index (BMI), previous abdominal surgeries, and comorbidities including chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), hypertension, diabetes mellitus (DM), chronic kidney disease (CKD), and nicotine dependence. Our goal was to determine significant differences between the two groups with regard to postoperative pain, wound infection, hernia formation, postoperative ileus, septic complications, length of hospital stay, readmission rate, time interval for postoperative chemotherapy if indicated, symptom distress score (SDS), Visick grade, Quality of life Index (QLI) and cosmetic score. RESULTS: The two groups were comparable for all categories. Follow up was available on all patients (100%). At a mean follow-up of 25.23 months (range 6–53, there was no difference between postoperative pain between the two groups on postoperative day one, postoperative day two or greater than 2 weeks (p = .571),(p = .861),(p = .688), respectively. The NOSE group had no postoperative hernia formation or wound infections compared to the LARH group which had 10% hernia formation rate and 5% wound infection rate, however the difference was not significant (p = .439)and (p = .267), respectively. There was no difference between groups in postoperative ileus (p = .192), septic complications (p = 1.000), length of hospital stay (p = .243), readmission rate (p = .394), time interval for postoperative chemotherapy (p = .645), SDS (p = .446), Visick grade (p = .176) or QLI (p = .175). The NOSE group, however, have statically significant better cosmetic scores (p = .018). CONCLUSION: NOSE is comparable LARH with regard to short and long term postoperative outcomes. NOSE is associated with better cosmetic outcome. Elizabeth Myers*1, Joon Ho Jang1, Daniel L. Feingold2, Tracey D. Arnell2, Kenneth A. Forde2, Jon Kluft2, Samer Naffouje1, Sonali A. Herath1, Richard L. Whelan1 1. Colorectal Surgery, St. Luke’s Roosevelt Hospital Center, New York, NY; 2. Surgery, College of Physicians and Surgeons, Columbia University, New York, NY INTRODUCTION: The overall incidence of colorectal cancer (CRC) in Western countries is falling in part due to aggressive adenoma surveillance programs. It has been previously noted that more patients (pts) under age 50 are developing CRC and are more likely to present with Stage 3 or 4 disease yet average risk pts under 50 are excluded from CRC screening programs. This review was undertaken to investigate CRC in pts under 50 at 2 institutions to determine if the above trends are observed in this population. METHODS: The records of pts under the age of 50 who underwent an operation for CRC between July 1996 and July 2011 at 2 hospitals were reviewed. The main study variables included: age, symptoms, family history, tumor location, resection performed, and stage & differentiation of disease. RESULTS: Over the 15 year period, a total of 174 CRC pts under age 50 were identified that underwent surgery (90 males, 85 females; mean age 41.4, range 17–49). Pts under 50 accounted for 12% of all CRC cases (all ages) for the 5 year period (2006–2011) for which the full data set was available. Sixteen pts (9%) had a first degree, 17 pts (10%) had a second degree, and 3% had both a first and second degree family history of CRC; 125 pts (71%) had a negative family history. The vast majority (93%) presented with symptoms: the most common were bleeding (57%), obstruction (9%), and abdominal/rectal pain (35%). Not uncommonly, work-up and diagnosis were delayed because of patient and/or doctor complacence. Bleeding was often attributed to hemorrhoids; 2 pts had symptoms for 18–24 months prior to colonoscopy. Advanced CRC (Stage 3 or 4) was found in 95 pts (55%). The tumor locations were: right or transverse, 46 (26%); descending or sigmoid, 59 (34%); rectal, 69 (40%). The vast majority of pts had segmental resections. Five pts had a subtotal/total abdominal colectomy, of which 2 had a first degree family history. Most pts (70%) had moderately or well differentiated cancers, whereas 21 pts (12%) had poorly differentiated lesions and 34 (19%) had mucin producing CRC’s, of which almost two thirds had Stage 3 or 4 disease. CONCLUSIONS: Young patients with sporadic CRC continue to present with advanced disease. In this series the tumors were predominantly located in the distal colon and rectum. The vast majority of these pts had no contributing family history similar to the situation for the over 50 CRC population. An alarming number of young pts have symptoms that are often attributed to common benign colorectal problems and that lead to a delay in diagnosis. Clinicians must maintain a low threshold for evaluating young symptomatic patients to exclude an occult cancer as the outcome of CRC treatment strongly depends on the stage at diagnosis. 170 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1750 CONCLUSIONS: Clostridium difficile colitis is a serious problem that carries significant morbidity and mortality. The majority of the patients did not require surgery, but those who did had a fourfold increase in mortality risk. Patients over 65 years old and those who develop acute renal failure also had a higher risk of in-hospital mortality. Clostridium Difficile Colitis: 21st Century Pandemia Haisar E. Dao*, Peter E. Miller, Justin Lee, Reza Kermani, Alan W. Hackford Surgery, St. Elizabeth’sMedical Center. Tufts University School of Medicine, Boston, MA OBJECTIVE: Clostridium difficile colitis has become a significant problem among healthcare facilities in the United States. Our objective is to analyze Clostridium difficile colitis associated hospitalizations and contemporary outcomes. METHODS: Analysis of the Nationwide Inpatient Sample (NIS) was performed for the years 2005–2007. This database incorporates 100% of all hospital discharges from a 20% stratified sample of US hospitals. Diagnosis and procedures were identified using ICD-9 codes. Primary outcomes were in-hospital mortality and need for surgical intervention. Multivariable analysis was performed to determine the relationship between independent variables and in-hospital mortality. RESULTS: 859,350 discharges were identified with a diagnosis of Clostridium difficile colitis. The mean age of the population was 68.5 ± 19.4 years (Female 58.8%), and the median length of stay was 8.0 days (0–360). Overall inhospital mortality was 8.1%. Total abdominal colectomy was performed in 6722 patients (0.8%). Multivariable analysis revealed that patients who underwent total abdominal colectomy had a higher mortality rate than patients that did not require surgical intervention, 31.8% vs.7.8%, respectively (OR 4.0, 95% CI 3.7–4.3, p < 0.0001). In addition to total abdominal colectomy, acute renal failure was independently associated with an increase in in-hospital mortality (OR 2.8, 95% CI 2.7–2.8, p < 0.0001). Multivariable Analysis of Risk Factors Associated with In-hospital Mortality in Patients with Clostridium Difficile Colitis n = 859,350 Odds Ratio 95% CI p Total abdominal colectomy 4.0 3.71–4.30 <0.0001 1.0 1.01–1.06 0.06 09 0.92–0.95 <0.0001 Age over 65 1.5 1.5–1.6 <0.0001 CHF 1.2 1.2–1.3 <0.0001 HTN 0.8 0.8–0.9 <0.0001 COPD 1.1 1.1–1.2 <0.0001 CRF 1.0 0.9–1.0 0.2 DM 0.5 0.5–0.6 <0.0001 CHF: Congestive heart failure, HTN: Hypertension, COPD: Chronic obstructive pulmonary disease,CRF: Chronic renal failure, DM: Diabetes mellitus. Never Too Old for Abdominal Surgical Repair of Rectal Prolapse Jaime Benarroch-Gampel*, Aakash Gajjar, Casey A. Boyd, Kristin Sheffield, Taylor S. Riall Surgery, University of Texas Medical Branch, Galveston, TX BACKGROUND: The effect of age on short-term outcomes in patients undergoing surgical repair for full-thickness rectal prolapse is unknown. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database (2005–2010) we selected a total of 1,876 patients with full-thickness rectal prolapse who underwent either perineal or abdominal repairs. Outcome variables included any or major postoperative complications (unplanned intubation, pulmonary embolism, acute renal failure, stroke, coma, cardiac arrest, myocardial infarction, sepsis/septic shock, bleeding requiring blood transfusion and death). Multivariate logistic regression models were used to describe the impact of age on outcomes. RESULTS: A total of 909 patients (48.5%) underwent an abdominal procedure. Comorbid illness increased with age. Use of an abdominal approach decreased from 80.95% in the youngest patients (≤54 years) to 14.76% in the oldest patients (≥85 years, P < 0.0001). When compared to patients younger than 54 years old, patients between 55–69 years were 51% less likely (OR = 0.49, 95% CI 0.36–0.66), patients between 70–84 years were 87% less likely (OR = 0.13, 95% CI 0.09–0.17) and patients older than 85 years were 95% less likely (OR = 0.05, 95% CI 0.03–0.07) to have an abdominal procedure. Even in patients with no comorbidities (N = 495) the use of an abdominal approach decreased with increasing age (83.78% to 10.42%, P < 0.0001). When patients in the overall cohort were stratified by age (≤54 y, 55–69 y, 70–84 y, and ≥85 y), there were no differences within each strata with regards to overall or major complication rates between the two approaches. After adjusting for patient comorbidities and surgical approach, no differences in overall complications or major complications were observed across age groups. (Table 1) CONCLUSIONS: With older age, fewer people with fullthickness rectal prolapse undergo abdominal surgical repair, even after controlling for baseline condition. Our data suggest that in carefully selected older patients, an abdominal approach to repair a rectal prolapse can be safely used. 171 Tuesday Poster Abstracts White Female Tu1751 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Table 1. Effect of Age on Postoperative Complications: Bivariate and Multivariate Analysis Any Complication Unadjusted Model Age Groups OR 95% CI ≤54 years Major Complications Adjusted Model* OR 95% CI Adjusted Model# Unadjusted Model OR Reference group 95% CI OR 95% CI Reference group 55–69 years 1.04 0.69–1.57 0.91 0.60–1.39 1.87 0.86–4.06 1.33 0.62–3.07 70–84 years 1.13 0.77–1.67 0.95 0.61–1.48 3.11 1.52–6.35 2.05 0.94–4.48 ≥85 years 0.88 0.57–1.37 0.71 0.42–1.19 2.55 1.18–5.48 1.60 0.68–3.78 *Adjusted to surgical approach, ASA class and dyspnea. #Adjusted to surgical approach, ASA class, cardiac comorbidities and chronic obstructive pulmonary disease Tu1752 Tu1753 Ventral Rectopexy with Biological Mesh: Surgical Option for Selected Patients with Obstructed Defecation Syndrome Complications of Hartmann Takedown in the Era of Primary Anastomosis Ari Garber*, Neil Hyman, Turner Osler Surgery, University of Vermont College of Medicine, Burlington, VT Angelo Stuto , Francesca Da Pozzo , Andrea Braini , Alessandro Favero1 1. 1st Surgical Department, Az. Osp “SMA”, Pordenone, Italy; 2. Department of Gen Surgery, Trieste University Hospital, Trieste, Italy *1 2 1 OBJECTIVE: The aim of this study is a retrospective analysis of our experience in Laparoscopic Ventral Rectopexy (LVR) with biological mesh to assess the safety and the efficacy of this surgical treatment for Obstructed Defecation Syndrome (ODS). METHODS: Between July 2010 and November 2011, fifteen patients had LVR with biological mesh for symptomatic ODS with enterocele, recto-rectal prolapse and third degree rectocoele. All patients underwent preoperative anoscopy, colonoscopy and perineo-defecography. The operative technique was standardized and in all cases a biological mesh was used. No colon resection or Stapled Transanal Rectal Resection (STARR) was performed in association with LVR. ODS score and Symptom Severity Score (SSS) were both used in follow up to assess morbidity and efficacy of this surgical procedure. RESULTS: Perioperative morbidity was 6,6% (one patient required reintervention for ileal volvolus) with no mortality. No major and minor complication as sepsis, bleeding, fecal urgency and urinary retention were recorded. The median hospital stay was . No recurrence after a mean follow up period of 5,7 months was observed with good overall patient satisfaction. The mean ODS score was 18 preop vs 5 postop, SSS 16 vs 7. CONCLUSION: In our experience LVR is a safe and effective procedure for treatment of ODS in selected patient. However for patient with internal rectal prolapse STARR procedure remains the gold standard. LVR is an innovative feasible technique for patients with ODS associated with complex pelvic disease. INTRODUCTION: Primary anastomosis with or without proximal diversion is increasingly applied to pts requiring urgent colectomy for complicated disease of the sigmoid colon. Conversely, the Hartmann procedure (HP) is now often restricted to patients who are unstable or otherwise ill suited to primary anastomosis. As such, pts who are evaluated for Hartmann takedown often have formidable comorbities and considerable judgment is often required in pt selection. We sought to define the complication rate of Hartmann takedown in this setting. METHODS: A prospective complication database was searched for consecutive adult patients undergoing colostomy takedown with colorectal anastomosis (HP) at an academic teaching hospital from 1/1/02 to 12/31/10. Demographics, BMI, ASA classification, interval between Hartmann procedure and subsequent takedown, surgical indication, surgeon volume and specialty, length of stay and complications were recorded. Fisher’s exact test was used to identify risk factors for postoperative complications. RESULTS: 104 pts underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons did 4 or fewer procedures during the study period. 39 pts had their original Hartmann procedure done elsewhere; 38 of these reversals were done by a colorectal surgeon. During the same time period, 334 patients underwent a Hartmann procedure at our institution. 77/104 pts (74%) had their HP for complicated diverticulitis; anastomotic leak was the second most common indication. The median age was 61 years (31–84 yrs) and the interval from Hartmann procedure to reversal ranged from 87–1489 days. Only 8 pts (7.7%) had an ASA of 1 and at least 30 patients required a concomitant ventral hernia repair. 30 pts (29%) had complications and 12 (11%) had two or more complications (Table 1). There were two deaths, four anastomotic leaks, and seven patients had inadvertent enterotomies. Only ASA status predicted postop complications (p = .01) 172 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA pre-operative comorbidities {cardiac (p = 0.009) and neurological (p = 0.005)}. Operative time was longer with a laparoscopic approach (mean 135 min vs. 87 min, p = 0.0001). Univariate analysis showed no difference in the complication rate between laparoscopic and perineal approach (4% vs 6.9%, p = 0.09). After risk adjustment for age, ASA, preoperative comorbidities and operative time, the difference in major complications between laparoscopic and perineal approach remained non significant on multivariate analysis. Independent predictors of major complication included presence of pulmonary disease (OR = 1.91, 95% CI = [1.03, 3.55], p = 0.04), bleeding disorder (OR = 3.42, 95% CI = [1.65, 7.10], p = 0.001), and anemia (OR = 2.09, 95% CI = [1.06, 4.10], p = 0.033). Table 1: Complications (n = 30 pts) SSI 7 Inadvertent enterotomy 7 Blood transfusions 6 Anastomotic leak 4 Arrhythmia 4 Urinary 3 MI 2 Death 2 Other 14 CONCLUSIONS: Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than fivefold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are largely restricted to patients who are poor candidates for takedown and that their colostomy is highly likely to be permanent. Tu1754 Rectal Prolapse Repair: Laparoscopic or Perineal Approach? Aaron S. Rickles*, Abhiram Sharma, James C. Iannuzzi, Andrew-Paul Deeb, Fergal Fleming, John R. Monson Surgery, University of Rochester, Rochester, NY INTRODUCTION: The perineal approach to rectal prolapse repair is commonly chosen over open abdominal rectopexy for high-risk patients. A higher risk of recurrence has been accepted as a tradeoff for reduced morbidity. Increasingly rectopexy is now performed laparoscopically and this approach may reduce the incidence of complications while maintaining the durability of an abdominal procedure. The aim of this study was to compare the 30-day outcomes of laparoscopic versus perineal rectal prolapse repair using outcomes from a national clinical database. RESULTS: During the study period 1385 patients underwent rectal prolapse repair by perineal approach and 248 had laparoscopic rectopexy. Perineal cases were older (p = 0.0001) with a higher ASA class (p = 0.0001) and more Tu1755 Effect of Iatrogenic Spleen Injuries During Colorectal Carcinoma Surgery on the Early Postoperative Result Meyer Frank*1,5, Rene Mettke2,5, A. Schmidt3,5, Stefanie Wolff1,5, Andreas Koch4,5, Henry Ptok2,5, Hans Lippert1,5, Ingo Gastinger5 1. Department of General, Abdominal & Vascular Surgery, University Hospital, Magdeburg, Germany; 2. Department of Surgery, Municipal Hospital, Cottbus, Germany; 3. Oncological Practice, Municipal Health Care, Cottbus, Germany; 4. Surgical Practice, Municipal Health Care, Cottbus, Germany; 5. Institute for Quality Assurance in Operative Medicine, University Hospital, Magdeburg, Germany INTRODUCTION: Unlike in gastric carcinomas, the consequences of a spleen injury during operative treatment of the colorectal carcinoma are hardly investigated, as a splenectomy is not performed on these tumour patients to extend the radicality. In this context, the only interest is in the iatrogenic intraoperative spleen lesions, which make a splenectomy necessary or require reconstructive spleen preservation. METHODS: During the study period 01/01/2000–12/31/2004, the perioperative data of a prospective multi-center observational study of 46,682 patients whose tumour had been removed with a curative or palliative intention were analysed with respect to the early postoperative consequences of an iatrogenic spleen lesion. RESULTS: Of these 46,682 patients, 640 patients (1.4%) suffered an iatrogenic spleen injury during the operative therapy. The spleens of 127 patients (0.3%) were removed, the spleens of 513 patients (1.1%) were able to be left in situ following repair. In more than 80% of the cases with an iatrogenic spleen injury, the tumour was localised in the left colon and in the rectum. In the logistic regression, the decisive risk factor for this organ lesion was the mobilisation of the left colonic flexure on tumour localisation in the left colon and rectum. Following a spleen lesion, compared to the patients without spleen injury (36.5%), a significantly higher morbidity rate was registered (47.2% following 173 Tuesday Poster Abstracts METHODS: Laparoscopic and perineal rectal prolapse surgeries were selected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP, 2005–2010) by cross referencing Current Procedural Terminology codes (CPT codes 45400, 45130, and 45541) and International Classification of Disease, 9th edition codes (ICD-9 codes) for rectal prolapse. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major complication (mortality, organ space infection, return to OR, renal failure, venous thromboembolism, cardiac, neurological or respiratory complications). Univariate (2), and multivariate (logistic regression) analysis was performed to identify independent predictors of major complications. CONCLUSION: This study shows that even after risk adjustment the complication rate for laparoscopic rectopexy is no higher than perineal approach. Laparoscopic approach for repair of rectal prolapse should therefore be the preferred approach in most patients in view of the lower recurrence rate. THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT splenectomy; 48.5% following spleen repair). Anastomotic leaks requiring operation were most frequently observed following a splenectomy (7.9%). This rate was significantly lower following spleen preservation with 3.3% (p = 0.003). The total hospital mortality was 3.1%. In patients with splenectomy the hospital mortality was 11.8% and following repair with organ preservation was 4.7% (p < 0.0001). CONCLUSION: Iatrogenic spleen lesion during colorectal carcinoma surgery represents a significant risk factor for a poorer early postoperative result. In particular, this concerns the high rate of anastomotic leaks and infectious—septic complications. This also affects the rate of higher total morbidity and hospital mortality. By comparison, a significantly worse postoperative result is found in the group of splenectomised patients compared to the group with organ preservation through repair of the injured spleen. Tu1757 Rectal Cancer in the Young: Is It a Different Disease? Dana M. Hayden*, Neha Hippalgaonkar, Marylise Boutros, Eric G. Weiss, Steven Wexner CCF, Weston, FL BACKGROUND: Patients under 50 years old are not screened for colorectal cancer (CRC) unless they have symptoms or family history. However, recent studies have shown a rising incidence of rectal cancer in young patients. This study examines patient and tumor characteristics of rectal cancer patients younger than 50. METHODS: Retrospective chart review was performed on patients who had radical resection for primary rectal cancer at two tertiary institutions by board-certified colorectal surgeons, 2002–2008. RESULTS: 57 of 294 patients (19.4%) were less than 50 years of age. 28 (49.1%) were male and the mean age was 42 (24–49 years). One patient had IBD (1.8%), 12 (21.1%) a family history of CRC and 13 (22.8%) a family history of CRC-related cancer. No patients had personal history of CRC or CRC-related cancer. The most common indication for colonoscopy was rectal bleeding (48%). 77.3% of the patients with accurate preoperative stage recorded had locally advanced tumors (>T2) and 41 out of the 57 (71.9%) received neoadjuvant treatment. When compared to patients over 50, young rectal cancer patients were more likely to be female (X2 = 4.63, p = 0.031), however, there were no differences in personal history of CRC or CRC-related cancer, family history or smoking. 20 of 41 patients with complete preoperative data had low tumors (<6 cm from anal verge; not different than patients over 50). Younger patients were more likely to have poorly or undifferentiated tumors (X2 = 9.276, p = 0.002); this difference remained significant in a logistic regression model (Wald test 8.11, p = 0.004), controlling for gender and other factors. Lymphovascular or perineural invasion and the presence of mucin were not more commonly found in the younger group. Six (14.6%) young rectal cancer patients had complete response to neoadjuvant therapy; complete and any response to neoadjuvant was not different between the groups. CONCLUSIONS: Patients younger than 50 with rectal cancer are more likely to have poorly or undifferentiated tumors. They may also be more likely diagnosed at an advanced stage. Interestingly, these young patients are not more likely to have a family history or personal history of CRC or CRC-related cancer. These results suggest that younger patients may have worse prognostic factors and we should be aggressive in evaluating symptoms in young patients regardless of their history. Tu1758 Tumors Confined to the Presacral Space: A Diverse Group Requiring Individualized Evaulation and Surgery Craig A. Messick*, Tracy L. Hull, Jorge M. Rosselli Londono, Pokala R. Kiran Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH Purpose: Tumors occurring within the presacral space are a heterogeneous group and occur with very low incidence. Their low incidence has led to a paucity of published experience regarding surgical approaches, recurrence rates, and survival. This study aims to update the current literature on these tumors from a single-center with three decades of experience. METHODS: Patients were identified using a combination of a natural language search and SNOWMED codes queried from a prospectively maintained Pathology database from 1981–2011. A retrospective chart review was conducted recording patient demographics, tumor characteristics, operative procedure, recurrence, and survival data. Only patients ≥18 years old and with complete data were included. RESULTS: Presacral tumors were identified in 87 patients; 77% (67/87) female, median age at diagnosis was 44 years (19–88), and median follow-up was 8 months (0.1–225). Fourteen patients developed recurrence. Of the 27 different histologic tumors diagnosed, hamartomas were the most common (29%; n = 28) followed by both teratomas and epidermal cysts each at 10% (n = 9). 52% (14/27) of tumor types were malignant totaling 43% (37/87) of all tumors. CT scans were obtained in 84% (73/87) of patients, MRI in 59% (51/87), and TRUS in only 16% (14/87). While 74% (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73% (46/63) of those tumors (one tumor not resected). Cumulatively, 3/87 patients were treated non-operatively. 28% (24/87) of patients had a diagnostic biopsy with no reported biopsy site recurrences. Malignant tumors recurred in 24% (8/34), while benign tumors recurred in 12% (6/50). Chordomas recurred in 5/7 patients. Overall survival was 93% (81/87), 84% (31/37) for malignant tumors and 98% (49/50) for benign tumors. 174 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1759 Histologic Types of Presacral Tumors Hamartoma 28 Teratomas* 9 Epidermal Cyst 9 Schwannoma 7 Chordoma 7 Dermoid Cyst 4 B-Cell Lymphoma 2 Myelolipoma 2 Neuroendocrine Tumor 2 Rectal Duplication Cyst 2 Chondrosarcoma 1 Ewing’s Sarcoma 1 Fibrosarcoma 1 Fibrous Histiosarcoma 1 Ganglioneuroma 1 Gastrointestinal Stromal Tumor 1 Hemangiopericytoma 1 Liposarcoma 1 Mucinous Cystic Neoplasm 1 Pecoma 1 Neurofibroma 1 Smooth Muscle Tumor 1 Spindle Cell Tumor 1 Squamous Cell Tumor (metastasis) 1 Squamous Cell Cyst (Ovarian) 1 Diabetic Patients Take Longer to Recover Than Non-Diabetics Within an Enhanced Recovery Programme Alison Luther*, Sofoklis Panteleimonitis, Peter Kang, John Evans Northampton General Hospital, Northampton, United Kingdom INTRODUCTION: The enhanced recovery after surgery (ERAS) protocol encompasses a number of evidence-based interventions designed to lessen the impact of surgery upon the patient. It has been shown to reduce the length of stay and improve outcomes in elective colorectal surgical patients when compared to traditional post-operative management. NHS diabetes has recently released guidelines on the management of adults with diabetes undergoing surgery. Despite this, no studies have assessed the impact of diabetes on patients in an ERAS programme. METHODS: Two laparoscopic colorectal surgeons trained in the national Fellowship Programme were appointed in early 2010. Consecutive patients undergoing elective major colorectal procedures from March 2010 to September 2011 had data regarding length of stay, comorbidities and major complications prospectively collected. RESULTS: 143 patients were included in the study. Average age was 64 (range 21–88). The median length of stay in the non-diabetic group was 5 days (Interquartile range 4–7.5, n = 125) whilst in the diabetic group the median length of stay was significantly longer at 7 days (5–15.5, n = 18, P = .041, Mann-Whitney). DISCUSSION: Diabetic patients who have elective colorectal procedures have a significantly longer length of stay in hospital than non-diabetic patients despite being managed with an ERAS protocol. This has implications for perioperative management of diabetic patients. It is unclear whether the increased length of stay is due to a higher rate of major complications or a slower return of gut function. Further work needs to be undertaken to look at markers of gut function in the postoperative period. *Teratomas included those that were only teratomas (6) and those with both adenocarcinoma (2) and carcinoid (1) components, totalling 27 different histologic types of presacral tumors. CONCLUSIONS: Presacral tumors remain a heterogeneous group and continue to be a diagnostic and treatment challenge. Even though these tumors are confined to one space, surgeons must individualize preoperative work-up and operative approach based on each individual patient. A selective biopsy, which would influence treatment decisions, appears to be safe for tumors not associated with cord lesions. Presacral tumors are rare and studies such as this add to our understanding and guide patient recommendations regarding treatment. Tuesday Poster Abstracts 175 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Esophageal Tu1760 Radiation Therapy for Locally Advanced Colon Cancer Sekhar Dharmarajan*1, James W. Fleshman1, Robert J. Myerson2, Bashar Safar1 1. Surgery, Washington Univ, St. Louis, MO; 2. Radiation Oncology, Washington University School of Medicine, St. Louis, MO Tu1761 Does Morbid Obesity Worsen Outcomes After Esophagectomy? PURPOSE: The surgical management of locally advanced colon cancer is associated with higher rates of positive surgical margins, which translates to higher local recurrence rates and reduced overall and disease-free survival. While the use of radiation therapy in rectal cancer is well established to downstage tumors preoperatively and reduce local recurrence, its application to patients with locally advanced colon cancer has not been well studied. The purpose of this study was to examine the use of radiation therapy in the pre- and post-operative management of locally advanced colon cancer. METHODS: This study was conducted as a retrospective review of patients with locally advanced colon cancer treated with radiation therapy at a single institution from 1997 to 2008. Only patients with adenocarcinoma located at least 15 cm above the anal verge were included in the study. The primary endpoints of the study were ability to achieve margin-negative resection, local recurrence rates and overall and disease-free survival. RESULTS: 32 patients with locally advanced colon cancer treated with RT were identified, with an average age at presentation of 58. 6 of these patients had distant metastases at the time of presentation. 19 patients received neoadjuvant RT and 13 were treated in the adjuvant setting. All patients received chemotherapy concurrent with RT. 1 patient developed hematologic toxicity and 6 developed GI toxicity. 57% of cancers were located in the sigmoid colon, 36% in the right colon, and 7% in the transverse colon. Of the 19 patients treated with preoperative RT, 18 underwent definitive surgery and 17/18 (94%) achieved an R0 (margin negative) resection. Of the 13 patients treated with postoperative chemoRT, 2 had positive surgical margins at the time of resection. Pathologic staging revealed, 18 patients had stage II disease, 8 patients had stage III disease. Average followup was 4.33 years. The overall survival was 97%; 1 death that occurred prior to surgical intervention. The disease free survival was 69% (22/32); 2 with local recurrence only, 6 with distant recurrence only, and 2 with both local and distant recurrence. Neil H. Bhayani*1, Aditya Gupta2, Valerie J. Halpin2, Kevin M. Reavis1, Christy M. Dunst1, Lee L. Swanstrom1 1. Providence Portland Cancer Center, Portland, OR; 2. Legacy Weight Management Institute, Portland, OR INTRODUCTION: With national and worldwide increases in both esophageal cancer and obesity, the number of esophagectomies in morbidly obese patients will increase. Proper surgical risk stratification and patient counseling require a better understanding of the esophagectomy morbidity associated with obesity. METHODS: We studied non-emergent, subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project database from 2005– 2009. After excluding patients with disseminated disease and with body mass index (BMI) <18.5, the outcomes of normal BMI patients, (BMI 18.5–25) were compared to morbidly obese patients (BMI ≥35). Outcomes were mortality, aggregated morbidity, wound, pulmonary and cardiac morbidity. Multivariable regression controlled for pre-operative comorbidities differing between groups (p < 0.2) and established confounders of outcomes. Table 1. Adjusted Odds of Morbidity with Morbid Obesity CONCLUSIONS: The use of radiation therapy in locally advanced colon cancer is safe and potentially provides better local disease control, negative resection margins and improved survival. Further studies are warranted in order to delineate the role of radiation therapy in the treatment of locally advanced colon cancer. Adjusted Odds Ratio Confidence Interval p-Value Death 1.1 0.7–1.7 0.8 Any Morbidity 1.1 0.9–1.3 0.2 Superficial SI 1.2 0.9–1.5 0.1 Deep SI 1.7 1.04–2.8 0.04 Organ SI 0.9 0.7–1.3 0.7 Pneumonia 1 0.8–1.2 0.7 Reintubation 1 0.9–1.3 0.7 Fail to Wean 1 0.8–1.2 0.9 PE 1.4 1.0–2.1 0.09 DVT 1.3 0.9–1.8 0.2 Cardiac Arrest 0.6 0.3–1.3 0.2 Myocardial Infarction 1.4 0.5–3.5 0.5 Bleeding 1.6 0.6–4.1 0.3 Sepsis 1 0.8–1.2 0.3 Shock 1.1 0.9–1.4 0.4 Return to OR 0.9 0.7–1.1 0.3 ** compared to normal-weight patients † Adjusted for age, smoking, diabetes, hypertension, red cell transfusion, American Society of Anesthesiologists class ≥3, and weight loss of >10%. 176 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA RESULTS: Of the 483 patients, 373 (77%) had a normal BMI and 315 (29%) were morbidly obese. The overall population was 77% male, with a mean age of 62 years with 43% of patients older than 65 years. Normal BMI patients were older (p = 0.02) and more likely to smoke (37% v. 15%, p < 0.001). Pre-operative co-morbidities were similar except for a significantly higher incidence of hypertension (62% v. 48%) and diabetes (24% v. 13%) and a lower incidence of preoperative weight loss of ≥10% (11% v. 23%) in the obese population (p < 0.001). Morbidly obese patients received fewer red cell transfusions intraoperatively (12% v. 22%, p = 0.02). Overall, the rate of major morbidity was 51% and mortality was 3.5%; there was no difference between the groups. On multivariable analysis, all outcomes were the same between groups except deep space infections (DSI). Morbidly obese patients were at 70% higher risk (OR 1.7, 95% CI 1.04–2.8, p = 0.04) of DSI. RESULTS: A total of 5,851 patients underwent partial (65.60%) and total (34.30%) esophagectomy during this period. The mean age was similar between groups (partial: 63.3, total: 64.4 years; p = 0.07) and the majority of patients were male (partial: 81.8%, total: 79.3%; p = 0.02) and Caucasian (partial: 84.92%; total: 87.55%; p = 0.02). Most of the comorbidities were similar between groups (hypertension, congestive heart failure, chronic lung disease, liver disease, renal failure, weight loss, anemia, smoking, peripheral vascular disorder and alcohol abuse). Outcome measures between groups are shown below. Perioperative Outocomes of Partial Esophagectomy vs. Total Esophagectomy Outcome Measures CONCLUSIONS: In our study, there were no differences in post-operative mortality or pulmonary, cardiac, and thrombo-embolic morbidity between morbidly obese and normal BMI patients. Morbidly obese patients had elevated odds of deep wound infections. Overall, a BMI >35 does not confer significant morbidity after esophagectomy. Obese patients with esophageal pathology should not be denied resection based on BMI alone. Tu1762 Outcomes of Partial Versus Total Esophagectomy for Malignancy Hossein Masoomi*, Brian R. Smith, Michael J. Stamos, Ninh T. Nguyen Surgery (Colorectal Division), University of California, Irvine-Medical Center, Orange, CA Partial Esophagectomy Total Esophagectomy Number 3838 2013 Acute respiratory failure (%) 23.2 32.4 Pneumonia (%) 10.3 11.3 0.25 Empyema (%) 3.5 1.8 <0.01 P-Value <0.01 Fistula (%) 1.9 1.6 0.47 Overall complication rate* (%) 43.0 50.7 <0.01 In-hospital mortality (%) 5.8 8.4 <0.01 Mean length of hospital stay (days) 16.9 18.1 0.20 146,542 161,962 0.12 Mean total hospital sharges ($) *Patient who had at least one postoperative complication INTRODUCTION: Despite improvement in surgical technique, morbidity and mortality is still significant after esophagectomy. Operative technique might be considered as an important factor in the outcomes of this operation. This study was intended to evaluate the perioperative outcomes of partial versus total esophagectomy for malignancy. CONCLUSION: The most frequent procedure for esophageal malignancy is partial esophagectomy. Compared to the total esophagectomy, partial esophagectomy was associated with lower morbidity and lower mortality and comparable hospital stay and hospital charges. Partial esophagectomy may improve morbidity and mortality in esophageal malignancy. METHODS: Using the Nationwide Inpatient Sample (NIS) database, clinical data of patients who underwent esophagectomy (partial or total) with the diagnosis of esophageal malignancy including carcinoma in situ from 2006–2008 were examined. Patient characteristics, comorbidities, perioperative complications, length of stay, hospital charges and in-hospital mortality were evaluated. 177 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1763 Tu1764 Esophageal Perforation: Trend Towards Endoscopic Treatment Esophageal Stripping Creates a Clear Operative Field for Lymph-Node Dissection along the Left Recurrent Laryngeal Nerve in Prone Video-Assisted Thoracoscopic Surgery of Esophagus (VATS-E) Peter P. Grimminger*1, Till Herbold1, Hartmut SchäFer1, Jan Brabender2, Wolfgang SchröDer1, Arnulf H. HöLscher1 1. Department of General-, Visceral- and Tumor surgery, University Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery, St. Antonius Hospital, Cologne, Germany INTRODUCTION: Esophageal perforation is rare, but despite improvements in detection, surgical techniques, and intensive care medicine, esophageal perforation remains potentially fatal. For treatment of esophageal perforation, there are several treatment options. Depending on the cause and extent of the perforation the treatment is primary surgical, endoscopic interventional or conservative. The intention for the presented retrospective study is to evaluate the causes and treatment in order to draw conclusions for appropriate therapy for this disease. MATERIALS AND METHODS: Esophageal perforations treated between 1996 and 2011 were assessed. These were 71 patients (46 men and 25 women) with a median age of 52 years. Clinical data was reviewed and analyzed retrospectively. RESULTS: Iatrogenic injury was the most frequent cause of esophageal perforation (n = 43, 60%), followed by Boerhaave syndrome (n = 19, 27%) and traumatic perforation caused by accidentally swallowed foreign bodies (n = 7, 10%). In two patients, the reasons were not determinable (3%). The patients were operated in 50.7%, 25 patients (35.2%) were treated endoscopically with stent (n = 23) or endo-VAC (n = 2), 9 patients (12.7%) were treated conservatively with antibiotics and nasogastric tube and one patient (1.4%) with a perforated aortic aneurism into the esophagus died before treatment. Before 2008 operation was performed in 57% (25/44) and after 2008 the proportion of patients who underwent surgery dropped to 41% (11/27), while 50.2% (14/27) received endoscopic management (stent, n = 12 and endo-VAC, n = 2). The hospital mortality was 7% (6.8% before 2008 and 7.4% after 2008). CONCLUSION: The evaluation of the individual management of esophageal perforation in a 15 year period shows a trend towards endoscopic treatment, with low mortality. Hiroshi Makino*1,2, Hiroshi Yoshida1, Tsutomu Nomura2, Takeshi Matsutani2, Nobutoshi Hagiwara2, Tadashi Yokoyama1, Atsushi Hirakata1, Masao Miyashita2, Eiji Uchida2 1. Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan; 2. Gastro-Enterological Surgery, Nippon Medical School, Tokyo, Japan INTRODUCTION: Video assisted thoracoscopic surgery of the esophagus (VATS-E) in prone position is remarkable in Japan because the lung moves below by the gravity, and a good operative field is obtained. A clear operative view of the middle and lower mediastinum has been obtained; however, the working space in the upper mediastinum is limited. PATIENTS: Twenty patients in left lateral position and 17 patients in prone position, with esophageal squamous cell carcinomas underwent VATS-E since 2005 and 2009, respectively. METHODS: At first the patients are fixed at semi-prone position because both prone and left lateral positions can be set by rotating. Three 5 mm ports and two 10 mm ports are used at the 3rd, 7th, 9th and 5 th, 9th intercostal space (ICS). The pneumothorax by maintaining CO2 insufflation pressure of 6 mmHg is made, and esophagectomy is performed in prone position. In the case of emergent thoracotomy the patient will be rotated to the left lateral position. The lymph nodes around the trachea and bronchus, above the diaphragm and along the bilateral recurrent laryngeal nerves are dissected. Working space at the left upper mediastinal area for lymph nodes dissection around recurrent laryngeal nerve is limited in prone position. To obtain the space the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. RESULTS: 1. Mean estimated blood loss was 166 ml of chest procedure in prone position. 2. The rate of recurrent laryngeal nerve paralysis was 11.7% (2/17), and anastomotic leak and postoperative pneumonia was 5.8% (1/17), respectively. 3. There was no incidence of conversion to open method. 4. Lymphadenectomy along the left recurrent laryngeal nerve after esophageal stripping is available in prone position of VATS-E. CONCLUSION: Our result indicates that esophageal stripping in prone VATS-E allows for safe and straight forward lymph node dissection along the left recurrent laryngeal nerve. Our technique overcame the difficulty of the lymph node dissection along the left recurrent laryngeal nerve in prone position. 178 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1765 METHODS: Patients with GERD confirmed by pHmonitoring and manometric pattern of DES (simultaneous contractions 20–90% of wet swallows), NE (increased mean distal amplitude greater than 180 mmHg), or HLES (lower esophageal sphincter pressure greater than 45 mmHg) that underwent LNF were studied. A group of 50 consecutive patients with normal esophageal motility that underwent LNF were used as controls. Groups were comparable to controls for age, gender, pre-operative symptoms, hiatal hernia and barrett s esophagus, except for NE that had younger individuals (Table 1). Outcomes of Laparoscopic Nissen Fundoplication in Patients with Manometric Patterns of Esophageal Motility Disorders Bruna D. Cassao1, Fernando A. Herbella*1, Jose F. Farah1, Adorisio Bonadiman1, Luciana C. Silva1, Alberto Goldenberg1, Marco G. Patti2 1. Surgery, Federal University of São Paulo, São Paulo, Brazil; 2. Department of Surgery, University of Chicago, Chicago, IL INTRODUCTION: Manometric pattern of either diffuse esophageal spasm (DES), nutcracker esophagus (NE), or hypertensive lower esophageal sphincter (HLES) can be considered a primary esophageal motility disorder only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, the motility abnormality is considered secondary, and treatment is directed toward reflux. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders. RESULTS: Symptomatic outcome was similar when groups were compared to controls (Table 2). CONCLUSION: LNF is an adequate treatment for patients with GERD and manometric patterns of esophageal motility disorders. Table 1. Preoperative Data N Age (Years) % Females Dysphagia Esophageal Symptoms Hypertensive Les 3 57 66 66 100 Diffuse Spasm 14 52 50 15 86 Extra-Esophageal Symptoms % Barrett’s Esophagus % Hiatal Hernia 0 0 66 29 29 86 Nutcracker 13 46 61 15 100 23 8 69 Controls 50 57 64 14 84 28 10 88 Table 2. Postoperative Data Follow-Up (Months) Dysphagia Esophageal Symptoms Extra-Esophageal Symptoms Hypertensive Les 21 33 0 0 Diffuse Spasm 32 7 7 7 Nutcracker 25 0 8 8 Controls 36 20 18 2 179 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1766 Prognostic Factors of Very Long-Term Survival and Causes of Death in Early Esophageal Adenocarcinoma Juha T. Kauppi1, Ines Gockel2, Tuomo Rantanen1, Torsten Hansen3, Ari RistimäKi4, Hauke Lang2, Theodor Junginger2, Jarmo A. Salo*1 1. Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2. Department of General and abdominal Surgery, University Medical Center, Mainz, Germany; 3. Institute of Pathology, University Medical Center, Mainz, Germany; 4. Department of Pathology, HUSLAB, Helsinki University Central Hospital and Haartman Institute and Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland PATIENTS AND METHODS: 85 patients (p) (36 women and 49 men, median age 72, range 40–94) without neoadjuvant treatment were operated on because of EEAC (pT1N0-1, M0) between 1984–2011. Autopsy records and death certificates were acquired. Medical and pathology reports were reviewed and 75 (88%) specimens could be reanalyzed for cancer penetration by two experienced pathologists (HT and RA). Survival was calculated according to Kaplan-Meier and the Cox regression proportional hazards model. 39 p had transhiatal, 36 transthoracic enbloc, 5 vagal-sparing esophageal resection and, 5 solely endoscopic mucosal resection. RESULTS: Cancer penetration: pT1a in 33 p and pT1b in 42 p. Overall survival probability: 67.7% at 5, 49.2% at 10, 41% at 20 years. Disease specific survival: 78.3% at 5, 72.3% at 10 years. Lymph-node metastasis: (HR 7.9 [95%CI 2.53– 24.78] p < 0.0001 and Sm2–3 infiltration (HR 4.85 [95% CI 1.36–17.3] p = 0.015) showed worse prognosis. Cumulative mortality: 33/85 (38.8%). Cause of death: esophageal adenocarcinoma (EAC) 13 (39.4%), secondary malignancy 5 (15.2%), cardiovascular 3 (9.1%), miscellaneous 9 (27.2%). Lowest number of EEAC-deaths in patients with infiltration depth pT1a and pT1b (Sm1): 4 p (12.1%). CONCLUSION: Patients with intramucosal and superficial submucosal (Sm1) cancer infiltration die mostly not of EEAC. Less invasive therapy may be sufficient in this group. For patients with deeper cancer infiltration (Sm2Sm3) more radical treatment options should be considered. Tu1767 Laparoscopic Ischemic Conditioning as a Modality to Reduce Gastric Conduit Morbidity Following Esophagectomy Laparoscopic Ischemic Conditioning As a Modality to Reduce Gastric Conduit Morbidity Following Esophagectomy Marco Zahedi*1, Sabha Ganai2, Amy K. Yetasook1, Mark Talamonti1,2, Michael B. Ujiki1,2, Joann Carbray1, John Howington1,2 1. Surgery, NorthShore University HealthSystem, Evanston, IL; 2. Surgery, University of Chicago, Chicago, IL INTRODUCTION: Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. We aimed to assess conduit morbidity in a two stage operation involving laparoscopic ischemic preconditioning of the stomach prior to esophagectomy and gastric pull-up, compared to a single stage operation. 180 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA METHODS: We conducted a retrospective review comparing conduit morbidity of 63 consecutive patients who underwent an esophagectomy for Stage I-III esophageal cancer. Twenty three patients received pre-conditioning, which included laparoscopic ligation of the left and short gastrics, celiac node dissection, and jejunostomy tube placement, followed by formal resection and reconstruction between 3–9 days later. Forty patients underwent thoracotomy, esophagectomy and gastric pull-up without pre-conditioning. RESULTS: The two groups were similar with respect to gender and mean age. More patients in the preconditioned group received neoadjuvant therapy (88% vs 40%, p < 0.0001). There were no conversions to open in the pre-conditioned group. Mean time interval between the conditioning procedure and esophagectomy was 6.6 ± 1.5 days. Seventeen percent of the preconditioned group demonstrated ischemic changes along the fundus leading to modification of the planned transection line. There were significantly less post-operative strictures in the preconditioned group (8% vs 32%, P < 0.03), and a trend toward less anastomotic leaks (13% vs 26%, P < 0.20), and delayed gastric emptying (25% vs 45%, P < 0.12). There was no statistical difference between groups in terms of morbidity or mortality. Mean follow-up in months was 11.4 ± 8.9 in the preconditioned group, and 26.0 ± 27.6 (P < 0.02) in the single-stage group. CONCLUSIONS: Laparoscopic ischemic conditioning results in less strictures and a trend toward less gastric conduit morbidity (anastomotic leaks, delayed gastric emptying) when compared to single-stage esophagectomy and gastric pull-up. PATIENTS AND METHODS: Data of 1127 patients with esophageal cancer presenting from 2000 to 2008 at the Regional Center of the Esophageal Diseases were prospectively collected. Detailed anthropometric data about the BMI before the disease onset were available for 464 patients who were then included in this study. Sixty seven of them were classified as obese (BMI >30), 199 were classified as overweight (BMI 25–29.9) and 168 were classified as normal weight (BMI <24.9). Outcome and survival of the three groups were compared. Frequency and survival analysis were preformed. RESULTS: Overweight and obese patients with esophageal cancer were more often male (p < 0.01), they tended to have more frequently multiple tumours (p = 0.06) and they more often suffered high blood pressure (p < 0.01) than normal weight patients. Adenocarcinoma was more frequent in overweight and obese patients (p < 0.01). No significant difference was observed among the three groups in term of preoperative neoadjuvant therapy, type of operation, radicality of the esophagectomy and postoperative outcome. Nodal metastasis were more frequently localized in paraesophageal nodes in overweight and obese patients (p = 0.01). No significant difference was observed among the three groups in term of disease free survival. At multivariate survival analysis the only independent predictors of overall survival after radical esophagectomy were a BMI between 25 and 29.9 [HR = 0.63 (0.43–0.93), p = 0.02], pT stage 3 or 4 [HR = 2.13 (1.34–3.26), p < 0.01] and pN 1 status [HR = 1.84 (1.20–2.82), p < 0.01]. CONCLUSION: This data seem to suggest that in spite of several unfavorable features a moderate increase of weight may be associated to increased long-term survival after esophagectomy for cancer. Tu1768 Overweight Patients Operated on for Cancer of the Esophagus Survive Longer Than Normal Weight and Obese Patients Marco Scarpa*1, Matteo Cagol1, Silvia Bettini2, Rita Alfieri1, Amedeo Carraro1, Francesco Cavallin1, Elisabetta Trevellin2, Alberto Ruol3, Roberto Vettor2, Ermanno Ancona3,1, Carlo Castoro1 1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS), Padova, Italy; 2. Department of Medical and Surgical Sciences, University of Padova, Padova, Italy; 3. Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy BACKGROUND: Esophageal adenocarcinoma is often associated to obesity and the relative risk to develop an esophageal adenocaricoma is 1.52 if the Body Mass Index (BMI) is increased of 5 Kgm-2. The aim of this study was to assess the surgical and oncological outcome and the survival of overweight and obese patients with esophageal cancer. 181 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1769 Tu1770 Esophageal Failure and Refractory Dysphagia Following Roux-en Y Esophagojejunostomy Esophageal Perforation: Review of Outcomes from a Single-Institution Series Alfredo Amenabar*, Toshitaka Hoppo, Omar Awais, Blair A. Jobe Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA Hugo Santos-Sousa*1, Tiago Bouca-Machado1, Attila Dubecz2, André GonçAlves1, John Preto1, José Barbosa1, José Costa-Maia1 1. Esophageal and Gastric Surgery Unit, General Surgery Department, Centro Hospitalar de São João/Faculty of Medicine, University of Porto, Porto, Portugal; 2. General, Visceral and Thoracic Surgery Department, Klinikum Nord Nuremberg, Nuremberg, Germany BACKGROUND: Roux-en-Y esophagojejunostomy (RYEJ) is an effective treatment option in some patients with complicated gastroesophageal reflux disease (GERD). Postoperative dysphagia is common, and is most often caused by mechanical problems such as stricture or bowel obstruction; however some patients develop refractory dysphagia in the absence of mechanical obstruction and do not respond to empiric dilation. The objective of this study was to evaluate the patients who underwent RYEJ and subsequently developed dysphagia, and assess the etiology of dysphagia. METHODS: This is a retrospective review of patients who had undergone RYEJ to treat GERD following prior upper gastrointestinal surgery. Prior to RYEJ, all patients underwent esophageal physiology testing including upper endoscopy, high-resolution manometry (HRM) and pH testing. Patients who developed postoperative dysphagia underwent both radiographic and endoscopic assessment to evaluate stricture formation and bowel obstruction, and subsequently underwent dilation (empiric or therapeutic). Patients who were un-responsive to dilation in the absence of mechanical obstruction, underwent HRM combined with antegrade impedance using both liquid and paste (pudding) to assess esophageal motility as a possible etiology of dysphagia. RESULTS: From July 2009 to July 2011, 13 patients underwent RYEJ, 10 of whom had prior surgery including Nissen fundoplication (n = 2), vertical banded gastroplasty (n = 3), Heller myotomy with Dor fundoplication (n = 1), gastric bypass (n = 3) and Billroth II gastrectomy (n = 1). Mean age and BMI were 55.3 years (range, 44–66 years) and 34.3 (range, 26.3–48.1), respectively. Eight of 13 (61.5%) patients developed dysphagia after RYEJ. No patients had radiographic evidence of small bowel obstruction. Upper endoscopy demonstrated anastomotic stricture (n = 8) or roux limb narrowing within the transverse mesocolon (n = 2), which was successfully treated with dilation. Three patients had incapacitating dysphagia with regurgitation in the absence of mechanical obstruction. HRM demonstrated esophageal primary peristaltic failure as evidenced by low mean wave amplitude ordered contractions and dropped peristaltic waves. All three patients had 100% incomplete bolus clearance with paste and this correlated with symptom of dysphagia. Two of three patients underwent esophagectomy with neck anastomosis and had complete symptom resolution. CONCLUSION: For patients with non-obstructive, dilation refractory dysphagia following RYEJ, HRM combined with antegrade impedance testing using a defined liquid and paste protocol with symptom correlation is effective in determining etiology. Esophagectomy is an effective treatment option in this setting but long-term follow-up is required. BACKGROUND: Esophageal perforation is an important therapeutic challenge. The aim of this study was to review the outcomes of esophageal perforations treated by a specialized unit in esophageal surgery. METHODS: We performed a retrospective review of 52 consecutive patients with non-neoplasic esophageal perforation, between January 1991 and December 2008. Demographics, cause and location of perforation, time of diagnosis, management results and outcomes were evaluated. The management and outcomes trends over time were evaluated. For that, the cases were catalogued in three groups of 6 consecutive years. RESULTS: Spontaneous perforation occurred in 9 (17,3%) patients. Iatrogenic perforations were present in 15 (28,8%) patients and 28 (53,8%) patients had traumatic perforations. In half of the patients diagnosis was done in the first 24 hours. The perforation’s location was cervical in 14 (26,9%) cases, thoracic in 31 (59,6%) and abdominal in 7 (13,5%). The traumatic perforations were diagnosed significantly later than the other causes (p = 0,02). In 9 patients (17,3%) the treatment was non-operatively. For the patients submitted to surgery (82,7%), a primary repair was done in 23 cases (53,5%), a bipolar exclusion was performed in 18 (41,9%) and a conservative operative approach (drainage only) performed in 2 (3,8%). There were significant differences in the type of operative treatment according to the location (p = 0,035) [thoracic perforations were more times treated with bipolar exclusion]. In the analysis of the trends over time, there were significant differences in the location (p = 0,027) and the type of management (p = 0,012) [more patients treated surgically with primary repair in the last periods]. The morbidity and mortality rates were 46,2% and 13,5%, respectively. There were significant differences in morbidity according to the cause of perforation (p = 0,047) [the iatrogenic perforations had less morbidity] and the type of management (p = 0,041) [the patients treated conservative either operatively or non-operatively had lower morbidity rate], but only the type of management was an independent risk factor in the logistic regression analysis (OR 0,071, CI95% 0,007–0,696, p = 0,003). There were significant differences in mortality according to the age (p = 0,022) [older patients with higher mortality rate] and age was an independent risk factor in multivariate analysis (OR 1,095, CI95% 1,003–1,196, p = 0,005). There weren’t significant differences in morbidity and mortality rate over time. 182 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA CONCLUSION: An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, nonoperative management may be successfully implemented in selected patients with a low morbidity rate. Tu1771 Comparative Manometric Characteristics of 3 Anti-Reflux Operations Alia Qureshi*1, Ralph W. Aye1, Brian E. Louie1, Alexander S. Farivar1, Ariel Knight1, Lee L. Swanstrom2 1. Swedish Medical Center, Seattle, WA; 2. Legacy Health, Portland, OR BACKGROUND: The impact of antireflux operations on esophageal motility and lower esophageal sphincter characteristics is incompletely understood. Comparing the manometric features of various repairs may provide insight through differences and similarities. MATERIALS AND METHODS: 153 patients with gastroesophageal reflux and/or hiatal hernia underwent one of 3 laparoscopic operations at 2 institutions through 1 of 2 IRB-approved prospective protocols evaluating Nissen fundoplication (NF), Hill repair (HR), or a combination of Nissen plus Hill hybrid repair (NH). Clinical and objective testing and quality of life metrics were administered preoperatively and at 6–12 month follow-up. Ninety patients underwent pre-and post-operative manometry (NF = 27; HR = 37; NH = 26). RESULTS: Manometric results are listed in the table. Postoperative lower esophageal sphincter pressure (LESP) was increased significantly for NF and NH but not HR; residual LESP was highest in NF. DeMeester scores were equivalent, NF = 6.58; HR = 10.89, NH = 7.3. Postoperative quality of life scores were equivalent, NF = 6.24; HR = 6.24; NH = 6.69; Postoperative dysphagia scores were better for NH, 43.0 vs NF = 37.2 and HR = 38.1 (p = 0.019). Postoperative medication use was less for NH, 2.4% vs NF = 19.5% and HR = 17.0%. CONCLUSIONS: Combining NF and HR in one operation results in manometric lower esophageal sphincter characteristics that are similar to the individual component repairs, with low medication use and reduced longterm dysphagia. This suggests that there may be benefit to intra-abdominal fixation of the gastroesophageal junction Further study of the relative contributions of the fundoplication and the diaphragmatic repair are warranted. Trivariate Manometric Comparisons Preoperative NF (N = 46) Preoperative HR (N = 55) Preoperative NH (N = 43) P Value Postoperative NF Postoperative HR Postoperative NH p Value Average LESP (mmHG) 14.3 18.2 18.5 0.152 26.3 19.3 23.2 0.027 Average residual LESP (mmHg) 4.6 9.48 4.6 0.059 14.7 8.5 11.1 0.042 Average mean distal amplitudes (mmHg) 75.6 85.4 72.3 0.238 81.6 99.0 76.1 0.074 Peristalsis normal 92% 92% 84% 79% 87% 77% Peristalsis moderate dysfunction 4% 4% 9% 7% 8% 23% Peristalsis severe dysfunction 4% 4% 7% 14% 5% 0% 183 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1772 Tu1773 The Influence of Postoperative Complications on Recurrence and Long-Term Survival After Esophagectomy for Esophageal Cancer Fully Covered Self Expanding Removable Metal Stents Are Effective for Esophageal Fistulas, Leaks, Perforations and Benign Strictures Arzu Oezcelik*1,2, Shahin Ayazi1, Steven R. Demeester1, Joerg Zehetner1, Jeffrey A. Hagen1, Tom R. Demeester1 1. Surgery, University of Southern California, Los Angeles, CA; 2. General, Visceral and Transplantation Surgery, University of Essen, Essen, Germany Jennifer L. Kramer*, Alexander S. Farivar, Eric VallièRes, Ralph W. Aye, Brian E. Louie Swedish Medical Center and Cancer Institute, Seattle, WA BACKGROUND: The aim of this study was to identify factors associated with postoperative complications and to evaluate whether the severity of postoperative complications as classified using the Clavien classification was associated with cancer recurrence and survival. METHODS: The records of all patients who underwent an esophagectomy for cancer between 2002 and 2007 were reviewed. Postoperative complications were graded using the Clavien Classification, and scored from minor (GradeI) through the most serious (GradeIV). We defined major complications as those ≥ Grade IIIb. RESULTS: The study population consisted of 422 patients with a median age of 63 years. Neoadjuvant therapy was given in 94 patients (22%). En bloc, transhiatal and minimally invasive esophagectomies were performed. Postoperative complications occurred in 191 patients (45%). Complications were considered minor (Clavien Grade I-IIIa) in 116 (27%) and major (Grade IIIb or IV) in 75 (18%). On multivariate analysis, increasing age, stage, blood transfusion and Clavien classification ≥ Grade IIIb complications were independent negative predictors of survival. Factors associated with cancer recurrence included tumor stage, blood transfusion and major postoperative complications. Factors associated with Clavien Grade IIIb or higher complications included increasing age and blood transfusion. Neoadjuvant therapy, tumor stage and type of resection were not associated with postoperative complications. CONCLUSION: The study suggests that in addition to known prognostic factors such as tumor stage, the occurrence of major complications are associated with a higher frequency of recurrence and decreased survival after esophagectomy for cancer. Esophagectomy should be done in experienced centers where major complications are minimized. PURPOSE: Expandable plastic stents are the only stent approved for benign esophageal disease. However these stents are prone to migration and inadequate leak control. The self-expanding design of fully covered metal stents (CS), approved for malignancy only, is ideally suited for benign esophageal disease. Not only are they removable, but the continued radial force may reduce migration, result in durable stricture resolution and effect control of fistulas, leaks and perforations. We reviewed our experience with CS in 2 groups: benign strictures and fistulas/leaks/perforations to evaluate our outcomes and define the role of CS in the treatment algorithms these complex problems. METHODS: Chart review of all stents inserted for fistulas, leaks, perforations, and benign strictures from 2005 to 2011. RESULTS: A total of 56 CS were placed in 39 patients. Indications were stricture (14), anastomotic leak (12), perforation (4), staple line leak (4), fistulas (4) and other (1). There was no procedural mortality. There were complications in 32%: 10 stent migrations, 3 upper GI bleeds, 4 impactions and 1 erosion. Benign Stricture Group: Strictures had been previously dilated a median of 2.5 times prior to stenting in 13/14 patients. Stents were removed at a mean of 25 days. At a mean of 219 days of follow up, strictures remained patent. Eleven patients were managed with a single stent but 3 patients required sequentially larger stents to achieve patency. Adjunctive intralesional steroids were used in 11/14 patients. Fistula/Leak/Perforation Group: Control of the disruption was achieved in 79% of patients with fistulas (3/4), leaks (12/16) and perforations (4/4), but needed to be combined with drainage, VATS or laparoscopy in 12/24 leaks. All disruptions healed but 13/24 had to remain NPO during this time. Stents were removed at a mean of 42 days in this group. CONCLUSIONS: CS are effective in the management of benign refractory strictures, fistulas, leaks, and perforations. A CS with intralesional steroids is an alternative to serial dilations for stricture. Whereas fistulas, leaks and perforations when combined with minimally invasive drainage, may avoid open repair or even salvage a prior open repair. CS are well tolerated and removable, with acceptable complication rates and have a low migration rate. 184 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1774 Tu1775 Predictors of Complicated Diaphragmatic Hernia Pathologic Response in Esophageal Cancer Does Not Necessarily Correlate with Improved Survival Roman Grinberg*, Muhammad Asad Khan, John Afthinos, Karen E. Gibbs Surgery, Staten Island University Hospital, Staten Island, NY OBJECTIVE: Due to their relatively infrequent occurrence, it has been historically difficult to predict which patient with a diaphragmatic hernia (DH) will go on to either obstruct or strangulate and result in a surgical emergency. Given that patients with DH tend to be older and have multiple comorbidities, avoiding such an emergent situation would be beneficial. Our goal was to define potential comorbidities which could predict the likelihood of developing a complicated diaphragmatic hernia. METHODS: Using the NSQIP database, we identified all diaphragmatic hernias and grouped them by ICD9M code as either uncomplicated (553.3—without obstruction or gangrene) or complicated (551.3—with gangrene,552.3— with obstruction). Preoperative comorbidities, operative time, length of hospitalization and perioperative mortality and morbidity were compared between the two groups using chi-square and independent t-test as appropriate. A multivariate regression analysis was used to analyze potential factors contributing to obstruction or strangulation. Logistic regression was used to select correlates of 30 day mortality that were subsequently weighted and integrated into a scoring system based on the number of comorbidities. RESULTS: We identified 4778 patients, of which 4059 (85%) had an uncomplicated DH and 719 (15%) who had a complicated DH. The mean age for uncomplicated DH was statistically less than for a complicated DH (62.2 ± 14.1 vs 66.9 ± 15.2, p < .001). Independent predictors associated with a complicated DH included dyspnea at rest (AOR 2.9), partially or totally dependent functional status (AOR 4.4 and 7.1), CHF (AOR 4.3), history of MI (AOR 7.97) and >10% weight loss (AOR 1.82). Active smoking, alcohol consumption, dyspnea at exertion and use of steroids had no significant association. Risk stratification based on the number of preoperative comorbid factors demonstrated a step-wise increase in the rate of complicated DH: 12.1% (0–2 comorbidities), 21.5% (3–4 comorbidities), and 38.5% (≥5 comorbidities). Analysis of perioperative outcomes revealed that the mortality rate in the complicated DH group is much higher when compared to that of the uncomplicated DH group (5.1% vs 0.7%, P < .001). The same is true for the reoperation rate (6.3% vs 3.2%, p < .001) and length of stay (9.1+9.6 d, vs 4.1+6.7 d, p < .001). Veeraiah Siripurapu*, Amit S. Khithani, John Jay, Dhiresh R. Jeyarajah Surgery, Methodist Dallas Medical Center, Dallas, TX INTRODUCTION: Esophageal cancer presents with a high mortality amongst the solid tumors with a threefold increase in the incidence of adenocarcinoma in recent decades. Despite the use of better diagnostic and staging modalities such as EUS and PET- CT, treatment of locally advanced tumors is associated with a poor survival. We aim to see if preoperative treatment with chemo-radiation has improved survival in those patients who respond compared to those who do not. METHODS: All esophageal surgeries performed cooperatively by two surgeons between 2005 to 2010 were retrospectively reviewed. Only those patients deemed locally advanced (>T2, Node positive) who received preoperative chemoradiation were included for analysis. All patients were staged by CT & endoscopic ultrasound. RESULTS: 52 patients were identified, with 5 patients excluded due to outside institution referral. Of the 47 patients, 38 (81%) had adenocarcinoma versus 9 patients (19%) who had squamous cell carcinoma. Majority of the patients received Paclitaxel, Carboplatin and 5FU with radiation. The operative surgery was either a minimally invasive or open transhiatal esophagectomy with no difference in survival (p = 0.09). There were 2 operative mortalities and no anastamotic leaks. Patient response to chemotherapy was designated either as No response, Partial response or complete pathologic response (cPR). 21 patients (45%) had no response, 9 ( 19%) had partial response, while 17 patients (36%) had a cPR. Median survival was respectively 22 months, 23 months and 27 months (p = 0.53) (see Fig2). CONCLUSIONS: Preoperative treatment with esophageal cancer can lend to a high complete pathologic response. Despite the encouragement of a cPR, this data would suggest that this does not translate to an improvement in survival. CONCLUSION: This tool provides a simple, accurate and easily applicable method for predicting a complicated DH. Of note, history of a prior MI and dependent functional status most strongly predicted a complicated diaphragmatic hernia. Our findings suggest that if patients with uncomplicated DH are discovered and have a high score, elective repair should be sought expeditiously to avoid a life-threatening emergency. More studies are needed to further evaluate the timing of the progression from diagnosis of an uncomplicated DH to complication. 185 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1776 Clinical: Hepatic Does FDG-Uptake on PET-CT Provide Additional Prognostic Information for Patients with Esophageal Carcinoma? Tu1777 Preoperative Chemotherapy, Histological Tumor Regression and Long-Term Outcome After Resection of Colorectal Liver Metastasis David Bowrey, Sukhbir Ubhi, Claire N. Brown* Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom BACKGROUND: Several previous studies have reported that the FDG standardised uptake value (SUVmax) on PETCT imaging may be a useful prognostic marker. The majority of these studies have assessed selected populations. The aim of this study was to report the influence of FDG SUVmax on the outcome of an unselected cohort of patients undergoing PET-CT for esophageal carcinoma. METHODS: The SUVmax was determined for 105 patients undergoing PET-CT during the time period 2007–10. Patients were subdivided into quartiles according to SUVmax and its influence on prognosis assessed by univariate and multi-variate analysis. RESULTS: The study population was 105 patients (77 male) of median age 65 years (range 41–83). Histology was adenocarcinoma in 77 patients, squamous carcinoma in 28. Treatment intent was curative for 64 patients (resection 31, radical chemoradation 31, endoscopic mucosal resection 2) and palliative for the remaining 41 patients. On univariate analysis, SUVmax was not influenced by sex (p = 0.08), age (p = 0.19), histology (p = 0.81) or tumor site (p = 0.07), but was heavily linked to UICC stage (p < 0.001). Survival was significantly associated with quartile of SUVmax score (p = 0.03). This effect disappeared on multivariate analysis because prognosis was so strongly linked to UICC stage (p = 0.01). However, subgroup analysis identified that for patients treated by radical chemoradiation, UICC stage (p = 0.002) and SUVmax (p = 0.01) were the only factors linked to prognosis. CONCLUSIONS: This study did not confirm the FDG SUVmax on PET-CT to offer additional prognostic information for most patients with esophageal carcinoma. It may be helpful in patients treated by primary chemoradiation. Frank Makowiec*1, Peter Bronsert2, Gerald Illerhaus3, Tobias Keck1, Oliver Drognitz1, Hannes P. Neeff1, Ulrich T. Hopt1 1. Department of Surgery, University of Freiburg, Freiburg, Germany; 2. Pathological Institute, University of Freiburg, Freiburg, Germany; 3Department of Oncology, University of Freiburg, Freiburg, Germany INTRODUCTION: In patients with colorectal liver metastases (CRC-LM) preoperative chemotherapy (preCTx) is frequently used in a perioperative setting and/or to downsize irresectable CRC-LM. Especially in the perioperative setting, however, the exact role of preCTx is not well defined. To improve patient selection for preCTx factors predicting response and/or prognosis should be identified. In our study we analyzed the pathohistological response to preCTx in almost 150 patients who had had any form of CTx before liver resection, and correlated this response with survival. METHODS: We could evaluate the outcome of 147 patients who had hepatic resection for CRC-LM during the last decade in our institution, with pathohistological assessment of tumor regression grade (TRG) of metastatic disease and sufficient follow-up. Preoperatively the patients had undergone various regimens of CTx (42% FU-based, 40% Oxaliplatin and/or Irinotecan, 18% CTx plus antibodies/targeted therapy). 55% of the resections were at least a hemihepatectomy, 45% segmental or wedge resections. Free hepatic margins were achieved in 90%, free overall margins (including extrahepatic disease) in 81%. For this study all pathological specimens were reanalysed to classify TRG (grade 1 = total regression to grade 5 = no regression/vital tumor). Survival was estimated by Kaplan-Meier- and Cox-methods. RESULTS: Only 3% of the patients showed TRG grade 1 (total regression), 28% had good or moderate regression (TRG 2/3), and 69% had minor or no regression (TRG 4/5). TRG was better after CTx + targeted therapy (11% TRG1, 33% TRG 2/3; p < 0.01 vs CTx alone). TRG was also better in patients receiving more than 6 months of preCTx (p < 0.03 vs preCTx < 6 months). Overall 5 year survival (5y-Surv) was 42%. 5y-Surv was formally 100% in the few patients with total tumor regression (TRG 1), but comparable in the groups with TRG2/3 or TRG 4/5 (44%/38%; p = 0.1). In univariate and multivariate analysis in this subgroup of 147 patients with assessment of TRG only the hepatic margin (p < 0.01) or the overall margin (p < 0.001) significantly influenced survival. Type and duration of preCTx, extent of hepatic resection, nodal disease of primary CRC, number and size of metastases, and gender did not influence survival. CONCLUSION: Only few patients with preoperative chemotherapy show total regression of the resected colorectal liver metastases. Addition of targeted therapy to CTx may enhance pathohistological tumor regression. Total response to preoperative chemotherapy may be associated with a clearly improved prognosis. 186 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1779 Clinical: Pancreas Impact of Non-Alcoholic Fatty Liver Disease on Long-Term Survival for Resected Intrahepatic Cholangiocarcinoma Tu1780 Role of Endoscopic Retrograde Pancreatography to Detect Early Pancreatic Ductal Adenocarcinoma Concomitant with Intraductal Papillary Mucinous Neoplasm of the Pancreas Clancy J. Clark*1, Shahzad M. Ali1,2, Victor M. Zaydfudim1, Michael L. Kendrick1, Kaye M. Reid Lombardo1, John H. Donohue1, Michael B. Farnell1, David M. Nagorney1, Florencia G. Que1 1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 2. 2nd Department of Internal Medicine, University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) leads to a chronic inflammatory state hypothesized as carcinogenic. The clinical significance of NAFLD for patients diagnosed with ICC is not known. The aim of this study was to evaluate the significance of NAFLD on overall survival (OS) for patients with ICC. METHODS: In this single-institution, retrospective cohort study, all patients who underwent curative resection for ICC from 1997 to 2011 were identified. NAFLD was defined as pathologic evidence of steatosis or steatohepatitis in uninvolved liver parenchyma at time of resection or preoperative liver biopsy. Patients with clinical history or pathologic evidence of underlying liver disease other than NAFLD (n = 17) and patients who died of perioperative complications (n = 2) were excluded from survival analyses. Kaplan-Meier estimates and Cox regression proportional hazards were used to evaluate predictors of OS. RESULTS: One-hundred and thirty-eight patients (median age 60.5; 39.9% male) underwent curative resection for ICC with pathologic evidence of NAFLD in 18 (13.0%) patients. Median follow-up was 29 months (IQR 43) and median OS was 55 months. Age, sex, ASA, MELD score, CA 19–9, and BMI were similar between NAFLD and non-NAFLD patients. AJCC 7th Edition T-Stage was significantly lower in NAFLD patients compared with non-NAFLD patients: T1 50% vs 44%; T2a 22% vs 2.5%; T2b 6% vs 23%; T3 11% vs 13%, and T4 11% vs 18% (p = 0.02). However, AJCC 7th Edition TNM Stage was not significantly different between NAFLD and non-NAFLD patients (p = 0.56). In univariate analysis, predictors of decreased OS were larger tumor size (p < 0.01), node positive disease (p < 0.01), and presence of multiple tumors (p = 0.02). Pathologic evidence of NAFLD did not predict decreased OS (HR 1.5, 95% CI 0.8–3.0, p = 0.20). In subgroup analysis of node-negative patients (n = 77), NAFLD was a predictor of decreased OS (HR 3.7, 95% CI 1.6–8.5, p < 0.01). Other predictors of worse OS in node-negative patients were tumor size, ASA, and positive resection margin (all p ≤ 0.04). After adjusting for other significant covariates in the node-negative cohort, NAFLD was an independent predictor of decreased OS (HR 2.7, 95% CI 1.1–6.6, p = 0.03). CONCLUSIONS: Although NAFLD is not a predictor of OS for all patients undergoing hepatic resection for ICC, NAFLD is associated with decreased OS in patients with node-negative ICC. This adverse correlation of NAFLD and OS in patients with ICC suggests that treatment strategies should include management of NAFLD. Takao Ohtsuka*, Noboru Ideno, Teppei Aso, Yousuke Nagayoshi, Hiroshi Kono, Yasuhisa Mori, Junji Ueda, Shunichi Takahata, Kazuhiro Mizumoto, Masao Tanaka Surgery and Oncology, Kyushu University, Fukuoka, Japan BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas often has distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. Roles of endoscopic retrograde pancreatography (ERP) during the management of IPMN in terms of early diagnosis of concomitant PDAC have not been well documented. The aim of this study was to clarify whether ERP would be useful for the early detection of concomitant PDCAs in patients with IPMNs. METHODS: Medical records of 179 patients who were histologically confirmed to have IPMNs by resected specimens at our department between 1987 and 2011 were retrospectively reviewed. The patients having concomitant PDACs were selected, and then the diagnostic abilities to detect concomitant PDACs of computed tomography (CT), magnetic resonance imaging/cholangiopancreatography (MRI/ MRCP), endoscopic ultrasonography (EUS), and ERP were compared between early-stage (stage 0 or I according to the Japanese general rules for pancreatic cancer) and advanced PDACs (stage II, III, and IV). Abnormal findings to suspect the presence of PDAC in CT, MRI/MRCP, and EUS included an irregular solid mass lesion and stenosis/dilation of pancreatic duct, distinct from IPMNs. Abnormalities suspicious of the presence of PDAC in ERP were defined as irregularity of pancreatic duct such as stenosis and obstruction, and/or positive results (class IV or V) of pancreatic juice/brushing cytology. RESULTS: A total of 23 PDACs developed synchronously or metachronously in 20 patients, and the prevalence of PDACs concomitant with IPMNs was 11.2% (20/179). Sensitivities to detect PDACs of CT, MRI, and EUS in early group (16%, 29%, 29%, respectively) were significantly lower than those in advanced group (87%, 93%, 92%, respectively) (p < 0.01). On the other hand, sensitivity of ERP in early group was as high as that in advanced group (86% vs. 82%, p > 0.99). Among 7 early PDACs, 3 were diagnosed only by ERP. CONCLUSION: ERP has an important role in the early diagnosis of distinct PDACs in patients with IPMNs. Further investigation is necessary to clarify the indication and timing of ERP during the management of IPMNs in term of early detection of concomitant PDACs. 187 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1781 Major Pancreatic Resections in Octogenarians: A Community Hospital Experience Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2 1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ BACKGROUND: Major pancreatectomies are increasingly being performed in octogenarian (≥80 y) patients with reported clinical outcomes from large-volume medical centers. In this study we analyzed the outcomes of pancreatic resections in octogenarians at our community-based institution. vs. 27%, p = 0.56), Clavien grade I and II complications (46% vs. 43%, p = 0.84), Clavien grade III and IV complications (21% vs. 21%, p = 0.99), clinically significant fistulas (21% vs. 14%, p = 0.43), and perioperative mortalities (8% vs. 5%, p = 0.49). Malignancy had a higher incidence in the older group (87% vs. 62%, p = 0.02). The median length of hospital stay was also significantly higher in ≥80 y patients (14 vs. 9 days, p = 0.03). Although survival was significantly less in the octogenarian group for all pathologies (p = 0.04), notably, for pancreatic cancer patients, one and two year survival outcomes were similar (p = 0.25). Perioperative and Survival Outcomes METHODS: A retrospective chart review of 148 patients undergoing pancreatic resections by a single surgeon (A.Y.) between 2006 and 2010 was performed. Data was collected for demographics, clinical presentation, perioperative course, histology, and survival. We compared patients who were older and younger than 80 years with statistical significance of p < 0.05. Survival analysis was performed using the Kaplan-Meier method. Patient Characteristics and Histopathology Age (years) ≥80 years (n = 24) <80 years (n = 124) P-Value ≥80 years (n = 24) <80 years (n = 124) P-value Pancreaticoduodenectomy (PD) 16 (67%) 83 (67%) 0.98 Distal Pancreatectomy (DP) 8 (33%) 41 (33%) Operative time 228 (160–290) 245 (125–560) 0.09 Estimated blood loss (ml) 273 (20–1400) 312 (20–3000) 0.60 Perioperative blood transfusion 8 (33%) 34 (27%) 0.56 Clavien grade I and/or II complications 11 (46%) 54 (43%) 0.84 83 (80–90 y) 67 (26–79) 26 (21%) 0.99 16 (67%) 47 (38%) 0.01 Clavien grade III and/or IV complications 5 (21%) Female ASA class ≥3 10 (59%) 47 (46%) 0.35 Perioperative mortality 2 (8%) 6 (5%) 0.49 Cardiovascular comorbidity 17 (71% 78 (63%) 0.46 24 (19%) 0.53 5 (21%) 35 (28%) 0.46 Postoperative pancreatic fistula: ISGPF (§) 6 (25%) Diabetes Mellitus Preoperative ERCP 5 (21%) 18 (14%) 0.43 Clinically significant pancreatic fistula ISGPF (§) grade B or C 5 (21%) 14 (18%) 0.43 9 (3–108) 0.03 21 (87%) 77 (62%) 0.02 Median length of hospital stay (days) 14 (4–41) Pancreatic carcinoma Neuroendocrine tumor 2 (8.3%) 11 (8.8% Reoperation 1 (4%) 15 (12%) 0.25 1 (4%) 14 (11%) 4 (17%) 25 (20%) 0.69 Other benign lesions 0 15 (12%) 30-days postdischarge readmission Chronic pancreatitis 0 5 (4%) Delayed Gastric Emptying (DGE) 6 (25%) 17 (14%) 0.16 Peripancreatic invasion 11 (52%) 44 (57%) 0.80 Positive surgical margins 4 (19%) 17 (22%) 0.75 1 year survival 45.7% 69.1% 0.04 Lymphovascular invasion 9 (43%) 42 (54%%) 0.46 2 year survival 32.6% 51.8% Positive lymph node spread 11 (52%) 47 (61%) 0.62 Histopathology IPMN Survival Median survival (months) RESULTS: Twenty-four patients ≥80 y old underwent pancreatectomies (n = 24, range 80–90 y) compared to 124 patients <80 y (n = 124, range 26–79 y). The two groups were similar in the distribution of their clinical characteristics, including ASA class. Pancreaticoduodenectomy (PD) was the most common procedure performed in the two groups (≥80 y n = 16, 67%; <80 y n = 83, 67%; p = 0.98). There were no significant differences between the older and younger patients in respect to the operative time (228 vs. 245 min, p = 0.09), perioperative blood transfusions (33% 8.7 33.2 Cancer only 1 year survival 40.7% 56.2% Cancer only 2 year survival 27.1% 33.5% § 0.25 ISGPF: International study group definition of postoperative pancreatic fistula. CONCLUSION: Major pancreatic resections can safely be performed in octogenarians in a community-based hospital with similar perioperative outcomes to younger patients. Comparable survival outcomes can be achieved in octogenarians when surgery is limited to malignant indications. 188 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1782 Tu1783 Neoadjuvant Chemoradiation Therapy Using S-1 for Patients with Pancreatic Cancer Meta-Analysis of Trials Comparing Central and Distal Pancreatectomies: Short and Long-Term Outcomes Sohei Satoi*, Hideyoshi Toyokawa, Hiroaki Yanagimoto, Tomohisa Yamamoto, Satoshi Hirooka, so Yamaki, Taku Michiura, Kentaro Inoue, Yoichi Matsui, a-Hon Kwon Department of Surgery, Kansai Medical University, Hirakata, Japan Mohammad Sarhan*1, Alan S. Rosman4, John D. Allendorf2, Leaque Ahmed1, Zahra Shafaee3 1. Columbia University at Harlem Hospital Center, New York, NY; 2. Columbia University College of Physicians and Surgeons, New York, NY; 3. Lawrence Hospital, Bronxville, NY; 4. Mount Sinai School of Medicine and Bronx VAMC, New York, NY INTRODUCTION: The results of surgical therapy alone for pancreatic cancer are disappointing. We have reported that surgical resection following neo-adjuvant chemoradiation therapy (NACRT) can be associated with the higher rate of R0, and with the lower rate of metastastic lymph nodes, resulting in improved prognosis of patients with T3/4 pancreatic cancer (Pancreas 2009 and 2011 in press). However, there is no consensus on the regimen of NACRT for pancreatic cancer. The aim of this study is to explore the short-term results of the new regimen of NACRT using S-1 followed by surgical resection. PATIENTS: Among 103 consecutive patients with potentially resectable pancreatic cancer between January 2006 and September 2010, 43 patients were classified as adjuvant group between Jan. 2006 and Sep 2008, and 34 patients who underwent NACRT between Oct 2008 and Sep 2010 were classified as NACRT group. The regimen of NACRT was consisted of S-1 (orally twice daily, 5days in a week, 80mg/m2/day) and concurrent radiotherapy (total of 50.4 Gy). The primary endpoint was the frequency of pathological curative resection (R0). All patients who underwent pancreatectomy were planned to receive adjuvant chemotherapy. RESULTS: The overall response rate and disease control rate in NACRT group were 18% and 88.0%, respectively. There was no difference in resection rate between NACRT and adjuvant groups (30/34 vs 36/43). Other organ resection including vascular resection was done for 17 of 36 patients in adjuvant group and for 19 of 30 patients in NACRT group. The primary end point analysis of this study demonstrated that in accordance with our study hypothesis, NACRT followed by surgical resection improved R0 rate in NACRT group compared with adjuvant group (28/30 vs 21/36, p = 0.005). The number of metastatic lymph nodes in NACRT group was significantly lower than in adjuvant group (p = 0.0363). On the comparisons of extension of metastatic lymph nodes, the frequency of N0/1 in NACRT group was also higher than in adjuvant group (p = 0.041). There were no significant differences in mortality and morbidity except intractable ascites between two groups. The rate of intractable ascites in NACRT group was significantly higher than in adjuvant group (8/22 vs 2/34, p = 0.035). The frequency of local relapse in NACRT group was significantly lower than in adjuvant group at 1year after surgical resection (0% vs 26%, p = 0.021). INTRODUCTION: Recent literature suggests superior pancreatic function after Central Pancreatectomy (CP) compared to Distal Pancreatectomy (DP) in patients with benign or low grade malignant neoplasms of the neck or body of pancreas. Available data is limited to single institutional studies with small sample size. In order to overcome these shortcomings, we performed the first systematic meta-analysis in this subject. METHODS: A systematic English literature review was performed using Pubmed database. All related articles comparing central and distal pancreatectomy from 1990 to 2010 were reviewed. The end-point was to compare peri-operative complication rate and long-term outcomes (new onset or worsening diabetes, tumor recurrence) after each procedure. Meta-analysis was performed based on random-effect model. RESULTS: Eight eligible studies were found, including 615 patients (CP: 343, DP: 272). Both groups were similar (age, sex, baseline pancreatitis, and incidence of IPMN and malignancy on final pathology). Baseline DM was higher in DP group (Odds Ratio: 0.35). Short term outcomes: CP was associated with longer Operative time (257 vs. 232min, P: 0.34) and less blood loss (378 vs. 651ml, P: 0.0006). Hospital stay was longer (12.75 vs. 9.63 days, P: 0.0038) and pancreatic fistula rate was higher in CP compared with DP (OR: 1.6, P: 0.04). Incidence of types B and C pancreatic fistulas were similar in two groups (OR: 1.3, P 0.44). The rate of new onset diabetes (OR: 0.11, P: 0.00) or worsening diabetes (OR: 0.03, P: 0.00) was significantly lower in the CP. There was no difference in tumor recurrence rate in both groups. CONCLUSION: NACRT using S-1 can improve the rate of pathologically curative resection and the number and extension of metastatic lymph nodes in patients with T3/4 pancreatic cancer, resulting in better local control. 189 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT of 25 months (CI 95% 19.5–30.8) compared to 30.5 months (CI 95% 25.7–35.2) for those without complications (P = 0.144). Adjuvant treatment was administered in 70.5% of patients with abdominal complications and in the 82% of those with an uneventful postoperative course (P = 0.010). On multivariable analysis factors independently associated with survival were: the presence of abdominal complications (HR 1.40; P = 0.009), adjuvant treatment (HR 0.628; P = 0.001), N1 status (HR 1.93; P < 0.0001), R1 resection (HR 1.87; P < 0.0001), G3 vs G1 (HR 4.33; P < 0.0001) and G2 vs G1 (HR 2.99; P = 0.005). CONCLUSIONS: Postoperative abdominal complications are independent predictors of survival after resection for PDAC. The mechanism behind this association may be related to an immunologic impairment due to surgical complications and to a lower rate of adjuvant therapy administration in this subgroup. CONCLUSION: Our analysis suggests that CP is associated with lower rate of pancreaticogenic diabetes. This will justify for slight increase in operative time, pancreatic fistula rate, and length of hospital stay. Preservation of uninvolved pancreas leads to conservation of the pancreatic function and make CP a good alternative to more radical distal pancreatectomy for benign and low-grade malignant neoplasms. Tu1784 The Presence of Abdominal Complications Is an Independent Predictor of Poor Survival After Resection for Pancreatic Cancer Stefano Crippa*1,2, Stefano Partelli1,2, Claudio Bassis1, Domenico Tamburrino1, Giuliano Barugola1,2, Riccardo F. Rossato1, Silvia Laiti1, Anna Neri1, Massimo Falconi1,2 1. Department of Surgery, Università di Verona, Verona, Italy; 2. Department of Surgery, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy BACKGROUND: Postoperative complications significantly affect disease-specific survival (DSS) after surgery for different tumors. The aim of the study is to assess the impact on survival of postoperative course after surgery for pancreatic ductal adenocarcinoma (PDAC). METHODS: Retrospective analysis of 431 patients who underwent pancreatic resections with curative intent (R0-R1) for PDAC between 2000 and 2009. RESULTS: Surgical procedures included pancreaticoduodenectomy (n = 347, 80.5%), distal pancreatectomy (n = 68, 16%) and total pancreatectomy (n = 16, 3.5%). Overall morbidity was 37%. In-hospital or 30-day mortality rate was 1.6%. Overall, 132 patients (31%) had abdominal complications, including 72 (17%) patients with pancreatic fistula and 46 (10.5%) with abdominal collections/abscesses. The median length of stay (LOS) was 10 days (IQR 8;15). Patients with abdominal complications had a significantly higher LOS (15 vs 9.5 days, P < 0.0001). The median DSS for the entire cohort was 28.4 months (CI 95% 24.5–32.3). Patients with abdominal complications had a median DSS Tu1785 Splenic Vein Thrombosis Is Associated with Specific Increased Complications and Reduced Survival in Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma Nishi Dedania, Nidhi Agrawal, Matthew Klinge, Salil Gabale, Jordan M. Winter, Leonidas Koniaris, Ernest L. Rosato, Patricia K. Sauter, Eugene P. Kennedy, Charles J. Yeo, Harish Lavu* Department of Surgery, Thomas Jefferson University, Philadelphia, PA INTRODUCTION: Distal pancreatectomy and splenectomy (DPS) is the procedure of choice for the surgical treatment of ductal adenocarcinoma (PDA) localized to the body and tail of the pancreas. Due to a lack of early symptoms, patients with distal pancreatic lesions can present at an advanced disease stage with large tumors. Splenic vein thrombosis (SVT) can occur in these patients secondary to direct tumor invasion or peri-tumoral inflammation. SVT is most commonly associated with chronic pancreatitis and little is known regarding its implications for patients with PDA. This study documents our institution’s experience with SVT in patients undergoing DPS for PDA and examines it’s effect on postoperative outcomes. METHODS: In this retrospective cohort study, we queried our pancreatic surgery database to identify all patients who underwent DPS from October 2005 to June 2011. These cases were evaluated for evidence of preoperative SVT through review of clinical records and imaging studies (CT, MRI, endoscopic ultrasound). Perioperative outcomes for patients undergoing DPS for PDA with and without SVT were compared. RESULTS: A total of 284 DPS were performed during the study period. Of these, 70 were for patients with PDA and were distributed into 27 (39%) who had preoperative SVT and 43 (61%) who did not. Both groups had similar demographic characteristics (Table). The median estimated blood loss was significantly higher in the SVT group versus the non- SVT group (675mL vs. 250mL, p < 0.001). Although the overall morbidity rate was similar between groups (48% vs 56%, p = NS respectively), the group with SVT had significantly higher rates of serious complications, such as 190 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA pancreatic fistula (33% vs 7%, p < 0.01) and delayed gastric emptying (15% vs 0%, p < 0.05). Tumor pathology was similar between groups with the SVT group having 67% T3 stage and 52% lymph node positive tumors while the non-SVT group had 56% T3 stage and 56% lymph node positive tumors. The median postoperative length of stay in the hospital (6 days) and readmission rates (30% vs 28%, p = NS) were similar between groups. Neither group had a perioperative mortality within 30 days of surgery. How- ever, one-year survival for patients with SVT was reduced compared to the non-SVT group (52% vs 76%, p = 0.08), a difference that approached significance. CONCLUSIONS: DPS for PDA can be performed safely in patients with preoperative SVT, but our findings reveal higher rates of intraoperative blood loss, pancreatectomyspecific complications, and suggests lower long term survival rates. Total n (%) SVT n (%) Without SVT n (%) 70 (100%) 27 (39%) 43 (61%) 67 63 68 <0.05 Male 42 (60%) 18 (67%) 24 (56%) NS BMI 26.1 24.5 26.9 NS Total p-Value Preoperative Demographics Age (years) DM 20 (29%) 7 (26%) 13 (30%) NS Tobacco Use* 26 (36%) 10 (37%) 16 (37%) NS 400 675 250 <0.0001 Any Complication 37 (53%) 13 (48%) 24 (56%) NS P. Fistula 12 (17%) 9 (33%) 3 (7%) <0.01 4 (6%) 4 (15%) 0 (0%) <0.05 EBL* (ml) Complications** DGE Chyle Leak 3 (4%) 1 (4%) 2 (5%) NS Intra-abdominal Abscess 4 (6%) 2 (7%) 2 (5%) NS Cardiac 6 (9%) 1 (4%) 5 (12%) NS UTI 5 (7%) 4 (15%) 1 (2%) NS Wound Infection 11 (16%) 4 (15%) 7 (16%) NS Sepsis 3 (4%) 2 (7%) 1 (2%) NS C. diff. colitis 2 (3%) 0 (0%) 2 (5%) NS DVT/PE 3 (4%) 2 (7%) 1 (2%) NS Pulmonary 6 (9%) 1 (4%) 5 (12%) NS 6 6 6 NS Length of Postoperative Hospital Stay (days) Pathology T3 Stage 42 (60%) 18 (67%) 24 (56%) NS Lymph Node Positive 38 (54%) 14 (52%) 24 (56%) NS Readmission 20 (29%) 8 (30%) 12 (28%) NS 1-year Overall Survival*** 36 (67%) 11 (52%) 25 (76%) NS DM, Diabetes Mellitus; EBL, Estimated Blood Loss; SVT, Splenic Vein Thrombosis; P. Fistula, Pancreatic Fistula; UTI, Urinary Tract Infection; DGE, Delayed Gastric Emptying; C. diff. colitis, Clostridium difficile colitis; DVT/PE, Deep Vein Thrombosis/Pulmonary Embolism. All values represent medians. *Tobacco Use data not available for 2 patients, EBL data not available for 4 patients. Total numbers for these variables exclude these patients **Number of patients with one or more complications. ***Only includes patients with date of surgery from 10/2005–06/2011. 191 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1786 Tu1787 Hepaticojejunostomy Leaks Following Pancreaticoduodenectomy: A Closer Look at a Rare Complication Parenteral Nutrition After Pancreatoduodenectomy: Who Needs It? Richard Burkhart*, Salil Gabale, Danielle Pineda, Patricia K. Sauter, Ernest L. Rosato, Leonidas Koniaris, Harish Lavu, Eugene P. Kennedy, Charles J. Yeo, Jordan M. Winter Department of Surgery and the Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA Ian K. Ferries*, Michael G. House, Thomas Z. Hayward, C. Max Schmidt, Nicholas J. Zyromski, Attila Nakeeb, Keith D. Lillemoe, Thomas J. Howard, Henry A. Pitt Surgery, Indiana University School of Medicine, Indianapolis, IN BACKGROUND: Hepaticojejunostomy (HJ) leaks after pancreaticoduodenectomy (PD) are poorly characterized in the literature, in contrast to more commonly encountered complications such as pancreaticojejunostomy (PJ) leaks. BACKGROUND: The impact of proactive nutritional repletion in reducing postoperative morbidity in patients undergoing pancreatoduodenectomy (PD) remains poorly understood. This study analyzes the clinical factors which are associated with the utilization of parenteral nutrition (PN) after PD. METHODS: We reviewed 650 consecutive PDs performed at our institution between 2005 and 2011 and categorized patients according to whether or not they experienced an HJ leak. Leaks were identified on either transhepatic-cholangiography or an abdominal drain contrast study. Preoperative variables were analyzed to identify risk factors for an HJ leak. The clinical presentation, morbidity, and treatment plan were examined in detail. METHODS: Between 2005 and 2009, 600 consecutive patients who underwent PD were included in the analysis. The most common indications for PD were adenocarcinoma (n = 249, 41%), pancreatitis (n = 88, 15%), and cystic neoplasms (n = 83, 14%). Two-way statistical comparisons were performed between patients who did (+PN) or did not (-PN) receive postoperative parenteral nutrition within 30 days of PD. RESULTS: An HJ leak was identified in 14 patients (2.2%), whereas 87 patients (13.5%) in the cohort developed a PJ leak. Univariate analysis demonstrated that low preoperative albumin was the only pre- or intraoperative factor found to be associated with increased risk of HJ leaks (3.5 vs. 4.0 mg/dL no leak; p = 0.001). Six of 14 patients (43%) had a preoperatively placed endostent in the common bile duct. Patients typically presented on the 6th postoperative day (range: 1 to 14 days), and in all cases a diagnosis was made prior to hospital discharge. Presenting signs and symptoms included leukocytosis (86%, median 15.3, range 6.6 to 26.1), increased abdominal pain (64%), fever (43%), failure to tolerate a diet (36%), abdominal distension (21%), and bilious drainage from the abdominal drain (21%). Thirteen of 14 patients were managed with a percutaneous intervention. Seven patients were managed with a percutaneous transhepatic biliary drain and six patients required manipulation of an intraoperatively placed surgical drain. No patients required surgical intervention. In addition to the HJ leak, patients also frequently developed a wound infection (71%), PJ leak (43%), and sepsis (29%). The median length of stay was 18 days (range: 16 to 55), as compared to 8 days in patients without an HJ leak (p = 0.000). Readmission rates were 26% in the HJ leak group and 15% in the total cohort (p = NS). There was a single 90-day mortality in the HJ group (7%) as compared to 17 (2.7%) in the entire cohort (p = 0.356). RESULTS: Pylorus-preserving PD was performed in 491 patients (82%), and a classic PD in 109 (18%). Operative mortality occurred in 18 (3%) patients. One hundred twenty-two (20%) patients were prescribed PN at a median of 8 days (range, 1–19) after PD. The median duration of PN usage was 9 days (range, 1–246). There were no differences in age, gender, renal function, operative time, or blood loss between the +PN and -PN groups. Patients requiring PN had lower preoperative (2.80 v. 2.93 g/dl, p = 0.03) and hospital discharge (2.05 v. 2.32 g/dl, p < 0.001) albumin levels. Higher preoperative total bilirubin levels were associated with postoperative PN usage (2.95, +PN v. 2.14 mg/ dl, -PN, p = 0.02). Operative outcomes with regards to postoperative PN utilization are listed in the table. Forty-seven percent of the patients who developed delayed gastric emptying (DGE) required PN. PD was complicated by a pancreatic fistula (all grades) in 13% of patients, 35% of whom required PN. CONCLUSIONS: HJ leaks are rare complications after PD and can result in substantial morbidity with increased length of hospital stay. However, early recognition with effective drainage typically results in a full recovery, without the need for surgical intervention when skilled interventional services are available. Low volume leaks are managed with effective abdominal drainage, while larger leaks may require placement of a transhepatic biliary drainage catheter. CONCLUSIONS: Postoperative parenteral nutrition is required frequently in patients undergoing pancreatoduodenectomy. Strong associations between poor nutritional parameters, postoperative morbidity, and PN utilization emphasize the crucial role of adequate nutrition in achieving good surgical outcomes. Establishing enteral nutritional access at the time of PD should be considered in patients at risk for postoperative complications. Postop PN 192 All Major RePancreatic Complications Complications Operation Fistula DGE No (n = 478) 198 (41%) 25 (26%) 20 (4%) 51 (10%) 44 (9%) Yes (n = 122) 79 (65%) 68 (56%) 18 (14%) 27 (21%) 39 (32%) p–value <0.001 <0.001 <0.01 0.001 <0.001 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1788 CONCLUSION: 13C-MTG-T as well as residual pancreatic exocrine cells represented by histological degree of pancreatic exocrine cells at cut margin, reliably show long-term fat absorptive function after PPPD. Glucose metabolism disturbance is also related to post operative fat absorption. Fat Absorptive Function After Pylorus Preserving Pancreatoduodenectomy Assessed by 13C-Labeled Mixed Triglyceride Breath Test Masahiko Morifuji*1, Yoshiaki Murakami2, Kenichiro Uemura2, Takeshi Sudo2, Yasushi Hashimoto2, Taijiro Sueda2, Akio Sakamoto1 1. Sanmu Medical Center, Chiba, Japan; 2. Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan Tu1789 Autoimmune Pancreatitis (AIP): Short and LongTerm Outcomes in Patients Treated Initially by Pancreaticoduodenectomy, a Comparative Study BACKGROUND: Long-term survival after pancreatic surgery has increased gradually due to recent improvements in surgical techniques and experiences; therefore, postoperative evaluation of fat absorption and glucose metabolism disturbances is important. We have been reported that the non-invasive 13C-mixed triglyceride breath test (13C-MTG-T), labelled long chain triglyceride mixture can reliably diagnose pancreatic exocrine insufficiency (Surgery, 2009). In this study, we investigate fat absorptive function in patients status post pylorus preserving pancreatoduodenectomy (PPPD) with pancreaticogastrostomy (PG) reconstruction more than 12 months after the procedure. METHODS: 13C-MTG-T (200 mg 13C-MTG, 20 g fat, and breath samples over 7 hours) was performed for 52 patients undergoing PPPD with PG reconstruction and 12 healthy volunteers, forming our control group. Pancreatic exocrine insufficiency was defined as percent of cumulative 7-hour 13CO2 exhalation (% dose 13C cum 7 h) <5%, assessed by 13C-MTG-T. Sections from the surgical pancreatic cut margin were used for histological assessment. The degree of pancreatic exocrine cells was calculated as ratio of the pancreatic exocrine cells area to total area measured in the entire section. We analyze the relationship between 13C-MTG-T as a measure of pancreatic exocrine insufficiency postoperatively and the degree of pancreatic exocrine cells by histology as well as the development of diabetes mellitus (DM) as a measure of pancreatic endocrine insufficiency. RESULTS: % dose 13C cum 7 h was significantly lower in patients with PPPD (6.8 ± 4.8%) than in healthy controls (15.5 ± 6.0%; P < 0.01). Pancreatic exocrine insufficiency assessed by 13C-MTG-T (% dose 13C cum 7 h < 5%) was observed in 20 patients (38%) in PPPD group but none in the control group. Of the 52 patients undergoing PPPD, the histological degree of pancreatic exocrine cells was significantly higher in patients with% dose 13C cum 7 h ≥ 5% (81.7 ± 5.4%) than those with <5% (67.8 ± 8.5%; P = 0.01). Patients with pancreatic insufficiency (% dose 13C cum 7 h <5%) significantly decreased body mass index at 12 months after PPPD comparing to those with% dose 13C cum 7h ≥ 5% (–10.9 ± 8.4% vs +0.9 ± 9%; P < 010). 6 patients had been diagnosed with DM prior to undergoing the procedure, and, of the remaining 46 patients, 5 (11%) became diabetic after the procedure. Patients with DM demonstrated significantly lower% dose 13C cum 7 h comparing to patients without DM (5.9 ± 4.3% vs. 10.5 ± 5.2%; P < 0.01). Greg Roberts*1, Lee Mchenry3, Romil Saxena2, Seth A. Moore4, Thomas J. Howard1 1. Surgery, Indiana University Medical Center, Indianapolis, IN; 2. Pathology, Indiana University Medical Center, Indianapolis, IN; 3. Gastroenterology, Indiana University Medical Center, Indianapolis, IN; 4. Gastroenterology, Ohio State University School of Medicine, Columbus, OH INTRODUCTION: Autoimmune pancreatitis (AIP) is a rare, benign inflammatory disease that clinically and radiographically mimics pancreatic adenocarcinoma (PA). When diagnosed, AIP responds well to steroid therapy, but can recur in either the pancreas or biliary system. The inability to accurately distinguish between these two diseases leads many AIP patients to undergo initial pancreaticoduodenectomy. While a 25% disease recurrence rate following steroid therapy in AIP is well established, disease recurrence rates following initial pancreaticoduodenectomy (PD) remains unknown. METHODS: With IRB authorization, 10 patients over a 10 yr period (1999–2009) with pathologically confirmed AIP treated with PD were identified. The study group was matched against two comparison groups of patients with idiopathic chronic pancreatitis (CP) or PA. Clinical presentation, operative variables, and postoperative clinical courses were analyzed. Long-term follow-up, along with quality of life (QOL) data using a validated instrument {Gastrointestinal Symptom Rating Scale (GSRS)} given by structured telephone survey were analyzed. Appropriate statistical tests were applied for nominal and ordinal variables. RESULTS: The AIP group was 50% male with a mean age of 62 (40–77) yrs. Presenting symptoms were similar between the AIP and PA groups. All groups (AIP, CP, PA) had similar gland morphology on radiographic imaging. Fifty percent of the AIP group had atypia on preoperative FNA biopsy. No AIP pts were diagnosed preoperatively and none had a history of autoimmune diseases. No statistically significant differences were found in operative times, blood loss, perioperative morbidity or mortality (90-day) rates between groups. Mean follow-up for the AIP group was 42 (4.5–83.2) months. Three AIP patients (30%) had disease recurrence: 2 with jaundice and 1 with pancreatitis, at a mean time of 7.7 (1.6–12.1) months postop. All 3 were treated with steroids and 2 had an additional recurrence once the steroids were stopped. Six patients (60%) had no recurrence during follow-up of whom 2 were treated with postoperative “prophylactic” steroids. One patient’s recurrence status remains unknown. Long-term rates of diabetes mellitus, pancreatic 193 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT exocrine deficiency, and GSRS scores [AIP (N = 5); 33 (20– 59): CP (N = 3); 28 (18–45)] were similar between AIP and CP groups. excluded patients who received narcotics within 7 days before their surgery in this group. All Alvimopan patients received their first dose immediately preoperatively. CONCLUSION:Preoperative diagnosis of AIP remains uncommon in our experience in patients with a pancreatic head mass and no history of autoimmune disease. PD in AIP is as safe an operation as it is for CP or PA. AIP recurrence following PD is approximately 30%, with similar long-term postoperative QOL as patients with CP. RESULTS: When comparing the two groups, significance was noted for the mean length of hospital stay (P = 0.0483), mean time to first clear liquid diet (P = 0.00212), and mean time to first soft/solid food diet (P = 0.0406). There was no significant difference noted between age, BMI, Co-morbidity, and mean time to first bowel movement (see Table 1). CONCLUSION: With a comparison between the Alvimopan and non-Alvimopan group, we recognize a significant decrease in the length of hospital stay with a possible cost benefit, due to a significantly earlier intake of diet in the Alvimopan’s group. We believe with a radical procedure, such as pancreaticoduodenectomy, Alvimopan results in earlier recovery. Tu1790 Alvimopan Patients Show Significant Improvement in Recovery Post Pancreaticoduodenectomy Surgeries Elizabeth T. Liu*, Veeraiah Siripurapu, Tanyss L. Winston, Dhiresh R. Jeyarajah Surgery, Methodist Dallas Medical Center, Dallas, TX INTRODUCTION: In recent publications, Alvimopan has been shown to improve gastrointestinal recovery in patients who are undergoing bowel resections. We intend to see if patients undergoing Pancreaticoduodenectomies, a major surgical resection, and who were administered Alvimopan demonstrate a significant improvement in bowel movement recovery, first intake of clear liquid diet, and first intake of soft/solid food diet; compared to patients not administered with Alvimopan. Table 1: Patients Treated with Alvimopan and No Alvimopan Alvimopan No Alvimopan 15 30 Mean Age 67.6 65.3 P = 0.430 [NS] Mean BMI 25.4 24.9 P = 0.738 [NS] Mean Co Morbidity Number of Patients P-Value 2.53 2.53 P = 1.00 [NS] Mean Length of Hospital Stay (days) 12 14.6 P = 0.0483 [S] Meant Time to 1st Bowel Movement (days) 6 6.77 P = 0.148 [NS] Mean Time to 1st Clear Liquid Diet (days) 6 7.63 P = 0.00212 [S] 8.67 9.9 P = 0.0406 [S] Mean Time to 1st soft/solid food diet (days) *[S] Significant *[NS] Not Significant METHODS: From a retrospective review of 255 pancreaticoduodenectomy patients under a single surgeon between years 2005–2011, 23 patients in 2011 were given Alvimopan. After excluding patients who received narcotics within 7 days before their surgery and after excluding Whipplepylorus preserving, 15 Whipple-standard patients were left to analyze. For every one patient who was given Alvimopan, we found 2 patients who shared similar age, BMI, and pathology diagnosis and same Co-Morbidity and pT stage. We collected 30 patients ranging from years (2005–2011) who met these criteria, were not given Alvimopan, and who underwent a Whipple-standard procedure. We also Tu1791 Total Pancreatectomy with Islet Autotransplantation for Chronic Pancreatitis: Who Is Undergoing This Radical Procedure? Katherine A. Morgan*, Stefanie M. Owczarski, Jingwen Zhang, Patrick Mauldin, Amy R. Wilson, David B. Adams Medical University of South Carolina, Charleston, SC BACKGROUND: Total pancreatectomy with islet autotransplantation (TPIAT) is utilized for management of intractable pain due to chronic pancreatitis. Patient selection is a major factor in improving clinical outcomes. Identifying characteristics of the population undergoing TPIAT is an important step in defining the patient selection process. METHODS: Inpatient and outpatient data were reviewed retrospectively utilizing a prospectively collected database (TPIAT patients) and a hospital administrative database (TPIAT patients and controls). Data from 70 TPIAT patients were compared to a random sampling of 140 controls (with pancreatitis, total population 1,889). For all patients, data were captured from January 2008 forward, allowing for 14 months prior to the first TPIAT patient in March 2009. Patients were considered to have a particular co-morbidity if they had 1inpatient ICD-9 or ≥2 outpatient ICD-9s recorded in the data. ICD-9 codes captured pre and posttransplant were not distinguished for transplant patients. Non-MUSC data was not available for this analysis. Fisher’s exact test was used to determine differences between groups, significance determined at 0.05. RESULTS: TPIAT patients were more likely to be women (p < 0.001), younger (p < 0.005) and more frequently white (p < 0.003) than controls. A higher proportion of TPIAT patients had drug dependence (p < 0.0001) and depression (p < 0.0001), compared to controls. Conversely controls more likely had hypertension (p = 0.0050) and renal failure (p = 0.0031). CONCLUSIONS: Patients undergoing TPIAT differ from the overall population of patients with chronic pancreatitis. Depression and narcotic dependence are important considerations in the selection of candidates for the procedure and are disorders which need targeted postoperative therapy. 194 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1792 Patient and Tumor Characteristics Neoadjuvant Chemoradiotherapy for Locally Advanced Pancreas Cancer Does Not Lead to Radiologic Tumor Regression Vikas Dudeja*1, Sidney P. Walker2, Edward W. Greeno3, Eric H. Jensen1 1. Surgery, University of Minnesota, Minnespolis, MN; 2. Radiology, University of Minnesota, Minneapolis, MN; 3Medical Oncology, University of Minnesota, Minneapolis, MN Age in years Median (range) 64 (45–78) Gender:% (n) Male 69% (11) Female 31% (5) Explored before neoadjuvant chemoradiation:% (n) INTRODUCTION: Neo-adjuvant chemo-radiotherapy is proposed to improve resectability of locally-advanced/ borderline-resectable pancreas cancer (LAPC). The ability of neo-adjuvant therapy to provide tumor regression has not been reported. METHODS: We reviewed pre and post treatment CT scans of patients undergoing neo-adjuvant chemo-radiotherapy (cisplatin, interferon-alpha, 5-FU, radiation) in a phase II clinical trial for LAPC between 2005 and 2008. Response to therapy and rates of surgical resection were assessed. RESULTS: 16 patients (median age 64years, males 69%) received neo-adjuvant therapy for LAPC during 2005–08 (Table). Mean tumor size before neo-adjuvant treatment was 3.85 cm. Indications for neo-adjuvant treatment included one or more of the following: Involvement of superior mesenteric artery (SMA) (≤180 degree-3 patients, >180 degree-1 patient), celiac axis (CA) (≤180 degree-2 patients, >180 degree-3 patients), hepatic artery (HA) (>180 degree-6 patients), and/or superior mesenteric vein/portal vein (SMV/PV) (≤180 degree-6 patients, >180 degree-7 patients). Regression of major vascular involvement, i.e. un-encasement or regression of abutment of any involved vessels was not observed in any patients. Pre-treatment and post-treatment CA19-9 levels as well as tumor density (Hounsfield units) were not statistically different. 50% of patients with borderline resectable disease (tumor involving ≤180 degree circumference of the SMA; short-segment encasement/abutment of the common HA; or tumor-associated deformity, abutment or short-segment occlusion of SMV/PV that was amenable to vascular resection and reconstruction) and none of the patients with locally advanced un-resectable pancreatic cancer (vascular involvement more than that described for borderline resectable pancreatic cancer) eventually underwent surgical resection. Out of 5 patients who eventually underwent resection, 4 had macroscopic tumor and 1 had only microscopic tumor. CONCLUSION(S): Neo-adjuvant treatment does not provide tumor regression of LAPC with major vascular involvement. Patient selection for neo-adjuvant trial enrollment should remain focused on borderline disease which may have potential for surgical resection. Yes 31% (5) No 69% (11) Location of tumor:% (n) Head 69% (11) Body 18% (3) Tail 13% (2) Tumor size (mean ± SD) Pre-Treatment 3.85 ± 1.92 (NS) Post-Treatment 3.39 ± 1.81 Tumor extension at presentation:% (n) Borderline Resectable 62.5% (10) Locally Advanced 37.5% (5) CA 19–9 levels: Pre-Treatment 1436 ± 772 (NS) Post-Treatment 772 ± 220 Tumor density in Hounsfield units Pre-Treatment 60.4 ± 6.5 (NS) Post-Treatment 58.2 ± 6.9 Radiological Response:% (n) Regression 6.25% (1) Stable 56.25% (9) Progression 37.5% (5) Surgical resection of cancer after neo-adjuvant chemoradiation:% (n) Yes 31% (5) No 69% (11) Patients undergoing surgical resection classified by tumor extension at presentation:% (n) Borderline Resectable 50% (5) Locally Advanced 0% (0) Pathologic response in those undergoing resection (n = 5) Macroscopic tumor 4 Microscopic tumor only 1 NS: non significant. 195 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1793 Tu1794 National Database Research Beyond ICD-9 Codes: Evaluating Post-Pancreatectomy Diabetes Using Pharmacy Claims Early Enteral Nutrition Support Does Not Improve Postoperative Outcome in Patients After Whipple Resection Elan R. Witkowski*1, Elizaveta Ragulin-Coyne1, Zeling Chau1, Sing Chau NG1, Heena P. Santry1, Shimul A. Shah1, Jennifer F. Tseng1,2 1. Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Worcester, MA; 2. Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Mario Muller*, Paul Karanicolas, Natalie G. Coburn, Calvin H. Law Department of Surgery, Torornto, ON, Canada BACKGROUND: Large databases are central tools in surgical research, but the utility of certain diagnosis and procedure codes may be limited. Diabetes can occur after pancreatic cancer (PC) resection, but being insulin-dependent vs. non-insulin-dependent may impact quality of life more than the simple diabetes/no diabetes dichotomy would suggest. We demonstrate novel use of the newly available Medicare Part D pharmacy claims as an improved method of describing the presence and clinical impact of post-pancreatectomy diabetes mellitus. METHODS: Patients (pts) who underwent PC resection between 5/1/07 and 5/1/08 were identified in the SEERMedicare linked database, including Part D. Neuroendocrine pts, pts who died during their index hospitalization, and pts without continuous Part D were excluded. Claims for insulin and oral hypoglycemic medications were identified during three intervals: (1) four months prior to operation until the day prior to operation, (2) postoperative day 0–60, and (3) >60 days after operation. Based on preoperative diabetes status, probabilities of developing oral-med-dependent or insulin-dependent DM were calculated. These results were compared to results determined by ICD-9 diagnosis code. RESULTS: After screening 455 patients, a cohort of 123 patients met the inclusion criteria. Using ICD9 codes, 53 patients (43.1%) were identified as having preoperative diabetes, of whom 37 (30.1%) had preop claims for diabetic medications. All patients who received treatment had an ICD9 diabetes diagnosis coded. Among these patients, 29 (23.6%) took oral hypoglycemics and 19 (15.5%) took insulin preoperatively, with some overlap between groups. Postoperative diabetes (>60 days) was examined in 114 patients with survival sufficient for analysis. Using ICD9 codes, 75 patients (65.8%) were identified as diabetic. Part D claims indicated that 67 (58.8%) never required medication, 19 (16.7%) required only oral hypoglycemics, and 28 (24.6%) insulin. Only 13 patients (11.4%) developed a new insulin requirement. INTRODUCTION: Pancraeticoduodenectomy (Whipple procedure) is still associated with a significant postoperative complication rate. There is evidence that early enteral nutrition support may reduce postoperative septic complications. However, the true value of early enteral nutrition support is still controversial. The aim of the present study was to investigate the postoperative outcome of Whipple patients with and without early enteral nutrition support. PATIENTS AND METHODS: By using a prospective institutional database, we identified 202 patients from 2001 through 2009 undergoing Whipple procedure. 121 patients matched the inclusion criteria such as non-pylorus preserving Whipple and assessment by a clinical dietitian within 48 hours post-operatively. 67 of 121 (55.4%) patients received early enteral nutrition support, whereas 54 of 121 (44.6%) patients had no early nutrition support (control group). Postoperative course, morbidity and mortality were recorded and analyzed. RESULTS: No significant differences were found in the postoperative course of the patients. Median length of hospital stay was 15 in the early nutrition support group compared to 14 days in the control group. Postoperative leak rate was 13.8% with and 14.8% without early enteral nutrition support (P = 0.964). 11 (13.4%) patients in the early enteral support group developed postoperative organ failure compared to 9 (11%) in the control group. Overall mortality was 4.9%. There was no difference in mortality within the two groups (4% vs. 5%, P = 0.881). 33 patients (33.3%) in the control group needed total parenteral nutrition initiation which was significant higher compared to the 9 patients (13.4%) in the early nutrition support group (P < 0.05). CONCLUSION: Early enteral nutrition support is not associated with lower rates of postoperative morbidity and mortality and does not enhance postoperative recovery after Whipple resection. However, TPN initation is less likely in the early enteral nurtrion support group and might be therefore usefull to reduce risks associated with TPN. CONCLUSIONS: Administrative database research is limited by the quality and clinical relevance of available data. Our pilot study demonstrates a novel use of outpatient pharmacy claims to define medication-dependent diabetes after pancreatic cancer resection. The utilization of pharmacy claims may augment researchers’ ability to detect the presence of various diseases and ascertain both their clinical relevance and potential quality of life impact. 196 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Clinical: Small Bowel Tu1797 Tu1795 Early Complications Following Diverting Loop Ileostomy: An Audit of 182 Consecutive Patients with a Special Emphasis on Preoperative Risk Stratification Surgical Therapy for Gastrointestinal Stromal Tumors (GIST) of the Duodenum Jens Hoeppner*, Goran Marjanovic, Birte Kulemann, Frank Makowiec, Ulrich T. Hopt Department of Surgery, University of Freiburg, Freiburg, Germany BACKGROUND: GIST of the duodenum are rare and represent only a small subgroup of all GIST. Up to now, various surgical procedures have been described for their treatment. Both radical resections by pancreaticoduodenectomy and limited local resections are performed. This retrospective analysis was conducted for the evaluation of the results of radical and limited resections for duodenal GIST. METHODS: We retrospectively reviewed the medical records of all patients which were surgically treated for duodenal GIST at our medical institution between 2002 and 2011. RESULTS: Nine Patients (5M/4F) with am median age of 58 years were surgically treated. The median follow-up period was 45 month (range 6–111 month). Most often the initial symptom was gastrointestinal bleeding in 5 of 9 patients (56%). Tumors were found in all 4 parts of the duodenum, with most frequent location at the descending part of the duodenum in 4 of 9 patients (44%). In one patient the resection of the GIST was done by pancreaticoduodenectomy. Eight patients were treated by wedge or segmental resections of the duodenum. One of these limited resections was done minimally invasive; seven were done in open fashion. The median diameter of the tumors was 54 mm (14–110 mm). Seven resections showed microscopically negative transsection margins (R0), two showed positive margins (R1). During follow up no patient developed local recurrence. The one patient in who underwent pancreaticoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence. Another patient died of cardiac disease in complete remission. Seven out of the nine patients are alive disease-free. CONCLUSION: In patients with duodenal GIST, limited surgical resection with microscopically negative margins, but interestingly also with microscopically positive margins leads to very good local and systemic disease-free survival. Alexandre Descloux1,3, Annelies Schnider2, Markus Weber2,1, Matthias Turina*1,2 1. University of Zürich, Zürich, Switzerland; 2. Surgery, Triemlispital, Zurich, Switzerland; 3. Surgery, Kantonsspital Baden, Baden, Switzerland INTRODUCTION: Diverting loop ileostomy is commonly used for a variety of indications in general surgery and is generally considered a safe technique. However, some patients develop ostomy-related complications necessitating revision surgery or early ostomy closure. The aim of this study was to better define the incidence and nature of early complications in relation to specific risk factors, and to recognize patients at risk in order to avoid preventable complications. METHODS: Single-center case-control study including all patients undergoing a protective loop ileostomy between 2001 and 2009. Complications were necrosis and retraction, peristomal infection, parastomal herniation, bowel obstruction, and individual problems related to postoperative ostomy care. Risk factors analyzed included age, gender, urgency of surgery, underlying pathology, body mass index, steroid use, diabetes mellitus, alcohol abuse, previous abdominal operations, dementia, renal insufficiency, inflammatory bowel disease (IBD), and chronic obstructive pulmonary disease (COPD). Univariate and subsequent multivariate analysis were performed using SPSS 18.0. RESULTS: 182 patients (43% female) were included, the majority of which (68%) were admitted for elective colorectal resections. Early complications were recorded in 16% of all cases (with 0% mortality), and occurred most frequently following emergency resections for obstructive colorectal cancer (44.4% complications) and perforated diverticulitis (18.7% complications). Median delay until ostomy closure was 74 (6–343) days in patients without and 51 (4–182) days in patients with complications. Problems with inadequate ostomy care (7.7%) were the main reason for early stoma closure. Parastomal herniation and peristomal infection occurred in 2.7% and 2.2%, respectively. Steroid use, diabetes mellitus, IBD, COPD and asthma were each associated with an increased risk for early ostomy complications and premature ostomy closure. CONCLUSIONS: The incidence of early complications after ileostomy formation is high, indicating the need for well-defined indications for this procedure. Patients admitted for emergency surgery due to colonic obstruction are at greatest risk for ostomy-related morbidity, especially those suffering from comorbidities such as diabetes. The most frequent complication is an overwhelmed patient unable to deal safely and appropriately with his ostomy. Home support with trained ostomy nurses should be encouraged in all ostomy patients to avoid premature ostomy closure. 197 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Clinical: Stomach Table 1: Subsequent Surgical Procedures and Complications After GES Insertion Nutrition Tu1798 Surgical Outcomes After Gastric Electric Stimulator Placement for Refractory Gastroparesis Deborah Keller*1, Daniel Boucek1, Abhinav Sankineni2, John E. Meilahn1, Henry P. Parkman2, Sean Harbison1 1. Surgery, Temple University Hospital, Philadelphia, PA; 2. Medicine, Temple University Hospital, Philadelphia, PA Central Access for TPN 21 PEG/ Gastrostomy Tube 19 Jejunostomy Tube 33 G-J Tube 4 SUBTOTAL 72 GES Explanted BACKGROUND: Gastric electric stimulation (GES) is used for refractory symptoms of gastroparesis. Although improvement in symptoms has been reported with GES, few studies have described the need for additional surgery after placement of gastric stimulators. The aim of this study was to evaluate the surgical outcomes of a large series of GES at a single institution. Secondary goals were to determine the need for additional surgery after insertion of GES. METHODS: A retrospective review of a prospective database was performed for patients undergoing GES placement for refractory gastroparesis at our single institution from 10/2000 to 10/2011. Demographic and clinical information was gathered from medical records. RESULTS: 266 patients had a GES implanted at our institution over the 11-year period. Medical records were available for 233 patients, with long-term outcome data for 74. All had delayed gastric emptying and refractory symptoms despite aggressive medical therapy. The mean age was 38 years (range 18–67), and 80% were female. The mean BMI was 24.8 ± 6.7 (SD), and pre-operative albumin level was 4.1 ± 0.7 (SD). The most frequent etiologies for gastroparesis were idiopathic (51.1%) and diabetic (42.9%). Common co-morbidities included depression/ anxiety (14.9%), chronic renal insufficiency (8.1%), and treated hypothyroidism (6.8%). GES were placed by 1 of 2 surgeons using a standardized surgical procedure and post-operative protocol. Mortality during the follow-up period was 2.1%, all unrelated to the procedure. The overall clinical outcomes for GES were favorable, with 70% of patients reporting improved symptoms. However, in a subset of patients, readmissions were common, with 90/233 patients re-presenting mainly for gastroparetic symptoms. The mean number of re-admissions for these 90 patients was 4.4 (range, 1–41). Additional surgery for nutrition was common- 45/233 patients required at least 1 procedure for nutritional access post-GES insertion. Reoperations were performed for device issues and surgical complications, including revision of GES stimulator in subcutaneous pocket (21), incisional hernia (4), battery failure (3), lead erosion (2), and small bowel obstruction (2). 12% of patients (29/233) had the GES explanted, mainly for continued gastroparetic symptoms (11), mechanical issues (9), and infection (4). No Relief of Symptoms 11 Mechanical Device Issues 9 Persistent Infection 4 Stimulator eroded through skin 3 Symptoms improved 2 SUBTOTAL 29 Revisions/ Surgical Complications Revision of stimulator in subcutaneous pocket 21 Incisional hernia repair 4 Battery failure 3 Laparotomy for Small Bowel Obstruction 2 Lead erosion 2 Colectomy for Colitis 1 Takedown enterocutaneous fistula 1 SUBTOTAL 34 Non-Operative Surgical Complications Wound Infection 5 Small Bowel Obstruction 4 Hematoma 2 Bleeding from Gastrostomy tube site 1 Suture Granuloma 1 Enterocutaneous Fistula 1 SUBTOTAL 14 CONCLUSIONS: Although there is symptomatic improvement in most patients undergoing GES for refractory gastroparesis, a significant number of patients (34%) required additional surgery after GES placement. This need for additional surgery was most frequently for surgical nutrition (53%) for ongoing gastroparesis symptoms. Removal was performed in 12% of patients and revision of the GES pocket in 9% of patients. Despite these additional surgeries, the majority of patients report good overall outcomes for GES. 198 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1799 Tu1800 Current Problems in General and GI Surgery for Super-Old Patients with Age over 85 Years Effect of Bariatric Surgery on Comorbidities vs Medical Treatment in a Cohort of Morbidly Obese Patients: A Prospective Study Tatsuya Ueno*1, Michinaga Takahashi1, Shinji Goto1, Shun Sato1, Masanori Akada1, Kyohei Ariake1, Minoru Kobayashi1, Chikashi Shibata2, Hiroo Naito1 1. Surgery, South Miyagi Medical Center, Miyagi-Pref, Japan; 2. Surgery, Tohoku University, Sendai, Japan Paolo Gentileschi*, Marco D’Eletto, Stefano D’ Ugo, Mara Capperucci, Domenico Benavoli, Pierpaolo Sileri, Achille Gaspari General Surgery, University of Rome Tor Vergata, Roma, Italy INTRODUCTION: As it is being common in Japan to perform surgery in patients over 85 years old, postoperative complications such as pneumonia, heart failure, dementia, and bedridden status become big problems for patients and their family. Although some prognostic scoring systems such as POSSUM score are available, these scoring systems do not precisely predict the postoperative complications. Aim of the present study was to evaluate mortality and morbidity after the surgery and consider surgical indication in super-old patients. METHODS: We retrospectively reviewed 222 patients who underwent surgery from 2003 to 2010 at the age over 85 years and analyzed postoperative mortality and morbidity rate. In our hospital, indications of surgery in super-old patients were, 1) informed consent from patient and his/ her family and 2) good pulmonary and cardiac function to tolerate operation. We evaluated POSSUM score for information, and poor POSSUM score was not considered as an absolute contraindication. RESULTS: Among 222 operations, emergent operations were 114, while elective operations were 108. Diseases for operation were gastric cancer in 24, colorectal cancer in 49, cholecystolithiasis in 9, inguinal hernia in 19 patients. Emergent operations included perforation of GI tract for 26, acute cholecystitis for 22, intestinal obstruction for 21, inguinal hernia for 20, acute appendicitis for 10, and colorectal cancer for 7 patients. Mortality and morbidity rates in elective surgery were 1.9% (2 patients) and 31.5% (34 patients), respectively, while those in emergent operation increased to 14.9% (17 patients) and 58.4% (66 patients) (p < 0.01 vs. elective operation), respectively. Pulmonary complications were observed in 5 (1.9%) and 24 (21.1%) patients in elective and emergent surgeries, respectively. In 19 patients with postoperative deaths, 15 (79.4%) suffered from pulmonary diseases including aspiration pneumonia. Mortality rate in patients with pulmonary complications increased to 51.7% in elective and emergent operations. In patients undergoing operations for upper GI tract, pulmonary complications were observed in 8.3% in elective operations and 42.9% (3/7) in emergent operations, and all 3 patients died of pulmonary complications. BACKGROUND: Aim of this study was to evaluate the role of bariatric surgery in a population of morbidly obese patients versus a medical treated cohort. We prospectively compared patients submitted to surgery with a cohort of surgically fit patients waiting for surgery and not operated for extra surgical reasons. MATERIALS AND METHODS: We divided the patients into two groups: not operated (group A) and operated (group B). The recruitment of the patients started in January 2003 and the study ended in November 2011. Median follow-up was 29.2 months (range 13.8–105.3 months) for group A and 38.2 months (range 11.8–106.7 months) for group B. Two hundred eighty-nine patients (M = 80; F = 209) entered the study, 81 in group A (M = 16; F = 65) and 208 in group B (M = 64; F = 144). In group B, we performed laparoscopic gastric bypass in 100 patients, laparoscopic sleeve gastrectomy in 71 patients and laparoscopic gastric banding in 37. Mortality, variation of BMI and comorbidities (diabetes, hypertension, obstructive sleep apnea syndrome and need for pharmacologic treatment) have been evaluated in both groups. RESULTS: Initial BMI was 41.5 ± 5.9 Kg/m2 for group A and 42.2 ± 7.0 Kg/m2 at last follow up visit (p = 0.56). The difference of comorbidities in group A are shown in Table 1. Four patients in group A (4.9%) died during the follow up for heart attack. Initial BMI for group B was 46.6 ± 7.0 Kg/m2 and 30.9 ± 6.4 Kg/m2 at the end of the follow up period (p < 0.001). Variation of comorbidities during follow-up are shown in Table 1. There was one death in group B. The difference between the two groups at last follow up visit are shown in Table 2. CONCLUSIONS: In super-old patients, mortality and morbidity rates in emergent operations were high compared to those in elective operations. These results indicate importance of preoperative estimation in super-old patients, and indication of the operation should be carefully considered in patients with poor pulmonary function. 199 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1801 Table 1 Medical Treatment Group First Visit (n° pts) Last Follow-Up Visit p Diabetes 18 23 0.37 Hypertension 22 25 0.61 Obstructive Sleep Apnea Syndrome 10 14 0.39 Pharmacologic treatment 26 32 0.33 Pre-Operative (n° pts) Last Follow-Up After Surgery (n° pts) Surgery group Primary Squamous Cell Carcinoma of the Stomach: Case Report and Literature Review Mohummed R. Khani*, Antonio I. Picon Surgery, Staten Island University Hospital, Staten Island, NY BACKGROUND: Primary gastric squamous cell carcinoma (PGSCC) is extremely rare, it accounts for 0.2% of all gastric carcinomas with fewer than one hundred cases have been reported in the literature. CASE PRESENTATION: We report a case of 70-year-old male who presented with melena and hypotension the same day he was discharged home after undergoing aortic valve replacement. He referred a 15 lb weight loss over few months. His past medical history is significant for smoking (60 pack-year) and aortic stenosis. His physical exam was unremarkable. Esophago-gastro-duodenoscopy (EGD) revealed a five-centimeter ulcerated mass in the fundus of the stomach, 2 cm from gastroesophageal junction without active bleeding. Imaging of the abdomen revealed a 7 × 4 cm mass in the fundus of the stomach with no evidence of locoregional extension or distant metastasis. Biopsy was not attempted. He was taken to the operating room and intraoperatively the mass was locally invading the left hemidiaphragm. He underwent partial left diaphragmatic resection, total gastrectomy with Roux-en-Y esophago-jejunostomy and feeding tube jejunostomy insertion. Histological studies revealed infiltrating moderately differentiated gastric squamous cell carcinoma with free margins resection, one perigastric lymph node was positive for metastatic disease, for a T4, N1, and M0 disease. Immunohistochemical studies result was positive for cytokeratin 5/6, P63 and negative for CD117, CK20, and P16. He is currently undergoing chemoradiation therapy. p Diabetes 64 9 <0.001 Hypertension 96 25 <0.001 Obstructive Sleep Apnea 21 2 <0.001 Pharmacologic treatment 106 29 <0.001 Table 2 BMI Group A (81 pts) Group B (208 pts) p 42.2 ± 7.0 30.9 ± 6.4 <0.001 Diabetes 23 9 <0.001 Hypertension 25 25 <0.001 Obstructive Sleep Apnea Syndrome 14 2 <0.001 Pharmacologic treatment 32 29 <0.001 Mortality 4 1 = 0.02 CONCLUSION: We observed no significant changes in weight loss and comorbidities in group A during the follow up. In group B we observed a significant reduction of BMI and all comorbidities. We observed significant changes in BMI and comorbidities variation between the two groups. In our study bariatric surgery influences the natural history of morbidly obese patients, determining a reduction of BMI, comorbidities and mortality. CONCLUSION: Primary gastric squamous cell carcinoma is more common in men with peak incidence in 6th decade. Most of the data available regarding PGSCC are case reports and no clear pathogenesis of this tumor has been reported. PGSCC is considered an aggressive tumor due to higher incidence of lymphovascular and serosal invasion which are responsible for poor prognosis. Aggressive approach with radical surgical resection is recommended in the absence of distant metastasis. Surgery followed by combined adjuvant chemoradiation is recommended despite the absence of adequate data to support this strategy. 200 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1802 Tu1803 Laparoscopic Bariatric Surgery Is Safe in Patients with Mild to Moderate Pulmonary Hypertension Recurrence Pattern of Gastric Cancer After Curative Gastrectomy Hernan Urrego*, William S. Richardson, James Wooldridge General Surgery, Ochsner Clinical Foundation, New Orleans, LA Wee Boon Tan* Department of General Surgery, Singapore National University Hospital, Singapore, Singapore BACKGROUND: Pulmonary hypertension (PH) has significant perioperative risks that may outweigh the benefit of elective surgery. There is very little data on laprascopic surgery in the setting of PH. Our objective was to look at our outcomes of bariatric surgery in patients with PH. METHODS: A retrospective review of a prospectively gathered database of all bariatric procedures was conducted for patients treated from 2007–2011. All patients with PH who underwent a bariatric procedure were reviewed for their preoperative evaluation, intra-operative monitoring and management, post-operative care, and clinic follow up. RESULTS: 809 bariatric procedures were performed from 2007–2011, 5 patients (0.6%), 3 males and 2 females, had PH. 2 patients had Type 1 PH, 2 had Type III PH, and the final patient did not have information on the etiology. The mean PAP of the 5 patients was 40 mmHG (range 25–60). The mean age of the patients was 58 years of age, and the mean BMI was 52. 3 laparoscopic Roux-N-Y, 1 laparoscopic sleeve gastrectomy, and 1 laparoscopic band were performed. Invasive monitoring, arterial line and/or pulmonary catheter, was used in 2 patients with mean PAP ≥40. There were no intra-operative complications and only one patient had a long term complication; band slipped and underwent removal. The mean length of stay was 2 days and mean follow up was 8 months. Mean excess body weight loss (EBL) at 3 months was 29% (N = 5), at 6 months was 42% (N = 4), and at 1 year 35% (N = 2). Over an average of 6 months, exercise tolerance in all 3 Roux-N-Y patients was doubled in terms of length of exercise time and distance walking, and remained the same in the other two. Postoperative pulmonary hypertension follow up with 2d echo was only performed in one patient. A decrease of mean PAP from 39 to 26, 1 year after surgery, without concomitant change in medical therapy was demonstrated. CONCLUSIONS: Laparoscopic surgery seems safe in patients with pulmonary hypertension without significant morbidity, mortality or increased length of stay. Invasive monitoring in patients with mean PAP >25 mmHG <40 mmHG may not be necessary. Exercise tolerance improves in most patients. EBL was modest but few patients had 1 year follow up. Further research is needed to determine long term weight loss, improvement in comorbidities and improvement in PH. Radical surgery with D2 extended lymphadenectomy together with various regimens of peri- or post-operative adjuvant therapy have been shown to be effective for advanced gastric cancer. We aim to evaluate the outcomes of patients who underwent intended curative gastrectomy in our institution and our recurrence rate and pattern. All patients who underwent radical gastrectomy with curative intent were selected from a prospective gastric cancer database at the National University Hospital, Singapore. Each patient was discussed at a multidisciplinary tumor meeting where decision on adjuvant therapy was made. Patients were followed up at regular intervals. Postoperative complications and recurrence were recorded. Survival and cause of death were confirmed with national registry. Between year 2000–2010, 645 patients with gastric cancer were treated in our hospital. 274 patients underwent radical surgery with curative intent. The median age was 69 (range: 19–89) and 67% are males. Most tumors were in antrum (53%) or body (28%) and proximal tumors were found in 19% of patients. Subtotal and total gastrectomies were performed in 70% and 30% of patients respectively. R0 resection was achieved in 252 patients (92%). 195 (71%) and 79 (29%) patients underwent extended lymphadenectomy (D2 or D1+) or limited lymphadenectomy (D1) respectively, according to Japanese Gastric Cancer Treatment Guideline 2010. There were 7 (2.5%) peri-operative deaths. Lymph nodes were harvested by pathologists and the median number was 25 for D2/D1+ (range: 15–64) and 18 (range: 3–25) for D1 respectively. Pathological staging (American Joint Committee on Cancer [AJCC] 7th edition) was as follows: I, 24%; II, 22%; III, 43%; IV, 10%. Peri-operative chemotherapy, postoperative chemo-radiotherapy and postoperative chemotherapy were received by 23, 39 and 21 patients respectively. Median follow-up was 25 months. Tumor recurrence occurred in 31% of our patients and the sites of recurrence were: local (29%); lymph nodes (15%); peritoneum (23%); hematogenous (33%). The overall median survival and recurrence free survival are 25 and 21 months respectively. Factors predictive of recurrence pattern will be analyzed and the results will be presented. Prognosis of gastric cancer remains poor despite earlier detection and improvement in treatment modalities. Recurrence is the most important factor associated with death after curative gastrectomy. Various disease and treatment factors may help to predict the pattern of recurrence and thus provide a tailored treatment guide for our patients. 201 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu1804 Tu1805 Surgical Treatment of Gastrointestinal Stromal Tumors (GIST) of the Stomach: Data Analysis of the East German Gastric Cancer Study (“EGGC Study 02”) Management of Synchronous Primary Adenocarcinoma and Carcinoid Tumor of the Stomach Maithao LE*, Rebecca Nelson, Rebecca Wiatrek, Steven L. Chen, Joseph Kim General & Oncologic Surgery, City of Hope, Duarte, CA Meyer Frank*1,5, Karsten Ridwelski2,5, Lutz Meyer3,5, Uwe Schmidt6,5, Henry Ptok4,5, Hans Lippert1,5, Ingo Gastinger5 1. Department of General, Abdominal & Vascular Surgery, University Hospital, Magdeburg, Germany; 2. Department of General & Abdominal Surgery, Municipal Hospital, Magdeburg, Germany; 3. Department of Surgery, Municipal Hospital, Plauen, Germany; 4. Department of Surgery, Municipal Hospital, Cottbus, Germany; 5. Institute for Quality Assurance in Operative Medicine, University Hospital, Magdeburg, Germany; 6. StatConsult, StaConsult, Magdeburg, Germany INTRODUCTION: Patients with gastric adenocarcinoma with concurrent primary gastric carcinoid are rarely observed. Since little is known about the course of synchronous disease, our objective was to compare the outcomes of patients with concurrent gastric adenocarcinoma and primary gastric carcinoid with patients harboring isolated gastric adenocarcinoma. BACKGROUND: Within the East German Gastric Cancer Study (“EGGC 02”), 1,199 gastric tumor lesions were documented. As a separate tumor entity, gastrointestinal stromal tumors (GIST, n = 55) were compared with gastric adenocarcinomas. The evaluation aimed, in particular, on early postoperative and oncosurgical outcome as a parameter for the quality of surgical results. In near future, data of a re-initiated, currently ongoing study over a 3-year time period (n = approximately 300 patients) can be compared to elucidate what (neo-)adjuvant treatment can additionally achieve with regard to the oncosurgical outcome of gastric GIST patients. PATIENTS AND METHODS: A systematic clinical multicentre observational study design with prospective items in a well characterized area (East Germany) was used including hospitals of each level of surgical care. RESULTS: From January 01 to December 31, 2002, data of 1,199 patients with gastric tumor lesions from 80 hospitals were documented. Ninety five% of 1,139 gastric carcinomas were preoperatively diagnosed with histologic investigation whereas this rate was 47.3% in 55 GISTs. 61.8% of the GIST patients were treated with local wedge resections or with a limited approach. The rate of radical surgical interventions (30%; e.g., gastrectomy, multivisceral resection) was relatively high. The surgical results achieved by operation alone showing i) a hospital mortality of 1.8%, and ii) a 5-year-survival rate of 78% (follow-up investigation period, 67 months; including 90.9% of all patients) compared with gastric carcinoma (30.6%, 70 months and 87.4%, respectively) are acceptable. METHODS: Patients surgically treated for concurrent primary gastric adenocarcinoma and carcinoid tumors from1973 to 2008 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. These patients were case-matched 3:1 with isolated gastric adenocarcinoma patients for year of diagnosis, age, stage, type of surgery, and receipt of radiation. Clinical and pathologic characteristics and survival were compared between the two cohorts. RESULTS: Our investigation identified 32 patients treated for concurrent gastric adenocarcinoma and primary gastric carcinoid. During the same period, 84 932 cases of isolated gastric adenocarcinoma were diagnosed. After case-matching, patient demographics and tumor characteristics were similar, with the exception of gender, whereby synchronous tumor patients were more likely to be female (p = 0.038). Kaplan-Meier curves were constructed to compare survival between the 2 cohorts, but no difference in survival was observed (5-year survival, 60 vs 47 months, p = 0.52). Univariate and multivariate analysis showed that synchronous disease was not a predictor of poor outcome (p = NS). CONCLUSIONS: Development of synchronous gastric adenocarcinoma and carcinoid tumor is extremely rare. Nevertheless, our results indicate that patients with synchronous disease fare similarly to patients with isolated gastric adenocarcinoma. Therefore, our results suggest that the prognosis of patients with synchronous disease is primarily driven by appropriate management of gastric adenocarcinoma. DISCUSSION: Results achieved by surgical intervention alone as reported can serve as an appropriate basis for the initiation and comparison of multimodal therapeutic concepts with the (neo-)adjuvant use of the tyrosin kinase inhibitor Imatinib according to the currently relevant guidelines (as being expected soon by novel data on patients treated surgically including [neo-]adjuvant protocols). Related to the exclusively surgical aspects of gastric GIST treatment, it appears to be indicated to achieve a reduction of the, in part, surgical overtreatment using such protocols including a significant improval of the preoperative diagnostic rate in clarifying gastric GIST appropriately for an adequate therapeutic approach. 202 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Tu1806 Tu1808 Laparoscopic Resection of Gastric Gastrointestinal Stromal Tumours Is Safe and Effective Does Helicobacter Pylori Migrate with Proton Pump Inhibitor Use? Rabih Wassel*1, Yasser Abdulaal1, Haythem Ali1, Ashraf M. Rasheed2 1. Maidstone Cancer Centre, Maidstone Hospital, Maidstone, United Kingdom; 2. Gwent Institute for Minimal Access Surgery, Royal Gwent Hospital, Newport, United Kingdom Joshua W. Long*, Ayman Obeid, Manasi S. Kakade, Jayleen M. Grams, Allison A. Gullick, Mary T. Hawn Surgery, UAB, Birmingham, AL INTRODUCTION: Minimal access surgical therapy is the emerging gold standard technique for treatment of gastric gastrointestinal stromal tumours (GISTs). Despite the above there continue to be lack of guidance or standardisation of the techniques. OBJECTIVES: To assess the safety, effectiveness and functional outcomes of a minimal access surgical strategy for gastric GISTs. METHODS: Thirty eight symptomatic gastric GISTs diagnosed during the years 2006–2010 satisfied the inclusion criteria for minimal access surgical resection. All procedures were performed according to an agreed surgical strategy based on the anatomical location of the gastric lesions. The size, site, histology, resection margin, complications, hospital stay, functional outcome, recurrence rate, survival and mutational analysis of the 38 consecutive resections were maintained on a prospective computerised database. All entered data was validated by the operating surgeon and the reporting pathologist. RESULTS: Twenty nine patients (76%) underwent a laparoscopic extra-gastric tangential resection while seven patients (18%) underwent a posterior trans-gastric resection, and two had a distal gastrectomy (5%). There were no conversions to open, no major intra-operative complications and no episodes of tumour rupture. There were no major immediate or early complications of surgery. Complete resection (R0) was achieved in 100% of cases with a mean lesion size of 44 mm (range 20–90 mm). There was no peri-operative (30 day or in-hospital) mortality and the mean post-operative length of stay was 5.6 days. The median follow-up for the surviving population (37/38 or 97.4%) is 24.5 months with a range of 4–77 months without any reported dysphagia, reflux, dumping syndrome or any CT evidence of disease recurrence. 25/26 (96.2%) of the low risk group remain alive with a median follow up of 24.5 months (range 4–77 months). The 8 patients in the intermediate risk group remain alive (100%) with a median follow-up of 51 months (range 20–77 months) and the 4 high risk group patients remain alive (100%) with a median follow-up of 15 months (range 8–24 months). The only death in this series occurred in the low risk group at 11 months secondary to a dissecting thoracic aneurysm. CONCLUSION: Most gastric GISTs are resected by simple tangential excision. Lesions close to gastro-oesophageal junction are best suited for laparoscopic intra-gastric excision to ensure complete resection while maintaining oesophageal patency and sphincteric competency. Juxtapyloric endophytic lesions are best treated via an anterior gastrotomy or by extra-gastric tangential excision if exophytic. This anatomic and function-based strategy for minimal access surgical resection of gastric GISTs conserve the organ and preserve its function leading to a quicker recovery and a better quality of life without breaching oncological principles. INTRODUCTION: Laparoscopic paraesophageal hernia (PEH) repair has classically been performed using a fundoplication as an adjunct to aid in resolution of reflux. However, fundoplication can be a morbid procedure with long term complaints of bloating and dysphagia. Optimal performance of the fundoplication requires the wrap to be around the esophagus and in the abdominal cavity. Slipped and herniated fundoplication following PEH repair contribute to symptoms associated with recurrence. Alternatively, lateral gastropexy (LGP) can be used with PEH repair. The purpose of this study was to determine whether LGP was an effective alternative in preventing postoperative morbidity and still promoting resolution of symptoms when compared to fundoplication. METHODS: A retrospective review was performed of patients who underwent PEH repair with fundoplication ± LGP (45%) or with LGP alone (55%) from 2005 to 2011. Inclusion criteria consisted of all patients with symptomatic type II, III or recurrent PEH. There were 71 patients who met inclusion criteria. Preoperative GI symptom score surveys, esophogram, and esophagogastroscopy were used to determine clinical symptoms and to diagnose gastroesophageal reflux, esophageal dysmotility, and aspiration. Postoperatively, GI symptom score surveys were used to evaluate for clinical symptoms and repeat esophogram and/or esophogastroscopy was performed in these symptomatic patients. Data were then recorded and compared using chi square analysis with SAS statistical software (version 9.2). RESULTS: Fundoplication at the time of PEH was more frequently performed in younger patients (59 ± 13 v 70 ± 13 years, p < 0.001), those with preoperative symptomatic reflux (97% v 55%, p < 0.001), and those with a prior fundoplication (44% v 21%, p = 0.035). The median length of stay was 2 days for each group, and there were 11 postoperative complications. Fundoplication had 2 complications (mean age 47 years) and LGP had 9 (mean age 72 years), but this was not statistically significant. Postoperatively, fundoplication and LGP had improvement of their preoperative reflux symptoms (93% each), although a significantly greater number of patients experienced early complete resolution of reflux after fundoplication (80% v 48%, p = 0.011). LGP demonstrated a trend toward an absence of postoperative dysphagia (76% v 54%, p = 0.063) or chest pain (81% v 63%, 0.099), although these were not significant. LGP did result in decreased complaints of postprocedure nausea and/or vomiting (5% v 33%, p = 0.047). CONCLUSION: In older patients with diminished esophageal motility and non-reflux dominant symptoms, PEH repair without fundoplication does not result in complaints of post-operative reflux. Consideration for LGP with PEH repair may be warranted to minimize postoperative morbidity associated with fundoplication in elderly patients. 203 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Translational Science: Colon-Rectal In those experiments, complete remission was obtained in 4/7 cases. Response to other drugs was again individual between xenografted cells. Tu2062 CONCLUSION: Here, we describe the successful establishment of three new MSI+ CRC cell lines. These well-characterized and low-passage lines provide a useful tool for subsequent investigating the biological characteristics of MSI+ CRCs, both of sporadic and hereditary origin. Additionally, matched EBV-transformed B cell lines are available for comparative genetic studies. Establishment and Characterization of Three Microsatellite-Instable Cell Lines Derived from Sporadic and Inherited Primary Colorectal Carcinomas Claudia Maletzki1, Ernst Klar1, Friedrich Prall2, Michael Linnebacher*1 1. General Surgery, University of Rostock, Rostock, Germany; 2. Institute of Pathology, University of Rostock, Rostock, Germany Tu2064 BACKGROUND: Microsatellite instability (MSI) is detected in about 15% of all colorectal cancers (CRC). In order to identify new biomarkers that potentially allow for evaluating the response to new cytostatic drugs, pre-clinical in vitro models are mandatory. We here describe the successful establishment and comprehensive characterization of three patient-derived MSI+ cell lines along with their corresponding xenografts. METHODS: Three primary CRC cell lines (HROC24, HROC87, and HROC113) were established from a total of ten clinicopathological well defined MSI+ cases. Cells were comprehensively characterized by phenotype, morphology, growth kinetics and molecular profile. Subsequently, the response to clinically relevant chemotherapeutics was examined in vitro and in vivo. Morphology of established MSI+ cell lines RESULTS: Two of the MSI+ cell lines derived from sporadic CRC showing CIMP-H (HROC24: APCmut p53wt, K-raswt, B-rafmut, HROC87: APCwt p53mut, K-raswt, B-rafmut), whereas one cell line (HROC113: APCwt p53wt, K-rasmut, B-rafwt) was HNPCC-associated. All cell lines were characterized as epithelial (EpCAM+, CEACAM+) tumor cells secreting different levels of cytokines. Response to chemotherapeutics was different between cell lines when analyzing in vitro and in vivo. Generally, the HNPCC-derived HROC113P cells tended to be more resistant than the sporadic MSI+ lines in vitro. However, when tested in nude mice, most pronounced effects were observed for HROC113P, especially following gemcitabine treatment. Development of a Novel Murine Model of Portal Vein Catheterization as a Strategy to Analyze Liver-Directed Therapies for Colorectal Cancer Metastasis Joe Valentino*1,2, Piotr Rychahou1,2, W.C. Mustain1,2, B. Mark Evers1,2 1. Markey Cancer Center, University of Kentucky, Lexington, KY; 2. Department of Surgery, University of Kentucky, Lexington, KY INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer deaths in the US. Despite progress in earlier stage disease, survival has only minimally improved in patients with systemic metastases (Stage IV), which occur primarily to the liver; therefore, more effective and targeted therapies are required. Small interfering RNA (siRNA) provides a highly selective method to target mutated pathways; however, its use is complicated by the inability to specifically target tumor cells. The purpose of this study was to: i) develop a novel murine model of portal vein catheterization for the chronic delivery of therapeutic agents to liver metastases, and ii) determine the utility of epithelial cell adhesion molecule (EpCAM) as a selective target for siRNA delivery to CRC metastases. METHODS: i) To establish a chronic portal vein catheterization model, a midline laparotomy was performed in 2 mo-old Balb/C mice and a 1.2F catheter inserted into the portal vein. Distribution of portal venous flow and catheter patency was evaluated using fluorescently-labeled microspheres. Uptake of siRNA within the liver was tested using DY-547-labeled siRNA followed by IVIS imaging 4h post injection. For metastatic studies, splenic injection of CT26 murine colon cancer cells, transfected with a luciferase vector, was performed and metastasis confirmed 10d later by IVIS imaging; siRNA delivery to liver metastases was confirmed using DY547-labeled siRNA and fluorescent microscopy. ii) The presence of EpCAM was evaluated using IHC staining of microarrays containing a total of 89 normal colon samples, 129 primary CRCs, 4 liver metastases and a normal liver specimen. RESULTS: i) Fluorescence was noted throughout the majority of the liver following injection of the microspheres thereby confirming excellent distribution; microsphere injection at 2 wks confirmed catheter patency. Portal 204 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA venous injection of DY547-labeled siRNA demonstrated a high level of fluorescence throughout the entire liver. In the metastatic model, fluorescent microscopy confirmed the presence of siRNA within the liver metastases demonstrating effective delivery to metastatic lesions. ii) EpCAM staining was absent in normal hepatocytes; mild staining was present in the biliary radicals. All primary CRCs and liver metastases stained strongly for EpCAM. CONCLUSIONS: Liver directed therapy provides an effective method for the delivery of siRNA to CRC metastases. Furthermore, the presence of EpCAM on the cell surface of CRC metastases, but not normal liver, may provide a method to selectively target hepatic metastases of epithelial origin. This targeted delivery, combined with the specific effects of siRNA, would provide a highly selective therapeutic strategy for treatment of CRC metastasis. Figure 1 Translational Science: Esophageal Tu2065 In Rats After Esophagojejunostomy, Reflux Esophagitis Is Accompanied by the Expression of SOX-9 in Basal Cells of the Squamous Epithelium and in Barrett’s Metaplasia Thai H. Pham*, David H. Wang, Robert M. Genta, Shelby D. Melton, Chunhua Yu, Stuart J. Spechler, Rhonda F. Souza, William Neumann Surgery, North Texas VAMC; UT Southwestern Medical Center, Dallas, TX INTRODUCTION: Metaplasia involves the change from one adult cell type into another that is phenotypically different, but that is often of similar embryonic origin. The embryonic esophagus initially is lined by columnar cells that are replaced by squamous cells as maturation proceeds. Barrett’s metaplasia involves the change from esophageal squamous cells back into columnar cells in the setting of gastroesophageal reflux disease. SOX-9, a transcription factor that regulates the development of columnar cell morphological features, is expressed in Barrett’s metaplasia and in the mouse embryonic, columnar-lined esophagus, but not in the normal adult squamous-lined esophagus. Furthermore, forced expression of SOX-9 in cultured esophageal squamous cells induces a columnar phenotype. We sought to determine whether SOX-9 expression is involved in the development of Barrett’s metaplasia in rats that have reflux esophagitis induced by esophagojejunostomy (EJ). METHODS: Groups of 5 Sprague-Dawley rats were sacrificed at 8, 10, 16, and 24 weeks after EJ. The distal esophagus was removed, sectioned, paraffin-embedded and mounted on slides, which were stained with H&E for histological evaluation; immunohistochemistry was performed to determine SOX-9 protein expression. We evaluated the specimens for 1) squamous basal cell and papillary hyperplasia, 2) Barrett’s metaplasia with and without dysplasia, and 3) adenocarcinoma. SOX-9 expression was assessed only in squamous epithelium and in non-dysplastic Barrett’s metaplasia. Shamoperated animals were used as controls. Figure 2 RESULTS: At 8 weeks after EJ, erosive esophagitis with prominent squamous basal cell and papillary hyperplasia was present in all animals. In addition, some of the squamous cells appeared to produce mucin, which was present both within and between cells. At 8 weeks, non-dysplastic Barrett’s metaplasia, dysplastic Barrett’s metaplasia, and adenocarcinoma were found in 4, 3 and 1 of the 5 rats, respectively (Figure 1B-D). Similar histologic findings were seen at the later time points but not in sham-operated animals (Figure 1A). SOX-9 was expressed by basal cells of the squamous epithelium close to the EJ anastomosis (Figure 2A), but not in squamous epithelium further from the anastomosis. Intense expression of SOX-9 was detected in areas of non-dysplastic Barrett’s metaplasia (Figure 2B). Control animals did not show any esophageal SOX-9 expression. CONCLUSIONS: In rats after esophagojejunostomy, the development of reflux esophagitis is accompanied by expression of SOX-9 in the basal cell layer of esophageal squamous epithelium near the anastomosis. In addition, SOX-9 is expressed in Barrett’s metaplasia in this rat model. These data suggest that this is a relevant model for studying the role of SOX-9 in the development of Barrett’s esophagus and esophageal adenocarcinoma. 205 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT Tu2066 Translational Science: Other AKT Expression Is Associated with Degree of Pathologic Response in Adenocarcinoma of the Esophagus Treated with Neoadjuvant Therapy Tu2067 Maki Yamamoto*1, Jill Weber1, Ravi Shridhar2, Sarah Hoffe2, Khaldoun Almhanna1, Richard Karl1, Ken L. Meredith1 1. Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL; 2. Radiation Oncology, Moffitt Cancer Center, Tampa, FL OBJECTIVE: Neoadjuvant chemoradiation (NCRT) has become standard in the treatment of locally advanced esophageal cancer with survival correlated to degree of pathologic response. The activation of the PI3K/Akt/mTOR pathway plays an important role in tumorigenesis and resistance to anticancer drugs. The aim of this study was to elucidate the role of the Akt/mTOR pathway in chemoresistance and the prognosis of patients with esophageal adenocarcinoma cell carcinoma (AC) who received NCRT. METHODS: After IRB approval, a prospective trial was instituted in which patients with locally advance esophageal requiring NCRT were consented for endoscopic biopsies of normal and tumor tissue prior to instituting therapy. The tissues underwent gene expression profiling using the Affymetrix 133 Plus 2.0 Gene chip. SAM method was used to analyze significant differentially expression of AKT within normal and tumor tissue. Expression was then correlated to degree of pathologic response. All patients were treated with NCRT followed by esophagectomy. Pathologic complete response (pCR) was defined as no residual tumor, partial pathologic response (pPR) as a 50% reduction in tumor size or nodal down-staging, and non-response (pNR) as no difference between pre-operative and post-operative stage based upon endoscopic ultrasound. RESULTS: Nineteen patients with adenocarcinoma had biopsies of normal and tumor tissue that were subsequently analyzed via microarray. Comparisons of expressions between normal and tumor revealed consistently significant overexpression of AKT in tumor tissues p = 0.007. We identified 10 patients exhibiting pathologic complete response, 6 partial pathologic response, and 3 non-responders. When comparing the expression of AKT between normal and tumor tissue in those ultimately designated as pCR, there persisted a significant over-expression of AKT in the tumor tissues p = 01. However in analyzing the degree of expression between pathologic response to NCRT we consistently demonstrated a linear correlation between the expression of AKT and degree of pathologic response. Partial and non pathologic responders consistently had higher expressions of AKT compared to pCR with the non-responders consistently illustrating the highest expression of AKT. CONCLUSIONS: AKT is overexpressed in patients with adenocarcinoma of the esophagus. Moreover, pathologic response to neoadjuvant chemoradiation may be correlated with degree of AKT expression. Additional data is needed to clarify this relationship further and potentially add targeted therapies to the neoadjuvant regimen. Nurses Attitudes Towards Women Surgeons Sharona B. Ross*1,2, Franka Co2, Krishen Patel2, Kenneth Luberice2, Harold Paul2, Alexander S. Rosemurgy2 1. Surgery, University of South Florida, Tampa, FL; 2. Tampa General Hospital, Tampa, FL INTRODUCTION: Best surgical care involves a team approach; nurses are an integral part of the team. Interactions between surgeons and nurses impact the working environment and, potentially, quality of care. Given the growing number of women surgeons, this study was undertaken to determine the attitudes of nurses towards women surgeons. METHODS: Nurses in a tertiary care university-affiliated hospital were queried about their attitudes toward women surgeons utilizing a validated questionnaire. RESULTS: 135 nurses, 93% women and 80% Caucasian, were queried; 60% had been nurses for more than 10 years and 25% for 1–5 years. Relative to men surgeons, 60% of nurses believe that women surgeons interact differently with them and 86% feel women surgeons are as reliable. 60% of nurses believe men surgeons have better doctor-nurse relationships. Relative to men surgeons, 79% of nurses feel women surgeons are “good surgeons”, 80% feel women surgeons are confident in their skills, and 49% believe that women surgeons bring “something unique to Surgery.” 38% of nurses feel women surgeons have the same opportunities for advancement as men, 38% feel that the discipline of Surgery is sexist against women surgeons, and 50% believe the discipline of Surgery is responsible for women leaving the field, which is perceived as a frequent event; 72% of nurses think there are too few women surgeons. CONCLUSIONS: A significant number of nurses believe women surgeons interact differently with them and patients; the majority of nurses believe they have better doctor-nurse relationships with men surgeons and that women surgeons have inferior surgeon-patient relationships. Most, but not all, nurses see admirable qualities in women surgeons; the majority of, though not all, nurses believe women surgeons are as “good,” confident, capable, and reliable as men surgeons. Less than half of the nurses believe women surgeons bring “something unique to Surgery”. Many nurses believe women surgeons have reduced opportunities in Surgery and that Surgery is sexist against women surgeons. Most nurses believe Surgery promotes women to leave Surgery and there are too few women surgeons. Nurses note discrimination in Surgery against women surgeons and a notable number, though a minority, are biased against women surgeons. Intervention in the work place is warranted to improve the perception of nurses towards women surgeons. 206 53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA Translational Science: Small Bowel Translational Science: Stomach Tu2068 Tu2069 Does Small Intestinal Atresia Impact on Amino Acid and Monosaccharide Transporter Expression in the Newborn Gut? Gastric Bypass and Duodenal Switch Cause Body Weight Loss Through Different Mechanisms in Rats Yosuke Kodama*1, Helene Johannessen1, Marianne W. Furnes1, Chun-Mei Zhao1, Gjermund Johnsen2, Ronald MåRvik2, Baard Kulseng2,1, Duan Chen1 1. Department of Cancer Research and Molecular Medicine, NTNU, Trondheim, Norway; 2. Department of Surgery, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway Raphael N. Vuille-Dit-Bille , Simone M. Camargo , Luca Mariotta1, Tom Sasse1, Eva E. Kummer1, Schirin Hunziker1, Luca Emmenegger1, Ueli MöHrlen2, Martin Meuli2, FrançOis Verrey1 1. Institute of Physiology, University of Zurich, Zurich, Switzerland; 2. Pediatric Surgery, Childrens Hospital of Zurich, Zurich, Switzerland *1 1 BACKGROUND: Intestinal segments distal to congenital atresia have been suggested to be immature due to lack of luminal access of amniotic fluid (before birth) and nutrition (after birth). Whether the concomitant deficiency of luminal amino acids (AA) and glucose (Glc) has an impact on small intestinal amino acid- and glucose transporter expression, has never been tested. PATIENTS AND METHODS: We therefore analyzed protein- (by immunoflurescence) and mRNA (by Real time RT-PCR) expression of several AA- and Glc transporters proximal and distal to small intestinal atresia in human newborns. To assess transporter function, we measured radiolabeled AA- and Glc uptake into small intestinal enterozytes located proximal and distal to the atretic segment. Furthermore villus morpholgy was analyzed by Hematoxylin-Eosin staining. RESULTS: Proximal sections showed morphological changes from normal intestinal architecture, consisting of villus atrophy and hemorrhages, necrotic areas and some lymphid aggregates within the lamina propria, whereas distal sections showed physiologic morphology. Preliminary results indicate a similar mRNA expression distal and proximal to small intestinal atresia for amino acid-, dipeptide-, monosaccharide- and fatty acid transporters, as well as for genes belonging to the Renin Angiotensin System (RAS). Protein expression of the amino acid transporter B0AT1 and its accessory RAS Protein Angiotensin Converting Enzyme 2 (ACE2), was similar in proximal- and distal segments. Radiolabeled uptake measurements showed a slight decrease in proximal sodium-independent Glucoseand Glutamine uptake, when compared to distal transport. CONCLUSIONS: With respect to the genes and proteins tested, the absence of intestinal continuity in case of Small Intestinal Atresia seems not to affect epithelial gene and protein expression or function. This indicates amino acidand monosaccharide transporter development independently of luminal components. BACKGROUND/AIM: It is still a challenge how to select the most suitable surgical procedure for each individual obese patient. Both gastric bypass (GB) and duodenal switch associated with sleeve gastrectomy (DS) have been widely used as bariatric surgery, and DS appears to be superior to GB, particularly for morbid obesity. The aim of the present study was to compare these procedures with respect to the mechanisms leading to body weight loss in rats. METHODS: Male Sprague-Dawley rats were subjected to GB, DS, or laparotomy (as controls) and followed for 2–14 weeks by an open-circuit indirect calorimeter composed in comprehensive laboratory animal monitoring system and adiabatic bomb calorimeter. RESULTS: Body weight loss was greater after DS than GB. Calorie intake in terms of kcal/day/rat, kcal/day/100 g body weight, and kcal/meal was reduced after DS but not GB. The fecal energy content (expressed as J/g) was increased after DS but not after GB. Energy expenditure (kcal/hr/100 g body weight) was increased during nighttime at 3 weeks and then during daytime at 14 weeks after GB. The energy expenditure was increased both at 2 weeks (during daytime) and 8 weeks (during both daytime and nighttime) after DS. Respiratory exchange ratio, i.e., VCO2/VO2, was unchanged after GB, but reduced after DS. Serum ghrelin levels were reduced at 3 weeks after GB but no longer afterwards. Serum CCK levels were greatly increased at least at 8 weeks after DS. CONCLUSION: GB induced body weight loss by increasing energy expenditure, whereas DS induced body weight loss by reducing food intake (probably due to hyperCCKemia), causing malabsorption, and increasing both fat metabolism and energy expenditure. ACKNOWLEDGEMENTS: The research leading to these results has received funding from the Central Norway Regional FUGE programme, Central Norway Regional Health Authority, and the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement n°266408. 207 2013 ANNUAL MEETING Be sure to join us for next year’s Annual Meeting— mark your calendars now! May 17–21, 2013, Orlando, FL SSAT 500 Cummings Center, Suite 4550 Beverly, MA 01915 Telephone: (978) 927-8330 Facsimile: (978) 524-8890 E-Mail: [email protected] Web Site: www.ssat.com SCHEDULE-AT-A-GLANCE All rooms at San Diego Convention Center unless otherwise indicated. indicates a ticketed session requiring a separate registration and fee. FRIDAY, 5/18/2012 7:30 AM – 2:30 PM RESIDENTS & FELLOWS RESEARCH CONFERENCE (by invitation only) 28ab SATURDAY, 5/19/2012 8:00 AM – 4:35 PM MAINTENANCE OF CERTIFICATION COURSE Evidence Based Treatment of Hepatopancreatobiliary Diseases 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM (ASGE-accredited) Treatment of Early Gastrointestinal Cancer: When is it Safe? Sponsored by:ASGE, SSAT 10:30 AM – 12:00 PM DDW COMBINED TRANSLATIONAL SYMPOSIUM (AGA-accredited) Probiotics in Health and Disease Sponsored by: AGA, AASLD, ASGE, SSAT 28abcd 6a 7ab SUNDAY, 5/20/2012 7:45 AM – 8:15 AM 8:15 AM – 9:15 AM 8:30 AM – 10:00 AM OPENING SESSION 28ab PRESIDENTIAL PLENARY A (PLENARY SESSION I) 28ab DDW COMBINED CLINICAL SYMPOSIUM 31abc (ASGE-accredited) Management of the Patient at High Risk for Colon Cancer Sponsored by: ASGE, SSAT 9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS 28ab Relationships Matter 10:30 AM – 11:15 AM PRESIDENTIAL PLENARY B (PLENARY SESSION II) 28ab 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 32ab (AGA-accredited) Gastrointestinal Management of the Patient With Obesity Sponsored by: AGA, ASGE, SSAT, AASLD 11:15 AM – 12:00 PM MAJA AND FRANK G. MOODY 28ab STATE-OF-THE-ART LECTURE The Treatment of Obesity: How Science CAN Influence Public Policy 12:00 PM – 2:00 PM POSTER SESSION I (non-CME) Halls C-G 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Operative Therapies for GERD: What are the Options? 28cd The Difficult Gallbladder: Tricks to Get Out of Trouble 29d 2:15 PM – 3:45 PM CONTROVERSIES IN GI SURGERY A 28cd Debate 1: C. Difficile Colitis: Ileostomy and Lavage vs. Resection Debate 2: Is Surgical Intervention for Cystic Neoplasms of the Pancreas Being Overutilized? 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20a Management of Fecal Incontinence Sponsored by: SSAT, AGA, ASGE 2:15 PM – 4:30 PM VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND 26ab ADVANCED LAPAROSCOPIC GI SURGERY 2:15 PM – 4:45 PM STATE-OF-THE-ART CONFERENCE 28ab Technological Advances in the Surgical Treatment of Colon and Rectal Cancer 2:15 PM – 5:00 PM PLENARY SESSION III 27b 4:00 PM – 5:00 PM CLINICAL WARD ROUNDS I 28cd The Difficult Bile Duct Stone: Case Presentations and Tricks of the Trade MONDAY, 5/21/2012 7:30 AM – 9:15 AM 8:30 AM – 9:30 AM 8:30 AM – 10:00 AM 9:30 AM – 11:00 AM VIDEO SESSION II: BREAKFAST AT THE MOVIES 28ab CLINICAL WARD ROUNDS II 28cd Diverticulitis: Lavage and Resection— Which Treatment When? SSAT PUBLIC POLICY AND ADVOCACY 27b COMMITTEE PANEL Will There Be a General Surgeon When You Need One? SSAT/AHPBA JOINT SYMPOSIUM 28ab Evaluation and Treatment of Benign Liver Neoplasms 10:00 AM – 11:15 AM 10:00 AM – 11:15 AM 10:00 AM – 11:15 AM 10:30 AM – 12:00 PM PLENARY SESSION IV 27b QUICK SHOTS SESSION I 26ab VIDEO SESSION III: HPB & FOREGUT VIDEOS 28cd DDW COMBINED CLINICAL SYMPOSIUM 20a Functional Disorders of the Esophagus Sponsored by: SSAT, AGA, ASGE 11:15 AM – 12:00 PM DORIS AND JOHN L. CAMERON GUEST ORATION 28ab Bringing Health Information to Life 12:00 PM – 2:00 PM POSTER SESSION II (non-CME) Halls C-G 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS Cystic Tumors of the Pancreas: To Operate or Not? 9 Diverticulitis: Two and Out or Not? 10 2:15 PM – 3:15 PM QUICK SHOTS SESSION II 28ab 2:15 PM – 3:45 PM CONTROVERSIES IN GI SURGERY B 28cd Debate 3: Ban the Band? Which is the Best Operation for Morbid Obiesity? Debate 4: 360 vs. Partial Fundoplication: Which is the Standard for GERD? 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20a (AGA-accredited) Multidisciplinary Management of Complicated Crohn’s Disease Sponsored by: AGA, SSAT, ASGE 2:15 PM – 4:00 PM PLENARY SESSION V 27b 3:15 PM – 4:45 AM SSAT/ASCRS JOINT SYMPOSIUM 28ab Controversies in Surgery for Ulcerative Colitis 4:00 PM – 5:00 PM CLINICAL WARD ROUNDS III 28cd The GI Surgeon and Endoscopy: Case Presentations Where the Endoscope Matters 4:00 PM – 5:00 PM QUICK SHOTS SESSION III 27b 4:00 PM – 5:30 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc Pancreatic Cystic Neoplasms and IPMN Sponsored by: SSAT, AGA 5:00 PM – 6:00 PM ANNUAL BUSINESS MEETING (non-CME) 28ab 7:00 PM – 9:00 PM MEMBERS RECEPTION The Don Room at El Cortez TUESDAY, 5/22/2012 7:30 AM – 9:30 AM SSAT/ISDS JOINT BREAKFAST SYMPOSIUM 28ab Optimizing Outcomes for Our Patients: Data and Practice: Combining Perioperative Patient Management and Expert Technical Tips 8:00 AM – 9:30 AM PLENARY SESSION VI 27b 8:30 AM – 10:00 AM DDW COMBINED CLINICAL SYMPOSIUM 20bc (AASLD-accredited) Management of HCC: Chemotherapy, Reduction of Tumor Load, or Transplant? Sponsored by: AASLD, SSAT 9:30 AM – 12:00 PM PLENARY SESSION VII 27b 10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc (AGA-accredited) Can You Eliminate Barrett’s Esophagus? Sponsored by: AGA, ASGE, SSAT 10:30 AM – 12:00 PM SSAT HEALTH CARE QUALITY & 28cd OUTCOMES COMMITTEE PANEL Three Ways to Bend thd Cost Curve in GI Surgery Without Sacrificing Quality 12:00 PM – 2:00 PM POSTER SESSION III (non-CME) Halls C-G 12:00 PM – 3:00 PM KELLY AND CARLOS PELLEGRINI SSAT/ 28ab SAGES JOINT LUNCHEON SYMPOSIUM Current Concepts and Controversies in Foregut Motility 12:30 PM – 1:45 PM MEET-THE-PROFESSOR LUNCHEONS CBD Stones: Laparoscopic or Endoscopic? 7ab Modern Staging and Treatment of Rectal Cancer 26ab 2:00 PM – 4:00 PM BEST OF DDW 2012 (non-CME) 28cd 2:15 PM – 3:45 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc (ASGE-accredited) Endoscopic Biliary Complications: What Can You Do? Sponsored by: ASGE, SSAT