Surg Endosc (2014) 28:S240–S286 DOI 10.1007/s00464-014-3474-1

and Other Interventional Techniques

2014 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Salt Lake City, Utah, USA, 2–5 April 2014 Oral Presentations

Ó Springer Science+Business Media New York 2014

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Laparoscopic Partial Splenectomy is Safe and Effective in Patients with Focal Benign Splenic Lesion Xin Wang, PhD, Yongbin Li, PhD, Hua Zhang, PhD, Bing Peng, PhD Department of Hepatobiliopancreatic surgery, West China Hospital, Chengdu, China

Posterior Retroperitoneoscopic vs Laparoscopic Adrenalectomy in Sporadic and MEN2A Pheochromocytomas Andreas Kiriakopoulos, MD, Dimitrios Linos, MD Hygeia Hospital

Background: Traditionally, splenectomy is considered the treatment of choice for splenic lesions. The risk of early and late complications and the awareness of pivotal immunologic function of spleen, has pushed the development of spleen sparing techniques. This study aimed to evaluate the safety and effectiveness of laparoscopic partial splenectomy in selected patients. Methods: From May 2011 we initiated performing laparoscopic partial splenectomy in patients with focal benign splenic lesion. The main surgical procedure consisted of four steps: (1) Mobilizing the perisplenic ligament; (2) Ligating and dissecting the vessels which supplying the involved spleen. (3) Dissecting the spleen along the demarcation. (4) Hemostasis using bipolar energy device. The remaining spleen was not routinely fixed except one case who underwent subtotal splenectomy. The perioperative data were collected and analyzed. The follow-up including evaluation of splenic regrowth (CT scan) and quality of life were routinely performed 6 months after surgery. Results: From May 2011 to August 2013, laparoscopic partial splenectomy had been performed in 9 patients aged from 13 to 57 (mean 34). The indications included nonparasitic cyst (n = 4), lymphangioma (n = 3), and hemangioma (n = 2). The mean operative time was 151 min (range 110–200 min). The mean estimated blood loss was 186 ml (range 100–400 ml). One patient was converted to laparoscopic splenectomy because of hemorrhaging. Two patients suffered from postoperative complications: the one who was converted to laparoscopic splenectomy suffered from portal vein thrombosis, the other one underwent laparoscopic partial splenectomy suffered from fluid collection around splenic recess. There was no blood transfusion and postoperative mortality. All patients discharged uneventfully. The mean postoperative hospital stay was 5 days (range 4–7 days). Six patients finished the follow-up including evaluation of splenic regrowth and quality of life 6 months after surgery. The results demonstrated all these patients had different degrees of splenic regrowth and gained a good quality of life. Conclusions: Laparoscopic partial splenectomy is safe and effective in patients with focal benign splenic lesion. Meanwhile, this technique potentially retains some splenic immunity, and confers the benefit of a minimal access technique.

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Introduction: Retroperitoneal adrenalectomy comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. Since pheochromocytoma constitute the most challenging adrenal pathology, we assess the impact of retroperitoneal adrenalectomy in the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting Patients and Methods: From May 2008 to January 2013, 17 patients (6 males and 11 females [mean age: 50 years (range 26–73)] with pheochromocytomas underwent posterior retroperitoneoscopic adrenalectomy. Demographics, tumor characteristics, operative time, complications, hospital stay and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls Results: 17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 18 pheochromocytomas with a mean size: 5 cm (range 1.7–7.3) at a mean operative time: 92.5 min (range 60–180) were accordingly excised. Seventeen patients, 10 females and 7 males [mean age of 49.2 years (range: 25–64)] comprised the laparoscopic group. Twelve patients had sporadic pheochromocytomas, whereas 4 patients had MEN2A syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7–8.5) at a mean operative time of 125 min (range 75–195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analogue scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.7 (0–1) vs 3.8 (3–6), P \ 0.05 and 0.2 (0–1) vs 3.2 (2–6) P \ 0.05 respectively]. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group (2.1 ± 0.35 vs 3.2 ± 0.22 days) (p \ 0.05). Conclusions: Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.

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Artificial Hand for Minimally Invasive Surgery: Design and Testing of Initial Prototype Jennifer Rosen, MD, Aaron Size, Yuzhang Yang, Andre Sharon, PhD, Alexis F Sauer-Budge, PhD Boston University School of Medicine, Fraunhofer USA - CMI

Novel Technique for Intraoperative Identification of Ureters Using Sodium Fluorescein Fernando Dip, MD, Mario Nahmod, MD, Pedro Ferraina, MD, Raul Rosenthal, MD, Steven Wexner, MD Training Center and Experimental Surgery Jose´Ó de San Martı´n Clinical Hospital, Buenos Aires, Argentina; Department of Colorectal Surgery, Department of Minimal Invasive, Metabolic and Bariatric Surgery, Cleveland Clinic, Florida, USA

Introduction: Compared with traditional open surgery, minimally invasive surgery may improve recovery and patient satisfaction while maintaining surgical principles. Laparoscopic, single incision, natural orifice and robotic approaches each hold their own appeal. However, they lack the ability to manipulate organs as easily as the human hand. The downside of adding hand-assistance is that it requires an additional larger incision. Robotic surgical systems are expensive, require a great deal of training, and thus their use is limited. Advances in minimally invasive surgical techniques will require new types of surgical tools with increased functionality of the end effectors. Multifunctional tools that also improve its dexterity with respect to those currently available are highly desired. Description of Methods: To address this challenge, we designed, built and tested the first prototype of a laparoscopic tool that provides the dexterity of a hand. The ‘‘hand’’ has two jointed fingers and a jointed thumb attached to a laparoscopic sheath that can be collapsed into a small space to fit through a 12 mm trocar or other small orifice. The handle provides control for 3 independent degrees of freedom: (1) finger motion (bending/ spreading), (2) finger tip bending, and (3) thumb bending. The tool can be used for pinching, grasping, and spreading motions. Furthermore, the thumb is ‘‘double jointed’’ so that the tool can be converted to a rake configuration (similar to a hand’s three middle fingers) to allow lifting motions. The initial prototype has been tested in a cadaver lab to demonstrate its utility. Preliminary Results: Our ‘‘lap-hand’’ was able to complete standard surgical tasks in a simulation device in a time comparable to open and laparoscopic approaches, including bowel manipulation and peg movement. Cadaver testing revealed the ability to grasp, elevate and move liver, stomach, colon and small bowel in a fashion expected by the hand. No adverse events were noted and no bowel injury or perforation resulted as one might expect from over-grasping. Conclusions: We have designed, built, and tested a first prototype of an artificial hand for minimally invasive surgery. Use of such tools could both reduce the number of hand-incisions required and potentially transition more patients to undergo their abdominal procedures laparoscopically.

Background: Due to its unique properties, sodium fluorescein has being used for medical applications such as diagnostic ophthalmology and intravenous angiography. Despite being excreted via the renal system it has never been used to aid in the intraoperative visualization of the ureters. The goal of our study was to assess the real-time visualization of ureters using intravenous sodium fluorescein under the stimulus of a 530 nm wavelength light. Materials and Methods: Nine, 250 g Wister rats were administered an intravenous dose of 0.01 ml of sodium fluorescein. Anesthesia was performed with an intraperitoneal dose of ketamine–xylazine. A laparotomy was immediately performed following the administration of the dye. The retroperitoneum was exposed and observed under an alternating white xenon and a 530 nm excitation light with an objective to visualize the organs captured within the fluorescence of the compound (sodium fluorescein). All rats were euthanized at the completion of the procedure. Results: Utilizing xenon light, the kidneys and urinary bladder were visualized. The light was then changed to a 530 nm wavelength mode making possible to visualize the location and orientation of the ureters along with its peristaltic movements. Fluorescence imaging of the ureters was noted 5–10 min after the kidney’s were visualized. In addition, the vascular structures in close proximity to the ureters were identified as well. Conclusion: Intravenous administration of sodium fluorescein enables intraoperative fluorescence visualization of the ureters in a rat model. This imaging modality might be applied in clinical settings to prevent ureteral injury when performing urologic or other pelvic procedures.

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Laparoscopic Versus Open Surgical Management of Small Bowel Obstruction –A Comparison of Outcomes James P Byrne, BSc Eng, MD, Fady Saleh, MD, MPH, FRCSC, Luciano Ambrosini, MD, Carolina Jimenez, MD, Joshua Gnanasegaram, Fayez Quereshy, MD, MBA, FRCSC, Timothy D Jackson, MD, MPH, FRCSC, Allan Okrainec, MDCM, MHPE, FACS, FRCSC Division of General Surgery, University Health Network, University of Toronto

SAGES Research Agenda In Gastrointestinal And Endoscopic Surgery: Updated Results of A Delphi Study Dimitrios Stefanidis, MD, PhD, Paul Montero, MD, David R Urbach, MD, MPH, Aurora Pryor, MD Carolinas Healtcare System, University of Colorado, University of Toronto, Stony Brook University

As the laparoscopic management of acute small bowel obstruction (SBO) grows as a tool in the armamentarium of the acute care surgeon, it is critical that outcomes are tracked to aid surgeons in making evidence-based decisions with regards to management of their patients. The purpose of this study was to review outcomes in patients with SBO treated laparoscopically compared to those treated by open surgery. We performed a retrospective review of all patients managed surgically for small bowel obstruction at our institution from 2009 to 2012. Data abstracted included pre-operative patient characteristics and investigations. Outcomes collected included details of postoperative recovery, length of stay (LOS), morbidity and mortality. The laparoscopic group included all cases started as such, regardless of conversion. Continuous variables were compared using Student’s t-test, while categorical variables with the Chi-square test. Univariate and multivariate analysis provided a comparison of the incidence of complications between both groups, while multivariable logistical regression was performed to assess predictors of adverse outcome. A total of 246 patients were managed surgically for acute small bowel obstruction during this period. 83 patients were treated with laparoscopy, while 163 had conventional open surgery. The most common etiology found at surgery was adhesive (63 %). Mean operative time was not significantly different between laparoscopic and open surgery groups (143.0 vs. 151.0 min, p = 0.362). There was however a significant reduction in time to recovery of bowel function in the laparoscopic group as indicated by passage of flatus (3.0 vs. 4.0 days, p = 0.017), as was there in median length of stay (5 vs. 8 days, p \ 0.001). Overall complication rate was significantly lower in those treated with laparoscopic surgery (30.1 vs. 45.4 %, p = 0.021), with associated reduction in the odds of an adverse event through multivariable logistical regression (OR 0.50, 95 % CI 0.28–0.91, p = 0.024). Treatment of patients with small bowel obstruction by an initial laparoscopic approach is safe, associated with quicker recovery, reduced length of stay, and a reduction in adverse outcome as compared to conventional open management. Further research is needed to understand predictors of successful laparoscopic completion.

Background: Research in gastrointestinal and endoscopic surgery has witnessed an unprecedented growth since the introduction of minimally invasive techniques in surgery. Coordination and focus of research efforts could further advance the impact of this rapidly expanding field. To guide such endeavors, the Research Committee of SAGES developed and published a research agenda in 2007. That agenda informed the research community of the top 40 research priorities in the field based on input from the SAGES membership. The objectives of this study were to update the SAGES research agenda for gastrointestinal and endoscopic surgery and explore differences in priority ratings between SAGES leadership and general membership. Methods: The modified Delphi methodology was used to create the research agenda. Using an iterative, anonymous web-based survey, the membership of SAGES was asked for input over three rounds. In Round 1 they were asked to submit up to five important research questions in gastrointestinal and endoscopic surgery. Submitted questions were reviewed by an expert panel, consolidated, and redistributed to the participants for priority ranking using a 5 point Likert scale of importance in Round 2. The top 40 research questions including their ratings from this Round were then redistributed to the participants for a final rating; the results of this final round were used to establish the updated research agenda. Comparisons were made between the ratings of SAGES leadership and general membership using Mann–Whitney-U test. P \ 0.05 was considered significant. Results: 283 initially submitted research questions were condensed into 89 distinct questions by the expert panel and were then redistributed to the membership for priority ranking. 383 members provided ratings during round 2 and the top 40 questions were rerated by 459 members during round 3 leading to the final ranking of these 40 most important research questions. The top ranked questions involved GI/Biliary, hernia, and bariatricrelated topics. The highest rated question was, ‘‘How do we best train, assess, and maintain proficiency of surgeons and surgical trainees in flexible endoscopy, laparoscopy, and open surgery?’’ 28 % of responders were leadership and the rest general members. The majority of ratings (73 %) were similar between SAGES leadership and general membership with differences mainly noted in questions relating to endoscopy, foregut, and colorectal surgery. SAGES leadership ratings were lower in 89 % of questions. Conclusions: An updated research agenda for gastrointestinal and endoscopic surgery was developed using a systematic methodology. This research agenda will enhance the ability of investigators and funding organizations to focus attention to areas most likely to advance the field and by editors and reviewers to assess the merit and relevance of scientific contributions.

Complications in laparoscopic vs. open surgery for SBO: univariate analysis Complication

Open, n (%)

Laparoscopic, n (%)

OR (95 % CI)

P value

Surgical site infection

39 (23.9)

14 (16.9)

0.65 (0.30–1.32)

0.203

Early reoperation

9 (5.5)

4 (4.8)

0.87 (0.19–3.22)

0.816

Death

16 (9.8)

3 (3.6)

0.34 (0.06–1.26)

0.085

Major complications

1 (25.2)

12 (14.5)

0.50 (0.23–1.06)

0.054

Any complication

74 (45.4)

25 (30.1)

0.52 (0.28–0.95)

0.021

Predictors of adverse outcome: multivariable logistic regression analysis Variable

Odds ratio

95 % CI

P value

Laparoscopic vs. Open Approach

0.50

0.28–0.91

0.024

Age

1.03

1.01–1.05

0.003

ASA*

1.69

0.57–5.02

0.348

Male

1.34

0.77–2.32

0.298

Previous abdominal surgery

0.86

0.45–1.63

0.650

Hypertension

0.85

0.45–1.57

0.595

Diabetes mellitus

1.10

0.52–2.29

0.806

Cardiac disease

1.43

0.76–2.68

0.267

*ASA 3–5 compared to 1–2

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An Analysis of Factors Affecting The Surgical Approach And Timing of Bilateral Adrenalectomy Billy Y Lan, Eren Taskin, MD, Erol Aksoy, MD, Onur Birsun, MD, Jaime Mitchell, MD, Allan Siperstein, Eren Berber, MD Cleveland Clinic Foundation

The Diagnostic Yield of Laparoscopic Lymph Node Biopsy is Superior to the Percuanteous Technique in Cases of Suspected Lymphoma Shaun C Daly, MD, Matthew Klairmont, BS, Bulent Arslan, MD, Minh B Luu, MD, Jonathan A Myers, MD Rush University Medical Center

Background: The optimal management of patients requiring bilateral adrenalectomy in regards to the surgical technique and timing of surgery has not been clearly defined. The aim of this study is to analyze the patient factors affecting the feasibility and outcomes of different surgical approaches to determine an algorithm for bilateral adrenalectomy. Methods: Between 2000 and 2012, a total of 285 patients underwent adrenalectomies at a single academic institution. Of these patients, 26 (9 %) underwent planned bilateral adrenalectomy. Pre-operative patient characteristics and intra-operative factors were compared for analysis. Results: Of the 26 patients that underwent bilateral adrenalectomy, eleven were male and 15 were female with a mean age of 58, median ASA of 3 and mean BMI of 32. Diagnosis in these patients included Cushing’s disease in 19 patients (7 with pituitary, 4 with ectopic, 7 with bilateral macronodular hyperplasia, and 1 with micronodular hyperplasia), pheochromocytoma in 5 patients, and adrenal metastasis in 2 patients. Of these 26 patients, successful laparoscopic bilateral adrenalectomy was performed in 18 patients, robotic in 6 patients, and open in 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while 3 adrenalectomies were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and morbid obesity in 1 patient. The operative times for the initial stage in these patients were 200, 306, and 420 min, respectively. Of the adrenalectomies completed using the minimally invasive approach, a posterior retroperitoneal (PR) approach was performed in 15 patients (63 %) and lateral transabdominal (LT) approach in 9 patients (37 %). An LT approach was favored due to tumor size greater than 6 cm in 6 patients, morbid obesity (BMI [35) in 2 patients, and need for a concomitant splenectomy for ITP in 1 patient. The total operative time was 315 min with average blood loss of 75 mL for laparoscopic cases compared to 389 min and 136 mL for robotic cases. Robotic cases had a shorter length of stay compared to laparoscopic cases (2.6 vs 3.5 days). The average hospital stay was 3.6 days for all minimally invasive adrenalectomies compared to 5 and 12 days for the two open cases There were no 30-day hospital mortality and only 3 minor complications (11 %) for the entire group. Conclusion: A minimally invasive operation is feasible in 92 % of patients undergoing bilateral adrenalectomy with 63 % of adrenalectomies completed using the PR approach not requiring repositioning of the patient. Indications for an LT approach are morbid obesity, tumor size [6 cm and other concomitant intraabdominal pathology. Single stage adrenalectomies are feasible in most patients. However, prolonged operative time greater than 200 min is a risk factor for a staged approach due to intraoperative respiratory decompensation.

Introduction: Optimal treatment of lymphoma requires an accurate tissue diagnosis. Immunohistochemistry and flow cytometry are the most common studies required for diagnosis and uniquely require more viable tissue than other malignancies to diagnose. Our objective was to compare the diagnostic yield of a laparoscopic biopsy to image-guided percutaneous biopsy for lymphoma. The primary end-point was successful retrieval of adequate tissue specimen for a definitive pathologic diagnosis. Methods: Records of patients who underwent laparoscopic and image-guided percutaneous lymph node biopsies for suspected cases of lymphoma at a large urban medical center over a 3-year period were reviewed. All patients demonstrated CT scan findings of intra-abdominal lymphadenopathy or a soft tissue mass [2 cm. All patients required intra-abdominal tissue retrieval because of the absence of peripheral adenopathy amenable to a less invasive approach. Patient demographics, complications, length of stay and diagnostic yield were analyzed. Results: Fifty-three biopsies were performed between 2010 and 2012 and were included in the study. Twenty-seven biopsies were performed laparoscopically while twenty-six were performed by a percutaneous technique. Demographics did not differ between cohorts. No significant procedural complications occurred in either cohort. Most patients in each cohort were discharged the day of intervention. Overall, 96.3 % of laparoscopic biopsies were successful in obtaining an adequate specimen for definitive pathologic diagnosis and subtyping compared to 65.4 % of percutaneous biopsies (p = 0.004). Among the failed percutaneous biopsies, 23 % required a subsequent biopsy attempt. Conclusion: In cases of suspected lymphoma, the diagnostic yield of laparoscopic lymph node biopsy is superior to an image-guided percutaneous approach. In cases of suspected lymphoma, when a greater amount of viable tissue is needed for an accurate diagnosis, a significant number of patients may be spared multiple interventions if first referred for diagnostic laparoscopy; reserving image-guided percutaneous techniques for cases when significant viable tissue is not required.

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Meta-Analysis of Safety and Efficacy of Laparoscopic Resection for Gastric Stromal Tumors Yuchen Zhou, MS, Ke Chen, MS, Yiping Mou, MD, FACS Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University

Tricks to Decrease the Suture Line Dehiscence Rate During Endoluminal Locoregional Resection (ELRR) by Transanal Endoscopic Microsurgery (TEM) Emanuele Lezoche, MD, FACS, Silvia Quaresima, MD, Andrea Balla, MD, Giancarlo D’Ambrosio, MD, Alessandro M Paganini, MD, PhD, FACS Department of General Surgery, Surgical Specialties and Organ Transplantation ‘‘Paride Stefanini’’, Sapienza University of Rome, Italy

Introduction: To evaluate the safety and efficacy of laparoscopic resection for gastric stromal tumors with systematic review and meta-analysis. Methods and Procedures: The literature database before September, 2013 was extensively searched to retrieve the comparative studies of laparoscopic (LR) and open resection (OR) for gastric stromal tumors with a relevance of study goal. The inclusion and exclusion criteria were formulated. After a quality evaluation, the data were extracted. The Cochrane collaboration RevMan5.1 version software was used for meta-analysis. Results: There are thirteen studies meeting the inclusion criteria for meta-analysis. The total sample size of these studies was 792 cases. The operation time was similar between the two groups [weighted mean difference (WMD) = -7.57 min, 95 % confidence interval (CI) -32.86 to 17.73, p = 0.56)]. Compared to OR, however, LR experience less blood loss (WMD = -48.88 ml, 95 % CI -72.90 to -24.85, P \ 0.001), earlier time to ?atus (WMD = -1.60 d, 95% CI -2.03 to -1.17, P \ 0.001) and oral diet (WMD = -1.68 d, 95% CI -2.33 to -1.03, P \ 0.001), shorter hospital stay (WMD = -3.55 d, 95% CI -4.56 * -2.53, P \ 0.001) and decrease in overall complications [relative risk (RR) 0.57, 95 % CI 0.33–0.97, p = 0.04)]. In addition, the long-term follow-up result shows that there is no significant difference in the two groups of patients. Conclusions: laparoscopic resection for gastrointestinal stromal tumors of the stomach is a safe and feasible procedure with less blood loss, less overall complications and quick recovery. The long-term survival situation of gastric stromal tumor patients mainly depends on the tumor itself risk, and laparoscopic surgery will not increase the risk of tumor relapse and metastasis.

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Introduction: ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long term oncological results and better Quality of Life. ELRR has a possible higher risk of dehiscence due to a larger defect, as compared to local excision by TEM. Aim was to evaluate if the introduction of a new technique during the ELRR procedure may reduce the risk of dehiscence. Methods and Procedures: The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients (12 males, 13 females, mean age 72.1 years, range 47–88) underwent ELRR by TEM with the authors’ standard technique, as previously described. In Group B, a subsequent series of 25 patients (16 males, 9 females, mean age 69.2 years, range 35–87) also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent (Floseal, Baxter Healthcare Corporation, Deerfield, Illinois, USA) prior to rectal wall closure, and after suture completion the rectal ampulla was stuffed with sponges to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla, together with a transanal Foley catheter for gas evacuation. All patients were closely followed up. Results: There were no significant differences in mean distance of the tumor from the anal verge, mean lesion diameter, mean operative time and pathological staging between the two groups. Neoadjuvant radiochemotherapy (nRCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 (12 %) patients and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6–7 cm) and final staging was pT0 (1), pTis (1), pT1 (1). None of these patients underwent nRCT. Conclusion: After ELRR by TEM, suture line dehiscence is presumably related to the size of the residual cavity and to the formation of a postoperative perirectal abscess after rectal wall closure. In the literature, suture line dehiscence rate after local excision by TEM is 13 % and after ELRR it is 11.5 %. In the present series the suture line dehiscence rate decreased from 12 % to 0 %. Obliteration of the residual perirectal space with a hemostatic agent and enlargement of the residual rectal ampulla volume may avoid formation of a postoperative perirectal abscess and may reduce the suture line dehiscence rate.

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Natural Orifice Specimen Extraction In laparoscopic colorectal surgery: Transvaginal Specimen Extraction Miguel A Hernandez, MD, Morris E Franklin, MD, FACS, Zanndor Del Real Romo, MD, Guillermo Peralta, MD, Denisse L Sepulveda, MD, David Martinez, MD Texas Endosurgery Institute

Single-Incision Pediatric Endosurgery (SIPES) Splenectomy: What Dictates The Need For Additional Ports? Aaron D Seims, MD, Robert T Russell, MD, Elizabeth A Beierle, MD, Mike K Chen, MD, Scott A Anderson, MD, Colin A Martin, MD, Carroll M Harmon Children’s of Alabama

Background: Since the first laparoscopic approach for colonic disease, minimal access techniques have revolutionized colonic surgery. Natural orifice specimen extraction (NOSE) offers the advantages of laparoscopic surgery and allows performing the anastomosis and extraction of the surgical specimen without enlarging any trocar incision. This study was designed to evaluate the outcomes of patients who underwent to a totally laparoscopic right hemicolectomy resection with transvaginal extraction. The predicted benefits of transvaginal extraction in colorectal surgery are to reduce incision-related morbidity such as pain, a reduced rate of surgical site infection and incisional hernias by avoiding minilaparotomy for specimen extraction. Methods: We analyzed a prospectively designed database of consecutive patients who underwent totally laparoscopic right colon surgery with transvaginal extraction for different pathologies between April 2007 and September 2013 at Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on a disease entities, site and size of the tumors. Results: A total of 31 patients underwent to right hemicolectomy with NOSE approach and vaginal extraction. The operative time for the procedure was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, trasvaginal extraction was associated with 2 complications 6.4 %); with no post operative complications. The length hospital stay was 5.2 ± 2.2 days. Conclusion: The NOSE approach is possible with favorable short-term surgical outcomes. This novel technical approach is feasible and safe, eliminates the need for extraction through minilaparotomy with a potentially shorter recovery time, earlier ambulation, bowel function, fewer complications, decreased drugs use, and improved cosmesis; it might be considered for patients requiring abdominal right hemicolectomy.

Introduction: As proficiency with single-incision pediatric endosurgery (SIPES) increases over time, more challenging operations such as splenectomy are being performed. While the ultimate goal is to perform a safe operation, a surgeon may wish to know at the onset of an operation what anatomical and technical factors contribute to the need for additional ports. This aspect of SIPES splenectomy, for which there is sparse literature, has yet to be addressed. The objective of this study is to identify such factors, allowing surgeons to gauge single incision appropriateness and to potentially tailor technique for optimal results. Methods and Procedures: This is an IRB approved (FWA00005960) retrospective analysis of prospectively collected data. All SIPES splenectomies performed at a tertiary children’s hospital since March of 2009 were included. Collected data were date of birth, operative date, age at operation, height, weight, body mass index (BMI), gender, diagnosis, surgeon, duration of operation, method for ligation of short gastric and splenic vessels, estimated blood loss, presence and quantity of accessory spleens, multiport type (Tri or Quad port) at the onset of surgery, the need for and quantity of additional ports, instances of conversion to open operation, splenic weight and long axis spleen radiographic measurements. Fischer’s exact and Wilcoxon rank sum tests were used to analyze categorical and continuous variables, respectively. Results: Thirty-seven patients eighteen years of age and younger underwent attempted SIPES splenectomy. Two were converted to open operations and were excluded from analysis. Of the remaining 35 laparoscopic operations, 15 (42.9 %) were completed with additional ports. The attached table provides a comparative analysis of clinical and procedural characteristics in SIPES operations and cases where additional ports were required. Gender, age, BMI, splenic weight, diagnosis for which splenectomy was being performed and the presence of accessory spleens did not significantly contribute to the need for additional ports. The only factor to reach statistical significance (p \ 0.05) was the number of channels present in the access device. Conclusions: Completion of splenectomy laparoscopically through a single incision is associated with the decision to utilize an access device with four channels over one with three. Anatomical variables do not appear to affect the ability to perform SIPES splenectomy.

Comparative analysis of clinical and procedural characteristics in SIPFS and multi-port splenectomy*

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SIPES (n = 20)

Multi-port (n = 15)

p-Valueà

Mate

12 (60.0)

8 (53.3)

0.7412

Female

8 (40.0)

7 (46.7)

7.1 (2.7–9.7)

6.4 (2.1–12.7)

0.9736

17.1 (15.3–20.7)

16.5 (14.7–19.5)

0.7786

Transperineal Notes-Inspired Approach to the Total Mesorectal Excision (TME) in Patients with Rectal Neoplasia A Preliminary Experience Elie K Chouillard, MD, PhD Department of General Surgery, Poissy Saint Germain Medical Center

Gender (%)

Background: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging surgical approach. In humans, ‘‘pure’’ NOTES is still slowed down by technical hurdles. However, ‘‘Hybrid’’ variants have been increasingly reported. Total mesorectal excision (TME) is the best treatment for patients with resectable mid or low rectal neoplasia. However, TME is still technically demanding and associated with significant morbidity, mainly related to anastomotic failure and nerve injuries. We have developed a transanal, NOTES-inspired approach to TME (taTME) in patients with rectal neoplasia. The aim was to further reduce or even avoid the abdominal wall invasiveness of laparoscopy. Eventually, this approach could reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and enhance cosmesis. Methods: taTME was attempted in 16 patients with mid or low rectal neoplasia (i.e., lower edge of the tumor between 0 and 12 cm from the dentate line). Additional criteria included ASA status I–III and the absence of prior major abdominal surgery. The technique was performed using a transanal approach with or without single-incision laparoscopic abdominal assistance. Results: taTME was completed in 14 patients (87.5 %). Conversion to conventional laparoscopy occurred in two patients. Mean operative time was 265 min (range 155–440). Mortality rate was 0 %. Post-operative complication rate was 18.8 % (2 intestinal obstructions, 1 pelvic abscess). No anastomotic leakage occurred. Resection was complete in all the patients. An average of 18 nodes were retrieved (range 12–81). Mean length of hospital stay was 10.4 days (range 4–29). Conclusion: taTME was found to be safe and feasible in this series of selected patients with mid or low rectal cancer. The short-term mortality and morbidity results seemed to be acceptable. There seemed to be no compromise in the oncological quality of resection occurred as based on the histological analysis of the specimen.

Port type (%)

Age BMI Splenic weight (g)

147.0 (114.5–219.0)

239.0 (134.0–327.0)

0.2023

Accessory spleens (%)

4 (20.0)

5 (33.3)

0.2003

0.0019

Tri port

1 (5.0)

8 (53.3)

Quad port

19 (95.0)

7 (46.7)

Autoimmune hemolytic anemia

1 (5.0)

1 (6.7)

Hereditary spherocytosis

5 (25.0)

5 (33.3)

Idiopathic thrombocytopenia purpura

4 (20.0)

1 (6.7)

Sickle cell disease

10 (50.0)

8 (53.3)

Diagnosis (%) 0.8170

* Presented as N (%) Or Median (IQR) à

Estimated from Fischer’s exact and Wilcoxon rank sum tests for categorical and continuous variables, respectively

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Impact of Previous Midline Laparotomy on the Outcomes of laparoscopic Intestinal Resections: A Case-Matched Study Erman Aytac, Luca Stocchi, Julie DeLong, Meagan M Costedio, Emre Gorgun, Hermann Kessler, Feza H Remzi Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio

Impact of an Enhanced Recovery Pathway for Colorectal Surgery on Quality of Life After Hospital Discharge Lawrence Lee, MD, MSc, Juan Mata, MD, Berson Augustin, Gabriela A Ghitulescu, MD, A S Liberman, MD, Patrick Charlebois, MD, Carol-Ann Vasilevsky, MD, Nancy Morin, MD, Franco Carli, MD, Liane S Feldman, MD McGill University Health Centre; Sir Mortimer B. Davis Jewish General Hospital

Introduction: The effectiveness of laparoscopic intestinal resection in patients with previous midline laparotomy (PML) is controversial. The aim of this study was to assess the feasibility of laparoscopic surgery and identify possible factors associated with postoperative outcomes in patients with PML. Methods and Procedures: Patients with PML (at least an infraumbilical incision or longer) undergoing elective laparoscopic intestinal resection between 1997–2011 were case-matched with patients without PML undergoing laparoscopic surgery based on age, gender, body mass index, ASA score, surgical procedure and diagnosis. Comparisons of the groups were performed by using v2 or Fisher exact tests with respect to categorical data and by using the Wilcoxon rank-sum test with respect to quantitative data. Parametric data were reported as means and nonparametric data as numbers. Results: Fifty patients with PML undergoing laparoscopic intestinal resection were well matched to 50 counterparts (Table 1). Conversion to open surgery (n = 8 vs. n = 4, p = 0.22), operating time (211 vs. 192 min, p = 0.22) and estimated blood loss (158 vs. 184 ml, p = 0.95) were similar between the groups. Intraabdominal adhesions (either disease-related or from previous operations) were significantly more common in patients with PML (n = 24 vs. n = 11, p = 0.01). Intraoperative complications included inadvertent enterotomy and hemorrhage and were comparable between the groups (1 vs. 0, p = 1 and 1 vs. 2, p = 1 for PML vs. no PML, respectively). One patient without PML died postoperatively from aspiration pneumonia. Overall morbidity (n = 26 vs. n = 10, p = 0.001), and particularly postoperative ileus (n = 10 vs. n = 3, p = 0.04) were significantly increased in the PML group when compared to laparoscopy without PML, unlike the respective differences in postoperative return of bowel function (4 vs. 3 days, p = 0.15), reoperations (n = 5 vs. n = 3, p = 0.72), length of hospital stay (9 vs. 6 days, p = 0.09) and readmissions (n = 5 vs. n = 4, p = 0.73). Conclusions: Intestinal resections in patients with PML can be frequently completed laparoscopically but are associated with worse postoperative outcomes when compared to laparoscopy on a virgin abdomen. Future studies should compare laparoscopic and open surgery in individuals with PML to further assess the benefits of laparoscopy in this patient subgroup.

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Table 1 Case-matching criteria and perioperative outcomes Previous midline laparotomy (n = 50)

No prior abdominal operation (n = 50)

P value

Age (years)

58 ± 17

57 ± 18

0.93

Gender (F/M)

28/22

28/22

1

ASA score

2 (2–3)

2 (2–3)

1

Body mass index (kg/m2)

26 ± 5

26 ± 5

0.99

0.91

Operations performed, n Partial colectomy (Right/left sided)

41

41

Total colectomy/proctocolectomy

4

4

Proctosigmoidectomy

3

3

2

2

Benign

38

38

Malignant

12

12

Adhesion

5

2

Unclear anatomy

1

2

Obesity

1

0

Bleeding

1

0

Small bowel resection Diagnosis, n

1

Causes of conversion, n 0.46

Specific postoperative complications, n Atelectasis Venous thromboembolism

Introduction: Enhanced recovery pathways (ERP) for colorectal surgery shorten length of hospitalization and may decrease morbidity, however there is little information about their impact on patient-reported outcomes, especially after hospital discharge. The objective of this study was to estimate the impact of an ERP compared to conventional care (CC) on patient recovery at 4- and 8-weeks after surgery. Methods and Procedures: Consecutive adult patients undergoing elective colorectal surgery at two university-affiliated institutions from Oct 2012 to July 2013 were prospectively enrolled. One centre used an ERP approach while the other did not. Recovery was measured using the SF-6D, a previously validated patient-reported measure of postoperative recovery, which is scored from 0.294 (poorest health) to 1.000 (perfect health). This was administered at baseline (within 2 weeks of surgery), and at 4- and 8-weeks after surgery. Multiple linear regression was used to determine the independent effect of ERP on recovery after adjusting for confounders. Data are presented as mean (SD) or median [IQR]. Results: A total of 124 patients (CC 73, ERP 51) were enrolled. There were no differences in age, gender, body mass index, comorbidities, malignancy or procedures. More patients in the ERP group underwent a laparoscopic approach compared to the CC group (88 vs. 40 %, p \ 0.001). Total length of stay was lower in the ERP group versus the CC group (5 [3–8] vs. 7 [4–8], p = 0.022), but there were no differences for laparoscopic cases only (ERP 4[3–7] vs. CC 4 [4–6], p = 0.661). No differences in 60-day complications (ERP 49 vs. CC 42 %, p = 0.471), emergency visits or readmissions between the two groups were found. Baseline SF-6D values were higher in the ERP compared to CC [0.802 (SD 0.098) vs. 0.750 (SD 0.149), p = 0.022]. At 4-weeks, ERP and laparoscopy were independently associated with improved recovery [ERP +0.063 (95 % CI 0.005, 0.122); laparoscopy +0.074 (95% CI 0.014, 0.134)], after adjusting for age, gender, co-morbidities, stoma, complications, and baseline SF-6D. However, at 8-weeks, there was no difference in recovery between ERP and CC [mean adjusted difference +0.040 (95 % -0.104, 0.185)] Conclusions: ERPs are associated with improved short-term recovery, independent of laparoscopy, after colorectal surgery.

3

1

0.62

2

1

1

Urinary complications

2

3

1

Anastomotic leak

3

1

0.62

Abdomino-pelvic abscess

4

1

0.36

Wound infection

7

3

0.32

Fistula

2

0

0.50

Liquid-Injection for Preperitoneal Dissection of Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair Tomoko Mizota, MD, Norihiro Takemoto, MD, PhD, Saseem Poudel, MD, Yusuke Watanabe, MD, Yo Kurashima, MD, PhD, Yuji Miyasaka, MD, PhD NTT East Sapporo Hospital, Department of Gastroenterological Surgery II Hokkaido University Graduate School of Medicine Introduction: The creation of sufficient peritoneal flap during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair without parenchymal injury is essential, but can be technically challenging. Liquid dissection technique might help to facilitate the blunt dissection and to reduce parenchymal injury. We describe this technique for TAPP hernia repair and report our experiences. Method and Technique: We performed 6 cases of TAPP inguinal hernia repair with liquid dissection technique from July to September 2013. After trocar placement and diagnosis of hernia type, 60 ml of 0.3 % lidocaine with 1:300,000 dilution of epinephrine is injected percutaneously under laparoscopic vision into preperitoneal space (Hesselbach’s triangle, above and below lateral triangle) to dissect the preperitoneal space (Fig. 1). The initial incision of peritoneum is performed at lateral side of the inguinal canal, followed by blunt dissection of the preperitoneal space until the following landmarks become visible: pubis symphysis medially, aponeurosis of transverses abdominis cranially and anterior superior iliac spine laterally. Adequate parietalization of the vas deferens and gonadal vessels is performed. A polypropylene mesh is finally placed in appropriate position and fixed on Cooper’s ligament with two tacks, followed by the closure of the peritoneal flap using a continuous absorbable suture. Data are resented as median and interquartile range. Result: The median age was 72.5 (61–84.5) years old, and 4 of 6 were male. The median ASA class was 1.5 (1–2). One patient had bilateral direct inguinal hernias, another patient had unilateral direct hernia and the other 4 patients had unilateral indirect hernias. The median operative time, injection time and dissection time were 128 (113–179.5), 5.3 (4.7–5.9) and 46 (40–48) min respectively. The median estimate blood loss was 7.5 (3.8–10) ml. All cases were performed by a resident without TAPP experiences. This procedure made enough space between peritoneum and the spermatic structures, and the preperitoneal space was dissected without difficulty. No intraoperative injury or conversion to laparotomy was observed. There was no hernia recurrence after a median 13.5 (10–20) days follow-up. Conclusion: The liquid dissection technique for laparoscopic TAPP inguinal hernia repair might be feasible to facilitate dissection of preperitoneal space and reduce injuries of vas deferens and gonadal vessels.

ASA: American Society of Anesthesiologists, IRA: ileorectal anastomosis, IPAA: ileal pouch-anal anastomosis

Fig. 1 A left direct inguinal hernia after injection. Injection point (w)

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Robotic Left Colon Cancer Resection: Dual Docking Technique For Splenic Flexure Mobilization Se Jin Baek, Chang Woo Kim, Min Soo Cho, Hyun A Jang, Hyuk Hur, Seung Hyuk Baik, Nam Kyu Kim, Byung Soh Min, Sung Uk Bae Yonsei University College of Medicine

24-Hour Multichannel Intraluminal Impedance-Ph Monitoring May be an Inadequate Test for Detecting Gastroesophageal Reflux in Patients with Mixed Typical and Atypical Symptoms Michelle S Han, MD, Michal J Lada, MD, Dylan R Nieman, MD, PhD, Andreas Tschoner, MD, Christian G Peyre, MD, Carolyn E Jones, MD, Thomas J Watson, MD, Jeffrey H Peters, MD Department of Surgery, University of Rochester

Background: The technique for robotic resection of the left colon is not well defined and has not been widely adopted due to limited range of motion of the robotic arms. We have developed dual docking technique for both the splenic flexure and the pelvis. We report our initial experience of robotic left colectomy using this technique for left-sided colon cancer. Methods: The study group included 61 patients who underwent a robotic left colon cancer resection using dual docking technique between July 2008 and January 2013. The operations were divided into two stages: colon mobilization (stage 1) and rectal dissection (stage 2). After completion of stage 1, the da Vinci arms were undocked and the operating table was rotated 60 degrees counterclockwise and redocked. Results: All 61 procedures were technically successful without the need for conversion to laparoscopic or open surgery. The median operation time was 227 min (range: 137–653) and estimated blood loss was 20 ml (20–2000). The median time to soft diet was 2 days (2–12) and length of stay was 7 days (4–20). The median total number of lymph nodes harvested was 17(3–61). According to the Clavien–Dindo classification, the numbers of complications for grade 1, 2, 3a, 3b, and 4 were 10, 2, 3, 3, and 1. There was no mortality within 30 days. Conclusions: Robotic left colon cancer resection using dual docking technique is safe and feasible. Our technique can be a suitable procedure to maximize the splenic mobilization.

S018 Cost Analysis Comparing Intraoperative Fluorescent Cholangiography With Fluoroscopic Cholangiogram Fernando Dip, MD, Domenech Asbun, MS, Armando Rosales-Velderrain, MD, Emanuele Lo Menzo, MD, PhD, Conrad H Simpfendorfer, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS Cleveland Clinic Florida

Introduction: The detection of gastroesophageal reflux (GER) via ambulatory pH testing is a key component of the preoperative evaluation of patients considered for antireflux surgery. Previous reports have suggested discrepancies between multichannel intraluminal impedance-pH monitoring (MII-pH) and wireless based (Bravo) methods. Further, a dual probe MII-pH catheter is often used preferentially in patients with atypical reflux symptoms. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH in a population of patients with mixed respiratory and GI symptoms of GER. Methods and Procedures: The study population consisted of 66 patients who underwent both MII-pH and Bravo pH monitoring tests between July 2009 and 2013. The median time interval between the two tests was 1 day (IQR = 2). The vast majority of patients (88 %, 58/66) presented with mixed typical and laryngorespiratory (LPR) or solely LPR symptoms; 12 % (8/66) had pure typical symptoms. Patient demographics, presenting symptoms, manometric and pH monitoring parameters were collected and compared. Patients were divided into four groups for comparison: both positive, MII-pH negative but Bravo positive, MII-pH positive but Bravo negative, and both negative groups. All studies were done off PPI medications for at least 7 days and a positive study defined by DeMeester score[14.72 on any day. Results: Nearly half of the patients (44 %, 29/66) had discordant test results. Of these, 90 % (26/29) had a negative MII-pH but positive Bravo study. In the MII-pH negative but Bravo positive group the difference in the overall score was usually large, a median of 33.5, suggesting that they were true positive. Further, the MII-pH negative but Bravo positive group (26/66) had significant differences in all pH parameters between two methods. There were 3 patients in which the MII-pH was positive but Bravo negative. These patients had similar pH parameters to patients in which both tests were negative suggesting they were likely true negative. Bravo day 1 and day 2 pH parameters were similar for each group. Patients with test discrepancies had slightly higher BMI (28.5 vs. 26.1, p = 0.0357) and more associated manometric findings of hiatal hernia (p = 0.0173) and structurally defective lower esophageal sphincter (LES, p = 0.0208). Conclusion: We identified a high prevalence of discordant ambulatory pH results in patients with LPR symptoms possibly secondary to GERD. The vast majority of these appear to be false negative MII-pH studies. A single 24 hour Multichannel intraluminal impedance-pH study may be an inadequate test to exclude GERD in this patient population.

Introduction: Laparoscopic cholecystectomy (LC) remains the gold standard approach for symptomatic cholelithiasis. Despite its standardization, the rate of bile duct injury (BDI) has risen from 0.2 to 0.5 % since its introduction. The resulting consequences of BDI significantly affect patients’ well being and leads to economic and legal implications. The routine use of intraoperative cholangiography (IOC) advocated by many as a diagnostic modality to prevent biliary tract injuries, has not been widely accepted, mainly because it is time consuming, costly and there is lack of evidence that it will prevent BDI. Fluorescent cholangiography (FC) is a novel, intraoperative procedure involving infrared visualization of biliary structures. We evaluated the costs and effectiveness of routinely implemented FC and IOC during LC. Material and Methods: We reviewed all patients between February and June 2013 that were enrolled in an IRB approved prospective study, comparing LC with FC and IOC. The procedure time, procedure cost and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method. Results: A total of 43 patients (21 males and 22 females) were analyzed during the study period. The mean age was 49.53 ± 14.35 yrs and mean body mass index (BMI) was 28.35 ± 8 kg/m2. The overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 min vs. 7.15 ± 3.76 min; p \ 0.0001). FC was successfully performed in 43 out of 43 cases (100 %), and IOC in 40 out of 43 cases (93.02 %). FC was less expensive than IOC (14.10 ± 4.31 vs. 778.43 ± 0.40 dollars; p \ 0.0001). FC use generated an additional cost of mean $14 ± 4.25 dollars per LC. Costs of IOC per surgery were found to be in the literature between $100 and $700. According to the survey, all surgeons found the routine use of FC useful. Conclusion: FC was effective in delineating important anatomic structures during LC. It required less time and expenses when compared to IOC. Additionally it was perceived by the surgeons to be easier to perform and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

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S021

Proficiency Training On A Virtual Reality Robotic Surgical Skills Curriculum Justin D Bric, BS, Michael J Connolly, BS, Matthew I Goldblatt, MD, Andrew S Kastenmeier, MD, Jon C Gould, MD Department of Surgery, Division of General Surgery, Medical College of Wisconsin

Long-Term Follow up after Laparoscopic Anti-Reflux Surgery in Patients with Barrett’s Esophagus Ellen H Morrow, MD, Daniel Bushyhead, BA, Eelco Wassenaar, MD, Marcelo Hinojosa, MD, Maximiliano Loviscek, MD, Carlos Pellegrini, MD, Brant Oelschlager, MD University of Washington

Introduction: This study sought to evaluate proficiency based virtual reality simulation training in developing robotic surgery skills. The clinical application of robotic surgery is increasing, and the skills necessary to perform robotic surgery are unique from those required in open and laparoscopic surgery. A validated laparoscopic surgical skills curriculum (Fundamentals of Laparoscopic Surgery or FLSTM) has transformed the way surgeons acquire laparoscopic skills. There is a need for a similar skills training and assessment tool specific for robotic surgery. Our research group previously developed and validated a robotic training curriculum in a virtual reality (VR) simulator. Proficiency levels were established based on the trimmed mean performance of experienced robotic surgeons. We hypothesized that novice robotic surgeons could achieve proficiency levels on the VR robotic curriculum, and that this would result in improved performance on the actual daVinci Surgical SystemTM. Methods and Procedures: Twenty-four medical students with no prior robotic surgery experience were recruited. Prior to VR training, subjects performed 2 FLS tasks 3 times each (Peg Transfer, Intracorporeal Knot Tying) using the daVinci Surgical SystemTM docked to a video trainer box. Task performance for the peg transfer tasks was assessed according to the formula: 300 - [time to complete (sec)] - [penalty for dropped pegs]. For the knot tying task, the formula was: 300 [time to complete] - [penalty for slipped or loose knots]. Subjects then practiced on the VR simulator (daVinci SiTM Surgeon Console and MimicTM simulator) until proficiency levels on all 5 selected tasks (Pick & Place, Camera Targeting 2, Peg Board 2, Matchboard 2, and Suture Sponge 3) were achieved before completing a post-training assessment of the 2 FLS tasks on the daVinci Surgical SystemTM in the video trainer box. Results: There was a significant improvement in performance on the FLS tasks following completion of the VR training curriculum. Subjects reached proficiency on all VR tasks in an average of 71 (±21.7) attempts, accumulating 164.3 (±55.7) minutes of console training time. Following completion of the VR training curriculum, there was no significant difference between subjects and experienced robotic surgeons on the Peg Transfer task (220.9 vs. 229; p = 0.36); however experienced surgeons significantly outperformed trained subjects on IC knot tying (213.5 vs. 104.7; p \ 0.001).

Introduction: Barrett’s esophagus (BE) is caused by chronic gastro-esophageal reflux disease (GERD). It is hypothesized that laparoscopic anti-reflux surgery (LARS) may change the natural course of BE. The purpose of this study is to determine the long-term outcome of LARS in patients with BE. Methods: We analyzed the records of patients with BE who underwent LARS and who had postoperative histological follow-up C3 years with special attention to endoscopy findings, histology, and pH studies. Post-operative GERD symptoms were evaluated via questionnaire. Histological regression was defined as either loss of dysplasia or BE returning to squamous mucosa. Progression was defined as development of new dysplasia or adenocarcinoma. Results: Eighty-two patients met the inclusion criteria with a median histological follow-up time of 8 years (range 3–16 years). Sixty-seven (82 %) patients completed the post-operative questionnaire; 86 % of patients reported durable improvement in heartburn and regurgitation, and 79 % of patients reported improvement in aspiration. Thirty-four (41 %) patients underwent pre- and postoperative dual probe pH studies. The median DeMeester score decreased from 54 to 9 (p = 0.00). Histological regression of BE occurred in 19 (23 %) patients. Three went from dysplasia to nondysplastic metaplasia, and 16 from metaplasia to normal squamous epithelium. Normalization of acid exposure and short segment Barrett’s (3 cm or less) were more common in the group with histological regression. Six patients (7 %) had evidence of progression; one to LGD, 4 to HGD, and 1 to invasive adenocarcinoma. Conclusions: LARS was associated with both physiologic and symptomatic control of GERD in the majority of patients with BE. Patients with LARS may experience histological regression of BE, which is more common in patients with short-segment Barrett’s and normalization of acid exposure. Progression can also occur after LARS, and thus continued surveillance is indicated.

Mean peg transfer and IC knot scores pre and post VR proficiency training n = 24

Peg score

IC knot score

% Successful knots

Pre VR training

175.5 ± 54.1

20.2 ± 40.0

38 % (27/72)

Post VR training

220.9 ± 25.0

104.7 ± 56.4

88 % (63/72)

p-value

0.01

0.01

0.01

Conclusions: Novice robotic surgeons are able to train to established proficiency levels on a VR simulator. Training to proficiency on a simulator leads to improved performance in the actual daVinci surgical platform on simulated tasks. Training to proficiency on a VR robotic surgery simulator is an efficient and viable method for acquiring robotic surgical skills.

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S022 Evaluation of The Learning Curve of Total Mesorectal Excision for Rectal Cancer: Comparison of the Laparoscopic and Robotic Approaches Hyejin Kim, MD, Gyu-seog Choi, MD, PhD, Junseok Park, MD, PhD, Sooyeun Park, MD Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University Introduction: The technical difficulties experienced during laparoscopic total mesorectal excision (LTME) have prompted many surgeons to adopt the robotic approach. However, the comparison of learning process with robotic total mesorectal excision (RTME) in treating rectal cancer has not yet been clearly described. We compared the learning curves of LTME and RTME in different learning periods. We also compared the clinical outcomes of the 2 different approaches performed by the same surgeon during the same period for a detailed assessment of safety of RTME. Methods and Procedure: We reviewed records on the first 167 patients who underwent LTME from December 2002 to April 2005 (early LTME group) and compared them with data on the first 167 patients who underwent RTME from December 2007 to August 2012 in order to compare the each learning curve. To compare the clinical outcomes of these 2 approaches, data on 167 patients who underwent LTME from December 2007 to November 2009 (late LTME group) were compared with data on those who underwent RTME during the same period. Results: The learning curves of the surgical approaches were evaluated on the basis of riskadjusted CUSUM analysis based on conversion, operative time, perioperative morbidity and circumferential resection margin status. The results showed that the learning curve plateaued after 65 cases for early LTME as opposed to after 32 cases for RTME. During the learning period, total operative time was significantly shorter in the RTME group than in the early LTME group (252.0 ± 42.1 min vs. 278.6 ± 49.2 min, p = 0.010). The mean length of the distal resection margin was significantly longer and the number of retrieved lymph nodes was significantly greater in the RTME group than in the early LTME group. In the same period, total operative time was significantly longer in the RTME group than that in the late LTME group (212.0 ± 49.8 vs. 156.4 ± 40.3, P \ 0.001). Although patients with low rectal cancer who underwent preoperative chemoradiation, were higher comprised in the RTME group than in the late LTME group, postoperative morbidity and histopathological results did not differ between the groups. Conclusions: The RTME group experienced a shorter learning period in comparison to early LTME group. The short-term outcomes in the RTME group were comparable to those of the late LTME group with exception of total operative time. Therefore, our experience shows that RTME is safe, can easily be learned, and is reproducible during the initial learning period even in complicated rectal cancer patients.

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S025

The Business Engineering Surgical Technologies (BEST) Teaching method: Incubating Talents for Surgical Innovation Vivian De Ruijter, Peter Halvax, MD, Bernard Dallemagne, MD, Lee Swanstrom, MD, Jacques Marescaux, MD, Silvana Perretta, MD, IRCAD-IHU University of Strasbourg, France

Surgical Outcomes After Insertion of Gastric Neurostimulator for Refractory Gastroparesis: A Single Institution’s Experience Ihab Saab, MD, Kellie McFarlin, MD Henry Ford Hospital

Introduction: Technological innovation in surgical science and healthcare is vital and calls for close collaboration between engineering and surgery. Platforms that facilitate effective and directed communication between professionals from both worlds would serve this purpose. To satisfy such an educational need facing the current economic crisis is particularly challenging. This study explores an innovative teaching method free of charge combining surgery, engineering and business in a multidisciplinary, highquality, low-cost and learning-by-doing philosophy. Methods and Procedures: From November 2011 to September 2013, the BEST educational method was delivered in two parts supported by a 40 K/year government grant: the first component consisted of 68 online lectures and corresponding evaluations by world-renowned faculty, streamed live or pre-recorded, with an interdisciplinary profile focused on surgery, engineering, and business. The second component was a yearly 5-day onsite course, organized at the IRCAD Institute in Strasbourg, France. The on-site program included workshops in engineering, interventional (MRI-CT-Zeego-US) radiology, entrepreneurship team projects, and in-depth hands-on training in laparoscopy, robotic surgery and flexible endoscopy delivered on ex-vivo and in-vivo models, and laparoscopic and flexible endoscopy simulators. A 1-to-5 Likert scale satisfaction survey was administered to all students. A panel of experts: surgeons, engineers, entrepreneurs, venture capitalists and scientists assessed the team projects ‘value in terms of innovation and market potential. Results: 803 individual and institutional users from 50 different countries attended the online course (mean age 27.1; SD 13.2) and participated to a total of 8,142 lectures. 134 young professionals (69 % medical, 31 % engineering and/or business background) from 32 different countries applied to participate to the onsite course. Thirty participants were selected each year for the onsite course (15 medical, 15 engineering and/or business students) based on the online course evaluation, curriculum vitae and a letter of intent. A satisfaction rate of 4.52 (SD 0.13) in 2012 and 4.87 (SD 0.06) in 2013 was awarded to the onsite course by the participants. Twelve provisional patents were filed. Conclusion: BEST proved to be a global talent incubator connecting students and high quality education despite institutional and economical boundaries. Viable and innovative ideas arose from this revolutionary approach which is likely to spin off significant technology transfer and lead the way for future interdisciplinary hybrid surgical education programs and career paths.

Introduction: Gastric electric stimulation (GES) has been approved by the FDA under a humanitarian device exemption for treatment of patients with refractory symptoms of diabetic gastroparesis (DG) or idiopathic gastroparesis (IG). Our goal is to evaluate the effect of GES on body mass index (BMI) and the hemoglobin A1C (HbA1c) of patients who underwent insertion of a gastric neurostimulator at a single institution. Methods and Procedures: A retrospective review of patients who underwent laparoscopic insertion of gastric neurostimulator for refractory IG or DG from June 2004 to June 2013 was analyzed. We compared the rates of symptomatic response to therapy, the overall treatment period, different patient demographic parameters, body mass index (BMI) and the hemoglobin A1c (HbA1c) levels at implant time, 6, 12 and 60 months intervals. ANOVA was used to analyze the data. Results: A total of 137 patients had a GES implanted with a median age of 43.9 years (range 19.5–78 years); 105 of which are still active patients in our database. Twenty-five percent (n = 34) where females. Sixty-four percent (n = 87) had the GES inserted for DG and thirty-six percent (n = 50) for IG.

0 months

6 months

12 months

24 months

HbA1c

7.95

7.2

8.07

7.78

SD

1.86

0.91

1.87

2.05

26.68

28.66

6.72

6.59

BMI SD

27.5 7.02

31 5.67

60 months

6.98 1.29 34.9 8.58

Mean HbA1c and mean BMI reported, SD: Standard deviation The HbA1c trended down when followed from 0 to 60 months (p = 0.738) The BMI increased (p = 0.049). Conclusion: GES has been shown to improve quality of life and symptom scores in previous studies. Our study shows improved weight stabilization while on GES therapy and stabile HbA1c over a long duration of therapy. Further studies are needed to delineate the cause and effect of this outcome and if device settings play a role.

S024

S026

Does the Cost of Robotic Cholecystectomy Translate to a Financial Burden? Sharona Ross, MD, Richard Klein, Carrie Ryan, MS, Paul Toomey, MD, Prashant Sukharamwala, MD, Alexander Rosemurgy, MD Florida Hospital Tampa; Tampa, Florida

Minilaparoscopic Cholecystectomy: The Lessons Learned After 13 Years of Experience and 1750 Cases Diego Laurentino Lima, MD, Gildo O Passos Junior, MD, Juscielle S Barros, Yukie C Konishi, Ingrid L V. Rodrigues, Frederico W C. Silva, MD, Gustavo L Carvalho, PhD Faculty of Medical Sciences, University of Pernambuco

Introduction: Robotic application to cholecystectomy has dramatically increased, though its impact on cost of care and reimbursement has not been studied. We undertook this study to evaluate and compare cost of care and reimbursement with robotic versus laparoscopic cholecystectomy. Methods and Procedures: The charges and reimbursement of all robotic and laparoscopic cholecystectomies at one hospital undertaken from June 2012 to June 2013 were determined. Operative duration is defined as time into and time out of the operating room. Data are presented as median (mean ± SD). Comparisons were undertaken using the Mann–Whitney U-test with significance accepted at p B 0.05. Results: Robotic cholecystectomy took longer (53 min longer) and had greater charges ($8,182.57 greater) than laparoscopic cholecystectomy (p \ 0.05 for each, Table 1). However, revenue, earnings before depreciation, interest, and taxes (EBDIT), and net income were not impacted by approach (Table 1). Conclusions: Relative to laparoscopic cholecystectomy, robotic cholecystectomy takes longer and has greater charges. Revenue, EBDIT, and net income are similar after either approach, denoting costs with either approach are determined to be similar. Notably, this is possible because much of hospital-based cost allocation is not based upon cost accounting. Thus, the cost of longer operations and costs inherent to the robotic approach for cholecystectomy do not translate to a perceived financial burden.

Table 1 Cost analysis : robotic cholecystectomy versus laparoscopic cholecystectomy Robotic Cholecystectomy n = 31

Laparoscopic Cholecystectomy n = 201

p-value

Operative duration (min)

140 (141 ± 25.38)

93 (102 ± 32.7)

\0.01

Charges

$33,238.42 ($34.178.10 ± $6.023.66)

$25,055.85 ($27,020.69 ± $8,624.90)

\0.01

Net revenue

$9,121.49 ($7,982.03 ± $3,885.15)

$6,512.61 ($7,119.79 ± $4,212.83)

0.29

EBDITa

$6,196.07 ($4,649.02 ± $3,959.69)

$3,507.86 ($3,755.88 ± $4,126.69)

0.26

Net income

$5,848.59 ($4,270.85 ± $3,996.05)

$3,058.83 ($3,358.79 ± $4,140.91)

0.25

a

Earnings Before Depreciation, Interest and Taxes

Objective: This review aims to demonstrate that minilaparoscopic cholecystectomy (MLC)

provides better results when compared with laparoscopic cholecystectomy (LC), explaining the most important lessons learned after 13 years of experience. Methods: From 2000 to 2013, 1.750 patients underwent MLC. Surgical technique: After introduction of 10 mm trocar for laparoscope in the umbilical incision, pneumoperitoneum was made and 3 trocars were inserted. Initially, there were 2 of 2 mm and 1 of 3 mm in diameter; after 2009, with the advent of dilating trocars, atraumatics and with low friction, 3 of 3 mm trocars started to be placed. Three millimeters laparoscope or clips were not used. The cystic artery was cauterized safely near the gallbladder and the cystic duct was sealed with surgical knots. The removal of the gallbladder occurred through the umbilical incision, initially using adapted bag made with surgical glove wrist and, in recent years, through manufactured bags for extraction (MTP—200 mL). Results: The operation video time was 24 min. 2.4 % of conversion to LC. There was no conversion to open surgery, no bleeding, no bile ducts injury or mortality, no complications in intra and postoperative. Only one case of reoperation occurred for leakage persistence of the Luschka’s duct. There was great satisfaction of patients regarding postoperative pain and reduced hospital stay. Conclusion: (1) The minilaparoscopy is an effective, safe, refined, cost-effective technique and with short learning curve for surgeons familiar with the LC. (2) Use of low friction atraumatics trocars with dilating extremities minimize abdominal wall injury and postoperative pain, besides provide better cosmetic with tiny and almost imperceptible scars. (3) The low friction trocars increase the precision of movements and facilitate the use of minilaparoscopy material. (4) The cauterization of the cystic artery is safe and effective. (5) The making of surgical knots in the cystic duct is easier and faster due to the reduced diameter of the material. (6) The monopolar electrocautery associated with the precision of the minilaparoscopy material presents safety standards similar to the bipolar electrocautery with laparoscopy instruments. (7) The minilaparoscopic instruments provide better visualization for tasks that require greater precision. (8) The removal of the gallbladder in a bag, such as a wrist glove or a manufactured one, is important not only to facilitate its extraction as to minimize trauma and to reduce risk of local infection or dissemination of cancer in cases of malignancy.

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The Utilization of Laparoscopy in Ventral Hernia Repair: An Update of Outcomes Analysis Using ACS-NSQIP Data Chetan Aher, MD, Shaun Daly, MD, Daniel J Deziel, MD, Keither W Millikan, MD, Jonathan A Myers, MD, Minh B Luu, MD Department of Surgery Rush University Medical Center

Age, Gender, and Vitamin D use Predict Regression of Barrett’s Esophagus —Results from a Retrospective Cohort of 2563 Patients Craig S Brown, Chi Wang, PhD, Jay L Goldstein, MD, John G Linn, MD, Ervin W Denham, MD, Stephen P Haggerty, MD, Mark S Talamonti, MD, John A Howington, MD, Michael B Ujiki, MD NorthShore University Health Systems, Pritzker School of Medicine at the University of Chicago

Introduction: Previous studies using ACS-NSQIP data demonstrated fewer complications associated with laparoscopic compared to open ventral hernia repair. Furthermore, the use of laparoscopy appeared to be low, accounting for only 17 % of ventral hernia repairs. We hypothesize that despite these reports demonstrating advantages of laparoscopic compared to open techniques, the utilization of laparoscopy continues to remain low. Methods: A retrospective review of the ACS-NSQIP database from 2009 to 2012 was conducted. All patients who underwent a laparoscopic or open hernia repair were included. The primary outcome was 30-day mortality. Secondary outcomes were associated 30-day morbidity that includes wound infections, respiratory complications, urinary tract infections, cardiac arrests requiring CPR, transfusions and sepsis. Data was evaluated with chi-squared analysis. Results: A total of 107,431 patients undergoing a ventral hernia repair were identified. Laparoscopy was performed in 23 % of the cases and open technique was performed in the remaining 77 %. Patients undergoing laparoscopic repair were more likely to have one or two operative risk factors, while patients undergoing open repair were more likely to have zero or four or more risk factors. Laparoscopy was associated with lower mortality (0.2 % vs 0.4 %, p = 0.001) and overall 30-day morbidity (4 % vs. 7.4 %, p \ 0.0001). There were fewer wound (1.38 % vs 4.33 %, p \ 0.0001) or respiratory (1.7 % vs 2.34 %, p \ 0.001) complications associated with laparoscopic repair, and transfusion (0.48 % vs 0.93 %, p \ 0.0001) and sepsis (0.55 % vs 0.89 %, p \ 0.0001) were both reduced with laparoscopy. Conclusion: According to the ACS-NSQIP database, utilization of laparoscopy to repair ventral hernias has risen only 6 % in recent years and remains low overall, despite decreased mortality and morbidity compared to the open technique. Whether this positive association is a function of laparoscopic procedure itself or a function of patient selection remains to be seen.

Introduction: Barrett’s esophagus is the most predictive risk factor for development of esophageal adenocarcinoma, a malignancy with the fastest increasing incidence rate in the US. Currently, there is a lack of consensus as to the proper management of patients who have a positive biopsy followed by a negative biopsy during a subsequent endoscopy. The aim of this study was to investigate the differences in exposures, demographics, and comorbidities between patients who regress and those who do not regress. Methods and Procedures: We retrospectively collected and analyzed data from a cohort of Barrett’s Esophagus patients participating in this single-center study comprised of all patients diagnosed with Barrett’s Esophagus at NorthShore University Health Systems hospitals and clinics over a 10 year period. Patients were followed in order to identify those progressing from Barrett’s Esophagus to high-grade dysplasia (HGD), esophageal adenocarcinoma (EAC), or those regressing to no Barrett’s. Mean follow up period was 5.4 years (9088 patient-years). We collected information from the patient’s electronic medical records regarding demographic data, endoscopic findings, histological findings, exposures, and history of antireflux surgery. Chi–squared and student’s t-tests were performed where appropriate. Results: This study included 2563 total Barrett’s esophagus patients, 473 of which had their Barrett’s esophagus regress (had a negative endoscopy confirmed by biopsy). The group that regressed was 53.1 % male, while the group that did not regress was 64.8 % male (p \ 0.0001). Mean age was 65.1 (± 13.6) and 61.8(± 13.2) years for non-regressing and regressing patients, respectively (p \ 0.0001). No difference was seen in BMI between groups, with non-regressing patients having a mean BMI of 28.04 ± 10.47 compared to regressing patients at 28.13 ± 12.70 (p = 0.88). No difference was seen between groups with respect to PPI use (91.1 % using for non-regressing patients vs 93.5 % using for regressed patients, p = 0.12). Interestingly, groups differed in their rates of vitamin D use, with regressing groups taking vitamin D more commonly (48.1 %) than those who did not regress (37.9 %) (p = 0.0001). As expected, groups differed with respect to their segment length at diagnosis. The group that regressed had an average segment length of 3.28 cm ± 3.07 cm, in contrast to the group that did not regress which had an average length of 1.46 cm ± 1.66 cm (p \ 0.0001). Interestingly, not a single patient in the regression group progressed to HGD/EAC, while 47 patients of the non-regressing patients in the cohort progressed to HGD/EAC, a result that was found to be independent of long segment vs. short segment on multivariate analysis (p = 0.029). Conclusions: Currently, several studies have shown risk factors that can predict progression from non-dysplastic Barrett’s esophagus to HGD/EAC, but few if any studies are available investigating predictors for regression. Our study reports several factors that can be used to predict patients who will regress from Barrett’s esophagus and those who likely will not, tools that will be useful in tailoring therapeutic and surveillance strategies.

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Preoperative Functional Health Status Predicts Outcomes After Elective Colorectal Surgery for Malignancy Nuri Okkabaz, MD, Jeffrey P Hammel, MS, Feza H Remzi, MD, Emre Gorgun, MD Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic

Quality Improvement Through Social Media: An Initial Look at The International Hernia Collaboration FacebookTM Group Patricia C Chui, MD, Brian P Jacob, MD Mount Sinai Medical Center, NYC

Background: The average life expectancy and number of elderly people has been increasing across the world. Age is a significant risk factor for colorectal cancer; thus, surgeons are commonly facing age-related perioperative difficulties while treating these patients. Accurate prediction of the risks for morbidity and mortality can help patients and physicians to have precise expectations; however, surgeons lack easily available bedside parameter. Hypothesis: Preoperative functional health status may help in predicting the risk of morbidity and mortality in the first appointment for the patients who are candidate for elective colorectal cancer surgery. Patients and Methods: all patients underwent colectomy for colorectal malignancy between 2006 and 2011 were included in the study with exemption of emergent colectomy and disseminated disease. Patients were classified as independent, partially dependent, and totally dependent as tracked in NSQIP database. Groups were compared in terms of preoperative risk factors and short term outcomes. A secondary comparison was performed after multivariate adjustment for age, wound class, ASA class, and work relative value units. Results: A total of 25,737 patients were identified: 24,246 (94.2 %) independent (IND), 1,307 (5.1 %) partially dependent (PDN), and 184 (0.7 %) totally dependent (TDN). Both PDN and TDN were older than IND and had more diabetes, chronic obstructive pulmonary disease, congestive heart failure and dialysis dependence (p \ .001). On the other hand, IND patients have had more radiotherapy before operation (p \ .001). Laparoscopic surgery was less commonly performed in TDN group (p \ .001). PDN patients had a higher incidence of all types of surgical site infections (SSI) (p \ .05) except organ/space SSI and stroke/CVA (p \ 0.001) compared to both IND and TDN. Both PDN and TDN patients had more respiratory problems (p \ .05), urinary problems (p \ .05), coma [ 24 h (p \ .001) and cardiovascular problems (p \ .05). Unplanned reoperation, length of postoperative stay (7.4 ± 6.4 vs. 11.4 ± 10.1 vs. 14.4 ± 13.9; p \ .001) and death [28 (15.2 %) vs. 109 (8.3 %) vs. 315 (1.3 %); p \ 0.001] were also more common in patients with partial or total dependency. After multivariate adjustment, patients with total dependency were found to have increased risk for most of the postoperative complications including pneumonia [odds ratio (OR) 2.53 (95 % confidence interval (CI) 1.56–4.10); p \ 0.001], unplanned reintubation [OR 2.84 (95 % CI, 1.77–4.54); p \ .001], acute renal failure [OR 4.00 (95 % CI 1.71–9.39); p = 0.001], septic shock [OR 4.04 (95 % CI 2.50–6.54); p \ .001] and cardiac arrest [OR 2.83 (95 % CI 1.20–6.67); p = .017]. Patients with total dependency also have an increased median incidence of death (12.3 %, 95 % confidence interval (CI):10.2 %–14.5 %: p \ 0.001) Conclusion: Patients with partial or total dependency in the activities of daily living have been observed to experience more frequent postoperative complications and death following elective colorectal surgery for malignancy. In the setting of major elective colorectal surgery for malignancy, functional health status may be helpful to predict high risk patients for postoperative complications.

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Introduction: The widespread accessibility to social media platforms, such as FacebookTM, affords all of the stakeholders interested in optimizing patient outcomes within a specific surgical discipline the extraordinary opportunity to participate in the rapid global exchange of education and ideas. Groups that promote the collaboration between professionals-to-professionals, professionals-topatients, professionals-to-students, and professionals-to-industry partners are equally effective in this process. Made up of surgeons, healthcare providers, and vetted medical device industry partners, The International Hernia Collaboration FacebookTM Group is a new example of a professional-to-professional-to-industry group where exchange of information is centered on the concept of improving patient outcomes. As its founders, we wanted to review the initial statistics and benefits surrounding its growth during the first 9 months of its use. Results: Since its inception in December 2012 with 9 members, the group has expanded to 302 members who have been individually vetted by the group’s board. Of these members, 102 are located outside of the United States and represent 36 individual countries, including but not limited to Saudi Arabia, Egypt, Algeria, Syria, Russia, Brazil, Japan, Colombia, Canada, Mexico, Guatemala, and Mauritius. 260 members are either surgeons or members of an academic institution (non-surgeon physicians, residents, and medical students), while 42 members work within industry. Of the nearly 200 different posts made to this forum since its creation, 40.9 % of the posts have involved discussions about unique case presentations; 39.8 % have sought technical expertise in some aspect of hernia repair; 10.2 % have involved questions about different types of mesh and other materials used in hernia repair; and 7.8 % discussed pain after hernia procedures. 27.3 % of the posts used de-identified images, including CT scans and videos, and 100 % of the posts are HIPAA compliant. Remarkably, the vast majority of the posts garnered a substantial number of responses from other members, ranging from 4 to 46 responses per post. Conclusions: Our initial review of The International Hernia Collaboration FacebookTM group demonstrates that social media can be used professionally as an extremely effective educational tool that provides rapid global collaboration with limitless possibilities, all designed to optimize patient care. Whether providing education to students and residents, market feedback to industry partners, tips and tricks to colleagues, referral or technical advice, or even second and third opinions, this group, and other groups like it, are revolutionizing the way the medical community collaborates. The growth of these types of surgical social media groups deserves careful and close attention in the coming years as they may very well replace the current methods used to disseminate and share information.

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Retention of Fundamentals of Laparoscopic Surgery (FLS) Proficiency with a Biannual Mandatory Training SESSION Lindsay Wenger, MD, Cory Richardson, MD, Shawn Tsuda, MD, FACS University of Nevada School of Medicine

Symptomatic and Physiologic Outcomes at One-Year After Peroral Esophageal Myotomy (POEM) Ezra N Teitelbaum, MD, Nathaniel J Soper, MD, Byron F Santos, MD, Fahd O Arafat, MD, John E Pandolfino, MD, Peter J Kahrilas, MD, Ikuo Hirano, MD, Eric S Hungness, MD Northwestern University Feinberg School of Medicine

Introduction: The Fundamentals of Laparoscopic Surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in 1997 with the goal of teaching surgeons the fundamental knowledge, judgment, and technical skills specific to laparoscopic surgery. This single academic institution observational study aimed to assess the effectiveness of a biannual FLS training curriculum on PGY 1–5 proficiency levels, with a focus on a single FLS task (PEG transfer). Previous studies have shown that obtaining expert FLS proficiency correlates with retaining this proficiency in the future. Methods and Materials: PGY 1–5 residents (n = 17) at an academic general surgery residency program performed two separate timed PEG transfer tasks biannually. Participants were monitored by FLS certified examiners and standard FLS instructions, rules, and time penalties applied. Residents were expected to meet or exceed standards set by SAGES and FLS in consecutive timed PEG transfer trials (proficiency time: 48 s). Results: Seventeen residents participated in the study ranging from PGY 1–5. Participants showed proficiency if they could complete the PEG transfer task in less than 48 seconds on two consecutive trials. None of the PGY-1 or PGY-2 residents completed two consecutive trials within the stated proficiency time during the one hour session, while 100 % of the PGY 3–5 residents showed proficiency in the PEG transfer task. No participant of any PGY level went over the time limit of 300 seconds. Conclusion: A biannual training session for FLS retains expert proficiency by PGY levels 3–5. Previous reports from our institution demonstrated that 95 % of the residents did not practice this task between mandatory biannual sessions. This suggests that in combination with standard residency training, a biannual FLS proficiency based sessions confers retained expert skills by PGY 3–5. As the FLS certification exam is generally taken by PGY 4 and 5 residents and is now a requirement for board certification, general surgery residents that participate in biannual training sessions will likely retain expert proficiency and achieve FLS certification.

Introduction: Peroral endoscopic myotomy (POEM) is a novel surgical operation for the treatment of achalasia. Here we analyze symptomatic and physiologic outcomes at one-year follow-up from a single-institution POEM series. Methods: Patients underwent preoperative high-resolution manometry (HRM), upper endoscopy, and timed barium esophagram (TBE). IRB-approved eligibility criteria for POEM included a diagnosis of achalasia, age C18 years, and a non-sigmoid esophagus. Routine early follow-up HRM and TBE were performed at 2 months. At 12 months, patients were encouraged to undergo routine repeat HRM, TBE, as well as upper endoscopy and 24-h pH monitoring off anti-secretory medication. Patients were contacted to obtain current Eckardt and GerdQ symptom scores. Only patients further than one year removed from surgery were included in this analysis. Results: Twenty-seven patients underwent POEM and were further than one year from their procedure. Seven (26 %) patients were female, mean age was 42 ± 14 years, and 3 (11 %) had undergone prior endoscopic treatment. One major (Grade IIIb) complication occurred: a contained perforation at the EGJ that required a take-back laparoscopy for drainage. Four (15 %) minor (Grade I) complications occurred. Median length of stay was 1 day (range 1–13). Current symptomatic follow-up was available for 24 patients at a mean of 16 months postoperatively. Mean Eckardt scores decreased from preoperatively (7.5 ± 2.1 vs. 1.5 ± 2.1, scale 0–12, p \ 0.001), with a 92 % treatment success rate (i.e. Eckardt\4). The two treatment failures (the first and third patients in the series) underwent reoperation with laparoscopic Heller myotomy and had subsequent symptom resolution. 6 (22 %) patients had a GerdQ [7, indicating symptoms of gastroesophageal reflux. 19 patients underwent early follow-up HRM at 2 months and 12 had repeat HRM at a mean of 15 months postoperatively. EGJ relaxation pressures were decreased from preoperatively at both postoperative time points, and there was no difference between the early and late postoperative studies (pre-op: 28.3 ± 12 mmHg vs. early postop: 10.4 ± 2.9 mmHg vs. late post-op: 10.9 ± 3.5 mmHg, p \ 0.001 pre vs. both post-op, p = ns early vs. late post-op). 15 patients underwent TBE at 2 months and 11 had repeat TBE at a mean of 12 months. Contrast column height at 5 min post-swallow decreased from preoperatively at both postoperative time points, and there was no difference between the early and late studies (preop: 15.3 ± 7.5 cm vs. early: 3 ± 3.8 cm vs. late: 4.7 ± 3.7 cm, p \ 0.01 pre vs. both post-op, p = ns early vs. late post-op). On follow-up upper endoscopy (n = 14, mean 14 months post-op) esophagitis was present in 8 (57 %) patients (all LA grade A) and 6 (43 %) had retained clips from POEM. On follow-up 24-hour pH monitoring (n = 7, mean 12 months post-op) esophageal acid exposure (pH \ 4) occurred a mean 1.5 ± 2.3 % of the study period, resulting in a mean DeMeester score of 5.4 ± 6.7. One (14 %) patient had abnormal esophageal acid exposure (i.e. time [4.2 %). Conclusions: In this series, POEM resulted in symptom resolution in over 90 % of patients with a sustained improvement in EGJ physiology at one-year follow-up. Esophageal acid exposure after POEM may be less than previously reported.

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A Systematic Review of Synthetic and Biologic Materials For Abdominal Wall Reinforcement in Contaminated Fields Lawrence Lee, MD, MSc, Juan Mata, MD, Tara Landry, MLIS, Kosar A Khwaja, MD, MBA, Melina C Vassiliou, MD, MEd, Gerald M Fried, MD, Liane S Feldman, MD McGill University Health Centre

Does Simulation Improve Learning of The Fundamental Use of Surgical EnergyTM (FUSE) Curriculum? A RandomizedControlled Trial in Surgical Trainees A Madani, MD, Y Watanabe, MD, Mc Vassiliou, MD, P Fuchshuber, MD, Db Jones, MD, S Schwaitzberg, MD, Gm Fried, MD, Ls Feldman, MD McGill University, Montreal, Canada; Kaiser Medical Center, Walnut Creek, CA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; Cambridge Health Alliance, Cambridge, MA, USA

Introduction: Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields. Methods and Procedures: A systematic literature search (Medline, Embase, Biosis Previews, Cochrane, Scopus and Web of Science databases, in addition to grey literature) identified all articles published up to April 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias), and reported outcomes specifically in contaminated fields. Quality assessment was performed using the MINORS instrument. Two authors independently screened all citations, reviewed relevant full-text articles and extracted data. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Secondary outcomes included incidence of prosthetic explantation and enterocutaneous fistula formation. Weighted pooled proportions were calculated using a random effects model. Results: A total of 2032 unique citations were identified, out of which 32 studies met the inclusion criteria and were included for synthesis (bioprosthetics: 18 studies; synthetic non-absorbable: 12; both 2). Mean sample size was 41.4 (range 10–190), and duration of follow-up was [1 year in 72 % of studies. Overall quality was low (mean 6.2, range 1–12). Pooled wound infection rates were 31.6 % (95 % CI 14.5–48.7) with biologic and 6.4 % (95 % CI 3.4–9.4) with synthetic non-absorbable prosthetics in cleancontaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2 % (95 % CI 9.5–44.9) with biologic and 3.2 % (95 % CI 0.0–11.0) with synthetic non-absorbable prosthetics. Other outcomes were comparable. In subgroup analyses, there were no differences in wound infection or hernia at follow-up for different synthetic non-absorbable (coated polypropylene (PP), heavyweight PP, lightweight PP) or biologic (human dermis, porcine dermis, porcine small intestine submucosa) in clean-contaminated, or contaminated and/or dirty fields.

Conclusions: The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.

Introduction: While energy devices are ubiquitous in the operating room, they remain poorly understood and can result in significant complications. The Fundamental Use of Surgical EnergyTM (FUSE) program was created to address this safety gap. The purpose of this study was to investigate, in surgical trainees, the effectiveness of the FUSE curriculum for electrosurgical training and estimate the extent to which the addition of a novel simulation-based component improves educational outcomes. Methods and Procedures: First and second year surgical residents participated in a 1-hour didactic electrosurgery (ES) course, based on the FUSE curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed simulation training session (Sim group). The one-hour simulation session included four bench-top modules designed to teach the safe use of ES devices. Pre- and post-curriculum knowledge of the safe use of ES was assessed using separate 35-item multiple-choice examinations. Self-perceived competence with each course objective and comfort with the performance of 7 tasks related to the safe use of ES were measured using Likert scale questionnaires. Data are expressed as median (interquartile range). Mann–Whitney-U test determined significance (p \ 0.05). Institutional ethics approval was obtained. Results: Fifty-six (29 control; 27 Sim) surgical trainees completed the curriculum (median age 27; 64 % male). Baseline characteristics, including pre-curriculum exam and questionnaire scores, were similar between the two groups. Total score on the exam improved from 46 % (40–54 %) to 84 % (77–91 %), p \ 0.0001 for the entire cohort, with higher post-curriculum scores in the Sim group compared to controls (89 % (83–94 %) vs 83 % (71–86 %), p = 0.02). This difference was due to better performance for the Sim group on the exam sections ‘‘Principles of Electrosurgery’’ (91 % (86–100 %) vs 82 % (73–91 %), p = 0.004) and ‘‘Electrosurgery-Related Adverse Events’’ (86 % (82–93 %) vs 71 % (64–86 %), p \ 0.0001). On the pre-curriculum questionnaires, participants in both groups reported feeling ‘‘Uncomfortable’’ for all 7 tasks or ‘‘Not Competent’’ with most of the 35 course objectives (Sim: 33/35 objectives; control: 31/35 objectives). Post-curriculum, the majority of participants felt either ‘‘Comfortable’’ or ‘‘Very Comfortable’’ for all 7 tasks, and either ‘‘Partially Competent’’ or ‘‘Fully Competent’’ for all 35 objectives. A higher proportion of the Sim group felt ‘‘Very Comfortable’’ or ‘‘Fully Competent’’ (Sim: 3/7 tasks and 28/35 objectives; control: 0/7 tasks and 10/35 objectives). Conclusion: A 2-hour curriculum based on the FUSE program improved surgical trainees’ knowledge and comfort in the safe use of electrosurgical devices. The addition of a structured interactive bench-top simulation curriculum further improved learning.

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Factors Leading to a Higher Conversion Rate After Laparoscopic Rectal Cancer Surgery and its Impact on Morbidity and Mortality Mhgm van der Pas, MD, Gsa Abis, MD, Es de Lange, PhD, Ma Cuesta, PhD, Hj Bonjer, PhD Color Ii Studygroup, Department of Surgery, Maastricht university Medical Center, the Netherlands and Department of Surgery, VU University Medical Center Amsterdam, The Netherlands

Hypnosis Induced Mental Training Improves Performance on The Fundamentals of Laparoscopic Surgery Simulator Gideon Sroka, MD, MSc, Monica Laniado, MD, Zahi Arnon, PhD, Elad Schief, MD, Ibrahim Matter, MD Department of General Surgery1, Complementary & Alternative Medicine Services2 Bnai-Zion Medical Center, Haifa, Israel

Background: Since the first reports on laparoscopic total mesorectal excision for rectal cancer, different factors influencing conversion rate have been suggested. Incidence, predictive factors, mortality and morbidity of conversion in the Colorectal cancer Laparoscopic or Open Resection COLOR II) trial are presented. Methods and procedures: Between January 20, 2004 and May 4, 2010, 1044 patients were enrolled in the COLOR II trial, comparing laparoscopic and open surgery for rectal cancer. Six hundred and ninety-nine patients were allocated to laparoscopic surgery. A total of 693 patients actual received laparoscopic surgery. Analysis was by treatment received. One hundred and fourteen (16 %) of 693 patients were converted to open surgery. Predictive factors were studied using multivariate analyses. Morbidity and mortality between patients needing conversion and patients who had planned open or laparoscopic surgery were compared. Results: Factors which were correlated with intraoperative conversion are: age above 65 years (OR 1.9; 95 % CI 1.2–3.0, p = 0.003), BMI [25 (OR 2.7; 95 % CI 1.7–4.3, p \ 0.001) and tumor location 5–10 cm from the anal verge (OR 2.1; 95 % CI 1.2–3.7, p = 0.020) and 10–15 cm (OR 2.0; 95 % CI 1.1–3.5, p = 0.008) compared to tumors located \5 cm from the anal verge. Gender was not significantly related to the need for conversion (p = 0.143). Conversion was associated with more blood loss (p \ 0.001) and prolonged operating times (p = 0.028) when compared to the non-converted laparoscopic group. No significant difference in hospital stay was shown between laparoscopic and converted patients (p = 0.063). Patients needing conversion had more postoperative complications compared to laparoscopic surgery and open surgery (p = 0.041 and p = 0.042 respectively). Mortality was comparable in both groups. Conclusions: Patients over 65 years of age with a BMI [25 and a tumor located between 5–15 cm from the anal verge are more likely to need intraoperative conversion reducing the benefits of laparoscopic surgery. After conversion, patients show a significantly higher postoperative complication rate. Colorectal cancer Laparoscopic or Open Resection II (COLOR II) study group: Andre´ D’Hoore, Dan Birch, Chris DeGara, Jaap Bonjer, Chris Jamieson, Poornoroozy Peiman, Karl Juul Jensen, Orhan Bulut, Per Jess, Jacob Rosenberg, Thomas Harvald, Henrik Ovesen, Eskilde Lundhus, Igors Iesalnieks and Ayman Agha, Christina Jaeger, Martin Kreis, Michael Kasparek, Alois Fuerst, Gudrun Liebig-Hoerl, Seon Hahn Kim, Donald van der Peet, Miguel Cuesta, Martijn van der Pas, Mark Buunen, Peter Neijenhuis, Peter Paul Coene, Edwin van der Harst, Yvonne van Riet, Willem Bemelman, Michael Gerhards, Hubert Prins, Eduardo Targarona, Carmen Balague, Carmen Martinez, Juan Franco Osorio, Garcı´a Molina, Antonio Lacy, Salvadora Delgado, Juan Lujan, Graciela Valero, Alfredo Alonso-Poza, Manual Losadar, Salvador Argudo, Hospital del Sureste de Madrid, Zoltan Lackberg, Stefan Skullman, Goran Kurlberg, Eva Haglind, Ulf Kressner, Peter Matthiessen.

Methods: 10 surgeons who completed proficiency based training program on the Fundamentals of Laparosopic Surgery (FLS) simulator, reached their plateau performance of the peg transfer task. They were exposed to music session as a relaxing intervention, then performed the task. Following a washout period they went through a hypnosis session guided by an experienced psychologist, with a suggestion of smooth flow of pegs from one position on the board to another, and re-performed the task. Results: plateau performance was 51.6 ± 8.3 s. After the music session performance improved by 5.9 % to 48.3 ± 6.4 s. (p = 0.03). After the mental training session performance further improved by 12.8 % to 42 ± 6 s. (p = 0.001), which was 18.2 % improvement from plateau (p = 0.0007). Subject’s satisfaction from performance was 4.3 ± 2.3 on 1–10 VAS after the music, and reached as high as 8.7 ± 0.7 after the mental training session. Conclusions: mental training significantly improves performance on the FLS simulator, which can not be attributed to its relaxing qualities alone. This study contributes evidence to the effectiveness of mental training in surgical skills acquisition. There is a need to further study its effect on operating room performance.

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Comparison of Long-Term Mortality ([8 years) of 7,862 Bariatric Patients to the General Population in New York State Dana A Telem, MD, Maria Altieri, MD, Jie Yang, PhD, Qiao Zhang, MS, Wendy L Patterson, MPH, Brittany D Peoples, MS, Gerald Gracia, MD, A. Laurie Shroyer, PhD, MSHA, Aurora D Pryor, MD Stony Brook Medicine, New York State Department of Health Office of Quality and Patient Safety

Differences in Gaze Behaviour of Expert And Novice Surgeons Performing Open Inguinal Hernia Repair Tony Tien, Philip Pucher, Mikael Sodergren, Kumuthan Sriskandarajah, Guang-Zhong Yang, Ara Darzi Imperial College London Department of Surgery and Cancer at St. Mary’s Hospital

Introduction: Obesity is a well-established risk factor for mortality. Sparse data is available on long-term patient mortality following bariatric surgery compared to the US general population. The purpose of this study is to assess patient long-term mortality rates and risk factors for all-cause mortality following the 3 most commonly performed bariatric procedures: laparoscopic Roux-enY gastric bypass, laparoscopic adjustable gastric band (AGB), and laparoscopic sleeve gastrectomy (SG). Methods: Following IRB approval, New York Statewide Planning and Research Cooperative System (SPARCS) administrative data was used to identify 7,862 adult patients who underwent bariatric surgery from 1999–2005. SPARCS is a comprehensive data reporting system which collects patient-level risk characteristics, treatments, and outcomes for all New York State (NYS) hospital discharges. Bariatric surgery was identified by discharges with a primary diagnosis of overweight or obesity and a primary procedure code for RYGB, AGB, or SG. For study records, the Social Security Death Index database was used to identify post-hospital mortalities through July 2013. Risk factors for mortality were univariately screened using a Cox proportional hazard (PH) model and analyzed using a multiple PH model. Based on age, gender, and race/ethnicity, actuarial projections for mortality rates in the general population were compared to the actual post-bariatric surgery mortality rates observed. For this study, the actuarial NYS death rates were obtained from Centers of Disease Control’s annual reports published through 2010; with actuarial projections for 2011-July 2013 based on the 2010 report. Results: Of the 7,862 obese patients evaluated, the average post-surgery mortality rate was 2.5 % with 8–14 years of follow-up. Mortality rates declined from 4–7 % for the period from 1999–2002 to 1.4–2.9 % for 2003–2005. Mean time to death following a bariatric procedure ranged from 4–6 year and did not differ between operations (p = 0.073). From 1999–2010, the actuarial mortality rate predicted was 2.21 % versus the observed 1.5 % for the bariatric population. Extrapolating actuarial projections to 2013, demonstrated the actuarial mortality predictions for the general NY State population at 3.2 % versus the bariatric surgery patients’ observed morality rate of 2.5 %. No difference in the risk of long-term mortality was observed among different operative procedures or for 30-day operative complications. Significant risk factors for mortality following multiple PH regression analysis included (hazard ration(HR) with 95 % confidence interval): Male gender (HR 2.2[1.6–3.0], p \ 0.001), Medicare (HR 2.49[1.65–3.77], p \ 0.0001), Medicaid (HR 2.85[1.71–4.76], p \ 0.0001), congestive heart failure (HR 3.2[2.0–4.9], p \ 0.0001), rheumatoid arthritis (HR 1.9[1.0–3.4], p = 0.03), chronic pulmonary disease (HR 1.7[1.3–2.3], p = 0.0007) and diabetes (HR 1.44 [1.2–2.0], p = 0.02). Conclusion: Long-term mortality rate following bariatric surgery normalizes to the actuarial rates predicted for the general population. This result did not vary by procedure choice. Additionally, perioperative complications do not increase the risk of longterm mortality. This study did identify specific patient risk factors for long-term mortality. Risk factors included: male gender, Medicaid/Medicare as primary insurance and presence of comorbidities including congestive heart failure, chronic pulmonary disease, rheumatoid arthritis and diabetes. Special attention and consideration should be given to these ‘‘at risk’’ patient subpopulations.

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Background: mental training is used extensively by musicians and athletes to improve their performance. Recently it has been suggested as a training method for surgical trainees. We assessed the influence of mental training, induced by hypnosis, on the performance of simulated task on a laparoscopic simulator, as compared to non-specific relaxing intervention.

Introduction: Gaze behaviour has been used in allied fields in the evaluation of task proficiency. Such differences may be identified in surgery for the assessment of technical skill, particularly in the context of certification and patient safety. Furthermore, understanding the underlying reasons of certain behavioural patterns may have implications for education and training. The aim of this study was to assess differences in gaze behaviour of expert and novice surgeons during open inguinal hernia repair. Method: Gaze behaviour of expert and novice surgeons (stratified according to operative experience) performing open inguinal hernia repairs was recorded using portable, wearable eye tracking glasses (SMI Eye Tracking Glasses 2.0, SensoMotoric Instruments, Germany). Primary endpoints were fixation frequency and dwell time and procedures were segmented into standardized operative steps. Gaze metrics were analysed for designated areas of interest in the subject’s visual field: operative site, sterile field, scrub nurse and operating theatre. Task load was assessed by the National Aeronautics and Space Administration Task Load Index (NASA TLX). Results: Thirteen open inguinal hernia repairs were collected in total resulting in 630 min of video being analysed. Assessing steps of the procedure least affected by patient-dependent anatomical variance, expert surgeons demonstrated both higher fixation frequency (0.81 [IQR 0.40] vs 0.59 [IQR 0.36]; p = 0.006) and dwell time on the operative site during application of mesh (792.1 s [IQR 169.5 s] vs 469.3 s [IQR 108.4 s]; p = 0.028), closure of the external oblique (1.79 [IQR 0.27] vs 1.20 [IQR 0.58]; p = 0.003) (625.2 s [IQR 153.7 s] vs 469.3 s [IQR 108.4 s]; p = 0.032) and dwelled more on the sterile field during cutting of mesh (716.1 [IQR 173.4] vs 267.5 [IQR 296.5]; p = 0.019). Expert surgeons found open inguinal hernia repairs less mentally demanding than novices (3 [IQR 2] and 12 [IQR 5.25]; p = 0.038). Conclusion: Differences in gaze behaviour during open inguinal hernia repair can be seen between expert and novice surgeons, and may in future be used in skills assessment. Observed differences in behaviour is likely due to automaticity and proficiency developed through practice. Based on these data, alternative teaching strategies such as instrument requirements per surgical step may be deployed to accelerate the learning curve of novices. Additional procedures should be evaluated to further validate eye tracking in surgical skill assessment.

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Camera Navigation and Cannulation: Validity Evidence for 2 New Tasks Y Watanabe, MD, E Bilgic, E M Ritter, MD, S Schwaitzberg, MD, P A Kaneva, MSc, K I Hoffman, PhD, J R Korndorffer, MD, D J Scott, MD, A Okrainec, MD, M T Odonnell, MD, L S Feldman, MD, G M Fried, MD, M C Vassiliou, MD McGill University Health Centre, Tulane University, Uniformed Services University/Walter Reed Medical Simulation Center, University of Southern California, University of Texas Southwestern Medical Center, University of Toronto

Validation of a Novel, Low-Cost Simulator for Laparoscopic Hiatal Hernia Repair And Fundoplication J Babowice, P Suarez, W Denham, J Linn, S Haggerty, R Tanaka, M Gitelis, J Carbray, M Ujiki NorthShore University Health System

Introduction: The Fundamentals of Laparoscopic Surgery (FLS) manual skills program consists of 5 tasks. Experts identified camera navigation and cannulation as important skills that are neither taught nor assessed with FLS. The purpose of this multicenter study was to provide validity evidence for camera navigation and cannulation tasks and to explore the value of adding these new tasks to the FLS program. Methods: Participants from 5 North American centers completed the camera navigation (N), cannulation (C), and five FLS tasks. They also completed a questionnaire about the educational value of the new skills. Two raters scored the new tasks at each institution, and an FLS certified proctor scored the other tasks. For N, participants were required to acquire and take a snapshot of 6 targets using a 30 degree simulated scope; accuracy was assessed at a single site based on photos. For the C task, participants were timed while introducing a catheter into a simulated duct from 3 different positions. Validity was assessed by comparing performance between Novice (PGY1 and 2) and Experienced (PGY3 and higher) participants and correlating scores on the new tasks with total FLS scores. Multiple regression analysis was conducted to evaluate the predictive validity of surgical experience. Internal consistency was assessed using Cronbach’s alpha. Intra class correlation coefficients (ICCs) were calculated to assess inter-rater reliability. Results: Sixty subjects (45 surgical residents, 4 fellows, 11 attending surgeons) participated. Fifty-five (92 %) participants had experience using a laparoscope and 32 (53 %) participants had never performed intraoperative cholangiogram (IOC) in practice. Novice and Experienced participants scored 74 ± 17.8 vs 85 ± 8.3 (p \ 0.01) and 21 ± 17.3 vs 39 ± 20.1 (p \ 0.01) on N and C tasks respectively. Correlation with FLS scores for the N and C tasks were .39, p \ 0.01 and .53, p \ 0.01 respectively. Regression analysis revealed that FLS score alone predicted 45 % of the training level variance (R2 = .45, p \ 0.01) which rose by 2 % when the 2 new tasks were added. Internal consistency of the five FLS tasks was .802; internal consistency adding N was .783, adding C was .796 and adding both new tasks was .785. Inter-rater reliability for both N and C was .99. Of 55 participants with scope experience, 51 % reported N to be similar in difficulty to reality, and 67 % of participants thought N added value to the FLS program. Of 28 participants who performed IOC, 25 % reported C as similar in difficulty to practice, and around 65 % thought it added value to FLS program. Conclusions: This study provides validity evidence for the metrics of both camera navigation and cannulation. Participants found the new tasks to add educational value to the FLS program. They measure important clinical skills that are not currently represented in FLS and have excellent inter-rater reliability. However, the benefit of adding these tasks to the FLS manual skills assessment is marginal in terms of predicting experience level.

Background: Laparoscopic simulation has become a widely accepted methodology in surgical training; however, few procedure specific training models have been developed and validated. The purpose of this study was to develop and validate a training model specific to hiatal hernia repair and fundoplication (HHRaF), including the initiation of a standardized scoring rubric for evaluation. Methods: A reproduction of correctable human hiatal hernia anatomy was assembled for use with laparoscopic tools and training video towers. A group of five novice (students), ten intermediate (senior residents), and five expert (attending foregut surgeons) participants were videotaped and assessed in HHRaF proficiency using the simulator by a team of blinded, expert surgeon video reviewers. A standardized HHRaF scoring rubric adapted from the Global Operative Assessment of Laparoscopic Skills was created. Results: Participants were assessed on their ability to properly communicate equipment needs, use equipment correctly, suture close the hiatus, perform a fundoplication, and manipulate instruments. Expert group participants performed significantly better than intermediate and novice group participants in every scoring category and required significantly less time to complete the procedure (p = 0.007). Intermediate group members performed significantly better than novices in communicating equipment needs (p \ 0.05), correct use of equipment (p = 0.02), and instrument manipulation (p = 0.02), but not hiatus closure or fundoplication. Inter-rater reliability using the scoring rubric was [0.72 for all scoring items and internal consistency of scoring items was 0.95. All three participant groups objectively reported the model to be an effective training tool and video reviewers objectively reported it to be an effective teaching tool. Conclusion: The hiatal hernia and fundoplication simulation model is an effective training and evaluation tool and its partner scoring rubric is a reliable and valid measure of HHRaF specific knowledge and skills.

S040 The Successful Development And Implementation af a Novel, Biliary Surgical Simulation Pathway Training Curriculum Joseph M Buchholz, BS, Charles M Vollmer, MD, Kiyoyuki W Miyasaka, MD, Denise LaMarra, MS, Noel N Williams, MB, BCh, MCh, FRCSI, FRCS, Jon B Morris, MD, Rajesh Aggarwal, MD, PhD, MA, FRCS Perelman School of Medicine at the University of Pennsylvania Introduction: Traditionally, the function of simulation in surgical education is to provide instruction in procedural tasks and technical skills. Recently, the importance of instruction in nontechnical areas, such as communication and teamwork, was realized and these elements need to be integrated into surgical simulation training programs. On rotation, the surgical resident requires proficiency in both technical and nontechnical skills in order to prevent adverse events through the entire patient care pathway: pre-op, intra-op, and post-op. We designed and implemented a PGY-1 surgical simulation training curriculum targeting these skills throughout an elective surgical procedure pathway focused on biliary disease. Methods: The implementation of a biliary surgical simulation curriculum was done in such a manner that summative pathway sessions were completed at the start and conclusion of the training module. These sessions provide proficiency assessments of resident performance across the entire biliary care pathway before and after simulation training. Each resident completed a pre-op, intra-op, and post-op scenario, sequentially, during each pathway session. The preop and post-op scenarios required the resident to interact with a standardized patient (SP) presenting either with choledocholithiasis (pre-op) or normal post-op course after a laparoscopic cholecystectomy (post-op). The intra-op session was held in a simulated operating room where the resident completed a laparoscopic cholecystectomy. The OR was complete with a confederate scrub tech, a confederate anesthesiologist, and a porcine liver/gallbladder model. This training session required the resident to follow the same patient through the entire pathway of care. Faculty assessments, resident self-assessments, and SP assessments of resident performance were collected for every pathway scenario. All performance evaluation tools used were standardized operative or clinical assessment forms approved by the American Board of Surgery. With summative pathway sessions at the front and back-end of the training module, the rest of the module was comprised of formative sessions with a biliary disease focus. These formative sessions were made up of hands-on sessions, didactic lectures, and standardized patient encounters. Surgical residents were removed from hospital service for the entirety of the simulation-training curriculum allowing them to focus all efforts on learning activities. Results: Preliminary data has been collected for the first five surgical interns to undergo this novel simulation training method. Faculty ratings indicated that resident performance improved in every single category evaluated during the pathway. Mean overall improvements for each scenario were (before training to after training): Pre-op 3.4 to 4.6 (out of 5); Intra-op 1.5 to 4.0 (out of 5); Post-op 6.2 to 7.6 (out of 9). The resident self-assessments also showed improvements: Pre-op 3.0 to 4.0; Intra-op 1.0 to 2.6; Post-op 5.6 to 7.4. Conclusion: It is imperative that surgical residents undergo simulation training directly linked to their hospital responsibilities so as to provide immediate performance improvement and reduce errors in the clinical environment. This pathway simulation training curriculum for biliary disease has successfully accomplished this and shows an improvement in intern performance across the entire pre-op, intra-op, and post-op surgical care pathway. These results support the continued use of this novel and innovative simulation educational concept.

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FLS Skill Acquisition: A Comparison of Blocked versus Interleaved Practice Steven B Goldin, MD, PhD, Gregory T Horn, BA, Michael J Schnaus, BA, Mark Grichanik, BA, Adam Ducey, BA, Charles Nofsinger, MD, David Hernandez, MD, Murray Shames, MD, Mark Zakaria, MD, Michael T Brannick, PhD University of South Florida

Construct Validity And Possible Educational Role For Motion Analysis In A Laparoscopic Trainer Maeve O’Neill Trudeau, MD, Ahmed Nasr, MD, FRCSC, Brian Carrillo, PhD, J. Ted Gerstle, MD, FRCSC, FACS, FAAP, Georges Azzie, MD, FRCSC Dept of Surgery, University of Toronto, Toronto ON Canada. Centre for Image Guided Innovation & Therapeutic Intervention, Hospital for Sick Children, Toronto. Dept of Surgery, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa ON Canada

Introduction: Fundamentals of laparoscopic surgery (FLS) certification is required for general surgery. FLS training requires a significant time commitment from residents to master the FLS skills. The recommended practice for learning FLS, as stated on the FLS website and in other papers, is to practice tasks one at a time until proficient (blocked practice). Learning theory suggests that interleaved practice, a method in which tasks are rotated rather than learned one at a time, may result in superior learning. Method: Residents in general surgery, orthopedic surgery, and OB/GYN at USF Morsani College of Medicine were randomized into one of two groups: blocked practice (with a pattern of practice of AABBCCDD) or interleaved practice (with a pattern of practice of ABCDABCD). We compared the performance of residents across groups over 20 trials of each of four FLS tasks (peg transfer, pattern cut, extracorporeal suture, intracorporeal suture). Four weeks later, participants returned to the lab and completed two additional trials of each of the four tasks, in order to assess for longer-term retention of skill. Results: Performance on each of the tasks, as measured by time to complete a task, improved with increased practice. The interleaved group showed significantly better performance during the learning process, and it showed better performance (but not always significantly so) on retention (Figs. 1, 2, 3, 4). Standardized mean differences in favor of the interleaved group were substantial both at the end of practice and at follow-up (Table 1). Conclusion: Interleaved practice appears to have advantages over blocked practice in developing and retaining FLS skills. Furthermore, in 3 out of 4 of the tasks (peg transfer, extra corporeal, and intracorporeal suturing), the mean retention of skill for the interleaved group was below the mean pass score of PGY-5 residents who passed the FLS exam in 2009–2010. Retention of skill was above the mean for the block group in all 4 tasks. These findings all point to a benefit of interleaved practicing over blocked practice when it comes to FLS preparation. We encourage others to experiment with the method to confirm our findings.

Introduction: Laparoscopic models for ex vivo upskilling are becoming increasingly important components of surgical education. This study aims to establish the construct validity and possible educational role of a new, low-cost laparoscopic box trainer program equipped with motion sensors at the trocar insertion ports. Methods and Procedures: The simulator was fitted with custom-built motion tracking hardware and software. Participants were recruited at the Education Booth of the 2012 combined SAGES/IPEG meeting, and were stratified into novice, intermediate and expert groups. They were asked to perform a defined intra-corporeal suturing task. Velocity, acceleration and range were studied in all degrees of freedom available during laparoscopic surgery (Pitch, Yaw, Roll and Surge). Results: We had a total of 64 participants (14 novices, 19 intermediates and 31 experts). Our laparoscopic simulator was able to discriminate between levels of expertise in the four degrees of freedom using the velocity and acceleration (see table below) but not using the range.

Standardized mean difference (d) values comparing blocked and interleaved groups on final two (19,20) and follow-up (21,22) trials

Task

Trials 19,20

Trials 21,22

Peg Transfer

12.28

0.99

Pattern Cut

1.36

0.22

Extracorporeal Suture

2.14

0.95

1.95

0.88

Intracorporeal Suture

Intermediate (N = 19)

Expert (N = 31)

mean ± SD

mean ± SD

mean ± SD

P value

83.3 ± 58.2

36.1 ± 26.7

19.1 ± 12.7

\0.0001

138.7 ± 78.1

63.1 ± 44.1

35.7 ± 22.2

\0.0001

PITCH Velocity [2SD

Table 1

Novice (N = 14)

Acceleration [2SD YAW Velocity [2SD

90.6 ± 48.6

48.4 ± 32.6

25.5 ± 14.6

\0.0001

Acceleration [2SD

151.3 ± 77.3

85.6 ± 55.1

49.4 ± 26.8

\0.0001

Velocity [2SD

26.5 ± 20.4

11.4 ± 11.6

5.7 ± 5.7

\0.0001

Acceleration [2SD

49.9 ± 36.8

18.3 ± 18.8

9.5 ± 12.0

\0.0001

ROLL

SURGE Velocity [2SD

44.7 ± 24.3

22.7 ± 24.0

11.5 ± 11.7

\0.0001

Acceleration [2SD

71.1 ± 44.9

36.7 ± 43.1

15.6 ± 16.4

\0.0001

Conclusion: Motion tracking analysis enabled us to significantly discriminate between novices, intermediates and experts. The system’s relatively simple technology and low cost may enhance its dissemination and use. This technology may be adapted to create a real-time motion feedback system that can be used for teaching and assessment of MAS skills.

Fig. 1 Peg Transfer

Fig. 2 Pattern Cut

Fig. 3 Extracorporeal Suture

Fig. 4 Intracorporeal Suture

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Comparison of Clinical Outcomes of Laparoscopic Cholecystectomy Done with Surgical Energy Versus Done Without Surgical Energy: A Prospective Randomized Control Study Brij B Agarwal, MD, Karan Goyal, MBBS, Nayan Agarwal, Krishna A Agarwal, MBBS, MK Gupta, Sheikh M Mustafa, Himanshu Pandey, Satish Saluja, MD Ganga Ram Institute for Post-Graduate Medical Education & Research, Sir Ganga Ram Hospital, University College of Medical Sciences, Vardhaman Mahavir Medical College & Dr. Agarwal’s Surgery, New Delhi, India

Hospital Acquired Conditions After Bariatric Surgery: We Can Predict, But Can We Prevent? Anne O Lidor, MD, MPH, Miloslawa Stem, MS, Erin Moran-Atkin, MD, Thomas H Magnuson, MD, Kimberley E Steele, MD, Hien Nguyen, MD, Michael A Schweitzer, MD Department of Surgery, Johns Hopkins University School of Medicine

Introduction: This study was undertaken to compare the clinical outcomes of laparoscopic cholecystectomy (LC) done by either using surgical energy i.e. energized dissection (ED) or without using surgical energy i.e. by cold dissection (CD) . Methods and Procedures: A prospective randomized control study (September 2008–June 2013) of consecutive unselected consenting candidates for LC performed on index hospitalization without any exclusion (except uncorrected coagulopathy & unfitness for general anaesthesia). The study population was randomized into ‘Control Group’ (LC with ED) and ‘Study Group’ (LC with CD). A standard perioperative clinical management protocol/ pathway for day care LC was followed. Standard technique of LC for the control group (ED) and our published technique of LC with CD for the study group (CD) were followed. All the LC candidates were operated in same operative complex with same surgical team & same set of instruments. Energy sources were available as ‘stand by’/rescue for the CD group if needed. Study Points Perioperative

Technical difficulty, Hemodynamic instability, Conversion, Blood transfusion (BT), Injury to Common Bile Duct(CBD)/ hollow viscera

Postoperative

Peritonism for [24 h (paralytic ileus); shoulder tip pain for [24 h; biliary leak; re-intervention; re-hospitalization for any complication

Other data

Length of hospital stay (LOS), Self-care ability after 1 day, Resumption of normal activity within 5 days, any adverse event in 3 months, mortality

Introduction: Centers for Medicare and Medicaid Services (CMS) initiated a nonpayment policy for certain hospital acquired conditions (HACs) in 2008. As of 2013, 11 HACs have been identified. This study aimed to determine the rate of the three most common HACs (surgical site infection (SSI), urinary tract infection (UTI), and deep vein thrombosis (DVT)) among bariatric surgery patients. Additionally, the association of HACs with patient factors and the effect of HACs on post operative outcomes were investigated.

Methods and Procedures: Patients 18 years of age and older with a diagnosis of obesity and body mass index (BMI) C35 who underwent bariatric surgery were identified using the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database (2005–2011). Patients were grouped into two categories for comparison: HAC versus no HAC patients and outcomes, including 30 day mortality and mean length of stay were compared. Procedure type, highest level of resident surgeon and multiple patient factors were closely investigated. Multivariate regression analysis was performed to identify risk factors for developing a HAC. Results: 81,565 patients were identified, of whom 2,389 (2.9 %) developed at least one of the three HACs. SSI was the most common HAC (1.8 %), followed by UTI (0.7 %) and VTE (0.4 %). The rate of these HACs have significantly decreased over the years (from 5 % in 2005 to 2.6 % in 2011, p \ 0.001). Laparoscopic gastric banding was associated with the lowest rates of HAC (1.3 %) and open gastric bypass with the highest (8.1 %). HAC patients had significantly higher rates of in-hospital mortality (0.7 % vs. 0.1 %, p \ 0.001) and stayed in the hospital longer (3.9 vs. 2.1 days, p \ 0.001). Unadjusted analysis revealed that preoperative patient factors such as age, ASA, BMI, diabetes, dyspnea, history of COPD, hypertension, and steroid use were significantly associated with HACs. In particular, patients with BMI C50 and those undergoing gastric bypass had significantly higher rate of HACs. Significantly more HACs were reported when residents (4–6 years post graduation) were present in the operating room compared to fellows or no residents being scrubbed (3.4 % vs. 2.6 % and 2.7 % p \ 0.001). Multivariate analysis showed similar results (Table 1). Conclusion: Our data demonstrate a strong correlation between the three most common HACs following bariatric surgery and factors intrinsic to the bariatric patient population itself. This calls into question the propriety of a payment policy which penalizes hospitals and surgical staff for inherent patient factors on which they can, by definition, have no impact. These findings are important to help inform health care policy decisions regarding access to care for bariatric surgery patients.

Prospectively collected data analysed using SPSS-17 version. Qualitative data was compared using chi-square and quantitative data was compared using T-test and P-value \0.05 was considered significant.

Results-Demographics & Pre-operative data Variable

ED (n = 361)

CD (n = 384)

Age, mean (SD) years

p-Value

44.4 (14.4)

46.4 (13.4)

0.04

Male = n (%)

100 (27.7)

122 (31.8)

0.22

Female = n (%)

261 (72.3)

262 (68.2)

Chronic cholecystitis

296 (82)

299 (77.9)

Acute cholecystitis

26 (7.2)

36 (9.4)

Mucocele

31 (8.6)

38 (9.9)

Gangrenous\perforated

8 (2.2)

11 (2.9

Table 1 Multivariable logistic regression analysis of variables associated with hospital acquired condition (HAC)

Grade of inflammation, n (%)

Variable

0.55

80 (22.1)

96 (25)

Hypertension

29 (8)

29 (7.5)

No diabetes/hypertension

252 (69)

254 (67.4)

Pre-operative ERCP, n (%)

35 (9.7)

42(10.9)

0.65

No complications

95 % CI

\49

Reference

Reference

Reference

50–64

1.15

0.005

(1.04–1.26)

C65

1.27

0.017

(1.04–1.54)

BMI

0.225

Results-Post-operative data Variable

P

Age group

Comorbidity n (%) Diabetes

OR

ED (n = 361)

CD (n = 384)

p-Value

356 (98.6)

383 (99.7)

0.08

35–39

Reference

Reference

Reference

40–49

1.20

0.009

(1.05–1.37)

C50

1.79

\0.001

(1.55–2.06)

Diabetes

1.24

\0.001

(1.13–1.36)

Dyspnea

1.10

0.049

(1.00–1.21)

History of COPD

1.42

0.003

(1.12–1.79)

1.16

0.003

(1.05–1.28)

1.68

0.002

(1.21–2.33)

0-no resident scrubbed

Reference

Reference

Reference

1–3 years post graduation

1.09

0.211

(0.95–1.25)

4–6 years post graduation

1.33

\0.001

(1.20–1.46)

7–11 years post graduation

1.05

0.427

(0.92–1.20)

Complications n (%)

5 (1.4)

1 (0.03)

Hypertension

Blood transfusion

2 (0.55)

0

Steroid use

Post-operative Bile leak

2 (0.55)

0

Highest level of resident surgeon

CBD injury

1 (0.27)

1 (0.03)

LOS, mean (SD) days

1.6 (1.03)

1.35 (1.2)

\0.001

Procedure type There was no technical difficulty in either group & no need of ‘rescue’ use of surgical energy in the CD group. All uncomplicated cases could be discharged as ‘day care’. Except for the complications given in the table above, other adverse study points were not observed in either of the groups. Conclusion: There was no statistically significant difference in clinical outcomes of LC done either with ED or CD. However occurence of post-operative biliary leaks & hemorrhage necessitating blood transfusion in the ED group (precluding discharge as ‘day care’) requires further studies to look for any association of adverse outcomes with the use of ED in LC.

Lap band

Reference

Reference

Reference

Lap sleeve

1.72

\0.001

(1.37–2.16)

Lap GBP

2.23

\0.001

(1.96–2.54)

Open GBP

5.23

\0.001

(4.45–6.14)

BMI: body mass index; COPD: chronic obstructive pulmonary disease; GBP: gastric bypass

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Improved Survival Following Minimally Invasive Oesophagectomy Compared to Open Surgery Oliver C Burdall, James Fullick, Alexander P Boddy, Jane Blazeby, Richard Krysztopik, Christopher Streets, Andrew Hollowood, Christopher P Barham, Daniel R Titcomb, Bristol Royal Infirmary

Comparison of Open versus Minimally Invasive Esophagectomy from the UHC Database Anton Simorov, MD, Tiffany N Tanner, MD, Rudy P Lackner, MD, Karin P Trujillo, MD, Dmitry Oleynikov, MD, FACS, Mark A Carlson, MD, FACS Department of Surgery, University of Nebraska Medical Center, Omaha NE

Introduction: Oesophageal cancer is one of the top ten most common cancers and increasing in incidence worldwide. As with other areas of surgery, minimally invasive techniques have been used to perform oesophagectomy, but concerns regarding these techniques remain. Since its description by Cuschiri in 1992 the use of minimally invasive oesophagectomy (MIO) has increased, but MIO was still only used 16 % of resections in the UK in 2009. In particular, there has been reluctance to use minimally invasive (thoracoscopic and laparoscopic) techniques in more advanced cancers for fears regarding the adequacy of the oncological resection. In order to identify any factors that could affect survival, we undertook a retrospective analysis on all patients that underwent surgery in our department over an 8 year period. Methodology: A retrospective data analysis was undertaken on all patients who underwent oesophagectomy in a tertiary upper gastrointestinal surgery unit, from 2005 to 2012 inclusive. Data was collected from the departmental data base and case note review, with follow-up and survival data to time of data collection. The survival data was analysed using univariate and multivariate Cox proportional hazard regression models to determine which variables affected survival. Variables examined included age, tumour position, tumour stage (T0, 1, 2 vs T3, 4), nodal stage (N0 vs N1), tumour histology, completeness of resection (R0 vs R1), use of neoadjuvant chemotherapy and operative technique (thoracoscopic/laparoscopic (MIO) vs laparoscopic abdomen/open chest (Lap assisted) vs Open) Results: 340 patients underwent oesophagectomy between 2005 and 2012. Male to female ratio was 3.75:1, with a mean age of 64 years (range 36–87). There were 83 open oesophagectomies, 189 laparoscopically assisted oesophagectomies and 68 minimally invasive oesophagectomies. Following univariate regression analysis the following factors were found to be correlated to survival: use of neoadjuvant chemotherapy (Hazard Ratio 2.889, 95 % CI 1.737–4.806), T stage 3 or 4 (3.749, 2.475–5.72), Node positive (5.225, 3.561–7.665), R1 resection (2.182, 1.425–3.341), type of operation (MIO compared to open oesophagectomy) (0.293, 0.158–0.541). There was no significant relationship between age, tumour position or tumour histology and length of survival. When these factors were entered into a multivariate model, the independently significant factors correlated to survival were found to be: T stage 3 or 4 (HR 1.969, 1.248–3.105), Node positive (3.833, 2.548–5.766) and type of operation (MIO compared to open) (0.5186, 0.277–0.972). Conclusion: Multiple small studies have found reduced pulmonary complication rates and duration of hospital stay when using a minimally invasive approach compared to open. Concerns in the literature over long term outcomes, however, have led to limited utilization of this method, especially in advanced disease. The data from this large study shows significantly better survival following operations performed using minimally invasive techniques compared to open, although we have not adjusted for some known or unknown confounding factors. International and national randomised controlled trials are required to provide more information in due course.

S047 Medical Tourism and Obesity Surgery: Who Pays? Caroline E Sheppard, BSc, Erica Lester, BSc, MD, David Kim, BSc, Daniel W Birch, MSc, MD, FRCSC, Shahzeer Karmali, MD, FRCSC, FACP, Christopher J de Gara, MB, MS, FRCS, Ed, Eng, C, FACS University of Alberta, Centre for the Advancement of Minimally Invasive Surgery Introduction: The objective of this study was to determine the financial impact that bariatric medical tourism has on a public healthcare system. Due to long wait times for weight reduction surgery services, Canadians are leaving to expedite treatment by venturing to private clinics in other provinces or countries. Consequently, postoperative care is facilitated in their original province. This not only burdens the provincial health system with the cost of interventions required for patients with complications, but also detracts from time allotted to patients in the public clinic. Minimal to no literature exists describing the cost and denominator of returning medical tourists. Methods and procedures: A chart review was performed of 62 patients deemed to be bariatric medical tourists to determine intervention costs between February 2009 and June 2013. As well, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, and the associated costs were determined. These costs were placed on a logarithmic curve to compare costs to our own institution. Results: At our institution a conservative cost estimate of $1.8 million CAD was calculated for all interventions for these 62 medical tourists. This amount is similar to the estimated cost elicited from the survey, which deduced that general surgeons in Alberta consult an estimated 300 medical tourists in a year, with an average of $20,000 in intervention costs per patient. The cost of conducting 300 primary bariatric surgeries in Alberta is approximately $1.7 million less than the cost of treating 300 medical tourists presenting postoperatively in Alberta. Conclusions: Medical tourism has a substantial impact on the cost of bariatric programs in Alberta. We have calculated the cost of bariatric medical tourism in Alberta to be, on average, $6 million CAD per year. This cost is a summation of funding the follow up and interventions due to complications or failure. It does not include the cost of subsidized externally conducted surgeries. As well, it does not take into account the cost of maintained obesity suffered by those on the wait list for bariatric surgery, whose surgery was not completed due to resources being directed to medical tourism surgical revision. Therefore, this cost is a broad yet conservative approximation. Thus, we conclude that it is more cost effective to conduct bariatric surgery in Alberta than to fund patients to seek surgery out of province/country.

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Introduction: Some retrospective data have accumulated which suggest improved perioperative outcome with minimally invasive esophagectomy compared to open esophagectomy. The goal of the present study was to compare perioperative outcome of minimally invasive versus open esophagectomy in a large retrospective database representing a consortium of academic medical centers in the United States. Methods and Procedures: Using the Clinical Recourse Manager from the University HealthSystem Consortium (UHC), patients were identified who underwent esophagectomy from 2008 to 2012. Data on perioperative outcome were collected and compared with the ANOVA or chi-square analysis, with significance defined as *p \ 0.05. Results: A total of 5,957 index esophagectomy cases were identified, including 5,313 (89.2 %) and 644 (10.8 %) open and minimally invasive cases, respectively; 182 of the latter were converted to open (conversion rate = 28.2 %). The overall morbidity and mortality rates were 21.6 % and 3.21 %, respectively. A summary of perioperative outcome data is shown in the Table 1. There were 114 reoperations after index procedures (1.91 %). Reoperative morbidity and mortality was 87.8 % and 13.2 %, respectively (*p \ 0.001 for both, compared to the index rates). The length of stay, ICU use, readmission rate, and hospital cost also was higher in the reoperative group compared to the index group (*p \ 0.05, data not shown). Conclusions: Mortality, morbidity, and cost were not different among open, minimally invasive, and converted esophagectomy in the UHC database from 2008–2012. The length of stay was different among the three, though just on the order of *2 days. ICU utilization appeared to be higher with minimally invasive esophagectomy, while readmission rates were higher in the converted cases. Reoperative cases had worse outcomes in most categories compared to index cases. Better perioperative outcome with minimally invasive esophagectomy was not obvious in this analysis of UHC data.

Table 1 . Variable

Open (5,313)a a

Min Invas (462)

Converted (114)

p value

Mortality

3.20 % (170)

3.25 % (15)

3.30 % (6)

Morbidity

21.5 % (1,142)a

20.8 % (96)

25.3 % (46)

0.435

*Length Stay (days)

16.7 ± 9.7b

15.2 ± 9.8

14.8 ± 13.4

\0.001

*ICU use

72.6 % (3,855)a

90.0 % (416)

77.5 % (141)

\0.001

*Readmission

5.30 % (283)a

3.90 % (18)

9.89 % (18)

0.009

Cost (x $1 K)

40.8 ± 44.4b

39.0 ± 24.8

35.2 ± 33.5

0.165

a

Number of cases given in parentheses

b

standard deviations shown

0.996

S049 Thromboembolic Events in Bariatric Surgery: The Cleveland Clinic Experience Mohammad H Jamal, MD, MEd, FRCSC, Hideharu Shimizu, MD, Stacy Brethauer, MD, FACS, Mathew Kroh, MD, FACS, Biban Chand, MD, FACS, Philip Schauer, MD, FACS Cleveland Clinic Introduction: The risk of venous thromboembolic (VTE) events is increased in patients undergoing bariatric surgery. Population studies examining VTE rates after bariatric surgery often lack details and uniformity regarding the prophylactic regimens used. The aim of this study is to determine the incidence of VTE in patients undergoing laparoscopic bariatric surgery from two centers within the same health care system. Methods: Database searches from Cleveland Clinic bariatric surgery programs in Cleveland, OH, and Weston, FL were conducted from 01/05 to 01/13. Mechanical and chemical prophylaxis (Lovenox BID) were given to all patients and extended chemoprophylaxis prescribed to patients at higher risk for VTE. Data on age, gender, body mass index (BMI), interval between procedure and VTE, inpatient versus outpatient status, anticoagulation prophylaxis, type of surgery and mortality were collected. Results: A total of 4,293 patients were identified. VTE events were identified in 57 patients (1.3 %). Pulmonary embolism (PE) was identified in 39 patients (0.9 %) and 15 of these patients had negative duplex studies of the lower extremities. Deep venous thrombosis only was identified in 18 patients (0.4 %). Six patients underwent an open procedure (10.5 %). VTE rates for gastric bypass (n = 2851), sleeve gastrectomy (n = 701), and revisional procedures (n = 159) were 1.1 %, 1.85 %, AND 0.6 %, respectively. Eight patients had VTE diagnosed during their inpatient stay. The mean time to VTE diagnosis after surgery was 24 days (range 2–124). . Seventeen patients who developed VTE had been prescribed extended prophylaxis for 2–4 weeks after discharge. There was only one VTE related mortality from PE reported in this cohort (0.02 %). Univariate and multivariate analysis revealed age, BMI, open and revisional surgery as predictive of VTE (p \ 0.05). Conclusion: The risk of VTE among morbidly obese patients undergoing bariatric surgery is persistent despite use of laparoscopy and aggressive prophylactic anticoagulation policy. Patients with advanced age, higher BMI and those undergoing open or revisional surgery should be considered candidates for extended chemoprophylaxis.

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S051

A Comprehensive Process for Disclosing and managing Conflicts of Interest Reduced Perceived Bias at the SAGES Annual Meeting Steven C Stain, MD, Erin Schwarz, Phillip Shadduck, MD, Paresh Shah, MD, Sharona B Ross, MD, Patricia Sylla, MD, Yumi Hori, C D Smith, MD Albany Medical College, Albany, NY; BSC Management, Los Angeles CA; Duke Regional Hospital, Durham NC; New York University, New York, NY; Florida Hospital Tampa, Tampa FL, Massachusetts General Hospital, Boston MA, Mayo Clinic Jacksonville, Jacksonville FL

Bile Duct Injury Prevention Requires a New National Training Paradigm Despite Successful Deployment of FLS Steven D Schwaitzberg, MD, Daniel J Scott, MD, Daniel B Jones, MD, Sophia K McKinley, BA,, EdM, Johanna Castrillion, MD, Tina Hunter, PhD, L. Michael Brunt, MD Harvard Medical School, UT Southwestern School of Medicine, S2 Statistical Solutions, Washington University School of Medicine

Introduction: The relationship between SAGES, its member surgeons and industry has been longstanding, productive technologically, and beneficial to patient care and education. In order to both maintain this important relationship as well as to honor its responsibility to society for increasing transparency, SAGES established a Conflict of Interest Task Force (CITF) and charged it with identifying and managing potential conflicts of interest (COI) and limiting bias at the SAGES Annual Scientific Meetings. To fulfill this responsibility, the CITF developed and implemented a comprehensive process for reporting, evaluating, and managing COI in accordance with ACCME guidelines. Methods: From 2011 to 2013, all presenters, moderators and session chairs received proactive and progressively increasing levels of education regarding the CITF rationale and processes. All presenters and faculty at the Annual Meeting (faculty, session directors, session moderators, course chairs, and program chairs) were required to disclose all relationships with commercial interests. All disclosures were reviewed and discussed by multiple layers of reviewers, including moderators, chairs, and CITF committee members. Tiered, prescribed actions were implemented in a standardized, uniform fashion (Table below). Level 1 Nothing to disclose

Level 2 Non-relevant relationship

Level 3 Relevant relationship

Level 4 Relationship with ownership interest

Level 5 Employee of commercial interest

Action by SAGES

Review for accuracy

Review by moderator & CITF

Peer review required prior to Presentation, with changes to Presentation as appropriate

Automatic peer review prior to presentation, with changes to presentation as appropriate

Presenter Removed from faculty

Resulting actions

Print & present disclosures

Print & present disclosures

Letter to faculty Explaining policy; print & present disclosures

Letter to faculty explaining policy; print & present disclosures

Presentation not Allowed

Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) with minimal improvement over the last 2 decades. Although Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. Methods: 53,632 LCs were reviewed from Q32009 to Q42010 from a large private payor claims database. Surgeon National Provider Identification (NPI), FLS certification status, ICD-9 and CPT were available for each event. Each record was analyzed for evidence of any major bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS + and FLS– surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. Results: 1694 LC were performed by FLS+ and 51,938 by FLS- surgeons. 82 BDI were identified: 8 in the FLS+ and 72 in the FLS– group. The FLS+ group had a higher rate of BDI than the FLS– group (.47 % vs .14 %, p = .0013); however, the FLS + group was also younger (mean age 38.2 FLS+ vs 50.4 yrs FLS-) had significantly fewer years in practice (FLS + = 6.1 vs FLS- = 20.7 p = .0012). No other complications showed differences between the groups. Conclusion: Nationally mandated training programs such as FLS allows for the study of the comparative effectiveness of training on clinical outcome. Although the scientific validity of FLS is well established, there is no content in the program relative to BDI prevention. Our results do suggest that FLS certification seems to offset lack of surgeon experience for general complications of LC, but not for bile duct injury. Large scale and validated training and assessment programs targeted at BDI prevention are needed if we are to attempt to shorten the pathway to higher levels of proficiency for surgeons performing laparoscopic cholecystectomy.

All attendees at the Annual Meetings were strongly encouraged to complete anonymous surveys regarding perceived biases. The CITF database was then analyzed and compared to the reports of perceived bias to determine if the implementation of this comprehensive process had been effective. Results:

Number of faculty, presenters, moderators, and chairs No industry relationships

Number of faculty, presenters, moderators, and chairs Yes industry relationships

Resolved CITF

by

Presentations reviewed in advance of Mtg

Changes made to presentation

Speaker Replaced

Reported bias by Attendees

2011

Data not avail

Data not avail

6

0

0

18/802 2.2 %

2012

350

173

124

49

8

1

10/797 1.2 %

2013

264

190

103

93

20

0

11/717 1.5 %

In the three years prior to the implementation of this process, reporting of bias by meeting attendees was 20/427 (4.7 %) in 2008, 37/596 (6.2 %) in 2009, and 38/856 (4.4 %) in 2010. Following implementation of this process, reports of bias were reduced to 1.2–1.5 %. Conclusion: It is possible to have a surgical meeting that includes participation of speakers that have industry relationships. Implementation of a comprehensive, standardized process for reporting, evaluating, and managing COI resulted in a reduction of perceived reports of bias from 4.4–6.2 % to 1.2–1.5 %, as reported by annual meeting attendees in anonymous surveys.

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S256

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S053

A Prospective Randomized Controlled Trial Assessing the Efficacy of Omentopexy During Laparoscopic Sleeve Gastrectomy in Reducing Postoperative Gastrointestinal Symptoms Cheguevara Afaneh, MD, Ricardo Costa, BS, Alfons Pomp, MD, Gregory Dakin, MD New York-Presbyterian Hospital/Weill Cornell Medical Center

Morbidity and Mortality in Bariatric Surgery using Age and BMI stratification—A NSQIP data study Aliu Sanni, MD, Sebastian Perez, MPH, Rachel Medbery, MD, Hernan Urrego, MD, Craig McCready, MD, Juan Toro, MD, Ankit Patel, MD, Arvin Singh, MD, Jahnavi Srinivasan, MD, Barbara Pettitt, MD, Edward Lin, DO, John Sweeney, MD, Scott Davis, MD Department of General & GI Surgery, Emory University Hospital

Objective: Patients undergoing sleeve gastrecomy experience a significant amount of postoperative gastrointestinal symptoms. The purpose of our study was to assess the efficacy of omentopexy during laparoscopic sleeve gastrectomy (LSG) in reducing postoperative gastrointestinal (GI) symptoms. Methods: Morbidly obese patients undergoing LSG were randomly assigned to have LSG with or without omentopexy from May 2012 to June 2013. A total of 60 patients were recruited with 30 patients in each group. Patients and the symptom-scorer were blinded as to the assigned surgery. All procedures were performed by one of two surgeons (A.P & G.D.). Patients were administered standardized surveys at various time points postoperatively to assess nausea, vomiting, retching, frequency of GI symptoms, and level of distress. All continuous variables were compared using the Mann-Whitney U test. Results: There was no significant difference in patient age, percent decrease in BMI, or length of hospitalization between the two groups (P [ 0.05). Furthermore, there was no significant difference (P [ 0.05) in postoperative GI symptoms between the two groups at baseline, postoperative day 1, 2, 3, 7, and 30 (Table 1). Moreover, the percent change in total symptoms from day 1 compared to days 2, 3, 7, and 30 was also not significantly different (P [ 0.05). Patients in the LSG with omentopexy group required significantly more Ondansetron perioperatively (16.1 ± 12.9 mg vs. 10.3 ± 10.2 mg, respectively; p = 0.04); however, there was no difference in metoclopramide requirement (p = 0.22) (Table 2). Finally, there was no significant difference in number of postoperative clinic visits, office telephone encounters, total postoperative readmissions, or postoperative readmissions associated with GI symptoms (P [ 0.05) (Table 2). Conclusions: Omentopexy did not significantly decrease postoperative GI symptoms in morbidly obese patients undergoing LSG in the first 30 days. Moreover, these patients had a slightly higher postoperative pharmacologic antinausea requirement compared to those patients undergoing LSG without omentopexy.

Introduction: Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remains low and acceptable. BMI[50 kg/m and age[45 years have been implicated as independent predictors associated with significantly increased mortality. This study looks to define the real trend of morbidity and mortality as it relates to increasing age and BMi in patients undergoing bariatric surgery. Methods: We queried the ACS/NSQIP 2010–2011 Public Use File for patients who underwent elective laparoscopic adjustable banding, sleeve gastrectomy and gastric bypass. Total morbidity and 30-day mortality were evaluated. The average BMI and age were compared for mortality using sample t-tests. Logistic regression models were created to estimate the effect increasing age and BMI on morbidity for these bariatric procedures. Results: A total of 20308 laparoscopic bariatric procedures were reviewed (11,617 gastric bypasses, 3,069 sleeve gastrectomy and 5,622 gastric bandings).There were 22 mortalities (0.11 %) and 801 patients with at least one reported complication (3.84 %).The mean age (52 years vs. 44 years: p \ 0.05) and BMI (50 vs. 46: p \ 0.05) were significantly higher in patients with mortality. The odds of postoperative complications increased by 2 % with each additional year of age (OR 1.02, 95 %CI 1.02–1.03) and every point increase in BMI (OR 1.02, 95 % CI 1.01–1.03)—see Figs 1 and 2. Postoperative complications were three times more likely after laparoscopic gastric bypasses (OR 2.87, 95 % CI 2.31–3.57) and two times more likely after sleeve gastrectomy (OR 2.06, 95 % CI 1.57–2.72) when compared to patients undergoing laparoscopic gastric banding. Conclusion: 30-day morbidity and mortality rates for bariatric surgery are low. Morbidity and mortality increases on a predictable trend with increasing age and BMI. . There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.

Table 1

.

Parameter

LSG with omentopexy (N = 30)

LBG without omentopexy (N = 30)

P Value

Baseline

Total Scale

0.47 ± 1.33

1.33 ± 2.59

0.11

Hausea Subscale

0.37 ± 1.25

1.03 ± 1.99

0.10

Vomiting Subscale

0

0

-

Retching Subscale

0.10 ± 0.55

3.30 ± 0.95

0.31

Symptom Occurrence

0.33 ± 1.03

O.87 ± 1.57

0.11

Symptom Distress

0.13 ± 0.43

0.47 ± 1.20

0.16

Total Scale

10.60 ± 8.22

Day +1

9.37 ± 6.21

0.78

Nausea Subscale

5.83 ± 3.89

6.13 ± 3.59

0.75

Vomiting Subscale

2.33 ± 3.06

1.17 ± 1.97

0.16

Retching Subscale

2.43 ± 2.33

Symptom Occurrence

6.40 ± 4.99

5.90 ± 4.05

0.95

Symptom Distress

4.20 ± 372

3.47 ± 2.60

2.07 ± 2.26

0.81

0.51

Total Scale

8.90 ± 6.13

Day +2

8.07 ± 5.19

0.67

Nausea Subscale

4.72 ± 2.83

5.03 ± 3.00

0.85

Vomiting Subscale

2.17 ± 2.35

1.40 ± 2.06

0.18

Retching Subscale

2.00 ± 2.14

Symptom Occurence

5.52 ± 3.64

5.20 ± 3.47

0.77

Symptom Distress

3.38 ± 2.86

2.87 ± 2.15

1.63 ± 2.01

0.67

0.53

Total Scale

4.29 ± 5.24

Day +3

4.08 ± 4.32

0.85

Nausea Subscale

2.50 ± 2.96

2.81 ± 3.09

0.66

Vomiting Subscale

1.07 ± 1.78

0.58 ± 1.42

0.25

Retching Subscale

0.71 ± 1.36

Symptom Occurrence

2.82 ± 3.38

2.62 ± 2.76

0.93

Symptom Distress

1.46 ± 2.06

1.46 ± 1.70

0.69 ± 1.35

0.59

0.90

Total Scale

2.04 ± 2.92

Day +7

1.33 ± 2.75

0.12

Nausea Subscale

1.74 ± 2.18

0.96 ± 1.95

0.10

Vomiting Subscale

0.15 ± 0.77

0.11 ± 0.58

1.0

Retching Subscale

0.15 ± 0.77

0.26 ± 0.71

0.19

Symptom Occurrence

1.26 ± 1.51

0.89 ± 1.81

0.15

Symptom Distress

0.78 ± 1.55

0.44 ± 0.97

0.23

Fig. 1 Probability of Morbidity with increase in Age

Day +30

Total Scale

2.27 ± 3.29

1.21 ± 2.40

0.14

NausEa Subscale

1.65 ± 2.35

0.83 ± 1.61

0.13

Vomiting Subscale

0.23 ± 0.71

0.21 ± 0.77

0.61

Retching Subscale

0.38 ± 1.13

Symptom Occurrence

1.54 ± 2.27

0.93 ± 1.75

0.20

Symptom Orstress

0.73 ± 1.19

0.28 ± 0.70

0.17 ± 0.54

0.08

0.82

Day 1 to Day 2

+23.7 ± 121.8

+15.0 ± 113.5

0.86

Day 1 to Day 3

-16.5 ± 146.0

-34.3 ± 93.9

0.62

Day 1 to Day 7

-51.2 ± 97.7

-67.0 ± 63.9

0.26

Day 1 to Day 30

-51.2 ± 108.7

-69.2 ± 71.0

0.38

Percent change in total scale

Table 2

.

Parameter

LSG with Omentopexy (N = 30)

LSG with out Omentopexy (N = 30)

P Value

Perioperative Data Age, years (mean ± SD)

37 ± 98

43 ± 12.6

0.07

Preop BMI, kg/m2

45.1 ± 7.1

49.1 ± 8.3

0.053

Postop BMI, kg/m2

40.4 ± 6.8

44.7 ± 7.4

Percent decrease in BMI

10.5 ± 3.3

9.9 ± 3.0

0.43

Length of Stay, hrs

71.0 ± 13.7

71.1 ± 16.4

0.72

0.04

Postoperative Antinau sea Pharmacologic Requirement Metoclopramide (mg)

12.8 ± 16.2

8.0 ± 11.0

0.22

Ondansetron (mg)

16.1 ± 12.9

10.3 ± 10.2

0.04

Follow-up Data (median, range)

Clinic Visits

2 (1–7)

2 (0–5)

0.81

Telephone Encounters

1 (0–10)

1.5 (0–6)

0.45

AII Readmissions

0 (0–3)

0 (0–1)

0.63

GI-associated Readmissions

0 (0–3)

0 (0–1)

0.24

123

Fig. 2 Probability of Morbidity with increase in BMI

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S056

Six Month Outcomes in Patients Experiencing Weight Gain After Gastric Bypass Who Underwent Gastrojejunal Revision Using an Endoluminal Suturing Device M Gitelis, M Ujiki, L Farwell, J Linn, K Miller, C Burnett, J Carbray, S Haggerty, W Denham NorthShore University HealthSystem

Presence of Hlelicobacter Pylori is not associated with late anastamotic complications in gastric bypass patients John J Kelly, MD, Richard A Perugini, MD, Lisa Q Wang, MD, Thomas Tomczyk, MD, Julie Flahive, MS University of Massachusetts Medical Center

Background and Objective: Weight gain after Roux-en-Y gastric bypass (RYGB) occurs in approximately 25 % of cases and this may lead to redevelopment of comorbid conditions. Currently, adequate treatment strategies for this group of patients are lacking. Endoscopic narrowing of the gastrojejunal anastomosis may result in a low-risk, minimally invasive treatment alternative compared to standard surgical revision. We aimed to assess short-term outcomes in patients undergoing endoscopic gastrojejunal revisions (EGJR) using an endoluminal suturing device. Methods: Institutional review board-approved retrospective analysis of 20 consecutive patients who underwent EGJR. Patients pre-operatively presented with a dilated gastrojejunal anastomosis and weight gain. An endoluminal suturing device (OverstitchTM, Apollo Endosurgery, Austin TX) was used to narrow the anastomosis. Study includes all clinically available data for cases beginning in June 2012. Results: Prior to EGJR, patients regained an average of 24.4 ± 11.7 kg from their weight loss nadir and had a mean body mass index (BMI) of 42.1 ± 6.9 kg/m2. In total, 23 revisions were performed on 20 patients. Two patients underwent gastrogastric fistula closure as well as stoma reduction. One patient required more than one session to fully close a fistula and stoma. The average procedure time was 43 ± 17 min. An average of 3.2 ± 1.1 sutures were placed per patient and the stoma diameter was reduced from 28.7 ± 6.4 mm to 6.2 ± 2.0 mm for an average of a 77.9 % reduction. At six weeks, 100 % of patients experienced weight loss (average 6.9 ± 5.0 kg; p-value .011). At three months, 80.0 % maintained weight loss (average 9.9 ± 5.6 kg; p-value .002). At six months, 100 % of available cases maintained weight loss (average 7.5 ± 6.2 kg; p-value .032). Percent excess weight loss was 11.9 % ± 7.9 %, 18.5 % ± 10.5 %, and 12.1 % ± 11.4 % at six weeks, three months, and six months, respectively. Lastly, BMI decreased at six weeks (average 2.6 ± 1.9 kg/m2; p-value .012), three months (average 3.6 ± 2.0 kg/m2; p-value .001), and six months (average 2.6 ± 2.1 kg/m2; p-value .027). There were no complications.

Weight loss (kg)

Incidence of ulcer complications relation to H. pylori status (+) H. pylori (n = 67)

BMI loss (kg/m2)

Excess weight loss (%)

6 weeks

3 months

6 months

6 weeks

3 months

6 months

6 weeks

3 months

6 months

Mean

6.9

9.9

7.5

11.9 %

18.5 %

12.1 %

2.6

3.6

2.6

SD

5.0

5.6

6.2

7.9 %

10.5 %

11.4 %

1.9

2.0

2.1

p-value

0.011

0.002

0.032

–

0.012

0.001

0.027

–

Background: Eradication of H. pylori prior to Roux-en-Y gastric bypass (RYGB) has been advocated as a measure to reduce anastomotic ulceration. However, the evidence to support a correlation between preoperative H. pylori status and postoperative anastomotic ulcer is weak. Our hypothesis is that there is no association between the preoperative presence of H. pylori and post-operative marginal ulcer development and associated complications such as perforation, stricture and pain. Methods: Consecutive intraoperative antral biopsies were obtained on patients who underwent laparoscopic RYGB at our institution from December 2007 to June 2010. These samples were analyzed by Warthin–Starry stain for H. Pylori organisms. Retrospective chart review was conducted to determine preoperative symptoms of acid dyspepsia and PPI/H2 blocker therapy and post-operative data of ulcer symptoms or ulcer visualization on EGD, perforation, stricture, GI bleed, smoking, NSAID or steroid use, and compliance with ulcer prophylaxis. Presence of marginal ulcer was defined by symptoms, EGD visualization, stricture, or perforation. Fisher’s exact test was used for analyzing associations between discrete groups. Multiple logistic regression was used to assess associations between anastomotic ulcer complications and potential predictors. Results: A total of 729 patients underwent RYGB, in whom histologic evaluation for H. Pylori organisms was possible in 708. Sixty-seven (9.2 %) patients were H. pylori positive; these patients did not receive definitive treatment for eradication. The H. pylori positive group was not different with regards to preoperative age, gender, BMI, diagnosis of GERD or peptic ulcer disease, and postoperative ulcer prophylaxis, usage of steroids, NSAIDs and cigarettes. Marginal ulcers and/or related late complications were seen in 105 (14.8 %) patients. Of those, diagnosis of simple ulcer was made in 88 (12.4 %) patients based on symptoms and/or seen on EGD, stricture in 31 patients (4.4 %) and perforation in 21 patients (2.9 %).

–

Conclusion: Six month outcomes for EGJR patients demonstrated a low-risk, minimally invasive treatment option to reverse weight gain subsequent to a failed gastric bypass. Procedures presented no complications and may provide an attractive alternative to standard surgical revision.

(-) H. pylori (n = 641)

Simple ulcer (%)

1 (1.5 %)

87 (14.4 %)

Stricture (%)

2 (3.1 %)

29 (4.6 %)

Ulcer perforation (%)

1 (1.5 %)

20 (3.2 %)

Anastomotic ulcer related complications combined

4 (6 %)

101 (16.0 %)

P value

0.002 0.76 0.71 0.03

Conclusion: This is the largest series in the literature studying tissue biopsy proven H. pylori colonization of the stomach and postoperative anastomotic ulcer complication in RYGB. Rather than a higher incidence, we found a significantly lower incidence of anastomotic ulcer complications in the population positive for H. pylori. This study brings into question efforts to eradicate H. pylori prior to RYGB.

S055 Hospital Admissions Greater Than 30 Days Following Bariatric Surgery: Patient and Procedure Matter Dana A Telem, MD, Wendy L Patterson, MPH, Brittany D Peoples, MS, Maria Altieri, MD, Gerald Gracia, MD, Jie Yang, PhD, Qiao Zhang, MS, Aurora D Pryor, MD, Stony Brook Medicine New York State Department of Health Office of Quality and Patient Safety Introduction: Sparse data is available regarding hospital admission rates greater than 30-days following a bariatric procedure. This has important implications in terms of patient care, resource utilization assessment and healthcare expenditure. The purpose of this study is to assess hospital admissions for two-years following bariatric surgery in order to identify potential differences by procedure and at risk patient populations. Methods: Following IRB approval, New York Statewide Planning and Research Cooperative System (SPARCS) administrative data was used to identify 22,139 adult patients who underwent bariatric surgery from 2006–2008. SPARCS is a comprehensive data reporting system which collects patient-level risk characteristics, treatments, and outcomes for all New York State (NYS) hospital discharges. Bariatric surgery was identified by discharges with a primary diagnosis of overweight or obesity and a primary procedure code for laparoscopic gastric band (LGB), laparoscopic Rouxen-y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG). Identified bariatric patients were followed for two years after surgery to identify all-cause hospital admissions. Statistical analysis was performed via the chi square test and calculation of odds ratios. Results: Of the 22,139 patients, 12,439 underwent RYGB, 9,099 LGB and 601 LSG. In total, 5,718(26 %) patients were admitted within two years of surgery for a total of 9,502 readmissions. Thirty-day admission rate was 5 %. Stratifying the 9,502 admissions demonstrated 14 % occurred within 30-days, 23 % within 90-days, 32 % within 6 months, 54 % within one-year, and 76 % within 18-months of surgery. The number of admissions per patient ranged from 1–22. Assessing the number of admissions per patient demonstrated that 3,741 (17 %) patients had one, 1,575 (7 %) had 2–3 and 402 (2 %) patients had greater than 4 admissions. By bariatric procedure, LSG had the highest admission rate (32 %), followed by RYGB (29 %) and then LGB (22 %), p \ 0.001. The number of admissions by procedure follow: 1 (18 % RYGB vs. 15 % LGB vs. 20 % LSG, p \ 0.001), 2–3 (8 % RYGB vs. 6 % LGB vs. 8 % LSG, p \ 0.001), and 4 + (2 % RYGB vs. 1 % LGB vs. 3 % LSG, p \ 0.001). Table 1 lists significant admission predictors. Conclusion: One out of four bariatric patients will be admitted to the hospital within 2 years of surgery. As such 30-day assessment underestimates hospital utilization. While the majority of patients are admitted only once, 7 % of patients required more than 1 admission. Operative procedure significantly correlates with hospital admission. LSG is associated with both the highest rate as well as highest frequency of hospital admissions, followed by RYGB, then LGB. In addition, several factors were identified that significantly identify at risk patients. Consideration and attention to these factors are necessary for operative planning and postoperative monitoring.

Table 1

S057 Preoperative Upper Endoscopy Should Be Standard of Care for Patients Undergoing Bariatric Surgery Kshitij Kakar, MD, Vikas Singhal, MD, Leena Khaitan, FACS University Hospitals - Case Medical Center, Cleveland Introduction: Obesity is a major medical problem in the United States (US). Prevalence of obesity is rising and according to the National Health and Nutrition Examination Survey in 2009–2010, 35.7 % of US adults were obese. Minimally invasive bariatric surgery is becoming an increasingly important tool to combat this epidemic. The most commonly performed procedures include the Roux-EN-Y gastric bypass, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. Many patients may have pathology in the proximal gastrointestinal (GI) tract that is not clinically evident prior to bariatric surgery. Currently, preoperative endoscopic evaluation of the proximal GI tract is not the standard of care and is performed only selectively in most centers. The purpose of our study was to determine the diagnostic yield of routine esophagogastroduodenoscopy (EGD) before bariatric surgery and the extent to which this changes medical or surgical management. Methods: We performed a retrospective analysis of upper endoscopy reports, and operative and medical management of patients undergoing bariatric surgery during the period from January 2011–December 2012. Patient factors including age, sex, body mass index (BMI) and presence of upper GI symptoms were tabulated. Positive findings including esophagitis, gastritis, duodenitis, hiatal hernia and presence of ulcers or polyps were assessed. Patient charts were reviewed for the operative procedure performed as well as medical and surgical modifications based on the EGD findings. Results: Three hundred and twenty six patients (52 males and 274 females) underwent bariatric surgery during the period from January 2011– December 2012 (age 19–75 years). Of these, EGD reports were available for 260 patients who were included in the data analysis. 46 patients (17.7 %) had established gastroesophageal reflux disease. The most common finding was presence of a hiatal hernia in 71 (27.3 %) patients. Other findings included gastritis in 66 (25.4 %), esophagitis in 33 (12.7 %), polyps in 27 (2 esophageal, 23 gastric and 2 duodenal, 10.4 %) duodenitis in 23 (8.8 %), and ulcers in 8 (7 gastric and 1 duodenal, 3.1 %) patients. 19 (7.3 %) patients were hence placed on proton pump inhibitors before surgery. Findings of severe GERD prompted patients to be counseled for a Gastric bypass rather than the Sleeve gastrectomy. 34 patients (13.1 %) had a hiatal hernia that required repaired at the time of their bariatric surgery. One patient was found to have a carcinoid tumor on the EGD and consequently underwent a lymph node dissection during surgery. Conclusion: Preoperative EGD provides useful information in patients undergoing bariatric surgery and helps to diagnose previously unknown pathology. In our study 56 (21.5 %) patients who had an EGD required some form of modification in management based on the endoscopy. The findings of our study suggest that routine EGD should become the standard of care in all patients undergoing bariatric surgery.

Significant patient specific risk factors for hospital readmission within 2 years of bariatric surgery

Patient Factor

Odds Ratio

95 % Confidence Interval

P-value

Black race

1.2

1.1–1.3

\0.001

Female gender

1.2

1.1–1.3

\0.001

Medicaid/medicare

1.7

1.6–1.9

\0.001

Operative complication

1.7

1.5–1.9

\0.001

Congestive heart failure

1.8

1.1–2.9

0.025

Neurological disorders

1.5

1.2–1.9

0.002

Chronic pulmonary disease

1.3

1.2–1.4

\0.001

Diabetes

1.2

1.1–1.3

\0.001

Rheumatoid arthritis

1.8

1.3–2.4

\0.001

Substance abuse history

2.0

1.1–3.5

0.022

Psychoses

1.7

1.4–2.2

\0.001

Depression

1.1

1.0–1.1

0.038

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Dimethyl Fumarate Ameliorates L-Arginine induced Acute and Chronic Pancreatitis Lourdes Y Robles, MD, Nosratola Vaziri, MD, MACP, Shiri Li, MD, PhD, Chie Takasu, MD, PhD, Kelly Vo, Michael Stamos, MD, Hirohito Ichii, MD, PhD University of California, Irvine

Real-Time Navigation by Fluorescence-Based Enhanced Reality For Precise Estimation of Future Anastomotic Site in Digestive Surgery Michele Diana, MD, Pierre Diemunsch, MD, PhD, Yoshihiro Nagao, MD, Peter Halvax, MD, Anne-Laure Charles, MD, PhD, Bernard Geny, MD, PhD, Bernard Dallemagne, MD, Vincent Agnus, PhD, Luc Soler, PhD, Nicolas Demartines, MD, FACS, FRCS, Didier Mutter, MD, PhD, FACS, Jacques Marescaux, MD, FACS, HON, FRCS, HON, FJSES 1) IRCAD/IHU, Digestive and Endocrine Surgery, University of Strasbourg 2) Anaesthesiology, University of Strasbourg, 3) Phisiology and Oxydative Stress Laboratory, University of Strasbourg 4) Visceral Surgery, University Hospital Lausanne, Switzerland

Introduction: The objective of this study was to examine the effects of an oral Nrf2-keap 1 pathway activator, Dimethyl fumarate (DMF) on experimental acute and chronic pancreatitis induced by L-Arginine. Nrf2-keap 1 pathway is the master regulator of hundreds of genes, encoding antioxidant, cytoprotective, and detoxifying molecules. DMF is a potent oral Nrf2 activator which exerts its protective effects by attenuation of oxidative stress and inhibition of NF-jB. The main hypothesis of this study is that DMF will protect the rats from oxidative stress-mediated pancreatic injury induced by L-Arginine. Methods: Rats were treated with daily DMF (25 mg/kg) or vehicle prior to induction of acute or chronic pancreatitis by L-Arginine. Acute pancreatitis was induced by two injections of L-arginine (350 mg/100 g) one hour apart, after which animals were monitored for 72 h prior to sacrifice. Chronic pancreatitis was induced by daily L-Arginine (400 mg/100 g) injections for 28 days. Objective assessments for both acute and chronic pancreatitis included serum amylase level, body weight, pancreas size, pellet size after collagenase digestion, and pancreas histology. Results: Fixed pancreas samples from DMF treated rats revealed a decrease in the level of pancreatic inflammation, edema, and acinar cell destruction compared to vehicle treated rats (p \ 0.001). Likewise, average serum amylase levels of the DMF treated rats was reduced at 2000 U/L compared to the vehicle treated rats at 4,015 U/L (control rats 700 U/L) (p \ 0.05). With chronic L-Arginine stimulation, the DMF rats were able to maintain their body weight and gain weight similar to control rats over the 4 week study period. In contrast, placebo treated rats had sluggish weight gain and a significant change in body weight compared to baseline. At sacrifice, the pancreases of the DMF rats were significantly larger and weighed more than the vehicle treated controls (1.12 g versus 0.77 g). The pancreases were dissociated after extraction and pellet size was measured and noted to be significantly smaller in the placebo treated rats (p \ 0.05). Histologically, 22 % of vehicle treated controls had evidence of severe chronic pancreatitis. In contrast, all of the DMF rats had normal pancreases. Conclusion: Treatment with DMF, a Nrf2 activator, significantly ameliorates experimental acute and chronic pancreatitis. DMF has also recently become FDA approved for the treatment of Multiple Sclerosis as clinical trials revealed a significant improvement in patients receiving the drug. This study may indicate that DMF may be useful in other inflammatory conditions as well.

Introduction: Fluorescence-based Enhanced Reality (FLER) is a novel technique to evaluate intestinal perfusion based on the use of a Near InfraRed endoscope (D-light P, Karl StorzÒ) to detect the Indocyanine Green (ICG) fluorescence signal. A digital perfusion cartography is computed from the time-to-peak of the fluorescent signal and is superimposed to the intraoperative laparoscopic image using VR-RENDERÒ software.The aim of this study was to assess the ability of the FLER to identify the future resection lines in a reiterate model of intestinal ischemia. Materials and Methods: An ischemic segment was created in 18 small bowel loops in 6 pigs (3 loops/pig) by sealing 3–4 mesenteric vessels. After 2 h (n = 6), 4 h (n = 6) and 6 h (n = 6), the ischemic segments were evaluated by clinical assessment (by a second surgeon blinded to the extent of the mesenteric window) and by FLER, to determine presumed viable margins. Five regions of interest (ROIs) were identified: ischemic (ROI 1), presumed viable margins (ROI 2a & 2b), and vascular areas (3a & 3b). Presumed viable margins as assessed by clinical evaluation (2aCLINIC + 2bCLINIC), were marked with a clip, while those identified under FLER guidance (2aFLER + 2bFLER) were outlined with a surgical marker. A laparotomy was performed and capillary blood samples were obtained by puncturing the bowel serosa at the ROIs and lactates were measured using the handheld EDGEÒ lactate analyzer (Apexbio, Taiwan). A surgical biopsy sampled at the ROIs as evaluated by FLER, was placed in a 2 mL water-jacketed oxygraphic cell (Oxygraph-2kÓ, OROBOROS instrumentsÒ, Innsbru¨ck, Austria). After determination of basal oxygen consumption (V0), the mitochondrial respiration rates were measured at 37 °C in the presence of a saturating amount of ADP as phosphate acceptor (VADP) to evaluate complexes I, III, and IV. Complex II was then stimulated with succinate to evaluate VMAX of mitochondrial respiration. Results: Mean capillary lactate levels at 2 h were 5.45 ± 2.44 vs. 1.9 ± 0.6 vs. 1.2 ± 0.3 mmol/L at ROI 1 vs. 2a & 2b (p \ 0.0001) vs. 3a & 3b (p \ 0.0001) respectively. At 4 h, lactates were 4.36 ± 1.32 vs. 1.83 ± 0.81 vs. 1.35 ± 0.67 mmol/L at ROI 1 vs. 2a & 2b (p \ 0.0001) vs. 3a & 3b (p \ 0.0001). At 6 h, lactates were 4.16 ± 2.55 vs. 1.8 ± 1.2 vs. 1.45 ± 0.83 at ROI 1 vs. 2a–2b (p = 0.013) vs. 3a–3b (p = 0.0035). Lactate levels at presumed viable margins assessed by clinical evaluation (2aCLINIC + 2bCLINIC) were statistically significantly higher when compared to those at 2aFLER + 2bFLER (2.43 ± 0.95 mmol/L vs. 1.55 ± 0.33 p = 0.02) after 4 h of ischemia. Mean basal mitochondrial respiratory rate expressed in pmolO2/second/mg of dry tissue (V0 and VMAX) were significantly impaired after 4 h and 6 h of ischemia at ROI1 (V04h = 42.7 ± 25.81; VMAX4h = 76.6 ± 29.09; V06h = 44.1 ± 12.37 and VMAX6h = 116.1 ± 40.1) when compared to 2a & 2b (V04h = 67.1 ± 17.47 p = 0.0003; VMAX4h = 146.8 ± 55.47 p = 0.0054; V06h = 63.9 ± 28.99 p = 0.03; VMAX6h = 167.2 ± 56.96 p = 0.01). V0 and VMAX were statistically significantly higher at the vascular areas at all-time points. No differences between ROIs 2a & 2b and 3a & 3b were found for lactate levels and mitochondria respiratory rate. Conclusions: Fluorescence-based enhanced reality allows for real time determination of the optimal anastomotic site and can detect the boundary between the ischemic and the vascularized zones even after repetitive assessments with a better performance when compared to clinical evaluation.

S061 S059 Minimally Invasive Colorectal Resection is Associated with Significantly Elevated Levels of Plasma Matrix Metalloproteinase 3 (MMP3) During the First Month After Surgery Which May Promote the Growth of Residual Metastases H. N. V Shantha Kumara, PhD, Xiaohong Yan, PhD, Hiromichi Miyagaki, MDPhD, Sahani De Silva, Vesna Cekic, RN, Richard L Whelan, MD Division of Colon and Rectal Surgery, Department of Surgery, St Luke’s-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USA; Department of Gastroenterological surgery, Graduate school of Medicine, Osaka University Introduction: MMP3, a member of the matrix metalloproteinase (MMP) family, is involved in the breakdown of extracellular matrix in normal physiologic processes such as tissue remodeling and may also play a role in cancer progression and metastasis. Minimally invasive colorectal resection (MICR) may increase plasma MMP3 levels directly via surgical trauma or indirectly due to surgery associated elevations in TNF-a, and IL1 which are biosynthetic regulators of MMP3. Over expression of MMP3 has been demonstrated in patients with breast, lung and colorectal cancer (CRC). MMP3 activates other MMPs such as MMP7 and MMP9 and is crucial in connective tissue remodeling. Together with its activator mtariptase, MMP3 has also been associated with the promotion of angiogenesis and wound epithelialization. The impact of MICR for CRC on plasma levels of MMP3 is unknown. This study’s purpose was to evaluate plasma MMP3 levels during first month after MICR for CRC. Method: Patients enrolled in an IRB approved data/plasma bank who underwent elective MICR for CRC for whom adequate plasma samples were available were included in this study. Clinical, demographic and pathological data were prospectively gathered. Blood samples had been collected PreOp and at varying postoperative (Postop) time points and were stored at -80 °C. Only patients for whom PreOp, Postop day (POD) 1, 3 and at least 1late postop plasma sample (POD7-34) were available were included in this study. The late samples were bundled into 4 time periods (POD713, POD14-20, POD21-27, and POD 28–34) and considered as single time points. MMP3 levels were analyzed in duplicate via ELISA and the results reported as mean and ±SD. The paired t-test was used for analysis (significance, p \ 0.008 after Bonferroni’s correction). Results: A total of 73 CRC patients who underwent MICR met the inclusion criteria (34 males /39 female, mean ages 66.3 ± 12.8 years; 28 % rectal and 62 % colon lesions). The mean incision length was 7.8 ± 3.6 cm and mean length of stay was 6.8 ± 4.4 days. The final cancer staging breakdown was; Stage I, 27 %, Stage II, 33 %, stage III, 36 % and stage IV, 4 %. The mean PreOp MMP3 level was 14.9 ± 7.8 ng/ml (n = 73). Significantly elevated mean plasma levels were noted on POD1 (21.4 ± 14.7 ng/ml, n = 73, p = \ 0.0001), POD3 (37.9 ± 21.5 ng/ml, n = 72, p B 0.0001), POD7–13 (22.0 ± 13.0 ng/ml, n = 56, p B 0.0001), POD14–20 (21.9 ± 10.3 ng/ml, n = 20, p = 0.003) and on POD 21–27 (21.9 ± 11.43 ng/ml, n = 20, p = 0.002) when compared to PreOp levels. Plasma levels returned to the PreOp baseline at the POD 28–41 time point (n = 16, p = 0.07). Conclusion: Plasma MMP3 levels remained significantly elevated from baseline for 4 weeks after MICR for CRC. The cause of the MMP3 elevations in the early postop period may be the short lived surgery-related acute inflammatory response which includes elevations in blood IL-1 and TNF levels. The increases during weeks 2–4 may be related to wound healing. Increased MMP-3 levels may promote metastases or the growth of residual cancer. Larger studies are warranted to validate these findings and to determine the clinical effects, if any, of elevated MMP-3 levels.

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Hypopharyngeal Pepsin and SEP70 as Diagnostic Markers of Laryngopharyngeal Reflux Yoshihiro Komatsu, MD, Lori A Kelly, BS, Ali H Zaidi, MD, Christina L Rotoloni, BS, Juliann E Kosovec, BS, Katie Nega, BA, Toshitaka Hoppo, MD, PhD, Blair A Jobe, MD, FACS Institute for the Treatment of Esophageal and Thoracic Disease, Allegheny Health Network, Pittsburgh, Pennsylvania Introduction: The management of patients with laryngopharyngeal reflux (LPR) has been challenging. Hypopharyngeal multichannel intraluminal impedance (HMII) has shown to increase the sensitivity in diagnosing LPR, potentially improving the outcome of antireflux surgery. The objective of this study is to investigate the potential use of pepsin and the heat stress protein Sep70 as diagnostic tools for the detection of LPR in combination with HMII. Methods and Procedures: Tissue samples of hypopharynx, distal esophagus, and gastric cardia were collected from patients with LPR symptoms regardless of gastroesophageal reflux (GERD) diagnosis and underwent HMII with a specialized catheter to detect LPR and high esophageal reflux (HER: reflux 2 cm distal to upper esophageal sphincter) events. Patients were classified into 2 groups based on the presence of abnormal proximal exposure (APE), which was defined as LPR C1/day and/or HER C5/day: (1) APE, (2) without APE. Patients with typical GERD symptoms such as heartburn and regurgitation, without LPR symptoms who did not undergo HMII were used as a ‘‘normal’’ GERD group. Protein was isolated from fresh frozen tissue samples and Western blot analysis of pepsin, Sep70, and actin (indigenous control) was performed. Pepsinogen was used as a control to differentiate pepsin from pepsinogen. Relative quantitation was performed using Image Studio Lite Software with normalization against the internal actin of each blot. Results: From Oct 2012 to Aug 2013, 49 patients underwent HMII. Of 49, 12 patients underwent biopsies from hypopharynx (9 APE [+] and 3 APE [-]). Ten patients with typical GERD symptoms who underwent biopsies from hypopharynx were identified from tissue bank as a ‘‘normal’’ GERD group. Pepsin was detected in distal esophagus in all groups; however patients with APE had decreased expression. In contrast, pepsin levels of hypopharyngeal tissue were 2-fold greater in patients with APE compared to patients without APE, and Sep 70 was significantly downregulated in the patients with APE (p = 0.015). The median DeMeester score of APE group and without APE group were 9 (range 2.1–38.6) and 3.5 (range 0.8–27.1), respectively. Conclusion: Presence of pepsin and depletion of Sep70 in the hypopharyngeal tissue may indicate tissue damage by abnormal reflux exposure to laryngopharynx. However, the normative data for these markers have to be validated. Data set is currently being expanded and will be presented at the conference.

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S064

Tissue Storage Ex Vivo Significantly Increases Vascular Fusion Bursting Pressure James D Cezo, PhD, Eric A Kramer, MS, Jonathan A Schoen, MD, Virginia L Ferguson, PhD, Mark E Rentschler, PhD University of Colorado at Boulder

Laparoscopic Needle-Assisted Inguinal Hernia Repair in Children Lauren E McClain, MD, Christian Streck, MD, Aaron Lesher, MD, Andre Hebra, MD Medical University of South Carolina

Introduction: Harvested biological tissue is a common medium for surgical device assessment in a laboratory setting; this study aims to differentiate between surgical device performance in the clinical and laboratory environments. Vascular tissue fusion devices are particularly sensitive to environmental changes due to a reliance on tissue-device temperature gradients, tissue water content and ionic concentrations, each of which can vary following ex vivo tissue storage. In this study, we aim to standardize the methods by which bursting pressure, the industry standard in fusion strength measurement, is collected in order to reduce extrinsic testing variance and facilitate comparisons of device performance. To assess the impact of tissue storage on the efficacy of vascular fusions, bursting pressures were measured for porcine venous tissues that were fused in vivo and compared to adjacent tissues that were harvested, stored, and then fused ex vivo. Methods: Epigastric veins (in 5 cm increments) from seven porcine models were subject to identical bursting pressure protocols after fusion. One half of each vein was fused in vivo, harvested and immediately analyzed for burst pressure, the remainder was stored (0.9 % Phosphate Buffered Saline, 24 h, 4 °C) and then subjected to identical fusion and burst pressure testing ex vivo. Histological slides were prepared for qualitative analysis of in versus ex vivo fusions (n = 2 sections / sample). Results: Bursting pressures were significantly different between vessels fused in vivo (310 ± 127.7 mmHg) and those fused ex vivo (514.7 ± 187.0 mmHg, p = 2.06 E-10). While the ex vivo samples displayed a greater variance between animals, they were consistent with a marked increase in bursting pressure (?BP = 216.7 ± 124.0 mmHg, a 70 % increase). Histological imaging of venous axial cross-sections indicated the lamination of adventitia and media layers in ex vivo fusions, whereas the media was compressed and buckled away from the fusion region in in vivo samples. Conclusions: These findings suggest that the fusion of porcine venous tissue ex vivo may overestimate the clinical performance of fusion devices. We have previously demonstrated that increased tissue hydration and the lamination of tissue layers both positively affect the bursting pressure of arterial fusions. The bursting pressure increase observed in this study may therefore be due to added tissue hydration during storage, structural variations between live and stored tissues, or alterations in the fusion process due to tissue-device temperature gradients. While harvested tissue provides an accessible medium for comparative study, the fusion of vascular tissue in vivo may avoid the biomechanical alterations induced by ex vivo tissue storage, and is likely a better indicator of fusion device performance in a clinical setting.

Background: For decades open inguinal hernia repair(Ferguson repair) has been the gold standard in treatment of inguinal hernias in children. Recurrence and complication rates are low and patient satisfaction is high, however, we propose a new method for inguinal hernia repair using laparoscopic techniques with comparable outcomes. Objective: We describe our technique and experience with the laparoscopic needle-assisted repair of inguinal hernia (LNAR). We report 502 cases (710 hernias) from 2009–2013 by 3 surgeons. Methods: We retrospectively reviewed a prospectively collected outcomes database of all patients receiving laparoscopic needle-assisted repair of inguinal hernia from January 2009-March 2013. 502 cases in 495 patients \13 years old with 710 inguinal hernias were identified for analysis and review. Hernia repair is accomplished with a single port needle-assisted technique. The internal inguinal rings are identified to confirm patent processus vaginalis and to evaluate for occult contralateral hernia. The ring is encircled in an extraperitoneal plane using a 22G Touhy needle for placement of a purse-string suture. The knot is tied extracorporally and then buried beneath the skin. The technique was standardized for all cases. Results: 710 inguinal hernias were laparoscopically repaired in 495 patients (408 boys & 87 girls). Patients’ age ranged from 11 days–12.8 years with a mean of 29.2 months and median of 15.5 months. 294 had unilateral repair (199 right & 95 left) and 208 had bilateral inguinal hernia repair. Mean operating time for unilateral hernia was 20.5 min (range 8–57 min) and bilateral hernia was 26.4 min (range 12–51 min). 150 of the patients who underwent bilateral hernia repair were diagnosed as having unilateral hernia preoperatively. 21 minor complications were identified and included 9 superficial wound infections, 8 suture granulomas, and 4 recurrent hydroceles. 4 recurrences (1 Preterm and 3 Term) have been identified in our data. Mean time since surgery is 30 months (range 3–54 months). Mean follow-up was 10.7 months (range 0.3–38.4 months). Follow-up included: Long-term (1 year) on 208 patients, medium-term (1–11 months) on 64 patients, and short-term (\1 month but [1 week) on 194 patients. Conclusion: Post-operative data shows our technique is safe with a 4 % (8 granuloma, 4 persistent hydroceles, 9 wound infections) rate of minor complication. Recurrence rate was 0.56 % for the total number of hernias (4/710). This makes recurrence rate comparable to classical open technique although further follow-up is required for additional post op data. Furthermore, laparoscopy objectively identifies asymptomatic or occult contralateral defect; uses a smaller incision; and eliminates dissection of the cord structures potentially reducing the risk of cord injury. LNAR is a safe and possibly very effective technique for minimally invasive inguinal hernia repair in children.

S063 Self-Assembling Biomimetic Hydrogels with Bioadhesive Properties for Tissue Engineering Applications Bryan A Johnson, MD, Jennifer Vernengo, PhD, Jennifer Kadlowec, PhD, Christine Iftode, PhD Cooper University Hospital of Rowan University, Rowan University Department of Engineering Tissue engineering is a multidisciplinary field that aims to repair or regenerate lost or damaged tissues and organs in the body. A key aspect of tissue engineering is the use of a scaffold, or threedimensional biomaterial that houses stem cells and provides biochemical cues to promote the formation of new tissue. However, for certain applications, success of a tissue engineering strategy depends on having a scaffold that adheres with adjacent tissue, anchoring it in place, and thereby potentially improving outcomes. Such integration may be achieved with the use of a bioadhesive polymer that covalently bonds with tissue. However, current bioadhesive polymers suffer from poor biocompatibility. In this collaborative project among faculty at Rowan University and Cooper University Hospital, we aim to design and characterize a bioadhesive polymer so that, in addition to bonding with tissue, it can support cell survival and differentiation post-adhesion with surrounding tissue. In the current work, we present the characterization of the adhesive strength of a multicomponent ‘‘smart’’ hydrogel system. We also demonstrate the thermally triggered release of ECM-derived components, which become integrated into the gel, allowing for the assembly of a biomimetic matrix. In future work, we will characterize the long-term viability of adipose-derived stem cells encapsulated within the scaffold. This work will have therapeutic potential for several tissue engineering applications, such as fistula and intervertebral disc repair.

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A Single Institutional Comparison of Endoscopic and Open Abdominal Component Separation with Risk Stratification Said C Azoury, MD, Andrew P Dhanasopon, MD, Xuan Hui, MD, MSc, Carla De La Cruz, BS, Justin M Sacks, MD, Kenzo Hirose, MD, Thomas H Magnuson, MD, Caiyun Laio, MD, Monica Lovins, MS, CRNP, Hien T Nguyen, MD Department of Surgery, The Johns Hopkins Hospital; The Johns Hopkins University, School of Medicine; Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital; Johns Hopkins Bloomberg School of Public Health

Endoscopic Versus Open Component Separation: Systematic Review and Meta-analysis Noah J Switzer, MD, Mark A Dykstra, MD, Stephanie Lim, BSc, Erica Lester, MD, Richdeep S Gill, MD, PhD, Christopher De Gara, MB, MS, FRCSC, FACS, Xinzhe Shi, Daniel Birch, MD, FRCSC, Shahzeer Karmali, BSc, MD, MPH, FRCSC, FACS Department of Surgery, University of Alberta, Edmonton, Alberta, Canada, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada, and Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital

Introduction: Open component separation (OCS) is associated with complications secondary to loss of blood supply to overlying skin flaps. Endoscopic component separation (ECS) has gained popularity in the last decade. We analyzed surgical factors and outcomes data in the largest single institutional study comparing endoscopic and open component separation. Methods and Procedures: A prospectively maintained database was queried, identifying 76 patients who underwent component separation for ventral hernia repair with mesh from 2010 to 2013: 34 OCS and 42 ECS. Comparisons were made for demographics, surgical factors, ASA class, percent of patients with a history of prior hernia and abdominal surgery, smoking (with and without COPD), diabetes, and the use of chronic anticoagulation. Estimated blood loss (EBL), operative time, and length of stay were analyzed. Group differences by continuous and categorical variables were compared by using simulation ANOVA and Fisher’s exact test respectively. Wound complications and hernia occurrence were reviewed. Univariate and multivariate analyses were used to assess association between technique, surgical factors, and outcomes. Results: The ECS group had a lower BMI (35 vs 42 kg/m2; P = 0.004), older age (58 vs 50; P = 0.0016) and smaller defect size (174 vs 268 cm2; P = 0.028), with no other differences in surgical factors. In the ECS group, 25 patients (60 %) underwent subsequent laparoscopic hernia repair, and 17 (40 %) underwent open repair. Primary fascial closure was achieved in all ECS patients, and all but one OCS patient (97 %). Operative time for ECS was significantly longer than OCS (334 vs 239 min; P \ 0.001) even when adjusting for BMI (P = 0.021) and defect size (P = 0.023), however there was no difference in length of stay (4 days in both groups, P = 0.64) and estimated blood loss (ECS: 97 vs OCS: 93 cc, P = 0.847). In a sub-analysis of ECS patients, those who underwent laparoscopic hernia repair had a 96 min shorter operative time (P \ 0.001) and lower EBL (63 versus 147 cc, P \ 0.001) than open repair. Wound complications were 23 % in the ECS (n = 10) and 32 % in OCS group (n = 11); 7 required intervention in the ECS versus 10 in the OCS group. There was one midline hernia recurrence in the ECS group (mean follow-up of 8 months, range 0.5–34.5 months) and no hernia recurrences in the OCS group (mean follow-up 10 months, range 0.5–30 months). Three of the patients in the ECS group developed new lateral abdominal wall hernias postoperatively. Conclusions: No significant associations were found between procedure, mesh type, risk factors and outcomes. ECS had a significantly longer operative time than OCS, however in the ECS group, those who underwent subsequent laparoscopic hernia repair had a shorter operative time and blood loss than open repair. Though endoscopic component separation has the potential to decrease morbidity for abdominal wall reconstruction, careful follow-up is essential to determine if hernia outcomes are similar to the open technique.

Background and Objectives: The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. CST is based on the concept of reestablishing a functional abdominal wall by relaxing the external oblique aponeurosis bilaterally, allowing for a tension free midline fascial closure. Open CST, introduced in 1990, necessitates a large subcutaneous skin flap in the midline, and therefore is associated with significant wound complications, related to ischemia and infection. The endoscopic component separation technique (ECST) was developed in efforts to minimize wound complications. It has been suggested in preliminary studies to reduce wound complication rates post-operatively. To date, there have been no systematic reviews to assess the effectiveness of endoscopic versus open component separation. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies.

S066 Prospective study of Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Mahak Chauhan, MBBS, Ashwani Kumar, MD, Anand Munghate, MD, Dr. Ashvind Bawa, MD Government Medical College and Hospital, Patiala, Punjab, India Background: Open Lichenstein repair method is commonly used to repair inguinal hernia although developing technology has led surgeons to consider using laparoscopy for the treatment of this commonly seen surgical disease. Here we have a prospective study which compares the results of an open mesh technique and laparoscopic transabdominal preperitoneal (TAPP) repair for inguinal hernia. Method: Over 2 years transabdominal preperitoneal (TAPP) laparoscopic repair and open Lichenstein repair method was performed in 180 patients. Patients were randomized into two equal groups. Group A (90) underwent transabdominal preperitoneal (TAPP) laparoscopic repair and Group B (90) had Open Lichenstein repair method. Patients rated their pain using the visual analogue scale (VAS), intra operative events and postoperative complications were noted. The Primary comparison was between duration of operation, post operative pain, complications, hospital stay, return to work, cost analysis and recurrence. Results: Of 180 patients undergoing surgery, the mean operative time for TAPP repair was 79.99 min, whereas it was 55.25 min for Lichenstein repair. Postoperative pain, measured at 12 and 24 h, was significantly less in TAPP group and the VAS pain score at 48, 72 h, postoperative day 7 was also lower than Lichenstein group, but these differences were not statistically significant. The only intra-operative complication which occurred in 5 patients (25 %) in TAPP group was peritoneal breach. There was no significant difference in length of hospital stay, which reflects the absence of major postoperative complications in both the groups. Patients in TAPP group returned to work in 14.6 days compared to 45.10 days for Lichenstein group. No short term recurrence was seen over 6 months of follow up. One of the most important issues dealt was the financial aspect of this comparison. TAPP procedure was more expensive even with its advantage of earlier return to work. Conclusions: The results of laparoscopic TAPP repair are comparable with Lichtenstein repair in terms of intraoperative and postoperative complications, success and short term recurrence rates. Though operative time was significantly higher than Lichtenstein group, Laparoscopic TAPP enable the patients to return to work earlier. More practice is essential to make operative time comparable to Lichtenstein repair.

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Methods: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of science and the Cochrane Library) using search terms ‘‘component separation’’ was completed. All randomized controlled trials, non-randomized comparison study, case series were included. All human studies limited to English were included. Two independently reviewers screened abstracts, reviewed full text versions of all studies classified and extracted data. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias (RoB) tools. Disagreements were resolved by re-extraction, or third party adjudication. Where possible and appropriate, a meta-analysis was conducted. Results: 64 primary studies (3200 patients) were identified that met our inclusion criteria for the systematic review and were assessed by full manuscript; no randomized controlled trials, 8 controlled studies and 56 case series. Endoscopic CST compared to open CST was shown to have lower mean rates of superficial wound infections (5.0 % vs 10.4 %), skin dehiscence (2.8 % vs 7.2 %), necrosis/debridement (4.1 % vs 6.1 %), hematoma/seroma formation (4.0 % vs 9.9 %), fistula tract formation (1.0 % vs 1.5 %), fascial dehiscence (0.0 % vs 0.4 %) and mortality (0.1 % vs 0.7 %. The open component CST did have lower rates of intraabdominal abscess formation (3.0 vs 4.3 %) and recurrence rates (10.1 % vs 12.9 %). The meta-analysis included 8 non-randomized controlled studies (412 patients). Endoscopic CST was associated with a significantly decreased rate of fascial dehiscence (Odds ratio = 3.18, p = 0.02). In addition similar trends were found that suggested endoscopic CST has decreased wound infection rates (Odds ratio = 1.61), necrosis (Odds ratio = 1.44), and hematoma/seroma formation (Odds ratio = 1.93), however these did not reach statistical significance. Conclusion: This systematic review and meta-analysis comparing ECST to open CST suggests ECST is associated with decreased overall post-operative wound complication rates including superficial infections, hematoma/seroma formation, necrosis, fistula formation, and both skin and fascial dehiscence. Further prospective studies are needed to verify these findings.

Surg Endosc (2014) 28:S240–S286

S261

S068

S070

Incidence and Risk Factors of Incisional Hernia Formation Following Abdominal Organ Transplantation Carter T Smith, MD, Micah G Katz, Janet M Bellingham, MD, Bridget Welch, Glen E Leverson, PhD, Luke Funk, MD, MPH, Jacob A Greenberg, MD, EdM University of Wisconsin Hospital and Clinics

Tacks, Staples or Suture: Method of Peritoneal Closure in Laparoscopic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair Effects early Quality of Life (QOL) Samuel W Ross, MD, MPH, Mimi Kim, MD, Bindhu Oommen, MD, MPH, Joel F Bradley, MD, Kristopher B Williams, MD, Amanda L Walters, MS, Kristian T Dacey, MHA, Vedra A Augenstein, MD, Brant T Heniford, MD Carolinas Medical Center, Dept. of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery

Introduction: The purpose of this study is to estimate the incidence of and risk factors for incisional hernia formation following primary abdominal solid organ transplantation. Hernia formation is common following abdominal operations and transplant patients are at increased risk due to their need for long-term immunosuppression. Methods and Procedures: We performed a single institution retrospective review of a prospectively collected database to evaluate all patients who underwent primary liver, kidney, or pancreas transplant over a ten year period. 3460 transplants were performed in the study period: 2247 kidney only, 718 liver only, and 495 pancreas or simultaneous pancreas and kidney (pancreas group). Patients who developed an incisional hernia at their transplant incision were identified. Univariate and multivariable Cox proportional hazards models were used to evaluate potential risk factors for incisional hernia formation. At our institution renal transplants are typically done through a flank, pancreas through a midline and liver through a bilateral subcostal incision. Results: The overall incisional hernia rate was 7.46 % (n = 258). The Kaplan-Meier rates of hernia formation at 1, 5 and 10 years were 2.46 %, 4.86 % and 7.04 % for kidney; 4.46 %, 8.67 % and 19.04 % for liver; and 2.49 %, 12.7 % and 21.76% for pancreas groups. Univariate analysis identified that surgical site infection (SSI) was associated with a statistically significant increase in hernia formation in all 3 groups as was BMI[25 in the kidney and liver groups (Table). Delayed graft function (DGF), not starting a calcineurin inhibitor, and not starting mycophenolic acid (MMF) during initial hospital stay were associated with an increase in hernia formation in the kidney group. As were the use of cyclosporine and the lack of MMF during the initial hospital stay in the pancreas group. Age, race, and gender and model end organ liver disease score (MELD) score were not associated with an increased hernia risk. On multivariate analysis, SSI was an independent risk factor for incisional hernia formation in all groups. Not including MMF in the induction %regimen was predictive of hernia formation in the kidney group as was the use of cyclosporine in the pancreas group. Median follow up was 4.55, 4.17 and 5.63 years in the kidney, liver, and pancreas groups. Conclusions: Incisional hernias are common following abdominal organ transplant. SSI is a known risk factor for hernia formation and was highly associated in all groups. Hernia rates were significantly lower in the renal transplant group, likely due to a retroperitoneal approach. Patients with a BMI [25 showed increased risk in the liver and kidney groups, but not in the pancreas group likely due to a lower mean BMI in this group. Initial immunosuppression appears to be important in rate of hernia formation.

Results of univariate analysis Kidney

(n = 2247)

Liver

(n = 718)

Pancreas

(n = 495)

Age

1.01

0.116

1.01

0.284

1.03

0.136

Male

0.980

0.909

1.50

0.097

1.03

0.902

African American

0.50

0.13

0.506

0.499

0.335

0.278

MELD

NA

NA

0.995

0.693

NA

NA

Diabetes

0.88

0.581

NA

NA

NA

NA

BMI \ 18.5

1.26

0.756

1.24

0.781

0

0.982

BMI [ 25

1.77

0.015

1.85

0.0437

1.06

0.808

SSI

28.75

\0.0001

13.241

\0.0001

12.95

0.0006

DGF

1.94

0.0026

NA

NA

NA

NA

Introduction: TAPP inguinal hernia repair (IHR) entails the development of a peritoneal flap (PF) in order to reduce the hernia sac and create a preperitoneal space in which to place mesh. Many methods for closure of the PF exist including sutures, tacks and staples. Given the physical characteristics of each closure type, we hypothesized that patients who had PF closure with suture had better short-term QOL outcomes. Methods and Procedures: A prospective institutional hernia-specific database was queried for all adult, TAPP IHRs from July 2012 to August 2013. Unilateral and bilateral patients were included and each hernia was analyzed separately. Demographics, operative characteristics, and complications were analyzed by PF closure method with standard statistical methods. A p B 0.05 was significant on the global test, and using the Bonferroni correction, p B 0.0167 was significant on the pairwise test. The main outcome of interest was QOL at two and four week follow-up, as measured by the Carolinas Comfort Scale, a hernia specific QOL tool measuring pain, mesh sensation and movement limitation with ‘‘mild, but bothersome’’ or greater being considered positive. Results: There were 227 patients who underwent TAPP, with 99 bilateral and 128 unilateral IHR, for a total of 326 IHR. PF closure was performed using tacks in 45.1 %, suture in 19.0 % and staples in 35.9 %. Patient characteristics were statistically similar between the tack, suture, and staple group: age (54.3 ± 14.7 vs 54.0 ± 13.9 vs 51.2 ± 15.4), male (95.9 % vs 83.9 % vs 94.9), BMI (26.4 ± 4.4 vs 26.6 ± 7.4 vs 26.0 ± 3.3 kg/m2), smoking (2.7 % vs 9.7 % vs 5.1 %), incarcerated (17.7 % vs 14.5% vs 23.9%), pre-operative pain (57.1% vs 50.0% vs 71.0%) and movement limitation (44.1% vs 40.9% vs 57.1%). There were 32.9% direct, 46.5% indirect, and 20.6% pantaloon hernias, which were not significantly different by PF closure method. Post-operative complications and length of stay were same for the three groups. There were no hernia recurrences. QOL outcomes are presented in the Table 1. Post-operative movement limitation at two weeks was significantly better in the suture group when compared to the stapled group (p = 0.006). Additionally, sutured PF closure had less early post-operative pain when compared to the tack group but this lost statistical significance with the Bonferroni correction (p = 0.038) Conclusions: Following TAPP IHR, suture closure of the PF significantly improves 2 week post-operative movement limitation compared to stapled PF closure. Although not statistically significant, the suture group had a trend toward better early post-operative pain, movement limitation, and mesh sensation when compared to tack and stapled PF closure methods. Continued prospective studies are needed to determine the best surgical hernia repair methods for ideal post-op QOL.

Table 1

Port-operative Early QOL by Peritoneal Flap Closure Method: Symptomatic

Movement Limitation* Mesh Sensation

Staple (%)

55.9

30.4

55.3

42.4

21.7

57.9

34.4

26.1

23.7

20.0

30.0

41.7

10.0

10.0

29.2

10.0

0

20.8

4 Week Pain Movement Limitation

Groin Defects Seen at Laparoscopic Extra-Peritoneal Dissection During Surgical Treatment OF Athletic Pubalgia Krzysztof J Wikiel, MD, George M Eid University of Pittsburgh Medical Center

Suture (%)

2 Week Pain

S069

Tack (%)

Mesh Sensation

* Statistically significant p \ 0.05, between suture and staple

Background: Over the past thirty years a new disease process, now known as athletic pubalgia or sports hernia has been acknowledged, nevertheless the etiology is still not fully understood. The patients suffering from this ailment, often young and active, present to the physician’s office with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. These pain symptoms can lead to reduction or withdrawal from the sports activity, which not only can affect the quality of life, but in some instances can cause career and financial losses, thus further study of this entity is important. Careful physical exam often reveals groin weakness which cannot explain the complexity of the patients’ symptoms. Though physical therapy and medical treatments are considered first line remedies by many, surgical treatment appears to have better, quicker, and more durable outcomes. Based on the available literature, procedures aimed at groin reinforcement such as laparoscopic reinforcement or other hernia repairs seem to relieve most if not all the symptoms in the majority of patients. Despite many surgeons intraoperatively noting rectus insertion or adductor anomalies, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. Materials and Methods: Forty patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for athletic pubalgia in our practice from 2007 through 2011. These patients were divided into four subgroups based on level of engagement in their respective sports. These were professional, college, high school, or recreational level sports players. All patients underwent wide and bilateral groin dissection and the findings were cataloged. Results: All of the patients presented with some defects upon wide groin dissection. Thirty-four patients (85 %) presented with small bilateral indirect inguinal defects and 28 (70 %) patients did not have any additional defects. Five patients (12.5 %) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to the defects mentioned above, five patients (12.5 %) had additional unilateral femoral hernias, whereas no patient had a solitary femoral hernia defect. Additionally, we noted that within the competitive sports player group (professional, college, high school level) all the patients had only small indirect bilateral defects. Conclusions: Athletic pubalgia is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports, and surgical methods appear most effective at offering the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in pathophysiology of the sports hernia.

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S073

Patient Centered Outcomes Following Laparoscopic Inguinal Hernia Repair Michael B Ujiki, MD, FACS, Chi Wang, PhD, Ryota Tanaka, MD, Mattew Gitelis, BS, Ermilo Barrera, MD, FACS, John Linn, MD, Steve Haggerty, MD, Zeeshan Butt, PhD, Joann Carbray, BS, Woody Denham, MD, FACS NorthShore University HealthSystem, Northwestern Univeristy

Utility of a Human-Type Robot as Humanoid Surgeon in Multi Piercing Surgery of Ultra-Minimally Invasive Laparoscopic Surgery Ohdaira Takeshi, Prof, Atsuo Takenishi, Prof Center for Advanced Medical Initiatives, Kyushu University

Introduction: Inguinal hernia repair is the most common surgical procedure performed in the world. Quality of life outcomes are probably the most important element of a successful repair. This study aimed to describe both short and long-term quality of life outcomes in a cohort of patients undergoing laparoscopic inguinal hernia repair.

Methods and Procedures: We prospectively followed 288 patients who underwent totally extraperitoneal laparoscopic inguinal hernia repair as part of an Institutional Review Board-approved study. Short form-36 (SF-36) and Surgical Outcomes Measurement System (SOMS) were administered pre-operatively, at three weeks, six months, and one year post-operatively. A mixed-effect regression model was constructed with unspecified variance-covariance structure. Pair-wise comparisons were made between time points, and p-values were Bonferroni adjusted. Results: Mean age was 56.2 ± 15.2 years and 92 % were male. Mean body mass index was 26.4 ± 3.7 kg/m2. Eighty percent presented with painful hernias, the majority of which were described as mild. Hernias were unilateral right-sided in 48 %, left-sided in 37 %, and bilateral in 15 %. Twenty-eight percent presented with a recurrent hernia. Average operative time was 46.0 ± 23.3 min and there were no intra-operative complications. Urinary retention occurred in 16 %. Length of stay averaged 10.8 ± 10.1 h. Visual analogue score at discharge was 1.9 ± 1.7. Analgesics were used an average of 2.5 ± 3.6 days and return to daily activities and work occurred on post-operative day 5.2 ± 4.3 and 5.4 ± 3.6 days respectively. Recurrence occurred in 2 %. Role limitations due to physical health was significantly worse at week 3 (baseline 81.9 ± 26.0 versus 68.8 ± 29.0, p = 0.02) but was significantly improved from baseline at one year (92.2 ± 19.0, p \ 0.05). Energy and fatigue were significantly worse at week 3 (70.5 ± 17.6 versus 65.5 ± 20.6, p = 0.01) but returned to baseline by 6 months. Pain significantly worsened at week 3 (84.6 ± 19.1 versus 69.9 ± 23.0, p 0.0006) but surpassed baseline at one year (91.2 ± 14.0, p = NS). Social function significantly improved at one year (78.4 ± 19.6 versus 83.8 ± 11.2, p = 0.0186). Conclusions: Laparoscopic totally extraperitoneal hernia repair negatively affects role limitations due to physical health, energy/ fatigue, and pain at three weeks but results in a significant improvement in social function and role limitations due to physical health at one year. On average, patients are able to return to activities of daily living and work within a week.

Purpose: The robot developed for clinical use such as da Vinci Surgical System allowed solo surgery, for example, prostatectomy within a restricted operative field. However, concerning gastrectomy or colectomy, which needs widely dynamic action such as overturning organs, it is difficult to operate at the same position. For its reason, surgeons frequently have to move the whole body of heavy robot. We successfully performed minimally invasive endoscopic surgery by using humanoid. The following four points are benefits of humanoid in compare with conventional commercialized surgical robots: 1) easy adaptation to conventional equipment of operation room as same as human surgeon; 2) prevention of instability caused by fatigue in robot hands; 3) quick transportation without help of commander surgeon; 4) possibility of storage in compact space. Methods: We carried out humanoid-assisted solo surgery by NOTES-assisted Needlescopic Surgery, what is defined as Multi Piercing Surgery (MPS). Partial gastrectomy and cholecystectomy were performed in two pigs. The utility of a humanoid was evaluated about 1) accuracy and 2) stability of posture. At first, instability and stability of endoscopic view were evaluated with the naked eye by observing the video recorded by the 3D camera in glassless 3D monitor. Furthermore, we clarified the instability of endoscope by the sensor coil of electromagnetic navigation system inserted through the channel of the endoscope. And then the time that required for move from storage position to surgery position for humanoid, was counted. Results: It turned out that flexible endoscope operation by humanoid did not cause any instability except for minor deviation that originated in the physical property of flexible endoscope. Center point of endoscopic view did not tremble in evaluation of both grassless 3D monitor and tracks of electromagnetic navigation system at all. Furthermore, unlike conventional robots, humanoid as same as surgeon of human-being was able to be quickly set at the surgery position. Conclusion: Humanoid in MPS possibly works as a useful tool to ensure safety and certainty without changing conventional equipment of operation room.

S074

S072 Robotic Versus Laparoscopic Surgery for Colonic Disease: A Meta-Analysis of Post-Operative Variables Lucy M De La Cruz, MD, Alvaro E Castillo, MD, Alberto Zarak, MD, Kandace M Kichler, MD, Leonardo Tamariz, MD, MPH, Srinivas Kaza, MD, FACS University of Miami, Regional Campus, West Palm Beach, Florida Background: Multiple studies provide evidence of superiority in laparoscopic compared to open colectomy. Little is known about the advantages or disadvantages of laparoscopic surgery (LC) versus robotic surgery (RC) in colon disease. This meta-analysis compares the post-operative findings including length of stay (LOS), return of bowel function (RBF) time, and complications. Methods and Procedures: We performed a MEDLINE database search with secondary referencing to identify studies suitable for inclusion. Selected studies included those in which LC and RC were compared in terms of post-operative outcomes. We calculated the I squared statistic as a measure of heterogeneity. We used fixed and random effects models to calculate the standardized mean difference (SMD) and the odds ratio (OR) between the LC and RC groups. Results: Seven studies with a total of 694 cases were analyzed: 236 RC cases and 458 LC cases. Resection due to malignancy was done on 60.7 % (421) of patients. No difference in LOS between RC and LC was found; however, right RC was associated with earlier RBF (p = 0.01). Surgical complications were similar between both groups, with OR of ileus 1.3 (0.7–2.7) p = 0.34, anastomotic leak 0.7 (0.1–3.6) p = 0.75, bleeding 1.1 (0.5–2.7) p = 0.68, and wound infection 1.4 (0.5–3.7) p = 0.45. Data comparing number of lymph nodes was similar for both groups (p = 0.74). Conclusions: There is no statistical difference in terms of LOS and surgical complications between RC and LC, however right colectomy demonstrated earlier RBF time in the RC group.

Robotic Versus Laparoscopic Cholecystectomy: Does the End Justify the Means? Jan P Kaminski, MD, MBA, Kenneth W Bueltmann, MD, Marek Rudnicki, MD, PhD University of Illinois Metropolitan Group Hospitals Introduction: Robotic-assisted cholecystectomy (RAC) was introduced about five years ago, and has recently gained popularity in general surgery as more surgeons have become familiar with the technique. High cost of the procedure seems to affect its widespread utilization. With its more extensive use by experienced surgeons familiar with this procedure, cost of RAC might be more controlled with similar outcomes. Methods and Procedures: The Nationwide Inpatient Sample (NIS) from the Health Cost Utilization Project was analyzed using HCUPnet, NIS datasets and SAS 9.2 for the years 2010–2011. Queries were made for RAC and LC (ICD-9 17.42 + 51.23, 51.23) procedures with a primary diagnosis of gallbladder disease (ICD-9 574.0–574.9, 575.0–575.9, 575.12). The NIS weighting algorithm was used for National estimates. Overall charges, costs, number of chronic conditions and lengths of stay were calculated. The NIS Z-score calculator was utilized for all statistics. Results: Total number of RAC and LC in the NIS database for years 2010 and 2011 are shown in the table. The incidence of RAC more than doubled between 2010 and 2011. Total costs for LC increased by 2.5 % (p \ 0.05) while total costs for RAC decreased by 14.6 % (p = 0.27) between 2010 and 2011, even though RAC was still costlier than LC in 2011. The estimated cost differences between RAC and LC in 2010 and 2011 were $7,518, +54 %, (p \ 0.05) and $4,044, +29 %, (p \ 0.05). The total charge of LC increased by 8 % (p \ 0.05) between 2010 and 2011, while the total charge for RAC increased by 13.3 % (p = 0.33). Total charge difference between RAC and LC in 2010 and 2011 were $19,719, +47 %, (p \ 0.05) and $24,526, +54 %, (p \ 0.05) respectively. There was no significant difference in the LOS between RAC and LC in either years. Interestingly, the patients undergoing RAC had an increased number of chronic conditions compared to patients undergoing LC in both 2010 and 2011. 2010

SMD (95 % CI) p value for RBF time

2011

SMD(95 % CI)p value for LOS

Both

0.35 (0.05–0.65) 0.02

Left

0.15 (-0.10 to 0.41) 0.25

-0.63 (-2.3 to 1.0) 0.47

0.04 (-0.89 to 0.94) 0.92

Right

0.32 (0.09–0.55) \ 0.01

-0.09 (-0.68 to 0.49) 0.74

Procedure

LC

RAC

LC

RAC

Number

362,971

524

370,958

1084

Total costs

$13,829

$21,346*

$14,180#

$18,224*

Cost difference

$7,518*; 54 %

$4,044*; 29 %

Total charges

$41,781

Charge difference

$19,719*; 47 %

Length of stay (days)

4.14

3.63

$61,500*

4.10

$45,150#

4.59

$69,677*

No of chronic conditions

3.02

3.59*

3.15#

3.96*

$24,526*; 54 %

Legend * p \ 0.05 for RAC vs LC within examined year # p \ 0.05 for 2010 vs 2011

Conclusion: The number of RAC is increasing in the United States. Outcomes of RAC, as measured by one available indicator, LOS, are similar to LC. Cost of RAC however remains higher compared to LC although there was noticeable reduction in cost of RAC in 2011 versus 2010. It would be very interesting to continue an observation of these trends since current cost of RAC might prohibit its more widespread use among laparoscopic surgeons.

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S075

S076

Multidimensional Analyses of the Learning Curve of Robotic Low Anterior Resection for Rectal Cancer: 3-Phase Learning Process Comparison Eun Jung Park, MD, Seung Hyuk Baik, MD, PhD, Byung Soh Min, MD, PhD, Kang Young Lee, MD, PhD, Nam Kyu Kim, MD, PhD Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea

Ergonomic Enhancements for Laparoscopic Surgery Using Surgical Platforms Charles B Becker, BS, MEM, J Scott Roth, MD University of Kentucky College of Medicine

Introduction: We aimed to investigate the learning curve of robotic rectal cancer surgery by multidimensional statistical methods, and to compare the learning curve phases with respect to perioperative clinical and pathologic outcomes. Methods and Procedures: From April 2006 to August 2011, a total of 130 consecutive patients who were diagnosed rectal cancer underwent a robotic low anterior resection (LAR) by a single surgeon at Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea. Robotic LAR was performed on all the patients using the hybrid technique with the da VinciÒ surgical system (Intuitive Surgical, Sunnyvale, CA, USA). The moving average method and the cumulative sum (CUSUM) were used to analyze the learning curve. The risk-adjusted CUSUM (RA-CUSUM) analysis by using logistic regression was used for evaluation of the points which showed completion of the surgical procedure in terms of R1 resection, conversion, postoperative complications, harvested lymph nodes less than 12, and local recurrence. Perioperative clinical outcomes and pathologic results were compared among the learning curve phases. Postoperative complications were graded by the Dindo classification. A p-value of less than 0.05 was considered statistically significant. Results: According to CUSUM, there were two critical points of the surgeon console time, which determined the learning curve phases at the 44th and the 78th cases. Based on these results, the learning curve was divided into three phases: phase 1 [the initial learning period (1st–44th case), n = 44], phase 2 [the competent period (45th–78th case), n = 34], and phase 3 [the challenging period (79th–130th case), n = 52]. From the results of RA-CUSUM, the possibility of surgical failure was minimized at the 75th case. The total operation time including the surgeon console time and docking time tended to decrease after phase 1 (phase 1 = 229.8 ± 48.5 min, phase 2 = 189.4 ± 52.3 min, phase 3 = 181.6 ± 54.0 min, p \ 0.001). Number of harvested lymph nodes was 16.7 ± 7.9, 15.6 ± 10.0, 15.9 ± 9.6, respectively (p = 0.851). Circumferential resection margin involvement rate was 9.1 %, 5.9 %, 5.8 % (p = 0.829), and local recurrence rate was 0 %, 0 %, 5.8 % (p = 0.116), respectively. Grade III and IV postoperative complication rate was 6.8 % (3 cases), 0 %, 11.5 % (6 cases), respectively (p = 0.191). Conclusion: According to CUSUM, the primary technical competence of the robotic procedure for rectal cancer was achieved at phase 1 of the 44th case. However, the learning curve consisted of three phases. Moreover, technical completion of the robotic procedure to assure feasible perioperative clinical and pathological outcomes was achieved at phase 2 of the 75th case by the RACUSUM method .

Introduction: Traditionally, the operating room environment requires the surgeon to stand adjacent to an operating room table. Although this interface was suitable for open operations, the dynamics of laparoscopic surgery may require alternative solutions. Surgical platforms are apparatuses designed to position a laparoscopic surgeon above a patient while relieving pressure from the surgeon’s lower back, knees, and feet. The ETHOS surgical platform adjusts vertically, horizontally, and allows for angulation of the surgeons torso resulting in a forward leaning posture. This study evaluates the ergonomics of a surgical platform compared to a traditional surgical stance in performing laparoscopic suturing. Methods: A prospective, IRB-approved study was performed evaluating the impact of a surgical platform upon surgical accuracy, task completion time, and body mechanics. Board certified surgeons performed laparoscopic suturing in a simulated environment under three scenarios: 1. Standing adjacent to the laparoscopic simulator, 2. Seated in the Ethos surgical platform calibrated manually by the surgeon, and 3. Seated in the Ethos surgical platform following calibration based upon measured biophysical data (forearm, arm, back, thigh, and leg lengths), surgical site, and port location. Video recordings from behind and lateral to the surgeon were obtained and were analyzed for shoulder flexion, extension, and abduction. Accuracy of suture placement and time to completion of the skills were also measured. Results: Using the surgical platform in both the self-calibrated and biophysical-calibrated modes, the surgeons were found to have both a reduced mean angle of flexion (19.0° and 4.2°, respectively, p \ 0.05) and a reduced mean angle of abduction of the dominant arm (28.4° and 32.1°, respectively, p \ 0.05) compared to the traditional standing position (39.6° in flexion, and 47.3° in dominant arm abduction). In addition, the standard deviation of observed angles of flexion (9.8°, p \ 0.05) was reduced with biophysical calibration compared to the standing position (16.9°), indicative of a minimization the number and degree of movements made during the laparoscopic exercises. Also, data was trending to demonstrate the biophysical calibration led to a further reduction of flexion angle and standard deviation of flexion angle from the surgeon-calibrated platform. Neither suturing time nor accuracy was demonstrated to be affected. Conclusion: In addition to reducing strain on a surgeon’s lower back and legs during lengthy procedures, surgical platforms allow a surgeon to reduce the amount of shoulder torque required to maintain arm position in flexion and abduction, while also reducing the degree of arm motion in the flexion/extension plane. In the long term, this reduction of motion and strain would reduce aches and pains felt by the surgeon, and has the potential to lengthen the careers of surgeons.

S077 Robot-Assisted Surgical Task Performance Confers Ergonomic Benefits Compared To Laparoscopic Task Performance Ahmed M Zihni, MD, MPH, Jaime A Cavallo, MD, MPHS, Ikechukwu Ohu, BS, Sohyung Cho, PhD, Michael M Awad, MD, PhD Department of Surgery, Washington University School of Medicine; Department of Engineering, Southern Illinois University Edwardsville Introduction: Surgeons suffer significant ergonomic stress when performing laparoscopic procedures. Robotic surgery has been touted for the potential ergonomic advantages it may offer to surgeons, and subjective reports suggest an ergonomic benefit of the robotic platform. To date, there have been no quantitative studies of the ergonomic differences between the laparoscopic and current robotic surgical platforms. We sought to quantify these differences using surface EMG (sEMG) and the NASA task load index (NTLX). We hypothesized that task performance on a laparoscopic surgical platform will generate significantly higher levels of muscle activation as quantified by sEMG when compared to task performance on the robotic platform. We further hypothesized that significantly higher subjective workload, as quantified by NTLX, would be reported for the laparoscopic platform compared to the robotic platform. Methods: Thirty subjects (25 right-hand dominant, 4 left-hand dominant, 1 ambidextrous) with varying levels of surgical experience performed FLS peg transfer (PT), pattern cutting (PC), and intracorporeal suturing (IS) tasks on laparoscopic and robotic platforms. sEMG measurements were obtained from each subject’s bilateral bicep, tricep, deltoid, and trapezius muscles. Mean normalized muscle activation (%MVC) was calculated for each muscle group for each task on each surgical platform. We compared mean %MVC values with paired t-tests and considered differences with a p-value \ 0.05 to be statistically significant. All subjects also provided responses to the NTLX after task performance on each platform. Mean responses for each domain (mental, physical, temporal, performance, frustration, effort) were compared using paired t-tests. Results: %MVC data are shown in the table below. Significant differences of subjective workload were noted in the physical demand (59.5 laparoscopic, 24.7 robotic; p \ 0.001), temporal demand (45.4 laparoscopic, 31.2 robotic; p = 0.020), and effort (74.3 laparoscopic, 39.6 robotic; p = 0.005) domains of the NTLX. Conclusions: Among surgeons of varying levels of experience, laparoscopic task performance generates greater muscle activation in most upper extremity muscle groups when compared to robotic task performance. In simpler tasks (PT, PC), robotic task performance appears to generate greater right trapezius activation compared to laparoscopic task performance. This is not seen in the more complex IS task, suggesting that the ergonomic challenges of laparoscopic surgery are exacerbated by increased task complexity. Subjective workload is also significantly increased by laparoscopic task performance compared to robotic task performance. Mean %MVC PT Lap

PC Robot

Lap

IS Robot

Lap

Robot

Left biceps

3.5

2.2*

2.8

1.6*

3.0

2.1

Left triceps

2.8

1.5*

2.2

1.2*

2.4

1.5*

Left deltoid

2.7

1.5*

1.7

1.2*

2.8

1.4*

Left trapezius

6.5

5.6

6.0

4.8

7.0

5.2

Right biceps

4.2

1.5*

4.3

1.8*

2.6

1.5*

Right triceps

2.5

1.8*

2.3

2.0

3.1

1.6*

Right deltoid

2.4

1.5*

2.1

1.8

3.4

1.4*

3.5

5.7*

4.1

6.5*

8.4

5.7*

Right trapezius

Increased activation

* p \ 0.05

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National Utilization and Outcome of Laparoscopic vs. Robotic Elective General and Bariatric Surgical Procedures James P Villamere, MD, Alana Gebhart, BA, Stephen Vu, Ninh T Nguyen, MD Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA

Evaluating the Effect of Implementation of Ergonomic Principles into Laparoscopic Tool Handle Design on Surgeon Performance and Efficiency Kryztopher D Tung, MS, Rami M Shorti, MS, Earl C Downey, MD, Donald S Bloswick, PhD, Andrew S Merryweather, PhD Mechanical Engineering Department, University of Utah, Salt Lake City, UT, USA

Background: The robotic platform has been shown to be of greatest benefit in enabling surgeons to transition open procedures to laparoscopy. Currently, most gastrointestinal procedures have a high rate of laparoscopic adoption; however, the role for robotic assisted laparoscopic surgery for common general surgical procedures is still unclear. The aim of this study was to compare the utilization and outcome of laparoscopic (Lap) vs. robotic assisted laparoscopic (R-A Lap) techniques for common elective general and bariatric surgical procedures performed at academic medical centers. Methods: A retrospective, multicenter analysis utilizing a large administrative database was implemented. Using the ICD-9th revision diagnosis and procedure codes, data was obtained between October 2009 and September 2013 from the University HealthSystem Consortium clinical database for all patients who underwent Lap vs. R-A Lap techniques for 8 common elective general surgical procedures (gastric bypass, sleeve gastrectomy, gastric band, antireflux surgery, Heller myotomy, cholecystectomy, colectomy, rectal resection). Outcome measures including demographics, rate of robotic assisted laparoscopy, length of stay (LOS), major complications, in-hospital mortality, 30-day readmission, and cost were compared between groups. Chi-square and t test were used to compare outcome variables. Results: There were 104,292 Lap and R-A Lap general and bariatric surgical procedures analyzed. For all procedures, the preoperative severity of illness was similar between groups. Utilization of the robotic approach was highest for rectal resection (18.8 %), followed by Heller myotomy (7.6 %), sleeve gastrectomy (5.0 %), antireflux surgery (4.9 %), gastric bypass (2.5 %), gastric band (1.9 %), colectomy (1.6 %), and cholecystectomy (1.0 %). Compared to laparoscopy, all procedures had a mean 29 % higher cost associated with the robotic approach. There was no significant difference in in-hospital mortality or major complications between the two techniques for all procedures. Compared to robotic approach, laparoscopic sleeve gastrectomy and gastric banding had a shorter LOS (2.1 ± 1.4 vs. 2.5 ± 1.0; p \ 0.05 for sleeve and 1.3 ± 1.1 vs. 1.5 ± 1.2; p \ 0.05 for band); laparoscopic gastric banding and laparoscopic antireflux surgery had a lower 30-day readmission (1.05 % vs. 3.50 %; p \ 0.05 for band and 1.74 % vs. 3.35 %; p \ 0.05 for antireflux surgery). Outcomes were comparable between laparoscopic vs. robotic gastric bypass, colectomy, and rectal resection with the exception of cost. Only two procedures had improved outcome associated with the robotic approach; robotic Heller myotomy and robotic cholecystectomy had a shorter LOS compared to the laparoscopic approach (2.2 ± 1.9 vs. 2.9 ± 3.7; p \ 0.05 for Heller myotomy and 2.2 ± 1.7 vs. 2.8 ± 2.3 for cholecystectomy). Results were similar after stratification by illness severity and increased body mass index. No significant difference in in-hospital mortality or major complications between techniques persisted for all procedures at stratification. Cost was more comparable between techniques for most surgical procedures in major/extreme illness severity patients. Conclusion: This nationwide analysis of academic centers showed a low utilization of robotic assisted elective general and bariatric surgical procedures. Compared to conventional laparoscopy, there were no observed clinical benefits associated with the robotic approach but there was a consistently higher cost.

Introduction: A multitude of factors can affect a surgeon’s performance in the operating room; these may include surgeon comfort and skill level, tool handle ergonomics, and fatigue. The goal of this study is to quantify the effects of ergonomic laparoscopic tool handle design on surgeon performance and task completion efficiency. A laparoscopic tool handle designed with ergonomic considerations (pistol-grip) was tested against a current market tool with a traditional (pinch-grip) handle. We hypothesized that there will be a measurable difference between the efficiency of FLS surgical trainer tasks of the pistol-grip versus the pinch-grip laparoscopic tool handle designs in three categories: time to completion, technical skill, and subjective user ratings. Methods and Procedures: The pistol-grip incorporates an ergonomic interface intended to promote a more neutral operating posture, and influence the degree of hand tremor and fatigue while reducing contact stress points on the hand and fingers. The pinch-grip is a widely used current market tool. Twenty-three (13 M, 10 F) naı¨ve participants (medical students) with no existing upper extremity musculoskeletal disorders were selected for this study. During a training session prior to testing, participants performed practice trials in a SAGES FLS trainer with both tools. During data collection, participants performed three evaluation tasks with each tool. These consisted of a peg transfer task, a cutting task, and a suturing task. Two participants (1 M, 1F) were excluded from the final analysis due to incomplete or missing data. Results: Quantified survey feedback (Figure 1) from test participants significantly favors the pistol-grip in every category (P \ 0.05). While there was no significant interaction between tool type and errors (P [ 0.7) made during trials, time to trial completion was significantly lower for the pistol-grip tool during cutting (P = 0.001) and peg transfer (P = 0.007) tasks (Table 1). While there was no difference for the suturing task (P = 0.586), it is important to note that the needle grasper was the same for both tools and was used in the dominant hand. Conclusions: These findings favor the pistol-grip design and are part of a much larger study to quantify the effect of laparoscopic tool handle design on upper extremity biomechanics. Further testing with professionally trained laparoscopic surgeons in a more realistic test environment is needed to evaluate performance metrics including contact stress, posture, muscle fatigue, and economy of movement.

Table 1 Table of time to completion data Time to completion (seconds) Cutting**

Peg transfer*

Suturing

Ergonomic

115

98

59

Traditional

163

117

54

* indicates significance on the 0.05 level

S079

** indicates significance on the 0.01 level

Short-Term Surgical Outcome of Robotic Gastrectomy for Gastric Cancer: Comparison with Open and Laparoscopic Gastrectomy Joong-Min Park, MD, PhD, Kyong-Choun Chi, MD, PhD Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea Introduction: The aim of this study was to determine the short-term surgical outcomes of robotic gastrectomy compared with open and laparoscopic gastrectomy for the treatment of gastric cancer. Methods: Since the da Vinci surgical system was introduced in April 2011 at Chung-Ang University Hospital, we performed 11 robotic gastrectomies, 25 open gastrectomies, and 94 laparoscopic gastrectomies for the patients with gastric cancer of a stage lower than cT2N1. Clinicopathologic findings and surgical outcomes were analyzed by comparing the three groups. Results: Although the preoperative clinical stage of the patients was lower than T2N1, 76 % (19/25) in open group were cT2, whereas 23 % (22/94) in laparoscopic and 18 % (2/11) in robotic groups were cT2 (p \ 0.001). Thus, the pathologic stage was more advanced in open group than in laparoscopic and robotic group (p = 0.009), while type of gastrectomy and the extent of lymph node dissection were not different among the three groups. Thus, the same extent of surgery was performed in each group. Operative time was greatly longer in robotic group than in other two groups (p \ 0.001). Number of retrieved lymph nodes were statistically similar (37.3, 37.4, and 39.0, p = 0.685). Postoperative hospital stay in robotic group (7.4 days) was shorter than those in open group (16.9 days, p \ 0.001) or laparoscopic group (9.5 days, p = 0.002). Postoperative complication was similar in the groups. There was no open or laparoscopic conversion. Conclusion: The numbers of retrieved lymph nodes and the short-term clinical outcomes of robotic gastrectomy was comparable to those of open and laparoscopic gastrectomy, despite the surgeon’s familiarity with laparoscopic and open gastrectomy with lack of robotic experience. The benefits of this procedure such as earlier postoperative recovery and expected oncological merit in accurate lymph node dissection have to be proved by randomized controlled trial or well matched case-control study. Long operative time and high financial cost should be overcome.

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Fig. 1 Subjective Survey Ratings (Higher numbers are better)

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Comparison of FLS Surgical Skills Performance Using a Motorised Instrument by Conventional Laparoscopy and by Single Port Access Patrice Crochet, MD, Rajesh Aggarwal, PhD, Sophie Knight, MD, Karine Baumstarck, MD, Maxime Marcelli, MD, Jean-Philippe Estrade, MD, Eric Lambaudie, PhD, Alexandre Lazard, MD, Aubert Agostini, MD 1. Department of Gynecology, La Conception Hospital, Assistance Publique des Ha˘’pitaux de Marseille, France. 2. Department of Surgery, Perelman School of Medicine, University of Pennsylvania

Management of Acute Cholecystitis in Cancer Patients–A Comparative Effectiveness Approach Thejus Thayyil Jayakrishnan, MD, Ryan T Groeschl, MD, Ben George, MD, James P Thomas, MD, PhD, Sam G Pappas, MD, T Clark Gamblin, MD, MS, Kiran K Turaga, MD, MPH Medical College of Wisconsin, Loyola University Medical Center

Introduction: Single Port Access laparoscopy (SPA) has been suggested as a safe and less invasive alternative to standard laparoscopic surgery (LS). In spite of an increasing number of publications reporting a good feasibility in different surgical specialties, the limited ergonomics raise the question of operative quality as well as adapted instruments for use through a single port. This study aimed to compare performances of expert laparoscopic surgeons performing in LS or in SPA. The impact of the use of an articulated motorised laparoscopic instrument was additionally studied. Methods and Procedures: In this study, six expert laparoscopic surgeons were recruited. All these subjects completed four tasks (1, 2, 4, 5) from the validated Fundamentals of laparoscopic surgery (FLS) curriculum. The tasks were performed using 4 consecutive operating setups with a randomized crossover design: LS or SPA using conventional straight instruments, LS or SPA using a 10 mm motorised articulated instrument (Kymerax, Terumo*). Assessment of the tasks was performed with standardized FLS metrics. Operative time (secs) and error scores were compared between the 4 operative setups using Mann-Whitney tests, and multiple comparisons were performed using Bonferonni corrections. Results: Operative time was significantly longer in SPA than in LS for tasks 1 and 4, using either conventional straight instruments (196 vs 70 secs, p = 0.013 and 206 vs 100, p = 0.013) or using motorised articulated instrument (229 vs 57, p = 0.013 and 255 vs 115, p = 0.026). Operative times were not statistically different between SPA and LS for task 2 and 5. By SPA, knot tying tasks 4 and 5 could not be performed within the maximum predefined cut off time (600 secs): once for task 4 and four times for tasks 5. By SPA, operative times were not significantly different using motorised articulated instrument compared to conventional straight instruments (task 1: 229 vs 196, p = 1.00; task 2: 330 vs 324, p = 1.00; task 4: 255 vs 206, p = 0.311; task 5: 284 vs 457, p = 1.00). No statistical difference was found in terms of error score for any of the tasks. Conclusion: This study demonstrated that SPA surgery required significantly longer operative time for expert surgeons and does not provide good operative conditions for knot tying. The use of the motorised articulated instrument tested does not provide a solution to counterbalance impaired operative ergonomics.

Background: Host factors and therapy characteristics predispose cancer patients to a high risk of acute cholecystitis. Management of cholecystitis is often difficult given complex decision making involving the underlying cancer, possible interruption of treatment and surgical fitness of the patient. Methods: A management pathway was developed for cholecystitis in cancer patients that incorporated patient-specific survival and risks of recurrence. Estimates were obtained from a multi-stage systematic review. A decision tree with a lifetime horizon was constructed to compare conventional strategies (conservative treatment (CT), percutaneous cholecystostomy (PC) and definitive cholecystectomy (DC)) with the new pathway (NP). The decision tree was optimized for highest estimated survival. Sensitivity analyses were performed. Results: In low surgical risk patients with cancer-specific survival of 12 months, the NP yielded estimated survivals of 11.9 months vs. 11.8 months (CT) vs. 11.8 months (PC) vs. 11.9 months for DC arm. For high risk patients, the estimated survival was 11.6 (NP), 9.9 (DC), 11.4(PC) and 11 (CT) months respectively. The decision to perform a definitive cholecystectomy at 6 weeks after a PC was optimum in patients expected to survive 24 months (23.2 months from NP) or with a shorter expected survival but a high recurrence risk (20 %) as shown in Table 1. Model estimates were robust in sensitivity analyses. Conclusions: Incorporation of the surgical risk and the risk of recurrent cholecystitis, while balancing the patient-specific survival and the impact of anti-neoplastic therapy in the management of cholecystitis yields improved survival. This work provides measures to evaluate surgical judgment and can augment the physician patient decision making.

Table 1 Optimum strategy for management at follow-up based on sensitivity analyses between probability of recurrence of cholecystitis and expected survival Expected survival

Low risk of recurrence (10–20 %)

Moderate risk of recurrence (20–30 %)

High risk of recurrence (30–40 %)

3 months

No cholecystectomy

No cholecystectomy

No cholecystectomy

6 months

No cholecystectomy

No cholecystectomy

Perform cholecystectomy

12 months

No cholecystectomy

Perform cholecystectomy

Perform cholecystectomy

24 months

Perform cholecystectomy

Perform cholecystectomy

Perform cholecystectomy

S082

S084

Intraperitoneal and intravenous lidocaine for pain relief after Laparoscopic Cholecystectomy: A prospective randomized double-blind placebo-controlled study Yoo Shin Choi, MD, Hyun Gang, MD Chung-Ang University Hospital

Laparoscopic liver resection using the rubber band technique: its usefulness and perioperative outcome of 100 consecutive cases Sung Hoon Choi, MD, Gi Hong Choi, MD, Dai Hoon Han, MD, Jin Sub Choi, MD, PhD Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea

Objective: The aim of this randomized, double-blind study trial was to evaluate the effect of intraperitoneal (IP) lidocaine instillation and intravenous (IV) lidocaine infusion on postoperative pain control after laparoscopic cholecystectomy (LC). Methods: Seventy-two patients who underwent LC were randomly assigned to 3 groups: Group IV (intravenous lidocaine infusion, n = 26), Group IP (intraperitoneal lidocaine instillation, n = 22), and Group C (control group, IP and IV saline, n = 24). Patients in each group were evaluated with regard to postoperative pain severity (TPPS) (using the VAS), total fentanyl consumption (TFC), frequency of pushing the button for a bolus of PCA (FPB), pain control satisfaction score (PCSS) (using the NRS). Results: Reduced TPPS, TFC, and FPB scores were observed in groups IP and IV as compared to group C (P \ 0.05). PCSS was also higher in groups IP and IV than in group C (P \ 0.05). TPPS was lower in group IP than group IV at 2 h, and FPB was lower in group IP than group IV from 0–2 h. Conclusions: The IP instillation of lidocaine and IV lidocaine infusion significantly reduced postoperative pain and opioid consumption in LC patients. IV lidocaine administration could be an alternative choice for the reduction of pain following LC on account of its convenience of use.

Introduction: Although laparoscopic liver resection is increasingly performed worldwide, surgeons still face technical challenge according to multiple different procedures by tumor locations. Therefore, various techniques and instruments have been introduced. The purpose of this study was to present our rubber band technique with the basic constant principal and to show perioperative and early postoperative outcomes. Methods: A series of 100 consecutive patients who underwent laparoscopic liver resection using the pure rubber band technique between August 2008 and June 2013 was analyzed retrospectively in terms of demographics, operation type, and in-hospital outcomes. All the study patients were applied rubber band retraction method at both resection edges to keep the resection plane horizontal with laparoscope view. Results: Overall, 36 % of the patients had underlying liver cirrhosis. There were 4 conversions. Types of operation included 86 % of minor hepatectomy [wedge resection (60 %), segmentectomy (12 %), and left lateral sectionectomy (14 %)] and 14 % of major hepatectomy (left hepatectomy (12 %), and right hepatectomy (2 %)). When 56 favorable location tumors (II, III, IVb, V, and VI) were compared with the remaining 30 unfavorable location tumors (I, Iva, VII, and VIII) among the minor hepatectomy, the former group required a shorter operation time (185 [60–395] minutes vs 248 [92–655], P = 0.002) and showed a lesser amount of blood loss 150 [10–550] vs 263 [10–1000] ml, P = 0.017). However, open conversion rate (2 % vs 1 %, P = 1.0), postoperative complication rate (7 % vs 3 %, P = 1.0), and hospital stay (6.7 days vs 6.8 days, P = 0.946) were not different between the two groups. When the operative time was analyzed using the moving average method, operative time for left lateral sectionectomy and left hepatectomy were stabilized at 9 and 6 cases, respectively. There was no postoperative mortality. Conclusion: Rubber band technique in laparoscopic liver resection provides useful and safe laparoscopic hepatectomy including unfavorably located tumors or major hepatectomy, and allows reasonable learning curve applying a constant surgical principle.

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Use of Biliary Stent in Laparoscopic Common Bile Duct Exploration Matthew J Lyon, MBBS, Seema Menon, MBBCh, MRCS, MCh, Abhiney Jain, MBBCh, Harish Kumar, MD, FRCS, FRCS Darling Downs Health Serivce, University of Queensland

Laparoscopic Subtotal Cholecystectomy is Safe and Effective When Faced with Challenging Anatomy R. P. Evans, MBBS, MRCS, N. S. Malik, BMed, Sci, Hons, BMBS, Hons, M. A. Khan, FRCS Mid-Staffordshire NHS Trust, UK

Introduction: It is well supported in the literature that laparoscopic common bile duct exploration for choledocolithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supraduodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stenting versus T-tube drainage following exploration of the common bile duct. Methods and Procedures: The study involved 126 patients with choledocolithiasis who underwent laparoscopic common bile duct exploration and decompression of the biliary system by either antegrade biliary stent or T-tube insertion. A 7 French Amsterdam straight biliary DiagmedTM stent (9–11 cm) was placed in 82 patients (stent group). T-tube insertion was used for 36 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study Results: The mean hospital stay for patients who underwent antegrade biliary stent or T-tube insertion after laparoscopic common bile duct exploration, were 1.04 and 3.41 days respectively. This a statistically significant result with a P value of less than 0.005. Of the T-tube group two patients required laparoscopic washout due to bile leak after tube removal and two reported ongoing pain whilst the T-tube was in-situ. There were no complications or concerns reported for the biliary stent group. Conclusion: Our results show that there is a significant reduction in length of hospital stay for patients that have antegrade biliary stent decompression of the common bile duct post laparoscopic choledochotomy when compared T-tube drainage. This implies antegrade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of antegrade biliary stent insertion during laparoscopic exploration of the common bile duct when primary closure is not preferred.

Background: Laparoscopic cholecystectomy has become a routine operation. The proportion of operations performed on an emergent or urgent basis is increasing. Laparoscopic cholecystectomy during acute inflammation is often significantly more challenging than the interval elective procedure. When faced with complicated cholecystitis, one must decide between sub-total laparoscopic cholecystectomy or conversion to open total cholecystectomy. The aim of the study is to determine whether complications can be kept to a minimum without needing to perform an open procedure. Methods: Retrospective analysis of a prospectively managed database in a UK District General hospital between 02/2011 and 03/2013. Results: Overall: In the 25-month period, 466 laparoscopic cholecystectomies were performed; comprising 375 (80 %) female and 91 (20 %) male patients. 95 (20 %) underwent simultaneous on-table cholangiogram. 60 cases (13 %) were performed as ‘hot’ emergency or urgent procedures. Only two cases (0.4 %) were converted to an open procedure: one in which a small incision was necessary to remove a large stone; another in which omental bleeding was encountered. 1 patients (0.2 %) developed post-operative bile leak. No bile duct injuries occurred. Laparoscopic subtotal cholecystectomy sub-group: 20 (4 %) patients underwent laparoscopic subtotal cholecystectomy. The median age of patients was 68 (range 43 to 83), 13 were men. 16 patients presented with cholecystitis, two with biliary colic, one with cholangitis and one with pancreatitis. Three required preoperative ERCP during immediate work-up for cholecystectomy. A further two had undergone ERCP with sphincterotomy during previous admissions. Only 5 of the procedures were performed on ‘hot’ gallbladders. Despite this, active inflammation was present in 12 cases. Empyema was present in four patients. Three gallbladders were perforated. 15 of the 20 cases required retrograde dissection. In one case Hartmann’s pouch was left open, in 5 Hartmann’s pouch was sutured and in the remaining 14 an Endoloop was applied. Post-operative management: All underwent sub-hepatic drain insertion. Of these, 14 were removed during admission and the remaining 6 were removed in clinic. Median time to drain removal was 2 days (range 1–13 days). Median length of stay was 2 days (range 1–6 days). Complications, follow up and re-intervention: No bile leakage or bile duct injury occurred. 7 patients were followed routinely, median follow up time was 10 days (range 6 days–3 months). 2 patients were re-referred to clinic from primary care with ongoing symptoms. Of these, one required laparoscopic completion cholecystectomy 13 months following the original procedure. Another suffered cholangitis attributed to pre-operative ERCP and sphincterotomy, managed conservatively. 2 patients re-presented to acute surgical services. One developed a sub-hepatic collection 6 months post operatively, managed conservatively. Another developed biliary obstruction due to small cell lung cancer and underwent stent insertion. Conclusion: In the context of indefinable anatomy, laparoscopic sub-total cholecystectomy with retrograde dissection is a safe procedure with minimal complications. It is sufficient management in the majority of patients. It allows for safe re-intervention in the small proportion of patients suffering on-going biliary symptoms.

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Comparison Between Intraoperative Cholangiography and Choledochoscopy for Ductal Clearance in Laparoscopic CBD Exploration —A Prospective Randomized Study Anubhav Vindal, MS, DNB, MRCSEd, MNAMS, Jagdish Chander, MS, Pawanindra Lal, MS, DNB, MNAMS, FRCSEd, FRCSGlas, FRCSEn, FACS, Balu Mahendra, MS Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College (University of Delhi), New Delhi, India

Technical Proficiency in Colonoscopy Correlates with Performance on The FES Manual Skills Test Carmen L Mueller, MD, Pepa Kaneva, MSc, Gerald M Fried, MD, Liane S Feldman, MD, Melina C Vassiliou, MD Montreal General Hospital, McGill University Health Centre

Introduction: Laparoscopic CBD exploration is an accepted treatment modality for single stage management of CBD stones in fit patients. A trans choledochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal laparoscopic CBD exploration. This series represents the first of those comparing the two from Asia. Methods and Procedures: Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal laparoscopic CBD exploration on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients 65 patients underwent intraoperative cholangiography (Group A) and 67 patients underwent intraoperative choledochoscopy with a rigid ureteroscope (Group B) to determine CBD clearance. Results: There were no significant differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures and stone clearance was achieved in all the 132 cases. The mean CBD diameter was comparable between the two groups. The mean number of CBD stones removed in Group A was 5.09 while in group B it was 4.76 (p [ 0.05). Mean operating time in Group A was 170 min while in group B it was 140 min (p \ 0.001). No difference in complications was noted between the two groups. Nine patients in Group A (13.8 %) showed non passage of contrast into the duodenum at IOC which resolved on administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Although inconsequential, this added to an increase in operative time in this group. Two patients (3%) showed a false positive result with IOC due to an air bubble in the distal end of the CBD, which had to be resolved with choledochoscopy. Conclusions: The present study showed that intraoperative choledochoscopy is a better option than IOC in determining ductal clearance after transcholedochal laparoscopic CBD exploration. It is less cumbersome and less time consuming than IOC, and avoids false positive results. We recommend intraoperative choledochoscopy as the standard procedure for determining the ductal clearance after laparoscopic transcholedochal CBD exploration in patients with CBD diameter more than 9 mm.

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Introduction: Ensuring proficiency in endoscopy has become a major priority for general surgery training programs in recent years. The Fundamentals of Endoscopic Surgery (FES) test is a high stakes examination testing proficiency in flexible endoscopy. The test includes a manual skills component administered on a virtual reality endoscopy simulator. The objective of this study is to determine the association between clinical colonoscopy skills and performance on the FES manual skills test. Methods: Participants included FES-naı¨ve general surgery residents and gastroenterology fellows at all levels of training, as well as attending physicians who regularly perform colonoscopy. Performance on live colonoscopy was measured using the validated GAGES-C global rating scale, and performance on the FES manual skills test was measured using a validated, computerized scoring algorithm based on efficiency and precision. Each trainee completed the two assessments within 2 weeks. Statistical analyses included Pearson’s r test of correlation. Results: A total of 20 participants were enrolled (median age: 29; 52 % male). Of these, 6/20 had performed 26–50 colonoscopies, and 7/20 had performed 51–100 upper endoscopies (range: 0 to [200). The median FES score was 68 and the median GAGES-C score was 13/20. Pearson’s correlation between GAGES-C scores and FES manual skills test scores was 0.82 (see Fig 1). All participants who scored [15/20 on the GAGES-C achieved a passing score on the FES manual skills test. Conclusions: There is a strong correlation between clinical colonoscopy performance and scores achieved on the FES manual skills test.

Fig. 1 Scatter plot of GAGES-C scores vs FES manual skills scores

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Reoperation Rates After Nissen Fundoplication: An Analysis of The California Outcomes Database (OSHPD) Cristina R Harnsberger, MD, Tianzan Zhou, BA, David C Chang, PhD, MPH, MBA, Ryan C Broderick, MD, Hans F Fuchs, MD, Garth R Jacobsen, MD, Santiago Horgan, MD, Bryan J Sandler, MD University of California, San Diego

A Multi-Center Study of Using Carbon Nanoparticles to Track Lymph Node Metastasis in T1–2 Colorectal Cancer Jun Yan, MD, Fangqin Xue, MD, Hui Zhang, MD, Gang Chen, MD, Jianping Lu, MD, Lisheng Cai, MD, Mingzhi Cai, MD, Gao Xiang, MD, Yunfeng Hong, MD, Wenbo Chen, MD, Guoxin Li, MD Department of General Surgery, Nanfang Hospital, Southern Medical University

Introduction: Current literature on redo antireflux surgery has limitations due to small sample size or single center experiences. This study aims to evaluate the reoperation rate of uncomplicated laparoscopic Nissen fundoplication in a large population database. Methods and Procedures: A longitudinal version of the California Office of Statewide Health Planning and Development (OSHPD) database from 1995 to 2010 was used. This database includes all patients from every civilian hospital in California during this time period. Inclusion criteria were patients who received a laparoscopic Nissen fundoplication for uncomplicated GERD or hiatal hernia (types I–IV). Patients were excluded if they had complications of GERD, esophageal or gastric cancer, prior esophageal or gastric surgery, vagotomy, esophageal dysmotility, and diaphragmatic hernia with gangrene or obstruction. The outcome was reoperation, specified as another Nissen fundoplication or reversal (ICD 9 codes 44.66, 44.67, and 44.69). Censoring events included esophageal or gastric cancer and any other esophageal or gastric surgery. Analysis was carried out via a Kaplan-Meier plot, hazard curve, and multivariate analysis adjusting for age, race, gender, comorbidities, insurance status, hospital teaching status, and year of procedure. Results: 13,050 patients were included in the study. The five and ten-year cumulative reoperation rates were 5.2 % (95 %CI 4.8–5.7 %) and 6.9 % (95 %CI 6.1–7.9 %), respectively. Of these reoperations, 30.1 % were performed at a different hospital from that of the initial fundoplication. Reoperation rate was highest at 1 year post-operatively (1.7 % per year), and steadily declined until 4 years post-operatively, after which it remained at approximately 0.5 % per year. Multivariate analysis demonstrated significantly higher rates of reoperation among younger patients (HR 3.56, 95 %CI 2.29–5.57 for \30 years; HR 1.89, 95 %CI 1.25–2.87 for 30–50 years; HR 1.65, 95 %CI 1.11–2.46 for 50–65 years) and female patients (HR 1.35, 95 %CI 1.12–1.63). Conclusions: Nearly one third of reoperations after failed Nissen fundoplication occur at a hospital different from the initial operation, which raises concern that existing literature does not reflect the true reoperation rate. The reoperation rate is highest in the first year postoperatively. The reasons for the higher rate of reoperation in females and younger patients remain unclear, and warrant further study.

Background: There are approximately 10 percent patients with lymph node metastasis in T1 colorectal cancer and approximately 20 percent patients with lymph node metastasis in T2 colorectal cancer. How to identify whether T1–2 colorectal cancer have lymph node metastases is a crucial problem in clinic. The purpose of this study was to evaluate the feasibility of using carbon nanoparticles to track lymph node metastasis in T1–2 colorectal cancer. Methods: A multi-center study was performed between July 2012 and September 2013. Seventy six patients with T1–2 colorectal cancer identified by pre-op endoscopic ultrasonography were recruited. One milliliter Carbon nanoparticles suspension, which was approved by Chinese Food and Drug Administration, was injected around cancer. Laparoscopic radical colorectomy with D2 (T1 cancer) or D3 (T2 cancer) lymph node dissection was performed. Carbon nanoparticles dyed lymph nodes were identified from all dissected lymph nodes, and pathology confirmed whether lymph nodes have cancer metastasis and the accuracy of carbon nanoparticles dyed lymph nodes as sentinel lymph node in T1–2 colorectal cancer. Results: There were 21 patients with T1 colorectal cancer and 55 patients with T2 cancer underwent surgery. Carbon nanoparticles could clearly show local lymph nodes, which were black-dyed under laparoscopy (Fig. 1a, b). Two patients (9.52 %) had lymph node metastasis in 21 patients with T1 colorectal cancer, and 10 patients (18.18 %) had lymph node metastasis in 55 patients with T2 colorectal cancer. In pathology, carbon nanoparticles were seen in lymphatic vessels (Fig. 1c), and lymphoid sinus (Fig. 1d, e) and macrophage (Fig. 1f) in lymph nodes. No other lymph node had cancer metastasis when carbon nanoparticles black-dyed lymph nodes were negative. When lymph nodes had cancer metastasis, carbon nanoparticles were seen around cancer cells in lymph nodes (Fig. 1g–i). Conclusions: It is feasible to use carbon nanoparticles to track lymph node metastasis in T1–2 colorectal cancer. Carbon nanoparticles black-dyed lymph node plays a role as sentinel lymph node in T1–2 colorectal cancer. Keywords: Carbon nanoparticles; Sentinel lymph node; Lymph node metastasis; T1–2 colorectal cancer; Multi-center study.

S090 Near Infrared Fluorescent Cholangiography Facilitates Identification of Biliary Anatomy During Laparoscopic Cholecystectomy Sylvester N Osayi, MD, Mark R Wendling, MD, Umer I Chaudhry, MD, Joseph M Drosdeck, MD, Kyle A Perry, MD, Sabrena F Noria, MD, Jeffrey W Hazey, MD, Peter Muscarella, MD, W. Scott Melvin, MD, Vimal K Narula, MD The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA Introduction: Bile duct injury remains the most feared complication of laparoscopic cholecystectomy. Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging and may reduce injury, but is not widely used. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel non-invasive method for real-time, radiation free, intra-operative biliary mapping. We hypothesized that NIRF-C is a safe and effective method for identifying biliary anatomy during laparoscopic cholecystectomy. Methods and Procedures: After obtaining informed consent, we administered 2.5 mg of indocyanine green (ICG) intravenously approximately 60 min prior to incision. NIRF-C was used to identify extrahepatic biliary structures at 3 time points: at initial entrance into the peritoneal cavity, partial dissection, and complete dissection of Calot’s triangle. IOC was performed after complete dissection. Identification of the following structures was recorded: right and left hepatic ducts, common hepatic duct (CHD), common hepatic/cystic duct (CH/CD) junction, cystic duct (CD), common bile duct (CBD), cystic artery, and anatomic variants. Time required to complete NIRF-C and IOC, length of procedure, complications, and procedure cost were collected. A student t-test was used for data analysis with significance when P \ 0.05. Results: Fifty-three patients underwent elective laparoscopic cholecystectomy with NIRF-C and IOC. Patients were 81.3 % female with a mean age of 41.7 (range 18–77) and mean BMI of 30.9 (range 17.7–48.8). ICG was administered 78.7 mins (range 29–162) prior to incision. Mean operative time was 72.4 min (range 33–225). There was a statistically significant difference between the average time spent on NIRF-C at 2.4 min (range 0.18–10.58) vs. 11.0 min (range 4.5–26.8) for IOC (p \ 0.001). NIRF-C did not visualize any structure in 2 (3.8 %) patients due to bile leak and chronic cholecystitis, while IOC was unable to be performed in 11 (20.8 %) patients either due to technical difficulties or unavailable equipment. After complete dissection of Calot’s triangle, visualization with NIRF-C of the CHD was achieved 73.6 % of the time, CBD 77.4 %, and CD 96.2 %, compared to IOC CHD 79.3 %, CBD 79.3 % and CD 75.5 %. There was a statistically significant difference between NIRF-C and IOC visualization of the CD (p = 0.002). Also, the CD was visualized with NIRF-C in 10 (90.9 %) of the cases where IOC was unable to be performed. There were no intra-operative complications. The cost of ICG for NIRF-C was $99/patient, significantly less than the additional hospital charge of $2755/patient for an IOC. Conclusions: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy. Significantly less time was required to perform NIRF-C than IOC and it is significantly cheaper to use compared to IOC. NIRF-C has the potential to decrease bile duct injury at a significantly lower cost than the use of routine IOC during laparoscopic cholecystectomy.

Fig. 1 .

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Early Post Operative Weight Loss After Laparoscopic Sleeve Gastrectomy Correlates with the Volume of the Stomach Excised and not with that of the Sleeve! Preliminary Data from an MDCT Based Study Pawanindra Lal, MS, DNB, MNAMS, FRCSEd, FRCSGlas, FRCSEn, FACS, Manoj K Midha, MBBS, Anubhav Vindal, MS, DNB, MRCSEd, MNAMS, Jagdish Chander, MS Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College (University of Delhi), New Delhi, India

Laparoscopic Complete Mesocolic Excision with Radical Lymph Node Dissection Along the Surgical Trunk in Right-Hemi Colon Cancer Shinichiro Mori, MD, Kenji Baba, MD, PhD, Masayuki Yanagi, MD, Yoshiaki Kita, MD, PhD, Shigehiro Yanagita, MD, PhD, Yasuto Uchikado, MD, PhD, Yoshikazu Uenososno, MD, PhD, Hiroshi Okumura, MD, PhD, Akihiro Nakajo, MD, PhD, Kosei Maemura, MD, PhD, Sumiya Ishigami, MD, PhD, Kuniaki Aridome, MD, PhD, Shoji Natsugoe, MD, PhD Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University

Introduction: Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5 % people. Laparoscopic sleeve gastrectomy (LSG) has emerged as a definitive and standalone bariatric procedure resulting in stable and adequate weight loss in high percentage of patients with morbid obesity. Pre and postoperative stomach volumes can be important determinants to find out the effectiveness of LSG in effecting weight loss. There is little data on preoperative stomach volumes and that excised during LSG. This study was designed to evaluate the change in gastric volume after LSG using multi slice CT and to correlate it with postoperative weight loss. Methods and Procedures: Twenty consecutive patients with BMI C33 kg/m2 and comorbidities like diabetes mellitus, hypertension, dyslipidemia, atherosclerotic heart disease and sleep apnoea syndrome, undergoing LSG between October 2011 and June 2013 were included in the study. The patients were evaluated by a multi disciplinary team and optimized for anaesthesia and surgery. All patients underwent a multi detector CT scan (MDCT) of the upper abdomen, one week before the surgery. The stomach was distended with a negative contrast, volume rendered images were generated, and the stomach volume was calculated by the MDCT software. LSG was performed in all the patients, fashioning the gastric tube over a 36F bougie. An MDCT of the upper abdomen was repeated at 3 months postoperatively to calculate the gastric sleeve volume. Weight loss and resolution of comorbid conditions were documented in each case. Results: The age of patients was in the range of 21 to 54 years with a male to female ratio of 1.14:1. The mean weight of patients at enrolment was 126.67 kg (range 86–168 kg). The mean stomach volume measured by MDCT before LSG was 1048 ml (range 601–1469 ml). All the surgeries were performed laparoscopically with no conversion to open surgery. Mean resected stomach volume measured immediately postoperatively by distension of specimen with water was 898 ml and that on MDCT was 820 ml (p = 0.191). The mean volume of gastric sleeve on MDCT 3 months post operatively was 228 ml with a reduction in stomach volume by 76 %. The mean weight 3 months after surgery was 103 kg. The stomach volume on preoperative MDCT correlated with preoperative weight (p \ 0.05, r = 0.661) and BMI (p \ 0.05, r = 0.569). Correlation was also seen between volume of the excised stomach on MDCT and weight loss achieved 3 months post operatively (p \ 0.05, r = 0.606). No correlation was seen between the volume of gastric sleeve 3 months post operatively and weight loss during this period (p = 0.980). At 3 months, all the patients had a complete resolution of their hypertension, diabetes and sleep apneoa, and 3 patients showed significant improvement in serum lipid profile. Conclusion: MDCT is a good method to measure gastric volume before and after LSG. Early postoperative weight loss (at 3 months) correlates well with the volume of the stomach excised but not with the volume of the sleeve.

Background: Laparoscopic colectomy with radical lymph node dissection has been recently accepted in colon cancer. We evaluated the safety and feasibility of laparoscopic complete mesocolic excision (CME) conducted by fusion fascia exposure with radical lymph node dissection along the surgical trunk in the right-hemi colon cancer. Patients and Methods: We retrospectively analyzed 27 patients with right-hemi colon cancer who underwent laparoscopic CME with radical lymph node dissection between January 2010 and June 2013. Video recordings of the procedure and specimens were utilized to assess the quality of the surgery and CME completion. Operative data, pathological findings, complications and length of hospital stay were also assessed. Surgical procedure: The dissection starts behind the pedicle of ileocolic vessels and proceed along the superior mesenteric vein (SMV). The ileocolic vessels are then cut at their roots. After embryological tissue planes comprising Told’s and pre-renal fascia were exposed, the wide separation between the pancreatic head and the transverse colon is performed. The dissection proceeds along the SMV, exposing the gastrocolic trunk of Henle. The middle colic artery can be identified from superior mesenteric artery and are cut at the roots of the right branch with lymph node dissection. After exposing the gastrocolic trunk of Henle and SMV, the exposure of fusion fascia between the omentum and the transvers mesocolon are performed. And then, the accessory middle colic veins are dissected with lymph node dissection, and transvers mesocolon is dissected below the lower edge of the pancreas, uncovering SMV. Results: All patients underwent en bloc resection of the enveloped parietal planes with radical lymph node dissection along the surgical trunk without any serious intraoperative complications. Six, three, seven, and eleven patients had T1, T2, T3, and T3 tumors, respectively. The median number of lymph nodes retrieved was 24, with lymph node metastasis identified in 11 patients. According to the UICC cancer staging, the number of patients with stage I, II, II, IV was five, nine, nine and four, respectively. The median operative time and intraoperative blood loss were 290 min (range: 204–420 min) and 41 g (range: 0–145 g), respectively. No postoperative complications occurred in any patient. The median hospital stay after surgery was 11 days. Conclusions: We propose that laparoscopic CME conducted by fusion fascia exposure with radical lymph node dissection along the surgical trunk is a safe and feasible procedure for right hemicolectomy.

S095 S093 Laparoscopic Total Pancreatectomy with Islet Autotransplantation for Chronic Pancreatitis Martin Makary, MD, MPH, Michol Cooper, MD, PhD, Niraj Desai, MD, Nicole Jiam, Daniel Warren, PhD, Zhaoli Sun, PhD, Vikesh Singh, MD, Anup K Manes, Rita Kalyani, MD, Erica Hall, MSN, CRNP, CDE, Bonny Thul, CRNP, Kenzo Hirose, MD Johns Hopkins Hospital Background: Pain management following surgery for chronic pancreatitis can be very challenging. Pre-existing nerve hypersensitization often magnifies postoperative pain and these episodes can impede improvement of long-term pain outcomes, elevating the importance of minimizing surgical pain in this unique population. We describe a totally laparoscopic pancreatectomy with islet autotransplantation (TP/IAT) to minimize pain outcomes in patients with chronic pancreatitis. Methods: We attempted a laparoscopic TP/IAT in six patients with chronic pain secondary to small-duct chronic pancreatitis over a six-month period (February 2013–August 2013). Two 5 mm ports and three to four 12 mm ports were used with injection of port sites with local anesthetic prior to insertion. To minimize operative time, a laboratory was set up in the operating room to perform the islet isolation immediately upon organ extraction. A laparoscopic hepaticojejunostomy and gastrojejunostomy were performed during the laboratory isolation. Islet autotransplantation was then performed by laparoscopically guiding an infusion catheter into the portal vein under direct visualization (see Figure). We collected data on operative time, baseline and postoperative pain score at follow-up at 6–8 weeks, glycemic outcomes, estimated blood loss, 30-day surgical complications, and mortality. Results: A totally laparoscopic approach including a laparoscopic islet autotransplantation was successful in all six patients. The mean operative time was 527 min (range = 471–619 min). The median estimated blood loss was 450 cc (range = 200–1250 cc). Mean preoperative pain score was 8.5 (range 7–10) among the five patients that had pain. One patient had no preoperative pain but underwent the procedure for cancer prevention as she met radiographic criteria and had both the CTFR and PRSS1 gene mutations. Mean postoperative pain score among patients with preoperative pain was 3.5 at their 6–8 week follow-up visit. All patients were insulin C-peptide positive at 6–8 weeks and none required short-acting insulin. Median hospital length of stay was 10.2 days (range = 6–21 days). Two patients were readmitted with intra-abdominal abscesses and had a drain placed. One patient developed a UTI post-operatively. There were no postoperative wound infections. The 30-day mortality was zero. Conclusion: We report outcomes following a novel surgical procedure of a totally laparoscopic TP/IAT with intraoperative islet isolation. In this early series, we observed high feasibility with reasonable operative time and good patient outcomes. The procedure should be considered in appropriate patients with small-duct chronic pancreatitis.

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Portomesenteric Venous Thrombosis Following Major Colon and Rectal Surgery: Incidence and Risk Factors Kristin A Robinson, MD, Mark E O’Donnell, MD, David G Pearson, MD, Melanie E Odeleye, MD, Zachary Bodnar, MD, Kristen A Kalkbrenner, PAC, J. Scott Kriegshauser, MD, Tonia M Young-Fadok, MD Mayo Clinic Hospital, Arizona Introduction: Portomesenteric venous thrombosis (PMVT) is a rare and potentially fatal complication of abdominal surgery. Current risk factor stratification models for PMVT following colon and rectal surgery are lacking. Pneumoperitoneum during laparoscopic procedures has been suggested to precipitate PMVT more frequently than open procedures due to alterations in portovenous blood flow. The main objective of this study was to assess PMVT risk factor profiles and patient outcome after major colorectal surgery. Methods: A single center retrospective review of all patients undergoing colon and rectal surgery was performed from 2007 to 2012. Patient demographics, clinical history, perioperative thromboprophylaxis regimen, operative procedure and clinical outcomes were reviewed from electronic medical records. PMVT was defined as thrombus within the portal, hepatic or superior mesenteric veins. Inferior mesenteric vein thrombosis was excluded. Independent samples T-test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess the effect of clinical characteristics on PMVT risk. Results: 1224 patients were included (mean age 61.6 years, male = 566). Bowel resection was performed electively for colon carcinoma (n = 302), rectal carcinoma (n = 112), ulcerative colitis (n = 125), Crohn’s disease (n = 78), polyps (n = 117), diverticulitis (n = 215) or during gynecological resections and emergent laparotomies (n = 275). 213 patients had BMI [ 30 kg/ m2. 108 patients were current smokers. 337 (27.5 %) patients were taking preoperative antithrombotic therapies. 1025 (83.7 %) received both routine pre and post-operative DVT chemoprophylaxis. Thirty-six patients (2.9 %) were diagnosed with PMVT by computed tomography at a mean time of 13.9 days post-procedure (range 3–69 days): 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were significantly younger (52.7 vs. 61.9 years, p = 0.001) with higher BMI (30.5 vs. 26.7, p \ 0.001) and maximum platelet levels (464 vs. 306, p \ 0.001) compared to patients without PMVT. However, both patient groups were otherwise matched for clinical and surgical variables including cancer diagnosis (PMVT: 13/36 = 36.1 % vs. non-PMVT: 462/1188 = 38.9 %, p = 0.73). Univariate logistic regression identified younger age (p \ 0.001), higher BMI (p \ 0.001), ulcerative colitis (p \ 0.001), higher maximal platelet levels (p \ 0.001) and proctocolectomy as significant predictors of PMVT. Stepwise multivariate logistic regression identified that higher BMI (p \ 0.001), higher platelet levels (P \ 0.001) and proctocolectomy (p = 0.001) were still significant predictors. However, gender, smoking, pre-operative antithrombotic treatment, indication for surgery, open or laparoscopic surgical approach and subsequent pneumoperitoneum pressure, peri-operative blood transfusion, and length of surgery were not significant predictors. No patients in the PMVT group suffered bowel infarction or required surgical intervention. Currently 1043 patients are alive with mean follow up of 42.5 months where 1 of 36 PMVT patients died and 180 of 1188 non-PMVT patients died (2.8 % vs. 15.2 %, p = 0.039). Conclusion: Higher BMI, higher platelet levels, and proctocolectomy were significant predictors of PMVT in multivariate analysis. Proctocolectomy may be a marker for ulcerative colitis and younger age, which were significant in univariate analysis. Laparoscopic approach was not a risk factor in either univariate or multivariate analysis. The significantly higher mortality rate in non-PMVT patients was an unexpected finding and further analysis is indicated.

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Does Laparoscopy Reduce The Need for Incidental Splenic Procedures During Colorectal Resections? An Assessment from The NSQIP Database Ozgen Isik, MD, Erman Aytac, MD, Jean Ashburn, MD, Gokhan Ozuner, MD, Feza Remzi, MD, Meagan Costedio, MD, Emre Gorgun, MD Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic

Efficacy of Laparoscopic-Assisted Approach for Reversal of Hartmann’s Procedure: Results From the American College of Surgeons National Surgical Quality Improvement Program Jeanine Arkenbosch, BS, Hirochimi Miyagaki, MD, PhD, Hmc Shantha Kumara, PhD, Xiaohong Yan, PhD, Vesna Cekic, RN, Richard L Whelan, MD Division of Colon and Rectal Surgery, Department of Surgery, St Luke’s Roosevelt Hospital Center

Introduction: Nearly half of all incidental splenectomies due to iatrogenic splenic injuries are performed during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes by using a nationwide database. Methods and Procedures: Patients who underwent colorectal resections between 2007 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database according to Current Procedural Terminology (CPT) codes. Patients were classified into two groups, based on whether or not they underwent a concurrent splenic procedure. Splenectomies intentionally performed in conjunction with colon or rectal resections, and ileocolic resections were excluded. Perioperative and short-term (30 day) outcomes were compared between the groups Table 1. Results: In total, 55910 patients who underwent colon and/or rectal resection were identified. Among these, 111 patients had incidental splenic procedures (92 splenectomy, 13 splenorraphy, 6 partial splenectomy). Laparoscopic colorectal resections were associated with a significantly lower rate of incidental splenic procedure (0.018 % vs. 0.32 %, p \ 0.001) compared to open surgery. Incidental splenic procedures were associated with increased total length of hospital stay (p \ 0.001), deep incisional surgical site infection (SSI) (p \ 0.001), organ space SSI (p = 0.006), pneumonia (p = 0.004), transfusion requirement (p \ 0.001), and mortality (p \ 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.01) and decreased need for re-operation (p = 0.041). Conclusions: Incidental splenic procedures during colorectal resections are associated with increased postoperative morbidity and mortality. Use of the laparoscopic technique is associated with less frequent incidental splenic procedures during colorectal resections.

Introduction: Postoperative morbidity after reversal of Hartmann’s procedure remains high. Proponents of minimally invasive methods believe the laparoscopic approach may be associated with a lower morbidity than open colostomy takedown and Hartmann’s closure. The aim of this study is to evaluate the efficacy of laparoscopic-assisted methods for reversal of Hartmann’s procedure. Methods and Procedures: The ACS-NSQIP database was queried from 2005 to 2011 based on Current Procedural Terminology (CPT) procedure codes 44227 (Laparoscopy, Surgical, Closure of Enterostomy, Large or Small Intestine, with Resection and Anastomosis) and 44626 (Closure of Enterostomy, Large or Small Intestine; with Resection and Colorectal Anastomosis {Eg, Closure of Hartmann Type Procedure}) as well as the ICD-9 diagnosis codes V44.3 (Colostomy Status) and V55.3 (Attention to Colostomy). Exclusion criteria included: preoperative (preop) ventilator dependence, ASA 4 and 5 classification, totally dependent functional status, SIRS, sepsis, emergency case, advanced malignancy, and current pneumonia. Patients were divided into laparoscopic-assisted approach group (LAP) and open approach group (OPEN) according to CPT codes. Demographic parameters were assessed as well as comorbidities, complications and other short term outcome measures. The statistical methods used were the Fisher’s exact test for categorical variables, the student t-test for BMI and surgery time and the Wilcoxon test for other continuous variables. Results: A total of 3312 patients underwent stoma closure and Hartmann’s reversal during the period assessed (LAP, 555 [16.8 %], OPEN, 2757 [83.2 %]. The mean BMI of the LAP patients (mean ± SD, 27.5 ± 6.6) was significantly lower than that of the OPEN group (28.2 ± 6.6, p = 0.0170). There was also a difference in the rate of ETOH ingestion (LAP, 3.2 %, OPEN 2.6 %, p = 0.0476). In regards to nutritional status and other comorbidities including cardiac and pulmonary issues there were no differences between the groups. The mean surgery time was not significantly different (LAP, 185.9 ± 81.6 min, OPEN, 189.8 ± 89.1 min). The length of stay (LOS) was significantly longer in the OPEN group (median LOS 6 days) vs the LAP group (median LOS 5 days). The overall morbidity for the LAP procedure (18.4 %) was significantly lower than the rate noted in the OPEN group (26.8 %, p \ 0.0001). In contrast, there was no difference in the mortality results between the groups (LAP 0.2 %, OPEN 0.4 %; p [ 0.05). The incidence of the following complications were significantly lower for the LAP patients vs the OPEN group’s results: incisional SSI (LAP 11.2 % vs OPEN 14.6 %, p = 0.0322), sepsis (LAP, 3.4 %; OPEN 6.5 %, p = 0.0043); wound disruption (LAP, 0.5 %; OPEN 2.0 % (p = 0.0125); urinary tract infection (LAP, 1.6 %; OPEN 3.3 %, p = 0.0301); and re-operation (LAP, 3.2 %; OPEN 5.4 %, p = 0.0334). Conclusion: Only 17 % of Hartmann’s reversal’s were done using LAP methods. The LAP and OPEN groups were similar except for BMI and ETOH use. LAP methods were associated with a 1 day LOS benefit and significantly lower overall morbidity including lower SSI, wound disruption, and reoperation rates. Surprisingly, the length of surgery was similar between groups. The short term results of the LAP approach are superior to the OPEN results.

Table 1

Patient characteristics and postoperative outcomes

Variable

Overall

Non-splenic procedure

Splenic procedure

p- value

Age

61.77 ± 15.59

61.75 ± 15.59

71.16 ± 12.93

\0.001

Female

28367 (50.7 %)

28321 (50.8 %)

46 (41.4 %)

Male

27543 (49.3 %)

27478 (49.2 %)

65 (58.6 %)

28.01 ± 6.64

28.02 ± 6.64

26.92 ± 5.76

22677 (40.6 %)

22673 (40.6 %)

4 (3.6 %)

Sex

BMI

0.051

0.18

S098

Open/Laparoscopy Laparoscopy

\0.001

Open

33233 (59.4 %)

33126 (59.4 %)

107 (96.4 %)

Unplanned intubation

1555 (2.8 %)

1545 (2.8 %)

10 (9.0 %)

\0.001

Prolonged ([48 h) ventilator dependency

2668 (4.8 %)

2640 (4.7 %)

28 (25.2 %)

\0.001

Acute renal failure

526 (0.94 %)

522 (0.94 %)

4 (3.6 %)

Sepsis

2359 (4.2 %)

2345 (4.2 %)

14 (12.6 %)

\0.001

0.007

Septic shock

1530 (2.7 %)

1519 (2.7 %)

11 (9.9 %)

\0.001

Reoperation requirement

3506 (6.3 %)

3489 (6.3 %)

17 (15.3 %)

\0.001

Mortality

1924 (3.4 %)

1912 (3.4 %)

12 (10.8 %)

\0.001

Genito-Urinary Disorders in 30 Consecutive Laparoscopic TME for Rectal Cancer: A Prospective Video-Controlled Study Andrea Costanzi, MD, Luca Rigamonti, Giulio Mari, MD, Valter Berardi, MD, Angelo Miranda, MD, Jacopo Crippa, Dario Maggioni, MD Desio Hospital, Italy Regardless of advances, radical surgery for rectal cancer jeopardizes pelvic nerves integrity with urinary and sexual disorders ranging from 10 to 30 %. This study primary endpoint is to prospectively assess the incidence of genitourinary dysfunctions in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neo-adjuvant treatment. Secondary endpoint is to detect the potential lesion site evaluating video recordings of operations. Patients and Methods: A court of 30 consecutive patients affected by extra-peritoneal rectal cancer not subjected to neo-adjuvant ChemoRadiation prior to surgery, M:F = 19:11, median age 70, was evaluated preoperatively and after LTME. Evaluations of bladder function were determined by uroflowmetry and postvoid residual urine measurement preoperatively and at 1 and 9 months, International Prostatic Symptoms Score (IPSS, score 1 to 35 showing worsening of symptoms) and International Consultation on Incontinence Modular Questionnaire (ICQI UI-Short Form, score 1 to 21 showing worsening of symptoms) preoperatively and at 1, 3 and 9 months. Evaluations of sexual function were carried out by International Index of Erectile Function (IIEF, score 0 to 25, highest value better function) in men and Female Sexual Function Index (FSFI, score 2 to 36, highest value better function) in women preoperatively and at 1, 3 and 9 months. Data were analyzed performing Wilcoxon test and paired samples t test by SPSS 21 statistical package. Evaluation of surgery reviewing recorded videos was outsourced to an independent expert. Results: Urinary function: Maximum bladder flow (Vmax) base-line average was 21.16 ± 10.47 ml/s, decreased to 16.94 ± 10.26 after 1 month and back to 16.94 ± 10.26 after 9 month (p NS). Voiding time baseline average was 36,67 seconds ± 18,74, at 1 month 37.18 ± 18.11, at 9 months 40.75 ± 17.79. IPSS average score moved from baseline 6.03 ± 5.51 to 7.26 ± 5.55, ICIQ scored from baseline 2.67 ± 5.42 to 3.63 ± 5.23, in both cases p = NS. Sexual function: IIEF average score decreased from baseline 19.38 ± 6.25 to 13.44 ± 9.19 at 1 month (p = .04) and to 15,20 ± 8,28 at 9 months, (p NS). FSFI average score remained always close from baseline 29.17 ± 1.86 to 29.37 ± 1.69 at 1 month and 30.25 ± 1.48 at 9 months (p NS). Ejeculation disorders occured in 4 patients out of 30 (2.5 %). Operations video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 2 cases, dissection of posterior mesorectum (right hypogastric nerve) in 2 cases and anterior dissection of the Denonvillers fascia from seminal vesicles possibly affecting the Walsh neurovascular bundles (Erigentes nerves) in 4 cases. Conclusions: Although average values of quantitative and qualitative data show significant variations only for sexual function at 1 month from surgery, the incidence of post-surgical urinary and sexual disorders is respectively 30 % and 37 % of our patients undergoing LTME for rectal cancer. Video review of laparoscopic surgery provides an important tool for detection of lesion sites and raises the issue of mandatory Denonvillers fascia respect whenever this does not compromise radicality.

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S101

Damage Control with Lavage and drainage in Acute Diverticulitis Long term follow up Miguel A Hernandez, MD, Morris E Franklin, MD, FACS, Zanndor Del Real Romo, MD, Guillermo Peralta, MD Texas Endosurgery Institute

Preoperative Repeat Endoscopy in Colorectal Cancer Patients: An Institutional Experience and Analysis of Influencing Factors Thamer Al Abbasi, MB, BCh, BAO, MRCSI, FRCSC, Fady Saleh, MD, MPH, Timothy D Jackson, BSc, MD, MPH, FRCSC, Allan Okrainec, MDCM, MHPE, FRCSC, FACS, Fayez A Quereshy, MD, MBA, FRCSC University Health Network, University of Toronto, Toronto, Canada

Background: The most common management for generalized purulent peritonitis due to perforated diverticulitis is emergency surgical intervention, because it has been associated to life threatening sepsis. For these cases Hartmann’s procedure is recommended as the standard treatment. Laparoscopic approach of peritoneal lavage and drainage (LLD) to treat severe acute diverticulitis has been criticized despite further studies including clinical trials have been suggested. The aim of this presentation is to describe the experience with laparoscopic peritoneal lavage and drainage approach in patients with acute diverticulitis. Methods: A prospective consecutive series database of patients with perforated diverticulitis who underwent emergent LLD was identified. All procedure-related information was collected and analyzed. Results: A total of 538 patients with acute diverticular disease were analyzed [Female: 290 (54 %), Male: 248 (46 %), Mean age: 62.8 ± 15.8, BMI: 29.4 ± 6.2], 140 patients underwent emergent laparoscopic procedure and 97 were managed by LLD between 1991 and 2013 for acute perforated diverticulitis. Demographic characteristics were analyzed (female: 34; Male: 63), mean age 62.8 ± 15.8, operative time for was 99.7 ± 39.8 min, the estimated blood loss 34.4 ± 21.2 ml. Three patients were reoperated, two of them to an open Hartmann’s procedure for worsening of septic symptoms during the immediate postoperative period, the other one to repeat the LLD, hospital length stay (6.6 ± 2.4 days); 57 of 97 LLD patients underwent an elective sigmoidectomy for the source control. Conclusions: The LLD can be performed safely and effectively for patients with severe acute diverticulitis with generalized peritonitis. The clinical application of this approach shows acceptable short and long-term outcomes.

S100 Impact of the Systemic Inflammatory Response Syndrome on Early Discharge After Laparoscopic Segmental Colectomy Bobby Johnson, MD, Ian M Paquette, MD, Bradley R Davis, MD University of Cincinnati College of Medicine Introduction: There is increasing pressure to decrease length of stay (LOS) after major surgical procedures. Although laparoscopic colectomy has been shown to shorten LOS compared to open colectomy, not all patients experience equal benefit. Predictive factors for early discharge after laparoscopic colectomy have not been clearly defined. We hypothesized that patients who exhibit a brisk diuresis within 24 h of surgery as a marker of a blunted inflammatory response would experience shorter postoperative stays after laparoscopic colectomy. Methods and Procedures: We performed a retrospective review of all patients who underwent a laparoscopic segmental colectomy by one of four colorectal surgeons at an academic institution from 2012 to 2013. No formal enhanced recovery pathway was used in any patient. Patient demographics, operative characteristics, and postoperative factors were examined. A multiple linear regression model was used to examine the impact of various factors on length of stay, while controlling for confounding variables. Systemic inflammatory response syndrome (SIRS) was defined using Society of Critical Care Medicine consensus definitions. Results: A total of 127 patients underwent a laparoscopic segmental colectomy. When controlling for confounding variables, ileus, postoperative complication, or a SIRS response were associated with 2.67, 1.16, and 0.42 additional hospital days respectively. Patients who experienced a brisk diuresis immediately following surgery were more likely to be discharged early with, each additional liter of urine output on postoperative day 1 associated with a 0.23-day decrease in LOS (p = 0.006). Conclusions: In the absence of postoperative ileus or overt complication, patients who do not exhibit a SIRS response, and have a brisk urine output on POD 1, may be targeted for early hospital discharge after laparoscopic colectomy

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Introduction: Preoperative repeat endoscopy in colorectal cancer patients has been considered an integral component of surgical planning. It is not without increased cost and morbidity. This study serves to establish the repeat endoscopy rate in patients undergoing surgery for colorectal cancer at a tertiary academic center, to identify significant factors that may influence the decision for preoperative repeat endoscopy, and to evaluate changes in the volume of laparoscopic colectomies over the study period and its relationship with the re-endoscopy rate. Methods: A retrospective review of 342 consecutive patients undergoing surgical resection for colorectal cancer was performed from January 2008 to December 2011. Descriptive statistics were used to define the patient population and to establish the institutional repeat endoscopy rate. In order to identify factors associated with repeated preoperative endoscopy, univariate and multivariate analysis was used using the chi-square test and logistic regression modeling. Results: Patients within the two comparison groups had similar demographic profiles. Excluding patients where the primary endoscopist was the operating surgeon, 122 of 299 patients (40.6 %) underwent re-endoscopy. The most common reasons for re-endoscopy included tattooing of the lesion in 55 patients (45 %), surgical planning in 43 (35.2 %), and repeated therapeutic attempts in 11 (9 %). A significant delay in operative management was encountered in patients who underwent re-endoscopy (P = 0.002). Significant factors associated with repeat endoscopy included left-sided colon cancers (compared to right-sided lesions, P = \0.001), planned laparoscopic procedures (P = 0.01), and the absence of a tattoo on the first colonoscopy (P B 0.001). There was also a trend towards a reduction in re-endoscopy if the operating surgeon was consulted at the time of the initial endoscopy (P = 0.08). Repeat endoscopy resulted in a significant change in the planned surgical resection in 5 patients (4 %). There was a clear trend towards increased laparoscopic procedures over the duration of the study (P B 0.001). Although this did not correlate with an increase in re-endoscopy, it did coincide with a significant increase in pre-operative tattooing at the first colonoscopy (P B 0.001). Multivariate analyses: Repeat endoscopy

Covariate

OR

95 % CI

P Value

Colonoscopist experience*

1.18

0.89–1.57

0.25

Operating surgeon consulted on primary colonoscopy

0.31

0.08–1.15

0.08

Planned laparoscopic surgery

2.22

1.19–4.16

0.01

Surgeon endoscopist

1.67

0.93–2.99

0.09

Lesion tattooed on primary colonoscopy

0.35

0.16–0.77

0.01

Transverse colon

3.58

0.73–17.55

0.12

Left colon

3.28

1.74–6.16

\0.001

Rectum

4.14

1.88–9.16

\0.001

Lesion location (Controlling for right sided lesions)

OR: odds ratio, CI: Confidence interval * Continuous

Conclusion: In a tertiary academic center, the repeat preoperative endoscopy rate was 40.6 %. Re-endoscopy was associated with an initial failure to tattoo the lesion, left-sided colonic neoplasms, and a planned laparoscopic resection. While re-endoscopy has the potential to alter surgical planning, this theoretical advantage may be realized in a select group of patients given that it is a procedure associated with increased cost, potential morbidity, and a delay in definitive therapy. Although the growing trend towards laparoscopic surgery did not yield the expected increase in reendoscopy rate, it may be explained by an institutional increase in preoperative tattoo localization. Further research is needed to help identify which patients would benefit from repeat endoscopy and where this may be safely omitted.

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S102

S104

Abdominal and Pelvic Adhesions After Laparoscopic Ileal PouchAnal Anastomosis Ryan W Day, MD, Tonia M Young-Fadok, MD Mayo Clinic Arizona

Complications of Laparoscopic Transgastric ERCP in Patients with Roux-en-Y Gastric Bypass Kevin L Grimes, MD, Kirpal Singh, MD, Maurice E Arregui, MD St. Vincent Hospital

Introduction: Abdominal adhesions are an expected outcome after any open surgical procedure. Patients who undergo open proctocolectomy with ileal pouch-anal anastomosis (IPAA) have up to a 25 % chance of developing a future small bowel obstruction secondary to abdominal or pelvic adhesions. Females who undergo open IPAA surgery are at a three-fold risk for infertility. The aim of this study is to evaluate adhesions after laparoscopic IPAA. Methods and Procedures: A retrospective review was performed of 70 consecutive patients who underwent laparoscopic proctocolectomy, IPAA and diverting loop ileostomy followed by closure of the loop ileostomy and laparoscopic evaluation of their adhesions. Adhesions to the abdominal wall were quantified at the time of the second surgery with the following scale: Grade 0 (no adhesions), Grade 1 (few adhesions, filmy thickness, a vascularity), Grade 2 (moderate thickness, limited vascularity), Grade 3 (severe, dense, thickness, vascularity). Adhesions to the adnexae were evaluated using the American Fertility Adhesion Score. Results: 70 patients underwent a two-stage IPAA procedure with laparoscopic evaluation of their adhesions. Mean age was 39 years (range 18–78) with 38 (54 %) of subjects being female. 44 patients (63 %) had no abdominal wall adhesions (Grade 0), 15 patients (21 %) had Grade 1 adhesions, 8 patients (11 %) had Grade 2 adhesions, 3 patients (4 %) had Grade 3 adhesions. Regarding adnexal adhesions, 25 of the female patients (66 %) had no adnexal adhesions, 5 patients (13 %) had filmy adhesions to less than one-third of a single adnexa, 1 patient had filmy adhesions encompassing one-third to two-thirds of a single adnexa, 1 patient had dense adhesions to greater than 2/3 of a single adnexa, 4 patients adnexae were unable to be evaluated due to abdominal wall adhesions, and 2 patients had surgically removed adnexae Table 1. Conclusions: Laparoscopic proctocolectomy, IPAA and diverting loop ileostomy has decreased abdominal wall and adnexal adhesions when compared to the previously reported numbers for comparable open surgery either with or without the use of a glycerol/sodium hyaluronate/carboxymethylcellulose bioresorbable adhesion barrier. 1 Reference:

Introduction: As more patients undergo Roux-en-Y gastric bypass, the population with altered anatomy continues to increase. This presents a challenge when duodenal access is required for ERCP. One technique, first described by Peters & Gagne in 2002, is laparoscopic transgastric ERCP. A handful of case series have been published (the largest includes 28 cases), but to our knowledge none addresses the complications of this procedure. We reviewed our experience with 84 transgastric ERCPs. Methods: Retrospective review was conducted of gastric bypass patients who underwent transgastric ERCP in our practice. Patients were identified by office records, and a review of operative reports, discharge summaries, office notes, and laboratory data was performed. Access site infection was defined by ‘‘infection’’ appearing in the records or antibiotics being prescribed. Results: Forty patients underwent 84 transgastric ERCPs (mean 2.1, range 1–14) in our practice from 2004–2013. Fifty-eight were for sphincter of Oddi dysfunction, 21 for pancreatic duct stenosis and/or chronic pancreatitis, 4 for choledocholithiasis, and 1 for gallstone pancreatitis. Ninety-three percent were female, 23 % had diabetes mellitus, mean age was 49 (range 23–69), and median follow-up was 15 months (range 2 weeks–8 years). One patient was lost to follow-up. Selective cannulation was achieved in 94 % of cases. Patients expected to undergo repeat ERCP had a G-tube placed in the remnant stomach rather than closure of the gastrotomy. Two patients (5 %) were converted from laparoscopic to open access of the remnant stomach. Overall, bowel injury occurred in 5/84 (5.9 %) cases: 2/40 (5 %) during initial laparoscopic access and 3/44 (6.8 %) during repeat access via an existing gastrostomy. There were 3 duodenal perforations: 2 were ERCP-related, caused by precut sphincterotomy, and were managed non-operatively; the third, which required operative intervention, was caused by dilation of the existing gastrostomy site with Savary dilators. One posterior stomach wall laceration during placement of the access trocar was repaired with endoscopic clips, and 1 false tract was created during gastrostomy site dilation, which required no intervention. Access site infection occurred in 4.8 % overall: 2/40 (5 %) during initial access and 2/44 (4.5 %) during repeat access. The only infection that required debridement was following repeat access. Discussion: Roux-en-Y gastric bypass eliminates the normal approach to the duodenum for ERCP. Laparoscopic transgastric access is feasible but associated with complications. Conversion to open procedure occurred in 5 % of patients, access site infection in approximately 5 %, and bowel injury in 5.9 %. Infections ranged from mild cellulitis to deep abdominal wall abscess, and the rate is consistent with that of PEG site infections, which is reported from 1 %–12 %. Both patients that required operative intervention (abdominal wall abscess & duodenal perforation) had complications from repeat access. Gastrostomy dilation may increase the risk of complications compared with initial laparoscopic access. Our study is limited by its retrospective design, which may underestimate the complication rate, and by our homogenous patient population (93 % female, 69 % sphincter of Oddi dysfunction). It is uncertain whether these results would generalize to male patients or calculus biliary disease.

(1)

Cohen Z, Senagore AJ, Dayton MT, Korudo MJ, Beck DE, Wolff BG, Fleshner PR, Thirlby RC, Ludwig KA, Larach SW, Weiss EG, Bauer JJ, Holmdahl L (2005) Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator blinded multicenter study. Dis Colon Rectum 48(6):1130–9.

*A portion of this data was presented at 2008 SAGES. This does represent a more than 50 % increase in patient population.

Table 1

. Lap IPAA (n = 70) (%)

Open Control (n = 61) (%)

Open GHA/GMC (n = 59) (5)

Grade 0

63

10

33

Grade 1

21

13

24

Grade 2

11

42

33

Grade 3

4

35

10

S103 Radiofrequency Ablation for Barrett’s Associated Intramucosal Carcinoma: A Multi-Center Follow-Up Study Adam C Strauss, MD, Agoston Agoston, MD, PhD, Parambir S Dulai, MD, Thadeus L Trus, MD, Amitabh Srivastava, MD, Richard I Rothstein, MD Dartmouth Hitchcock Medical Center; Brigham and Women’s Hospital Purpose: Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett’s esophagus. Its durability in eradicating Barrett’s associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC. Methods: Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and/or IMC in this high risk group. IMC eradication was defined as eradication of IMC and all co-existing dysplasia. Durable eradication was defined as completed eradication without recurrence to date. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC. Our secondary outcome of interest was complications. Results: 36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett’s length of 3.5 ± 2.5 cm, underwent RFA for biopsy proven IMC. 35 (97 %) patients had co-existing high-grade dysplasia at index biopsy and EMR was performed in 31 (86 %) prior to RFA. Complete eradication of IMC and intestinal metaplasia was achieved in 32/36 (89 %) and 27/36 (75 %) patients, respectively. Patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication of IMC. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC and intestinal metaplasia was achieved in 29/36 (81 %) and 22/36 (61 %) patients, respectively. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC (p = 0.03; 95 % CI 0.060–0.818). Treatment related complications included: bleeding (5 %) and stricture formation (19 %). Patients developing strictures underwent more EMR sessions (p = 0.07). Conclusion: Radiofrequency ablation is an effective and durable treatment option for Barrett’s associated intramucosal carcinoma. Greater than 80 % of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up. Patients should undergo EMR prior to RFA to improve treatment durability.

S105 Early Human Experience with Per-Oral Endoscopic Pyloromyotomy (POP) Eran Shlomovitz, MD, Radu Pescarus, MD, Ahmed Sharata, MD, Kevin M Reavis, MD, Christy M Dunst, MD, Lee L Swanstrom, MD Providence Portland Medical Center, The Oregon Clinic Introduction: Gastroparesis, a condition characterized by delayed gastric emptying, and a constellation of symptoms including nausea, vomiting, early satiety and bloating, is a debilitating condition. A variety of surgical options are available including pyloroplasty and pyloromyotomy. Although these have been shown to be effective they are associated with surgical trauma. We hypothesize that an endoscopic submucosal myotomy technique can be applied to endoscopically divide the pyloric sphincter, provide the benefits of a natural orifice procedure and improve gastric emptying in gastroparetic patients. Methods and procedures: Endoscopic per-oral pyloromyotomy (POP) was performed in four female patients ages 65, 59, 33 and 32 years old. All patient underwent a complete pre-operative work-up including upper endoscopy, gastric emptying study as well as a pH study and esophageal manometry if a concomitant fundoplication was performed. Three procedures were performed under laparoscopic guidance as patients required other concurrent laparoscopic procedures (see table). In one patient the procedure was fully endoscopic. The myotomy was performed by a technique similar to the one utilized in the POEM procedure. After the creation of a mucosotomy, a submucosal tunnel is established up to the duodenal bulb followed by a myotomy of the circular fibers of the pylorus. The mucosotomy is subsequently closed with clips. Results: Endoscopic per-oral pyloromyotomy was technically successful in all four cases and patients were discharged home on post operative day 2 or 3. There were no immediate procedural complications. One patient presented to the hospital 2 weeks post procedure with an upper GI bleed necessitating transfusions. On endoscopy a 1 cm ulcer was found in the pyloric channel and an exposed vessel was clipped. The patient was subsequently discharged home on high dose proton pump inhibitors. Three month follow-up nuclear medicine gastric emptying studies (GES) are available for 3 of the 4 patients. Normalization of gastric emptying studies was demonstrated in 2 patients. Patient 3 showed improved gastric emptying half life, but unchanged residual activity at 4 h.

Patient 1

Concomitant procedure

Operative time

Blood loss

Cholecystectomy

102 min

Minimal

65 F Patient 2

Redo-PEH repair and Nissen

295 min

100 cc

Nissen

231 min

Minimal

59 F Patient 3 33 F

Pre-op GES

Post-op GES

Half life: 150 min

Half life: 36 min

Residual at 4 h: 29 %

Residual at 4 h: 0 %

Half life: 90 min

Half life: 18 min

Residual at 4 h: 14 %

Residual at 4hrs: 0 %

Half life: 160–170 min

Half life: 70–90 min

Residual at 4 h: 15 %

Residual at 4 h: 14 %

Conclusion: Endoscopic pyloromyotomy is a technically feasible and potentially much less morbid endoscopic surgical procedure. Early follow-up suggests objective improvement in gastric emptying. Further long-term follow-up and additional clinical experience is required to establish the role of this technique in the management of gastroparesis.

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S108

Endoscopic Resection for Esophageal Carcinoma: Experience in a Large Academic Medical Center Justin T Huntington, MD, Jon P Walker, MD, Michael P Meara, MD, Jeffrey W Hazey, MD, Scott Melvin, MD, Kyle A Perry, MD The Ohio State University Wexner Medical Center

Peroral Endoscopic Myotomy (POEM) Leads to Similar Results in Patients with and Without Prior Endoscopic or Surgical Therapy Sean B Orenstein, MD, Siavash Raigani, BA, Yuhsin V Wu, MD, Eric M Pauli, MD, Melissa S Phillips, MD, Jeffrey L Ponsky, MD, Jeffrey M Marks, MD Department of Surgery, University Hospitals Case Medical Center, Cleveland OH; Department of Surgery, Penn State Hershey Medical Center, Hershey PA; Department of Surgery, University of Tennessee, Knoxville, TN

Background: Endoscopic management represents a less invasive approach with decreased morbidity compared to esophagectomy for the treatment of early esophageal cancers. Endoscopic mucosal resection (EMR) has emerged as a preferred method for staging and treatment of esophageal nodules. We report our initial experience with EMR for management of early esophageal cancer. Methods: A retrospective review was conducted for all patients undergoing EMR for esophageal nodules between 2008 and 2013. Patients with pathologic confirmation of carcinoma were included in this study. The primary outcome measure was need for esophagectomy based on tumor stage or disease progression. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, and complications resulting from endoscopic treatment. Patients were followed for a median follow up interval of 11 months following EMR. Data are presented as incidence (%) or median (range) as appropriate. Results: During the study period, 84 patients underwent EMR for treatment of nodular disease, and 24 met the inclusion criteria for this study. Grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42 %) had evidence of submucosal invasion in the EMR specimen and were recommended to undergo esophagectomy. Seven of these were identified at their initial endoscopy, and 3 arose following radiofrequency ablation of dysplastic Barrett’s esophagus. Patients with margin negative EMR (n = 10, 42 %) or positive radial margins without evidence of submucosal invasion (n = 4, 16 %) underwent continued endoscopic surveillance and treatment. Five patients underwent multiple EMRs due to positive radial margin (n = 1) or recurrent nodular disease (n = 4). One showed no evidence of persistent disease, 3 had dysplastic Barrett’s esophagus, and 1 nodule contained recurrent intramucosal cancer. Ten patients (72 %) underwent subsequent radiofrequency ablation of Barrett’s esophagus. Thirteen patients (93 %) with intramucosal cancer have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow up of 11 months. One patient underwent esophagectomy due to recurrent IMC despite margin negative EMR in the setting of long-segment multifocal high-grade dysplasia. Overall, successful endoscopic management of esophageal nodules containing esophageal cancer was achieved in 13 (54 %) patients. Esophagectomy was recommended to 11 patients during the study period, and 9 agreed to proceed with surgery. Complete surgical resection was achieved in each case, and one patient was found to have lymph node metastasis. There were no esophageal perforations in this series, and one patient (4%) developed an esophageal stricture following EMR and radiofrequency ablation that was successfully managed with endoscopic dilation. Conclusions: Curative treatment of early esophageal cancer can be achieved with EMR and thus avoid esophagectomy in a significant proportion of patients. Endoscopic management may be successfully utilized in the setting of complete resection, or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow up is of paramount importance, because recurrent disease may occur following EMR with a negative resection margin. Long-term follow up studies are needed to accurately assess the recurrence rate following endoscopic management of IMC.

Introduction: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients that have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients that have undergone POEM and compare outcomes between patients that have or have not received previous treatment for achalasia. Methods and Procedures: We retrospectively evaluated our prospectively-collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and post-operative GERD-Health Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring. Results: Forty patients received a POEM procedure between 2011–2013. Of these, 40 % (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Group 1) and 118 min for patients without any prior procedure (Group 2) (p = 0.07). Intraoperative complication rates for Group 1 were 12.5 % (one pneumoperitoneum requiring catheter evacuation and one full-thickness mucosal tear requiring endoscopic stenting and extended hospitalization), versus 16.7 % for Group 2 (two arrhythmias, one pneumoperitoneum requiring catheter evacuation, and one superficial mucosal tear not requiring any intervention). One patient in Group 1 was readmitted for postoperative Mallory-Weiss tear requiring blood transfusion and upper endoscopy. Mean follow-up was 10 months. There were no statistical differences between the two groups for pre- or post-operative reflux and dysphagia scores. Both groups independently demonstrated clinical improvement, with statistical differences for pre- versus post-operative total GERD-HRQL and dysphagia scores (p \ 0.05). Conclusions: We found favorable outcomes following POEM in patients that have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no differences between these two groups with regards to operative times and patient symptom scoring. One complication requiring intervention occurred in a patient that had received prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.

S107

S109

To Stent or not to Stent: Outcomes of Self-Expanding Intraluminal Stents in Foregut Surgery Hrishikesh Nerkar, MD, Anna Ibele, MD, Jon Gabrielsen, MD, William Strodel, MD, Anthony T Petrick, MD Department of MIS and Bariatric Surgery, Geisinger Medical Center

Over the Scope Clip (OTSC) Placement for Perforation, Fistula and Anastomotic Leak Closure P Umamaheswaran, MD, D Davila-Bradley, MD, A Bastawrous, MD, D Schembre, MD, R Kratz, MD, J A Cervera-Servin, MD, R W Aye, MD, B E Louie, MD Swedish Medical Center

Background: Self-expanding stents (SES) have been used with increasing frequency to treat the complications of foregut surgery. The safety and effectiveness of SES for these indications has been difficult to determine due to lack of comparative controls. The aim of our study was to compare the complications and effectiveness of SES placed for esophageal complications (eSES) against those placed for bariatric complications (gSES). Methods: We reviewed EMR data from our patients, aged 18 years or older, who underwent bariatric and/or foregut surgery between January 2002 and June 2013 and in whom SES were utilized post-operatively. Demographic data was collected as well as perioperative and outcomes data. Data between the eSES and gSES groups was then compared using the Wilcoxon rank-sum test and Cochran–Armitage test. Results: A total of 102 patients had 132 SES placed over the study period. Eleven patients with SES placed to treat non-operative problems were excluded. Indications for SES included leaks (n = 59), strictures (n = 18), prophylactic anastomotic (n = 11), masses with obstruction (n = 9) or perforation (n = 2), fistula (n = 2), and idiopathic perforation (n = 1). Eighteen stents were secured with sutures. Mean follow was 17 months (range 1–84) for eSES and 27 months (range 2–161) for gSES patients. 41 patients had 58 eSESs placed (21 for leaks), while 50 patients had 63 gSESs placed (38 for leaks). eSES patients underwent 159 endoscopies (median = 3/patient), whereas the gSES group required only 136 endoscopies (median = 2/patient; p = NS). There was no significant difference in rates of dysphagia (53 % eSES vs 52 % gSES) or the need for premature stent removal (2 % eSES vs 2 % gSES). More patients with eSES required stent replacement (41 % vs 28 %) but this was not significant (p = 0.18). Persistent leaks occurred similarly for each group (19 % eSES vs 16 % gSES), as did stent migration (17 % eSES vs 16 % gSES). Stents were sutured in 1 eSES patient and 17 gSES patients. The overall migration rate for all SES was higher for non-sutured stents (19 % vs 5 %) but not significant (p = 0.12). 12 % (n = 5) required IR intervention in both groups and there was no significant difference in re-operative rates (34 % eSES and 40 % gSES). Stents caused no anastomotic disruptions. The eSES group took longer to return to full liquid diet (mean 11.6; median 3 days) when compared to the gSES patients (mean 7.7; median 2 days) and had longer LOS (mean 12.3: median 8 vs mean 10.1; median 5 days) but neither was significant. Conclusion: Current SES models were designed for esophageal placement. Our study demonstrates that the patient tolerance, safety and effectiveness are similar for both esophageal and bariatric surgical complications. Migration is common but suturing may lower the frequency. We need to develop randomized trials to determine if SES are cost effective or clinically superior to more conventional management strategies.

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Introduction: Gastrointestinal fistulas and perforations can be challenging problems for surgeons and endoscopists. Traditional management was surgical if the patient was systemically unwell or nil per os combined with image-guided drainage and supportive care if stable. A new over-the-scope clip (OTSC) has shown promise in closing perforations or post operative fistulas thus avoiding the need for repeat surgical intervention. The purpose of our study is to determine the clinical and radiological success of the OTSC during conservative management of post-operative fistulas, leaks and perforations after bariatric, foregut and colorectal surgery. Methods: We performed a retrospective review of patients with spontaneous anastomotic fistulas, rectovaginal fistulas (RVF), or iatrogenic perforations that had OTSC clips placed as primary treatment between Jan 2011 to the August 2013. The OTSC clips are placed endoscopically and the patients were followed clinically. Data was collected from hospital records to include technical success in deployment, clinical improvement in symptoms, radiological evidence of fistula improvement subsequent imaging, and complications associated with the OTSC. Results: Twenty-one patients underwent OTSC clip placement: 11 in the upper gastrointestinal tract (UGIT) and 10 in the lower gastrointestinal tract (LGIT). In the UGIT, 4 were for acute endoscopic perforations (3 ERCP and 1 endoscopic drainage of a periduodenal fluid collection), 2 for acute surgical leaks (POD 4 and 7) after laparoscopic Roux-en-Y gastric bypass and 5 for chronic esophageal/gastric fistulas (4 after sleeve gastrectomy and 1 after revision of gastro-gastric fistula). In the LGIT, 2 were spontaneous colonic fistulas after severe necrotizing pancreatitis, 3 were RVFs after postoperative injuries, and 5 were anastomotic fistulas (4 after a low anterior resection, and 1 after repair of a rectosigmoid injury following a salphingooopherectomy). The two spontaneous colonic fistulas did not have follow-up imaging to assess radiologic success of fistula closure. Tract

Deployment success

Clinical success

Radiologic success

UGI (n = 11)

10/11 (91 %)

7/10 (70 %)

5/10 (50 %)

Interval between fistula/perforation and OTSC (days)

Acute: 0–7 Chronic: 74–882

LGI (n = 10)

8/10 (80 %)

6/8 (75 %)

2/6 (33 %)

11–564

Deployment was not successful in three patients secondary to acute angulation of the LGI fistula tract (duration = 58 days), rigidity of the LGI fistula tract wall (duration = 186 days), and technical difficulty with OTSC getting caught in the three-pronged grasper (duration = 32 days). Clinical success did not occur in 2 LGIT anastomotic fistulas, 1 acute leak after gastric bypass and 2 chronic fistulas after sleeve gastrectomy. One UGI fistula enlarged after 2 clips were placed onto the same fistula tract necessitating removal and continued nil per os and external drainage till healed. Conclusions: The placement of OTSC clips is a novel approach to the treatment of gastrointestinal perforations and fistulas. Even though radiologic success is not always evident, clinical improvement of symptoms is achieved in over 70 % of cases. The majority of clinical failures are in those patients with chronic fistulas, and are likely attributed to epithelialization, ischemia and persistent infection.

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S110

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Bariatric Postoperative Fistula: A Life-Saving Endoscopic Procedure Giorgio Baretta, PhD, Joa˜o Henrique Lima, PhD, Josemberg Campos, PhD, Manoel Galva˜o Neto, MSc Vita Batel Hospital - Department of Bariatric Advanced Endoscopy

Predicting Operative Techniques and Outcomes in Laparoscopic Paraesophageal Hernia Repair (PEHR) by Computed Tomography (CT) Measurements Samuel W Ross, MD, MPH, Blair A Wormer, MD, Bindhu Oommen, MD, MPH, Mimi Kim, MD, John D Watkins, Amanda L Walters, MS, Vedra A Augenstein, MD, Brant T Heniford, MD Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center

Background: Fistula after batiatric surgery occurs in 0.8 % to 7 % with high incidence of mortality, reoperations and long hospital stay. Some reasons are well-described such as distal obstruction: stenosis of the anastomosis, restrictive ring and narrowing on angularis incisura like a ‘‘time machine’’. Others like stappling of the distal esophagus, His angle ischaemia, tension on the anastomosis, superobesity and comorbidities are also important. A great number of endoscopic procedures have been used to close the fistula, such as biological glue (tissucol), stents, surgisis and endoclips. The authors describe the feasibility of this new technique called septotomy or endoscopic internal drainage that avoids reoperations and allows an earlier hospital discharge with no mortality. Methods: Twenty-eight patients underwent to an endoscopic internal drainage–septotomy—after bariatric surgery. All procedures were done in the operating room with general anesthesia and antibiotics. The cut of the septum was made with a needle knife or argon plasma in order to communicate the perigastric cavity with the pouch. This technique allows the drainage of the perigastric abscess into the pouch due to its lower pressure after the cut. If any distal obstruction had been present, a dilatation with a pneumatic balloon was performed. Water per oral was initiated 24 h later. Results: Twenty-eight patients were included to septotomy with no mortality. Fourteen of them (50 %) were submitted to gastric bypass, nine patients (32.1 %) to sleeve gastrectomy, four patients (14.3 %) to duodenal switch and one patient (3.6 %) to a conversion of gastric bypass in duodenal switch. All of them presented with His angle fistula. Eight patients with gastric bypass (57.1 %) had stenosis of the anastomosis treated with balloon dilatation. All sleeve gastrectomy and duodenal switch patients (100 %) presented with angularis incisura stenosis treated with a rigiflex balloon as well as the patient submitted to the conversion for duodenal switch. The number of endoscopic sessions to perform the cut of septum range from 1 (14 patients) to 6 (1 patient), with 4 sessions made in 1 patient, 3 sessions made in 2 patients, 2 sessions made in 10 patients. Nine patients were submitted to this procedure as a day procedure. Only 1 patient need an endoscopic prosthesis due to an abdominal sepsis after the internal drainage. This patient was discharge 30 days after the procedure. The time for the first endoscopic procedure was on the 7th PO day and the lastest 5 years after the surgery in a patient with a late onset of fistula after duodenal switch. Conclusions: This new endoscopic procedure is safe, feasible and effective. It avoids reoperations and allows oral feeding and early hospital discharge with no mortality.

Introduction: Large PEHR can be challenging to plan pre-operatively given the multiple options for surgical repair. We hypothesized that greater dimensions of paraesophageal hernia (PEH) on pre-operative CT of would predict the need for salvage techniques in PEHR. Methods and Procedures: We queried our prospectively collected, institutional hernia-specific database for all PEHR from 2008 to March 2013. Only PEHR with pre-operative CT of the chest and/or abdomen were included. CT measurements of defect and hernia sac were obtained using transverse, coronal and sagittal views. Area and volume were calculated using standard formulas. CT measurements, esophageal length on upper endoscopy, and recurrent hernia status were then analyzed by operative techniques and patient outcomes using standard statistical methods; significance set at p B 0.05. Results: There were 103 laparoscopic PEHR, with three conversions to open. Mean age was 63.8 ± 11.7 years, BMI was 30.2 ± 12.8 kg/m2, and esophageal length was 35.2 ± 3.7 cm. The population was 35.0 % male, 12.6 % diabetic, 8.7 % smoker. Distribution of PEH by classification was 17.5 % Type I, 1.9 % Type II, 57.3 % type III and 23.3 % Type IV PEH; 13.6 % were emergent and 14.6 % recurrent. There were no Collis gastroplasties; biologic mesh was used in 65.1 %, and fundoplication was performed in 51.5 %. Average CT measurements were as follows: defect width 4.5 ± 2.0 cm, depth 6.8 ± 3.0 cm, area 19.4 ± 15.7 cm2; sac length 7.8 ± 3.5 cm, width 10.3 ± 5.0 cm, depth 6.8 ± 3.1 cm, area 74.4 ± 59.1 cm2, volume 3,369 ± 3,723 cm3. The crura could not be closed in 17.7 %: salvage gastropexy was performed in 13.6 %, and gastric diversion in 7.8 %. Average length of stay was 5.8 ± 6.9 days and inpatient charges were $61,285 ± 48,749. There was a 4.6 % recurrence rate, 6.3 % required post-operative endoscopy, 7.3 % had recurrent symptoms and there was one death. Operative techniques and patient outcomes association with pre-operative CT measurements are presented in the Table 1. Mesh use, reoperation, readmission, incisional hernia formation, and death were not associated with increased CT measurements or recurrent hernia; p [ 0.05. Esophageal length did not correlate with any operative techniques or outcomes; p [ 0.05. Conclusion: Repair of large PEH requires a variety of techniques to adequately prevent reherniation and recurrent symptoms. Preoperative CT measurements of defect area, hernia sac area and volume correlate with increased use of operative salvage techniques, post-operative complications, and charges. CT can be a valuable adjunct in operative planning and risk assessment in large and recurrent hernias. Additionally, recurrent hernia is an indicator that gastric diversion or other salvage technique is required.

Table 1 Operative Techniques and Patient Outcomes by CT Measurements and Recurrent Hernia Status: Averages and Correlation Coefficients Crural Defect Area (cm2)

Hernia Sac

Recurrent Hernia (%)

Area (cm2)

Volume (cm3)

Crura closed

S111

Yes

17.78*

63.3*

2627.0*

13.1

No

30.4

128.1

7162.7

15.7

Yes

19.2

90.4

2417.0

3.8*

No

21.2

61.5

4577.1

26.0

Yes

28.4*

126.8*

6831.7*

13.3

No

18.5

66.1

2913.6

14.7

Yes

16.2

32.0*

1288.0*

62.5*

No

20.5

79.2

3729.0

10.5

Yes

31.2

127.9*

7099.5

28.6

No

19.2

71.3

3136. 8

13.5

Yes

30.0

134.1*

6658.3*

37.5

No

19.2

70.1

3064.7

12.6

Length of stay

0.21

0.32*

0.38*

10.0 vs 5.0 days*

Inpatient charges

0.27*

0.17

0.17

$91,664 vs $56,144*

Fundoplication

The Effect of Differential Proximal Myotomy Length on Esophagogastric Junction Distensibility During Heller Myotomy and POEM Ezra N Teitelbaum, MD, Nathaniel J Soper, MD, Lubomyr Boris, BS, Frederic Nicoda¯me, MD, Peter J Kahrilas, MD, John E Pandolfino, MD, Eric S Hungness, MD Northwestern University Feinberg School of Medicine Introduction: For laparoscopic Heller myotomy (LHM), it has been shown that a myotomy extending 3 cm distal to the esophagogastric junction (EGJ) results in superior physiologic and clinical outcomes when compared with a distal segment that is shorter than 2 cm. However, the optimal length of the myotomy proximal to the EGJ is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Methods: Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured intraoperatively with FLIP (distension volume of 30 ml) in patients undergoing LHM and POEM for treatment of achalasia. Measurements were taken after each operative step. Additionally, during both LHM and POEM, each patient’s myotomy was performed in two stages: first, a myotomy across the EGJ with a short proximal (SP) segment was created, extending from 2 cm proximal to the EGJ to 3 cm distal to the EGJ (5 cm total length). After SP myotomy creation, a FLIP measurement was taken. Next, the myotomy was extended 4 cm cephalad to create a long proximal (LP) segment, and thus a total myotomy length of 9 cm (from 6 cm proximal to 3 cm distal to the EGJ), and another FLIP measurement was taken. Myotomy lengths were measured using a sterile ruler during LHM and via scope shaft markings during POEM. DI before and after each operative step was compared using a paired t-test. Results: Six LHM and 16 POEM patients underwent intraoperative FLIP measurements with stepwise proximal myotomy extension. LHM caused an overall increase in DI (2.0 ± 1.8 vs. 6.4 ± 3.9 mm2/mmHg, p = .02). During LHM, the steps of insufflation of pneumoperitoneum and hiatal dissection did not affect DI. Similarly, creation of a SP myotomy across the EGJ did not alter DI (pre 1.2 ± 0.4 vs. post 1.4 ± 1.1 mm2/mmHg, p = ns). After LP myotomy extension, DI increased (1.4 ± 1.1 vs. 4.4 ± 1.7 mm2/mmHg, p \ .01). Creation of a partial fundoplication resulted in a non-significant decrease in DI (4.4 ± 1.7 vs. 3.2 ± 2.4 mm2/mmHg, p = ns). Final deinsufflation of pneumoperitoneum caused an increase in DI (3.2 ± 2.4 vs. 6.4 ± 3.9 mm2/ mmHg, p = .001). POEM resulted in an overall increase in DI (1.9 ± 1.4 vs. 9.5 ± 4.5 mm2/mmHg, p \ .01). During POEM, creation of the submucosal tunnel caused an increase in DI (1.9 ± 1.4 vs. 7.1 ± 6.8 mm2/mmHg, p \ .01). Creation of a SP myotomy caused an increase in DI (7.1 ± 6.8 vs. 7.9 ± 3.2 mm2/mmHg, p = .02) and extension to a LP myotomy caused an additional increase (7.9 ± 3.2 vs. 9.5 ± 4.5 mm2/mmHg, p = .001). POEM resulted in a larger overall increase in DI than LHM at a trend level (7.7 ± 3.7 vs. 4.5 ± 2.5 mm2/mmHg, p = .07). Conclusions: During LHM, creation of a myotomy across the EGJ with a 2 cm proximal component did not affect DI, and an additional 4 cm proximal extension was required to increase distensibility. During POEM, a LP myotomy further increased DI, but a 2 cm proximal component may be sufficient to normalize EGJ distensibility.

Salvage gastropexy

Gastric diversion

Post-operative endoscopy

Recurrent symptoms

*Statistically Significant, p B 0.05

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Increased Incidence of Diaphragmatic Herniation After Minimally Invasive Esophagectomy—Initial Experience in a UK Specialist Unit David E Messenger, MD, FRCS, Simon M Higgs, MD, FRCS, David F Hewin, MD, FRCS, Vipond N Mark, MD, FRCS, Hugh Barr, MD, FRCS, Simon J Dwerryhouse, MD, FRCS, Martin S Wadley, MD, FRCS Worcestershire Royal Hospital, Worcester and Gloucestershire Royal Hospital, Gloucester, UK

Assessment and Reduction of Diaphragmatic Tension During Hiatal Hernia Repair Brian E Louie, MD, Daniel Davila Bradley, MD, Peter Baik, MD, Alexander S Farivar, MD, Ralph W Aye, MD Swedish Cancer Institute and Medical Center

Introduction: The uptake of minimally invasive esophagectomy (MIE) in the UK has increased dramatically in recent years. Diaphragmatic herniation post-esophagectomy is rare, although some reports suggest that its incidence is increased in patients undergoing MIE as opposed to open surgery. This may be due to a reduction in adhesion formation during the laparoscopic abdominal phase. We aimed to compare the incidence of diaphragmatic herniation following open and MIE in our centre. Methods and Procedures: Consecutive patients undergoing esophagectomy for malignant disease between 1996 and 2012 were included. (Specialist Unit and MIE program established 2008). Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database. Two-stage Ivor Lewis Esophagectomy was the procedure of choice either open or MIE. In our unit both laparoscopic assisted (LAE) and more recently complete MIE procedures are performed. Results: During the study period 273 patients (205 open, 68 MIE) underwent esophagectomy. Of the 68 MIEs, 62 (91 %) had a laparoscopic assisted procedure with 6 total MIEs. 9 (13.2 %) patients developed a diaphragmatic hernia in the MIE group compared with 2 (1.0 %) patients in the open group, (p \ 0.001). 5 patients developed hernias in the early post-operative period (days 2–10), all from the MIE group. Both cases of herniation in the open group occurred following a transhiatal esophagectomy at an interval of 44 and 114 months, respectively. All patients who developed a hernia were symptomatic and required surgical repair. A CT scan of the thorax was used to confirm the diagnosis in 10 patients. Repair of seven hernias was achieved laparoscopically, including two cases in the early post-operative period. Diaphragmatic hernias were repaired using the following techniques: suture apposition of the crura (n = 6), mesh repair (n = 4) and fixation of the gastrocolic omentum to the undersurface of the anterior abdominal wall as the defect was too large to close (n = 1). Conclusions: There was a significantly increased incidence of diaphragmatic herniation following MIE compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and the omentum to the abdominal wall may reduce the incidence of herniation.

Background: During hiatal hernia repair both axial tension along the esophagus and radial tension on the diaphragmatic hiatus need to be reduced in order to effect a successful repair and hopefully long term resolution. Axial tension is typically and simply assessed by determining the length of intra-abdominal esophagus, and then reduced by mediastinal mobilization and when necessary Collis gastroplasty. There is no similar simple intra operative assessment of radial tension nor is there data that estimates baseline tension or quantifies the effect of induced left pneumothorax or relaxing incisions. Methods: We assessed the diaphragmatic characteristics and tension of consecutive patients undergoing hiatal hernia repair with a calibrated tension gauge designed specifically for use during laparoscopy. Tension was estimated after complete dissection of the hiatus and mobilization of the esophagus at the point on the diaphragm where when closed it would approximate the size of the esophagus. Tension was then assessed after a deliberate left pleurotomy or partial thickness relaxing incision or both. Results: A total of 51 patients (23M:28F) underwent laparoscopic hiatal hernia repair. Hernias were classified as type 1 (16 patients), 2 (2 patient), 3 (28 patients), 4 (5 patient). After dissection, the ‘‘left to right’’ size of the hernia was an average of 3.47 cm (2–5) and the average baseline tension 16.6 mmHg (8–25). There was a linear correlation between size of the hernia and tension on the hiatus. A relaxing maneuver was not performed in 15 in whom the baseline tension was 10 mm Hg. Relaxing maneuvers were left pleurotomy (18), relaxing incision right crus (14) and both maneuvers (4). Tension was reduced by 35 % after a left pleurotomy; where as a right crural relaxing incision reduced tension by 47.8 %. When both maneuvers were performed tension was reduced via pleurotomy by 20.8 % and an additional 26.3 % with the relaxing incision for a total reduction of 41.6 %. Conclusions: Tension on the diaphragmatic hiatus can be measure with a special device introduced via laparoscopy. Diaphragmatic tension appears to be related to the width of the opening of the diaphragmatic hiatus. Relaxing maneuvers such as a left pleurotomy or a right crural relaxing incision lead to reduced tension on the diaphragm. These findings provide objective data on the tension during hiatal closure and may help reduce the incidence of hiatal failure after primary repair.

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Truncal Vagotomy Without Drainage: Are There Long Term Concerns? Matt B Martin, MD Central Carolina Surgery, PA, Cone Health, Greensboro, NC

Treatment of Foregut Fistulas with Biologic Fistula Plugs Rhys Filgate, Dr, Alan Thomas, Mr, Mohammed Ballal, Assoc, Professor School of Surgery, University of Western Australia

Introduction: Panelists at SAGES 2012 implied that inadvertent vagotomy was the cause of the bloating, diarrhea, and delayed gastric emptying that is often seen after complex foregut reconstructions that require extensive esophageal dissection. Is it correct to ascribe these symptoms to vagotomy and imply that a drainage procedure should accompany truncal vagotomy? To examine the long term sequelae of truncal vagotomy alone the present report examines clinical outcomes of 49 patients who had truncal vagotomy without drainage. Methods: 49 patients underwent truncal vagotomy with laparoscopic gastric banding in a trial to determine if the addition of a vagotomy would increase the achieved weight loss when compared to gastric banding alone. The details of this trial were presented at SAGES in 2010. The patients in this study are all now out greater than 5 years Results: 49 patients have been followed a mean of 4.9 years. All except one have experienced a loss of hunger and cessation of gastric borborygmi. One patient showed mild delayed gastric emptying when evaluated for GERD. No patient has experienced intractable diarrhea. Conclusions: These outcomes do not support the prevailing surgical thinking that vagotomy should always be accompanied by a drainage procedure. Furthermore, these outcomes would suggest that it is misleading to ascribe inadvertent vagotomy as the cause of the bloating, diarrhea, and delayed gastric emptying that occasionally is seen after difficult esophageal dissections.

Introduction: Enteric fistulas are a recognized complication of various diseases and surgical interventions. 15–25 % are spontaneous and are most commonly associated with Chron’s disease, malignancy and infection. The remaining 75–85 % are iatrogenic and arise most frequently as a surgical complication. They have traditionally been associated with a high risk of mortality and morbidity. Non-operative medical management will result in closure of 60–70 % of all fistulas over a six to eight week period, those that fail non-operative management will require operative intervention if they are to close. Biological materials consisting of an acellular matrix fashioned from porcine small intestine sub-mucosa stimulate fibroblast proliferation and incorporate into a scar without producing a foreign body reaction. The use of porcine small intestine sub-mucosa plugs in the management of anal fistulas has been well documented and described, producing closure rates of 38–65 %. We present a series of upper gastrointestinal fistula managed with endoscopic intervention and insertion of biological fistula plug over a 2 year period across 3 Hospitals, both public and private, in Western Australia and a video of the procedures will be presented. Methods: Over a two-year period 13 patients were referred for treatment of acute or persistent foregut fistulas. All fistulas were managed with endoscopic intervention and insertion of a porcine small intestine sub-mucosa plug (BiodesignÒ Cook medical Inc., Bloomington, IN, USA). No patients with fistula were excluded. Data was collected on patient demographics and underlying diagnosis. The biological plugs were deployed using 2 different endoscopic techniques (deployment via the endoscope, or Pull through via a guide wire using a rendezvous technique), both under a general anaesthetic. Results: Between January 2012 and April 2013 we treated 13 patients with foregut fistula using biological plugs. The age of the fistulas treated ranged from 14 days to 3 years. All fistulas were wither low or moderate output (\500 ml/day). There were no high output fistulas managed during this period. The fistulas were predominantly gastric in origin (7 cases). 3 oesophageal, 1 bronchopleural and 2 jejunal fistulas were also managed using this technique. The aetiology of the fistulas varied, with 3 being persisting gastrostomy sites which had failed to close, 4 were anastamotic leaks which had fistulated, and 3 were enteric perforations, either iatrogenic (2) or due to traumatic injury (1). Of the 13 fistulas treated using this method, 12 resolved following the treatment. Time to closure of the fistula varied from 1 day to 26 days (median 2 days). Proximal enteric feeding was commenced in 7 of the patients on the first postoperative day. In one patient the fistula was bronchopleural, and as such feeding was not an issue. In the failed procedure proximal feeding of the patient was never established. 2 patient required two applications of the plugs to complete closure. Conclusion: Biological plugs offer a further option for management of the traditionally difficult foregut fistulas without major morbidity associate with other treatment modalities. It is limited to the ability to deploy the plug endoscopically.

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S119

Laparoscopic Revision Anti-Reflux Surgery for Prior Failed Transoral Incisionless Fundoplication is Safe —Technical Details Reginald Bell, MD, Kate Bell, NP, Carrie Morrison, PA, Ashwin A Kurian, MD SurgOne Foregut Institute

Mesenteric Defect Closure in Laparoscopic Roux en-Y Gastric Bypass: A Randomized Control Trial Ulysses Rosas, BA, Shusmita Ahmed, MD, Natalia Leva, BA, Trit Garg, BA, Michael Russo, MD, John M Morton, MD, MPH Stanford University School of Medicine

Background: Transoral Incisionless Fundoplication (TIF) treats gastro-esophageal reflux disease (GERD) by creating full-thickness esophagogastric plications using transmural fasteners. Laparoscopic revision anti-reflux surgery for failed TIF has been reported, albeit with increased perforation risk secondary dissecting the transmural fasteners. We report the safety and efficacy of laparoscopic antireflux surgery in a series of patients with failed TIF. Methods: All patients with a prior failed TIF undergoing laparoscopic revision anti-reflux surgery were analyzed prospectively. Data collected included patient demographics, pre-procedure clinical symptom scores, intraoperative and postoperative outcomes. Descriptive statistics were used to define the population. Results: Between 3/2009 and 8/2013, twenty-eight patients underwent laparoscopic revision of a prior TIF (mean age 55 years, 43 % males) at a mean 37 months post-TIF (range 8–126). 71 % underwent TIF primarily for typical GERD symptoms, the rest for extra-esophageal symptoms. 82 % had initial improvement/resolution of symptoms, followed by recurrence motivating revision. Two patients had de novo chest pain post-TIF. All patients demonstrated abnormal pH testing prior to revision. All revisions were completed laparoscopically with a mean duration of 88 ± 18 min. Twenty patients underwent complete fundoplication; 8 patients underwent partial fundoplication. All patients were discharged by postoperative day 2. No intraoperative complications or postoperative leaks or abscesses occurred. Two patients required subsequent surgery, one for small paraesophageal hernia, one for refractory gas-bloat. Operative findings: (1) Dense adhesions in 14 % patients (2) Fasteners incorporating the lateral crus in 95 % (3) Good residual anterior plication in 75 %, although frequently free fasteners were observed medially. (4) Good residual posterior plication in 0 %. (5) Traction diverticuli from esophagus to crura in 21 %. (6) The anterior-posterior dimension of the hiatus was [3 cm in 90 % of patients. Operative approaches: (1) Areas where the fundus was fused to the esophagus were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of intussusception. (2) Fasteners with one end free were left in-situ. (3) Fasteners between the lumen and another structure (e.g. esophagus and crura) were gently displayed, then cut and left to migrate into the lumen. (4) Seven patients with hiatal hernias underwent circumferential, level 1 mediastinal dissection and hiatal repair (5) In 8 patients with good intra-abdominal esophageal length, no significant hernia, and fusion of the lateral crus to TIF fundoplication, revision laparoscopic fundoplication was performed without mediastinal mobilization and the fused crura/fundoplication was left intact. (5) Traction diverticuli were divided, the fastener left in the esophageal lumen, and then oversewn. Conclusion: Failure after TIF fundoplication leading to reoperation is associated with a hiatus [3 cm and complete loss of the posterior portion of the fundoplication. The anterior portion of the fundoplication and lateral crural fixation generally remain intact. Meticulous attention to technical detail obviates the perforation risk from the transmural fasteners. Laparoscopic revision anti-reflux surgery for failed TIF is feasible and safe.

Introduction: Bowel obstruction caused by internal herniation is a potential complication following laparoscopic Roux-en-y Gastric Bypass (LRYGB). Previous studies have shown that closure of mesenteric defects after LRYGB may reduce the incidence of internal herniation and its potential complications. However, controversy remains as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias and complications after LRYGB. Objective: To determine if jejeunal mesenteric defect closure reduces incidence of hernias and complications in patients undergoing LRYGB. Methods: 105 patients undergoing laparoscopic antecolic RYGB were randomized into two groups: Closed mesenteric defect (n = 50) or Open mesenteric defect (n = 55). Complication rates were obtained from medical record. Patients were contacted up to three years post-operatively to obtain self-reported incidences of complications. Patients also completed the Gastrointestinal Quality of Life Index (GI QoL) pre-operatively and 12 months post-operatively in order to determine symptoms associated with obstruction. Outcome measures included incidence of complications, readmissions and reoperations, GI QoL scores, and percent excess weight loss. Dichotomous variables were analyzed using chi-squared test, and continuous using two-tailed t-test. Analysis was performed using STATA software, release 12 and GraphPad Prism 6. Results: Preoperatively, there were no significant differences between the two groups. The Closed group had a significantly longer operative time (Open 139 min, Closed 157 min, p = 0.044). There were three internal hernias in both groups. Between the two groups, there was no significant difference at 12 months for decrease in BMI (-16.2 vs. -15.1, p = 0.329), change in waist circumference (-11.7 cm vs. -10.0, p = 0.357), or the percent excess weight loss (69.0 vs. 75.3, p = 0.134). There was no significant difference between the groups in incidence of internal hernias and general complications postoperatively. Multivariate logistic analysis controlling for age, sex, race, insurance, and preoperative BMI also showed no significant effect of closure on incidence of hernias and complications. Both groups showed significantly improved GI QoL index scores from baseline to 12 months post-surgery, but there were no significant differences at 12 months between groups in total GI QoL (Open 111.10, Closed 108.50, p = 0.612), physical domain score (Open 17.26, Closed 18.59, p = 0.464), and symptoms domain score (open 59.74, closed 60.00, p = 0.910). Conclusions: In this study, closure or non-closure of the jejeunal mesenteric defect following LRYGB appears to result in equivalent internal hernia and complication rates.

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The Effect of Smoking on Open and Laparoscopic Bariatric Outcomes Ivy N Haskins, MD, Richard Amdur, PhD, Khashayar Vaziri, MD, FACS George Washington University Department of General Surgery

Is Next-Day Discharge Following Laparoscopic Roux-en-Y Gastric Bypass Safe in Select Patients? Analysis of Short-Term Outcomes Ahmad I Elnahas, MD, FRCSC, David R Urbach, MD, MSc, FRCSC, Allan Okrainec, MDCM, MHPE, FACS, FRCSC, Fayez Quereshy, MD, MBA, FRCSC, Timothy D Jackson, MD, MPH, FRCSC Division of General Surgery, Department of Surgery, University Health Network, University of Toronto

Background: Bariatric surgery is an effective long-term treatment for morbid obesity. Although the effect of smoking on bariatric surgical outcomes is unclear, many bariatric surgeons recommend smoking cessation prior to surgery. We investigated the association of smoking on adverse bariatric surgical outcomes using the National Surgical Quality Improvement Program Database (NSQIP). Methods and Procedures: Bariatric patients were identified in NSQIP using Current Procedure Terminology Codes (CPT) for all types of bariatric procedures except adjustable gastric banding. Pre-treatment variables’ univariate associations with smoking were examined using chi-square regression and t-tests. Association of smoking with outcomes, corrected for relevant covariates, were tested with logistic regression within laparoscopic and open treatment groups. Results: 41,445 patients underwent gastric bypass surgery (35,696 laparoscopic; 5,749 open). Table 1 depicts outcomes for smokers and non-smokers who have undergone laparoscopic and open bariatric surgery. Smokers had a significantly increased risk of reintubation, sepsis, septic shock, and length of stay greater than one week in laparoscopic bariatric surgery when compared to nonsmokers. In open bariatric procedures, smoking was significantly associated with pneumonia, prolonged intubation, organ space infection, and length of stay greater than one week. Conclusions: These data suggest that smoking is a modifiable preoperative risk factor that leads to increased pulmonary morbidity and length of hospital stay for all types of bariatric surgery. Smoking also increases the risk of organ space (intra-abdominal) infection in open bariatric surgery. Smoking cessation should be encouraged in order to minimize the risk of adverse outcomes. Future investigations are needed to identify the optimal length of cessation.

Table 1

Effect of smoking on laparoscopic and open bariatric surgery Laparoscopic bariatric surgery n = 35, 696

Open bariatric surgery n = 5, 749

Outcome

p

Odds ratio (95 % CI)*

p

Pneumonia

.14

1.35 (0.91–2.00)

\0.001

3.06 (1.95–4.80)

Re-intubation

.04

1.61 (1.02–2.54)

.27

1.44 (.076–2.72)

Odds ratio (95 % CI)

Prolonged intubation

.05

1.63 (1.01–2.64)

.01

2.14 (1.21–3.80)

Organ space infection

.10

1.35 (0.94–1.92)

.03

1.79 (1.07–3.00)

Sepsis

.04

1.44 (1.02–2.03)

.20

1.45 (0.82–2.57)

Septic shock

.02

1.96 (1.14–3.36)

.19

1.59 (0.79–3.19)

LOS [ 7 Days

.05

1.29 (1.00–1.66)

.03

1.47 (1.04–2.08)

Introduction: There is controversy surrounding the safety and feasibility of next-day discharge following laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. The objective of this study is to determine if ‘‘next-day discharge’’ following LRYGB is comparable to ‘‘standard discharge’’ (i.e. on postoperative day two) with respect to 30-day patient outcomes. Methods and Procedures: Data was obtained from the American College of Surgeons’ National Surgery Quality Improvement Program (ACS-NSQIP) participant use file to perform a retrospective cohort analysis. The study population consisted of patients discharged on either postoperative day (POD) 1 or 2 that underwent an elective LRYGB for morbid obesity between 2005 and 2011. Patients were excluded if they had prior surgery within 30 days, any relative contraindication to bariatric surgery, or any recorded complication/death during their principal admission. The primary outcome was 30-day overall complication rate and secondary outcomes included major complication and reoperation rates. A multivariate logistic regression analysis was performed to evaluate each study outcome based on the day of discharge. Results: The sub-selected population consisted of 4798 and 25790 patients discharged on POD 1 and 2, respectively. No major clinical differences were found between the two groups with respect to relevant patient and operative characteristics. With respect to 30-day mortality, the POD 1 group had no deaths and the POD 2 group had 19 (0.06 %). Using a multivariate logistic regression analysis, an odds ratio (OR) estimate was adjusted for potential patient and operative confounders. No statistical difference was found between ‘‘next-day discharge’’ and ‘‘standard discharge’’ with respect to the 30-day overall complication rate (OR 0.99, p = 0.95, 95 % CI [0.79–1.24]). The adjusted OR estimate also showed no statistical difference between day of discharge and the 30-day major complication rate (OR 0.78, p = 0.22, 95 % CI [0.52–1.16]) or reoperation rate (OR 1.16 p = 0.37, 95 % CI [0.84–1.58]). Body mass index[50 and medical co-morbidities such as diabetes, steroid use, dyspnea and hypertension were found to be predictors for complications in patients discharged the next day. Conclusion: Using this large national surgical database, LRYGB patients discharged on POD 1 did not have a significantly higher rate of adverse events compared to patients discharged on POD 2. Understanding the important predictors of adverse events following LRYGB will help bariatric surgeons implement ‘‘next-day discharge’’ protocols based on the proper perioperative evaluation.

*Odds ratios are expressed in comparison to nonsmokers for each group respectively

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Laparoscopic Roux-Limb placement for the Management of Chronic Proximal Fistulas After Sleeve Gastrectomy Simon van de Vrande, Jacques Himpens, PhD, Ramon Vilallonga, PhD AZ Sint Blasius

Does Laparoscopic Sleeve Gastrectomy Have any Influence On Gastroesophageal Reflux Disease? Preliminary Results Veronica Gorodner, MD, Rudolf Buxhoeveden, MD, Gaston Clemente, MD, Laura Sole, MD, Luis Caro, MD, Alejandro Grigaites, MD Programa de Unidades Bariatricas

Introduction: Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. However, after LSG, leaks may occur that are difficult to treat and that can persist for months. Treatment is controversial and ranges from stent placement to total gastrectomy. We propose an alternative laparoscopic treatment. The aims of our study were to report on the incidence of chronic fistulas after LSG and the outcome of Roux-limb placement on these defects. The setting was a major teaching hospital in Belgium. Methods: From January 1, 2002, to December 31, 2011, we performed LSG as a primary weight loss operation (PLSG) in 728 patients and as a corrective operation (CLSG) in 84 patients. A retrospective chart and database review was conducted. When a chronic leak persisted beyond 4 months, we performed a laparoscopic Roux-limb placement on the defect. Results: Leaks occurred in 26 patients (3.6 %) after PLSG and in 6 (7.1 %) after CLSG. A leak persisted beyond 4 months in 7 patients (26.9 %) after PLSG and in 2 patients (33.3 %) after CLSG. Two patients with a chronic fistula after PLSG were referred to our hospital. In 11 patients, a Roux limb was laparoscopically sutured to the defect. The mean time for a chronic fistula to heal alter Roux-limb placement was 12.5 ± 10.2 days, and the mean length of hospital stay was 19.6 ± 14.2. Conclusion: Proximal leaks after LSG are relatively rare. However, a significant number become chronic. Laparoscopic placement of a Roux-limb on the defect is a safe treatment with an eventual success rate of 100 %.

Introduction: Gastroesophageal reflux disease (GERD) prevalence is clearly increased among obese population. There is no question that gastric bypass is the best treatment option for obesity combined with GERD. However, the influence of laparoscopic sleeve gastrectomy (LSG) on this disease remains controversial. It has been said that LSG could induce de novo GERD or worsen it in those patients that already have it. So far, objective data are scarce. The aim of our study was to evaluate the influence of LSG on GERD. Methods and Procedures: candidates for LSG were studied with esophageal manometry (EM) and 24 h pH monitoring before and 1 year after LSG. Demographics and perioperative data were reported. Severity of symptoms was evaluated using a score from 0 to 3. Esophageal function test (EFT’s) results and symptoms score were compared before and after surgery. Results: Between April 2012 and September 2013, 118 patients underwent LSG at our Institution. EFT’s were performed in 92 (78 %) of them preoperatively. Thus far, of the 19 patients one year out of surgery, 8 (42%) completed their EFT’s postop. There were 7 women, mean age 41 ± 11 yrs, initial BMI 40 ± 7 kg/m2. At 14 months follow up, % excess weight loss (EWL) was 74. Esophageal manometry

PRE sleeve

POST sleeve

p

LES length (cm)

2.5 ± 0.9

2.5 ± 1

NS

LESP (mmHg)

14.8 ± 4.1

14.1 ± 4.9

Esoph body diagnosis Normal

8 (100 %)

5 (63 %)

NSEMD

-

2 (25 %)

IEM DEA

NS NS

-

1 (12 %)

66 ± 22

67 ± 23

NS

24 pH monitoring %Time pH \ 4(total)

4.5 ± 3.1

9.2 ± 4.6

\0.05

De Meester score

12.3 ± 7.6

35.4 ± 17

\0.001

Symptoms Heartburn

S122 Alcohol Metabolism is not Affected After Laparoscopic Sleeve Gastrectomy: A New Finding Martin A Berducci, MD, Sheetal Nijhawan, MD, Diego F Nino, Alberto S Gallo, MD, Eric Cramer, MS, Cristina R Harnsberger, MD, Ryan C Broderick, MD, Bryan J Sandler, MD, Garth R Jacobsen, MD, Santiago Horgan, MD Division of Minimally Invasive Surgery, University of California, San Diego Introduction: It has been published that gastric bypass surgery patients have impaired alcohol metabolism, predisposing these patients to higher rates of intoxication and DUI charges. The impact of laparoscopic sleeve gastrectomy (LSG) on alcohol metabolism is still unknown. We designed a prospective trial to evaluate the effect of LSG on alcohol metabolism. Methods: A prospective cohort study of 10 patients undergoing LSG was conducted. Blood alcohol concentration (BAC) was determined using a BreathalyzerÒ examination every 5 min after a 150 ml of wine (12 % alcohol by volume) until BAC was equal to zero. Subjects were queried regarding alcohol intoxication symptoms. All parameters were obtained preoperatively, as well as 3 and 12 months postoperatively. Results: From 05/2011 to 12/2012, 10 patients (9 female) with a mean age and BMI of 46.6 years and 43.5 ± 2 kg/m2 respectively were evaluated. The percent excess weight loss (%EWL) was 39.5 ± 3.3 % at 3 months and 56.2 ± 5 % at 12 months. Peak BAC was noted at 20 min and was not different at 3 months (0.068 ± 0.007, p = 0.765) or at 12 months (0.05 ± 0.008, p = 0.1679) when compared to the preoperative (0.059 ± 0.014) assessment. In addition, the time for BAC to return to zero was not significantly different between the three time points evaluated (preoperative: 70 ± 9 min, 3 months: 95 ± 18 min and 12 months: 57 ± 8 min). Furthermore, symptoms of intoxication were not significantly different in patients before and after surgery. Conclusions: This study, one of the first with 12-month follow-up data, suggests that, unlike previous work regarding gastric bypass and other metabolic procedures, LSG patients do not have impaired alcohol metabolism postoperatively.

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1.3 ± 1.5

1 ± 1.4

NS

Regurgitation

1.2 ± 1.3

1 ± 1.1

NS

Chest pain

0.3 ± 0.5

1 ± 1.5

NS

Dysphagia

0

0

Cough

0

0

LES: lower esophageal sphineter, LESP: LES pressure; NSEMD: non specific esophageal motility disorder, IEM: ineffective esophageal esophageal motility

Postoperatively, 4 (50 %) pts had de novo GERD, in 3(37 %) GERD worsened and 1 (13 %) patient remained without reflux. Conclusion: our preliminary data showed that there was no difference in the pre and postop manometric findings. However, LSG was clearly associated with GERD, demonstrated by significantly increased in the De Meester score. There was no difference in symptoms score. Although LSG results appear appealing in terms of weight loss, patients should be warned that they might need proton pump inhibitors after the operation, and that symptoms are not reliable for the diagnosis of GERD.

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Laparoscopic Sleeve Gastrectomy in Morbidly Obese Children Below 14 Years of Age Aayed R Alqahtani, MD, FRCSC, FACS, Mohamed O Elahmedi, MD Obesity Chair, Department of Surgery, College of Medicine, King Saud University

Changes in Bone Metabolism After Gastric Bypass Lawrence E Tabone, MD, Alexander Mor, MD, Anna Spagnoli, MD, Khoo Chin Meng, MD, Mike Muehlbauer, PhD, Alfonso Torquati, MD, MSCI Duke University, University of North Carolina, National University of Health Systems Singapore

Background: In spite of the increased prevalence of extreme obesity and its associated comorbid conditions at earlier ages, treating younger children with bariatric surgery is not yet accepted due to concerns regarding safety and efficacy as well as effect on growth. This has denied children a treatment shown to cause effective weight loss, cure of comorbidities, and improvement in the quality of life. No previous study has evaluated the outcomes of bariatric surgery performed exclusively on children below 14 years of age. Herewith, we present the largest experience to date of performing Laparoscopic Sleeve Gastrectomy on this age group. Methods: We performed a retrospective review on prospectively collected data of all morbidly obese children below the age of 14 who underwent LSG between April 2008 and August 2013. We analyzed patient demographics, anthropometric measurements and comorbidities at baseline and at each follow-up point. Effect on growth was assessed using the growth velocity charts constructed by Tanner and Davies. Results: The review yielded 94 children among whom 10 had Prader–Willi Syndrome and 3 had Bardet–Biedl Down’s, and Kleinfelter Syndromes each. Median age was 10.5 ± 2.7 years. Median preoperative BMI was 43.6 kg/m2. Median %EBMIL at 1-year was 63.5 % (n = 45) and at 2-years it was 59.6 % (n = 21) (Figure 1). Comorbidity data indicate that 8 (88.9 %) hypertensive children experienced complete resolution. All 10 children with prediabetes and diabetes were cured, while normalization was observed in 41.7 % of the children for total cholesterol, 71.0 % for triglycerides, 33.3 % for LDL, and 67.6 % for HDL levels. Of the 32 children who had symptoms of obstructive sleep apnea (OSA), 30 (93.75 %) showed complete symptom resolution after surgery. Overall, LSG achieved cure or improvement of 89.7 % of comorbidities Table 1. All children experienced normal growth velocity, with no mortality or significant morbidity. Conclusion: This study challenges the existing concern regarding the safety and efficacy of BS in younger children. It demonstrates that LSG is a safe and effective bariatric procedure in this age group, resulting in significant weight loss, resolution of comorbidities, with no mortality or significant morbidity.

Introduction: We hypothesize that metabolic operations increase bone metabolism. Our study objective was to determine the change in osteoclast activity and bone mineral density (BMD) one year after Roux-en-Y gastric bypass (RYGB) as compared to a control group. Methods and Procedures: Subjects were enrolled in a one year prospective longitudinal cohort study and were assigned to either surgical treatment with laparoscopic RYGB or medical management with diabetes support and education programs (DSE). All enrolled subjects had type II diabetes mellitus and morbid obesity (body mass index of 35 kg/ m2 or greater). Dual-energy X-ray absorptiometry (DEXA) scans was performed at baseline and one year follow-up to determine change in BMD. Serums samples were collected at the same time points and analyzed using enzyme-linked immunosorbent assay for cross linked c-telopeptide of type I college (CTX), a marker of osteoclast activity. One year changes in BMD and serum CTX levels were compared within each group using a paired sample t-test. Results: One year after intervention subjects undergoing RYGB has a 280 percent increase in osteoclast activity as compared to a 7.6 percent increase in the DSE control group (p \ 0.001). A statistically significant decrease in bone mineral density in the left ribs (decrease of 6.8 %, P \ 0.05) and lumbar spine (decrease of 4.0 %, P \ 0.05) was seen one year after RYGB, which was not seen in the DSE group. The total bone mineral density was statistically unchanged within one year of intervention in both treatment groups. Conclusion: There is a significant increase in osteoclast activity that is seen one year after RYGB along with a site specific decrease in lumbar spine BMD. Metabolic operations, like RYGB, increase bone metabolism. At one year after operation these changes are most evident with biochemical assessment and not by DEXA scan.

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Table 1

Comorbidity resolution in children below the age of 14 who underwent LSG

Comorbidity

Cured

Improved

No Change

LDL

34.6 % (9)

30.8 % (8)

34.6 % (9)

HDL

66.7 % (26)

33.3 % (13)

0.0 % (0)

TC

48.3 % (14)

27.6 % (8)

24.1 % (7)

Triglycerides

71.8 % (28)

20.5 % (8)

7.7 % (3)

Fasting blood glucose

100.0 % (10)

0.0 % (0)

0.0 % (0)

Hypertension

88.9 % (8)

11.1 % (1)

0.0 % (0)

Obstructive sleep apnea

93.75 % (30)

6.25 % (2)

0.0 % (0)

Cure + Improvement

89.7 % (165)

10.3 % (19)

Cardiovascular Risk in Obese and Diabetic Patients is Significantly Reduced One Year After Gastric Bypass Compared to A One Year of diabetes Support and Education Alessandro Mor, MD, Philip Omotosho, MD, Alfonso Torquati, MD Department of Surgery, Duke University Introduction: Roux-en-Y Gastric Bypass (RYGB) has been proven effective in reducing most of the obesity-related comorbidities that concur to increase the cardiovascular risk in obesity. The Framingham Risk Score (FRS) is designed to be independent of weight and estimates the 10-year risk for coronary heart disease (CHD), myocardial infarction, stroke, cardiovascular disease (CVD), and death from CHD and from CVD. For the first time, we prospectively studied two obese populations with type 2 diabetes (T2DM) matched by weight and most of the risk factors that mainly impact the FRS (age, gender, blood pressure, serum cholesterol and smoking status). Our aim was to evaluate the RYGB effectiveness on improving cardiovascular risk when compared to a control medical group not participating in designed weight-loss intervention. We hypothesize that obese diabetic patients who undergo RYGB will significantly reduce their FRS compared to matched diabetic subjects who undergo Diabetes Support and Education program (DSE). Methods: In a prospective cohort study, we evaluated preoperatively and at 12-month sixty-one morbidly obese subjects (BMI 41.7 ± 0.6 kg/m2) with T2DM. 30 patients underwent laparoscopic RYGB and 31 patients received 1-year of DSE, consisting of educational sessions on diet/nutrition, exercise and living with diabetes. The two groups were matched according to gender, age, weight, waist circumferences, systolic blood pressure, serum cholesterol and triglyceride levels, and menopausal status. The cardiovascular risk was assessed at baseline and at 1-year follow-up in both groups using the strict gender-specific Framingham Risk Score which is based on age, total cholesterol, HDL cholesterol, blood pressure, ECG evidence of left ventricular hypertrophy and smoking and diabetes status. Pre- and postoperative variables were compared using a paired sample t-test. The independent t-test was used to determine differences between the two groups. Results: Change in BMI was -12.20 ± 0.8 Kg/m2 in the RYGB group and 0.3 ± 0.4 Kg/m2 in the DSE group (respectively, P \ 0.001 and P = 0.446). As shown in Table 1, the two groups were matched for baseline FRS. After 12 months of intervention, RYGB experienced a significant decrease in all the FRS, whereas control subjects did not show this significant decrease for the 10-year risk for CHD, CVD and death from CVD. The between-group differences for the changes from baseline to 12-month in all the FRS were significant. No Spreaman’s correlations between reduction in FRS and %EWL were found in the RYGB surgery. Conclusions: In a population of diabetic obese patients, the RYGB’s benefits on FRS has never been prospectively compared to the effects of a diabetes support and education program in a matched control group who did not undergo bariatric surgery. As expected, the long-term effects of RYGB surgery on FRS are independent on weight loss and, as we hypothesized, a significant improvement of the cardiovascular risk is observed in morbidly obese patients with diabetes who underwent RYGB, but not in those who were offered DSE.

Table 1 Outcomes calculated using the gender-specific FRS. Data are presented with mean ± SEM. CHD, coronary hearth disease; MI, Myocardial infarction; CVD, Cardiovascular disease; CHD-death, death from CHD; CVD-death, death from CVD CHD

DSE

Baseline

RYGB

12-months

Delta

Paired t test

Baseline

independent t test between groups

12-months

Delta

Paired t test

Baseline

12-month

Delta

CHD

11.3 ± 1.3

10.2 ± 1.3

-0.4 ± 0.8

NS

15 ± 1.5

5.9 ± 1

-9.2 + 1.5

\0.001

NS

0.011

\0.001

Ml

5.9 ± 0.8

4.8 ± 0.7

-1.1 ± 0.4

0.015

8.2 ± 1

2.5 ± 0.6

-5.7 + 0.9

\0.001

NS

0.022

\0.001

STROKE

2.5 ± 0.4

2 ± 0.4

-0.5 ± 0.2

0.047

3 ± 0.4

1.4 ± 0.2

-1.7 ± 0.4

\0.001

NS

NS

0.009

CVD

17.1 + 1.8

14.5 ± 1.7

-2.6 ± 1.4

NS

21.4 ± 1.9

8.9 ± 1.4

-12.5 ± 1.8

\0.001

NS

0.013

\0.001

CHD-death

2 ± 0.4

1.4 ± 0.3

-1.4 ± 1.3

0.03

3.1 ± 0.5

0.7 ± 0.2

-9.1 ± 1.5

\0.001

NS

NS

\0.001

CVD-death

2.5 ± 0.4

2 ± 0.5

-0.5 ± 1 0.4

NS

3.5 ± 0.5

1 + 0.2

-2.5 ± 10.4

\0.001

NS

NS

\0.002

Fig. 1 .

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Early Versus Delayed Cholecystectomy Following Endoscopic Sphincterotomy for Mild Biliary Pancreatitis Brett D Mador, BSc, MD, O Neely M Panton, MB, BS, FRCSC, FACS, S Morad Hameed, MD, MPH, FRCSC, FACS Division of General Surgery, University of British Columbia

Preliminary Evaluation of the Pattern Cutting and The ligating loop Virtual Laparoscopic Trainers Amine Chellali, PhD, Woojin Ahn, PhD, Ganesh Sankaranarayanan, PhD, Jeff Flinn, MS, Steven D Schwaitzberg, MD, Daniel B Jones, MD, Suvranu De, ScD, Caroline G. L Cao, PhD Cambridge Health Alliance, Harvard Medical School, Rensselaer Polytechnic Institute, Wright State University, Beth Israel Deaconess Medical Center

Introduction: The recommended treatment for patients with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data is less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity. Methods and Procedures: A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006–2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications and conversion rate. Student t-test was used to compare continuous data and Fischer’s exact test was used for categorical data. Results: 80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5–10) in the early group and 141.6 (range 18–757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60 %) in the delayed group experienced biliary complications compared with 1 of 45 (2 %) in the early group (p \ 0.001). 14 patients in the delayed group required re-admission (40 %) and 5 (14 %) required additional procedures. Secondary outcomes were not statistically significant. Conclusions: The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.

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Introduction: The Fundamentals of Laparoscopic Surgery (FLS) trainer is currently the standard for evaluating laparoscopic skills. However, it lacks objective and automated assessments of performance. The Virtual Basic Laparoscopic Skill Trainer (VBLaSTÓ) is the virtual version of the FLS trainer which allows automatic and real time performance assessment of laparoscopic skills without the need of a human proctor. In this study, the VBLaSTÓ pattern cutting (VBLaST-PCÓ) and ligating loop (VBLaST-LLÓ) trainers were evaluated as part of a validation study. We hypothesized that performance would be similar on the FLS and VBLaSTÓ trainers, and that subjects with more experience would perform better than those with less experience on both trainers. Methods: A total of fifty five subjects with varying surgical experience (33 for the pattern cutting task and 22 for the ligating loop) were recruited at the learning center during the 2013 SAGES annual meeting. For each task, subjects were divided into two groups: experts (PGY 5, surgical fellows and practicing laparoscopic surgeons) and novices (PGY 1–4). The subjects were asked to perform the pattern cutting task or the ligating loop task on both the FLS and the VBLaSTÓ trainers (Figure 1). Their performance scores for each trainer, based on the time to complete the task and error, were calculated and compared. Results: Pattern Cutting task The Mann Whitney U-test showed that the FLS and the VBLaST-PC scores (Table 1) were significantly higher in the expert group than in the novice group (U = 39, Z = 3.49, p = 0.000; U = 68, Z = 2.45, p = 0.01, respectively). Moreover, the Wilcoxon signed rank sum test showed no significant difference between the FLS and the VBLaST-PC scores (Z = 1.94, p [ 0.05). Ligating loop task The Mann Whitney U-test showed that the FLS and the VBLaST-LL scores (Table 1) were significantly higher in the expert group than in the novice group (U = 27.5, Z = 2.16, p = 0.03; U = 27.5, Z = 2.13, p = 0.03). Moreover, the Wilcoxon signed rank sum test showed no significant differences between the FLS and the VBLaST-LL scores (Z = 0.21, p [ 0.05). Conclusion: In this preliminary study, the VBLaSTÓ trainer was compared to the FLS box trainer to validate the pattern cutting and the ligating loop tasks. Results showed that the subject’s performance on the VBLaSTÓ trainer was similar to the FLS performance for both tasks. Moreover, the VBLaST-PC VBLaST-LL permitted discrimination between the novice and expert groups, providing supporting evidence of concurrent validity. Further improvements of the VBLaSTÓ system will likely be needed to further studies of validation. Once validated as a training system for laparoscopic surgical skills, the VBLaST system is expected to overcome the current limitations of the FLS box trainer.

Table 1

For novice and expert groups

Task

Pattern cutting task

Trainer

FLS trainer

Ligating loop task VBLaST-PCÓ

VBLaST-LLÒ

FLS trainer

Mean score

SD

Mean score

SD

Mean score

SD

Mean score

SD

Novices

45.31

30.47

39.41

Experts

81.57

14.52

65.27

30.49

6^.27

28.68

71.53

19.37

21.80

90.03

8.93

89.07

14.37

Perioperative Outcomes of Robot-Assisted Versus Laparoscopic Sleeve Gastrectomy Rena C Moon, MD, Derek Stephenson, MD, Andre F Teixeira, MD, Muhammad A Jawad, MD, FACS Orlando Regional Medical Center Background: Currently, sleeve gastrectomy (SG) is most commonly performed laparoscopically. However, robot-assisted approach for sleeve gastrectomy is increasing in number among bariatric surgeons. The aim of our study is to compare perioperative outcomes of laparoscopic SG and robot-assisted SG. Material and Methods: Between May 2012 and June 2013, 50 patients underwent laparoscopic SG and 90 underwent robotassisted SG at our institution. The first 40 robot-assisted cases were excluded from current study to minimize the influence of learning curve. A retrospective review of a prospectively collected database was performed for 50 laparoscopic and 50 robotassisted SG patients, noting the outcomes and complications of the procedure. Perioperative outcomes were length of operation, intraoperative blood loss, length of stay, and mortality and complication within the first 30 days. Results: Laparoscopic group had lower mean preoperative body mass index(BMI) of 43.9 ± 5.9 kg/m2 (range 34.2–60.7) when compared with the that of robot-assisted group 47.9 ± 9.0 kg/m2 (range 34.4–67.4)(p \ 0.02). All the other demographics were clinically comparable in these two groups. Mean length of operation was 91.1 ± 21.1 min (range 59–148) in the laparoscopic group, and 120.6 ± 25.9 min (range 75–200) in the robot-assisted group (p \ 0.001). Mean intraoperative blood loss was 21.0 ± 17.3 ml (range 5–100) in the laparoscopic group, and 36.3 ± 28.3 ml (range 10–150) in the robot-assisted group (p \ 0.002). Mean length of stay was 1.1 ± 0.3 days (range 1–2) in the laparoscopic group, and 1.3 ± 0.5 days (range 1–3) in the robot-assisted group (p \ 0.05). Three (6.0 %) patients in the robot-assisted group were found to have leak within the first 30 days, and required readmissions. No patient in the laparoscopic group developed leak, two patients required readmission due to abdominal pain and chest pain and both were managed conservatively. No mortality occurred within the first 30 days. Conclusions: Robot-assisted SG may result in longer operation, more intraoperative blood loss, longer length of hospital stay, and higher complication rate.

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Fig. 1 (1) The pattern cutting trainers, (2) the ligating loop trainers (left: VBLaSTÓ, right: FLS trainer)

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A Prospective Randomized Controlled Trial to Compare Single-Port Endo-Laparoscopic Surgery vs Conventional Tep Inguinal Hernia Repair Sujith I Wijerathne, MBBS, MRCS, Narendra Agarwal, MBBS, MS, Ahmad Ramzi, MD, Davide Lomanto, MD, PhD, FAMS Minimally Invasive Surgical Centre, Department of Surgery; National University Health System, Singapore

A Single Institution Experience with 85 Consecutive Robotic-Assisted Pelvic Dissections Jennifer E Hrabe, MD, Mary Charlton, PhD, John C Byrn, MD University of Iowa

The success of laparoscopic surgery was due to the less surgical trauma, including less operative pain, complications and better cosmetics. Evolution in the last decades has brought new advancement to further reduce trauma and improve patient’s outcome and among them the single access or reduced port surgery. Several studies and reports describe feasibility and safety in different surgical procedures but very few RCTS are published. Objective of our study is to compare in two blind randomized groups of patients, the surgical outcome of Total Extra-Peritoneal (TEP) inguinal hernia repair using either single port or conventional surgical technique. We will report our Interim results in the first group of 50 patients Our study is a prospective, randomised, controlled clinical trial conducted from August 2011 to June 2013 in our institution with DSRB approval (2011/00092). 50 patients aged between 21–80 years undergoing surgery for unilateral inguinal hernia were randomised into 2 groups: one group underwent conventional laparoscopic TEP inguinal hernia repair while the other group was selected for single port TEP Repair. Patients with bleeding disorders, incarcerated, recurrent or bilateral hernia and previous lower abdominal surgery were excluded. Clinical Data on patient demographics, surgical technique and findings, post-operative complications were collected; pain scores using Visual Analogue Scale (VAS) were collected blindly post-operatively and standard analgesia administered. All data were analysed using SPSS software. Primary endpoint is the VAS while secondary end-points are recurrence, chronic pain and complications. Out of the 50 patients, 26 underwent single port hernia TEP repair and 24 had conventional 3-port TEP hernia repair after randomisation. The two groups were comparable in terms of co-morbidities, patient demographics, mesh type and operative findings and no statistically significant differences were observed. Mean operative time was 51.7 ± 13.4 min. in the multiport group and 59.3 ± 14.9) minutes in the single-port group respectively (p = 0.064). Mean hospital stay was 19.7 ± 4.8 h in the conventional group and 22.1 ± 4.5 h in the single port group (p = 0.079). No statistically significant differences were observed between the two groups for post-operative complications and no recurrence reported at 11 months follow-up. Mean VAS at 6 h post-surgery was 2.7 ± 1.7 in the conventional group and 2 ± 1.8 in the single-port group (p = 0.187). VAS was 0 in both groups at 6 months. Size scar in the single port group was 13 mm The outcomes after laparoscopic TEP inguinal hernia repair with a single-port device are similar to the standard three-port technique, adding the obvious effect on better cosmesis.

Introduction: The purpose of our study was to analyze our first 85 robotic-assisted pelvic dissections performed for benign and malignant colorectal disorders and assess learning curve and cost. Though robotic and robotic-assisted laparoscopic procedures in colorectal surgery have garnered much attention, wide adaptation of the technology has not been achieved. We aim to contribute our experience with this technique. Methods and Procedures: Following IRB approval, a retrospective chart review of 85 consecutive robotic-assisted pelvic dissections performed between 9/1/2010 and 12/31/2012 was conducted. Patient demographic, clinicopathologic, procedure, and complication data was gathered, and cost data was obtained from the University HealthSystem Consortium (UHC) clinical database. The first 43 cases (‘‘Time 1’’) were compared to the next 42 cases (‘‘Time 2’’) in regards to patient characteristics, short-term operative outcomes, operating times, and costs. Observed direct hospital costs were compared to expected direct hospital costs which were calculated based on patient characteristics. An observed:expected direct hospital costs ratio of 1 indicates observed costs equaling expected costs. Chi-square and Fisher’s exact tests for categorical variables and t-tests for continuous variables were used to compare demographic variables, clinical characteristics and outcomes of interest. Results: Of the 85 patients undergoing robotic-assisted pelvic dissection, the indication for surgery was cancer for 51 patients (60 %), inflammatory bowel disease for 18 (21 %), and rectal prolapse for 16 (19 %). The most commonly performed procedures were low anterior resection (n = 25, 29.4 %) and abdominoperineal resection (n = 21, 24.7 %). The only statistically significant difference between patients in the two groups was a higher mean body mass index (BMI) for Time 2 (26.1 kg/m2 for Time 1 vs. 29.4 kg/m2 for Time 2, p = 0.02). Complication and conversion rates did not differ between the two groups and there were no mortalities reported within the first 30 days. Mean operating time was significantly shorter for Time 2 (266.9 min for Time 1 versus 224.4 min for Time 2, p \ 0.05). Though it did not reach statistical significance, the mean observed direct hospital cost showed a trend of decreasing ($17,349 for Time 1 versus $13,680 for Time 2, p [ 0.05). The observed:expected cost ratio significantly decreased (1.47 for Time 1 versus 1.05 for Time 2, p = 0.007). Conclusions: Our initial experience with robotic-assisted pelvic dissections demonstrates clear improvement in operating times despite a higher mean BMI in the later group of patients. Additionally, a trend towards decreasing cost was demonstrated. Future studies to compare cost, profitability, and patient outcomes to open and traditional laparoscopic approaches will be important for a further understanding of the benefits of robotic colorectal surgery.

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A Meta-Analysis of Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer Lin Chen, Prof, Hongqing Xi, Weisong Shen, Dr Chinese People’s Liberation Army General Hospital

Patient-Centered Outcomes Following Laparoscopic Ventral Hernia Repair: A Systematic Review of the Current Literature Michael Sosin, MD, Ketan M Patel, MD, Lucy Guevara, Maurice Y Nahabedian, MD, Parag Bhanot, MD Georgetown University Hospital, Division of General Surgery

Aim: To perform a meta-analysis of high-quality published trials by comparing robot-assisted gastrectomy (RAG) with laparoscopyassisted gastrectomy (LAG). Methods: A literature search was performed in PubMed, Embase, and Web of Science databases for clinical research published before May 2013 that compared RAG with LAG. Inclusion and exclusion criteria were established and applied. Non-randomized controlled trials were assessed using modified Methodological Index for Nonrandomized Studies (MINORS) items. Complications, harvested lymph nodes, proximal margin, distal margin, hospital stay, operative time, and estimated blood loss were compared using odds ratios and weighted mean differences (WMDs). Stata 12.0 software was used for statistical analysis. Results: Eight studies were included in the analysis, comprising 1875 patients (506 RAGs, 1369 LAGs). RAG was associated with a longer operative time (WMD 48.46 min; 95 % confidence interval (CI) 29.49–67.43; p \ 0.05), lower estimated blood loss (WMD -38.43 ml; 95 % CI -67.55 to -9.30; p \ 0.05), and a longer distal margin (WMD 1.04 cm; 95 % CI 0.46–1.62; p \ 0.05). RAG can be performed safely with lower estimated blood loss and a longer distal margin than with LAG. Complications, hospital stay, proximal margin, and harvested lymph nodes for RAG and LAG were similar. RAG is as acceptable as LAG for obtaining a safe surgical margin and for performing radical lymph node dissection. Radical resection can be achieved by RAG. Conclusions: With acceptable complications and radical resection, RAG is a promising approach when compared with LAG. Keywords: Gastric neoplasm; Robot-assisted gastrectomy; Laparoscopy-assisted gastrectomy; Postoperative complications; Metaanalysis

Background: Health related quality of life (HRQoL) measures are becoming increasingly important in defining successful outcomes in ventral hernia repair (VHR). The purpose of this study was to systematically review patients that underwent laparoscopic ventral hernia repair (LVHR) and assess QoL, pain, functionality, and patient satisfaction. Methods: MEDLINE Pubmed and Cochrane databases were searched, and 880 articles were identified. After limits were applied, 14 articles were accepted for review. Analysis included HRQoL measures including quality of life, pain, function, satisfaction with surgery, and mental and emotional well-being. Results: Of the 14 included studies, 50 % were randomized prospective trials, 42.9 % were nonrandomized prospective cohort studies, and 7.1 % were nonrandomized retrospective cohort studies. Mean study size was 92.6 subjects (24–306), and mean defect size was 71.7 cm2. LVHR improved overall HRQoL in 75 % (6/8) studies. Thirteen studies assessing pain demonstrated that LVHR improved pain scores relative to preoperative levels or over time as significant improvements ranged from 2 weeks to 2 years postoperatively. LVHR was not associated with long term pain. Functionality improved in 12 studies. Return to work ranged from 6–18 days postoperatively in 50 % of studies, and physical function scores improved in the remaining 50 % of the studies. Patient satisfaction improved after LVHR in all four studies assessing patient satisfaction. Method of fixation did not influence HRQoL. Laparoscopic repair was associated with improving mental and emotional well-being as described in 85.7 % (6/7) of studies. Conclusions: Patients with a ventral hernia are likely to report a lower HRQoL than the general population. Laparoscopic VHR improves patient-centered outcomes measures including overall HRQoL, physical function, decreased long term pain, patientreported satisfaction after surgery, and emotional and mental well-being.

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Laparoscopic Treatment of Incisional and Primary Ventral Hernia in Morbidly Obese Patients with a BMI Over 35 Ludovic Marx, MD, Mahery Raharimanantsoa, MD, Stefano Mandala, MD, Antonio D’Urso, MD, Michel Vix, MD, Didier Mutter, MD, PhD, FACS University Hospital of Strasbourg, Department of Digestive and Endocrine Surgery; IRCAD; IHU Strasbourg

Conventional vs. Robotic-Assisted Laparoscopic Distal Gastrectomy in Gastric Cancer: A Systematic Review Comparing the Outcomes Andrew Raffaella, MBBS, MSC, Badria Al Araimi, Mrs, Bijendra Patel, MBBS, MS, FRCS Barts Cancer Institute

Introduction: Incisional and ventral hernias are commonly encountered surgical indications in regular surgical practice and emergency situations. Their management is associated with significant surgical site infections (SSI) (20 to 40 %) and recurrence rates in open surgery (15 to 25 %). Since laparoscopic surgery has been established as a standard for bariatric surgery, there was a natural trend for treating obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and safety and the results of the laparoscopic approach for the management of parietal wall defects in morbidly obese patients with a BMI over 35. Method: Between March 2003 and August 2013, 334 patients were operated on laparoscopically for ventral and/or umbilical hernia, with application of a partially absorbable composite mesh. When 166 patients were obese (BMI [30 kg/m2), 71 presented with severe obesity (BMI C35 kg/m2) and 8 were super-obese (BMI [50 kg/m2). Patient data were prospectively acquired and retrospectively analyzed. Early and late complications were evaluated. All surgical procedures were performed in a standard fashion including composite mesh fixation (ParietexTM Composite mesh, Covidien, France), using non-absorbable transfascial suture and a single crown of tackers (AbsorbaTackTM fixation device, Covidien, France). Results: Out of 79 patients (29 men, 50 women) treated laparoscopically, 43 presented with umbilical hernias and 36 ventral hernias. Mean patient age was 51.8 years for men and 52.7 for women. Mean BMI was 40.83 kg/m2 (41.02 kg/m2 for men, 40.71 kg/m2 for women). Five patients were operated on in emergency. Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by VAS (Visual Analog Scale) was 2.86. No intraoperative complications or death were observed. The postoperative complication rate was 7.11 % (9 patients). We observed two parietal wall hematomas treated by radiological embolization, two cases of postoperative pain managed by painkillers, one postoperative obstruction for one day, one respiratory failure spontaneously resolving after two days in the ICU, one acute parietal wall defect with early reoperation at postoperative day one on the optical trocar incision site, two umbilical abscesses treated locally. Postoperative seroma rate was 16.59 % (21 patients), all treated conservatively. Postoperative follow-up was 18.10 months (1–84 months) and recurrence rate was 1.58 % (2 patients). Discussion: This study confirms the feasibility and safety of the laparoscopic approach to ventral hernia in severely obese patients. SSI and recurrence rates (1.5 % for each) appeared significantly lower than those currently observed in the literature (respectively 20 to 40 % and 15 to 25 %). The recurrence rate appeared particularly low as compared to other studies with a rate lower than 2 %. Postoperative hemorrhage and trocar site hernia are specific complications of this approach. Postoperative hospital stay is significantly reduced (2 days) as compared to open surgery. The minimally invasive treatment of parietal wall defects should be considered a standard option in morbidly obese patients with specific benefits in terms of low SSI, recurrence rates, and hospital stay.

Introduction: The objective of the study is to evaluate the outcomes of robot-assisted distal gastrectomy (RADG) and laparoscopyassisted distal gastrectomy (LADG) in gastric cancer cases. There has not been any systematic review or meta-analysis on this topic prior to this. Methods: This study is a systematic review of the literature following the PRISMA guidelines. Keywords for the robotic group are ‘robot*’, ‘distal’, and ‘gastrectomy’; and for the laparoscopic group are ‘laparo*’, ‘distal’, and ‘gastrectomy’. Database used were PubMed and Science Direct. Inclusion criteria were English articles from 2000 onwards, articles which include distal gastrectomy only, and articles which reported surgical outcomes. In the robotic group, only Da Vinci system studies were included and in the laparoscopic group, only RCT studies were included. Exclusion criteria were case reports or case series with \ 5 patients, other reviews, meta-analyses, and other types of gastrectomy. Data were then analysed with SPSS, including the use of descriptive statistics, T-test, and Mann-Whitney U test. Results: 11 studies were collected, 1 study consisted of 2 LADG groups and 1 RADG group and were added to each group separately for better analysis, making 7 studies in RADG group (n = 81) and 6 studies in LADG group (n = 287). In the descriptive statistics results, contradictory to its larger sample size, LADG group has lower complication rates compared to RADG group. Further analyses were then done for other parameters. With T-test, we got the mean number of complications in LADG group 6 ± 2.98 and in RADG group 2.14 ± 0.88 with p value of 0.21 as a not statistically significant result. For other parameters, we provided the Tables 1 and 2 below: We acquired the results of no statistical significance differences in surgical outcomes between LADG and RADG. Conclusion: Our research revealed that RADG are on par with LADG in terms of surgical outcomes and could be an alternative in selected cases. This could be related to uneven number of subjects between the two arms. Surgeons nowadays are fully adapted to conventional laparoscopic and this is manifested in zero number of conversions as compared to robotic group.

Table 1 Complication Rates Group

Wound

Bleeding

Leakage

Total

LADG RADG

0.7 % 1.2 %

1.3 % 4.9 %

1% 3.7 %

3% 9.8 %

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Post-Cholecystectomy Acute Bile Duct Injury: Two Decade Experience from a Tertiary Hospital in India Joji Abraham A, Dr, Vk Kapoor, Professor, Anand Prakash, Dr, Rk Singh, Dr, Ak Gupta, Professor, Anu Behari, Dr, R Saxena, Professor Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGIMS)

A Comparative Trial of LINX versus Lap Nissen: Caveats for Patient Selection Eric G Sheu, MD, DPhil, Peter Nau, MD, Barbara Nath, MD, Braden Kuo, MD, David W Rattner, MD Massachusetts General Hospital

Introduction: Post-cholecystectomy acute bile duct injuries have been addressed less frequently in the recent literature search. We analyzed our experience over the last two decades and report the short-term and long-term outcomes. Patients: Retrospective analysis of prospectively kept data of 309 patients with post-cholecystectomy acute BDI that were managed in a single institution from January 1989 to Dec 2010 and in whom follow up information was available. Results: There were 96 male & 213 female patients with a median age of 40(12–74) years. The index surgery was open cholecystectomy in 185, open cholecystectomy with common bile duct (CBD) exploration in 20 and laparoscopic cholecystectomy in 104 patients. Patients were referred to us at a mean 20 (1–270) days after cholecystectomy. 136/309 (44 %) patients had single or multiple pre-referral interventions. Post-referral, 93 patients were managed conservatively, 134 had percutaneous intervention, 101 had endoscopic intervention attempted, 64 were operated and 43 required a combination of these procedures. 9/309 (3 %) patients died due to the complications of BDI. Acute BDI injury could be classified as partial (110/309) or complete (157/309) on the basis of scintigraphy or cholangiography (ERCP, fistulogram or MRCP). Of the 157 with complete injury, endoscopic stenting was attempted in 38 pts. but failed in 32/38(84 %). Whereas in the 110 pts. with partial injury, endoscopic stenting was successful in 45 pts. out of the 58 attempted. In pts with complete injury, 89/157(57 %) had persistent biliary fistula whereas 62/157(39 %) had closure of fistula. In terms of long term outcome 132/157(84 %) with a complete injury had biliary stricture that needed correction, whereas only 13/158(8 %) had normal anatomy. In pts with partial injury, 89/110(81 %) had closure of fistula as the short-term outcome and only 29/110(26 %) had biliary stricture requiring intervention. Complete injury was one of the predictors for persistence of fistula and development of biliary stricture. Conclusion: The management and prediction of outcome of the acute BDI could be based on whether the injury is complete or partial. While partial injuries are amenable to endoscopic management, the role of endoscopic stenting in complete injury is limited. Complete injury is associated with delayed fistula closure & high rates of stricture formation needing surgical intervention. Keywords: Bile duct injury, External biliary fistula, Bile ascites, Bile peritonitis, Biloma, Open Cholecystectomy, Laparoscopic cholecystectomy

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Background: The LINX procedure, magnetic sphincter augmentation (MSA), is a promising new therapy for the treatment of gastroesophageal reflux disease (GERD). While initial clinical trials have shown MSA to be safe and effective, MSA has not been directly compared to laparoscopic Nissen fundoplication (LNF). Methods: A single institution, case matched-control study was conducted of MSA (n = 12) performed from 2012–2013 and a cohort of LNF (n = 12) matched for age, gender, symptoms, and hiatal hernia size. Exclusion criteria for MSA included prior antireflux surgery and hiatal hernia[2 cm. Intra-operatively, the LINX device was sized according to manufacturer’s instructions with a manufacturer representative present. The median size of the implanted MSA devices was 13 mm. No crural repair sutures were placed in MSA patients. LNF were performed with a floppy wrap constructed over a 56 Fr dilator. A procedure specific post op pathway was used in all patients. The indication for esophageal dilation was inability to tolerate a soft diet [6 weeks post op with ongoing weight loss. Results: Significant post-operative dysphagia occurred in the majority of MSA patients with the usual onset of symptoms 5–10 days post op. 50 % of MSA patients required endoscopic dilation (mean time to dilation, 130 days) for ongoing dysphagia with weight loss, while no LNF patients required dilation (50 % vs. 0 %, p = 0.01). Need for dilation did not correlate with the size of LINX device, presence of hiatal hernia, sex, BMI, or pre-operative manometry. 33 % of LNF patients developed mild abdominal bloating or hyperflatulence; no MSA patients reported these symptoms. Both operations effectively treated reflux symptoms, with 75 % of MSA and 83 % of LNF patients reporting resolution of symptoms at a mean follow-up of 7 months. Compared to LNF, MSA patients had a shorter operative time (64 vs. 90 min, p \ 0.001), were more likely to be self-referred (58 % vs. 0 %, p \ 0.01), and had a non-significant trend towards decreased post-op narcotic usage. Hospital length of stay was equivalent in both groups (1 vs. 1.1 days). There were no 30-day re-admissions, re-operations, or any other serious complications in either group. Conclusions: Laparoscopic magnetic sphincter augmentation is a safe and effective therapy for GERD. While MSA is easier and faster to perform than LNF, in our initial experience, more post operative care was required for MSA patients. Dysphagia occurs frequently and requires intervention more often with MSA; however, fewer MSA patients develop ‘‘the windy symptoms’’ post op than with LNF. Consideration should be paid to these distinct post-operative symptom profiles when selecting MSA vs. LNF as a treatment for GERD.

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Long Term Outcomes of Radiologic Recurrence After Paraesophageal Hernia Repair with Mesh Rachel A Jones, MD, Anton Simorov, MD, Carl J Tadaki, MD, Dmitry Oleynikov, MD University of Nebraska Medical Center, Department of General Surgery

Comprehensive Enhanced Recovery Pathway Significantly Reduces Postoperative Length of Stay and Narcotic Usage in Elective Laparoscopic Colectomy Martin Alvarez, MD, Katherine Foley, MD, Steven A Fassler, MD, D M Zebley, MD, Soo Y Kim, MD Department of Surgery, Abington Memorial Hospital

Introduction: Paraesophageal hernia repair has historically had a high radiologic recurrence rate in the literature, even with the use of biologic mesh as a prosthetic buttress to reinforce the primary crural repair. This review was done to evaluate outcomes at our institution after paraesophageal hernia with mesh. Methods: A retrospective analysis was done of all patients who underwent paraesophageal hernia repair with mesh at our institution between December 2004 and March 2013. Patients were reviewed for evidence of recurrence, defined as stomach extending vertically at least 2 cm above the diaphragm on upper gastrointestinal studies (UGI). Time specific, mesh specific, and size specific recurrence was analyzed as well as pre- and postoperative symptom scores. Results: A total of 209 patients underwent paraesophageal hernia repair with mesh. The mean follow up for patients with mesh was 21 months (range 0–101). In all cases an absorbable mesh was used (159 Alloderm, 35 BioA, 15 Strattice). 156 (75 %) were 5 cm or larger. Of the patients repaired with mesh 160 (77 %) had UGIs available to review for radiologic recurrence. Total recurrence was 21 % (n = 33). No mesh erosions were seen and only 1 patient required reoperation for early hernia recurrence. Recurrence rates increased over time: 22 % after 1 year (n = 28), 31 % after 2 years (n = 16), 33 % after 3 years (n = 14), 37 % after 4 years (n = 11), and 42 % after 5 year follow up (n = 8). Recurrence rates were higher for large hernias (23 vs 16 %) with 50 % recurrence rate at 5 years for hernias 5 cm or larger. The median size of the recurrence was 3.8 cm (range 2–7 cm) and consisted of posterior gastric migration above the diaphragm with gastroesophageal junction and the wrap below the diaphragm. Overall, patients showed significant improvement in their symptom scores. Heartburn had 83 % reduction (CI 78.2–87.7; p \ 0.05), regurgitation had 81.1 % reduction (CI 76.1–86.1; p \ 0.05) and belching had 63 % reduction (CI 56.7–69.3; p \ 0.05) and there was no significant difference in postoperative symptom scores between patients with or without radiologic recurrence. Conclusions: In this study, paraesophageal hernia repair with mesh was safe and effective at controlling symptoms over the long term. Radiologic recurrence rate increased over time and was highest in patients with hiatal hernias greater than 5 cm. No patients were symptomatic if the gastroesophageal junction remained below the diaphragm. Therefore, in our experience, paraesophageal hernia repair with mesh is a safe therapy and though radiologic recurrence does increase with time, symptom resolution is maintained.

Introduction: A comprehensive enhanced recovery pathway (ERP) was implemented in patients undergoing laparoscopic colectomy in an attempt to reduce postoperative intravenous (I.V.) narcotic consumption. We hypothesized that improved local analgesia and increased use of non-narcotic pain medication combined with earlier feeding and ambulation would allow for earlier return of bowel function and shorter postoperative length of stay (LOS). Methods and Procedures: We retrospectively reviewed the charts of 89 patients who underwent elective partial laparoscopic colectomy in the first 6 months since our new ERP became fully integrated. Results were compared to a control group of 162 patients who underwent similar operations in the 9 months before its implementation. Differences between the ERP and control groups average return of bowel function, postoperative LOS, narcotic medication usage, and complications were compared statistically using the student’s t-test. The ERP was a fully integrated program that included a laparoscopically guided transversus abdominis plane (TAP) local analgesic block performed by the surgeon at the time of surgery. Postoperative pain was controlled through scheduled doses of acetaminophen, greatly expanded use of non-steroidal anti-inflammatory drugs (ketorolac and ibuprofen), with the use of narcotics reserved for patients reporting severe pain. Patients were given an instruction sheet preoperatively that included expectations of early ambulation, diet with rapid progression as tolerated, and anticipated discharge criteria. Early ambulation was mandated and systematically enforced on postoperative day 1. Results: Patients in the ERP group had a significant decrease in the use of postoperative I.V. narcotics, earlier return of bowel function, and shorter postoperative hospital LOS. Narcotic use was reduced by 74 % from 75 mg to 19 mg I.V. morphine (p = 0.0001). Patients had an average return of bowel function of 0.66 days earlier from post operative day (POD) 2.99 to POD 2.33 (p = 0.0001) and were discharged from the hospital 1.02 days sooner on POD 2.68 compared to POD 3.7 (p = 0.0013). There was no statistically significant difference in postoperative complications between the control and ERP groups with the most common complications being early postoperative small bowel obstruction/ileus (6.7 % vs. 5.6 %, p = 0.7937) and bleeding (4.3 % vs. 6.7 %, p = 0.5526). Conclusion: The new ERP, including TAP block and postoperative pain medication protocol limiting I.V. narcotics, is effective in controlling pain in elective laparoscopic colectomy. Pain control management together with regimented early feeding and ambulation allow for significantly earlier return of bowel function and shorter postoperative LOS.

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Long Term Results OF Hydatid Disease of The Liver Managed Using Palanivelu Hydatid System C Palanivelu, MS, MCH, FACS, P Senthilnathan, MS, FACS, R Parthasarathi, MS, P Praveen Raj, MS, V P Nallankilli, MS, I Swathi, MS, S Sandeep, MS GEM Hospital & Research Centre, Coimbatore, India

Comparative Analysis of Laparoscopic and Robot-Assisted surgical Task Performance in Laparoscopic Novices and Experts Ahmed M Zihni, MD, MPH, Jaime A Cavallo, MD, MPHS, Jason Chiu, BA, Ikechukwu Ohu, BS, Sohyung Cho, PhD, L. Michael Brunt, MD, FACS, Michael M Awad, MD, PhD Washington University in St Louis, Southern Illinois University Edwardsville

Introduction: Surgical management of hydatid disease of the live can be challenging. Both conservative and radical surgeries are being followed worldwide with merits and demerits in each approach. Aim is to review the presentation, management and longterm outcomes of patients who underwent laparoscopic surgery for the hydatid disease using Palanivelu Hydatid Trocar system (PHS) in a single institution over a 17 years period Method: A retrospective review of all patients who were managed from 1997 to May 2013 for hydatid disease formed the study group. PHS system is a 12 mm continuous suction irrigation apparatus, which minimizes spillage of contents and also facilitates intracystic visualization. Clinical presentation, surgical modalities, perioperative complications and outcomes were analyzed. Results: 116 patients underwent surgery for hydatid disease over the study period of which 11 patients were excluded due to radical procedure done in these patients. Mean age is 32 years with male/female ratio of 76/29. The most common presentation was abdominal pain (58 %), 16(15 %) had multiple cysts of which 9(8 %) were in both lobes. 77(73.3 %) cysts were uncomplicated. Out of 28 complicated cases 19(17 %) had cyst-biliary communication, 2 were ruptured cysts (intraperitoneally, mediastinum and stomach) and 7 recurrent cysts. All of them underwent successful laparoscopic management using PHS trocar decompression and partial cystectomy. Postoperative infection was noted in 2, bile leak in 14 (all except one were managed conservatively). Mean hospital stay was 3.2 days and follow up was 5.2 years with 15 patients lost for follow up. The recurrence was seen in 2 patients Conclusion: PHS is a simple, safe and effective tool to treat hepatic hydatid cysts with excellent long term results which are comparable to radical surgery. Its closed suction and irrigation principle avoids intra peritoneal spillage thereby resulting in better outcomes.

Introduction: Robot-assisted laparoscopic surgery (RALS) utilizes wristed instruments that provide more degrees of freedom than rigid traditional laparoscopic (TLS) instrumentation and 3-D visualization. These features have been touted to improve accuracy and efficiency during surgical performance. However, there have been few quantitative evaluations of surgical task performance on RALS and TLS platforms among both novice and experienced surgeons. We compared objective measures of quality and efficiency of Fundamentals of Laparoscopic Surgery (FLS) task performance on RALS and TLS platforms in surgical novices and experienced laparoscopic surgeons. We hypothesized that both quality (as measured by errors per trial) and efficiency (as measured by completion time) would be significantly enhanced by task performance on the RALS platform compared to the TLS platform among novices and experts. Methods: Twelve novices (\100 laparoscopic procedures performed) and sixteen expert laparoscopic surgeons (C100 laparoscopic procedures performed) were recruited to perform three FLS tasks on both the TLS and the RALS platforms: peg transfer (PT), pattern cutting (PC), and intracorporeal suturing (IS). All tasks were performed using FLS testing parameters and repeated three times by each subject on each platform in a randomized order. Errors in task performance were defined as drops in the PT task, faults C5 mm cut from the defined pattern during PC, and faults C1 mm in suture placement from the defined points in IS. Errors were evaluated in a blinded manner. Mean errors per trial (EPT) and mean completion time (seconds) were calculated for each task on both platforms. Results were compared using unpaired student’s t-test, with p \ 0.05 considered the threshold of significance. Results: Among novices, significantly fewer errors occurred during PC on the RALS compared to the TLS platform (2.3 EPT, 0.8 EPT, respectively; p \ 0.001). No statistically significant differences in errors were seen for PT or IS tasks, or in mean completion times for PC, PT, or IS tasks when comparing RALS and TLS platforms. Among experts, no statistically significant differences in errors were noted during performance of any of the three FLS tasks. Among experts, PT (TLS 80.0 s, RALS 100.6 s, p = 0.007) and PC (TLS 116.1 s, RALS 145.2 s, p = 0.040) tasks were completed significantly faster on the TLS platform; no significant difference in completion time was noted for the IS task. Conclusions: Novice surgeons demonstrate reduced errors in task performance on the RALS platform when performing the PC task, and performed tasks at comparable speeds on the TLS and RALS platforms. Among expert laparoscopic surgeons, no qualitative benefit in task performance was noted, and PT and PC task performance were significantly faster on the TLS platform. These findings suggest that the dexterity of the RALS platform may provide a slight performance advantage compared to the TLS platform among surgical novices but not for expert laparoscopic surgeons. Further studies comparing task performance in expert laparoscopic surgeons and a robust sample of expert robotic surgeons with comparable levels of experience are under way.

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Application of Fluorescence in Robotic General Surgery: Our Experience Giuseppe Spinoglio, MD, Fabio Priora, PhD, Alessandra Marano, MD, Giampaolo Formisano, MD, Andrea Pappalardo, MD, Francesca Pagliardi, MD Department of General and Oncologic Surgery, SS Antonio e Biagio Hospital, Alessandria, Italy

Comparison of Stricture Rates Using Three Different Gastrojejunostomy Anastamotic Techniques in Laparoscopic Roux-en-Y Gastric Bypass Azam Qureshi, MD, Mujjahid Abbas, MD, Lindsay Cumella, BS, J J Choi, MD, P. Vemulapalli, MD, D. R Camacho, MD Montefiore Medical center, Bronx, NY

Introduction: Indocyanine green (ICG) is a vital dye with the distinctive feature of being fluorescent if properly excited and it is therefore currently used in near-infrared (NIR) fluorescence image-guided oncologic surgery. Recently, with the advent of the robotic surgery, a new camera has been introduced and it allows real-time switching between a standard three-dimensional vision to a near infrared view. Thanks to this new system, the technique of fluorescence imaging can be applied in several fields of robotic general surgery, some still experimental and continuously evolving. Methods and procedures: Since the introduction of the NIR camera integrated into the robotic system at our Center in 2011, we performed a total of 227 procedures with the application of the ICG fluorescence technique to visualize vascular and biliary anatomy, assess bowel anastomotic perfusion, tattoo gastrointestinal lesions and perform lymph node (LN) road mapping and sentinel LN biopsy during robotic surgery. Results: ICG fluorescent cholangiography allowed safe viewing as well as immediate and real-time identification of the biliary tract anatomy preventing bile duct injuries in all 97 cases of Single SiteÒ robotic cholecystectomies. Moreover, the intravenous injection of ICG aided the surgeon in visualizing the correct perfusion of the colonic stump in order to perform a safer bowel anastomosis during 92 colorectal resections, mainly for cancer. For the lymphatic road mapping and sentinel LN biopsy, NIR with ICG allowed a rapid and complete lymphatic drainage visualization in the majority of cases. Conclusion: Our strengthened experience with the application of fluorescence in robotic general surgery shows promising outcomes in all the possible fields of application of this novel technology. However, several technical details still need to be optimized, including the dose of the dye, the timing, the method of injection and especially its role.

Introduction: No one gastrojejunostomy anastomosis technique (GJA) in Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently preferred over another. Bendewald et al confirmed that there was no difference in anastomotic stricture rates when comparing hand-sewn (HS), linear-stapled (LS), and circular-stapled (CS) GJA techniques. We present and analyze our own institutional data to readdress stricture rates. Methods: From January 2010 to January 2013 860 consecutive patients underwent LRYGB using HS, LS, and CS anastomotic techniques at a single institution. All patients in this study were followed for a duration of 60 days to see if they had a complication of a stricture within this time period. Hospital records were retrospectively reviewed. Stricture complications were defined as those patients who had a clinical exam suspicious for stricture which were then confirmed by endoscopy. Results: Preoperative demographics, length of hospital stay, and postoperative follow-up did not differ between the three groups. The most common technique employed was LS (n = 429, 49.8 %), followed by CS (n = 254, 29.5 %) and HS (n = 177, 20.6 %), respectively. Using multivariate analysis, there was a significant difference in the rate of strictures between the anastomotic techniques (LS 3.96 %, HS 2.26 %, CS 0.394 %, p = 0.0163). Conclusions: Our data shows that the discussion of which anastomotic technique is superior should be reopened given the statistically significant low rate of strictures in patients who underwent LRYGB with a CS anastomosis in comparison to LS and HS anastomoses.

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Lymph Node Mapping and Sentinel Lymph Node Biopsy with Fluorescence Imaging System in Robotic Colorectal Surgery Giuseppe Spinoglio, MD, Ferruccio Ravazzoni, PhD, Giampaolo Formisano, MD, Alessandra Marano, MD, Domenico Piscioneri, MD Department of General and Oncologic Surgery, SS. Antonio e Biagio Hospital, Alessandria, Italy

Laparoscopic Gastrectomy Versus Open Gastrectomy for Gastric Cancer in Patients with Body Mass Index of 30 kg/m2 or more Do Joong Park, MD, PhD, Sang-Yong Son, MD, Chang Min Lee, MD, Do-Hyun Jung, MD, Sang-Hoon Ahn, MD, Hyung-Ho Kim, MD, PhD Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

Introduction: The prognosis and quality of life of patients with colorectal cancer depend on the extent of the tumor and on the quality of surgical care. A correct locoregional lymphadenectomy is mandatory for staging and treatment. The aim of this study is to evaluate the advantages of the definition of a lymph node map that should in principle permit a more extensive but guided lymphadenectomy, thus offering patients a ‘‘tailored surgery’’ and avoiding extended lymph nodes dissections with additional unnecessary surgical risks and perioperative morbidity. In addition, the SLN procedure could improve accurate staging and therefore subsequent oncological management by providing the pathologist with one or two lymph nodes for detailed micrometastasis evaluation. Methods and procedures: From November 2011 to September 2013, we performed at our institution a total of 25 robotic colorectal procedures (5 right colectomies, 4 left colectomies, 12 low anterior resections and 4 abdominoperineal resections) for cancer with lymph node mapping and sentinel node biopsy with near-infrared (NIR) fluorescence DaVinciÒ imaging system. The technique differs in the timing of injection of the indocyanine green (ICG) to assess the lymph node map rather than to identify the sentinel lymph-node. In the case of lymph node mapping, 1 or 2 cc of a solution of 0.5 % ICG (5–10 mg) is injected endoscopically around the tumor in the submucosa 3 to 24 h before surgery. The lymph nodes are removed en-bloc if present in typical sites by a standard lymphadenectomy; however, they are removed with the ‘‘berry-picking’’ technique when present in unusual locations. To identify the sentinel node, the dye is injected intraoperatively into the subserosa. If the location of the tumor cannot be identified laparoscopically, the dye is injected into the submucosa by the endoscopist. Results: With robotic ICG-system, the lymph nodes and lymph vessels that received ICG appeared as shining fluorescent spots and streams in the fluorescence image: in the majority of cases, this allowed the detection of lymph nodes located at the origin of the superior and inferior mesenteric artery, in the interaortocaval region, in the mesorectum and along lateral pelvic walls. One of the limitations of the application is the rapid diffusion of ICG to surrounding tissues that, in a limited number of cases, prevented us from correctly identifying the lymphatic dye spread. Conclusion: Our preliminary experience confirms that the application of fluorescence in robotic surgery for lymph node mapping and sentinel lymph node biopsy may provide the surgeon an important tool to optimize the staging and treatment process of patients affected by colorectal cancer. Further investigation is needed to confirm its role and to address its shortcomings and pitfalls.

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Background: High body mass index (BMI) and high visceral fat area (VFA) are known to be a preoperative risk factor for laparoscopic gastrectomy (LG) for gastric cancer. However, the impact of obesity on LG still remains controversial. In the present study, we compared the operative outcomes of LG with those of OG in patients with BMI of C30 kg/m2. Methods: Seventy-seven patients who underwent distal or total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups by approach method; an OG group (n = 19) and a LG group (n = 58). Aquarius iNtuitionÒ program was used to measure VFA. The operation time, estimated blood loss, complication rate, the number of retrieved lymph nodes, and patient survival were compared between two groups. Results: The mean BMI and VFA were 31.6 kg/m2 and 194.8 cm2. The complication rate was 42.1 % in OG group and 15.5 % in LG group, respectively (p = 0.015). LG group showed less estimated blood loss (p = 0.031) and fast recovery of bowel movement (p \ 0.001). However, there were no significant differences in operation time, the number of retrieved lymph nodes, and the length of hospital stay between two groups. In subgroup analysis, there was significant correlation between estimated blood loss and VFA (R2 = 0.124, p = 0.012), but there was no correlation between operation time and VFA (R2 = 0.011, p = 0.474). The 5-year survival was not different between two groups (p = 0.186) Conclusion: LG showed better operative outcomes compared with OG, in terms of less estimated blood loss, fast recovery of bowel movement, and low complication rate, in patients with BMI of C30 kg/m2.

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Perioperative Risk and Complications of Revisional Bariatric Surgery Compared to Primary Roux-en-Y Gastric Bypass Linda P Zhang, MD, Wen Hui Tan, MD, Ronald Chang, MD, Valerie Halpin, MD, J. Chris Eagon, MD Department of Surgery and Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO

Validation of an Advanced Laparoscopic Skills Curriculum Dmitry Nepomnayshy, MD, James Whitteledge, Richard Birkett, MD, Ted Delmonico, MD, Neal Seymour, MD Lahey Clinic, Baystate Medical Center

Introduction: There have been a growing number of patients requiring revisional bariatric surgery. This study compares the perioperative course and outcomes of revisional versus primary bariatric surgery. Methods: All patients who underwent revisional bariatric surgery at our institution from January 1997 to September 2012 were reviewed retrospectively. For each revisional patient with BMI [35 and age \70, a primary Roux-en-Y gastric bypass control patient was matched based on preoperative BMI (±5 units), age (±5 years), sex, and year of surgery (±2 years). Patients’ preoperative indications, operative procedure, intraoperative and postoperative course, and complications were analyzed. Statistical analysis was done by Student’s t-test, where p \ 0.05 indicated significance. Results: 255 patients underwent revisional bariatric surgery with a resulting Roux-en-Y gastric bypass anatomy while 1,674 patients underwent primary gastric bypass surgery in the same time interval. Of the 255 patients, 172 patients (BMI[35 with age\70 years) were paired with 172 primary gastric bypass patients. The revisional bariatric group had preoperative BMI 48 ± 9, age 52 ± 9 years, 93 % female, 44 % laparoscopic, 30 % diabetic, 60 % hypertensive. Primary bypass patients had preoperative BMI 49 ± 8, age 52 ± 9 years, 93 % female, 97 % laparoscopic, 49 % diabetic, 67 % hypertensive. Compared to primary bypass patients, revisional patients had significantly higher estimated blood loss (463.7 vs 113.3 mL), longer operative time (272.5 vs. 175.5 min), greater risk for postoperative ICU stay (N = 24, 14 % vs. N = 2, 1 %), and longer length of stay (5.6 vs. 2.5 days). There were significantly more intraoperative liver (N = 13, 8 % vs. N = 1, 1 %) and spleen (N = 18, 10 % vs. N = 0) injuries, as well as more enterotomies (N = 9, 5 % vs. N = 0) in the revisional group compared to the primary group. There were also significantly more postoperative complications (N = 94, 55 % vs. N = 48, 28 %), and more readmissions (N = 27, 16 % vs. N = 12, 7 %) and reoperations (N = 16, 9 % vs. N = 3, 2 %) within 30 days of surgery. Mean percentage weight loss at 1 year was 27 % for revisional patients and 37 % for primary bariatric patients. The 30-day mortality rate in the revision group was 3.5 % (N = 6) while the primary group had no mortalities. Conclusion: Even in experienced hands, complex revisional bariatric surgery is associated with more perioperative morbidity and mortality than primary bypass surgery. There is also less percentage weight loss at 1 year than primary bariatric surgery.

Introduction: Since FLS represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the need of current surgical training. We wanted to establish face and construct validity of a new set of skills building on the FLS model that would represent a more advanced proficiency standard—Advanced Laparoscopic Surgery (ALS) which addresses operating room challenges like off-set camera view, restricted space and difficult angles. Methods: Prospective comparison of novice, (PGY 1–2), intermediate (PGY 3–4), and expert (PGY 5+) surgeons in the performance of FLS tasks—peg transfer (PT), circle cut (CC), intra-corporeal suture (ICS) and ALS tasks—Off-Set Camera PT and ICS, Vertical Plane PT and CC, Back-hand ICS, Confined Space ICS and Reverse Angle PT. To assess face validity, expert participants completed questionnaires. To assess construct validity, performance data on FLS and ALS were analyzed. Standard FLS errors were added to task time to create a composite time score which was used for comparison (lowest score is best). Results: Out of 48 participants, there were 15 (31 %) attendings, 3 (6 %) fellows and 30 (63 %) residents which included 11 PGY12, 12 PGY3-4 and 7 PGY5. By specialty, 54 % were General/MIS/Bariatric, (GMB), 10 % were GYN, and 36 % Urology. Majority of the respondents felt that ALS was a realistic task set, however not all the tasks were felt to be equally important. Offset Camera and Confined Space tasks were the best perceived while Reverse Angle was the worst. Initial analysis of composite data did not reveal statistically significant differences between novice, intermediate and experts. However, divided by specialty, GMB experts performed significantly better than other specialties on FLS and ALS. (Figs. 1 and 2*) In the GMB subset, there were significant difference in performance between experience levels on ALS, while there was no difference in performance on FLS (Figs. 1 and 2++). When looking at specific tasks, ALS suturing tasks (Backhand, Off-Set Camera and Confined Space) showed statistically significant improved performance in experts compared to novices while other tasks did not differentiate. Conclusion: We were able to demonstrate face and construct validity of a series of advanced laparoscopic tasks (ALS) for General/ MIS/Bariatric surgeons. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.

Fig. 1 ALS Compound Score

S147 Laparoscopic Choledochoduodenostomy for Treatment of Benign Common Bile Duct Strictures N. Y. Bayramov,, Taryel I. Omarov, N. A. Zeynalov Azerbaijan Medical University, Baku, Azerbaijan Objective: This article presents the results of laparoscopic choledocho-duodenostomy (CDD) applied to 25 patients with benign strictures of distal part of common bile duct (CBD) and its dilatation. Material and methods: 23 patients had combination of distal stricture of CBD and stones in gallbladder and CBD (2 patients—in CBD, 12- in gallbladder, 9-both in CBD and gallbladder), 2 patients had acalculous postcholecystectomy stricture. Laparoscopic CDD was performed by 5 trocars. 4 trocars were placed in the standard points for cholecystectomy, the 5-th trocar was placed by the right pararectal line at the umbilicus level and used for traction of duodenum and continuous aspiration. 2 sm length CDD was applied side-to-side by 4/0 vikryl or PDS interrupted sutures. 1, 3, 6 and 12 months after the surgery patients underwent USG examination and liver function tests, 6–12 months later endoscopic investigation to evaluate the anastomosis. Results: 23 patients underwent laparoscopic cholecystectomy and choledochoduodenostomy, 2 patients- choledochoduodenostomy only. The mean duration of operation was 127 ± 36 min (90–205 min). There was no conversion. The mean hospital stay was 4.5 days (3–9 days). There was no mortality. 2 patients developed an anastomotic leak. One of them underwent relaparoscopy and T- drainage, in another patient the biliary leakage ceased spontaneously. 6–12 months later 19 patients were examined by endoscopy. In 4 of them anastomosis was not visualized, 15 had working anastomosis 6–10 mm diameter. Thus, after 25 laparoscopic CDD executed due to benign pathologies complications were noted in 2 patients (8 %), excellent and good outcome in 21 (84 %) patients, poor in 3 (12 %) and very poor in 1 (4 %) patient. Conclusion: Laparoscopic choledochoduodenostomy performed by experienced surgeons in selected patients provides good longterm results and could be the alternative to endoscopic sphincterotomy. Keywords: Laparoscopic choledochoduodenostomy Endoscopic sphincterotomy Benign strictures Common bile duct.

Fig. 2 FLS Compound Score

Table 2

Surgical Outcomes

Parameters

LADG (means ± SD)

RADG (means ± SD)

P value

Operation time

233.1 ± 32.9

302.8 ± 26.6

0.13

Blood loss

166.1 ± 52.29

130.2 ± 28.9

0.53

Retrieved lymph nodes

35.7 ± 5.3

32 ± 3.2

0.57

Hospital stay

10.6 ± 1.96

7.5 ± 1.18

0.19

0.5 ± 0.35

0.14 ± 0.14

0.38

0.57 ± 0.37

0.17

Mortality Conversion

0

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20-Years Later: Laparoscopic Fundoplication Durability Benjamin J Robinson, Christy M Dunst, MD, Kevin M Reavis, MD, Ahmed Sharata, MD, Lee L Swanstrom, MD Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic

Laparoscopic Ventral Hernia Repair with Polyester Mesh: Primary Fascial Repair with Mesh vs. Mesh Only Priya Joshi, BS, Farah Karipineni, MD, MPH, Afshin Parsikia, MD, Amit Joshi, MD, FACS Jefferson Medical College, Philadelphia, PA & Einstein Healthcare Network, Philadelphia, PA

Introduction: The objective of this study is to present long-term 20-year outcomes after laparoscopic fundoplication. In the early 1990s, this advanced surgery for gastrointestinal reflux disease (GERD) started in highly selected institutions. Long-term outcomes studies are rare. The longest study to date showed a 73 % success rate of the laparoscopic fundoplication procedure at 10-years. Methods and Procedures: A prospectively collected database was queried for all patients who underwent primary laparoscopic fundoplication procedures for GERD between 1991 and 1995. A single surgeon performed all procedures (LLS). Patients were contacted by phone and completed a 20-year follow up survey. Patients were asked whether they underwent a revision surgery, and a symptom questionnaire was administered. Symptomatic success of fundoplication was defined by lack of surgical re-intervention and a symptom score of 0-1 using a validated GERD symptom scoring system (0 = never, 1 = once a month, 2 = once a week, 3 = everyday, 4 = continuous). Symptom scores were analyzed for heartburn, regurgitation, and dysphagia. Results: One hundred ninety-three patients were identified as having had surgery between 1991–1995. Of these, 100 could not be contacted, 40 were deceased, and 2 declined to answer, leaving 51 patients who completed a standardized survey. Respondents had a median follow up of 19.4 years (inter quartile range 18.7-20 years). Overall, 63 % (32/51) of patients were successful, being free of consistent GERD symptoms. Specifically, 94 % (48/51) had no or rare regurgitation and 75 % (38/51) had no or rare heartburn. Of all patients, 16 % (8/51) of respondents had revision, and 45 % (23/51) were on proton pump inhibitors (PPI). Furthermore, 26 % (13/51) had dysphagia (5 patients with occasional, 8 patients with daily). Lastly, 10 % (5/51) of respondents were unsatisfied with surgery, but 3 of them had one or more of the analyzed symptoms: heartburn, reflux, or dysphagia. The fourth was not happy to have to take PPI’s again, and the final patient was dissatisfied because of short-term post-op dysphagia. Conclusion: Laparoscopic fundoplication has a symptomatic success of 63 % for regurgitation and heartburn at 20-year follow up. There is a relatively high rate of dysphagia (26 %) at long-term follow up, but need for reparative surgery is relatively low (16 %). A high percentage of patients (90 %) are happy they underwent fundoplication.

S150 Intraoperative use of Fluorescent Imaging with Indocyanine Green changes Management of Abdominal Wall Flaps During Open Hernia Repair Jonathan Cho, MS, Audriene Sanchez, MS, Heidi Ryan, MD, Shawn Tsuda, MD, FACS Department of Surgery, University of Nevada School of Medicine Background: Wound complications including infection and necrosis remain common during complex open ventral hernia repair. Advancements or enhancements in imaging technology may abate some of these issues but requires more investigation. Laser-assisted fluorescent imaging with indocyanine green (Spy Elite, LifeCell) allows visualization and quantification of perfusion, facilitating management of poorly perfused tissue. Methods: Ten patients, who underwent large or massive ventral/incisional hernia repair with biologic graft reinforcement and either perforator-sparing components separation or primary open repair, underwent intraoperative use of laser-assisted fluorescent imaging with indocyanine green from August 2012 to August 2013. The cases were reviewed by an independent data collector with primary outcomes of postoperative skin infection and/or abdominal wall necrosis. Results: Three (30 %) patients had adequate perfusion, while 7 (70 %) patients had inadequate skin perfusion and necessitated excision of additional tissue. Of the patients whose ischemic tissue was removed, 4 (57 %) patients developed an infection, while no patients developed necrosis. Of the patients who had no removal of additional skin, 1 (33 %) and 1 (33 %) patients developed an infection and necrosis, respectively. Conclusion: The intraoperative use of laser-assisted fluorescent imaging with indocyanine green may change management of abdominal wall flaps, even in perforator sparing operations. Our study series is small and cannot suggest statistical significance in the potential benefit of intraoperative imaging, but shows that up to 70 % of patients may require change in management due to poorly perfused tissue flaps.

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Introduction: Several studies have suggested that primary closure of hernia defects may decrease recurrence rates of laparoscopic ventral hernia repair (LVHR). This paper expands on the data regarding recurrence rates in primary closure with mesh versus mesh-only repair of LVHR and examines the ideal overlap required to prevent recurrence. Methods and Procedures: An IRB-approved, retrospective review was conducted on 57 patients who underwent LVHR performed by a single surgeon between August 2010 and July 2013. Polyester dual-sided mesh was used in all patients. These patients were divided into mesh-only (non-closure) and primary fascial closure with mesh (closure) groups. Patient demographics, hernia locations, mesh overlap, complications, and recurrence rates were compared between the two groups. The data were tested for normality. Non-parametric tests and medians were utilized for the data which were not in normal distribution. Results: Of the 57 patients included, 39 (68 %) were in the closure group and 18 (32 %) in the non-closure group. Median defect sizes were 5.1 cm2 and 9.1 cm2, respectively (p = 0.378). Participants were followed for a mean of 1.3 years (SD = 0.7). Recurrence rates were 2/39 (5.1 %) in the closure group and 1/18 (5.6 %) in the non-closure group (p = 0.947). There were no post-operative complications in the non-closure group. The closure group experienced 3 (7.7 %) post-operative complications (hematoma and paralytic ileus). This was not statistically different between the two groups (p = 0.544). The median mesh-to-hernia ratio (surface area of mesh:surface area of hernia) for all repairs was 15.2 (1.3 to 769.2). Median length of stay was 14.5 (1.7 to 1496.6) hours for patients with non-closure and 11.9 (6.9–815.9) hours for patients with closure (P = 0.466) Conclusions: This is one of the largest series of LVHR using polyester dual-sided mesh. Our recurrence rate was quite favorable at about 5 %. Significant overlap is needed to achieve such low recurrence rates. The surface area of the mesh should be at least three times that of the hernia defect itself. Primary closure of hernias seems less important than adequate mesh overlap in preventing recurrence after LVHR. Primary closure may help to prevent postoperative seroma formation.

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Preoperative Warm-Up The Key to Improved Resident Technique Erin Moran-Atkin, MD, Ransom Wyse, MPH, CPH, Grace Chen, MD, Bethany Sacks, MD, Hien Nguyen, MD, Anne Lidor, MD, Thomas Magnuson, MD, Michael Schweitzer, MD, Kimberley Steele, MD Johns Hopkins University School of Medicine

Laparoscopic Hernia Repair with Adductor Tenotomy for Athletic pubalgia: An Established Procedure for an Obscure Entity Georgios Rossidis, MD, Andrew Perry, MD, Husain Abbas, MD, Isaac Motamarry, MD, Tamara Lux, PA, Kevin Farmer, MD, Michael Moser, MD, Jay Clugston, MD, Angel Caban, MD, Kfir Ben-David, MD University of Florida College of Medicine

The ACGME has required that a simulation and skills lab be incorporated into surgical residency training curricula. The benefit of practicing in the lab has been studied in recent years and is well accepted. While the value of warm-up is generally accepted in other areas requiring complex motor skills, e.g. athletics and musical performance, there is little evidence to support the benefits of warmup prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period, just prior to operating, results in better operative technique. Methods: All general surgery residents from PGY1 to PGY5, as well as the MIS fellow, were asked if they wished to participate in this IRB approved study. The procedures eligible for the study were laparoscopic appendectomy or cholecystectomy for junior level residents (PGY1 and 2), and laparoscopic ventral or inguinal hernia repair, colon resection, vertical sleeve gastrectomy, or Roux-enY gastric bypass for senior levels (PGY 3, 4, 5 and fellow). Participants were randomized to warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 minute practice session in the simulation lab within 1 hour of starting the case, using an FLS training box. PGY1 and PGY2 training skills performed were pegboard transfer, pattern cutting, and endoloop; PGY3 to PGY5 and fellow skills were pegboard transfer, pattern cutting, intracorporeal suturing and endostitch. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use or not of pre-procedure warm-up. The results of the questionnaire were analyzed using student T-Test with p \ 0.05 for significance. Results: Pilot data was obtained enrolling 15 residents randomized to warm up (10) or no warm-up (12) for 22 laparoscopic procedures. Attending surgeon evaluations on resident performance showed a statistical significance in instrument handling (0.03) and bimanual dexterity (0.01) (Table 1). Although the rest of the grading points did not show statistical significance there was a notable improvement in overall scores. Participants’ perception of their performance during the procedure using warm-up was not significantly altered (Table 2). Conclusion: Preoperative warm-up significantly improves bimanual dexterity and instrument handling. There did appear to be improvement in operative technique among subjects using warm-up as judged by the attending surgeon, though this effect did not reach statistical significance. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect an important finding; namely, that surgical performance, as with other areas of human performance, can be enhanced through structured warm-up activities. The potential importance of this finding justifies further data collection and replication of our findings at other institutions.

Introduction: Athletic pubalgia, also known as sports hernia, is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is an entity that is not well understood but has been popularized through the treatment of professional athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. Methods: Under IRB approval we conducted a retrospective review of our prospectively followed database on competitive athlete patients with athletic pubalgia from 2007–2013. Results: A cohort of 54 patients was examined. Mean age was 22.4 years. Most of the patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1) tennis player (n = 1). 51 were males and 3 were females. All patients failed medical therapy with physiotherapy prior to the surgical consultation. 76 % of patients had an MRI performed. The MRI findings were as follows: 26 % of patients had a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Two patients had evidence of marrow edema in the left pubic body and two patients had evidence of obturator externus strain and osteitis pubis. Twenty patients had no findings on their preoperative MRI and only one patient was noted to have an inguinal hernia present on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients followed a strict rehabilitation regimen and all patients were able to return to full sports related activity in 24 days (range 21–28 days). One patient experienced urinary retention, another developed subsequent pain 6 months following his initial operation requiring a contralateral adductor longus tentomy, and one patient sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months. Conclusion: Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy. Strict rehabilitation program following surgical repair and tenotomy can provide excellent results and early return to sports related activity with minimal complications.

S154 Table 1

Attending global rating scale

GRS

No Warm-UP

Reznick

Warm-Up

T-Test

Mean

SD

Mean

SD

3.87

0.67

4.14

0.69

0.21

3.45

0.78

3.62

0.74

0.31

3.29

0.62

3.75

0.46

0.03

3.5

0.67

3.75

0.46

0.16

3.62

0.82

3.57

0.53

0.43

3.66

0.88

3.75

0.70

0.40

3.25

1.05

3.75

0.70

0.11

2.95

0.91

3.71

0.48

0.01

3.12

0.80

3.5

0.53

0.11

3.54

0.78

3.75

0.70

0.27

3.24

0.86

3.5

0.53

0.21

l

2

3

4

5

6

Vassiliou

1

2

3

4

5

Reznick globed rating score (GSR) evaluates: 1—Respect for Tissue, 2—Time and Motion, 3—Instrument Handling, 4—Knowledge of Instruments, 5—Use of Assistants, 6—Knowledge of Specific Procedure Vassiliou GSR evaluates: 1—Depth Perception 2—Bimanual Dexterity, 3—Efficiency of Movements, 4—Tissue Handling, 5—Autonomy There is an evident improvement in the warm-up group and a statistical significant improvement on instrument handling (p = 0.03) and bimanual dexterity (p = 0.01)

Table 2

Resident global rating scale

GRS

Reznick

No Warm-Up

Warm-Up

T-Test

Mean

SD

Mean

SD

3.50

0.90

3.80

0.63

0.18

3.25

0.75

3.20

0.63

0.43

3.66

0.88

3.30

0.67

0.14

3.66

0.88

3.80

0.63

0.34

3.33

0.88

3.60

0.69

0.22

3.50

1.00

3.60

0.51

0.38

3.50

0.90

3.40

0.69

0.38

3.16

0.71

3.30

0.48

0.30

3.33

0.77

3.30

0.67

0.45

3.41

0.90

3.60

0.84

0.31

3.33

0.88

3.30

0.67

0.46

1

2

3

A Little Slower, But Just as Good: Resident Outcomes in Laparoscopic Ventral Hernia Repair by Post-Graduate Year (PGY) Samuel W Ross, MD, MPH, Bindhu Oommen, MD, MPH, Joel F Bradley, MD, Mimi Kim, MD, Amanda L Walters, MS, John M Green, MD, Vedra A Augenstein, MD, Brant T Heniford, MD Carolinas Medical Center, Department of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery Introduction: The controversy of resident experience level and involvement in operations and its associated surgical outcomes have been long debated. We sought to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR), and hypothesized that increasing PGY level would correlate with better outcomes. Methods: The American College of Surgeons NSQIP database was queried from 2005–2011 for LVHR. Inclusion criteria were age [18 and resident PGY level data. All emergent cases were excluded. Attending only cases were used as the control and resident cases were stratified into junior (PGY 1–3), chief (4–5), and fellow (6+) cases. Demographics, comorbidities, complications, and patient outcomes were compared between resident and attending as a whole and by PGY level using standard statistical tests with a significance of p B 0.05. New variables were created to group post-operative complications. Multivariate regression controlling for age, BMI, Charlson Comorbidity Index (CCI), smoking, functional status, and inpatient cases was performed. Results: There were 6,841 VHR that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups: age (57.4 ± 13.6vs 56.8 ± 13.4), male (39.7 % vs 41.2 %), BMI (33.7 ± 8.2 vs 33.4 ± 8.3 kg/m2), CCI (0.4 ± 0.8 vs 0.4 ± 0.8), smoking (19.2 % vs 19.4 %), independent functional status (98.9 % vs 98.7 %); all p [ 0.05. In the resident group, there was a higher rate of inpatient cases (41.9 % vs 53.7 %, p \ 0.001), minor complications (3.0 % vs 4.1 %, p = 0.018), longer operative time (92.2 ± 55.3 vs 114.6 ± 65.3 min; p \ 0.001) and hospital length of stay (LOS) (2.0 ± 8.0 vs 2.2 ± 4.5 days; p \ 0.001). However, after controlling for confounders in multivariate analysis only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0–20.6; p \ 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. Outcomes by PGY level are presented in the Table 1. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2–19.2), chiefs (18.0 min, CI 14.7–21.3), and fellows (24.9 min, CI 19.1–30.7) had significantly longer cases than attendings alone; all p \ 0.001. Conclusion: After accounting for confounding variables, patients undergoing LVHR with resident involvement in their operation have equal clinical outcomes as patients with an attending alone. Interestingly, operative time is significantly longer with increasing PGY level, perhaps indicating the difficulty of the operation or increasing resident or fellow autonomy. Surgical trainee participation in LVHR does increase operative time, but patient care does not suffer.

4

Table 1

LVHR patient outcomes by PGY level

5

Junior n = 1644 (%)

6

Vassiliou

Chief n = 19B3 (%)

Fellow n = 441 (%)

Attending n = 2773 (%)

1

Wound complications

1.2

1.3

0.9

1.3

Minor complications*

4.0

4.4

3.0

3.0

2

3

4

5

Rezmck global rating score (GSR) evaluates: 1—Respect for Tissue, 2—Time and Motion, 3—Instrument and Handling, 4—Knowledge of Instruments, 5—Use of Assistants, 6—Knowledge of Specific Procedure

Major complications

2.6

2.6

2.6

2.1

Operative time (minutes)*

110.8 ± 62.4

115.3 ± 64.4

125.5 ± 77.9

92.2 ± 553

Hospital LOS (days)*

2.1 ± 4.6

2.3 ± 4.0

2.5 ± 5.6

2.0 ± 8.0

Reoperation

1.4

3.5

1.0

2.6

Readmission

5.6

6.0

5.9

5.5

Mortality

0.1

0.3

0.7

0.3

Vassiliou GSR evaluates: 1—Depth Perception 2—Bimanual Dexterity, 3—Efficiency of Movements, 4—Tissue Handling, 5—Autonomy No Statistical differences were perceived by residents in their self-assessment of their performance

* Statistically Significant, p \ 0.05

123

S286

Surg Endosc (2014) 28:S240–S286

S155 A Comparison of Robotic Single Incision and Traditional Single Incision Laparoscopic Cholecystectomy Tariq Lescouflair, MD, Monica Gustafson, MD, Ibrahim Daoud, MD, FACS Department of Minimally Invasive Surgery, St. Francis Hospital and Medical Center; Hartford, CT Introduction: Once laparoscopy proved to be a safe and reliable method of performing many abdominal surgical procedures, surgeons have continued to advanced technology and develop less invasive methods for performing common surgical procedures. This trend ultimately led to the invention of robotic surgery, which began in ernest in the 1990s. In recent years, robotic surgery has gained popularity, with many urologic, gynecologic and general surgical procedures exploring its many advantages. The aim of this project is to evaluate the utility of robotics in the context of single incision laparoscopic cholecystectomy (SILC). Methods: A retrospective review of a prospectively maintained database of both robotic single incision laparoscopic cholecystectomy (RSILC) and traditional SILC was performed. The database includes all consecutive RSILC and SILC performed by a single surgeon at our institution from August 2010 to the present date. All consecutive RSILC patients were matched with patients of similar age, gender, ASA, and BMI undergoing SILC. Outcomes and cost were compared between the two groups. Primary outcomes include rate of conversion, defined by the use of any additional ports and operative time. Secondary outcomes include duration of narcotic use, time to independent performance of daily activities and cost. Categorical variables were evaluated using chi square analysis and continuous variables using t-test. Results: 41 patients undergoing RSILC and 41 patients undergoing SILC included in the analysis. Demographics, including age, gender, ASA and BMI were similar. There was no difference in conversion rate between RSILC and SILC (9 vs 11 %, p = 0.60). Mean operative time for RSILC was significantly greater compared to SILC (96.7 vs 65.2 min, p = 4.8 9 10-6). RSILC was associated with a slightly longer duration of narcotic use (1.6 vs 2.4 days, p = 0.0068) and time to independent performance of daily activities (2.3 vs 4 days, p = 8.5 9 10-6). Cost is higher but does not seem to be significantly so in RSILC ($3673 vs $7518, p = 0.056) Discussion: Conversion rates are similar in RSILC and SILC suggesting that technical difficulty is comparable. Narcotic use and time to restoration of independent activity seem to be slightly higher in the RSILC group. The mean cost was higher in the RSILC group, however this did not seem to be a statistically significant difference. This may be due in part to specialized equipment required for the robotic platform as well as increased operative time. Conversion

Narcotic Use

SILC

9%

1.6 days

RSILC

11 %

2.4 days

p value

123

0.60

4.8 9 10

Independent

2.3 days

$3673

4 days -6

Cost

$7518 -6

8.5 9 10

0.056