Scientific Session of the 16th World Congress of Endoscopic Surgery, Jointly Hosted by Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) & Canadian Association of General Surgeons (CAGS), Seattle, Washington, USA, 11–14 April 2018: Poster Abstracts

P001

Utility of Fibrin Glue in Robotic Transversus Abdominis Release (RTAR)

Zachary Sanford, MD, Adam S Weltz, Igor Belyansky, MD; Department of Surgery, Anne Arundel Medical Center

Introduction: The use of mesh fixation devices has become a subject of increasing debate in the minimally invasive surgical community, with recent data suggesting mesh fixation devices do not afford significant intraoperative and postoperative benefits in surgical outcomes. This relationship has not been investigated with regards to robotic transversus abdominis release (RTAR) for the repair of abdominal wall defects. We report our analysis of perioperative outcomes in RTAR candidates in whom fibrin glue was both used and spared during abdominal wall reconstruction.

Methods: Retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either fibrin glue or no fixation during abdominal wall reconstruction via the RTAR technique from August 2015 to June 2017 at a single high volume hernia center. Perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life measures assessed using the Carolina Comfort Scale.

Results: Of the 30 patients identified, 21 underwent RTAR with the use of fibrin glue for mesh fixation (RTARG) and 9 underwent RTAR without the aid of any mesh fixation device (RTARNG) with no past medical history significant for hernia recurrence. The RTARG cohort had a mean BMI, defect area, mesh area, and operative time of 32.1, 197 cm², 844 cm² and 222 minutes, respectively, compared to 32.1, 139 cm², 898 cm², and 287 minutes in the RTARNG group. All cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the RTARG and RTARNG subgroups. There were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections. Hernia recurrence was not identified in either the RTARG or RTARNG cohorts through a mean follow up of 220 days (7 months). There were no statistically significant differences in postoperative outcomes.

Conclusion: Our series review suggests that the use of fibrin glue may not afford significant benefits compared to the use of no mesh fixation with the RTAR technique in the hands of an experienced surgeon. Additional expense associated with fibrin sealant may be unnecessary.

P002

Endoscopic-Assisted Debridement as a Definitive Treatment for Recurrent Fluid Collections After Ventral Hernia Repair

Manuel Garcia, MD, Jeffrey Quigley, DO, Daniel Srikureja, Marcos Michelotti, MD, FACS; Loma Linda University Health

Introduction: Seroma formation and subsequent mesh non-incorporation are troublesome complications after complex ventral hernia repair with synthetic mesh placement. Although many times seroma will resolve spontaneously, failure of medical management often necessitates surgical intervention.

Case Report: 39 year male presented with large ventral and parastomal hernia 2 years after end colostomy takedown with protective ileostomy performed after Hartmann’s procedure 3 years ago. Past medical history included GERD, HTN and Morbid obesity (BMI 38.5 kg/m^2). The patient was offered ileostomy takedown, as well as ventral and parastomal hernia repair using a Tranversus Abdominus Release and retro-rectus composite mesh repair. Despite surgical drain placement with routine removal at 2 weeks, the patient returned 3 months post op with seroma, which was treated with percutaneous drain. By 6 months, a deep seroma had reformed in the retro-muscular space and a portion of the mesh was non-incorporated. The patient was re-operated with endoscopic debridement of the non-incorporated mesh as well as irrigation and drainage of the seroma without violating the primary closure of the abdominal wall. A wound VAC was applied through one of the incisions, and two closed suction drains were left, being removed at around 2 and half weeks. At three months the patient demonstrated complete resolution of the seroma.

Discussion: Failure of seroma to respond to non-operative management represents a challenge in the post-operative management of patients undergoing complex ventral hernia repair. Open surgical intervention to explant non-incorporated mesh frequently leads to recurrence. Only very small case series are currently available to describe an endoscopic approach to this complication. We report a satisfactory outcome with endoscopic approach which combined partial mesh explantation and washout and drainage of the seroma cavity, with the benefit of avoiding alteration to the anatomy of the primary closure and avoiding recurrence.

P003

Laparoscopic Repair of Amyand Hernia with Simultaneous Appendectomy

Alice A Higdon, DO, Alexander Gonzalez-Jacobo, DO, Jackie Battista, DO, FACOS; St. John’s Episcopal Hospital

Between 5–10% of Americans experience an inguinal hernia in their lifetime, however, only 1% of these hernias contain the vermiform appendix, which is termed an Amyand Hernia. Even more rare, is the 0.1% of the Amyand hernias which contain a perforated appendix. This hernia is difficult to diagnose and typically is an intraoperative finding. This rare inguinal hernia is named for Claudius Amyand, an English surgeon credited with the first successful appendectomy in 1735 when he removed the first vermiform appendix from a right inguinal hernia sac from an 11-year-old boy. Though Dr. Amyand recounted this surgery as “quiet perplexing”, there are many ways in which a vermiform appendix can be appreciated in the inguinal canal: adherent or non-adherent, inflamed or non-inflamed, perforated or contained. The incidence of Amyand Hernia is 0.07–0.13% regardless of the stage of presentation. In the case presented here, the patient had a non-inflamed, reducible right Amyand’s Hernia, which was repaired via laparoscopic appendectomy and laparoscopic transabdominal preperitoneal right inguinal hernia repair with mesh.

P004

Laparoscopic Preperitoneal Hernia Repair for Treatment Ventral Hernia (The Rectus Abdominal Diastasis, Flank Hernia and Recurrent Incision Hernia). Case Report

Kin San Leong; Taiwan Far Eastern Hospital

Background: Rectus abdominal diastasis, flank hernia and recurrent incision hernia are kinds of ventral hernia. The totally extraperitoneal hernia repair for inguinal hernia had already performed for many years. It had benefits at post operation hospitalization, wound pain, cosmetics. We believe that we can use the same approach for treatment the ventral hernia. We want to share our early experiences with this approach. We also evaluate the feasibility and post operation results.

Methods: We performed the preperitoneal hernia repair with mesh for treatment ventral hernia since 2011, had already performed 37 cases. In this case of rectus abdominal diastasis patients and right flank hernia patient and left lower abdomen recurrent incision hernia status post mesh hernia repair with right lower abdomen incision hernia were performed at 2017. The demographic information and defect size were measured.

Results: This rectus abdominal diastasis female was 41 years old. The rectal muscle distance about 7 cm. The operation time was about 4 hours. The right flank incision hernia male was 69 years old. The fascia defect was about 10 × 8 cm. The operation time was about 2 hours. The left lower abdomen recurrent incision hernia status post mesh hernia repair with right lower abdomen incision hernia female was 60 years old. The left lower abdomen fascia defect about 7 × 5 cm and right lower abdomen fascia defect about 2 × 2 cm. The operation time was about 4.5 hours. The 3 cases blood lose were about 5 ml. The wound pain was VAS:4 ~ 5. They discharged from our hospital within the 24 hours postoperative period. The seroma was noted at right flank incision hernia patient.

Conclusions: We shared our early experience with preperitoneal hernia repair with mesh. They showed benefits at post operation hospitalization, wound pain and cosmetic to compare with open approach.

P005

Efficacy of Single-Incision Totally Extraperitoneal Repair for Incarcerated Inguinal Hernia

Masaki Wakasugi, Yujiro Nakahara, Masaki Hirota, Takashi Matsumoto, Hiroyoshi Takemoto, Ko Takachi, Kiyonori Nishioka, Satoshi Oshima; Department of Surgery, Kinki Central Hospital

Purpose: To evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (SILS-TEP) of incarcerated inguinal hernia.

Patients and Methods:

Clinical setting

A retrospective analysis of 14 patients undergoing SILS-TEP for incarcerated hernia from May 2016 to August 2017 at Kinki Central Hospital was performed.

Exclusion criteria

SILS-TEP was contraindicated for the following conditions in our hospital: a history of radical prostatectomy; a small indirect inguinal hernia in a young patient; and unsuitable for general anesthesia.

Surgical procedure

Laparoscopic abdominal exploration through a single, 2.5-cm, intraumbilical incision was performed. The incarcerated hernia content was gently retracted from the hernia sac into the abdominal cavity. In some cases, simultaneous manual compression on the incarcerated hernia from the body surface was required. If no bowel resection was needed, a standard SILS-TEP using mesh was performed following laparoscopic abdominal exploration and incarcerated hernia reduction. If bowel resection was required, inguinal hernia repair using mesh was not performed to avoid postoperative mesh infection, and two-stage SILS-TEP was performed 2–3 months after the bowel resection.

Results: Fourteen patients (11 men, 3 women) with irreducible inguinal hernias, including 11 with unilateral hernias and 3 with bilateral hernias, underwent surgery. The patients’ median age was 74 years (range, 38–83 years), and median BMI was 23.5 kg/m² (range, 18.8–30.5 kg/m²). Of the 14 patients, 7 had acute incarceration, and 7 had a chronic irreducible hernia. Seven patients with acute incarcerated hernias underwent emergency surgery, and two of the seven patients needed single-incision laparoscopic partial resection of the ileum, followed by two-stage SILS-TEP. Twelve patients, excluding two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by SILS-TEP. One case of chronic incarceration out of the twelve patients who underwent SILS-TEP after hernia reduction required conversion to Kugel patch repair. The median operative times were 102 min (range 52–204 min) for unilateral hernias and 165 min (range 83–173 min) for bilateral hernias. The median blood loss was minimal (range 0–177 ml). The median postoperative hospital stay was 1 day (range 1–3 days). The median follow-up period was 7 months (range 1–15 months). A seroma developed in 25% (3/12) of patients and was managed conservatively. No other major complications or hernia recurrence were noted during the follow-up period.

Conclusions: SILS-TEP, which offers good cosmetic results, could be safely performed for incarcerated inguinal hernia.

P006

18 Months Follow Up of Incisional Hernia Repair Using P4HB in Patients After Liver Transplantation

Thomas S Auer, MD, James E Waha, MD, Erwin Mathew, MD, Daniela Kniepeiss, MD, MBA, FEBS, Peter Schemmer, MD, MBA, FACS; Department of Surgery, Medical University Graz

Introduction: The challenges in hernia following liver transplantation are the types of incision, surgical site infection due to immunosuppressants and the multimorbidity these patients often present with. Therefore, patients with hernia after solid organ transplantation can be considered grade 2 according to the classification of the ventral hernia working group. The incidence for developing ventral hernia after transplantation has a wide variation according to literature. At our centre in Graz we have an incidence of 26%. Repair using mesh implantation reduces recurrence rates. Polypropylene mesh is prone to chronic contamination in immunosuppressed patients. Biomesh did not fulfill the expectations due to high recurrence rates and inflammatory reactions. P4HB bioabsorbable mesh seems to be a good alternative. It is a knitted monofilament, it degrades gradually via hydrolysis, it is fully resorbed after 18 months, while providing mechanical strength for 12 months, and it enables remodelling by host tissue. This mesh shows good results even in grade 3 morbidity wounds which we showed last year in a poster presentation at SAGES in Houston.

Methods: In 2016 we treated 5 patients with incisional hernia following liver transplantation with P4HB mesh in onlay technique and small bites suture.

Results: The follow-up period was between 10 to 20 months and still ongoing. No mesh had to be explanted, no surgical site infections, no delayed wound healing were observed. One hernia recurrence presented after 12 months with a 2,5 cm herniation along the left subcostal margin. 4 patients remained without complications and discomfort.

Conclusion: Treating incisional hernia of patients after liver transplantation with P4HB mesh in onlay-enforced technique is feasible and safe. Of course, more data is needed. In order to lower the incidence of incisional hernia in this group of patients we are preparing a trial for prophylactic P4HB mesh placement in patients undergoing liver transplantation.

P008

Laparoscopic Component Separation in Complex Ventral Hernias. Initial Experience in a Hernia Clinic in Colombia

Evelyn Dorado, MD, Jesica Correa, MD; Fundacion Valle Del Lili

Introduction: Complex hernias require special management, the first 12 months the relapse of primary closure is between 40–50%. Laparoscopic techniques such as the IPOM are reserved for defects of < 10 cm, recurrences or major defects require techniques like components separation, which previously were only performed open but can now be done by laparoscopy. Integral management merits hernia centers, in Colombia there are no hernia centers, in Fundacion Valle del Lili we have the first specialized center for this type of patients.

Methods and Procedures: Descriptive, 4 patients were schedualed between December 2016 and July 2017 to eTEEP Rives Stopa repair. 2 male and 2 female patients, mean age 40 years, 1 patient with BMI 50, 1 patient BMI 34 and 2 patients with 26, 2 of them with 2 previous repairs with failed mesh one with hepatic transplant, 1 with recurrence of IPOM and one with a defect Secondary to an intestinal resection without prior repair. Diameter of defects between 10 and 20 cm.

Results: All patients were studied with CT Scan to determine the size of the hernia and the contents of the sac, all were schedualed for eTEEP RS, I used a balloon for the preperitoneal, technique of 5 trocars, first step: dissection of the space, second: reduction the content of the sac, one patient requiered remove a composite mesh, posterior and anterior fascia closure with bearded suture and placement of polypropylene mesh 30 × 30 cm medium weight and fixation with fibrin sealant. All patients required drainage and 1-day hospitalization. At 7 days removed the drain and started of physical therapy for strengthening with exercise hypopresives. Control of the first two patients with CT at 3 months without relapse. No operative site infections.

Conclusion: The benefits of laparoscopy are recognized, the use of this technique in complex defects has proven effective and has a positive impact on the quality of life of the patient. This type of procedure requires trained personnel and a hernia clinic to ensure interdisciplinary management and follow-up to ensure results.

P009

An Analysis of the Interval Between Major Abdominal Operations and Hernia Repair

Jenny M Shao, MD ¹, Chris Devulapalli, MD¹, Anne Fabrizio, MD¹, Hepzibha Alexander, BSN², Sameer Desale³, Mohammed Bayasi, MD¹, Lynt B Johnson, MD, MBA¹, Parag Bhanot, MD^{1; 1}Medstar Georgetown University Hospital, ²Georgetown University School of Medicine, ³Medstar Health Research Institute

Introduction: Patients undergoing major abdominal surgery have increased risk of developing incisional hernias, which can be associated with significant morbidity. This is a multi-institutional study looking at patients undergoing major abdominal operations, defined as colectomy, hepatectomy, pancreatectomy, and gastrectomy, and the incidence and duration to symptomatic hernia occurrence requiring repair within each cohort.

Methods and Procedures: An IRB- approved retrospective study within the MedStar Hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across 11 hospitals between the years of 2002 to 2016. All patients were identified using ICD-9 and ICD-10 codes for relevant procedures. Exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. Data validation was performed to verify the accuracy of the data set. The rate of symptomatic incisional hernia rates (IHRs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. Descriptive statistics and chi squared test were used to report IHRs in each group.

Results: During this 15-year span, a total of 7,583 major abdominal operations were performed at all 11 institutions, comprising of 4,970 colectomies, 1,122 hepatectomies, 1,165 pancreatectomies, and 326 gastrectomies. Total incidence of symptomatic incisional hernia occurrence requiring repair was 375 (4.9%). Incisional hernia rate was 297 (5.98%) in colectomies, 28 (2.5%) in hepatectomies, 41 (3.52%) in pancreatectomies, and 9 (2.76%) in gastrectomies (p < 0.001). The mean duration to hernia surgery was 804 days for colectomy, 564 days for hepatectomy, 484 days for pancreatectomy, and 840 days for gastrectomy (p = 0.076).

Conclusion: Symptomatic incisional hernia rates following colectomy was significantly higher than other major abdominal surgeries. However, mean duration to hernia development was not significantly different among all patients undergoing major abdominal surgery and ranged from 484 to 840 days.

P010

Related Factors to the Presentation of Complications of Inguinal Hernia Repair with TEP Technique and Self-fixation Mesh

Ricardo Manuel Nassar Bechara, Andres Mauricio Garcia Sierra, Ernesto Pinto, Felipe Giron Arango, Juan David Linares, Juan David Hernandez Restrepo; Fundacion Santa Fe

Introduction: Hernias are a very common pathology, which can cause severe complications associated with the defect per se to the surgical treatment. The estimated risk of developing inguinal hernias throughout life is about 27% in men and 3% in women. One of the surgical techniques used for its management is the total extra peritoneal (TEP) technique with self fixation meshes. The main purpose of making a tension-free repair, through the implantation of a mesh in the preperitoneal space is to exclude the defect and to reinforce the inguinal abdominal wall. However, the factors related to this surgical technique and the presentation of complications are unknown.

Objective: Identify related factors to the presentation of complications in patients that underwent laparoscopic total extra peritoneal (TEP) hernia repair with self-fixation mesh in "Fundación Santa fe de Bogotá" from 2012 to 2017.

Methods: A cross-sectional study was performed with secondary analysis of the database of patients with inguinal hernias who underwent an inguinal hernia repair procedure with TEP technique and self-fixation mesh. A descriptive and bivariate analysis of the patients characteristics was performed relating to the presentation of complications through a chi square for Pearson correlation.

Results: A sample of 77 operated patients was obtained, with a male/female ratio of 1:1. On average, the patients were 30 years old, with no significant difference between the sex. The surgical complication that showed statistical significance was postoperative pain associated with an increased hospital stay (p < 0.005). The conditions that showed a positive relationship with this complication were the hernia classification, bilaterality, grade II obesity and a surgical time greater than 40 minutes (p < 0.005).

Conclusion: Inguinal hernia repair with TEP technique and self-fixation mesh for this population showed only one complication. Patients who have a bilateral NYHUS IV hernia and have grade II obesity may present an increased risk of postoperative pain with this technique. More studies are needed to increase the external validity of these results.

P011

Important Anatomical Pointer to Reduce Complications in Laparoscopic Inguinal Hernia Repair in Pediatric

Muhammad Armughan, FCSP, MRCSI, MRCS, Eng¹, Malik Muhammad Makki, MD ², Muhammad Tariq, FCPS, Surg, FCPS, uro¹, Samia Yunas, MD³, Javed Iqbal, FRCS, FACS^{1; 1}Bahawal Victoria Hospital, Bahawalpur, Pakistan, ²Sheikh Khalifa Medical City, Ajman, United Arab Emirates, ³Dr. Sulaiman Al Habib Medical Center, Dubai, UAE

Objective: Introduction of MIS in pediatric age group has been proved feasible and safe. There is considerable evolution with introduction of a number of invovation in MIS pediatric inguinal hernia repair. High ligation of sac is the basic premise of surgical repair in pediatric inguinal hernias. There are different MIS techniques broadly grouped into intracorporeal or intracorporeal with extracorporeal component namely the suturing. Every techniques has its own complications. The main objective of our study was to focus on different anatomical pointers which can lead inadverent complications mainly bleeding and recurrence.

Methods and Procedures: Prospective review of 37 hernias (29 male and 2 female) (8 months–13 years) performed laparoscopically between September 2015 and June 2016. Under laparoscopic guidance, the internal ring was encircled extraperitoneally using a 2-0 non-absorbable suture and knotted extraperitoneally. Data analyzed included operating time, ease of procedure, occult patent processus vaginalis (PPV), contralateral inguinal hernia, complications, cosmesis and recurrence.

Results: Sixteen right (52%), 14 left (45%) and 1 bilateral hernia (3%) were repaired. Five unilateral hernias (16.66%), all left, had a contralateral PPV that was repaired (P = 0.033). Mean operative time for a unilateral and bilateral repair were 13.20 (8–25) and 20.66 min (17–27 min) respectively. One hernia repair still recurred (2.7%) even with all precautions and another had a post operative hydrocoele (2.7%). One case (2.7%) needed an additional port placement due to inability to reduce the contents of hernia completely. because of our techinique we could not find any adverent peroperative bleeding. There were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries.

Conclusion: The results confirm safety, efficacy and cost effectiveness of laparoscopic inguinal hernia repair. During our per-operative analysis we focus to address the anatomical landmark to minimize future recurrence and peroperative surgical complications. We identified and named a point as J. Point at the tip of triangle of “Doom”. That is most important point to address peroperatively. There is high chance of recurrence if that point is not encircled well or inadequately circled because of fear of iliac vessels injury. We aslo concluded that ‘water dissection technique’ is effective techniques in un-experienced hand and in early stages of laparoscopic hernia repair to prevent inadvertent iliac vessels injury.

P012

Where Patients Get Medical Information: Characterization of Online Search Results for Common Hernia-Related Terms

Rebecca G Lopez, MD, H. Alejandro Rodriguez, MD, Dustin R Cummings, MD, Andrew S Wright, MD; University of Washington

Background: It has become commonplace for patients to arrive to their appointments self-educated on their medical issues. Popular search engine algorithms are not necessarily based on validity or accuracy of information. The aim of this study is to examine Google search results focused on a top general surgery diagnosis: hernia.

Methods: A Google search was performed in incognito mode, examining the top 20 results for the following phrases: hernia, hernia surgery, hernia mesh, hernia repair, and hernia complications. Results were categorized into the following: medical information (i.e. WebMD, healthcare organization, or society-based pages), non-medical information (i.e. patient-driven community), medical device information, legal advertisement, medical ad, other ads, journal or news article, or links to another search engine. Results were categorized as being high or low-quality information, written by an MD, or being biased against mesh based on qualitative analysis of link content.

Results: Of all searches, only 33% returned medical information and the second most common result was a legal ad, at 18%. 59% of search results were judged to be high-quality and 25% were felt to be biased against use of mesh. A majority of search results for “hernia mesh” were found to be advertisements from law firms. “Hernia mesh” also yielded the highest number of results biased against mesh at 70%. “Hernia repair” yielded the most medical information at 50%.

Conclusions: The results of Internet search engine queries for hernias or hernia repairs are highly variable, subject to bias and low-quality information. Notably, a search for "hernia mesh" resulted in greater than 50% of links by legal firms and links biased against hernia mesh use. Further investigation into patient education will help physicians guide their conversations and counseling of patients.

P013

Hybrid Pre-peritoneal Approach in a Thrice Recurrent Ventral Hernia

Chintan Patel, MS, DNB, FMAS, FIAGES, FBMS¹, Ajay Bhandarwar, MS, FMAS, FIAGES, FBMS, FICS ², Amol Wagh, MS, FMAS, FIAGES, FBMS, FICS², Eham Arora, MS², Shubham Gupta, MS², Dharmesh Dhanani, MS, FNB^{1; 1}Kiran Multi Super Specialty Hospital & Research Center, Surat, India, ²Grant Government Medical College & Sir JJ Group of Hospitals, Mumbai, India

Introduction: Incisional hernias occur at prior operative sites & their repair is one of the most common surgeries in everday clinical practice. Recurrence after repair is related to several risk factors, some of which include uncommon hernial sites, morbid obesity, large defect sizes & prior surgery in an emergency setting.

We present the case of a 61 year old female who suffered an incisional hernia after abdominal hysterectomy in 2006. She underwent two open & one laparoscopic repair of the same, but she suffered a third recurrence for which she underwent a hybrid repair.

Materials and Methods: Intra-operative survey showed multiple previously inserted meshes with dense fibrotic bands & omental adhesions with the hernia recurrence occuring between the inferior border of the mesh & the pubic symphysis. A diligent adhesiolysis was performed to entirely expose the defect. An attempt at primary closure of the defect was made using a loop nylon suture, but the previously inserted meshes & dense fibrotic tissues were a barrier to the same. A hybrid approach was employed where defect closure was performed as in open surgery – this reduces the risk of post-operative seroma & abdominal bulge. A composite intra-peritoneal mesh was fixed laparoscopically, ensuring an overlap which extending beyond the pubic symphysis inferiorly.

Result: Hybrid approach is particularly suited to difficult, recurrent hernia cases, as it is technically less demanding, reduces operative time, allows a secure defect closure & provides an improved abdominal wall contour. Dissection in the pre-peritoneal place was performed to allow a wide overlap of a composite mesh in all directions.

Difficult, recurrent hernias are a difficult clinical entity to treat, with a successively worsening risk of recurrence with each subsequent repair. A thorough clinical & imaging evaluation with a well-planned hybrid approach would combine the advantages of both open & laparoscopic repairs.

P014

A Prospective, Multi-center Trial of a Long-Term Bioabsorbable Mesh with Sepra Technology in Challenging Laparoscopic Ventral or Incisional Hernia Repair

William W Hope, MD¹, A G El-Ghazzazy, MD², B A Winterstein, MD³, J A Blatnik, MD⁴, S S Davis, MD⁵, J A Greenberg, MD⁶, N C Sanchez, MD⁷, E M Pauli, MD⁸, D M Tseng, MD⁹, K A LeBlanc, MD¹⁰, K E Roberts, MD¹¹, C E Bower, MD¹², E Parra-Davila, MD¹³, J S Roth, MD ¹⁴, E F Smith, MD^{15; 1}New Hanover Regional Medical Center, ²Overalake Medical Center, ³Methodist Hospital, ⁴Washington University, ⁵Emory University, ⁶University of Wisconsin, ⁷VIa-Christi Hospital, ⁸Hershey Penn Sate Medical Center, ⁹Legacy Health, ¹⁰OUr Lady of the Lake Regional Medical Center, ¹¹Yale-New Haven Medical Center, ¹²Carillion Clinic, ¹³Celebration Health, ¹⁴University of Kentucky, ¹⁵Georgetown Community Hospital

Objective: The objective of this prospective, multi-center, single-arm, open-label study is to assess the safety, performance and effectiveness of Phasix™ ST in laparoscopic ventral or incisional hernia repair in subjects at high risk for Surgical Site Occurrence (SSO). Subjects at high risk for SSO are defined as having one or more of the following comorbid conditions: body mass index (BMI) between 30–40 kg/m² (inclusive), active smokers, chronic obstructive pulmonary disease (COPD), diabetes, immunosuppression, coronary artery disease, chronic corticosteroid use, low pre-operative serum albumin, advanced age, or renal insufficiency.

Methods: The primary endpoint is SSO requiring intervention within 45 days post-implantation, including Surgical Site Infection (SSI), seroma, hematoma, wound dehiscence, skin necrosis, mesh infection and fistula. Secondary endpoints include: surgical procedure time, length of stay, SSO > 45 days post-implantation, hernia recurrence rate, device-related adverse event incidence, rate of reoperation due to the index hernia repair, and Quality of Life assessments (Surgical Pain Scale-VAS, Carolinas Comfort Scale®, and SF-12®), assessed at 1, 3, 6, 12, 18, and 24-months postoperatively.

Results: A total of 90 subjects (54/90, 60% male) with a mean age of 55 ± 14.6 years and BMI of 33.4 ± 4.4 kg/m² were implanted with Phasix™ ST Mesh. Comorbid conditions included: obesity (74/90, 82.2%), active smoker (13/90, 14.4%), COPD (5/90, 5.6%), diabetes (13/90, 14.4%), immunosuppression (3/90, 3.3%), coronary artery disease (7/90, 7.8%), chronic corticosteroid use (3/90, 3.3%), low preoperative serum albumin (1/90, 1.1%), advanced age (8/90, 8.9%), and renal insufficiency (0/90, 0.0%), and hernia types were primary ventral (42/90, 46.7%), primary incisional (32/90, 35.6%), first time recurrent ventral (6/90, 6.7%), first time recurrent incisional (7/90, 7.8%), multiply recurrent ventral (1/90, 1.1%), and multiply recurrent incisional (2/90, 2.2%). Subjects underwent laparoscopic ventral or incisional hernia repair with Phasix™ ST Mesh in laparoscopic only (48/90, 53.3%) or robotic assisted cases (42/90, 46.7%) with mean defect 9.2 ± 11.4 cm², 84.4 ± 42.3 minute procedure time, and 1.2 ± 1.7 day length of stay. There were no SSOs requiring intervention within 45 days post-implantation, including SSI, seroma, hematoma, wound dehiscence, skin necrosis, mesh infection and fistula (0/90, 0.0% in all cases).

Conclusion: Phasix™ ST Mesh demonstrated promising early results in subjects at high risk of SSO with no SSOs requiring intervention within 45 days post-implantation. Longer-term 24-month follow-up is ongoing.

P015

Laparoscopic Repair of Inguinal Hernia Developed After Robot-Assisted Laparoscopic Radical Prostatectomy

Shuto Fujita, MD, Hitoshi Idani, MD, FACS, Kanyu Nakano, MD, Toshihiro Ogawa, MD, Yasuhiro Komatsu, MD, Naoki Mimura, MD, Tetsushi Kubota, MD; Department of Surgery, Hiroshima City Hiroshima Citizens Hospital

Background: Inguinal hernia developed after robot- assisted laparoscopic radical prostatectomy (RALP) have usually been treated by anterior approach. We have introduced a new technique of laparoscopic transabdominal repair of inguinal hernia after RALP and evaluated the outcome.

Surgical Procedures: Under general anesthesia, 3 trocars was inserted at the same position as transabdominal preperitoneal approach (TAPP). Bilateral inguinal legion was observed carefully and bilateral hernia repair was performed when the hernia was detected at the contralateral side. At first, preperitoneal space was dissected laterally and then medially enough to detect the Cooper’ ligament and pubic bone. When the Cooper’s ligament could not be detected, the surgery was converted to anterior approach. When the preperitoneal space was fully dissected, TAPP was performed with 14 × 10 cm mesh. When the Cooper’s ligament was detected but the medial preperitoneal space could not be further dissected due to scar formation caused by dissection during RALP, parietex composition mesh was fixed to the Cooper’s ligament and medial and cephalad side was directly fixed to the abdomen and the caudal side was sutured and covered with peritoneum (modified intraperitoneal onlay mesh: MIPOM).

Methods: From April 2014 to August 2017, 15 patients with inguinal hernia developed after RALP underwent laparoscopic repair in our hospital and its short-term outcome was evaluated.

Results: Mean age of patients was 69 years old. There were 8 right indirect hernias, 2 left indirect hernia and 5 bilateral indirect hernias (one of which was combined with left direct hernia). Two Contralateral side hernias were diagnosed during laparoscopy. TAPP, MIPOM and anterior approach were performed on 4, 7 and 4 patients, respectively. Operation time was 142 min for TAPP, 150 min for PIPOM (including 2 bilateral repair) and 144 min for anterior approach. Postoperative pain was minimum and well controlled by painkiller which disappeared within a week. Hospital stay was 3.5 days. Seroma was occurred in two patients after MIPOM, one of which was treated conservatively. The other was symptomatic and recurrence could not completely be denied and laparoscopy was performed. By laparoscopy, the mesh was beautifully incorporated without recurrence and the remnant hernia sac was resected by anterior approach. During the follow-up period of 26 months, there has been no recurrence.

Conclusion: Our new laparoscopic repair including TAPP and MIPOM is safe and effective although further examination in a large number of patients and long term follow up will be needed.

P016

Laparoscopic Abdominal Drainage in Treatment of Abdominal Wall Hernia in Cirrhotic Patients Accompanied by Ascites

Gheorghe Anghelici, PhD, Profesor, Sergiu Pisarenco, Md, Tatiana Zugrav, Md; State University of Medicine and Pharmacy "Nicolae Testemitanu"

Background: Management of abdominal wall hernias in cirrhotic patients accompanied by ascites is still under debate. The objective of this study was to compare the outcome in our series of urgently versus scheduled operated treatment of these patients.

Methods: In the period between 2012 and 2016, 102 patients with an abdominal wall hernia combined with liver cirrhosis and ascites were identified from our hospital database.

I group: 48 cirrhotic patients operated on urgently, including 36 (75%) - with hernia sac erupts with ascites fluid overflow and 12 (25%) with strangulated hernias. 9 (18.8%) patients was performed endoscopic hemostasis simultaneously for variceal bleeding. In 55% cases ascites fluid was present bacterial microflora.

Group II: 54 cirrhotic patients with massive ascites and spontaneous eruption risk of hernia, operated scheduled after a thorough preoperative preparation, laporoscopic drainage of abdominal ascites and abdominal cavity lavage with antibacterials. In 85% cases ascites fluid was present bacterial microflora.

Plasty method - "tension-free no mesh" with Platelet-rich fibrin application. Sealing prophylactic endoscopic variceal was performed in 29 (53.7%) patients.

Conclusions: Patients with leaver cirrhosis with massive resistance ascites should be operated in a planned way for hernia anterior abdominal wall. In this cases its obligatory the endoscopic exam for prevention of variceal bleeding. The priority has the procedures „tension free no mesh” or „tension free no mesh” with Platelet-rich fibrin application. Laparoscopic abdominal drainage and lavage with antibacterials reduces the risk of ascites-peritonitis, improves wound healing. Drain of abdominal cavity in post operatory period decrease the risk of developing the ascites peritonitis and improve the wound healing.

P017

Incisional Hernia Rates in Patients Undergoing Major Abdominal Operations for Benign vs Malignant Disease

Jenny M Shao, MD ¹, Chris Devulapalli, MD¹, Anne Fabrizio, MD¹, Hepzibha Alexander, BSN², Sameer Desale, MS³, Mohammed Bayasi, MD¹, Lynt B Johnson, MD, MBA¹, Parag Bhanot, MD^{1; 1}Medstar Georgetown University Hospital, ²Georgetown University School of Medicine, ³Medstar Health Research Institute

Introduction: Incisional hernias following abdominal surgery can be associated with significant morbidity leading to decreased quality of life, increase in health care spending and need for repeat operations. Patients undergoing gastrointestinal and hepatobiliary surgery for malignant disease may be at higher risk for developing incisional hernias. Identifying these risk factors for incisional hernia development can help decrease occurrence. This will be the largest multi-institutional study looking at incidence of symptomatic hernia rates for major abdominal operations including colectomy, hepatectomy, pancreatectomy, and gastrectomy.

Methods and Procedures: An IRB- approved retrospective study within the MedStar Hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across 11 hospitals between the years of 2002 to 2016. All patients were identified using ICD-9 and ICD-10 codes for relevant procedures and then subdivided into either having benign or malignant disease. Exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. Data validation was performed to verify the accuracy of the data set. The rate of symptomatic incisional hernia rates (IHRs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. Descriptive statistics and chi squared test were used to report IHRs in each group.

Results: During this 15-year span, a total of 7,583 major abdominal operations were performed at all 11 institutions, comprising of 4,970 colectomies, 1,122 hepatectomies, 1,165 pancreatectomies, and 326 gastrectomies. Malignancy was the indication for surgery in 2,178 (43.8%) colectomies, 747 (66.6%) hepatectomies, 763 (65.5%) pancreatectomies, and 207 (63.5%) gastrectomies. IHR in each cohort for benign vs malignant etiologies, respectively, are as follows: 193 (6.9%) vs 104 (4.8%) in colectomy (p = 0.002), 12 (3.2%) vs 16 (2.1%) in hepatectomy (p = 0.385), 17 (4.2%) vs 24 (3.1%) in pancreatectomy (p = 0.431), and 4 (3.4%) vs 5 (2.4%) in gastrectomy (p = 0.88) patients.

Conclusion: Symptomatic incisional hernia rates following major gastrointestinal and hepatobiliary surgery ranges from 2.1 to 6.9%. There was no significant increase in hernia rates in patients undergoing surgery for malignancy. Patients undergoing colectomy for benign disease had a high incidence of symptomatic IHRs.

P019

Laparoscopic Ventral Hernia Repair with Intra-peritoneal Suturing Technique

Chintan Patel, MS, DNB, FMAS, FIAGES, FBMS ¹, Jalbaji More, MS², Ajay Bhandarwar, MS, FMAS, FIAGES, FBMS, FICS², Eham Arora, MS², Shubham Gupta, MS², Jasmine Agarwal^{2; 1}Kiran Multi Super Specialty Hospital & Research Center, Surat, India, ²Grant Government Medical College & Sir JJ Group of Hospitals, Mumbai, India

Objective: To evaluate laparoscopic repair of ventral hernia by intraperitoneal suturing method.

Method: Ten patients with a mean BMI of 31.84 kg/m² underwent a laparoscopic ventral hernia repair between 2015 to 2016. A laparoscopic approach with three trocar incisions was used to repair ventral hernia; intraperitoneal fixtion of mesh was done using slow absorbing sutures and short-term follow-up results up to May 2017 are reported.

Results:

Conclusion: Laparoscopic ventral hernia repair by intra peritoneal suturing method is a easy, safe, and effective procedure in the treatment of ventral hernia in our short term experience.

Laparoscopic repair of incisional hernia and ventral hernia appears to be safe, especially with the use of Gore-Tex mesh, and is proving to be effective as it decreases pain, complications, hospital stay, and recurrences.

P020

Correlation of Ultrasound Results with Intraoperative Findings in Primary Groin Hernias

Maia S Anderson, MD ¹, Arielle E Kanters, MD, MS¹, Jonathan Melendez, BS², Dana A Telem, MD, MPH^{1; 1}University of Michigan Department of Surgery, ²University of Michigan Medical School

Introduction: Studies have demonstrated wide variability in the sensitivity and specificity of ultrasound in determining the presence of groin hernias. Further, analyses of the accuracy of this modality in the diagnosis of specific types of groin hernias are lacking. In this context, we sought to investigate the correlation between ultrasound and intraoperative findings in groin hernias.

Methods: This is a single center retrospective chart review of 187 patients who presented to the division of Minimally Invasive Surgery and underwent repair of a primary groin hernia between 1/2014 and 4/2017. After excluding patients without preoperative ultrasound, 54 patients were left for evaluation. Accuracy of physical exam and ultrasound findings for presence of groin hernia were calculated using intraoperative findings as the gold standard and compared using McNemar’s test. For each hernia type (direct, indirect, femoral), ultrasound diagnosis was compared to intraoperative findings using Fisher’s exact test.

Results: A hernia was identified intraoperatively in all 54 patients with ultrasound results. A hernia was identified preoperatively by physical exam in 89% (n = 48) of patients and by ultrasonography in 96% (n = 52) of patients (p = 0.109). Intraoperative findings included 21 direct, 36 indirect, and 7 femoral hernias, with 10 patients presenting with multiple hernias identified at the time of surgery. Ultrasound correctly identified 33% (n = 7) of direct, 56% (n = 20) of indirect, and 14% (n = 1) of femoral hernias. The total accuracy of ultrasonography for specific hernia type was 67%. Ultrasound results did not correlate with intraoperative findings for any particular hernia type. For female patients (n = 8), ultrasound correctly identified 88% (n = 7) hernias versus 50% (n = 4) on physical exam. For patients with a BMI > 30, ultrasound correctly identified 100% (n = 15) of hernia vs. 80% (n = 12) by physical exam.

Conclusions: While groin ultrasound accurately detected the presence of a hernia, specific hernia type was frequently misidentified using this imaging modality. Given that physical exam was equivalent in diagnosing the presence of a hernia, ultrasound may be redundant in the evaluation of patients with a clinically evident groin hernia. The poor sensitivity of ultrasound for hernia type also suggests the potential for misdiagnosis, which could be detrimental in the setting of a femoral hernia and could impact operative planning and execution in an open repair. Our study shows that ultrasound does not appear to have a clear benefit in the diagnosis of groin hernias and results should be viewed with caution.

P022

Laparoscopic Spigelian Hernia with Re-recurrent Umbilical Hernia Repair with Sleeve Gastrectomy - A Rare Case Report

Jitendra T Sankpal, MBBS, MS, FMAS, FIAGS, FALS ¹, Khushboo K Kadakia, MBBS¹, Sweety S Agarwal, MBBS, DNBE¹, Sushrut Sankpal, MBBS², Priyanka Saha, MBBS¹, Ameya S Gadkari, MBBS¹, Atish K Parikh, MBBS¹, Manjiri J Sankpal, MBBS, MS³, Saad Shaikh, MBBS¹, Avinash Gonnade, MBBS¹; ¹Grant Government Medical College And Sir JJ Government Hospitals, Mumbai, India, ²Rajiv Gandhi Medical College, Thane, Maharashtra, India, ³New Millenium Hospital, Sanpada, Navi Mumbai, India

Introduction: Obesity is one of the important precipitating factor for occurence and recurrence for obvious and silent ventral hernias. Review of literature shows various studies recommending concomitant repair of umbilical hernia with bariatric procedures like sleeve gastrectomy, Roux-en-Y gastric bypass. But here we report probably the first case in world literature where in incidentally detected left spigelian hernia and irreducible re-recurrent umbilical hernia were repaired with IPOM Plus along with concomitant sleeve gastrectomy successfully.

Materials and Method: A 36 years old female patient with morbid obesity (BMI − 45) presented with re-recurrent (twice operated) irreducible umbilical hernia with no co-morbid conditions. Complicated umbilical hernia being the primary pathology with obesity as the predominant etiological factor, the patient was posted for laparoscopic IPOM plus with sleeve gastrectomy. During surgery, after adhesiolysis and reducing the omental contents from 4 cm × 3 cm umbilical defect, an additional spigelian hernia with omentum as a content, was incidentally noted along the left rectus abdominis muscle. This spigelian hernia and umbilical hernia were repaired by IPOM Plus with two separate 15 × 15 cm composite meshes followed by sleeve gastrectomy.

Discussion: It is not uncommon for bariatric patients to also have ventral hernias, and during diagnostic laparoscopy the surgeon should not be surprised if additionally masked secondary defects or simultaneous ventral hernias are found.

Concomitant laparoscopic IPOM Plus for this spigelian hernia and re-recurrent umbilical hernia along with sleeve gastrectomy can be safely performed for following reasons

• Immediate symptomatic pain relief due to reduction of irreducible hernia.

• The chances of subsequent incarcaration and strangulation were reduced.

• By performing sleeve gastrectomy, obesity, as a risk factor for recurrence of ventral hernia was significantly reduced.

• By obviating the need for second surgery, there was a cumulative decrease in cost/stress/morbidity/anaesthetic complications.

Conclusion: Numerous studies have shown the advantage of laparoscopic IPOM Plus with sleeve gastrectomy or other bariatric procedures and this particular case report highlights probably the first case in world literature where in laparoscopic IPOM Plus repair of spigelian hernia was done with simultaneous sleeve gastrectomy with fair and favourable outcome.

P023

Of Mice of Mesh: Evaluating Mesh Structure on Bacterial Adherence

Lawrence N Cetrulo, MD¹, Alisan Fathalizadeh, MD, MPH ², Michelle Nguyen, MD², Pak Shan Leung^{2; 1}Carolinas Healthcare Network, ²Einstein Healthcare Network

Introduction: Prosthetic infections, although relatively uncommon, are a major source of cost and morbidity. The study aimed to evaluate the influence of mesh structure including the polymer type and mean pore size on bacterial adherence in a mouse model.

Methods: Three commercially available hernia meshes were included in the study. For each mesh type, a 1 cm square was surgically placed intraabdominally in 6 mice. One mouse served as a control while an enterotomy was made in the subsequent mice to introduce a bacterial load onto the mesh. After 24 hours the meshes were harvested. The inoculated meshes were then plated on agar plates and bacterial counts were counted after 24 hours. The bacterial counts were compared between the various mesh types.

Results: The mean bacterial adherence was increased in the large pore mesh was 695 colonies, for the small pore mesh was 892 colonies, and in the biologic mesh group it was 504 colonies.

Conclusions: Through the use of a mouse model, the influence of mesh type and pore size on bacterial adherence was evaluated. Meshes that have larger pores with a lower prosthetic load and the biologic mesh interestingly had lower early bacterial colonization after 24 hours following an enterotomy. Further evaluation with a longer incubation time could be helpful to determine the effect of bacterial colonization of mesh.

P024

Laparoscopy for Complex Groin Hernia Repair: A Single Centre Institutional Experience in an Asian Cohort

Hrishikesh Salgaonkar, Raquel Maia, Lynette Loo, Wee Boon Tan, Sujith Wijerathne, Davide Lomanto; National University Hospital, Singapore

Laparoscopic repair of groin hernias is widely accepted approach over open due to lesser pain, faster recovery, better cosmesis and decreased morbidity. However, there is still debate on its use in large inguino-scrotal hernias, recurrent hernias and history of lower abdominal surgery anticipating adhesions and difficulty in dissecting extensive hernia sac. Retrospective analysis of prospectively collected data was done of patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and history of previous lower abdominal surgery.

Between January 2013 to July 2015, 89 patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia underwent laparoscopic inguinal hernia repair. Patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence up to 18 months recorded.

51 patients had large inguino-scrotal hernia, 22 recurrent hernia (17 previous open, 5 previous lap), 14 history of lower abdominal surgery (4 LSCS, 6 Appendectomy, 2 prostatectomy, 2 midline laparotomy), 1 incarcerated femoral hernia, 1 meshoma removal. 75 patients underwent total extraperitoneal (TEP) repair, 9 transabdominal pre-peritoneal (TAPP), 5 needed conversion to open. Mean operation time was 74 min for unilateral and 118 min for bilateral hernia. Seroma formation seen in 19 patients, 2 minor wound infections treated conservatively.

We conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias; surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates.

P025

Learning Curve for Single-Incision Totally Extraperitoneal Inguinal Hernia Repair

Masaki Wakasugi, Yujiro Nakahara, Masaki Hirota, Takashi Matsumoto, Hiroyoshi Takemoto, Ko Takachi, Kiyonori Nishioka, Satoshi Oshima; Department of Surgery, Kinki Central Hospital

Purpose:

The aim of this study was to clarify the learning curve for single-incision laparoscopic surgery for totally extraperitoneal repair (SILS-TEP).

Patients and Methods:

Clinical setting

A retrospective analysis of 50 consecutive patients with unilateral inguinal hernia undergoing elective SILS-TEP by a single surgeon between July 2016 and September 2017 was performed.

Exclusion criteria

Patients with a history of radical prostatectomy, young patients with a small indirect inguinal hernia, and patients for whom general anesthesia was contraindicated were excluded from this study.

Surgical procedure

A single, 2.5-cm, intraumbilical incision was made, and blunt dissection was performed between the muscle and the posterior sheath to create a preperitoneal space. After placing a Lap-Protector Mini in this space, three 5-mm trocars were inserted through a single-port access device. The preperitoneal space was dissected gradually, using straight laparoscopic instruments without a dissection balloon. Mesh was placed in this preperitoneal space, covering the inguinal floor, and was fixed with absorbable tacks. After completion of the operation, the preperitoneal space was carefully deflated to avoid displacing the mesh. The anterior rectus sheath and skin were closed with an absorbable suture.

Results:

Clinical characteristics

The first 25 cases were categorized into the learning period group, and the later cases were categorized into the experienced period group. There were no significant differences between the two groups in age, sex, and body mass index.

Moving average curve

The mean operating time for each set of 10 cases decreased continuously. The operating time gradually stabilized after 20 cases and showed a decrease after 30 cases.

Comparison of operative outcomes

The median operative time for a unilateral hernia in the learning period group and the experienced period group was 102 min and 75 min, respectively (p < 0.05). There were no conversions to a different operative procedure in either group. The median duration of postoperative hospital stay was 1 day in both groups. Peritoneal injury occurred in 32% (8/25) of the learning period group and 24% (6/25) of the experienced period group (p = 0.8).

Postoperative complications

Postoperative complications, including seroma, wound infection, and mesh infection, were seen in 24% (6/25) of patients in the learning period group and 4% (1/25) of patients in the experienced period group (p = 0.1). These complications were managed conservatively. No other major complications or hernia recurrence were noted.

Conclusions: The number of patients needed to become proficient in SILS-TEP might be approximately 25 cases.

P026

Comparison of Permanent or Absorbable Tack Fixation When Used Alone or with Suture Fixation in Laparoscopic Ventral Hernia Using the Americas Hernia Society Quality Collaborative (AHSQC)

Jordan A Bilezikian, MD, Irene L Israel, MD, William F Powers, MD, William B Hooks, MD, William W Hope, MD; New Hanover Regional Medical Center

Mesh fixation in ventral incisional hernia is a topic of ongoing debate. Permanent and absorbable tacks are acceptable and widely used methods for mesh fixation. The purpose of this study was to compare outcomes of permanent tack fixation versus absorbable when used alone or with suture fixation in laparoscopic incisional hernia repairs.

A retrospective review of all patients undergoing laparoscopic ventral hernia using tack fixation (absorbable/permanent) alone or in conjunction with suture fixation was queried from the AHSQC database. Outcome measures included hernia recurrence rate, pain, quality of life, wound related issues, and hospital length of stay. Propensity match scoring was performed to compare patients undergoing tack only fixation versus tack and suture fixation with a p-value of < 0.05 considered significant.

A total of 804 patients were identified after propensity match scoring with 402 who underwent repair with permanent tacks alone or with sutures and 402 who underwent repair with absorbable tacks alone or with sutures. Following matching there were no differences in BMI, Age, Hernia Width/Length, or baseline pain/quality of life. There were no significant differences found in outcome measures including recurrence rates, pain and quality of life outcomes at 30 days, 6 months, and 1 year, surgical site infection (SSI), and postoperative length of stay (p > 0.05). There was a significant increase in any post op complication in the permanent tack fixation group compared to the absorbable tack fixation group (21% vs 14%, p < 0.0003) which is likely due to the increase in surgical site occurrences noted in the permanent tack fixation group (14% vs. 10%, p < 0.005).

Based on this large data set, there are no significant differences in postoperative outcomes in permanent versus absorbable fixation in laparoscopic hernia repair except in surgical site occurrences. Further study is needed to evaluate but at the present time, there is no convincing evidence that one type of fixation is superior to another in laparoscopic ventral hernia repair.

P027

Single Incision Laparoscopic Transabdominal Preperitoneal Mesh Hernioplasty for Inguinal Hernia in 290 Japanese Patients

Kazuo Tanoue; Ueno Hospital

Introduction: Inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. Laparoscopic Transabdominal preperitoneal mesh hernioplasty (TAPP) has been also popular surgical method in Japan. Single incision laparoscopic surgery is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex surgery. We report our experience with single incision laparoscopic TAPP (S-TAPP) for Japanese patients with inguinal hernia.

Case Description: A consecutive series of 290 patients (247 male, 43 female) who underwent S-TAPP during June 2010 to September 2017 in a single institution. Twenty eight of the patients had bilateral inguinal hernia. The mean follow-up was 1192 days. The average age of the patients was 61.2 ± 16.5 years.

Establishment of the ports: A 25-mm vertical intra-umbilical incision is made for port access. One 5-mm optical port and two 5-mm ports were placed side-by-side through the umbilical scar.

Surgical procedure: The procedure was carried out in the conventional fashion with a wide incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and an appropriate placement of polypropylene mesh (3DMaxTM light, Bard) with fixation using the tacking device (AbsorbaTack®, Covidien). The hernia sac is usually reduced by blunt dissection, or is ligated and transected with ultrasound activated device. The peritoneal flap is closed by one suture with 4-0 PDS and the 6–7 tacks using AbsorbaTack®.

Discussion: In one patient, we encountered a large sliding hernia on the right side having sigmoid colon as content of the sac, which required conversion to the conventional laparoscopic procedure. There were nine recurrence cases after surgery of laparoscopic or anterior approach, and two cases after prostatectomy. There was no intra-operative complication. The mean operative time was 87.4 ± 31.1 min, and blood loss was minimum in all cases. The average postoperative stay was 5.4 ± 2.7 days. There was one recurrence case (0.3%) 16 months after the surgery. There was no severe complication after the surgery, but there were 15 seromas (4.7%) and one hematoma (0.3%). Two patients had blunt tactile sense in the area of the lateral femoral cutaneous nerve (0.9%), which improved in two months.

Conclusion: Our results suggest that S-TAPP is a safe and feasible method without additional risk. Moreover, cosmetic benefit is clear. However, further evaluation for postoperative pain and long-term complications compared to standard laparoscopic TAPP mesh hernioplasty should be required.

P028

One-Year Histologic Behavior Assessment on GORE® Synecor®

Manuel Garcia, MD, Daniel Srikureja, MD, Marcos J Michelotti, MD, FACS; Loma Linda University Health

Introduction: Prosthetic mesh use has become standard practice during ventral hernia repair to reduce the risk of recurrence. The ideal mesh is macro-porous which favors rapid cellular ingrowth and tissue integration, has limited tissue reactivity, low profile and weight, and has high tensile strength to add resilience to the repair. Additionally, the material is expected to have good handling characteristics. Currently, there is a wide variety of options for mesh. Biosynthetic material (poliglycolic acid/trimethylene carbonate – PGA/TMC) has been shown to behave well in terms of early vascularization and ingrowth as well as adequate long term tissue generation. GORE® Synecor® Biomaterial is a composite mesh including two layers of absorbable biosynthetic material (PGA/TMC) with one tridimensional non-absorbable macro-porous knit of dense PTFE mesh. It has shown good vascularization and ingrowth at 30 days in animal examination. However, there is still no evidence of long term behavior of this mesh in human tissue. We present the first histologic analysis of this mesh 1 year after placement in a human.

Objective: To perform a histologic analysis of the GORE® Synecor® Biomaterial one year after placement in the human body.

Methods: After incidentally finding incorporated GORE® Synecor® mesh in a patient with prior ventral hernia repair 1 year ago, during open bilateral inguinal hernia repair, a sample of mesh was taken and sent to pathology lab for analysis. Tissue healing, vascularization, and ingrowth of the composite mesh were analyzed.

Results: Histologic findings significant for a biomaterial consistent with a knitted PTFE material surrounded by mature fibrovascular tissue and foreign body inflammation consistent with expected healing response for this time frame. No evidence of any other biomaterial (PGA/TMC) or evidence of infection.

Conclusion: GORE® Synecor® Biomaterial has shown to be well integrated into appropriately healed tissue, with pronounced vascularization and ingrowth. The PGA/TMC layers have been seen to be completely absorbed and replaced by collagen. These findings, in a human 12 months sample, replicate what had been shown in animal specimens.

P029

Hybrid Approach to Ventral Hernia Repair – When is it Most Beneficial?

Gideon Sroka, MD, Husam Mady, MD, Ibrahim Matter, MD; Bnai-Zion Medical Center

Introduction: since the introduction of the laparoscopic approach to ventral hernia repair its advantages have been clear but it comes with limitations as well. The purpose of this study is to examine a hybrid approach that uses both open and laparoscopic techniques for ventral hernia repair, and to define the type of defect for which this approach would be most beneficial.

Methods: a case series of all patients who went through a hybrid ventral hernia repair in our department from 01/2015 to 6/2017. Patient selection is related to defect and sac sizes and content. Operation starts in laparoscopic exploration and adhesiolysis, then a limited incision is performed over the defect in order to achieve a safe content reduction, complete sac excision, and defect closure. A return to the laparoscopic approach allows optimal mesh placement and fixation without a need for wide undermining (short video will be presented). Data is presented as as mean ± SD.

Results: 18 patients (10:M, 8:F) went through the procedure. All of them had post operative ventral hernia (POVH). Defect size was 5.2 ± 1.6 cm and sac diameter was 8.2 ± 1.9 cm. Operating time was 71 ± 13 min. LOS was 3.5 ± 1.2 days. Two patients had seromas that were treated conservatively. There were no small bowel injeries. Patient satisfaction was high. In 11 ± 9 months of follow up there was no recurrence.

Conclusion: for patients with small to medium size POVH with larger sacs with dense adhesions to their content, a hybrid approach allows achieving all goals of the operation safely, in a minimal invasive way and good functional outcome.

P030

Laparoscopic Trans-abdominal Retro-Muscular Repair for Ventral/Incisional Hernias: A Novel & Promising Technique

Ashwin A Masurkar, DR, Seema A Masurkar, DR, Shamala A Masurkar, DR; Masurkar Hospital

Introduction: There has been a need to devise a feasible, reliable and replicable Laparoscopic technique for Ventral/Incisional hernias; with Retro-muscular mesh placement. The reports of complications with Intra-peritoneal Onlay repair using composite meshes makes Retro-muscular mesh placement a safer option. This study is from a small town private hospital in South India.

Methods and Procedures: The aim is Laparoscopic placement of a polypropylene mesh into the retro-muscular plane with midline closure. The approach is trans-peritoneal and three techniques were devised based on hernia size & location. Technique 1 For small umbilical & infra-umbilical hernias; 3 ports are used in the upper abdomen. After adhesiolysis and reduction of sac contents; a transverse incision is taken on the peritoneum-posterior sheath complex, 6 cm proximal to the defect. A retro-muscular space is created by raising a flap of posterior sheath peritoneum complex. Intra-abdominal pressure is reduced. The Anterior sheath & Rectus muscles are approximated using no 1 Polydiaxanone (PDS) sutures. A Polypropylene Mesh of desired size is parked into the space and anchored to muscles using 1-0 Polypropylene sutures. The incision and hernial defect are closed using 1-0 PDS sutures creating a natural mesh-bowel barrier. Technique 2:- For large central defects; 6 ports were used. 3 supra and 3 infra-umbilically; to create two flaps superiorly and inferiorly. Next, trocars are withdrawn into retro-muscular space. The Sheath-Peritoneum flap & hernial defect are approximated followed by insertion and anchoring of mesh of required size. One or two meshes upto 30 × 30 cm are used. Technique 3 Devised for large defects with wide divarication; uses the previous technique with addition of Posterior component separation by Transversus abdominis release to facilitate midline closure.

Results: Study period 2010 to present. Uncomplicated hernias with defect size 2 cm to 15 cm without large redundant skin fold were selected. Large hernias with loss of domain or excess redundant skin were offered open Rives-Stoppa repair. Total cases operated-57. Primary ventral 15 (Umbilical 14, Epigastric-1). Incisional 42 (Previous surgery C-Sect. 20; Hysterectomy- 7; Sterilisation 10 Exploratory laparotomy 3 Appendicectomy 2). Average operating time 160 minutes Complications:-Intra-operative bleeding 3. Conversion to open 2, Bowel injury nil. Mesh infection 1. Seroma 7. Bowel obstruction 0. Recurrence early nil, late 2. Mortality nil. Average length of stay 5 days.

Conclusion: Laparoscopic Trans-Abdominal Retro-muscular (TARM) repair using polypropylene mesh is safe, effective and inexpensive. It delivers the benefits of Rives-Stoppa repair via Laparoscopy.

P031

A Systematic Review of RCTs Evaluating Laparoscopic Repair of Inguinal Hernias with Self-gripping Mesh Versus Mechanically Fixed ‘Lightweight’ Mesh in the Treatment of Medium to Large Sized Defects

Nehemiah Samuel, Mr, Maria Tsachiridi, Miss, Ajay Gupta, Fayyaz Mazari, Mr, Antonio Durham-Hall, Miss, Srinivasan Balachandra, Mr; Doncaster Royal Infirmary

Background: In Laparoscopic Inguinal Hernia (LIH) surgery, the type of mesh and its fixation techniques have been long debated in context to post-operative pain, recurrence, shrinkage, and migration. The relatively new Self-gripping mesh is intended to address these shortcomings and has been shown to shorten duration of operation, with studies declaring non-inferiority in perioperative complications, chronic groin pain and recurrence rates (in open hernia repairs); also lowering the cost of the procedure by combining the functionality of mesh and fixation into one device (in laparoscopic repairs).

Aim: This study was designed to systematically analyse all published RCTs comparing early and long term outcomes of self-gripping mesh and ‘lightweight’ polypropylene mesh often fixed with a fixation device in the laparoscopic repair of moderate to large sized inguinal hernia defects.

Methods: A literature search was performed using the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase and Science Citation Index Expanded. RCTs comparing self-gripping mesh with standard polypropylene mesh was included.

The primary outcome measures were chronic pain after operation and hernia recurrence. Secondary outcome measures were technical success, operative time, analgesia requirement, perioperative complications, return to work, quality of life improvement and cost effectiveness of the two techniques.

Results: From all the studies reported in literature on the treatment of inguinal hernias and the newer self-gripping mesh, unfortunately not a single RCT was identified that compared the self-gripping mesh with the standard mesh in the laparoscopic repair of inguinal hernias. Hence meaningful outcome measures could not be compiled from the published studies which were predominantly retrospective case-series.

Conclusion: With the introduction of the newer self-fixating mesh (functionality of mesh and fixation combined in the same device) the hypothesis that it offers advantages of less post-operative pain and increased effectiveness of repair even in moderate to large sized hernia defects is well worth pursuing in an RCT setting. In the era of laparoscopic ‘key-hole’ surgery, evidence that a particular technique improves patient based surgical outcome measures will have a significant impact on future clinical practice.

P032

Laparoscopy Utilization for Inguinal Hernia Repairs in the United States: Ambulatory and Inpatient Settings

Piotr J Bachul, MD ¹, Marek Rudnicki, MD, PhD, FACS^{2; 1}University of Chicago, ²University of Illinois, Advocate Masonic Medical Center

Introduction: Inguinal hernia repairs are considered as one of the most common procedures in modern practice. Laparoscopic repairs appear to have advantages over the open approach. Relatively little information is available regarding the utilization of healthcare services for these commonly performed procedures in the United States. The redesigned Healthcare Cost and Utilization Project (HCUP) Database offers comparisons between HCUP State Ambulatory Surgery and Services databases with statistics from the HCUP State Inpatient databases (nine states participated in the most recent data collection in 2013). This new databank allows more detailed insight into ambulatory trends in utilization of healthcare services.

Material and Methods: The HCUP National Inpatient Sample was queried for inguinal hernia repairs performed in 2013, using ICD-9 procedure codes 17.11–17.13, 17.21–17.24 for laparoscopic and 53.00–53.17 for open inguinal hernia repairs. Ambulatory vs. inpatient settings were compared for frequency, patients’ demographics and payer using chi-square statistical analysis.

Results: A total of 160 935 inguinal hernia repairs were identified in the referred 2013 database. 131 354 (81.6%) were done in ambulatory setting vs. 29 581 (18.4%) as an inpatient treatment. Overall, majority of repairs were done in open manner (123 349 vs 37 586 laparoscopic, 76.6% vs. 23.4%). Patients in age range between 18–44 and 45–64 had highest chance of getting laparoscopic repair (30.7% and 30%, respectively) vs. those who were younger than 18 at maximum rate of 2.8%. Laparoscopic technique was employed in 26% of cases done in ambulatory setting whereas only in 11.5% cases were performed as inpatients. Laparoscopic repair was most commonly used in patients with private insurance (30.6% in ambulatory vs 15% in the hospital setting).

Conclusions: In the United States, inguinal hernia repairs are performed predominantly in ambulatory settings. Despite the expected increase in its utilization, laparoscopic technique is only used in one out of four patients, usually for adults between 18–64. Laparoscopic repairs are done in ambulatory settings more than twice as inpatients. Patients with private insurance tend to have laparoscopic surgery more often than patients covered by other payers. It needs to be mentioned that the collected data is reflective of a limited sample of hernia surgery practiced in the US.

P033

Posterior Component Separation and Transverus Abdominus Release Hernia Repair: Outcomes in an Initial Cohort

S Shirazi, MD, J Janzen, MD, S D Pooler, MD, FRCSC, G K Kaban, MD, FRCSC; University of Saskatchewan

Introduction: Repair of midline incisional hernias utilizing posterior component separation and transversus abdominus release (PCS/TAR) was first described in 2006. The technique is growing in popularity for incisional hernia repair with several large series documenting its success. There are no reports demonstrating its utilization in low volume centres. Our aim was to evaluate our outcomes with PCS/TAR incisional hernia repair in the first series of patients in our institution.

Methods and Procedures: Following ethics board approval, patients with a history of PCS/TAR hernia repair were identified retrospectively from the health records of our institution, performed by our senior author during the period of 2009-15. Patient demographics, hernia characteristics, indications, and short term outcomes were collected. Patients were invited to undergo evaluation by a non-operative surgeon for signs of clinical recurrence. Participating patients completed a survey regarding overall satisfaction and quality of life with repair.

Results: A total of 18 PCS/TAR repairs were performed. Patient participation for follow-up was 61% (11/18). Average patient age was 64 years. Average operative time was 3 hrs 50 min and length of hospital stay was 5.2 days. Average mesh size was 633 cm². Mesh was uncoated polypropylene in the majority of cases (16/18). Surgical site occurrences (SSO) occurred in 5 patients. SSO risk stratified by the Ventral hernia Working Group (VHWG) classification was: 1 (28%), 2 (50%), 3 (22%), 4 (0%). Three (11%) patients needed explantation of the mesh due to non-resolving infection. All three patients requiring mesh explanation were VHWG 3 accompanied by closure of stoma or repair in the presence of a stoma. Early recurrence rate was 18% (2/11), occuring in a patient with biologic mesh repair only, and one patient with a 2 cm recurrence inferior to the mesh requiring operative repair. Patient satisfaction was excellent (by Likard scale, mean 7/10, median 10/10) as was patients self-reported improvement in quality of life (mean 8/10, median 9/10).

Conclusions: PCS/TAR is associated with a low peri-operative wound morbidity when performed in patients with a low VHWG classification. Caution should be excercised when entertaining simultaneous repair of large hernias and closure of stomas due to a high risk of wound infection in our series. Short-term recurrence rates appear acceptable within the limits of the follow-up. Patient satisfaction and quality of life following this procedure appears to be high. This technique may be utilized in a low volume centre with good outcomes and low early hernia recurrence rates.

P034

Laparoscopic Repair of Renal Paratransplant Hernia

Chintan Patel, MS¹, Shubham Gupta, MS², Jasmine Agarwal², Eham Arora, MS ², Gagandeep Talwar², Kalpesh Gohel, MD, DNB^{1; 1}Kiran Multi-Superspeciality Hospital, Surat, India, ²Grant Government Medical College & Sir JJ Group of Hospitals

Objective: Kidney recipients are susceptible to incisional hernia. Reports of hernia mesh repair after kidney transplantation are rare; thus the benefit of mesh hernioplasty in transplanted patients is not widely researched or published.

Method: From 2014 to 2017, 6 patients came to hospital with renal paratransplant hernia. They were evaluated for this study. The following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method and the treatment results with composite PTFE mesh.

Results: For laparoscopic repair of Incisional hernia after renal transplant, the median interval between kidney transplantation and developing of incisional hernia was 64 (range 12 to 425) days. Predisposing factors were obesity, age over fifty years, and female gender. In six patients, hernia was large, and the repair was performed with using composite PTFE mesh. One patient had developed serous collection in surgical site, which was managed successfully with multiple punctures. Hernia recurrence or infection was not noted in these patients during 3 to 36 months follow-up periods.

Conclusion: Incisional hernia is not a rare entity after kidney transplantation. Predisposing factors, such as obesity, age over 50 years, and female gender have a role in its development. Repeated surgeries in kidney recipients can increase the risk of incisional hernia. Managing this complication by laparoscopic approach is a safe and effective method.

P035

Endo-Laparoscopic Approach for Repair of Femoral Hernia in an Asian Cohort

Sujith Wijerathne, Raquel Maia, Hrishikesh Salgaonkar, Wee Boon Tan, Lynette Loo, Davide Lomanto; National University Hospital, Singapore

Introduction: A femoral hernia is a less common type of hernia. It is estimated to account for less than 5% of all abdominal wall hernias. Only about 1 in every 20 groin hernias are femoral hernias. They are found more commonly in females due to wider shape of pelvis. Laparoscopy by offering magnification and better vision provides us the opportunity for clear visualization of the myopectineal orifice. Laparoscopy seems to be a safe and feasible approach for femoral hernia repair in an Asian population.

Case Description: Between 2013 and 2016, 70 consecutive patients with femoral hernia who underwent laparoscopic hernia repair were prospectively studied. Patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured.

Discussion: Total of 83 femoral hernias were repaired, 45 on right and 38 on left groin. This included 52 patients with bilateral and 18 unilateral hernia. 19 concomitant obturator hernia were found. There were 65 male and 5 female patient. No conversion was reported. One patient had injury to bowel at the 10 mm port entry site, without contamination, identified and managed immediately. 10 patients developed seroma, all were managed conservatively except one who needed aspiration. Peri-port bruising was noticed in 3 patients and 2 patients had hematoma. One patient with hematoma underwent excision of the organised hematoma.1 of the hematoma patient was on aspirin pre-operatively. No wound infection, chronic groin pain or recurrence was documented during follow up till date.

Conclusion: Laparoscopic repair offers accurate diagnosis and simultaneous treatment of both inguinal and femoral hernia with minimum morbidity and good clinical outcomes. Better visualisation and magnification gives us an opportunity to identify occult hernias which can be repaired during the same setting, thereby reducing the chance of recurrence and possible need for second surgery. Laparoscopic repair has become the procedure of choice for the treatment of the majority of groin hernia at our institution.

P036

TEP Repair that Follows the Anatomy of the Inguinal Fascia: A Method for Reaching the Preperitoneal Cavity Through Sharp Incision of the Posterior Rectus Sheath

Fujio Ito, PhD, Takao Tsuchiya, PhD, Satoshi Otani, PhD, Takahiro Saito, PhD, Hajime Matsuida, MD, Junichi Miura, PhD; Iwase General Hospital

Introduction: Totally extraperitoneal (TEP) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. However, balloon- or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. Furthermore, they have a disadvantage in that they are difficult to understand anatomically. We therefore developed a novel preperitoneal approach to resolve this issue.

Methods: A 12-mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. A 5-mm trocar is inserted 5 cm towards the pubic bone from the umbilicus. Using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. The third 5 mm-trocar is inserted near the lateral margin of the rectus abdominis. On the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. A small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. Due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. Utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. Once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. On the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. The umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed.

Results: By individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma.

P037

Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair with Liquid-Injection and Gauze Dissection

Shogo Ohta, Mitsuo Shimada, Kozo Yoshikawa, Jun Higashijima, Takuya Tokunaga, Masaaki Nishi, Hideya Kashihara, Chie Takasu, Daichi Ishikawa; Department of Surgery, University of Tokushima

Introduction: The recurrence during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair has been reported to occur in 3.0%. To prevent the recurrence, adequate dissection of preperitoneal space was important. In this report, a novel technique for TAPP inguinal hernia repair using liquid injection and gauze dissection was described.

Methods: Before initial peritoneal incision, 10 ml of normal saline solution with 2 mg ropivacaine and 0.01 mg epinephrine was injected percutaneously into the preperitoneal space at three points. This liquid-injected space was effectively dissected by using the gauze, especially at the lateral and ventral side of the inguinal canal. The surgical outcome of this technique was assessed.

Results: Twenty-five cases (unilateral cases, except for recurrence) underwent TAPP with liquid-injection and gauze dissection. In the comparison of the cases without liquid-injection and gauze dissection (n = 59), the cases who underwent TAPP with liquid-injection and gauze dissection showed shorter operation time (117 min. vs 89 min., p < 0.05), no complication and recurrence.

Conclusions: TAPP with liquid-injection and gauze dissection assists preperitoneal dissection and contributes to better surgical outcomes. This novel technique appears to be safe and feasible.

P038

Does Re-animating Laparoscopic Mesh in Local Anesthetic Confer an Antimicrobial Effect?

Gary Ko, MD, Darren Siu, BScH, Lewis Tomalty, PhD, David Robertson, MD; Queen’s University

Introduction: Previous studies have demonstrated that local anesthetics have antimicrobial effects, but there have been none looking at these effects on hernia mesh.

Methods: The minimum inhibitory concentration (MIC) of lidocaine, bupivacaine, and cefazolin were determined on strains of methicillin-sensitive and methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis using a micro broth dilution method. The agents were then introduced in combination with an anti-adhesive coated polypropylene mesh to determine changes to the MIC. The fractional inhibitory concentration (FIC) index for each agent was calculated to determine whether if the changes seen were additive or synergistic.

Results: Lidocaine did not exert an antimicrobial effect on S. aureus or S. epidermidis. Bupivacaine and cefazolin each produced inhibitory effects on these organisms. The introduction of the coated polyproylene mesh eliminated the antimicrobial effect of bupivacaine, but the antimicrobial effect of cefazolin was unaltered. An additive effect was noted when bupivacaine and cefazolin were used together on methicillin-sensitive S. aureusand S. epidermis. A synergistic effect was seen when bupivacaine and cefazolin were used together on methicillin-resistant S. aureus and S. epidermis. Furthermore, these effects were preserved in the presence of mesh.

Conclusion: Local anesthetics exhibit varying degrees of antimicrobial activity. This effect was synergistic when used with cefazolin on methicillin-resistant organisms and was preserved when used with coated polypropylene mesh.

P039

Single Incision Endo-Laparoscopic Inguinal Hernia Repair in an Asian Cohort: Single Centre Experience

Sujith Wijerathne, Hrishikesh Salgaonkar, Wee Boon Tan, Lynette Loo, Davide Lomanto; National University Hospital, Singapore

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures. A variety of techniques have been described for the same. Recent development and advancement in MIS has focused towards reducing the access related scars and the resulting pain and morbidity in patients. Single incision surgery is a rapidly evolving field is gaining popularity among surgeons. More surgeons today readily accept and advocate Single or Reduced incision laparoscopic surgery. Single incision laparoscopic Surgery (SILS) for inguinal hernia repair is seen to be feasible and safe. The aim of our study is to evaluate our clinical experience, early and short term results and complications of single incision laparoscopic inguinal hernia repair at our centre.

Case Description: Between Jan 2008 to November 2016 total 88 patients underwent single incision endo-laparoscopic inguinal hernia repair (n = 88). Patients underwent either TEP (n = 60) or TAPP (n = 28). All parameters of patients operated using SILS were collected and analyzed. Data including patient demographics, operating time, conversion if any, intraoperative and early postoperative complications were analyzed and compared.

Discussion: The mean age was 48.48 years (range, 20–81)). The mean operating time was 72.42 (44 to 100 min). Both procedures TEP and TAPP were comparable in terms of operative time and post op results. Except 1 conversion in TEP group, no intra–operative or early post–operative complications were reported. Most patients were discharged before 23 hours and none had a pain score > 2 at the time of discharge. Two patients developed seroma and one minor wound infection at port site which were managed conservatively. One patient developed recurrence after 3 years. No incisional hernia was detected during the follow-up. The operating time stabilized at around 12 cases.

Conclusion: Single incision laparoscopic surgery is a safe and feasible approach for inguinal hernia repair in experienced hands and at specialized centre’s. Even during the initial learning period it carries a low morbidity and conversion rate. Further randomized control studies with larger patient group are required to validate the results.

P040

Comparative Study of Tacker Versus Glue Fixation of Mesh in Laparoscopic Intra-peritoneal Onlay Mesh Repair of Ventral Hernias

Eham Arora, MS¹, Jalbaji More, MS ¹, Shubham Gupta, MS¹, Jasmine Agarwal¹, Gagandeep Talwar¹, Chintan Patel, MS^{2; 1}Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India, ²Kiran Multi-super Speciality Hospital and Research Centre, India

Objective: The dilemma always persists regarding choice of fixation technique in ventral hernia. So we conducted a comparative prospective study of laparoscopic intraperitoneal onlay mesh fixation using Tacker and Glue.

Method: Sample size: 60 cases, 30 cases assigned randomly in two groups for either Tacker or Glue Fixation.

Inclusion criteria: Patients between 18–70 years of age, Patients with ventral hernias with defect size less than 6 cm without any complications.

Exclusion criteria: Patients with BMI > 35, Patients with recurrence after previous repair or, Patients afflicted with COPD, LUTS, Prostatomegaly with complaints of nocturia, Patients unfit for general anesthesia, Patients with acute abdominal emergency.

The patients eligible for the study were selected, informed and explained regarding the above study and a proper informed, valid, written consent taken for participation in the study.

Results: The mean duration of surgery was 83.67 minutes in the glue fixation group, which was significantly more than the tacker fixation group where mean duration of surgery was 64.50 minutes.

There was no intraoperative and postoperative complications with glue fixation.

In tacker fixation, Seroma was seen in 4 cases (13.33%), hematoma in 1 (3%), bowel ileus in 1 (3%), whereas intra-abdominal complications, bowel obstruction, bleeding from trocar site, enterocutaneous fistula were 0 (0%). The glue fixation group did have a lesser complication rate 0/30 (0%) as compared to 6/30 (20%) in tacker group.

The post-operative pain was recorded at 24 hrs, 48 hrs and 1 month after operation by using Visual Analogue Scale (VAS) pain scoring system. The mean pain score of glue fixation and tacker fixation at 24 hrs was 1 and 2.23 respectively (p = 0.00).

Median (range) post-operative hospital stay for patients with tacker fixation is 3 (2–4) days which is more as compared to 2 (1–3) in glue fixation which is statistically significant.

Cost of glue fixation is 50% less as compared to tacker fixation owing to the added cost of tacker.

Conclusion: Return to normal physical activity is earlier in patients with glue fixation.

• Length of hospital stay was less in the glue fixation group

• Cost of glue fixation is 50% less as compared to tacker fixation owing to the added cost of tacker.

• Postoperative follow up upto 1 year doesn’t show any recurrence however, no data of efficiency with longer follow up are available.

P041

Strangulated Diaphragmatic Hernia from Left Ventricular Assist Device: Plea to Close Diaphragmatic Defect at the Time of Device Explantation

Akshay Pratap ¹, Maria Albuja-Cruz¹, Tiffany Tanner^{2; 1}University of Colorado, ²University of Nebraska

Introduction: LVAD [left ventricular assist device] has emerged as a mainstay of destination therapy or bridge to heart transplant in patients with end-stage cardiac disease. Despite the tremendous success with LVAD devices, device related and procedure related complications contribute to significant morbidity in these patients. Diaphragmatic hernia is a known complication. We report two cases of diaphragmatic hernias who underwent LVAD explantation without closure of diaphragmatic defect and orthotopic heart transplant, which resulted in strangulation of small bowel and incarceration of stomach respectively.

Case 1: A 70-year-old man presented to our emergency room with the chief complaint of epigastric and central abdominal pain. He denied any recent trauma to chest or abdomen. He had undergone LVAD 5 years ago followed by explantation of LVAD and orthotopic heart transplantation 4 years ago. The diaphragmatic defect for the outflow cannula was not closed at the time of LVAD explantation. An upright chest x-ray and a computed tomography showed a closed loop small bowel obstruction through a diaphragmatic defect with significant stranding of the mesentery of the herniated bowel and mass-effect on the right ventricle of the heart. Laparoscopic resection of strangulated jejunum and closure of defect with a biological mesh was successfully performed. He made an uneventful recovery and was discharged on POD#5.

Case 2: A 52 year old female with a history of LVAD bridge to heart transplant presented with nausea and hematemesis. An upright chest xray and CT scan showed a large diaphragmatic hernia with stomach in left hemithorax. She underwent a laparoscopic reduction of stomach. Stomach was viable. The defect was closed primarily with a composite Parietex mesh. She made an uneventful recovery and was discharged on POD#3.

Conclusion: Emerging technological advancements in cardiac mechanical devices is a new paradigm in the care of patients with end-stage heart failure. There is ongoing debate whether to close the diaphragmatic aperture for the inflow or outflow cannulas of LVAD device at the time of explantation. We believe closure of the diaphragmatic defect should be done, as it may prevent life threatening catastrophic complications in an immunosuppressed patient.

P042

A Case Report of TEP Procedure by 3 mm Laparoscope for Postoperative Pain Suppression and for Economical Outcome

Hideto Oishi, MD, PhD, Takayuki Iino, MD, PhD; Murayama Medical Center, National Hospital Organization

Objective: Using 3 mm laparoscopic TEP procedure, we describe an effectiveness of postoperative pain suppression. We usually performed the TEP procedure for inguinal hernia cases who had no post history of operation in preperitoneal space, and who had been able to undergo general anesthesia. In our standard TEP procedure, we performed it by 3 port (12-5-5 mm). We believe that TEP procedure is a very effective training system for beginner of laparoscopic surgery. For the purpose of diagnosis confirmation and operative method choice and repair confirmation, we usually added intraabdominal observation before and after TEP procedure. However, some cases had postoperative wound pain at their navel. We looked for causes of this pain, and guessed that it was caused by suturing of incisional wound of umbilical ring after intraabdominal observation. For postoperative pain suppression, we tried to prohibit incision of umbilical ring for intraabdominal observation before and after TEP procedure.

Materials and Methods: Without incision of umbilical ring, we performed this procedure to 3 cases by 3 mm laparoscope and 3 mm forceps in intraabdominal observation before and after TEP procedure. In this new procedure, we performed it with 3 port (5-3-3 mm) by 3 mm laparoscope and 3 mm forceps. And we used 3 mm monopolar scissors as an reusable energy device in this procedure.

Result: There were no technical difficulty and no complication in this procedure. Because patients had no complaint of wound pain after this procedure, they took only prophylactic sedative oral medicine between only 3 days after surgery.

Conclusion: Minimally invasive TEP procedure by 3 mm laparoscope and 3 mm forceps was very effective method for postoperative pain suppression and for economical outcome.

P043

P4 HB Meshes and the First 2 Years Results of a Single Center University Hospital Experience Using it for Infected, Complex and Small Hernia Repairs

Thomas S Auer, Prof, MD, James E Waha, MD, Daniela Kniepeiss, PhDMD; University Clinic of Surgery Graz

Introduction: Infected or contaminated hernia places still present very demanding and not solved surgical challenge. Biological meshes were thought to solve the problem of infected hernia situations and complex hernia in high risk patients. However, recent results were disappointing for the benefit of the use of the cost intensive material. In vitro and animal studies have demonstrated an enhanced bacterial growth and late hydrolysis, after 15 to 18 months, for P4HB meshes, and the remaining scar tissue of high strength.

Methods and Procedures: Between September 2015 and September 2017, 37 Patients were operated for complex, infected and small hernia, using the bio-absorbable P4 HB meshes. The meshes were placed mainly in onlay position, in some cases sublay or as a supplement enforcement onlay when a permanent mesh was placed sublay (sandwich). For groin hernia, TAPP procedure was used.

Results: All cases showed a primary ingrowth of the mesh, none had to be explanted. Observation period is 4–24 months (mean 12). The main complication was observed with 2 cases of seroma, one of them infected. 3 Patients were re-operated due to skin necrosis. In these cases, the meshes left in site and were seen and documented with excellent granulation activity. No hernia recurrence was observed in the first 12 months, 1 recurrence in the first 24 months.

Conclusions: The use of P4 HB meshes showed to be an excellent plan B for very complicated and infected hernia cases that need repair. Onlay position of these meshes is not an additive risk factor also in complicate skin situation. P4HB mesh can be considered as an alternative to permanent mesh or suture alone for small incisional and groin hernia.

P044

The Decision to Use Closed Suction Drains in Abdominal Wall Reconstruction by Robotic Transversus Abdominis Release (RTAR): Are they Necessary?

Zachary Sanford, MD, Adam S Weltz, Igor Belyansky, MD, FACS; Department of Surgery, Anne Arundel Medical Center

Introduction: In the field of abdominal wall reconstruction, the utility of drain placement is of debatable value. We present outcomes evaluating drain placement vs no drain placement at the time of robotic transversus abdominis release (RTAR) technique with placement of mesh in the retromuscular position, a currently understudied subject.

Methods: Retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either drain placement or no drain placement during abdominal wall reconstruction via the RTAR technique from August 2015 to June 2017 at a single high volume hernia center. Perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life (QOL) measures assessed using the Carolina Comfort Scale.

Results: Thirty-five patients were identified for this study, of which 9 had drains placed intraoperatively in the retromuscular position at the conclusion of RTAR (DRN) and 25 underwent RTAR without the placement of draining devices (ND). The DRN cohort had a mean BMI, defect area, mesh area, and operative time of 37.1, 247 cm², 940 cm² and 248 minutes, respectively, compared to 31.8, 157 cm², 822 cm², and 305 minutes in the ND group. All cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the DRN and ND subgroups. There were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections in either group. Hernia recurrence was not identified in either the DRN or ND cohorts through a mean follow up of 200 days (6.7 months). There were no statistically significant differences in postoperative QOL outcomes.

Conclusion: Our series review suggests that the use of intraoperative drains may not afford any benefits with the RTAR technique when mesh is placed in the retromuscular position. Additional postoperative management associated with drain care may be unnecessary.

P045

BMI Threshold for Complications After Open Ventral Hernia Repair

Rumbidzayi Nzara, MD, Sowmya R Rao, PhD, Luise I Pernar, MD; Boston University School of Medicine

Introduction: While it is clear that extreme obesity is associated with increased postoperative complications after open ventral hernia repair (VHR), the threshold BMI beyond which complications increase is not certain. Predominantly single institution data has been evaluated to address this question. The aim of this study was to analyze multi-institutional perioperative outcomes of patients undergoing open VHR stratified by BMI.

Methods and Procedures: Patients undergoing open VHR were identified in the 2002–2015 National Surgical Quality Improvement Program (NSQIP) data sets. Patients were divided into eight groups based on BMI in kg/m²: Group 1 (< 25); 2 (25–29.9); 3 (30–34.9); 4 (35–39.9); 5 (40–44.9); 6 (45–49.9); 7 (50–54.9); 8 ( > = 55). The primary outcome was defined as any of 18 captured postoperative complications. Multivariable, adjusted logistic regression was performed to evaluate the association between BMI categories and postoperative complications.

Results: 131,922 patients in the data set had undergone open VHR. Operative time increased with increasing BMI; Mean procedure time for normal weight individuals was 77.6 minutes while individuals with BMI over 35 kg/m² had mean times of 106.5 minutes, 113.4 minutes, 118.2 minutes, 118.5 minutes and 128 minutes for Groups 4 to 8 respectively. 7.6% of patients had at least one complication after VHR. While 6.4% of patients in Group 1 experienced a complication, 6% had a complication in Group 2, 6.9% in Group 3, 8.1% in Group 4, 10.2% in Group 5, 12.2% in Group 6, 13% in Group 7 and 17.5% in Group 8. The complication most frequently observed was a surgical site infection. Using the normal weight patients in Group 1 as a reference standard, the adjusted odds of experiencing any complication was 0.92 for patients in Group 2; 1.07 in Group 3; 1.30 in Group 4; 1.70 in Group 5; 2.11 in Group 6; 2.24 for Group 7 and 3.36 for Group 8.

Conclusions: Our results demonstrate that BMI over 35 kg/m² appears to be the threshold above which complications with open VHR begin to rise. However, the odds of complications continue to rise at the extremes of BMI. Based on these results, surgeons should consider recommending weight loss by lifestyle changes or bariatric surgery for patients with BMI over 35 kg/m² to decrease risk of complications. Delay of elective VHR until weight loss can be achieved should be strongly considered in patients with BMI above 40 kg/m².

P046

Short Learning Curve for Self-adhering Mesh in Laparoscopic Inguinal Hernia Repair

Gideon Sroka, MD, Bothaina Nakad, MD, Basel Haj, MD, Ibrahim Matter, MD; Bnai-Zion Medical Center

Introduction: One of the pitfalls in laparoscopic inguinal hernia repair is mesh fixation with tacks. Their use could cause bleeding and chronic pain. This study examines the implementation of self-adhering mesh – Lap ProGrip ™ in Trans Abdominal Pre-Peritoneal (TAPP) approach of inguinal hernia repair.

Methods: the first patients who went through the procedure in our department from May 2016 to April 2017 were included in the study. Visual Analog Scale (VAS) pain scores were recorded at the Post Anasthesia Care Unit (PACU), one day after surgery before discharge (OD), and one week post op at the clinic (OW). Data is presented as mean ± SD.

Results: 73 hernias were repaired in 50 (43M; 7F) patients. Time of the operation was 39 ± 9 min for unilateral and 51 ± 12 min for bilateral procedure. Patients were admitted for one night post op. Pain scores were 3.6 ± 1.8, 1.7 ± 0.6 and 0.8 ± 0.2 at PACU, OD and OW respectively. 43 (86%) patients used analgesics for only 2 days post op. One patient had a seroma that was treated conservatively. At follow up time of 9.3 ± 4.6 months there was no requrrence.

Conclusion: for surgeons with high volume of laparoscopic procedures there is a quick learning curve for the adoption of a TAPP use of self-adhering mesh. It seems that there is reduced pain after use of this type of mesh. Comparative studies are needed for further evaluation of this approach.

P047

Laparoscopic Inguinal Hernia Repair: TAPP Versus TEP

Girish Bakhshi, MS, Jasmine Agarwal, Ajay Bhandarwar, MS, Amol Wagh, MS, Saurabh Gandhi, MS, Gagandeep Talwar; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Objective: Inguinal hernia repair is the most frequently performed operation in general surgery. The surgical technique has evolved significantly over the past few decades. The aim of this study was to compare the results of laparoscopic inguinal hernia repair using two commonly used methods: transabdominal preperitoneal (TAPP) repair and the totally extraperitoneal repair (TEP).

Methods: This is a retrospective study comparing the laparoscopic approach for inguinal hernia repair through transabdominal preperitoneal approach versus the totally extraperitoneal technique. 237 cases were included in this study who were electively operated from May 2012 to April 2017. The outcomes compared were intraoperative and postoperative course and complications.

Laparoscopic TAPP and TEP repair was done conforming to the standard procedural guidelines using three trocars and a 14 × 10 cm polypropylene mesh, anchored at the level of Cooper’s ligament and to the anterior abdominal wall muscles using permanent tacks. The peritoneal opening in TAPP was closed using absorbable polyglactin suture.

Intra- and postoperative complications:

Duration of operation and Length of stay:

Conclusion: Laparoscopic approach for inguinal hernia repair is a safe and viable option with TEP repair having a slight edge over TAPP repair, subject to the expertise and comfort of the surgeon with the procedure. The two procedures differed only in their minor complication rates and the duration of operation. No recurrences have occurred in 165 patients in the 2-year follow-up period.

P048

Evaluation of the Operative Time for Robotic Assisted Laparoscopic Groin Hernia Repair During the Learning Curve of 125 Cases

Filip Muysoms, PhD ¹, Conrad Ballecer, MD², Archana Ramaswamy, MD, MBA^{3; 1}Maria Middelares, Ghent, Belgium, ²Center For Minimally Invasive and Robotic Surgery, Phoenix, Arizona, ³Department of Surgery, University of Minnesota, Minneapolis VA Medical Center, US

Background: Robotic assisted laparoscopic transabdominal preperitoneal inguinal hernia repair (rTAPP) is demonstrating rapid adoption in the United States. Barriers to adopting this innovative technique in Europe include: low availability of the robotic system to general surgeons, cost of robotic instruments and perception of longer operative time.

Methods: Patients undergoing rTAPP in our 12 month start-up period were entered in the prospective EuraHS database. Operations were performed with the DaVinci Xi by the same surgeon. Operative time is recorded as the time from incision to complete closure of skin, thus including docking time.

Results: Following proctoring on the use of the robotic system for this procedure in September 2016 by US surgeons, 125 rTAPP procedures have been performed up to September 2017. Of these, 76 were unilateral and 49 were bilateral repairs.

Mean operative time for unilateral hernias was 50 min (range: 27–103). For the first 25 unilateral hernias mean operative time was 57 min, compared with 50 min for the second 25 patients and 51 min for the last 26 patients. Mean operative time for bilateral hernias was 71 min (range: 38–118). For the first 25 bilateral hernias mean operative time was 80 min, compared with 62 min for the next 24 patients.

There were no conversions to conventional laparoscopy or open surgery. The operation was performed on an outpatient basis in 83 patients (66%), with overnight stay in 37 patients (30%) and extended stay in 5 patients (4%). Urinary retention requiring urinary catheterization was the main early postoperative complication noted in 6 patients (5%). At 4 weeks follow-up, 14 patients (6%) had a seroma, but no other complications were seen.

The same surgeon performed a consecutive series of 205 conventional laparoscopic TAPP operations prospectively recorded in the EuraHS database since March 2015. Mean operative times were 49 min (range: 24–104) and 65 min (range: 40–114) for 108 unilateral hernias and 97 bilateral hernias, respectively.

Conclusion: Robotic TAPP was associated with a rapid reduction in operative time during our learning curve with similar operative times compared to laparoscopic TAPP after 25 cases.

P049

Professional Fee Payments by Specialty for Open Ventral Hernia Repair: Who Gets Paid for Treating Comorbidities and Complications?

Daniel L Davenport, PHD ¹, Margaret Plymale, DNP, RN², Ray Mirembo, BA³, Travis Hughes, MD², John S Roth, MD^{2; 1}University of Kentucky, Department of Surgery, ²University of Kentucky, Division of General Surgery, ³University of Kentucky, College of Medicine

Introduction: The purpose of this study was to determine professional fee payments by specialty for the care of patients undergoing open ventral hernia repair.

Methods and Procedures: A retrospective review of patients undergoing open ventral hernia repairs (OVHR) at an academic medical center between October, 2011 and September, 2014. Perioperative data were selected from our NSQIP database. Follow up for wound occurrences, readmissions and other major morbidity was extended to 180 days via review of the clinic record and phone calls to the patient. Professional fee payments (PFPs) to all providers were obtained from our physician billing system for the OVHR hospitalization (OVHR), for 180 days prior (180 Prior), and for 180 days post-discharge (180 Post) and summed to 360 d PFPs.

Results: A total of 301 OVHRs were analyzed. Patients had mean age of 52 years; 56% were female; 18% were morbidly obese; and 60% were ASA class III or IV. Thirteen percent were emergent cases and 81% of wounds were clean. Mean 360 d PFPs were $3,320 ± SD 3,239, comprised of: 180 Prior, 15.1% ($501 ± 1,539); OVHR, 71.8% ($2,383 ± 1,865); and 180 Post, 13.1% ($436 ± 1,071). The surgical service received 62% of 360 d PFPs followed by anesthesia at 18%, medical specialties at 9%, radiology 6% and all others 5%. Patient age and creatinine levels correlated with medical specialty PFPs (rho = .30 and.15 resp., p’s < .05) but not with surgeon PFPs. None of the other demographic or clinical risk factors available in NSQIP data correlated with surgeon or any specialty’s PFPs, including ASA class, obesity, COPD, diabetes, and preoperative open wound. Operative factors such as emergent status, operative duration, and separation of components increased surgeon PFPs (all p < .05). Major 30-day complications such as sepsis and pneumonia increased medical specialty ($2,800 and $2,600 resp., p’s < .001) and radiology PFPs ($400 for sepsis, p < .01) but not surgeon PFPs. At 6 months, wound complications were associated with increased surgeon ($500, p < .05) and radiology payments ($400, p < .01).

Conclusions: Management of acute comorbid conditions and the associated higher early morbidity is unreimbursed to the surgeon, potentially pressuring busy surgeons to select against these patients. In negotiating bundled payments, surgeon groups should keep in mind that surgeon reimbursement, unlike medical and hospital reimbursement, has been bundled since the 90’s with no comorbid adjustment, and vigorously defend what is an already disproportionately reduced share of reimbursement.

P050

Clinical Comparison Between Laparoscopic Appendectomy and Open Appendectomy for Treating Complicated Appendicitis

Tomoya Takami; Departments of Surgery, Kishiwada Tokushukai Hospital

Background: Appendectomy is one of the most common operations performed during emergency surgery. Although laparoscopic appendectomy (LA) has become the treatment of choice, there is still a debate regarding the use of LA for treating complicated appendicitis. In this retrospective analysis, we aimed to clinically compare LA and open appendectomy (OA) for treating complicated appendicitis.

Methods: We retrospectively identified 339 patients who underwent an operation for complicated appendicitis at our hospital; these patients were operated on between 2011 and July 2017.[Editor1] In total, 222 patients underwent conventional appendectomy and 117 patients were laparoscopically treated. Outcomes included operation time, blood loss, length of hospital stay, and postoperative complications. Logistic regression analysis was performed to analyze the concurrent effects of various factors on the rate of postoperative complications.

Results:The mean ± standard deviation ages of the patients in the LA and OA groups were 46.98 ± 26.2 and 49.56 ± 22.4 years, respectively (P = 0.443). There were no significant differences in the operation time between the patients in the LA and OA groups (92.83 ± 39.5 vs. 90 ± 44.3[Editor2] ; P = 0.63). Length of hospital stay was shorter for the patients in the LA group than for those in the OA group (8.5 ± 4.64 vs. 12.67 ± 9.89; P = 0.0005). Return to soft diet was faster for the patients in the LA group than for those in the OA group (1.88 ± 1.59 vs. 2.48 ± 2.33; P = 0.04). Multivariable analysis found that the rate of postoperative complications was significantly reduced among the patients in the LA group than among those in the OA group (15.2% vs. 27.5%; odds ratio, 0.455; 95% confidence interval, 0.2–0.996; P = 0.048).

Conclusions: Our results demonstrated that LA is a safe and effective procedure with clinically beneficial advantages. Appendectomy for treating complicated appendicitis should be attempted first laparoscopically.

P051

A Study of Laparoscopic Repair of Small Bowel Perforation

Ajay Bhandarwar, MS, Amol Wagh, MS, Saurabh Gandhi, MS, Shubham Gupta, MS, Eham Arora, MS, Gagandeep Talwar; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Objective: Small bowel perforation has conventionally been dealt with open exploration, which frequently leads to many wound-related complications. Wound infection is the major reason for increasing morbidity in these patients and delay recovery. Laparoscopic surgery has various benefits over open surgery like, smaller wound, lesser pain and faster recovery. The aim of this study was to relay the advantages of minimally invasive surgery (MIS) to patients with small bowel perforation to decrease postoperative wound complications and duration of hospital stay.

Methods: It is a retrospective study, including 136 patients with small bowel perforation from 2013 to 2016. Of these 136, 43 had traumatic etiology, 28 had typhoid-related perforation and the remaining 65 had a duodenal perforation. 84 of them were male, and the average age was 30.4 years. Only patients who presented within 96 hours of perforation were included in the study.

Laparoscopic exploration was done on introducing camera from 10-mm infraumbilical port after intraperitoneal carbon dioxide insufflation. The remaining two 5-mm working ports were then introduced depending on the site of perforation once identified. The perforations were then repaired using intracorporeal single-layer suturing using Polydioxanone 3– 0 suture. The peritoneal cavity was given thorough lavage and abdominal drain placed in the pouch of Douglas.

Results:

Fecal contamination was found in all the patients. A total of 6 patients underwent conversion to open surgery due to inability to find the site of perforation laparoscopically. Of the 136 operated patients, 7 patients developed port-site infection, and there were no major postoperative complications in the 4-week follow up period.

Conclusion: We conclude from our study that laparoscopic intervention in early small bowel perforation is a safe approach with favorable outcomes, especially with regards to wound complications, that are a major factor in increasing the morbidity in such patients postoperatively. Laparoscopic approach leads to early discharge and recovery postoperatively. With the emerging era of laparoscopic surgery, leading to its easy accessibility, more patients can advantage from this technique when they arrive in emergency with intestinal perforation.

P052

Intestinal Obstruction Secondary to Torsion/Diverticular Inflammation of a Meckel’s Diverticulum in an Adult

Ryan Robalino, DO, Vadim Meytes, DO, Robert L Davis, MD; NYU Langone Hospital - Brooklyn

Background: Acute abdominal pain caused by small bowel obstruction is amongst the most common entities facing acute care surgeons. The vast majority to these obstructions (> 90%) are secondary to adhesions, hernias, and malignancy. Miscellaneous causes, such as Meckel’s diverticulum (MD), make up a small (2–3%) but important sub-group of this disease process. The presence of a MD predisposes to obstruction in a number of ways. The diverticulum can serve as a lead point for intussusception, it could twist around it’s associated fibrous cords (volvulus), it can undergo torsion, or it could become acutely inflamed and narrow the diameter of surrounding bowel. In younger, previously healthy patients with no surgical history or hernias on physical exam it is important to keep in mind the other rarer causes of small bowel obstruction as they are rarely diagnosed pre-operatively.

Case Presentation: The patient is a 46-year-old Caucasian male with no significant past medical history presenting with chief complaint of excruciating abdominal pain associated with nausea and vomiting. Patient was diaphoretic with low grade tachycardia. Physical exam showed distention, diffuse tenderness, and voluntary guarding. A CT was obtained and notable for a large (> 15 cm) inflamed tubular, fluid and air containing structure ending blindly in the right upper quadrant. Suspicion was raised for acute infection/inflammation of this tubular structure vs. ischemia. He was taken to the operating room for a diagnostic laparoscopy which an additional bowel segment running in parallel with normal jejunum. Procedure was converted to open exploratory laparotomy with segmental small bowel resection of the blind-ended bowel with primary anastomosis. Surgical pathology later revealed a Meckel’s Diverticulum (with ectopic tissue) and necrosis/ulceration consistent with torsion/obstruction.

Discussion: MD is the most common congenital anomaly of the gastrointestinal tract (prevalence 1.2%). It results from incomplete obliteration of the omphalomesenteric duct during week 5–6 of gestation. It is a true diverticulum off the antimesenteric boarder of normal small bowel often containing metabolically active tissue. In adults, the most common presentation tends to be that of intestinal obstruction/inflammation (vs. GI bleed in children). The mechanism of obstruction includes intussusception, volvulus, torsion, incorporation into a hernia, or diverticular inflammation. The pathogenesis of MD is similar to that of appendicitis. Diverticular obstruction leads to bacterial overgrowth, venous congestion, and ischemia. The associated inflammation leads to decreased luminal diameter of adjacent small bowel which can cause obstructive pathology.

P053

Surgical Techniques and Clinical Outcomes of Laparoscopic Management for Strangulated Small Bowel Obstruction

Kenichi Mizunuma, MD ¹, Yusuke Watanabe, MD¹, Fumitaka Nakamura, MD¹, Nobuichi Kashimura, MD¹, Satoshi Hirano, MD^{2; 1}Department of General Surgery, Teine Keijinkai Hospital, ²Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine

Back ground: While laparoscopic management have been increasingly used for small bowel obstruction (SBO), the clinical outcomes and benefits of applying laparoscopic surgery to strangulated SBO are limited. With growing experience of laparoscopy for SBO, the laparoscopic treatment for strangulated SBO has been introduced gradually into our institute. The objective of this study was to report our experience with laparoscopic management of strangulated SBO and describe our techniques.

Methods: Electronic medical records of patients with strangulated SBO undergoing initial laparoscopic treatment between January 2010 and March 2016 were reviewed. Medical records were reviewed to obtain data on demographics, intraoperative findings, 30-day morbidity and mortality, postoperative length of stay, and readmission. With growing experience, the definitive indication for laparoscopy was all suspected strangulated SBO regardless of the type of previous laparotomy, case difficulty, or predicted working space. The cases requiring a small incision (< 5 cm) for a segmental bowel resection were considered laparoscopic treatment and not counted as a conversion. Data are expressed as n (%) and median [interquartile range]

Results: Of 199 consecutive patients with SBO who required emergency surgery at our institute, 92 patients with strangulated SBO were included for this study (46% male, median age 74[55; 94]). Of 38 patients that underwent initial laparoscopic management (34% male, median age 73 [54; 91]), the pneumoperitoneum was successfully created in all patients. The obstructions were relieved using various laparoscopic techniques without bowel resections in 31 (82%) patients, and 7 (19%) patients required a segmental bowel resection through a small incision after laparoscopic reliefs. The conversion rate to open was 19% (9 patients). The reasons for conversion were the lack of working space [4 (9%)], intraoperative bowel perforation [3 (6%)], unknown origin [1 (2%)] and dense bowel necrosis [1 (2%)]. One or more complications occurred in 9 patients (17%), including surgical site infection [1 (2%)], paralytic ileus [5 (10%)] and aspiration pneumonia [3 (6%)]. The mortality was 4% following the death of 2 very elderly patients (> 85 years old): presented a severe aspiration pneumonia. The postoperative length of stay was 7[4; 11] days and there were no readmissions.

Conclusions: Initial laparoscopic management seems to be a feasible approach to patients with strangulated SBO in most cases. This approach could target the location of incision when requiring a bowel resection and may result in lower morbidity rate and a shorter hospitalization.

P054

Penetrating Precordial Trauma in a Stable Patient, is Minimally Invasive Management Possible? Our Series of Cases

Mauricio Zuluaga, MD, FACS, General and MIS Surgeon ¹, Ivo Siljic, MD, FACS, General and MIS Surgeon¹, Juan Carlos Valencia, General and MIS surgeon², Uriel Cardona, General and MIS surgeon^{2; 1}IJP Colombia, Hospitla Universitario Del Valle, Universidad Del Valle, ²IJP Colombia, Clinicafarallones, Clinica Desa, Cali Colombia

Introduction: The use of minimally invasive surgery in trauma, has more and more field in this specialty. Precordial trauma with stable patient can be approached to make the diagnosis and define the definitive route of management according to the findings.

Material and Method: report of 10 cases of penetrating precordial trauma, hemodynamically stable, resolved by minimally invasive surgery between July 2014 and December 2016, a pericardial window was made thoracoscopically, intervention was performed 2–5 days after admission, 7 2 with pericardial effusion, 5 without echocardiogram due to lack of resources, cardiorraphy was performed in 2 patients, 6 pericardial wound that did not require management and 2 patients with non-bleeding myocardial wound in biological sealant management. The operative time was 30 100 minutes, the associated chest pathology was performed in the 10 patients, the hemothorax drainage was performed. Patients were discharged between 3–10 postoperative day, all of them had a post-operative transthoracic echocardiogram without findings.

Results: precordial trauma can be fully managed by minimally invasive surgery, the primary requirement is adequate patient selection, hemodynamic stability, video-assisted thoracoscopy and teamwork. the patients treated were solved by this route, without complications. Follow-up at 12 months without alterations.

Conclusion: Minimally invasive surgery gains space in handling stable patient trauma, depends on the surgeon’s skills and teamwork. It is a novel subject that does not have many reports in the medical literature.

P055

Small Bowel Obstruction Presenting with Pneumatosis Intestinalis and Portal Venous Gas

Holly Foote, DO ¹, Amanda Chiu², Itnia Pramanik, MBBS¹, William Buniak², Sharique Nazir, MDFACSFICS^{1; 1}St Barnabas Hospital, Bronx, New York, ²New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY

Introduction: Pneumatosis intestinalis (PI), or gas in the bowel wall, can be seen on various imaging modalities. The pathophysiology behind PI is unclear. One theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology. Management of PI in adults is difficult as often there is a benign clinical course. However, when paired with specific clinical features such as hepatic portal venous gas (HPVG) on imaging, the course of management changes as the suspicion of bowel ischemia increases. HPVG alone has been associated with a high mortality rate and a poor prognosis. Management in this case becomes surgical.

Case Presentation: We present a case of 59-year-old Latino male who presented to the emergency room with abdominal pain and altered mental status. Focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. CT scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. Laboratory studies revealed metabolic acidosis and a lactic acid level of 2.9 mmol/L. Due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. The laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. Intraoperatively, there was no small bowel compromise and no identifiable transition point. Extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. Patient tolerated the procedure well, clinically improved, and was discharged from the hospital.

Discussion: This case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on CT imaging. HPVG has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion.

P056

Paraduodenal Hernia – An Unexpected Cause for Peritonitis in the ICU

Mary E Huerter, MD, MA, Caroline Hudson, BS, Eduardo Smith-Singares, MD, FACS; University of Illinois at Chicago

Purpose: Paraduodenal hernias are a type of uncommon cogenital internal hernia. Their clinical presentation is typically nonspecific. Acurate diagnosis is critical as the risk of strangulation can be as high as 50% with an exceedingly high mortality of up to 50%.

Methods: We present a case of a 77 year-old woman with a history of congestive heart failure, atrial fibrillation, pulmonary fibrosis, AICD placement, hysterectomy and cholecystectomy, who was transferred from an outside hospitalwhere she was admitted for a congestive heart failure exacerbation and sustained a traumatic femoral arterial line placement.

She became peritonitic during her hospitalization and was taken emergently to the operating room. The small bowel was found to be herniated under the inferior mesenteric vessels. She had dense adhesions extending into the pelvis. A hernia sac was identified near the fourth portion of the duodenum, consistent with a paraduodenal hernia. The hernia was reduced and the hernia space (Landzert’s fossa) was closed with interrupted silk suture. There were some necrotic portions of sigmoid colon that were resected. The patient was left in disconinuity due to her critical status. The patient subsequently returned to the operating room for further resection and creation of an end ileostomy. She was ultimately closed at her fourth operation. The patient had an extended intensive care course, but showed no further signs of obstruction for the remainder of her hosptialization.

Conclusion: Paraduodenal hernias are a relatively uncommon cause of an acute surgical abdomen. Diagnosis is often challenging due to its vague clinical presentation and variable radiologic manifestation. Prompt surgical intervention has the potential to minimize the significant morbidity and mortality associated with a missed or delayed diagnosis.

P057

A Comparison of Short-Term Outcomes Between Laparoscopic and Open Emergent Repair of Perforated Gastric Ulcers

Daniel L Davenport, PhD¹, Walker R Ueland, BSc², Margaret Plymale, DNP³, Andrew C Bernard, MD³, John S Roth, MD ^{3; 1}University of Kentucky, Department of Surgery, ²University of Kentucky, College of Medicine, ³University of Kentucky, Division of General Surgery

Introduction: We sought to compare 30-day outcomes in patients undergoing emergent open and laparoscopic repair of perforated gastric ulcers in a recent, large, multicenter cohort.

Methods and Procedures: A retrospective review of the prospectively obtained data in the American College of Surgeons National Surgical Quality Improvement Program public use files from 2010 through 2015. Cases were selected using ICD-9/10™ and CPT™ codes. Perioperative risks and 30-day outcomes were compared in unmatched and propensity matched groups using parametric or non-parametric statistical tests as appropriate. Significance was set at p < .05.

Results: A total of 3,486 procedures were identified, 265 (7.6%) laparoscopic, and 3221 (92.4%) open. Laparoscopic repairs increased from 4.2% of 2010 cases to 10.3% of 2015 cases (Figure, p < .001). Open repair patients had higher rates of numerous clinical factors indicating more acute presentation including ASA class, hypoalbuminemia, preoperative septic shock, renal failure and mechanical ventilation (all p < .01). The average duration of the operation was 19 minutes higher (p < .001) in the laparoscopic group. Mortality (8.9% vs. 4.2%), median length of stay (7 vs. 5), transfusion rates, renal failure and respiratory outcomes were all worse in the unmatched open group (all p < .01).

The propensity matching resulted in 235 laparoscopic and 437 open cases of similar age, ASA class, preoperative SIRS/sepsis, hypoalbuminemia, and wound class. The matched groups had few patients with preoperative septic shock given it was rare in the laparoscopic group. Mortality did not differ between the matched groups (4.7% Lap. vs. 5.7% Open, p = .720), nor did most complication rates. Operative duration was 20 minutes longer in the laparoscopic group (p < .001). Median length of stay was 1 day longer in the open group (6 [5–9] vs. 5 [4–7], p < .001) which also had higher rates of prolonged ventilation (7.8% vs. 3.4%, p = .029). Return to the operating room and readmission within 30 days did not differ between the two matched groups.

Conclusions: We have shown in a contemporary, large multicenter cohort of patients that emergent laparoscopic repair of perforated gastric ulcer is increasingly being performed, is safe relative to open repair (in patients without preoperative septic shock), and confers a modest benefit in terms of length of stay and respiratory complications.

P058

Transversus Abdominis Muscle Release for Loss of Domain and Radiation Damaged to the Lower Anterior Abdominal Wall

Gabriel Arevalo, MD¹, Jessica Belchos, MD ², Douglas Kaderabek, MD², Jordan Wilkerson, MD^{2; 1}Case Western Reserve University, ²St Vincent Hospital Indianapolis

Background: Ventral Hernia repair is one of the most common surgical procedures facing the general surgeon. There is little consensus as to the best surgical technique for complex scenarios. Often these patients have complicating co-morbid conditions such as radiation therapy, that has an inevitable effect in the abdominal wall structures, which can lead to non-traditional repairs.

Case Report: We present a case of a 62 year-old female who underwent a TAH/BSO and right hemicolectomy which was complicated by wound dehiscence. She underwent primary repair and adjuvant whole pelvis radiation for her squamous cell carcinoma. Subsequently, the patient developed acute obstructive symptoms do to a stricture within her small bowel and a large ventral hernia measuring 14 × 13 cm with non-reducible abdominal contents below the level of the fascia more prominent in the suprapubic area. The patient’s BMI was 15.3.

Various considerations are important in planning a surgical repair in a previously irradiated field with loss of domain which include, minimal dissection, and the use of an atraumatic surgical techniqueque with either external oblique release or transversus abdominis muscle release (TAR). We chose a A TAR, as it provides wider myofascial release and dissection below the arcuate line towards the space of Retzius and Bogros allowing for a larger sublay mesh placement. Also it avoids the need of skin flaps reducing the risk for wound complications in under-perfused tissue.

The TAR was performed successfully and there were no intraoperative and postoperative complications. Her follow-up at 6 months revealed no wound complications or hernia recurrence.

Conclusion: For patients with compromised tissue and loss of domain a TAR technique may be useful when reconstructing complex abdominal wall hernias. It provides the core principals of hernia repair such as primary fascial closure, wide mesh overlap, and finally it provides a reliable approach for the under-perfused tissue without need of skin and soft tissue flap creation.

P059

Outcomes in the Management of Cholecystectomy Patients in the Setting of a New Acute Care Surgery Service Model: Impact on Hospital Course

Larsa Al-Omaishi, BS, William S Richardson, MD; Ochsner Medical Clinic Foundation

Introduction: The acute care surgery (ACS) model, defined as a dedicated team of surgeons to address all emergency department, inpatient, and transfer consultations, is quickly evolving within hospitals across the United States due to demonstrated improved patient outcomes in the non-trauma setting. The traditional model of call scheduling consisted of one senior attending and one senior resident on call per 24-hour shift. Attendings were responsible for consults, previously scheduled operations, as well as clinic time. Multiple recent studies have shown statistically significant improvements in several parameters of patient care by using ACS including but not limited to 1. Time from emergency department to surgical evaluation 2. Time from surgical evaluation to operating room 3. Operative time 4. Percent laparoscopic 5. Length of hospital stay 6. Intra-operative complications (blood loss, perforation rates) 7. Post-operative complications (fever, infection, redo) 8. Cost. One study demonstrated a statistically significant cost savings for the Acute Care Surgery model with respect to appendectomies, but not cholecystectomies.

Study Design: A retrospective analysis of patients who underwent cholecystectomy in the setting of non-traumatic emergent cholecystitis was performed to compare data from two cohorts: the traditional model and the ACS between January 1, 2013 and Dec 1, 2016 at Ochsner Medical Center, a 600-bed acute care center in New Orleans. Parameters gathered included 1. Time from emergency department to surgical evaluation 2. Time from surgical evaluation to operating room 3. Operative time 4. Percent laparoscopic 5. Length of hospital stay 6. Intra-operative complications (blood loss, perforation rates, conversion to open) 7. Post-operative complications (fever, infection, redo). Demographics were also collected including age, weight, height, ethnicity, ASA, etc. Inclusion criteria included: Age > 18 and having undergone cholecystectomy between Jan 1, 2013 and December 1, 2016. Exclusion criteria included choledocholithiasis, gallstone pancreatitis, ascending cholangitis, gangrenous cholecystitis, septic complications precipitating further procedures and delays, or researcher discretion.

Results: 699 patients were initially identified as having undergone cholecystectomy within the allotted time period [2013 – 178, 2014 – 166, 2015 – 157, 2016 – 198]. 470 were excluded due to one of the reasons above. Median patient age was 53 years old and the average patient encounter was 3.9 days.

Conclusion: The ACS model is better suited to manage emergent non-traumatic cholecystectomies than the traditional call service at our institution, as evidenced by several parameters.

P060

Single Incision Laparoscopic Surgery (SILS) for Emergencies

Fernando Arias, MD, FACS ¹, Sergio Augusto Cáceres-Maldonado², Alexandra Bastidas, MD², Daniel Guerra^{2; 1}University Hospital Fundación Santafé de Bogotá Bogotá, Colombia, ²Faculty of Medicine University of the Andes Bogotá, Colombia

Introduction: The aim of this study is to evaluate early outcomes when performing SILS for emergency abdominal surgical conditions in our hospital.

Methods and Procedures: Patients who visited the emergency department and underwent a surgical abdominal emergency procedure at the University Hospital Fundación Santafé de Bogotá (Bogotá DC, Colombia) by our group using a SILS technique were included for analysis. Data was collected from July 2008 through July 2017. Outcomes regarding length of surgery, hospital stay, operative complications (classified following the Accordion Severity Grading System parameters), conversion rates and reintervention were analyzed descriptively.

Results: A total of 593 patients and 644 procedures from the registry met our inclusion criteria. Female patients accounted for 55.8% (331) of the sample. The most common procedures performed were appendectomies (405; 62.9%), followed by cholecystectomies (134; 20.8%), and adhesiolysis for bowel obstruction (37; 5.7%). Other procedures included emergency hernia repairs (16; 2.5%), bowel resections (15; 2.3%), and perforated ulcer repairs (3; 0.5%) amongst others. Total surgical time was under 2 hours on 90% of procedures, and 75% of procedures were discharged home on the first 24 hours. A total of 34 (5.1% of procedures) postoperative complications were reported classified as follows: 16 mild, 11 moderate, and 7 severe, 6 of which underwent surgery. Finally, we report a total of 9 (1.5%) readmissions and 6 (1%) reinterventions all within the first 30 days after surgery. Reinterventions were performed for drainage of surgical infections on 2 cases (abdominal collections), bowel obstruction on 2 cases and 2 cases of wound dehiscence. One procedure was converted to multi-port and none to open surgery. No cases of 30-day-mortality were identified on the registry.

Conclusions: SILS is an alternative to multiport laparoscopic surgery, but most institutions nowadays perform the SILS approach only in selected elective procedures. We analyzed the outcomes of SILS in an acute care setting showing complication rates comparable to those in standard multiport laparoscopy. It is important to emphasize how the expertise of the surgeon is critical towards obtaining appropriate results with SILS.

P061

The Use of Laparoscopy in the Surgical Management of Small Bowel Obstruction

Catherine Denkler, MD, Erica Emery, MS, Devon Collins, MPH, Chang Liu, Tracy Fennessy, MD, Ashley Rodgers, Jonathan Dort, MD, FACS; Inova Fairfax Medical Campus

Introduction: The objective of our study was to determine clinical factors associated with success of laparoscopy in managing small bowel obstruction (SBO). The use of laparoscopy in the management of SBO has been shown to be a safe alternative to laparotomy with studies demonstrating reduced morbidity, mortality, postoperative length of stay, and overall decreased complications with laparoscopy. Nationally the use of laparoscopy in the management of SBO has not been fully adapted into general practice. Many studies look at laparoscopy only in the setting of SBO secondary to adhesions.

Methods and Procedures: A retrospective study was conducted identifying all patients who were admitted to a large tertiary academic center with a diagnosis of SBO from 2014 to 2016. The operative cases were grouped by method of surgical intervention: laparoscopy, laparoscopy converted to open, or laparotomy. Clinical data included: gender, age, body mass index (BMI), presence of medical co-morbidities, smoking history, duration of obstruction prior to surgical intervention, presence of transition point on imaging, total number of prior abdominal surgeries (laparoscopic and open), etiology of SBO, number of adhesive bands (single versus multiple), return of bowel function prior to discharge, and need for additional procedures related to SBO during the same admission. The primary outcome was successful laparoscopic procedure in the management of SBO, defined as resolution of SBO and no conversion from laparoscopic to open procedures. Student’s t-test and Pearson’s x2 test were used to assess the association between each factor and the primary outcome.

Results: A total of 227 adult patients admitted with a diagnosis of SBO received operative intervention. There were 40 successful laparoscopic cases, 36 failed laparoscopic cases (laparoscopic converted to open or no resolution of SBO), and 151 open cases. With the exception of an association between success and BMI, our results demonstrated no other clinical or demographic differences among the successful laparoscopic group and the failed laparoscopic group.

Conclusions: Laparoscopy is effective in treating SBO due to various etiologies including single band adhesions, multiple adhesions, hernias, and masses. Other than BMI, there was no single predictor of success or failure with laparoscopy. Therefore, we conclude, that perhaps all patients requiring operative treatment for SBO deserve consideration for a diagnostic laparoscopy.

P063

Laparoscopic Interval Appendectomy as Standard of Care

Hirotaka Sasada, PhD, Shuto Watanabe, Takemichi Suto, PhD, MD, Fuminori Wakayama, MD, Kohji Nagao, Tadashi Iwabuchi, MD, Nobuo Yagihashi, PhD, MD, Shunnichi Takaya, PhD, MD; Tsugaru General Hospital

Introduction: Conservative therapy is the first choice for acute appendicitis at our department, and after several months we perform laparoscopic appendectomy. We report laparoscopic interval appendectomy.

Subjects: The subjects comprised 81 patients who were performed laparoscopic appendectomy at our department between October 2012 and Jun 2017.

Results: There were 21 cases performed interval appendectomy, and 4 of 21 patients have abdominal abscess. There were 58 patients who performed early appendectomy after hospitalization. The patients who performed early appendectomy after failure of conservative therapy is 25 of 58 patients. There were no significant differences in the mean duration of operative time between interval appendectomy and early appendectomy (71.0 vs. 71.6 min). There were no significant differences in the mean volume of blood loss between interval appendectomy and early appendectomy (3.9 vs. 6.8 mL). The mean length of postoperative hospital stay for interval appendectomy was significantly shorter than that for early appendectomy (2.6 vs. 8.1 days). Surgical site infection occurred in one patient after interval appendectomy. Other 6 postoperative complications developed after early appendectomy.

Conclusion: Laparoscopic interval appendectomy represents an effective surgical procedure. The duration of hospital stay was shortest in the interval appendectomy treated cases. Laparoscopic interval appendectomy decrease complications. Therefore, our departmental treatment strategy is to conservatively treat patients whenever possible and follow the laparoscopic procedure when surgery is indicated.

P064

Mortality Predictors in Elderly Patients with Perforated Peptic Ulcer

Jun Su, Dr¹, Yiong Hauk Chan, Dr², Vishalkumar G Shelat, Asst Professor ^{1; 1}Tan Tock Seng Hospital, ²National University of Singapore

Introduction: Surgery for perforated peptic ulcer (PPU) is associated with high mortality in elderly patients. Existing PPU mortality risk prediction models (MRPM) lack simplicity and objectivity. We validate two widely used MRPMs. We hypothesize that more accurate mortality can be predicted in elderly PPU patients by simple preoperative variables.

Methods: Patients with age > 70 years and operated for PPU from January 2004 to December 2012 were recruited. Preoperative, operative and postoperative data were collected. Boey’s score and Mannheim peritonitis index (MPI) are commonly used and validated. Mortality predictors were obtained using odds ratios of the significant multivariate variables on mortality as weightage.

Results: 170 patients were eligible. 95 (55.9%) patients were male and 111 patients (65.3%) presented > 24 hours after abdominal pain onset. 68 (40%) patients had co-morbidities and 95 (55.9%) showed free air on erect chest X-ray. Median length of stay was 12 days (1–128). Intra-abdominal collection, leakage, reoperation and mortality were 15.9%, 5.3%, 1.8% and 19.4% respectively. Boey’s score and MPI had areas under curve (AUC) of 64.4% and 63.0% respectively for mortality prediction. On univariate analysis, preoperative shock, cardiac failure, chronic renal failure, American society of Anesthesiology (ASA) score, urea and serum createnine were predictive of mortality. Urea > 15 mg/dL (p = 0.015, OR- 4.73 (95% CI 1.35–16.58)) and ASA score > 2 (p = 0.03, OR − 10.6 (95% CI 1.3–88.4)) were identified as mortality predictors in the elderly PPU population.

Conclusion: Boey’s score and MPI lack accuracy to predict mortality in elderly PPU patients. ASA status and elevated urea predict mortality. It remains to be explored if adding urea and ASA status enhances existing MRPMs.

P065

He Nailed It

Hugo Bonatti; University of Maryland Community Medical Group

Background: Nail guns are powerful tools and are widely used. Injuries with these devices may be devastating due to the significant force they can deploy.

Patients and Methods: We herein report a first case of a self inflicted abdominal injury with a nail gun.

Results: A 55 year old male with history of coronary artery disease, type 2 DM and early signs of dementia attempted to refill a nail gun. He lodged the device against his right abdomen while the air hose was still attached and then accidently fired 2 nails into his abdomen. After he unsuccessfully tried to pull the nails out he drove himself 25 minutes to our emergency room. He was hemodynamically stable on arrival; pain control was achieved, antibiotics were given and he received tetanus immunization. CT-scan showed the two foreign bodies penetrating from the RUQ with one reaching the transverse colon. On emergency laparoscopy, the nails were found to have penetrated the thick omentum and the puncture site of one nail into the colon was identified. The omentum was resected off the colon and the right colon was completely mobilized. No additional injuries were found. The entrance area of the nails was then used to create a loop colostomy. The postoperative course was initially uneventful but the patient developed a severe posttraumatic inflammatory reaction of the fat tissue in the right upper quadrant and had to be readmitted for pain control and antibiotics were again administered. He recovered and was discharged with a plan for laparoscopically assisted colostomy closure after 6 weeks.

Discussion: To the best of our knowledge this is the first reported isolated colonic injury by a nail gun. Given the tremendous force of the device with unknown collateral damage to the surrounding tissue it was decided to manage the accident with a laparoscopic assisted colostomy using the entrance point of the nails for fecal diversion.

P066

Risk Factors for Postoperative Intra-abdominal Abscess After Laparoscopic Appendectomy in Gangrenous Appendicitis

Naoki Akishige, MD ¹, Koetsu Inoue¹, Kentaro Shima¹, Tatsuya Ueno¹, Shinji Goto¹, Michinaga Takahashi¹, Takanori Morikawa², Takeshi Naitoh², Hiroo Naito^{1; 1}Department of Surgery, South Miyagi Medical Center, ²Department of Surgery, Tohoku University Graduate School of Medicine

Background: Laparoscopic appendectomy (LA) has been widely performed as standard treatment of acute appendicitis (AA). Intra-abdominal abscess (IAA) is one of the refractory postoperative complications requiring antibiotics and/or drainage, resulting in prolonged hospital stay. It is generally recognized that IAA develops following appendectomy in gangrenous appendicitis rather than other type of appendicitis. However, risk factors for IAA after LA in gangrenous appendicitis still remain unclear. The aim of this study is to assess risk factors for IAA after LA.

Methods: 386 patients who underwent LA for AA from April 2008 to August 2017 were retrospectively reviewed. 132 patients who were diagnosed as gangrenous appendicitis by operative findings and/or pathological findings were enrolled in this study. We defined IAA as a patient who had purulent discharge from drains and/or intra-abdominal abscess detected by postoperative CT scan. Patients were divided into two groups according to presence of IAA (Group A: Postoperative intra-abdominal abscess, Group B: Without postoperative intra-abdominal abscess). Perioperative characteristics, intraoperative findings and laboratorial data were analyzed.

Results: Twenty patients (15.1%) were considered to suffer postoperative IAA. In univariate analysis, there was no significant difference between two groups regarding age, sex, BMI, intraoperative findings such as diameter of the appendix and presence of fecal stone. Preoperative white blood cells (16.4 ± 0.98 vs. 13.8 ± 0.41 (x103/µL), p = 0.016), preoperative value of serum C-reactive protein (11.5 ± 1.7 vs. 6.2 ± 4.8 (mg/dL), p = 0.006), and value of serum C-reactive protein on first postoperative day (19.8 ± 1.5 vs. 13.8 ± 0.65 (mg/dL), p = 0.0004) were significantly high in Group A. Multivariate logistic regression analysis showed that value of serum C-reactive protein on first postoperative day higher than 15.48 (OR 14, 95%CI 2.94–66.1, p = 0.0009) was an independent risk factor for postoperative IAA in gangrenous appendicitis.

Conclusion: Patients with value of serum C-reactive protein on first postoperative day higher than 15.5 is a likely risk for IAA after LA. Therefore, we should offer careful postoperative management to these patients.

P067

Total Repair of Obturator Hernia with a Custom-Made Mesh

Koichi Takiguchi, Shunji Kinuta, Kazuma Sato, Naoyuki Hanari, Naoki Koshiishi; Takeda General Hospital

Introduction: It is difficult to diagnose obturator hernias by routine physical examination. Obturator hernias are frequently complicated by ileus and the diagnosis is often first made from abdominal CT. Obturator hernias are difficult to reduce, and often necessitate emergency surgery. They are common in elderly people, and they often had bad general condition. So it was high in the death rate. At our hospital, we first attempt to reduce the hernia from the body surface under ultrasonographic guidance. After relieving the strangulation, we perform radical operation electively in patients who are for possible for surgery under the general anesthesia. We perform laparoscopic repair for obturator hernias. Obturator hernias are often complicated by other types of hernia. In these cases, we perform total repair. Herein, we present a review of the patients who underwent surgery for obturator hernia at our hospital.

Methods: We review the data of 9 cases of obturator hernia encountered by us from February 2012 to December 2014. We performed total repair in three of the cases. However, it is difficult to procure a mesh that would be adequate for all the defects (inner inguinal ring, femoral ring, obturator). No single mesh can fit, because the inguinal and pelvic curves present opposing curves near the obturator. Therefore, we placed two pieces of mesh available at our hospital (3D max [Bard] and onlay sheet of Kugel patch[Bard]) together in the patientsWe could successfully cover all the defects using these two pieces of mesh and could fit the mesh to the pelvic shape by devising an appropriate connection between the meshes.

Results: We reviewed a total of 9 operated cases for obturator hernia. The hernia was bilateral in 7 cases, and complicated by other hernias in 6 cases. We first determined the appropriate approach for the repair. We performed total repair in 3 cases. They were no complications and no cases of recurrence.

Conclusion: Our approach to the repair of obturator hernias was very useful. We can use the exact area and shape of the mesh needed in individual patients by this method. We show the method of shaping the mesh to fit the pelvic form.

P068

Castleman’s Disease: An Acute Care Surgeon’s Perspective

Najiha Farooqi, MD ¹, Daoning Liu, MD², Greta Berger¹, Muhammad Maaz, MD¹, Chunyi Hao, MD², James V Harmon, MD, PhD, FACS^{1; 1}University of Minnesota, ²Peking University Cancer Hospital and Institute

Introduction: Castleman’s disease (CD) is a very rare, lymphoproliferative disorder associated with a Rhadinoviral infection of B lymphocytes and can be either unicentric or multicentric in distribution. There an important role for a surgeon in both unicentric and multicentric types. Approximately 1000 cases have been reported to date, we present 28 unpublished cases.

Methods: A retrospective review of cases from two large teaching hospitals was reviewed. Baseline demographics including age, race, gender, clinical variables such as anatomical site and foci of disease, histopathological type, nature of the surgical approach (resective vs diagnostic), and outcome (disease-free survival vs death due to disease) was collected and analyzed.

Results: A total of 28 patient were reviewed for this study. Mean age at the time of presentation was 45.9 yrs. 64.3% of patients were female. 89.3% of the cases were unicentric and 10.7% were multicentric. 57.1% of the patients presented with an asymptomatic mass; 39.3% had local symptoms and 3.5% patients had systemic symptoms. Anatomical distribution of disease was: 42.9% intrabdominal, 32.1% retroperitoneal, 10.7% neck, 7.14% pelvis and 3.57% axilla and 3.57% in the epitrochlear region. In terms of histopathological type, hyaline vascular accounted for 57.1% of all cases, 17.9% of cases were of the plasma cell type. Complete surgical resection was performed 96% of patients with unicentric disease. Diagnostic biopsy and medical therapy were provided to all patients with multicentric disease. Overall survival rate was 92.6%.

Conclusion: Castleman’s disease is a very rare tumor; acute care surgeons are likely to have little experience when encountering this tumor. Significant differences exist in the clinical presentation, surgical approach, and patient outcomes between unicentric and multicentric Castleman’s Disease. The anatomic distribution of cases in this series emphasizes its importance to an acute care surgeon. Complete surgical resection for unicentric disease is likely to be curative. In multicentric disease, lymph node biopsy should be performed without complications, so as to avoid delay in initiating medical therapy.

P069

Cecal Volvulus and Internal Hernia, a Rare Case Presentation in a Bariatric Patient

Demin Aleksandr, DO, Ajit Singh, DO, Noman Khan, DO; Flushing Hospital

Introduction: Internal hernias are known complications that are well documented to involve Peterson’s defect. In bariatric patient’s post gastric bypass there is a high index of suspicion for internal hernias as well as a low threshold to operate. There have been some debates around the closure of the potential Peterson’s space with several studies advocating closure versus some which show that there is no difference in the rate of symptomatic internal hernias. We present a case of an unusual cause of small bowel obstruction due to internal hernia caused by a cecal volvulus. It is an atypical presentation however the patient was triaged and brought to the OR within 5 hours of admission. Although it is rare there have been reports of internal hernias caused by other structures like congenital bands or natural potential spaces. There have been reports of unusual presentations of the cecum herniating through the foramen of Winslow. The anatomical rearrangements after bypass create potential areas where an internal hernia can occur. In this case a bowel resection was undertaken due to the anatomical variation of the cecal bascule and cecal volvulus due to high rate of recurrence of this cecal pathology. Majority of internal hernias do not require bowel resection especially when detected earlier and prompt surgical exploration is undertaken. Mortality as direct consequence internal hernia is extremely rare. However late diagnosis of internal hernias can lead to catastrophic gut loss and may require lifelong TPN and/or visceral transplantation or autologous reconstruction.

Conclusion: Careful history and physical of our bariatric patient can elicit the signs and symptoms of internal hernias and prevent the morbidity and mortality that can come with the complications of this condition. Unusual presentations and causes are reason for prompt diagnosis and complete exploration.

P070

Laparoscopic Cholecystectomy in the Third Trimester of Pregnancy: A Case Report

Shingo Ishida ¹, Naotsugu Yamashiro¹, Satoshi Taga², Koichi Yano^{2; 1}Shinkomonji Hospital, ²Shinmizumaki Hospital

Symptomatic cholelithiasis is common disease performed with laparoscopic cholecystectomy (LC). We will hesitate to operate if the patient is pregnant in the third trimester. Pregnant patients undergoing laparoscopic surgery have been reported increasingly. However, most case reports are confined to patients in the first and second trimester. We report a patient who underwent LC in the third trimester and review the relevant literature. A 26 -year-old woman in the third trimester (34w2d) of pregnancy was seen in the emergency department of our hospital with a history of upper abdominal pain. There was no problem in the course of pregnancy. The result of the examination proved to be attack of gallstone colic. She was hospitalized the same day and underwent LC the next day. The base of pregnancy uterus was 20 cm above the navel. We needed to consider the surgical approach, for example inserting the first trocar under left hypochondrium. Operative duration was 63 minutes. She complained abdominal distension at postoperative day (POD) 1 and 2 but there was no abnormality in the fetus. She was discharged on POD 4. After that she gave birth to a healthy baby. LC in third trimester of pregnancy was safely performed with obstetrics back up.

P071

Weekday or Weekend Hospital Discharge: Does it Matter for Acute Care Surgery?

Ibrahim Albabtain¹, Roaa Alsuhaibani², Sami Almalki², Hassan Arishi ¹, Hatim Alsulaim^{1; 1}KAMC, ²KSAUHS

Background: Hospitals usually reduce staffing levels over weekend. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk for adverse events post-discharge. The aim of this study was to assess the outcomes of common acute care surgery procedures for patients discharged over weekend, and identify the key predictors of early readmission.

Methods: This retrospective cohort study was conducted at a tertiary care hospital between January and December 2016. Surgical procedures included were cholecystectomy, appendectomy, and hernia repairs. Patients’ demographic, co-morbidities, complications, readmission and follow-up details were collected from the electronic medical records. Predictors and post-operative outcomes associated with weekend discharge were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders.

Results: A total of 743 patients were included. Overall median age was 35 years (IQR: 22, 58). The majority of patients were female (n = 397, 53.4%). 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. Weekend discharge was 16.8% vs. 83.2% of weekday discharge. Patients discharged during weekend were younger (34.2 vs. 41, p-value < 0.001, mean). Post-discharge 14-day follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, p-value 0.006). Overall, 30-day readmission rate was 3.2% (n = 24), and did not differ between those of weekend and weekday discharge (OR = 0.28, 95% CI 0.52–9.70).

Conclusions: Patients discharged on weekends tended to be younger in age and less likely to have chronic diseases. Patients discharged over the weekend were less likely to follow up compared to weekday discharge patients. However, the readmissions rate did not differ between the two groups.

P072

Safe Laparoscopic Surgical Approach of Foreign Body Migration

Alvarenga S Emanuela, MD, Aupont Schlermine, MD, Derek McCranie, Alexander Ramirez, MD, FACS; Florida State University

Intrauterine device (IUD) migration out of the uterine cavity is a serious complication. Its incidence in the US has been reported to be about 0.001% annually. Previously published systematic review supports the use of laparoscopic surgery for elective removal of migrated IUCDs from the peritoneal cavity. We present the safety and efficacy of the Laparoscopic approach to this complication in the acute care setting. Depicted is an otherwise healthy 40 year old female with no previous surgical history who presented to the ED with worsening abdominal pain for one week with no associated symptoms. On physical exam, patient was non toxic. Abdomen was moderately distended with guarding and rebound tenderness to palpation, no rigid. Patient had been seen shorlty prior to ED admission by her OBGYN and recent work up with abdominal/pelvic x-ray and ultrasound has revealed a misplaced IUD in the transverse position (side ways). Pregnancy test was negative. Based on patient clinical presentation and recent radiologic findings, we decided to proceed with Diagnostic Laparoscopy. After systematic review of cavity, the foreign body was found to be incorporated within the greater omentum. We procceded, laparoscopically with omentectomy + foreign body removal. There were no perioperative complications, patiet was discharged on the following day.

The use of laparoscopy in elective IUD retrieval within in the abdominal cavity has been considered standard of care in surgical management to date. This poster demonstrates its use as an effective approach for safe removal of intra-abdominal foreign bodies also in the acute setting.

P073

Symptomatic Inguinal and Umbilical Hernias in the Emergency Department: Opportunity Lost?

Andrew T Bates, MD, Jie Yang, PhD, Maria Altieri, Chencan Zhu, BS, Salvatore Docimo, Jr., DO, Konstantinos Spaniolas, MD, Aurora Pryor, MD; Stony Brook University Hospital

Introduction: Patients with symptomatic inguinal and umbilical hernias often present to the emergency department (ED) when their symptoms change or increase, usually not requiring emergent surgery. However, little is known about how often these patients present prior to eventual repair and whether they undergo surgery at the initial presenting institution. The aim of this study was to assess the clinical flow of patients presenting in the ED for inguinal and umbilical hernia.

Methods: All patients presenting to EDs in New York State from 2005 to 2014 with symptomatic inguinal and umbilical hernias were identified using the New York State longitudinal hospital claims database (SPARCS). Patients were followed for records of hernia repair and subsequent inpatient and outpatient visits up to 2014.

Results: 42,950 patients presenting to the ED for symptomatic inguinal hernia were identified. 5.3% (2,297) of ED presentations resulted in inpatient admissions. 14,491 (33.7%) had repair later and their average time from ED presentation to inguinal hernia repair was 158 (± 351) days. 90.1% of patients who did not have subsequent surgery had only one ED visit. Of those that underwent interval repair, 79.7% had only one ED visit prior to surgery. For those patients with only one ED visit before repair, 29.3% had repair at a different hospital, as opposed to 48.6% if multiple ED visits were made. 15,297 umbilical hernia patients presenting to the ED were identified. 7.2% (1,109) resulted in inpatient admission. 3,507 (22.9%) had interval repair, with the average time from ED presentation to umbilical hernia repair being 175 (± 369.82) days. 92% of patients who did not record of later repair presented to the ED once. Of those patients who underwent repair, 78.5% did so after one ED visit. For those patients with only one ED visit before repair, 32.9% had repair at a different hospital, as opposed to 48.6% if multiple ED visits were made.

Conclusion: A majority of patients with symptomatic inguinal and umbilical hernias that present to the ED do so once with no subsequent follow-up or repair. For those patients that undergo interval repair, a significant portion willnopt for surgery at other hospitals. A significant proportion of patients with acutely symptomatic inguinal/umbilical hernias who undergo interval repair after a previous ED visit, will opt for definitive surgery at another hospital facility. This represents a missed opportunity for continuity of care for providers and healthcare systems.

P074

A Comparative Study Between Apache II Scoring and Mannheim Peritonitis Index to Assess Prognosis in Perforation Peritonitis

Nikhil Gupta, Dr, Himanshu Agrawal, Dr, Arun K Gupta, Dr, Dipankar Naskar, Dr, C K Durga, Dr; PGIMER Dr RML Hospital, Delhi

Introduction: Peritonitis is the inflammation of the serous membrane that lines the abdominal cavity and the organ contained therein and is one of the most common infections, and an important problem that a surgeon has to face. Reproducible scoring system that allows a surgeon to determine the severity of intra-abdominal infections are essential to prognosticate the patient. This study was done to compare APACHE II scoring and MPI score to assess prognosis in perforation peritonitis.

Methods: All patients admitted with hollow viscus perforation from 1st November 2015 till 31st March 2017 was included in the study. It was a cross sectional observational study. APACHE II and Mannheim Peritonitis Index (MPI) scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. The outcome variables were studied postoperatively -

Post-operative wound infection, wound dehiscence, Anastomotic leak, Respiratory complications, Duration of Hospital stay, need of ventilator support and Mortality. The inferences were drawn with the use of appropriate tests of significance.

Results: The study comprised of 63 patients. Neither APACHE II nor MPI could predict postoperative wound infection. The mean APACHE II score of 63 subjects included in the study was 11.2 ± 8.1 with range of 0 to 35 and the mean MPI score of 63 subjects included in the study was 26.9 ± 7.2 with range of 6 to 39. APACHE II was able to predict post-operative respiratory complications, post-operative need for ventilatory support, hospital stay duration and Mortality while MPI was able to predict post-operative wound dehiscence, post-operative respiratory complications, post-operative need for ventilatory support and Mortality. Neither APACHE II nor MPI could predict postoperative anastomotic leak and postoperative wound infection.

Conclusion: Mannheim Peritonitis index is a useful and simple method to determine outcome in patients with peritonitis. MPI is comparable to APACHE II in assessing the prognosis in perforation peritonitis and can well be used in emergency setting in place of APACHE II scoring when time is a definite constraint.

P075

MicroRNA-17 and the Prognosis of Human Carcinomas: A Systematic Review and Meta-analysis

Chengzhi Huang, Mengya Yu; Guangdong General Hospital (Guangdong Academy of Medical Science)

Background: The recognition of biomarkers to predict the outcome of caner is in need. MicroRNA-17 (miR-17) family has been thoroughly studied and reported to contribute to the progress of human carcinomas. miR-17 is one of the most important miR-17 family member, and has been reported as a tumor biomarker by various researches. However, the prognostic value of miR-17 in cancers remains unclear. Therefore, we put up with a systemic review and meta-analysis to summarize and analyze the relationship between the miR-17 status and clinical outcome in several kinds of human cancers.

Methods: Published articles associated with miR-17 and clinical outcome of cancers were screened by searching the online databases of PubMed, Web of Science, Embase, China Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Technology of Chongqing (VIP) and Wan Fang databases. The patients’ survival results were pooled, and pooled hazard ratio (HR) with 95% confidential intervals (95% CI) were calculated and used for measuring the strength of association between miR-17 and the prognosis of cancers, including hepatocellular carcinoma (HCC), lung cancer, osteosarcoma, glioma, T-cell lymphoblastic lymphoma and colon cancer (CC). Heterogeneity, publication bias and subgroup analysis were also conducted.

Results: The systematic review and meta-analysis is registered in PROSPERO (No. CRD42017065749). In all 12 articles, totally 1096 patients were included in this meta-analysis. The results indicated that the increased expression of miR-17 played an unfavorable role in overall survival (OS) in various human carcinomas with the HR of 1.342 (95% CI = 1.238–1.456) concerning the publication bias. In subgroup analysis, HR of ethnicity (Caucasian HR = 1.48 and Asian HR = 1.40), disease (digestive system HR = 1.36 and non-digestive system HR = 1.54), detection method (qRT-PCR HR = 1.40 and in situ hybridization, ISH HR = 2.59) and detection sample (tissue HR = 1.45 and serum HR = 1.32), all p < 0.05. On the analysis of disease-free survival (DFS) and recurrence-free survival (RFS), the unfavorable prognosis role was also found with the increased expression of miR-17 (HR = 1.40, 95% CI = 1.23–1.60).

Conclusions: miR-17 might be a useful biomarker in predicting the clinical outcome of human cancers.

Keywords: microRNA-17, Cancer, Outcome, Prognosis, Meta-analysis.

P076

Role of Mitochondrial Enzymes in Gastrointestinal System of Mitochondrial Myopathy Patients

Muhammad Nadeem ¹, Julian Ambrus, MD¹, Steven Schwaitzberg, MD¹, John Butsch, MD^{2; 1}University at Buffalo, ²Buffalo General Medical Center

Introduction: Mitochondria is a small energy producing structure of a cell. Mitochondrial myopathy (MM) is mixed disorder clinically, which can affect various systems besides skeletal muscle. MM starts with muscle weakness or exercise weakness. MM patients have decreased skeletal muscle mitochondrial function than the healthy person, because of weakened intrinsic mitochondrial function and decreased mitochondrial volume density. No one has studied the MM role in GERD and constipation so far. This study is aimed to see effects of MM on the gastrointestinal system specifically gastroesophageal reflux disease (GERD), gall bladder issues, and constipation.

Methods: Between May 2011 and June 2016, 101 MM diagnosed patients at Buffalo General Hospital were included in this retrospective study. We assessed their DeMeester score for GERD and Wexner’s constipation questionnaire for constipation. DeMeester Score > 14 and constipation score > 15 were set points for GERD and constipation respectively. Data was analyzed by using SPSS version 24. Mitochondrial enzymes were assessed by using their muscle biopsy report.

Results: Out of 101 (85.1% female, 14.9% male) mitochondrial myopathy patients, 38.6% and 13.9% were suffering from GERD and constipation respectively. 35.1%, 43.4% and 95.9% patients had gall bladder issues, obstructive sleep apnea (OSA) and fatigue respectively. MM GERD patients (87.2% female, 12.8 male) had mean DeMeester score 22.56 (SD: 6.49) more than normal although 76.3% patients were on GERD medications and 29.2% patients had NADH cytochrome C reductase, cytochrome C oxidase and citrate synthase abnormal mitochondrial enzyme in MM associated GERD but 26.1% MM patients had abnormal cytochrome C oxidase enzyme only. MM along with constipation had mean wexner’s constipation score 19.14 (SD: 2.568) more than the normal although 94.9% were taking enema, medications or digital assistance. 50% patients had cytochrome C oxidase and NADH cytochrome C reductase enzymes were abnormal in those patients. 29.4% MM associated gall bladder issues patients had cytochrome C oxidase abnormal. 63.6% MM associated GERD and constipation patients had gall bladder issues.

Conclusion: In this present study, we found that MM had effects on gastrointestinal system causing GERD, constipation and gall bladder issues. GERD, constipation and gall bladder problems are common in MM patients even patients are taking medications for GERD and constipation. Cytochrome C oxidase, citrate synthase and NADH cytochrome C reductase are the most commonly impaired mitochondrial enzyme in MM patients and MM associated GERD, constipation and gall bladder issues patients.

P077

MicroRNA-124 Inhibition Upregulates Hippocampal Expression of Genes Central to Synaptic Plasticity, Glucocorticoid Signaling, and Neurogenesis in a Rat Model of Gulf War Illness

Nicole Laferriere, MD, Wendy Kurata, MS, C. T. Grayson, MD, Lisa Pierce, DSc; Tripler Army Medical Center

Objectives: Gulf War Illness (GWI) is a chronic, multisymptom illness marked by cognitive and mood dysfunction and disrupted neuroendocrine-immune homeostasis affecting 30% of GW veterans. After 25+ years, useful treatments are lacking and its cause is poorly understood, although exposures to pyridostigmine bromide and pesticides are consistently identified among the strongest risk factors. Previous work in our laboratory using an established rat model of GWI identified persistent elevation of microRNA-124 (miR-124) levels in the hippocampus whose gene targets are involved in cognition-associated pathways and neuroendocrine function, suggesting that miR-124 inhibition is a promising therapeutic approach to improve the complex symptoms exhibited by GWI. The purpose of this study was to identify broad effects of miR-124 inhibition in the brain by profiling the expression of genes known to play a critical role in synaptic plasticity, glucocorticoid signaling, and neurogenesis in GWI rats administered a miR-124 antisense oligonucleotide (miR-124 inhibitor).

Methods and Procedures: Nine months after completion of a 28-day exposure regimen involving GW-relevant chemicals and stress, rats underwent intracerebroventricular infusion of miR-124 inhibitor (n = 9) or scrambled negative control oligonucleotide (n = 8) and were implanted with 28-day osmotic pumps delivering 0.1 nmol/day. Intranasal delivery of oligonucleotides was performed on additional rats (n = 4 per group; daily for 10 days) to determine whether miR-124 inhibition is achievable using a noninvasive procedure. Hippocampi were harvested and quantitative PCR arrays were used to profile the expression of focused panels of genes important for 1) synaptic alterations during learning and memory, 2) signaling initiated by the glucocorticoid receptor (known miR-124 target), and 3) neurogenesis. Hippocampi were also analyzed by quantitative PCR to examine expression levels of endogenous miR-124.

Results: Upregulation (> 2.5 fold change, p < 0.05) of 8 synaptic plasticity genes, 11 glucocorticoid signaling genes, and 4 neurogenesis genes was observed in the hippocampus of GWI rats infused with miR-124 inhibitor compared to scrambled control, consistent with a significant reduction (p < 0.001) in miR-124 levels detected in rats receiving miR-124 inhibitor. Altered gene expression and a reduction in miR-124 levels were not observed in rats after intranasal delivery.

Conclusion: miR-124 antagonism in the hippocampus upregulates the expression of several downstream targets involved in synaptic plasticity, glucocorticoid signaling, and neurogenesis and is a promising therapeutic approach to improve cognition, emotion regulation, and neuroendocrine dysfunction in GWI. Further testing is being pursued to discover the optimal dose for intranasal administration to test viability of this option for ill GW veterans.

P078

A Prospective Randomized Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast

Nikhil Gupta, Dr, Ananya Deori, Dr, Arun K Gupta, Dr, Dipankar Naskar, Dr, C K Durga, Dr; PGIMER Dr RML Hospital, Delhi

Background: The ultrasonic dissector, commonly known as the harmonic scalpel, has been in use for achieving haemostasis in surgery for almost 20 yrs. Its advantages in breast surgery, especially in the dissection of axilla, have been a matter of debate as previous studies have shown inconsistent results. This study compares the outcomes of the ultrasonic dissector in axillary dissection with that of the conventional electrocautery.

Methods: Patients who were undergoing MRM and BCS with axillary dissection from November 2014 till March 2016 were included in the study. Patients were randomized into two groups, group A undergoing axillary dissection with ultrasonic dissector and group B with electrocautery. The operative time, intra-op bleeding, post-op pain, post op drain volume, hospital stay and any other complications were noted in the two groups.

Results: The numbers of patients in both groups were 35 each. Group A had a significantly shorter operative time, both for axillary dissection (30.86 min vs. 40.63 min, p < 0.001) and the total duration (77.20 vs. 90.20 min, p = 0.001). The blood loss was significantly less in group A, as measured by the mop count. There was significant reduction in the total post-op drainage volume, which resulted in fewer days of drain in-situ and the total number days stayed in the hospital. There was no significant change in the post-op complications such as haematoma, seroma, flap necrosis, oedema, etc.

Conclusion: With the use of ultrasonic dissector, the operative time, blood loss and the axillary drainage was significantly reduced. The axillary drainage in turn, reduced the hospital stay. There was no significant difference in terms of complications like haematoma formation, seroma formation, skin flap necrosis or oedema.

P079

Role of Intraoperative Cholangiography for Detecting Residual Stones After Biliary Pancreatitis: Still Useful? A Retrospective Study

Laura Meiler, DO, Justin Gusching, DO, Dwayne North, DO, Courtney Pisano, DO, Christian Massier, MD; South Pointe Hospital

Introduction: Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure.

Case Description: Demographic and clinical factors were assessed in patients with ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ2 or Fisher’s exact tests to compare proportions and the nonparametric Mann-Whitney U test for analysis of values with abnormal distribution were used.

Discussion: The study included 579 patients. All preoperative laboratory indicators were elevated. The laboratory tests do not demonstrate any statistical significance between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters < 0.8?mm and with diameters ≥ 0.8?mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significant difference. All patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9?days [range 2–12?days] vs. 6.1?days [range 2–23?days]), from surgery until hospital discharge (2.0?days [range 0–4?days] vs. 2.2?days [range 0–11?days]), and overall length of stay (7.9?days [range 3–19?days] vs. 8.3?days [range 3–23?days]) (P > 0.001).

Conclusion: IOC is rarely useful to diagnose residual CBD stones, without increasing complications related to the procedure itself. It can be safely avoided if other preoperative imaging procedures for the bile ducts have ruled out biliary malformations.

P080

Robotic-Assisted Completion Cholecystectomy: A Safe and Effective Minimally Invasive Approach to a Challenging Surgical Scenario

William B Lyman, MD, Michael Passeri, MD, David A Iannitti, MD, FACS, Dionisios Vrochides, MD, PhD, FACS, FRCSC, Erin H Baker, MD, FACS, John B Martinie, MD, FACS; Carolinas Medical Center

Background: Housed in a high volume tertiary referral center, our division receives a large amount of transfers and referrals from outside institutions for patients who require completion cholecystectomies. In this study “completion cholecystectomy” refers to patients that meet one of three criteria: 1. previous subtotal cholecystectomy, 2. previously aborted cholecystectomy, or 3. previous cholecystectomy with incidental finding of cancer on pathology. Traditionally, exploration of a reoperative field in the right-upper quadrant mandates an open approach due to dense adhesions and inflammation. Over the past few years, we have found that robotic-assisted surgery has allowed us to perform these completion cholecystectomies in a minimally invasive fashion.

Methods: Case logs and operating room billing logs were reviewed from 2010 to 2017 to identify all robotic-assisted cholecystectomies performed at our institution. Review of all reports identified 30 completion cholecystectomies. All additional variables including demographics, operative variables, and postoperative outcomes were determined from manual chart review of all consultation notes, operative reports, anesthesia records, progress notes, discharge summaries, and postoperative office visits.

Results: Of the 30 identified robotic-assisted completion cholecystectomies, 16 patients had a previous subtotal cholecystectomy, 11 patients had an aborted cholecystectomy, and 3 patients had an incidental finding of T2 gallbladder carcinoma on pathology. Fifteen patients (50%) underwent preoperative ERCP either for choledocolithiasis or to determine biliary anatomy. Average time from original procedure was 44 months with 30.0% of previous procedures performed in an open approach. Average OR time was 142.1 minutes, average EBL was 102.1 cc, and average length of stay was 2.1 days. One patient (3.3%) was readmitted within 30 days for nausea that resolved with antiemetics. Three patients (10.0%) had minor postoperative complications (Clavien-Dindo grade 1 or 2) which resolved with pharmacologic therapy. No patients suffered a 90-day mortality. All cases were completed in minimally invasive fashion without a conversion to an open procedure.

Conclusions: Although rare, completion cholecystectomies present a challenging surgical scenario. Although traditionally performed in an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. We feel that the robotic approach offers certain advantages in a hostile, reoperative field which allows us to perform these procedures in a minimally invasive fashion with no conversions to an open procedure to date. Previously limited to case reports, this report of 30 procedures represents the largest case series of robot-assisted completion cholecystectomies to our knowledge.

P081

Impact of Timing of Interval Cholecystectomy, Following Percutaneous Cholecystostomy Tube for Acute Cholecystitis, on Operative and Patient Outcomes

Usman Asad, BS, Amir Aryaie, MD, Eneko Larumbe, PhD, Mark Williams, MD, Edwin Onkendi, MD; Texas Tech University Health Sciences Center

Background: Percutaneous cholecystostomy tube (PCT) has been used as a bridge treatment for grade II-III moderate to severe acute cholecystitis (AC) to “cool” the gallbladder down over several weeks and allow the inflammation to resolve prior to performing interval cholecystectomy (IC) and removal of the PCT, often laparoscopically. The aim of this study was to assess the impact of timing of IC after PCT on operative success and outcomes.

Methods: A retrospective review of electronic medical records of patients who were treated for AC with a PCT, and subsequently underwent IC at our institution between January 2005 to December 2016 was performed. The patients were divided into three groups (n = 7 each), based on the duration of the PCT prior to IC, and these groups were comparatively analyzed. A comparative sub-analysis of clinical outcomes between patients who underwent surgery within the first week vs. third week or later after PCT was also performed.

Results: A total of 21 patients met the study criteria. Each group had 7 patients. There were no statistically significant differences between the 3 groups in regards to age, gender, BMI, imaging findings, and indications for cholecystostomy tube placement. Overall, there was no statistically significant difference in outcomes between performing IC within the first 5 weeks, 5–8 weeks and > 8 weeks after PCT placement. The length of stay, overall morbidity, Clavien-Dindo grade of complications and mortality were similar between the 3 time intervals. However, a sub-analysis showed that patients who underwent IC within the first week of PCT placement had statistically significant higher mortality rate (p = 0.048) compared to those who underwent IC > 3 weeks of PCT placement. The two patients who died in our sample had IC within a week after PCT placement. Even though there was a statistically significantly higher morbidity rate in those who had IC > 3 weeks after PCT, the Clavien-Dindo grade of these complications was lower than.

Conclusion: Delaying IC to > 5 weeks after PCT placement for AC is not associated with any improvement in patient morbidity, length of stay or rate of conversion from laparoscopic to open cholecystectomy. Cholecystectomy within the first week of PCT placement is associated with higher mortality rate than after 3 weeks likely due to associated sepsis.

P083

The Effect of Intraoperative Bile Spillage on Operative Decisions and Surgical Outcomes in Laparoscopic Cholecystectomy

Young Lee, MD, MSc, Arjun Chandrasekaran, MD, MSMPh, Gonzalo Ausqui, MD, Connor McGinley, BS, Pratibha Vemulapalli, MD, FACS, Luca Milone, MD, PhD; The Brooklyn Hospital Center

Introduction: The effect of intraoperative bile spillage during laparoscopic cholecystectomy (LC) on operative time (OR time), length of stay (LOS), postoperative complication rates, and 30 day readmission rates was analyzed. Laparoscopic cholecystectomy is the gold standard operation for gallbladder disease in the United States. Number of studies have shown that same day discharge in elective laparoscopic cholecystectomy is feasible and safe. Bile spillage during this procedure can be a common occurrence in teaching institutions, however, data on the effects of operative outcomes is lacking.

Methods: This is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at The Brooklyn Hospital Center (TBHC), both emergent and elective, from 2016 to 2017. Patient data was collected on demographics, comorbidities, bile spillage, operative findings, complications, LOS, and 30 day readmission rates. Statistical analysis was performed using IMB SPSS Statistics v. 19. Covaried analysis of variance (ANCOVA) was performed on continues variables and significance levels were calculated. Pearson’s Chi Square significance level was calculated for all binomial variables.

Results: Of the 281 patients who underwent LC during this time period, intraoperative bile spillage was encountered in 32 patients. Interestingly, bile spillage was significantly more likely to be seen in elective cases over acute cases (11.8% vs 10.8%, p < 0.05). There was a statistically significant increase in OR time in cases where intraoperative bile spillage was encountered vs. cases where no bile spillage was encountered (146 vs. 124 min, p = 0.007). There was a significant increase in rate of conversion to open procedure when bile spillage was encountered (3.1% vs. 0.4%, p < 0.05). Drain placement rates increased, not surprisingly, when bile spillage was encountered (34.4% vs. 5.6%, p < 0.05). There was no statistically significant difference in LOS between cases with bile spillage and cases without (2.47 days vs. 1.75 days). There was no significant increase in complication rate or 30 day readmission rates.

Conclusions: Intraoperative bile spillage significantly increases OR time, conversion to open procedure, and drain placement. However, there was no significant effect observed of intraoperative bile spillage on length of stay, complication, and 30 day readmission rates. Thus, intraoperative bile spillage appears to have little clinical significance on surgical outcomes. However it may have an impact on overall healthcare costs. Larger prospective studies evaluating the effect of intraoperative bile spillage on LOS, OR time, complication rates, and 30 day readmission rates are needed to analyze these effects further.

P084

Vascular Surprises in Calot’s Triangle During Laproscopic Choleystectomy

Tariq Nawaz, MD; Rawalpindi Medical University

Study Design: Prospective and observational study.

Place and Duration: From January, 2012 to July 2017. Surgical Unit ll, Holy Family Hospital, Rawalpindi.

Patients and Methods: Thousand patients with a diagnosis of cholithiasis were included. Exclusion criteria are patient younger than 12 year and older than 80 year. Calot’s triangle dissection was done meticulously. Cystic artery and hepatic artery anomalies and variations were observed and analyzed on SPSS 21.

Results: The age varies from 12 to 80 years. On the basis of distributional variation the cystic artery was single in 90% cases, branched in 7% cases and absent in 3% cases. On positional variations the cystic artery was superomedial to the cystic duct in 85% cases, anterior in 7% cases, and posterior in 3% cases and low lying in 5% of the cases. On the basis of length variation results showed that 800 (80%) cases had a normal cystic artery. A short cystic artery was found in 150 (15%) cases and a long cystic artery was present in 50 (5%) cases. Other arterial variations are of hepatic artery i.e Moynihan’s Hump (3%) and and right hepatic artery present in calots triangle in 5%

Conclusions: For the safety of laparoscopic cholecystectomy one should be well aware of the anatomical variations of the cystic and hepatic artery.

Keywords: Cholelithiasis, Cholecystitis, Laparoscopic Cholecystectomy.

P085

As Small as it Gets: Micro-invasive Laparoscopic Cholecystectomy Using Only two 5 mm Trocars and a Needle Grasper

Hugo Bonatti, MD; University of Maryland Community Medical Group

Background: The majority of surgeons use four ports including for laparoscopic cholecystectomy (LC). Multiple efforts have been made to reduce number and size of ports. left upper quadrant (LUQ).

Patients and Methods: Of 114 LCs performed from 6/2014–4/2017, 109 (96%) were done using three instruments including 55 cases in which 2 trocars and the Teleflex needle grasper were used. In 26 cases only two 5 mm trocars were (left upper quadrant (LUQ) and umbilicus) with the minigrasper being placed between the two. The gallbladder (GB) serosa was incised on both sides and a window was created behind the GB midportion and widened towards fundus and infundibulum. Cystic artery (CA) and cystic duct (CD) were dissected out obtaining the critical view and after the last fundus adhesion was cut, CA and CD were secured with clips or endoloop.

Results: Median age of 19 women and 7 men was 42.4 (range 24.1–77.4) years. LC was done for acute cholecystitis (n = 4), chronic cholecystitis (n = 8), biliary dyskinesia (n = 9), choledocholithiasis (n = 5). Three patients had an ERCP with bile duct clearance prior to the LC. In one case a Keith needle was used to suspend the GB fundus for better exposure. Twelve patients had additional procedures together with their LC (wedge liver biopsy (4), lysis of adhesions (3), umbilical hernia repair (1), mesenteric/lymphnode biopsies (4). Median OR time was 51 (range 34–129) minutes. The specimen was removed through the LUQ port site in 9 patients. There were no vascular or bile duct injuries in this series. 71% of cases were done as outpatient procedures, 25% of patients required 23 hours observation only three patients were hospitalized for medical reasons.

Conclusion: In selected cases with either small stones or biliary dyskinesia, LC with only two 5 mm ports and a needle grasper is possible. The Teleflex minigrasper can completely replace a port based grasper.

P086

Surgical Outcomes Following Percutaneous Cholecystostomy Placement: A Retrospective Chart Review

Julia F Kohn, BS ¹, Alexander Trenk, MD², Kristine Kuchta, MS², Woody Denham, MD², John Linn, MD², Stephen Haggerty, MD², Ray Joehl, MD², Michael Ujiki, MD^{2; 1}University of Illinois at Chicago; NorthShore University HealthSystem, ²NorthShore University HealthSystem

Introduction: Laparoscopic cholecystectomy is a common procedure in the United States, and is safe even in patients with acute disease. However, some patients are still not candidates for urgent surgery; in these circumstances, percutaneous cholecystostomy may be used as a temporizing measure until patients can undergo definitive surgery. This study examined surgical outcomes in patients who underwent percutaneous cholecystostomy (PC) placement, versus all other patients and versus those who underwent early laparoscopic cholecystectomy (LC).

Methods: After IRB approval, 900 of approximately 3,000 cholecystectomies performed within one four-hospital system between 2009 and 2015 were randomly selected and retrospectively reviewed. Pre-, intra-, and postoperative data were collected, including all complications within 90 days. Early LC was defined as surgery within 7 days of admission for acute illness, per Gurusamy et al (2013). Following preliminary data analysis, multivariable logistic regression models were generated to identify whether PC was predictive of outcomes of interest.

Results: Of the patients reviewed, 35 (3.9%) had percutaneous cholecystostomy placement prior to cholecystectomy, all but one within our institution. The decision to pursue PC versus early LC was made clinically by the attending surgeon; PC was preferred in patients whose disease severity, or comorbidities including postsurgical anatomy, pregnancy, or medical disease, made them poor surgical candidates.

The average duration of PC was 57.6 ± 33.8 days. There was one CBD injury in the PC cohort, and three cystic duct stump leaks and three CBD injuries in the non-PC group. There was no significant difference in operative duration, critical view of safety, or choice of fundus-first dissection due to inflammation between PC and non-PC patients. Patients who underwent PC were more likely to have a surgical site infection or bile duct injury; although there were no significant differences in rates of wound dehiscence or hernia, need for transfusion, or postoperative medical complications, the PC cohort was significantly more likely to have any complication when all complications were pooled. Compared to patients who underwent early LC for acute illness requiring hospitalization, the PC cohort remained significantly more likely to require conversion to an open procedure. However, there were no differences in postoperative complications.

Conclusions: Although percutaneous cholecystostomy may be an appropriate temporizing measure in patients who are poor surgical candidates, it appears that surgery may be more difficult, even after the gallbladder has “cooled off.” It is also important to counsel these patients about the potential for additional postsurgical complications.

P087

Advantages and Limitations about Early Laparoscopic Cholecystectomy: Experience in a District Hospital

Susanna Mazzocato, MD ¹, Angela Maurizi, MD², Damiana Mandriani, MD², Fernando De Rose, MD², Roberto Campagnacci, MD, PhD^{2; 1}Department of General Surgery, Università Politecnica delle Marche, 60126 Ancona, Italy, ²General Surgery, ASUR Regione Marche, "Carlo Urbani" Hospital, Jesi, Italy

Introduction: The standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. The aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital.

Methods and Procedure: All patients undergoing laparoscopic cholecystectomy at the Surgical Department of “Carlo Urbani” Hospital in Jesi (Italy) from May to September 2017 were consecutively enrolled. Clinical data such as gender, age, BMI, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. Subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). For each group, we compared data concerning surgery, such as operative time, intraoperative and postoperative complications, length of hospital stay and cost analysis.

Results: This study is a part of an ongoing research. So far, we collected 67 laparoscopic cholecystectomies. Ten (15%) of them were admitted with acute cholecystitis and were operated during the hospital stay (group A). Group B included patients scheduled for elective surgery (n = 57; 85%). The two groups were comparable with respect to clinical data. Conversion to open approach was performed in 3 cases, all of them in group B. Mean surgical time was 67.5 ± 22.01 minutes in group A and 62.4 ± 19.77 minutes in group B (p = 0.494). No significant differences in intraoperative and postoperative complications rates were seen in the two groups, just a few in both of them. Mean overall length of hospitalization was 6.4 ± 3.89 days in group A and 2 ± 1.63 days in group B (p = 0.001), whereas the difference in length of postoperative hospitalization was not statistically significant. Due to the extended hospitalization for group A, the cost increase as compared to group B was statistically significant, too.

Conclusions: Early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. A longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. However, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to non-operative treatment of group B inpatients with acute cholecystitis.

P088

Reduced Consciousness, Malignancy and Quick Sequential Organ Failure Assessment (qSOFA) Score Predict Mortality in Octogenerian Patients with Acute Cholangitis

Charleen S Yeo ¹, Joseph Wong², Lavisha Punjabi², Winston Woon¹, Jee Keem Low¹, Terence Huey¹, Junnarkar Sameer¹, Vishal Shelat^{1; 1}Tan Tock Seng Hospital, ²Lee Kong Chian School of Medicine

Introduction: With improvements in healthcare access and technology, admissions of octogenarian population with acute cholangitis (AC) are increasing. Octogenarians are vulnerable to inferior outcomes. There is no study to evaluate factors predicting outcomes of AC in octogenarians. The aim of our study is identify factors predicting outcomes, and to evaluate the quick sequential organ failure assessment (qSOFA) score and Tokyo Guidelines 2013 (TG13) severity grading for octogenarian patients with AC.

Methods: A retrospective review of octogenarian patients admitted with AC from January 2010 to December 2016 was performed. Demographic profile, clinical presentation and discharge outcomes were studied. Systemic inflammatory response syndrome (SIRS), qSOFA and TG13 severity grading scores were calculated. Mortality is defined as death within 30 days of admission or in hospital mortality. Statistical analysis was performed using SPSS Version 21.

Results: There were a total of 1875 patients admitted for AC, of which 284 (15%) were octogenarians. Majority (n = 167, 59%) were female, with a mean age of 83 (range 80–86) years. Majority were secondary to gallstones (n = 197, 69%), and 53 (19%) were due to malignancies. 140 (49%) and 8 (3%) patients fulfilled SIRS and qSOFA criteria of severity respectively. 142 (50%) and 93 (33%) of patients had a TG13 severity grading of moderate and severe respectively. Nine (3%) patients required inotropic support in the emergency department (ED) and 48 (17%) patients were admitted to critical care unit (CCU). 166 (58%) patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and 33 (12%) underwent percutaneous transhepatic biliary drainage (PTBD) for biliary decompression. 8 patients underwent index cholecystectomy. Length of stay was 11.5 (range 1–91) days and 30-day mortality of 11%.

Multivariate analysis performed showed that an abnormal Glasgow coma score (p = 0.017) and malignancy (p < 0.001) predicted 30-day mortality. The use of ED inotropic support predicted CCU admission (p = 0034). A positive blood culture (p = 0.005), presence of malignancy (p < 0.001), use of ED inotropes (p = 0.001), and index cholecystectomy (p = 0.008) predicted a longer length of stay.

qSOFA (p < 0.001) and TG13 severity grading (p = 0.001) were predictive of 30-day mortality. SIRS criteria did not predict 30-day mortality.

Conclusion: Reduced consciousness and malignancy predicted 30-day mortality in octogenarian patients with AC. qSOFA and TG13 severity grading system is superior to SIRS criteria in predicting mortality of octogenerians with AC.

P089

Randomized Control Study of Needlescopic Grasper Assisted Single- Versus Three-Incision Laparoscopic Cholecystectomy

Kee-Hwan Kim, Professor; Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea

Introduction: Single incision laparoscopic cholecystectomy (SILC) has some technical problems. Our group has performed needlescopic grasper assisted SILC (nSILC) to overcome these problems. We evaluate the technical feasibility, safety and benefit of nSILC versus three-port laparoscopic Cholecystectomy (TPLC).

Methods and Procedures: This prospective randomized control study was conducted to compare the advantages if any between the nSILC and TPLC. One hundred and forty eight patient were randomized into two groups, with one group underwent n0SLIC (74 patients) and a control group underwent TPLC (74 patients). Basic information about the patient and diagnosis was collected. The surgical outcome that was composed with critical view of safety (CVS) time, major procedure time and total operation time, and the comparison of postoperative complication was made.

Result: nSILC group was consisted of 20 male (27.0%) and 54 female (73.0%), and TPLC group was consisted of 32 male (43.2%) and 42 female (56.8%) (p = 0.038). The average age of nSILC group was 44.5 ± 13.2 years old, and TPLC group was 52.5 ± 15.2 years old (p = 0.003). CVS time of TPLC group was shorter than SILC group (nSILC: 14.4 ± 8.9 min, TPLC: 10.0 ± 7.1 min, p = 0.002), major procedure time (skin incision to GB removal from liver bed) of TPLC group was shorter than nSILC group (SILC group: 21.7 ± 15.3 min, TPLC: 10.6 ± 8.4 min, p = 0.002). However, there was no significant difference in postoperative complication (nSILC: 3, TLC: 6, p = 0.634).

Conclusion: Although CVS time, major procedure time, and operation time of SILC were longer than TPLC, Overall clinical results were similar. nSILC is feasible and safe surgical procedure in patient with benign gallbladder disease.

P090

Outcomes of Percutaneous Cholecystostomy in Malignant Biliary Obstruction

Essa M Aleassa, MD, MSc, Mena Boules, MD, Madonna Michael, MD, Gareth Morris-Stiff, MD, PhD; Cleveland Clinic

Introduction: Management of malignant biliary obstruction not amenable to surgery is usually by means of ERCP or PTHC. However, on occasions, these routes are not accessible and the alternate decompressive technique of percutaneous cholecystostomy (PC) has to be adopted. The aim of this study was to evaluate the efficacy and outcomes of PC in a highly selected series at a tertiary referral center.

Methods: We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, etiology of MBO, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC.

Results: Four hundred and eight patients underwent PC placement of which 28 patients including 18 (64%) males and 10 (36%) females, with malignant biliary obstruction. The mean age at the time of PC placement was 63.5 ± 11.7 years of age, and the mean CCI was 8.03 ± 2.82 for all patients. of MBO in all 28 patients was due to pancreatic malignancies (n = 14), cholangiocarcinoma (n = 6), primary hepatic malignancies (n = 3), secondary hepatic tumors (n = 4), and ampullary carcinoma (n = 1). PC tube complications were reported in 7 (25%) patients. Mean number of tube exchanges was 3.4 ± 2.65. Mean duration from PC tube placement to death was 159 ± 159.4 days. 14 total deaths were recorded.

Conclusion: PC placement appears to be a viable option in MBO in elderly and frail patients. In this cohort, PC may be a potential definitive management to improve quality of life.

P091

Association of Biliary Disease and Reflux

Melanie Boyle, Daivyd Palencia, Philip Leggett; Houston Northwest Medical Center

Background: There are very few studies assessing the relationship between gastroesophageal reflux and biliary disease. This is surprising as they share presenting symptoms as well as risk factors, particularly obesity. Our group previously produced a review of 36 patients in our practice who had undergone some type of reflux procedure. Conclusions showed that the prevalence of gallbladder disease in our severe reflux population is much higher compared to that found in the general population. Our goal of this study is to expand on that data to include a larger sample size to investigate the incidence of biliary disease in our reflux population and decide if this should influence our pre-operative algorithm for anti-reflux surgery patients.

Methods: We expanded on our previously performed retrospective review of patients that underwent laparoscopic fundoplication for reflux disease. We previously reviewed data from 2015 to 2017. We are now looking at data from 2012 to 2017. Our expected sample size will include approximately 150 patients, 75 of which have currently been reviewed. Our previous study included only 36. The surgery preformed was either a Toupet or Nissen fundoplication, and one underwent a Dor. Demographic data, imaging studies, and pathology results were reviewed.

Results: We looked at whether each patient who underwent antireflux surgery had a prior cholecystectomy either remotely or recently, underwent concomitant cholecystectomy, or had no biliary disease in their workup. The groups had similar age and were predominantly women.

Conclusion: We once again demonstrated that the prevalence of gallbladder disease in our severe reflux population is much higher than the general population. When approaching a patient with gastroesophageal reflux disease, attention should be paid to gallbladder symptomatology as well. We recommend that it may be beneficial to include gallbladder ultrasound in pre-operative workup for antireflux surgery so that concomitant cholecystectomy can be performed if indicated.

P092

Is High Morbidity and Cost Associated with Tube Cholecystostomy Worth It? A Paradigm Shift

Steven Schulberg, DO, Jonathan Gumer, DO, Matt Goldstein, Vadim Meytes, DO, George Ferzli, MD; NYU Langone Hospital - Brooklyn

Introduction: Acute cholecystitis is a common surgical disease with roughly 500,000 cholecystectomies performed in the US annually. The current dogma revolves around the “72 hour rule” advocating early cholecystectomy if within the window, and if beyond 72 hours, conservative treatment and interval operation. In patients beyond the 72 hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystectomy. While this has become an appropriate treatment modality, it does not come without its own set of complications. We aim to evaluate the rate of complications in our institution.

Methods: This is a retrospective review of all patients at our institution who underwent cholecystostomy placement between 2013 and 2016. We evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy.

Results: Our cohort includes 100 patients, 52% of whom were male, with a mean age of 71. We had an overall complication rate of 49.5%, including tube dislodgements, leaking tubes, and misplaced tubes. All cause readmission rate was 56% and only 32% of patients who had cholecystostomy drains underwent interval cholecystectomy.

Conclusion: There has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. In review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. In an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of malfunction which will in turn, lead to increases in these two metrics. While there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction.

P094

Does Selective Use of Hepatobiliary Scintigraphy (HIDA) Scan for Diagnosis of Acute Cholecystitis, Following Equivocal Non-diagnostic Gallbladder Ultrasonography, Affect Outcomes

Fahad Ali, BA, Amir Aryaie, MD, Eneko Larumbe, PhD, Mark Williams, MD, Edwin Onkendi, MD; Texas Tech University Health Sciences Center

Introduction: Acute cholecystitis (AC) is diagnosed by characteristic gallbladder ultrasonographic findings (high specificity, low sensitivity). Hepatobiliary scintigraphy (HIDA) may be needed to confirm AC (higher sensitivity and specificity). The aim of this study was to assess the impact of the current selective use of HIDA scan for sonographically equivocal cases of AC on outcomes.

Methods: A retrospective chart review of patients treated for AC at our institution (1/2015 to 12/2016) was performed. Patients were divided into 2 groups: the Ultrasound Only group (US-only) and the Ultrasound-HIDA group (US-HIDA). Timing of US and HIDA, and intervention for AC since presentation to emergency room (ER), and their impact on outcomes were analyzed. AC severity was graded per the TG3-Tokyo guidelines.

Results: A total of 110 patients were analyzed. The 2 groups were statistically similar with regards to age, body mass index, ASA class II, III and IV, extent of leukocytosis at presentation and liver functions test levels at presentation. In the US-only group, diagnostic ultrasound was obtained sooner, [median of 3 (interquartile range, IQR 1.3–8.7) hours] from presentation to the ER compared to the US-HIDA group, [10.9 (IQR 3.6–40.6) hours], p = 0.007. HIDA was obtained after a median delay of 11.5 (IQR 3.7–25) hours from a non-diagnostic ultrasound. Majority of patients (87%) in the US-only group had mild (TG3 grade I) to moderate (TG3 grade II) AC, while 78% of the US-HIDA group had moderate (TG3 grade II) to severe (TG3 grade III) AC (p = 0.003). Despite this, more patients in the US-HIDA group (39%) had a “normal” non-diagnostic ultrasound compared to the US-only group (4.3%), p < 0.001. Seven patients in the US-HIDA group had no intervention due to normal HIDA scan (2), AC misdiagnosis due to liver cirrhosis (1), and severe medical comorbidities (4). More patients (74%) in the US-only group underwent laparoscopic cholecystectomy, compared to 39% in the US-HIDA group (p = 0.006). Between the two groups, there was no significant differences in 90-day morbidity, mortality and reoperations. However, the length of stay was longer by a median of 3.5 days in the US-HIDA group (p = 0.003).

Conclusion: Patients with moderate to severe AC are more likely to need HIDA scan due to a “normal” non-diagnostic ultrasound, have a delay in diagnosis, not have intervention for AC due to severe medical comorbidities and have lower chance of laparoscopic cholecystectomy. The length of hospital stay is significantly longer for these patient by a median of 3.5 days.

P095

Is Routine Histopathology Necessary for all Gallbladder Specimens?

Andrea Zaw, MD, Farrukh A Khan, MD, Prashanth Ramachandra, MD, Piotr Krecioch, MD, Leslie Anewenah, MD; Mercy Catholic Medical Center

Introduction: Benign gallbladder disease is commonly treated with Laparoscopic cholecystectomy (LC). Gallbladder cancer (GBC) is a rare malignancy characterized by high invasiveness and poor survival. In our institution, all gallbladder specimens are routinely sent to pathology, to rule out GBC. The purpose of our study was to assess the efficacy for routine histopathology of gallbladder specimens after cholecystectomy (CLY) for all gallbladder disease.

Methods and Procedures: After obtaining approval from our institutional review board, a retrospective review was conducted on all patients who underwent CLY from June of 2012 to May 2016 were included in the study. The data obtained include gender, age, American Society of Anesthesiologist score (ASA), body mass index (BMI), comorbidities, length of stay (LOS), radiological imaging and pathology results. Independent T and Chi-square tests were performed using IBM® SPSS® 24 software.

Results: There were 903 CLY performed at our institution, of which 842 (93%) were LC. Females composed of 675 (75%) patients and the median age was 48.7 (1%) gallbladder specimens were found to be cancerous. 896 (99%) gallbladder specimens were benign. Majority 533 (59%) were chronic cholecystitis, 238 (27%) were acute cholecystitis and 22 (2%) were gangrenous cholecystitis. 29 (3%) were found to be acalculus cholecystitis and 5 (1%) were cholelithiasis. 69 (7%) were found to be adenomyositis, and other.

Conclusion: In our institution, less than 1% (7) of all gallbladder specimens were found to be cancerous. It would decrease cost and work load if gallbladder specimens are selectively sent to pathology.

P096

Identifying Factors Contributing to Morbidity in Recurrent Cholangitis

Emanuel A Shapera, MD ¹, Matteusz Lapucha, MD¹, Lauren Baumgarten, MD¹, Steven Kaspick, MD¹, Cyrus Rahnema, MD¹, Matthew Johnson, MD, MMS, FACS², Paul Nelson, MD, FACS^{1; 1}Mountain View Hospital, ²Desert Surgical Associates

Introduction: Recurrent Cholangitis can be caused by parasitical, calculous or malignant disease. We sought to determine clinical factors associated with recurrent cholangitis in two Las Vegas community hospitals to aid providers in management of this disease.

Methods and Procedures: Retrospective, multi-center study. Over 4000 ERCPs were analyzed between 2010 and 2017. 24 patients were identified as having multiple (60) admissions for cholangitis per Tokyo criteria. Univariate and multivariate analysis was conducted.

Results: Patients with a significantly (p < 0.0001) higher albumin level on admission (3.7) were discharged home more often than patients discharged to a facility or hospice (2.7). On Multivariate analysis, non-home discharge was associated with lower albumin level at admission (p = 0.0055) and greater maximum temperature prior to decompression (p = 0.0354). Increased hospital stay was associated with lower albumin level at admission (p = 0.0019).

A majority (31/60) of recurrent episodes involved stent placement, exchange or removal. 14 patients (58%) had either biliary malignancy, gallbladder or both. Blood cultures were drawn in 52% of all episodes and positive in 45%, E coli being the most common pathogen isolated. All patients had low HDL levels (6–36, mean 22).

Conclusions: High fevers and poor nutritional status was associated with increased length of hospital stay and fewer home discharges. Tumors, gallbladders and malfunctioning stents contribute substantially to morbidity. Close follow up for indicated gallbladder removal, stent management and nutritional optimization is critical to reduce the burden of this disease.

P097

Laparoscopic Versus Open Excision of Choledochal Cyst in Neonates; Surgical Methods and Outcomes

Jung-Man Namgoong, MD, JuYeon Lee, MD, SeongChul Kim, MD, PhD, DaeYeon Kim, MD, PhD; Department of Pediatric Surgery, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea

Purpose: Laparoscopic excision of choledochal cyst (LEC) can be performed preferably in pediatrics and adults. However, LEC is not performed well in neonates because the safety and feasibility of neonatal LEC remain unknown. The purpose of this study is to evaluate our surgical outcomes of LEC in neonates.

Methods: More than 350 pediatric patients with choledochal cyst underwent surgical treatment in Asan Medical Center, South Korea. This is a retrospective study of 35 neonates who underwent excision of choledochal cyst between November 2001 and May 2016. The 19 neonates underwent open excision of choledochal cyst (OEC) and 16 neonates underwent LEC. We compared the surgical method in neonate choledochal cyst between OEC and LEC. The perioperative and surgical outcomes that were reviewed included age, operative time, postoperative hospital stay, time to diet, and surgical complications. The patients were followed up for 42 months (range, 9–146 months).

Results: There was no difference in range of bile duct excision and manner of Roux-en-Y hepaticojejunostomy between OEC and LEC groups. There was no intraoperative complication in both groups and no open conversion in the LEC group except one case which was ruptured choledochal cyst. The median age of OEC and LEC groups were 13 days (range, 2–30) and 12.5 days (range, 6–26) and median body weight at the time of operation were 3.50 kg (range, 2.64–4.22) and 3.32 kg (range, 2.73–4.22), respectively. The median operative time was 163 minutes (range, 126–336) in OEC and 237.5 minutes (range, 150–351) in LEC groups and there was no significant difference between OEC and LEC groups (P = 0.116). Intraoperative bleeding was minimal in both groups. The postoperative hospital-stay, time to start diet, and time to return to full feeding had no significant differences in both groups. After discharge, 5 of 19 (26%) OEC patients experienced readmission due to cholangitis and ileus, while there were none in the LEC group.

Conclusions: This study revealed that LEC had better prognosis compared to OEC. LEC provided an excellent cosmetic result. So we suggest LEC could be the treatment of choice for neonatal choledochal cyst. This is a small series, therefore future studies will have to include a larger number of patients and evaluate long-term follow-up.

Keywords: Choledochal cyst, Laparoscopy, Neonate.

P098

Laparoscopic Narrow Band Imaging for Intraoperative Diagnosis of Tumor Invasiveness in Gallbladder Carcinoma: A Preliminary Study

Yukio Iwashita, Hiroki Uchida, Teijiro Hirashita, Yuichi Endo, Kazuhiro Tada, Kunihiro Saga, Hiroomi Takayama, Masayuki Ohta, Masafumi Inomata; Oita University Faculty of Medicine

Introduction: Determining tumor invasiveness before operation is one of the most important unsolved issues in the management of gallbladder cancer. We hypothesized that the assessment of irregular vessels on the gallbladder wall may be useful for detecting subserosal infiltration. We present an initial report on the clinical usefulness of laparoscopic narrow band imaging (NBI) for the intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma.

Methods: Thirteen patients with gallbladder cancer were included in this study. Patients with tumors located in the liver bed and those with definitive invasion observed on computed tomography findings were excluded from this study. Gallbladders were observed using NBI and the microvasculature was evaluated. According to previous reports of endoscopic NBI, we defined four findings as positive: vessel dilatation, tortuousness, interruption, and heterogeneity. The NBI findings were compared with postoperative pathological findings. The study protocol was approved by the Institutional Review Board of the Oita University.

Results: The serosal surface of the tumor site and its microvasculature were successfully observed in all 13 patients. Laparoscopic NBI detected at least one abnormal finding in seven patients, and postoperative pathology showed subserosal infiltration accompanied by vessel invasion. On the contrary, six patients with no positive NBI findings showed mild or no subserosal infiltration and no vessel invasion.

Conclusions: Our study indicated that laparoscopic NBI may be useful for diagnosing subserosal infiltration accompanied by a vessel invasion.

P099

Reduced-Port Laparoscopic Cholecystectomy for Young Surgeons

Shuichi Iwahashi, Mitsuo Shimada, Satoru Imura, Yuji Morine, Tetsuya Ikemoto, Yu Saito, Hiroki Teraoku; Department of Surgery, Tokushima University

Introduction: Laparoscopic cholecystectomy (Lap-C) is the standard operation for the benign diseases. We have reported reduced port Lap-C (RPL-C) was safely and comparable method to SILS-C and conventional Lap-C (SAGES 2017). In this time, we examined the utility of RPL-C containing the post-operative adverse event.

Procedures: The adjustment is the benign illness including the cholecystolithiasis, and advanced obesity and the cases of the inflammation remaining have been excluded. The incision is put and cut open the abdomen to the umbilical region, and camera port was inserted. We used 5 mm flexible scope. 3 mm forceps for holding of the gallbladder bottom and left hand of operator were inserted directly with no port.

Methods: RPL-C has been introduced in this department since July, 2009. We performed 224 cases of Lap-C, containing SILS-C and American style conventional Lap-C, and we performed RPL-C has been performed already 156 cases. We compared the patient background and the operation factor between RPL-C, SILS-C, conventional Lap-C. Operators were young surgeons, they were not specialists of gastroenterological surgery or endoscopic surgery.

Results: The difference was not admitted in the age, gender, the physique, and the disease, and the difference was not admitted in hospital stay after the operation (RPL-C:SILS-C:conventional Lap-C = 5.3 ± 0.2 days:5.5 ± 0.2 days:6.7 ± 1.0 days) and the amount of blood loss (RPL-C:SILS-C:conventional Lap-C = 4.7 ± 0.9 ml:9.0 ± 1.9 ml:9.6 ± 4.2 ml) and operation time (RPL-C:SILS-C:conventional Lap-C = 129 ± 3 min:118 ± 6 min:136 ± 3 min). And surgical wound after RPL-C was cosmetically acceptable. Regarding as the post-operative adverse event, there were no patients of bile duct injury.

Conclusion: In the patients on reduced port Lap-C, there were no bile duct injuries of post-operative adverse event. Reduced port Lap-C is safely for young surgeons and comparable method.

P100

Endoscopic Retrograde Cholangiopancreatogram (ERCP) Stent Occlusion After Sphincterotomy Due to Bleeding and Clot Formation

Shinban Liu, DO, David Parizh, DO, Vadim Meytes, DO, Mohan Kilaru, MD; NYU Langone Hospital - Brooklyn

Introduction: Acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. The most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. We present the case of a patient with blood clot obstruction of a common bile duct (CBD) stent after ERCP with sphincterotomy and stone extraction.

Case Presentation: A 58 year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. Biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. Biliary ultrasound demonstrated multiple gallstones and dilation of the CBD with a distal obstructing calculus. He proceeded to ERCP where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. An 8 mm stone was removed from the CBD by balloon sweep with completion cholangiogram demonstrating no filling defects. A stent was then placed in the CBD with adequate flow. Following the procedure, the patient continued to have increasing hyperbilirubinemia. A repeat ERCP revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. The former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. After retrieval of additional clots, a new stent was placed with adequate return of bile. The patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy.

Discussion: Cholangitis is characterized by Charcot’s triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. Cholangiography via ERCP with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. While debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. Although pancreatitis is the most common cause of hyperbilirubinemia post-ERCP, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. Proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications.

P101

Choledochal Cyst Excision in Adults: Experience by Laparoscopic Approach

Sarrath Sutthipong, MD, Panot Yimcharoen, MD, Poschong Suesat, MD; Bhumibol Adulyadej Hospital

Background: Choledochal cyst (CC) is a rare disease, characterized by dilatations of the extra- or/and intrahepatic bile ducts. CCs occur most frequently in Asian and female populations. CC is associated with biliary lithiasis and considered at risk of malignant transformation. Todani’s classification dividing CC into 5 types is the most useful in clinical practice. The current standard treatment is complete cyst excision with Roux-en-Y hepaticojejunostomy and cholecystectomy for the extrahepatic disease (Todani type I and IV). In this report we present our experience using a total laparoscopic technique to treat adult patients with CC in 5-year period.

Methods: A retrospective review of the records of the patients above 15 years who underwent laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in our hospital between January 2013 and May 2017 was carried out. The data included the clinical presentation, investigation, perioperative details and complication. The type of CC was classified according to Todani’s classification.

Results: Seven cases of CC were reviewed, 6 females and 1 male with mean age 33 years (range 20–65 years). These included 5 cases of Todani type IB and 2 cases of type 4A. The predominant symptoms were chronic abdominal pain and jaundice. A case of both pancreatitis and cholangitis were also seen. Investigations included ultrasound with MRCP in 6 cases and ERCP in 1 case. The mean operative time was 4 hours and 20 minutes (3 hours 30 minutes to 5 hours range) with mean intraoperative blood loss 85 ml (range 20–200 ml). All the resected specimens showed chronic inflammation. Malignancy was not seen in any patients. The early postoperative complications included bile leakage with intra-abdominal collection in 2 patients, which were managed conservatively (evidenced by clinical status and imaging study), re-operation was not required. The median duration of hospital stay was 8 days (range 6–23 days). There was no perioperative mortality. All patients were followed up at 1, 6, and 12 months postoperatively, late complication were not detected during each visit.

Conclusion: In our opinion, laparoscopic cyst excision and hepaticojejunostomy could offer more feasible and safe methods of treatment for CCs in adult patients with potentially less postoperative morbidity, a shortened length of stay and a lower blood loss when compared to the preferred open approach. However, we would need to study this on a larger sample of patients to report the efficacy and safety of laparoscopic approach.

P102

The Application of Supine Position in ERCP: Is it as Safe and Effective as Prone Position?

Luyang Zhang, MD, Minhua Zheng, MD, Zhihai Mao, MD; Department of General Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China

Objective: To investigate if ERCP (endoscopic retrograde cholangiopancreatography) conducted with patient in supine position is as safe and effective as in traditional prone position.

Methods: 52 consecutive patients who were undergoing ERCP in our center were randomized to be operated in either prone or supine position. Demographic and clinical characteristics of the 52 study patients were recorded. Difficulty of cannulation of the ampulla of Vater was assessed with the Freeman Score. Total procedure time, intra-operative vital signs (Heart rate, oxygen desaturation and mean artery pressure), patient tolerance were also recorded and compared.

Results: There was no statistically difference for the Freeman score and procedure time between the two groups. Vital signs were compared in the two groups respectively on the basis of 4 steps during the procedure: enter of endoscope; canulation; sphincterotomy and nasobiliary drainage, no significant difference were found between the two groups during each step, while heart rate and MAP during enter of endoscope in both supine (p = 0.01; p = 0.001) and prone group (p = 0.027; p = 0.021) increased significantly compared to base line level.

Conclusion: We believe that ERCP could be performed with the patient in the supine position since it is as safe and effective as that in prone position.

P103

Endoscopic Trans-papillary Gallbladder Drainage (ETGBD) in Acute Cholecystitis: A Single Center Experience

Arun Kritsanasakul, Chotirot Angkurawaranon, Jerasak Wannapraset, Thawee Rattanachu-ek, Kannikar Laohavichitra; Rajavithi Hospital

Background: Surgery is the mainstay of treatment for cholecystitis, however, it may not be safe or feasible in some circumstances such as severe cholecystitis or cholecystitis in extremely high-risk patients. Gallbladder drainage may be an appropriate alternative or a bridging option prior to cholecystectomy. Endoscopic trans-papillary gallbladder drainage (ETGBD) has been proposed as a modality that is feasible and effective in cholecystitis.

Objective: The primary outcome of this study is to evaluate the effectiveness of ETGBD. The secondary outcome is to evaluate the safety, early experience outcomes, and complications of this procedure.

Methods: Retrospective medical records review between January 2014-December 2016 from a single tertiary referral hospital center, Rajavithi Hospital, Bangkok, Thailand. A total of 6 patients who was diagnosed with cholecystitis and underwent ETGBD. The procedure was performed at the endoscopic suite under light sedation via total intravenous anesthesia. The patient demographic data and procedures were collected. The technical success of ETGBD was defined as decompression of the gallbladder by successful cystic duct stent placement. The clinical success was defined as resolution of symptoms and/or improved laboratory data or ultra-sonographic findings.

Results: A total of 6 patients underwent ETGBD. Among these patients, 4 were high risk for surgery due to age or comorbidity, 1 had concomitant jaundice and 1 was failure of medical treatment. Both technical and clinical success of ETGBD was achieved in 4 of 6 cases (67%). The two patients that did not achieve technical success were due to failure to cannulate guidewire through cystic duct and the other had trans-cystic guidewire perforation that needed surgical intervention. There were two intra-operative complications (33%). One was the patient who had trans-cystic guidewire perforation and another had anesthesia-related complication (hypoventilation requiring endotracheal intubation). There were no 30-day mortality.

Conclusion: Endoscopic trans-papillary gallbladder drainage is an alternative treatment modality for patients with cholecystitis who are at high-risk for surgery and or those who are unsuitable for percutaneous gallbladder drainage. The technique is feasible, however, careful case selection and high endoscopic skill is needed.

P104

Long-Term Outcomes After Subtotal Cholecystectomy: A Retrospective Case Series

Julia F Kohn, BS ¹, Alexander Trenk, MD², Woody Denham, MD², John Linn, MD², Stephen Haggerty, MD², Ray Joehl, MD², Michael Ujiki, MD^{2; 1}University of Illinois at Chicago; NorthShore University HealthSystem, ²NorthShore University HealthSystem

Introduction: Subtotal cholecystectomy, where the infundibulum of the gallbladder is transected to avoid dissecting within a heavily inflamed triangle of Calot, has been suggested as a method to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. However, some case reports have suggested the possibility of recurrent symptoms from the remnant gallbladder. This retrospective case series reports a minimum of two-year follow-up on patients who underwent subtotal cholecystectomy within one four-hospital system.

Methods: A retrospective chart review database containing 900 randomly selected cholecystectomies, all of which occurred between 2009 and 2015, was reviewed to identify all instances of subtotal cholecystectomy. Charts for these patients were reviewed through 09/2017, including any documentation from other providers, including primary care.

Results: Six patients who underwent subtotal cholecystectomy with a remnant of infundibulum left following surgery were identified. Surgical approach and the choice to perform subtotal cholecystectomy were dependent on the attending surgeon; all decisions were made intraoperatively. There was an average of 70 months of follow-up for these patients within our institution.

Discussion: This case series adds six cases to the literature surrounding long-term outcomes in patients who underwent subtotal cholecystectomy. Although one patient was lost to follow-up, no patient had recurrent biliary colic or other complications arising from the remnant gallbladder. This may be encouraging to surgeons who feel that subtotal cholecystectomy with an infundibular remnant is the safest way to proceed with cholecystectomy in patients with severe inflammation.

P105

Indocyanine Green Use in Laparoscopic Cholecystectomy: Potential Shift in Standard of Care?

Jenny Lam, MD, Toshiaki Suzuki, MD, Carlos T Maeda, MD, David Bernstein, MD, Thach Pham, Garth R Jacobsen, MD, FACS, Bryan J Sandler, MD, Santiago Horgan, MD, FACS; University of California - San Diego

Objective: This study aims to evaluate the utility and efficiency of ICG as an alternative to routine intraoperative cholangiogram in patients undergoing cholecystectomy.

Introduction: Common bile duct injury is an uncommon, but serious complication associated with laparoscopic cholecystectomy. Current guidelines state that when used routinely intraoperative cholangiogram (IOC) can decrease biliary injury, however it is not routinely used due to increased time of operation, and inaccessibility of equipment. Indocyanine Green (ICG) has been found to be effective for identification of biliary anatomy during cholecystectomy, however has not yet been widely adopted. We aim to assess if ICG is able to overcome the obstacles of IOC, while still effectively assessing biliary anatomy.

Methods: We performed a retrospective analysis of laparoscopic cholecystectomies performed in a single institution from January 2014 to September 2017. Elective and emergent cases were included. We stratified patients into ICG and non-ICG groups. Patients who had concomitant procedures performed were excluded. We analyzed patient demographic information, as well as BMI, ASA classification and comorbidities in both groups. Our primary outcome was operation time (skin to skin), and laparotomy conversion rate. Secondary outcomes were effectiveness of ICG in visualizing biliary anatomy, and cost.

Results: 145 patients were included in our study, 59 in the non-ICG arm and 86 in the ICG arm. Both groups were similar in background. There were no statistical differences in patient demographics, ASA classification, BMI, or comorbidities. There was no statistical difference in operation time (58.0 vs 54.5 minutes; p < 0.202) or conversion rate (1.6 vs 0%; p < 0.226). ICG was able to delineate biliary anatomy in 100% of the patients. The cost of a 25 mg/Vial kit of ICG is approximately $70.

Conclusion: The use of ICG does not increase operating time during laparoscopic cholecystectomy. ICG is an inexpensive and effective tool used to delineate biliary anatomy without the inherent burden and limitations of IOC.

P106

Outcomes of Laparoscopic-Assisted ERCP in Gastric Bypass Patients at a Community Hospital Center

Benefsha Mohammad, MD ¹, Michele Richard, MD¹, Steve Brandwein, MD², Keith Zuccala, MD^{3; 1}Danbury Hospital, ²Danbury Hospital Department of Gastroenterology, ³Danbury Hospital Department of Surgery

Introduction: Obesity is a prevalent issue in today’s society, which has increased the number of gastric weight loss surgeries. This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP). In gastric bypass patients, traditional ERCP via the mouth in these patients is technically more challenging, requiring a longer endoscope with a reported success rate of less than 70%. A solution is laparoscopic assisted ERCP (LA-ERCP) via gastrostomy. This minimally invasive technique has become increasingly more prevalent and safe. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients.

Methods and Procedures: Retrospective chart review was performed on all patients with a history of prior laparoscopic gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure was performed by two different general surgeons and one gastroenterologist. A pursestring suture and transfacial stay sutures were used to bring the gastric remnant to the abdominal wall. A gastrostomy was then created and accessed by the duodenoscope to perform the ERCP. Biliary sphincterotomy, papillary or biliary dilation, lithotripsy, stent placement, and/or stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital re-admission and bile leak.

Results: Thirty-two patients met inclusion criteria. Six patients were male and twenty-six were female, with mean ages of 59 (std dev 7) and 53 years (std dev 15), respectively. Indications for LA-ERCP included suspected choledocholithiasis (25/32), cholangitis with choledocholithiasis (2/32), acute pancreatitis (2/32), abdominal pain with abnormal LFT (1/32), cholangitis with cholecystitis (1/32), and bile leak (1/32). LA-ERCP was successfully performed in all thirty-two patients. Biliary cannulation, sphincterotomy and stone extraction were performed on 31/32 patients, and one patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved after conservative treatment. One patient required a second LA-ERCP for stent replacement due to a persistent bile leak. The median length of stay was 2 days (range 1–10 days).

Conclusions: LA-ERCP is a safe and feasible alternative to open surgery, and can be safely implemented at community hospitals with adequately trained providers. Obesity is a growing burden on society, increasing the incidence of weight loss surgery. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.

P107

Recurrent Bile Duct Stones After Endoscopic Sphincterotomy in 2255 Patients

Ahmed Elgeidie, Elsayed Adel; Gastrointestinal Surgery Center

Background: Endoscopic sphincterotomy (ES) is an effective therapeutic procedure for common bile duct (CBD) stone clearance but it carries a substantial risk of recurrent stones at long-term outcome.

Aim of the Study: To evaluate the rate of CBD stones recurrence after primary complete endoscopic clearance, and to identify the risk factors of recurrence.

Methods: Between January 2002 and December 2016, 2255 patients with CBD stones who underwent successful ES and complete stone clearance were studied retrospectively. Recurrent CBD stone, was defined by the confirmation of the presence of CBD stone at least 6 months after previous complete CBD stone clearance by ES. The risk factors for recurrent CBD stones and mean time interval between initial ES and stone recurrence were analyzed.

Results: In Total, 2255 patients we included. The median follow up period was 89 (6–187) months. Recurrent CBD stones appeared in 159/2255 (7.05%) patients after a median time interval of 22 (6–216) months following ES. Stone recurrences were observed on multiple occasions in 20 patients (0.88%). On the univariate analysis, the significant risk factors related to recurrent CBD stone were male sex (P = 0.001), previous history of cholecystectomy (P = 0.001) multiple CBD stones (P = 0.001), large CBD stone (P = 0.001) the presence of periampulary diverticulum (P = 0.001) and stone crushing using mechanical lithotripsy (P = 0.001)

Conclusion: Recurrence of CBD stones is an identified long-term risk after ES and stone clearance.

P108

Two Port Laparoscopic Cholecystectomy in a Pregnant Woman

Hugo Bonatti, MD; University of Maryland Community Medical Group

Background: Laparoscopic cholecystectomy during advanced pregnancy is challenging due to the limited intraabdominal space. Patients may be at increased risk for developing trocar site hernia.

Case Report: A 35 year old Hispanic female in her 22th week of pregnancy came to the ER with acute right upper quadrant pain. Due to lack of accessibility she had poor prenatal care. She had mildly elevated amylase but normal LFTs and ultrasound showed some gallbladder wall thickening suggestive for acute cholecystitis and no dilated biliary duct. Fetal ultrasound was normal. She was admitted to the hospital and started on antibiotics, obstetrics was consulted. Her amylase peaked at > 600 U/L but then normalized and indication for laparoscopic cholecystectomy was made. MRCP and ERCP were not performed as it was assumed that the patient had passed a stone. Five mm trocars were placed in the LUQ and the umbilicus and a Teleflex minigrasper between the tow. The uterus was found at the umbilical level. The GB was pulled out and the serosa was incised on both sides and a window was created behind the GB midportion and widened towards infundibulum and fundus. There was GB wall thickening and edema. The critical view was obtained and the cystic artery and duct were clipped and divided. The common bile duct appeared normal and no IOC was done. The specimen was retrieved through the LUQ port site using a 5 mm endobag after dilatation to 1.5 cm due to the presence of two large stones. The port site fascia was closed using a suture passer. The postoperative course was uneventful and both mother and baby were well at the two weeks follow up.

Discussion: In case of biliary pancreatitis during pregnancy, LC should be performed and if ultrasound shows a normal biliary system and amylase/lipase normalize, MRCP/ERCP and IOC may be avoidable to protect the baby. LC with two ports is feasible during pregnancy. Removal of the specimen through a lateral abdominal wall site may help prevent an umbilical port site hernia in this patient population.

P109

Laparoscopic Cholecystectomy in Left-Sided Gallbladder

Yun Kyung Jung, Dongho Choi, Hwon Kyum Park, Kyeong Geun Lee; College of Medicine, Hanyang University

Introduction: Left-sided gallbladder (LSGB) is one of rare congenital anomalies in gallbladder and defined as a gallbladder located on left side of falciform ligament without situs inversus. Although there has been remarkable development on diagnostic imaging tools, almost left-sided gallbladder was found intraoperatively, not preoperatively.

Methods: Of 2,657 patients who underwent laparoscopic cholecystectomy (LC) for the treatment of gallbladder disease between August 2007 and December 2016, 7 patients (0.26%) were diagnosed as left-sided gallbladder. All LSGBs were found incidentally during LC and reviewed the preoperative computed tomography (CT) for finding evidence of LSGB and associated anomaly.

Results: All of 7 patients were men and mean age was 52.4 years (from 24 to 69). All patients had laparoscopic cholecystectomy for gallbladder disease (5 due to acute cholecystitis, 2 due to gallbladder polyp). In all cases, the gallbladder was located on the left side of falciform ligament. The operation was performed successfully with standard 4-trocar technique with confirming “critical view of safety (CVS)” as usual without 1 case. In 1 case which had a intraoperative complication and needed choledochojejunostomy due to common bile duct injury, there was an associated anomaly called double common bile duct. Furthermore, in reviewing CT after operation, abnormal intrahepatic portal venous branching was found in all cases.

Conclusion: LSGB can be managed with laparoscopic cholecystectomy with CVS successfully. However, surgeons who found left-sided gallbladder have to make efforts to be aware of the possibility of associated anomalies.

P110

Three Month Interval Laparoscopic Cholecystectomy Using Endoscopic Gallbladder Stenting for Severe Acute Cholecystitis

Norimasa Koide, MD, Takehiko Enomkoto, MD, Kazuyoshi Suda; Department of Surgery, Niigatakensaiseikai Sanjyo Hospital

Introduction: The Tokyo guideline for acute cholecystitis (AC) recommends percutaneous transhepatic gallbladder drainage (PTGBD) followed by cholecystectomy for severe AC. But the optimal timing for the subsequent laparoscopic cholecystectomy remains unclear. And if PTGBD is performed, it appears to increase hospital stay and fee. So recently endoscopic gallbladder stenting (EGBS) after PTGBD has been performed in our institute, and interval laparoscopic cholecystectomy (ILC) performed more than three months from the onset of symptoms is recommended. The aim of this study is to investigate this procedure in our institution.

Methods and Procedures: From April 2016 and September 2017, three patients with severe AC underwent ILC using EGBS at our institution. The surgical outcomes were analyzed retrospectively.

Results: The patients consisted of two men and one woman with a mean age of 66 years (ranging from 63 to 69). Mean white blood cell count was 11933/m² (ranging from 10000 to 13100). Mean duration from onset of AC to PTGBD was 6 days (ranging from 3 to 10). Mean duration from onset to EGBS was 20 days (ranging from 10 to 20). Mean duration from onset to surgery was 117 days (ranging from 94 to 149). One case was removed EGBS tube preoperatively. The number of ports was three or four. The dome down technique after dissection of gallbladder neck was performed in two cases. Mean operating time was 248 minutes (ranging from 112 to 350), and mean blood loss was 20 ml (ranging from 0 to 50). There were no conversions to open surgery and no intraoperative complications without contamination of bile juice because of gallbladder injury. The drainage tube was inserted in two cases. Average length of postoperative hospital stay was 4.3 days (ranging from 4 to 5). There were no postoperative complications and no 30 day readmission.

Conclusion: ILC using EGBS at our institution is a safe and feasible procedure. So this procedure seems to be one option of the treatment for severe AC.

P111

Splenic Abscess Arising After Routine Laparoscopic Cholecystectomy

Kevin Bain, DO, Vadim Meytes, DO, David Parizh, DO, Sampath Kumar, MD; NYU Langone Hospital - Brooklyn

Introduction: Splenic abscess is a rare, potentially lethal condition, with autopsy studies showing incidence rates between 0.14–0.7%. Mortality rates ranging from 47 to 100% making early diagnosis and prompt intervention vital. Several case reports have documented post surgical splenic abscess, most notably after laparoscopic sleeve gastrectomy. To the best of our knowledge, there has not been any reported cases of splenic abscess arising after laparoscopic cholecystectomy. It is important to remember this disease process for expeditious targeted treatment in future cases.

Case Presentation: A 69 year-old female with past medical history significant for cholilithiasis, hypertension, and hyperlipidemia presented to the emergency department (ED) with a chief complaint of abdominal pain for two days. Labs and imaging were obtained which confirmed the diagnosis of choledocholithiasis and pancreatitis. ERCP was performed which showed a 1.5 cm stone causing obstruction, with several other smaller filling defects. The stones were removed after sphincterotomy. Post procedurally, the patient underwent an uncomplicated laparoscopic cholecystectomy on Hospital Day (HD) #5.

Post operatively, the patient had persistent leukocytosis peaking at 16.8 thousand on postoperative day (POD) #6. A CT scan was performed which showed a rim-enhancing splenic collection measuring 6.6 × 2.2 cm suggestive of an abscess.

Interventional radiology was consulted and aspirated 50 ml of purulent fluid. Cultures grew out Klebsiella pneumoniae and Enterobacter cloacae complex, and the patient was discharged home on Zosyn.

Discussion: Laparoscopic cholecystectomy has become the cornerstone in treatment of symptomatic biliary colic and acute cholecystitis. Of the many recognized complications of laparoscopic cholecystectomy, splenic abscess has not yet been reported in current literature.

The nonspecific signs and symptoms of splenic abscess make clinical diagnosis difficult. The classic triad of fever, palpable spleen and left upper quadrant pain are only seen in about two-thirds of patients. CT scan has been shown to be the most sensitive imaging modality for diagnosis of splenic abscess.

Current treatment options for splenic abscess are broken down into two subsets: percutaneous and surgical intervention. Percutaneous treatment includes image guided aspiration with or without placement of drainage catheter. Surgical intervention can be either laparoscopic or open and includes drainage of abscess with splenectomy or splenic conservation. The best treatment option remains unclear, and there is lacking prospective data demonstrating which modality is superior.

P112

Loop Versus Suture Closure of the Gall Bladder Stump During Sub-total Cholecystectomy – A Retrospective Analysis

Sunay Bhat¹, Gokul Kruba Shanker ¹, Vadiraj Hunnur¹, N. Subrahmaneswara Babu², Balu Kuppusamy^{3; 1}Dept. of Surgical Gastroenterology, VGM Gastro Care, Coimbatore, ²Dept. of Surgical Gastroenterology, JIPMER, Pondicherry., ³Dept. of Surgical Gastroenterology, GEM Hospital, Coimbatore

Introduction: Laparoscopic subtotal cholecystectomy is widely accepted as a safe alternative to the conventional laparoscopic cholecystectomy in case of acute cholecystitis with frozen calot’s triangle. The remnant stump of the gallbladder may be either sutured or looped. However, there are limited studies comparing the outcomes of the two techniques. The present study is aimed at comparing loop and suture closure of the gall bladder stump.

Methods: A retrospective analysis of our prospectively maintained database revealed that between January 2013 and December 2016. 81 patients underwent laparoscopic subtotal cholecystectomy for acute cholecystitis, chronic cholecystitis or empyema gallbladder with frozen calot’s triangle. The decision to use endoloop or sutures for stump closure was made intra-operatively after dividing the gallbladder through the infundibulum. A no.20 sized drain was kept in all the cases. The patients were discharged with drain in situ, and were reviewed on post-operative day 7 during which an ultrasound was done and drain removed if the progress was satisfactory. The intra-operative and post-operative data between the two groups were recorded and analyzed.

Results: Endoloop closure was performed in 45 patients and suture closure using 2.0 ethibond was done in 36 patients. Three patients from the sutured group had post operative bile leak among which one patient underwent endobiliary stenting. The other 2 were managed conservatively while the drain had to be retained for 2 weeks. Two patients in the endoloop group were detected to have retained stone in the remnant gallbladder cuff among which one had recurrent cholecystitis requiring laparoscopic completion cholecystectomy. None of the patients had bile duct injury or surgical site infection. Mean post operative stay was 2.5 + 1.2 days, did not significantly vary between the groups. Suturing needed more surgical expertise and had prolonged operative time than endoloop (68 + 22 min versus 84 + 18 min, p = 0.04).

Conclusion: Suture or loop closure of the remnant gallbladder after subtotal cholecystectomy are equally effective. Suturing the stump may be associated with increased incidence of biliary leak while endoloop may have higher incidence of retained gallstones. The choice between the two may be made intra-operatively based on the surgeon’s expertise and preference.

P113

Current State of Complex Minimally Invasive Biliary Surgery

Shadi Aboudi ¹, Samer Kawak², Katherine Su³, Tyrone Rogers³, Eugene E Ceppa^{3; 1}St. Vincent Medical Group, Indiana University Health, ²Beaumont Health, ³Indiana University School of Medicine

Introduction: Although minimally invasive surgery is a well-recognized part of modern surgery, the adoption of complex minimally invasive biliary procedures (MIBP) is unknown.

Methods: A comprehensive literature search of MIBP from 2011 to 2016 was performed by querying multiple electronic databases regardless of language of origin. All diagnoses and procedures relating primary to the biliary system were included. Laparoscopic cholecystectomy and related procedures were excluded from the search due to its universal application. Postoperative outcomes were assessed. Historical controls for open complex biliary procedures were used for comparison. P value < 0.05 was defined as statistically significant.

Results: A total of 16 studies from 2011 to 2016 were included in this review; multiple other studies were excluded for lacking sufficient details. A total of 352 patients underwent complex MIBP. Three minimally invasive modalities were distinguished including laparoscopic assisted (n = 12), laparoscopic (n = 329), and robotic (n = 11). Various surgical techniques were used including Roux-en-Y (REY) hepaticojejunostomy (n = 132), hepaticojejunostomy (n = 116), primary anastomosis + T-tube (n = 94), choledochoduodenostomy (n = 7), and REY cholangiojejunostomy (n = 3). Observed major morbidity (20% vs. 17%), biliary fistula (6% vs. 3%), anastomotic stricture (1.2% vs. 2%), reoperation rate (2% vs. 2%), and mortality (0.6% vs. < 1%) after MIBP and open procedures respectively; no postoperative occurrence was statistically distinct. Mean operative times were found to be significantly longer in MIBP (385 minutes vs. 256 minutes), yet each study found operative times decreased in the MIBP with increased surgeon experience. Length of stay was significantly less in the MIBP compared to open procedures (5.8 days vs. 8 days).

Conclusion: Very few reports and a paucity of data exist documenting outcomes from complex MIBP. The limited data suggest that complex MIBP can be performed safely and effectively, yet universal adoption is not apparent based on the total number of patients in the literature. Further series are needed to more accurately compare outcomes.

P114

How to Learn the Laparoscopic Cholecystectomy (LC)?: A Learning Curve of One Surgical Resident for Initial 151 Cases

Yun Kyung Jung, Dongho Choi, Hwon Kyum Park, Kyeong Geun Lee; College of Medicine, Hanyang University

Introduction: Laparoscopic cholecystectomy (LC) has been widely performed for the treatment of gallbladder disease. However, it has potential fatal complications like bile duct injury which are correlated with inexperience. Therefore, surgical training for safe and exact LC technique is important for surgical residents. The aim of this study is to investigate the personal learning curve of one resident and confirm the safety of LC performed by surgical residents.

Methods: We retrospectively reviewed 151 patients who underwent LC by one surgical resident at the Hanyang University Hospital. Three or four trocars were inserted and we established the “critical view of safety” in all patients. All procedures were supervised by an experienced HBP surgeon.

Results: Of total 428 LCs during the study, 151 cases were performed by one surgical resident. There were no statistical differences between two groups (group 1 – experienced surgeon, and group 2 – surgical resident) in open conversion rate (3.2% vs 0.7%, p = 0.106) and postoperative complications (3.3% vs 6.6%, p = 0.107). No major complications including bile duct injury were recorded in both groups. There was significant difference between two groups in operative time (51.52 vs 62.48, p < 0.001).

Conclusion: LC performed by surgical residents is safe although they operated with longer operative time. However, inexperience surgeons must always keep in mind confirmation of CVS and basic laparoscopic surgery technique during LC. These principles should be trained by attending staff for learning curve period.

P115

Development of the Endoscopic Treatment for Bile Duct Injury-The Method of Direct Closure Using Bioabsorbable Polymer at the Part of Bile Duct Perforation-

Mitsuo Miyazawa, MD, FACS ¹, Masayasu Aikawa, MD², Yasumitsu Hirano¹, Kaizo Taniguchi¹, Shozo Fujino^{1; 1}Teikyo University Mizonokuchi Hospital, ²Saitama Medical University International Medical Center

Background and Aim: In recent years, due to the spread of laparoscopic cholecystectomy, bile duct injury as its complication has been reported at a certain frequency. Current surgical treatments include 1) suturing and closing the injured part laparoscopically during surgery, 2) transitioning to laparotomy and closing the suture, 3) inserting a tube such as T-tube under the laparotomy, 4) bile duct-intestinal anastomosis under the laparotomy, etc. are taken into consideration. Regardless of which treatment method, it is not a definite ideal treatment. We have developed a bioabsorbable material (caprolactone: lactic acid (50: 50) polymer reinforced with polyglycolic acid fiber and designed to be absorbed in about 8 weeks). At this conference, we would like to talk about the current state and problems of development of minimally invasive therapy for biliary damaged area using bioabsorbable materials we developed.

Method: In order to overcome the problem of the current bile duct injury cure method, we have been developed, a) a method of closing a perforation part endoscopically from the luminal side of a bile duct (a covered stent using a bioabsorbable material in the damaged part), b) Develop a method of closing the biliary duct injury under the laparoscope from the outside of the bile duct (adhering the bioabsorbable sheet to the bile duct perforation using a biocompatible adhesive).

Results: Experimental results of suturing the bioabsorbable material in the biliary duct in surgery of laparotomy were able to regenerate the bile duct without stenosis in the damaged area. However, various adhesives were tried to bond the sheet of this bioabsorbable material and the native bile duct under the endoscope, but at the moment, there is no glue that will allow the sheet to be adhered readily and reliably where there is moisture to a certain extent. A tool for delivering the sheet from the bile duct into the injured part is under development and good results are obtained at present.

Conclusion: It is possible to regenerate the bile duct without constriction using a bioabsorbable material. It is difficult to laparoscopically adhere to the injured part of the bile duct, but we hope that it will be possible in the near future to develop further adhesives.

P116

A Comparative Study of Needlescopic Grasper Assisted Single Incision Versus Three-Port Versus Pure Single Incision Laparoscopic Cholecystectomy

Kee-Hwan Kim, Professor; Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea

Introduction: Single incision laparoscopic cholecystectomy (SILC) has emerged as a surgical option for disease of gallbladder, with the goal of reducing postoperative pain and cosmetic reason. However, pure SILC has some difficulties because of inherent limitations. The authors report on the surgical outcomes of SILC with needle grasper compared with pure SILC and conventional three port laparoscopic cholecystectomy.

Methods and Procedures: We analyzed the medical records of the patients who underwent laparoscopic cholecystectomy for benign disease of gallbladder in our hospital between January 2013 and January 2015. One hundred and three patients underwent laparoscopic cholecysectomy. Among them, 33 patients underwent pure SILC (pSILC), 35 patient underwent needle gasper SILC (nSILC), and 35 patients underwent three-port cholecystectomy (TPLC).

Results: All procedures were completed by laparoscopy, and the gallbladder was completely removed in three groups. There were statistical differences in the skin to skin operation time (pSILC: 65.2 ± 19.1 min, nSILC: 49.5 ± 12.8 min, and TPLC: 43.4 ± 14.7, p < 0.001), and major procedure time (pSILC: 42.2 ± 18.7 min, nSILC: 26.0 ± 8.9 min, and TPLC: 30.3 ± 16.2, p < 0.001). However, there were no significant differences in the visual analogue scale (pSILC: 2.2 ± 0.8 min, nSILC: 2.6 ± 1.0 min, and TPLC: 2.6 ± 0.9, p = 0.161), postoperative hospital stay (pSILC: 2.6 ± 1.6 min, nSILC: 2.3 ± 1.0 min, and TPLC: 2.1 ± 0.5, p = 0.185), and intraoperative blood loss (pSILC: 32.7 ± 13.8 min, nSILC: 31.9 ± 21.0 min, and TPLC: 37.0 ± 22.0, p = 0.495).

Conclusions: nSILC is feasible and safe surgical procedure in patients with benign gallbladder disease compared with TPLC, and it is effective approach to overcome the limitation of pSILC.

P117

The Influence of Obesity During Single-Incision Laparoscopic Cholecystectomy

Nobumi Tagaya, PhD, Yoshitake Sugamata, PhD; Department of Surgery, Dokkyo Medical University Koshigaya Hospital

Introduction: Obesity has been influenced the outcomes of laparoscopic surgery. Here we investigate the influence of obesity during single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods: We performed SILC in 298 patients, comprising 146 males and 152 females with a mean age of 55 years. Their diagnoses included 276 gallbladder stones, 15 polyps and 7 adenomyomatosis. Body mass index (BMI) were divided into 4 groups consisting of less than 25 kg/m² (A), 25–30 kg/m² (B), 30–35 kg/m² (C) and more than 35 kg/m² (D). We made a 2.5-cm longitudinal skin incision within the umbilicus. A wound retractor and a surgical glove were applied at that incision. We used the three 5-mm ports technique. After retracting the gallbladder upward, the cystic duct and artery were divided and identified using pre-bending forceps through the flexible port and laparoscopic coagulating shears (LCS). The cystic artery was dissected using the LCS and the cystic duct was also dissected after clipping. The gallbladder was freed from the liver bed using the LCS, and the specimen was retrieved from the umbilical wound.

Results: There were conversions to open laparotomy in 4 cases (1.3%) and requirement of additional ports in 23 (7.7%). The mean age (years), operation time (min), blood loss (ml) and postoperative hospital stay (days) in group A, B, C and D were 60.0, 55.5, 51.2 and 41.2 (p = 0.05>), 89.5, 101.7, 98.4 and 85.3 (p = 0.206), 19.7, 18.5, 15.6 and 3.4 (p = 0.935), and 3.5, 3.6, 3.2, and 3.0 (p = 0.882), respectively. There was a significant difference in age only. The complications were bile duct injury in one case (0.3%) and pneumothorax in two (0.6%).

Conclusion: Obesity had no influence of surgical outcomes for performing SILC.

P118

Antegrade Method of Laparoscopic Cholecystectomy for Left-Sided Gallbladder

Kwang Yeol Paik, WonKyung Kang, Prof; Catholic University of Korea, Yeouido St. Mary’s Hosp

Introduction: The gallbladder (GB) placed in the left side (LS) of liver bed is a rare anatomy. This variation makes operator hard to perform cholecystectomy. Despite it is important to apprehend the detailed anatomy of bile duct and GB and understand how to approach LSGB in advance cholecystectomy, we usually encounter difficulties with this unusual situation just after begining operation. We herein report surgical process of LSGB with video in this manuscript.

Patients: The patient was following up with gallstones about ten years and occasionally complained of the pain migrating from Left upper quadrant to epigastric area. LSGB was encountered after begining laparoscope approach. Laparoscopic cholecystectomy was done antegrade method not to injure anomalous bile duct.

Results: To prevent the injury to anomalous bile duct, we began to carefully separate GB from its fundus first, prior to cystic duct ligation. Cholecystectomy was successfully done after complete detachment of GB from liver bed. Postoperative lab findings and patient’s condition showed little possibility of injury on surgical site. Patient was discharged two days after surgery.

Conclusion: When surgeon encounter LSGB without diagnosis prior to operation, Antegrade dissection of GB enables surgeons to detect Calot’s triangle easily and to complete operation safely. For unpredictable but possible anomalous GB, surgeon should always give a thought to suitably modified cholecystectomy.

P119

Klatskin Tumor in the Light of ICD-O-3. A Population-Based Clinical Outcome Study Involving 1,144 Patients from the Surveillance Epidemiology and End Result (SEER) Database (2001–2012)

Abdul Waheed, MD, Jill S Motl, MD, Justin Kelly, MD, FRCS, Rebecca Rowen, MD, John R Monson, MD, FACS, FRCS, FASCRS; Surgical Health Outcomes Consortium, Florida Hospital Medical Center, Orlando, FL, USA

Introduction: Klatskin tumors (KT) occur at the confluence of right and left extrahepatic ducts and classified based on their anatomical and histological code in the International Classification of Diseases for Oncology (ICD-O). The second edition of ICD-O (ICD-O-2) allocated a distinctive histological code to KT, which was cross-referenced to the intrahepatic cholangiocarcinomas. This unclear coding may result in ambiguous reporting of the demographical and clinical features of KT. The current study aims to investigate the demographic, clinical and pathological factors impacting prognosis and survival of KT in the light of updated third edition of ICD-O (ICD-O-3).

Methods: Data on 1,144 KT patients from the Surveillance Epidemiology and End Result (SEER) database (2001–2012) was abstracted. KT patients were analyzed for age, gender, race, stage, treatment, and long-term survival. The data was analyzed using Chi-square tests, T-tests, univariate and multivariate analysis. Kaplan- Meier analysis was used to compare long-term survival between KT and sub-groups of all biliary cholangiocarcinomas (CC).

Results: Of all biliary CC, KT comprised of 9.35% with the mean age of diagnosis 73 ± 13 years, was more common in males (54.8%) and Caucasians patients (69.5%). Histologically, moderately differentiated tumors were commonest (38.9%), followed by poorly differentiated (35.7%), well differentiated (23.3%) and undifferentiated tumors (2.2%), p ≤ 0.001. Most tumors in KT group were 2–4 cm (41.5%), while fewer were > 4 cm (29.7%), and < 2 cm (28.8%), p ≤ 0.001. ICD-O-3 defined most KT tumors in extrahepatic location (53.5%), while the remainder were in other biliary locations (46.5%), p ≤ 0.001. Most KT patients received no treatment (73%), and those who were treated, the most frequent modality was radiation (52.7%), followed by surgery (28.1%), and both surgery and radiation (19.2%), p ≤ 0.001. Mean survival time for KT patients treated with surgery was inferior to all CC of the biliary tree (1.72 ± 2.61 vs. 1.87 ± 2.18 years). P = 0.047. Multivariate analysis identified regional metastasis (OR = 2.8, CI = 2.6–3.0), distant metastasis (OR = 2.1, CI = 1.9–2.4), lymph node positivity (OR = 1.6, CI = 1.4–1.8), Caucasian race (OR = 2.0, CI = 1.8–2.2), and male gender (OR = 1.2, CI = 1.1–1.3) to be independently associated with increased mortality for KT, p < 0.001.

Conclusion: ICD-O-3 has permitted greater understanding of Klatskin tumors. This is a rare and lethal biliary malignancy that presents most often in Caucasian males in their seventh decade of life with moderately differentiated histology. Surgical resection does not provide any survival advantage compared to similarly treated biliary CC. Also, the combination of surgery and radiation appeared to provide no added survival benefits compared to other treatment modalities for KT.

P120

Laparoscopic Subtotal Cholecystectomy for Difficult Acute Calcular Cholecystitis

Hamdy Abdallah, PhD; Faculty of Medicine, Tanta University, Egypt

Background: When the critical view of safety can’t be obtained during dissection of Calot’s triangle in difficult gallbladder, conversion to open surgery is recommended to prevent bile duct injury. Several “damage control” techniques, such as cholecystostomy and subtotal cholecystectomy (SC), aim to decrease the conversion rate and risks of bile duct injury.

Materials and Methods: The medical records of all patients who had laparoscopic SC (LSC) for acute calcular cholecystitis (ACC) during the period from May 2009 to August 2016 at Tanta University Hospital, Egypt were retrospectively reviewed.

Results: During the study period, laparoscopic cholecystectomy (LC) was attempted in 68 difficult GBs out of 376 patients presenting with ACC. LSC was performed for 65 patients and cholecystostomy for the remaining 3 patients. LSC group included 50 females (77%) and 15 males (23%) with a mean age of 42.35 ± 12.4 years. The mean duration of symptoms was 27.5 ± 13.3 days before surgery. Six patients (9.2%) had pericholecystic abscesses and 4 (6.2%) had bile duct obstruction due to Mirrizi syndrome or choledocholithiasis (2 patients each). The cystic duct (CD) was dissected and controlled successfully in all patients and drains were used in 42 patients (64.6%). The mean operative blood loss was 45.28 ± 18.6 CC and the mean operative time was 96.3 ± 24.19 minutes. There were no conversions to open surgery, no operative complications or mortality. Three patients (4.6%) had superficial port site infection and 1 patient (1.5%) had post-ERCP bleeding that was controlled endoscopically. The mean postoperative hospital stay was 28 ± 17.8 hours. No patients developed bile leak, intra-abdominal collections or jaundice and there was no postoperative mortality.

Conclusion: When surgery is indicated for difficult ACC, LSC with control of the CD, performed by experienced surgeons, is safe with excellent outcomes.

P121

Subtotal Cholecystectomy: Safe, Tolerated, but with Increased Need for Re-intervention

Jennifer A Rich, BS, Guillaume S Chevrollier, MD, Andrew Brown, MD, Emanual Okolo, BS, Adam Berger, MD, Ernest L Rosato, MD, Francesco Palazzo, MD, Michael J Pucci, MD; Sidney Kimmel Medical College of Thomas Jefferson University

Introduction: Subtotal cholecystectomy (SC) is a standard operation utilized to prevent bile duct injury (BDI) when the Critical View of Safety cannot be safely achieved when encountering the difficult gallbladder. Although SC remains safe, the long-term implications, such as quality of life and need for further intervention, are less well known.

Methods and Procedures: All patients who underwent cholecystectomy at our institution since 2011 were identified in a retrospectively collected, IRB-approved database. Operative notes where carefully reviewed to identify all cases of SC, along with the appropriate subtype grouping (fenestrating or reconstituting). SC patients where matched to contemporary cases of total cholecystectomy (TC) based upon age, sex, and procedure method (open or laparoscopic). Patient charts were carefully reviewed for perioperative and long-term outcomes, including re-interventions and additional surgical procedures. The patients were subsequently contacted via telephone and asked to complete SF-36 and GIQOL surveys.

Results: Sixty-three cases (2.6%) of SC where identified out of 2418 cases (15 fenestrating, 48 reconstituting). Thirty (48%) cases were completed laparoscopically. Demographics of the two matched cohorts are presented in Table 1. Five SC patients required re-operative completion cholecystectomy for recurrent biliary disease. No TC patients required reoperation, however 2 major BDI occurred in this group (3%), versus no major BDI in the SC group. Quality of life surveys were completed in 21 (33%) SC and 23 (37%) TC patients. SF-36 and GIQOL scores are non-significant between groups with the exception of one sub-category “role limitations due to physical health,” which was improved in the SC group.

Conclusions: In our series, long-term QOL scores do not differ between patients undergoing SC and TC. SC may be protective of major BDI; however it clearly comes with an increased risk for the need for re-operative procedures. SC should be considered in difficult operative scenarios, however, patients should be followed for recurrent biliary disease and need for re-operative management.

P122

A Prospective Randomised Study of Intra-peritoneal Instillation of Ropivacaine Versus Bupivacaine in Reduction of Post-operative Pain After Laparoscopic Cholecystectomy

Goldendeep Singh, Bimaljot Singh, Ashwani Kumar, PROFESSOR; Government Medical College Patiala

Introduction: The study was conducted to compare the efficacy of intraperitoneal instillation of Ropivacaine versus Bupivacaine for post operative pain relief after laparoscopic cholecystectomy and to compare the analgesic requirement and overall morbidity in patients with either of two interventions.

Material and Method: This prospective study was conducted in the Department of General Surgery, Govt. Medical College & Rajindra Hospital Patiala. 60 patients with symptomatic gall stones disease undergoing laparoscopic cholecystectomy were included with equal distribution either Group A (n = 30 patients) received 0.5% of 30 ml (150 mg) of ropivacaine instillation at gall bladder bed ; Group B (n = 30) received 20 ml of 0.5% bupivacaine hydrochloride at gall bladder bed and sub diaphragmatic space at the end of surgery. All cases were performed by experienced laparoscopic surgeons.

Intensity of pain was assessed on visual analogue scale (VAS) with evaluation at 6, 12, 24, 48 hr postoperative. Analgesic requirements was assessed in terms of requirement of number of Inj. Diclofenac Sodium (75 mg) I/m. Nausea and vomiting was assessed depending upon the episodes, number & need for anti emetic medication.

Results and Conclusion: Intensity of pain was assessed on visual analogue scale (VAS) with evaluation at 6, 12, 24, 48 hr postoperative. There was found significant difference among both the groups in terms of VAS score, abdominal pain, shoulder pain and analgesic requirement at 12 hours but no such significance was seen in 6, 24 and 48 hours.

To conclude intraperitoneal instillation of Ropivacaine or Bupivacaine reduced post operative pain significantly and amongst two groups. Bupivacaine was better at 12 hrs as shown by decreased VAS score, decreased shoulder tip pain, decreased analgesic requirement. Otherwise at 6, 24 and 48 hrs this difference was not significant among two groups.

P123

Factors Affecting Coversion of Laparoscopic Cholecystectomy to Open Surgery

Papot Charutragulchai, MD, Chotirot Angkurawaranon, MD, Kannikar Laohavichitra, MD, Jerasak Wannapraset, MD, Thawee Rattanachu-ek, MD, Siripong Sirikurnpiboon, MD; Department of Surgery, Rajavithi Hospital, Bangkok, Thailand, 10400

Background: Laparoscopic cholecystectomy (LC) is the standard procedure for cholecystectomy. However, in some patients, LC cannot be successfully performed requiring conversion to open cholecystectomy (OC). This study was to analyze the factors affection conversion of LC to OC.

Method: Retrospective medical records review between January 2008 to September 2016 from a single tertiary referral hospital, Rajavithi Hospital, Bangkok, Thailand. Patients who underwent elective LC and was converted to OC was analyzed. Exclusion criteria were cases that required emergency LC.

Result: A total number of 2,045 patients underwent elective LC during the 9 year review. Only 123 patients had conversion to OC (6.01%). The mean age was 59 (± 13.6) years. Sixty-four patients were male (52%) and 59 patients were female (48%). Most patients had ASA score£2 (87%). The diagnosis of the patients for elective LC were symptomatic gall stone (51.2%), subsided cholecystitis (34.1%), choledocholithisis post endoscopic removal (12.1%), and gall stone pancreatitis (2.43%). The most common factor influencing conversion is unclear anatomy in Calot’s triangle (103 patients, 83.7%). The remaining factors were bleeding (6 patients, 4.87%), bile duct injury (6 patients, 4.87%), cholecystoduodenal fistula (3 patients, 2.43%), injury to other organ (3 patients, 2.43%), common bile duct exploration (1 patient, 0.81%), and other (1 patient, 0.81%).

Conclusion: The factors affecting conversion of LC to OC in elective setting were most commonly unclear anatomy of the Calot’s triangle.

P124

Surgeon Procedure Volume Strongly Associated with Adverse Events Post Laparoscopic Cholecystectomy

Yazen Qumsiyeh ¹, Curtis T Adams, MD¹, Sean Wrenn, MD², Ashley Deeb¹, Charles Maclean, MDCM, FACP³, Wasef Abu-Jaish, MD, FACS, FASMBS^{2; 1}University of Vermont Larner College of Medicine, ²University of Vermont Medical Center, Department of Surgery, ³University of Vermont Medical Center, Department of Medicine

Introduction: Recent studies have reported mixed outcomes when comparing surgeon case volume and Laparoscopic Cholecystectomy (LC) outcomes. Formal minimally invasive surgical training (MIST) has been shown to be associated with shorter post-operative length of stay (LOS), but no difference in major adverse events such as bile leak, bile duct injury, intra-abdominal abscess formation, and death. We aim to determine 30-day rates of major adverse events after LC in a university hospital setting, to identify significant associated risk factors, and to determine if MIST or surgeon volume are associated with differences in LOS and major adverse events.

Methods: We conducted a single-center retrospective review of 2,764 cholecystectomies performed over a seven-year period (2009–2016). Characteristics and outcomes were compared using Chi squared or rank sum tests. Multivariable regression modeling was used to determine independent associations with the two main outcomes, major adverse events and LOS.

Results: We identified 2,764 adults who underwent LC during the study period, with a median age of 50, and 70% women. About 19% (n = 531) of patients had a LOS > 1 day and 4.3% (n = 120) were re-admitted within the first 30 days after surgery for any reason. Within 30 days of LC, 2.2% (n = 60) of patients suffered from one or more major adverse events. This includes 0.18% (n = 5) of patients with bile duct injury, 1.3% (n = 35) of patients with bile leak, 0.3% (n = 7) of patients with intra-abdominal abscess, and 0.3% (n = 9) of patients died for reasons related to their procedure or post-operative recovery. Table 1 shows the characteristics of the patients and procedures with a comparison of the patients with an adverse event versus those without one. In univariate analysis, high annual surgical volume (40+ cases/year) and procedure urgency were found to be significant predictors of adverse events and LOS, however, MIST was not. In multivariable analysis, controlling for significant univariate predictors, urgent or emergent cases were associated with a 3-fold increase in odds of an adverse event (OR = 3.0 [CI 1.7, 5.1]) and high surgical volume with a significantly lower risk (OR = 0.37 [CI 0.2, 0.8]. For the LOS outcome, procedure urgency (OR = 45 [CI 33, 61]) and surgeon volume (OR = 0.4 [CI.03, 0.6]) were also the strongest predictors.

Conclusion: Our adverse events rate from LC falls below the range of recently published data. After controlling for clinical covariates, procedure urgency and surgeon case volume were the strongest predictors of adverse events and LOS, whereas MIST was not.

P125

Is it Feasible and Safe in Single Incision Laparoscopic Cholecystectomy in Resident Training Program?

Kee-Hwan Kim, Professor; Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea

Introduction: Single incision laparoscopic cholecystectomy (SILC) has some technical problems. Our group has performed needlescopic grasper assisted SILC (nSILC) to overcome these problems. nSILC are now taught to resident surgeon in training. We evaluate the safety and feasibility of this technique comparing with the three-port laparoscopic cholecystectomy (TPLC)

Methods and Procedures: We retrospectively reviewed the medical records of a single institution experiences in nSILC with resident training program. The surgical outcome of 79 patients who underwent cholecystectomy for gallbladder benign disease at our hospital between March 2013 and June 2016 was analyzed. A needlescopic grasper was used in nSILC, which was inserted through a direct puncture on right upper quadrant of abdomen. The scope and other instrument were inserted through umbilical port. All surgical procedure was performed by residents under the supervision of an experienced surgeon. Gallbladder stone, mild (grade I and II) acute cholecystitis, gallbladder polyp, gallbladder adenomyomatosis were included. Grade III severe cholecystitis (Tokyo Guideline) was excluded. 25 patients underwent SILC and 54 patients underwent TPLC. The data of these patients were collected and included clinical presentation, age, sex, BMI, stone type and umber, critical view of safety (CVS) time, main procedure time, skin to skin operation time, total operation time, hospital stay, intraoperative blood loss, and complications.

Results: All patients successfully underwent nSILC or TPLC without open conversion and postoperative complications. There were no statistical differences in sex, BMI, stone number, CVS time, main procedure time, skin to skin operation time, total operation time, hospital stay, and intraoperative blood loss (sex: p = 0.468, BMI: p = 0.491, stone number: p = 0.305, CVS time: p = 0.340, main procedure time: p = 0.722, skin to skin operation time: p = 0.892, total operation time: p = 0.764, hospital stay: p = 0.0.062, and intraoperative blood loss: p = 0.574), However, age of nSILC was younger than that of TPLC (p = 0.047).

Conclusions: In our study, there were no significant differences in surgical outcomes. However, nSILC group was younger than TPLC group, this result was thought that the number of performed cases were small. There was no case of intra-operative and post-operative complications. A single incision laparoscopic cholecystectomy performed by resident merits training under experienced supervisor surgeon. This training could improve the skill and help encourage the motivation of resident surgeon.

P126

The Effect of Prior Ultrasound on Outcomes in Acute Versus Elective Laparoscopic Cholecystomy

Young Lee, MD, MSc, Arjun Chandrasekaran, MD, MSMPh, Gonzalo Ausqui, MD, Connor McGinley, BS, Pratibha Vemulapalli, MD, FACS, Luca Milone, MD, PhD; The Brooklyn Hospital Center

Patients who received ultrasound prior to admission for acute cholecystitis were compared with patients who presented electively for LC. Laparoscopic cholecystectomy (LC) is the gold standard operation for gallbladder disease. It is one of the most common operations performed on emergency services in the United States. Many patients receive diagnostic ultrasound imaging prior to presentation but are not operated on immediately.

Methods: This is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at The Brooklyn Hospital Center (TBHC), both emergent and elective, from 2016 to 2017. Patient data was collected on demographics, comorbidities, operative findings, complications, length of stay (LOS), and 30 day readmission. Statistical analysis was performed using IMB SPSS Statistics v. 19. Covaried analysis of variance (ANCOVA) was performed on continues variables and significance levels were calculated. Pearson’s Chi Square significance level was calculated for all binomial variables.

Results: Of the 281 patients who underwent LC during this time period, 152 cases presented electively and 139 presented acutely. Of the patients who presented acutely, 20 had ultrasound prior to admission. There was no statistically significant difference between patients who presented acutely with a prior ultrasound and patients who presented electively for LC when comparing operative time (OR time), complication rates, LOS, and 30 day readmission rates. Acute cases (with NO prior ultrasound) were still associated with a statistically significantly increased length of stay (LOS) 3.5 days vs. 0.4 days for elective (p < 0.05) as well as a statistically significantly increased OR time 135 minutes vs. 119 for elective (p = 0.002). Complication rates and 30 day readmission rates did not differ significantly between acute and elective cases.

Conclusions: We found that receiving prior ultrasound in patients who presented acutely appears to have no statistically or clinically significant effect on OR time, complication rates, LOS, and 30 day readmission rates when compared to patients who presented for LC electively. However, there was a statistically and clinically significant increase in OR time and LOS in acute vs. elective cases in general. Thus, it is possible that having prior symptomatic disease, as indicated by prior ultrasound testing, appears to confer a protective advantage to this group. Larger prospective studies evaluating the effect of prior symptomatic disease on operative findings, complication rates, LOS and 30 day readmission rates when patients present acutely and undergo LC are needed to analyze these effects further.

P127

Tobacco Use Does Not Contribute to Complications After Cholecystectomy: A Retrospective Chart Review

Julia F Kohn, BS ¹, Alexander Trenk, MD², Kristine Kuchta, MS², Woody Denham, MD², John Linn, MD², Stephen Haggerty, MD², Ray Joehl, MD², Michael Ujiki, MD^{2; 1}University of Illinois at Chicago; NorthShore University HealthSystem, ²NorthShore University HealthSystem

Introduction: Laparoscopic cholecystectomy is an extremely common procedure in the United States, with over 700,000 cases performed annually. Despite the procedure’s overall safety, there has been some evidence that tobacco use is associated with increased risk of wound infection after LC. This retrospective chart review sought to examine whether tobacco use is associated with increased complications following laparoscopic cholecystectomy within a high-volume healthcare system.

Methods: After IRB approval, 900 of approximately 3,000 cholecystectomies performed within one four-hospital system between 2009 and 2015 were randomly selected, and patient charts were retrospectively reviewed. Pre-, intra-, and postoperative data were collected, including all complications within 90 days. Tobacco use cohorts were defined as follows: never, former (any historical tobacco use), and current (active tobacco use within 1 year of surgery) per the ACS NSQIP Surgical Risk guidelines. Following preliminary data analysis, multivariable logistic regression models were generated to identify whether tobacco use was predictive of outcomes of interest.

Results:

Of the 900 cases analyzed, 535 patients (59.4%) were never smokers; 31.3% were former smokers, and 9.2% were current tobacco users or had quit less than 12 months prior to surgery. There were 17 surgical site infections, one wound dehiscence, one port site hernia, three common bile duct injuries, and 44 medical complications requiring prolonged hospitalization or readmission within 90 days.

Current tobacco users were significantly more likely to undergo urgent surgery (following emergency admission or direct admission to the hospital) than former or nonsmokers. However, there was no difference between cohorts for prolonged duration of surgery, conversion to an open procedure, surgical site infection, wound dehiscence or hernia, common bile duct injury, or other medical complication. There was no significant difference between cohorts when all postoperative complications were pooled.

Conclusions: There does not appear to be a significant difference in 90-day surgical outcomes or complications in active tobacco users vs. former or non-users. Although studies in other surgical settings have indicated a possible reduction in complications if patients abstained from smoking prior to surgery, this may not be beneficial in laparoscopic cholecystectomy. Moreover, as current tobacco use appears to be associated with higher rates of urgent surgery, these patients may not be able to stop smoking prior to an elective procedure. Prospective studies to further clarify whether there is any benefit towards tobacco cessation prior to LC may be valuable.

P128

Patients Prioritize Safety First: Opinions of Transfer of Care for Unexpected Findings Versus Bile Duct Injury in Laparoscopic Cholecystectomy

Shanley B Deal, MD ¹, Jennifer A Rich, BS², Elizabeth Carlson, MD¹, Guillaume S Chevrollier, MD², Michael J Pucci, MD², Adnan A Alseidi, MD, EdM^{1; 1}Virginia Mason Medical Center, ²Sidney Kimmel Medical College of Thomas Jefferson University

Introduction: Surgeons often assume patients may be dissatisfied if their operation were stopped due to suspicious intraoperative findings or injury requiring transfer of care. Knowledge of patient centered opinions may help clarify how patients feel when these situations arise to support patient safety. We sought to assess patient opinions regarding transfer of care for unexpected intraoperative findings during laparoscopic cholecystectomy with and without bile duct injury, and whether these perceptions may differ.

Methods and Procedures: The investigators developed two clinical scenarios comparing transfer of care for unexpected intraoperative findings during elective laparoscopic cholecystectomy (without bile duct injury and with injury requiring open repair). A multi-institutional structured telephone interview process was conducted with patients ≥ 18 years of age who had an outpatient, uncomplicated laparoscopic cholecystectomy within the last year. The first scenario presented a case of suspicious findings prompting the surgeon to stop and transfer for specialized care; whereas, the second case was a bile duct injury requiring transfer of care. Textual and thematic analysis, as well as descriptive statistics, were used to analyze our interview results.

Results: Forty-five patients were contacted and completed the survey. Satisfaction with transfer of care for unexpected intraoperative findings without bile duct injury was 69% and over 95% of respondents were satisfied their surgeon stopped the procedure to initiate transfer due to safety concerns; 64% of patients would return to that surgeon for post operative care and 78% would see that surgeon for another operation in the future. In the scenario with bile duct injury requiring open repair, 86% were satisfied with their surgeon’s decision to stop the operation, 91% of patients were satisfied with transfer of care, and 32% would see their first surgeon again in the future. Themes of prioritizing safety, providing explanations, appreciation for admission of error and setting aside ego were frequently cited in both scenarios.

Conclusions: Patients prioritize safety and are highly satisfied with halting a procedure to facilitate transfer of care for suspicious intraoperative findings during routine laparoscopic cholecystectomy. The majority would return to that surgeon for surgical care.

P129

Progressively Increasing CA19-9 Sounded the Alarm of an Intra-hepatic Cholangiocarcinoma

Dandan Hu ¹, Yilei Mao^{2; 1}Sun Yat-sen University Cancer Center, ²Peking Union Medical College Hospital

Potential good prognosis of preclinical cholangiocarcinoma underwent laparoscopic liver segmentectomy.

A 76 years old male presented to gastroenterology department on January 4, 2016, with progressively increasing carbohydrate antigen 19-9 (Ca19-9) level.

Clinical manifestations only include a blood stool with less than 10 ml/d, with occasionally tenesmus. No special findings about physical examinations.

Past history includes middle segmentectomy of left lung in 1964, post-operation pathology implied tuberculosis. In 2013, he went through radical prostatectomy (Gleason 3+3, T2cN0Mo). In 2014, he was discovered to have elevated PSA level and went through 1-month radiotherapy. Now, he is on oral bicalutamide medication. In 2015, as he developed groin hernia, a tension-free hernioplasty was performed. He has hypertension, diabetes mellitus, and hemorrhoid as well. He also has 5-years history of hypertension, diabetes mellitus, and hemorrhoids.

Ca19-9 level was 237.9 (reference range: 0–34.0) on October 28, 2015. It rose to 310.5 on December 2, 2015. After admission, another test was done on January 4, 2016, and the figure rocketed to 338.3. Meanwhile, Ca242 were 118.9, > 150, > 150 respectively (0–20), cyfra 211 were 8.11, 9.22, 6.36 respectively (0–3.5). AFP and CEA were negative.

As for this patient, he is of high risk of hepatobiliary system diseases. Due to common bile duct calculi, ERCP was applied in 2010. He was affected by recurrent cystitis, and an open cystectomy surgery was performed in 2011, along with common bile duct incision, lithotomy under choledochoscope, and T tube drainage. Post-surgical pathology showed no evidence of tumor cells. His serum tests indicated that he was previously infected with hepatitis virus B.

After admission, a contrast enhanced computer tomography was performed and no malignancy was reported. PET/CT was suggested and a 3.6*3.7*2.7 cm high standard uptake value (SUVmax = 6.0) lesion was indicated at the margin of left lobe of liver, where it can hardly distinguish the relationship between the lesion and lesser curvature of stomach.

After consultation by Department of Liver Surgery, laparoscopic left liver segmentectomy under general anesthesia was performed on January 19, 2016. The surgery lasted for 200 minutes, with less than 100 ml bleeding. The lesion was 3*1.8*2.5 cm, soft, parenchymal, partly enveloped, and its section is gray and poorly demarcated. Pathology reported it was poorly differentiated cholangiocarcinoma with necrosis, AFP(-), CAM5.2(+), CD34(vessel +), CEA(+), CK19(+), CK7(+), CK8(+), EGFR(+), Hepatocyte(-), Ki-67(index 30%). Margin was negative.

Ca19-9 dropped to 107 7 days after the surgery.

P130

Thoracoscopic Thymectomy - A Case Report

Raj Gajbhiye, MS, Arati Kirange, MS, Ram Khare, MS, Vikrant Akulwar, MS, Lajpat Agrawal, MS, Sanjay Pal, MS; Government Medical College, Nagpur, Maharashtra, India

Introduction: Thymoma is one of the rare tumor entity benign or malignant arsisng from the epithelial cells of thymus gland, frequently associated with neuromuscular disorder Myasthenia Gravis. So, we are presenting this rare case of thymoma with myasthenia gravis in our institute.

Methods: We operated a single patient of thymoma in a case of myasthenia gravis by Video Assissted Thoracoscopic Approach.

Results: Operative time- 78 min, intraoperative blood loss − 20 ml, post operative analgesia requirement in form of NSAIDS is for 2 days, no ventilatory support required post operatively, With follow up reduction in AchR Ab from 99 nmol/L to 15 nmol/L and reduction in symptoms in form of reduced ptosis.

Conclusion: Thoracoscopic thymectomy is feasible and safe in terms less operative time, less post operative pain and analgesia requirement and no post operative ventilatory support requirement.

P131

Endoscopic Transmural Stents for Resolution of Duodenal Fistulas Following Necrotizing Pancreatitis

Carter C Lebares, MD, Stanley J Rogers, MD; UCSF

Background: Duodenal fistulas are uncommon but morbid complications of acute necrotizing pancreatitis. If percutaneous drainage fails, surgical correction via roux-en-Y diversion or pancreaticoduodenectomy can be required. While self-expanding metal stents have been tried, complications like migration and perforation have limited such use. Endoscopic transmural stents have successfully treated fistulas of the stomach, particularly post-sleeve gastrectomy. Here we present a case of endoscopic transmural stents used to treat a non-resolving duodenal fistula following acute necrotizing pancreatitis.

Methods: Under general anesthesia, using a standard adult gastroscope, the fistula was identified in the second portion of the duodenum (Fig. 1). A flexible-tipped guide wire was used to identify the fistula tract and two 7 Fr 5 cm double pigtail biliary stents were deployed (Fig. 2) with positioning verified under fluoroscopy. Two weeks later these were removed and a single stent deployed into the visibly smaller tract (Fig. 3). Two weeks after that, the single stent was removed and contrast medium was injected under fluoroscopic visualization, demonstrating resolution of the fistula (Fig. 4).

Case: This patient is a 72 year old woman with hypertension and congenital hearing loss who underwent a cholecystectomy for biliary colic and subsequent ERCP with sphincterotomy for retained stone. This was complicated by acute pancreatitis which progressed to severe necrotizing pancreatitis with infected retroperitoneal necrosis. Percutaneous drainage yielded initial improvement but a persistent moderate collection (300 cc per day) lead to the identification of a fistula in the second part of the duodenum. Repositioning and exchange of percutaneous drains over 8 weeks did not hasten resolution. Endoscopic transmural pigtail stents were tried after visualization of a large (8–10 mm diameter) fistula tract. Stents were utilized as described in Methods, with a total of three endoscopic interventions, at 2 week intervals, resulting in resolution of the fistula as evidenced by contrast injection into the duodenum under fluoroscopy and subsequent CT scan with oral contrast. The patient’s symptoms resolved and she was tolerating a normal diet. She remained thus at 1 month follow-up.

Conclusion: This case demonstrates the benefit of endoscopic transmural stents for the resolution of duodenal fistulas, expanding the utility of this technique to address leaks and fistulas of the upper gastrointestinal tract. Further study is warranted to clarify the timing and adjuncts to optimize the use of this promising approach.

P132

Totally Laparoscopic ALPPS Combined with the Microwave Ablation for a Patient with a Huge HCC

Hua Zhang; Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting hepatic tumors that were previously considered unresectable due to the insufficient future liver remnant (FLR) which may result in postoperative liver failure (PLF). The procedure has been accepted and modified in many medical centers worldwide. But reports about the laparoscopic ALPPS were rare. This study aimed to report a totally ALPPS combined with microwave ablation for a patient with huge HCC and confirm the feasibility of laparoscopic ALPPS.

Methods: A 51-year-old man had complained of 1-year history of right upper abdominal pain, and the syndrome was worsened in recent month. Abdominal enhanced computed tomography (CT) imaging revealed a 15 × 11 cm solid mass in right lobe of liver with non-uniform and unclear boundary, the right posterior branch of the portal vein was invaded. In addition, a small lesion was simultaneous found in left lateral lobe of liver. The tumor was evaluated as unresectable due to the FLR was only 355 ml (25%). We decided to perform the laparoscopic ALPPS procedure. First stage including microwave ablation of the lesion in left lobe, cholecystectomy, ligation of the portal vein and transection of liver parenchyma. The second stage was done 11 days later and consisted of laparoscopic right hemihepatectomy.

Results: The two stages were underwent by laparoscopy successfully. The operation duration was 300 and 200 minutes, respectively. Estimated blood loss was 550 and 250 ml. The hospitalization time in intensive care unit was 1 and 3 days. There was no need for transfusion in both stages. The patient was discharged 22 days after the second stage and the total hospitalization time was 38 days. Recovery of the patient was uneventful in addition to the incision infection after the second stage which recovered with conservative management. The patient did not show any signs of liver failure. The CT scan before the second stage showed an enlargement of left lobe, the FLR was 533 ml (37.5%). There was no signs of residual liver disease in the CT scan 10 days after the operation. The patient showed no signs of recurrence or liver failure in the following up period of six months.

Conclusion: Totally laparoscopic ALPPS combined with microwave ablation is safe and feasible for the multiple HCC which was not resectable. The hypertrophy of remaining liver was fast and can achieve an adequate volume in a short time.

P134

Pancreatojejunal Derivation (Puestow) by Laparoscopy, About 2 Cases

Mauricio Zuluaga, General and MIS surgeon ¹, Ivo Siljic, General and MIS surgeon¹, Juan Carlos Valencia, General and MIS surgeon², Uriel Cardona, General and MIS surgeon^{2; 1}IJP Colombia, Hospitla Universitario Del Valle, Universidad Del Valle, ²IJP Colombia, Clinicafarallones, Clinica Desa, Cali Colombia

Introduction: Chronic pancreatitis is a benign, irreversible inflammatory disorder characterized by the conversion of the pancreatic parenchyma into fibrous tissue. Initial management should be conservative, surgery is applied in case of failure of medical treatment. The development of minimally invasive techniques has made it possible to perform these highly technical procedures in a laparoscopic manner.

Materials and Method: We have the history of 2 patients with 19 and 42 years with chronic pancreatitis and pancreatic lithiasis of difficult handling but intractable pain to those who decided to surgical management.

We performed the procedure under general anesthesia, epidural analgesia catheter was placed. Neumoperitoneum technique of cali, at 14 mmHg and approach using a 12 mm umbilical port, 2 working ports of 12 and a 1 of 5 mm port,. The pancreas was exposed by a section of the gastrocolic ligament with a 5 mm ultrasonic scalpel, with cephalic retraction of the stomach, opening of a smaller sac and approaching the transpavity of omentum. The ventral surface of the pancreas was exposed from the neck. An incision was made in a pancreas body with a monopolar hook. Primary pancreatic duct lumen was identified and the incision was extended longitudinally from the neck to the tail of the pancreas (8 cm). Roux’s Y loop was prepared 50 cm from the Treitz ligament, with a jejunum section with a 60 mm stapler, Roux’s loop was transmecoscopically retrocollic, closing the gap of the mesocolon with Monocryl. A 60-cm jejunum-jejunal anastomosis was performed with Endo-GIA stapler and closure of enterotomy with 2-0 polypropylene intracorporeal suture. Jejunal (Roux) isoperistaltic loop was placed longitudinally at the opening of the main pancreatic duct, and enterotomy was performed with monopolar in antimesenteric segment. The intracorporeal pancreatico and jejunum anastomosis was performed using a lower and an upper plane, with single points of total thickness with ethnobond 2-0. 1 closed drains were placed towards each anastomosis. this procedure was performed in the 2 patients reported.

Results:

Operative time 180–300 min

complications none

operative time 4–7 days

minimal bleeding

drains No1 retired in both cases at 7 days

1 year follow-up of patients improved pain\

Conclusions: Minimally invasive surgery is a fundamental tool for the approach and management of patients with biliopancreatic pathologies. the establishment of multidisciplinary groups, offer an excellent alteranativa in the integral management of the patients.

P135

Hourglass Gallbladder Recognized During One-Step Laparoscopic Cholecystectomy and ERCP for Chronic Cholecystitis and Choledocholithiasis: A Case Report

Christopher F McNicoll, MD, MPH, MS ¹, Minh-Tri N Pham, MD¹, Hasanali Z Khashwji, MD¹, Charles R St. Hill, MD, MSc, FACS¹, Nathan I Ozobia, MD, FACS^{2; 1}UNLV School of Medicine, ²University Medical Center of Southern Nevada

Gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. Variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, Phrygian cap, ectopic, and hourglass gallbladder. The hourglass gallbladder has been described from the earliest days of cholecystectomy, as Morton described a congenital case in 1908, and Else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in 1914. We describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy.

This 71 year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. He endorsed a history of similar pain several times in the past. His abdomen was soft, nontender, and without Murphy sign. Laboratory evaluation revealed total bilirubin 2.0 mg/dL, alkaline phosphatase 195 U/L, AST 835 U/L, ALT 800 U/L, and no leukocytosis. CT abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra- and extra-hepatic ductal dilation, and a 3.8 centimeter left liver hemangioma. He was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a 7.7 millimeter common bile duct without choledocholithiasis. He was taken to the operating room for a one-step ERCP and laparoscopic cholecystectomy. Upon laparoscopy, dense adhesions to the gallbladder were found. After initially attempting to obtain the critical view of safety, we then embarked on the retrograde “top down” dissection. This isolated a spherical structure measuring 2.4 × 2.2 centimeters. Two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. The common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. The intra-operative ERCP identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. Given the unusual anatomy, we completed the operation, ordered a post-operative CT liver and MRCP, and consulted a hepatopancreatobiliary surgeon. A small remnant gallbladder was identified on CT liver, though not on MRCP. Completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day 4.

This hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. In anatomic uncertainty, the “top down” dissection, intraoperative cholangiography, CT liver, and expert consultation are safe methods to avoid iatrogenic injury.

P136

Laparoscopic Management of Bronchogenic Cyst of Stomach: A Case Report

Veena Bheeman, MBBS, MS, Prem Vignesh Mohan, Vishwanath M Pai, MS, DNB, FRCS, FIAGES, Parimuthukumar Rajappa, MS; Sri Ramachandra Medical College and Research Institute

Introduction: Bronchogenic Cysts are congenital cysts that arise as anomalous budding from the primitive tracheobronchial tree. Incidence of bronchogenic cyst in the wall of the stomach is extremely rare.

Case Description: A 23 year old male presented with epigastric pain for one month with no obstructive symptoms. On evaluation with CT, he was found to have a 5.3 × 3.1 cm cystic lesion arising from the posterior aspect of the body of the gastric fundus, partially compressing the stomach. He was provisionally diagnosed to have a stromal tumour of the body of stomach. Owing to persistent pain, the patient was planned for a diagnostic laparoscopy. With the patient in right lateral position, the surgery was then proceeded to Laparoscopic Partial Gastrectomy with excision of the gastric mass using endoscopic staplers. The postoperative course was uneventful. Histopathological Exam showed a serosal cyst with pseudostratified ciliated columnar epithelium with adjacent extensive xanthomatous changes. The final diagnosis was Gastric Bronchogenic Cyst. On follow-up at 4 weeks, patient was asymptomatic.

Discussion: Bronchogenic cysts of stomach are rare developmental malformations of the foregut. They are lined with cuboidal or pseudostratified ciliated epithelium and may or may not be surrounded by elastic fibres, smooth muscle and cartilage. Bronchogenic cysts are common in the hilar and middle mediastinal area, whereas extrathoracic and subdiaphragmatic bronchogenic cysts are rare. Of the 39 previously reported cases of gastric bronchogenic cysts, only 4 have been managed laparoscopically. On radiological imaging, they often appear uncharacteristic and are often diagnosed as GIST. Surgical resection is advised to treat symptoms and prevent malignant transformation.

Conclusion: Gastric bronchogenic cysts are a diagnostic challenge as they often mimic GIST. Symptomatic cases should be dealt with surgical resection.

P137

Endoscopic Magnet Compression Anastomosis for Small Bowel Obstruction

Carter Lebares, MD, Sandhya Kumar, MD, Matthew Lin, Nicholas Fidelman, MD, John Cello, MD, Michael Harrison, MD, Stanley Rogers, MD; University of California San Francisco

Introduction: Endoscopic entero-enteral bypass could change our approach to small bowel obstruction in patients with prohibitively high operative risk. Magnetic compression anastomoses have been well-vetted in animal studies, but remain infrequent in humans. Isolated cases of successful use in humans include treatment of biliary strictures and esophageal atresia. While endoscopic gastro-enteric magnetic anastomoses have been described, the associated multicenter cohort study was terminated due to serious adverse events. Since then, the technology has evolved and recently our own institution reported results of the first in-human trial of Magnetic Compression Anastomosis (Magnamosis), deployed through an open approach. Here we present the first case of endoscopic delivery of the Magnamosis device and the successful creation of an entero-enteral anastomosis for chronic small bowel obstruction in a patient with prohibitively high operative risk.

Methods: The Magnamosis device has previously been approved by the Food and Drug Administration (FDA) for use in clinical trial. Our Institutional Review Board approved emergency compassionate endoscopic use of the device in this patient due to a non-resolving small bowel resection and prohibitively high operative risk.

Case: This is a 59 year old man with advanced liver disease, chronic obstructive pulmonary disease, and history of emergent right colectomy with end ileostomy for cecal perforation. He presented with multiple acute on chronic episodes of small bowel obstruction with a stable transition point in the distal ileum, radiographically estimated at 15 centimeters proximal to the ileostomy. Endoscopic evaluation through the ileostomy revealed a traversable obstruction with proximally dilated small bowel. The magnets were delivered via endoscopic snare under fluoroscopic guidance and positioned in adjacent loops of bowel on either side of the obstruction (Image 1). By 7 days post-procedure, healthy villi were visible through the central portion of the mated magnetic rings (Image 2). By 10 days the magnetic rings were mobile and the anastomosis was widely patent allowing easy passage of the gastroscope (Image 3), and the patient’s symptoms were completely resolved. The rings passed through the ileostomy 11 days post-procedure. At 1 month follow up, the anastomosis was unchanged (Image 4).

Conclusion: This case demonstrates the benefit of an endoscopically created magnetic compression anastomosis in a patient with small bowel obstruction and high operative risk. Further studies are indicated to evaluate the use of this technique in similar patients or those with malignant obstruction.

P138

Congenital Agenesis Presenting as a Small Contracted Gallbladder

Desiree Raygor, MD, Ruchir Puri, MD; University of Florida Health Jacksonville

Cholecystectomy is one of the commonest operations in general surgery [1]. Occasionally chronic cholecystitis can lead to a small contracted gallbladder. This diagnosis can be misleading as it may represent congenital agenesis of the gallbladder [2]. A 28-year-old female with a past history of pancreatitis presented with a three day history of right upper quadrant pain associated with nausea and vomiting. Upon exam she exhibited tenderness in the right upper quadrant. Her leukocyte count and liver function tests were within normal limits. Ultrasound revealed a poorly visualized, contracted gallbladder without stones and a dilated common bile duct (CBD). Cholescintigraphy revealed non visualization of the gallbladder after two hours, which was suggestive of acute cholecystitis. Decision was made to proceed with a laparoscopic cholecystectomy. The abdomen was entered by an open Hasson technique and standard trocar placement for a cholecystectomy was performed. On initial inspection, the gallbladder was not readily visible. A structure appearing to be the CBD was present and was mobilized circumferentially (Fig. 1). A 19 gauge butterfly cannula was utilized and multiple cholangiographic images were obtained (Fig. 2). No cystic duct or gallbladder was identified which was suggestive of congenital agenesis of the gallbladder. The patient did well postoperatively, and was discharged home on postoperative day two. The patient’s symptoms resolved and she continues to be pain free one month postoperatively.

Congenital agenesis of the gall bladder is a rare disorder. A high index of suspicion is required especially in the setting of a small contracted gall bladder. If preoperative imaging is inconclusive then diagnostic laparoscopy should be the next step. Cholangiogram should be performed routinely to confirm the diagnosis and to rule out an ectopic gall bladder. Conversion to open does not offer any distinct advantage, and laparotomy should be avoided if possible given its associated morbidity.

P139

A Laparoscopic Aneurysm Ligation for Aneurysm of Left Inferior Phrenic Artery: A Case Report

Hanlim Choi ¹, Dong-Hee Ryu¹, Jae-Woon Choi¹, Yanjie Xu^{2; 1}Chungbuk National University Hospital, ²Chungbuk National University College of Medicine

There are many reports upper abdominal major arterial aneurysms. However, an aneurysm of left inferior phrenic artery had never been reported. A 48-year-old woman with liver cirrhosis associated with hepatitis B viral infection was referred to department of surgery for treatment of aneurysm of left inferior phrenic artery. She underwent trans-arterial chemoembolization (TACE) for treatment of hepatocellular carcinoma three times, previously. On 20 months after last TACE, 7 mm sized highly enhancing nodular lesion of gastric fundus was found on follow-up abdomen-pelvis computed tomography (A-P CT). One year later, the size of this lesion increased to 18 mm, and an aneurysm was diagnosed. She underwent angiography and attempted embolization with an aneurysm of the left inferior phrenic artery, but access failed. We performed a laparoscopic vessel ligation. She recovered with no complication and discharged on the 3th postoperative day.

P140

Post CPR Liver Injury in a Pregnant Lady

Yousef Almuhanna, Vatsal Trivedi, Fady Balaa; University of Ottawa

A 34 years old female, G7 and 10 weeks pregnant, was brought to the hospital by EMS, after being found on the floor in her toilette surrounded by vomitus and urine. Mother-in-law, who happens to be at the house that time, have heard severe retching followed by a loud bang sound. Firefighters have found no pulse and therefore started CPR. Return of spontaneous circulation was achieved, yet unfortunately, she had arrested again 5 minutes prior to arrival to ER. POCUS assessment showed large RVOT, and therefore tPA was started on the assumption of pulmonary embolism. Upon arrival of blood work, it was found that her hemoglobin had dropped from 110 to 54. FAST was repeated showing moderate to severe amount of free fluid in the Morrison’s pouch and pelvis. She was then taken to the operating theatre, had undergone laparotomy showing liver segment II injury. Pringle’s maneuver and aortic clamping did not control the bleed, therefore finger fracture and venous clips were used to temporary minimize the bleed, and head to interventional radiology suite. After multiple attempts to control the bleed, and the massive transfusion, she vital signs were not maintained, and had arrested afterwards.

P141

Mesenteric Panniculitis: A Case Report

Sarrath Sutthipong, MD, Chumpunut Chuthanan, MD, Chinnavat Sutthivana, MD, Petch Kasetsuwan, MD; Bhumibol Adulyadej Hospital, Bangkok, Thailand

Background: Mesenteric panniculitis (MP) is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small bowel and colon. The specific etiology is unknown and no clear information about the incidence. The diagnosis is suggested by CT and is usually confirmed by surgical biopsy. Treatment is based on some selected drugs. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We reported a case of the MP diagnosed with CT and surgical biopsy by laparoscopic approach.

Case Report: 50-year-old woman with 5 months history of chronic abdominal pain, mainly localized in the sub-epigastrium, intermittent and mild. She had anorexia but no weight loss or change in bowel habits. No history of medical illness or surgery. The physical examination was unremarkable, except for palpation of ill-defined mass about 5 cm at mid-abdomen, firm, smooth surface with mild tenderness. The laboratory profile and tumor marker were normal. CT of the abdomen, which showed focal heterogeneous enhancement of the mesenteric fat with stranding (8.7 × 4.8 × 10 cm) with multiple internal subcentimeter LNs in the supra-umbilical area, which was probably inflammatory in origin and suggestive of MP. 18F-FDG PET/CT showed faint FDG uptake in multiple mesenteric LNs. The patient was subsequently underwent diagnostic laparoscopy with biopsy. Intra-operative finding showed a fat-like surface of yellowish mass at mesentery of jejunal segment, incisional biopsy was performed laparoscopically. The histology showed adipose tissue with areas of fat necrosis, fibrosis, foamy macrophages infiltration and predominant chronic inflammation, no evidence of malignancy. IHC studies (including CD68, S-100, CD3 and CD20) were performed and the result was compatible with reactive process. Treatment was started with 40 mg prednisone once daily and planned for follow-up with repeated CT scan.

Discussion: MP involves the small bowel mesentery in over 90% of cases. The diagnosis is made by 3 pathologic findings: fibrosis, chronic inflammation and fatty infiltration. The differential diagnosis is broad and has been associated with malignancies such as lymphoma, well-differentiated liposarcoma and melanoma. The imaging appearance varies depending on the predominant tissue component. A definitive diagnosis is biopsy but open biopsy is not always necessary. No data of laparoscopic biopsy, which has been reported previously. Treatment has been reserved for symptomatic cases with a variety of drugs. Our case was started on oral corticosteroid treatment and waited for responsive evaluation.

P142

Internal Hernia Caused by a Free Intraperitoneal Staple After Laparoscopic Appendectomy

Lisa M Angotti, MD, MS, Christopher Decker, MD, Todd Beyer, MD; Albany Medical Center

Background: Laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. Stapled closure of the appendiceal stump is often performed and has been shown to have several advantages. Few prior cases have been reported demonstrating complications from free staples left within the abdominal cavity after the laparoscopic stapler has been fired.

Case Report: A previously healthy 29 year old female initially underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (GIA) staplers. Her initial postoperative recovery was uncomplicated and she was discharged home the same day.

The patient returned to the emergency department on postoperative day 17 with one day of sharp mid-abdominal pain, obstipation, and emesis. Her abdomen was distended and mildly tender but not peritoneal. She was afebrile but was found to have a leukocytosis of 13.2. CT demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction.

Diagnostic laparoscopy was performed through the three prior appendectomy incisions. An adhesion was noted between the Veil of Treves and the mesentery of a more proximal loop of ileum caused by a solitary free closed staple, remote from the staple lines, resulting in an internal hernia containing several loops of ileum (Fig. 1). The hernia was reduced, and the small bowel was noted to have early ischemic discoloration. The adhesion was lysed by removing the staple from both structures to prevent recurrence. Through the remainder of the procedure, the compromised loops of bowel began to peristalse and the color normalized. The procedure was concluded without resection. The patient recovered on a surgical floor and was discharged home on postoperative day one.

Conclusion: Gastrointestinal staplers are commonly used secondary to ease of use and low complication rate. It is not uncommon to leave free staples in the abdomen during laparoscopy as retrieval can often be more difficult and time consuming. Our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staple. Choosing the most appropriate size staple load, to reduce the number of extra staples after the fire, and removing as many free staples as possible can prevent potentially devastating complications.

P143

Video-Assisted Thoracoscopic Pulmonary Wedge Resection in a Patient with Hemopytsis and Intralobar Sequestration: A Case Report

Mary K Lindemuth, MD, Subrato J Deb, MD; The University of Oklahoma Health Science Center

Case Report: A 19-year-old male with history of Noonan’s syndrome, bronchitis, and asthma presented with acute hemoptysis. While chest x-ray was unremarkable, a computed tomography angiogram of his chest was significant for intralobar pulmonary sequestration in the right lower lobe. The aberrant pulmonary artery originated from the abdominal aorta, immediately proximal to the celiac axis, and coursed through the hiatus in the retroperitoneum. Flexible, fiberoptic bronchoscopy revealed blood within the right lower lobe bronchus with no appreciable source. A right video-assisted thoracoscopic approach was taken for wedge resection of the sequestration. Two-portal technique was utilized with the patient on single lung ventilation. The sequestration was easily identified; the anomalous pulmonary artery coursed directly to a large, focal area of hemorrhage noted within the lower lobe pulmonary parenchyma, as seen in Image [rectangle marking the aberrant artery and oval marking the sequestration]. Pathologically, the specimen was noted to be benign lung parenchyma with bronchiectasis and abundant, acute hemorrhage.

Discussion: Pulmonary sequestration (PS) is a rare, congenital bronchopulmonary foregut malformation. Literature describes the incidence of PS to be only 0.15–6.4% of all pulmonary malformations. As PS is most frequently diagnosed during childhood, the occurrence of diagnosis during adulthood is estimated to be less than 3 per 10,000 adults. Two types (intra- and extralobar) are described, with intralobar sequestration most common and contained within the normal visceral pleura. Both types have aberrant systemic arterial blood supply, most frequently from the thoracic aorta. Likewise, both types are nonfunctioning lung tissue, as there is no direct communication with the bronchopulmonary tree. The most common presentation is pneumonia, and often patients will have had recurrent symptoms before diagnosis.

It is rare to present with hemoptysis, which is understood to be secondary to elevated capillary pressure within the sequestration and then communication through the pores of Kohn. While endovascular embolization of the aberrant pulmonary artery has been described as a safe alterative for surgical intervention, the subjects of these studies have primarily been children and long-term outcomes are unknown. The definitive treatment of PS continues to be surgical intervention. The surgeon should strive to leave as much normal lung parenchyma as possible. Video-assisted thoracoscopic resection is well tolerated by patients when compared to thoracotomy. However, it is vital for the surgeon to be aware of the potential risk of life-threatening hemorrhage secondary to the sequestration having systemic blood supply that must be controlled and ligated.

P144

Resection of Giant Mesenteric and Ovarian Cysts by Hybrid Minimally Invasive Technique: A Case Report

Diego L Lima, MD ¹, Gustavo L Carvalho, MD, phD², Raimundo H Furtado, MD², Gustavo H Belarmino de Goes, Medical Student², Natália L Costa, Medical Student^{2; 1}State Servers Hospital, ²University of Pernambuco

Case Report: a 51 years-old female patient with history of an increased mass and weight loss of 7 kilograms in 15 months, associated with vomiting and nausea for eight months. Abdominal ultrasound showed an irregular cyst, without solid projections and without signs of flow in Doppler, measuring 20 × 11 × 20 cm. Investigation continued with CT scan that showed a large homogeneous cystic lesion with no septum in the abdominopelvic region, possibly mesenteric, measuring 20.5 × 10.5 × 24 cm. A laparoscopic approach for resection of the cyst was then performed. The surgery was performed with a patient in the dorsal decubitus, using three trocars: one in the umbilical region (11-mm) for the camera, and where the pneumoperitoneum was created by the Hasson open technique under direct vision; and another two located in the epigastrium (5-mm) and in the right upper quadrant (3-mm). In addition to the mesenteric cyst, a simple cyst in the right ovary and a solid nodule with a lipomatous characteristic of approximately 3 cm in the abdominal cavity were visualized. Total resection of the mesenteric cyst with periprancreatic fibrous tissue was performed. The cyst was punctured and its contents fully aspirated. Resection of the right ovarian cyst was also performed. At the end of the procedure the mesenteric and ovarian cysts, the nodule, part of the omentum, and the peripancreatic tissue were removed through the 11- mm trocar at the umbilicus. Patient had no further complications, being discharged four days after the procedure. Histopathologic result showed a serous cyst in the right ovary, serous cyst in peripancreatic mesentery with chronic inflammatory process and signs of calcification; no signs of malignancy were observed in any specimen.

Conclusion: The Hybrid Laparoscopic technique was safe and effective for this procedure. The known advantages of the minimally invasive approach such as less trauma, greater dexterity, higher precision, lower postoperative pain, and shorter hospitalization time were confirmed.

P145

Videolaparoscopic Treatment for Wilkie Syndrome Developed 10 Years After a Heller-Dor Procedure for Achalasia

Felipe C Victer, MD, FACS, Pedro Henrique Salgado Rodrigues, MD, Andre M Silva, MD; Hospital Federal do Andaraí

Male 45 years old suffering from achalasia were submiited a heller dor procedure 10 years agor. Despite the fact of better life outcome, he begins to suffer difficulties to swallon in the last yera. During investigation it was observed a upper gastro insteinal obstruction, due to a superior mesenteryc artery syndrome. Tc scan was used to conclued the diagnosis. The patient were submmited to a duodenum-jejunun anastomosis with laparoscopic approach. After surgery he had relif of syntoms.

P146

Case Report: Ulcerative Roux Limb Jejunitis After Gastric Bypass

Madalyn Morse, DO, Mukund Srinivas, BS, Joon K Shim, MD, MPH, FACS; Wright State University Boonshoft School of Medicine

Introduction: The differential diagnosis for abdominal pain after gastric bypass include dietary disorders, functional disorders, biliary disorders as well as pouch and remnant stomach disorders. With regards to small intestine disorders, the usual culprits are hernias, adhesions, stenosis, and intussusception. We describe a rare case of a patient with ulcerative roux limb jejunitis.

Case Description: A 48 year old female with asthma, diabetes mellitus, fibromyalgia, hypertension and roux-en-y gastric bypass in 2005 for weight loss presented to our hospital with one week history of abdominal pain, vomiting and poor oral intake. At that time, she reported one episode of dark colored stool with admission hemoglobin of 8.2 with known chronic iron deficient anemia. She endorsed recent heavy NSAID use to control her fibromyalgia discomfort. Patient was not on home proton pump inhibitors or H2 blockers after her gastric bypass. Inpatient upper endoscopy showed erosive pouchitis and moderately severe jejunitis thirty centimeters from the gastrojejunal anastomosis in the mid-jejunal roux limb. Biopsies taken at that time demonstrated acute ulceration of jejunum and patchy/non-specific gastritis. Patient was recommended to discontinue NSAID use and begin twice daily proton pump inhibitor treatment. Helicobacter pylori testing was negative during admission. Hemoglobin remained stable.

Discussion: Roux-en-y gastric bypass is associated with risk of several postoperative complications including malnutrition, GERD, internal hernia, anastomotic leak and marginal ulceration. There are several hypothesized causes of marginal ulceration post-RYGB including pouch size, orientation, staple line integrity, mucosal ischemia secondary to tension, NSAIDs, helicobacter pylori and smoking. Although several sources site jejunitis in post-RYGB patients, there are minimal reports of ulcerations thirty centimeters distal to the gastrojejunal anastomosis in the roux limb. Our patient’s ulcer was attributed to her heavy NSAID use for fibromyalgia. Although not yet a standard of care, it is not an uncommon practice for patients to be placed on long-term acid-suppression therapy with proton-pump inhibitors to mitigate this risk. Our patient was not on long term PPI use at time of her jejunal limb ulcer diagnosis.

Conclusion: Marginal ulcers at the gastrojejunal anastomoses are well known post-operative complication of RYGB as well as asymptomatic jejunitis of the roux-limb. Patients with increased risk factors including heavy NSAID use and smoking are also at risk for jejunal ulceration up to 30 centimeters from the GJ anastomosis as demonstrated by our patient case. Long-term PPI suppression therapy for post-RYGB patients should be considered in those at high risk for ulcers.

P147

Safe Laparoscopic Surgical Approach to GI Bleed in Jehovah’s Witness Patient

Emanuela S Alvarenga, MD, Heather Stewart, MD, Justin Lee, MD, Alexander Ramirez, MD, FACS; Florida State University

We aimed to present the succesul therapeutic approach utilizing laparoscopy for safely removing a Gastrointestinal Stromal Tumor. Depicted is a 66 year old Jehova’s witness female who presented to the emergency department for evaluation of bitemporal headache and dizziness and found with profound anemia with hemoglobin 5.4 and hematocrit 16.6 upon arrival to ED. The patient refused blood transfusion as her religious beliefs, Jehovah’s Witness, preclude her from taking blood products. As part of her work up, endoscopy was performed and revealed a large, approximatelly 4 × 4 cm, prolapsed, ulcerated, nodular lesion with active bleeding in the cardia of the stomach. This was temporized but the friable tissue, with no single identifiable lesion for clip placement, left the patient at high risk for re-bleeding. She was taken to the operating room and Laparoscopic partial gastrectomy with intraoperative esophagogastroduodenoscopy were succefully perfomed, with minimall blood loss and no intra operative complications. Patient was discharged on post op day 3.

P148

Duodenal Stump Blowout After SADI-S Conversion to RYGB Managed with a Percutaneous Duodenostomy Tube. A Case Report and Review of the Literature

Alvaro F Galvez, MD ¹, Daniel A Galvez, MD², Alexander Onopchenko, MD³, Nicholas J Petruzzi, MD^{3; 1}Hahnemann University Hospital, ²Virginia Commonwealth University Health System, ³Atlanticare Regional Medical Center

We present the case of a 46-year-old male with a history of morbid obesity with an initial BMI of 44.7, who underwent an elective laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S). Postoperatively he developed an anastomotic leak at the duodeno-ileal anastomosis that would not resolve despite reoperation. He was then converted to a Roux-en-Y gastric bypass (RYGB). Postoperative imaging failed to reveal any signs of anastomotic leak and the patient was discharged tolerating an oral diet. He returned to the emergency department 11 days later with a 6 × 3 × 2 cm sub-hepatic collection arising from the duodenal stump from the surgical conversion. Interventional radiology percutaneously drained the collection and found a connection between the cavity and the duodenum. Using this connection, a percutaneous decompressive duodenostomy drain was successfully inserted into the duodenum using a guidewire through the abscess cavity along with an extra-enteric drain placed within this cavity. The collection was obliterated and the duodenal leak was controlled successfully with percutaneous drainage, bowel rest with parenteral nutrition and broad-spectrum intravenous (IV) antibiotics. The patient was reintroduced to a bariatric clear diet after a week of bowel rest and the abscess drain was then discontinued during the same hospital admission. The patient was discharged with the percutaneous duodenostomy tube which was removed in clinic 34 days later, after the patient tolerated capping trials and imaging failed to reveal any further collections, oral contrast extravasation or distal obstruction.

In this article we analyze notable imaging from the case and review current literature on the different management options for a duodenal stump blowout. We also discuss the basics of the SADI-S procedure and conversion of a SADI-S procedure to a RYGB.

Keywords: Anastomotic leak, Duodenal stump blowout, SADI-S, Duodenostomy tube.

P149

Pancreatic Heterotopia Mimicking an Internal Hernia

Leigh Gerson, DO ¹, Danielle Luchessi¹, John Brady¹, Timothy Harrison^{2; 1}Philadelphia College of Osteopathic Medicine, ²Crozer Chester Medical Center

Pancreatopic heterotopia is often an incidental finding on autopsy, but in some cases can lead to abdominal pain, obstruction, or intussusception. We present a case of pancreatic herterotopia mimicking an internal hernia on radiologic imaging.

A 47 year old female with seven month history of chronic abdominal pain treated for low back pain and recurrent urinary tract infections. She was found to have a Computed Tomography (CT) scan concerning for internal hernia and labs consistent with acidosis. She was taken for a laparotomy and did not have an internal hernia, but an exophytic mass in the proximal jejunum. The mass was resected and a stapled side to side jejunojejunostomy was created. On pathologic review, the specimen was found to be pancreatic heterotopia. Her post operative course was complicated by an ileus, but was discharged post op day three. At her two week follow up she had minimal incisional pain and at one year follow-up she had resolution of her left upper quadrant abdominal pain.

Prior to this report, pancreatic heterotopia has never been described as presenting on CT scan as an internal hernia. Although uncommon it should remain in the differential when evaluating a patient presenting with abdominal pain and radiologic evidence of obstruction or internal hernia.

P150

A Refractory Abscess of the Adrenal Gland Associated with Suboptimal Indwelling Catheter Management in a Diabetic Patient

Peng Yu, MD, PhD, Kathleen Hromatka, MD, Alan Posner, MD; Department of Surgery, SUNY Buffalo, Kaleida Health System, Buffalo, NY

Introduction: Adrenal gland abscess is an extremely rare finding in adults. We present a case of a refractory adrenal abscess likely secondary to inadequate drainage of an adrenal cyst.

Case: The patient is a 53-year-old female with a history of poorly controlled type 2 diabetes and prior treatment of a non-functioning, benign cyst of the left adrenal gland. In Singapore in 2016, the patient underwent four separate episodes of percutaneous aspiration and drainage with an indwelling catheter. Shortly after immigrating to the U.S. in February 2017, she was admitted to our facility with flank pain and a non-healing draining sinus at the prior left flank drain site without significant systematic symptoms. CT images confirmed a 4 × 5 × 7 cm³ left suprarenal fluid collection with a calcified rim (Figs. 1–3). An ultrasound-guided percutaneous drainage obtained 40 mL of purulent fluid, and an indwelling drain catheter was placed. The drain fluid was cultured and found to be positive for Methicillin-sensitive staphylococcus aureus. The patient was treated with a course of antibiotics and discharged home. The patient demonstrated poor compliance with care of her drain catheter and the adrenal abscess persisted on follow-up CT imaging (sizing 4.2 × 4.4 × 4.7 cm³). Subsequently, the patient elected to undergo a laparoscopic left adrenalectomy with excision of associated adrenal abscess in April 2017 after establishing care with a primary care physician and optimizing her diabetic control. The procedure and postoperative course were uneventful and the patient recovered well. Pathology revealed benign inflammation of the left adrenal gland, with necrosis, calcification and fibrotic changes in the para-adrenal tissue.

Discussion: There are few instances of adrenal gland abscess reported in the literature. Our patient has a recent surgical history of multiple percutaneous aspiration and indwelling catheter drainages for a symptomatic benign adrenal cyst. Her uncontrolled diabetes and noncompliance with instructions for drain care likely contributed to her development of a refractory adrenal abscess. This case highlights the importance of prudent decision making with regards to electing to drain adrenal gland pathology, as well as vigilant management of indwelling catheters.

P151

A case of Leiomyosarcoma of duodenum

Lavith Kuttichi, Vishwanath Pai, Pari Muthukumar; Sri Ramachandra Medical College

Introduction: Leiomyosarcoma of the duodenum is a rare disease it can occurs in both sexes with approximately the same frequency. Peak incidence is in the 40 to 49 year age. Leiomyosarcoma is relatively infrequent compared to adenocarcinoma of the duodenum. It may develop from all parts of the gastrointestinal tract. The duodenal localisation is rare.

Case Report: A 64 year old male presented with complaints of abdominal pain for one month in the epigastric region which increased after food intake. No obstructive symptoms. On palpation, palpable mass occupying epigastric and right hypochondrium. On evaluation with CECT abdomen shows growth in the second part of duodenum. Patient underwent pancreaticoduodenectomy. The postoperative course was uneventful. Histopathological examination revealed as leiomyosarcoma of second part of duodenum. On follow-up at 4 weeks, patient was asymptomatic.

Conclusion: Leiomyosarcoma of the duodenum is relatively infrequent compared to adenocarcinoma of the duodenum. They are usually large tumours that involve the full thickness of the bowel wall and present in small intestine and Colon. Present with intestinal bleeding, obstruction and weight loss. They are aggressive often Metastasis to peritoneum, liver, lungs and bone.

Clinical latency makes the diagnosis often at an advance stage stage. The most effective surgical therapy has been radical local excision of the tumor. Extensive removal of regional lymphatics would not seem to be a fruitful pursuit, since nodal metastases are rare. Since the techniques of pancreatic and duodenal surgery have been refined, excisional therapy has been possible with a low mortality. Aggressive surgical therapy is indicated both for relief of symptoms and because of the definite chance for cure in some cases.

P152

Left Adrenalectomy and Retroperitoneal Lymphadenectomy by Hybrid Minimally Invasive Technique: A Case Report

Diego L Lima, MD ¹, Gustavo L Carvalho, MD, phD², Raimundo H Furtado, MD², Gustavo H Belarmino de Goes, Medical Student², Lucyeli L Amorim, Medical Student^{2; 1}State Servers Hospital, ²University of Pernambuco

Case Report: A 26-year-old male patient who was diagnosed with high blood pressure at 18 years-old and presented tetraparesis and intense asthenia for six months. Blood tests showed hypokalemia, hypernatremia, and suppressed renin activity. Ultrasound of the urinary tract was normal. CT scan of the abdomen showed a hypodense nodule with regular margins, measuring 1.4 × 1.0 cm with a density of 18 HU in the non-contrast phase and heterogeneous uptake after the injection of the contrast in the left adrenal gland. Thus, the diagnosis of hyperaldosteronism secondary to the left adrenal nodule was confirmed, and surgical resection was indicated. The procedure was performed with the patient in the right lateral decubitus. Two 3-mm and one 5-mm trocars were used on the left flank, as well as the 10-mm portal for the camera in the lower right quadrant under direct vision. The pneumoperitoneum was created by the Hasson open technique in the transumbilical incision. The procedure consisted of the dissection, isolation and electrocautery of the left renal capsule and the left adrenal region with ultrasonic device, as well as the periadrenal vessels, adjacent lymph nodes and periadrenal and adrenal fat tissue. The surgery was uneventful and the patient had no further complications, being discharged the next day. Histopathologic result showed a completely excised adrenocortical adenoma.

Conclusions: The hybrid minimally invasive approach proved to be safe and effective for this procedure, and the known advantages of minilaparoscopy such as less trauma, better visualization, better dexterity, better aesthetics, and reduced hospital stay were observed.

P153

An Unusual Presentation of Coccidioidomycosis with Peritoneal Involvement in an Immunocompetent Individual

Joseph D Krocker ¹, Benjamin Clapp, MD, FACS^{2; 1}The Texas Tech Health Sciences Center Paul L Foster School of Medicine, ²The Texas Tech Health Sciences Center Department of Surgery

Background: Coccidioidomycosis is a fungal infection endemic to the southwestern United States, Central America and South America. Coccidioides is ubiquitous in many of these endemic regions, with near 100% seroconversion in some communities. Two-thirds of these mycotic infections may be asymptomatic. The most common presentation of coccidioidomycosis consists of “flu-like” symptoms or pneumonia. Less than five percent of symptomatic cases progress to disseminated coccidioidomycosis which may involve any organ system. Very rarely infection may include the peritoneum. We report a case of coccidioidomycosis with peritoneal involvement in an immunocompetent individual.

Case: A 36-year-old male presented to the Emergency Department with progressive abdominal pain. He was seen and treated for pneumonia in the Emergency Department one week prior. The patient worked outdoors in Arizona and was otherwise healthy with a family history of malignancy and blood disorders. Fever, leukocytosis and ascites on computed tomography scan prompted a diagnostic laparoscopy which revealed peritoneal granulomas positive for Coccidioides. The patient was treated outpatient with Fluconazole.

Discussion: Since 1939 this is the 38th reported case of peritoneal coccidioidomycosis to our knowledge. The patient described in this case report was an otherwise healthy 36-year-old male; this is incongruent with many of the previously recorded cases which involved disseminated disease in immunocompromised patients. The patient’s family history of malignancy and blood disorders suggests a potential underlying genetic predisposition that could account for this abdominal presentation. Possible mutations include genes coding for the interleukin-12 β1 receptor and the signal transducer and activator of transcription 1 which have been implicated in increased coccidioidomycosis susceptibility. Peritoneal infection presents a unique challenge in diagnosis. In these cases coccidioidomycosis may not be suspected due to nonspecific symptoms and imaging, the infrequency of this extra-pulmonary manifestation and clinical characteristics that mimic the presentation of tuberculosis and malignancy. Abdominal infections have been misdiagnosed as appendicular abscesses, iliopsoas abscesses, adnexal abscesses and pancreatic masses. Consequently, the diagnosis of peritoneal coccidioidomycosis is often made after laparoscopic exploration of the abdomen and histopathology, as it was in this case report.

Conclusions: Coccidioidomycosis incidence is on the rise in endemic areas and it often falls on the surgeon to make the diagnosis in extra-pulmonary cases. The peritoneal subset of coccidioidomycosis should be considered in endemic areas when a young, otherwise healthy patient presents with abdominal pain. Failure to recognize the possibility of coccidioidomycosis may lead to unnecessary treatments and procedures.

P154

Indocyanine Green Cholangiography to Detect Anomalous Biliary Anatomy

Steven D Schwaitzberg, MD, Gabrielle Yee, MS; University at Buffalo Jacobs School of Medicine

Introduction: Common bile duct injury is the most feared complication of cholecystectomy. Imaging with indocyanine green (ICG) is a safe and effective technique to detect biliary anatomy in open, laparoscopic and robotic surgery. Several studies report detecting aberrant biliary anatomy with the use of ICG in laparoscopic cholecystectomy with high success rates. By identifying the cystic duct–common hepatic duct confluence before dissecting Calot’s triangle, ICG allows surgeons to perform “virtual” cholangiography at the start of procedures to identify either normal anatomy or possible anatomic variants. It is clear that ICG use is an effective tool to achieve the critical view of safety. However, no reports have suggested ICG cholangiography as the last operative step in cholecystectomy to identify hidden biliary anomalies and avoid postoperative bile leak complications.

Case Report: We report a novel use of ICG cholangiography in visualizing anomalous biliary anatomy prior to closing, thus avoiding potential bile duct leakage. In our case, ICG cholangiography was used to fluoresce the common hepatic duct, common bile duct and cystic duct.

The cystic duct was transected, and the gallbladder was removed using electrosurgery. At the completion of the gallbladder removal, the liver was elevated to inspect the clips on the cystic duct and artery. At this point, near infrared imaging was reinitiated, and a small 1 mm structure was noted to fluoresce next to the cystic artery. This structure was identified using white light and subsequently clipped.

Discussion: The use of ICG in this context after the completion of the cholecystectomy facilitated the identification of a small hepatocystic or aberrant duct, which would have likely leaked bile sometime in the postoperative period. Based on our experience, we recommend one additional routine near infrared viewing to identify small structures or potential leaks at the completion of cholecystectomy. Improved visualization of the extrahepatic biliary anatomy by ICG has the potential to translate into improved clinical outcomes. Limitations to ICG cholangiography include the inability to visualize deep ductal structures due to limited penetration of near infrared light and poor exposure of Calot’s triangle with inexperienced laparoscopic surgeons. Future studies should aim to establish guidelines on optimal dosage and time frame for ICG administration and bile duct visualization.

P155

Malignant Solitary Fibrous Tumor of the Stomach: Uncommon Differential Diagnosis for GIST Tumors

Elida Voth, BA ¹, Steve Serio, MD², John Gross, MD³, Nicholas Dietz, MD³, Kalyana Nandipati, MBBS^{2; 1}Creighton University School of Medicine, ²Department of Surgery, Creighton University School of Medicine, ³Department of Pathology, Creighton University School of Medicine

Solitary fibrous tumors (SFT) are uncommon fibroblastic mesenchymal neoplasms that display a wide range of histologic behaviors. These tumors, which are estimated to account for 2% of all soft tissue neoplasms, typically follow a benign clinical course. However, it is estimated that 10–30% of SFTs are malignant and demonstrate aggressive behavior with local recurrence and metastasis up to several years after surgical resection. We report a case of SFT arising from the stomach, which is an exceptionally rare finding and has been reported only six times in the literature. Additionally, this tumor was associated with dedifferentiation into undifferentiated pleomorphic sarcoma. To our knowledge, there are no documented cases of a malignant SFT arising from the stomach to demonstrate dedifferentiation into an undifferentiated pleomorphic sarcoma.

A 68-year-old male presented to the emergency department with vague complaints of right-sided flank pain. The patient had a history of nephrolithiasis and underwent a CT abdomen. This scan revealed a large heterogeneous mass in the left upper quadrant. The patient underwent endoscopic ultrasonography with fine needle aspiration of the mass, which stained strongly for CD34. Gastrointestinal stromal tumor (GIST) was the favored diagnosis as it is by far the most common mesenchymal neoplasm of the stomach, especially CD34 positive spindle cell neoplasm. Accordingly, the patient began treatment with imatinib; however, after four weeks of therapy, there was no significant radiologic regression. A second biopsy was performed and the specimen was sent for STAT6 immunohistochemistry, which revealed diffuse strong nuclear positivity. A diagnosis of solitary fibrous tumor was provided. Surgical resection of the tumor was performed, which measured 17 × 14 × 10.5 cm. The patient was to undergo surveillance imaging every 3 to 6 months post-operatively. Surveillance scan showed solitary metastatic disease in the left lateral segment of the liver. He underwent left lateral segmentectomy with an uneventful recovery.

Our case was complicated by diagnostic dilemma with GIST, highlighting the challenges of diagnosing and characterizing SFTs. Dedifferentiation, or the abrupt transition from a classic SFT into a high-grade sarcoma, is a particularly concerning finding in our case, as it is associated with a worse prognosis than classic malignant SFT. The STAT6 marker by immunohistochemistry is very specific for SFT and may have aided in the diagnosis earlier. Therefore, it is imperative to keep solitary fibrous tumor, albeit exceedingly rare, in the differential diagnosis of mesenchymal neoplasms of the stomach.

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Appendiceal Diverticulitis, an Uncommon but Relevant Pathology, Successfully Treated with Laparoscopic Appendectomy

Elizabeth A Verrico, DO, Lindsay Tse, DO, Maurizio Miglietta, DO; Hackensack Meridian Health Palisades

Appendiceal diverticulitits is an uncommon pathology that can clinically mimic acute appendicitis. Some radiographic distinctions have been reported, but final pathologic examination of the surgical specimen is required to confirm the diagnosis. Symptoms are often more mild, which can lead to a delayed diagnosis, and increases the risk of severe complications such as perforation.

A 48 year old female presented with a three day history of right lower quadrant pain. She described the pain as constant and radiating to the left lower quadrant. Associated symptoms included nausea and vomiting, and decreased appetite; she denied fevers or diarrhea. The patient had no significant past medical history, and surgical history was significant for a total nephrectomy for living donor kidney transplant to her mother. On physical exam she was tender in the right lower quadrant with rebound and a positive Rosving’s sign. All laboratory results were unremarkable, and she was hemodynamically stable. CT scan was performed and demonstrated a dilated fluid filled appendix with surrounding inflammatory change without abscess or free intra-peritoneal air. She was subsequently admitted to the hospital, made npo, started on IV antibiotics, and was taken to the operating room where she underwent an uncomplicated laparoscopic appendectomy. Post-operatively, her hospital course was unremarkable. Pathology revealed acute suppurative appendicitis secondary to an acutely inflamed appendiceal diverticula, consistent with a final diagnosis of acute appendiceal diverticulitis.

Appendiceal diverticulitis should be considered in patients presenting with acute right lower quadrant abdominal pain. Although some consider appendiceal diverticulitis a variant of acute appendicitis, it is important to distinguish between the two diagnoses. Appendiceal diverticulitis has a higher rate of complications, including perforation, and is associated with a higher risk of neoplasm, particularly mucinous adenomas and carcinoid tumors. Appendectomy should be performed in all cases in order to obtain appropriate pathological examination and rule out coexistent neoplasms. Laparoscopic appendectomy is a safe and appropriate approach to treatment of appendiceal diverticulitis.

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Resection of Stromal Tumor by Minilaparoscopy Assisted by Upper GI Endoscopy: A Case Report

Diego L Lima, MD ¹, Gustavo L Carvalho, MD, phD², Gustavo H Belarmino de Goes, Medical Student², Raquel N Cordeiro, Medical Student³, Gustavo A Carvalho, MD^{2; 1}State Servers Hospital, ²University of Pernambuco, ³Health Faculty of Pernambuco

Case Report: A 62-year-old male patient, who had had melena for about a year. Upper GI endoscopy and biopsy showed a gastrointestinal stromal tumor (GIST) in the stomach. A videolaparoscopic partial gastrectomy was then proposed. The surgery was performed with the patient in the right lateral decubitus. Two 3-mm minilaparoscopic trocars, a 5-mm conventional trocar for an ultrasonic instrument and a 10-mm trocar in the umbilical region for the camera were used. Pneumoperitoneum was created using the Hasson open technique under direct vision. Trans-operatory endoscopy was perfomed to identify the tumor easily. Initially, the ultrasonic device released the large omentum, and, then, the tumor was resected in the body of the stomach. The gastric wall was manually sutured with a 2-0 Vicryl, and the tumor was removed in an endobag through the 10-mm incision in the umbilicus. The surgery was uneventful, with a total time of 72 minutes. The patient had no further complications, being discharged two days after the procedure with good clinical conditions. Histopathological result showed a free margins GIST.

Conclusion: The minimally invasive approach proved to be safe and effective for this procedure. The known advantages of video-surgery such as less trauma, better visualization, increased dexterity, better esthetics, and less postoperative recovery time were confirmed. The Upper GI endoscopy contributed to improve the safety and efficacy of the procedure, allowing a more precise resection of the GIST, as well as the intragastric review of the suture line at the end of the surgery.

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Portal Vein Thrombosis After Elective Laparoscopic Right Hemicolectomy for Recurrent Diverticulitis

Amanda Fazzalari, MD ¹, Laura Tafuri, MS, III¹, Vladimir Coca-Soliz, MD², Shady Macaron, MD, FACS^{1; 1}Saint Mary’s Hospital, ²University of Maryland

Background: Portal vein thrombosis (PVT) is a rare post-operative complication, which has been associated with a wide range of precipitating factors. Most commonly described associated conditions include; cirrhosis, bacteremia, myeloproliferative disorders and hypercoagulable states. PVT most frequently occurs as a complication after hepatobiliary surgery, and although possible, very few cases have been documented occurring after laparoscopic surgery of the gastrointestinal tract. Herein, we describe a case of PVT in a patient who underwent elective laparoscopic right hemicolectomy and was treated successfully at our center.

Case: A 39 year-old female with past medical history of depression, migraines and endometriosis underwent an uncomplicated laparoscopic right hemicolectomy at our facility, for recurrent right-sided diverticulitis. She had suffered 4 previous episodes of diverticulitis and desired definitive surgical treatment. Her hospital course was uneventful and she was discharged to home on post-operative day 2. On post-operative day 9, she presented to the emergency department complaining of severe abdominal pain, back pain and nausea. Computed tomography of abdomen and pelvis revealed PVT. She was initiated on therapeutic anticoagulation with heparin. Hematology was consulted for hypercoagulable workup. Further investigation revealed that she had a family history of a brother who had had a lower extremity deep venous thrombosis, with negative hypercoagulable workup. She had also previously been taking leuprolide and conjugated estrogen and medroxyprogesterone for her endometriosis. She was ultimately found to have a heterozygous prothrombin G20210A gene mutation. Her anticoagulation was bridged to Coumadin and she was discharged home. She has recovered as expected, without any further complications.

Discussion: Although more common in patients with cirrhosis after hepatobiliary surgery, PVT is a rare complication that can occur after virtually all types laparoscopic surgeries, including elective right hemicolectomy. Patients may be completely asymptomatic, or present with a broad spectrum of symptoms including; severe abdominal pain, fever, diarrhea, or gastrointestinal bleeding. Physicians should be aware of this possible complication, since early diagnosis and treatment is imperative to prevent life-threatening complications, such as intestinal ischemia and perforation. A detailed medical and family history is imperative, and all patients with post-operative PVT should undergo complete hypercoagulability workup.

P159

Upper GI Bleed in the Setting of Fundoplication: An Occult Presentation of Late Onset Gastric Ischemia

Carmen Tugulan, MD, Christopher Mellon, DO, Keng-Yu Chuang, MD, Paul Anthony R Del Prado, MD; Maricopa Integrated Health System

This is a case of a 37 year old male with a previous history of a redo-hiatal hernia 5 years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. During his second admission, initial hemoglobin was 5.5 g/dL and endoscopy performed showed massive amount of blood in the stomach. Continuous oozing was seen originating in the fundus area but no clear source could be identified. Empiric epinephrine was injected to the area but failed to achieve hemostasis. Angiography was also negative. Repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. The patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. The patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. The patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. He subsequently underwent a Roux-en-Y reconstruction and gastrostomy tube placement via the distal gastric remnant. Upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. His recovery was uneventful and he was discharged home in stable condition.

Pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. On reviewing the literature, gastric ulcers and ischemia have been previously described. Incidence was up to 3% and their onset of presentation ranged from the early post-operative period up to 5 years. Most were located in the lesser curvature. The exact pathophysiology for its occurrence is not completely understood. Factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion.

Treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. Our case presents failed medical and endoscopic management. We recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. Otherwise emergent cases will require staged gastrectomy including the wrap followed by Roux-en-Y reconstruction.

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Acalculous Cholecystitis Associated with a Large Periampullary Duodenal Diverticulum: A Case Report

Peng Yu, MD, PhD, Austin Iovoli, Aaron Hoffman, MD; Department of Surgery, SUNY Buffalo, Kaleida Health System, Buffalo, NY

Introduction: Periampullary diverticulum (PAD) could compress common bile duct (CBD), and consequently cause obstructive jaundice and cholangitis as few publications have documented. Here we first report an acalculous cholecystitis associated with a PAD-related CBD obstruction.

Case: The patient was a 60-year-old female with a past surgical history of laparoscopic sleeve gastrectomy who presented at the emergency room with upper abdominal pain and vomiting for one day, associated with leukocytosis and left shift. Serum total bilirubin raised up to 6.1 mg/dL on hospital day (HD) 3. CT, ultrasound, and MRCP images confirmed a distended, wall-thickening gallbladder with pericholecystic fluid, and a significantly dilated CBD at 1.2 cm of diameter (Fig. 1), without cholelithiasis or choledocholithiasis. ERCP was unable to be completed due to the post-gastrectomy anatomy and the failure in cannulation into the ampulla which embedded in a large food-impacted PAD (Fig. 2). On HD5, the patient underwent a diagnostic laparoscopy and an intra-operative cholangiogram which confirmed a mildly inflamed edematous gallbladder, and a 3.8 × 3.8 cm² large PAD with a narrow neck that was distorting the distal CBD (Fig. 3). Since the patient’s bilirubin level had been improving, we decided to only do a laparoscopic cholecystectomy. Intraoperatively an anatomic variation of the cystic artery encircling the cystic duct (Fig. 4) was also identified. Postoperatively the patient recovered well during the thereafter inpatient course and at the postoperative 3-week outpatient follow-up. The pathology of the excised gallbladder confirmed cholecystitis without cholelithiasis.

Discussion: Lemmel’s syndrome is defined, in the absence of cholelithiasis or other detectable obstacle, by obstructive jaundice due to PAD. Since Lemmel described this duodenal-diverticulum-obstructive jaundice in 1934, there still have been very few cases reported or investigated. To date there is no report describing the association of acalculous cholecystitis with Lemmel’s syndrome. This patient’s mild acalculous cholecystitis probably attributed to the biliary obstruction and consequent gallbladder hydrops. Her symptoms could be from either acalculous cholecystitis or intermittently worsening biliary obstruction. In this case, the contribution of the anatomic variation of the cystic artery is unclear. In the future, if this patient’s symptoms recur, the treatment plans for her will be sphincterotomy, removal of the impacted food in the PAD, or diverticulectomy.

P162

Accidental Fish Bone Ingestion Masquerading as Acute Abdomen

Anil Khetarpal; Khetarpal Hospital

Aim: To report a case of fish bone ingestion masquerading as acute abdomen.

Case Report: A 48 years old female patient presented with complaints of severe abdominal pain since 5 days. There was no history of associated nausea or vomiting, fever or altered in bowel habits. On examination patient had tenderness and guarding localized to the right iliac fossa. Blood investigations revealed raised inflammatory markers. Ultrasound whole abdomen and Contrast Enhanced Computed Tomography (CECT) were normal. Patient was managed conservatively but in view of persistence of symptoms a triple puncture diagnostic laparoscopy was performed on day 3 of admission. Omental inflammation with soapy appendix was found and appendicectomy was performed. On further assessment a foreign body was also found in the ileum which was removed and identified as a fish bone. Patient had a satisfactory post operative recovery and was discharged in stable condition.

Discussion: Acute abdomen due to fish bone ingestion is not a very common occurrence. Unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. CT scans can be useful to aid diagnostics. It is however not fully sensitive in detecting complications arising from fishbone ingestion.

Conclusion: Any patient with acute abdomen, with non-specific history and normal imaging may still benefit from a diagnostic laparoscopy.

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Nothing but NET: Neuroendocrine Tumor Masquerading as a Small Bowel Obstruction and Cecal Necrosis

Yael Marks, MD, Denis Gratsianskiy, MD, Neal Mineyev, Jeffrey Aronoff, MD; Lenox Hill Hospital

Introduction: Here we report an isolated cecal necrosis likely secondary to mesenteric fibrosis from a small bowel neuroendocrine tumor.

Case Presentation: 69 yo M with BPH, COPD, and HTN who presented with a four day history of abdominal pain, vomiting, constipation and obstipation. He had never had any abdominal surgeries. CT demonstrated dilated loops of small bowel a transition point in the mid abdomen and submucosal fat deposition in the distal small bowel and cecum and calcified right mesenteric lymph nodes. Creatinine was 1.8, WBC 17,000, and stable vital signs. During exploratory laparotomy a loop of ileum had wrapped itself around an infarcted wall of the cecum (non-circumferential). On closer inspection of the small bowel, a small nodule and tethering of the mesentery were noted 35 cm from the ileocecal valve. An ileocecectomy was performed.

Pathology revealed transmural gangrenous necrosis of the cecum. A 1.7 cm well-differentiated neuroendocrine tumor was found in the resected ileum. Six of sixteen lymph nodes showed metastatic neuroendocrine tumor cells. Surgical margins were clear from malignant cells. The tumor was considered well-differentiated neuroendocrine carcinoma with a Ki-67 index of < 3%. Biochemical testing were significant for a 5 HIAA level of 5.2, Chromogranin A of 125 and a Serotonin level of 340.

Discussion: This patient presented with a bowel obstruction, partial cecal necrosis and neuroendocrine carcinoma. Literature suggests that cecal necrosis in the majority of cases is caused by a vascular event, occlusive or non-occlusive. The patient had atherosclerosis and an underlying malignancy which can be associated with prothrombotic states and contributes to an overall risk of thrombosis.

The cecum can sustain ischemic ischemic injury in the presence of severe or prolonged hypotension. Most frequent causes being decompensated heart failure, hemorrhage, arrhythmia or severe dehydration, only 1 of which was present in this patient.

The midgut neuroendocrine tumor is generally located in the terminal ileum, as a fibrotic submucosal tumor 1 cm or less. Mesenteric metastases are often larger than the primary tumor and associated with fibrosis which may entrap loops of the small intestine and cause bowel obstruction. This may eventually encase the mesenteric vessels with resulting venous stasis and ischemia in segments of the intestine as seen in this patient.

Conclusion: Cecal necrosis is a rare entity, but its incidence increases with age. Isolated cecal necrosis may manifest as a CT-negative appendicitis or a small bowel obstruction in the absence of past surgical history.

P164

Inusual Cases of Small Bowel Herniation Through the Falciform and Triangular Ligament

Andres Falla, MD ¹, Santiago Navas, MD², Gustavo Aguirre, MD^{1; 1}Hospital Militar Central, Bogota, ²Fundacion Cardioinfantil Bucaramanga

Introduction: Internal hernias account for a small percentage of small bowel obstruction, and the condition involves herniation of a viscus through a normal o abnormal opening within the peritoneal cavity. Paraduodenal hernias account for more than 50% of the cases. Other less common causes include transmesenteric, transomental, foramen of Winslow and paracecal hernias. Only surgical findings can confirm the diagnosis and offer adequate treatment. Here we report two unusual cases of small bowel herniation through a defect in the Falciform ligament in an male and an woman 75 and 49 years old, and a case an male 65-years-old with herniation bowel trought triangular ligament without surgical history abdominal.

Discussion: The falciform ligament separates the left lateral and left medial segments along the umbilical fissure and anchors the liver to the anterior abdominal wall. The non-peritonealization of this ligament, which may be better understood as the failure of the two layers of peritoneum to fuse around the umbilical vein and to the abdominal wall leads to a defect between the round ligament and the anterior wall, configurating an abnormal opening through which any viscous could potentially herniate.

We present a very unusual cases of right upper abdominal pain due to the presence of an internal hernia through the falciform and triangular ligament in a patients without surgical history and otherwise healthy. Upon arrival, clinical findings did not suggest small bowel obstruction in the absence of nausea, vomiting or abdominal distention. Instead, biliary origin of symptoms was suspected. Ultrasonography only showed severely distended bowel loops and free liquid in right subphrenic space. It was abdominal CT scan findings and the persistence of symptoms what made us take the patients to the operating room.

Laparoscopic transection of the Falciform and triangular Ligament successfully released the entrapped loop with successful reperfusion by the end of the surgery. In the absence of any prothrombotic comorbidity, the patients were discharged asymptomatic without further anticoagulation.

To date only few similar cases have been reported, and most of them described in neonates and pediatric patients. To our knowledge, this cases reporteds in the elderlys. In this patients laparoscopic approach was both diagnostic and therapeutic with the transection the ligament.

P165

Management of Spontaneous Splenic Rupture

Roberto Javier Rueda Esteban¹, Andres Mauricio Garcia Sierra ², Felipe Perdomo^{2; 1}Universidad de los Andes, ²Fundacion Santa Fe

This is a patient´s rare case of spontaneous splenic rupture associated to chronic myeloid leukemia as an uncommon complication. The case report and review of the relevant literature on symptomatology and clinical management is presented. Emphasis is made about the importance of including splenic rupture as differential diagnosis for acute abdominal pain, especially in a patient with neoplastic hematopathology, since early treatment increases patient survival and prognosis.

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Perforated Peptic Ulcer and Cachexia Associated with Unsuspected Severe Hyperparathyroidism from an Occult Giant Parathyroid Adenoma

Sarah Pearlstein, MD, Daniel Kuriloff, MD, FACS, ECNU, Rebecca Kowalski, MD, FACS; Northwell Health

Introduction: Giant parathyroid adenomas (> 3.5 gm) are a rare cause of primary hyperparathyroidism (PHPT). Despite having elevated calcium and PTH levels, they usually present with asymptomatic disease, especially with the widespread use of biochemical assays in screening exams. Symptomatic hyperparathyroidism classically can present as fatigue, muscle weakness, memory loss/confusion, bone pain, abdominal pain, constipation, and nephrolithiasis. We present a case of abdominal pain and cachexia from a perforated peptic ulcer (PPU) as the first presenting sign of occult primary hyperparathyroidism from a giant parathyroid adenoma.

Case Description: A 59 year-old cachectic male presented with two days of worsening abdominal pain and nausea. The patient had no history of gastroesophageal reflux or peptic ulcer disease (PUD). On admission, serum calcium was elevated to 12.3 mg/dL (upper limit 10.5 mg/dL). CT scan of the abdomen/pelvis demonstrated duodenal wall thickening with perforation and pneumoperitoneum. There were no renal calcifications. He was taken to the OR for a laparoscopic Graham patch and abdominal washout. On POD1 (post-operative day 1), serum calcium remained elevated at 12.5 mg/dL A PTH on POD2 was 1184 pg/mL (normal: up to 65 pg/mL) confirming primary hyperparathyroidism. He was treated with intravenous fluids and furosemide, but the serum calcium remained elevated. A SPECT/CT Sestamibi scan showed a giant left extrathyroidal mass with intense uptake, consistent with giant parathyroid adenoma. Ultrasound of the neck revealed a 5.4 × 2.7 × 2.8 cm mass. DEXA scan showed osteoporosis in the lumbar spine and left femoral neck. Serum gastrin level was normal 39 pg/mL (4–200 pg/mL). He underwent a parathyroidectomy. Calcium and PTH returned to normal by POD1 (9.8 mg/dL, 22.6 pg/dL). Pathology confirmed a giant parathyroid adenoma (3.6 × 3.0 × 1.2 cm and 12 gm).

Discussion: PPU is associated with a mortality of up to 30%, and morbidity of 50%. The etiology of PUD includes H pylori, NSAIDs and smoking. The association of PUD and hyperparathyroidism is well known, and studies have shown that improvement in peptic ulcer symptoms can occur after parathyroidectomy. It has been suggested that increased calcium levels due to hyperparathyroidism can lead to gastric acid hypersecretion and therefore PUD. Peptic ulcer perforation as the first manifestation of PHPT is rare and to our knowledge the first reported case caused by giant parathyroid adenoma.

Conclusion: In patients with a perforated peptic ulcer without obvious cause, we recommend obtaining a serum calcium level, and if elevated, a PTH to rule out hyperparathyroidism.

P167

Gastric Conduit Bronchial Fistula 13 Years After Esophagectomy

Daniel French, Ellsmere James, MD, MSc, Sunil Patel, MD, Drew Bethune; Dalhousie University

Esophagectomy is a complex operation associated with serious immediate complications and long term chronic complications. Gastric ulcers are a common chronic complication after esophagectomy with gastric conduit reconstruction. These are rarely complicated by significant bleeding or perforation. We report a case of delayed diagnosis of a fistula forming between a gastric conduit and right bronchial tree 13 years after esophagectomy. This was successfully treated using multiple therapeutic approaches including endoscopic localization and resection through a right thoractomy. To the best of our knowledge, our patient is the only survivor from a chronic gastric conduit bronchial fistula.

A 53 year old male with type 1 diabetes mellitus, dyslipidemia, asthma and smoking history presented 15 years after an Ivory-Lewis esophagectomy for a gastrointestinal stromal tumor (GIST) with a chronic cough starting 13 years after his esophagectomy followed by multiple episodes of hematoptysis over the next 2 years. The patient was known to have ulcers in his gastric conduit with a massive bleed 1 year after his esophagectomy.

Repeat endoscopy revealed two large chronic ulcers that had increased in size based on comparison of pictures from endoscopies 3 to 6 years after his esophagectomy despite maximal medical management. The patient presented to numerous specialists at tertiary care centers in Canada and the United States. Ultimately, in a clinic the patient was observed to cough immediately after the ingestion of water, but not solids leading to a provisional diagnosis of a gastrobronchial fistula. A barium swallow failed to show a fistula (Fig. 1). However at endoscopy, instillation of saline directed at an ulcer immediately induced a cough, but this was not reproduced when the saline was directed away from the ulcer. The fistula was ultimately demonstrated by placing a wire through the ulcer and visualizing it bronchoscopically in the right superior segmental bronchus (Figs. 2–4).

In an effort to pursue a minimally invasive approach two attempts were made to close the fistula with over-the- scope clips (OTSC). Unfortunately, the patient’s symptoms persisted. A wire was placed through the fistula and delivered through the patient’s mouth and endotracheal tube. A right thoracotomy allowed access to the conduit, which was opened and the fistula localized using the wire. The fistula was resected and the bronchus closed. At twelve month follow up the patient did not have a recurrent cough or hemoptysis while tolerating a full diet.

P168

Snap, Crackle, Pop: A Case of Non Operative Pneumoperitoneum, Penumoretroperitoneum and Pneumomediastinum

Christopher De Jesus, MD, Neal Mineyev, MD, Yael Marks, MD, Parswa Ansari, MD; Lenox Hill Hospital

The simultaneous finding of spontaneous pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema is an extremely rare presentation. We present a case of a patient in which the workup for abdominal pain resulted in a surprising but rather benign entity. There have been multiple reviews in the literature regarding workup for spontaneous pneumomediastinum, however, there are no recommendations regarding non-operative management for spontaneous and extensive pneumoretroperitoneum. It may seem quite difficult to not undertake aggressive diagnostic workup in a patient with the constellation of signs and symptoms as presented. We present the case in which laparoscopy or further surgical intervention was not pursued and clinical observation was adequate after ruling out obvious perforation with less invasive diagnostic studies. Knowledge about this clinical scenario would avoid unnecessary workup and most importantly, mobilization of operating rooms and invasive diagnostic procedures to find no signs of perforation.

P169

Late Obliteration of Gastrojejunal Anastomosis with a Gastrogastric Fistula After Laparoscopic Roux-en Y Gastric Bypass

Piotr Gorecki, MD, Victor Gazivoda, BS, Gabriel Rivera, MD, Mukul Arya, MD; New York Presbyterian Brooklyn Methodist Hospital

Introduction: Roux en-Y gastric bypass (RYGB) is one of the initial and most studied weight reduction procedures and remains the gold standard for comparison in bariatric surgery clinical outcomes. Although RYGB is an effective procedure for weight loss, it has been less popular over last several years because of increased morbidity compared to the more utilized vertical sleeve gastrectomy (VSG). Early complications of RYGB include bleeding, perforation, or leakage. Late complications include internal hernias, small bowel obstruction, anastomotic stenosis, marginal ulcers, and gastrogastric fistulas.

Case Report: A 50-year old female with a past medical history of morbid obesity, diabetes mellitus type 2, hypertension, GERD, peptic ulcer disease, cholelithiasis, liver dysfunction with ascites, asthma, and a past surgical history of RYGB (11 years ago) presented to our institution with acute on chronic abdominal pain associated with nausea, vomiting, dysphagia, inability to eat and maintain hydration, and an additional weight loss of about 100 lbs. over the last year. In addition, the patient was a chronic opioid and NSAID user, had an extensive smoking history, and had not followed with her surgeon for 11 years. At the time of presentation, the patient weighed 82 lbs (BMI: 13.2), had normal vital signs, and appeared cachectic. An upper gastrointestinal study followed by an upper endoscopic examination demonstrated complete obliteration of the gastrojejunal anastomosis and revealed a 2-cm long gastrogastric fistula originating from the distal end of the gastric pouch to the lesser curvature of the excluded stomach. After conservative measures were initiated to hydrate and metabolically stabilize the patient, the decision was made to proceed with diagnostic laparoscopy and surgical placement of a gastrostomy tube to the gastric remnant. The patient was discharged after tolerating a full liquid diet and gastrostomy tube feedings, for plan of future revision of gastrojejunostomy when optimal nutritional status is achieved.

Conclusions: Late complications of RYGB occur at a rate of 15–20%. Major risk factors for anastomotic complications include non-compliance, smoking, and opiate and NSAID abuse. Though abdominal pain, anastomotic stenosis, marginal ulcers, and fistulas are relatively common late complications of RYGB, complete obliteration of the gastrojejunal anastomosis has not been well described in the literature. This case demonstrates the importance of long term follow up post RYGB for early diagnosis of late complications and brings attention to this rare, but possible sequele that can arise in patients after RYGB. Contrast radiograms and upper endoscopic photographs will be presented.

P170

Laparoscopic Resection of a Hypoglycemia- Inducing Retroperitoneal Fibrosarcoma

Hany G Fahmy, FRCS, FACS, Mohamed A Abdelwahab, Alaa Taha; Royal Commission Medical Center, Yanbu Industrial, K.S.A

Introduction: Retroperitoneal sarcoma represents approximately 12–15% of all sarcomas and less than 0.5% of all neoplasia. Radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. The ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. In a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ILA) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. Laparoscopic surgery represents an alternative technique for radical resection of such tumors as a minimally invasive rather than traditional surgery. Only few cases were reported in the literature.

Case Report: We report a rare case of 53 years old Filipino gentleman presented to emergency department unconscious due to hypoglycemia. The patient was resuscitated, recovered and admitted for further investigations. Multiple Hypoglycemic attacks recurred during admission. Initial investigations were within average normal except for serum glucose value of 35 mg (2.0 mmol/L). His TSH, glucagon, and fasting cortisol levels were within the normal range, and his serum insulin and C-peptide levels were undetectable. We could detect hypokalemia (serum potassium, 2.3 mEq/L) in his serum. He tested negative for the anti-insulin antibodies. His abdominal ultrasound as well as his computed tomography scans showed the presence of a large retroperitoneal tumor (15 cm × 12 cm × 7 cm) with a heterogeneous contrast effect. A glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. The procedure was performed using three ports.

The sarcomatous mass was completely resected by the use of a harmonic scalpel with clipping of the main vascular blood supply. Patient passed through a smooth postoperative period with minimal wound pain and did not show any further hypoglycemic attacks. Pathological diagnosis of retroperitoneal solitary fibrosarcomatous tumor was confirmed.

Conclusion: Diagnosis of such hypoglycemia inducing Retroperitoneal Fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons.

P171

Remnant Stomach Perforation: A Unique Presentation of Obstructed Internal Hernia After Gastric Bypass

Katherine H Yancey, MD ¹, Andrew M O’Neill, MD^{2; 1}Mission Health, ²MAHEC

Introduction: Roux-en-Y gastric bypass (RYGB) is a frequently performed bariatric procedure, of which internal hernia (IH) is a known complication. We discuss a rare finding of occult gastric remnant perforation as a result of an obstructed IH in a post bypass patient.

Methods: We present a case report of a single bariatric surgeon’s experience at a tertiary care hospital. Literature review of PUBMED confirms the unique presentation and operative findings in our patient, as few similar cases have been published. A 59-year-old male s/p RYGB 12 years ago presented to the ED with right upper quadrant pain, nausea, vomiting, and a leukocytosis of 24,100. BMI was 31.7; weight was 254 lbs. Workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. Liver function tests were normal. Further imaging included a CT scan, remarkable for a paraesophageal hernia (PEH) containing the gastric pouch, and an elevated left hemidiaphragm. The scan showed no evidence of IH or bowel obstruction. An upper GI series was additionally obtained, which was also negative for small bowel obstruction. Due to unclear etiology for this patient’s symptoms or source of leukocytosis, diagnostic laparoscopy was planned.

Results: Intraoperative findings were significant for IH containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. IH was reduced and closed without bowel resection. Cholecystectomy was completed. Subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. In attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. Methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. The purulence was attributed to an occult remnant stomach perforation related to distal obstructed IH. A drain was left in the abscess and the PEH was not surgically addressed. Patient was discharged on postoperative day 5. He has not suffered any further complications or recurrent complaints.

Conclusion: Gastric perforation following RYGB is an uncommon complication resulting from IH. This diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. Surgeons should maintain a high clinical suspicion of IH in post RYGB patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. Threshold for operative exploration in this clinical setting should remain low.

P172

Adenocarcinoma in Gastric Remnant After Gastric Roux-en-Y Bypass Surgery for Morbid Obesity: A Case Report

Alejandro Garza, MD, Robert Alleyn, MD, Jose Almeda, MD, Ricardo Martinez, MD; UTRGV

Obesity is an epidemic condition worldwide carrying significant morbidity and mortality. Surgical therapy is the only proven effective method to sustain weight loss. Among the different surgical procedures gastric bypass is the most effective. During this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. This could potentially lead to delay in diagnosis of any pathology in the bypass stomach. Gastric Cancer is the 14th most common cause of cancer and cause of cancer death in the United States.

We present a case report of a patient who underwent a Roux-en-Y gastric bypass and went on to developed adenocarcinoma in the gastric remnant 28 year after her surgery. She underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. Pathology showed grade 4 undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. There was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in 5 out of 6 lymph nodes. Patient received adjuvant chemotherapy. The patient continues to be in clinical and radiological remission 3 years after her diagnosis.

There are multiple risk factors for the development of gastric cancer in general. Infection of the gastric mucosa by Helicobacter pylori, which can cause inflammation and result in a pre-malignant lesion. It is one of the most clinically relevant factors because it can be treated before neoplastic changes occurs. Other risk factors include a family history, low fruit and vegetable consumption, obesity, smoking, and previous gastric surgeries.

Due to the surgical anatomic changes, inherent to the Roux N Y Gastric Bypass it is technically difficult to monitor and evaluate the remnant stomach with upper endoscopy which highlights the importance of pre-operative evaluation. There are different non–surgical methods to evaluate the remnant stomach besides any abdominal CT scan. These include radiographic techniques with percutaneous contrast injection, placement of a gastrostomy tube for later access, as well as retrograde endoscopy with a pediatric colonoscope or a double-balloon enteroscope.

According to the literature there are only 8 cases reported of malignancy arising in the remnant stomach after bypass surgery. Due to the low incidence, this case is reported to help physicians carry a high level of clinical suspicion in these patients.

P173

Ruptured Hepatic Aneurysm as First Presenting Symptom of Polyarteritis Nodosa

Shinban Liu, DO, Vadim Meytes, DO, Maria Roberto, DO; NYU Langone Hospital - Brooklyn

Introduction: Polyarteritis nodosa (PAN) is a systemic transmural inflammatory vasculitis that affects medium-sized arteries. Inflammation of the vessel wall and intimal proliferation creates luminal narrowing which can lead to stenosis and insufficiency. The same inflammatory process causes disruption of the elastic lamina leading to aneurysm formation and possible spontaneous rupture with life-threatening bleeding. Multifocal segments of stenosis and aneurysm formation are characteristically identified as a “rosary sign” or “beads on a string”. Unlike other vasculitides, PAN does not involve small arteries or veins, and is not associated with anti-neutrophil cytoplasmic antibodies. We present the case of a 66 year old female with a significant intra-abdominal bleed that was explored and repaired primarily. She was subsequently found on angiogram and postmortem pathology to have findings consistent with PAN.

Case Presentation: 66 year old female who presented to the emergency department with abdominal pain followed by hemorrhagic shock and found to have a ruptured left hepatic artery aneurysm during exploratory laparotomy. This aneurysm was suture ligated with a successful outcome. A mesenteric arteriogram was performed the following day and demonstrated lesions consistent with PAN including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. However, 2 days after hospital discharge she developed massive pulmonary embolism from which she did not recover. Postmortem examination confirmed rupture of the left hepatic artery aneurysm in addition to gross anatomical and histological findings consistent with PAN.

Discussion: Polyarteritis nodosa is a systemic inflammatory vasculitis that causes intimal proliferation and elastic lamina disruption. This multifocal disruption of the vessel results in aneurysm formation alternating with stenosis creating a characteristic “rosary sign” on imaging. Spontaneous rupture of these aneurysms is rare and almost always fatal due to life-threatening hemorrhage. With acutely ruptured aneurysms, prompt diagnosis, aggressive resuscitation, and hemostasis through transarterial embolization or surgery is paramount for patient survival. While acute rupture of an aneurysm as the result of PAN is exceedingly rare, it must be considered as a differential diagnosis in the setting of acute abdominal pain and hemodynamic instability. In a patient known to have a medical history of PAN and aneurysm formation, routine monitoring and disease progression should be followed.

P175

Laparoscopic Repair of Paraduodenal Hernia Presenting as Small Bowel Obstruction

Savni Satoskar, MD, Manthan Makadia, MD, Abdul Badr, MD, Sarang Kashyap, MD, Avian Chang, MD, Monzur Haque, MD, Harjeet Kohli, MD; Easton Hospital

Introduction: 300,000 surgeries are done annually in the US for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. 0.2 to 5.8% of small bowel obstructions are due to paraduodenal hernias. Paraduodenal hernias carry a 50% lifetime risk of incarceration with a mortality of 20 to 50%.

Case Report: The patient is a 78 year old male who presented with severe upper abdominal pain for one day. He was passing flatus and had had a bowel movement the previous day. On examination, the patient was tender over the upper abdomen. Computed tomography (CT) scan with IV contrast showed a mesenteric swirl sign. The decision was made to perform diagnostic laparoscopy with possible small bowel resection.

Intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. The herniated bowel and its mesentery were edematous. The defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. The patient had an uneventful recovery postoperatively and was discharged on postoperative day 2. He returned on postoperative day 28 with periumbilical pain which resolved with conservative management. He was followed up 6 weeks postoperatively and was doing well.

Discussion: Paraduodenal hernias are the most common internal hernias. They are seen more often in males. They are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks 2 to 12 of embryonic development. Paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. They may present acutely with symptoms of bowel obstruction. Peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. CT scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. If imaging is equivocal, diagnostic laparoscopy may be undertaken.

Surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. In summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention.

References: Laparoscopic Repair of a Right Paraduodenal Hernia (2009) James Bittner et al PMID PMC3015939

Right Paraduodenal Hernia in an Adult Patient: Diagnostic Approach and Surgical Management (2011) Carlos M. Nuño-Guzmána José et al PMID PMC3180666

P176

Laparoscopic Resection of Giant Pseudo Diverticulum of Appendix: A Very Rare Disease

Hiromitsu Ito ¹, Naoto Nhisi¹, Haruhiko Aoyagi¹, Katsumi Higuchi¹, Keita Koseki¹, Ichiro Watanabe¹, Masashi Ito¹, Marius Calin, MD², Baongoc Nasri, MD^{3; 1}Toujun Hospital, ²Virtua Hospital New Jersey, ³Saint Vincent Hospital Indianapolis

Diverticulosis of the appendix is a rare disease found in 0.004–2.1% of appendectomies, first described in 1893. The clinical presentation may be acute inflammatory with or without appendicitis or it may be an incidental finding in an uninflamed appendix. The congenital type is rare and it has all the bowel wall layers. It most frequently represents as pseudo diverticulum which lacks the muscularis layer. The pathogenesis of appendiceal diverticula is not completely elucidated. Its symptoms are similar to and often misdiagnosed for that early acute or chronic appendicitis. While appendectomy is curative for both entities, it is important to distinguish diverticulum of the appendix from appendicitis as it is four times more likely to perforate and may be a sign of an underlying neoplasm. We reported a very rare giant pseudo diverticulum of the appendix in a 69-year-old male presenting with chronic abdominal discomfort for months. Abdominal X-ray showed abnormal gaseous finding. Physical exam was significant for a soft rubbery mass in the periumbilical region. Blood work revealed slight elevation of C-reactive protein. Preoperative CT and MRI showed a 9-centimeter- large cavity composed of thin wall, located at the tip of the appendix with peri appendicular fat stranding. In the concern of pending obstructive symptom and chronic abdominal pain, we decided to perform the resection laparoscopic. The soft mass arose from the tip of the appendix. There were dense adhesions between the appendix, mesentery, and sigmoid colon. After adhesiohedlysis, laparoscopic appendectomy was performed with EndoGIA. The specimen was extracted through a small incision without spillage. Hospital course was uneventful and the patient was discharged on post-operative day 4. The pathological finding was consistent with a pseudo diverticulum of the appendix which lacked muscularis layer and the inner wall of the cavity was lined with a scattered cubital epithelial layer in the continuity with the appendiceal mucosal membrane. Here we report a successful laparoscopic resection of an extremely rare giant chronic pseudo diverticulum of the appendix.

P177

Laparoscopic Management of Colonic Lipoma Causing Sigmoid Intussusception

Yvette Farran, MS, Jorge A Miranda, MS, Benjamin Clapp, MD, Elizabeth De la Rosa, MD; Texas Tech University Health Sciences Center

Introduction: Sigmoid colon intussusception is rarely encountered and given its vague symptomatology diagnosis and management can be difficult. The treatment of an intussusception in adults is different than in children. Lipomas as the causative etiology for intussusception are encountered up to 0.83% of the times and up to 70%- 90% of the patients require surgical resection for treatment.

Methods: This is a case report about a 62 year old male that presented with two weeks of worsening abdominal pain and distention. Physical exam was only pertinent for abdominal pain on light palpation, guarding and moderate distress. CT scan of abdomen and pelvis demonstrated a lipomatous mass causing complete obstruction of the sigmoid colon with intussusception. This was managed with laparoscopic sigmoidectomy. The patient had an uncomplicated post-operative period and was discharged on post-operative day 2. Pathology of the lipomatous mass confirmed a benign lipoma.

Discussion: Intussusception is rarely encountered in clinical practice in adults and constitutes 5% of all cases. Lipoma induced sigmoid intussusception with complete obstruction is rare. Symptoms can be non-specific as in this case. This case report highlights the importance of timely diagnosis and treatment of an intussusception in adult patients. CT scan is the gold standard for diagnosis and often shows a “target sign”. Other imaging techniques like ultrasound have shown adequate results but remain less effective than CT scan. The treatment in adults is not a reduction by enema like in pediatrics but rather resection of the lead point. This can be appropriately done with a laparoscopic technique in most cases.

Conclusion: Colonic intussusception is rare. Surgery is the only treatment for an intussusception in adults since the lead point needs to be removed, and can be attempted safely with a laparoscopic approach.

P178

Case Presentation: Achalasia and Large Epiphrenic Esophageal Diverticulum

Joshua Smith, MD, Kern Brittany, MD, Amie Hop, MD, Amy Banks-Venegoni, MD; Spectrum Health

Case Report: 60 year-old female with no significant past medical history presents with a 10-year history of nocturnal cough that had worsened over the past 3 months and had associated regurgitation. She underwent esophagogastroduodenoscopy (EGD) that showed a tortuous esophagus and tight lower esophageal sphincter that required dilation. She received an upper gastrointestinal (UGI) contrast study that showed a dilated, tortuous esophagus with ‘bird’s beak’ tapering, consistent with achalasia, as well as a large epiphrenic diverticulum measuring 7 × 7 cm.

Esophageal manometry confirmed “pan-esophageal pressurization” consistent with Type II achalasia. Given her symptoms in the presence of these findings, she elected to proceed with surgery. She underwent laparoscopic, trans-hiatal epiphrenic diverticulectomy, Heller myotomy and Dorr fundoplication. Extensive dissection allowed for approximately 8 cm of retraction down from the chest and we were able to come across it with a single blue load of a 60 mm linear cutting stapler.

Post-operatively, she tolerated the procedure well with immediate improvement in her symptoms. Her UGI on post-operative day 1 showed no evidence of leak, she tolerated a soft diet and was discharged home.

She was seen at 2-week and 1-year follow-up appointments with complete resolution of symptoms.

Discussion: Epiphrenic diverticula in the presence of achalasia has an occurrence rate of 25%. Large diverticula (> 5 cm), are even more rare with only a handful of case reports in the literature. Historically, thoracotomy or, more recently, thoracoscopic approaches are required for resection. However, thoracic approaches are associated with a 20% increase in morbidity, namely due to staple line leak and the resulting pulmonary complications. Only a single case report exists on our review of the literature that demonstrates successful trans-hiatal laparoscopic resection without post-operative complications of a diverticulum of this size. The shortest documented length of hospital stay post-operatively for similar cases is 4 days, while the average is 7–10 days or longer for those with complications. Our patient was able to go home on post-operative day 1 after a normal UGI and was tolerating a soft diet. Not only does this case show that a large epiphrenic diverticulm can be successfully resected via the trans-abdominal laparoscopic approach, this case makes the argument that patients undergoing any minimally-invasive epiphrenic diverticulectomy and myotomy, with or without fundoplication, may be successfully managed with early post-operative contrast studies and dietary advancement, thus decreasing their length of hospitalization and overall cost of treatment.

P179

Laparoscopic Distal Gastrectomy with D2 Lymph Node Dissection for Gastric Cancer in a Patient with Situs Inversus Totalis

Kazuma Sato, Shunji Kinuta, Koichi Takiguchi, Naoyuki Hanari, Naoki Koshiishi; Takeda General Hospital

Background: Situs inversus totalis (SIT) is a rare congenital condition in which the abdominal and thoracic organs are located opposite to their normal positions. Few cases of laparoscopic surgery for gastric cancer with SIT have been reported. We report a case of laparoscopic distal gastrectomy with D2 lymph node dissection performed for gastric cancer in a patient with SIT.

Case Description: An 80-year-old woman was admitted to our hospital for treatment of gastric cancer that was diagnosed by esophagogastroduodenoscopy (EGD) at a local clinic after she experienced anemia and nausea. EGD identified an irregularly shaped gastric ulcer located at the anterior side of the lesser curvature of the antrum. A biopsy revealed a moderately differentiated adenocarcinoma. She was then diagnosed with SIT by chest radiography and abdominal computed tomography (CT). The abdominal CT showed that all organs were inversely positioned and that the wall of the antrum had thickened; it also showed the lymph nodes in the lesser curvature of the stomach, without distant metastasis or an abnormal course of vascularity. The patient was clinically diagnosed with T3N1M0 stage IIIA gastric cancer according to the Japanese Classification of Gastric Carcinoma. A laparoscopic distal gastrectomy with D2 lymph node dissection in accordance with the Japanese Gastric Cancer Treatment Guidelines as well as a Roux-en-Y anastomosis due to an esophageal hiatal hernia were performed. The surgery was safely and successfully performed, although it required more time than usual because the inverted anatomic structures were repeatedly examined during the surgery. The postoperative course was positive, and the patient was discharged on postoperative day 7 without any complications. The final stage of this case was pT1bN0M0 stage IA. Currently, the patient is doing well without recurrent gastric cancer.

Conclusion: Gastric cancer with SIT is an extremely rare occurrence. We experienced a case of laparoscopic distal gastrectomy with D2 lymph node dissection performed for gastric cancer in a patient with SIT. We simulated the operation for SIT by viewing left-right reversed ordinary surgical videos. The abdominal CT angiography with a three-dimensional reconstruction helped reveal any variation and confirmed the structures and locations of vessels before the surgery. The operation could safely be performed following the standardized surgical technique by reversing the surgeon standing position and trocar position.

P180

Rhabdomyosarcoma of the Sternum in 2 Years Old Child Challenges in the Management

Mohammad Al-Onazi, MD, MME, Mohammed Babiker, MD; Prince Sultan Military Medical City

Sternum or chest wall resection is performed for a variety of conditions such as primary and secondary tumors of the chest wall or the sternum.

Sternum reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements. Advances in the fields of surgery and anesthesia result in more aggressive resections. Nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability. Chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect.

Here I`ll present, the youngest ever case reported, 2 years old girl with rhabdomyosarcoma involving the sternum. I will present the management challenges and the reconstruction options.

P181

A Clinicopathological Study of Neuroendocrine Tumours of the Gastrointestinal Tract – A Case Series

Veena Bheeman, MBBS, MS, Pari M Rajappa, MBBS, MS, Vishwanath M Pai, MBBS, MS, DNB, Dip, MASFr, FRCSGlas, Sandhya Sundaram, MBBS, MD, Sushruthan M, MBBS, MD; Sri Ramachandra Medical College

Introduction: Neuroendrocrine malignancies constitute 0.5% of all cancers. The gastrointestinal tract is the commonest site, followed by the lung. The last decade has seen a steady increase in their incidence. This is a case series of twenty five such tumours and their clinicopathological characteristics.

Materials and Methods: Twenty five patients with neuroendocrine tumours of the gastrointestinal tract were studied with reference to their demographic and clinicopathological characteristics. Apart from routine pathological examination, these tumours were also checked for E Cadherin expression as an independent marker of aggressive disease.

Results: The age of our patients ranged from 18 to 67 years. We had 13 female and 12 male patients, contradicting a female preponderance in literature. The vast majority of the tumours we encountered were from the stomach and duodenum, with 5 and 12 patients, respectively. Two tumours were at the gastroduodenal junction, two from the appendix, small intestine and pancreas, each, and one each from the rectum and gall bladder. This is in contrast to literature that shows that neuroendocrine tumours of the GIT most commonly arise from the appendix and small bowel, followed by the rectum, stomach and duodenum. Two of these tumours were functional. The diagnosis was confirmed by immunohistochemistry staining for Chromogranin A and Synaptophysin. Grading was done using WHO criteria that takes into account the mitotic count, Ki 67 Index and necrosis. 21 of our cases were Grade I. Further, Immunohistochemistry for E cadherin showed that absence of expression correlated with more aggressive clinical behavior. 18 out of twenty five patients were operable at presentation and standard resections depending on the organ of origin with adjuvant therapies were given as required. 5 could only be given palliative care. The 2 functional tumours were treated with radiolabelled somatostatin analogues following uptake studies.

Conclusion: As neuroendocrine tumours are relatively rare, information about them is not as abundant as with other malignancies. Absence of E Cadherin expression is associated with more aggressive disease. More studies are required that document the pathological characteristics and clinical behavior in order to offer well rounded treatment protocols that treat not only the primary, but also the generalized effects of the secretions produced by them. Targeted chemotherapy is gaining prominence, but more specific drugs directed at the plethora of receptors these tumours express, could potentially revolutionize treatment.

P182

Double Gallbladder – A Rare Anomaly?

Rosemary O.C. Oche, MD¹, Konstantina Foufa, MD², Ada M Krzak, BA³, Jan M Krzak, MD ^{1; 1}Department of Surgery South Jutland Hospital, Aabenraa, Denmark, ²Department of Radiology South Jutland Hospital, Aabenraa, Denmark, ³University of Cambridge, UK

Introduction: When searching for "Double Gallbladder" in PubMed, 129 results are obtained, many dated within the last decade (1). Unfortunately there are no publications from Denmark. We would like to present first to our knowledge reported case of double gallbladder in Denmark. Double gallbladder is a rare anomaly with a prevalence of 1:3800 in autopsy studies, described first by Boyden in 1926 (2). There are several classifications of double gallbladder that are based on relation between gallbladder, cystic duct and common bile duct (2,3). Non-specific symptoms and inadequate imaging are possible causes of lack of awareness of the condition. Removal of all gallbladders, preferably laparoscopic with special attention to the biliary anatomy, is recommended (4).

Method: Case report with review of the literature.

A 55-year-old female patient of Polish origin was hospitalized due to upper right quadrant pain. On admission clinical manifestations and paraclinical abnormalities of pancreatitis were present. Ultrasound scanning of the abdomen showed bile stones, ultrasonic manifestations of acute cholecystitis and normal intra- and extrahepatic bile ducts. Because of elevated liver enzymes MRCP was performed and showed double gallbladder, double cystic duct and signs of pancreas anulare. Scheduled ERCP confirmed bile stones in CBD, double gallbladder with double cystic duct, H-type according to Harlaftis classification (3). Because of minor retroperitoneal perforation second ERCP was needed for removal of all stones. The patient was then scheduled to laparoscopic cholecystectomy with perioperativ cholangiography.

Conclusion: Anatomical variations of the gallbladder such as double gallbladder are rare and often remain unnoticed. They are most often identified because of clinical manifestations symptoms, diverse imaging studies, during surgery or autopsy. As most of them are not expected, they can contribute to complications during surgery. Careful preoperative imaging is very important to prevent accidental bile duct injury. Looking at the number of case reports, double gallbladder seems to be slightly more common than expected. The interesting question is whether a gallbladder discovered during an unrelated radiological investigation in a patient that previously underwent a cholecystectomy can represent undetected case of double gallbladder. We would like to present a review of the literature as well as images from MRCP, ERCP and laparoscopy.

P183

Repair of Perforated Gastric Ulcer with Falciform Pedicle Flap

Michael Jaroncyzk, MD, Courtney E Collins, MD, MS, Vladimir P Daoud, MD, MS, Ibrahim Daoud, MD; St. Francis Hospital; Hartford CT

Introduction: Several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. Since the introduction of histamine-2 blockers and proton pump inhibitors, these procedures have dwindled significantly. However, there are still instances where patients require surgical intervention for peptic ulcer disease. Perforation is one of the indications for surgery. The surgical options to treat a perforated peptic ulcer are numerous. One of the most common options is a Graham patch. We are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair.

Methods and Procedures: Recently, a 64-year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. She underwent a work-up and imaging that did not reveal any pathology. At diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. She was discharged on the same day, but presented to the Emergency Department two days later with severe abdominal pain and fevers. The work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. She was emergently brought to the Operating Room for a diagnostic laparoscopy. During laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. Attention was turned to the upper cavity to find the pathology. Bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. Intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. A biopsy was performed and the decision was made to perform a Graham patch. However, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. Due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a Graham patch. The patient recovered without any additional issues. The biopsy was reported as a chronic gastric ulcer.

Conclusion: Surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. Perforated ulcers can be managed laparoscopically and Graham patches are a common choice for repair. However, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. We have shown in this patient that a falciform pedicle flap can be successfully used as a substitution.

P184

Laparoscopic Management of Boerhaave’s Syndrome After a Late Presentation: A Case Report and Literature Review

Tahir Yunus, Hager Aref, Obadah Alhallaq; IMC

Background: Boerhaave’s syndrome involves an abrupt elevation in the intraluminal pressure of the oesophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Having a nonspecific presentation may contribute to a delay in diagnosis and results in poor outcomes. Treatment is challenging, yet early surgical intervention is the most important prognostic factor.

Case Presentation: We present a case of a thirty-two-year-old male with a long medical history of dysphagia due to benign oesophagal stricture. He presented with acute onset of epigastric pain after severe emesis. Based on Computed Tomography scan, he was diagnosed with Boerhaave’s syndrome. Presenting with signs of shock, mandated immediate Surgical exploration. For which he was taken for Laparoscopic primary repair with uneventful postoperative recovery.

Conclusion: The Golden period of the first 24 hours of insult still applies for cases of oesophagal perforation. The rarity of these cases makes a comparison between the various treatment methods difficult. Our data support that the use of Laparoscopic operative intervention with primary repair as the mainstay of treatment for the management of oesophageal perforation.

P185

Intermittent Intussusception and Microcytic Anemia Caused by a Submucosal Jejunal Lipoma: A Rare Case Report

Lindsay Tse, DO, Elizabeth Verrico, DO, Maurizio Miglietta, DO; HUMC Palisades

Lipomas of the gastrointestinal tract are rare benign soft tissue tumors that are often discovered incidentally. These lesions are often asymptomatic, but have occasionally been reported to have clinical significance as will be described in this case report. A 40 year old male initially presented to his primary care physician’s office with a three week history of vague intermittent abdominal pain. His pain was located in the mid epigastrium and was associated with mild nausea. Past medical history was significant for hyperlipidemia and a right- sided goiter, and he denied any previous surgeries. Outpatient work up revealed a microcytic anemia, intermittent melena and hemoccult positive stools. The patient was referred to hematology and gastroenterology. Endoscopies revealed gastritis, and small internal and external hemorrhoids. He underwent an outpatient CT scan which demonstrated a 6.0 × 2.3 cm mass within the lumen of the jejunum causing long segment non-obstucting intussusception. Subsequently, the patient was referred to surgery and underwent a diagnostic laparoscopy. At the time of surgery, an approximately twelve centimeter segment of proximal jejunum was identified intussuscepting into a distal limb. This segment was attempted to be reduced laparoscopically, however there was significant mesentery within in the intussusceptum and the segment could not be safely reduced. Therefore, the section of bowel was delivered through a small periumbilical incision. The intussusceptum was then able to be manually reduced from the intussusception. At this point a large mass was palpated inside the lumen of the jejunum. A small bowel side to side, functional end to end resection and anastomosis was preformed. The bowel was returned to the abdomen and the abdomen was re-insufflated. The remainder of the small bowel was run and no additional lesions were identified. Final pathology revealed a 5.5 × 3.6 × 3.5 cm submucosal partially obstructing lipoma with ulceration at the tip. The patient recovered uneventfully and was discharged home on the second post operative day. This case report describes a submucosal jejunal lipoma that was acting as a lead point for intermittent non-obstructing small bowel intussusception, while simultaneously causing a microcytic anemia due to ulceration at the tip of the lipoma. Laparoscopic assisted reduction and small bowel resection is a safe and effective treatment for gastrointestinal tract lipomas that are unable to removed endoscopically.

P186

Gastrocolocutaneous Fistula Following Percutaneous Endoscopic Gastrostomy Tube Placement: Case Report of Endoscopic Management

Crystal J Yi, DO ¹, Eric Seitelman, MD², Rajiv Datta Rajiv, MD², Joel Lowenstein, MD², Robert Amajoyi, MD^{2; 1}St. John’s Episcopal Hospital, ²South Nassau Communities Hospital

Percutaneous endoscopic gastrostomy (PEG) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. Despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula.

The case describes a 90 year old female who presented with a PEG placed 6 months prior with reports of leakage of tube feeds from the gastrostomy site. As there was concern for possible ileus or obstruction, an upper GI series was completed which seemed to indicate dislodgement of the g-tube. The g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. Soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis.

The patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. The g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. The decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. A follow up upper GI study 72 hours later showed no extravasation of contrast through the gastric fistula. The colocutaneous fistula had self-resolved over the next couple days as well.

Placement of the PEG tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. Treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. However, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. If the PEG becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. On the other hand, non-surgical management has been suggested in management of a well-established fistula. Fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. Endoscopic clipping of the fistula tract employing the hemoclips is a treatment option.

P187

Median Arcuate Ligament Release for Celiac Compression Syndrome: Single Surgeon Experience

Brett M Baker, MD, MBA, MS, John F Kelly, MD, Donald R Czerniach, MD; Department of Surgery, University of Massachusetts Memorial Health Care, University of Massachusetts Medical School

Median Arcuate Ligament Syndrome (MALS) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. Patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. Diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. Standard of care for MALS patients is laparoscopic celiac artery dissection with release of the median arcuate ligament.

At our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with CT angiogram, MR angiogram, Arteriogram, or multiple modalities. All but one patient had multiple diagnostic imaging modalities, with the most common being CT angiogram; eight patients had invasive imaging. The mean age at presentation was 58.7 years in men and 47.8 years in women. On average, male patients presented with a longer duration of symptoms, 17.7 years (range 3–30 years), as compared to women, 3.3 years (range 1–15 years). Symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. All male patients reported at least two symptoms, most commonly nausea and post-prandial pain. In female patients, 82% reported having three or more symptoms. Notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by 73%. Pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, 156 cm/s versus 345 cm/s. Post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative 210 cm/s for an average of 112 cm/s after decompression. In all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament.

In total, 79% of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. Of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. Our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis.

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Congenital Abdominal Adhesions in a Bariatric Patient

Matthew A Goldstein, MA, Kirill Zakharov, DO, Sharique Nazir, MD; NYU Langone Brooklyn

Adhesions are fibrotic bands that form between and among abdominal organs. The most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. These bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here.

Congenital abdominal adhesions are rare and have received little attention in research and field of study. The patient described in this case is a 25-year-old female with a past medical history of morbid obesity, BMI of 45, hypertension and no past abdominal surgical procedures. The patient presented in August 2017 for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy.

Upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. The splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. Additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. After extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. The patient also demonstrated significant hepatomegaly and a wedge resection was performed. The amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated.

This case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. One such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. Further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. Today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months.

P189

Laparoscopic Spenulectomy: An Interesting Case Report

Riva Das, MD ¹, Daniel A Ringold, MD², Thai Q Vu, MD^{2; 1}Orlando Health, ²Abington Jefferson Health

Introduction: Spenules, or accessory spleens, are a rare disease entity. Most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. Torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies.

Case Description: A 61-year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. She denied any similar episodes in the past, or any associated symptoms. Further investigation with a CT scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a 4.5 cm soft tissue mass. This indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. Differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. An MRI was recommended for further evaluation, but did not reveal any additional significant findings. Nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. Following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. Diagnostic laparoscopy revealed an approximately 5 cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. The superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. This pedicle was easily ligated, and the mass removed. Pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. The patient had an uncomplicated post-operative course.

Discussion: This case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. Scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. Operative exploration was both diagnostic and therapeutic.

P190

Chikungunya Disease: Infection Associated with Atypical Presentation of Duodenal Perforation

Sughra Parveen Qureshi, Professor, Abdul Malik Magsi, Dr, Mariam Malik, Dr, Mazhar Iqbal, Dr, Mohammad Iqbal Khan, Dr, Imran Khan, Dr, Sarwar Qureshi, Dr; Jinnah Postgraduate Medical Center

Abstract: Introduction: To observe surgical emergency of Duodenal perforation with atypical presentation in already diagnosed cases of Chikungunya disease.

Methodology: This was an observational study that was conducted in the tertiary care setup of Jinnah Postgraduate Medical center. The study duration was from November, 2016 till August, 2017 and consecutive convenient sampling technique was employed. Patients diagnosed with Chikungunya presenting with symptoms of peritonitis were included in the study. Patient’s demographics, physical findings, intraoperative findings and post-operative complications were recorded. The data was entered in SPSS version 18.

Results: Included in this study were thirty (30) patients with the mean age of 45.37 ± 9.25 SD, being more common in males. Mean Duration of disease in days = 14.38 ± 4.168 SD and Mean Duration of Peritonitis = 1.683 ± 0.77 SD. With a history of Chikungunya virus of average 2 weeks, diagnosed with serum Chikungunya IgM antibodies. The unusual presentation of slit like perforation with a mean length of 1 cm was observed. All the cases were repaired with Graham’s Omentopexy. Postoperatively the only complication noted was surgical site infection in 8 (eight) patients which was treated with antibiotics suggested by culture and sensitivity report and local wound care. One patient died due to sepsis at presentation.

Conclusion: Chikungunya virus was found circulating in rodents in Pakistan as early as 1983. Duodenal ulcer perforation which is a common surgical emergency in our part of the world usually presents with pinpoint perforation in ant wall of first part of duodenum unlike in already diagnosed cases of Chikungunya Disease where a slit like duodenal perforation is noted in the anterior wall of first part of duodenum. Literature and consensus relate this perforation with the excessive use of Nsaids due to usual presentation of arthritis in Chikungunya disease but the unusual presentation is still to be answered.

P191

Bouveret’s Syndrome: Endoscopic and Surgical Management of a Rare Form of Gallstone Ileus

Arthur Berg, DO, Joshua Klein, DO, Steven Shikiar, MD, Maurizio Miglietta, DO; Hackensack UMC Palisades

Introduction: Bouveret’s Syndrome is a rare form of gallstone ileus in which an impaction of a gallstone in the duodenum results in a gastric outlet obstruction. Gallstone ileus accounts for approximately 2–3% of all cases of small bowel obstruction. The terminal ileum is the most common location for a calculus to cause obstruction followed by the proximal ileum, jejunum and duodenum/stomach respectively. Open and laparoscopic surgery has previously been the mainstay of treatment for Bouveret’s Syndrome, however with the advent of new endoscopic techniques and instruments there has been increasing success in endoscopic management. This case report looks at a patient with a gastric outlet obstruction from a gallstone, and discusses the current literature regarding diagnosis and management.

Case: 69 year old male presented with several day history of epigastric abdominal pain and multiple episodes of nonbloody, nonbilious emesis. He had previously been diagnosed with cholelithiasis, however had refused surgery at that time. On admission the patient was found to have a leukocytosis of 13.5. An ultrasound was performed in which the images were limited due to pneumobilia. A subsequent CT scan revealed pneumobilia, and a large 2 cm gallstone impacted in the first portion of the duodenum causing a gastric outlet obstruction. The patient underwent failed endoscopic attempts at removal and ultimately required a laparotomy, enerotomy with stone extraction.

Discussion: Bouveret’s syndrome is a rare variant of gallstone ileus. With newer endoscopic techniques and electrohydraulic lithotripsy, there has been increasing success with endoscopic retrieval of the impacted gallstones. There is some controversy in regards to the need for definitive operative management. Stone extraction, without cholecystectomy and fistula repair, has been shown to have less postoperative complications as well as lower mortality rates compared to when a cholecystectomy and fistula repair has been performed.

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Why Does Conversion From Laparoscopy to Open Surgery Occurr?

Rocco Ricciardi ¹, Caitlin Stafford¹, Todd Francone¹, Peter Marcello², Patricia L Roberts^{2; 1}MGH, ²Lahey Hospital & Medical Center

Introduction: We studied the risk factors for laparoscopic (Lap) conversion across a group of subspecialist colorectal surgeons with expertise in minimally invasive techniques.

Methods: We reviewed our prospective database for Lap conversion cases among all consecutive abdominopelvic procedures performed from 7/1/2007 through 12/31/2016. First, we identified procedures that were converted from Lap to open. Next, we performed a case-controlled trial by matching Lap converted procedures to Lap completed procedures. Then we abstracted covariates such as reason for conversion, prior abdominal surgery, procedure type, patient diagnosis, BMI, incision time, use of a hand assist, and ASA score. Last we developed multivariate models to identify risk factors for Lap conversion to open surgery adjusting for all listed covariates.

Results: From a database of 12,454 procedures, we identified 100 Lap colorectal procedures converted to open surgery and matched them to 339 Lap completed procedures. In the entire dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. Among surgeon’s with more than 50 Lap cases, we found significant variability in Lap attempts (range of 16–65% of any one surgeon’s cases) and substantial variability in surgeon specific conversion rates (range 1–8%; median of 7%). However, there was no correlation between surgeon Lap attempt rate and surgeon Lap conversion rate (p = 0.4). There was also no correlation between surgery start time and Lap conversion. The most common reasons for conversion were adhesions (n = 47) and difficult patient anatomy (n = 35). Proportionately more patients with a diagnosis of inflammatory bowel disease (6%) were converted to open as compared to the diagnoses of neoplasm (3%) or diverticulitis (4%) (p < 0.05). Furthermore, proportionately more lap abdominoperineal resections (12.5%) were converted to open as compared to ileocolic resections (5.5%) or left colectomy (2.8%) (p < 0.05). On multivariate analysis, both male sex and prior history of abdominopelvic surgery increased the risk of Lap conversion while the use of a hand assist technique attenuated conversion risk.

Conclusions: Our data reveal a low rate of Lap conversion to open surgery despite a high rate of Lap attempted colorectal surgery. Increased surgeon affinity for Lap attempted surgery did not influence Lap conversion rates but the surgical indication of inflammatory bowel disease and the procedure of abdominoperineal resection did elevate the risk of Lap conversion. On multivariate analysis, prior abdominal surgery was associated with increased risk of conversion and was the most common reason reported for conversion on the operative report.

P193

Patient-Reported Outcomes Among Patients Undergoing Open and Laparoscopic Colorectal Surgery: A Pilot Study

Taryn E Hassinger, MD, MS, George Stukenborg, PhD, Charles M Friel, MD, Traci L Hedrick, MD, MS; University of Virginia

Introduction: The use of minimally-invasive techniques in colorectal surgery has gained popularity due to benefits in both short-term and long-term clinical outcomes. Patient-reported outcomes (PRO) are increasingly recognized as vital measures of clinical outcomes and performance. This study aims to compare physical, mental, and social PRO in patients undergoing open and laparoscopic colorectal surgery with the hypothesis that patients undergoing laparoscopic surgery will report higher PROs.

Methods: This pilot study utilized the National Institutes of Health Patient-Reported Outcomes Measure Information System (PROMIS) to collect responses from patients undergoing open and laparoscopic colorectal surgery at a single institution from July 2013 to April 2015. Domains included pain interference, ability to participate in social roles and activities, depression, and interest in sexual activity. Scores were collected at 1-month preoperative and postoperative appointments. Data was reviewed using a multivariable linear model controlling for patient and procedural characteristics to determine associations between mean change in PROMIS scores and laparoscopic surgery.

Results: Surveys were completed by 107 patients, with 57 (53.3%) undergoing laparoscopic surgery. Open surgery was more common in men [31 (62.0%) vs. 17 (29.8%); p = 0.008]. Colon cancer was the most common diagnosis overall, but the rate of rectal cancer was higher in the open surgery group [18 (36.0%) vs. 9 (15.8%)], as were rates of neoadjuvant chemotherapy (p = 0.02) and radiation (p = 0.004). Preoperative (p = 0.01) and postoperative (p < 0.0001) stomas were less common in the laparoscopic group. There were no unadjusted differences in mean PROMIS score changes among patients undergoing open and laparoscopic surgery across included domains. Likewise, the multivariable analysis identified no association between the mean changes in PROMIS scores and laparoscopic surgery in any of the assessed domains (Table).

Conclusions: This pilot study demonstrated that PROMIS can be used to collect PROs in a busy colorectal surgery clinic. These data do not demonstrate a difference in PROs between laparoscopic and open colorectal surgery patients, but larger prospective studies are needed.

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A Study of Neoadjuvant Modified FOLFOXIRI for Locally Advanced Low Rectal Cancer

Shinsuke Masubuchi ¹, Tetsuji Terazawa², Keitaro Tanaka¹, Masashi Yamamoto¹, Masatsugu Ishii¹, Yoshihiro Inoue¹, Takayuki Ki², Masahiro Goto², Junji Okuda³, Kazuhisa Uchiyama^{1; 1}Department of General and Gastroenterological Surgery, Osaka Medical College, ²Department of Cancer Chemotherapy Center, Osaka Medical College, ³Department of Cancer Center, Osaka Medical College

Total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (NACRT) is standard treatment for rectal cancer, which has resulted in a decrease in local recurrence. However, NACRT has shown no significant overall survival and some adverse effects mainly caused by radiation therapy. Recently, the usefulness of neoadjuvant chemotherapy (NAC) has been reported. We retrospectively assessed the efficacy and safety of the neoadjuvant mFOLFOXIRI compared with NACRT followed by laparoscopic surgery.

A total of 76 patients undergoing laparoscopic surgery for lower rectal cancer (clinical Stage: II or III) from July 2014 to February 2017 in our department were retrospectively evaluated. 40 patients underwent NAC, and 36 patients underwent NACRT. The following data were collected: pathological complete response (pCR), histological grade, down staging, radial margin (RM) and postoperative complications. Histological grade was defined as follows: tumor cell necrosis or degeneration is present in less than one third of the tumor area (Grade 1a), between one and two thirds (Grade 1b), more than two thirds but viable cells remain (Grade 2), and complete response (Grade 3).

These two groups were demographically comparable. Down staging did not differ between the two groups. Histological grade (?Grade 1b) and pCR were significantly higher in the NACRT than in the NAC group (p < 0.05). RM had no significant difference in both groups, but tended to be able to secure negative RM in the NAC group (95% vs. 83.3%, p = 0.06). There were no significant differences in complications (wound infection, pelvic abscess, ileus, urinary disturbance, urinary tract infection). However, NAC group reduced complications after stoma closure (0% vs. 17.4%; rectovaginal fistula:1, rectourethral fistula:2, ischemic enteritis:1, p < 0.05).

Compared to NACRT, NAC was inferior in local control, but it was able to secure negative RM, and reduced complications after stoma closure. Neoadjuvant mFOLFOXIRI for locally advanced low rectal cancer seems to be promising. Long-term outcome should be evaluated in the near future.

P195

Single Incision vs Multi-port Laparoscopic Complete Mesocolic Excision (CME) Colectomy for Colon Cancer. A Systematic Review and Meta-analysis

C Athanasiou ¹, A Athanasiou², G Markides^{3; 1}Ipswich Hospital NHS Trust, ²University of Texas, ³East Lancashire Hospitals NHS Trust

Aims: Increasing evidence suggest that CME may improve overall and disease free survival in colon cancer. Our aims were to investigate the safety and efficacy of single incision laparoscopic CME colectomy (SILCC) compared to multiport CME laparoscopic colectomy (MPCLC) providing the first meta-analytical evidence.

Methods: PUBMED, Scopus and Cochrane library were searched. Studies comparing the SILCC to MPCLC in adults with colon adenocarcinoma were included. The studies were critically appraised using the Newcastle Ottawa Scale. Statistical heterogeneity was assessed with x2 and I2. The symmetry of funnel plots was examined for publication bias.

Results: One randomized and four case control trials were included (540 SILCC Vs 609 SL). No difference was found in anastomotic leakage [OR: 0.95 (0.37, 2.43); P = 0.92], post-operative ileus [OR = 0.86 (0.44, 1.69); P = 0.66], surgical site infection [OR = 0.70 (0.35, 1.43); P = 0.33], number of retrieved lymph nodes [Weighted mean difference (WMD) = 0.54 (-0.43, 1.50), P = 0.28], length of hospital stay [WMD = -0.09 (-0.28, 0.11); p = 0.38] and pulmonary complications [OR = 2.05 (0.28, 15.20); P = 0.48]. Operative time was significantly longer in the MPCLC [WMD = -6.79 (-11.84, -1.71); P = 0.008] but with a high level of heterogeneity i2 = 63%.

Conclusions: The increased technical requirements of the SILCC don’t seem to increase morbidity or mortality. The equal number of lymph nodes in the two groups suggest that the extent of the dissection in the single incision group was not compromised.

P196

Does Obesity Class Impact Outcomes of Total Proctocolectomies with Ileal-Pouch Anal Anastomosis? An ACS-NSQIP Analysis

Maria Abou Khalil ¹, Nancy Morin², Carol-Ann Vasilevsky², Gabriela Ghitulescu², Jennifer Motter³, Marylise Boutros^{2; 1}McGill University, Montreal, QC, Canada, ²Jewish General Hospital, Montreal, QC, Canada, ³Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA

Introduction: Obesity has been associated with increased morbidity following total proctocolectomies with ileal-pouch anal anastomosis (TPC-IPAA). However, the incremental added risk of increasing obesity class is not known. The aim of this study was to evaluate the additional morbidity of increasing obesity class for TPC-IPAA.

Methods: After ethics board approval, the ACS-NSQIP database (2005–2015) was accessed to identify patients who underwent elective TPC-IPAA. Body mass index (BMI, kg/m²) was classified as normal (18.5–24.9), overweight (25.0–29.9), obesity class-I (30–34.9), obesity class-II (35–39.9) and obesity class-III (≥ 40). Primary outcomes were overall surgical site infection (SSI) and organ-space infection (OSI). Secondary outcomes were 30-day major morbidity and length of hospital stay (LOS).

Results: Of 4581 patients who underwent TPC-IPAA, 57.4%, 17.6% and 9.8% were for ulcerative colitis, malignant colonic neoplasms and benign colonic neoplasms. Median (IQR) age was 44 (31,56) years and 56.3% were male. Half (51.21%) of patients underwent a laparoscopic TPC-IPAA. Rates of overall SSI, OSI and major morbidity were 15.5%, 8.5% and 27.3%. Median LOS was 7 (5,10) days. Over one-third of patients (38.5%) had a normal BMI, 4.1% were underweight, 32.9% were overweight, 16.0% were class-I obese, and 8.4% were class II/III obese. On multivariate regression analysis, higher obesity class was associated with significantly increased odds of SSI and OSI (Table 1). Similarly, increased risk of 30-day major morbidity and a one day increase in LOS were observed accross all obesity categories.

Conclusion: Increasing obesity class was associated with a significant incremental risk of SSI and OSI following TPC-IPAA. Knowledge of this increased risk stratified by obesity class may help guide preoperative planning, especially pertaining to counseling patients for staged procedures to allow for appropriate preoperative weight loss prior to IPAA reconstruction.

P197

Reduced Port Laparoscopic Lymph Node Dissection Around the Inferior Mesenteric Artery with Preservation of the Left Colic Artery for the Treatment of Sigmoid and Rectal Cancer

Mari Shimada, MD ¹, Yasumitsu Hirano, MD, PhD², Chikashi Hiranuma, MD, PhD¹, Masakazu Hattori, MD, PhD¹, Kenji Douden, MD, PhD¹, Yasuo Hashizume, MD, PhD^{1; 1}Fukui Prefectural Hospital, ²Teikyo University Mizonokuchi Hospital

Aim: In curatively intended resection of sigmoid and rectal cancer, many surgeons prefer to perform ligation of the root of the inferior mesenteric artery (IMA), high tie, because of oncological reasons. However, ligation of the IMA has been known to decrease blood flow to the anastomosis. There are few reports of patients undergoing the reduced port laparoscopic approach (RPS) including single-incision laparoscopic approach (SILS) even among those undergoing laparoscopic lymph node dissection around the IMA with preservation of the left colic artery (LCA). Our objective was to evaluate the quality of this procedure regarding application of RPS for the treatment of sigmoid and rectal cancer.

Methods: The feasibility of this procedure was evaluated in 61 consecutive cases of RPS for sigmoid and rectal cancer. A Lap protector (LP) was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and three 5-mm ports were placed. Almost all procedures were performed with standard laparoscopic instruments using a flexible scope (SILS). A 12 mm port was inserted in right lower quadrant mainly in rectal cancer surgery (SILS+1). Our method involves peeling off the vascular sheath from the IMA and dissection of the LN around the IMA together with the sheath.

Results: Lymph nodes around the IMA were dissected with preservation of the LCA in 26 cases (group A). The IMA was ligated at its root in 35 cases (high tie, group B). In group A, 11 patients were treated with SILS and 15 patients were treated with SILS+1. In group B, 15 patients were treated with SILS and 20 patients were treated with SILS+1. Median operative time was 187.7, and 154.8 min for group A, and B, respectively. The operative time was significantly longer in group A. Estimated blood loss was 13.7 and 13.0 g, and mean numbers of harvested LN were 21.7, and 23.8. None of the other operative results of groups A and B were different statistically. In this series, there was only one anastomotic leakage in group B.

Conclusion: Our method allows equivalent laparoscopic lymph node dissection to the high tie technique. The operative time tends to be longer, however this procedure has a possibility to reduce an anastomotic leakage.

P198

Splenic Flexure Mobilization in Robotic Colorectal Surgery: How to Approach It?

Alberto Mangano, MD, Federico Gheza, MD, Roberto E Bustos, MD, Gabriela Aguiluz, MD, Eleonora M Minerva, MD, Pier Cristoforo Giulianotti, MD, FACS, Professor of Surgery; UIC Departement of Surgery. Division of Minimally Invasive

Introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate. We present our surgical approach with data. This technique may increases the surgical expertise/confidence when the surgical maneuver is necessary. Up to 40% of all splenectomies are for surgery-related injuries;80% of those splenic injuries are treated by splenectomy. The iatrogenic splenic injury rate during colorectal surgery is 0.96%. Iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs. Risk factors for iatrogenic splenic injury are: advanced age, adhesions, underlying pathology. Obesity is not a risk factor. It is debated if the left colonic flexure mobilization is a risk factor for splenic injury. The ligament over-traction is the most frequent damage mechanism. The most dangerous surgical manuever is the spleno-colic ligament surgical dissection. Moreover, laparoscopy descreases by almost 3,5 times the splenic injury risk. Some surgeons are reluctant to routinely take down the splenic flexure.

Materials and Procedures: 129 robotic left colonic/rectal cases with routine splenic flexure mobilization technique have been performed: left colectomy (n = 74), rectal surgery (n = 45), transverse-colectomy (n = 6) and pancolectomy (n = 4). Conversion rate 1,6%, EBL < 100 ml,1 postop-leak (0.8%) and 0% iatrogenic splenic injuries.

Results: In our approach, there are 4 pathways that need to be mastered for the splenic flexure mobilization:a) medial to lateral dissection (underneath the inferior mesenteric vein); b) lateral to medial (from the lateral peritoneal reflection); c) access to the lesser sac with omental detachment from the transverse colon; d) access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas. The dissection should be closer to the colon rather than to the spleen. In our experience the routine mobilization of the splenic flexure may have some advantages:a) Better (without tension) distal anastomosis formation; b) Better perfusion of the proxiaml stump; c) Wider oncological dissection; d) No need of going back to the flexure when the proximal stump is too short; e) mastering a surgical manuver useful in other procedures (e.g. distal pancreasectomy). The theoretical drawbacks of routine splenic flexure mobilization can be:a) longer operative time, which is on average increased by 35 minutes; b) Risk of splenic injuries, in our experience, no splenic injuries have been registered.

Conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate. Laparoscopy decreases splenic injury rate. Robotic surgery may have the potential to further reduce this complications. Our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate. More trials are needed in order confirm our findings.

P199

Preliminary Experience of the Use of Robotic Stapler in Total Mesorectal Excision - Low Anterior Rectal Resection: Comparison with the Laparoscopic Device

Maria Carmela Giuffrida, Luca Pellegrino, Alessandra Marano, Diego Sasia, Gaspare Cannata, Felice Borghi; Santa Croce e Carle Hospital

Introduction: The robotic stapler with the EndoWrist™ technology (Intuitive Surgical, Inc.) includes a larger range of motion and articulation compared to the laparoscopic device, and may provide some benefits in difficult areas like the pelvis. To date, few studies have been published on the application of robotic endowristed stapling. We present our preliminary experience using the robotic stapler in low anterior rectal resection (LARR) with total mesorectal excision (TME) for rectal cancer.

Methods and Procedures: Between March 2016 and September 2017, 24 patients underwent elective robotic LARR with TME and primary colorectal anastomosis within the ERAS program. Patient demographic, intra-operative data and post-operative outcomes were compared between the EndoWrist™ 45 robotic stapler group (RS group) and the laparoscopic stapler group (LS group).

Results: The two groups were homogeneous in terms of demographic and clinical characteristics. Thirteen (10 males) and 11 patients (8 males) were included in RS and in LS group, respectively. Seven patients received preoperative chemoradiation in RS group, 8 in LS group. There was no difference in intra-operative blood loss and total operative time. The median number of stapler fires for patients in RS group and in LS group was 2 (range, 1–3) and 3 (range, 2–4), respectively. Loop-ileostomy was fashioned in 8 patients in RS group (61.5%) and 8 patients in LS group (72.7%). The 30 days mortality was nil. Two cases of anastomotic leaks have been detected in RS group (15.4%), 2 cases (18.2%), occurred in LS group, all treated conservatively. The mean length of postoperative stay was 6.5 ± 5.7 days in RS group, 6.9 ± 3.9 days in LS group.

Conclusions: In our preliminary experience the application of robotic stapler during LARR with TME has shown to be safe and feasible with acceptable morbidity. Even if our case series is pretty small, fewer stapler fires were required in the RSG compared to LSG. We believe that the robotic stapler might lead to a more precise firing during pelvic surgery: it can explain the trend toward a decreased number of fires, that has been well documented in literature to be related to a lower risk of anastomotic leak. Further high quality studies are required to confirm these findings.

P200

Laparoscopic Ultralow Anterior Resection with Total Mesorectal Excision and Transanal Specimen Extraction for Rectal Cancer: A Consecutive Series of 51 Patients

Song Liang, MDPHD ¹, Morris Franklin, Jr, MDFACS^{2; 1}Fastrack Medical, ²Texas Endosurgery Institute

Background and Objectives: The present study was aimed at investigating the safety and feasibility of laparoscopic ultra-low anterior resection (L-ULAR) with total mesorectal excision (TME) and transanal specimen extraction for rectal cancer located at lower one-third rectum, and specifically understanding the oncological outcome of the operation.

Patients and Method: A prospective designed database of a consecutive series of patients undergoing laparoscopic ultra-low anterior resection for rectal malignancy with various tumor-node-metastasis (TNM) classifications from 1991 to 2012 at the Texas Endosurgery Institute was analyzed. In this study ultra-low anterior resection is defined as low anterior resection for the malignant lesion at distal 1/3 of rectum.

Results: 51 ultralow anterior resections were completed laparoscopically with TME and transanal specimen extraction. The operating time for the surgery was 169.7 ± 31.1 minutes, and estimated blood loss during the procedure was 104.5 ± 72.1 ml. The length of the lesion from the anal verge measured with intraoperative colonoscopy ranged from 3.5 cm to 6.9 cm, and shortest distance of colorectal anastomosis from the anal verge is 1 cm. Since diverting ileostomy was routinely installed after L-ULAR, none was found to have anastomotic leakage, however 3 patients developed anal stenosis within 6-month follow-up. Therefore the overall rate of postoperative complication is 5.9%. Moreover 4 patients were reported to have local recurrence in 2-year follow-up with the rate of 7.8%.

Conclusions: L-ULAR is safe and effective procedure for the rectal cancer at distal 1/3 rectum with comparable local recurrence and postoperative complication rates, thereby suggesting L-ULAR can be considered as a procedure of choice for rectal cancer at very low location in the rectum.

P201

Transanal Endoscopic Microsurgery (TEMS) for Mucosal Excisional Biopsy of Rectal Tumors of Uncertain Behavior – Case Report and Description of Technique

Kasim L Mirza, MD ¹, Andreas M Kaiser, MD, FACS, FASCRS^{2; 1}Keck USC Dept of Surgery, ²Keck USC Dept of Surgery, Division of Colorectal Surgery

Introduction: Transanal local excision is an excellent treatment choice for benign rectal lesions. For rectal cancer, however, local full-thickness excisions are fraught with high local recurrence rates - even if limited to early and best selected lesions. This corroborated observation is likely caused by a combination of missed nodal disease and direct implantation of tumor cells into the mesorectum, which upstages even early T1 lesions to at least a T3 lesion. The treatment of choice for invasive adenocarcinoma consists of an oncological total mesorectal resection, possibly with other modalities. Rectal tumors of uncertain behavior can present a treatment dilemma between over-treatment vs under-treatment.

Concept: If the nature of a lesion is not certain or if contradictory results have been obtained, we propose a superficial local excision as a mucosal excisional biopsy to establish the diagnosis while avoiding interference with subsequent definitive treatment modalities by preserving the integrity of the external rectal wall and mesorectum. A benign final pathology concludes the treatment, whereas a detection of invasive cancer will be managed with a subsequent oncological resection.

Methods: This is a case report of a 70-year-old woman found to have a 4.4 cm villous lesion in the mid to distal rectum without proven or disproven invasive cancer. A TEMS-guided mucosal resection of the rectal mass at 3 cm above the anal verge was performed whereby the lesion was dissected off the underlying muscularis.

Results: With preoperative discrepant ERUS and MRI staging uT0-1 vs cT3 lesion, a technically successful mucosal resection of the large rectal mass was carried out. Pathology revealed a tubulovillous adenoma without high grade dysplasia or malignancy and a complete resection.

Conclusion: TEMS mucosal excisional biopsy of rectal tumors of uncertain behavior allows for a less invasive diagnostic approach that may (a) be definitive treatment if the lesion is proven benign, or (b) confirm the need for more aggressive treatment without having burned any treatment bridges or upstaged an early tumor by violating the mesorectal plane. An oncologic resection with appropriate (neo-)adjuvant chemotherapy can be carried out while preventing the potential for tumor seeding at initial operation.

P202

Questionnaire to Survey Cosmetic Outcomes in Minimally Invasive Surgery for Colon Cancer

Ichiro Takemasa ¹, Mitsugu Sekimoto², Masaaki Miyo³, Toshiyuki Mori⁴, Masazumi Okajima⁵, Yuko Ohno⁶, Yuichiro Doki³, Masaki Mori^{3; 1}Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, ²Department of Surgery, National Hospital Organization Osaka National Hospital, ³Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, ⁴Department of Surgery, Kyorin University Hospital, ⁵Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, ⁶Department of Mathematical Health Science, Osaka University Graduate School of Medicine

Background: There has been a steady increase in penetration of minimally invasive surgery for colon cancer including conventional multiport laparoscopic colectomy (MLC) and single-site laparoscopic colectomy (SLC). However, it is not clear how important the cosmetic outcome, one of the advantages of SLC, is to patients and whether SLC reflects social needs.

Methods: We used a web-based questionnaire to survey both non-medical persons and medical specialists for what factors were considered important on the assumption that respondents undergo surgery and that the MIP (most important person) for them undergoes. Five factors (curability, safety, pain, duration of hospital stay, and cosmetic outcomes) were compared. After randomly paired pre and postoperative photographs of the abdomen of the patients performed SLC and MLC were shown, perceptions of body image and cosmesis were assessed using a visual analogue scale.

Results: This study included a total of 1,352 respondents (990 non-medical and 362 medical). Curability was assigned as the most important factor, followed by safety. The scores for cosmetic outcomes were almost equal with those of the duration of hospital stay, which was associated with medical costs and pain. Participants who were female, younger, and in the non-medical group placed great importance on cosmetic outcomes. For all questions regarding body image and cosmesis, SLC had superior scores compared with MLC.

Conclusions: Understandably, curability and safety were scored as the most important factors in colon cancer surgery. Although, medical specialists should consider cosmetic outcomes as social needs, even in malignant cases.

Keywords: Colon cancer, Sngle-site laparoscopic colectomy, Cosmetic outcomes, Minimally invasive surgery.

P203

The Use of a Novel Smart Phone Application and the Quality of Bowel Preparation for Colonoscopy, a Randomized Controlled Trial

David Yu, MD, Sunil Patel, MD, FRSCS; Kingston General Hospital, Queen’s University

Background: Adequate visualization of the entire lumen of the large bowel is essential in detecting pathology and establishing diagnoses during colonoscopies. Patients are provided dietary instructions and medications in order to achieve adequate bowel preparation. Given the extensive amount of preparation required, some patients may be unable to adhere to the prescribed routine, resulting in rescheduling or repeat procedures and misallocation of limited resources. A number of previous quality-improvement efforts have been implemented to ensure adequate preparation prior to colonoscopy.

Objective: The objective of this study was to develop and assess the feasibility of a novel smart phone application in the delivery of bowel preparation instructions.

Methods: A novel smart phone application was developed to deliver bowel preparation instructions to patients undergoing colonoscopy for the first time. Patients were included in the pilot phase of this project if they were undergoing a colonoscopy for the first time. We included patients who had access to a smart phone, had not previously had a bowel preparation for any reason. We excluded patients with a previous diagnosis of inflammatory bowel disease or colorectal cancer.

Patient surveys were administered at the time of colonoscopy. Patients were questioned regarding the completeness of bowel preparation and adherence to bowel preparation instructions. Patient questionnaires were completed to ascertain the ease of use of the smart phone application and any concerns that arose. Quality of bowel preparation was assessed by the colonoscopist using the validated Ottawa bowel preparation score.

This is the pilot study results for the “COLOPREP” Trial (NCT03225560).

Results: A total of 20 patients were enrolled in the pilot phase of this study. Patient satisfaction, adherence to instructions and ease of use of the smart phone application were ascertained. Bowel preparation, as assessed by the colonoscopist, was reported.

Conclusions: This study assessed the feasibility of using a novel smart phone application for delivery of bowel preparation instruction. This pilot study is the initial phase of a randomized controlled trial to compare smart phone application vs. written instructions in the delivery of bowel preparation instructions.

P204

The Equivalence of Short-Term Perioperative Outcomes Among Pediatric Patients Undergoing Laparoscopic and Open Ileoanal Pouch Anastomosis

Piyush Kalakoti, Paolo Goffredo, Alan Utria, Imran Hassan; University of Iowa Hospitals & Clinics

Introduction: Limited literature exists evaluating the differences in efficacy between laparoscopic and open proctocolectomy with ileal-pouch anal anastomosis (IPAA) among pediatric patients. We hypothesized that patients undergoing a laparoscopic IPAA would have superior short-term outcomes compared to an open IPAA due to the accepted benefits of minimally-invasive surgery (MIS).

Methods: Using the ACS-NSQIP pediatric PUF [2012–2015], we identified patients (< 18 years) that underwent laparoscopic or open IPAA. The association of laparoscopic MIS (with respect to open surgery) with 30-day perioperative outcomes [superficial, deep and organ SSI, sepsis, UTI, length of hospital-stay (LOS), readmission and Return-to-OR (RTOR)] was investigated using multivariable regression techniques.

Results: A total of 256 pediatric patients (median age: 13 years, 52% female, Caucasian 84%, ASA I/II 68%) underwent IPAA (laparoscopic: 62%; open: 38%), with no significant differences in demographic and clinical characteristics across the two groups. In terms of outcomes, patients undergoing laparoscopic IPAA had significantly fewer superficial SSIs (1.9% vs 8.2%; p = 0.023) and a shorter median LOS (7 vs 8 days; p = 0.008). All other outcomes were not significantly different [Table-1].

In multivariable models adjusted for confounders, patients undergoing laparoscopic IPAA had a lower likelihood of developing superficial SSI compared to open IPAA (OR: 0.16; 95%CI: 0.03–0.83; p = 0.029). However, no significant differences were noted across the two approaches for sepsis, UTI, median LOS, 30-day readmission and RTOR rates in multivariable models (Figure-1). In a subset analysis, older age (OR: 1.18; 95% CI: 1.04–1.33; p = 0.010) and increased operative duration (OR: 1.02; 95% CI: 1.01–1.04; p = 0.041) were associated with an increased risk of 30-day readmission.

Conclusions: Most of the perceived benefits of a MIS on perioperative outcomes were not objectively validated. Laparoscopic IPAA in the pediatric population has similar short-term perioperative outcomes compared to patient undergoing open IPAA except for superficial SSI.

P205

Management of Right-Sided Colonic Uncomplicated Diverticulitis: Conservative Treatment or Laparoscopic Diverticulectomy?

Luu H Le, MD ¹, Vuong L Nguyen¹, Yen H Vo², Phuong T Do², Vu K Bui², Thanh V Nguyen¹, Hai V Nguyen^{1; 1}University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam, ²People of Gia Dinh Hospital, Ho Chi Minh City, Vietnam

Purpose: Right-sided diverticulitis is a rare clinical entity in Western countries but is more common in some Asian countries. At present, there are only guidelines for patients with acute left-sided diverticulitis. Controversies abound as regards the optimal treatment for those with acute right colonic diverticulitis, ranging from conservative therapy, diverticulectomy to right hemicolectomy. This study aims to establish guidelines for patients with right colon diverticulitis (RCD).

Methods: This prospective non-randomized controlled study ran from December 2009 to May 2014. Patients were enrolled if diagnosed with first attack of uncomplicated RCD by typically clinical symptoms and computerized tomography scan images or diagnosis during surgery. Included patients were divided into two treatment arms, conservative treatment or laparoscopic diverticulectomy, depending on their choice. The outcomes were treatment success, complications and recurrent diverticulitis during follow-up.

Results: 158 patients (male:female ratio: 2:1, median age 35.6 years) were included (81 conservative arm and 74 surgical arm). Median follow-up was 44 months. There were no statistically significant differences found in clinical features and laboratory findings between the two groups. No statistically significant difference was found regarding the overall success rates and the complication rates between the conservative and the surgical arms (success rates: 90.1% and 86.5% (p = 0.48) and complication rates: 8.6% and 12.2% (p = 0.472), respectively). However, surgical treatment was better than conservative treatment in preventing recurrent diverticulitis (recurrence rates: 0% and 5.4% (p = 0.031), respectively).

Conclusion: Conservative management with bowel rest and antibiotics is a safe and effective treatment for right-sided colonic uncomplicated diverticulitis and may be considered as the initial option. On the other hand, laparoscopic diverticulectomy is also safe, effective and adequate. Surgery is advocated to decrease the recurrence rate.

P206

Does Time to Closure of Loop Ileostomy Increase the Risk of Postoperative Ileus? A Large, Single-Institution Review

Richard Garfinkle, MD, Gregory Sigler, Nancy Morin, MD, Gabriela Ghitulescu, MD, Sahir Bhatnagar, PhD, Julio Faria, MD, Philip Gordon, MD, Carol-Ann Vasilevsky, MD, Marylise Boutros, MD; Sir Mortimer B. Davis Jewish General Hospital

Introduction: It has been hypothesized that the structural and functional changes that develop in the defunctioned segment of bowel may contribute to the development of postoperative ileus (POI) after loop ileostomy closure (LIC). As such, longer intersurgery interval between ileostomy creation and LIC may increase POI.

Methods and Procedures: After institutional review board approval, all patients who underwent LIC at a single institution between 2007–2017 were identified. The primary endpoint, primary POI, was defined as either a) being kept nil-per-os on or after postoperative day 3 for symptoms of nausea/vomiting, distension, and/or obstipation or b) having a nasogastric tube (NGT) inserted, without postoperative obstruction or sepsis. Secondary endpoints included length of hospital stay (LOS) and non-POI related morbidity. Patients who left the operating room with a NGT, had a planned laparotomy with a concomitant procedure at the time of LIC, had a total proctocolectomy as their index operation, or had secondary POI, were excluded. Patients were then divided into two groups based on timing from the index operation to LIC (< 6 months vs. > 6 months).

Results: Two hundred fifty-nine patients underwent LIC – 92 within 6 months of ileostomy creation, and 167 after 6 months. The median age was 65.2 (56.0–73.0) years and 58.7% were male. Patients with > 6 months intersurgery interval were more likely to have a diagnosis of colorectal cancer (89.8% vs. 77.2%, p = 0.010), to have had an open index colorectal resection (88.6% vs. 76.1%, p = 0.040), and to have suffered an anastomotic leak after the index resection (15.0% vs. 4.3%, p = 0.012). POI was observed in 18.9% of patients, while overall 30-day postoperative and non-POI related morbidity were 39.5% and 23.6%, respectively. POI was more frequently observed in patients with > 6 months intersurgery interval (22.8% vs. 12.0%, p = 0.046). Completion of adjuvant chemotherapy prior to LIC was the only other predictor of POI on univariate analysis (51.0% vs. 34.9%, p = 0.049). In all patients, POI resulted in a greater median LOS (9 (8–16.5) vs. 5 (4–6) days, p < 0.001) but was not associated with an increase in non-POI related morbidity (27.3% vs. 22.4%, p = 0.55). On multivariable regression, intersurgery interval > 6 months remained a significant predictor of POI (OR 2.57, 95% CI 1.21–5.91).

Conclusions: Intersurgery interval > 6 months is an independent predictor of primary POI after LIC. Such patients may benefit from preoperative bowel stimulation; a novel intervention being evaluated to decrease POI after LIC.

P207

Sacral Neuromodulation in the Treatment of Fecal Incontinence in a Pediatric Patient with Hirshsprung’s Disease: A Case Report

Katherine Cameron, MD, Joshua Tyler, MD, Ramon Brown, MD; Keesler Medical Center

Objective: Fecal incontinence can be a debilitating problem significantly diminishing productivity and quality of life. Sacral neuromodulation has emerged as a first line surgical option treatment in patients with fecal incontinence. Though its efficacy has been rigorously evaluated in adult populations there is scant data available for its use in the pediatric pateints with fecal incontinence. This case study discusses the management of fecal incontinence in a pediatric patient with a history of Hirschsprung’s disease utilizing sacral nerve stimulation.

Methods: Our patient is a 15-year-old female with a history of Hirshsprung’s diagnosed in infancy and treated surgically with coloanal pull through at the age of 1 who presented with complaints of fecal incontinence. The patient was wearing pads daily, noting frequent uncontrolled bowel movements as well as having frequent missed days of school due to these symptoms. Despite maximal medical management and pelvic floor physical therapy the patient continued to have 3–10 episodes of fecal incontinence daily. A CT scan with rectal contrast was used to establish her post-operative anatomy. Anal manometry showed low rest/squeeze pressures, absent resting anal inhibitory reflex, and abnormal sensation. Furthermore, during balloon expulsion testing the patient failed to pass device. The patient was deemed a candidate for Stage 1 testing with sacral nerve neuromodulation. During follow-up, the patient was noted to have resolution of her episodes of fecal incontinence and the second stage was completed. The patient continues to note 100% continence and dramatic improvement in her quality of life.

Conclusion: In this patient with a history of severe fecal incontinence due to Hirschsprung’s disease, sacral neuromodulation has had a significant impact on her quality of life. Post-operatively she continues to have marked improvement in her symptoms with 4–5 bowel movements a day with no recurrence of fecal incontinence. The use of sacral neuromodulation is a promising treatment for fecal incontinence in the pediatric population. Future research investigating the long-term efficacy of this treatment modality in the pediatric population is needed.

P209

A Study of Small Bowel Obstruction After Laparoscopic Colectomy

Shintaro Kohama, Masaki Fukunaga, Kunihiko Nagakari, Yoshito Iida, Seiichiro Yoshikawa, Masakazu Ouchi, Kazuhiro Takehara, Yuu Gyoda, Kunpei Honjo, Daisuke Azuma, Yoshinori Kohira, Jun Nomoto, Hirotaka Momose; Department of Surgery, Juntendo Urayasu Hospital

Background: We adopt laparoscopic colectomy for all colorectal cancer since we have introduced in 1993. To assess the safety of laparoscopic colectomy, we retrospectively examined surgical cases of postoperative small bowel obstruction.

1861 colorectal cancer patients underwent laparoscopic colectomy between January 2000 and September 2016 in our department. Among them, cases where surgery was required for treatment of postoperative small bowel obstruction were examined in this study. Postoperative small bowel obstruction which developed during hospital stay was defined as early bowel obstruction, and that which developed after discharge was defined as late bowel obstruction.

Cases of bowel obstruction caused by colorectal cancer recurrence and progression were excluded. 9 surgical cases (0.48%) were considered to be early bowel obstruction and 15 (0.81%) were classified as late bowel obstruction. Left hemicolectomy (n = 4, 3.03%) was a significantly more frequent procedure in early bowel obstruction, and abdominoperineal resection (n = 5, 4.20%) was significantly more common in late bowel obstruction (p < 0.05). Both early and late bowel obstruction included adhesive small bowel obstruction (n = 19), internal hernia (n = 3), and strangulation obstruction (n = 2). Internal hernia (n = 3) and strangulation obstruction (n = 2) occurred after left hemicolectomy and abdominoperineal resection, respectively. There is no apparent relationship between surgical procedures and adhesion regions (abdominal wall, intestinal tract, and pelvic cavity).

The incidence rate of postoperative small bowel obstruction remained low, and laparoscopic colectomy had been safely performed. However, countermeasures are needed because of the high frequency of both early and late bowel obstruction which occurred after left hemicolectomy and abdominoperineal resection, respectively.

P210

Improved Utilization of Resources as an Improvement of Outcome: The Effect of Multidisciplinary Team for Rectal Cancer in a District Hospital

Angela Maurizi, MD ¹, Susanna Mazzocato, MD², Roberto Campagnacci, MD, PhD^{1; 1}General Surgery, ASUR Regione Marche, "Carlo Urbani" Hospital, Jesi, Italy, ²Department of General Surgery, Università Politecnica delle Marche, 60126 Ancona, Italy

Introduction: Nowadays, treatment decisions about patients with rectal cancer are increasingly made within the context of a multi-disciplinary team (MDT) meeting. The outcomes of rectal cancer patients before and after the era of multi-disciplinary team was analyzed and compared in this paper. The purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team.

Methods and Procedures: In our health institute, weekly MDT conferences were initiated in January 2015. Meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. All rectal cancer patients diagnosed and treated in 2014–2015 in the General Surgery Division of the “Carlo Urbani” hospital in Jesi (AN, Italy) were included. Then, the data from rectal cancer patients in 2014 were evaluated, before the adoption of MDT and in year 2015, after the adoption of meetings. Datasets regarding demographics, tumor stage, treatment, and outcomes based on pathology after operation were obtained. During an MDT discussion patient history, clinical and psychological condition, co-morbidity, modes of work-up, clinical staging, and optimal treatment strategies were discussed. A database was created to include each patient’s workup, treatments to date and recommendations by each specialty. ‘‘Demographic variables’’ consisted of age at diagnosis, sex, body mass index, comorbidities, American Society of Anesthesiologists physical status classification system, clinical stage and pathological stage. Other analyzed variables included baseline carcinoembryonic antigen (CEA), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ‘‘Outcome variables’’ consisted in a comparison for each group between clinical and pathological stage.

Results: Sixty-five patients were included in this study: thirty patients in 2014 (pre-MDT) and thirty-five patients in 2015. Demographic variables did not differ significantly between groups. Preoperative clinical stages with baseline preoperative CEA and postoperative pathological stage were analysed, too. Thanks to the MDT and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the MDT group was verified.

Conclusions: The vast majority of rectal MDT decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. Analysis of the implementation of team decisions is an informative process in order to monitor the quality of MDT decision-making.

P211

Single-Incision Plus One Port Laparoscopic Lateral Lymph Node Dissection for Lower Rectal Cancer

Yasumitsu Hirano, MD, PhD ¹, Chikashi Hiranuma, MD, PhD², Mari Shimada, MD², Masakazu Hattori, MD, PhD², Kenji Douden, MD, PhD², Yasuo Hashizume, MD, PhD^{2; 1}Teikyo University Mizonokuchi Hospital, ²Fukui Prefectural Hospital

Purpose: In Japan, lateral pelvic node dissection (LPND) is the standard treatment for locally advanced lower rectal cancer. There are few reports of patients undergoing single-incision plus one port laparoscopic (SILS+1) LPND even among those undergoing laparoscopic LPND. The aim of this study is to describe our initial experience and assess the feasibility and safety of SILS+1 LPND for patients with advanced lower rectal cancer.

Methods: A Lap protector (LP) was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and three 5-mm ports were placed. A 12 mm port was inserted in right lower quadrant. A single institutional experience of SILS+1 LPLND for rectal cancer are presented. Inclusion criteria was Indications for LLD were lower rectal cancer with T3–4, or T1–2 rectal cancer with metastasis of lateral lymph node, as described by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines for the treatment of colorectal cancer. Perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively.

Results: Between January 2014 and December 2016, 19 consecutive patients underwent SILS+1 LPND for rectal cancer. Median patient age was 67.5 years (range 43–86). Operative procedures included low anterior resections (n = 10), Hartmann procedures (n = 4) abdominoperineal resections (n = 4), and intersphincteric resection (n = 1). Bilateral lymph node dissection was performed in 16 patients. The median operative time was 429.0 (range 276–700) min, and the median blood loss was 125.8 mL (range 10–310). There were no cases of open surgery or laparoscopic conversion. The median duration of postoperative hospital stay was 14.5 days (range 8–33). No Clavien–Dindo classification Grade III–IV complications occurred, and there was no perioperative mortality. The median number of harvested lymph nodes was 28.4 (range 19–59). One patient (5.6%) developed local recurrence in this series during a median follow-up of 15 month.

Conclusions: SILS+1 LPND is a safe, feasible, and useful approach for patients with advanced lower rectal cancer. Further studies are needed prove the advantages of SILS+1 LPND or to evaluate long-term oncological outcomes.

P212

The Assessment of a Flexible Self-expandable Metallic Stent for Malignant Colorectal Obstruction as ‘Bridge to Surgery’ in Our Institute

Kazuki Ueda, MD, Junichiro Kawamura, MD, Koji Daito, MD, Hokuto Ushijima, MD, Tadao Tokoro, MD, Jin-ichi Hida, MD, Haruhiko Imamoto, MD, Kiyotaka Okuno, MD; Kindai University Faculty of Medicine

Introduction: Endoscopic stenting with a self-expandable metallic stent (SEMS) is widely accepted procedure for malignant colorectal obstruction. We assessed the safety and efficacy of insertion of a SEMS followed by elective surgery as ‘Bridge to Surgery (BTS)’ in our institute.

Methods: This study was a retrospective study in our institute. The data was collected from medical charts from January 2014 to June 2017.

Results: A total of 408 consecutive patients underwent radical surgery for colorectal malignancy during this period. In this series, 16 patients (3.9%) were diagnosed malignant colorectal obstruction and intended to a BTS. The stent was successfully placed in 13 patients and all the patients were planned to undergo radical surgery. The failed 3 patients underwent stoma creation (2 patients) and Hartmann’s procedure. The technical success rate was 81% and the clinical success rate was 100%. The median time from SEMS to surgery was 11 days (2–31 days). Open and laparoscopic surgery was performed in 4 and 8 patients, respectively, except for one patient refused radical surgery because of a great age. The tumor could be resected in 12 patients (BTS patients) with primary anastomosis. However, diverting stoma creation was needed in 3 patients and decompression rectal tube was placed in 1 patient. The entire patient laparoscopically was no conversion to open surgery. There was no anastomotic leakage in BTS patients. The median duration of postoperative hospital stay was 10 days (8–54 days). The overall postoperative complication was 23% (3/13) including 2 bowel obstruction and 1 anastomotic stricture. The median follow-up period was 580 days. During the follow-up period, 3 patients were relapsed peritoneal dissemination, ovarian metastasis, and liver and pulmonary metastases, respectively. Former 2 patients were diagnosed Stage Iva at the time of primary surgery. One patient died from sudden death.

Conclusions: Our data suggested that routine use of SEMS insertion was safe and effective procedure for malignant colorectal obstruction as a BTS. Moreover, laparoscopic procedure was useful procedure in BTS patient. The short- and long-term surgical outcomes were also acceptable.

P213

Diverticular Disease: Is it Rare in Africans?

Emeka Ray-Offor, DMAS(Ind), FWACS, FMAS, FACS ¹, Patrick Igwe^{2; 1}Digestive Disease Unit, Oak Endoscopy Centre Port Harcourt Rivers State Nigeria, ²Department of Surgery University of Port Harcourt Teaching Hospital Port Harcourt Rivers State Nigeria

Introduction: Diverticular disease is uncommon among Africans with traditional high fibre diet. A westernization of diet, increasing aged population and access to colonoscopy in a metropolitan population is likely to affect the prevalence pattern. This study aims to study the prevalence of diverticular disease in a Nigerian metropolis of Sub-Saharan Africa.

Patients and Method: This is a cohort study of all consecutive patients presenting for colonoscopy to a referral ambulatory care endoscopy facility in Port Harcourt metropolis, Niger Delta region of Nigeria from March 2014-September 2017. The variables studied included: demographics; clinical and endoscopic findings; treatment. Statistical analysis was done using SPSS (Chicago lL, USA) version 20.

Results:`A total of 213 colonoscopies were performed with 29 (13.6%) cases of diverticular disease. The age range of patients was from 27 to 80 years (mean 62.76 ± 12.77 yrs). There were 22 males and 7 females; a male to female ratio of 3:1. Bleeding per rectum was the most common presentation. Seven (24.1%) and 6 (20.7%) cases showed evidence of inflammation and bleeding respectively; > 5 diverticula were seen per patient in 18 cases. The left colon was affected in 23 (79.3%), especially the sigmoid colon in 15 (51.7%) cases. Colectomy was performed for 3 patients.

Conclusion: Diverticular disease is not uncommon. A male and left-sided colon predominance is the trend.

P214

Plasma Levels of Serpin E1, a Tumorgenic Protein, are Persistently Elevated During the First Month After Minimally Invasive Colorectal Cancer Resection Which May Support Residual Tumor Growth and Metastasis

H M C Shantha Kumara, PhD, Carl S Winkler, MD, Erica Pettke, MD, Sandhu K Jaspreet, MD, Simon Tian, BS, Abhinit Shah, MBBS, Xiaohong Yan, PhD, Cekic Vesna, RN, Nipa D Gandhi, MD, Richard L Whelan, MD; Mout Sinai West, New York USA

Introduction: Serpin E1, also known as Plasminogen activator inhibitor-1 (PAI-1) is an inhibitor of urokinase type plasminogen activator (uPA) and tissue-type plasminogen activators (tPA ). PAI-1 plays a role in the regulation of angiogenesis, wound healing, and tumor cell invasion; over expression has been noted in breast, esophageal, and colorectal cancer (CRC). PAI-1 is also a potent regulator of endothelial cell (EC) proliferation and migration in vitro and of angiogenesis and tumor growth in vivo. The plasminogen/plasmin system plays a key role in cancer progression by mediating extracellular matrix degradation and tumor cell migration. Surgery’s impact on plasma PAI-1 levels is unknown. This study’s purpose was to measure plasma PAI-1 levels before and during the first month after minimally invasive colorectal resection (MICR) for CRC.

Method: CRC patients who had MICR who were enrolled in an IRB approved data/plasma bank for whom adequate plasma samples were available were eligible. Clinical and pathologic data were reviewed. Only patients for whom preoperative (PreOp), postoperative day (POD) 1, POD 3 and at least 1 late postop plasma sample (POD 7–34) were available were studied. Late samples were bundled into 7 day time blocks and considered as single time points. Plasma was isolated and stored at -80°C. PAI-1 levels were determined in duplicate via ELISA and the results reported as mean ± SD. The Wilcoxon paired t-test was used for analysis (significance, p < 0.05).

Results: 91 MICR CRC patients (colon 73%; rectal 27%; 45 male/46 female, mean age 67.3 ± 13.6 years) were studied. The mean incision length was 8.0 ± 3.9 cm and mean length of stay was 6.8 ± 4.3 days. The final cancer stage breakdown follows; I (n = 30), II (n = 30), III (n = 36) and IV (n = 4). %. When compared to mean Preop levels (18.5 ± 8.3 ng/ml), significantly elevated mean levels (ng/ml) were noted on POD 1 (32.2 ± 22.4; n = 91, p < 0.001), POD 3 (22.9 ± 13.1, n = 86, p = 0.003), POD7-13 (30.2 ± 17.5, n = 65, p < 0.001), and POD14-20 (28.5 ± 16.4, n = 26, p = 0.001), POD 21–27 (28.2 ± 15.8, n = 19, p < 0.001) and There was no significant difference noted between the POD 27–34 and PreOp results.

Conclusion: Plasma PIA-1 levels are significantly elevated vs. Preop levels for 1 month after MICR for CRC. The early increase after MICR may be related to the acute inflammatory response via macrophage activation. The elevation noted during weeks 2–4, however, may be related to PAI-1 associated VEGF induced angiogenesis occurring in the healing wounds; these plasma changes may also promote angiogenesis in residual tumor deposits. Further studies are warranted.

P215

Rate of Polyp Detection in Cecum/Ascending Colon, With and Without Retroflexion: A Retrospective Analysis

Nimy John, MD, Anand Curuchi, MD; St. Vincent Hospital, Worcester, MA

Objectives: Retroflexion in the rectum at the end of a colonoscopy is a requirement for a complete endoscopic evaluation. Retroflexion helps to visualize and detect polyps which would be missed otherwise. Currently new endoscopes are available which can do retroflexion in the caecum.

Aim: Our study aims to compare the rate of polyp detection rate in Cecum and Ascending colon with and without retroflexion in cecum.

Methods: This is a single center, single operator, retrospective study. A total of two hundred patients were involved. A single center IRB waiver was obtained. Patients were divided into two groups based on the presence/absence of retroflexion in caecum during their colonoscopy. The data was obtained from 2017 records.

Group A (n = 100) had colonoscopy without retroflexion in caecum

Group B (n = 100) had colonoscopy with retroflexion in caecum

Inclusion criteria: Patients undergoing screening colonoscopy between the age of 40 and 85.

Results: Group A: Total of 100 patients were screened. A total of 95 polyps were detected in group A. Number of cecal polyps were 4 (4.2% of total polyp count). Number of ascending colon polyp were 18 (19% of total polyp). On analyzing the pathology 60% of the cecal polyps were tubular adenoma, 20% hyperplastic polyps 20% and 20% lymphoid aggregate. Number of ascending colon polyps were 18, of which 72% were tubular adenoma, 22% tubular adenoma and 6% tubulovillous adenoma

Group B: Total of 100 patients were screened. A total of 80 polyps were detected. Number of cecal polyps detected were 5 (6.2% of total polyp count). Number of ascending of ascending colon polyps were 11 (13%). On analyzing pathology, 80% cecal polyps were tubular adenoma and 20% were sessile serrated. Out of the ascending colon polyps 27% were tubular adenoma, 27% sessile serrated,27% tubulovillous and 18% hyperplastic polyp.

Side Events: Two mass lesions were noted in both group A and B. There was incomplete colonoscopy in group A and B.

Conclusion: This retrospective analysis reveals a small increase in polyp detection in the cecum with retroflexion, especially in detecting sessile polyps which have more malignant potential. However, a large multicenter analysis will be required to validate the above observation.

P216

Minimally Invasive Rectopexy for Rectal Prolapse has Improved Postoperative Morbidity Compared to Traditional Open Repairs, an Analysis Using the ACS-NSQIP Database

Matthew Skancke, Dr, Richard Amdur, PhD, Bindu Umapathi, Dr, Vincent Obias, Dr; George Washington University

Background: While uncommon, rectal prolapse is a disabling condition affecting older females. In a small subset of patients, concomitant organ prolapses with or without incarceration can lead to significant morbidity. As the field of laparoscopy has evolved, minimally invasive surgical options for rectal prolapse have led to improved quality and reduced morbidity for patients suffering this debilitating disease.

Methods: The 2012–2015 ACS-NSQIP databases was queried for patients undergoing a traditional or minimally invasive rectopexy based on CPT codes (45400,45402,45540,45541 and 45550). Emergent cases and patients with preoperative infections or inflammatory states were excluded. The primary outcome of interest was a 30-day postoperative composite morbidity score. Statistical analysis incorporated multivariate analysis and binomial logistic regression with p < 0.05 holding significance.

Results: These inclusion and exclusion criteria identified 2393 patients undergoing traditional (1113) and minimally invasive (1280) rectopexy for prolapse between 2012 and 2015. Patients undergoing traditional rectopexy were older (p < 0.001), had a higher body mass index (p = 0.018), more comorbid conditions (diabetes, COPD, hypertension) and less functional independence (p = 0.026). Patients undergoing a traditional rectopexy had a higher composite morbidity incidence of 13.2% vs. 8% for minimally invasive rectopexy (p < 0.001). Specifically, minimally invasive rectopexy patients had a 2.63% reduction in wound complications (p = 0.002) and a shorter hospital stay (3.3 days vs. 4.3 days, p < 0.001) compared to a traditional rectopexy. Readmission rates were also 2.6% lower in the minimally invasive group (p = 0.015). After controlling for the differences in the cohorts, a minimally invasive approach was a significant protective factor against the incidence of 30-day postoperative morbidity (OR 0.476, p < 0.001).

Conclusion: A minimally invasive rectopexy has improved 30-day postoperative morbidity compared to a traditional rectopexy and should be strongly considered for the treatment of rectal prolapse.

P217

Optimal Interval from Placement of a Self-expandable Metallic Stent to Surgery in Patients with Malignant Large Bowel Obstruction

Akihisa Matsuda, MD, Satoshi Matsumoto, MD, Nobuyuki Sakurazawa, MD, Youichi Kawano, MD, Kumiko Sekiguchi, MD, Masao Miyashita, MD, Eiji Uchida, MD; Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital

Objectives: The short-term safety and efficacy of a self-expandable metallic stent (SEMS) placement followed by elective surgery, “bridge to surgery (BTS)”, for malignant large-bowel obstruction (MLBO) have been well described. The aim of this study was to investigate the risk factors for postoperative complications and optimal interval between SEMS placement and surgery in patients with MLBO.

Methods: Retrospective examination of patient records revealed that the BTS strategy was attempted in 49 patients with MLBO from January 2013 to March 2017 in our institution. Two of these patients were excluded because they had undergone emergency surgery for SEMS migration; thus, 47 patients with MLBO who had undergone SEMS placement followed by elective surgery were included. Of these patients, eight had developed postoperative complications (Clavien–Dindo grading ≥ II) (postoperative complication: POC group) whereas 39 patients had no such complications (No POC group).

Results: Univariate analyses showed that the factors of ASA score, number of lymph nodes resected, interval between SEMS and surgery, and preoperative albumin concentration were associated with postoperative complications. Multivariate analysis identified only the interval between SEMS and surgery as an independent risk factor. Furthermore, a cut-off value of 15 days for interval between SEMS and surgery was identified by ROC curve analysis.

Conclusions: An interval of ≥ 15 days from SEMS placement to surgery is an independent predictive factor for postoperative complications in patients undergoing elective surgery in a BTS setting. Thus, an interval of over 15 days is recommended for minimizing postoperative complications.

P218

Selective Colorectal Cancer Imaging by Use of Indocyanine Green Versus Next-Generation Cancer-Specific Targeting Agents

Haseeb Kothar, Ronan Cahill; Mater Misericordiae University Hospital

Current clinical advances in operative near-infrared visualisation of cells, tissues and structures are predicated on the use of commercial available near-infrared cameras to excite and visualise emission energy from non-selective, approved compounds (predominantly indocyanine green (ICG)). It is expected that new generation compounds wholly selective for specific cellular components are now needed for further advance and a variety of molecular targets have been proposed and are being developed primarily for oncological imaging purposes. Recent publications have however suggested ICG itself is retained within malignant tissue differently to its uptake and clearance from surrounding non-malignant tissue which is important for two reasons. Firstly, it exploits and makes visual the increased vascular permeability and disordered clearance associated with carcinogenesis which is a common endpoint of a variety of mediators including but not limited to VEGF. This raises the useful option of targeting downstream effects of cancer compounds on a metabolic basis as opposed to tagging individual cell or antigen components. This means that a single agent could be used to target a variety of cancers rather then needing a specific one for each specific sub-type as well as obviating the issue of cancer cells heterogeneity even in a single cancer deposit. Second, it is very likely that some or all of the “localisation” effect of proposed selective compounds may well be due to a similar phenomenum rather then cell-specific binding and may make distinction from other areas of similar metabolic behaviour (ie inflammatory regions) difficult. The crucial step-advance for such agent development so may well relate to timing of compound delivery and “visualisation window” at the region of interest rather then highly selective oncocellular-targeting. To illustrate this in more detail, we have been examining the tissue-specific effects and actions of near-infrared excitation in patients (n = 7) with localised malignant colorectal primaries receiving an aliquot of ICG before such examination at the time of resection. ICG can be selectively apparent in the colorectal primary 15 minutes after its systemic administration likely due to altered vascular dynamics. Additional dose-related work has shown that early administration (40–180 minutes before examination) does not give useful information related to tumour fluorescence. Interestingly none of these patients had fluorescence seen within their regional lymphatics but none also had malignant lymph nodes associated with their large primaries on pathological examination.

P219

Pelvic Peritoneum Closure with Improved Techniques as a Standard Surgical Procedure in Laparoscopic Abdominoperineal Resection: A Retrospective Study of 82 Cases

Xialin Yan, MD, Jiaoyang Lu, MD, PhD, Sen Zhang, MD, Leqi Zhou, MD, Jianwen Li, MD, PhD, Pei Xue, MD, PhD, Mingliang Wang, MD, PhD, Aiguo Lu, Junjun Ma, Lu Zang, MD, PhD, Feng Dong, MD, PhD, Zirui He, MD, PhD, Fei Yue, MD, PhD, Jing Sun, MD, PhD, Hiju Hong, MD, PhD, Minhua Zheng, Bo Feng, MD, PhD; Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China

Introduction: Pelvic peritoneum closure (PPC) is a standard operative procedure in conventional open abdominoperineal resection (APR) to prevent postoperative complications. However, this procedure is not usually performed in laparoscopic APR for its technique difficulty, which may lead to increased rates of complications (Fig. 1). Here, we compared the feasibility and peri-operative outcomes of the laparoscopic APR with and without pelvic peritoneum closure (PPC) for lower rectal cancer.

Methods and Procedures: From September 2015 to May 2017, clinical data of 82 patients with lower rectal cancer undergoing APR in our medical center were studied retrospectively. Among all these eligible patients, 38 of them were in the PPC group (received laparoscopic APR with PPC via barbed sutures and Hemo-lock clips, Fig. 2) and the other 44 cases were in the non-PPC group (received laparoscopic APR without PPC). Short-term outcomes were contrasted between these two groups.

Results: None of cases were conserved to open surgery. There was no significant difference in PPC and non-PPC group for operation time (148.1 ± 26.2 min vs 141.5 ± 21.0 min, P = 0.213), the operative time for pelvic peritoneum closure in PPC group was 7.9 ± 2.9 min, and intra-operative blood loss (105.5 ± 41.6 ml vs 112.9 ± 46.2 ml, P = 0.471) between these two groups. In terms of postoperative complications, incidence of perineal hernia, perineal wound infection and postoperative bowel obstruction were significantly reduced in PPC group compared with the non-PPC group (Table 1). Besides, no significant difference was found in terms of the number of lymph nodes harvested (14.4 ± 2.4 vs 13.9 ± 2.3, P = 0.272), circumferential resection margin (CRM) positivity (2.6% vs 4.5%, P = 0.645) and the time of hospital stay ((15.4 ± 3.0) d vs (16.2 ± 4.1) d, P = 0.333 ).

Conclusions: PPC should be served as a standard procedure in laparoscopic APR for lower rectal cancer, which didn’t significantly increase the length of surgery or intra-operative blood loss, and might result in a significantly reduced incidence of postoperative complications including perineal hernia, perineal wound infection and intestinal obstruction. This surgical procedure could be easily managed with barbed sutures and Hemo-lock clips by experienced hands.

P220

Effects of Obesity on Laparoscopic Colon Cancer Surgery Performed by Various Operative Methods

Ryuichi Oshima ¹, Yukihito Kokuba¹, Yuta Ogura¹, Taichi Mafune¹, Ryuichi Kishi¹, Kuniyasu Horikoshi¹, Keiichi Tanaka¹, Takehito Otsubo^{2; 1}Department of Gastroenterological Surgery, St. Marianna University Yokohama-City-West Hospital, ²Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine

Introduction: There are reports of increased operative duration, blood loss and postoperative morbidity, caused by difficulties in obtaining good visualization and in controlling bleeding when laparoscopic resection is performed in obese patients with colon cancer.

Purpose: The aim of this study was to investigate the impact of obesity on perioperative outcomes after laparoscopic colorectal resection performed by various operative methods in our department.

Patients and Methods: We conducted a retrospective analysis of 435 patients with colorectal cancer who underwent laparoscopic surgery between January 2011 to December 2015. Right colectomy was performed in 84 patients, sigmoidectomy in 73 patients, and low anterior resection in 50 patients. The surgical outcomes were compared between non-obese (body mass index [BMI] < 25 kg/m²) and obese (BMI ?25 kg/m²) patients.

Results: Right colectomy cases: The amount of blood loss was significantly increased in the obese group compared with the non-obese group, but operation time did not differ significantly between the groups. There were no significant differences between the two groups in the rate of postoperative complications and duration of post-operative hospitalization. Sigmoidectomy cases: There were no significant differences between the two groups in operation time and amount of blood loss. Even though the preoperative ASA score and the rate of postoperative complications were higher in the obese group, the mean postoperative hospital stay did not differ significantly between the two groups. Low anterior resection cases: There were no significant differences between the obese group and the non-obese groups in operation time, amount of blood loss, rate of postoperative complications, and duration of post-operative hospitalization.

Discussion: Although there are some reports of increased operative times in obese patients, the operative procedure was not extended in any of the present study patients. The amount of blood loss was significantly increased in the obese group compared with the non-obese group when right colectomy was performed. Among the patients undergoing sigmoidectomy, the postoperative rate of complications was higher in the obese group; however, the preoperative ASA status was also higher in the obese group than non-obese group, indicating that factors other than obesity may be involved.

Conclusion: We concluded that laparoscopic colorectal resection appeared to be safe and feasible in both obese patients and non-obese patients. However, BMI may not accurately reflect the amount of visceral fat present.

P221

Endoscopic Mucosal Resection for Early Colorectal Cancer Followed by Surgery or Surveillance

Chang Woo Kim, MD¹, Sun Jin Park, MD², Kil Yeon Lee, MD², Suk-Hwan Lee, MD ^{1; 1}Kyung Hee University Hospital at Gangdong, ²Kyung Hee University Medical Center

Introduction: The aim of this study was investigate the safety of Endoscopic mucosal resection (EMR) for early colorectal cancer comparing with outcomes of radical resection after EMR. EMR has been applied for early colorectal cancer with the strict indications. The radical resection after EMR is often required if the known risk factors including poor differentiation, lymphovascular invasion, resection margin involvement, and deep invasion depth.

Methods: Between June 2006 and June 2017, 8490 EMRs were performed for 5250 patients with colorectal polyps at Kyung Hee University Hospital at Gangdong. After the patients with benign polyps were excluded among them, medical records and pathologic reports were reviewed. Colonoscopic finding and pathologic variables were analyzed and compared.

Results: A total of 103 patients underwent EMR for early colorectal cancer. 40 patients had risk factors and were recommended for surgery after EMR, whereas 28 patients among them underwent surgery. 12 patients refused surgery due to old age, poor condition, and avoidance of stoma formation. In contrast, one patient without risk factors underwent surgery because he wanted.

The gross types of polyp and tumor size were not different between the two groups. However, rectal polyps than colon polyps were found frequently in the observation group than in the surgery group (25.7% vs. 10.3%, P = 0.047). In addition, there were more favorable differentiation of the tumor and shallow depth of invasion in the observation group. In contrast, lymphovascular invasion and resection margin involvement were more found in the surgery group (34.5% vs. 1.4%, P < 0.001 and 20.7% vs. 4.1%, P < 0.001, respectively). During 48.4 months of follow up period, no recurrence was noted in the both groups.

Conclusion: EMR for early colorectal cancer appeared to be safe and feasible. Pathologic reports as well as colonoscopic findings are important to decide performing surgery or observation. Even some patients with risk factors could benefit from EMR alone, but close surveillance is mandatory to confirm long-term oncologic results.

P223

A Prospective Study Beyond the RCT Between Our Modified Ripstein Method and Modified Wells Method for Complete Rectal Prolapse

Tokihito Nishida, PhD, Hajime Ikuta, PhD, Kunio Yokoyama, PhD, Takuya Kudo, MD; Department of Surgery, Kasai City Hospital, Hyogo, Japan

Background: For the complete rectal prolapse (basically longer than 3 cm), we thought sling rectopexy was most reasonable to hang up and fix the rectum, which drooped down and prolapsed due to the relaxation of supporting tissue. We considered Ripstein method had enough fixed power of rectum to sacrum. However, complications of rectal stenosis, constipation, mesh infection and mesh penetration were reported. Therefore, we modified Ripstein method to conquer such complications.

Aim: A prospective study beyond the randomized control trial (RCT) between our modified (m)-Ripstein method and m-Wells methods was performed to evaluate feasibility and efficacy of our m-Ripntein method.

Materials and Methods: From December 2007 to August 2017, 79 rectopexies for complete rectal prolapse were assigned to RCT. To prevent the complication of original Ripstein method, we devised to set the horizontal length of T style BARDTM mesh up to almost 1.2 fold of rectal circumference for loose fit, and prolong the vertical length of the mesh to almost 2 fold of the original for straight fit. Mesh was fixed to rectum with Endo Universal StaplerTM and to sacrum with AbsorbaTackTM. When each 25 cases were registered to RCT, second recurrence of m-Wells method occurred. We stopped m-Wells method until the cause would be clear and continued m-Ripstein method to 51 cases. After the cause of recurrence by m-Wells method was revealed, it was resumed to 28 cases.

Results: Patient’s characteristics (average value) in m-Ripstein 51 cases vs. m-Wells 28 cases were not significantly different; age 79.1 vs. 78.9-year-old, female 86.3 vs. 85.7%, BMI 21.7 vs. 21.1, length of prolapse 4.7 vs. 4.3 cm, comorbidities number per patient 4.4 vs.4.8 and ASA-PS 2.6 vs. 2.6. In clinical outcomes (average value), operative time was 164 vs. 143 minutes (P = 0.0318) and the others; blood loss 33 vs. 11 grams, intraoperative accident 18 vs. 7%, postoperative complication 9.8 vs. 3.6%, mesh infection/morbidity 0 vs. 0%, meal start 1.9 vs. 1.9 POD, postoperative constipation 14 vs. 14%, postoperative fecal incontinence 7.8 vs. 0%, postoperative urinary incontinence 5.9 vs. 0%, postoperative stay 9.4 vs.9.0 days, follow up interval 39 vs. 31 months and recurrence rate 0 vs. 7.1% were not significantly different.

Conclusion: Primary evaluation item of recurrence rate were not significantly different. Secondary evaluation items of postoperative constipation, fecal incontinence and urinary incontinence were not significantly different between two groups. Our m-Ripstein method was feasible and showed good outcome especially in recurrence.

P224

Metastatic 253 Lymph Nodes were Associated with Metastatic 251 and 252 Lymph Nodes and the Numbers of Harvested 253 Lymph Nodes in Rectal Cancer

Kai Li, Zhangyuanzhu Liu, Dexin Chen, Weisheng Chen, Wei Jiang, Xiumin Liu, Ziming Cui, Zhiyao Wei, Zhiming Li, Yuliang Huang, Jun Yan, MD; Department of General Surgery, Nanfang Hospital, Southern Medical University

Background: Inferior mesenteric artery lymph nodes (253 lymph nodes) metastasis occurs in approximately 0.3 to 13.9% according to different T stage in rectal cancer, which is an important prognostic factor after curative resection for rectal cancer. The aim of this study was to evaluate the independent risk factors of 253 lymph nodes metastasis in rectal cancer.

Methods: A total of 200 patients who underwent curative resection of the rectal cancer between January 2014 and August 2017 were selected. The patients were classified into 2 groups: 253-positive group (n = 18) and the 253-negative group (n = 182). The status of 253 lymph nodes were analyzed using univariate and multivariate analysis.

Results: The rate of 253 lymph nodes metastasis in our study was 9%. Univariate analysis revealed that the risk factors of 253 lymph nodes metastasis were as follows: Mucinous adenocarcinoa and poorly differentiated (p = 0.025); depth of tumor invasion (p = 0.013); 251 lymph nodes positive (p < 0.001); 252 lymph nodes positive (p < 0.001); the number of 253 lymph nodes harvested (p = 0.003). After multivariate regression analysis, only 251 lymph nodes positive (OR, 7.627; 95%CI, 1.664–34.976; p = 0.009), 252 lymph nodes positive (OR, 5.273; 95%CI, 1.457–19.081; p = 0.011); the numbers of 253 lymph nodes harvested (OR, 1.255; 95%CI, 1.082–1.454; p = 0.003) were identified as independent risk factors of 253 lymph nodes metastasis in rectal cancer.

Conclusions: The status of 251 and 252 lymph nodes metastasis, and the numbers of 253 lymph nodes harvested were identified as independent risk factors of 253 lymph node metastasis in rectal cancer.

P225

Surgical Procedure for Laparoscopic Transanal Total Mesorectal Excision and Bilateral Lateral Lymph Node Dissection of Lower Rectal Carcinoma

Kentaro Sato, Hajime Morohashi, Yoshiyuki Sakamoto, Takuya Miura, Tatsuya Yoshida, Takahiro Suzuki, Kenichi Hakamada; Department of Gastroenterological Surgery, Hirosaki University

Introduction: The results of the Japan Clinical Oncology Group (JCOG) 0212 Study suggested that total mesorectal excision (TME) and lateral lymph node dissection (LLND) could become the standard treatment for lower rectal carcinoma. However, LLND must also be performed laparoscopically if surgery for lower rectal carcinoma is to be carried out as a completely laparoscopic procedure. Transanal TME (TaTME) is expected to provide better results than the conventional TME, both oncologically and in terms of pelvic function, and its use has recently been spreading in Japan. We started performing laparoscopic TaTME + LLND in our department in July 2016 and here report the short-term outcomes.

Subjects and Methods: We used laparoscopic TaTME + LLND to treat 5 men and 3 women with cT3 or deeper rectal carcinoma in whom the inferior margin of the tumor was on the anal side of the peritoneal reflection. This was a retrospective study of short-term postoperative outcomes.

Surgical Procedure: Laparoscopic surgery was started simultaneously by two teams, one working transabdominally and the other working transanally. The transabdominal team performed the standard proximal LLND and mobilization of the splenic flexure via five ports. They then dissected the bilateral lateral lymph nodes, mainly in the obturator (#283) and internal iliac (#263) groups. During this time, the transanal team performed laparoscopic TaTME. Finally, both dissection layers were connected and the cancer was excised.

Results: Six patients had clinical stage II and two had clinical stage III lower rectal carcinoma. All the patients underwent preoperative chemotherapy with S-1 + L-OHP. Five underwent a sphincter-preserving surgery, and three underwent rectal amputation. The mean operating time was 335 minutes (range, 267–382 minutes), and the mean amount of hemorrhage was 136 g (20–440 g). The mean number of lymph nodes dissected was 24, and R0 resection was performed in all the cases. The mean length of hospital stay was 14 days, and a postoperative complication of Clavien-Dindo grade III or higher occurred in one patient (anastomotic failure).

Conclusions: Laparoscopic TaTME + LLND performed by two teams simultaneously is an extremely useful procedure that not only reduces operating time, but also is less invasive than laparoscopic surgery. It may also be effective for improving curative nature, nerve preservation, and anal function.

P226

The Advantages of Endostapler in Securing the Base of Appendix in Laparoscopic Appendectomy

Saurabh Gandhi, MS ¹, Eham Arora, MS¹, Gagandeep Talwar¹, Chintan Patel, MS², Ajay Bhandarwar, MS, FMAS, FIAGES,, FLCS, FBMS, FICS¹, Tina Gandhi, MS^{1; 1}Grant Govt. Medical College & Sir JJ Group of Hospitals, India, ²Kiran Multi-Super Speciality, India

Objective: In laparoscopic appendectomy, the base of the appendix is usually secured by applying a roeders knot. The aim of this study was to compare the advantages of using staplers and hem-o-locks for securing the base of the appendix.

Method: The study included 82 patients between age of 12 to 75 years with acute appendicitis randomly divided into two groups. In the first group, the base of the appendix was secured using roeders knot. In the second group, mesoappendix was not dissected and was included in the endostapler jaws. The primary outcome was overall morbidity. Secondary outcomes were total duration of surgery, total length of stay and ease in difficult cases.

Result: No morbidity was recorded in any group. The time of the operative procedure was significantly longer in the cases with roeders knot than in the Stapler group (P < 0.0001) as mesoappendix was not dissected in the later. 2 cases with unhealthy base were progressed to laparoscopic quadricolectomy. Apart from the ease of applying a stapler, cases of second group with gangrenous base were easily tackled using endostapler, avoiding the need of a hemicolectomy.

Conclusion: All forms of closure of the appendix base are acceptable, but endostapler technique apart from providing a secure base, reduces operative time and is an essential tool in cases of gangrenous base.

P227

Factors Influencing the Quality of Lymph Node Dissection in Colorectal Cancer

Cristians A Gonzalez, MD ¹, Jung-Myun Kwak, MD¹, Talitha Mendes, MD², Carlos Veo, MD², Maximiliano Cadamuro Neto, MD², Marcos Denadai, MD², Armando Melani, MD², Bernard Dallemagne, MD³, Jacques Marescaux, MD, FACS, HON, FRCS, HON, FJSES, HON, FASA³, Luis Romagnolo, MD^{2; 1}IHU-Strasbourg Institute for Image-Guided Surgery (Strasbourg, France), ²Barretos Cancer Hospital (IRCAD LATIN AMERICA - Sao Paulo, Brazil), ³IRCAD, Research Institute against Cancer of the Digestive System (Strasbourg, France)

Introduction: Accurate staging is essential to estimate the prognosis of patients with colorectal cancer (CRC) and lymph node evaluation is key to determine it. In non-metastatic CRC, the number of harvested lymph nodes is the strongest prognostic factor for outcome and survival. Additionally, it is thought that a higher lymph node yield may be representative of a higher quality of surgical care. Due to the importance of the association between lymph node evaluation and outcome in CRC, it is necessary to evaluate factors which may affect lymph node harvest.

Methods and Procedures: In order to determine the influence of different patient-related factors, of tumor characteristics and operative parameters impacting the quality of oncological lymph node dissection and harvesting intraoperatively, a prospective collection and retrospective analysis of all cases of colorectal cancer patients operated on in the Digestive Surgery Department at Barretos Cancer Hospital (IRCAD LATIN AMERICA, Sao Paulo, Brazil) was performed between July 2015 and February 2017.

Results: Over the abovementioned period, 640 radical surgeries for colorectal cancer were performed, 294 (46%) of which were performed in female patients and 346 (54%) in male patients. Lesions were located as follows: right colon (99 cases, 15.5%), transverse colon (19 cases, 3%), left colon (30 cases, 4.8%), sigmoid colon (163 cases, 25.6%) and rectum (325 cases, 51.1%). Seventy percent of patient cases were performed laparoscopically with a conversion rate of 3.6%. The mean number of resected nodes according to tumor location was the following: 19 for the right colon, 20 for the transverse colon, 24 for the left colon, 20 for the sigmoid colon and rectum. Preoperative radiotherapy (p < 0.001) has a negative impact on the number of dissected nodes. Other patient-related factors such as age, gender and BMI have no influence on this. There was no relationship between tumor-specific factors and the quality of node dissection. Finally, operative time (p = 0.021) is the only technique-specific factor affecting the radicality of surgical resection in patients with colorectal cancer, probably as a reflection of more surgically complex cases.

Conclusion: Preoperative radiotherapy and operative time are factors which are often interrelated, have a significant impact on the number of harvested nodes. The relationship of these findings with the outcome and survival of CRC patients is yet to be determined.

P228

Outcome of Laparoscopic Reversal of Hartmann’s Procedure

Taha A Esmail, Professor, Osama H Abd-Rabo, Leccturer, Amir F Shaban, Lecturer, Tarek M Sehsah, Aassist Lecturer; Tanta University-Egypt

Introduction: Hatmann’s procedure is commonly done in treating complicated diverticulitis, negleccted rectal trauma with sepsis and sometimes malignancy. the traditional techniques to restore the intestinal continuity after Hartmann’s procedure were for many years the standard of care in these operations, but in fact they carry many morbidity and even mortality and failure. laparoscopic techniques is not only carry the advantage of minimal invasive surgery, but also of better visualizationn and magnification. the aim is evaluating the outcome of using the laparoscope in reversal of Hartmann’s procedure as regard feasibility and safety.

Patients and Method: Forty patients were subjected to laparoscopic reversal of Hatmann’s procedure in Tanta University Hospital, there ages ranged between 25 to 70 years, the time elapsed after the original operation ranged from 6 months to 5 years, excluding advanced malignany. conversin occurred in 6 cases due to extensive adhesions and bleeding.

Results: No mortality, or major morbidity in our study and only single leak treated by covering ilestomy. Conclusion; Laparoscopic Hartmann’s procedure is feasible, promising tehnique with minimal morbidity.

P229

Laparoscope in the Colorectal Emergent Surgery-Analysis of Consecutive 57 Patients Single Center Experience

Yi Chang Chen, Yuan Yao Tsai, Yu Chun Huang, Shen Ji Chang, Tao Wei Ke, Hung-Change Chen, Huei Ming Wang, William Tzu-Liang Chen; Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan

Background: Minimal invasive surgery has been well established in the elective colorectal surgery and it has been proven better clinical outcome compared with open surgery. In the emergent setting, laparoscope is used mostly in the colecystectomy, appendectomy but laparoscopic emergent colorectal surgery is limited for it`s complexity and difficulity. The aim of this study was to envaluate the feasibility of laparoscopic emergent colorectal surgery.

Methods: This study is prospective collected, observational single center study of patients undergoing laparoscopic emergent colorectal surgery from 2011 to 2016. The patient demographics, surgery indication and detail, complication, clinical outcome and hospital stay were collected and analyzed.

Results: There are total 130 emergent colorectal operations and 57 patients were managed with minimal invasive method. Among these laparoscopic emergent surgery, there are 33 male patients and 24 female patients. Mean age of the patients was 63.8 years (Range 31–89 years). The main indication for operation: perforation 49.1% (28/57), leakage after elective colorectal surgery 42.1% (24/57), obstruction 3.5% (2/57), ischemia colitis 3.5% (2/57,), bleeding 1.8% (1/57). There are 19 cases in ASA 2, 32 cases in ASA 3, 6 cases in ASA 4. The qSOFA score for sepsis:23 cases was 0, 28 cases was 1, 5 cases was 2, 1 case was 3.

There are 27 cases undergoing laparoscopic lavage with diverting stomy, 15 cases were Hartmann procedure, 5 cases were anterior resection,4 cases were right hemicolectomy, 3 cases were perforation repair, 3 cases were redo anastomosis. There are 6 cases coversion to open method including 3 cases were due to bowel adhesion,2 cases were due to bowel distension,1 case was due to severe shock status. Mean operative time is 180.3 minutes.

The overall mortality rate was 5.2% and major complication rate (Clavien-Dindo grade above 2) was 24.5%. Re-operation rate was 15.7%. The mean hospital stay was 17.1 days.

Conclusions: This study presents evidence of an initially clinical outcome in emergent laparoscopic colorectal suregry. In the absence of large case series, the benefits of a laparoscopic approach should befall to at least a minority of these patients.

P230

In Vivo Real-Time Assessment of Anastomotic Blood Supply of Colorectal Surgery Using Confocal Laser Endomicroscopy in an Anastomotic Model

Xiumin Liu, Yuanzhu Liuzhang, Kai Li, Haibin Lin, Wei Jiang, Weisheng Chen, Jun Yan, MD; Department of Surgery, Guangzhou Nanfang Hospital

Introduction: Anastomotic leakage (AL) is one of the serious postoperative complications in the colorectal surgery. One of the significant factors leading to leakage is the poor bowel perfusion. Confocal laser endomicroscopy (CLE) can provide real-time observation of the cell structure and tissue morphology. In our study, we aim to assess the situation of anastomotic perfusion using CLE.

Method: The experimental rabbits were separated into two groups: group A (good anastomotic perfusion, n = 6), group B (poor anastomotic perfusion, n = 6). The partial colectomy and anastomosis was performed for group A and B. Then detection for anastomotic perfusion using CLE was carried out after the surgery. During the continuous scanning, we counted the number of blood cells that cross over the certain point of anastomotic stoma in the same period.

Results: Assistant with fluorescein sodium, the blood vessels are highlighted. We can see significant difference of imaging effect between group A and group B. The average number of blood cells are 34.7/min of group A and 6.0/min of group B (p < 0.001), which has significant difference.

Conclusion: CLE can allow real-time observation of the blood flow of anastomotic stoma in vivo. Therefore, it is feasible to assess the anastomotic perfusion using CLE in colorectal surgery.

P231

Intra-operative Colonoscopy During Colorectal Surgery Does Not Increase Postoperative Complications: An Assessment from the ACS-NSQIP Procedure-Targeted Cohort

Cigdem Benlice, Ahmet Rencuzogullari, James Church, Gokhan Ozuner, David Liska, Scott Steele, Emre Gorgun; Cleveland Clinic

Background: Intraoperative colonoscopy (IOC) is an adjunct in colorectal surgery (CRS) especially in patients with malignancies in order to detect location of the primary or synchronous lesions as well as assessing anastomotic integrity. However, effects of intraoperative colonoscopy on short term outcomes during CRS is a concern. This study aims to evaluate safety and feasibility and post-operative outcomes of intraoperative colonoscopy in left-sided colectomy patients for colorectal cancer patients by using the nationwide database.

Patients and Methods: Patients undergoing elective left-sided colectomy with low pelvic anastomosis without any proximal diversion for colorectal cancer were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure-targeted database (2013–2015) according to their primary procedure Current Procedural Terminology (CPT) code. Subsequently, patients who underwent intraoperative colonoscopy were identified from concurrent CPT codes and divided into two groups based on the simultaneous intraoperative colonoscopy. Demographics, comorbidities, 30-day postoperative complications were evaluated and compared between the groups. Multivariate logistic regression was conducted adjusting for significant factors between the groups.

Results: A total of 5579 patients were identified and IOC was performed for 651 (11.7%) patients. The groups were comparable in terms of demographics, characteristics and operative factors except for surgical approach (laparoscopic surgery: 85.8% vs 75.2%, p < 0.001), mechanical bowel preparation (71.7% vs 75.8%, p = 0.03), oral antibiotic use with bowel preparation (32.8% vs. 39.5%, p = 0.002) and preoperative chemotherapy within 90 days (15.6% vs. 18.9%, p = 0.04). Comparison of individual postoperative complications and length of stay were summarized in the table. After multivariate risk-adjustment, the results did not change and groups remain comparable.

Conclusion: Use of intraoperative colonoscopy does not adversely affect short term outcomes after colorectal resections. Surgeons should utilize intraoperative colonoscopy liberally for left sided colorectal resections.

Table: Comparison of postoperative outcomes between patients who had colonoscopy or not.

P233

Laparoscopic Ileostomy via Reduced Port Surgery for the Patients with Advanced Colorectal Cancer Before Chemotherapy

Tomohiro Sonoda, Shinichiro Mori, Yoshiaki Kita, Kan Tanabe, Kenji Baba, Masayuki Yanagi, Yasuto Uchikado, Hiroshi Kurahara, Yuko Mataki, Masahiko Sakoda, Kosei Maemura, Shoji Natsugoe; Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine

Objective: Laparoscopic ileostomy commonly performed for the patients with colorectal obstruction due to cancer, peritonitis with perforation of colon or the other reason. Reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a cosmetic benefit. The aim of this study was to evaluate safety and feasibility of reduced port laparoscopic ileostomy for the patients with advanced colorectal cancer before chemotherapy.

Methods: Between July 2012 and August 2017, 39 patients who underwent reduced port laparoscopic ileostomy were included (15 male and 14 female, age: 66 years old. The outcomes were evaluated in terms of operation time, intraoperative blood loss and perioperative complications.

Sugical Procedures: The patients were placed in the supine position and the operator stood left side. An access device with the wound-protector (EZ access, HAKKO, Nagono, Japan) was inserted on the future ileostomy site in the right lower abdomen, inserting two of 5-mm trocars, maintaining pneumoperitoneum at 10 mmHg with carbon dioxide. A 5-mm trocar was inserted in the left lower abdomen. A 5-mm flexible laparoscope was inserted from access device port. After exploring abdominal cavity, ileum end was identified. Then the marking using dye was put on the ileum of 25 cm proximal from the ileum end. The ileum marked by dye was grasped, and extracted through the access devise. Then a Blooke ileostomy was created.

Results: Reduced port laparoscopic ileostomy was performed for 39 patients with colorectal obstruction due to cancer before chemotherapy. The mean operative time was 107 minutes, the mean blood loss was 5.0 ml. Three patient received one additional port. There were no intraoperative complications. Five patients (12.8%) experienced postoperative complications (two of deep surgical site infection, one of pneumonia, one of outlet obstruction and one of renal dysfunction). There were no other intraoperative or postoperative complications.

Conclusion: Reduced port laparoscopic ileostomy is a safe and feasible procedure for the patients with advanced colorectal cancer before chemotherapy.

P234

Impact of Past History of Abdominal Operation in Laparoscopic Colorectal Surgery

Tadashi Yoshida, MD, PhD, Shigenori Homma, MD, PhD, Yosuke Ohno, MD, PhD, Nobuki Ichikawa, MD, PhD, Hideki Kawamura, MD, PhD, Akinobu Taketomi, MD, PhD; Hokkaido University Grduate School of Medicine

Background/Aim: Laparoscopic colorectal surgery has been widely spread even if patients have past history of abdominal operation. However, widespread adhesion caused by past abdominal operation may result in increase of postoperative complications. We evaluated the impact of past abdominal operation in laparoscopic colorectal resection (LCR).

Methods: We performed elective LCR on 354 patients for primary colorectal cancers between June 2008 and June 2015. Seventy-two patients were excluded in this study following reasons: 44 patients underwent multiple organ resection, and colorectal cancer was diagnosed with Stage IV in 28 patients. Accordingly, 282 patients were eligible for comparative analysis, with 70 in group PO (post operation) and 212 in group C (control). In group PO, past operative procedures were as follows: appendectomy (57%), digestive tract (7%), hepato-billiary-pancreatic (7%), gynecologic (17%), urologic surgery (10%), and others (2%).

Results: There were no significant differences between two groups in ASA (grade ≤ 2: 81 vs. 88%, p = 0.14), BMI (23.4 vs. 23.1 kg/m², p = 0.53), tumor location (right colon/left colon/rectum 47/19/34 vs. 33/30/37%, p = 0.48), or Stage (≤ 1: 40 vs. 36%, p = 0.53) except for age (Group PO vs. C: 70.4 vs. 66.7 y.o., p < 0.01) and the ratio of male patients (49 vs. 67%, p < 0.01). Peri- and postoperative factors were almost equivalent between two groups including operative procedure (right side colon/left colon/rectal resection 47/14/39 vs. 35/22/43%, p = 0.15), the number of dissected lymph nodes (16.6 vs. 16.6, p = 0.99), surgical time (173.9 vs. 183.7 min, p = 0.18), estimated blood loss (32.4 vs. 26.6 gram, p = 0.67), conversion to open surgery (1.4 vs. 1.9%, p = 0.80), re-operation (4.3 vs. 1.4%, p = 0.15), length of postoperative stay (14.6 vs. 13.0 days, p = 0.41), and re-admission (2.9 vs. 1.4%, p = 0.60). However, the incidence of postoperative complications (Clavien-Dindo classification grade ≥ 2) was significantly higher in group PO than in group C (24 vs. 11%, p < 0.01), especially in surgical-site infections (9 vs. 3%, p = 0.07). To evaluate the risk factors of postoperative complications, logistic regression analysis was performed. Univariate analysis showed four variables associated with the risk of postoperative complications: male (p = 0.03), past operative history of digestive organs including appendectomy, digestive tract, and hepato-biliary-pancreatic surgery (p < 0.001), conversion to open surgery (p = 0.09), and estimated blood loss (p = 0.03). Multivariate analysis showed that only past operative history of digestive organs was an independent factor associated with postoperative complications.

Conclusions: The incidence rate of postoperative complications in LCR was high in patients who had past history of abdominal operation, especially in digestive organs.

P235

Laparoscopic Transanal Abdominal Transanal Resection with Descending Coloanal Anastomosis (TATA) for Rectal Cancer. Our Own Experience

Javier Ernesto Barreras Gonzalez, MD, PhD, Jorge Gerardo Pereira Fraga, MD, Francisco Llorente Llano, MD, Miguel Angel Martinez Alfonso, MD, PhD, Rafael Torres Peña, MD, PhD, Juan Bautista Olive Gonzalez, MD, Damayanty Hernandez Palacios; National Center for Minimally Invasive Surgery. Havana. Cuba

Introduction: The treatment of rectal cancer requires highly skilled practice by the entire multidisciplinary team. Important aims of treatment are: to reduce the risk of residual disease in the pelvis, with lower morbidity and to preserve good sphincter function. The TATA procedure is Transanal Transabdominal radical proctosigmoidectomy with coloanal anastomosis. This technique was first developed in 1984 by Dr. Gerald Marks to avoid a permanent colostomy for low-lying rectal cancer. This study reports the long-term results of TATA procedure for low rectal cancer.

Methods and Procedures: A prospective study was on 38 patients with low rectal cancer between April 2007 and July 2017 in a tertiary referral university-affiliated center specializing in laparoscopic surgery. All resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all pre-and-post-operative care. All the patients underwent total mesorectal excision.

Results: 38 consecutive patients (19 male, 19 female, mean age 57) underwent TATA procedure, 30 of them (78,9%) after neoadjuvant radiochemotherapy. The mean operation time was 201 min (range 90–360) and the mean estimated blood loss was 73 ml (range 10–500). The overall incidence of morbidity was 15,8% (6/38) and the mean hospital stay was 4,4 days. The mean follow-up period was 36,8 (range, 1–123) months with a recurrence rate of 7,9% (3/38), overall estimated 5-year survival 78,2% and the disease-free survival rate 89,5%.

Conclusion: Laparoscopic total mesorectal excision with TATA procedure is safe with excellent local recurrence and disease-free survival rate.

P236

Transanal Total Mesoractal Excision – Two Years experience

Jacek Piatkowski, Md, PhD, Marek Jackowski, Prof; Clinic of General, Gastroenterological and Oncological Surgery

Introduction: More than 10 years ago, laparoscopic technique was considered to be a fully accepted surgical method for treatment of rectal cancer. The following years are a further search for a new surgical method that reduces invasiveness and improves treatment outcomes.

It seems that such a method is transanal total mesorectal excision.

The aim of this study was to evaluate the new method of rectal cancer surgery (TaTME) after 2 years of its use.

Methods: Radicality of treatment (R0 resection, local recurrence), outcome of surgical treatment and quality of life of patients after surgery were evaluated.

Results: In the period from 10.03.2015. - 30.06.2017. 33 patients (19 men, 14 women) were operated in the Clinic. In 29 cases the indication for surgery was lower and middle rectal cancer and in 4 cases high grade dysplasia. All patients underwent laparoscopic rectal proctectomy with transanal access (TaTME). In all cases, complete oncological radicalization (resection R0) was obtained. The average operation time was 156 minutes. We had used two teams approach (Cecil approach) with 2 laparoscopic sets – abdominal and perineal starting at the same time.

In the postoperative course, 6 patients had signs of anastomosis leak (3 of them required reoperation).

The follow-up period is 1–29 months. None of the patients had any recurrence of cancer.

Conclusions:

• 1. Transanal TME for rectal cancer surgery is an alternative method to conventional laparoscopic surgery.

• 2. In a large proportion of patients with lower and middle tumors, the rectum can avoid abdomino-perineal resection with permanent colostomy.

• 3. Because of the small group of patients and short observation period, the method requires further investigation

P237

Study on the Suitable Height of Staple of Laparoscopic Surgery Use Liner Stapler for Better Double Stapling Technique for Left-Sided Colorectal Cancer

Hidekazu Takahashi, MD, PhD, Kazuhiro Saso, MD, Norikatsu Miyoshi, MD, PhD, Naotsugu Haraguchi, MD, PhD, Taishi Hata, MD, PhD, Chu Matsuda, MD, PhD, Hirofumi Yamamoto, MD, PhD, Tsunekazu Mizushima, MD, PhD, Yuichiro Doki, MD, PhD, Masaki Mori; Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine

Background: The double stapling technique (DST) has widely spread colorectal anastomosis especially for anastomosis after low anterior resection. As for the colorectal cancer treatment, Heald reported total mesorectal excision (TME) in 1982, and has been accepted as the standard technique for rectal resection due to the decreased local recurrence rate and improved functional results. With advent of DST, there is a background that it has become possible to preserve anus, even in the case with the lesion at lower rectum. Laparoscopic surgery for colon cancer was introduced in the 1990s, and has had promising results including long-term outcomes. According to the spread of laparoscopic surgery, laparoscopic surgery had been applied to the rectal resection, with technical difficulty. One of the reasons for the difficulty is that the high rate of anastomotic leakage, a critical adverse effect of low anterior resection (LAR). Thus, risk factors for anastomotic leakage were widely discussed, including technical factors such as pre-compression and number or firing. The decisive difference in conventional LAR and laparoscopic LAR in DST, is the stapler used for transection of the rectum. The laparoscopic staplers which are currently available are thought to be not ideal, and there is little evidence of specific specifications of stapler for laparoscopic surgery.

Materials and Methods: All method described in this study was approved by the institutional ethical review committee. We reviewed the colon and rectal wall thickness according to histological examination using H&E staining of distal margin of resected specimen of the patients who underwent surgery for left-sided colorectal cancer from April, 2016 to March 2017 (n = 77). For clinical experience, we performed 23 laparoscopic surgeries for left sided colorectal cancer using laparoscopic surgery use high-height staple stapler (Powered Echelon Flex GST® 60 mm loaded with black cartridge, closed staple height 2.3 mm), followed by DST using circular stapler.

Results: Average entire wall and muscularis thickness of resected specimen were 2.93 mm (95% confidence interval (CI), 2.57–2.93), and 1.56 mm (95% CI, 1.36–1.78). Since two intestinal walls overlap during rectal transection, we chose the high-height staple stapler in clinical cases. No remarkable adverse event using high-height stapled stapler, including misfiring, bleeding from stump, and anastomotic leakage in clinical cases.

Summary: Although, among the techniques that are currently available, transection of rectal stump by laparoscopic surgery was feasible, rectal closure with laparoscopic stapler with high-height staple seemed to be a potentially useful option for laparoscopic LAR.

P238

Robotic Subtotal Colectomy for Severe Acute Ulcerative Colitis is as Safe as Laparoscopic Approach

Patricio Lynn, David Schwartzberg, MD, H. Hande Aydinli, MD, Mitchell Bernstein, MD, FACS, FASCRS, Alexis Grucela, MD, FACS, FASCRS; New York University Langone Medical Center

Introduction: Laparoscopic subtotal colectomy (LSTC) was initially controversial in patients with severe acute Ulcerative Colitis (UC) given patients’ severity of illness, toxicity, and technical factors such as colonic dilatation. Since then, it has been shown to be feasible and safe in experienced hands. The development and adoption of the Intuitive da Vinci® Xi Robot has allowed ease of use for multiquadrant surgery with minimal docking time. Our goal is to compare the intraoperative and postoperative outcomes of our early experience with Robotic Subtotal Colectomy (RSTC) vs. LSTC.

Methods: We queried our prospectively maintained database of patients who underwent RSTC from 2015 to 2017. We identified patients who underwent RSTC for severe acute UC and compared them to a matched cohort of patients who underwent LSTC for the same diagnosis. Statistical significance was set at 0.05. The Intuitive da Vinci Xi was used for all Robotic approaches. Port placement and specimen extraction (via the ileostomy site) were uniform within both groups.

Results: We identified 6 patients who underwent RSTC (4 females, median age: 41.5 years) and 13 patients who underwent LSTC (6 females, median age: 29 years). They were well matched for gender and demographic variables. The RSTC group had more patients with significant comorbidities (5/6 = 83%) than the LSTC group (3/13 = 23%) (p = 0.01). There were no differences in operative time (mean RSTC 314.0 vs. LSTC 294 minutes, p = 0.5) or estimated blood loss (RSTC 79 ml vs. LSTC 75 ml, p = 0.9). Mean length of stay was shorter (1.2 days) for RTSC (3.4 vs. 4.6 days, p = 0.2) and return of bowel function was earlier (0.7 days) in the RSTC group (1.3 vs. 2 days, p = 0.1), however, these were not statistically different. There were no intraoperative complications in either group. Postoperative major complication rates were similar (RSTC, 1/6 = 16% vs.3/13 = 23% for LSTC; p = 0.9). Readmission rate was less for the RSTC group (16%) than LSTC group (38.4%) (p = 0.3). No patient required reoperation in the RSTC group (0%) vs. 2 patients (15.3%) in the LSTC (p = 0.2).

Conclusions: RSTC for severe acute UC is at least as safe as the laparoscopic approach. Although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to LSTC. RSTC was also associated with an earlier return of bowel function and shorter length of stay. A prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible.

P239

Carcinoma Colon; Risk Factors for Conversion from Laparoscopic to Open, An Experience from a Tertiary Care Hospital

Irfan Ul Islam Nasir, Muhammad Ijaz Ashraf, Shahid Khattak, Aamir Ali Syed; Shaukat Khanum Memorial Cancer Hospital

Introduction: We conducted this study to identify the risk factors responsible for conversion from laparoscopic (L) to open (O) in Asian population.

Methods and Procedures: Retrospective analysis of the medical record files of all the patients who presented to our hospital with the diagnosis of carcinoma colon who underwent laparoscopic resection from Jan 2006 to Dec 2015. Demographics, operative findings and histopathological reports were all recorded on a pre-formed data sheet. Risk factors responsible for conversion were identified and compared. All the analysis was performed on SPSS 21.

Results: In total 244 patients were operated in these 10 years period, in which 127 were operated laparoscopically. There were 19 conversions from laparoscopic to open constituting 15% of total laparoscopic surgeries. Increase BMI (24.7 for Lap Vs 29.3 for Open), male sex and large tumor size (6 cm for Lap Vs 7 cm for Open) are significant risk factors that contributed to laparoscopic conversion rates, similarly locally advance disease (T4) was also a factor responsible for conversion (14.8% in lap and 31.6% in open group). Age, comorbidities and CEA levels were not significant risk factors. Intra-operatively there was not much difference in two procedures in terms of blood loss (mean 50 mls for Lap Vs 100 mls for Open), duration of surgery (mean 227 minutes for Lap Vs 235 minutes for Open) which were statistically not significant. Proximal, distal and mesenteric resection margins were comparable. Median number of lymph nodes retrieved was more in open group (average 22 for open Vs 16.5 for lap).

Conclusion: Advance stage, large size of tumor, male sex and obesity were the risk factors associated with conversion from laparoscopic to open surgery. Late presentation to a physician might be one of the reasons for this high conversion rate.

P240

Robotic-Assisted Right Colectomy Decreases Conversion in Mini-invasive Right Colectomy in Right Colon Cancer

Yuki Liu, MS¹, Emelline Liu, MSHS¹, Jorge A Lagares-Garcia, MD, FACS, FASCRS², Gabriel Chedister, MD ^{3; 1}Intuitive Surgical, ²Roper Hospital, ³Medical University of South Carolina

Objectives: To evaluate the rate, risk factors and impacts of conversion to open right colectomy (ORC) for both traditional laparoscopic (LRC) and robotic-assisted right colectomy (RRC) performed for right colon cancer patients.

Methods: Patients > 18 with right colon cancer undergoing elective right colectomy as the primary procedure during 2013-2105Q3 were identified from Premier Perspective Database® using ICD-9-CM diagnosis and procedures codes. Three level analyses were conducted: (1) Unadjusted and Propensity-Score Matching (PSM) adjusted conversion rates were compared between LRC and RRC groups; (2) A multivariate logistics regression was used to quantify the effect of surgical modality on conversion adjusting for patient, surgeon, and hospital level risk factors of conversion to open; and (3) impacts of conversion were assessed through comparing the 30-day perioperative outcomes and cost between the converted and non-converted groups.

Results: There were 10,622 eligible patients during January 2013-September 2015. Among them, 6,024 patients underwent LRC and 662 patients underwent RRC. Both unadjusted and PSM adjusted results suggest RRC had a significantly lower conversion rate than LRC (Unadjusted: 6.8% vs. 12.3% P ≤ 0.0001; adjusted: 6.7% vs. 11.2%, P = 0.01). The multivariate logistic regression quantified that RRC was associated with a 47% decreased odds of conversion to ORC compared with LRC (adjusted odds ratio [OR] 0.53, 95% confidence interval [CI] 0.38–0.72). Other significant preventive factors of conversion included lower patient Charlson comorbid index/CCI, high volume surgeon, colorectal specialized surgeon, and simpler concomitant procedure such as cholecystectomy. Significant risk factors of conversion included BMI > 40, male gender, other concomitant colorectal resection, and previous abdominal surgery. Comparing converted to non-converted patients, conversion was found to be associated with significantly higher perioperative complication (including surgical site infection), postoperative blood transfusion, 30-day complication related readmission, longer operative time and higher perioperative 30-day cost (All P values < 0.01).

Conclusion: Conversion to open surgery for right colon cancer patients is associated with higher perioperative complication, longer LOS, operation-room time and higher cost. Robotic assistance, high volume surgeon and surgeon with colorectal specialty are associated with decreased odds of conversion.

_{[1] Other factors included in the multivariate regression: Age category (18−34, 35−44, 45−64, 65+), race, presence of benign polyps, presence of diverticulisis/diverticulosis, smoker, concomitant hernia procedures, payor, provider bed size, provider region, year}

P241

Laparoscopic Surgery for Colorectal Cancer Patients with a Poor Performance Status

Rikiya Sato, Masaki Kitazono, Naotaka Ikeda, Mayumi Kanmura, Tomohiro Oyama, Tatsuji Katsue, Go Kamimura, Ryoichi Toyosaki, Toyokuni Suenaga; Nanpuh Hospital

Introduction: As the proportion of elderly people increases, the number of patients with a poor performance status (PS) because of previous illnesses is likely to continue to increase. The aim of this study is to compare short-term and long-term outcomes of laparoscopic surgery (LS) to open surgery (OS) for those patients with colorectal cancer.

Materials and Methods: In this study, patients with ECOG performance status of 3 or greater were defined as poor PS patients. This was a retrospective study of poor PS patients with colorectal cancer who underwent either laparoscopic or open surgery from January 2006 to September 2017 in our hospital. Data on baseline characteristics, intraoperative findings, short-term outcomes, and long-term outcomes were analyzed statistically.

Results: During the study period, 16 and 23 consecutive poor PS patients underwent open and laparoscopic surgery for colorectal cancer, respectively. In LS group, 19 procedures (82.7%) were technically successful without the need for conversion to open surgery. There were no significant differences between two groups with regard of the baseline characteristics. LS group was associated with less cumulative blood loss (185 vs. 20 mL; p < 0.001), and intraoperative blood transfusion (44.0 vs. 8.7%; p = 0.018). Although there were no differences in 30-day mortality and morbidity, the rate of major complications (Clavien-Dindo grade ≥ III) was significantly lower in LS group (31.2 vs. 4.3%; p = 0.033). There were no differences in long-term outcomes between two groups.

Conclusion: Laparoscopic surgery was beneficial approach for poor performance status patients with colorectal cancer.

P242

Comparison Between Conventional Colectomy & Complete Mesocolic Excision For Colon Cancer – A Systematic Review and Pooled Analysis

N Alhassan, M Yang, N Wong-Chong, A S Liberman, P Charlebois, B L Stein, G M Fried, L Lee; McGill University Health Centre

Introduction: Complete mesocolic excision (CME) has been advocated based on oncologic superiority, but is not commonly performed in North America. Furthermore, many data are limited to case series with few comparative studies. Therefore the objective was to systematically review studies comparing the short- and long-term outcomes between CME and non-CME colectomy for colon cancer.

Methods: A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were only included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using the Methodological Index For Non-Randomized Studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Study eligibility, data extraction and quality assessment was performed by two independent reviewers, and disagreements resolved by consensus. Weighted pooled means and proportions with 95%CI were calculated using a random-effects model when appropriate.

Results: Out of 825 citations, 23 studies underwent full-text review and 14 met the inclusion criteria, of which 10 were unique series. Mean MINORS score was 13.6 (range 11–16). The mean sample size in the CME group was 1075 (range 45–3756) and 785 (range 40–3425) in the non-CME group. In the 10 unique studies, 4 included only right-sided resection, and 44.2% (95% CI 35.8–52.6) of the remaining 6 were right-sided colectomies. Of the 5 studies that reported surgical approach, 52.2% (95%CI 31.0–73.3) of CME were performed laparoscopically. There were 4 papers reporting plane of dissection, with CME plane achieved in 87.4% (79.7–95.2). Mean OR time in CME group was 167 minutes (range 163–171) and in non-CME group 138 minutes (range 135–142). Perioperative morbidity was reported in 6 studies, with pooled overall complications of 22.5% (95%CI 18.4–26.6) for CME and 19.6 (95%CI 13.6–25.5) for non-CME resections. Anastomotic leak occurred in 6.0% (95%CI 2.2–9.7) of CME versus 6.0% (95%CI 4.1–7.9) in non-CME colectomies. CME surgery consistently resulted in more lymph nodes retrieved, longer distance to high tie, and specimen length. There were 7 studies that compared 3- or 5-year overall or disease-free survival, or local recurrence. Only 2 studies reported statistically significant higher disease-free or overall survival in favour of CME. Local recurrence was lower after CME in 1 of 4 reported studies.

Conclusions: The quality of the current evidence is limited and does not consistently support the superiority of CME. More rigorous data are needed before CME can be recommended as the standard of care for colon cancer resections.

P243

Laparoscopic Re Intervention for the Treatment of Fecal Peritonitis Without Stoma

Gilberto Lozano Dubernard, MD, FACS, Ramon Gil-Ortiz, MD, Gustavo Cruz-Santiago, MD, Bernardo Rueda-Torres, MD, Javier Lopez-Gutierrez, MD, FACS; Hospital Angeles Del Pedregal

Introduction: To assess the feasibility of a single-stage colorectal laparoscopic re intervention without ostomy. Colonic Laparoscopic interventions on patients that previously underwent a minimally invasive procedure, constitutes the current boundary in the management of the acute colorectal pathology. That includes, patients with fecal peritonitis due to diverting procedures already treated surgically. The outcome of our patients could significantly improve if the surgical procedure is performed in one time, with no stoma.

Method and Procedures: From September 1995 to June 2016, one hundred thirty-two patients underwent colorectal laparoscopic surgery. Five of these patients developed complications: three perforations due to colonoscopy and two due to dehiscence of the anastomosis. These five patients underwent a second laparoscopic procedure that included resection and anastomosis. No stoma required.

Results: All five patients underwent a second laparoscopic procedure due to an anastomosis leak. No stoma was required. The procedure consisted on resection of the previous anastomosis, re anastomosis, abdominal lavage, aspiration and drains placement. All of them supported with parenteral nutrition. There were no surgical complications. Only one patient developed pneumonic symptoms that were solved.

Conclusion: The reported results, regarding no conversion rate, nor mortality, on our series of patients, suggest that single stage laparoscopic re intervention is feasible, despite fecal peritonitis.

P244

Complete Mesocolic Excision for Transverse Colon in Our Hospital

Shun Ishiyama, PhD, MD, Kota Amemiya, MD, Yuki Tsuchiya, MD, Hirokazu Matsuzawa, MD, Shingo Kawano, PhD, MD, Masaya Kawai, PhD, MD, Koichiro Niwa, PhD, MD, Kiichi Sugimoto, PhD, MD, Hirohiko Kamiyama, PhD, MD, Makoto Takahashi, PhD, MD, Hiromitsu Komiyama, PhD, MD, Yutaka Kojima, PhD, MD, Atsushi Okuzawa, PhD, MD, Yuichi Tomiki, PhD, MD, Tetsu Fukunaga, PhD, MD, Yoshiaki Kajiyama, PhD, MD, Seiji Kawasaki, PhD, MD, Kazuhiro Sakamoto, PhD, MD; Juntendo University Faculty of Medicine, Tokyo, Japan

Introduction: Total mesorectal excision is known to be a gold standard surgical procedure for the rectal cancer. Subsequently complete mesocolic excision (CME) is recognized as an essential surgical procedure for the colon cancer. The transverse colon is relatively minor location for colon cancer. Variety of vessels and mobilization of splenic flexure and dissection close to pancreas make operations for the transverse colon cancer complicated. Laparoscopic transverse mesocolic excision in our hospital is presented.

Method: laparoscopic surgery is conducted with five trocars under the lithotomy position. Inferior mesenteric vein is cut after dissection of the descending colon with medial approach. The lower edge of pancreas is exposed near the inferior mesenteric vein and is dissected along toward the tail of pancreas. The splenic flexure is mobilized with lateral approach and the dissection between transverse mesocolon and the lower edge of pancreas is continued in the direction to the pancreas head. Coming to the exposure of superior mesenteric artery and vein, the origin of middle colic artery and vein are cut. The transverse mesocolon is separated from the pancreas head and the duodenum with preserving the gastrocolic trunk of Henle and the right gastroepiploic vein. The hepatic flexure is mobilized and CME for the transverse colon is finished. This method, the ‘tail to head of pancreas’ approach, we called, was performed from September 2015. This method is well performed with one series of surgical view, and seems to be a simple procedure as CME with central vascular ligation for the transverse colonic cancer. There were no intraoperative complications, and one postoperative pancreatitis with grade ? of Clavien-Dindo classification of surgical complications.

Conclusion: Our method, the ‘tail to head of pancreas’ approach, with transverse mesocoloc excision is simple, safe and feasible.

P245

The Role of Intraoperative Colonoscopy After Colorectal Anastomosis

Yoo Sung Lee, Hyung Jin Kim, Seung Rim Han, Ri-Na Yoo, Gun Kim, Hyeon-Min Cho; Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea

Introduction: Anastomotic complication after stapled anastomosis in colorectal cancer surgery is a considerable problem. There are various types of anastomotic complication and they have different severity. This study was aimed to evaluate the impact of intraoperative colonoscopy on detection of anastomotic complication, and its effectiveness in treatment of anastomotic complications after anterior resection (AR) and low anterior resection (LAR) for colorectal cancer intraoperatively.

Methods: From Dec. 2016 to Jul. 2017, a total of 72 patients who underwent anastomosis between sigmoid colon and rectum after colorectal resection were reviewed retrospectively. Intraoperative colonoscopy was performed routinely since December 2016 in our hospital after anterior resection and low anterior resection. To identify effectiveness of intraoperative colonoscopy, we compared postoperative complications with non-intraoperative colonoscopy group during previous 11 months. Intraoperative colonoscopy was performed after anastomosis to visualize the anastomosis line and to perform an air leakage test. If anastomotic defect and moderate bleeding were found in intraoperative colonoscopy, it was managed by means of reinforcement suture or transanal suture repair. We used Logistic regression to analyze anastomotic complication between two groups with or without intraoperative colonoscopy.

Results: Of the 72 patients who were performed intraoperative colonoscopy after AR (n = 50) and LAR (n = 22), abnormal findings including bleeding and air leak were found in 14 patients (19.4%). Among those, 9 cases were observed without any procedure, additional procedures were performed in 5 patients (6.9%, transanal suture (3), Lembert suture (2)). Postoperative complication was developed in 12 patients; 6 patients had anastomosis bleeding (8.3%), 2 patients had ileus (2.8%), 1 patient had pneumonia (1.4%), 3 patients had minor complication (4.2%, acute urinary retention, chylous drainage, laparoscopic port site bleeding). Among 6 patients who had anastomosis bleeding, 4 patients were treated by endoscopic clipping, 2 patients were cured by conservative treatment. There was no postoperative anastomotic leakage. The cases of AR and LAR were 62 and 48 in non-intraoperative colonoscopy group, there was no significant difference between two group (P = 0.07). The proportion of laparoscopic surgery was 86.4% and 92.2% on intraoperative colonoscopy and non-intraoperative colonoscopy group, respectively, there was significant difference statistically (P = 0.02). However, there was no significant difference in anastomotic complication rate between two groups. (RR = 0.27, 95% CI, 0.34–2.585).

Conclusions: Although there was no significant difference in postoperative anastomotic complication rate between two groups, intraoperative colonoscopy may be valuable method for decreasing postoperative complication by visualizing anastomosis line and performing additional procedure.

P246

Investigation of Lymph Node Metastasis of Laparoscopic Splenic Flexure Colon Cancer Resection

Takuhisa Okada, MD, Shigeki Yamaguchi, Toshimasa Ishii, Hiroka Kondo, Kiyoka Hara, Hiroki Shimizu, Keniti Takemoto, Asami Suzuki, Shintaro Ishikawa; Saitama Medical University International Medical Center

Introduction: The splenic flexure colon cancer is relatively small number, the anatomical characteristics and the dominant artery are complicated. It is essential to accurately identify the lymph node dissection range. The distribution of lymph node metastasis was assessed from laparoscopic splenic flexure colon cancer resection at our hospital.

Materials: Harvested lymph nodes by laparoscopic splenic flexure colon cancer resection in which both the middle colonic artery (MCA) and left colic artery (LCA) were dissected, were examined in this study.

Results: There were 52 (29 males and 23 females) splenic flexure colon cancer resection from January 2012 to August 2017. The patients number of depth of invasion was; T1: 10, T2: 6, T3: 25, T4a: 10, T4b: 1, and those of pathological stage was; I: 14, IIA: 14, IIB: 2, IIC: 1, IIIA: 4, IIIB: 10, IIIC: 2, IV: 6. The lymph node metastasis was positive in 22/52 patients (42.3%), grades were; N1a: 10, N1b: 8, N2a: 3, N2b: 1. There were 14 patients of transverse colon cancer and 8 patients of descending colon cancer. The dominant vessels of transverse colon cancer were MCA: 8 patients, LCA: 3 patients, and accessory middle colon artery (acce.MCA): 3 patients. Despite transverse colon cancer, lymph node metastasis of the LCA region was observed in 4/14 patients (28.6%). The dominant vessels of descending colon cancer were LCA: 7 patients, acce.MCA: 1 patient. Despite descending colon cancer, lymph node metastasis of the MCA region was observed in 2/8 patients (25%).

Conclusion: It was suggested that lymph node dissection of both middle and left colic regions is necessary for splenic flexure colon cancer, because lymph node metastasis was recognized in both region.

P247

The Effectiveness of Single-Incision Laparoscopic Right Hemicolectomy with Intracorporeal Resection for Colon Cancer: Propensity Score Matching Analysis

Masashi Yamamoto, Keitaro Tanaka, PhD, Shinsuke Masubuchi, PhD, Masatsugu Ishii, PhD, Hiroki Hamamoto, MD, Junji Okuda, PhD, Kazuhisa Uchiyama, PhD; Osaka Medical College

Aims: Laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many centers. Most centers use laparoscopic colectomy with extracorporeal resection and anastomosis (LC). Single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (SC) remains controversial. The aim of the present study is to compare these two techniques using propensity score matching analysis.

Methods: We analysed the data of 111 patients who underwent laparoscopic right hemicolectomy with LC or SC between December 2015 and December 2016. The propensity score was calculated from age, gender, body mass index, the American Society of Anesthesiologists score, previous abdominal surgery and D3 Lymphnode dissection. Short-term outcomes were recorded. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use as outcome measure.

Results: The length of skin incision in the SC group was significantly shorter than in the LC group: median (range) 3 (3.5–6) cm verses 4 (3–6) cm (P = 0.007). The VAS score on day 1 and day 2 after surgery was significantly less in the SC group than in the LC group: median (range) 30 (10–50) verses 50 (20–69) on day 1 (P = 0.037) and median (range) 10 (0–50) verses 30 (0–70) on day 2 (P = 0.029). Significantly fewer the number of requiring analgesia in the SC group on day 1 and day 2 after surgery: median (range) 1 (0–3) times verses 2 (0–4) times on day 1 (P = 0.024) and 1 (0–2) times verses 1 (0–4) times on day 2 (P = 0.035). There were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups.

Conclusions: SC for right colon cancer is safe and technically feasible. SC reduces the length of skin incision and postoperative pain compared with conventional LC.

P248

Comparative Study of Clinical Efficacy Between Cephalo-Medial-to-Lateral Approach and Medial-to-Lateral Approach in Laparoscopic Total Mesorectal Excision in Rectal Cancer Surgery: Midterm Results

Jing Sun, MD, PhD, Hiju Hong, Chaoran Yu, Junjun Ma, MD, PhD, Aiguo Lu, MD, PhD, Minhua Zheng, MD, PhD; Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

The Clinical data of 137 patients with rectal carcinoma who underwent laparoscopic radical resection in three Surgery Centers between May 2016 and September 2017 were randomized and analyzed prospectively, to investigate the operative technique, postoperative recovery, feasibility and safety of the Cephalo-Medial-to-Lateral approach in Laparoscopic Total Mesorectal Excision of Rectal Cancer.

Patients were divided into the following groups: Cephalo-Medial-to-Lateral approach group (CML group, n = 63) and Medial-to-Lateral approach group (ML group, n = 74). In the CML group (40 males, 23 females ), the average age was 61.68 ± 10.38 (range 36–90 years); In the ML group (44 males, 30 females ), the average age was 62.05 ± 11.96 (range 38–86 years). There was no conversion to open, intraoperative complications or operation related death. In the CML group, the mean operative time was 103.11 ± 22.40 min, and the mean blood loss was 97.89 ± 53.35 ml. The mean hospitalization days was 9.48 ± 5.04 days. In the ML group, the mean operative time was 101.37 ± 20.27 min (P = 0.634), and the mean blood loss was 94.18 ± 93.32 ml (P = 0.780). The mean hospitalization days was 10.08 ± 6.92 days (P = 0.605). In the CML group, there were 2 cases with postoperative anastomotic leakage, while there were 8 cases in the ML group.

The mean number of dissected lymph nodes was 15.61 ± 5.08 in CML group. The mean number of harvested LN.253 was 1.75 ± 1.03, and the number of cases with metastatic LN.253 was 4 (7.14%) in CML group. The mean number of dissected lymph nodes was 15.71 ± 4.89 in ML group (P = 0.081). The mean number of harvested LN.253 was 15.71 ± 4.89 (P = 0.904), and the number of cases with metastatic LN.253 was 4 (12.90%) in ML group.

All the cases were followed up for 0.5–15 months. During the follow-up period, there were 3 cases of recurrence in CML group and 2 cases in ML group; there were no cases of tumor-related death in both two groups. The midterm results concluded that the effect of Cephalo-Medial-to-Lateral approach in laparoscopic total mesorectal excision of rectal cancer was similar to the traditional Medial-to-Lateral approach. We look forward to the final result to thoroughly evaluate the oncological effect of this technique.

P249

Short-Term and Long-Term Outcome Following Laparoscopic Versus Open Surgery for Pathologic T4 Colorectal Cancer: A 10-Years Experience in a Singe Centre

Deqing Wu, Zifeng Yang, Yong Li; Guangdong General Hospital, Guangdong Academy of Medical Sciences

Introduction: Laparoscopic technique has been widely used in the treatment of colorectal cancer, while playing its minimally invasive advantages, but also achieved a good effect of radical oncology. However, T4 colorectal cancer is not recommended laparoscopic surgery.

Methods: Retrospectively collected pT4 colorectal cancer data from 2006 to 2015 in Guangdong General Hospital, all cases were undergoing radical surgery.

Results: A total of 211 cases were enrolled in the pT4 group, including 101 cases of laparoscopic group, 110 cases of open group, conversion rate was 12.9%. There was no difference in baseline data (age, sex, BMI, ASA, etc.)(P < 0.05). There was a significant difference between the two groups (p < 0.05) in blood loss, postoperative complications and postoperative recovery index. In the pathologic T4a/b, combined-organ resection, postoperative recurrence, the laparotomy group had more cases, and there was a statistically significant difference between the two groups (p < 0.05). The 3-and 5-year overall survival rates were 74.9% and 60.5% for the LAP group and 62.4% and 46.5% for the OPEN group (p = 0.060). Meanwhile, the 3-and 5-years disease- (P = 0.053). IIIC stage, lymph node status, CA19-9 and adjuvant chemotherapy were independent prognostic factors affecting overall survival. The age, pT4a/b, IIIC stage, CA19-9 and adjuvant chemotherapy were independent influencing factors of disease-free survival.

Conclusions: Laparoscopic surgery for pT4 colorectal cancer surgery, it is not only in the play of its minimally invasive but also obtained with the similar long-term effect. But we need more multicenter, prospective, and large sample clinical studies to validate our findings.

P250

Efficacy of Fat Dissolution Fluid Containing Collagenase and Lipase for Lymph Node Retrieval After Laparoscopic Lymph Node Dissection for Colorectal Cancer

Michiya Kobayashi, Hiromichi Maeda, Ken Okamoto, Tsutomu Namikawa, Kazuhiro Hanazaki; Kochi Medical School

Introduction: Lymph node (LN) retrieval after surgery is important. In the present study we evaluated the efficacy of the fat dissolution technique using fluid containing collagenase and lipase to avoid staging migration after laparoscopic colorectal surgery.

Methods: Seventeen patients who underwent laparoscopic LN dissection for colorectal cancer were evaluated. First, unfixed LNs within the resected mesentery were explored by visual inspection and palpation immediately after the operation by the surgeon, which is the most common practice in Japan. Subsequently, the fat dissolution technique was used on remnant fat tissue, and the LNs were evaluated again. The primary endpoint was whether the second assessment increased the number of LNs evaluated.

Results: The median number of LNs identified at the first and second assessments was 14 and 6, respectively, resulting in a significant increase in the total number of LNs evaluated (14 vs. 21, P < 0.01, paired t-test). One positive node was identified among all the additional LNs identified (1.0%; 1/96). Although staging was not altered in any patient, the second assessment resulted in an increase in the originally insufficient number of LNs evaluated (< 12 for Stage II) in three patients, whose treatment may be altered. Tumor cells detected after the fat dissolution technique were stained with carcinoembryonic antigen and cytokeratin-20.

Conclusion: Using the fat dissolution liquid on remnant fat tissue of the mesentery of the colon and rectum enabled identification of additional LNs. This method should be considered when the number of LNs identified is not sufficient after conventional LN retrieval, and may avoid stage migration.

P251

Laparoscopic Lateral Lymphadenectomy for Selective Primary Rectal Cancer Patients

Shigeki Yamaguchi, PhD, MD, Takuhisa Okada, Shintaro Ishikawa, Toshimasa Ishii, PhD, MD, Hiroka Kondo, MD, Kiyoka Hara, MD, Asami Suzuki, MD, Hiroki Shimuzu, MD, Ken-ichi Takemoto, MD, Shin-ichi Sakuramoto, PhD, MD; Department of Gastroenterological Surgery, Saitama Medical University International Medical Center

Background: Recently lateral lymph node (LN) metastasis of rectal cancer is also recognized in Western countries. Currently our indication of lateral lymphadenectomy (LLA) is existing suspicious positive lateral lymph node metastasis by MRI or CT scan. Purpose of this study is to assess short and long term outcome of laparoscopic LLA for rectal cancer.

Method: Curative laparoscopic resection was performed for 354 lower rectal cancer since April 2007 to April 2016, and 36 patients (10.2%, 5 bilateral and 31 unilateral) underwent laparoscopic LLA starting from 2009. LLA was performed mainly for internal iliac part and obturator fossa part with autonomic nerve preservation if possible. Short and long term results were assessed.

Results: Mean age was 62.8 years old, and 29 males and 7 females were included. Procedures were; low anterior resection: 17, intersphincteric resection: 14, and abdominoperineal resection: 5. LLA was performed in 6 patients in early phase (2007–2011, 6.6%), and in 30 patients in late phase (2012–2016, 11.4%). Preoperative chemoradiation (CRT) was performed for 7 pts (19.4%). Pathological stage was; I: 2 (post CRT), II: 10, III: 24. Lateral LN metastasis positive rates were 44.4% (16/36). Number of positive lateral LN was; one: 14 pts, two bilateral: 1pt, and three unilateral: 1pt. Mean operative time was 357 minutes (230–611) and mean blood loss was 72 g (0–575). Median postoperative hospital stay was 10 days (6–43). Postoperative complications were; ileus 8.3% (3/36), anastomotic leak 6.5% (2/31, one conservative, one surgical drainage), wound infection 0%, and mortality 0%, respectively. Urinary dysfunction using self-catheterization was observed 2 pts (5.6%) and they were unnecessary one month later. Five year overall survival was 90.0%. Three year and 5 year relapse free survivals was 80.8%, 51.3% in lateral LN positive and 76.8% and 69.1% in lateral LN negative, respectively. Local recurrence was observed 18.8% (3/16) in lateral LN positive and 20.0% (4/20) in lateral LN negative. Distant metastasis without local recurrence was observed 31.3% (5/16) in lateral LN positive and 10.0% (2/20) in lateral LN negative.

Conclusion: Laparoscopic lateral lymphadenectomy for selective primary rectal cancer patients was effective for local and distant metastasis control.

P252

Evaluation of Pathological Resection Margin After Laparoscopic Intersphincteric Resection for Low Rectal Cancer

Toru Tonooka, Nobuhiro Takiguchi, Yoshihiro Nabeya, Atsushi Ikeda, Hiroaki Souda, Isamu Hoshino, Toshiya Sakamoto, Yousuke Iwadate; Chiba Cancer Center

Aim: The aim of this study is to evaluate the pathological resection margin after laparoscopic intersphincteric resection for low rectal cancer.

Method: From 2010 to 2014, there were eight laparoscopic intersphincteric resection cases for low rectal cancer. We evaluated the clinicopathological findings and the positivity of pathological resection margin.

Results: The median distance from the anal verge to the tumor was 40 mm (range, 10–45), and the median diameter of the tumor was 27 mm (range, 15–60). There was no case with neoadjuvant therapy. The estimated tumor depth were cT1 in 5 cases (62.5%) and cT2 in 3 cases (37.5%), and the actual tumor depth were pTis in 3 cases (37.5%) and pT1 in 2 cases (25.0%) and pT2 in 3 cases (37.5%). The median distal resection margin was 10 mm (range, 5–25). Pathological resection margin, such as the proximal, distal and circumferential margin was negative in all cases (100%). There was no mortality, but morbidity occurred in two cases (one case of anastomotic leakage and one case of small bowel obstruction). No recurrence nor distant metastasis was observed in the follow up period.

Conclusion: There was no positive resection margin case in the series. Our patient selection, indication and the technique were considered to be precise and appropriate.

P253

Correction of Colovesical and Colovaginal Fistulas by Minimally Invasive Surgery, Our First 28 Cases

Mauricio Zuluaga, General and MIS surgeon¹, Juan Carlos Valencia, General and MIS surgeon², Ivo Siljic, General and MIS surgeon ¹, Uriel Cardona, General and MIS surgeon^{2; 1}IJP Colombia, Hospitla Universitario Del Valle, Universidad Del Valle, ²IJP Colombia, Clinicafarallones, Clinica Desa, Cali Colombia

Introduction: The fistulas of the intestine to the vagina or the bladder include a highly morbid entity, with several functional limitation and loss of the quality of life, its diagnosis is complex and more than its treatment, which include a wide range of possibilities that go from the simple derivative colostomy in search of the spontaneous closure of the fistula, under the complete correction of the pathology with resections, anastomosis and mini-vasive reconstructions.

Give to know our experience in the minimally invasive treatment of whole vaginal and whole vesicial fistules by laparoscopic via, for the last 3 years.

Material and Methods: Description of cases operated in this period 2014–2017

Results: A total of 28 patients were operated in this period, 26 women and 2 men, all those by laparoscopic via, with intestinal resection, in 26 thick intestine cases, in one small intestine and in another case with the commitment of the two, everyone restriction and intestinal anastomosis and in no matter were colostomy, primary closures of the fistula in 7 patients were required, conversion to open surgery in a case and there was no recurrence, 2 patients had prolonged hospitalization for localized infections, a requirement reintervencion for revision. A patient suffried a umbilical eventration for the extraction site, which was corrected one year after laparoscopy.

Conclusion: Minimally invasive surgery in patients with this type of pathology becomes an excellent strategy for the integral management of these patients. Group work guarantees good results.

P254

Fallibility of Preoperative Localisation (Including Ink Tattoo) Ahead of Laparoscopic Resection of Colon Tumors

Robbie Sparks, Dr, Ronan Cahill; Mater Misericordiae University Hospital

Background: Precise preoperative localisation of colonic cancer is a prerequisite for correct oncological resection. Effective endoscopic lesional tattoo is vital for small, radiologically unseen tumors planned for laparoscopic resection but its practice may be imperfect.

Methods: Retrospective review of consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection identified from our prospectively-maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation.

Results: 169 patients (95 males, mean age 68 years, median BMI 27.8 kg/m², 77 left sided lesions, 36 screen detected, 21 benign polyps, 23% conversion rate). In 104 operations (60%) tattoo visibility was documented with tattoo absence noted in 9 (8.5%) although tattoo was identifiable in the pathological specimen in four. In those with “missing tattoos”, six of the lesions were radiologically occult and in three the tumor was found in a different colonic segment then had been judged at colonoscopy. Four patients had on-table colonoscopy and five were converted to laparotomy (55% conversion rate, p < 0.005). Mean postoperative length of stay was 15.5 (range 4–38) days. One patient’s segmental resection contained only benign pathology requiring a second operation to remove the cancer. On univariate analysis, time between endoscopy and surgery (but not patient age, gender, BMI, endoscopist or surgeon seniority, tumor size or location) was significantly associated with absence of tattoo intraoperatively (p = 0.006).

Conclusion: Recording related to tattoo is variable but definite lack of gross tattoo visualisation significantly impacts the procedure. The mechanism of tattoo absence is multifactorial needing careful consideration but solvable.

P255

The Role of Antibiotics in Acute Uncomplicated Diverticulitis: A Systematic Review and Meta-analysis

Valentin Mocanu, BSc, MD, Jerry Dang, BSc, MD, Noah Switzer, BSc, MPH, MD, Iran Tavakoli, BSc, MSc, MD, Chunhong Tian, PhD, Chris De Gara, BSc, MB, MS (Lond), Daniel W Birch, BSc, MSc, MD, Shahzeer Karmali, BSc, MPH, MD; University of Alberta

Introduction: The aim of the present study was to perform a systematic review of the literature to determine the role of antibiotics in the management of acute uncomplicated diverticulitis (AUD).

Diverticular disease is the most common disease of the large bowel and poses a significant burden on healthcare resources. In the United States alone, the cost of diverticular disease has been estimated to be over $3 billion making it the fifth most important gastrointestinal disease economically. The use of antibiotics in the management of AUD, however, is primarily based on expert opinion as current high-quality evidence is lacking. Recent studies have not only questioned the optimal type and duration of antibiotic regimens, but whether antibiotics provide any benefit in the treatment of AUD.

Methods and Procedures: A comprehensive literature search for both published and unpublished studies of “diverticulitis AND antibiotics” from 1946 to June 2017 was performed using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases. Included studies were assessed for methodological quality and bias. Abstracts and titles were screened for inclusion by two independent reviewers as per PRISMA guidelines. Outcomes assessed in the meta-analysis included treatment failure, recurrence, abscess, perforation, bleeding, stenosis, hospital length of stay, need for elective surgery or emergent surgery and overall morbidity using the Revman 5.3 software.

Results: Eight studies with 2469 patients were included for review. Overall complication rates (Fig. 1) were not statistically significant between groups (OR 0.72; CI 0.45 to 1.16; P = 0.18), but antibiotic use was associated with a longer length of stay in hospital (MD -1.13; CI -1.77-to -0.48; P = 0.0006). Subgroup analysis revealed no difference in readmission rates (OR 0.77; CI 0.55 to 1.09; P = 0.14), treatment failure rates (OR 0.43; CI 0.15 to 1.27; P = 0.13), progression to complicated diverticulitis, or increased need for elective (OR 0.66; CI 0.24 to 1.79; P = 0.80) or emergent surgery (OR 0.69; CI 0.24 to 1.79; P = 0.80) between study groups.

Conclusions: Antibiotic use in patients with acute uncomplicated diverticulitis is not associated with a reduction in major complications, readmissions, treatment failure, progression to complicated diverticulitis, or need for elective and emergent surgery. However, it increases the length of hospital stay. Given the risk of selection bias in included studies, further randomized trials are needed to clarify the need for antibiotics in uncomplicated diverticulitis.

P256

Laparoscopic Para-Aortic Lymph Node Resection for Colorectal Cancer

Kazuhiro Sakamoto ¹, Toshiaki Hagiwara¹, Hirokazu Matsuzawa¹, Shingo Kawano¹, Shinya Kawai¹, Koichiro Niwa¹, Shun Ishiyama¹, Kiichi Sugimoto¹, Hirohiko Kamiyama¹, Makoto Takahashi¹, Yutaka Kojima¹, Yuichi Tomiki¹, Tetsu Fukunaga², Yoshiaki Kajiyama², Seiji Kawasaki^{2; 1}Coloprocotological Surgery, Juntendo University Hospital, ²Gastroenterological Surger, Juntendo University Hospital

Aims: Isolated para-aortic lymph node (PALN) metastasis is a relatively rare type of metastasis in colorectal cancer. PALN metastases are frequently associated with other distant metastases, and their surgical management remains controversial. This study aimed to investigate the technical feasibility and oncological outcomes of laparoscopic PALN resection in patients with colorectal cancer.

Methods: This retrospective study was performed between July 2011 and December 2016 and included 7 patients who underwent laparoscopic PALN resection for colorectal cancer. Indications of laparoscopic PALN resection were as follows: (1) no other synchronous distant metastases except PALN; and (2) PALN metastasis located below the renal vein and without invading a major vessel. Five ports were placed, and if necessary, an additional port was inserted near the median line to avoid the operator’s instruments contacting the abdominal aorta.

Results: The median age was 67 years (range, 57–74 years), and 4 patients were men. The primary tumor was rectal cancer in 4 patients and colon cancer in 3. Six patients were clinically diagnosed with synchronous PALN metastasis, and 1 patient had metachronous PALN metastasis. Four patients received neoadjuvant chemotherapy before PALN resection. The median operating time was 423 min (range, 183–770 min), and the blood loss was 23 mL (range, 5–210 mL). There was no conversion to an open procedure. Postoperative complications occurred in 3 patients. However, the patients were conservatively treated. The median postoperative hospital stay duration was 16 days.

Conclusion: The results of our retrospective study suggest that laparoscopic PALN resection in patients with colorectal cancer may be a feasible approach for selected patients.

P258

Laparoscopic Sigmoidectomy with Transanal Extraction

Mohamed Aboulkacem Bourguiba, MD ¹, Alaeddine Khemir², Atef Ben Taher², Faten Souai^{2; 1}Faculty of Medecine of Tunis. University Tunis el Manar, ²Department of Surgery A Charles Nicolle Hospital Tunis Tunisia

Aim: We want to highlight the feasibility of a sigmoidectomy using total laparoscopic with a transanal extraction of the specimen.

Methods: it is a 34-year-old female patient, obese (BMI = 34 kg/m²) to the antecedents of laparoscopic cholecystectomy and chronic constipation. she was treated three months ago for a sigmoidal diverticulitis complicated with a pelvic abscess. the evolution has been favorable under antibiotic therapy and percutaneous drainage of the abscess. The Colonoscopy showed a multiple diverticula located between 20 and 25 cm from the anal verge. prophylactic sigmoidectomy was performed laparoscopically using 3 trocars (10 mm supra ombilical, 12 mm FID and 5 mm right flank). The specimen was extracted transanally, thus avoiding a pubic incision. The steps of the intervention were: 1- mobilisation of left colon 2- closing of distal left colon stump 3- rectal stump lavage 4- opening on the rectum 5-transanal introduction of the anvil 6-specimen transanal extraction 7- closing og rectal stump 8-colonic positioning of the anvil 9- coloractal anastomosis.

Results: the intervention was 150 minutes. no perioperative incidents. the liquid regime was authorized on the night of the intervention. the operating procedures were favorable with an exit to J2 post operative. the anapath examination of the surgical specimen confirmed the presence of sigmoidal diverticula.

Conclusion: laparoscopic sigmoidectomy with transanal extraction of the specimen for benign desease is a seductive technique with satisfactory results. it avoids a pubic incision with its parietal and aesthetic complications.

P259

SIK1 Expression is Down-regulated in Colorectal Cancer and Implies Poor Clinical Outcome

Chengzhi Huang; Guangdong General Hospital (Guangdong Academy of Medical Science)

Background: Colorectal cancer (CRC) is one of the most common malignant diseases over the world. Of the causes of the death of CRC, metastasis to liver or lung are the major factors. However, there is still lack of precise tumor biomarker that precisely predict the clinical outcome of CRC. The salt-inducible kinase 1 (SIK1) encodes a serine kinase of AMP-activated protein kinase (AMPK) family, which may play critical roles in tumorigenesis and tumor progression. This study aimed the study the expression and clinical significance of SIK1 and CRC patients.

Methods: The expression of SIK1 protein was measured by western-blot and analysis of immunohistochemistry. SIK1 mRNA expression in cancerous tissue was measured by RT-PCR.

Results: The expression level of SIK1 was correlated with the following factors: tumor invasion (T stages), lymph node metastasis, clinical stages (TNM) and tumor location. The down-regulated SIK1 implies poor clinical outcome measured by Kaplan-Meier analysis (P-value < 0.05), and may act as an independent risk factor of CRC patients.

Conclusions: The protein SIK1 is down-regulated in CRC cancer tissues, and may implies poor clinical outcome.

Keywords: SIK1, Colorectal cancer, Prognosis, Tumor biomarker.

P260

A Novel Technique Using Fluorescence to Identify Lymphatic Patterns in Colon Cancer

Deborah S Keller, MS, MD ¹, Heman M Joshi, MBChB, MRCS², Laurence Devoto, MBBS, MSc, MRCS², Richard Cohen, MD, FRCS², Manish Chand, MBA, FRCS, PhD^{2; 1}Colon and Rectal Surgeons of Central NJ; University College London Hospitals, NHS Trusts, ²University College London Hospitals, NHS Trusts

Background: Surgical specimens for resected colon cancer vary in quality and there remains no universally accepted technique to guide resection margins. A minimum of 12 lymph nodes provides some quality assurance, however this remains a crude marker of optimal oncological surgery. A tool to precisely identify lymphatic drainage within the mesentery could improve the oncologic quality of resection and better guide adjuvant treatment through more optimal mesenteric lymphadenectomy. While fluorescence imaging (FI) has been described to identify nodal disease in several other cancers, feasibility and best practices have not been established in colon cancer. We describe a novel technique of FI using Indocyanine Green (ICG) to identify lymphatic spread and potentially guide optimal mesenteric lymphadenectomy in colon cancer.

Methods: Three consecutive patients with colon cancer undergoing a laparoscopic resection had peritumoral subserosal injection of ICG for FI after extracorporealization of the mobilized specimen. Three concentrations of ICG were injected − 5 mg/10 mL, 5 mg/5 mL, and 5 mg/3 mL. A total of 4 mL was given for each patient. Using a modified laparoscopic camera, the ICG was excited by light in the near-infrared (NIR) spectrum, for real-time visualization of the lymphatic drainage. The main outcome measure was identification of lymphatic drainage.

Results: Three patients with right-sided primary colon cancer were evaluated. All three patients had successful identification of the lymphatic drainage pattern along the mesentery. The most successful protocol was 1 mL (concentration 5 mg/10 mL) subserosal injection at 4 points within close proximity (1 cm) of the tumor with a 23-gauge needle, then waiting 5 minutes for complete mapping. No intraoperative or injection-related adverse effects occurred with 30-day follow-up. The median lymph node yield was 31. All specimens had tumor-free margins.

Conclusion: From this small series, fluorescence imaging with ICG is a potentially safe and feasible technique for identifying mesocolic lymphatic drainage patterns. This proof of concept and protocol will lead to future studies to examine the utility of fluoresence imaging to guide more precise surgery in colon cancer.

P261

Indocyanine Green (ICG)-Enhanced Fluorescence and Perianastomotic Tissue Perfusion During Robotic and Laparoscopic Colorectal Surgery. Review of the Literature and University of Illinois at Chicago (UIC) Data

Alberto Mangano, MD, Federico Gheza, MD, Roberto E Bustos, MD, Eleonora M Minerva, Matrovito Sara, Sam Papasotiriou, Liaohai Leo Chen, PhD, Pier C Giulianotti, MD, FACS, Professor of Surgery; UIC, Department of Surgery. Division of General, Minimally Invasive and Robotic Surgery

Introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from 1 to 30%. The associated mortality rate is between 6–22%. The white-light intraoperative subjective surgical assessment (the most frequently used approach) underestimates the actual anastomotic leakage rate. Intraoperative tissue perfusion assessment by Indocyanine green (ICG)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/robotic surgery, as well as for for bowel perfusion assessment. This technology can detect microvascular impairment, potentially preventing anastomotic leakage. We reviewed the literature and present our data to evaluate the feasibility and usefulness of ICG-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery.

Methods and Procedures: A PubMed literature narrative review has been performed. Moreover, out of a total of 164 robotic colorectal cases, we retrospectively analyzed 28 ICG-enhanced fluorescence robotic colorectal resections (15 left colectomies-8 rectal resections-3 right-1 transverse-1 pancolectomy).

Results: After ICG-technology use, the biggest (n > 100) case-series showed a rate of 3.7–19% of cases in which they changed the level of resection based on ICG. ICG technology may variably reduce the anastomotic leak rate from 4 to 12%. However, the threshold values to define the actual sub-optimal perfusion are still under investigation. In our experience, out of 28 ICG cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all 0%. Post-op surgical complications: 1 case of leak (3,6%) and 1 SBO for incarcerated hernia (3.6%). In 2 cases, with normal white-light assessment, the level of the anastomosis was changed after ICG showed ischemic tissues. Despite the application of ICG, 1 anastomotic leak has been registered.

Conclusions: ICG-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. Our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. However, the decision making is still too subjective and not data driven. At this stage ICG, beside being a promising technique, doesn’t have high level of evidence (most of the reports are retrospective). Some randomized prospective trials with an adequate statistical power are needed. A precise injection dose and timing standardization is required. The main challange is to develop a method to objectively obtain a real-time intensity assessement. This may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making.

P262

Does Bariatric Surgery Decrease the Risk of Colorectal Cancer Diagnosis Post-operatively?

Sitembile Lee, MS ¹, Siri Chirumamilla¹, Chike Okolocha¹, Aliu Sanni, MDFACS^{2; 1}Philadelphia College of Osteopathic Medicine GA Campus, ²Eastside Bariatric and General Surgery

Introduction: According to the World Health Organization, colorectal cancer is the 3rd most commonly diagnosed cancer in the world. One of the main risk factors for the development of colorectal cancer is obesity. Obesity is seen to increase the risk of colorectal cancer by 9% in women per 5 kg/m² and 24% in men per 5 kg/m². Bariatric surgery is one of the treatments that is considered to achieve and sustain a significant amount of intentional weight loss in patients. Considering that fact that bariatric surgery decreases obesity, this intentional weight loss would seem to provide a favorable outcome in terms of diagnosis and prognosis of colorectal cancer.

Methods: A systemic review of the literature was conducted via PubMed to identify relevant studies from January 2008 through May 2017. The main outcome for this study is to assess whether patients who underwent bariatric surgery (restrictive and malabsorptive procedures) had an increased or decreased risk of colorectal cancer. All studies included in this meta-analysis are retrospective cohort studies. Results were expressed as standard difference in means with standard error. Statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups between bariatric surgery and non-surgery in patients with colorectal cancer. (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).

Results: Four out of 86 studies were quantitatively assessed and included for meta-analysis. Among the four studies, 22,857 underwent bariatric surgery and 78,536 did not undergo bariatric surgery. There is a significant decrease (0.139 ± 0.057; p = 0.016) in the risk in patients developing colorectal cancer in patients who underwent bariatric surgery compared to those who didn’t get surgery.

Conclusion: Bariatric surgery patients appear to have a decreased risk of colorectal cancer compared to patients who did not have bariatric surgery.

P263

Initial Experience of Endoscopic Mucosal Resection for Rectal Carcinoid Tumors

Guh Jung Seo, Hyung-Suk Cho; Department of Colorectal Surgery, Dae Han Surgical Clinic, Gwangju, South Korea

Introduction: The incidence of rectal carcinoid tumors is increasing due to the widespread use of screening colonoscopy. Endoscopic mucosal resection (EMR) is a useful method for small rectal carcinoid tumors (≤ 10 mm) because of its simplicity, quick procedure and low complication rates. We aimed to describe our experience and evaluate the outcomes of EMR for rectal carcinoid tumors.

Methods and Procedures: The patients enrolled in this study were 13 patients with small rectal carcinoid tumors who underwent EMR using a submucosal injection technique of epinephrine-saline mixture between August 2010 and October 2016. All medical records, including characteristics of the patients and tumors, complications, were retrospectively reviewed.

Results: The patients were 6 men and 7 women, with a mean age of 40.8 years (range, 21–72 years). En block resection was performed by EMR in all cases. The endoscopic mean size of tumors was 6.46 mm (range, 5–10 mm). The pathologically measured mean size of the resected specimens was 5.92 mm (range, 4–10 mm). The mean size of resected carcinoid tumors was 4.33 mm (range, 1.8–7 mm). The tumor shape was submucosal tumor in 10 and polyp in 3. Histological examination revealed that 5 cases had resection margin positive of tumor and 1 case had undetermined resection margin of tumor. Of the 6 patients, 4 patients underwent endoscopic treatment and 2 patients underwent transanal excision. No residual tumor was found in additionally removed tissue. There were 2 cases with EMR-related complications: 1 early postprocedural bleeding and 1 postpolypectomy syndrome. There was no significant bleeding requiring blood transfusion or perforations.

Conclusion: Endoscopic mucosal resection is considered to be a relatively safe and useful method for treatment of small rectal carcinoids in selected patients.

P264

Disturbance of Sexual Function After an Operation for Rectal Cancer and a Fundamental Study of the Relationship Between Autonomic Nerves and Arteries in the Pelvis

Akiyo Matsumoto, MD, Kaida Arita, MD; Tsuchiura Kyodo General Hospital

Background: Disturbance of sexual function after an operation for rectal cancer has often occurred. The relationship between autonomic nerves and arteries in pelvis was examined.

Methods: Clinical studies of 15 male patients with resected rectal cancer were performed using Snap Gauge method, Penile-Brachial Index and evoked Bulvo-Cavernous Reflex. In 30 canine experiments, pelvic splanchnic nerve (PSN) electric stimulation, arterial flow measurement, corpus cavernosum pressure measurement and muscle strip study using drugs were evaluated.

Results: In clinical studies of 15 male patients, transection of the hypogastric nerve (HGN) and the sympathetic trunk did not affect the erectile function in the postoperative course. In animal experiments transection of these nerves did not affect the increase in inner pressure of the penis cavernosum. In postoperative cases in which only one side of the lower grade branches of the PSN (S4) were preserved, the erectile function was preserved. In animal experiments in which the PSN of one side was disturbed, the IPA flow of the same side decreased, while the flow of the other side increased. We have evaluated the role of adrenergic components in the PSN on the erectile function in the dog. The effect of norepinephrine hydrochloride on canine vascular smooth muscle was examined in vitro. Vascular smooth muscle strips from the IPA relaxed longitudinally. Electrical stimulation of the PSN increased blood flow in the IPA and also elevated the cavernous pressure. These increases were blocked in part by phentolamine, but not by propranolol or atropine. The effects of cholinergic and adrenergic agonists and antagonists on mechanical responses were also examined in muscle strips obtained from various arteries in the intra-pelvic region including the IPA. Norepinephrine induced contraction in the iliac artery and relaxation in the IPA, and both the contraction and relaxation responses were blocked by phentolamine but not by propranolol. These findings suggest that in the dog, α-adrenergic components projected through the PSN may contribute to penile erection.

Conclusion: Blood flow in the IPA was controlled significantly by the same side PSN, but compensatory by the other side PSN. It is also conceivable that the erectile function through the PSN is controlled by the sympathetic nerve, not by the parasympathetic nerve. In postoperative cases in which only one side of the lower grade branches of the PSN (S4) were preserved, the erectile function was preserved.

P265

Total Laparoscopic Approach for Rectal Cancer Resection -A Single Center Experience

Dr. Ranbir Singh, MS, FMUHS, MIS ¹, Shailesh Puntambekar^{2; 1}Galaxy Care Laparoscopic Institute, Pune, India, ²Galaxy Care Laparoscopic Institute

Introduction: The role of minimal invasive surgery is well established. As regards rectal cancers particularly low lying rectal cancer studies are still going on for safety, feasibility and duplicability. A large prospective single institutional study aims to assess the effectiveness of our technique of Laparoscopic resection of rectal cancer in terms of oncological safety, complications and long term prognosis.

Method: Between July 2006 to June 2016, 582 patients underwent laparoscopic LAR for rectal adenocarcinoma at our Minimal Invasive Oncology Centre. Routine preoperative work up was done. Patients were evaluated for complications and were graded and managed as per Clavien-Dindo classification. Survival probability analysis rate using Kaplan Meier method.

Results: Total number of Patient included in the study was 582 (375 men and 207 women) average age of 65 years. Tumour located in upper, middle and lower rectum were 132, 258 and 192 patients respectively. A total of 33 patients received chemoradiation preoperatively and 450 patients received chemotherapy/Radiation and chemoradiation postoperatively. Laparoscopic TME was done in 381 patients. 6 out of 381 patients underwent low anterior resection with hand sewn coloanal anastomosis (CAA).

Average operating time was 124 minutes with an average of 70 ml blood loss and an average of 5 days as hospital stay. Average number of Lymph nodes removed were 25.4

The overall complication rate was 20.8% i.e. 121 out of 582 patients had complications graded under Clavien-Dindo classification. No conversion to conventional surgery was required. The most common postoperative complication was the anastomotic leak. (Grade II, IIIB and IV acc. to Clavien- Dindo classification) we had 71 leaks (13.4%). After a mean follow up of 46 months (1–128 months), tumor recurrence occurred in 39 patients of 582. Overall recurrence rate was 6.7%. Overall Cancer related survival rate was 99.3%, 96.7%, and 90.7%, 90.7% and 87.7% at 1st, and 2nd, 3rd, 4th and 5th year respectively. Five year survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.

Conclusion: Laparoscopic TME technique is feasible and safe. With development of improved technique, devices and expertise, laparoscopic resection for rectal cancer should be a standard method. Our results clearly demonstrate that laparoscopic rectal resection is not associated with higher morbidity or mortality. Furthermore oncological and surgical principles were respected and long term outcomes compared to the previous literature and open surgery were comparable.

Single largest Series of Laparoscopic management of Rectal cancer from India.

P266

Neoadjuvant Therapy for Rectal Cancer: Is Surgery the Best Consecutive Option for Everybody?

Angela Maurizi, MD ¹, Susanna Mazzocato, MD², Francesco Falsetti, MD¹, Giorgio Degano, MD¹, Mario Masella, MD¹, Roberto Campagnacci, MD, PhD^{1; 1}General Surgery, ASUR Regione Marche, "Carlo Urbani" Hospital, Jesi, Italy, ²Department of General Surgery, Università Politecnica delle Marche, 60126 Ancona, Italy

Introduction: Currently, neoadjuvant chemo-radiotherapy (nCRT) followed by low anterior resection or abdominoperineal resection are the standard treatments for locally advanced rectal cancer. nCRT can improve resecability, achieve better sphincter preservation and reduce local recurrence. Although total mesorectal excision is the standard treatment for advanced rectal cancer, recent trends in minimally invasive treatments led to an increase in local excision or “watch and wait” in patients with an excellent response to nCRT. The purpose of this study, part of an ongoing research, is critically evaluating the feasibility of “non-operative treatment” for rectal cancer in a district hospital.

Methods and Procedures: A total of 29 patients with rectal cancer, who where treated with nCRT from January to August 2017 at “Carlo Urbani” district Hospital in Jesi (Italy), were retrospectively reviewed. All patients had histologically-confirmed primary adenocarcinoma of the rectum located within 12 cm from the anal verge. The involved patients completed nCRT and had no recurrence disease, distant metastasis, synchronous malignancies. They were classified according to the Mandard’s Tumor Regression Grade (TRG) into two clusters: group A (TRG 1–3) and B (TRG 4–5).

Results: The average age of people is 67.2 and 17 were male. Five patients underwent abdominoperineal resection and 76% fell within group A. Six patients had lymph nodes involved. Four patients suffered relevant complications, such as wound complication, anastomotic leak, operative reintervention and death. Univariate analysis showed that the main predictors of tumor regression were the absence of lymph-nodes involvement from initial imaging (p < 0.05), normal initial carcinoembryonic antigen level (p < 0.05) and tumor downstaging in imaging (p < 0.05). In addition, most relevant complications occurred to elderly patients although they observed a good clinical response. Besides, 13% of patients were found to be complete pathologic responders upon examination of the surgical specimen.

Conclusions: The oncologic feasibility of non-operative management for the patients with complete clinical response after nCRT has been growing, but some studies have suggested lack of oncologic safety in these patients. The patients with a complete clinical response expect good survival, but they may still harbor residual disease. No consensus on “watch and wait” policy in the field of rectal cancer was obtained, yet. Our data did not entirely support this policy although it might be the best strategy, based on the predictors of tumor regression, to avoid the complications associated with surgery in elderly patients with significant medical comorbidities and fear of a permanent stoma.

P267

Laparoscopic Total Abdominal Colectomy for Emergent Ulcerative Colitis Reduces Postoperative Morbidity, an Analysis Using the ACS-NSQIP Targeted Colectomy Database

Matthew Skancke, Dr, Khashayar Vaziri, Dr, Richard Amdur, Bindu Umapathi, Dr, Vincent Obias; George Washington University

Background: The adoption of the laparoscopic approach to complex abdominal surgery has grown, and minimally invasive treatment for ulcerative colitis (UC) has gained popularity. We evaluated the outcomes of emergent laparoscopic and open total abdominal colectomy (TAC) of UC.

Methods: The 2012–2015 ACS-NSQIP and targeted colectomy databases were queried for patients undergoing TAC emergently for UC. Patients admitted to the hospital for more than 20 days prior to surgery and those in septic shock were excluded. Statistical analysis incorporated t-test and binomial logistic regression with p < 0.05 holding significance. The primary outcome of interest was morbidity and mortality within 30 days following surgery.

Results: This search identified 209 patients undergoing open (163) and laparoscopic (47) TAC emergently for UC. Patients undergoing open TAC were older (p = 0.003), had more comorbidities and were more inflammatory (SIRS or Sepsis 63% vs. 36%, p = 0.001). Laparoscopic operative times were also longer than laparotomy (219 vs. 152 min, p < 0.001) and had a 13% conversion rate. Within the 30 days postoperative period, patients who underwent laparotomy had a higher morbidity (69% vs. 42%, p = 0.001), higher mortality (13% vs. 2%, p = 0.034) and a longer postoperative length of stay (14.5 days vs. 10.4 days, p = 0.037) compared to laparoscopic total abdominal colectomy. After controlling for the differences in cohorts, regression analysis indicated that a laparoscopic approach had a protective effect on postoperative morbidity (OR 0.439, CI 0.206 to 0.933, p = 0.032) but no significant effect on mortality (p = 0.296).

Conclusion: Emergent laparoscopic TAC for UC reduces composite morbidity without effecting mortality when compared to open TAC. Laparoscopic TAC should be considered for emergent UC patients who are not in septic shock.

P268

Minimally Invasive Versus Open Low Anterior Resection for Rectal Cancer: Results from the Single Medical Center

Yu-Chun Huang, YI-Chang Chen, Yuan-Yao Tsai, Sheng-Chi Chang, Tao-Wei Ke, Hung-Change Chen, Hwei-ming Wang, William Tzu-Liang Chen; Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan

Objective: To examine survival of patients who underwent minimally inva- sive low anterior resection (LAR) versus open LAR for rectal cancer in single medical center in Taiwan.

Background: The utilization of minimally invasive surgery (including of laparoscopic and robotic LAR) for rectal cancer has steadily increased. Short-term outcomes between these techniques and open surgery have shown equivalent results. However, long-term survival outcomes between these groups are unknown.

Methods: We retrospectively enrolled 613 patients who suffered from the rectal cancer and underwent LAR in China Medical University Hospital from January 2012 from December 2016. Patients were classified as laparoscopic, robotic, and open groups. The clinicopathological and surgical data of these patients were collected and retrospectively analyzed.

Results: Among 613 patients with rectal cancer, 93.8% minimally invasive LAR (MI-LAR) and 6.2% underwent open LAR (O-LAR) and. Among 613 patients, 95% of the patients underwent sphincter-preserving operation. Overall, 5-year overall survival rate was 80.6% and 5-year disease-free survival rate was 75.3%. Local recurrence occurred in 4.23% of the patients and distant metastases occurred in 23.9% of the patients. MI-LAR was associated with shorter length of stay, shorter days of urinary catheterization, less circumferential resection margin, less 30-day mortality, but equivalent distal resection margin. In a subgroup analysis of laparoscopic LAR (L-LAR) versus robotic LAR (R-LAR), there were no differences in lymph node harvest, distal and circumferential margin positivity, length of stay. The 3-year and 5-year overall survival for MI-LAR were 86.6% and 80.5%. The 3-year and 5-year overall survival for O-LAR were 81.1%. The 3-year and 5-year disease-free survival for MI-LAR were 79.6% and 75.6%. The 3-year and 5-year disease-free survival for O-LAR were 69.3%.

Conclusions: In our retrospective study, minimally invasive LAR for rectal cancer has better short-term and long-term outcome than open LAR. Our findings support the ongoing adoption of minimally invasive techniques for rectal cancer.

P269

Short-Term Clinical and Oncological Outcomes After Transumbilical Single Incision Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Retrospective Analysis from One Center

Ren Zhao, Xi Cheng, Yimei Jiang; Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China 200025 2. Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China 200025

Introduction: Conventional 5 incision laparoscopic surgery procedure for rectal cancer is widely accepted as a successful alternative to laparotomy now, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumors, but the literature lacks sufficient data analyzing the suitability of SILS for rectal cancer especially for total resection mesorectal excision (TME), particularlyon oncological outcome. We report the short-term clinical and oncological outcomes from a large cases retrospective analysis of observational study of SILS for TME procedure of rectal cancer.

Methods: 95 rectal cancer patients who underwent transumbilical single incision laparoscopic TME surgery were recruited in the current study. Short-term perioperative clinical parameters and oncological outcomes were observed and all patients were followed up after surgery. Then summarize the preliminary application results.

Results: 87 operations were accomplished successfully with single incision laparoscopy, 7 patients were converted to multiport approach, and 1 was converted to laparotomy, no diverting ileostomy was performed. The average operative time was (128.5 ± 43.6) min, with an average blood loss of (75.5 ± 121.7) ml, the median postoperative hospital stay was (10.3 ± 2.1) days. All patients received a R0 resection and the surgical margin were conformed negative in all 87 cases, the median number of harvested lymph node is (18.4 ± 8.9), the specimens met the requirement of TME. There were 3 postoperational complications, no operation-related mortality or postoperative anastomotic leakage was observed. No patient appeared recurrent in a median follow up of 14 months.

Conclusions: Total mesorectal excision surgery for rectal cancer can be safely performed using transumbilical single incision laparoscopic technique, with acceptable short-term clinical and oncological outcome.

P270

Inflammatory Response to Acute Treatment of Colonic Obstruction due to Colorectal Malignancy, Comparing Colonic Stenting and Surgery

Maria Bergstrom, Ramia Stolt, MD, Patrik Cikota, Roger Ahlen, Per-Ola Park; Dept of Surgery, South Alvsborg Hospital

Background: Any surgical trauma induces an inflammatory response, which is considered as a negative factor in the general immune response, specially in malignant disease. The C-Reactive Protein (CRP) is an acute phase protein often used as a marker of surgical trauma. Stent treatment has been used as a treatment option for colonic obstruction in palliative cases for many years, and also as a bridge to surgery in selected cases. In a pilot study we compared the inflammatory response after acute stent treatment or surgery for malignant colonic obstruction.

Method: We compared two consecutive series of treatment of acute malignant colonic obstruction, stent treatment or emergency surgery during 2011–2012. All patients were admitted with acute colonic obstruction due to colorectal cancer. Choice of treatment was based on attending senior colorectal surgeons’ preference, patient comorbidities and disseminated disease was considered. Patient age, CRP, time to first defecation and length of stay was recorded.

Results: A total of 31 patients were identified in a retrospective analysis. 15 patients had acute stent treatment and 16 had acute surgical treatment for colonic obstruction, all due to colorectal cancer. Median age was 77 y (30–95) with no difference between the groups. There was no difference in metastatic disease between the groups. Median time until first defecation after treatment was significantly shorter for the stented patients (39 h (4–73)) compared with those operated (96 h (24–168)) (p < 0,001). Median hospital stay was also shorter in the stent group, 6 days (2–32), versus 11 days (7–30) in the surgical group (p = 0,016). CRP did not differ between the groups before treatment. Both treatments resulted in increased CRP levels at postoperative days 1 and 2, but the CRP levels were significantly higher in the surgical group than in the stent group at both time points (POD 1 p = 0,017, POD 2 p < 0,001)

Conclusion: Acute stent treatment in colonic malignant obstruction seems to induce a less pronounced inflammatory response compared with surgery, as shown by a significantly reduced increase in postoperative CRP resulting in shorter time to first defecation and a shorter hospital stay.

P272

Short-Term Outcome of Transanal Total Mesorectal Excision for Rectal Cancer: Experience of CMUH

Yu-Chun Huang; Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan

Purpose: Because conventional laparoscopic rectal surgery is difficult due to narrow pelvix, then the new surgical method, Transanal Total Mesorectal Excision (TaTME) has been developed for middle or low rectal cancer. This study to evaluate the safety and short-term outcome of TaTME for rectal cancer.

Materials and Methods: We enrolled 37 patients with rectal cancer diagnosed in China Medical University Hospital from January 2016 to August 2017. All the patients received TaTME for rectal cancer. The clinicopathological and surgical data of these patients were prospectively collected and analyzed.

Results: Of 37 patients, 70.3% were men. The mean age of all patients was 64.3 years-old. 46% of rectal tumor were located at middle rectum and 51% were located at low rectum. 67.6% of patients received neoadjuvant chemoradiation. Median operative time was 335 min. Median distal margin was 1.9 cm. Positive circumferential margin rate was 2.6%. Three patients underwent intraoperative complication, urethra injury, vaginal perforation, and left internal iliac artery injury. Median harvested lymph nodes were 14.1. The anastomotic leakage rate was 18.9%. Median hospital stay was 7.1 days. Median days of urinary catheterization was 2.3 days. There were 18.9% of patients who needed urinary re-catheterization. Three patients discharged with Foley catheter.

Conclusion: Although conventional laparoscopic rectal surgery is difficult, transanal total mesorectal excision for middle and low rectal cancer is the alternative method and it is feasible and safety. It can provide good short-term clinical and oncological outcomes.

P273

Meckel’s Diverticulum: Analysis of 27 Cases in an Adult Population

Gustavo Andres Valencia, Andres Mauricio Garcia Sierra, Juan David Hernandez Restrepo, Felipe Giron Arango, Ricardo Manuel Nassar Bechara; Fundacion Santa Fe

Introduction: Meckel’s diverticulum is the most common congenital abnormality in newborns, present in about 2–4% of them. Diagnostic of Meckel’s diverticulum requires a high index of suspicion, and even with the use of modern imaging technologies, they are often diagnosed intraoperatively. What to do when an asymptomatic diverticulum is found incidentally during surgery for other causes is a matter of discussion.

Objective: The aim of this article is to report 27 symptomatic and asymptomatic incidentally found cases seen in a fourth-level hospital in Colombia.

Materials and Methods: The reports of the histopathologic examinations carried out in the hospital in the last 12 years were reviewed searching for those containing Meckel’s diverticulum in their diagnosis. patients were divided in asymptomatic and symptomatic groups. The asymptomatic group was defined as patients who were operated for a different indication and a Meckel’s diverticulum was found incidentally. Morbidity was divided in early and late complications after the initial surgery.

Results: From January 2004 to June 2017, a total of 42 pathology reports included the diagnosis Meckel’s diverticulum. A total of 27 adult patients were retrieved. All of those patients with Meckel’s diverticulum a total of 22 patients were symptomatic, being SBO the most common complication and required the surgical remove incidentally.

Conclusion: The correct approach of the patients with diverticular pathology allows the early identification and the appropriate management of the surgical complications that can be presented.

P274

Neuroendocrine Tumor Arising from a Tailgut Cyst: A Rare Presacral Mass

Robert J Czuprynski, MD, Grace Montenegro, MD; Saint Louis University Hospital

Presacral masses are a rare entity, with an incidence of 0.014% and can be classified in several categories, including inflammatory, neurogenic, congenital, osseous and miscellaneous. In this case, a neuroendocrine tumor was identified with concern for iliac chain lymphatic and gluteal metastasis. The patient underwent abdominoperineal resection, excision of presacral mass, lymph node biopsy and omental flap. Final pathology returned as a grade II neuroendocrine tumor arising from a tailgut cyst.

A 29 year old female with a ten year history of recurrent perianal, ischiorectal and deep postanal abscesses presents with a presacral mass biopsy proven well-differentiated neuroendocrine tumor. Octreotide scan demonstrated avidity for presacral mas as well as left intergluteal lymph node and two internal iliac lymph nodes. Chromogranin A, neuron-specific enolase and serotonin markers were all negative. The patient was taken to the operating room and underwent abdominoperineal resection, resection of presacral mass and internal iliac nodes with an omental flap.

Neuroendocrine tumors arising from tailgut cysts of the presacral space are rare in nature. In a retrospective study from Great Britain, four of thirty one tailgut cysts had malignant transformation, so it is generally recommended to resect the cysts. In this case, the patient’s tumor was a moderately differentiated, Grade II with extensive lymphovascular and perineural invasion. There are no prospective studies showing neoadjuvant therapies in neuroendocrine tumors of the presacral space. According NCCN guidelines, patient is currently asymptomatic with low tumor burden. Recommended treatment at this time is observation with surveillance tumor markers every 3–12 months or octreotide.

P275

LCA-Preserving Technique Reduces the Anastomotic Leakage Rate in Laparoscopic Mid/Low Rectal Cancer Surgery: Midterm Results from a Single-Center Randomized Controlled Trial

Jing Sun, MD, PhD, Wenqin Feng, Chaoran Yu, Pei Xue, MD, PhD, Aiguo Lu, MD, PhD, Minhua Zheng, MD, PhD; Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Anastomotic leakage has been commonly regarded as one of the toughing postoperative complications in laparoscopic mid/low rectal cancer surgery, attenuating the short-term clinical benefits. The left colic artery (LCA) has been routinely central-ligated in dissection process to guarantee the oncological effects, which may potentially attribute to the postoperative ischemia-induced anastomotic leakage in the patients with left-colic vessel variation, e.g. bypass or absent of Riolan arch. However, no specific study focuses on the surgical benefits of LCA preservation compares to conventional ones. Herein, we conduct a single center randomized controlled trial, demonstrating that LCA-preserving technique shows significant reduction rate of postoperative leakage as well as overall complications comparing to the traditional central-ligation group. No difference in survival rate and recurrence in short term is found between the two groups. The LCA-preserving strategy is proven to be repeatedly safe and feasible, potentially reduce the risk of anastomotic leakage with comparable short-term outcomes. Further investigation is required for both the oncological safety and long-term prognosis for this innovative technique.

P276

Laparoscopic Surgery for the Very Elderly Patients with Colorectal Cancer

Yu Sato, MD, PhD, FASCRS, Takashi Oshiro, Tomoaki Kitahara, Yutaka Yoshida, Tasuku Urita, Ryuichi Takagi, Kentaro Kawamitsu, Kengo Kadoya, Taiki Nabekura, Mika Ando, Shin-ichi Okazumi; Toho University Sakura Medical Center

Objective: An increasing number of laparoscopic surgery are being performed on more elderly patients. The aim of this study was to evaluate the outcomes of laparoscopic resection for colorectal cancer in the very elderly patients.

Methods: A retrospective analysis of 28 consecutive patients aged ≥ 85 years who underwent curative laparoscopic resection for colorectal cancer between January 2009 and February 2017 was collected. Short-term and oncological outcomes were investigated.

Results: The analyzed group included 15 males and 13 females with a mean age of 86.5 (range, 85–94) years. The majority had right-sided tumors and multiple comorbidities [18 (64.3%) and 17 (60.7%), respectively]. Twenty-two patients (78.6%) were diagnosed as over stage II cancers, but 7 patients (25.0%) underwent D3 lymphadenectomy. The mean number of harvested lymph nodes was 15 (range, 1–41). Nine patients (32.1%) developed postoperative complications with delirium (21.4%) as the most frequently observed complaint. Adjuvant chemotherapy was applied for only one patients (3.6%). With a median follow-up time of 17.8 months, the recurrences occurred in 5 patients (17.9%), and 3 of them chose best supportive care.

Conclusions: Laparoscopic colorectal resection with modified lymphadenectomy for the very elderly patients is feasible. However, more active adjuvant therapy might improve prognosis.

P278

Corrosive Proctcolitis: A Case Report

Chalerm Eurboonyanun, Somchai Ruangwannasak, Kulyada Eurboonyanun, Anan Sripanaskul; Khon Kaen University

Unintentional administration of corrosive enema have occurred after accidental contamination of endoscopes in most patients. But accidental administration of corrosive agents for bowel cleansing can occur. The agents implicated for chemical colitis is 15% Hydrochloric acid and 2% Ethoxylated alcohol. We present a case of corrosive proctocolitis, present with abdominal pain and bloody diarrhea. Endoscopy revealed edema, erythema and friability of colonic mucosa. An experience of successful non-operative treatments had been demonstrated.

P280

Real-Time 3D Optical Diagnosis of Colorectal Cancer Using Three-photon Imaging

Dexin Chen, Wei Jiang, Zhangyuanzhu Liu, Kai Li, Weisheng Chen, Xiumin LIu, Jun Yan; Department of General Surgery, Nanfang Hospital, Southern Medical University

Background: Three-photon imaging (TPI), which was based on the field of nonlinear optics and femtosecond lasers, has been proved to be able to provide the 3-dimensional (3D) morphological feature of living tissues without the administration of exogenous contrast agents. The purpose of this study is to investigate whether TPI could make a real-time histological 3D diagnosis for colorectal cancer compared with the gold standard hematoxylin-eosin (H-E).

Methods: This study was conducted between January 2017 and August 2017. A total of 30 patients diagnosed as colon or rectum carcinoma by preoperative colonoscopy were included. All patients received radical surgery. The fresh, unfixed and unstained full-thickness cancerous and the corresponding normal specimens in the same patient, were immediately prepared to receive TPI after surgery. For 3D visualization, the z-stacks were reconstructed. All tissue went through routine histological procedures. TPI images were compared with H-E by the same attending pathologist.

Results: The schematic diagram of TPI is shown in Fig. 1A. Peak TPI signal intensity excited at 1300 nm was detected in living tissues. The field of view (FOV) was 500 × 500 µm and the imaging deep was 200 µm in each specimen. In normal specimens, glands lined regularly and characterized as a typical foveolar, which was comparable to H-E images (Fig. 1B and 1D). In cancerous specimens, irregular tissue architecture and shape were identified by TPI, which was also validated by corresponding H-E images (Fig. 1C and 1E). TPI images can be acquired with a view of 3D visualization. Based on rates of correlation with pathological diagnosis, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value were 95%, 90%, 100%, 100%, 90.9%, respectively.

Conclusions: It is feasible to use TPI to make a real-time 3D optical diagnosis for colorectal cancer. With the miniaturization and integration of colonoscopy, TPI has the potential to make a real-time histological 3D diagnosis for colorectal cancer in the future, especially in low rectal cancer.

P281

Alvimopan Use in Colorectal Resection Patients

Erica Pettke¹, Abhinit Shah¹, Vesna Cekic¹, Daniel Feingold², Tracey Arnell², Nipa Gandhi¹, Carl Winkler, MD ¹, Richard Whelan^{1; 1}Mount Sinai West, ²Columbia University

Introduction: Alvimopan (Alvim) is a peripherally acting µ-opioid receptor antagonist used to accelerate gastrointestinal functional recovery postoperatively (postop) after bowel resection. The purpose of this retrospective study was to compare the time to first flatus and bowel movement (BM) as well as length of stay (LOS) following elective minimally invasive colorectal resection (CRR) in a group of patients (pts) who received alvimopan perioperatively (periop) vs a group that did not get this agent.

Methods: A data review from 2000 to 2015 from 2 IRB approved databases was carried out. Operative, hospital and office charts were reviewed. Routine use of Alvim for elective CRR cases was stared in 2013. Besides GI data, preoperative comorbidities and 30 day postop complication rates were assessed. The results with periop Alvim were compared to a no-Alvim group. The Students T and Chi-Square tests were used.

Results: A total of 902 pts underwent elective CRR. Alvim was administered periop to 262 pts (29%). The breakdown of indications between groups were similar. Alvim pts were younger (60.4 vs. 63.8 years old, p = 0.002) and, as regards comorbidities, less likely to have heart disease (CAD 4.1% vs 13.9%, other heart disease 13.2% vs 19.5%) but were otherwise similar. The rate of laparoscopic-assisted (Alvim, 80.9%; No Alvim, 68%) and hand assisted or hybrid operations (Alvim, 19.1%; No Alvim, 32%) were similar. Alvim pts had significantly earlier return of flatus (2.4 vs 2.9 days) and first BM (2.6 vs 3.5, p < 0.001 for both) than the No Alvim group. There was also a trend toward a shorter LOS (6.1 vs 6.7 days, p = 0.05) for the Alvim group. Overall complication rates were similar, however, Alvim pts had lower rates of post-operative ileus (5.3% vs 14.1%, p < 0.0002), sSSI’s (5.8 vs 10%, p = 0.04), and blood transfusion (7.1 vs 13.0%, p = 0.01) than the No Alvim group.

Conclusion: The two groups compared were largely similar (most co-morbidities, indications, CRR type) with the differences in age and cardiac issues noted. The impact of the higher rates of sSSI’s, blood transfusion, and MI in the no Alvim group on GI function is unclear. Pts who received Alvim periop had an accelerated return of bowel function, decreased postoperative ileus and shorter length of stay. These results suggest that Alvim is effective in reducing the postoperative ileus but further study is warranted.

P282

Laparoscopic Total Proctocolectomy, Results of Different Strategy for FAP and IBD

Shintaro Ishikawa, S Yamaguchi, T Ishii, H Kondo, M Suzuki, K Hara, H Shimizu, K Takemoto, T Okada, S Sakuramoto, K Okamoto, I Koyama; Saitama Medical University International Medical Center, Japan

Background: Laparoscopic total proctocolectomy (TPC) is selected for minimally invasive surgical treatment of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). Our policy of TPC is no diverting ileostomy for FAP and creating ileostomy for IBD because most of the patients received steroid therapy.

Objective: We examined the outcome of laparoscopic TPC according to disease of FAP and IBD (UC and Crohn’s disease).

Methods: Twenty-three consecutive patients who underwent laparoscopic TPC between April 2007 and March 2017 were examined. The patients were divided into FAP group and IBD group.

Results: Seven patients of FAP and 16 patients of IBD (UC 15, Crohn’s disease 1) underwent laparoscopic TPC or total colectomy. Among them, 12 patients (FAP 3, IBD 9) were cancer-associated cases. The procedures of the FAP group was TPC with IACA in 6 patients and HALS total colectomy with IRA in 1 patient. The procedures of IBD group were TPC with IACA in 11 patients, TPC with IAA in 2 patients, total colectomy with IRA in 3 patients, of which 5 HALS cases. The mean operative time and blood loss were 318 minutes, 32.0 g in the FAP group and 382 minutes, 86.8 g in the IBD group, respectively. Diverting ileostomy was constructed in 11 patients of only UC group. Early complications of FAP group were observed in 3 cases (postoperative ileus 2, anastomotic leak with conservative treatment 1), and those of IBD were observed in 8 cases (ileus 4, anastomotic leak with conservative treatment 1, abdominal abscess 1, wound infection 1). The median postoperative hospital stay was 12 days in the FAP group and 14 days in the IBD group. Complications requiring reoperation were 2 cases (FAP 1: intestinal obstruction, IBD 1: inflammation of stoma-closure site). No cancer recurrence and mortality were observed. One case of FAP underwent additional transanal mucosal resection due to new lesion of adenoma.

Conclusions: Laparoscopic total proctocolectomy for FAP and IBD was performed safely, especially less complications occurred in FAP patients without diverting ileostomy. In addition, follow-up of remaining mucosa is important in IACA and IRA patients.

P283

Video Endoscopic Treatment of Complex Anal Fistula-Results of Series of 210 Cases

Prof Subhash Khanna; Swagat Super Speciality Surgical Institute

Treatment of complex anal fistula has always been a nightmare for surgeonsby conventional means.

Even the lowest and simple looking fistula at times comes out to be a complex one with high incidence of recurrence above 20%.

Most of the availability diagnostic including MRI is nit conclusive and many a times the surgeon remains in a state of confusion as to what is going to come at the operation table.

The conventional treatment modalities also usually leave the patient wounded needing almost 6 to 12 weeks to heal with a risk of sphincter damage and a high risk of recurrence.

We would be presenting the technical details and results of our series of 210 cases of complex anal fistula treated by Video assisted endoscopic therapy.

P285

Usefulness of Indocyanine Green (ICG) Fluorescence System and Thermography for Evaluating Bloodflow of Intestine in Laparoscopic Anterior Resection

Jun Higashijima, PhD, Mitsuo Shimada, Professor, Kozo Yoshikawa, PhD, Takuya Tokunaga, PhD, Masaaki Nishi, PhD, Hideya Kashihara, PhD, Chie Takasu, PhD, Daichi Ishikawa, PhD; Department of Surgery, The University of Tokushima

Background: One of the important causes for anastomotic leakage (AL) in anterior resection is an insufficient blood flow of the stump. The HEMS (Hyper eye medical system) and SPIES (laparoscopic ICG system) can detect the blood flow of fresh organ intraoperatively by injection of indocyanine green (ICG). And thermography also can evaluate the bloodflow less invasively. The aim of this study is to evaluate the usefulness of ICG system and thermography in laparoscopic anterior resection.

Patients and Methods: This study retrospectively included 86 patients who underwent laparoscopic anterior resection for colon cancer with double stapling anastomosis procedure. Blood flow evaluation of oral stumps was performed with measurement of fluorescence time (FT) using HEMS and SPIES. And bloodflow was also evaluated by thermography.

Result: Evaluation by ICG system: In all cases, the AL rate was 8.1% (7/86 cases). Over 60 FT cases, the AL rate was 60%, higher than that of under 60 s cases and these patinets need additional management, covering stoma or additional resection. And in border cases, FT 50 ~ 60 sec, AL rate is 10.0%, higher than under 50 s cases. In these borderline cases, if covering stoma was performed in patinets with more than three well known risk factors, the AL rate reduced to 2.6% and false positive was 6.9%. And under 50 s cases, they need no additional management.

Evaluation by thermography: In residual intestine, the temperature was siginificantly higher than resected intestine (31.5 vs 29.0?, p < 0.01). And the temperature in FT under 50 s cases was significantly higher than over FT over 50 s cases (26.3 vs 30.8?). The temperatue and FT was tended to be oppositely correlated (R² = 0.36).

Conclusion: Both ICG system and thermography may be useful to avoid anastomotic leakage.

P286

The Role of Laparoscopic Primary Tumor Removal for Patients with Stage IV Colorectal Cancer

Shinobu Ohnuma, MD, PhD, Hideaki Karasawa, MD, PhD, Kazuhiro Watanabe, MD, PhD, Akihiro Yamamura, MD, PhD, Hirofumi Imoto, MD, PhD, Atsushi Kohyama, MD, PhD, Takeshi Aoki, MD, PhD, Naoki Tanaka, MD, PhD, Hiroaki Musha, MD, PhD, Fuyuhiko Motoi, MD, PhD, Takashi Kamei, MD, PhD, Takeshi Naitoh, MD, PhD, Michiaki Unno, MD, PhD; Department of Surgery, Tohoku University Hospital

Introduction: The role of primary tumor removal in patients with stage IV colorectal cancer (CRC) is still controversial. We assessed the impact of primary tumor removal for patients with stage IV CRC, and evaluated the role of laparoscopic surgery for patients with stage IV CRC.

Materials and Methods: One hundred eighty-four patients (male: 105, female: 79, median age: 66 (26–91)) with stage IV CRC who had surgical treatments in Tohoku University Hospital from 2000 to 2017 were retrospectively analyzed. Survival analysis was conducted using Kaplan-Meier methods. The relationship between primary tumor removal and overall survival (OS) was evaluated by Cox-proportional hazards regression models with age, sex, CEA, primary tumor location, metastatic sites and number, metastasectomy, and receipt of systemic chemotherapy.

Results: Primary tumor was surgically removed in 147 (80%) patients (group A), however, palliative procedures, such as colostomy or bypass, were carried out in 37 (20%) patients (group B). Three and five-years survival rate were 49% and 25% for group A, 7% and 0% for group B, respectively (p < 0.0001). Cox-proportional hazards regression models indicated that female (HR: 0.60, 95%CI: 0.41–0.89, p = 0.0096), primary tumor removal (HR: 0.32, 95%CI: 0.20–0.52, p < 0.0001), and metastasectomy (HR: 0.26, 95%CI: 0.11–0.53, p < 0.0001) were associated with improved survival with the patients with Stage IV CRC. In group A, primary tumor of 109 patients (74%) were removed with open-laparotomy (OPEN), on the other hand, that of 38 patients (26%) were laparoscopically removed (LAP). LAP group showed statistically shorter hospital-length of stay after surgery (11 vs 19 days, p < 0.0001), and less blood-loss (38 vs 309 ml, p < 0.0001). There was no difference in operative time between the two groups (LAP vs OPEN, 224 vs 214 ml, p = 0.7535). Furthermore, LAP was associated with a longer survival compared to OPEN group; three and five-years survival rate: 62% and 40% vs 44% and 22%, respectively (p = 0.0345).

Conclusion: Primary tumor removal may improve the outcome of patient with stage IV CRC. Less invasive laparoscopic approach may be beneficial for the patients with stage IV disease who need further immediate treatments for distant metastases.

P287

5-Year Pathologic Complete Response Outcomes in Rectal Cancer Patients Undergoing Neoadujvant Chemoradiation Therapy: A Community-Based Hospital Study

Andrew J Geiser ¹, Supriya Patel, MD², Ina Zamfirova, MS¹, Jeremy Sugrue, MD³, Slawomir Marecik, MD², John Park, MD^{2; 1}James R. & Helen D. Russell Institute for Research & Innovation, Advocate Lutheran General Hospital, Park Ridge, Illinois, ²Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, ³Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, Illinois

Introduction: Some patients who undergo neoadjuvant chemoradiation therapy (CRT) for rectal cancer achieve a pathologic complete response (pCR) in which no tumor cells are discovered during pathologic analysis of the resection specimen. Achievement of pCR is correlated to improved prognoses relative to non-pCR counterparts. Such correlations are not well established in the context of a community-based hospital. The study sought to examine response rates, recurrences, and survivals in locally advanced rectal cancer patients and compare patient outcomes to those achieved at major academic institutions.

Methods and Procedures: A single-center retrospective chart review was performed at a local, community-based hospital. Study population consisted of 118 patients with locally advanced rectal cancer treated with neoadjuvant CRT followed by surgical resection. Patients with a history of metastasis, Inflammatory Bowel Disease (IBD), hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded.

Results: 24 patients (20.3%) achieved pCR in the test population. Across both groups, mean age (p = .352), gender (p = .254), and ethnicity (p = .529) were found to be comparable. Mean interval between CRT and OR (p = .116), pre-op stage (p = .736), number of nodes (p = .208), radiation dose (p = .094), tumor location (p = .753), and days of follow-up (p = .497) presented statistically insignificant differences between groups. At 5 years, 26 non-pCR patients (27.7%) had a recurrence with zero recurrences in the pCR group. 5-year mortality presented 25 non-pCR patients (26.6%) compared to 1 pCR patient (4.17%).

Conclusion: A multidisciplinary approach to rectal cancer consisting of standardized preoperative treatment and surgical resection can achieve patient outcomes and survival similar to those of larger academic institutions, even in the context of a community-based hospital.

P288

Transanal Total Mesorectal Excision Within the Holy Plane for Rectal Cancer

Shinichiro Mori, MD, PhD, Yoshiaki Kita, MD, PhD, Kan Tanabe, MD, PhD, Kenji Baba, MD, PhD, Masayuki Yanagi, MD, Takaaki Arigami, MD, PhD, Hiroshi Kurahara, Masahiko Sakoda, MD, PhD, Yasuto Uchikado, MD, PhD, Kosei Maemura, MD, PhD, Yuko Mataki, MD, PhD, Shoji Natsugoe, MD, PhD; Department of Digestive Surgery, Breast and Thyroid Surgery Graduate School of Medicine, Kagoshima University

Objective: The aim of this study was to assess safety and feasibility of total mesorectum excision (TME) within the holy plane based on embryology for rectal cancer.

Methods: Prospectively collected data of 36 consecutive patients with rectal cancer who underwent TaTME from November 2014 to August 2017 were enrolled. Surgical outcomes including TME completeness, operative time for TME completion, blood loss, complications, pathological findings and length of hospital stay were assessed.

Surgical Procedure: After performing ractal lavage, self-retaining anal retractor was set, and anal dilators were used for an atraumatic introduction of the transanal access devise (GelPOINT path). Three of 10-mm trocars and one of 15-mm trocar were inserted through the GelPOINT path in a quadrant shape. Then the GelPOINT path was introduced through the anal to rectum. After rectosigmoid colon was temporally clamped using an atraumatic endo bulldog clip, pneumoperitoneum was maintained at 15 mmHg with carbon dioxide via an Air Seal platform. A purse-string suture using a 0 polypropylen with 26-mm rounded needle was performed clock-wise to tightly occlude the rectum with a 3 cm margin distal to the tumor. After irrigation with saline and marking dissection line with tattooing the rectal mucosa distal to the mucosal folds, a mucosal transection of rectum was initiated. Then a full-thickness rectal transection was performed circumferentially. After dissection of rectococcygeal muscle at 6 o’clock and rectourethral muscle in the anterior wall, circumferential sharp dissection within the holy plane was performed. Dissection proceeded between the endopelvic fascia and the prehypogastric nerve fascia in the posterior plane, between the Denonvilliers’s fascia and the anterior mesorectum in the anterior plane, and between pelvic nerve and the mesorectum with recognition of the neurovascular bandle in the lateral plane. Then the dissection connected to the abdominal plane via laparoscopic team with working together until TME completed.

Results: TME completion performed in 34 (94.4%) patients. Thirty five (97.2%) patients had negative of circumferential resection margin. Mean of TME completion time and blood loss were 146 min and 72 g, respectively. One (2.8%) patient had an intraoperative complication and 7 (19.4%) patients had postoperative complications. No other complications occurred. The length of hospital stay was 12 days.

Conclusions: TaTME within the holy plane on based on embryology is a safe and feasible procedure for rectal cancer.

P289

Colorectal Cancer and Acromegaly: A Case Report and Review of the Current Guidelines

Mina Saeed, MD, Christine Tat, MD, Jan Kaminski, MD, Joaquin Estrada, MD; UIC-MGH

Abstract: Acromegaly is a debilitating condition marked by excessive production of growth hormone. This leads to disfiguration, cardiopulmonary complications, and increased risk for cancer. With up to a two-fold increased risk of developing colon cancer and worse prognosis for diagnosed patients, earlier and more frequent screening has been recommended. We present a case of a 54-year-old Hispanic male with acromegaly who presented to our hospital with hematochezia and weight loss. A near-obstructing rectal adenocarcinoma with metastasis to the liver was discovered. After completing neoadjuvant chemoradiotherapy, he underwent laparoscopic low-anterior colon resection and simultaneous open hepatic trisegmentectomy. In this case report, we review the literature and current guidelines in screening this high-risk group of patients.

References:

Ali Riza Koksal, Meltem Ergun, Salih Boga, et al., “Increased Prevalence of Colorectal Polyp in Acromegaly Patients: A Case-Control Study,” Diagnostic and Therapeutic Endoscopy, vol. 2014, Article ID 152049, 4 pages, 2014. doi:10.1155/2014/152049

Dutta, Pinaki, et al. “Colonic Neoplasia in Acromegaly: Increased Proliferation or Deceased Apoptosis?” Pituitary, vol. 15, no. 2, 2011, pp. 166–173., doi:10.1007/s11102-011-0300-9

Dworakowska, D, et al. “Repeated Colonoscopic Screening of Patients with Acromegaly: 15-Year Experience Identifies Those at Risk of New Colonic Neoplasia and Allows for Effective Screening Guidelines.” European Journal of Endocrinology, 1 July 2010

Lois K, Bukowczan J, Perros P, Jones S, Gunn M, James RA. The role of colonoscopic screening in acromegaly revisited: review of current literature and practice guidelines. Pituitary. 2015;18:568-574.

Renehan, Andrew G., and Bernadette M. Brennan. “Acromegaly, Growth Hormone and Cancer Risk.” Best Practice & Research Clinical Endocrinology & Metabolism, vol. 22, no. 4, 2008, pp. 639–657., doi:10.1016/j.beem.2008.08.011.

Rokkas T, Pistiolas D, Sechopoulos P, Margantinis G, Koukoulis G. Risk of colorectal neoplasm in patients with acromegaly: A meta-analysis. World Journal of Gastroenterology?: WJG. 2008;14(22):3484–3489. doi:10.3748/wjg.14.3484.

Torre, Maria Luisa, et al. “MTHFR C677T Polymorphism, Folate Status and Colon Cancer Risk in Acromegalic Patients.” Pituitary, 2013, doi:10.1007/s11102-013-0499-8.

Wassenaar, M. J. E., et al. “Acromegaly Is Associated with an Increased Prevalence of Colonic Diverticula: A Case-Control Study.” The Journal of Clinical Endocrinology & Metabolism, vol. 95, no. 5, 2010, pp. 2073–2079., doi:10.1210/jc.2009-1714.

Yamamoto M, Fukuoka H, Iguchi G, Matsumoto R, Takahashi M, Nishizawa H, et al. The prevalence and associated factors of colorectal neoplasms in acromegaly: a single center based study. Pituitary (2014). doi:10.1007/s11102-014-0580-y.

P290

A New Strategy of Lymph Node Dissection in Complete Mesocolic Excision (CME) for Laparoscopic Right Hemi-colectomy: Feasibility and Outcome

Leqi Zhou, BD, Sen Zhang, Xialin Yan, Bo Feng, Minhua Zheng; School of Medicine, Shanghai Jiaotong University

Introduction: In this study, we discovered that in CME for laparoscopic right hemi-colectomy starting at the ileocolic vessel and proceeds along the superior mesenteric artery (SMA) achieved a better oncologic outcome compared with the conventional ones proceeding along the superior mesenteric vein (SMV).

Methods and Procedures: 46 patients admitted to a Shanghai minimally invasive surgical center were included from September 2015 to January 2017 and were randomly divided into two groups: study group (n = 26) and conventional group (n = 20). Operation time, blood loss during surgery, liquid intake time, postoperative hospital stay, postoperative complications within 30 days after surgery, Specimen length, and number of lymph nodes harvested as well as the positive lymph node rate were observed and studied.

Results: There was no statistical difference between the two groups with the exception of number of lymph node dissected and the positive lymph node rate for stage III colon cancer. The study group had more lymph node retrieved and also a higher positive rate compared with the conventional group. The mean number of lymph node retrieved of study group was 21.8 ± 2.47, while the conventional group was 19.9 ± 2.24 (P < 0.05). And the positive lymph node rate for study group was 41.6%, the conventional group was 34.4%.

Conclusion: When performing the laparoscopic right hemi-colectomy, dissecting the lymph node along with the left side of SMA could be achievable and there were no differences of surgical outcomes compared with the conventional ways, while there was a higher number of lymph nodes dissected and positive rate probably leading to a better oncologic outcome.

P291

A Study on Rectum Cancer Surgery Using Needlescopic instruments

Toshiaki Hagiwara, Yuki Tsuchiya, Shunsuke Motegi, Ryoichi Tsukamoto, Shingo Ito, Shingo Kawano, Shun Ishiyama, Kiichi Sugimoto, Makoto Takahashi, Yutaka Kojima, Tetsu Fukunaga, Yoshiaki Kajiyama, Seiji Kawasaki, Kazuhiro Sakamoto; Juntendo University

Aims: We describe laparoscopic surgery for rectal cancer using needlescopic instruments performed at our department.

Methods: From 2012 to 2016, 19 cases of rectal cancer underwent surgery using needlescopic instruments: 3 cases at rectosigmoid colon, 5 at upper rectum, and 11 at lower rectum. An umbilical camera port (12-mm) and two needlescopic instruments (EndoReliefTM) were directly punctured into the assistant surgical site. We started with 5 port sites. In low rectum cancer cases, we kept the good pelvic visualization to lifting the peritoneum of the bladder onto the ventral side using the Lone Star Retractor StaysTM.

Results: The median age was 70 years (56–91 years), with 9 males and 10 females, and body mass index was 21.1 kg/m² (16–25 kg/m²). Anterior resection was performed in 2 cases, low anterior resection in 7 cases, intersphincteric resection in 4 cases, abdominoperineal resection in 4 cases, Hartmann’s procedure in 2 cases, and lateral lymph node dissection in 1 case. In addition, one case of T4b (bladder) was converted from laparoscopic to open surgery. However, there were no cases in which needlescopic instruments were replaced with conventional forceps. Moreover, intraoperative complications related to the forceps were not observed.

Conclusions: In rectum cancer surgery, needlescopic instruments leave a small postoperative wound; healing is rapid and the cosmetic result is excellent. Surgical safety is comparable to that using conventional forceps. There is no problem with the rigidity of needlescopic instruments. However, where the shaft is curved, operative control requires attention to mobility and directionality. In low rectum surgery, use of needlescopic instruments is limited due to the curvature of the shaft during the dissection of the anterior rectum wall, but it is possible to maintain a good field of view by using auxiliary equipment. Therefore, more cases could be considered for surgeries using needlescopic instruments with the help of auxiliary equipment.

P292

Retrospective Review of Immunofluorescence Imaging for Colorectal Anastomoses

Rozana H Dwyer, MD, Alyssa Mowrer, Yanzhi Wang, PhD, David L Crawford, MD, Eileen Hou, Steve S Tsoraides, MD; University of Illinois College of Medicine at Peoria

Introduction: Anastomotic leaks are devastating complications of colorectal operations that lead to significant morbidity and potential mortality. Inadequate tissue perfusion is considered a key contributor to anastomotic failure following colorectal operations. Currently, clinical judgment is the most commonly used method for evaluating adequate blood supply to an anastomosis. More recently intraoperative laser angiography using indocyanine green (ICG) has been utilized to assess tissue viability, particularly in reconstructive plastic surgery. This technology provides a real-time evaluation of tissue perfusion and is a helpful tool for intra-operative decisions, particularly in deciding to revise an intended colorectal anastomosis. Our study aimed to determine if there is a statistical significance in colorectal anastomotic leak or abscess rate using ICG compared to common clinical practice.

Methods and Procedures: 126 patients undergoing left-sided colorectal operations, between March 2012 and February 2015, were retrospectively reviewed. 55 patients’ colorectal anastomoses were evaluated using ICG angiography (ICGa) to qualitatively assess tissue perfusion (ICG group). Peri-operative and post-operative outcomes, including anastomotic leak and abscess rates, were compared to 65 patients who had colorectal operations without ICGa (control group). The primary outcomes of intra-abdominal leak rate and intra-abdominal abscess rate were compared using exact Chi-square tests. The secondary outcomes of 30-days OR return, mortality, and readmission rate were compared using Chi-square tests. All statistical analyses were performed using SAS software.

Results: Two leading indications for surgery included malignancy (n = 57) and diverticulitis (n = 48). The majority of patients either had a low anterior resection (n = 75) or sigmoidectomy (n = 42). All operations were primarily minimally invasive. No statistically significant difference was seen between the two groups in regards to patient demographics, rate of proximal diversion (p = 0.112), and splenic flexure mobilization (p = 0.200). Patients in the ICGa group were more likely to have high IMA ligation than in the control group (70.9% vs. 24.4%, p-value < 0.001). Of the ICGa group, 16 of the 55 patients underwent additional colonic resection while 39 of the 55 did not undergo additional colonic resection. There was no statistically significant difference in primary or secondary outcomes between the two groups.

Conclusion: ICG angiography has become a helpful adjunct in determining adequate perfusion to an intended colorectal anastomosis. This data is unable to support any difference in patient outcome utilizing this technology over surgeons’ visual and clinical assessment. Our results may contribute to larger studies to determine if there is a true difference in anastomotic leak or abscess rate using this technology.

P293

Completely Medial Access by Page-Turning Approach for Laparoscopic Right Hemi-Colectomy: 6-Year-Experience in Single Center

Zirui He, Sen Zhang, Pei Xue, Minhua Zheng, FRCS, Bo Feng; Shanghai Minimally Invasive Surgery Center, Ruijin Hospital

Objective: To investigate the feasibility and surgical strategy of complete mesocolic excision (CME) with completely medial access by “page-turning” approach (CMAPA) for the laparoscopic right hemi-colectomy.

Methods and Procedures: The CMAPA is a modified medial approach of CME, which focus on the exploration of surgical plane instead of the recognition of vessels.

Surgical Procedures: (1) Start point: the anatomy projection of ileocolic vessel; (2) Expose the whole trunk of SMV to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location;(3) Enter the intermesenteric space (IMS) and right retrocolic space (RRCS) with cranial and right extension through transverse retrocolic space (TRCS); (4) Complete mobilize the mesocolon and remove the tumor en-bloc. See Figure 1?2.

Results:

Clinical outcome:

From September 2011 to March 2017, there were 72 patients underwent CMAPA in Shanghai Ruijin Hospital. The average operation time was 135.9 ± 28.3 minutes, average blood loss was 63.2 ± 32.2 ml, number of lymph node was 20.6 ± 7.7, average specimen length was 23.9 ± 4.7 cm, flatus time was 2.5 ± 0.8 days, fluid intake time was 3.2 ± 0.8 days and average hospital stay was 8.9 ± 4.7 days. The overall complications rate was 6.94% (5/72). Compared to traditional medial approach of CME performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing CMAPA for laparoscopic right hemi-colectomy.

Conclusion: The advantage of the CMAPA

(1) To avoid the laparoscopic “leverage effect” and “tunnel effect”.

(2) To make the branches of superior mesenteric vessels more easily recognized.

(3) To offer surgeons an alternative route entering the TRCS, IMS and RRCS.

(4) To avoid repetitive flipping of the colon complying with the “no touch” principle, and to lower the requirements of assistants.

Figure 1: Anatomy and surgical planes concerning CMAPA.

Figure 2: The surgical procedures of CMAPA. A: Start point; B: Dissection of the surgical trunk; C: Exploring the TRCS and RRCS; D: Dissection of lymph nodes and vessels.

P294

Usefulness of “One-Stop Shop” Simulation for Liver Surgery Using EOB-MRI

Mitsuo Shimada, MD, Shuichi Iwahashi, MD, Yuji Morine, MD, Satoru Imura, MD, Tetsuya Ikemoto, MD, Yu Saito, MD, Hiroki Teraoku, MD, Jun Higashijima, MD; Tokushima University

Aim: We have reported a possibility of “One-stop shop” simulation for liver surgery by MRI using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB-MRI) (Emerging technology, SAGES 2017)., which is characterized by (1) one-time examination, (2) no-radiation exposure, (3) demonstration of liver vasculatures including biliary tract, (4) diagnosis of tumors, (5) volumetry and (6) estimation of liver functional reserve in each segment. The aim of this study is to investigate usefulness of “One-stop shop” simulation for liver surgery using EOB-MRI.

Methods:

Accuracy of liver vasculatures: 3D-reconstruction of dynamic EOB-MRI imaging was done by SYNAPSE VINCENT software (FUJIFILM Medical Co., Ltd., Japan), using a manual tracing method. Visualization of hepatic vessels in EOB-MRI was compared with that in dynamic CT in 10 patients.

Assessment of liver functional reserve: The standardized signal intensity (SI) of each segment was calculated by SI of each segment divided by SI of the right erector spine muscle. The standardized total liver functional volume (TLFV) was calculated by ∑ [k = 1 to 8] (standardized SI of segment (k) × volume of segment (k)) divided by body surface area. The following formula of resection limit was established using 28 normal liver cases (70% of the liver is resectable) and 5 unresectable cirrhotic patients such as recipients of liver transplantation (0% of the liver is resectable). The estimated resection limit (%) = 70% × (the standardized TLFV of the patient - 962)/1,076. This formula was validated using other 30 patients who underwent hepatectomy.

Results:

Accuracy of liver vasculatures: The liver simulation by EOB-MRI succeeded in demonstrating hepatic vasculatures including biliary tract, diagnosis of hepatic tumors, and volumetry without any radiation exposure. Regarding the vessel anatomy at hilar area, biliary tract was more clearly visualized in EOB-MRI. Regarding the hepatic artery, right and left hepatic arteries were well visualized in all cases, however, small-sized middle hepatic artery was visualized in only one out of 10 patients.

Assessment of liver functional reserve: As a result of validation of the 30 patients, one patient having resection volume with over the resection limit died of liver failure, however, the other 29 cases within their resection limits did not suffer from liver failure.

Conclusion: “One-stop shop” liver surgery simulation could contribute to safety of liver surgery such as laparoscopic hepatectomy, because of no radiation exposure, accurate assessment of anatomical variations especially biliary tract, and helping decision making of resection volume.

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Ten Years of Live Broadcast Laparoendoscopic Surgeries for Students Exploring Health Careers

Lauren Schaller, Director of Education¹, Ann M Rogers, MD ^{2; 1}Whitaker Center for Science and the Arts, ²Penn State Hershey Medical Center

Background: A national shortage of nearly 400,000 MDs and RNs is projected by 2025. To help meet this need, in 2010 the American Hospital Association recommended not only improving workflow and staff retention, but attracting a new generation of healthcare workers. With this impetus, our group developed a multidisciplinary program to broadcast live operations to high school students starting in 2008. We are currently in our 10th year of the curriculum.

Methods: An educational grant from Highmark BlueShield supported technical upgrades to allow streaming of live procedures to a remote studio audience at a prominent center for science and the arts, as well as for independent research evaluation through follow-up questionnaires. We selected commonly-performed and generally uncomplicated elective procedures, starting with laparoscopic gastric bypass in Year 1; expanding to include robotic and laparoscopic hysterectomy in Year 2; sleeve gastrectomy in Year 3; robotic nephrectomy in Year 4; cholecystectomy in Year 5; and then adding endoscopic therapeutic interventions. Students received pre-visit teaching modules including images showing key steps of the procedure to be viewed. The in-studio program was hosted by an education specialist from the science center and a surgical resident from our institution, with laparoscopic instruments available for manipulation by participants. Participants then viewed a video highlighting the roles of all healthcare providers involved in the specialty to be featured, including nurses, physicians, dietitians, psychologists, technologists, etc. Live questions and answers were then encouraged between students and surgeons during the surgery broadcast. The program also expanded from high schools to vocational-technical colleges and nursing schools.

Results: During the 2008–2009 academic year there were 6 sessions presented to 11 schools, with 421 student participants. By the 2016–2017 year this increased to 19 sessions presented to 55 schools, with 1721 participants. In sum, throughout the first 9 years of the program, there were 395 schools attending, with a total of 11,351 participants. Of polled high school participants, 63% of responders acknowledged considering a career in healthcare after this experience.

Conclusion: Over 10 years, our program has grown steadily in popularity such that schools from several counties attend and regularly return, and we have been asked to expand the program to create a surgical summer camp for students interested in science and technology. Live broadcast surgery in an elective, minimally invasive format provides unique visibility and access to surgical procedures for student audiences and promotes future interest in healthcare careers.

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Improving Trainees’ Self-assessment Through Gaze Guidance

Yuanyuan Feng¹, Katie Li², Ivan George³, Hamid Zahiri³, Helena Mentis ^{1; 1}University of Maryland, Baltimore County, ²Pomona College, ³Anna Arundel Mendical Center

Introduction: Effective learning to become competent in surgery depends on a trainee’s ability to accurately recognize their strengths and weaknesses. However, a surgical trainee’s self-assessment is poorly correlated with expert assessment. This study aimed to improve self-assessment by the visual gaze guidance provided through telestration in laparoscopic training. We hypothesized that visual conveyance of where to look or perform actions on the laparoscopic video enhances the trainees’ awareness of the gaps in their skills and knowledge.

Methods and Procedures: A lab-developed telestration system that enables the trainer to point or draw a free hand sketch over a laparoscopic video was used in the study (Fig. 1). Seven surgical trainees (1 surgical fellow, 1 research fellow, 2 PYG-2 and 3 PYG-1) participated in a counterbalanced, within subjects controlled experiment, comparing standard guidance with telestration-supplemented guidance. The trainees performed four laparoscopic cholecystectomy tasks – mobilizing cystic duct and artery, clipping the duct, clipping the artery, and cutting the duct and artery, on a laparoscopic simulation. Performance assessment, adapted from the global rating scale (GRS) instrument, was completed by the trainers and trainees at the end of each task. The mean self-assessment scores were compared with the trainers’ scores by the linear mixed model, where the trainees’ performance indicated by the trainers’ scores was control. The assessment alignment was evaluated by Spearman’s Rho.

Results: The trainers’ scores were significantly lower than the self-assessment scores in the standard guidance, while the scores of the trainers and trainees were much more similar (Fig. 2).

The correlation between the trainers’ and trainees’ assessment in telestration guidance was high (r = 0.852, p < 0.001), compared to the standard guidance (r = 0.569, p = 0.03). The correlation comparison for each GRS criterion shows a significant increase (p = 0.005) in the assessment alignment for depth perception in telestration guidance (r = 0.90, p < 0.001), compared to the standard guidance (r = 0.30, p = 0.31) (Fig. 3).