49th AnnuAl Meeting - Society for Surgery of the Alimentary Tract

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					THE SOCIETY FOR SURGERY
OF THE ALIMENTARY TRACT


 49   th

 AnnuAl
 Meeting



 May 17 – 21, 2008
 San Diego Convention Center
 San Diego, California



PROGRAM BOOK
Table of Contents
Continuing Medical Education Accreditation Statement .....................2

Current Officers and Board of Trustees .................................................3

Standing Committees ............................................................................4

History of the SSAT................................................................................6

SSAT Foundation .................................................................................13
                                                           Available in Print Version Only

Founders Medal ...................................................................................31

Guest Oration ......................................................................................32

State-of-the-Art Lecture .......................................................................33

Program Schedule ................................................................................34

Poster Session Detail ............................................................................66

Plenary, Video, and Quick Shot Session Abstracts ..............................98

Poster Session Abstracts .....................................................................184

Author Index .....................................................................................461

Disclosure Index ................................................................................477
 THE SOCIETY FOR SURGERY
 OF THE ALIMENTARY TRACT




                   PROGRAM
 FORTY-NINTH ANNUAL MEETING
    San Diego Convention Center
        San Diego, California
          May 17–21, 2008


PLEASE BRING THIS PROGRAM BOOK WITH YOU TO THE ANNUAL MEETING.
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT



                CME STATEMENT
ACCREDITATION STATEMENT
                This activity has been planned and implemented in
                accordance with the Essential Areas and Policies of
                the Accreditation Council for Continuing Medical
                Education through the joint sponsorship of the
                American College of Surgeons and the Society for
  American      Surgery of the Alimentary Tract. The American
  College of    College Surgeons is accredited by the ACCME to
   Surgeons     provide continuing medical education for physicians.
  Division of
  Education

AMA PRA CATEGORY 1 CREDITS™
The American College of Surgeons designates this educational activity
for a maximum of 23.5 AMA PRA Category 1 Credits™. Physicians
should only claim credit commensurate with the extent of their
participation in the activity.

DISCLOSURES
Turn to page 477 for a complete index of program committee, moderator,
and speaker disclosures.




AMERICANS WITH DISABILITIES ACT
If you require special accommodations to attend or participate in the
CME activity, please provide information about your requirements to
SSAT, 900 Cummings Center, Suite 221-U, Beverly, MA 01915;
phone: (978) 927-8330; fax: (978) 524-8890;
e-mail: ssat@prri.com

                                  2
49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA



THE SOCIETY FOR SURGERY




                                                        INFORMATION
                                                           GENERAL
OF THE ALIMENTARY TRACT
                      OFFICERS:
                      2007–2008

                       President
             John C. Bowen, New Orleans, LA
                     President-Elect
            David W. McFadden, Burlington, VT
                      Vice President
                Richard A. Prinz, Chicago, IL
                        Secretary
               John G. Hunter, Portland, OR
                         Treasurer
               Robin S. McLeod, Toronto, ON
                         Recorder
           Bruce D. Schirmer, Charlottesville, VA


             BOARD OF TRUSTEES
       L. William Traverso, Chair    Seattle, WA
                   Barbara L. Bass   Houston, TX
                  Kevin E. Behrns    Gainesville, FL
                   Mark P. Callery   Boston, MA
                  Merril T. Dayton   Buffalo, NY
              James W. Fleshman      St. Louis, MO
                      Yuman Fong     New York, NY
                 Keith D. Lillemoe   Indianapolis, IN
               Fabrizio Michelassi   New York, NY
                Nathaniel J. Soper   Chicago, IL
                Selwyn M. Vickers    Minneapolis, MN




                              3
  THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


      STANDING COMMITTEES 2007–2008
EDUCATION COMMITTEE              PATIENT CARE COMMITTEE
   Daniel B. Jones, Chair          John W. Kilkenny, III, Chair
      John S. Bolton                      Elijah Dixon
   Thomas A. Broughan                   Douglas B. Evans
     Michael A. Choti                  Howard S. Kaufman
       O. Joe Hines                    Peter Muscarella, II
     Darryl T. Hiyama                    Seth I. Wolpert
    Michael J. Stamos                   Michael J. Zinner
      Debra L. Sudan                  Randall S. Zuckerman

  FINANCE COMMITTEE                PROGRAM COMMITTEE
   Robin S. McLeod, Chair            Mark P. Callery, Chair
        John C. Bowen                    John C. Bowen
       John G. Hunter                   Craig P. Fischer
       A. James Moser                    Donald E. Low
      Sean J. Mulvihill               David W. McFadden
     William H. Nealon                    Attila Nakeeb
       Richard A. Prinz                Bruce D. Schirmer
     L. William Traverso                  David Shibata
                                      L. William Traverso
 LOCAL ARRANGEMENTS                    Sharon M. Weber
      COMMITTEE                        Edward E. Whang
   Mark A. Talamini, Chair
                                 PUBLIC POLICY COMMITTEE
MEMBERSHIP COMMITTEE                 Steven C. Stain, Chair
                                       Thomas J. Howard
  Stanley W. Ashley, Chair           Kimberly S. Kirkwood
       Joseph J. Cullen                 Stuart G. Marcus
     Karen E. Deveney                     Margo Shoup
       Gerald M. Fried                    Lygia Stewart
       Lynt B. Johnson
        Ernst J.M. Klar
      Ronald F. Martin           PUBLICATIONS COMMITTEE
      Rodrigo O. Perez              Bruce D. Schirmer, Chair
       Marek Rudnicki                    Kevin E. Behrns
    Richard T. Schlinkert                  Zane Cohen
        David Shibata                   Jeffrey A. Drebin
      Jennifer F. Tseng                   Daniel J. Scott
     Selwyn M. Vickers                   Brad W. Warner
      Sharon M. Weber
      John A. Windsor              RESEARCH COMMITTEE
     Michael S. Woods                 Herbert Chen, Chair
                                       Gerard V. Aranha
NOMINATING COMMITTEE                   Richard A. Hodin
  Keith D. Lillemoe, Chair             Elin R. Sigurdson
       Barbara L. Bass                 Diane M. Simeone
    Steven M. Strasberg                 Scott A. Strong
     Mark A. Talamini
    L. William Traverso




                             4
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


        STANDING COMMITTEES 2007–2008




                                                                             INFORMATION
                                                                                GENERAL
                                REPRESENTATIVES
                             Board of Governors of the
                           American College of Surgeons
                                   Merril T. Dayton
                             American Board of Surgery
                                   David M. Mahvi
                         ABS GI Surgery Advisory Council
                                    John G. Hunter
                             Fellowship Council Board
                                 Michael S. Nussbaum
                   Fellowship Council Accreditation Committee
                                   Keith D. Lillemoe
                                 Theodore N. Pappas
                                  Nathaniel J. Soper
                       Gastroenterology Women’s Coalition
                                   Natalie E. Joseph
                                   Jennifer F. Tseng
                        Journal of Gastrointestinal Surgery
                               John L. Cameron, Editor
                        Jeffrey B. Matthews, Associate Editor
                           Charles J. Yeo, Associate Editor



                          PROGRAM SUBCOMMITTEES

       Biliary/Hepatic                                      Pancreas
      Craig P. Fischer, Chair                       Sharon M. Weber, Chair
        Eddie K. Abdalla                               Gerard V. Aranha
          Elijah Dixon                                 John D. Christein
       D. Rohan Jeyarajah                               Jason B. Fleming
          Julie A. Stein                                   O. Joe Hines
       Magesh Sundaram                                    Taylor S. Riall

Colon-Rectal/Combined Science                      Small Bowel/Stomach
      David Shibata, Chair                         Edward E. Whang, Chair
       Alessandro Fichera                           Thomas H. Magnuson
          Tracy L. Hull                                 John Morton
        Neil H. Hyman                                  John T. Mullen
       Deborah A. Nagle                               Ninh T. Nguyen
       Richard C. Thirlby                            Robert W. O’Rourke

           Esophageal                                        Video
      Donald E. Low, Chair                            Attila Nakeeb, Chair
         Steven P. Bowers                              Robert E. Glasgow
      Jonathan F. Critchlow                            Ellen J. Hagopian
           Blair A. Jobe                               Rebecca M. Minter
          Vic Velanovich                              Timothy M. Pawlik
         Tracey L. Weigel                            Randall S. Zuckerman



                                       5
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


                     HISTORY OF THE SSAT
                    The history of the SSAT begins in 1957 when Dr.
                    Robert Turell dreamed “of launching a new surgical
                    organization oriented to the problems of the
                    alimentary tract and of creating a research or
                    educational foundation.”1 He discussed the
                    possibility of a new society with many prominent
                    surgeons and many discouraged him, but he found
                    substantial support from Dr. Warren Cole, who
Dr. Warren Cole     agreed to help under the condition that Dr. John
                    Waugh would assist in the formation of the society.
                    The three met in Rochester, Minnesota, at which
                    time Dr. Waugh confessed that he had been
                    entertaining similar thoughts for a society devoted
                    to the advancement of alimentary surgery.
                    The Society was incorporated on March 30, 1960,
                    and was initially named the Association for Colon
                    Surgery. The founding membership consisted of
                    authors who had contributed papers to six issues
                    of the Surgical Clinics of North America edited by
                    Dr. Turell and the authors of the chapters in his
                    textbook Diseases of the Colon and Anorectum. In
Dr. Robert Turell
                    the beginning it was thought advisable to limit the
                    Society’s interest to surgery of the colon, but Dr. Cole
                    proposed that the name be changed to The Society
                    for Surgery of the Alimentary Tract to reflect wide
                    interest in abdominal surgery. Dr. Robert Zollinger,
                    the Society’s third president, gave a convincing
                    address entitled “Justifying our Existence.”2 He
                    noted that papers related to the alimentary tract
                    made up less than half of the programs of other
                    societies including the American College of Surgeons
                    Clinical Congress, and that SSAT was the only North
                    American organization focused on surgical problems
                    of the entire alimentary tract, a situation which still
Dr. John Waugh      exists today.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


The requirements for membership in the Society have been a matter




                                                                             INFORMATION
of frequent debate since its inception. In 1965, five years after the




                                                                                GENERAL
founding of the society, the Board of Trustees directed that the
membership should be enlarged rather than restricted to a small
group. The first constitution of the Society was approved that same
year. The requirements for membership were:

  1. Fellowship in the American College of Surgeons or its equivalent;
     and

  2. Demonstrated interest in the function and disease of the
     alimentary tract as evidenced by fundamental research or by
     publication of significant papers.

Initially, the number of published papers was flexible, but by 1981,
sixteen years later, the requirement for at least 10 publications became
the law of the membership committee. As a result, the society’s
growth flattened.
In 1984, the Board of Trustees became concerned over the lack of
growth and again decided that the publication requirement should be
liberalized. Dr. James Thompson, Chairman of the Board, noted that
“the ascendancy of our collegial organization, the American Gastroen-
terological Association (AGA), to a position of great importance, many
believe, dates from its adoption of the recommendation of Dr. Mort
Grossman that it be an egalitarian and not an elitist organization.”
Dr. Thompson urged the membership to identify surgeons practicing
alimentary surgery in their community and propose them for mem-
bership. At this time, the only membership criteria were certification
by the American Board of Surgery or its equivalent, membership in
the American College of Surgeons or its equivalent, and an interest in
gastrointestinal surgery.
In 1993, President-Elect Dr. Bernard Langer set an agenda that focused
on three important issues facing the Society: first, the creation of
advanced training programs in gastrointestinal surgery; second, the
need to increase substantially the membership of the Society to
include the vast majority of surgeons practicing alimentary tract surgery
in North America; and third, an assessment of starting the Society’s
own journal of gastrointestinal surgery. During his presidency, Dr. Langer
convened a task force that recommended to the Board a campaign to
aggressively recruit members, a change in the membership process to
one of direct application, and the creation of a trainee membership.
The proposed criteria for membership were:

                                    7
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  1. A degree from a medical school acceptable to the Board of
     Trustees;

  2. A license to practice medicine in the applicant’s state, providence
     or country;

  3. Certification by a board that is a member of the Board of the
     American Board of Medical Specialties, the Royal College of
     Physicians and Surgeons in Canada or an equivalent body; and

  4. An interest in surgical aspects of digestive disease. The most
     important part of the proposal was that applications for
     membership could be initiated by the applicant.
The result of these changes has been a substantial increase in the
membership of the Society in recent years.




The development of the Society’s own journal took many years. The
founders of the organization wished to live in harmony with the
already established surgical organizations, which precluded consideration
of an independent journal. After the first annual meeting, several
existing journals expressed interest in publishing the Society’s papers
the publication of the papers presented at the first annual meeting.
Ultimately, a decision was made to publish in the American Journal of
Surgery, edited by Dr. Zollinger; that journal subsequently published the
papers presented at the Society for the next ten years. Only once during
that period, in 1965, the Society reviewed the possibility of publishing
its own journal, but thought it not to be desirable at the time. In 1970,
the American Journal of Surgery became the official journal of the
Society, with all members subscribing to the journal as part of their
membership.


                                    8
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


The issue resurfaced again in 1993 as one of Dr. Langer’s three important




                                                                            INFORMATION
decisions facing the Society. The issue became part of the agenda of




                                                                               GENERAL
the special task force convened during his presidency. In response to the
report of the task force, the Board appointed a Publication Committee,
chaired by Dr. Keith Kelly, to study the issue. At its October, 1995
meeting, the Board accepted the recommendation of the Publication
Committee to proceed with establishing an SSAT journal. The name
selected was the Journal of Gastrointestinal Surgery. Most importantly,
the journal was to be owned and copyrighted by the Society. The Board
made the decision to have dual editors and appointed Drs. Keith Kelly
and John Cameron to the position.
From the beginning, SSAT has shown an interest in integrating with
other professional organizations. It all started in 1964, when Dr. Helger
Jenkins urged that a committee be appointed to work out a joint
membership with gastroenterologists. Apparently in response to his
request, a Liaison Committee to the AGA was appointed by the Board
around 1966. Dr. Lloyd Nyhus chaired the committee. Their charge
was to explore possible ways of bringing the two societies interested in
gastrointestinal diseases into closer relationship. The committee found
it impossible to schedule a joint meeting with the AGA and the whole
issue would have been dropped if it was not for the death of a promi-
nent individual in Minneapolis from ulcerative colitis. The family of
the deceased individual established the Digestive Disease Foundation
of Minneapolis for the purpose of funding research in the broad scope
of digestive diseases. In February, 1967 Dr. Nyhus, still attempting to
make contact with the AGA, attended a conference on Digestive Disease
as a National Problem. This conference was sponsored by the Digestive
Disease Foundation of Minneapolis, the National Institute of Arthritis
and Metabolic Diseases and the AGA. The purpose of the conference
was to stress to the federal government the overall importance of
digestive disease on the American public. Details regarding the promi-
nence of the problem, the need for continued research, the needs for
manpower and a plan to provide for these needs in the future were
presented. As a direct result of the conference, the National Institute
of Arthritis and Metabolic Disease identified the problem of gastrointes-
tinal disease for in-depth study.
The following year, Dr. Nyhus reported to the Society that the AGA had
taken an interest in our Society because of the desire to have surgeons
involved in discussions about digestive disease with governmental
agencies. This provided an opportunity for the two societies to discuss
a variety of issues, including the possibility of a joint annual meeting.




                                    9
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


At that time, the SSAT’s annual meeting was held in conjunction with
the AMA meeting, and it was suggested that SSAT change its meeting
dates to coincide with the AGA.
The AGA, in moving towards its goal of obtaining research dollars,
formed both a Federation of Digestive Disease Societies and a Digestive
Disease Foundation. Dr. Morton Grossman addressed the SSAT’s Board
of Trustees at its 1970 meeting, explaining that the goal of the Federation
and Foundation was to develop a National Digestive Disease Institute
similar to the National Cancer Institute. The purpose of the Institute
would be to support research, education of the lay public, unify public
relations and initiate legislation regarding digestive diseases. He
expressed the hope that our Society would join both organizations.
There was considerable discussion of Dr. Grossman’s presentation, and
the decision was made to join both the Federation and Foundation.
When the action of the Board was reported at the Society’s annual
business meeting, Dr. Ward Griffen took the issue of integration with
the AGA one step further and recommended that the membership be
polled regarding moving the meeting of our Society to coincide with
the AGA meeting.
At the 1972 meeting, Dr. Nyhus reported that the poll of the membership
showed that eighty percent were strongly in favor of changing the
date and location of the meeting to coincide with the AGA in a so-
called Digestive Disease Week; accordingly, arrangements for a combined
meeting in New York were set for May, 1973.
The combined meeting went exceedingly well and most members
enthusiastically supported the motion to continue the arrangement.
In October, 1974, six months after the annual meeting, Dr. Robert
Zeppa and Dr. Frank Moody were authorized to attend the newly
formed Digestive Disease Week Council as representatives of our
Society. So it was that Digestive Disease Week came into being.
Four years later, in his presidential address entitled “Cooperation to
Meet the Challenges,”3 Dr. Zeppa reviewed the Society’s decision to
join Digestive Disease Week Council. He noted that financial benefit
and stability came to each of the four societies, namely the AGA, the
American Association for the Study of Liver Diseases (AASLD), the
American Society for Gastrointestinal Endoscopy (ASGE) and the
SSAT; second, attendance at our meeting increased; third, the quality
of our program improved; fourth, the educational benefits for our
members expanded by the diversity of programs available; and fifth,
there was increased accessibility for dialogue, formal and informal,



                                    10
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


with our medical colleagues. He concluded that the membership was




                                                                           INFORMATION
to be congratulated for its wise decision.




                                                                              GENERAL
More recently we have furthered our relationship with the component
societies of DDW by contributing to combined clinical symposiums,
organizing a yearly consensus conference, and integrating appropriate
oral and poster presentations of our papers into AGA focused research
sections and the president’s plenary poster session.
The Society’s founder, Dr. Robert Turell, in his presidential address,
spoke of his dream of creating a research and educational foundation
for alimentary surgery. In practical terms, creating a research and
educational foundation required the development of an enduring
source of funding. The first move in realizing this dream occurred at
the Board of Trustees meeting in October, 1985. Dr. Bernard Jaffe,
Chairman of the Ad Hoc Committee on Research and Education,
recommended that the Board issue a policy statement supporting the
development of a two year program for post-residency experience in
research and clinical surgery of the digestive tract for the purpose of
providing leadership for the discipline in the future. The committee
further recommended that the Society sponsor a Career Development
Award to support individuals involved in this advanced experience.
The next year, the Society used its share of DDW profits to fund the
fellowship. Drs. David Nahrwold and Jaffe worked out the process of
application and selection with the understanding that the first award
would be given in 1987. The annual award was subsequently increased
step wise to its current level of $50,000 per year. The majority of its
recipients currently have University appointments and many have
ongoing NIH funding. The program has been a tremendous success.
Five decades after Dr. Turell’s initial imaginings, the SSAT is a strong
organization with a growing membership, strong ties to other disciplines
in medicine involved in the study and treatment of digestive diseases,
and a commitment to support the next generation of alimentary tract
surgeons.




                                   11
      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


References
   1. Turell R. Quo Vadis. Am J Surg. 1968;115:2–5.

   2. Zollinger RM. Justifying our existence. Am J Surg. 1964;107:233–38.

   3. Zeppa R. Cooperation to meet the challenges. Am J Surg. 1979;137:3–6.




* This history of the SSAT was excerpted from the Presidential Address of Tom DeMeester at
  the 38th Annual Meeting in Washington DC by Richard Bell. The full text can be found in—
  DeMeester TR. Change, Relationships, and Accountability: Marks of a Vibrant Society.
  J Gastrointest Surg. 1998;2:2–10.




                                             12
49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


              FOUNDERS MEDAL




                                                        INFORMATION
                                                           GENERAL
                Monday, May 19, 2008
                  8:00 AM – 8:15 AM
          San Diego Convention Center 25ABC

             RONALD K. TOMPKINS, MD
              Professor Emeritus of Surgery
                General Surgery Division
        David Geffen School of Medicine at UCLA
                     Los Angeles, CA




                          31
 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


      DORIS AND JOHN L. CAMERON
            GUEST ORATION
“The Coming American Revolution: How China Will
      Cause the Greatest Changes in the U.S.
         Since the Birth of the Nation”

                 Monday, May 19, 2008
                  11:15 AM – 12:00 PM
          San Diego Convention Center 25ABC

              LOUIS McDANIEL BOWEN
        Chairman, Asia Capital Management Ltd. &
                  China Advisors Ltd.
                Hong Kong, SAR, China




                           32
   49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


           MAJA & FRANK G. MOODY




                                                           INFORMATION
          STATE-OF-THE-ART LECTURE




                                                              GENERAL
“The Early Detection of Pancreatic Cancer: Lessons from
        Surveillance of 100 High-Risk Patients”

                    Tuesday, May 20, 2008
                    11:15 AM – 12:00 PM
             San Diego Convention Center 25ABC

                  TERESA BRENTNALL, MD
                Associate Professor of Medicine
                 Division of Gastroenterology
                   University of Washington
                          Seattle, WA




                              33
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT



         SCIENTIFIC PROGRAM
               Forty-Ninth Annual Meeting
                        May 17–21, 2008
 All rooms at the San Diego Convention Center unless otherwise indicated.

       Indicates a ticketed session requiring a separate registration and fee.

   Indicates a session offering Simultaneous Oral Translation in Spanish and
Japanese.



Saturday, May 17, 2008
8:30 AM – 2:30 PM          RESIDENTS & FELLOWS               Omni Hotel Gallery 2
                           RESEARCH CONFERENCE
              Participation in and attendance at this conference by invitation
           only. The 21 papers being presented are indicated throughout this
           program schedule by the icon to the left.


Monday, May 19, 2008
8:00 AM – 8:15 AM             OPENING SESSION                                    25ABC
         Moderator:        John C. Bowen
                           New Orleans, LA
           Welcome and introduction of new members, announcements of SSAT
           scholarship awards, reports from the SSAT Foundation, recognition of
           the Foundation donors, and conferment of the Founders Medal.




                                         34
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


8:15 AM – 9:15 AM           PRESIDENTIAL PLENARY A                            25ABC
                         (PLENARY SESSION I)
         Moderator:      Richard A. Prinz
                         Chicago, IL
  215    Stepwise Circumferential and Focal Radiofrequency
         Ablation of Barrett’s Esophagus with High-Grade
         Dysplasia or Intramucosal Cancer




                                                                                         SCHEDULE
         Roos E. Pouw1, Joep J. Gondrie1, Frederike G. Van Vilsteren1,




                                                                                           DAILY
         Carine Sondermeijer1, Wilda Rosmolen1, Wouter L. Curvers1,
         Lorenza Alvarez Herrero4, Fiebo J. Ten Kate2, Kausilia K. Krishnadath1,
         Thomas M. Van Gulik3, Paul Fockens1, Bas L. Weusten4,
         Jacques J. Bergman*1
         1Gastroenterology and Hepatology, Academic Medical Center, Amsterdam,
         Netherlands; 2Pathology, Academic Medical Center, Amsterdam, Netherlands;
         3Surgery, Academic Medical Center, Amsterdam, Netherlands; 4Gastroenterology,
         St. Antonius Hospital, Nieuwegein, Netherlands
  216    Long-Term Results of Transanal Excision After
         Neoadjuvant Chemoradiation for T2 and T3
         Adenocarcinomas of the Rectum
         Rajesh Nair*1, Erin M. Siegel1, Timothy J. Yeatman1,
         Mokenge P. Malafa1, Jorge Marcet2, David Shibata1
         1Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research
         Institute, Tampa, FL; 2Surgery, H. Lee Moffitt Cancer Center and
         Research Institute, Tampa, FL
  217    High Volume Surgery and Outcome After Liver
         Resection: Surgeon or Center?
         Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng,
         Shimul A. Shah*
         Surgery, University of Massachusetts, Worcester, MA
  218    Laparoscopic Vertical Sleeve Gastrectomy for Morbid
         Obesity: A Report of a Five-Year Experience with
         750 Patients
         Crystine M. Lee, Paul T. Cirangle*, Gregg H. Jossart
         Surgery, California Pacific Medical Center, San Francisco, CA




                                        35
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


9:15 AM – 10:00 AM         PRESIDENTIAL ADDRESS                           25ABC
SP339    Introduction
         Richard A. Prinz, Chicago, IL
SP340    Evolution of a Surgeon: A 40-Year Perspective
         John C. Bowen, New Orleans, LA

10:30 AM – 11:15 AM        PRESIDENTIAL PLENARY B                         25ABC
                        (PLENARY SESSION II)
         Moderator:     John C. Bowen, New Orleans, LA
  249    Role of Prophylactic Antibiotics in Laparoscopic
         Cholecystectomy: A Meta-Analysis
         Abhishek Choudhary*, Matthew L. Bechtold, Craig Karpman,
         Srinivas R. Puli, Mohamed O. Othman, Praveen K. Roy
         Department of Internal Medicine, University of Missouri, Columbia, MO
  250    Comparison of Surgically Resected Polypoid Lesions of
         the Gallbladder to Their Pre-Operative Ultrasound
         Characteristics
         Martin D. Zielinski*1, Peyton W. Davis1, Florencia G. Que1,
         Michael L. Kendrick1, Thomas D. Atwell2
         1Gastrointestinal and General Surgery, Mayo Clinic, Rochester, MN;
         2Radiology, Mayo Clinic, Rochester, MN

  251    The Incidental Asymptomatic Pancreatic Lesion:
         Nuisance or Threat?
         Teviah E. Sachs*, Wande B. Pratt, Mark P. Callery, Charles M. Vollmer
         General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical
         School, Boston, MA

11:15 AM – 12:00 PM       DORIS AND JOHN L. CAMERON                       25ABC
                        GUEST ORATION
SP359    The Coming American Revolution: How China Will
         Cause the Greatest Changes in the U.S. Since the Birth
         of the Nation
         Louis McDaniel Bowen, Hong Kong, SAR, China

12:00 PM – 2:00 PM      POSTER SESSION I                           Sails Pavilion
         Authors available at their posters to answer questions 12 PM – 2 PM;
         posters on display 8 AM – 5 PM.




                                      36
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


12:30 PM – 1:45 PM               MEET-THE-PROFESSOR LUNCHEONS
SP386    Local Therapy for Rectal Cancer                 Carlsbad, South
         Anthony J. Senagore, Grand Rapids, MI           Tower, Marriott
                                                         Hotel & Marina
SP391    Surgical Management of Achalasia                           26B
         Donald E. Low, Seattle, WA




                                                                           SCHEDULE
SP394    What’s New in Liver Tumor Ablation                         26A




                                                                             DAILY
         David M. Mahvi, Madison, WI

2:15 PM – 3:45 PM           DDW COMBINED CLINICAL SYMPOSIA
         ESOPHAGEAL CANCER                                Ballroom 20A
         Sponsored by: SSAT, AGA
         Moderators: John G. Hunter, Portland, OR
                       Stuart Jon Spechler, Dallas, TX
SP401    The Intriguing Epidemiology of Esophageal Cancer:
         What Factors Underlie the Trends?
         Stuart Jon Spechler, Dallas, TX
SP402    The Biology of Esophageal Cancer: What Factors
         Influence the Choice of Therapy?
         Jeffrey H. Peters, Rochester, NY
SP403    Endoscopic Treatment of Esophageal Cancer
         Jacques J. Bergman, Amsterdam, Netherlands
SP404    Surgical Treatment of Esophageal Cancer
         John G. Hunter, Portland, OR
SP405    A Balanced Approach to the Treatment of Esophageal
         Cancer
         Charles R. Thomas, Jr., Portland, OR
         Discussion
         THE OPTIMAL MANAGEMENT OF                      Ballroom 20BCD
         LGI BLEEEDING
         Sponsored by: ASGE, AGA, SSAT
         Moderators: Kenneth R. McQuaid, San Francisco, CA
                       Lisa L. Strate, Seattle, WA
SP406    Why Is There So Much Controversy?
         Lisa L. Strate, Seattle, WA




                                       37
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


SP407     Should Urgent Colonoscopy Be Performed in Most
          Patients with Acute LGIB? YES!
          Dennis M. Jansen, Los Angeles, CA
SP408     Should Urgent Colonoscopy Be Performed in Most
          Patients with Acute LGIB? NO!
          Don C. Rockey, Dallas, TX

2:15 PM – 5:00 PM        PLENARY SESSION III                                24ABC
          Moderators:    Gerard V. Aranha, Maywood, IL
                         Donald E. Low, Seattle, WA
   338    Cervical Nodal Metastasis from Intrathoracic
          Esophageal Squamous Cell Carcinoma Is Not
          Necessarily an Incurable Disease
          Daniel K. Tong*, Simon Law, Kam Ho Wong, John Wong
          Department of Surgery, The University of Hong Kong, Hong Kong, China
   339    The 3-Year Outcome of Optimal Medical or Surgical
          Management of GERD Patients with Barrett’s
          Esophagus: The Lotus Trial Experience
          Stephen E. Attwood*1, Lars R. Lundell2, Jan G. Hatlebakk3,
          Stefan Eklund4, Ola Junghard4, Jean Paul Galmiche5, Christian Ell6,
          Roberto Fiocca7, Tore Lind4
          1North Tyneside Hospital, North Shields, United Kingdom; 2Karolinska
          University Hospital Huddinge, Stockholm, Sweden; 3Haukeland Hospital,
          Bergen, Norway; 4AstraZeneca R&D, Mölndal, Sweden; 5Hotel Dieu-CHU
          de Nantes, Nantes, France; 6Dr.-Horst-Schmidt-Kliniken Wiesbaden,
          Wiesbaden, Germany; 7University of Genova, Genova, Italy
   340    Zenker’s Diverticula: Is a Tailored Approach Feasible?
          Christian Rizzetto1, Mario Costantini*1, Raffaele Bottin2, Elena
          Finotti1, Lisa Zanatta1, Martina Ceolin1, Loredana Nicoletti1,
          Giovanni Zaninotto1, Ermanno Ancona1
          1Clinica Chirurgica 3, University of Padua, Padova, Italy; 2Medical and
          Surgical Specialities, University of Padua, Padua, Italy
   341    Quality of Life and Symptomatic Response to Gastric
          Neurostimulation for Gastroparesis
          Vic Velanovich*
          Surgery, Henry Ford Hospital, Detroit, MI




                                        38
 49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


342   Results of the Surgical Treatment of Cardia Carcinoma
      (Ca) Characterized by Outcome and Perioperative
      Factors in a Prospective Observational Multicentre
      Study for Quality Control
      Lutz Meyer*1, Olof Jannasch2, Frank Meyer2, Hans Lippert2,
      Ingo Gastinger3
      1Surgery, HELIOS Vogtland Hospital Plauen, Plauen, Germany; 2Surgery,
      University Hospital Magdeburg, Magdeburg, Germany; 3Surgery,




                                                                                 SCHEDULE
                                                                                   DAILY
      Carl Thiem Hospital Cottbus, Cottbus, Germany
343   Probiotics Improve Weight Loss, GI-Related Quality
      of Life and H2 Breath Tests After Gastric Bypass
      Surgery: A Prospective Randomized Trial
      Gavitt A. Woodard*, Joseph Peraza, John Downey, Betsy Encarnacion,
      John M. Morton
      Surgery, Stanford School of Medicine, Stanford, CA
344   Factors Related to Anastomotic Dehiscence and
      Mortality After Terminal Stomal Closure in the
      Management of Patients with Severe Secondary
      Peritonitis
      Jose L. Martinez*, Pablo Andrade, Enrique Luque-De-Leon
      Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional
      SXXI, Mexico DF, Mexico
345   Predictors of Survival in 865 Patients with Acinar Cell
      Carcinoma of the Pancreas: Survival After Surgery
      Compared to Ductal Adenocarcinoma
      C. Max Schmidt*1,4, Jesus M. Matos1, David J. Bentrem3,
      Mark S. Talamonti2, Keith D. Lillemoe1, Karl Y. Bilimoria3
      1Department of Surgery, Indiana University School of Medicine,
      Indianapolis, IN; 2Department of Surgery, Evanston Northwestern
      Healthcare, Evanston, IL; 3Department of Surgery, Feinberg School
      of Medicine, Northwestern University, Chicago, IL; 4Department of
      Biochemistry/Molecular Biology, Indiana University School of Medicine,
      Indianapolis, IN
346   Preoperative Liver Function Tests and Hemoglobin
      Will Predict Complications Following
      Pancreaticoduodenectomy
      Christopher D. Hughes*1, Karen Rychlik2, Margo Shoup1,
      Gerard V. Aranha1
      1Department of Surgery, Division of Surgical Oncology, Loyola University
      Medical Center, Maywood, IL; 2The Cardinal Bernardin Cancer Center,
      Loyola University Medical Center, Maywood, IL



                                    39
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   347   Surgical Management of Early Hepatocellular
         Carcinoma: Resection or Transplantation?
         Emily C. Bellavance*2, Steven Cunningham2, Kimberly M. Lumpkins2,
         Warren R. Maley1, Cinthia Drachenberg3, Richard D. Schulick1,
         Andrew M. Cameron1, Michael Choti1, Nader Hanna2,
         Benjamin Philosophe2, Timothy M. Pawlik1
         1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, University of
         Maryland, Baltimore, MD; 3Pathology, University of Maryland, Baltimore, MD
   348   Increasing Regionalization of Hepatic Resection in
         Canada: 1995–2004
         Ryan McColl*, Xiaoqing You, William A. Ghali, Elijah Dixon
         Department of Surgery, Medicine, and Community Health Sciences,
         University of Calgary, Calgary, AB, Canada

2:15 PM – 5:00 PM         SSAT/AGA/ASGE                                    25ABC
                        STATE-OF-THE-ART CONFERENCE
         OPTIMAL TIMING OF SURGERY FOR IBD
         Moderator: Richard A. Hodin, Boston, MA
SP449    Introduction
         Richard A. Hodin, Boston, MA
SP450    Pregnancy: Before, During, and After
         Robin S. McLeod, Toronto, ON
SP452    An Updated Approach to Dysplasia in IBD
         David Rubin, Chicago, IL
SP453    Fulminant Colitis
         Bruce Sands, Boston , MA
SP454    Pyogenic Complications of Crohns
         James W. Fleshman, St. Louis, MO
         Case Presentations
         Q&A




                                       40
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


2:30 PM – 4:00 PM         VIDEO SESSION I: HPB SURGERY                          27B
          Moderators:     Rebecca M. Minter, Ann Arbor, MI
                          Randall S. Zuckerman, Cooperstown, NY
   349    The Lateral Laparoscopic Approach to Lesions in the
          Posterior Segments
          Andrew A. Gumbs*1,2, Brice Gayet2
          1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital,




                                                                                      SCHEDULE
          New York, NY; 2Medical and Surgical Department of Digestive Diseases,




                                                                                        DAILY
          Institut Mutualiste Montsouris, Paris, France
   350    Small Diameter Prosthetic H-Graft Portacaval Shunt
          for Portal Decompression
          Alexander S. Rosemurgy*, Harold Paul, Mark Shapiro, Desiree
          Villadolid, Sam Al-Saadi, Sharona B. Ross, Sarah Cowgill
          Surgery, University of South Florida and Tampa General Hospital,
          Tampa, FL
   351    Functional Magnetic Resonance Imaging of Pancreatic
          Disease
          Tara S. Kent*1, Ivan Pedrosa3, Sunil Sheth2, Alphonso Brown2,
          Mark P. Callery1, Charles M. Vollmer1
          1Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2Medicine,
          Beth Israel Deaconess Medical Center, Boston, MA; 3Radiology, Beth Israel
          Deaconess Medical Center, Boston, MA
   352    Laparoscopic Extended Distal Pancreatectomy for
          Tumors of the Pancreatic Neck
          Christos A. Galanopoulos*, D. Rohan Jeyarajah
          HPB/Foregut Surgery, Methodist Dallas Medical Center, Dallas, TX
   353    Laparoscopic Approach in Patients with Gastrinoma
          Which Are the Limits?
          Laureano Fernández-Cruz*
          Surgery, Hospital Clínic, Barcelona, Spain




                                        41
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


4:00 PM – 5:30 PM        DDW COMBINED
                       CLINICAL SYMPOSIA
         MEDICAL AND SURGICAL                          Ballroom 20BCD
         MANAGEMENT OF NAFLD
         Sponsored by: AASLD, SSAT
         Moderators: Nathan M. Bass, San Francisco, CA
                       John M. Morton, Stanford, CA
SP457    The Pathogenesis of NAFLD: The Rational Basis for
         Treatment Strategies
         Stephen H. Caldwell, Charlottesville, VA
SP458    The Medical Management of NAFLD
         Paul Angulo, Rochester, MN
SP459    The Surgical Management of NAFLD
         John M. Morton, Stanford, CA

         PANCREATIC CANCER                              Ballroom 20A
         Sponsored by: SSAT, ASGE, AGA
         Moderators: William R. Brugge, Boston, MA
                       Douglas B. Evans, Houston, TX
SP460    The Importance of Pretreatment Radiographic
         Staging: Definitions of Resectable, Borderline
         Resectable and Locally Advanced Pancreatic Cancer
         Chuslip Charnsangavej, Houston, TX
SP461    Preoperative Biliary Stenting for Resectable Disease:
         Current Controversy and the Role for Metal Versus
         Plastic
         Peter B. Kelsey, Boston, MA
SP462    Endoscopic Ultrasound-Guided FNA: Should It Be
         Routine in Patients with Localized Pancreatic Cancer?
         Michael J. Levy, Rochester, MN
SP463    Patient Selection for Surgery: Diagnostic and
         Treatment Sequencing
         Mark P. Callery, Boston, MA
         Case Presentations




                                       42
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA



Tuesday, May 20, 2008
7:30 AM – 10:00 AM       VIDEO SESSION II: BREAKFAST                       25ABC
                         AT THE MOVIES
         Moderators:     Craig P. Fischer, Houston, TX
                         Attila Nakeeb, Indianapolis, IN




                                                                                      SCHEDULE
                                                                                        DAILY
  449    Combined Treatment of Esophageal Perforation: A
         New Approach
         Bryan J. Sandler*, Michelle K. Savu, Garth R. Jacobsen, John Cullen,
         Thomas J. Savides, Mark A. Talamini, Santiago Horgan
         Department of Surgery, University of California, San Diego, San Diego, CA
  450    Dual Incision Adjustable Gastric Band Placement
         Garth R. Jacobsen*, Bryan J. Sandler, John Cullen, Mark A. Talamini,
         Adam Spivack, Santiago Horgan
         Department of Surgery, University of California, San Diego, San Diego, CA
  451    A Simplified Technique for Placement of Biologic Mesh
         in Paraesophageal Hernia Repair (PEH)
         Tayyab S. Diwan*, Danny V. Martinec, Michael Ujiki, Christy M. Dunst,
         Lee L. Swanstrom
         Minimally Invasive Surgery, Legacy Health System, Portland, OR
  452    Human NOTES Hybrid Transgastric Cholecystectomy
         Edward Auyang*1, Khashayar Vaziri1, John A. Martin2, Eric S. Hungness1,
         Nathaniel J. Soper1
         1Department of Surgery, Northwestern University, Chicago, IL;
         2Gastroenterology, Northwestern University, Chicago, IL

  453    Totally Laparoscopic Extended Right Hepatectomy
         Andrew A. Gumbs*1,2, Brice Gayet2
         1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New
         York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut
         Mutualiste Montsouris, Paris, France
  454    Standardization of Laparoscopic Distal Pancreatic
         Resection (LapDPR) with Regional Lymphadenectomy
         in Malignant Pancreatic Neoplasms (MPN)
         Laureano Fernández-Cruz*
         Surgery, Hospital Clínic, Barcelona, Spain
  455    Laparoscopic Sigmoid Resection for Complicated
         Diverticulitis (Colovaginal Fistula)
         Barry Salky*
         Surgery, Mount Sinai Hospital, New York, NY


                                       43
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  456    Laparoscopic Celiac Artery Decompression
         Khashayar Vaziri*, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness
         Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
  457    Pneumatosis Coli: Resection of the Splenic Flexure
         with Intracorporeal Anastomosis
         Melina C. Vassiliou*1, Douglas S. Smink2, Gina L. Adrales1
         1GeneralSurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH;
         2GeneralSurgery, Brigham and Women’s Hospital, Boston, MA

8:30 AM – 10:00 AM      PUBLIC POLICY COMMITTEE PANEL                     28ABC
         THE EFFECTS OF QUALITY INITIATIVES
         AND REPORTING ON PATIENT CARE AND
         REIMBURSEMENTS TO PHYSICIANS
         AND HOSPITALS
         Moderator: Lygia Stewart, San Francisco, CA
SP538    Measuring Quality, and the Effects on the Quality
         of Care
         Clifford Ko, Los Angeles, CA
SP539    Payment Reform: The Impact of CMS Value Based
         Payment Policies on Your Practice and Your Patients
         Susan Nedza, Chicago, IL
SP560    How Are Quality Initiatives and Public Reporting
         Affecting Hospitals?
         Andrea Snyder, San Diego, CA
SP561    Improving the Quality of Surgical Care Throughout a
         Region: The SCOAP Initiative of Washington State
         Carlos A. Pellegrini, Seattle, WA
         Panel and Audience Discussion

9:30 AM – 11:00 AM      SSAT/AHPBA JOINT SYMPOSIUM                        24ABC
         CURRENT APPROACH TO CARCINOMA
         OF THE GALLBLADDER
         Moderator: Bruce D. Schirmer, Charlottesville, VA
SP550    Preoperative Detection and Approach to the
         Suspicious Gallbladder
         Reid B. Adams, Charlottesville, VA




                                      44
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


SP551    Intraoperative Approach to an Unexpectedly Detected
         Lesion During Lap Cholecystectomy
         Charles M. Vollmer, Jr, Boston, MA
SP552    Treatment Plan When Last Week’s Routine Lap
         Cholecystectomy Returns Cancer
         Brett C. Sheppard, Portland, OR
SP553    Current Best Options for Stage III Disease




                                                                                   SCHEDULE
                                                                                     DAILY
         Andrew M. Lowy, La Jolla, CA
         Panel and Audience Discussion

10:00 AM – 11:15 AM BASIC SCIENCE PLENARY                                 25ABC
                     (PLENARY SESSION IV)
         Moderators: David Shibata, Tampa, FL
                     Sharon M. Weber, Madison, WI
   557   Epigenetic Regulation of WnT Signaling Pathway
         Genes in Inflammatory Bowel Disease (IBD) Neoplasia
         Mashaal Dhir*1, Elizabeth A. Montgomery2, Kornel Schuebel3,
         Susan L. Gearhart1, Nita Ahuja1,3
         1Surgery, Johns Hopkins University, Baltimore, MD; 2Pathology, Johns
         Hopkins University, Baltimore, MD; 3Oncology, Johns Hopkins University,
         Baltimore, MD
   558   Sodium-Coupled Transport of Butyrate by SLC5A8
         Mediates Tumor Suppression in the Colon
         Gail Cresci*1,2, Muthusamy Thangaraju2, Darren Browning2,
         Vadivel Ganapathy2
         1Surgery, Medical College of Georgia, Augusta, GA; 2Biochemistry and
         Molecular Biology, Medical College of Georgia, Augusta, GA
   559   Applying Proteomics Based Biomarker Tools for the
         Accurate Diagnosis of Pancreatic Cancer
         John D. Christein*1, Kyoko Kojima2, Senait G. Asmellash3,
         Christopher A. Klug2, James A. Mobley1
         1Surgery, University of Alabama at Birmingham, Birmingham, AL;
         2Microbiology, University of Alabama at Birmingham, Birmingham, AL;
         3Biochemistry and Molecular Genetics, University of Alabama at
         Birmingham, Birmingham, AL




                                      45
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   560    A Neurokinin-1 Receptor Antagonist (NK1RA)
          That Reduces Intraabdominal Adhesions Augments
          the Anti-Adhesive Effects of a Hyaluronic Acid/
          Carboxymethylcellulose (HA/CMC) Adhesion Barrier
          in Rats
          Rizal Lim*1, Jonathan M. Morrill1,2, Karen L. Reed1,2, Adam C. Gower1,
          Bilaal McCloud1, Susan E. Leeman2,1, Arthur F. Stucchi1,2,
          James M. Becker1
          1Surgery, Boston University Medical Center, Boston, MA; 2Pharmacology,
          Boston University Medical Center, Boston, MA
   561    Differential Ileal Adaptation After Massive Proximal-
          Based Small Bowel Resection: Importance of the
          GLUT2 Hexose Transporter
          Michael G. Sarr, Corey W. Iqbal*, Javairiah Fatima, Molly E. Gross
          Department of Surgery, Mayo Clinic, Rochester, MN

10:00 AM – 11:15 AM QUICK SHOTS I                                                 27B
         Moderators: Jonathan F. Critchlow, Boston, MA
                     Julie A. Stein, Royal Oak, MI
   562    Perioperative Allogenic Blood Transfusions Significantly
          Affect Survival Following Transthoracic En Bloc
          Resection for Esophageal Cancer
          Daniel Vallbohmer*1, Frederike C. Ling1, Daniel Schmidt1,
          Roland Grunenberg2, Birgit S. Gathof2, Elfriede Bollschweiler1,
          Arnulf H. Hoelscher1, Paul M. Schneider1,3
          1Department of Surgery, University of Cologne, Cologne, Germany; 2Institute
          of Transfusion Medicine, University of Cologne, Cologne, Germany; 3Department
          of Visceral and Transplantation Surgery, University of Zurich, Zurich,
          Switzerland
   563    A New Biomechanical Device to Augment Lower
          Esophageal Sphincter (LES) Continence in Patients
          with Gastroesophageal Reflux Disease (GERD)—Initial
          Results of a Pilot Clinical Trial
          Luigi Bonavina*1, Greta Saino1, Davide Bona1, Tom R. Demeester2,
          John C. Lipham2, Robert A. Ganz3, Daniel H. Dunn3
          1Department of Surgery, University of Milano, IRCCS Policlinico San Donato,
          Milano, Italy; 2University of Southern California, Los Angeles, CA; 3Abbott
          Northwestern Hospital, Minneapolis, MN




                                         46
 49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


564   Long-Term Outcome After 92 Duodenum-Preserving
      Pancreatic Head Resections for Chronic Pancreatitis:
      Comparison of FREY- and BEGER-Procedures
      Tobias Keck*1, Ulrich Adam2,1, Hartwig Riediger1,2, Ulrich T. Hopt1,
      Frank Makowiec1
      1Department of Surgery, University of Freiburg, Freiburg, Germany;
      2Department of Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany




                                                                                  SCHEDULE
565   Is Liver Resection Justified in Advanced Hepatocellular




                                                                                    DAILY
      Carcinoma? Results of an Observational Study in
      464 Patients
      Andrea Ruzzenente*1, Franco Capra2, Calogero Iacono1,
      Gianluca Piccirillo1, Marta Lunardi2, Stefano Pistoso3,
      Alessandro Valdegamberi1, Alfredo Guglielmi1
      1Department of Surgery and Gastroenterology, University of Verona Medical
      School, Verona, Italy; 2Department of Internal Medicine, University of
      Verona Medical School, Verona, Italy; 3Department of Internal Medicine,
      Desenzano Hospital, Desenzano, Italy
566   An Improved Method of Assessing Esophageal
      Emptying Using the Timed Barium Study Following
      Surgical Myotomy for Achalasia
      Arzu Oezcelik*1, Jeffrey A. Hagen1, James M. Halls2, Jessica M. Leers1,
      Emmanuele Abate1, Shahin Ayazi1, John C. Lipham1, Farzaneh Banki1,
      Steven R. Demeester1, Tom R. Demeester1
      1Surgery, Keck School of Medicine, University of Southern California,
      Los Angeles, CA; 2Department of Radiology, Keck School of Medicine,
      University of Southern California, Los Angeles, CA
567   Manometric Profile After Laparoscopic Nissen
      Fundoplication and Endoluminal Fundoplication: A
      Comparative Study in Animals
      Silvana Perretta*, Bernard Dallemagne, Jacques Marescaux
      Digestive and Endocrine Surgery, IRCAD-EITS University of Strasbourg
      France, Strasbourg, France
568   Immunologic Ignorance and Tolerance Both Play a
      Role in Hepatic Tumorigenesis
      Diego Avella*, Luis J. Garcia, Serene Shereef, Hephzibah Tagaram,
      Yixing Jiang, Mehrdad Nikfarjam, Niraj J. Gusani, Eric Kimchi,
      Kevin Staveley-O’Carroll
      Surgery, Penn State, Hershey, PA




                                   47
 THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


569   Downregulation of AdiponectinAdipor2 Is
      Associated with Hepatic Inflammation and
      Steatosis in Obese Mice
      Yanhua Peng2,3, Drew A. Rideout*1,2, Steven S. Rakita1,2,
      Mini Sajan2,3, Robert Farese2,3, Min You3, Michel M. Murr1,2
      1Department of Surgery, University of South Florida, Tampa, FL;
      2Department of Surgery and Research, James A. Haley Veterans Affairs
      Medical Center, Tampa, FL; 3Department of Molecular Medicine, University
      of South Florida, Tampa, FL
570   Ischemic Colitis Following Endovascular Aortoiliac
      Aneurysm Repair: A 10-Year Retrospective Review
      Aaron Miller*, Michael S. Marotta, Irini A. Scordi-Bello,
      Yolanda Tammaro, Celia M. Divino
      The Mount Sinai Hospital, New York, NY
571   Perianal Fistula Occurring After Ileal Pouch for
      Non-Crohn’s Colitis: A Word of Caution
      Isabella Mor*, Bo Shen, Susan Shedda, Margaret O’Malley,
      Jeffery Hammel, Feza H. Remzi
      Colorectal Surgery A-30, Cleveland Clinic Foundation, Cleveland, OH
572   Resection Versus Laparoscopic Radiofrequency
      Thermal Ablation of Solitary Colorectal Liver
      Metastasis
      Eren Berber*, Michael Tsinberg, Conrad H. Simpfendorfer,
      Allan Siperstein
      Cleveland Clinic, Cleveland, OH
573   Frequency of Extrapancreatic Neoplasms in
      Intraductal Papillary Mucinous Neoplasm of the
      Pancreas Compared to Pancreatic Adenocarcinoma
      and Referral Patients
      Kellie L. Mathis*, Kaye M. Reid Lombardo, Christina M. Wood,
      William S. Harmsen, Michael G. Sarr
      Surgery, Mayo Clinic, Rochester, MN




                                   48
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


10:30 AM – 12:00 PM       DDW COMBINED                     Ballroom 20BCD
                        CLINICAL SYMPOSIUM
         MANAGING COMPLICATIONS OF GI PROCEDURES
         Sponsored by: AGA, SSAT, ASGE
         Moderators: Kevin E. Behrns, Gainesville, FL
                       Martin Freeman, Minneapolis, MN




                                                                                SCHEDULE
SP556    Complications of Esophagogastroduodenoscopy (EGD)




                                                                                  DAILY
         and Endoscopic Muscosal Resection (EMR)
         Jonathan Cohen, New York, NY
SP557    Complications of Colonoscopy
         Douglas Brooks Nelson, Minneapolis, MN
SP558    Complications of Endoscopic Retrograde
         Cholangiopancreatiography
         Martin Freeman, Minneapolis, MN
SP559    Role of Surgery in Management of Endoscopic
         Complications
         George A. Sarosi, Jr, Gainesville, FL

11:15 AM – 12:00 PM     MAJA AND FRANK G. MOODY                       25ABC
                        STATE-OF-THE-ART LECTURE
SP601    The Early Detection of Pancreatic Cancer: Lessons
         from Surveillance of 100 High-Risk Patients
         Teresa Brentnall, Seattle, WA

12:00 PM – 2:00 PM      POSTER SESSION II                      Sails Pavilion
         Authors available at their posters to answer questions 12 PM – 2 PM;
         posters on display 8 AM – 5 PM.

12:30 PM – 1:45 PM               MEET-THE-PROFESSOR LUNCHEONS
SP616    Laparoscopic Hepatectomy                                        26A
         Alan Koffron, Chicago, IL
SP624    NOTES Update                                                    30A
         Lee L. Swanstrom, Portland, OR
SP626    Re-Classifying Acute Pancreatitis                               26B
         Michael G. Sarr, Rochester, MN




                                       49
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


2:15 PM – 3:30 PM        PLENARY SESSION V                                   28ABC
          Moderators:    Susan Galandiuk, Louisville, KY
                         Thomas H. Magnuson, Baltimore, MD
   678    NOTES Rectosigmoid Resection Using Transanal
          Endosocopic Microsurgery (TEM) with Transgastric
          Flexible Endoscopic Assistance: A Pilot Study in Swine
          Patricia Sylla*1, Field F. Willingham2, Denise W. Gee1, William R. Brugge2,
          David W. Rattner1
          1Surgery, Massachusetts General Hospital, Boston, MA; 2Medicine, GI unit,
          Massachusetts General Hospital, Boston, MA
   679    Who Should Do NOTES: Initial Endoscopic Performance
          and Early Learning Curve of Laparoscopic Surgeons in
          Comparison to Endoscopists and Untrained Individuals
          Oliver J. Wagner*1, Monika E. Hagen2, Francois Pugin2, Philippe Morel2,
          Daniel Candinas1
          1Department of Visceral and Transplantation Surgery, University Bern, Bern,
          Switzerland; 2Digestive Surgery, University Hospital Geneva, Geneva,
          Switzerland
   680    To Prepare or Not the Colon for Elective Surgery with
          Primary Intraperitoneal Anastomosis. There Is No
          Question
          María Jesús Peña-Soria, Julio M. Mayol*, Rocio Anula, Ana M. Arbeo-Escolar,
          Jesus A. Fernandez-Represa
          Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain
   681    Routine Liver Biopsy to Detect Non-Alcoholic
          Fatty Liver Disease (NAFLD) During Laparoscopic
          Cholecystectomy for Symptomatic Gallstone Disease
          (GD)—Is It Justified?
          Antonio Ramos-De La Medina*1, Federico B. Roesch2,
          Alfonso Perez Morales3, Silvia Cid-Juarez2, Jose M. Remes-Troche2
          1Gastroenterology and Gastrointestinal Surgery Department, Veracruz
          Regional Hospital, Boca del Rio, Mexico; 2Digestive Physiology and Motility
          Laboratory, Medical-Biological Research Institute University of Veracruz,
          Veracruz, Mexico; 3University of Veracruz Medical School, Veracruz, Mexico
   682    Reinterventions for Specific Technique-Related
          Complications of Stapled Haemorrhoidopexy (SH):
          A Critical Appraisal
          Pierpaolo Sileri*, Vito M. Stolfi, Antonio Chiaravalloti,
          Achille Lucio Gaspari
          Surgery, University of Rome Tor Vergata, Rome, Italy




                                        50
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


2:15 PM – 3:45 PM         DDW COMBINED                Ballroom 20A
                        CLINICAL SYMPOSIUM
         FECAL INCONTINENCE: NEW PERSPECTIVES ON
         EARLY DETECTION, CURRENT AND FUTURE
         THERAPIES
         Sponsored by: AGA, SSAT
         Moderators: Tracy L. Hull, Cleveland, OH




                                                                       SCHEDULE
                                                                         DAILY
                       William E. Whitehead, Chapel Hill, NC
SP636    Epidemiology, GI Disease Risk Factors, and
         Recommendations of the NIH State of the Science
         Conference on the Prevention of Fecal and Urinary
         Incontinence
         Frank A. Hamilton, Bethesda, MD
SP637    Quality of Life Impact
         Nancy Jean Norton, Milwaukee, WI
SP638    Pathophysiology and New Diagnostic Tests
         Adil E. Bharucha, Rochester, MN
SP639    Medical Management and Biofeedback
         Steve Heymen, Chapel Hill, NC
SP640    Surgical Management
         Ann C. Lowry, St. Paul, MN

2:15 PM – 4:15 PM       CONTROVERSIES IN GI SURGERY            24ABC
        DEBATE 1: INTRAMUCOSAL ESOPHAGEAL CANCER
                   AND HIGH GRADE DYSPLASIA: WHICH
                   TREATMENT?
        Moderator: Donald E. Low, Seattle, WA
SP693    Frame the Issue
         Brant K. Oelschlager, Seattle, WA
SP694    Endoscopic Therapy: Effective and Patient Friendly
         Drew Schembre, Seattle, WA
SP695    Surgical Therapy: Improved Outcomes and Piece
         of Mind
         Jeffrey H. Peters, Rochester, NY
         Panel and Audience Discussion




                                      51
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


         DEBATE 2: HEPATOCELLULAR CARCINOMA IN
                    THE MILD CIRRHOTIC: TRANSPLANT
                    OR RESECT?
         Moderator: Michael A. Choti, Baltimore, MD
SP696     Frame the Issue
          Michael A. Choti, Baltimore, MD
SP697     Transplant if Eligible
          Alan W. Hemming, Gainesville, FL
SP698     Resection Is Best if Possible
          Timothy M. Pawlik, Baltimore, MD
          Panel and Audience Discussion
         DEBATE 3: BEST PRACTICES/CENTERS OF
                    EXCELLENCE: EFFECTIVE TOOLS
                    OR GOOD ADVERTISING?
         Moderator: John C. Bowen, New Orleans, LA
SP699     Frame the Issue
          Daniel B. Jones, Boston, MA
SP700     ACS and ASMBS Accreditation: Metrics Drive Quality
          James K. Champion, Marietta, GA
SP701     Just Another Form of Consumer Marketing
          Edward L. Felix, Fresno, CA
          Panel and Audience Discussion

3:30 PM – 4:30 PM        QUICK SHOTS II                                     28ABC
          Moderators:    Robert E. Glasgow, Salt Lake City, UT
                         Taylor S. Riall, Galveston, TX
   772    Two-Hundred Consecutive Laparoscopic Liver
          Resections
          Andrew A. Gumbs*1,2, Brice Gayet2
          1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New
          York, NY; 2Medical and Surgical Department of Digestive Diseases, Institut
          Mutualiste Montsouris, Paris, France
   773    Long-Term Quality of Life Is Similar After Hepatic
          Resection for Malignant and Benign Diseases
          Vanessa Banz*, Regula Fankhauser, Peter Studer, Beat Gloor,
          Daniel Inderbitzin, Daniel Candinas
          University Hospital Bern, Bern, Switzerland



                                        52
 49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


774   Does Staging Laparoscopy Detect a Higher Rate of
      Occult Metastases in Patients with Resectable
      Pancreatic Adenocarcinoma?
      Carlo M. Contreras*, Robert J. Rettammel, David M. Mahvi,
      Layton F. Rikkers, Clifford S. Cho, Sharon M. Weber
      General Surgery, University of Wisconsin, Madison, WI
775   Excellent Results from Limited Resection of Duodenal




                                                                                  SCHEDULE
      Carcinoid Tumors




                                                                                    DAILY
      Kenzo Hirose*, Brown Nancy, Kristina Potanos, Bipan Chand,
      R. Matthew Walsh
      General Surgery, Cleveland Clinic, Cleveland, OH
776   Five-Year Outcome of a Randomized Trial Comparing
      Pylorus- and Duodenum-Preserving Pancreatic Head
      Resection for Chronic Pancreatitis
      Ulrich Adam*, Frank Makowiec, Eva Fischer, Tobias Keck,
      Hartwig Riediger, Ulrich T. Hopt
      Department of Surgery, University of Freiburg, Freiburg, Germany
777   Tailored Transoral Incisionless Fundoplication (TIF) in
      the Treatment of GERD: The Anatomic and Physiologic
      Basis for Reconstruction of the Esophagogastric
      Junction Using a Novel Approach
      Blair A. Jobe1, Ger H. Koek2, Stefan J. Kraemer3, Barry P. Mcmahon4,
      Bart Witteman2, Flemming H. Gravesen5, Cedric S. Lorenzo*1,
      Robert W. O’Rourke1, Douglas A. Shumaker6, Michael M. Owens6,
      John G. Hunter1, Nicole Bouvy2
      1Surgery, Oregon Health & Science University, Portland, OR; 2Surgery,
      Maastricht University Hospital, Maastricht, Netherlands; 3Endogastric
      Solutions, Inc., Redmond, WA; 4Medical Physics & Clinical Engineering,
      Adelaide & Meath Hospital and Trinity College, Dublin, Ireland; 5Visceral
      Biomechanics and Pain, Aalborg Hospital, Hobrovej, Denmark; 6West Hills
      Gastroenterology, Portland, OR
779   Signal Detection: A New Statistical Method to Predict
      NASH in Gastric Bypass Patients
      John M. Morton*, Gavitt A. Woodard, Tina Hernandez-Boussard
      Surgery, Stanford School of Medicine, Stanford, CA




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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   780   Visceral Sensitivity Is Increased During the Initial
         Development of Postoperative Ileus in Mice
         Mario H. Mueller*1, Mia Karpitschka3, Andrej Sibaev3, Jörg Glatzle2,
         Bing Xue1, Michael S. Kasparek1, Martin E. Kreis1
         1Department of Surgery, Ludwig-Maximilians University, Munich, Germany;
         2Department of Surgery, Eberhard-Karls University, Tuebingen, Germany;
         3Institute of Surgical Research, Ludwig-Maximilians University, Munich,
         Germany
   781   Tissue and Serum Levels of Substance P Correlate in
         Patients with Chronic Pancreatitis
         Giuseppe Mascetta1, Fabio Francesco Di Mola1, Federico Selvaggi1,2,
         Massimo Falconi4, Claudio Bassi4, Nathalia Giese2, Markus W. Buechler2,
         Helmut M. Friess3, Pierluigi Di Sebastiano*1
         1Department of Surgery, IRCCS Casa Sollievo Sofferenza, San Giovanni
         Rotondo, Italy; 2Department of General Surgery, University of Heidelberg,
         Heidelberg, Germany; 3Department of Surgery, Technical University of
         Munich, Munich, Germany; 4Department of Surgery, University of Verona,
         Verona, Italy

3:30 PM – 5:00 PM       SSAT/ASCRS JOINT SYMPOSIUM                        25ABC
         LAPAROSCOPIC RECTAL CANCER SURGERY: IS IT
         READY FOR PRIME TIME?
         Moderators: David Shibata, Tampa, FL
                     Michael J. Stamos, Orange, CA
SP702    Current State-of-the-Art
         Conor P. Delaney, Cleveland, OH
SP703    Pro: The Time Is Now
         Jeffrey W. Milsom, New York, NY
SP704    Con: Let’s Wait for the Data
         Peter W. Marcello, Burlington, MA
         Panel and Audience Discussion




                                      54
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


4:00 PM – 5:30 PM        DDW COMBINED            Ballroom 20BCD
                       CLINICAL SYMPOSIUM
         OBESITY SURGERY: ENDOSCOPIC AND SURGICAL
         MANAGEMENT OF COMPLICATIONS
         Sponsored by: SSAT, ASGE, AGA
         Moderators: Ram Chuttani, Boston, MA
                       Ninh T. Nguyen, Orange, CA




                                                                    SCHEDULE
                                                                      DAILY
SP710    Overview of Bariatric Operations
         Raul J. Rosenthal, Weston, FL
SP711    Endoscopic Clips, Sutures and Stents for Leaks,
         Fistule and Stomal Dilation
         Christopher Thompson, Boston, MA
SP712    Laparoscopic and Endoscopic Management of
         Band Erosion
         Santiago Horgan, Chicago, IL
SP713    Endoscopic Balloon Dilation for Gastrojejunal
         Stenosis
         Kenneth Chang, Orange, CA
SP714    Laproscopic and Endoscopic Management of
         Postoperative GI Bleeding
         Ninh T. Nguyen, Orange, CA
SP715    Emerging Endoscopic Bariatric Technologies
         Ram Chuttani, Boston, MA

5:00 PM – 6:00 PM      ANNUAL BUSINESS MEETING             25ABC
                       Members Only

7:00 PM – 9:00 PM      MEMBERS RECEPTION          The Don Room
                                                     at El Cortez




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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT



Wednesday, May 23, 2008
7:00 AM – 8:30 AM       SSAT/ISDS JOINT BREAKFAST      25ABC
                        SYMPOSIUM
         HOW I DO IT: AROUND THE WORLD IN 90 MINUTES
         Moderators: Mark P. Callery, Boston, MA
                     Fabrizio Michelassi, New York, NY
SP757    Laparoscopic Proctocolectomy with J-Pouch Ileo-Anal
         Anastomosis
         Tonia M. Young-Fadok, Scottsdale, AZ
SP758    Advanced Liver Resections
         Chung-Mau Lo, Hong Kong, China
SP759    Laparoscopic Sleeve Gastrectomy
         Herbert Freund, Jerusalem, Israel
SP760    Debridment for Infected Pancreatic Necrosis
         Claudio Bassi, Verona, Italy
SP761    Laparoscopic Paraesophageal Hernia Repair:
         Facts and Myths
         Marco G. Patti, San Francisco, CA
         Audience Discussion

8:30 AM – 10:00 AM      EDUCATION COMMITTEE PANEL      24ABC
         TEACHING SAFETY IN THE OR
         Moderator: Michael J. Zinner, Boston, MA
SP792    Learning from Errors and Near Misses
         Caprice Christian Greenberg, Boston, MA
SP793    Aviation
         Richard C. Karl, Tampa, FL
SP794    Who Belongs in the OR? (Who’s In and Who’s Out?)
         Debra L. Sudan, Omaha, NE
SP795    Building More Effective Teams in Surgery
         Donald W. Moorman, Boston, MA
         Q&A




                                        56
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


8:30 AM – 10:00 AM       TRANSLATIONAL SCIENCE                                 25ABC
                         PLENARY (PLENARY SESSION VI)
         Moderators:     Deborah A. Nagle, Boston, MA
                         Edward E Whang, Boston, MA
  948    The Role of ERCC1 RNA Expression in Blood as a
         Non-Invasive Predictor of Response to Neadjuvant
         Radio-Chemotherapy in Patients with Locally




                                                                                         SCHEDULE
         Advanced Cancer of the Esophagus




                                                                                           DAILY
         Jan Brabender*1, Daniel Vallböhmer1, Frederike C. Ling1,
         Andreas C. Hoffmann1, Georg Lurje1, Elfriede Bollschweiler1,
         Arnulf H. Hölscher1, Paul M. Schneider2, Ralf Metzger1
         1Department of Surgery, University of Cologne, Cologne, Germany;
         2Department of Surgery, University of zuerich, Zuerich, Switzerland

  949    Strong Prognostic Value of Nodal Microinvolvement
         in Patients with Carcinoma of the Papilla of Vater
         Receiving No Adjuvant Chemotherapy
         Dean Bogoevski*, Paulus G. Schurr, Jussuf T. Kaifi, Guell Cataldegirmen,
         Oliver Mann, Yogesh K. Vashist, Emre F. Yekebas, Jakob R. Izbicki
         General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf,
         Hamburg, Germany
  950    The Prognostic Superiority of Log Odds of Lymph
         Nodes in Stage III Colon Cancer
         Jiping Wang*1,2, James M. Hassett1, Merril T. Dayton1,
         Mahmoud N. Kulaylat1
         1Department of Surgery, State University of New York at Buffalo, Buffalo, NY;
         2Department of Biostatistics, State University of New York at Buffalo,
         Buffalo, NY




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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  951    High Expression of Heparanase Is Significantly Associated
         with Dedifferentiation and Lymph Node Metastasis in
         Patients with Pancreatic Ductal Adenocarcinomas and
         Correlated to PDGF-A and via HIF1a to HB-EGF and bFGF
         Andreas C. Hoffmann*1,2, Ryutaro Mori1, Daniel Vallbohmer2,
         Jan Brabender2, Uta Drebber3, Stephan E. Baldus5, Mizutomo Azuma1,
         Ralf Metzger2, Christina Hoffmann4, Arnulf H. Hölscher2,
         Kathleen D. Danenberg6, Klaus L. Prenzel2, Peter V. Danenberg1
         1Department of Biochemistry and Molecular Biology and Norris Comprehensive
         Cancer Center, University of Southern California, Los Angeles, CA;
         2Department of Visceral and Vascular Surgery, University of Cologne, Cologne,
         Germany; 3Department of Pathology, University of Cologne, Cologne,
         Germany; 4Department of Cardiology, Nuclear Medicine and Molecular
         Imaging, Heart Center North Rhine-Westphalia, Bad Oeynhausen,
         Germany; 5Department of Pathology, University of Düsseldorf, Düsseldorf,
         Germany; 6Response Genetics Inc, Los Angeles, CA
  952    VEGF Gene Therapy Improves Anastomotic Healing in
         the Gastrointestinal Tract: Applications in Esophageal
         Surgery
         Kristian Enestvedt*1, Shelley R. Winn1, Brian S. Diggs1, Luke Hosack1,
         Barry Uchida2, Robert W. O’Rourke1, Blair A. Jobe1
         1Department of Surgery, Oregon Health and Science University, Portland, OR;
         2Dotter Institue, Department of Interventional Radiology, Oregon Health
         and Science University, Portland, OR
  953    Loss of Heterozygosity Portends Poor Survival of
         Patients with Resected Periampullary Cancer
         Jan Franko*1, Alyssa M. Krasinskas2, Marina N. Nikiforova2, Yuri E.
         Nikiforov2, Steven J. Hughes1, Kenneth K. Lee1, David L. Bartlett1,
         Herbert Zeh1, Arthur J. Moser1
         1Division of Surgical Oncology, University of Pittsburgh Medical Center,
         Pittsburgh, PA; 2Department of Pathology, University of Pittsburgh Medical
         Center, Pittsburgh, PA

10:30 AM – 12:00 PM        DDW COMBINED                              Ballroom 20A
                         CLINCIAL SYMPOSIUM
         THE BIG POLYP: WHO OWNS IT?
         Sponsored by: ASGE, SSAT, AGA
         Moderators: Marcia R. Cruz-Correa, San Juan, PR
                       Peter W. Marcello, Burlington, MA
SP799    Endoscopic Mucosal Resection for Colorectal Polyps
         Michael B. Wallace, Rochester, MN


                                        58
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


SP800     Transendoscopic Mucosal Resection for Rectal Polyps
          Theodore J. Saclarides, Chicago, IL
SP801     Endoscopic Submucosal Dissection for Colorectal
          Polyps: How I Do It
          Mainor R. Antillon, Columbia, MO

10:30 AM – 12:00 PM PLENARY SESSION VII                                      25ABC




                                                                                     SCHEDULE
                                                                                       DAILY
         Moderators: O. Joe Hines, Los Angeles, CA
                     Blair A. Jobe, Portland, OR
 1018     Long-Term Results After Minimally Invasive
          Repair of Giant Paraesophageal Hernia in
          105 Patients
          Katie S. Nason*, James D. Luketich, Rodney J. Landreneau,
          Irfan Qureshi, Samuel B. Keeley, Shannon E. Trainor,
          Manisha Shende, Arjun Pennathur
          Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh
          Medical Center, Pittsburgh, PA
  1019 Perioperative Treatment with Infliximab (IFX) in
       Patients with Crohn’s (CD) and Ulcerative Colitis (UC)
       Is Not Associated with Increased Rate of Postoperative
       Complications
          Hiroko Kunitake*1, Richard Hodin1, Paul C. Shellito1, Bruce E. Sands2,
          Joshua R. Korzenik2, Liliana Bordeianou1
          1Surgery, Massachusetts General Hospital, Boston, MA; 2Gastroenterology,
          Massachusetts General Hospital, Boston, MA
 1020     Use of Infliximab Within Three Months Prior to
          Ileocolonic Resection Is Associated with Significant
          Adverse Postoperative Outcomes in Crohn’s Patients
          Kweku A. Appau*, Victor W. Fazio, James M. Church, Bo Shen,
          Feza H. Remzi, Scott A. Strong, Bret Lashner, Takayuki Yamamoto,
          Paris P. Tekkis, Jeffery Hammel, Ravi P. Kiran
          Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH
 1021     Selective Management of Iatrogenic Colonoscopic
          Perforations
          Dimitrios V. Avgerinos*, Omar H. Llaguna, Andrew Y. Lo,
          I. Michael Leitman
          Surgery, Beth Israel Medical Center, New York, NY




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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 1022    Pancreatic Fistula Rates After 442 Distal
         Pancreatectomies: Staplers Do Not Decrease
         Fistula Rates
         Cristina R. Ferrone*, Andrew L. Warshaw, J. Ruben Rodriguez,
         Sarah P. Thayer, Carlos Fernandez-Del Castillo
         Surgery, Massachusetts General Hospital, Boston, MA
 1023    Reoperation for Recurrent Pain Following Failed
         Primary Operation in Chronic Pancreatitis
         Jeffrey S. Browne1, Nicholas J. Zyromski1, Harish Lavu1,
         Marshall S. Baker2, James A. Madura1, Thomas J. Howard*1
         1Surgery, Indiana University, Indianapolis, IN; 2Surgery, Northwestern
         University, Chicago, IL

10:30 AM – 12:00 PM      VIDEO SESSION III: NOTES: WHERE ARE                      27B
                         WE TODAY?
         Moderators:     Brian J. Dunkin, Houston, TX
                         Nathaniel J. Soper, Chicago, IL
 1024    NOTES: Dissection of the Critical View of Safety
         During Transcolonic Cholecystectomy
         Edward Auyang*1, Khashayar Vaziri1, Eric S. Hungness1,
         John A. Martin2, Nathaniel J. Soper1
         1Department of Surgery, Northwestern University, Chicago, IL;
         2Gastroenterology, Northwestern University, Chicago, IL

 1025    Single Port Access (SPA) Cholecystectomy
         Paul G. Curcillo, Erica R. Podolsky*, Steven J. Rottman
         Surgery, Drexel University College of Medicine, Philadelphia, PA
 1026    Single Incision Laparoscopic Cholecystectomy Using
         Flexible Endosocopy
         Glenn Forrester*, John N. Afthinos, Eugenius J. Harvey,
         Steven Binenbaum, Grace J. Kim, Julio Teixeira
         Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center,
         New York, NY




                                       60
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 1027    NOTES-Assisted Roux-en-Y Gastric Bypass
         Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3,
         Nicolas C. Buchs1, Priya A. Jamidar5, Margherita Cadeddu4,
         Jean Fasel6, Philippe Morel1
         1Digestive Surgery, University Hospital Geneva, Geneva, Switzerland;
         2Department of Visceral and Transplantation Surgery, University Bern, Bern,
         Switzerland; 3Imperial College, London, United Kingdom; 4Department of
         Surgery, McMaster University, Hamilton, ON, Canada; 5Section of Digestive




                                                                                       SCHEDULE
                                                                                         DAILY
         Diseases, Yale University, New Haven, CT; 6Division of Anatomy, University
         Geneva, Geneva, Switzerland
 1028    Reverse NOTES: Transgastric ERCP
         Yoav Mintz, Santiago Horgan, Thomas J. Savides, John Cullen*,
         Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini
         Department of Surgery, University of California, San Diego,
         San Diego, CA

12:00 PM – 2:00 PM      POSTER SESSION III                          Sails Pavilion
         Authors available at their posters to answer questions 12 PM – 2 PM;
         posters on display 8 AM – 5 PM.

12:00 PM – 3:00 PM      SSAT/SAGES JOINT LUNCHEON                           25ABC
                        SYMPOSIUM: THE GASTROINTESTINAL
                        ANASTOMOSIS: EVIDENCE VERSUS
                        TRADITION
         Moderators:    David W. McFadden, Burlington, VT
                        Mark A. Talamini, San Diego, CA
         THE ESOPHAGEAL ANASTOMOSIS
SP825    Traditional Methods to Prevent Leak
         Daniel Raymond, Rochester, NY
SP826    Improving Blood Supply Decreases Leak Rate
         Kevin M. Reavis, Orange, CA
         Question & Answer
         THE PANCREATIC ANASTOMOSIS: THE DANGER
         OF A LEAK
SP827    Which Anastomotic Technique Is Better?
         David B. Adams, Charleston, SC




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   THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


SP828   Stents, Glue, Etc.: Is Anything Proven to Help Prevent
        Leaks/Fistulae?
        Richard D. Schulick, Baltimore, MD
SP829   Defining, Controlling, and Treating a Fistula
        David M. Mahvi, Madison, WI
        Question & Answer
        Break
        THE COLON ANASTOMOSIS: DIVERSION OR PRIMARY
        ANASTOMOSIS
SP830   Diverting Ostomy with Pouch Procedure: Should Be
        Done to Prevent Severe Morbidity
        Charles M. Friel, Charlottesville, VA
SP831   Diverting Ostomy with Pouch Procedure: Causes More
        Morbidity Than It Prevents
        Mark J. Koruda, Chapel Hill, NC
SP832   Colonic Trauma: Indications for Diversion vs. Repair
        Joseph DuBose, Los Angeles, CA
        Question & Answer
        THE BARIATRIC GASTROJEJUNOSTOMY: WHEN
        THINGS GO WRONG
SP833   Dilating the Stenotic Gastrojejunostomy After Gastric
        Bypass
        Raul J. Rosenthal, Weston, FL
SP834   Leak: Reoperate, Drain, and Feed Distally
        Eric J. DeMaria, Durham, NC
SP835   Leak: Treat with Endoscopic Stent
        Klaus Thaler, Columbia, MO
        Question & Answer




                                     62
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


12:30 PM – 1:30 PM       QUICK SHOTS III                                     24ABC
                         Timothy M. Pawlik, Baltimore, MD
                         Magesh Sundaram, Morgantown, WV
 1029    Outcome of Esophagectomy Based on Surgical
         Subspecialty Training
         Brian R. Smith*, Marcelo W. Hinojosa, Kevin M. Reavis,
         Ninh T. Nguyen




                                                                                        SCHEDULE
         Department of Surgery, UC Irvine Medical Center, Orange, CA




                                                                                          DAILY
 1030    Optimizing Outcome Measurement in Pancreatic
         Surgery: Can NSQIP Measure Up?
         Craig P. Fischer*1,2, Thomas A. Aloia1,2, Bridget N. Fahy1,2,
         Stephen L. Jones1,2, Barbara L. Bass1,2
         1Surgery, The Methodist Hospital, Houston, TX; 2Weill Medical
         College of Cornell University, New York, NY
 1031    The Learning Curve of Laparoscopic Rectal Resection
         for Cancer: A Single-Center Experience
         Marco Montorsi*, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi,
         Riccardo Rosati
         General Surgery, University of Milan, Istituto Clinico Humanitas IRCCS,
         Milan, Italy
  1032 Short-Term Outcomes After Laparoscopic-Assisted
       Compared to Open Colectomy for Cancer
         Karl Y. Bilimoria*1, David J. Bentrem1, Heidi Nelson2,
         Steven J. Stryker1, Clifford Y. Ko3, Nathaniel J. Soper1
         1Department of Surgery, Feinberg School of Medicine, Northwestern
         University, Chicago, IL; 2Department of Surgery, Mayo Clinic, Rochester, MN;
         3Department of Surgery, UCLA and Greater Los Angeles VA, Los Angeles, CA

 1033    Patient Demographics and Surgeon Volume in
         Pancreatic Resection Mortality
         Robert W. Eppsteiner*, Nicholas Csikesz, Jennifer F. Tseng,
         Shimul A. Shah
         Surgery, University of Massachusetts, Worcester, MA
 1034    Are Seasoned Surgeons Still Safe in a Laparoscopic
         Surgical Crisis?
         Kinga A. Powers*1,2, Scott Rehrig1, Noel Irias1, Mark P. Callery1,
         Steven D. Schwaitzberg2, Daniel B. Jones1
         1Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School,
         Boston, MA; 2Surgery, Cambridge Health Alliance, Harvard Medical School,
         Boston, MA




                                       63
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 1035    Meta-Analysis of Mechanical Bowel Preparation for
         Elective Colon and Rectal Resection
         Carlos E. Pineda*, Andrew A. Shelton, Tina Hernandez-Boussard,
         John M. Morton, Mark L. Welton
         Department of Surgery, Stanford University, Stanford, CA
 1036    Sequential Resections of Liver and Pulmonary
         Metastases of Colorectal Cancers: Results of 45 Patients
         Hannes Neeff*1, Frank Makowiec1, Eva Fischer1, Ulrich T. Hopt1,
         Bernward Passlick2
         1Department of Surgery, University of Freiburg, Freiburg, Germany;
         2Department of Thoracic Surgery, University of Freiburg, Freiburg, Germany

  1037 Prognostic Factors Associated with Survival Following
       Hepatic Resection of Early-Stage Hepatocellular
       Carcinoma
         Hari Nathan*, Michael Choti, Richard D. Schulick, Timothy M. Pawlik
         Surgery, Johns Hopkins Hospital, Baltimore, MD
 1038    Staging Error Does Not Explain the Relationship
         Between the Number of Nodes in a Colon Cancer
         Specimen and Survival
         Jesse Moore*1, Neil H. Hyman1, Peter Callas2, Benjamin Littenberg3
         1Surgery, University of Vermont College of Medicine, Burlington, VT;
         2Mathematics & Biostatistics, University of Vermont College of Medicine,
         Burlington, VT; 3Med-Gen Internal Medicine, University of Vermont College
         of Medicine, Burlington, VT

12:30 PM – 1:45 PM              MEET-THE-PROFESSOR LUNCHEONS
SP860    The Difficult Cholecystectomy                                          26B
         Lygia Stewart, San Francisco, CA
SP861    Total Mesorectal Excision                                            26A
         James W. Fleshman, St Louis, MO




                                       64
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


2:15 PM – 3:45 PM        DDW COMBINED                Ballroom 20A
                       CLINCIAL SYMPOSIUM
         BALANCING THE USE OF BIOLOGICS AND
         SURGERY IN MANAGEMENT OF ULCERATIVE
         COLITIS
         Sponsored by: AGA, SSAT
         Moderators: Stephen B. Hanauer, Chicago, IL




                                                                    SCHEDULE
                                                                      DAILY
                       Scott A. Strong, Cleveland, OH
 SP94    Benefits of Biological Therapy in Severe Ulcerative
         Colitis
         Russell D. Cohen, Chicago, IL
 SP95    Benefits of Surgery in Severe Ulcerative Colitis
         David W. Larson, Rochester, MN
 SP96    Risks of Biological Therapy in Severe Ulcerative Colitis
         Walter Koltun, Hershey, PA
 SP97    Risks of Surgery in Severe Ulcerative Colitis
         Asher Kornbluth, New York, NY




                                      65
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT



     POSTER SESSION DETAIL
         Designated presenting authors listed. For complete author strings,
         turn to the Poster Session Abstracts starting on page 184.


Monday, May 19, 2008
12:00 PM – 2:00 PM      SSAT POSTER SESSION                     SAILS PAVILION
         Authors available at their posters to answer questions 12:00 PM –
         2:00 PM; posters on display 8:00 AM – 5:00 PM. In addition,
         Posters of Distinction ( ) will be available for further viewing in
         Room 25ABC on Tuesday, May 20, 2008.

CLINICAL SCIENCE POSTERS

Clinical: Biliary
 M1500 Acute Calculous Cholecystitis: Indications for Early
       Percutaneous Cholecystostomy
         Gidon Almogy, Hadassah University Hospital, Jerusalem, Israel
 M1501 Polypoid Lesions of Gallbladder: Diagnosis and
       Follow-Up
         Hiromichi Ito, Memorial Sloan-Kettering Cancer Center, New York, NY
 M1502 Single Incision Laparoscopic Cholecystectomy Using a
       Flexible Endoscope
         Glenn Forrester, St. Luke’s-Roosevelt Hospital Center, New York, NY
 M1503 Laparoscopic Cholecystectomy as a Standardized
       Teaching Operation: A Comparison of Operative
       Complications and Short-Term Outcome Between
       Surgical Residents and Attending Surgeons in
       1220 Patients
         Rene Fahrner, Limmattal Hospital, Schlieren, Switzerland
 M1504 Malignant Melanoma of Lung and Gallbladder,
       Presenting with Hemoptysis: A Case Report and
       Review of Literature
         Ming-Chin Yu, Chang Gung Memorial Hospital, Taoyuan, Taiwan




                                       66
  49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


M1505 Choledochal Cysts: Risk of Malignancy and Outcome in
      68 Patients Undergoing Surgical Management at a
      Single Institution
       John P. Bois, Mayo Clinic, Rochester, MN
M1506 Single Incision Laparoscopic Cholecystectomy
       Michael Albrink, University of South Florida and Tampa General Hospital,
       Tampa, FL
M1508 Plugging Away at the Anal Fistula: An Exercise in
      Futility?
       Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH
M1509 Clinical Feature and Management of Postoperative
      Pouch Bleeding After Ileal Pouch-Anal Anastomosis




                                                                                   SESSIONS
                                                                                    POSTER
      (IPAA)
       Lei Lian, Cleveland Clinic, Cleveland, OH
M1510 Dosimetric Evaluation of Endoscopic Radiofrequency
      Ablation in the Human Colonic Epithelium in a Treat
      and Resect Trial
       Joseph A. Trunzo, University Hospitals Case Medical Center, Cleveland, OH
M1511 A Population-Based Study of Surgical Treatment of
      Colon Cancer in Ontario, Canada
       Rahima Nenshi, University of Toronto, University Health Network, Toronto,
       ON, Canada
M1512 Health Related Quality of Life and Clinical Outcome
      After Colonic Resection for Diverticular Disease:
      Long-Term Results
       Imerio Angriman, Clinica Chirurgica I°, University of Padova,
       Padova, Italy
M1513 Prognostic Factors for Survival in 61 Patients with
      Carcinoma of the Splenic Flexure
       Simon S. Ng, The Chinese University of Hong Kong, Hong Kong, China
M1514 Risk of Infection and Recurrence over Prolonged
      Follow Up in Patients Undergoing Ventral Hernia
      Repair During Colorectal Resection: Can the Use of
      Mesh Be Justified?
       Levilester B. Salcedo, Cleveland Clinic, Cleveland, OH
M1515 The Prognostic Significance of Circumferential
      Resection Margin Involvement in Colon Cancer
       Selman Sokmen, Dokuz Eylul University School of Medicine, Izmir, Turkey




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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 M1516 Results of Surgical Treatment of Local Recurrence in
       Rectal Cancer Patients
           Jörn Gröne, Charité Universitätsmedizin Berlin, Berlin, Germany
 M1517 Preoperative Plasma Levels of Fractalkine (CX3CL1)
       Are Significantly Lower in Patients with
       Adenocarcinoma of the Colon When Compared to
       Benign Disease Patients
           Aviad Hoffman, Columbia University, New York, NY
 M1518 Hemorrhoidectomy in Day Surgery: A Comparison
       Between Four Techniques
           Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy
 M1519 Comparison of Quality of Life (QOL) Between Ileal J
       Pouch-Anal Anastomosis and Permanent Ileostomy
       After Proctocolectomy for Ulcerative Colitis in Elderly
       Patients
           Munenori Nagao, Tohoku university, Sendai, Japan
 M1520 CT Scan in the Diagnosis of Acute Appendicitis: Help
       or Hindrance?
           Akpofure Peter Ekeh, Wright State University Boonshoft School of Medicine,
           Dayton, OH
 M1521 The Likely Cause of Postoperative “Feeding
       Intolerance” and Its Prevention
           Gerald Moss, Rensselaer Polytechnic Institute, White Plains, NY
 M1522 The Clinical Significance of Adult Intussusception
       Found by Computed Tomography
           Parissa Tabrizian, The Mount Sinai Medical Center NY, New York, NY

Clinical: Esophageal
 M1523 Gastroesophageal Reflux Disease and Connective
       Tissue Disorders. Pathophysiology and Implications
       for Treatment
           Warren J. Gasper, University of California San Francisco, San Francisco, CA
 M1524 Association of Gastroesophageal Reflux and O2
       Desaturation in Patients with GERD: A Novel Study of
       Simultaneous 24-Hour Impedance-pH and Continuous
       Pulse-Oximetry
           Renato Salvador, University of Rochester, Rochester, NY

 Poster of Distinction


                                          68
   49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


M1525 Acid Reflux to the Proximal Esophagus Predicts
      Postoperative Success in Patients with
      Laryngopharyngeal Reflux Disease
          Carlos Godinez, University of Maryland Medical Center, Baltimore, MD
M1526 Outcomes Following Esophagogastrectomy in
      Octogenarians
          Sebastian Defranchi, Mayo Clinic, Rochester, MN
M1527 Analyzing Treatment Costs for Esophageal Cancer
      Patients at Different Stages
          Chih-Cheng Hsieh, Taipei Veterans General Hospital, Taipei, Taiwan
M1528 Incorporation of Biologic Mesh Into Crural Closure
      Decreases Complications and Recurrence of




                                                                                          SESSIONS
                                                                                           POSTER
      Paraesophageal Hernias
          Tayyab S. Diwan, Legacy Health System, Portland, OR
M1529 New Techniques for Endoscopic (Laparoscopic and
      Thoracoscopic) Esophagectomy of Esophageal Cancer,
      Ropeway Technique for Dissection Along with the
      Nerve and Double-Gloving Method of HALS for
      Reconstruction
          Hitoshi Satodate, Showa University Northern Yokohama Hospital,
          Yokohama, Japan
M1530 Accidental Mucosal Perforation During Laparoscopic
      Heller-Dor Myotomy Does Not Affect the Final
      Outcome of the Operation
          Mario Costantini, University of Padua, Padova, Italy
M1531 Prevalence of Kyphoscoliosis Among Patients with
      Giant Paraesophageal Hernia: Proposed
      Pathophysiology and Clinical Significance
          Matthew J. Schuchert, University of Pittsburgh Medical Center, Pittsburgh, PA
M1532 Preoperative Chemoradiation with Intensify-
      Modulated Radiation Therapy (IMRT) Increases
      Pathological Complete Response Rate in Locally
      Advanced Squamous Cell Carcinoma of the Esophagus
          Chadin Tharavej, Chulalongkorn University, Bangkok, Bangkok, Thailand




Poster of Distinction


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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


Clinical: Hepatic
 M1533 Hepatobiliary Resection with Inferior Vena Cava
       Resection and Reconstruction Using an Autologous
       Patch Graft for Intrahepatic Cholangiocarcinoma
           Tsuyoshi Sano, Aichi Cancer Center Hospital, National Cancer Center
           Hospital, Nagoya, Japan
 M1534 Postoperative Complications After Liver Resections for
       Colorectal Metastases: Analysis of Risk Factors and
       Influence of Preoperative Chemotherapy
           Frank Makowiec, University of Freiburg, Freiburg, Germany
 M1535 Second Liver Resection for Recurrent Metastases of
       Colorectal Cancer: Perioperative Complications and
       Oncological Results
           Hannes Neeff, University of Freiburg, Freiburg, Germany
 M1536 A Decision Analysis Model of Hepatectomy Versus
       Radiofrequency Ablation for Hepatocellular
       Carcinoma
           Amanda Cooper, Indiana University, Indianapolis, IN
 M1537 Image-Guided Laparoscopic Radiofrequency Ablation
       of Giant Liver Hemangiomas
           Rocio Anula, Hospital Clinico San Carlos, Hospital Clinico San Carlos,
           Madrid, Spain
 M1538 Monopolar Floating Ball Versus Bipolar Forceps for
       Hepatic Resection: A Prospective Randomized Clinical
       Trial
           Guido Torzilli, University of Milan, Istituto Clinico Humanitas – IRCCS,
           University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano –
           Milano, Italy

Clinical: Pancreas
 M1539 Long Term Follow-Up (7–34 Years) After Surgical
       Treatment of Chronic Pancreatitis
           Sergio Pedrazzoli, IV Surgical Clinic, PADOVA, Italy




 Poster of Distinction


                                         70
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


M1540 High Complication Rate After Pancreas Preserving
      Surgical Procedures for Benign or Borderline Pancreatic
      Lesions. Careful Selection of Patients Is Needed
          Sergio Pedrazzoli, IV Surgical Clinic, PADOVA, Italy
M1541 Predictable Factors for Poor Outcome After Severe
      Acute Pancreatitis
          Takeo Yasuda, Kinki University School of Medicine, Osaka-sayama, Japan
M1542 Serum Immunosuppressive Acidic Protein Levels in
      Patients with Severe Acute Pancreatitis
          Makoto Shinzeki, Kobe University Graduate School of Medical Sciences,
          Kobe, Hyogo, Japan
M1543 Risk Factors for Postoperative Complications After




                                                                                   SESSIONS
                                                                                    POSTER
      Pancreatic Head Resection: Multivariate Analysis of
      608 Consecutive Operations
          Tobias Keck, University of Freiburg, Freiburg, Germany
M1544 Quality of Life After Total Pancreatectomy: Requiem
      for a Surgical Dogma?
          Roberto Salvia, Università di Verona, Verona, Italy
M1545 The Assessment of the Malignant Potential of IPMN:
      How Reliable Is the New Score from Fujino?
          Dominique Suelberg, University Hospital of Bochum, Bochum, Germany
M1546 Volume in Pancreatic Surgery: The German Situation
          Guido Alsfasser, University of Rostock, Rostock, Germany
M1547 The Lymph Node-Ratio Is the Strongest Factor
      Predicting Survival After Resection of Pancreatic
      Cancer
          Frank Makowiec, University of Freiburg, University of Freiburg,
          Freiburg, Germany
M1548 Dynamic Magnetic Resonance Imaging (DMRI) of the
      Pancreas as a Predictor of Anastomotic Leakage After
      Pancreatic Resections
          Marco Niedergethmann, University Hospital Mannheim, Mannheim,
          Germany
M1549 Combination of Bioabsorbable Polyglicolic Acid (PGA)
      Felt and Fibrin Glue for Prevention of Pancreatic
      Fistula Following Pancreaticoduodenectomy
          Kenichiro Uemura, Hiroshima University, Hiroshima, Japan


Poster of Distinction


                                         71
    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 M1550 Radiofrequency Ablation of Locally Advanced
       Pancreatic Cancer
        Jennifer Logue, Glasgow Royal Infirmary, Glasgow, United Kingdom
 M1551 Antibacterial Prophylaxis Does Not Prevent Infection
       of Pancreatic Necrosis in Acute Pancreatitis
        Eduardo A. Villatoro, University of Nottingham Medical School, Derby,
        Derby, United Kingdom
 M1552 Development of a Dedicated Team Decreases ICU
       Admission After Pancreaticoduodenectomy (PD)
        Julio Sokolich, Methodist Dallas Medical Center, Dallas , TX
 M1553 Predictive and Prognostic Value of CA 19-9 in Resected
       Pancreatic Adenocarcinoma
        Joshua G. Barton, Mayo Clinic, Rochester, MN

Clinical: Small Bowel
 M1554 Long-Term Outcome After Distal Gastric Bypass
       Combined with Swedish Adjustable Gastric Banding
       (SAGB)
        Bruno M. Balsiger, Spitalnetzbern, Bern, Switzerland
 M1555 Gastro Intestinal Intramural Hematomas Versus
       Mesenteric Ischaemia- Clinico-Radiological Profile
        Sudhindran Surendran, Amrita institute of medical Sciences, Kochi, India

Clinical: Stomach
 M1556 Laparoscopic Lymphatic-Basin Dissection as an
       Additional Treatment to Endoscopic Submucosal
       Dissection in Early Gastric Cancer
        Toshiyuki Mori, Kyorin University, Tokyo, Japan
 M1557 Long Term Improvement of Comorbidities in Older
       and Medicare Patients with Gastric Bypass
        Peter T. Hallowell, University Hospitals Case Medical Center, Cleveland, OH
 M1558 Indications and Results of Reversal of Vertical Banded
       Gastroplasty (VBG)
        Rebecca Thoreson, University of Iowa, Coralville, IA
 M1559 Gastrectomy and Lymphadenectomy for Gastric
       Cancer: Is the Pancreas Safe?
        Fernando A. Herbella, Federal University of São Paulo, São Paulo, Brazil



                                      72
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 M1560 Long Term Results of Completion Gastrectomies in
       Patients with Post-Surgical Gastroparesis
           James E. Speicher, Virginia Mason Medical Center, Seattle, WA
 M1561 Is Neoadjuvant Chemoradiation for Locally Advanced
       Gastric Cancer Feasible?
           Brian R. Untch, Duke University Medical Center, Durham, NC
 M1562 Inpatient Mortality Analysis of Paraesophageal Hernia
       Repair in Octogenarians
           Benjamin K. Poulose, University Hospitals Case Medical Center, Cleveland, OH
 M1563 Surgeon Performed Endoscopic Balloon Dilation for
       Gastrojejunostomy Stenosis
           Atul K. Madan, University of Tennessee Health Science Center, Miami, FL




                                                                                          SESSIONS
                                                                                           POSTER
 M1564 Qualifying the Relationship: Interaction Effects in the
       Correlation Between Bmi and Abdominal Wall
       Thickness
           Mark Ranzinger, University of Maryland, Baltimore, MD

BASIC SCIENCE POSTERS

Basic: Biliary
 M1842 CD44-Hyaluronan Interaction Plays a Critical Role in
       Biliary Proliferation During the Development of
       Hepatic Cholestasis
           Gordon D. Wu, Cedars-Sinai Medical Center, Los Angeles, CA

Basic: Colon-Rectal
 M1843 Decreased PLD2 Expression Correlates with NM404
       Retention in Human Colorectal Cancer Xenografts
           Joseph Nwankwo, University of Wisconsin, Madison, WI
 M1844 The Effects of Dai-Kenchu-to (TU-100) on Propulsive
       Motility in the Colon
           Michael Wood, University of Vermont College of Medicine, Burlington, VT
 M1845 Effect of NOD2/CARD15 Mutations on Ileal Gene
       Expression Profiles in Crohn’s Disease
           Steven R. Hunt, Washington University, Saint Louis, MO


 Poster of Distinction


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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 M1847 The Effect of Toll Like Receptor (TLR) 9 Agonist, CpG
       Oligodeoxynucleotides (ODN), on Abdominal and
       Gastrotomy Wound Healing in a Murine Model
           Ik-Yong Kim, Columbia University, Yonsei University, Wonju College of
           Medicine, New York, NY

Basic: Esophageal
 M1848 Evaluation of the Cell Proliferation Expansion in the
       Columnar Mucosa of the Distal Esophagus in Patients
       with GERD: Immunohistochemical Analysis of KI67
       (MIB1) Antigen in Columnar Mucosa With and
       Without Intestinal Metaplasia
           Richard R. Gurski, UFRGS, Porto Alegre, RS, Brazil
 M1849 The Pathogenesis of Barrett’s Esophagus: The
       Combination of Acid and Bile Is Synergistic in the
       Induction of CDX2 and EGFR Activation in Esophageal
       Cells
           Nelly E. Avissar, University of Rocehster, School of Medicine and Dentistry,
           Rcohester, NY
 M1850 Bile Reflux Induces Higher COX-2 Expression Than
       Mixed Acid and Bile Reflux in a Rat Model of
       Esophagitis
           Reginald V. N. Lord, University of Southern California Keck School of
           Medicine, St. Vincent’s Hospital, Sydney, NSW, Australia

Basic: Hepatic
 M1851 Cellular Liver Regeneration After Extended Hepatic
       Resection in Pigs
           Ruth Ladurner, University of Tuebingen, Tuebingen, Germany
 M1852 Basics of Mouse Liver Anatomy from a Microsurgical
       Point of View
           Peter Studer, Inselspital, Bern, Switzerland
 M1853 Simultaneous Splenectomy Enhance Liver Regeneration
       After Major Hepatectomy via Decreasing Activin-A
       Expression
           Yan-Shen Shan, National Cheng Kung Univ Hosp, Tainan, Taiwan



 Poster of Distinction


                                          74
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Pancreas
 M1854 Cannabinoid Receptor Blockade Attenuates Acute
       Pancreatitis by an Adiponectin Mediated Mechanism
           Nicholas J. Zyromski, Indiana University, Indianapolis, IN
 M1855 Over-Expression of Focal Adhesion Kinase Inhibits Cell
       Proliferation in Gastrointestinal Neuroendocrine
       Tumor Cells
           Li Ning, University of Wisconsin, Madison, WI
 M1856 Potential Therapeutic Targets in Invasive Pancreatic
       Cancer Identified by Gene Expression Profiling
           Annamarie Rogers, University of Dublin, Trinity College, Dublin , Ireland




                                                                                         SESSIONS
                                                                                          POSTER
 M1857 A Xenograft Model and Cell Line Deriving from
       Invasive Intraductal Papillary Mucinous Neoplasm
       of the Pancreas
           Stefan Fritz, Massachusetts General Hospital, Harvard Medical School,
           Cambridge, MA
 M1858 pp32 Is a Key Regulator of Cellular Differentiation:
       Implications for Anti-Cancer Therapy
           Timothy K. Williams, Thomas Jefferson University, Philadelphia, PA
 M1859 The Effect of ras/raf-1 Pathway Activation on
       Somatostatin Receptors in Gastrointestinal Carcinoid
       Tumor Cells
           Scott N. Pinchot, University of Wisconsin Hospital and Clinics, Madison, WI
 M1860 Pterostilbene Inhibits Pancreatic Cancer in Vitro
           Julie A. Alosi, University of Vermont College of Medicine, Fletcher Allen
           Health Care, Burlington, VT

Basic: Small Bowel
 M1861 Practical Considerations and Survival Techniques for a
       Rat Model of Roux-en-Y Gastric Bypass
           Drew A. Rideout, University of South Florida, James A. Haley Veterans
           Affairs Medical Center, Wesley Chapel, FL




 Poster of Distinction


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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 M1862 Activation of Wnt Signaling Protects Intestinal
       Epithelial Cells from Apoptosis by Increasing
       Cytoplasmic Levels of RNA-Binding Protein HuR
           Emily C. Bellavance, University of Maryland School of Medicine and
           Baltimore VA Medical Center, Baltimore, MD
 M1863 The Immunonutrient Fish Oil Increases Blood Flow in
       the Ileum During Chronic Feeding in Rats
           Ryan T. Hurt, University of Louisville, University of Louisville, Louisville, KY

Basic: Stomach
 M1864 Survivin Expression in Gastric Cancer: Association
       with Histomorphological Response to Neoadjuvant
       Therapy and Prognosis
           Daniel Vallbohmer, University of Cologne, Cologne, Germany

COMBINED SCIENCE POSTERS

Combined Science
 M2091 The Effect of Major Abdominal Procedure Type on
       the Incidence and Economic Burden of Deep Vein
       Thrombosis or Pulmonary Embolism
           Debraj Mukherjee, Johns Hopkins Bloomberg School of Public Health,
           Johns Hopkins School of Medicine, Baltimore, MD
 M2092 Removal of Visceral Fat Improves Metabolic Syndrome
       and Hepatic Steatosis in Diet-Induced Obese Mice
           Xavier Dray, Johns Hopkins School of Medicine, Baltimore, MD
 M2093 Novel Therapeutic Targets in Esophageal Cancer:
       Impact of Coexpression of Receptor-Tyrosine-Kinases
       (RTK) and Chemokine Receptor CXCR4
           Ines Gockel, Johannes Gutenberg-University, Mainz, Germany




 Poster of Distinction


                                           76
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA



Tuesday, May 20, 2008
12:00 PM – 2:00 PM      SSAT POSTER SESSION                     SAILS PAVILION
         Authors available at their posters to answer questions 12:00 PM –
         2:00 PM; posters on display 8:00 AM – 5:00 PM. In addition,
         Posters of Distinction ( ) will be available for further viewing in
         Room 25ABC on Wednesday, May 21, 2008.

CLINICAL SCIENCE POSTERS

Clinical: Biliary




                                                                                 SESSIONS
                                                                                  POSTER
  T1695 Comparison Hilar Bile Duct Cancer with Intrahepatic
        Cholangiocarcinoma Involving the Hepatic Hilus
         Tsuyoshi Sano, Aichi Cancer Center Hospital, National Cancer Center
         Hospital, Nagoya, Japan
  T1696 Progress in Laparoscopic Surgery for Adult
        Choledochal Cysts-Kyushu University Experience
         Hiroki Toma, Kyushu university, Fukuoka city, Japan
  T1697 Outcomes of Endoscopic and Surgical Management of
        Sphincter of Oddi Dyskinesia in Patients Not
        Responding to Cholecystectomy for Chronic
        Acalculous Cholecystitis
         James O. Johnson, St Vincent Hosp & Hlth Care Ctr, Indianapolis, IN
  T1698 The Significance of CD44 Expression in Ampullary
        Cancer
         Hui-Ping Hsu, National Cheng Kung Univ Hosp, Tainan, Taiwan
  T1699 Asymptomatic Cholelithiasis Occurrence in Patients of
        Kidney Transplantation List
         José Jukemura, Faculdade de Medicina da Universidade de São Paulo,
         São Paulo, São Paulo, Brazil
  T1700 Significance of Tissue Expression of MUC5AC in Hilar
        and Intrahepatic Cholangiocarcinoma
         Andrea Ruzzenente, University of Verona Medical School, Verona, Italy
  T1701 Preoperative Assessment of Intrahepatic
        Cholangiocarcinoma: CT Features with Pathological
        Correlation
         Riccardo Manfredi, University of Verona Medical School, Verona, Italy


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Clinical: Colon-Rectal
  T1702 Anastomotic Leaks After Bowel Resection: What Do
        We Learn from Peer Review?
        Neil H. Hyman, University of Vermont College of Medicine, Burlington, VT
  T1703 Preoperative Assessment of Nutritional Status in
        the Patients with Ulcerative Colitis: Evaluation of
        Nutritional Markers Which Predict Septic
        Complications
        Ken-ichi Takahashi, Tohoku Rosai Hospital, Sendai, Japan
  T1704 Cytokine Network in Rectal Mucosa in Perianal
        Crohn’s Disease: Relations with Inflammatory
        Parameters and Need for Surgery
        Imerio Angriman, Clinica Chirurgica 1°, University of Padova,
        Padova, Italy
  T1705 Abdominal Surgery Impact Scale (ASIS) Is Responsive
        in Assessing Outcome Following IPAA
        Indraneel Datta, Dr. Zane Cohen Digestive Diseases Clinical Research
        Center, Calgary, AB, Canada
  T1706 Morbidity and Mortality Associated with Emergency
        Abdominal Surgery in the Elderly
        Jill M. Zalieckas, Lahey Clinic Medical Center, Burlington, MA
  T1707 Is There a Critical Number of Recovered Nodes in
        ypT3-4 Rectal Cancer After Neoadjuvant CRT in
        Order to Provide Proper Final Disease Staging?
        Igor Proscurshim, University of São Paulo School of Medicine,
        São Paulo, Brazil
  T1708 Is Initial Pre-Treatment Staging for Distal Rectal
        Cancer Undergoing Neoadjuvant CRT Useful?
        Rodrigo O. Perez, University of São Paulo School of Medicine,
        São Paulo, SP, Brazil
  T1709 Are There Any “High Risk” Features in Stage II Rectal
        Cancer After Neoadjuvant CRT and Radical Surgery?
        Rodrigo O. Perez, University of São Paulo School of Medicine, São Paulo,
        SP, Brazil
  T1710 Does Laparoscopic Approach Affect the Number of
        Lymph Nodes Harvest in Colorectal Cancer?
        Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH




                                      78
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 T1711 Risk of Leak After Laparoscopic Versus Open Bowel
       Anastomosis
        Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH
 T1712 Postoperative Bowel Function After Lumber Colonic
       Nerve Preserving Low Anterior Resection for Rectal
       Cancer
        Yoshitaka Tanabe, Kitakyushu Municipal Medical Center, Graduate School
        of Medical Sciences, Kyushu University, Kitakyushu, Japan
 T1713 Prospective Study on the Management of Acute
       Diverticulitis
        Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy
 T1714 Incidence of Adhesional Small Bowel Obstruction




                                                                                     SESSIONS
                                                                                      POSTER
       (SBO) After Colorectal Surgery
        Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy
 T1715 Laparoscopic Appendectomy for Complicated
       Appendicitis
        Pierpaolo Sileri, University of Rome Tor Vergata, Rome, Italy
 T1716 Small Intestinal Bacterial Overgrowth Is Common in
       Patients with Lower Gastrointestinal Symptoms and a
       History of Previous Abdominal Surgery
        Grant G. Sarkisyan, University of Southern California, Los Angeles, CA
 T1717 Contemporary Surgical Management for Ileosigmoid
       Fistulas in Crohn’s Disease
        Genevieve B. Melton, Cleveland Clinic Foundation, Cleveland, OH
 T1718 The Usage of Botulinum Toxin in the Treatment of
       Chronic Anal Fissures
        Alex J. Ky, Mt Sinai Hospital, New York, NY

Clinical: Esophageal
 T1719 Esophageal Adenocarcinoma Associated with Barrett’s
       Esophagus: Survival Benefit?
        Valerie A. Williams, University of Rochester Medical Center, Rochester, NY
 T1720 Changing Prognosis of Spontaneous Esophageal
       Perforation (Boerhaave Syndrome): A Personal
       Experience of 64 Cases in a Single Center
        Jarmo A. Salo, Helsinki University Central Hospital, Helsinki, Finland




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  T1721 The Value of Endoscopic Ultrasound to Distinguish the
        Number of Lymph Node Metastases in Patients with
        Esophageal Adenocarcinoma
           Jessica M. Leers, Keck School of Medicine, University of Southern California,
           Los Angeles, CA
  T1722 Significant Pressure Differences Between Solid-State
        and Water Perfused Systems in Lower Esophageal
        Sphincter Measurement
           Heinz Wykypiel, Medical University Innsbruck, Innsbruck, Austria
  T1723 Understanding Laryngopharyngeal Reflux (LPR): The
        Prevalence of Anatomic Esophagogastric Junction
        Degradation in LPR Patients
           Kyle A. Perry, Oregon Health & Science University, Portland, OR
  T1724 The Effect of Body Position on Hiatal Anatomy in
        Patients with GERD
           Kyle A. Perry, Oregon Health & Science University, Portland, OR
  T1725 Better Reflux Control with a Nissen Fundoplication:
        10-Year Results After Laparoscopic Antireflux Surgery
           Martin Fein, University of Wuerzburg, Wuerzburg, Germany
  T1726 Association of Pregnane X Receptor (PXR) with
        Esophageal Disease in an Irish Population
           Mahwash Babar, St. James’s Hospital, Dublin, Trinity College, Dublin,
           Dublin, Ireland
  T1727 The Influence of FDG-PET on the Decision to Operate
        for Esophageal Carcinoma
           Jason W. Smith, Loyola University Medical Center, Maywood, IL
  T1728 Surgical Outcomes Following Laparoscopic Re-Do
        Heller Myotomy in the Treatment of Achalasia
           Matthew J. Schuchert, University of Pittsburgh Medical Center, Pittsburgh, PA

Clinical: Hepatic
  T1729 Validation of the E-PASS Scoring System for Prediction
        of Mortality and Morbidity in Hepatic Resections
           Vanessa Banz, University Hospital Bern, Bern, Switzerland
  T1730 Prolonged Survival in Selected Patients Following
        Metastasectomy from Hepatocellular Carcinoma
           Chen Fang Lee, Chang-Gung Memorial Hospital, Taoyuan, Taiwan

 Poster of Distinction


                                          80
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1731 Prognostic Factors After Liver Resection for Colorectal
        Metastases: Multivariate Analysis and Comparison
        with the FONG-Score
        Ulrich Adam, University of Freiburg, Freiburg, Germany
  T1732 Ultrasound Guided Liver Resection: Does This Approach
        Limit the Need for Portal Vein Embolization?
        Guido Torzilli, University of Milan, Istituto Clinico Humanitas – IRCCS,
        University of Milan, Istituto Clinico Humanitas – IRCCS, Rozzano –
        Milano, Italy
  T1733 Surgical Management of Leiomyosarcoma of the
        Inferior Vena Cava in Eight Patients
        T. Clark Gamblin, University of Pittsburgh Medical Center, Liver Cancer




                                                                                   SESSIONS
                                                                                    POSTER
        Center, Pittsburgh, PA

Clinical: Pancreas
  T1734 EUS-Guided Drainage of Peripancreatic Fluid Collections
        Following Distal Pancreatectomy
        Shyam Varadarajulu, University of Alabama at Birmingham, Birmingham, AL
  T1735 Management of Intraductal Papillary-Mucinous
        Neoplasms of the Pancreas (IPMN): A 10-Year
        Experience in Two Pancreatic Centers in Germany
        Robert Grützmann, University Hospital Dresden, Dresden, Germany
  T1736 Indication for Special Therapies in Acute Pancreatitis:
        Optimum Severity Score for Continuous Regional
        Arterial Infusion and Enteral Nutrition
        Takashi Ueda, Kinki University School of Medicine, Osaka-sayama, Japan
  T1737 Usefulness of 13C-Labeled Mixed Triglyceride Breath
        Test for Evaluating Exocrine Pancreatic Function
        After Pancreatic Surgery
        Hiroyuki Nakamura, Hiroshima University, Hiroshima, Japan
  T1738 Surgical Resection of Renal Cell Carcinoma Metastatic
        to the Pancreas
        Joshua G. Barton, Mayo Clinic, Rochester, MN
  T1739 Pancreatic Acinar Cell Carcinoma: A Multi-
        Institutional Study
        Jesus M. Matos, Indiana University School of Medicine, Indianapolis, IN




                                      81
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 T1740 Pancreatic Exocrine Function in Patients Undergoing
       Distal Pancreatectomy as Assessed by Human Stool
       Elastase-1
           James E. Speicher, Virginia Mason Medical Center, Seattle, WA
 T1741 Risk Factors for Pancreatic Leak Following Distal
       Pancreatectomy
           Hari Nathan, Johns Hopkins University, Baltimore, MD
 T1742 Analysis of Organ Failure, Mortality and Pancreatic
       Necrosis in Patients with Severe Acute Pancreatitis
           Tercio De Campos, Santa Casa School of Medical Sciences, University of
           São Paulo, São Paulo, SP, Brazil
 T1743 Quality of Life in Long-Term Survivors After
       Pancreaticoduodenectomy
           Stefano Crippa, Università di Verona, Verona , Italy
 T1744 Intraoperative Assessment of Margin Status at the
       Time of Pancreaticoduodenectomy Ensures R0
       Resection in Patients with Pancreatic Cancer
           Robert Yates, Ohio State University, Columbus, OH
 T1745 Surgical Drainage of Symptomatic Peripancreatic
       Fluid Collections in the Era of Endoscopic
       Management
           Luis A. Benavente-Chenhalls, Mayo Clinic, Rochester, MN
 T1746 Estimation of Physiologic Ability and Surgical Stress
       (E-PASS) as a Predictor of Immediate Outcome After
       Pancreatic Surgery: The Score Needs to Be Adapted!
           Beat Gloor, Inselspital, University Bern, Bern, Switzerland
 T1747 Is Adjuvant Therapy Indicated After Pancreatectomy
       for Adenocarcinoma?
           Jonathan M. Hernandez, University of South Florida and Tampa General
           Hospital, Tampa, FL

Clinical: Small Bowel
 T1748 Can Plain Abdominal X-Ray Predict the Need for
       Operation in Patients with Adhesive Small Bowel
       Obstruction?
           Nathan M. Novotny, Indiana University, Indianapolis, IN



 Poster of Distinction


                                          82
   49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 T1749 A Proposed Algorithm for Ventral Hernia Repair
       Optimizes Patient Outcome
       Judy Jin, University Hospitals Case Medical Center, Cleveland, OH
 T1750 Laparoscopic Roux-en-Y Gastric Bypass in 400
       Consecutive Patients Without Internal Hernia
       Richard S. Flint, Brigham & Women’s Hospital, Boston, MA

Clinical: Stomach
 T1751 Surgical Therapy for Adenocarcinoma of the True
       Gastric Cardia
       Marcus Feith, Technische Universitaet Muenchen, Munich, Germany




                                                                                   SESSIONS
                                                                                    POSTER
 T1752 Surgical Technique Affects the Incidence of Marginal
       Ulceration After Roux-en-Y Gastric Bypass
       Yong-Kwon Lee, University Nebraska Medical Center, Omaha, NE
 T1753 Results of Uncut Roux-En Y Reconstruction After
       Distal Gastrectomy for Gastric Cancer
       Chikashi Shibata, Tohoku University School of Medicine, Sendai, Japan
 T1754 Changes in Inflammatory Biomarkers Across Weight
       Classes in a Representative US Population: A Link
       Between Obesity and Inflammation
       Xuan-Mai T. Nguyen, Univ of CA, Irvine Medical Center, Ithaca, NY
 T1755 Order of Placement Does Not Change Complication
       Rates for Patients with Concomitant
       Ventriculoperitoneal Shunt and Percutaneous
       Endoscopic Gastrostomy
       Nora C. Meenaghan, University of Maryland, Baltimore, MD
 T1757 The Influence of Anastomotic Line Tumor Invasion
       and Mesenterial Lymph Node Metastases in Survival of
       Patients with Gastric Stump Cancer
       Claudio Bresciani, University of São Paulo School of Medicine, São Paulo,
       Brazil
 T1758 Duodenal Bypass in Lean Individuals Do Not Decrease
       Glucose Levels
       Ana C. Tineli, Federal University of São Paulo, São Paulo, Brazil




                                     83
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  T1759 Use of Polypropylene Mesh for Laparoscopic
        Adjustable Gastric Banding (LAGB) Allows for
        Minimum Post-Op Pain with No Narcotic Usage and
        Less Pain for Adjustments
           Leonierose Dacuycuy, Boston University, Boston, MA, SkyLex Advanced
           Surgical Inc., Los Angeles, CA

BASIC SCIENCE POSTERS

Basic: Biliary
  T1901 Systemic Inflammatory Response After Natural Orifice
        Translumenal Surgery: Transvaginal Cholecystectomy
        in Porcine Model
           Daniel K. Tong, University of Hong Kong, Queen Mary Hosp, Hong Kong, China

Basic: Colon-Rectal
  T1902 Curcumin Inhibits the Mammalian Target of Rapamycin
        Subunits Rictor and Raptor in Colon Cancer Cells
           Sara M. Johnson, UTMB, Galveston, TX
  T1903 Increased Expression of Pontin in Human Colorectal
        Cancer Tissue
           Johannes C. Lauscher, Charite, Berlin, Germany
  T1904 Human Acute Immune Response to Colon and Rectal
        Surgery: Comparison Between Open, Laparoscopic and
        Hand Assisted Resection
           Laurie S. Norcross, Colon and Rectal Clinic of Orlando, Orlando Regional
           Hospital System, Orlando, FL
  T1905 Src Kinase Inhibition May Inhibit Experimental
        Cancer Metastasis
           Njwen Anyangwe, Wayne State University School of Medicine and John D.
           Dingell VAMC, Detroit, MI
  T1906 CD8+ T Cell Infiltration and Cancer Recrurrence in
        Squamous Cell Cancer of the Anus
           Sonia Ramamoorthy, UCSD, San Diego, CA




 Poster of Distinction


                                        84
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Esophageal
  T1907 Inhibition of YB-1 as a Novel Approach to Decrease the
        Expression of EGFR, HER-2 and IGF-1R in Esophageal
        Cancer
           Sabrina Thieltges, University Hospital Hamburg-Eppendorf, Hamburg,
           Germany
  T1908 Gene Polymorphisms of ERCC1 Predict Response to
        Neoadjuvant Radiochemotherapy in Esophageal
        Cancer
           Ralf Metzger, University of Cologne, Cologne, Germany
  T1909 Successful Evaluation of a New Animal Model Using




                                                                                         SESSIONS
                                                                                          POSTER
        Mice for Esophageal Adenocarcinoma
           Joerg Theisen, TU Munich, Munich, Germany

Basic: Hepatic
  T1910 Postconditioning in Liver Ischemia-Reperfusion Injury
           Roberto Teixeira, University of São Paulo, São Paulo, Brazil
  T1911 Reversibility of Liver Fibrogenesis in Mice: STI571
        Inhibit the Activation of Hepatic Stellate Cells
           Ming-Chin Yu, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Basic: Pancreas
  T1912 Calcineurine Inhibitors Accelerate Microvascular
        Thrombus Formation in Vivo
           Anja Pueschel, University of Rostock, Rostock, Germany
  T1913 OSU-03012, a Celecoxib Derivative, Has Increased
        Cytotoxicity and Does Not Stimulate Vascular
        Endothelial Growth Factor Production Regardless of
        Cyclooxygenase-2 Expression in Pancreatic Cancer Cell
        Lines
           Desmond P. Toomey, University of Dublin, Trinity College, Tallaght, Ireland
  T1914 Inhibition of VEGF and Not COX-2 Is Effective in a
        Model of Pancreatic Cancer Angiogenesis
           Desmond P. Toomey, University of Dublin, Trinity College, Tallaght, Ireland



 Poster of Distinction


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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 T1915 Anti-Lewis Y Antibody as a Novel Target for Pancreatic
       Adenocarcinoma
       Vivian E. Strong, Memorial Sloan-Kettering Cancer Center, New York, NY
 T1916 Differentiation, Origin and Mesothelial Adhesive
       Potential Affect Growth and Metastasis of Ductal
       Adenocarcinoma of the Pancreas
       Soeren Torge Mees, University Hospital Muenster, Muenster, Germany
 T1917 Pancreatic RegI and PAP2 Proteins Have Different
       Potencies on Macrophage TNF Expression
       Ehab Hassanain, SUNY Downstate, Brooklyn NY, NY

Basic: Small Bowel
 T1918 Cold Ischemia of the Small Bowel Could Be Prolonged
       by Intestinal Lipid Absorption Before Gut Procurement
       Judith Junginger, University of Tuebingen, Tuebingen, Germany
 T1919 Diurnal Rhythmicity in the p53-Mediated Apoptotic
       Pathway in Rodent Small Intestine
       Anita Balakrishnan, Brigham and Women’s Hospital and Harvard Medical
       School, Boston, MA

Basic: Stomach
 T1920 Pre-Op Antibiotic Gastric Lavage Reduces Post-
       Operative Peritoneal Infection in a Murine Natural
       Orifice Surgery Model
       John Cullen, University of California, San Diego, San Diego, CA
 T1921 Roux-en-Y Gastric Bypass Improves Obesity-Related
       Steatosis and Is Associated with Reduction in Serum
       Adiponectin
       Drew A. Rideout, University of South Florida, James A. Haley Veterans
       Affairs Medical Center, Wesley Chapel, FL




                                     86
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


COMBINED SCIENCE POSTERS

Combined Science
 T2095 Assessment of “Gene-Environment” Interaction in
       Cases of Familial and Sporadic Pancreatic Cancer
           Theresa P. Yeo, Thomas Jefferson University, Philadelphia, RI
 T2096 Natural Orifice Translumenal Endoscopic Surgery for
       Roux-en-Y Gastric Bypass: An Experimental Surgical
       Study in a Human Cadaver Model
           Monika E. Hagen, University Hospital Geneva, Geneva, Switzerland




                                                                              SESSIONS
 T2097 A Novel System for Classifying Paraesophageal Hernias




                                                                               POSTER
           Tommy H. Lee, University of Maryland, Baltimore, MD




 Poster of Distinction


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Wednesday, May 21, 2008
12:00 PM – 2:00 PM      SSAT POSTER SESSION                      SAILS PAVILION
         Authors available at their posters to answer questions 12:00 PM –
         2:00 PM; posters on display 8:00 AM – 5:00 PM.

CLINICAL SCIENCE POSTERS

Clinical: Biliary
 W1635 Management of Preoperatively Suspected
       Choledocholithiasis: A Decision Analysis
         Bilal Kharbutli, Henry Ford Hospital, Detroit, MI
 W1636 A Novel Hepatico-Jejunostomy Technique Featuring a
       Purse-String Anastomosis and a Biodegradable Stent: A
       Preclinical Study in Minipigs
         Johanna Laukkarinen, Tampere University Hospital, Boston, MA
 W1637 Primary Gallbladder Cancer: A 22 Year Experience in a
       Tertiary Care Center
         Rubayat Rahman, West Virginia University, Morgantown, WV
 W1639 Only Pain from Acute Inflammation Is Relieved One
       Year Following Laparoscopic Cholecystectomy in
       Dyspeptic Patients with Cholelithiasis
         Samaad Malik, University of Saskatchewan, Saskatoon, SK, Canada
 W1640 Surgery for Symptomatic Portal Biliopathy
         Puneet Dhar, Amrita Institute of Medical Sciences, Cochin, Kerala, India
 W1641 Study of a Reverse Phase Polymer in Cholecystectomy:
       Prevention of Stone Migration and Enhancment of
       Dissection
         Marvin Ryou, Brigham & Women’s Hospital, Boston, MA

Clinical: Colon-Rectal
 W1642 Laparoscopic and Open Anterior Resection and Low
       Colorectal Anastomosis for Adult Megacolon: Surgical
       Outcomes
         Sergio E. Araujo, University of São Paulo Medical School, São Paulo,
         São Paulo, Brazil



                                       88
   49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


W1643 To Control Intraoperative Bacterial Contamination
      and SSI During Anterior Resection or Hartmann’s-
      Mile’s Operation: What Can We Do?
       Katsunori Nishikawa, Machida Municipal Hospital, Machida-shi, Japan
W1644 Preoperative Versus Postoperative Radiotherapy for
      Rectal Cancer: Decision Analysis and Outcome
      Prediction Using a Modified Markov Model
       Andreas M. Kaiser, University of Southern California, Los Angeles, CA
W1645 Effect of Metastatic to Examined Lymph Nodes Ratio
      on Colon Cancer Survival
       Sukhyung Lee, William Beaumont Army Medical Center, El Paso, TX
W1646 A Prospective Single Center Experience of “Fast-Track”




                                                                                     SESSIONS
                                                                                      POSTER
      in Colorectal Surgery: Toward Zero Anastomotic
      Complications
       Pierluigi Di Sebastiano, IRCCS casa Sollievo Sofferenza, San Giovanni
       Rotondo, Italy
W1647 Laparoscopic Versus Conventional Colostomy Closure
      of Hartmann’s Procedure: A Case-Matched Study
       Jung C. Kang, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
W1648 A New Method to Analyze the Quality and Progression
      of Colonoscopy
       Lars Enochsson, Karolinska Institutet, Stockholm, Sweden
W1649 Image-Guided Sentinel Lymph Node Navigation in
      Colon Cancer: A Pilot Study
       Julio M. Mayol, Hospital Clinico San Carlos, Hospital Clinico San Carlos,
       Madrid, Spain
W1650 Low Preoperative Serum Albumin Levels Do Not Affect
      Early Outcomes After Ileoanal Pouch Surgery but May
      Be Associated with Long-Term Mortality
       Kweku A. Appau, The Cleveland Clinic Foundation, Cleveland, OH
W1651 TGF-Beta1 and IGF-1 and Anastomotic Recurrence of
      Crohn’s Disease After Ileo-Colonic Resection
       Imerio Angriman, Clinica Chirurgica 1°, University of Padova, Padova, Italy
W1652 Pre- Versus Postoperative Pelvic Radiotherapy in
      Patients Undergoing Abdominoperineal Resections for
      Rectal Cancer: Does Timing Make a Difference on
      Long-Term Patient Quality of Life?
       Michael S. Kasparek, Mayo Clinic Rochester, Ludwig-Maximilians-University
       Munich, Munich, Germany


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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1653 Sacral Neuromodulation for the Treatment of Fecal
       Incontinence and Voiding Dysfunction in Female
       Patients: A Longterm Follow Up
        Galal S. El-Gazzaz, Cleveland Clinic, Cleveland, OH
 W1654 Long Term Out Come and Quality of Life After
       Restorative Proctocolectomy in a Cohort of 955
       Canadian Patients
        Marco Scarpa, University of Padova, Padova, Italy
 W1655 Colorectal Surgical Specimen Lymph Node Harvest:
       Improvement of Lymph Node Yield with a Physicians
       Assistant
        Robert C. Moesinger, McKay-Dee Hospital Center, University of Utah School
        of Medicine, Ogden, UT
 W1656 Relevance of Comorbidity for Postoperative Lethality
       and Morbidity After Surgery for Perforated
       Diverticulitis of the Sigmoid Colon
        Mario H. Mueller, Maximilians-University, Munich, Germany
 W1657 Management and Treatment of Iliopsoas Abscess
        Parissa Tabrizian, The Mount Sinai Medical Center NY, New York, NY
 W1658 Comparison of GFAP Expression and Mucosal Mast Cell
       Numbers in Pediatric Intestinal Diseases
        Eumenia Castro, Children’s Hospital of Pittsburgh, Pittsburgh, PA

Clinical: Esophageal
 W1659 Outcomes of Laparoscopic Assisted Transhiatal
       Esophagectomy for Adenocarcinoma of Esophagus
        Martin I. Montenovo, University of Washington, Seattle, WA
 W1660 The Challenge of Diagnostic Assesment of a Failed
       Fundoplication: Benefits of High-Resolution
       Manometry of the GE-Junction
        Attila Dubecz, University of Rochester, Rochester, NY
 W1661 Looking Beyond Age and Comorbidities as Predictors
       of Outcomes in Paraesophageal Hernia Repair
        Anirban Gupta, Johns Hopkins University School of Medicine, Baltimore, MD
 W1662 No Additional Value of Bronchoscopy After EUS in the
       Preoperative Assessment of Patients with Esophageal
       Cancer at or Above the Carina
        Mark Van Heijl, Academic Medical Centre, Amsterdam, Netherlands



                                      90
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1663 Analysis of First-Time Antireflux Redo-Surgery Versus
       Multiple Redo-Surgery
        Karl H. Fuchs, Markus-Krankenhaus, Frankfurt, Germany
 W1664 A Meta-Analysis of Trials Comparing the Effectiveness
       of Use of Mesh in Laparoscopic Repair of
       Paraesophageal Hernias
        Anne O. Lidor, Johns Hopkins University School of Medicine, Baltimore, MD
 W1665 Prediction of Response to Neoadjuvant Therapy in
       Esophageal Carcinoma by PET-CT
        Kirsten Thurau, University of Münster, Münster, Germany
 W1666 Endolumenal Fundoplication with EsophyX™: The
       Initial North American Experience




                                                                                           SESSIONS
                                                                                            POSTER
        Simon Bergman, The Ohio State University Medical Center, Columbus, OH
 W1667 Analysis of Utilization and Outcome of Laparoscopic
       and Open Paraesophageal Hiatal Hernia Repair
        Marcelo W. Hinojosa, University of California, Irvine Medical Center, Orange, CA
 W1668 High Prevalence of Lymph Node Metastases in pT1
       Esophageal Cancer: Is Local Therapy Justified?
        Ines Gockel, Johannes Gutenberg-University, Mainz, Germany
 W1669 The Use of Alveolus Stents in the Treatment of
       Esophageal Leaks, Perforation or Fistulae
        Irfan Qureshi, University of Pittsburgh Medical center, Pittsburgh, PA

Clinical: Hepatic
 W1670 Treatment Strategy for Synchronous Metastases of
       Colorectal Cancer: Is Hepatic Resection After an
       Observation Interval Appropriate?
        Yasuhiro Shimizu, Aichi Cacer Center Hospital, Nagoya, Aichi, Japan
 W1671 Non-Operative Management of High Grade Liver Injuries
        Beat Schnüriger, Bern University Hospital, Switzerland, Bern, Switzerland
 W1672 Yttrium-90 Microsphere Induced Gastrointestinal
       Tract Ulceration
        Christopher D. South, The Ohio State University Medical Center, Columbus, OH
 W1673 Hepatic Neuroendocrine Metastases: Bland or
       Chemoembolization?
        Susan C. Pitt, University of Wisconsin, Indiana University, Madison, WI
 W1674 Laparoscopic Treatment of Nonparasitic Hepatic Cysts
        Orlando J. Torres, Federal University of Maranhão, São Luis, Maranhão, Brazil

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Clinical: Pancreas
 W1675 Human Telomerase Reverse Transcriptase (hTERT)
       Expression in Carcinogenesis of Serous Cystic
       Neoplasm of the Pancreas
        Akira Nakashima, Graduate School of Biomedical Sciences, Hiroshima
        University, Hiroshima, Japan
 W1676 Pulmonary Dysfunction Associated with Severe Acute
       Pancreatitis
        Hidehiro Sawa, Kobe University Graduate School of Medical Sciences,
        Nishi-Kobe Medical center, Kobe, Japan
 W1677 Incidence and Management of Chylous Leaks
       Following Pancreatic Resection: A High Volume
       Single-Center Institutional Experience
        Timothy M. Pawlik, Johns Hopkins Hospital, Baltimore, MD
 W1678 Clinical Significance and Natural History of
       Microinvasive Pancreatic Adenocarcinomas Associated
       with Resected Intraductal Papillary Mucinous
       Neoplasms: A Multi-Institutional Experience
        Eugeen P. Kennedy, Thomas Jefferson University, Philadelphia, PA
 W1680 Surgical Management of Failed Endoscopic Treatment
       of Pancreatic Disease
        Kimberly A. Evans, University of Florida, Gainesville, FL
 W1681 Is Distal Pancreatectomy (DP) Useful for Treatment of
       Cancer of the Body or Tail of the Pancreas?
        Jane S. Wey, University of Pittsburgh Medical Center, Pittsburgh, CA
 W1682 In-Hospital Mortality for Distal Pancreatectomy: A
       National Study
        Melissa M. Murphy, UMass Memorial, Worcester, MA
 W1683 Pancreatic Adenocarcinoma with Isolated Local
       Venous Invasion: Does Surgical Resection Confer a
       Survival Benefit?
        Michael Abramson, Brigham and Women’s Hospital, Brookline, MA
 W1684 Gemcitabine-Based Adjuvant Chemotherapy Following
       R1 Resection Still Improves Survival for Patients with
       Locally-Advanced Pancreatic Cancer
        Keita Wada, Teikyo University School of Medicine, Tokyo, Japan




                                      92
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1685 Intra-Operative Application of the Hand-Held
       Confocal Microscope: A Pilot Study
        Nam Q. Nguyen, Bankstown Hospital, Adelaide, SA, Australia
 W1686 Complications Following Pancreaticoduodenectomy
       Are Common but Do Not Impact Long-Term Survival
        Mary E. Dillhoff, Ohio State University, Columbus, OH
 W1687 A National Survey Regarding the Management of
       Acute Pancreatitis in Brazil
        Tercio De Campos, University of São Paulo, Santa Casa School of Medical
        Sciences, São Paulo, SP, Brazil
 W1688 The Striking Incidence of Venous Thromboembolism
       in Hospitalized Patients with Necrotizing Pancreatitis




                                                                                  SESSIONS
                                                                                   POSTER
        James Lopes, Indiana University, Indianapolis, IN
 W1689 Feasibility of Laparoscopic Partial Pancreatic Head
       Resection with Lateral Pancreaticojejunostomy
       (Frey Procedure) for Chronic Pancreatitis
        Jayleen M. Grams, Mayo Clinic, Rochester, MN
 W1690 Surgeon’s Contribution to Long Term Survival of
       Pancreatic Cancer
        Calogero Iacono, University of Verona Medical School, Verona, Italy

Clinical: Small Bowel
 W1691 Enteral Stenting: Management of Complications and
       Malfunctions in a Single Center Series of 46 Patients
        Melissa S. Phillips, University of Virginia, University of Virginia,
        Charlottesville, VA
 W1692 Primary Ileostomy Adenocarcinoma: Rare Condition
       After Proctocolectomy
        Rachel Forbes, Vanderbilt University, Nashville, TN
 W1693 Surgical Management of Acute Appendicitis: 50 Years
       of Progress
        William Scott Melvin, The Ohio State University, Columbus, OH




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    THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


Clinical: Stomach
 W1694 Distal Roux-en-Y Gastric Bypass for the Treatment of
       Morbid Obesity
        Jean-Marc Heinicke, Inselspital, Bern University Hospital and University of
        Bern, Bern, Switzerland
 W1695 Utilization of Pre-Operative Patient Factors to Predict
       Post-Operative Vitamin D Deficiency for Patients
       Undergoing Gastric Bypass
        Judy Jin, University Hospitals Case Medical Center, Cleveland, OH
 W1696 Primary Stenting for Malignant Gastric Outlet
       Obstruction with Self-Expanding Metal Stents (SEMS)
       in Cape Town, South Africa
        John M. Shaw, University of Cape Town and Groote Schuur Hospital, Cape
        Town, Western Cape, South Africa
 W1699 The Molecular and Clinical Significance of CD44
       Proteolytic Cleavage in Gastrointestinal Stromal
       Tumors
        Kai-Hsi Hsu, Tainan Hospital, Department of Health, Executive Yuan,
        ROC, Institute of Clinical Medicine, College of Medicine, National Cheng
        Kung University Medical Center, Tainan, Taiwan, Tainan, Taiwan
 W1700 Laparoscopic Ajustable Gastric Banding: 4-Year Follow Up
        Philipp Busch, University Medical Center Hamburg-Eppendorf,
        Hamburg, Germany
 W1701 Gastrojejunal (GJ) Leak After Laparoscopic Roux-en-Y
       Gastric Bypass (LRYGB) Carries Minimal Risk with an
       Aggressive Detection/Management Approach, Whereas
       Greater Morbidity/Mortality Occurs with Leak at the
       Jejunojejunostomy (JJ)
        Alexander Perez, Duke University Medical Center, Durham , NC
 W1702 Quantitative Analysis of Free Ubiquitin and Multi-
       Ubiquitin Chain in Precancerous and Cancerous
       Gastric Tissues
        Yoshio Ishibashi, Jikei University Shool of Medicine, Tokyo, Japan
 W1703 Surgical Outcomes of Patient with Gastrointestinal
       Stromal Tumors in the Era of Selective Drug Therapy
        Mehrdad Nikfarjam, Penn State, Milton S. Hershey Medical Center,
        Hershey, PA




                                      94
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Colon-Rectal
 W1827 Fluorophore-Conjugated Anti-CEA Antibody for
       Intraoperative Imaging of Pancreatic and Colorectal
       Cancer
        Michele McElroy, UCSD Medical Center, San Diego, CA
 W1828 Murine Colitis Is Inhibited in MMP-9 Knockout Mice:
       The Addition of IGFBP-3 Overexpression Does Not
       Further Decrease Disease Severity
        Raymond Baxter, Columbia University Medical Center, New York, NY
 W1829 Everolimus Impairs the Healing of Intestinal
       Anastomoses




                                                                                            SESSIONS
                                                                                             POSTER
        Markus A. Kueper, University of Tuebingen, Tübingen, Germany
 W1830 Polyphenon E, an EGCG Containing Green Tea Extract
       That Inhibits Tumor Growth, Has No Impact on Wound
       Collagen Content or Clinical Rate of Wound Infection
       or Dehiscence Yet Has a Mild Inhibitory Effect on
       Healing as Judged by Tensometry
        Aviad Hoffman, Columbia University, New York, NY

Basic: Esophageal
 W1831 Polymorphism Arg290Arg in Esophageal Cancer
       Related Gene 1 (ECRG1) Is a Prognostic Factor for
       Survival in Esophageal Cancer
        Kai Bachmann, University Medical Center Hamburg Eppendorf,
        Hamburg, Germany
 W1832 Barrett’s Intestinal Metaplasia mRNA Expression
       Profile in Formalin-Fixed, Paraffin-Embedded
       Endoscopic Biopsy Specimens
        Reginald V. N. Lord, UNSW, St. Vincents’ Hospital, Sydney, NSW, Australia
 W1833 KI-67 Antigen Is Overexpressed in Barrett’s
       Carcinogenesis
        Richard R. Gurski, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil




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Basic: Hepatic
 W1834 Enteral Immunonutrition with Long Chain Triglycerides
       Significantly Reduces the Recruitment of Immune
       Cells Into the Liver During Experimental Sepsis
        Maximilian Feilitzsch, University of Tuebingen, Tuebingen, Germany
 W1835 Association of Non-Alcoholic Steatohepatitis (NASH)
       and Inflammatory Mediators from Adipose Tissue
        Atul K. Madan, University of Miami, Miami, FL

Basic: Pancreas
 W1836 Reduction of Local Inflammatory Response on Acute
       Pancreatitis in Rats: Effects of a Hypertonic Saline
       Solution
        Ana Maria M. Coelho, University of São Paulo, São Paulo, Brazil
 W1837 Effects of Late Administration of Pentoxifylline in
       Experimental Severe Acute Pancreatitis
        José Jukemura, Faculdade de Medicina da Universidade de São Paulo,
        São Paulo, São Paulo, Brazil
 W1838 Development of Monoclonal Antibodies to Aid in the
       Diagnosis of Pancreatic Cancer
        Karin M. Hardiman, Oregon Health and Science University, Portland, OR
 W1839 Combination Therapy with Suberoyl Bis-Hydroxamic
       Acid (SBHA) and Lithium Chloride for Gastrointestinal
       Carcinoid Tumors
        Joel T. Adler, University of Wisconsin, Madison, WI
 W1840 Epithelial to Mesenchymal Transition in Pancreatic
       Cancer: Expression and Role of the Transcription
       Factors Snail, Slug, and Twist
        Hubert G. Hotz, Charite Medical School, Berlin, Germany
 W1841 A Model for Defining Molecular Aspects of Pancreatic
       Ductal Adenocarcinoma Patients for Targeted
       Adjuvant Therapy
        Shayna L. Showalter, Thomas Jefferson University, Philadelphia, PA




                                      96
    49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Small Bowel
 W1842 Small Bowel Engineering Using Small Intestinal
       Submucosa (SIS)
        Syde A. Taheri, University at Buffalo, Williamsville, NY
 W1843 Diurnal Regulation of Drug Transporters in the
       Small Bowel
        Adam T. Stearns, Brigham & Women’s Hospital and Harvard Mediacl
        School, Oxford University, Boston, MA
 W1844 Electrosurgical and Ultrasonic Devices: An Evaluation
       of Thermal Spread and Other Device Characteristics
        Charles J. Dolce, Carolinas Medical Center, Charlotte, NC




                                                                                     SESSIONS
                                                                                      POSTER
Basic: Stomach
 W1845 Epithelial Cell Turnover Is Increased in the Excluded
       Stomach Mucosa After Vertical Banded Roux-en-Y
       Gastric Bypass for Morbid Obesity
        Adriana V. Safatle-Ribeiro, University of São Paulo, São Paulo, SP, Brazil

COMBINED SCIENCE POSTERS

Combined Science
 W1993 Single Incision Laparoscopic Cholecystectomy Using
       Flexible Endoscopy: Saline Infiltration Gallbladder
       Fossa Dissection Technique
        John N. Afthinos, St. Luke’s-Roosevelt Hospital Center, New York, NY
 W1994 The Effect of Bariatric Surgery on Non-Alcoholic Fatty
       Liver Disease
        Mankanwal S. Sachdev, University of Tennessee, Memphis, TN
 W1995 Impact of Gastric Irrigation on NOTES Mesh
       Placement
        Lauren Buck, UTHSCSA, San Antonio, TX




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 SSAT PLENARY, VIDEO, AND
  QUICK SHOT ABSTRACTS
                      Printed as submitted by the authors.



Monday, May 19, 2008
8:15 AM – 9:15 AM            PRESIDENTIAL PLENARY A                        25ABC
                          (PLENARY SESSION I)
           Moderator:     Richard A. Prinz
                          Chicago, IL
   215     Stepwise Circumferential and Focal Radiofrequency
           Ablation of Barrett’s Esophagus with High-Grade
           Dysplasia or Intramucosal Cancer
Roos E. Pouw1, Joep J. Gondrie1, Frederike G. Van Vilsteren1, Carine Sondermeijer1,
Wilda Rosmolen1, Wouter L. Curvers1, Lorenza Alvarez Herrero4, Fiebo J. Ten Kate2,
Kausilia K. Krishnadath1, Thomas M. Van Gulik3, Paul Fockens1, Bas L. Weusten4,
Jacques J. Bergman*1
1Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands;
2Pathology, Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Academic
Medical Center, Amsterdam, Netherlands; 4Gastroenterology, St. Antonius Hospital,
Nieuwegein, Netherlands
BACKGROUND: Stepwise endoscopic circumferential and focal radiofre-
quency ablation (RFA) has been proven safe and effective for complete eradi-
cation of non-dysplastic Barrett’s esophagus (BE) in several trials. There is,
however, little information regarding RFA for treatment of BE with high-
grade dysplasia (HGD) or intramucosal carcinoma (IMC), and regarding the
role, timing, and extent of endoscopic resection (ER) as adjuvant to RFA.
AIM: Assess efficacy and safety of RFA for BE-HGD/IMC in pts ± prior ER.
METHODS: Enrolled pts had BE10 cm with HGD ± IMC. Any visible lesions
were endoscopically resected using the cap– or multiband mucosectomy
(MBM) technique. Exclusions: cancer >T1m3, N+ disease on EUS. Circumfer-
ential ablation (CA) was performed with a balloon-based catheter and focal
ablation (FA) with an endoscope-based catheter (HALO Systems). CA was per-
formed 6 wks after last ER (if applicable), followed by CA/FA every 2 mos
until BE was no longer evident on EGD. Thereafter, EGD with narrow band
imaging and biopsies were performed at 2, 6, 12 mos, then annually.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


RESULTS: 44 pts were included (35 M, median age 68 yrs, median Prague
C5M7). 35 ER sessions were performed in 31 pts (70%) prior to RFA. ER com-
plications: 4 bleeds, 1 perforation. Worst ER histology per pt: 16 IMC, 12
HGD, 3 LGD. Post-ER/pre-RFA worst histology: 32 HGD, 10 LGD, 2 IM. Com-
plete histological eradication of dysplasia and intestinal metaplasia (IM) was
achieved in 43 pts (98%) after 1 (1–2) CA and 2 (1–2) FA, and 1 additional
MBM in 3 pts. In one pt (2%) a 5-mm island with dysplasia persisted (proto-
col failure). In 3 pts a a non-transmural laceration (all asymptomatic) was
observed at the level of the prior ER after CA using an ablation catheter with a
relatively large diameter in relation to the esophageal diameter. Four pts
developed dysphagia that resolved with dilations; all of them had widespread
ER and/or a narrow esophagus at baseline. No stenoses or lacerations were
observed in patients whithout prior ER.After a median of 12 mos (IQR 5–17)
after last RFA, no dysplasia has recurred. In one patient, an endoscopically
evident 1-mm BE island was identified at 18 mos after RFA, located where a
12 mo biopsy revealed 1 focus of subsquamous IM (SSIM). Five pts had focal
IM detected immediately distal to the neo-squamocolumnar junction at a sin-
gle FU. In 1475 biopsies obtained from neosquamous epithelium only one
(0.07%) showed SSIM.
CONCLUSION: Stepwise CA and FA of BE-HGD/IMC with and without prior
ER is highly effective in achieving complete eradication of dysplasia and IM




                                                                                   ABSTRACTS
                                                                                    MONDAY
(98%) and compares favorably to alternatives such as esophagectomy, radical
ER or photodynamic therapy.




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    216      Long-Term Results of Transanal Excision After
             Neoadjuvant Chemoradiation for T2 and T3
             Adenocarcinomas of the Rectum
Rajesh Nair*1, Erin M. Siegel1, Timothy J. Yeatman1, Mokenge P. Malafa1,
Jorge Marcet2, David Shibata1
1Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute,
Tampa, FL; 2Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa,          FL
INTRODUCTION: Traditionally, selected early distal rectal cancers have
been considered for treatment by transanal excision (TAE) with acceptable
oncologic results. With the frequent use of neoadjuvant chemoradiation (NC)
for the treatment of locally advanced rectal cancer, there is growing interest
in the application of TAE for such lesions. We report our experience of TAE
for T2 and T3 rectal cancers following NC.
METHODS: Between July 1994 and August 2006, 44 patients were identified
as having undergone full thickness TAE of pretreatment ultrasound-staged T2
and T3 rectal cancers that were treated with NC. Patients with a clinical com-
plete response (CR) to preoperative treatment (n = 31) were offered TAE as an
alternative to standard radical resection. The remaining patients did not have
a clinical CR and were either deemed medically unfit for (n = 3) or refused
(n = 10) radical resection.
RESULTS: Our patient population consisted of 26 men and 18 women, with
a median age of 69 (range 43–89) and a median follow up of 64 months
(6–153). Of patients who had a clinical CR, 61% had a pathologic CR. Seven
(16%) patients sustained disease recurrence of which 2 were local only, 2 local
and systemic and 4 systemic only. Only 4 (9%) patients had died of disease at
current follow up. Overall 5-year survival by stage was as follows (Table 1):
100% (8/8) for T2N0 patients; 72% (13/18) for T3N0 patients; and 71% (5/7)
for T3N1 patients. Five patients underwent radical excision immediately fol-
lowing TAE for either positive margins or residual cancer. There was minimal
morbidity with no perioperative mortality associated with TAE.
CONCLUSIONS: TAE of T2 and T3 rectal cancers following NC is a safe alter-
native to radical resection in a highly select group of patients for which recur-
rence and survival rates comparable to radical resection can be achieved. This
study supports ongoing efforts to assess this approach in prospective, multi-
center trials.
Table 1. Patient Characteristics
Number of Patients                                   44
Pretreatment Tumor Diameter Mean (cm)                3.3 ± 0.98 cm
Distance from Anal Verge Mean (cm)                   5.2 ± 2.1 cm
Differentiation Well Moderate Poor Not specified     4 (9%) 35 (80%) 2 (4%) 3 (7%)
Pretreatment Stage T2N0 T3N0 T2/3N1 Unknown          10 (23%) 22 (50%) 11 (25%) 1 (2%)
Clinical Response Complete Partial None              31 (70%) 11 (25%) 2 (5%)
Pathologic Response Complete Partial None            25 (57%) 17 (39%) 2 (5%)
Overall Survival 3 year 5 year                       32/39 (82%) 26/34 (76%)
5 year Overall Survival by Stage T2N0 T3N0 T2/3N1    8/8 (100%) 13/18 (72%) 5/7 (71%)
Disease-Specific Survival 3 year 5 year              94% 91%


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   217      High Volume Surgery and Outcome After Liver
            Resection: Surgeon or Center?
Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah*
Surgery, University of Massachusetts, Worcester, MA
INTRODUCTION: Although center volume has been shown to be important
in improved outcomes after liver resection (LR), the relationship of surgeon
to center volume remains unclear. In a case controlled analysis, we attempted
to determine if volume (surgeon or center) truly affects survival in LR after
eliminating differences in background characteristics.
METHODS: We used the Nationwide Inpatient Sample (NIS) to identify all
LRs with available surgeon/hospital identifiers performed from 1998–2005.
High volume (HV) hospitals were defined as ≥20 LR/yr and HV surgeons per-
formed ≥10 LR/yr. Preoperative comorbidities were assessed with the Elix-
hauser index. Incorporating patient and hospital factors, we used propensity
scoring to adjust for background characteristics and create matched controls
of low volume (LV) and HV hospitals. A logistic regression for mortality was
then performed with these matched groups. To assess the relationship of sur-
geon and hospital volume, different combinations of HV and low volume
(LV) surgeons and hospitals were grouped and assessed separately.




                                                                                ABSTRACTS
                                                                                 MONDAY
RESULTS: 3032 LRs were performed in the 8-year period. Compared to LV
centers (n = 1504), patients treated at HV hospitals (n = 1528) were more
often white (75% vs. 70%) than black (7% vs. 12%), private insurance holders
(56% vs. 48%), elective admissions (93% vs. 78%) and high income residents
(42% vs. 34%) (p < 0.005). Unadjusted in-hospital mortality was significantly
lower in the HV group (6% vs. 3%, p <0.001). Propensity matching success-
fully eliminated differences in background characteristics between HV and LV
hospitals. Logistic regression found that factors that significantly decreased
risk of in-hospital mortality after LR were private insurance (OR 0.4, 95% CI
0.2–0.8) and elective admission type (OR 0.3, 95% CI 0.1–0.7); preoperative
comorbidity increased risk of death. Patients treated by HV surgeons or cen-
ters alone did not achieve a survival benefit after adjustment of patient and
hospital factors. Only LR performed by HV surgeons at HV centers was inde-
pendently associated with improved in-hospital mortality (OR 0.5, 95% CI
0.3–0.8).
CONCLUSIONS: Our results confirm that a socioeconomic bias (race, insur-
ance, income) may exist at HV centers. When these factors are accounted for
and adjusted, center volume does not appear to influence in-hospital mortal-
ity unless LR are performed by HV surgeons at HV centers.




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    218     Laparoscopic Vertical Sleeve Gastrectomy for Morbid
            Obesity: A Report of a Five-Year Experience with
            750 Patients
Crystine M. Lee, Paul T. Cirangle*, Gregg H. Jossart
Surgery, California Pacific Medical Center, San Francisco, CA
INTRODUCTION: The vertical sleeve gastrectomy (VSG) is a purely restric-
tive procedure that was first published in 2002 as the first stage of a two-stage
duodenal switch with the idea that it would reduce mortality due to a shorter
operative time and no anastomoses. It has also been performed as a single
stage alternative to gastric bypass and banding in lower BMI patients. This
abstract reports our 5 year experience with 750 patients.
METHODS: Laparoscopic VSG was performed in obese patients and com-
pared retrospectively to patients who underwent the Roux-en-Y gastric bypass
(RGB). A greater curvature gastrectomy was perfomed using linear GI staplers
along a 32 Fr bougie to create a 40–80 ml gastric tube. Staple-line reinforce-
ment with buttress material was used selectively.
RESULTS: Between Nov 2002 and Sep 2007, 750 patients underwent VSG
and 487 underwent RGB. The mean age in the VSG group was 43.1 years
(range 16–68) and 595 (79%) were female. The mean VSG preop weight was
286 ± 69 lbs (range 201–620) vs. 280 ± 47 lbs (range 190–477) in the RGB. The
mean VSG BMI was and 46 ± 9 kg/m2 (range 35–89) vs. 46 ± 6 kg/m2 (range
35–82) in the RGB. Of the 750 patients, 18 (2.4%) had a BMI of 70 + kg/m2,
50 (6.7%) had a BMI of 60–70 kg/m2, and 139 (18.5%) had a BMI of 50–60 kg/m2.
The mean OR time for VSG was 79 ± 26 mins (range 34–297) vs. 137 ± 37
mins (range 90–300) in the RGB. The mean VSG length of stay was 1.7 ± 1.1
days vs. 2.7 ± 1.4 days after RGB. Staple-line dehiscence (only in high risk
patients) occurred in 8 (1.0%) of VSG patients vs. 1 (0.2%) in RGB, strictures
in 1 (0.1%) VSG vs. 19 (3.9%) in RGB, and bowel obstruction in 1 (0.1%) VSG
vs. 12 (2.5%) in RGB. Ulcers occurred in 13 (2.7%) RGB and 0 VSG patients.
No conversions to open or deaths occurred in the VSG group. No complica-
tions in the VSG group occurred beyond one month after surgery.
CONCLUSIONS: Laparoscopic VSG demonstrates comparable weight loss to
the RGB after three years with 0% mortality. Long term morbidity is almost
nonexistent compared to the RGB.

            VSG Weight Loss (lbs)   VSG %EWL       RGB Weight Loss (lbs)   RGB %EWL
1 year           108 ± 39            69 ± 17%           113 ± 29            78 ± 14%
2 years          124 ± 58            67 ± 17%           110 ± 40            78 ± 28%
3 years          132 ± 64            59 ± 19%           103 ± 33            72 ± 19%




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


10:30 AM – 11:15 AM           PRESIDENTIAL PLENARY B                     25ABC
                           (PLENARY SESSION II)
           Moderator:      John C. Bowen, New Orleans, LA
   249     Role of Prophylactic Antibiotics in Laparoscopic
           Cholecystectomy: A Meta-Analysis
Abhishek Choudhary*, Matthew L. Bechtold, Craig Karpman, Srinivas R. Puli,
Mohamed O. Othman, Praveen K. Roy
Department of Internal Medicine, University of Missouri, Columbia, MO
BACKGROUND AND PURPOSE: The role of prophylactic antibiotics in
laparoscopic cholecystectomy in low risk patients is controversial. Several
randomized controlled trials (RCTs) have reported conflicting results. We con-
ducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in
low risk patients undergoing laparoscopic cholecystectomy.
METHODS: MEDLINE, Cochrane Central Register of Controlled Trials &
Database of Systematic Reviews, PubMed, and recent abstracts from major
conference proceedings were searched (through 10/07). RCTs comparing pro-
phylactic antibiotics to placebo or no treatment in the setting of low-risk lap-
aroscopic cholecystectomy were included. Standard forms were used to




                                                                                    ABSTRACTS
                                                                                     MONDAY
extract data by two independent reviewers. The effects of prophylactic antibi-
otics were analyzed by calculating pooled estimates of all infections (superfi-
cial wound infections, sub-hepatic fluid collections, and distant infections)
and length of hospital stay. Separate analyses were performed for each out-
come by using odds ratio (OR) or weighted mean difference (WMD). Both
random and fixed effect models were used. Publication bias was accessed by
funnel plot. All studies were graded by Jadad scores. Heterogeneity among
studies was assessed by calculating I2 measure of inconsistency.
RESULTS: Eight RCTs (N = 1,361) met the inclusion criteria. The antibiotics
used in the trials were: cefazolin (3 trials), cefotaxim (2 trials), cefotetan (1
trial), cefuroxime (1 trial), & cefotetan/cefazolin (1 trial). Antibiotics were
administered preoperatively in all studies. 3 trials used multiple doses; first
dose pre-operatively and other doses post-operatively. There was no signifi-
cant heterogeneity among the studies (I2 = 0%). Quality score ranged from
2–5. Prophylactic antibiotics did not decrease the odds of post-operative
infective complications (including superficial, deep and distant infections)
(OR 0.64, 95% CI: 0.31–1.30, p = 0.22), superficial wound infections (OR 0.74,
95% CI 0.30–1.82, p = 0.52), sub-hepatic fluid collections (OR 1.03, 95% CI:
0.21–5.13, p = 0.98), or distant infections (OR 0.50, 95% CI: 0.13–1.97,
p = 0.32). Prophylactic antibiotics also did not alter the length of hospital
stay (WMD 0.02, 95% CI –0.10–0.14, p = 0.77). Funnel plot did not reveal the
presence of publication bias. Pooling of data from high quality studies (Jadad
score > 3) also did not reveal a reduction in the odds for total infection (OR
0.75, 95% CI 0.35–1.63, p = 0.72).
CONCLUSIONS: Prophylactic antibiotics do not prevent infections in low
risk patients undergoing laparoscopic cholecystectomy.




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   250      Comparison of Surgically Resected Polypoid Lesions of
            the Gallbladder to Their Pre-Operative Ultrasound
            Characteristics
Martin D. Zielinski*1, Peyton W. Davis1, Florencia G. Que1, Michael L. Kendrick1,
Thomas D. Atwell2
                and General Surgery, Mayo Clinic, Rochester, MN; 2Radiology,
1Gastrointestinal
Mayo Clinic, Rochester, MN
BACKGROUND: Polypoid lesions of the gallbladder have been a common
finding on ultrasound examinations of the abdomen and are more prevalent
since our use of equipment incorporating pulse shaping, increased band-
width and better phase use for image reconstruction began in 1996. Our
study correlates the pre-operative ultrasonographic findings of these lesions
to the surgically resected specimen with specific regard to identifying neo-
plastic polyps.
METHODS: A retrospective review was performed of 137 patients who had a
pre-operative ultrasonographic diagnosis of a polypoid lesion of the gall-
bladder and subsequently underwent cholecystectomy between August 1996
and July 2007 at the Mayo Clinic Rochester.
RESULTS: 114 pseudopolyps (cholesterol polyps, inflammatory polyps and
adenomyomas) and 23 true polyps (83.2% and 16.8% respectively) were iden-
tified on histopathologic analysis. 30 polyps had suspicious ultrasonographic
characteristics for neoplastic changes. 26 were ≥10 mm, 3 had vascularity and
1 demonstrated invasion. Of these, there were 21 pseudopolyps, 2 benign
adenomas and 7 with neoplastic changes on final pathology (2 low grade dys-
plasia, 2 high grade dysplasia and 3 adenocarcinomas). 2 asymptomatic pol-
yps, sized 6 mm and 7 mm by ultrasound, were identified pre-operatively and
not regarded as suspicious but had neoplastic changes at pathology (one low
grade and one high grade dysplasia). 25 patients were followed with at least
two serial ultrasound examinations. Of these, 6 demonstrated polyp growth
of at least 3 mm. None of these specimens demonstrated neoplastic changes.
The positive predictive value and negative predictive value for ultrasound
diagnosing neoplasia based on current criteria was 23% and 98% respectively
with a false negative rate of 7%.
CONCLUSION: Histopathologic analysis of polypoid lesions of the gall-
bladder continues to be the gold standard to identify neoplasia. Ultrasound
has been used extensively in the pre-operative management of these lesions
but modern ultrasound techniques are unable to differentiate between
pseudopolyps and true polyps with any certainty. We identified 2 polyps with
neoplastic changes that were less than 10 mm. Therefore, we recommend
decreasing the current threshold for surgical resection to 5 mm while con-
tinuing to offer cholecystectomy for lesions that demonstrate vascularity,
show invasion or are symptomatic.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    251     The Incidental Asymptomatic Pancreatic Lesion:
            Nuisance or Threat?
Teviah E. Sachs*, Wande B. Pratt, Mark P. Callery, Charles M. Vollmer
General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
INTRODUCTION: Although asymptomatic pancreatic lesions (APLs) are
being discovered incidentally with increasing frequency, their true signifi-
cance remains obscure. Treatment decisions pivot off concerns for malig-
nancy, but at times might be excessive. To better understand the role of
surgery, we scrutinized a spectrum of APLs as they presented to our surgical
practice over defined periods.
METHODS: All incidentally identified APLs that were operated upon during
the past 5 years were clinically and pathologically annotated. Among features
evaluated were method/reason for detection, location, morphology, interven-
tions and pathology. For the past 2 years, since our adoption of the Sendai
guidelines for cystic lesions, we scrutinized our approach to all patients pre-
senting with APLs, operated upon or not.
RESULTS: Over 5 yrs, APLs were identified during evaluation of: GU/Renal
(14%), Asymptomatic rise in LFTs (13%), Screening/Surveillance (7%) and




                                                                                            ABSTRACTS
Chest Pain (6%). APLs occurred throughout the pancreas (body/tail—63%;




                                                                                             MONDAY
head/UP—37%) with 51% being solid. 110 operations were performed with
no operative mortality including 89 resections (Distal—57; Whipple—32) and
21 other procedures. During these 5 years, APLs accounted for 27% of all pan-
creatic resections we performed. In all, 21 different diagnoses emerged includ-
ing IPMN (19%), serous cystadenoma (13%), and neuroendocrine tumors
(13%), while 8% of pts had >1 distinct pathology and 12% had no actual pan-
creatic lesion at all. Invasive malignancy was present 17% of the time and
these pts were older (67.3 to 60.9 yrs; p < .05). Adenocarcinoma predomi-
nated (16%). An asymptomatic rise in LFTs correlated significantly (p < .01)
with malignancy. Seven pts ultimately opted for operation over continued
observation (mean 2.7 yrs), but none had cancer. In the last 2 years, we have
evaluated 132 new patients with APLs, representing 47% of total referrals for
pancreatic conditions. Nearly half were operated upon, with a 3:2 ratio of
solid to cystic lesions. This differs significantly (p < .05) from the previous 3
years (2:3 ratio), reflecting tolerance for cysts <3 cm and side-branch IPMN.
Surgery was undertaken more often for solid APLs (74%) than cysts (32%).
Some solid APLs were actually unresectable cancers. Due to anxiety, 2 pts
requested operation over continued observation, and neither had cancer.
CONCLUSIONS: APLs occur commonly, are often solid and reflect a spec-
trum of diagnoses. Sendai guidelines are not transferable to solid masses, but
have safely refined management of cysts. An asymptomatic rise in LFTs can-
not be overlooked, nor should a patient or doctor’s anxiety, given the preva-
lence of cancer in APLs.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


2:15 PM – 5:00 PM         PLENARY SESSION III                           24ABC
          Moderators:     Gerard V. Aranha, Maywood, IL
                          Donald E. Low, Seattle, WA
   338     Cervical Nodal Metastasis from Intrathoracic
           Esophageal Squamous Cell Carcinoma Is Not
           Necessarily an Incurable Disease
Daniel K. Tong*, Simon Law, Kam Ho Wong, John Wong
Department of Surgery, The University of Hong Kong, Hong Kong, China
BACKGROUND: It remains controversial whether metastatic cervical lymph
nodes in patients with intrathoracic esophageal cancer signify distant
metastases, and therefore incurable; or they should be regarded as regional
spread with still a potential for cure. The aim of this study is to review the
treatment results in this group of patients.
PATIENTS AND METHODS: Patients with intrathoracic esophageal squa-
mous cell carcinoma from 1995–2007 were included. Only those who had
cervical lymph node spread confirmed by fine needle aspiration cytology
were studied. Patients with cancers in the cervical esophagus or gastric cardia,
or histology other than that of squamous cell were excluded.
RESULTS: There were 115 patients who satisfied the inclusion criteria, of
whom 98 (89.9%) were men. The median age was 62 years (range: 34–88).
Treatment methods included: chemoradiation plus salvage surgery (n = 22
[20.2%]); chemoradiation (n = 51 [46.8%]); primary surgical resection (n = 4
[3.7%]); chemotherapy (n = 2 [1.8%]); radiotherapy (n = 7 [6.4%]); chemorad-
iation with bypass surgery (n = 2 [1.8%]); prosthetic intubation (n = 12
[11%]); and no intervention (n = 9 [8.2%]). The median survival of patients
with chemoradiation plus salvage surgery was significantly longer than those
with surgery alone (34.8 months vs 5.9 months; p = 0.029) or patients with
chemoradiation (34.8 months vs 8.9 months; p = 0.0003). There was no hos-
pital mortality in patients who had chemoradiation plus salvage surgery.
Twelve out of the 22 patients who had chemoradiation and resection were
downstaged from stage IV to stage 0–II.
CONCLUSIONS: Despite staged as stage IV disease; prognosis of patients
with metastatic cervical nodes was not uniformly poor. Up to 20% could
derive good survival after chemoradiation and surgical resection.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   339      The 3-Year Outcome of Optimal Medical or Surgical
            Management of GERD Patients with Barrett’s
            Esophagus: The Lotus Trial Experience
Stephen E. Attwood*1, Lars R. Lundell2, Jan G. Hatlebakk3, Stefan Eklund4, Ola
Junghard4, Jean Paul Galmiche5, Christian Ell6, Roberto Fiocca7, Tore Lind4
1North Tyneside Hospital, North Shields, United Kingdom; 2Karolinska University Hospital
Huddinge, Stockholm, Sweden; 3Haukeland Hospital, Bergen, Norway; 4AstraZeneca R&D,
Mölndal, Sweden; 5Hotel Dieu-CHU de Nantes, Nantes, France; 6Dr.-Horst-Schmidt-
Kliniken Wiesbaden, Wiesbaden, Germany; 7University of Genova, Genova, Italy
INTRODUCTION: The long-term management of gastroesophageal reflux
disease (GERD) in patients with Barrett’s esophagus (BE) is not well supported
by an evidence-based consensus. In patients with BE, standard doses of acid-
suppression therapy often result in incomplete reflux control, both symptom-
atically and as measured by pH monitoring. Similarly, the outcomes of anti-
reflux surgery reported in the literature have been poor. This analysis aimed
to compare the long-term outcome of optimal medical vs surgical anti-reflux
treatment in patients with BE (biopsy-proven intestinal metaplasia). A sec-
ondary aim was to identify if there were any differences in treatment out-




                                                                                           ABSTRACTS
come comparing patients with and without BE.




                                                                                            MONDAY
METHODS: In the LOTUS trial (a European multicenter randomized study;
ClinicalTrials.gov identifier: NCT00251927), standardized laparoscopic anti-
reflux surgery (LARS) was compared with dose-adjusted medical therapy,
starting with esomeprazole 20 mg od (ESO), and increasing if needed to
20 mg bd. Operative difficulty, complications, pre- and post-treatment symp-
toms (GSRS), time to treatment failure (i.e., need for alternative therapy), pre-
and post-treatment measurements of esophageal acid exposure (after 6
months) and endoscopic findings (at 3 years) are reported.
RESULTS: Out of 554 patients with chronic GERD, 60 patients had BE of
whom 28 were randomized to medical treatment and 32 to LARS. The
median acid exposure times before treatment were not significantly different
in patients with or without BE. Before surgical treatment, patients with BE
had acid with pH < 4 in their esophagus for 13.2% of the time, which reduced
to 0.4% 6 months after surgery. The corresponding figures for medically
treated patients were 7.4% and 4.9%. Operative difficulty was greater in
patients with BE (23% vs 13% in patients with no BE). This was based on a
longer operating time (30% >2 hrs vs 23% in non-BE), and larger hiatus her-
nias (37% >5 cm vs 15% in non-BE) requiring >3 crural sutures in 40% BE vs
28% non-BE. There was no apparent difference between the groups in post-
operative complications. The GSRS scores of patients were similar for the
medically and surgically treated groups, regardless of the presence or absence
of BE, both at baseline and at 3 years. Three BE patients in the medically
treated group and one in the surgically treated group were judged to be treat-
ment failures at 3 years.
CONCLUSION: There is a high degree of success at 3 years with optimal
medical or surgical anti-reflux therapy. In a well-controlled surgical environ-
ment, the success of LARS in patients with BE is greater than expected and
similar to that in patients without BE.

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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   340      Zenker’s Diverticula: Is a Tailored Approach Feasible?
Christian Rizzetto1, Mario Costantini*1, Raffaele Bottin2, Elena Finotti1,
Lisa Zanatta1, Martina Ceolin1, Loredana Nicoletti1, Giovanni Zaninotto1,
Ermanno Ancona1
1Clinica  Chirurgica 3, University of Padua, Padova, Italy; 2Medical and Surgical
Specialities, University of Padua, Padua, Italy
BACKGROUND: Zenker’s diverticula (ZD) can be treated by transoral diver-
ticulostomy or open surgery (upper esophageal sphincter myotomy and
diverticulectomy or diverticulopexy). The aim of this study was to compare
the effectiveness of minimally invasive (Group A) versus traditional open sur-
gical approach (Group B) in the treatment of ZD.
METHODS: Between 1993 and September 2007, 128 patients underwent
transoral stapling (n = 51) or cricopharyngeal myotomy and diverticulectomy
or diverticulopexy (n = 77). All patients were evaluated for symptoms with a
detailed questionnaire. Manometry recorded upper esophageal sphincter
(UES) pressure, relaxations and intrabolus pharyngeal pressure. The dimen-
sion of the pouch was based on the barium swallow. The choice of the treat-
ment was based on the operative risk, the size of the diverticulum and the
patients’ preference. Long-term follow-up data were available for 120/128
(94%) patients with a median follow-up of 40 months (IQR: 17–83).
RESULTS: Mortality was nil. Three patients (5.8%) in the group A and 10 in
the group B (13%) had postoperative complications (p = n.s.). Hospital stay
were markedly reduced in patients after diverticulostomy (p < 0.01). Postoper-
ative manometry showed a UES pressure reduction, improved UES relaxation,
and decreased intrabolus pressure in both groups (p < 0.05). Four patients in
the open surgical group (5.2%) complained of severe dysphagia after surgery
(3 of them required endoscopic dilations). In the transoral diverticulostomy
group, 11 patients (21.5%) required additional septal reduction (n = 8) or a
surgical myotomy (n = 3) for the persistence of symptoms (p < 0.01). All these
11 patients had a ZD smaller than 3 cm in dimension. After primary treat-
ment and complementary treatment, 93.5% and 96% of patients, respectively
for group A and group B, were symptom-free or significantly improved at
long term follow-up.
CONCLUSION: Diverticulostomy is safe, quick, and effective for most
patients with medium-sized ZD, but open surgery offers better long-term
results as primary treatment and should be recommended for younger,
healthy patients, especially with small diverticula. Small ZD may represent a
formal contraindication to the transoral approach because too short a septum
does not allow a complete division of the sphincter fibers.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   341      Quality of Life and Symptomatic Response to Gastric
            Neurostimulation for Gastroparesis
Vic Velanovich*
Surgery, Henry Ford Hospital, Detroit, MI
BACKGROUND: Gastroparesis can be a difficult problem with patients suf-
fering from symptoms intractable to medical management. Gastric neuro-
stimulation has been developed as a treatment for diabetic and idiopathic
gastroparesis for patients unresponsive to standard treatment. The purpose of
this study is to report symptomatic and quality of life response to gastric neu-
rostimulation.
METHODS: This study was IRB-approved. Candidates for placement were
patients with either idiopathic or diabetic gastroparesis who had symptom-
atic failure to standard dietary, prokinetic and antiemetic treatment. Prior to
placement, the patients’ symptoms were recorded, and patients completed
the Gastrointestinal Symptom Rating Scale (GSRS, three domains: dyspeptic
syndrome, indigestion syndrome, and bowel dysfunction syndrome) and the
SF-36 (eight domains: physical functioning, role-physical, role-emotional,
bodily pain, vitality, mental health, social functioning, general health, plus a
health transition item). The device (Enterra Therapy, Medtronic, Inc., Minne-




                                                                                   ABSTRACTS
                                                                                    MONDAY
apolis, MN)was surgical placed using a hybrid laparoscopic/open technique.
Patients were followed and adjustments made on the device until satisfactory
symptom control was achieved or no response determined. At that time,
patients completed both the GSRS and SF-36 and comparisons were made to
preoperative values.
RESULTS: 32 patients had the device placed, 23 females, mean age 42 + 14
yrs., with 20 diabetic patients and 12 idiopathic patients. 24 patients (75%)
responded to variable degrees. 8 patients had no response. Of the responders,
there were statistically significant improvements in all three domains of the
GSRS—median scores (with interquartile ranges): Dyspeptic syndrome, 9
(7–12) to 4 (2–6), p = 0.02; indigestion syndrome 5 (3–9) to 4 (0–4), p = 0.02;
bowel dysfunction syndrome 6 (3–8) to 3 (0–6), p = 0.05. In the SF-36, there
were statistically significant improvement in the health transition item, 4
(4–5) to 1.5 (1–3), p = 0.01; and social functioning domain, 25 (12.5–62.5) to
75 (50–87.5), p = 0.03. Of non-responders, there was no difference between
preoperative and postoperative scores.
CONCLUSIONS: Three-quarters of gastroparesis patients respond to gastric
neurostimulation to variable degrees. Gastrointestinal specific symptoms,
health transition and social functiong are improved in responders. These
results are encouraging considering that these patients had intractable symp-
toms with no other effective treatments available.




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    342     Results of the Surgical Treatment of Cardia Carcinoma
            (Ca) Characterized by Outcome and Perioperative
            Factors in a Prospective Observational Multicentre
            Study for Quality Control
Lutz Meyer*1, Olof Jannasch2, Frank Meyer2, Hans Lippert2, Ingo Gastinger3
1Surgery,HELIOS Vogtland Hospital Plauen, Plauen, Germany; 2Surgery, University
Hospital Magdeburg, Magdeburg, Germany; 3Surgery, Carl Thiem Hospital Cottbus,
Cottbus, Germany
INTRODUCTION: Cardia Ca is characterized by different features compared
with the remaining gastric Ca; its incidence in Western countries is increas-
ing. The aim of the study was to investigate diagnostic, therapeutic and out-
come measures of cardia Ca in daily surgical practice.
PATIENTS AND METHODS: All consecutive patients with cardia Ca out of
a pool of patients with histologically confirmed diagnosis of gastric Ca who
were treated in surgical departments were enrolled in this prospective obser-
vational multicenter study through a period of 12 months. Detailed patient,
diagnostic and treatment characteristics were recorded in a computer-based
format for analysis. Short-term outcome was characterized by hospital stay,
complication rate, morbidity and hospital mortality.
RESULTS: From 01/01–12/31/2002, 1,139 patients with gastric Ca from 80
surgical departments of each level of care were registered, out of them 198
subjects (17.4%) with cardia Ca. Tumor localization was classified in 186
patients according to Siewert: Type I, n = 44 (22.2%); Type II, n = 80 (40.4%);
Type III, n = 62 (31.3%). 172 patients underwent surgical intervention (opera-
tion rate, 86.9%) of whom 145 individuals underwent resection (rate, 84.3%).
A potentially curative resection could be offered to 111 patients (R0 resection
rate, 56.1% versus 82,3% in all gastric Ca). Fresh frozen section was only used
in 72 resections (rate, 49.7%). Of 142 standard resections (distal esophagec-
tomy with proximal or total gastrectomy), systematic D1, D2 and D3 lym-
phadenectomy was performed in 81.0%, 67.6% and 7.7%, resp. Histologic
investigation revealed UICC stage I/II in 39.5% of all operated patients; III/IV,
54%; not classified, 6.5%. Distant metastases occurred most frequently at the
peritoneal site (15.2%), liver (10.6%) and non-regional lymph nodes (7.1%).
Postoperative morbidity was 33.7%. Anastomotic leakage occured in 13
patients (9.1% versus 5.8% in total of all gastrectomies in gastric Ca) from
whom 8 subjects (5.6%) underwent surgical reintervention. Hospital mortal-
ity was 8.6% (n = 17) compared to 8.0% in all patients with gastric Ca.
CONCLUSION: More than 50% of patients diagnosed with cardia Ca show
an advanced tumor stage at the time of surgical intervention. Not all resec-
tions estimated as potentially curative were accompanied by D2 lym-
phadenectomy. In particular, to further improve R0 resection rate, to
consequently use intraoperative fresh frozen section for the detection of an
adequate tumor-free resection margin and to lower the rate of anastomotic
insufficiency, it is suggested to treat patients with cardia Ca at surgical centres
for optimal outcome (5-year survival rate is being under investigation).



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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   343      Probiotics Improve Weight Loss, GI-Related Quality
            of Life and H2 Breath Tests After Gastric Bypass
            Surgery: A Prospective Randomized Trial
Gavitt A. Woodard*, Joseph Peraza, John Downey, Betsy Encarnacion,
John M. Morton
Surgery, Stanford School of Medicine, Stanford, CA
INTRODUCTION: Roux-en-Y Gastric Bypass (RNYGB) surgery provides sig-
nificant improvement in weight loss, comorbidity resolution, and life span.
One potential complication after gastric bypass surgery is bacterial over-
growth which may affect the outcomes of gastro-intestinal motility, serology,
quality of life, and weight loss. Our study aim was to determine if probiotic
administration after surgery influenced these outcomes.
METHODS: 42 patients successfully underwent laparoscopic RNYGB and
were randomized into two groups. One group (PS) received 2.4 Billion Lacto-
bacillus daily post-operatively while the other group served as control sub-
jects (CS). The Gastro-Intestinal Related Quality of Life (GIRQoL) survey,
Hydrogen (H2) breath test (H2 Sleuth®) and weight were obtained pre- and
post-operatively at 3 months and 6 months. At baseline, patient demograph-




                                                                                    ABSTRACTS
ics for the two groups were similar including GIRQoL, H2 breath test, H.Pylori




                                                                                     MONDAY
status, age 43, 82% female, and average pre-op BMI 49 for both groups. Con-
tinuous and categorical variables were analyzed via T-test and Chi Square test
respectively with a p value of 0.05 set as significant.
RESULTS: At six months, the probiotic group had a smaller H2 peak (3.6 vs
6.8), lower fasting insulin (6.7 vs 7.5), Lipoprotein A (28 vs 41), Triglycerides
(99 vs 146), and higher HDL (46 vs 40) versus the control group. In addition,
the probiotic group had a statistically significant improvement in GIRQoL
versus the control group (115 vs 109, P < .05). Furthermore, a difference in
excess weight loss was noted, with the probiotic group losing 70 vs 66% for
controls.
CONCLUSION: In this novel prospective randomized trial, the use of probi-
otics after gastric bypass clearly reduces H2 breath test values, improves GI
quality of life and leads to increased weight loss.




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   344     Factors Related to Anastomotic Dehiscence and
           Mortality After Terminal Stomal Closure in the
           Management of Patients with Severe Secondary
           Peritonitis
Jose L. Martinez*, Pablo Andrade, Enrique Luque-De-Leon
Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI,
Mexico DF, Mexico
BACKGROUND: Management of severe secondary peritonitis (SSP) may
require intestinal resections and bowel exteriorization due to an unacceptable
high risk for anastomotic dehiscence (AD). Bowel exteriorization can be
achieved through loop or terminal stomas. There are no studies addressing
the fate of these latter.
AIM: To determine factors associated with AD and mortality in patients sub-
mitted to restoration of intestinal continuity after creation of terminal stomas
as part of their operative management for SSP.
MATERIAL AND METHODS: We analyzed prospectively collected data-
bases on all consecutive patients with SSP submitted to restoration of intesti-
nal continuity after having had terminal ileostomies (TI) or terminal
colostomies (TC) as part of their operative management during a 30 month
period. Several patient, disease and operative variables were evaluated as fac-
tors related to AD and mortality in this group of patients. Univariate statisti-
cal comparisons were made using Student’s T Test for continuous variables
and chi-square or Fischer’s exact test when categorical variables were com-
pared. Multivariate analyses were also performed.
RESULTS: A total of 72 male patients and 36 female patients were included
in the study; 54 had TI and 54 TC. Median number of operations performed
as part of their management for SSP (prior to stomal closure) were 2.5 (range,
1–15). A total of 76 (70%) had had generalized peritonitis and 33 (30%)
required management with an open abdomen (20 of them with a skin only
closure technique). Median time interval between stomal creation and clo-
sure was 190 days (range, 14–2192). Stapled and hand sewn anastomosis were
done in 23 and 85 patients, respectively. AD occurred in 11 patients
(10%).Univariate analyses disclosed management with an open abdomen
(p < 0.03) and lower preoperative hemoglobin values (p < .05) as risk factors
for AD. None prevailed after multivariate analyses. A total of 7 patients died
(6%). Factors associated with mortality were preoperative use of TPN (p < 0.03),
lower preoperative hemoglobin values (p < 0.05), time interval between
stomal creation and closure < 3 months (p < 0.01), AD (p < 0.01) and need for
reoperation after stomal closure (p < 0.02). After multivariate analyses, AD
and need for reoperation almost achieved statistical significance (p < 0.06);
time interval between stomal creation and closure < 3 months was the only
factor that prevailed as a risk for mortality.
CONCLUSIONS: Although several variables were related to AD and mortal-
ity, waiting longer than 3 months before attempting restoration of intestinal
continuity seems to be the best approach in this group of challenging
patients.


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    345     Predictors of Survival in 865 Patients with Acinar Cell
            Carcinoma of the Pancreas: Survival After Surgery
            Compared to Ductal Adenocarcinoma
C. Max Schmidt*1,4, Jesus M. Matos1, David J. Bentrem3, Mark S. Talamonti2,
Keith D. Lillemoe1, Karl Y. Bilimoria3
1Department    of Surgery, Indiana University School of Medicine, Indianapolis, IN;
2Department    of Surgery, Evanston Northwestern Healthcare, Evanston, IL; 3Department
of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 4Department
of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
BACKGROUND: Pancreatic acinar cell carcinoma (ACC) is a rare tumor with
poorly defined risk and prognostic factors. Our objective was to compare a large
population of ACC to pancreatic adenocarcinoma in order to assess factors pre-
dicting ACC, assess differences in survival, and identify prognostic factors.
METHODS: From the National Cancer Data Base (NCDB), patients with pancre-
atic ACC and adenocarcinoma were identified. Multiple logistic regression was
used to assess differences between ACC and adenocarcinoma. Median follow-up
in resected patients was 22 months. 5-year overall survival was estimated by
Kaplan-Meier method and compared using log-rank tests. Cox proportional haz-




                                                                                             ABSTRACTS
                                                                                              MONDAY
ards modeling was used to identify predictors of survival in resected patients.
RESULTS: 865 patients with ACC were identified (Stage I: 14.1%, II: 20.5%,
III: 11.6%, IV: 33.5%, unknown 20.2%). Median age at diagnosis was 67 yrs.
Tumors were located in the head of the pancreas 42.3%, body 7.6%, tail
19.8%, and diffuse/NOS 30.3%. Of the 333 who underwent resection, 62%
underwent surgery alone, 17% received chemotherapy, 7% received radia-
tion, and 26.8% underwent chemoradiation. Median tumor size was 6.9 cm
(vs. 4.6 cm for adenocarcinoma). 32.1% had nodal metastases (vs. 48.0% for
adenocarcinoma). 47% had high-grade tumors (vs.37.3% for adenocarci-
noma). Resection margins were R0 in 77.3%, R1 in 13.7%, and R2 in 9.0%.
Patients underwent resection at NCI centers 12.3%, other academic hospitals
34.2%, VA facilities 1.2%, and community hospitals 52.2%. Patients were
more likely to have ACC if male, white, larger tumor size, no nodal involve-
ment, or pancreatic tail tumors. Five-year survival in resected patients was sig-
nificantly better than in patients who did not undergo resection: 36.2% vs.
10.4%. Stage-specific survival was significantly better for resected ACC vs.
adenocarcinoma: I: 52.4% vs. 28.4%, II: 40.2% vs. 9.8%, III: 22.8% vs. 6.8%,
and IV: 17.2% vs. 2.8%. On univariate analysis, age <65 yrs, well-differenti-
ated tumors, R0 status, and adjuvant chemoradiation were associated with
better long-term survival. On multivariate analysis, age <65, well-differenti-
ated tumors, and negative margins (R0 vs. R1/R2) were the only independent
prognostic factors.
CONCLUSIONS: ACC accounts for ~1% of resected pancreatic cancers; how-
ever, it carries a considerably better prognosis than pancreatic adenocarci-
noma. Tumors are typically larger, but size is not associated with survival and
should not preclude resection. Thus, surgical resection with negative margins
and consideration of adjuvant therapy is the best chance for long-term sur-
vival in these favorable pancreatic cancers.


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   346      Preoperative Liver Function Tests and Hemoglobin
            Will Predict Complications Following
            Pancreaticoduodenectomy
Christopher D. Hughes*1, Karen Rychlik2, Margo Shoup1, Gerard V. Aranha1
1Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center,
Maywood, IL; 2The Cardinal Bernardin Cancer Center, Loyola University Medical
Center, Maywood, IL
BACKGROUND: Previous studies have identified an association between
dilated pancreatic and biliary ducts and lower rates of pancreatic leak after
pancreaticoduodenectomy (PD), but it remains unclear whether elevated liver
function tests (LFTs) are also associated with lower rates of complications. The
purpose of this study was to determine the predictive ability of preoperative
LFTs on morbidity following PD.
MATERIALS AND METHODS: We identified 452 patients who received PD
at Loyola University Medical Center from 1990–2007. Each patient received
standard PD with one of two anastomotic variants: pancreaticogastrostomy
(PG) or pancreaticojejeunostomy (PJ). A panel of preoperative serum lab val-
ues and postoperative complication data was collected for each patient, and
regression analyses were performed to identify predictors of postoperative
complications. Normal values were determined according to our institution’s
laboratory guidelines.
RESULTS: 452 patients were analyzed. Mean age at surgery was 65 years, and
56% of the patients were male. 64% of patients experienced no significant
postoperative complications. Among those patients who experienced compli-
cations, pancreatic leak was most commonly observed, with an incidence of
16%. There were no significant differences between PG and PJ with respect to
postoperative complications. Mortality within 30 days of PD was 2% for the
study population and was not significantly different between PG and PJ
groups. In a univariate analysis, patients with a low or normal preoperative
AST had a higher incidence of complications when compared to those
patients with an elevated AST (p = 0.03). Additionally, a higher proportion of
postoperative complications was demonstrated in those patients with a low
or normal alkaline phosphatase when compared to patients with elevated
preoperative levels (p = 0.03). Interestingly, preoperative hypoalbuminemia
was not significantly associated with increased rates of complications.
Multivariate analysis confirmed that an elevated alkaline phosphatase was
associated with a lower incidence of postoperative complications (OR = 0.56,
p = 0.02). Preoperative anemia (hemoglobin <14.0) was found to be an
independent predictor of postoperative complications following PD as well
(OR = 2.01, p = 0.02).
CONCLUSIONS: Patients who were anemic and those with normal LFTs were
significantly more likely to experience a complication after PD. This may rep-
resent extent of disease and tumors not causing biliary or pancreatic dilata-
tion, respectively. Precautions, such as intraoperative ductal stents, should be
considered when operating on this group of patients in order to minimize
complications.


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    347     Surgical Management of Early Hepatocellular
            Carcinoma: Resection or Transplantation?
Emily C. Bellavance*2, Steven Cunningham2, Kimberly M. Lumpkins2,
Warren R. Maley1, Cinthia Drachenberg3, Richard D. Schulick1,
Andrew M. Cameron1, Michael Choti1, Nader Hanna2, Benjamin Philosophe2,
Timothy M. Pawlik1
1Surgery,Johns Hopkins Hospital, Baltimore, MD; 2Surgery, University of Maryland,
Baltimore, MD; 3Pathology, University of Maryland, Baltimore, MD
INTRODUCTION: Although liver transplantation (LT) is the treatment of
choice for patients (pts) with hepatocellular carcinoma (HCC) and advanced
cirrhosis, the management of pts with early HCC within the Milan criteria
and well-compensated cirrhosis is controversial. The purpose of the current
study was to compare the outcome of pts with early HCC and compensated
cirrhosis who were treated with initial resection (RSX) vs LT.
METHODS: Between 1985 and 2007, 42 pts underwent hepatic RSX and 61
pts underwent LT for HCC within the Milan criteria. All pts had well-compen-
sated Childs A or B cirrhosis. Data on morbidity, recurrence, and long-term
survival were collected. Prognostic factors were evaluated using univariate




                                                                                    ABSTRACTS
                                                                                     MONDAY
and multivariate analyses; survival was calculated using the Kaplan-Meier
method.
RESULTS: RSX pts were younger than LT pts (mean age: 42 y vs. 61 y, respec-
tively; P = 0.01) but had the same gender distribution (male: 83% vs. 82%,
respectively; P = 0.54). There was no difference in the incidence of hepatitis
(RSX 64% vs. LT 82%; P = 0.07). The median number of hepatic lesions was 1
(range: 1 to 3) in both treatment groups (P = 0.10). However, tumors in the
resected group tended to be larger (mean size: RSX 3.2 cm vs. LT 2.7 cm;
P = 0.03). No pt in either group had preoperative evidence of major vascular
invasion. For pts who underwent RSX, surgery consisted of wedge resection
(n = 34, 80%), hemihepatectomy (n = 5, 12%) or extended hepatectomy (n
= 3, 7%). 6 (14%) pts had a positive margin. Of the LT patients, 5 (8%) under-
went living donor LT and 56 (92%) had orthotopic LT. On pathologic analy-
sis, there was no difference in the incidence of microscopic vascular invasion
(RSX 26% vs. LT 15%; P = 0.12) or tumor grade (P = 0.08). 30-day operative
mortality was similar (RSX 4.7% vs. LT, 6.5%; P = 0.83). Overall morbidity was
also the same (RSX 52% vs. LT 67%; P = 0.15), with most complications being
minor (Clavien grade 1–2) (RSX 31% vs. LT 39%; P = 0.83). The recurrence
rate was 38% following RSX and 20% following LT (P = 0.05). Pts who under-
went RSX had a similar 5-year survival rate (34%) compared with pts treated
with LT (47%) (P = 0.19). Survival remained comparable when stratified by
pre-MELD vs post-MELD era (both P > 0.05). Presence of microscopic vascular
invasion predicted worse long-term prognosis (HR = 5.35, P = 0.005).
CONCLUSION: In well-compensated pts with early-stage HCC, RSX and LT
have comparable morbidity, mortality, and long-term survival. Given current
limitations in organ availability, RSX should be considered as initial treat-
ment in select pts with HCC.



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   348     Increasing Regionalization of Hepatic Resection in
           Canada: 1995–2004
Ryan McColl*, Xiaoqing You, William A. Ghali, Elijah Dixon
Department of Surgery, Medicine, and Community Health Sciences, University of
Calgary, Calgary, AB, Canada
PURPOSE: Liver resection is the only curative therapy for hepatic malig-
nancy, both primary and secondary. Despite this, recent trends in the use and
outcomes of hepatic resection in Canada are unknown. This study sought to
describe patient characteristics and crude outcomes along with patterns of
regionalization for hepatic resection in Canada from 1995–2004.
METHODS: Discharge data from all hospitals across Canada except Quebec
were obtained from the Canadian Institute for Health Information for
1995–2004. All patients undergoing a hepatic resection were identified using
ICD 9 and 10 codes. Calculated mortality rates are based on in-hospital
deaths according to year and surgical indication. High-volume hospitals were
defined as those performing 10 or more procedures per year.
RESULTS: Over the study period, 9912 patients (mean age 59.10) underwent
hepatic resection at 247 hospitals. The national age- and sex-adjusted hepatic
resection rate per 100 000 people aged ≥18 years increased from 3.22 in 1995
to 5.86 in 2004. Patients who underwent resection in the years 1995–1999
had a significantly increased chance of mortality compared to those operated
on from 2000–2004 (odds ratio 1.43, 95% confidence interval 1.18–1.73).
Rates of hepatic resection for metastases increased by 29% and had outcomes
superior to that observed for primary malignancy (mortality rate 2.65% com-
pared to 6.01%, p < 0.0001). The proportion of procedures performed at high-
volume hospitals increased from 41.52% in 1995 to 83.53% in 2004.
CONCLUSIONS: The rate of hepatic resection in Canada has increased
dramatically, especially for metastatic disease. Over the same time period,
mortality rates have significantly improved. Our study also demonstrates
increasing regionalization likely due to growing evidence that high-volume
centers have superior outcomes for complex procedures.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


2:30 PM – 4:00 PM           VIDEO SESSION I: HPB SURGERY                          27B
          Moderators:       Rebecca M. Minter, Ann Arbor, MI
                            Randall S. Zuckerman, Cooperstown, NY
   349      The Lateral Laparoscopic Approach to Lesions in the
            Posterior Segments
Andrew A. Gumbs*1,2, Brice Gayet2
1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY;
2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris,
Paris, France
Although some authors believe that laparoscopy is contraindicated for the
posterior hepatic segments, we use a lateral approach for resections in these
segments. The hepatic inflow is approached with patients in a modified par-
tial left lateral with the surgeon between the legs. The hepatic outflow is then
controlled laterally if not done so retrohepatically. We have safely performed
this procedure in >25 patients with a 5% rate of major morbidity and 0%
mortality. Average margin is >10 mm for malignant lesions. Long-term results
are similar to our open patients. The Lateral Laparoscopic Approach to
hepatic lesions in the posterior segements of the liver are feasible and safe.




                                                                                          ABSTRACTS
                                                                                           MONDAY
   350      Small Diameter Prosthetic H-Graft Portacaval Shunt
            for Portal Decompression
Alexander S. Rosemurgy*, Harold Paul, Mark Shapiro, Desiree Villadolid,
Sam Al-Saadi, Sharona B. Ross, Sarah Cowgill
Surgery, University of South Florida and Tampa General Hospital, Tampa, FL
H-graft portacaval shunts reduce portal pressures and, thereby, discourage
variceal rehemorrhage and promote long-term survival. This video presents
our technique of small diameter prosthetic H-graft portacaval shunt.Only a
limited Kocher maneuver is necessary. The IVC and portal vein are exposed.
Ringed PTFE graft, 3 cm from toe-to-toe and 1.5 cm from heel-to-heel, is uti-
lized. Portal and caval pressures are measured before and after shunting. The
cava-graft anastomosis is completed first, followed by the portal vein-graft
anastomosis. Shunting should decrease the portal pressures >10 mmHg and
result in a gradient of <10 mmHg between the portal vein and IVC.




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    351     Functional Magnetic Resonance Imaging of Pancreatic
            Disease
Tara S. Kent*1, Ivan Pedrosa3, Sunil Sheth2, Alphonso Brown2, Mark P. Callery1,
Charles M. Vollmer1
1Surgery,Beth Israel Deaconess Medical Center, Boston, MA; 2Medicine, Beth Israel
Deaconess Medical Center, Boston, MA; 3Radiology, Beth Israel Deaconess Medical
Center, Boston, MA
MRCP serves as a useful diagnostic tool for many pancreatic diseases. Exogenous
secretin administration augments traditional MRCP, converting it to a functional
study (sMRCP) that better delineates ductal anatomy and pathology. This video
depicts the successful application of sMRCP in a pancreatic surgical practice. The
principles of sMRCP are explained and examples are provided of its utility in
diagnosing and managing difficult pancreatic conditions such as chronic pancre-
atitis, the disconnected pancreatic segment, pancreatic duct stenosis, pancreas
divisum, and anomalous pancreaticobiliary junction. This modality provides
added value in managing these challenging disease processes.

    352     Laparoscopic Extended Distal Pancreatectomy for
            Tumors of the Pancreatic Neck
Christos A. Galanopoulos*, D. Rohan Jeyarajah
HPB/Foregut Surgery, Methodist Dallas Medical Center, Dallas, TX
BACKGROUND: Laparoscopic distal pancreatectomy has been used for
tumors of the pancreatic body/tail. Tumors overlying or adjacent to the SMV/
PV junction have been traditionally resected using open surgery.
METHOD: 5 patients with tumors between 1–5 cm overlying/adjacent to the
SMV/PV confluence were laparoscopically resected by extending resection to
the right of the vessels.
RESULT: All had R0 resection and margins were to the right of the SMV/PV
confluence. Splenic vessels were ligated at their origin. Oncologic vascular
control was completed prior to pancreatic transection.
CONCLUSION: Tumors of the pancreatic neck can be laparoscopically
resected with no change in morbidity or mortality.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   353      Laparoscopic Approach in Patients with Gastrinoma
            Which Are the Limits?
Laureano Fernández-Cruz*
Surgery, Hospital Clínic, Barcelona, Spain
To present the limits of the laparoscopic approach in patients with gastri-
noma in 4 consecutive patients. The Laparoscopic Approach (Lap A) was suc-
cessful in one patient after tumor excision (1 cm) localized between the
duodenum and vena cava (primary lymph node gastrinoma) and in another
MEN-1 patient after spleen-preserving distal pancreatectomy. Conversion in 2
patients, one localized in the posterior duodenal wall, and in another with
lymph node metastasis. The Lap A was feasible and achieved cured in 50% of
gastrinomas. The association of lymph node metastasis or the localization in
difficult surgical areas, may limit its success.




                                                                               ABSTRACTS
                                                                                MONDAY




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Tuesday, May 20, 2008
7:30 AM – 10:00 AM         VIDEO SESSION II: BREAKFAST                      25ABC
                           AT THE MOVIES
            Moderators:    Craig P. Fischer, Houston, TX
                           Attila Nakeeb, Indianapolis, IN
   449      Combined Treatment of Esophageal Perforation: A
            New Approach
Bryan J. Sandler*, Michelle K. Savu, Garth R. Jacobsen, John Cullen,
Thomas J. Savides, Mark A. Talamini, Santiago Horgan
Department of Surgery, University of California, San Diego, San Diego, CA
Esophageal perforation can be difficult to manage. This demonstrates a novel
approach to this problem, using a combination of laparoscopic and endo-
scopic techniques to close and stent the perforation. The patient presented
following dilatation of an esophageal stricture. His post-operative recovery
was uneventful and he was discharged home without further intervention.
This result is an example of the close collaboration between surgery and gas-
troenterology as both fields move forward, developing minimally invasive
and endolumenal therapeutics.

   450      Dual Incision Adjustable Gastric Band Placement
Garth R. Jacobsen*, Bryan J. Sandler, John Cullen, Mark A. Talamini,
Adam Spivack, Santiago Horgan
Department of Surgery, University of California, San Diego, San Diego, CA
Laparoscopic operations require multiple incisions to achieve the angles nec-
essary to perform the operation. Wristed instruments allow for completion
from fewer access points. Two patients underwent AGB placement using a
two incision technique, under an IRB approved protocol. All ports were
placed through a 3 cm incision in the patient’s abdomen. A liver retractor was
placed in the epigastrium. Either a laparoscope or endoscope was used for
visualization. The operation was successfully completed in both patients in
under one hour. Flexible laparoscopic instruments can reduce the number of
incisions needed to perform AGB placement.




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   451      A Simplified Technique for Placement of Biologic Mesh
            in Paraesophageal Hernia Repair (PEH)
Tayyab S. Diwan*, Danny V. Martinec, Michael Ujiki, Christy M. Dunst,
Lee L. Swanstrom
Minimally Invasive Surgery, Legacy Health System, Portland, OR
The placement of mesh in the crural closure of PEH repairs has been shown to
decrease hernia recurrence rates. Synthetic mesh is easy to use but has a high
rate of esophageal erosion and therefore has been largely abandoned. Use of
biologic mesh decreases the risk of erosion and recurrence rates, but there is
currently no well described method for placement. We present a method
which requires no additional sutures or staples and achieves excellent contact
and reinforcement of the crural closure. Our method incorporates biological
mesh into the standard closure using pledgeted polyester sutures placed in a
horizontal mattress fashion. This technique has worked well in over 150 PEH
operations.

   452      Human NOTES Hybrid Transgastric Cholecystectomy
Edward Auyang*1, Khashayar Vaziri1, John A. Martin2, Eric S. Hungness1,
Nathaniel J. Soper1
1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology,
Northwestern University, Chicago, IL
Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a rapidly devel-
oping area of minimally invasive surgery that has the potential to improve




                                                                                          ABSTRACTS
post-operative outcomes by eliminating abdominal incisions. Hybrid tech-




                                                                                           TUESDAY
niques using mostly endoscopic and minimal laparoscopic instruments are
being performed in human patients. At Northwestern, we have successfully
performed two human NOTES hybrid transgastric cholecystectomies and this
video demonstrates the technique we have used to perform this procedure.

   453      Totally Laparoscopic Extended Right Hepatectomy
Andrew A. Gumbs*1,2, Brice Gayet2
1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY;
2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris,
Paris, France
This video will demonstrate the relevant technical maneuvers necessary to
perform a totally laparoscopic extended right hepatectomy. The five principal
steps of this procedure include: mobilization of the liver, control of hepatic
inflow, division of the hepatic parenchyma, control of the hepatic outflow
and removal of the specimen. A total of 4 totally laparoscopic extended right
hepatectomies have been successfully performed at our institution. Our short
and long-term results have been similar to our open historical controls. No
mortalities have been observed. The minimally invasive approach to hepatic
resections is limited by the comfort level of the operator and not the
technique.


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   454      Standardization of Laparoscopic Distal Pancreatic
            Resection (LapDPR) with Regional Lymphadenectomy
            in Malignant Pancreatic Neoplasms (MPN)
Laureano Fernández-Cruz*
Surgery, Hospital Clínic, Barcelona, Spain
Some surgeons have suggested that MPN are contraindicated to LapDPR
because of concerns for the radicality of resection and oncological outcomes.
Herein, described the LapDPR with and without splenectomy in patients with
suspected pancreatic malignancy. The LapDPR includes radical lymph node
dissection of the peripancreatic, portal, hepatic and superior mesenteric areas;
the Gerota fascia and fatty tissue on the adrenal gland are also removed.The
LapDPR achieved 90%. Ro resection in 15 patients with ductal adenocarci-
noma and 100% in 10 patients with neuroendocrine MPN.

   455      Laparoscopic Sigmoid Resection for Complicated
            Diverticulitis (Colovaginal Fistula)
Barry Salky*
Surgery, Mount Sinai Hospital, New York, NY
This video demonstrates the technical challanges that can occur in compli-
cated diverticulitis. This case has the small intestine walling off an abscess
from the sigmoid in conjunction with the sigmoid’s attachment to the back
wall of the bladder and the vagina. It demostrates a safe way to approach
these structures, and it demostrates a good way to avoid ureteral injury. A ten-
sion free anastomosis to the upper rectum is shown, along with sigmoidos-
copy to check the anastomosis.

   456      Laparoscopic Celiac Artery Decompression
Khashayar Vaziri*, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness
Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
Compression of the celiac artery by the diaphragmatic crura, the median arc-
uate ligament or fibrous periaortic ganglionic tissue results in a rare constella-
tion of symptoms known as celiac artery compression syndrome (CACS). First
described in 1963 by Harjola in a patient with symptoms of mesenteric
ischemia, it remains an elusive diagnosis. External compression of the celiac
artery leads to a wide variety of symptoms frequently resulting in multiple
diagnostic tests. A firm diagnosis is difficult to establish, and treatment is
equally challenging. We describe a laparoscopic approach to decompression
of the celiac artery facilitated by intraoperative ultrasound.




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   457     Pneumatosis Coli: Resection of the Splenic Flexure
           with Intracorporeal Anastomosis
Melina C. Vassiliou*1, Douglas S. Smink2, Gina L. Adrales1
1General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2General Surgery,
Brigham and Women’s Hospital, Boston, MA
Pneumatosis coli is a clinical problem that infrequently requires surgical
treatment. This video describes laparoscopic resection of the splenic flexure
in a patient with symptomatic pneumatosis coli limited to this area. The deci-
sion to perform an intracorporeal anastomosis was based on body habitus
and location of the diseased segment. Intracorporeal anastomosis requires
less mobilization, limits the size of the extraction incision, and provides more
flexibility when selecting the incision site. This video presentation briefly
demonstrates mobilization of the left colon and splenic flexure and the
creation of a side to side anastomosis entirely intracorporeally.




                                                                                       ABSTRACTS
                                                                                        TUESDAY




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10:00 AM – 11:15 AM BASIC SCIENCE PLENARY                                   25ABC
                     (PLENARY SESSION IV)
         Moderators: David Shibata, Tampa, FL
                     Sharon M. Weber, Madison, WI
   557     Epigenetic Regulation of WnT Signaling Pathway
           Genes in Inflammatory Bowel Disease (IBD) Neoplasia
Mashaal Dhir*1, Elizabeth A. Montgomery2, Kornel Schuebel3, Susan L. Gearhart1,
Nita Ahuja1,3
1Surgery, Johns Hopkins University, Baltimore, MD; 2Pathology, Johns Hopkins
University, Baltimore, MD; 3Oncology, Johns Hopkins University, Baltimore, MD
BACKGROUND: DNA methylation of promoter CpG islands in the Wnt sig-
naling pathway is an important event in the pathogenesis of Colorectal Can-
cer (CRC). We hypothesized that chronic inflammatory states, like IBD, may
lead to increased aberrant methylation and inactivation of Wnt genes which
in turn accelerate the development of cancer. This study examined the role of
epigenetic silencing of Wnt genes in the pathogenesis of IBD Neoplasia
(Dysplasia and Cancer).
METHODS: Paraffin embedded tissue samples were obtained from The Johns
Hopkins Hospital Pathology archive with IRB approval. We analyzed 11 Wnt
genes using methylation specific PCR including APC1A, APC2, dickkopf fam-
ily genes (DKK1, DKK2), soluble frizzled related proteins (sFRP1, sFRP2,
sFRP4, sFRP5), Wnt inhibitory factor-1 (WIF-1), Delta like3 (DLL3) and a
serine threonine kinase, LKB1. Methylation analysis was performed in 41 IBD
samples (6 IBD cancers, 2 High grade dysplasia [HGD], 8 Low grade dysplasias
[LGD] and 25 IBD colitis) from 20 IBD patients (Median disease duration = 12
years), 27 normal colons (NCs) and 24 sporadic CRCs (Stage 1–3).
RESULTS: There was no significant difference in the overall frequency of
methylation of Wnt signaling pathway genes in sporadic CRC and IBD cancers
(52% vs. 61%; p = 0.42). However, a progressive increase in the percentage of
methylated genes from NCs (3.7%) to IBD Colitis (39.7%) to IBD Neoplasia
(63.39%) was seen (NC vs. IBD Colitis p < 0.001, IBD Colitis vs. IBD associated
Neoplasia p = 0.016). More importantly, a distinct increase in methylation of
APC1A and APC2 was seen during progression to IBD Neoplasia (Figure 1).
Multivariate logistic regression analysis showed that methylation of APC1a
and APC2 were predictive of IBD Neoplasia as compared to IBD colitis (OR
APC1a:6.2, 95% CI: 1.1–36.3; OR APC2:8.5, 95% CI: 1.2–59.0).




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           Figure 1. Progressive increase in methylation frequency of
                     APC1A & APC2 during IBD Neoplasia


CONCLUSIONS: The frequency of methylation of the Wnt signaling path-
way genes increases progressively during development of IBD Neoplasia.
Moreover, the findings of early methylation of APC1A and APC2 in IBD asso-
ciated dysplasia may provide a method for early detection of IBD associated
carcinoma.




                                                                              ABSTRACTS
                                                                               TUESDAY




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    558     Sodium-Coupled Transport of Butyrate by SLC5A8
            Mediates Tumor Suppression in the Colon
Gail Cresci*1,2, Muthusamy Thangaraju2, Darren Browning2, Vadivel Ganapathy2
1Surgery,Medical College of Georgia, Augusta, GA; 2Biochemistry and Molecular
Biology, Medical College of Georgia, Augusta, GA
INTRODUCTION: Short-chain fatty acids (SCFA), generated in the colon by
bacterial fermentation of dietary fiber, protect against colorectal cancer.
Among the SCFAs, butyrate is believed to be most relevant to colonic health.
Butyrate induces differentiation of colonocytes and promotes apoptosis in
colonic tumor cells. The ability of butyrate to induce apoptosis in tumor cells
is related to its function as an inhibitor of histone deacetylases (HDACs). To
do this, butyrate must enter the colonocyte. SLC5A8 is a Na+-coupled trans-
porter for SCFA expressed predominantly in the colon. SLC5A8 has been
shown to be silenced in colon cancer and re-expression of the transporter in
colon cancer cell lines leads to apoptosis. However the underlying mecha-
nism of tumor suppression is unknown.
HYPOTHESIS: SLC5A8-mediated concentrative entry of butyrate into colon
cancer cells is responsible for tumor cell-specific induction of apoptosis.
METHODS: Expression of SLC5A8 was compared in paired samples of
human tumor and normal colon tissue, colon tissue from ApcMin/+ mice, a
model for intestinal/colon cancer, and wild type mice, and several colon can-
cer and normal colon cell lines. Mature oocytes from X.laevis, injected with
human SLC5A8 cRNA, were used for electrophysiological studies to character-
ize SLC5A8-mediated butyrate transport. The Na+-activation kinetics of
butyrate-induced currents was analyzed by measuring the butyrate-specific
currents with increasing amounts of Na+. Normal and colon cancer cell lines
transfected with pcDNA or SLC5A8 cDNA and treated with or without
butyrate were used to evaluate apoptosis, HDAC activity, and expression of
pro- and anti-apoptotic genes.
RESULTS: SLC5A8 transports butyrate via a Na+-dependent electrogenic pro-
cess. Na+-activation of the transport process exhibits sigmoidal kinetics, indi-
cating involvement of more than 1 Na+ in the activation process. SLC5A8 is
silenced in colon cancer in humans, in a mouse model of colon cancer, and
in colon cancer cell lines. The tumor-associated silencing of SLC5A8 involves
DNA methylation by DNA methyltransferase 1. Re-expression of SLC5A8 in
colon cancer cells leads to apoptosis, but only in the presence of butyrate.
SLC5A8-mediated entry of butyrate into cancer cells is associated with inhibi-
tion of histone deacetylation. Changes in gene expression in SLC5A8/butyrate-
induced apoptosis include upregulation of pro-apoptotic genes and downreg-
ulation of anti-apoptotic genes. Also, expression of phosphatidylinositol-3-
kinase subunits is affected differentially.
CONCLUSION: These studies show that SLC5A8 mediates the tumor-sup-
pressive effects of the SCFA butyrate in the colon.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    559     Applying Proteomics Based Biomarker Tools for the
            Accurate Diagnosis of Pancreatic Cancer
John D. Christein*1, Kyoko Kojima2, Senait G. Asmellash3, Christopher A. Klug2,
James A. Mobley1
1Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Microbiology,
University of Alabama at Birmingham, Birmingham, AL; 3Biochemistry and Molecular
Genetics, University of Alabama at Birmingham, Birmingham, AL
BACKGROUND: Clinical proteomics is the study of proteins and the physio-
logic state of an individual. The human proteome or biologic signature con-
tains biomarkers associated with varying diseases. There is no biomarker set
specific to pancreatic cancer and only a few proteomic studies have
attempted to differentiate patients with pancreatic cancer from those without
disease.
AIMS: To evaluate the biologic fluid proteome of patients with and without
pancreatic disease. For the first time, to accurately differentiate patients with
pancreatic cancer based on proteome analysis by mass spectrometry.
METHODS: From 2003–2007, 245 patients underwent prospective serum,
plasma, and urine collection. Endoscopic ultrasound and/or surgical pathol-
ogy were used to distinguish normal (N) patients from cancer (CA) or chronic
pancreatitis (CP). A reproducible high throughput (HTP) method using a high
affinity solid core lipophilic extraction resin enriched the low molecular
weight protein fraction of a sample. Proteome analysis coupled the extraction
with a high speed 200 Hz matrix-assisted laser desorption/ionization-time of
flight (MALDI-ToF/ToF) mass spectrometer (Bruker Ultraflex III). Poor quality




                                                                                   ABSTRACTS
                                                                                    TUESDAY
samples and outliers were excluded from the sample set. Samples from N, CA,
and CP groups underwent software processing with FlexAnalysis, Clinprot,
MatLab, and Statistica to align and normalize spectra. Statistical non-
parametric pairwise analysis, multidimensional scaling (MDS), hiearcical
analysis, and leave one out cross validation (LOOCV) using a k-means based
approach completed the comparison.
RESULTS: Fifty usable serum samples (15 N 24 CA, 11 CP) underwent pro-
teomic based analysis. Sensitivity (sn) and specificity (sp) of group compari-
sons were determined. Using 6 serum features, we accurately differentiated
CA from N (sn 88.9%, sp 93.8%), CA from CP (sn 88.9%, sp 61.1%), and N
from both CA and CP when combined (sn 88.9%, sp 76.4%). When com-
bined with 14 features from urine spectra, CA was differentiated from N and
CP with a sensitivity approaching 94%. Interestingly, the plasma samples
(considered by the Human Proteome Organization to be the preferred biolog-
ical fluid) did not show significant differences between patient groups.
CONCLUSION: Human biologic fluids can successfully be used to differenti-
ate patients with pancreatic cancer from those without disease or chronic
pancreatitis. Proteomic analysis of human serum and urine can provide a
high level of predictability for diagnosing pancreatic cancer. The proteomic
analysis of biologic fluids may be able to be used to screen individuals for
pancreatic cancer or differentiate benign from malignant disease.



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    560     A Neurokinin-1 Receptor Antagonist (NK1RA)
            That Reduces Intraabdominal Adhesions Augments
            the Anti-Adhesive Effects of a Hyaluronic Acid/
            Carboxymethylcellulose (HA/CMC) Adhesion Barrier
            in Rats
Rizal Lim*1, Jonathan M. Morrill1,2, Karen L. Reed1,2, Adam C. Gower1,
Bilaal McCloud1, Susan E. Leeman2,1, Arthur F. Stucchi1,2, James M. Becker1
1Surgery,Boston University Medical Center, Boston, MA; 2Pharmacology, Boston
University Medical Center, Boston, MA
INTRODUCTION: Intraabdominal adhesions can be a significant cause of
postoperative morbidity. Previous work from this laboratory has shown that
an NK1RA significantly reduces adhesion formation in a rat model. HA/CMC
(Seprafilm Adhesion Barrier® Genzyme), proven to reduce the incidence of
adhesions in patients undergoing laparotomy, may have its efficacy limited to
the location of the film, typically under the midline incision. The purpose of
this study was to evaluate the anti-adhesion efficacy of the NK1RA (CJ-
12,255; Pfizer) when administered in combination with HA/CMC in a rat
model of adhesion formation.
METHODS: Adhesions were created via a midline laparotomy by placing 3
ischemic buttons, 1 cm apart on each side of the peritoneum. Rats received
no treatment (n = 6), NK1RA (25 mg/kg) (n = 5), HA/CMC and saline (n = 12),
or HA/CMC and NK1RA (25 mg/kg) (n = 12) administered intraperitoneally at
the time of surgery. HA/CMC was applied unilaterally over half the ischemic
buttons and the NK1RA was administered in a 1ml saline lavage. The rats
were sacrificed at 7 days and adhesions scored as percent of buttons with
formed adhesions. To evaluate peritoneal fibrinolytic activity, ischemic but-
tons were created as above and randomized to receive NK1RA alone (n = 6),
bilateral HA/CMC and saline lavage (n = 6), or bilateral HA/CMC and NK1RA
lavage (n = 6). Animals were sacrificed at 24 hours, and peritoneal tissue and
fluid collected for tissue plasminogen activator (tPA) activity assay, a measure
of fibrinolytic activity.
RESULTS: Rats treated with NK1RA had significantly fewer adhesions com-
pared with controls (80 ± 8% vs. 20 ± 4%; p < 0.05). HA/CMC also signifi-
cantly decreased adhesions from 75 ± 8.3% to 44 ± 10.3% (p < 0.05); however,
adhesion reduction was limited to buttons over which HA/CMC was placed.
The combination of the NK1RA and HA/CMC increased the efficacy of HA/
CMC, further reducing adhesions to 11 ± 4.7%, a 75% reduction compared to
HA/CMC alone (p < 0.05). In these same animals the adhesions were reduced
by 45% on the non- HA/CMC side (p < 0.05). Administration of the NK1RA
alone increased peritoneal tPA activity more than 137% compared with HA/
CMC alone (26.7 ± 3.5 vs. 11.2 ± 2.2 U/ml, p < 0.05); however, this increase
was attenuated when NK1RA was administered in the presence of HA/CMC
(14.6 ± 3.5 U/ml, p < 0.05 compared with NK1RA alone).
CONCLUSIONS: The efficacy of HA/CMC was significantly augmented by
the addition of an NK1RA suggesting that further research is warranted to
develop a biodegradable, barrier-based delivery system for more effective pre-
vention of adhesions.

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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   561     Differential Ileal Adaptation After Massive Proximal-
           Based Small Bowel Resection: Importance of the
           GLUT2 Hexose Transporter
Michael G. Sarr, Corey W. Iqbal*, Javairiah Fatima, Molly E. Gross
Department of Surgery, Mayo Clinic, Rochester, MN
INTRODUCTION: SGLT1 and GLUT2 are the predominant glucose trans-
porters in rat intestine but are present in low quantities in the ileum where
very little glucose absorption occurs normally; however, glucose uptake in the
ileum is highly adaptable after small bowel resection.
HYPOTHESIS: Ileal adaptability for glucose absorption after jejunal resec-
tion is mediated predominately by an increase in GLUT2.
METHODS: Lewis rats (250–300 g) underwent massive (70%) proximal-based
jejunoileal resection (starting at the duodenojejunal junction). Transporter-
mediated glucose uptake was measured in the proximal and distal aspects of
the remnant ileum at 1 and 4 wk postoperatively (n = 6 each) in 20 mM
D-glucose using the everted sleeve technique. Corresponding segments of
ileum in naïve control and 1-wk sham laparotomy rats (n = 6 each) were also
studied. Selective inhibitors of hexose transporters were then evaluated. Phlo-
rizin (0.2 M) was used to inhibit SGLT1-mediated glucose uptake and indi-
rectly any uptake by GLUT2 by inhibiting GLUT2 trafficking to the apical
membrane (Iqbal et al., Gastroenterology 2007; 132(4): A-891); phloretin
(1 M) was used to inhibit GLUT2-mediated glucose uptake. Villous height of
the proximal ileum was measured to assess for ileal adaptation.
RESULTS: There was essentially no transporter-mediated glucose uptake in




                                                                                  ABSTRACTS
                                                                                   TUESDAY
control or sham rat ileum. After massive 70% proximal intestinal resection,
the proximal aspect of the remnant ileum had markedly greater glucose
uptake at 4 wk compared to controls and shams (80 vs 0 nmol/cm/min,
p < 0.0001). In the terminal ileum, there was little increase in uptake (9 vs 0
nmol/cm/min, p = 0.17). Treatment with phlorizin (SGLT1 inhibition and
indirect GLUT2 inhibition) led to complete inhibition of transporter-
mediated glucose uptake in resected rats in both proximal and terminal
ileum. Phloretin (GLUT2 inhibition) also inhibited completely transporter-
mediated glucose uptake 4 wk after resection in both proximal (0 vs 80 nmol/
cm/min, p < 0.0001) and terminal ileum (0 vs 9 nmol/cm/min, p = 0.17);
there was partial inhibition in the proximal ileum for the 1-wk resection
group (1.4 vs 11 nmol/cm/min, p = 0.05). Histology of proximal ileum at 4
wk demonstrated markedly greater villous height compared to controls (500
vs 200 µm, p = 0.0001).
CONCLUSIONS: Terminal ileum is not as adaptable as proximal ileum after
proximal small intestinal resection. Complete inhibition of glucose uptake at
4 wk with either phlorizin or phloretin suggests that GLUT2 is the primary
glucose transporter in the adapted ileum. (Support: NIH DK39337 [MGS]).




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10:00 AM – 11:15 AM QUICK SHOTS I                                                    27B
         Moderators: Jonathan F. Critchlow, Boston, MA
                     Julie A. Stein, Royal Oak, MI
    562     Perioperative Allogenic Blood Transfusions Significantly
            Affect Survival Following Transthoracic En Bloc
            Resection for Esophageal Cancer
Daniel Vallbohmer*1, Frederike C. Ling1, Daniel Schmidt1, Roland Grunenberg2,
Birgit S. Gathof2, Elfriede Bollschweiler1, Arnulf H. Hoelscher1, Paul M. Schneider1,3
1Department of Surgery, University of Cologne, Cologne, Germany; 2Institute of Transfusion
Medicine, University of Cologne, Cologne, Germany; 3Department of Visceral and
Transplantation Surgery, University of Zurich, Zurich, Switzerland
BACKGROUND: Recent studies suggest that the number of transfused allo-
genic blood in the surgical therapy of gastrointestinal tumors significantly
correlates with survival. The aim of this study was to evaluate the prognostic
influence of allogenic blood transfusions following resection for esophageal
cancer.
METHODS: A retrospective analysis (1997–2006) was performed including
305 patients (median age 59.8 years) with esophageal cancers who underwent
transthoracic en bloc esophagectomy and 2-field lymphadenectomy. Squa-
mous cell cancer was found in 46.9% and adenocarcinoma in 50.5% (2.6%
rare histologies). Neoadjuvant chemoradiation was performed in 159 (52%)
patients. Number of perioperative blood transfusions were determined and
the potential prognostic cut-off for transfused units was calculated according
to LeBlanc.
RESULTS: The median number of perioperative blood transfusions was 2
(range 0–53). 107 patients (35.2%) received no transfusions. One hundred-
eighteen patients were treated before and 187 patients after the legally
mandatory introduction of leukocyte-depleted blood. Patients with ≤1 blood
transfusion showed a significant survival benefit compared to patients receiv-
ing >1 unit (p < 0.02). Multivariate analysis in R0 resected tumors demon-
strated that in addition to the pTNM categories (pT: p < 0.002, pN: p < 0001,
pM: p < 0.02), perioperative blood transfusions (≤1 versus >1) were an inde-
pendent prognostic factor (p < 0.05). There was no difference in survival for
patients getting none versus one unit or more and there was no detectable
influence of leucocyte-depleted versus non-depleted units (p = 0.28).
CONCLUSIONS: The number of perioperative allogenic blood transfusions
appear to be an independent factor for survival after R0 resections by tran-
sthoracic en bloc esophagectomy for esophageal cancer. The prognostic influ-
ence of leucocyte-depleted blood deserves further evaluation due to a shorter
observation time and the observation that there was no difference between
patients getting none or one unit of blood in our retrospective analysis.




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    563     A New Biomechanical Device to Augment Lower
            Esophageal Sphincter (LES) Continence in Patients
            with Gastroesophageal Reflux Disease (GERD)—Initial
            Results of a Pilot Clinical Trial
Luigi Bonavina*1, Greta Saino1, Davide Bona1, Tom R. Demeester2, John C. Lipham2,
Robert A. Ganz3, Daniel H. Dunn3
1Department of Surgery, University of Milano, IRCCS Policlinico San Donato, Milano, Italy;
2University of Southern California, Los Angeles, CA; 3Abbott Northwestern Hospital,
Minneapolis, MN
BACKGROUND: The high prevalence of GERD and the growing public
awareness of the related malignant complications continue to generate new,
minimally invasive treatments for this disease. Recently, a biomechanical
device (Torax Medical, Inc. Minneapolis, MN) designed to augment LES
strength has been developed and tested in animal models. The Magnetic
Esophageal Sphincter (MES) deploys magnetic attraction forces, in a circular
fashion, to precisely augment the LES. The forces can attenuate to accommo-
date swallow and belch functions. A multi-center pilot clinical study was
designed to develop a minimal dissection technique for laparoscopic implan-
tation of the device and to assess the clinical and functional outcome of the
procedure.
METHODS: The study was approved by the Ministry of Health and the local
Ethical Committee. Patients with typical reflux symptoms responding to PPI,
abnormal esophageal acid exposure, <3 cm sliding hiatal hernia, and normal
esophageal peristalsis were enrolled in the study. All patients had the MES




                                                                                             ABSTRACTS
device placed laparoscopically around the esophagus at the GE junction. A




                                                                                              TUESDAY
sizing tool was used to determine the outer circumference of the esophagus
and the size of device to be used. The surgical approach involved partial dis-
section of the phreno-esophageal ligament and exclusion of the posterior
vagus nerve. The fundus and short gastric arteries were left intact in all
patients. After the procedure, position and function of the device were evalu-
ated with barium esophagram. Upper endoscopy and 24-hour esophageal pH
monitoring were planned at 3 months postoperatively.
RESULTS: In our center, since March 13, 2007, 19 patients underwent lap-
aroscopic MES device implantation. Operative time ranged from 24 to 84
minutes. No operative complications were recorded. A free diet was allowed
after radiological assessment of esophageal transit on post-operative day 1,
and patients were discharged within 48 hours. No migrations nor erosions of
the device occurred. All patients stopped using proton pump inhibitors and
other antireflux medications. 6/6 patients were found to have complete nor-
malization of 24-hour pH at 3 months after operation.
CONCLUSIONS: Laparoscopic implantation of the MES is safe and requires a
minimal surgical dissection compared to the conventional Nissen fundoplica-
tion. Control of reflux symptoms and complete normalization of pH occurred
in all tested patients. Further follow-up of these patients is eagerly awaited.




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   564      Long-Term Outcome After 92 Duodenum-Preserving
            Pancreatic Head Resections for Chronic Pancreatitis:
            Comparison of FREY- and BEGER-Procedures
Tobias Keck*1, Ulrich Adam2,1, Hartwig Riediger1,2, Ulrich T. Hopt1, Frank Makowiec1
1Department  of Surgery, University of Freiburg, Freiburg, Germany; 2Department of
Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany
INTRODUCTION: Duodenum-preserving pancreatic head resections
(DPPHR) in the techniques described by FREY or BEGER may be an alterna-
tive to pancreaticoduodenectomy (PD) or drainage procedures for chronic
pancreatitis (CP) predominantly of the pancreatic head. Data comparing the
outcomes after both operations are rare. We, therefore, analyzed our long-
term results after DPPHR in 92 patients.
METHODS: Since 1995 113 patients underwent DPPHR for CP predomi-
nantly of the pancreatic head. The decision to perform either a FREY- or a
BEGER procedure was always made individually depending upon the compli-
cations and morphological classification of CP. Up to now prospective out-
come results including standardized questionnaires could be obtained in 92
patients with a median postoperative follow-up of 43 months. Of those 92
patients (82% male, median age 44 years) 77% had alcoholic CP. The leading
indications for surgery were pain (87%), recurrent attacks of CP (90%), jaun-
dice (22%) or symptomatic duodenal stenosis (10%).
RESULTS: Any/surgery related postoperative complications occurred in
31%/20% after FREY-procedures and in 41%/30% after BEGER-procedures
(n.s.). In median 43 months after surgery 62% (FREY) and 50% (BEGER) of
the patients were completely free of pain, respectively. In the collection of
patients still or again suffering from pain (FREY vs. BEGER) 6%/19% had pain
at least once per week or daily and the remaining 32%/31% experienced pain
attacks at least once per year (difference for pain frequency p = 0.55). Diabetes
was documented in 57% (BEGER) and 60% (FREY; n.s.). During postoperative
follow-up a de-novo diabetes occured in 17% after BEGER- and in 34% after
FREY-procedures (p = 0.06). The frequencies of an exocrine insufficiency (74%
vs. 76%, p = 0.8) and a postoperative de-novo exocrine insufficiency (33% vs.
34%; p = 0.9) were identical. The median gain in body weight until the last
follow-up was not significantly different (three kg after BEGER vs. two kg after
FREY). Two patients in each group had relevant biliary complications (steno-
sis or symptomatic duct stones) during follow-up requiring re-intervention.
Actuarial five-year survival after DPPHR was 96% and clearly higher than sur-
vival in the 110 patients who underwent PD for CP at our institution (five-
year survival 82%).
CONCLUSIONS: Comparison of the outcomes after either a FREY- or a
BEGER-procedure for CP reveals a tendency for better pain control after the
FREY-operation. The functional outcomes (organ function, biliary) were
almost identical. Surprisingly, late mortality after DPPHR was clearly lower
than reported in other series and in the patients undergoing PD for CP at our
institution.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   565      Is Liver Resection Justified in Advanced Hepatocellular
            Carcinoma? Results of an Observational Study in
            464 Patients
Andrea Ruzzenente*1, Franco Capra2, Calogero Iacono1, Gianluca Piccirillo1,
Marta Lunardi2, Stefano Pistoso3, Alessandro Valdegamberi1, Alfredo Guglielmi1
1Department   of Surgery and Gastroenterology, University of Verona Medical School,
Verona, Italy; 2Department of Internal Medicine, University of Verona Medical School,
Verona, Italy; 3Department of Internal Medicine, Desenzano Hospital, Desenzano, Italy
BACKGROUND AND OBJECTIVE: The role of liver resection of multinod-
ular hepatocellular carcinoma (HCC) or with major vascular involvement is
still controversial. The aim of this study is to evaluate the role of surgical
resection compared to other therapeutic modalities in patients with advanced
HCC.
METHODS: 464 patients with HCC observed from 1991 to 2007 were
included into the study. All the patients were evaluated for treatment of HCC
in relation to the severity of liver impairment and tumor stage. All the
patients included into the study had no evidence of distant metastases.
RESULTS: Median follow up time for surviving patients was 25 months
(range 1–155). 260 patients were in Child-Pugh class A, 148 in class B and 18
in class C. 260 patients had sigle HCC, 79 patients had two HCCs, 37 three
HCCs and 69 more than three HCCs. 136 (29.2%) patients were submitted to
liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol
injection, radiofrequency ablation, chemoembolization), 8 (1.7%) to liver
transplantation (LT) and 88 (19.0%) to supportive therapy (ST) Median sur-




                                                                                        ABSTRACTS
                                                                                         TUESDAY
vival time for all patients was 30.4 months (95% CI 24–36). Median survival
time was 57 months for LR, 30 for LAT and 8 for ST, with a 5 year survival of
47%, 20%, and 2.5% respectively (p = 0.001). 5-year survival for patients sub-
mitted to LT was 75%. Overall survival was significantly shorter in patients
with multiple HCCs compared to single HCC with a median survival time of
39, 36, 18 and 11 months for patients with single HCC, with 2 HCCs, with 3
HCCs and with more than 3 HCCs respectively (p = 0.001). Survival for
patients with single HCC was significatly longer in patients submitted to LR
compare to LAT and ST with a median survival time of 57, 37, and 14 months
respectively (p = 0.001). Also in patients with multinodular HCCs (2–3 HCCs)
LR showed the best results with a a median survival time of 59 months com-
pared to 22 and 8 months for LAT and ST (p = 0.001). In patients with more
than 3 HCCs LR did not showed different results compared to LAT and ST. 66
patients had evidence of major vascular involvement, median survival in this
subgroup of patients was significantly shorter compared to patients without
vascular involvement, 19 and 52 months respectively. Survival for patients
with major vascular involvement submitted to LR or LAT was significant
longer compared to ST with a mean survival of 27, 30 and 12 respectively
(p = 0.001).
CONCLUSIONS: The present study shows that multinodular HCCs (2–3 nod-
ules) can benefit from LR compared to LAT or ST. In patients with more than
3 HCCs or with major vascular involvement LR have similar results of LAT.


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     566       An Improved Method of Assessing Esophageal
               Emptying Using the Timed Barium Study Following
               Surgical Myotomy for Achalasia
Arzu Oezcelik*1, Jeffrey A. Hagen1, James M. Halls2, Jessica M. Leers1, Emmanuele
Abate1, Shahin Ayazi1, John C. Lipham1, Farzaneh Banki1, Steven R. Demeester1,
Tom R. Demeester1
1Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA;
2Department of Radiology, Keck School of Medicine, University of Southern California,
Los Angeles, CA
INTRODUCTION: The timed barium study is a test used to quantitatively
assess esophageal emptying in patients with achalasia by measuring the per-
cent difference in area of the barium column on films obtained 1 and 5 min-
utes after ingesting 150 ml of barium. Improvement in emptying on the
timed barium study has been documented after endoscopic therapy. After sur-
gical myotomy, the improvement in esophageal emptying reported has been
variable. Many patients following myotomy who have little change in empty-
ing as traditionally measured have improved clearance of the barium before
the 1 minute film is taken. The aim of this study was to evaluate a new
method for assessing improvement in esophageal emptying after therapy in
patients with achalasia.
METHODS: A standard timed barium study was performed before and 3–6
months after a myotomy for achalasia in 30 patients. Esophageal emptying
was assessed by comparing the area of the residual barium column on digital
images obtained 1 and 5 minutes after ingestion of 150 ml of barium.
Improvement in emptying was determined by comparing the results before
and after therapy. We also assessed improvement after therapy by comparing
the area of the barium column on the 1 minute images obtained before and
after therapy, which we defined as initial esophageal clearance. Both mea-
sures of improvement were compared to clinical outcome.
RESULTS: On clinical follow up, 21 (70%) patients had no symptoms, 4 (13%)
had minimal symptoms, and 5 (17%) had moderate/severe symptoms. When
calculated using the traditional method, esophageal emptying before and after
surgery were not significantly different (25% vs. 37%; p > 0.05) and did not cor-
relate with clinical outcome. However, when improvement in emptying was
assessed by comparing clearance, the median improvement comparing the 1
minute films before and after therapy was 81%. Improvement in clearance corre-
lated significantly with clinical outcome (Table). All patients with esophageal
clearance less than 40% had moderate or severe symptoms.
CONCLUSION: Esophageal emptying measured by the timed barium study
calculated by the traditional method is not useful to assess outcome after sur-
gical myotomy. We have described a new method for calculating esophageal
clearance that correlates well with clinical outcome after surgical therapy.
                                                      Minimal       Moderate/Severe   Kruskal-Wallis
                                  No Symptoms
                                                    Symptoms          Symptoms           p-value
  Traditional Method (Ratio of     0.7 (0.2–1.6)    0.4 (0.2–2.7)     0.9 (0.6–1.8)      p = 0.78
      pre- vs. post-therapy)
  Initial Esophageal Clearance     89 (77–98)        89 (77–98)        44 (28–48)       p < 0.0002
     (Percent improvement)
Value are shown as median (IQR)
                                                   134
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   567      Manometric Profile After Laparoscopic Nissen
            Fundoplication and Endoluminal Fundoplication:
            A Comparative Study in Animals
Silvana Perretta*, Bernard Dallemagne, Jacques Marescaux
Digestive and Endocrine Surgery, IRCAD-EITS University of Strasbourg France,
Strasbourg, France
INTRODUCTION: Laparoscopic Nissen Fundoplication (LNF) is considered
the gold standard of surgical treatment of GERD. An emerging endoscopic
technology, the EsophyX (EsophyX™, EndoGastric Solutions Inc.) Endo
Luminal Fundoplication (ELF), aims at reproducing the effect of the fundopli-
cation by creating an intragastric valve with fasteners applied at the Gastro-
Esophageal Junction (GEJ). Both techniques increase resting pressure and
length of the Lower Esophageal Sphincter (LES). This study aims to compare
the short term manometric profile of ELF with 8 fasteners to LNF.
MATERIALS AND METHODS: Twelve 40-kg pigs were randomized to
either ELF or LNF. Under general aesthesia, the LES resting pressure (mm Hg)
and length (cm), were manometrically assessed before (T0), immediately after
(T2) and 1 and 4 weeks after each procedure (ELF and LNF). In the ELF group
manometry was carried out midway through as well, after the placement of 4
corner fasteners (T1). Solid state manometric catheters with 4 sensors were
used. Endoscopies were performed to assess the anatomy and location of the
GEJ before and after fundoplication.
RESULTS: The 2 groups were comparable according to preoperative manom-
etry and endoscopy. Median operative time was 45 minutes (range, 40–50) for




                                                                                 ABSTRACTS
ELF and 30 min (range, 25–35) for LNF. LES mean increase in resting pressure




                                                                                  TUESDAY
(9.22 for ELF vs 10.6 mmHg for LNF) and length (2 cm for both ELF and LNF;
range, 1–3 cm) improved similarly and significantly (p < 0.05) in both groups
with no significant difference in the measured parameters between the two
techniques at any of the given time points. In the ELF group the main
increase in LES resting pressure was achieved at T1 (p 0.02) with no signifi-
cant raise between T1 and T2. The postoperative manometric profile in both
groups was unchanged and similar 1 and 4 weeks postoperatively. Notably,
the significant increase in LES resting pressure was preserved (p < 0.05). The
endoscopic aspect of ELF and LNF was comparable 1 and 4 weeks postoperatively.
CONCLUSIONS: This study demonstrated an immediate and short term
physiological effect of ELF comparable to that achieved with the gold stan-
dard LNF, providing a similar increase in LES resting pressure and length. The
position of the fasteners is an important factor of efficacy of the ELF.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   568      Immunologic Ignorance and Tolerance Both Play a
            Role in Hepatic Tumorigenesis
Diego Avella*, Luis J. Garcia, Serene Shereef, Hephzibah Tagaram, Yixing Jiang,
Mehrdad Nikfarjam, Niraj J. Gusani, Eric Kimchi, Kevin Staveley-O’Carroll
Surgery, Penn State, Hershey, PA
INTRODUCTION: Current literature suggests that immunologic tolerance
plays a major role in allowing hepatic tumor growth. However, the immune
system is dynamic and its response to tumor antigens may very well be differ-
ent at various stages of tumor growth. We have developed a reliable model of
spontaneous HCC in which tumor progression can be accurately followed
with MRI even at very small sizes. Using this model, we evaluated tumor spe-
cific immune responses at different stages of tumor growth.
METHODS: C57BL/6 mice were inoculated with syngeneic HCC cells
expressing Tag of the SV40 virus via splenic injections (ISPL). Tumor growth
was evaluated with contrast enhanced magnetic resonance imaging (MRI)
after ISPL. Basal immune responses were evaluated at 9, 14, 21, 28, 42, and 56
days after ISPL. Animals were vaccinated with WT-19 (cell line expressing Tag)
at three time points 14, 28, and 56 days after ISPL. Tetramer analysis was used
to quantify Tag-specific CD8+ T cell proliferation and T-cell function was
assessed through Tag-specific γ-interferon production. Autopsies were per-
formed for macroscopic evaluation of tumor. Immunohistochemistry (IHC)
was used to confirm Tag expression in the tumor foci.
RESULTS: All animals injected ISPL developed HCC. These tumors were first
detectable by 28 days after injection with MRI. MRI performed at 14 days did
not reveal evidence of tumor foci. At 28 days, MRI demonstrated small tumor
foci, <1 mm. At 56 days, MRI demonstrated tumor foci, 7–10 mm in size. At
all time points there was no basal tumor specific CD8+ T cell proliferation or
activation. At 14 and 28 days after injection there was a robust tumor specific
CD8+ T cell proliferation and activation after vaccination. At 56 days after
injection there was no tumor specific CD8+ T cell proliferation or activation
after vaccination. Necropsies confirmed findings of MRI examinations. IHC
showed T ag expression in tumor foci.
CONCLUSION: Otherwise immunogenic tumor cells when delivered to the
liver will grow. When this occurs, T cells are present and remain capable of
producing a robust immune response when presented with the same tumor
antigen. This response however, is not evident in animals with larger tumors.
These results suggest that immunological ignorance is responsible for allow-
ing tumor growth during early stages of tumorigenesis. Immunological toler-
ance appears to be important when tumors grow to a certain size. The exact
size of tumor and mechanism responsible for this phenomenon is yet to be
fully characterized.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   569      Downregulation of AdiponectinAdipor2 Is Associated
            with Hepatic Inflammation and Steatosis in Obese
            Mice
Yanhua Peng2,3, Drew A. Rideout*1,2, Steven S. Rakita1,2, Mini Sajan2,3,
Robert Farese2,3, Min You3, Michel M. Murr1,2
1Department of Surgery, University of South Florida, Tampa, FL; 2Department of Surgery
and Research, James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department
of Molecular Medicine, University of South Florida, Tampa, FL
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a common
manifestation of obesity and is linked to the metabolic syndrome through a
complex interplay of hepatic glucose and lipid metabolism. Adiponectin reg-
ulates fat storage, lipid oxidation, energy expenditure and inflammation. We
propose that high fat diet reduces adiponectin and induces steatosis and
hepatic inflammation.
METHODS: 4 week-old C57BL mice were fed high fat diet (n = 8) or regular
chow (control; n = 6) for 7 weeks to induce obesity. Body weight, liver weight
and serum adiponectin were measured. Liver sections were stained with H&E
and Oil Red for fat content. Liver homogenates were used to measure protein
(immunoblotting) and mRNA (RT-PCR) of TLR4, TNF–α, SREBP-1, Adiponec-
tin receptors (AdipoR1 and AdipoR2) in addition to nuclear phorsphorylated
p65NF-κB. Gels were quantified using densitometry; t-test was used, p < 0.05
was significant.
RESULTS: High fat diet increased body and liver weight by 50% and 33%,
respectively. Serum adiponectin decreased in mice fed a high fat diet (2,500 ± 20




                                                                                         ABSTRACTS
                                                                                          TUESDAY
vs. 6,500 ± 30; p < 0.001 vs. control). In liver sections, high fat diet increased
fat content in hepatocytes (10,280 ± 120 vs. 1,542 ± 12 fat droplets; p < 0.001,
vs. control) and hepatocyte ballooning (8,900 ± 50 vs. 1,523 ± 23 cells;
p < 0.001 vs. control). Liver AdipoR2 decreased with high fat diet (protein:
1,308 ± 10 vs. 3,045 ± 18; mRNA: 1,981 ± 15 vs. 4,738 ± 20; all p < 0.001 vs.
control); however, AdipoR1 was not changed. High fat diet increased hepatic
levels of TLR4, TNF–α and SREBP-1 protein (TLR4: 4,678 ± 35 vs. 2,675 ± 15;
TNF–α: 4,429 ± 35 vs. 2,390 ± 25, SREBP1: 4,543 ± 37 vs. 2,574 ± 26, all p <
0.001 vs. control) and mRNA (TLR4: 6,789 ± 35 vs. 3,458 ± 29; TNF–α: 3,200 ±
24 vs. 1,301 ± 25; SREBP1: 3,456 ± 23 vs. 1,528 ± 10; all p < 0.001 vs. control).
Additionally, high fat diet increased activation of phorsphorylated p65NF-κB
(5,438 ± 30 vs. 2,560 ± 21; p < 0.01 vs. control).
CONCLUSIONS: High fat diet induces obesity, increases body and liver
weight as well as hepatocyte fat content. Liver steatosis induced by high fat
diet is associated with upregulation of hepatic SREBP-1 that promotes
lipogenesis and fat storage. In addition, high fat diet is associated with upreg-
ulation of pro-inflammatory transcription factors and cytokines and down-
regulation of AdipoR2 that has anti-inflammatory properties. Moreover,
obesity-induced reduction in serum adiponectin suggests that adiponectin
signaling may be the crosslink between high fat diet, inflammation and
NAFLD.



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   570     Ischemic Colitis Following Endovascular Aortoiliac
           Aneurysm Repair: A 10-Year Retrospective Review
Aaron Miller*, Michael S. Marotta, Irini A. Scordi-Bello, Yolanda Tammaro,
Celia M. Divino
The Mount Sinai Hospital, New York, NY
INTRODUCTION: The use of endovascular stent grafts for repair of abdomi-
nal aortic aneurysms (AAA) has become increasingly popular since its initial
introduction in the early 1990’s. Endovascular stents are less invasive and can
be done under spinal anesthesia, thus, generally providing less risk to the
patient and quicker recovery times when compared with the traditional open
repair. A major complication after traditional open repair is ischemic colitis,
reported to be approximately 2–3 percent in the literature. The goal of this
study is to examine the incidence, cause and outcomes of ischemic colitis
after endovascular stent graft repair of aortoiliac aneurysms (EVAR).
METHODS: 809 total patients from 1996 to April 2007 who underwent
EVAR at the Mt. Sinai Hospital were included in the study. Preoperative data
regarding the size of the AAA, hypogastric coil embolization and inferior
mesenteric artery (IMA) patency were evaluated using CT scans and aorto-
grams. Patients with suspicion of colonic ischemia underwent a lower endos-
copy and/or surgical exploration. The diagnosis of ischemic colitis was made
via lower endoscopy reports or pathological examination of specimens.
RESULTS: Eleven patients total were found to have ischemic colitis (1.4%).
Seven patients’ episode occurred less than 30 days from repair (early) while
the other 4 occurred 30 days or later from repair (late). Three of the 4 patients
with late ischemic colitis had factors other then the EVAR to explain the
ischemia while this was not true for any of the 7 patients with early ischemic
colitis. Microembolization was seen histologically in 2 patients with both of
these patients undergoing bowel resections and ultimately expiring. The IMA
was occluded in 10 of 11 patients preoperatively and the one patient it was
patent had evidence of extensive microembolization. Six patients (3 early and
3 late) underwent preoperative unilateral hypogastric coil embolization and
there was a significant increase in ischemic colitis in these patients (p = 0.02).
CONCLUSION: The incidence of ischemic colitis is decreased in patients
undergoing EVAR versus traditional open repair. Ischemic colitis occurring
early is directly related to the surgery and is often multifactorial. When
microembolization is involved, the patients tend to have more extensive
ischemia with a higher incidence of bowel resection and mortality. Patients
with late ischemic colitis often have another co-morbidity to explain the
ischemia. The incidence of ischemic colitis is increased in patients with pre-
operative hypogastric coil embolization, and it seems to affect patients with
both early and late ischemia.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   571      Perianal Fistula Occurring After Ileal Pouch for
            Non-Crohn’s Colitis: A Word of Caution
Isabella Mor*, Bo Shen, Susan Shedda, Margaret O’Malley, Jeffery Hammel,
Feza H. Remzi
Colorectal Surgery A-30, Cleveland Clinic Foundation, Cleveland, OH
INTRODUCTION: A perianal fistula occurring after proctocolectomy and
ileal pouch-anal anastomosis (IPAA) for ulcerative (UC) or indeterminate coli-
tis (IC) may herald a change in diagnosis to Crohn’s disease (CD). However
evidence for this association is limited. The aim of this study is to assess how
often a perianal fistula following IPAA indicates the presence of CD.
METHODS: Patients developing a perianal fistula after IPAA for UC or IC
were identified from a prospective database and their medical record
reviewed. Demographics, date of pouch surgery, colectomy histopathology,
date of fistula diagnosis, clinical or pathological evidence of CD and follow-
up were abstracted. Patients with anastomotic leak or fistula only to the
abdominal wall or vagina were excluded.
RESULTS: 105 patients were identified, 32 were female. 68 had an initial
diagnosis of UC and 37 IC. Mean follow up was 118 ± 70 months. 43 (41%)
patients with perianal fistulas were subsequently diagnosed with CD. This
diagnosis was based on complex perianal disease in 18 patients, characteristic
inflammation of the pouch and/or anal canal in 16, small bowel disease in 4,
additional fistulas in 2 and Prometheus testing in 2. 11/43 (25%) had histo-
logical evidence of CD in the pouch, perianal area or small bowel. The
median age of these patients was 28 ± 8 years compared with 34 ± 12 in those




                                                                                     ABSTRACTS
without CD (p = 0.007). Of those with an initial diagnosis of UC, 38% (26/68)




                                                                                      TUESDAY
were subsequently diagnosed with CD compared with 51% (19/37) who had
an initial diagnosis of IC (p = 0.2). Smoking was not a significant risk factor
for change of diagnosis with 4/12 smokers (33%) diagnosed with CD com-
pared with 8/12 (66%) who were not (p = 0.51) Management of the fistula is
presented in Table 1. Four patients with CD were treated with infliximab and
3 of these 4 were able to retain their pouches.
CONCLUSION: Perianal fistula complicating IPAA for UC or IC is associated
with a change in diagnosis to CD, with all the therapeutic and prognostic
implications inherent in such a change. This is especially so in younger
patients and those without pouchitis. While medical management continues
to improve, this complication results in a significant incidence of pouch loss.

Table 1. Management of Fistula
                   Outcome                CD (n = 43)    Non-CD (n = 62)   p-value
                     Seton                    15               2           <0.001
                  Fistulotomy                  7              23             0.02
      Flap repair or Pouch advancement         1               9             0.04
                      Plug                     1               0            0.41
                   Diversion                   2               2             0.7
            Abscess drainage alone             0               3             0.27
               Pouch Excision                  9               1            0.001


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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   572     Resection Versus Laparoscopic Radiofrequency
           Thermal Ablation of Solitary Colorectal Liver
           Metastasis
Eren Berber*, Michael Tsinberg, Conrad H. Simpfendorfer, Allan Siperstein
Cleveland Clinic, Cleveland, OH
PURPOSE: There is scant data in the literature regarding radiofrequency
thermal ablation (RFA) versus resection of colorectal liver metastases. Non-
comparative studies have suggested a survival benefit of RFA for unresectable
colorectal liver metastases. The aim of this study is to compare the overall sur-
vival for patients with solitary colorectal liver metastasis treated with resec-
tion versus RFA from a single institution.
METHODS: Between 1996 and 2007, 153 patients underwent RFA (n = 63)
and open liver resection (n = 90) of solitary liver metastasis from colorectal
cancer. Patients were evaluated in a multidisciplinary fashion and allocated to
a treatment type. Data was collected prospectively for the RFA patients and
retrospectively for the resection patients.
RESULTS: There were 97 men and 56 women with an average age of 65 years
(68 for RFA and 63 for Resection, p = 0.98). Mean tumor size was 3.9 cm ± 0.4
for RFA and 3.8 cm ± 0.4 for Resection (p = 0.81). 70% of the RFA patients had
an ASA score ≥3 vs 48% of the Resection patients (p = 0.007). The main indi-
cation for RFA included technically challenging tumor location (n = 23),
patient comorbidities (n = 20), extrahepatic disease (n = 10), patient prefer-
ence (n = 7) and suspected bilobar disease (n = 3). Overall 19 RFA patients
(30%) had extrahepatic disease at the time of treatment. 81% of the RFA
patients received chemotherapy preoperatively versus 68% of the Resection
patients. Mean operative time was 116 ± 7 min for RFA and 198 ± 8 min for
Resection. There were no peri-operative mortalities in either group. The com-
plication rate was 3.1% (n = 2) for RFA and 33.7% (n = 30) for Resection.
Mean length of hospitalization was 1.2 ± 0.1 days for RFA and 6.8 ± 0.4 days
for Resection. The overall Kaplan Meier median survival from the date of sur-
gery was 29.5 months for RFA and 64.3 months for Resection (p < 0.0001).
The 3- and 5-year survival rates were 35% and 19%, respectively for RFA, and
70% and 53%, respectively for Resection. The overall median survival after
diagnosis of liver metastasis was 38.8 months for RFA and 72.1 months for
Resection (p = 0.0005).
CONCLUSIONS: This study shows that, although patients in both groups
had a solitary liver metastasis, other factors including medical comorbidities,
technically challenging tumor locations and extrahepatic disease were differ-
ent, prompting selection of therapy. With a simultaneous ablation program,
higher risk patients have been channeled to RFA, leaving a highly selected
group of patients for resection with a very favorable survival.This study shows
that RFA still achieved long term survival in patients who were otherwise not
candidates for resection.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   573     Frequency of Extrapancreatic Neoplasms in
           Intraductal Papillary Mucinous Neoplasm of the
           Pancreas Compared to Pancreatic Adenocarcinoma
           and Referral Patients
Kellie L. Mathis*, Kaye M. Reid Lombardo, Christina M. Wood, William S. Harmsen,
Michael G. Sarr
Surgery, Mayo Clinic, Rochester, MN
AIM: To estimate the frequency of extra-pancreatic benign and malignant
neoplasms in patients with intraductal papillary mucinous neoplasm (IPMN)
of the pancreas and compare the derived frequency to two, matched, control
groups.
METHODS: We identified all cases of IPMN diagnosed from 1994–2006
using 4 institutional registries. For matched groups, we used control Group 1
consisting of patients diagnosed with pancreatic adenocarcinoma during the
same time period matched for sex and age at diagnosis (±2 years). Control
Group 2 was a random selection of referral patients seen at our institution
during the time period matched 3:1 for sex, birth date (±5 years), year of reg-
istration at our clinic (±5 years), and geographic location of primary address.
We compared the proportions of patients with any extra-pancreatic benign or
malignant neoplasm diagnosed before and/or coincident with the diagnosis
of IPMN or pancreatic adenocarcinoma between the IPMN cases and each
control group separately using the Chi-square test. We calculated the risk of
new benign or malignant neoplasms diagnosed after the diagnosis of IPMN or
adenocarcinoma between groups using Cox proportional hazards regression.




                                                                                   ABSTRACTS
                                                                                    TUESDAY
RESULTS: The IPMN group consisted of 477 patients, pancreatic adenocarci-
noma group 471, and general referral group 1431. The proportion of patients
in the IPMN group having any extra-pancreatic neoplasm (benign or malig-
nant) diagnosed before or coincident to the index date was 52% (95% CI
47–56%), compared with 36% (95% CI 32–41%) in Group 1 (p < 0.001), and
43% (95% CI 41–46%) in Group 2 (p = 0.002). The most common benign
neoplasms in the IPMN group were adenomatous colon polyps (n = 116), Bar-
rett’s neoplasia (n = 18), and carcinoid neoplasms (n = 6). The most common
malignant neoplasms were non-melanoma skin (n = 36), breast (n = 24), pros-
tate (n = 24), and colorectal cancers (n = 19). The hazard ratio of diagnosis of
any neoplasm after the index date was 3.8 (95% CI 2.0–7.3, p < 0.001) for the
IPMN group compared to Group 1, and 1.4 (95% CI 0.9–2.1, p = 0.09) for
the IPMN group compared to the Group 2. In the IPMN group, 47 patients
had a new neoplasm diagnosed after the index date.
CONCLUSIONS: Patients with IPMN are at greater risk of benign or malig-
nant extra-pancreatic neoplasms compared to both control groups. The
majority of neoplasms were diagnosed prior to or coincident with the IPMN
diagnosis; however, the risk of developing neoplasms after the diagnosis of
IPMN remains increased. Based on the frequency of colonic polyps, screening
colonoscopy should be considered in all patients with IPMN.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


2:15 PM – 3:30 PM           PLENARY SESSION V                                  28ABC
          Moderators:       Susan Galandiuk, Louisville, KY
                            Thomas H. Magnuson, Baltimore, MD
   678      NOTES Rectosigmoid Resection Using Transanal
            Endosocopic Microsurgery (TEM) with Transgastric
            Flexible Endoscopic Assistance: A Pilot Study in Swine
Patricia Sylla*1, Field F. Willingham2, Denise W. Gee1, William R. Brugge2,
David W. Rattner1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Medicine, GI unit, Massachusetts
General Hospital, Boston, MA
BACKGROUND: Transcolonic access has been used as an alternative to
transgastric and transvaginal access for NOTES. Direct access to the rectosig-
moid and specialized equipment makes TEM an ideal platform for transanal
colorectal resection.
PURPOSE: To determine the feasibility of transanal segmental colectomy in
a porcine model.
METHODS: Procedures were performed in 7 swine cadavers ranging 30–40 kg.
After occluding the lumen of the proximal rectum with a pursestring suture, a
full thickness incision was created through the posterior rectal wall to enter the
presacral space. Circumferential dissection of the rectum and mesorectum was
extended cephalad to the mid-sigmoid. A flexible therapeutic colonoscope
inserted through a gastrotomy was used to assist with retraction and achieve
more proximal colon dissection. Once mobilized, the rectosigmoid was
extracted transanally, transected, and a stapled anastomosis was completed.
RESULTS: Transanal rectosigmoid resection was successfully completed in
all animals with an average procedure time of 157 mins (range, 120–240). The
average length of resected colon was 20.3 cm (range 10–27). Both procedure
time and length of specimen improved with time and experience. The anas-
tomoses were complete in 6 of 7 animals. In one animal, a posterior anasto-
motic defect was noted. The peritoneal cavity was entered in all animals. On
post-procedure laparotomy, no leak or adjacent organ injury was observed.




CONCLUSIONS: Transanal colorectal resection with TEM is feasible in swine
and allows resection of up to 27 cm of rectosigmoid. The combination of
TEM and transgastric endoscopic assistance is a promising technique for
NOTES segmental colectomy.
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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   679      Who Should Do NOTES: Initial Endoscopic Performance
            and Early Learning Curve of Laparoscopic Surgeons in
            Comparison to Endoscopists and Untrained Individuals
Oliver J. Wagner*1, Monika E. Hagen2, Francois Pugin2, Philippe Morel2,
Daniel Candinas1
1Department   of Visceral and Transplantation Surgery, University Bern, Bern,
Switzerland; 2Digestive Surgery, University Hospital Geneva, Geneva, Switzerland
BACKGROUND: A concern in the field of NOTES is the question if surgeons
with their lack of endoscopic experience or endoscopists without intrabdomi-
nal routine should perform that type of new treatment. Still, due to well
trained manual dexterity, spatial orientation and hand-eye alignment, laparo-
scopically experienced surgeons—even without endoscopic experience—should
master very quickly the handling of endoscopic equipment. Initial perfor-
mance should be superior when compared to individuals without surgical
training and learning curve rapid. Endoscopically inexperienced laparoscopic
surgeons may even quickly reach the endoscopic dexterity of endoscopists.
METHODS AND DESIGN: 25 individuals were tested for endoscopic dexter-
ity. Group1 included 5 endoscopists. Group 2 included 10 laparoscopic sur-
geons without endoscopic experience. Group 3 contained 10 medical
students without endoscopic and surgical experience. Each individual per-
formed 10 times an easy, a medium and a difficult task with endoscopic
equipment on a NOTES skills-box. Time and errors were meassured, an over-
all score allocated and evaluated statistically.
RESULTS: Group 3 performed all 3 of their allocated tasks significantly




                                                                                   ABSTRACTS
                                                                                    TUESDAY
worse when compared to group 1 and 2 (p < 0.05). No differences were
detected between the performances of group 1 and 2 for the easy and the
medium task (p > 0.05). Group 1 performed the difficult tasks significantly
better than group 2 (p < 0.05). Group 2 demonstrated a very rapid learning
curve between the first and tenth performance with a significantly better
result for the tenth time of performance when compared to the first (p < 0.05).
CONCLUSION: The data support the conclusion that endoscopically inexpe-
rienced laparoscopic surgeons learn very quickly the handling of endoscopic
equipment. Their initial performance is superior when compared to individu-
als without any surgical training. Furthermore, intitial performance is similar
when compared to trained endoscopists for easy and tasks of moderate diffi-
culty. However, endoscopists are still superior in handling endoscopic mate-
rial for complex tasks when compared to endoscopically untrained surgeons.
The data therefore suggest that laparoscopic surgeons are not severely disad-
vantaged by their lack of endoscopic experience and—due to their surgical
experience—should perform NOTES.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   680      To Prepare or Not the Colon for Elective Surgery with
            Primary Intraperitoneal Anastomosis. There Is No
            Question
María Jesús Peña-Soria, Julio M. Mayol*, Rocio Anula, Ana M. Arbeo-Escolar,
Jesus A. Fernandez-Represa
Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain
INTRODUCTION: The definitive analysis of a prospective single-blinded
randomized trial to investigate whether preoperative mechanical bowel prep-
aration decreases the incidence of surgical site infection and anastomotic fail-
ure after elective colorectal surgery by a single surgeon is presented.
PATIENTS AND METHODS: All patients scheduled to undergo an elective
colorectal procedure with a primary anastomosis by the same surgeon from
October 2001 until January 2007 were enrolled and randomized to receive
either oral polyethylene glycol (PEG) lavage solution (Group A) or no
mechanical bowel preparation whatsoever (MBP) (Group B). Dietary restrictions
were limited to 12 hours prior to surgery. A standard intravenous antibiotic pro-
phylaxis scheme was used. Exclusion criteria included immunosupression, pre-
operative chemoradiotherapy, diverting stoma and perforated and/or obstructing
tumor. Patients were followed by an independent observer for wound infec-
tion, intrabdominal sepsis and anastomotic failure within 30 days after sur-
gery. Student’s T and Chi square tests were used for statistical analysis.
Statistical significance was defined as p < 0.05. The number of patients needed
to treat (NNT) was calculated as the inverse of the absolute risk reduction. The
study was approved by Hospital Clinico San Carlos ethics committee.
RESULTS: One hundred and forty five patients were enrolled. Three patients
(2.06%) were preoperatively excluded because of active immunosupression.
One hundred and forty two patients were randomized but 13 of them (8.9%)
were excluded from analysis (diverting stoma in 10 cases, contained perfora-
tion in 1 patient and unresectable tumor in 2 patients). Of the remaining 129
patients, 64 were assigned to Group A and 65 to Group B. The mean age was
67.39 ± 15.9 years in Group A and 67.2 ± 12.6 years in Group B (NS). There
was no difference in sex distribution between groups. Overall, 27 patients
(20.9%) developed postoperative wound infection, 16 (24.6%) patients in
Group A vs. 11 (17.2%) in Group B (NS). There were 3 cases of intrabdominal
sepsis and all of them occurred in Group A (6.3%). The SSI rate was 29.7%
(19/64) for Group A vs. 17.2% (11/65) for group B (NS). The overall rate of
anastomotic failure was 5.4% (n = 7), 4 patients in Group A (6.2%) vs. 3
patients in Group B (4.6%) (NS). The overall complication rate (SSI+ anasto-
motic failure) in Group A was 35.9% vs., 21.5% in Group B (NS). The NNT
was 7.
CONCLUSION: the NNT in our definitive analysis suggests that better out-
comes in terms of SSI and anastomotic failure rates would be achieved by a
single surgeon if preoperative MBP with PEG is routinely omitted.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   681      Routine Liver Biopsy to Detect Non-Alcoholic
            Fatty Liver Disease (NAFLD) During Laparoscopic
            Cholecystectomy for Symptomatic Gallstone Disease
            (GD)—Is It Justified?
Antonio Ramos-De La Medina*1, Federico B. Roesch2, Alfonso Perez Morales3,
Silvia Cid-Juarez2, Jose M. Remes-Troche2
1Gastroenterology and Gastrointestinal Surgery Department, Veracruz Regional Hospital,
Boca del Rio, Mexico; 2Digestive Physiology and Motility Laboratory, Medical-Biological
Research Institute University of Veracruz, Veracruz, Mexico; 3University of Veracruz
Medical School, Veracruz, Mexico
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and its inflam-
matory and progressive subtype non-alcoholic steatohepatitis (NASH) have
emerged as a major health burden. NAFLD and Gallstone disease (GD) share
common pathophysiologic and risk factors. Currently there are no recom-
mendations regarding screening of NAFLD in patients at increased risk. More-
over, non invasive methods to diagnose NAFLD are unreliable and liver
biopsy is the only method for assessing the presence and extension of this
condition. Firm recommendations of when to perform a liver biopsy in the
routine clinical evaluations have not been developed. In this study our aim
was to assess the prevalence of and factors associated with NAFLD in a cohort
of patients operated for symptomatic GD and to evaluate the usefulness of
routine liver biopsy as a screening method.
METHODS: We prospectively evaluated 95 consecutive patients referred for
cholecystectomy due to symptomatic GD between January 1st 2005 and June
30th 2006. All patients had a liver biopsy performed at the end of a standard




                                                                                          ABSTRACTS
                                                                                           TUESDAY
laparoscopic cholecystectomy. Demographics, anthropometric measurements,
family history, risk factors, laboratory tests and abdominal ultrasound were
registered and analyzed. Patients with a positive serology for hepatitis B or C
virus, those with a history of alcohol ingestion greater than 150 gr/day,
autoimmune hepatitis or other liver disease where excluded.
RESULTS: Twenty-nine patients (30.5%) were male and 66 (69.4%) were
female. Mean age was 52.15 ± 16.82 years (range 2–84 years) Forty-three
patients (45%) had normal biopsies (Group A) while 52 patients (55%) had
histological findings compatible with NAFLD (Group B). The patients in the
later group where further classified according to the system proposed by
Brunt as follows: stage I 51.93%, stage II 28.84%, stage III 19.23% and cirrho-
sis 3.15%. Patients in group B were older, had a higher body mass index,
higher prevalence of diabetes, higher glicosilated hemoglobin levels, serum
cholesterol and serum triglycerides than those in group A although they were
not statistically significant. There were no complications secondary to the
liver biopsies.
DISCUSSION: In our series, our findings show that more than 50% of
patients with GD have associated NAFLD. Awareness of this association may
result in an earlier diagnosis of NAFLD in patients with GD. Moreover, the
fact that NAFLD is highly prevalent in patients with GD may justify routine
liver biopsy in all patients undergoing laparoscopic cholecistectomy. Laparo-
scopic liver biopsy is a safe and effective method to establish the diagnosis
and stage of NAFLD in patients with GD.


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   682      Reinterventions for Specific Technique-Related
            Complications of Stapled Haemorrhoidopexy (SH):
            A Critical Appraisal
Pierpaolo Sileri*, Vito M. Stolfi, Antonio Chiaravalloti, Achille Lucio Gaspari
Surgery, University of Rome Tor Vergata, Rome, Italy
INTRODUCTION: Stapled haemorrhoidopexy (SH) is an attractive alterna-
tive to conventional haemorrhoidectomy (CH) because of reduced pain and
earlier return to normal activities. However complications rates are as high as
31%. Although some complications are similar to CH, most are specifically
technique-related. In this prospective audit we report our experience with the
management of some of these complications.
METHODS: Data on patients undergoing haemorrhoidectomy at our unit or
referred to us are prospectively entered in a database. The onset/duration of
specific SH-related complications as well as reinterventions for failed/compli-
cated SH were recorded.
RESULTS: From 1/03 to 10/07, 110 patients underwent SH, while 17 patients
were referred after complicated/failed SH. Among SH performed in our group,
we observed 21 specific complications in 17 patients (15.5%): urgency (12),
tenesmus (5), severe persistent anal pain (2), haemorrhoidal thrombosis (2).
Urgency resolved within 4 months in all patients but one in which lasted 8
months.Three patients (2.7%) had tenesmus up to 3 months. One patient
with anal pain underwent exploration under anaesthesia (EUA) and retained
stapled removal with complete symptoms resolution. The haemorrhoidal
thrombosis occurred 4 and 12 days after SH and were treated medically. Six
patients developed haemorrhoidal recurrence after 16 ± 5 months after SH
(range 9–26 months). Four symptomatic patients underwent further CH. Two
patients (1,8%) developed symptomatic anorectal stenosis with urgency and
frequency and responded to anal dilatation with dilators. Overall reinterven-
tions rate for this group was 5.5%. Among the referred SH-group, 1 patient
underwent Hartmann’s procedure because of rectal perforation. The remain-
ing 16 patients experienced at least one of the following: recurrence (6),
urgency (6), severe anal pain (4), tenesmus (4), colicky abdominal pain (1),
anal fissure (1) and stenosis (1). Recurrences where observed after 16 ± 6
months from surgery (range 9–36 months). Four patients underwent CH with
regular postoperative recovery. Two patients underwent EUA because of per-
sisting pain after SH (7 ± 6 months). Anorectal manometry and ultrasound
were performed in both and pelvic MRI in one. In one patients the US
showed a small submucosal abscess at the stapled line. The abscess was not
seen at the MRI and it was not found at EUA. In both patients, surgical removal
of retained staples resolved the pain. One patient underwent anoplasty.
CONCLUSIONS: SH presents unusual and challenging complications. Abuses
should be minimized and longer-term studies are needed to further clarify
its role.




                                          146
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


3:30 PM – 4:30 PM           QUICK SHOTS II                                     28ABC
          Moderators:       Robert E. Glasgow, Salt Lake City, UT
                            Taylor S. Riall, Galveston, TX
   772      Two-Hundred Consecutive Laparoscopic Liver
            Resections
Andrew A. Gumbs*1,2, Brice Gayet2
1Upper GI and Endocrine Surgery, New York-Presbyterian Hospital, New York, NY;
2Medical and Surgical Department of Digestive Diseases, Institut Mutualiste Montsouris,
Paris, France
INTRODUCTION: Since the first report of a laparoscopic liver resection in
1992, laparoscopic resection of peripheral hepatic segments has become
increasingly more common in the surgical treatment of both benign and
malignant tumors. The minimally invasive approach to resections of the
entire liver, however, is still only being performed in highly specialized centers
do to lingering concerns about feasibility and efficacy.
METHODS: Patients who underwent minimally invasive techniques were
compared to results in the literature of patients treated at other European
referral centers who were approached with open techniques. Our data was
collected retrospectively, including our first cases of advanced laparoscopic
resections. Five-year Kaplan-Meier curves of patients with hepatocellular car-
cinoma (HCC) and non-neuroendocrine metastatic disease were calculated to
ascertain disease free and overall survival.
RESULTS: Over a 12-year period from January 1995 until June 2007, a total




                                                                                          ABSTRACTS
of 357 liver procedures were performed. Of these a total of 200 laparoscopic




                                                                                           TUESDAY
liver resections were performed. The average OR time, estimated blood loss
and length of stay was 192 minutes (±106), 324 mL (±365) and 10 days (±9).
Conversions occurred in 13 patients (7%). Complications occurred after lap-
aroscopic resection for primary liver cancer in 23% and in 24.2% after resec-
tions of non-neuroendocrine hepatic metastases compared to 31% and 25%
as reported in the open European literature, respectively. Overall 5-year sur-
vival in patients with primary liver cancer is 66% and 55% in patients with
non-neuroendocrine secondary hepatic tumors in the laparoscopic group
compared to 36% and 32%, respectively, in the open group. Thirty day mor-
tality occurred in 1% in the laparoscopic group compared to 2% in the open
group.
CONCLUSIONS: Minimally invasive techniques for hepatic resections of the
entire liver are feasible and safe, and high volume centers that specialize in
these procedures can have results similar to historical open series. Five year
overall survival may be superior when minimally invasive techniques are used,
however, larger randomized-controlled trials are necessary to ascertain this.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


   773      Long-Term Quality of Life Is Similar After Hepatic
            Resection for Malignant and Benign Diseases
Vanessa Banz*, Regula Fankhauser, Peter Studer, Beat Gloor, Daniel Inderbitzin,
Daniel Candinas
University Hospital Bern, Bern, Switzerland
BACKGROUND: Morbidity and mortality are continuously decreasing after
major hepatic surgery due to more advanced operative methods and perioper-
ative care. The extent and indications of liver resections (LR) are being
pushed to the limits. As survival increases post-hepatectomy, quality of life
(QOL) becomes a leading issue. Up until now, no studies address potential
differences in long-term QOL in patients necessitating LR for benign or
malignant conditions. Our aim was to see how postoperative diagnosis
affected long-term self estimated QOL and health.
METHODS: Patients eligible for QOL analysis were selected from our pro-
spectively collected database. Long-term QOL was evaluated based on the
European Organization for Research and Treatment of Cancer Quality of Life
Questionnaire Core-30 (EORTC QLQ-C30, Version 3.0) questionnaire and the
liver-specific QLQ-LMC21 module with 51 questions addressing 5 functional
and 3 symptom scales. EORTC scores and clinical variables such as malignant
versus benign diseases, age or extent of LR were analyzed to identify factors
influencing overall QOL. Statistical analysis included the Wilcoxon rank-sum
test and a cumulative logistic regression model.
RESULTS: Between 2002–2006, 249 patients had hepatic surgery in our insti-
tution. Interventions were carried out in 76% for malignant and 24% for
benign conditions and ranged from segmental resections to extended hemi-
hepatectomies. 134 patients were contacted for further QOL analysis after a
mean of 26.5 months (±16.2). There was no statistical difference in the global
QOL and health scores between patients with malignant and benign diseases
(p = 0.367) with an estimated odds ratio of 0.745 (95% CI 0.396–1.399). Note
that the 95% confidence interval covers the value 1. Neither the extent of the
resection (>2 segments versus <2 segments) (p = 0.975, OR 0.988, 95% CI
0.461–2.119) nor age significantly influenced over QOL and health and
(p = 0.092).
CONCLUSIONS: Contrary to general expectations, overall long-term QOL is
surprisingly high in patients requiring LR for malignant diseases. Although
patients with malignant conditions tended to fare worse within certain sub-
group analyses, it is reasonable to conclude that patients with malignant and
benign diseases have a similar QOL, although no p-value can be associated
with this statement.A worse clinical prognosis does not correlate with a low
QOL as judged in the eyes of the patient. For selected patients, “palliative
liver resections” may be warranted. However, we are currently monitoring
extended hepatic surgery and its associated QOL in a prospective trial with
preoperative, short and long-term QOL assessment.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   774     Does Staging Laparoscopy Detect a Higher Rate of
           Occult Metastases in Patients with Resectable
           Pancreatic Adenocarcinoma?
Carlo M. Contreras*, Robert J. Rettammel, David M. Mahvi, Layton F. Rikkers,
Clifford S. Cho, Sharon M. Weber
General Surgery, University of Wisconsin, Madison, WI
BACKGROUND: Preoperative computed tomography understages pancre-
atic adenocarcinoma, with occult metastatic disease identified in up to 25%
of patients at the time of operation. Because the role of staging laparoscopy
continues to be debated, we sought to compare the incidence of occult unre-
sectable disease for patients with radiographically resectable pancreatic ade-
nocarcinoma explored with laparotomy versus laparoscopy, all of whom were
evaluated with contemporary imaging over a recent time span.
METHODS: Patients with radiographically resectable pancreatic adenocarci-
noma were identified from a prospective hepatobiliary database and divided
into two groups: those explored initially with laparoscopy versus laparotomy.
Preoperatively, all patients were determined to be resectable based on imag-
ing review at a multidisciplinary tumor conference with evaluation by spe-
cialists in surgical and medical oncology, gastroenterology, and radiology.
Endpoints of resectability, survival, cost, and hospital stay were evaluated.
RESULTS: Between April 2002 and November 2006, 78 patients with pancre-
atic adenocarcinoma underwent exploration. Twenty-five underwent initial
laparoscopic exploration, and 53 underwent immediate laparotomy. There
was no difference in the type or number of preoperative imaging tests. Occult




                                                                                   ABSTRACTS
metastases were identified in 7/25 (28%) patients undergoing laparoscopy. In




                                                                                    TUESDAY
addition, 3/25 laparoscopy patients had unresectable disease identified at
subsequent laparotomy. Thus, 40% (10/25) of the laparoscopy group had
unresectable tumors. In the laparotomy group, only 6/53 (11%) patients were
found to have intraoperative evidence of unresectable disease (p = 0.003 vs.
laparoscopy). Occult peritoneal disease was identified more frequently in lap-
aroscopy patients (32% vs. 11%, p = 0.03). Median survival for resected
patients was 16 months versus 4 months for patients with unresectable
tumors (p < 0.0001). Survival for resected patients was not significantly differ-
ent between the laparoscopy and laparotomy groups. In patients with unre-
sectable disease, there were no differences in length of stay, direct hospital
costs, or interval to initiating postoperative chemotherapy between laparos-
copy and laparotomy groups.
CONCLUSIONS: In patients with apparently resectable pancreatic adenocar-
cinoma, occult metastatic disease is identified more frequently at the time of
staging laparoscopy than at laparotomy. For the first time, this study demon-
strates that improved visualization of the abdominal cavity with pneumoperi-
toneum results in an enhanced ability to detect peritoneal disease in patients
evaluated with contemporary imaging.




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   775      Excellent Results from Limited Resection of Duodenal
            Carcinoid Tumors
Kenzo Hirose*, Brown Nancy, Kristina Potanos, Bipan Chand, R. Matthew Walsh
General Surgery, Cleveland Clinic, Cleveland, OH
AIM: To describe a single center’s experience with treatment of duodenal and
periampullary carcinoid tumors.
METHODS: This is a descriptive, retrospective review of 40 patients treated
for duodenal and periampullary carcinoid. Clinical findings, operative treat-
ment, pathologic staging, and recurrence rates were assessed.
RESULTS: 40 patients underwent 45 interventions for duodenal or periamp-
ullary carcinoid tumors between 1990 and 2007. Mean follow-up was 44
months. Results are summarized in Table 1. Interventions included endo-
scopic resection (either forceps biopsy or endoscopic mucosal resection),
transduodenal local excision (either laparoscopic or open), segmental duode-
nal resection (with or without antrectomy), pancreaticoduodenectomy, and
double bypass for unresectable disease. Recurrence was most common in the
endoscopic resection patients (n = 5), all treated successfully with either
repeat endoscopic or surgical therapy. Two patients in the other groups expe-
rienced recurrent disease, both metastatic disease to the liver. 5 patients died;
two died due to metastatic carcinoid tumor; the other three died of causes
unrelated to carcinoid. Neither recurrence nor survival correlated with size of
the original lesion or presence of positive lymph nodes.
CONCLUSION: Excellent recurrence free and overall survival is enjoyed by
patients with duodenal and periampullary carcinoid tumors. Selection of the
appropriate resection strategy is largely based on location and technical con-
siderations. More extensive resection is associated with higher detection of
positive lymph nodes, but does not conclusively provide oncologic benefit.

           Therapy         n Duodenal Peri-Ampullary Mean Size Node Positive Recurr. Death
   Endoscopic resection    18   17           1        1.1 cm        0          5       2
 Transduod. local excision 15   12           3        0.9 cm        2          1       0
   Segmental resection      5    5           0        4.0 cm        1          0       1
          Whipple          6    0           6         1.5 cm        3          1       1
    Palliative procedure    1    1           0        4.0 cm        1          0       1
            TOTAL          45   35          10        1.5 cm        7          7       5




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   776      Five-Year Outcome of a Randomized Trial Comparing
            Pylorus- and Duodenum-Preserving Pancreatic Head
            Resection for Chronic Pancreatitis
Ulrich Adam*, Frank Makowiec, Eva Fischer, Tobias Keck, Hartwig Riediger,
Ulrich T. Hopt
Department of Surgery, University of Freiburg, Freiburg, Germany
INTRODUCTION: The “ideal” technique of pancreatic head resection (PHR)
for chronic pancreatitis (CP) is still discussed controversially. Although few
trials have shown advantages for duodenum-preserving (DPPHR) techniques
many centres continue to perform pancreaticoduodenectomies either as
Whipple or pylorus-preserving (PPPD) procedures. After presentation of our
initial results to the Society in 2004 we have performed further follow-up
evaluations and can now report the five-year outcomes after randomization
of patients to either DPPHR or PPPD. Our initial evaluations (perioperative
course and three-year outcome) showed comparable results between the
groups including quality of life.
METHODS: We re-evaluated the outcome in 85 patients who were randomly
assigned to DPPHR (n = 42) or PPPD (n = 43) between 1997 and 2001. After
randomization for DPPHR the surgeon could decide, depending upon the
morphology of CP, to perform either a FREY- (n = 22) or a BEGER-procedure
(n = 20). Follow-up evaluations were performed by standardized question-
naires, supplemented by phone contacts with the home physicians. Median
postoperative follow-up was now 61 months.
RESULTS: Preoperatively, demographic and CP-related data showed no dif-




                                                                                 ABSTRACTS
ference between the groups. After a median of 61 months following surgery




                                                                                  TUESDAY
63% (PPPD) and 57% (DPPHR) of the patients were completely free of pain,
respectively (n.s.). Among the patients still suffering from pain (PPPD vs.
DPPHR) 2%/4% had pain every day, 7%/7% had pain at least once per week,
7%/14% at least once per month and 20%/17% complained of pain less fre-
quently (no difference between the groups). The pain scores as well showed
no differences. Diabetes was documented in 44% (PPPD) and 45% (DPPHR),
respectively, postoperative de novo-diabetes in 19% (PPPD) and 26% (DPPHR;
n.s.). The frequencies of exocrine insufficiency (61% vs. 76%, p = 0.12) and
postoperative de-novo exocrine insufficiency (21% vs. 26%; p = 0.57) were
also comparable. Median gain in body weight was three kg after PPPD and
two kg after DPPHR; n.s.). Further subgroup comparisons in the patients
undergoing DPPHR (FREY vs. BEGER) did not reveal any differences in out-
come. Up to now 15 of the 85 patients died a median of 3.5 years after sur-
gery, in most cases as a consequence of alcohol and/or tobacco use. Actuarial
survival was 82% after five and 70% after ten years, without differences
between the two randomized groups.
CONCLUSIONS: The late results of our randomized study demonstrate a
comparable outcome after PPPD or DPPHR even five years after surgery. The
type of PHR for CP might, therefore, be adapted to the morphology of CP and
its local complications.




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    777      Tailored Transoral Incisionless Fundoplication (TIF) in
             the Treatment of GERD: The Anatomic and Physiologic
             Basis for Reconstruction of the Esophagogastric
             Junction Using a Novel Approach
Blair A. Jobe1, Ger H. Koek2, Stefan J. Kraemer3, Barry P. Mcmahon4,
Bart Witteman2, Flemming H. Gravesen5, Cedric S. Lorenzo*1, Robert W.
O’Rourke1, Douglas A. Shumaker6, Michael M. Owens6, John G. Hunter1,
Nicole Bouvy2
1Surgery,Oregon Health & Science University, Portland, OR; 2Surgery, Maastricht
University Hospital, Maastricht, Netherlands; 3Endogastric Solutions, Inc., Redmond,
WA; 4Medical Physics & Clinical Engineering, Adelaide & Meath Hospital and Trinity
College, Dublin, Ireland; 5Visceral Biomechanics and Pain, Aalborg Hospital, Hobrovej,
Denmark; 6West Hills Gastroenterology, Portland, OR
OBJECTIVE: To determine the anatomic and physiologic basis and short-
term efficacy of Transoral Incisionless Fundoplication (TIF) in GERD patients.
METHODS: Nine patients with PPI-dependent GERD underwent TIF using
the EsophyX™ device. TIF was performed endoscopically by enveloping the
distal esophagus for 3 cm within the proximal stomach and securing this
with transmural polypropylene fasteners. Pre- and post-TIF testing with pH,
manometry, LES vector volume analysis, impedance planimetry, and upper
endoscopy was performed. Mean time to follow-up was 3 months.
RESULTS: Mean operative time was 60 minutes (range, 40–90). One patient
developed pneumoperitoneum requiring needle aspiration. 8/9 patients were
discharged within 24-hours post-TIF. All patients had complete symptomatic
resolution of GERD and were off PPI at follow-up. LES cross-sectional area
decreased in all patients post-TIF on impedance planimetry.
CONCLUSIONS: TIF results in the elimination of symptoms and normaliza-
tion of distal esophageal pH exposure in patients with GERD. Evaluation of the
post-procedure EGJ indicates restoration to normal anatomy and physiology.

                   Endpoint                     Pre-TIF         Post-TIF      p-value
         Resting LES Pressure (mmHg)             10.57            25.15        0.124
       LES Total/Abdominal Length (cm)          2.8/1.5          3.6/2.6     0.075/0.13
      LES Vector Volume (mmHg2 × mm)               354            2904         0.015
        Mean Hill Classification, Range         II (I–IV)        I (all I)     0.005
                Nipple Valve (%)                     0              89          0.02
        Hiatal Hernia (% and mean size)        89/2 (1–3)           0/0        0.004
                Esophagitis (%)                     57               0         0.025
           % time pH < 4 in 24 hours        8.5% (1.2–26.6)   0.7% (0–1.6)     0.019




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   779      Signal Detection: A New Statistical Method to Predict
            NASH in Gastric Bypass Patients
John M. Morton*, Gavitt A. Woodard, Tina Hernandez-Boussard
Surgery, Stanford School of Medicine, Stanford, CA
BACKGROUND: Non-alcoholic steatohepatitis (NASH) is associated with
morbid obesity, cardiac risk factor abnormalities, and metabolic syndrome.
Currently, there are no adequate pre-operative predictive models for NASH
identification. We present a new statistical method to address this need.
METHODS: Signal detection affords the ability to identify patients at risk
with both homogeneous outcomes and risk predictors and has been used in
cardiac risk assessment. Potential risk factors for NASH were entered into the
Signal Detection model by Kraemer et al. All patients underwent laparoscopic
gastric bypass surgery with intra-operative liver biopsy at a single academic
institution by a single surgeon. Preoperatively, liver function tests, cardiac
risk factors, and comorbidities were assessed. We dichotomized liver pathol-
ogy into NASH vs Steatosis (SS) per Brunt criteria for analysis by T-test or Chi-
Square analysis as appropriate.
RESULTS: 141 patients successfully underwent laparoscopic Roux-en-Y gas-
tric bypass surgery. Patient demographics were mean age, 45; female, 88%;
mean BMI, 49; diabetic, 38%; hypertensive, 62%; and hepatitis or alcohol
abuse, 0%. Liver biopsy results were Normal (2%), Steatosis (60%) and NASH
(38%). The model identified the following variables in order as most discrimi-
nating in identifying patients with NASH: ALT >31, excess weight >109 kg,
Lipoprotein A >21 and Hemoglobin A1C >6.9. This model identified this sub-
group as having an 81% chance of having a pathologic NASH diagnosis.




                                                                                    ABSTRACTS
                                                                                     TUESDAY
CONCLUSION: In this study, ALT, excess weight and hemoglobin A1C were
correlated with NASH. This innovative new statistical technique affords a
new ability to successfully identify gastric bypass patients with biopsy proven
NASH.




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   780      Visceral Sensitivity Is Increased During the Initial
            Development of Postoperative Ileus in Mice
Mario H. Mueller*1, Mia Karpitschka3, Andrej Sibaev3, Jörg Glatzle2, Bing Xue1,
Michael S. Kasparek1, Martin E. Kreis1
1Department of Surgery, Ludwig-Maximilians University, Munich, Germany; 2Department of
Surgery, Eberhard-Karls University, Tuebingen, Germany; 3Institute of Surgical Research,
Ludwig-Maximilians University, Munich, Germany
INTRODUCTION: Neurogenic, inflammatory and pharmacological alter-
ations during surgery contribute to the pathophysiology of postoperative
ileus (POI). We hypothesized that during the initial hours after surgery, affer-
ent nerve fibers supplying the intestine are sensitized for the pain mediator
bradykinin and mechanical stimuli which may contribute to efferent reflex
inhibition of intestinal motility. We, therefore, aimed to explore intestinal
afferent nerve sensitivity and motility during the early development of POI in
mice.
METHODS: Under enflurane anesthesia, C57BL/6 mice underwent laparot-
omy followed by sham treatment or standardized small bowel manipulation
to induce ileus. Then, after 1 h, 3 h or 9 h, extracellular multi-unit mesenteric
afferent nerve recordings were established in vitro from 2 cm segments of
jejunum (each subgroup n = 6) continuously superfused with Krebs buffer
(32˚C, gassed with an O2/CO2 mixture). The segment was cannulated from
both ends to monitor luminal pressure and intestinal motility simulta-
neously. Afferent discharge to luminal distension (0–80 cm H2O) and brady-
kinin (1 µM) was recorded. Peak discharge frequency and intestinal motor
events were analyzed by two-way ANOVA.
RESULTS: The mean amplitude of intestinal contractions was 0.8 ± 0.2 cm
H2O 1 h after induction of POI and 5 ± 0.8 cm H2O in segments taken after
1 h from sham controls (p < 0.05). A similar difference was observed for seg-
ments harvested at the 3 h and 9 h time point (both p < 0.05). Serosal brady-
kinin was followed by an increase in afferent discharge to 61 ± 6 impsec-1
after 1 h, 217 ± 25 impsec-1 after 3 h and 217 ± 6 impsec-1 after 9h in ileus
segments increased compared to 46 ± 3 impsec-1 after 1 h, 57 ± 10 impsec-1
after 3 h and 140 ± 13 impsec-1 after 9 h in sham controls (*P < 0.05). The
afferent response during ileus was augmented at high threshold luminal dis-
tension at 80 cm H2O (912 ± 79 impsec-1 after 1 h, 933 ± 30 impsec-1 after 3
h and 1131 ± 63 impsec-1 after 9 h) when compared to sham controls (639 ±
39 impsec-1 after 1 h, 714 ± 40 impsec-1 after 3 h and 1,165 ± 30 impsec-1
after 9 h), (P < 0.05).
CONCLUSIONS: Afferent discharge to bradykinin and high pressure luminal
distension is augmented in the early stage of postoperative ileus. As high-
threshold mechanosensitivity and the algesic mediator bradykinin activate
predominantly spinal afferents, spinal sensitization seems to occur at the ini-
tial stage of postoperative ileus which may trigger a reflex inhibition of intes-
tinal motility perpetuating postoperative ileus.




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   781     Tissue and Serum Levels of Substance P Correlate in
           Patients with Chronic Pancreatitis
Giuseppe Mascetta1, Fabio Francesco Di Mola1, Federico Selvaggi1,2,
Massimo Falconi4, Claudio Bassi4, Nathalia Giese2, Markus W. Buechler2,
Helmut M. Friess3, Pierluigi Di Sebastiano*1
1Department   of Surgery, IRCCS Casa Sollievo Sofferenza, San Giovanni Rotondo, Italy;
2Department   of General Surgery, University of Heidelberg, Heidelberg, Germany;
3Department   of Surgery, Technical University of Munich, Munich, Germany;
4Department   of Surgery, University of Verona, Verona, Italy
INTRODUCTION: The pathophysiology of pain in chronic pancreatitis (CP)
is still unclear. Recent data suggest a role for neuropeptides such as substance
P (SP) and the neuroimmune interaction in the inflammatory process of the
pancreas. SP degradation is mediated by the endogenous extracellular metal-
loenzyme called neutral endopeptidase (NEP). Actually, no data are available
regarding the relationship between tissue and serum levels of SP in CP. In this
study we aimed to investigate a possible correlation between SP mRNA
expression in pancreatic tissue and serum levels of SP in patients undergoing
surgical resection for CP and to test the hypothesis that neuroimmune
inflammation is a pathogenetic factor in CP.
MATERIALS AND METHODS: SP and NEP mRNA levels were analyzed by
quantitative RT-PCR in pancreatic tissue specimens from 30 patients undergo-
ing pancreatic resection for CP and 8 healthy organ donors. In addition, SP
serum levels were determined before and after surgery and in 8 healthy indi-
viduals (control group) using an ELISA test.




                                                                                         ABSTRACTS
                                                                                          TUESDAY
RESULTS: Quantitative RT-PCR demonstrated increased SP mRNA expres-
sion in CP tissues (P < 0.05) compared to controls, while NEP mRNA expression
showed no significant changes between CP and healthy controls. The SP pre-
operative serum levels correlated with SP tissue levels in CP patients. After
pancreatic resection, the majority of CP patients exhibited a significantly
reduced expression of SP serum levels compared with preoperative levels.
CONCLUSIONS: The present data show that expression of SP is increased
during chronic inflammation whereas NEP tissue levels are unaltered. In the
SP pathway, it would appear that NEP is unable to sufficiently degrade the
increased amount of SP, which may in part explain the perpetuation of pan-
creatic inflammation. Removal of pancreatic inflamed tissue, the “pace-
maker” of neuroimmune inflammation, resulted in the reduction of the
circulating level of SP, supporting the hypothesis of neuroimmune crosstalk
in CP. Furthermore the correlation between serum and tissue levels of SP sug-
gest that this neuropeptide might also represent a reliable marker of neuro-
genic inflammation in CP.




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Wednesday, May 23, 2008
8:30 AM – 10:00 AM         TRANSLATIONAL SCIENCE                             25ABC
                           PLENARY (PLENARY SESSION VI)
           Moderators:     Deborah A. Nagle, Boston, MA
                           Edward E Whang, Boston, MA
   948     The Role of ERCC1 RNA Expression in Blood as a
           Non-Invasive Predictor of Response to Neadjuvant
           Radio-Chemotherapy in Patients with Locally
           Advanced Cancer of the Esophagus
Jan Brabender*1, Daniel Vallböhmer1, Frederike C. Ling1, Andreas C. Hoffmann1,
Georg Lurje1, Elfriede Bollschweiler1, Arnulf H. Hölscher1, Paul M. Schneider2,
Ralf Metzger1
1Department  of Surgery, University of Cologne, Cologne, Germany; 2Department of
Surgery, University of zuerich, Zuerich, Switzerland
BACKGROUND: Only patients with locally advanced cancer of the esopha-
gus with a major response to neadjuvant radio-chemotherapy do benefit from
this treatment. Unfortunately, no non-invasive molecular marker exists that
can reliably predict response to neadjuvant therapy in this disease. To
improve the treatment of patients with cancer of the esophagus, molecular
predictors of response are desperately needed. Aim of this study was to deter-
mine the value of ERCC1 RNA-Expression in peripheral blood of patients
with cancer of the esophagus as a non-invasive molecular predictor of
response to neoadjuvant therapy.
MATERIAL AND METHODS: A total of 29 patients with locally advanced
cancer of the esophagus were included in this study. Blood samples were
drawn from each patient prior to neoadjuvant therapy (cis-Platin, 5-FU,
36Gy). Transthoracic en-bloc esophagectomy was performed in all patients
following completion of neadjuvant therapy. After extraction of cellular
tumor-RNA from blood samples, quantitative expression analysis of ERCC1
and the internal reference gene beta-Actin was done by real-time RT-PCR. His-
tomorphological regression was defined as major response when resected
specimen contained <10% of residual vital tumor cells, and minor response
with >10% of vital residual tumor cells.
RESULTS: Nineteen of 29 (65.5%) patients showed a minor histopathologi-
cal response and 10 (34.5%) showed a major-response to neadjuvant therapy.
ERCC1 RNA expression in blood of patients was detectable for ERCC1 in
82.8% and 100% for beta-Actin. The median ERCC1 expression was 0.62
(min.: 0.00, max.: 2.48) in minor-responders and 0.24 (min.: 0.00, max.:
0.45) in major-responders (p = 0.004). No significant associations were
detected between ERCC1 expression levels and patients clinical variables (his-
tology, tumor stage, gender etc.). Relative ERCC1 expression levels above
0.452 were not associated with major histopathological response (sensitivity:
68.4; specificity: 100%) and 13 of 19 patients with minor response to the
delivered neadjuvant therapy could be unequivocally identified.

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CONCLUSION: The applied method is technically feasable for the analysis of
cellular ERCC1 RNA expression in blood of patients with cancer of the esoph-
agus. Minor-responders to the applied therapy show a significant higher
ERCC1 expression level in their blood compared to major-resonders prior to
therapy. ERCC1 expression levels in blood appear to be highly specific to pre-
dict minor-response to neoadjuvant radiochemotherapy in patients with
esophageal cancer and could be applied to prevent expensive, noneffective,
and potentially harmful therapies in a substantial number (45%) of patients.




                                                                                WEDNESDAY
                                                                                ABSTRACTS




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   949      Strong Prognostic Value of Nodal Microinvolvement
            in Patients with Carcinoma of the Papilla of Vater
            Receiving No Adjuvant Chemotherapy
Dean Bogoevski*, Paulus G. Schurr, Jussuf T. Kaifi, Guell Cataldegirmen, Oliver Mann,
Yogesh K. Vashist, Emre F. Yekebas, Jakob R. Izbicki
General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg,
Germany
BACKGROUND: To assess the prognostic significance of nodal microin-
volvement in patients with carcinoma of the Papilla of Vater.
METHODS: From 1993 to 2003 at the University Clinic Hamburg, 777
patients were operated upon pancreatic and periampullary carcinomas. The
vast majority of patients were operated upon pancreatic ductal adenocarci-
noma (n = 566, 73%), followed by carcinoma of the papilla of Vater (n = 112,
14%), neuroendocrine carcinoma (n = 39, 5%), IPMN (n = 33, 4%) and distal
bile duct carcinoma (n = 27, 3%). Fresh-frozen tissue sections from 169 LN’s
classified as tumor free by routine histopathology from 57 patients with R0
resected carcinoma of the papilla of Vater who had been spared from adju-
vant chemotherapy were immunohistochemically (IHC) examined, using a
sensitive IHC assay with the anti-epithelial monoclonal antibody Ber-EP4 for
tumor cell detection. With regard to histopathology, 39 (63%) of the patients
were staged as pT1/pT2, 21 (37%) as pT3/pT4, 30 (53%) as pN0, while 38
(67%) as G1/G2.
RESULTS: Of the 169 “tumor free” LN’s, 91 LN’S (53.8%) contained Ber-EP4-
positive tumor cells. These 91 LN’s were from 40 (70%) patients. The mean
overall survival in patients without nodal microinvolvement of 35.8 months
(median-not yet reached) was significantly longer than that in patients with
nodal microinvolvement (mean 16.6; median 13) (p = 0.019). Multivariate
Cox regression analysis for overall survival revealed that grading was the
most significant independent prognostic factor (p = 0.001), followed by nodal
microinvolvement (p = 0.013).
CONCLUSIONS: The influence of occult tumor cell dissemination inLN’s of
patients with histologically proven carcinoma of the papilla of Vater supports
the need for further tumor staging through immunohistochemistry.




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    950      The Prognostic Superiority of Log Odds of Lymph
             Nodes in Stage III Colon Cancer
Jiping Wang*1,2, James M. Hassett1, Merril T. Dayton1, Mahmoud N. Kulaylat1
1Department of Surgery, State University of New York at Buffalo, Buffalo, NY;
2Department of Biostatistics, State University of New York at Buffalo, Buffalo, NY

BACKGROUND: Recent literature has shown that lymph node ratio (LNR)
and log of odds (LODDS) of positive lymph nodes (LN) can equally predict
prognosis in patients with breast cancer. We hypothesize that in patients with
stage III colon cancer, LODDS is even superior to LNR.
METHODS: 24,477 stage III colon cancer cases from SEER are included.
Based on LNR, patients are categorized into four groups, LNR1 to 4, according
to cutoff points 1/14, 0.25 and 0.50 and on LODDS, patient are divided into
five groups, LODDS 1 to 5, according to cutoff points –2.2, –1.1, 0 and 1.1.
Kaplan-Meier and Cox proportional hazard model were used to evaluate the
prognostic effect and estimate the relative risk (RR) and 95% confidence
interval (CI).




                                                                                     WEDNESDAY
                                                                                     ABSTRACTS
RESULTS: In stage III colon cancer, both LNR and LODDS are in agreement
in staging patients except LNR4. When stratify LNR4 into LODDS4 and
LODDS5, patients have significant different 5-year survival (33.5% vs. 23.3%,
p < 0.0001). The observed 5-year survival for stage IIIB patients classified as
LODDS1 to LODDS5 is 63.7%, 54.4%, 44.4%, 35.8% and 30.6% respectively
(p < 0.0001). On the other hand, the observed 5-year survival for patients
with stage IIIC diseases who are classified as LODDS2 to LODDS5 is 49.7%,
41.7%, 29.8% and 18.8% respectively (p < 0.0001). Univariate analysis shows
that LODDS, LNR, age, race, number of negative LN (NNLN) or total number
of LN examined (TNLN), tumor grade, size, and number of positive LN are
significantly associated with survival. Whereas, in the multivariate Cox
model, NNLN or TNLN, and LNR are not independently associated with sur-
vival after adjusting for LODDS.




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CONCLUSION: Patients with stage IIIB and IIIC colon cancer represent a het-
erogeneous group of patients with the majority either over-staged or under-
staged. Patients with LNR4 also represent a heterogeneous group. In patients
with stage III colon cancer, LODDS is a more accurate prognostic method
than AJCC N staging, NNLN, and TNLN.

Table 1. Multivariate Cox model
                               Tumor       Tumor
Variables    Age       Race                            TNLN       NPLN       LNR     LODDS
                                Grade       Size
 P-value   <0.0001   <0.0001 <0.0001      <0.0001       0.54     <0.0001     0.52    <0.0001
Risk Ratio  1.04       1.24      1.16       1.003      1.001       1.04      0.90      1.28
 95% CI 1.037–1.040 1.19–1.30 1.12–1.21 1.002–1.003 0.997–1.005 1.03–1.05 0.65–1.24 1.19–1.39




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   951      High Expression of Heparanase Is Significantly Associated
            with Dedifferentiation and Lymph Node Metastasis in
            Patients with Pancreatic Ductal Adenocarcinomas and
            Correlated to PDGF-A and via HIF1a to HB-EGF and bFGF
Andreas C. Hoffmann*1,2, Ryutaro Mori1, Daniel Vallbohmer2, Jan Brabender2,
Uta Drebber3, Stephan E. Baldus5, Mizutomo Azuma1, Ralf Metzger2,
Christina Hoffmann4, Arnulf H. Hölscher2, Kathleen D. Danenberg6,
Klaus L. Prenzel2, Peter V. Danenberg1
1Department of Biochemistry and Molecular Biology and Norris Comprehensive Cancer
Center, University of Southern California, Los Angeles, CA; 2Department of Visceral and
Vascular Surgery, University of Cologne, Cologne, Germany; 3Department of Pathology,
University of Cologne, Cologne, Germany; 4Department of Cardiology, Nuclear Medicine
and Molecular Imaging, Heart Center North Rhine-Westphalia, Bad Oeynhausen,
Germany; 5Department of Pathology, University of Düsseldorf, Düsseldorf, Germany;
6Response Genetics Inc, Los Angeles, CA

BACKGROUND: Pancreatic cancer still has the worst prognosis of all cancers
with a 5-year survival rate of 5%. Due to late symptoms of pancreatic cancer
and therefore often late diagnosis, only 10%–20% of the patients are eligible
for complete resection with curative intention, making it necessary to find
markers or gene-sets which would further classify patients into different risk
categories and thus allow more individually adapted multimodality treat-
ment regimens. Some of the most promising genes described also in other
entities are linked to angiogenesis. Especially HPSE has recently been dis-
cussed as a key factor in pancreatic cancer.
MATERIALS AND METHODS: Paraffin-embedded tissue samples were
obtained from 41 patients with pancreatic adenocarcinoma with a median age
of 65 years (range 34–85 years) at time of operation who were scheduled for pri-
mary surgical resection. After laser capture microdissection direct quantitative
real-time reverse transcriptase PCR (RT-PCR, TaqMan™) assays were performed
in triplicates to determine HPSE, HIF1a, PDGF-A, HB-EGF and bFGF gene
                                                                                          WEDNESDAY
                                                                                          ABSTRACTS
expression levels. Gene expression was normalized with beta-Actin. Decision
tree analysis and the maximal chi-square method were adapted to determine
which gene expression value best segregated patients into lymph node negative
and positive, and high and low dedifferentiation subgroups.
RESULTS: HPSE was significantly correlated to PDGF-A (p = 0.04) and to
HIF1a (p = 0.04). The correlation of HIF1a to bFGF and HB-EGF expression
was significant (p = 0.04, p = 0.02). We put all clinical, histopathological
parameters and the used genes as independent variables in a stepwise multi-
ple linear regression model with lymph node metastasis as the dependent
variable. The overall model fit had a significance level of p = 0.029 (<0.05)
with HPSE as the only significant predictor of lymph node metastasis, though
pT was almost included. Using a stepwise multiple regression analysis to eval-
uate the most influential of the accessible factors on the dedifferentiation of
the tumor the overall model fit was significant at a level of p = 0.003 (<0.05).
The most significant independent factor was HPSE for predicting the grade of
dedifferentiation.


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CONCLUSIONS: Considering the fact that Heparanase seems to be a highly
significant independent variable for lymph-node metastasis (p = 0.029; <0.05)
as well as for dedifferentiation (p = 0.003; <0.05) we assume that HPSE plays a
crucial role for the aggressiveness of pancreatic cancer. Though these results
were obtained on a relatively small number of patients, larger studies includ-
ing patients treated with actual chemotherapeutics seem to be warranted.




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     952       VEGF Gene Therapy Improves Anastomotic Healing in
               the Gastrointestinal Tract: Applications in Esophageal
               Surgery
Kristian Enestvedt*1, Shelley R. Winn1, Brian S. Diggs1, Luke Hosack1,
Barry Uchida2, Robert W. O’Rourke1, Blair A. Jobe1
1Department of Surgery, Oregon Health and Science University, Portland, OR; 2Dotter
Institue, Department of Interventional Radiology, Oregon Health and Science University,
Portland, OR
BACKGROUND: Anastomotic leak related to ischemia is a source of signifi-
cant morbidity and mortality. The aim of this study was to utilize VEGF gene
therapy for the purpose of up-regulating angiogenesis, increasing anasto-
motic strength, and ultimately preventing dehiscence.
METHODS: An opossum esophagogastrostomy model was employed. The
vascular endothelial growth factor (VEGF165) gene was incorporated into a
circular recombinant plasmid. The plasmid was complexed with a non-viral
synthetic vector, Jet-PEI. Control animals received plasmid devoid of
VEGF165 (n = 6). The experimental group received VEGF165 plasmid (n = 5).
After esophagogastrectomy and gastric tubularization, plasmid was injected
into the submucosa of the neoesophagus at the anastomotic site. Conduit
arteriography was performed before and 10 days after injection. Euthanasia
occurred on post-injection day 10 and the anastomosis was removed en bloc.
Blood flow was measured with laser-Doppler prior to euthanasia. Ex vivo
anastomotic bursting pressure was performed. Tissue samples were procured
for RNA extraction and Factor VIII staining. Microvessel counts were obtained
by 2 blinded observers. VEGF mRNA transcript levels were measured with
quantitative RT-PCR using custom primers.
RESULTS: There were no deaths in either group. There was one leak in the
control group. Experimental animals demonstrated significantly increased
bursting pressure and neovascularization compared to controls (Table). In
addition, there was a strongly positive correlation between the number of
                                                                                                     WEDNESDAY
microvessels and bursting pressure (r = 0.808, p = 0.015, Pearson’s). On angio-                      ABSTRACTS
graphic examination, treated animals demonstrated more neovascularization
compared to controls. RT-PCR demonstrated a 2.1 fold increase in VEGF
mRNA tissue transcript levels in treated animals compared to controls (p =
0.05, t-test).
DISCUSSION: This first description of successful gene therapy in the gas-
trointestinal tract using VEGF165 transfection demonstrates improved anas-
tomotic healing in a clinically relevant model which may directly translate to
human application.

                                                Blood Flow at Harvest
                         Microvessels (#/hpf)                            Bursting Pressure (mm Hg)
      Groups                                       (ml/min/100gm)
                          (p = 0.032, t-test)                                 (p = 0.021, t-test)
                                                   (p = 0.191, t-test)
     Control                    20.33                     4.18                    86.73
   Experimental                 33.87                     6.68                    104.25
*all numbers are mean values




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    953      Loss of Heterozygosity Portends Poor Survival of
             Patients with Resected Periampullary Cancer
Jan Franko*1, Alyssa M. Krasinskas2, Marina N. Nikiforova2, Yuri E. Nikiforov2,
Steven J. Hughes1, Kenneth K. Lee1, David L. Bartlett1, Herbert Zeh1,
Arthur J. Moser1
1Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh,     PA;
2Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA

BACKGROUND: Traditional AJCC staging system for periampullary adenocar-
cinoma has been well validated but improvements in prognostic accuracy are
still needed. We hypothesized that molecular and genetic methods may predict
biological behavior and postoperative survival independently of stage.
METHODS: Pancreatic ductal and ampullary carcinomas treated by pancre-
aticoduodenectomy in 2006 (n = 50) were subjected to laser capture microdis-
section followed by loss of heterozygosity (LOH) analysis at 14 different
chromosomal loci including 5q (APC), 6q (thrombospondin), 9p (p16), 10q
(Pten), 12q (MDM2), 17p (p53), and 18q (DDC/DPC4). Mutations at k-ras
exon 1 (codons 12 and 13) were assessed by PCR. The relationship between
genetic alterations and clinical outcome was studied.
RESULTS: Negative resection margins were achieved in 43 (86%) cases. AJCC
stage distribution was: Ia/b (3), IIa (16), IIb (29), and III (2). K-ras mutations
were observed in 31 cases (62%). Allelic losses were identified in 26 (52%)
with a median fractional allelic loss score of 18% (range 7–64%). There was
no concordance between LOH and k-ras mutations (McNemar p = 0.405). Sur-
vival was significantly shorter in patients with allelic losses (17.5 versus 21.2
months; p = 0.039). Both higher AJCC stage (HR = 1.29, p = 0.018) and pres-
ence of LOH (HR = 6.60, p = 0.027) were identified as independent predictors
of shorter survival in a Cox regression model. Increased fractional allelic loss
portended worsened survival (HR = 1.043 per percent loss, p = 0.034),
whereas age and k-ras mutations did not.




Figure 1. Survival of patients with resected periampullary cancer stratified by LOH status.

CONCLUSION: Loss of heterozygosity predicts survival independently from
stage in resected periampullary cancer. Allelic losses indicate more aggressive
tumor biology and may improve risk stratification in future clinical trials.


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10:30 AM – 12:00 PM PLENARY SESSION VII                                        25ABC
         Moderators: O. Joe Hines, Los Angeles, CA
                     Blair A. Jobe, Portland, OR
  1018      Long-Term Results After Minimally Invasive Repair of
            Giant Paraesophageal Hernia in 105 Patients
Katie S. Nason*, James D. Luketich, Rodney J. Landreneau, Irfan Qureshi,
Samuel B. Keeley, Shannon E. Trainor,
Manisha Shende, Arjun Pennathur
Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center,
Pittsburgh, PA
BACKGROUND: Laparoscopic repair of giant paraesophageal hernias (LRG-
PEH) is increasingly utilized with excellent short-term results. Long-term (>60
months) clinical and radiographic results, however, are poorly described. Our
objective was to evaluate the long term results after minimally invasive repair
of GPEH.
METHODS: We performed a review of patients undergoing elective LRGPEH
(1995 to 2002) who had a minimum of 60-month clinical or radiographic
follow-up. Clinical outcomes, barium swallow and quality-of-life measures
were reviewed.
RESULTS: There were 256 patients who underwent LRGPEH in this time-
period. A minimum of 60-month clinical or radiographic follow-up was avail-
able on 105 patients. Hernia reduction, sac excision, crural repair (13.7%
mesh-reinforcement) and fundoplication were performed in 98%. A Collis-
gastroplasty was performed in 89 patients (85%). Median time for clinical
follow-up was 82 months (60–124). GERD-Health-Related-Quality-of-Life
(GERD-HRQL) scores were available for 98 patients, with a mean 3.9 ± 6
(median 1, range 0–23; 0 = no symptoms–45 = worst). Occasional heartburn
and dysphagia to solids were the most common persistent symptoms in 30%
of patients. According to the GERD-HRQL scale (excellent = 0–5; good = 6–10;

                                                                                         WEDNESDAY
fair = 11–15; poor = 16–45), the results were excellent to good in 86.8% of              ABSTRACTS
patients, confirming the mild nature of the symptoms. Barium-swallow was
obtained in 79/105 (75%) at a median time of 80 months (60–126). Radio-
graphic recurrence of a hiatal hernia was identified in 9 (11%). GERD-HRQL
scores were excellent in 77% of patients with radiographic recurrence com-
pared to 72% in patients without radiographic recurrence. When patients
were queried regarding satisfaction with surgery, over 90% (83/90) were satis-
fied or very satisfied. Re-operation was required in 5 (4.7%) patients for symp-
tomatic recurrence at a median 44 months post-operative (range 8–80).
CONCLUSIONS: This report summarizes the long-term results (7 years) of
LRGPEH in 105 patients. Reoperation was required for symptomatic recur-
rence in only 4.7%. The GERD-related quality of life was well preserved and
90% of patients were satisfied with their surgery.




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   1019 Perioperative Treatment with Infliximab (IFX) in
        Patients with Crohn’s (CD) and Ulcerative Colitis (UC)
        Is Not Associated with Increased Rate of Postoperative
        Complications
Hiroko Kunitake*1, Richard Hodin1, Paul C. Shellito1, Bruce E. Sands2,
Joshua R. Korzenik2, Liliana Bordeianou1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Gastroenterology, Massachusetts
General Hospital, Boston, MA
PURPOSE: Small studies looking at the impact of IFX on postoperative com-
plications after abdominal surgery in patients with CD or UC have had con-
tradictory findings. Our aim was to clarify the relationship between IFX use
and postoperative complications in a large cohort of patients.
METHODS: 413 consecutive patients—45.5% with CD, 30.5% with UC,
23.8% with indeterminate colitis—underwent abdominal surgery at Massa-
chusetts General Hospital between January 1993 and December 2006. Of
these patients, 101 (24.5%) received IFX 8 weeks pre-surgery. They were com-
pared to the other 312 with respect to demographics, Charlson Comorbidity
Index (CCI), presence of preoperative infections, rate of steroid use, and
nutritional status by using Chi Square, Fisher’s Exact or Student’s T-test. The
two groups’ rates of surgical complications, including death rates, anasto-
motic leaks, infections, thrombotic complications, prolonged ileus/small
bowel obstructions, cardiac and hepatic/renal complications were compared
with chi square analysis. Statistically significant differences were further eval-
uated with logistic regression analysis, controlling for rates of preoperative
infections and steroid exposure.
RESULTS: Patients in both groups were similar with respect to gender (59.4
vs. 48.1, p = 0.06), age (36.1 vs.37.8, p = 0.32), Charlson Comorbidity Index
(5.7 vs. 5.3, p = 0.83), concomitant steroids (75.3 vs. 76.9%, p = 0.89), preop-
erative albumin level (3.3 vs. 3.2, p = 0.36), rate of emergent surgery (3.0 vs.
3.5%, p = 0.79). IFX patients had higher rates of CD (56.4 vs. 41.9%, p < 0.05),
concomitant azathioprine use (34.6 vs. 16.6%, p < 0.0001), and lower rates of
intraabdominal abscess (3.9 vs. 11%, p < 0.05). Following surgery, the two
groups had similar rates of death (0.3 vs. 2%, p = 0.09), anastomotic leak
(2.98 vs. 2.9%, p = 0.97), thrombotic complications (0.6 vs. 2.9%, p = 0.06),
prolonged ileus/small bowel obstructions (2.8 vs. 3.9%, p = 0.59), cardiac (0.6
vs. 0%, p = 0.42), hepatic or renal complications (0.6 vs. 0.9%, p = 0.72). On
initial chi square analysis, rates of postoperative infections appeared higher in
patients who did not receive IFX (1.0 vs. 5.7%, p < 0.05). However, the differ-
ence was not statistically significant on logistic regression analysis (OR 2.5,
p = 0.14) after controlling for steroid use (OR = 1.2, p = 0.74) and preoperative
infection (OR = 1.2, p = 0.76).
CONCLUSIONS: In a surgical referral center where decisions to treat with
IFX are frequently made in collaboration between gastroenterologists and sur-
geons, preoperative IFX was not found to be associated with an increase in
postoperative surgical complications.



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   1020         Use of Infliximab Within Three Months Prior to
                Ileocolonic Resection Is Associated with Significant
                Adverse Postoperative Outcomes in Crohn’s Patients
Kweku A. Appau*, Victor W. Fazio, James M. Church, Bo Shen, Feza H. Remzi,
Scott A. Strong, Bret Lashner, Takayuki Yamamoto, Paris P. Tekkis, Jeffery Hammel,
Ravi P. Kiran
Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH
BACKGROUND: Few studies have evaluated postoperative outcomes of
Crohn’s disease (CD) patients treated with infliximab prior to surgery. The
aim of this study is to determine 30-day postoperative outcomes for CD
patients treated with infliximab within three months before ileocolonic resection.
METHODS: Retrospective review of prospectively accrued Crohn’s database
of patients undergoing ileocolonic resection after 1998. Patient, disease, oper-
ative characteristics, 30-day complications and mortality for patients treated
with infliximab (INF) within three months preoperatively were compared
with those never treated with infliximab (NINF). Since adverse outcomes
detected in the infliximab group could potentially reflect its use in sicker
patients rather than ill-effects of the medication,outcomes for INF were com-
pared with non infliximab patients undergoing surgery before 1998 (pre INF).
RESULTS: 60 of 389 CD patients undergoing ileocolonic resection received
infliximab. INF and NINF had similar gender (p = 0.73), cormorbidity
(p = 0.99), severity of CD (p = 0.35), smoking history (p = 0.80), indication for
surgery (p = 0.30), surgical technique (p = 0.91), ASA score (p = 0.35), and
abscess at/before surgery (p = 0.43). Intraoperative complications,intra or
post-operative transfusions, steroid and immunosuppressive use were similar
between groups. Postoperative ileus, cardiopulmonary, neurological, and renal
complications were similar. Significant findings on univariate analysis are
shown in table. On Cox multivariate analysis, INF had significantly higher

Table 1.

                                                                                                               WEDNESDAY
     30-day                                                                 Odd’s Ratio                        ABSTRACTS
                     NINF (n = 329)     INF (n = 60)   Pre-INF (n = 69)                          P-value
 complications                                                               (95%CI)
    Urinary                 0%             1.7%              0.0%                               0.15* 0.47†
 complications
     Wound                0.30%            0.0%              1.4%                                1.0* 1.0†
   dehiscence
     30-day                 0%             1.7%              0.0%                                1.0* 1.0†
    mortality
  Readmission              9.4%           20.0%              2.9%           2.40 (1.15,5)*     0.019* 0.007†
      rate                                                                8.37 (1.79,39.15)†
     Sepsis                9.7%           20.0%              5.8%         2.32 (1.12, 4.82)*   0.024* 0.021†
                                                                          4.06 (1.23,13.37)†
 Intraabdominal            4.3%           10.0%              4.3%         2.50 (0.92, 6.79)*    0.10* 0.30†
     abscess                                                              2.44 (0.58,10.23)†
   Anastomotic             4.3%           10.0%              1.4%                              0.09* 0.049†
       Leak
  Re-operation             3.0%            8.3%              0.0%          2.9 (0.95,8.81)*     0.06* 0.02†
*p: NINF VS. INF. †p: Pre-INF VS. INF



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risk of 30-day postoperative readmission (p = 0.045), sepsis (p = 0.027), and
intra-abdominal abscess (p = 0.005). For INF patients, stoma use (n = 17) was
associated with a significantly lower risk of sepsis (0% vs 27.9%, p = 0.013).
Despite similar pre and perioperative factors, INF had significantly higher
postoperative sepsis (20 vs. 5.8%, p = 0.021), anastomotic leak (p = 0.04) and
readmissions (20% vs. 2.9%, p = 0.007) when compared with pre-INF.
CONCLUSION: Use of infliximab within three months prior to surgery is
associated with increased postoperative sepsis, abscess and re-admissions in
CD patients. Presence of stoma above anastomosis appears to protect patients
treated with infliximab.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  1021      Selective Management of Iatrogenic Colonoscopic
            Perforations
Dimitrios V. Avgerinos*, Omar H. Llaguna, Andrew Y. Lo, I. Michael Leitman
Surgery, Beth Israel Medical Center, New York, NY
INTRODUCTION: Colonoscopy is a safe procedure in the hands of experi-
enced physicians. However, perforations are unavoidable and occur in rare
occasions, with a reported incidence rate of 0.03%–0.19% in the literature.
The management of those perforations remains controversial. The present
study evaluates the treatment options for patients with colonoscopic perfora-
tions based on their clinical presentation and indications for colonoscopy.
METHODS: After Institutional Review Board approval, a retrospective analy-
sis of all the patients that were treated for colonic perforation after diagnostic
or therapeutic colonoscopy at a tertiary care teaching hospital over a twenty
one-year period (from January 1986 to October 2007). Patient demographics,
past medical and surgical history, type and indications for colonoscopy,
colonoscopic findings, clinical presentation after suspected perforation, type
of operation and intra-operative findings when operative management was
undertaken, and method of non-operative approach were analyzed. Injury
was verified by ability to visualize the intra-peritoneal space or diagnostic
imaging. The decision to perform surgery was based upon the physical find-
ings of peritonitis, signs of infection or hemodynamic changes.
RESULTS: A total of 105,786 colonoscopies during the study period. Thirty-
five perforations occurred (0.033% perforation rate). Twenty (57%) of these
perforations followed routine diagnostic colonoscopy, whereas the rest 15
(43%) occurred following some type of therapeutic colonoscopy. Nineteen
(95%) of the patients that previously underwent diagnostic colonoscopy
required operative treatment, whereas only three patients (20%) of the
patients that had perforation following therapeutic colonoscopy required
operation and were managed conservatively with antibiotics and bowel rest.
Both groups had comparable outcomes, with minimal morbidity and zero
mortality.
                                                                                     WEDNESDAY
                                                                                     ABSTRACTS
CONCLUSIONS: Although many surgeons recommend operation for all
colonoscopic perforations, the present study shows that careful selection of
patients who suffer bowel perforations during colonoscopy may be managed
without surgery. Perforations resulting from therapeutic colonoscopies usu-
ally result in small injuries to the bowel wall, which often heal without the
need for surgical intervention. On the other hand, perforations from diagnos-
tic colonoscopies are usually large linear lacerations that require surgical
repair or resection.




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  1022     Pancreatic Fistula Rates After 442 Distal
           Pancreatectomies: Staplers Do Not Decrease
           Fistula Rates
Cristina R. Ferrone*, Andrew L. Warshaw, J. Ruben Rodriguez, Sarah P. Thayer,
Carlos Fernandez-Del Castillo
Surgery, Massachusetts General Hospital, Boston, MA
INTRODUCTION: Pancreatic fistula is a common complication and a major
source of morbidity after distal pancreatectomy (DP). We evaluated consecu-
tive patients undergoing DP to determine if the type of stump closure could
decrease fistula rates.
METHODS: Retrospective review of a prospectively collected database
between 2/1994 and 10/2007 identified 442 patients who underwent distal
pancreatectomy. Clinicopathologic variables were reviewed. Pancreatic fistula
was defined as a JP amylase >300U/L and an output >30 cc on POD#5 or
development of a postoperative collection up to POD 30.
RESULTS: Distal pnacreatectomy was performed in 442 patients with a mor-
tality of <1% and a pancreatic fistula rate of 29% (130/442). Distal pancreate-
ctomy with splenectomy was performed in 311 (70%) patients. Additional
organs were resected in 99 (22%) patients and a laparoscopic procedure was
performed in 12 (3%) patients. The pancreatic stump was closed with a fish-
mouth suture closure in 228, of whom 69 (30%) developed a fistula. If a sepa-
rate ductal ligation was performed the fistula rate was 27.6% (44/158) vs. 36%
(25/70) if the duct was not ligated. A peritoneal falciform patch was used in
106, with a fistula rate of 30% (33/106). Stapled compared to stapled with sta-
ple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (10/30). The
pancreatic fistula rate was lowest (15%; 3/20) in patients who had a fish
mouth suture closure with an omental patch. There is no significant differ-
ence in the rate of fistula formation between the groups (p = 0.33).
CONCLUSIONS: In a series of 442 distal pancreatectomies the pancreatic fis-
tula rate was 29%. Staplers with or without staple line reinforcement do not
significantly reduce fistula rates after distal pancreatectomy. Reduction of
pancreatic fistulas after DP remains an unsolved challenge.




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       49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  1023            Reoperation for Recurrent Pain Following Failed
                  Primary Operation in Chronic Pancreatitis
Jeffrey S. Browne1, Nicholas J. Zyromski1, Harish Lavu1, Marshall S. Baker2,
James A. Madura1, Thomas J. Howard*1
1Surgery,Indiana University, Indianapolis, IN; 2Surgery, Northwestern University,
Chicago, IL
INTRODUCTION: Resection and drainage procedures achieve long-term
pain relief in approximately 80% of patients with chronic pancreatitis. In the
20% of patients who develop recurrent pain following failed primary opera-
tion, little data exists on effective treatment options. This study reports our
experience with reoperation for recurrent pain following failed primary oper-
ation in patients with chronic pancreatitis.
METHODS: Over 18 years (1988–2006), 316 pts. with histopathologically
verified chronic pancreatitis underwent primary operation to achieve pain
relief. Etiologies of chronic pancreatitis included: ETOH (38%), pancreas
divisum (30%), idiopathic (25%), and miscellaneous (7%). Primary operations
included: pancreaticoduodenectomy [PD] (N = 100), duodenum preserving
pancreatic head resection [DPPHR] (N = 53), Peustow pancreaticojejunostomy
[PPJ] (N = 51), and distal pancreatectomy [DP] (N = 112). Forty patients (13%)
who failed primary operation had reoperations for pancreatic duct strictures
(N = 25), biliary strictures (N = 6) or parenchymal disease progression (N = 9)
identified by radiographic imaging (CT, MRCP, EUS, ERCP) and were retro-
spectively reviewed.
RESULTS: Table.

Table 1.
    Reoperation           N         Morbidity‡ > IIIa              New Endocrine Insuff.   Pain Relief
        TP                7            2 (29%)                           5 (71%)              83%
     Revision             14            1 (7%)                           2 (14%)              50%
        DP                3            2 (67%)                           1 (33%)              50%
                                                                                                         WEDNESDAY
      DPPHR               8            2 (25%)                           2 (25%)              25%        ABSTRACTS
        PD                8            3 (38%)                           3 (38%)              13%
‡Grading   system of DeOliveira (Ann Surg 2006:244:931–9.) TP = total pancreatectomy


CONCLUSIONS: In reoperations, TP achieves the best pain relief (83%) at a
high cost of new endocrine insufficiency. Revision operations have a low
morbidity, less endocrine insufficiency, and a 50% incidence of pain relief.
Pancreatic head resections (DPPHR, PD) are less effective (25%, 13% pain
relief) than when used as the primary operation.




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10:30 AM – 12:00 PM         VIDEO SESSION III: NOTES: WHERE ARE                    27B
                            WE TODAY?
            Moderators:     Brian J. Dunkin, Houston, TX
                            Nathaniel J. Soper, Chicago, IL
  1024      NOTES: Dissection of the Critical View of Safety
            During Transcolonic Cholecystectomy
Edward Auyang*1, Khashayar Vaziri1, Eric S. Hungness1, John A. Martin2,
Nathaniel J. Soper1
1Department of Surgery, Northwestern University, Chicago, IL; 2Gastroenterology,
Northwestern University, Chicago, IL
Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging field
that is driving the development of new surgical technology and techniques.
Before NOTES gains widespread popularity, it must be proven to be a safe and
efficacious technique. In this porcine model, we demonstrate the NOTES dissec-
tion of the critical view of safety during cholecystectomy which allows for safe
identification and division of the cystic duct and artery. Demonstration of this
view has been shown to reduce bile duct injuries in human patients.

  1025      Single Port Access (SPA) Cholecystectomy
Paul G. Curcillo, Erica R. Podolsky*, Steven J. Rottman
Surgery, Drexel University College of Medicine, Philadelphia, PA
The desire to minimize incisions has moved us to explore novel methods for
standard laparoscopic procedures. We have developed a Single Port Access (SPA)
surgical technique that allows us to perform a variety of standard laparoscopic
procedures through a single umbilical incision (<18 mm). We have successfully
applied this technique to cholecystectomy. A new approach of trocar placement
and positioning within a single umbilical incision allows for standard laparo-
scopic dissection to be performed in SPA Cholecystectomy. We believe this tech-
nique can be easily taught and made available to our colleagues and ultimately
to the large number of patients requiring cholecystectomy.

  1026      Single Incision Laparoscopic Cholecystectomy Using
            Flexible Endosocopy
Glenn Forrester*, John N. Afthinos, Eugenius J. Harvey, Steven Binenbaum,
Grace J. Kim, Julio Teixeira
Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY
We describe a technique for performing laparoscopic cholecystectomy
through a single periumbilical incision using flexible endoscopic technology.
Both a dual-channel flexible endoscope and a 5 mm laparoscopic trocar are
inserted into the peritoneal cavity through the same skin incision. The dissec-
tion of the gallbladder and the hilum is performed mostly using endoscopic
tools, while ligation of hilar structures is done using standard clips. Though
the procedure is technically challenging, the skills developed may serve as a
bridge to performing NOTES.

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  1027       NOTES-Assisted Roux-en-Y Gastric Bypass
Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3, Nicolas C.
Buchs1, Priya A. Jamidar5, Margherita Cadeddu4, Jean Fasel6, Philippe Morel1
1Digestive Surgery, University Hospital Geneva, Geneva, Switzerland; 2Department of
Visceral and Transplantation Surgery, University Bern, Bern, Switzerland; 3Imperial
College, London, United Kingdom; 4Department of Surgery, McMaster University,
Hamilton, ON, Canada; 5Section of Digestive Diseases, Yale University, New Haven, CT;
6Division of Anatomy, University Geneva, Geneva, Switzerland

BACKGROUND: NOTES-assisted Roux-en-Y gastric bypass (RYGB) might
offer certain advantages, but the technical feasibility is unknown.
METHODS AND DESIGN: We have performed NOTES-assisted RYGB in 4
human cadavers.
VIDEO: The video shows pouch creation using a flexible gastroscope intro-
duced transvaginally. Articulated linear staplers placed transumbilically
transect the stomach. Measurement of small bowel is done with flexible and
rigid graspers. A flexible transesophageal stapler is used for the gastrojejunos-
tomy, a linear stapler for the jejuno-jejunal anastomosis.
CONCLUSION: The video demonstrates the technical feasibility of RYGB in
human cadavers using a NOTES-assisted approach.

  1028       Reverse NOTES: Transgastric ERCP
Yoav Mintz, Santiago Horgan, Thomas J. Savides, John Cullen*, Bryan J. Sandler,
Garth R. Jacobsen, Mark A. Talamini
Department of Surgery, University of California, San Diego, San Diego, CA
Choledocholithiasis following Roux-en-Y gastric bypass is a challenging prob-
lem to manage due to the anatomic changes. This case represents a novel
approach with collaboration between surgeons and gastroenterologists when
dealing with this problem. The patient was taken to the operating room and a
                                                                                        WEDNESDAY
                                                                                        ABSTRACTS
laparoscopic gastrotomy was performed, through which ERCP was then
accomplished via the excluded gastric remnant. These cases will undoubtedly
become more and more common as gastric bypass is done more often and the
patients live longer with their altered anatomy.




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12:30 PM – 1:30 PM                    QUICK SHOTS III                                     24ABC
                                      Timothy M. Pawlik, Baltimore, MD
                                      Magesh Sundaram, Morgantown, WV
   1029          Outcome of Esophagectomy Based on Surgical
                 Subspecialty Training
Brian R. Smith*, Marcelo W. Hinojosa, Kevin M. Reavis, Ninh T. Nguyen
Department of Surgery, UC Irvine Medical Center, Orange, CA
BACKGROUND: Esophagectomy is commonly performed by general or tho-
racic surgeons and the type of operation is often dictated by the surgeons’
training.
OBJECTIVE: The objective of the current study was to investigate the vol-
ume of operations and outcomes of esophagectomies performed by subspe-
cialty vs. non-subspecialty surgeons.
DATA SOURCES AND STUDY SELECTION: Clinical data of patients who
underwent partial or total esophagectomy for esophageal cancer from 2003
through 2007 were obtained from the University Health System Consortium
database. This database contains data from all major teaching hospitals in the
US. The data were categorized between general vs. thoracic surgeon and were
reviewed for the type and number of operations performed by each surgical
specialty, demographics, length of stay, and postoperative morbidity and
mortality.
DATA SYNTHESIS: During the 60-month period, a total of 2,657 esoph-
agectomies were performed; 1,079 (41%) were performed by general sur-
geons, while 1,578 (59%) were performed by cardiothoracic surgeons.
CONCLUSIONS: The majority of esophagectomies for carcinoma of the
esophagus are being performed by subspecialty trained surgeons. Thoracic
specialists perform more Ivor-Lewis esophagectomies, while general surgeons
favor the blunt transhiatal approach. Despite these differences, specialty
training does not appear to be an important factor in determining the out-
come for this complex operation.
                                             General Surgeons   Cardiothoracic Surgeons   p-value
      Total no. of esophagectomies                1,079                  1,578              N/A
     Procedure, blunt transhiatal (%)               56                     37             <0.01*
        Procedure, Ivor-Lewis (%)                   44                     63             <0.01*
              Gender: male                         4.3                    4.2               N/A
          Mean ICU stay (days)                     8.4                    9.7             0.287†
    Mean length of hospital stay (days)            16.6                   16.9            0.800†
        Overall complications (%)                   55                     52              0.11*
         Observed mortality (%)                     3.6                   2.9              0.31*
        Mortality index (obs/exp)                  0.79                  0.65               N/A
*Chi square test; †2-sample t-test.




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         49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   1030           Optimizing Outcome Measurement in Pancreatic
                  Surgery: Can NSQIP Measure Up?
Craig P. Fischer*1,2, Thomas A. Aloia1,2, Bridget N. Fahy1,2, Stephen L. Jones1,2,
Barbara L. Bass1,2
1Surgery, The Methodist Hospital, Houston, TX; 2Weill Medical College of Cornell
University, New York, NY
INTRODUCTION: A validated system to measure and compare outcomes in
complex GI and HPB surgery has not been established. The ACS NSQIP has
been criticized as inadequate, citing lack of procedure-specific outcomes and
limitations inherent to sampling methodology. Institutional registries have
been an alternative, but do not allow site to site comparison. To assess the
accuracy of NSQIP data collection, we investigated the utility of our institu-
tional NSQIP data to capture procedure specific outcomes after a complex
abdominal procedure – pancreatectomy.
METHODS: From July 2006–July 2007 31,332 surgical procedures were per-
formed at our medical center. 1,638 (5.2%) were captured by the sampling
method of NSQIP, including 32 pancreatic resections. Our institutional pan-
creatic database captured 75 patients having pancreatic resection during the
same time period and included NSQIP occurrence categories and pancreatic
fistula (PF) rates (ISGPF grade A, B, C). NSQIP nurses were instructed in ISGPF
definitions and asked to retrospectively categorize patients with PF. Postoper-
ative occurrences were compared.
RESULTS: NSQIP captured equivalent outcomes to the pancreatic surgery
database including rates of pancreatic fistula (Table 1). However, grading of
pancreatic fistula by NSQIP increased the ISGPF grade in 3 cases. Two cases
were upgraded from A to B, due to the discovery of a drain in-situ in the out-
patient setting. NSQIP discovered readmission of one patient, upgrading this
patient from grade A to B. All three upgrades were not detected by the pancre-
atic registry, which only focused on in-hospital morbidities.
CONCLUSIONS: The data collected within the NSQIP at our institution com-
pares favorably to a procedure specific clinical database. The sampling meth-
                                                                                       WEDNESDAY
odology inherent to NSQIP did not compromise the validity of outcome                   ABSTRACTS
observations. The quality of data collection by NSQIP nurse reviewers may
lead to more accurate appraisal and interpretation of outcomes due to lack of
self reporting bias. The collected PF data were sufficient to allow accurate
grading according the ISGPF system. These findings suggest that NSQIP may
be further improved by consensus development of procedure specific out-
come variables.
Table 1. NSQIP Pancreatic Surgery Outcomes
                 Category               Pancreatic Registry      NSQIP       p-value
                      N                         75                 32          NA
                    Death                     2.66%              3.13%         NS
              Wound Infection                 9.33%              12.5%         NS
              Organ/Space SSI                13.33%              9.38%         NS
                Respiratory                    8.0%              6.25%         NS
                  Urinary                     5.33%              9.36%         NS
           Pancreatic Fistula (total)         21.3%              15.63%        NS
SSI – surgical site infection.


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  1031      The Learning Curve of Laparoscopic Rectal Resection
            for Cancer: A Single-Center Experience
Marco Montorsi*, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi, Riccardo Rosati
General Surgery, University of Milan, Istituto Clinico Humanitas IRCCS, Milan, Italy
INTRODUCTION: Laparoscopic rectal resection (LRR) has been shown to be
feasible but challenging. The role of the learning curve in this surgery is not
fully elucidated. To evaluate its impact, we prospectively collected, in two
consecutive periods, operative and outcome data of pts submitted to LRR for
cancer at a single institute performed by four surgeons equally experienced in
laparoscopic surgery.
METHODS: From November 1999 to May 2007, 141 patients with rectal can-
cer were treated by laparoscopy. Learning curve was evaluated in two consec-
utive periods, 1999 to 2003 (first period) and 2004 to 2007 (second period).
The evaluated variables were: operative data (operative time, conversion rate,
intraoperative complications), short-term outcomes (postoperative complica-
tions, mortality, lenght of hospital stay, readmission rate), and oncological
outcomes (site of the tumor, number of lymphnodes, resection margins, port
recurrence).
RESULTS: Number of patients (71 and 70), demographic data and oncologi-
cal stage were similar in the two periods. No differences were found in opera-
tive time (274 and 294 minutes, p = 0.12), intraoperative (7% and 12.9%,
p = 0.25) and postoperative complications rate (19.7% vs 17.1%, p = 0.69).
Anastomotic leakages occured in 8 patients, equally in the first (11.3%) and
in the second period (11.4%, p = 0.97). Lenght of hospital stay decreased in
the second period (9 vs 8 days, p = 0.18). There were no readmission in hospi-
tal after discharge in both groups. No differences were observed among the
four surgeons in operative data and outcomes. The number of resected
lymphnodes per patient (18) was the same in the two periods. There were sta-
tistically significant differences in the distribution of tumor site (percentage
of the tumors located in the mid and lower rectum was 45.1% in the first
period and 72.9% in the second period, p = 0.01) and in conversion rate
(23.9% vs 11.4%, p = 0.05). There were 2 microscopical infiltrations of the
distal margin (2.8%) and 1 port site metastasis (1.4%), all in the second
period. Five yrs overall and disease free survival rates were 82.1% and 75.6%.
Disease free survival rate was significantly lower when conversion to open
surgery was required (78.7% vs 61.8%, p = 0.04).
CONCLUSIONS: When performed by experienced surgeons, LRR for cancer
is feasible, safe and oncologically effective since the beginning of the experi-
ence. The parameters which significantly changed during the learning curve
were conversion rate and the anatomic site of the rectal tumors. Operative
time and morbidity did not show an improvement, probably due to a differ-
ent case-mix in the second period (more distal tumours).




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   1032 Short-Term Outcomes After Laparoscopic-Assisted
        Compared to Open Colectomy for Cancer
Karl Y. Bilimoria*1, David J. Bentrem1, Heidi Nelson2, Steven J. Stryker1,
Clifford Y. Ko3, Nathaniel J. Soper1
1Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago,
IL; 2Department of Surgery, Mayo Clinic, Rochester, MN; 3Department of Surgery, UCLA
and Greater Los Angeles VA, Los Angeles, CA
BACKGROUND: Randomized clinical trials have demonstrated that laparo-
scopic-assisted colectomy (LAC) outcomes are comparable to open colectomy
(OC) when performed by experts; however, LAC has not been examined in a
multi-institutional setting outside of trials. The objectives of this study were
to assess differences in perioperative outcomes for LAC compared to OC.
METHODS: Using the American College of Surgeons-National Surgical Qual-
ity Improvement Project’s (NSQIP) participant-use dataset, patients were
identified who underwent colectomy for cancer at 120 participating hospitals
in 2005–2006. Multiple logistic regression was used to assess the risk-adjusted
association between surgical approach (LAC vs. OC) and 30-day outcomes.
Propensity scores were used to adjust for group differences. Patients were
excluded if they underwent emergent procedures, were ASA class 5, or had
metastatic disease.
RESULTS: Of the 3,059 patients who underwent colectomy for cancer, 837
(27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no
significant differences in age, comorbidities, ASA class, or BMI between
patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likeli-
hood of developing any adverse event (includes wound, cardiac, pulmonary,
renal, neurologic, or hematologic complications) compared to OC (14.6% vs.
21.7%; OR 0.64, 95% CI 0.51–0.81, P < 0.0001). Mean length of stay was sig-
nificantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P < 0.0001). There was no
difference between LAC and OC in the rate of returns to the operating room
(5.5% vs. 5.8%, P = 0.79) or 30-day mortality (1.4% vs. 1.8%, P = 0.53).

                                                                                         WEDNESDAY
CONCLUSIONS: LAC was utilized in one-quarter of patients with colon cancer.              ABSTRACTS
LAC was associated with lower morbidity and length of stay in select patients.




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  1033      Patient Demographics and Surgeon Volume in
            Pancreatic Resection Mortality
Robert W. Eppsteiner*, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah
Surgery, University of Massachusetts, Worcester, MA
INTRODUCTION: Improved outcomes after pancreatic resection (PR) by
high volume (HV) surgeons have been reported in single center studies which
may be confounded with potential selection and referral bias. We attempted
to determine if improved outcomes by HV surgeons are reproducible when
patient demographic factors are controlled at the population level.
METHODS: Using the Nationwide Inpatient Sample (NIS), discharge records
for all non-trauma PR (n = 3,705) were examined from 1998–2005. Surgeons
were divided into two groups: high volume (HV; ≥5 operations/year) or low
volume (LV; <5/year). The Elixhauser index adjusted for patient comorbidity.
We created a logistic regression model to examine the relationship between
surgeon type and operative mortality while accounting for patient/hospital
factors. To eliminate differences in cohorts and determine the true effect of
surgeon volume on mortality, case-control groups based on patient demo-
graphics were created using propensity scores.
RESULTS: 128 HV and 1,329 LV surgeons performed 3,705 PR in 449 hospi-
tals across 11 states that report surgeon identifier information over the 8-year
period. Patients who underwent PR by HV surgeons were more likely to be
male, white race, and a resident of a high-income zip code (p < 0.05). HV sur-
geons had a lower unadjusted mortality compared to LV surgeons (2.5% vs.
6.8% p < 0.0001). Significant independent factors for in-hospital mortality
after PR included increasing age, male gender, Medicaid insurance and sur-
gery by HV surgeon (Table). Propensity scoring was used to create matched
HV and LV groups; when HV surgeons performed PR an in-hospital mortality
benefit was found across all groups.
CONCLUSIONS: PR by a HV surgeon in this cohort was independently asso-
ciated with a 60% reduction in in-hospital mortality. Removal of potential
selection bias still resulted in improved outcomes after PR by HV surgeons. To
our knowledge, this is the first population-based case-controlled evidence
that demonstrates improved in-hospital mortality after PR is directly related
to surgeon volume.
           Table 1. Logistic Regression of Operative Mortality
            Factor                                       OR (95% CI)
            Age                                          1.1 (1.0–1.1)
            Female gender                                0.6 (0.4–0.9)
            Black race                                   1.6 (0.9–2.7)
            Hispanic race                                1.5 (0.9–2.7)
            Medicaid insurance                           2.4 (1.1–5.5)
            Highest income bracket                       1.5 (1.0–2.1)
            Urgent admission                             0.9 (0.6–1.3)
            Elixhauser comorbidity                       1.1 (0.9–1.2)
            Malignant diagnosis                          1.4 (0.9–2.2)
            High volume surgeon                          0.4 (0.3–0.6)


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  1034        Are Seasoned Surgeons Still Safe in a Laparoscopic
              Surgical Crisis?
Kinga A. Powers*1,2, Scott Rehrig1, Noel Irias1, Mark P. Callery1,
Steven D. Schwaitzberg2, Daniel B. Jones1
1Surgery,   Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA;
2Surgery,   Cambridge Health Alliance, Harvard Medical School, Boston, MA
INTRODUCTION: Seasoned surgeons are confronted with emerging tech-
nologies which were not part of their formal residency training. Our aim was
to compare technical and team performances of surgeons of different ages
and expertise. We hypothesize that seasoned surgeons are less prepared to
deal with a laparoscopic surgical crisis than younger, expert laparoscopic
surgeons.
METHODS: Six seasoned surgeons (age 55–83) were compared to six control,
expert laparoscopic surgeons (age 34–53). In a simulation mock operating
room, surgeons established pneumoperitoneum, trocar access, and managed
an intraabdominal hemorrhage in a previously described and validated
model of an abdomen. Blood loss and time to control hemorrhage were mea-
sured. Videos were evaluated as part of an approved IRB. Surgeons’ perfor-
mance in the simulated operating endosuite was assessed using described and
validated technical and team performance scales. Statistics were by SAS/STAT
software with p < 0.05 significance.
RESULTS: All seasoned surgeons when confronted with the use of unfamil-
iar technologies (Veress needle and optical trocar) used junior assistants
appropriately. All control surgeons achieved intraabdominal pneumoperito-
neum and trocar entry themselves. Mean blood loss for seasoned surgeons
and control surgeons was 2.7 versus 2.8 liters, respectively (p = NS). Bleeding
was successfully managed laparoscopically by two senior teams and one con-
trol team. On hemorrhage recognition, senior surgeons converted after 2:40
min vs. 3:30 min for the control surgeons (p = NS). Overall technical and
team abilities of both groups were comparable. On debriefing, 85% of all sur-

                                                                                        WEDNESDAY
geons recommended simulation for recertification.                                        ABSTRACTS
CONCLUSIONS: Seasoned surgeons use their assistant surgeons well and are
safe even when confronted with emerging technologies. Conversion to lap-
arotomy addresses hemmorrhage during laparoscopic crisis. Simulation may
prove a valuable tool for self assessment and recredentialing.




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  1035      Meta-Analysis of Mechanical Bowel Preparation for
            Elective Colon and Rectal Resection
Carlos E. Pineda*, Andrew A. Shelton, Tina Hernandez-Boussard, John M. Morton,
Mark L. Welton
Department of Surgery, Stanford University, Stanford, CA
INTRODUCTION: Despite prior publications, including several meta-analy-
ses and randomized controlled trials, mechanical bowel preparation (MBP)
remains the standard of practice for patients undergoing elective colorectal
surgery. The aim of this paper is to review all the published prospective ran-
domized controlled trials and perform a meta-analysis to evaluate the impact
of MBP on anastomotic leak and wound infection rates.
MATERIALS AND METHODS: We performed a systematic review of the lit-
erature of all trials that prospectively compared MBP with no MBP for
patients undergoing elective colorectal surgical resection. We performed a
search in MEDLINE, LILACS, and SCISEARCH, followed by a manual search of
reference lists for each article found, as well as abstracts of pertinent scientific
meetings. Experts in the field were queried as to knowledge of additional
reported trials. The outcomes we abstracted were anastomotic leaks and
wound infections. Meta-analysis was performed using Peto-Odds ratio.
RESULTS: Of 3,247 patients (12 trials), 1,634 were allocated to MBP (Group 1)
and 1,613 were allocated to no MBP (Group 2). Anastomotic leaks (Figure 1)
occurred in 65 (4%) patients in Group 1, and in 44 (2.7%) patients in Group 2
(Peto OR = 1.488, CI 95%: 1.014–2.183, P = 0.04). Wound infections occurred
in 137 (8.4%) patients in Group 1, and in 105 (6.5%) patients in Group 2
(Peto OR = 1.332, CI 95%: 1.024–1.733, P = 0.033). Subgroup analysis for low
anterior resection favored no preparation.




DISCUSSION: This meta-analysis, that includes trials published in 2007, dem-
onstrates that MBP provides no benefit to patients undergoing elective colorec-
tal surgery and in fact, appears to be harmful, because the MBP group
experienced higher anastomotic leak rates and wound infection rates. This data
supports elimination of routine MBP in elective colorectal surgery and yet the
persistence of the practice suggests that a multicenter randomized controlled
trial may be necessary to provide sufficient evidence to change clinical practice.
CONCLUSION: Mechanical bowel preparation is of no benefit to patients
undergoing elective colorectal resection and need not be recommended to
meet “standard of care.”
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  1036      Sequential Resections of Liver and Pulmonary
            Metastases of Colorectal Cancers: Results of 45 Patients
Hannes Neeff*1, Frank Makowiec1, Eva Fischer1, Ulrich T. Hopt1, Bernward Passlick2
1Department  of Surgery, University of Freiburg, Freiburg, Germany; 2Department of
Thoracic Surgery, University of Freiburg, Freiburg, Germany
INTRODUCTION: Multimodal therapies (especially surgery of metastases
and aggressive chemotherapy) in patients with metastases of colorectal can-
cers (CRC) are increasingly performed and may even provide healing in
selected patients with more than one site of metastases. In the current litera-
ture there are only few studies with relatively low patient numbers reporting
the outcome after resection of both, hepatic and pulmonary metastases of
CRC. We, therefore, evaluated survival of patients who underwent sequential
resections of hepatic and pulmonary metastases under potentially curative
intention.
METHODS: From 1989 until 2006 45 patients (31% female, median age 58
years) with (during the course of the disease) hepatic and pulmonary CRC-
metastases underwent sequential resections at both metastatic sites. In all
patients further tumor locations were excluded preoperatively. Metastases
occurred synchronously (regarding primary CRC) in 29%. In 82% liver resec-
tion was performed prior to pulmonary resection. First resection of metastases
was performed a median of 16 months after resection of the primary CRC,
the median interval to the second resection of metastases was seven months.
The primary CRCs were in 53% rectal and in 47% colon carcinomas (62%
nodal positive, all with free resection margins). Survival analysis was per-
formed using the Kaplan-Meier-method.
RESULTS: In both, the first and the second resection of metastases, free mar-
gins were achieved in 94%. Actuarial five-year survival (5-y SV) was 63% after
initial diagnosis of CRC, forty-three percent after the first resection of
metastases and 29% after the last resection. Patients with synchronous
metastases had a significant poorer survival compared to patients with
metachronous metastases (37% 5-y SV after first metastasectomy vs. 72% in
                                                                                     WEDNESDAY
                                                                                     ABSTRACTS
patients with metachronous disease; p < 0.01). The nodal status and the loca-
tion of the primary CRC did not influence survival so far.
CONCLUSIONS: Within a multimodal management of patients with metas-
tasized CRC a resection of both, hepatic and pulmonary metastases may
achieve acceptable survival rates or even healing in selected patients, espe-
cially in the presence of biologically less aggressive (=metachronous) disease.
Survival rates in these selected patients are comparable to those of patients
after isolated hepatic resection reported during the last decade.




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   1037 Prognostic Factors Associated with Survival Following
        Hepatic Resection of Early-Stage Hepatocellular
        Carcinoma
Hari Nathan*, Michael Choti, Richard D. Schulick, Timothy M. Pawlik
Surgery, Johns Hopkins Hospital, Baltimore, MD
INTRODUCTION: Factors associated with prognosis following resection of
early-stage (5 cm) hepatocellular carcinoma (HCC) remain ill-defined. We
sought to identify clinicopathologic factors that predict long-term survival in
patients (pts) with early-stage HCC following hepatectomy.
METHODS: The Surveillance, Epidemiology, and End Results (SEER) data-
base was used to identify 921 pts with histologically confirmed early-stage
HCC who underwent surgical resection (not ablation or transplantation)
between 1988–2004. Prognostic factors were evaluated and survival was strat-
ified according to a novel clinical scoring system.
RESULTS: Median tumor size was 3.3 cm; 19% of pts had tumors 2 cm. Most
HCC lesions were solitary (74%), low histologic grade (84%), and had no evi-
dence of vascular invasion (78%). Hepatic resection consisted mostly of
wedge resection (59%) or hemi-hepatectomy (35%). Overall median and 5-yr
survival were 39 mos and 37%, respectively. After adjusting for socio-
demographic factors and histologic grade, tumor size >2 cm (HR = 1.9) and
vascular invasion (HR = 1.4) remained independent predictors of poor sur-
vival (both P < 0.05). In contrast, tumor number (multiple vs single) had no
effect on prognosis (HR = 1.3, P = 0.06). Based on these findings, a prognostic
scoring system was developed that allotted 1 point each for tumor size >2 cm
and vascular invasion. Using this system, pts with early-stage HCC could be
stratified into 3 distinct prognostic groups (median and 5-yr survival, respec-
tively: 0 points–60 mos, 49%; 1 point–38 mos, 37%; 2 points–23 mos, 24%;
P < 0.001) (Figure).




CONCLUSIONS: Although early-stage HCC is generally associated with a
good prognosis, a subset of high-risk pts can be identified. Pts with early-stage
HCC who have tumors >2 cm ± vascular invasion have a significantly
increased risk of death. These data emphasize the importance of pathologic
staging even in small HCC.
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  1038      Staging Error Does Not Explain the Relationship
            Between the Number of Nodes in a Colon Cancer
            Specimen and Survival
Jesse Moore*1, Neil H. Hyman1, Peter Callas2, Benjamin Littenberg3
1Surgery, University of Vermont College of Medicine, Burlington, VT; 2Mathematics &
Biostatistics, University of Vermont College of Medicine, Burlington, VT; 3Med-Gen
Internal Medicine, University of Vermont College of Medicine, Burlington, VT
PURPOSE: Survival in colon cancer is greater in those patients who have
more lymph nodes identified at the time of resection. It is not clear if this is
due to under-staging, confounding by treatment, social or clinical character-
istics, or factors intrinsic to the tumor or host response. We studied whether
the number of nodes analyzed per specimen remains predictive of survival
while controlling for patient factors, surgeon, and hospital.
METHODS: A retrospective cohort study of 11,399 patients in the SEER-
Medicare database who were diagnosed with Stage I, II, or III colon cancer
between 1994 and 1998 was performed. The primary predictor was the num-
ber of lymph nodes identified. Cox proportional hazards models were con-
structed to analyze overall and cancer-specific survival. Analyses were
adjusted for age, sex, race, income, use of chemotherapy, surgeon’s specialty,
and the usual tendency of the surgeon and hospital to identify lymph nodes.
RESULTS: Overall and cancer specific survival was significantly higher as the
number of nodes examined increased. Patients with more than 12 nodes
examined had a 20% lower hazard (HR 0.80; 95% confidence interval
0.75–0.85) than those with fewer than 7 nodes examined. Controlling for
patient factors did not change the hazard ratio associated with an increasing
number of nodes. Further controlling for surgeon type, the surgeon’s and the
hospital’s mean number of nodes examined per case in the models did not
change the hazard ratios associated with an increasing number of nodes. This
indicates that something other than patient demographics, treatment, oper-
ating surgeon or the hospital’s process for retrieving lymph nodes accounts

                                                                                      WEDNESDAY
for the observed effect.                                                              ABSTRACTS
CONCLUSIONS: The number of analyzed nodes in a colon cancer specimen
is predictive of survival, but is independent of patient demographics, surgeon
and hospital. This argues strongly against under-staging or confounding as
the mechanism for the improved survival with higher node counts. Other
factors, such as those intrinsic to the tumor or the host immune response
may be responsible for the differences in prognosis.




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      POSTER SESSION DETAIL
                        Printed as submitted by the authors.


Monday, May 19, 2008
12:00 PM – 2:00 PM          SSAT POSTER SESSION                      SAILS PAVILION
           Authors available at their posters to answer questions 12:00 PM –
           2:00 PM; posters on display 8:00 AM – 5:00 PM. In addition,
           Posters of Distinction ( ) will be available for further viewing in
           Room 25ABC on Tuesday, May 20, 2008.

CLINICAL SCIENCE POSTERS

Clinical: Biliary
  M1500 Acute Calculous Cholecystitis: Indications for Early
        Percutaneous Cholecystostomy
Orly Barak1, Ram Elazay1, Liat Appelbaum2, Avraham Rivkind1, Gidon Almogy*1
1Department   of General Surgery, Hadassah University Hospital, Jerusalem, Israel;
2Department   of Radiology, Hadassah University Hospital, Jerusalem, Israel
OBJECTIVE: To identify risk factors for failure of conservative treatment for
acute cholecystitis and to identify earlier patients who will require percutane-
ous drainage.
SUMMARY BACKGROUND: Current treatment options for acute calculus
cholecystitis include either early cholecystectomy, or conservative treatment
consisting of intra-venous antibiotics and an interval cholecystectomy several
weeks later. Percutaneous drainage of the gallbladder is reserved for patients
who have failed conservative therapy or as a salvage procedure for high-risk
patients.
METHODS: Data on consecutive patients admitted with the diagnosis of
acute cholecystitis was prospectively collected from January 01, 2005,
through Jun, 31, 2006. Demographic, clinical, laboratory and imaging results
were collected. Admission parameters, and parameters at 24 and 48 hours,
were compared between patients who were successfully treated conserva-
tively and those who required percutaneous cholecystostomy (PC). Logistic
regression analysis was performed to identify predictors for failure of conser-
vative treatment.




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RESULTS: The study population consisted of 103 patients (59 females,
57.3%) with a median age of 60 (range 18–97) who were treated for acute cal-
culus cholecystitis during the study period. Twenty-seven patients (26.2%)
required percutaneous drainage. Gender, length of symptoms, and the degree
of abdominal tenderness were not different between the groups. On univari-
ate analysis, age >70 years, diabetes mellitus, elevated white blood cell count
(WBC) and tachycardia at admission, and sonographic findings of a dis-
tended gallbladder were found to be significantly more common in the PC
group then in the conservative group (p < 0.001). Tachycardia and elevated
WBC were significantly higher in the PC group throughout the initial 48
hours. On multivariate analysis age >70 (odds ratio [OR] 3.6), diabetes melli-
tus (OR 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder
(OR 8.5) were found to be predictors for the need for early cholecystostomy
(p < 0.001). Age >70 (OR 5.2) and WBC >15000 (OR 13.7) were predictors for
failure of conservative treatment after 24 and 48 hours (p < 0.001).
CONCLUSIONS: The majority of patients suffering from acute cholecystitis
can be successfully treated conservatively. Diabetes, age above 70, and a dis-
tended gallbladder are predictors for failure of conservative treatment and
such patients should be considered for early cholecystostomy. Persistently
elevated WBC (>15000) is a marker of refractory disease and should play a
more crucial role in the clinical follow-up and decision-making process of
patients with acute cholecystitis.




                                                                                  POSTER ABSTRACTS
                                                                                      MONDAY




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   M1501 Polypoid Lesions of Gallbladder: Diagnosis and Follow-Up
Hiromichi Ito*1, Lucy E. Hann2, Michael D’Angelica1, Yuman Fong1,
Ronald P. Dematteo1, David S. Klimstra3, Leslie H. Blumgart1, William R. Jarnagin1
1Department      of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY;
2Department      of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY;
3Department      of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
BACKGROUND: Polypoid lesions of the gallbladder (PLG) are commonly
seen on ultrasonography (US) but optimal management of them is ill-
defined. The aims of this study were to assess the natural history and the his-
tological characteristics of US-detected PLG.
METHODS: Patients with PLG detected by US from were identified retro-
spectively. Patients with suspected gallbladder cancer were excluded. Histo-
logic findings were analyzed in patients who underwent cholecystectomy and
change in polyp size was determined in patients who underwent serial US
imaging.
RESULTS: From 1996 through 2007, 418 patients with PLG detected on
abdominal US were identified. Two hundred and thirty patients (55%) were
women and the median age was 59 years (range 20–94). Two hundred and
sixty-five patients (64%) were found to have PLG on US during the work-up
of unrelated disease while 94 patients (23%) had abdominal symptoms. Three
hundred and ninety patients (93%) had PLGs 1cm while 28 patients (7%) had
PLGs > 1 cm; 59% of patients had a single polyp and 12% had associated gall-
stones. Among 141 patients who had repeat US followup, growth was
observed in 9 patients (7%), no change in 120 patients (85%) and regression
in 12 patients (9%). Eighty patients underwent cholecystectomy and the his-
tological diagnoses are shown in the Table. Most patients had no polyps
(32%) or pseudopolyps (57%) (including cholesterol, inflammatory or hyper-
plastic polyps). Adenomas were seen in 9% of patients while invasive or in
situ cancer was only seen in 2 patients, both with lesions ≥11 mm.
CONCLUSION: Small PLG (less than 10 mm in diameter) detected by US are
infrequently associated with symptoms and can be safely observed. The risk
of cancer is size dependent, and cholecystectomy is warranted for lesions
greater than 10 mm.
Table 1. Pathological Diagnosis of PLG and the Size on US
                                                 Largest Diameter of PLG on US
             Histology                     <1–5 mm          6–10 mm          11 mm   Total (%)
Normal gallbladder                             8                1               0     9 (11)
Cholecystitis (no polyp)                       3                3               2     8 (10)
Cholelithiasis                                 6                1               2     9 (11)
Cholesterol polyp, cholesterolosis            22                8               3     33 (41)
Inflammatory polyp                             0                0               3      3 (4)
Hyperplastic polyp                             5                2               3     10 (13)
Adenoma                                        0                4              3*      7 (9)
Adenocarcinoma                                 0                0               1      1 (1)
Total                                         44               19              17    80 (100)
*including one adenoma with carcinoma in situ




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  M1502 Single Incision Laparoscopic Cholecystectomy Using a
        Flexible Endoscope
Glenn Forrester*, Eugenius J. Harvey, Steven Binenbaum, John N. Afthinos,
Grace J. Kim, Julio Teixeira
Minimally Invasive Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY
BACKGROUND: The development of a purely NOTES cholecystectomy will
be limited by the safety profile of access techniques and the sophistication of
flexible instrumentation. Although NOTES cholecystectomy in humans has
been reported, in all cases some form of percutaneous transperitoneal assis-
tance has been required. We report our experience with 8 cases performing a
laparoscopic cholecystectomy through a single periumbilical incision using
flexible endoscopy.
METHOD: From August to October 2007, a total of 8 patients (7 women, 1
man) underwent elective single incision laparoscopic cholecystectomy (SILC)
using flexible endoscopic instruments. The patients’ ages ranged from 19 to
67 years old. Access was obtained through a 1.5 cm periumbilical incision. A
dual-channel flexible endoscope (Olympus) was inserted into the peritoneal
cavity. A 5 mm trocar was inserted through the same incision. In all but one
case, dissection of the gallbladder and hilum was performed in a retrograde
fashion using flexible endoscopic instruments, while ligation of the cystic
duct and artery was accomplished with a standard laparoscopic clip applier.
RESULTS: All procedures were completed through the single incision. There
were no conversions to either traditional laparoscopic or open technique.
Operative time ranged from 1 hour 50 minutes to 4 hours. Six of eight
patients were discharged home on the same day of surgery; the other two
were kept for observation overnight and were discharged the next morning.
There were no complications.
CONCLUSION: SILC is a technically challenging though feasible option in
select patients requiring laparoscopic cholecystectomy. With fewer incisions,
improved cosmetic outcome is an obvious advantage over traditional laparo-
scopic cholecystectomy. However, further studies are needed to establish its
overall safety as well as to evaluate other potential benefits. Additionally, this
approach avoids the potential risks of transgastric and transvaginal access
while affording surgeons the opportunity to develop advanced endoscopic
skills.
                                                                                    POSTER ABSTRACTS
                                                                                        MONDAY




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  M1503 Laparoscopic Cholecystectomy as a Standardized
        Teaching Operation: A Comparison of Operative
        Complications and Short-Term Outcome Between
        Surgical Residents and Attending Surgeons in
        1220 Patients
Rene Fahrner*, Matthias Turina, Valentin Neuhaus, Thomas Kostler, Othmar Schöb
Department of Surgery, Limmattal Hospital, Schlieren, Switzerland
INTRODUCTION: Standardized, efficient surgical training is increasingly
confronted with the public demand for high quality of surgical care in mod-
ern teaching hospitals. The aim of this study was to compare perioperative
morbidity and mortality of laparoscopic cholecystectomy (LC) as a highly
standardized teaching operation when being performed by junior and senior
surgical residents (SR) as opposed to those performed by attending surgeons
(AS), in a hospital with high percentage of laparoscopic operations.
MATERIALS AND METHODS: 1220 LC were performed in a university-
affiliated Swiss community hospital between 1999 and 2006. There were 788
(65%) female and 432 (35%) male patients, with an average age of 55 years
(range 16–93 years); 874 operations were performed electively, 346 cases were
urgent operations. All LC performed by resident surgeons were assisted by
attending surgeons or chief residents. Intraoperative cholangiography was
routinely performed. Observed parameters were the duration of operation
and of hospital stay, 30-day perioperative morbidity, mortality, and readmis-
sion rate. Results are stated as mean ± SEM, with p < 0.05 defined as statisti-
cally significant.
RESULTS: Overall length of operation was 92 ± 2 minutes for SR vs. 80 ± 2
minutes by AS (p < 0.001). Elective operations were shorter (91 ± 2 [SR] vs. 76
± 2 [AS] minutes, p < 0.001) than urgent operations (96 ± 3 [SR] vs. 90 ± 3 [AS]
minutes, p = 0.3). Length of hospital stay was shorter in patients treated by SR
as compared to those treated by AS (elective LC: 5.2 ± 0.3 days [SR] vs. 6.7 ±
0.2 days [AS], p < 0.001; urgent LC: 6.8 ± 0.6 days [SR] vs. 8.2 ± 0.5 days [AS],
p = 0.1). Intraoperative complications occured in 4.2%, and were indepen-
dent of surgeon’s experience. Bile duct lesions occurred in 0.2% of all
patients. Conversion to an open cholecystectomy for technical difficulties
was performed in 24 patients (1.9%). Thirty day morbidity was 8.7% in
urgent LC versus 3.3% in elective LC (p < 0.001). Overall mortality was 0.4%
in elective LC and 1.9% in urgent LC (p > 0.001), again independent of surgi-
cal expertise. Discussion: Surgical residents are able to perform LC under
appropriate supervision with results comparable to those of experienced sur-
geons. No differences could be detected with respect to perioperative morbid-
ity or mortality; in particular, serious surgical complications such as bile duct
injury are rare and are again independent of surgeon’s’ experience. A struc-
tured residency quality control program can improve the quality of surgical
care and pinpoint weaknesses of surgical training at individual institutions.




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  M1504 Malignant Melanoma of Lung and Gallbladder,
        Presenting with Hemoptysis: A Case Report and
        Review of Literature
Ming-Chin Yu*, Miin-Fu Chen, Yi-Yin Jan
Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
BACKGROUND: Malignant melanoma (MM) has the potential to spread to
virtually any organ. We reported a case of MM presenting as hemoptysis, with
two suspicious primary foci, lung and gallbladder, confirmed by histology.
CASE PRESENTATION: A 56 year-old female smoker presented with pro-
ductive cough and hemoptysis for half a year. She denied any dyspnea, fever,
malaise, abdominal discomfort, and any personal history of lung or gas-
trointestinal disease. Chest film disclosed patchy opacity over right lower
lung. Thorough physical examination of all skin surfaces, including her oral
mucosa, was negative. The patient underwent the right lower lung lobectomy
without complication, and a black, firm MM measured 4.7 × 4.5 × 4 cm was
found. For searching other possible primary or metastatic site, PET-CT was
performed and showed F-18 FDG avid lesions in the gallbladder. Partial
hepatectomy and cholecystectomy were done and revealed one black, fragile
and polypoid tumor measuring 9.0 × 4.0 × 3.4 cm. Both specimens were
proved of MM.
DISCUSSION: The pathologic diagnosis of MM in tumors from lung and
gallbladder is confirmed by immunochemical study of S-100 and HMB-45.
The imaging study of endoscopic ultrasound, computed tomography, and
MRI was reported. Surgical therapy should be performed aggressively for com-
plete removal. PET-CT plays a crucial role in detecting asymptomatic MM in
gallbladder for this patient, and certainly help for more accurate patient selec-
tion for surgical excision. A series of image studies, including CT, MRI, endo-
scopic ultrasound, and abdominal ultrasound will be presented. After review
of the literature, surgical resection is mandatory for improve survival in lim-
ited metastatic melanoma.
                                                                                    POSTER ABSTRACTS
                                                                                        MONDAY




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  M1505 Choledochal Cysts: Risk of Malignancy and Outcome
        in 68 Patients Undergoing Surgical Management at a
        Single Institution
John P. Bois*, Michael L. Kendrick, Michael B. Farnell, Florencia G. Que,
John H. Donohue, Christopher Moir, David Nagorney
Surgery, Mayo Clinic, Rochester, MN
BACKGROUND: Choledochal cysts are an uncommon entity. Surgical man-
agement is considered standard of care to prevent morbidity and to avoid the
potential risks of malignant transformation. Our aim is to describe the clini-
cal presentation, evaluation, management, and outcome of these patients.
METHODS: A retrospective review of clinical, imaging, surgical, and out-
come data of patients undergoing surgical management of choledochal cysts
from 1982 to 2006 at a single institution.
RESULTS: A total of 68 patients (57 female, 11 male) with a mean age of 30
years (range: 2 mo–79 y) were identified. Symptoms prompted evaluation in
96% of patients with abdominal pain (81%), jaundice (21%), and cholangitis
(18%) being the most frequent. Cysts were classified as Type I (79%), II (6%),
III (4%), or IV (12%). Operative management was based on cyst type and
included complete excision (n = 56, 82%), incomplete excision (n = 9, 13%),
or biliary diversion (n = 3, 4%). Reconstruction after excision included Roux-
en-Y hepaticojejunostomy (n = 42, 62%), hepaticoduodenostomy (n = 15,
22%). Decision to avoid complete cyst resection was based on cyst type, oper-
ative findings, and patient comorbidities. Median cyst size was 4.5 cm (range:
1–14). Neoplastic changes of cyst epithelium were identified in 4 (6%)
patients, including cholangiocarcinoma in 2. Perioperative major morbidity
or mortality occurred in 19% and 0% patients respectively. Follow-up was
available in 78% of patients for a mean of 5 years (range: 1–242 months).
Recurrent symptoms of cholangitis (n = 3), pancreatitis (n = 1), or chronic
liver disease (n = 1) were observed in 9% of patients having undergone com-
plete cyst excision. Of two patients with cholangiocarcinoma at cyst excision,
both underwent an R0 resection. An additional patient developed intrahe-
patic cholangiocarcinoma 7 years after complete cyst excision of a benign
type I choledochal cyst. When comparing children (<18 years) (n = 19) with
adults (n = 49), no major differences were notable in presentation, surgical
management, or outcome, although associated neoplasia was not observed in
children.
CONCLUSION: Choledochal cysts are an uncommon biliary tract abnormal-
ity which my cause significant morbidity and risk of malignancy. While an
uncommon harbinger of malignancy, cholangiocarcinoma was identified in
4% of patients at initial cyst resection or on subsequent follow-up. Compared
to earlier series, this incidence appears to be decreasing in an era where early
complete cyst excision is more widely accepted. Thorough preoperative eval-
uation, surgical treatment, and follow-up are recommended in patients with
choledochal cysts.




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  M1506 Single Incision Laparoscopic Cholecystectomy
Michael Albrink*, Connor Morton, Desiree Villadolid, Sharona B. Ross,
Sarah Cowgill, Donovan Tapper, Alexander S. Rosemurgy
Surgery, University of South Florida and Tampa General Hospital, Tampa, FL
INTRODUCTION: The application of laparoscopy advanced General Sur-
gery. Single Incision Laparoscopic Surgery may prove to be a further advance-
ment, though currently an evolving concept. This study was undertaken to
report our early experience with single incision laparoscopic cholecystectomy.
PROCEDURE: Cholecystectomies were carried out utilizing two 5 mm ports
placed through a single 1 cm incision at the umbilicus. 5 mm 0-degree or 30-
degree laparoscopes were used. Sutures were placed into the gallbladder to
facilitate extirpation. Gallbladders were removed through the umbilicus. Data
are presented as median, mean + SD, where appropriate.
RESULTS: Nine patients, six males and three females, of median age 45
years, 43 + 16 and median BMI of 27 kg/m2, 27 + 3.7, underwent single inci-
sion laparoscopic cholecystectomy. No patients undergoing attempted single
incision cholecystectomies had conversions to “open” operations. Duration
of operations was 73 minutes, 71 + 14.1. No intraoperative inadvertent events
or complications occurred. Intraoperative blood loss was minimal. All patients
had documented cholelithiasis and chronic cholecystitis. One patient experi-
enced significant nausea and pain postoperatively, leading to a 3-day hospital
stay. Eight patients were discharged within 23 hours.
CONCLUSIONS: Single incision laparoscopic cholecystectomy is feasible and
safe, though it may require more time than conventional laparoscopic chole-
cystectomy. While many parameters of laparoscopic cholecystectomy are not
notably impacted by single incision laparoscopic cholecystectomy, cosmesis
and patient satisfaction is subjectively improved. Realistically, randomized
trials comparing laparoscopic cholecystectomy to single incision laparoscopic
cholecystectomy will doubtfully be undertaken. Nonetheless, single incision
laparoscopic cholecystectomy will be embraced by consumers. Laparoscopic
surgeons need to become proficient in Single Incision Laparoscopic Surgery
to meet consumer demand.
                                                                                 POSTER ABSTRACTS
                                                                                     MONDAY




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  M1508 Plugging Away at the Anal Fistula: An Exercise in
        Futility?
Galal S. El-Gazzaz*, Massarat Zutshi, Tracy L. Hull
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: The many options for treatment of anal fistulas indicate that no
one option has consistent results. The aim of this study was to analyze the
efficacy of the Cook Surgisis® AFP™ anal fistula plug for the management of
complex anal fistulas in our institution.
METHODS: A retrospective review of all patients who underwent treatment
for complex anal fistulas using Cook Surgisis® AFP™ anal fistula plug between
October 2005–2007 was undertaken. Patient’s demographics, fistula etiology
and success rates were recorded. The plug was placed in accordance with the
company’s guidelines. Success was defined as closure of all external openings,
absence of drainage without further intervention, and absence of any inflam-
mation process.
RESULTS: Thirty three patients underwent 49 plug insertions. The median
age of the patients was 44.35 (±13.18) years; 18 females and 15 males. The fis-
tula etiology was cryptoglandular in 20 (61%) patients and Crohn’s disease-
associated in the 13 (39%) patients (23 high transphincteric; 8 low anal and 2
rectovaginal). Two patients had concomitant treatments; one underwent
concomitant anal advancement flap at the time of plug placement and failed,
the other underwent concomitant fibrin glue in multiple fistulas and healed.
There were 11 smokers, 4 patients with diabetes and 7 patients on steroids.
The mean follow up was 251.12 days (±163.06). One patient was lost to fol-
low up. Twenty one patients had previously undergone failed surgical ther-
apy to cure their fistula (anal advancement flap in 8, fistulotomy 10 and
fibrin glue in 3). Twenty nine patients had draining setons in-situ at the time
of plug placement. The mean time the seton was in place before insertion of
plug was 55 days (range 31–143 days). The overall success rate was 11/48
(41%). The success rate after first attempt was 8/33 (24%), 2/14 (14%) after
second attempt and 1/2 (50%) after third attempt. Two of the 22 (15%)
Crohn’s disease-associated fistulas healed and 9 out of 26 (12.5%) procedures
resulted in healing of cryptoglandular fistulas. The reasons for failure were
sepsis in 31 procedures (87.0%), plug dislodgement in 6 (13.0%) procedures.
Other predictor factors were race (African-American patient’s healing rates
were higher p = 0.009), low fistula (internal os below dentate line) did better
than high fistula, also presence of seton had a better outcome (p = 0.05).
CONCLUSIONS: Anal fistula plug is associated with a low success rate than
previously reported. African-Americans and presence of seton at time of plug
placement were predictors of good outcome.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1509 Clinical Feature and Management of Postoperative
        Pouch Bleeding After Ileal Pouch-Anal Anastomosis
        (IPAA)
Lei Lian*, Victor W. Fazio, Feza H. Remzi, Pokala R. Kiran, Christine Hannaway,
Bo Shen
Digestive Disease Center, Cleveland Clinic, Cleveland, OH
AIM: The clinical features of postoperative pouch bleeding vary and the
management can be difficult. There is no published literature regarding
pouch bleeding and its treatment.
METHODS: Pouch bleeding was defined as significant bleeding or passing of
clots transanally or into loop ileostomy bag with/without hypotension or
drop in hemoglobin within 30 days after surgery. Patients were identified
from a prospectively maintained Pouch Database.
RESULTS: Pouch bleeding developed in 47 (1.5%) patients out of 3194
patients undergoing IPAA since 1983. 42 had inflammatory bowel disease, 4
had familial adenomatous polyposis, and 1 had colonic inertia. Staple line
reinforcement was used in 17 (44.7%) patients with J pouch. 66% bleeding
occurred within 7 days, of who 41.9% had postoperative anticoagulant use
for thrombosis prophylaxis. 34 (72.3%) bled from neo-rectum, 9 from ileo-
stomy, 2 from both. 2 patients had concurrent abdominal bleeding and 2 had
anemic symptoms who were later found bleed from pouch by endoscopy.
After initial fluid resuscitation, 28 patients had pouch endoscopy and clot
evacuation followed by cauterization or iced saline and saline with epineph-
rine (1:100000) enemas. 27 of 28 had cessation of bleeding within 24 hours. 1
patient required 3 days of enema treatment before complete cessation. Epi-
nephrine enema was used as initial treatment in 12 patients. 1 patient failed
and had endoscopy with cauterization of bleeding point. 5 patients were
observed. 28 patients were transfused. No surgery was required for pouch
bleeding. 1 patient had reoperation and 1 patient died after transferred to
intensive care unit due to concurrent intra-abdominal bleeding.

Table 1. Comparison: Patients with and without Pouch Bleeding
                                   Pouch Bleeding        No Pouch Bleeding
                                                                             p-value
                                      (N = 47)               (N = 3147)
Age                                  33.3 ± 10.5             47.3 ± 13.8     0.011
                                                                                       POSTER ABSTRACTS




Gender = male                        34 (72.3%)            1752 (55.5%)      0.106
                                                                                           MONDAY




Pouch type = J (vs. S)               38 (80.9%)            2764 (87.8%)      0.148
Anastomotic type = Stapled           35 (74.5%)            2618 (83.2%)      0.114
(vs. Hand-sewn)




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Table 2. Management of Pouch Bleeding and Outcomes
Initial Treatment: Endoscopy and Clot Evacuation (No. = 28,59.6%)
Followed by Cauterization (Active Bleeding)                         15 (53.6%)
Followed by Epinephrine Enema (No Distinct Bleeding)                13 (46.4%)
Initial Treatment: Epinephrine Enema (No. = 12,25.5%)
Success                                                             11 (91.7%)
Need Endoscopy and Cauterization                                     1 (8.3%)
Observation with/without Transfusion                                     5

CONCLUSION: Postoperative pouch bleeding after IPAA usually required
intervention and can be managed nonoperatively. Pouch endoscopy with
clot evacuation and cauterization of visible bleeding point followed by iced
saline and saline with epinephrine enema is successful in managing this
complication.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1510 Dosimetric Evaluation of Endoscopic Radiofrequency
        Ablation in the Human Colonic Epithelium in a Treat
        and Resect Trial
Joseph A. Trunzo*1, Michael F. Mcgee1, Benjamin K. Poulose1, Joseph Willis2,
Bridget Ermlich1, Michelle Laughinghouse1, Bradley J. Champagne1,
Conor P. Delaney1, Jeffrey M. Marks1
1Surgery,University Hospitals Case Medical Center, Cleveland, OH; 2Pathology,
University Hospitals Case Medical Center, Cleveland, OH
BACKGROUND: Radiofrequency ablation (RFA) has been used effectively for
the treatment of Barrett’s esophagus. This technology may additionally have
a role in the treatment of bleeding or neoplasia in the lower GI tract. The goal
of this study was to determine the optimal treatment parameters to create
ablative effect to the colonic mucosa/submucosa, without deeper transmural
colonic injury.
METHODS: In this IRB approved protocol, patients undergoing elective left
colon or rectal resection were enrolled. Once margins of resection were deter-
mined intra-operatively, a colonoscope mounted with a planar RFA device
(HALO90, BÂRRX Medical) with a 13 mm by 20 mm bipolar array was
advanced to the resection segment. Areas of normal mucosa were ablated
in situ with 2 or 4 applications (APP) while varying energy density (12, 15, or
20 J/cm2). After removal with the surgical specimen, ablation zones and
untreated normal adjacent tissue were multiply sectioned and stained with
H&E. An expert GI pathologist, blinded to the treatment parameters, assessed
the deepest histological layer with any histopathological change (inflamma-
tion, ablation, abnormal pattern, necrosis.)
RESULTS: We created 51 ablations zones in 16 patients. When comparing
max depth of histological change in 2 vs. 4 APP, regardless of energy density,
evidence of serosal change occurred in 0% (0/24) vs. 15% (4/27) of zones (p =
0.11), whereas changes to the muscularis propria (MP) occurred in 25% (6/24)
vs. 63% (17/27) of zones (p < 0.05).Comparing energy density settings of 12,
15, and 20 J/cm2, regardless of APP, we observed an unexpected inverse rela-
tionship of energy vs depth, in that changes were present in MP in 74% (17/
23), 35% (6/17), and 0% (0/11), respectively (P < 0.05); and in serosa in 9%
(2/23), 12% (2/17), and 0% (0/11) (P = 0.517). No changes in serosa were seen
in any 2 APP ablation zone at any energy density.
                                                                                   POSTER ABSTRACTS




CONCLUSIONS: We observed a direct correlation between APP and ablation
effect depth for this device in the colon. All ablation zones at 2 APP demon-
                                                                                       MONDAY




strated no changes to the serosa and only a 25% incidence of MP changes. We
observed an unexpected inverse relationship between energy and ablation
depth, counter to reports in similar trials involving the esophagus. This
observed variability may be due to inconsistent electrode approximation to
mucosa, variable colonic wall thickness, and possible coagulum formation on
the electrode preventing conduction of energy. This evaluation has identified
a safe treatment parameter (12 J/cm2, 2 APP) that penetrates no deeper than
MP, and will guide follow-up trials for disorders of the lower GI tract, includ-
ing hemorrhagic radiation proctitis.


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  M1511 A Population-Based Study of Surgical Treatment of
        Colon Cancer in Ontario, Canada
Rahima Nenshi*1,2, Marko Simunovic5,3, Nancy N. Baxter4,3, Nadia Gunraj3,
Erin Kennedy2, Sue Schultz3, Drew Wilton3, David R. Urbach2,3
1University of Toronto, Toronto, ON, Canada; 2University Health Network, Toronto, ON,
Canada; 3Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; 4St. Michael’s
Hospital, Toronto, ON, Canada; 5Hamilton Regional Cancer Centre, Hamilton, ON,
Canada
BACKGROUND: Colorectal cancer is the third most common cause of can-
cer and the second most common cause of cancer death among Canadian
men and women. In 2007, an estimated 8,129 persons in Ontario, Canada
will be diagnosed with colorectal cancer and 2,793 will die from this disease.
Surgical treatment is the cornerstone of the management of colorectal cancer;
however there are few population-based reports of patterns of treatment. Lap-
aroscopic colorectal surgery is also changing the surgical approach to the
treatment of colorectal cancer. We used a population-based cancer registry
and administrative health data to describe patterns of the surgical treatment
of colon cancer in Ontario in the period 2003–2004.
METHODS: We linked data from administrative health databases (Canadian
Institute for Health Information [CIHI] and the Ontario Health Insurance
Plan [OHIP]) to a population-based cancer registry (the Ontario Cancer Regis-
try [OCR]) to measure hospitalizations and surgical treatment received by all
patients with a new diagnosis of colon cancer in Ontario from March 1, 2003
to April 30, 2004.
RESULTS: During this 1 year period, 5265 residents of Ontario were newly
diagnosed with primary colon cancer. Of these, 50.9% were men and 20.3%
were aged less than 60 years. 91.2% of all patients had a surgical procedure.
Among persons aged less than 60 years, 1.3% (95% confidence interval [95%
CI] 0.5–1.9) had a resection with a permanent stoma, 11.9% (95% CI 9.9–14)
had a resection with creation of a reversible stoma, 69.1% (95% CI 66.2–71.9)
had a resection with primary anastomosis and 17.8% (95% CI 15.4–20.1) had
an “other” surgical procedure (intestinal bypass, local excision or other
abdominal procedure). Among persons older than 60 years, 1.1% (95% CI
0.8–1.4) had a resection with a permanent stoma, 11.5% (95% CI 10.5–12.6)
had a resection with creation of a reversible stoma, 70.7% (95% CI 69.3–72.1)
had a resection with primary anastomosis and 16.7% (95% CI 15.5–17) had
an “other” surgical procedure. 354 (7.4%) of all cases were done laparoscopi-
cally. Among persons aged < 60 years, 8.8% (95% CI 7.1–10.6) had laparo-
scopic surgery compared to 7% (95% CI 6.2–7.8) in the older group (p for
difference = 0.047). There was no difference in the rate of laparoscopic proce-
dures between men and women.
CONCLUSIONS: The majority of patients newly diagnosed with colon can-
cer in Ontario undergo resection without creation of a stoma. There was no
significant difference in rates of the different types of surgery received accord-
ing to age. Less than 10% of operations were done laparoscopically and
younger patients were more likely to undergo laparoscopic procedures.


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1512 Health Related Quality of Life and Clinical Outcome
        After Colonic Resection for Diverticular Disease:
        Long-Term Results
Marco Scarpa, Duilio Pagano, Cesare Ruffolo, Anna Pozza, Francesa Erroi, Lino Polese,
Davide F. D’Amico, Imerio Angriman*
Clinica Chirurgica I°, University of Padova, Padova, Italy
BACKGROUND AND AIMS: Colonic resection is mandatory in compli-
cated colonic diverticular disease (DD). The most appropriate treatment in
case of recurrent diverticulitis episodes, is less clear. The aim of the present
study was to evaluate the long term clinical outcome and quality of life in
patients affected by DD submitted to colonic resection compared to those
who had only medical treatment.
PATIENTS AND METHODS: Seventy-one consecutive patients admitted in
our department for left iliac pain and endoscopical or radiological diagnosis
of diverticular disease were enrolled. During the hospital stay 25 of them
underwent colonic resection while 46 were treated with medical therapy. Dis-
eased severity was assessed with Hinchey scale. After a median follow up of 47
(3–102) months after colonic resection, they were interviewed and they
answered to Cleveland Global Quality of Life (CGQL) questionnaire and to a
symptoms questionnaire. Admittance and surgical procedures for DD were
also investigated and surgery- and symptoms-free were calculated. Non para-
metric tests and survival analysis was used.
RESULTS: After the follow up, CGQL total score obtained by the two
patients were similar as well as the symptoms frequency. Only current quality
of health item was significantly worse in patients who had undergone colonic
resection (p = 0.05). No difference was evidenced in the rate and in the tim-
ing of surgical procedures and hospital admitting for DD in the two groups.
In particular the 9 patients who had been operated on for an Hinchey 1 class
diverticulitis reported the same quality of life, symptoms frequency, opera-
tion and hospital admitting rate than those who had been admitted for an
Hinchey 1 class diverticulitis and treated conservatively.
CONCLUSIONS: Our study did not show any long term advantage in sub-
mitting patients to colonic resection for DD. Thus, in our opinion, surgical
resection should be reserved to patients who present with a complicated DD
and not to patients who present a mere abdominal discomfort attributed
                                                                                        POSTER ABSTRACTS




to DD.
                                                                                            MONDAY




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  M1513 Prognostic Factors for Survival in 61 Patients with
        Carcinoma of the Splenic Flexure
Simon S. Ng*, Janet F. Lee, Wing Wa Leung, Raymond Y. Yiu, Jimmy C. Li,
Sophie S. Hon, K. L. Leung
Surgery, The Chinese University of Hong Kong, Hong Kong, China
BACKGROUND: While carcinoma of the splenic flexure is uncommon, it is
associated with a high risk of obstruction and a poor prognosis. The aim of
this study was to evaluate the prognostic factors for recurrence and survival
after surgery for carcinoma of the splenic flexure.
METHODS: Between March 1986 and September 2007, a total of 2987
patients with colorectal carcinoma underwent surgery at our institution, of
whom 61 (2%) had carcinoma of the splenic flexure. The clinicopathological
factors possibly predicting survival among these 61 patients were retrospec-
tively reviewed. Survival was calculated using Kaplan-Meier method and
compared by log-rank test. Multivariate analysis was performed using Cox’s
regression model.
RESULTS: Forty-five patients (73.8%) underwent curative surgery (leaving
no residual or metastatic disease). Thirty-five patients (57.4%) presented with
intestinal obstruction and underwent emergency surgery. Multivisceral resec-
tions were needed in 14 patients (23%). Postoperative morbidity and mortal-
ity developed in 26 (42.6%) and 6 (9.8%) patients, respectively. Among
patients surviving surgery, the cancer-specific survival at 5 years was 47.1%.
Postoperative morbidity (P = 0.016), T4 tumour (P < 0.001), and non-curative
surgery (P < 0.001) were found to be independent prognostic factors for poor
cancer-specific survival. Thirteen patients developed recurrence after curative
surgery, and the probability of being disease free at 5 years was 62%. Postop-
erative morbidity (P = 0.020) and T4 tumour (P < 0.001) were found to be
independent predictors for recurrence. Intestinal obstruction and surgical
approach were not predictors for poor survival.
CONCLUSION: In addition to curative surgery, T stage of tumour and post-
operative morbidity are found to be independent prognostic factors for sur-
vival after surgery for carcinoma of the splenic flexure.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1514 Risk of Infection and Recurrence over Prolonged
        Follow Up in Patients Undergoing Ventral Hernia
        Repair During Colorectal Resection: Can the Use of
        Mesh Be Justified?
Levilester B. Salcedo*, Ravi P. Kiran, Ian Lavery, James M. Church, Victor W. Fazio
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: Concerns pertaining to the risk of wound infection and subse-
quent need for mesh excision or recurrence deters the use of mesh to repair
ventral hernia during colorectal resection. We evaluate the risk of infection
and hernia recurrence after mesh repair in these patients over a prolonged
follow up period.
METHODS: A retrospective review of 274 patients with mesh repair for ven-
tral hernia during colorectal surgery from 1991–2007 was done. Patients who
did not have a bowel resection and those with only parastomal hernia were
excluded. Patients demographics, diagnosis, comorbidity, size of defect, mesh
type, surgical technique and early complications were evaluated from medi-
cal records. Long term follow up was determined by telephone interviews.
Patients who had recurrence were compared with those without recurrence
using Fishers exact, Chi-squared and Wilcoxon tests as appropriate statistical
tools.
RESULTS: 110 patients (56% male,mean age 59,median BMI 29) met the
inclusion criteria. Diagnoses included colorectal cancer (n = 34), Crohn’s
(n = 25), Diverticulosis (n = 18), ulcerative colitis (n = 16) and others (n = 17).
Goretex (n = 39), Prolene (n = 38), Permacol (n = 23), Alloderm (n = 4), Bard
composite (n = 3), Surgisis (n = 1) and others (n = 2) were used intraperito-
neally with mean fascial defect of 10 × 11 cm. Mean follow up was 4 years.
Rate of wound infection was 13.6% and recurrence 40%. Patients who had
recurrence (n = 44) and non-recurrence (n = 66) had similar age (p = 0.4), gen-
der (p = 0.2), BMI (p = 0.4), smoking history (p = 0.8), pulmonary comorbid-
ity (p = 0.9), type of mesh (p = 0.7) and drain use (p = 0.5). A significantly
greater proportion of recurrent group had hypertension (p < 0.05), diabetes
(p < 0.01), larger fascial defect (p < 0.05), steroid use (p < 0.05), emergency
surgery (76 vs 24%, p < 0.001) and wound infection (7 vs 4%, p < 0.05). On
long term follow up, additional 6 patients (4 from recurrent group and 2 non-
recurrent group) developed wound infection requiring readmission. 78% of
patients were satisfied with their surgery. Quality of life for recurrent and
                                                                                      POSTER ABSTRACTS




non-recurrent group was comparable (p = 0.5).
                                                                                          MONDAY




CONCLUSIONS: Recurrence following mesh repair of ventral hernia during
colorectal resection is associated with emergency surgery, large fascial defects,
presence of comorbidities, perioperative steroids and wound infection. In
these situations use of synthetic mesh may be best avoided until conditions
are more favorable.




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  M1515 The Prognostic Significance of Circumferential
        Resection Margin Involvement in Colon Cancer
Selman Sokmen*1, Mucahit Ozbilgin1, Aras Emre Canda1, Sulen Sarioglu2,
Ozgul Sagol2, Mehmet Fuzun1
1Surgery,Dokuz Eylul University School of Medicine, Izmir, Turkey; 2Pathology, Dokuz
Eylul University School of Medicine, Izmir, Turkey
PURPOSE: Failure pattern after colon cancer surgery demonstrated that
tumors localized at non-peritonealized part of the colon and sited adjacent to
anatomically narrow mesentery were responsible for locoregional recurrent
disease and reduced survival. The aim of this study was to assess the prognos-
tic significance of circumferential resection margin (CRM) involvement in
patients who underwent potentially curative resection for colonic cancer.
METHODS: Prospectively collected clinicopathological data of 107 patients
(T3–T4 tumors) who underwent curative radical resection were analyzed. The
CRM represents the retroperitoneal or peritoneal adventitial soft tissue mar-
gin closest to the deepest penetration of tumor.
RESULTS: CRM was not involved in 96 patients and involved in 11 patients.
There was a significant association between CRM involvement and lymphatic
vessel invasion, lymph node positivity, number of involved lymph nodes,
and overall TNM stage (p < 0.01). Number of involved lymph nodes and over-
all TNM stage were independent predictors of clinical outcome. CRM positive
tumors were associated with increased local recurrence and distant metastasis
(p < 0.01). The median survival for patients with CRM involvement was only
13 months compared to 20 months without CRM involvement. CRM status
had a significant prognostic value in T4 tumors (Figure 1).




CONCLUSION: The CRM involvement in the colon can be considered to be
representative of advanced tumor spread. The CRM status is an important
predictor of local and distant recurrence as well as survival. Patients with
CRM involvement may benefit from adjuvant treatment. It should be routine
to comment on this prognostic factor in histopathology reports of resected
colonic specimens.




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  M1516 Results of Surgical Treatment of Local Recurrence in
        Rectal Cancer Patients
Jörn Gröne*, Martin Kruschewski, Joerg P. Ritz, Uwe Pohlen, Hubert G. Hotz,
Monika Ciurea, Anton J. Kroesen, Heinz J. Buhr
Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
BACKGROUND AND AIM: The implementation of total mesorectal exci-
sion (TME) in surgical treatment of rectal cancer has resulted in a reduced
local recurrence rate. In spite of these technical improvements and multimo-
dal therapy concepts local recurrence still occurs in 8%–16%. Tumor recur-
rence in the small pelvis continues to be a major challange für surgery. The
only chance for cure in these patients is a new R0 resection. The aim of the
study was to evaluate the rate of successfull R0 resection in patients with local
recurrence of rectal cancer and the morbidity and mortality rates associated
with extended surgical treatment.
METHODS: Prospective observational study of all consecutive surgically
treated patients with local reccurrence of rectal cancer in our department
from 01st january 1995 to 30th june 2007.
RESULTS: In that period 1314 patients with colorectal cancer underwent
surgical treatment. Local recurrence of rectal cancer was diagnosed in 90
patients (7%), 52 men und 38 women, with median age of 65 years. Intralu-
minal recurrence was diagnosed in 18%, extraluminal tumor in 77% and
both, inta- and extraluminal tumor recurrence was found in 56% of the
patients. 67% of the patients (n = 60) have been treated by tumor resection.
In 37 patients (62%) surgery resulted in local R0 resection. R1 situation was
histologically proven in 13 patients (22%) and a local R2 situation was diag-
nosed in 10 patients (16%). The rate of surigical major complications was
19%: 3 lesions of the ureter, 1 lesion of the bladder, 1 leakage of colon anasto-
mosis, 5 abscesses (intraabdominal, sacral cavity), 1 fistula of the small intes-
tine, 2 intraabdominal bleeding, 1 prolonged intestinal paralysis and 3
disruptions of bladder function. Surgical revision rate was 4%, 30 days mor-
tality was 5%.
SUMMARY: (1) Most of the local recurrent tumor manifestions were located
extraluminally. (2) More than 60% of the patients were treated by resection
whereof in another two-thirds R0 resection succeeded. (3) Surgical treatment
of local recurrence of rectal cancer is associated with a notable complication
                                                                                    POSTER ABSTRACTS




rate whereas mortality rate seem to be acceptable in comparison with morbidity.
(4) Surgical treatment of local recurrence of rectal cancer should be performed
                                                                                        MONDAY




primarily in specialized centers.




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  M1517 Preoperative Plasma Levels of Fractalkine (CX3CL1)
        Are Significantly Lower in Patients with
        Adenocarcinoma of the Colon When Compared to
        Benign Disease Patients
Aviad Hoffman*, Raymond Baxter, Ik-Yong Kim, Kumara H. Shantha, Abu Nasar,
Vesna Cekic, Vincent Dimaggio, Daniel L. Feingold, Richard L. Whelan
Surgery, Columbia University, New York, NY
INTRODUCTION: Chemokines are a group of small proteins that play a part
in angiogenesis, inflammation, tumor cell migration as well as lymphocyte
and leukocyte recruitment, activation and chemotaxis. Fractalkine (CX3CL1)
is a chemokine found on the surface of normal and malignant intestinal epi-
thelial cells and also in the plasma in a soluble form. Its receptor, CX3CR1, is
found on monocytes/macrophages, natural killer cells, and T cells. High tis-
sue expression levels of fractalkine in colon cancers has been linked to better
prognosis, presumably via recruitment of lymphocytes (tumor infiltrating
lymphocytes) and immune cells to the tumor. Soluble fractalkine increases
monocyte, NK cell, and T-cell chemotaxis and has also been shown to inde-
pendently inhibit liver and lung metastases in the murine setting. Blood frac-
talkine levels have not been well studied thus far. It is possible that soluble
fractalkine levels in the plasma may be altered in the cancer population and
predictive of disease stage or prognosis. As the first step in evaluating soluble
fractalkine as a cancer marker, plasma levels of this chemokine were deter-
mined in patients with cancer or benign colonic diseases.
METHODS: Blood samples were taken preoperatively from 50 colorectal can-
cer patients and from 50 patients with benign colonic diseases. Plasma levels
of soluble human Fractalkine were measured using a homemade ELISA kit in
duplicate. Results are presented as mean ± SD. The Mann Whitney U-test and
the students t-test were used (p-value < 0.05 was considered significant).
RESULTS: The mean age of the patients was similar (Cancer 66.9, Benign
63.8). The majority of the benign disease patients had adenomas. The cancer
stage breakdown was: Stage 1, 12; Stage 2, 17; Stage 3, 18, and Stage 4, 3
patients. Preoperative fractalkine values in cancer patients were significantly
lower than those in benign patients (256.7 ± 116.9 pg/ml vs 438.5 ± 400.3 pg/
ml respectively, p = 0.005). No differences in fractalkine levels was noted
between cancer stages.
CONCLUSION: Cancer patients were found to have significantly lower
plasma fractalkine levels than benign disease patients, however, no correla-
tion was found between cancer stage and blood levels. Additional study is
needed to determine whether plasma levels return to normal after surgery
and to further investigate the potential role of fractalkine as a tumor marker.




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  M1518 Hemorrhoidectomy in Day Surgery: A Comparison
        Between Four Techniques
Vito Maria Stolfi, Pierpaolo Sileri*, Chiara Micossi, Alessandro Falchetti,
Achille Lucio Gaspari
Surgery, University of Rome Tor Vergata, Rome, Italy
INTRODUCTION: We report the results of a prospective randomized study
comparing 4 techniques of surgical treatment of haemorrhoids in the Day
Surgery department of our teaching Hospital. The hypothesis of the study
was that hemorrhoidectomy in day care is feasible and safe, the aim of the
study was to compare 4 techniques: Ferguson closed Hemorrhoidectomy
(FH), Milligan Morgan hemorrhoidectomy (MMH), Longo Hemorrhoidopexy
(LH), Hemorrhoidectomy with Ligasure (radiofrequency) (RFH).
PATIENTS AND METHODS: Between January 2004 and June 2007, 413
patients, 231 male and 182 female, mean age 48.28 ± 12.97 were prospec-
tively enrolled in this study and enclosed in a data base. Only ASA I and ASA
II patients were included. Visual analogic scale (VAS) was recorded daily for 8
days. Postoperative duration of pain, soiling and bleeding, complications and
recurrence were recorded. Statistical evaluation included chi square test for
qualitative variables, parametric test for quantitative variables. Statistical test-
ing was carried out on the basis of the following hypothesis: bilateral test and
a first degree α-error risk of 0.05 (α = 5%).
RESULTS: pain in the first 8 days was less (p = 0.05) in LH compared the
other techniques which were not significantly different among them.
Patients had prescription for Ketorolac 20 mg up to t.i.d. The rest of the data
observed are gathered in table I. Postoperative pain duration showed LH vs
MMH (p = 0.05). Soiling and bleeding were significantly less in LH vs MMH,
RDH, FH (p < 0.02). Anal fissure was significantly higher in LH vs MMH and
FH, p = 0.05, while anal stricture was significantly higher in RFH vs LH
p = 0.05. recurrence and urgency at defecation had significantly higher rates
in LH compared to MMH, FH, RFH.
CONCLUSION: LH had some advantages in postoperative symptoms pain, pain
duration, soiling and bleeding compared to the other techniques, although
showed higher rate of anal fissure, urgency and recurrence, and a higher cost.
                               Longo         Ligasure       MMH           Ferguson
Number of cases                  108            137           81             87
Pain durat. (days)           14 ± 10.9      15.5 ± 9.9    19.4 ± 14.6    16.3 ± 10.4
                                                                                        POSTER ABSTRACTS




Soiling duration              5.6 ± 8.5     17.8 ± 17.4   17.5 ± 13.2     19 ± 18.9
Bleeding duration             6.5 ± 8.5     11.3 ± 13.8    18 ± 15.2     15.2 ± 13.6
                                                                                            MONDAY




Hitching duration            6.1 ± 13.3     9.8 ± 15.8    7.0 ± 14.8     7.6 ± 15.9
Complications
Anal fissure                 6 (5.5%)        4 (2.9%)          0             1 (1.1%)
Anal stricture               2 (1.8%)        6 (4.3%)      2 (2.4%)          2 (2.3%)
Hemorrhage                   5 (4,6%)        7 (5.1%)      2 (2.4%)          2 (2.3%)
Recurrence                   6 (5.5%)        2 (1.4%)      2 (2.4%)          1 (1.1%)
Urgency                      6 (5.5%)        2 (1.4%)          0             1 (1.1%)
Fecal incont.                1 (0.9%)            0             0                 0


  Poster of Distinction
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  M1519 Comparison of Quality of Life (QOL) Between Ileal J
        Pouch-Anal Anastomosis and Permanent Ileostomy
        After Proctocolectomy for Ulcerative Colitis in Elderly
        Patients
Munenori Nagao*1, Kouhei Fukushima1, Chikashi Shibata1, Koh Miura1,
Hitoshi Ogawa1, Yuji Funayama2, Michiaki Unno1, Iwao Sasaki1
1surgery,   Tohoku university, Sendai, Japan; 2surgery, Tohoku-Rosai hospital, Sendai,
Japan
AIM: The aim was to study if different operative procedures affect postopera-
tive QOL in elderly patients (≥50 years) with ulcerative colitis (UC).
METHODS: Questionnaire to score QOL was mailed to each patient, and
IBD-Q of Japanese edition was used for questionnaire. IBD-Q consists of ques-
tions asking bowel symptoms, systemic symptoms, emotional functions, and
social functions. Patients were classified into 2 groups; young group (N = 18,
20–29 years old) as control and old group (N = 41, 50 years or older). Old
group was further classified into 2 groups by operative procedures; 19 patients
undergoing proctocolectomy with ileal J pouch-anal (canal) anastomosis
(IPA(C)A group) and 22 patients undergoing proctocolectomy with perma-
nent ileostomy (stoma group). All patients in young group underwent procto-
colectomy with IPAA.
RESULTS: There was no difference in the median age between IPA(C)A (56.5
years: range 50–75) and stoma (64.2 years: range 52–75) groups. Median total
QOL scores did not differ between IPA(C)A (160) and stoma (166) group. The
same was true for bowel function scores (55 in IPA(C)A group, 52 in stoma
group), systemic function scores (24 in IPA(C)A group, 21.5 in stoma group),
emotional function scores (66 in IPA(C)A group, 68 in stoma group), and
social function scores (23 in IPA(C)A group, 21.5 in stoma group). Median
total QOL scores in old group (166) were lower than those in young group
(180, p < 0.05). Bowel symptom scores and social function scores in old group
(54 for bowel symptom scores and 23 for social function scores) were also low
compared to young group (61 for bowel symptom scores and 27 for social
function scores, p < 0.05). Systemic function scores and emotional function
scores were not different between old and young groups.
CONCLUSIONS: Proctocolectomy with permanent ileosotomy was consid-
ered an acceptable procedure for elderly patients with UC, because not only
total QOL scores but also each functional score did not differ between old
patients undergoing IPA(C)A and permanent ileostomy. Total QOL scores as
well as bowel symptoms and social functions were impaired in old patients
compared to young patients.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1520 CT Scan in the Diagnosis of Acute Appendicitis: Help
        or Hindrance?
Akpofure Peter Ekeh*, Benjamin Monson, Curtis Wozniak, Jennell Smith,
Mary C. Mccarthy, Alex Little
Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH
OBJECTIVE: The use of preoperative abdominal Computerized Tomography
(CT) in the evaluation of presumed appendicitis has improved diagnostic
accuracy and reduced negative appendectomy rates. We sought to identify
the effect of the increased use of CT on the time to operative intervention
and perforation rates at a single institution.
METHOD: Patients who had appendectomies for presumed appendicitis
between January 2000 and May 2006 were identified. Patients who had pre-
operative CT were recognized as was the type of CT technology used at the
time of presentation (single slice, 4-slice or 16-slice). The length of time
between presentation to the emergency department and the operative proce-
dure, and histopathology reports were reviewed.
RESULTS: In the studied period, 1416 appendectomies were performed for
presumed appendicitis. Preoperative CT was performed in 56% of patients
(30.2% in the single-slice period, 55.8% in 4-slice period and 78.6% in16-slice
period.) The average time between presentation and commencement of sur-
gery was increased in patients who had preoperative CT—12.2 ± 9.8 hours vs.
7.7 ± 6.3 hours in patients without preoperative CT. This was statistically sig-
nificant (p < .001) The results were similar in the single slice, 4-Slice and 16-slice
periods. There was also a statistically significant increase in the perforation
rate in patients with preoperative CT (16.4% vs. 6.0%; p < 0.01). Preoperative
CT was noted to be an independent risk factor for perforation by multivariate
analysis—odds ratio of 3.16 (95% CI 2.09–4.77).
CONCLUSION: Preoperative CT improves preoperative diagnostic accuracy
for acute appendicitis but is associated with a delayed time to surgery and an
increase in the perforation rate. Its use should be more selectively applied for
these reasons.                                                                            POSTER ABSTRACTS
                                                                                              MONDAY




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  M1521 The Likely Cause of Postoperative “Feeding Intolerance”
        and Its Prevention
Gerald Moss*
Biomedical Engineering Department, Rensselaer Polytechnic Institute, Troy, NY
HYPOTHESIS: “Feeding intolerance” results from localized proximal G-I
distention caused by total inflow to the feeding site (feedings + secretions)
exceeding peristaltic outflow. Vagal reflexes initiate a “downhill spiral” that
paralyzes the already sluggish gut, leading to generalized distention, poor res-
piratory mechanics, etc.
METHODS: We studied consecutive surgical patients (160 cholecystectomy,
17 colectomy, and 3 esophagectomy). All were immediately fed elemental
diet @ ≥100 kcal/hour into the distal duodenum. Efficient aspiration 7 cm
proximal to the feeding site removed all air and any excess liquid (confirmed
by X-ray). Colectomy patients had contrast X-ray motility study. Serial analy-
ses were conducted for serum amino acids and glucose; aspirate was assayed
for removed foodstuff; hourly nitrogen balances were determined. Cholecys-
tectomy aspirate was replaced by IV fluids. Colectomy patients had degassed
aspirate “refed” manually. Esophagectomy patients were “refed” automati-
cally, in effect performing a “check for residual” every 30 seconds.
RESULTS: No adverse events were attributable to the feeding-decompression
regimens. Aspirate was free of feeding solution within two hours; serum levels
of amino acids had risen above basal; glucose was >150 mg/dl. Most (even
non-diabetics) required supplemental insulin to maintain euglycemia.
Requirement for insulin dependent diabetics rose markedly during those ini-
tial 24 hours. All except esophagectomy patients (still on respiratory support)
tolerated their usual diets by 24 hours after surgery without supplemental
insulin.Every cholecystectomy patient (160:160) had a cathartic induced
bowel movement, and was discharged within 24 hours of surgery. One
patient (1:160) died of a pulmonary embolus 29 days later. One patient
(1:160) developed an abdominal infection. One patients (1:160) was re-
admitted for percutaneous aspiration of a sterile biloma. One patient (1:160)
was re-admitted for a transient ischemic attack. Normal motility was noted
within hours of colectomy. Net absorption was >2,300 kcal the initial 24
hours. Contrast traversed secure anastomoses to exit in a bowel movement
within 48 hours, and all achieved positive protein balance within 2–24 hours.
Four patients were discharged uneventfully 24 hours after colectomy. “Refed”
patients had only 100–200 ml/day of aspirate discarded, containing <100 ml
of elemental diet.
CONCLUSIONS: “Feeding intolerance” appears to be triggered by G-I disten-
tion at the intestinal feeding site. A regimen that titrates inflow to match
peristaltic outflow prevents this complication, while permitting more rapid
achievement of nutritional goals.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1522 The Clinical Significance of Adult Intussusception
        Found by Computed Tomography
Parissa Tabrizian*1, Scott Q. Nguyen1, Alexander Greenstein1, Uma Rajhbeharrysingh1,
Pamela A. Argiriadi2, Meade Barlow1, Tiffany E. Chao1, Celia M. Divino1
1GeneralSurgery, The Mount Sinai Medical Center NY, New York, NY; 2Radiology, The
Mount Sinai Medical Center NY, New York, NY
OBJECTIVE: The finding of intestinal intussusception on radiographic
imaging in adults remains a challenging clinical dilemma. The clinical signif-
icance of this finding is unknown and determining cases requiring operative
therapy is difficult. We present a series of cases of adult intussusception (AI)
found on computed tomography (CT) and examine the significant parame-
ters that would guide the management of this condition.
METHODS: A retrospective review of records of adult patients found to have
intussusception on CT at the Mount Sinai Medical Center from 2001–2007
was performed. Chi-Square and multivariable logistic regression analyses
were used to identify factors associated with a true intussusception.
RESULTS: AI was found on CT scan in 80 patients (M = 34, F = 46) during
the study period. The mean age was 45 years. Patients presented with obstruc-
tive symptoms in 41% and abdominal pain in 56%. On CT, the intussuscep-
tions were enteroenteric in 87% enterocolic in 4%, and colocolic in 9%.
Imaging demonstrated multiple intussusceptions in 6% and obstructive find-
ings in 11% of patients. 53 patients were observed and all of these had no fur-
ther associated clinical sequelae. 9 patients, found to have an incidental
finding of intussusception on CT scan underwent surgery with no intraopera-
tive finding of true intussusception. 18 patients were explored based on CT
findings, out of which 12 were found to have a true intussusception. The
operative specificity was 67%. A pathologic leadpoint was identified in 9 cases
(Crohns enteritis [2], appendiceal mucinous cystadenoma [1], cecal fibroid
tumor [1], carcinoid [2], and adenocarcinoma [3], idiopathic [3]). All patients
with negative explorations recovered without complication. Factors associ-
ated with a true intussusception on univariate analysis were gastrointestinal
symptoms, obstruction on imaging studies, and involvement of the colon
(p < 0.05). Factors independently associated with a true intussusception on
multivariate analysis were obstruction on imaging studies and colonic
involvement (p < 0.05).
                                                                                       POSTER ABSTRACTS




CONCLUSION: The radiographic finding of AI remains a clinical dilemma.
The majority of cases are incidental findings on CT and have no significant
                                                                                           MONDAY




clinical sequelae. Factors such as gastrointestinal symptoms, obstruction on
imaging studies, colonic involvement are clinically significant and mandate
prompt surgical intervention.




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Clinical: Esophageal
   M1523 Gastroesophageal Reflux Disease and Connective
         Tissue Disorders. Pathophysiology and Implications
         for Treatment
Warren J. Gasper*, Piero Fisichella, Francesco Palazzo, Marco G. Patti
Department of Surgery, University of California San Francisco, San Francisco, CA
BACKGROUND: It has been postulated that in patients with connective tis-
sue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal
function is routinely deteriorated, often with absence of peristalsis. This belief
has led to the common recommendation of avoiding antireflux surgery for
fear of creating dysphagia.
HYPOTHESIS: a) in most patients with CTD and GERD, esophageal function is
preserved; b) only in patients with end-stage lung disease (ESLD) peristalsis is fre-
quently absent; c) a tailored approach (total vs. partial fundoplication) allows
control of reflux without a high incidence of postoperative dysphagia.
DESIGN: Retrospective review of a prospectively acquired database.
SETTING: University tertiary care center.
PATIENTS: Forty-eight patients with CTD were evaluated by esophageal
manometry and 24 hour pH monitoring (EFT). Twenty patients (Group A)
had EFT because of foregut symptoms and 28 patients with ESLD (Group B)
had EFT as part of the lung transplant evaluation. Two hundred eighty-eight
consecutive patients with GERD (Group C) served as a control group. Eight
patients in Group B underwent a laparoscopic fundoplication (3 patients,
360˚; 5 patients, 240˚).
RESULTS: Fundoplication resulted in control of reflux for 8 patients in
Group B. One patient developed post-operative dysphagia, which resolved
with Savary dilatation.
CONCLUSIONS: These data show that: a) peristalsis was preserved in most
patients with CTD, similar to patients who had GERD without CTD; b) peri-
stalsis was absent in a third of patients with CTD and ESLD; and c) a surgical
approach tailored to the esophageal peristalsis achieved control of reflux
without a high incidence of dysphagia.

                                                                     Group A        Group B        Group C
LES pressure (mean ± SD)                                              14 ± 9         11 ± 7         11 ± 6
% patients with abnormal peristalsis                                   30%*          79%*‡           36%‡
% patients without peristalsis (median, mmHg)                            0            39%              0
Peristaltic amplitude (median, mmHg)                               76 (26–186)*   19 (0–140)*‡   79 (11–292)‡
Median reflux score (nl < 14.7)                                                   83 (15–191)‡   49 (15–280)‡
*p < 0.05, A vs. B; †p < 0.05, A vs. C; ‡p < 0.05, B vs. C




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  M1524 Association of Gastroesophageal Reflux and O2
        Desaturation in Patients with GERD: A Novel Study of
        Simultaneous 24-Hour Impedance-pH and Continuous
        Pulse-Oximetry
Renato Salvador*, Fernando A. Herbella, Attila Dubecz, Marek Polomsky, Thadeus
Trus, Carolyn E. Jones, Daniel Raymond, Thomas J. Watson, Jeffrey H. Peters
Department of Surgery, University of Rochester, Rochester, NY
BACKGROUND: Respiratory symptoms are present in up to 50% of GERD
patients and are the primary or sole symptoms in 20%–25%. The well
described role of both reflex and reflux mechanisms, coupled with the lack of
optimal diagnostic tests, make assessment of the role of GERD in symptom
causation a challenge. The aim of this study was to assess the association of
gastroesophageal reflux with O2 saturation in patients with and without res-
piratory symptoms using combined simultaneous ambulatory monitoring
systems.
METHODS: The study population consisted of 11 patients with symptoms of
GERD in which 443 reflux episodes were detected by MII-pH study. Eight
patients had primary respiratory symptoms (cough, wheezing, hoarseness),
and 3 typical symptoms (heartburn and regurgitation). All patients under-
went simultaneously timed 24 hr MII-pH and continuous O2 saturation mon-
itoring via ambulatory reflux and pulse-oximetry monitoring. Reflux events
were defined by 24 hr esophageal pH and/or impedance and O2 desaturation
by one of 3 possible observations; 1) O2 saturation < 90%, 2) O2 saturation
drop of 7%, and 3) any event 7% below the mean saturation over 24 hours.
Proximal reflux was defined by pH < 4 20 cm above the LES or reflux in prox-
imal 2 impedance channels. A reflux-desaturation association was considered
present if O2 desaturation occurred within 30 seconds prior to or 10 minutes
after a reflux event.
RESULTS: Three hundred thirty eight reflux events occurred in patients with
primary respiratory symptoms and 105 in those with typical GERD symp-
toms. Nearly 60% of these 443 reflux events were associated with O2 desatu-
ration. Markedly more events were associated with O2 desaturation in
patients with respiratory symptoms (68%, 229/338) than in patients with
typical reflux symptoms (25%, 26/105, p < 0.01). The difference in reflux-
desaturation association was even more profound when proximal reflux
events were compared, occurring in 76% (130/171) of patients with respira-
                                                                                 POSTER ABSTRACTS




tory symptoms vs 14% (8/56) of those with typical GERD symptoms (p < 0.01).
                                                                                     MONDAY




CONCLUSION: There is a remarkably high prevalence of oxygen desatura-
tion associated with esophageal acidification in patients with primary respira-
tory symptoms. This novel observation adds to our understanding of the
pathogenesis of GERD related respiratory symptoms and, given further study,
may prove to be a useful diagnostic test in this difficult group of patients.




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  M1525 Acid Reflux to the Proximal Esophagus Predicts
        Postoperative Success in Patients with
        Laryngopharyngeal Reflux Disease
Carlos Godinez*1, Stephen M. Kavic1, George T. Fantry3, Paul F. Castellanos2,
J. Scott Roth1, F Jacob Seagull1, Adrian E. Park1
1Surgery, University of Maryland Medical Center, Baltimore, MD; 2Otolaryngology, UAB,
Birmingham, AL; 3Gastroenterology, University of Maryland Medical Center, Baltimore, MD
BACKGROUND: Acid reflux to the proximal esophagus and oropharynx is
reasonably assumed to play a role in the etiology of atypical symptoms of
reflux disease. To date, little published data exists to confirm this relationship.
Similarly, the role of laparoscopic Nissen fundoplication (LNF) as therapy for
this condition remains unproven over the long term. We theorized that
symptoms of laryngopharyngeal reflux disease (LPR) could be correlated to
documented episodes of proximal acid reflux, and that LNF would improve or
relieve these symptoms.
METHODS: One hundred and forty-three patients were diagnosed with LPR
based upon clinical evaluation, 24 hour esophageal pH probe monitor, and
Reflux Symptom Index (RSI) score. pH probe data was analyzed for total num-
ber of proximal reflux episodes (defined as pH < 4.0 in the proximal esophagus),
and correlation of symptom occurrence with proximal reflux episodes. Patients
who underwent operation then completed validated symptom assessment
instruments at multiple time points postoperatively.
RESULTS: Since July 2002, 114 patients have undergone LNF for laryn-
gopharyngeal reflux at our institution. Patients were followed for up to 3
years (mean follow-up 11.5 months). pH probe data was available for analysis
on 45 patients. Eighteen patients (40%) reported symptoms in association
with proximal reflux. Following LNF, Reflux Symptom Index score improved
most significantly in patients experiencing five or more symptomatic proxi-
mal reflux episodes, compared to those experiencing four or fewer (p = 0.045).
Further, patients whose absolute number of proximal reflux episodes
exceeded thirty in a 24 hour period, regardless of symptom correlation, also
had greater improvement in postoperative RSI scores (p = 0.032).
CONCLUSIONS: Full-height acid reflux episodes do not uniformly corre-
spond to symptom occurrence in patients with LPR. However, patients expe-
riencing five or more symptomatic proximal reflux episodes in a 24 hour
period report greater improvement in atypical symptoms following LNF. LNF
is an effective therapy for LPR in carefully selected patients.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1526 Outcomes Following Esophagogastrectomy in
        Octogenarians
Sebastian Defranchi*, Francis C. Nichols, Claude Deschamps, Mark S. Allen,
Stephen D. Cassivi, Dennis A. Wigle, K. Robert Shen
General Thoracic Surgery, Mayo Clinic, Rochester, MN
BACKGROUND: Conflicting information with regards to morbidity and
mortality has been reported for esophagogastrectomy in octogenarians.
METHODS: From our prospectively maintained database, all patients 80-
years of age and older who underwent esophagogastrectomy at our institu-
tion between January 1999 and December 2005 were identified and their
records reviewed.
RESULTS: There were 34 patients (30 men and 4 women). Median age was
81.8 years (range: 80 to 86 years). Twenty-eight patients (82%) were symp-
tomatic at presentation. Most common were dysphagia in 17 patients (50%)
and bleeding in 8 (23%). Comorbdities included hypertension in 22 patients
(64%), coronary artery disease in 14 (41%), cardiac arrhythmias in 6 (17%),
and diabetes and renal failure in 4 each (11%). Histopathology was adenocar-
cinoma in 30 patients (88%) and squamous cell in 3 (8%). One patient (2%)
had end-stage achalasia without malignancy. Four patients (11%) received
neoadjuvant chemoradiation therapy. The type of esophagogastrectomy
included Ivor Lewis in 19 patients (56%), transhiatal in 11 (32%), and McKeown
in 4 (12%). Pathologic stage was 0 or I in 12 patients (35%), II in 12 (35%),
and stage III in 10 (29%). Operative mortality occurred in 2 patients (5.9%).
Complications occurred in 24 patients (70%)and included: pulmonary in 11
(32%), atrial fibrillation in 10 (29%), aspiration in 6 (21%), and anastomotic
leak in 5 (15%). Only 1 patient with anastomotic leak required reoperation.
Median hospitalization was 11.5 days (range: 6 to 83 days). Overall morbidity
was more common in patients with a prior cardiac history, patients whose
BMI was >30, or patients who had a McKeown procedure. In particular, pul-
monary complications were more common in patients who had a history of
major cardiac disease, or underwent a McKeown procedure. One-, two-, three-
, and five-year survivals were 63%, 38%, and 30%, and 15% respectively.
CONCLUSION: Esophagogastrectomy in octogenarians can be performed
with low mortality but has high morbidity. Increasing morbidity is associated
with a history of major cardiac disease, BMI > 30, and performance of the
                                                                                 POSTER ABSTRACTS




McKeown esophagogastrectomy procedure.
                                                                                     MONDAY




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   M1527 Analyzing Treatment Costs for Esophageal Cancer
         Patients at Different Stages
Chih-Cheng Hsieh*1, Ching-Wen Chien2
        Taipei Veterans General Hospital, Taipei, Taiwan; 2Institute of Hospital and
1Surgery,
Health Care Administration, National Yang-Ming University, Taipei, Taiwan
BACKGROUND: Esophageal cancer (EC) is a complex disease. Poor treatment
results and high medical expense make it unpopular in cost-effectiveness
analyses. At present, the main treatment for EC is surgical or non-surgical
treatment. The aim of this study is to compare relative performance in terms
of survival time and medical expenses of the 2 treatments for EC patients at
different stages. This Result can be used to assist clinical decision making.
MATERIALS AND METHODS: Charge and clinical data of 356 EC patients
treated between 2000/1 to 2003/6 were collected. Patients were divided into 2
groups—surgical and non-surgical groups. Survival time, total expense,
expense per month and relative expense performance index (REPI) for 2 treat-
ments were calculated and compared between patients at different stages.
RESULTS: The survival time and total expense in surgical group were longer
and higher than in non-surgical treatment at all stages. Expense per month of
EC patients at stage I, II, and III were not significantly different between 2
groups. The expense per month in surgical group is significantly more than
non-surgical group only for patients at stage IV. The REPI for patients at stage
III was the highest and for patients at stage IV was lowest among four stages.
CONCLUSIONS: From the perspective of survival time and REPI, patients at
early stage of EC, even stage III, surgical treatment was a better treatment
than non-surgical treatment. But, for EC patients at stage IV, surgical treat-
ment has a low REPI which suggests that surgical treatment may need further
evaluation if medical expenses were included in clinical consideration.
  Stage                Variable                    Surgical group            Non-surgical group         p-value
    I             Survival time (mo)                    47.4                        14.7                 0.002
                   Total expense*                      23216                       9564                  0.021
                 Expense per month*                     919                         822                  0.773
                       REPI**                                            2.882
     II           Survival time (mo)                     37.0                       23.0                0.035
                    Total expense                       25200                      11420                < 0.001
                 Expense per month                      2266                       1332                 0.243
                        REPI                                             0.946
    III           Survival time (mo)                     23.0                       12.9                < 0.001
                    Total expense                       24694                      11676                < 0.001
                 Expense per month                      2373                       1965                 0.408
                        REPI                                             1.476
    IV            Survival time (mo)                     13.8                        8.6                < 0.001
                    Total expense                       22873                      12352                < 0.001
                 Expense per month                      5000                       2414                 0.004
                        REPI                                             0.775
*Total expense and expense per month were calculated within 3 years after diagnosis in USD
**REPI was calculated by the ratio of survival time benefit divided by the ratio of expense per month




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1528 Incorporation of Biologic Mesh Into Crural Closure
        Decreases Complications and Recurrence of
        Paraesophageal Hernias
Tayyab S. Diwan*, Michael Ujiki, Yashodhan S. Khajanchee, Christy M. Dunst,
Lee L. Swanstrom
Minimally Invasive Surgery, Legacy Health System, Portland, OR
INTRODUCTION: In 1973, Allison reported a 49% recurrence rate in 421
paraesophageal hernia (PEH) cases followed over 22 years. A more recent
study shows a recurrence rate of 30% following a laparoscopic repair without
mesh. The placement of mesh has been shown to decrease the PEH recur-
rence to less than 7% in some studies. Typical synthetic mesh are easy to use
but have an unacceptable rate of erosion into the esophagus. Biologic mesh
have recently gained favor as an alternative for crural reconstruction of PEH.
In a recent randomized, prospective study by Oelschlager, recurrence rates
decreased from 25% to 9% with the use of biologic mesh. However, a simple
method for placing and securing the mesh to the diaphram has never been
described. Methods that have been suggested include sutures, tacks, and staples,
but risk complications of mesh migration, diaphragmatic injury, and pericar-
dial injury as well as increased cost. We have employed a technique of crural
incorporation (CI) of the biologic mesh into the closure of the diaphragmatic
hiatus. We hypothesize that this method of crural repair will decrease the rate
of hernia recurrence and avoid the cost and complications of other mesh
placement techniques.
METHODS: The pre-operative and post-operative data from 35 patients
operated on from December 2005 to May 2007 was analyzed, including pre-
and post-op EGD, manometry, and UGI. All patients were pre-operatively
diagnosed with PEH using one or all of the tests formerly mentioned. A struc-
tured systems assessment tool was also administered to all patients pre- and
post-operatively. All pts underwent PEH repair with CI. Biologic mesh was
incorporated into the crural closure using pledgeted zero polyester suture in a
horizontal mattress stitch. Mean follow-up was 6.1 months (range 1–16
months).
RESULTS: Pre-operatively, 60% of pts had GERD symptoms, 42% pulmonary
symptoms (SOB, cough), and 25% had chest pain. Post-operatively 100% of
pts had resolution of their pre-op symptoms. 5/35 (14%) of pts were found to
have post-operative dysphagia. Twenty-one pts had post-op studies (egd,
                                                                                   POSTER ABSTRACTS




manometry, or UGI). No patients were found to have recurrence of their PEH.
                                                                                       MONDAY




No intra-operative complications were noted.
DISCUSSION: The use of biologic mesh has been demonstrated to decrease
recurrence rates following PEH repair. The safest and most efficient method of
mesh placement has not been defined. Our method of PEH repair with CI
decreases the rate of mesh complications and the rate of recurrence while uti-
lizing no extra suture or staples, while providing excellent apposition of mesh
to the underlying crura and securely closing the hiatus.




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  M1529 New Techniques for Endoscopic (Laparoscopic and
        Thoracoscopic) Esophagectomy of Esophageal Cancer,
        Ropeway Technique for Dissection Along with the
        Nerve and Double-Gloving Method of HALS for
        Reconstruction
Hitoshi Satodate*, Haruhiro Inoue, Shin-Ei Kudo
Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
INTRODUCTION: The concept of three-field lymph node dissection for
esophageal cancer was developed by Japanese surgeons and now the three-
field esophagectomy is in the mainstream of the esophageal cancer surgery in
Japan, and also in the various countries. With advent of minimal access sur-
gery, a myriad of different approaches have been devised and studied in
recent years. Thoracoscopic esophageal mobilization is becoming popular
approaches.
METHODS: Hand-assisted laparoscopic surgery (HALS) for gastric conduit
preparation, modified radical cervical node dissection and cervical esophago-
gastrostomy followed by thoracoscopic esophagectomy through the right
chest is the authors practice. Recently we added two new methods toward
complete and safe lymph node dissection. One is for excision of the nodes
along both recurrent laryngeal nerves as they course through the mediasti-
num to the neck. Both recurrent nerves are taped after the neck dissection,
and the tapes are extracted thoracic cavity during the thoracoscopic proce-
dure. Then the tapes are retracted by the forceps and nodes along to the
recurrent nerves are thoroughly excised. This procedure is also contributed to
the protection of the nerves. We named this method as ropeway technique,
because the nerves can be seen as ropeways after the completion of the dissec-
tion. Another one is new HALS method, named as double gloving method for
HALS. With this method, thorough lymph node dissection of the lower medi-
astinum can be securely performed.
RESULTS: Between April 2004 and October 2007, we had performed this
procedure for 76 cases of esophageal cancer patient. After introduction of this
method, the operation time has become shorter and the complication rate,
especially hoarseness has decreased.
CONCLUSIONS: These new two techniques, ropeway technique and double
gloving method of HALS are feasible for endoscopic esophagectomy with the
three-field lymph node dissection and also contribute to safer procedures.




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  M1530 Accidental Mucosal Perforation During Laparoscopic
        Heller-Dor Myotomy Does Not Affect the Final
        Outcome of the Operation
Mario Costantini*, Christian Rizzetto, Lisa Zanatta, Elena Finotti, Alessandra Amico,
Loredana Nicoletti, Emanuela Guirroli, Giovanni Zaninotto, Ermanno Ancona
Clinica Chirurgica 3, University of Padua, Padua, Italy
It is commonly believed that inadverted mucosal lesions during myotomy
may affect the final result of the operation. This study was therefore under-
taken to determine if esophagotomy during myotomy jeopardized the out-
come of the surgical treatment for achalasia. From 1992 to date, 400
laparoscopic Heller-Dor procedures were performed by 4 staff surgeons at the
same institution. All patients were evaluated preoperatively by a detailed
symptom questionnaire, esophageal manometry, endoscopy and barium
swallow. Accidental perforation during the operation occurred in 14 patients
(3.5%), that represent the object of this study (Group A). The population of
the remaining 386 patients who underwent the operation uneventfully was
used for comparison. Further, two different groups of patients, operated by
the same surgeon immediately before (Group B) and immediately after the
patients who experienced the perforation (Group C), were considered. All but
2 perforations were recognized and repaired during operation. Two perfora-
tion were detected by the routine gastrografin swallow and treated conserva-
tively. Perforations were not related to the severity of the disease, age,
duration of symptoms, LES characteristics, vigourous achalasia or surgeon’s
experience. A previous endoscopic treatment (87 patients) did not increase
the perforation rate (2/87 vs 12/313 in the primarily treated patients, p = ns).
The duration of the operation tended to be longer in Group A patients (185
min vs 135 min, p = ns); these also required a longer hospitalization (14 vs
5.5 days, p < 0.05). At a median follow up of 32 months, symptoms recurred
in 2/14 (14.3%) patients who experienced a mucosal lesion, requiring com-
plementary pneumatic dilation. That applied to 34 of the remaining 386
patients (8.8%, p = ns). Symptoms recurred in 1 patient of Group B and in
none of the Group C. Further, post operative median symptom score was sim-
ilar in all the 3 groups of patients.In conclusion, accidental perforation dur-
ing laparoscopic Heller myotomy is infrequent and cannot be predicted by
preoperative therapy or other factors such as the surgeon’s personal experi-
ence. In spite of a more complicated operation and a more prolonged recov-
ery, the outcome of surgical treatment in these patients is similar to those
                                                                                        POSTER ABSTRACTS




undergoing uneventful myotomy. Moreover, patients undergoing the opera-
                                                                                            MONDAY




tion immediately after the same surgeon scored a mucosal perforation in a
previous case, receive the same carefully performed operation and achieve the
same excellent results as the patients operated before.




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  M1531 Prevalence of Kyphoscoliosis Among Patients with
        Giant Paraesophageal Hernia: Proposed
        Pathophysiology and Clinical Significance
Matthew J. Schuchert*1, Prasad Adusumilli2, Chris C. Cook1, Brian L. Pettiford1,
Joshua P. Landreneau1, Ricardo S. Santos1, James D. Luketich1, Rodney J. Landreneau1
1Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center,
Pittsburgh, PA; 2Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
BACKGROUND: Kyphoscoliosis, more common among women, is seen in
approximately 4% of the octogenarian population of the United States. We
hypothesized that patients with kyphoscoliosis are affected with a reduced
intra-abdominal volume and progressive laxity of the musculature of the dia-
phragmatic hiatal sling mechanism leading to an increased risk of hiatal her-
nia formation and progression over time.
METHODS: We retrospectively reviewed the clinical history and roentgeno-
graphic data of 341 paraesophageal hernia patients over the last 4 years. The
prevalence of kyphoscoliosis among this patient cohort, and the outcomes of
surgical management were compared to paraesophageal hernia patients with-
out kyphoscoliosis.
RESULTS: Ninty-three of the 341 patients (27%) were found to have signifi-
cant kyphoscoliosis (mean age 74; 85% female). Laparoscopic repair of parae-
sophageal hernia with fundoplication was performed in 91% of these
patients. There was one mortality (aspiration pneumonia) and 15% major
postoperative morbidity. Mean length of hospital stay was 8 days (range
2–71). Prolonged stays were related mainly to marginal pulmonary status.
Surgical outcomes among patients with or without kyphoscoliosis are com-
pared in the Table. The presence of kyphoscoliosis was associated with
increased major perioperative morbidity and length of stay following parae-
sophageal hernia repair.
CONCLUSION: The prevalence of kyphoscoliosis was nearly 30% among
patients with paraesophageal herniation. This frequently under-appreciated
condition may contribute to the development and progression of type I “slid-
ing” hiatal hernias into type III “mixed” paraesophageal hernias. Surgeons
approaching paraesophageal hernia repair in this setting should be aware of
the increased morbidity and postoperative care required in managing these
patients.

Table 1. Clinical Significance of Kyphoscoliosis in Paraesophageal Hernia Patients
                                        Paraesophageal                Paraesophageal
                                         Hernia Patients               Hernia Patients
                                       With Kyphoscoliosis         Without Kyphoscoliosis
Number of Patients (n)                         93                           248
Age (mean)                                     74                            67
Length of Stay (mean days)                      8                             3
Major Complications (%)                        15                             6


  Poster of Distinction

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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1532 Preoperative Chemoradiation with Intensify-
        Modulated Radiation Therapy (IMRT) Increases
        Pathological Complete Response Rate in Locally
        Advanced Squamous Cell Carcinoma of the Esophagus
Chadin Tharavej*, Patpong Navicharern
Surgery, Chulalongkorn University, Bangkok, Thailand
INTRODUCTION: Pathological complete response (pCR) has been defined
as a favorable indicator in esophageal cancer patients undergoing preopera-
tive chemoradiation treatment. About 20%–30% of pCR has been reported in
prospective randomized trials. Increased rate of pCR may translate into long
term survival benefit for esophageal cancer patients.
METHODS: Twenty-two patients with locally advanced squamous cell
esophageal cancer (T3, N0-1, M0) underwent preoperative chemoradiation
during 2006–2007. Concurrent chemoradiation with 2 cycles of cisplatin and
5-FU and 50Gy irradiation using IMRT were given to all patients. Esophagec-
tomy was performed in all patients with resectable cancer within 6–8 weeks
after complete neoadjuvant treatment.
RESULTS: One out of 22 patients (4.5%) died during preoperative chemora-
diation treatment from sepsis. Three out of 22 patients (13.6%) developed
distant metastasis during preoperative therapy. Three patients refused surgery
because of much clinical improvement which were able to have solid food.
They underwent upper GI endoscopy and PET scan with no residual tumor
demonstration in all 3 patients. Fifteen patients underwent esophagectomy
with no operative mortality. Resectability rate was 83%. R0 resection was
achieved in all 15 patients. Ten out of 15 patients (67%) had pathological
complete response. Two patients had T0 N1, 1 patient had T1N0 and 2
patients had T1N1 lesion. All patients were still alive at the median follow up
of 10 months.
CONCLUSIONS: Two-third of locally advanced squamous cell esophageal
cancer who had preoperative chemoradiation with high dose IMRT had
pathological complete response. No operative mortality has been found with
this treatment. This may translate into long term survival benefit over surgery
alone for locally advanced esophageal cancer. Prospective randomized trial is
ongoing in our institute.
                                                                                  POSTER ABSTRACTS
                                                                                      MONDAY




  Poster of Distinction

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Clinical: Hepatic
  M1533 Hepatobiliary Resection with Inferior Vena Cava
        Resection and Reconstruction Using an Autologous
        Patch Graft for Intrahepatic Cholangiocarcinoma
Tsuyoshi Sano*1,2, Kazuaki Shimada2, Minoru Esaki2, Yoshihiro Sakamoto2,
Tomoo Kosuge2, Yasuhiro Shimizu1, Yuji Nimura1
1gastroenterological surgery, Aichi Cancer Center Hospital, Nagoya, Japan;
2Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital,
Tokyo, Japan
BACKGROUND: In patients with advanced cholangiocarcinoma involving
the inferior vena cava (IVC), an extended hepatobiliary resection with com-
bined resection and reconstruction of the IVC is often prerequisite to obtain a
clear resection margin.
PATIENTS AND METHODS: We present our approach to repair of approxi-
mately half of a cross-sectional wall defect of the IVC using an autologous
external iliac venous patch graft during extended hepatobiliary resection
with a total hepatic vascular exclusion technique. The harvested external iliac
vein graft was incised longitudinally and trimmed to fit the IVC defect. After
multiple stay sutures, a continuous running suture using 4-0 prolene was
made.
RESULTS: A 72-year-old woman underwent the complex surgery (left trisec-
tionectomy with total caudate lobe resection) survives 28 months without
recurrence sign of the tumor after surgery. Total operation time was 863 min-
utes and intraoperative blood loss was 2775 g. The patient was discharged on
the 26th postoperative day. A 64-year-old man underwent the complex sur-
gery (right trisectionectomy with total caudate lobe resection, portal vein
sleeve resection and reconstruction) survives 21 months with lung metastasis
after surgery. Total operation time was 780 minutes andintraoperative blood
loss was 2110 g. Morbidity of transient edema of the ipsilateral lower leg
potentially related to graft harvesting was noted in the latter patient after sur-
gery, and thereafter no anticoagulant therapy was required. The patient was
discharged on the 62nd postoperative day.
CONCLUSIONS: The external iliac vein patch graft for IVC resection and
reconstruction during hepatobiliary resection is technically simple, produces
no stenosis or caliber change in the reconstructed IVC, and is applicable for at
least half or less of a cross-sectional defect of the IVC wall to be reconstructed.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1534 Postoperative Complications After Liver Resections for
        Colorectal Metastases: Analysis of Risk Factors and
        Influence of Preoperative Chemotherapy
Frank Makowiec*1, Ulrich Adam1,2, Hannes Neeff1, Ulrich T. Hopt1
1Department  of Surgery, University of Freiburg, Freiburg, Germany; 2Department of
Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany
INTRODUCTION: In the context of multimodal therapy liver resections
(LR) for metastases of colorectal cancer (CRC) are frequently performed after
chemotherapy (CTx). Several CTx-medications may result in liver damage up
to fibrosis or cirrhosis. Recent studies reported conflicting results regarding
complications after LR in correlation to prior CTx. We, therefore, analyzed
our experience with postoperative complications after LR for CRC metastases.
METHODS: Since 1998 199 primary LR were performed for CRC metastases
(wedge resections 14%, segmental 32% and hemi- or extended hemihepatec-
tomy 54%). Following neoadjuvant CTx LR was performed not earlier than
four weeks after CTx. CTx was performed in 62% before LR either as adjuvant
CTx of the primary CRC or as neoadjuvant therapy for liver metastases. Dur-
ing our analyses we also differentiated between the first and second part of
the study period (P1/P2) and between limited (wedge/segmental) and
extended (at least hemihepatectomy) LR. In P2, under new direction of the
hepatobiliary surgery team, refined surgical techniques and perioperative
management strategies were applied. In P2 the frequency of LR increased 3-fold
compared to P1. Seven clinical, multiple laboratory parameters and preopera-
tive CTx were evaluated on their prognostic influence on the occurrence of
complications. Multivariate risk factors were analyzed by binary logistic
regression.
RESULTS: Any complication occurred in 48%, surgical complications in 32%
and hepatic insufficiency in 6.5%. Mortality was 2.5%. In P1 four patients
died perioperatively, in P2 only one (mortality < 1% in P2). Four of those five
patients were diabetic. Multivariate risk factors for any complication were a
diabetes (p < 0.05; relative risk RR 3.1) and extended resections (p < 0.05; RR
2.5). Risk factors for surgical complications were again extended resections
(p < 0.001; RR 3.3) and male gender (p < 0.01; RR 3.2). Independent risk fac-
tors for hepatic insufficiency were a diabetes (p < 0.02; RR 2.0) and extended
resections (p < 0.02; RR 2.3). A diabetes (p < 0.01; RR 3) and resections per-
formed during P1 (p < 0.01; RR 2.6) were independent risk factors for mortal-
                                                                                     POSTER ABSTRACTS




ity. Age, BMI, laboratory values and blood transfusions did not influence any
                                                                                         MONDAY




of the various complication rates. Preoperative CTx did not correlate with
complications (even tendency of fewer complications after CTx)
CONCLUSIONS: The extent of resections and diabetes are relevant risk factors
for complications following hepatic resection for CRC metastases. An increas-
ing centre experience clearly decreases perioperative mortality. In our experi-
ence a preoperative chemotherapy did not increase postoperative morbidity.




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  M1535 Second Liver Resection for Recurrent Metastases of
        Colorectal Cancer: Perioperative Complications and
        Oncological Results
Hannes Neeff*1, Frank Makowiec1,2, Eva Fischer1, Oliver G. Opitz2, Ulrich Adam1,2,
Ulrich T. Hopt1,2
1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer
Cancer Center Freiburg, University of Freiburg, Freiburg, Germany
INTRODUCTION: Resections of liver metastases of colorectal cancer (CRC)
are performed with increasing frequency, due to advances in multimodal
therapy, low mortality and relatively good outcomes. However, only few data
have been reported regarding the results of repeat liver resections for recur-
rent metastases. We, therefore, analyzed our experience of those selected
patients in whom a second liver resection could be performed.
METHODS: From 2002 until 2006 thirty-six patients had a second liver
resection for recurrent hepatic metastases of CRC in our department (28%
female, median age 64 years) a median of 16 months after first liver resection.
In all patients other (extrahepatic) tumor manifestations were excluded dur-
ing preoperative staging (CT/MRI, PET). Eighty-four percent of the patients
had received chemotherapy prior to re-resection. A segmental or atypical
resection was performed in 23 patients whereas the other 13 patients
underwent hemihepatectomy. During five of the 36 re-resections an addi-
tional radiofrequency thermoablation was done. Survival analysis was per-
formed using the Kaplan-Meier-method. The median follow-up after hepatic
re-resection was two years (n = 34).
RESULTS: Two of the 36 patients died postoperatively (hospital mortality
5.6%). Perioperative complications (any) occurred in 50%, surgical complica-
tions in 25% and hepatic insufficiency in two patients (5.6%). Blood transfu-
sions were necessary in 37% of the re-resections. Free hepatic resection
margins could be achieved in 78%. During follow-up eight of 34 patients died
of recurrent CRC. The cumulative two- and four-year survival rates in our
series are currently 75% und 64%. The status of the resection margin showed
a clear tendency to influence prognosis after hepatic re-resection: After a mar-
gin-negative resection four-year survival was 75% whereas it was only 36% in
patients with positive margins (p = 0.12). No further potential prognostic fac-
tors could be identified up to now, also because of the limited follow-up time.
CONCLUSIONS: Repeat liver resections for recurrent metastases of CRC can
be performed with acceptable morbidity and mortality in selected patients.
Hepatic re-resections with free margins achieved (surprisingly) high survival
rates in our series. In the context of modern multimodal treatment (especially
chemotherapy) hepatic re-resection should always be considered in the
absence of other tumor manifestations in patients fit for major surgery.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1536 A Decision Analysis Model of Hepatectomy Versus
        Radiofrequency Ablation for Hepatocellular
        Carcinoma
Amanda Cooper*, Mary A. Maluccio
General Surgery, Indiana University, Indianapolis, IN
BACKGROUND: With the introduction of less invasive modalities to treat
hepatocellular carcinoma (HCC), the debate regarding whether hepatectomy
is required has emerged. Recent studies suggest that radiofrequency ablation
(RFA) is equivalent to resection for small solitary tumors. Decision analysis
modeling is a unique method of evaluating medical decisions and highlight-
ing features that might persuade us that one method is, in fact, superior. The
objective of this study was to use decision analysis to predict which of these
two treatments would result in the longest average survival for patients with
early hepatocellular carcinoma.
METHODS: An English language literature review was performed in PubMed
and Medline to locate articles reporting outcomes for patients with hepato-
cellular carcinoma after hepatectomy and/or RFA. A decision tree was con-
structed in TreeAge Pro (Williamstown, MA). Weighted averages of values
from the literature were used to determine the probabilities entered in the
decision tree. Sensitivity analyses vary individual variables over a range of
values and were performed to determine if varying individual probabilities
impacted the outcome of the model.
RESULTS: The following weighted averages were used in the mathematical
model: 3.5% peri-operative mortality after hepatectomy, 69.2% 5-year tumor
recurrence rate, 22-month median disease free interval, and 80.5% of recur-
rences amenable to salvage therapies. For RFA, we used a 0.2% peri-proce-
dural mortality, 72.4% 5-year tumor recurrence rate, 16-month median
recurrence free interval, and 77.4% of post RFA recurrences amenable to addi-
tional treatment. A 46-month median survival for patients who recur and are
amenable to additional treatment was used for both groups, as was a 7.5-
month median survival for patients unable to received additional therapy.
The decision model predicted a 68.9-month survival after hepatectomy and a
64.7-month survival after RFA for a 4.2-month survival benefit to for hepatec-
tomy over RFA. This preferred treatment strategy was insensitive to changes
within the published range for peri-procedural/operative mortality, 5-yr.
tumor recurrence rate after RFA, median time to recurrence, percentage ame-
                                                                                 POSTER ABSTRACTS




nable to additional therapy, or the median survival of patients ineligible to
                                                                                     MONDAY




additional treatment.
CONCLUSION: The baseline analysis predicts that hepatectomy results in a
4.2 month longer life expectancy compared to the less invasive RFA treat-
ment. However, RFA does result in an equivalent or potentially superior sur-
vival benefit over hepatectomy for certain variables within the range reported
in the literature.




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  M1537 Image-Guided Laparoscopic Radiofrequency Ablation
        of Giant Liver Hemangiomas
Rocio Anula*1,2, Ernesto Santos Martin3,2, Julio M. Mayol1,2, Iris Sanchez-Egido1,
Jesus A. Fernandez-Represa1
        de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; 2Unidad de Cirugía
1Servicio
Guiada por Imagen, Hospital Clinico San Carlos, Madrid, Spain; 3Servicio de
Radiodiagnóstico, Hospital Clinico San Carlos, Madrid, Spain
INTRODUCTION: The management of giant liver hemangiomas remains
controversial because of their benign nature, the unclear risk of developing
complications and the relatively high morbidity and mortality associated
with surgical resection. New therapeutic modalities for liver malignancies,
such as radiofrequency ablation, may be useful to treat these tumors in a min-
imally invasive fashion. We present a patient with a giant hepatic hemangi-
oma successfully treated with laparoscopic ultrasound-guided multipolar
radiofrequency ablation.
CASE REPORT: A 38 year-old male patient who had been complaining of
constant pain in his right upper quadrant for over 1 year and diagnosed with
a cavernous hemangioma on an abdominal ultrasound, was referred for eval-
uation. A 7.5 cm hypervascular tumor in segments V–VI of the liver, near the
gallbladder, was confirmed on abdominal CT scanning. The patient was
informed of the different alternatives and chose to undergo a minimally inva-
sive treatment. Under general anesthesia, the patient was placed in the
French position for laparoscopic cholecystectomy. Laparoscopic ultrasound
scanning confirmed the presence of a giant hemangioma occupying part of
segments V and VI and adjacent to the gallbladder, After performing a laparo-
scopic cholycystectomy, six T40 needles of the bipolar Celon Power System
(Celon AG medical instruments Olympus, Germany) were percutaneously
inserted into the abdomen under direct laparoscopic control and into the
tumor under ultrasound guidance. Radiofrequency energy was delivered with
an initial power setting of 40 watts and subsequently increased until reaching
a power of 250 watts at 470 Hz. Tissue impedance was continuously moni-
tored by the generator. The effect of radiofrequency on the hemangioma was
imaged on real time. After completing tumor ablation, the needles were
slowly withdrawn while ablating the tract in the liver. No intraoperative com-
plications occurred. The patient remained asymptomatic in the immediate
postoperative period and was discharged on postoperative day 2. A follow-up
CT scan obtained 3 months after the procedure showed complete ablation of
the lesion without residual enhancement. The lesion was completely replaced
by hypodense material.
SUMMARY: Radiofrequency ablation is a safe and effective treatment for
giant liver hemangiomas. The laparoscopic approach combined with intraop-
erative ultrasonographic imaging may become a sound minimally invasive
option for symptomatic patients.




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         49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1538 Monopolar Floating Ball Versus Bipolar Forceps for
        Hepatic Resection: A Prospective Randomized Clinical
        Trial
Guido Torzilli*1,2, Matteo Donadon1,2, Matteo Marconi1,2, Fabio Procopio1,2,
Angela Palmisano1,2, Daniele Del Fabbro1,2, Florin Botea1,2, Marco Montorsi2
1LiverSurgery Unit, 3rd Department of Surgery, University of Milan, Istituto Clinico
Humanitas – IRCCS, Rozzano – Milano, Italy; 23rd Department of Surgery, University of
Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy
BACKGROUND: Intraoperative blood loss and blood transfusions are impor-
tant predictors of outcome in hepatic surgery. Controversies exist about
methods for coagulation, while the dissection technique by Pean-clasia is still
effective. Monopolar floating ball (Tissuelink-TM) (MFB), used for blunt liver
dissection, seems effective but leads to tissue necrosis, which may represent a
source of morbidity. The aim of this study was to compare in a prospective
randomized trial, the vessel coagulation after Pean-clasia dissection obtained
with bipolar forceps (BF) versus the MFB coagulation.
METHODS: Seventy-six patients (58 men, 18 women; mean age: 64.7 yrs)
scheduled for liver resection were randomized in two groups: Group A (MFB,
n = 38) and Group B (BF, n = 38). The two groups were homogeneous in terms
of tumors presentation, and background liver features. Blood loss (ml/cm2),
blood transfusions, transection time (min/cm2), ligatures (number/cm2),
drains amount, drains bilirubin levels at 3rd, 5th, and 7th postoperative day,
postoperative morbidity and mortality were analysed.
RESULTS: Mean resection area was 93.9 cm2 in group A and 79.8 cm2 in
group B (p = 0.956). Mean Pringle time was 112 min in group A and 94 min
in group B (p = 0.847). There were no significant differences in blood loss
(mean 7.6 versus 7.2 ml/cm2; p = 0.162), blood transfusions (11.5% versus
16.5%; p = 0.450), transection time (mean 1.3 versus 1.3 min/cm2; p = 0.289),
number of ligatures (mean 0.7 versus 0.7/cm2; p = 0.200), drains amount
(median 55 versus 66.7 ml; p = 0.451), and drains bilirubin levels (mean 1.9
versus 2.1 mg/dL; p = 0.664). Both the transection devices were equally safe,
and no mortality or major morbidity was recorded.
CONCLUSION: Our preliminary data showed that the use of Pean-clasia with
the MFB was safe, and minimized the blood loss during hepatic resection.
However, the use of MFB offered no significant benefit over the BF technique.
                                                                                        POSTER ABSTRACTS
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Clinical: Pancreas
  M1539 Long Term Follow-Up (7–34 Years) After Surgical
        Treatment of Chronic Pancreatitis
Sergio Pedrazzoli*1, Claudio Pasquali1, Stefano Guzzinati2, Mattia Berselli1,
Cosimo Sperti1
1Medical  and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Venetian Tumor
Registry, Venetian Oncological Institute, PADOVA, Italy
BACKGROUND: The natural history of chronic pancreatitis (CP) pts after
surgery is rarely reported. (J Clin Gastroenterol 2003;36:159-65).
METHODS: Between 1970 and 1999, 193 pts underwent surgery (S) for CP.
After review 19 pts were excluded: 12 post SAP and 4 post-traumatic
pseudocysts, 2 Vater’s papilla stenosis, 1 IPMN. 174 pts (mean age 45 ± 10.2;
range 24–75 yrs) were followed with clinical examination, CT or MR, and/or
telephone interview. They were divided in 4 Groups: 1) Resective S: 62 (Whip-
ple [41], left pancreatectomy with [6] or without [13] pancreaticojejunos-
tomy, Warren procedure [2]). 2) Derivative S: 82 (Puestow [20], Partington-
Rochelle or Frey [44], cystojejunostomy [12] or cystoduodenostomy [1], fistu-
lojejunostomy [1], personal procedure [4]). 3) Non pancreas directed S: 23
(Cholecystectomy [1] and/or surgical sphincteroplasty or choledochoduode-
nostomy [19], bilateral splanchnicectomy [1], embolization of a bleeding
pseudoaneurysm [1], remake of a hepaticojejunostomy after a Whipple [1]).
4) Marsupialization: 7. A second S was required in 23 pts, a third in 4 of them:
Group 1: 6 + 0, Group 2: 11 + 2, Group 3: 3 + 1, Group 4: 3 + 1. The actual sta-
tus at December 31 2006 of all pts was retrieved. The cause of death was
retrieved for 111/117 pts. Of the 6 remaining, 1 died abroad, and privacy pre-
vented us to retrieve the cause for the other 5.
RESULTS: Hospital mortality was 4/174 (2.3%). 57 pts (32.8%) are still alive.
49 pts (28.2%) developed cancer and 38 died of their cancer, 5 of another dis-
ease, 1 of unknown cause, and 5 are still alive. The more frequent was the
lung cancer (22 pts) followed by oral, pharynx, larynx and esophageal can-
cers (10 pts). A small pancreatic cancer (PC) was found in the surgical speci-
men in 3 pts: 1 died of PC 18.3 years later, 1 died of unknown cause 30.5
years later, and 1 is alive and well 29 years later. A further patient died of PC 9
years after surgery. The other main causes of death were: liver cirrhosis (15
pts), vascular disease (11 pts), MI or failure (10 pts), acute pancreatitis, acci-
dental trauma, complications of diabetes, bronchopneumonia (4 pts each).
The overall 5, 10, 15, 20, 25 and 30 years survival rate was 82.8, 63.5, 49.7,
36.4, 27.5 and 23.1 and was the same for the 4 groups (P = 0.8447).
CONCLUSIONS: The incidence of PC was 2.3%, but only 1 (0.6%) appeared
during follow-up. The high incidence of lung, oral, pharynx, larynx and
esophageal cancers (32/170; 18.8%) during follow-up is due to the smoking
habits of almost 100% of our pts (Int J Cancer 2008;122:155–64). Eliminating
smoking and increasing tests on organs at risk of cancer during follow-up
may prolong survival in these pts.



 Poster of Distinction
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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1540 High Complication Rate After Pancreas Preserving
        Surgical Procedures for Benign or Borderline
        Pancreatic Lesions. Careful Selection of Patients
        Is Needed
Cosimo Sperti, Claudio Pasquali, Mattia Berselli, Laura Frison, Tania Saibene,
Sergio Pedrazzoli*
Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy
BACKGROUND: Since the first report in 1980, organ-function-preserving
pancreatectomy has been increasingly performed in patients with benign or
low-grade malignant lesions, in order to decrease the loss of normal pancre-
atic tissue. The aim of this study was to evaluate our experience with limited
pancreatic resections with attention to perioperative and long-term outcome.
METHODS: From November 1985 to December 2005, 54 patients underwent
segmental pancreatectomy: 30 patients had central pancreatectomy (CP) and
24 had duodenum-preserving pancreatic head resection (DPPHR). Ten patients
who underwent CP (Sperti C et al., J Am Coll Surg 2000;190:711–718) and 13
patients who underwent DPPHR (Pedrazzoli S et al., Pancreas 2001;23:309–315)
were previously reported. There were 19 males and 35 females, with mean age
of 50.2 years (range 13–74 years). The pathologic diagnosis was: serous cysta-
denoma (13), insulinoma (9), nonfunctioning endocrine tumor (9), Intraductal
Papillary Mucinous Neoplasm (7), chronic pancreatitis (7), mucinous cystade-
noma (4), metastasis from renal cell carcinoma (2), papillary-cystic tumor (1),
biliary cyst (1), and solitary true cyst (1).
RESULTS: There were no operative death. Postoperative course was unevent-
ful in 27 patients (50%). Complications occurred in 15/30 CP and 12/24
DPPHR. In particular a pancreatic fistula was diagnosed in 13/30 CP (43.3%)
and in 3/24 DPPHR (12.5%), a biliary fistula in 5/24 DPPHR (20.8%) (1 reop-
eration), an abdominal abscess in 2/24 DPPHR (1 reoperation), a peritoneal
bleeding in 1 CP and 1 DPPHR (1 reoperation), a digestive bleeding in 1/24
DPPHR and a pneumonia in 1 CP. After a median follow-up of 48 months
(range 23–264) only one patient recurred after a CP for renal cancer
metastases: she underwent pancreaticoduodenectomy and partial resection of
the residual body-tail. Four patients developed type two diabetes (2 after CP
[6.9%] and 2 after DPPHR [8.7%]); one CP and one DPPHR patient were
diabetics before surgery. Ten patients (18%) required pancreatic enzyme
supplementation.
                                                                                  POSTER ABSTRACTS




CONCLUSIONS: Segmental pancreatic resection preserves long term endo-
                                                                                      MONDAY




crine and exocrine function in a significant proportion of patients. While
operative mortality is absent, this type of surgery is associated with a high
complication rate, even in experienced hands. This is due to the presence of a
normal pancreas, at high risk of pancreatic fistula, in almost all patients. The
incidence of biliary fistula decreased with increasing experience. Therefore,
caution is necessary when using these procedures, accurate selection of the
patients being essential.




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  M1541 Predictable Factors for Poor Outcome After Severe
        Acute Pancreatitis
Takeo Yasuda*1, Yoshifumi Takeyama1, Takashi Ueda1, Makoto Shinzeki2,
Hidehiro Sawa2, Yonson Ku2, Yoshikazu Kuroda2, Harumasa Ohyanagi1
1Department of Surgery, Kinki University School of Medicine, Osaka-sayama, Japan;
2Department of Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan

BACKGROUND/PURPOSE: Long-term outcome of severe acute pancreati-
tis (SAP) is often complicated, because the etiology, severe inflammation and
pancreatic necrosis can affect the endocrine/exocrine function and morphol-
ogy of pancreas. It is favorable to predict the long-term outcome in the fol-
low-up of patients after the recovery from SAP, but there have been no
analyses about the predictable factors for poor outcome after SAP. This study
was undertaken to evaluate the post discharge outcome of severe acute pan-
creatitis (SAP) and clarify the predictable factors for poor outcome.
METHODS: Among 103 patients who had recovered from SAP according to
the Japanese criteria, we analyzed 45 patients (36 men and 9 women) that we
could follow-up more than 12 months after SAP. The mean follow-up period
was 56 ± 6 months (range: 12–184). We analyzed the relationships of recur-
rence of acute pancreatitis (AP), transition to chronic pancreatitis (CP), and
development into diabetes mellitus (DM) with the etiology and pancreatic
necrosis at SAP, respectively. Moreover, we surveyed the predictable factors for
poor outcome in laboratory data on admission of SAP by univariate and mul-
tivariate analyses.
RESULTS: The recurrence rate of AP was 19%. The mean interval after SAP
was 25 ± 6 months. The recurrence rate of AP in patients with pancreatic
necrosis was higher than that in patients without pancreatic necrosis (32%
vs. 5%, P < 0.05). Univariate analysis showed that the predictable factors for
the recurrence of AP were CRP and white blood cell (WBC) count (P < 0.05).
Multivariate analysis revealed that the independent predictable factor was
CRP (P < 0.05). The transition rate to CP was 22%. The mean interval after
SAP was 52 ± 10 months. The transition rate to CP was higher in alcoholic
SAP than that in biliary SAP (32% vs. 0%, P < 0.05). Univariate analysis
showed that the predictable factors for the transition to CP were WBC count,
hematocrit, base excess (BE), Ranson score, and Japanese severity score (JSS)
(P < 0.05). Multivariate analysis disclosed that the independent predictable
factors were WBC count and JSS (P < 0.05). The development rate into DM
was 39%. The mean interval after SAP was 26 ± 12 months. Univariate analy-
sis showed that the predictable factors for the development into DM were
blood glucose and BE (P < 0.05). Multivariate analysis revealed that the inde-
pendent predictable factor was blood glucose (P < 0.05).
CONCLUSIONS: Degree of inflammation and pancreatic necrosis may be
related to the recurrence of AP. Alcoholic SAP with high severity may contrib-
ute to transition to CP. Impaired glucose tolerance is easy to develop into DM
after SAP.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1542 Serum Immunosuppressive Acidic Protein Levels in
        Patients with Severe Acute Pancreatitis
Makoto Shinzeki*1, Takashi Ueda2, Yoshifumi Takeyama2, Takeo Yasuda2,
Kenro Hirata1, Hirochika Toyama1, Ippei Matsumoto1, Toshiaki Tsujimura1,
Tsunenori Fujita1, Tetsuo Ajiki1, Yonson Ku1
1Division of Hepato-Billiary-Pancreatic Surgery, Kobe University Graduate School of
Medical Sciences, Kobe, Japan; 2Department of Surgery, Kinki University School of
Medicine, Osaka, Japan
OBJECTIVES: In severe acute pancreatitis (SAP), immunologic impairment
in the early phase may be linked to subsequent infectious complications.
Immunosuppressive acidic protein (IAP) is an immunosuppressive factor to
be present in serum and ascites of cancer patients, and it is utilized as a tumor
marker and an index of immune status of cancer hosts.
METHODS: We measured serum IAP levels obtained on admission from 42
patients with SAP (Japanese severity score ≥ 2), and analyzed the relationships
with disease severity, pancreatic necrosis, blood biochemical parameters on
admission, and clinical outcome (infection and death).
RESULTS: Serum IAP level increased (791 ± 285 µg/ml) on admission and
recognized abnormal high level (normal range <500 µg/ml) in 37 patients
(88.1%). Serum IAP level was significantly lower in patients of Stage 3 and 4
(Japanese severity score ≥ 9) (678 ± 187 µg/ml) than that in patients of Stage 2
(2 ≤ Japanese severity score ≤ 8) (848 ± 311 µg/ml). It was also significantly
lower in patients whose Ranson score ≥ 5 (674 ± 287 µg/ml) than that in
patients whose Ranson score ≤ 4 (910 ± 287 µg/ml). Moreover, it was signifi-
cantly lower in patients with pancreatic necrosis (693 ± 194 µg/ml) than that
in patients without pancreatic necrosis (922 ± 336 µg/ml). Among the blood
biochemical parameters on admission, serum IAP was significantly negatively
correlated with hematocrit, serum lipase, and serum interferon–, and was sig-
nificantly positively correlated with serum total protein. Serum IAP levels in
patients of Stage 2 reached higher peak 7 days after admission and decreased
more rapidly than those in patients of Stage 3 and 4.
CONCLUSIONS: Serum IAP levels were elevated in patients with SAP, but
were significantly lower in patients with higher grade of severity or pancreatic
necrosis. These results suggest that serum IAP levels may be related to sys-
temic inflammatory response and reflect the immunoresponsiveness in
                                                                                      POSTER ABSTRACTS




patients with SAP.
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  M1543 Risk Factors for Postoperative Complications After
        Pancreatic Head Resection: Multivariate Analysis of
        608 Consecutive Operations
Tobias Keck*1, Frank Makowiec1, Eva Fischer1, Ulrich Adam2,1, Ulrich T. Hopt1
1Department  of Surgery, University of Freiburg, Freiburg, Germany; 2Department of
Surgery, Vivantes-Humboldt-Klinikum, Berlin, Germany
INTRODUCTION: Mortality after pancreatic head resections (PHR) has been
decreased clearly below five percent. However, complications are still fre-
quent and influence the postoperative course and costs. The aim of our anal-
yses was to evaluate morbidity after more than 600 PHR and to assess risk
factors for various complications.
METHODS: From 7/1994 to 2007 608 consecutive PHR were performed by
five responsible surgeons in one team. The first 317 PHR were performed until
2001 in department A, the other 291 (after the team had moved end of 2001)
since 2002 in department B. The documentation of the perioperative out-
come was performed prospectively. Indications for surgery were periampul-
lary or other malignancies (52%), chronic pancreatitis (43%) or others (5%).
The techniques of PHR were: classical Whipple-procedure 14%, pylorus-
preserving PHR 66%, duodenum-preserving PHR (DPPHR) 18% and total pan-
createctomy 2%. Forty percent of the patients preoperatively had undergone
biliary drainage (PBD). After examining 16 potential risk factors for complica-
tions univariately, multivariate analyses were performed using binary logistic
regression.
RESULTS: Any complication (AnyCompl) occurred in 49% of the patients,
surgery-related complications (SurgCompl) in 33% and infectious complica-
tions (InfCompl) in 17%. Mortality was 2.4%. Multivariately significant risk
factos (M-RF) for AnyCompl were the type of surgery (PD more complications
than DPPHR), duration of surgery >7 Std., absence of PBD, extended resec-
tions (including adjacent organs), PHR performed in department B and a pre-
operatively increased creatinine (above upper normal value; 10% of the
patients). M-RF forSurgCompl were the abscence of a PBD, a BMI >25, PHR
performed in department B and again an increased creatinine-level. M-RF for
InfCompl were again the type of PHR, the abscence of a PBD, a BMI >25, sur-
gery performed in department B and an increased creatinine. None of the
other laboratory values assessed (including bilirubine) showed any correla-
tion with complication rates. Mortality decreased from 2.8% in department A
to 1.8% in department B. The only risk factor for mortality was a preoperative
diabetes (p < 0.05), although this parameter did not show any correlation
with the different complication types.
CONCLUSIONS: Obesity, impaired renal function and the absence of a PBD
are relevant risk factors for complications which may be corrected preopera-
tively and/or considered in the perioperative management of patients under-
going PHR. Centre experience leads to decreased mortality even though
complication rates increased. This phenomenon might reflect a more aggres-
sive management of those complications.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1544 Quality of Life After Total Pancreatectomy: Requiem
        for a Surgical Dogma?
Roberto Salvia*, Silvia Germenia, Stefano Partelli, Stefano Crippa, Claudio Bassi,
William Mantovani, Massimo Falconi, Paolo Pederzoli
Department of Surgery, Università di Verona, Verona, Italy
Among pancreatic resections, total pancreatectomy (TP) is generally consid-
ered to lead to significant impairments in patients’ quality of life (QoL). Aim
of this work was to evaluate QoL and long-term complications in patients
undergoing TP at a tertiary referral center. Forty-eight patients undergoing TP
between 1994 and 2006 were identified; the 32 survivors (median follow-up
30.5 months) were interviewed with the European Organization for Research
and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-
C30), and with an Institutional questionnaire on pancreatic exocrine-
endocrine function. Mortality after surgical resection was zero, and there
were no deaths related to the long-term complications. Overall QoL after TP
was acceptable (median: 5, scale from 1 to 7), despite a slightly decrease com-
pared to the preoperative period (median: 6). A significant impairment in
QoL was found only in patients with malignancies (P < 0.05). Twenty-nine
patients (91%) complained of hypoglycemia, 72% of them at least once a
week. Steatorrhea and abdominal pain were found in 66% and 44% of
patients. Major impairments of leisure and work activities were reported in
56% and 31% of cases. In experienced centers TP is a viable and safe proce-
dure. However, TP substantially affects health status, and the risk for long-
term complications should be well evaluated; therefore careful patient-selec-
tion and long-term follow-up are of paramount importance in this setting.




                                                                                     POSTER ABSTRACTS
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  M1545 The Assessment of the Malignant Potential of IPMN:
        How Reliable Is the New Score from Fujino?
Dominique Suelberg*1, Ansgar M. Chromik1, Andrea Tannapfel3, Matthias H. Seelig1,
Ulrich Mittelkötter2, Waldemar Uhl1
1SurgicalDepartment, University Hospital of Bochum, Bochum, Germany; 2Surgical
Department, Katharinen-Hospital, Unna, Germany; 3Institut of Pathology, University
Hospital of Bochum, Bochum, Germany
BACKGROUND: The intraductal papillary mucinous neoplasia of the pan-
creas (IPMN) was first reported 1982 in Japan. IPMNs are primary benign
lesions but have an unknown malignant potential. In September 2007 a new
score to assess the dignity preoperatively has been published by Fujino et. al.
(Am.J.Surg.2007; 194; 304–307). The aim of this study was to evaluate this
score using the prospective database of our institution.
METHODS: All patients with a pancreatic operation were prospectively ana-
lyzed during a three year period (01.01.2004 to 31.12.2006). Patients with a
diagnosed IPMN were analyzed by age, sex, surgical procedure, histological
findings and preoperative findings of jaundice, diabetes mellitus, patulous
papilla, tumor size ≥ 42 mm (scored 1 pt); main-duct-type (scored 2 pt); size
of pancreatic duct ≥ 6.5 mm and Ca 19-9 ≥ 35 U/ml (scored 3 pt). These data
were evaluated applying the score by Fujino. Predictive values were estimated
by using a cross-tabulation.
RESULTS: Among n = 402 patients receiving a pancreatic operation 17
patients (n = 10 men, n = 7 women) were diagnosed as IPMN. N = 12 had
benign lesions and n = 5 carcinomas. Malignant lesions were significantly
more frequent in male patients (80%) (p ≤ 0.05). The proportion of benign
lesions was balanced. Histologically, the lesions were classified as n = 7 ade-
nomas (41.2%), n = 5 tumors with unknown malignant potential (29.4%)
and n = 5 carcinomas (29.4%). The values of the Fujino-Score were 8.4 for car-
cinomas, 4.0 for IPMN with unknown malignant potential and 4.14 for ade-
nomas (p ≤ 0.05; T-Test). Only 2 lesions were scored from 0 to 1 pt and
therefore predicted as benign lesions. Interestingly, the histological findings
of these cases were tumors with unknown malignant potential. 10 lesions
had score values ≥ 5 pt and so predicted as malign. All patients with carcino-
mas had a score ≥ 5 pt. N = 2 patients with adenomas were also scored as
malign. The IPMN patients with unknown malignant potential were scored
in all categories. All patients with carcinomas were scored true positive (sensi-
tivity: 100%), whereas n = 5 benign tumors were scored false positive. 7
patients of 12 patients with benign tumors were scored true negative (speci-
ficity: 58%). Taken together the efficiency of the Fujino-Score was 71%.
CONCLUSION: This analysis of the Fujino-Score showed a high sensitivity of
100% for the identification of carcinomas in IPMN lesions. One drawback
might be the high proportion of false positive findings leading to a specificity
of only 58%. The IPMN with unknown malignant potential were scored in all
categories. Surgical exploration should be considered at a Fujino-Score ≥ 2
points.




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  M1546 Volume in Pancreatic Surgery: The German Situation
Guido Alsfasser*1, Julia M. Kittner1, Guenther Kundt2, Sven Eisold1, Ernst Klar1
1Dept of Surgery, University of Rostock, Rostock, Germany; 2Institute of Medical
Informatics and Biometry, University of Rostock, Rostock, Germany
INTRODUCTION: The relationship between operation volume and quality
has been an ongoing debate for years. With an anonymous questionnaire
amongst members of the German Society of Visceral Surgery (DGVC) we try
to describe the situation in Germany.
METHODS: A questionnaire was sent to Surgeons-in-chief with questions
about frequency and results of pancreas resections in the year 2006. Opera-
tions were divided in following volume categories: 1–5 operations (very low),
6–20 (low), 21–40 (medium) and more than 40 (high). Surgeon volume was
defined as the total number of operations of each hospital divided by the
number of participating surgeons.
RESULTS: 262 of 520 hospitals returned the questionnaire (50.4%). 40 hos-
pitals (15.3%) did not perform pancreatic surgery. In the remaining 222 hos-
pitals 5253 pancreatic resections were performed. 20 hospitals were very low
volume institutions (9%), 114 low volume (51%), 48 medium (22%) und 40
high volume (18%). Comparing very low/low/medium volume hospitals
(LVH) with high volume hospitals (HVH) there are 26.1% with more than 5%
mortality vs. 20% in HVH (n.s.). However, above 7.5% mortality there are sig-
nificant more LVH than HVH (17.7% vs. 5%, p = 0.04). Considering surgeons
volume, mortality is decreasing with higher volume (3.4% mortality with <5
operations per year, 3.2% with 6–10, 2.4% with >10 operations and 1.5%
with >20). A single surgeon performs pancreatic surgery in 34.3% of all cases
(mean mortality 2.2%). Two surgeons operate in 32.4% of hospitals with
mean mortality of 2.8%. With four or more surgeons mean mortality rises to
4.4%. Overall, mortality in university hospitals, teaching hospitals and others
was 2.5%, 2.9% and 2.6%. Summary: Pancreatic surgery is performed in
many hospitals outside university institutions in Germany. Mortality in high
volume centers is lower compared with all other hospitals. However, 20% of
HVH have mortality rates >5%. Two Thirds of all operations are performed by
one or two surgeons with a mean mortality of 2.5%. Hospitals with four of
more surgeons showed a higher mortality (4.4%).
CONCLUSION: Hospital volume does not seem to influence mortality in
pancreatic surgery in Germany. Quality in pancreatic surgery highly depends
                                                                                   POSTER ABSTRACTS




on specialized surgeons, whereas increase of mortality in centers with four or
                                                                                       MONDAY




more surgeons is an effect of the training process. Based upon this question-
naire of the year 2006 no general conclusion can be drawn. However, the
implementation of a national pancreatic registry seems to be a suitable way to
further analyze the volume-quality relationship in Germany.




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  M1547 The Lymph Node-Ratio Is the Strongest Factor
        Predicting Survival After Resection of Pancreatic
        Cancer
Frank Makowiec*1,2, Hartwig Riediger1, Eva Fischer1, Tobias Keck1, Oliver G. Opitz2,
Ulrich Adam1, Ulrich T. Hopt1,2
1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer
Cancer Center, University of Freiburg, Freiburg, Germany
INTRODUCTION: Survival after surgery of pancreatic cancer is still poor
even after curative resection. Some prognostic factors like the status of the
resection margin, lymph node (LN) status or tumor grading were identified.
However, only few data have been published regarding the prognostic influ-
ence of the LN-ratio (number of LN involved to number of examined LN),
with sometimes conflicting results. We, therefore, evaluated potential prog-
nostic factors in 182 patients after resection of pancreatic cancer.
METHODS: Since 1994, 204 patients underwent pancreatic resection for
ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients
with complete follow-up evaluations (54% female). Of those 182 patients
88% had cancer of the pancreatic head, 5% of the body and 7% of the pancre-
atic tail. Patients underwent pancreatoduodenectomy (86%), distal resection
(11%) or pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier-
and Cox-methods.
RESULTS: In all 204 resected patients mortality was 3.9% (n = 8). In the 182
patients with follow-up 70% had free resection margins, 62% had G1 or G2-
classified tumors and 70% positive LN. Median tumor size was 30 (7–80) mm.
The median number of examined LN was 16, median number of involved LN
one (range 0–22). Median LN-ratio was 0.1 (0–0.79). Cumulative five-year sur-
vival (5-y SV) in all patients was 16%. In univariate analysis a LN-ratio ≥ 0.2
(5-y SV 6% vs. 19% with LN-ratio <0.2; p = 0.003), LN-ratio ≥ 0.3 (5-y SV
zero% vs. 18% with LN-ratio <0.3; p < 0.001), a positive resection margin (p <
0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer
survival. In multivariate analyses a LN-ratio ≥ 0.2 (p < 0.01; relative risk RR
1.7), LN-ratio ≥ 0.3 (p < 0.001; relative risk RR 2.4), positive margins (p < 0.03;
RR 1.6) and poor differentiation (p < 0.05; RR 1.4) were independent factors
predicting poorer outcome. The LN-ratio as a continuous variable also signifi-
cantly correlated with survival whereas the conventional nodal status or the
number of involved LN per se had no significant influence on survival.
Patients with one LN involved had the same outcome than patients with neg-
ative nodes but prognosis worsened significantly in patients with two or
more LN involved.
CONCLUSIONS: Not the lymph node involvement per se but especially the
LN-ratio is an independent prognostic factor after resection of pancreatic
head cancers. In our series this LN-ratio was even the strongest predictor of
survival (cutoff 0.2). The routine estimation of this LN-ratio may be helpful
not only for the individual prediction of prognosis but also in the planning of
adjuvant therapy and further outcome and therapy studies.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1548 Dynamic Magnetic Resonance Imaging (DMRI) of the
        Pancreas as a Predictor of Anastomotic Leakage After
        Pancreatic Resections
Marco Niedergethmann*1, Dietmar J. Dinter2, Stefan Post1
1Department   of Surgery, University Hospital Mannheim, Mannheim, Germany;
2Department   of Radiology, University Hospital Mannheim, Mannheim, Germany
BACKGROUND: The degree of pancreatic fibrosis is a main factor for leckage
after pancreatico-jejunostomy. “Soft” and “firm” pancreatic tissue types are
characterized by different perfusion behaviour in DMRI. In order to identify
risk factors for postoperative pancreatic anastomotic leakage and in order to
assess the role of pancreatic DMRI in detection of this complication and in
prediction of pancreatic texture a cohort of patients was retrospectively
reviewed.
METHODS: Between 2000 and 2006 a total of 107 consecutive patients were
examined by means of a standardized DMRI protocol (1.5 tesla MRI): 1) mor-
phological T1 and T2 sequences, 2) transversal T1 with fat suppression (5 mm
layer thickness) at 25 and 60 seconds after i.v. application of Gd-DTPA (Mag-
nevist®, 0.1 mmol/kg body weight), 3) T1 sequences after Gd-DTPA applica-
tion. The time intensity curve on DMRI was measured in the aorta, the
pancreas, and the muscle tissue. For all patients with a standardized contrast
medium curve in the aorta (n = 72) a muscle-normalized time intensity curve
was calculated. The time intensity curves were classified in three groups: rapid
increase (>1.1, early-arterial value > portal-venous value), intermediate
(0.9–1.1), and slow increase (<0.9). All patients received a pancreatico-jejun-
ostomy (duct-to-mucosa). The DMRI data was correlated with prospectively
acquired clinical data.
RESULTS: Leakage of the pancreatico-jejunostomy occurred more frequently
(27%, p < 0.05) in patients with a time intensity curve >1.1 (“soft” pancreas,
n = 37) compared to those with intermediate (0.9–1.1, n = 11) and slow
curves (<0.9, n = 24, “firm” pancreas). Furthermore, patients with a rapid
increase (>1.1) had significantly more abdominal complications such as
abscess, delayed gastric emptying, as well as a pre-existing diabetes (p < 0.05).
DISCUSSION: DMRI with time intensity curve calculation provides reliable
information for prediction of the pancreatic texture. A rapid increase of the
time intensity curve correlates with anastomotic leakage and further abdomi-
                                                                                    POSTER ABSTRACTS




nal complications after pancreatic head resection.
                                                                                        MONDAY




 Poster of Distinction

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  M1549 Combination of Bioabsorbable Polyglicolic Acid (PGA)
        Felt and Fibrin Glue for Prevention of Pancreatic
        Fistula Following Pancreaticoduodenectomy
Kenichiro Uemura*, Yoshiaki Murakami, Yasuo Hayashidani, Takeshi Sudo,
Yasushi Hashimoto, Akira Nakashima, Hiroyuki Nakamura, Taijiro Sueda
Surgery, Hiroshima University, Hiroshima, Japan
BACKGROUNDS AND AIMS: Mortality after pancreaticoduodenectomy
(PD) in high volume centers had decreased to less than 2%. However, morbid-
ity still remains considerably high, ranging 20%–50%. The most frequent
cause of morbidity is pancreatic fistula (PF) in early postoperative period.
Polyglicolic acid (PGA) felt is bioabsorbable recombinant membrane. It is eas-
ily shaped and it rapidly reacts with fibrin glue. PGA felt combined with
fibrin glue as the topical agent have been reported to be successful in preven-
tion of bile leakage after liver resection compared with fibrin glue alone. PGA
felt combined with fibrin glue is also reported to be useful in preventing air
leakage after lung surgery and cerebrospinal leakage after spinal surgery. The
aim of this study was to assess the efficacy of PGA felt combined with fibrin
glue as an adjunct of pancreaticoenterostomy for prevention of postoperative
PF following PD.
METHODS: PGA felt combined with fibrin glue as an adjunct of pancreati-
coenterostomy were applied prospectively to 20 consecutive patients
undergoing pancreaticoduodenectomy. The pancreatic anastomosis was
reconstructed with a duct-to-mucosa pancreaticogastrostomy into the posterior
wall of the stomach. Internal pancreatic duct stenting were used in all cases.
No prophylactic octreotide was administered in this study. Drain amylase
were measured daily after the surgery until drain was removed on the postop-
erative day 5. The incidence of postoperative pancreatic fistula and other
postoperative complication were recorded. Pancreatic fistula was defined as
drain output amylase levels greater than 3 times than the upper normal
serum amylase value on or after postoperative day3 and graded according to
the International Study Group Pancreatic Fistula definition.
RESULTS: There were 11 males and 9 females (mean age 65 ± 15). The mean
operative time was 351 ± 75 minutes. The pancreatic texture of the stump was
“soft” in 16 cases. The median of the level of amylase in drain were 745 U/l
on POD1, 427 U/l on POD2, 97 U/l on POD3, and 38 U/l on POD5. Only one
patient (5%) developed grade A postoperative PF. The incidence of PF with
clinically significant impact (grade B+C) was 0%. No patients required a
change in management or adjustment in the clinical pathway. Other postop-
erative complications include one wound infection (5%) and one bile leakage
(5%). Patient did not present any side effects related to the PGA and fibrin
glue. There was no percutaneous drainage, readmission and reoperation.
There was no mortality.
CONCLUSIONS: Combination of bioabsorbable PGA felt and fibrin glue was
extremely favorable for prevention of postoperative PF following PD.




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  M1550 Radiofrequency Ablation of Locally Advanced
        Pancreatic Cancer
Jennifer Logue*, Edward Leen, Susan J. Moug, Ross Carter, Colin Mckay
Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
INTRODUCTION: Radiofrequency ablation has been demonstrated to be
effective in the treatment of unresectable hepatic tumours and promising
results have been obtained in other cancers. Small series and case reports sug-
gest that this technique is feasible and safe in selected patients with pancre-
atic cancer. The aim of this study was to assess the safety of radiofrequency
ablation in patients with non-metastatic, locally advanced pancreatic cancer.
METHODS: Full ethical approval was obtained from the Local Research Eth-
ics Committee. Pre-operative consent was obtained from 8 patients with non-
metastatic pancreatic tumours staged as being of borderline resectability. Five
patients (3 female, 2 male) with tumours deemed inoperable after full laparo-
tomy were recruited. Radiofrequency ablation was performed using the Cool-
tip ablation system with a single, cooled electrode. Accurate needle place-
ment was confirmed by intra-operative ultrasound and the target temperature
controlled by a thermosensor at the tip of the needle was 90°C.
RESULTS: Three of the five patients developed life-threatening post-ablation
complications. One patient died as a result of a post-operative biliary leak,
severe sepsis and multi-organ failure. Significant gastrointestinal haemor-
rhage occurred in two cases requiring angiographic embolisation. Given these
initial complications, the study was terminated after discussion with the local
ethics committee. Overall median survival was 6.6 months (range 0.4–4).
CONCLUSION: The results of this pilot study suggest that radiofrequency
ablation for locally advanced pancreatic cancer is associated with unaccept-
able, life-threatening post-ablation complications.



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  M1551 Antibacterial Prophylaxis Does Not Prevent Infection
        of Pancreatic Necrosis in Acute Pancreatitis
Eduardo A. Villatoro*1, Mubashir G. Mulla2, Richard I. Hall2, Mike Larvin1
1Divisionof Surgery, University of Nottingham Medical School, Derby, Derby, United
Kingdom; 2Surgical Directorate, Derby Hospitals, Derby, United Kingdom
A series of randomised controlled trials (RCTs) has led to confusion as to the
precise role of antibacterial prophylaxis against infection of pancreatic necro-
sis (PN) in acute pancreatitis. Published RCTs comparing antibacterial therapy
versus placebo in patients with CT proven pancreatic necrosis were sought.
Seven were found (Jan 1993–Sep 2007): five evaluated beta-lactams (n = 302)
and two quinolone/imidazole (n = 102). None was adequately powered, end
point reporting varied and overall study quality was variable. Three studies
were double-blinded, but the latest only provided extractable data on PN
infection rates. Meta-analysis was performed using “RevMan 4.2” software
(Update, Oxon UK). Mortality was significantly lower after therapy (6.8%)
versus control (15%), odds ratio (OR) 0.44 (95% CI 0.21–0.91), p 0.03, in 6
fully evaluable studies (n = 322). However infected PN rates did not differ sig-
nificantly in all 7 studies. Non-pancreatic sepsis was significantly lower after
therapy (20%) versus controls (30%), OR 0.54 (95% CI 0.30, 0.98), p 0.04,
although only 4 studies (n = 236) provided these data. Four evaluable beta-
lactam studies showed a trend to lower mortality (7.4%) versus controls
(16%), but this was non-significant and no significant survival differences
were found in two quinolone/imidazole studies. Beta-lactam therapy showed
a trend towards less infected PN (16.8%) versus controls (24%), OR 0.61 (95%
CI 0.34, 1.08), p 0.09, but there was a non-significant trend to higher infected
PN rates with quinolone/imidazole therapy. Non-pancreatic infections were
significantly lower after beta-lactams (15.4%) versus controls (28%) in 3 eval-
uable studies, OR 0.43 (95% CI 0.20, 0.92) p = 0.03. Only one quinolone/
imidazole study reported non-pancreatic infections which were not signifi-
cantly different.This results suggest that antibacterial prophylaxis does reduce
overall mortality, but not by reducing infection of PN. The mechanism is
unclear, but contrary to the rationale for these RCTs, prophylaxis may be pro-
tective against fatal non-pancreatic infections, such as respiratory infection.
More data are awaited from the most recent study, but we conclude that fur-
ther, adequately powered, double-blinded studies, perhaps targeting beta-
lactam agents, are required to elucidate the mechanism for reduced mortality.
REFERENCES: Pederzoli et al. SGO 1993;176(5):480–483. Sainio et al., Lan-
cet 1995;346:663–667. Nordback et al. J GI Surg 2001;5(2):113–118. Schwarz
et al., Dtsch Med Wschr 1997;122:356–361. Isenmann et al., Gastroenterol-
ogy 2004;126:997–1004. Rokke et al., Sc J Gastro 2007;42:771–776. Dellinger
et al., Ann Surg 245:674–683.




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  M1552 Development of a Dedicated Team Decreases ICU
        Admission After Pancreaticoduodenectomy (PD)
Julio Sokolich*, Christos A. Galanopoulos, Allison Vo, Maggie White, Ernest
Dunn, D. Rohan Jeyarajah
General Surgery, Methodist Dallas Medical Center, Dallas, TX
BACKGROUND: Outcome from PD is based not only in the natural history
of the disease, but also on patient selection, operative technique, and postop-
erative care. Multiple studies have focused their attention on the former two
factors. The purpose of this study is to evaluate if development of a dedicated
multidisciplinary team can increase direct admission to the floor and reduce
the ICU admission after PD.
STUDY DESIGN: Between 2005 and 2007, 76 patients underwent a PD by a
single surgeon at a non-university tertiary referral center (NUTRC). During
the first year 45 PD were preformed and this data was compared with the 31
PD cases performed during the second year. The multidisciplinary team con-
sists of gastroenterologist, surgeon, fellow, resident, ICU nursing staff, operat-
ing room team, and a surgery floor nursing staff. Standardized algorithms and
a dedicated floor nursing staff were developed during this time period.
RESULTS: Number of patients who suffered some type of complication
dropped from 53% to 38% in the second year; Mortality rates remain similar
(2.6% compared to 2.2% in year one); Pancreatic fistula rates dropped from
6.6% down to 5.3% at year two; Mean operative times (240 minutes) and
mean blood loss (350 ml) were minimally impacted over the study period.
Most importantly, ICU admission after PD dropped from 80% in the first year
to 45% in the second year.
CONCLUSION: This study demonstrates that a multidisciplinary team can
be developed in a NUTRC for patients with pancreatic disease. This dedicated
process can result in improved outcomes, as measured by complication rate.
Importantly, this improved outcome can be achieved with decreased use of
the ICU if a dedicated floor nursing team is developed. This decreased utiliza-
tion of ICU care will translate to decreased hospital charges, earlier mobiliza-
tion, and a more streamlined pathway for patients after PD.
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  M1553 Predictive and Prognostic Value of CA 19-9 in Resected
        Pancreatic Adenocarcinoma
Joshua G. Barton*1, John P. Bois1, Christina M. Wood2, Rui Qin2,
Michael L. Kendrick1, Michael B. Farnell1
1GIand General Surgery, Mayo Clinic, Rochester, MN; 2Biostatistics, Mayo Clinic,
Rochester, MN
BACKGROUND: Although CA 19-9 is most often used in pancreatic cancer
as a diagnostic adjunct, or to follow response to treatment, its preoperative
value has been reported to correlate with survival and recurrence. A cor-
rected-CA 19-9 (c-CA19-9), obtained by dividing the CA 19-9 by total biliru-
bin, has been reported to improve this correlation. Our aim is to evaluate the
predictive and prognostic value of CA 19-9 in a large single-institutional
experience.
METHODS: A retrospective review of all patients undergoing pancre-
atoduodenectomy from July 2001 through June 2007 at our institution was
conducted. Preoperative serum CA 19-9 and total bilirubin levels were ana-
lyzed with histologic and survival data.
RESULTS: Of 328 patients identified, 231 (58% male; 42% female) with a
mean age of 66 (37–90) had both pre-operative serum CA 19-9 and total
bilirubin levels and comprised our study group. Median follow-up was 2.1
years. All patients underwent pancreaticoduodenectomy for histologically
confirmed pancreatic adenocarcinoma. Using receiver operator curves, nei-
ther CA 19-9 nor c-CA 19-9 demonstrated predictive value for lymph node
status (c = 0.55/0.56) or margin status (c = 0.50/0.46). Tumor size and lymph
node ratio very weakly correlated with CA 19-9 and c-CA 19-9 levels (Spear-
man correlation coefficients for tumor size: 0.26 and 0.28; for lymph node
ratio: 0.17 and 0.16, respectively). Survival was not different at 1 year (73%
vs. 68%), 3-years (33% vs 22%), or 5-years (27% vs 16%) for patients with CA
19-9 ≤ 300 compared to those with values >300. Using corrected c-CA 19-9
with a cut-off of 50 also failed to demonstrate a significant difference in sur-
vival. Even at cutoffs of 500 and 100 for CA 19-9 and c-CA-19-9 respectively,
there was no difference in survival compared to patients with lower levels
(p > 0.2). Patients with a CA 19-9 > 300 or c-CA19-9 > 50 were at 1.30 and
1.29 times risk of death than those with CA 19-9 < 300 or c-CA 19-9 < 50
respectively.
CONCLUSION: This large, single institution study demonstrates no histo-
logic (lymph node or margin status) predictive value or prognostic value of
CA 19-9 or c-CA19-9 in patients undergoing resection for pancreatic adeno-
carcinoma. These findings are in contrast to smaller previous studies that
have suggested such a correlation. Our findings do not support broadening
the use of CA 19-9 beyond aiding diagnosis and following therapeutic
response.




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Clinical: Small Bowel
  M1554 Long-Term Outcome After Distal Gastric Bypass
        Combined with Swedish Adjustable Gastric Banding
        (SAGB)
Bruno M. Balsiger*1, Folkert Maecker1, Andreas Glaettli2
1InternalMedicine, Spitalnetzbern, Bern, Switzerland; 2Visceral Surgery, Hirslanden
Salem Spital, Bern, Switzerland
BACKGROUND: Swedish adjustable gastric banding (SAGB) is currently one
of the most performed laparoscopic procedures in bariatric surgery. This pro-
cedure was combined with an additional distal gastric bypass in patients with
a BMI >50.
AIM: To determine long-term outcome after SAGB and distal gastric bypass
in a group of 37 consecutive patients studied prospectively.
PATIENTS AND METHODS: Thirty seven patients, 11 men and 26 women,
have been operated from 1996 to 2002. Age was 37 ± 1 (mean ± sem) years,
BMI 54 ± 1 kg/m2. Follow-up was 65% at 60 months.
RESULTS: Procedures: Most underwent a laparotomy (21) due to additional
necessary surgery. Median hospital stay was 10 (4–26) days. One Patient died
in hospital due to a pulmonary embolism, two patients needed antibiotic
treatment for cystitis and pneumonia. 4 Patients suffered from local compli-
cations, such as wound infection, seroma, or healing problems. In one Patient
the spleen was injured so splenectomie had to be performed in the same
operation. Two patients required reoperation while still in hospital. Late com-
plications were usually caused by problems with the SABG. Leakage of the
adjustable ring in one patient, damage of the flexible tube in 6 patients. Mean
time to occurance was 17.25 months (10 to 29). Three patients needed a sec-
ond operation due to infections. In one patient a seroma needed to be
removed 14 days after bariatric surgery. The same patient suffered from cho-
langitis due to choledocholithiasis 35 months later. In two patients the gas-
tric banding was definitively removed after 95 months, there was significant
dilatation of the oesophagus. Three patients required closure of hernias. Total
cumulative reoperation rate was 62.9%. After 5 years BMI decreased from 54 ±
1 kg/m2 to 33 ± 1 kg/m2. Excess weight loss, EWL was 69 ± 1% after 5 (n = 24)
and 70 ± 1% after 7 (n = 20) years. According to the Baros score the over all
                                                                                      POSTER ABSTRACTS




results are good. 5 ± 3 points after 5 and 7 years.
                                                                                          MONDAY




SUMMARY: 5 Years after SAGB with additional gastric bypass 71% of the
patients reached >65% EWL, 29% between 65 and 30% EWL. Weight reduc-
tion was a maintained between 5 to 7 years (EWL 71%). According to the
Baros score the intervention was good, despite of a cumulative reoperation
rate of 62.9%.
CONCLUSION: A majority of the patients does well even after 7 years. Due
to the high reoperation rate, the combined operation of SAGB with addi-
tional distal gastric bypass should be considered as a rescue when non-
combined procedures have failed.


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  M1555 Gastro Intestinal Intramural Hematomas Versus
        Mesenteric Ischaemia- Clinico-Radiological Profile
Sudhindran Surendran*1, Unnikrishnan Gopalakrishnan1,
Dayananda Lingegowda2, Sudheer Othiyil Vayoth1, Puneet Dhar1
1Gastro Intestinal Surgery, Amrita institute of medical Sciences, Kochi, India; 2radiology,
Amrita institute of medical Sciences, Kochi, India
AIM: Gastro intestinal (GI) Intramural bleeds, secondary to anticoagulation
often mimic Mesenteric Ischemia. Whilst intramural bleeds can be conserva-
tively managed, mesenteric ischaemia requires active intervention. Aim of
the study was to analyze characteristics of patients presenting with GI intra-
mural hematomas to help evolve guidelines based on clinical and imaging
features to differentiate them from mesenteric ischemia.
METHODS: Clinico-radiological features of all GI Intramural Hematomas
diagnosed between 2000–2006 (Group 1 = 8) were compared with a group of
surgically confirmed mesenteric ischemias in the same period (Group 2 = 27)
by retrospective analysis of database.
RESULTS: All patients in Group 1 were on anticoagulation for cardiac co-
morbidities. All underwent CT abdomen with plain and IV contrast aimed for
venous phase. The first patient in Group I underwent an exploratory laparot-
omy and small bowel resection, due to suspicion of mesenteric ischaemia.
The histopathology showed extensive hemorrhage with no evidence of
ischaemia. The subsequent seven patients were suspected to have intramural
bleeds and were managed conservatively with stabilization of INR.Clinical
and imaging features of the two groups are given in Tables 1 and 2.
Table 1. Imaging Features
Characteristics                  Group I (n = 8)     Grup II (n = 27)        p-value
Proximal Site                          6                    3                 0.002
Short segment                          7                   13                  0.6
Thockness (mm)                      17 ± 4               8±3                  0.001
Hounsefield Units                   65 ± 14              34 ± 6               0.001
Fat stranding                          4                   15                  0.8
Ascites                                6                   18                  0.3
Mucosal enhancement                    6                   11                 0.01
Dilatation                             3                   12                  0.7


Table 2. Clinical Features
Characteristics                  Group I (n = 8)     Group II (n = 27)       p-value
Age                                 54 ± 13              49 ± 14               0.3
Pain                                   8                   23                  0.2
Vomiting                               7                   17                  0.2
Peripheral vascular disease            0                    6                 0.143
Rectal bleed                           3                    2                 0.03
Anticoagulation                        8                   12                 0.005
INR over 3                             7                   22                 0.001



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CONCLUSIONS: Anticoagulant therapy with rectal bleeding often suggest
the possibility of GI Intramural hematoma. On CT scan-proximal location,
increased wall thickness, hyper density on plain scan and contrast enhance-
ment of mucosa were suggestive of mural hematoma. In such cases, a conser-
vative approach maybe appropriate, albeit exercising a low threshold for
laparotomy, given the differential diagnosis of mesenteric ischaemia.




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Clinical: Stomach
  M1556 Laparoscopic Lymphatic-Basin Dissection as an
        Additional Treatment to Endoscopic Submucosal
        Dissection in Early Gastric Cancer
Toshiyuki Mori*, Nobutsugu Abe, Masanori Sugiyama, Yutaka Atomi
Surgery, Kyorin University, Tokyo, Japan
BACKGROUND: Endoscopic submucosal dissection (ESD) is widely accepted
in Japan for early gastric cancer. Indication for this less invasive treatment is
early cancer confined in the mucosa, 20 mm or less in diameter in differenti-
ated carcinoma, and 10 mm or less for undifferentiated carcinoma, because
the cancer can usually be completely removed and lymph node metastasis is
extremely rare. When the tumor exceeds in size or in depth of invasion
beyond the above-mentioned criteria, lymph node metastasis becomes more
likely and standard gastrectomy may be indicated. As we previously reported,
however, positive rate for lymphnode metastasis is as low as 10% in this
group and parameters to predict lymphnode metastasis include tumor size
and cancer invasion to lymphatic vessels. It is thus reasonable to remove the
primary lesion by ESD for detailed pathologic examination and, if the risk
factor(s) are identified, lymphatic basin potentially positive for metastasis is
laparoscopically resected for further treatment. When the lymphnode posi-
tive for metastasis is identified, gastrectomy is indicated for potential residual
cancer cells. When the negative result is obtained, the patients can be sub-
jected for follow-up without further treatment.
METHOD: Among the 158 cases with early gastric cancer in which primary
lesion(s) were treated by ESD, 17 cases ware diagnosed for potentially positive
for lymphnode metastasis. Mean prediction values for metastasis positive rate
was 13%. Laparoscopic lymphatic basin dissection was performed in these
cases.
RESULTS: Responsible lymphnode basin was identified with ICG endoscopi-
cally injected around the ESD scar. Lymphatic vessels and nodes were identi-
fied with either laproscopic observation or infra-red laparoscopy. The upper
lesser curvature lymphnodes were completely dissected in 13 cases, the upper
lesser and greater curvature in 2 cases, and lower lesser and greater curvature
in 2 cases, respectively. Mean duration of operation was 258 min, and post-
operative course was uneventful except for one case who needed re-operation
for ischemic perforation of the lesser curvature. There were two cases in
which metastatic positive lymphnodes were identified, and both of them
denied further treatment and were subjected to strict follow-up. The mean
duration of follow up is 25 mo (2–62 mo), and no cancer recurrence is identi-
fied. Quality of life is fur much better in this group when compared to any
type of series of gastrectomy.
CONCLUSION: Although indication and steps in this treatment is somewhat
complicated, ESD and lymphatic basin dissection serves as ultimate function
preserving treatment for early gastric cancer.



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  M1557 Long Term Improvement of Comorbidities in Older
        and Medicare Patients with Gastric Bypass
Peter T. Hallowell*, Thomas A. Stellato, John Jasper, Kristen Graf,
Margaret M. Schuster
Surgery, University Hospitals Case Medical Center, Cleveland, OH
INTRODUCTION: A recently published review of bariatric surgery in a large
Medicare database suggested a prohibitively high mortality rate. We have
demonstrated that in carefully selected elderly and Medicare recipients’ gas-
tric bypass can be safely performed with low morbidity and mortality. Evi-
dence for benefit in terms of improvement in co morbidities in these patients
however, is lacking. Our hypothesis is that these patients should have
improvement in their co morbidities with successful bypass surgery.
METHODS: We reviewed our prospectively maintained bariatric database.
Over 1000 patients have been accumulated. We identified 46 patients 60
years or older and 31 patients with Medicare as their primary insurer.
RESULTS: In the older patients we had a 1, 3, 5 yr Follow up of 87%, 48%,
and 75%. The average length of follow up was 30 months with a range of
1–84. The male female ratio for the elderly patients was 13%/87% and was
6%/94% in the Medicare group. The mean pre-op BMI for the elderly group
was 50.4 and 56 in the Medicare group. Resolution or improvement of co
morbidities is described in the table below. We know of one death 4.5 years
from surgery in the Medicare group.
CONCLUSIONS: Improvement in the major obesity related co morbidities is
seen in elderly and Medicare recipients undergoing gastric bypass surgery.
Resolution of GERD is seen in over 90% of both groups. Although hyperten-
sion is the least effected in the elderly, 50% still have improvement or resolu-
tion of this important co morbidity.

                    Elderly Patients Age 60–66      Medicare Recipients Age 31–66
                         Mean 61.6 (n = 45)                Mean 47.7 (n = 31)
 Co Morbidities    Resolved            Improved      Resolved           Improved
 Hypertension      8/34 (24%)         9/34 (26%)    13/21 (62%)         2/21 (10%)   p = 0.02
 DM oral meds     15/20 (75%)          2/20 (10%)    9/11 (81%)          1/11 (9%)      ns
  DM Insulin       1/3 (33%)           1/3 (33%)     2/6 (33%)           4/6 (67%)      ns
     OSA          10/32 (31%)         13/32 (41%)    8/22 (36%)        10/22 (46%)      ns
                                                                                                POSTER ABSTRACTS




     GERD         23/25 (92%)               0       16/17 (94%)               0         ns
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  M1558 Indications and Results of Reversal of Vertical Banded
        Gastroplasty (VBG)
Rebecca Thoreson*, Joseph Cullen
Surgery, University of Iowa, Iowa City, IA
BACKGROUND: Vertical Banded Gastroplasty (VBG) was initiated in 1980
as a weight loss operation that restricted oral intake. A small volume pouch is
created along the lesser curvature and the outlet is reinforced with a band of
polypropylene mesh. Aims: To determine the results of patients who pre-
sented with complications of the VBG and wanted reversal of the VBG, not a
conversion to another gastric weight loss operation.
METHODS: From 1993 to 2007 26 patients had reversal of a VBG. 85% of
the patients were female and presented on average 13 years (range 2–27 years)
after the VBG. Presenting symptoms included nausea/vomiting in 88%, reflux
in 65%, stricture requiring endoscopic dilatation in 38%, while 7% of
patients had upper gastrointestinal bleeding or required total parental nutri-
tion. All patients were offered conversion to another weight loss operation
but decided on reversal of the VBG alone. All takedowns were performed in a
similar manner by making a gastrotomy below the VBG pouch and placing a
linear stapler through the gastrotomy with one of the limbs within the lumen
of the gastroplasty and the other within the stomach pouch/fundus. The stapler
is fired resulting in division of the polypropylene mesh band, resulting in
continuity of the pouch with the rest of the stomach and reversal of the VBG
pouch.
RESULTS: No patients died from the procedure and morbidity included one
wound infection and one wound seroma. Preoperative Visick score was
2.8 ± 0.1 and decreased to 1.3 ± 0.1 after the reversal (P < 0.001). Patients had
significant weight loss after the VBG (P < 0.001) and prior to the VBG reversal
(Table). With a mean followup of 32 months (range 2–144 months), there was
not a significant weight gain after the VBG reversal (P = 0.3) (Table). After the
reversal, reflux symptoms continued in two patients and nausea and vomit-
ing continued in one patient.
CONCLUSIONS: Reversal of a VBG results in symptomatic relief in the
majority of patients. Patients should be instructed that some weight gain may
occur after the reversal.

Table 1. Weight changes prior to VBG, prior to reversal, and most recent weight.
    Pre-VBG Weight (Range)        Weight at Reversal (Range)    Weight After Reversal (Range)
       139 kg (105–182)*               96 kg (56–151)                 105 kg (63–157)




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1559 Gastrectomy and Lymphadenectomy for Gastric
        Cancer: Is the Pancreas Safe?
Fernando A. Herbella*, Ana C. Tineli, Jorge L. Wilson, Jose C. Del Grande
Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
BACKGROUND: Resection of the capsule of the pancreas is part of the radi-
cal operation for the treatment of gastric cancer proposed by the Japanese
Gastric Cancer Association. It is unclear; however, if resection of the capsule
is a safe procedure or even if it is necessary. This study aims to assess in
patients treated for gastric cancer the occurrence of: (a) pancreatic fistula, and
(b) metastasis to the pancreatic capsule.
METHODS: We studied 80 patients (mean age 61 years, 42 males) submitted
to gastrectomy and lymphadenectomy with resection of the pancreatic cap-
sule by hydrodissection. Patients with anastomotic leakage, pancreatic dis-
ease, tumoral invasion of the pancreas, or submitted to concomitant
splenectomy were excluded. The tumor was located in the distal third of the
stomach in 61% of the patients, in the middle third in 27%, and proximally
in 12%. Total gastrectomy was performed in 27% of the cases and partial gas-
trectomy in 73%. In all patients, amylase activity in the drainage fluid was
measured on day 2. Subsequent measurements were performed in alternated
days until normalization if initial measurement was abnormal. Pancreatic fis-
tula was defined as amylase levels greater than 600. In 25 of these patients
(mean age 53 years, 16 males) the pancreatic capsule was histologically ana-
lyzed for metastasis.
RESULTS: Pancreatic fistula was diagnosed in 8 (10%) patients. The mean
amylase level was 5863. Normalization of amylase levels was achieved within
7 days in all patients. No clinical complications of pancreatic fistula, such as
intraabdominal abscesses, were noticed. In only one case, the surgeon sus-
pected of pancreatic injury during removal of the capsule. Pancreatic fistula
was associated to younger age (p = 0.03), but not to gender (p = 0.1), tumor
location (p = 0.6) and type of gastrectomy (p = 0.8). Metastasis to the pancre-
atic capsule was not identified.
CONCLUSION: Resection of the pancreatic capsule must be discouraged due
to subclinical pancreatic fistula in a significant number of the cases and
absence of metastasis to the capsule.
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  M1560 Long Term Results of Completion Gastrectomies in
        Patients with Post-Surgical Gastroparesis
James E. Speicher*, Richard C. Thirlby, Joseph Burggraaf, Christopher P. Kelly,
Sarah M. Levasseur
Department of Surgery, Virginia Mason Medical Center, Seattle, WA
INTRODUCTION: Post-surgical gastroparesis occurs in less than 5% of
patients undergoing gastric surgery. The symptoms, however, are disabling
and refractory to medical management. The only effective surgical procedure
is completion gastrectomy. Few studies have examined in detail the long term
results of this radical procedure.
METHODS: From 1988 through 2007, 44 patients (84% female, 16% male)
underwent near-total or completion gastrectomies for refractory post-surgical
gastroparesis by the same surgeon at a tertiary referral center. The average age
was 52 (range 32–72). Gastroparesis was documented using a radionuclide
solid food emptying study. Charts were reviewed retrospectively to identify
preoperative symptoms and long term postoperative function, and the
patients were contacted by phone to evaluate their current level of function.
RESULTS: Of the original 44 patients, 57% (n = 24) were evaluated postoper-
atively at a mean of 6.0 years (range 0.5–14.2 years). Fourteen patients (32%)
had expired, and nine (20%) were lost to follow up. Presenting symptoms
were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation
(75%), heartburn (64%), and weight loss (59%, ave = 19% of BW). Postopera-
tive complications occurred in 33%, most commonly bowel obstruction (9%),
anastomotic stricture (9%), and anastomotic leak (7%), and there was one
perioperative death, from leak leading to sepsis. At last follow up, there were
significant improvements in abdominal pain (96% to 58%, p < 0.01), vomit-
ing (96% to 38%, p < 0.01), nausea (83% to 46%, p < 0.01), and diet limited to
liquids or nothing at all (52% to 9%, p < 0.01). Some symptoms were more
common postoperatively: early satiety (25% to 93%, p < 0.01), postprandial
fullness (13% to 71%, p < 0.01), bloating (25% to 43%, p = 0.3), and diarrhea
(38% to 42%, p = 0.8). Average BMI was 23 prior to surgery and 21 at follow
up. Osteoporosis was diagnosed pre- and postoperatively in 21% and 64% of
patients, respectively (p < 0.01). Seventy-one percent of patients stated that
they were in better health after surgery, while 21% were neutral; mean satis-
faction with surgery was 4.8 (1–5 Likert scale).
CONCLUSION: Completion gastrectomy in this patient population resulted
in significant improvements in abdominal pain, vomiting, nausea, and severe
diet limitations. Most patients, however, have ongoing gastrointestinal com-
plaints and the incidence of osteoporosis is high. Regardless, patient satisfac-
tion is very high and about 75% of patients believe their health status is
improved. We believe these data support the selective use of completion gas-
trectomies in patients with severe post-surgical gastroparesis.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1561 Is Neoadjuvant Chemoradiation for Locally Advanced
        Gastric Cancer Feasible?
Brian R. Untch*1, Michael E. Barfield1, Johanna C. Bendell2, Brian G. Czito3,
Christopher G. Willett3, Theodore N. Pappas1, Rebekah White1, Douglas S. Tyler1
1Surgery,Duke University Medical Center, Durham, NC; 2Medical Oncology, Duke
University Medical Center, Durham, NC; 3Radiation Oncology, Duke University Medical
Center, Durham, NC
BACKGROUND: Neoadjuvant chemoradiation is an effective strategy for the
treatment of locally advanced esophageal carcinoma because it can down-
stage tumors and improve resectability. Neoadjuvant chemotherapy has been
shown to improve survival in patients with gastric cancer. The purpose of this
study was to evaluate the feasibility of neoadjuvant chemoradiation for
locally advanced gastric cancer.
METHODS: A retrospective review identified 16 patients with biopsy-
proven, locally advanced (T3/T4 or N1) gastric cancer that underwent neoad-
juvant chemoradiation between 1997 and 2006 (41% with GE-junction
involvement). Patients received external beam radiation with concurrent 5-FU
or platinum-based chemotherapy. If restaging CT demonstrated no metastatic
disease, surgical exploration was performed with the intent of performing
gastrectomy.
RESULTS: Five patients required hospitalization for treatment-related com-
plications, but all patients were able to complete therapy. The median time
from diagnosis to attempted gastrectomy was 104 days and the median time
from completion of neoadjuvant therapy to attempted gastrectomy was 42
days. At the time of restaging, disease burden was evaluated: 3 patients
showed evidence of local progression, 4 patients had decreased disease, and 9
patients had stable disease. All 16 patients underwent attempted gastrectomy.
Gastrectomy was performed in 13 patients; in the remaining 3 metastatic dis-
ease was identified. In the gastrectomy patients, a complete histologic
response was identified in 3 patients (19% of those treated neoadjuvantly), 8
patients had a partial response and 2 patients had no response. Two patients
had positive margins and 8 patients had lymph node involvement. There was
no perioperative mortality. Two gastrectomy patients developed anastomotic
leaks that were treated conservatively. The median length of stay for patients
undergoing gastrectomy was 10 days. The median survival for patients under-
going gastrectomy was 22 months.
                                                                                      POSTER ABSTRACTS




CONCLUSIONS: Locally advanced gastric cancer carries a poor prognosis.
                                                                                          MONDAY




Neoadjuvant chemoradiation was well tolerated and was associated with
acceptable perioperative morbidity. Patients with complete or partial histo-
logic responses may translate to improved rates of R0 resection.




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  M1562 Inpatient Mortality Analysis of Paraesophageal Hernia
        Repair in Octogenarians
Benjamin K. Poulose*, Jeffrey M. Marks, Christine Gosen, Leena Khaitan,
Michael J. Rosen, Joseph A. Trunzo, Jeffrey L. Ponsky
Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
INTRODUCTION: Paraesophageal hernia (PEH) repair is often performed in
an elderly population. Few studies have evaluated perioperative mortality in
this high risk group. We examined outcomes of patients who underwent PEH
repair and identified predictors of inpatient mortality using a national
dataset.
METHODS: Patients 80 years of age or older undergoing PEH repair from an
abdominal approach were identified in the 2005 Nationwide Inpatient Sam-
ple (NIS). A coding algorithm was developed to include patients with type II,
III, and IV hiatal hernias while excluding those with congenital diaphrag-
matic defects or traumatic injuries. Statistical methodology appropriate for
NIS analysis was used accounting for its weighted and stratified database
structure.
RESULTS: 1005 patients with mean age of 84.7 years met inclusion criteria
for analysis including 738 women (73%) and 267 men (27%). Overall inpa-
tient mortality was 8.2% with mean length of stay 10.1 days. Emergent or
urgent repair was performed in 43% of patients. In this group, length of stay
(14.3 days) and mortality (16%) were increased compared to patients under-
going elective repair (7.0 days and 2.5% mortality; p < 0.05). A 7.1 increase in
odds of death was observed for non-elective patients in univariate analysis
(95% CI of 2.1–24.9, p < 0.05). Chronically symptomatic patients admitted
electively were not associated with increased odds for death. When control-
ling for gender, hospital characteristics and comorbidities, emergent or
urgent repair remained the sole predictor of inpatient mortality (odds ratio
6.2, 95% CI 1.8–21.3, p < 0.05).
CONCLUSION: This study defines demographics, length of stay, and inpa-
tient mortality risk in elderly patients undergoing PEH. Emergent or urgent
repair was associated with an increased inpatient length of stay and mortality,
including a 6 to 7 fold increase in the odds of death. However, chronically
symptomatic patients who underwent elective repair were not at increased
odds for inpatient death. Based on these data, earlier elective repair of PEH
may reduce mortality.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1563 Surgeon Performed Endoscopic Balloon Dilation for
        Gastrojejunostomy Stenosis
Atul K. Madan*2, Khurram Khan1, David S. Tichansky1
          of Miami, Miami, FL; 2University of Tennessee Health Science Center,
1University
Memphis, TN
INTRODUCTION: Gastrojejunostomy stenosis after Roux-en-Y gastric
bypass (RYGB) can usually be treated with endoscopic methods. This study
tested the hypotheses that surgeon performed endoscopic balloon dilation
for gastrojejuntostomy stenosis is effective and safe.
METHODS: All patients who underwent endoscopic balloon dilation for a
gastrojejunstomy stenosis by two surgeons were included in this study. All
patients underwent similar techniques of endoscopic balloon dilation. Wire
guided balloon dilation was performed in each case where the endoscope
could not be passed into the jejunum. Charts were reviewed for success and
complications.
RESULTS: There were 32 endoscopic balloon dilations in 20 patients. Steno-
sis occurred an average of 2.4 years (Range: 1 month to 20.5 years) after the
original RYGB. Patients required an average of 1.7 dilations (Range: 1 to 10
dilations) for success; although 75% of patients only required 1 dilation.
There was 1 (3%) microperforation (pneumoperitenum with no evidence of
radiographic dye leak) after one of the dilations in the patient who received
10 total dilations. The patient was observed with no further sequelae from
her dilation. No other complications were noted. After the last dilation, all
patients had resolution/improvement of their symptoms.
CONCLUSIONS: Surgeon performed endoscopic balloon dilation is effective
and safe. Multiple dilations can be performed in patients who have recurrent
stenosis. Patients who have multiple dilations may be at a higher risk of
complications.


                                                                                 POSTER ABSTRACTS
                                                                                     MONDAY




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  M1564 Qualifying the Relationship: Interaction Effects in
        the Correlation Between Bmi and Abdominal Wall
        Thickness
Mark Ranzinger*, F Jacob Seagull, Adrian E. Park
Surgery, University of Maryland, Baltimore, MD
BACKGROUND: While NOTES promises incisionless access to the abdomen,
for the foreseeable future laparoscopic entry will be via trocars. Understand-
ing abdominal wall morphology is a key to optimal trocar placement, opera-
tive planning, and port design.
METHODS: In a non-selected consecutive series of patients undergoing lap-
aroscopic surgery of the foregut, colon, and solid organs, trocar location and
abdominal wall thickness (AWT) under 12–15 mmHg of insufflation was mea-
sured. (Correlations are noted as * = p < .05)
RESULTS: Data from 50 patients (mean age = 51.3, range = 18–77) with BMI
average 29 (SD = 6.0, range = 17–46) are reported below. Averaged across all
abdominal locations, BMI was predictive of AWT. However, the quality of this
prediction varied across patient morphology, age, port location, and position-
ing. Morphology: In the non-obese population, BMI correlated well to AWT
averaged across all abdominal locations (r = .53*), and at the epigastrum (r =
.50), but less so in the obese population (r = .32, and r = .22). Age: Age also
interacted with the strength of correlation, with BMI correlating more highly
with AWT in those under age 55 overall and at the epigastrum (r = .73* and
r = .63* respectively), compared to those aged over 55 (r = .56* and r = .37).
Location: Umbilicus had the thinnest AWT, the lowest variability of all mea-
sured abdominal locations, and no significant correlation to BMI (r =
–.37).Positioning: BMI is highly correlated with AWT when the patient is
positioned laterally (r = .81*), compared to supine positions (r = .58*). Proce-
dure: No interaction was found between the type of surgery and AWT.
CONCLUSIONS: In previous research we have shown that BMI correlates to
AWT and that there are regional differences in the abdominal wall. This
study, based on a larger sample, shows that there is a better correlation
between BMI and AWT in the young and non-obese populations, and for
patients positioned laterally. Data suggest that, because of decreased AWT and
AWT-variability, coupled with AWT’s low correlation to BMI, placing a port at
the umbilicus may be a useful strategy to minimize at-the-trocar wall thick-
ness and AWT variability between patients.The data presented here may be
useful in providing further refinement for the understanding of differences
in AWT.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


BASIC SCIENCE POSTERS

Basic: Biliary
  M1842 CD44-Hyaluronan Interaction Plays a Critical Role in
        Biliary Proliferation During the Development of
        Hepatic Cholestasis
Gordon D. Wu*1, Yao He1, Haimei Wang1, Hong Wang1, John M. Vierling2,
Andrew S. Klein1
1Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles,   CA;
2Department of Hepatology, Baylor College of Medicine, Houston, TX

BACKGROUND: High levels of CD44 and its ligand hyaluronic acid (HA) are
present in cholestatic livers. The role of CD44-hyaluronic acid (HA) interac-
tion in biliary pathology, however, is poorly undrstood.
METHODS: A rat model of cholestatic liver induced by bile duct ligation
(BDL) was employed for the studies. Histological distribution of CD44-
expressing cells and disposition of extracellular hyaluronic acid (HA) were
examined in cryostat sections of the livers with immunofluorescence or his-
tochemistry. Biliary epithelial cells (BEC), hepatic stellate cells (HSC), CD31+
hepatic endothelial cells (HEC) and ED2+ Kupffer cells (KC) were isolated and
examined for expression of CD44 standard (s) and variant (v) isoforms with
quantitative real time PCR. The regulatory role of CD44-HA interaction in bil-
iary proliferation was investigated in biliary epithelial cell (BEC) cultures.
RESULTS: BDL livers developed intensive intrahepatic bile duct prolifera-
tion. Epithelia lining the proliferative bile ducts were strongly positive for
CD44. CD44 expression by the proliferative BEC was associated with mark-
edly increased interstitial HA accumulation. Quantitative PCR revealed that
CD44 expressed by the cholestatic livers increased 26-fold over the control
(p < 0.01). BEC isolated from the cholestatic livers expressed high levels of
CD44 mRNA, which was 3-fold, 17-fold, and 19-fold as that expressed by
sinusoidal endothelia, Kupffer cells and hepatic stellar cells (p < 0.01, respec-
tively). BEC significantly increased expression of CD44 (p < 0.01) and cell
proliferation marker ki-67 (p < 0.05) in responses to hyaluronan stimulation
in cultures. Cellular proliferation assay demonstrated that cholangiocyte
                                                                                    POSTER ABSTRACTS




propagation accelerated upon HA stimulation, and was antagonized by anti-
CD44 treatment (p < 0.05).
                                                                                        MONDAY




CONCLUSION: The study provides compelling evidence to suggest that pro-
liferative BEC lining the intrahepatic bile ducts are the major source of
hepatic CD44. CD44-HA interaction, by enhancing biliary proliferation, plays
a pathogenic role in the development of cholestatic liver diseases.




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Basic: Colon-Rectal
  M1843 Decreased PLD2 Expression Correlates with NM404
        Retention in Human Colorectal Cancer Xenografts
Joseph Nwankwo*1, Jaime H. Mccord1, Mary Wentworth1, Jamey Weichert2,
Sharon M. Weber1
        University of Wisconsin, Madison, WI; 2Radiology, University of Wisconsin,
1Surgery,
Madison, WI
INTRODUCTION: Radioiodinated NM404 (12-(4-iodophenyl)-octade-
cylphosphocholine), a second-generation phospholipid ether analog, has dis-
played remarkable tumor selectivity in rodent tumor models. This novel
agent is retained within tumor cells for a prolonged time, thus allowing for
clinical imaging applications that may enhance preoperative staging. Phos-
pholipid ether analogs appear to be a substrate for phospholipase D (PLD) but
not phospholipase A or C based on preliminary data. We hypothesized that
the mechanism of prolonged retention of NM404 is likely due to a decrease in
its breakdown secondary to either decreased PLD1 or PLD2 expression.
METHODS: Three human colorectal cancer cell lines, DLD-1, HT-29 and LS-
180, were simultaneously implanted subcutaneously (1 × 106 cells) into SCID
mice. When tumor size reached 0.5 cm, animals were injected i.v. with 124I-
NM404 (80–100 µCi in 0.1 ml). MicroPET and microCT images were obtained
at 24 and 72 hrs. post injection, while quantification of NM404 retention was
determined by ROI analysis of the PET scans. Cell lines were analyzed for
PLD1 and PLD2 mRNA using quantitative PCR. qPCR for the PLD gene tran-
scripts involved 50 cycles of amplification by real-time PCR to give PCR prod-
ucts of 560 bp for PLD1 and 557 bp for PLD2.
RESULTS: On microPET imaging, tumor conspicuity was excellent in all 3
tumor types at both 24 and 72 hours post injection. For NM404 retention,
tumor-to-muscle ratios of 11.1, 6.0, and 4.0 were obtained for LS180, DLD-1,
and HT-29, respectively. qPCR results from three separate experiments for
PLD1 and PLD2 in the colorectal cancer cell lines were determined and
expressed as a ratio to the level of gene expression in the normal CCD-18co
colorectal cells after normalizing to the S26 house-keeping gene. There was
no difference in PLD1 expression in the colorectal cell lines compared to
CCD-18co. However, expression of PLD2 was markedly decreased in all three
cell lines, with PLD2 values of 0.05 ± 0.02 (p = 0.006): 0.47 ± 0.19 (p = 0.083);
and 0.14 ± 0.06 (p = 0.021) for LS-180, DLD-1, and HT-29, respectively. Thus a
decreased PLD2 expression level correlated with increased retention levels of
NM404.
CONCLUSION: Human colorectal tumors showed excellent tumor conspicu-
ity when utilizing 124I-NM404 microPET. This appears to be associated with a
decrease in expression of PLD2. Further evaluation of the mechanism of selec-
tive retention of NM404 is needed in order to define a molecular profile that
may classify tumors as more sensitive to NM404, enabling the selection of a
subset of patients that would benefit from preoperative staging with NM404.



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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1844 The Effects of Dai-Kenchu-to (TU-100) on Propulsive
        Motility in the Colon
Michael Wood*1, Neil H. Hyman1, Gary M. Mawe2
1Surgery,University of Vermont College of Medicine, Burlington, VT; 2Anatomy &
Neurobiology, University of Vermont College of Medicine, Burlington, VT
PURPOSE: Opioid analgesics have long been the primary treatment of post-
operative pain. The use of these agents, however, is often associated with
adverse effects on gastrointestinal motility including postoperative ileus.
Recent efforts have focused on selective antagonists of the opioid-mu recep-
tor. The purpose of this study is to examine the use of the herbal medicine
Dai-Kenchu-to (DKT) as a potential treatment for opiate-induced slowing of
intestinal transit in an isolated guinea-pig colon model of motility. We then
investigated whether DKT could act synergistically with the non-selective
opiate receptor antagonist, naloxone to promote propulsive motility.
METHODS: Isolated segments of distal guinea-pig colon were mounted in a
perfusion chamber and imaged with a digital video camera interfaced with a
computer. Fecal pellets were placed into the lumen at the oral end of the
colonic segment and the rates of motility over a 3–4 cm segment of colon
were determined. In addition, intracellular recording were obtained from
intact circular muscle. Inhibitory and excitatory junction potentials, evoked
by stimulation above or below the recording site, respectively were analyzed.
RESULTS: The addition of DAMGO (D-Ala2, N-Me-Phe4, Gly-ol5), a selec-
tive mu-receptor agonist, caused a concentration-dependent decrease in
colon motility. Naloxone did not affect basal activity, but partially restored
motility in the DAMGO treated preparations. DKT (1 × 10–4–3 × 10–4 g/ml)
also reversed the inhibitory effect of DAMGO treated colon in a concentra-
tion dependent manner. At higher concentrations (1 × 10–3–3 × 10–3 g/ml),
however, this effect was lost. Motility slowed even further when naloxone
and DKT were combined, with noticeable disruptions in spatiotemporal pat-
terns. Interestingly, when added alone, DKT caused a reversal of the peristal-
tic reflex resulting in propulsion of the pellet in an anal to oral direction. In
electrophysiological studies, DKT inhibited both excitatory and inhibitory
junction potentials.
CONCLUSIONS: DKT appears to be as effective as naloxone in restoring
motility in DAMGO treated colon. These two agents, however, do not appear
                                                                                   POSTER ABSTRACTS




to have an addictive effect. When used on untreated colon segments, DKT
appears to cause disruptions in the intrinsic reflex circuit of the gut by inter-
                                                                                       MONDAY




fering with neuromuscular communication.




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  M1845 Effect of NOD2/CARD15 Mutations on Ileal Gene
        Expression Profiles in Crohn’s Disease
Casey K. Mccullough2, Christina M. Hamm2, Elizabeth Gorbe2,
Jonathan T. Unkart2, Ellen Li2, Qing Qing Gong2, Candace R. Miller1,
Thaddeus S. Stappenbeck3, Christian Stone2, David W. Dietz4, Steven R. Hunt*1
1Department   of Surgery, Washington University, Saint Louis, MO; 2Division of
Gastroenterology, Washington University, Saint Louis, MO; 3Department of Pathology
and Immunology, Washington University, Saint Louis, MO; 4Department of Colon and
Rectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
BACKGROUND: Three mutations (Leu1007InsC, R702W, G908R) in the
nucleotide-binding oligomerization domain (NOD)2/caspase recruitment
domain (CARD)15 have been associated with an increased risk of Crohn’s dis-
ease (CD) and ileal disease location. Analysis of the effect of NOD2/CARD15
mutations on ileal gene expression could provide further insight on the
pathogenesis of ileal CD.
METHODS: We performed microarray analysis on normal ileal mucosa from
three NOD2– (none of the three mutations) normal control subjects, and on
inflamed and uninflamed ileal mucosa from three NOD2– CD patients, and
three NOD2+ (at least one of three mutations) CD patients. All patients were
nonsmokers. In the six CD patients, both inflamed and macroscopically
uninflamed tissue biopsies were obtained from fresh pathologic specimens at
the time of their initial ileocolic resection. The probes prepared from the ileal
RNA and the common reference ileal RNA (from a fourth NOD2– control sub-
ject) were hybridized with the Agilent Whole Human Genome array using the
two-color protocol. The data was analyzed using Statistical Analysis of
Microarrays (SAM) software.
RESULTS: SAM analysis detected no significant difference between NOD2+
and NOD2– uninflamed mucosa. We identified a number of genes that were
upregulated in the NOD2+ inflamed ileal mucosa relative to NOD2– inflamed
ileal mucosa. One of the identified target genes, CYBB, encodes cytochrome
b-245, beta polypeptide, which is a component of the microbicidal oxidase
system in phagocytes (q = 0.04). In addition, we observed altered expression
of genes (q < 0.05) in the uninflamed mucosa in CD patients compared to
control subjects that was independent of NOD2 status.
CONCLUSIONS: We have identified target genes that are upregulated in
inflamed ileal mucosal biopsies from NOD2+ CD patients relative to inflamed
mucosa from NOD2– CD patients. One of these genes, CYBB, plays an inte-
gral role in mucosal defense. These experiments have also detected altered
expression of genes in macroscopically normal ileal mucosa from CD patients
compared to control subjects, prior to upregulation of pro-inflammatory
genes associated with CD activity.




  Poster of Distinction

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1847 The Effect of Toll Like Receptor (TLR) 9 Agonist, CpG
        Oligodeoxynucleotides (ODN), on Abdominal and
        Gastrotomy Wound Healing in a Murine Model
Ik-Yong Kim*1,2, Xiaohong Yan1, Raymond Baxter1, Thomas R. Gardner3,
Chandana Shantha Kumara Hm1, Aqeel Ahmed4, Carlos Cordon-Cardo4,
Richard L. Whelan1
1Colorectal Surgery, Columbia University, New York, NY; 2Surgery, Yonsei University,
Wonju College of Medicine, Wonju, South Korea; 3Orthopedic Surgery, Columbia
University, New York, NY; 4Pathology, Columbia University, New York, NY
INTRODUCTION: The synthetic TLR9 ligand, CpG ODN (CpG) has been
used clinically as an anti-cancer immunotherapy. It has largely been used in
the adjuvant or stage 4 setting. It has been shown experimentally that CpG,
when given alone prior to surgery (preop), limits postoperative tumor
growth. Perioperative (Periop) CpG might also limit post-surgical immuno-
suppression. Prior to human periop studies CpG’s impact on wound healing
must be determined. This study’s purpose was to assess abdominal wall
wound and anastomotic healing after periop CpG.
METHODS: Thirty Balb/C mice were randomized into 2 groups and given
CpG 1826 (20 ug/dose) or PBS via i.p. both PreOP (7, 5, 3, and 1 day before
surgery) and on PostOP day (POD) 1, 2, and 3. All mice underwent a laparot-
omy and gastrotomy that were carefully suture closed. The mice were sacri-
ficed on POD7 and 21 and their abdominal pelts and stomachs excised.
Tensometry was used to determine the peak force and total energy required to
disrupt the abdominal wall wounds while the bursting pressure of the gastric
wounds was measured via saline infusion. The Sircol assay was used to deter-
mine soluble collagen content and a blinded pathologist used a wound heal-
ing scoring system histologically to assess the pelts.
RESULTS: There were no significant differences in the bursting pressures of
the gastrotomy wounds or in the peak force or total energy needed to disrupt
the abdominal wounds when comparing the results of treated group to those
of the control group on POD7 or 21. In regard to abdominal wound collagen
content, no differences were noted between the control and treated groups at
either time point. Importantly, there were no abdominal wall dehiscence or
clinical gastrotomy leaks in CpG treated group. The histologic healing assess-
ment scores were similar between groups.
                                                                                       POSTER ABSTRACTS




CONCLUSIONS: Perioperative administration of CpG doesn’t appear to have
                                                                                           MONDAY




a negative impact on abdominal wall or gastric wound healing in mice.
Although it is not possible to extrapolate these results directly to the human
setting, these findings lend support to the concept of a human Phase I perio-
perative CpG study.




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Basic: Esophageal
  M1848 Evaluation of the Cell Proliferation Expansion in the
        Columnar Mucosa of the Distal Esophagus in Patients
        with GERD: Immunohistochemical Analysis of KI67
        (MIB1) Antigen in Columnar Mucosa With and
        Without Intestinal Metaplasia
Marcelo Binato1,2, Renato B. Fagundes4, Luise Meurer3, Maria Isabel A. Edelweiss3,
Richard R. Gurski*2
1General Surgery, UFSM, Santa Maria, Brazil; 2General Surgery, UFRGS, Porto Alegre, Brazil;
3Pathology, UFRGS, Porto Alegre, Brazil; 4Gastroenterology, UFSM, Porto Alegre, Brazil

INTRODUCTION: Columnar mucosa without intestinal metaplasia in distal
esophagus is considered to be the stage that precedes the metaplasia—dyspla-
sia—adenocarcinoma sequence. In 20% of these cases, upper endoscopy and
biopsy shall confirm diagnosis of intestinal metaplasia in subsequent tests.
Histology alone cannot establish the percentage of patients that will develop
intestinalization of columnar mucosa. Therefore, it is necessary to seek
molecular markers capable of predicting progression to more severe stages of
the disease.
OBJECTIVES: Determine the proliferative activity of columnar mucosa in
patients with gastroesophageal reflux subjected to digestive endoscopy and
biopsy in the Unit of Digestive Endoscopy of Hospital Universitário de Santa
Maria, between 2003 and 2006.
METHODS: The Ki67 antigen was assessed by immunohistochemical tech-
nique with use of monoclonal antibody Ki67 (MIB1) in the 1:400 dilution.
Proliferative activity was determined by the Ki67 index in every proliferative
compartment of the intestinal crypt (lower layer, middle layer and epithelial
surface). The 62 patients who had columnar mucosa in the distal esophagus
were divided into two groups: G1: 30 patients with columnar epithelium
without intestinal metaplasia and G2: 32 patients with columnar epithelium with
intestinal metaplasia.
RESULTS: In G1, proliferative activity of the Ki67 was limited to the lower
layer of the gland in 83% of the patients, 3% showed positive reactivity up to
the middle layer and 13% showed immunoreactivity up to the epithelial sur-
face of the esophageal crypt. In G2, proliferative activity of the Ki67 was lim-
ited to the lower layer of the gland in 46.9% of the patients, 21.9% showed
positive reactivity up to the middle layer and 31.2% showed immunoreactiv-
ity up to the epithelial surface. A significant increase in the prevalence of pro-
liferative activity in the compartments above the lower layer of the gland in
patients with metaplastic columnar mucosa was found (p < 0.001).
CONCLUSION: The expansion of cell proliferation was significantly associated
to the process of intestinalization of the columnar mucosa in the distal esopha-
gus. Therefore, the presence of proliferative activity above the lower layer of the
intestinal crypt in patients with columnar mucosa may assist in the identifica-
tion of patients more prone to malignant transformation of the gastric mucosa
or intestinalization and, consequently, at a greater risk of disease progression
(metaplasia—dysplasia—adenocarcinoma sequence). Keywords: Ki67 (MIB1).
Barrett’s esophagus. Columnar mucosa. Intestinal metaplasia.

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1849 The Pathogenesis of Barrett’s Esophagus: The
        Combination of Acid and Bile Is Synergistic in the
        Induction of CDX2 and EGFR Activation in Esophageal
        Cells
Nelly E. Avissar*, Liana Toia, Yingchuan Hu, Alexi Matousek, Daniel Raymond,
Carolyn E. Jones, Thomas J. Watson, Jeffrey H. Peters
Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, NY
INTRODUCTION: Clinical evidence strongly suggests that mixed reflux of
duodenal and gastric content is associated with esophageal mucosal injury,
particularly the development of Barrett’s esophagus. Caudal homeobox 2
(CDX2), a transcription factor involved in normal intestinal development is
thought to be the key factor responsible for the intestinal phenotype. We
have previously shown that deoxycholic acid (DCA), at neutral pH induces
CDX2 through transactivation of the epidermal growth factor receptor
(EGFR). The aim of this study was to test the hypothesis that a combination
of bile and acid pH is more potent in inducing CDX2 and activating the EGFR
than either component alone.
METHODS: SEG-1 human esophageal adenocarcinoma cells were incubated
with acid alone (pH 5), deoxycholic acid alone (100 or 300 µM), or their com-
bination for up to 24 hours. CDX2 mRNA was determined by real-time PCR
and EGFR site-specific tyrosine phosphorylation and receptor degradation
were determined by Western blot analysis.
RESULTS: Neither acid (pH 5) nor the 100 µM DCA dose alone induced
CDX2 mRNA. In contrast, there was a synergistic 55 fold increase in CDX2
mRNA expression with exposure to 100 µM DCA at pH5. Each treatment
(pH 5, DCA or pH 5 plus DCA) activated the EGFR on all tyrosines tested, but
in different time courses. Acid alone induced peak EGFR phosphorylation at
8 h, DCA alone at 30 min and 8 hours and acid plus DCA at 1 hour. Interest-
ingly, degradation of the EGF receptor occurred with the combination treat-
ment but not with either acid or DCA alone, indicating differential
transactivation pathways. The combination of pH 5 and 300 µM DCA resulted
in significant cell death at all time points.
CONCLUSION: The addition of acid markedly enhances bile salt induced
activation of the transcription factor CDX2 and occurs coincident with acti-
vation of the epidermal growth factor receptor. CDX2 gene induction occurs
                                                                                    POSTER ABSTRACTS




at significantly lower concentrations of bile salt than in the absence of acid,
and may be due to differential EGFR transactivation. This data provides fur-
                                                                                        MONDAY




ther insight into the molecular pathogenesis of Barrett’s columnar metaplasia
and identifies molecular targets useful for diagnosis, risk assessment and ther-
apeutic intervention.




  Poster of Distinction
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  M1850 Bile Reflux Induces Higher COX-2 Expression Than
        Mixed Acid and Bile Reflux in a Rat Model of
        Esophagitis
Reginald V. N. Lord*1,2, Stefan Oberg1,3, Jeffrey H. Peters1,4, Steven R. Demeester1,
Jeffrey A. Hagen1, Tom R. Demeester1
1Department   of Surgery, University of Southern California Keck School of Medicine,
Los Angeles, CA; 2UNSW Department of Surgery, St. Vincent’s Hospital, Sydney, NSW,
Australia; 3Department of Surgery, Lund University, Lund, Sweden; 4Department of
Surgery, University of Rochester, Rochester, NY
BACKGROUND AND AIMS: A rat model of severe esophagitis is induced by
performing either an esophagoduodenostomy (ED, acid and non-acid/bile
reflux) or esophagoduodenostomy with total gastrectomy (ED + TG, non-acid
reflux only). Esophagitis is not found in control animals in which total gas-
trectomy with Roux-en-Y reconstruction is performed (TG + RY, no reflux).
All three operations result in formation of well-differentiated tumors at the
esophageal anastomosis. Consequently, the nature of these tumors is contro-
versial. COX-2 is overexpressed in a stepwise manner in esophagitis, Barrett’s
esophagus, and esophageal adenocarcinoma. The aim of this study was to (1)
compare esophageal cyclo-oxygenase 2 (COX-2) expression in the three oper-
ation models, and (2) characterize the tumors.
METHODS: COX-2 enzyme expression was measured in the distal esophageal
mucosa of 60 rats, 20 in each operation group, using a polyclonal rabbit anti-
body. Tumor and normal tissues were examined for DNA content and apop-
totic index using flow cytometry with immunofluorescent propidium iodide and
annexin V labeling, and for protein expression using immunohistochemistry.
RESULTS: COX-2 expression was higher than controls in severe esophagitis
in both ED and ED+TG arms but was significantly higher in the non-acid bile
reflux ED+TG arm. The tumors were diploid in 5 of the 6 examined and the
remaining animal had aneuploidy in both tumor and normal tissues. None of
12 tumors examined showed immunoreactivity with p53, DAS-1, c-erbB-2,
CEA, chromogranin A, or synaptophysin antibodies.
CONCLUSIONS: Injury severity, as measured by COX-2 overexpression, was
significantly higher in a non-acid reflux environment in this animal model of
esophagitis. The esophageal tumors that developed in this surgical model
without exogenous carcinogen exposure were dissimilar to human esoph-
ageal adenocarcinomas.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Hepatic
  M1851 Cellular Liver Regeneration After Extended Hepatic
        Resection in Pigs
Ruth Ladurner*, Martin Schenk, Frank Traub, Alfred Koenigsrainer, Jorg Glatzle
General and Transplant Surgery, University of Tuebingen, Tuebingen, Germany
BACKGROUND: The liver has an extremely effective regenerative capacity.
There is some evidence, that a portosystemic shunt is beneficial for liver
regeneration after extended resection. The aim of the study was to estimate,
whether the regeneration is due to hypertrophy or hyperplasia of the rem-
nant liver tissue and whether a portosystemic shunt is beneficial for liver
regeneration.
MATERIAL AND METHODS: An extended left hemihepatectomy (approxi-
mately 75% of liver volume) was performed in 6–8 weeks old domestic pigs (n
= 25, body weight 25–35 kg). In n = 14 pigs a portosystemic H-shunt was
inserted between the portal vein and the infrahepatic cava vein after
extended resection. After surgery, animals were weaned from anesthesia and
resumed oral feeding. Liver biopsies were histological examined before
extended liver resection and weekly until the 3rd postoperative week. Liver
regeneration was estimated by the liver volume, the size of the portal fields
(mm2), the amount of hepatocytes per portal field and the amount of hepato-
cytes per mm2.
RESULTS: Extended left resection was technically feasible in all animals with
and without portosystemic shunt. Volume of the remnant right lateral seg-
ment reached 250% at the end of the first week after resection. The size of the
portal fields increased significantly after resection (portal field [mm2]; animals
with shunt before resection: 1.0 ± 0.4, 1 week after resection: 1.8 ± 0.9*; 3
weeks: 2.9 ± 1.3*, *p < 0.05; animals without shunt before resection: 1.1 ± 0.3,
1 week after resection 1.8 ± 0.7*; 3 weeks: 2.9 ± 1.7*, *p < 0.05). The number
of hepatocytes in the portal fields increased significantly (hepatocytes/portal
field, animals with shunt before resection: 3438 ± 1281; 1 week after resec-
tion: 5831 ± 3419*; 3 weeks: 8793 ± 3690*; *p < 0.05; animals without shunt
before resection: 3053 ± 1096, 1 week after resection: 4580 ± 2007*; 3 weeks:
8014 ± 4809*, *p < 0.05). Interestingly there was no increase in hepatocytes/
mm2 and there was no difference between animals with or without portosys-
temic shunt.
                                                                                   POSTER ABSTRACTS




CONCLUSION: After extended liver resection the restoration of the liver vol-
                                                                                       MONDAY




ume is accomplished by an extensive and significant hyperplasia of hepato-
cytes within the preexisting portal fields, indicated by increased portal fields
and hepatocytes per portal field, but constant hepatocytes per mm2. How-
ever, there was no beneficial effect of a portosystemic shunt, regarding liver
regeneration after extended liver resection.




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  M1852 Basics of Mouse Liver Anatomy from a Microsurgical
        Point of View
Peter Studer*, Daniel Sidler, Beat Gloor, Andre E. Dutly, Daniel Candinas,
Daniel Inderbitzin
Inselspital, Bern, Switzerland
BACKGROUND: During the development of different mouse liver resection
models for the study of hepatic regeneration and basic liver pathology a sig-
nificant lack of relevant anatomical data of the mouse liver became obvious.
It has been shown, however, that different mouse liver lobes exhibit different
regenerative capacities (less for the caudate lobe). In order to create a mouse
model with standardized resections allowing a meaningful study of adaptive
and regenerative responses the following basic anatomical studies of the
mouse liver were undertaken.
METHODS: In Balb/c mice (n = 32, 18–26 g) and Black 6 transgenic blue
mice (n = 69, 19–27 g) liver mass and individual liver lobe weights were deter-
mined. The detailed three-dimensional anatomy of the hepatic vascular
system was studied with corrosion casts (n = 8). For scanning electron micros-
copy (EM) the mouse liver was perfused with a Mercox solution. Casts were
sputtered with gold (10 nm) and examined in a Philips XL 30 FEG scanning
electron microscope.
RESULTS: When comparing liver weight (LW)/ bodyweight (BW) ratio sig-
nificant strain specific differences were detected. In Balb/c mice liver weight
(LW) was increasing up to a mouse body weight (BW) of 23.6 g ± 1.6 gr and
decreasing thereafter (LW [g] = –0.0022 * BW [g] 2 + 0.1025 * BW [g]). In con-
trast the LW in the Black 6 transgenic mice showed a linear increase with
increasing BW. In Balb/c mice vascular corrosion casts demonstrated a single
vascular pedicle in the right superior, right inferior and caudate lobes. In con-
trast, a common pedicle was seen for medial and left lobes in 26%, explaining
the necrosis of the left lobe after medial lobe resection in around 30% of
cases. In Balb/c mice histological sections vascular density, total vascular
luminal area and calculated volumes of liver lobules were not different
between liver lobes. EM showed significantly smaller hepatic lobules in the
cudate lobe (when compared with the right superior lobe) with significantly
increased vascular density.
CONCLUSIONS: Relative mouse liver mass varies considerably with body-
weight and strain. A common vascular pedicle of the medial and left lobe in
Balb/c mice explains the inhomogeneous perfusion of the liver remnant after
some isolated medial lobe resections. This resection is therefore not recom-
mended. A higher vascular density in the caudate lobe with smaller hepatic
lobules as seen in EM might explain the impaired hepatic regenerative capac-
ity. Our anatomical data underline the importance of careful selection of the
appropriate microsurgical model when studying mechanisms of liver regener-
ation and basic liver pathologies.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1853 Simultaneous Splenectomy Enhance Liver Regeneration
        After Major Hepatectomy via Decreasing Activin-A
        Expression
Yan-Shen Shan*, Pin-Wen Lin
National Cheng Kung Univ Hosp, Tainan, Taiwan
BACKGROUND AND PURPOSE: Splenectomy can enhance liver regenera-
tion after major hepatectomy probably due to removal of inhibitory factors
released from the spleen. Activin-A, a superfamily of TGF-, can negatively reg-
ulate liver regeneration. Aim of our study was to investigate whether activin-a
may play a role in enhancing liver regeneration in hepatectomized rats with
splenectomy.
MATERIAL AND METHODS: Male wistar rats, weighing 250 gw, received
70% hepatectomy without (PH) or with splenectomy (PHSL). These rats were
sacrificed at different time schedule. The increasing liver/body weight ratio,
regeneration of hepatocytes, mRNA and protein expression of activin-A were
compared.
RESULTS: The liver/body weight ratio was significantly higher in the PHSL
group than that in PH group since 1 day later. The mRNA and protein expres-
sion of activin-A are significantly lower in the PHSL group than those in PH
group in the first 12 hours. In the PHSL group, PCNA staining showed the
regeneration of hepatocytes was increased and the expression of activin-A in
the hepatocytes and kupper cells was decreased when compared with the PH
group in the first 48 hours after operation. After the early mitogenic stimula-
tion by HGF, the protein expression of activin-A is persistent decreased and
negative correlated with liver weight ratio in PHSL group.
CONCLUSION: After major hepatectomy, simultaneous splenectomy can
accelerate early liver regeneration via decreasing expression of activin-A.



                                                                                  POSTER ABSTRACTS
                                                                                      MONDAY




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Basic: Pancreas
   M1854 Cannabinoid Receptor Blockade Attenuates Acute
         Pancreatitis by an Adiponectin Mediated Mechanism
Nicholas J. Zyromski*, Abhishek Mathur, Terence Wade, Sue Wang,
Deborah A. Swartz-Basile, Andrew Prather, Keith D. Lillemoe, Henry A. Pitt
Surgery, Indiana University, Indianapolis, IN
BACKGROUND: Obesity is an independent risk factor for developing severe
acute pancreatitis. Adipose tissue produces hormones (adipokines) that regulate
metabolism and inflammation. We recently showed that the potent anti-
inflammatory adipokine adiponectin inversely mirrors the severity of acute
pancreatitis in lean and congenitally obese mice. The endocannabinoid system
is also important in regulating appetite and metabolism. Increases in circulat-
ing levels of adiponectin are observed after central blockade of the cannab-
inoid-1 (CB-1) receptor. We therefore hypothesized that CB-1 blockade would
attenuate the severity of acute pancreatitis by elevating adiponectin.
METHODS: 32 congenitally obese (Lepdb/db) mice were studied at 16 weeks
of age. Half were subjected to acute pancreatitis by cerulein injection (50 µg/kg
IP hourly × 6); the others received saline. For 7 days prior to study, half of the
animals in each group (pancreatitis/control) received the CB-1 receptor
antagonist rimonabant (10 mg/kg IP); the other half received vehicle. Mice
were sacrificed 9 hours after pancreatitis induction. Histologic pancreatitis
severity was determined by a validated method. Serum levels of adiponectin
and tissue levels of the pro-inflammatory cytokine interleukin-6 (IL-6), and
the chemoattractant molecule MCP-1 were measured by ELISA. ANOVA and
Tukey’s test were applied where appropriate; p < 0.05 was considered statisti-
cally significant.
RESULTS: CB-1 blockade with rimonabant significantly increased circulating
adiponectin levels (p < 0.05, Table). In the control group, treatment with
rimonabant did not change pancreatic levels of IL-6 or MCP-1. In the pancre-
atitis group, CB-1 blockade with rimonabant significantly decreased the his-
tologic pancreatitis score (p < 0.001) as well as pancreatic IL-6 and MCP-1
expression (p < 0.001) compared to vehicle treated animals.
CONCLUSION: These data demonstrate that CB-1 receptor blockade
1) increases circulating adiponectin and 2) significantly attenuates the sever-
ity of acute pancreatitis in congenitally obese mice. We conclude that the adi-
pokine milieu is important in the pathogenesis of severe acute pancreatitis in
obesity, and that CB-1 blockade attenuates acute pancreatitis by an adiponec-
tin mediated mechanism.
                                             CONTROL                                       PANCREATITIS
                                 Vehicle           Rimonabant                      Vehicle          Rimonabant
Adiponectin (µg/mL)              2.2 ± 0.3           4.1 ± 0.6*                   2.9 ± 0.4          4.8 ± 0.8*
Pancreatitis Score               0.2 ± 0.5             0±0                         7.6 ± 1.0         2.9 ± 0.9†
IL-6 (pg/mL)                     231 ± 58            237 ± 148                   3445 ± 1432         373 ± 52†
MCP-1 (pg/mL)                    380 ± 51            293 ± 66                    7740 ± 1386        2096 ± 239†
*p < 0.05 vs vehicle in each group (control/pancreatitis); †p < 0.001 vs vehicle within pancreatitis group



                                                            262
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1855 Over-Expression of Focal Adhesion Kinase Inhibits Cell
        Proliferation in Gastrointestinal Neuroendocrine
        Tumor Cells
Li Ning*, Muthusamy Kunnimalaiyaan, Herbert Chen
Surgery, University of Wisconsin, Madison, WI
BACKGROUND: Gastrointestinal neuroendocrine (NE) tumors frequently
metastasize and have limited treatments. We have recently found that over-
expression of focal adhesion kinase (FAK), a non-receptor tyrosine kinase that
plays an important role in cancer biology, led to a significant reduction in NE
tumor markers in gastrointestinal NE tumor cells. However, the role of FAK
on gastrointestinal NE tumor growth is not known. We hypothesize that
over-expression of FAK might inhibit gastrointestinal NE tumor cell growth.
METHODS: Human pancreatic carcinoid BON cells were transiently trans-
fected with recombinant pKH3-FAK constructs encoding the full-length of
wild-type FAK protein or vector alone and analyzed by Western blot for evi-
dence of FAK over-expression in transfected cells. MTT (3-(4,5-Dimethylthia-
zol-2-yl)-2,5-diphenyltetrazolium bromide) rapid colorimetric assay was used
to measure cell viability in FAK transfected BON cells. Finally mechanism of
growth inhibition was analyzed by Western blotting.
RESULTS: At baseline, no FAK protein was present in BON cells. Transfection
with recombinant pKH3-FAK constructs resulted in FAK over-expression and
a concomitant decrease in cell viability (percentage) compared to vector
alone in BON cells. Moreover, Western blotting identified an increase in
phosphorylation of FAK Tyr407 only, and no change in FAK Tyr397 or FAK
Tyr576/577 in BON cells transfected with pKH3-FAK plasmid. FAK over-
expression in BON cells led to an increase in p21 and a decrease in CyclinD1
protein, indicating that the growth inhibition was mediated by cell cycle
arrest.
CONCLUSIONS: FAK expression leads to a reduction in cellular proliferation
in gastrointestinal NE tumor cells. The mechanism of growth suppression is
mediated by cell cycle arrest. FAK Tyr407 phosphorylation may contribute to
negative regulation of kinase activity. Therefore, FAK is a potential target for
the development of new treatments for advanced gastrointestinal NE tumors.
                                                                                   POSTER ABSTRACTS
                                                                                       MONDAY




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  M1856 Potential Therapeutic Targets in Invasive Pancreatic
        Cancer Identified by Gene Expression Profiling
Annamarie Rogers*, Joseph Murphy, Ellen Manahan, Desmond P. Toomey,
Kevin C. Conlon
Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
INTRODUCTION: Current management of pancreatic cancer is mired by
late presentation and lack of effective adjuvant therapy. We investigated the
genome-wide expression profiles of pancreatic cancer cell lines, AsPC-1 and
BxPC-3, to identify diagnostic markers and therapeutic targets for this disease.
METHODS: Cells were treated with Camptothecin (pro-apoptotic) or phor-
bol 12-myristate 13-acetate (PMA—pro-inflammatory). Non-treated cells were
used as control. RNA was extracted and hybridised to Affymetrix arrays. Dif-
ferentially expressed genes were identified using ArrayAssist®. Significantly
interacting genes were linked and pathways mapped using Pathway Studio®.
Genes were selected for validation by qRT-PCR based on pathway significance
and fold change.
RESULTS: Genesets for each condition displayed a 1.5 fold differential
expression with p-values < 0.02. Pathway analysis revealed that camptothecin
was primarily involved in signal transduction via MAP kinase pathways. PMA
induced apoptotic signalling through a family of receptors known collec-
tively as “death receptors” including Fas, DR3 and DR4-5. Quantitative RT-
PCR confirmed microarray expression profiles. Genes selected included those
already implicated in pancreatic cancer (SMAD3, BRCA2, MMP-1, IL1-R1) and
also several not previously reported. Although camptothecin and PMA had
distinct expression profiles, 3 genes (ATF3, PLAU and SOD2) were ≥ 10 fold
up- and down-regulated in AsPC-1 and BxPC-3, respectively.
CONCLUSION: novel genes have been identified in pancreatic cancer for
evaluation as screening and therapeutic targets. Three genes (ATF3, PLAU and
SOD2) are involved in early stage invasion and cell dissociation, thus demon-
strating potential as specific tumour markers or molecular targets in pancre-
atic cancer.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1857 A Xenograft Model and Cell Line Deriving from
        Invasive Intraductal Papillary Mucinous Neoplasm
        of the Pancreas
Stefan Fritz*1, Carlos Fernandez-Del Castillo1, A. John Iafrate2, Mari Mino-Kenudson2,
Nancy L. Neyhard1, Jennifer Lafemina1, Amy Stirman1, Andrew L. Warshaw1,
Sarah P. Thayer1
1Department  of Surgery, Massachusetts General Hospital, Harvard Medical School,
Boston, MA; 2Department of Molecular Diagnostics Laboratory, Department of
Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
OBJECTIVES: Intraductal papillary mucinous neoplasms (IPMNs) of the
pancreas are characterized by a prominent intraductal component, which has
malignant potential. Adenocarcinoma arising in IPMN has a less aggressive
biological behavior, and survival after surgery has been shown to be better
than for pancreatic ductal adenocarcinoma (PDAC). Many authors suggest
that IPMNs are distinct neoplasms with a unique genetic signature. In addi-
tion to chromosomal instability, PDAC carries characteristic mutation types
such as K-ras and p53 mutations. For PDAC, cell culture and xenograft mod-
els have become a powerful tool to study tumor behavior and genetics. Our
lab recently reported that the Sonic Hedgehog (Shh) pathway is over-
expressed in >95% of PDAC. In this study we describe a novel xenograft
model and cell culture deriving from malignant IPMN, created to biologically
and genetically characterize IPMNs and compare them to PDAC.
METHODS: From a fresh surgical specimen of invasive main duct IPMN a
xenograft tumor line and cell culture were created and its histology, K-ras and
P53 status determined. Members of Shh pathway signalling (Shh, Ptch1,
Ptch2, Smo, and Gli2) were assessed by quantitative RT-PCR, and global
genomic changes were evaluated by array Comparative Genomic Hybridiza-
tion (CGH).
RESULTS: IPMN tumors were successfully implanted and enriched in a
xenograft model, and a cell line was established. Histology of the xenograft
tumors revealed characteristics identical to those of the parent tumor. Cyto-
genetic analysis showed a tetraploid karyotype with multiple chromosomal
aberrations reflecting genomic instability, K-ras mutation at codon 12 (GGT >
GTT) and p53 mutation at codon 273 in exon 8 (CGT > TGT) as well as over
expression of the Shh pathway. Thus, IPMNs do share certain genetic features
                                                                                         POSTER ABSTRACTS




that characterize PDAC. Array CGH reveals chromosomal gains at 3q, 5p, 9p,
12p, 18p, and 19q, and losses which involve chromosomes 4, 5q, 6q, distal
                                                                                             MONDAY




6p, 8p, 8q, 9q, 13q, 14q, 15q, 17p, 18q, 19p, and 21. These data are compara-
ble to previously published chromosomal aberrations in IPMNs and show
overlapping and distinct characteristics compared to PDAC.
CONCLUSION: This study describes a novel xenograft model and cell line
deriving from adenocarcinoma arising in IPMN. Characterization of the model
shows similarities to the parent tumor in accord with previously published data
on IPMNs. Compared to PDAC, this model shows shared aberrations as well as
evidence for distinct genomic changes. More importantly, the xenograft model
may be useful for future preclinical chemotherapy studies in vivo.


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  M1858 pp32 Is a Key Regulator of Cellular Differentiation:
        Implications for Anti-Cancer Therapy
Jonathan R. Brody1, Timothy K. Williams*1, Agnes Witkiewicz2, Joseph Cozzitorto1,
Gary Pasternack3, Shrihari Kadkol3, Charles J. Yeo1
1Surgery, Thomas Jefferson University, Philadelphia, PA; 2Pathology, Thomas Jefferson
University, Philadelphia, PA; 3Pathology, Johns Hopkins University, Baltimore, MD
OBJECTIVE: To evaluate pp32 expression as a signal for the complex process
of differentiation in normal and malignant cells.
BACKGROUND: pp32 is a highly-conserved multi-functional nuclear pro-
tein whose biologic activities include inhibition of oncogene-mediated trans-
formation, inhibition of histone acetyl transferase activity (INHAT), a role in
the caspase-independent apoptotic pathway, and message stability of specific
cytokine and oncogene messages. It has been previously shown that reduc-
tion of pp32 in a neoplastic cell line induced differentiation that accompa-
nied inhibition of proliferation. Further, we recently reported that pp32
expression is nearly absent in poorly differentiated pancreatic ductal adeno-
carcinoma cells (Modern Pathology 2007 (20), 1238–1244). In adult tissues,
pp32 is found in self-renewing (often basal) cells as well as in neoplastic cells,
but not in most terminally differentiated cells. These findings suggest that in
normal or cancer cells, pp32 expression is either involved in the control of
differentiation, or is regulated by mechanisms that control differentiation.
METHODS: We evaluated whether pp32 expression correlated with differen-
tiation both in in vitro models and in vivo during murine embryogenesis.
Undifferentiated HL-60 promyelocytic leukemia cells as well as ML-1 and
K562 myeloid leukemia cell lines were assayed for levels of pp32 mRNA and
protein. To determine the pattern of pp32 expression at different gestational
ages, we examined transverse sections of embryos from Days 8, 10, 12 and 15
and sagittal sections from embryos from days 8–15.
RESULTS: In all three cell line models, mRNA and protein levels decreased
dramatically following phorbol ester-stimulated differentiation into different
lineages. In the K562 system, reduction of pp32 expression induces morphol-
ogy that is consistent with megakaryocytic differentiation. In murine
embryos, pp32 mRNA levels are generally high in most tissues on Day 10, but
are decreased after Day 12. As tissues differentiate, only a small fraction of
cells continue to express pp32 at high levels.
CONCLUSIONS: Based upon these results and our previous findings, we con-
clude that pp32 is differentiation-regulated in normal tissues, neoplastic cells,
and during embryogenesis and is most likely a critical signal and marker for
this process. These findings provide evidence that manipulation of pp32
expression may provide a novel ‘differentiation-induced’ therapy against dif-
ferent types of cancers that have the plasticity to differentiate. This strategy,
in theory, would be more specific and safer than recent, similar approaches
using HDAC inhibitors against cancers.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  M1859 The Effect of ras/raf-1 Pathway Activation on
        Somatostatin Receptors in Gastrointestinal Carcinoid
        Tumor Cells
Scott N. Pinchot*, Herbert Chen
Surgery, University of Wisconsin Hospital and Clinics, Madison, WI
BACKGROUND: Gastrointestinal (GI) carcinoid tumors often cause debili-
tating symptoms due to excessive hormonal secretion. We have previously
shown that activation of the ras/raf-1 signal transduction pathway in GI car-
cinoids markedly suppresses chromogranin A (CgA) and serotonin produc-
tion. Since somatostatin agonists have been shown to have similar effects, we
hypothesized that raf-1 activation modulates neuroendocrine (NE) hormone
production through alterations in somatostatin receptor (SSTR) expression.
METHODS: Gastrointestinal carcinoid (BON) cells and an estrogen-inducible
raf-1 cell line (BON-raf) were used to study the effects of raf-1 activation on
somatostatin receptors (SSTR1-5). Cells were treated with either control (etha-
nol) or β-estradiol for two days. Protein isolates were analyzed by Western
blot to confirm raf-1 activation and determine the level of somatostatin
receptor activity utilizing subtype-specific antibodies for SSTR1-5.
RESULTS: Estrogen treatment of BON-raf cells resulted in raf-1 pathway acti-
vation. Western blot analysis identified the presence of SSTR 1 and SSTR3-5
subtypes in BON cells; the SSTR2 subtype was not expressed. Raf-1 activation
resulted in no significant alterations in SSTR subtype expression.
CONCLUSIONS: Raf-1 mediated suppression of CgA and serotonin is not
due to alterations in SSTR expression. NE hormonal suppression is therefore
effected via an alternative mechanism. However, understanding the regula-
tion of these receptors in response to raf-1 activation is an important first step
in studying a potential synergistic effect between raf-1 activating compounds
and somatostatin agonists.


                                                                                    POSTER ABSTRACTS
                                                                                        MONDAY




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  M1860 Pterostilbene Inhibits Pancreatic Cancer in Vitro
Julie A. Alosi*1,2, Debbie E. Mcdonald1, David W. Mcfadden1,2
1Department   of Surgery, University of Vermont College of Medicine, Burlington, VT;
2Department   of Surgery, Fletcher Allen Health Care, Burlington, VT
BACKGROUND: Stilbenes are phenolic compounds present in grapes and
blueberries. Resveratrol, a naturally occurring compound present in grapes,
has been shown to have potent antioxidant properties as well as an ability to
induce apoptosis. Resveratrol has also been reported to have significant inhib-
itory effects against a variety of primary tumors including breast, colon, and
prostate. Pterostilbene, a naturally occurring analogue of resveratrol found in
blueberries, also has antioxidant and antiproliferative properties. These
effects have not been studied in pancreatic cancer. We hypothesized that
pterostilbene would inhibit pancreatic cancer cell growth in vitro.
METHODS: Two pancreatic cancer cell lines (MIAPACA and PANC1) were
cultured using standard techniques. Cells were treated with graduated doses
of pterostilbene ranging from 10 to 100 µM. Cell viability was measured by
MTT at 24, 48, and 72 hours.
RESULTS: Pterostilbene decreases cell viability in both cancer cell lines in a
concentration- and time-dependent manner. Higher doses (75–100 µM)
caused a significant reduction in cell viability at 24 and 48 hours. However,
by 72 hours all tested concentrations of pterostilbene (10 to 100 µM) resulted
in significantly reduced cell viability in both pancreatic cancer cell lines in a
dose dependent fashion. Inhibition was slightly greater in PANC1 cells.
Pterostilbene caused a dose-dependent 10%–63% inhibition in MIAPACA cells
and 10–75% inhibition in PANC1 cells.
CONCLUSIONS: Pterostilbene inhibits the growth of pancreatic cancer in
vitro. Further in vitro mechanistic studies and in vivo experiments are war-
ranted to determine its potential for the treatment of pancreatic cancer.




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       49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Small Bowel
  M1861 Practical Considerations and Survival Techniques for a
        Rat Model of Roux-en-Y Gastric Bypass
Drew A. Rideout*1,2, Steven S. Rakita2,1, Yanhua Peng2,3, William R. Gower2,3,
Michel M. Murr1,2
1Department of Surgery, University of South Florida, Tampa, FL; 2Department of Surgery,
James A. Haley Veterans Affairs Medical Center, Tampa, FL; 3Department of Molecular
Medicine, University of South Florida, Tampa, FL
BACKGROUND: A rat model for Roux-en-Y gastric bypass (RYGB) is associ-
ated with high operative mortality. We herein describe techniques to improve
survival of obese rats that undergo RYGB.
METHODS: Sprague-Dawley male rats were fed high fat diet for 14 weeks to
induce obesity; subsequently obese rats underwent RYGB or sham operation.
Despite following protocols published by others we continued to observe
high rates of mortality in the immediate post-operative period. We, therefore,
introduced a group of interventions aimed at improving survival after RYGB:
1) changed to inhalational anesthetic with streamlined operations to
minimize anesthesia exposure (71 ± 4 min); 2) used metabolic cages peri-
operatively to prevent rats from eating their bedding and feces; 3) modified
the peri-operative diet with a 12 hour pre-operative fast and a gradual
advance to full-strength Ensure post-operatively, followed by solid chow at 1
week; 4) created smaller gastric pouch and larger gastrojejunostomy to facili-
tate gastric emptying; 5) minimized handling and manipulation of the tis-
sues. Weight and survival in the pre and post-intervention groups were
compared.
RESULTS: The first 8 rats were excluded to eliminate the confounding
nature of the “technical” learning curve. RYGB was undertaken in 18 rats
done according to published protocols and in 21 rats after introducing our
set of interventions. All deaths in the pre-intervention group were in the
immediate 36 hours post-operatively (Table). Overall survival at 6 weeks post-
operatively increased dramatically from 11% to 86% immediately after intro-
ducing our interventions. Obese rats who underwent sham operations (n = 8)
had similar overall survival (88%) as post-intervention RYGB rats. Survival
was the same in all groups at the time of earliest tissue harvest for molecular
                                                                                           POSTER ABSTRACTS




studies (6 weeks). Body weight at 9 weeks was lower in RYGB rats compared to
sham controls (364 ± 45 gm vs. 496 ± 32 gm; p < 0.01).
                                                                                               MONDAY




CONCLUSION: RYGB is a technically challenging procedure in rodents; sim-
ple modifications in the operative conduct and peri-operative care of rats
undergoing RYGB improve mortality in a predictable manner. Lessons
learned from our experience will likely shorten the learning curve for
researchers trying to establish animal models of obesity and RYGB.
                                    Operation       Survival 36 Hours   Survival 6 Weeks
Pre-intervention (n = 18)            RYGB                 11%                 11%
Post-intervention (n = 21)           RYGB                 91%                 86%
Post-intervention (n = 8)            Sham                 100%                88%


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  M1862 Activation of Wnt Signaling Protects Intestinal
        Epithelial Cells from Apoptosis by Increasing
        Cytoplasmic Levels of RNA-Binding Protein HuR
Emily C. Bellavance*1, Lan Liu1, Rao N. Jaladanki1, Tongtong Zou1,
Douglas J. Turner1, Jian-Ying Wang1,2
1Department  of Surgery, University of Maryland School of Medicine and Baltimore VA
Medical Center, Baltimore, MD; 2Department of Pathology, University of Maryland
School of Medicine and Baltimore VA Medical Center, Baltimore, MD
INTRODUCTION: Apoptosis plays a critical role in maintenance of gut
mucosal homeostasis, but the mechanism underlying this process remains
unclear. Wnts are cysteine-rich glycoproteins that act as short-range ligands
to locally activate receptor-mediated signaling pathways. Central to this sig-
naling pathway is the stabilization of β-catenin and its interaction with DNA-
binding factors of the T-cell factor family in the nucleus. Recently, genetic
studies have shown an essential role for canonical Wnt signaling in gut devel-
opment and intestinal epithelial cell (IEC) proliferation. Activation of Wnt
signaling is implicated in controlling cell fate and carcinogenesis by modulat-
ing its target gene expression. HuR is the RNA-binding protein and plays a
critical role in regulating apoptosis. Predominantly nuclear in unstimulated
cells, HuR rapidly translocates to the cytoplasm where it induces expression
of anti-apoptotic genes posttranscriptionally. We hypothesized that Wnt sig-
naling activation protects IECs against apoptosis by altering HuR functions.
METHODS: Studies were conducted in IEC-6 cells derived from rat small
intestinal crypts. Wnt activation was induced by stable transfection with the
expression vector containing Wnt-3 cDNA. Apoptosis was induced by expo-
sure to tumor necrosis factor-α (TNF–α) in combination with cyclohexamide
(CHX). Apoptosis was assessed by immunohistochemical staining for
Annexin-V and by caspase-3 activity. Levels of cytoplasmic and nuclear HuR
were determined by Western blot analysis.
RESULTS: Stable Wnt3-transfected IEC-6 cells (Wnt-IECs) highly expressed
Wnt3 protein. Levels of Wnt3 protein in Wnt-IECs were ~5-fold the value of
parental IEC-6 cells (C-IECs) transfected with the vector containing no Wnt3
cDNA. After exposure to TNFα/CHX, Wnt-IECs had a significantly lower per-
centage of apoptotic cells and exhibited decreased levels of caspase-3 activity
compared with C-IECs (p < 0.001). C-IECs showed higher levels of caspase-3
activity and stronger Annexin-V staining, while Wnt-IECs displayed lower
apoptotic indicators. Wnt-IECs also demonstrated 2-fold higher levels of
cytoplasmic HuR, although there were no differences in total levels of HuR
between C-IECs and Wnt-IECs.
CONCLUSION: These findings indicate that 1) activation of Wnt signaling
pathway protects IECs against TNF–α/CHX-induced apoptosis and 2) increased
resistant to apoptosis by Wnt3 overexpression is associated with an increase
in levels of cytoplasmic HuR.



  Poster of Distinction

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  M1863 The Immunonutrient Fish Oil Increases Blood Flow in
        the Ileum During Chronic Feeding in Rats
Ryan T. Hurt*3,4, Paul J. Matheson1,2, Brian M. Derhake5, El Rasheid Zakaria4,
Richard N. Garrison1,2
1Surgery, University of Louisville, Louisville, KY; 2Research, Louisville VAMC, Louisville,
KY; 3Medicine, University of Louisville, Louisville, KY; 4Physiology & Biophysics,
University of Louisville, Louisville, KY; 5Anesthesiology, University of Louisville,
Louisville, KY
BACKGROUND: Benefits (decreased septic complications and length of stay)
of enteral feeding with immune-enhancing diets (IED) depend on route
(enteral vs. parenteral), timing (early vs. delayed) and composition (i.e.,
omega-3 fatty acids, arginine or RNA nucleotides). A central question is, why
does enteral IED delivery provide benefits while parenteral delivery does not.
We hypothesized that chronic feeding with certain individual immunonutri-
ents would enhance gastrointestinal blood flow.
METHODS: Male Sprague-Dawley rats (200–225 g) were fed a standard
enteral diet supplemented with immunonutrients for 5 days prior to study.
Study groups (n = 8) were: 1) standard rat chow; 2) liquid control diet alone
(CD); 3) CD + Fish Oil; 4) CD + L-arginine; and 5) CD + RNA nucleotide frag-
ments. Whole organ blood flow distribution was measured by colorimetric
microsphere technique in antrum, small intestine (in thirds), colon, liver,
spleen, pancreas and kidneys.




                                                                                              POSTER ABSTRACTS
                                                                                                  MONDAY




RESULTS: Chronic feeding with CD + Fish Oil increased blood flow in the
distal third of the small intestine compared to CD alone. CD + L-arginine
decreased blood flow in the small intestine (all segments) compared to CD
alone. CD + RNA did not alter blood flow distribution.
CONCLUSIONS: These findings agree with prior studies of acute gavage with
CD, CD + individual immunonutrients or IED. Our current data suggest that
blood flow benefits associated with fish oil persist during chronic feeding in
rats. Enhanced GI perfusion might partially explain the benefits of early
enteral feeding with immune-enhancing diets not seen with parenteral
immunonutrient delivery.

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Basic: Stomach
  M1864 Survivin Expression in Gastric Cancer: Association
        with Histomorphological Response to Neoadjuvant
        Therapy and Prognosis
Daniel Vallbohmer*1, Uta Drebber2, Paul M. Schneider1,3, Stephan E. Baldus4,
Elfriede Bollschweiler1, Jan Brabender1, Stefan Monig1, Arnulf H. Hoelscher1,
Ralf Metzger1
1Department  of Surgery, University of Cologne, Cologne, Germany; 2Department of
Pathology, University of Cologne, Cologne, Germany; 3Department of Visceral and
Transplantation Surgery, University of Zurich, Zurich, Switzerland; 4Department of
Pathology, University of Dusseldorf, Dusseldorf, Germany
BACKGROUND: Neoadjuvant multimodality treatment is frequently
applied to improve the poor prognosis associated with locally advanced gas-
tric cancer. However, only patients with a major histopathologic response to
neoadjuvant therapy seem to have a significant survival benefit. Predictive
markers to allow individualization of multimodality treatment could be very
helpful. We aimed to examine the association of survivin protein expression,
an inhibitor of apoptosis, with histopathologic response to neoadjuvant che-
motherapy and prognosis in patients with gastric cancer.
PATIENTS AND METHODS: Forty patients (30 men, 10 women; median
age 54.1 years) with gastric cancer (cT2-4, Nx, M0) received neoadjuvant
chemotherapy (PLF-protocol: cisplatin, leucovorin, 5-FU; 2 cycles over 6
weeks). Afterwards, 38 patients underwent total gastrectomy, while 2 patients
received definitive chemotherapy because of tumor progression. Histomor-
phologic regression was defined as major response when resected specimens
contained less than 10% vital tumor cells. Intratumoral survivin expression
was determined by immunohistochemistry in pretherapeutic biopsies and
posttherapeutic resection specimens and correlated with clinicopathologic
parameters.
RESULTS: The pre- and posttherapeutic intratumoral survivin protein
expression was not associated with the histomorphologic regression. In addi-
tion, posttherapeutic survivin expression did not have any prognostic
impact. However, a significant association was detected between pretherapeu-
tic survivin levels and prognosis: patients with a higher survivin protein
expression showed a significant survival benefit compared with patients hav-
ing low intratumoral protein levels (5-year survival rate: 50% vs. 21%;
p = 0.038). In multivariate analysis pretherapeutic survivin expression was
characterized as an independent prognostic marker, besides pN-status and
histopathologic regression (p = 0.008).
CONCLUSION: The pretherapeutic survivin protein expression seems to be
an independent prognostic marker in the multimodality treatment of locally
advanced gastric cancer. If intratumoral survivin levels can be used as a surro-
gate marker in the neoadjuvant therapy of gastric cancer, has to be validated
in prospective trials.


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COMBINED SCIENCE POSTERS

Combined Science
  M2091 The Effect of Major Abdominal Procedure Type on
        the Incidence and Economic Burden of Deep Vein
        Thrombosis or Pulmonary Embolism
Debraj Mukherjee*2,1, Susan L. Gearhart1, Anne O. Lidor1, David C. Chang1,2
1Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD; 2Department
of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD
BACKGROUND: Deep vein thrombosis/pulmonary embolus (DVT/PE) is a
significant cause of morbidity for surgical patients. The comparative risk
across major abdominal procedures is unknown.
METHODS: Retrospective analysis of a representative 20% sample of data from
37 states (Nationwide Inpatient Sample) over 5 years (2001–2005). Eight surger-
ies were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrec-
tomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age <18,
patients with multiple major surgeries, or non-elective surgery were excluded.
Primary outcome was occurrence of DVT/PE per AHRQ Patient Safety Indicator
methodology. Independent variables included age, gender, race, Charlson
Comorbidity Index, hospital teaching status, and calendar year.




                                                                                       POSTER ABSTRACTS
                                                                                           MONDAY




RESULTS: 244,387 patients were identified, with 2286 DVT/PE (0.94%) (DVT
0.63%, PE 0.39%). Overall death rate was 1.42%, and death rate among DVT/
PE was 8.86%. The unadjusted rate (0.35%) and adjusted risk for DVT/PE were
lowest among bariatric patients. On multivariate analysis, the highest risk for
DVT/PE, relative to bariatric surgery, was esophagectomy (odds ratio 4.45,
95% CI 2.80–7.07), (Figure) and is associated with $118,407 excess charges in
those patients. The odds ratio of in-hospital mortality for DVT/PE was 4.84
(95% CI 3.98–5.89), and is associated with excess LOS of 9.86 days. This trans-
lates into approximately $145 million per year in the US.

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CONCLUSION: The highest risk for DVT/PE following major abdominal sur-
gery was seen in esophagectomy patients while the lowest risk was seen in
bariatric patients. Since bariatric patients are known to have greater risk for
this complication, these findings may be the result of better awareness and
prophyalaxis in this population. Further studies are necessary to quantify the
effect of best-practice guidelines, such as in bariatric surgery, on prevention of
this costly complication.




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  M2092 Removal of Visceral Fat Improves Metabolic Syndrome
        and Hepatic Steatosis in Diet-Induced Obese Mice
Xavier Dray*1, Zhiping Li1, Jing Hua1, Samuel A. Giday1, Susan K. Redding2,
Eun Ji Shin1, Ron J. Wroblewski1, Jonathan M. Buscaglia1, Priscilla Magno1,
Dawn Ruben2, Michael A. Schweitzer4, Jeanne Clark3, Anthony N. Kalloo1
1Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine,
Baltimore, MD; 2Radiology Research Service Centre, Johns Hopkins School of Medicine,
Baltimore, MD; 3Department of Medicine, Johns Hopkins School of Medicine, Baltimore,
MD; 4Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD
BACKGROUND: Increased visceral adiposity is a common feature of obesity
and metabolic syndrome. The amount of visceral fat (VF) correlates with the
insulin sensitivity, the key component of metabolic syndrome. We evaluated
the effect of VF removal by laparotomy in a mouse model of diet-induced
obesity and metabolic syndrome.
METHODS: Wild type C57BL6 male mice were fed either a high fat diet
(HFD, n = 14) or a normal diet (ND, n = 6) for 8 weeks. HFD mice were
assigned to surgical removal of VF (HFD+VF–) or to sham surgery (HFD+VF+).
The mice were fed additional 4 weeks on the same diet. Body weight, glucose
tolerance,serum adipokines (ELISA), hepatic cytokine expressions (quantita-
tive PCR) and liver histology were evaluated at the end of the 12 week study
period.
RESULTS: HFD induced obesity, insulin resistance and hepatic steatosis. A
mean of 2.1 ± 0.4 g (4.9 ± 0.5% of body weight) VF was removed in HFD+VF–
mice. Both HFD+VF– and HFD+VF+ mice recovered equally well from surgery
and consumed similar amount of diet post operation. However, HFD+VF–
mice lost more weight and had significant improvement in insulin sensitivity
and hepatic steatosis. HFD+VF– mice also had significant lower serum leptin
level, but a similar adiponectin level compared to controls, and had lower
expression of hepatic TNFα.

                                                                                       POSTER ABSTRACTS
                                                                                           MONDAY




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CONCLUSION: Surgical VF removal improves insulin resistance and hepatic
steatosis in mice with diet-induced metabolic syndrome and improves adi-
pokine and cytokine profiles. VF removal may be a useful tool to treat meta-
bolic syndrome in obesity.

            Week 12                           ND              HFD+VF+        HFD+VF–
           Weight (g)                     24.0 ± 1.8         47.6 ± 0.1*   37.0 ± 3.8**
         Steatosis grade                   0.0 ± 0.0         2.8 ± 0.4 *    0.3 ± 0.5**
         Leptin (ng/mL)                    8.3 ± 4.5         56.3 ± 2.5*    40.5 ± 6.1*
          TNF/GAPDH                       0.2 ± 0.1           2.2 ± 0.8     1.1 ± 0.4**
*p < 0.05 compared to ND; **p < 0.05 compared to HFD




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  M2093 Novel Therapeutic Targets in Esophageal Cancer:
        Impact of Coexpression of Receptor-Tyrosine-Kinases
        (RTK) and Chemokine Receptor CXCR4
Ines Gockel*1, Carl C. Schimanski2, Daniel Drescher1, Kirsten Frerichs1,
Markus Moehler2, Stefan Biesterfeld3, Peter R. Galle2, Theodor Junginger1
1Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz,
Germany; 2First Medical Clinic, Johannes Gutenberg-University, Mainz, Germany;
3Institute of Pathology, Johannes Gutenberg-University, Mainz, Germany

BACKGROUND: Despite curative surgery, prognosis of esophageal cancer is
still poor. The aim of our study was to define the (co-) expression pattern of
target receptor-tyrosine-kinases (RTK) and to evaluate the role of chemokine
receptor CXCR4 in esophageal adenocarcinoma and squamous cell cancer.
METHODS: The (co-) expression pattern of VEGFR1-3, PDGFR alpha/beta
and EGFR1 was analyzed by RT-PCR in 50 human esophageal cancers (35 ade-
nocarcinomas and 15 squamous cell cancers). In addition, IHC staining was
applied for confirmation of expression and analysis of RTK localisation. In
102 consecutive patients undergoing esophageal resection for cancer, the
LSAB+ system was used to detect the protein CXCR4. Tumor samples were
classified into two groups based on the homogeneous staining intensity
(weak and strong CXCR4 expression).
RESULTS: Adenocarcinoma samples revealed a VEGFR1 (97%), VEGFR2
(94%), VEGFR3 (77%), PDGFR alpha (91%), PDGFR beta (86%) and EGFR1
(97%) expression at different intensities. 94% of esophageal adenocarcinomas
expressed at least four out of six RTKs. Similarly, squamous cell cancers
revealed a VEGFR1 (100%), VEGFR2 (100%), VEGFR3 (53%), PDGFR alpha
(100%), PDGFR beta (87%) and EGFR1 (100%) expression at different intensi-
ties. All esophageal squamous cell carcinomas expressed at least four out of
six RTKs. With regard to CXCR4 expression, in adenocarcinoma, a rate of
89.1% was detected with a weak intensity in 71.7% compared to strong stain-
ing in 29.3%. The overall expression rate for CXCR4 in esophageal squamous
cell carcinoma was 94.1%, subdivided into 54.9% with weak and 45.1% with
strong staining.
CONCLUSION: Our results reveal a high rate of receptor-tyrosine-kinases
(co-) expression and expression of chemokine receptor CXCR4 in esophageal
adenocarcinoma and squamous cell cancer and might therefore encourage an
                                                                                      POSTER ABSTRACTS




application of multiple-target RTK-inhibitors as well as of CXCR4-antagonists
within a multimodal concept as a promising novel approach for innovative
                                                                                          MONDAY




treatment strategies.




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Tuesday, May 20, 2008
12:00 PM – 2:00 PM         SSAT POSTER SESSION                    SAILS PAVILION
            Authors available at their posters to answer questions 12:00 PM –
            2:00 PM; posters on display 8:00 AM – 5:00 PM. In addition,
            Posters of Distinction ( ) will be available for further viewing in
            Room 25ABC on Wednesday, May 21, 2008.

CLINICAL SCIENCE POSTERS

Clinical: Biliary
  T1695 Comparison Hilar Bile Duct Cancer with Intrahepatic
        Cholangiocarcinoma Involving the Hepatic Hilus
Tsuyoshi Sano*1,2, Kazuaki Shimada2, Minoru Esaki2, Yoshihiro Sakamoto2,
Tomoo Kosuge2, Yasuhiro Shimizu1, Yuji Nimura1
1gastroenterological surgery, Aichi Cancer Center Hospital, Nagoya, Japan;
2Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital,
Tokyo, Japan
BACKGROUND: Clinically hepatobiliary resection is indicated for both hilar
bile duct cancer (BDC) and intrahepatic cholangiocarcinoma involving the
hepatic hilus (CCC). The aim of this study was to compare the long-term out-
come of BDC and CCC.
METHODS: Between 1990 and 2004, we surgically treated 158 consecutive
patients with perihilar cholangiocarcinoma. The clinicopathological data on
all of the patients were analyzed retrospectively.
RESULTS: The overall 3-year survival rate, 5-year survival rate, and median
survival time for BDC patients were 48.4%, 38.4%, and 33.7 months, respec-
tively, and 35.8%, 24.5%, and 22.7 months, respectively, in CCC patients (p =
0.033). Significant differences were noted between stages I and II (p = 0.002),
stages I and III (p = 0.045), and stages I and IV (p < 0.001) in BDC patients.
Significant differences were also noted between stages I and IV (p = 0.004),
stages II and IV (p = 0.011), and stages III and IV (p = 0.029) in CCC
patients.According to subgroup analyses, there were no significant differences
in pathological grading (p = 0.193 in wel, pap, p = 0.193 in others), lymph
node status (p = 0.222 in patients with negative lymph node, p = 0.315 in
those with positive), resected portal vein invasion (p = 0.513 in negative, p =
0.062 in positive invasion). There was a significant difference according to
the resectional status in pathology, longer survival was achieved in BDC not
R0 (p = 0.131) but R1, 2 resection (p = 0.014). Also, there was significant dif-
ference according to T-factor, longer survival was achieved in BDC with not
T1, 2 (p = 0.915) but T3 and 4 tumor (p < 0.001).On multivariate analysis,
three independent factors were related to longer survival in BDC patients:

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achieved in curative resection with cancer free margin (R0) (p = 0.024), well
differentiated or papillary adenocarcinoma (p = 0.011), and absence of lymph
node metastasis (p < 0.001). Five factors were related to longer survival in
CCC patients: absence of intrahepatic daughter nodules (p < 0.001), CEA
level ≤ 2.9 ng/mL (p = 0.005), no red blood cell transfusion requirement (p =
0.016), and absence or slight degree of lymphatic system invasion (p < 0.001),
and negative margin of the proximal bile duct (p = 0.003).
CONCLUSIONS: BDC and CCC appear to have different prognosis after
hepatobiliary resection. Therefore, differentiating between these two catego-
ries must impact on predicting postoperative survival in patients with peri-
hilar cholangiocarcinoma.




                                                                                 POSTER ABSTRACTS
                                                                                     TUESDAY




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  T1696 Progress in Laparoscopic Surgery for Adult
        Choledochal Cysts-Kyushu University Experience
Hiroki Toma*, Shuji Shimizu, Shunichi Takahata, Masafumi Nakamura, Eishi Nagai,
Koji Yamaguchi, Masao Tanaka
Kyushu University, Fukuoka City, Japan
AIM: Congenital choledochal cysts are considered an indication of surgery
for recurrent cholangitis and/or pancreatitis and the potential development
of bile duct cancer. Since our first report in the world of a successful adult case
in 1996, we have accumulated clinical experience with a total of 20 patients
with laparoscopic surgery for choledochal cysts. We attempted to elucidate
our clinical outcomes of the procedure.
METHODS: Surgical parameters including operation time, blood loss, com-
plications, postoperative hospital stay, rate of open conversion were com-
pared between the former period (group A: 1996 to 2000) and the latter
period (group B: 2001 to 2007).
RESULTS: Of 20 patients (6 men, 14 women, average age 33 years), 10 cases
were allocated to group A and B, respectively. There was a statistically signifi-
cant decrease in operation time (587 vs 464 min, p = 0.049) from group A to
group B. Blood loss (485 vs 241 ml, p = 0.133) and postoperative hospital stay
(48 vs 14 days, p = 0.053) tended to decrease, but the difference was not sig-
nificant. The procedure was converted to open in 3 patients in group A (40%)
and 1 patient in group B (10%) due to severe adhesion, bleeding, anatomical
disorientation and pancreatic duct injury. The major postoperative complica-
tions occurred in 2 patients in group A (1 bile leakage and 1 pancreatic duct
injury) and in 2 patients in group B (1 postoperative bleeding and 1 postoper-
ative pancreatic fistula). There was no mortality in this study.
CONCLUSIONS: Laparoscopic surgery for choledochal cysts still remains a
challenge mainly due to technical difficulties, but we have shown promising
results in this study. Both advances in surgical devices and our learning curve
will contribute to future progress in this minimally invasive procedure.




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  T1697 Outcomes of Endoscopic and Surgical Management of
        Sphincter of Oddi Dyskinesia in Patients Not
        Responding to Cholecystectomy for Chronic
        Acalculous Cholecystitis
James O. Johnson*, Kirpal Singh, Maurice E. Arregui
St Vincent Hosp & Hlth Care Ctr, Indianapolis, IN
OBJECTIVE: Sphincter of Oddi dyskinesia (SOD) remains a challenge todiag-
nose and treat with patients having variable results. Manometry is the gold
standard for this diagnosis. The treatment is controversial, but centers on
endoscopic retrograde cholangio-pancreatography with sphincterotomy
(ERCP/ES). Transduodenal sphincteroplasty (TS) and pancreaticoduodenec-
tomy are also utilized. We present our experience with longitudinal follow-up
of a group of patients with mainly Type III SOD who did not resolve follow-
ing cholecystectomy for chronic acalculous cholecystitis (CAC).
METHODS: Patient charts, including manometry reading, operative reports
and imaging were retrospectively reviewed.
RESULTS: 69 patients, predominately female (89%),with a mean age of 52.3
that who did not respond to cholecystectomy were diagnosed with SOD
using sphincter of Oddi manometry and clinical criteria. 63 of these patients
had manometry studies that were available for interpretation. Normal
manometry was found in 23 patients and of those 12 (52%) were improved
after ERCP/ES. Abnormal manometry was found in 39 patients and of these
25 (64%) had a significant improvement with ERCP/ES alone. 52 (75%)
patients had ERCP/ES as their only intervention with 40 (77%) of them hav-
ing a significant improvement in symptoms and 11 (21%) with complete res-
olution of symptoms. 12 (23%) patients had initial success with a relapse or
no success with ERCP/ES. 43 (83%) of these patients required 3 or fewer inter-
ventions. 13 (18%) of the initial patient population required TS. This was
done after either initial or long term failure of ERCP/ES. Improvement of
symptoms was seen in 10 (77%) patients and resolution in 1. Four (5%) of the
initial cohort, that failed both ERCP/ES and TS, underwent pancreati-
coduodenectomy. One of these patients had improvement in symptoms.
Mean follow-up for this cohort was 21.9 months. Range of follow-up was 1 to
137 months.
CONCLUSION: Overall, the patients in this study did well. ERCP/ES and TS
                                                                                 POSTER ABSTRACTS




did decrease or eliminate symptoms in over 73% of patients. Early, aggressive
intervention with ERCP/ES and if this fails, then TS may provide more relief
                                                                                     TUESDAY




to patients with Type III SOD after cholecystectomy for CAC.




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  T1698 The Significance of CD44 Expression in Ampullary
        Cancer
Hui-Ping Hsu*1, Kai-Hsi Hsu2, Yan-Shen Shan1, Pin-Wen Lin1
1National Cheng Kung Univ Hosp, Tainan, Taiwan; 2Department of Surgery, Tainan
Municipal Hospital, Tainan, Taiwan
PURPOSE: CD44 is a transmembrane protein involving cell proliferation,
cell differentiation, cell migration, cell-cell adhesion or cell-matrix interac-
tion. Cleavage of extracellular domain is prominent in human tumors and
CD44 standard (CD44st) is the conservative portion. In present study, we
evaluated the expression of CD44st in ampullary cancer in order to identify
the potential predictor.
MATERIAL AND METHODS: The paraffin blocks of ampullary neoplasms
surgically resected specimens from patients at National Cheng Kung Univer-
sity Hospital between March 1989 and June 2007 was collected. The collected
specimens included dysplasia, adenoma, early or advanced adenocarcinoma.
Immunohistochemistry (IHC) staining was performed over deparaffinized
sections with using anti-human CD44st monoclonal antibody. The expres-
sion of CD44st was defined as loss, low or high.
RESULTS: Total 81 patients (41 female and 40 male) were enrolled with aver-
age age 63 years, ranged from 32 to 90 years. IHC staining revealed mem-
brane-type staining of CD44st in normal pancreatic duct, but not in normal
duodenum. In ampullary neoplasms, diffuse dense membraneous positivity
for CD44st was noted in 40 patients (49%), week staining in 24 patients
(30%) and complete loss of CD44st in 17 patients (21%). The grading of
CD44st staining was not related with age, sex, preoperative tumor markers,
tumor size or lymph node involvement. But trends of CD44st loss were
detected in tumors with pancreatic invasion or advanced TNM stage. The 5-
year disease-specific survival rate was lower in patients with low or negative
CD44st expression than those with dense CD44st expression. But in patients
without pancreatic invasion, the expression of CD44st represented poor long-
term survival, opposite to those with pancreatic invasion.
CONCLUSION: CD44st expression in patients of early ampullary cancer is a
poor predictor, but not in advanced cancer. Dual role of CD44 in ampullary
cancer and other malignancies represent the complexities of adhesion mole-
cules in carcinogenesis.




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  T1699 Asymptomatic Cholelithiasis Occurrence in Patients of
        Kidney Transplantation List
André T. De Brito1, André M. Siqueira1, Luiz S. Azevedo2, José Eduardo M. Cunha1,
José Jukemura*1
1Gastroenterology, Faculdade de Medicina da Universidade de São Paulo, São Paulo,
Brazil; 2Urology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
INTRODUCTION: There is no agreement in literature about the most cor-
rect treatment for patients with asymptomatic gallstones in kidney transplan-
tation list. Some authors suggested routine screening to gallstones for
patients who are awaiting a kidney graft and cholecystectomy is indicated to
all the candidates with cholelithiasis. Meanwhile, the occurrence of asymp-
tomatic cholelithiasis in the Brazilian kidney transplantation population is
not well known.
OBJECTIVE: This study aims to determine asymptomatic cholelithiasis
occurrence in patients who are in the kidney transplantation list of the Hos-
pital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.
METHODS: We evaluated the 342 patients who were in kidney transplanta-
tion list of Hospital das Clínicas de São Paulo in the moment of the study.
The candidates to a transplant were screened to gallstones and asked about
previous cholecystectomy and symptoms related to cholelithiasis. All patients
were submitted to total abdomen ultrasound. Data about symptoms, sex, age,
body mass index, number of pregnancies, previous digestive system surgeries,
hepatic diseases, hemodialysis time and laboratory exams were collected.
RESULTS: The occurrence of biliary disease was 11.9% (41/342), which of
these 29 (8.4%) patients had cholelithiasis and 12 (3.5%) had been cholecys-
tectomized before being included in transplant list. All cholecystectomized
patients were symptomatic (biliar colic pain, acute cholecystitis, jaundice or
pancreatitis) at the time of the surgery. Among the evaluated, 41.5% (17/41)
were or remained symptomatic.
CONCLUSION: The occurrence of cholelithiasis in kidney transplantation
list patients is similar to the general population, however an important part is
symptomatic.
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   T1700 Significance of Tissue Expression of MUC5AC in Hilar
         and Intrahepatic Cholangiocarcinoma
Andrea Ruzzenente*1, Calogero Iacono1, Tommaso Campagnaro1, Paola Capelli2,
Sara Mazzoldi1, Alessandro Valdegamberi1, Paola Nicoli1, Alfredo Guglielmi1
1Department of Surgery and Gastroenetrology, University of Verona Medical School, Verona,
Italy; 2Department of Pathology, University of Verona Medical School, Verona, Italy
BACKGROUND AND AIMS: Cholangiocarcinoma is a rare tumor with an
increasing incidence wordwide. The surgical resection with curative intent is
the only treatment for long term survival. Different prognostic factors have
been identified in surgical series but the biological behaviour of this disease
has not been clarified yet. The aim of this study is to evaluate the significance
of tissue expression of mucins (MUC1, MUC2, MUC5AC, MUC6) in a group
of patients with hilar and intrahepatic cholangiocacinoma (ICC) submitted
to surgical resection with curative intent.
PATIENTS AND METHODS: Between 1990 and 2007 224 patients with
cholangiocarcinoma was evaluated at a single division of surgery of the
Department of Surgery and Gastroenterology of University of Verona. 120
patients underwent surgical treatment. In the 38 consecutive recently
observed patients (13 with hilar cholangiocarcinoma and 25 with ICC) tissue
mucin expression was evaluated in surgical specimens. All the patients with
ICC were classified according to Liver Cancer Study Group of Japan macro-
scopic criteria (2003): Mass Forming type (MF), periductal infiltrating type
(PI) and intraductal grow type (IG).
RESULTS: Macroscopic analysis showed MF type in 11 patients (44%), PI
type in 12 (48%) and mixed MF + PI in 2 cases (8%). Pathology showed
lymph-nodes involvement in 11 patients (29%), perineural invasion in 24
(63%), microscopic vascular invasion in 25 (65%) and macroscopic vascular
invasion in 14 (37%). Tumors were well differentiated in 4 cases, moderate in
14 and poor in 8 cases. Mucin analysis showed that MUC2 and MUC6 were
not present in all specimens. MUC1 was present in 38.5% of hilar tumors, in
41.7% of MF ICC, in 100% of PI ICC and in 45.5% of MF+PI ICC. MUC5AC
was present in 84.6% of hilar cholangiocarcinoma, in 0% of MF ICC, in 100%
of PI ICC anf in 63.6% of MF+PI type (p = 0.001). Further analyses in patients
with hilar cholangiocarcinoma did not showed relationship between mucins
expression and the following pathology findings: tumor diameter, lymph
nodes involvement, vascular invasion and perineural invasion. Also in ICC
MUC1, MUC2 and MUC6 were not related with pathology findings. Whereas
expression of MUC5AC was significantly related with tumor diameter inferior
to 3 cm (P = 0.01); poor differentiation degree (p = 0.05) and perineural inva-
sion (p = 0.05).
CONCLUSIONS: This study identify a significant relationship between
MUC5AC expression and gross type of ICC (all the MF type tumors were neg-
ative) and with pathology findings related to aggressive biological tumor
behavour. Further studies are necessary to clarify the prognostic significance
of MUC5AC.




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  T1701 Preoperative Assessment of Intrahepatic
        Cholangiocarcinoma: CT Features with
        Pathological Correlation
Riccardo Manfredi*2, Sara Mehrabi2, Marco Motton2, Roberto Pozzi Mucelli2,
Andrea Ruzzenente1, Paola Capelli3, Calogero Iacono1, Alfredo Guglielmi1
1Department   of Surgery and Gastroenetrology, University of Verona Medical School,
Verona, Italy; 2Department of Radiology, University of Verona Medical School, Verona,
Italy; 3Department of Pathology, University of Verona Medical School, Verona, Italy
AIM: The aim of this study is to determine the accuracy of computed tomog-
raphy (CT) in assessing local spread of Intrahepatic Cholangiocarcinoma
(ICC), and to compare radiological and pathological findings after surgical
resection with curative intent.
MATERIAL AND METHODS: A retrospective study over a period of 36
months was performed involving 28 patients (pts) with diagnosis of
ICC.Inclusion criteria: Pts with CT exam before surgery; Pts with radiological
diagnosis of ICC that underwent surgical resection with pathological confir-
mation of malignancy.
EXCLUSION CRITERIA: Pts without CT exam before surgery (4 pts); surgi-
cal exploration with evidence of peritoneal metastases (5 pts). A final group of
19 pts was included in this Institutional Review Board (IRB) approved retro-
spective study. Two independent radiologists retrospectively reviewed CT
imaging features with final consensus; imaging analysis included evaluation
of: localization; size; presence of satellites nodules; macroscopic type accord-
ing to Liver Cancer Study Group of Japan criteria (mass-forming (MF) type,
periductal infiltrating type (PI), intraductal growth type (IG); hepatic atrophy;
vascular invasion (arterial, portal vein or hepatic veins); bile ducts dilatation
and infiltration; lymph-nodes involvement.
RESULTS: Localization of ICC was correctly detected in 19/19 (100%) pts.
Size of the tumor was correctly defined in 18/19 (95%) pts. Satellites nodules
were correctly detected at CT exam in 6/8 (75%) pts and 2 pts with nodules
smaller than 2 mm weren’t detected. CT showed 14/19 (73%) MF type and 4/
19 (21%) PI type and 1/19 (5%) IG type. Whereas at pathological examina-
tion of the specimen tunors were classified as MF type in 11/19 (57%), as PI
type in 5/19 (26%) and as IG type in 2/19 (10%). Presence or absence of atro-
phy of hepatic lobe of ICC was correctly detected in 19/19 (100%) Pts. Arte-
                                                                                        POSTER ABSTRACTS




rial infiltration was correctly detected by CT in 6/7 (85%) pts, in 1/7 (15%) pts
CT didn’t detect the infiltration. Portal vein invasion was correctly detected
                                                                                            TUESDAY




at TC in 4/4 (100%) pts. Hepatic veins invasion was correctly detected at TC
in 7/7 (100%). Presence or absence of intra-hepatic bile ducts dilation was
correctly detected in 19/19 (100%) At pathology bile duct infiltration was
present in 9/19 (47%) pts, CT correctly detected this features in 8/9 (88%). CT
detected lymph-nodes suspect for metastases (size > 10 mm) in 15/19 (79%),
whereas pathological examination confirmed positive lymph-node metastases
only in 11/19 (58%).
CONCLUSIONS: CT is a good technique for evaluation of ICC and preopera-
tive fidings are well correlated with surgical and pathological patterns.


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Clinical: Colon-Rectal
   T1702 Anastomotic Leaks After Bowel Resection: What Do
         We Learn from Peer Review?
Neil H. Hyman*, Turner Osler, Peter Cataldo, Betsy Burns, Steven R. Shackford
Surgery, University of Vermont College of Medicine, Burlington, VT
PURPOSE: Anastomotic leaks are a dreaded complication of intestinal resec-
tion and have been associated with a high mortality rate. However, it is
uncertain whether the leaks are typically the actual cause of death. We sought
to assess the impact of surgeon on leak rates and determine the relationship
of a leak to postoperative mortality.
METHODS: All adult pts having a small or large bowel resection with anasto-
mosis at a university hospital from 7/03–6/06 were entered into a prospec-
tively maintained quality database; data was entered by a specially trained
nurse practitioner who rounded daily with housestaff. Pts with a postop leak
based on standardized criteria were identified. Pt characteristics, surgical pro-
cedure and operating surgeon were noted. Overall complication and leak rate
by surgeon were compared using Fisher’s exact test. Individual case review by
a group of peers was performed for all pts with a leak who died to determine
the relationship to mortality.




RESULTS: 556 pts underwent resection with anastomosis during the study
period. There were 27 leaks (4.9%), 6 of whom died. Leak rate for the highest
volume surgeons ranged from 2.1 to 9.9% (p < .01; Figure 1) and overall com-
plication rate varied from 30.5 to 44% (p = .04). In 4/6 deaths, leaks occurred
in very ill pts undergoing emergency procedures and appeared to be premor-
bid events. In only one case did the leak appear to be the primary cause of
death.
CONCLUSIONS: The variability in leak rate by surgeons doing similar cases
suggests that many may be preventable. However, death after a leak is most
often a surrogate for a critically ill patient and infrequently is the actual cause
of death.

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1703 Preoperative Assessment of Nutritional Status in
        the Patients with Ulcerative Colitis: Evaluation of
        Nutritional Markers Which Predict Septic
        Complications
Ken-Ichi Takahashi*1, Tohru Asakura2, Yuji Funayama1, Kouhei Fukushima3,
Chikashi Shibata3, Hitoshi Ogawa3, Hiromi Tokumura4, Iwao Sasaki3
1Department  of Colorectal Surgery, Tohoku Rosai Hospital, Sendai, Japan; 2Division
of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan;
3Department of Surgery, Division of Gastrointestinal and Colorectal Surgery, Tohoku
University Graduate School of Medicine, Sendai, Japan; 4Department of Surgery, Tohoku
Rosai Hospital, Sendai, Japan
BACKGROUND: Patients with refractory ulcerative colitis (UC) need to
undergo total colectomy (TC) and ileal pouch anal anastomosis (IPAA). These
patients are often malnourished prior to surgery, especially the patients with
severe inflammation of entire colon are severely malnourished. And the inci-
dence of early postoperative septic complications such as surgical site infec-
tion (SSI) is relatively high compared to other colorectal diseases. As
malnutrition has been reported to be the risk factor of postoperative compli-
cation in abdominal surgery, the preoperative nutritional status is also
thought to have an influence on these complications after TC for UC. How-
ever, it has not been fully evaluated yet which nutritional markers are useful
in predicting these postoperative septic complications.
METHODS: Forty-four patients with UC who underwent TC in our hospital
from 2003 to 2006 were included in this study. Eleven patients underwent TC
and IPAA with loop ileostomy, three patients underwent TC with permanent
end ileostomy and 30 patients underwent subtotal colectomy with end ileo-
stomy. And nutritional markers such as anthropometry and laboratory data
were compared between the patients with and without postoperative septic
complications retrospectively.
RESULTS: Septic complications occurred in 14 patients. Thirteen patients
were affected by SSI, and one patient was affected by MRSA enteritis. In com-
plication group, serum prealbumin level was significantly lower than in non-
complication group (21.8 vs 28.6 mg/dl, p < 0.05). Retinol binding protein
level was also significantly lower in complication group (2.7 vs 3.7 mg/dl,
p < 0.01). However, there was no significant difference in serum albumin,
                                                                                        POSTER ABSTRACTS




choline esterase, total cholesterol and total lymphocyte count between two
groups. There was also no significant difference in anthropometry such as
                                                                                            TUESDAY




BMI, triceps skin fold thickness and arm muscle circumference. Although the
preoperative daily dosage of prednisolone just before surgery was compared,
no difference was observed between two groups. And no relationship was
observed between the route of preoperative nutritional support (oral intake or
total parenteral nutrition) and septic complications.
CONCLUSIONS: It is suggested that preoperative mesurement of rapid turn-
over protein level such as prealbumin and retinol binding protein is useful in
predicting the risk of postoperative septic complications.



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   T1704 Cytokine Network in Rectal Mucosa in Perianal
         Crohn’s Disease: Relations with Inflammatory
         Parameters and Need for Surgery
Cesare Ruffolo1, Marco Scarpa1, Diego Faggian2, Anna Pozza1, Filippo Navaglia2,
Renata D’Incà4, Pravera Hoxha2, Giovanna Romanato3, Lino Polese1,
Giacomo C. Sturniolo4, Mario Plebani2, Davide F. D’Amico1, Imerio Angriman*1
1Clinica Chirurgica 1°, University of Padova, Padova, Italy; 2Medicina di Laboratorio,
University of Padua, Padua, Italy; 3CNR-Institute of Neurosciences—Aging Section,
Padua, Italy; 4Gastroenterologia, University of Padua, Padua, Italy
BACKGROUND: Nowadays anti-TNF-alpha antibodies are often used for the
therapy of perianal Crohn’s disease. Nevertheless this treatment is effective
only in a part of these patients and recent studies suggested an important role
for other cytokines, such as IL-6, IL-1beta, IL-12 and TGF-beta1 in chronic
bowel inflammation
AIM: The aim of this study was to assess the cytokine profile in the rectal
mucosa of patients affected by perianal Crohn’s diseases and to understand
its relations with the systemic cytokine profile, the systemic inflammatory
parameters and the need for surgery.
PATIENTS AND METHODS: Seventeen patients affected by perianal
Crohn’s disease, 7 affected by Crohn’s disease without perianal involvement
and 17 healthy controls were enrolled in this study and underwent blood
sampling and endoscopy. During endoscopy two rectal mucosal samples were
taken and expression of TNF-alpha, IL-6, IL-1beta, IL-12 e TGF-beta1 was
quantified with ELISA. Local cytokine levels were then compared and corre-
lated to diagnosis, therapy, phenotype (fistulizing and stenosing) and disease
activity parameters.
RESULTS: In the group with perianal Crohn’s disease rectal mucosal IL-
1beta, IL-6 and serum IL-6 and TNF-alpha were higher than in patients with
small bowel Crohn’s disease and healthy controls. IL-12 and TGF-beta1
mucosal levels did not show any differences among the three groups.
Mucosal IL-6 significantly correlated with PDAI and mucosal TNF-alpha and
IL-1beta. Mucosal TNF-alpha and IL-1beta showed a direct correlation with
the histological grade of disease activity.
CONCLUSIONS: The cytokines network analysis in perianal CD shows the
important involvement of IL-1beta, IL-6 and TNF-alpha produced by mac-
rophage and dendritic cells. These results seem to suggest that IL-6 and IL-
1beta might be alternative targets of an immunomodulatory therapy in case
of anti-TNF-alpha failure.




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  T1705 Abdominal Surgery Impact Scale (ASIS) Is Responsive
        in Assessing Outcome Following IPAA
Indraneel Datta*1, Brenda I. O’Connor1, J Charles Victor3, Robin S. Mcleod2,4
1Dr. Zane Cohen Digestive Diseases Clinical Research Center, Toronto, ON, Canada;
2Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada;
3Department of Health Policy, Management and Evaluation, University of Toronto,
Toronto, ON, Canada; 4Departments of Surgery and Health Policy, Management and
Evaluation, University of Toronto, Toronto, AB, Canada
PURPOSE: Various generic and disease specific quality of life instruments are
available to assess outcome following surgery. However, they are not sensitive
to assess outcome in the early postoperative period, which is important when
assessing changes in postoperative care. Thus the aim of this study was to
evaluate the responsiveness of the Abdominal Surgery Impact Scale (ASIS) in
assessing quality of life in a cohort of patients undergoing ileal pouch-anal
anastomosis (IPAA).
METHODS: All patients over the age of 18 undergoing IPAA between March
2005 and October 2007 completed the ASIS on postoperative day 2 or 3 and
at time of discharge. The ASIS consists of 6 domains and 18 items with scores
ranging from 18 to 126. In addition, demographic, clinical and surgical data
was collected including gender, age, steroids, laparoscopic assisted versus con-
ventional surgery, ileostomy diversion, anastomotic leaks and small bowel
obstructions. Length of stay data was also analyzed. Internal reliability of the
ASIS was measured using Cronbach’s alpha coefficients.
RESULTS: 92 patients (36 female, 56 male, mean age = 36.83 ± 10.79) com-
pleted the ASIS at the 2 time intervals (mean 3 days and mean 7 days postop-
eratively). 47 patients had an IPAA performed with an ileostomy; 11 patients
had he IPAA performed laparoscopically. The mean hospital stay was 10.78
days. The overall mean ASIS score significantly increased over time (mean
56.93 ± 18.3 vs. 81.83 ± 17.27, p < 0.001). Patients who had an ileostomy had
a significantly lower mean score at discharge (77.32 vs. 86.82), secondary to
lower scores on the physical limitations, functional impairment and visceral
function domains. Seven patients (7.6%) had ileo-anal anastomotic leaks and
seven patients (7.6%) had small bowel obstructions. Both leaks and bowel
obstructions resulted in increased length of stay. Laparoscopic patients had a
significantly lower length of stay (8.8 days vs. 11.1 days). Cronbach’s alpha
coefficient was 0.94 overall and ranged from 0.69 to 0.91 for subscales indi-
                                                                                    POSTER ABSTRACTS




cating internal reliability.
                                                                                        TUESDAY




CONCLUSIONS: ASIS is a reliable instrument for measure quality of life in
the postoperative period and is responsive to changes over time. Although
quality of life increases postoperatively during hospital stay, at discharge,
patients with IPAA still have decreased quality of life. Patients with ileosto-
mies have further decreased scores.




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   T1706 Morbidity and Mortality Associated with Emergency
         Abdominal Surgery in the Elderly
Jill M. Zalieckas*, Patricia L. Roberts
Lahey Clinic Medical Center, Burlington, MA
BACKGROUND: Over 35 million Americans are at least 65 years old. This
population is projected to double in the coming decades and as a result, the
number of elderly (age ≥70) who present to the hospital requiring emergency
surgery is rising. Emergency surgery is associated with increased morbidity
and mortality, and is further magnified among the elderly. The aim of this
study was to determine the mortality rates of elderly patients who underwent
emergency laparotomy, and to define the variables associated with increased
risk of morbidity and mortality, which can be used for quality improvement
and informed surgical decision making in the preoperative setting.
METHODS: A retrospective cohort study of patients age ≥70 that required
emergency abdominal surgery by the Colorectal Surgery Department at a ter-
tiary care center from 1994 to 2004 was conducted. Outcome variables
included age, ASA classification, albumin level, diagnosis, co-morbid condi-
tions and APACHE II score. The endpoints of in hospital mortality, length of
hospitalization and one-year mortality were examined.
RESULTS: Eighty-eight patients met inclusion criteria for analysis (55 F,
33 M). The average patient age was 79 years. Initial diagnoses included bowel
obstruction, perforated diverticulitis, perforated cancer, ischemic colon and
appendicitis. The primary procedures performed included resection with pri-
mary anastomosis, Hartman resection, diverting colostomy/ileostomy,
appendectomy or lysis of adhesions. There was a 20% in hospital mortality.
The 1-year mortality rate was 38%. Univariate analyses were performed on
outcome variables. Increased ASA class (p < 0.001), length of stay in the SICU
(p < 0.001), advanced age (p < 0.011) and decreased albumin level (p < 0.007)
were associated with statistically significant increased mortality. There was no
statistical difference in mortality based on etiology of abdominal emergency,
APACHE II score or co-morbid conditions. However, patients presenting with
perforated diverticulitis had an increased hospitalization compared with all
other patients (21 vs. 14 days, p < 0.03).
CONCLUSIONS: Emergency abdominal surgery in the elderly is associated
with high 30-day morbidity and mortality. This cohort found an appreciable
1-year mortality (38%). Additionally, this study demonstrated that increased
mortality was associated with increased ASA class, advanced age and
decreased albumin level. The results of this study illustrate the factors which
can augment the preoperative evaluation of elderly patients who present with
abdominal emergencies, as well as provide data which can be used to
enhance informed decision making between the surgeon and patient.




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   T1707 Is There a Critical Number of Recovered Nodes in
         ypT3-4 Rectal Cancer After Neoadjuvant CRT in
         Order to Provide Proper Final Disease Staging?
Igor Proscurshim*1, Rodrigo O. Perez1, Angelita Habr-Gama3,
Guilherme São Julião1, Joaquim Gama-Rodrigues3, Fabio Campos1,
Viviane Rawet2, Desiderio Kiss1, Ivan Cecconello1
1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo,
Brazil; 2Pathology, University of São Paulo School of Medicine, São Paulo, Brazil;
3Habr-Gama Research Institute, São Paulo, Brazil

BACKGROUND: Decreased number of recovered nodes is a poor prognostic
factor in rectal cancer and may reflect quality of surgery and inadequate sam-
pling of nodes leading to significant understaging of patients. Neoadjuvant
CRT seems to contribute to a decrease in the number of recovered nodes after
radical surgery and therefore, the least number of nodes required to minimize
underestimation of disease staging is undetermined. The purpose of this
study was to determine the influence of the total number of nodes recovered
on the risk of finding node metastases for advanced rectal cancer following
neoadjuvant CRT.
METHODS: Patients with non-metastatic distal rectal cancer who underwent
neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery
(TME) were eligible for the study. All patients with ypT3-4 rectal cancer man-
aged by neoadjuvant CRT and radical surgery were retrospectively reviewed
in order to determine a correlation between the number of recovered nodes
and the risk of lymph node metastases and the critical number nodes associ-
ated with significant underestimation of nodal spread and disease staging.
RESULTS: 435 patients with distal rectal cancer managed by neoadjuvant
CRT were included in the study. Overall, 165 patients had ypT3-4 rectal can-
cer after radical surgery and TME. The median number of recovered nodes
was 9 nodes/patient. Patients with >9 nodes/specimen were at increased risk
for N+ disease (47% vs 27%; p = 0.01). Less than 6 nodes/specimen was asso-
ciated with significant decreased risk of finding node metastases (p = 0.006:
Sensitivity 82% and Specificity 39%).
CONCLUSIONS: A minimum of 6 nodes/specimen is required to provide
proper nodal staging in ypT3-4 rectal cancer after neoadjuvant CRT and radi-
cal surgery. Less than 6 lymph nodes/specimen in patients with ypT3-4 rectal
                                                                                          POSTER ABSTRACTS




cancer managed by neoadjuvant CRT and TME should be considered at
                                                                                              TUESDAY




increased risk for disease stage underestimation.




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   T1708 Is Initial Pre-Treatment Staging for Distal Rectal
         Cancer Undergoing Neoadjuvant CRT Useful?
Angelita Habr-Gama2, Rodrigo O. Perez*1, Igor Proscurshim1,
Joaquim Gama-Rodrigues2, Guilherme São Julião1, Antonio R. Imperiale1,
Desiderio Kiss1, Ivan Cecconello1
1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo,
Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil
BACKGROUND: One of the benefits from neoadjuvant CRT for distal rectal
cancer is tumor downstaging determined by radiation necrosis. It is still con-
troversial if final disease stage, recurrence or survival is dependent on initial
(radiological) staging.
METHODS: Patients with non-metastatic distal rectal cancer who underwent
neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery
(TME) and available initial disease staging were eligible for the study. all
patients with distal rectal cancer managed by neoadjuvant CRT were staged
according to estimation of TNM parameters based on spiral CT scans or
endorectal ultrasound.
RESULTS: Overall, 331 patients had available information on initial radio-
logical staging and were included in the study. There were 39 patients with
stage I (12%), 198 with stage II (60%) and 94 patients with stage III disease
(28%). There was no correlation between initial disease stage and final patho-
logical ypT status (p = 0.5), final tumor size (p = 0.06), ypN status (p = 0.7),
overall recurrences (p = 0.8) or final disease stage (p = 0.2). 5-year overall and
disease-free survival were similar for radiological stage I, stage II, and stage III
disease (p = 0.4 and p = 0.9 respectively). Post-CRT staging was significantly
associated with development of recurrent disease (p < 0.001) and with overall
and disease-free survival (p < 0.001).
CONCLUSIONS: Even though Initial radiological staging is crucial for
patient selection there is no influence in final disease staging, recurrence or
survival.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1709 Are There Any “High Risk” Features in Stage II Rectal
         Cancer After Neoadjuvant CRT and Radical Surgery?
Rodrigo O. Perez*1, Igor Proscurshim1, Guilherme São Julião1,
Angelita Habr-Gama2, Joaquim Gama-Rodrigues2, Antonio R. Imperiale1,
Fabio Campos1, Desiderio Kiss1, Ivan Cecconello1
1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo,
Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil
BACKGROUND: Stage II rectal cancer (pT3-4N0) comprises a considerably
heterogenous group of patients in terms of disease recurrence and long-term
survival. Therefore, several pathological and molecular features have been
associated with poor prognosis among these patients and may ultimately be
used for adjuvant therapy recommendations. However, neoadjuvant CRT has
been considered the preferred initial treatment strategy for distal rectal. This
neoadjuvant approach leads to significant tumor downstaging and may ulti-
mately influence pathological features in this subgroup of patients and diffi-
cult identification of “high risk” patients. The purpose of this study was to
determine clinico-patholgical features associated with increased risk of recur-
rence development in stage rectal cancer after neoadjuvant CRT and radical
surgery.
METHODS: Patients with non-metastatic distal rectal cancer who underwent
neoadjuvant CRT (50.4Gy and 5FU/Leucovorin) followed by radical surgery
(TME) were eligible for the study. All patients with ypT3-4N0 rectal cancer
managed by neoadjuvant CRT and radical surgery were retrospectively
reviewed in order to determine risk factors for recurrent disease by univariate
and multivariate analysis.
RESULTS: 435 patients with distal rectal cancer managed by neoadjuvant
CRT were included in the study. Overall, 108 patients had ypT3-4N0 rectal
cancer after radical surgery and TME. None of the clinical (age, gender, initial
disease staging, distance from anal verge or initial tumor size) or pathological
findings (ypT, tumor grade, final tumor size, mucinous component, number
of recovered nodes, perineural invasion and vascular invasion) were associ-
ated with increased risk for recurrent disease (p > 0.05).
CONCLUSIONS: Current recommended high risk features for stage II rectal
cancer should not be considered in management decision of these patients in
regards to additional therapy after neoadjuvant CRT and radical surgery.
                                                                                          POSTER ABSTRACTS
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   T1710 Does Laparoscopic Approach Affect the Number of
         Lymph Nodes Harvest in Colorectal Cancer?
Galal S. El-Gazzaz*, Geisler P. Daniel, Tracy L. Hull
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: Adequate lymph node (LN) retrieval (>12 LN) is increasingly
being considered a surgical quality indicator for colorectal cancer. The pur-
pose of this study is to assess LN yield after laparoscopic colorectal cancer
resection compared to the open approach and to analyze changes in harvest-
ing over time in our practice.
METHODS: From 1996–2007, 431 colorectal cancer patients underwent cur-
ative laparoscopic resection. During the study periods of 1996–1997,
2002–2003, and 2006–2007, 243 patients undergoing laparoscopic resection
for colorectal cancer were studied. They were matched to 260 control patients
undergoing conventional surgery identified from our cancer database and
matched by age, operation, gender, date of operation and body mass index.
Numbers of examined and involved LNs were compared between the two
techniques according to location of tumor and year of surgery.
RESULTS: A total of 503 patients (303 male) with a mean age of 66.2 ± 12.3
years, and a mean body mass index of 26.7 ± 7.3 kg/m2 underwent colorectal
cancer resection (243 laparoscopically, 260 open resection) during the study
period. The overall average number of LNs retrieved per case was 23.9 ± 18.3.
There was no statistically significant difference in number of LNs retrieved by
laparoscopic versus conventional open surgery (24.1 ± 19.3 laparoscopic vs
23.79 ± 17.50 for open p = 0.4) There were significant difference between
involved LNs retrieved laparoscopically and by open technique (2.04 ± 3.6 vs
1.88 ± 4.69 P = 0.032). Also, There were significant differences between num-
ber of LNs retrieved from right colon, left colon and rectum (28.03 ± 14.62,
24.48 ± 17.59 and 19.13 ± 15.11) respectively (P < 0.001).The year of surgery
show significant difference in number of involved LNs in laparoscopic cases
only between 1996/1997 and 2006/2007 (P = 0.003).
CONCLUSION: Laparoscopic resection of colorectal cancer can achieve simi-
lar LN retrieval to the open approach. In this era of new technology and
refinement of laparoscopic techniques, LN harvest becomes more optimized.

                               Laparoscopic         Open                 p-value
              Overall No    Examined Involved Examined Involved   p-value        p-value
Variable      (lap/open)       LN         LN     LN       LN    Examined LN Involved LN
Laparoscopic  243 (48.3%)
Open          260 (51.7%)
Examined LN               24.1 ± 19.3                23.8 ± 17.5                        0.97
Involved LN                              2.0 ± 3.6                 1.8 ± 4.7           0.032
Rt Colon     194 (101/93) 26.2+/12.4     2.1 ± 4.6   28.4 ± 15.6   1.5 ± 2.7    0.2            0.04
Lt Colon      161 (82/79) 25.19 ± 11.9    2.2 ± 4    23.8 ± 19.7   2.3 ± 6.0    0.3            0.4
Rectum        148 (60/88) 19.0 ± 11.2    1.7 ± 4.3   19.8 ± 16.1   2.1 ± 5.3    0.4            0.3
1996–1997     125 (61/64) 25.0 ± 16.0    2.2 ± 3.2   23.4 ± 16.2   1.9 ± 3.6   0.23            0.29
2002–2003     127 (54/73) 20.5 ± 16.5    2.6 ± 5.5   23.8 ± 18.7   1.9 ± 4.8   0.052           0.04
2006–2007    251(128/123) 26.4 ± 17.4    1.7 ± 4.8   23.5 ± 19.8   1.9 ± 1.5   0.13            0.3


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       49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1711 Risk of Leak After Laparoscopic Versus Open Bowel
         Anastomosis
Galal S. El-Gazzaz*, Daniel P. Geisler, Tracy L. Hull
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: Anastomotic leak after colorectal surgery is a major complication
that is associated with sepsis, prolonged hospitalization, and increased mor-
bidity and mortality. The aim of this study was to investigate the safety of
laparoscopic surgery (LS) as reflected by the anastomotic leak rate compared
to open surgery (OS) for colorectal resective procedures.
METHODS: From 2000 through 2007, all data relative to 4774 patients
undergoing colorectal resective procedures with anastomosis (1516 laparo-
scopic and 3258 open) were prospectively recorded and retrospectively
reviewed from IRB approved databases. Patients were equally matched with
regards to site of anastomosis, pathology, date of surgery, age, gender, and
BMI. The incidence of anastomotic leak was compared between the two
groups according to location of bowel anastomosis, primary diagnosis, and
year of surgery.
RESULTS: There was no significant difference in anastomotic leak rate
between the two groups: 2.3% of the LS group (N = 35) versus 2.1% of the OS
group (N = 67) (p = 0.57). With regards to the site of anastomosis, there was
no significant difference in anastomotic leak rate between the two groups:
right colectomy (p = 0.32) and left colectomy (p = 0.79). There was no signifi-
cant difference in leak rate between the two groups when the operation was
performed for cancer (p = 0.6) or diverticulitis (p = 1). There was a significant
difference in anastomotic leak rate when the primary diagnosis was Crohn’s
disease: 5.3% of the LS group versus 1.8% of the OS group (p = 0.002).
CONCLUSIONS: Laparoscopic colorectal surgery is not associated with a
higher risk of anastomotic leaks. The incidence of anastomotic leaks in
Crohn’s patients may be higher when the procedure is done laparoscopically
and needs to be studied further.

                                              Colorectal Resection with Anastomotic Bowel
                                                                                               P Value
                                                     Anastomosis                Leak
        Variables               Overall           lap           open       lap       open
Total number                     4774            1516           3258    35 (2.3%) 67 (2.1%)   P = 0.57
                                                                                                          POSTER ABSTRACTS




Age (Mean ± SD)               55.8 ± 17.4   51.97 ± 16.07 55.14 ± 16.62                       P = 0.89
BMI (Mean ± SD)                27.8 ± 6.2    27.39 ± 6.03 28.43 ± 6.54                        P = 0.25
                                                                                                              TUESDAY




Diagnosis      Cancer        2162 (45.3%)    282 (18.6%) 1880 (57.7%)     2.8%       2.3%     P = 0.6
              Crohn’s        1412 (29.6%)    247 (16.3%) 1165 (35.8%)     5.3%       1.8%     P = 0.002
            Diverticulitis    588 (12.3%)    375 (24.7%)     213 (6.5%)   1.3%       0.94%    P=1
               Others         612 (12.8%)    612 (40.4%)       0 (0%)     1.5%        0%
Years        2000–2003       2822 (59.1%)    681 (44.9%) 2141 (65.7%)     3.9%       2.9%     P = 0.51
             2004–2004       1952 (40.9%)    835 (55.1%) 1117 (34.3%)     3.6%       2.0%     P = 0.55
Site            Right         987 (20.7%)    343 (22.6%)    644 (19.8%)   3.8%       2.6%     P = 0.32
                 Left        1951 (40.9%)    743 (49.0%) 1208 (37.1%)     2.4%       2.2%     P = 0.79
                Other        1836 (38.5%)    430 (28.4%) 1406 (43.2%)     1.7%       1.2%     P = 0.23



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   T1712 Postoperative Bowel Function After Lumber Colonic
         Nerve Preserving Low Anterior Resection for Rectal
         Cancer
Yoshitaka Tanabe*1,2, Hiroaki Matsunaga1, Takashi Ueki2, Shosaku Nakahara1,
Masao Tanaka2
1Surgery,Kitakyushu Municipal Medical Center, Kitakyushu, Japan; 2Surgery and
Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
AIM: We previously investigated the control mechanism of lumber colonic
nerve (LCN) on colonic motility in the animal experiments, and have pro-
spectively introduced LCN preserving low anterior resection (LAR) for rectal
cancer on clinical setting. We have demonstrated that LCN preserving LAR
has the better bowel function even though autonomic nerve preserving
lateral pelvic lymphadenectomy (LPA) was combined. As the LPA is uncom-
mon in the western countries, the aim of this study was to re-evaluate the
functional effects of LCN preserving LAR for rectal cancer added the cases
without LPA.
PATIENTS AND METHODS: Since 1994, prospective functional question-
naire have been cumulated consecutively after LAR. Between January 1994
and August 2003, inferior mesenteric artery (IMA) was ligated at the origin of
the abdominal aorta (LCN-divided group). Since September 2003, IMA has
been ligated at the level of superior rectal artery just beyond the bifurcation
of the left colonic artery (LCA), and IMA and LCA were preserved with neural
sheath of LCN while dissecting the adipose tissue around the IMA (LCN-pre-
served group). Total mesorectal excision (TME) with autonomic nerve preser-
vation was performed principally. The LPA was performed for T3 or more
advanced cancers in the lower rectum. The end to end anastomosis with dou-
ble stapling technique was performed in all patients, and the patients whose
anastomotic line was within 4 cm from the anal verge were enrolled. Func-
tional questionnaire was obtained at postoperative month 1, 3, 6, and 12,
and data were analyzed comparing LCN-divided group (n = 33) and LCN-
preserved group (n = 14). Functions were assessed in four aspects: bowel fre-
quency, degree of soiling, ability to distinguish flatus from stool, prolonged
defecation and persistent anismus. Subjective questions were expressed as
quantitative values utilizing time interval until recognition of symptomatic
improvement or satisfaction.
RESULTS: There were no significant differences in the mean age and the
level of anastomotic line between two groups. Bowel frequency in LCN-
preserved group was significantly less than in LCN-divided group at postoper-
ative month 1 (6.1 ± 0.8 versus 9.7 ± 1.0, p < 0.05). Bowel frequency was not
significantly different at the other time points, but LCN-preserved group
tended to have better functions at any observing time points assessed.
CONCLUSIONS: We have revealed the LCN preserving LAR expressed better
bowel function at the early postoperative period compared with the conven-
tional procedure irrespective of LPA. LCN preservation may be one of the fea-
sible procedures for improving the postoperative bowel function after LAR.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1713 Prospective Study on the Management of Acute
         Diverticulitis
Pierpaolo Sileri*1, Vito M. Stolfi1, Paolo Gentileschi1, Giuseppe S. Sica1,
Girolamo De Andreis2, Alessandra Di Giorgio2, Alberto Galante2,
Achille Lucio Gaspari1
        University of Rome Tor Vergata, Rome, Italy; 2Internal Medicine, University of
1Surgery,
Rome Tor Vergata, Rome, Italy
INTRODUCTION: Acute diverticulitis (AD) is the most common presenta-
tion of diverticular disease with high morbidity and mortality. We report our
experience with the management of AD and we examined several clinical
parameters in order to evaluate their predictive role for early discharge or pro-
longed hospitalization/surgery.
PATIENTS AND METHODS: We prospectively evaluated all patients with
AD admitted to our teaching Institution between January 2005 and October
2007. AD requiring admission was defined by the presence of lower abdomi-
nal pain and tenderness and/or guarding in left iliac fossa associated with sys-
temic inflammatory response as shown by the presence of one or more of the
following: fever (>38˚C), WBC count >12.000 or CRP elevation (>20 mg/dl).
Patient’s related data including age, gender, co-morbidities, onset and dura-
tion of symptoms before admission as well as clinical data were prospectively
entered in a database and analyzed to assess their predictive role for pro-
longed hospitalization/surgery.
RESULTS: According to our criteria, 146 patients were identified (68 M, 78 F;
mean age 64 years, range 27–91). Duration of symptoms before admission
averaged 5 days (1–30 days). At admission, fever was present in 58.2% of
patients, increased WBC count in 61% and raised CRP in 78.1%. Nine-two
patients (63%) had a previous diagnosis of diverticular disease, 31 (21.2%)
had one or more previous admission for AD. Ten patients (6.8%) required
immediate surgery, while the remaining were initially treated conservatively
(analgesia, bowel rest and appropriate antibiotics). Medical treatment alone
was effective in 94.1% of patients and 84.6% were discharged within 4 days.
Twenty-one patients required prolonged hospitalization (average 11 days,
range 5–112). Two patient required abscess percutaneos drainage. Medical
treatment failed in 6 patients (4.4%) after 5.5 days ± 3.5 days. Overall, 16
patients (11%) underwent surgery: 9 Hartmann’s procedure, 5 bowel resec-
tions with primary anastomosis, 1 subtotal colectomy and 1 laparoscopy with
                                                                                         POSTER ABSTRACTS




abscess drainage. Overall mortality and morbidity rates were 2.1% and 12.3%.
                                                                                             TUESDAY




Surgical mortality and morbidity were 12.5% and 56.2% including intra-
operative bleeding managed with Mikulicz packing (1), surgical site infections
(5), pneumonia (2) and cardiac arrhythmia (1). Previous AD, duration of
symptoms before admission (>3 days), obesity, and steady elevation of CRP
predicted prolonged hospitalization or surgery.
CONCLUSIONS: After admission for AD the risk of hospitalization or surgery
is significantly higher if patient is obese, experienced previous similar admis-
sions or if CRP mantains steady elevation.




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   T1714 Incidence of Adhesional Small Bowel Obstruction
         (SBO) After Colorectal Surgery
Pierpaolo Sileri*, Alessandra Mele, Vito Maria Stolfi, Nicola Di Lorenzo,
Paolo Gentileschi, Giuseppe S. Sica, Achille Lucio Gaspari
Surgery, University of Rome Tor Vergata, Rome, Italy
BACKGROUND: Colorectal surgery (CRS) leads to high rates of access-
related complications. Adhesive small bowel obstruction (SBO) is reported as
high as 35% with large clinical impact and financial burden. In this study we
evaluated the cumulative incidence of adhesive SBO in a cohort of patients
after CRS. We also assessed the role of laparoscopy as adhesion prevention
strategy.
METHODS: Data on patients undergoing elective or emergency CRS (either
open or laparoscopic) were prospectively entered in a database. Adhesive SBO
episodes requiring admission or reintervention were recorded. The diagnosis
of SBO was defined by a combination of clinical criteria and imaging. Time
interval of SBO, surgery type and setting, readmission length and findings at
reintervention were recorded. Patients undergoing CRS for inflammatory
bowel disease, patients with peritoneal carcinosis, or patients with SBO sec-
ondary to local or peritoneal recurrence during the follow-up were excluded.
Patients who underwent other abdominal surgery during the follow-up were
also excluded. Data were analysed using Mann-Whitney U test and chi-square
test. The Kaplan Meier method was used to calculate the cumulative probabil-
ity of developing SBO.
RESULTS: From 1/03 to 10/07, 426 patients satisfied our criteria and under-
went elective (48.6%) or emergency (51.4%) colorectal surgery (73.7% open
and 26.3% laparoscopic). Mean follow-up was 28 months. Eleven (2.6%)
patients experienced 14 SBO episodes and 8 (1.9%) required surgery. There
was a large variation in the first readmission interval, 54% occurred within 3
months, 38.5% between 3 and 12 months and 14.3% after 1 year. At first
admission 54.5% of patients underwent surgery. Seven patients required
adhesiolysis and 1 patient needed resection for small bowel ischaemia. The
risk of readmission for SBO was higher during the first postoperative year and
the cumulative risk steadily increased every year thereafter. The risk of reoper-
ation was related to the number of readmissions for SBO, doubling at the sec-
ond readmission and reaching 100% after the third. Mean length of stay was
8 and 15 days respectively for non-operative and operative treatment. SBO
risk was significantly higher after pelvic surgery/extensive resections com-
pared to minor procedures (5.2% vs 2.6%; p < 0.03), after open compared to
laparoscopic (3.2% vs 0.9%; p < 0.001) but similar after emergency surgery
compared to elective (NS).
CONCLUSIONS: Colorectal surgery results in significant ongoing risk of SBO
depending from the colorectal procedure. The number of readmissions for
SBO predicts the need of surgery. Laparoscopy seems to minimize the risk of
adhesive SBO.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1715 Laparoscopic Appendectomy for Complicated
         Appendicitis
Pierpaolo Sileri*, Paolo Gentileschi, Giuseppe S. Sica, Piero Rossi, Luana Franceschilli,
Federico Perrone, Achille Lucio Gaspari
Surgery, University of Rome Tor Vergata, Rome, Italy
BACKGROUND: Laparoscopic appendectomy (LA) is associated with less
postoperative pain and earlier return to normal activity. However its role in
the management of complicated appendicitis remains undefined and the
choice of the operative approach is mostly at surgeon’s discretion. In this pro-
spective study we compared the laparoscopic and the open approaches in
terms of safety and efficacy for complicated appendicitis.
PATIENTS AND METHODS: Consecutive patients who underwent appen-
dectomy for acute appendicitis from January 2003 to November 2007 at our
teaching Institution were studied. Patient’s data including demographics,
operative time, short term complications (including surgical site infections-
SSI), length of stay and access-related longer-term complications (small bowel
obstruction, incisional hernia) were prospectively recorded and entered in a
database. Data from patients who underwent OA or LA for complicated
appendicitis were compared. These data were also matched with OA or LA for
uncomplicated appendicitis (controls). Complicated appendicitis was defined
as gangrenous or perforated appendicitis with or without the presence of
abscess. Exclusion criteria were: age <14 years, patients presenting with gener-
alized peritonitis or patients requiring additional surgery to appendectomy.
Student’s t-test, Mann-Whitney U test and the Fisher exact test were used for
statistical analysis.
RESULTS: A total of 260 patients (124 M, 136 F, mean age 29 ± 12 years)
underwent appendectomy during the study period. Eighty-two (31.5%) were
complicated appendicititis: 38 patients underwent open appendectomy (OA)
while 44 underwent LA. Conversion rate to OA complicated appendicitis rate
was significantly increased compared to uncomplicated (15.4% vs 2.2%;
p < 0.003). No significant differences were observed in terms of mean opera-
tive time or length of stay between OA and LA for complicated appendicitis
and results were similar to OA and LA performed for uncomplicated controls.
Overall complication rate was higher (but not significant) after OA compared
to LA for complicated appendicitis (7.9% vs 4.5%). Both rates were also
similar to uncomplicated controls. Overall incidence of SSI was 3.1% and
                                                                                            POSTER ABSTRACTS




infections were equally distributed between groups (complicated vs uncom-
                                                                                                TUESDAY




plicated: 2.4% vs 3.4%; OA vs LA: 4.5% vs 2.2%). One patient of OA group
experienced incisional hernia.
CONCLUSIONS: Complicated appendicitis is associated with an increased
need of conversion to open technique. However this study failed to show
significant differences between LA and OA performed for complicated
appendicitis.




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   T1716 Small Intestinal Bacterial Overgrowth Is Common in
         Patients with Lower Gastrointestinal Symptoms and a
         History of Previous Abdominal Surgery
Grant G. Sarkisyan*1, Maura Fernandez1, Eileen A. Coloma1, Patrizio Petrone1,
Gabriel Akopian1, Adrian E. Ortega1,2, Howard S. Kaufman1,2
1Surgery,University of Southern California, Los Angeles, CA; 2Keck School of Medicine,
Los Angeles, CA
PURPOSE: Small intestinal bacterial overgrowth (SIBO) is a condition associ-
ated with irritable bowel syndrome (IBS) and a variety of autonomic symp-
toms. The SIBO breath test has been found to be positive in 84% of patients
with IBS vs 20% of controls. We hypothesized that SIBO would be more prev-
alent in patients with IBS-like symptoms who have undergone previous
abdominal surgery due to adhesions and potential for stasis.
METHODS: A retrospective review of patients from a tertiary colorectal sur-
gery clinic was performed to identify patients with SIBO considered in the
differential diagnosis. Demographics, past medical and surgical history, pre-
senting symptoms, and diagnostic evaluations were recorded. SIBO-positive
patients were compared SIBO-negative patients in case-control fashion. Mul-
tiple regression analysis was performed to identify etiologic factors for SIBO.
RESULTS: Seventy subjects were identified during a 36-month period
(2004–2007). 18 patients were excluded due to noncompliance with testing,
and 2 were excluded due to a decision to treat for SIBO without formal test-
ing. Common presenting symptoms included chronic abdominal pain (52%),
bloating (46%), constipation (66%), and diarrhea (12%). Mean symptom
duration was 45 months (range 2–216). Mean age was 52 years (range 17–91),
weight 152 lb (range 93–264), and 86% were female. The majority of patients
were Caucasian (81%) and Hispanic (17%). 80% of patients had previous
abdominal surgery, mean 2 procedures (range 0–6), 18% of which involved
foregut, 12% midgut, 27% hindgut, and 43% female reproductive organs.
Prior surgery was performed laparoscopically in 20% of patients vs open in
80%. 8% of patients had a history of small intestinal obstruction. 76% of
patients tested positive for SIBO, 78% with previous surgery vs 70% without
previous surgery. SIBO-positive patients were older than SIBO-negative
patients: mean age 56 vs 44 yrs, (p < 0.01). Logistic regression analysis did not
reveal any clinically significant independent factors associated with SIBO.
Symptoms resolved in 50% of patients treated with GI tract antibiotics.
CONCLUSIONS: SIBO is very common in a colorectal surgery population
presenting with lower GI complaints. Although a past history of abdominal
and pelvic surgery was not associated with a statistically higher incidence of
SIBO, the high prevalence of SIBO-positive breath tests was greater than his-
torical control rates. While further study is needed to assess the risk of SIBO
after abdominal surgery, SIBO should be considered in the differential diag-
nosis of patients with normal anatomic findings and chronic lower gas-
trointestinal complaints.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1717 Contemporary Surgical Management for Ileosigmoid
        Fistulas in Crohn’s Disease
Genevieve B. Melton*, Luca Stocchi, Elizabeth Wick, Kweku A. Appau,
Victor W. Fazio
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
BACKGROUND: Ileosigmoid fistula (ISF) in Crohn’s disease (CD) is a chal-
lenging clinical condition. The current role of diagnostic modalities and
specific surgical management options for ISF in CD are not well characterized.
METHODS: Patients from a prospectively collected CD database who under-
went surgery for ISF during 2002–2007 were included. Demographics, disease
extent, diagnostic modalities, operative approach, perioperative outcomes,
concurrent medication use, and smoking status were retrospectively
reviewed. Overall length of hospital stay included any postoperative readmis-
sion and stoma reversal. Converted cases were considered as laparoscopic pro-
cedures in an intent-to-treat analysis.
RESULTS: A total of 61 patients underwent operative management for ISF
(37 females, median age 37 [range 18–78] years, 19 [31%] laparoscopic). All
patients had ileocolic resection. Management of the sigmoid colon included
primary repair 14 (23%), segmental resection 45 (74%), or subtotal colectomy
2 (3%). Additional CD findings were identified in 25 (41%) patients, includ-
ing ileovesical fistula 8 (13%), enterocutaneous fistula 8 (13%), and small
bowel disease requiring resection 8 (13%), strictureplasty 5 (8%), or both 2
(3%). Sensitivities of colonoscopy, CT scan and fluoroscopic contrast studies
for ISF were 40% (21/53), 47% (21/45) and 54% (14/26), respectively. The
combination of all diagnostic studies resulted in a preoperative diagnosis of
ISF in 35 (57%) patients. Protective stoma was used in 33 (54%) patients and
was more frequent if additional small bowel disease required surgery (77% vs.
44%, p = 0.03), for open vs. laparoscopic surgery (64% vs. 32%, p = 0.02),
when a phlegmon or abscess were present (85% vs. 46%, p = 0.007), and was
associated with the use of intraoperative ureteral stents (33% vs. 4%,
p = 0.003). Sigmoid resection was more common in laparoscopic vs. open
approach (95% vs. 69%, p = 0.02). There were no deaths. Overall morbidity
was 35% and leak rate 8%. Neither was affected by stoma diversion, use of
laparoscopic technique, or treatment of the sigmoid colon with resection vs.
primary closure. Overall length of hospital stay was non-significantly shorter
with laparoscopic compared to open surgery (median 6 vs. 9 days, p = 0.25).
                                                                                POSTER ABSTRACTS




CONCLUSIONS: ISF in CD remains an often incidental surgical finding. Sig-
                                                                                    TUESDAY




moid resection and primary sigmoid repair have comparable morbidity if
appropriately individualized. Laparoscopic treatment is acceptable in select
cases and may allow reduction in diverting stoma rates and overall length of
hospital stay with similar morbidity.




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  T1718 The Usage of Botulinum Toxin in the Treatment of
        Chronic Anal Fissures
Alex J. Ky*, Randolph M. Steinhagen, Erin K. Ly, Emily Steinhagen
Surgery, Mt Sinai Hospital, New York, NY
INTRODUCTION: To assess the role of botulinum toxin in the treatment of
chronic anal fissure compared to conservative non-surgical treatment.
METHOD: A retrospective chart review was performed on all patients who
presented with anal fissure for more than 4 weeks. These patients were given
the option of continuing conservative management of topical analgesic, fiber
and hot sitzs bath or the option of having a fissurectomy with botulinum
toxin (BTX) injection. Most of our patients did not want a sphincterotomy as
a first line treatment so those were excluded from the study.
RESULTS: A total of 722 patients were diagnosed with chronic fissure from
January 2000 to December 2005. 490 were female and 232 male. The average
duration of the CAF was 9 weeks. 115 patients underwent fissurectomy with
botulinum toxin injection while 607 patients had conservative treatment. An
average of 50 units of BTX were injected in those who had surgery. 697 (96
percent) were in the posterior midline while the rest of the fissures were
located in the anterior midline. Overall fissure healing in those who under-
went BTX injections and fissurectomy was 93 percent at 4 weeks. Thirteen of
those still have a visible deep fissure but was asymptomatic since the surgery.
For those who failed, 5 percent went on to have lateral internal sphincterot-
omy which cured their fissure. None of the patients reported problems with
incontinence. The average follow up was 8 months. Twenty three of the 107
patients who were healed needed repeat treatment of either LIS or BTX injec-
tion an average of 13 months after the fissure was declared healed.
CONCLUSION: BTX injection along with fissurectomy is a good first line sur-
gical intervention for patient who does not want a sphincterotomy. The risk
of incontinence is low and the potential benefit of a healed fissure is high.
However, those patients who have extremely hypertrophied internal sphinc-
ters, they should be prepared for possible repeat treatment.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Clinical: Esophageal
   T1719 Esophageal Adenocarcinoma Associated with Barrett’s
         Esophagus: Survival Benefit?
Valerie A. Williams*, Thomas J. Watson, Katherine A. Dudley, Svetlana Zhovtis,
Carolyn E. Jones, Daniel Raymond, Jeffrey H. Peters
Surgery, University of Rochester Medical Center, Rochester, NY
OBJECTIVE: Prior studies have suggested that adenocarcinoma associated
with Barrett’s epithelium may represent a unique tumor biology. This has
arisen from observations that patients with adenocarcinoma and residual Bar-
rett’s in the surgical specimen may have better survival than those without
residual Barrett’s. The aim of our study was to determine the influence of Bar-
rett’s epithelium on survival of patients with esophageal adenocarcinoma as
well as to identify factors predicting survival.
METHODS: The study population consisted of 194 patients who underwent
esophagectomy for adenocarcinoma. Eighty-four (43.3%) patients had Bar-
rett’s epithelium identified in the surgical specimen. Mean age, M:F ratio,
location of tumor, type of operation and mean follow-up were not signifi-
cantly different between those with or without Barrett’s. Outcome measures
included overall survival, morbidity and mortality and factors associated with
prolonged survival. The effect of age, gender, operative approach, Barrett’s,
stage, T and N-classification, and endoscopic surveillance on survival was
assessed via logistic regression.
RESULTS: Patients with adenocarcinoma associated with Barrett’s had signif-
icantly better 5-year survival as compared to those without Barrett’s, (37.2%
v. 23.1%; p = 0.020). Patients with Barrett’s also had earlier stage cancers
(I–IIb) (57/82, 69.5% v. 35/110, 31.8%; p < 0.05) and a higher prevalence of
endoscopic surveillance (20/64, 31.3% v. 1/79, 1.3%; p < 0.05) than those
without Barrett’s. There was no difference in perioperative morbidity or mor-
tality between the two groups. On multivariate analysis, tumor depth, nodal
status and enrollment in a surveillance program were significant predictors of
long-term survival. The presence of Barrett’s epithelium was not. Survival was
also similar when those with and without Barrett’s epithelium were examined
via matched pair analysis.
CONCLUSIONS: Long-term survival of patients with adenocarcinoma and
                                                                                  POSTER ABSTRACTS




Barrett’s epithelium in the surgical specimen is superior to those without evi-
                                                                                      TUESDAY




dent Barrett’s epithelium. This survival advantage is due to earlier detection
and to surveillance endoscopy and not the underlying tumor biology. Screen-
ing endoscopy and subsequent surveillance of patients with Barrett’s esopha-
gus should be strongly encouraged to allow for the detection of esophageal
adenocarcinoma at an earlier stage.




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  T1720 Changing Prognosis of Spontaneous Esophageal
        Perforation (Boerhaave Syndrome): A Personal
        Experience of 64 Cases in a Single Center
Jarmo A. Salo*, Jari V. Räsänen, Eero I. Sihvo
Division of General Thoracic and Esophageal Surger, Dept of Cardiothoracic Surgery,
Helsinki University Central Hospital, Helsinki, Finland
BACKGROUND: Spontaneous esophageal perforation (SEP) or Boerhaaven
Syndrome is a rare and life-threatening disease. Published series usually con-
tain less than 10–15 patients treated variously during a long period of time.
Therefore, the management of SEP is often based on personal experience and
not on evidence-based results.
PATIENT AND METHODS: We scrutinized retrospectively the possible
changes in the prognosis of 64 SEP patients (mean age 62 years) treated in a
single institute between 1979–2007 by a team having special interest in
esophageal surgery.
RESULTS: There was no significant difference between decades in diagnostic
delay. This delay was >24 h in 43% and >48 h in 34% of patients. The primary
treatment strategy included aggressive conservative treatment of infection
and homeostasis with the best possible available medical resuscitation in all
64 patients. Surgical strategy was primary repair through thoracotomy in 30
patients having vital esophagus (47%), and esophagectomy in 24 cases (38%)
with severe wall necrosis or large esophageal damage making primary repair
impossible. 10 patients (16%) with a small perforation and no/or very small
pleural fistula or no empyema were treated non-operatively or with endo-
scopically installed esophageal prosthesis. Of treated patients, 29 (45%) had
1–4 reoperations. Mortality of SEP (30-d) decreased significantly from 28%
(8/29) in 1980s–1990s to 3% (1/35) in the 21st century (p = 0.029). Similarly,
leak-rate after primary repair decreased significantly from 53% (8/15) to 7%
(1/15). Median survival after discharge was 120 months, similar to general
population.
CONCLUSIONS: The treatment of SEP has improved despite of similar strate-
gies during 3 different decades. One reason is a decrease in leak-rate after
primary repair. In this retrospective study, other factors are difficult to point
out. These are probably multi-factorial including improved intensive care and
team experience. Evidence-based results are needed in the treatment of SEP.
Until then, the results of more conservative strategies including covered
stents have to be compared to presented results.




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   T1721 The Value of Endoscopic Ultrasound to Distinguish the
         Number of Lymph Node Metastases in Patients with
         Esophageal Adenocarcinoma
Jessica M. Leers*, Jeffrey A. Hagen, Shahin Ayazi, Arzu Oezcelik, Emmanuele
Abate, Farzaneh Banki, John C. Lipham, Steven R. Demeester, Tom R. Demeester
Department of Surgery, Keck School of Medicine, University of Southern California,
Los Angeles, CA
BACKGROUND: The presence and the number of lymph node metastasis
have been identified as significant prognostic factor in patients with esoph-
ageal adenocarcinoma. Therefore, assessment of lymph node status is impor-
tant to separate patients with advanced lymph node disease who may benefit
from neoadjuvant therapy from those with limited lymph node disease who
can be cured by surgical resection alone. Endoscopic ultrasound (EUS) is a
reliable staging tool to determine tumor depth and identify abnormal lymph
nodes. The aim of this study was to assess the accuracy of EUS in determining
the number of lymph nodes involved.
METHODS: We reviewed the records of all patients who underwent esoph-
agectomy with a systematic thoracic and abdominal lymphadenectomy at
our institution between 1991 and 2007 as primary therapy for esophageal
adenocarcinoma. EUS was performed by the operating surgeon and limited
disease was defined by involvement of ≤4 lymph nodes and advanced disease
by involvement of 5 or more lymph nodes. The results of EUS were compared
with pathological findings of the esophagectomy specimen.
RESULTS: A total of 139 patients were included. In 103 patients (74%), EUS
correctly identified limited versus advanced lymph node involvement. The
positive predictive value for identifying limited node disease was 79%. EUS
was more accurate in assessing lymph node involvement in patients with T1
and T2 tumors than in T3/T4 disease (98%, 79%, and 56%, p < 0.0001). In
patient with T1/T2 tumors, EUS had a positive predictive value of 100%.
There were 23 patients (17%) with advanced lymph node disease and the pre-
dictive value for EUS was only 48%. Patients with advanced node disease on
EUS had a significantly worse disease free survival compared to patients with
limited node disease (p = 0.0035).
CONCLUSIONS: Endoscopic ultrasound can accurately identify patients
with limited node disease with a positive predictive value of nearly 80%. This
                                                                                     POSTER ABSTRACTS




allows identification of patients unlikely to benefit from neoadjuvant
therapy. Advanced node disease on EUS is associated with less survival.
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   T1722 Significant Pressure Differences Between Solid-State
         and Water Perfused Systems in Lower Esophageal
         Sphincter Measurement
Heinz Wykypiel*1, Ronald A. Hinder2, Kenneth R. Devault3, Gerold J. Wetscher4,
Alexander Klaus1, Paul J. Klingler1
1Department of General and Transplant Surgery, Medical University Innsbruck, Innsbruck,
Austria; 2Department of Surgery, Mayo Clinic Jacksonville, Jacksonville, FL; 3Department
of Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, FL; 4Department of Surgery,
General Hospital Schwaz, Schwaz, Austria
OBJECTIVE: To compare lower esophageal sphincter (LES) measurements
obtained with water-perfused manometry with a new solid-state technique.
Normal values for LES resting pressure in suspected GERD (gastroesophageal
reflux disease)-patients have been established using water-perfused manome-
try. These standard-values are also applied using new solid-state techniques,
although they have never been compared before.
METHODS: Thirty healthy subjects were studied twice on the same day:
Technique 1: Station pull through using a water perfused catheter with ports
arranged at 0, 90, 180, and 270 degrees which were averaged to give a mean
LES pressure. Technique 2: Solid-state circumferential probe with a single sta-
tion pull through. Data were collected using the same computer system and
program. The LES pressures were randomly and blindly analyzed.
RESULTS: 28 subjects of 30 were analyzed. Using the solid state system, the
mean LES pressure was higher (26.6 vs. 21.7 mm Hg, p < 0.02) and 24 of 28
(85%) individual measurements were higher. The correlation between the
two sets of measurements was also poor (r = 0.54). Two subjects had a hyper-
tensive LES by solid state (53.4 and 41.9 mm Hg) while their pressures were
normal with water perfused manometry (19.4 and 23.4 mm Hg). The distal
esophageal pressures (mean of pressure at 3 and 8 cm above LES) were the
same with the two techniques.
CONCLUSIONS: In normal control subjects LES measurement using circum-
ferential solid-state transducers yields higher pressures than standard water
perfused manometric measurement. Which system yields the more accurate
measurement of the physiologic LES remains to be determined.




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  T1723 Understanding Laryngopharyngeal Reflux (LPR): The
        Prevalence of Anatomic Esophagogastric Junction
        Degradation in LPR Patients
Kyle A. Perry*1, Cedric S. Lorenzo1, Paul H. Schipper1, Joshua S. Schindler2,
Cynthia Morris3, Blair A. Jobe1
1Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department
of Otolaryngology, Oregon Health & Science University, Portland, OR; 3Department of
Medical Informatics and Clinical Epidemiology, Oregon Health & Science University,
Portland, OR
INTRODUCTION: Distortion of esophagogastric junction (EGJ) architecture,
caused by repeated proximal gastric distention, creates susceptibility to
GERD; the end result is permanent dilation of the gastric cardia which is
directly proportional to disease severity, with the largest circumference
present in those with Barrett’s esophagus (BE). Because of their propensity to
reflux in the upright position, it is unclear whether cardia dilation with
resultant anatomic valve deformation is also present in patients with laryn-
gopharyngeal reflux (LPR) symptoms.
METHODS: In a prospective study, 113 patients recruited from ENT (N = 87)
and Gastroenterology Clinics (N = 26) underwent unsedated upper endos-
copy in the upright position after completing validated questionnaires for
GERD and LPR symptoms. Exclusions were made for a poor endoscopic view
of the gastric cardia. Three populations were stratified based on symptom
complex: 1) LPR symptoms only (Pure LPR), 2) Typical GERD symptoms only
(GERD), and 3) Both LPR and typical GERD symptoms (Mixed). The primary
outcome was cardia circumference (mm) as measured by an observer blinded
to symptom complex using previously validated software. The secondary out-
come was the prevalence of biopsy proven BE within each group as a proxy
for disease severity and cancer risk.
RESULTS: The Pure LPR group (N = 32) had a mean gastric cardia circum-
ference of 33.6 ± 7.3 mm. Similarly, the values in GERD (N = 41) and Mixed
(N = 40) groups were 36.5 ± 9.6 mm and 35.1 ± 8.0 mm, respectively
(p = 0.347, One Way ANOVA). Hiatal hernia size positively correlated with
cardia circumference (r = 0.219, p = 0.02, Pearson’s). The overall prevalence of
BE was 20.4%. BE was present in 15.6%, 34.2%, and 10.0% of Pure LPR,
GERD, and Mixed patients, respectively (p < 0.02, Chi square test). BE
                                                                                        POSTER ABSTRACTS




patients had a larger cardia circumference of 39.1 mm compared to 34.2 mm
in those without BE (p < 0.02, t-test).
                                                                                            TUESDAY




CONCLUSION: Patients with LPR display the same degree of EGJ anatomic
degradation as those with typical GERD symptoms which suggests a similar
pathophysiology. This finding indicates that although LPR patients may
sense reflux differently, they have similar risks as patients with typical symp-
toms. Further, the identification of BE, accompanied by increased gastric car-
dia diameter in the complete absence of typical GERD symptoms, suggests
the potential for occult disease progression and late discovery of cancer.




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  T1724 The Effect of Body Position on Hiatal Anatomy in
        Patients with GERD
Kyle A. Perry*1, Cedric S. Lorenzo1, Paul H. Schipper1, Joshua S. Schindler2,
Cynthia Morris3, Blair A. Jobe1
1Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department
of Otolaryngology, Oregon Health & Science University, Portland, OR; 3Department of
Medical Informatics and Clinical Epidemiology, Oregon Health & Science University,
Portland, OR
INTRODUCTION: Permanent disruption of the clasp and collar sling muscle
fibers that comprise the distal aspect of the lower esophageal sphincter is
believed to predispose patients to GERD. However, little is known about the
effect of body position on hiatal anatomy in patients with GERD. We propose
that body position has a significant impact on esophagogastric junction anat-
omy, and that investigations of these differences may enhance our under-
standing of the pathophysiology underlying GERD.
METHODS: Fifty-three patients with PPI responsive heartburn and/or regur-
gitation underwent upper endoscopy in the upright and supine positions. All
patients having undergone prior hiatal surgery were excluded. Digital images
of the cardia were obtained in both positions under a set insufflation volume.
Gastric cardia circumference measurements were performed by an observer
blinded to position using validated software. Measurements were compared
using paired t-test with results presented as mean cardia circumference ±
SEM.
RESULTS: The gastric cardia circumference for patients in the supine posi-
tion was 53.1 ± 2.3 mm. These values decreased to 32.9 ± 1.4 in the upright
position (p < 0.01). A subgroup of patients with biopsy proven BE (N = 18)
had increased cardia circumferences of 58.2 ± 4.2 mm for CSE and 37.1 ± 2.4
mm for SCE with a mean difference of 21.1 ± 4.4 mm (p < 0.01).
CONCLUSION: Body position has a significant impact on the anatomic con-
figuration of the esophagogastric junction as indicated by changes in the gas-
tric cardia circumference. Whether this effect is directly related to positional
changes in the crural diaphragm diameter or the cardia itself is unknown and
requires further study.




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  T1725 Better Reflux Control with a Nissen Fundoplication:
        10-Year Results After Laparoscopic Antireflux Surgery
Martin Fein*1, Marco Bueter1, Andreas Thalheimer1, Karl-Hermann Fuchs2
1Department of Surgery, University of Wuerzburg, Wuerzburg, Germany; 2Department of
Surgery, Markus-Hospital, Frankfurt, Germany
BACKGROUND: Reflux recurrence is the most common long-term compli-
cation following fundoplication. Its frequency was independent from the
type of fundoplication in randomized studies. Results for different techniques
of laparoscopic antireflux surgery were retrospectively compared after ten
years.
METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fun-
doplication with a “tailored approach” (type of wrap chosen according to
esophageal peristalsis): 88 received a Nissen-, 22 an anterior, and 10 a Toupet-
fundoplication. Follow-up of 87% of the patients included disease related
questions and the gastrointestinal quality of life index (GIQLI).
RESULTS: 89% of patients would select surgery again. Heartburn was
reported by 30% of the patients independent of the type of fundoplication.
Regurgitations were noted from 15% of patients after a Nissen, 44% after
anterior fundoplication, and 10% after a Toupet (p = 0.04). 28% were on acid
suppression therapy again. Proton pump inhibitors were less frequently used
following Nissen-fundoplication (p = 0.01). The GIQLI was 110 ± 24 without
significant differences for the type of fundoplication.
DISCUSSION: Ten years after laparoscopic fundoplication, overall results are
satisfactory. A quarter of the patients are on acid suppression therapy. Nissen
fundoplication appears to control reflux better than a partial fundoplication.




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   T1726 Association of Pregnane X Receptor (PXR) with
         Esophageal Disease in an Irish Population
Mahwash Babar*1,2, John V. Reynolds1, Ross Mcmanus2
1Surgery,St. James’s Hospital, Dublin, Dublin, Ireland; 2Clinical Medicine, Trinity
College, Dublin, Ireland
It has been shown that acid and bile reflux play a role in oesophageal inflam-
mation and carcinogenesis and enhanced expression of bile acid/xenobiotic
receptors (Farnesoid X receptor, FXR and Retinoid X receptor, RXR) has been
shown in Barrett’s esophagus. These receptors act as transcriptional regulators
of Cytochrome P450 3A4 (CYP3A4) which is an important xenobiotic/drug
metabolizing enzyme (DME). Genome Wide Association studies have shown
genetic polymorphisms in DME to be linked with susceptibility to oesoph-
ageal carcinoma in the Chinese population. Here we examined the associaton
of variants in the Pregnane X Receptor (PXR) gene, a member of the xenobi-
otic receptor family, and oesophageal disease in the Irish population. We gen-
otyped the SNP –25385 (C/T) (rs3814055) which is a promoter polymorphism
in the PXR gene in 1614 individuals (EAC, n = 186, Barrett’s, n = 186, Reflux
oesophagitis, n = 180, Controls, n = 876). The data from all loci conformed to
Hardy-Weinberg Equilibrium in all the populations. When the allele frequen-
cies between the patients and the healthy controls were compared, the reflux
population showed an increased frequency of the C allele which reached sig-
nificance when compared to the random irish control population (59 vs 65,
p = 0.008, OR = 1.53). No significant association was observed between the
other groups and the control population for this locus. These preliminary
data show a suggestive association of the PXR gene polymorphism with reflux
in the Irish population.




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  T1727 The Influence of FDG-PET on the Decision to Operate
        for Esophageal Carcinoma
Jason W. Smith*, Jonathan Moreira, Gerard Abood, Margo Shoup
Surgery, Loyola University Medical Center, Maywood, IL
BACKGROUND: The use of [18F] flourodeoxyglucose positron emission
tomography (FDG-PET) as an adjunct to computerized tomography (CT) and
endoscopic ultrasound (EUS) in the staging of esophageal carcinoma has
increased. FDG-PET has been shown to have an increased sensitivity for iden-
tifying distant metastases over CT and EUS, however it is not known how
often this additional information alters the clinical decision avoiding major
surgical resections and its associated morbidity for patients who are unlikely
to benefit. The purpose of this study is to evaluate the influence of FDG-PET
on the decision to operate in patients undergoing a staging work up for distal
esophageal carcinoma.
METHODS: A review of patients with distal esophageal carcinomas who
were staged preoperatively with FDG-PET in addition to standard screening
with CT or CT and EUS to determine if the use of FDG-PET significantly
changed the decision to perform a curative operation. Patients who were
restaged after the administration of neoadjuvant or primary chemoradiother-
apy were reviewed to determine if the change in the intensity of FDG uptake
in primary lesions, using the standardized uptake value (SUV), correlated
with response to therapy and survival for its potential use in estimating
prognosis.
RESULTS: Of the 53 patients who had were considered for surgery based on
traditional staging methods including CT and EUS, 10 (19%) had findings on
FDG-PET that precluded surgical intervention. 36 patients who had PET scans
before and after CRT were evaluated based on the effect of therapy on SUV. A
reduction in SUV by greater than 50% resulted in recurrence in 9 of 23 (39%)
patients whereas a less than 50% reduction in SUV resulted in 10 of 13 (77%)
patients (p < 0.05, RR = 2.6, 95% CI 0.92 to 7.53) recurring over an average
follow-up period of 23 months. Interestingly, of the patients that did develop
recurrent disease, the patients with larger reductions in SUV tended to suc-
cumb to their disease more rapidly than patients that recurred who had
smaller reductions in SUV.
CONCLUSION: The use of FDG-PET in the staging of patients with esoph-
ageal carcinoma saves nearly 20% of patients from undergoing a morbid sur-
                                                                                 POSTER ABSTRACTS




gical procedure unnecessarily. Additionally, A large reduction in SUV after
                                                                                     TUESDAY




CRT selects a group of patients that have a significantly better prognosis. PET
scan should become a routine elemet in the preoperative evaluation of esoph-
ageal carcimoma and repeat PET after CRT may become an important prog-
nostic indicator.




  Poster of Distinction

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   T1728 Surgical Outcomes Following Laparoscopic Re-Do
         Heller Myotomy in the Treatment of Achalasia
Matthew J. Schuchert*, James D. Luketich, Arman Kilic, Neil Christie,
Miguel Alvelo-Rivera, Manisha Shende, Rodney J. Landreneau, Arjun Pennathur
Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center,
Pittsburgh, PA
INTRODUCTION: Approximately 10%–15% of patients undergoing mini-
mally invasive esophagomyotomy for achalasia will require further surgical
intervention for ongoing control of symptoms. The objective of this study is
to review the outcomes of patients undergoing laparoscopic re-do Heller
myotomy for recurrent or refractory symptoms in the setting of achalasia.
METHODS: All patients undergoing laparoscopic re-do Heller myotomy
were identified from 1992–2007. Outcome variables included perioperative
morbidity and mortality, symptomatic improvement, and need for subse-
quent esophagectomy. Dysphagia was scored 1 (no dysphagia) to 5 (unable to
swallow saliva).
RESULTS: A total of 19 patients (10 men, 9 women) underwent laparoscopic
re-do Heller myotomy for achalasia. The mean age was 49.3 years (range
23–80). Mean follow-up was 39.8 months. Median hospital stay was 3 days
(range: 2–10), with no operative mortality or conversions to open. There were
3 complications (15.8%): 1 esophageal mucosal perforation that was repaired
intraoperatively, 1 pneumothorax, and 1 case of chronic intraluminal mesh
erosion subsequent to re-do Heller with cruroplasty. Immediate symptomatic
improvement occurred in 89.5% of patients with the mean dysphagia scores
improving from 3.4 to 1.8 (p = 0.003). However during longer term follow-up,
esophagectomy was ultimately required in 6/19 (31.6%) patients due to recur-
rent dysphagia.
CONCLUSIONS: Laparoscopic re-do Heller myotomy is safe and effective in
the immediate improvement of dysphagia in nearly 90% of patients. On
longer term follow-up, approximately two-thirds of patients remain free of
subsequent surgical intervention. Further prospective studies with longer
follow-up are required to identify the factors affecting the outcome in these
patients.




  Poster of Distinction

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Clinical: Hepatic
   T1729 Validation of the E-PASS Scoring System for Prediction
         of Mortality and Morbidity in Hepatic Resections
Vanessa Banz*, Peter Studer, Regula Fankhauser, Beat Gloor, Daniel Inderbitzin,
Daniel Candinas
University Hospital Bern, Bern, Switzerland
BACKGROUND: In-hospital mortality and morbidity are—if well defined—
readily measurable and objective parameters for monitoring standard of care
within a single institution and for comparisons between centres. The Estima-
tion of Physiologic Ability and Surgical Stress (E-PASS) score was initially
developed to predict adverse postoperative effects for patients requiring elec-
tive gastrointestinal surgery ranging from laparoscopic cholecystectomy
through to transthoracic esophagectomy. Our aim was to review whether the
E-PASS scoring system could be used without restrictions in hepatic surgery as
a means of correctly predicting morbidity and mortality.
METHODS: E-PASS predictor equations were prospectively collected and
analyzed retrospectively for 243 patients requiring hepatic resections between
2002–2006. The Comprehensive Risk Score (CRS) was calculated using the
E-PASS equations as previously stated, which includes calculation of the Pre-
Operative Risk Score (PRS) and the Surgical Stress Score (SSS). Patients were
divided into 5 severity groups, also as previously stated, for whom expected
adverse outcomes increase with increasing CRS. Observed morbidity and
mortality rates were compared with rates predicted by E-PASS using either the
Fisher’s Exact Test, or for larger sample sizes the chi2 Test. The Wilcoxon
rank-sum Test and the t-Test were applied for comparison of PRS and SSS
between patients with and without morbidity or mortality.
RESULTS: The observed and predicted overall mortality rates were 3.3 and
3.7 per cent respectively, morbidity rates were 31 and 28 per cent. The E-PASS
model showed no significant difference between expected and observed in-
hospital mortality (p = 0.641), indicating that it predicted outcome effec-
tively. E-PASS under-predicted morbidity and showed significant lack of fit
(chi2 = 11.1, 3d.f. p = 0.011). Although comparison of PRS and SSS between
patients with and without complications revealed no overall significant
difference (t = –0.37, 241d.f. p = 0.714 and t = –1.69, 241d.f. p = 0.093), group
                                                                                    POSTER ABSTRACTS




specific comparisons showed lack of fit for groups 1, 2 and 4. Equally, patients
who died postoperatively did not have a significantly higher PRS or SSS
                                                                                        TUESDAY




(p = 0.157 and p = 0.305).
CONCLUSIONS: These data suggest that E-PASS does up to a certain extent
accurately predict outcome in patients undergoing hepatic resections. This
was especially true for predicting mortality. Morbidity was however under-
predicted in the E-PASS model. A modified, new logistic equation might be
required for liver-specific resections in order to correctly foresee postoperative
complications and mortality after hepatic surgery.




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  T1730 Prolonged Survival in Selected Patients Following
        Metastasectomy from Hepatocellular Carcinoma
Chen Fang Lee*, Miin-Fu Chen
Chang-Gung Memorial Hospital, Taoyuan, Taiwan
OBJECTIVES: Hepatocellular carcinoma (HCC) is the most common cancer
causing death in Taiwan. With the recent advances in diagnostic and surgical
techniques, more patients are suitable for hepatectomy. However, the long-
term outcome of patients remains poor due to high recurrence rate. Few arti-
cles have discussed the benefit of metastasectomy. The aim of this study was
to evaluate the role of surgery for pulmonary and other resectable metastases
from HCC.
METHODS: Eight patients underwent metastasectomy at Chang Gung
Memorial Hospital between April 2000 and June 2007 were enrolled in this
study. All of them had received the hepatectomy for primary HCC. The
demographic information, the site of extrahepatic recurrence, the method of
surgical intervention and the outcome were retrospectively reviewed.
RESULTS: There were 6 men and 2 women with the mean age of 48.5 years.
Five of them accepted multiple metastasectomy. Six patients had pulmonary
metastases removed by wedge resection or lobectomy. One patients accepted
craniotomy for metastatic HCC. One patient had the excision of right second
rib and right femoral metastasis. One patient had removal of the metastasis
from scalp, right atrium and inferior vena cava. The mean survival was 50.7
months (18 to 96 months). Four patients are still alive with or without the
disease.
CONCLUSIONS: Resection for metastases from HCC resulted in long-term
survival in these highly selected patients. Although the number of patients
suitable for resection of extrahepatic metastasis after curative hepatectomy
for HCC is small, some long-term survivors will benefit. Especially for
patients with lung metastases, aggressive surgical resection is recommended if
complete resection can be achieved.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1731 Prognostic Factors After Liver Resection for Colorectal
        Metastases: Multivariate Analysis and Comparison
        with the FONG-Score
Ulrich Adam*1, Frank Makowiec1,2, Hannes Neeff1, Oliver G. Opitz2, Eva Fischer1,
Ulrich T. Hopt1,2
1Department of Surgery, University of Freiburg, Freiburg, Germany; 2Ludwig-Heilmeyer
Cancer Center, University of Freiburg, Freiburg, Germany
INTRODUCTION: Because of low mortality and morbidity and increasing
survival rates the resection of liver metastases of colorectal cancer (CRC) plays
an important role in the multimodal management of patients with metasta-
sized CRC. The knowledge of prognostic factors (as for example the FONG-
criteria) is crucial in the planning of different treatment options. We here
evaluated the outcome after liver resection for CRC metastases and analyzed
potential prognostic factors.
METHODS: Long-term follow-up was available in 186 patients (32% female,
median age 63 years) who underwent primary liver resection for CRC
metastases between 1996 and 2006. Initially 57% had colon and 43% rectal
cancer. 66% of the primary tumors were lymph node positive. The median
time interval between resection of the primary and of liver metastases was 12
(range 0–140) months. For further analyses this interval was classified as <12
months or ≥12 months. Survival analysis was performed by the Kaplan-Meier-
and Cox-methods. The FONG-criteria as well as age, gender, blood trans-
fusions and extent of resection were evaluated for potential prognostic
influence.
RESULTS: An atypical or segmental resection was performed in 47%,
whereas 53% had at least a hemihepatectomy. Free resection margins were
achieved in 88%. Five year survival (5-y SV) of all patients after liver resection
was 45% (median survival 4.1 years). Univariate risk factors for poorer sur-
vival were a positive margin (5-y SV 36% vs 47% with R-0; p = 0.001) and size
of metastases ≥5 cm (5-y SV 33% vs 50% <5 cm; p = 0.009). A trend to poorer
survival was found for patients with node-positive primaries, female gender,
more than one metastasis and elevated CEA-levels. In multivariate analysis
the resection margin (p = 0.003), size of metastases (p = 0.002) and gender
(p < 0.05) were factors independently influencing survival. After classifying
patients according to the FONG-criteria (0 to 5 positive) univariate survival
analysis showed a clear correlation of survival with this FONG-score (p <
                                                                                       POSTER ABSTRACTS




0.01): patients with a score of 0 or 1 had a 5-y SV of almost 60%, whereas the
                                                                                           TUESDAY




five-year survival of patients with a score of four of five was below 35%/20%.
CONCLUSIONS: Prognosis after resection of CRC liver metastases is rela-
tively good especially in the case of small metastases and free resection mar-
gins. Identified prognostic factors (e.g., FONG-criteria) should be considered
in the planning of multimodal therapy in order to achieve optimal treatment
results in the individual patient, possibly even without (primary) resectional
therapy in high-risk patients.




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   T1732 Ultrasound Guided Liver Resection: Does This Approach
         Limit the Need for Portal Vein Embolization?
Guido Torzilli*1,2, Matteo Donadon1,2, Angela Palmisano1,2, Matteo Marconi1,2,
Fabio Procopio1,2, Florin Botea1,2, Daniele Del Fabbro1,2, Marco Montorsi2
1LiverSurgery Unit, 3rd Department of Surgery, University of Milan, Istituto Clinico
Humanitas – IRCCS, Rozzano – Milano, Italy; 23rd Department of Surgery, University of
Milan, Istituto Clinico Humanitas – IRCCS, Rozzano – Milano, Italy
BACKGROUND: Since major removal of liver parenchyma is undoubtedly
associated with higher risk of morbidity and mortality, portal vein emboliza-
tion (PVE) has been advocated to minimize that risk. However, PVE itself has
associated morbidity. Ultrasound-guided resection minimizing the need for
major resections, could make PVE mostly unnecessary. The aim of this study
was to validate this hypothesis.
MATERIAL AND METHODS: Two hundred and fifty-three consecutive
patients who underwent liver surgery were reviewed. Sixty-eight of these
patients with tumors corresponding to right 1st/2nd order portal branches
(Zone P) and right hepatic vein (Zone H) were selected as potential candidates
for major hepatectomy and as consequence to PVE. Indications to PVE were
defined according to the most recent reported criteria based on liver back-
ground, and expected remnant liver volume. Surgical strategy was based on
the relationship between the tumor and the intrahepatic vascular structures
at intraoperative ultrasonography (IOUS). Postoperative outcome, rate of
local recurrence, rate of major hepatectomy and PVE were analyzed.
RESULTS: Thirty-seven (54%) patients with tumors located in Zones H and P
were potential candidates to PVE, but none underwent this procedure. Major
hepatecomies were performed in 5 (7%) patients. No hospital mortality was
seen. Morbidity rate was 15% and major morbidity occurred in 2 patients.
Blood transfusion rate was 11%. Mean tumor-free margin was 0.13 cm
(median 0.1; range 0–0.6). None had local recurrence after a mean follow-up
of 27.3 months (median 25; range 6–61).
CONCLUSIONS: In conclusion, these results show that IOUS guidance
allows an alternative, safe, and effective surgical approach for patients gener-
ally submitted to major hepatectomy and most of them to preoperative PVE.
In this perspective, further studies are required to reassess indications to PVE.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1733 Surgical Management of Leiomyosarcoma of the
         Inferior Vena Cava in Eight Patients
Sung W. Cho, James W. Marsh, David A. Geller, Jason Heckman, Shane Holloway,
Matthew Holtzman, Herbert Zeh, David L. Bartlett, T. Clark Gamblin*
University of Pittsburgh Medical Center, Liver Cancer Center, Pittsburgh, PA
INTRODUCTION: Leiomyosarcoma of the inferior vena cava (IVC) is a rare
tumor for which en bloc resection offers the only chance of cure. Due to its
rarity, however, optimal surgical and adjuvant treatment strategies are not
well defined.
METHODS: We performed a retrospective review of eight patients with IVC
leiomyosarcoma. We evaluated clinical presentations, operative techniques,
patterns of recurrence and survival.
RESULTS: From 1990 to 2007, 8 patients (4 females) underwent curative
resection. Median age was 58 years (40–76). Presentations included abdomi-
nal pain (5), back pain (2), leg swelling (3) and abdominal mass (2). Preopera-
tive CT or MRI scans showed location of the tumor to be from the right
atrium to renal veins (1), retrohepatic (4), and from hepatic veins to the iliac
bifurcations (3). En bloc resection included right nephrectomy (3), right
adrenalectomy (4), pancreaticoduodenectomy (1), right hepatic trisegmentec-
tomy (1) and right hemicolectomy (1). The IVC was ligated in 5 patients, and
a prosthetic graft was used for IVC reconstruction in 3 patients. Median size
of the tumor was 10 cm in diameter (6–30). Resection margins were negative
in 6 cases and microscopically positive in 2 cases. Median length of stay was
13 days (6–22). Morbidity included two cases of atrial fibrillation, one retro-
peritoneal hematoma, and one transient hepatic encephalopathy. There was
one postoperative death from multi-system organ failure. Three patients
received adjuvant chemotherapy and/or radiation. Median follow-up was 43
months (2–111). 7 patients were alive at last follow-up. 4 patients had recur-
rence; liver (3), retroperitoneum (2) and lungs (1). The median time interval
to recurrence was 14 months (3–28). 2 patients underwent successful resec-
tion of recurrence (ex-vivo right hepatic lobectomy and resection of a retro-
peritoneal mass respectively), and one received TACE for intrahepatic
recurrence.
CONCLUSIONS: Curative resection of IVC leiomyosarcoma can lead to long-
term survival. However, recurrence is common, and effective adjuvant treat-
                                                                                   POSTER ABSTRACTS




ments are needed. In selected cases, aggressive surgical treatment of local
recurrence should be considered.
                                                                                       TUESDAY




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Clinical: Pancreas
  T1734 EUS-Guided Drainage of Peripancreatic Fluid Collections
        Following Distal Pancreatectomy
Shyam Varadarajulu*1, John D. Christein2, Charles M. Wilcox1
1Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL;
2Surgery, University of Alabama at Birmingham, Birmingham, AL

BACKGROUND: Peripancreatic fluid collections (PFC) are a frequent com-
plication following distal pancreatectomy (DP). Trans-papillary pancreatic
stenting and percutaneous drainage are non-surgical management options
with variable outcomes. Endoscopic trans-mural drainage by means of cyst-
gastrostomy is feasible only when the PFC is large enough to causes luminal
compression. However, endoscopic ultrasound (EUS) offers the potential to
access PFC under direct sonographic visualization in patients without lumi-
nal compression.
AIM: Evaluate the role of EUS in management of PFC following DP.
METHODS: We prospectively collected data on all symptomatic patients
referred for EUS-guided drainage of PFC following DP over a 3-yr period. Prior
to EUS, all patients underwent contrast enhanced CT of the abdomen and
ERCP. PFC was classified per Atlanta criteria. EUS-guided drainage was under-
taken when trans-papillary pancreatic stenting failed or was ineffective. At
EUS, the PFC were accessed trans-gastrically using a 19-gauge FNA needle and
after passage of a 0.035 inch guidewire, sequential dilation of the trans-gastric
tract was performed up to 8 mm and 7 Fr/10 Fr double pigtail stents/drainage
catheters were deployed. Technical success was defined as successful place-
ment of stent/drain within the PFC. Treatment success was defined as resolu-
tion of clinical symptoms and fluid collection on follow-up CT at 6-weeks.
RESULTS: Ten patients (6 Male, mean age 54.1yrs [range, 29–79]) underwent
EUS-guided drainage of PFC (5 pseudocyst, 5 abscess) following DP. These
were inclusive of referred patients from outside facilities and different subspe-
cialties. Indications for DP were neuroendocrine tumor in 4, cyst neoplasm
(3), splenectomy (2), and trauma (1). Eight of 10 patients had undergone
prior trans-papillary pancreatic stenting; ERCP was unsuccessful in 2 patients.
Mean size of the PFC (largest dimension) was 68 mm (range, 40–110 mm) and
did not cause luminal compression in any patient. EUS-guided drainage was
technically successful in 9 of 10 (90%) patients. Trans-gastric site for PFC
drainage was gastric cardia in 5 patients, fundus (3) and lesser curvature (1).
Mean procedural duration was 46 minutes (range, 18–95). Treatment was suc-
cessful in 7 of 9 patients (78%): two patients with pancreatic abscess had per-
sistent symptoms requiring surgical drainage. No procedural complications
were encountered. One patient had recurrence of PFC after 8 months and was
managed successfully by repeat EUS-guided drainage.
CONCLUSIONS: EUS-guided drainage is a safe, minimally invasive, and
highly effective technique for management of PFC that develop following
distal pancreatectomy.



                                       318
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1735 Management of Intraductal Papillary-Mucinous
         Neoplasms of the Pancreas (IPMN): A 10-Year
         Experience in Two Pancreatic Centers in Germany
Robert Grützmann*1, Dag Dittert3, Ralf Hildenbrand4, Stefan Post2,
Hans Detlev Saeger1, Marco Niedergethmann2
       University Hospital Dresden, Dresden, Germany; 2Surgery, University Hospital
1Surgery,
Mannheim, Mannheim, Germany; 3Pathology, University Hospital Dresden, Dresden,
Germany; 4Pathology, University Hospital Mannheim, Mannheim, Germany
BACKGROUND: The intraductal papillary-mucinous neoplasms (IPMN)
were officially introduced into the TNM Classification in 1996. Based on a
two-centre database we set out to reevaluate histopathological findings, clini-
copathological clusters, predictive markers for malignancy and outcome.
METHODS: Between 1996 and 2006 a total of 1,424 pancreatic resections
were performed in the University Hospitals Dresden and Mannheim. Patholo-
gists of both institutions reviewed the IPMN-cases and other with cystic or
solid tumor diagnoses. All possible markers such as diabetes, jaundice, etc. were
analyzed for prediction of malignancy. We performed a survival analysis based
upon the morphologic classification to determine the prognosis of IPMN.




RESULTS: There were 43 cases of primarily diagnosed IPMN along with 1174
cases with diagnoses such as ductal adenocarcinoma. In 207 cases the diag-
noses revealed other cystic or small solid tumors. A histopathological review of
these cases revealed 54 IPMNs, resulting in a total of 97 IPMN-cases (29 non-
                                                                                      POSTER ABSTRACTS




invasive, 68 invasive). All IPMN-cases had a median survival of 36 months.
                                                                                          TUESDAY




Recurrence occurred more frequently in invasive IPMN. Predictive markers of
malignancy were pain, preoperative weight loss, jaundice and elevated CA
19.9. The strongest independent prognostic factor was invasive growth. The
survival analysis revealed excellent prognosis for non-invasive IPMN.
CONCLUSIONS: Since the introduction of IPMN in 1996 even specialized
centers have had to deal with a learning curve. By re-evaluating all cystic or
small solid tumors centres can improve and their patients treatment can be
optimized. Since the preoperative diagnostic methods are not sensitive
enough to differentiate between benign and malignant lesions surgery is
advocated for all IPMN lesions.


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   T1736 Indication for Special Therapies in Acute Pancreatitis:
         Optimum Severity Score for Continuous Regional
         Arterial Infusion and Enteral Nutrition
Takashi Ueda*1, Yoshifumi Takeyama1, Takeo Yasuda1, Makoto Shinzeki2,
Hidehiro Sawa2, Yonson Ku2, Yoshikazu Kuroda2, Harumasa Ohyanagi1
        Kinki University School of Medicine, Osaka-sayama, Japan; 2Surgery,
1Surgery,
Kobe University School of Medical Sciences, Kobe, Japan
BACKGROUND/AIM: Despite advances in intensive care, the mortality rate
in severe acute pancreatitis (SAP) is still high. As special therapies, continuous
regional arterial infusion of protease inhibitor and antibiotics (CRAI), and
enteral nutrition (EN) are now utilized in Japan. Since 1999, we have per-
formed CRAI in patients with pancreatic necrosis and EN in patients with SAP
according to the Japanese criteria. We recently reported that the mortality
rate was lower in CRAI (+) group (37%) than that in CRAI (–) group (54%) and
that the mortality rate was lower in EN (+) group (19%) than that in EN (–)
group (35%). However, there have been no analyses about the indications for
CRAI and EN. This study aimed to clarify the optimum severity score for CRAI
and EN.
METHODS: We evaluated 125 patients with SAP according to the Japanese
criteria between 1990 and 2006. Severity scores (Ranson and APACHE II) were
estimated on admission. CRAI administered a protease inhibitor (nafamostat
mesilate: 250 mg/day) and an antibiotic (imipenem: 1.0 g/day) via the celiac
artery and SMA for 5–7 days after admission. EN was started through the N-J
tube within 3–7 days after admission and was continued until day 21. We
analyzed the relationships between severity scores and the mortality rates in
patients with and without CRAI and EN, respectively.
RESULTS: In patients with Ranson ≤4, there was no significant difference
between the mortality rates in CRAI (+) and CRAI (–) group. In patients with
Ranson ≥5, the mortality rate was lower in CRAI (+) group (12/25 = 48%) than
that in CRAI (–) group (15/19 = 79%) (P < 0.05). In patients with APACHE II
0–7, 8–14, and ≥22, there were no significant differences between the mortal-
ity rates in CRAI (+) and CRAI (–) group, respectively. In patients with
APACHE II 15–21, the mortality rate was lower in CRAI (+) group (5/13 =
38%) than that in CRAI (–) group (9/12 = 75%) (P = 0.07). In patients with
Ranson ≤2, there was no significant difference between the mortality rates in
EN (+) and EN (–) group. In patients with Ranson ≥3, the mortality rate was
lower in EN (+) group (9/38 = 24%) than that in EN (–) group (27/57 = 47%)
(P < 0.05). In patients with APACHE II 0–7, 8–14, and ≥22, there were no sig-
nificant differences between the mortality rates in EN (+) and EN (–) group,
respectively. In patients with APACHE II 15–21, the mortality rate was lower
in EN (+) group (3/10 = 30%) than that in EN (–) group (11/15 = 73%) (P < 0.05).
CONCLUSIONS: In patients with Ranson ≥5 or APACHE II 15–21, CRAI was
effective in reducing the mortality rate. In patients with Ranson ≥3 or
APACHE II 15–21, EN was effective in reducing the mortality rate.




                                        320
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1737 Usefulness of 13C-Labeled Mixed Triglyceride Breath
        Test for Evaluating Exocrine Pancreatic Function
        After Pancreatic Surgery
Hiroyuki Nakamura*, Yoshiaki Murakami, Kenichiro Uemura, Yasuo Hayashidani,
Takeshi Sudo, Taijiro Sueda
Department of surgery, Graduate school of biomedical sciences, Hiroshima University,
Hiroshima, Japan
BACKGROUND: Among the previous described noninvasive markers for
screening of exocrine pancreatic insufficiency, fecal elastase-1 test has been
reported to be the most satisfactory exocrine pancreatic function test.
Recently, indirect tests such as breath tests have developed in which stable
isotopes (13C) are incorporated into test meals. The aim of this study was to
evaluate the diagnostic efficacy of 13C-labeled mixed triglyceride breath test
as an exocrine pancreatic test for patients undergoing pancreatic resection.
METHODS: The 13C-labeled mixed triglyceride breath test and fecal
elastase-1 test were performed in 7 healthy subjects, 10 patients with chronic
pancreatitis and 95 patients undergoing pancreatic surgery. The 95 pancreatic
resections consisted of 42 pylorus-preserving pancreatoduodenectomies
(PPPD), 9 pancreatic head resections with segmental duodenectomy, 14 local
resections of head of the pancreas combined with longitudinal pancreaticoje-
junostomy for chronic pancreatitis (Frey procedure), 8 necrosectomies for
necrotizing acute pancreatitis, 6 segmental resections of the pancreas (SR), 13
distal pancreatectomies (DP) and 3 total pancreatectomies (TP). All patients
undergoing surgery were examined when about one year had passed since
operation. After a 12-hour fast, 200 mg of 13C-labeled mixed triglyceride was
orally administered with a test meal, and breath samples were taken before
and at 1-hour intervals for 7 hours. Thereafter, the increase in 13C/12C isoto-
pic ratio in breath was analyzed by mass spectrometry. The concentration of
fecal elastase-1 was determined using an enzyme-linked immunosorbent
assay (Schebo-Tech, Wettenberg, Germany).
RESULTS: The 13CO2 cumulative recovery at 7 hours was found to be signif-
icantly correlated with the concentration of fecal elastase-1 (n = 112, R2 = 0.14,
P < 0.0001). Not only the 13CO2 cumulative recoveries at 7 hours, but also
fecal elastase-1 concentrations of patients undergoing PPPD, patients under-
going Frey procedure and patients undergoing TP were significantly lower
than those of healthy volunteers (P < 0.05). On the fourth day after with-
                                                                                       POSTER ABSTRACTS




drawal of oral pancreatic enzyme supplement, 20/25 (80%) patients with low
                                                                                           TUESDAY




13CO2 cumulative recoveries (less than 5%) showed symptoms of exocrine
pancreatic insufficiency such as excessive volumes of stool or loose stool.
CONCLUSIONS: These results suggested that 13C-labeled mixed triglyceride
breath test was an useful test for evaluating exocrine pancreatic function in
patients undergoing pancreatic resection.




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   T1738 Surgical Resection of Renal Cell Carcinoma Metastatic
         to the Pancreas
Joshua G. Barton*1, Jarrod R. Daniel1, Andrew C. Mccoy1, Michael J. Levy2,
David Nagorney1, Florencia G. Que1, Michael B. Farnell1, Michael L. Kendrick1
1Surgery,Mayo Clinic, Rochester, MN; 2Gastroenterology and Hepatology, Mayo Clinic,
Rochester, MN
BACKGROUND: Metastatic lesions to the pancreas account for less than 2%
of pancreatic neoplasms. Outcomes of pancreatic resection for disease-specific
metastases are poorly defined due to their low incidence and grouping of
multiple tumor types in current series. Renal cell carcinoma appears to be the
most common source of pancreatic metastases. Overall 5-year survival rates
for unresectable metastatic renal cell carcinoma are typically less than 10%.
Our aim is to define the surgical management and outcome of patients with
metastatic renal cell carcinoma to the pancreas.
METHODS: Retrospective review of all patients who underwent pancreatic
resection for metastatic renal cell carcinoma at our institution from January
1990 to November 2007. Analysis included clinical evaluation, operative
management, histology, and outcomes.
RESULTS: A total of 32 patients (18 male, 14 female) with a mean age of 68
years (44–82) were identified. Presentation of the pancreatic metastases was
metachronous in 31 patients and synchronous in 1. Solitary pancreatic
metastases were identified in 21, while 11 patients had multiple pancreatic
metastases (range: 1–6). Resection was limited to the pancreas (n = 19),
involved additional metastatic sites (n = 9), or included renal-bed recurrence
(n = 3). The median interval from nephrectomy to pancreatic resection was 9
years (1–42). Pancreatic resection included distal pancreatectomy (n = 26),
total pancreatectomy (n = 3), and pancreaticoduodenectomy (n = 2). R0 resec-
tion was accomplished in 31 patients (97%). One patient underwent a pallia-
tive (R2) resection. One patient underwent completion pancreatectomy for
recurrent pancreatic metastases 55 months after distal pancreatectomy. Perio-
perative mortality was not observed. Follow-up data was available in 31
patients (97%) for a mean of 53 months. Tumor recurrence was observed in
15 patients (48%), a mean of 29 months (4–96) after pancreatic resection. Dis-
ease-free and overall survival following pancreatic resection was 35 and 53
months respectively, with an actual 5-year survival of 42%.
CONCLUSION: Metastatic renal cell carcinoma is typically associated with
poor survival. Pancreatic resection for metastases may offer a survival advan-
tage; however, potential patient selection bias and lack of comparative trials
limit validation. Pancreatic resection does appear warranted in selected
patients where an R0 resection is possible.




                                        322
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1739 Pancreatic Acinar Cell Carcinoma: A Multi-
        Institutional Study
Jesus M. Matos*1, C. Max Schmidt1,5, Marco Niedergethmann3, Hans Detlev Saeger2,
Nipun Merchant4, Keith D. Lillemoe1, Robert Grützmann2
1Department   of Surgery, Indiana University School of Medicine, Indianapolis, IN;
2Department   of Surgery, University Hospital Dresden, Dresden, Germany; 3Department
of Surgery, University Hospital Mannheim, Mannheim, Germany; 4Department of
Surgery, Vanderbilt University Medical Center, Nashville, TN; 5Department of
Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
BACKGROUND: Acinar cell carcinoma of the pancreas (ACC) accounts for
approximately 1% of exocrine pancreatic tumors. Prognosis is poor, but
recent studies suggest a better prognosis than ductal adenocarcinoma (DA).
This study represents pooled data from multiple academic institutions to bet-
ter understand the natural history and outcomes of patients with this rare
form of pancreatic cancer.
METHODS: Multi-institutional retrospective review of patients with ACC
was conducted to evaluate the clinical presentation and outcomes of patients
with ACC.
RESULTS: Between the years 1988 and 2007, 16 patients were identified
with acinar cell carcinoma (ACC) of the pancreas. Median age at presentation
was 65 years. Patients commonly presented with abdominal (56%), back pain
(44%) and weight loss (40%). Jaundice was not a typical presenting symptom.
Fourteen patients underwent 15 operations: pancreaticoduodenectomy (8),
distal pancreatectomy (4), and exploratory laparotomy (3). Three patients
were found to be unresectable at initial operation, two with regionally
advanced tumors and one with occult liver metastases. One patient with a
regionally advanced tumor received neoadjuvant chemotherapy and was sub-
sequently resected, and the other underwent chemoradiation but developed
distant disease (supraclavicular node). Two patients were referred for surgery,
but were managed non-operatively due to metastases. Mean tumor size was
5.5 ± 0.7 cm. AJCC tumor stages were stage I (1); stage II (9); stage III (3); and
stage IV (3). In resected cases, 1 year survival was 100% and 5 year survival
was 50%. Seven of 12 resected patients remain alive. One, the longest survi-
vor to date (stage II), has survived 83 months. Two experienced hepatic
metastases as a first sign of recurrence. One succumbed 13 months after distal
                                                                                          POSTER ABSTRACTS




pancreatectomy, and the other remains alive 76 months after pancreati-
coduodenectomy. Patients with pre-operative metastases managed non-oper-
                                                                                              TUESDAY




atively were found to have a broad range of survival (1–63 months).
CONCLUSION: ACC of the pancreas is rare and has a presentation and out-
come distinct from pancreatic ductal adenocarcinoma. Tumor size is larger at
presentation, and prognosis in resected patients reflects other recent series
demonstrating better survival. Patients with advanced disease managed non-
operatively experience variable survival. A larger study is needed to examine
treatment related outcomes and other predictors of survival in patients with
ACC of the pancreas.



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  T1740 Pancreatic Exocrine Function in Patients Undergoing
        Distal Pancreatectomy as Assessed by Human Stool
        Elastase-1
James E. Speicher*, L. William Traverso
Department of Surgery, Virginia Mason Medical Center, Seattle, WA
INTRODUCTION: What impact does distal pancreatectomy have on pancre-
atic exocrine function? With the recent ability to measure human stool
elastase-1 (HSE-1), the evaluation of exocrine insufficiency has become less
complex and has a negative predictive value of almost 100%. Our studies
have suggested that pancreatic insufficiency after pancreaticoduodenectomy
is caused by exocrine atrophy from pancreatic cancer and/or parenchymal
loss from resection. Our objective was to use HSE-1 to determine exocrine
function after distal pancreatectomy (DP)—this has not previously been
studied.
METHODS: During a 65 month period (July 2002–November 2007), 100
patients underwent DP by the same surgeon. The pathologic tissue diagnosis
and the amount of pancreas resected were recorded. Extent of resection was
divided into two categories, those limited to the left of the portal vein (PV)
and those extending to the PV or further. HSE-1 values were measured preop-
eratively in 68 patients and repeated at 3 ± 2 months, 12 ± 3 months, and 24
± 6 months in 39, 19, and 9 patients, respectively. HSE-1 was expressed as
abnormal at ≤200 µg/g stool.
RESULTS: Preoperative HSE-1 values were abnormal in 19% of patients prior
to undergoing DP (67% if chronic pancreatitis, 38% if pancreatic adenocarci-
noma, and 11% in all other diseases; p < 0.001). Postoperative HSE-1 levels
were then compared by the amount of pancreas resected. At three months
after resection, HSE-1 was normal or became normal in all patients if resec-
tion was limited to the left of the PV, but in just 79% if resection extended to
the PV (p = 0.03). At 12 months, normal HSE-1 was observed in 100% of
patients if the resection was to the left of the PV and 88% if resection
extended to the PV (p = 0.2). At 24 months, our limited results showed nor-
mal function in 100% of patients if the resection was to the left of the PV and
75% if resection extended to the PV (p = 0.2). In the subgroup with normal
preoperative HSE-1 (81% of patients) whose resection was limited to the left
of the PV, 100% had normal exocrine function at all timepoints. If the resec-
tion extended to the PV, 82% had normal exocrine function at three months
(p = 0.09), while 100% had normal exocrine function at 12 and 24 months.
CONCLUSION: Of patients undergoing DP, one-fifth will have pancreatic
insufficiency, most commonly those with pancreatic adenocarcinoma or
chronic pancreatitis. Postoperative pancreatic insufficiency was seen only in
those with resection that extended to the PV or beyond, and was transient.
Exocrine insufficiency before and after DP is related to both the disease and
the extent of resection, and can improve with time.




  Poster of Distinction

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1741 Risk Factors for Pancreatic Leak Following Distal
        Pancreatectomy
Hari Nathan*, Michael Choti, Christopher L. Wolfgang, C. Rory Goodwin,
Akhil K. Seth, Jordan M. Winter, Edil H. Barish, Richard D. Schulick,
Timothy M. Pawlik, John L. Cameron
Surgery, Johns Hopkins University, Baltimore, MD
BACKGROUND: Pancreatic leak (PL) remains a major cause of postoperative
morbidity in patients undergoing pancreatic resection. We sought to evaluate
the incidence of and identify risk factors for the development of PL in
patients undergoing distal pancreatectomy (DP).
METHODS: All patients who underwent primary DP (excluding completion
pancreatectomy and debridement) between 1/1/1984 and 7/1/2006 were
identified. Data on demographics, clinicopathologic features, operative details,
complications, and mortality were analyzed. Chi-squared and multivariate
logistic regression analyses were performed to identify risk factors for PL.
RESULTS: In a cohort of 704 patients undergoing primary DP, the median
age was 58 years, 45% were male, and 80% were white. The indications for DP
were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm
(31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%),
and trauma (3%). Splenectomy was performed in 89%. The pancreatic rem-
nant was sutured alone in 83%, stapled alone in 5%, and both stapled and
sutured in 9%. Duct ligation was performed in 22%. Perioperative mortality
was <1%, but overall morbidity was 33%. PL requiring a change in clinical
management was seen in 12% of cases. Development of PL was associated
with an increase in perioperative mortality from 1% to 4% (P = 0.04) and an
increase in median length of stay from 7 to 10 days (P < 0.001). Of those with
PL, 35% required additional percutaneous drainage, but only 2% required
reoperative intervention. Multivariate analysis revealed that malignant neo-
plasm (odds ratio (OR) 1.3, P = 0.29) and chronic pancreatitis (OR 1.6,
P = 0.12) as indications for DP did not change PL risk as compared to benign
neoplasm. However, increased risk of PL was seen when DP was performed for
trauma (OR 6.2, P = 0.001) or pseudocyst (OR 3.3, P = 0.02). Tobacco use (OR
2.0, P < 0.001) was associated with increased PL risk, while preoperative dia-
betes was associated with decreased risk (OR 0.33, P = 0.003). Neither staple
vs. suture closure of the pancreatic remnant (OR 1.4, P = 0.65) nor ligation of
the pancreatic duct (OR 2.0, P = 0.05) affected PL risk.
                                                                                     POSTER ABSTRACTS




CONCLUSIONS: This largest reported series of DP demonstrates that this
                                                                                         TUESDAY




procedure can be performed with low mortality but still carries a substantial
risk of morbidity, particularly PL. DP in the trauma setting significantly
increases the risk of PL. In contrast to previous studies, PL risk was not associ-
ated with surgical management of the pancreatic remnant. These results
emphasize the need for prospective randomized trials to evaluate strategies to
reduce PL occurrence.




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   T1742 Analysis of Organ Failure, Mortality and Pancreatic
         Necrosis in Patients with Severe Acute Pancreatitis
Tercio De Campos*1,2, Cinara Cerqueira1, Laise Kuryura1, Silvia Solda1,
Jacqueline Perlingeiro1, Jose C. Assef1, Samir Rasslan2,1
1Emergency  Unit, Santa Casa School of Medical Sciences, São Paulo, Brazil; 2General
Surgery, University of São Paulo, São Paulo, Brazil
BACKGROUND: Mortality in severe acute pancreatitis varies from 10% to
20%. The early identification of patients with higher risk of complications is
crucial to treat them properly. APACHE II is the most used scoring system to
determine the severity of acute pancreatitis. However, some problems have
been related, as the overestimation of severity, and other scores have been
proposed, such as SOFA and Marshall. The aim of this study is to determine
variables related to the development of organ failure, mortality and necrotiz-
ing pancreatitis in patients with severe acute pancreatitis.
METHODS: Evaluation of all patients with acute pancreatitis admitted in
this hospital, including in the analysis only patients with APACHE II > 8 at
admission. SOFA score and Marshall score were also obtained. The variables
analyzed were age, sex, aetiology, hematocrit, leukocytes, C-reactive protein,
computerized tomography and length of stay. These variables were related
with the development of organ failure, mortality and necrotizing pancreatitis.
RESULTS: One hundred and seventy-five patients were admitted with acute
pancreatitis, and 39 (22.3%) were classified as severe acute pancreatitis due to
APACHE II >8. The mean APACHE II value was 11.6 ± 3.1, SOFA score 3.2 ± 2
and Marshall 1.5 ± 1.9. Respiratory failure was present in six (15.4%) patients
with severe acute pancreatitis. Eleven patients developed necrotizing pancre-
atitis. Mortality of patients with APACHE II >8 was 7.7%. The variables related
with organ failure were APACHE II, SOFA >3 and Marshall >3, and variables
related with mortality were SOFA >3 and leukocytosis >19,000. C-reactive
protein >19.5 mg/dl and length of stay were related to necrotizing pancreatitis.
CONCLUSION: The scoring systems, particularly the SOFA score, are related
to the development of organ failure and mortality. C-reactive protein demon-
strates relationship with necrotizing pancreatitis. There is no relationship
between scoring systems and necrotizing pancreatitis in severe acute
pancreatitis.




                                         326
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1743 Quality of Life in Long-Term Survivors After
         Pancreaticoduodenectomy
Roberto Salvia, Stefano Crippa*, Francesca Mazzarella, Claudio Bassi,
Stefano Partelli, Massimo Falconi, Giovanni Butturini, Paolo Pederzoli
Department of Surgery, Università di Verona, Verona, Italy
Few data are available with respect to quality of life (QoL) in long-term survi-
vors after pancreaticoduodenectomy (PD). Aim of this study is to evaluate
QoL and long-term outcomes in patients who underwent PD between 1990
and 2003 with a minimum follow-up of 48 months. Among 268 patients
identified, 168 were still alive and were surveyed with the European Organi-
zation for Research and Treatment of Cancer Quality of Life Questionnaire
C30 (EORTC QLQ-C30), and with an Institutional questionnaire on long-
term complications. Of the 168 surviving patients, 109 (65%) agreed to parte-
cipate at a median of 7.5 years postoperatively. Pylorus-preserving pancreati-
coduodenectomy (PPPD) was performed in 75% of cases; 56 patients (51.5%)
had malignant neoplasms, 23 (21%) borderline tumors, and 30 (27.5%)
benign neoplasms. Intraductal papillary mucinous neoplasms (IPMNs) was
the most common indication for surgical resection (27.5%) followed by duc-
tal adenocarcinoma (12%). Postoperative complications were recorded in 63
patients (58%). Overall, 75% of patients reported good scores in their percep-
tion of QoL. A significant decrease in QoL was found in patients with malig-
nancy, with IPMNs, in survivors > 10 years, and in those with postoperative
complications (P < 0.05). Despite no significant differences in overall QoL
perception, Whipple resection was more frequetly associated with alterations
of functional and symptomatic domains than PPPD. 55% of patients com-
plained of steatorrhea, 40% of dumping syndrome, 54% of weight loss.
Dumping syndrome is not associated with Whipple procedure, while weight
loss was more frequently observed after pancreo-gastrostomy than pancreo-
jejunostomy. New endocrine insufficiency was found in 17% of cases. Recur-
rent abdominal pain was found in 41% of patients, who had also a significant
impairment of QoL. PD is associated with acceptable QoL over time. However
a careful long-term follow-up is necessary given the significant rate of exo-
crine insufficiency rate and impairments in digestive function. Patients who
had complicated postoperative course, malignancies and who undewent PD
with pancreogastric anastomosis are at higher risk of long-term complications
and QoL impairments.
                                                                                   POSTER ABSTRACTS
                                                                                       TUESDAY




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   T1744 Intraoperative Assessment of Margin Status at the
         Time of Pancreaticoduodenectomy Ensures R0
         Resection in Patients with Pancreatic Cancer
Robert Yates*1, Kristian Wall1, Peter Muscarella2, E. Christopher Ellison2,
Mark Bloomston1
1Surgical Oncology, Ohio State University, Columbus, OH; 2General Surgery, Ohio State
University, Columbus, OH
BACKGROUND: The utility of intraoperative assessment of surgical margins
is often brought into question by experienced pancreatic surgeons. We
sought to review our experience with pancreaticoduodenectomy for pancre-
atic cancer to determine the impact of frozen section (FS) on margin negative
resection and long-term outcome.
METHODS: Between 1992 and 2007, 310 patients underwent PD at our
institution, 223 of these were for pancreatic cancer. Charts were reviewed to
determine demographics, final pathology, perioperative course, and long-
term outcome. Data were compared by Fisher’s Exact and Student’s T tests.
Survival curves were created using the Kaplan-Meier method and compared
by Log-rank analysis. Predictors of R0 resection were determined by logistic
regression analysis and predictors of survival determined by Cox Proportional
Hazards analysis.
RESULTS: FS analysis of resection margins were obtained in 75 while no
intraoperative assessment was done in 148. Although patients who under-
went FS were younger (median 62 yrs vs. 67, p = 0.01), the two groups were
similar in terms of gender, comorbidities, preoperative stenting, pylorus pres-
ervation, tumor differentiation, nodal status, T stage, tumor size, length of
stay, and complication rate. Margin-negative resection was more common
when FS was undertaken (99% vs. 70%, p < 0.0001). However, intraoperative
FS did not significantly increase disease-free (median 17.3 months vs. 12.5,
p = 0.12) or overall survival (median 21.7 vs. 14.6, p = 0.20). Nodal status and
tumor grade were predictive of survival only in patients not undergoing FS.
CONCLUSIONS: Intraoperative assessment of margin status at the time of
pancreaticoduodenectomy for pancreatic cancer increases the likelihood of
obtaining an R0 resection. Noteworthy is that final margin status was not pre-
dictive of survival, however. While nodal metastasis was predictive of poorer
survival for the entire cohort, this effect was lost when frozen section was
undertaken.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1745 Surgical Drainage of Symptomatic Peripancreatic
        Fluid Collections in the Era of Endoscopic
        Management
Luis A. Benavente-Chenhalls*1, Eduardo E. Montalvo-Jave3, Michael B. Farnell1,
Michael G. Sarr1, Todd H. Baron2, Michael L. Kendrick1
1General Surgery, Mayo Clinic, Rochester, MN; 2Gastroenterology, Mayo Clinic,
Rochester, MN; 3Gastroenterology Research Unit, Mayo Clinic, Rochester, MN
BACKGROUND: With the advent of endoscopic drainage of symptomatic
peripancreatic fluid collections (PPFC), the role of surgical intervention has
decreased. Patients with complex, inaccessible collections or with prior
unsuccessful drainage attempts account for an increasing proportion of those
managed surgically. Our aim was to evaluate the morbidity, mortality and
outcomes of the surgical management of symptomatic PPFC in this new era.
METHODS: Retrospective review of all patients undergoing surgical manage-
ment of benign, symptomatic PPFC from 1990 to 2006.
RESULTS: Of 449 patients having undergone drainage procedures for PPFC,
105 (23%) had surgical drainage, comprising our study group. The mean age
was 50 years (21–86), with 58% male. The mean interval from the first epi-
sode of pancreatitis to surgical intervention was 18 months. Surgical inter-
vention was the primary treatment in 57%, or secondary after previous
endoscopic (38%) or percutaneous (5%) attempts. The mean number of endo-
scopic procedures was 2.6 (1–14) and included transgastric (63%), transpapil-
lary (27%), and transduodenal (7%) approaches. Operative intervention
included cyst-enterostomy (47%), cyst-gastrostomy (31%), distal pancreatec-
tomy (10%), external drainage (9%), lateral pancreaticojejunostomy (1%),
and total pancreatectomy (1%). Evidence of peripancreatic necrosis at opera-
tion was evident in 8%. Major postoperative morbidity or perioperative mor-
tality occurred in 41% and 0% respectively. Perioperative complications
included infection-related complications (23%), anemia requiring transfusion
(17%), pulmonary embolism (6%), pancreatic fistula (3%), and small bowel
obstruction (3%). Perioperative ICU admission was necessary in 15%, with a
mean ICU stay of 8 days (1–33). Perioperative reoperation for abdominal sep-
sis or hemorrhage was required in 4 patients. The mean hospital stay was 31
days (2–242). Recurrent pancreatitis or pseudocyst occurred in 17% and 9%
respectively.
                                                                                 POSTER ABSTRACTS




CONCLUSION: Surgical drainage of PPFC is less commonly performed in the
era of endoscopic drainage. Operative intervention in these select patients is
                                                                                     TUESDAY




associated with a high morbidity and may be attributed to increased disease
complexity preventing endoscopic drainage attempts, or to complicating fac-
tors after attempted drainage.




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   T1746 Estimation of Physiologic Ability and Surgical Stress
         (E-PASS) as a Predictor of Immediate Outcome After
         Pancreatic Surgery: The Score Needs to Be Adapted!
Simone Deyle, Markus Wagner, Katrin Becker, Daniel Inderbitzin, Beat Gloor*,
Daniel Candinas
Visceral and Transplantation Surgery, Inselspital, University Bern, Bern, Switzerland
OBJECTIVE: In-hospital mortality and major morbidity following pancre-
atic resections has dropped significantly over the past decade. Single factors
such as preoperative jaundice or renal or hepatic co-morbidity have been
found to be associated with a worse outcome in various studies. The Estima-
tion of Physiologic Ability and Surgical Stress (E-PASS) score was designed on
the premise that the balance between the patient’s physiologic reserve capac-
ity and the surgical stress may determine postoperative morbidity and mor-
tality. The initial calculation of the E-PASS included among 1281 patients
only 32 (2.4%) patients undergoing pancreaticoduodenectomy. Our aim was
to review whether the E-PASS scoring system could be used without restric-
tions in elective pancreatic surgery as a means of correctly predicting morbid-
ity and mortality.
METHODS: Relevant data of all patients undergoing pancreatic surgery at
our institution are entered in a prospectively recorded statistical database.
E-PASS data items were computed retrospectively and operative morbidity
and mortality rates were compared with the preoperative risk score (PRS), sur-
gical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The rela-
tionship of the CRS to the incidence of morbidity and mortality was
retrospectively examined and Receiver operating characteristics (ROC curve)
were calculated.
RESULTS: Between January 2002 and October 2007 a total of 305 consecu-
tive patients were operated on pancreatic lesions. Median age was 63 (range
18–86), median BMI was 24 kg/m2 (range 15–38). 198 patients underwent
pancreatic head resections (65%), 58 distal resections (19%), 17 total pancre-
atectomies (5%) and 30 other types of resection (11%). There were 9 deaths
(2.9%) and 105 patients (34.5%) had complications postoperatively. Mean
CRS in the groups of patients who survived and died were 0.47 (±0.28) and
0.75 (±0.43), respectively (p < 0.01). PRS, SSS, and CRS all failed to predict
mortality and morbidity as demonstrated by low areas under the ROC curve
(range 0.500 to 0.595). Neither did CRS show a linear association with length
of hospital stay.
CONCLUSION: The E-PASS scoring system appears to be ineffective in pre-
dicting postoperative morbidity and mortality in patients undergoing elective
pancreatic surgery. Thus, further refinements focusing on problems specific
for patients undergoing pancreatic resections may be warranted in order to
delineate differences in immediate surgical outcome.




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         49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    T1747 Is Adjuvant Therapy Indicated After Pancreatectomy
          for Adenocarcinoma?
Jonathan M. Hernandez*, Daniel Molloy, Jennifer C. Cooper, Carl B. Bowers, Sarah
Cowgill, Steven B. Goldin, Alexander S. Rosemurgy
Surgery, University of South Florida and Tampa General Hospital, Tampa, FL
INTRODUCTION: Resection is the only hope of cure for patients with pan-
creatic cancer, though 5-year survival after resection remains dismal. With
hope of improving survival, application of adjuvant therapy is intuitively
rational. However, adjuvant therapy is applied to a minority of patients after
pancreatectomy. The rationale of adjuvant therapy is disconnected from its
application. This study was undertaken to assess the data supporting adju-
vant therapy following pancreatectomy for adenocarcinoma.
METHODS: The National Library of Medicine and the National Institutes of
Health were searched for trials of adjuvant therapy after pancreatectomy for
adenocarcinoma published since 1980. This search identified 191 trials; 10
were observation-controlled prospective randomized trials. Each trial was
graded on its level of data utilizing a National Cancer Institute scale (best
score of 1iA to worst score of 3iiiDiii). Methodological deficiencies, including
inclusion of other cancers, excluded 7 trials from further review. Meta-
analysis was applied to 3 observation-controlled prospective randomized
trials of adjuvant therapy. Data collected from the trials included therapies
utilized, median survival, 1-year, 2-year, and 5-year survival, and differences
in survival by survival curve analysis (Table). Meta-analysis attests that there
was not a significant advantage to adjuvant therapy during the first two years
after resection, but that a survival advantage did become apparent by five
years after resection (odds ratio = 2.291, 1.002–5.246, 95% CI).
RESULTS: See Table
CONCLUSIONS: There are few observation-controlled prospective random-
ized trials of adjuvant therapy following pancreatectomy for adenocarcinoma
and very few withstand scrutiny. Though very few in numbers, together these
trials assert that adjuvant therapy after pancreatectomy for adenocarcinoma
improves long-term survival and should be applied. All patients undergoing
pancreatectomy for adenocarcinoma should be considered for adjuvant
therapy.
                                                                                                                                   POSTER ABSTRACTS




                                                              Median                                               Survival
                                                  No.                       1-Year   2-Year   5-Year
   Author            Therapy          Grade                   Survival                                              Curve
                                                                                                                                       TUESDAY




                                                Patients                   Survival Survival Survival
                                                             (Months)                                             Difference
   GITSG         5FU/XBRT5FU           1iiA        21           20           63%          42%          19%          p = .03
   GITSG          Observation                      22           11           49%          15%          8%
 Klinkenbijl       5 FU/XBRT           1iiA        60          17.1          68%          37%          20%          p = .10
 Klinkenbijl      Observation                      54          12.6          54%          23%          10%
   Oettle         Gemcitabine          1iiD        179         22.1         72.5%         48%          23%          p = .06
   Oettle         Observation                      175         20.2         72.5%         42%          12%
Meta-analysis attests that there was not a significant advantage to adjuvant therapy during the first two years after resection,
but that a survival advantage did become apparent by five years after resection (odds ratio = 2.291, 1.002–5.246, 95% CI).




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Clinical: Small Bowel
   T1748 Can Plain Abdominal X-Ray Predict the Need for
         Operation in Patients with Adhesive Small Bowel
         Obstruction?
Nathan M. Novotny*1, Daniel A. Liesen2, Anthony Senagore3, Thomas Z. Hayward1,
Don J. Selzer1, Robert E. Pennington1, Imtiaz A. Munshi1, Nicholas J. Zyromski1
1General Surgery, Indiana University, Indianapolis, IN; 2General Surgery, Medical
University of Ohio, Toledo, OH; 3General Surgery, Michigan State University, Grand
Rapids, MI
BACKGROUND: The decision to operate on a patient with adhesive small
bowel obstruction (SBO) is multifactorial. However, in an age of ubiquitous
computed tomography scans, our hypothesis was that plain abdominal x-ray
(AXR) alone can predict whether or not patients would eventually need lap-
arotomy for definitive management of SBO.
METHODS: Thirty patients’ acute abdominal series were selected for inclu-
sion. All patients had adhesive SBO; patients with SBO due to cancer or her-
nia were excluded. Half of these patients underwent laparotomy, with
intraoperative findings or pathology confirming the need for operative inter-
vention. The others half were successfully managed conservatively. Long-
term (>1 year) follow-up confirmed no subsequent readmission or operation
for SBO. Sixteen general surgeons of varying experience were asked to predict
need for laparotomy based solely on AXR findings.
RESULTS: Surgeons’ overall accuracy in predicting the need for operation
was 50%. (Table) Surgeons with 0–10, 11–20, and 21+ years post-residency
had an accuracy of 37%, 50%, and 56% respectively. Compared to surgeons
with 0–5 years experience, surgeons with 11–20 and 21+ years of experience
were significantly more accurate (p = 0.029 and p = 0.003 respectively). Three
patients needing laparotomy had high agreement among all surgeons with
88–94% accuracy. In each of these patients, surgeons identified degree of small
bowel distention as the primary reason for predicting need for laparotomy.
CONCLUSION: These data show that plain abdominal x-ray alone is still
important in deciding which patient with adhesive SBO will require operative
intervention. Experienced gastrointestinal surgeons (>11 years) are signifi-
cantly more likely than junior surgeons (0–5 years) to predict the need for
surgery based on AXR alone.

Table 1. Summary of Surgeons Responses with Breakdown by Experience (Years Post Training)
                   N        Percent Correct (Mean, Range in Parentheses)   Specificity   Sensitivity
  All Surgeons     16                     50% (30%–63%)                      51%           49%
   Experience
    0–5 years       3                        37% (30%–43%)                    36%           37%
  11–20 years       7                       50%* (43%–63%)                    62%           43%
    21+ years       6                       56%* (47%–63%)                    46%           63%
*p < 0.05 when compared to experience of 0–5 years



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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1749 A Proposed Algorithm for Ventral Hernia Repair
        Optimizes Patient Outcome
Judy Jin*, Christina P. Williams, Michael J. Rosen
Surgery, University Hospitals Case Medical Center, Cleveland, OH
INTRODUCTION: In ventral hernia repairs, no single approach can ade-
quately treat the full spectrum of this disease. This study reports our initial
experience using a management algorithm incorporating both laparoscopic
and open techniques for the repair of all ventral hernias.
METHODS: Patients undergoing ventral hernia repair by a single surgeon
from August 2005 to August 2007 were reviewed. Complex non-infected cases
underwent open retro-rectus prosthetic repair (OP). Infected or contaminated
cases were repaired with biologic mesh after fascial reapproximation (OB).
Massive ventral hernias with loss of abdominal domain underwent staged
ePTFE serial excision (SE). All other cases were initially approached laparo-
scopically (LP).
RESULTS: 123 patients (LP = 85, OP = 17, OB = 13, SE = 8) were identified
during the period. Patient demographic information was similar in these
groups in terms of age (p = 0.38), body mass index (p = 0.34), American Society
of Anesthesiology score (p = 0.09), however, the number of prior laparotomies
or failed hernia repairs was significantly less in the LP group (p < 0.0001). The LP
group also had the smallest defect (145 cm2, range 6–720 cm2) when com-
pared with OB (252 cm2, range 48–600 cm2), OP (450 cm2, range 32–1305
cm2) and SE group (584 cm2, range 264–1258 cm2) (p < 0.001). The conver-
sion rate to open repair in the LP group was 11%, and was most commonly
due to dense adhesions. Five enterotomies occurred intra-operatively (LP 2,
OB 1, SE 2). The SE group had the longest hospital stay at 27 days (LP 4 day,
OP 5 day, OB 9 day, p < 0.001). There was no perioperative mortality noted.
The LP group had the lowest overall post operative complication rate (LP
12%, OP 35%, OB 46%, SE 63%, p = 0.0002) and a significantly lower wound
infection rate (LP 5%, OP = 53%, OB 46%, SE 50%, p < 0.0001). One patient
developed an infected seroma 10 months after a LP repair eventually requir-
ing mesh resection. There were no recurrences in the LP and OP group while
one recurrence each was identified in OB and SE group.
CONCLUSION: This study demonstrates that a standardized approach to the
management of ventral hernias can result in minimal post operative compli-
cations and low recurrence rate. In addition, the routine use of laparoscopic
                                                                                      POSTER ABSTRACTS




ventral hernia repairs resulted in significantly lower post operative wound
                                                                                          TUESDAY




complications without recurrences.




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  T1750 Laparoscopic Roux-en-Y Gastric Bypass in 400
        Consecutive Patients Without Internal Hernia
Richard S. Flint*, Thien K. Nguyen, David B. Lautz
Surgery, Brigham & Women’s Hospital, Boston, MA
BACKGROUND: Elevated rates of small bowel obstruction (SBO)and inter-
nal herniation have been reported following laparoscopic Roux-en-Y gastric
bypass (LRYG).
METHODS: We reviewed our series of LRYGB for the incidence of SBO or
internal hernia. The medical records of 409 consecutive patients who under-
went LYRGB from April 2004, through November 2007 were reviewed. All
procedures were antegastric and antecolic LRYGB, with complete running
closure of both mesenteric defects, including closure of the Petersen defect to
the margin of the transverse colon. The main outcomes measure was readmis-
sion with the diagnosis of small bowel obstruction.
RESULTS: 409 patients underwent LRYGB during the time period examined.
8 admissions for SBO in 7 patients (1.7%) were identified. Mean preoperative
BMI was 48.9 ± 7.8 kg/m2. Median time to development of SBO was 5.5
(2–442, IQR = 53) days with 5 patients presenting within the first postopera-
tive week. All SBO episodes required re-operation with small bowel resection
necessary in 3 episodes (all port site hernias). The causes of SBO at explora-
tion were umbilical port site hernia (n = 5), incarcerated ventral hernia from
previous laparotomy (n = 2), adhesions (n = 1). No admissions for SBO with
subsequent findings of internal hernia were identified. The mean excess body
weight loss in this group was 55.0 ± 17.4% at 1 year.
CONCLUSION: This study suggests that the incidence of small bowel
obstruction secondary to internal herniation following antecolic LRYGB can
be minimized by running closure of all mesenteric defects. Most small bowel
obstructions in this series were secondary to fascial defects.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Clinical: Stomach
  T1751 Surgical Therapy for Adenocarcinoma of the True
        Gastric Cardia
Marcus Feith*1, Hubert J. Stein2
1Department   of Surgery, Technische Universitaet Muenchen, Munich, Germany;
2Department   of Surgery, University Salzburg, Salzburg, Austria
BACKGROUND: The classification and the surgical management of patients
with true cardia carcinoma of the esophago-gastric junction (AEG Type II
according to Siewert’s classification) are still controversial. In the classifica-
tion of these tumour entity the UICC guidelines for gastric or esophagus car-
cinoma is contrary used and a standard surgical approach is missing. A clear
outline for the surgical technique is requested.
METHODS: We investigated 532 consecutive resected patients with an AEG
Type II, the classification according the UICC guidelines for gastric and
esophageal carcinoma were used and the optimal surgical approach was
reported.The tumour infiltration, lymph node and distant metastases, resid-
ual tumour and the long time outcome were evaluated. Statistical analysis
with Kaplan-Meier-Survival and Cox regression analysis were performed.
RESULTS: Of the 532 consecutive resected patients, in 379 (71.2%) a transhi-
atal extended gastrectomy, in 91 (17.1%) an esophagectomy, in 32 (6.0%) an
esophago-gastrectomy, and in 30 (5.7%) a limited resection of the cardia
were performed. The strictly indication for an esophagectomy or esophago-
gastrectomy in up to 23% of the patients were the preoperatively (endos-
copy) or intraoperatively (biopsy) detected tumour infiltration of the distal
esophagus or lymph node metastases in the mediastinum. The R0-resection
rate was with all approaches greater than 74%. In early carcinoma, limited to
the mucosa or submucosa, the limited resection of the cardia with oncologi-
cal lymphadenectomy and reconstruction with pedicled jejunal graft showed
optimal results in the long-time follow-up (R0-resection rate 100%, 5-year
survival 96%).The operative complications, the radicalism of the procedures
and the long time survival between gastrectomy and esophagectomy are not
significant different (p > 0.05). For the evaluation of the prognostic outcome
showed the UICC classification for gastric carcinoma in true cardia carcinoma
the better differentiation.
                                                                                   POSTER ABSTRACTS




CONCLUSION: The classification and operative approach in true carcinoma
                                                                                       TUESDAY




of the cardia request an own regulation. With the infiltration of the distal
esophagus an esophagectomy is oncologically required and results not in ele-
vated complications or reduction of the long time prognosis.




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    T1752 Surgical Technique Affects the Incidence of Marginal
          Ulceration After Roux-en-Y Gastric Bypass
Yong-Kwon Lee*, Jon S. Thompson, Valerie Shostrom, Corrigan L. Mcbride
University Nebraska Medical Center, Omaha, NE
BACKGROUND: Marginal ulceration (MU) is an increasingly recognized
complication of Roux-en-Y gastric bypass (RYGBP) surgery. Several possible
risk factors have been reported. However, the mechanism of this is poorly
understood. The aim of this study is to compare the effect of surgical tech-
nique on the incidence of marginal ulceration.
METHODS AND MATERIAL: This is a retrospective study of 752 patient
undergoing RYGBP over a ten year period with at least 1 year of follow up.
The diagnosis of MU was made based on clinical symptoms and confirmed by
endoscopy. We assessed four different RYGBP techniques (T1: Open, non-
divided stomach, TA 90-B transverse, circular stapler, non-vagotomy; T2:
Open, divided, GIA vertical, circular stapler, vagotomy; T3: Laparoscopic,
divided, GIA, circular staple, vagotomy; T4: Laparoscopic, divided, GIA, linear
stapler, vagotomy). Parameters evaluated included demographics, risk factors,
number of post operative endoscopy (POE) and number MU. Incidence of
MU was compared among groups using the log-rank test.
RESULTS:

Table 1. Clinical Characteristics
         Techniques                      T1                    T2            T3             T4
       Number of cases                  334                    91           152            175
      Mean BMI (range)              51.8 (36–88)         52.2 (36–76)   52.1 (32–78)   50.8 (36–79)
    Mean age (range) years           47 (25–72)           44 (25–71)     44 (22–74)     46 (26–71)
     Gender (% of Female)               88.3                   78           91.4           88.6
       POE number (%)                 54 (16.2)            23 (25.3)      43 (28.3)      48 (27.4)
  Number of Marginal Ulcer (%)         7 (2.1)              5 (5.5)*     23 (15.1)*      22 (12.6)
*p-value < 0.05 compared to T1.


CONCLUSION: The incidence of MU after RYGBP surgery is influenced by
surgical technique. The overall 7.5% incidence of MU is consistent with other
studies. The lowest incidence of MU was with a non-divided stomach, no vag-
otomy and transverse staple line. There was no difference in MU using linear
or circular stapler for the gastrojejunostomy and no difference in laparoscopic
versus open bypass if a similar technique was employed.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1753 Results of Uncut Roux-En Y Reconstruction After
        Distal Gastrectomy for Gastric Cancer
Chikashi Shibata*, Terutada Kobayashi, Tatsuya Ueno, Masayuki Kakyou,
Makoto Kinouchi, Kouhei Fukushima, Iwao Sasaki
Tohoku University School of Medicine, Sendai, Japan
INTRODUCTION: Roux stasis syndrome occurs in 10–25% of patients after
distal gastrectomy with Roux-en-Y (RY) reconstruction. Aim of the present
study was to study clinical results of uncut RY reconstruction, proposed to
eliminate Roux stasis, after distal gastrectomy for gastric cancer.
PATIENTS AND METHODS: Thirteen patients with gastric cancer under-
went distal gastrectomy with uncut RY reconstruction. Briefly, after distal
stomach was removed, a side-to-side gastrojejunostomy was performed by
anastomosing greater curvature of the remnant stomach and the jejunum 35
cm distal to the ligament of Treitz in an isoperistaltic direction. A side-to-side
jejunojejunostomy was performed between the jejunum 20 cm distal to the
ligament of Treitz and the jejunum 40 cm distal to the gastrojejunostomy.
Finally, the jejunum 3 cm proximal to the gastrojejunostomy was enterically
closed using “knifeless” linear stapler. Transmural silk stitches were added
around the staples to prevent the dislocation of the staples.
RESULTS: There were 9 male and 5 female patients, and their mean age was
65 (range: 47–88) years. Clinical stages according to Japanese classification of
gastric carcinoma were IA for 4, IB for 7, and II for 2 patients. Degree of
lymph node dissection according to Japanese classification of gastric carci-
noma was D1+α for 2, D1+β for 4, and D2 for 7 patients. As additional proce-
dures, cholecystectomy was carried out in 3 patients, and resection of the
rectum for rectal cancer was done in 1 patient. Mean operative time and
intraoperative blood loss were 246 (range: 157–452) minutes and 381 (range:
185–895) ml, respectively. Mean time until start of normal diet was 8.7
(range: 6–22) days, and mean time of postoperative hospital stay was 16.2
(range: 9–42) days. Morbidity was observed in three patients (aspiration
pneumonia, delayed gastric emptying with nausea and vomiting, and leakage
of the duodenal stump). Re-canalization of the jejunum at enterically closed
site was investigated endoscopically or fluoroscopically; 2 patients had re-
canalization, 6 patients were free from re-canalization, and remaining 5
patients are scheduled to undergo endoscopic examination. Two patients
having re-canalization did not complain of symptoms associated with
                                                                                     POSTER ABSTRACTS




re-canalization.
                                                                                         TUESDAY




CONCLUSIONS: These results indicate that uncut RY after distal gastrectomy
was a safe procedure. Re-canalization of enterically closed portion did not
cause specific symptoms associated with re-canalization.




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  T1754 Changes in Inflammatory Biomarkers Across Weight
        Classes in a Representative US Population: A Link
        Between Obesity and Inflammation
Xuan-Mai T. Nguyen*, Marcelo W. Hinojosa, Brian R. Smith, Ninh T. Nguyen
Univ of CA, Irvine Medical Center, Orange, CA
BACKGROUND: Obesity has been linked with inflammation which may be
involved in the early onset of metabolic syndrome, cardiovascular disease,
nonalcoholic steatohepatitis, and even cancer. The objective of this study was
to examine the association between body mass index (BMI) and levels of
inflammatory biomarkers from men and women participating in the latest
National Health and Nutrition Examination Survey (NHANES).
METHODS: Serum concentrations of C-reactive protein (CRP) and fibrino-
gen were reviewed from US participants in the NHANES between 1999 and
2004. Biomarker levels were calculated across the different weight classes
where normal weight, overweight, and obesity classes 1, 2 and 3 were defined
as BMI of <25.0, 25.0–29.9, 30.0–34.9, 35.0–39.9, and >40.0, respectively.
RESULTS: With increasing overweight and obesity class, there are direct lin-
ear increases in both the mean CRP and fibrinogen concentrations. With CRP
levels of normal weight individuals as a reference, CRP levels nearly doubled
with each increase in overweight and obesity class: +0.11 mg/dL (95% CI,
0.06–0.16) for overweight, +0.21 mg/dL (95% CI, 0.16–0.27) for obesity class
1, +0.43 mg/dL (95% CI, 0.26–0.61) for obesity class 2, and +0.73 mg/dL (95%
CI, 0.55–0.90) for obesity class 3. In contrast to individuals with BMI <25.0,
fibrinogen levels were highest among obesity class 3 with an increase by
+93.5 mg/dL (95% CI, 72.9–114.1).
CONCLUSIONS: Obesity is associated with a chronic inflammatory state
which may contribute to the development of many obesity-related comorbid-
ities. Our findings suggest that the optimal weight class to minimize inflam-
mation should be within the normal range with a BMI <25.0. Further research
is needed to determine whether weight reduction in obese individuals is asso-
ciated with a reduction in inflammation.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1755 Order of Placement Does Not Change Complication
        Rates for Patients with Concomitant
        Ventriculoperitoneal Shunt and Percutaneous
        Endoscopic Gastrostomy
Nora C. Meenaghan*, Elizabeth Franco, Adrian E. Park, J. Scott Roth
Department of Surgery, University of Maryland, Baltimore, MD
Ventriculoperitoneal shunt (VPS) placement is a common neurosurgical pro-
cedure performed for the treatment of hydrocephalus. Patients requiring VPS
due to acute stroke, intracerebral hemorrhage, or trauma often require enteral
access as a result of their neurologic injury. Percutaneous endoscopic gastros-
tomy (PEG) placement is the most commonly utilized method of enteral
access in these patients. VPS and PEG are often performed in a staged manner
to minimize the risk of VPS infections. This study investigates what effect the
order of VPS and PEG procedures has on the outcomes of patients requiring
both. From a retrospective review of 749 patients who underwent PEG place-
ment at a single institution between January 2002 and June 2007, patients
who underwent both PEG and VPS were identified. Information regarding the
order and timing of the two procedures, VPS complications, PEG complica-
tions, and demographic information were recorded. Results were analyzed
using chi square test. Fifty-six (7.5%) patients underwent PEG and VPS. Nine-
teen (34%) patients underwent VPS prior to PEG (VP-PEG). Thrity-seven
(66%) underwent PEG prior to VPS (PEG-VP). Number of days between proce-
dures ranged from 5 to 414 (mean = 41 days) for the VP-PEG group and from
5 to 1080 (mean = 75 days) for the PEG-VP group. VPS complications
occurred in 2/19 (10.5%) of patients undergoing VP-PEG and 6/37 (16.2%) of
PEG-VP patients (p = 0.56). CSF infection rates were 1/19 (5.3%) in the VP-
PEG group and 2/37 (2.7%) in the PEG-VP (p = 0.62). The CSF infections in
both groups were treated with antibiotics alone without shunt revision.In the
VP-PEG group one patient required proximal shunt revision for clogged
shunt. In the PEG-VP group, 5 patients developed obstruction, 4 required
proximal shunt revision and one patient required revision of the abdominal
portion of the shunt. PEG-related complications occurred in 0/19 of the VPS-
PG group and 2/37 (5.4%) of the PEG-VP group (p = 0.30). Both of these
patients had intolerance to gastric feeds.VPS and PEG may be safely per-
formed in the same patient. When this is the case, the incidence of PEG com-
plications and VP-shunt complications is similar to the reported incidence of
these complications when either procedure is performed alone. Additionally,
                                                                                  POSTER ABSTRACTS




the order of the procedures does not appear to impact outcomes and compli-
                                                                                      TUESDAY




cations for either the shunt or the PEG.




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   T1757 The Influence of Anastomotic Line Tumor Invasion
         and Mesenterial Lymph Node Metastases in Survival of
         Patients with Gastric Stump Cancer
Claudio Bresciani*1, Ana L. Carrasco1, Rodrigo O. Perez1, Carlos E. Jacob1,
Joaquim Gama-Rodrigues2, Bruno Zilberstein1, Ivan Cecconello1
1Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo,
Brazil; 2Habr-Gama Research Institute, São Paulo, Brazil
BACKGROUND: Gastric stump cancer may represent a malignancy with dis-
tinct clinical and pathological features due to the anatomical differences in
lymphatic drainage determined by previous gastric resection. The presence of
mesenteric lymph nodes metastases may not only difficult radical excision
but also significantly affect survival of these patients. The purpose of this
study was to determine the influence of anastomotic line invasion of the pri-
mary tumor and the risk of mesenteric lymph node metastases and survival.
METHODS: Seventy-two patients with gastric stump cancer managed by rad-
ical surgery were retrospectively reviewed. Resected specimens were reas-
sessed to correlate the presence of anastomotic line (AL) tumor invasion with
the presence of perigastric or mesenteric lymph node metastases and with
survival.
RESULTS: Overall, 54 patients had AL+ tumors. Of these, 66% had any
lymph node metastases and 9% had mesenteric lymph node metastases.
There was no correlation between the presence of AL+ and the risk of any or
mesenteric lymph node metastases (p = 0.5). Survival was significantly worse
for patients with any lymph node metastases and for patients with mesen-
teric lymph node metastases (p < 0.001 and p = 0.003 respectively). Anasto-
motic line invasion had no significant impact on survival (p > 0.05).
CONCLUSIONS: Anastomotic line tumor invasion is not a risk factor for
mesenterial lymph node metastases and is not prognostic factor after radical
surgery for gastric stump cancer. Lymph node metastases remains an inde-
pendent and significant poor prognostic factor in gastric stump cancer.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1758 Duodenal Bypass in Lean Individuals Do Not Decrease
         Glucose Levels
Ana C. Tineli*, Fernando A. Herbella, Jorge L. Wilson, Jose C. Del Grande
Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
BACKGROUND: It has been suggested that bariatric operations can control
diabetes irrespective of weight loss. Change in glucose metabolism is credited
to duodenal bypass and consequent variation in digestive hormones levels.
This study aims to evaluate the effect of duodenal bypass on glucose levels in
lean individuals submitted to gastrectomy for gastric cancer.
METHODS: We reviewed 56 patients (36 males, mean age 61 years) submit-
ted to gastrectomy and Roux-en-Y reconstruction for gastric cancer between
January, 2000 to July, 2006. Partial gastrectomy was the operative approach in
37 (66%) patients and total gastrectomy in 19 (34%). Patients were excluded
if obese (BMI > 30), diabetic, submitted to palliative surgery, or with a follow-
up lower than 1 month. Six patients with the diagnosis of diabetes mellitus
were studied separately (2 treated with insulin, 4 with oral medication). Glu-
cose levels were measured the day before operation in all patients but did not
follow specific clinical protocols after the operation.
RESULTS: Glucose levels were not significantly altered after operation,
p = 0.5 (table 1). There was no correlations between glucose level and time
of follow-up for the whole population (r = 0.0002), partial gastrectomy
(r = 0.0001) or total gastrectomy (r = 0.0042) (figure 1). Diabetes control was
improved in 1 patient with oral medication (decrease in dosage).
CONCLUSION: Duodenal bypass in lean individuals treated for gastric cancer
do not decrease glucose levels.

          Time (months)           0      1–6    7–12   13–18   19–24   24–36   37–48   >48
   Glucose Level mg/dL (median)   99     94      94     90      93      96      91     102


                                                                                             POSTER ABSTRACTS
                                                                                                 TUESDAY




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   T1759 Use of Polypropylene Mesh for Laparoscopic
         Adjustable Gastric Banding (LAGB) Allows for
         Minimum Post-Op Pain with No Narcotic Usage and
         Less Pain for Adjustments
Carson D. Liu1, Leonierose Dacuycuy*2,1
1Surgery,SkyLex Advanced Surgical Inc., Los Angeles, CA; 2Medicine, Boston University,
Boston, MA
INTRODUCTION: Outpatient bariatric surgery is a viable option for patients
thinking about weight loss surgery. We describe our technique of 960 patients
who have undergone Laparoscopic Adjustable Gastric Banding (LAGB) with-
out using fixating sutures at the port. The implantation of polypropylene
mesh allows for very little post-op pain and the lack of narcotics use post-
operatively. Patients who had LAGB and mesh implantation experienced
minimal pain without the need for admission to a hospital inpatient setting.
METHODS: All patients undergoing LAGB underwent implantation of mesh
sewn to the posterior aspect of the port device. Polypropylene mesh was
placed over the 15 mm trocar site with coverage of the fascial defect. Prolene
sutures were used to sew the hernia mesh to the port device. The port was
placed in a superficial subcutaneous pocket to allow for easier access of port.
RESULTS: Two patients out of 960 had a peri-port infection requiring re-
siting of port. All other patients did not require narcotic pain medications to
control post-op pain. Patients tolerated liquid acetaminophen for pain con-
trol in the post-op pain.
CONCLUSION: Implantation of mesh at the port site allows for removal of
all post-op pain and the ability to remove all post-op narcotics. The use of
non-narcotic pain medication decreases nausea and dysphoria after surgery.
Patients also had all lap band adjustments under local anesthesia in a clinic
setting as the port was easier to palpate in the more superficial position. The
mesh prevents rotation of the port which has been reported as a common
problem with LAGB.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


BASIC SCIENCE POSTERS

Basic: Biliary
  T1901 Systemic Inflammatory Response After Natural Orifice
        Translumenal Surgery: Transvaginal Cholecystectomy
        in Porcine Model
Daniel K. Tong*, Joe Fan, Simon Law, Wai-Lun Law
Univ of Hong Kong, Queen Mary Hosp, Hong Kong, China
BACKGROUND: In the development of laparoscopic surgery, tremendous
research was performed to address the immunological and inflammatory
response following laparoscopy. Theoretically, with the lesser degree of
trauma induced by NOTES, less perioperative proinflammatory response
would be expected. In the current study, we aimed to study the systemic
inflammatory responses associated with transvaginal cholecystectomy in por-
cine model.
OBJECTIVE: To study circulating TNF-α and IL-6 after transvaginal Chole-
cystectomy in porcine model.
METHODS: Six female pigs were used for survival study after transvaginal
cholecystectomy using endoscopic submucosal dissection (ESD) instruments
and single channel endoscope. Blood was drawn pre-operatively and within
24 to 48 hours post-operatively. Another four pigs were used as control with-
out intervention. Circulating serum TNF-α and IL-6 were measured 24–48
hours after the operation.
RESULTS: In all six pigs in the treatment group, no major intra-operative
complication occurred. The median post-operative TNF–α level for control
group was 65.97 pg/ml (range 52.75–80.78 pg/ml) whereas transvaginal
cholecystectomy group was 66.35 pg/ml (range 40.23–71.65 pg/ml). With
Mann-Whitney test, there was no significant difference between 2 groups
(p = 0.67). In addition, there was no significant difference between IL-6 level
in operated group and control group with the mean of 57.04 pg/ml to 51.22
pg/ml (p = 0.45; Mann-Whitney test) with range of 49.47–93.78 pg/ml and
49.5–102.01 pg/ml respectively.
CONCLUSIONS: NOTES is safe in animal models in terms of anatomical and
                                                                                 POSTER ABSTRACTS




cellular level with minimal systemic inflammatory host responses elicited.
                                                                                     TUESDAY




Further study need to be carried out in human before generalization as daily
routines.




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Basic: Colon-Rectal
  T1902 Curcumin Inhibits the Mammalian Target of Rapamycin
        Subunits Rictor and Raptor in Colon Cancer Cells
Sara M. Johnson*1, B. M. Evers1,2
1Departmentof Surgery, UTMB, Galveston, TX; 2Sealy Center for Cancer Cell Biology,
UTMB, Galveston, TX
INTRODUCTION: Curcumin, a plant polyphenol derived from the spice tur-
meric, possesses anti-cancer and anti-inflammatory properties, and can be
safely ingested with a low toxicity profile. Curcumin decreases cellular prolif-
eration by inhibiting a variety of molecular targets, including Akt, a down-
stream effector of phosphatidylinositol 3-kinase (PI3K). However, the effects
of curcumin on the related growth and survival signal, mammalian target of
rapamycin (mTOR), have not been investigated in colon cancer cells. The
purpose of this study was to: (i) determine the sensitivity of certain colon
cancer cells to the antiproliferative effects of curcumin, and (ii) examine the
effects of curcumin on the PI3K-mTOR pathway.
METHODS: (i) Human colon cancer cells HT29 and KM20 were treated with
varying doses of curcumin (10–200 µM) for 24, 48, or 72 h and cell prolifera-
tion was measured. (ii) Cytotoxicity was assessed using a colorimetric assay
for lactate dehydrogenase (LDH), which is released from cells when their
plasma membrane is damaged. (iii) Western blotting was used to detect
changes in protein expression of the epidermal growth factor receptor
(EGFR), PI3K catalytic and regulatory subunits (p110α and p85α, respectively),
phosphorylated Akt, phosphorylated mTOR, raptor and rictor (subunits
required for assembly of mTOR complexes 1 and 2, respectively), p70S6K, and
4EBP1.
RESULTS: (i) Cell viability after 48 h of treatment with a moderate dose of
curcumin (25 µM) was 32% and 75% in KM20 and HT29 cells, respectively.
(ii) Cytotoxicity after 16 h treatment with curcumin (50 µM), was 120% for
KM20 and 5% for HT29 cells. (iii) Expression of mTOR, rictor and raptor sub-
units was decreased after 2 h treatment with low doses of curcumin (5–20
µM). Protein expression of EGFR and the PI3K subunits was decreased after
overnight treatment with high-dose curcumin (100 µM). Expression of pAkt,
p70S6K and 4EBP1 was also decreased in most cells after curcumin treatment.
CONCLUSIONS: We show, for the first time, that curcumin decreases protein
expression of raptor and rictor, proteins required for the assembly of mTOR
complexes 1 and 2. The inhibition of mTOR and PI3K subunits by curcumin,
in addition to its established effects on Akt activation, is likely to contribute
to the anticancer activity in colorectal cancer.




  Poster of Distinction

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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1903 Increased Expression of Pontin in Human Colorectal
        Cancer Tissue
Johannes C. Lauscher*1, Jörn Gröne1, Christoph Loddenkemper2, Heinz J. Buhr1,
Hubert G. Hotz1, Otmar Huber3
1Department  of General Surgery, Charite, Berlin, Germany; 2Department of Pathology,
Charite Universitaetsmedizin, Berlin, Germany; 3Department of Laboratory Medicine
and Pathobiochemistry, Charite Universitaetsmedizin, Berlin, Germany
INTRODUCTION: Development of colorectal carcinomas is often caused by
dysregulation of the wnt pathway, which plays a fundamental role in cell
growth and differentiation. By interacting with beta-catenin, pontin (also
known as TIP49a) enhances the transcriptional activity of the LEF-1/TCF/
beta-catenin-complex in wnt pathway. The aim of our study was the evalua-
tion of a possible involvement of pontin in the pathogenesis of colorectal
carcinoma (CRC).
PATIENTS AND METHODS: Immunhistochemical staining of pontin and
beta-catenin on paraffin slides from colorectal cancer tissue and correspond-
ing normal mucosa of 52 patients with CRC was followed by semiquantita-
tive evaluation by two examiners and western blot analysis of pontin in
cancer and normal tissue. Correlation with clinical and pathological data
(age, sex, tumor localization, UICC-stage, grading, histological subtype) was
done.
RESULTS: Pontin staining was stronger in tumor tissue than in normal tis-
sue in 86.8% of cases and equal in 13.2% of cases. In every case more than
76% of tumor cells showed cytoplasmatic pontin expression. In 29/52
(55.8%), nuclear staining in tumor tissue was observed (10–80% of nuclei
were stained); whereas there was no nuclear staining in normal tissue. In
32.7% of cases we found a stronger and in 67.4% an equal staining of the
invasive margin vs. tumor center; in dissociating tumor cells (tumor buds) in
32.6% a stronger and in 67.4% of cases an equal staining vs. tumor center was
detected. In the subgroup of undifferentiated carcinomas (G4) (n = 18), we
detected a higher percentage of nuclear expression (66.7%) vs. 50% in well to
badly differentiated adeno carcinomas. Intensity of staining in undifferenti-
ated carcinomas was at least moderate in 66.7% of cases vs. 47.1% in the rest
of colon carcinomas. Pontin showed a co-expression with beta-catenin in
nuclear staining, in the invasive margin and in tumor buds. In 8 patients a 4-
8-fold increase of pontin-expression in tumor tissue vs. normal tissue was
                                                                                       POSTER ABSTRACTS




detected by western blot.
                                                                                           TUESDAY




CONCLUSION: This is the first study revealing an enhanced pontin expres-
sion in human colorectal cancer tissue and the co-expression of pontin with
beta-catenin as a key player in wnt signaling. By enhancing the transcrip-
tional activity of the LEF-1/TCF/beta-catenin-transcriptional complex pontin
may influence the control of proliferation in colorectal carcinoma and may
have oncogenic potential by enhanced expression in colorectal cancer tissue.
Pontin is a possible diagnostic marker and therapeutic target for colorectal
cancer.




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  T1904 Human Acute Immune Response to Colon and Rectal
        Surgery: Comparison Between Open, Laparoscopic and
        Hand Assisted Resection
Laurie S. Norcross*1,3, Melissa Donigan2,4, John Aversa1,3, Paul Williamson1,3,
Samuel Dejesus1,3, Renee Mueller1,2, Andrea Ferrara1,3, Cheryl H. Baker2,4,
Joseph T. Gallagher1,3
1Colon  and Rectal Cancer, Colon and Rectal Clinic of Orlando, Orlando, FL; 2Cancer
Research Institute, MD Anderson Orlando, Orlando, FL; 3Sugery, Orlando Regional
Hospital System, Orlando, FL; 4Burnum School of Medical Sciences, Univ of Central
Florida, Orlando, FL
BACKGROUND: Cytokine levels in the serum, blood and tissue may be pre-
dictive of the degree of stress perceived by patients undergoing major abdom-
inal surgery and may impact cancer related outcomes. Inflammatory response
to trauma includes IL-1b, IL-6, and TNFa in varying levels. Furthermore, alter-
ations in circulating proteins VEGF and PDGF could directly stimulate tumor
growth in cancer patients. We hypothesize the surgery-related differences in
IL-6, and TNF-α will correlate with the degree of surgical trauma. Therefore,
this study will compare the differences in cytokine/protein levels between
patients undergoing hand-assisted laparoscopy, laparoscopy, and laparotomy.
METHODS: Patients presenting to a private practice for colon resection were
included as possible participants. Because the majority of immunologic alter-
ations that occur following major surgery are not diagnosis related, this study
includes patients with both benign and malignant conditions. Specific exclu-
sion diagnoses included active acute diverticulitis, inflammatory bowel dis-
ease and hematologic disorders. Blood draws were performed in pre-operative
holding and post-operative times of 4 hours, 24 hours, and 48 hours. Serum
was evaluated for levels of IL-6, IL-1β, TNF-α, VEGF and PDGF-A using stan-
dard ELISA procedures and analyzed by ANOVA 2-way statistical analysis.
RESULTS: Data evaluates ten open, nine hand assist and seven laparoscopic
cases. In all three surgical techniques, serum levels of IL-6 are significantly
different between the pre-operative time point and 4 hours post surgery
(p = 0.07). At 4 hours post surgery the TNF–α levels are lower in the laparo-
scopic patients as compared to those who received hand-assisted or open
surgery. There is no change in the post-operative trend of IL-1β in all three
surgical techniques. The VEGF serum levels significantly decreased 48 hours
post surgery only in laparoscopic patients (p = 0.007). Interestingly, serum
levels of PDGF-A are increased at 4 hours post surgery in patients undergoing
open surgery when compared to both minimally invasive techniques.
CONCLUSION: The data suggest an immunological benefit to patients
undergoing laparoscopic large bowel resection as compared to laparotomy.
There is a trend toward similar benefits in hand-assisted laparoscopy. Clearly,
these results warrant more investigation as we continue to accrue patients for
all three surgical techniques.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1905 Src Kinase Inhibition May Inhibit Experimental
        Cancer Metastasis
Njwen Anyangwe*, David H. Craig, Jochem Van Der Voort Van Zyp, Marc D. Basson
Department of Surgery, Wayne State University School of Medicine and John D. Dingell
VAMC, Detroit, MI
Acutely increased extracellular pressure stimulates cancer cell adhesion to
matrix proteins or endothelial cells via Src. We hypothesized that extracellu-
lar pressure might be chronically increased in rapidly growing tumors, and
that such chronic pressure might similarly activate the metastatic potential of
shed cancer cells via Src. We first measured interstitial pressure adjacent to
and within human cancers undergoing percutaneous image-guided biopsy
using a coaxial needle. Interstitial pressure in human cancers was on average
17 mmHg higher than interstitial pressure outside the tumors (n = 11,
p < 0.05). Co26 murine colon cancer cells (105 cells/mL) were then exposed
to ambient or 15 mmHg increased pressure for 30 minutes without or with
the Src antagonist PP2 (20 µM), and seeded into murine surgical wounds for
30 minutes before non-adherent cells were washed away and the wounds
were closed. We measured time to palpable tumor and time to 100 mg tumor
in 2 independent studies over 160 and 90 days. In the first study, pressure pre-
treatment of the cancer cells caused palpable tumors in 80.6% of mice vs.
47.2% for controls. (n = 67, p < 0.001) Time to 100 mg tumor paralleled time
to palpable tumor. We then blocked Src in some cells with 20 uM PP2. Pres-
sure again promoted tumor formation by vehicle control cells (67% vs 49% at
ambient pressure, n = 47, p < 0.04). However, PP2 not only blocked the pro-
motion of tumor formation by pressure, but reduced tumor formation by
pressure-treated cells even below untreated ambient pressure controls (34% in
the PP2 and pressure group vs. 54% in the untreated ambient pressure con-
trol, n = 47, p < 0.05). Because PP2 inhibits 9 Src-related kinases, we reduced
Src by specific siRNA in human SW620 colon cancer cells to prove Src was the
key target. Increased pressure for 48 hrs stimulated subsequent SW620 adhe-
sion under ambient pressure (511 + 21 cells/HPF) compared to cells main-
tained for 48 hrs at ambient pressure (392 + 16 cells/HPF, n = 42, P < 0.0001).
Maintaining the increased pressure during the adhesion assay further
increased adhesion (595 + 30 cells/HPF, n = 42, P < 0.001). siRNA-reduction of
Src by 67 + 8% (p < 0.003) not only prevented stimulation of adhesion by 48
hrs of increased pressure but actually inhibited adhesion 46 + 7% vs. pressure-
treated cells transfected with non-targeting control siRNA (n = 60, p < 0.01).
                                                                                       POSTER ABSTRACTS




Pressure-activated Src signaling may stimulate metastatic tumor formation in
                                                                                           TUESDAY




vivo, and mask a second counterregulatory pathway which inhibits adhesion.
Src blockade may unmask this counterregulatory pathway and inhibit the
stimulation of cancer cell metastatic potential by increased pressure within
rapidly growing tumors.




  Poster of Distinction

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  T1906 CD8+ T Cell Infiltration and Cancer Recrurrence in
        Squamous Cell Cancer of the Anus
Sonia Ramamoorthy*1, Katsumi N. Miyai1,2, Linda Luo1, John M. Carethers1,2
1UCSD,   San Diego, CA; 2VA San Diego, San Diego, CA
BACKGROUND: The prognosis of patients with squamous cell cancer of the
anus is most dependent on tumor staging and histopathology. Recent evi-
dence suggests that the adaptive immune response, represented by T cells, is
important in predicting clinical outcome in colon and other cancers. CD8+ T
cells are a subpopulation of cytotoxic immune cells that have the potential to
respond to and kill cancer cells. In this study, we correlated CD8+ T cell
tumor infiltration with histopathology, HIV and HPV status, and anal cancer
recurrence.
METHODS: Archived, formalin-fixed tissues from 16 cases of squamous cell
cancer of the anus were analyzed for CD8+ T cell infiltration using an anti-
CD8 antibody. High-power microscope images were taken of the tumor with
CD8+ cells counted by two observers. Tumors were called high infiltration if
>150 CD8+ cells/HPF, low infiltration if <10 CD8+cells/HPF, and medium
infiltration if >10 and <150 CD8+ cells/HPF. Each case was reviewed for histo-
pathologic grade of tumor (well, moderate or poorly differentiated). This data
was then correlated with retrospective clinical data on HIV status, and cancer
recurrence after IRB approval was obtained.
RESULTS: Of the sixteen cases of anal cancer included in the study, the his-
topathology showed: well-differentiated 4/16 (25%), moderately-differenti-
ated 7/16 (44%) and poorly-differentiated 5/16 (31%). HIV was documented
in 7/16 (44%) of cases. The overall recurrence rate in this population was 6/16
(37%). High CD8+ T cell infiltration was seen in 6/16 (37%) of cases, medium
4/16 (31%), and low infiltration in 6/16 (38%) of cases. There was a signifi-
cant correlation between high CD8+ T cell infiltration and well to moderately
differentiated tumors and between low CD8+ T cell infiltration and poorly
differentiated tumors (p < 0.05). Of the patients with cancer recurrence two-
thirds had low CD8+ T cell infiltration (p < 0.05). Of the seven patients in our
cohort that were HIV positive, 70% of these patients had low CD8+ T cell
infiltration (p < 0.05).
CONCLUSIONS: There is a strong correlation of infiltrating CD8+ T cells
with anal cancer tumors and histopathologic diagnosis, HIV status and can-
cer recurrence. The CD8+ T cell infiltration may confer part of the improved
survival observed in HIV negative patients and in those patients with tumors
that are well to moderately differentiated.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Esophageal
   T1907 Inhibition of YB-1 as a Novel Approach to Decrease the
         Expression of EGFR, HER-2 and IGF-1R in Esophageal
         Cancer
Sabrina Thieltges*1, Tanya Kalinina1, Uta Reichelt2, Jussuf T. Kaifi1, Yogesh K. Vashist1,
Paulus G. Schurr1, Peter R. Mertens3, Ronald Simon2, Jakob R. Izbicki1, Emre F. Yekebas1
1Department  of General-, Visceral- and Thoracic Surgery, University Hospital Hamburg-
Eppendorf, Hamburg, Germany; 2Department of Pathology, University Hospital
Hamburg-Eppendorf, Hamburg, Germany; 3Department of Nephrology and Immunology,
University Hospital Aachen, Aachen, Germany
The Y-box binding protein-1 (YB-1) is an oncogenic transcription factor that
is highly expressed in many malignant tissues, including cancers of the
breast, non-small cell lung cancer, ovarian adenocarcinoma and prostata can-
cer. Although these findings suggest an involvement of YB-1 in the progres-
sion of malignancies, so far no data as to its role in esophageal cancer (EC) are
available. Different molecular profiling studies have identified HER-2, Epider-
mal Growth Factor Receptor (EGFR) and Insulin-like-Growth-Factor I Recep-
tor (IGF-IR) as important co-factors in tumor progression. Inhibition of YB-1
leads to suppression of EGFR and HER-2 in breast cancer. Also, EGFR, IGF-IR
and HER-2 are highly expressed in EC and associated with tumor growth and
poor survival. The aim of this study was to evaluate the impact of YB-1 in EC
and its influence on different protein tyrosine kinase receptor expression. For
this reason, a tumor tissue microarray (TMA) was constructed from 293 pri-
mary ECs (130 adenocarcinomas and 163 squamous cell carcinomas), 146
corresponding lymph nodes and 47 distant metastases. The TMA slides were
analysed by immunhistochemistry for YB-1 expression. YB-1 was not
detected in control tissues, including normal esophageal tissue. Overexpres-
sion of YB-1 was seen in 141/276 cases (51.1%) without difference between
adeno- and squamous cell carcinoma. There was a 67% concordance of YB-1
positivity in primary tumors and corresponding lymph node (p = 0.34) and
metastasis (p = 0.07). Nevertheless, no significant relationship between YB-1
expression and survival was seen. YB-1 was simultaneously expressed with
IGF-1R, EGFR and proliferation marker Ki67. The Fishers exact test showed
that coexpression was significant. In 51% of patients YB-1 and HER-2 were
coexpressed. A synergistic growth inhibition was shown by IGF-IR and HER-2
co-targeting in EC cell lines. These results suggest that YB-1 can transcription-
                                                                                            POSTER ABSTRACTS




ally induce EGFR, IGF-1R and HER-2. Using three different EC cell lines
including one lymph node metastasis cell line, downregulation of endoge-
                                                                                                TUESDAY




nous YB-1 led to a reduction of proliferation of EC cell growth of more than
50%. Ongoing experiments knocking down YB-1 will clarify its interference
with protein tyrosine kinase receptor expression. EGFR, HER-2 and IGF-1R are
essential for EC tumor growth and progression. Targeting YB-1 is an attractive
approach to inhibit simultaneously the expression of most important growth
factor receptors. Therefore, YB-1 could be a novel therapeutic target for
esophageal tumor suppression.


  Poster of Distinction

                                          349
      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


  T1908 Gene Polymorphisms of ERCC1 Predict Response to
        Neoadjuvant Radiochemotherapy in Esophageal
        Cancer
Ralf Metzger*, Ute Warnecke-Eberz, Elfriede Bollschweiler, Daniel Vallbohmer,
Jan Brabender, Arnulf H. Hoelscher
Department of Surgery, University of Cologne, Cologne, Germany
PURPOSE: Neoadjuvant treatment strategies have been developed to
improve survival of patients with locally advanced esophageal cancer. Since
only patients with major histopathological response benefit from this treat-
ment, predictive markers indicating response or non-response would be
needed. We examined the gene polymorphisms of ERCC1 to predict response
to neoadjuvant radiochemotherapy (cis-platin, 5-FU,36 Gy) of patients with
advanced esophageal cancer.
PATIENTS AND METHODS: For analysis of single nucleotide polymor-
phisms (SNPs) genomic DNA was extracted from paraffin-embedded tissues of
52 patients. Allelic discrimination was performed by quantitative real-time
PCR. Two allele-specific TaqMan probes in competition were used for amplifi-
cation of ERCC1. Allelic genotyping was correlated with therapy response.
RESULTS: ERCC1 SNP A/G (rs11615) was predictive for therapy response
(p < 0.003). Within the AA genotype group of 25 patients 20 (80%) did not
respond to chemoradiation, whereas 14 patients (70%) of 20 patients with
the heterogenous A/G genotype were major responders. The GG genotype
comprising 7 patients was not of predictive importance. The ERCC1 polymor-
phism was significantly (p < 0.02) associated with formation of lymph node
metastases.
CONCLUSION: Our data strongly support the role of ERCC1 as a predictive
marker for therapy response. Single nucleotide polymorphisms of ERCC1
could be applied to further individualize treatment of patients with locally
advanced esophageal cancer.




  Poster of Distinction

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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1909 Successful Evaluation of a New Animal Model Using
        Mice for Esophageal Adenocarcinoma
Joerg Theisen*, Matthias C. Raggi, Helmut Friess
Department of Surgery, TU Munich, Munich, Germany
INTRODUCTION: For the better understanding of the pathophysiological
events occurring in the sequence inflamation-metaplasia-carcinoma in esoph-
ageal adenocarcinoma established rat model have been used in the past. In
order to study theses events on a molecular level mouse models would be
desirable. This has not been successful in the past due to the high mortality
involved.
METHODS: Thirty BALB-C mice weighing between 22–25g underwent a
esophago-jejunostomy as previously described in the rat model. After
euthanisation between weeks 24 and 30 the esophgogastric junction and the
esophagus were harvested and analysed histopathologically.
RESULTS: Overall mortality was high with 33%, but these fatal outcomes
happened during the first 10 animals. After that only 2 animals died due to
the procedure. In 18 out of the 20 analysed animals a carcinoma was found
just above the anastomosis, histologically an adenocarcinoma. All animals
showed a severe esophagitis indicating a profound reflux. One animal dem-
onstrated diffuse lung metastasis.
CONCLUSION: These results demonstrate for the first time the feasibility of a
mouse model for esophageal adenocarcinoma. However, a significant learn-
ing curve has to be expected when attempting these procedures.




                                                                                POSTER ABSTRACTS
                                                                                    TUESDAY




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Basic: Hepatic
   T1910 Postconditioning in Liver Ischemia-Reperfusion Injury
Roberto Teixeira*, Nilza Molan, Marcia S. Kubrusly, Marta Privato,
Ana Maria M. Coelho, Telesforo Bacchella, Marcel C. Machado
University of São Paulo, São Paulo, Brazil
INTRODUCTION: Liver ischemia-reperfusion injury (LIRI) is a process
present in several events like liver resections, transplantation, shock and sep-
sis. Ischemia-reperfusion injury is a complex cascade of interactions that
results in alteration of many different organs. The restoration of blood flow
may lead to local and sistemic injury. Several techniques have been devel-
oped in order to avoid or ameliorate LIRI in clinical situations. Precondition-
ing, intermittent vascular occlusion, anti TNF-alpha and antioxidants have
been tested with limited clinical results. Postconditioning is the application
of a gradual, staged or stutter reperfusion after the ischemic lesion. Postcondi-
tioning alters the hydrodynamics of early reperfusion and stimulates endoge-
nous mechanisms that attenuate the reperfusion injury.
OBJECTIVE: To evaluate the local and systemic potential protective effect of
postconditioning in liver ischemia-reperfusion injury in rats.
METHODS: Hepatic anterior pedicle of median and left anterolateral seg-
ments were exposed and clamped with an atraumatic vascular bulldog clamp
for one hour. Two hours later, clamp was released in two different ways: Con-
trol Group (n = 7): clamp was release straightforward; Postconditioning
Group (n = 6): clamp was released intermittently, in 5 periods of 5 seconds
open, followed of 5 seconds of closure. Hepatic liver enzymes, serum TNF-α
and interleukins, pulmonary myeloperoxidase, malondialdehyde (MDA) and
GST-α3 gene expression were studied.
RESULTS: There was no significant difference for all analysis between con-
trol and postconditioning groups except for MDA analysis. Lipidic peroxida-
tion was reduced in the ischemic and non-ischemic liver by postconditioning.
CONCLUSION: Postconditioning reduces LIRI in the ischemic and non-
ischemic liver in this model. This protective action is independent of cytokines
and TNF production. Further studies will be addressed to clarify this issue.




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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1911 Reversibility of Liver Fibrogenesis in Mice: STI571
        Inhibit the Activation of Hepatic Stellate Cells
Ming-Chin Yu*, Miin-Fu Chen, Tsung-Han Wu, Chi-Neu Tsai, Wei-Chen Lee,
Yi-Yin Jan
Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
PURPOSE: Hepatic stellate cells (HSC), known as Ito cells, are important
cells in the hepatic fibrogenesis. Through activation, HSCs transdifferentiate
to myofibroblasts and produce extracellular matrix and induce tissue remodel-
ing. The aim of this study is to inhibit the activation of HSC by STI571 to
treat liver cirrhosis in mice.
MATERIALS AND METHODS: C3H mice were treated with CCl4 2.0 gm/kg
two times per week for 6 weeks. STI571 was used to treat mice by intra-perito-
neal injection for one week. Four groups were designed: (1) no treatment, (2)
with STI571, (3) CCl4 treatment, and (4) both CCl4 and STI-571). The mice
were euthanized to check the histology and liver proliferation.




                                                                                 POSTER ABSTRACTS
                                                                                     TUESDAY




RESULTS: STI571 has good antifibrotic effect in HE and Trichrome staining.
This is also demonstrated in SMA immunohistochemistry. The apoptosis
staining showed more positive in CCl4 group (3). In primary cell culture,
HSCs showed lower proliferation activity with STI571 treatment and the
cytoskeleton production in confocal microscopy. The extracellular matrix
(procollagen (I)) production was also decreased in STI571 treated group.
CONCLUSION: STI571 is effective to reverse the fibrogenesis in vivo and in
vitro. This mechanism through tyrosine kinase inhibitors induce lower prolif-
eration and higher apoptosis of HSC.


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Basic: Pancreas
   T1912 Calcineurine Inhibitors Accelerate Microvascular
         Thrombus Formation in Vivo
Anja Pueschel*1, Nicole Lindenblatt3, Juliane Katzfuss1, Brigitte Vollmar2, Ernst Klar1
1Department of Surgery, University of Rostock, Rostock, Germany; 2Institute for Experimental
Surgery, University of Rostock, Rostock, Germany; 3Department of Reconstructive Surgery,
University of Zürich, Zürich, Switzerland
BACKGROUND: Thrombotic microangiopathy (TMA) is a fatal complica-
tion that occurs after pancreas-kidney transplantation leading to allograft
dysfunction and graft loss. Immunosuppressants, e.g., calcineurine inhibitors,
have been implicated in the development of nonimmune TMA. Tacrolimus
has been shown to be associated with decreased NO-production, thus con-
tributing to thromosis. ADMA acts as an endogenous NO-synthase inhibitor
and is considered to be a marker of endothelial dysfunction. Aim of this study
was to analyse the influence of different immunosuppressants on microvas-
cular thrombus formation in vivo and to further examine the underlying
endothelial function.
METHODS: Using the skin fold chamber in C57BL/6J mice, microvascular
thrombus formation was induced photochemically and quantitatively ana-
lyzed by intravital fluorescence microscopy. Mice were treated with Tacroli-
mus (TAC: 10 mg/kg/d; n = 7), Cyclosporine (CYA: 5 mg/kg/d) or Sirolimus
(RAPA: 1.5 mg/kg/d ip) on 3 consecutive days. Control-mice received NaCl
0.9% (10 ml/kg/d ip; n = 5). Drug plasma levels were examined to ensure ther-
apeutic doses. Additionally, sP-, sE-Selectin and ADMA-plasma levels were
measured by ELISA.
RESULTS: Application of immunosuppressants produced clinically relevant
plasma levels (TAC: 8 ± 2 ng/ml, CYA: 214 ± 16 ng/ml; RAPA: 9 ± 1 ng/ml).
Microvascular thrombus formation was significantly accelerated in mice
receiving TAC compared to control-mice (arteriolar and venular occlusion:
251 ± 101 s and 179 ± 27 s vs. control 818 ± 221 s and 749 ± 231 s; p < 0.05).
Application of CYA significantly increased thrombus formation only in
venules (276 ± 49 s; p < 0.05 vs. control), whereas RAPA had no significant
effect on thrombosis induction. Plasma concentrations of sP- and sE-Selectin
were slightly reduced after TAC and CYA application. ADMA-levels however
were significantly increased in mice receiving TAC (1.28 ± 0.16 µmol/l vs.
control: 0.74 ± 0.13 µmol/l; p < 0.05).
CONCLUSIONS: The impact of immunosuppressants on TMA as well as the
underlying mechanisms have not been clearly delineated. Our results show
that clinically relevant plasma levels of Cyclosporine enhanced thrombus for-
mation only in venules whereas Tacrolimus significantly accelerated thrombus
formation in arterioles and venules. This effect could be explained by increased
ADMA-levels in plasma resulting in impaired NO-bioavailability and increased
thrombogenicity, thus presenting a new molecular mechanism in the develop-
ment of transplant-thrombosis. Preliminary results in post-ischaemic tissue
confirm the effect of Tacrolimus on microvascular thrombus formation, further
underlining the significant role of calcineurine inhibitors in TMA.

  Poster of Distinction
                                            354
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


   T1913 OSU-03012, a Celecoxib Derivative, Has Increased
         Cytotoxicity and Does Not Stimulate Vascular
         Endothelial Growth Factor Production Regardless of
         Cyclooxygenase-2 Expression in Pancreatic Cancer
         Cell Lines
Desmond P. Toomey*, Ellen Manahan, Ciara K. Mckeown, Annamarie Rogers,
Kevin C. Conlon, Joseph Murphy
Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
INTRODUCTION: There is increasing evidence that Non Steroidal Anti-
inflammatory Drugs (NSAIDs) have Cyclooxygenase-2 (COX-2) independent
actions in cancer. These effects occur regardless of COX-2 expression and may
be beneficial or detrimental. This study compared the actions of specific
COX-2 inhibitors (Celecoxib, NS398) with that of OSU-03012, a celecoxib
derivative, in pancreatic cancer.
METHODS: A previous study confirmed that pancreatic cancer cell lines
BxPC-3 and AsPC-1 have consistently high and negligible COX-2 expression,
respectively. Proliferating cells were treated with NS398, celecoxib or OSU-
03012 and LC50’s determined using MTT assay. Prostaglandin E2 (PGE2) and
Vascular Endothelial Growth Factor (VEGF) production were measured by
ELISA. Significance was calculated using unpaired t test.
RESULTS: Each of the reagents had a concentration dependant effect on cell
viability regardless of cellular COX-2. The LC50 for NS398 was > 100 µM and
for Celecoxib >50 µM. OSU-03012 was cytotoxic at 10 µM in AsPC-1 cells and
had a LC50 of 15–20 µM in both cell lines. Of note, proliferating cells more
susceptible than confluent (p < 0.01). COX-2 was inhibited by 1 µM Cele-
coxib or NS398 (p < 0.001). PGE2 was moderately reduced by 10 µM OSU-
03012 (p < 0.001). NS398 and OSU-03012 did not effect VEGF levels however
it was increased 1.8 (AsPC-1) and 2.1 (BxPC-3) fold by 50 µM Celecoxib (p < 0.01).
CONCLUSION: Although high dose Celecoxib is cytotoxic to pancreatic can-
cer cells, it stimulates production of VEGF, a growth factor associated with
worse prognosis. OSU-03012, a celecoxib derivative, has similar cytotoxicity
but at lower, physiologically achievable concentrations without affecting
VEGF. Thus OSU-03012 has exciting potential for pancreatic cancer therapy.
                                                                                     POSTER ABSTRACTS
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   T1914 Inhibition of VEGF and Not COX-2 Is Effective in a
         Model of Pancreatic Cancer Angiogenesis
Desmond P. Toomey*1, Ellen Manahan1, Ciara K. Mckeown1, Annamarie Rogers1,
Helen Mcmillan2, Stephen Thow2, Michael Geary2, Kevin C. Conlon1,
Joseph Murphy1
            Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland; 2The
1Professorial
Department of Obstetrics, The Rotunda Hospital, Dublin, Ireland
INTRODUCTION: In pancreatic cancer, angiogenesis is an exciting thera-
peutic target that has been linked to Cyclooxygenase-2 (COX-2) and Vascular
Endothelial Growth Factor (VEGF) expression. The relationship of COX-2 and
VEGF to endothelial cell (EC) survival and proliferation within the neoplastic
environment was investigated in this study.
METHODS: BxPC-3 or AsPC-1 pancreatic cancer cell lines (COX-2 positive
and negative, respectively) were co-cultured with EC for 3–5 days. A 4µm
porous membrane, insert system was used to facilitate passage of growth fac-
tors but not cells. SC-560 (COX-1 inhibitor), NS398 (COX-2 inhibitor) or
VEGF neutralising antibody were added to the lower chamber. EC viability
was measured by Giemsa staining and WST assays. PGE2 and VEGF were
quantified by ELISA. Significance was calculated using unpaired t test.
RESULTS: BxPC-3 co-cultures produced 2.7 fold more PGE2 and 1.5 fold
more VEGF than AsPC-1 wells (P < 0.01). This was associated with a 2 times
greater EC viability in BxPC-3 wells relative to AsPC-1 (P < 0.01). PGE2 was
reduced to minimal levels in BxPC-3 wells by NS398 but this had no effect on
either VEGF production or EC viability. AsPC-1 showed similar patterns but at
a proportionally lower level (P < 0.01). EC viability was reduced to that of
negative control in both cell lines by VEGF neutralising antibody.
CONCLUSION: COX-2 inhibition did not reduce VEGF production or EC
viability. However, neutralisation of VEGF did markedly inhibit EC prolifera-
tion and survival. Therefore VEGF is not downstream of COX-2 and VEGF
inhibitors have an important role in therapies targetting pancreatic cancer
angiogenesis.




                                          356
        49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


    T1915 Anti-Lewis Y Antibody as a Novel Target for Pancreatic
          Adenocarcinoma
Vivian E. Strong*1, Achim A. Jungbluth3, Peter J. Allen1, Laura H. Tang4, Lloyd Old3,
Steven Larson2, Jorge Carrasquillo2, Yuman Fong1
1Surgery,Memorial Sloan-Kettering Cancer Center, New York, NY; 2Nuclear Medicine,
Memorial Sloan-Kettering Cancer Center, New York, NY; 3Ludwig Institute for Cancer
Research, Memorial Sloan-Kettering Cancer Center, New York, NY; 4Pathology, Memorial
Sloan-Kettering Cancer Center, New York, NY
Lewis Y antigen is a blood group antigen homogeneously expressed at high
density on the surface of various tumor cells. Hu3S193 is a specific antibody
against Lewis Y antigen and this antibody has shown exceptionally high speci-
ficity for Lewis Y antigen with no cross-reactivity and potent immune effector
function. This study evaluated Lewis Y expression in pancreatic adenocarci-
noma. Human tissue samples (n = 43) from paraffin embedded blocks were
evaluated via immunohistochemical (IHC) staining with 3S193 antibody. An
antigen retrieval technique was performed by immersing slides in preheated
DAKO-TRS solution and ultimate detection with avidin biotin system. Binding
was graded by review of two dedicated pathologists who were blinded as to the
clinical history of each specimen. Grading was categorized as negative, focally
positive or graded % binding. IHC staining of human pancreas tissue shows
intense uptake of 3S193 antibody in regions consistent with pancreas adeno-
carcinoma (panel A). In contrast, panel B demonstrates minimal IHC staining
of normal pancreatic tissue. Table 1 shows results of IHC staining for 55 human
pancreas adenocarcinoma specimens with 80% showing strong staining. The
results of this study demonstrate the up-regulation of Lewis Y antigen in pan-
creatic adenocarcinoma, and the targeting capability of Hu3S193. These results
may allow the development of better imaging and novel therapies to specifi-
cally target pancreatic adenocarcinoma.

Table 1. Immunohistochemical (IHC) Staining From Human Pancreas Cancer Specimens
       Amt of Staining via
                                               Number of Pancreas                  Percentage of Total Specimens
    Immunohistochemistry for
                                            Adenocarcinoma Specimens                          (n = 55)
       Hu3S193 Antibody
           Negative                                        11                                      20%
        Focally Positive                                    3                                      5%
            5–25%                                          13                                      24%
                                                                                                                         POSTER ABSTRACTS




            25–50%                                          9                                      16%
                                                                                                                             TUESDAY




            50–75%                                          8                                      15%
           75–100%                                         11                                      20%
              Total                                        55                                     100%
         Total Positive                                    44                                      80%
In 80% of all specimens examined (44/55) there was detectable staining of cancer cells with the anti-lewis Y antibody.




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Figure 1. 3S193 immunostaining of pancreas adenocarcinoma (panel A) versus
          normal pancreas tissue (panel B). Brown regions represent positive
          staining for Lewis Y antigen.




                                       358
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  T1916 Differentiation, Origin and Mesothelial Adhesive
        Potential Affect Growth and Metastasis of Ductal
        Adenocarcinoma of the Pancreas
Soeren Torge Mees*, Christina Schleicher, Mario Colombo-Benkmann,
Norbert Senninger, Joerg Haier
General Surgery, University Hospital Muenster, Muenster, Germany
BACKGROUND: Adenocarcinomas of the exocrine pancreas belong to the
most aggressive malignancies with an overall 5-year survival rate of still less
than 5%. The early development of distant metastases, such as peritoneal car-
cinomatosis, is a specific characteristic of this particular tumor entity, but
their mechanisms are poorly understood. In a series of newly established
orthotopic models for pancreatic carcinomas tumor growth, metastasis and
their potential for mesothelial adhesion as one of the first steps of metastasis
formation were investigated.
METHODS: 16 cell lines of well- to undifferentiated pancreatic cancers from
different tumor sites (primary or metastatic lesions) were used to implant sub-
cutaneous donor tumors and subsequent orthotopic transplantation in nude
mice. After 12 weeks primary tumor volume, local infiltration, and patterns
of systemic metastases were assessed using a standardized dissemination
score. This in vivo behaviour was compared with in vitro tumor cell adhesion
to mesothelial cells. The data was tested for significant differences using
Scheffé- and t-test (SPSS 13.0).
RESULTS: In vivo experiments resulted in a tumor take rate of 100%. Differ-
ences regarding tumor size, infiltration and metastatic spread were found
depending on differentiation and origin of the cell lines. Less differentiated
cells of primary tumors and metastasis caused higher dissemination scores
than better-differentiated cells (p < 0.05). A significant increase (p < 0.05) of
tumor growth, infiltration and metastasis was also seen for cells originating
from metastases compared to those from primary tumors. Adhesion assays
revealed an adhesive potential at mesothelium of all cell lines (21%–95%).
Primary tumors with well-moderate differentiation presented significantly
increased adhesion rates (mean 74%–95%) compared to poorly-undifferenti-
ated primary tumors (mean 31%–55%) and well-moderately differentiated
(mean 21%–44%) or poorly-undifferentiated (mean 25%–45%) metastases (p <
0.05). The maximum adhesion rates were found in average 76 min after addi-
tion of pancreatic cells to mesothelial monolayers (observation period 90 min).
                                                                                   POSTER ABSTRACTS




CONCLUSION: These experimental systems are an interesting tool for the
                                                                                       TUESDAY




investigation of mechanisms or pancreatic cancer progression and demon-
strate that grade of differentiation and origins are relevant factors for tumor
growth and metastatic spread. The correlation of pancreatic cells adhesion at
the mesothelium with their origin and differentiation suggests that this adhe-
sive potential is a required, but not rate-limiting step for the formation of
peritoneal carcinomatosis in this tumor entity.




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  T1917 Pancreatic RegI and PAP2 Proteins Have Different
        Potencies on Macrophage TNF Expression
Ehab Hassanain*, Domenico Viterbo, Cathy M. Mueller, Martin Bluth,
Michael E. Zenilman
Dept Surgery, SUNY Downstate, Brooklyn, NY
BACKGROUND: Reg and PAP are homologous, endogenous proteins differ-
entially expressed in the pancreas. We recently showed that PAP2 is protec-
tive in pancreatitis, and it may exert its effect by activating macrophages.
Since RegI is constituitively expressed and PAP2 is induced only during pan-
creatitis, we postulated that they would have differential effects on macroph-
ages. We also postulated that the highly conserved C-terminus, previously
identified as critical for this activity, would be a bioactive fragment.
METHODS: Rat macrophages (NR8383 alveolar cell line) were cultured with
recombinant rat RegI or PAP2 proteins created in our lab, and isolated by
affinity chromatography, a commercial PAP2 protein isolated by NH4 precipi-
tation, or a synthetic 30 amino acid C-terminus peptide (20–10000 ng/ml) for
24 hr. Media was evaluated for TNF expression via ELISA. Controls consisted
of cells cultured with vehicle alone. Significance was set at p < 0.05 (Student’s
t-test).
RESULTS: See Figure. Macrophages cultured in the presence of our labora-
tory’s recombinant rat RegI and PAP2 resulted in increased expression of
TNFa when compared with controls (p < 0.05). But, PAP2 was 2 log-orders
more potent. The highly conserved C-terminal peptide showed no activity.
Importantly, commercially purchased PAP2 isolated by ammonium sulfate
precipitation was inactive; its activity returned only after chemical refolding
using serial dialysis in urea.




CONCLUSIONS: Despite their structural similarities, PAP2 is a much more
potent macrophage stimulant than RegI. Since PAP2 is induced during acute
pancreatitis, it is likely to be the more important signal for macrophage acti-
vation in the disease. A conserved peptide sequence is inactive, intact confor-
mational structure is critical for its activity, and standard isolation techniques
can render the protein non-functional.


                                       360
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Small Bowel
  T1918 Cold Ischemia of the Small Bowel Could Be Prolonged
        by Intestinal Lipid Absorption Before Gut Procurement
Judith Junginger*, Theo Maier, Tobias Meile, Markus A. Kueper, Ruth Ladurner,
Alfred Koenigsrainer, Jorg Glatzle
General and Transplant Surgery, University of Tuebingen, Tuebingen, Germany
INTRODUCTION: Small bowel transplantation is an established treatment
option for patients with intestinal failure. However, the short cold ischemic
tolerance of the small bowel is still an imminent problem. Recently, we have
shown, that the inflammatory response of the gut during abdominal sepsis
was significantly reduced during oral lipid administration (Glatzle; J. Gas-
trointest. Sug 2007).
HYPOTHESIS: An enteral treatment with long chain fatty acids before pro-
curement will reduce the damage of the gut during cold ischemia.
METHODS: Rats were continuously intestinally infused for 12 h either with
NaCl, 1% olive oil or 4% olive oil (ClinOleic, Baxter, Germany, 3 ml/h; n = 4
each group). Thereafter rats were anesthetized, systemically infused with an
organ preservation solution (Histidine-Tryptophan Ketoglutarate), the small
bowel was immediately removed and stored in the HTK solution on ice. At
the time periods t = 0, t = 2 h, t = 4 h, t = 8 h, t = 12 h a tissue sample of the
gut was fixed and stained with H&E. The tissue was analyzed by three inde-
pendent observers and scored for tissue damage (0 = no damage, 1 = minor
damage, 2 = major damage, 3 = loss of structure) of the basal membrane of
the mucosa, the integrity of the mucosa and integrity of villi. Data are repre-
sented as median.
RESULTS: Both lipid pretreated groups reached after 4 h of cold ischemia a
median damage score of 2 for the integrity of the basal membrane, whereas
the control group reached a damage score of 3. The 1% olive oil treated rats
showed either no damage or minor damage to the mucosa after 4 h of cold
ischemia, whereas in the control group 75% of the animals had at least minor
damage scores up to loss of structures. The most impressing results were seen
in the lipid pretreated groups regarding the integrity of the villi. None of the
1% lipid treated animals showed a damage for the integrity of villi within 4h
of cold ischemia, whereas 50% of the control animals showed al least minor
                                                                                          POSTER ABSTRACTS




damage scores. (median damage score for the integrity of villi, control: 0h: 0;
                                                                                              TUESDAY




2 h: 0; 4 h: 0.5; 8 h:1.5; 12 h: 2; 1% lipid: 0 h: 0; 2 h: 0; 4 h: 0; 8 h:1; 12 h: 1.5;
4% lipid: 0h: 0; 2 h: 0; 4 h: 0; 8 h:2; 12 h: 3).
CONCLUSIONS: Intestinal lipid absorption before gut procurement clearly
decreases the histological damage of the small bowel during cold ischemia
and 1% olive oil seems to be more efficient than 4%. Lipids or their metabo-
lites stored in the enterocytes may have some anti-inflammatory character.
Intestinal lipid administration in organ donors might also be a useful tool to
increase cold ischemia of the small bowel in humans.




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  T1919 Diurnal Rhythmicity in the p53-Mediated Apoptotic
        Pathway in Rodent Small Intestine
Anita Balakrishnan*1, Adam T. Stearns1, David B. Rhoads2, John S. Young1,
Stanley W. Ashley1, Ali Tavakkolizadeh1
1Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA;
2Pediatric Endocrinology, MassGeneral Hospital for Children and Harvard Medical
School, Boston, MA
INTRODUCTION: The intestine exhibits a diurnal rhythm in apoptosis,
cued by feeding and peaking during fasting. The pathways regulating this
rhythm have not been elucidated. p53 upregulates pro-apoptotic Bax and
Bak, and downregulates anti-apoptotic Bcl-w and Bcl-XL, culminating in
caspase-3 activation, in other models of apoptosis and proliferation. We
hypothesized that diurnal rhythmicity in apoptosis was similarly regulated.
METHODS: Rats were acclimatized to a 12:12 hour light/dark cycle and jeju-
nal mucosal scrapings harvested at 6 hourly intervals, beginning at ZT0 (Zeit-
geber Time 0, corresponding to 7 am and “lights-on,” n = 6 to 7 rats per time).
mRNA expression of p53, Bcl-XL, Bcl-w, Bax, Bak and caspase-3 was deter-
mined using real-time PCR and statistical significance using ANOVA.
RESULTS: p53 mRNA expression peaked at ZT0, the termination of the normal
nocturnal feeding period (p < 0.05 vs. ZT18). Bak similarly peaked at ZT0 (p <
0.0001 vs. ZT6, ZT12 and ZT18), however, no significant difference in expression
was noted for Bax. In contrast, Bcl-w and Bcl-XL expressions were significantly
higher during the feeding period with a peak at ZT18 (p < 0.005 vs. ZT0 and
ZT12). Bax and Bak expression were more than 3-fold higher than Bcl-XL and
Bcl-w at ZT0 (p < 0.0005 vs. ZT12 and ZT18). Caspase-3 expression was signifi-
cantly higher during the lights-on period at ZT0 and ZT6 (p < 0.05 vs. ZT12).




CONCLUSION: Our results identify a diurnal rhythm in the expression of
components of the p53-mediated apoptotic pathway. Pro-apoptotic genes
exhibited peak expression in the light period, when rats consume little food.
Our findings suggest that diurnal rhythmicity in apoptosis may occur via a p53-
mediated caspase-3 dependent pathway. Further understanding of the regula-
tion of these apoptotic rhythms may allow the development of improved che-
motherapeutic regimens with reduced gastrointestinal side-effects.


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Basic: Stomach
  T1920 Pre-Op Antibiotic Gastric Lavage Reduces Post-
        Operative Peritoneal Infection in a Murine Natural
        Orifice Surgery Model
Yoav Mintz, John Cullen*, Santiago Horgan, Bryan J. Sandler, Garth R. Jacobsen,
Mark A. Talamini
Department of Surgery, University of California, San Diego, San Diego, CA
INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES)
is an emerging surgical technique through which operations are performed
by entering the abdominal cavity through a natural orifice such as the stom-
ach. Infection is a potential risk of the procedure and the potential pathogens
are different than with skin incisions. Currently, there is little data regarding
prophylactic antibiotic treatment for NOTES.
METHODS: 30 Sprague-Dawley rats underwent mini-laparotomy under gen-
eral anesthesia in accordance with the UCSD Institutional Animal Care and
Use Committee regulations. The control group (n = 10) underwent a sham
procedure where a single stitch was placed in the anterior stomach. The saline
treated group (n = 10) underwent mini-laparotomy followed by needle gastro-
tomy and gastric irrigation with normal saline. Following irrigation, the fluid
was expressed from the stomach into the abdominal cavity. The gastrotomy
and then the abdomen were closed. The antibiotic treated group (n = 10)
underwent gastric irrigation with diluted antibiotic containing enrofloxacin
solution followed by spillage and closure. All rats survived the operation. One
rat from the Saline group was euthanized on post-operative day 2 for wound
complications due to a technical error. All other rats survived and were eutha-
nized at 4 weeks.
RESULTS: Weight gain was similar amongst groups. In the saline treated
only group, 3 out of 9 rats (33%) developed intra-abdominal abscess found at
necropsy. In the control and antibiotic treated groups, no abscess was found
at necropsy. Adhesions to the abdominal wall formation were found in four
rats out of ten in the saline group. No adhesions were noted in the control or
antibiotic treated groups.
CONCLUSIONS: In a pilot study of a murine model designed to simulate
NOTES gastric spillage, pre-op gastric antibiotic lavage decreased the adhe-
                                                                                    POSTER ABSTRACTS




sion and infection rate when compared to saline only lavage.
                                                                                        TUESDAY




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  T1921 Roux-en-Y Gastric Bypass Improves Obesity-Related
        Steatosis and Is Associated with Reduction in Serum
        Adiponectin
Drew A. Rideout*1,2, Yanhua Peng2,3, Steven S. Rakita2,1, William R. Gower2,3,
Min You3, Michel M. Murr1,2
1Department of Surgery, University of South Florida, Wesley Chapel, FL; 2Department of
Surgery and Research, James A. Haley Veterans Affairs Medical Center, Tampa, FL;
3Department  of Molecular Medicine, University of South Florida, Tampa, FL
BACKGROUND: Non-Alcoholic Fatty Liver Disease (NAFLD) is a manifesta-
tion of obesity and leads to cirrhosis. Adiponectin, an adipocyte hormone,
has direct effects on inflammation and lipid metabolism. We tested the
hypothesis that Roux-en-Y gastric bypass (RYGB) improves liver steatosis in a
rat model of obesity and induces changes in serum adiponectin.
METHODS: Five-week-old Sprague-Dawley male rats were randomized to
regular chow or high fat diet (HFD) for 14 weeks to induce obesity prior to
undergoing RYGB (n = 4) or sham (n = 3). Subsequently, rats were sacrificed at
9 weeks post-operatively. Body weight (weekly) and serum adiponectin were
measured. Liver sections were stained with H&E and Oil Red. All tests were
repeated in triplicate; gels were quantified using densitometry; data are mean
± SD; t-test, p < 0.05 was significant.
RESULTS: HFD induces obesity and increases body weight in rats (452 ±
24 gm vs. 406 ± 22 gm; p < 0.01 vs. regular chow). RYGB induces progressive
and significant weight loss in obese rats (364 ± 45 gm vs. 496 ± 32 gm; p <
0.01 vs. sham). Prior to RYGB, rats fed HFD had an increased serum adiponec-
tin compared to regular chow (16,185 ± 2,459 vs. 7,309 ± 434; p < 0.01 vs.
regular chow); RYGB reduced serum adiponectin in obese rats compared to
obese sham controls (914 ± 564 vs. 3,441 ± 933; p < 0.05 vs. sham); similarly;
serum adiponectin was reduced after RYGB as compared to levels from the
same obese rats pre-operatively (5,099 ± 878 vs. 6,916 ± 415; p < 0.01). HFD
increased the number and size of fat droplets in the liver compared to regular
chow. RYGB decreased liver weight by 30% and significantly reduced the
number and size of fat droplets in the liver compared to obese sham rats.
More importantly, the degree of steatosis improved in rats after RYGB as com-
pared to the same rats pre-operatively.
CONCLUSION: HFD induces obesity and steatosis in obese rats. Surgically-
induced weight loss in a rat model of RYGB exhibits an anti-lipogenic profile
by improving liver steatosis. The novel observation that RYGB reduces serum
adiponectin warrants further investigation into the complex signaling
between peripheral adipose tissue and the liver in obese rats with NAFLD.




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COMBINED SCIENCE POSTERS

Combined Science
  T2095 Assessment of “Gene-Environment” Interaction in
        Cases of Familial and Sporadic Pancreatic Cancer
Theresa P. Yeo*1, Ralph H. Hruban2, Alison P. Klein2, Kieran Brune2,
Charles J. Yeo3
1School  of Nursing, Thomas Jefferson University, Philadelphia, PA; 2Department of
Pathology, Johns Hopkins University, Baltimore, MD; 3Department of Surgery, Thomas
Jefferson University, Philadelphia, PA
INTRODUCTION: Pancreatic cancer (PC) is the fourth leading cause of can-
cer death in the United States. This study characterizes one of the largest
national registries of familial PC (FPC) and sporadic PC (SPC), focusing on
demographics, clinical factors, self-reported environmental and occupational
lifetime exposures and survival status.
BACKGROUND: Reported risk factors for PC include: advancing age, a fam-
ily history of PC, high-risk inherited syndromes, cigarette smoking, exposure
to occupational and environmental carcinogens, African-American race, high
fat/high cholesterol diet, obesity, chronic pancreatitis, and diabetes mellitus.
METHODS: This retrospective cross-sectional, case-only analysis includes
cases of FPC (n = 569) and SPC (n = 689) from the Johns Hopkins National
Familial Pancreas Tumor Registry (NFPTR) enrolled between 1994 and 2005.
RESULTS: Significant findings include: 1) Mild, multiplicative interaction
between family history of PC and exposure to asbestos, environmental radon,
and environmental tobacco smoke (ETS) (Odds Ratios >1.0). 2) Non-smoker
ETS exposed cases were diagnosed at a significantly younger mean age (64.0
years) than non-smoker non-ETS exposed cases (66.5 years) (p < 0.0004). 3) FPC
smokers with ETS exposure were diagnosed at a significantly (p = 0.05) younger
mean age (63.7 years) compared to FPC non-smokers without ETS exposure
(66.6.years). 4) Mean age at diagnosis for Ashkenazi Jewish SPC subjects was
significantly younger (by 2.1 years) than Ashkenazi Jewish FPC cases (p = 0.05).
5) Ashkenazi Jewish FPC subjects who smoked were diagnosed 5.9 years earlier
than Ashkenazi Jewish FPC non-smokers (p = 0.05). 6) Median survival for
                                                                                     POSTER ABSTRACTS




unresected FPC cases was significantly shorter (168 days) compared to unre-
                                                                                         TUESDAY




sected SPC cases (200 days) (p = 0.04), survival significantly improved to 713
days for FPC cases and 727 days for SPC cases after surgical resection.
CONCLUSIONS: These are the first data to show that occupational and envi-
ronmental exposures may act synergistically with inherited or acquired
genetic polymorphisms, resulting in earlier occurrence of PC. Exposure to cig-
arette smoking and ETS is associated with a younger mean age of diagnosis in
FPC and SPC cases and those with an Ashkenazi Jewish heritage, compared to
non-exposed cases. These results imply that unaffected individuals from fam-
ilies with a history of PC who smoke, have had early life ETS exposure, or
have certain occupational and environmental exposures may benefit from
screening and early identification of pre-malignant lesions.
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  T2096 Natural Orifice Translumenal Endoscopic Surgery for
        Roux-en-Y Gastric Bypass: An Experimental Surgical
        Study in a Human Cadaver Model
Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3,
Nicolas C. Buchs1, Margherita Cadeddu4, Priya A. Jamidar5, Jean Fasel6,
Philippe Morel1
1Division of Digestive Surgery, University Hospital Geneva, Geneva, Switzerland;
2Department of Visceral and Transplantation Surgery, University of Bern, Bern,
Switzerland; 3Imperial College, London, United Kingdom; 4McMaster University,
Hamilton, ON, Canada; 5Section of Digestive Diseases, Yale University, New Haven, CT;
6Division of Anatomy, University Geneva, Geneva, Switzerland

BACKGROUND: Advantages of a NOTES or NOTES hybrid approach to
Roux-en-Y gastric bypass (RYGB) might include: easier access to the perito-
neal cavity, subtantial reduction in number of ports and port related compli-
cations, improved cosmesis and others. NOTES was initially concieved as a
procedure for relatively minor intraperitoneal operations. The most common
NOTES procedure currently is cholecystectomy which is of moderate com-
plexity. RYGB is a complex surgical procedure of advanced level. The techni-
cal feasibility of a NOTES-RYGB and limitations of available flexible and rigid
instrumentation for such a procedure is unknown.
METHODS: NOTES hybrid RYGB was performed in 4 human cadavers
(frozen or preserved) using a combination of flexible and rigid instruments.
Pouch creation was achieved by needle knife dissection of a retrogastric win-
dow using a flexible gastroscope introduced transvaginally. Articulated linear
staplers were placed through a transumbilical port to transect the stomach.
Measurements of the bilary and alimenary limbs were accomplished with
flexible and rigid graspers. A 21 mm anvil was introduced through a needle-
knife incision into the small intestine and connected to the flexible shaft of a
flexible transesophageal stapler to form a gastrojejunostomy. A linear stapler
was used for the jejuno-jejunal anastomosis.
RESULTS: It was feasible to perform bypass surgery in all cadavers. Dissec-
tion and pouch creation was easier than expected using flexible instruments
to form the pouch. Ordinary rigid instruments (graspers and staplers) were
too short for some transvaginal or transrectal manipulations. Anvil manipula-
tion and docking was difficult using flexible instruments. Combinations of
flexible and rigid visualization and manipulation were especially helpful for
pouch creation and stapler manipulation. Transabdominal port access num-
ber was reduced from 5–7 to 1–3 with 1–2 translumenal access ports.
CONCLUSIONS: Roux-en-Y bypass surgery is technically feasible in human
cadavers using a NOTES hybrid approach. Port numbers can be reduced. A
combination of flexible with rigid endoscopic techniques devices offers
specific advantages for components of this type of surgery. Changes in
instrument design are required to improve complex hybrid endosurgical
procedures.




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  T2097 A Novel System for Classifying Paraesophageal Hernias
Tommy H. Lee*, Carlos Godinez, Stephen M. Kavic, Ivan M. George,
George T. Fantry, Adrian E. Park
University of Maryland, Baltimore, MD
INTRODUCTION: The current system for classifying paraesophageal hernias
is based on the herniated contents and the location of the gastroesophageal
(GE) junction in relation to the diaphragmatic hiatus. While this system rep-
resents a basic anatomic description of the hernia, there is little clinical rele-
vance to aid in pre-operative or intra-operative management. New imaging
technology permits the study of these hernias in 3-dimensions, providing an
understanding of their anatomy at a greater level of detail and relevance to
the clinician.
METHODS: 24 patients who underwent laparoscopic paraesophageal hernia
repair were reviewed. Pre-operative CT scans were reconstructed using a
unique protocol with semi-automatic segmentation. Reconstructions permit-
ted analysis of the geometry of hiatal defects and herniated contents. Patients
were categorized by hiatal shape, angulation of herniated contents, and the
location of the herniated stomach. These groupings were then compared to
patient outcomes, specifically, need for Collis gastroplasty, need for buttress
of hiatus repair, gastrostomy, and intra-operative complications.
RESULTS: Analysis revealed four distinct defect morphologies. The geometry
of the herniated contents was described according to the amount of stomach
situated in the chest, and by the angle formed by three anatomic structures:
the GE junction, the base of the diaphragmatic crura, and the antrum (the
“PEH angle”). Symmetric defects less often required gastric fixation, but were
more likely to need a Collis gastroplasty. The mean PEH angle was 87˚.
Patients requiring an esophageal lengthening had a mean angle of 82˚, com-
pared to 100˚ in those who did not. Stomach location also influenced opera-
tive events, as evidenced by a 57% incidence of intra-operative complications
such as enterotomies and liver injuries in patients with a stomach equally
above and below the diaphragm, compared to 15% in those with the stomach
mostly above, and 0% in those with the stomach mostly below (p = .106,
Fisher Exact Test).
CONCLUSION: Paraesophageal hernias remain a significant management
challenge. Patients and surgeons alike stand to benefit from highly detailed
pre-operative information on hernia anatomy and visceral relationships.
                                                                                     POSTER ABSTRACTS




Combining advances in imaging and computing power, we propose a novel
                                                                                         TUESDAY




classification system based on advanced reconstruction techniques, which
allows us to view these challenging surgical problems in ways not previously
possible with fluoroscopy or even CT alone. Key anatomic features and rela-
tionships identified by these means can aid in pre-operative decision making
and patient counseling, and predict operative difficulty.




  Poster of Distinction

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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT



Wednesday, May 21, 2008
12:00 PM – 2:00 PM          SSAT POSTER SESSION               SAILS PAVILION
            Authors available at their posters to answer questions 12:00 PM –
            2:00 PM; posters on display 8:00 AM – 5:00 PM.

CLINICAL SCIENCE POSTERS

Clinical: Biliary
 W1635 Management of Preoperatively Suspected
       Choledocholithiasis: A Decision Analysis
Bilal Kharbutli*, Vic Velanovich
Surgery, Henry Ford Hospital, Detroit, MI
BACKGROUND: The management of symptomatic or incidentally-discov-
ered common bile duct (CBD) stones is still controversial. Of patients under-
going elective cholecystectomy for symptomatic cholelithiasis, 5%–15% will
also harbor CBD stones, and those with symptoms suggestive of choledoch-
olithiasis will have an even with higher incidence. Options for treatment
include preoperative ERCP with sphincterotomy (ERCP/ES) followed by lap-
aroscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative
cholangiogram (LC/IOC), followed by either laparoscopic common bile duct
exploration (LCBDE) or placement of a common bile duct double lumen
catheter with postoperative management. The purpose of this analysis was to
determine the optimal management of such patients.
METHODS: A Decision Analysis was performed to analyze the management
of patients with suspected common bile duct stones. The basic choice was
between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE
or Common Duct Double Lumen Catheter (Fitzgibbons tube) placement with
either expectant management or postoperative ERCP/LS. Data on morbidity
and mortality was obtained from the literature. Sensitivity analysis was done
varying the incidence of positive CBD stones on IOC with associated morbid-
ity and mortality.
RESULTS: One stage management of symptomatic CBD stones with LC/
LCBDE is associated with less morbidity and mortality (7% and 0.19%) than
two stage management utilizing preoperative ERCP/ES (13.5% and 0.5%).
Sensitivity analysis shows that there is an increase in morbidity and mortality
for LC/LCBDE as the incidence of positive IOC increases but are still less than
two stage management even with a 100% positive IOC (9.4%, 0.5%). If a dou-
ble lumen catheter is to be used for positive IOC, the morbidity would be
higher than the two stage management only if the positive IOC incidence is
more than 65% but still with no mortality.



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     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


CONCLUSION: LCBDE has a lower morbidity and mortality rates compared
to preoperative ERCP/ES in the management of patients with suspected CBD
stones even if the chance of CBD stones reaches 100%. Using a Common
Duct Double Lumen catheter may be considered if LCBDE is not feasible and
the chance of CBD stone is less than 65%.




                                                                            POSTER ABSTRACTS
                                                                               WEDNESDAY




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1636 A Novel Hepatico-Jejunostomy Technique Featuring a
       Purse-String Anastomosis and a Biodegradable Stent: A
       Preclinical Study in Minipigs
Johanna Laukkarinen*1, Juhani Sand1, Jenni Leppiniemi2, Minna Kellomaki2,
Isto Nordback1
1Department  of Gastroenterology and Alimentary Tract Surgery, Tampere University
Hospital, Tampere, Finland; 2Institute of Biomaterials, Tampere University of
Technology, Tampere, Finland
INTRODUCTION: In small-caliber bile ducts (BD), performing a well-
functioning hepatico-jejunal (HJ) anastomosis can be challenging: bile leak-
age and stricture formation are well-known anastomotic complications. We
have developed a biodegradable stent (BDS) and showed that it can be safely
and effectively used in conventional HJ anastomosis, as well as in the treat-
ment of cystic duct leakage and benign biliary strictures (GIE 2007). In addi-
tion, we have reported good results in patients with novel-technique
pancreato-duodenectomy, where the anastomosis was created using purse-
string technique and a BDS. We hypothesized that, instead of interrupted
sutures, in small caliber BDs it might be easier and safer to create a purse-
string anastomosis, and to use a BDS to ensure its patency. The aim of this
study was to investigate the use of this novel technique for HJ, featuring a
purse-string anastomosis and a BDS, and to compare the results to a conven-
tional anastomosis without any stent in the minipigs.
MATERIALS AND METHODS: In this study the self-expanding PLA-BaSO4
BDSs (length 25 mm, wall 0.25 mm, diam 4/5 mm) and 23-kg minipigs were
used. Cholecystectomy was performed and BD inner diameter measured. HJ
was performed randomly either conventionally with interrupted sutures
without any stent (n = 5) or by the novel purse-string technique (n = 4),
where a BDS was first introduced into the BD, after which the BD with the
stent was slide with the aid of 3 stay-sutures well inside the jejunal purse-
string, which was then tightened. The animals were followed by repeated x-
rays and liver chemistry.
RESULTS: The preoperative BD diameter was similar in the groups (aver
4.2 mm). 10 interrupted sutures in average were used in the conventional
anastomosis. The time needed for creating the anastomosis was similar in the
two groups (28.2 min in the conventional and 25 min in the purse-string +
stent group). In the conventional group, one animal was sacrificed due to
uncontrolled anastomotic bile leak on the 2nd postoperative day, and another
animal developed a mild liver function failure with increased liver values at 1
month, and almost normal values at 3 months. All other animals (3/5 in con-
ventional group and 4/4 in purse-string + stent group) had no signs of anasto-
motic leakage or liver function failure. In the abdominal radiograph the
biodegradable stent had disappeared from all animals by 3 months.
CONCLUSIONS: The described novel HJ technique featuring a purse-string
anastomosis and a BDS is easy and safe to perform, and seems to ensure a
well-functioning anastomosis in small-calibre BDs. These encouraging initial
results point to further trials in the near future.


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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1637 Primary Gallbladder Cancer: A 22 Year Experience in a
       Tertiary Care Center
Rubayat Rahman*2, Yevgeniy Ostrinsky3,2, Magesh Sundaram1
1Department  of Surgery/Surgical Oncology, West Virginia University, Morgantown, WV;
2Department  of Medicine, West Virginia University, Morgantown, WV; 3Division of
Digestive Diseases, West Virginia University, Morgantown, WV
BACKGROUND: Gallbladder cancer (GBC) is an aggressive and an uncom-
mon malignancy with overall dismal outcome. There have been only few
studies examining the epidemiology, surgical outcomes and survival of GBC.
AIM: To examine the demographic characteristics, pathology, surgical out-
comes and survival of patients with GBC in a tertiary care center.
METHODS: Patients diagnosed with primary GBC were identified from the
WVU cancer registry. Cases were arbitrarily divided into pre-laparoscopic
(1985–1995) and laparoscopic era (1996–2006). Information on demograph-
ics, symptoms, clinical staging, treatment modality, surgical procedures with
outcomes and survival were obtained.
RESULTS: A total of 47 cases were identified with 40 (85%) female and 7
(15%) male (p < 0.001). Average age was 66 years (37–85, median 68). 42
(90%) were white in the patient cohort. 39 (83%) patients had cholelithiasis
and 32 (68%) had cholecystitis. Abdominal pain (85%) and nausea (81%)
were the most common symptoms at presentation. 24 (51%) patients had
jaundice at initial presentation and of these 15 (63%) had ERCP. US and CT
were the most common initial modalities for evaluation. Of the cases where
the type of cancer was reported, 39 (83%) patients had adenocarcinoma with
17 (36%) moderately differentiated and 30% (14) poorly differentiated cancer,
2 (4%) had squamous cell carcinoma, one small cell and one histiocytoma.
Although the complication rate with attempted laparoscopic surgery was
high, it did not affect the median survival when compared with open chole-
cystectomy. 30% (14) of patients had curative surgery and 45% (21) had pal-
liative surgery. 51% (24) of patients were treated with chemotherapy, 32%
(15) with radiation and 30% (14) with combination chemotherapy and radia-
tion therapy. In the two eras we see a trend in improved survival (28 wks vs.
41 wks) that is statistically significant (Table).
CONCLUSIONS: Our 22 year experience showed that significantly more
patients were diagnosed with GBC in the laparoscopic era. Even though the
outcomes are dismal, there is a trend of significant increase in stage specific
                                                                                           POSTER ABSTRACTS




and overall survival over the last two decades.
                                                                                              WEDNESDAY




Table 1. GBC in Pre-Laparoscopic (1985–1995) and Laparoscopic (1996–2006) Era
                                                       Pre-Lap Era    Lap Era    p-value
No of patients, n (%)                                    14 (30)      33 (70)    <0.001
Incidental open cholecystectomy, n (%)                   10 (71)       6 (18)     <0.01
Incidental laparoscopic cholecystectomy, n (%)            0 (0)       20 (82)    <0.0001
Stage I/II/III, n (%)                                     4 (29)      10 (30)      NS
Stage IV, n (%)                                          10 (71)      23 (70)      NS
Stage I/II/III survival (wk)                            379/—/42     450/67/58   <0.001
Stage IV survival (wk)                                      23           37      <0.001
Overall survival (wk)                                       28           41      <0.001


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 W1639 Only Pain from Acute Inflammation Is Relieved One
       Year Following Laparoscopic Cholecystectomy in
       Dyspeptic Patients with Cholelithiasis
Roger G. Keith, Samaad Malik*, Bruce Reeder, Rajni Chibbar
Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, SK, Canada
INTRODUCTION: The purpose of this study was to determine if laparo-
scopic cholecystectomy (LC) in patients with cholelithiasis and dyspepsia will
produce complete symptomatic relief one year after surgery. In this study dys-
pepsia was defined by a validated scoring system which measured epigastric
pain, heartburn, belching and bloating.
METHODS: Patients undergoing LC for uncomplicated gallstone disease in
three university affiliated hospitals, from January 1, 2004 to June 30, 2005
received a validated questionnaire one year after surgery. This population
based study used the questionnaire to identify patients with cholelithiasis
and dyspepsia (Group I). For each symptom, the severity, frequency and dura-
tion were quantified using a Likert scale to produce a preoperative and post-
operative total score per patient. Preoperative scores greater than 16
identified Group I patients. Postoperative scores less than 6 defined complete
cessation of symptoms. Each gallbladder specimen was examined by a single
pathologist blinded to patient clinical information.
RESULTS: The survey response rate from 942 patients was 43%. Group I
(N = 264) were dyspeptic (77%); Group II (N = 79) who had scores less than
16, had no dyspepsia (23%). Although Group I patients were improved over-
all one year after surgery (median postoperative total score: 12); only 40
patients (18.6%) achieved complete cessation of symptoms (scores <6).
Ninety six patients (36.4%) had persisting dyspepsia (scores >16). One hun-
dred and nineteen patients (45.1%) had reduced scores (7–15) one year after
operation. Analysis of this subset identifed only pain was significantly
reduced (p < 0.001). Pathological examination of these 119 gallbladders
revealed histological evidence of acute cholecystitis in 57%, which accounts
for the pain reduction in this subset. One hundred and forty four of all Group
I patients (54.5%) had acute cholecystitis. Only 99 (37.5%) had chronic
cholecystitis; 21 (8.0%) had normal gallbladders with cholelithiasis.
CONCLUSIONS: This is the largest study to report outcomes for patients
with gallstones and dyspepsia one year after LC. The majority of patients do
not achieve complete cessation of symptoms. Pain was relieved more than
other dyspeptic symptoms in this population. Half of the study group had
acute inflammation of the gallbadder on histopathological examination.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1640 Surgery for Symptomatic Portal Biliopathy
Puneet Dhar*, Sudhindran Surendran, Sudheer Othiyil Vayoth,
Shaji Ponnambathayil
Gastrointestinal and HPB Surgery, Amrita Institute of Medical Sciences, Cochin, India
BACKGROUND: Portal biliopathy is the presence of functional or structural
biliary changes due to porto-systemic collaterals in portal hypertension
(especially in extra hepatic portal vein obstruction—EHPVO). A preliminary
portosystemic shunt is usually recommended before attempts at biliary
decompression or bypass in symptomatic patients.
AIM: To review our experience in the surgical management of symptomatic
portal biliopathy.
METHODS: From a prospectively maintained computerised database, 93
patients presenting with EHPVO were evaluated over the last 8 years. Surgery
was required in 23 patients. Seven of these patients had features of portal bil-
iopathy, and form the basis of this review.
RESULTS: Presenting features were jaundice in 5 (cholangitis in 4); Gas-
trointestinal bleeding in 3 and symptomatic hypersplenism in one. One of
the jaundiced patients had been referred as hilar cholangiocarcinoma. Com-
monest structural change observed was combined involvement of extrahe-
patic and bilateral intrahepatic biliary system (Type III b, n = 5). Five patients
had Common bile duct calculi and 2 had gallstones. Three patients under-
went portosystemic shunting (splenorenal in 2 and mesocaval in 1). Four
patients had hepaticojejunostomy—one with bile duct resection (for pre-
sumed malignancy) and 3 without manifest GI bleed and operative appear-
ance of mild portal hypertension, although they were kept prepared for a
shunt (should it have been required). One patient each after shunt and
bypass respectively, developed recurrent cholangitis but resolved on conser-
vative management. The patient with bile duct resection had subsequent
ectopic variceal bleed and required a splenorenal shunt. Follow-up serum
bilirubin reduced faster (Range 4–57 weeks) than alkaline phosphatase levels
(Range 4–208 weeks).
CONCLUSIONS: Portal biliopathy must be considered in evaluation of bil-
iary complications in EHPVO. Jaundice is the commonest presentation, and
Type III b is the most frequently encountered anatomical anomaly. Surgery
can relieve most symptomatic patients. Shunt surgery (usually splenorenal)
                                                                                        POSTER ABSTRACTS




may be adequate in some patients to decompress the biliary obstruction.
                                                                                           WEDNESDAY




Direct hepaticojejunostomy is possible in selected patients without severe
portal Hypertension.




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 W1641 Study of a Reverse Phase Polymer in Cholecystectomy:
       Prevention of Stone Migration and Enhancment of
       Dissection
Marvin Ryou*1, Gloria Fernandez-Esparrach1, Sohail N. Shaikh1, David B. Lautz2,
Christopher C. Thompson1
                 Brigham & Women’s Hospital, Boston, MA; 2Surgery, Brigham and
1Gastroenterology,
Women’s Hopital, Boston, MA
INTRODUCTION: Migration of stones from the gallbladder to the cystic
duct has been reported in up to 15% of cases during laparoscopic cholecystec-
tomy, with significant risk of residual choledocholithiasis. Additionally, gall-
bladder dissection is occasionally difficult due to adherence to the liver, with
increased risk of bleeding and perforation. Poloxamer 407 is a non-ionic
surfactant with rapid reversible sol-gel transition (solid at body temperature,
liquid at cold temperatures), behavior that has been used to prevent ureteral
stone migration in animal studies.
AIM: To investigate a reverse phase polymer as a method of stabilizing stones
in the gallbladder during cholecystectomy and as a means of tissue dissection
in NOTES.
METHODS: A partial NOTES cholecystectomy was performed in 2 non-
survival using a double-channel endoscope via a transcolonic approach. The
procedural steps were as follows: identification and exposure of the gallblad-
der; filling of the gallbladder with the polymer; injection of the polymer
between the gallbladder and the liver, and dissection of the gallbladder from
its bed. For the polymer injection we used a 22-G endoscopic needle. Polox-
amer 407 was kept on ice during the intervention. Saline containing syringes
were also kept on ice to cool the catheter immediately before poloxamer
injections. Animals were sacrificed immediately after the surgery and necropsy
performed.
RESULTS: The gallbladder was able to be filled until distention was
observed. No leakage of bile following needle withdrawal was noted, confirm-
ing gel occlusion. Injection between the gallbladder and liver was feasible and
appeared to aid in gallbladder resection. At necropsy, 25 minutes after the
polymer was injected, the gallbladder was filled by a yellow gel that con-
firmed the polymer had mixed with bile and remained in the solid phase. No
polymer was identified in the cystic duct. The surgical bed did not show
bleeding and there was a gel interface between the remaining gallbladder and
the fossa allowing an easy manual separation of both structures.
CONCLUSIONS: The use of a reverse phase polymer for cholecystectomy
may prevent the leakage of bile in the case of a gallbladder perforation and
the migration of stones through the cystic duct. Additionally, this may facili-
tate the dissection of the gallbladder from the fossa.




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Clinical: Colon-Rectal
 W1642 Laparoscopic and Open Anterior Resection and Low
       Colorectal Anastomosis for Adult Megacolon: Surgical
       Outcomes
Sergio E. Araujo*, Afonso H. Sousa, Fabio G. Campos, Sergio C. Nahas, Caio S. Nahas,
Desiderio R. Kiss, Ivan Cecconello
Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
Chagas disease (American trypanosomiasis) is the most common cause of
megacolon in adults in Brazil. Surgical treatment is indicated when complica-
tions occur or when quality of life remains severely compromised. Adequate
surgical treatment requires resection of a largely dilated left colon and con-
struction of a low colorectal anastomosis. Improvements in laparoscopic
techniques enabled most colorectal procedures, even the most challenging
one, to be performed using a video approach. This study was designed to
compare the outcomes of laparoscopic anterior resection with low colorectal
anastomosis with the open approach for treatment of acquired (chagasic)
megacolon.
A total of 22 patients who underwent laparoscopic (LAP) anterior resection
for chagasic megacolon were compared to 22 patients submitted to open
(OPEN) operation at the same time interval and at one institution. There were
no differences between the groups regarding age, sex and previous abdominal
operation. Operation time was longer in the LAP group (278 vs. 231 min; P =
0.031) but the blood loss was less (210 vs. 260 ml; P = 0.027). There was no
difference regarding specimen length (29.8 vs. 30.9 cm; P = 0.775). There was
no mortality. There were no intraoperative complications neither need for
conversion. Length of stay was reduced for LAP group (10.5 vs. 12.7 days) but
not significantly (P = 0.173). There was no difference in postoperative mor-
bidity between the groups. Anastomotic leakage occurred in two patients
after LAP and in 3 patients after OPEN. Only one patient at the LAP group
needed a reoperation. Four patients in the OPEN group were reoperated due
to infectious complications.
A laparoscopic approach for the treatment of acquired megacolon through
colon resection and low colorectal anastomosis is feasible and represents a
safe option with short-term advantages when compared to the open
                                                                                       POSTER ABSTRACTS




approach.
                                                                                          WEDNESDAY




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 W1643 To Control Intraoperative Bacterial Contamination
       and SSI During Anterior Resection or Hartmann’s-
       Mile’s Operation: What Can We Do?
Katsunori Nishikawa*, Nobuyoshi Hanyuu, Masami Yuda, Hideharu Yasue,
Takenori Hayashi, Susumu Kawano, Teruyuki Usuba, Isao Miyoshi, Ryouji
Mizuno, Shuuichi Iwabuchi
Surgery, Machida Municipal Hospital, Machida-shi, Japan
BACKGROUND: The prevalence of surveillance of surgical site infection
(SSI)have been playing important role in the prevention for the postoperative
infection. However, intraoperative bacterial contamination (IBC) which can
be a major cause for SSI has not been well investigated.
AIM: The aim of study is to investigate whether ingenuity of surgical proce-
dure could have an effect on decrement to IBC/SSI rate.
METHODS: The subjects were 50 patients who underwent elective colorectal
surgery (anterior resection (AR)/34, Hartmann’s-Mile’s operation (HM)/16)
from November 2004 to June 2007. Of these, adoral colonic transection in
early period during surgery (early transection: E-Tx) was performed in 30
patients (AR: 21, HM: 9) and late colonic transection, which colonic continuity
was not cut off until anastomosis or stomal construction (late transection: L-Tx)
was in 20 patients (AR: 13/HM: 7). Three samples as of 1) lrrigation fluid
before abdominal closure (CLOS), 2) remained cutting suture ligated for peri-
toneal closure (SUTURE), and 3) subcutaneous swab of surgical wound (SUBCUT)
were obtained intraoperatively and examined for the bacterial identification.
RESULTS: The overall SSI rate was 26% (AR: 4/HM: 9) and all SSI occurred
superficially. Eleven out of 13 SSI patients had extremely high IBC rate of
85%, as well as IBC patients had high SSI rate at 72%. Bacterial detection was
highest in the CLOS (26%), and SUBCUT (26%), and followed by SUTURE
(12%). SSI rate of L-Tx group was significantly lower than that of E-Tx group
(10% vs. 36.7%, p < 0.05). Comparison of IBC rate between those 2 groups
was also significant (E-Tx: 47%/ L-Tx: 20%, p < 0.05).
CONCLUSION: Intraoperative contamination was considered as the one of
important factor for SSI. Both IBC and SSI rate can be reduced by the shorten-
ing of transected colonic time from which might contaminated by bacteria.
Therefore thorough control of IBC should reconsider as the priority for SSI
prevention than other remedy.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1644 Preoperative Versus Postoperative Radiotherapy for
       Rectal Cancer: Decision Analysis and Outcome
       Prediction Using a Modified Markov Model
Andreas M. Kaiser*, Daniel Klaristenfeld, Robert W. Beart
USC Department of Colorectal Surgery, University of Southern California, Los Angeles, CA
BACKGROUND DATA: Treatment for resectable rectal cancer has evolved
into a multi-modality approach. Reduction of local recurrences has been
achieved by radiotherapy, but also by improved surgical technique (total
mesorectal excision). Radiotherapy has been associated with significant
adverse effects and cannot exceed local dose limits. We hypothesized that
reserving radiotherapy as treatment tool for high risk tumors and local recur-
rences improves the overall outcome of the group.
OBJECTIVE: To simulate the benefit of preoperative versus selective postop-
erative radiotherapy in a theoretical Markov state-transition model with local
recurrence and overall survival being the primary endpoints. Probabilities of
life-time events were calculated based on a systematic literature review.
DATA SOURCES: Computerized literature search of MEDLINE for publica-
tions in English between 1996–2006, supplemented by manual review of the
retrieved reference lists. Medical subject headings used were rectal cancer,
radiotherapy, surgery, RCT, randomized, clinical trial, mortality, adverse
effects.




RESULTS: With baseline assumptions entered into the model, selective post-
operative radiotherapy evolved as preferred strategy with cure rates of 65.6%
                                                                                           POSTER ABSTRACTS




vs. 63.7% for selective and neoadjuvant radiotherapy, respectively, and a
                                                                                              WEDNESDAY




decrease of radiation exposure to 42.9% of the cohort. The system was sensi-
tive to (1) the fraction of stage I cancers included in the cohort, (2) the differ-
ence between local recurrence rates for neoadjuvant, adjuvant radiotherapy,
or surgery-only approach, and (3) the compliance with the postoperative
radiotherapy. After adjuvant radiotherapy, the local recurrrence threshold
values to reverse the impact of compliance were 6.3%, 8.5%, and 18.3% if the
surgery-only recurrence was set to 10%, 13%, and 27%, respectively.
CONCLUSION: In patients with resectable rectal cancer, routine preoperative
radiotherapy does not improve cancer-specific survival of the cohort com-
pared with modern surgery alone or with selective postoperative radiation of
high-risk individuals and local recurrences.

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 W1645 Effect of Metastatic to Examined Lymph Nodes Ratio
       on Colon Cancer Survival
Sukhyung Lee*, Brad Waddell
Department of Surgery, William Beaumont Army Medical Center, El Paso, TX
INTRODUCTION: Effect of Metastatic to Examined Lymph Nodes Ratio on
Colon Cancer SurvivalIntroduction The number of lymph nodes examined in
colon cancer surgery varies widely. The current staging system is based on the
number of metastatic lymph nodes (N1: metastatic lymph nodes ≤3, N2: met-
astatic lymph nodes ≥4) and does not consider any variations of the number
of lymph nodes examined. Therefore, a ratio-based staging system has been
proposed. The aim of this study is to evaluate the metastatic to examined
lymph node ratio (LNR) as a prognostic factor in stage III colon cancer.
METHODS: Retrospective review of the Automated Central Tumor Registry
of the Department of Defense was performed. There were 1,286 stage III
colon cancer patients who underwent curative surgical resections. Cases were
divided into quartiles by LNR (0.01–0.11 vs. 0.12–0.22 vs. 0.23–0.45 vs.
0.46–1.00). Effects of the LNR on colon cancer survival were analyzed using a
Kaplan Meier survival curve and Cox proportional hazard model.
RESULTS: Decreasing LNR was found to be associated with improved sur-
vival in colon cancer patients. Five year-overall survival was 68%, 65%, 56%,
and 39% for the lowest to the highest quartiles (p < 0.001). Multivariate anal-
ysis identified age, sex, tumor grade, tumor T stage, tumor N stage, and LNR
as prognostic factors. Cox proportional hazard analysis identified LNR as a
better prognostic factor compared with conventional lymph node staging for
stage III colon cancer.
CONCLUSION: The metastatic to examined lymph node ratio is an excellent
prognostic indicator in stage III colon cancer patients. This ratio-based stag-
ing system may provide more comparable prognostic information for colon
cancer patient outcome.




                                       378
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1646 A Prospective Single Center Experience of “Fast-Track”
       in Colorectal Surgery: Toward Zero Anastomotic
       Complications
Pierluigi Di Sebastiano*, Nicola Mastrodonato, Giovanni Bisceglia, Beniamino Rucci,
Antonio Cafaro, Antonio De Bonis, Angelo Ambrosio, Matteo Scaramuzzi,
Vincenzo Crucinio, Fabio Francesco Di Mola, Giuseppe Mascetta, Matteo Tardio
Department of Surgery, IRCCS casa Sollievo Sofferenza, San Giovanni Rotondo, Italy
INTRODUCTION: The present study report a prospective observational sin-
gle center experience of a multimodal perioperative management protocol
(fast-track) in patients undergoing elective colorectal resection for cancer. We
aimed to explore whether fast-track surgery can be safely applied and
improve the outcomes of patients undergoing elective colorectal resection for
cancer.
METHODS: In December 2006 we started a fast-track protocol for patients
with colorectal cancer. Since dec. 2006 to nov. 2007 we performed 252 col-
orectal procedures. Perioperative data from 90 consecutive patients (Group 1)
who underwent elective R0 colorectal resection by means of fast-track surgery
in a high-volume medical center were analysed and compared with 109 previ-
ously performed consecutive elective R0 resections out of 369 colorectal oper-
ations (group 2, nov 2005–nov 2006) and treated before the beginning with
our fast-track management protocol. Fast-track patients received intravenous
fluid restriction, early oral intake and prokinetic agents, early mobilisation
and fixed pain treatment by mean of continuous elastomeric pump. Patients
belonging to group 2 received conventional fluid administration to prevent
oliguria, restricted oral intake until return of bowel motility and conventional
analgesia. Endpoints were postoperative complications, postoperative stay
and mortality.
RESULTS: Of the 90 patients of group 1, 73 received a colon resection, 17 a
total mesorectal excision for rectal cancer. Of the 109 patients of group 2, 83
received a colon resection, 26 a total mesorectal excision for rectal cancer.
Patients in the group 2 required a longer median postoperative stay of 2 days
(10 vs. 8). Patients of group 1 had significantly lesser medical and surgical
complications, first of all in terms of respiratory distress (1.2% vs. 2%). In
addition, we observed zero anastomotic leakage vs. 5% in group 2. There were
2 deaths in patients belonging to group 2 vs. 1 death in group 1.
                                                                                      POSTER ABSTRACTS




CONCLUSIONS: Our data confirm that fast-track surgery is feasible in col-
                                                                                         WEDNESDAY




orectal surgery and demonstrate that a multimodal management protocol is
safe and able to significantly reduce postoperative stay and morbidity.




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 W1647 Laparoscopic Versus Conventional Colostomy Closure
       of Hartmann’s Procedure: A Case-Matched Study
Jung C. Kang*
Colon and Rectum Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
BACKGROUND: Reversal of Hartmann’s procedure is a major surgical proce-
dure associated with substantial morbidity and mortality. The aim of this
study was to compare the outcomes of patient who underwent laparoscopic
or conventional colostomy closure of Hartmann’s procedure.
METHODS: We reviewed all patients undergoing laparoscopic colostomy
closure of Hartmann’s procedure at our institution between 2003 and 2007.
Laparoscopic procedure was matched to conventional procedure by patient
age, gender, American Society of Anesthesiologists score type and years of sur-
gery. All of the patients had a left side colostomy.
RESULT: Seventeen laparoscopic cases were matched with 17 conventional
cases. There were three conversions (18%): two of dense adhesion and one of
small bowel injury. There was no mortality. The hospital stay, length of inci-
sion wound, use of analgesics, estimated blood loss and bowel function
return were significantly less for the patients in the laparoscopic group. There
was no difference in the postoperative complications and operative times in
either group.
CONCLUSION: Laparoscopic colostomy closure of Hartmann’s procedure is a
feasible and safe procedure and has a similar complication rate to that of con-
ventional procedure.




                                       380
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1648 A New Method to Analyze the Quality and Progression
       of Colonoscopy
Hans Törnblom2, Sanian Akbar3, René Tour4, Michael Wedén2, Urban Sjöqvist2,
Lena B. Flodqvist2, Monica Boman-Galiamoutsa2, Leif Torkvist1, Lars Enochsson*1
1Department    of Surgery, Karolinska Institutet, Stockholm, Sweden; 2Department of
Gastroenterology and Hepatology, Karolinska Institutet, Stockholm, Sweden; 3Karolinska
Institutet, Stockholm, Sweden; 4Department of Medicine Gastroenterology Unit, Capio St
Görans Hospital, Stockholm, Sweden
INTRODUCTION: Methods to objectively determine the performance of
laparoscopic cholecystectomy have been established. We describe a new
method to evaluate the quality of colonoscopy in patients where anatomical
landmarks and instrument position can be identified.
METHODS: Fourteen colonoscopies were evaluated (6 by specialists and 8 by
residents). The colonoscopy image was mixed together with the digital image
from ScopeGuide® (Olympus, Japan) and recorded on a laptop computer. The
result was then stored on digital media. Endoscopists and patients graded
their experience of the colonoscopy on a VAS-scale immediately after the
examination. A new experimental evaluation protocol (Enochsson-Ritter) was
used to objectively evaluate the progression and outcome of the colonoscopy.
Two independent observers who were blinded with regard to identity of the
endoscopist made the formal evaluation.
RESULTS: The specialists reached the splenic flexure faster than the resi-
dents (3.8 ± 1.0 vs. 22.8 ± 7.9 min, P < 0.05). Residents found the
colonoscopies to be technically more difficult and generally “worse than
expected” compared with the specialists. The time for both specialists and
residents to reach each segment of the left colon correlated with the parame-
ter “worse than expected” as scored by the patient. The estimated technical
difficulties for the specialist correlated better than that of the residents with
the objectively measured time for the passage of the endoscope. Prolonged
passage in the right colon during endoscopy by specialists increased the pain
in patients.
CONCLUSION: A new method to estimate the quality and progression of
colonoscopy in patients is described. The method can distinguish between
residents and experts and also demonstrates differences in examination qual-
ity that correlates with patient satisfaction. The method might be a valuable
                                                                                         POSTER ABSTRACTS




future tool to monitor the quality and technical skills of endoscopists.
                                                                                            WEDNESDAY




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      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1649 Image-Guided Sentinel Lymph Node Navigation in
       Colon Cancer: A Pilot Study
Julio M. Mayol*1,3, Rocio Anula1,3, Roberto Delgado-Bolton2,3, Iris Sanchez-Egido1,
Jose Luis Carreras-Delgado2,3, Jesus A. Fernandez-Represa1,3
1Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain; 2Servicio de Medicina
Nuclear, Hospital Clinico San Carlos, Madrid, Spain; 3Unidad de Cirugia Guiada por
Imagen, Hospital Clinico San Carlos, Madrid, Spain
INTRODUCTION: Over the last two decades, the concept of sentinel lymph
node (SLN) biopssy has emerged as a minimally invasive staging tool for mel-
anoma and breast cancer. There is no consensus on its indication for colon
cancer because technical issues limit its validity for staging and prognosis. We
present our initial experience with intraoperative lymphascintigraphic scan-
ning/mapping for SLN navigation using a portable gamma camera in patients
with non-metastasic colon cancer.
PATIENTS AND METHODS: Between March and October 2007, patients
over 18 years of age with histologically proven colorectal adenocarcinoma
and non-metastasic disease, scheduled to undergo curative resection by the
same group of surgical oncologists were included in this pilot study. Although
the group of surgeons had extensive experience with SLN biopsy in mela-
noma patients, they had not done any colon cancer SLN biopsies previously.
The in vivo technique required open exploration of the abdomen to exclude
metastasic disease, after location of the primary tumor, a peritumoral subsero-
sal injection of 4 doses (0.5 mCi in 2 ml each) of 99mTc- nanocolloid (diameter
<80 nm) was performed. The intraoperative portable miniature gamma cam-
era (Sentinella 102TM, GEM Imaging SA Valencia, Spain) was intraoperatively
used to monitor radiocolloid migration via lymphatic vessels. Once the SLN
had been located as a “hot spot” in situ, the specimen was removed as the
standard resection, and the node isolated ex vivo for histophatological exam-
ination. H&E and immunohistochemical staining were used.
RESULTS: Five women and 4 men with a mean age of 71 years (39–87), all of
them had resectable adenocarcinomas without metastasic disease, were
included. In three cases the primary tumor was in the right colon, two in the
transverse colon and 4 in the left colon. Migration of the radiocolloid to the
first lymph node took between 5 and 15 minutes. One SLN was identified and
isolated in 8 of 9 patients. The only failure occurred in a patient with a bulky
tumor located in the cecum (failure rate: 12%). TNM pathologic staging
showed 7 tumours were T3 and 3 were T4. Seven tumours were N0, one were
N1 and two N2. In those 3 N-positive patients, the sentinel lymph node was
also positive with H&E staining.
CONCLUSIONS: Our pilot study suggests that intraoperative image-guided
SLN mapping with a portable gammacamera is technically feasible and may
be useful for SLN identification in colon cancer patients. Further research will
be necessary to determine if image-guided SLN detection and biopsy provides
additional prognostic information, improves staging and modifies patient
management.




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      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1650 Low Preoperative Serum Albumin Levels Do Not Affect
       Early Outcomes After Ileoanal Pouch Surgery but May
       Be Associated with Long-Term Mortality
Kweku A. Appau*, Ravi P. Kiran, Feza H. Remzi, Ian Lavery, Victor W. Fazio
Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH
BACKGROUND: Despite reports of adverse outcomes for patients with low
serum albumin levels undergoing general surgical operations, this association
has not been investigated in ileoanal pouch surgery (IPAA). We investigated
the effect of preoperative albumin on early and late outcomes after IPAA in
ulcerative colitis (UC).
METHODS: Data of patients prospectively accrued into a pouch database
were evaluated to determine the association between preoperative albumin
and outcomes after IPAA. Preoperative and perioperative factors and 30-day
complications for patients with albumin of ≤3.0, 3.1–3.5 and >3.5 g/dl were
compared. Chi-squared, Fisher’s exact tests, Kaplan-Meier method and Cox
multivariable statistical analyses were performed.
RESULTS: 1185 UC patients (44% female) had documented preoperative
serum albumin. Comparing patients with albumin <3.5 (n = 139) and >3.5
(n = 1046), there was no difference in gender (p = 0.98), ASA score (p = 0.13),
comorbidity (p = 0.92) and use of defunctioning ileostomy (p = 0.09). The
group with albumin <3.5 was older (p = 0.004), and received greater intraop-
erative transfusion (p = 0.01). A greater proportion of patients in the <3.5
group had predominant surgical indication as failed medical therapy and ste-
roid dependence (p = 0.001), perioperative steroid use (p = 0.001) and under-
went proctocolectomy at IPAA (p = 0.001). Despite this, 30-day complications
including wound infection (p = 0.2), sepsis (p = 0.4), anastomotic separation
(p = 1) and long-term pouch-failure (p = 0.9) and pouchitis (p = 0.73) were
similar. Estimated 5-year mortality risk was significantly greater for the <3.5
albumin group (6.2% vs. 1.4%, p = 0.02). Age (p = 0.001), steroid use (p =
0.012), and albumin of <3.5 were associated with long-term mortality on
multivariate analysis. Comparison of the <3.0 and >3.1 group did not show
any difference in 30-day postoperative complications or long-term outcomes.
CONCLUSION: Serum albumin levels <3.5 g/dl are seen in patients who are
ill and are associated with long term mortality. Proctocolectomy in these
patients may be inevitable. When performing IPAA, due care directed to sur-
                                                                                  POSTER ABSTRACTS




gical technique and decision-making prevents adverse early outcomes.
                                                                                     WEDNESDAY




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  W1651 TGF-Beta1 and IGF-1 and Anastomotic Recurrence of
        Crohn’s Disease After Ileo-Colonic Resection
Marco Scarpa1, Marina Bortolami2, Susan L. Morgan3, Andromachi Kotsafti2,
Cesare Ruffolo1, Renata D’Incà2, Eugenia Bertin1, Lino Polese1, Davide F. D’Amico1,
Giacomo C. Sturniolo2, Imerio Angriman*1
1Clinica Chirurgica 1°, University of Padova, Padova, Italy; 2Gastroenterologia,
University of Padua, Padua, Italy; 3Department of Pathology, Institute for Cancer Studies,
Birmingham Medical School, University of Birmingham, Birmingham, United Kingdom
BACKGROUND: After bowel resection, Crohn’s disease (CD) recurs fre-
quently in the site of anastomosis and “end-to-end” anastomoses are associated
with a higher rate of recurrence compared to “side-to-side” ones. Alteration of
normal healing processes may play a role in this phenomenon. Transforming
growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) are
involved in wound healing mechanisms with pro-fibrogenic properties. The
aim of this study is to understand if a differential expression of reparative fac-
tors in the different zones of the bowel wall can explain why side-to-side
anastomoses are associated to a lower rate of recurrence.
PATIENTS AND METHODS: Sixteen patients affected by CD who under-
went ileo-colonic resection in our department, over the period 2004 to 2005,
were enrolled in this study and their follow up investigated. Full-thickness tis-
sue samples were obtained from the mesenteric side, the lateral side and the
anti-mesenteric side of the ileum wall. Two samples series were collected from
macroscopically diseased and healthy ileum for each patient. TGF-beta1 and
IGF-1 mRNAs were quantified by absolute Real Time PCR using GAPDH as the
housekeeping gene. Myeloperoxidase (MPO) activity and histological disease
activity were assessed to quantify the ileal inflammation. Comparisons and
correlations were carried out with nonparametric tests.
RESULTS: Although no significant difference was observed between the
three groups, a significant correlation between TGF-beta1 relative levels in
diseased bowel and the sampling site was observed (tau = 0.43, p = 0.03); the
closer the sampling site was to the mesenteric side the higher were TGF-beta1
relative levels. In comparison, neither IGF-1 mRNA transcripts nor MPO
activity showed any relation with the sampling site.
CONCLUSION: Our study seems to suggest that TGF-beta1 mRNA expression
is lower in the anti-mesenteric side of the ileum. Since we have previously
demonstrated that high expression of TGF-beta1 is associated with early recur-
rence it seems rational to construct the anastomosis on the anti-mesenteric
side of the bowel. Therefore a side-to-side anastomosis seems to be the most
suitable to minimize the recurrence risk of CD.




                                           384
        49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  W1652 Pre- Versus Postoperative Pelvic Radiotherapy in
        Patients Undergoing Abdominoperineal Resections for
        Rectal Cancer: Does Timing Make a Difference on
        Long-Term Patient Quality of Life?
Michael S. Kasparek*1,2, Imran Hassan3, Robert R. Cima1, David W. Larson1,
Eric J. Dozois1, Rachel E. Gullerud4, Dirk R. Larson4, John H. Pemberton1,
Bruce G. Wolff1
1Department   of Colorectal Surgery, Mayo Clinic Rochester, Rochester, MN; 2Department
of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany; 3Department of
General Surgery, Southern Illinois University School of Medicine, Springfield, IL;
4Division of Biostatistics, Mayo Clinic Rochester, Rochester, MN

INTRODUCTION: Pelvic radiotherapy (XRT) whether given pre- or postop-
eratively is associated with improved oncologic outcomes in patients (pts)
undergoing abdominoperineal resection (APR) for locally advanced rectal
cancer. However, few reports have compared quality of life (QOL) of pts after
preoperative (preop) or postoperative (postop) XRT and APR.

                                        Postoperative XRT     Preoperative XRT
                                                                                   p
                                        (n = 35) mean (SD)   (n = 53) mean (SD)
EORTC QLQ-C30
Global health status                         74 (17)              68 (21)         .16
FS: Physical functioning                     88 (17)              84 (19)         .38
FS: Role functioning                         87 (21)              77 (31)         .21
SS: Nausea and vomiting                        4 (9)              6 (12)          .61
SS:Appetite loss                              7 (14)              12 (21)         .35
SS: Constipation                             11 (20)              14 (24)         .86
SS: Diarrhoea                                15 (22)              19 (26)         .56
EORTC QLQ-CR38
FS: Sexual functioning: Males                76 (22)              72 (24)          52
FS: Sexual functioning: Females              92 (16)              85 (17)         .17
FS: Sexual enjoyment: Males                  57 (16)              44 (28)         .33
FS: Sexual enjoyment: Females                56 (38)              100 (0)         .18
SS: Micturition problems: Males              24 (15)              26 (21)         0.90
SS: Micturition problems: Females            16 (14)              17 (14)         .96
SS: Symptoms of GI-tract                     12 (22)              20 (16)         .01
                                                                                         POSTER ABSTRACTS




SS: Stoma-related problems                   27 (21)              32 (23)         .34
                                                                                            WEDNESDAY




FS: functionalscale; SS: symptomscale


METHODS: At a single institution between 1994–2004, 204 pts underwent
APR for rectal cancer and received XRT (112 preop and 92 postop). One hun-
dred and twenty nine (63%) pts were alive at last follow-up and mailed the
EORTC QLQ-C30 and EORTC QLQ-CR38. Response rate was 68% (53 preop
and 35 postop XRT) and not different between the two groups (69% vs. 67%
p = 0.86). Median follow-up was 77 months (mo) (range 25–148 mo).
Responders had a higher proportion of males (70% vs. 54%, p = 0.06) but



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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


were similar in age (59 vs. 62 years, p = 0.16) compared to non responders.
Data are on a 0–100 point scale (100 = best [functional scales] or worst [symp-
tom scales]; mean [SD]).
RESULTS: Pts receiving preop XRT had a higher proportion of males (77%
vs. 60%, p = 0.08 ) and a shorter median follow-up (62 vs. 103 mo, p < 0.001)
compared to pts receiving postop XRT; however, the mean age (58 vs. 60
years, p = 0.73) was similar. There were no significant clinical differences
between the two groups in any of the symptom and functional subscales of
the EORTC QLQ-C30 and EORTC QLQ-CR38 except GI tract symptoms
which was worse in pts receiving preop XRT (20(16) vs. 12(12), p = 0.01).
CONCLUSION: Among APR pts receiving XRT for locally advanced rectal
cancer, timing of XRT (preop or postop) does not affect long-term patient
QOL. These findings are important for counselling pts with locally advanced
rectal cancer requiring an APR and XRT.




                                     386
        49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  W1653 Sacral Neuromodulation for the Treatment of Fecal
        Incontinence and Voiding Dysfunction in Female
        Patients: A Longterm Follow Up
Galal S. El-Gazzaz*, Levilester B. Salcedo, Massarat Zutshi, Tracy L. Hull
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: Sacral nerve modulation (SNM) for fecal incontinence (FI) is not
yet approved by the FDA. The aim of this study is to evaluate the efficacy of
SNM in treatment of fecal incontinence with voiding dysfunction (VD) in
female patients.
METHODS: Twenty four female patients with FI and VD underwent two
stage SNM implantation after successful peripheral nerve stimulation
between October 2003–2007 by the Urologists. Patients demographics and
morbidity were reviewed. The patients were evaluated by preoperative and
postoperative questionnaires which included Wexner incontinence scores,
Fecal Incontinence Quality of Life Scale (FIQL) and Bristol stool scale. This
was done via review of their medical records and telephone interviews.
RESULTS: Twenty four female patients underwent successful implantation
of the stimulator. 16 patients could be contacted. The median follow up was
28 months (range 3–49 months). Seven (43.8%) experienced no symptom
improvement after SNM, five (31%) patients had the stimulator removed;
three (19%) because of poor clinical response and two due to infection at the
site of the stimulator. Two (12%) received a colostomy for symptom control
although the stimulator remains in place for urinary symptoms. Nine (56%)
patients in whom SNM is currently functioning show significant improve-
ment in their symptoms. Incontinence scores (Wexner 0–20,) was reduced
from mean 15 ± 2.8 before sacral nerve stimulation to mean 10 ± 7.2
(p = 0.006). FIQL scores improved significantly with improvement in all
areas: life style from 1.9 to 2.5 (p = 0.01), coping-behavior from 1.8 to 2.3
(p = 0.03), depression and self-perception from 2.5 to 3.2 (p = 0.003), and
embarrassment from 2.39 to 3.03 (p = 0.03). This was also accompanied by a
change stool form on the Bristol scale.
CONCLUSIONS: SNM in patients with FI and VD helps control of symptoms
and improves quality of life. The lack of FDA approval limits the use of SNM
for FI as an exclusive diagnosis.
                                                                                                          POSTER ABSTRACTS




Table 1. Showing Preoperative and Postoperative Scores
                                                                                                             WEDNESDAY




                                                             Pre-Sacral          Post-Sacral
Parameter                                                                                       p-value
                                                          Nerve Stimulation   Nerve Stimulation
Wexner Score for FI Mean ± SD                                 15.6 ± 2.8         10.13 ± 7.12    0.006
                                           Life style            1.91                2.55         0.01
Fecal Incontinence
                                            Coping               1.18                2.30        0.03
Quality Of Life Scale (FIQL)
                                          Depression             2.52                3.23        0.003
Mean values
                                         Embarrassment           2.39                3.03         0.03
Wexner Score = 0–20 . 0 = Total continence




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 W1654 Long Term Out Come and Quality of Life After
       Restorative Proctocolectomy in a Cohort of 955
       Canadian Patients
Marco Scarpa*1, Brenda I. O’Connor2, J Charles Victor2, Robin S. Mcleod2
1ClinicaChirurgica I, University of Padova, Padova, Italy; 2Department of Surgery,
Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
BACKGROUND AND AIMS: Restorative proctocolectomy (RPC) is the pro-
cedure of choice for ulcerative colitis (UC) and familial adenomatous polypo-
sis (FAP) but it has an important impact on quality of life (HRQL). The aims of
this cross sectional study were to validate an English version of the Padova
Inflammatory Bowel Disease Quality of Life questionnaire (PIBDQL) in
patients undergoing RPC to investigate the possible predictors of long term
HRQL. Functional outcome was also investigated.
PATIENTS AND METHODS: In 2005, the English PIBDQL, the Short
Inflammatory Bowel Disease Questionnaire, Short Form-36 and the Pelvic
Pouch Follow-up questionnaires were mailed to 1379 patients who under-
went RPC at the Mount Sinai Hospital between 1982 and 2004. Nine hundred
sixty-nine (69%) returned the questionnaires. The translation and validation
of PIBDQL into English language implied the assessment of test-retest reliabil-
ity, internal consistency, construct validity and discriminative ability.
RESULTS: The test-retest reliability, internal consistency, construct validity
and discriminative ability of the English version of PIBDQL were adequate.
Multivariate analysis showed that although female patients experienced the
same rate of complications and stool frequency as males, they obtained worse
PIBDQL scores (p < 0.01); patients with Crohn’s disease (CD) experience
worse long term HRQL compared to UC or FAP patients (p < 0.01); patient
who had pouch reconstruction obtained significantly worse scores than
patients who had not.In our study group the 67% of patients reported a full
continence during the day time after a follow up of about 9 years. Only very
few patients (<1%) reported a complete day time incontinence. The bowel
movement frequency in the 24 hours was 7.7 ± 3.2 and mean frequency dur-
ing the night was 1.7 ± 1.3. Female patients reported more frequent sexual
restrictions due to pelvic pouch.
CONCLUSIONS: As far as we know, this is the largest series of RPC patients
to be investigated with a disease specific tool for the measurement of HRQL
and in this series female gender, CD and pouch redoing were significant risk
factors for a worse HRQL long term outcome.




                                         388
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1655 Colorectal Surgical Specimen Lymph Node Harvest:
       Improvement of Lymph Node Yield with a Physicians
       Assistant
Robert C. Moesinger*1,2, Christopher L. Hall3, Jeffery A. Reese4
1Department of Surgery, McKay-Dee Hospital Center, Ogden, UT; 2Department of Surgery,
University of Utah School of Medicine, Salt Lake City, UT; 3Department of Pathology,
McKay-Dee Hospital Center, Ogden, UT; 4Department of Radiology, McKay-Dee Hospital
Center, Ogden, UT
INTRODUCTION: Adequate lymph node harvest (at least 12) from colorec-
tal cancer resection specimens has become a standard of care, influencing
both staging and survival. To improve lymph node harvests in our hospital, a
physicians assistant in the Department of Pathology was trained to harvest as
many lymph nodes as possible from colorectal cancer specimens. An analysis
of trends in lymph node harvest over time in our community hospital is
presented.
METHODS: Pathology reports were retrospectively reviewed of the number
of lymph nodes harvested from 391 consecutive colorectal adenocarcinoma
specimens in a single community hospital over an 8 year period (1999–2006).
This spanned 4 years prior to the training of the physicians assistant and 4
years after.
RESULTS: In the following table, results are given for each year in terms of
average lymph node harvest and percent of specimens greater than 12 lymph
nodes. Comparing 1999–2002 with 2003–2006, the difference in the average
lymph node harvest reaches a p-value of <0.00001 (T-test). Comparing the
number of specimens with at least 12 lymph nodes between 1999–2002 and
2003–2006, the difference reaches a p-value of <0.00001 (Chi-square).

      Year        # of Specimens   Mean # of Lymph Nodes   % Specimens with >11 Lymph Nodes
      1999               18                 13.3                         67%
      2000               48                 12.2                         50%
      2001               53                 14.3                         55%
      2002               49                 14.4                         67%
 Training of PA
      2003             40                  20.7                          83%
      2004             50                  20.6                          84%
                                                                                              POSTER ABSTRACTS




      2005             75                  18.4                          87%
                                                                                                 WEDNESDAY




      2006             58                  20.0                          86%

CONCLUSIONS: As the awareness of the importance of adequate lymph
node harvests in colorectal cancer specimens increased, lymph node harvests
at our hospital steadily increased. The training of a physicians assistant to
meticulously harvest as many lymph nodes as possible from colorectal cancer
specimens dramatically affected lymph node harvests and can be a crucial
component of pathologic analysis of these specimens.




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     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1656 Relevance of Comorbidity for Postoperative Lethality
       and Morbidity After Surgery for Perforated
       Diverticulitis of the Sigmoid Colon
Mario H. Mueller*, Mia Karpitschka, Michael S. Kasparek, Martin E. Kreis
Department of Surgery, Maximilians-University, Munich, Germany
INTRODUCTION: Perforated diverticulitis of the sigmoid colon is a com-
mon cause for emergency laparotomy. Several non-randomized studies
reported in recent years that a sigmoid colectomy with primary anastomosis
in Hinchey I–III patients yields similar results when compared to the Hart-
mann procedure, while avoiding the frequently difficult operation for take-
down and reanastomosis of the colostomy. The aim of this study was to
review the results of this practise in our hospital and to identify patients at
risk for morbidity and lethal outcome.
METHODS: All patients who were admitted to our hospital with the diagno-
sis diverticulitis of the sigmoid colon from 1996 to 2006 were identified by
the institutional data base and the patient charts reviewed. While 787
patients were admitted, 73 were operated on an emergency basis i.e., within
24 h after hospitalization (f:m ratio 1.3:1; median age 66 years, range 42–91).
The primary end points were lethality, anastomotic leakage in patients with
primary anastomosis and leakage of the rectal stump following Hartmann’s
procedure. Statistical analysis was performed by Chi-Square Test.
RESULTS: 36 (49%) of 73 patients who were operated on an emergency basis
had a primary anastomosis without any stoma. 11 (15%) patients received a
primary anastomosis and a loop ileostomy. A Hartmann procedure was per-
formed in 26 (36%) patients. Complications were observed in 27 (37%) of all
patients. Anastomotic leakage occurred in 9 of 36 patients (25%) following
primary anastomosis without protective loop ileostomy and in 1 of 11
patients (10%) who had an additional loop ileostomy. Seven patients died.
Six of them had undergone a Hartmann operation and two primary anasto-
mosis; one with and one without loop ileostomy (total mortality 10%). The
incidence of anastomotic leakage was independent of the Hinchey classifica-
tion (Hinchey I. 3 pts, Hinchey II: 4 pts., Hinchey III 2 pts; n.s.), but associ-
ated with the comorbidity of the patients (ASA II: 1 pts; Asa III: 5 pts; ASA IV:
III pts.; p < 0.05).
CONCLUSIONS: Lethality and morbidity following operations for perforated
sigmoid diverticulitis are high. Anastomotic leakage was primarily associated
with severe comorbidity and was not dependent on the extent of the abdom-
inal infection according to the Hinchey classification. The indication for a
primary anastomosis following emergency surgery for sigmoid colectomy in
perforated diverticulitis should not be based on the local intraabdominal
findings but rather on the extent of the patients comorbidity.




                                       390
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1657 Management and Treatment of Iliopsoas Abscess
Parissa Tabrizian*, Scott Q. Nguyen, Alexander Greenstein,
Uma Rajhbeharrysingh, Celia M. Divino
General Surgery, The Mount Sinai Medical Center NY, New York, NY
BACKGROUND: Iliopsoas abscess (IPA) is an uncommon condition present-
ing with vague clinical symptoms often resulting in delayed diagnosis and
significant morbidity. Treatment strategies remain nonstandardized.
METHOD: A retrospective review was performed of patients diagnosed with
IPA at the Mount Sinai Medical Center from 2000–2007. Records were
reviewed with respect to patient demographics, medical history, predisposing
and presenting features, diagnostic workup, laboratory results, microbiologi-
cal investigation, treatment options and hospital course.
RESULTS: IPA was diagnosed in 61 patients (M = 32, F = 29). The average age
was 53 years. The majority of patients presented with pain (95%), gastrointes-
tinal complaints (43%) and lower extremity pain (29%). Mean duration of
symptoms was 13 days and mean hospital stay was 25 days. Primary abscess
occurred in 11% and secondary in 89%. Underlying causes of secondary
abscesses were gastrointestinal in 29%, bacteremia in 13%, immunosupressed
state in 8%, and post-procedural in 8%. Broad spectrum antibiotics were pre-
scribed in 100% of cases. Computed tomography (CT) was the most common
diagnostic modality used and was successful in 88% of cases. Abscesses were
larger than 6 cm in 39%, bilateral in 13% and multiple in 25%. 15% of
patients were initially treated with antibiotics alone (Group1) with a success
rate of 78%. 89% of these were less than 3.5 cm and the most common cause
was bacteremia. 85% of patients initially underwent drainage (open 6%
[Group2] and percutaneous 79% [Group3]) with a success rate of 100% and
40%, respectively. Among those cases which did not resolve, 71% ultimately
required operative therapy. The majority of these cases had an underlying
gastrointestinal etiology. Overall mortality was 5%.
CONCLUSION: IPA remains a therapeutic challenge. Gastrointestinal disease
is the most common underlying etiology. CT scan is the diagnostic modality
of choice. Antibiotic treatment alone for abscesses less than 3.5 cm and with-
out gastrointestinal cause is typically successful. Percutaneous drainage
remains the primary initial treatment modality but rarely is the sole therapy
required. Cases with a gastrointestinal etiology are likely to require ultimate
operative management.
                                                                                  POSTER ABSTRACTS
                                                                                     WEDNESDAY




                                       391
        THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1658 Comparison of GFAP Expression and Mucosal Mast Cell
       Numbers in Pediatric Intestinal Diseases
Eumenia Castro*1, John Ozolek1, Kelly A. Miller2
1Pathology, Children’s Hospital of Pittsburgh, Pittsburgh, PA; 2Surgery, Children’s
Hospital of Pittsburgh, Pittsburgh, PA
BACKGROUND: Enteric glia likely play major roles in gut barrier function
and vascular integrity. Glial fibrillary acidic protein (GFAP) expression is
decreased in Crohn’s, Hirschsprung Disease (HD), and necrotizing enterocoli-
tis (NEC). Inflammatory cells including mast cells are present in normal
bowel and evidence suggests a functional interaction between mast cells and
enteric glia in diseased bowel. The aims are to enumerate and delineate the
relationship between enteric glia and mucosal mast cell number in pediatric
diseased bowel.
DESIGN: Paraffin-embedded colon from 47 cases of ulcerative colitis (UC),
resolved NEC (R-NEC), acute NEC (A-NEC), ischemic bowel (ISC), HD associ-
ated with inflammation (HDI), HD, and normal (NL) were stained for GFAP
and mast cell tryptase. All stain controls were appropriate. Glial cells with a
visible process and cytoplasmic staining for GFAP were counted in myenteric
(M) and submucosal (S) plexi. In HD, cells were counted in ganglionic (G),
transitional zone (TZ), and aganglionic segments (AG). Non-parametric anal-
ysis was done with p-values <0.05 significant. Results are shown as density
(median number of cells per centimeter; minimum and maximum values in
parentheses).
RESULTS: Glial cells (M) were greater than glial cells (S) except in UC where
UC demonstrated the highest median number of glial (S). Glial (M) in ISC
and A-NEC were significantly higher than glial (S). While glial cells within the
ganglionic segment of HDI were greater than in the TZ, this was not statisti-
cally significant. UC and NL had significantly higher number of mast cells
compared to other groups (p < 0.05). The number of mast cells did not differ
between the G, TZ, and AG segments in either HDI or HD. A-NEC had the
highest ratio of glial (M) to mast cell number (1.18) while A-NEC, HDI, and HD
had the highest ratio of glial (S) to mast cell number (0.10, 0.17, and 0.095
respectively).
CONCLUSION: Mast cell numbers appear increased in UC. HD shows decreased
myenteric glial cells compared to other groups except NL. Other conditions
including HD show decreased numbers of mast cells compared to NL and UC.
We speculate that mucosal mast cells may exert an effect on expression of GFAP
within submucosal glial cells under chronic inflammatory conditions.

                                                                      MAST       MAST        MAST
        N GFAP#-G-M GFAP#-G-S GFAP#-TZ-M GFAP#-TZ-S
                                                                     CELL#-G    CELL#-AG CELL#-TZ
NL      8    0 (0,53)     0 (0,2)        —                 —        110 (45,72)     —           —
UC      7   12 (0,30)    12 (0,50)       —                 —       180 (57,222)     —           —
HDI     7   30 (2,55)    10 (0,41)   7.5 (0,49)         9 (0,35)   51 (39,110) 40 (22,45) 51.5 (20,68)
HD      6   3.5 (0,49)    3 (0,8)     5 (0,23)          6 (1,15)    43 (18,66) 44.5 (21,63) 40 (26,56)
ISC     7   36 (0,72)     0 (0,3)        —                 —       64 (28,180)      —           —
A-NEC   7   30 (0,80)    1 (0,15)        —                 —         29 (9,72)      —           —
R-NEC   5   22 (0,75)    0 (0,10)        —                 —        62 (46,90)      —           —


                                                  392
       49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


Clinical: Esophageal
  W1659 Outcomes of Laparoscopic Assisted Transhiatal
        Esophagectomy for Adenocarcinoma of Esophagus
Martin I. Montenovo*, Kyle J. Chambers, Carlos A. Pellegrini, Brant K. Oelschlager
Surgery, University of Washington, Seattle, WA
HYPOTHESIS: Laparoscopic-assisted transhiatal esophagectomy (LA-THE)
decreases the morbidity and mortality associated with esophagectomy, at the
same time enabling a more oncologic operation.
DESIGN: Retrospective cohort study.
SETTING: University tertiary care medical center
METHODS: Seventy-two consecutive patients that underwent LA-THE for
adenocarcinoma between 9/1995 and 12/2006. Follow-up was complete to
July 2007, 6 to 140 (mean 34) months after LA-THE.
RESULTS: Patient characteristics and treatment: Mean patient age: 63.9 ± 9.6
years; mean body mass index: 27.5 ± 3.8. Thirty-nine patients (54%) under-
went neoadjuvant chemoradiotherapy. LA-THE was used in all patients. The
mean operative time: 321 ± 73 minutes; blood loss 318 ± 239 ml. All margins
were free of cancer and a mean of 11 ± 7 lymph nodes were retrieved. The
median ICU stay was 1 day (1–35) and hospital-stay 9 days (7–58). One
patient (1.4%) died within 30-days postoperatively. Complications: Minor:
atrial fibrillation 8 (11.1%) patients; pleural effusion 9 (12.5%); wound infection
7 (9.7%); transient recurrent nerve palsy 6 (8.3%); pneumothorax requiring
no intervention 12 (16.7%). Major complications: anastomotic leak requir-
ing intervention 7 (9.7%) patients; anastomotic leak requiring no interven-
tion in 7 (9.7%); pneumonia in 7 (9.7%); pneumothorax requiring intervention
6 (8.3%); deep vein thrombosis 4 (5.5%); pulmonary embolism 3 (4.1%);
myocardial infarction 2 (2.7%). Late complications included anastomotic
stricture in 13 (18.0%) patients. (See Survival Table)
CONCLUSION: Our study suggests that LA-THE may reduce morbidity and
mortality of esophagectomy and with good survival rates, thus should be
considered an alternative to open esophagectomy in the treatment of esoph-
ageal adenocarcinoma.
                                                                                     POSTER ABSTRACTS




Table 1. Kaplan-Meier Survival by stage
                                                                                        WEDNESDAY




                                   1-Year         3-Year             5-Year
Stage I (n = 22)                   100%           100%                80%
Stage IIa (n = 21)                  86%            57%                57%
Stage IIb (n = 5)                  100%            80%                80%
Stage III (n = 24)                  68%            41%                41%
Overall                             85%            68%                63%




                                            393
      THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1660 The Challenge of Diagnostic Assesment of a Failed
       Fundoplication: Benefits of High-Resolution
       Manometry of the GE-Junction
Attila Dubecz*, Renato Salvador, Marek Polomsky, Oliver Gellersen,
Thomas J. Watson, Jeffrey H. Peters
University of Rochester, Rochester, NY
BACKGROUND: Assessing symptomatic patients following failed fundopli-
cation can be challenging. Although upper endoscopy, and barium esopha-
gography often reveal anatomic abnormalities, functional information
allowing insight into the cause of recurrent symptoms can be key to clinical
decision making. Previous studies have shown that LES residual pressures or
percent LES relaxation measured by postoperative conventional manometry
correlates with dysphagia, but it is highly susceptible to interobserver vari-
ability. High resolution manometry (HRM) is a novel, imaged based technol-
ogy which may yield superior, more easily interpreted results in the
evaluation of esophageal function particularly given difficult postoperative
anatomy.
AIM: To study the high resolution manometric characteristics of postfundo-
plication patients with dysphagia.
PATIENTS AND METHODS: The study population consisted of 17 patients
with foregut symptoms following fundoplication referred between 2005–2007.
The most common symptom was dysphagia in 12/17 (71%), regurgitation in
9 (53%), heartburn in 4 (24%), cough in 3 (18%), vomiting in 2 (12%), chest-
pain in 5 (29%) and bloating in 1 (6%). HRM studies were analyzed systemat-
ically with particular attention to characteristics of the neo-high pressure
zone including resting/residual pressure, total and abdominal length and
esophageal body function. Values of 50 normal subjects studied in the same
laboratory were used as reference. Endoscopy revealed a failed fundoplication
in 13/17 patients, 4 patients had no apparent anatomic changes.
RESULTS: Percent LES relaxation was significantly lower (31.4 vs. 76.1), and
LES residual pressure was significantly higher (12.1 vs. 6.1) in postfundoplica-
tion patients. Eighty eight percent of the patients had lower than normal
intra-abdominal LES lengths. There was no significant difference between
esophageal body amplitudes. A majority (59%) of post-fundoplication
patients had abnormal double-peaked waves suggesting outflow obstruction.
The percent LES relaxation in postfundoplication patients with dysphagia
was significantly lower than in patients with other symptoms.
CONCLUSION: HRM revealed high residual pressures and low percent LES
relaxations of the neo-high pressure zone in virtually all patients with post-
fundoplication dysphagia. Further this measure correlated with the presence
of dysphagia. The image based analysis and high density of recording sides
coupled with software interpolation available in HRM, allows novel and clin-
ically useful observations in the evaluation of complex esophageal pathology.




                                         394
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  W1661 Looking Beyond Age and Comorbidities as Predictors
        of Outcomes in Paraesophageal Hernia Repair
Anirban Gupta*1, David C. Chang1,2, Michael A. Schweitzer1, Kimberley E. Steele1,
Anne O. Lidor1
       Johns Hopkins University School of Medicine, Baltimore, MD; 2Health Policy
1Surgery,
and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
INTRODUCTION: Patients undergoing paraesophageal hernia (PEH) repair
are typically older with more comorbidities than patients undergoing antire-
flux operations for gastroesophageal reflux disease (GERD) and these factors
are thought to contribute to worse outcomes for PEH patients. Clinically, it
would be useful to identify potentially modifiable variables leading to
improved outcomes.
METHODS: We performed a retrospective analysis of a representative sample
from 37 states, using the Nationwide Inpatient Sample database over a 5-year
period (2001–2005). Patients undergoing any abdominal anti-reflux opera-
tion with or without PEH repair were included, and comparison was made
based on primary diagnoses of PEH or GERD. Exclusion criteria were diagno-
sis codes not associated with GERD or PEH, emergency admissions, and age
<18. Primary outcome was in-hospital mortality. Two sets of multivariate
analyses were performed, one adjusting for pre-treatment variables (age, gen-
der, race, comorbidities, hospital teaching status and volume of antireflux
surgery, calendar year), and the second adjusting further for post-operative
complications (splenectomy, esophageal laceration, pneumothorax [PTX],
hemorrhage, cardiac, pulmonary, and thromboembolic events [VTE]).
RESULTS: Of the 23,458 patients, 6706 patients had PEH. Of 88 total deaths,
50 were in the PEH group (0.75%). PEH patients are older (60.4 vs 49.1,
p < 0.001) and have significantly more comorbidities than GERD patients. On
multivariate analysis, adjusting for pre-treatment variables, PEH patients are
more likely to die and have significantly worse outcomes than GERD
patients. (Table) Further adjustment for pulmonary complications, VTE, and
hemorrhage eliminates the mortality difference between PEH and GERD
patients. Adjustment for cardiac complications or PTX does not eliminate the
difference.
CONCLUSIONS: Although PEH patients have worse post-operative outcomes
than GERD patients, age and comorbidities alone should not preclude a
patient from PEH repair; rather, attention should be focused on peri-operative
optimization of pulmonary status and prophylaxis of VTE. Additionally, the
                                                                                    POSTER ABSTRACTS




impact of hemorrhagic complications underscores the importance of experi-
                                                                                       WEDNESDAY




enced surgeons.
Complications                           OR: PEH vs GER (95% CI)        p-value
                Mortality                   1.81 (1.06–3.09)            0.030
                Esophageal laceration       2.00 (1.29–3.10)            0.002
                Splenectomy                 1.44 (1.03–2.01)            0.033
Technical
                Pneumothorax                2.45 (1.64–3.65)            0.000
                Hemorrhage                  1.53 (1.22–1.92)            0.000
                Pulmonary                   1.48 (1.26–1.75)            0.000
Peri-op         Cardiac                     2.11 (1.43–3.11)            0.000
                Thromboembolic              2.34 (1.29–4.23)            0.005


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  W1662 No Additional Value of Bronchoscopy After EUS in the
        Preoperative Assessment of Patients with Esophageal
        Cancer at or Above the Carina
Mark Van Heijl*1, Jikke M. Omloo1, Jacques J. Bergman2, Mia G. Koolen4,
Mark I. Van Berge Henegouwen1, Jan J. Van Lanschot1,3
1Surgery,Academic Medical Centre, Amsterdam, Netherlands; 2Gastroenterology,
Academic Medical Center, Amsterdam, Netherlands; 3Surgery, Erasmus Medical Center,
Rotterdam, Netherlands; 4Pulmonary Diseases, Academic Medical Center, Amsterdam,
Netherlands
INTRODUCTION: Esophageal cancer is an aggressive disease with a strong
tendency to infiltrate into surrounding structures. Especially tumors at or
above the carina are associated with early invasion of the tracheobronchial
tree, precluding radical surgical resection. Endoscopic ultrasonography (EUS)
is considered the most accurate diagnostic modality to determine the T-stage
of the tumor. In the preoperative work-up for patients with tumors at or
above the carina, it is recommended to perform a bronchoscopy (with biopsy
on indication) to exclude airway invasion. Aim of the present study is to
determine the additional value of bronchoscopy (with biopsy on indication)
for detecting invasion of the tracheobronchial tree after having performed
EUS in the preoperative assessment of patients with esophageal cancer at or
above the carina.
METHODS: Between January 2003 and December 2006, 45 patients were
analyzed in our department for histologically proven esophageal cancer at or
above the carina. All patients underwent both EUS and bronchoscopy (with
biopsy on indication) in the preoperative assessment of local resectability.
RESULTS: After extensive diagnostic work-up 19 of 45 patients (42%) were
eligible for potentially curative oesophagectomy. Distant metastases were
found in 13 of 26 patients (50%) not suitable for curative surgery. In the 13
other patients (50%) local irresectability (T-stage 4) due to invasion of vital
structures was described on EUS: invasion of the aorta in three patients, inva-
sion of the pleura in six patients and invasion of the lung in two patients; in
two patients invasion of the tracheobronchial tree was described, which was
confirmed by bronchoscopy with positive biopsy results. Therefore, no addi-
tional value of bronchoscopy after EUS was seen in this cohort of patients.
CONCLUSION: For patients with newly diagnosed esophageal tumors at or
above the carina, no additional value of bronchoscopy (with biopsy on indi-
cation) to exclude invasion of the tracheobronchial tree is seen after perform-
ing EUS in a specialized centre. Even though based on small numbers, we
conclude that bronchoscopy is not indicated if no invasion of the airways is
identified on EUS.




                                       396
     49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


 W1663 Analysis of First-Time Antireflux Redo-Surgery Versus
       Multiple Redo-Surgery
Karl H. Fuchs*, Wolfram Breithaupt, Martin Fein
Surgery, Markus-Krankenhaus, Frankfurt, Germany
INTRODUCTION: Laparoscopic antireflux surgery is well established since
more than 15 years. Redo-antireflux surgery with laparoscopic and open
access is following this development, since 4%–5% of failures need operative
revision. The purpose of this study is the analysis of a possible difference
between a first time failure and redo-surgery versus multiple failures and mul-
tiple Redo-surgery.
METHODS: In a center with experience of approximately 80 primary laparo-
scopic antireflux cases per year in a time period of 10 years 104 consecutive
redo operations were performed and all involved perioperative details were
prospectively documented. There were 61 males and 43 females with a mean
age of 48 years (17–85). Diagnostic work up consisted of history and physical
examination, endoscopy, video barium sandwich study, esophageal manome-
try, 24 pH monitoring and in selectve cases bilirubine monitoring and scintg-
raphy. Operative techniques in Redo surgery consisted of laparoscopic
adhesiolysis, esophageal mobilisation, hiatoplasty, fundoplication full or par-
tial, in case of short esophagus a lengthening by Collis plasty and in cases of
massive shortage and/or destruction, strictures and scaring of the gastroe-
sophageal junction a resection and jejunal interposition or gastrectomy and
Roux-en-Y pouch reconstruction.All details were prospectively documented.
Follow up was performed within the first year. Quality of Life was assessed by
the Gastrointestinal Quality of Life Inedx GIQLI.
RESULTS: Redo-surgery was performed in 59 first failure cases (group FR)
and in 45 multiple failure cases (group MR). Recurrent reflux was the major
problem in the first failure cases (81%) compared to 53% in the multiple fail-
ure cases. Dysphagia was similar frequent in both groups. However pain and
vomiting was significant different (FR: 6%; MR: 36%). Major reason for fail-
ures were in both groups migration (FR: 53%; MR: 40%). In the MR group
paraesophageal herniation and scaring (“frozen Hiatus”) was an important
reason for pain and vomiting. Standard Nissen and Toupet fundoplication in
the laparoscopic technique was performed in 93% in the FR group and only
in 53% in the MR group. Collis-plasty and resections were performed in 46%
of the MR group. Outcame in Quality of life showed preop/postop 1year: FR
                                                                                  POSTER ABSTRACTS




in 14% <100 (normal 120) MR in 29% <100.
                                                                                     WEDNESDAY




CONCLUSION: Multiple failures of laparoscopic antireflux procedures are
difficult to manage. Outcome can be worse than first time redo-surgery. Pain
and vomiting are major symptoms, which require revision. Therefore revision
in cases with multiple failure should be performed in specialized centers.




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  W1664 A Meta-Analysis of Trials Comparing the Effectiveness
        of Use of Mesh in Laparoscopic Repair of
        Paraesophageal Hernias
Anne O. Lidor*1, Debraj Mukherjee1, Dorry Segev1, David C. Chang1,2,
Kimberley E. Steele1, Michael A. Schweitzer1
       Johns Hopkins University School of Medicine, Baltimore, MD; 2Health Policy
1Surgery,
and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
OBJECTIVE: Paraesophageal hernias (PEH) are commonly and safely repaired
via a laparoscopic approach, usually with a posterior cruroplasty followed by
an anti-reflux operation. Unfortunately, there is a relatively high rate of recur-
rent hiatal herniation reported postoperatively. We sought to determine the
effectiveness of the routine use of mesh in laparoscopic repair of PEH.
METHODS: A systematic literature search (Medline, Embase, Cochrane
Library, and Pub of Med) was performed to identify all eligible articles. Ran-
domized controlled trials (RCT) and prospective cohort studies (PCS) compar-
ing use of mesh (biologic and prosthetic) versus primary suture repair were
reviewed and the methodologic quality of included studies was evaluated
independently by 2 authors. Pooled estimates of relative risk of recurrences
were calculated using a random effects model to account for heterogeneity in
study designs.




RESULTS: In total, 216 abstracts were reviewed and assessed for eligibility,
with 3 RCT and 3 PCS identified. A total of 455 patients were analyzed. Mesh
closure was associated with 60% lower risk of recurrence than primary suture
repair (Relative risk (RR) = 0.40, 95% CI 0.22 to 0.73, p = 0.003). Similar
trends were seen when stratified by study design type (for RCT, RR = 0.30,
95% CI 0.15 to 0.62, p = .001) but were not statistically significant for cohort
studies (RR = 0.77, 95% CI 0.26 to 2.34, p = 0.60), possibly due to sample size
(only 47 patients with mesh closure in PCS) or selection biases inherent in
PCS. There were no reports of mesh erosion in any study.
CONCLUSION: In pooled analysis, the use of mesh seems to offer an advan-
tage over primary suture closure in laparoscopic repair of paraesophageal hernia.
Future well designed studies evaluating the clinical implications of use of bio-
logic versus prosthetic mesh are warranted.

                                       398
      49TH ANNUAL MEETING • MAY 17-21, 2008 • SAN DIEGO, CA


  W1665 Prediction of Response to Neoadjuvant Therapy in
        Esophageal Carcinoma by PET-CT
Kirsten Thurau*1, Matthias Bruewer1, Joerg Haier1, Christine Franzius2,
Kai U. Juergens3, Norbert Senninger1
1Surgery,University of Münster, Münster, Germany; 2Nuclear Medicine, University of
Muenster, Muenster, Germany; 3Radiology, University of Muenster, Muenster, Germany
OBJECTIVES: To evaluate the use of hybrid positron emission tomography
using [(18)F]-fluorodeoxyglucose (FDG-PET)/CT scan in the assessment of pri-
mary staging and evaluation of treatment response during neoadjuvant
radio-chemotherapy (RTX) in esophageal carcinoma (EC).
BACKGROUND DATA: In EC accurate pre-therapeutic tumour evaluation
should be provided for a multi-disciplinary and individually tailored patient
management programme. Therefore, the ability to predict early treatment
response in an individual EC patient would greatly aid therapeutic planning.
METHODS: 84 patients with histologically proven EC underwent PET/CT. 28
patients underwent primary esophagectomy, 9 palliative treatment and 47
neoadjuvant RTX (cisplatin, 5-FU, radiation: 50.4 Gy). In the latter PET/CT
was repeated 6 weeks after induction chemotherapy. Quantitative measure-
ments of tumour FDG uptake (SUV) were correlated with histopathologic
response. Degree of histomorphologic regression was classified into major
(<10% vital residual tumor cells [VRCT]) and minor histomorphologic
response (≥10% VRCT). Statistics: Wilcoxon U-test
RESULTS: At primary staging SUV was increased in 81 of 84 EC (negative in
3 T1 tumours) and was more intense towards locally advanced tumours.
Additional findings by PET/CT were found in 15 patients leading to a therapy
change in 6. In patients with primary esophagectomy pathologic lymph
nodes were found in 14 and 8 by endoscopic ultrasound and PET/CT (histol-
ogy n = 10), respectively. Until now 36 patients underwent surgery after RTX.
Overall SUV decreased in median by 52%. 4 patients did not show any
decrease in SUV after induction therapy. In patients with major histomorpho-
logic response decrease of SUV was significantly higher than in patients with
minor histomorphologic response (67% vs 45%, p < 0.001).
CONCLUSIONS: PET/CT is a valuable tool for the noninvasive assessment of
initial staging and histopathologic tumour response during neoadjuvant RTX
and may differentiate responding and nonresponding tumours early. By
                                                                                     POSTER ABSTRACTS




avoiding ineffective and potentially harmful treatment, this may markedly
                                                                                        WEDNESDAY




facilitate the use of preoperative therapy, especially in patients with poten-
tially resectable tumors.




                                        399
     THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT


 W1666 Endolumenal Fundoplication with EsophyX™: The
       Initial North American Experience
Simon Bergman*1, Cedric S. Lorenzo2, Blair A. Jobe2, Dean J. Mikami1,
John G. Hunter2, W. S. Melvin1
1Department   of Surgery, The Ohio State University Medical Center, Columbus, OH;
2Department   of Surgery, Oregon Health and Science University, Portland, OR
BACKGROUND: Es