<figure><img src="image_140.png" /></figure>

# SAGES POSTER ABSTRACTS

tion provides an excellent symptomatic and physiological outcome in patients with typical symptoms of GERD. This procedure can be a safe and effective therapeutic modality even without manometric studies.

## Esophageal/Gastric Surgery - P320

**PARAESOPHAGEAL HERNIA AFTER LAPAROSCOPIC FUNDOPLICATION, COMPLICATIONS AND FOLLOW-UP, Jose F Farah PhD, Alberto Goldenberg PhD, Vladimir Schraibman MD, Renato A Lupinacci PhD, Jose C Del Grande PhD, Federal University of Sao Paulo and Hospital Servidor Publico Estadual**

**Introduction:** Post-operative laparoscopic anti-reflux anatomical failure range between 5-40% and may be related to hazard complications. Anatomical failure can occur in asymptomatic patients making difficult to know the natural history of this complication.

**Objective:** evaluate the evolution of patients with anatomical failure.

**Methods:** 842 patients were evaluated through our records after laparoscopic fundoplication between 1995-2006. 508 (60,3%) performed an upper endoscopy. Only cases with stomach migration or gastric fundus migration through the torax (intact valve) were included.

**Results:** 32 (6,2%) patients presented paraesophageal hernia, 3 between 7-90 days after surgery. All were re-operated due to pain, disphagia and vomit. Other 29 were diagnosed during routine exams (assymptomatic or dispeptic symptoms) between 13-60 months after surgery. Only one of these presented symptoms (vomit or pain) when all the others 28 did not present any event in a medium follow-up (12-84 months - mean 22 months).

**Conclusions:** This study suggests that clinical follow-up without re-operation in cases of asymptomatic migration may be enough.

## Esophageal/Gastric Surgery - P321

**LAPAROSCOPIC VERSUS OPEN D2 GASTRECTOMY FOR GASTRIC CARCINOMA, Douglas Fenton-Lee MD, Annanya Chakrabati MD, Eva Segalov PhD, David Williams MD, St Vincent's Hospital, Sydney**

In specialised units D2 gastrectomy is performed for the management of gastric carcinoma. Laparoscopic D2 gastrectomy has been performed with minimal morbidity and mortality and with the benefits of a minimally invasive approach. The aim of this study was to evaluate the laparoscopic approach compared with the traditional open technique.

**Method:** In the period from January 2005-Aug 2006 we performed a prospective audit on patients undergoing laparoscopic and open D2 gastrectomy. Clinical data was prospectively collected and included patient demographics, stage of tumour, nodal harvest, postoperative complications, length of stay and survival. There was no difference in the surgical procedure performed whether it was performed open or laparoscopically. The oesophago-jejunal or gastrojejunal anastamosis was hand sutured and the entero-enterostomy a stapled anastamosis.

**Results:** Laparoscopic staging detected metastases in 13/36 (36%) of those patients deemed operable following other staging modalities. Thirteen patients underwent open and Ten laparoscopic D2 gastrectomy. The operative time was significantly longer in the laparoscopic group and length of stay was no different.

There was no postoperative mortality and no reoperations. There was one radiologically detected anastamotic leak in the laparoscopic group.

The median follow up is 7months(1-18). There was no difference in the nodal harvest for the lap versus open group was median(range) 20(10-27) versus 15(6-36).

In this study the two groups were comparable in terms of patient demographics, postoperative complications and length of postoperative hospital stay. Laparoscopic D2 gastrectomy fulfilled the essential criteria for optimal cancer surgery in terms of R0 resection and number of lymph nodes harvested. Laparoscopic D2 gastrectomy may well become the optimal approach for the management of gastric cancer.

## Esophageal/Gastric Surgery - P322

**PREVENTION OF POSTOPERATIVE LEAKS FOLLOWING LAPAROSCOPIC HELLER MYOTOMY, Kelly R Finan**

MD, David Renton MD, Ruth R Leath MPH, Mary T Hawn MD, University of Alabama

**Purpose:** Laparoscopic Heller myotomy has emerged as the preferred treatment for patients with achalasia. Post-operative leaks cause significant morbidity and impair functional outcome. This study assesses the efficacy of intra-operative leak testing on post-operative leak rate.

**Methods:** A retrospective analysis of all patients undergoing laparoscopic Heller myotomy by a single surgeon between November 2001 and August 2006 was undertaken. Prior therapy for achalasia, intra-operative mucosal injuries and post-operative leaks were assessed. Procedures were performed in a standardized fashion and a leak test was performed intraoperatively in all patients to assess for mucosal injury. Preoperative factors associated with mucosal injury was assessed by Chi-square analysis.

**Results:** One hundred and four patients were included in the study. Diagnosis was made by barium swallow and manometry. Prior treatment for achalasia, included previous Botox injection (25%), pneumatic dilation (27%), and prior transthoracic myotomy (12%). Intraoperative mucosal injuries occurred in 25% patients. All leaks were repaired with Vicryl suture and tested with Methylene blue stained saline (90%) or EGD (10%). There were no post-operative leaks and patients were started on diet day of surgery. Analysis of factors associated with mucosal injury demonstrated that prior Botox injection was associated with a statistically significant decrease in the rate of mucosal tear or injury (p=0.0296). A Dor fundoplication was performed in 70% of the patients. There were 3 postoperative complications; one aspiration pneumonia with induction of anesthesia, one mesenteric vascular injury, and one postoperative MI. There were no conversions to open procedure. The mean length of stay was 1.4 (+0.8) days.

**Conclusion:** Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites postoperative management with early refeeding. Prior treatment does not impair operative results. Long-term functional outcomes need to be assessed.

## Esophageal/Gastric Surgery - P323

**THORACOSCOPIC INTRATHORACIC ANASTOMOSIS USING SIDE-TO-SIDE (MODIFIED FROM ORRINGER) METHOD, S. Furuta MD, R. Sunagawa MD, K. Inaba MD, S. Tonomura MD, M. Shoji MD, Y. Nakamura MD, J. Isogaki MD, Y. Komori MD, Y. Sakurai MD, I. Uyama MD, Fujita Health University, Aichi, Japan**

**BACKGROUND:** Resection of the esophagus is the principal way for curative therapy of esophageal cancer. The right side thoracotomy combined with laparotomy is usually applied for esophageal resection, and the indication of thoracoscopic approach for esophagectomy is gradually increasing. In this procedure, the intrathracic manipulation of esophago-gastric anastomosis is one of the choices for reconstruction. We applied side-to-side anastomosis (Modified from Orringer) for this anastomosis thoracoscopically.

**METHODS:** Our procedure for thoracoscopic esophago-gastric anastomosis is based on the side-to-side anastomosis reported by Orringer. The points of this technique are following. After esophagectomy, the mobilized stomach is manipulated into the posterior mediastinum in the original esophageal bed. The stump of the esophagus is pulled down until the distal end of the esophagus overlaps about 4cm with the stomach roll. A small esophagotomy is made at the distal end of the esophagus. A small gastrotomy is also made on the anterior gastric wall. This gastrotomy is made sufficiently below the tip of the proximal end of the stomach roll to allow the following insertion of the stapling device. After that, a stapling device is inserted both into the esophagus and stomach. Firing the stapler creates side-to-side esophago-gastrostomy. The common entry hole was
# SAGES POSTER ABSTRACTS

closed with interrupted suture.

**RESULTS:** We applied this anastomotic procedure to 5 cases of esophagectomy. No stenosis or failer of the suture was observed.

**CONCLUSION:** Thoracoscopic intrathoracic esophago-gastric anastomosis by side-to-side method is comparatively simple and safe method. We herein report our procedure.

## Esophageal/Gastric Surgery - P324

### LAPAROSCOPIC ANTIREFLUX RE-OPERATIONS IN ICELAND; OUTCOME AND ANALYSIS OF DATA FOR PREDICTABLE FACTORS FOR RE-OPERATIONS, Hildur

Guðjónsdóttir, Kristinn Tómasson PhD, Margrét Oddsdóttir MD, 1) University of Iceland, Medical school, Reykjavik, Iceland, 2) Research Center for Occupational Health and Working Life, Reykjavik, Iceland, 3) Dept of Surgery, Landspitali-University Hospital, Reykjavik, Iceland.

**OBJECTIVE:** The first laparoscopic antireflux reoperation (LAR) in Iceland was done in 1997. How do our re-operated patients fare, especially compaired to those who are satisfied after a single operation? Do the patients that undergo re-operation have any common features?

**METHODS AND MATERIAL:** Data was collected from medical charts from all patients (N = 42) who have undergone LAR in Iceland (1997-2004). All patients received by mail the Icelandic Quality of Life Questionair (IQL), Gastrointestinal Symptom Rating Scale (GSRS) along with additional questions on medications used, medical history. They were also asked to answer yes or no if they were satisfied with the results of the operation. The data from the re-operated patients (group A) was compared to our long-term results of laparoscopic antireflux operations (group B), in particular in relation to pre-operative symptoms, co-morbid illnesses and results of the questionaires. The data was also analyzed for factors that could predict the need for re-operation.

**RESULTS:** 33 of 42 patients (79%) sent in their answers. 23 (70%) answered yes that they were satisfied with their second operation but 10 said no. Of those 10, seven patients (21%) had complaints that could be due to the operation or to GERD. The re-operated patients, group A, reported more severe pre-operative reflux symptoms compaired to group B. The re-operated patients had a significantly higher number of co-morbid diseases that affected their quality of life. They also had significantly worse results on the IQL and on the GSRS as compared to patients in group B.

**CONCLUSION:** Patients with GERD who have required re-operation for their disease are less satisfied than those who have required a single operation, and their quality of life is significantly worse. Pre-operatively, the re-operated patients have in common a complex medical history and they report more severe symptoms of GERD as compared to patients who required only a single operation.

## Esophageal/Gastric Surgery - P325

### REVISIONAL LAPAROSCOPIC ANTIREFLUX SURGERY IS SAFE AND EFFECTIVE IN PROPERLY SELECTED PATIENTS, Ryan W Hardy MD, Yaron Perry MD, Carly Whitehead, Murali R Basker MD, Allie Scheuss, Anthony T Petrick MD, Geisinger Medical Center

The purpose of our study was to review the outcomes of Revisional Laparoscopic Antireflux Surgery (RLARS). Historically, RLARS has been less successful than initial Laparoscopic Antireflux Surgery (LARS), however, experienced centers have found RLARS to be effective in patients who suffer recurrent GERD-related symptoms.

**STUDY DESIGN:** We retrospectively reviewed data that was prospectively collected for 41 consecutive patients (17 men and 24 women; mean age, 52.7; age range=19-77) undergoing 44 RLARS between Jan 2002 and Feb 2006. Pre and postoperative evaluation included standardized GERD symptom questionnaire, assessment of antacid use, UGI, and EGD. Manometry and esophageal pH testing were used selectively. QOLRAD questionnaires were completed in consecutive patients beginning August 2004. Statistical analysis was done using T-test and Chi-square testing.

**RESULTS:** 17 of the initial antireflux surgeries had been performed open. 43 RLARS were completed laparoscopically

with 1 conversion to open surgery. Mean LOS was 3.9 days (1 to 30). The mean follow-up was 23.1 months (2 to 48). Symptom results are summarized below

<table><thead><tr><td></td><td>PREOP</td><td>POSTOP</td></tr></thead><tbody><tr><td>Heartburn</td><td>89%</td><td>24% c</td></tr><tr><td>Regurgitation</td><td>56%</td><td>20% c</td></tr><tr><td>Dysphagia</td><td>60%</td><td>33% c</td></tr><tr><td>PPI Use</td><td>78%</td><td>33% c</td></tr><tr><td>QOLRAD</td><td>94.94</td><td>149.47 †</td></tr></tbody></table>

Chi-square c = p&lt;lt;0.025; t-test t=p&lt;lt;0.0001. Post op UGI was completed in all patients (mean 7.5 mo) and demonstrated intact fundoplication with no hiatal hernia in 84% of patients. 67% of patients judged their outcomes to be good to excellent at most recent follow-up. 90-day major complications included leak and liver abscess (4.9%) and 6 minor complications (14.6%) occurred. There was no procedure related 90-day or in-hospital mortality.

**CONCLUSIONS:** RLARS was shown to be technically feasible even in patients with previous open fundoplication. Over a 2-year objective follow-up, RLARS was more effective than has previously been demonstrated at improving the triad of clinical symptoms, PPI usage and QOLRAD scores. Conversion and complication rates were low in our specialized center.

## Esophageal/Gastric Surgery - P326

### CLINICAL EVALUATION OF A LAPAROSCOPICALLY ASSISTED DISTAL GASTRECTOMY WITH AN EXTRA-PEIGASTRIC REGIONAL LYMPH NODE DISSECTION PRESERVING VAGAL NERVE BRANCHES FOR GASTRIC CANCER, Hideki Hayashi MD, Hiroshi Kawahira MD, Yoshihiro Kawahira MD, Yutaka Tanizawa MD, Hideaki Shimada MD, Takenori Ochiai MD, Research Center for Frontier Medical Engineering, Chiba University

**Introduction:** Laparoscopically assisted distal gastrectomy (LADG) with an extra-perigastric regional lymph node dissection accompanying preservation of hepatic and abdominal branches of vagal nerve has been performed on 9 patients with early gastric cancers in the Chiba University Hospital between November 2004 and September 2006. Clinical outcomes of these patients were compared with those of the 15 patients with LADG without preservation of vagal nerve branches (LADG group) performed during the same period.

**Surgical procedure:** Under pneumoperitoneum, the left and right gastroepiploic, and the right gastric vessels were divided at their origin, and the nodes along common hepatic and left gastric arteries, and celiac trunk were then dissected intracorporeally. Hepatic and celiac branches of the vagal nerve were preserved during the dissection of the nodes for LADG-VP group. Afterward, 6 cm mini-laparotomy was made in the epgastrium, and four-third of distal gastrectomy and B1 or Roux-en-Y reconstruction was performed extra-corporeally.

**Result:** There were no conversion to open surgeries in both groups, and no statistically significant differences were observed between two groups in the mean operating time (327 min for LADG-VP and 332 min for LADG), mean time for laparoscopic procedure (208 and 219 min, respectively), blood loss (110 and 179g, respectively), and mean number of harvested lymph nodes in the extra-perigastric area (4.9 and 3.7 nodes, respectively). Postoperative course such as time to flatus (2.3 days for LADG-VP and 2.4 days for LADG) and body weight loss of 3 months after surgery (12% for both groups) were also similar between the groups. In contrast, ratios of the patients complaining of frequent constipation (20% for LADG and 0% for LADG-VP), diarrhea (7% and 0%, respectively) and dumping syndrome (7% and 0%, respectively) after surgery were relatively higher in the LADG group.

**Conclusions:** LADG with an extra-perigastric regional lymph node dissection accompanying preservation of vagal nerve branches is safely feasible and could contribute to postoperative quality of life of patients with gastric cancer.

<figure><img src="image_141.png" /></figure>
<figure><img src="image_142.png" /></figure>

SAGES POSTER ABSTRACTS

Esophageal/Gastric Surgery - P327

LAPAROSCOPIC SUTURING AND PERITONEAL LAVAGE
FOR DUODENAL ULCER PERFORATION, Atsushi Jida MD, Kei
Honda MD, Akio Yamaguchi MD, First Department of
Surgery, University of Fukui, Japan

(Introduction) Perforated duodenal ulcer induces pan-peri-
titonitis. Recent conservative treatment gets success to avoid
surgery, however many of the patients are bearing their
pain, fasting and having a nasogastric tube for several days.
We think the minimal invasive surgery is the best way for
those patients, and introduce our procedure and results.

(Procedure) We have emergently operated for perforated duodenal ulcer patients since 2000. We performed laparoscopic suturing to close the perforation and covered the lesion by omentum to 17 patients. Peritoneal lavage was sufficiently performed, and then drain tube was placed on the duodenum.

(Results) Under the laparoscopic view, all of the patients had perforated duodenum and dirty ascites with white coat. We could close the hole and wash out the peritoneal cavity for all. The operating time were 71 -115 min, the blood loss was negligible. Oral intake and walking were started at the next day, and the hospital stay was seven to 16 days. All the patients were infected helicobacter pyroli in their stomach and disinfected by oral antibiotics.

(Conclusion) The patients discharged finely without bearing conservative treatment. Laparoscopic suturing and peritoneal lavage were useful and satisfactory treatment for perforated duodenal ulcer patients.

Esophageal/Gastric Surgery - P328

HAND-ASSISTED LAPAROSCOPIC TOTAL GASTRECTOMY WITH SPLENECTOMY FOR ADVANCED GASTRIC CANCER, Mikito Inokuchi MD, Kazuyuki Kojima MD, Hiroyuki Yamada MD, Yoshihisa Sekita MD, Tatsuyuki Kawano MD, Dept. esophagogastric surgery, Tokyo medical and dental universi-
ty

We performed hand-assisted laparoscopic total gastrectomy with splenectomy and D2 lymphadenectomy for advanced gastric cancer in the upper portion. We show this technique and the results.

We placed five ports and GelPortTM (Applied) through inci-
sion of 8 cm at the epigastrium. After dividing of the greater
omentum, the distal pancreas and spleen were dissected
from the retroperitoneum by a technique of hand-assisted
laparoscopic surgery. The splenophrenic ligament and phre-
noesophageal membrane was divided. We performed
laparoscopic lymphadenectomy following that. The right
gastroepiploic vessels were divided. The duodenum was
dissected with endoscopic linear stapler. After the right gas-
tric vessels were divided, we dissected the lymph nodes
along common hepatic artery. The celiac artery, splenic
artery (SPA) and left gastric artery (LGA) were exposed, and
the LGA was divided. The vagal nerves were dissected.

The dissection of the lymph nodes along the SPA was per-
formed extracorporeally through the incision at the epigas-
trium. The dissection of esophagus and the anastomosis by
the Roux-en-Y method were accomplished extracorporeally.
We performed this procedure in five cases (three were male,
two were female). The median age of the patients were 70
years (range; 56 ~ 76 years). The median operative time was
338 minutes (range; 311 ~ 382 minutes). Postoperative com-
plication was observed in one case. Pneumonia and sepsis
occurred, and were recovered conservatively. The median
postoperative hospital stay was 17 days (11 ~ 40 days).

Esophageal/Gastric Surgery - P329

LAPAROSCOPIC RESECTION FOR GASTRIC REMNANT CAN-
CER : REPORT OF 8 CASES., J. Isogaki MD, R. Sunagawa
MD, S. Furuta MD, K. Inaba MD, S. Tonomura MD, M. Shoji
MD, Y. Nakamura MD, Y. Komori MD, Y. Sakurai MD, I. Uyama
MD, Fujita Health University, Aichi, Japan

BACKGROUND: Since laparoscopic gastrectomy is increas-
ingly applied for gastric cancer resection along with the
improvement in instrument and technique in Japan, laparo-
scopic surgery for gastric remnant cancer (GRC) is still

uncommon. We applied laparoscopic treatment for 8 cases of GRC and accomplished the surgical procedure laparo- scopically in 7 cases. There are very few reports about laparoscopic GRC resection, we herein report our experi- ence.

**Patients and methods:** From April 2002 to January 2006, 8 patients received laparoscopic surgery for GRC. Five were male and three were female. The primary diseases for the initial gastrectomy were peptic ulcer (n=4) or gastric cancer (n=4). The mean latency period between the initial surgery and diagnosis of GRC was 19.9 years. Seven GRC were defined as early stage and one was advanced.

**RESULTS:** Out of the 8 cases, we resected laparoscopically in 7 and converted to laparotomy in one. Total gastrectomy with Roux-en-Y reconstruction (n=6) or partial gastrectomy (n=1) were performed laparoscopically. Mean operation time was 383 minutes. At median follow up period of

**CONCLUSION:** We applied laparoscopic surgery for GRC and accomplished curative resection laparoscopically in 7 (87.5%) cases out of 8. Although our limited experience, laparoscopic resection for GRC is feasible and might be a choice of treatment for GRC.

Esophageal/Gastric Surgery - P330

NEW CONCEPT OF HYBRID ESOPHAGECTOMY TO ENHANCE ITS SAFETY AND RADICALITY FOR ESOPHAGEAL CANCER, Yosuke Izumi MD, Akinori Miura MD, Tsuyoshi Kato MD, Tokyo Metropolitan Komagome Hospital

**Background:** Minimally invasive esophagectomy offers many theoretical advantages including reducing postoperative mobility and mortality. But numerous issues remain unresolved including the optimum approach and applicability to general surgeons.

**Aim:** To assess our outcomes after minimally invasive esophagectomy and investigate the optimum approach and applicability to general surgeons.

**Method:** Between August 2000 and December 2005, we introduced VATS esophagectomy for 21 cases with Stage I or II esophageal cancer. Our hybrid surgery consists of a right video-assisted thoracoscopic (VATS) approach for mobilization of the intrathoracic esophagus and lymph node dissection, and gasless laparoscopic gastric reconstruction for the esophagus. It preserves the advantages of open procedures by offering tactile sensation, while maintaining the benefits of a minimally invasive procedure.

**Results:** Postoperative serum CRP level and postoperative complications are not significantly different between open and VATS esophagectomy. Actual benefits of the minimally invasive procedures are improved exposure in upper and lower mediastinum and reducing postoperative pain. Postoperative vital capacity is well recovered in VATS group. The surgeons' ability to feel the tumor helps ensure wide-field dissection safely with hand-assisted technique during thoracoscopic surgery. Five-year survival is 100% in Stage 0 and 80% in Stage I, which is comparable to open surgery(82%). Postoperative mortality was 0% and morbidity rate was 35%, which is lower than open surgery.

**Conclusion:** Hand-assisted techniques can be the ideal bridge between open and totally thoracoscopic and laparoscopic procedures for surgical treatment of esophageal cancer.

Esophageal/Gastric Surgery - P331

TEN-YEAR FOLLOW-UP OF LAPAROSCOPIC HELLER MYOTOMY FOR ACHALASIA SHOWS DURABILITY, Louis O Jeansonne MD, Brent C White MD, Matthew D Shane MD, Craig B Morgenthal MD, Stanley Zagorski MD, Vickie Swafford BS, S. Scott Davis MD, Leena Khaitan MD, Barbara J Pettitt MD, John G Hunter MD, Edward Lin DO, C. Daniel Smith MD, Emory University School of Medicine

**OBJECTIVE:** Reports of long-term outcomes for laparoscopic Heller myotomy (LHM) are scarce. In this work, outcomes of LHM for achalasia in patients who underwent surgery more than 10 years prior were investigated.

**METHODS:** A cohort of patients treated with LHM and partial fundoplication (either Dor or Toupet) for achalasia
between 1993 and 1996 was followed for long-term outcomes, which were compared to baseline data at presentation.

**RESULTS:** Thirty-two consecutive patients were identified, and follow-up information was obtained for 20 patients (62.5%). Mean follow-up was 11.2 years (range 10.3 to 12.3 years). Three patients (9.4%) were deceased (mean of 40 months post-op). Of the 17 living patients, dysphagia was rated as severe in one (5.9%), mild to moderate in eight (47.1%) and absent in eight (47.1%) at 10 years. These were decreased from pre-operative scores, in which dysphagia was rated as severe in 42.9%, mild to moderate in 57.1%, and absent in 0% (p < 0.05). In addition, 10-year dysphagia scores were unchanged from those at short-term follow-up (mean of 27 months, p = 0.84). Other symptoms of heartburn, chest pain, voice symptoms, cough, and asthma were reported in less than 30% of patients at 10 years. Esophageal dilation following surgery was required in three patients, and two patients required repeat operations (esophagectomy in one patient, hiatal hernia in one patient). Satisfaction with the operation was reported by 16 patients (94.1%) at 10 years.

**CONCLUSION:** Most patients who underwent LHM with partial fundoplication reported satisfaction 10 years after the operation. A small number of patients required additional intervention. Dysphagia scores at 10 years were not different from those collected at short-term follow-up. Our data suggest that the efficacy of LHM is sustained at 10-year follow-up.

## Esophageal/Gastric Surgery – P332

### LAPAROSCOPIC ANTIREFLUX PROCEDURES; A SINGLE SURGEONS LONG-TERM RESULTS (5-10 YEARS),

Adalheidur Jóhannesdóttir, Kristinn Tómasson PhD, Margrét Oddsdóttir MD, 1) University of Iceland, Medical school, Reykjavík, Iceland, 2) Research center for occupational health and working life, Reykjavík, Iceland

**OBJECTIVE:** Laparoscopic antireflux procedures (LAP) were introduced in Iceland in 1994. For the first 5 years, LAP in Iceland was almost solely done by a single surgeon. To evaluate the long-term results this study was undertaken.

**METHODS AND MATERIAL:** From 1994-1999, 158 patients underwent LAP in Iceland and fulfilled the inclusions definition (i.e. are alive today, LAP was the main procedure done, were adults, etc). These patients were sent 3 questionnaires - Gastrointestinal Symptom Rating Scale (GSRS), Quality of Life in Reflux and Dyspepsia (QOLRAD) and the Iceland Quality of Life Questionnaire (IQL) - in addition to questions on medications and medical history. They were also asked to answer yes or no if they were satisfied with the results of the LAP. Their medical charts were reviewed and pre-op symptoms, medical history, measurements, procedure specifics and post-op problems noted.

**RESULTS:** One hundred and twenty answered or 76%. Ninety nine (83%) answered "yes" to the question are you satisfied with the results of the LAP, but 21 (17%) answered "no". The satisfied ones had significantly better quality of life scores than those who were dissatisfied. The satisfied patients scored significantly better on the GSRS. Twenty eight reported symptoms of gastroesophageal reflux (GERD) after the operation. Fourteen of those were in the unsatisfied group and 14 were satisfied with LAP. The seven that were dissatisfied, but without reflux symptoms reported bad health, bloating, abdominal pain, diarrhea, etc. Overall, the GERD symptoms were significantly worse in the unsatisfied patients.

**CONCLUSION:** Five to 10 years after LAP, more than 80% of patients are satisfied with the results. Compared to those that are dissatisfied, the satisfied ones score significantly better on both IQL and GSRS. These subjective results are acceptable, but objective data is needed to allow definitive conclusions to be made.

## Esophageal/Gastric Surgery – P333

### AERODIGESTIVE FUNCTIONAL OUTCOMES FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY, L Kautzman MD, C Senkowski MD, S Brower MD, J Garber MD, Memorial Health University Medical Center, Mercer University School of Medicine Savannah Campus

Improvement of swallowing function is an important outcome after esophageal surgery. Minimally invasive esophagectomy (MIE) for esophageal disease is being evaluated for both functional and oncological outcomes. Few studies have evaluated swallowing function. We review the ability to identify dysphagia in MIE patients.

A retrospective chart review of 18 patients over 3 years was performed. Demographics collected were pathology, stage, and use of induction therapy. Data obtained included radiographic swallow studies; speech therapy evaluation with modified barium swallow (MBS); type and timing of first diets; duration of tube feed supplementation; need for dilation; and dysphagia scores at 2 weeks and 2 months. Subjective dysphagia scores were given from a scale of 0 to 6, ranging from no symptoms to solid food dysphagia. These data compared radiographic and clinical data with patient outcome.

Of 16 radiographic swallows performed, 3 (17%) anastomotic leaks were reported and correlated with the patients clinically. Delayed gastric tube emptying (DGE) was demonstrated in 3 (17%) patients and aspiration in another 3 (17%). Speech therapists evaluated 14 patients and 3 underwent MBS secondary to bedside failure, which confirmed their clinical severe dysphagia. Diet was initiated on median day 7 and primarily was full liquid or pureed. Fifteen patients required tube feeding supplementation on discharge. Of these, median time of discontinuation was 8 weeks. Stricture was diagnosed in 7 (39%) patients with endoscopy, all requiring dilatations. Mean dysphagia scores at 2 weeks and 2 months were 1.6 and 1.8 respectively.

<table><thead><tr><td>Patient group</td><td>Feeds @ 8 weeks</td><td>Stricture</td><td>Dysphagia score</td></tr></thead><tbody><tr><td>1 (N=8)</td><td>N=3</td><td>N=4</td><td>1.3/2</td></tr><tr><td>2 (N=8)</td><td>N=3</td><td>N=3</td><td>1.8/1.4</td></tr></tbody></table>

group 1 passed studies; group 2 failed studies

MIE was associated with significant early morbidities including leaks, DGE, and aspiration. However, a comprehensive algorithm is needed to control for these complications and prevent the more serious event of aspiration. These observations are not translated into sustained morbidities and satisfactory outcomes are observed at two months.

## Esophageal/Gastric Surgery – P334

### RESULTS OF D2 LYMPH NODES DISSECTION IN LAPAROSCOPY-ASSISITED DISTAL GASTRECTOMY, Hideki Kawamura MD, Yukifumi Kondo MD, Kuniaki Okada
MD, Hiroyuki Isizu MD, Hiroyuki Masuko MD, Department of Surgery, JA Sapporo Kosei Hospital

**Introduction:** Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer has recently been spreading rapidly, with an increasing number of medical institutions performing D2 lymph nodes dissection in this surgery, especially in Japan. Although the procedures are essentially the same as laparotomy, D2 lymph nodes dissection in LADG is more difficult. So we investigated safety and accuracy of D2 lymph nodes dissection in LADG. Knack of dissection is very careful handling of forceps. In the event of bleeding from lymph nodes or adipose tissue, hemostasis by compression and the like must be assured before proceeding to the next step.

**Methods:** This is a retrospective analysis of 104 patients undergoing gastrectomy for gastric cancer in our institution between November 2004 and April 2006. 35 cases were D2 in LADG and 69 cases were D2 in open distal gastrectomy (DG).

**Results:** Mean operative time was LADG; 284.2 minutes versus DG; 268.7 minutes (NS). Bleeding volume was LADG; 97.3 ml versus DG; 270.4 ml (p<0.05). Postoperative hospital stay was LADG; 17.2 days versus DG; 22.6 days (p<0.05). Complication rate was LADG; 8.6% versus DG; 18.8% (NS)
<figure><img src="image_143.png" /></figure>

# SAGES POSTER ABSTRACTS

(breakdown of complications in LADG: duodenal stump suture failure in Roux-en Y construction in 1 case, pancreatic juice leakage in 1 case, stenosis at anastomosis in 1 case), and the number of lymph nodes dissected was 49.5 versus 47.7 (NS).

**Conclusion:** D2 lymph nodes dissection in LADG is well applicable without problems with safety and dissection accuracy, if performed by a surgeon skilled in laparoscopic procedures. Currently, early gastric cancer is the only indication of LADG at our department. After carefully evaluating long-term results, this technique may be applicable to some advanced cancers.

## Esophageal/Gastric Surgery - P335

**RESULTS OF ROUX-EN-Y RECONSTRUCTION AFTER LAPAROSCOPY ASSISTED DISTAL GASTRECTOMY COMPAIRED WITH CONVENTIONAL OPEN DISTAL GASTRECTOMY**, Kojima Kazuyuki MD, Inokuchi Mikito MD, Yamada Hiroyuki MD, Kawano Tatuyuki MD, Sugihara Kenichi MD, Esophagogastric Surgery Tokyo Medical and Dental University Graduate School of Medicine

**BACKGROUND:** Although several studies compare surgical results of laparoscopic and open colonic resections, there is few study of laparoscopic gastrectomy compared with open gastrectomy.

**HYPOTHESIS:** When compared with conventional open gastrectomy, laparoscopy-assisted R-Y gastrectomy is less invasive in patients with gastric cancer. **DESIGN:** Retrospective review of operative data, and postoperative clinical course after R-Y gastrectomy.

**SETTING:** University hospital in Tokyo Japan.

**PATIENTS:** The study included 136 patients who were treated with R-Y gastrectomy for gastric cancer from February 2004 to August 2006: 94 with laparoscopy-assisted gastrectomy and 42 with conventional open gastrectomy.

**MAIN OUTCOME MEASURES:** Demographic features examined were operation time; blood loss; length of postoperative hospital stay; postoperative complications; co-morbidity rate; rehospitalization rate; BMI; and number of harvested lymph nodes.

**RESULTS:** Significant differences ($P<.01$) were present between laparoscopy-assisted and conventional open gastrectomy when the following features were compared: postoperative hospital stay (7.3 vs. 12.1 days), blood loss (86 vs. 353g) and operation time (283 vs. 223 minutes). There was no significant difference between laparoscopy-assisted and conventional open gastrectomy with regard to, number of harvested lymph nodes (31.4 vs. 33.9), BMI (22.9 vs. 23.0), co-morbidity rate (32% vs. 40%), rehospitalization rate (3.2 vs. 4.8%) and complication rate (11% vs. 10%).

**CONCLUSIONS:** Laparoscopy-assisted R-Y gastrectomy, when compared with conventional open gastrectomy, has several advantages, including less blood loss, and shorter hospital stay, with no decrease in operative curability and complications. When performed by a skilled surgeon, laparoscopy-assisted R-Y gastrectomy is a safe and useful technique for patients with gastric cancer.

## Esophageal/Gastric Surgery - P336

**MINIMALLY INVASIVE MYOTOMY FOR ACHALASIA IN THE ELDERLY**, Arman Kilic BS, Matthew J Schuchert MD, Arjun Pennathur MD, Rodney J Landreneau MD, Hiran C Fernando MD, Neil A Christie MD, Sebastien Gilbert MD, Ghulam Abbas MD, James D Luketich MD, Department of Surgery, Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center

**INTRODUCTION:** Elderly patients with achalasia are more frequently being referred for minimally invasive Heller myotomy (MIM). The associated morbidity and mortality of MIM in the elderly are not well defined. The objective of this study was to review our experience with MIM in the elderly.

**METHODS:** From May 1996 to May 2006, 56 patients (33 men, 23 women) 70 years or older (mean age 78, range 70 to 96) underwent MIM [54 laparoscopically (LAP), 2 video-assisted thoracic surgery (VATS)]. Variables analyzed included operative and hospital course, perioperative mortality,

postoperative interventions (re-do myotomy, esophagoRECTOMY, balloon dilation, botox injection), and dysphagia scores (range 1? no dysphagia to 5? dysphagia to saliva). This was compared to a concurrent series of 144 young (< 70 years old) patients undergoing MIM (140 LAP, 4 VATS) for achalasia at our institution.

**RESULTS:** Median hospital stay (2 vs. 3 days), conversions to open (0 vs. 3.6%), overall complication rate (13 vs. 11%), perioperative mortality (0 vs. 0%), improvement in mean dysphagia score following MIM (3.25 to 1.32 vs. 3.41 to 1.27), and postoperative interventions (17 vs. 20%) were similar between young and elderly patients at a mean follow-up of 20.9 and 13.3 months, respectively. Complications in the elderly group included 2 (3.6%) intraoperative esophageal perforations, 1 (1.8%) intraoperative gastric perforation, 1 ileus, 1 postoperative intubation, and 1 C. difficile infection. The two conversions to open were due to a significant degree of adhesions discovered intraoperatively and concern regarding the viability of the myotomy after microperforation.

**CONCLUSIONS:** MIM can be performed safely in elderly patients with achalasia. MIM affords similar symptomatic improvement in the elderly as compared to younger patients. MIM should be strongly considered as a therapeutic strategy in the good risk elderly achalasia patient.

## Esophageal/Gastric Surgery - P337

**THE ROLE OF LAPAROSCOPIC ANTI REFLUX SURGERY IN THE PREVENTION OF LUNG FAILURE DUE TO GASTRO OESOPHAGEAL REFLUX IN LUNG TRANSPLANT**

**PATIENTS**, Douglas Fenton-Lee MD, Monique Malouf PhD, John Morton MD, Roo Killick PhD, Allan Glanville PhD, St Vincents Hospital, Sydney, Australia

The major cause of delayed graft failure in lung transplantation is the development of bronchiolitis obliterans syndrome (BOS). There appears to be a causal relationship between reflux and early graft rejection as well as the development of BOS. The mechanisms involved that produce these pathological changes have not been elucidated.

The aim of this study was to evaluate the efficacy of laparoscopic antireflux surgery in the prevention of graft failure in those lung transplant patients with gastro oesophageal reflux

**Method:** In the period from Jan. 2004-Dec 2005 lung transplant patients seen at the St Vincent's lung transplant clinic with deteriorating lung function attributed to BOS were investigated for reflux. Patients with reflux were identified from clinical history, endoscopy and 24 hr pH monitoring. Oesophageal manometry was also performed in all patients. Laparoscopic Nissen fundoplication was performed in all patients with definite reflux.

**Results:** There were 25 lung transplant patients that underwent laparoscopic Nissen fundoplication out of a total of 62 performed at St Vincent's Hospital.

There were no postoperative mortality and no reoperations. The median follow up is 5months(1.5-19). There have been 2 deaths. Six patients have continued to deteriorate. Eight patients are stable and seven have improved lung function. The results of surgery in this cohort of patients are encouraging. The majority of patients in this study had well established BOS with irreversible lung damage. Therefore identifying transplant patients with reflux at an earlier stage for surgery may prevent permanent lung damage with loss of the transplant.

## Esophageal/Gastric Surgery - P338

**INDICATION OF LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY FOR GASTRIC CANCER: AUDIT FOR THE INSTITUTIONAL GUIDELINE**, Young-Woo Kim MD, YW Doh MD, HJ Jung, JH Lee, KW Ryu, IJ Choi, CG Kim, JY Lee, JS Lee, JY Rho, SR Park, JM Bae, National Cancer Center

**Backgrounds:** Laparoscopy-assisted distal gastrectomy (LADG) is becoming popular procedure. However, oncological outcome is still not confirmed and the operation is not standardized yet. Therefore, in our institution, LADG was applied according to the strict guideline. The aim of this
study was to evaluate propriety of institutional guideline
through comparing outcomes of LADG and those of ODG.

**Materials and Methods:** From October 2002 to May 2006, 210 cases of LADG were performed in clinical stage T1N0 or T1N1. 169 cases out of 210 were performed by one surgeon. During the same period, 528 cases of ODG were performed. A LADG was performed by one experienced surgeon and a ODG was done by four surgeons including laparoscopic surgeon. Data were analyzed retrospectively.

**Result:** The clinical and pathological parameters, including age, body mass index, tumor size, lymph node metastasis, TNM staging, histological type and extents of lymph node dissection were not significantly different. Mean operating time for the LADG group were significantly longer than that of the ODG group (264.9 vs. 171.7 minutes, p<0.5). Mean blood loss were significantly lower in the LADG group than in the ODG group (125.6 vs. 253.4 ml, p<0.5). Extents of lymph node dissection and the mean number of harvested lymph nodes was not significantly different between two groups (38.0 vs. 38.2 p=0.878) The LADG group showed faster recovery than ODG group. The average time to return of bowel function (first flatus and first liquid diet) was significantly shorter in the LADG group than in the ODG group. Also, postoperative hospital stay were shorter in the LADG group (7.7 vs. 10.2days, p<0.5). Postoperative complications rate were significantly lower in the LADG group (1.8% vs. 9.1%, p<0.5). Recurrence rate were not significantly different between two groups so far.

**Conclusion:** LADG showed better clinical outcome than ODG in many aspects when performed in cT1N0 and cT1N1 gastric cancer. So, our institutional guideline for LADG could be justifiable in short-term basis. Before considering expansion of indication of LADG, developing careful guideline and audit will be desirable.

Esophageal/Gastric Surgery – P339

TOTALLY LAPAROSCOPIC UNCUT ROUX-EN-Y GASTROJE-
JUNOSTOMY, Jin Jo Kim MD,Seung Man Park MD,Cho
Hyun Park MD,Jun Gi Kim MD, Department of Surgery, Our
Lady of Mercy Hospital, College of Medicine, The Catholic
University of Korea, Incheon, Korea

**Purpose:** Uncut Roux-en-Y gastrojejunostomy (uRYGJ) has been known to be effective in avoiding bile reflux and delayed gastric emptying in the remnant stomach. The purpose of this study is to evaluate the efficacy of totally laparoscopic uRYGJ (TLuRYGJ) in avoiding bile reflux gastritis and delayed gastric emptying after distal gastrectomy.

**Methods:** Fourteen consecutive patients who underwent TLuRYGJ and were followed up at least 6 months after surgery. Eight male and 6 female patients with age of 55.1?10 years and BMI of 23.4?73.4 were enrolled. The reasons for gastrectomy were adenocarcinoma in 13 and duodenal ulcer obstruction in 1 patient. Intracorporeal uRYGJ was performed with laparoscopic linear staplers. First B-II anastomosis and then Braun anastomosis, finally in-continuity stapling with white cartridge on the afferent loop were performed.

**Results:** The operation time was 298i?66 minutes, time for anastomosis was 44i?13 minutes and the estimated blood loss was 90.6i?51.55¢. Oral feeding of liquid meal was started at 3.6i?0.9 days and the hospital stay was 8.5i?2.2 days after surgery. There were 2 cases of complication (14.3%, bleeding and ventral hernia) and was no case of mortality nor conversion to an open procedure. After follow up of 6 months, one patient (7.1%) showed symptom of delayed gastric emptying which need medication and 4 patients showed mild dumping syndrome, but there was no symptomatic bile reflux. In modified Visick classification, eight patients (57.1%) were classified as grade 1 and 6 patients (42.9%) were classified as grade 2. There was no patient whose grade is more than 3. Serum albumin level of the patients was not different from preoperative level (p=0.144), but there was significant difference in body weight (p=0.001) between the weight of pre and postoperative 6 months, though the amount of weight loss was mere (5.8i?74.8%). Follow up endoscopic findings showed 1 case of bile reflux

(7.1%), 1 case of mild gastritis (7.1%) and 4 cases of moder-
ate degree of residual food (28.6%) in the remnant stomach.
In all patients, the in-continuity staple line made on the
afferent loop was remained airtight.

**Conclusions:** TLuRYGJ showed good short term and long term clinical results, especially in avoiding bile reflux and delayed gastric emptying. In-continuity stapling with white cartridge seems to be suitable in occluding the afferent loop without cutting the bowel in TLuRYGJ.

Esophageal/Gastric Surgery – P340

QUALITY OF LIFE AFTER LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY, Seiichi Kitahama MD, Nobuyasu Kano MD, Hiroshi Kusanagi MD, Makio Mike MD, Hisakazu Hoshi MD, Michiko Kitagawa MD, Seiko Uwafuji MD, Yukihiro Watanabe MD, Satoshi Matsuda MD, Satoshi Endo MD, Keitaro Harasawa MD, Department of Surgery, Kameda Medical Center

**Objective:** To evaluate the quality of life of patients who had undergone laparoscopy-assisted distal gastrectomy (LADG) and its clinical outcome.

**Methods:** Quality of life was estimated using the 24-item questionnaire with a scoring system of 1, 2, and 3, and was compared between 27 consecutive patients with LADG and 24 with conventional open gastrectomy. All patients underwent reconstruction by gastroduodenostomy (Billroth I), and the pre- and postoperative diagnoses were early gastric cancer. All the patients who were treated between January 1996 and August 2003 are alive without recurrence as of today.

Results: Patients who had undergone LADG were taking a normal diet with >66% of volume at each meal, and showed significantly better results with regard to weight loss and faster postoperative recoveries. Length of postoperative stay was shorter in LADG group than in conventional group.

**CONCLUSIONS:** Quality of life after LADG was better than that of conventional distal gastrectomy. LADG is technically safe, less invasive and more preferably accepted by patients. This can be the procedure of choice for the treatment of early gastric cancer.

Esophageal/Gastric Surgery – P341

PROBLEMS AND SOLUTIONS FOR INTRODUCTION OF LAPAROSCOPY-ASSISTED GASTRECTOMY FOR GASTRIC CANCER, Nobuhiro Kurita MD, Tomohiko Miyatani MD, Jyun Higashijima MD, Kouzou Yoshikawa MD, Hidenori Miyamoto MD, Masanori Nishioka MD, Mitsuo Shimada MD, Department of Surgery, The University of Tokushima

**Introduction)** Laparoscopy-assisted gastrectomy including lymph node dissection is one of complicated procedures. The aim of this study is to clarify the problems and solutions for introduction of this procedure.

**Patients and methods) The 31 patients (28: distal gastrecto-  
my, 3: total gastrectomy) performed laparoscopy-assisted  
gastrectomy were evaluated after introducing to our insti-  
tute in 2001. The hand assisted laparoscopic surgery (HALS)  
was performed from May, 2004 to October, 2004.

The patients were divided into three groups. The 9 patients (9: distal gastrectomy) before introduction of HALS were divided into the prior group. The 9 patients (7: distal gastrectomy, 2: total gastrectomy) were included in HALS group. The 13 patients (12: distal gastrectomy, 1: total gastrectomy) after October, 2004 were divided into the latter group.

All of the 27 patients of the prior and latter group were clas-
sified Stage I (Japanese Classification of Gastric Carcinoma).
The 9 patients in the HALS group were classified Stage I: 2,
Stage II: 4, Stage III: 1 and IV: 2, respectively.

The classification of lymph node dissection was D1 for the patients with Stage I and IV. D2 lymph node was dissected for the patients with Stage II and III.
Billroth I reconstruction was performed in the prior and HALS group. In the latter group, Roux-en Y reconstruction was selected.

**Results)** The one case in the prior group was converted to ordinary open surgery. The mean operation time was 8h. 2m. in the prior group and 8h. 32m. in the HALS group,

<figure><img src="image_144.png" /></figure>
<figure><img src="image_145.png" /></figure>

# SAGES POSTER ABSTRACTS

respectively. The mean volume of bleeding was 545ml and 558ml, respectively. In the latter group, HALS was not selected and standardization of procedure was promoted after learning the procedures in the high volume center. The mean operation time was 7h. 46m and mean blood loss was 65ml in the latter group. The mean volume of bleeding in the latter group was significantly decreased compared with those of other two groups.

There are no death resulted from progress of gastric cancer except for the patients with Stage IV.

**Conclusions** HALS is not useful for introduction of this procedure. Standardization of procedures is considered to be essential to improve laparoscopy-assisted gastrectomy.

## Esophageal/Gastric Surgery - P342

### PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN THE DIRECT PUNCTURE TECHNIQUE -- AN ALTERNATIVE TO OPEN JEJUNAL FEEDING TUBE PLACEMENT?, Jessica M Leers MD, Hartmut Schaefer MD, Jeffrey A Hagen

MD,Peter H Collet MD,Arnulf H Hoelscher MD, Department of Surgery, University of Cologne, Germany and Division of Thoracic and Foregut Surgery, University of Southern California, Los Angeles, CA

**Introduction:** The percutaneous endoscopic gastrostomy (PEG) is a common procedure performed to restore enteral feeding in patients with temporary or permanent swallowing disorders. Most commonly, a PEG is placed by the pull through technique, however it has limitations. In patients with obstruction of the pharynx or esophagus, a bumper pull through is not feasible. Additionally, the pull through technique in patients with an esophageal stent risks dislocation. To address these difficulties a new device called the direct puncture PEG (cliny®) has been established.

**Methods:** The direct puncture PEG (cliny®) was placed in 26 patients with swallowing disorders and anticipated difficulties pulling the button through the pharynx or the esophagus. After passing the endoscope into the stomach two gastropexies were performed with the introducer system. These two sutures fixed the anterior gastric wall onto the abdominal wall. A trocar was then placed safely in between the two sutures. With a peel away system, the tube was introduced into the stomach. Finally, a water balloon at the tip of the tube was filled with 5 ml of saline to secure the catheter placement, and an external bumper fixed the system at the abdominal wall. The cuff of the catheter was deflated and inflated every 24 hours for the first 2 weeks to avoid dislocation. Afterwards, a constant gastrocutaneous fistula has been created and a new catheter can be placed safely.

**Results:** There were 9 female and 17 male patients included in the series. 25 patients had cancer of the pharynx or esophagus, one patient had an esophageal stricture caused by severe reflux esophagitis. The cliny® PEG was safety placed on all 26 patients. Two patients developed minor wound infections that were treated conservatively. In another two patients, tube dislocation occurred. One of these patients was referred for an open placement of a jejunal feeding tube. The other patient received a second percutaneous placement with the introducer technique while the gastropexies were still in place. In both patients the cuff was empty and the standard post interventional treatment was not performed.

**Discussion:** The cliny® direct puncture PEG system is safe, and can be used in cases of severe esophageal stenosis where a standard pull through PEG is not feasible. Other theoretical advantages include elimination of the risk of tumor implants and the ability to place the PEG in a patient who has a stent in place.

## Esophageal/Gastric Surgery - P343

### LAPAROSCOPIC GASTRIC RESECTION FOR BENIGN AND MALIGNANT CONDITIONS, Victor Y Liew MD, Craig Taylor MD,Murtaza Jannagerwalla MD, Michael Ghusn MD, Laurent Layani MD, John Flynn Hospital Queensland Australia
35 cases of laparoscopic gastric resection has been performed at our institution. There were 21 laparoscopic partial gastrectomy, 8 distal gastrectomy & 4 total gastrectomy. Laparoscopic surgery was performed on benign ulcers,

polyps, GIST and EGC as curative intent whereas for invasive adenocarcinoma surgery was performed mainly for palliative intent. The conversion rate was 6% (2 cases). The mortality rate was 3% (1 case) and there was a case of non fatal anastomotic leak. 1 patient (benign leiomyoma) was lost to follow up. Overall the median follow up period was 12months, range 1-46months.

There were 8 cases of benign GIST, all had a laparoscopic partial gastrectomy. 1 patient died 5 months later from unrelated cardiac causes at the age of 90 years. All the others are still alive after a median follow up of 6.5 months, range 1-30 months. There were 5 cases of EGC, 4 underwent laparoscopic partial gastrectomy and 1 laparoscopic total gastrectomy for recurrent EGC. All patients are still alive after a median follow up of 7 months, range 1-46 months.

There were 10 cases of adenocarcinoma, 1 underwent a partial gastric resection, distal gastrectomy was performed in 6 patients and 3 had a total gastrectomy. Excluding the 1 post operative mortality, 5 out of the 8 patients are still alive after a median follow up of 18 months, range 7-38 months. The median number of lymph nodes harvested during a distal or total gastrectomy was 11, range 8-34.

There were 3 cases of local recurrence after initial successful resection. There was a case of isolated cutaneous (non port site) metastasis. All these cases were managed by further surgery.

For laparoscopic partial gastrectomy the median operating time was 75 minutes, median LOS 5 days. The median operating time for laparoscopic distal & total gastrectomy was 205 & 252.5 minutes respectively, the LOS was 6.5 & 8 days respectively.

At the present time laparoscopic gastric surgery remains an alternative treatment option. Its role in the surgical management of gastric neoplasm is still evolving. As the data supporting the adequacy of laparoscopic nodal dissection remains in its infancy the most appropriate indication for laparoscopic gastric surgery at the present time is for benign diseases especially for GIST. It may be an option for EGC or invasive adenocarcinoma in those who are not suitable for an open gastrectomy.

## Esophageal/Gastric Surgery - P344

### INITIAL EXPERIENCE WITH MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY IN A COMMUNITY HOSPITAL,

Rockson C Liu MD, James S Choi MD, Samuel K Liu MD, CK Chang MD, Kanti M Uppal MD, Kaiser Permanente Medical Center, Walnut Creek, California

**BACKGROUND:** Tertiary university centers have demonstrated the feasibility and safety of minimally invasive esophagectomy. However, there is a paucity of data from non-academic institutions. This study details our initial experience with minimally invasive Ivor Lewis esophagectomy in a community hospital.

**METHODS:** In the early part of 2006, 4 minimally invasive Ivor Lewis esophagectomies were performed with collaboration between a cardiothoracic surgeon and a fellowship-trained laparoscopic surgeon. The abdominal portion, completed entirely laparoscopically, included complete mobilization of the stomach and distal esophagus, Kocherization of the duodenum, lymph node dissection, a Heineke-Mikulicz pyloroplasty and a feeding jejunostomy. Resection of the esophagus/stomach, mediastinal lymph node dissection and a high thoracic anastomosis (above the azygos vein) with a circular stapler was performed through a minithoracotomy. Charts were reviewed retrospectively.

**RESULTS:** The mean age was 57 years (range, 44 to 68) and average BMI was 24.7 kg/m2 (range, 18.7 to 30.6). Fifty percent of patients received preoperative chemoradiation. One patient had squamous cell carcinoma-in-situ and 3 patients had invasive adenocarcinoma. All procedures were completed as planned, with no conversions. The average operative time was 5 hour 27 mins (range, 4:42 to 7:13). The average hospital stay was 6.25 days (range, 6 to 7). There were no anastomotic leaks as demonstrated by esophagram on postoperative day 5 or 6. There were no mortalities and no complications with an average follow up of 75 days (range, 39 to 108).
**CONCLUSION:** Our initial results demonstrate the feasibility and safety of minimally invasive Ivor Lewis esophagectomy at a community hospital. Extended followup is necessary to demonstrate oncologic equivalence to the traditional approach.

## Esophageal/Gastric Surgery - P345

**DOES TREATMENT VOLUME INCREASE SURVIVAL IN PATIENTS WITH ESOPHAGEAL CANCER?** CK Chang MD, RC Liu MD, JS Choi MD, SK Liu MD, K Uppal MD, PR Fuchshuber MD, Department of Surgery, Kaiser Permanente, Walnut Creek CA

**Background:** The aim of this study was to review the overall survival in patients diagnosed with esophageal cancer among various medical centers based on diagnostic volume.

**Methods:** A retrospective review was undertaken to identify patients diagnosed with esophageal cancer at all Northern California Kaiser Permanente facility. All patients received their treatments between January 1988 and December 2004. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and Cox regression.

**Results:** An analysis of 1495 patients among the 19 medical facilities identified only 5 locations had greater than 100 esophageal cancer diagnoses during the study period. Mean age was 65, with median survival of 9 months. Overall survival was 29 months versus 23 months in patients treated at high volume and low volume facilities, respectively (p<.05). Multivariate analysis demonstrated that age, stage and high volume centers were statistically significant in OS.

**Conclusion:** Multidisciplinary approach to the treatment of esophageal cancer may improve overall survival. Further research is needed to further identify factors which may lead to improved clinical outcomes.

## Esophageal/Gastric Surgery - P346

**LAPAROSCOPIC CARDIECTOMY (LC) FOR EARLY GASTRIC CANCER WITH PRESERVATION OF THE VAGUS NERVE,** Eishi Nagai MD, Masato Watanabe MD, Shuji Shimizu MD, Hirokazu Noshiro MD, Masao Tanaka MD, Department of Surgery and Oncology, Kyushu University

**Objective:** One of the biggest advantages of laparoscopic surgery is that magnified view provided by the laparoscope enables the surgeons to identify and preserve the nerve fibers easily. Cardiectomy for early gastric cancer has been reported to have the advantages of preventing poor nutrition. We report here the surgical technique of LC with preservation of the vagal nerve to mainly keep pyloric function.

**Methods:** After cutting the greater omentum, we divided left gastroepiploic artery and short gastric arteries with Ligasure Atlas. Next, we exposed the lesser omentum, taking care not to damage the hepatic branch of the vagal nerve. After that, we cut the anterior vagus on the distal side. After tapping the posterior vagus and the celiac branch of the vagus, we cut the gastric branches from the posterior vagus and detached the root of the left gastric artery to complete the No.7 lymphadenectomy. We divided the stomach along the anal cutting line to resect upper third of the stomach with liner stapler. After transection of the esophagus, the resected stomach was pulled out through the left subcostal incision of 3cm. After that, esophagogastrectomy was performed with linear staplers.

**Results:** Six out of 253 patients who underwent laparoscopy-assisted gastrectomy for gastric neoplasm received LC in our department. Mean operation time was 294 min, mean blood loss 131g, and mean hospital stay 18 days. No complications including reflux esophagitis was found in this series

**Conclusion:** LC may be an excellent option of the surgical treatment for early gastric cancer because of its minimal surgical invasiveness and better postoperative quality of life.

## Esophageal/Gastric Surgery - P347

**A PROSPECTIVE STUDY OF THE IMPACT OF INDUCTION, CONCURRENT CHEMORADIATION ON PERIOPERATIVE MORBIDITY AND MORTALITY FOLLOWING AN**

**ESOPHAGECTOMY,** Tracey L Weigel MD, Katie S Nason MD, James Maloney MD, Cassandra Kight MD, Kenneth Kudsk MD, University of Wisconsin-Madison

**Background:** Esophageal cancer (EC) treated with esophagectomy alone has poor long-term survival. Trials using induction chemoradiation (iCTRT) followed by esophagectomy are ongoing, but the impact of iCTRT on outcomes following esophagectomy is not well-documented. We hypothesize that perioperative complications and length of stay(LOS) are increased in patients undergoing esophagectomy after iCTRT.

**Methods:** Patients evaluated for EC were included in a prospective, IRB-approved database between January 1, 2006 and May 31, 2006. Preoperative variables (e.g. body mass index, nutritional indices, percent body weight loss and treatment with iCTRT) were collected. Perioperative variables including major complications (e.g. pneumonia, anastomotic leak) and death were recorded. Statistical analysis was performed using STATA®. Student's t-test and chi-square analysis was used for determination of differences between groups and univariate analysis to determine odds of increased LOS and major complications.

**Results:** To date, 23 patients have consented for inclusion in the database (first 6 months of data accrual). 21 patients underwent esophagectomy performed by a single surgeon with resident surgeon assistance. 8/21 (38%) patients received iCTRT. There were no perioperative deaths. Median LOS (11.3 vs 11.2;p=0.95) and anastomotic leak rates (n=2, 25% vs n=1, 7.7%;p=0.27) for each group were similar. There was, however, a statistically significant difference in the rate of major complications in the iCTRT group (p=0.03).

**Conclusions:** iCTRT is associated with a higher rate of major complications following esophagectomy. This is not associated with an increased LOS or mortality. Additional phase II trials are necessary to confirm the safety of esophagectomy following future iCTRT strategies.

## Esophageal/Gastric Surgery - P348

**REVISIONAL SURGERY AFTER HELLER MYOTOMY FOR TREATMENT OF ACHALASIA: A DESCRIPTIVE META-**

**ANALYSIS FOCUSING ON OPERATIVE APPROACH,** Biswanath Gouda MD, Thomas J Nelson MD, Sunil Bhoyrul MD, Scripps Clinic, Torrey Pines, CA 92037

**Background:** We conducted a systematic review of published literature to study the incidence, demographics, operative approach and mortality associated with revisional surgery following primary Heller myotomy for achalasia. Management of achalasia has evolved from using whale-bone dilation to current modalities including botulinum toxin injection, pneumatic dilation and Heller myotomy. Although surgical myotomy is the gold standard in therapy, treatment failures are problematic and require revisional surgery.

**Methods:** We conducted a MEDLINE search of peer-reviewed articles published in English from 1970 to December 2005 using the following search terms: esophageal achalasia, Heller myotomy and revisional surgery. 33 articles satisfied our inclusion criteria.

**Results:** A total of 12,727 patients underwent Heller myotomy (open 94.8%, laparoscopic 5.2%) with mean age of 43.3 yrs (males 46%, females 50%). 16% of patients underwent an additional anti-reflux procedure during the same operation. Revisional surgery was performed in 6.19% (n= 789) cases with mean age of 41.8 yrs (males 53.7%, females 50.5%). Approaches to re-operation included thoracic or abdominal, open or videoscopic. Procedures performed at the second operation included revision of the original myotomy or creation of a new myotomy with or without an anti-reflux procedure or esophagectomy. The laparoscopic approach was used less frequently during revisional surgery than for the primary operation (2.3% vs. 5.2%). Reasons for re-operation were incomplete myotomy (51.8%), onset of
<figure><img src="image_146.png" /></figure>

# SAGES POSTER ABSTRACTS

reflux (34%), mega esophagus (16.2%) and esophageal carcinoma (3.04%). The mean follow up before revisional operation was 105.8 months for open approach and 25.7 months for laparoscopic approaches. The overall mortality rate was 0.63% following re-operative surgery.

**Conclusions:** Our systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of re-operation with a low mortality rate. Few patients underwent concomitant anti-reflux procedures during the primary operation. Most of the long-term follow-up has been in patients with open approach.

## Esophageal/Gastric Surgery - P349

**HELLER LAPAROSCOPIC SURGERY AS TREATMENT FOR ACHALASIA**, Pablo E Omelanczuk MD, Jorge A Nefa MD, Sergio E Bustos MD, Walther Minatti MD, Department of General Surgery, Hospital Italiano de Mendoza, Argentina. Lateral Este 1015 Guaymallén, Mendoza, Argentina

**Objective:** Heller esophagocardiomyotomy is the surgery of choice for the treatment of Achalasia. In addition, laparoscopy gives a mini-invasive quality to this surgery. Disphagia constitutes the main symptom. Diagnosis is performed by means of esophageal manometry. To show the technique and results.

**Materials and Method:** Over a period of 40 months, 45 patients were treated with Heller myotomy plus Dor fundoplication laparoscopically. All patients had lost weight, and there was a prevalence of females with an average age of 46. Twelve patients had Chagas disease. They were all assessed with serial X-rays, endoscopy, esophageal manometry, and their symptoms were assessed with a 0-4 score, 4 being the most severe.

**Results:** There was no conversion or mortality. In 2 patients the mucosa was perforated during myotomy. The mucosa was sutured without altering the result of the treatment. Average hospital stay was 48 hours. There were no post-operative complications. Twenty patients were followed up with manometric control and pH-probe testing, and only six of those had pathologic reflux.

**Conclusions:** Laparoscopic treatment of achalasia is possible and reproducible, while reducing the morbidity of laparotomy.

## Esophageal/Gastric Surgery - P350

**LAPAROSCOPIC INTRAGASTRIC RESECTION OF GASTROINTESTINAL STROMAL TUMORS**, T Omori MD, K Nakajima PhD, A Nishitani MD, T Takahashi MD, J Nishimura MD, T Ito PhD, T Nishida PhD, Department of Surgery, Osaka University Graduate School of Medicine

Gastrointestinal stromal tumors (GISTs) are a rare neoplasm arising from the intestinal cells of Cajal. Laparoscopic wedge resections have become an acceptable approach to gastric GISTs because wide resections and excessive lymphadenectomies are usually not required. Laparoscopic intragastric surgery (LIGS) has been known as an intraluminal approach to gastric lesions. Recently, LIGS for intraluminal growth type of gastric GISTs have been sporadically reported with acceptable immediate surgical outcome. However, it still remains unknown whether LIGS is appropriate for gastric GISTs in regard to oncologic outcome e.g. tumor recurrence and long term survival. The objectives of this study were 1) to confirm the feasibility and safety of LIGS for gastric GISTs, and 2) to assess its short- and intermediate-term oncologic results. To our knowledge, this is the first surgical literature that evaluated intermediate-term oncologic results of LIGS for gastric GISTs.

**Methods:** A retrospective analysis of 10 patients with intraluminal growth type of gastric GISTs undergoing LIGS between April 2000 and July 2006 was performed. There were 4 males and 6 females with median age of 63 years old. Initially, balloon-type port 12mm in diameter was introduced just above the umbilicus and the stomach was then insufflated with carbon dioxide via the port, using an automatic surgical insufflator with the intraluminal pressure of 8 mmHg. Two working ports were placed into the stomach via the abdominal wall. The partial intragastric resection was performed using laparoscopic linear stapling devices. The resected specimen was removed via the initial port site.

**Results:** Stapler resections of gastric GIST were performed in all cases without any intraoperative complications. There was no conversion to open or any other laparoscopic surgeries. The median operative time was 136 minutes (range, 95-140 minutes), and median blood loss was 15 ml (range, 15-40 ml). The median maximal diameter size of the resected specimens was 35 mm (range, 25-45 mm). All patients showed rapid and uneventful recovery after surgery. There was neither mortality nor serious morbidity in this series. There were no recurrences during a median follow-up period of 53 months (range, 2-78 months).

**Conclusion:** The laparoscopic intragastric approach to gastric GIST tumors is feasible and safe, and associated with excellent short- and intermediate-term results. LIGS can be promising therapeutic methods for gastric GIST.

## Esophageal/Gastric Surgery - P351

**LAPAROSCOPIC HIGHLY SELECTIVE VAGOTOMY FOR DUODENAL ULCER WITH OR WITHOUT GASTRIC OUTLET OBSTRUCTION**, Hiroaki Omori MD, Akira Sasaki MD, Go Wakabayashi MD, Department of Surgery, Iwate Medical University, Shizuoka-ishi Omori Clinic

**Background:** Medical treatment helps ulcers in 90% of the cases but they recur in 50-70% of the patients. We present a proposal of laparoscopic treatment for patients with recurrent ulcer after a long-term medical treatment or with gastric outlet obstruction.

**Method:** Four patients underwent laparoscopic highly selective vagotomy (HSV) with or without pyloroplasty between 1998 and 2006. There were 4 male patients aged 19-45 years (mean age: 30years). All patients were operated electrically. For patients with a chronic peptic ulcer disease, preoperative assessment involved a recent gastroscopy, upper G.I., gasric acid output measurment and mandatory 24-hour pH measurement.

**Results:** HSV proved feasible in 100% of the cases in spite of a history of previous surgery and peritonitis on patients with a perforated ulcer. There were neither conversions nor intraoperative complications. There was no mortality or morbidity except one patient with transient esophageal stricture following vagotomy around abdominal esophagus. All patients were rated Visick I and II. The acid output had significantly decreased 6.3 to 0.9 in BAO, 26.9 to 3.4 in MAO, respectively. No patient had recurrence in follow-up periods without medication.

**Conclusions:** Laparoscopic highly selective vagotomy is a treatment of choice for recurrent duodenal ulcer with or without gastric outlet obstruction. The laparoscopic approach shortens the hospital stay and improves patient's comfort.

## Esophageal/Gastric Surgery - P352

**LAPAROSCOPIC MANAGEMENT OF MARGINAL ULCER PERFORATION AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS**, Sotero E Peralta MD, Frank Borao MD, Monmouth Medical Center, Long Branch, New Jersey

Marginal ulceration after Roux-en-Y gastric bypass occurs in 2-10% of patients. The cause of stomal ulcer is multifactorial and may result from a combination of acid from parietal cells in the pouch, ischemia of (or tension on) the Roux-en-Y limb to the pouch, and a history of tobacco or nonsteroidal anti-inflammatory drug (NSAID) use. Laparoscopic repair of perforated peptic ulcer was reported in 1990 but has not gained wide acceptance. We present the case of a 33 year-old female who presented two years and a half after a laparoscopic Roux-en-Y gastric bypass with pneumoperitoneum and peritonitis. An exploratory laparoscopy demonstrated an ulcer on the gastric pouch, with severe peritonitis and intraabdominal abscesses. A laparoscopic suture closure of ulcer with an omental patch was performed. We describe a case report of a successful laparoscopic management of an acute abdomen in patient status laparoscopic roux-en-y gastric bypass.
<figure><img src="image_147.png" /></figure>

## Esophageal/Gastric Surgery - P353

**LAPAROSCOPIC HELLER MYOTOMY? TEN YEAR EXPERIENCE.**, Joseph B Petelin MD, J. T Methvin DO, Department of Surgery, University of Kansas School of Medicine, Kansas City Kansas, Surgix Minimally Invasive Surgery Institute, Shawnee Mission, Kansas.

**Objective:** We sought out to review the senior author's (JBP) 10-year experience with laparoscopic treatment of achalasia in a community-based hospital setting.

**Methods:** The records of all patients with achalasia admitted to JBP from January 3, 1996 through July 13, 2006 were reviewed.

**Results:** All 37 patients had esophagogastroduodenoscopy (EGD) findings consistent with (c/w) achalasia. All patients had an esophageal manometry study; 30 were c/w achalasia and 7 were non-diagnostic. Radiological studies performed in 35 patients revealed 34 c/w achalasia and 1 non-diagnostic. Sixteen patients had previous dilatation for achalasia, 4 had botulinum toxin injection (Botox), 9 had both Botox and dilatation, and 1 patient had previous open Heller myotomy. Laparoscopic Heller myotomy with Dor plication (LHD) was performed in 30 patients, and laparoscopic Heller myotomy with Nissen fundoplication (LHN) was performed in 7 patients. Robotic interface (DaVinciTM) was used in 10 cases. No cases were converted to laparotomy. 18 concomitant procedures were performed in 13 patients.

Mean overall operative time was 115.6 min. (94.4 min for the last 12 patients). Mean postoperative length of stay was 35.1 h. The mean postoperative time to first liquid and solid oral intake was 12.1 h and 41 hr respectively. Dysphagia was resolved in 31 patients (84%); 5 patients had mild dysphagia but still improved from preoperative status. One patient reported moderate dysphagia that was not improved from preoperative status. Mild reflux symptoms were reported in 8 patients (22%). Intraoperative complications occurred in 4 patients (10.8%): 2 esophageal perforations repaired intraoperatively, 1 small bowel serosal injury during enterolysis repaired intracorporeally, and a small (5-10%) right apical pneumothorax which resolved without intervention. Postop alectasia developed in 3 patients and pulmonary edema in one patient. Mean length of follow up was 100.4 days.

**Conclusions:** Laparoscopic treatment of achalasia can be performed successfully with minimal complications in a community hospital in the hands of adequately trained laparoscopic surgeons.

## Esophageal/Gastric Surgery - P354

**UTILITY OF TIMED BARIUM ESOPHAGRAM IN THE SURGICAL TREATMENT OF ACHALASIA**, Christian G Peyre MD, Steven R DeMeester MD, Andrew L Tang MD, Shahin Ayazi MD, Jessica M Leers MD, Nuttha Ungnapanatin MD, Jeffery A Hagen MD, John C Lipham MD, Tom R DeMeester MD, Department of Surgery, Keck School of Medicine of the University of Southern California

**Objective:** Timed barium esophagram (TBE) is a simple and objective test that we hypothesize is a useful measure of improvement in esophageal emptying after laparoscopic myotomy (LM) and correlates with improvement in symptoms.

**Methods:** From 1999 to 2006, 29 patients underwent LM with partial fundoplication and had TBE obtained both before and after surgery. TBE was performed by ingesting 100-150 cc of thin barium in 30-45 seconds. Fluoroscopic images were obtained in the upright position at 1 and 5 minutes intervals. Difference in area of the residual column of barium within the esophagus between time intervals was calculated to obtain percent degree of emptying. Results: Preoperatively, all 29 patients complained of dysphagia and 28/29 complained of regurgitation. The median esophageal emptying on TBE was 24% (IQR 7, 42) with 24/29 having <50% esophageal emptying. LM resulted in complete resolution of dysphagia in 26/29 patients, complete resolution of regurgitation in all patients, and a significant increase in esophageal emptying [median 100% (IQR 42, 100), p<0.0001(paired T-test)] on TBE. All patients with emptying >50% were asymptomatic at follow-up. Emptying was <50%

in 9 patients and of these 3 had persistent or recurrent dysphagia and 6 were asymptomatic.

**Conclusion:** TBE is an objective assessment of relief of outflow obstruction after LM and esophageal emptying >50% was reliably associated with complete relief of dysphagia and regurgitation. Whether < 50% emptying in patients with improved symptoms will indicate a higher risk of late recurrence of obstructive symptoms remains to be seen.

## Esophageal/Gastric Surgery - P355

**LAPAROSCOPIC GASTRIC RESECTION: TECHNIQUE AND OUTCOMES IN 25 PATIENTS.**, George Poultsides MD, G. Peter Bloom MD, Rocco Orlando 3rd MD, Connecticut Surgical Group, Department of Surgery, Hartford Hospital, University of Connecticut School of Medicine

**OBJECTIVE:** The purpose of this study is to evaluate different laparoscopic approaches in the management of gastric neoplasms based on tumor location.

**METHODS:** Over a seven-year period 25 patients with benign or premalignant gastric tumors, less than 7 cm in size were evaluated for laparoscopic resection. Medical records were reviewed retrospectively to define technical details and perioperative outcomes.

**RESULTS:** Mean patient age was 61 years (range, 23-89). Operative strategies included wedge resection (n=9), segmental resection with gastroenteric anastomosis (n=5), transgastric resection (n=4) and enucleation (n=2). Five cases (20%) were converted to open; two secondary to adhesions, two due to tumor involvement of the transverse mesocolon and one following the intraoperative discovery of linitis plastica. Five antral tumors warranted laparoscopic distal gastrectomy due to size or proximity to the pylorus. Reconstruction with an extracorporeal hand-sewn Billroth I gastroduodenostomy was performed through a 5-cm accessory paramedian incision. Hand-assistance was mainly utilized for resection of cardia or prepyloric lesions. Purely laparoscopic resection was achieved in 55% of patients (n=11). Tumor localization with intraoperative EGD or preoperative endoscopic tattooing was utilized in 6 cases (30%). Mean operative time was 135 min (range, 49-295) and mean blood loss was 75 ml (range, 10-700). Final pathologic findings were gastrointestinal stromal tumor- GIST (10 patients), adenoma (3), in situ carcinoma (3), carcinoid (2), and gastric glomus tumor (2). All lesions had negative margins (range 2-45 mm). Mean tumor size was 3.3 cm (range, 1-5.5 cm). Mean hospital stay was 5 days (range 2-15). Three patients (15%) experienced major complications including splenic capsule tear requiring splenectomy, pseudomembranous colitis, and hand-port incisional hernia.

**CONCLUSIONS:** Laparoscopic gastric resections can be performed safely in selected patients with a variety of benign or premalignant gastric disorders. The use of an accessory incision for hand-assistance, extracorporeal anastomosis, and specimen extraction facilitates the procedure in difficult cases.

## Esophageal/Gastric Surgery - P356

**HAND-ASSISTED LAPAROSCOPIC TRANSDUODENAL RESECTION: INITIAL EXPERIENCE.**, George Poultsides MD, Biju Lukose MD, G. Peter Bloom MD, Rocco Orlando 3rd MD, Connecticut Surgical Group, Department of Surgery, Hartford Hospital, University of Connecticut School of Medicine

**OBJECTIVE:** The purpose of this study is to evaluate the feasibility and benefits of hand-assisted laparoscopic local excision of duodenal neoplasms.

**METHODS:** Over a seven-year period eight patients with duodenal tumors not amenable to endoscopic excision were evaluated for hand-assisted laparoscopic transduodenal resection. Contraindications included severe obesity and malignancy. Medical records were reviewed retrospectively to define technical details and perioperative outcomes.

**RESULTS:** Mean patient age was 70 years (range, 49-85). Mean body mass index (BMI) was 23 (range 21-25). Mean tumor size was 3 cm (range, 2-4.5 cm). Two lesions were located at the duodenal bulb, three at the second portion of the duodenum, but discrete from the ampulla of Vater, and
<figure><img src="image_148.png" /></figure>

SAGES POSTER ABSTRACTS

three at the third portion. The procedure was initiated using a right paramedian hand-port and additional working ports in the left upper quadrant for hepatic flexure takedown and wide Kocher maneuver. The duodenum was then delivered extracorporeally through the right paramedian incision and local excision of the lesion was carried out followed by hand-sewn closure of the duodenotomy. The plane of resection was submucosal when feasible (4 patients) and transmural in the remaining of the cases. Conversion to open by extending the incision for 3 cm was necessary for one lesion located at the third portion of the duodenum. Final pathologic diagnoses were tubular adenoma (four patients), carcinoid, gastrointestinal stromal tumor (GIST), lipoma, and Brunner's gland hyperplasia. All lesions were removed completely with negative margins. Estimated blood loss was < 50 ml in all cases. Mean operative time was 130 min (range, 105-170) Mean hospital stay was 5 days (range, 3-8). One patient developed a hand-port site incisional hernia. Recurrence has been observed in one of the four adenoma patients on routine endoscopic surveillance at a mean follow up of 33 months (range 6-84).

**CONCLUSIONS:** In selected patients, the addition of hand-assistance can safely facilitate laparoscopic local excision of benign duodenal tumors by providing tactile feedback, atraumatic and versatile retraction, safe blunt duodenal kocherization and extracorporeal transduodenal resection.

Esophageal/Gastric Surgery - P357

LAPAROSCOPIC TRANSHIALATÉR ESOPHAGECTOMY (THE)
WITH SELECTIVE LYMPHADENECTOMY FOR HIGH GRADE
DYSPLASIA AND OESOPHAGEAL CANCER, S RAWAT,A.I
SARELA,J WELLS,HM SUE-LING,MJ McMahon,SPL Dexter,
LIMIT and LEEDS GENERAL INFIRMARY, LEEDS, U.K

**Aim/ Introduction** Laparoscopic THE may be an acceptable approach to early esophageal cancer with the potential for fewer pulmonary and wound related complications. This report summarizes our early experience with laparoscopic THE with selective lymphadenectomy in patients with HGD or early esophageal cancer.

**Method** Case notes for 23 consecutive laparoscopic transhiatal esophagectomies between June 2003 and July 2006 were reviewed. Patients with HGD in Barrett's esophagus or early esophageal cancer were selected. Patient demographics, intra-operative features, pathology results and clinical follow-up were examined.

**Result** There were 16 men and 7 women; median age 69 years (range, 50-80 years). Laparoscopic THE was successfully completed in 22 patients, with one conversion. The median operative time was 420 minutes (range 300-660 minutes). Two patients required blood transfusion. The median hospital stay was 18 days. There was no perioperative mortality. 6 Patients developed cervical anastomotic leakage that was managed in standard fashion. Median number of harvested lymph node was 18. Final pathological staging was HGD (n=3), Tis (n=11) and invasive cancer (n=9). There was no cancer recurrence or death at Follow-up range of 2 to 36 months.

**Conclusions** Laparoscopic transhiatal oesophagectomy is a technically challenging operation. It is possible to achieve adequate lymph node clearance with no mortality but morbidity is not avoided. Further experience and a longer term follow up are needed to assess its value and confirm the oncological safety of the procedure.

Esophageal/Gastric Surgery - P358

LAPAROSCOPIC HELLER MYOTOMY USING HOOK ELECTROCAUTERY: A SAFE, SIMPLE, AND INEXPENSIVE ALTERNATIVE, Josh E Roller MD,Eric J DeMaria MD,Sebastián G de la Fuente MD,Aurora D Pryor MD, Department of Surgery, Duke University Medical Center, Durham, NC

**Objective:** Laparoscopic Heller myotomy (LHM) is currently considered the standard surgical therapy for achalasia. Historically, it has been associated with an intra-operative esophageal perforation rate of 5-10%. Recent literature has suggested robotic-assisted Heller myotomy is safer because of a reported lower incidence of intra-operative esophageal perforation than conventional techniques. We evaluated the

results of LHM in a large series using simple hook electrocautery.

**Methods:** All patients undergoing LHM with Dor fundoplication (LHMDF) for achalasia by a single surgeon (AP) from 2003 through 2006 were retrospectively reviewed at a multi-center academic institution. Demographic, peri-operative and follow-up data were collected.

**Results:** A total of 54 patients underwent LHMDF for the treatment of achalasia. 52% were female and 48% were male and the average age was 50 years with 6 patients under the age of 18 years. The average BMI was 26.7 with 4 patients whose BMI was over 35. Average operative times, EBL, and length of stay were 113 minutes, 44ml, and 34 hours respectively. Only one patient was converted to an open procedure (1.9%) secondary to inadequate exposure attributed to an enlarged liver. There was one (1.9%) intraoperative esophageal perforation in the series, which was sutured during the original operation without sequelae. Botox injection therapy and endoscopic dilatation were administered pre-operatively in 24% and 43% of patients, respectively. Despite evidence that pre-operative Botox increases the risk of esophageal perforation, this was not demonstrated in our patient population. There were no post-operative leaks and persistent dysphagia was present in only 3.7% at an average of 5 months follow-up.

**Conclusion:** LHMDF using simple hook electrocautery is safe, inexpensive and effective for the treatment of achalasia. Our series demonstrates that with meticulous surgical technique, intra-operative esophageal perforation is a rare event using hook electrocautery and provides comparable safety to robotic-assisted Heller myotomy without the added expense of a robotic system.

Esophageal/Gastric Surgery - P359

GIANT HIATAL HERNIA DOES NOT ADVISELY IMPACT
OUTCOME AFTER LAPAROSCOPIC FUNDOPLICATION FOR
GERD, Sharona Ross MD,Sarah M Cowgill MD,John E
Mullinax BS,Emily Kraemer,Sam Al-Saadi MD,Desiree
Villadolid MPH,Paul Toomey BS,Alexander S Rosemurgy
MD, Department of Surgery, University of South Florida
College of Medicine

**INTRODUCTION:** Giant hiatal hernia, and, thereby, a shortened esophagus, is believed to predispose to recurrence of symptoms and failure after laparoscopic fundoplication. This study was undertaken to compare long-term outcomes after laparoscopic fundoplication for patients with giant hiatal hernias and GERD alone.

**METHODS:** Since 1990, 135 patients with GERD and giant hiatal hernias, defined as a patulous esophageal hiatus with at least half of the stomach in the mediastinum, underwent laparoscopic fundoplications and have been prospectively followed. Their symptoms were compared to symptoms of 135 concurrent patients with GERD alone undergoing laparoscopic fundoplication. Before and after fundoplication, patients scored, among many symptoms, the frequency and severity of dysphagia, chest pain, regurgitation, choking, and heartburn using a Likert scale (0=none/never to 10=always/severe). Data is presented as mean ± SD.

**RESULTS:** For patients with giant hiatal hernias and GERD vs. GERD alone, preoperative median DeMeester scores were similar (46 vs. 39, p=0.65) with similarly troubling symptoms (Table). Mean follow-up is 27 months ± 26.7. Laparoscopic fundoplication ameliorated the frequency and severity of symptoms of GERD (Table) without differences between patients with or without giant hiatal hernias (Table). For patients with giant hiatal hernias and GERD vs. GERD alone, 89% vs. 82% felt their symptoms were greatly improved or resolved, 87% vs. 80% felt their outcome was satisfying or better, and 91% vs. 84% felt they would undergo fundoplication again knowing what they know now.

**CONCLUSIONS:** After laparoscopic fundoplication, patients? symptoms improve and satisfaction is durable and high. Giant hiatal hernia does not adversely impact symptomatic outcome after laparoscopic fundoplication for GERD, and therefore, the need for concomitant esophageal lengthening procedures is questioned.
SAGES POSTER ABSTRACTS

<table><thead><tr><th>Frequency</th><th colspan="2">Dysphagia</th><th colspan="2">Regurgitation</th><th colspan="2">Coughing</th><th colspan="2">Heartburn</th></tr><tr><th>GEH and GERD</th><th>Plego</th><th>Postop</th><th>Plego</th><th>Postop</th><th>Plego</th><th>Postop</th><th>Plego</th><th>Postop</th></tr></thead><tbody><tr><td>GEH alone</td><td>4 ± 3.6</td><td>3 ± 3.1*</td><td>4 ± 3.7</td><td>1 ± 2.9*</td><td>4 ± 3.6</td><td>1 ± 1.8*</td><td>6 ± 3.7</td><td>1 ± 2.1*</td></tr><tr><td>GERD alone</td><td>4 ± 3.7</td><td>2 ± 3.4</td><td>6 ± 3.7</td><td>2 ± 3.9*</td><td>3 ± 3.6</td><td>2 ± 3.1*</td><td>7 ± 3.3</td><td>2 ± 2.6*</td></tr><tr><td>Severity</td><td colspan="2">Dysphagia</td><td colspan="2">Regurgitation</td><td colspan="2">Coughing</td><td colspan="2">Heartburn</td></tr><tr><td>GEH and GERD</td><td>4 ± 3.7</td><td>1 ± 2.3*</td><td>5 ± 3.8</td><td>1 ± 1.9*</td><td>4 ± 4.0</td><td>± 2.2*</td><td>5 ± 4.1</td><td>± 1.7*</td></tr><tr><td>GERD alone</td><td>3 ± 3.5</td><td>2 ± 2.8*</td><td>5 ± 4.6</td><td>2 ± 2.7*</td><td>4 ± 3.8</td><td>2 ± 2.1*</td><td>7 ± 2.7</td><td>2 ± 2.5*</td></tr></tbody><tfoot><tr><td colspan="9">*p < 0.05, Less than GERD p < 0.05, Intermediate, mid-range test p < 0.15, Less than GERD p < 0.05, Moderate, high-range test p < 0.15</td></tr></tfoot></table>

Esophageal/Gastric Surgery - P360

LAPAROSCOPIC WEDGE RESECTION OF A DUODENAL

CARCINOID: A CASE REPORT, Sam Rossi MD,Jeff Landers
MD,Suthep Udomsawaengsup MD,Vijaya Nirujogi
MD,Brethauer Stacy MD,Matt Metz MD,Bipan Chand MD,
Cleveland Clinic Foundation

**Background:** Carcinoids of the small bowel arise from the Kulchitsky cells in the crypts of Lieberkuhn. Duodenal carcinoids are rare, with a reported incidence between 2-3%. Duodenal carcinoids are most commonly found in the proximal duodenum and rarely become symptomatic.

**Methods:** A 63 y.o. white male who underwent an EGD for anemia revealed a 8mm carcinoid lesion on the anterior duodenal bulb. Endoscopic ultrasound showed the lesion confined to the mucosa and submucosa. An endoscopic snare polypectomy was performed with residual disease in the duodenal bulb by final pathology. A CT scan of the abdomen and octreotide scan looking for metastatic disease were negative. Twenty-four hour urinary 5-HIAA levels were negative.

<figure><img src="image_149.png" /></figure>

The patient underwent an exploratory laparoscopy and intra-operative endoscopy to localize the residual lesion. The residual polypectomy site was localized in the anterior duodenal bulb by endoscopy. The duodenum was kocherized laparoscopically, revealing a 1 cm lesion involving the anterior/inferior aspect of the duodenal bulb with serosal involvement. A laparoscopic wedge resection of the lesion was performed with gross -negative margins. The defect was closed laparoscopically with a hand-sewn closure.

**Results:** The patient underwent a laparoscopic wedge resection of a duodenal carcinoid with a hand-sewn closure of the defect. The final pathology confirmed a 1cm carcinoid lesion with negative margins. The patient had an uneventful post-operative course.

**Conclusion:** Laparoscopic duodenal wedge resections are a safe approach for selective duodenal carcinoids that are amenable to laparoscopic resection.

Esophageal/Gastric Surgery - P361

LEARNING CURVE FOR LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY: CUSUM ANALYSIS FOR ONCOLOGICAL

SURGERY, Junho Lee MD, Keun Won Ryu MD,Byung Ho
Nam PhD,Young Woo Kim MD,Jae Moon Bae MD, Center for
Gastric Cancer, National Cancer Center, Republic of Korea

**Introduction:** This study was conducted to evaluate the learning curve of laparoscopy-assisted distal gastrectomy (LADG) for patients with early gastric cancer in the aspect of oncological surgery.

**Methods and Procedures:** The authors prospectively reviewed the data of all patients that underwent LADG during 1-year period. Retrieved lymph node number was used as a surrogate marker of oncological outcome. The retrieved lymph node number cutoff value required for satisfactory LADG was defined as 15 or more. Cumulative sum (CUSUM) analysis was used to examine the learning curves of individual surgeons at CUSUM target accuracy rates of 85%, 90%, 92.5%, 95%, and 98%.

**Results:** One surgeon performed 55 curative intent LADG during the study period; their success rates exceeded 90%. Operating time was found to decrease with operative experience (Spearman correlation coefficient=-0.336, p=0.012) and closely correlated with body mass index. The learning period for LADG was calculated as 25 cases presuming a 92.5% success rate (Spearman correlation coefficient=0.545, p<0.001).

**Conclusions:** The current study suggests that the oncological learning period for LADG extends to 25 cases or 6 months. In clinical trials containing laparoscopic gastric cancer surgery, the learning curve for qualified surgery from a standpoint of oncological outcome, should be considered to minimize bias due to surgeon-associated factors.

Esophageal/Gastric Surgery - P362

3-DEMENTION WRAPPING FOR ESOPHAGEAL ACHALASIA
BY ENDSCOPIC PROCEDURE, Kazuo Sato MD, Motoo

Yamagata MD,Yukie Morishita,Minoru Matsuda MD,Shigeoki
Hatashi MD, Surugadai Nihonuniversity hospital
Laparoscopic treatment for esophageal achalasia is becoming routine procedure in clinical fields. In study on 144cases of esophageal achalasia?@?iinclude open method and endoscopic procedure?, postoperative dysphasia was remained in advanced cases (Sigmoid type, Width of esophagus over 6cm,). The course of postoperative dysphasia was based on the shape of lower esophagus. Girard -Tanaka?es method was consist of long myotomy with 2-demention wrapping (sagital and transverse direction) for improving of the shape of esophagus. 13cases of sigmoid type with grade?Eof Achalasia?except history of surgical operation in upper abdomen were selected ,and the recently 2cases were Sigmoid type after balloon dilation .The procedure is as follows; Under general anesthesia, Supine position was made. 5 trockers were placed in abdomen and initial dissection exposing esophagus was made by LCS. About 12cm of esophagus and Cardia were freed by gentry dissection around esophagus. Vaginal nerves were confirmed and preserved.??About 10cm of Longmyotomy was performed by J-Hook and Muscle specimen for pathological diagnosis was collected. Next ,27'3 of transverse suture (sutured the edge of myotomy and serosa of cardia)were made each side. Sigmoid Type of esophagus was made straight by this suture for improving passage .Fainally, fundus was sutured with left side of hiatus of diaphragm and then fundopexy was performed. As the result, we made shorter duration of operation (from 256min. to 165min. as average). ?mo Complication was observed and Symptom were improved in 12cases, but postoperative dysphasia was remained in 3cases of sigmoid type Grade ?V. In addition, dilatation of esophagus was still remained in 5 cases of sigmoid type by postoperative X-ray findings. E.P.T of these cases showed type B.??Our method was very useful for advanced esophageal achalasia like sigmoid type esophagus.

Esophageal/Gastric Surgery - P363

LAPAROSCOPIC ANTRECTOMY: A DEFINITIVE TREATMENT
FOR WATERMELON STOMACH, Kerrington D Smith

MD,Charles E Dye MD,Vivek N Prachand MD, University of
Chicago Department of Surgery

Laparoscopic antrectomy has recently been described in a case report as a treatment for gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach. The optimal treatment of GAVE is unknown. Ablative endoscopic approaches using Argon Plasma Coagulator (APC) effectively decrease transfusion requirements but recurrent bleeding is common requiring repeat ablative endoscopies. While surgical treatment in the form of antrectomy is curative, early reports of perioperative complications in high risk patients has generally limited surgery to patients who fail ablative therapies or medical management. We report the successful use of laparoscopic antrectomy in a series of three high surgical risk patients with GAVE whose gastrointestinal bleeding was refractory to medical and endoscopic therapies. Three female patients, ages 56, 60 and 64 years old, with complicated medical and surgical histories presented with upper gastrointestinal bleeding. Upper endoscopy revealed the characteristic mucosal appearance of sharply demarcated, punctuate red spots scattered diffusely throughout the antrum. Histology demonstrated dilated mucosal capillaries with fibrin thrombi and fibromuscular hyperplasia of the lamina propria, characteristic of GAVE. Comorbidities in two patients included a history of multiple deep vein thromboses and pulmonary emboli requiring the placement of inferior

<figure><img src="image_150.png" /></figure>
<figure><img src="image_151.png" /></figure>

SAGES POSTER ABSTRACTS

vena cava filter in addition to therapeutic oral anticoagulation. The third patient was a Jejomaa's Witness and would not accept blood products. All three patients had prior abdominal surgery. Despite repeated APC therapy the patients continued to have anemia with ongoing gastrointestinal bleeding. Uncomplicated, laparoscopic antrectomy and Roux-en-Y gastrojejunostomy was performed. At 3 month and one year follow-up hemoglobin levels normalized and there were no ongoing signs of gastrointestinal blood loss. The cases reported here demonstrate a definitive therapy for ongoing blood loss in patients with GAVE syndrome refractory to medical and endoscopic management. As more surgeons become trained in advanced laparoscopy, the threshold for the recommendation for curative resection following failure of medical therapy will be lowered allowing even high risk patients to benefit from a definitive surgical treatment at an earlier stage of the disease process. Laparoscopic antrectomy is a curative and safe treatment for GAVE syndrome.

Esophageal/Gastric Surgery - P364

EVALUATION OF ENDOSCOPIC HEMOSTASIS BY LOCAL INJECTION OF A FIBRIN GLUE IN HEMORRHAGIC GASTRIC ULCER IN DOGS, Hiroyasu Suga MD, Takao Nakagawa MD, Yukihiro Soga MD, Masaru Abe MD, Yoshizumi Deguchi MD, Noboru Akizuki MD, Takashi Kobayash MD, Masatake Ishikawa* MD, Tadashi Suzuki* MD, Yoshiaki Imamura** MD, Department of Emergency Medicine, Tokyo Women's Medical University Medical Center East; *Department of Emergency Medicine, Tokyo Women's Medical University; **Department of Surgical Pathology, University Hospital Faculty of Medicine University of Fukui

**Introduction:** Emergency patients suffer from disorders of the coagulation-fibrinolysis system, posing a problem in the endoscopic control of hemorrhagic gastrointestinal complications. Since October 2000, fibrin glue has been used in endoscopic hemostasis of hemorrhagic ulcer in those patients with coagulation disorders or who resisted the use of conventional clips or local ethanol injection. An experimental study was conducted on dogs to evaluate the hemostatic and wound healing effects of fibrin glue (FG) and basic fibroblast growth factor (bFGF).

**Method:** Dogs (weighing 13 to 15 kg) underwent a laparotomy under Nembutal anesthesia to produce 4 mechanical hemorrhagic ulcers at the pyloric antrum. A physiological saline (sham), a hypertonic physiological saline solution of Bosmin (HSE), ethanol (ET), or FG was injected locally followed by closure of the wound. On the 3rd and 5th postoperative day, a second laparotomy was conducted for gastrectomy for comparative evaluation of the local hemostatic effects and wound recovery. Then bFGF was locally injected to examine the local tissue for wound healing effects.

**Results:** The epithelial regeneration was most satisfactory in the FG-treated group. Fibrin remained under the mucosa until the 5th day, suggesting its persistent hemostatic effect. The sham group was free of injection-induced tissue damage but exhibited mucosal and submucosal hemorrhage. The ET-treated group was free of hemorrhage but had marked tissue damage and inflammatory cell infiltration. Tissue damage was slight in the HSE-treated group but the epithelial regeneration was poor in comparison with the FG-treated or sham group. When combined with bFGF, epithelial regeneration was noted on the 3rd day.

**Conclusion:** local FG injection resulted in good epithelial regeneration, suggesting satisfactory anti-hemorrhagic and wound healing effects. The addition of bFGF enhanced the ulcer healing effect.

Esophageal/Gastric Surgery - P365

LAPAROSCOPIC RESECTION OF GASTROINTESTINAL MESHCHYMAL TUMORS IN THE STOMACH, Nobumi Tagaya PhD, Akihito Abe MD, Masashi Tachibana MD, Tadashi Furihata PhD, Kiyoshige Hamada PhD, Keiichi Kubota PhD, Second Department of Surgery, Dokyo Medical University, Tochigi, Japan

**Background:** At present, local resection with adequate margins is considered to be an effective treatment for a gas-

trointestinal mesenchymal tumor (GIMT). The treatment strategy for GIMTs located close to the esophagogastric junction (EGJ) is still controversial. We evaluated our technique and results to discuss the safety and usefulness of laparoscopic resection.

**Materials and Methods:** We performed laparoscopic resection of GIMT in 19 patients. The criteria that were used to select cases for resection were that the tumor was more than 2 cm in diameter or that there had been a tendency to increase in size during the follow-up period. In 9 patients in whom the tumor was located within 3 cm of the EGJ an intragastric laparoscopic approach was used, while in 10 patients where the tumor was further from the EGJ an exogastric approach was used.

**Results:** In all 19 patients the laparoscopic resection was successful with no complications. The intragastric group had a mean age of 63.1 years, whilst the exogastric group had a mean age of 59.7 years. The intragastric group had a mean maximal tumor size of 2.8 cm, mean operation time of 162 min and a mean post-hospital stay of 8.2 days whilst in the exogastric group these values were 3.5 cm, 106 min and 8.0 days, respectively. There was a significant difference (p=0.0084) in operation time between two groups. In both group, there were no recurrences during follow-up period of 83.9 months (intragastric) and 54.9 months (exogastric).

**Conclusion:** The good clinical outcomes suggested that the criteria that were used as an indication for laparoscopic resection and the surgical techniques were appropriate for the resection of GIMTs.

Esophageal/Gastric Surgery - P366

LAPAROSCOPIC RESECTION OF AN ESOPHAGEAL EPIPHRENIC DIVERTICULUM WITH LONG MYOTOMY: A CASE REPORT AND REVIEW OF THE LITERATURE., Janos Taller MD, Gordon Wisbach MD, Jay Grove MD, Department of Surgery, Naval Medical Center, San Diego

Esophageal epiphrenic diverticuli are a rare disorder of the GI tract. Their true prevalence is not fully appreciated as most diverticuli are asymptomatic. Their mean age of presentation is in the 6th decade of life when decreasing physiological reserve directly impacts on the patient's ability to tolerate large, invasive operations. Previously treated by thoracotomy, recent advances in optics, instrumentation and experience have allowed surgeons to apply minimally invasive techniques to esophageal pathology. We present a case report of such an operation and review the relevant literature on this topic.

Our patient is a 68 y/o man with a 50 year history of dysphagia who sought treatment as his symptoms worsened over the last year. He was evaluated with EGD, upper GI series, chest CT and manometry. These studies demonstrated a large 4+cm epiphrenic diverticulum with abnormal esophageal motility. The patient was offered laparoscopic resection with myotomy and consented for possible VATS or thoracotomy as needed.

5 trocars were placed for access: 2 - 10mm ports for a camera & stapler, 3 - 5mm ports for working instruments and 1 subxyphoid incision for liver retraction. The anterior diaphragm was split to facilitate access high into the mediastinum. Supporting esophageal tissue was divided with a combination of electrocautery and blunt dissection until the diverticulum was freed at its base. A 2.5mm endoscopic staple load was applied across the diverticulum for resection. A long myotomy was performed on the medial esophagus from the GE junction to the proximal aspect of the staple line. The anterior diaphragm was then repaired. No complication was performed.

The case was completed in 278 minutes with 150 ml EBL. A small left pneumothorax was followed to resolution with serial CXR's. An UGI performed on POD#1 demonstrated no leak. The patient was advanced to liquids on POD#3 and discharged home on POD#6 on a soft mechanical diet. He returned to normal activity in 2 weeks & unrestricted diet in 3 weeks. His dysphagia has completely resolved. He has occasional GERD symptoms when lying supine within an hour of eating.

The laparoscopic approach to epiphrenic diverticuli allows
for superior exposure to anatomy while providing the inherent benefits of decreased morbidity and recovery times associated with minimally invasive surgery. Supported in the literature, we believe this approach is the desired treatment method for this problem

## Esophageal/Gastric Surgery - P367

### PREVENTION OF ESOPHAGEAL ANASTOMOTIC LEAK WITH TEMPORARY PLACEMENT OF AN EXPANDABLE

POLYVINYL STENT IN A PORCINE MODEL., Michelle Taylor MD,Steven C Gross MD,Yashodhan S Khajanchee MD,Lee L Swanstrom DO, Minimally Invasive Surgery Program, Legacy Health System, Portland, Oregon

**Objective:** Anastomotic leaks and strictures are a major cause of morbidity and mortality following esophageal resection and anastomosis. The aim of the current study was to assess the role of self-expandable removable polyvinyl stents in preventing postoperative leaks and strictures following a flawed cervical esophageal anastomosis in a porcine model.

**Method:** A total of 18 adult pigs were studied. Under general anesthesia the cervical esophagus was exposed and divided. A single layer anastomosis was performed using 4-0 absorbable sutures. After completion of the anastomosis a 1 cm defect was created at the anastomotic site by removing 2-3 sutures. The defect was marked with two clips and a self-expandable polyvinyl stent (14-18 mm) was placed across the anastomosis under fluoroscopic guidance in 16 animals. Contrast studies were performed before and after placement of the stents. No stents were placed in 2 control animals. Stents were explanted endoscopically after a maximum follow-up period of 4 weeks. Contrast esophagograms were performed and the strength of the scar was assessed by recording burst pressure. Histological assessment of the scar was performed to assess the quality of healing at the defect site.

**Results:** In control animals no spontaneous healing of the defect site was observed. One animal died within 48 hours and another was sacrificed on POD #7 due to severe dysphagia and continued leakage. 14/16 study-group animals demonstrated complete healing on contrast radiographs after a mean follow-up duration of 28 (+ 7) days. The bursting pressures of the healed area were in excess of 450 mmHg. Two animals that received 18 mm stents died within 48 hours due to tracheal compression. Nine of these animals had minimal or no stricture at the anastomotic site. In five animals (receiving 14-16 mm stents) the stents had migrated into the stomach. These animals demonstrated moderate-to-severe strictures. Histological assessment revealed adequate collagen deposition at the defect site.

**Conclusions:** Prophylactic placement of flexible polyvinyl stents across the esophageal anastomosis at the time of surgery dramatically reduces the chances of postoperative leaks. Care must be taken while selecting the stent diameter as larger stents may lead to tracheal compression and smaller stents may migrate and fail to prevent stricture.

## Esophageal/Gastric Surgery - P368

LAPAROSCOPIC NISSEN FUNDOPLICATION DOES NOT INCREASE DYSPHAGIA IN PATIENTS WITH ABNORMAL ESOPHAGEAL MOTILITY, Zurab Tsereteli MD,Klaus Thaler MD,Nathan P Hasemann BS,Brent Miedema MD,Bruce Ramshaw MD,William S Eubanks MD, Department of General Surgery, University of Missouri-Columbia, Columbia, MO

**Introduction:** Patients with GERD and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. After introduction of laparoscopic Nissen fundoplication a so called tailored approach was proposed: patients with esophageal dysmotility undergo partial (270° wrap) rather than complete (360°) fundoplication. However, many high-volume centers perform a total fundoplication on all patients with severe GERD regardless of the baseline esophageal function. Our objective was to determine if complete fundoplication is associated with increased

postoperative dysphagia in patients with ineffective esophageal motility.

**Methods:** Medical records of all adult (>18 yo) patients who underwent laparoscopic Nissen fundoplication for GERD the last five years were reviewed retrospectively. Of the 151 patients 28 (group A) met manometric criteria for abnormal esophageal motility (<30mm Hg mean contractile pressure or <80% peristalsis), 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. The follow-up time ranged from 1 month to 5 years; seven patients were lost to f/u in group B. The analyses done used stratification based on time of follow-up. Outcomes (postoperative dysphagia-primary endpoint, recurrence of GERD symptoms, free of medications) were compared using Cochran-Mantel-Haenszel methodology.

**Results:** The groups did not differ in terms of gender (p=0.46). Group A had higher age and ASA score (p=0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up times, there was no significant difference between the groups (p=0.94). Group B had more cases of recurrent heartburn,10.7% vs. 3.6% (p=0.039), and more patients in this group were back on medications, 21.4% vs. 7.1% (p=0.05)

**Conclusion:** This retrospective study found equally low rate of dysphagia regardless of baseline esophageal motility. Preoperative esophageal dysmotility is therefore not a contraindication for laparoscopic Nissen fundoplication.

## Esophageal/Gastric Surgery - P369

LAPAROSCOPIC INTRAPERITONEAL CISPLATIN WITH REAL-TIME RT-PCR MONITORING OF FREE CANCER CELLS IN PATIENTS WITH SCIRRHOUS GASTRIC CANCER, Shunichi Tsujitani MD,Kenji Fukuda MD,Hiroaki Saito MD,Shigeru Tatebe MD,Masahide Ikeguchi MD, Tottori University, Yonago, Japan

**Introduction:** The prognosis for patients with scirrhous gastric cancer (SGC) is extremely poor. To improve the patients' prognosis, laparoscopic intraperitoneal cisplatin (LIPC) was introduced for SGC. We analyzed whether LIPC reduced the number of free cancer cells estimated by real-time RT-PCR and improve the prognosis of patients with SGC.

**Methods:** LIPC included laparoscopic detection of peritoneal seeding, peritoneal washing cytology at the Douglas pouch and intraperitoneal administration of cisplatin at a dose of 50 mg/body with 1000 ml of saline. The drains were clamped for 1 hour after the administration. Additional 2 times of intraperitoneal cisplatin (same doses) were given through a drain placed into the Douglas pouch 2 and 4 days after LIPC. Total RNA was extracted from 50 ml of peritoneal wash from 12 SGC patients before and after LIPC. Carcinoembryonic antigen (CEA) messenger RNA (mRNA) was used to identify the number of gastric cancer cells in peritoneal washes by the real-time RT-PCR method. The number of cancer cells in the peritoneal cavity was compared before and after LIPC treatment.

**Results:** The average number of cancer cells in the peritoneal cavity ranged from 9 to 7 x 100,000 before LIPC and from 0 to 1 x 100,000 after LIPC. The median survival time (MST) of 3 cases with more than 1 x 10,000 cells before LIPC was 7.3 months, whereas the MST of 9 cases with less than 1 x 10,000 cells before LIPC was 11.4 months. In 8 cases, more than 90% of the cancer cells were removed from the peritoneal cavity after LIPC. These 8 cases were named the LIPC effective group, and the remaining 4 cases were named the LIPC ineffective group. The MST of the LIPC effective group (9.9 months) was not different from that of the LIPC ineffective group (11.5 months).

**Conclusion:** The number of cancer cells before LIPC may correlate with survival period of patients with SGC. However, the prognostic benefits of effectiveness of LIPC for SGC patients remain unclear.
<figure><img src="image_152.png" /></figure>

# SAGES POSTER ABSTRACTS

## Esophageal/Gastric Surgery - P370

### PREVALENCE OF BARRETT'S ESOPHAGUS IN PATIENTS WITH CHRONIC GERD REFERRED FOR SURGICAL OPINION,
Sameena Uddin MD, Mehran Anvari PhD, Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton Ontario Canada

**Background:** The recent reports on prevalence of Barrett's mucosa in the GERD population suggest lower rates than earlier suspected. This may be in part due to visual reporting of Barrett's at endoscopy (EGD) rather than using systematic biopsy protocol. Diagnosis of Barrett's in patients undergoing laparoscopic fundoplication is important for both follow-up surveillance, as well as documenting the impact of surgery on this metaplastic change. In addition, the accuracy of detecting BE on diagnostic endoscopy is unknown.

**Methods:** We prospectively studied all GERD patients requiring long-term PPI therapy (>1 year) referred for surgical opinion over a 3 year period. All patients underwent confirmatory GERD testing (GERD Symptom Score and Global Rating Scale, Bernstein test, 24h pH test and manometry) as well as EGD. Endoscopic signs of BE were graded according to MUSE protocol and planned biopsies taken at 5 sites including cardia, squamocolumnar junction and distal esophagus. BE was defined as specialized intestinal metaplasia within columnar-lined epithelium.

**Results:** EGD was performed in 391 patients (mean age 45 +/- 12, female 50.6%). Sensitivity for detecting metaplasia visually was 25.6%, while the specificity on biopsy was 91.8%. The overall accuracy rate for detecting then biopsy-ing BE was 85%. BE was present in 39 patients (10%) with GERD. Using multivariate analysis, significant risk factors included age greater than 60 (p=0.012), history of smoking (p=0.049) and positive 24hour pH testing (p=0.001). Severity of GERD symptoms was not a risk factor.

**Conclusion:** The prevalence of BE in patients with GERD referred for surgery is 10% on biopsy. Many patients with Barrett's may have normal endoscopy on visual inspection and the diagnosis of Barrett's will be missed unless a standard biopsy protocol is used routinely.

## Esophageal/Gastric Surgery - P371

### ACHALASIA IN OBESE PATIENTS; A COMPARATIVE STUDY,
Nathaniel E Uecker MD, Prakash Gatta MD, Will Lockhart MD, Lee L Swanstrom, Legacy Health Systems

**Objective:** In the literature, there are few studies of obese achalasia patients. This chart review study compares 24 obese (BMI >30) patients with 104 non-obese (BMI<30) patients over several parameters—duration and severity of symptoms, pre-operative manometry, post-operative complaints and finally, weight loss or gain.

**Methods:** Chart review identified 128 patients (24 with BMI>30, 104 with BMI<30, 72 men, 56 women, median age 48, range 16-77) with symptoms of achalasia from 1995 to 2006. All patients included complained of dysphagia, all underwent Heller myotomy and partial fundoplication, and all were followed for at least three months after surgery. Patients with nutcracker esophagus or redo procedures were excluded. Duration of dysphagia was recorded as dictated in the consultation note. Pre-operative dysphagia, post-operative dysphagia, and post-operative reflux were graded 0 to 4 based on severity. Any Grade 2 or greater dysphagia or reflux three months after surgery was defined as failure of treatment. Weight changes were obtained by chart review.

**Results:**
1. Duration of symptoms was similar between groups.
2. Averaged severity of pre-operative dysphagia was also remarkably consistent (2.91±1.03 for obese and 2.85±1.07 for non-obese).
3. Vigorous achalasia was more prevalent in the obese group (62.5%).
4. BMI>30 patients had more numerous dysphagia failures (29.2% vs. 15.4%) but the groups had consistent reflux failures (25% vs. 24%).
5. BMI>30 patients had greater weight changes peri and post-operatively (10.2 lbs vs. 6.16 lbs), although this was not statistically significant.
6. None of the BMI>30 patients gained weight in the follow-up period.
7. Weight loss in the

obese population did not correlate with severity of post-operative dysphagia or reflux.

**Conclusions:** In comparing obese and non-obese achalasia patients, vigorous achalasia is clearly the more prevalent type of achalasia in the obese group and post-operative dysphagia a more significant concern. Weight loss in either group may be due to a combination of peri-operative pain, poor appetite and post-operative diarrhea, a frequent complaint. But when compared with the non-obese group, where both weight losses and gains were found, and coupled with lack of correlation between post-operative symptoms and weight loss, the possibility of further factors leading to post-operative weight loss must be entertained. Further study is required.

## Esophageal/Gastric Surgery - P372

### ROLE OF ROUTINE INTRAOPERATIVE USAGE OF BOUGIE IN PREVENTING DYSPHAGIA FOLLOWING LAPAROSCOPIC NISSEN ROSSETTI'S FUNDOPLICATION - A PROSPECTIVE COMPARATIVE STUDY,
P C Munipalle, Y K S Viswanath,
Department of General Surgery, The James Cook University Hospital, Middlesbrough, TS43BW, UK

**Aim:** Placement of a bougie across the gastro-oesophageal junction (GOJ) to guide the tightness of wrap has been a standard practice in laparoscopic Nissen - Rosetti's fundoplication (LNRF). There is anecdotal evidence to suggest that this practice decreases the incidence of postoperative dysphagia. We aim to evaluate this role of routinely placed of bougie during LNRF through this prospective comparative study.

**Methods:** All patients who underwent LNRF after clinical, endoscopic and manometric assessment over a period of four years were studied. Group 1 consists of 40 consecutive patients who had bougie placed across GOJ in the form of standard 12mm endoscope and Group 2 has 37 consecutive patients that did not have the endoscope placed intraoperatively. The operative procedure was standardised in all the patients and all of them were followed up over a total period of 4 years to observe the incidence of significant dysphagia (dysphagia score 2 or above).

**Results:** One patient form group 1 and two patients from group 2 have developed significant dysphagia in the long term (p>0.05). The patient in group 1 responded after 2 endoscopic dilatations while revision surgery was needed to relieve dysphagia for two patients in group 2 (p>0.05). All three patients have shown low amplitude peristalsis with features of secondary oesophageal dysmotility on pre-operative manometry.

**Conclusion:** There is no evidence from this study to support the routine prophylactic placement of bougie during LNRF. Selective usage of bougie or partial fundoplication might be beneficial in the subgroup of patients with oesophageal dysmotility to ensure loose wrap and decrease the incidence of significant post operative dysphagia.

## Esophageal/Gastric Surgery - P373

### EFFECT OF BODY MASS INDEX (BMI) ON INTRA AND IMMEDIATE POSTOPERATIVE MORBIDITY FOLLOWING LAPAROSCOPIC NISSEN ROSSETTI'S FUNDOPLICATION,
M Wong, P C Munipalle, A Eltaye, Y K S Viswanath, Dept. of General Surgery, The James Cook University Hospital, Middlesbrough, TS43BW, UK

**BACKGROUND:** Gastro-oesophageal reflux disease (GORD) is a common disorder in the Western world and obesity plays an aetiological role in the causation of GORD. Laparoscopic Nissen Rosetti's fundoplication (LNRF) is currently the most popular technique for the surgical treatment of GORD. It is well known that high BMI is associated with increased intraoperative and postoperative morbidity in open abdominal surgery. We evaluated in this study whether BMI adversely affect the intraoperative and immediate postoperative morbidity in patients undergoing LNRF.

**METHODS:** 90 consecutive patients who underwent LNRF by a single surgeon over 4 year period were evaluated retrospectively. The body mass index (BMI) of the patients, operative time, duration of postoperative hospital stay before discharge and morbidity data in the immediate postopera-
SAGES POSTER ABSTRACTS

tive period were collected from clinical notes/ letters/ hospital computers.

**RESULTS:** The patients fell into 3 categories based on the BMI: Group 1 (BMI ≥ 25) - 27, group 2 (BMI 25 - 30) °C 41 and group 3 (BMI > 30) °C 22 patients. The mean operating time and postoperative stay are comparable between the three groups (p>0.05). There were no intraoperative complications or major postoperative morbidity in any of these groups.

**CONCLUSION:** High BMI does not adversely influence the immediate outcome in GORD patients undergoing LNRF. Hence high BMI should not dissuade the laparoscopic surgeon to carry out LNRF in indicated severe GORD patients.

Esophageal/Gastric Surgery – P374

LAPAROSCOPY-ASSISTED PYLORUS PRESERVING GASTRECTOMY WITH TRIANGLE END-TO-END ANASTOMOSIS., Norihito Wada MD,Yoshiro Saikawa MD,Masashi Yoshida MD,Yoshihide Otani MD,Tetsuro Kubota MD,Koichiro Kumai MD,Masaki Kitajima MD, Department of Surgery, School of Medicine, Keio University

**Introduction:** As a function preserving surgery, we have performed laparoscopy-assisted pylorus preserving gastrectomy (LAPPG) for twelve patients with early gastric cancer since 2003. The purpose of this study is to demonstrate the technique and outcome of this procedure.

**Methods:** Twelve patients with early gastric cancer were enrolled in this study and have had LAPPG. Indication for this surgery is sT1N0 gastric tumor. We usually confirm negative sentinel lymph node (LN) metastasis intraoperatively, and omit #5 and #6 LN dissection. Using 5 trochars, LN dissection was performed laparoscopically. Then through a mini-laparotomy, resection of stomach and end-to-end anastomosis was performed. For this anastomosis, three linear staplers were used. First, we inverted the posterior wall of the stomach making a base of the triangle, and make the linear stapler fire. Next, we closed the everted anterior wall using linear staplers twice.

**Results:** Twelve patients were treated with this method. There were no intraoperative complications. Blood loss was minimal. No anastomotic stenosis was observed. Post-operative dietary intake was enough and reflux of duodenal juice was minimal.

**Conclusions:** LAPPG with triangle anastomosis is a feasible technique for surgery to preserve pyloric function in the patients with early gastric cancer. Further follow up would be needed to confirm the curability of this treatment and preserved gastric functions.

Esophageal/Gastric Surgery – P375

GASTRIC PACEMAKER FOR MEDICALLY REFRACTORY GASTROPARESIS, Robert L Wroblewski MD,Robert P Sticca MD,Bhargav Mistry MD, University of North Dakota, MeritCare Health System

**Introduction:** Gastroparesis is a chronic disease of gastric motility causing delayed emptying of the stomach. Symptoms include nausea, vomiting, electrolyte imbalances, early satiety, abdominal pain and malnutrition. This pseudoobstruction is associated with diabetes mellitus, vagus nerve injury, GERD and chronic disease. Management is typically achieved with diet modification and medication including prokinetics and anti-emetics. A minority of patients are refractory to diet modification and medications and experience unrelenting symptoms leading to weight loss and malnutrition. Gastric pacemakers (GP) were introduced in the 1960's as an option for refractory gastroparesis. A renewed interest in this technology in the past few years has prompted the FDA to grant humanitarian device status to GP for patient care and further research.

**Methods:** Data was gathered on all patients at a university affiliated teaching hospital who underwent gastric pacemaker placement from July 2005 until September 2006. Patient demographics including, age, weight, medications, prior treatments, diet modification and comorbid conditions were recorded. Indications for placement, surgical procedure, postoperative outcome, morbidity and mortality were also noted.

**Results:** Thirteen GP were placed during this time. Indications for placement were diabetic gastroparesis in 10 patients(77%) and idiopathic gastroparesis in 3 patients(23%). The average age was 50 (range 30-77). Eleven patients were female and two were male. The first five procedures were performed using an open technique and the remaining eight were placed laparoscopically. Five patients previously receiving nutrition via gastric feeding tubes had symptom resolution allowing removal of feeding tubes. Eight patients (62%) had complete resolution of symptoms, while an additional 5(38%) had partial resolution of symptoms. No surgical mortality was noted. Surgical morbidity included 2/13 patients(15%), one wound infection and one with persistent pain at the stimulator site. Both complications resolved with generator relocation.

**Conclusion:** Medically refractory gastroparesis remains a difficult and frustrating condition for both patient and physician. GP placement is highly effective in managing patients with this problem and can be placed safely with minimal morbidity either through an open or laparoscopic technique.

Esophageal/Gastric Surgery – P376

CLINICAL EXPERIENCE WITH A SMALL OPENER (MULTI FLAP GATE) FOR LAPAROSCOPICALLY ASSISTED CANCER SURGERY, Hideo Yamada MD,Juri Kondo MD,Takahiro Kinoshita MD, Endoscopic surgery center, Toho university sakura hospital

**Objective** Organ extraction and anastomosis in the event of laparoscopic digestive cancer surgery is performed in direct view from a small opening; an instrument is needed to re-insufflate the peritoneal cavity and perform laparoscopy again after anastomosis is complete. Various instruments are currently being developed, although the current situation is one in which there are no instruments with which a sufficient opening and laparoscopic manipulation afterwards can be smoothly performed. Thus, the authors jointly developed a small opener for laparoscopically assisted digestive cancer surgery (Multi Flap Gate : afterwards, MFG) intended for protection and effective opening of the peritoneal wound and simple re-insufflation in laparoscopically assisted colorectal cancer surgery with Sumitomo Bakelite. ?

**Subjects and Methods** The specifications of the MFG have been indicated. In addition, there is a small hole in the center and it can be used as a port through insertion of a cannula here. We have three type S,M,L of MFG. The MFG was used in 200 cases of laparoscopically assisted surgery for digestive cancer cases from March 1999 to August 2006. The length of the skin incision was 3-9 cm.

**Results** The MFG was easily attached in all cases and retraction strength was favorable. Damage to the MFG during surgical handling and trouble with regard to manipulation was not seen. The shape of the opening was almost square; extraction of organs and surgical manipulation in direct view were favorable. Gas leaks were also not noted during re-insufflation. In addition, no cases of postoperative wound infection or portsite recurrence were noted.

**Conclusion** The MFG has exceptional opening strength and is an optimal instrument for laparoscopically assisted colorectal cancer surgery that allows re-insufflation. A favorable surgical field was ensured by this instrument and laparoscopically assisted digestive cancer surgery can be performed; it was also useful for prevention of wound infection and cancer cell implantation. In the future, there are plans to perform further development of a converter and proceed with development of this instrument as an instrument that can be adapted for HALS use as well.

Flexible Endoscopy – P377

COLORECTAL POLyps: LOCATION, SIZE, NUMBER, HISTOPATHOLOGY AND RISK OF CANCER, Adem Akcakaya MD,Ismail Okan MD,Aytekin Coskun MD,Gurhan Bas MD, Mustafa Sahin MD, Vakif Gureba Training and Research Hospital, First Department of Surgery, Istanbul, Turkey

**Objectives:** A major aim of colonoscopy is the recognition and removal of premalignant polyps. Colonoscopy is highly sensitive at detecting colonic polyps. The aim of this study is to ascertain the differences of polyps? size, number,

<figure><img src="image_153.png" /></figure>
<figure><img src="image_154.png" /></figure>

SAGES POSTER ABSTRACTS

histopathology and the risk of cancer according to location.

**Methods:** We retrospectively evaluated 378 patients who underwent colonoscopy and detected polyps in our Surgical Endoscopy Unit during past five years. Endoscopic information included the number of polyps, location, size, macroscopic appearance, procedure for removal, histological features, and presence of atypia or malignancy. According to the size, polyps were divided into three groups: large (> 1 cm), small (6-10 mm), diminutive (<6 mm). To facilitate analysis, the polyps were classified according to their anatomic locations as such: the rectosigmoid area, descending colon, transverse colon, ascending colon and cecum.

**Results:** There were 244 men (64%) and 134 women (36%). The mean age was 55 ± 14(15-90) years. The distribution of polyps in colonic segments were as follows: 204 in rectosigmoid (54%), 66 in descending colon (18%), 36 in transverse colon (%9,5) and 10 in ascending colon-cecum (%2,6). While in 42 patients polyps involved at least two segments of colon (11%), polyps were scattered throughout whole colon in 20 patients (%5,3). Forty percent of patients had polyps with size < 6 mm. Only 29 % had polyps more than 10 mm in size. Solitary polyps were detected in 66,7 % of patients. More than half of the cases had neoplastic polyps (64.5%). While 21,4 % had dysplasia, only 9,7% had carcinoma (36 patients). Nearly half of the cases with carcinoma or dysplasia were solitary and located in the rectosigmoid area.

**Conclusion:** Colorectal polyps were usually solitary and located mostly in rectosigmoid area. Moreover dysplasia and cancer were most frequently detected in rectosigmoid colon polyps.

Flexible Endoscopy – P378

**IDIOPATHIC DIFFUSE COLONIC VARICES: AN UNUSAUAL CAUSE OF ANEMIA**, Hisham Elhassan MD, Robert Sinnott DO, Larry Bardawil MD, Lehigh Valley Hospital

**Introduction** : Colonic varices are uncommon and they are usually segmental. The commonest cause is portal hypertension/ chronic liver disease. Colonic varices of the entire colon are even more uncommon. However recognition and mangement of the different presentations of this abnormality is very important.

**Method** : This is a case report of 78 year old female who was admitted with generalized weakness & fatigue, diagnosed with severe anemia. The Patient denied any gross bleeding. Upper endoscopy was normal, colonoscopy revealed extensive varices throughout the colon. Liver enzymes are normal. CT abd/pelvis showed diffuse colonic wall thickness.

**Conclusion:** Idiopathic diffuse colonic varices are very uncommon. Most of the reported cases in the literature presented as recurrent or massive bleeding. Colonoscopy is the most accurate method of diagnosis. Therapy is conservative and may require transfusions. massive bleeding may require surgical treatment.

Pictures & radiologic films are available and to be submitted when requested.

Flexible Endoscopy – P379

**ROUTINE PREOPERATIVE ENDOSCOPY PRIOR TO LAPAROSCOPIC ROUX-EN-Y BYPASS: IS IT NECESSARY?**, Wesley P Francis MD, William J Curtiss BS, John D Webber MD, Minimally Invasive section, Department of Surgery Wayne State University School of Medicine

**Introduction** The use of routine pre-operative endoscopy has been questioned in patients undergoing Laparoscopic Roux-en-Y gastric Bypass (LRYGB). The purpose of this study is to review our institutions policy of routine endoscopy prior to LRYGB and to determine whether it is justified.

**Methods** From November 2003 to July 2006 we retrospectively reviewed the charts of all patients who were potential candidates for LRYGB. All patients who had a screening Esophagogastroduodenoscopy (EGD) and biopsy for Helicobacter pylori performed were included in the study. Demographic data, including age and gender were collected. EGD reports were reviewed and any pathology identified

was documented. Any intervention as a result of the pathology identified was noted, including outcomes.

**Results** One hundred and seventy patients had routine EGD prior to undergoing LRYGB. There were 89% females and 11% males. The age range was 20 - 61 years. Hiatal hernias were found in 101 patients. These were characterized as small, medium and large and amounted to 43.6%, 47.5% and 8.9% respectively. Seventy one patients had varying degrees of esophagitis; Grade I - 65.5%, Grade II - 29.5% and Grade III - 5%. One patient had Barrett's epithelium and required medical therapy and surveillance EGD. One patient had an esophageal diverticulum that required surgical repair. There were four esophageal polyps and 1 ulcer. Acute gastric mucosal lesions (AGML) were present in 39.5% of patients. Mild to moderate antral gastritis accounted for 90%, whereas severe antral gastritis accounted for 10 % of AGML. Ten patients had ulcer disease, 4 gastric and 6 duodenal. Twelve percent of the population was positive for Helicobacter pylori and required medical therapy for eradication. There were 12 gastric polyps ,all benign. Two patients had duodenal polyps. One patient had a biopsy proven adenocarcinoma arising in a duodenal villous adenoma. This patient required a pancreaticoduodenectomy.

**Conclusion** EGD prior to LRYGB identified significant pathology that required medical or surgical intervention. Although the yield may be low, pathology which contraindicated LRYGB was correctly identified and therefore justifies its use routinely.

Flexible Endoscopy – P380

**CLINICAL EVALUATION AND MANAGEMENT OF CAUSTIC INJURY IN THE UPPER GASTROINTESTINAL TRACT IN 92 ADULT PATIENTS IN AN URBAN MEDICAL CENTER,**

Christopher P Gayer MD, Choichi Sugawa MD, Gen Tohda MD, Timothy W McGuire MD, Charles E Lucas MD, Department of Surgery, Wayne State University, Detroit, MI

**BACKGROUND:** Caustic ingestion is a challenging problem requiring emergency medical and sometimes surgical treatments. Ingestion of caustic materials causes a wide spectrum of injuries, and appropriate treatment varies with the severity and extent of injury. Early endoscopic evaluation provides the best initial assessment of the upper GI tract in those patients without obvious perforation. This retrospective study represents 92 adult caustic injury patients and their endoscopic evaluation, treatment, and outcome.

**METHODS:** From 1979-2006, 92 consecutive adult patients were admitted to our urban emergency hospital for ingestion of caustic materials. Every patient in this study underwent upper endoscopy to evaluate the injury. The results were graded from one to three, with three being the most severe. The same endoscopist was present for all cases and grade determinations. Treatment was based on the endoscopic grade.

**RESULTS:** Of the 92 patients, there were 59 men and 33 women with an average age of 36.9 years (range 17-81). Ingestion was a suicide attempt in 48 patients and accidental in 44 patients. There was no mucosal damage in 10 patients (11%). Of those with mucosal injury, 47 patients were grade 1 (51%), 24 were grade 2 (26%), and 11 were grade 3 (12%). The extent and severity of the injury varied according to the ingested materials. The ingestion of strong acid (n=15) or strong alkali (n=29) produced significantly more severe injury than bleach (n =25), detergent (n=13), and ammonia (n=4), which caused more mild injury. Twelve patients (13%) required operative treatments (10 grade 3 injuries and 2 grade 2 injuries). Procedures included six esophagectomies, three total gastrectomies, two partial gastrectomies, and one tracheostomy and jejunostomy tube. Conservative treatment (NPO, IVF/TPN, repeat endoscopy) on 22 patients (25%) with grade 2 injuries was successful and all 22 were discharged home without surgery. The overall mortality rate was 1.1% (1/92). There were no complications associated with the endoscopic procedure.

**CONCLUSION:** Upper gastrointestinal endoscopy for caustic ingestion should be performed early in patients not requiring immediate operation and can be performed safely. Though all grade 3 injuries in our study required surgery,
both grade 2 and 3 injuries can be treated conservatively. These patients usually require repeat endoscopy to ensure healing. The likelihood of requiring surgery for grade 3 injuries is, however, higher.

## Flexible Endoscopy – P381

### DECISION-MAKING PROCESS FOR SCREENING

**COLONOSCOPY**, M V Geana, T M Geiger MD, N J Rangnekar MD, G T Cameron, B W Miedema MD, University of Missouri, Departments of Journalism and General Surgery, Columbia MO

**Introduction:** Colonoscopy is currently underutilized as a screening technique for colon cancer. The purpose of this study is to use qualitative research techniques to analyze the decision-making process for screening colonoscopy.

**Methods and Procedures:** Screening colonoscopy is an innovation that has only been partially accepted by the population. A Penetration of Innovations model (Geana, 2006) has been developed that postulates that, when a decision resides with the individual, a change in attitude is needed before a change in behavior is seen. The model progresses from explanation (information gathering), to engaged (convinced of usefulness) to adaptation (overcoming barriers to using the innovation) and emphasizes the existence of two essential types of knowledge about the innovation: delivered (from experts) and created (from experience or inferential). Structured interviews were conducted with 16 patients that had undergone screening colonoscopy in the past 30 days. Each interview was analyzed before the next interview to provide categories for testing dimensions of the penetration of innovation model. A three step systematic procedure is then conducted using NVIVO software: developing a category, defining relationships among categories, and analyzing how category relationships compare with the penetration of innovation model.

**Results:** The informed decision for undergoing screening colonoscopy occurs in 3 major steps; a knowledge building period, a triggering event, and an active search for knowledge to overcome identified barriers to colonoscopy. The four main identified triggering events are age, doctor's recommendation, family history, and a personal medical event. In their decision process, patients progress from a passive attitude (I know something about screening colonoscopies), through a triggering event (I should have colonoscopy), to overcoming barriers (fear, cost, inertia) to schedule a colonoscopy.

**Conclusions:** Screening colonoscopy is consistent with the Penetration of Innovations model. Tailored public education, application of recognized triggers, and physician input in helping overcome specific barriers can increase the use of screening colonoscopy.

## Flexible Endoscopy – P382

### SCREENING ENDOSCOPY BEFORE BARIATRIC SURGERY: A SERIES OF 452 PATIENTS, Mark Loewen MD, Jeanine Giovanni MD, Carlos Barba MD, St Francis Hospital & Medical Center

**Introduction:** The role of upper endoscopy (EGD) in morbidly obese patients prior to bariatric surgery is controversial. The purpose of this study was to determine the diagnostic yield and cost of routine EGD prior to bariatric surgery.

**Methods:** A consecutive series of 452 patients, who were otherwise cleared for bariatric surgery following a series of consultations, underwent routine EGD. All patients were interviewed before EGD regarding gastroesophageal symptoms. Findings were tabulated and analyzed. Small hiatal hernia was not considered a clinically relevant finding.

**Results:** Of 452 patients undergoing EGD, one had transient desaturation and was unable to complete the procedure. Of the remaining 451, 109 (24.2%) had abnormal findings. Gastritis was the most prevalent finding, being found in 62 patients (13.7%), of which only 6 were associated with Helicobacter pylori (H-pylori). Polyps were found in 20 (4.4%) patients, both gastric (14) and duodenal (6). Ulcer disease was found in 11 (2.4%), both gastric (3) and duodenal

(8); 2 of the gastric ulcers were found to contain H-pylori. There were 11 moderate hiatal hernias. Pre-procedure gastroesophageal reflux (GERD) was reported by 24 patients (5%), but GERD was not significantly related to hiatal hernia (HH) or non-HH findings. There were 5 patients with esophagitis, of whom one had undergone Barretts metaplasia. A treatment change occurred in 78 patients: 69 were newly placed on proton pump inhibitors because of findings of inflammation and ulcers, and 9 were placed on triple therapy for H-pylori. Overall, 10 patients were delayed for surgery, 9 for H-pylori treatment and 1 to further work-up a moderate hiatal hernia for whom a gastric band was planned (the other patients with moderate hiatal hernias were planning to undergo gastric bypass). One patient had a finding of a large vessel in the fundus who had the gastric remnant staple line oversewn at the time of surgery.

**Conclusions:** In this consecutive series of 451 successful screening EGDs, there was a high (24%) yield of positive findings, leading to change in medical treatment in a significant (17%) number of patients. Upper endoscopy should be routinely performed preoperatively in bariatric patients.

## Flexible Endoscopy – P383

### TRANSABDOMINAL LESSER SAC FLEXIBLE PERITONEOSCOPY (LSFP): A NOVEL APPROACH FOR PANCREATIC BIOPSY, Ozanan R Meireles MD, Bryden J Stanley MSc, Lucas A Julien MD, Jeffrey M Gauvin MD, Donald N Reed, Jr. MD, Keith N Apelgren MD, Departments of Surgery, Colleges of Human and Veterinary (Stanley) Medicine, Michigan State University, East Lansing, MI

**INTRODUCTION:** Pancreatic masses demand histologic confirmation for diagnosis to direct subsequent treatment, but available methods of pancreatic biopsy have limitations (e.g. minute needle sampling) and pose undesirable risks (e.g. open laparotomy with open biopsy), leading to our hypothesis that minimally invasive direct biopsy is feasible. Our group has performed successfully Lesser Sac Flexible Peritoneoscopy (LSFP) for pancreatic biopsy under direct visualization in a canine model.

**METHODS:** With animal use approved by the IACUC (Institutional Animal Care and Use Committee) of Michigan State University, 6 canines averaging 30kg were used as an animal model. All procedures were performed in the approved surgical teaching suite in the College of Veterinary Medicine, MSU. Under general anesthesia and after accomplishing pneumoperitoneum, a conventional flexible gastro-scope was introduced into the abdominal cavity through a 10 mm port inserted supraumbilically with an auxiliary 10 mm port being placed in the right upper quadrant under direct visualization. The gastroscope (Olympus GIF 160) was advanced through the epiploic foramen (of Winslow) providing access to the lesser sac. From that location, the pancreas was directly inspected and biopsied. The animals were euthanized after the procedure.

**RESULTS:** On histological examination, five out of six specimens were confirmed to be pancreatic tissue. No complications were observed during the experiments and all the canines remained hemodynamically stable during the procedure. The continuous insufflation delivered from gastro-scope proved insufficient to maintain adequate pneumoperitoneum within the lesser sac. The 10 mm Babcock used for gastric retraction through the auxiliary port greatly enhanced the visualization.

**CONCLUSIONS:** LSFP combines laparoscopic and flexible endoscopic techniques, representing a novel method of pancreatic tissue sampling under direct vision, which is performed in a safe and controlled manner. We believe LSFP may be better than CT or EUS-guided biopsy. This study demonstrated that this technique is feasible and safe in an animal model. LSFP for pancreatic biopsy has the potential to improve patient care and open new horizons for minimally invasive procedures of the lesser sac.

<figure><img src="image_155.png" /></figure>
<figure><img src="image_156.png" /></figure>

# SAGES POSTER ABSTRACTS

## Flexible Endoscopy - P384

**ROLE OF FLEXIBLE ENDOSCOPY IN PENETRATING NECK TRAUMA**, S. Nijhawan MD, V. Mathavan MD, N. Ahmed MD, Dept. Of surgery, Huron Road Hospital/Cleveland Clinic Health System

**Introduction:** Historically, radiological contrast studies are the main stay in diagnosing orophyrangeal and esophageal injuries; these may be difficult in intubated patients and require transporting a critical ill patient to radiology suite. Flexible endoscopy may provide direct visualization at the bedside.

**Method:** The study, approved by IRB, was done in a busy trauma service with a high volume of penetrating trauma. All patients included in the study had penetrating injuries to the neck, with clinical suspicion of orophyrangeal or esophageal injuries, which had both EGD and Contrast study. Data was collected and compared for detection of injuries to orophyranx, esophagus and complications resulting from intervention.

**Results:** Total number of patients, N=12

<table><thead><tr><td></td><td>EGD</td><td>Barium Study</td></tr></thead><tbody><tr><td>Oropharyngin inj</td><td>3</td><td>0</td></tr><tr><td>Esophageal inj</td><td>1</td><td>1</td></tr><tr><td>Aspiration</td><td>0</td><td>1</td></tr><tr><td>Iatrogenic inj</td><td>0</td><td>0</td></tr></tbody></table>

*No missed injuries on 2-week follow-up. Esophageal injury was detected in same patient by both the studies.

**Conclusions:** Although limited due to the size of the study, our experience shows that endoscopy is comparable to radiological studies in detection of esophageal injuries. It may be superior in detecting orophyrangeal injuries, especially in intubated patients, as instilling contrast into esophagus bypasses orophyranx. Flexible endoscopy was also found to be convenient and safe.

## Flexible Endoscopy - P385

**ENDOSCOPIC PERCUTANEOUS TRANS-ESOPHAGEAL GASTRO-TUBING (E-PTEG) -FOR SIMPLER AND EASIER PROCEDURE-**, Hideto Oishi MD, Noriyasu Shirotani MD, Department of Surgery, Division of Digestive and General Surgery, Yachiyo Medical Center, Tokyo Women's Medical University

In 1994, we developed a non-surgical esophagostomy called the percutaneous trans-esophageal gastro-tubing (PTEG) for the patient who had difficulty to create the percutaneous endoscopic gastrostomy (PEG). PTEG is the trans-esophageal tube placement for enteral nutrition and/or digestive tract decompression as well as PEG and is a non-vascular interventional technique using ultrasound and fluoroscopy with rapture free balloon (RFB). We performed in total of 165 conventional PTEG since 1994 and from 2003, we started endoscope assisted PTEG (EA-PTEG) to make sure the tube insertion with an endoscopic view. Using the endoscope, we treated another 28 patients with satisfied results and for wider acceptance of this innovative option with simpler and easier procedure we developed the endoscopic percutaneous trans-esophageal gastro-tubing (E-PTEG).

The aim of this presentation is to introduce E-PTEG and clarify its usefulness with early clinical experiences. To perform E-PTEG, we developed a needle holder pusher (NHP) to create the puncture site without ultrasound. NHP has a simple round shape like an ultrasound transducers and is made from 2 clear plastic blocks with a slit to hold the puncture needle. We performed E-PTEG using NHP for 11 patients and 5 patients could succeed without using ultrasound and fluoroscope. However, 6 out of 11 patients still required the ultrasound and/or fluoroscopic intervention other than endoscopy. Then we developed a double balloon over-tube RFB (DBot-RFB) to puncture the cervical esophagus by transmitted light guide of an endoscope without ultrasound. Further evaluations are required, however, E-PTEG using NHP and DBot-RFB might be the simplest and the easiest esophagostomy technique even for endoscopists like PEG procedure.

## Flexible Endoscopy - P386

**COLONOSCOPIC SURVEILLANCE AFTER POLIPECTOMY**, Nicolas Rotholtz MD, Alexandra Mandry MD, Sandra Lencinas MD, Carlos Peczan MD, Gerardo Zanoni MD, Mariano Laporte MD, Daniel Cimmino MD, Colorectal Surgery Section. General Surgery Department and Endoscopy Department. Hospital Alemán de Buenos Aires. Argentina.

**Introduction:** Patients who have undergone colonoscopy and have had polypectomy are at increased risk of having new polyps in the future, and therefore might benefit from colonoscopic surveillance. The aim of this study was to evaluate the frequency of colonoscopic surveillance after polypectomy.

**Methods and Procedures:** From 1728 colonoscopies performed between January and December 2005, 194 were surveillance after polyps removal. 64 patients were excluded because there were few data regarding previous polypectomy. Finally 130 patients were evaluated. Patients were divided in two groups. Group 1 (G1): patients with no polyps at the colonoscopic control and Group 2 (G2): patients with polyps. Number, size, location and histological features of polyps identified at the first colonoscopy were assessed. Statistical analysis was performed by the chi-square test.

**Results:** 71 patients (54.6%) were included in G1 and 59 (45.4%) in G2. There were no differences in age and gender between the two groups. Polyps were detected in sigmoid colon (G1: 41,4% vs. G2: 30,1%; p= 0.12), rectum (G1: 15,1% vs. G2: 14.1%; p= 0.99) and right colon (G1: 21,2% vs. G2: 30,1%; p= 0.19). More polyps > 5 mm were found in Group 2 than Group 1 (33.5% vs. 15%; p= 0.004). There were more patients with 2 or more polyps resected in G2 (50.8% vs. 22.5%; p= 0.001). Mean polypectomy done per patient was significantly higher in G2 (1.79 vs. 1.33; p= 0.002).

There were no differences in the prevalence rates for hiperplastics polyps, adenomas and colorectal cancer between the groups. No difference was identified in the mean follow-up between the groups (31 vs. 25 months; p= 0.283).

**Conclusion:** Patients with two or more polyps, and with lesions greater than 5 mm have increased risk for having others polyps at the colonoscopic surveillance.

## Flexible Endoscopy - P387

**TRANS CHOLEDOCHODUODENOSTOMY ENDOSCOPIC MANAGEMENT OF A STRICTURE ASSOCIATED 2.5 CM.**

**LEFT INTRA-HEPATIC DUCT STONE: A CASE REPORT.**, Ray Sarmiento MD, V.J. Villaflor MD, Gozar Duque MD, Vivencio Villaflor, Dagupan Endoscopic and Laparoscopic Surgery Center Inc., Dagupan Doctors Villaflor Memorial Hospital, Dagupan City, Philippines

Management of hepatolithiasis associated with biliary duct stricture has remained to be surgical. We are presenting non-conventional route for endoscopic management of this problem.

This is a 35 year old female who presents with cholangitis. ERCP showed the CBD to be dilated ~1.0cm with a choledochoduodenostomy. The L Intrahepatic duct with a stricture of ~0.5 cm in length before it dilates to a diameter ~2.5 cm. distally. Inside was a 2.5 cm stone. The use of conventional ERCP accessories was not able to extract the L IHD stone.

The gastroscope (Olympus GIF-Q145) was used as a cholangioscope through the choledochoduodenostomy. The CBD accessed and the lumen of the IHDucts visualized. The R IHD was normal. Pus and stone fragments was seen coming out from the L IHD. The scope was advanced beyond the strictured area. With direct visualization of the stone, it and was crushed into fragments by a dormia basket until all were extracted. The L IHD strictured segment was dilated with a CRE balloon dilator (Boston Scientific) with 1.8 cm largest diameter to approximate the size of the distal dilated portion. Two days post endoscopy the cholangitis resolved. The patient is well 1 and 3 months into the follow up. This cholangioscopic technique with direct visualization, lithotripsty and dilatation can be done as long as a direct access into the CBD is available. Long-term follow up of this patient is needed to assess the effectiveness of this modality.
## Flexible Endoscopy – P388

**COLORECTAL CANCER SCREENING: A REVIEW OF A COLONOSCOPY-BASED SCREENING PROGRAM IN NORTH-EASTERN ONTARIO**, Alex Omiccioli, Ravinder Singh MD, Susan G Hegge MD, Craig A McKinley MD, The Centre for Minimal Access Surgery (CMAS-McMaster University and CMASNorth-North Bay District Hospital)

**Introduction:** Colo-rectal cancer (CRC) is the second leading cause of death from cancer in Canada. In Northeastern Ontario the risk of developing CRC in males and females is 78.5/100,000 and 64/100,000 respectively. These rates are among the highest in the country. The goal of this study was to evaluate the results of a screening colonoscopy program implemented by two community surgeons who practice in Northeastern Ontario.

**Methods:** Between January 2004 and March 2006 a prospective study was performed on 552 patients who were referred by their family doctor for screening colonoscopy. In order to assess the utility of colonoscopy for a purely screening purpose, patients with signs/symptoms of CRC other than fecal occult blood positive stools were excluded from the study. In the remaining 462 patients, indications to perform colonoscopy were threefold: positive fecal occult blood test (OB+) with no family history of CRC (53 patients), age greater than 50 (Age>50) with no family history of CRC (213 patients) and positive family history of CRC in a first degree relative (FH+) (196 patients). Clinically significant findings were defined as adenomatous polyps or CRC as identified by pathological review.

**Results:** In the OB+ group there were clinically significant findings in 32.1% of patients (16 patients with adenomatous polyps (4 with high grade dysplasia) and 3 patients with CRC). In the Age > 50 group there were clinically significant findings in 15.5% of patients (31 patients with adenomatous polyps (5 with high grade dysplasia) and 2 patients with CRC). Finally, in the FH+ group there were clinically significant findings in 15.3% of patients (30 patients with adenomatous polyps).

**Conclusion:** The current recommendations strongly suggest screening colonoscopy be offered to any patient with a FH of CRC in a first degree relative. Given that in our series the clinical yield of screening colonoscopy in age > 50 patients is similar to clinical yield of screening colonoscopy in patients with a FH of CRC in a first degree relative, we believe that screening colonoscopy should be offered to all patients of age > 50 in Northeastern Ontario. OB stool testing remains a valuable interim screening tool for general practitioners in Northeastern Ontario. However, we believe that the high incidence of CRC in Northeastern Ontario is a serious public health issue and that a screening colonoscopy program should be developed for this region.

## Flexible Endoscopy – P389

**DIAGNOSING THE CAUSE OF CHRONIC ABDOMINAL PAIN AFTER GASTRIC BYPASS:** IS ENDOSCOPY USEFUL?, Suthep Udomsawaengsup MD, Stacy Brethauer MD, Jeffrey Landers MD, Sam Rossi MD, Tracy Pitt DO, Vijaya Nirujogi MD, Silas Chikunguwo MD, Matthew Metz MD, Valentine Nfonsam MD, Bipan Chand MD, Philip Schauer MD, The Cleveland Clinic Foundation, Cleveland

**INTRODUCTION:** Chronic abdominal pain is a common complaint after gastric bypass. Marginal ulcers and gastrojejunostomy strictures remain the most common causes. Endoscopy is a valuable test to diagnose these conditions, but patients with normal endoscopy present a challenge. The purpose of this study is to examine the utility of EGD in patients with chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) and to determine what other testing was necessary to diagnose the cause of pain.

**METHODS AND PROCEDURES:** A retrospective review of patients who underwent EGD for chronic abdominal pain after RYGB was conducted. Patients with dysphagia were excluded. For patients with a normal EGD, additional testing and procedures were performed based on the patient's clinical course.

**RESULTS:** From July 2004 to June 2006, 67 patients presented with chronic abdominal pain after RYGB. 16 (24%) had a marginal ulcer and were treated medically. Fifty-one of the 67 patients (76%) had a normal EGD. Two patients were lost to follow-up. With a mean follow-up of 7 months, 17 patients improved with medical therapy and did not undergo further testing. Thirty-two patients had persistent pain and required additional evaluation. Of these, 14 have no source identified and 18 required operative intervention. Six patients had a biliary source for their pain. Four underwent cholecystectomy and two underwent transgastric ERCP, all with relief of their symptoms. Twelve patients underwent laparoscopic exploration. Seven had lysis of adhesions for partial bowel obstruction, four had a ventral hernia repair, and one patient had an internal hernia. Two patients (ventral hernia, lysis of adhesions) still persist with chronic pain. **CONCLUSION:** Although endoscopy can be a useful test to diagnose common causes of pain after RYGB, patients with normal endoscopy should undergo further testing, including laparoscopy, to diagnose and treat their pain.

## Flexible Endoscopy – P390

**TITLE:** THE TAILORING SIGMOIDOSCOPY SCREENING FOR COLORECTAL CANCER IN CHINESE PEOPLE(A RETROSPECTIVE STUDY ON 21 631 CASES) Hao Wang, Ronggui Meng, Chuangang Fu, Enda Yu, Wei Zhang, Lianjie Liu, Department of Colorectal Surgery, Changhai hospital, the Second Military Medical University, Shanghai, China 200433

**INTRODUCTION:** The retrospective study is examining the efficacy of the tailoring sigmoidoscopy screening for colorectal cancer in Chinese people.

**METHODS AND PROCEDURES:** The tailoring sigmoidoscopy screening means screening sigmoidoscopy which is used to identify patients with elevated risk of colorectal neoplasms firstly, then these patients with polyps in the sigmoid colon and rectum are referred for total colonoscopy and polypectomy. So a part of additional proximal cancer will be found, which can partly overcome the defect of sigmoidoscopy screening. There were 21 631 consecutive colonoscopies in our hospital from Jan 1998 to Dec 2002. Lesions in the sigmoid colon and rectum were taken as findings of FS(Flexible sigmoidoscopy). The incidence and distribution of colorectal cancer and polyps were analysed.

**RESULTS:** There were 21 631 consecutive colonoscopies in our hospital from Jan 1998 to Dec 2002. A total 759(3.5%) cases of primary colorectal cancer were diagnosed. Among these cases, 540 cases were located in the sigmoid colon and rectum, which should be found by the sigmoidoscopy directly. Among the remaining 219 cases of proximal colon cancer, the presence of coexisting polyps was found in 60(27.4%) cases and the coexisting polyps was located in the sigmoid colon and rectum in 46(21.0%) cases. If the 46 cases are included, there are 586(77.2%) cases of colorectal cancer being found by tailoring sigmoidoscopy screening.

**CONCLUSION(S):** The tailoring sigmoidoscopy screening is a good choice for colorectal cancer screening in Chinese people because the high incidence of the cancer in the sigmoid colon and rectum. The tailoring sigmoidoscopy screening can partly overcome the defect of sigmoidoscopy screening that it only examines a portion of the colon, at the same time, it solves the problems brought up by universal colonoscopy screening: cost, safety, resource constraints.

## Hepatobiliary/Pancreatic Surgery – P391

**SCHEDULED LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS**, Akihito Abe MD, Nobumi Tagaya PhD, Masashi Tachibana MD, Keiichi Kubota PhD, Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan

**Background:** Laparoscopic treatments for acute cholecystitis have remained controversial. The aim of study is to evaluate the result of scheduled laparoscopic cholecystectomy for the patients with acute cholecystitis.

**Materials and Methods:** We experienced scheduled laparoscopic cholecystectomy for acute cholecystitis in 82 cases. Twenty-seven cases (32.9%) with preoperative percutaneous transhepatic gallbladder drainage or aspiration (PTGBD (A)
<figure><img src="image_157.png" /></figure>

# SAGES POSTER ABSTRACTS

group) were compared with 55 cases without PTGBD (A) (Non-PTGBD (A) group).

**Results:** The mean ages of PTGBD (A) and Non-PTGBD (A) groups were 61 and 54 years, respectively. There were no significant differences in gender, previous abdominal surgery and preoperative combined diseases. The mean period from onset to PTGBD (A) was 4.0 days. The mean period from onset to surgery, operation time, estimated blood loss and conversion to open laparotomy of PTGBD (A) and Non-PTGBD (A) groups were 27.4 and 24.5 days, 174 and 184 min, 115 and 143 ml, and 4 (15.4%) and 8 (14.5%) cases, respectively. There were no significant differences in intra- and postoperative complications, postoperative and total hospital stay. The patients with PTGBD (A) for severe acute cholecystitis provided the same outcome comparing with those of Non-PTGBD (A).

**Conclusion:** We concluded that PTGBD (A) for severe acute cholecystitis was useful to perform safe scheduled laparoscopic cholecystectomy.

## Hepatobiliary/Pancreatic Surgery - P392

**AVOIDING ANY ENERGY SOURCE FOR A SAFE & BETTER LAPAROSCOPIC CHOLECYSTECTOMY, B B Agarwal MS, M K Gupta MS, S Agarwal MS, K C Mahajan MS, Sir Ganga Ram Hospital & Lady Hardinge Medical College, India**

**Objectives?** Assessing the health related quality of life after laparoscopic cholecystectomy performed without using any energy source.

**Methods & Procedures?** 93 consecutive, unselected patients of symptomatic cholelithiasis including acute cholecystitis, empyema, adhesions, post ERCP and with co-morbid conditions had cholecystectomy with standard Laparoscopy equipment without using any energy source. Health related quality of life was assessed incorporating Physical, Psychological & Work-performance parameters with the help of standard questionnaire.

Closed technique for creation of pneumoperitoneum (Carbon dioxide) and four port technique using a 5mm telescope was followed. Cholecystectomy was begun by sharp division of omental or visceral adhesions to gallbladder. The triangle of Calot was opened by cutting the cholecystoduodenal fold and dividing its anterosuperior and posteroinferior leaves. The peritoneal reflection from gall bladder to liver was cut with scissors along both margins of gallbladder fossa. Gallbladder was separated from liver by traction-counter traction and sharp dissection in the avascular plane identified in the loose areolar tissue. All procedures were video recorded.

**Results?** Better & smokeless endovision, lesser lens cleaning, reduced operative time. There was no biliary or visceral injury or any bleeding. Avoiding energy source spared the patients from unrecognizable biliary/vascular/visceral injury and molecular level insult. Patients were comfortable within 8hours of surgery and discharged soon after except for those with co-morbidity. Their quality of life returned to pre-operative status within 72 hours of sugery.

**Conclusions?** Laparoscopic cholecystectomy can be performed safely without using any energy source with benefits to the patients quality of life. The operative room atmosphere and the surgical team is not subjected to the surgical smoke. Due to no possibility of combustion substitution of carbon dioxide seems feasible and needs to be explored.

## Hepatobiliary/Pancreatic Surgery - P393

**A PROPOSAL FOR SCORING SYSTEM TO PREDICT THE DIFFICULTY IN TREATMENT OF BILIARY CALCULI BY ERCP, Adem Akcakaya MD, Mustafa Sahin MD, Ismail Okan MD, Atilla Karakellepglu MD, Vakif Gureba Training and Research Hospital, Istanbul, TURKEY**

**Aim:** The extraction of stones in biliary tree by ERCP is challenging to endoscopists in some cases. Here we propose a scoring system for the prediction of the difficulty encountered during ERCP in the treatment of choledocholithiasis.

**Methods:** Between 2000-2005, the data corresponding to the

patients with choledocholithiasis who underwent ERCP was reviewed. To determine the difficulty of procedure; the size, number, localization of the stone, stone impaction and associated anatomical abnormalities were taken into consideration as variable parameters. Each parameter was assigned with a numeric value resembling the degree of difficulty. The sum of the assigned values was between the ranges of 1 to 10. Then the patients were stratified into two groups: Group 1, regarded as easy, consisted of patients whose sum of numeric parameters was between 1 and 5. Group 2, defined as difficult, contained patients whose sum was between 6 and 10.

**Results:** A total of 744 ERCPs were performed to 592 patients with choledocholithiasis. Group 1 consisted of 610 ERCP (82%), whereas Group 2 contained 134 ERCP (18%). The treatment modalities in Group 1 were as follows: Stone extraction in 559 patients (92%), lithotrypsy in 30 cases (5%), stenting in 15 patients (2%), repeat ERCP and stent exchange in 6 patients (1%). In Group 2, 51 patients were treated with stone extraction (38%), 40 with lithotrypsy (30%), 29 patients with stent placement (22%). Fourteen patients required repeat ERCP and stent exchange (10%). The most common complication in both groups was bleeding after ERCP. Group 2 had pancreatitis and basket impaction additionally. There was significant difference in scoring between groups (p<0.001). The significant factors to be associated with difficulty were the content, size and localization of stones.

**Conclusions:** The scoring system could predict the difficulty during ERCP in treatment of patients with biliary calculi.

## Hepatobiliary/Pancreatic Surgery - P394

**INSULINOMA: IS LAPAROSCOPIC PANCREATECTOMY ONCOLOGICALLY SUPERIOR TO ROUTINE ENUCLEATION?, Yasir M Akmal MD, David G Sheldon MD, Geisinger Medical Center**

**Objective:** To provocatively examine the role of laparoscopic distal pancreatectomy in the routine management of insulinoma.

**Methods:** An examination of two recent cases of pancreatic tail insulinoma managed laparoscopically at a rural tertiary referral center.

**Results:** Two patients with biochemical evidence of insulinoma and CT findings of enhancing pancreatic tail mass were managed with laparoscopic pancreatic tail resection with splenectomy. Both patients were found to have histologic features of malignancy. One patient had metastatic involvement of a regional lymph node; a second had histologic criteria for angioinvasion of the surrounding pancreatic parenchyma. Both lesions were otherwise bland neuroendocrine tumors of the islet cells with no features suggestive of malignancy. Neither patients had a perioperative complication.

**Conclusions:** Insulinoma is an uncommon neuroendocrine tumor of the pancreas, that is traditionally thought to be of benign histology and clinical course; therefore open enucleation has been the procedure of choice. Our recent experience raises the question of whether the true incidence of malignant insulinoma is under-reported secondary to the limited procedure being performed in the first place. If a concomitant pancreatic resection with insulinoma is done, routine examination of the pancreas/tumor interface and regional nodes can be performed. The fact that malignancy cannot be identified with simple enucleation, the standard of care, leads to the inference that a more oncologically aggressive procedure will identify more malignant insulinomas. With the advent of laparoscopic pancreatic resection safely being performed in experienced hands, a routine removal of normal pancreatic margins and regional nodes may lead to a change in the management paradigm of the characteristically benign insulinoma and is recommended based on our recent experience.
<figure><img src="image_158.png" /></figure>

## Hepatobiliary/Pancreatic Surgery - P395

**SINISTROPOSITION:** LEFT-SIDED GALLBLADDER TREATED BY 2 MM LAPAROSCOPIC CHOLECYSTECTOMY. A REPORT OF TWO CASES, Ziad Amr MD, Faris Al-Gebory MD, John Macoviak MD, Garth Davis MD, Robert Davis MD, Patrick R Reardon MD, Department of Surgery, The Methodist Hospital, Houston, Texas

**Introduction:** True left-sided gallbladder (LSG) is a very rare anatomic variant. We report two such cases treated by laparoscopic cholecystectomy (LC) with 2 mm instrumentation. Both cases were performed utilizing the dome-down technique.

**Methods:** A prospective database of all LC's performed by the senior author (PRR) has been maintained since 1991. A retrospective review of 1120 consecutive cases in this database revealed 2 cases of LSG. Clinical data queried included operative time (OT), estimated blood loss (EBL), length of stay (LOS), port size, position, and intraoperative and postoperative complications. The cases were initiated with a mid-line, supraumbilical, 2 mm port, as is our standard. A 10 mm port was then placed at the umbilicus. Viewing through a 30° 10 mm laparoscope, the left-sided position of the gallbladder was noted. A 2 mm left subcostal port was then placed, in a mirror image fashion to a standard LC port placement. Inspection of the area of the cystic duct revealed that the ductal anatomy was obscured by the gallbladder as it crossed over to the right side. The cholecystectomy was then completed in a dome-down fashion.

**Results:** Neither of the two cases was diagnosed preoperatively. Both cases were successfully completed utilizing 2 mm instrumentation and the dome-down technique. There was one male patient, age 63 and one female patient, age 47. Mean values, ± standard deviation, were: OT = 75.5 ± 6.4 min; EBL = 37.5 ± 17.7 ml; LOS = 0.0 ± 0 days. One case required conversion of a 2 mm port to a 5 mm port because of a thickened gallbladder. The cystic duct entered the common bile duct on the right side in both patients. There were no intraoperative complications or complications within 30 days. The incidence of LSG in this series of 1120 consecutive cases of LC was 0.18%.

**Conclusion:** True LSG, or sinistroposition, is a very rare anatomic variant. The gallbladder is attached to segment IV of the liver and approaches the common bile duct from left to right, obscuring the cystic duct. The dome-down technique allows the gallbladder to be rotated to the right, exposing the cystic duct for safe completion of the operation. When this rare anatomic variation is encountered it can be safely treated laparoscopically and with the use of 2 mm instrumentation. The authors recommend using a dome-down technique to improve visualization of the cystic duct junction with the common bile duct, increasing the safety of the operation.

## Hepatobiliary/Pancreatic Surgery - P396

**THE ROLE OF PERITONEAL LAVAGE CYTOLOGY IN LOCAL-LY UNRESECTABLE PANCREATIC CANCER, Fru Bahiraei MD, L W Traverso MD, V Picozzi MD, Virginia Mason Medical Center**

Peritoneal lavage cytology (PLC) is a controversial part of the AJCC staging system for staging pancreatic cancer. Conflicting reports suggest an important role of peritoneal cytology in the prognosis and management of pancreatic cancer. Focus has been on the resectable patient; however, the role of peritoneal cytology in locally unresectable patients, as determined by CT scan, is not known. We propose that Diagnostic Laparoscopy and PLC should be standard of care in patients with locally unresectable disease. Using a prospective database, we reviewed the records of 132 patients with locally unresectable pancreatic cancer and no evidence of distant metastasis. These patients underwent staging laparoscopy with peritoneal lavage cytology. In comparing patients with positive and negative cytology, survival is not statistically significant (p-value 0.29). The estimated median survival for the positive group is 12.3 months (95% CI = 10.1-17.3), and for the negative group it is 15.2 months (95% CI = 11.1-18.9). The associated relative risk of

death is 1.32x in patients with positive cytology, but this finding is not statistically significant. In addition, 38% of our patients were upstaged with positive cytology and spared radiotherapy.

The role of PLC in the diagnosis, treatment, and staging of pancreatic cancer remains poorly defined. We feel that PLC status is important in locally unresectable patients. We will discuss our findings and compare them to current studies exploring the key issue of how PLC can help guide the management of patients with pancreatic cancer.

## Hepatobiliary/Pancreatic Surgery - P397

**THE ROLE OF LAPAROSCOPY WITH LAPAROSCOPIC ULTRASOUND FOR STAGING OF PANCREATIC CANCER IN THE ERA OF MODERN ADVANCED IMAGING, Boris I Bronfine MD, Maurice E Arregui MD, Dept. of Surgery, St. Vincent Hospital, Indianapolis, IN, 46240**

The goal of this study is to re-evaluate the role and the yield of staging laparoscopy (SL) with laparoscopic ultrasonography (LUS) in selecting patients with pancreatic cancer for pancreatoduodenectomy, considering the progress in quality of non-invasive imaging used for the same purpose.

**METHODS:** We retrospectively reviewed the data of patients with adenocarcinoma of the head of the pancreas, which were referred to our service as potential candidates for Whipple resection between Sept. 1999 and July 2006. After comprehensive assessment by dual phase fine cut CT, ultrasound and/or EUS all these patients had SL with LUS. The correlation between the results of imaging studies, conclusions at the staging laparoscopy and actual resectability at open exploration was reviewed.

**RESULTS:** The records of 40 consecutive patients with adenocarcinoma of the head of the pancreas were evaluated. Based on extensive imaging evaluation 35 of them were considered to be candidates for Whipple procedure. In five remaining cases the neoadjuvant therapy prior to a potential resection was suggested to downstage the local extent of the disease. All the patients then underwent routine SL with LUS. It revealed the unresectability in 4 out of 35 patients of the first group (11.4%), including one case of peritoneal carcinomatosis detected by SL alone, and three contraindications for resection found by LUS (5mm. hepatic metastasis; encasement of multiple vessels, and the involvement of celiac lymph nodes). The remaining 31 patients (88.6%) were classified as resectable; 30 of them had an open exploration and one patient (3.33%) was not resectable. The negative predictive value (in detecting unresectable cancers) was 85.2% for pre-operative imaging studies, 96.7% for staging laparoscopy combined with LUS and 85.3% for SL alone. The sensitivity of SL with LUS for the detection of contraindications to resection was 90%. Comparatively, the similar study from our institution in February 2000 has reported the negative predictive value of 74% for imaging modalities alone, 78% for laparoscopy alone, and 90% for SL with LUS.

**CONCLUSION:** Current dual phase CT multislice scanning with fine cuts has improved ability to detect disease precluding respectability. Staging laparoscopy with LUS has a higher negative predictive value (96.7%) compared with CT(85.3%). It remains a useful approach for predicting respectability and avoiding unnecessary open exploration with its attending morbidity.

## Hepatobiliary/Pancreatic Surgery - P398

**COST-EFFICIENCY RATIO OF LAPAROSCOPIC CHOLEDOCOLITHOTOMY, Sergio E Bustos MD, Pablo E Omelanczuk MD, Jorge A Nefa MD, Walther Minatti MD, Department of General Surgery, Hospital Italiano de Mendoza. Argentina. Lateral Este 1015 Guaymallén, Mendoza. Argentina**

**Objective:** Nowadays, laparoscopic treatment of cholecolithiasis aims to be cost-effective without affecting quality. Cost efficiency is the equation between effectiveness and cost, and it is necessary to develop strategies to obtain the best economic outcomes.

To evaluate the effectiveness of laparoscopic resources for LP cholecolitholithotomy and its global cost.

**Materials and method:** Out of 335 LP explorations for cholecolithiasis, the effectiveness rate was determined for
<figure><img src="image_159.png" /></figure>

SAGES POSTER ABSTRACTS

Transcystic and Choledochotomic access, as well as the ratio between intralaparoscopic endoscopy and conversion. To determine the global cost of laparoscopic surgery, four groups of economic factors were analyzed: Hospital stay with medication and analysis, Pharmacy expenses, Medical fees and Operating room expenses. The standard was 2 days of hospital stay, 2 operating room hours, and 1 radioscopy period (5 minutes). The cost of anesthesia and supplies was analyzed for the first two hours, and next the expenses of each procedure or conversion to LP surgery with one assistant were also analyzed.

**Results:** Effectiveness for Choledocholithotomy with TC access was 85% and for Choledochotomy 97.5%. Those cases in which a combined laparoendoscopic treatment was required, the success rate was 100% as well as when intrabdominal assistance was required.

Costs derived from: 60% surgical expenses (supplies, equipment-instruments, and general surgical expenses (staff, sterilization. electricity, air conditioning, etc.) The remaining 40% of expenses derived from hospital stay, medication, lab tests and medical fees.

Costs increased under certain conditions: adding procedures: starting transcystic and then converting to Choledochotomy, or converting from an initial Choledochotomy, assisting intrabdominally, or indicating postoperative endoscopy.

The operating time after two hours only increases 20% the cost of anesthesia. Routine IO Colangiography detected over 7 % of asymptomatic choledocholithiasis, thus avoiding residual lithiasis and making it cost efficient.

**Conclusion:** The most cost-efficient approach is Transcystic, next Choledochotomy with primary closure of the Common Bile Duct, and finally, intraoperative endoscopy. The key to reducing costs without affecting the quality of the procedure is to reduce surgical time, the number of associated procedures, hospital stay and an adequate use of resources.

Hepatobiliary/Pancreatic Surgery - P399

LAPAROSCOPIC COMMON BILE DUCT EXPLORATION AFTER PREVIOUS BILIARY TREE SURGERY, Kuo-Hsin Chen MD,Jen-Min Wu MD,Hen-Fu Lin MD,Li-Min Tseng MD,Hsin-An Chen MD,Shin-Horng Huang BA, Far-Eastern Memorial Hospital, Taipei, Taiwan

**Background:** The aim of this study was to evaluate the feasibility of laparoscopic common bile duct surgery in patients with a history of previous biliary tree procedure.

Laparoscopic approach to choledocholithiasis is an integrated part of minimally invasive treatment of biliary tree stones. Most series demonstrated high success rate even in patients after previous upper abdominal surgery. However, in patients with history of previous biliary tree surgery, the choices were limited. Laparoscopic approach in these patients may be limited by the adhesion caused by previous surgery and the anatomical landmarks may be obscured. Herein, we presented our initial experience of laparoscopic common bile duct exploration in patients after previous biliary tree surgery.

**Methods:** From Sep 2000 to May 2006, total 118 patients received laparoscopic CBD exploration at our hospital. Nineteen patients (total 20 procedures) have a history of previous biliary tree surgery, including laparoscopic cholecystectomy in 4, open cholecystectomy in 8, choledocholithotomy in 7 patients. There are 10 men and 9 women, aged from 49 to 87 years. Most patients received preoperative ERCP which failed to clear the common bile duct stones. Laparoscopic choledochotomy was the primary procedure. For patients with recurrence CBD stones, laparoscopic bilioenteric anastomosis was used to prevent further stone recurrence. Postoperative cholangiography was done in all patients with T-tube.

**Results:** Laparoscopic common bile duct exploration was successful in all patients without open conversion. The operation time ranged from 105 to 315 min. Hospital stay ranged from 3 days to 55 days. The longest stay happened in a dementia woman with ventilator dependence. The stone size ranged from 1 cm to 3 cm. No retained stone was

found in postoperative cholangiography. Recurrent CBD stones developed in two patients, however. One patient received further ERCP and the other received laparoscopic hepaticojejunostomy. Transient bile leakage developed in one patient which resolved gradually without intervention. Pneumonia developed in a woman with senile dementia. Pleural effusion was found in another woman which needed thoracocentesis.

**Conclusions:** Laparoscopic common bile duct reexploration is feasible after previous biliary tree surgery. Laparoscopic choledochotomy is effective, however, in patients with recurrent CBD stones, bilioenteric anastomosis is necessary.

Hepatobiliary/Pancreatic Surgery - P400

EXPERIENCE WITH LAPAROSCOPIC DISTAL PANCREATECTOMY AT A TERTIARY CARE COMMUNITY TEACHING HOSPITAL, Shea Chia MD,Danielle Bischof BS,Quoc Huynh MD,Paul Sullivan MD,Lloyd Smith MD,Richard Hart MD, Department of Surgery, St. Joseph's Health Centre, Toronto, Canada.

**Background.** Laparoscopic pancreatectomy is increasingly utilized in the community setting for selected cases of distal pancreatic disease.

**Methods.** A retrospective review was carried out of all laparoscopic pancreatic resections carried out by 2 surgeons at a community teaching hospital in an urban centre over a 4-year period. 12 patient charts were identified for review. Data was collected on patient characteristics, tumour characteristics, procedure performed, pancreas-specific complications, major and minor complications, early and late outcome.

**Results.** Of the 12 patients reviewed, 11 of the cases were performed in the last 18 months. 10 patients had benign disease, 1 had an endocrine lesion of uncertain malignant potential, and 1 had known metastatic disease from a neuroendocrine primary. 8 had splenic preserving procedures. A single patient had an enucleation, 1 had a central segment pancreatectomy. Mean operating time was 168 min (SD +/- 47.5 min), mean operative blood loss was 195 ml (SD +/- 164 ml). Average LOS was 8.3 days (SD +/- 7.3 days). Of the uncomplicated patients, average LOS was 5.3 days (SD +/- 1.3 days). There were no deaths. 3 pancreatic duct leaks (25%) were identified, 2 (17%) of which were clinically significant. These 2 patients had an enucleation and a central segment excision. Both went on to have a completion distal pancreatectomy and splenectomy as an open procedure. All patients were satisfactory at follow up.

**Discussion.** Our study results are comparable to existing laparoscopy literature with respect to operative time, LOS and rate of complications. Clinically significant pancreatic duct leaks only occurred in the patients that did not undergo a formal distal pancreatectomy.

Hepatobiliary/Pancreatic Surgery - P401

RANDOMISED CLINICAL TRIAL OF LONGITUDINAL VERSUS TORSIONAL MODE ULTRASONIC SHEARS FOR LAPAROSCOPIC CHOLECYSTECTOMY, Siok S Ching MD,Abeezar I Sarela MS,Michael J McMahon PhD, Department of Surgery, Leeds General Infirmary, Leeds, United Kingdom.

**Introduction:** Ultrasonic shears are increasingly used in surgery for hemostatic cutting. Conventional ultrasonic shears such as the UltraCision Harmonic Scalpel (Ethicon Endosurgery) uses longitudinal mode (LM) vibration whilst the recently developed LOTUS system (SRA Developments Ltd.) uses torsional mode (TM) vibration. TM shears produce compressive force between the vibrating blade and the inactive jaw giving theoretical advantages for hemostasis. We compared TM with LM shears for laparoscopic cholecystectomy.

**Methods:** During 2003-2006, 91 patients undergoing elective laparoscopic cholecystectomy were pre-operatively randomised to either TM or LM shears. Operations were performed by a standard technique, with routine intra-operative cholangiography. Intra-operative events, such as failure in hemostasis and time taken for dissecting the gallbladder off the liver bed, were recorded. Post-operatively, a sample of
<figure><img src="image_160.png" /></figure>

suctioned fluid was analysed for hemoglobin concentration [Hb]. Intra-operative blood loss was estimated by volume of suctioned fluid x [Hb]fluid / [Hb]blood. Mann-Whitney U Test and Fisher's Exact Test were used for statistical analyses.

**Results:** There were 21 men and 70 women, median age 51 years (range 18-81). Forty-five patients were randomized to TM shears and 46 patients to LM shears. Median intra-operative blood loss was 5.0 ml (IQR 1.4-15.1) with TM shears and 10.5 ml (IQR 2.6-27.4) with LM shears, p = 0.19. Median gallbladder dissection time was similar in both groups (15 min, IQR 10-27 vs. 19 min, IQR 10.5-29, p = 0.45). Other modalities of hemostasis (Surgicel or electrosurgery) were required on 6 patients in the TM group compared with 10 patients in the LM group, p = 0.41. One patient in the LM group developed post-operative hemoperitoneum that required urgent laparoscopic re-exploration. There were no other major vascular, biliary or enteric complications.

**Conclusion:** TM ultrasonic shears appear to be as effective as shears that utilize LM vibration. Blood loss in the TM group was half of that in the LM group. The results support the theoretical advantages of TM ultrasonic shears for hemostasis although statistical significance was not reached in this study.

## Hepatobiliary/Pancreatic Surgery - P402

**HAS THE MANAGEMENT OF GALLSTONE ILEUS CHANGED IN THE LAPAROSCOPIC ERA?,** Benjamin L Clapp MD, Lizbeth Alarcon-Bernes MD, Morris Franklin MD, The University of Texas Health Sciences Center at Houston and the Texas Endosurgery Institute

**Introduction:** Gallstone ileus is a rare cause of small bowel obstruction in the elderly. We report two cases of gallstone ileus that were managed laparoscopically. With the advent of laparoscopic management of bowel obstruction becoming commonplace, should we change our management of gallstone ileus? We review the management in the pre-laparoscopic and current eras.

**Case Series:** We report the successful laparoscopic management of complete bowel obstructions in a 69 year old female and a 65 year old female, both with gallstone ileus.

**Discussion:** Older surgical literature indicates that a patient with gallstone ileus should be managed by laparotomy with enterotomy and removal of the offending gallstone or by segmental bowel resection. With the advent of laparoscopic surgery, multiple reports have illustrated the safety and efficacy of a laparoscopic approach.

**Conclusion:** Gallstone ileus is a rare cause of intestinal obstruction. The diagnosis of gallstone ileus should be entertained in the elderly. Laparoscopic management of gallstone ileus is feasible and safe in the hemodynamically stable patient and should be the preferred approach.

## Hepatobiliary/Pancreatic Surgery - P403

**LAPAROSCOPIC RFA IN THE COMMUNITY SETTING.,** M S Cohen DO, M E Arregui MD, Dept. of General Surgery St. Vincent Medical Center Indianapolis,

**Purpose:** To describe our experience with the efficacy of Laparoscopic Radiofrequency Ablation (LRFA) of hepatic malignancies in the community setting.

**Methods:** Data from 36 consecutive patients with hepatic malignancies from Sept. 1999 to May 2006 were retrospectively reviewed and compared with the literature to evaluate failure patterns, morbidity/mortality rates, and progression free survival. 19 male and 17 female patients from a single surgical service had laparoscopic ultrasound guided RFA. The number of lesions, size, and pathology, were compared. Patients were followed to assess treatment response, recurrence and complications. A literature search of Medline from 1999-2006 was performed to gather comparable studies.

**Results:** LRFA was used to treat lesions in all liver segments comprising 228 lesions in 36 patients. One patient had LRFA combined with open resection. The median lesion diameter was 2.5 cm (.5-13cm). Our average number of lesions per pt was 4.3(1-26). 29 (80.5%) patients had metastatic lesions. Of these 21 (72.4)% were colorectal cancer, 3 (10%) endocrine

cancer, 2 (6.8%) lung cancer, 1 (3.4%) duodenal cancer, 1 (3.4%) cervical cancer, and 1 (3.4%) was from a duodenal GIST. 7 (19%) patients had primary hepatic malignancy. 3(8.3%) patients suffered complications. This is compared to the 8.9% rate in a large meta-analysis of 95 published series. Success was defined as: 1.) Ablation of all visualized tumor at the time of surgery, and 2.) Findings at 6 month imaging (CT and or PET) confirming complete necrosis of target lesions. We report 28/36 patients had successful eradication of disease by LRFA. Of the remainder; 3 (8.3%) were lost to follow up, 1 (2.7%) developed extra-hepatic malignancy, 2 (5.5%) developed local recurrence, and 3 (8.3%) had a staged ablation of multiple lesions over several months. Our local recurrence rate per patient was 1(5.8%) for colorectal cancer and 4 (14%) overall measured at 12 months. This compares well with the 3.3-39 % recurrence rates of series with similar heterogeneous patients. At 12 months, 12/27 (44%) patients had no new lesions. At 18 months, 7/27 (26%) had no new lesions. At 24 months, 3/27 (11%) had no new lesions. 8 (29%) patients had a second RFA for new hepatic lesions. Of these, 2 were also for local recurrence. Of those having a second RFA, 7 survived for >24 months. 3 (11%) patients went on to a third RFA for new hepatic lesions, of these 1 also had local recurrence, and all survived for 12 or more months after third RFA. 19/36 (52%) remain alive, average survival is 21 months (1-72).

**Conclusion:** LRFA can be applied successfully in the community setting with results that compare favorably to published studies from university settings.

## Hepatobiliary/Pancreatic Surgery - P404

**LCBDE LESS RISKY TO PANCREAS THAN ERCP,** Donald E Wenner MD, Jason M Degani MS, Paul R Whitwam MD, David M Turner MD, James C Rosser MD, Huining Kang PhD, Eastern New Mexico Medical Center, Center for Ambulatory Surgery and Endoscopy, University of New Mexico School of Medicine

**Objectives:** This study was undertaken to evaluate the safety and efficacy of LCBDE compared to ERCP. Special focus was placed on the post-operative incidence of pancreatitis after LCBDE in order to demonstrate that the procedure is less likely than ERCP to cause pancreatitis and associated morbidity and mortality.

**Methods and Procedures:** A comprehensive chart review was conducted on 129 consecutive patients undergoing LCBDE. The surgeons in this study are all proficient at LCBDE using a 2.8mm flexible choledochoscope and a multiple-channel instrument guide. Data on complication rates, morbidity, and mortality were analyzed for statistical significance. Clinical evidence and laboratory results including pre and post-operative amylase levels were analyzed to evaluate for the incidence of pancreatitis caused by the LCBDE procedure.

**Results:** No cases of clinical pancreatitis developed in any of these patients after the LCBDE procedure. The post LCBDE amylase was significantly lower than the pre-LCBDE amylase. 1 case of post-LCBDE pancreatitis was identified using diagnostic guidelines of serum amylase above 3 times normal, for a total incidence of 0.8% (95% confidence interval 0.02%-4.56%). This incidence is significantly less than the 7% incidence reported for ERCP (p-value = 0.0016). Successful stone clearance was accomplished in 96% (n=124) of cases. 19 patients presented with gall stone pancreatitis prior to the LCBDE procedure. In none of these patients was the post LCBDE amylase level > pre op level. Major complications included a 2.3% incidence of bile leakage (n=3) and a 1.6% incidence of infection of a drain site (n=2). There was no mortality in this study.

**Conclusions:** LCBDE is found to be superior to ERCP in terms of complication rates, particularly that of post-operative pancreatitis. Because of the morbidity and mortality associated with pancreatitis, we conclude that LCBDE should be further investigated as a viable and potentially safer approach to the remediation of choledocholithiasis.